One of SA’s key industry associations for medical schemes has proposed setting up a special fund to share the risk of covering extremely expensive medicines, such as those used to treat Gaucher’s syndrome and Cushing’s disease.
The aim is to buffer schemes from financial shocks that could force them to significantly increase premiums, and provide patients with a standardised approach to costly treatments regardless of which scheme they belong to.
Under the “cell-captive arrangement” being developed by the Board of Healthcare Funders (BHF), participating medical schemes would collectively own an insurance fund created to cover a defined list of medicines, polling both funds and risk, BHF head of research Charlton Murove said at the organisation’s 22nd annual conference, under way in Cape Town. The BHF represents medical schemes, their administrators and managed fund organisations.
Schemes would pay an annual contribution at the start of each year, eligible claims would be paid out from the fund, and at the end of the year any remaining money would be redistributed among the participants, said Murove.
The BHF is proposing the mechanism cover 25 of the most expensive medicines per beneficiary per year, costing upwards of R100,000 per patient per year, he said.
Murove said BHF’s proposal had received a “very positive” response from schemes. “We need to do something to improve sustainability” he said.
Analysis of the financial impact of covering the cost of treatment for just one patient with Gaucher’s syndrome indicated very small schemes with less than 20,000 beneficiaries would be compelled to hike premiums by up to 10 percentage points — more than their routine annual increase, he said. Gaucher’s syndrome is a rare genetic disorder that affects the body’s metabolism of fats, and treatment can cost up to R5m per patient per year, according to Murove.
“We would like to see a situation where these expensive, life-saving medicines become available to more people,” he said.
Covering treatments that cost more than R100,000 per patient per year could cost schemes as little as R13 per beneficiary per year, he said.
Murove said work was under way to finalise the costing and regulatory requirements for the proposed fund.
Earlier in the day, University of Stellenbosch pulmonologist Coenie Koegelenberg told delegates of a new lung cancer screening programme recently launched by Discovery Health Medical Scheme (DHMS), saying he hoped other schemes would soon follow suit. Lung cancer received far less public attention than breast or prostate cancer, yet it was the number one cause of cancer deaths for both women and men, he said.
Screening for lung cancer using low-dose computed tomography (CT) among people at high risk of lung cancer had the potential to diagnose patients earlier, improve their chances of survival, and reduce the cost of treatment, he said. The scan uses very low dose X-rays to take multiple images that are then compiled by a computer to create a detailed image of the lungs.
Discovery Health chief clinical officer Noluthando Nematswerani confirmed that DHMS had, since the beginning of 2023, offered cover for low-dose CT scans for lung cancer for eligible members, in line with local and international guidelines.
Discovery Health is a medical scheme administrator owned by JSE-listed Discovery, and counts DHMS among its client schemes.
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