Further Helsana Reports
Increasing quantities and increasing prices. The costs of basic insurance for pharmaceuticals also rose in 2022. Overall, costs amounted to CHF 8.5 billion in the outpatient sector, which corresponds to an increase of CHF 360 million (+4.4%) compared with the previous year. One in four premium francs is now spent on medication. Analyses show that new drugs are becoming increasingly expensive. The new drugs, however, are often not innovations. In order to ensure the continued financing of real innovations, new pricing rules and cost-cutting measures such as volume discounts are needed. We increase transparency regarding the volume and cost development of the pharmaceutical market and the use of medications for cystic fibrosis and hepatitis C.
Medications are of crucial importance in healthcare. They have the potential to have a positive influence on the progress of diseases, shorten or prevent expensive hospital stays and increase the quality of life of patients. On the other hand, medications incur high costs and sometimes are unable to deliver on their promises, are not used in accordance with the latest medical knowledge or are disproportionately expensive.
Our figures show that medications are being used with increasing frequency: there are more people taking medication and more medication is being used per person. One aspect that stands out: new medications are often very expensive and usually have package prices of over CHF 1,000. These new treatments are not always an improvement on the previous ones and only 4 out of the 45 new ingredients in medications in 2022 were of an innovative nature. The public must be confident that it will not pay excessive prices for medicines, particularly in the case of pseudo-innovations. To determine this, we need to take a clear, unbiased look at the developments. As the largest health insurance company in Switzerland, Helsana Insurance has now made this possible for the 10th time by means of the drug report. The underlying publication from the Institute for Pharmaceutical Medicine (ECPM) at the University of Basel is available for download. The analyses provide the population and decision-makers with an overview of the developments in the pharmaceutical market. The information is intended to promote the sensible and efficient use of medication and to provide a sound basis for health policy discussions.
These are medications that are drive up costs in particular.
Last year, 6.8 million people (+5.2% more than in the previous year) purchased 127 million packs of medication (+3.7%), resulting in a total additional cost of CHF 360 million (+4.4%). The cost increases are primarily a result of relatively new drugs in the high-price segment. This leads to very high per capita costs for modern treatments, such as cancer, diabetes and cystic fibrosis treatments.
Cancer drugs cost over CHF 1 billion, just 0.7% of packs purchased. Modern monotherapies for the treatment of cancer are extremely expensive and now cost CHF 30,000 or significantly more per person per year. If different expensive medications are combined in one treatment, the costs are particularly high.
The diabetes market is currently changing as a result of new treatment approaches. The widespread disease has experienced a cost increase of CHF 50 million and will result in total costs of EUR 411 million in 2022. Two new drugs for lowering blood sugar and weight loss recorded strong cost increases of +57% and +32% respectively. Treatment used to cost around CHF 650 per year. Today it costs an additional CHF 1,000. More than 110,000 people have taken these new medications.
A new medication in the area of cystic fibrosis costs around CHF 135,000 per person. A total of 500 people were treated with it. The costs of around CHF 68 million for a single drug place a heavy burden on the healthcare system and are incurred every year.
There are significant differences in per capita medication costs from region to region.
Reasons for this include, for example, demographics, individual preferences and differences in the range of services on offer. Ticino, parts of north-western Switzerland and the canton of Geneva have 25% higher expenditure per capita than parts of central Switzerland and some cantons in eastern Switzerland.
Medication prices must fall – in the form of a volume discount.
The medication report shows that increasingly more expensive products are being taken. The population feels the results of this every year in the form of increased health insurance premiums. The formula prescribed for setting prices by means of comparing the prices of pharmaceutical products used for similar purposes domestically (therapeutic cross-comparison) and the prices of similar pharmaceutical products in other countries (international price comparison), plus any innovation surcharge that may be added, inevitably results in an upward price spiral because the comparative value is set at an increasingly higher level. To ensure that costs do not continue to rise by these amounts, the rules for setting prices must be fundamentally adjusted. An important element must be that prices automatically fall when a medication is used more frequently – in accordance with the principle of a volume discount.
Biologics are drugs that are produced in a biotechnological manner either from biological organisms or by means of biological processes. As a result of the fact that they intervene in the body’s own processes in a targeted manner, biologics have enabled great progress to be made in various therapeutic areas, such as the treatment of diabetes. These medicines are usually more expensive than conventional medicines, however, because they are complicated to develop and produce.
When the patent protection of a biologic has expired, other manufacturers can market imitation products, known as biosimilars. Biosimilars are, to a certain extent, generics of the original reference product, also called biologics. Because the manufacturing process is very complex, exact copies are not possible, although this also applies to different batches of the original biologics.
Therefore, a biologic and its associated biosimilars are interchangeable and do not differ in terms of their therapeutic efficacy, tolerability or safety. Concerns about their safety and fears of a complex switch from the original biologic to a biosimilar are therefore completely unfounded. Nevertheless, there is still great reluctance on the part of patients and specialists due to a lack of knowledge. This is probably the reason why, in 2022, biosimilars were only used for around a fifth of the purchases of active ingredients for which they were available.
A handful of affected individuals result in costs running into millions. Does the benefit to individuals and society justify such high costs for basic insurance?
There are new medications for the treatment of cystic fibrosis (CF), known as “CFTR modulators” (cystic fibrosis transmembrane conductance regulator modulators). They make it possible to treat the cause of the disease in affected individuals for the first time, rather than just alleviating the symptoms. This has revolutionized treatment and has significantly improved the quality of life of affected individuals, leading to positive economic and social effects. These positive effects, however, are offset by extremely high costs for medication. The annual recurring therapy costs for Trikafta® are estimated at CHF 135,000 per person. This is multiple times the medication costs for CF treatment in the period before the introduction of CFTR modulators. In 2022, the total cost of all CFTR modulators for adults was almost CHF 70 million. Trikafta® can be used much more widely than other alternatives of the same type, so this includes CHF 68 million for Trikafta® patients alone. Savings on other medications and in other areas of medicine, such as doctor’s visits, physiotherapy or inpatient stays are available, but in comparison to medication.
