And now for something completely indifferent
Episode 3 Transcript
[0:00:14.9] SM: Hello, David.
[0:00:15.7] DW: Hi, Sarah. I just want to call out a bit of your introduction there, because it’s consistent with the advertising we’ve been doing around this brand new podcast where we are I think attempting to be quite humble about our expectations for this particular adventure, and you made reference to this is the benefits industry podcast that no one really wanted, but we’re forcing on them anyways. I think another ad suggest that we are filling a void that actually no one thinks exists, and I think I’ve said to you that the sentence, what the health benefits industry really needs is a podcast is one that was never uttered.
[0:00:53.1] SM: Ever, by anyone.
[0:00:53.9] DW: Ever. Never, and rightfully so. So our expectations are not tremendous for listenership, and I think we’ve been dreaming of numbers in the tens.
[0:01:04.1] SM: Of non-GSCers.
[0:01:04.6] DW: Yeah, we may get there in three or four years, numbers in the tens.
[0:01:07.4] SM: Yup.
[0:01:07.9] DW: But essentially as I sort of looked at the podcast landscape and what is attracting listeners across Canada, across the world, something I noticed in my iCloud as well, because I’ve been a long time podcast listeners, a famous podcast by Bill Simmons on sports and Marc Maron on entertainment and comedy, but increasingly over the last couple of years, sharing a cloud with my teenage daughter, I’ve seen the influx of a lot of podcast centered around, one; crime, and I use crime at the high-level and then to go down a level, murder. Obviously, that led to some self-reflection about perhaps the environment she was brought up in which we thought was quite positive, but she seems to have a burgeoning infatuation with all things dark. We are certainly considering family therapy at this point in time.
What’s your experience with this?
[0:02:02.6] SM: I think that’s actually quite normal, because at GSC, we used to have a book club and we’ve since almost folded that book club and opened a podcast club, and believe it or not what we’re into in our club is listening to also podcasts about crime, a subset of that podcast about murder, and podcast about unsolved murders.
[0:02:26.4] DW: Okay. So this is a thing.
[0:02:27.3] SM: Oh, it’s an absolute thing. It’s a complete trend. It’s not just your teenage daughter. No.
[0:02:30.9] DW: It’s just my family.
[0:02:32.7] SM: No, it’s just not your family. This is a pretty broad representation of people on our club here at GSC, so I think it’s a trend. It’s a thing.
[0:02:40.6] DW: I think we have to be honest. Whenever you start one of these things, you are looking for listenership and I think we’re waiting with bated breath on what those numbers would look like, and we’re anticipating the worst. I think we have to have the conversation now about if those numbers are as disappointing as we think they might be. Do we need to pivot and recognize where listenership is, and I think it’d be sort of nakedly ambitious to just go do a set of a serial killer podcast by then wondering if we could combine what we know is popular.
[0:03:10.5] SM: Crime and murder.
[0:03:10.9] DW: Crime and murder is very popular with our industry, and I anticipate a day perhaps, and our listeners will know this day when we put out the call to them to send us any instances where they feel maybe they have been the victim of crime and it’s unsolved and this podcast will be the avenue to solve crimes committed upon insurance industry individuals.
[0:03:36.8] SM: Absolutely. Good idea.
[0:03:37.3] DW: If in 2018 you start hearing that, you can deduce strongly that the numbers are bad.
[0:03:45.5] SM: They’re bad. Yes.
[0:03:47.1] DW: So on to today, and the topic of medical marijuana. One that is much talked about in our industry. Perplexing to some, vexing to some about how our industry will handle this particular product. We’re going to have three guests in the studio with us today. Two from our pharmacy strategy team here at GSC; Marilyn Jung, who is a pharmacist; Ned Pojskic, who is our pharmacy strategy leader; and a very special guest from outside these four walls down on Queen Street actually, a fellow named Mike Sullivan who many of us know from the industry from his articles in Benefits Canada. Also, a pharmacist but also a thought leader around pharmacy benefit management. We’re going to get started now.
[0:04:35.1] DW: Okay. I think we’re ready to go. We have never had so many people in the podcast studio/wellness room. We’re a little bit jammed in here today. We have four microphones, but five people, so we’re going to see how this is going to work.
