How do kids in Ontario and “best of rest” of Canada get drugs today: public, private, and not at all (Chris Bonnett, H3 Consulting)

1. How do Ontario children and young
adults access prescription drugs?
Chris Bonnett, MHSc, PhD (Cand.)
H3 Consulting / hthree.ca
CORD / Toronto / June 14, 2017

2. In ten minutes…
1. Special drug coverage for children and young adults across Canada
2. Estimates of coverage in Ontario: provincial and private drug plans
3. Potential therapeutic classes relevant to children and young adults
4. Considerations and questions
5. Paying for drugs: OHIP+ conclusions

3. Provincial Special Drug Coverage
Children and Young Adults
Prov Special
Drug
Programs Eligibility
Notes
BC None
AB Child
Health
Benefit Low
income
(<
$26,023,
+);
<
age
19/21
SK Children’s
Drug
Plan,
Insulin
Pump
(IP)
CDP:
$25 per
drug;
<
age
15.
IP:
<
age
26.
MB Insulin
Pump <
age
18.
ON OHIP+
(proposed) Universal
<
age
25;
ODB+EAP
drugs;
no
cost
QC None
NB Growth
Hormone
Deficiency
(GHD) <
age
19;
20%
up
to
$20/drug,
up
to
$500/family/yr.
NS Insulin
Pump <
age
25
PEI GHD;
Immunization; IP GHD,
Imm:
<
age
18.
IP:
<
age
19.
NL Select
Needs
Plan;
IP SN:
GHD
up
to
18.
IP:
<
age
25.
Sources: (1) Clement FM, et al., 2016. Canadian Publicly Funded Prescription Drug Plans, Expenditures and an Overview of
Patient Impacts. University of Calgary, School of Public Policy. https://obrieniph.ucalgary.ca/system/files/comparison-­‐of-­‐
canadian-­‐publicly-­‐funded-­‐drug-­‐plans-­‐for-­‐alberta-­‐health-­‐feb-­‐1-­‐2016.pdf. (2) Provincial government websites.

4. Public: Unclear
Government
drug
spending
(2014,
ages
0
– 24):
$146,005,000
1
Incremental provincial
drug
spending:
$319,000,000
Proposed
annual
drug
spending
(2018): $465,000,000
2
Total
ON
Beneficiaries
(ages
0
– 24): 3,914,000
3
Percent
of
total
population
(13,448,000): 29
3
Per
capita
(ages
0
– 24): $119
(2018,
implied)
OPDP
Coverage
Estimates
4
ODB
Programs 3.94
mm
(28%)
• Beneficiaries
(ages
0
– 19) 400,000
eligible
• Beneficiaries
(ages
0
– 24) 244,000
(60%)
claim
Other
public 0.24
mm
(2%)
Private
insurers
7.74
mm
(55%)
Uninsured 2.24
mm
(16%)
Total 14.16
mm
(105%
of
population)
Sources: (1) CIHI NHEX 1975-­‐2016 Open Data. (2) Ontario government News Release, May 23, 2017. (3) Statistics Canada,
2016 Census. (4) 2015/16 Report Card for the Ontario Drug Benefit Program. Private insurance coverage is unreliable.

5. Private: We know even less
• Typical private drug plan prescription drug coverage is for children to
age 18, except age 23 or 25 if a full time student, or if physically or
mentally incapable of self-­‐support. 1
• Most plans reimburse 100%, 80% or 90% of a much broad(er) formulary,2
though few have limits on out-­‐of-­‐pocket spending.
• Current private drug spending for ages 0 to 24: unknown.
• Telus Health, ages 0 – 29: 3
• 30.7% of claimants account for 12.4% of total eligible costs.
• OHIP+ may save 8% to 11% of drug claims, defer other cost controls. 4
Notes: (1) There are over 100,000 private health plans, and many variations on eligibility for both members and drugs.
(2) PDCI Market Access reported that their database of private drug plans reimbursed 3,300 more DINs than the ODB
formulary. See Pharmacare Costing in Canada, March 2016, p.21. (3) Telus Health, 2016 Data Trends. (4) M. Sullivan,
Cubic Health, LinkedIn blog May 1, 2017; F. Naranjo, Collins Barrow, quoted in Cdn HR Reporter, May 23, 2017

6. Top 10 Therapeutic Classes
Children and Young Adults
Class
Rank
/
Name
Avg.
Cost
$
per
script
Notes
2 Diabetes 80 Metformin
only
generic
in
top
10;
14%
trend
4 Depression 41 Higher
use
offset
by
lower
cost
generics
5 Asthma 73 Most
products
brand
only;
generic
fill
35%
6 Infections 33 Rank
3rd in
utilization;
-­‐8%
trend
9 Cancer 503 Biggest
pipeline;
12%
trend
10 ADHD 96 Mostly
generic,
but
14%
trend
11 Multiple
sclerosis 1,847 Most
often
diagnosed
in
young adults
41 Rare
diseases 4,686 Few
products
currently,
but
42% trend
48 Cystic
fibrosis 3,216 Orkambi®
could
benefit
50%
@
$260,000/yr
Source: Express Scripts Canada, 2016 Drug Trend Report. http://www.express-­‐scripts.ca/knowledge-­‐centre/drug-­‐trend-­‐
reports. Rank is by annual claim cost.

7. Considerations and Questions
General
1. Who are “most in need and least able to pay”? 1
2. No detail / certainty on estimated cost. What assumptions?
3. Will impacts (intended and not) of new drug coverage be measured?
Private Drug Plans
1. Insured plans will not see immediate cost reductions; ASO will. 2
2. Young plan members are usually low cost; rates may increase for others.
3. Will some employers exclude members under age 25, even though the
OPDP formulary provides less extensive coverage?
4. Unknown future costs: Could Employer Health Tax be increased? 3
Notes: (1) 2017 Ontario Budget. http://www.fin.gov.on.ca/en/budget/ontariobudgets/2017/. (2) Insured plans (pooled or
experience-­‐rated) are typical for smaller employers (<50 to 100 employees). ASO (Administrative Services Only) plans
are self-­‐insured by larger employers. (3) 2017 Budget (Table 6.14) estimates EHT revenue at $5.9 billion for 2016-­‐17.

8. OHIP+ Conclusions
1. OHIP+ coverage is unique in Canada. Other provinces have specific
targets: low income families or certain diagnoses. Some have co-­‐pays.
Quebec offers consolidated, consistent universal coverage model.
2. Budget speaks of those in need, but message then changes to equity
and supporting notion of universal pharmacare. Immediate purpose
and longer-­‐term goals are unclear.
3. Quick implementation means consultation may be welcomed…or
discouraged so that Ministry can meet its deadline…but something
will have to be implemented before the 2018 election.
4. A welcome surprise to employers. Biggest impact will be on ASO plans
with large, recurring claims…but smaller employers could choose to
eliminate all coverage for Ontario plan members under age 25.