PMB for Oncology - 11/6/11

PMB word-play keeps essential treatment from cancer patients

THE prescribed minimum benefits (PMBs) do not give medical scheme members who have cancer the protection they deserve, because they are neither well defined nor is the minimum treatment detailed. Leading oncologists say that the PMBs for cancer do not cover either the treatment of all curable cancers or palliative care for people whose illnesses cannot be cured. Medical schemes are using the vagueness of the PMB regulations to deny benefits - particularly for more expensive treatments - to members, they say. Medical schemes are obliged by law to provide the PMBs, which cover the diagnosis, treatment and care of all medical emergencies, a number of conditions that if left untreated would severely affect the quality of your life and 27 common chronic diseases. The Council tar Medical Schemes and the Department of Health last year completed a review of the PMBs. which are contained in regulations tinder the Medical Schemes Act, but revised regulations have yet to be published. The Council for Medical Schemes is now busy with a project to define the required level of care for cancer PMBs, and oncologists are assisting with this project. Oncologists say they have long alerted the council to the failings of the cancer PMBs. However, the council, in consultation with the medical profession and the medical schemes industry is expected to rework the definitions of only three cancers this year. Professor Paul Ruff, the chairman of South African Society of Medical Oncologists and the head of Oncology at the University of the Witwatersrand's Faculty of Health Sciences and Donald Gordon Medical Centre, is involved in the council's PMB project. He describes the PMBs as a "muddle", and says that defining the cancer PMBs properly and detailing the minimum treatments for them requires a lot of work. Currently schemes are interpreting both the definitions of PMBs and the required treatment as they see fit, because the regulations are so vague, he said. Medical schemes have to provide treatment for PMB conditions at a level that is at least equal to the treatment that you would receive in state healthcare facilities. Ruff says that one of the main problems is that schemes typically consider what treatment is provided by state hospitals excluding the treatment that is a result of international access programmes. This may result in a scheme paying only for an old-fashioned therapy that is no longer appropriate, Ruff said.

Dr Waldemar Szpak, the chairman of the South African Oncology Consortium (SAOC), an organisation to which all accredited local oncologists belong, said in many cases schemes interpret the regulations to exclude their having to pay for expensive treatment. Medical scheme members can be denied essential treatment based "on word-play rather than clinical criteria and clinical indications", Szpak said. The ease with which schemes are excluding newer and essential treatments "is alarming", with biologics a case in point, he said. Szpak said medical schemes still take a short-term view on the cost-benefit ratio for many treatments and often ignore the potential downstream savings of initially more expensive but appropriate treatments and investigations. The PMBs distinguish between "treatable" and "untreatable" cancers, and state that schemes have to cover only "treatable" cancers. Many cancers that can in fact be treated or cured are not, however, covered by the PMBs. Ruff said. The PMBs also distinguish between cancers that affect non-solid organs and systems, and cancers of the solid organs. In terms of the existing regulations, many cancers of the non-solid organs and systems, such as leukemia, lymphomas and multiple myeloma, are PMBs whether or not they are regarded as treatable. A cancer that affects a solid organ is a PMB only if it is "treatable". A cancer is regarded as "treatable" when: it affects only the organ of origin, there is no evidence that it has spread to other organs (metastatic spread); and, it has not caused incurable damage to the organ in which it originated or to any other life-supporting organ. If these three provisions are not met, a cancer is regarded as "treatable" when there is scientific evidence that more than 10 percent of people with a similar cancer survive on treatment for at least five years. Ruff said this provision in the regulations is another big problem with the PMBs. Some schemes are using this provision to deny that certain cancers are PMBs, he said. Szpak said that the distinction between treatable and untreatable cancers is discriminatory, and no other disease or condition is described in the PMBs in a similarly restrictive way. Every patient has a right to have his or her disease or condition treated, without exception, he said. In a document that outlines its view oil the PMBs to the Council for Medical Schemes, the SAOC says that it believes it would be better to distinguish between four stages of cancer: "cancer in curable stage", "cancer in chronic stage", "cancer in palliative stage" and, "oncological emergencies". The SAOC said that all stages of cancer should be treated in terms of evidence-based medicine, taking into account the cost-effectiveness and the affordability of the treatment. The PMBs should provide for cost-effective and evidence-based medical therapy, including chemotherapy or other anti-cancer agents and radiotherapy for cancers in a curable stage, the SAOC said. Cancers that have progressed too far to be cured require palliative care, and in this respect the PMBs have significant shortcomings, Szpak said.

