High-cost drugs amplify need for new reimbursement model

JANUARY 2020 – Service and not the cost of a drug needs to determine reimbursement levels for pharmacy, agreed participants in a panel discussion about specialty drugs at the Pharmacy Forum conference in November 2019, presented by the Canadian Foundation for Pharmacy.

“It should not matter if a drug is $1 million or $100. To prevent the current distortions [in reimbursement,] we need to put funding in place based on the complexity of the service,” said Chris Potter, Senior Vice-President, Healthcare Businesses, Shoppers Drug Mart.

“You can have extremely complex services on a $200 drug and not-so-complex services on a $10,000 drug,” agreed Sandra Hanna, CEO of Neighbourhood Pharmacy Association of Canada.

Unfortunately, when it comes to the high-cost drugs, payers have used the example of hep C to reduce or cap margins across the board. “They decided [that the hep C drugs] were not difficult to service, and have taken that approach to other drugs,” said Hanna.

“What’s happening in some provinces is just not sustainable. They may be saving on their drug costs, but they are devastating an industry that can do a lot more for them,” said Karl Frank, Divisional Director, Specialty Rx, Bayshore Healthcare. “Specialty pharmacy is being lumped in with the rising costs of pharmaceuticals, and caught in the crossfire.”

Neighbourhood Pharmacy has been working on a new reimbursement model for more than two years. It promotes a “tiered framework that recognizes we can’t fund pharmacy solely based on product,” said Hanna. The challenge, however, is getting payers on board; that requires health outcomes data that show savings to the healthcare system. It also requires more education of payers, and to that end Neighbourhood Pharmacies plans to release a report on specialty drugs and associated services early in 2020. “It will focus on following the journey of the patient.”

Quebec may also serve as a model for other provinces. For several years the Association quebecoise des pharmaciens proprietaires and the provincial government have been negotiating a new reimbursement model, which incorporates tiered fees based on the complexity of clinical services. Implementation is scheduled for April 2020.

Meanwhile, when it comes to specialty drugs in community pharmacy, shrinking margins make it even more difficult to justify paying for the inventory, let alone the training and services required for to support patients with complex conditions.

“Theoretically it makes business sense not to dispense some of these drugs, but we can’t do that. We have to help patients,” stressed Karen Chuk, Vice-President, Specialty Prescription Services, McKesson Specialty Health. “Payers and pharmacy have to come together and agree on reasonable payments. We must focus on what is best for the patient.”

Community and specialty pharmacies must also integrate and collaborate. Corporations such as McKesson and Shoppers Drug Mart do that by offering training to pharmacists at the community level, while a centralized specialty pharmacy takes referrals for more complex cases. “Our goal is to optimize each channel,” said Chuk.

Community-based training should be prerequisite as more lower-cost, self-administered specialty drugs come out, added Dr. Alan Low, pharmacy lead at BioPro Biologics Pharmacy in Vancouver, B.C. Administration and storage may be simpler, but counselling requirements may remain complex. “You also need to build relationships with the prescribing practitioner. Interactions with specialists are very different than interactions with GPs.”

For their part, patients would like the current system to be simpler. “This system is built on the back of patients. It’s not built for patients,” said Dawn Richards, who has rheumatoid arthritis and is Vice-President of the Canadian Arthritis Patient Alliance.

Paper-based prior authorizations delay access, and manufacturers’ patient support programs (PSPs) can add stress. Patients are often “very confused and scared because now they have to speak to a stranger to get their drug. The first month is crazy,” said Alan Birch, Drug Access Facilitator, Oncology Drug Access Navigators of Ontario. He added that prior authorizations “should be online and real-time, based on clinical criteria.”

Community pharmacists could also play a greater role, noted Richards—ideally before patients require specialty drugs. “It’s not until we’re on expensive drugs that our hands our held. But there are a lot of things we can do when people are first diagnosed.”

The community pharmacy is a good setting for such proactive support. “It’s a place where I can feel like myself. I’m not in an institution. And I always find when I talk to my pharmacist, they are very willing to give me the time I need,” explained Richards.

For more on specialty drugs, see “Specialty drugs cast large shadow.”