OBJECTIVES: This year marks the fifth anniversary of the national HTA service commencement in Singapore, embodied by the Agency for Care Effectiveness (ACE) with the mission to issue credible guidance and inform sound reimbursement decisions. The purpose of this review was to identify methodological patterns and key areas of consideration driving those decisions.

METHODS: Published drug guidances were critically reviewed and pivotal clinical and economic evidence informing the deliberations was extracted and appraised.

RESULTS: Fifty appraisals for seventy-seven medications have been undertaken by the ACE resulting in inclusion of eighteen drugs in the Standard Drug List (SDL) and twenty-two in the Medication Assistance Fund (MAF); six of the drugs were subsidized following revised price proposals. Thirty-seven drugs received a negative recommendation on the ground of unacceptable cost-effectiveness or budget impact. Available clinical evidence on effectiveness and unmet need were scrutinized and two medications (daptomycin, mychophenolate) were assessed for off-label use in view of local clinical practice. In the absence of local cost-effectiveness analyses, overseas assessments - primarily from NICE and PBAC - were used as benchmarks to explore their generalizability to the Singaporean setting. Furthermore, cost-minimization approach was used to determine cost-effectiveness in nineteen assessments where scope medications exhibited comparable efficacy and safety. Thorough budget impact estimates were fundamental component in all assessments and value-based pricing negotiations played a significant role in subsidy discussions. None of the assessments accounted for patient commentary or insights.

CONCLUSIONS: Although clinical attributes and need are taken into account, drug prices and budget impact are of core significance in the ACE HTA procedures. Price discounts by the manufacturers seem to provide an extra edge for positive recommendations. Going forward, Singapore would benefit from endorsing patient voice in guidance development, as this will enhance the legitimacy and credibility of the decision-making process.