Oncology benefits: What to look for

June 12 2011 at 12:15pm
By Laura du Preez

When you consider the cover that your medical scheme provides for cancer, the obvious limits to look at are those for chemotherapy and radiotherapy.

But there are a number of other benefits you will need if you get cancer and you should try to check how your scheme will cover them.

* Diagnostic tests, such as blood tests and scans, including X-ray computed tomography (CT or CAT) scan), magnetic resonance imaging (MRI), positron emission tomography (PET), ultrasound, isotope or nuclear bone scans, and specialised scans.

You should check whether diagnostic tests are included in your oncology limit, because more expensive scans, such PET and CT scans, together with regular blood tests, can add up to large amounts very quickly, says Professor Paul Ruff, the chairman of South African Society of Medical Oncologists and the head of Oncology at the University of the Witwatersrand’s Faculty of Health Sciences and Donald Gordon Medical Centre.

Ruff says that PET scans can cost R20 000 a time and, as a result, some schemes limit these scans significantly.

If used appropriately, however, expensive examinations may results in huge savings by avoiding extensive surgery or ensuring that expensive treatment is discontinued or changed appropriately, Dr Waldemar Szpak, the chairman of the South African Oncology Consortium (SAOC), says. Doctors use these examinations at the beginning of cancer management as well as to regularly re-examine its effectiveness, Szpak says.

  • Surgery.
  • Hormonal therapy related to your cancer.
  • The medicines you may need before having chemotherapy to prevent nausea and vomiting.
  • Consultations with cancer specialists. Ruff says you should check whether your scheme has a limit on the number of visits to a specialist or the amount that may be spent on specialist consultations – if you have cancer, you may have to see your doctor two to four times a month.
  • The fees charged by the facilities in which you will be treated.
  • Materials, such as needles and drips, used to administer treatment.
  • Medication for pain, nausea, depression and other side effects of cancer and its treatment.
  • Stoma products (products for people who have had their bowels or urinary tracts removed).
  • Oxygen and masks.

Your medical scheme may have certain protocols or managed care principles that stipulate what it will or will not pay for oncology. Usually, schemes appoint a managed care company to manage these protocols and determine if your treatment is compatible with the protocols.

The SAOC offers managed care services to medical schemes.

Szpak says the SAOC was formed to ensure that schemes’ decisions on oncology are made by oncologists and not by other professionals who do not have the required expertise.

If your scheme does not use the SAOC to manage its oncology benefits, check that the company that it does use is staffed by oncologists and not by general practitioners as is the case with some managed care entities, he says.

In the case of a PMB cancer, your scheme’s protocols must at least offer you the level of treatment that you can obtain from state hospitals.

Neil Kirby, a director of Werksmans Attorneys who specialises in medical law and is the chairperson of Campaigning for Cancer, says that you are entitled to ask to see your scheme’s treatment protocols.

If your doctor wants to treat you with a medicine that is not available from state healthcare facilities, you may be covered if you have benefits beyond the PMBs and have not exhausted these, Kirby says.

Your scheme’s protocols may lay down the first line of treatment that you need to follow, and only when that fails can you move on to the next line of treatment. Your medical scheme may ask for evidence that the first line of treatment has failed before it approves the next line of treatment.

The problem, Dr Szpak says, is often doctors cannot verify the effectiveness of the treatment because CT or other scans are not allowed or are limited to one a year.

Szpak says managed care protocols differ between benefit options within a scheme, and also from scheme to scheme.

The devil is often in the detail in these protocols. For example, he says, the biologic Herceptin is given to certain breast cancer patients to reduce the risk of it re-occurring. Scientific evidence shows the treatment is most effective if administered for a year, Szpak says.

However, some prominent schemes that use a particular oncology programme that was not developed by oncologists approve the treatment for only nine weeks, he says.

Often, you need to obtain pre-authorisation for oncology benefits, and your doctor may have to submit certain information, including a treatment plan, to your medical scheme.

As soon as you are diagnosed with cancer, you should upgrade your medical scheme option to the very best you can afford, Szpak says.

Some schemes allow you to upgrade during the year, but others allow you to upgrade only at the beginning of a new year.

Kirby says that before you join a scheme you should consider your family history and the worst-case scenarios for your health. Then consult with the scheme or your healthcare broker and study its treatment protocols for cancer.

Also read your scheme’s exclusions, where you will find details such as for how long the treatment may continue and the level of chemotherapy to which you are entitled, Kirby says.

“Many South Africans put more research and thought into what car they will buy than into what healthcare option they should purchase,” he says.

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