Solutions in Drug Plan Managment

Expert Panel / Solutions in Drug Plan Management

Mike Lee Sal Cimino
Bruce Fraser Sal Cimino #2
Margaret Brna Barbara A. Martinez
David Alter Lyle Hargrove
Peter Singer Chris von Heymann
Marc-André Gagnon Chris von Heymann #2
Allan Smofsky Chris von Heymann #3
Sonya Felix Barbara A. Martinez & Francois Joseph Poirier
Johnny Ma Suzanne Lepage
Wendy Poirier and Karen Millard Rob Green
Sarah Beech Dorian Lo
Stephen Frank Peter Zawadzki
Brett Ruffell Theresa Rose
* See below for our Expert Q&A
Theresa Rose

Generic Drug Utilization: We all have a role to play

by Theresa Rose, Director of Group Product Management at Medavie Blue Cross

Generic drugs have been at the forefront of discussions in industry and health news over the past couple of years. That interest is shining a light on the impact generics can have on keeping drug plan costs affordable.

With more than 79% of our plans already following generic substitution, our organization has long been an advocate for this approach to drug plan management and its positive impact.

Getting plan members on board

With our history in utilizing generic substitution as part of our strategic approach to drug plan management, we’ve noticed a number of trends and challenges. Over the past couple of years we have seen a rise in requests for “Doctor No Substitution” — this is where a prescription is written for the brand, and the brand gets dispensed and not filled with a generic alternative when one exists. And with a generic substitution plan, the plan absorbs the full cost of the brand drug. The concept for having a “Doctor No Substitution” provision in contracts was to allow for people who experience negative drug reactions to have the full cost of the medication needed reimbursed. Research suggests this should only be 0.5% of individuals.*

Do we as general consumers believe expensive is better when it comes to treatment effectiveness? With the growing number of generics on the market, we are actually in a better position to leverage affordable options that provide equally effective treatment while keeping plans and out-of-pocket expenses affordable.

Wise consumer choices make the difference

When plan sponsors and their members take shared responsibility for their benefit plan’s affordability and sustainability it pays dividends. The more we select higher cost items our choices affect the overall cost of the plan. Most of the time a generic will provide the same beneficial results as its more expensive counterpart – leaving more money for the plan to invest in expanding other health care needs or providing rate stability.

Marketing versus reality

Part of helping plan members make wise financial choices is addressing the misconception that expensive brands are better when lower cost alternatives exist. Generics contain the same active ingredient in the same dosage as the brand name product they are replacing. Although the size and look may be different than the more expensive brand name, in Canada, all generics must have undergone review to ensure they are comparable to their brand-name counterparts.

A step further: mandatory generic substitution

In spring 2013, we introduced mandatory generic substitution for all our current fully-insured group plans and as our preferred standard approach on all new insured business. This helps ensure the right people are getting the right treatment at the most affordable cost to their plan. It’s also about empowerment when it comes to how members wish to manage their health care expenditures. These plans still offer a choice – if a member chooses a brand name drug where a lower cost alternative exists, their plan will reimburse up to the cost of the generic – the member makes a choice to pay the difference out-of-pocket.

Dealing responsibly with those who truly do require “no substitutions”

Through our experience we also recognize some people do have adverse reactions to certain drugs —remember that 0.5%? With this in mind, our plans consider “Doctor No Substitution” if there is a true adverse reaction—but this consideration is done responsibly for both the member and plan sponsor. We look for the physician to validate a generic drug has been tried and failed before accepting “no substitutions” on requests for brand name prescriptions.

Is mandatory generic substitution keeping plans affordable?

Our approach to mandatory generic substitution is having impact. As of May 2013, 94.5% of our fully insured groups have switched to mandatory generic substitution. On average, groups are now seeing a 1.6-2% savings on drug plan spend. Educating our members about generics has also had influence. Since May 2013, with targeted communication, over a third of claimants (38%) who previously were taking a brand name medication that was indicated with a “doctor no sub” switched to the generic available. Most notable, the incidence of “doctor no substitution” went to 1.48%, down from 2.37%.

We all have a role to play

Providers and health care professionals can all leverage their areas of expertise to help patients determine their best options when it comes to treatment and health care affordability.

Case in point: with an expanding scope of practice in many areas, pharmacists are well equipped to help engage patients in their drug therapy. Pharmacists are in a position to understand a person’s drug plan and health needs, and to help determine options for the plan member to consider. Prescribing physicians are still best equipped to ensure treatment is in line with a person’s overall health and well-being.

Insurers must play a lead role

It can be confusing for patients, caregivers and medical teams to understand drug coverage. But with a growing number of online and mobile tools, caregivers, pharmacists and plan members have greater access to the information needed to make informed decisions about their health care.

For example, we recently launched Medavie Mobile for our plan members to help them manage their benefits and better understand their drug coverage. We’re also working on our Drug Cost Compare app for health professionals to use to consider cost when all else is equal with their prescribing decisions–maintaining the affordability of their patient’s health plan and guarding against unnecessary out of pocket expenses.

Looking Ahead: Collaborative generic utilization

Collaboration among all stakeholders is key when it comes to drug plan accessibility, management and affordability. Most of all, by taking a collaborative approach, everyone can work together to ensure members receive the right drug at the right time balancing cost - while also protecting the value, integrity and, most of all, sustainability of a plan.

* National Center for Biotechnology Information

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Brett Ruffell

Pharmacists leading innovative employee initiatives

by Brett Ruffell, associate editor of Drugstore Canada and Pharmacy Practice.

About 100 stakeholders involved in managing drug benefit programs gathered in Toronto late September for the 13th annual Pharmacy Solutions in Drug Plan Management conference.

Attendees heard keynote presentations and panel discussions featuring a variety of experts discussing how pharmacists fit into the private drug plan equation.

And one point was clear: With the expanding scope of pharmacy practice, pharmacists can have an even greater impact on patient care and, thus, provide employers with significant cost savings.

“Pharmacists are turning a corner with expanded scope,” said opening keynote speaker David Gardner, professor of psychiatry and pharmacy at Dalhousie University.

Gardner explained how enhanced scope and other changes are enabling pharmacists to have a greater impact on employee wellness programs by providing chronic disease management.

As one example, he discussed an employer-sponsored wellness program for diabetes patients implemented in the U.S. called the Ashville Project.

For that initiative, community pharmacists delivered several services for sponsored employees. These included such things as setting diabetes management treatment goals, performing glucose meter training, educating patients about cholesterol management, and carrying out adherence checks.

As a result of the interventions pharmacists carried out, patients drastically improved their results related to several self-care behaviours. The consultations also significantly reduced direct medical costs such as money companies spent on insurance claims and prescriptions.

What’s more, the program improved productivity by slashing the number of sick days employees took.

Gardner then highlighted an area where pharmacists offer an untapped potential for employers—helping employees with mental health. The psychiatric expert said mental health-related challenges cost $51 billion annually in lost productivity.

And while pharmacists’ work in this area often goes unrecognized, Gardner said they have the knowledge to product significant savings through services such as med reviews and promoting adherence. “And also by meeting with these patients pharmacists could segue into other services like smoking cessation counselling,” he added.

Next Karen Welds, a pharmacy and health benefits journalist, went into further detail about the changes that are affecting pharmacy.

“It’s both the best of times and the worst of times for pharmacists,” she said, referring to how governments are simultaneously expanding the profession’s scope of practice to include acts such as adapting prescriptions while also cutting into their revenues.

She then outlined how pharmacies are taking advantage of new opportunities. For example, when governments introduced paid med reviews for diabetics, some chains responded by ensuring they had at least one Certified Diabetes Educator per pharmacy.

While cognitive services aren’t enough to make up for revenues lost from generic drug costs, Welds assured the audience such programs were gathering momentum.

