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Challenges and Innovation in
Canadian Access to Treatments and Innovation
November 19, 2015
• George Wyatt
• Stephen Frank
• Suzanne Lepage
• Lisa Callaghan
AGENDA
• Panel A
Canadian Public and Private
Access Environment
2
• Panel B
Access and Innovation –
International Access to Innovative
Therapies
• Neil Palmer
• Sandra Anderson
• Glenn Monteith
Followed by Qs and As
Followed by Qs and As
Public Drug Plan
Reimbursement
in Canada
November 19, 2015
George Wyatt
Flow of Public Drug Plan
Reimbursement in Canada
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Health Canada
Manufacturer
CDR/INESSS (non-cancer)
pCODR/INESSS (cancer)
Public Plans
pCPA
PMPRB
CDR vs. Quebec (INESSS)
Recommendations
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
11
189
141
52
157
89
0
20
40
60
80
100
120
140
160
180
200
Positive Conditional Negative
CDR Quebec (non-cancer)
Conditional recommendations include:
List in a Similar Manner, List with Criteria, List with Criteria/Condition, Not at Submitted Price
pCODR vs. Quebec (INESSS)
Recommendations
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Condition for INESSS means conditional of improved cost-effectiveness
Positive for INESSS means conditional (no financial restrictions)
9
8
27
11
*
19
0
5
10
15
20
25
30
Positive Conditional Negative
pCODR Quebec (cancer)
CDR Recommendation Codes
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
2003 to
October 2012
List (LIST)
List in a Similar Manner (LSM)
List with Criteria (LWC)
Do not List (DNL)
November 2012
To Present
List (LIST)
List with Criteria/Conditions (LWCC)
Not at Submitted Price (NSP)
Do not List (DNL)
Under
Consideration
Fund (LIST)
Fund with Conditions (FWC)
Do not Fund (DNL)
www.cdrtracker.com
CDR Patient Input
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Voluntary Pipeline Notification/
Mandatory Notification of
Submission/Resubmission
CDR notifies Patient Groups
for Input
Deliberation/Recommendatio
n
CDR Review Process
(Clinical/Economic/Patient Input)
CDR Patient Input
https://www.cadth.ca/about-cadth/what-we-do/products-services/cdr/patient-input
pCODR Patient Input
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Mandatory Notification of
Submission/Resubmission
pCODR notifies Registered
Patient Groups for Input
Initial Recommendation
pCODR Review Process
(Clinical/Economic/Patient Input)
Final Recommendation
Patient Groups can only provide feedback on the initial
recommendation if they first provided input in the early
stages of the review.
pCODR Patient Input
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
https://www.cadth.ca/pcodr/patient-input-and-feedback
Pan-Canadian Pharmaceutical
Alliance (pCPA) – 2015-09-30
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
80
2
22
11
33
148
54%
1%
15%
7%
22%
100%
0
20
40
60
80
100
120
140
160
Complete Closed
(agreement not
reached)
Ongoing Province No Negotiation Total
Number Percent
CADTH Newsletter
https://www.cadth.ca/subscribe
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
0
50
100
150
200
250
NL NS PEI NB QC ON MB SK AB BC NIHB Avg.
CDR – Public Plan Reimbursement
Based on CDR Recommendations from 2004 through 2014
Reimbursed Do Not Reimburse No Decision Yet Removed from Formulary
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
pCODR – Public Plan Reimbursement
Based on pCODR Recommendations from 2012 through 2014
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Average Completion Time
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
203.4 203.1
392
247.1
340.4
0
50
100
150
200
250
300
350
400
450
CDR (Submission to
Recommendation)
pCODR (Submission to
Recommendation)
pCPA (CDR
Recommendation to
Completion)
pCPA (pCODR
Recommendation to
Completion)
pCPA (All
Recommendation to
Completion)
Days
Time from NOC to
Public Reimbursement
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
676
628
835
721
800
590
773
1057
404
653
699 712
930
773
1005
1082
981
1094
875
1021
969
738
*
927
0
200
400
600
800
1000
1200
AB BC MB NB NL NS ON PEI QB SK NIHB Average
Days
CDR pCODR
* NIHB currently only covers drug that were reviewed prior to pCODR (e.g. jODR)
Summary
• Quebec acts quicker than CDR / pCODR
• Patient input is important for
reimbursement recommendation
• pCPA process is delaying access to
medications
• Overall it takes almost 2 (non-cancer) to 3
(cancer) years from time of NOC to have
drug reimbursement
19
Presentation to Expert Patients
Forum
Private Payer Industry Trends & Emerging
Considerations
November 19, 2015
Stephen Frank
Vice President, Policy Development and Health
19
Prescription Drugs: costs are rising again
• Recent cost growth – while at historical lows – remained higher for private payers than
provinces
• Cost's are rising back to more of the historical average
• Specialty drugs driving much of this and pose serious concern
• New challenge: mass market + high costs = budget buster
• Private insurers drug pooling framework is helpful, but growing unexpectedly quickly
20
Employers are the ones who bear these costs – not insurer. They are increasingly looking for
ways to limit their financial exposure to new, high cost drugs
Provincial gov't responses: program changes
• Across the board, provinces are responding with changes to their programs, although each
on their own priorities and timelines
21
Provincial gov't responses: collaboration to reduce prices
• General view that prices are relatively high in Canada
• Provincial governments working together to negotiate lower prices for brand drugs and
generics
– 9 provinces participate in pan-Canadian Pharmaceutial Alliance (PCPA)
• NB: Quebec joined in October; Federal plans will join in 2015/16
– PCPA completed 68 pricing negotiations – estimated $400 million per year in savings
– These rebates are confidential and do not apply to private payers
22
23
Insurers' responses: unprecedented innovation
Managed
Formularies
Mandatory
Generics
Step TherapyPPNs
Case
Management
24
Insurers' responses: Advocating for system reform
Include all payers in PCPA
Continued reform of generic drug
pricing
Fundamental reform to PMPRB
• In addition, individual insurers starting to engage in pricing agreements – varying degrees of
energy around this at the moment
25
Thoughts on the future
26
Closing thoughts
• New specialty drugs will continue to strain sustainability and drive dialogue
around major reform
• Government healthcare reform will continue and accelerate
• Insurers will continue to enhance their capabilities
• Only long-term solution is for greater collaboration between public and
private sectors
• Without reform, unclear that the system is sustainable
27
Thank-you
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 28
Evolution of Private Payer
Plans in Canada
Expert Patient Advocates and
21st Century Therapies Forum
Hyatt Regency Toronto
Toronto, Ontario
November 19, 2015
Presented by:
Suzanne Lepage, Private Health Plan Strategist
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC.