As promised, we have a few guests with us today talk about medical marijuana. People cannot see this podcast, but to my left is my colleague Marilyn Jung, who is a pharmacist in our pharmacy strategy team. You’re an actual real pharmacist, right?
[0:05:04.3] MJ: That’s right.
[0:05:05.0] DW: Okay. We’re going to get back to that in a second. Sitting across from me in the far corner is Ned Pojskic, our pharmacy strategy leader. Ned, you’re not a pharmacist.
[0:05:15.2] NP: I’m not.
[0:05:16.5] DW: Defend yourself.
[0:05:18.9] NP: I can’t. I obviously can’t.
[0:05:20.5] DW: Ned, you have a Ph.D. in what?
[0:05:24.5] NP: In pharmaceutical policy.
[0:05:26.4] DW: Okay, and you teach at —
[0:05:29.6] NP: Leslie Dan Faculty of Pharmacy at UFT.
[0:05:32.9] DW: And you have somehow found your way to work in Benefits Industry.
[0:05:37.3] NP: Somehow.
[0:05:38.5] DW: Okay. We’re happy to have you. Last but not least we have a very special external guest, one Mike Sullivan of Cubic Health. Somebody who’s very well-known in our industry. Mike, Cubic Health is known as a tremendous integrator of data and bringing insights from drug data, now even beyond drug data. You in fact are a pharmacist too. Am I correct?
[0:06:02.1] MS: Yeah, not much one. That is true.
[0:06:05.4] DW: Something I know about Mike that not everybody probably knows is you also married a pharmacist. Is that correct, sir?
[0:06:11.5] MS: Not intentionally. I do. Yeah. She’s real.
[0:06:15.9] DW: So I’m fascinated, because in marriages I know it’s probably common to diagnose one another overtime with different conditions. Is it legal for you to actually prescribe to each other?
[0:06:29.5] MS: No. It depends on what you’re talking about though. Medication, no.
[0:06:33.9] DW: You cannot prescribe a medication to your spouse.
[0:06:36.9] MS: Not yet.
[0:06:37.0] DW: Even if you strongly belief he or she needs something.
[0:06:42.6] MS: Yeah, I’m going to take that one offline, but — Fair enough.
[0:06:46.3] DW: Marilyn, do you agree with that answer?
[0:06:48.3] MJ: I agree with that.
[0:06:48.6] DW: Okay. Is that something in the regulations, in the code of conduct? Where does that come from?
[0:06:52.1] MJ: That would be unethical.
[0:06:54.0] DW: Unethical. Okay. That haven’t crossed my mine. But an interesting take on that subject. Let me go right to medical marijuana. Mike has written an article in Benefits Canada this year. Certainly here internally at GSC, probably like any other benefits carrier or pharmacy benefit manager, we’ve been looking at the issue of medical marijuana and how to properly or potentially include it in health benefit plans. Before Ned and Mike got an opportunity to man-slain their ideas around medical marijuana, I wanted to ask Marilyn a very specific technical question around this concept of medical marijuana. First; is there a difference between — We use the word marijuana and we use the word cannabis. Is that the same thing?
[0:07:37.7] MJ: Great question, David. They’re actually used interchangeably, so either term is fine. Some people prefer one over the other, but really they’re used interchangeably.
[0:07:46.7] DW: Okay. We’re fine with the industry just talking constantly about medical marijuana. That makes sense.
[0:07:50.9] MJ: Correct.
[0:07:52.4] DW: In terms of medical marijuana, is that different than the stuff that the cool kids in high school used to smoke behind the school in the ravine? Is that the same stuff or different?
[0:08:03.9] MJ: The difference between medical and recreational really is that people who are using it for medical reasons, they’re using it to either treat their disease or treat symptoms, whereas those using it recreationally are really using it for non-medical purposes. So there is a difference.
[0:08:17.4] DW: Okay, got it. Either to Marilyn or Ned, we reimburse medical marijuana today as a benefits carrier. How do we do that and what circumstances do we do that?