Another way drugstores are responding is with innovative private partnerships, she said. For example, last year Shoppers Drug Mart formed a deal with Great West Life to provide a diabetes support program to the insurer’s clients. As part of that program, pharmacists offer eligible plan members a diabetes support program with A1C testing and one-on-one education on adherence and lifestyle behaviours

Fittingly, representatives from Shoppers, CostCo and MHCSI Managed Health Care Services followed by sharing their experiences with drug benefits programs, their results and lessons learned.

Promoting adherence
This year’s sessions wrapped up with a discussion on the importance of improving adherence to therapy as a drug plan management strategy. “Many employers are frustrated their plan members aren’t adhering to their medications,” said Connie Wong, director, pharmacy benefits with Manulife Financial.

Atul Goela, senior pharmacy services consultant with Green Shield Canada, added that non-adherence costs taxpayers as well. He cited a recently released document titled the Sustainable Solutions Report that shows non-adherence results in five per cent of hospitals admissions and physicians visits. The problem also contributes $4 billion to healthcare costs each year.

One way pharmacists and other healthcare professionals could improve adherence rates is by doing a better job of communicating the benefits of doing so, said Dr. Peter Lin of the University of Toronto Health and Wellness Centre and the Canadian Heart Research Centre.

“I don’t think pharmacists and doctors sell the benefits of adherence well enough,” he said. Dr. Lin contrasted that with how skilled many manufacturers of herbal remedies are at convincing customers to buy into their sometimes-questionable benefits. “They pledge all of these wonderful benefits and patients are willing to pay $80 for a bottle without thinking twice.”

Dr. Lin then recommended an adherence strategy. “I try to help patients envision why it’s important for them to take their medications,” he said. “You need to make adherence easier for the patient so that they become a true partner.”

Also look stateside for solutions, Goela recommended. For example, one common practice in the U.S. is to offer pharmacists incentives for improving adherence.

Adhering to behavioural and lifestyle changes is also important, stressed Marc Mitchell, cardiac rehab supervisor with Toronto Rehab. He offered one example: “We’ve conducted studies showing exercise leads to significant direct and indirect cost savings.”

Ruth Ackerman, director of professional affairs with Shoppers Drug Mart, said that spending face time with patients is another key to promoting adherence. That’s why as the most accessible healthcare professional pharmacists are so important.

However, she offered one word of caution: Patients have a lot of faith in physicians’ orders. Therefore, pharmacists must carefully explain things to patients when making interventions. “If you share that relationship, you could cause an interruption in adherence.”

Photos of the 13th annual conference can be viewed at:

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Stephen Frank

KYC: Know your (biggest) customer

by Chris von Heymann, senior vice-president, Cubic Health Inc.

Just so that we’re all on the same page: the private sector contributes the majority of drug spending in Canada, and its piece of the pie is growing. According to the Canadian Institute of Health Information, third-party payers or “plan sponsors” (in most cases the employer is the sponsor subsidizing costs) and their plan members were responsible for 55.5% of all prescribed drug costs in 2012, up from 53.5% in 2011. These same employers have a clearly stated need to get more value from their benefits programs, and are looking to their services providers (i.e. pharmacies within the context of their drug plans) for solutions, or they will have no choice but to take matters into their own hands. The stark reality for pharmacy? Many plan sponsors have already begun taking matters into their own hands, so it’s not a matter of “if” the private payer world is going to change on a large scale, but “when.”

Why is it, then, that this customer group, one that is providing an ever-growing source of pharmacy’s revenue picture, continues to garner so little attention, thought or tangible action from the profession?

I fully appreciate that some pharmacists reading this may be wondering if the author is either nuts, really a pharmacist, or has some particular hate on for the business and profession of pharmacy to suggest that it help employers lower their prescription drug benefit costs––to which I would humbly respond (in order): no, yes, no.

After 10 years with Cubic Health and even longer as a pharmacist, I truly believe that there is a very real opportunity for a strategic and mutually beneficial relationship between pharmacy and employers, and I’m not the only one. To quote a pharmacist and pharmacy owner I worked with just this past month: “Here is a novel idea: why not use the pharmacist to control costs?!”

For employers reading this article, this may be a challenging notion, an apparent conflict of interest to their own bottom line. But this is where the “strategic” part of “strategic partnership” comes from, and where pharmacy groups have the opportunity to make enormous strides in developing relationships with third-party payers. Pharmacies need to think of it this way: If employers are going to implement a plan design with financial incentives for their employees to come to your pharmacy to get their prescriptions filled (as well as spend more money on your higher-margin cosmetics, OTC products and other front shop purchases), what are you going to do to help them optimize the health and pharmacotherapy regimens for their plan members, both fiscally and clinically?

Here’s the thing: we’re now a long way past “preferred” pharmacy arrangements simply being a drop in dispensing fee from $11.99 to $7.00. Plan sponsors today are more sophisticated, and have a greater understanding of their drug plan experience, than ever before. They have the data and the tools required to measure (to name only a few):

  • what they’re paying for ingredient cost markups on Manufacturer List Price right down to the penny – and the dramatic ranges in submitted costs seen between different pharmacies in their claims experience;

  • average days’ supply on their maintenance drug claims, the specific opportunity to optimize three-month maintenance supplies for these claims, and which pharmacies have been doing the best job optimizing refill quantities;

  • members’ adherence with therapy in key disease states, and which pharmacy groups are doing a better job in assisting patients in this area than others; and

  • trends in suboptimal therapy and/or management of their members’ conditions.

In other words, employers have the data they need to measure pharmacy’s performance, so to the extent that pharmacy is telling them it can do X, Y or Z, they can immediately tell if pharmacy has actually delivered on X, Y or Z. They are looking to potential preferred pharmacy partners for a more comprehensive strategy, a more holistic approach to managing the health of their members and the financial health of their benefit plan. Those pharmacies that develop and deliver such strategies with tangible, measurable outcomes for employers will stand to gain a lot of new business.

As a case in point, a major pharmacy group recently floated a very interesting idea to a client of ours covering more than 40,000 employees (over 100,000 people if you include their spouses and dependents) in anticipation of some pharmacy-based analytics work: expand the focus past simply the cost components of a drug claim to their plan (i.e. ingredient costs and dispensing fees) to the overall annual cost per individual patient filling their prescriptions at their pharmacies. Their point? If they’re doing a great job optimizing refills, ensuring the most clinically appropriate therapies, intervening for the selection of more cost-effective therapies (where appropriate), ensuring optimal adherence to key chronic therapies, and delivering enhanced pharmacy services and clinical care, then their well-managed patients will ultimately cost the plan less in drug, short-term disability and long-term disability claims over the course of a year than less optimally managed patients at pharmacies with discounted dispensing fees or cheaper ingredient costs.

What’s the right strategy here? Instead of purporting to know all of the answers, pharmacies must start asking their customers what their challenges are, and help to quantify their problems to be able to demonstrate how they can help. To pharmacies, here’s the key message: start developing relationships with your customers, keeping in mind the following: your patient is the member in your store, but your customer is the plan sponsor.

Chris von Heymann is a pharmacist and senior vice-president of Cubic Health Inc.

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Stephen Frank

The time for prescription drug reform for the benefit of all Canadians is now

by Stephen Frank, vice-president, policy development and health for the Canadian Life and Health Insurance Association (CLHIA)

One of the most frustrating challenges for 100,000 plus employers in Canada that offer prescription drug benefits to their employees, is trying to design a benefit package that is both sustainable from a financial perspective and fair and equitable for all their employees regardless of where they live. What should be a relatively straightforward exercise is anything but, given the prescription drug system that exists in Canada today.

