Forum: A way to balance escalating healthcare spending and individual patients' needs

The recent flurry of articles and Forum letters about the upcoming insurance coverage changes for oncology drugs has highlighted fundamental issues that policymakers and healthcare providers have to address.

First, clinical practice is not "cookbook medicine". Patients, especially in this age of precision medicine, can and do deviate from clinical practice guidelines which are population-based.

The Ministry of Health's (MOH) Cancer Drug List, made up of only "effective and cost-effective drugs" is developed similarly based on population-level clinical studies and will be inadequate for every patient; some individual cases will merit off-label prescriptions.

Second, there are significant price differences between the public and private sectors. The drug dabrafenib, as highlighted by MOH, has a $12,000 per month price difference (Cancer patients can access more affordable care and financial support at public healthcare institutions, June 27).

Third, private sector doctors and pharmaceutical companies are commercial entities and have to balance patient care and access with profits. If we want to optimise outcomes for the public good - for example, straightforward access to the latest medicines and best possible pricing - then the Government will have to intervene.

What, then, should we do? On off-label use, Straits Times senior health correspondent Salma Khalik has suggested that MOH stipulate that use of such drugs must show benefit within a limited period for its continued insurance coverage (Rules on cancer treatment financing in Singapore can be improved, June 13).

I suggest an independent panel of experts to review doctors' appeals on behalf of their patients, and the panel's findings could even be made public for good governance and public education.

Some combination of my and Ms Khalik's suggestions could help balance the overarching public interest of managing escalating healthcare spending with individual patients' very natural desire to have affordable access to what could be life-saving therapies for them.

Harmonising drug pricing across public and private sectors might be trickier but could be achieved if all stakeholders - insurers, doctors and pharmaceutical companies - come together.

We have to recognise the legitimacy of each group's position and agree on what are reasonable profits for private sector stakeholders while moderating annual premium increases for Singaporeans.

The rule changes take effect in just two months. These fundamental issues need to be resolved, for the sake of the more than 23,000 people here who are diagnosed with cancer every year.

Jeremy Lim (Dr)

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