Medical aid agrees to once-off cancer fighting treatment

04 September 2015 - 16:41 By Katharine Child

Bonitas Medical Scheme has decided to give a 12-month course of Herceptin to cancer patient Veroney Judd-Stevens. This follows a 15-month-long battle between Judd-Stevens and the medical scheme for the drug.The donation is being made on a ex-gratia basis‚ which means it is just for her and does not set a precedent for other patients‚ the medical aid told The Times on Friday.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 R550000‚ and most medical aids will not pay for it in full.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.On Thursday‚ Bonitas 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 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 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.Bonitas did just that‚ saying Herceptin is not on the government’s essential drug list.But Judd-Stevens’ representative‚ Reg Broekman‚ argued that what the government provides is not the standard by which to decide whether a drug should be made available in private practice.“It appears on the World Health Organisation (WHO) recommended essential drug list.“This means the WHO is saying it is a drug governments ought to have.“There is no doubt the world is moving towards utilising this drug‚” he said.Broekmann‚ a doctor‚ also argued consumers are in an unfair position when they take on their medical aids as they can’t afford lawyers‚ which medical schemes could.In addition‚ the appeal process was lengthy‚ he said.“When treating cancers‚ time is of the essence and this appeal process has been going on for over a year and it has not been resolved yet.”He said the delays in the appeal case had caused Judd-Stevens psychological and financial harm...

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