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HEALTH CARE BENEFITS IN CANADA
March 2006
We Take a Closer Look Wendy Murkar
Vice-President, Claims Administration
Green Shield Canada
ƒ State of health care in Canadaƒ Issues affecting benefit utilization ƒ Impact on benefit plan design



STATE OF HEALTH CARE
IN CANADA
Benchmarking of
Canada's Health Care System
ƒ Canada and 23 other countries benchmarked on 24 health status indicators Conference Board of Canada ƒ Canada's results: • Middle of pack -13th overall out of the 24 countries• 3rd highest in total health spending • 6th highest public spender• Spending as a % of Gross Domestic Product - 7.4%, one of the highest in world



Health of Canadians
ƒ Benchmarking results: • Good on health status indicators i.e. life expectancy, low birth weight etc. • 20th out of 23 on health outcomes i.e. lung cancer rates, myocardial infarcts, stroke rates, breast cancer, suicide etc.
• 6th in obesity• 2nd highest sulphur dioxide emission * CIHI (Canadian Institute for Health Information) ƒ In Feb 2006 Conference Board of Canada issued a report benchmarking the health of Canadians by province – health status, healthcare outcomes, utilization and • No province does well in all areas• British Columbia and Alberta have top performance but B.C. lowest satisfaction level • Higher spending not associated with better health • Ontario – second lowest female life expectancy, second highest low birth weights, very low satisfaction levels but shortest wait times


