To use an overused word, human life is priceless but on the obverse side, there is the small matter of cost. Simply put: With the whole slew of new & innovative medical treatments and medicines coming onto the market where does one draw the line in providing all these potentially life-saving treatments?
Lest anyone is under the misapprehension that this conundrum is not pervasive today let us consider the dilemmas that doctors and medical aid schemes face today when confronted by such quandaries.
Let us take the case of Neville, a running acquaintance. Some time ago his grand-daughter was born with a debilitating life threatening condition. Even though the prognosis was an early death, what was everybody’s understandable and natural reaction: despite the prognosis they decided to keep the child alive for as long as possible.
The dilemma was cost: a million Rand per month. The family approached the medical aid, Discovery who agreed to fund it without demurring. Six weeks later the child was dead.
Imagine if the Medical Aid had declined to cover the costs and quoted a clause if their agreement. The newspapers would have been inundated with accusations of the medical aid being uncaring rapacious capitalists. Stories regarding the excessive salary that the CEO earns would have adorned the headlines.
Discovery would have been in a lose–lose situation.
What about the case of brain tumours? What is the underlying reason for classifying many tumours as inoperable? The potential harm to the patient. Even though the patient could survive the treatment, they could suffer impairment such as loss of sight or speech. In spite of assurances or indemnities from the patient, in most cases the doctor will be sued for negligence. To prevent this, the tumour is classified as inoperable.
Maybe this stance is justifiable in this case but what about the instance where hospital management in America were incentivised based on the level of deaths. This type of incentive had to be terminated when the perverse unintended consequence was that doctors refused to treat certain conditions in spite of the likelihood of the patient recovering fully became the norm.
The medication that is currently making waves in the affordability stakes is Herceptin which has become the international standard of care for patients with a specific type of cancer. About 20% of breast cancer patients suffer from HER-2 positive cancer, an aggressive form of cancer which is highly likely to return. A year’s course of Herceptin reduces that risk by 40%.
Most medical aids contend that this drug is unaffordable and refuse to reimburse patients for its use. I am personally aware of somebody who was diagnosed as being terminal. She elected to receive Herceptin at her own cost and is now cancer-free. To claim that she is ecstatic is a gross understatement but it came at a huge cost: a depleted pension fund.
Locally there is the case of Veroney Judd-Stevens who has recently taken her Medical Aid, Bonitas, to court to provide her with this drug. The basis of her case is that cancer is categorised as a disease for which the prescribed minimum benefit condition will apply. As such the Medical Aids is mandated by law to pay for the treatment in full. What Bonitas has rightly contested in court is whether they are required to provide treatments which are clearly unaffordable. As the legal requirement is not proscribed with affordability conditions, the courts will probably find in favour of the complainant.
By now it is increasingly obvious that such disputes will become legal matters. In Bonitas’ defence, they claim that State Hospitals in South Africa refuse to provide such expensive treatments. In light of this double standard, they contend that they are not obliged to provide it either.
Even without these medical advances, it is increasingly obvious that medical cost inflation which is already 50% greater than general inflation will accelerate to atmospheric levels placing all these treatments outside the affordability levels of public hospitals and medical aids.
For most of the ordinary folk will medical progress prove to be a chimera outside their ability to take advantage of these advances?
Sadly that is the reality. Unlike the basis of rationing used in the UK where the one can wait for years for treatment, it is only those who can pay the piper who will be able to call the tune.
Photographs: Received on an email which stated that they were originally from a National Geographic Photographic Contest.