Collaboration fundamental when managing, altering private drug plans

As the landscape of Canadian drug plan management continues to evolve, several programs are being implemented by insurers and pharmacy benefits managers to help plan sponsors manage costs.

Speaking on a panel at Benefits Canada’s 2019 Face to Face Drug Plan Management Forum on Dec. 3 in Toronto, Ned Pojskic, leader of pharmacy and health provider relations at Green Shield Canada, said employers often find it difficult to navigate the complexities of these programs.

When considering these complexities, plan sponsors need to request outcome data, he added. “If we evolve to a place where we look at things in a quantified fashion, we’re going to have more solid conversations around the value of various programs.”

Read: Measuring quality of health-care providers touted as opportunity for change

When it comes to the relationship between PBMs and pharmacies, there’s been a significant change, said Billy Cheung, executive director of pharmacy, marketing and professional affairs at Pharmasave Ontario, who also spoke on the panel. Payers are now looking at outcomes and inquiring whether pharmacists are doing their jobs. “I think that’s critical here,” he added. “It’s pointless to be paying for medication if it’s not doing what it’s supposed to do.”

This evolving relationship involves accountability and results. If employers are simply paying pharmacies on a fee-for-service basis, volume will be the only benefit, said Pojskic. Alternately, paying for outcomes will result in better outcomes, he added, noting payers and PBMs have a precedent to set on behalf of plan sponsors.

Preferred pharmacy networks, structures where prescriptions are filled through specific pharmacies, are essentially prescription exchanges for lower prices, noted Pojskic, but the most recent development has been specialty PPNs, which come with a lot of infrastructure. Since specialty drugs are complex by nature, dispensing them isn’t comparable to common drugs and it’s harder to develop knowledge if quantities are low, he added. “There’s value in PPNs, not only from a centre of excellence perspective, where specialty drugs are dispensed at a higher volume and can develop expertise, but also from the perspective of all the support involved.”

Read: Important questions to consider before making changes to a benefits plan

Also speaking on the panel, Karen Kesteris, chief product officer at Express Scripts Canada, said plan sponsors can help ease employees into PPN transitions through adequate communication, with digital methods the best option. “Plan members become comfortable with pharmacists. They have long-standing relationships and it can be difficult for them to break these. The more support you can provide, the easier it will be.”

When looking at a PPN model, employers should also question whether they’re considering short- or long-term effects, noted Cheung. “You may simply be gaining short-term savings and your costs will continue to rise. What you should be looking at is the long-term perspective — whether or not you’re contributing to health and wellness overall.”

In addition, non-adherence rates, which range between 30 and 50 per cent, are critical and affect health outcomes data, said Kesteris. For example, a person with asthma is far less adherent to their medication than an oncology patient, she added. Also, the more medication a plan member takes, the less adherent they are. “If a person’s taking one medication, they’re normally not too bad. But by the time they get to two, three or four, their level of adherence drops off completely.”

According to Cheung, adherence is a huge opportunity for long-term savings and reducing negative outcomes. However, Pojskic noted it’s extremely difficult to address. For instance, studies have shown post-heart attack patients aren’t adherent to medications. “If someone has such a symptomatic condition, they just went through a tragic event and still aren’t adherent, how are we going to get a patient who’s taking a statin to prevent a first heart attack to stay on their medication? It’s a systematic challenge and I do think pharmacy is the best position to handle that.”

Read: Express Scripts Canada rolls out medication non-adherence detection program

In the private insurance industry, most plans have historically had open formularies, said Pojskic, which meant a drug approved by Health Canada was available and automatically covered. But managed formularies, which are given thorough review before listing, are now much more prevalent. “We’re encouraging plan sponsors to move toward this because it’s essential going forward — not only as a signal to the pharma industry, but because of the necessary rigour that needs to take place to ensure they’re paying for the most valuable drugs,” he said.

The idea that managed formularies exclude a variety of drugs is a myth, said Kesteris, noting 85 per cent of available drugs are normally covered. “They may not be on a tier one or tier two — or they may be for the generic and not the brand drug — but from a therapeutic perspective, you’re going to get the drug you need.”

Read more stories from the 2019 Face to Face Drug Plan Management Forum.