2014 Drug Trend Report
• Average annual drug spending per claimant increased by 2.7% (up from
1.3% in 2013)
• Spending on traditional prescription medications declined by 0.3%
• 12.1% increase in spending for specialty medications
o 9.2% increase in cost per script
o Utilization grew 2.9%
o Represents only 2% of claims, but 26.5% of total spending
o Expected to reach 35% in the next four years.
• Top 1% of all claimants comprised 28% of total spending
o Total spending for the top 1% = bottom 85%
29
Express Scripts Canada 2014 Drug Trend Report
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC.
Hepatitis C
Impact on Private Drug Plans
Green Shield (2013 to 2015)
• For all hepatitis C drugs combined
o Claims increased by 189%
o Spend increased by 424%.
Express Scripts Canada (2014 Drug Trend Report)
• Hepatitis C = therapy class with most growth in 2014
• Overall trend increased 252%
o Utilization increased by 132.7%
o Cost increased by 118.5%
• Spending on hepatitis C increased more than 10x in 15 months
http://www.greenshield.ca/sites/corporate/en/Documents/Follow%20the%20Script/2015/Follow%20the%20Script_Fall%202015.pdf
http://www.express-scripts.ca/sites/default/files/ESC_14101_annual_report_ENG3.pdf
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 31
Private Drug Plan Trends
Impact on Specialty Drug Access
1. Case management of drug claims
2. Increased Prior Authorization
3. Preferred Pharmacy Networks (PPN)
4. Managed Formularies
5. Maximum Allowable Cost (MAC) Pricing
6. Step Therapy
7. Government Integration
8. Product Listing Agreements
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC.
Food for thought….
1. How are private plans assessing drug value and comparing
treatments? What is the right price?
2. What is the purpose of a benefit plan? Cover every drug plan
members need? Or protect from catastrophic illness?
3. Drug plan costs are a line item for plan sponsors to manage.
Confidentiality impacts plan sponsors ability to assess the
value of drug coverage, health outcomes or potential impact
of plan design changes.
4. Where are the patient stories?
5. How to shift dialogue about drug plans from cost to
investment?
32
Lisa Callaghan. MBA, MSc
AVP, Group Product
Manulife Financial
33
End of Panel A
34
Expert Patient Advocates & 21st Century Therapies Forum
International Access to Drugs for Rare Diseases
W. Neil Palmer
Toronto November 2015
Australia – Challenges in Funding Rare Diseases
Issues
• Australians are generally waiting from 2 to 4 years
longer for access to rare disease therapies available in
comparable countries like the United Kingdom,
Canada, Germany and the Netherlands.
• Some medications remain unavailable 8 years after
becoming available overseas.
• No common definition of a rare disease across the
Australian health system
– Therapeutic Goods Act includes a limit of 2,000 patients for the
registration of orphan drugs - the equivalent of approximately 1
patient in 10,000 persons
Source: The McKell Institute, Funding Rare Diseases in Australia , November 2014
36
Australia - Recommendations
1. The Australian Government should develop a National Strategy for Rare
Diseases that provides a holistic approach to rare disease management
2. Australia should be mindful of international practice and developments
when designing rare disease policy frameworks.
3. A more flexible analysis of cost-effectiveness should be adopted in the
assessment of new therapies that balances other considerations such as
equity, the rule of rescue, community values, patient needs and the long-
term costs avoided as a result of access to treatment.
4. The unique nature of therapies for rare diseases, including small patient
populations and the implications this has for clinical trials, should be
recognised in the evidence requirements for funding.
5. The process for assessing new therapies for rare diseases should be
efficient, fit-for-purpose, transparent and informed by community and
patient values.
Source: The McKell Institute, Funding Rare Diseases in Australia , November 2014
37
Germany
The Federal Joint Committee in Germany (GBA) commissions IQWiG to examine the benefits and
harms of medical interventions and recommends level of additional benefit
Orphan Drugs often given “not quantifiable” benefit
Additional
Benefit
Price Discount
Negotiation
Implications for Pricing
European Prices
Considered
Major
Yes
Adjusted premium vs. the
appropriate therapy in
pricing negotiation
YesModerate
Marginal
Not Quantifiable Yes Similar to above Yes
None
No (negotiation only if
there is no reference
group or comparator)
Reference price or at max.
the price of the appropriate
comparative therapy
No
Less Benefit Yes
Discount vs. the appropriate
comparative therapy
No
Adapted from: : Markus Jahn, Novartis Pharma GmbH, Pharma Pricing & Market Access Outlook, March 2012
38
England - NICE: Highly Specialised Technologies (HST)
• Highly specialised technology (HST) evaluations are
recommendations on the use of new and existing
highly specialised medicines and treatments within the
NHS in England.
• The HST programme only considers drugs for very rare
conditions.
• Most are identified by the National Institute for Health
Research Horizon Scanning Centre at the University of
Birmingham.
• They aim to notify the Department of Health of new /
emerging technologies to be referred to NICE:
– New drugs, in development, at 20 months prior to
marketing authorisation
– New indications, at 15 months prior to marketing
authorisation
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-highly-specialised-technologies-guidance
39
Overview of NICE HST Process
1. Provisional evaluation topics chosen
2. Consultees and commentators identified
3. Scope prepared
4. Evaluation topics referred
5. Evidence submitted (clinical & cost effectiveness)
– Manufacturer submission
– Statement from non-manufacturer consultees
6. Evidence Review Group (ERG) report prepared
7. Evaluation report prepared
– Includes all of the evidence that will be looked at by the Evaluation Committee:
• the ERG report and any comments received on it
• written submissions
• personal statements from patient experts and clinical specialists.
