Answering our own questions

The good news: we have all the data we need in Canada to make data-driven decisions that relate to Canadian employer-sponsored healthcare plans. The not-so-good news: the answers aren’t just lying there; they need to be actively mined from the various data sets that the benefits industry has access to.

A case in point is the topic of patient assistance cards that allow plan members to stay on a brand name medication, if they so choose, without any additional out-of-pocket cost. These programs have been growing in significance in recent years due to the release of blockbuster generic drugs, as well as from the sophistication in the technology in the way these programs are developed and maintained. On a personal note, I have handled more questions from plan sponsors and advisors on this topic over the past three months than any other topic—so this is a great example to make the case for the need for Canadian-specific analytics.

Despite this topic of co-pay assistance (otherwise known as patient benefit) programs being of keen importance to all the major stakeholders (i.e., carriers, claims processors, generic and brand name pharmaceutical manufacturers, pharmacies, advisors, and plan sponsors and their members), there is very little, if any, objective information currently available in the marketplace.

Depending on what side of the fence you are on, you will likely have a strong opinion as to the value of these programs, but why does the conversation seem to focus almost exclusively on anecdotal stories and comparisons to the U.S. marketplace? Here are a few reasons why relying on U.S. data, or comparing ourselves to what is happening south of the border in this area, is dangerous.

• There are more than 400 co-pay assistance programs in the U.S., but only about 10% of these programs are targeted at multi-source brand drugs (i.e., brand drugs that have lost exclusivity and now face generic competition), according to research completed by Source Healthcare Analytics. Here in Canada, most of the conversation within the plan sponsor community with respect to patient benefit programs has been on programs for multi-source brand drugs. So if we are comparing to the U.S. experience, are we comparing apples to apples?
• In the U.S., co-pay assistance programs make up less than 1% of all prescriptions. Has anyone assessed the penetration rate of patient assistance programs in Canada? Is it reasonable to use that 1% figure, especially when you consider that generic penetration rates in the U.S. are now more than 80%, on average?
• According to Source, about one in six multi-source brand claims is filled using one of these programs, although that figure apparently has grown exponentially over the last year. How relevant is that figure in Canada? What does that mean in a Canadian context from a financial and utilization perspective?
• The No. 1 product for co-pay assistance in the U.S. is Advair—an asthma medication that is a single-source drug in Canada and covered by virtually every private plan at the top level of reimbursement (hence, there is no need for a focus on developing a major patient benefit program for this drug in Canada). Given that some of the biggest market drivers in the U.S. in the area of co-pay assistance are not multi-source products, how comparable are the experiences?
• As many as 25% of the co-pay assistance claims in the U.S. are first-payer. Do we have any idea what that number is in Canada and what that means? Has anyone bothered leveraging data to answer that question? What have been the financial impacts on plan sponsors and plan members? Positive? Negative? Neutral?
• Given that many key co-pay assistance cards in the U.S. are for non-multi-source drugs, do some of the figures that support higher costs for plan sponsors in the U.S. with the use of these cards have any relevance in Canada if we are not comparing similar programs? Maybe? Maybe not? How do we know if we aren’t assessing the data objectively?
• There are some compelling numbers to suggest that adherence to therapy figures are higher in the U.S. when members take advantage of these co-pay assistance programs. Does the same hold true in Canada, given our co-insurance (as opposed to co-pay) structures and the different product mix? If adherence is improved, is it sustained? What value has that rendered for Canadian employers in terms of lower absenteeism and disability rates and Canadian plan members in terms of improved outcomes?

Given all of the variables at play, and the profound differences between how these programs have been developed in Canada and the U.S., how can anyone on any side of the discussion make a compelling case for their position without going back to claims data?

It’s ironic. We are so fiercely proud of our healthcare system as Canadians, and very quick to note the major differences between the system in the U.S. and our own, yet somehow we are willing to grab U.S. data and/or experiences, hash them together with Canadian anecdotes and render an opinion. How does that make any sense?

We have the data at our disposal to assess our own experiences and make our own decisions. It’s amazing we don’t leverage our data assets more frequently to help make informed decisions on topics of great relevance to our industry.