Skin cancer patients pushed towards less effective treatment by insurance shortfalls

Dermatologists are worried insurance changes are pushing patients with skin cancer towards less effective treatment because they can't get cover for the full cost.

Southern Cross has narrowed the criteria for Mohs surgery, which has a 99 percent cure rate.

Mohs is a treatment for skin cancer that removes the tumour, layer by layer, while saving as much healthy tissue as possible.

Changes to insurance coverage have seen people paying more, or choosing cheaper, less effective options.

President-elect of the NZ Dermatological Society Dr AJ Seine said the 20 Mohs surgeons around the country mostly carried out the surgery in the private system as it was largely unavailable in public hospitals.

"It's the gold standard internationally recognised treatment for certain skin cancers, particularly for heads and necks."

Southern Cross, the country's biggest health insurer, announced a year ago it was tightening the criteria for funding Mohs surgery.

The criteria changes in December stated that, to get coverage, the lesion needs to be a basal cell carcinoma or squamous cell carcinoma.

Additionally: "At least one (a or b) of the following apply to the skin lesion.

"a) The lesion has either recurred, has aggressive histopathology, or is clinically justified as high risk AND the lesion is on the head and neck OR site of previous radiation or burn scarring.

"b) The lesion is on eyelids, periorbital skin, ears, pre and post auricular, lips, nose, chin, mandible, temple, fingers, toes, or genitals ONLY, AND tissue preservation is critical for maintaining function (as evidenced by clinical photography which must be retained for audit purposes)."

However, it has since broadened the access criteria after being approached by the society, Dr Seine said.

"The bigger issue now comes with the funding of people's skin cancer treatments and most policies have limits with regard to their skin lesion benefit."

Mohs surgery used to sit outside that area, so it wasn't limited on price, however, since April patients were having to choose between Mohs surgery and having less effective treatments, based on the amount of money that had left under their policy.

Specialists were having to inform patients of the funding shortfall every day and for some that amounted to thousands of dollars.

For patients who were older needing three or four surgeries a year usually only the first one would be covered and after that "they're out of pocket", he said.

Many patients had paid their premiums for years and then found when they got skin cancers in their 70s their premiums were even more expensive but they weren't covered for the treatment they needed, Dr Seine said.

The less effective option was to cut out the lesion and hope it was all removed. The Mohs surgery looked at 100 percent of the surgical margin while the lesser option left surgeons and patients in the position of "you don't know what you don't know".

The standard incisions had a high failure rate, Dr Seine said, meaning a re-incision might be needed.

"When you start cutting skin cancer out for the second time it becomes less effective, no matter which modality you're looking at, be that Mohs or a standard incision."

Dr Seine agreed all health treatments were becoming more expensive, however, specialists were upset Southern Cross had introduced the limits without consultation.

He was pleased that recently the insurer had become more willing to meet with consultants to discuss the problems.

"It is a real issue when you start compromising your decisions on health care based on money. You do start seeing increasing rates of complications. You see poorer health decisions simply due to finances."

Southern Cross Health Insurance spokesperson Regan Savage told RNZ in October the eligibility criteria focus Mohs cover on circumstances where there is a clinical need for the procedure, and are intended to ensure members for whom the surgery is most clinically important continue to have access to the specialised treatment.

"Where the Mohs eligibility criteria are not met, standard surgical excision remains available as an established treatment for skin cancer, subject to the member's policy."

Savage said eligibility criteria are regularly reviewed as practice, technology and evidence change, to ensure they remain clinically appropriate and reflect current practice.