Helsana-Report: Drug Report 2022
Costs at an all-time high

High cost growth due to individual, very expensive treatments

The medication costs borne by basic insurance exceeded CHF 8 billion for the first time in 2021. Costs grew considerably faster than in the previous year (+4.6%), as did both the number of people purchasing medications (+1.3%) and the number of medications purchased (+0.5%). This trend is primarily attributable to individual and very expensive new medication-based treatments.

• The ranking of the highest-cost drug groups has been unchanged for years and is headed by immunosuppressants, which generated an impressive CHF 1,217 million or 15% of the total costs in 2021. They also have the highest per capita costs, with average treatment costs of CHF 10,030 per year. Total costs for this group increased by 4.8% or CHF 50 million year on year.
• The second-most expensive group of active ingredients is cancer drugs, which accounted for 12% or CHF 971 million of total costs, a marked increase of 11.9% compared with 2020. This was the largest percentage increase in costs across all drug groups compared with the previous year. Costs for this group of active ingredients have risen by a full 30% since 2018.
• The most expensive individual active ingredients in 2021 were the eye medication aflibercept, the cancer drug pembrolizumab and the anticoagulant rivaroxaban. Of particular note was the entry to the market of the combination product Trikafta^® for the treatment of cystic fibrosis, which generated sales of CHF 39.2 million in the first ten months after it was launched in February 2021.
• The two high-cost medications Keytruda^® (pembrolizumab) and Trikafta^® (ivacaftor, tezacaftor, elexacaftor) together generated sales growth of over CHF 65 million year on year. Both medications are governed by pricing models, casting doubt on the FOPH’s ongoing assertion that pricing models actually result in lower costs.

Pricing models do not help to reduce costs

Medication pricing is based primarily on a therapeutic cross-comparison (efficacy and treatment costs compared with approved medications for the same illness) and a price comparison with other countries (currently nine reference countries). In addition, an innovation premium is occasionally applied for new and especially innovative products. Deviations from the conventional method used to set prices are referred to as pricing models. Such pricing models have become increasingly prevalent since 2020 in particular. In many cases this is because a manufacturer does not accept the prices determined using the conventional method, leading to delays in approval.

• The proportion of new medications subject to pricing models is increasing year on year. While a total of 17 new approvals with a pricing model were added to the specialities list in 2015, this rose to 76 in 2021. Overall, 39% of the preparations added to the list between 2015 and 2021 were governed by a pricing model.
• Pricing models are chiefly used for high-cost medications and accounted for 15% of all medication market sales in 2021. The approach is particularly prevalent for cancer and immunotherapy drugs, but pricing models are also becoming increasingly important in other areas.
• Pricing models can help facilitate access to innovative treatments thanks to the additional flexibility they offer. It is still debatable, however, whether the “actual price” does result in lower costs. This would only be the case if the prices were lower than those determined using standard pricing rules. In reality, manufacturers have practically zero interest in accepting lower prices than those currently guaranteed by law.
• Moreover, pricing models generate additional administrative costs that are borne by premium payers. Sales margins and VAT are calculated on the basis of the artificially inflated “shop window” price, while the reimbursement procedure associated with the pricing model approach also increases administrative costs without creating any additional economic benefits for premium payers.

Despite all these critical aspects, their growing international popularity means the trend for pricing models is unlikely to be reversed any time soon.

Pricing models achieve very little in terms of reducing costs, as there is no incentive for the industry to accept prices below those under the current statutory pricing rules. The opaque elements of pricing models should be eliminated wherever possible rather than being legitimised. Contrary to current political efforts, therefore, the rules on transparency, governance and the Freedom of Information Act should actually be strengthened rather than weakened. Since the international ramifications of the issue limit individual countries’ scope for unilateral action, Switzerland should lobby for innovative, sustainable and transparent forms of medication pricing at a European level.

Better information on medication with regard to pregnancy

It has long been known that taking medication during pregnancy carries a risk. However, it cannot always be avoided. To back this up, analysis of the data from 2021 revealed that 87.7% of pregnant women purchased at least one drug that was covered by health insurance. Overall, this figure is even higher during pregnancy than before it. In most cases these were well-tested, safe drugs used to treat common pregnancy-related conditions and complications, indicating that pregnant women in Switzerland generally receive high-quality and integrated care.

Some medications can be particularly harmful for an unborn child, however, and should therefore definitely be avoided during pregnancy. These are known as teratogens.

• In 2021 14.4% of all women of childbearing age purchased teratogenic drugs. Among women under 26, these were most commonly acne treatments (systemic retinoids, 4.7%), which are classed as recognised strong teratogens.
• It is pleasing to note that in most cases women switched from potentially teratogenic drugs to safe alternatives prior to becoming pregnant. This shows that doctors are largely aware of the risks of potential teratogens.
• Nevertheless, 1.4% of pregnant women took potential teratogens in the first trimester of their pregnancy. Recognised strong teratogens were purchased in 36 out of 100,000 pregnancies, which may have far-reaching consequences in individual cases.
• In 14 of these 36 pregnancies the medication in question was the anti-epileptic drug valproate and was primarily purchased in the first trimester. Valproate was the recognised strong teratogen most commonly purchased in the first trimester, at a rate of 1.1 per 10,000 pregnancies. Exposure to valproate in the first trimester can cause occasionally serious structural abnormalities in around 11% of children. Exposure at later stages of pregnancy also causes neurodevelopmental disorders in 30-40% of children. Valproate should therefore be avoided during pregnancy wherever possible. However, this was still a more frequent occurrence until the introduction of a birth control programme at the end of 2018 led to a fall in purchases of valproate during pregnancy. The situation must now be monitored to see whether this positive trend continues.

The data analysed shows that pregnant women are well served in Switzerland where medication is concerned. However, the analysis did identify room for improvement with regard to women of childbearing age who regularly take potentially teratogenic medications. They need to be informed in good time, for example during regular gynaecological check-ups, about the risks of teratogens in the event of pregnancy. In the case of women with chronic conditions, an interdisciplinary assessment of treatment options must take place prior to their becoming pregnant.

Increase in volume must lead to lower prices

Over one million people in Switzerland suffer from migraines. Alongside tension headaches, migraines are one of the most common types of headache, affecting 18% of women and 6% of men.

• A comparison of triptan purchases before and after the start of treatment with CGRP antibodies showed that patients receiving long-term CGRP treatment purchased 60% fewer triptans for the treatment of acute migraines than they did beforehand. This suggests that patients receiving long-term treatment with CGRP antibodies suffer fewer (acute) migraine attacks.
• There are concerns from a pharmacoeconomic perspective, however, as the annual costs of treatment with CGRP antibodies are many times higher than the costs of conventional standard preventive treatments. In 2021, for example, costs of CHF 19 million were generated by 4,800 people who purchased at least one CGRP antibody drug.
• In the case of long-term CGRP purchasers, medication costs rose by a remarkable 82% following the start of CGRP treatment. Three quarters of this was solely attributable to CGRP antibodies.

In Switzerland, the prescribing of CGRP antibodies is subject to conditions (known as limitations), such as a certain severity of symptoms and the frequency with which they occur. Discussion is required to establish whether simplifying access to this form of treatment may be sensible in some cases. However, current study data shows that CGRP antibodies only lead to a slight reduction in the number of migraine days; this justifies the strict conditions, but not the high costs!

As the new CGRP medications almost double treatment costs compared with existing methods, access to them is heavily restricted. If these limitations are lowered, as is currently being called for, the resulting increase in volume must be accompanied by a substantial price reduction. Otherwise, insured persons will face a further financial burden.