Increased drug spending and the arrival of new, high-cost medications require innovative approaches to drive better decisions by plan members, according to John Herbert, director of strategy, product development and clinical services for Express Scripts Canada.

As recent data from the Canadian Institute for Health Information shows, prescription drug spending in the private sector in Canada rose to $18 billion last year from $11 billion in 2006.

The majority of the spending, Herbert told attendees at the 2017 Pharmacy Solutions in Drug Plan Management forum in Toronto on Oct. 18, is for maintenance medications, such as those for blood pressure and diabetes.

At the same time, he noted, specialty drug spending is a growing concern, including for medications to treat complex conditions such as multiple sclerosis and cancer.

Read: Drug Plan Trends Report: Alarm about costs sparks ‘monumental shift’

“The rapid uptake of new, high-cost drugs really jeopardizes the sustainability of the drug plan benefit overall. This can translate into limiting coverage, annual dollar maximums for employers that are struggling with ever-increasing premiums,” said Herbert.

As Herbert pointed out, the top 14 per cent of claimants drive 72 per cent of drug spending, noting that less than one per cent claim more than $10,000 per year.

Focusing on encouraging better decisions among that group, “is really the greatest opportunity to capture savings, while achieving healthier outcomes,” said Herbert, noting the need for a holistic approach to care that includes solutions to manage overall costs, as well as multiple co-morbidities, physicians and medications.

Looking to the future, Herbert said high-cost specialty drug therapies will continue to dominate new drug approvals and development pipelines, leaving payers with the challenge of balancing patient care and benefit affordability.

Read: Sales of high-price drugs up 200% since 2006: PMPRB

“The concern here is that some plans may take a knee-jerk response to this challenge by choosing to put in an annual dollar limit or excluding access to certain new drugs, which can really jeopardize patient health and may end up driving greater costs in the long-run,” he said.

A better approach, he said, is to optimize existing spending through a comprehensively managed plan to help ensure it can fund access to new high-cost medications. Herbert cited step therapy as an option and also noted efforts at the pharmacy level to engage patients through proactive outreach, therapy optimization across all medications and a personalized health action plan.

“This approach can help Canadian plan sponsors continue to afford benefit plans that members depend on to lead productive lives,” said Herbert.

Copyright © 2018 Transcontinental Media G.P. Originally published on

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