[0:08:28.1] NP: We do. Again, it’s used up as any other medical expense other healthcare spending accounts. We do track it, so we’re able to understand the current utilization of it, but we do reimburse for it. There are procedures and aspects that have to be taken into account, but they are a part of plans, benefits plans from that perspective.
[0:08:45.0] DW: Actually we get in some sort of documentation and we simply pay for it. There’s no prior authorization or any system in place to verify the need for this.
[0:08:56.8] NP: No. I guess the prescription from the doctor would be the verification, and that you cannot obtain medical marijuana unless you have that medical prescription. If you haven’t, from as far as we’re concerned, it’s an eligible expense under HSCAs.
[0:09:08.9] DW: Okay. Great. Mike, I’m going to turn to you. You’re a great supplier of advice to Canadian employers about managing their benefit plans, specifically their drug plans, their health plans very strategically. What’s your take on the situation we have now where this is being reimbursed that only at this point through HSCAs?
[0:09:29.5] MS: It’s a big mistake. If you’re doing it that way, you’re really trying to spread the benefit out across too many people and not providing enough benefit. I think financially there’s an enormous risk to doing so, but I also think it’s an irresponsible form or coverage.
[0:09:42.6] DW: Okay. What are the alternatives that exist — As we’re taping this podcast early in December 2017. We’re going into a year where marijuana will be legalized in the country where we’re going to have even more dialogue about this. I’ve said before, I’m sure people are going to conflate recreational marijuana with medical marijuana. It will just be talked about a lot whether it’s the same thing or not. What can plan sponsors think about doing that would make better the situation that you just described?
[0:10:11.6] MS: It’s really only now that we’ve got the first few plan sponsors that we’re working with that are actually going through a much more rigorous approach, almost using a prior authorization infrastructure to do it. It’s the beginning of that right now. I would expect to see the first few coming live in January of 2018 and going beyond, but these are groups that are having to effectively engineer this process independent of their vendor, their partners, because nothing exist today. Really, the infrastructure that I’m preaching to the choir here in the room, the infrastructure has been healthcare spending accounts, because it’s a CRA benefit, but in terms of being able to address this in a meaningful way going forward, it’s going to require a much more robust clinical infrastructure to deal with.
[0:10:52.7] DW: Ned, obviously inside our company, and I’m sure this is true at some of our competitors as well, we have been talking a fair bit about this over the past year. Where has our thinking sort of evolved and where is it taking us into how we can accommodate what Mike is here talking about?
[0:11:08.3] NP: Yeah, it has evolved. Again, because I think we do recognize that medical marijuana does have a place in treatment. The challenge has always been in that the current level of evidence may not be the level which we’re used to at other drug therapies. As a result we’re sort of questioning, “Where does the place lie?” However, as our thinking has evolved, it’s evolved along the lines of what Mike mentioned, which is that a prior authorization process is a necessity to ensure that the patients who are getting on this therapy, if you will, for those indications where there is the most evidence.
Though I think in this particular space, the question of evidence is a really challenging one, because evidence across the board is lacking both in quantity and quality, but where it does exist where it is stronger, there is a place for inclusion and benefit plans in most cases. Then the idea is how do you create the necessary infrastructure as Mike mentioned to accommodate those specific clinical indications.
[0:11:58.5] DW: So this is to open to anybody. Where is the better evidence than the worst evidence today?
[0:12:05.5] MS: From our perspective, there’s only response, where there’s enough evidence today, that’s chronic pain, chemotherapy, induced nausea and vomiting, and the third one is spasticity in patients that have MS. Those are the only three areas where there’s enough evidence today where you can definitively that there’s an impact, and as Ned said, there’s a role for medical cannabis. It’s not a first line role to be clear about that, but there’s certainly a role.
The next wave of disease states where we’re starting to see evidence emerge, and there’s over 180 clinical trials happening worldwide now, so the evidence is going to be coming at a substantial pace moving forward. The next wave would include things like pediatric refractory epilepsy for young children that can’t find the appropriate coverage on existing anti-epileptic therapy, getting into short term sleep disorders with things like sleep apnea and getting into — The evidence still isn’t there, but it’s emerging around decreasing opioid doses by onboarding medical cannabis for people who are at very substantial retribalization of opioids.
