This is Part 3 in our 3-part coverage of the Employers Cancer Care Summit, held in February at Toronto’s Sutton Place Hotel.
Read Part 2: Raising awareness
The good news in cancer care is that improved treatments are increasing survival rates. But as the model of care shifts from hospital-based acute care to outpatient chronic care, employers are facing new challenges, as outlined in the presentation by Stephanie Mazzei and Bernie Manente, principals with Strategic Answers Inc.
One challenge is that more cancer therapies (20% to 25% of those currently in development, according to Mazzei) are oral medications, which are typically not covered by provincial drug plans. “[Patients who] are actively working are looking for benefits to fund these therapies,” said Mazzei. Manente pointed to tyrosine kinase inhibitors, which are used to treat a variety of cancers, as an example. In 2000, these inhibitors were entirely funded by the public sector, as they were administered in hospital. Today, the private sector pays $36 million for these drugs, since they can now be taken orally on an outpatient basis, according to the 2008 Report Card on Cancer in Canada by the Cancer Advocacy Coalition of Canada (CACC).
Similarly, newly developed oral drugs to treat metastatic renal cancer represent a tremendous advance in therapy—but at a cost. In 2011, metastatic renal cancer drugs cost private payers $14 million compared with no cost to private payers in 2003, according to OncoEdge Forecasting Platform, IMS Canadian Drugstore and Hospital data.
Employers struggling with these costs need to remember the rationale for offering benefits in the first place: to attract and retain employees, to keep them healthy and at work, and to offer a safety net if they get sick.
Employers also “need to look at the interconnectivity of the components of what they are spending,” Manente explained, including the return on investment of drugs to maintain employee health, innovative plan designs and options for special consideration for individual cases.
Finally, Manente urged employers to take a leadership role in establishing a dialogue with the government on the extent of the challenges and creating a sustainable system that works for all.
The insurance gap
Private payers are not the only ones concerned about the impact of cancer treatments shifting from an in-patient to an outpatient model. The CACC warns that the transition of many new high-cost cancer drugs from an intravenous to an oral format will create a significant issue around access to insurance. “This insurance deficit is a bomb out there, ready to explode. We have to get public and private parties together to address it,” said Darwin Kealey, past chair of the CACC and founding president and CEO of the Trillium Gift of Life Network.
The CACC issued its 11th annual Report Card on Cancer in Canada in March. This report highlights several promising developments, including the adoption of the pan-Canadian Oncology Drug Review in 2010, which means that new cancer drugs will now undergo only one review nationally rather than individual reviews by each province and territory. “It saves time and resources, and gives us equity across the country,” said Kealey.
While inroads are being made in access to quality cancer care, Kealey fears we are falling behind in access to insurance. Two key issues are the increasing burden that new oral cancer drugs place on private payers (as noted by Mazzei and Manente) and the regional disparities in private versus public coverage. (In Western Canada, 35% of drug costs are dependent on private insurers, compared with 50% in Central Canada and 68% in Atlantic Canada.)
Urgent steps are required to prevent Canadians—especially retirees—from falling into an insurance gap. The CACC recommends that The Council of the Federation—which comprises the premiers of Canada’s provinces and territories—rationalize the current collection of provincial catastrophic drug plans.
“We also need to have a summit of CEOs of larger insurance companies and the premiers to take an objective look at the insurance approach in Canada and find a co-operative way to cover everyone,” said Kealey. “If we don’t, the insurance issue 10 years from now will be bigger than the access to products or access to care.”
Accessing treatment
As Barnard noted in her opening presentation, she failed to access some features of her employer’s benefits plan because she didn’t know they existed. Jay Mayers, vice-president of Adjuvantz, a patient support organization, sees people like Barnard every day. “In our experience, people typically do not know what they are and are not covered for,” he said.
When people are diagnosed with cancer, they can become overwhelmed with navigating their health benefits plans and accessing life-saving therapies. The most common struggles that patients face when dealing with their group coverage are high co-payments and lack of coverage for supportive care therapies (medications that mitigate the side effects of chemotherapy).
Private payers are increasingly adding maximums to certain benefits and turning to co-insurance in an attempt to manage high costs. The net effect is higher expenses to the cancer patient. As a result, patients may have to reduce or stop treatment, often leading to poorer health outcomes. “This is a prime example of cost downloading that has little long-term benefit to the plan sponsor and no benefit to the patient,” commented Mayers.
Part of the problem is that plan design typically focuses on providing coverage for low-cost/high-use products (i.e., less expensive drugs that people use frequently) on which co-insurance and plan maximums have less impact. But when thinking about plan cost containment, employers should consider the differences between a patient with an asymptomatic chronic condition and a patient with an acute and potentially life-threatening disease, such as cancer. “Does your cost-containment strategy treat the cancer patient unfairly simply because of the cost differential between these therapies? Do your plan maximums mean that a therapy course cannot be continued or started at all?” he asked.
Confidential communication is a secondary but equally important issue that employers must address. “Having a safe resource within the organization where coverage options can be discussed in a private and confidential manner could mean the difference between life and death for cancer patients,” Mayers added.
Cancer is everywhere, and the workplace is not exempt from its impact. Employers have the opportunity to make a difference in every phase of their employees’ cancer journey—from awareness and prevention to treatment and recovery. Innovative programs and drug plans not only support the individual employee but also provide long-term benefits to the entire workforce.
Elizabeth Garel is a freelance writer and editor based in Toronto. editor47eg@yahoo.com
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