But Dr Boshoff Steenekamp, the head of strategic projects at the Council for Medical Schemes, disagrees. He said that the treatment of people who face imminent death, regardless of the cause, is covered by the PMBs. Treatment includes comfort care, pain relief and hydration, Boshoff said. The SAOC says that the palliation of cancer-related symptoms is an important, effective and cost-effective aspect of cancer therapy. Such therapy may not only improve quality of life but may also prolong productive life, it said. The SAOC said that chemotherapy and/or radiotherapy may provide significant palliation for some cancers, such as oesophageal cancer, which could not be achieved by other means. The SAOC said the PMBs do not deal with haematological cancers, with the exception of lymphoma, and the SAOC takes this to mean that these cancers are treatable. In addition, the SAOC said, cancer and its treatment may lead to a range of potentially life-threatening conditions or oncological emergencies that require urgent action to correct them. The assessment of the acutely ill cancer patient should proceed as it would for any person with an acute illness. Neil Kirby, a director at Werksmans Attorneys who specialises in medical law says that certain medical schemes have in the past paid for the costs of PMBs only up to the rates set in the scheme's rules for a particular option. But the Council for Medical Schemes has taken the view that the PMB regulation that entitles you to payment of a PMB claim in full means payment at the rate charged by the healthcare provider - not at the rate set in the scheme rules. This matter is the subject of a High Court case, but in the meantime the Council for Medical Schemes is insisting that schemes pay PMB claims in full.

Laura du Preez: Personal Finance, 11 June 2011

Your medical scheme's cancer cover may not buy you the treatment you need

ONE in seven men and one in eight women in South Africa will suffer from cancer during their lives, the most recent National Cancer Registry statistics show. With such a high chance that you could contract this dread disease, it makes sense to ensure that you have enough healthcare cover to pay for the rapidly escalating costs of treatment. You, as a medical scheme member, may expect that, because it is a major medical expense, your scheme will cover most of the costs of treating cancer. But in the face of the rising costs to treat cancer and the increasing prevalence of the disease, as well as a host of other cost pressures, schemes have been limiting their oncology benefits in recent years. Many schemes place an annual limit on the amount that you can spend on oncology and/or exclude cover for more expensive treatments. These limits and exclusions do not apply to the cancer diagnoses that fall under the prescribed minimum benefits (PMBs) - the benefits that all medical schemes must by law provide. However, oncologists say that the definitions of cancer in the PMBs and the treatment that must be provided in terms of the PMBs are vague, and they may be used to deny you essential treatment rather than to ensure that you receive it. Most medical scheme members are unaware that schemes typically offer benefits that cover cancer treatments based on one of three tiers developed by the South African Oncology Consortium (SAOC). The SAOC is an organisation to which all accredited South African oncologists belong, and most medical schemes draw on its guidelines and expertise to manage their oncology benefits. Cheaper medical scheme options typically provide the SAOC's first level of cover for oncology. At this level, you can expect cover to be only that provided in terms of the PMBs. Some low-cost scheme options specify that oncology benefits are limited to those provided in the PMBs and that you must be treated in a state healthcare facility. Other cheaper scheme options offer limited annual benefits for oncology, such as R90 000 or even R150 000 per family. At these levels, you will be able to afford only the treatment provided by the PMBs, says Professor Paul Ruff, the chairman of the South African Society of Medical Oncologists, and the head of Oncology at the University of the Witwatersrand’s Faculty of Health Sciences and Donald Gordon Medical Centre. If your scheme provides only PMB cover for cancer, you may be better off using state facilities than trying to stretch your benefits to pay for healthcare in the private sector. Cancer patients who use state healthcare facilities receive a very good level of treatment, although these facilities may not be as comfortable as those in the private sector, Ruff says. Many academic facilities can provide newer cancer treatments through access to programmes provided by large international pharmaceutical companies. In addition, patients in academic hospitals may participate in international clinical trials for newer treatments, Ruff says. Medical scheme options that provide cover at the SAOC's second tier offer reasonably good cover for oncology but exclude some very costly treatments. A number of the newer biologics, with excellent benefits based on clinical research, are included in the second tier of treatment, Ruff says. Dr Waldemar Szpak, the chairman of the SAOC, says that, at the second tier, the treatment may be less toxic than what you would be able to afford on an option that provides tier-one benefits only. A decent oncology benefit would be one with an overall annual limit of about R300 000 to R400 000 per beneficiary, Szpak says. While they are not ideal, oncologists can work more easily with benefits that are structured in a flexible way - such as those provided by Discovery Health Medical Scheme - rather than benefits with a fixed limit, he says. The annual oncology benefit on Discovery Health is unlimited but only the first R400 000 or R200 000 is covered in full, depending on the option. Thereafter benefits are subject to a co-payment of 20 percent by the member. The co-payment is not payable if your cancer diagnosis falls under the PMBs and you use the scheme's designated service provider and follow its protocols. Szpak says a benefit structured in this way enables an oncologist to use more effective but expensive treatments and diagnostic tests to achieve the best results as soon as you are diagnosed with cancer. However, the oncologist must use the benefits judiciously to ensure that your benefit does not run out. The most expensive medical scheme options use the SAOC's third tier of benefits, which will provide you with cover for the latest treatments. Typically, these options have high overall oncology limits and/or additional limits for expensive chemotherapy. Szpak says that some newer treatments may be more radical and offer you the chance of long-term remission and even cure, although Ruff says that the benefits of some newer treatments may be quite marginal, although they could extend your life by a few months.