That second tier is still emerging. You could probably throw PTSD in that tier as well, but you’ve really only got those first three that I referenced where you’ve got strong evidence.
[0:13:16.2] DW: I have heard noise around this issue, and given everything we’ve read the last couple of years about the opioid crisis here in North America more generally, there is probably the hope out there that this is somehow going to be the replacement for obviously a category of drugs that’s causing a lot of discomfort and distress in our societies. Are we there? Is that realistic thought or is that not what’s going to happen?
[0:13:47.5] MJ: I mean that’d be great if we’re able to get there one day, but right now the current [inaudible 0:13:51.3] states, it’s not there yet. A lot of the studies out there that have looked at opioid use and tying it to decreased used the marijuana, it’s really just anecdotal. So definitely the evidence still needs some work, and we have a lot more to go in terms of that.
[0:14:08.0] DW: Okay. Obviously, there’s a push in society to bring this product mainstream, and certainly for the conditions that Mike just mentioned, you would think that overtime there’s going to be quite a bit of support for helping that patient population deal with the horrible things that they have to go through. It’s probably wrong to say that marijuana comes without sort of risks or side effects. What are some of those inevitable things that come with its use?
[0:14:37.3] MJ: There’s a lot of short term effects that come with it. It’s mostly tied to the THC level in there, so the active cannabinoid. A lot of discussions around there in terms of — Especially between motor vehicle accidents and using cannabis, there’s a lot of long term effects too, particular with mental illnesses and things like that they’ve shown. Although just like with the evidence, the long term effects are still being studied as well. So it’s not fully understood at this time, but again that level of evidence is growing every day.
[0:15:03.3] MS: The other important consideration too and the other reason why it’s important to treat this like you would any other drug that’s subject to prior authorization is twofold. Number one; cost. This is a specialty drug for a number of users especially in the chronic pain area, but the second one is there’s some fairly material drug interactions that people have to consider with very commonly prescribed medication, BPIs, antidepressants, antibiotics, antifungals, you name it. So there’s really a need to consider this in a more thoughtful way, because there are certainly some potential, unintended consequences for people who haven’t been looked at properly.
[0:15:37.1] DW: You just brought up the cost, and again I’m not sure if people are thinking this product cost as much as it does. Why don’t we educate people on what’s sort of the going rate these days.
[0:15:50.1] MS: That’s a loaded question. It’s very difficult to answer for a couple of reasons. Number one; the going rate for dried leaf cannabis that most people would equate with medical cannabis, medical marijuana is somewhere between $8 to $9 per gram. Now, we get into the issue of is there going to be excess tax put on this come July, etc., etc., or come the New Year.
The bigger problem and the reason why nobody can really thoughtfully answer your question intelligently right now is for individuals to be using this properly from a workplace standpoint, they’re going to have to look at CBD dominant strains that have very low, if any levels of THC or active levels of THC to reduce cognitive impairment in the workplace, safety issues. The challenge is, is that really interesting dosage forms that are CBD dominant; gel caps, creams, edibles overtime, things like that, they’re going to come at a price premium to dry leaf cannabis. When we say, “Oh, it’s just a 8.50 a gram or $8 a gram or $9 a grams,” it’s not going to be the case when you get into some of these more interesting dosage forms that are going to be required in the workplace. That’s the big question mark that people don’t really understand, which is another reason why you have to link this to a meaningful prior authorization, because you can’t just leave this open-ended.
[0:17:07.0] DW: That’s sort of like a specialty product on top of an already expensive product.
[0:17:11.5] MS: The range of potential doses, because it’s so highly individualized. So one member could be using a very limited amount and another member could have much more significant need. The dosage range and then the cost to treat depending on the dosage form is going to be literally from one end of the spectrum to the other. The cost to treat somebody on this is going to be profoundly different individual to individual. I think some of the less responsible reporting I see around this topic looks in saying, “Well, the average person is between maybe one to two grams a day if they’re using this for chronic pain, etc., and this is the cost,” but that’s not looking at the full story. It’s going to be a lot more complicated.
