Moving toward a healthier drug plan

The effects of plan design are far-reaching. The following excerpt from the conference panel discussion, moderated by Suzanne Lepage, private health plan strategist, Suzanne Lepage Consulting Inc., touches on just how far.

❯ Chris Bonnett, president, H3 Consulting
❯ Dr. John Haggie, immediate past president, Canadian Medical Association (CMA)
❯ Tanya Hogan, director, health solutions and pharmacy projects, Shoppers Drug Mart
❯ Shannon MacDonald, vice-president, public affairs and partnerships, Rx&D
❯ Leanne MacFarlane, senior director, business development, MHCSI Managed Health Care Services Inc.
❯ Diane McArthur, assistant deputy minister and executive officer, Ontario Public Drug Programs
❯ Denis Morrice, operations committee member, Best Medicines Coalition
❯ Mark Rolnick, product director, pharmaceutical benefits, Sun Life Financial

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SL: I want to get your opinions of plan sponsors’ true understanding of what these programs offer, how they work and the potential impact upon members. Do you have any suggestions on how we can help plan sponsors better understand and improve their knowledge of these options?

LM: Very often, plan sponsors are coming at this because they’re feeling the pressure of cost and they haven’t done the foundational work to understand what they’re trying to achieve with their plan. One of the things they have to do is look at the fundamentals of the philosophy of their plan, how they want to engage with members, and then build for success by making sure the things they’re doing are fully understood and are going to deliver the results they’re looking for.

MR: On the one hand, you can say that there’s been a lot of new solutions on the market. On the other hand, prior authorization and generic substitutions have been around for years. Part of it, I think, is that there’s just more of an appetite for this given the cost equation. There certainly are tweaks to existing processes; directionally, this isn’t a huge shift in product offerings as much as it is tweaks to existing products. Plan sponsors’ knowledge is a big issue because, in the past, we’ve had solutions with very few sponsors really adopting them. When I get asked to do a presentation with a client, they’ll say we have 30 to 45 minutes to talk about drugs. It’s like, let’s not even start, because it’s really tough to engage and talk about all the solutions we have and what all the options are in that time.

JH: There’s a feeling among physicians that insurance plans are there to drive you to drink. My colleagues universally just can’t see why the paperwork seems to multiply year upon year.
In my own jurisdiction, the manufacturers of some of the biological agents have actually put people on the ground in tertiary care centres to do the paperwork for you, because it’s got so bad. But that still leaves the other 99% of claims. Physicians are really feeling that, a lot of the time, the paperwork becomes a huge barrier both for the patient and for the physician.

SL: Is there a message that you’d like to give to the plan managers about working with physicians?

JH: Before I was involved with the CMA, never once did we hear from any private insurer about a collaborative approach. It may well be that the world was not going that way at the time. One of the difficulties is, whom do you talk to? Which company do you pick?

SM: At Rx&D, with our member companies we prioritize understanding the perspectives of the many stakeholders in the private payer environment precisely for…better collaboration. We’ve started working collaboratively within our own companies so that we can pair up HR with the folks who have the understanding of private drug plans for better quality conversations.

SL: Could we get some commentary from the panel about how we see the relationship between the public and private systems evolving?

DMc: For the longest time, we took each other for granted—the private payer and the public systems—mostly because, while drug costs were always a rapidly escalating component of the system, we were seeing that they were a manageable component.

Most people were employed, and we had a social contract, which was if you were employed, then your drug costs were covered through your private employer, and employers could manage that. And then we had the public plans that were safety baskets for the unemployed. And then there was the advent of the very high-cost catastrophic drugs…so Ontario, along with a number of other jurisdictions, put in place the safety basket that is our Trillium program.

What we’ve found is that the plans are bumping up against each other and we’re seeing the [high-cost] therapies spreading. Employers are now noticing their bottom line much more closely and they’re just turning to their plan providers for help. For the most part, we’re having good dialogue. We sit down with the insurers now, at least once a quarter, to talk about how our plans work more collaboratively together.

The public plan—when we change, we change big. And if we’re not careful about that, that can have a very detrimental impact on patients. Similarly, there are some private insurers that are doing things that are making it very difficult for the public plans to operate smoothly and actually have those conversations.

[One example is] making patients and physicians go to the public plan to get rejected before their private coverage kicks in. We need to make sure that we’re providing the right balance and coverage.

TH: One of the other key stakeholders is pharmacy in this full cycle. When we talk about patient experience, pharmacists and pharmacy want to get their patient on medication, too, and they’re the face of this patient experience and the ones who are having these difficult conversations, that the patient is going to have to go through some hurdles to get on medication.

For pharmacists and pharmacy technicians to understand the programs by the insurer or even all of the provincial programs that are available is just not feasible. So we’re struggling trying to manage patients and get them on therapy and provide that clinical assistance, while also dealing with a lot of the administrative pieces associated with these programs. So, as much as we can, we should automate through the adjudication system, as opposed to some of these very generic response messages that are sent back to pharmacy. I think everybody’s on the right track here. The forms are a challenge, and we talk about the overlap between programs and some of the insurance programs. An approach that we need to take is not to try to reinvent components of the program that are already available.

MR: I don’t see a huge overlap between our programs and the pharmaceutical patient assistance programs. What we hear from our discussions with the physician community is, some physicians love the program because of all the help that it gives, but, as well, some physicians say, ‘Well, actually, Mark, when I think about it, we’re prescribing a lot more biologics than we ever had before because it’s been so easy now to prescribe them.’ That’s one of the utilization issues that comes out of these programs. On the patient assistance programs, I think they’re a good thing, but the best thing we can do is get patients on the most cost-effective drug in these categories initially, which helps remove the back-and-forth piece.

CB: We seem to default to a discussion around things like common forms and standardizing, for example, co-ordination of benefits or drug reviews, whether it be from a clinical or an economic perspective, or perhaps generalizing the view that we might take toward pharmacy. All good things, but I think what we’ve missed so far is developing any kind of a framework for those discussions to occur. My fear is that we’ll all go off in many different directions, and we’ll squander an opportunity to get the bang for the buck with a lot of people who have great intentions, great ideas, want to make it happen. We need some structure to make sure those efforts generate the most good.

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