Lung cancer experts call for fairer execution of health insurance finance

Lung cancer experts have criticized the reimbursing situation of anticancer drugs, pointing out that the government grants insurance benefits only after patients petition for them.

The cancer specialists raised questions about whether healthcare financing is being executed more fairly and efficiently.

They noted, for instance, that the 3 trillion won ($2.23 billion) currently poured into oriental medicine could reimburse 20 Keytruda-class anticancer drugs, 34 Tagrisso-class drugs, and 35 Leclaza-class drugs for the first-line treatment of lung cancer.

The experts also raised issues with the Cancer Disease Review Committee (CDRC) under the Health Insurance Review and Assessment Service (HIRA), which has been criticized for its “reviewing-in-the-dark style” operation. They pointed out that the results of the meetings were not disclosed even to the experts who gave their opinions.

Noting that anticancer drugs are in a “gray zone,” the experts said that if the reimbursement standards are not concretized further, it may be difficult to provide optimal treatment to some patients.

On Thursday, the Korean Association for Lung Cancer (KALC) held a “joint symposium” with HIRA at its fall conference to discuss ways to improve the reimbursement structure for anticancer drugs.

Professor Yoon Shin-kyo of the Department of Oncology at Asan Medical Center raised the issue with the CDRC’s deliberation structure, which is the first gateway to the reimbursement of anticancer drugs.

“I was asked for an expert opinion on the use of immuno-oncology drugs to prevent recurrence after lung cancer surgery. The letter asked for a submission in three days,” Professor Yoon said. “However, one must not have participated in the relevant research to qualify as an expert. I understand the need for such an expert. Still, having an expert who hasn't participated in the study doesn't make sense, even though it's to avoid being cited for a COI (conflict of interest). There are no experts who have not participated in global clinical research.”

Yoon pointed out that the problem is that the comments experts present by taking time out of their busy schedules are not accepted, and they don't even know why their comments were not accepted.

“Even if you submit your views amid difficult situations, the disclosed result of the CDRC’s deliberation is just ‘no reimbursement standard has been set,'” Yoon said. “If they discussed the appropriateness of benefits, it would be convincing if they provided a report on the discussion process. In this way, if you need to make an opinion later, you can make an opinion based on it.”

“We must think about whether ‘saying just the reimbursement standard has not been set’ befits the mission vision of the HIRA, which is a fair evaluation process and a solid healthcare system,” Professor Yoon said. “I am skeptical whether experts expect all these administrative procedures. In contrast, Europe and the U.S. are very detailed about why they approve drugs and their reimbursement.”

Notably, Yoon pointed out the government’s policy of expanding the benefits of oriental medicine by comparing it to anticancer drugs.

“This year, the support for herbal medicine has been expanded, and for example, the evidence level for allergic rhinitis ‘Socheongyongtang,’ which is prescribed in herbal medicine, is shallow, but CDRC said it is listed in the herbal medicine prescription book, is in textbooks, and is used frequently in China and other countries,” Professor Yoon said. “I would like to ask again whether the reason for not setting the benefit standard is due to the difference of 5-20 percent and whether the economic opportunity cost could explain it. We must consider whether the public agrees and whether it is an efficient use (of insurance finance).”

“In 2022, 76 trillion won in health insurance premiums was collected, of which 10 trillion won was spent on malignant neoplasms, and 3 trillion won was spent on oriental medicine,” Yoon said. “However, the opportunity cost of 3 trillion won for oriental medicine is enough to pay for 20 Keytruda-class anticancer drugs assuming it required 176.2 billion won for using Keytruda as the first-line lung cancer treatment, 34 Tagrisso-class anticancer drugs if Tagrisso is used for primary lung cancer (92 billion won), and 35 Leclaza-class anticancer drugs if Leclaza is used for primary lung cancer (88.1 billion won).”

“I would like to say that an environment should be created where the government and experts can proactively provide benefits without the need for patients to petition,” Yoon said. “It is important to have an environment where fairness and common sense can be expected. For this, the decision-making process should be predictable, the basis for the decision should be disclosed, and in the case of pharmaceuticals, fair and predictable evaluation criteria should be established regardless of the field.”

Professor Yoon also called for “establishing review criteria based on science and technology, respecting expert opinions.”

Professor Hong Min-hee of Yonsei Cancer Hospital took issue with the “gray zone,” where the criteria for reimbursement of anticancer drugs are unclear.

“The number of reimbursed drugs in lung cancer has indeed increased compared to the past, but there are many areas where the staging or pathological diagnosis is ambiguous or insufficient in the application of reimbursement,” Professor Hong said, presenting the examples of “gray zone” in clinical practice.

She pointed out that the current reimbursement criteria may not fully reflect the rapidly evolving lung cancer treatment landscape, as it is unclear whether different treatment options are available for different stages or pathologic diagnoses.

“If the HIRA's reimbursement standards are not further concretized, it may be difficult to provide optimal treatment to some patients,” Hong warned. “To provide the best treatment to more patients, it is necessary to collect opinions from experts continuously, flexibly apply the collected opinions to reimbursement policies, and provide channels for free communication with the HIRA.”

Kim Kook-hee, head of the Pharmaceutical Management Office at HIRA, introduced various cases where reimbursement standards were not set.

“The fact that many anticancer drugs do not have reimbursement standards does not mean that they are ineffective,” Kim said. “There are many good drugs out there, but they are too expensive, so we must consider their cost-effectiveness.”

“We are preparing financial arrangements by, for instance, excluding artificial tear solutions and cholinergic drugs from the reimbursement list. Still, it is not easy,” Kim said. “Considering the overall sequence, allowing new anticancer drugs to be used in the first line may be good. However, as a review agency, we are still agonizing over whether we are conducting a reasonable financial operation.”