PMR.africa’s annual survey rated listed and large managed healthcare companies, closed and open medical aid schemes, and medical aid administrators. The survey was conducted through nationwide interviews in August, September and October.

The ICON network involves more than 80% of South Africa’s oncologists, who are seeking to widen access to healthcare by providing innovative, cost-effective oncology services and solutions in the field of managed healthcare. It received the highest rating in their category, 3.88 out of a possible 5. The ratings are based on the perceptions of the respondents surveyed; a random national sample of 95 respondents comprising of chairmen and principal officers of listed and large companies.

Companies were rated across fifteen different attributes: ability to manage risk, ability to manage unique member profile, BEE plan, clinical expertise, integrated computer systems, knowledge of business and healthcare environment, managed/integration of data, meeting of expectations, negotiating strength, professionalism/confidentiality/trust, relationship with providers, reporting on results/interventions, return on investment, service excellence and value-adding partnerships.

“The purpose of the awards is to celebrate excellence. Through the awards we want to acknowledge and set a benchmark for others to aspire to,” says CEO of PMR.africa, Johan Hattingh.

He said that, through the awards, PMR.africa is also creating “opportunity for companies and institutions whereby a team or division can be recognised for all their hard work. After all there is a successful team behind each successful and highly rated company and institution.”

ICON national network and relationship manager, Dr Ernst Marias, said that it is a privilege to have received the award and to be perceived among peers as one of the best.

“The awards celebrate excellence, so naturally to be considered for the award its self is great and means a lot, but to win is even greater. We feel honoured and are happy to know our efforts are all in the right places. Having a Golden Arrow Award for specialist service proves that ICON is becoming a major player in the field,” says Marais.

He says he’d like to see these kinds of results every year, if not better. “These rankings show us where we are doing excellently, but also points out to us those areas in which we can do better,” he said. “We are very grateful for this award.”

ONCOLOGY Cancer treatment is often costly and places enormous financial burdens on people and society. Local and international specialists say trends in treatment approaches are in need of serious reform, write Gareth Coetzee and Marika Sboros.

LIKE most people, you probably know someone who has cancer, had it, or has died from it. Cancer remains a leading cause of illness and death worldwide. Treatment is costly and places an enormous financial burden on people and society. Local and global specialists believe trends in cancer treatment are proving inaccessible, unsustainable, and in need of serious reform.

In an article in the New England Journal of Medicine in May, titled Bending the Cost Curve in Cancer Care, Dr Thomas Smith and Dr Bruce Hillner, oncologists at Virginia Commonwealth University, say annual direct costs for cancer care in the US will reach $173bn in 2020. In 2009, the Lance Armstrong Foundation released The Global Burden of Cancer report which showed that the total global economic burden of new cancer cases was $305bn. To put that in perspective, SA’s GDP is roughly $380bn.

What drives these costs? Smith and Hillner say it is the rising costs of therapy and extent of care — a clear focus on secondary rather than preventative care. “In the US, sales of anticancer drugs are now second only to drugs for heart disease; 70% of these sales come from products introduced in the past 10 years,” they write. In SA, the top 20 drugs used in chemotherapy account for 75% of costs incurred; branded drugs are responsible for 83% of the costs. Yet this is a controversial area, says medical oncologist Dr Daniel Vorobiof, director of the Sandton Oncology Centre, as the cost of prevention of some cancers is higher than the treatment.

So much so, he says, that the American Cancer Society said in a recent communiqué: “After decades in which cancer screening was promoted as an unmitigated good, as the best — perhaps only — way for people to protect themselves from the ravages of a frightening disease, a pronounced shift is under way.” It quoted chief medical officer Dr Otis Brawley, saying: “Screening is always a double-edged sword. We need to be more cautious in our advocacy of (it).”

Smith and Hiliner argue for fundamental behavioural changes in cancer treatment to reduce costs, and give more people access to treatment. Their core argument is that there is a trend among oncologists to maximise profit by prescribing trials, tests and costly treatment plans that often have little effect on survival rates, let alone quality of life.

Vorobiof says parts of this argument are wrong. “Trials are not costly to the patient or medical funders,” he says. “Trials allow patients with no cover and those with limited benefits to undergo state-of-the art treatments, as costs are fully covered by the trial sponsors. No clinical trial performed anywhere in the world causes any direct cost to patients or their insurers.” Expensive drugs and the tests (blood tests, radiology and so on) are covered by the sponsors, Vorobiof says, resulting in huge savings for patients in clinical trials.

Smith and Hiliner also say medical oncologists directly or indirectly “control or influence most cancer-care costs, including use and choice of drugs, types of supportive care, frequency of imaging, and the number and extent of hospitalisation”. That’s not the case in SA, says Vorobiof, as medical oncologists represent only 25% of practising oncologists — the rest are radiation/clinical oncologists. And there is no drug mark-up in SA. There is a single exit price from manufacturers to patient, Vorobiof says. That was a major legal step forward in order to contain costs.

Medical aid schemes are also being fingered as culprits. Earlier this year, Health Minister Aaron Motsoaledi said at a roundtable in Johannesburg to discuss the proposed National Health Insurance (NI-II) that the cost of healthcare was more ruthlessly profit-driven now than during apartheid.

Smith and Hillner propose changes that place responsibility of decision-making squarely on the shoulders of oncologists to be open and honest with patients. One problem has been a tendency in the last stages of life for treatment to intensify — a last surge of medicine and costs to prolong the inevitable, says Cape Town GP Dr Ernst Marais, a member of the Independent Clinical Oncology Network (ICON).

