5 COUNCIL FOR MEDICAL SCHEMES APPEALS COMMITTEE (CENTURION) IN

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5


COUNCIL FOR MEDICAL SCHEMES APPEALS COMMITTEE

(CENTURION)



In the matter between:



BONITAS MEDICAL SCHEME Appellant


and


MEMBER Respondent




RULING


___________________________________________________________



  1. This is an appeal in terms of section 49(1) of the Medical Schemes Act, 131 of 1998 (“the MSA”) against a ruling of the office of the Registrar of Medical Schemes (“the registrar”) dated 14 July 2015.

  1. In that ruling, the registrar’s office found that the scheme is liable to fund the cost of a biological drug Revellex® for the management of Crohn’s Disease because it is more cost-effective than Humira®. It adds, however, that “managed care principles must be applied”. The scheme did just that and preferred Humira® to Revellex® because, says the scheme, Humira® is less expensive by some R70 000.

  1. Aggrieved by the registrar’s ruling, the scheme lodged this appeal on 14 August 2015 and so within the 30-day period prescribed by s 49(1) of the MSA. It advanced two grounds:


3.1 The first is that it has no obligation to fund a biological for Crohn’s Disease where the formulary drugs have been exhausted.


3.2 The second is that the registrar has “incorrectly costed” Humira® as Revellex® is “more expensive to administer in this case”.


  1. The first ground has no basis in law because regulation 15I(c) (and arguably 15H(c)) prescribes precisely the obligation that the scheme seeks to avoid.


  1. The second ground is more on point since it talks to the “efficiency and effectiveness of health care provision” for which regulation 8(4) provides. By opting for a less expensive non-formulary drug, the scheme cannot be faulted because:


5.1 the therapeutic algorithm for Crohn’s Disease is the protocol envisaged in regulation 15H. It is in turn the very “managed care principle” which the registrar’s office says “must be applied” in its ruling. If it proves to be ineffective, regulation 15H(c) provides for “appropriate exceptions” to be made;


5.2 the therapeutic algorithm for Crohn Disease does not prescribe Revellex® or the more expensive drug. It provides for a “review” of Corticosteroids where they have not been effective;


5.3 providing a list of clinically approved drugs for the treatment or management of a prescribed minimum benefit condition (such as Crohn’s Disease) is regulated by regulation 15I which is in turn informed by the power conferred on schemes by regulation 8(4) to use formularies with a view to the provision of effective and effective health care;


5.4 both Revellex® and Humira® are non-formulary drugs for Crohn’s Disease and there is no evidence that the one is more (or less) effective than the other;


5.5 the member has been on Humira® since October 2015 (some 2 months) and it is too early to tell whether or not it has been effective;


5.6 even if the member were to switch to Revellex®, it will take some time (at least 6 months according to the scheme) before its effectiveness can be ascertained.


  1. In our view, there is no basis in law or logic to discontinue Humira® and put the member on Revellex® at this stage without knowing what effect the first drug will have. It appears the member wants Revellex® simply because that is the drug prescribed by the treating doctor. But there is no evidence that Humira® is a less effective drug. Schemes cannot be obliged to fund non-formulary drugs simply on the demand of treating doctors. Managed health care principles, as the registrar’s office says, must be applied. The scheme has done precisely that.


  1. In the result, the appeal must succeed and the registrar’s ruling set aside.



__________________________________________

VR NGALWANA SC for Appeal Committee



For the scheme: A Mohammed; Ms Shaw; Dr Van Beneke


For Member: Mr & Mrs Member


For the registrar: R Smit; L Pautz


Date of hearing: 11 December 2015

Date of Ruling: 17 December 2015


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