8. Evaluation Committee
– An independent advisory committee considers the evaluation report and hears evidence
from nominated clinical experts, patients and carers. Evaluation Committee discussions are
held in public
9. Evaluation consultation document (ECD) if produced
10. Final evaluation determination (FED) produced
11. NICE Guidance issued
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-highly-specialised-technologies-guidance
40
Compliance with a NICE-approved medicine or treatment
• Commissioners (of the 200+ CCGs) have a statutory responsibility
– to make funding available for a drug or treatment recommended by a NICE TA
or HST within the timeframe recommended in that guidance.
– Compliance is therefore achieved if a clinician and their patient think a health
technology is the right treatment and it is available on the NHS without any
local funding or local formulary restrictions.
• For the avoidance of doubt, when NICE recommends a drug as ‘an option’,
this is an option for the clinician and patient to consider alongside other
potential treatments, not an option for commissioners or providers to not
make the treatment available.
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-technology-appraisal-guidance/achieving-and-demonstrating-
compliance
41
HTA / P&R Activities over Product Life Cycle
Market assessment
Pricing environment
NPV calculations
Business planning
Initial pricing scenarios
Market potential based on
price scenarios
Early scientific advice with
payers / HTA agencies
Pre-clinical Phase I Phase II Phase III
Filing / Pre-
marketing
Launch / Contracting
Post Launch
Price Mgmt
Identify comparators
Define outcomes, trial
endpoints
HE study design
Identify P&R barriers
Monitor competitors
Quantitative research
Payer research
Analysis of value
scenarios
Initial pricing strategy
Finalize global pricing
strategy
Define price corridor /
fix target and floor
prices for each
market
Define launch
sequence
Develop global value /
P&R dossier
Develop market
specific dossiers for
affiliates
Negotiate prices
Negotiate risk-
sharing / price-
volume
agreements
Launch approval
Monitor launch
process
Indication
sequencing
Price change
approval
Report / assess
mandatory price
changes
Monitor price
trends globally
Assess impact of
exchange rates
Assess impact of
new indications
• Patient focused engagement typically not part of the early HTA planning process –
should start much earlier – patient groups should be pro-active
• Horizon scanning
• Early advice process
Adapted from Simon - Kucher
<===== Patient Engagement =====>
42
Thank you
43
Biography
W. Neil Palmer
President & Principal Consultant
PDCI Market Access Inc
Neil.Palmer@pdci.ca
www.pdci.ca
Neil Palmer President and Principal Consultant of PDCI Market Access Inc. (PDCI) a leading pricing and reimbursement
consultancy founded in 1996. He leads a senior team of market access professionals with pricing & reimbursement
engagements covering Canada, Europe, and the United States.
Prior to PDCI, Neil worked with the Canadian Patented Medicine Prices Review Board (PMPRB) where his
responsibilities included policy development, overseeing the price review of patented medicines and conducting
economic research. Prior to the PMPRB, he worked with the Health Division of Statistics Canada where he was
responsible for economic and statistical analysis of health care costs and utilization. Neil also worked with RTI Health
Solutions (Research Triangle Park, North Carolina) where he served as global vice president for pricing and
reimbursement. After completing his studies at the University of Western Ontario, Neil began his career in Montreal
with the research group of the Kellogg Centre for Advanced Studies in Primary Care. He has written extensively on
pharmaceutical pricing and reimbursement issues and is a frequent speaker at conferences in North America and
Europe.
In January 2015, Neil was appointed Adjunct Assistant Professor at the University of Southern California School of
Pharmacy graduate program in Health Care Decision Analysis where he lectures on health technology assessment,
pricing and market access from a global perspective.
44
Customized Patient Care
through Patient Support
Programs for Rare/Orphan Drugs
Sandra Anderson
November 2015
Why Orphan Drugs are Different
 Difficult to diagnose
 Population size
 Unique patient and caregiver needs
 Cost
 Reimbursement challenges
 Wait times for Specialist
 Large amount of stakeholders involved
to get patient on therapy
There is no clear path to get Orphan Drugs Funded
46
A Typical Journey of a Patient with a Common Disease
Insert visual of patient with high
blood pressure- ie asymptomatic
disease
Insert visual of a patient with asthma-
a symptomatic disease
Physician Office
The Patient Journey in Rare Disease
PSP Introduction
• Coverage information is captured
• Services explained
Enrolment in PSP
Demographics, clinical history
Prescription
Journey to Dx
$
Patient set up to
receive treatment
Coverage is secured
SA submissions
Life time
Max
Injection/Infusion
Services? Copay?
Call – review
Coverage
decision
Infusion/Injection
Continued Care Calls
• Determine status
• Coach patient
Annual Renewals
Maintenance
Onboarding
Explore
Reimbursement
coverage
Rx
Key Trends for Orphan Drugs
Different reimbursement routes across
Canada. Public reimbursement/Private
reimbursement – 50/50
Traditionally very high cost medication requires
additional administrative work and numerous
stakeholders involved in treatment
Changes in Private Payer Marketplace ie
PPNs
Small patient populations may have
regional bias
The Patient Perspective
The high drug cost, and out-of-
pocket component, (co-
payment or deductible) can be
unmanageable for many
patients (especially for Orphan
drugs ~hundreds of 000s/year)
Most income-based public
plans such as Trillium in Ontario
require patient contributions in
the form of co-
payments/deductibles (~3-5%
of household income)
With complex therapies, the
primary concerns for patients
are access, convenience and
the level of customer service
Private plans vary: range from
100% coverage to 50%
coverage, though the most
commonly seen co-payments
are set between 0 and 20%
Case Study: Real Life Patient Access Barriers Defined
Source: Berry SA, et al. Genet Med 2013:15(8):591–599
Condition and Therapy
Patient
Social and Economic
Healthcare System
Patient Support Programs
Focus on Orphan/Rare Disease Drugs
Needs for Orphan Rare Disease PSPs
High Touch
Require specific administration or monitoring requirements
before and ordering administration
High Support
Education, counselling, compliance monitoring, and drug
information, Customized clinic needs
Special Distribution
Special handling techniques; and / or require special
handling, have special shipping requirements or need
complex reconstitution
Customized Patient Assistance
Clinical , Diet and Lobbying/Financial Support to assist with
access to drug
(i.e. co-pay assistance)
Customized Patient Support Programs
Nurse Case Manager – One point of contact to deliver quality care at every touch-point
Pre Infusion
Checklist
(Program)
Enrolment
Reimbursement
Specialty
Pharmacy
Update on
Patient
Progress
Infusion ScheduledPatient Experience
*****
Infusion
Drug
Dispensed,
shipped to
clinic)
Nurse
completes
pre-infusion
checklist
Infusion Scheduled: Clinic chosen, Fax to
physician, Pre-infusion checklist, Reminder
call, Drug order
Enrolment: Entered in CRM, NCM
assigned, patient contacted
Reimbursement: Case Manager confirms
coverage with the patient and sets up financial
assistance
Specialty Pharmacy: Deferral of copay, Drug
Order (Direct through Database), Warehouse
sends drug to pharmacy, Drug delivered to
Clinic
Infusion: Nurse confirms Drug is onsite, Pre-
infusion assessment by nurse, Medical
clarification needed?, Infusion, PIR
Patient experience touch-point
Innomar
Nurse Case Manager
Case Study: Coordination of Public Insurance
• Solution
– Public EAP requested
– Patient Advocacy: Lobby on behalf of
patient; media releases; Canada wide
petition; add pressure to decision makers;
weekly telephone conferences with
stakeholders
• Outcome
– Provincial compassionate program obtained
to start and then successfully gained full
approval from the province
Patient is still on therapy!
