As a job title, ‘drug case manager’ can imply different things across the health-care and benefits industries.

In Canada, a drug case manager may be part of a drug manufacturer’s patient support program or an insurance company’s preferred pharmacy network, while hospitals have case managers at various levels, says Suzanne Nagy, drug consulting leader for Canada at Mercer. There’s a fourth group, she adds, which is made up of third-party companies providing case management services. “The term ‘case manager’ is pretty interchangeable to all of them.”

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But it’s up for debate whether an employer or plan sponsor should hire an internal drug case manager. “It may be wasteful, because insurers don’t charge for health case management,” says Barb Martinez, practice leader for benefits solutions at Great-West Life Assurance Co.

Case-by-case management

One reason a plan sponsor may choose to use drug case management is to ensure the appropriate party is paying for medication, whether that’s a benefits plan, a public payer or a pharmaceutical company, says Noel MacKay, director of national benefits consulting at Cowan Insurance Group Ltd.

“And hopefully to make sure claimants, or the users of the medication, are getting the best possible service from everyone involved,” he says. “Are they going to the right specialty pharmacy locations? Are they getting coaching on adherence?”

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An employer may also use a drug case manager to look at which drugs have the highest claims and how this ties into health issues across the workforce. In her role, Nagy conducts diagnostics that look at drug utilization and chronic disease. “So do you have an abnormally high number of diabetes or cardiovascular disease [cases]? To those clients we say, ‘There are options out there that may help around that.’ “We may look to potentially recommend one of the third-party case management services,” she adds, noting those usually come with a cost per member.

Third-party players

In numbers

High-cost speciality medications, which made up 2% of total claims in 2017, accounted for more than 31% of total drug spending that year.

Medications for inflammatory conditions and diabetes accounted for almost 24% of overall spending in 2017.

Drugs for inflammatory conditions accounted for the largest portion of spending, with 1.2% of claimants but 14.2% of overall spending in 2017.

Source: 2017 Express Scripts Canada report

The aim of using a third-party service or a drug case manager via an insurer is a more engaged employee base and support around overall wellness initiatives, says Nagy. As well, better health outcomes naturally lead to less absenteeism and presenteeism. “If I have a case manager and I can better manage my depression, am I taking less drugs?” says Nagy.

But many employers may not even know case management is part of their benefits plan, notes MacKay. “It really only comes to light when there’s a big, high-cost drug claim,” he says. “For the most part, it’s a non-item for employers until the event takes place.”

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Indeed, a third-party case manager can be useful where plan sponsors have a high number of claims for specialty drugs, says Nagy, referring to medications that cost more than $5,000 per year. “Then we recommend, or ensure, they’re enrolled in an insurer’s preferred pharmacy network.”

However, cost can also be a downside, she says, suggesting case management can be an additional expense, particularly if it’s provided by a third party. She recommends weighing the cost of the service against the savings on the long-term cost incurred by the plan member.

Whatever role and responsibilities a drug case manager may have, the role is becoming more common, she says. “We’re starting to see some data that supports case management. We know there are some benefits in terms of supporting patients in complex disease states.”

Ryan Murphy is a former associate editor at Benefits Canada.