During the symposium, SA Heart® emphasised the cardiac profession’s difficulty in obtaining approval and full reimbursement for the evidence-based treatments, shown to improve patient outcomes. The rules and regulations surrounding the availability of treatments, variously determined by the NDoH, the CMS and funders, currently inhibit access to effective cardiovascular disease management. SA Heart®, an affiliate member of the European Society of Cardiology (ESC), adopts the ESC’s guidelines as its own, supplemented by consensus statements that take prevailing local circumstances into account. Instead of following the up-to-date recommendations of the ESC, both the NDoH and various private sector funders rather give preference to the CMS algorithms that are years out of date. These anachronisms determine standards of care, despite ongoing advances in evidence-based medicine.
Prescribed Minimum Benefits (PMB’s) are a set of defined benefits to ensure that all medical scheme members have continuous access to defined minimum health services, regardless of the benefit option they select. PMB’s are limited in their reach. Private sector funders often retreat behind rules and regulations within the state sector, as to the type and level of treatment that they approve. Each funder independently determines what will be funded and at what level. Based upon their unique Health Technology Assessments, each funder then decides what treatment is approved or declined. It is unfair to restrict treatment to what is available only in the state sector. Novel therapies could be more widely available if there were more constructive agreements between state and industry. The CMS is currently reviewing the PMB package and defining patient entitlement.
SA Heart® pointed out that physicians are at the interface between the patient and the funder. Frequently, the patient misunderstands their own relationship with their medical aid and may deem the practitioner responsible for limitations imposed on his/her treatment. The administrative burden on clinicians is often intolerable, requiring repeat motivations, chronic medication forms, PMB applications and telephone calls to funders.
During the symposium pertinent questions were raised around funder and regulator reimbursement decisions, as well as the obscure mechanisms governing the pricing of medicines and devices. SA Heart® also raised concerns about the future of both the public and private healthcare system. A balance between the two sectors is a delicate one, requiring careful policy decisions to ensure that both systems will contribute effectively to the overall health of our country. Debates often focus around issues of equity and quality of service. The idea of centralizing decisions and distribution in the pharmaceutical and medical device sectors can be seen as an effort to ensure equitable access to essential medicines and equipment. However, this approach could negatively impact the ability to cater for South Africa’s diverse and specific needs – with more bureaucracy and inefficiency.
The meeting was called to determine interest amongst the various parties in establishing a forum to find solutions to these problems, and to harmonise the regulations around access to both medications and devices. The panellists were unanimous in their agreement that the current rules, regulations and disparities between the public and private sectors need to be reworked and there was consensus that a forum should be created to continue these discussions and arrive at effective, durable solutions. SA Heart® committed to driving this process, and will regularly engage all stakeholders in future meetings, with the ultimate goal of improving patient access to innovative cardiovascular treatments.
About the SA Heart Association:
The South African Heart Association (SA Heart®) is Non-Profit company and voluntary Association representing the interests of health care practitioners and basic scientists interested in cardiovascular health. Besides adult and paediatric cardiologists and cardio thoracic surgeons, membership now includes medical technologists, nursing personnel, radiographers, and other healthcare providers as well as scientists and members of industry involved in cardiovascular research. It is the scientific leader in South Africa in cardiovascular healthcare delivery, research, and education. Its mission is to champion equitable and sustainable healthcare, to lead and innovate in the cardiovascular sciences, to educate healthcare professionals and the public as well as influence cardiovascular healthcare policy. Its ultimate vision is the advancement of cardiovascular healthcare for all those living in South Africa.
The special interest groups under the umbrella of and affiliated to SA Heart® include the Paediatric Cardiac Society of South Africa, the Cardiac Arrhythmia Society of Southern Africa, the Cardiac Imaging Society of South Africa, the South African Society of Cardiovascular Intervention together with the Interventional Society of Cath Lab Professionals, the Heart Failure Society of South Africa, the South African Society of Cardiac Research and the Lipid and Atherosclerosis Society of Southern Africa.
SA Heart® is an affiliated member of the European Society of Cardiology, a member of the World Heart Federation and a member of the Pan African Society of Cardiology.
For further information, visit: www.saheart.org