Cystic fibrosis (CF), also known as mucoviscidosis, is a complex genetic metabolic disease for which there is no cure. It therefore requires lifelong treatment. The salt-water balance of the cells is disrupted by a genetic mutation, which leads to the formation of thick, sticky mucus in certain organs. This mucus clogs the respiratory tract and makes patients subject to infections. In addition, the mucus blocks the ducts of the pancreas, which affects the release of digestive enzymes and the absorption of nutrients.
CF is a comparatively rare disease. At the end of 2022, there were almost 1,050 adults affected by the disease living in Switzerland. Early diagnosis (part of newborn screening since 2011), as well as medical progress in treatments and drug treatments, have significantly improved both the quality of life and the life expectancy of people with CF in recent years.
As a result of the fact that CF is considered a birth defect, disability insurance (Invalidenversicherung, IV) covers the costs of all medical measures necessary to treat the disease up to the age of 20. Health insurance is only responsible for the costs after the age of 21. The Helsana report therefore does not include data on CF-specific services for those affected up to the age of 20.
Used increasingly widely with expensive consequences
An important basis for determining the price of a new medication is therapeutic cross-comparison. The Swiss Federal Office of Public Health (FOPH) uses similar preparations as a basis; in the case of Trikafta®, probably as a result of the very expensive CFTR modulator, Kalydeco®. This comparison is flawed, however. While Kalydeco® was only suitable for a very small proportion of those affected by CF, Trikafta® can be used by the majority.
The high price for the medication, which can be used much more widely, has resulted in Trikafta® becoming one of the 20 active ingredients associated with the highest costs in just two years since its introduction, with sales of CHF 68 million. And that with only 500 people having received treatment. This makes Trikafta® the main cause of the enormous increase in costs relating to medications that affect the respiratory system. It is unlikely to stay that way, either, because a further increase in the volume of Trikafta® is foreseeable, as studies are already underway for use in CFTR mutations other than those for which it was previously approved. And there are more new products on the horizon. On the one hand, this means that more sufferers have the chance of receiving effective treatment. On the other hand, an increase in volume of this kind must also be reflected in the price. This is the only way to ensure that the basic insurance is capable of funding the costs of medication.
With lower prices when it was introduced, many more of those affected would have benefited from improved treatment at an early stage.
If a new active ingredient promises that it can heal, not just in the short term but also in the long term, then that is a major achievement. In the past, hepatitis C was treated using medications that were only partially effective. Almost half of the people treated had no treatment success; severe side effects and many contraindications occurred. Treatment typically lasted 24 to 48 weeks. Direct-acting antiviral agents (DAA) are now available and have a higher cure rate. The latest generation was approved in Switzerland in 2014 and, according to current knowledge, resulted in the elimination of the virus from the body and therefore to complete healing of the disease in 95% of cases after 8 to 12 weeks of treatment. These second-generation DAAs are a prime example of the market entry of a new class of drugs with significantly improved treatment results. Their use resulted in a clear increase in the efficiency of treatment and at the same time to a significant increase in the number of treatment starts, per capita costs and total costs.
As a result of the fact that the launch price of modern DAA treatments was very high at just under CHF 90,000, its use was initially limited to patients in very advanced stages of the disease and with substantial liver damage. The budget problem resulted in the rationing of the treatment for infected individuals. Today, the therapy costs are around CHF 30,000. Lower launch prices could have prevented this limitation on treatment. This would have meant that when the DAA were introduced, all known infected people who wanted treatment could have been treated and cured at an early stage and further infections would have been prevented.
Number of treatment starts
Per capita costs (CHF)
Hepatitis C is an infectious disease. It is caused by the hepatitis C virus and can be acute or chronic. The acute infection is usually asymptomatic or has very few symptoms and becomes a chronic form in around 70% of cases. The chronic form usually does not have many symptoms, but if untreated after several decades it can lead to serious liver diseases, such as liver cirrhosis or liver cancer, and require a liver transplant.
The epidemiological situation with regard to hepatitis C in Switzerland has undergone significant improvements in recent years. Nevertheless, 1,074 new cases were still reported in 2022. Hepatitis C is transmitted through contact with infected blood, for example through sharing needles when taking drugs, blood transfusions or (dental) medical procedures. In Switzerland, the first-mentioned transmission route is the main cause. In 2022, it was estimated that 30,000 people in Switzerland were infected; some of them are still untested and untreated. The number of unreported cases is therefore high.
The current total costs associated with hepatitis C arise almost exclusively from treatment with the medications and only to a small extent from the costs of other medications, hospital stays and doctor’s visits. The overall total cost level is almost the same as before the introduction of the second-generation DAAs. As a result of fact that the newer DAAs enable healing, they not only avoid follow-up costs, but also prevent new infections. This has improved the cost-benefit ratio for these drugs. However, this does not necessarily mean that the price is appropriate. The social and economic benefits are not factored into pricing when it comes to basic insurance. From a budgetary perspective, the treatment costs for a single person remain high, at CHF 30,000, particularly as a result of the fact that there is a long delay in the main benefit, i.e. the avoidance of serious complications at a late stage.
The Swiss hepatitis strategy has the aim of one day eliminating viral hepatitis in Switzerland. It is important that the price of medications should continue to fall in order to ensure that this goal can be financed. At current prices, medical treatment alone for the estimated 30,000 infected people in Switzerland would still cost around CHF 900 million.