Effect of New Insurance Coverage Limits on Cancer Patients and Their Treatments

8 Dr Lim Wee Kiak asked the Minister for Health regarding exceptional cases where patients urgently require drugs that are not within HSA’s approved list (a) how can the Ministry assist these patients who require non-standard treatment options to qualify for claims under the current health insurance policy; (b) whether the Ministry will consider setting up a national body where medical experts can be swiftly mobilised to consider and approve these requests; and (c) how often does the list of approved drugs get updated to keep pace with medical advances.

9 Mr Yip Hon Weng asked the Minister for Health (a) how many cancer patients will be affected by the new policy that limits insurance coverage for outpatient cancer drug treatments; (b) what is the recourse for patients who do not respond to these drugs; and (c) how often will the list of drugs be reviewed to ensure that it stays abreast with medical developments, especially new and rare cancers.

The Senior Parliamentary Secretary to the Minister for Health (Ms Rahayu Mahzam) (for the Minister for Health): Mdm Deputy Speaker, with your permission, may I address Question Nos 8 and 9 together, and also Question No 71 for oral answer and Question No 41 for written answer filed by Mr Gerald Giam for the Sitting on 4 July, please?

Mdm Deputy Speaker: Please proceed.

Ms Rahayu Mahzam: The current claim limit that is applied to all types of cancer drugs gives pharmaceutical companies little or no reason to lower prices and takes away the Government’s negotiating power. This has resulted in an unsustainable rise of cancer drug prices. If left unchecked, cancer drugs will, eventually, be unaffordable for the majority of cancer patients.

The changes, focusing MediShield Life and Integrated Shield Plans (IPs) to cover a Cancer Drug List (CDL) of clinically-proven and more cost-effective cancer drug treatments, improve affordability in two ways.

First, it provides the incentive for pharmaceutical companies to price their drugs more reasonably so as to benefit from financing coverage. Since we announced the changes in 2021, we have managed to secure an average price reduction of 30%. For some cancer drugs, the price reduction achieved was over 60%. The lower prices have made more cancer drugs cost-effective, enabling 66 more cancer drugs to be listed for subsidy.

Second, nudging utilisation of cancer drugs towards proven and cost-effective care will ensure that treatment costs for the broad majority do not rise unsustainably as a result of liberal use of very expensive and novel cancer drugs. These changes will benefit thousands of patients and improve affordability of more cancer drugs for all Singaporeans.

The CDL is extensive. We already have a panel of experts, comprising senior public and private oncologists and haematologists across various specialisations, who recommend new treatments for inclusion into CDL. This panel has approved treatments that cover multiple lines of therapy, beyond first line treatment, as well as rare cancer treatments to CDL.

This has allowed us to include around 50 more treatments into CDL since it was announced in August 2021. The current CDL covers some 90% of treatments used in the public sector and is updated every four months to keep up with medical advancements and latest clinical evidence.

However, we note that there could be exceptions where patients do not respond to treatments on CDL and their doctors may exercise clinical discretion to prescribe non-CDL treatments based on evidence of benefit. In these cases, doctors must be prepared to justify their clinical decisions to patients and their colleagues. Doctors must also counsel the patient on its risks, efficacy and costs so that the patient may make an informed choice. Some patients may still be covered for such non-CDL treatments by their private insurance, such as riders or critical illness plans.

In this transitional period, MOH will put in place measures for the small number of exceptional cancer patients who require non-CDL treatments and are affected by the policy changes. Private patients who have difficulty affording their bills may opt to be transferred to subsidised care at public healthcare institutions. Once patients are in subsidised care, they can benefit from more affordable drugs and medical fees, as well as access a range of financial assistance, such as MediFund. All patients can also appeal to use more MediSave.

Mdm Deputy Speaker: Dr Lim Wee Kiak.

Dr Lim Wee Kiak (Sembawang): I would like to thank the Senior Parliamentary Secretary for the reply. I would like to ask, since we know that once the policy is changed and companies can drop the drug price by as much as 60%, is this not proof of profiteering? What actions are taken against this company for profiteering?

My second supplementary question is on patients who have rare cancers and are requiring those drugs which are not on the list currently. Is there a mechanism for them to appeal for them to be added on to the ad hoc list? And what is the timeframe for that?

