CGIB December 2016 Newsletter


Rising drug plan costs


The Trick of Selling is NOT Selling
Group brokers’ association asks insurers to stop making unilateral changes to contracts

Ontario government’s plan should reduce burden of higher drug costs


Innovative Solutions Needed To Sustain Benefit Plans
With the continued increase in high-cost specialty drugs and new therapies, plan sponsors are faced with yet another challenge to maintain drug plan sustainability. However, opportunities exist to continue to provide access to new drugs while ensuring sustainability, says John Herbert, director of strategy, product development & clinical services with Express Scripts Canada. Speaking at the Benefits and Pensions Monitor Meeting & Events ‘Benefits Conference: Managing Health Plans and Ensuring Future Sustainability’ session on ‘Ensuring Drug Plan Sustainability through Innovative Solutions,’ he said innovative solutions can drive healthier outcomes at lower costs. Reducing waste and managing spend are two examples of this. Private plans in Canada wasted $15.7 billion over the past five years, which was 19 per cent of total drug spend. Another $12 billion dollars was wasted on poor drug choices – using higher cost medications that generate no additional health benefit – and $3.7 billion was wasted by poor pharmacy choices – using more costly distribution channels and/or fewer than optimal dispensing intervals. Herbert said waste is highly prevalent in maintenance medications spend and significant cost reductions can be achieved with better drug choices. In addition, the majority of patients suffer from multiple conditions, and they need assistance managing their treatment complexity. “Patients are not aware of the options available to them,” he said. Actively engaging them can lead to lower costs and healthier outcomes. “Patients can work as a partner in their therapy. They are looking to take part.”

MOHLTC Makes Improvements To Drug Plans
The Ontario Ministry of Health and Long-term Care (MOHLTC) continues to improve its Exceptional Access Program (EAP) and Trillium Drug Program (TDP), says Menzies Jardine, a senior manager for the ministry of health and long-term care. Speaking at the Canadian Group Insurance Brokers Inc’s November seminar, she said in October, it received approval to move some older EAP drugs to its Ontario Drug Benefits (ODB) program. As of this month, it has added interchangeability for EAP drugs; however, the drugs will be subject to the rules of the ODB formulary. In addition, processes for the EAP program will become simpler with the ministry’s new web-based application system, Special Authorization Digital Information Exchange system (SADIE). This will allow direct online services for submission and management of requests; potential real-time adjudication; automation for renewal and tracking; and the ability to collect and analyze real-time, real-world clinical data to support funding decisions. The system is slated for full implementation in early 2018. New initiatives underway for the TDP include co-ordination of benefits (COB) between Trillium and private plans. In order to enhance the health network system and supporting systems, the ministry will allow pharmacies to submit COB claims for TDP recipients with private insurance to the health network system for online adjudication once the initial claim has been adjudicated by the patient’s private insurance plan(s). The patient will no longer need to submit paper receipts to TDP if the pharmacy has already co-ordinated the benefits between ODB and private insurance through the online system. TDP deductible contributions will still need to be paid by the patient, however it will be tracked in the health network system so that the patient can receive the TDP benefit immediately once the TDP quarterly deductible has been met. Trillium is a payor of last resort in the pre-deductible phase. Members must submit receipts first to the insurance provider, then pay the TDP deductible before Trillium becomes the first payor. The member will be reimbursed for the amount they have spent in excess of the deductible. The COB will roll out in the fall of 2017.
Health insurers’ pooling system vital amid Canada’s sky-high drug prices, says industry body
Drug costs for expensive and recurring treatments rose 22% in 2015, report finds
It’s not me, it’s you: clients leave insensitive advisors
How health benefits plan design is changing

Sponsors Should Consider Plan Goal When Controlling Drug Spend

With many factors influencing the cost of drug plans, employers need to look for ways to control spend while making sure the benefits remain aligned with the original goal of the plan, says Barbara A. Martinez, national practice leader, drug benefits solutions, for Great-West Life Assurance Company. Speaking at the Benefits and Pensions Monitor Meeting & Events ‘Benefits Conference: Managing Health Plans and Ensuring Future Sustainability’ session on ‘Drug Plan Management in an Era of Growth,’ she said while there are few factors reducing drug spend, many more factors are increasing drug spend. For example, 68.6 per cent of prescriptions now use generic substitution and result in in a pull effect ? or cost reduction ? for drugs, while factors such as growth in the aging population, increased use of drugs, and the shift to higher cost drugs have a push effect ? or increase ? on drug spending. “There is not much pull effect going forward, but lots of push,” said Martinez. However, “it’s your plan design that’s going to increase your costs going forward.” She said there are many ways to reduce drug spend. For example, new, higher cost drugs are prescribed when less expensive drugs will suffice for most people. Where possible, lower cost drugs should be used first and patients should only graduate to the next level if the original doesn’t work. In addition, preventable illness accounts for approximately 70 per cent of the total cost of illness. The World Health Organization has estimated that at least 80 per cent of all heart disease, stroke, and type 2 diabetes would be prevented with education and treatment and about 40 per cent of all cancers could be prevented. Martinz said ultimately, drug plans are an investment in the health and productivity of employees; it is important to be strategic about balancing cost and health.