Challenge:
Patient was hospitalized
with multiple organ failure.
The medication was still
under review by the
Province.
Case Study: Reimbursement Solutions in Rare Diseases
CLIENT SITUATION
Client was having challenges
obtaining coverage for their
orphan drug with a major
private payer.
OUR SOLUTION
 Payer wanted real health outcomes data and a
negotiated a price per patient based on HO data.
 Innomar worked with the manufacturer to obtain and
analyze relevant HO data from their patient support
program.
 Innomar developed PLA scenarios and brokered the
meeting between manufacturer and payer to negotiate a
listing.
OUTCOME
 Manufacturer was successful in obtaining their desired PLA
scenario
 Program continues to report monthly HO data, and payer
continues to cover patients who meet agreed upon criteria.
KEY INSIGHT
Building a data strategy early-on and
utilizing relevant data through the PSP
will be critical to the overall market
access strategy
Conclusions and Key Insights to Consider
• Diagnosis
• Testing
• Reimbursement
• Financial assistance
• Ongoing treatment
• Monitoring
Rare diseases
present
unique
challenges for:
• Product focused, patient centric;
• Gather valuable real life data extremely useful for
payers – useful for potential Adaptive Listing initiatives;
• Manufacturer funded with the opportunity to become
more centralized to support overall Rare Disease
Strategy
PSPs for Rare
Diseases are:
Key Goal: Leverage your PSP to demonstrate
real world effectiveness value to gain access to payers
58
 Rare diseases present unique
challenges for:
- Diagnosis, Testing,
- Reimbursement, Financial assistance,
- Ongoing treatment
- Monitoring
 PSPs for Rare Diseases are:
- Product focused, patient centric;
- Gather valuable real life data extremely
useful for payers – useful for potential
Adaptive Listing initiatives;
- Manufacturer funded
- Opportunity to become more centralized
to support overall Rare Disease Strategy
Ultimate objective is to build a build a different framework for Orphan Drugs
which will shorten the timelines to access
Health
Outcomes
Research
Value to
Payers
Patient
Support
Program
Demonstr
ate
Real
World
Effective
ness
and
Value
Presentation to Expert Patients Forum
Innovative Pathways to Drug Access in Private Drug
Coverage Plans
November 19, 2015
Glenn Monteith
Vice President Innovation and Health Sustainability
November 19, 015
60
Players involved in private market – insurers and
others
Plan
Members
19 Million
Plan
Sponsors
500,000+
Advisors &
Consultants
3,000
Insurance
Carriers
24
Pharmacy
Benefit
Managers
3
Community
Pharmacies
8,600
• Many players and decision-makers are involved in private
drug plans
Diseases Have Major Impacts on Canadian Economy
Diseases affect productivity at work, both physically and/or mentally
Examples:
62
1 Source: http://www.phac-aspc.gc.ca/media/nr-rp/2011/2011_0919-bg-di-eng.php
2 Source: Cranswick K., Dosman D. Eldercare: Canadian Social Trends. 2008, Vol. 86, pp. 48-56 and Fast, et al. A Profile of Canadian Chronic
Care Providers: A Report Submitted to Human Resources and Development Canada. Univ. of Alberta. Edmonton : s.n., 2002.
$7,000 / employee / year
Presenteeism
$10,000 / employee / year
Abstenteeism
Chronic Diseases Have a Big Impact on Productivity
and Absenteeism
Top 15 drivers of lost work time Total cost of condition of employees
with a primary condition
63
Source: Kessler’s HPQ—Adjusted to work Force (2007) Source: Collins et al, Assessment of chronic conditions
on work performance, absence and total economic
impact for employers, NEOJM, 2005
Cost containment measures
used by private drug plans
64
Generic substitution
• Not mandatory – physician may prescribe innovative medicine and
write “no substitution”
• Mandatory – in all cases, a generic drug, if available and considered
“interchangeable” then it will be dispensed, or, plan only pays up to
cost of generic drug and plan member must pay the difference in
price to access the innovative medicine *exceptions process for
some plans
Get to know your plan options and ask questions of your
pharmacist/pharmacy when getting a prescription filled.
65
Prior Authorization GWL 100+ Drugs
Tiered Formulary
Therapeutic Sub / Mac Price
Case Management
Summary of Scorecard Findings – 2013 Actuals
• PDP drug cost growth in 2013 is the lowest in recent years.
• Drug cost growth of 2.2% was in line with the Forecast CAGR (1.6% to
2.8%) for the 2013-2017 forecast period.
• Generic savings was higher than forecast; as anticipated generic pricing
changes had the greatest impact.
• Impact from new medicine entry was lower due to a mix consisting of
fewer specialty medicines than forecast.
• Though marginal, the aging event had a slightly higher impact than
forecast due to growth in the number of older claimants and increase in
utilization amongst these older claimants.
