Conference coverage: Perfect match

“I expect to see more changes in the next five years than we have in the last 20,” predicted Peter Zawadzki, practising pharmacist and principal with Peter Zawadzki Consulting, who opened the event along with Bessie Wang, a private payer consultant. “Pharmacists are already the leading source of help for plan members in navigating coverage, but we’re not tapping into their healthcare expertise,” Wang added.

Shifts in their respective landscapes have brought the two sectors to common ground. On the payer side, higher-cost specialty pharmaceuticals and the growing prevalence of chronic disease are directing attention to adherence and the appropriateness of therapy. In pharmacy, dramatic reforms in the public sector— slashed generic pricing and expanded professional scopes of practice—are driving a new business model that includes offerings for the private sector.

New Alliances
In this vein, a committee with senior executives from insurance and pharmacy is working to identify common interests and areas for collaboration. The Pharmacy Health Insurance Steering Coalition (PHISC), which began meeting early this year, is a collaboration between five associations: the Canadian Life and Health Insurance Association, the Canadian Pharmacists Association, the Neighbourhood Pharmacy Association of Canada, the Health Industry Electronic Commerce Association and the Canadian Health Care Anti-fraud Association.

“We determined that the first priority should be expanding coverage of pharmacy services,” said Gary Coles, co-chair of PHISC and senior vice-president of administration with Industrial Alliance. To do that, “we need to understand each other’s industries,” said Dr. Dorian Lo, PHISC’s other co-chair and executive vice-president of pharmacy and healthcare with Shoppers Drug Mart.

The committee has put together a fact book summarizing how governments in Canada are expanding the role of pharmacists and “leading the world in the funding of pharmacy services,” said Lo. It’s also creating a tool kit and “reasonable and customary guidelines to help plan sponsors wrap their heads around what these services could be on the private side,” Coles added.

PHISC has identified health spending accounts (HSAs) as an entry point for funding. “We recognize that HSAs are not the endgame, but until plan sponsors are convinced they’re not bearing costs that are already borne elsewhere—and that the benefits are not all going to the public sector—we need to take small steps,” noted Coles.

Evolution of PPNs
An expert panel explained how pharmacies and plan sponsors are seeing preferred provider networks (PPNs) in a different light. Specialty networks for higher-cost pharmaceuticals show PPNs can include multiple pharmacy chains and banners and do not necessarily preclude interactions with traditional community pharmacies.

“Our relationship with pharmacies to date has been very transactional, but the intent behind these specialty PPNs is to take this to the next level,” said Mark Rolnick, assistant vice-president, product development for group benefits, with Sun Life Financial. “The opportunity to both manage costs and build services is really exciting. The table is well set for that opportunity.”

Among pharmacists, “today, there is a new willingness to enter into designated provider agreements,” said Alan Kyte, a principal and pharmacy specialist at Mercer. “As a pharmacist myself, I still struggle with the possibility of losing patients. At the same time, it’s an exciting prospect to work with an engaged patient population that has distinct professional service expectations.”

Panellists agreed pharmacists’ perceptions are shifting, “but they’re concerned about taking a too-narrow focus on cost and pharmacy services being commoditized,” said Dimitris Polygenis, vice-president and general manager of pharmaceutical solutions with McKesson Canada.

“With prescribing authority, pharmacists can adapt and substitute prescriptions,” noted Leanne MacFarlane, senior director of business development at MHCSI. Publicly funded services also help create an infrastructure for expanded services for all patients.

Citing her company’s PPN with Lawtons and Sobeys pharmacies, MacFarlane described how “we’ve evolved from the transaction level—for example, optimizing generics—to documenting and quantifying the value of medication therapy management. Feedback from plan members is very, very positive.”

“Pharmacy needs to show that it can play a significant role in managing escalating drug costs and earn credibility on the plan sponsor side,” added Polygenis. “This partnership would set the right stage for reinvesting savings into pharmacist services.”

Report Back
Also, benefits providers must be clear on the criteria for reimbursable pharmacist services, and pharmacies need to provide quality assurance, said the panel. “We can create a pharmacy score card, for example, to measure individual pharmacies’ performances,” said MacFarlane.

“It’s incumbent on all of us to provide reporting—and this is where consultants and advisors can really step up by demanding it,” said Lo. “We see a greater adoption of PPNs in the U.S. because reporting is much more extensive, and employers can be confident in making the proper decisions about a particular program or pharmacy. It also becomes iterative: if a pharmacy not in the network proves they have stepped up their game, then they could join. It really gets down to reporting, but that takes a lot of investment in technology across all stakeholder groups.”

Investments in technology also lay the groundwork for other connections. “Our goal across all specialty PPNs must be to integrate all available public and private programs, including manufacturers’ patient assistance programs,” said Polygenis.

“There has to be a seamlessness among all stakeholders and providers across PPNs. Otherwise, we have failed.”

Karen Welds is a pharmacy and health benefits journalist near Oshawa, Ont.

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