As drug costs surge, US patients turning to Canadian pharmacies
Future Benefit Plans Will Be More Flexible
The benefit world of tomorrow will change from a paternalistic system to one that is more flexible with more engaged plan participants, says Paul Kennedy, group benefits actuary and principal in the Employee Health & Benefits business at Mercer. Speaking at the Benefits and Pensions Monitor Meeting & Events ‘Benefits Conference: Managing Health Plans and Ensuring Future Sustainability’ session on ‘Benefit Trends 2017,’ he said the changes in employee cultures are driving these trends, including an increase in Millennials who are driving the conversation, as well as innovative benefits offered by employers in Silicon Valley that are trickling into the traditional workforce. Now, governments are shifting more responsibility to individuals to take care of themselves in retirement and in self-care, he said. Millennials prefer this environment because they are used to taking care of themselves. It used to be that employers kept adding better benefit programs to attract and retain the best talent, but those programs weren’t utilized in a beneficial way. Going forward, new generations will demand flexible options and voluntary benefits will play a huge role. One of the ways these new plans will be delivered is through market exchanges, a health insurance marketplace where employers can offer more choices and employees can choose what they need. These are not available in Canada just yet, but advancing, particularly in the area of retiree benefits.
Everyone Affected By Benefit Fraud
It is estimated that two to 10 per cent of healthcare dollars are lost to fraud and abuse. That’s significant on a total health benefit spend of $32.2 billion in 2015 and affects everyone, especially small- to medium-sized employers, says Karen Voin, assistant vice-president of group benefits and anti-fraud at the Canadian Life and Health Insurance Association (CLHIA). She told the Benefits and Pensions Monitor Meeting & Events, ‘Benefits Conference: Managing Health Plans and Ensuring Future Sustainability’ session on ‘Trends in Benefits Fraud and Prevention’ that fraud and abuse have an impact on the sustainability of benefit plans and can create higher costs for everyone. “Employees don’t always see it as doing something wrong because they have a sense of entitlement,” says Voin. Employers need to communicate that it’s wrong and what the implications are. Other areas of fraud include organized schemes – which can occur at all levels – to cross-industry schemes, identity theft, billing for services not rendered, collusion, and fake facilities. “The best way to mitigate fraud is to prevent it. Education and communication are key.” She says a team effort is required and suggest collaborating with various health profession associations and colleges, law enforcement, other industries, etc. Plan sponsors should provide continued education on how all stakeholders can protect themselves.
The fees are coming and the fun is gone
The high cost of specialty drugs
With an abundance of new drugs set to enter the market, your clients need to understand the potential impact of specialty drugs on plan costs.
Ontario introduces legislation for new Financial Services Regulatory Authority
CLHIA expects premium hikes for employers

Biosimilar Growth Falls Short Of Biologic
Although biologic growth has historically exceeded overall pharma market growth in Canada, the uptake of biosimilars has been much slower, says Brad Millson, a principal in the health access and outcomes consulting group at QuintilesIMS. Speaking at the Benefits and Pensions Monitor Meeting & Events ‘Benefits Conference: Managing Health Plans and Ensuring Future Sustainability’ session on ‘Biosimilars,’ he said in 2015 half of the top 10 brands overall and four of the top 10 private drug plan brands. He said several areas of the biologic market have reached maturity, while others are just emerging. “Biosimilars are like generics for biologics but not quite. The biologic market is inherently different than pills; they are brewed like beer or wine and distilled into a drug that is typically injected. They are never the same twice.” At this time, biosimilars are not considered ‘bioequivalents’ to biologics as generics are to traditional pharmaceuticals and pharmacists are not allowed to interchange them. Biosimilars will also not necessarily provide a huge relief for payers due to lower rate of discount versus brand biologic. Multiple factors have influenced a slower uptake of biosimilars. However, the biosimilar pipeline is strong, particularly for molecules treating auto-immune diseases, said Millson. And, going forward, multiple dynamic factors will influence the uptake of biosimilars, including dependency on new patients versus switching, the varying confidence by prescribers, regulatory decisions, pricing strategies, and marketing strategies.

The 3-tiered strategy for filling your pipeline with referrals

How eliminating commissions leads to business growth
Founder of ‘Moneyball for health benefits’ says employee plans unsustainable

Market Trend Generate Concern
A look at drug plan market trends during Mapol’s ‘3rd Annual Benefits Advisors’ Drug Plan Outlook’ meeting generated some concerns as they relate to plan sponsors being able to adjust to drug plan cost pressures, especially among small to mid-sized employers. The advisors spoke to the increasing use of annual plan maximums within this market and a trend towards implementing a defined contribution rather than defined health benefits plan. To support the sustainability of drug plans, plan members are increasingly asked to share in the cost of premiums or pay a greater portion of the claim.
Insurance advisors must get ready for greater regulation
Most life agents in Ontario only sell a handful of policies a year
How do patients feel about biosimilars?
Agents and advisors must differentiate themselves
The proper way to set a call back
CDC Call to Test All Boomers for Hep C Has Fallen Flat

Benefits exchanges predicted for Canada as plans continue to evolve



Join us on Thursday, December 1st from 12:00 p.m. – 1:00 p.m. EDT for the “Success with Ethics” webinar.

