[Reporter's View] Reimb criteria for cancer therapy

Latest updates & remaining issues

The Ministry of Health and Welfare (MOHW) has recently issued an administrative notice announcing an improvement to the National Health Insurance-covered reimbursement criteria for combination cancer therapy.

 

The revised policy states that the patient's co-payment will remain the same as the previously initiated treatment regimen, even if a new cancer therapy approved by the Ministry of Food and Drug Safety (MFDS) is combined with a drug previously approved for reimbursement.

 

Until now, the system has been unfavorable to patients.

 

When an individual uses a new drug in combination with existing therapy, the existing drug becomes non-reimbursed.

 

Therefore, the patient was responsible for the entire treatment course out-of-pocket.

 

The industry and patients welcomed the current measure, but a bigger issue related to new drug-new drug combination therapy remains unresolved.

 

In fact, almost 48% of 70 cases of combination cancer therapy that the MFDS approves falls into the category of new drug combination therapy.

 

Now that discussions about expanding reimbursement for combination therapies have been initiated, the focus has shifted to improve new drug combinations.

 

However, the interests of the government and the industry still do not align perfectly.

 

The government must consider a finite National Health Insurance fund, thereby demanding careful approach before green‑lighting high‑cost anticancer drugs.

 

Patient demand for innovative therapies is high, but broadened coverage could strain the National Health Insurance fund.

 

Pharmaceutical companies aim to quickly commercialize their products after the value of a new drug is acknoweldged.

 

The rationale behind this is to secure profits that meet global standards, compensating for the substantial investment in R&D.

 

Consequently, companies tend to pushback during price negotiations with the government or reluctance to supply detailed cost‐effectiveness data.

 

Pharmaceutical companies stress the significance of a 'patient‑centric' value and vision, declaring patient access improvement a core mission.

 

As they emphasize societal duties, critics say they must also accept the consequences during discussions for expanded reimbursement.

 

The recent measure to improve reimbursement criteria for combination therapy has prompted calls for companies to adopt a more forward-looking partnership.

 

At times, the pharmaceutical industry has placed the blame for new‑drug patient access issues on the government’s stringent approval criteria and low-price proposals.

 

Of course, a fundamental difference exists between a government that must respect budgetary constraints and companies driven by profit motives.

 

However, some critics argue that a company with a 'patient-centric' operation as its company core value must also proactively participate in improving the system that obstructs patients from receiving new drug benefits.

 

Several opinions suggest that the health authorities should reciprocate such efforts by fast‑tracking reimbursement decisions for therapies with proven benefits.

 

If each side defers responsibility to the other, the patients may be affected.

 

If pharmaceutical companies truly prioritize patients, they must fulfill their role as partners in improving policy to help solve remaining issues.

 

The government must also balance fair compensation and sustainable fund management in line with the evolving treatment landscape.

 

The issue of reimbursing new drug combination therapy is a complex challenge that can only be met through government-industry partnerships.

 

The government and pharmaceutical companies must be in the same boat for collaborating and have mutual responsibility toward this goal.

 

The recent improvements to the reimbursement criteria have opened the door to change.

 

We hope that the remaining issues will be resolved quickly and improvements will be made continuously.