Drug plan stakeholders discuss cost management and patient needs at Benefits Canada‘s 2014 Toronto Face to Face Drug Plan Management Forum

At this year’s forum, dialogue centred on achieving a careful balance. While focused on managing drug costs effectively, employers also identified concerns over balancing potential savings from new benefits plan designs with the specific needs of the members who use those plans.

Brent Fraser, director of drug program services at the Ontario Ministry of Health, described the gains the government has made in bringing down expenditures in Ontario’s public drug program through initiatives such as negotiations with manufacturers and reductions in generic drug prices. “The cost per claim has dropped by 10%,” he said.

But he also sounded the alarm on the rising costs of specialty drugs—a concern that’s clearly top of mind for both government and private payers. Fraser said the “unprecedented growth rate” of cancer drugs emerging on the market—a rate he estimates will be 10% to 20% over the next few years—will be a big headache, as these medications are gradually moving into the private payer realm. He also explained Ontario is wrestling with a small percentage of claimants with high drug costs—a reality employers know all too well. “Seven percent of our beneficiaries account for 40% of our costs,” he noted. “How do you support these high-cost users?”

Cost drivers

Most of the specialty drug spend relates to a handful of conditions—a fact revealed through a careful examination of drug claims. Specialty drugs include biologics and small cell molecule drugs used to treat conditions such as rheumatoid arthritis and psoriasis. These medications can cost $15,000 to $30,000 a year per patient, said Andrew Gosse, president of the Canadian Psoriasis Network. Even though subsequent entry biologics (biologic drugs that are similar to and enter the market following an approved biologic) are coming onto the market, costs will still be in the thousands of dollars per patient annually.

“It’s essential to drill down on any numbers to see what’s happening,” said John Herbert, director, strategy, product development and clinical services, with Express Scripts Canada. This includes examining utilization figures and extended drug claims, he added.

Read: Massaging the data: A Canadian health benefits trend study

Chronic conditions, such as diabetes and asthma, also have a significant impact on drug plans. Cardiovascular, central nervous system, mental health and diabetes drugs are among the biggest cost drivers, said Leanne MacFarlane, senior director, business development, with MHCSI. And there’s a new addition: hepatitis C medication. “Hep C is going to make its presence known,” she noted.

Diabetes is definitely top of mind for plan sponsors, and rightfully so. David Willows, vice-president, strategic market solutions, with Green Shield Canada, said diabetics take “four times the drugs as the non-diabetic population. It’s a very complex population, and it’s not easy to affect that population on the cheap.”

Treating a diabetic plan member costs an average of $2,000 per year, noted Mike Sullivan, president of Cubic Health. Included in that spend are medications needed to treat the comorbidities associated with diabetes, such as high blood pressure and high cholesterol. “What is fascinating is that [diabetic employees] spend even more money on drugs that have nothing to do with their diabetes than non-diabetic members spend in total in a year,” Sullivan explained.

He said treating diabetes properly not only improves the patient’s quality of life and work productivity but also lowers the costs of treating comorbid conditions. “If we’re managing people’s central condition, we can have an impact on their comorbidities as well,” Sullivan added.

William Chung, senior vice-president, payer partnerships and pricing, with Shoppers Drug Mart, believes pharmacists are integral in managing chronic diseases such as diabetes rather than having patients continually return to their physician. He compares monitoring diabetes objectively using point-of-care tests to tracking blood pressure using screening systems: something that’s routinely done in most pharmacies.

Read: The pros and cons of patient support programs

Fraser, too, said he’s keen on working with pharmacists to ensure patients with multiple diseases are properly diagnosed, are receiving and taking appropriate medication, and are encouraged to monitor their health and make lifestyle changes. “There’s a real opportunity for pharmacists and other professionals to manage utilization in this pool.”

New focal points

Willows agreed that although plan sponsors are extremely focused on specialty drug costs, the conditions that are passed over need more attention. “What are we freaking out about? Specialty drugs. You can manage those with proper claims administration. What do we rarely think about? Chronic disease states, screening and vaccine programs,” he said. “If we look at our benefits programs in total, we are paying for a lot of things that have zero impact on disease management.”

