The Council for Medical Schemes is “failing South African patients” and needs to clarify the extent to which schemes are obliged to cover costly specialised treatments not routinely used in the public sector, a local advocacy group has said.
The Autoimmune Association of SA (AASA) says dozens of patients with conditions like Crohn’s disease and rheumatoid arthritis are contesting virtually identical issues with different medical schemes, reports Business Day.
The CMS must issue guidance so patients can benefit from the experience of those who went before them, it has urged.
“Schemes are not shifting despite repeated CMS rulings,” said AASA executive director Catherine McCormack.
Since 2021, the AASA has since 2021 helped more than 70 patients lodge complaints with the CMS over medical schemes’ refusal to fund specialised treatment. Complainants included members of Fedhealth, Bonitas, Profmed and Discovery Health, she said.
While the CMS had found in favour of every patient assisted by the AASA, some schemes had appealed and thus suspended rulings in their members’ favour, McCormack said.
The complaints centre on funding for expensive biologicals and biosimilars, like ustekinumab for Crohn’s disease and adalimumab for treating rheumatoid arthritis.
The battle focuses on the application of regulations to the Medical Schemes Act that set out schemes’ obligations to cover treatment for prescribed minimum benefit (PMB) chronic conditions.
Schemes are compelled to provide PMB cover for all beneficiaries, regardless of their benefit option. But this obligation is limited to the level of care provided in the public sector, and schemes may use designated service providers, treatment protocols and formularies to help manage costs.
Regulations 15H (c) and 15I (c) of the Act contain provisions allowing patients to apply for an exception to these rules if they have failed to respond to conventional, PMB-level treatment, but medical schemes regularly reject these – only overturning them after patients complain to the CMS, according to McCormack.
It can be months before complaints are resolved, during which time patients are unable to get funding for the treatments they are needing.
“The CMS is failing patients. It is its job to fight this fight: it is duty bound to protect members’ interests,” she said.
Fedhealth medical scheme principal officer Jeremy Yatt said the needs of individual members had to be balanced against the overall financial stability of scheme. Schemes faced growing demand for new and expensive treatments for various conditions, and could not afford to routinely provide them to all members on all plan types, he said.
“We are being blamed for not funding drugs that could really change the life of a member, but no one is pointing fingers at the pharmaceutical companies,” he said, and applications for exceptional funding were considered on a case-by-case basis, as each one needed careful review.
A review of the PMB benefits and the implementation of a risk-sharing mechanism between schemes had the potential to widen access to expensive treatments, he added.
Discovery Health CEO Ron Whelan expressed doubt at the prospect of the CMS issuing a blanket decision for the industry, saying the treatment of autoimmune conditions was complex and there were numerous clinical and health economic considerations.
“It is not possible to set standardised treatment criteria for these cases, and all cases must be considered on individual merits,” he said.
Since 2021, a total of 45 Discovery Health Medical Scheme members with autoimmune disorders had lodged complaints with the CMS after their applications for specialised treatment had been rejected, Whelan said.
The CMS generally ruled in favour of the member as it relied on regulations 15H (c) and 15I (c). But it failed to acknowledge the aspects of the regulations relating to cost-effectiveness and affordability, he said.
Discovery had not appealed against the majority of the CMS rulings, as most clinicians agreed to use reference-priced alternatives that enabled full funding for the affected members, he added.
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