Negligent and ********* behaviour

I have never written a review on behalf of a patient, but I feel that, this is something that needs to be addressed. I am a provider of service, located in a rural area of the Northern Cape Province. I had a patient (On momentum health custom plan) that presented to me with signs and symptoms of an acute stroke. I admitted the patient to the local state hospital for stabilisation. This was around 08:30 in the morning. I stabilized the patient as best I could with the resources available to me. I evaluated that this patient was in urgent need for a transfer to a facility capable of performing the required scans, perform tests and specialist review to treat him optimally. The closest facility capable of offering such a service is about 365km away (CreastCare Malmesbury). I discussed the patient with the receiving facility as well as the doctors there. This was at 09:20. They immediately accepted the patient understanding the logistical situation and the need for urgent tests. Scans etc that is indicated. I logged a transfer request with the closest EMS-Ambulance service to my location (09:39). The EMS then contacted NetCare 911 (which is the company that Momentum uses for arranging their patient transfers) to obtain an authorization for the transfer. I was contacted by NetCare to confirm the transfer request as per protocol. The request was confirmed (10:07). At this point in time NetCare told me that the facility in question (CreastCare Malmesbury ) was not a designated service provider (DSP) for Momentum Health Custom Plan and therefore an automatic 30% co-payment would be levied on the patient. Despite this being logged as an emergency case for transfer to the closest facility. This is the first violation from Momentum. DSP-arrangements are not applicable in a case of an emergency. An emergency is an immediate threat to the patient’s life or where severe complications to the patient’s health can be expected if immediate treatment is not appropriately offered. The patient was not able to cover this 30% co-payment. Therefore, I needed to find a next facility.

Patient’s Location – CrestCare Malmesbury: 356km (Non-DSP) – 1st Choice Patient’s Location – Mediclinic Cape Gate: 404km (DSP) – 2nd choice Patient’s Location – Mediclinic Paarl: 389km (DSP) Patient’s Location – Mediclinic Durbanville: 403km (DSP) Patient’s Location – NetCare Blauuwberg: 409km (Non-DSP) Patient’s Location – Mediclinic Panorama 412km (DSP) Patient’s Location – Mediclinic Stellenbosch: 421km (DSP) The patient has been to Cape Gate Mediclinic before. The patient did not have any problems there in the past. The patient has family nearby. They therefore requested Cape Gate Mediclinic. It was therefore decided to arrange the transfer to Cape Gate Mediclinic. The specialist in Cape Gate also immediately accepted the patient for transfer as soon as possible. I updated the EMS (Ambulance) service with this information. Netcare 911 (Acting on behalf of Momentum Healthcare) submitted the request to Momentum Healthcare. Momentum Healthcare did handle this case urgently nor did they agree with the transfer location. The started by questioning the chosen location. Explaining that it requires to “drive past other hospitals”. I explained to them again, that I wanted this patient to go to the nearest facility, but because of Momentum’s DSP policy – it was not feasibly for the patient. Looking at the distances of the next available facilities – they are all in a radius of 20km from each other. Nothing in comparison to the 400km drive just to get to the area. Momentum and NetCare went back and forth on the authorisation. First requesting more quotes from different EMS service providers. Then they indicated that they (Momentum Health) will waver the 30% co-payment to allow transfer to CrestCare Malmesbury. This was said, but still no authorization was given the ambulance to come and collect the patient for transfer. Throughout the entire afternoon I and the EMS phoned to get the authorization completed. By 18:00 the afternoon – Momentum still did not approve the transfer. NetCare just told us that they cannot authorize without Momentum Health. I requested on several occasions to speak with the clinical manager in charge to find out the problem. NetCare just told me that Momentum Health is on e-mail basis only and that I cannot contact them (Momentum Health Case Manager). Momentum Health’s call center diverts all their transfer calls to NetCare’s call enter. Since nothing was authorized up until 18:00 the family of my patient decided to take the matter in their own hands. They loaded the patient in their own car on the backseat and drove him to Cape Gate Mediclinic themselves. This was not ideal but given the situation and delay from Momentum Healthcare – I understood their decision. The patient did arrive in Cape Gate Hospital at 23:00 and as far as I know is stable.

To me this is utterly and completely NEGLIGENT from Momentum Healthcare as well as NetCare.

Momentum Healthcare: When you have a problem with something. Phone the service provider to get clarity. Get a medically trained person to phone the service provider. I cannot explain to a call centre agent the medical complications of delaying definitive treatment and transfer of a stroke patient. Get a doctor to phone a doctor and explain your problem with the authorizing if you have one. NetCare: As a provider of emergency services. How can you sit by and watch how Momentum delays this transfer? You should know the urgency of situations like this. How can you not have direct contact to get urgent authorizations. You act as a gate keeper. Preventing me from getting in contact with Momentum directly. But you just calmy tell me that your are waiting for authorization from Momentum. For hours… When do act? When do escalate?

Neither NetCare nor Momentum Healthcare personnel where on site with this patient. I am the service provider with a medical degree requesting an urgent transfer. You have NO place to question my clinical judgment. You have NO place to delay transfer in an emergency like this! It is inappropriate and *********. It borders on *****! What does your client pay your for? When your client has an emergency, do you get to delay their treatment of transfer because your first need to investigate and question the cost? If a patient is safer in the hands of their own family for an emergency transfer because the medical aid cannot get things done – then you have a huge problem. Your priorities were very clearly NOT with the well-being of this client/patient. I will never recommend Momentum Healthcare to any patient that ask for my advice if this is the way you treat your clients when they need urgent care. For your review: Member number: *** Case ***

I urge you to contact this family and explain your lack care when they needed you. From my side as a service provider, I challenge your MEDICAL case manager to call me and explain your MEDICAL reasoning behind your decisions in this case.