100 instead of more than 1000 francs for eye medication: health insurers are fooling the federal government

Critical patient asks questions

Like thousands of other elderly people, Elfie Grendene suffers from poor eyesight. “I started losing my sight more and more in just a few months,” says the 87-year-old. She suffers from wet age-related macular degeneration. There are three medications available, but in Switzerland only the two most expensive ones may be administered.

“For each eye treatment, the medicine alone costs almost 1,000 francs. When I found out, I thought I wasn’t hearing properly,” says Elfie Grendene. “I have problems with this commercial drug. We all pay for this with our premiums. No wonder they keep rising.” Elfie Grendene did not want to support that and changed doctors. “My new ophthalmologist said: ‘The injection costs a lot less for me.’” By switching doctors, the patient also saves money. The lower costs mean she has less to pay your own risk.

Effective, but not approved

The new doctor’s prescription to combat high drug prices is as simple as it is effective. He simply injected the cheap drug Avastin into the vitreous humor of his patient’s eye – instead of one of the two expensive drugs. Many other doctors do this too.

Medically speaking, there is nothing wrong with the cheap Avastin. It is safe and effective, this has even been proven in court. The only problem: Avastin is not approved as an eye drug because manufacturer Roche does not want it. The Basel-based pharmaceutical company has never registered Avastin as a treatment for wet age-related macular degeneration. It is only registered as an anti-cancer drug. If a doctor does inject Avastin into the eyes, this is called off-label use. This means he is taking a drug that is outside of official approval. This is allowed if patients agree.

Ten times more expensive than the alternative

If a doctor chooses Avastin, the cost of the medication drops by a tenth. Avastin is 90 percent cheaper per application compared to the two officially approved drugs from the Basel pharmaceutical company Novartis. Specifically: the Novartis drug Lucentis costs CHF 866.75 per pre-filled syringe, the Novartis drug Eylea costs CHF 987.50. Avastin, on the other hand, only costs CHF 80.95 per application, as shown by the medical bills available to the observer.

The federal government prohibits health insurers from saving money

However, health insurers are not actually allowed to pay these bills – due to a federal regulation. Payment is “not permitted,” the Federal Office for Public Health emphasizes when asked. However, health insurers have found a creative way to circumvent the Berne directive.

Several health insurers confirm in background interviews that they pay Avastin bills from ophthalmologists without any problems. In these cases you simply look away. As long as they don’t check the bill, they won’t officially notice anything. Therefore, their behavior is legally acceptable. They simply turned a blind eye in the interest of premium payers and in the interest of economic efficiency. This means: To save costs on compulsory basic insurance, health insurers must circumvent the law.

Fines of 175 million francs for Roche and Novartis

There are good reasons for this secret resistance from health insurers. In ophthalmology it has been known for 18 years that Avastin works. Five years ago, the European Court of Justice ruled that Avastin could be used against wet age-related macular degeneration. And in May 2023, Roche and Novartis were even convicted in Italy in the final instance – for anti-competitive price fixing for the two medicines Avastin and Lucentis. The Italian competition authority interpreted their behavior as cartel formation to the detriment of Italian patients. Roche was fined 90.5 million euros, Novartis 92 million euros.

The two pharmaceutical companies from Basel had litigated against these fines in all courts for nine years – and lost. Italian courts are convinced that Roche and Novartis conspired to prevent the off-label use of the cheap drug Avastin. Because Roche and Novartis are intertwined through investments and licensing agreements for these drugs, both benefit.

Pharma is not aware of any culpability

A spokesperson for Novartis said they regretted Italy’s decision. “Novartis firmly believes that the company has at all times acted appropriately and in accordance with competition law and the interests of patients.”

A Roche spokeswoman said only about the Italian fine: “Avastin is not approved for the treatment of eye diseases.” Roche’s job is to research and develop new medicines.

Pharmaceutical companies are lobbying against a solution in Switzerland

Italy took action, Switzerland did not. In September 2023, the Federal Council bowed to the demands of the health lobbies. A spokeswoman for the federal media says that the responsible parliamentary committees of the National Council and the Council of States have strongly criticized the project. During a roundtable discussion, Federal Councilor Alain Berset’s Interior Department looked for “compromise solutions” and ultimately decided not to propose broad off-label use to the Federal Council as a whole. The off-label use of cheap drugs such as Avastin was not legalized on January 1, 2024 as planned.

During the consultation, Roche and Novartis tried to dissuade the Federal Council from its plan. The Novartis spokesperson gives the Observer the reasons: widespread off-label use is a “threat to the established legal, medical and regulatory system designed to ensure the official approval and use of effective and safe medicines in patients.” Roche’s spokeswoman said the project would have “undermined guaranteed patient safety and intellectual property protection.” In principle, medicines may only be used in those areas for which they have been developed, tested and approved by Swissmedic.

However, the price monitor regrets that the Federal Council “has abandoned this important cost-saving measure in favor of those who pay premiums”. It could have been implemented “without any loss of quality for the patients”.

Ophthalmologists earn very well from the procedure

Doctors are paid very well for administering the shot, even if it is used off-label. Regardless of which drug you use, for the short pecks per eye you can expect between 268 and 402 francs. These costs are in addition to the medicine costs. This is confirmed by health insurer Santésuisse and the purchasing combination of Helsana, Sanitas and KPT.

The ophthalmologist’s reimbursement is so high because injecting into the eye was considered far too time-consuming under the Tarmed tariff system. For a long time no one was interested. “But when the drug Lucentis came onto the market, this process became a mass intervention,” says the person responsible at a major health insurer. “Nowadays eye clinics are like a factory. The exercise aid gives everyone a drop in the eye and then people are treated as if they were on a treadmill.” The health insurer describes administering an injection in the eye as “the best-known, much too expensive Tarmed position”.

Lower reimbursements for doctors demanded

The spokesperson for health insurer Santésuisse confirms this: “The tariff classification will probably be relatively high.” However, there is no room for significant price reductions due to Tarmed’s high rankings. Unfortunately, negotiations for a new Tarmed have been blocked. Santésuisse is therefore dissatisfied and has developed a new flat-rate system that is based on real cost data and not on Tarmed.

Elfie Grendene is simply grateful to her doctor, who chose the cheap Avastin. “He was able to stop the deterioration of my vision. As he promised. He took my concerns about this matter with the injection of R1,000 seriously.”