Is innovation causing accessibility, timing issues for private drug plans?

Pharmaceutical companies and private payers can interact in different ways to ensure the right drugs are getting to the right patients, according to Kathy Sotirakos, senior manager of market access and private insurance at Amgen.

Real world evidence will help inform better decision-making from a predictability and outcomes perspective, she said during a panel at Benefits Canada’s 2019 Face to Face Drug Plan Management Forum on Dec. 3 in Toronto.

In particular, Sotirakos highlighted that not harnessing this data is a missed opportunity from a result and risk-share model perspective. “We need to overcome our access barriers and tap into that evidence so we can create new models for novel therapies.”

Read: The value of private drug plans from a Canadian and global context

A lot of high-cost, skilled labour is being wasted, noted Sarah Shephard, director of health policy and patient access at Novartis Pharmaceuticals Canada, who also spoke on the panel. When pharmaceutical companies provide dossiers to Health Canada and the Canadian Agency for Drugs and Technologies in Health, they’re also sent to several insurance companies and pharmacy benefits managers, which results in varied feedback.

“If we have different prior-authorization criteria for one doctor with 30 people waiting in reception, who have waited six to eight months to get an appointment, at that point, there’s so much wasted, highly skilled labour,” she said.

Also speaking on the panel, Joe Farago, executive director of private payers and investment at Innovative Medicines Canada, said the harmonization of drug submissions is an opportunity for the private insurance industry to improve. There’s no reason these can’t be the same across the board, he added, noting this collaboration would accelerate and simplify submissions.

Transparency and trust are other important areas, said Farago. When a drug is under review on the public side, the time it will take to make a decision is typically known. But there seems to be hesitation on the private side because nobody wants to tell people the answer is no, he added. “This is one area, in terms of drug submission and transparency around decisions, where the public sector is far greater. This is something the private [system] could easily do.”

It can take years for a molecule to be studied and researched and go through all the phases of clinical trial before human trial and then it’s a viable product that can be submitted to jurisdictions in Canada, Europe and the US, said Sotirakos, and from there, this process can range from one to eight years. “If it’s approved by Health Canada, then you have your notice of compliance.”

However, after receiving this designation, it can take anywhere between 18 and 24 months for listing through public drug plans, if it’s listed at all, added Farago.

Read: How changing public coverage could affect the pharmaceuticals industry

In comparison, time-to-listing on the private side can take just a few months, though nine months to a year isn’t uncommon for specialty drugs, he said, noting that speed, breadth and the conditions of access are the value of private insurance. “If those start to diminish, the value of the private market starts to diminish.”

Historically, the private market was quicker in listing and decision-making was expeditious, noted Sotirakos, but accessing private plans is becoming a challenge as innovation is altering the treatment and insurance landscapes. New policies are delaying time-to-listing, she added, which impacts new drugs. “It’s important that private payers look at this through the employer lens for the working population.”

While previously, the insurance industry wasn’t as interested in seeing what was in the pipeline, people now want to know, said Shephard, and it’s critical to provide forewarning. “We’d like to give more information ahead of time. . . . The biggest thing is, we never know the price until the last minute, which is because of a complex global market.”

Since it makes up just 1.7 per cent of the global pharmaceutical industry, Canada doesn’t drive international drug prices. Indeed, it’s the other way around, said Farago. If the prices in Canada are too low, it will affect markets globally. But how will this affect the private payer industry?

Read: What will PMPRB drug pricing changes mean for plan sponsors?

The proposed Patented Medicine Prices Review Board changes will be the most impactful the industry has seen in more than 30 years, since the subsequent costs to the sector are estimated to total about $35 billion in 10 years, said Farago. New drugs coming to Canada may experience a 70 per cent price reduction, he added, which has associated risks because the decision to launch in a country is related to market attractiveness.

“If the PMPRB changes go through as is, we’re making it very clear that new drugs won’t come to Canada,” he said. “We recognize the government’s need to lower drug prices, but it’s about a balance — not low enough, but not so low that there’s a lack of new medicines.”

If Canada doesn’t have access to the latest drugs, then clinical trials, which compare the newest treatment with the market standard, won’t follow, said Shephard.

However, with studies ongoing, Farago noted Canadians won’t actually see this effect immediately. “The new trials — the ones for more innovative, newer, more expensive medicines to treat smaller populations — will be at risk.”

Read more stories from the 2019 Face to Face Drug Plan Management Forum.