The Council for Medical Schemes recently sided with Storm Ferguson in a ground-breaking ruling that requires his medical aid to fund his single-use hydrophilic-coated catheters to prevent recurring urinary tract infections (UTIs). This will surely set a precedent for other medical aid members.
Where it began
For many years Ferguson, who lives in Durban, suffered from recurring UTIs – a common occurrence when managing urinary retention, especially when using or reusing poor quality catheters. These recurring UTIs impacted greatly on Ferguson’s quality of life and overall bladder health, and could have had dire consequences.
In 2015, however, his bladder health changed! A urologist suggested that Ferguson switch to single-use hydrophilic-coated catheters. These are the standard of care internationally with guidelines and scientific evidence backing their benefits for users. The urologist prescribed 150 catheters a month (or five per day).
Since switching, Ferguson hasn’t suffered a single infection. One would assume that his medical aid would be happy to pay for these single-use catheters with the evidence presented, especially since the cost of treating a UTI is much more expensive. However, they refused.
Challenges with PMB
The medical aid rejected Ferguson’s claim, arguing that these catheters didn’t fall within the prescribed minimum benefits (PMB) level of care. The PBM is a set of defined minimum health services available to all medical scheme members no matter their benefits option, which is regulated by the Medical Schemes Act.
Under this Act, someone who has “difficulty in bowel or bladder control due to non-progressive neurological (including spinal) condition or injury” should have access to the appropriate treatment and care.
The medical aid provider argued that single-use hydrophilic-coated catheters was not recognised as PMB level of care as it was not used in public hospitals.
Taking a stand
With years of experience with his alternative, Ferguson decided to dispute the decision. Soon he found his case with the Council for Medical Schemes Appeal Board, which ruled in his favour.
The council based its ruling on an interpretation of a regulation within the Medical Schemes Act, which states: “If managed healthcare entails the use of a protocol, provision must be made for appropriate exceptions where a protocol has been ineffective, causes or would cause harm to a beneficiary without penalty to that beneficiary.”
Simply put, the council found that the reusable catheters Ferguson had used (and that are used in public hospitals) were ineffective and would cause harm. As a result, he was entitled to an appropriate exception – single-use catheters.
The council explained that the medical aid can’t assume that the technology used previously or by the state is appropriate for the member without referring to the latest evidence. It is also not necessary for a member to prove that they have suffered harm.
PMB level of care is evidence based. In other words, it is not necessary to suffer to prove that a particular treatment is better. There just needs to be evidence to prove potential harm. As one lawyer explains: “Risk of harm is enough. You don’t have to prove that you were harmed to establish PMB level of care. We use evidence to quantify the risk of harm rather than having people suffer repeatedly.”
The existing evidence, which indicates a significant increased risk of UTIs when using reusable catheters, is enough to support the funding of single-use catheters.
As the regulation states that the member should not be penalised for this exception, the ruling required Ferguson’s medical aid to fund the single-use catheters with no co-payment required.
Setting a new standard
Although Ferguson suffered for years, his brave stance in favour of single-use catheters will surely be life-changing for many others. This ruling now sets precedence for all those suffering from a neurogenic bladder and recurring UTIs who would benefit from access to sterile single-use hydrophilic-coated catheters.
You can help by sharing this article with your urologist and asking them to motivate a switch to single-use hydrophilic-coated catheters with the help of the template available on the QASA website.
They can also access the QASA-sponsored update on guidelines for bladder management, published by The South African Medical Journal, available here.