“This often ends in shortened time, more pain caused by toxins, more hospital time, and less dignity and quality of life as death approaches,” says Marais.

Vorobiof says cancer specialists should offer supportive care, and quality, not quantity, of life, for patients in their last stages, but it can be difficult to determine the length of survival a patient might have. And unexpected events happen when patients have been treated and die soon thereafter. “This doesn’t happen in most cases,” Vorobiof says, “but, as oncologists are also human, it might occur occasionally.” As well, some cancers cannot be treated, and thus a premature death is inevitable, but specialists say dignity and quality of life should be nurtured through palliative care, not corroded by aggressive last-stage treatments that can create financial burdens.

A study by the Massachusetts Medical Society, in the New England Journal of Medicine last year, examined the effects of palliative care on survival and quality of life of newly diagnosed cancer patients. It showed that those offered palliative care early experienced better quality of life, and in some cases survived longer than patients on traditional treatments. Vorobiof says conditions have changed, and supportive care has become a major component of therapy.

Chemotherapy and/or radiation therapy, offered in many case to patients-with-advanced disease, are also of palliative nature, and patients and families should be informed of that, he says. There are also newer drugs that have fewer side effects, better benefits, and induce longer responses, he says.

In the early 1990s, doctors had about 15 chemotherapy agents only, says Vorobiof. Today they have more than 50. Doctors also did not have the anti-emetics they have today, and all other supportive and palliative care available. And these days, most oncologists don’t treat all patients with advanced cancer, he says. “We are upfront. We tell those with advanced, incurable disease that we can do nothing, and we recommend palliative and supportive care,” Vorobiof says. Patients usually understand that, he says, and most reconcile with the bad news. However, their families often do not. “They push patients to ‘other’ practitioners, some practising on the fringe of medicine, so that something can be done, usually with poor or no results,” says Vorobiof.

Research has suggested that palliative care is more cost effective. In a report by The Board of Healthcare Funders of Southern Africa earlier this year, Cape-based oncologist Dr Leon Gouws, a founder member of ICON, quotes a US study showing significantly higher bankruptcy rates among cancer sufferers, and asks: “What kind of system do we have when those diagnosed with cancer are being driven to bankruptcy?”

No similar study has been conducted in SA, but given the high cost of some life-saving drugs and limited medical scheme resources, results are likely to be similar, Gouws says.

Gouws is outspoken about the role of patients in their own care. He says ICON is a forerunner of patient-centric care models. These aim at reducing costs and wastage, to secure the highest-quality care for the broadest number of people, through treatment protocols based on the latest evidence, developed by network doctors. Organised by treatment intent, the protocols effectively hand the power of decision-making regarding treatment back to the doctor and the patient, he says.

ICON encourages collaboration with medical schemes in this process. Close to 80% of SA’s specialist oncologists are part of ICON, and most major medical schemes have accepted the model, Gouws says. ICON has contracts with service providers, that have hi-tech chemotherapy and radiation therapy facilities in most major centres in all nine provinces.

Gouws criticises Prescribed Minimum Benefits (PMBs) that focus mainly on curable cancers, or cancers with a 10%, five-year survival rate, as this makes provision for some end-of-life care, but neglects palliative care and thus a significant number of sufferers.

He believes that drugs and expensive technology are being used injudiciously. “With one in four South African men and one in eight women getting cancer, it is not difficult to calculate the costs involved in treating the disease,” Gouws says. “With the costs so high, many have no access at all, hence the support for an NHI.”

Motsoaledi has said the (private) healthcare system is “at best destructive, unsustainable, very expensive and curative, and we need to change that”. The first five years of the implementation of the NHI are to be dedicated to overhauling the healthcare system.

Gouws says that with an obvious need for services across the full continuum of care, from prevention to detection, active treatment and end-of-life care, oncology should be “smack bang at the core of reform”.

Yet while ICON is doing good work, patients need to know not all oncologists are part of its network. And its altruistic attempt to give service to all is limited by the relative number of oncology specialists and centres, mostly available only in large urban centres. ICON also imposes limitations on patients’ access to some drugs, and the number and duration of chemotherapies, but is less restrictive in the area of radiotherapy, Vorobiof says.

He says the major obstacles to cost containment and management are pathology laboratories, radiology department, large medical enterprises and the medical insurance counterparts.

“True scientific and transparent partnerships are needed to tackle (the problems),” he says. It doesn’t help, Vorobiof says, that the media often focuses on drug costs, and increased use of expensive chemotherapies, but overlooks an area with little or no regulation: overuse of services. “This grey area is probably the main driver of rising costs, because cancer costs and spending (in drugs) are a transparent mechanism, while the challenge is to figure which services are actually needed, which are totally unnecessary, and which ones we could be paying less for,” he says.

Another challenge is an ageing population that is most at risk, and therefore will be increasing projected costs as people grow older, Vorobiof says.

Yet another challenge is the move towards more evidence based medicine and guidelines that is “leaving aside the art and practice of medicine,” he says. “We do need to embrace evidence-based medicine, but also to integrate it with clinical research and a change in the practice environment. “That will allow us to offer the highest quality care with judicious use of available resources.” Vorobiof quotes British scientist and writer Dr June Goodfield: “Cancer begins and ends with people. In the midst of scientific abstraction it is sometimes possible to forget this basic fact.

“Doctors treat diseases, but they also treat people, and this precondition of their professional existence sometimes pulls them in two directions at once.”