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

The cost of medication once again increased in 2020. Although a qualitative supply of medicinal products has its justification and its price, it is important to observe the development carefully and to adopt corrective action. With the eighth Drug Report, Helsana, in collaboration with the University of Basel and the University Hospital Basel, provides reliable figures regarding volume and cost developments in the Swiss pharmaceutical market. By doing so, we make an important contribution to greater transparency and create the basis for well-founded discussions on how to ensure a high-quality, safe and yet cost-efficient supply of medicinal products.

The following questions were selected as examples from the comprehensive Drug Report 2021, which is also available for download: How did the costs for medicinal products in Switzerland evolve in 2020 and what were the differences or special features compared to previous years? Which drug groups mainly contributed to these costs? Where can potential for savings be found and what do these have to do with biosimilars? How did the coronavirus pandemic affect drug procurement? Are there legitimate concerns concerning supply shortages for active substances? And finally: what about the varying frequency of use of controversial pain medication? We shall address these highly interesting issues in more detail below.

 

1. Which drug groups are the most expensive?

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%).

 

 

Overview of purchases, costs and persons with medication purchases

 

Compensation [in millions]

 

Costs [in CHF billion]

 

Persons receiving medicines [in millions]

  • Man

  • Woman

Source: Helsana; projection for the whole of Switzerland (2017 - 2020)

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.

 

Brief explanation: cost increase due to pembrolizumab

The active substance pembrolizumab was approved in Switzerland in 2015 for treating non-resectable or already metastasised skin cancer (malignant melanoma), but has since undergone several indication expansions (including for non-small cell lung cancer, Hodgkin’s lymphoma and urothelial carcinoma), again in 2020. The resulting increase in volume, however, has not yet been reflected in a significant price reduction.

2. Where is the potential for savings?

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.

 

Brief explanation: biosimilars

Biosimilars are imitation products (like generics in chemically produced drugs) of a biotechnologically produced medication. They have strong similarities to the original products but are considerably cheaper in price.

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%). 

 

Biosimilar quota by canton and active substance


Titel
Text
BE ZH LU UR SZ OW NW GL ZG FR SO BS BL SH AR AI SG GR AG TG TI VD VS NE GE JU
  • <=10.0%
  • 10.1 - 15.0%
  • 15.1 - 20.0%
  • >20.0%
Titel
Text
BE ZH LU UR SZ OW NW GL ZG FR SO BS BL SH AR AI SG GR AG TG TI VD VS NE GE JU
  • 0.0 – 10.0%
  • 10.1 – 20.0%
  • 20.1 – 30.0%
  • 30.1 – 40.0%
  • v
Source: Helsana; projection for the whole of Switzerland (2020)

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. 

 

«Today, service providers earn more when they dispense a more expensive medication. This is why low-cost generics and biosimilars are not achieving acceptance in Switzerland and an enormous savings potential of several hundred million per year remains unused. To eliminate this false incentive, fixed margins are needed that would always compensate the service providers to the same extent – whether it’s an original medication or a generic.»

Mathias Früh, Head of Health Policy & Public Affairs, Helsana

3. How did the coronavirus pandemic affect drug procurement?

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. 

 

«The many press reports about medication that can help against possible COVID-19 infections or make them worse have led to a high level of uncertainty within the population. For many medications, there was or is no clear evidence of a positive or negative influence on a SARS-CoV-2 infection. Due to concerns about ibuprofen, paracetamol was suggested to patients as an alternative. With ACE inhibitors, patients were advised not to simply stop taking the drug without reliable data. There was also increased demand for vitamin D. However, vitamin D is repeatedly publicised, without any evidence for preventing numerous health problems, and the argument in these cases is sometimes highly emotional.»

Professor Andreas Zeller, Head of the University Centre for Family Medicine of Basel (UNIHAM-BB), University of Basel

Purchases of three selected medications


1. Lockdown (2020)
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Source: Helsana; projection for the whole of Switzerland (2019 - 2020)

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. 

 

«We discussed the situation with patients at the beginning of the lockdown and where the clinical situation allowed, we delayed systemic therapies for a short time. Also, it wasn’t clear at the time whether and how a possible infection would affect immunotherapy, for example. But since we had sufficient resources at all times at the hospital, and for most patients, cancer posed a far greater threat to their lives than COVID-19, within a few weeks we continued the therapies in the same form.»

