Canadian HR Reporter - Ontario

CANADIAN HR REPORTER NOVEMBER 2018 10 NEWS Figuring out pharmacare Exclusive roundtable explores past lessons, roadblocks and potential solutions to national pharmacare program BY SARAH DOBSON THE Canadian government has said it is seriously considering the implementation of a national pharmacare program. But how exactly would it work, which model would make the most sense? Who would be covered? What drugs would be included? Who would pay for it? And how would employers be affected? Looking to answer these ques- tions and more, Canadian HR Reporter hosted a special round- table sponsored by Sun Life that delved into national pharmacare, including lessons to be learned from similar programs such as Quebec; the potential impact on employer benefit plans; and challenges around costs and administration. e need for change Canada's universal health-care system is really a reflection of how health care was designed in the 1960s, anchored around hos- pitals and acute care — but that design hasn't really evolved, said Louis ériault, vice-president of policy and research at Innovative Medicines Canada. On the other hand, western Eu- ropean countries include pharma as part of universal health care. "It's a reflection of a political re- ality in Canada, a fragmentation of how health care is provided by province. It's hard to keep pace with the changes that would be needed to stay up to date in terms of what I call the business model of health-care services." While the system is federally funded, and governed by the Can- ada Health Act, there are different levels of care delivered across the provinces, said Jennifer Schmidt, a principal at Mercer. "The term 'universal health care' is not necessarily universal for all Canadians. ere are sys- tems in place for all Canadians — for catastrophic, for seniors, for low income — but they vary by province, and even the drugs that are covered by the province vary. So I think part of the univer- sal discussion needs to be about bringing consistency for Canadi- ans across provinces and across territories." There's a new realization of how varied the models are, both among the provinces and at the federal level, said Jean-Michel Lavoie, assistant vice-president of group benefits at Sun Life. "(For example) I live in Ontar- io, this drug is covered; I live next door in another province, and that drug is not covered. So it's created a realization of the fragmentation, and maybe a political willingness now to intervene to standardize, to a certain extent." Part of it also has to do with the patients themselves, said Nadia Alam, president of the Ontario Medical Association. "The disease patterns that were there in the 1960s have… changed drastically over time. It isn't necessarily… the senior pop- ulation that has illnesses, (it's) chronic illnesses that require medications. We're now seeing a growing burden of illness among working-age adults between 25 and 65. It's the largest number of the population that now has chronic diseases like diabetes, like hypertension, like heart dis- ease, that have very predictable pharmaceutical needs." Canada's federalist model is very difficult, said Alam. "It's trying to herd 13 cats into moving in the same direction but, at the same time, we kind of need a firm hand from the federal gov- ernment as well, so that we don't lose what's good in the system." Lessons from Quebec Quebec created a semi-public drug prescription plan in 1997, making it mandatory for work- ers to enrol in private plans when available, or go on a public plan. People still have to pay an out- of-pocket expense when buying prescriptions. "Quebec has a mixed model, but it's mandated coverage. And I think if you talk to many of the residents of Quebec, as well as the government, there is a prefer- ence for that type of model. ere are some challenges with how it's been established and implement- ed around some of the cost of the co-pay's deductibles, which is part of that underinsured component of affordability. It's not just the uninsured, it's the underinsured," said Justin Bates, CEO of the Neighbourhood Pharmacy Asso- ciation of Canada. "But, as a general model, one of the benefits of Quebec is that is it does have a very robust for- mulary. And I think it's really im- portant that we take a principled approach to equitable access to medicines across the country, and ensure that if you have coverage today on the private side, you do not have a walk-back of coverage if you're on a public plan. We should be looking at increasing access, not decreasing what's available to patients." e Quebec model is helpful in understanding what a model at the federal level could look like, said Lavoie. "ere's good and bad, and it requires tons of co-ordination, be- cause it's a dual regime, and it's co- administered to a certain extent between private and the RAMQ (Régie de l'assurance maladie du Québec). But there are good things (there)," he said. "It is a very robust (formulary) list that could become an inspira- tion for some type of pharmacare in the future, to have this manda- tory minimum coverage across a region, a country, that provinces have to provide, and then private insurers' employers can decide if they want to meet that minimum requirement, or if they want to go over that." But the downside is Quebec's model is fragmented because it involves a multi-payer model, which means higher administra- tion costs, said Alam. "It's a bit regressive in the sense that more of the cost burden is borne by patients (and employ- ers)," she said. "at regressive system speaks against the model in Quebec." "And it has to be taken into ac- count, because one of the prob- lems with patients bearing the cost, an increased cost for drugs, is that it has been shown again and again that that plays a signifi- cant role in how patients use their medications, whether they take them every day as prescribed, or whether they parse them out so that they can make them last longer, or whether they skip them entirely." Cost challenges Really, it comes down to what kind of principle we want, said Alam. "Do we want everybody to be covered, whatever the cost, or do we want everybody to be covered in a certain way? What are the trade-offs?" Another flaw in the system is the list price of the drugs is not equal, said Lavoie. "At point of sale, the prices are different, depending on who's paying. And it's kind of a missed opportunity in the principle that this could have been addressed at the principal site. And then your administration model — you can still have a model that's admin- istered by multiple payers, if you will, if the principle is that the prices are going to be the same." "But we should learn from this, and maybe it's an opportunity in the national debate around phar- macare to say, 'OK, let's address that,' because joint negotiation, joint purchasing, everybody paying the same price maybe is an opportunity in a national pharmacare." But when it comes to bulk buy- ing, the provinces have been will- ing to make changes to their plans while, historically, private plans have not, said Helen Stevenson, founder and CEO of the Reformu- lary Group, adding they have this notion "You can have whatever you want, no matter how much it costs." "I know there's lots of talk about sort of jumping in… but public plans are set up differently than private plans. Public plans will say, 'No, that drug doesn't dem- onstrate the right kind of cost- effectiveness, or clinical cost-ef- fectiveness,'" she said. "If there's one system, then fair enough. But if there's going to continue to be these, let's say, two systems that are going to work in parallel, they are going to need to restructure themselves as well, to be able to take advantage of some of those tools, and combined re- ally around sustainability." As costs become increasingly unsustainable, employers are more willing to talk about those changes, said Schmidt. "Plan sponsors aren't really sure how to manage it without restrict- ing access to employees. And so the public formularies cover a list of drugs (and) the private plans enhance that list," she said. "The employers and private plan sponsors need that flexibil- ity. ey need to be able to say, 'You know what, we're having an issue attracting and retain- ing employees in this sector. We want to make our benefits plan, our retirement plan, our com- pensation top of the tier, so that we can get people in.' So I think it's important to recognize that the design partly flows out of that compensation model." SPONSORED BY A roundtable of experts gathered in Toronto recently to discuss the many questions surrounding a national pharmacare program in Canada, and suggest possible solutions (see names on pg. 12). Credit: John Hryniuk REDEFINING > pg. 12 "One problem with patients bearing the increased cost is that plays a significant role in how they use their medications, and they may skip them entirely."

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