SPEECH BY DR JANIL PUTHUCHEARY, SENIOR MINISTER OF STATE, MDDI & MOH, IN RESPONSE TO ADJOURNMENT MOTION ON “RECOGNISING ECZEMA AS A CHRONIC DISEASE”

1. Mr Speaker, Sir, I would like to thank Ms Tin Pei Ling for raising the situation of patients with eczema, and for explaining to the House the condition and the symptoms suffered by these patients.

2. Eczema can affect anyone at any age. As Ms Tin pointed out, in Singapore, about 20% of children and 11% of adults have eczema. Most cases are mild to moderate, and for most patients the symptoms can be managed with over-the-counter moisturisers, topical and oral medications, self-care measures and the avoidance of triggers. For most patients, this approach works quite well. Ms Tin has highlighted the difficulties faced by the patients that have the most serious forms of Atopic Dermatitis and Eczema.

Including eczema into the CDMP

3. I thank Ms Tin for her suggestion to include moderate to severe eczema into the Chronic Disease Management Programme, or CDMP.

4. The CDMP is a programme established since 2006 with the intention to improve care for chronic disease patients, by making treatments more accessible and affordable for Singaporeans. Today, the CDMP covers 23 chronic conditions, including common conditions like diabetes mellitus, hypertension, and hyperlipidemia.

5. Patients with these conditions can use MediSave to pay for the out-of-pocket costs for their outpatient treatment. Those with complex conditions can claim up to an annual limit of $700. They can also tap on government subsidies of up to $500 per year under the Community Health Assist Scheme, if they are eligible for CHAS, and special subsidies of up to $540 per year if they are Pioneer Generation or Merdeka Generation cardholders.

6. Conditions under CDMP are regularly reviewed by the Clinical Advisory Committee (CAC). This comprises Family Physicians and specialists from the public and private sectors. Gout, allergic rhinitis and chronic hepatitis B were most recently added to the CDMP on 1 July 2022.

7. In selecting conditions for review for inclusion into the CDMP, the CAC takes into account feedback from medical professionals, patients and the public.

8. The CAC consults clinical experts in various healthcare settings, and considers factors such as the disease burden, potential benefits of early intervention to patient outcomes, the cumulative cost to the patient from long-term treatment, and the availability of evidence-based clinical guidelines for appropriate care of the condition.

9. In 2020, the CAC had decided not to include eczema under the CDMP. Care practices for eczema currently vary significantly and there are currently no standardised national guidelines for the treatment of eczema. Without such standardised and accepted guidelines, we may run into challenges such as overdiagnosis, or inappropriate treatment. The Agency for Care Effectiveness at MOH is currently developing these clinical guidelines for the treatment of atopic dermatitis. Once these guidelines have been established, the CAC will review if eczema can be included into the CDMP.

10. Even though eczema is currently not on the CDMP, patients can already receive subsidies for the treatment of eczema today.

11. Topical steroid creams and oral systemic immunosuppressants such as ciclosporin, azathioprine, methotrexate and mycophenolate mofetil are listed on the Standard Drug List. Abrocitinib, a Janus Kinase inhibitor drug, as mentioned by Ms Tin, is also listed on the Medication Assistance Fund (MAF) for patients who do not respond adequately to immunosuppressants.

12. Eligible patients who are prescribed these drugs for eczema can receive up to 75% subsidies at polyclinics and the Specialist Outpatient Clinics, or SOCs.

13. Additionally, Singaporeans aged 60 and above can use up to $300 a year of their MediSave under the Flexi-MediSave scheme to pay for their outpatient eczema treatment and medication at polyclinics, SOCs and CHAS clinics.

Inclusion of dupilumab into MOH’s list of subsidised drugs

14. I would also like to acknowledge Ms Tin’s suggestion to include biologics or monoclonal antibodies such as dupilumab into MOH’s list of subsidised drugs.

15. Today, MOH provides subsidies for a list of drugs that are assessed by the Drug Advisory Committee (DAC) to be both clinically- and cost-effective. This ensures limited healthcare resources are directed to therapies that provide good value compared to existing standards of care, and keeps healthcare spending sustainable.

16. In 2023, the DAC listed abrocitinib on the Medication Assistance Fund for people who do not respond adequately to immunosuppressants. Abrocitinib was assessed to be at least as efficacious as dupilumab and available at a cheaper price. It is also an oral medication. Dupilumab, an injectable, was not recommended for subsidy, as its benefits do not justify its costs, at the current price proposed by the manufacturer.

17. Ms Tin mentioned that overseas assessments of the incremental cost-effectiveness ratio for dupilumab range from $48,000 to over $160,000 per Quality-Adjusted Life Year gained. However, we are unable to rely on cost-effectiveness assessments if there were significant limitations in the methodology and design of the studies. For example, many published industry sponsored cost-effectiveness studies provide favourable results due to overly optimistic assumptions made about the clinical outcomes of treatment. The studies may also not be generalisable to our local setting if the price of the medication differs significantly compared to that offered to patients here in Singapore.

18. Ms Tin had also suggested to allow the use of dupilumab for children below six. There are several subsidised treatment options available for children, such as topical steroid creams, and, for the more severe patients, oral immunosuppressants. We note that some of these young patients may still require dupilumab if they are not assessed to be suitable for these subsidised treatments.

19. And notwithstanding the benefits of dupilumab for this age group, dupliumab remains non-cost-effective at the population level in this setting.

20. So if patients face issues affording dupilumab, they may approach medical social workers at our public healthcare institutions to apply for financial assistance through MediFund.

21. We will continue to regularly review the list of subsidised drugs to ensure that the list stays relevant to changes in our local population needs, medical practice and the evidence on clinical and cost effectiveness.

22. Mr Speaker, Sir, MOH will continue to review the adequacy of support for eczema patients, taking into consideration the safety, clinical efficacy, and cost-effectiveness of these treatments. No Singaporean will be denied access to appropriate healthcare due to an inability to pay.

23. Thank you, Sir.