Professor Alfred Zippelius, Deputy Head of Oncology and Head of the Tumour Immunology Laboratory at the University Hospital Basel

Cancer therapies before, during, and after lockdown


1. Lockdown (2020)
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
  • 2019

  • 2020

Source: Helsana; projection for the whole of Switzerland (2019 - 2020)

4. Is there a risk of supply shortages for medication?

Responsibility of policy-makers and service providers

Who hasn’t stood in the pharmacy and had to accept the statement “unfortunately that’s not available at the moment”? Often an alternative solution can be quickly found but in some cases, the lack of a certain medication leads to difficult situations and even to health problems. Also in Switzerland, the number of supply shortages has been steadily increasing for several years. Although the situation last year was a special one and supply shortages were more severe and also more in the public focus, the issue must be seen in general terms because it is not a special feature of the coronavirus year. Since the production sites of many medications are not located in Switzerland and the Swiss market is relatively small, the country is often one of the first to suffer from supply shortages.

 

The cause of the problem is a worldwide decline in manufacturers. As a consequence, production is concentrated to a few or even only a single location. Due to globalisation, increasing cost pressure and regulatory requirements, parts of active substance production were also relocated to Asia in recent years. If, under these new circumstances, one particular site fails or reports a delay in production, a global shortage rapidly occurs.

 

Already in 2019, a year not yet affected by the COVID-19 pandemic, there were supply shortages for a total of 673 products of 371 active substances in the category of prescription medication from the specialities list (SL). This corresponds to almost one-third of all active substances of these dispensation categories in the SL. The majority of these were long-term supply shortages lasting longer than six weeks.

A quarter of all supply shortages affected products acting on the nervous system. These included, for example, antidepressants, antiepileptics, medication for Parkinson’s, analgesics and anaesthetics. Products with an effect on the cardiovascular system, which are vital for the survival of many patients, were also heavily affected.

 

Fortunately, the supply shortages were mainly non-critical, because other pack sizes and dosage strengths were still available to compensate. However, almost one-third proved to be very critical, as only one preparation is available on the Swiss market at a time. Despite the supply shortages, between 50% and 90% of affected patients were still able to obtain the medication affected at least once after the shortage began.

 

 

Distribution of medications affected by a supply shortage

  • Little critical

  • Critical

  • Very critical

Source: Helsana; projection for the whole of Switzerland, according to anatomical group (2019)

«The form of impact differs between medications for acute therapy and chronic therapies. With acute therapies, it's usually possible to decide which medication to use before treatment. This is exacting and in some cases risky but it doesn't require ongoing therapies to be adjusted. In the case of chronic therapies, a supply shortage is much more complex because new decisions have to be made very abruptly under ongoing therapy. Patients usually appear at the pharmacy or doctor's surgery when the medication is almost used up. It becomes particularly complex when complete active substances are missing. This means that patients have to be readjusted while under active therapy.»

Doctor of Pharmacy Enea Martinelli, Chief Pharmacist at Hospitals fmi AG (Frutigen, Meiringen Interlaken) and operator of the website Drugshortages.ch

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. 

 

 

5. What about the use of controversial pain medication?

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.

Brief explanation: agranulocytosis

Agranulocytosis is defined as a massive drop in white blood cells (leukocytes), which play an important role in the immune system. The resulting greatly increased risk of infection leads to death in an estimated 5% of affected patients.

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. 

«Metamizole is one of the most frequently prescribed painkillers in Switzerland. The medication gained a poor reputation in the 1970s because undesirable effects on blood formation (agranulocytosis) can occur. It is however now known that agranulocytosis as a result of the use of metamizole is only a very rare occurrence and is offset by high efficacy and good tolerability. According to the WHO phase model of pain therapy, metamizole – after paracetamol and ibuprofen – is on the first model phase as a non-opioid pain reliever for the treatment of fever and pain. The risk assessment of metamizole differs between Switzerland and other countries, but has not yet been conclusively clarified.»

Dr Carola A. Huber MPH, Head of Public Health Sciences, Helsana

Brief explanation: non-opioid analgesics (NOA) and non-steroidal anti-inflammatory drugs (NSAID)

Non-opioid analgesics (NOAs) are used to treat mild to moderate pain and reduce inflammation and fevers. NOAs include the classic non-steroidal anti-inflammatory drugs (NSAIDs, e.g. diclofenac, ibuprofen, mefenamic acid), cyclooxygenase-2 inhibitors (coxibs), paracetamol and metamizole. Between 2006 and 2013, purchases of all NOAs in Switzerland increased by 25% to 237%.

Purchases of metamizole, ibuprofen, paracetamol, diclofenac, mefenamic acid and etoricox-ib

Source :  Helsana ; Extrapolation pour toute la Suisse, achats par 100 000 personnes (2014–2019)

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.

 

Regional differences in purchases of metamizole, ibuprofen and paraceta-mol


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BE ZH LU UR SZ OW NW GL ZG FR SO BS BL SH AR AI SG GR AG TG TI VD VS NE GE JU
  • > +25.0%
  • +10.1 bis +25.0%
  • -10.0 bis +10.0%
  • -25.0 bis -10.1%
  • < -25.0%
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