Ontario general manager with Fasken Martineau. LLP, one of two plan .... Kathy Sotirakos, private insurance senior marke
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Combining forces Insurers, pharmaceutical manufacturers and advisors put forward joint strategies to safeguard the future of drug plans
Ph otos: J o h n ny L a m , JL P
A powerhouse gathering of benefits providers
representing more than 16 million plan-member lives recently sat down with some of Canada’s largest brand-name pharmaceutical manufacturers to explore a single objective: Improved collaboration to protect the sustainability of private drug plans. “It was heartening to see these people in the room looking for solutions,” says Tony Pierro, the Ontario general manager with Fasken Martineau LLP, one of two plan sponsors invited to the table. “One thing that really struck me is that the current drug system is really a fractured system. Members of the ‘supply chain,’ so to speak, don’t really talk to each other. This meeting tells me there is hope to change that, which is critical, because there is huge potential to save money that is currently falling through the cracks.”
“The premise of collaboration definitely makes sense, though prior to the meeting it was hard to see how big pharma and insurers could really work together,” notes Jason MacLean, senior consultant with ArcelorMittal Dofasco, the second plan sponsor. At the end of the full-day session, “I left feeling somewhat optimistic. The right stakeholders are starting to recognize there are issues around sustainability. There needs to be more alignment between them and plan sponsors.” The timing is also right. The growing incidence of chronic disease, higher-cost specialty drugs and lack of plan-member accountability exert increasing pressure on drug-plan spending. “We are approaching a tipping point where plan sponsors will need to become stringent about what drugs and other benefits they’ll pay for. It’s important
for these stakeholders to be more proactive now,” says MacLean. “We understand there is a sense of urgency, in part, because if we don’t do something, someone else will and we will be forced to a new paradigm that may not be best for anyone, including plan sponsors or members,” says Janet Jackson, vicepresident of marketing, with Empire Life. “We’re too used to doing what we do. The time has come to do things differently.”
Group action Best practices to build value Revamping renewals Renewal meetings typically focus on controlling costs. To redirect the conversation so that plan sponsors see benefits as investments that can deliver value, “it would be great to receive better intelligence on the profile of our employee population in terms of current utilization and emerging trends, followed by recommendations for benefits management and wellness supports, going forward,” says Tony Pierro, general manager with Fasken Martineau LLP’s Ontario office. Communicating to members Current technology enables an unprecedented level of targeted communications to consumers, which is much more effective than general awareness-raising campaigns. Carriers can send disease management information to plan members with diabetes, for example. “People are okay with this now; they’re used to it thanks to the internet and smartphone apps. A carrier could even send a personal note about claim ABC with a message along the lines of, ‘Did you know that using drug Z could have saved your drug plan X dollars?’ The response is positive if the message is positive,” says Tim Clarke, health and benefits innovation leader, Aon Hewitt.
Path to innovation The Canadian Leadership Council on Drug Plan Partnerships, a meeting hosted by Benefits Canada, convened in June in Toronto. Representatives from nine carriers, seven brand-name pharmaceutical manufacturers, three pharmacy benefits managers and three benefits advisors, as well as representation from the respective industry associations — the Canadian Life and Health Insurance Association, and Canada’s Research-Based Pharmaceutical Companies (Rx&D) — heard from guest presenters who shared case studies on successful collaborations between diverse stakeholders. They then participated in breakout sessions to identify action steps (see sidebars). “The global healthcare system is increasingly challenged by entrenched inefficiencies. The lack of connection between stakeholders is one of its problems,” Heather Fraser, global lead for healthcare and life sciences with the IBM Institute for Business Value, states in her presentation. Collaboration begins internally, by “working collaboratively across your own internal projects and having partnering as part of an organization’s overall strategy. It requires a rethinking of business structures and relationships, and taking the time to understand your partners. You need to really look at the risk-sharing in the relationship, and you solidify the alliance by putting your governance structures in place.” Such “expanded scopes for partnering” will not only improve system efficiencies, but also pave the way for innovation. “Global research from IBM finds that CEOs from outperforming organizations
“Let us work out the details behind the scenes so that the patient and the caregiver and the physician can do what they need to do together. We don’t want to impede that process; we want to make it easier.” – Sarah Shephard, Novartis Canada actively pursue partnerships. Partnering for innovation is particularly prolific in regulated industries,” says Fraser.
