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Mediclinic News : DISCOVERY LOSES APPEAL ON BASIC CARE BENEFITS

Title

DISCOVERY LOSES APPEAL ON BASIC CARE BENEFITS

Date

2020-02-18

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News Description

BUSINESS DAY - PAGE 3 In a scathing and precedent - setting ruling against Discovery Health Medical Scheme, the industry regulator has opened the door for consumers to force the industry to pay for treatment not available in state hospitals. The Council for Medical Schemes’s (CMS’s) ruling follows a case by a glaucoma patient, who took the scheme on after it refused to pay for an implant of a medicated device called a Xen stent to lower eye pressure as recommended by a specialist. The scheme, which would have paid for a treatment more than two times what the device would have cost, argued that clinical evidence on the effectiveness of the stent was weak, and that it was legally entitled to refuse payment for it as it was not offered in state hospitals. Judge Bernard Ngoepe, head of the CMS final appeals board, said in a ruling that it was mind-boggling that Discovery would be willing to fund the inappropriate treatment for R20 000 and refuse to fund an effective, affordable and cost-effective treatment for R9 000. He said this kind of decision-making is viewed as irrational. The ruling opens the door for patients to force the industry to fund any drug or medical care deemed necessary by their doctors to treat any disease that falls under the prescribed minimum benefits. It could lead to an increase in patients demanding access to expensive drugs, such as lung cancer prescription medication called Yervoy, which can cost up to R1- million a year and is usually not provided in state hospitals and refused by many medical schemes. Ngoepe said that the state did not solely rely on affordability and effectiveness when deciding whether to introduce a new treatment. He said state hospitals can be affected by budgetary constraints, delayed bureaucratic tendering and procurement processes, skills shortages, training priorities, administrative challenges. The medical aid industry relies on a regulation that it only has to fund procedures available in state hospitals. Health economist Alex van den Heever said no reasonable person could accept the prevailing care offered in the state sector as a benchmark. However, Discovery Health also contended that there was limited evidence about the efficacy of the stent, with its CEO Ryan Noach saying the type of approval from the US regulators was for products that “have not undergone a rigorous clinical assessment”. He added that it is not unusual in this type of approval for retractions to follow after evidence matures. In 2018, Swiss-based pharmaceutical company Novartis withdrew its surgical stent for glaucoma patients after clinical data showed it might damage the eye. The drug was approved by the US Food and Drug Administration (FDA) in 2016. Xen stent was given FDA clearance in 2016. It is manufactured by Irish-based Allergan, which declined to comment. The CMS’s ruling also puts the spotlight on the interpretation of regulations under prescribed minimum benefits, which requires medical aids to pay in full the treatment of a long list of diseases but has not been updated in 20 years. The list, which includes pregnancy, 270 diseases and 26 chronic conditions, was supposed to be evaluated by the regulator every two years from 2000, taking into account new treatments and costs, but the regulator is undertaking its first review of the list. It has been a source of disputes as there is no limit on how much medical aids must spend.
Created at 2020/02/24 09:05 AM by Mediclinic
Last modified at 2020/02/24 09:05 AM by Mediclinic