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January 16, 2019

  • The Inside Story

The Inside Story: Where do we go from here?

...Issues from 2018 gain momentum in 2019

Ah yes, the New Year… always a good time to reflect on the previous year. But it’s also a good time to look ahead and prepare for the coming year. So we decided to do both! Here’s an overview of what transpired regarding the main issues we covered in 2018—plus, some predictions for 2019…

Pharmacare ‘big reveal’ – spring 2019

The July/August 2018 edition of The Inside Story focused on the debate surrounding pharmacare. As you may recall, as part of the debate, the House of Commons Standing Committee on Health was charged with studying the development of a national pharmacare program as an insured service under the Canada Health Act. The Committee heard from more than 100 of what they referred to as “witnesses” (everyone from patient groups, health care professionals, and academics to pharmaceutical companies, unions, and various government agencies).1 Witnesses’ feedback varied widely regarding two options the committee was considering: (1) A universal, single-payor, public prescription drug program, or (2) Reform of the existing
system with initiatives specifically directed at addressing gaps in coverage.

The result? The Committee voted for the first option—their recommendation is that the government should opt for expanding the Canada Health Act to include prescription drugs dispensed outside of hospitals as an insured service. In the meantime, even before the Committee released its recommendation, the government announced the launch of The Advisory Council on the Implementation of a National Pharmacare Program led by Dr. Eric Hoskins. This new council officially began work in September 2018 on its mandate of (as its name implies) studying the implementation of a national pharmacare program.

So what’s happened since? More consultation. But word on the street is that the consultation process has been productive. The Council encouraged Canadians to share their views and ideas via an online questionnaire and written submissions. They also sought feedback from provincial, territorial, and Indigenous leaders, as well as other stakeholders—like the insurance industry, which of course, means that the Canadian Life and Health Insurance Association (CLHIA) was on it!

…And fortunately, we got the inside scoop directly from the CLHIA. (Here’s the lowdown, but if you haven’t listened to episode 13 of our podcast yet, you’ll find even more details during our interview with the president of the CLHIA, Stephen Frank, where we discuss pharmacare— and more.) Overall, the CLHIA feels that discussions have been useful in that they have shifted away from what was perceived by many as quite a simplistic view of how to address the coverage gap. The recent discussions have been more concrete—as in more insightful and more realistic—regarding the challenges of affordability and judicious use of limited finances.

Essentially, there appears to be more receptiveness to the reality that greater choice and greater access are of course both good, but strategies to achieve this must also be financially responsible. Accordingly, this receptiveness to addressing the fiscal realities is now extending to a more open attitude toward considering a collaborative approach to pharmacare where public and private payors work together to fill the gaps and cost-share.

What’s next? The Council is expected to release a “thisis- what-we-heard” type of report early in 2019. And then, finally, the big reveal will come this spring where the Council will report to the federal government on how to implement a national pharmacare program—just in time for the issue to become part of a federal election platform for fall of 2019.

So where do we go from here? It all depends on which party wins the election—we have already seen the impact of the Ontario election with the partial roll-back of OHIP+. No matter what format pharmacare ends up taking, the only prediction we can be fairly sure of is that there likely won’t be any concrete implementation any time soon, maybe at some point beyond 2020.

Pharmacogenomics gains scientific evidence – summer 2019

In the April 2018 edition of The Inside Story we discussed how pharmacogenomics represents promise, potential, and possibilities, but lacks real-world evidence. We also explained that GSC is aiming to remedy this by conducting a research study. And not just any research study, but a study that specifically aims to assess whether information obtained through pharmacogenomics testing can influence patient outcomes.

As you may recall, the limited scientific evidence around pharmacogenomics that does exist focuses more on system processes, not patient health outcomes. However, as you may also recall, there is evidence indicating that when community pharmacies deliver clinical services of many sorts, patient outcomes improve. So what if pharmacists deliver pharmacogenomic testing, will this influence patient outcomes? We’re going to find out.

Remember John Papastergiou? He’s the pharmacist that we’re collaborating with for this study. It is being run out of three large, urban, high-volume pharmacies in downtown Toronto, so we’re talking a lot of patients with broad demographics. Accordingly, the study results will reflect the use of pharmacogenomics in a real-world setting. And the study is focusing on psychiatric drugs because that’s where the greatest promise of the impact of technology has been postulated. Plus, psychiatric drugs can have a range of side-effects, so there is often a lot of pharmacist intervention. Therefore, it would be very useful if pharmacogenomics testing helps get patients on the right therapy quicker with less trial and error.

So where are we at? We anticipate wrapping up recruitment of all 200 study participants in early 2019—with study results available by the summer. And then, where do we go from here? As always, we’ll follow the evidence. The research results should help us determine whether pharmacogenomics influences patient outcomes or not—and we’ll take it from there.