[0:17:51.0] DW: Yeah. Ned, I know we’re doing exactly that kind of analysis right now internally and trying to figure that out. Where are you and your team sort of landing on a viable approach for GSC plan members?
[0:18:04.1] NP: Yeah, I like what everything Mike said from the perspective that are multitude of products, multitude of strains, multitude of permutations of this. Controlling it is very difficult, and the traditional way which we have within which we know the standard dosing, which we know the cost of the product. That’s a real challenge, and I think a lot of that will get sorted out as we go forward, but at the moment we’re looking at simply, from the perspective, what are the maximums? Where is the greatest evidence for indication? That’s about as far as we can go in the early stages as this sort of the potential options of products get a little bit more standardized, then we can go down the root of understanding what are the oils cost. Then we can sort of go further there.
Again, you’re going to have — We have 75 growers today. We’re going to have over 200 that’s estimated over the next couple of years. The multitude of products available is going to grow substantially as well. So rigor is necessary in this space for sure.
[0:18:55.5] MS: There’s one other really important piece that I also haven’t seen very many people discuss, which I think is a huge miss, is if anybody wants to tackle this properly, again, from an employer’s standpoint, coming at this from an ASO plan sponsor standpoint or even the small and the medium size group that want to fund this on a cost-plus basis, is the fact that if you’re going to do this intelligently and responsibly, you have to be aligned with specific license producers, because very license producer will have a different array of products, but most importantly they’re going to have different equivalency factors. There’s not one equivalency factor that says one gram of dried cannabis equals X in a capsule or in a transdermal and oil.
Every single set of equivalency is going to have to be done at a specific LP level, meaning that they’re going to have to be preferred vendors for this, not necessarily just one, but there’s going to have be alliances or partnerships with specific license producers for this to be done properly. The other consideration too is making sure that there’s going to be enough product available to satisfy the needs of plan sponsors who are clearly going to be looking for CBD dominant strains that are workplace friendly.
Come July 2018 when the recreational market opens up, the availability of product is going to be something that’s a concern, because Ned hit the nail on the head. We’ve got 75 growers today, [inaudible 0:20:17.9] today give or take and we’re going to have many more fold that overtime, but the medical market, which is the one that employers have to be concerned about is not going to be at the front of the line. You’re going to see a lot of these groups going into the recreational market, and for good reason because that market is going to be a lot easier to access and it’s going to be a lot bigger initially for sure.
There are going to be some really material considerations around this. So whereas some people have shied away from having preferred relationships with healthcare vendors, etc., it’s going to be an absolutely necessity in this space.
[0:20:49.4] DW: Okay. Mike, you mentioned that you’ve already got some clients looking at building policy and building this into their benefits program. Not that you can speak for all clients or all of them think the same way, but what was the impetus for them to want to be leading on this as supposed to waiting on this?
[0:21:08.2] MS: Well, I think a lot of this is sort of financial necessity. I’ll tell you an interesting story that happened very recently. This happened in two separate cases, so I’ll just focus on one for the time being because I have a hard time keeping more than one story straight, because I’m high right now.
One plan sponsor said, “We really want to be a leader in this space and we want to come at this the right way.” They said, “So we think —” By the way, this is fully insured group. This is a smaller group. It’s not an ASO group “We really want to be out there. What do you think is going to be a feasible budget?” They said, “Well, how long is a piece of string?” They said, “Good question.”
I said to them, “What kind of budget are you comfortable with, because this is going to have to go cost-plus. No carrier in the world is going to underwrite medical cannabis anytime soon given the enormous complexities we’re trying to underwrite something like this.” They said, “Okay. Good question.” They said, “Well, we’re not really sure what kind of budget do you think we need.”