Currently, there are 14 different public drug plans in Canada, each with their own list of drugs that are covered and eligibility rules. In addition, rising costs–particularly related to the increasing incidence of rare but very high cost drugs–are undermining the ability of employers to continue to offer drug coverage benefits. The net effect is a system that is increasingly being challenged from a financial perspective and that results in inequitable access to needed medication, simply based on where an individual lives or who their employer is. This reality was the catalyst for Canada’s life and health insurance industry to release a comprehensive policy paper titled “Ensuring the Accessibility, Affordability and Sustainability of Prescription Drugs In Canada,” found here which makes actionable recommendations to reform the prescription drug system in Canada.

Prescription drug coverage in Canada is a mixed public and private accountability and in 2011, Canada’s life and health insurers provided prescription drug coverage to more than 23 million Canadians and facilitated benefit payments for prescription drugs in Canada of $10.1 billion. We are convinced that if we get reform right, there is a significant potential for savings that will benefit all Canadians. Canada currently ranks second highest, behind the U.S., in total per capita spending on drugs (both prescribed and non-prescribed) of the 25 OECD countries. If Canada were able to implement reform to move us more in line with the median of the OECD in this regard, we would save more than $9.6 billion per year in drug costs. This is money that provinces can use to reduce their deficits, employers can use to grow their businesses and create new jobs, and workers can use for other important priorities.

Putting the system on a more equitable and financially sustainable path must be the clear priority for reform over the short term and our industry has identified a number of actionable priority areas for reform. In particular, the federal agency that regulates prices for new drugs needs fundamental reform in order to reduce drug prices for all Canadians. Going forward, we believe that this agency should use a market-based approach to negotiate the lowest possible prices for the benefit of all Canadians. Equally, providing a greater degree of standardization for which drugs are covered across Canada is an area that needs immediate attention. Governments, in collaboration with the private sector, should work towards developing a common, national minimum list of drugs that will be covered to reduce the complexity and inequities in our current patchwork system of drug coverage. Adopting a minimum list of drugs would have the added benefit of allowing provinces, employers and individuals to continue to have choice, as well as foster competition in the marketplace.

Finally, Canada needs a comprehensive strategy to deal with the likely increase in the number of very expensive “orphan drugs” that will be coming to market in Canada. Orphan drugs are typically expensive drugs that treat very rare diseases and Canada will, rightly so, be introducing a new streamlined approach to approving such drugs for sale. However, if we do not, in tandem, develop an equitable and financially sustainable funding approach to paying for these drugs, we risk creating expectations that simply will not be met, as many such drugs may not be affordable to provinces and private payers on an ongoing basis. As a priority, therefore, we argue that Canada needs to get ahead of the game and that government needs to lead a discussion towards creating a new, collaborative, end-to-end approval and funding regime for orphan drugs.

The ultimate goal from a policy perspective must be to ensure that Canadians have access to the drugs they need without undue financial hardship. To this end, any long-term solution to these challenges will require both public and private payers to make adjustments to their programs and to work more collaboratively going forward. The time for reform is now. The Canadian life and health insurance industry is committed to meaningful change in this sector and looks forward to engaging with governments and other stakeholders to ensure Canadians continue to benefit from a strong prescription drug system well into the future.

Stephen Frank, vice-president, policy development and health for the Canadian Life and Health Insurance Association (CLHIA), is responsible for overseeing and advocating for the industry's extensive interests related to health and disability insurance and sits as on the Board of the Canadian Drug Insurance Pooling Corporation.

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Peter Zawadzki

Why should private payers care about covering expanded pharmacists' services?

by Peter Zawadzki, professional affairs executive, Pharmasave National.

Private insurance companies and health plans face no shortage of demands for health-related coverage. With an aging population, a rise in chronic conditions and public health budgets struggling to meet demands, private payers are often expected to fill many voids within the Canadian health system. Of course, not all demands can be met – private payers need to make coverage decisions based on value, risk, clients’ needs, and return on investment. However, it is for all these considerations that extending coverage within private plans to include expanded pharmacist services would provide significant value to both plan sponsors and beneficiaries/patients in helping them meet these demands.

Why is the time right for private payers to extend coverage for expanded pharmacist services? Much has changed in pharmacy in the past several years however some in the private payer sector remain unaware of these changes, and the value and impact that pharmacists can bring to improve healthcare outcomes for Canadians.

A few observations:

  • The scope of pharmacy services has increased in many provinces over the last few years. Although specific services differ by jurisdiction, pharmacists in many provinces can now administer drugs by injection (including flu shots), prescribe for minor ailments, provide diabetes counselling, order lab tests, and provide smoking cessation programs. Jurisdictions are introducing these expanded services because they understand that pharmacists are the most accessible healthcare providers in Canada, and can provide better value than more traditional points of contact with the health system such as physician and emergency room visits. All provinces are expected to expand pharmacists scope of practice in the coming year. As Saskatchewan Premier Brad Wall has said, “pharmacists are seen as the most underutilized profession in the country—but that is quickly changing”.

  • Pharmacists are the most trusted profession in Canada, according to several recent surveys. Given that trust and their accessibility, Canadians are more apt to rely on their pharmacist for provision of healthcare services.

  • There is a proven return on investment from expanded pharmacist services. Numerous academic studies conducted in Canada, the US, and Europe point to the returns provided by pharmacist services, including lower hospitalization costs, fewer health-related complications, lower absenteeism and number of reported sick days, and enhanced productivity. One large scale study in the United States, dubbed the Asheville Project, concluded there was a 4 to 1 return on investment for employers as a result of expanded pharmacist services. The Canadian Pharmacists Association (CPhA) is developing a toolkit which will define new pharmacy services and discuss the features and benefits for private payers, public payers and, most importantly, for beneficiaries and patients. The toolkit will identify research studies that have looked at return on investment and value for specific services.

  • Currently, fees for many expanded pharmacist services are being paid out of the patient’s pocket and therefore their full benefits are not yet tracked or fully realized. Although many jurisdictions have expanded the scope of services a pharmacist is legally able to provide, they do not always cover the cost of these services in the public budgets. This means many patients don’t take advantage of the value-added services pharmacists can provide. Coverage of expanded services through private plans would encourage greater uptake of expanded pharmacist services resulting in cost containment and sustainability of the broader health benefits program.

There is more work to be done before the private payer market fully embraces the notion of expanding their plans to cover the full range of all the expanded services that pharmacists can now offer, not least of which is addressing the fluctuations in the number of funded services as they expand across Canada. But at a minimum, pharmacy and private payers need to engage in dialogue about the role that pharmacists can play towards delivering better health at better value. We need to talk about the rapid changes that are occurring. We need to talk about how private payers can ensure their plans are meeting the needs of their beneficiaries—our patients—in a cost-effective manner, and how trusted, accessible, qualified pharmacists can help.

Over the coming months, the Canadian Pharmacists Association will be looking for opportunities to engage private payers in that dialogue. Our goal is to work collaboratively to increase workplace productivity, decrease absenteeism and presenteeism, and decrease short-term and long-term disability. We look forward to the discussion.

Peter Zawadzki is an Ontario representative on the Canadian Pharmacists Association Board of Directors, and is currently Co-Chair of its Pharmacy Advisory Committee on Private Payers formed in collaboration with the Canadian Association of Chain Drug Stores. He is the Professional Affairs Executive for Pharmasave National.

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Sarah Beech

Prescription Drug Plans: Are Industry Expectations for Cost Containment Measures Too High?

by Sarah Beech, president, Pal Benefits Inc.

These are interesting times for those involved in the design and delivery of prescription drug plans. At the same time that we are experiencing the longest period of low single-digit prescription drug trend increases we’ve ever seen (National Health Expenditure Trends: Canadian Life and Health Insurance Association, October 2012), we are collectively creating and presenting to the market the most complicated cost-containment plan designs that we have ever produced.

On the surface, this situation may seem contradictory. However, current efforts anticipate the introduction of new, expensive drugs, the cost of which could cripple some private plans, even as they help address serious medical issues. Cost-containment measures are undoubtedly more critical now than ever and our industry needs to help ensure their effectiveness.

