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Well-Managed Drug Plans Don’t Just Happen

With prescription drug costs increasing at a rate much higher than inflation, Canadian employers are faced with the challenge of maintaining their cherished prescription drug plans, while ensuring that those plans are sustainable well into the future. The only way to do both at the same time is to implement comprehensively managed drug plans. But these types of plans don’t just happen by accident. They require a coordinated approach that integrates a number of different strategies aimed at driving down costs while delivering better health outcomes.

Express Scripts Canada’s 2016 Drug Trend Report uses case studies to illustrate the significant impact of comprehensively managed plans in terms of bringing drug plan costs under control. The following are three key elements of such a plan:

  • Aligning drug choices with clinical guidelines;

  • Engaging patients to make better choices; and

  • Offering more support for patients with complex health issues

          Read: What’s happening in the Canadian prescription drug benefits marketplace?

1.     Aligning drug choices with clinical guidelines

Doctors ultimately decide what drugs will be used to treat a given condition. The patient can have some influence, but will usually accept their doctor’s choice of drug. This can be problematic both from a cost perspective and a health perspective when a doctor chooses a drug that is not the most effective and/or safe drug for that condition, or prescribes a drug that is significantly more expensive than another choice that is just as effective.

In order to encourage better health and financial outcomes for patients and employers, Express Scripts Canada (ESC) has developed a list of common medications, called the Dynamic Therapeutic Formulary (DTF), that directs group health insurers to cover certain drugs at a higher reimbursement level than others, based on clinical guidelines (proven best practices). This is meant to encourage doctors and patients to choose the most effective and affordable drugs.

          Read: What you need to know about specialty drugs

Some plans also include strategies like step therapy, meaning that more expensive drugs are only covered after proven, lower-cost drugs have failed. With a condition like diabetes, this is a huge opportunity for savings, given that the most proven drug, metformin, costs up to 98% less than some other approved diabetes drugs.  

2.     Engaging patients to make better choices

Although a formulary like the DTF and strategies like step therapy provide financial incentive to follow clinical guidelines, we know that some doctors continue to prescribe less effective or lower value drug options. Continuing with the diabetes example, in 2016, 30% of diabetes patients who were prescribed more expensive secondary therapies did not try metformin first.

Not all patients are necessarily aware of their treatment options. Some may need a nudge to make decisions that are in their best interest. In some cases, they are being treated by two, three or more different doctors, and those doctors may not be coordinating the treatments in the most effective way. Patients that are members of the ESC Pharmacy have the advantage of a pharmacy that can analyze their past and current prescription history and, where needed, recommends options to coordinate treatments to improve health outcomes and save money.  

A patient can propose changes to their doctors, or empower the ESC Pharmacy team to do so on their behalf. Either way, it can lead to significant savings. In one case study involving a man with an ulcer and high blood pressure, the patient and his drug plan were able to save 86%. The patient’s out-of-pocket costs were cut by more than $150 a year.

          Read: Understanding high-cost, specialty drugs and your options

3.     Offering more support for patients with complex health issues

We know that 14% of drug plan members account for 72% of all costs. So in terms of keeping overall prescription drug costs in check, it makes sense to pay special attention to these patients who are typically dealing with multiple complex health issues. The ESC Pharmacy is able to quickly identify members that would benefit from more intensive support to make the most out of their prescription drug plan.

In these cases, experienced ESC pharmacists not only alert patients to better drug options as described above. They reach out proactively to patients to ensure that they understand how their coverage works, counsel patients on how to ensure best results from their multiple drug therapies and follow up if they see gaps in prescriptions that suggest the patient may not be taking their medications as prescribed. In some cases, they may even direct patients to alternative funding sources for their treatment.

This approach helps to avoid negative drug interactions, minimizes the need for multiple courses of treatment in the case of one-time therapies such as those for Hepatitis C, and in one case study led to a faster cure (Hepatitis C) and close to $50,000 in savings (combined plan and patient costs).  

Comprehensively managed plans, as described above, are highly dependent on an active pharmacy program like the one in place at the Express Scripts Canada Pharmacy. Contact us for information about joining the Express Scripts Canada Pharmacy, either as an individual member or as a plan sponsor.

Express Scripts Canada