Many patients suffering from rheumatoid arthritis (RA) have had an awful start to 2024 due to changes to medical scheme rules that have affected their access to essential medication.
While jumping through hoops of red tape in order to access the treatment they need and while waiting (for weeks or months) for medical schemes and review boards to make decisions on a case-by-case basis, these patients will experience pain, swelling and irreversible joint damage that could impact their lives for years to come.
What is rheumatoid arthritis and how is it treated?
Rheumatoid arthritis is an autoimmune disease, where the patient’s own immune system attacks their joints, causing pain, swelling, loss of range of motion and (if not controlled) irreversible joint damage.
Disease severity varies, and although some patients are well-managed on first-line treatments like anti-inflammatories or a drug called hydroxychloroquine, some only respond to much more specialised and much more expensive medications, like biologic drugs and janus tyrosine kinase (JAK) inhibitors. The goal of treatment is to control active inflammation, reduce pain, improve functionality and prevent flare-ups.
Doing this successfully helps these patients to live relatively pain-free, remain active, work effectively in whichever field they are employed, contribute to our economy and generally just look after themselves and remain independent. It also lowers the amount of irreversible joint damage the patient suffers and reduces the chances of these patients needing special surgeries like arthroscopies and joint replacements later on in their lives.
Access to care is already challenging
It is already hard for these patients to access the care they need, for several reasons:
Some patients’ symptoms aren’t recognised early and it can take months (years, even) for them to be diagnosed.
Rheumatology is a specialised field and visiting a specialist is expensive, never mind the cost of tests and scans.
There is an algorithm to follow in terms of which treatments the doctor tries first. Again, it can take weeks or months for a treatment to control the disease and/or for the doctor to establish the right treatment for that particular patient.
Medical schemes have just made things even harder
The problem now is that patients who have already been through this long and painful process have been left in the lurch by their medical schemes.
In 2023, a well-known medical scheme in South Africa announced not only that some of their mid-tier plans would fall away (leaving patients with the choice of either an extremely expensive plan or an entry-level plan), but also that they would be reducing their threshold relating to the advanced therapies they cover. In this particular example, instead of the 2023 threshold of R6090 per month, this medical scheme announced that they would only cover R3040 per month, despite the scheme increasing their monthly premiums by 11.9% for 2024.
So, instead of spending January and February of 2024 looking forward to a new year with new opportunities and trying to maintain a positive attitude despite living with chronic disease, these patients have spent the last few weeks filling in forms, waiting for their doctors to get back from leave, asking for letters of motivation and spending hours on the phone with their medical schemes – all the while hoping –, praying –, that their disease won’t flare while they’re fighting for access to care they should already have.
What needs to happen
These patients should be ‘grandfathered’; it’s as simple as that. No, this has nothing to do with becoming a grandparent ... ‘Grandfathering’ is when a patient who has been stabilised on a certain medication is allowed to continue taking it, without needing to meet any authorisation criteria. Instead of expecting these already-stable patients to go through the long process of authorisation, again, risking flare-ups and everything that goes along with them, medical schemes should quite simply keep them on the treatments that keep them well.
How can you help?
Medical aid providers and relevant stakeholders can engage with rheumatologists and patients to better understand the problems with these proposed changes.
Doctors treating these patients can assist them with their letters of motivation and appeals to medical aid providers.
Patients affected by this change can find out if their condition is on the Prescribed Minimum Benefit (PMB) list of chronic diseases – rheumatoid arthritis is.
Doctors and RA patients can read up on the RA disease algorithm, the Medical Schemes Act and related Regulations.
Join the CoverMyCondition campaign, a campaign that advocates for these patients.
Let’s work together to protect the rights, quality of life and future well-being of these patients!
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