20-20 hindsight

In retrospect, perhaps we should have introduced cost management years ago when annual prescription drug costs were increasing by double digits. If we had, we would likely have instituted greater shared responsibility for dealing with cost increases among employees, employers and providers. But for a variety of reasons (such as technology advancements that changed the way we reimburse and manage plans––electronic submission and tracking of prescription drug claims did not exist in its current form 20 years ago––and plan sponsors focused more on building workforces than managing costs), we just weren’t ready as an industry to do so. To be clear, however, the issue was certainly not ignored and a lot of good thinking has gone into cost containment solutions over the last two decades. Some progressive employers have had designs that incorporate elements such as managed formularies for years.

Today, though, our entire industry is focused on approaches to managing future cost increases. We are now prepared to embrace and understand concepts that address drug usage (generic substitution, therapeutic alternatives, ingredient costs, brand name drugs, lower cost alternatives, drug utilization review, step therapy, continuity of care), reimbursement (managed formularies, PPOs and PPNs, prior authorization, drug plan price files, dispensing fee caps/deductibles, tiered co-pays), and accessibility (mail order pharmacy, 90-day drug supplies, maintenance medication).

Stumbling block

All of these are important solutions to manage the plans offered to employees, retirees and their families, as well as the choices they are able to make. However, the complex and often complicated procedures that plan members need to follow to get coverage may affect the viability of these cost-containment strategies. Are we doing enough now or have we done enough in the past to help plan members understand the basics of how plans work? Without an awareness of “the basics” as a foundation, how can we expect plan sponsors and members to successfully adopt “new” concepts and products?

Consider an example. Jack pays $5 every time he picks up his monthly prescription. Jack believes this is fair and reasonable. But if you asked Jack, “Are you satisfied with the per prescription deductible/co-pay on your plan?”, odds are he would not know what you are referring to. Likewise, if you then asked him, “Do you ever buy your monthly prescription in a 90-day supply to save on the dispensing fee cost?”, he would likely look at you with a blank stare.

Jack’s example is not unique, and Jack uses his plan. Think about all the plan members who do not make claims regularly and how little plan terminology they actually understand.

Driving effectiveness

If these cost management strategies are to succeed, what should we be doing? Communication is the obvious answer. However, as an industry, we need to re-think how we present and explain these solutions. If we follow some of these strategies, we may well see increased understanding on the part of employees regarding how plans work and more willingness from plan sponsors to adopt change.

  • Keep it simple – start with the basics

  • Think about how a plan is used from a plan member point of view, not from an industry perspective

  • Tell stories. Clarify for Jack why “buying in bulk”, e.g., a 90-day supply of his prescription, is more cost effective than buying one month at a time. Compare this to another consumer product he may buy in bulk to save money. Share real experiences from employees who have used a mail order pharmacy and how it saved them time and money. Illustrate how an app that details personalized plan coverage will be useful on a doctor’s visit

  • Explain things from the perspective of “What’s in it for the plan member” and “What’s in it for the plan sponsor?”

  • Provide the viewpoints of multiple key stakeholders: pharmacists, doctors, insurance company call centre

  • Use available technology. Create an environment for two-way, open dialogue about the plan (blogs, postings, Twitter)

  • Ask plan members what they understand today and what they need to know so they can embrace plan changes in the future

  • Communicate often – and ask for feedback!

Our industry’s focus on benefit plan affordability and sustainability has resulted in innovative thinking, strategic approaches and exciting new plan design. However, in order for us to truly realize success, employees and plan sponsors need to understand and feel comfortable with the new solutions that are being offered. We cannot assume that all stakeholders are at the same stage of readiness and need to invest the time to bring everyone along by providing support, understanding and education.

Sarah Beech is president of Pal Benefits Inc.

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Dorian Lo

Getting You and Your Employees Prepared Against the Flu (Influenza)

by Dorian Lo

Fever, chills, cough, sore throat, runny nose, headache, muscle aches, fatigue…sound familiar? Yes, these are typical flu symptoms. The flu is not like the common cold. Influenza, a highly contagious respiratory infection, is a serious illness which may potentially lead to complications, such as pneumonia, and may even worsen conditions like asthma, congestive heart failure or diabetes.

Flu in the workplace:

The influenza (flu) virus spreads through the droplets of people infected with the flu. Spread can occur by actions such as coughing, sneezing or even talking. Did you know that a sneeze can send these viruses flying as far as six feet? And that's not all…they are also pretty hardy. Flu viruses can live on surfaces for 2-8 days; so if you come into direct contact with objects or surfaces like phones, door knobs, eating utensils, drinking glasses, or unwashed hands, you're not out of the woods.

A healthy and present workforce is important to all employers. Employers can reduce the risk of increased absenteeism during flu season by encouraging their employees to get their flu vaccination every year during the fall season.

Typical flu symptoms usually last about a week to 10 days. Remember that people may be contagious for a few days BEFORE they know they have the flu and AFTER their symptoms have gone.

In Canada, the flu season usually runs from November to April

This is why it is important to get your flu vaccination between October and December. Even if you had a flu vaccination last year, you still need to get a flu shot again this year. It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against the flu. Every Canadian over the age of six months should get an annual flu vaccination. The flu vaccine is especially important for:

  • people with weakened immune systems

  • young children

  • the elderly

  • pregnant women

  • healthcare workers and caregivers

Here's what you need to do to reduce your risk of getting the flu:

  • Get a flu vaccination each year

  • Maintain a healthy lifestyle

  • Wash your hands frequently, and for at least 10 seconds, using warm water and soap. When soap and water are not available, use an anti-bacterial hand sanitizer

  • Use a tissue when you sneeze or cough, throw away used tissues and wash your hands immediately. If a tissue is not available, sneeze or cough into your elbow or upper arm to avoid spreading germs to your hands

  • Clean household surfaces and children's toys often

  • Avoid touching your eyes, nose or mouth if you think you may have come in contact with flu germs

  • Don't share drinking glasses or eating utensils and give each family member his/her own towel

  • Try to avoid crowds during the flu season and if you have the flu, stay at home

During the fall and winter, pharmacists can provide you and your employees with all the important information you need about the flu, flu prevention, how to reduce your risk of catching or spreading the flu and how to manage flu symptoms. Pharmacists in several provinces now have authority to administer flu shots, which are available at many pharmacies in British Columbia, Alberta, Ontario, and New Brunswick. Provincial ministries of health and regional pharmacy associations can provide lists of local pharmacies providing the service. To find a Shoppers Drug Mart location offering flu shots near you, go to:

Dorian Lo is executive vice-president, pharmacy & healthcare, Shoppers Drug Mart

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Chris von Heymann

Predicting—and Acting Upon—the Unpredictable

by Chris von Heymann

I dispensed my first $10,000+ prescription recently: $13,720.45 to be precise.

The innocuous looking prescription basket worked its way down the line in the dispensary, following a typical 10-day supply of amoxicillin 500mg and a 3-month refill of atorvastatin (LipitorTM) 10mg. Suddenly, there it was: a box of 168 tablets of Incivek® (telaprevir) 375mg, the new oral medication for Hepatitis C that I’d first heard about at a conference in the U.S. last year. After the initial sticker shock wore off (it’s one thing to read about these kinds of high-cost specialty drugs in magazine articles, yet quite another to sign off on one), the following facts regarding Incivek® came flooding back:

  • This prescription was only the first of three for the recommended 12-week course for the patient. Translation: the total cost for the one course of therapy with Incivek® would exceed $41,000.

