Wednesday, 19 November 2014

Different in Canada? We Like To Think So

Today at the Best Medicines Coalition Conference I learned a lot more about private drug plan insurance in Canada. Suzanne Lepage spoke on the topic Private Market: Special Issues. Through her company, Suzanne Lepage Consulting she provides private health plan strategies. In the past she has worked for both pharma and insurance companies. I have heard a lot about medication issues from my friends in the US and naively thought that things were different in Canada.

Here we have 5 main types of drug plans, though for people over 65 only about 25% have private drug plans and most of them have various types of limits. One fact many of us did not know is that if you are terminated from a group insurance plan, for instance through job loss, you have 30 days to get what is called a conversion policy privately. That is an advantage because there is no medical exam.

Suzanne told us about trends in private insurance plans and some of them are worrying for patients. The voice of the patient is important with insurers and plan sponsors and if they don't hear from patients they imagine that everything they are doing is fine. 

One trend is the increase in Preferred Provider Pharmacy Networks - this means that if you work for CP Rail or Canada Post for example you must get your drugs through a specific pharmacy provider by mail. This deprives you of regular contact with the pharmacist in your drug store.

Another is the rise of case managers for drug claims. In this case the relationship is no longer the traditional doctor/patient that we are used to. There is a 3rd party involved - the insurance company case manager. They might well have a conflict as they are working to save the insurance company and the employer money, so may override your doctor's treatment plan or force you to try various other drugs before you can get approval for the one your doctor originally prescribed. Insurance companies suggest that this type of management may save the plan sponsors 25%. We saw from Denis Morrice a great example of just how many forms the doctors are required to fill out for approval of drugs.

Denis Morrice demonstrated the complexity and size of insurance company forms that Drs must fill out. They are different for each company!

Another two trends deal with mandatory generic pricing where you and your doctor must provide medical evidence for you to receive a brand name drug, or therapeutic substitution which was yesterday's blog topic. In at least one province pharmacists are paid an incentive to succeed in 'counselling' the patient to change to a cheaper drug.

A disturbing trend for people with chronic disease who are on specialty (expensive) drugs is that these drugs are targeted. One way this occurs involves "enhanced government integration" where you have to explore every avenue of getting reimbursement for drugs from the government. This is creating bottlenecks that slow down the whole approval process, and of course while you wait for the government to notify you, the insurance companies say "It's not our fault" you can't get the drug yet.

These are not the only issues that we see or will be seeing in Canada. If you are in a union bargaining for benefits, or you have a small business and are looking for a drug plan, or if you have a plan yourself, it's a good idea to look at the restrictions and requirements. Are you trying to look after your employees or is your bottom line the deciding factor? What would you want for yourself?

These are the reasons that we need a public plan for drug and pharmacy benefits.  I suggest that everyone look into this and make wise choices.


  1. The bottom line with any insurance plan is a message to ill people: go die. We don't care. And any employee of an insurance company inserted into the decisions is absolutely a conflict of interest. Their JOB is to deny expensive claims. This is true everywhere, and especially with National Health Plans.

  2. You have a good point. We are already having to "fail" on certain drugs to be able to take biologics if we have rheumatoid arthritis, and I have been told that if I stop taking my current biologic to try another one I can't go back to it if the new one doesn't work for me.