What are the implications of pharmacare reform for private drug plans?

As the federal government continues its consultations on a national pharmacare system, many questions are still up in the air.

Will the new system follow a single-payer model? And if so, what would be the implications for a private-payer system? As discussions examine the various possibilities, the private industry says pharmacare reform is a complex issue that requires more than a simple solution.

Read: A primer on the parliamentary report on pharmacare and its impact on the benefits industry

“I think it’s important, when we’re looking at pharmacare and access to medicine, that we look at what the need is and where that need exists so we’re able to zero in on the most affective policy approach,” says John-Paul Dowson, director of reimbursement strategy at PDCI Market Access Inc. “Pharmacare doesn’t have to be a single-payer system. Pharmacare can, and probably should, be a system that fills in the gaps to make sure people are not going without access to the care they need.”

Canada can address specific issues around pharmacare without changing the country’s current dual-payer system, says Louis Thériault, vice-president of policy and research at Innovative Medicines Canada. “When you reflect on [the health-care system’s] history, ask yourself what isn’t working as best as possible when it comes to the pharmaceutical aspect.”

One clear problem is that certain pockets of the population, such as low- to middle-income Canadians, are struggling to pay drug expenses, says Thériault. On top of that, small- and medium-sized businesses are wrestling with providing employees coverage for expensive specialty drugs.

Read: Lessons for Canada from pharmacare systems around the world

Instead of looking at the general population as a whole, Canada should consider starting the dialogue on national pharmacare by looking at where the greatest need for financial support lies — rare diseases, says Thériault.

Currently, Canada doesn’t have a policy or framework on how to handle drugs for rare diseases, he says. “It’s hard to get the drug to the country in the first place. It’s hard to get to a price point for these drugs given the limited number of patients. It’s hard from a business sustainability standpoint to launch some of these drugs. So what’s the funding model that would work here to make sure patients aren’t left behind?”

Specialty drugs make up 80 per cent of pharmaceuticals that come to the market, says Dowson, noting new treatments continue to enter the pipeline, including potentially curative gene therapies. Rare-disease medications, which require significant investment in research and development, are expensive and carry the biggest risk in terms of costs, he adds. “It seems that if there was a pooled approach across the country for these small-patient populations with high, unmet clinical needs, that could be a place to start.”

Read: Plan sponsors bracing for onset of new orphan drugs

The discussion around pharmacare reform should also look at how to address the variety of pharmaceutical coverage across Canada, says Thériault. He notes each jurisdiction varies on what drugs are covered and the level of reimbursement. “There should be a national standard for a list of pharmaceutical products that would ensure, wherever you live in the country, you have access to the best treatment possible.”

Also, 5.2 per cent of Canadians, largely those from Ontario and Newfoundland, simply don’t have drug coverage, according to a 2017 report by the Conference Board of Canada, says Thériault. The report estimated the number would drop to 1.8 per cent with the introduction of OHIP+ in 2018. “In that case, the public plan could address that gap for Canadians and there are programs within the provinces, but they’re difficult to access.”

As well, a single-payer system isn’t necessarily the ultimate solution to address the issues within the pharmacare system, says Dowson, noting Canada has a very successful private benefits system. For one, he notes, many plans help workers with their drug costs by reimbursing 75 to 80 per cent of costs.

Indeed, private plans have always been a fundamental element of the health-care system, says Thériault, adding private plans cover about 23 million Canadians, which comprise more than half the population.

Read: Youth pharmacare plan’s growing pains creating challenges for some patients

Private plans have also been tailored to meet certain workforces, says Thériault. For example, plan designs for the construction industry would be different from those for the financial industry. “Many of these large plans have been negotiated with the unions over the years, and they reflect the need of the industries for which these plans were negotiated for.”

As well, it will be difficult to reach a consensus on such a complex issue, especially when so many Canadians are satisfied with their coverage under private drug plans, says Dowson.

While he considers OHIP+ to be well-intentioned, Dowson calls it a misguided approach to providing access to youth and children in Ontario, noting issues abounded when children moved from public to private plans as part of the initiative. “People like their private plans because they generally provide different levels of access, better access and faster access to new medicines coming into marketplace.

“That, to me, is a case example of what can happen when you have a movement from private plans into the public plans where coverage is different,” he adds, noting public and private plans have different objectives. While public plans ensure Canadians get the treatments they need while adhering to a strict budget, private plans aim to provide benefits to their employees that would boost productivity in the workplace.

Read: Pharmacare reform should guarantee viability of workplace benefits plans: CLHIA 

“We understand the importance of ensuring every Canadian has access to appropriate coverage of drug therapy, but to achieve that we feel a mix of private and public insurance would be the best mechanism,” says Ned Pojskic, leader of pharmacy and health provider relations at Green Shield Canada.

Instead, the pharmacare should look at how to improve the collaboration between public and private plans, he suggests. “Even with public plans, there are different [designs] across the country, with provinces providing different levels of coverage. At the very least, we need to ensure two things: that we have better coordination among public and private plans and that we cover uninsured individuals. So how can we combine those two core components in some kind of plan that continues to offer coverage to almost everybody?”

Beyond pharmacare, Canada should look at its whole health-care system — which includes services like dental and home care — if it wants to provide universal access for everyone, says Thériault, pointing to western European countries that have implemented an integrated system of health-care services for their citizens.

“What we’re saying is that, because of how the [health-care] system has evolved, you can’t just switch overnight to a single-payer model for pharmacare,” says Thériault. “It wouldn’t be the most effective way to address the problems, which we’ve identified are really specific.”

Read: The impact of Ontario’s public drug program changes on private plans