Issues – Health Care
ƒ Canadians have high expectations versus other countries and do not use health care resources effectively – i.e. high incidence of emergency room use.
ƒ 2004 estimated health spending – $130.1 billion* • Public spending more than $91.1 billion ƒ Canada performing okay – male life expectancy, mortality rates on strokes, incidence of AIDS ƒ Canada performing poorly and needs attention to: • obesity, prostate cancer, infant mortality, female lung cancer, breast cancer and colorectal cancer *Conference board of Canada Costs of Health Care
Total Health Care Spending
Billions
Costs - Health Benefits
Benefit plan costs (Conference Board):
1990 – 3.7% of payroll
2003 – 6% of payroll
2007 – expected to reach 8% of payroll
Cost Drivers
ƒ Aging populationƒ Diminishing demographicsƒ Increasing consumer and provider expectations ƒ Cost of chronic disease ƒ Health human resources: • Access• Patient safety• Environmental issues ƒ Pharmaceuticalsƒ Home care ƒ Expectations for quick access to sophisticated and high quality services will continue to grow ƒ Failure to match the expectations of the providers and consumers will lead to the erosion of universality for services not deemed medically necessary (hip /knee replacements, etc) ƒ First wave of boomers – age 65 in 2012, but they will attempt to hold onto their youth – watch grandma windsurf - new drugs to do so.
ƒ Accountability and access on every Government agendaƒ Chaoulli ruling opened door to two tier Heath Care Health Council of Canada
2005 Health Care Summit's Goals for New Health
Funding: their solution and how we fix the problem
ƒ Reduce waiting timesƒ Add health professionalsƒ Home care – expand services ƒ Health innovation – HER (electronic health records), prescribing, science, research ƒ Primary care reformƒ National RX (catastrophic) strategyƒ Prevention promotion and public health National Pharmaceutical Strategy
By June 2006 a Report on Progress Including Options for:
ƒ Catastrophic coverage (national)
ƒ National Drug Formulary
ƒ Strengthening evaluation of drug safety and effectiveness
ƒ Pursuing purchasing strategies
ƒ Influencing prescribing patterns – drugs only used when needed
ƒ Expanding access to non-patented drugs, pricing information
ƒ Better analysis of cost drivers, best practices etc.
ƒ Increasing e-prescribing and deployment of EHR (electronic health records)
Ontario Drug Secretariat
ƒ Appointed mid 2005 by Minister Smithermanƒ Ontario Drug Benefit Plan unsustainable and not achieving results needed to increase health of Ontarians ƒ Report was tabled January 2006 – consulted with all external stakeholders including benefit plan sponsors ƒ Report not yet released. changes will be forthcoming and implemented over next year + ƒ Will form basis of Ontario's response to National Catastrophic Drug plan National Pharmaceutical Strategy
Issues
ƒ Income based eligibility:
• With up front out of pocket expense required • 5% to 10% of taxable income estimated as out of pocket • No Canadian to be financially disadvantaged because of drug National Pharmaceutical Strategy
Issues
ƒ Formularies will be limited and drugs will be reviewed before added
(time delays) and will consider cost/value equation. some drugs now covered by province may not be . i.e. basic meds like PPI's may be ƒ Out of Pocket to qualify will increase (Ontario - now one of lowest)ƒ May introduce other things like Maximum Allowable Costs in therapeutic classes . (drug plans pick up slack if not dealt with in plan language) ƒ Few employer plans currently have annual or life time maximums nor do they restrict medications i.e. limited or managed formularies ƒ Without changes the concern is most plans will automatically pick up shortfall – plan wording will be significant go forward issue Changes to Drug Costs as a Result
ƒ Bulk purchasing by provinces ƒ National catastrophic drugs could force up prices to private sector ƒ Drug pricing strategies: • Manufacturers listed prices not what drug sells for • Possibly change/influence Primary Health Care Reform
ƒ Fundamental to improving our health care system and making it sustainable and accessible ƒ Built on four pillars • Teams• Information ( E.H.R)• Access• Health Living Primary Health Care Reform
ƒ Interdisciplinary teams working cooperatively – doctors, nurses , pharmacists, physiotherapists, nutritionists etc. ƒ Shared information across all health professionals (E.H.R.- electronic health record and diagnosing tools ) ƒ Access beyond office hours -goal 50% of Canadians have access to 24/7 by 2011 ƒ Health living, chronic disease prevention ,management ISSUES AFFECTING BENEFIT
UTILIZATION AND COSTS
ƒ 16 million Canadians live with a chronic disease: cardiovascular, cancer, mental illness, diabetes, chronic obstructive lung ƒ Chronic disease accounts for 87% of disability ƒ Chronic disease accounts for 67% of all direct health care costs and 60% of The Most Important Common Risk Factors*:
ƒ Smoking including exposure to second-hand smoke
ƒ Obesity – 48% of Canadians are overweight;
ƒ Physical inactivity – 56% of Canadians are inactive; only 18% of teenagers active enough to meet international guidelines * Conference Board Mental Health &
Work Life Conflict
ƒ $16 billion or 15% of payroll is the economic impact of work related health and mental health issues Job stress
ƒ Work life conflict adds $6 billion 60% of Canadians indicate they can't balance work and family life Addiction
Back pain
On the job injuries
ƒ By 2020, depressive disorders will become one of the leading cause of disease burden in Canada; represents anywhere from 4% to 12% of payroll costs in Canada.
ƒ Depression & stress disorders at work account for more than 30% of disability claims ƒ Mental health claims are the fastest growing category of disability costs in Canada (overtaking cardiovascular disease) Source: Canadian Mental Health Association
ƒ 3 million Canadians depressed ( 10% of population)ƒ 1.4 million working Canadians depressed ( 10% of labour ƒ Over 33% of teenagers likely to experience depressionƒ 8% of Total Drug Expenditure in 2004 Source: Global Business And Economic Roundtable on Addiction And Mental
Health

Home Care
ƒ Home Care is considered an Extended Health Care Service under the Canada Health Act and is deemed a non-insured service ƒ Currently no strategy in Canada to address home care ƒ Throughout the 1990's the cost of home care increased at an annual rate 4X greater than other health care spending (not pharmaceuticals) ƒ Significant cost off loaded to drug plans and growing Escalating Drug Costs
ƒ CIHI reports drug spending at $22 billion (5x > than in 1995) ƒ Public sector finances only 37.6% of cost of prescription drugs Escalating Drug Costs
ƒ 1980's; $1.00/day was considered expensive (e.g. Tagamet, Zantac) ƒ Today's barrier has been estimated ƒ Biologics (DNA technology) – next wave of pharmaceuticals – over 800 in development - 350 in late stages of development Escalating Drug Costs
Average Prescription Price*
* HKS & Company, Warren, NJ, Academy of Managed Care Pharmacists, 2003 % of all pipeline
0% 3% 5% 8% 10% 13% 15% 18% 20% 23% 25% Antineoplastic & Immunosup.
Central Nervous System Cardio & Lipid.
drugs that treat
specialty
Anti-infective Agents Hormones & Synthetic Subst.
Skin & Mucous Memb. Prep.
Autonomic Agents, Agent for Specific
Disease, Enzymes, Diagnostic Agents,
Electrolytic & Water Balance, Sexual

