Discovery Health members are up in arms about two issues: the new limits on allied therapeutic services, and a sudden increase in the co-payments of certain chronic medications.
A Facebook group has been created by members wishing to air their grievances on the decision to limit access to allied health services (psychologists, physiotherapists, occupational therapists, and speech and hearing therapists).
On Discovery’s top-end plans members used to have unlimited access to these services, but this has now come to an end with the following limits put into place for a family of four: this year the maximum cover for a member with three dependants on the Executive plan is R21 000; R19 000 for members on the Comprehensive plan; and R13 000 for Priority plan members.
In a statement on Discovery Health’s homepage, Dr Jonathan Broomberg stated that “abuse of medical scheme benefits resulted in the majority of members paying inappropriately for a small minority. This challenge forms part of the broader ‘abuse factor’ which medical schemes need to address”.
Chronic medication shock
But many more members will be affected by changes to their co-payments for chronic medication.
“An elderly client at Synergy Pharmacy was most surprised that his asthma medication, Symbicort, which used to be paid for by Discovery in full, suddenly now attracted a co-payment of R144,” according to Helen Emery, pharmacist at Synergy Pharmacy in Claremont.
According to a letter sent to pharmacies by Discovery Health, it has reviewed its medicine list (formulary) in order to “reflect price changes accurately, and the availability of medicines in this dynamic market”.
It goes on to say that “the Discovery Health chronic formulary contains a maximum rand amount per month, per medicine category used to treat listed chronic conditions”.
“But what has come as a surprise to both members and pharmacists is that this price no longer is determined by the cheapest generic available on the market. It is now determined by the closest ‘therapeutic equivalent’,” says Emery.
A therapeutic equivalent does not necessarily include the same active ingredient as the prescribed medicine does. According to medical-dictionary.thefreedictionary.com, a therapeutic equivalent is a “drug that has essentially the same effect in the treatment of a disease or condition as one or more other drugs. A drug that is a therapeutic equivalent may or may not be chemically equivalent, bioequivalent, or generically equivalent”.
What this means in practical terms is that large co-payments may now have to be made by members for certain chronic medicines.
Here is the Discovery list of chronic medications for 2012 that the scheme will pay for, and the rand amount by which treatment for each condition is capped.
Direct commentary from Discovery Health will be added as soon as it becomes available.