Limitation of Choice and potentially Healthcare quality

This post is specifically related to MediHelp’s Prime 1 Network Option, their new GP Network, and what transpires from their own messages when queried in this regard.

They introduced a GP network and a penalty of 35% co-payment for going to a specialist without the referral from a doctor on their GP network.

I enquired about that because I consider it unfair to their members. It limits their choice, or otherwise makes them incur extra expenses, even if they had been referred by an excellent practitioner, if that practitioner is not part of their network. To prevent that, many members would avoid doctors that otherwise they would choose, if those doctors are not part of the MediHelp’s GP network. From the viewpoint of GPs not part of their Network, this is then also an unfair "competitive" practice, as it basically puts them at a disadvantage.

But what is worse is that their response to my enquiry included, among other, statements like this, to refer to the GPs who agree to join their network: “Obviously, the range of service providers willing to participate in the networks (at lower incomes) is quite limited”. This, then, sounds like a decision that potentially compromises the quality of healthcare for the members of this network. Their proposed solution for members to deal with this is essentially: move out of the network option if you don’t like it. This is also part of their reply: “If members of the network options find that their medical aid needs are not catered for sufficiently, they can switch to a non-network option at any time”.

They are unlikely to change their stance on this, but I hope this post is informative for members of the MediHelp’s Prime 1 Network Option.

Just to make sure there is no room for: our reply was taken out of context, below are the actual full sections of the MediHelp response:

“Benefits are therefore limited to services rendered within specific scheme designated service provider networks. The participants in the networks are selected by the scheme on the basis of mainly the cost-effective delivery of services. Obviously, the range of service providers willing to participate in the networks (at lower incomes) is quite limited. In the secondary (medical specialists) and tertiary (hospitals etc.) area there is therefore limited opportunity to achieve sufficient savings with this contracting. Consequently, medicine benefit management is also used to contribute to the savings needed to lower the membership fees of the edo options. The composition of the edo options is therefore quite complex and separate single benefits thereof should not be evaluated in isolation.”

“Due to the strict network applications as well as the strict management of medical expenses, members of the network options may experience that accessibility and choice are limited. If members of the network options find that their medical aid needs are not catered for sufficiently, they can switch to a non-network option at any time.”

Somewhere else, and in additional replies, they mention that members of their GP network are “reimbursed at an enhanced rate”, but then again, this is contradictory with the “at lower incomes” statement above.

While network options with certain limitations are allowed by the Council for Medical Schemes, perhaps because they provide more affordability, MediHelp’s sudden introduction of the GP network on this already established medical aid option, and in the middle of this pandemic, is unlikely to be for the benefit of members, particularly if quality is compromised, unlikely to meet any goal regarding preventative care, and more likely to be an additional monetary and administrative burden.

Transparency then, is another problem. I think they should make sure the limitations of their network option, in every sense, are clearly understood by new and existing members. Some members, might not be aware of those limitations till they become a problem. It should not be a paragraph on their website or a simple comparison of options. It should be highlighted in direct emails to members, as well as in the heading of the specific medical aid option. Particularly for their Hospital Plan, it shouldn’t just highlight it as a good thing, like it does from their current home page (22 Feb 2021): “Choose a hospital plan with a popular 22% discounted network alternative that provides for hospitalisation and other minor expenses.”, which encourage members to join that network option.