70
Closing thoughts
• Private drug plans are important to providing access to innovative
medicines and vaccines
• Get to know your plan and inform yourself of how plan design
features can impact access
• Coordination of benefits between plans (e.g. public and private or
two private plans) can be complex
Rx&D advocates for timely, quality access to innovative medicines and
vaccines so people get the treatments they need when they need them.
71
End of Panel B
72

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Challenges and Innovation in Canadian Access to Treatments and Innovation

  • 1. Challenges and Innovation in Canadian Access to Treatments and Innovation November 19, 2015
  • 2. • George Wyatt • Stephen Frank • Suzanne Lepage • Lisa Callaghan AGENDA • Panel A Canadian Public and Private Access Environment 2 • Panel B Access and Innovation – International Access to Innovative Therapies • Neil Palmer • Sandra Anderson • Glenn Monteith Followed by Qs and As Followed by Qs and As
  • 3. Public Drug Plan Reimbursement in Canada November 19, 2015 George Wyatt
  • 4. Flow of Public Drug Plan Reimbursement in Canada © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved Health Canada Manufacturer CDR/INESSS (non-cancer) pCODR/INESSS (cancer) Public Plans pCPA PMPRB
  • 5. CDR vs. Quebec (INESSS) Recommendations © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved 11 189 141 52 157 89 0 20 40 60 80 100 120 140 160 180 200 Positive Conditional Negative CDR Quebec (non-cancer) Conditional recommendations include: List in a Similar Manner, List with Criteria, List with Criteria/Condition, Not at Submitted Price
  • 6. pCODR vs. Quebec (INESSS) Recommendations © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved Condition for INESSS means conditional of improved cost-effectiveness Positive for INESSS means conditional (no financial restrictions) 9 8 27 11 * 19 0 5 10 15 20 25 30 Positive Conditional Negative pCODR Quebec (cancer)
  • 7. CDR Recommendation Codes © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved 2003 to October 2012 List (LIST) List in a Similar Manner (LSM) List with Criteria (LWC) Do not List (DNL) November 2012 To Present List (LIST) List with Criteria/Conditions (LWCC) Not at Submitted Price (NSP) Do not List (DNL) Under Consideration Fund (LIST) Fund with Conditions (FWC) Do not Fund (DNL) www.cdrtracker.com
  • 8. CDR Patient Input © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved Voluntary Pipeline Notification/ Mandatory Notification of Submission/Resubmission CDR notifies Patient Groups for Input Deliberation/Recommendatio n CDR Review Process (Clinical/Economic/Patient Input)
  • 10. pCODR Patient Input © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved Mandatory Notification of Submission/Resubmission pCODR notifies Registered Patient Groups for Input Initial Recommendation pCODR Review Process (Clinical/Economic/Patient Input) Final Recommendation Patient Groups can only provide feedback on the initial recommendation if they first provided input in the early stages of the review.
  • 11. pCODR Patient Input © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved https://www.cadth.ca/pcodr/patient-input-and-feedback
  • 12. Pan-Canadian Pharmaceutical Alliance (pCPA) – 2015-09-30 © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved 80 2 22 11 33 148 54% 1% 15% 7% 22% 100% 0 20 40 60 80 100 120 140 160 Complete Closed (agreement not reached) Ongoing Province No Negotiation Total Number Percent
  • 13. CADTH Newsletter https://www.cadth.ca/subscribe © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
  • 14. 0 50 100 150 200 250 NL NS PEI NB QC ON MB SK AB BC NIHB Avg. CDR – Public Plan Reimbursement Based on CDR Recommendations from 2004 through 2014 Reimbursed Do Not Reimburse No Decision Yet Removed from Formulary © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
  • 15. pCODR – Public Plan Reimbursement Based on pCODR Recommendations from 2012 through 2014 © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
  • 16. Average Completion Time © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved 203.4 203.1 392 247.1 340.4 0 50 100 150 200 250 300 350 400 450 CDR (Submission to Recommendation) pCODR (Submission to Recommendation) pCPA (CDR Recommendation to Completion) pCPA (pCODR Recommendation to Completion) pCPA (All Recommendation to Completion) Days
  • 17. Time from NOC to Public Reimbursement © Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved 676 628 835 721 800 590 773 1057 404 653 699 712 930 773 1005 1082 981 1094 875 1021 969 738 * 927 0 200 400 600 800 1000 1200 AB BC MB NB NL NS ON PEI QB SK NIHB Average Days CDR pCODR * NIHB currently only covers drug that were reviewed prior to pCODR (e.g. jODR)
  • 18. Summary • Quebec acts quicker than CDR / pCODR • Patient input is important for reimbursement recommendation • pCPA process is delaying access to medications • Overall it takes almost 2 (non-cancer) to 3 (cancer) years from time of NOC to have drug reimbursement
  • 19. 19 Presentation to Expert Patients Forum Private Payer Industry Trends & Emerging Considerations November 19, 2015 Stephen Frank Vice President, Policy Development and Health 19
  • 20. Prescription Drugs: costs are rising again • Recent cost growth – while at historical lows – remained higher for private payers than provinces • Cost's are rising back to more of the historical average • Specialty drugs driving much of this and pose serious concern • New challenge: mass market + high costs = budget buster • Private insurers drug pooling framework is helpful, but growing unexpectedly quickly 20 Employers are the ones who bear these costs – not insurer. They are increasingly looking for ways to limit their financial exposure to new, high cost drugs
  • 21. Provincial gov't responses: program changes • Across the board, provinces are responding with changes to their programs, although each on their own priorities and timelines 21
  • 22. Provincial gov't responses: collaboration to reduce prices • General view that prices are relatively high in Canada • Provincial governments working together to negotiate lower prices for brand drugs and generics – 9 provinces participate in pan-Canadian Pharmaceutial Alliance (PCPA) • NB: Quebec joined in October; Federal plans will join in 2015/16 – PCPA completed 68 pricing negotiations – estimated $400 million per year in savings – These rebates are confidential and do not apply to private payers 22
  • 23. 23 Insurers' responses: unprecedented innovation Managed Formularies Mandatory Generics Step TherapyPPNs Case Management
  • 24. 24 Insurers' responses: Advocating for system reform Include all payers in PCPA Continued reform of generic drug pricing Fundamental reform to PMPRB • In addition, individual insurers starting to engage in pricing agreements – varying degrees of energy around this at the moment
  • 26. 26 Closing thoughts • New specialty drugs will continue to strain sustainability and drive dialogue around major reform • Government healthcare reform will continue and accelerate • Insurers will continue to enhance their capabilities • Only long-term solution is for greater collaboration between public and private sectors • Without reform, unclear that the system is sustainable
  • 28. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 28 Evolution of Private Payer Plans in Canada Expert Patient Advocates and 21st Century Therapies Forum Hyatt Regency Toronto Toronto, Ontario November 19, 2015 Presented by: Suzanne Lepage, Private Health Plan Strategist
