Medical scheme hits back

The Medical scheme that was severely criticised for refusing a member surgery, classifying it as "too risky", was proven right when the patient died after undergoing the surgery anyway. TeleMed medical scheme came under fire from the member's family and some medical practitioners for refusing to pay for a complex back operation for a 79 year old man, until his health improved enough to be considered fit for surgery.

Accused of refusing care by using managed care protocols adopted from the United States, in which risk is reduced to the medical schemes by providing clinically approved guidelines for treatment processes for diseases, including cancer and HIV/AIDS, TeleMed is hitting back by publicising the procedures leading to the decision:

"The patient was at very high risk for anesthesia and surgery due to his cardiac conditions being poorly controlled. It also transpired that the patient had cancer which he was unaware of. A second opinion was requested to determine whether the patient was fit for surgery in his condition delaying the operation for a few days before performing it. The second opinion also indicated  that TeleMed should not fund the required procedure as the patient was not fit for surgery. The patient was discharged; readmitted and passed away within 2 weeks of the procedure after his family decided to fund the procedure themselves," says Carel Stadler, TeleMed CEO

"At TeleMed we believe that we have a responsibility to alert members to the fact that their health should be in the most favourable condition and that they have to be declared fit for surgery before undergoing scheduled elective surgery", continues Stadler.

"Anaesthesia poses a high risk in patients whose cardiac and respiratory fitness is not optimal.  Therefore, in these instances, pre-determining fitness for surgery is key to a safe and successful operation and ensuring the best clinical outcome of your planned procedure." explains Patrick Lubbe a Director at MSO, who is contracted to do hospital utilisation management for TeleMed.

He adds that: "Medical Service Organisations follow specifically designed protocols and guidelines to apportion the appropriate level of hospital resources in relation to the clinical needs of the person and monitor the quality and cost of care for all patients. In complicated cases such as spinal surgery and joint replacements for example, we often require a second opinion as well as a fit-for-surgery report which can take more than a few days to complete.  We do this to ensure that surgery is the most favourable option for the patient."

Medical schemes and companies have been strongly criticised by the Managed Care Coalition, which represents about 3500 doctors nationally, of putting their profits before the health care of their patients by practicing "managed care".

Prof Morgan Chetty, National Chairperson of the Managed Care Coalition, said this had resulted in the transfer of risk management from schemes on to the shoulder of the general practitioner, who was placed in an ethical dilemma by schemes' refusal to pay for certain treatments.

He said a single national list of treatment and drug protocols needed to be established.