Following a ruling by the Council for Medical Schemes, catheter users might now get the financial support they need from medical aids to purchase single-use catheters. MARISKA MORRIS investigates
Earlier this year, the Council for Medical Schemes (CMS) sided with catheter user Storm Ferguson in his case against medical aid provider Discovery. After realising the health benefits of single-use intermittent catheters, Ferguson approached the medical aid to fund these devices. After Discovery declined, Ferguson took action by approaching the CMS Appeal Board.
Ferguson’s decision to appeal was deeply motivated by his struggles with recurring urinary tract infections (UTIs). Many people with SCI who rely on intermittent self-catheterisation to empty their bladders suffer from UTIs, mostly because they use or reuse poor-quality catheters.
“Recent research on the standard of care and related quality of life of the spinal cord-afflicted community in South Africa revealed significant gaps in practice and challenges regarding levels of care and access to services and supplies specifically related to the neurogenic bladder,” Dr Francois Theron and his fellow researchers explain in their study titled “Best practice recommendations for bladder management in spinal cord-afflicted patients in South Africa”.
“There is evidence that people with disabilities experience poorer health outcomes than the general population,” the study states. “People with spinal cord afflictions are at higher risk of secondary conditions such as UTIs. These conditions frequently lead to hospitalisation and can result in increased costs for care, reduced employability, decreased quality of life and lowered life expectancy.”
True benefits of single-use
The researchers indicated that clean intermittent catheterisation was considered the global “gold standard” for neurogenic bladder management. While the international guidelines don’t recommend single-use hydrophilic-coated catheters, they do suggest patient choice. If a patient experiences fewer UTIs with single-use catheters, they should have access to these devices.
According to Theron and his team, a study reported that the use of a hydrophilic-coated catheter for clean intermittent catheterisation is associated with a 21 percent reduction in the incidence of symptomatic UTI in patients with acute spinal cord injury.
“Using a hydrophilic-coated catheter minimises UTI-related complications, treatment costs and rehabilitation delays,” they wrote. “Given evidence of fewer UTIs and better quality of life, compact hydrophilic-coated intermittent catheterisation appears to be the best treatment option.”
This was Ferguson’s experience too. After struggling with recurring UTIs for many years, his urologist suggested switching to single-use hydrophilic-coated catheters. The urologist prescribed 150 catheters a month (five per day). Since the switch in 2015, Ferguson hasn’t suffered a single bladder infection.
However, these catheters can be expensive. Thus, Ferguson approached his medical aid to have it cover the cost. While costly, this device is less expensive than repeat hospital visits. Yet Discovery was unwilling to cover the cost.
The battle begins
On refusing the claim, the medical scheme argued that these catheters didn’t fall within the prescribed minimum benefits (PMB) level of care – a set of defined minimum health services available to all medical scheme members, no matter their benefits option, that are 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.
Discovery argued that single-use hydrophilic-coated catheters were not recognised as PMB level of care, as they were not used in public hospitals.
However, the CMS Appeal Board disagreed with this argument. It 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, which are used in public hospitals, were ineffective and would cause harm. Thus Ferguson 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 used by the state is appropriate for the member without referring to the latest evidence.
A new precedent
Patients are not required to show that they have suffered harm to prove a particular treatment is better, as the PMB level of care is evidence based. 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. The ruling also stated that the medical aid needs to fund these catheters without a co-payment from the member.
Ferguson’s brave actions have changed the lives of many other catheter users. This ruling now sets a precedent 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:
www.samj.org.za/index.php/samj/issue/view/240.