This is a relatively small group spending in the order of magnitude of call it $130,000 a year on drug benefits today. If you sit down and take a look at their experience right now, and we did the analytics recently for them, we said, “You’ve got almost a virtual certainty there’s going to be three claimants coming through as soon as this is made available to them. If they come through prior authorization, there are three claimants in here. If you restrict utilization to just the conditions where there is evidence today, we think there’s a homerun that there’s three people here all treating variants of chronic pain and neuropathic pain. If they came through our process today, with one or two questions that we can’t see in the data that we had, it’s almost a virtual certainty they would be approved. That by itself with these claimants could very easily translate into about 22 to $23,000 of annual cost even with cost-sharing applied, because we also think it’s a really important factor that groups have cost-sharing in here so that it’s not just an open-ended benefit for somebody.”
We said, “So that’s going to now take your drug plan benefit and bump it up from call it roughly 130. All of the things being equal, you’re going to be adding 20+ grand to the baseline. Forget anything else in the specialty side moving forward. Are you ready for this? If so, great. If not, do you need to think about redesigning other elements to your benefit plan to get more efficient, or does this going to change some of the limitations and some of the ideas about what you want to put into place?”
The very first thing any plan sponsor needs to do is say, “Based on my own profile today, what is my likelihood and what’s my exposure,” and then work backwards from there, because if not, if this is going to be, “Well, I’ll just wait and see what happens.” There’s a lot of money that’s come in to this market, a lot of capitals flowing in here. There’s a lot of money going into efficacy. You’re going to see more and more groups challenging coverage on this moving forward. If you don’t have established policies and an established prior authorization piece and a design piece, you’re going to be exposed.
I think part of this is being a leader from the point of view from having another tool. I think both Ned and Marilyn refer to this. You’ve got another tool in the toolbox for people who have uncontrolled chronic pain or if they have spasticity related to their MS, why not consider it? That’s nice. But by the same token, if we’re not being responsible, it’s a big deal. That’s where people need to start. They’re starting, I think, an equal balance out of the initial ones out of the gate or starting an equal balance of trying to be fiscally prudent, but at the same time trying to be leaders. As the wave starts to go through, it won’t be around being leaders anymore, it will be around fiscal prudence.
[0:24:44.7] DW: Are there some groups either in your portfolio or certainly segments of groups that you think should wait this out of it? That should not go down this path until some of these questions are answered?
[0:24:55.9] MS: Absolutely not. I think if we think about smaller groups, and small and medium size groups, they need to be on top. They need to have process, procedure. They need to have some kind of documents and policies around what their intent is. Absolutely not. If they stand there waiting and hoping that this storm is going to pass them by and they get hit with a big claim, they may have to be very reactive and it may not be good. I think everyone has to look at this. More importantly, we think about July 2018 when this is legalized. There’s no more, “Well, let’s just push this under the rug.”
I grew up in a Catholic family where we just pushed everything under the rug, right? We don’t talk about sex ed, we don’t talk about drinking, we don’t talk about drugs. Everything is just under the rug. Just hope it doesn’t happen, but that’s not the way the world works. So it’s the same thing here.
100%, everybody has to think about this regardless of size granted for small and medium size employers. I say that with the utmost respect, as Cubic is a small employer, we recognize that there’s not going to be an endless amount of money available here and perhaps the decision will be not to cover it for specific reasons, but they need to be documented and discussed upfront.
[0:26:03.4] DW: Okay. This has been great. I think we’d given our listeners some food for thought.
[0:26:09.4] MS: Did you want to talk a bit more about my background? My childhood?
[0:26:16.6] DW: Well, I’m afraid you’re going to talk more about religion now actually. There’s a reason we’re ending now, Mike. Sarah, can’t you turn off Mike Sullivan’s microphone?
No. Thank you very much. As I said, it was great insight. There is a companion written piece to this podcast. Follow the Script December version is talking about a lot of these issues around medical marijuana. So I encourage folks to also read that. Thank you for listening and we’ll be back shortly with our next podcast.
[0:26:49.1] SM: Thank you to our listeners for tuning in to another episode of And Now For Something Completely Indifferent, a Canadian health benefits podcast. To be sure to get future episodes, assuming we continue to do this, please subscribe to this podcast wherever you get your podcasts or visit our website at greenshield.ca/podcast to download.
As a reminder, we do talk about these issues consistently in our publications, which are available on our website. Specifically for today’s episode, you can check out our winter issue of Follow the Script.
Thank you for listening, and we’ll talk again soon.