This webinar introduces Financial Advisors to the most important concepts and issues related to ethics and the financial services industry. This seminar is provided by financial services author, educator, and ethics specialist, Rod Burylo.
Earn your CE:

1 hour FPSC-approved CE under the Professional Responsibility category
1 hour Saskatchewan Ethics Credit
1 hour RIBO under the Management category
1 hour of CE for Life Licenses (BC, SK, MB, & ON)
1 hour Life and A&S for Alberta (pending)

$20.00 for IFB Members
$ 30.00 for Non Members

Prices do not include tax

Click HERE and Register Today!

2016 Face to Face Drug Plan Management.

Register Now!

December 8, 2016. Fairmont Royal York, Toronto

The Face-to-Face Drug Plan Management Forum (Toronto) is a half-day event focusing on drug plan management issues.


Debunking Myths in Drug Plan Management
In order to better understand drug plan management, it’s important to highlight some of the myths and misconceptions that exist. This panel will use live polling technology to help drive discussion.

The Burden of Non-Adherence
Non-adherence to medication means a less healthy workforce and plan sponsor dollars wasted. This panel will discuss what impacts plan member adherence and what role the plan sponsor should play.

Employee benefit and drug plan sponsors, benefit consultants, group insurers and other healthcare stakeholders.

$129 + Tax (employers)
$249 + Tax (industry providers)


BBC – DECEMBER 1, 2016

A Window Into Public Drug Plans:
A Balance Between Public
and Private Payers

Menzies Jardine, Ontario Ministry of Health
and Long-Term Care
Karen Voin, Canadian Life and Health
Insurance Association

Our theme this season is Making the Link: Financial Sustainability and Measuring Outcomes. Our first session on September 22nd explored the progress of drug and disability analytics. On November 3rd we heard about the three top chronic diseases that are driving drug costs and new workplace and benefit solutions to address them.

Register now for our third session this season which takes place on Thursday, December 1, 2016 at our new Brampton location (see below).

CE Credits: Unless otherwise noted each session is eligible for 2 continuing education credits for those who are life licensed. Mark your calendars now! (*NEW FEATURE: When you register be sure to let us know if you require CE credits.)

A Window Into Public Drug Plans:
A Balance Between Public
and Private Payers

DECEMBER 1, 2016


Menzies Jardine, ?Senior Manager at Ontario Ministry of Health and Long-Term Care and Karen Voin, Director, Health Claims Anti-Fraud and Electronic Claims at the Canadian Life and Health Insurance Association will review changes to the Ontario Drug Benefit program and national integration between provincial drug reimbursement plans and private plans. Also discussed will be Ontario-specific issues with respect to linking private drug plan claimants with Trillium, administrative challenges and complexities, the insurer role in the process now and in the future, creating linkages between support resources publicly and privately, improving patient access and the future of support for patients to improve health management.

Location (*new venue*):

Lionhead Golf Club and Conference Centre
8525 Mississauga Road
Brampton, ON (North of the 407)
L6Y 0C1
(905) 455-4900
Registration, breakfast and networking: 7:30 – 8:00am
Presentations and Panel Discussion: 8:00 – 10:30am

Register now at our Early Bird price of $65 incl. HST. The session price increases to $75 incl. HST on November 25, 2016.

Register early to guarantee your place at this session.

Specialty Drugs and Plan Sustainability
Specialty drugs are turning often-fatal or disabling diseases into manageable chronic conditions—at prices that can make drug plans unsustainable. According to Express Scripts Canada, in 2015:

The average annual drug spend per claimant increased by 4%, across Canada. Hidden in this seemingly manageable increase is the fact that spending on traditional drugs actually decreased by 1% while it increased by 19% for specialty drugs
Only 2% of claims were for specialty drugs, but these accounted for 30% of total drug spend. And this is forecast to reach 42% by 2020
Almost 60% of drugs approved for use in Canada were specialty drugs. Specialty drugs are being developed in ever greater numbers
According to CDIPC:

The cost of expensive/ recurring drug treatments in 2015 increased 22% over the previous year
The new drug for Hep C, Harvoni, represented an estimated $3 million in paid claims in 2014, but grew to $42 million in 2015.
Pooling helps shield customers from the full impact of high cost claims, but the impact of specialty drugs on our EP3 and LAP—and pooling charges—could be substantial.

In this webinar we will explore how specialty drug programs work, and how they can help build sustainability into customers’ plans.

Steve Nowak, Director of Sales and Marketing, Express Scripts Canada

Warren Chau, Director, Pharma Relations, Express Scripts Canada

December 6, 2016
1:30-2:30 p.m. Eastern (10:30-11:30 a.m. Pacific; 11:30-12:30 p.m. Mountain; 12:30-1:30 p.m. Central; 2:30-3:30 p.m. Atlantic)

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