for cervical cancer
Disorder, Musculoskeletal, etc.
New Drugs
Drug Name
Rheumatoid Arthritis $10,000 - $34,000 * Replax®
Colorectal Cancer ƒ Growing scope of pharmacotherapy: • New treatments for diseases• Maintenance medication • Preventative medication• Multiple medications – same condition ƒ More consumer driven demandƒ Direct marketing to physicians by drug companies ƒ 5% of claimants have highest drug costs - more than 40% of all costs ƒ Average utilization of high costs claimants - heavily weighted to 55-64 year old age group ƒ Selected therapy users average costs - $11,500 + • Cancer, Rheumatoid Arthritis, Multiple sclerosis, HIV, ƒ Multiple chronic diseases - average annual use $17,251 "Study of how an individuals genetics affects the
body's response to drugs"
ƒ 1/3 of drugs in testing are genetic/biologic . ƒ Estimate is that about 50 of the top 100 drugs ( anti depressants, pain meds etc. ) are affected by "one metabolizing enzyme" – 5-8% of Caucasians, 70% of Asians have some defect in this gene strand.
ƒ Statin study Iceland – 10,000 users – 2,000 no effect at all 20% ƒ Development of predictive genetic tests – prevention, planning ƒ Will ensure the right drug for the right patient - better, safer. more powerful drugs- which could decrease overall costs ƒ Extremely high cost entitiesƒ More drugs coming to market for previously untreated/under treated diseases ƒ Patents are being awarded on genetic markers/testing (no cost controls) ƒ 2003 in U.S. > 1 million genetic tests performed ƒ Market growing by 30% per year ƒ In use at University of Montreal and Genome Quebec: • Childhood leukemia • Antidepressants • Pain medication• Herceptin (breast cancer) ƒ Test costs – who pays? (U.S. – some drug plans pay)ƒ Complexity in deciphering gene variations and interpretation of testing on drug response – who can do it ƒ How do you ensure information is used by physician and not just another alternative.
ƒ How does physician/pharmacist apply to prescription/dosingƒ Disincentives for drug companies - limits their markets ƒ Limited drug alternatives – if does not work • Education – public and health care providers Electronic Health Record
Objectives:
ƒ Improve health outcomes
ƒ E-prescribing – reduce error rates,
improve patient safety ƒ Improve decision making ƒ More efficient use of resources ƒ Permit remote access – Electronic Health Record - Model
The Old World
The New World
Patient and family focus Continuum of care Episode management Disease management Supply management Demand management Lone Ranger decisions Collaborative, evidence- based Decentralized care Centralized, specialized Electronic Health Record Issues
ƒ Costs of implementation – technology, cognitive fees, transaction fees, consent etc.
ƒ Compliance with standards by all providers – adds costsƒ Privacy- knowledgeable patientsƒ Plan Adjudication increased sophistication new information, new standards, new plan types ƒ Emergence of e-prescribing will affect : • formulary design, utilization of pharmaceuticals• the current supply chain Impact on Benefit Plan Design
Impact on Benefit Plan Design
ƒ Existing publicly funded benefits will be significantly changed: • More off-loading, home care, drugs for home use - cancer therapy oral not IV • Income based –provincial coverage • Limited use drugs and drugs not on formularies - increasing ƒ Current benefit plans can not meet all expectations – high cost drugs may be available only to a few people, need to consider ƒ Shift from "paternal view" of taking care of employees to "shared ƒ Plan sponsors will have to make choices – focus on sustainable costs Impact on Benefit Plan Design
ƒ If issues with access not addressed: • 2 - tier pricing• Private clinics/Private referrals ƒ EHR will add costs to the delivery model - cognitive fees, transaction fees, password maintenance, consent maintenance etc.
ƒ National Catastrophic Drug Plan - how does plan language ensure plan members are protected? ƒ National Pharmaceutical Strategy Impact on Benefit Plan Design
