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HEALTH CARE BENEFITS IN CANADA
We Take a Closer Look Wendy Murkar
Vice-President, Claims Administration
Green Shield Canada
State of health care in Canada Issues affecting benefit utilization Impact on benefit plan design
STATE OF HEALTH CARE
Canada's Health Care System
Canada and 23 other countries benchmarked on 24 health status indicators Conference Board of Canada 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
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) 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
Canadians have high expectations versus other countries and do not use health care resources effectively – i.e. high incidence of emergency room use.
2004 estimated health spending – $130.1 billion* • Public spending more than $91.1 billion Canada performing okay – male life expectancy, mortality rates on strokes, incidence of AIDS 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
Costs - Health Benefits
Benefit plan costs (Conference Board):
1990 – 3.7% of payroll
2003 – 6% of payroll
2007 – expected to reach 8% of payroll
Aging population Diminishing demographics Increasing consumer and provider expectations Cost of chronic disease Health human resources: • Access• Patient safety• Environmental issues Pharmaceuticals Home care Expectations for quick access to sophisticated and high quality services will continue to grow 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) 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.
Accountability and access on every Government agenda 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
Reduce waiting times Add health professionals Home care – expand services Health innovation – HER (electronic health records), prescribing, science, research Primary care reform National RX (catastrophic) strategy Prevention promotion and public health National Pharmaceutical Strategy
By June 2006 a Report on Progress Including Options for:
Catastrophic coverage (national)
National Drug Formulary
Strengthening evaluation of drug safety and effectiveness
Pursuing purchasing strategies
Influencing prescribing patterns – drugs only used when needed
Expanding access to non-patented drugs, pricing information
Better analysis of cost drivers, best practices etc.
Increasing e-prescribing and deployment of EHR (electronic health records)
Ontario Drug Secretariat
Appointed mid 2005 by Minister Smitherman Ontario Drug Benefit Plan unsustainable and not achieving results needed to increase health of Ontarians Report was tabled January 2006 – consulted with all external stakeholders including benefit plan sponsors Report not yet released. changes will be forthcoming and implemented over next year + Will form basis of Ontario's response to National Catastrophic Drug plan National Pharmaceutical Strategy
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
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 Out of Pocket to qualify will increase (Ontario - now one of lowest) May introduce other things like Maximum Allowable Costs in therapeutic classes . (drug plans pick up slack if not dealt with in plan language) Few employer plans currently have annual or life time maximums nor do they restrict medications i.e. limited or managed formularies 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
Bulk purchasing by provinces National catastrophic drugs could force up prices to private sector Drug pricing strategies: • Manufacturers listed prices not what drug sells for • Possibly change/influence Primary Health Care Reform
Fundamental to improving our health care system and making it sustainable and accessible Built on four pillars • Teams• Information ( E.H.R)• Access• Health Living Primary Health Care Reform
Interdisciplinary teams working cooperatively – doctors, nurses , pharmacists, physiotherapists, nutritionists etc. Shared information across all health professionals (E.H.R.- electronic health record and diagnosing tools ) Access beyond office hours -goal 50% of Canadians have access to 24/7 by 2011 Health living, chronic disease prevention ,management ISSUES AFFECTING BENEFIT
UTILIZATION AND COSTS
16 million Canadians live with a chronic disease: cardiovascular, cancer, mental illness, diabetes, chronic obstructive lung Chronic disease accounts for 87% of disability Chronic disease accounts for 67% of all direct health care costs and 60% of The Most Important Common Risk Factors*:
Smoking including exposure to second-hand smoke
Obesity – 48% of Canadians are overweight;
Physical inactivity – 56% of Canadians are inactive; only 18% of teenagers active enough to meet international guidelines * Conference Board Mental Health &
Work Life Conflict
$16 billion or 15% of payroll is the economic impact of work related health and mental health issues Job stress
Work life conflict adds $6 billion 60% of Canadians indicate they can't balance work and family life Addiction
On the job injuries
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.
Depression & stress disorders at work account for more than 30% of disability claims Mental health claims are the fastest growing category of disability costs in Canada (overtaking cardiovascular disease) Source: Canadian Mental Health Association
3 million Canadians depressed ( 10% of population) 1.4 million working Canadians depressed ( 10% of labour Over 33% of teenagers likely to experience depression 8% of Total Drug Expenditure in 2004 Source: Global Business And Economic Roundtable on Addiction And Mental
Home Care is considered an Extended Health Care Service under the Canada Health Act and is deemed a non-insured service Currently no strategy in Canada to address home care Throughout the 1990's the cost of home care increased at an annual rate 4X greater than other health care spending (not pharmaceuticals) Significant cost off loaded to drug plans and growing Escalating Drug Costs
CIHI reports drug spending at $22 billion (5x > than in 1995) Public sector finances only 37.6% of cost of prescription drugs Escalating Drug Costs
1980's; $1.00/day was considered expensive (e.g. Tagamet, Zantac) Today's barrier has been estimated 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
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.
