Column by Stefan Meyerhans: And the groundhog greets you every day…

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Health insurance premiums are increasingly becoming a luxury item in terms of price. This is why it is so important to eliminate as many costly errors and obstacles from the system as possible. There are many of them, and it is incredibly difficult to change this, since the lobby fiercely defends its sinecures.

Here’s the latest twist on the old story: maximizing profits by juggling permits with Medis. Instead of an impending happy ending to our healthcare costs… nothing happens again.

What’s the matter? To give an impressive example, the widespread eye disease wet AMD (wet age-related macular degeneration) can be effectively treated. In theory, expensive drugs are available, each costing between 600 and 1000 francs (per injection!), as well as a drug called Avastin, which “only” costs between 50 and 100 francs per injection. The effect is equally good for all drugs.

Both the cheap Avastin in this case and the much more expensive Medi Lucentis (which is approved for the treatment of wet AMD) were developed by Roche. Avastin was originally developed and approved as a cancer treatment. Effectiveness in wet AMD is an added benefit, so to speak.

Because the pharmaceutical industry is not interested in selling a cheap drug instead of an expensive one, Roche ended its use by never applying for approval of Avastin as an eye drug.

This is very bad for us because health insurance companies are generally only allowed to reimburse for drugs approved to treat this disease. There can only be exceptions, the so-called “off-label use”, if there are no other effective drugs.

However, in the case mentioned, there are other drugs available and therefore Roche can legally prohibit the use of the cheaper Avastin for the treatment of wet AMD.

In 2022, the Federal Office of Public Health (BAG) estimated the savings potential at this level alone to be up to 150 million francs per year. And this example, of course, is not an isolated case.

This is why I suggested that the cost-effectiveness criterion should also play a role in rewarding off-label use. To put it simply: drugs should be able to be reimbursed by health insurance, even if they are not only effective but also cheaper than approved alternatives. After all, cost savings are not only urgently needed, but also enshrined in health insurance law.

Last year, BAG wanted to include a cost-effectiveness criterion in its rule changes. Unfortunately, this sensible proposal for change was again buried – probably after intense lobbying.

The Federal Council was unable to insist on this provision. This means that large potential savings are not realized, which could be realized without loss of quality. This is not clear to me.

Source: Blick