Issued by: Cape Medical Plan


Charlene Schoeman, the only woman head of a South African medical aid, Cape Medical Plan, believes that the information is lacking and the lack affects the decision-makers - women. She says: “Typically married women both choose the medical aid and conduct routine and emergency relations with it and medical suppliers - doctors and pharmacists.

“Today the world of health care has become commercialised. Sources of trustworthy independent information are few and hard to find in South Africa. Traditional sources alone - like doctors and friends - are inadequate. ”

As medical treatment here and elsewhere in the world becomes more expensive and profit driven, some public interest organisations are questioning the quality of information on which people base important health care decisions. And they recognise that this affects the female decision makers most. Schoeman observes: “Gender-skewed decision making is a feature of roles that are fast breaking down. Men still need to be more involved in health care decisions affecting themselves and women need to let go.”

Concern about the amount and quality of information to support decision-making has also been expressed by health care bodies. A year ago, the American Blue Cross medical insurance of Massachusetts found that seven out of 10 women surveyed (younger than 50) made choices on behalf of others - partners, children or parents.

The study - and significantly there is no equivalent here - discovered that “consumers often choose doctors and nurses rapidly and with little information”. It noted a difference between the ways consumers secured information to back up medical decisions and how they went about making other, major choices, like buying a car or house. They tended to research decisions about house-buying or car-buying for example, and to seek out independent sources of information. Their decisions involved scrutinising a range of information from a range of sources. And these sources included information from disinterested bodies - those that did not stand to gain financially from a consumer choice.

Decisions about medical care, by contrast, tended to be impressionistic. There were fewer sources of information of the kind consumers wanted and fewer disinterested sources.

Blue Cross discovered that consumers had difficulty finding the information they said they wanted - not the information that providers chose to give them. For example, they wanted to know, but found it hard to find, information about infection rates of different hospitals, doctors' experience and nurse to patient ratios in clinics and hospitals.

The study's findings apply here. The range of information to inform medical choices is narrow; the information provided by producers, like hospitals and medical aids, tends to reflect what they believe consumers need to know or what will benefit the producers. At worst, it involves telling, rather than responding.

Then traditional trusted sources of information, like doctors, have new and different relationships with the medical care industry. Often these are quasi-commercial, are seldom declared to the provider and are therefore skewed. Traditional patterns of deference to authority figures inhibit consumers from questioning them. Much media information is geared to producers, rather than users of medical services. And in some cases, especially internet sites offering advice about choosing a medical aid, the range of choice is determined by the (undisclosed) ad-spend of the medical aid. Increasingly brokers are a source of information about health care. But the information they supply is about the medical aids that agree to pay them commissions. Those medical aids that prefer to spend members' money on medical care and not advertising or brokers' commissions are off the media and broker map. The state is a major supplier of health care industry information because they are regulators. But this is naturally not geared to users of health care services. It, like many of the health care communications, is a top-down approach: telling people what organisations believe they should know. No wonder consumers tend to rely on what Blue Cross calls “next-best” sources: the anecdotal experience of friends and associates.

Today's consumers are better educated than their parents and have more access to more and different information than they did. But increased volumes make the business of evaluating their reliability more difficult.

All this might suggest that the power of female decision-makers to secure reliable information is limited. Schoeman disagrees. She says: “The tale of the child who asked why the emperor had no clothes indicates the power and influence of the simple, direct question. And asking questions comes more easily to individuals than organisations - from those who need the information, the users, the women.”

Key questions to ask in choosing a medical aid

Generally people choose a medical aid because they are in some kind of transition. They are divorcing or marrying, starting a new occupation; they may be dissatisfied or angry at their present medical aid; or entering employment. Transition times have their own stresses: this means the more information you have and the more systematic you are in deciding the better the decision will be.

First:

• Know your health, your family's and your family's history. Some health conditions recur down the generations.
  
• The older you get, the more you will probably have to spend on health care
  
• Accept that without health cover, the cost of possible ill-health would be calamitous.
  
• Accept that you won't always be happy with any medical aid all the time. Any relationship has ups and downs. You're better off working out hassles than acting on anger or disappointment.
  
• Medical aid is also a financial decision. Know what you can afford - and what you can't.

Second

• Medical aids have different plans for different people.
  
• Shop around on the internet.
  
• Ask friends and people you trust what they recommend and why.
  
• Select three plans that seem to cover you best where you need it most and at a cost reasonable for you.
  
• Phone or mail the medical aids that run them and ask questions. The experience of contact will give you a feel for them

Third: Questions

1. How many members do you have?

The more members, the more service is likely to be mechanised to reduce costs to members. This may make routine interactions smoother but may also make it more difficult to have informed human contact with the medical aid, especially in emergencies.

2. What is the age profile of the scheme?

All medical aids work on an ethical and financial basis of shared cost. This means in practice that the healthy subsidise the ill or the younger the older. Since ill-health and age are human conditions, this is fair. The degree of subsidisation varies according to the membership profile of the scheme. Comparing this profile may be an element in your decision-making.

3. What is the scheme's solvency ratio?

By law, medical aids have to have a safety net of 25 percent of members' funds available for emergencies. If the scheme has less, it breaches the law and if mass claiming takes place, in an epidemic, for example, your medical cover might be at risk.

4. Does an administration company run the scheme?

Some schemes hire professional administrators. The purposes are to achieve efficiencies that lower members' costs and provide higher standards of routine service. Yet professionals represent a cost to members that is often higher than that of self-administered schemes.

5. Who decides what doctors, specialists or hospitals to use?

Some medical schemes have “preferred suppliers”. In exchange for guaranteeing them business, they discount costs. This is a standard business practice; it also tends to be standard business practice to keep them secret. Since the deals affect you, you have a right to ask what they are and to be told. Health consultation involves delicate issues of privacy: you may be more comfortable with someone you know, rather than someone the medical aid has chosen, though many medical aids let you use your own doctor but may pay less towards the costs.

6. Check out their language.

If they use jargon you don't understand, they may be more concerned with their needs than yours. That's the equivalent of being with someone who calls you a friend but begins every sentence with ‘I'.

7. Ask where your money goes.

At Cape Medical Plan we work on the basis that no more than R194-45 (figure as at 30/6/08) of your monthly premium should be going into administration. More should set off alarm bells. And you have a right to expect your medical aid to tell you.

Finally, any arrangement involves trust that both parties are clear about what they have to do and what the other will do. You have the right to expect clear, sensitive treatment. Medical aids have the right to expect honest disclosure from members and prospective ones.

Visit our PRESS OFFICE: Established in 1961, Cape Medical Plan combines 40 years of time-proven experience with 21st century technology. Cape Medical Plan has designed its new generation Medical Scheme for South Africans who want to play an active role in managing their family's health and wellness.- more....

[22 Jul 2008 15:57]

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