Ms Rahayu Mahzam: I thank the Member for the question. Actually, the whole intent of this is to make sure that cancer drug prices are lowered and the best safeguard against profiteering is competition. In this regard, the Agency for Care Effectiveness (ACE) uses the established Health Technology Assessments to evaluate the relative value of new drugs, compared to existing standards of care. In parallel, ACE also conducts value-based pricing negotiations to ensure drug prices are competitive.

So, the financing changes that we made have been a major step to incentivise drug companies to price drugs competitively so that their drugs would be eligible for subsidies, MSHL and IPs. And because of this, we have seen the promising results that I mentioned earlier.

In respect of the Member's concern with regard to profiteering, actually, the Competition and Consumers Commission of Singapore also has levers to investigate all reports of anti-competitive behaviour and will take action against instances of anti-competitiveness.

The Member has also asked about the process and I would like to take some time to explain the assessments made by ACE I mentioned earlier. ACE assesses the clinical and cost effectiveness, using published methodologies that are in line with international best practices. And it draws on clinical, epidemiological and health economic data, compare the incremental costs and incremental improvements in health benefits of the treatment relative to the existing standard of care.

As part of this process, ACE consults MOH's Oncology Drugs Sub-Committee comprising local clinical experts from the public and private sectors to ascertain the clinical value of medicines and evaluation and the appropriate use of cancer therapies based on clinical evidence.

The Member also asked about the timing. Actually, the process has been put up on ACE's website. Drug companies that wish to participate in this process would be able to time their applications accordingly. The key process deadlines have been put up online and it usually takes about five months from submission until the funding decision. Funding implementation, typically, occurs within four to six months after a funding decision has been made. But with timely evidence submission, high quality of clinical evidence and reasonable pricing proposals from the pharmaceutical companies, these will help to expedite it.

Since January 2021, ACE has also established a new process in consultation with the pharmaceutical industry to enable cancer treatments to be evaluated for subsidy and MediShield Life, in parallel with HSA's regulatory approval process. Under this process, companies will be responsible for providing evidence submission to ACE, in parallel with HSA's regulatory approval process. All these would be done in tandem. This will bring funding decisions upstream, close to the point of market entry. So, they can do it ahead of time. By the time it comes in, we would already have allowed for it to be put in. This minimises the time gap between HSA registration and inclusion into the drugs list. I hope this addresses the Member's questions.

Mdm Deputy Speaker: Mr Yip Hon Weng.

Mr Yip Hon Weng (Yio Chu Kang): I thank the Senior Parliamentary Secretary for her reply. I have two supplementary questions.

First, how does MOH ensure that insurers do not shortchange policyholders who have been dutifully paying their dues and what recourse do policyholders have to appeal against decisions from insurers?

Second, are there guidelines on the premiums that insurers charge and what is the oversight on this? While patients are allowed to change insurers, many, often, have little choice in changing insurers due to the coverage of existing conditions and risk loading.

Ms Rahayu Mahzam: Actually, there is an existing regulatory oversight. MOH and MAS work closely together in exercising regulatory oversight over Integrated Shield Plan (IP) insurers. IP insurers have to seek approval from MOH for any changes in terms and conditions and MAS will take action against insurers if they do not pay claims in accordance with the policy terms and conditions that they have agreed to or if there is any unfair handling of claims.

IP premiums are set, reviewed and adjusted by insurers based on commercial and actuarial considerations. Insurers may adjust premiums, taking into account the impact of the changes and their own claims experience and other factors. So, insurers have an incentive to help keep premiums competitive to attract and retain their policyholders. So, we hope all these changes, in the long run, will help to moderate premium increases.

I also realised that I have not really addressed Dr Lim Wee Kiak's question about how patients can appeal for drugs to be considered for inclusion in CDL. They can refer the drug to ACE for ACE to make that assessment. We also note that, in the process where there are private patients, there is that opportunity for them to have direct referral to the public health institutions and this is where the assessment can also be made in respect of the appropriate treatment. There will also be subsidies available to that patient.

Mdm Deputy Speaker: Mr Gerald Giam.

