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The Inside Story: Thorny issues will persist in 2018. Here’s how we’ll lessen their sting…

To say that the health benefits industry faced some challenges in 2017 would definitely be an understatement. Certain issues were downright thorny as they dug-in deeply in 2017 shaking up the industry and plan sponsors’ pocket books. And we predict that the industry will continue to feel their jabs in 2018. Here’s a recap of how GSC tried to lessen their sting last year—and how we’ll continue to do so in 2018…

The challenge: Slow uptake of biosimilars

In 2017, the drug pipeline continued to produce ground-breaking biologics and other high-cost drugs. And you don’t need a crystal ball to predict—and in fact, know for certain—that biologics will continue as one of the fastest growing areas of pharmaceutical development into 2018 and well beyond. But that’s not all that’s coming down the pipeline. Another growth area is biosimilars— which represent more alternatives for plan members and lower costs for your plan. A good news story all round. However, stimulating the uptake of biologics remains challenging in Canada. But why?

Although there is strong evidence surrounding the comparable safety and efficacy of biosimilars to their originator biologics, the main culprit may be a lack of awareness and understanding of this evidence. And that may be the case because most of the evidence is coming out of Europe—with the European market much further ahead of North America in terms of adoption.

For example, remember the NOR-SWITCH trial that we covered in the December 2016 edition of The Inside Story? This Norwegian study found there was no difference in disease worsening between patients that transitioned to the biosimilar compared to those that continued treatment with the originator biologic.1

The lack of awareness and understanding about biosimilars may be triggering a domino effect resulting in public and private payors lagging in terms of assigning preferred status to biosimilars in plan designs. And then, coverage for the originator biologic may be translating into doctors being less likely to change their prescribing practices, so they continue to prescribe originator biologics rather than biosimilars.

Fortunately, with GSC’s fixation on scientific evidence, we’re “in the know”—in fact, we were the first major benefits carrier to preferentially list biosimilars. And now we’re seeing some provincial health plans follow suit as—like us—they are recognizing that the evidence is showing efficacy and safety, but at lower costs.

Looking to 2018, we see more good news on the horizon: there are more biosimilars coming to market and the evidence regarding transitioning from an originator biologic to a biosimilar is moving fast, indicating that one-time transitions are safe and effective. For example, in the case of patients with rheumatoid arthritis, a study showed no risk associated with transitioning patients from the originator biologic etanercept—brand name Enbrel®—to the biosimilar, Brenzys™.2

Of course, as always, GSC will be following the evidence (our analysts are pleased to now have this on their weekend “social calendar”). As the evidence mounts and warrants a change in policy, we’ll be on it (and likely sooner than later)!

The challenge: Managing medical marijuana

Throughout 2017, a big story continued to be the extensive societal debate about the legalization of marijuana for recreational use. For our industry, of course, the focus is on medical marijuana (MM) and the industry debate regarding what exactly is its appropriate place in private plans.

For several years, GSC has standardly covered medical marijuana under health care spending accounts (HCSAs). Throughout 2017, we immersed ourselves in the scientific evidence to determine how to provide plan sponsors with more options for incorporating MM into benefits plans for evidence-based indications but with a greater level of oversight and rigour than is currently available through HCSAs.

For instance, one of the conclusions in the comprehensive 2017 study, The Health Effects of Cannabis and Cannabinoids, The Current State of Evidence and Recommendations for Research, is that there is conclusive or substantial evidence of MM’s effectiveness for chronic neuropathic pain, spasticity due to multiple sclerosis, and nausea and vomiting due to cancer chemotherapy.

Accordingly, the solution for 2018 (as you may recall from the Winter 2017 edition of Follow the Script) is that MM will now be a standalone benefit that requires prior authorization for claims for the three conditions above. And as always, as the scientific evidence mounts regarding the clinical benefit of MM for additional medical conditions, we’ll investigate expanding indications—just as we do with other drugs.

The challenge: Smooth transition to OHIP+

Nothing like a tight deadline to get the industry pulling together and all the brainiacs brain-storming. This is precisely what happened after the Ontario government announced OHIP+ on April 28, 2017—with implementation set for January 1, 2018. (Whoa!)

