Opportunities around drug coverage for traditional ‘lifestyle’ issues

Although certain drug categories have always been considered optional in benefits plans, this may be an opportune time to look at modernizing coverage in a number of areas, according to Suzanne Nagy, national drug consulting leader at Mercer Canada.

Speaking at Benefits Canada‘s 2018 Face to Face Drug Plan Management Forum in Toronto on Dec. 5, Nagy said optional drug coverage categories such as weight loss, smoking cessation, erectile dysfunction, fertility and vaccines have traditionally been treated differently for a number of reasons.

For example, they were aimed at addressing lifestyle issues, contracts were simply duplicated year after year or modernization wasn’t often a focus. “The focus over the last 10 to 15 years has been on the high-cost biologics,” said Nagy. “We’re not focusing on smaller cost items like optional drug coverage.” 

Read: Staples Canada’s $750 incentive to quit smoking

Very few plans cover smoking cessation medications as an unlimited benefit, she noted, but instead impose a lifetime maximum allowing one or two attempts. However, studies show it can take some individuals up to 30 attempts to successfully quit smoking, she said.

“What would really happen if those products were just included in normal drug benefits and were available to people who could access them as many times as they needed to quit smoking? Would costs really spiral out of control?”

Although vaccines are a public health issue, adult vaccines aren’t funded across the Canadian population, said Nagy, yet the human papilloma virus vaccine is indicated for adults and can prevent five cancers, while the shingles vaccine, indicated for adults over age 50, can positively affect workplace health.

“Where vaccine coverage is selected by an employer, it’s usually unlimited, which is great, but there’s still only about 60 per cent of employers that are covering vaccines. And we do get asked if we can cover just one vaccine.” 

Read: How HPV is causing more than just cervical cancer

While insurers don’t currently have the capability to operationalize coverage in this way, Nagy pointed to the ability to carve off various vaccines as an area where some modernization may be appropriate.

It may also be time to look at modernizing coverage for the group of drugs and devices under the sexual health heading, suggested Nagy, whether that’s related to lifetime caps imposed on fertility treatment or coverage for contraceptive devices.

When it comes to weight loss, Nagy noted that although the lifestyle component of the diet industry had been reinforced through the 70s and 80s, obesity is known today to be a complex chronic disease. “It’s multifocal, and is the primary cause of chronic conditions such as diabetes and cancer,” she said.

However, many benefits plans still exclude weight loss drug coverage and those that do cover it often impose a lifetime cap, noted Nagy. “I do think that one of the first steps of modernization is to align the drug benefits and, specifically, the weight loss coverage with wellness.”

Also speaking during the session, Dr. Megha Poddar, an endocrinologist and internal medicine specialist, said one of the biggest misnomers is calling obesity a lifestyle issue because that assumes it’s a choice. “Obesity is a chronic, progressive medical condition. I think, in order to understand what obesity is, what we need to understand is it’s really a mismatch between our biology and our sociocultural environment.”

Read: Employers urged to boost tracking of obesity efforts

But while she noted workplace wellness programs are a great start when it comes to treating obesity, they also pose a challenge because they only target one aspect of the condition for a high-intensity, short period of time.

Instead, Poddar suggested employers look at obesity as a multifactorial issue, rather than a diet and exercise problem. This requires a sociocultural shift. “Giving people access to educational resources, doing educational sessions or health-care sessions and access to dietitians, counsellors and medications is going to be probably the most helpful.” 

Ultimately, Nagy noted a strong benefits philosophy for employers is key to a meaningful dialogue around these historically optional drug categories. “It makes these kinds of ethical discussions much easier, if they have a strong understanding if their benefits plan is either a compensation or insurance risk mitigation plan.” 

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