9 drugs to be subsidised, rationale made public for the first time
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SINGAPORE — Nine drugs will be subsidised for patients with conditions such as acute migraine attacks, metastatic breast cancer and rheumatoid arthritis, according to the first tranche of 11 drug guidances issued by the Agency for Care Effectiveness (Ace) yesterday.
The materials published online by the agency — started by the Ministry of Health (MOH) in 2015 to promote appropriate patient care — are meant to give medical professionals and patients added information on suitable treatments as well as the availability of government subsidies for the medicines they need.
The guidances are based on an internationally accepted methodology used to assess the clinical and cost effectiveness of new technologies, the MOH said. They include the criteria for their appropriate clinical use, how they may be cost-effectively administered, and key evidence considered by the Drug Advisory Committee (DAC) in deciding on the subsidies.
This was the first time the MOH is making public the rationale behind the committee’s decisions on subsidies.
The ministry said this raised “the transparency of decision-making” and was in line with practices adopted by agencies abroad, such as Australia’s Pharmaceutical Benefits Advisory Committee.
In the first batch of guidances, the prices of some drugs — including rivaroxaban, a novel oral anticoagulant (Noac) used to prevent strokes in patients with atrial fibrillation — will be capped at a fair standard rate determined by “value-based pricing”, which considers the drug’s worth based on its health benefits, instead of cost, for example.
Atrial fibrillation is a form of irregular heartbeat and sufferers have a five-fold risk of a stroke.
Public healthcare institutions, including hospitals, must comply with the stipulated price ceilings.
Ace executive director Daphne Khoo said that with value-based pricing, patients would pay less for some drugs, and those eligible for subsidies will pay even less. “They also have better-quality information about the effectiveness of the treatments they’re opting for,” she added.
It also allows clinicians to grasp the benefits and costs of various forms of treatment, and give policymakers better information to aid decision-making on funding and subsidies, for instance.
In the case of atrial fibrillation, Ace found that Noacs were as effective as and safer than warfarin — an inexpensive drug that is commonly used to treat the condition but can vary in its effectiveness because of its frequent interactions with food, drugs and supplements.
Noacs were found to carry a lower risk of bleeding in the brain than warfarin, but were 30 to 50 times costlier. Despite this, Ace’s assessment found that they brought good value for money, taking their health outcomes into account.
Three Noacs were evaluated, with rivaroxaban significantly cheaper than the other two.
With value-based pricing, the drug will cost up to S$3.08 a day for patients without Medication Assistance Fund (MAF) subsidies, down from S$4.40 to S$5.70 previously. For patients who qualify for help under the MAF, it will cost S$0.77 a day with a 75 per cent subsidy, for instance.
Other drugs that will see stipulated price ceilings are the intravenous formulation of trastuzumab to treat metastatic breast cancer and dapagliflozin for Type 2 diabetes mellitus. Other newly subsidised drugs include immediate-release gliclazide for diabetes and sumatriptan for acute migraine attacks.
Each year, Ace asks the public hospitals about the drugs that patients would like subsidies for, drawing an average of between 40 and 50 submissions. Typically, about 20 from this pool are chosen for evaluation for clinical and cost effectiveness. Some drugs cannot be assessed accurately because of factors such as inadequate information.
Using health-technology assessment to compare their effectiveness, the agency takes anytime between six weeks for simpler assessments and nine months to complete more complex economic models. Its guidances will also encompass devices, procedures and services in future.
The assessment measures the differences in health outcomes and costs of a new technology and those of the present standard of care over, for example, a 30-year timeframe for drugs.
The agency looks not only at the extent that a drug being considered is superior, but also its cost-effectiveness — in other words, its clinical benefits for patients relative to its cost.
With the information, the DAC, which comprises about 15 expert clinicians, meets to decide whether a drug should be subsidised, by way of inclusion in the Standard Drug List or the MAF.
Among the criteria that informs the committee’s decisions are patients’ clinical needs and the nature of the condition, the safety of the technology and whether it is value for money in comparison to present alternatives.
After the committee’s decisions are set out in the pieces of guidance issued by Ace, other MOH units will track their appropriate use to ensure compliance through audits.