  • 29. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 2014 Drug Trend Report • Average annual drug spending per claimant increased by 2.7% (up from 1.3% in 2013) • Spending on traditional prescription medications declined by 0.3% • 12.1% increase in spending for specialty medications o 9.2% increase in cost per script o Utilization grew 2.9% o Represents only 2% of claims, but 26.5% of total spending o Expected to reach 35% in the next four years. • Top 1% of all claimants comprised 28% of total spending o Total spending for the top 1% = bottom 85% 29 Express Scripts Canada 2014 Drug Trend Report
  • 30. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Hepatitis C Impact on Private Drug Plans Green Shield (2013 to 2015) • For all hepatitis C drugs combined o Claims increased by 189% o Spend increased by 424%. Express Scripts Canada (2014 Drug Trend Report) • Hepatitis C = therapy class with most growth in 2014 • Overall trend increased 252% o Utilization increased by 132.7% o Cost increased by 118.5% • Spending on hepatitis C increased more than 10x in 15 months http://www.greenshield.ca/sites/corporate/en/Documents/Follow%20the%20Script/2015/Follow%20the%20Script_Fall%202015.pdf http://www.express-scripts.ca/sites/default/files/ESC_14101_annual_report_ENG3.pdf
  • 31. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 31 Private Drug Plan Trends Impact on Specialty Drug Access 1. Case management of drug claims 2. Increased Prior Authorization 3. Preferred Pharmacy Networks (PPN) 4. Managed Formularies 5. Maximum Allowable Cost (MAC) Pricing 6. Step Therapy 7. Government Integration 8. Product Listing Agreements
  • 32. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Food for thought…. 1. How are private plans assessing drug value and comparing treatments? What is the right price? 2. What is the purpose of a benefit plan? Cover every drug plan members need? Or protect from catastrophic illness? 3. Drug plan costs are a line item for plan sponsors to manage. Confidentiality impacts plan sponsors ability to assess the value of drug coverage, health outcomes or potential impact of plan design changes. 4. Where are the patient stories? 5. How to shift dialogue about drug plans from cost to investment? 32
  • 33. Lisa Callaghan. MBA, MSc AVP, Group Product Manulife Financial 33
  • 34. End of Panel A 34
  • 35. Expert Patient Advocates & 21st Century Therapies Forum International Access to Drugs for Rare Diseases W. Neil Palmer Toronto November 2015
  • 36. Australia – Challenges in Funding Rare Diseases Issues • Australians are generally waiting from 2 to 4 years longer for access to rare disease therapies available in comparable countries like the United Kingdom, Canada, Germany and the Netherlands. • Some medications remain unavailable 8 years after becoming available overseas. • No common definition of a rare disease across the Australian health system – Therapeutic Goods Act includes a limit of 2,000 patients for the registration of orphan drugs - the equivalent of approximately 1 patient in 10,000 persons Source: The McKell Institute, Funding Rare Diseases in Australia , November 2014 36
  • 37. Australia - Recommendations 1. The Australian Government should develop a National Strategy for Rare Diseases that provides a holistic approach to rare disease management 2. Australia should be mindful of international practice and developments when designing rare disease policy frameworks. 3. A more flexible analysis of cost-effectiveness should be adopted in the assessment of new therapies that balances other considerations such as equity, the rule of rescue, community values, patient needs and the long- term costs avoided as a result of access to treatment. 4. The unique nature of therapies for rare diseases, including small patient populations and the implications this has for clinical trials, should be recognised in the evidence requirements for funding. 5. The process for assessing new therapies for rare diseases should be efficient, fit-for-purpose, transparent and informed by community and patient values. Source: The McKell Institute, Funding Rare Diseases in Australia , November 2014 37
  • 38. Germany The Federal Joint Committee in Germany (GBA) commissions IQWiG to examine the benefits and harms of medical interventions and recommends level of additional benefit Orphan Drugs often given “not quantifiable” benefit Additional Benefit Price Discount Negotiation Implications for Pricing European Prices Considered Major Yes Adjusted premium vs. the appropriate therapy in pricing negotiation YesModerate Marginal Not Quantifiable Yes Similar to above Yes None No (negotiation only if there is no reference group or comparator) Reference price or at max. the price of the appropriate comparative therapy No Less Benefit Yes Discount vs. the appropriate comparative therapy No Adapted from: : Markus Jahn, Novartis Pharma GmbH, Pharma Pricing & Market Access Outlook, March 2012 38
  • 39. England - NICE: Highly Specialised Technologies (HST) • Highly specialised technology (HST) evaluations are recommendations on the use of new and existing highly specialised medicines and treatments within the NHS in England. • The HST programme only considers drugs for very rare conditions. • Most are identified by the National Institute for Health Research Horizon Scanning Centre at the University of Birmingham. • They aim to notify the Department of Health of new / emerging technologies to be referred to NICE: – New drugs, in development, at 20 months prior to marketing authorisation – New indications, at 15 months prior to marketing authorisation https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-highly-specialised-technologies-guidance 39
  • 40. Overview of NICE HST Process 1. Provisional evaluation topics chosen 2. Consultees and commentators identified 3. Scope prepared 4. Evaluation topics referred 5. Evidence submitted (clinical & cost effectiveness) – Manufacturer submission – Statement from non-manufacturer consultees 6. Evidence Review Group (ERG) report prepared 7. Evaluation report prepared – Includes all of the evidence that will be looked at by the Evaluation Committee: • the ERG report and any comments received on it • written submissions • personal statements from patient experts and clinical specialists. 8. Evaluation Committee – An independent advisory committee considers the evaluation report and hears evidence from nominated clinical experts, patients and carers. Evaluation Committee discussions are held in public 9. Evaluation consultation document (ECD) if produced 10. Final evaluation determination (FED) produced 11. NICE Guidance issued https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-highly-specialised-technologies-guidance 40
  • 41. Compliance with a NICE-approved medicine or treatment • Commissioners (of the 200+ CCGs) have a statutory responsibility – to make funding available for a drug or treatment recommended by a NICE TA or HST within the timeframe recommended in that guidance. – Compliance is therefore achieved if a clinician and their patient think a health technology is the right treatment and it is available on the NHS without any local funding or local formulary restrictions. • For the avoidance of doubt, when NICE recommends a drug as ‘an option’, this is an option for the clinician and patient to consider alongside other potential treatments, not an option for commissioners or providers to not make the treatment available. https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-technology-appraisal-guidance/achieving-and-demonstrating- compliance 41