Laura du Preez: Personal Finance, 11 June 2011

Schemes' exclusions on cutting-edge drugs 'are not in patients' best interests

ONCOLOGY treatment is expensive, and the cost of medication in particular has increased rapidly in recent years, says Professor Paul Ruff, the chairman of the South African Society of Medical Oncologists, and the head of Oncology at the University of the Witwatersrand’s Faculty of Health Sciences and Donald Gordon Medical Centre. A number of new drugs have been developed or are in the process of being developed, and treatments for cancer are expanding at a rapid rate. Cancer is now often treated with monocolonal antibodies and tyrosine kinase inhibitors, Ruff says. Many of these drugs are still on patent in order to recover the costs of research and development, which may be as much as US$1 billion, he says. As a result, the medication is very expensive. Biologics, genetically engineered proteins derived from human genes, are one of the main drivers of the cost of oncology medicines. Biologics cannot be manufactured in laboratories; they have to be "farmed", or grown from living organisms, such as genetically modified yeast cells, says Lauren Pretorius, the head of strategy and operations at Campaigning for Cancer, a non-governmental organisation that helps cancer patients. As a result, many biologics do not have cheaper generics, and can cost anything from R100 000 to R500 000 for a six-month course. Some biologics have been developed for cancers for which doctors could previously do very little - for example, cancer of the kidney - while others are used with existing chemotherapies to improve the treatment regimen.

Dr Waldemar Szpak, the chairman of the South African Oncology Consortium (SAOC), says that biologics may be controversial, because they are newer treatments, most are very expensive and are not always used appropriately. But biologics represent an essential and critical advance in the treatment of cancer - their role in the treatment of cancer is similar to that of antibiotics in treating bacterial infections, Szpak says. When used appropriately, the benefits of using biologics outweigh the additional cost, he says. All accredited South African oncologists must belong to the SAOC, and most medical schemes use the organisation's guidelines and expertise to manage their oncology benefits. Biologics are essential for treating some cancers: renal and liver cancer, and some gastrointestinal tumours or haematological diseases are exclusively treated with biologics, Szpak says.


The SAOC has drawn up guidelines on the treatment of cancer, and it has a review system to help medical schemes to decide when it is appropriate to pay for the use of biologics, he says. Despite this, many schemes have in recent years introduced exclusions for biologics that the SAOC believes are not in the best interest of patients, Szpak says. Some prominent medical schemes state that they exclude cover for all specialised oncology drugs, whereas all cancer medicines are in fact specialised for use in the treatment of the disease, he says. Such exclusions illustrate a lack of understanding of how cancer is treated and are likely to be used to deny cover for more expensive and more effective medications, Szpak says. Ruff says another problem is that at times your oncologist may recommend a treatment that involves a drug that is not yet registered in South Africa. Medical schemes often refuse to pay for these medicines, arguing that they are experimental. In fact, they have been used internationally for some time, but it takes a long time for them to be approved for use in this country. Some medical schemes will pay only after the oncologist negotiates with the scheme, he says.

Hospital costs are an issue for about five to 10 percent of all cancer patients. Most cancer patients are treated on an outpatient basis, and you are usually hospitalised only if your treatment is very intense or you develop complications. Radiation is used to treat some cancers. Szpak says problems that arise with medical schemes' funding of radiation is that newer techniques have been developed that minimise damage to your body's normal tissues, which do not have to be irradiated. Some schemes view these techniques as a luxury, whereas they should be a necessity, Szpak says.


Illustrating the high cost of cancer treatment, Dr Brian Ruff, Discovery Health's head of risk intelligence, told a Campaigning for Cancer conference recently that less than one percent of Discovery Health Medical Scheme members had cancer in 2010, but the scheme spent seven percent of its total healthcare spend on cancer in that year. Discovery's seven percent of total healthcare spend compares well with the annual healthcare spend (private and public) on cancer in developed countries, which ranges from four to seven percent, Brian Ruff says. Medical schemes do not have a choice but to manage the costs of treating cancer, he says. If contributions were increased constantly to keep pace with the rising cost of treating cancer, young and healthy members would leave schemes and the cost of contributions would rise for the older and sicker people who remained on the schemes, Brian Ruff says. Medical schemes do not control costs only by limiting your benefits, he says. They also have a responsibility to get pharmaceutical companies to bring new medicines to the market at prices that make sense. For example, it makes sense to pay for a new medicine that improves treatment, but if the improvement is marginal, it is not worth paying twice as much for the medicine, Brian Ruff says.

Laura du Preez: Personal Finance, 11 June 2011

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