Your cancer cover may not be enough

June 12 2011 at 12:35pm
By Laura du Preez

Illustration: Colin Daniel

One in seven men and one in eight women in South Africa will suffer from cancer during their lives, the most recent National Cancer Registry statistics show. With such a high chance that you could contract this dread disease, it makes sense to ensure that you have enough healthcare cover to pay for the rapidly escalating costs of treatment.

You, as a medical scheme member, may expect that, because it is a major medical expense, your scheme will cover most of the costs of treating cancer.

But in the face of the rising costs to treat cancer and the increasing prevalence of the disease, as well as a host of other cost pressures, schemes have been limiting their oncology benefits in recent years.

Many schemes place an annual limit on the amount that you can spend on oncology and/or exclude cover for more expensive treatments. These limits and exclusions do not apply to the cancer diagnoses that fall under the prescribed minimum benefits (PMBs) – the benefits that all medical schemes must by law provide.

However, oncologists say that the definitions of cancer in the PMBs and the treatment that must be provided in terms of the PMBs are vague, and they may be used to deny you essential treatment rather than to ensure that you receive it.

Most medical scheme members are unaware that schemes typically offer benefits that cover cancer treatments based on one of three tiers developed by the South African Oncology Consortium (SAOC). The SAOC is an organisation to which all accredited South African oncologists belong, and most medical schemes draw on its guidelines and expertise to manage their oncology benefits.

Cheaper medical scheme options typically provide the SAOC’s first level of cover for oncology. At this level, you can expect cover to be only that provided in terms of the PMBs.

Some low-cost scheme options specify that oncology benefits are limited to those provided in the PMBs and that you must be treated in a state healthcare facility.

Other cheaper scheme options offer limited annual benefits for oncology, such as R90 000 or even R150 000 per family. At these levels, you will be able to afford only the treatment provided by the PMBs, says Professor Paul Ruff, the chairman of the 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.

If your scheme provides only PMB cover for cancer, you may be better off using state facilities than trying to stretch your benefits to pay for healthcare in the private sector.

Cancer patients who use state healthcare facilities receive a very good level of treatment, although these facilities may not be as comfortable as those in the private sector, Ruff says.

Many academic facilities can provide newer cancer treatments through access to programmes provided by large international pharmaceutical companies. In addition, patients in academic hospitals may participate in international clinical trials for newer treatments, Ruff says.

Medical scheme options that provide cover at the SAOC’s second tier offer reasonably good cover for oncology but exclude some very costly treatments. A number of the newer biologics, with excellent benefits based on clinical research, are included in the second tier of treatment, Ruff says.

Dr Waldemar Szpak, the chairman of the SAOC, says that, at the second tier, the treatment may be less toxic than what you would be able to afford on an option that provides tier-one benefits only.

A decent oncology benefit would be one with an overall annual limit of about R300 000 to R400 000 per beneficiary, Szpak says.

While they are not ideal, oncologists can work more easily with benefits that are structured in a flexible way – such as those provided by Discovery Health Medical Scheme – rather than benefits with a fixed limit, he says.

The annual oncology benefit on Discovery Health is unlimited but only the first R400 000 or R200 000 is covered in full, depending on the option. Thereafter benefits are subject to a co-payment of 20 percent by the member.

The co-payment is not payable if your cancer diagnosis falls under the PMBs and you use the scheme’s designated service provider and follow its protocols.

Szpak says a benefit structured in this way enables an oncologist to use more effective but expensive treatments and diagnostic tests to achieve the best results as soon as you are diagnosed with cancer. However, the oncologist must use the benefits judiciously to ensure that your benefit does not run out.

The most expensive medical scheme options use the SAOC’s third tier of benefits, which will provide you with cover for the latest treatments. Typically, these options have high overall oncology limits and/or additional limits for expensive chemotherapy.

Szpak says that some newer treatments may be more radical and offer you the chance of long-term remission and even cure, although Ruff says that the benefits of some newer treatments may be quite marginal, although they could extend your life by a few months.

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