‘The more innovative the treatment, the higher the price tag of the cancer drug’

Between 2017 and 2022, expenditure on expensive cancer treatments increased from 651 million euros to 2.7 billion euros. These increased expenditures can mainly be attributed to innovative treatments.

“The question is how far we want to go along with this as a country,” says health economist Renaud Heine of Erasmus University Rotterdam. He recently obtained his PhD, under the supervision of ‘expensive medicine expert’ Carin Uyl, for research into access to expensive, innovative cancer therapies for Dutch patients.

The cost dilemma is increasing, Heine outlines: “It is often true: the more innovative and targeted the treatment, the higher the price tag. But at the same time we are also getting older and the number of people who will develop cancer is increasing. It is currently the leading cause of death in the Netherlands and, according to predictions, the number of cancer diagnoses will increase by 47 percent between 2019 and 2040. We cannot ignore this patient group.”

The costs can be considerable. Take CAR-T therapy, a cell therapy against blood cancer. Producing this treatment costs around 350,000 euros per patient. Although CAR-T therapy is reimbursed from the basic package, only a small group of strictly selected patients are eligible due to the high costs. If the Netherlands were to offer and reimburse the therapy for all cancer patients for whom the treatment may provide health benefits, the treatment would cost around 1.4 billion euros per year – if the government did not make price agreements with the pharmaceutical company.

Aren’t there guidelines for this, which determine when a drug is ‘too expensive’ for what it delivers?

“We approach it differently than many countries around us. In Germany, for example, a drug comes onto the market as soon as the European Medicines Agency (EMA) has approved it and the added value is primarily an important factor; Does the treatment possibly offer something that comparable, already available treatments do not yet offer? The downside is that in Germany no less than 14 percent of the healthcare budget is spent on medicines. In the Netherlands the price tag carries much more weight. Here, after approval from the European Medicines Agency (EMA), the Healthcare Institute gives advice to the minister – whether or not to reimburse in the basic package – and it is a political choice what happens to that advice. For expensive medicines, that choice also depends on the extent to which the government is successful in negotiating prices with the pharmaceutical company.”

If we demand that these medicines be offered at a much lower price, the question is whether companies will still want to invest

Patients are therefore largely dependent on the price that the pharmaceutical company attaches to an innovative drug. Is that price justified?

“The Netherlands is one of the leaders in Europe in the use of generics. These are products whose patent has already expired and which can now be produced at a low price because manufacturers compete with each other on efficiency.

“But this market law does not apply to innovative medicines. Developing such medicines requires large and daring investments, so it is ultimately the pharmaceutical company that determines the price tag. This is partly based on production and research costs, but on top of that they can turn the ‘added value’ button to further increase profits. This method raises ethical questions, but we must also remain realistic: if we demand that these medicines be offered at a much lower price, the question is whether companies are still willing to invest in such innovative medicines.”

How big is the difference between the sales price and the cost price of such resources?

“That cost is often unknown. Pharmaceutical companies keep market-sensitive information secret. We have tried to calculate the cost price for a number of well-known gene therapies against hereditary diseases and have arrived at significantly lower prices than what the pharmaceutical company asks for them. Take Zolgensma, a drug against the muscle disease SMA: 380,000 euros instead of the 1.9 million euros it currently costs. Or Libmeldy, for people with a rare hereditary metabolic disease: 1 million euros instead of 3 million euros. We expect good long-term effects from both treatments, but that remains to be seen. Is such a high price justified? You can question that.”

Because the bar for reimbursing expensive therapies is so high here, patients are also declared ‘finished’ more quickly

With treatments with such high prices, shouldn’t we just say: we won’t do it?

“Compared to neighboring countries, we test the effectiveness of a drug much more stringently, but because the bar for reimbursing expensive therapies is so high here, patients are also declared ‘out of treatment’ more quickly than in other countries. Not every patient wants to continue treatment at all costs, but depriving someone of the opportunity in advance is a sensitive matter.

“Moreover, the percentage of our healthcare budget that is spent on medicines (8 percent) is relatively low compared to neighboring countries. In Europe, only Denmark spends less on medicines than us in percentage terms. That is certainly worth a compliment to our government, but the individual patient has a different interest.”

Are you saying: we are too frugal in the Netherlands?

“Just like in many other European countries, the Ministry of Health, Welfare and Sport (VWS) negotiates vigorously with pharmaceutical companies about the price of a new drug. I see that as something positive, we are a star in haggling in this market in the Netherlands. For some resources we only pay half the original price. But here lies another risk for the patient: if such a negotiation takes too long or falls apart, the patient will not have access to the drug.

“It is a political choice how far we want to go as a country, but we are now seeing the first signs that we are becoming less and less attractive to pharmaceutical companies: there are recent examples of products for which the Ministry of Health, Welfare and Sport has demanded a discount that the pharmaceutical company has not yet agreed to. gone. These resources will therefore not be reimbursed here for the time being.”

Will the treatments you talk about in your dissertation save lives on a large scale?

“Most of the treatments in my dissertation are used for metastatic cancer and are therefore life-prolonging rather than life-saving. It may be the case that drugs that are now used as life-prolonging therapy may later prove to be life-saving, whether or not in combination with other treatment. We are talking about brand new treatments, so we often do not yet know what their long-term potential is.”

In your dissertation you say: whether a patient has access to such a drug is not just a matter of money.

“Certainly not. Money is a major factor in the Netherlands, but it is also a matter of time: how long after the development of a new medicine can the patient use it?

It is not always a bad thing to do things differently than other countries

How well is the Netherlands doing in that respect, compared to other countries?

“It starts with the enormous difference between Europe and the United States. The American medicines agency FDA takes an average of 181 days to approve an innovative cancer drug for use, compared to 378 days for the European Medicines Agency EMA. That’s strange; The same studies are based on both processes and both agencies almost always give the same assessment.”

And once the drug has been approved for the European market?

“Then there is the time between approval and the moment that it is decided in the Netherlands to reimburse the drug and the hospitals can actually purchase it. There we see enormous differences between European countries, from seventeen days in Germany to sometimes up to two thousand days in some Eastern European countries.

“The Netherlands did reasonably well about ten years ago with an average of 128 days, but in our research we studied products that were approved in 2012. It now seems to be taking a lot longer, due to the tough negotiations with the pharmaceutical company. We notice a trend towards longer waiting times for patients, which worries me.

“It is not always a bad thing to approach things differently than other countries, but it is extremely frustrating for the individual patient. You simply live in the wrong country.”

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