Key stakeholders highlighting value of private payer health care amid plans for dental, pharmacare programs

Read: Liberals, NDP to move forward on dental-care program, national pharmacare

“Private payers certainly see themselves as part of the full Canadian health-care systems,” said Joan Weir, vice-president of group benefits at the Canada Life and Health Insurance Association, during the webinar. “Funding drugs keeps Canadians out of the hospital and helps them manage their conditions well with prescriber oversight. We add value to that full entirety of the Canadian health-care system.”

Weir doesn’t believe the national pharmacare initiative will come to fruition in the next three years. However, she noted the federal government has several peripheral initiatives in play that could eventually lead to a national plan.

Also speaking during the webinar, Joe Farago, executive director of private payers and investment at Innovative Medicines Canada, urged employers to keep in mind that the provinces are the main stakeholders in any implementation of a national pharmacare strategy. Ontario and Quebec have already issued statements noting they won’t allow federal encroachment of their provincial drug reimbursement policies, he said. “It’s going to be a long time until we see significant movement.”

Read: Employers pausing benefits plan redesigns amid talk of national dental, pharmacare programs

While Prince Edward Island was the first province to put its hand up for additional dollars, it really was based on a fill-the-gap model, added Farago, noting the $35 million provided to PEI to advance its implementation of universal pharmacare was a way for the province to fund its drug program, which lagged behind other provinces.

The federal government’s announcement also included establishing an essential medicines list, said Weir, adding that key questions, such as eligibility and funding, for this formulary remain unanswered. As well, the federal alliance included a bulk-buying initiative, which it plans to have in place by the end of 2025. Farago said almost every drug on the essential medicines list will likely already be included on insurers’ private formularies.

Questions still abound regarding the feds’ proposed national dental-care plan as well, said Weir, particularly on whether it will primarily be available to the uninsured and not for Canadians with private benefits coverage. But any successful national dental-care plan also hinges on adoption by the provinces, she pointed out. She cautioned employers making changes to their plans to consider whether the public plan will provide the type of dental care without wait lists that currently exists today or that attracts and retains employees.

Read: Ontario Liberals promising portable drug, dental and mental-health services

And while the government’s announcement didn’t include much about plans for drugs for rare diseases, work is going on behind the scenes in this area with the Canadian Drug Agency, noted Weir. In 2020, private insurers paid out $650 million on drugs for rare diseases to more than 15,000 Canadians, so private payer stakeholders are rightfully wondering what a new model might look like under the new alliance, she said.

Weir surmised that the public or private plan may pay out a claim up to a certain threshold — for example, $80,000. If the drug is $120,000, then the remaining $40,000 could then go onto the drug agency for payment or it could be shared in some way by the participants in a risk pool, she explained. “If there were three payers, the formulary and the eligibility criteria would all be determined jointly by all three — public, private and Health Canada.”

Private health plans have been one of Canada’s most under-appreciated capabilities, said Cole Pinnow, president of Pfizer Canada, also speaking during the webinar. Canadians with a private plan have a two-fold increase to access in treatment, he added, noting those treatments are made available much sooner than they would for someone solely on a public plan. “Having earlier access to innovative treatments has a huge impact on employers, workers and the economy.”

There are 26 million Canadians with private drug coverage and the onus is on this group to highlight the value of private health benefits, said Farago.

Read: An update on Canada’s national strategy for drugs for rare diseases