Request for Medical Advisory Board Rationale – Endoscopic vs Open Spinal Surgery

I will post the email i sent more than 3 weeks ago which they have not had the decency to respond to....

Good afternoon

This is email is with regards to the pre-authorisation obtained for patient Mishke Buchanan (auth number:006853106) The initial authorisation for Unilateral biportal endoscopic (UBE) surgery at Mercantile Hospital was declined. I would like to know the exact reason why the medical advisory board declined authorisation for endoscopic approach but authorised an open procedure. Research clearly shows that performing an endoscopic approach for spinal decompression has less risk of infection, reduced bleeding rates and quicker recovery. By forcing the patient to undergo open surgery she is now having to endure severe pain, extended sick leave and a far longer road to recovery.

I have been a member of Profmed for 10years and have generally been happy with the service received but I am struggling to understand the reason behind this decision. As the surgery was of an urgent nature and we did not want to prolong it any longer due to the severe pain my wife was in, we ended up accepting the decision and she underwent open spinal decompression yesterday.

I have not managed to find any specific exclusion criteria on your website with regards to endoscopic spinal surgery. I do not believe it was declined based on the plan that I was on as the feedback from pre-auth was that “Profmed does not cover endoscopic spinal surgery”. Your website states verbatim "Profmed’s vision is to address the healthcare needs of South Africa’s professionals. This is achieved through the tailored and comprehensive design of benefits that suit the specific requirements of professionals”but your decision has now resulted in a professional attorney being unable to work for at least the next month most likely 6 weeks and increased her post op complications significantly.

If the endoscopic procedure was declined purely based on operating costs involved, I would expect a tailored medical aid such as Profmed to look at the bigger picture in terms of : extended time in hospital, increased risk of complications, extended rehabilitation and prolonged time to return to work. These decisions should be based on evidence based medicine and what is best for the patient in terms of long term outcome. Should you continue with declining minimally invasive procedures, which is the direction that surgery is moving, you will find that you will end up having to cover far more medical costs in the long run with added complications and rehabilitation costs.

I urgently await response from the medical advisory team as I would like to advocate for better decision-making with regards to minimally invasive procedures in the future. This has not only impacted my direct family but will impact the patients that myself and other doctors care for.

Regards Dr Beth Buchanan (10118909)