As Express Scripts Canada unveils its flagship Prescription Drug Trend Report, there is much cause for optimism. The rapid spending increases that had become the norm over more than a decade, and threatened the long-term sustainability of our treasured drug plans, seem to be held at bay once again, for the third year in a row. Following up modest trend increases of 2.9% and 2.5% in 2016 and 2017, 2018 saw a miniscule 0.9% increase in overall drug spending. This is great news, but as one might expect, it is not the whole story.
Overall drug spending in 2018 was affected quite dramatically by the implementation, on January 1st of that year, of OHIP+, a new program from the Ontario government that began paying for all prescription drugs for Ontarians under the age of 25. Claims for that age group dropped by 63%. Without OHIP+, the overall drug trend for 2018 would still have been modest, but it would have landed closer to 2.8%. And with the new Ontario government changing the program in 2019 to now exclude those with private drug coverage, the 2018 dip was a one-time deal.
Many of the underlying challenges in the heath care system remain. Challenges with super high-cost specialty drugs remain prevalent, with a clear shift in research effort and dollars going in this direction. Emerging gene therapies show great promise in terms of improving health outcomes, but it is unclear how the high costs associated with gene therapy will be managed as these treatments become more widely used. The specialty drug class in 2018 had another big increase of almost 7%, a trend that seems sure to at least continue, and very likely accelerate given what is coming down the development pipeline. Specialty spending, which represented 15% of total spending ten years ago, now accounts for 33%.
Our research looked into the connection between chronic conditions and mental health (Read pg. 20). Overall, about a quarter of plan members are taking some kind of medication for depression, anxiety or another mental health condition. Among plan members being treated for cancer, this number jumps to about one in three, and all the way to 57% for those with Multiple Sclerosis.
Another challenge that we took a closer look is that of medication nonadherence. This is a huge problem that is not only inhibiting the effectiveness of treatments, but is robbing the system of vital financial resources related to longer courses of treatment, hospital visits, etc. Nonadherence seems to increase when there is more than one a chronic condition (Read pg. 18) (70% nonadherence in patients with asthma, 45% for diabetes), and when there are multiple medications (77% in patients taking 4+ medications, compared to 44% for one medication). We know that the reasons for nonadherence are complex, but it is essential that we address them, for the good of patients, and the sustainability of the private drug system.
In order to add more specificity to the challenges faced by plan members at different life stages, the 2018 report presents a robust case study of a Canadian multigenerational family*. Helen, the matriarch of the family, mother to three boys, suffers from hypothyroidism, and is prone to missing doses of her medication simply because she leads an incredibly busy life, balancing full-time work and running a household.
Helen’s husband John suffers from three different conditions, including an inflammatory condition that requires a specialty medication. His primary challenge to remain adherent is the complexity of his treatment, including multiple drugs, condition and prescribers.. Their youngest son, Alex, has asthma, and he is underusing his maintenance inhaler, while overusing his rescue inhaler, because neither he nor his parents have a good understanding of his condition and his treatment. This is leading to frequent asthma attacks.
Take a look at this infographic for more information on nonadherence, the factors that contribute to nonadherence and the solutions.
Then there’s Helen’s dad, Gus, who lives with them and is concerned about the long-term impacts of his diabetes, and the cost of his treatment. Four plan members at different stages of life, each with unique health challenges. This case study is used to outline the different plan design features that can be called upon to help each plan member overcome their biggest hurdles to achieving better health.
Finally, a theme that carries over from past Prescription Drug Trend Reports is the need to offer specialized care to the 20% of plan members who account for 80% of total drug spending. These are some of the people who struggle the most with nonadherence, and it’s no wonder why. Not only do members of this group account for 15 times the drug spending of the average plan member, they are also dealing with, on average, 6 different conditions, and taking almost 9 different medications, prescribed by 4 different doctors. Drug plans need to be active partners with doctors and pharmacists, to help these patients better understand and manage their care.
*The family in the case study presented in the 2018 Express Scripts Canada Prescription Drug Trend Report is a fictional representation of a typical Canadian multigenerational family.