The reality of chronic disease treatment

• Jeff Aarssen, vice-president, GRS sales and marketing and wealth management, Great-West Life
• Sal Cimino, manager, pharmacy and professional services, Green Shield Canada
• Tim Clarke, Canada’s health and benefits innovation leader, Aon Hewitt
• Dr. Lynn Hamilton, rheumatologist, Toronto
• Lincoln Lee, pharmacy district manager, southwestern Ontario, Sobey’s Pharmacy Group
• Mark Rolnick, product director, pharmaceutical benefits, Sun Life Financial

Moderator Suzanne Lepage, a Toronto-based private plan strategist, launched the discussion by asking panellists what principles they followed when making decisions about drugs. In Clarke’s view, “it’s more useful to frame the issue around which drugs to prioritize rather than which costs to avoid.” If a new drug passes the test, “perhaps we don’t need to add another $100 to the visioncare plan,” he said.

Where do biologic drugs fall along the priority continuum? Hamilton recalled “admitting our rheumatoid arthritis patients to the hospital for ‘rest’ because we couldn’t do anything to help them anymore,” when she began practising more than 20 years ago. “With biologic drugs, we can halt the disease process before irreversible damage occurs, effectively buying many high-quality years for our patients. This point cannot be emphasized enough.”

Specialty drugs like biologics don’t work on every patient. In this regard, Lee noted that the prior authorization programs used by most private payers “can help to determine whether a patient is likely to need or benefit from treatment.” In Rolnick’s experience, such programs offer a net savings of 1% to 2%. “About 30% of plan members don’t complete the authorization form for a specialty drug, which tells us they’re being treated effectively with another drug,” he said. With more specialty products in the pipeline, “we believe savings of closer to 5% are possible going forward.” Cross-industry and cross-employer poolings take further risk out of biologics coverage, Clarke added.

Still, the prospect of underwriting lifelong biologic therapy—not to mention combinations of biologic drugs—has plan sponsors understandably nervous. Hamilton allayed both concerns. For one thing, “we’ve found that using two biologics doesn’t add anything to the outcome,” she said. What’s more, “the earlier we start treatment, the better it can prevent joint damage and disability. In selected patients, it may even be possible to halt treatment.”

Cimino addressed the issue of sustainability—the “elephant in the room”—head on. “Our old sense of entitlement has to change,” he said simply. Rolnick, in turn, boiled the challenge down to “changing plan design and educating members about the need for such changes.”

While deeply grateful that his employer covers his treatment, Aarssen recognized the need for employees to absorb some of the costs if drug plans are to survive. “As long as I can afford it, I would not object to a $1,000 deductible for a $20,000 drug,” he said.

Pharmaceutical companies have also stepped up to the plate with support programs (in some therapeutic areas) that assist patients with the costs of biologics or other specialty drugs. As Clarke put it, “it’s difficult for any one of us to absorb the costs. We need multiple stakeholders working together to find a solution.”

Gabrielle Bauer is a freelance writer in Toronto. gbauer@sympatico.ca

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