Discovery retracts second appeal against CMS

Sylvia Erasmus

Described by rheumatologists as ‘miracle drugs', anti-rheumatic biologics have been shown to halt the inflammatory process and to prevent further disease activity and joint damage in RA patients who have not responded to standard drugs and who are literally crippled by the condition. The downside is price, with the cost for anti-rheumatic biologics being in the region of R100,000 per annum.

“The reinstatement of the first appeal ruling in the Erasmus case is significant for RA sufferers because it interprets the current treatment algorithm for RA to include biologics as a Disease Modifying Anti-Rheumatic Drug (DMARD) of last resort,” says attorney Lisa Metzer who represented Erasmus on behalf of the SA Rheumatism and Arthritis Association (SARAA).

“This makes it illegal,” Metzer stresses, “for a medical scheme to levy a co-payment on an anti-rheumatic biologic if it is used by an RA patient after all other standard DMARDs, or fully funded biologics, have failed.”

A further push for full funding of anti-TNF agents as PMB drugs of last resort has been given by their inclusion in the third draft of the algorithm for Rheumatoid Arthritis just published in the PMB consultation document on the CMS website.

This year, Discovery is funding the biologics Revellex, Humira and MabThera in full. They will, however, continue to levy a 10% co-payment on members using Wyeth's more expensive biologic Enbrel. The reason according to Discovery's legal advisor, Elton Krawitz, is that, “It is not cost-effective at its current price.”

“Unfortunately, there are still many barriers preventing medical scheme members in a critical condition from accessing biologics,” says Mike Boddy, CEO of The Arthritis Foundation. “Generally, they have to be on a comprehensive plan in order to apply for a biologic. Some medical schemes continue to levy co-payments on all biologics making them unaffordable. Many medical schemes also put an annual price limit on biologics."

“Only 1500 SA patients require anti-rheumatic biologics in the private sector,“ says Dr Beverley Traub, chairman of SARAA. “Of these, approximately 800 have RA. The others have Juvenile Idiopathic Arthritis, Ankylosing Spondylitis or Psoriatic Arthritis.

“Anti-rheumatic biologics can only be prescribed for patients who meet the criteria specified by SARAA. These patients are recorded on an official registry controlled by SARAA, with their numbers therefore being strictly controlled,” stresses Dr Traub.

“Getting medical schemes to fund anti-rheumatic biologics for treatment resistant patients has been a long, tough battle since 2005,” says Arthritis Foundation CEO, Mike Boddy. “However, there are now approximately 95 medical schemes funding biologics as drugs of last resort for members with RA, many without co-payments.

“The central issue with biologics has always been price and the pharmaceutical companies have co-operated since 2006 by dropping or restricting their prices on biologics.”

Putting the price of biologic drugs into context, health economist, Professor Tienie Stander says that in 2006 only R8.7 billion, or 16.9% of total medical scheme contributions in South Africa were paid for medication. This equated to R104 per beneficiary per month, with merely R1.50 per beneficiary per month being for anti-cancer biologics, and 64 cents per beneficiary for anti-rheumatic biologics.