  • 42. HTA / P&R Activities over Product Life Cycle Market assessment Pricing environment NPV calculations Business planning Initial pricing scenarios Market potential based on price scenarios Early scientific advice with payers / HTA agencies Pre-clinical Phase I Phase II Phase III Filing / Pre- marketing Launch / Contracting Post Launch Price Mgmt Identify comparators Define outcomes, trial endpoints HE study design Identify P&R barriers Monitor competitors Quantitative research Payer research Analysis of value scenarios Initial pricing strategy Finalize global pricing strategy Define price corridor / fix target and floor prices for each market Define launch sequence Develop global value / P&R dossier Develop market specific dossiers for affiliates Negotiate prices Negotiate risk- sharing / price- volume agreements Launch approval Monitor launch process Indication sequencing Price change approval Report / assess mandatory price changes Monitor price trends globally Assess impact of exchange rates Assess impact of new indications • Patient focused engagement typically not part of the early HTA planning process – should start much earlier – patient groups should be pro-active • Horizon scanning • Early advice process Adapted from Simon - Kucher <===== Patient Engagement =====> 42
  • 44. Biography W. Neil Palmer President & Principal Consultant PDCI Market Access Inc Neil.Palmer@pdci.ca www.pdci.ca Neil Palmer President and Principal Consultant of PDCI Market Access Inc. (PDCI) a leading pricing and reimbursement consultancy founded in 1996. He leads a senior team of market access professionals with pricing & reimbursement engagements covering Canada, Europe, and the United States. Prior to PDCI, Neil worked with the Canadian Patented Medicine Prices Review Board (PMPRB) where his responsibilities included policy development, overseeing the price review of patented medicines and conducting economic research. Prior to the PMPRB, he worked with the Health Division of Statistics Canada where he was responsible for economic and statistical analysis of health care costs and utilization. Neil also worked with RTI Health Solutions (Research Triangle Park, North Carolina) where he served as global vice president for pricing and reimbursement. After completing his studies at the University of Western Ontario, Neil began his career in Montreal with the research group of the Kellogg Centre for Advanced Studies in Primary Care. He has written extensively on pharmaceutical pricing and reimbursement issues and is a frequent speaker at conferences in North America and Europe. In January 2015, Neil was appointed Adjunct Assistant Professor at the University of Southern California School of Pharmacy graduate program in Health Care Decision Analysis where he lectures on health technology assessment, pricing and market access from a global perspective. 44
  • 45. Customized Patient Care through Patient Support Programs for Rare/Orphan Drugs Sandra Anderson November 2015
  • 46. Why Orphan Drugs are Different  Difficult to diagnose  Population size  Unique patient and caregiver needs  Cost  Reimbursement challenges  Wait times for Specialist  Large amount of stakeholders involved to get patient on therapy There is no clear path to get Orphan Drugs Funded 46
  • 47. A Typical Journey of a Patient with a Common Disease Insert visual of patient with high blood pressure- ie asymptomatic disease Insert visual of a patient with asthma- a symptomatic disease Physician Office
  • 48. The Patient Journey in Rare Disease PSP Introduction • Coverage information is captured • Services explained Enrolment in PSP Demographics, clinical history Prescription Journey to Dx $ Patient set up to receive treatment Coverage is secured SA submissions Life time Max Injection/Infusion Services? Copay? Call – review Coverage decision Infusion/Injection Continued Care Calls • Determine status • Coach patient Annual Renewals Maintenance Onboarding Explore Reimbursement coverage Rx
  • 49. Key Trends for Orphan Drugs Different reimbursement routes across Canada. Public reimbursement/Private reimbursement – 50/50 Traditionally very high cost medication requires additional administrative work and numerous stakeholders involved in treatment Changes in Private Payer Marketplace ie PPNs Small patient populations may have regional bias
  • 50. The Patient Perspective The high drug cost, and out-of- pocket component, (co- payment or deductible) can be unmanageable for many patients (especially for Orphan drugs ~hundreds of 000s/year) Most income-based public plans such as Trillium in Ontario require patient contributions in the form of co- payments/deductibles (~3-5% of household income) With complex therapies, the primary concerns for patients are access, convenience and the level of customer service Private plans vary: range from 100% coverage to 50% coverage, though the most commonly seen co-payments are set between 0 and 20%
  • 51. Case Study: Real Life Patient Access Barriers Defined Source: Berry SA, et al. Genet Med 2013:15(8):591–599 Condition and Therapy Patient Social and Economic Healthcare System
  • 52. Patient Support Programs Focus on Orphan/Rare Disease Drugs
  • 53. Needs for Orphan Rare Disease PSPs High Touch Require specific administration or monitoring requirements before and ordering administration High Support Education, counselling, compliance monitoring, and drug information, Customized clinic needs Special Distribution Special handling techniques; and / or require special handling, have special shipping requirements or need complex reconstitution Customized Patient Assistance Clinical , Diet and Lobbying/Financial Support to assist with access to drug (i.e. co-pay assistance)
  • 54. Customized Patient Support Programs Nurse Case Manager – One point of contact to deliver quality care at every touch-point Pre Infusion Checklist (Program) Enrolment Reimbursement Specialty Pharmacy Update on Patient Progress Infusion ScheduledPatient Experience ***** Infusion Drug Dispensed, shipped to clinic) Nurse completes pre-infusion checklist Infusion Scheduled: Clinic chosen, Fax to physician, Pre-infusion checklist, Reminder call, Drug order Enrolment: Entered in CRM, NCM assigned, patient contacted Reimbursement: Case Manager confirms coverage with the patient and sets up financial assistance Specialty Pharmacy: Deferral of copay, Drug Order (Direct through Database), Warehouse sends drug to pharmacy, Drug delivered to Clinic Infusion: Nurse confirms Drug is onsite, Pre- infusion assessment by nurse, Medical clarification needed?, Infusion, PIR Patient experience touch-point Innomar Nurse Case Manager
  • 55. Case Study: Coordination of Public Insurance • Solution – Public EAP requested – Patient Advocacy: Lobby on behalf of patient; media releases; Canada wide petition; add pressure to decision makers; weekly telephone conferences with stakeholders • Outcome – Provincial compassionate program obtained to start and then successfully gained full approval from the province Patient is still on therapy! Challenge: Patient was hospitalized with multiple organ failure. The medication was still under review by the Province.