Common ground When it comes to healthcare, participants at the meeting agreed that positive health outcomes and the empowerment of consumers are the common driving principles that can unite the industry’s diverse group of stakeholders. The group discussed two possible areas on which to focus: better access to care and improved adherence to therapy. “These are patient-centric issues that everyone can easily latch on to,” says Linda Lin, director of clinical services and pharmacy relations, with ClaimSecure Inc. “Everything we do should be seamless for the patient, as well as the physician and other providers,” says Sarah Shephard, director of Ontario and private markets, with Novartis Canada. “Let us work out the details behind the scenes so that the patient and the caregiver and the physician can do what they need to do together. We don’t want to impede that process; we want to make it easier.”
Group action Checklist for standardization Drug evaluations Everyone would benefit from a standard submission format that is specific to the private sector. Pharmaceutical manufacturers and carriers can work together to create a template, which can be an adaptation of the Format for Formulary Submissions developed by the Academy of Managed Care Pharmacy in the United States. Prior authorizations Currently, carriers develop their own criteria for prior or special authorizations, resulting in confusion and significant paperwork for physicians, pharmacists and patients. Standard prior authorization forms would recoup a substantial amount of time, which can be put back into patient care. Frontline education So much has changed, and is changing, for private drug plans, and often it’s left to the healthcare provider to explain things to plan members at the point of care. Accredited continuing education programs would help build a common understanding. “Doctors and pharmacists are crying out for more information on how all this works; for example, when there’s a drug on special authorization for one plan with one carrier, but not for others,” says Sarah Shephard, director of Ontario and private markets, with Novartis.
“We learned that it’s hard for an organization, such as ours, to change individual behavior; instead, we can focus on how to change the delivery system in order to better incentivize behavioural change.”– Kevin Walker, The Partnership to Fight Chronic Disease
Group action Access to higher-cost drugs “One of the largest challenges for physicians and nurses, pharmacists and patients is understanding the nuances between carriers and individual plans, particularly in terms of access to higher-cost specialty and biologic medications. A secure online platform or portal to provide coverage details in real time is one solution and could reduce plan members’ time off work and improve access to care by weeks, or even months. Right now, this process tends to be spread out over specialist appointments. This central site would simplify co-ordination between private plans and pharmaceutical companies’ patient-assistance programs, as well as emerging case-management programs on the carrier side.” – Kathy Sotirakos, private insurance senior market access manager, Amgen Canada
As well, “reducing non-adherence is probably one of the lowest-hanging fruits in terms of improving outcomes and reducing costs,” suggests Leanne MacFarlane, senior director of business development, with Managed Health Care Services Inc. — MHCSI. “Pharmacist-directed medication therapy management improves adherence; but fundamental coverage of these services? We’re not quite there yet.” “We share a common interest in having people take their medications properly. We haven’t addressed this as an industry. What are the pan-Canadian strategies that we can enact? We can be entrepreneurial about this,” says David Willows, vice-present of strategic markets, with Green Shield Canada. Such entrepreneurial thinking across diverse stakeholder groups essentially enables you to think
Group action Quest for real-world evidence Why is real-world evidence important? Currently, most decisions to establish a drug’s clinical and cost effectiveness are made from published controlled clinical trials; however, a drug’s value cannot fully be understood until it has been used for a period of time by patients in the “real world.” Such real-world evidence, sometimes referred to as phase-four studies, can help formulary managers determine which drugs to include, or maintain, in managed formularies. What are the necessary steps to gather real-world evidence? Partnership is essential. “Manufacturers need to work with carriers, plan sponsors and other stakeholders to access benefits utilization data. Only then can we build a complete story that explains where all costs are coming from and the influence of drug coverage on real-world outcomes,” says Adam Marsella, national manager, private market solutions, with GlaxoSmithKline. How could real-world evidence eventually come into play when making listing decisions? “One option for the future could be listings with conditions,” says Donald Allard, director of government
big. For example, The Partnership to Fight Chronic Disease, a U.S.-based global coalition of patient, provider, business and labour groups, including pharmaceutical manufacturers, has been able to “move from trying to help people individually, for instance, by promoting lifestyle change, to delivery system reforms, such as care co-ordination,” says Kevin Walker, executive director of the partnership and a guest speaker at the meeting. “We learned that it’s hard for an organization, such as ours, to change individual behavior; instead, we can focus on how to change the delivery system in order to better incentivize behavioural change.”