Rheumatoid Arthritis $10,000 - $34,000 * Replax®
Colorectal Cancer Growing scope of pharmacotherapy: • New treatments for diseases• Maintenance medication • Preventative medication• Multiple medications – same condition More consumer driven demand Direct marketing to physicians by drug companies 5% of claimants have highest drug costs - more than 40% of all costs Average utilization of high costs claimants - heavily weighted to 55-64 year old age group Selected therapy users average costs - $11,500 + • Cancer, Rheumatoid Arthritis, Multiple sclerosis, HIV, Multiple chronic diseases - average annual use $17,251 "Study of how an individuals genetics affects the
body's response to drugs"
1/3 of drugs in testing are genetic/biologic . 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.
Statin study Iceland – 10,000 users – 2,000 no effect at all 20% Development of predictive genetic tests – prevention, planning Will ensure the right drug for the right patient - better, safer. more powerful drugs- which could decrease overall costs Extremely high cost entities More drugs coming to market for previously untreated/under treated diseases Patents are being awarded on genetic markers/testing (no cost controls) 2003 in U.S. > 1 million genetic tests performed Market growing by 30% per year In use at University of Montreal and Genome Quebec: • Childhood leukemia • Antidepressants • Pain medication• Herceptin (breast cancer) Test costs – who pays? (U.S. – some drug plans pay) Complexity in deciphering gene variations and interpretation of testing on drug response – who can do it How do you ensure information is used by physician and not just another alternative.
How does physician/pharmacist apply to prescription/dosing Disincentives for drug companies - limits their markets Limited drug alternatives – if does not work • Education – public and health care providers Electronic Health Record
Improve health outcomes
E-prescribing – reduce error rates,
improve patient safety Improve decision making More efficient use of resources 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
Costs of implementation – technology, cognitive fees, transaction fees, consent etc.
Compliance with standards by all providers – adds costs Privacy- knowledgeable patients Plan Adjudication increased sophistication new information, new standards, new plan types 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
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 Current benefit plans can not meet all expectations – high cost drugs may be available only to a few people, need to consider Shift from "paternal view" of taking care of employees to "shared Plan sponsors will have to make choices – focus on sustainable costs Impact on Benefit Plan Design
If issues with access not addressed: • 2 - tier pricing• Private clinics/Private referrals EHR will add costs to the delivery model - cognitive fees, transaction fees, password maintenance, consent maintenance etc.
National Catastrophic Drug Plan - how does plan language ensure plan members are protected? National Pharmaceutical Strategy Impact on Benefit Plan Design
Plan members will demand expansion of covered services i.e. value of semi private in relation to other "at High costs for new tests/diagnostics will have to be evaluated and costed –when they bring value, who MRI in private clinic for active employee only – get employee back to work 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
Benefit plan language needs to address 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 Consider costs transactions, private The requirement to use any government coverage as first payer.
Introduction of new costs from Give employer alternatives with cost implementation of emerging initiatives: containment – right person, right drug - picked up by existing language - significant pressure to add Overall plan maximums , so as additional costs are added exposure does not increase. Impact on Benefit Plan Design
Chronic Disease and Mental Health
Costs of diagnoses and treatments Provide education and prevention Prevention and healthy lifestyle need to Have a healthy life focus be encouraged and rewarded Put attention to employees versus dependents and spouses – i.e. physio for active only not dependents Reward good consumerism and healthy choices through plan design Impact on Benefit Plan Design
If expectations are not dealt with - Offer co-pays, deductibles, maximums, costs unsustainable increased off-loading to public plans Generic vs. Brand drugs, Maximum Flexible technology and ongoing due diligence allowed costs, EGS to ensure maximum coordination with all Off-loading from Government Move to formularies that same or similar restrictions that government wil or picking up costs - Conditional Drug Formulary- prescribing guidelines Coverage for preventive services enhanced , chronic decreased, Flex Benefits ® Impact on Benefit Plan Design
Education and Interventions
Plan members have high Communicate cost/value of current plan and benefits plan, expectations – but not everything covered all the Education to make better decisions Ensure patients understand impact of treatment options – plan design must force choices Coverage personalized to 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" Reward good lifestyle choices e.g. (nicotine patches covered) Reward good consumerism - (generic drugs – lower Health care spending account to deal with diverse needs and offer protection from delisting, new costs and services Frivolous Cost or Sound Investment?
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:
Green Shield Canada Conditional
Drug Formulary Initial Days Supply Enhanced Generic substitution and Maximum Allowed Costs Claims Management – Green Shield Green Shield Canada Passport to Health Reporting and Analysis – Web ShieldStats®
Systemic hypertension Disease Coverage Report reference: DMKC12591 Published on: 27/06/2016 About Datamonitor Healthcare Bringing you a clearer, richer and more responsive view of the pharma & healthcare market. Complete market coverage Our independent research and analysis provides extensive coverage of major disease areas,