Bonitas Medical Scheme has decided to give a 12-month course of Herceptin to cancer patient Veroney Judd-Stevens. The Times reports that this follows a 15-month-long battle between Judd-Stevens and the medical scheme for the drug.
The donation is being made on an ex-gratia basis‚ which means it is just for her and does not set a precedent for other patients‚ the medical aid is quoted in the report as saying. It said: “The decision was based on the merits of her case and for that reason it does not create a precedent for past or future claims of this nature which will be also be decided on merit. The decision was also made regardless of the outcome of the appeal.”
Herceptin reduces the risk of an aggressive form of cancer‚ known as HER 2-positive cancer‚ returning‚ but the international standard of care is one year of treatment‚ which costs on average R550,000 – but many medical schemes claim the drug is unaffordable‚ a point that South Africa’s medical aid regulator‚ the Council for Medical Schemes‚ concedes.
Last year‚ Bonitas won round one of the fight at the council when it was told it did not have to provide the drug. However‚ Judd-Stevens won her appeal in March and the scheme was told to make the drug available for 12 months. Bonitas has appealed the ruling. One reason it did so‚ Bonitas lawyer JD Rust said at the hearing‚ is it that it has to be fair. “We have empathy with Judd-Stevens’s position‚ but understand the need to be fair in the bigger picture (to all members)”.
The report says the fight highlights the difficult position medical aids find themselves in: paying for high-cost drugs to save a handful of lives leaves less money for hundreds of thousands of other members.
The 2014 Mediscor report that analysed a million medical aid members‚ from various schemes‚ found that Herceptin was the second-most expensive drug medical aids paid for in 2014 – up from fifth the year before- yet less than one percent of the million members benefitted.
Judd-Stevens’s breast cancer is a prescribed minimum benefit condition‚ which is a disease that by law‚ medical aids have to pay for “in full” – no matter the cost. But, the report says, medical aids can legally limit what drugs they provide‚ using the argument that if the medicine is not in “predominant” use in the state sector‚ they don’t need to provide the drug.
Another, earlier, Timeslive report notes that Discovery Health Medical Scheme is one of the few medical aids that covers Herceptin, a decision made after the scheme faced court action in 2006 brought by women demanding that they be covered for the medicine.
Judd-Stevens is with Bonitas and after upgrading her medical cover in 2014 was put on Herceptin for nine weeks, which the scheme contended was the duration accepted internationally – and nine weeks was better than none.
Inexplicably, the scheme covered her treatment for a further several weeks, leading Judd-Stevens to believe that she was going to be covered for a year, said to be the international norm.
According to the Independent Clinical Oncology Network, which advises local medical aids, 12 months is standard treatment but the biggest problem is the cost of the drug.
But Bonitas stopped paying, forcing Judd-Stevens to approach the Council for Medical Schemes.
She lost her case in August but won at an appeal hearing in March.
Bonitas is now appealing that ruling, but did not inform Judd-Stevens before she started another round of Herceptin treatment.
Bobby Ramasia, Bonitas’s principal officer, said: “We empathise with the member. Bearing in mind that one 12-month course of Herceptin costs R558700, due to the limited financial resources available, medical aids must balance the need of an individual member against those of the total membership .”
The Council for Medical Schemes’ spokesman, Elsabe Conradie, agrees in part, saying costing studies revealed that Herceptin “might not be cost-effective or affordable for a medical scheme to use”.