The next level Ultimately, government needs to be part of the collaboration. With that in mind, it becomes all the more important to present a united front. “We realized that, independently, we didn’t have the weight or scope to drive the kind of change we wanted,” Shannon MacDonald states in her presentation about Neurological Health Charities Canada. The coalition of non-profit neurological organizations began with 11 members in 2008 and has since grown
relations and public affairs, with Bristol-Myers Squibb. “You would secure the initial listing based on a risk assessment of the covered population and, from that, derive the promised value of the new drug. And then we would review in, say, three to five years’ time using the real-world data.” Are there other factors to consider? “Electronic records are one of a number of important links for real-world evidence,” notes Andrew Merrick, director of patient access, with Eli Lilly Canada. “Right now, the healthcare system has difficulty connecting the dots and following patients on their journeys, from the doctor writing the prescription, through to its effect on the patient, the workplace and the entire health system.” Provincial governments are slowly laying the foundation for electronic health records, for example, just over half of Canadian doctors report using electronic medical records, according to the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Private payers need to be part of the evolution. “We need to connect the technology with all stakeholders in order to provide the ultimate care to patients in the real world,” says Laureen Rance, senior director for the Centre of Excellence, with Telus Health.
to 26. Months after its launch, it persuaded government to fund the first population health study of neurological conditions. The coalition has since worked with three government agencies to help direct the highly anticipated research, the results of which will be released later this year.
at the table Insurance companies
“What made this work from day one was buy-in at the CEO level,” says MacDonald, the coalition’s former director of policy and partnerships (currently vice-president of public affairs and partnerships with Rx&D). “Then it’s all about building relationships. You need to understand each other and how to deal with conflicts. It’s important to ask the tough questions early.” Improved data collection, information-sharing, open communications and standardization are some of the building blocks not only for collaboration, but for sustainability in the healthcare system. Keeping in mind the ballooning economic and societal burden of chronic disease, which Walker describes as “a public health emergency in slow motion,” all stakeholders need to regard collaboration as their best hope. “If everyone keeps going ad hoc down their own road, things will come to a very unproductive head,” emphasizes Martin Chung, assistant vice-president with Equitable Life. “Far better to think positively about what we can accomplish together.”
Thank you to THE LEADERSHIP COUNCIL sponsors
Shanta Zurock, Alberta Blue Cross Janet Jackson, Empire Life Martin Chung, Equitable Life Ben Harrison, Great-West Life Mark Jackson and David Willows, Green Shield Canada Simon Chan and Connie Wong, Manulife Financial France Gauthier, Medavie Blue Cross Joanne Jung, Pacific Blue Cross Marilee Mark, Sun Life Financial Stephen Frank, Canadian Life and Health Insurance Association Pharmaceutical manufacturers
Kathy Sotirakos and Geoff Sprang, Amgen Canada Martin McNeil, AstraZeneca Canada Donald Allard, Bristol Myers Squibb Andrew Merrick and Kinsley Wilson, Eli Lilly Canada Adam Marsella, GlaxoSmithKline Sarah Shephard and Lison Prevost, Novartis Pharma Canada Doug Daniell and Danny Peak, Sanofi Canada
Pharmacy benefits managers/ adjudicators
Linda Lin, ClaimSecure Priscilla Po, Express Scripts Canada Leanne MacFarlane, Managed Health Care Services Inc. — MHCSI Laureen Rance and Bessie Wang, Telus Health Solutions Benefits advisors
Tim Clarke, Aon Hewitt Johanne Brosseau, Mercer Benefits plan analytics
Mike Sullivan, Cubic Health Plan sponsors
Jason MacLean, ArcelorMittal Dofasco Tony Pierro, Fasken Martineau LLP academic speakers
Kevin Walker, Partnership to Fight Chronic Disease Celina CaesarChavannes, ReSolve Research Solutions Inc. Heather Fraser, IBM Institute for Business Value Shannon MacDonald, Canada’s ResearchBased Pharmaceutical Companies (Rx&D)
