Plan members need help with co-ordinating care: report

The number of high-cost drugs and patients with multiple chronic conditions continues to rise, according to Express Scripts Canada’s drug trend report for 2016.

While some plan sponsors have addressed increasing costs with measures such as generic pricing or limiting access to some drugs, the report suggested they should focus on providing certain plan members with expert guidance at key decision points in their treatment plans.

Patients with multiple chronic conditions usually receive a number of treatments by doctors and specialists but they may not understand their drug benefits or the advantage of co-ordination of care, Michael Biskey, president of Express Scripts Canada, said in a release. “Most Canadians simply do not have the clinical knowledge they need to figure out which drug is the most cost-effective, clinically appropriate option for their treatment.”

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The report, which analyzed millions of prescription drug claims in 2016, found that a small percentage of plan members (14 per cent) actually accounted for the majority (72 per cent) of total plan spending. As well, the proportion of members with annual claims totalling more than $10,000 increased significantly in the last five years, to 28.8 per cent in 2016 from 18.1 per cent in 2011.

According to the report, those plan members need help making treatment decisions, managing their conditions, co-ordinating their care and handling their many medications.

There are many ways for patients to receive guidance, says Suzanne Lepage, a private health plan strategist in Kitchener, Ont. They include services provided by pharmacists, insurance companies that work with case management professionals and even pharmaceutical companies that provide patient support programs.

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But the problem is employees often find the multiple resources confusing, says Lepage. “So what’s missing and a challenge for the plan sponsor is how to co-ordinate all the different touch points these patients with complex diseases have. We need to do a better job of that.”

Lepage also notes that Canada’s fragmented health-care system makes it difficult to implement co-ordination of care.

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The report found that spending on high-cost drugs grew to 30 per cent of total expenditures in 2016 from 13 per cent in 2007.

It also noted that specialty drugs costs increased by 10.6 per cent in 2016. Though their medications are expensive, hepatitis C patients actually reduce the overall specialty drug cost per claimant because their treatment doesn’t continue indefinitely.

“The increase in specialty is driven by an increase in the prevalence of these conditions,” says John Herbert, director of strategy, product development and clinical services at Express Scripts Canada. “We see new medications that are treating conditions that weren’t previously treatable by medications. We also see expanding indications of these specialty treatments so some of these medications are being approved for additional indications and broadening the target population for these high cost medications.”

Herbert adds he also sees orphan drug pricing on some conditions that are simply not rare.  “So what we see is a very high price tag associated with some specialty conditions that still affect thousands of Canadians where that high price tag isn’t necessarily justifiable.”

For instance, patients with non-alcoholic steatohepatitis, a condition that inflames and damages the liver, can now use a drug whose initial indication is for a rare condition called primary biliary cirrhosis that destroys bile ducts in the liver, says Herbert. “Our concern is as the indications [of a drug] expands to include a broader set of population, the price isn’t necessarily going to come down. So you have this misalignment between the pricing of a drug and its patient population.”

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The report also found that a continued shift from hospital-administered drugs for conditions such as cancer to self-administered medications will mean higher costs for private plans in the future.

It noted that $1 out of every $5 spent on prescription drugs was to treat diabetes or an inflammatory condition. There was also an upward trend in spending on cancer and attention-deficit hyperactivity disorder medications in 2016.

And despite the growth of biosimilars, the report noted that the savings gleaned from those products aren’t comparable to those resulting from using generic drugs.

There are a lot of complexities around biosimilars, says Lepage. “They’re not automatically interchangeable for the brand names and, as a result, they won’t generate the same savings as generics.”