Many perspectives required when covering cancer drugs on benefits plans

While treatment options for cancer are more than they used to be, many still aren’t covered under the public health-care system, according to Tim Clarke, president of TC Health Consulting Inc.

In a session at Benefits Canada’s 2020 Employers Cancer Care Summit on Mar. 3, he said employer costs for cancer drug treatments have doubled between 2015 and 2019, making it the fourth largest spending category.

In addition, 89 per cent of employees expect their employers to cover all cancer drugs, including high-cost ones, said Clarke, referring to a 2016 survey sponsored by AstraZeneca Canada. However, it’s recognized that an employer’s benefits budget does have a limit. “Sixty per cent of employees say they understand it’s necessary to ensure only the right people are getting the right treatments. Prior-authorization is something employees accept.”

Read: Gaps persist in plan sponsor, member views on benefits: Sanofi

That said, plan members do expect the coverage to be there. Indeed, 75 per cent of the survey’s respondents said finding out their employer doesn’t cover cancer treatments would negatively impact their perception of the employer, said Clarke, while only 28 per cent said they think it’s reasonable to have limitations or maximums that could potentially impact cancer drug coverage.

He also noted the shift in cancer treatment from a hospital setting to a person’s home or an infusion clinic. As a result, there’s been movement from in-patient to out-patient and from the public health-care system to employer plans. This creates an lot of grey areas in how, where and who pays for the treatment, he added.

Further, there’s a gap between Health Canada’s approval for a new drug and approval under public health care, said Clarke, noting 18 months isn’t uncommon for a delay between Health Canada’s approval and coverage under provincial plans — and not all provincial plans are doing the same thing.

The fact that more cancer drugs are going through this process is positive, but fewer drugs are receiving public funding, he noted. “Or they’re getting public funding eventually and the clarity over whether it’s going to be publicly funded or whether private plans need to step up is another area for consideration.”

Read: A primer on the role of drug access navigators

It’s important to look at cancer in a different way, said Clarke, noting it could be short- or long-term treatment, or treatment that only requires coverage under an employer plan for 18 months before the government steps in. “When [plan sponsors] sit down to look at how they’re going to address cancer drugs within a plan, it may not be one question and one answer. It’s more a matter of understanding all the different nuances and making sure they have a partner taking account of those nuances properly.”

Plan sponsors can only absorb so much information, he added, since they have other priorities and knowing what’s in the cancer pipeline or whether an oncology drug is infused in hospital or out is beyond their scope. In these situations, insurers and advisors should know what to do — and should be able to work with employers to find a solution.

Also, more early stage, preventative oncology treatments are available, said Clarke, noting the concept of cancer as a chronic disease and not a death sentence. “We talk about asthma and mental health a lot and now cancer’s thrown into that same category of helping employees in the workplace manage a chronic disease.”

However, one area private plans haven’t picked up on yet is the diagnostic piece that coincides with cancer treatment, he noted. In some cases, employers are covering the drug but not the diagnostic, or they’re covering both. “You need to make sure the companion diagnostics are on your radar — where they fit with prior-authorization, benefits coverage, whether the public health-care system’s paying for it and so on,” he advised the audience.

Read: Rising cost of drugs, benefits plans top priorities for employers: survey

Fortunately, several tools are available to help plan sponsors manage drug costs, but they need to be used judiciously, said Clarke. “It’s not a matter of simply turning on the formulary. It’s more complicated. [Employers] need to look a little deeper as to what it means, how it works and which elements need to be taken on.”

Ultimately, plan sponsors must be adaptable, he said, noting the solution that worked five years ago isn’t necessarily the solution moving forward. “Things change in the world and [employers] have to step back and take a look at what they’re doing and how they’re doing it because the world’s changed.”

When an expensive cancer drug is claimed through a benefits plan, plan sponsors need to figure out how to manage it, added Clarke. “But let’s step back and look from the perspective that we’re saving lives. We have benefits plans and human resource people talking about how they help their employees and the cure for cancer. This hasn’t always been a thing that benefits plans are trying to solve. This is hard, but exciting. Take both these points to mind when looking at oncology drugs.”

Read more coverage from the 2020 Employers Cancer Care Summit.