MEDICAL schemes and their administrators are prioritising short-term savings over patient health with their unscientific formularies, the Health Market Inquiry heard earlier on Wednesday from specialist physician cardiologist Jeff King.
Medical schemes typically incentivise patients to use the medicines listed on their formularies by levying additional fees, or co-payments on medicines that are not on the list. Dr King said many of the patients he saw in his practice required medicines that were not on their schemes’ formularies, which were drawn up by non-experts with a vested interest in minimising costs instead of optimising therapeutic outcomes.
Without pointing fingers at specific schemes, Dr King said there was an inherent conflict of interest between medical scheme protocols devised by "non-neutral" individuals and evidence-based medicine, he told the HMI, which is in its second week of public hearings. The HMI was established by the Competition Commission to probe the private healthcare market and establish whether there are features than undermine competition and access to services.
Dr King made the case for the treatments he prescribed for his patients, presenting evidence sent to him by Discovery Health Medical Scheme in 2010 that showed the rate of hospitalisation among his patients was much lower than among his peers.
Dr King said he regularly motivated on behalf of his patients to get their medical schemes to agree to pay for drugs that were not on their formularies. He emphasised that he was not opposed to generic medicines, which are generally cheaper than innovator medicines, but aimed to put patients on the medicine that would provide the best therapeutic benefit.
For example, few medical schemes had the statin Crestor on their formularies because it was more expensive than generics, yet for patients who needed a high dose of these medicines as well as a calcium blocker it was a safer option, he said in subsequent interview.
Discovery Health CEO Jonathan Broomberg said the medical scheme administrator developed formularies for its client schemes based on "peer reviewed international evidence and clinical guidelines", and took into account factors such as clinical effectiveness and cost effectiveness.
"These formularies are regularly reviewed by independent clinical experts and, where appropriate, specialist societies. Specifically in respect of cardiology, Dr King’s specialty, the formularies are regularly discussed with the SA Heart Association. In addition, DHMS offers members a monthly budget for chronic medicines over and above the formularies, allowing their doctors to prescribe alternatives to formulary medicines where these are preferred," said Dr Broomberg.
Dr King also took aim at medical scheme administrators, saying they received their fees regardless of the outcomes for medical schemes and patients. Both administrators and healthcare professionals should be remunerated based on performance, he said.
Picture: THINKSTOCK
MEDICAL schemes and their administrators are prioritising short-term savings over patient health with their unscientific formularies, the Health Market Inquiry heard earlier on Wednesday from specialist physician cardiologist Jeff King.
Medical schemes typically incentivise patients to use the medicines listed on their formularies by levying additional fees, or co-payments on medicines that are not on the list. Dr King said many of the patients he saw in his practice required medicines that were not on their schemes’ formularies, which were drawn up by non-experts with a vested interest in minimising costs instead of optimising therapeutic outcomes.
Without pointing fingers at specific schemes, Dr King said there was an inherent conflict of interest between medical scheme protocols devised by "non-neutral" individuals and evidence-based medicine, he told the HMI, which is in its second week of public hearings. The HMI was established by the Competition Commission to probe the private healthcare market and establish whether there are features than undermine competition and access to services.
Dr King made the case for the treatments he prescribed for his patients, presenting evidence sent to him by Discovery Health Medical Scheme in 2010 that showed the rate of hospitalisation among his patients was much lower than among his peers.
Dr King said he regularly motivated on behalf of his patients to get their medical schemes to agree to pay for drugs that were not on their formularies. He emphasised that he was not opposed to generic medicines, which are generally cheaper than innovator medicines, but aimed to put patients on the medicine that would provide the best therapeutic benefit.
For example, few medical schemes had the statin Crestor on their formularies because it was more expensive than generics, yet for patients who needed a high dose of these medicines as well as a calcium blocker it was a safer option, he said in subsequent interview.
Discovery Health CEO Jonathan Broomberg said the medical scheme administrator developed formularies for its client schemes based on "peer reviewed international evidence and clinical guidelines", and took into account factors such as clinical effectiveness and cost effectiveness.
"These formularies are regularly reviewed by independent clinical experts and, where appropriate, specialist societies. Specifically in respect of cardiology, Dr King’s specialty, the formularies are regularly discussed with the SA Heart Association. In addition, DHMS offers members a monthly budget for chronic medicines over and above the formularies, allowing their doctors to prescribe alternatives to formulary medicines where these are preferred," said Dr Broomberg.
Dr King also took aim at medical scheme administrators, saying they received their fees regardless of the outcomes for medical schemes and patients. Both administrators and healthcare professionals should be remunerated based on performance, he said.
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