Can rare disease access reforms resolve the blind spots?

Reblozyl, despite demonstrating 1.7× effectiveness vs. existing therapy, remains non-reimbursed for 4 years

Need for flexible evaluation of new drugs where cost-effectiveness analysis is difficult

Attention is focused on whether the government’s policy to strengthen access to rare disease drugs can be properly implemented in Korea.

As many new drugs still remain unattended, in the “blind spots,” some are also expressing doubts about the effectiveness of the policy.

Last March, the Ministry of Health and Welfare approved measures to improve the drug pricing system, and formalized its direction to increase patient access to treatments for severe and rare diseases and to appropriately evaluate the value of innovative new drugs.

While the pharmaceutical industry views this as a meaningful first step toward lowering the reimbursement barrier for rare disease treatments in Korea’s health insurance system, it notes that innovative rare disease drugs subject to cost-effectiveness evaluations remain in a blind spot.

The pharmacoeconomic evaluation is a stage that takes the longest in South Korea’s health insurance reimbursement evaluation process. New drugs that do not meet the criteria for exemption from pharmacoceconomic evaluation or for which the weighted average price of alternative drugs cannot be accepted must follow the existing procedure.

One example is ‘Reblozyl (luspatercept),’ a treatment for anemia in myelodysplastic syndromes (MDS) and beta-thalassemia. Reblozyl, which was approved in Korea in 2022, has remained a non-reimbursed drug to date after failing to pass the Health Insurance Review and Assessment Service (HIRA) Drug Reimbursement Evaluation Committee in August 2023.

This drug is the first erythropoiesis-inhibiting agent introduced in the MDS and anemia treatment landscape in decades. Based on the Phase III COMMANDS study, it is evaluated to have fundamentally reduced transfusion dependency by achieving a 1.7 times higher transfusion independence compared to existing treatment. A follow-up analysis published last year also suggested the potential for long-term survival benefits, including extended overall survival (OS).

Reblozyl is facing structural limitations in the reimbursement entry process. This is because the current health technology assessment framework, which requires setting the low cost of blood transfusions as the comparator, makes it difficult to reflect the drug’s true value.

Professor Joonshik Hong, Secretary of the Acute Myeloid Leukemia and Myelodysplastic Syndrome Research Group at The Korean Society of Hematology (Professor, Department of Hematology, Seoul National University Hospital) said, “Reblozyl not only practically changes the treatment paradigm by reducing prolonged hospital stays and the high burden of complications in patients who required repeated transfusions, but also has significant clinical meaning in that it is the first in the hematologic malignancy field to demonstrate long-term transfusion independence, thereby alleviating the burden on healthcare resources.”

He added, “Although it is effectively the optimal alternative and the only hope for patients with MDS-related anemia at moderate risk or lower who require blood transfusions, delays in its inclusion in the national health insurance reimbursement list mean that patients are forced to bear the full burden of transfusions and complications.”

In addition, in clinical practice, the need for a flexible evaluation system that reflects disease-specific characteristics is being raised for patients with de facto rare diseases who have difficulty making their voices heard within institutional blind spots.

In the case of MDS, there are only about 1,700 new cases annually in Korea, and only a very small fraction of those require treatment for transfusion-dependent anemia. Last March, a petition urging reimbursement coverage for Reblozyl was posted on the National Assembly’s public petition platform, but due to such limitations, the agreement rate remained at around 2% until just before its closure.

Professor Hong added, “The fact that MDS was excluded from the special calculation for rare diseases is merely because a separate review was not conducted due to it being applied a special designation for severe cancers. But it is, in fact, a rare disease. Just as paroxysmal nocturnal hemoglobinuria, which has a similar pathophysiology and requires chronic blood transfusions, is recognized as a rare disease, MDS also urgently requires flexible evaluation that takes into account its disease-specific characteristics.”