So said Dr Maurice Goodman, Head of Clinical Communication and Marketing for Discovery Health, in a discussion with journalists in Cape Town this week.

“The issue that comes to the fore here is the weighing up of the rights of the many vs. the rights of the few. New medical breakthroughs could save countless lives, but what if the costs are prohibitive and medical schemes buckle under the costs?”

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Discovery in court over breast cancer drug
Discovery Health recently hit the headlines when they refused to pay for the breast cancer drug, Herceptin, that cost up to R450 000 per patient annually and they were taken to court. The issue has since been resolved and Discovery Health announced they would pay for the drug, Herceptin, in several cases.

For most of the complainants in the case, a short course of nine weeks of treatment (at a cost of R100 000 per patient) was prescribed. This was recommended by the South African Oncology Consortium in February this year.

In certain cases, however, the full year-long treatment was recommended. Discovery Health has agreed to pay for this. Those concerned were members, whose surgery had been performed more than three months prior to the date on which this decision was reached, and whose genetic profile fit those who would most benefit from this drug.

Herceptin is used to treat women who have Stage IV breast cancer. The genetic profile of a woman with breast cancer can determine her treatment. Women diagnosed with breast cancer and who carry the HER-2/neu, gene react very well to Herceptin. It is recommended that women who are diagnosed with breast cancer, go for genetic testing, as this can point the way to the most effective treatment for each individual.

The rights of the many vs. the rights of the few
“While most medical schemes really have their clients’ interests at heart, paying out huge amounts to a few clients could be to the detriment of the majority,” said Dr Maurice Goodman, Head of Clinical Communication and Marketing for Discovery Health. “The issue that comes to the fore here is the weighing up of the rights of the many vs. the rights of the few.”

“However, everything changes when the person who needs the expensive treatment in order to save her life, happens to be you.”

He mentioned that Discovery Health were in consultation with Roche, the manufacturers of Herceptin, in an effort to have the costs of the drug reduced. Many new treatments, although they represent medical breakthroughs, come at a very high price and are unaffordable to most individuals and also to medical schemes.

Greater cover for more in SA
The high costs of new technology and new treatments represent a dilemma for many medical schemes. For the past decade, the numbers of medical scheme members in South Africa have been more or less static at 7 million – a situation the government and medical schemes are trying to rectify, as they are attempt to increase the numbers of people with medical cover.

However, according to Goodman, the central question remains the extent of the cover that medical schemes can offer if premiums that members pay are low enough to make them affordable. (Susan Erasmus, Health24, May 2006)
 

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