Singapore Experience Shows Benefits of Value-Driven Strategies in Generating Biosimilar Savings

Value-driven health care strategies in Singapore's public health care institutions have led to high biosimilar adoption rates, improving affordable access through reduced treatment costs and producing significant savings for the health care system, according to a study published in PharmacoEconomics – Open.¹

Escalating health care costs are a global concern, with drug spending in the Asia-Pacific region accounting for nearly one-third of total health care expenditure. In Singapore, the pharmaceutical market reached $1.2 billion in 2022, with public sector drug spending growing at an 11% compound annual growth rate from 2017 to 2020, driven by high-cost biologics. Additionally, total spending on biologics increased 51% from 2023 to 2016, according to Singapore's Health Sciences Authority (HSA).²

Value-driven strategies to increase biosimilar use in Singapore have produced significant savings and expanded affordable access to medications. | Image credit: whitcomberd - stock.adobe.com

Drugs in Singapore's public health care sector receive subsidies via the Standard Drug List (SDL) or Medication Assistance Fund (MAF). Financial assistance schemes like the Pioneer Generation and Merdeka Generation packages further improve affordability. Infliximab biosimilar was the first to be subsidized under the MAF in 2018, followed by adalimumab, which was later listed on the SDL in 2020 after a cost-minimization approach.

Patent expiries have introduced lower-cost biosimilars, but adoption faces challenges like clinician concerns and patent litigations. To overcome these, the HSA and Agency for Care Effectiveness (ACE) implement value-driven strategies. Since approving the first biosimilar in 2012, ACE has facilitated the adoption of several biosimilars, including infliximab, which achieved a 70% utilization rate within a year of listing for subsidy in 2018. Other biosimilars like adalimumab and trastuzumab have also been subsidized to enhance affordability and access.

In Singapore, the ACE successfully promoted biosimilars by providing evidence and highlighting cost benefits, leading to faster adoption. ACE also worked with health officials to showcase the benefits of biosimilars. This approach worked well in Denmark and Sweden but has been less effective in the Republic of Korea and the US. Another key strategy is to replace expensive drugs with cheaper, effective alternatives. For instance, ACE recommended switching from the original infliximab to a biosimilar and supported doctors with resources.

Pricing strategies include negotiating significant price reductions for biosimilars. Ongoing monitoring by the National Pharmacy and Therapeutics Committee helps track biosimilar adoption. Despite initial slow uptake due to COVID-19, continued efforts increased trastuzumab biosimilar use to 72% in 2 years. Regular review and engagement are essential for improving adoption.

The retrospective cross-sectional analysis sought to examine changes in adoption rates and utilization and spending trends driven by different value-based strategies now that the nation has reached the 5-year anniversary of the inclusion of the first monoclonal antibody biosimilar on the subsidy list.

“Such insights provide valuable information about Singapore’s experience and contribute to the global understanding of effective strategies for driving biosimilar use,” the authors explained.

The study focused on 5 monoclonal antibodies with biosimilars subsidized by the Ministry of Health (MOH) in Singapore from 2018 to 2022: infliximab, adalimumab, trastuzumab, rituximab, and bevacizumab. Data on product details, subsidy implementation dates, and background information were sourced from the HSA register, MOH circulars, and ACE technology guidance documents.

Additionally, the study utilized aggregated drug utilization data from public health care institutions, including hospitals and polyclinics, covering 12 months before subsidy listing until December 2022. The analysis involved monthly trends in utilization volume, biosimilar usage proportion, drug spending, patient treatment numbers, and cost savings. PDD and drug spending were calculated, excluding rebates and free stocks.

Researchers observed that ACE’s strategies produced an upward trend in biosimilar use corresponding with subsidy implementation dates. Infliximab use doubled post listing in 2018, stabilizing in 2022, with biosimilars reaching 80% market share after 2 years. Rituximab, adalimumab, and bevacizumab biosimilars captured over 95% market share within a year. Trastuzumab biosimilar adoption was slower, reaching 72% after 2 years, influenced by the introduction of new formulations and drugs like trastuzumab deruxtecan.

Spending on biosimilars dropped significantly due to lower prices, with an 80% average price reduction across biosimilars. Infliximab saw a 90% price drop with the second biosimilar entry. Despite increased adalimumab use, spending stabilized and then decreased as prices fell. The number of patients using these biosimilars increased from 1800 in 2018 to nearly 4100 in 2022, while overall spending halved from $57 million to $25 million. The introduction of biosimilars saved the health care system $74 million in 2022, totaling $136 million over 5 years, with trastuzumab contributing the most savings.

“Singapore’s success in its high adoption rate of biosimilars hinges on a multi-pronged approach, similar to what is practiced in the United States (US) and several European countries. In addition, Singapore’s efficient healthcare system, geographical advantage, and synergies in supply chain within public healthcare facilitated swift biosimilar adoption,” wrote the authors.

References

1. Tan SH, Goh LGH, Ong BSK, et al. Impact of value-driven healthcare strategies for biosimilar adoption: The Singapore story. Pharmacoecon Open. Published online July 23, 2024. doi:10.1007/s41669-024-00491-w

2. Biologics and biosimilars clinician fact sheet. Singapore's Health Sciences Authority. February 2018. Accessed July 29, 2024. https://www.ace-hta.gov.sg/docs/default-source/drug-guidances/biosimilar-clinician-fact-sheet-(1-mar-2018).pdf?sfvrsn=a5078756_0#:~:text=Biosimilars%20that%20are%20approved%20for,equivalent%20to%20the%20reference%20biologic.