GSC worked closely with the Canadian Life and Health Insurance Association (CLHIA) and its members, in collaboration with the Ontario Ministry of Health and Long-Term Care (yes, lots and lots of looooong meetings). The result? A process that ensures plan members under 25 do not experience a gap in coverage. Not bad for an eight-month turnaround!

For 2018, as OHIP+ takes hold and things evolve, we’ll be evolving right along with it. And we’ll be keeping tabs on what the future may hold in terms of the bigger-picture questions, for instance, will other provinces introduce pharmacare programs or expand existing ones? And what about the federal government and the ongoing debate about a national pharmacare program? You might want to take a listen to this Inside Story’s companion podcast to hear the CLHIA’s view— conveyed by its President and CEO, Stephen Frank, on how this debate may unfold.

The challenge: Magnitude of issues surrounding mental health

Throughout 2016 and 2017 we were out across Canada sharing our concern about a worrisome and costly trend. GSC claims data indicates that antidepressants are prescribed in massive numbers—amounting to high costs—to the mild-to-moderate depression population. However, the scientific evidence indicates that instead of antidepressants, the first-line therapy for many of these patients should be psychotherapy combined with healthy lifestyle habits.

There is strong evidence of the effectiveness of antidepressants, but for severe depression.3 Meanwhile, due to a range of issues, including low adherence to antidepressants and sub-therapeutic prescribing, plan members with severe depression—who could benefit most from antidepressants—may not necessarily be getting all the support they need.

In addition to spreading the word about these trends—that we refer to as the “medicalization of unhappiness” (check out the January 2017 edition of The Inside Story)—we also moved into problem-solving mode. Psychotherapy for depression and anxiety increasingly includes mindfulness techniques (as you may recall from the November 2017 edition of The Inside Story). And so, a new Change4Life module focused on mindfulness came to be! And we are thrilled that thousands of plan members have visited and used the module in its first few weeks.

Finding ways to continue to support plan member mental health is certainly a top priority for 2018. And we’re on a prevention quest! Just imagine if we could help plan members protect against potential mental health issues down the road? To get the prevention ball rolling, we’re already involved in a pilot project with the new Work and Mental Health Research Unit at the Institute of Mental Health Research affiliated with the University of Ottawa. With support from the Canadian Institutes of Health Research, the pilot involves an online depression risk calculator. Adults who are not currently experiencing a major depressive episode answer an online survey and receive a report that includes the survey questions and answers and indicates their probability of developing major depression in the next four years—all excellent for awareness and education.

In addition, to further support prevention, the report includes recommendations. For instance, the participant may be encouraged to discuss the results with their doctor. You can try out the tool here—and join our prevention quest by also encouraging your plan members to try it out:

Thorny indeed…

Although the issues that dominated 2017 will continue to be thorny throughout 2018, each is sure to take on new dimensions—dimensions that we’ll continue to combat for a less prickly 2018!

In the meantime, don’t miss episode five of our podcast, “And Now for Something Completely Indifferent…” As mentioned earlier, David Willows, GSC’s chief innovation and marketing officer, talks with special guest Stephen Frank of the CLHIA to review issues from 2017 and what’s coming up in 2018 for our industry, including pharmacare in Canada, the rising cost of drugs in benefits plans, and getting on top of claims fraud.

Click here to download the full publication


1”Biosimilar Infliximab (CT-P13) Is Not Inferior to Originator Infliximab: Results from a 52-Week Randomized Switch Trial in Norway,” American College
of Rheumatology, Abstract Number 19L. Retrieved November 2016:
2”Long-term efficacy and safety in patients with rheumatoid arthritis continuing on SB4 or switching from reference etanercept to SB4,” Paul Emery, Jirˇí
Vencovský, Anna Sylwestrzak, Piotr Leszczyn´ ski, Wieslawa Porawska, Barbara Stasiuk, Joanna Hilt, Zdenka Mosterova, Soo Yeon Cheong, Jeehoon
Ghil, Annals of the Rheumatic Diseases, August 29, 2017. Retrieved January 2018:
3”Antidepressant Use Has Gone Crazy: Bad News From the CDC,” Psychiatric Times, Allen Frances, October 28, 2011. Retrieved December 2016: