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Medical aid schemes – a dilemma for practitioners

Written by Stella Pascale on Thursday, 7 July 2016 07:16

Medical aid schemes – a dilemma for practitioners

Healthcare practitioners are increasingly challenged by the constraints of medical aid schemes. Emanating from the power that medical scheme managers have in determining the treatment options for the patient, they prescribe what and how much can be done for the patient.

This practice of managed healthcare poses a dilemma and a frustration to both the healthcare provider and the patient, because the healthcare provider, when consulting with the patient, formulates a diagnosis and prepares a treatment plan.

However, the treatment plan proposed by the healthcare practitioner, which is in the best interests of the patient, may not be funded by the medical scheme. For example, in dental care, some medical schemes only cover the costs for basic treatment such as restorations and extractions. Managed healthcare plans also determine the number of teeth to be filled per year. The scheme may not cover extensive but necessary treatment, such as root canal therapy. Hence, a patient belonging to such a scheme will have to cover the high costs themselves (out of pocket expenses) or opt to lose the tooth through extractions.

In view of best practice and to ensure patients are receiving optimal care, medical scheme managers and healthcare providers should negotiate solutions that will result in optimal and appropriate patient management.