Focus on Rheumatoid Arthritis

What is Rheumatoid Arthritis? Rheumatoid arthritis (RA) is a chronic autoimmune disorder in which the immune system mistakenly attacks the body's own tissues, leading to persistent inflammation in the joints. While the primary impact of RA is on the joints, the condition can also extend to other organs, particularly as the disease advances. Individuals suffering from RA may encounter episodes of heightened symptoms, commonly referred to as flares, which can persist for days or even weeks. Conversely, they may also experience periods of remission characterized by minimal to no symptoms. Although there is currently no definitive cure for rheumatoid arthritis, various medications are available that can help to decelerate the disease's progression and alleviate its symptoms.

The signs and symptoms of rheumatoid arthritis

• Tender, warm, swollen joints
• Joint stiffness that is typically more pronounced in the mornings and after periods of inactivity
• Fatigue, fever, and unintended weight loss

In the early stages of rheumatoid arthritis, the condition tends to target the smaller joints, particularly those that connect the fingers to the hands and the toes to the feet. As the disease evolves, the symptoms frequently extend to larger joints, including the wrists, knees, ankles, elbows, hips, and shoulders. Notably, in most cases, the symptoms manifest symmetrically, affecting the same joints on both sides of the body.

Approximately 40% of individuals diagnosed with rheumatoid arthritis may also experience symptoms that extend beyond the joints. This systemic nature of the disease means that it can impact various non-joint structures, which include:

• Skin
• Eyes
• Lungs
• Heart
• Kidneys
• Salivary glands
• Nerve tissue
• Bone marrow
• Blood vessels

The severity of rheumatoid arthritis symptoms can fluctuate significantly, with episodes of increased disease activity, known as flares, alternating with periods of relative remission when the inflammation and discomfort may diminish or completely resolve. Over time, if left untreated, rheumatoid arthritis can lead to joint deformities and misalignment.

Possible causes of rheumatoid arthritis The onset of rheumatoid arthritis is attributed to an aberrant response from the immune system, which mistakenly targets the synovium—the membrane lining that encases the joints. This misdirected immune response leads to inflammation that thickens the synovium and can ultimately result in the deterioration of cartilage and bone within the joints.

As the disease progresses, the tendons and ligaments that stabilize the joints may weaken and elongate, causing the joint to lose its normal shape and alignment. Although the exact triggers of this process remain unclear, there is evidence to suggest a genetic component may play a role. While genetics alone do not cause rheumatoid arthritis, they can predispose individuals to environmental factors—such as infections from specific viruses and bacteria—that might act as catalysts for the disease.

Risk factors Several factors may heighten the likelihood of developing rheumatoid arthritis, including:

• Gender: Women are statistically more likely than men to develop rheumatoid arthritis.
• Age: Although rheumatoid arthritis can manifest at any age, it most frequently begins between the ages of 40 and 60.
• Family history: A familial history of rheumatoid arthritis can increase an individual's risk of developing the condition.
• Smoking: Cigarette smoking is associated with a higher risk of developing rheumatoid arthritis, particularly in individuals with a genetic predisposition. Additionally, smoking has been linked to more severe manifestations of the disease.
• Environmental exposures: While not entirely understood, certain environmental exposures, such as asbestos or silica, may elevate the risk of developing rheumatoid arthritis. For instance, emergency workers exposed to dust from the collapse of the World Trade Center have shown a higher incidence of autoimmune diseases, including rheumatoid arthritis.
• Obesity: There appears to be a correlation between obesity and an increased risk of developing rheumatoid arthritis, especially among women diagnosed with the condition at age 55 or younger.

How to register on the chronic programme If you receive a diagnosis of Addison’s disease, it is essential to request that your doctor reach out to our Chronic Medicine Department at 0860 11 78 59 to initiate your registration on the Chronic Medicine Management Programme. A chronic medicine consultant will collaborate with your healthcare provider to manage your treatment plan. Following the fulfillment of diagnostic criteria and submission of blood test results, the treatment will be authorized. You will be informed whether your treatment is covered under the Momentum Medical Scheme formulary or if a co-payment will be required. Once you receive authorization, you can present your prescription to your designated service provider to obtain your medication, and the claim can be processed. A designated service provider (DSP) is a healthcare professional (doctor, pharmacist, hospital, etc.) that the medical scheme prefers for diagnosing, treating, or caring for members with a Prescribed Minimum Benefit condition. If you choose to use a different healthcare provider instead of the DSP, you may incur a co-payment. Authorization typically expires after 12 months. If your medication remains unchanged, your doctor or pharmacist can contact us at 0860 11 78 59 to renew the authorization. The same procedure applies if there are any changes or additions to your authorization.

For more information regarding your chronic benefits and where to access chronic medication and treatment, please click here.

Hospitalisation If you require hospitalization due to complications from cardiac failure, please log in to the Momentum App, reach out to us through the web chat feature on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message, or call us at 0860 11 78 59 to request pre-authorization. We will assign a case manager to monitor your hospital stay.

Treatment plan Once you are registered in the program, you will gain access to a comprehensive treatment plan, which may cover necessary tests, consultations with doctors, or other benefits deemed medically essential by your healthcare provider. These will be reviewed by our clinical team to ensure their appropriateness and effectiveness.

Compliance It is vital that you adhere to the following guidelines:

• Obtain your chronic medication on a monthly basis.
• Ensure that you take your medication according to the dosage and quantity prescribed by your healthcare provider.
• Do not miss any doses; this is crucial not only for compliance but also for your overall health and well-being.

Please ensure your claims include the appropriate ICD-10 code It is essential that all claims submitted include the correct ICD-10 codes (diagnostic codes) so that we can accurately identify and process the claims from the Chronic Benefit. Claims may be processed from your Day-to-Day Benefits if:

• The claims are submitted without the relevant ICD-10 codes.
• You have surpassed the frequency limit for consultations or tests.
• The treatment is deemed clinically inappropriate.

Contact us You can reach us through the web chat feature on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message, or call us at 0860 11 78 59.

Glossary of terms

• Designated service providers: Momentum Medical Scheme utilizes a network of designated service providers, including associated general practitioners and specialists, as well as state facilities, depending on the circumstances, to diagnose and treat our members for the Prescribed Minimum Benefits.
• A formulary: This is a list of medications that are covered under your plan, from which your doctor can prescribe appropriate treatments for your chronic condition.
• ICD-10: This refers to the diagnostic code used for identifying medical conditions.
• Prescribed Minimum Benefits: This is a defined list of benefits that all medical schemes in South Africa are mandated to cover in accordance with the Medical Schemes Act 131 of 1998 and its regulations. To access these benefits, the following criteria must be met:
  • Your medical condition must qualify for coverage and be included in the defined list of Prescribed Minimum Benefit conditions.
  • The necessary treatment must align with the treatments specified in the defined benefits.
  • You must utilize the Scheme’s Designated Service Providers. For more details, refer to the definition of Designated Service Providers provided on page 2.
• If you voluntarily opt to use non-designated service providers, the Scheme will cover benefits up to the Momentum Medical Scheme Rate, and relevant co-payments will apply. However, if you use non-designated service providers in emergency medical situations, this is considered involuntary, and co-payments will be waived.