Plan Members
ƒ Plan members will demand expansion of covered services i.e. value of semi private in relation to other "at ƒ High costs for new tests/diagnostics will have to be evaluated and costed –when they bring value, who ƒ MRI in private clinic for active employee only – get employee back to work ƒ All benefits and services will have to be reviewed to ensure they meet medically necessary criteria of improved health outcomes . Vision care every two years- cosmetic or a health requirement Impact on Benefit Plan Design
ƒ Benefit plan language needs to address ƒ traditional drug language probably not appropriate, consider if language covers drug ingredient costs alone, - delivery chain and primary health cognitive fees, amount covered if care model (Canada Health Act) physician dispenses etc.
- reimbursement model ƒ Consider costs transactions, private ƒ The requirement to use any government coverage as first payer.
ƒ Introduction of new costs from ƒ Give employer alternatives with cost implementation of emerging initiatives: containment – right person, right drug - picked up by existing language - significant pressure to add ƒ Overall plan maximums , so as additional costs are added exposure does not increase. Impact on Benefit Plan Design
Chronic Disease and Mental Health
ƒ Costs of diagnoses and treatments ƒ Provide education and prevention ƒ Prevention and healthy lifestyle need to ƒ Have a healthy life focus be encouraged and rewarded ƒ Put attention to employees versus dependents and spouses – i.e. physio for active only not dependents ƒ Reward good consumerism and healthy choices through plan design Impact on Benefit Plan Design
ƒ If expectations are not dealt with - ƒ Offer co-pays, deductibles, maximums, costs unsustainable increased off-loading to public plans ƒ Generic vs. Brand drugs, Maximum ƒ Flexible technology and ongoing due diligence allowed costs, EGS to ensure maximum coordination with all ƒ Off-loading from Government ƒ Move to formularies that same or similar restrictions that government wil or picking up costs - Conditional Drug Formulary- prescribing guidelines ƒ Coverage for preventive services enhanced , chronic decreased, ƒ Flex Benefits ® Impact on Benefit Plan Design
Education and Interventions
ƒ Plan members have high ƒ Communicate cost/value of current plan and benefits plan, expectations – but not everything covered all the ƒ Education to make better decisions ƒ Ensure patients understand impact of treatment options – plan design must force choices ƒ Coverage personalized to ƒ Begin philosophy of not everything covered – lag fee health condition, level of guides eliminate things cosmetic alone.
compliance (diabetic - benefit of dietician), target "at risk" ƒ Reward good lifestyle choices e.g. (nicotine patches covered) ƒ Reward good consumerism - (generic drugs – lower ƒ Health care spending account to deal with diverse needs and offer protection from delisting, new costs and services Frivolous Cost or Sound Investment?
ƒ Conference Board of Canada– Dec. 2005 • Very difficult in turbulent times ( survive today is focus)• Absenteeism and disability rates for "personal" reasons • Rising drug and dental costs, cost shifting from public sector is significant concern • Still uncertainty of results and the link to productivity and competitiveness is tenuous.
• Research has evidence of the relationship between employee satisfaction and profitability, higher employee • ROI on workplace health promotion wrong debate – focus has to be strategic and long term.
Green Shield Canada
Right Benefit, Right Person, Right Time:
ƒ Green Shield Canada Conditional
Drug Formulary ƒ Initial Days Supplyƒ Enhanced Generic substitution and Maximum Allowed Costs ƒ Claims Management – Green Shield ƒ Green Shield Canada Passport to Healthƒ Reporting and Analysis – Web ShieldStats®

Source: http://www.selectpath.ca/Employers/Resources/pres_2006_Closer_Look.pdf

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