  • Incivek® (and Victrelis® (boceprevir), the other new oral agent for Hepatitis C approved in Canada) is an add-on specialty therapy – it must be used in combination with injectable peginterferon alfa and ribavirin. Translation: while it is considered to be a “game changer” for Hepatitis C patients, providing for a much higher cure rate, Incivek® is literally the second of two concurrent specialty therapies now being used to manage this condition.(1)

  • The majority of Hepatitis C patients are candidates for add-on Incivek® therapy, including those being treated for the first time, those with no response or only partial response to more traditional therapy, and those in relapse. Translation: long overshadowed by specialty therapeutic categories like Rheumatoid Arthritis (RA), Multiple Sclerosis, Crohn’s Disease and Cancer, the future risk for substantial increases specialty spending from this therapeutic area has suddenly become very real for plan sponsors.

Considering that the general theme of the upcoming Solutions in Drug Plan Management conference focuses on chronic disease management and how to prepare for the high cost of biologicals and other specialty drugs, I would suggest that plan sponsors have to first understand their own unique specialty experience and risk for future specialty claims before turning to a “solution.” How many members are treating Hepatitis C with traditional specialty agents only? How many are currently treating RA with non-specialty agents only? Therapeutic shift for only one member with either of these conditions can quickly translate into $25,000 - $40,000+ of additional plan spending. To what extent is the plan being sheltered from potential specialty costs through coordination of benefits for members in provinces like B.C. in which public coverage kicks in once an income-based annual deductible is satisfied? If you’re not clear on your own unique (potential) problem, how will you know which is the best solution?

While most employers are justifiably concerned about the potential volatility these expensive therapies can impart on their plan costs, the reality of the situation is that 83.3% of all specialty spending for the average working plan population in Canada in 2011 was for chronic conditions that translate into recurring specialty claims going forward (down slightly from 84.4% in 2010).(2) Translation: depending on your experience, a good portion of your specialty spending can actually be quite predictable; you just have to know where to look.

On the chronic disease management front, we have recently come across two profoundly interesting and innovative approaches to finding meaningful solutions in this area.

Is your future already in your experience?

As noted by the executive director of a large benefit plan in the education sector: “Many children of teachers grow up to be teachers. It’s imperative that we understand the utilization, health and wellness of the dependents within our plan experience now in order to anticipate, manage and benefit their utilization, health and wellness in the future as teachers.” With this foresight in mind, the plan is diving into its data for this typically overlooked claimant subgroup to investigate things like the prevalence of certain disease states among dependents in Elementary versus Junior High versus High School, the impact of these disease states and related co-morbidities among its youth, and how rates of adherence with therapy change among the three age bundles. Armed with this information, the plan has committed to designing and implementing targeted health programs to benefit its youngest members today—and its workforce of the future.

Impacting non-adherence where it counts: at the dispensary counter

While member communication initiatives at the plan sponsor level may facilitate awareness surrounding the issue of non-adherence, it is arguably the day-to-day, patient-by-patient, interactions between the pharmacist and the plan member that will drive positive change in member behaviour. Whether it be through better counselling on initial therapies to set patients’ expectations regarding onset of activity, the required duration of therapy and potential side effects, or routine and structured patient follow-up efforts, or refill reminder programs for chronic therapies, pharmacy has the most “touch points” with members in this area. Recognizing this, Managed Health Care Services Inc. (MHCSI) has taken the initiative to measure the rates of adherence within four key disease states impacting plans within its book of business where it counts: at the individual pharmacy level. “By focusing on adherence at this level,” says Leanne MacFarlane, senior director business development, “we’re able to determine how each store is performing, disease state by disease state. For those ranking towards the bottom, we’ve now got a clear understanding of the specific reasons for non-adherence among members frequenting those stores and are working on targeted communications and solutions for our pharmacy providers.”


1. Canadian Pharmacist’s Letter; September 2011; Vol: 27

2. Cubic Health National Benchmarks

Chris von Heymann is a pharmacist and senior vice-president of Cubic Health Inc.

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Rob Green

Get ready for the end of the "drug holiday"

by Rob Green (Guest Columnist)

It is without question that one of the largest concerns and cost drivers in a company’s employee benefit plan is their drug benefits program. Over the last decade, many organizations have seen their drug claims rise anywhere from 7 to 12% per certificate per year, forcing a number of companies to modify their drug coverage and deductibles, looking at ways to slow rising costs.

When you dig into the figures further, you find some even more concerning trends. Prescription drug spending amounted to just over $25 billion in 2011. What most people might not be aware of is that 55% of these costs ($14 billion) came from private plans and out of individuals’ pockets. For the first time, the private benefit side paid out more for drugs than public plans and each year Canadians pay more out of their own pockets as well. As Green Shield noted last year, the average claimant’s out of pocket expenses rose by 75% over four fiscal years ($32.93 in 2005/2006, up to $57.75 through 2009/2010).

The last couple of years, though, there has been an about face for a number of companies’ rising drug costs. We’ve experienced an unprecedented number of significant drug patent losses, combined with aggressive provincial generic price regulations and no new “blockbuster” drugs being introduced. As Martin Chung of Equitable Life told our Benefits Alliance Group back in April, “We are, for now, arguably in an extraordinary ‘drug holiday’.”  Sounds great, doesn't it?

Martin went on to share a number of strong points in our meeting, specifically pointing out a number of highly utilized drugs that have come off patent. The most notable example, he said, is the recent loss of patent protection for Crestor and the subsequent launch of various lower cost generic equivalents. However, in just the past few months other commonly used drugs also expired: Cozaar, Hyzaar, Maxalt and Micardis to name just a few. These drugs are used for common medical conditions such as cholesterol, blood pressure and migraine.

It should also be noted that on April 1, 2012 the most recent phase of generic price regulations came into effect in many provinces, resulting in most generic drugs listed on provincial drug formularies now being regulated as low as 25% of brand name drug costs in a number of provinces, including Ontario.

Based on our research and communication with a number of major insurance carriers and pharmacists, most anticipate the “drug holiday” to come to an end over the next two years. Some of the reasons include:

  • Drug plan utilization continues to increase as indicated by the ongoing increase in the average number of claims per employee (certificate);

  • An aging workforce with employees now working longer;

  • The diminished number of significant patent losses combined with more high-cost drugs entering the Canadian market; and

  • The end of significant additional changes in generic price regulations in key provinces.

How can companies get ready for the end of the drug holiday?

Here are three options that companies should be implementing now:

  1. Educate your staff on the importance of seeking generic medication alternatives. Have them speak with their doctor and pharmacist about prescribing generic alternatives. With generic medications costing 25% of brand name prices, depending on your plan design, not only could your employee pay less out of pocket but your plan will definitely benefit from lower claims costs. Take advantage of the hundreds of drugs that already have or are about to come off patent.

  2. Consider tiered plan design options in your health benefits plan. Most of the time, if you want to change employee habits, you have to hit them in the wallet. Consider a higher coinsurance level in your plan for generic drugs versus a lower coinsurance for brand name drugs. The majority of employers in Canada have a significant portion of their drug plan costs coming from brand name drugs – despite the availability of generic equivalents.

  3. Consider implementing a therapeutic substitution program to assist with both options above.

A thoughtful approach to drug plan management is more important than ever during this window of opportunity. Some of the approaches outlined above could not only save your plan in premium and claims dollars today, but depending on your plan design, could also offer significant savings to your employees. Remember that proper communication to your employees is the key to any successful plan design changes.

Rob Green is president of Green Benefits Group in Burlington, Ont. and is a principal at the Winch Group, a financial consulting firm specializing in employee benefit programs.

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Johnny Ma

Pharmacists ready to help sponsors manage drug plans

by Johnny Ma

Do you have a drug plan? This question is often asked when a prescription is written or when it is dispensed at the pharmacy. However, when the person receiving the prescription has a private drug plan, neither the physician nor the pharmacist can be certain that the drug is covered until a claim is made to the drug plan. Furthermore, the plan member often does not know what their plan covers until they actually need it. This creates a situation which can sometimes result in frustrations with the system and a poor perception of the benefit program provided by their employers.

