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You don’t expect it – and then suddenly it’s there. Cancer. In Germany, more than every fifth person falls ill before their 70th birthday. What’s it like being terminally ill and not knowing if you can get cancer medication? A cancer patient tells.
Sarah Siksou is 46 years old and has cancer. She has completed 15 cycles of chemotherapy. She needs a break. Her doctor is hoping for the drug Tibsovo from the French pharmaceutical company Dienst.
However, the drug has not yet been approved in Switzerland. Siksou’s doctor submits a cost credit request to the health insurance company. This examines it and rejects a assumption of costs. Siksou is outraged about this: “It can’t be the case that my therapeutic option vanishes into thin air because of one or the other’s greed for profit.”
On your own
After the cancellation of the health insurance company, she finally turned directly to the manufacturer, with the help of her lawyer and her doctors. Together they were able to negotiate that Siksou’s drug therapy is free every other month. She has to pay for 25,000 francs every other month herself.
Sarah Siksou only received the drug in the autumn of last year and has not yet had to pay anything. At this point in time, she does not know whether it will also affect her.
Helsana, Sarah Siksou’s health insurance company, wrote on request that it was a tragic case. Helsana receives more than 6,000 such inquiries every year, 80 to 90 percent of which are either approved immediately or allow a therapy attempt.
“A rejection only occurs if the legally required criteria are not met,” says the health insurance company. She tells Sarah Siksou that the price is too high and the benefit of the drug is too small.
Julian Wampfler from Inselspital Bern is Sarah Siksou’s oncologist. Many of his patients depend on medicines that are not yet approved.
Applying for cost credits is part of Wampfler’s everyday life and takes time. This is “very disturbing”, especially for patients like Siksou, whose lifespan is limited.
If a drug is not approved in Switzerland but is vital, Article 71 of the Health Insurance Ordinance applies. This obliges the health insurance company to check whether the costs will be covered.
Specifically, a doctor issues a cost approval to the health insurance company. One or more medical examiners from the health insurance companies check the application for effectiveness, practicality and cost-effectiveness and try to negotiate a price with the manufacturer of the drug. In many cases, the first step is a so-called therapy trial, in which the pharmaceutical company makes the drug available free of charge for a few months. If it helps, the health insurance company will cover the costs.
In the case of Sarah Siksou, the health insurance company and Dienst were unable to agree on a price or an attempt at therapy. The manufacturer, Dienst, writes on request: “Servier does not communicate the prices of products that are not registered in Switzerland.”
Her case is particularly poignant for Siksou’s doctor. Because it is unusual for a seriously ill patient to negotiate directly with the pharmaceutical company. Not all people would have the energy and the ability to stand up for themselves like that. “But ultimately the situation is a result of the prevailing framework conditions,” says Wampfler.
The back and forth with the health insurance company and the pharmaceutical company cost Sarah Siksou a lot of energy, as she says herself: “I find that very frustrating. It’s a one on one fight. If you don’t lead it yourself, nobody will lead it.”