Employers challenged in balancing member care, plan sustainability

Plan sponsors and administrators walk a razor’s edge, striving to ensure members have access to the services they need while also making certain the plan is financially sustainable. Working collaboratively with health-care providers is a critical step, but these partnerships have often proved elusive, delegates heard at the 2018 Halifax Benefits Summit.

“There is a disconnect. We work in silos,” said Anne-Marie Smith, a pharmacist consultant and practice lead for drug plan solutions at Medavie Blue Cross, during a panel discussion on drug management at the conference in September.

Read: Knowledge of private coverage affects doctors’ prescribing behaviour: survey

“The system has not changed in the last 30 years in terms of how it interacts with the external world,” she noted. “There are no questions asked when prescriptions are written. There is often a mismatch between how the prescriber assesses risk and those in the external world do.”

Also on the panel, Dr. Jennifer Jones, a gastroenterologist and associate professor of medicine at Dalhousie University, pointed to a lack of integration at all levels as a major problem. “We see fragmentation before patients access care and once they do.”

There is some pushback on individual choice for therapy, although discussions over drug costs are now more common, she added. “I would like to see those discussions happen more, [but] time is an issue.”

Compounding demands on people’s time are increasing drug costs. “We are seeing significant growth in the pipeline of high-cost drugs,” said Chris Goguen, manager of pharmacy benefit strategy and partnership with Medavie Blue Cross and another panel member. “The changing dynamics of the workforce is also an issue. We need to evolve health plans.”

Read: What’s the role of doctors in boosting drug plan sustainability?

Employers should expect that evolution to be rocky, cautioned Smith. “There are often competing interests within the plan. There will be no right approach for everyone.”

There will also be no immediate resolution, said Jones, noting it takes time for best practices to be identified and data to be scrutinized. Still, she noted, physicians feel the pressure to prescribe more affordable drugs. “We are cognizant of the need to move to a less costly option. That is absolutely necessary.”

What concerns Jones is the move to less-costly options for non-medical reasons. For low-risk patients, this might be acceptable, she said, however, “a non-medical switch for high-risk patients is difficult to defend ethically.”

Read more coverage from the 2018 Halifax Benefits Summit