Laura du Preez: Personal Finance
A CODE of conduct for prescribed minimum benefits (PMBs) is the cause of a least one scheme changing its stance on paying for a costly cancer treatment in full. A pensioner member of Liberty Medical Scheme suffering from chronic myeloid leukaemia was recently shocked to find the scheme had decided to impose a 10-percent co-payment on the Gleevec she is taking for the illness. The member had been taking the medicine for a number of years and had had a ruling from the office of the Registrar of Medical Schemes in 2009, to the effect that her scheme had to pay for the medication in full and could not impose a co-payment. The member complained to the registrar's office again this year. In a letter to the member last month, the office noted that "Gleevec is currently not affordable to the industry and therefore not included in the PMB level of care". However, in 2009 the registrar's office had ordered Liberty Medical Scheme to pay for Gleevec without any co-payment on the basis that Gleevec was available in state hospitals and that, for PMBs, schemes have to provide at least the same treatment as is available in state hospitals. State patients continue to receive Gleevec. Novartis, the pharmaceutical company that developed the drug, provides it at no cost to eligible patients through its Gleevec International Patient Assistance Programme. The drug is provided at eight public-sector hospitals through the Max Foundation, a United States-based non-profit organisation dedicated to improving the lives of people with rare cancers. But, ironically for paying members of schemes that do not pay for Gleevec, the rules of the assistance programme exclude people with health insurance. Dr Monwabisi Gantsho, the Registrar of Medical Schemes, said that in 2009 his office did not have information on the number of people who required biologics. It had therefore based its decision solely on the member's clinical circumstances. However, he said, last year the council analysed the financial impact of biologics on medical schemes. According to Andrew Edwards, the executive principal officer of Liberty Medical Scheme, in July 2010 the Council for Medical Schemes, schemes and industry stakeholders drew up and published a code of conduct for PMB benefits. The code states that when schemes consider the levels of treatment for PMB conditions that are available in state hospitals, the technology, medicine or service must have been purchased through a tender or buy-out process and not be available as a consequence of research, sponsored treatment trials or compassionate programmes. Edwards said that after the code was published, Liberty Medical Scheme decided that paying for Gleevec in full for members with chronic myeloid leukaemia resulted in a disparity in the way in which benefits were distributed among members. It therefore informed the affected patients that it would continue to pay for the medicine in full as a PMB only until the end of last year. Members who want PMB cover now need to use the alternative treatment, while members of the scheme's Platinum options can continue to enjoy 90 percent funding for Gleevec, but must pay the remaining 10 percent. Edwards said Liberty cannot influence the price of Gleevec because the medicine is governed by the single exit price in terms of the medicine pricing regulations. Asked about the cost implications for the scheme of giving members with chronic myeloid leukaemia Gleevec or treating them less effectively and possibly having to pay for a bone marrow transplant, Edwards said it was not possible to compare the cost-effectiveness. He admitted the costs were significant either way, but said the Council for Medical Schemes had acknowledged that Gleevec was unaffordable for schemes.