Mr Gerald Giam Yean Song (Aljunied): Thank you, Mdm Deputy Speaker. I am not sure if my question on the introduction of a National Cancer Care Appeals Board was answered. I understand from the ACE website, which the Senior Parliamentary Secretary just referred to, that it takes about 10 to 11 months from the time the pharmaceutical firms submit their pre-submission form to ACE to the time the Drug Advisory Committee (DAC) meets. However, for individual cancer patients, for whom time is of the essence, anything more than one week may be too long to wait for a decision on a drug subsidy approval. Can we, therefore, have a National Cancer Care Appeals Board which can make rigorous yet speedy decisions to subsidise drugs for these patients to get the life-saving drugs that they need? DAC can then take the necessary time to review the drug for inclusion into the Cancer Drug List to benefit patients at the national level.

Secondly, has MOH modelled out how many patients per year will be adversely affected by these changes to the insurance schemes and how much in cost savings are expected and what is the price in human lives that MOH is prepared to accept in order to achieve these cost savings?

Ms Rahayu Mahzam: I thank the Member for the question. First off, we need to appreciate that when doctors actually make recommendations for treatment, it has to be on the basis of evidence. All new and existing patients should be properly advised of the proven efficacy, side effects and costs of the available treatment options, including the financial implications of receiving a treatment that is not on CDL at the earliest opportunity.

So, we appreciate that by creating this drug list, there may be some patients who may require drugs outside the drug list and may face difficulties. This could include patients who already have tried drugs on CDL and found them ineffective for patients with contraindications to the drugs on the cancer list. But there needs to be evidence of efficacy of the prescribed drug outside CDL. I just wanted to make that clear.

In respect of those patients on a case-by-case basis, because what happens is that we have provided this lever where there is, actually, a direct referral to the public healthcare institutions (PHIs). They can, therefore, get discretionary funding that is available to them, thereby getting treatment at a far lower cost. It is through this referral that the doctors in the PHIs will then be able to assess the appropriate treatment that is meant for the patient.

The other question is related to the number. The number of patients who will be affected by the cancer drug treatment changes is actually constantly fluctuating. As patients drop in and out of treatments and, given the ongoing work, we are, actually, expanding the treatments on CDL.

Nonetheless, we have looked at this and CDL actually covers around 90% of cancer drug treatments used in PHIs. And we have already said that, if they face difficulty and require non-CDL treatments, if they face difficulty affording the drugs, they can be referred to PHIs and they can get discretionary financial assistance.

I know this is something that is challenging for patients who are facing these situations. But we need to look at the bigger picture and, that is, to reduce the ever-increasing drug prices. With the moves that we have made, we have seen a reduction and this is something that we need to continue with. We have to help those who are not able to be covered under the list as much as we can. We also then have to monitor the process as we go along to see and ensure that, in the long run, it will actually benefit more Singaporeans when all the drug prices can be moderated and are lowered because there is an incentive for the pharmaceutical companies to lower their prices.

Mdm Deputy Speaker: Ms Ng Ling Ling.

Ms Ng Ling Ling (Ang Mo Kio): Thank you, Mdm Deputy Speaker. I want to thank Senior Parliamentary Secretary Rahayu Mahzam for her replies and explaining the ACE process on how cancer drugs are evaluated, negotiated, because bringing the prices down really helps our Singaporeans. I wanted to ask whether MOH will consider extending the negotiated price – or maybe more of a clarification – whether the negotiated price is also extended to benefit the private healthcare providers. This is because ACE does tap on a committee that comprises public and private oncologists and, as parliamentarians, we would all know of a resident or someone we love who has cancer and is battling cancer and seeking private healthcare for reasons that we all understand, because they want to get well. So, I just wanted a clarification whether that negotiated price also benefits our private healthcare providers to help our Singaporeans battling cancer.

Ms Rahayu Mahzam: I thank the Member for the question. The challenge is, private clinics have varied business models and pricing arrangements. So, the feasibility of applying negotiated drug prices to the private sector really depends on whether price controls can be introduced to ensure cost-savings are passed on to the patients. This is also subject to the agreement by the drug companies. This is something that will require further study. We will take this back and look into it and have extensive engagements with the industry.