One of the main contributing factors to this situation is the lack of access to information about drug plan coverage and rules for those who need it. Some public drug programs make online resources available to healthcare providers, but there are few resources pharmacists and pharmacy technicians can use to help plan members with their employer drug plan questions. Pharmacists and pharmacy technicians are at the front line when dealing with plan member questions. However, due to a lack of accessible drug plan information, they often must refer plan members back to their plan administrator, which can result in delays in patient care.

There are two significant developments which will allow pharmacists and pharmacy technicians to be a more important partner in drug plan management in the future. First, in many provinces, pharmacy technicians are becoming regulated healthcare professionals, able to take on more responsibilities.This is part of a transformation of the pharmacy profession to allow pharmacists more time to focus on medication management services and less on product distribution activities. In terms of drug plan management, pharmacy technicians can help plan members access all the available drug funding options available to them, whether they are publicly or privately supported. By helping patients with this integration of the claims process, pharmacy techs can help ensure employer plans get the best value from their investment.

Pharmacists can help in this process as well. With greater drug plan transparency, pharmacists can help guide physicians in prescribing the most appropriate therapy that is covered by a patient's plan. Any supplementary information required to support the claim (such as indication for use, or previous therapies tried), can be gathered at the point of prescribing, rather than after the plan member has left the physician's office.

Pharmacists are also gaining greater responsibilities in other areas, including the authority to prescribe drugs for minor ailments, to administer injections and inhalations, to adapt prescriptions to optimize drug therapy, and to renew prescription refills when the physician is not available. These services are all aimed at helping plan members receive the care they need, when they need it, rather than requiring them to wait for another physician visit. In other words, pharmacists can reduce plan members' need to take time off work to see a physician for minor ailments. This is a benefit which may not be tracked in the drug plan utilization, but is of great value to employers.

Those plan sponsors and advisors who view pharmacy as a partner in drug plan management, rather than just as a service provider, will benefit most from this relatively "untapped" stakeholder. Several pharmacy organizations and independent pharmacies have started to promote their services to plan sponsors and their advisors. As with any partnership, it's important that each party share information in order to come up with an agreement on the services to be provided. The suite of services offered will often be tailored to each plan sponsor's needs and geographic location.

While recognizing that each employe, and each pharmacy services provide, has its own unique business model, it's worth exploring how these new pharmacy services can help plan sponsors manage their drug plans in the long-term.

Johnny Ma, a pharmacist and president at Equilibrium Health Consulting Inc.

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Chris Von Heymann

Express Scripts Canada launches alternative business model for drug plans

by Suzanne Lepage

As plan sponsors keep looking for ways to better manage their drug costs, all stakeholders in the private drug plan supply chain have a role to play. Express Scripts Canada has long offered traditional pharmacy benefit management (PBM) services to insurance companies, third party administrators and government agencies, however their launch of Active PBM and Home Delivery Pharmacy in January offers an alternative business model for potential plan savings.
In the traditional model, the PBM works with the payer, typically the insurer, to manage the pharmacy relationships to provide pay direct drug services and transactions. This could include setting up contracts with the pharmacies for processing and payment of drug claims, managing systems, maintaining plan member eligibility and communicating plan design to pharmacy at the point of sale. In some situations the PBM also provides clinical services to review new drugs and recommend formulary placement. In this scenario the insurer manages the plan sponsor relationship and the PBM’s customer is the insurer. The pharmacist works with the plan member to dispense and manage their medication and process their claim.
In this new business model the PBM offers their services to existing clients, as well as directly to the plan sponsor, instead of working through the insurer. Express Scripts Canada PBM service works on behalf of the plan sponsor to manage their drug benefit and works with individual plan members to manage their prescriptions. What also differentiates this setup is that the plan sponsor can add these new programs without changing their existing PBM or insurance carriers.
In the U.S. it is quite common for PBMs to own pharmacies and work with plan members to optimize their treatment. Express Scripts Inc., Express Scripts Canada’s U.S. parent, offers Home Delivery Pharmacy services and has extensive experience in behavioural science and decision making in patient behaviour; which they are leveraging for the Canadian market.
Once a plan sponsor elects to work with Express Scripts Canada they can offer one of two options to their plan members to fill their prescriptions for maintenance medications:

  • Select Home Delivery allows plan members to choose to use the Express Scripts
    Canada Pharmacy,

  • Exclusive Home Delivery requires plan members to use the Express Scripts Canada Pharmacy. If they choose another pharmacy their drug plan will not reimburse the cost
    of the maintenance medication.

Some of the more traditional services offered by the pharmacy include free shipping for a 90 day supply of their medication and automatic refills. However, in the new business model the Express Scripts Canada pharmacist will also review prescriptions to determine if there are lower cost therapeutic alternatives to treat the plan member’s condition and work with the plan member and their physician to change the prescription if appropriate. According to Mike Biskey, President, Express Scripts Canada, “our goal is to offer the best available health outcomes at the lowest possible cost”
In order to make a recommendation for an alternative treatment, the pharmacists use a combination of proprietary and publicly available research on prescription drug use, pricing, as well as the clinical and therapeutic benefits of both brand-name and generic drugs. They also rely on the recommendations and counsel from the Express Scripts Canada Drug Evaluation Committee (DEC), which conducts monthly reviews of new drugs to ascertain their place in therapy and their possible impacts on the private payer sector. The DEC is an internal group of pharmacists, pharmacy technicians, and claim professionals who will also engage physician consultants and appropriate medical specialists when necessary.
Once the pharmacist has reviewed and filled the prescription, the claim will be submitted to the appropriate insurance carrier or PBM, adjudicated and shipped directly to the plan member at the address of their choice.
Less than a month following their launch, Express Scripts Canada already has two large plan sponsors with a national presence who have signed on to use the service, and several others are considering the program.

Considerations for plan sponsor

The proposed advantages of this new model are plan member convenience and plan savings, however here are some considerations:

  • While some plan members may find home or office delivery of their medications convenient, there are others that may prefer to pick up their medications at a retail pharmacy where they have an existing relationship with their pharmacist.

  • It is difficult to assess the potential savings of these new programs up front, and it will take some time to see how the new model might impact a plan sponsor’s drug plan experience. A robust set of reporting tools that can demonstrate the return on investment for the plan sponsor will be needed. For example, how much was saved by converting a plan member’s prescription from a 30 to 90 day supply or how many prescriptions were subjected to a therapeutic substitution to a lower cost medication?

  • Plan sponsors should also assess how Express Scripts Canada’s Active PBM and Home Delivery Pharmacy will be received by their plan members. Will they be open to being asked to fill their prescriptions at a new pharmacy, or having a new pharmacist recommend therapeutic alternatives? Will the pharmacist have sufficient patient medical history and clinical information to make recommendations for alternative treatment?  

  • Plan sponsors should also ensure they have considered other plan design features that may have less impact on plan members and may generate more savings. Do you require generic medications to be dispensed when available? Do plan members contribute towards the cost of their medication? A plan member is far more likely to pay attention to the cost of their medications if they are paying 20% of the amount paid.

As with any plan design change, a plan sponsor has to weigh the potential drug plan savings to the impact or disruption to their plan members.
Suzanne Lepage is a private health plan strategist at Suzanne Lepage Consulting Inc., Kitchener, ON

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Chris Von Heymann

Positive outcomes from Shoppers Drug Mart's drug plan redesign

A summary of Basil Rowe's presentation at the 2011 Solutions in Drug Plan Management Conference

by Sonya Felix

Just a few months after launching a newly redesigned employee drug plan, Shoppers Drug Mart is seeing lower drug costs and higher participation in wellness programs. Basil Rowe, vice-president, total rewards and shared services, Shoppers Drug Mart, shared details about the drug plan changes and the impact at the 2011 Solutions in Drug Plan Management conference, held on Sept. 8 in Toronto.

