Will my medical expenses get paid
Medical aids cover far less for pschiatric illnesses than they do for physical ailments
Katlego Badimo sits quietly on the white leather couch in his lounge. Resting his elbows on his knees he stares out of the window. It is a warm autumn day in Johannesburg — a far cry from his late teens and earlier 20s. Then every day felt like winter.
Now aged 24, Badimo recalls how he struggled with depression through most of his high school years.
“It subsided a little and then got bad again when I was in second year at university,” he remembers.
In 2013, when he was 20 years old, Badimo’s GP recommended that he see a psychiatrist, as he wasn’t getting better.
The specialist wanted to admit him to hospital but, because it meant Badimo missing part of the second year of his law degree at the University of Pretoria, he didn’t go. He was scared it would result in him not being able to complete that year.
But a year later, in July 2014, Badimo’s depression had worsened to such an extent that he could no longer function. He was admitted into a psychiatric facility east of Pretoria.
“By then I was having a whole lot of suicidal ideation,” he says. “The counsellor I had been seeing at the university accommodation I was living in told my mother that we had one of two options: either I got admitted to hospital or I had [to] move back home, because they couldn’t ensure my safety all the time.”
Badimo pauses and takes a sip of water.
“They said I could be a danger to myself and other people at the hostel.”
Badimo’s medical aid paid for the standard 21 days, as prescribed by law, of his admission to a psychiatric facility. But his psychiatrist wasn’t comfortable discharging him at the end of this period.
“She said ‘there’s been progress but I don’t think you’re at a point where you should be out and going back to studying because it will be very easy for you to relapse’.
“I also knew that I wasn’t ready. So we made an agreement that I’ll see her once a week as an outpatient to try and deal with that.”
But his medical scheme funds to see a psychiatrist had depleted in the three weeks Badimo was in hospital.
This meant he and his mother had to pay cash for the psychiatry visits.
“She charged me R1200 for an hour-long session,” Badimo says. “I only went to three sessions. My mother and I just couldn’t afford it.”
Badimo was back in the psychiatric facility a year later and was, once again, discharged during his treatment and had to see a psychologist as an outpatient. He could only afford four sessions.
Last year he was admitted to hospital for the third time.
Discharging psychiatry patients too early from hospital and placing them in society results in unmanageable stress, says Eugene Allers, a psychiatrist and former president of the South African Society of Psychiatrists.
“They can either take longer to recover or not recover at all.”
He explains: “That’s why we hospitalise patients. It is not just to stabilise them on medicine; it also takes Mia Malan miam@mg.co.za or @miamalan Laura López González laural@mg.co.za or @llopezgonzalez Adri Kotze adrik@mg.co.za or @adrikotze Ina Skosana inas@mg.co.za or @inaskosana them out of a stressful environment.”
Allers says “the primary purpose of a hospital is nursing and care”. “Patients with psychiatric illnesses have the same needs when they go to hospital: they need to be looked after and cared for. If they are discharged too soon, who will look after them when they get home?”
He considers medical aids’ 21 day limit on psychiatric hospital admission as problematic. Although the average duration of patients’ stays in hospital is 11 days, “some patients with bipolar or schizophrenia do need to stay a little longer”.
Badimo was diagnosed with bipolar mood disorder. Formerly known as manic-depressive illness, United States-based medical website WebMD describes it as “a mental illness that brings severe high and low moods and changes in sleep, energy, thinking and behaviour ... People who have bipolar disorder can have periods in which they feel overly happy and energised and other periods of feeling very sad, hopeless and sluggish.
“In between those periods, they usually feel normal. You can think of the highs and the lows as two ‘poles’ of mood, which is why it’s called ‘bipolar’ disorder.”
The benefits available for mental health are simply not enough, says Rajesh Patel from the Board of Healthcare Funders, an industry body for medical schemes.
“Mental health benefits are not comprehensive, but there is no consensus of what a comprehensive benefit [for mental health] should look like,” he says. “In fact, the majority of medical schemes’ mental health benefits are just what is in the prescribed minimum benefits.”
The list of prescribed minimum benefits (PMBs) contains 270 medical conditions and 26 chronic diseases that medical aids are obliged to pay for, says Elsabe Conradie from the Council for Medical Schemes, a regulatory body for medical aids.
According to the Medical Schemes Act, medical aids must cover the entire cost of the diagnosis, treatment and care of PMBs, without charging the member a copayment or using funds from their medical savings account, regardless of the medical plan or option they are on.
PMBs include psychiatric illnesses such as depression, anxiety and bipolar disorders. People with such conditions qualify for 21 days annually in hospital or outpatient psychotherapy of up to 15 sessions a year with a psychologist.
“Normally schemes do comply, but there are several cases where prescribed minimum benefits are short paid or not paid for at all,” says Conradie.
According to the latest Council report, in 2015 there were just over 1 000 complaints about medical aids not paying the entire amount for a PMB.
Allers says: “Every time we try to speak to them [medical aids] about mental health cover they revert back to the law and stick to the prescribed minimum benefits. They escape through the law. When it comes to mental health, the minimum benefits become the maximum benefit. From the lowest to the most expensive plan, the prescribed minimum benefits are the benchmark they use.”
Noluthando Nematswerani, the head of the clinical policy unit at Discovery Health Medical Scheme, the country’s largest medical scheme, confirms that the PMBs are indeed what Discovery uses as its guideline: “The legislated maximum requirement for most mental health conditions is 21 days, and the benefits of Discovery Health Medical Scheme are consistent with this,” she says.
Nematswerani says the cover includes the cost of the doctor, medication and allied healthcare costs such as psychotherapy during the hospital stay.
But Khensani Mthombeni , also from Discovery Health Medical Scheme, points out that the scheme only covers the full cost of 21 days in a psychiatric facility if the hospital is part of Discovery Health’s approved network of hospitals.
“If you go elsewhere, we will pay up to 80% of the costs,” Mthombeni says.
Roseanne Murphy da Silva, president of the Actuarial Society of South Africa, says the challenge for medical aids is the fact that they are “mutual funds”. The monthly contribution by members is the only income they get so “they have finite resources from which to pay claims”.
“The board of trustees has to ration [the funds] because they can’t meet all of these demands, so they have to come up with a way of prioritising how medical aid contributions are allocated between paying healthcare benefits to members and the costs of running the scheme,” she says.
According to Murphy da Silva, actuaries advise medical schemes on the benefits and the costs of medical aid plans or options to ensure the pricing of contributions is based on statistical analysis.
The Government Employee Medical Scheme (Gems), one of the biggest medical schemes, also offers limited mental health benefits.
“Gems has a mental health benefit that covers accommodation in hospital, medicines, theatre and professional fees while the member is admitted,” says Gems executive Vuyo Gqola. “The limit for this benefit varies from option to option as set out in the Gems scheme rules. The prescribed minimum benefit entitlement for mental health illness is 21 days admission.”
According to Allers, mental health patients have few options once this benefit is depleted. The first is for the patient to pay cash, but a stay at such facilities can cost as much as R15 000 a day. The second option is for the patient and their doctor to write a letter to the medical aid applying for “ex gratia” cover, asking the scheme to pay more than what the benefit option allows.
On a hot afternoon, a row of cars line up to get into the parking lot of Milpark Hospital in Parktown, Johannesburg. Drivers peer impatiently out of their windows. Visiting hours have begun.
Inside the hospital, the foyer