The Council for Medical Schemes has published for comment an amendment to the definitions of the minimum treatment that medical schemes must provide for breast cancer. The draft definitions cover early and locally advanced breast cancer, as well as breast cancer that has spread to other organs.
Changing the definitions could be significant for women who belong to medical schemes, because breast cancer is the most frequently diagnosed cancer among women in 140 out of 184 countries, according to 2013 World Health Organisation statistics. There were 508 000 deaths from breast cancer in 2011 and 522 000 in 2012.
In a circular released late last year, the Council for Medical Schemes quotes research stating that although breast cancer is thought to be a disease of the developed world, almost half of cases and 58 percent of breast cancer deaths occur in less developed countries.
In South Africa, it states, only 10 percent of breast cancer patients see a doctor for the first time when their cancer is at stage one. The remainder see a doctor for the first time when their cancer has progressed to stage two (30 percent), stage three (30 percent) or stage four (30 percent).
According to 2006 statistics from the South African National Cancer Register, one in 35 South African women are at risk of being diagnosed with breast cancer at some point in their life.
Breast cancer is one of the prescribed minimum benefits (PMBs) listed in regulations under the Medical Schemes Act that medical schemes are obliged to cover. However, the regulations do not describe in sufficient detail how PMB conditions should be treated and are silent on many aspects of how they should be diagnosed and monitored. This has resulted in medical schemes interpreting the benefits differently and in members being uncertain of what they are entitled to.
The current definitions of breast cancer are silent on the use and frequency of diagnostic screening to establish the existence or growth of tumours. Another shortcoming is that they recognise only two classes of breast cancer: treatable and untreatable. The treatment specified is “medical and surgical management”, which includes chemotherapy and radiation therapy.
The council’s draft definitions cover the management of early and locally advanced breast cancer, as well as recurrent and metastatic breast cancer (cancer that has spread to other parts of the body).
Dr Bettina Taylor, the group functional specialist at the health policy unit of scheme administrator Medscheme, says the regulations were drafted in broad terms, resulting in confusion over and different interpretations of what healthcare funders should cover. For example, she says the regulations do not state what “periodic breast examinations” should and should not cover.
“Does it suffice that a scheme, as a bare minimum, covers visits to a primary care provider annually for a manual examination, or should a scheme fund mammography? If so, at what intervals, at what age and for which patients? If only for high-risk patients, how should such risk be defined? Similarly, what should be covered as part of chemotherapy for breast cancer?” Taylor says.
Dr Elsabé Conradie, the general manager of stakeholder relations at the Council for Medical Schemes, says some of the confusion the council has encountered includes whether the use of mammograms, ultrasound and magnetic resonance imaging (MRI) is appropriate for early breast cancer diagnosis. Additionally, in metastatic cancer patients, the question of which cancers are classified as treatable has been raised.
The council’s circular describes the optimum diagnosis for breast cancer. It says that women with signs and symptoms of breast cancer should undergo a triple assessment, including clinical examination, imaging and pathological assessment.
The document says that different types of scans (mammograms, ultrasound, MRI and positron emission tomography) can play a role in the diagnosis, classification and monitoring of breast cancer, although not all of them should be routinely recommended.
Pathological assessment, which involves an ultrasound-guided needle biopsy, is the method of choice for diagnosing breast cancer.
The document also proposes that, where appropriate, diagnosis should include blood tests, liver function tests, renal function tests, lymph node biopsies and histology (the study of cell structure).
The document details a proposed standard for the management of localised breast cancer, which could include a combination of surgery, radiation therapy, hormone therapy and surveillance. It also covers a proposed standard for the management of locally advanced breast cancer.
Conradie would not say whether the draft definitions are likely to result in cost increases for schemes, saying only that the definitions have been developed to clarify what members are entitled to and the liabilities that schemes face.
Milton Streak, the principal officer of Discovery Health Medical Scheme, says the draft definitions were formulated using input from many interested parties, with support and input from the clinical advisory committee established by the Council for Medical Schemes.
“The proposed new definitions provide medical schemes with the appropriate guidance, based on the insight and expertise of these stakeholders, to ensure that members have access to a clinically appropriate level of care as intended by the PMB legislation,” he says.
Streak says the new definitions are likely to increase costs for medical schemes, but schemes have an opportunity to analyse the cost implications and affordability of the draft definitions before the final definitions are published.
Stakeholders have until January 22 to submit comments on the draft definitions to the Council for Medical Schemes. The circular is available on the council’s website, www.medicalschemes.com. Click on “Publications” and scroll down to “Discussion papers”.
PROJECT TO REVISE PMB DEFINITIONS
The Medical Schemes Act provides for a regular review of the prescribed minimum benefits (PMBs) by the Department of Health, the Council for Medical Schemes, provincial health departments, consumer representatives and other stakeholders.
The Act requires officials to review and revise the PMBs at least every two years, taking into account inconsistencies or flaws in the legislation, the cost-effectiveness of health technologies, developments in health policy, and the impact of PMB costs on medical scheme viability and member affordability.
However, a review as envisaged by the Act, which was enacted in 2002, has never been completed.
Noting the vacuum and the uncertainty among medical scheme members in the absence of such a review, in 2010 the Council for Medical Schemes initiated the Benefit Definition Project.
According to Dr Elsabé Conradie, the general manager of stakeholder relations at the council, the project was started as part of work on an industry-agreed code of conduct for the PMBs.
“The process was initiated due to inadequate clarity of certain [treatments] in the PMB regulations. Multi-disciplinary committees were formed to interrogate submissions and propose recommendations regarding the management of PMB conditions,” she says.
Conradie says the process is intended to define the PMB package, guide the interpretation of the PMB provisions by the relevant stakeholders and develop clear, comprehensive descriptions of the benefits that should be available for prescribed conditions.