Before the redesign, Shoppers’ benefit plans were inconsistent and inequitable across employee groups and the average amount per claim was above benchmark for its corporate plan and below benchmark for its retail plan. The company wanted to group all employees under one best-in-class plan and to leverage the organizational capabilities to offer value-added services. There was also the realization that increased genericization and a decrease in generic drug prices would only provide temporary savings.

During the drug plan review, Shoppers articulated its goals: to improve the health of employees and their families; to reduce the cost risk to the organization; to engage, empower and share accountability for better health; and to integrate the company’s benefit offering. Opportunities were identified by the current cost drivers: chronic conditions and rare diseases; open formulary and specialty drugs, lack of coordination of benefits; and drugs and short and long-term disability claims.

The re-making of the company’s drug plan began in 2010 and it took only nine months before implementation in January 2011. To better manage drug costs, Shoppers introduced a formulary solution that includes a custom formulary, tiered copay, generic leadership and utilization management. The new plan also has a wellness solution (health risk assessment, mentored and self-help programs, mental health and stress triage, and personal wellness account and incentives) as well as a chronic disease management program (diabetes, rheumatoid arthritis, multiple sclerosis and cancer). “We were able to leverage our pharmacy team to understand how we could invest in health and wellness for our employees,” says Rowe. “Reinvesting savings into wellness is now a cornerstone of our new plan.”

By the end of six months, drug costs fell by nearly 15%, 20% of plan members had enrolled in wellness programs and the chronic care program had 40% participation. “We are seeing changes in our members’ behaviour, they appreciate their benefits more and they are taking advantage of disease management,” said Rowe. “And there are still significant opportunities to leverage pharmacy services for medication reviews, retroactive drug utilization reviews (DURs), step therapy and extended specialty disease management.”

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Sal Cimino

Medication non-compliance: a dangerous side effect for all of us

by Sal Cimino, director, pharmacy services, Green Shield Canada

Where medication is concerned, compliance refers to both persistence (how long a patient takes a medication) and adherence (to what degree a patient follows the prescribed directions for the medication). Put another way, medication non-compliance is when a patient fails to take the right drugs—at the right time—in the right prescribed dosages—for the right length of time. Regardless of the health condition, compliance is always important. However, with chronic conditions, strict compliance is especially critical not only for effective disease management but also to avoid the risk of other complications. And although compliance is by far the best medicine, non-compliance is increasingly the reality, especially within certain drug classes like statins for high cholesterol, oral anti-hyperglycemics for diabetes, and anti-hypertensives for high blood pressure.

Non-compliance is more often the rule than the exception…

In developed countries, adherence to long-term therapy for chronic diseases averages only 50% ¹—even lower in developing countries. The Journal of Managed Care Pharmacy highlights the complexity of the non-compliance issue in that “two thirds of Americans on prescription medication fail to take either any or all of the prescription. Breaking down this noncompliant behaviour even further, 29% stop taking their medication before the prescription runs out, 22% take less than the prescribed amount on the label, and 12% never even fill the prescription. Polypharmacy further compounds the problem, with 59% of people with 5 or more medications taking them improperly, irrespective of age.” 2

Whether patient, plan sponsor, pharmacy benefit manager, healthcare professional, government stakeholder, or society as a whole, the costs associated with this degree of non-compliance are devastating. The costs of non-compliance create a negative domino effect of poor health outcomes and increased health care costs down the road. As emphasized by the Canadian Pharmacists Journal, “The importance of improving strategies to encourage persistence of patients with these chronic therapies cannot be underestimated. The cost savings to the health care system is far superior to the cost of the drug in an adherent patient or to the additional services of the pharmacist; conversely, non-adherent patients cost the health care system thousands of additional dollars and effectively deceive the health care community, because we think the patient is “on” the recommended therapy and forego any further interventions.”3

As a plan sponsor, the issue of medication non-compliance is a “no win”: you lose in terms of both drug costs and poor plan member health that can negatively affect productivity. In addition, efforts you make toward enhancing medication compliance may not necessarily be reflected directly in your bottom line but rather the government’s in terms of fewer hospital admissions, fewer doctors’ visits, and overall, fewer future interventions. This issue of who pays versus who benefits further muddies the waters in terms of the best approach toward combating medication non-compliance.

Boosting medication compliance is everyone’s business

Just because a plan member fills a prescription and submits a claim, or even re-fills the prescription, we can’t assume compliance. Did they take the full prescription? Did they take it properly? Did they follow instructions for re-filling it? The answers are anyone’s guess, but the solution to boosting medication compliance is everyone’s business. Motivating compliance represents an issue where we all need to work together:

  • Plan sponsors can help boost compliance by, for example, making sure you have a pay-direct drug plan. Surprisingly, approximately 30% of plans still follow a reimbursement model rather than a pay direct system. Pay-direct plans allow online Drug Utilization Review messages to come into play, alerting the pharmacist about potential compliance issues right at the point of sale.

  • Pharmacy Benefit Managers can help prevent waste by putting in place programs like “Initial Days Supply” that limits the dispensing of all new prescriptions to an initial 30-day supply. This ensures the patient is tolerant before filling the balance of the original prescription.

  • Physicians could be trained to provide more in-depth education to their patients about the prescriptions they are taking, and then conduct more specific follow-up. Research shows that physicians are poor at guessing which patients are not complying, accordingly there is a school of thought that more emphasis needs to be made on teaching medical students how to detect and handle medication non-compliance.

  • Pharmacists have proven effective in enhancing health care outcomes through counseling services. Perhaps with the expanding role of pharmacists across the country that includes authority to adapt prescriptions, we will see an increase in pharmacist counseling services. However, as always, the question remains, who pays? And how/what would pharmacists bill for counseling services?

  • Government has the potential--through the health care delivery system--to affect adherence in numerous ways like control over health care providers’ schedules in terms of appointment lengths, allocation of resources in terms of fee structures including reimbursement for patient counseling and education, and communication and information systems for enhancing continuity of care through information sharing.

Collaboration + Communication = the best medicine for increased compliance

So what about the patient’s role? Where does patient responsibility come in? Although rationally we would like to think that the threat of serious consequences like a heart attack, inability to breathe, blindness, and even amputation would motivate medication compliance, reality reveals otherwise. Our best chance is to work together to “get through to” the patient. We each need to do our part in motivating compliance regardless of where we are in the drug delivery model. The need for a system-wide multidisciplinary approach is voiced by the World Health Organization that urges, “Increasing the effectiveness of adherence intervention might have a far greater impact on the health of the population than any improvement in specific medical treatments.” 4

Working together is the best medicine for enhancing non-compliance because through ongoing collaboration and communication, we can influence system-wide changes that enhance compliance—and in turn, enhance the cost/benefit scenario of who pays versus who benefits.


1,4 Adherence to long-term therapies: evidence for action, World Health Organization, 2003

2 “Pharmacy Management Strategies for Improving Drug Adherence,” Supplement of Journal of Managed Care Pharmacy, Journal of Managed Care Pharmacy, July 2008, Vol. 14, No. 6 S-b

3 An adherence study of prescription refill data, with and without a periodic patient education program, Canadian Pharmacists Journal, CPJ/RPC, March/April 2007, Volume 140, No 2

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Barbara Martinez

Succeeding in Workplace Wellness: A step by step strategy

by Allan Smofsky, workplace health strategist, Allan Smofsky & Associates

It is increasingly clear that more organizations are seriously talking about the importance of improving employee health and well-being, and a growing number are actually doing something about it. Progress is patchy, however, and employee health/wellness initiatives are still frequently put in place with little in the way of strategy, planning, resources–and evaluation.

