Helsana-Report: Drug
Drug situation with potential for savings and dangers

Increased costs due to lack of price adjustments for indication expansions

In 2020, a total of CHF 7,741 million was paid into medicinal products from basic insurance, with a total of 118 million purchases by 6.45 million recipients. Although slightly fewer medications were purchased compared to 2019 (-2.2%), the total costs continued to rise slightly (+1.2%).

As in the previous year, the immunosuppressant group generated the highest medication costs. These are medications used to prevent rejection reactions in organ transplants and for the treatment of various autoimmune disorders. This drug group alone generated total costs of CHF 1,167 million in 2020. In terms of per capita costs, immunosuppressants also take the top spot with CHF 10,250.

In second place among the cost drivers are cancer drugs with CHF 898 million and a cost increase of +10.5% compared to the previous year. With +CHF 93 million, they recorded the largest total cost increase of all groups of medications between 2019 and 2020. This striking increase is mainly due to the monoclonal antibody pembrolizumab (see info box), which has caused costs to increase by approximately CHF 80 million over the last two years alone. 

The costs for pembrolizumab per capita and year are over CHF 36,000. This is why even small changes in quantity, for example, due to indication expansions, lead to a very large financial burden on the healthcare system. This effect should be taken into account in the official price-setting process.

Dormant savings potential with biosimilars

Biologics are medicinal products produced by biotechnological processes. This means that they are produced from or with the aid of biological organisms. Depending on the class of active substance, they aim to replace, supplement or block the body’s own neurotransmitters and proteins. Once the patent protection of these drugs expires, other manufacturers can launch corresponding imitation products on the market, known as biosimilars (see info box). 

By the end of 2020, 31 biosimilars had been approved for use in Switzerland. The enormous savings potential through their use in the Swiss healthcare system remains almost untapped even after more than ten years since the first launch of a biosimilar and is increasing from year to year as increasingly cheaper generic products enter the market due to the expiry of patents.

The market sales of all biologics for which biosimilars were available was a total of CHF 474 million in 2020. Only CHF 70 million (14.8%) of this is attributable to biosimilars. The savings potential is, therefore, far from being exhausted. This becomes particularly clear when comparing the market for biosimilars in Germany, where, for example, the biosimilar share of infliximab in 2020 was an impressive 70.4%, whereas infliximab biosimilars in Switzerland only achieved a share of purchases totalling 27.9%.

By consistently replacing biologics with biosimilars, approximately CHF 275 million could have been saved between 2015 and 2020. For the active substance infliximab alone, savings potential of almost CHF 150 million has been given away. 

Among the biologics purchased, there were significant regional differences in the share of biosimilars: The biosimilar quota of the purchases varied between the cantons, with the quotas in German-speaking Switzerland tending to be slightly higher than in French-speaking Switzerland and Ticino. With the dispensing service providers, there was little difference between the biosimilar share of hospitals (16.4%) and those of doctors in medical practices (11.0%). 

The highest cantonal savings potentials, consisting of CHF 13 million and CHF 15 million respectively, existed for the cantons Bern and Zurich. With a savings potential of almost CHF 24 million, infliximab also accounted for a large part of the theoretically possible savings in this respect, with the canton of Bern alone accounting for over CHF 5.3 million and the canton of Zurich for CHF 4.3 million. Premium payers have to shell out for the millions “passed up” annually, and because most cantons as hospital operators are apparently passive on this matter and exert little influence on their hospitals. 

To realise this enormous savings potential, the decisive disincentive for dispensing the medication must be eliminated: the service providers should not be allowed to earn more if they dispense more expensive medication. This creates a direct incentive to dispense high-cost original medications instead of lower-cost biosimilars or generic medications. This false incentive leads to enormously high and, above all, unnecessary additional costs for the health system. Mandatory reforms, such as the introduction of price-independent margins (fixed margins) or equivalence between biosimilars and generics, would set important incentives to prescribe them and finally remedy this unfortunate situation. 

More uncertainty, fewer infectious diseases, stable cancer care

2020 was strongly impacted by the global COVID-19 pandemic. Due to the rapidly increasing number of people testing positive for COVID-19, the Swiss Federal Council decided in March to implement a nationwide lockdown, which also restricted medical treatments. Elective surgery was not allowed until the end of the lockdown on 26 April 2020, and surgery was only permitted in urgent cases. What effect did the situation have on prescription behaviour and the start of vital cancer therapies?

The general uncertainty caused purchases of medication to increase sharply immediately before the lockdown and decrease again sharply during the lockdown. Above all, the traditional medicine cabinet was armed with medication for pain, coughs and colds as well as eye drops. Due to the high levels of psychological stress and uncertainty, increasingly more psychoanaleptics and sleep remedies were purchased during the lockdown. Furthermore, purchases of vitamin D3 preparations increased sharply before the lockdown due to reports that vitamin D provided protection against COVID-19. Although later studies contradicted this, reference figures remained almost constantly above the level of the previous years. During the observation period, on the other hand, fewer medicines were prescribed for infectious diseases such as influenza and gastrointestinal infections – this can be attributed to contact restrictions during the lockdown as well as the increased hygiene measures. 

Essential therapies such as cytostatic and immunotherapies for cancer patients were started even during the lockdown, and there were only very brief delays. We expect no cancer epidemic as a result. 

Responsibility of policy-makers and service providers

In the past, it has always been possible to find suitable solutions to supply shortages. However, these often entail extra work and expenditure, which should be avoided. Moreover, the increase in supply shortages is alarming. The industry and policy-makers are, therefore, called upon to work out innovative solutions, alongside the service providers, to improve and secure the supply situation. 

Risk-benefit considerations with different assessments

Gauging the desired and undesired effects of a medicinal product is essential for its approval. This risk-benefit assessment is performed carefully on the basis of sound evidence for the benefit of patients. Due to the increased risk of agranulocytosis (see info box), metamizole, for example, was withdrawn from the market or not even approved in various countries. With this in mind, it is surprising that metamizole is still one of Switzerland’s most frequently prescribed painkillers and is prescribed with a similar frequency to classic non-steroidal anti-inflammatory drugs (NSAIDs, see info box) or paracetamol.

Other possible adverse drug reactions (ADRs) of metamizole have, so far, been less well researched. However, it is assumed that metamizole has little effect on renal function and that there are no adverse cardiac drug effects. The risk of gastrointestinal bleeding and gastric mucosal lesions is also judged to be lower than with classic NSAIDs. In recent years, however, there has been growing suspicion that metamizole can, in rare cases, cause acute liver damage. 

Throughout Switzerland, purchases of metamizole increased by 44% between 2014 and 2019, while purchases of all NOAs increased by only 6% over the same period. Metamizole was purchased on average 20,136 times per 100,000 people. In 88.3% of metamizole purchases, the amount purchased per year was sufficient for a maximum duration of treatment of 30 days (with a daily dose of 3 g). Furthermore, 78% of all recipients purchased only one to two packs of metamizole each year. Metamizole is, therefore, mainly purchased for short-term use.

Interestingly, strong regional differences exist in the number of metamizole purchases in Switzerland. In French and Italian-speaking cantons metamizole was purchased much less frequently than the Swiss average (Geneva -93%, Vaud -76%, Valais -62%, Jura -54%, Neuchâtel -46%, Fribourg -43%, and Ticino -40%). However, more ibuprofen, paracetamol and etoricoxib were purchased in these regions.