Today (8 Aug), Xaba is waiting anxiously at her home in Katlehong as Discovery appeals against a ruling by the Council on Medical Schemes (CMS) compelling it to pay for her treatment.
Discovery wants Xaba to be treated by a medicine called Doxorubicin, but her oncologist says this will damage her patient’s heart
Ironically, Paclitaxel, the medicine she has been prescribed, costs R32 000 less a year than Doxorubicin. But Discovery told Xaba in a letter that Paclitaxel is on a “tier” that Xaba is not entitled to with her medical plan.
In May, advocacy organisation Campaigning for Cancer helped Xaba to lay a complaint against Discovery with the Council on Medical Schemes.
In a letter to the Council on 31 May, Discovery said it would not pay for Xaba’s medicine as it “is not a covered benefit on her selected plan type and the treatment requested is not the level of care available in the public sector”.
In early June, the Council ruled against Discovery, saying that the laws governing medical schemes obliged them to substitute drugs when there was a risk of the patient being harmed “without penalising the patient”.
Two weeks later, Discovery wrote to the Council indicating that it would appeal against the decision and it has continued to refuse to pay for Paclitaxel.
In the meantime, Xaba has been without chemotherapy for four months and is at risk of losing her arm.
“My left arm is much bigger than the right one. The veins are racing and I can’t lift up my arm or wear my clothes,” said the sweet-voiced young woman from Katlehong.
“The medical aid said I can’t have the medicine from my doctor,” said Xaba yesterday. “I can’t get an operation because the cancer is all over. My arm is getting worse but I have to wait to see what the medical aid is saying.”
Oncologist Dr Daleen Geldenhuys, who has been treating Xaba for the past three years, described her patient’s cancer as “an aggressive tumour that has penetrated the muscle in her left arm and shoulder and formed what looks like an extra breast on her chest”.
“The circumference of her arm has grown by six centimetres in a two-week period,” said Dr Geldenhuys. “If we leave it much longer, the nerves in her arm will be compressed beyond repair and she will develop gangrene and may lose her arm.
Surgically removing the tumour is not an option, as her arm, shoulder and part of her chest would have to be amputated.
“She has already been on Doxorubicin twice, and this drug has an accumulative toxic effect,” added an exasperated Geldenhuys. “If she gets it again, she has up to 40 percent chance of heart failure. So if the medical aid has a heart ready for a transplant, then I will give it to her because the regimen they want me to give my patient will damage her heart.”
Xaba has struggled with this form of cancer called fibromixoid sarcoma, since she was a child, which is why she has had Doxorubicin before.
“At this stage, we don’t think Thobeka will go into remission. But we want to shrink the tumour to a manageable size so that this lovely, sweet young woman can have a life like others her age,” said Geldenhuys.
Discovery Health CEO Dr Jonathan Broomberg says the scheme’s decision to appeal the CMS ruling “is not based on the cost of the medication at all, but rather on ensuring that the member obtains the appropriate medication, both in terms of her plan entitlements, and in clinical terms”.
Broomberg gives three reasons for refusing to pay for Xaba’s medicine, which he says is based expert clinical advice, namely “there are other appropriate medications that would be fully covered by the scheme in terms of this members plan benefits”, “there is no published evidence to support the use of the requested medicine in this member’s clinical condition” and “ the requested medication is certainly not in use in the state hospital system for her condition, which is the ultimate test for prescribed minimum benefits entitlements in terms of the Medical Schemes Act.”
Broomberg also claims Discovery made “several attempts” to engage with Xaba’s doctor to discuss alternatives but “co-operation in this regard has not been forthcoming.” – Health-e News Service.