  • 56. Case Study: Reimbursement Solutions in Rare Diseases CLIENT SITUATION Client was having challenges obtaining coverage for their orphan drug with a major private payer. OUR SOLUTION  Payer wanted real health outcomes data and a negotiated a price per patient based on HO data.  Innomar worked with the manufacturer to obtain and analyze relevant HO data from their patient support program.  Innomar developed PLA scenarios and brokered the meeting between manufacturer and payer to negotiate a listing. OUTCOME  Manufacturer was successful in obtaining their desired PLA scenario  Program continues to report monthly HO data, and payer continues to cover patients who meet agreed upon criteria. KEY INSIGHT Building a data strategy early-on and utilizing relevant data through the PSP will be critical to the overall market access strategy
  • 57. Conclusions and Key Insights to Consider • Diagnosis • Testing • Reimbursement • Financial assistance • Ongoing treatment • Monitoring Rare diseases present unique challenges for: • Product focused, patient centric; • Gather valuable real life data extremely useful for payers – useful for potential Adaptive Listing initiatives; • Manufacturer funded with the opportunity to become more centralized to support overall Rare Disease Strategy PSPs for Rare Diseases are:
  • 58. Key Goal: Leverage your PSP to demonstrate real world effectiveness value to gain access to payers 58  Rare diseases present unique challenges for: - Diagnosis, Testing, - Reimbursement, Financial assistance, - Ongoing treatment - Monitoring  PSPs for Rare Diseases are: - Product focused, patient centric; - Gather valuable real life data extremely useful for payers – useful for potential Adaptive Listing initiatives; - Manufacturer funded - Opportunity to become more centralized to support overall Rare Disease Strategy Ultimate objective is to build a build a different framework for Orphan Drugs which will shorten the timelines to access Health Outcomes Research Value to Payers Patient Support Program Demonstr ate Real World Effective ness and Value
  • 59.
  • 60. Presentation to Expert Patients Forum Innovative Pathways to Drug Access in Private Drug Coverage Plans November 19, 2015 Glenn Monteith Vice President Innovation and Health Sustainability November 19, 015 60
  • 61. Players involved in private market – insurers and others Plan Members 19 Million Plan Sponsors 500,000+ Advisors & Consultants 3,000 Insurance Carriers 24 Pharmacy Benefit Managers 3 Community Pharmacies 8,600 • Many players and decision-makers are involved in private drug plans
  • 62. Diseases Have Major Impacts on Canadian Economy Diseases affect productivity at work, both physically and/or mentally Examples: 62 1 Source: http://www.phac-aspc.gc.ca/media/nr-rp/2011/2011_0919-bg-di-eng.php 2 Source: Cranswick K., Dosman D. Eldercare: Canadian Social Trends. 2008, Vol. 86, pp. 48-56 and Fast, et al. A Profile of Canadian Chronic Care Providers: A Report Submitted to Human Resources and Development Canada. Univ. of Alberta. Edmonton : s.n., 2002. $7,000 / employee / year Presenteeism $10,000 / employee / year Abstenteeism
  • 63. Chronic Diseases Have a Big Impact on Productivity and Absenteeism Top 15 drivers of lost work time Total cost of condition of employees with a primary condition 63 Source: Kessler’s HPQ—Adjusted to work Force (2007) Source: Collins et al, Assessment of chronic conditions on work performance, absence and total economic impact for employers, NEOJM, 2005
  • 64. Cost containment measures used by private drug plans 64
  • 65. Generic substitution • Not mandatory – physician may prescribe innovative medicine and write “no substitution” • Mandatory – in all cases, a generic drug, if available and considered “interchangeable” then it will be dispensed, or, plan only pays up to cost of generic drug and plan member must pay the difference in price to access the innovative medicine *exceptions process for some plans Get to know your plan options and ask questions of your pharmacist/pharmacy when getting a prescription filled. 65
  • 68. Therapeutic Sub / Mac Price
  • 70. Summary of Scorecard Findings – 2013 Actuals • PDP drug cost growth in 2013 is the lowest in recent years. • Drug cost growth of 2.2% was in line with the Forecast CAGR (1.6% to 2.8%) for the 2013-2017 forecast period. • Generic savings was higher than forecast; as anticipated generic pricing changes had the greatest impact. • Impact from new medicine entry was lower due to a mix consisting of fewer specialty medicines than forecast. • Though marginal, the aging event had a slightly higher impact than forecast due to growth in the number of older claimants and increase in utilization amongst these older claimants. 70
  • 71. Closing thoughts • Private drug plans are important to providing access to innovative medicines and vaccines • Get to know your plan and inform yourself of how plan design features can impact access • Coordination of benefits between plans (e.g. public and private or two private plans) can be complex Rx&D advocates for timely, quality access to innovative medicines and vaccines so people get the treatments they need when they need them. 71
  • 72. End of Panel B 72