Money or your life!

Despite the recent South African test case (Erasmus vs Discovery) resulting in the inclusion of biologics as the current treatment algorithm for Rheumatoid Arthritis, this does unfortunately not change the position for a large percentage individuals identified with other forms of arthritis.

As an individual suffering from severe psoriatic arthritis that has evolved to ankylosis spondylitis, with severe debilitation over the years (last 28 years, since the age of 16) resulting in 3 hip replacements to date, my medical scheme has declined the increase of annual limit of biologics, without providing any reason thereto. Off- course the reason is a simple one – simply a financial consideration. The fact remains that medical schemes are run by accountants (financial decision makers) and not medical specialists that would consider the health of an individual or the merit of a

specific case before the financial consideration and possible benefit of such a decision.

Why should a different type of arthritis be excluded as PMB (Prescribed Minimum Benefit), whilst rheumatoid arthritis is deemed to be the only qualifying PMB? For those suffering from severe psoriasis and the debilitating pain and physical deformity linked to ankylosis spondylitis (as example), surely this could not have been a decision based on medical knowledge?

Of the present 1500 SA patients that require anti-rheumatic biologics in the private sector, approximately 800 have RA. The majority of the remaining 47% suffer from Juvenile Idiopathic Arthritis, Ankylosis Spondylitis and/or Psoriatic Arthritis. Why then discriminate in arthritis type as PMB.? Anti-rheumatic biologics can only be prescribed for patients who meet the criteria specified by SARAA. All patients are recorded on an official registry controlled by SARAA, with their numbers therefore being strictly controlled. What case is there for the exclusion of other forms of arthritis as PMB? Surely it is clear that the chances of financial floodgates opening is limited in any event by the prescribed algorithm linked to such a disease – in other words, unless you are deemed physically sufficiently disabled and unless falling within the parameters of Prescribed Minimum Benefit (where leggaly the medical aid is compelled to fund the medication), you WILL be denied or limited in receiving full access to disease modifying biologics!

When a minimal funding per medical scheme member is relevant to biologics medication in South Africa compared to certain other diseases (According to health economist, Professor Tienie Stander in 2006 only R8.7 billion, or 16.9% of total medical scheme contributions in South Africa were paid for medication. This equated to R104 per beneficiary per month, with merely R1.50 per beneficiary per month being for anti-cancer biologics, and 64 cents per beneficiary for anti-rheumatic biologics), it is difficult to understand the measure of résistance to the funding thereof.

The matter remains one of principle – medical schemes pay billions for funding of non-medication expenses, whilst denying full access to medication such as disease modifying biologics that not only beneficially impacts the individual, but also beneficially impacts the contribution of such an individual within society. But then again – an understanding of this can only be developed by being subjected to the disability inherent to arthritis sufferers – a medical decision, not a money decision...

From a personal point of view I will continue pursuing the advocacy of this matter for all types of arthritis to be included as PMB, so as to include biologics as a Disease Modifying Anti-Rheumatic Drug (DMARD) of last resort.