Discovery’s new ruling ‘puts lives at risk’
Doctors balk at medical aid's new rule that certain surgeries must be performed at day hospitals
Doctors have expressed concern at a new rule introduced by Discovery medical aid in 2019 that some of their members have to use day clinics for certain procedures.
Members of the Discovery saver, smart, keycare, core and priority plans have to use day hospitals – where patients cannot stay overnight – or pay hefty co-payments to go to an ordinary hospital.
Discovery chief executive Jonathan Broomberg said in an e-mail to Times Select: “In the US, for example, up to 90% of all surgical procedures are performed on a same-day basis, whereas the equivalent figure in South Africa is below 15%.
“South African private healthcare is lagging well behind global trends in moving surgery to more cost-effective settings.”
But local doctors say the healthcare system here cannot be compared to the US. The main concerns about day hospitals are that patients cannot be monitored overnight after procedures, the day hospitals do not have intensive care units, and many are not equipped to do blood transfusions.
Doctors say they were not consulted before the decision was made, while many of the day hospitals are not up to the appropriate standard to ensure operations take place safely, or even have the equipment needed.
Wits University professor and ear, nose and throat (ENT) specialist Chris Joseph said: “Patients should feel abused and exposed to possible risk.”
He said Discovery did not assess whether the day hospitals had the correct equipment or staff for a procedure.
“ENT theatre requires very expensive instruments and trained staff.”
Joseph explained that doctors must observe patients who have had surgery on their airways to ensure they don’t have complications that compromise breathing. This means the operations at a day hospital must be done in the morning so they can be watched closely in the afternoon.
“Many ENT day cases must be done in mornings for patient safety. Discovery did not check whether the day clinics have morning lists (availability).”
A Facebook post by paediatric pulmonologist Fiona Kritizinger, which has been widely circulated among doctors on WhatsApp, drives the point home. “We do airway endoscopies in babies and children because their airway is at risk or because they have significant lung disease,” she wrote. “Performing such high-risk procedures in babies and children in a facility with no aftercare and no ICU back-up will never be safe no matter how Discovery spins this story regarding what happens in other countries.”
She said there was not a single day hospital in the Western Cape with equipment to perform the surgeries Discovery wanted to be done in day hospitals. In response, Discovery’s Broomberg said doctors could ask for exceptions to be made in these cases.
Specialist physician Adri Kok said there was a real risk that complications from surgery could not be dealt with by a day hospital.
“We are very worried about what is happening. This is about a risk to patient care, not about [unhappy] doctors.
“What if a child has a tonsillectomy and bleeds to death? This happened last year in a day hospital. We hear anecdotes [about incidents at day hospitals] all the time.”
A day hospital does not always the have skilled resuscitation staff or an ICU and may even not have blood for transfusions, she added.
Surgeon Stefaan Bouwer said equipment for ear, nose and throat surgery cost up to R3m and some day hospitals couldn’t afford it.
However, Discovery said this was not true. “We do not expect doctors to examine hospitals in this way at all. Day clinics are accredited in South Africa, and the procedures on the Day Surgery Network list are aligned with those of the Day Hospital Association of South Africa.”
Broomberg said: “Day surgery centres have been shown to be safer and more cost-effective when operated efficiently.
“The list of procedures that are performed in the Discovery Health medical scheme day surgery network ... has been approved by the Council for Medical Schemes before implementation.”
Joseph said: “Ear, nose and throat societies are not opposed to day clinics. We use many currently. [But] we need to ensure that the day clinic can deliver on quality care.
“The Discovery modus operandi is to expose patients to risk and or poorer quality and rely on specialists to correct this by checking the day clinics’ services and facilities.”
Joseph said ENT doctors were now checking every day clinic that has to be used to ensure the clinic meets safety standards. Broomberg said it was adjusting its approved hospital list in consultation with doctors. “Discovery Health has consulted and continues to consult the relevant specialist bodies, and we will continue to make adjustments to the procedure list based on these interactions and the advice of these bodies.”
Kok said SA could not be compared to the US where most operations took place in day hospitals. She said the US had better medical support at day hospitals and more doctors to travel between day and acute hospitals.
“The Cleveland hospital group has 3,000 specialists. We don’t have that many in the whole of South Africa.”
Kok said she was a medico legal witness in 2018, in a case of a patient who had a hysterectomy at a day clinic. The patient began to bleed internally and the gynaecologist didn’t pick up the internal bleeding in time. By the time the doctor realised it, the day clinic did not have blood for a transfusion.
Kok said the patient almost died.
She said she believed doctors should have the authority to decide which patients should be operated on at a day hospital.
Broomberg said doctors could apply for exemptions if they needed to perform surgery on a patient in an acute hospital owing to the risks.
“The entire process has been designed to ensure that any doctor who believes that their patient is not suitable for a day-surgery setting can easily request an exception. This process is operating smoothly and exceptions are being granted where appropriate.”