Medical cannabis coverage evolving – ongoing

As predicted in the February 2018 edition of The Inside Story, medical cannabis (MC) endured as a thorny issue in 2018. Thorny in that the industry continued to assess what exactly is the most appropriate place for MC in private plans. (For a refresher, your go-to podcast is episode three with special guest Mike Sullivan of Cubic Health Inc.)

As you may recall (and as also covered in the winter 2017 edition of Follow the Script) our solution for 2018 was to cover MC as a drug benefit, with a benefit maximum of up to $6,500 annually. It requires prior authorizatiob based on the three medical conditions specified in the scientific evidence: chronic neuropathic pain, spasticity due to multiple sclerosis, and nausea and vomiting due to cancer chemotherapy.

Although other insurers have followed our lead—and there is certainly a lot of interest in MC across the industry—the adoption rate continues to be very low. While many plan sponsors continue to be interested in the role of MC in their benefit plans, they continue to have questions around the net added value of this treatment above and beyond what is already on benefit plans. Some of this dialogue is also occurring in the context of collective bargaining between employers and unions.

Where do we go from here? Ned Pojskic, GSC’s leader, pharmacy and health provider relations explains, “As is the case with pharmacogenomics, this represents another follow-the-evidence scenario. As we gain a better understanding of the value and impact of medical cannabis for other clinical indications, we’ll investigate and adjust accordingly, just like we do with other drugs.”

Speaking of which, just like with other drugs, GSC’s position is that the ideal approach to dispensing MC is via pharmacists. This is an issue that is sure to get more airtime in 2019 as it has been picking up steam for years. Back in November 2017, the Canadian Pharmacists Association (CPhA) announced that it is disappointed with Health Canada’s proposed cannabis regulations. Mirroring their message from back in April 2016, the CPhA stated that…

“A notable omission in the proposed current regulatory framework is the failure to integrate pharmacists into the medical cannabis regulations. Pharmacists are best equipped to provide clinical advice to patients and appropriate oversight in the safe management and dispensing of medical cannabis. Pharmacists are highly accessible and can assess patient medication profiles for drug interactions and help prevent, monitor, and report side-effects to help build a body of evidence. We need to ensure that patients have access to a system that offers appropriate medical and clinical support at every touchpoint, and which recognizes the specific needs of patients.”4

At the root of the issue is that so far, the Canadian Medical Association’s concept is that patients who need MC will access it in whatever way recreational users do, which is being left up to provincial and territorial discretion. So for example, depending on what direction each region takes, users could access cannabis online and/or in-person from government and/or private retailers, as well as potentially via their own personal household plants. The CPhA feels that:

“It’s both unsafe and completely illogical to create a disjointed system where medical cannabis patients are forced to access cannabis from retail outlets or mail-order delivery systems that do not have clinical expertise. As health care providers, we cannot support this fragmented delivery of care for Canadians.”5 Overall, the CPhA feels that “Canadians requiring medical cannabis as part of their prescribed therapy should have the same rights and expectations of access to their medication and clinical oversight as is the case for all other medications.”6

Where do we go from here? Overall, everything MC is evolving—and we’ll continue to evolve along with it.

Fraud goes high-tech – forevermore

We realize that reading the December 2018 edition of The Inside Story might not have been top of your eat, drink, and be merry plan this holiday season, so just in case you haven’t got to it yet, it was all about fintech and insurtech. For 2019, another area of insurtech that is sure to gain momentum in 2019 and beyond, is technology applied to fraud management. For example, we touched on the use of artificial intelligence in GSC’s fraud initiatives way back in the October 2017 edition. Basically, newer technologies are enabling GSC to compile and analyze large amounts of data— and to identify patterns—at a much more sophisticated level than in the past. We can quickly assess all the circumstances surrounding a claim to either confirm or question it and, as needed, flag it for further investigation.

Where do we go from here? Not only will GSC continue to ramp up its fraud management by adopting new technologies, so too will the industry as a whole. For example, in 2019 the CLHIA is piloting a sophisticated technology-driven fraud initiative. It involves sharing and pooling claims data across carriers. Combining data into one overall database should allow trends and anomalies to become evident that may not come to light with “individual” data. (Remember we mentioned that podcast episode 13 with Stephen Frank includes pharmacare “and more”—well, future fraud management initiatives is just one of the “and more” discussion points.)

Property and casualty insurers have been using this collaborative approach for a while, so now we’ll see if it’s something that will work in the life and health space. In any case, projects like the CLHIA pilot—plus, ongoing adoption of technologies as they come out—will help guide our fraud management and point investigations in the direction where issues most likely are.

More to come… more to report

Important issues like these will continue to evolve in 2019—and new issues are sure to emerge. Keep an eye out for upcoming editions of The Inside Story where we’ll keep reporting. Things really are never dull in the insurance industry (…hard to imagine, we know).