What does have an impact? Wellness programs. Programs tracking drug utilization and adherence rates. Preferred pharmacy networks. Medication therapy management. “Those are really the elixir to getting those solutions in place,” said MacFarlane.

Herbert said minimizing waste can also have a big effect on costs. For example, he suggested refilling medications for chronic conditions for 90 days rather than 30 to reduce dispensing fees.

Barbara Martinez, practice leader, drug solutions, with Great-West Life, said another approach is to have the discussion of who pays for the medication in the doctor’s office, when it’s being prescribed. “This approach can ensure lower-cost alternatives are considered when they constitute reasonable treatment.”

Read: Factors affecting drug trends

But it’s important not to forget the patient experience—especially when the path to managing the condition involves navigating the complexities of both insurer and manufacturer-sponsored specialty drug programs. “You’ve got to focus on the patient,” said Chung. “Are they achieving their treatment end points? That can be complicated when they’re on multiple medications.”

Measuring the success of these programs is a challenge. Chung said when plan sponsors set up specialty drug management programs, they have to keep in mind how they measure success and how they can track it. For employers, this can include designing a scorecard with certain parameters they wish to measure, said Chung, such as patient adherence.

Costs aside, Michelle Boudreau, vice-president, private markets, with Rx&D, articulated the core message that often gets lost in the drug plan management dialogue: having access to drugs, high costs notwithstanding, is a gift.

“How lucky we are that we live in a country where these drugs come to market,” she said. “We are very fortunate people.”

Managing patient outcomes

Lucky though they may be, many patients are left in the dark about the cost management structures their plan sponsors have established. They need help, panellists agreed, including providing information and making the process as seamless as possible—whether the issue is navigating the healthcare system, accessing specialty drugs in a timely manner or taking medication correctly.

“We don’t want to overmanage that patient; we want to find the sweet spot where we are providing the appropriate level of support so we can effectively manage their care,” said Godfrey Mau, a pharmacy consultant with Manulife Financial.

That sweet spot, said Gosse, is to remember the humanity in the whole equation rather than just the dollars and cents. He feels how patients respond to the drug and how effective it is for them is just as important, because it means the difference between sick, non-functioning employees and successful, contributing members of the workforce.

Read: Face-to-Face Drug Plan Management Forum photos

“It’s not just about reimbursement. It’s also about tolerance; it’s about efficiency,” he said.

Gosse said patients often fall through the cracks, facing numerous obstacles to receiving the treatment they need. Integration of myriad programs is critical to ensure the patient receives the right treatment at the right time, he explained, and sponsors need to recognize that any alteration they make to manage their plans may have repercussions for patients.

“Everything you change has an impact that’s unseen,” said Gosse—even something as simple as changing pharmacies. When a patient applies for a biologic drug and has recently changed pharmacies because of a preferred provider program, he or she needs to return to the original pharmacy to obtain a medication history. A small switch like this can mean the difference between timely access to a drug and a patient foregoing treatment, he explained.

Plan sponsors and service providers agree on one thing: the time to act is now.

Many conference attendees acknowledged plan sponsors have been dragging their feet when it comes to introducing wellness programs or initiating drug plan management strategies into their benefits plan design. Given the increased abilities of service providers to analyze claims data and the emergence of new ways to manage those claims, panellists feel employers need to take a more aggressive approach.

“Just start doing something,” said MacFarlane. “Let’s get moving forward off our duffs.”

Read: Rewriting the prescription: creative ways to control drug costs

Sullivan agreed. Given the data available—which can show patient outcomes, track long- and short-term disability rates, and illustrate how drug spends on comorbid conditions are reduced—he feels there’s no excuse not to enlist the help of providers to help satisfy cost containment goals while ensuring a patient’s well-being and ultimately improving productivity.

“Let’s stop referring to change as a negative,” he added.

Anna Sharratt is a freelance writer based in Toronto.

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All the articles from the events can be found in our special section: Face to Face Drug Plan Management Forum coverage.

Copyright © 2019 Transcontinental Media G.P. This article first appeared in Benefits Canada.

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