“Individuals accessing mental health and psychiatric services are frequently uninformed, not only about what services are offered, but also about what to expect from mental health and psychiatric professionals,” says Cassey Chambers, SADAG’s Director. Expectations from patients and their loved ones are all too often misrepresented or left unaddressed. “Mental health and psychiatric patients frequently complain that they haven’t been told their diagnosis, what the medication they have been prescribed is for, or what to expect from the medication,” she says. Disturbingly, as recent cases like the Life Esidimeni and Genesis show, psychiatric patients often do not seem to enjoy the same rights that people with more general medical conditions do – from state-funded health systems or from private medical aid schemes.
The South African Depression and Anxiety Group (SADAG) will be using its Facebook Friday online chat on 5 May to highlight issues patients have with their medical aid schemes. Psychologist and Director at the Akeso Clinic, Allan Sweidan, will be hosting the 1pm to 2pm chat; and psychiatrist Dr Mike West will be chairing the online chat from 7pm to 8pm. Receiving a diagnosis of a mental health condition can be frightening. As with any diagnosis, it comes with questions that need to be answered – questions about medication, alternative treatments, long-term prognosis, as well as what will be paid for by the medical aid. What is often daunting is who to ask for advice – and when. SADAG’s Facebook Friday sessions address this need. With millions of South Africans on Facebook, it is the perfect medium to impart information. “Facebook is an unthreatening forum for people to share experiences and ask questions from experts that they may not usually have access to,” says Sweidan. Log on via Facebook: TheSouthAfricanDepressionandAnxietyGroup or through www.sadag.org
As the market has become more competitive and the member demographics have changed, medical aid funders have had to tighten their belts. However, not all medical conditions are given equal consideration. Patients with mental illness are often not given parity, with some medical aids only covering 15 outpatient visits per year or 3 weeks of hospitalisation. “Some patients have been penalised for not gaining prior authorization before being hospitalised for a psychotic episode,” explains Chambers. A psychotic episode is like a heart attack – often unpredictable.
While medications for heart disease are considered chronic and covered with less hesitation, psychiatric medications often require time-consuming motivations from psychiatrists. There are an increasing number of cases where patients have finally found the right treatment for their condition, only to discover that they can no longer afford the treatment. Their medical aid has run out and they are now expected to cover the remaining costs themselves, which are most often substantial. Unfortunately, in many cases, the very disorder that is costing them so much, is the reason they don't have the necessary funds available. “Mental illness can severely impact on the financial productivity and social cohesion of direct users and their loved ones,” says Chambers.
“It is crucial for a patient to be familiar with their medical aid scheme’s formulary and protocol,” says Sweidan. The patients’ expectations must be within the realm of what their schemes offer, and their rights are protected as long as they fulfil certain criteria.
Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable. PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of any emergency medical condition; a limited set of 270 medical conditions; and 25 chronic conditions defined in the Chronic Diseases List (CDL). Medical schemes must pay in full, without a co-payment or the use of deductibles, for the diagnosis, treatment and care costs of the PMB conditions. Each option offered by a medical scheme must make provision for the PMBs, including hospital plan options. Medical schemes can make a benefit conditional on a patient obtaining pre-authorisation or joining a benefit management programme.
SADAG invites patients to log on to Facebook on Friday, 5 May at 1pm and 7pm and understand the message that there can be no health without mental health.
For more information, please contact Cassey Chambers on 011 234 4837