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Cancer treatment is a PMB, but…

21 November 2022 Myra Knoesen

Prescribed Minimum Benefits (PMBs) form part of the Medical Schemes Act, which states that medical schemes are legally obligated to provide full cover for costs related to the diagnosis, treatment and care of emergency medical conditions, a limited set of approximately 271 acute medical conditions and 27 chronic conditions.

Access is not as simple as it seems

Cancer, according to a report by the Cancer Alliance, ‘Analysis of Oncology Benefits Offered By 10 Medical Schemes in South Africa’, is regarded as a speciality disease and most medical schemes have a specific oncology benefit program from which cancer treatments will be paid in accordance with the rules of the scheme. 

In the private sector, the report states that patients are more fortunate than those in the public sector in that they are able to access diagnostic and treatment services much more easily. Access, however, is not as simple as it seems. With highly priced monthly contributions that increase yearly, coupled with stagnant and inadequate oncology benefits, those that are covered by medical schemes also face serious access issues, ranging from having to consult with an oncologist within a network determined by their scheme and benefit option, to limited or no cover for specialised life-saving medicines and the heavy financial burden that comes with a cancer diagnosis. 

Many patients, according to the report, are subjected to out-of-pocket spending, as a result of their particular scheme’s benefit rules. The implications for members in relation to the cover and, consequently, access to either full or partial treatment of their PMB and non-PMB cancer cases was covered in the report. 

If a patient is diagnosed with leukaemia, for example, which is often a PMB cancer, they are entitled to receive full cover for the diagnosis, treatment and care of their condition. Full cover, however, is often not clearly described and is, in general, seen as the consultations, diagnostic tests and care a patient would be able to access in the state sector. 

The patient whose treatment is approved within the oncology benefits and without any co-payments is the exception, states the report. The reality is that there are many patients whose treatment has been rejected and who then need to navigate themselves through a maze. Many times, the patient’s oncologist may have prescribed a specific treatment without them actually understanding their patient’s specific oncology benefit. 

The maze that a patient has to navigate

If a claim is rejected, then a motivation has to be submitted. Some of these motivations, according to the report, are not even evaluated by specialists in oncology at the medical schemes. The people who deal with claims are not health care professionals. So, in essence, what you have is that the person has approval power with a tick list and does not necessarily understand the disease complexities, the report states. 

A recent case of prescribing trastuzumab for an early breast cancer patient serves as an example, in the report. When the medical scheme turned the application down, the Cancer Alliance became involved in the merits of the rejection. Upon further investigation it transpired that the clinician did not fully understand the exclusionary criteria of treatment with trastuzumab. The rejection by the medical scheme was, therefore, within the PMB framework. The Managed Care Organisation (MCO) should have alerted the oncologist that the patient fell outside of the treatment guideline. 

Whether it’s a PMB case or not

There is significant pressure on medical schemes, according to the report, to provide adequate cover and value for oncology members in a private healthcare environment, where oncology medicines are highly costly and most patients, even with medical cover, may not have the financial means to acquire expensive benefit plans. Access to medical schemes and comprehensive cover for oncology are thus influenced by affordability, amongst other things. The affordability of cover is, in turn, influenced predominately by the contributions a member can make relative to their income, states the report. 

Although the general assumption is that those who have private healthcare cover in South Africa have equitable access to affordable medicines, the report states this is not always the case. According to the report, there is inequity within schemes, between schemes and also between the MCOs. In such situations, where there is a difference in clinical guidelines between managed care organisations and medical schemes, problems could be avoided if the medical scheme oncology benefits were equitable. This, the report states, would require standardised treatment guidelines and protocols. It would reduce the stress of patients who have to navigate themselves through a myriad of layers of people to fight for their own lives. 

FAnews spoke to Damian McHugh, Executive at Momentum Health Solutions about oncology benefits and cancer treatment as a PMB. 

The complexities around PMBs

“There are numerous complexities around PMBs, not the least being regulations that require schemes to fund claims at the full rate charged by the provider without limitation. The greatest complexity arises when members select an option based on the most affordable contribution, and then later, develop a chronic illness or are diagnosed with a significant disease at which time, they realise the cover they purchased is insufficient for their specific needs. The other complexity that often arises is where treating providers prescribe expensive novel therapies, often unregistered medicines, as the first line of treatment,” said McHugh. 

He added that the lack of enforced global benchmark pricing, as well as the fact that pharmaceutical and medical device manufacturers are actively searching for new molecules and coming up with novel and innovative therapies launched under patent protection laws, equity is unachievable. “The annual review of PMBs by the Council for Medical Schemes (CMS), and application thereof across medical schemes does, however, provide parity.” 

Educating members on PMB entitlements

The CMS, according to McHugh, does an excellent job in preparing and publishing consumer education material on PMB conditions, including cancers, on their website. 

“Likewise, many brokers take an active role in educating members on PMB entitlements linked to the members selected benefit option. Patient advocacy is a critical element in every medical scheme’s duty of care, particularly where the member option makes use of a designated service provider network. In fact, the role of a ‘Patient Navigator’ is a common care support service across many medical schemes, assisting members in navigating the complexities of the healthcare system, particularly where terminology is complicated and care requirements are intensive. Lastly, although the world of oncology in South Africa is relatively small, there are a number of longstanding oncology management groups that actively work with treating providers on defining and maintaining acceptable, evidence-based treatment guidelines and formularies geared to the appropriate treatment of cancer,” stated McHugh. 

Brokers are key stakeholders

“Within our broker community, our experience is that most brokers or advisers make the effort to understand the products they represent, with many having an in-depth understanding of benefit access procedures and PMB entitlements,” said McHugh. 

Brokers, McHugh concluded, are key stakeholders in the education process and most medical schemes ensure that they have seamless access to product information and conduct regular roadshows and training sessions to keep them informed and updated. 

Every broker and adviser should read this

The article on cancer, as a PMB, is a piece every broker and adviser should read and use in their communication to clients. Read the full article and report in the November edition of the FAnews magazine, because we got a lot of information from it. It’s worth the read.

Writer’s Thoughts
There are numerous complexities around PMBs, which is why clients need brokers’ input. Brokers are the key stakeholders in educating members on PMB entitlements linked to the members selected benefit option. Do you agree? Please comment below, interact with us on Twitter at @fanews_online or email me your thoughts myra@fanews.co.za

Comments

Added by Myra, 21 Nov 2022
Thanks Paul!
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Added by Paul Kruger, 21 Nov 2022
Excellent educational article, Myra. Thanks also for the link to the full article. Recent negative remarks by the FAIS Ombud on the role of advisers are negated by this article.
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