We know from decades of research that improved employee health is directly associated with reduced health and absence costs. In recent years, employee engagement research has shown that improved productivity and overall performance increase as employee engagement increases. We are now beginning to draw links between these two research streams, and health/well-being is increasingly being perceived within organizations in a broader context. For example, Aon Hewitt's 2009 Best Employers in Canada study indicated that:

- Absenteeism per employee per year is much lower at high-engagement organizations (6.38 days) than at those with lower engagement (12.89 days); and

-Engaged employees are healthier. Data supports a clear link between high engagement and better personal health.

In their 2010 survey entitled WORKING WELL: A Global Survey of Health Promotion and Workplace Wellness Strategies, Buck Consultants listed the top strategic objectives for wellness programs in Canada as being:

  1. Improving productivity / reducing presenteeism

  2. Reducing employee absence

  3. Improving workforce morale / engagement

These studies underscore the thinking beginning to emerge that workplace wellness is as much –or more–about driving employee engagement and performance than about “just” health. This is good news for those of us who work in this area. Why? Because when the benefits of healthier employees are linked to key organizational drivers such as productivity, customer satisfaction and profitability, securing the buy-in for these initiatives becomes easier.

As awareness of the value of employee health/well-being grows, demand is heightened for programs that yield measurable improvements in both employee health and organizational performance. This effectively raises the bar on workplace wellness–indeed, it represents a challenge to wellness program sponsors, providers and advocates to deliver clear, measurable results.

The challenge many plan sponsors–and other workplace health stakeholders—face, is therefore not so much WHETHER to seek to improve employee health/well-being but HOW to get started in a practical manner and show results as soon as possible, without a significant investment of new money or resources, and without negatively impacting employees.

With this in mind, all stakeholders in the workplace health market should be proactively seeking ways to better enable organizations to deliver health/well-being initiatives to their employees. Below are some practical considerations:

  1. Understand and prioritize the issues

It is interesting that the rigorous process so ingrained in organizational planning is so often absent when it comes to employee health/well-being. Organizations often implement such initiatives without a clear understanding of the problem--and the solution--and without clear objectives. Consequently, programs unable to generate–or identify–measurable improvement in employee health/well-being, are often discontinued.

Organizations already have a great deal of employee health/well-being data on hand, including internal data on employee engagement and performance, and external data on drug/health claims, short/long-term disability claims, and EAP utilization. However, this data is generally piecemeal and is generated at different points during the year.

Organizations need to be able to organize all this information into an overall picture of employee health/well-being. The ability to look across the various data components and draw key conclusions will go a long way towards enabling an organization to understand its key employee health/well-being issues and establish strategic priorities.

In addition to what organizations typically have in employee data, the development of powerful analytics tools enables organizations to look more deeply into this data. As this article is appearing in Solutions in Drug Plan Management, let’s use drug plans as an example. These analyses delve more deeply into the main drivers of drug plan claims, and consistently reveal a steady increase in the cost of medications associated with chronic disease. This enables organizations to get a better handle on where emphasis should be on managing disease as well as prevention, and through this, to yield better health results.

  1. Establish a meaningful business case

Having the strategic issues and potential solutions in mind will enable development of an effective business case, one that will resonate with stakeholders across the organization. Traditionally, the wellness business case has relied upon health metrics to illustrate improvements in employee health. As we have discussed earlier, though, newer thinking around employee health has broadened to include the deeper aspects of well-being and links to engagement, performance, etc. As many of us who work with senior leaders know, employee health/well-being is often not on their radar–unless they can see how this will impact strategic organizational measures such as productivity, customer satisfaction/loyalty, and other performance metrics.

Many organizations already measure health, well-being and organizational performance in various ways, yet few attempt to correlate the various components. Here are 4 key elements of a meaningful health/well-being business case:

    1. Identify key health measures, and ensure data is organized and linked accordingly;

    2. Link health data to well-being data, e.g. employee health and employee engagement;

    3. Link health/well-being data to broader organizational performance objectives and related measures; and

    4. Keep it simple. Try to make 1-2 of these linkages initially, and build from there.

Another reason for getting the measurement framework in place within organizations is to begin to build the business case for government to incentivize workplace health. As stakeholders increasingly collaborate to improve health/well-being in the workplace, a logical next step should be to evaluate the impact of workplace wellness on utilization of public health system resources.

  1. Leverage & optimize existing resources

Organizations sometimes decide not to proceed with desired wellness initiatives because of perceived cost, complexity, or both. In reality, though, most organizations have numerous opportunities to move ahead with wellness initiatives in a more cost-effective and less complex manner, simply by taking stock of current resources. From in-house resources to tools and programs available through their current vendors, employers generally have a number of existing resources available to them, and some of these are available for free! In addition, public health and community agencies all offer resources around prevention and disease management.

With priorities and objectives established as per Step 1, organizations can then map out a plan and assess the various resources available to them. The key here, though is to strategically link resources as part of the plan rather than piecemeal. Employers should sit down with some of their vendors to collectively discuss how best to achieve the desired outcomes.

For example, many employers have access to Health Risk Assessments (HRAs), biometric screening, online health tools and information, and health coaching. But the opportunities to link these, for example through automatically populating the HRA with the screening results, or linking at risk employees with online support resources or health coaching, are rarely leveraged.

Another missed opportunity: Even though these diagnostic tools can identify and segment risk levels for various diseases, people identified as “at-risk” are seldom directed to follow-up resources. These linkages can in fact be created relatively easily, either on an employee choice basis, or as automatic referrals if the employee has provided prior consent.

  1. Maximize employee buy-in

One of the biggest barriers to successful workplace health/well-being programs is lack of employee uptake. Yet in hindsight, many employers admit that the programs were not well communicated, or that only one means of communication was used. The key here is twofold. First, employees must be able to see the WIIFM (What’s In It For Me). Wellness needs to be personalized, and individuals who are motivated in the moment to take action need to be able to do so right then and there. As discussed above, there are numerous ways to do this. Incentives have also been shown to be a good means of motivating people to get started, however, in the long run they will need to see the WIIFM in terms of their health.

Secondly, it is important to use multiple communication channels. Organizations have many opportunities to drive employees to wellness programs by using communications vehicles that employees already use. These include using benefits and/or EAP plan member websites, for example featuring pop-up messages that ask the employee if he/she would like to learn more based on their activity on the site; using the benefits enrollment process to allow employees to call up their HRA/screening results to help them make benefits choices; and using social media to communicate key wellness program messages as well as to connect employees with patient groups.

  1. Adherence

Employee adherence, or compliance, with prescribed drugs and other therapies aimed at managing or preventing illness, is an unmet need. Until now, there was very little in the way of active promotion of adherence by organizations and their vendors to employees. The “new” dialogue around prevention and health management for employees should include the importance of adhering to prescribed medication and other therapies, and a number of employers and other stakeholders are now beginning to include this in employee/plan member communication. Some are going a step further and implementing adherence programs, mainly around specific long-term use drugs such as statins.

Ultimately, the success of any wellness program depends upon employees following the recommended courses of action–both drug and other approaches-suggested by their doctors and/or other resources.


There’s little argument today that a benefits/health plan cost management strategy that relies on employee non-compliance and plan cutbacks is unsustainable. Still, many organizations feeling the pain of benefits cost increases tend to focus on short term cost-savings opportunities.

Many others, however, want and need to be shown a better way to manage their spend. When this knowledge is shared, drug and other benefits plans will be perceived as they frankly should be--as an investment in employee health and organizational performance, rather than as a strictly a cost item.

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Barbara Martinez

Dr. Peter Singer

Strategy needed to manage rising drug costs

by Barbara Martinez and Francois Joseph Poirier

The recent wave of drug policy reforms in Ontario, Alberta and British Columbia focus on lowering the cost of generic drugs. But it is doubtful that plan sponsors will see much benefit from these policies, since the legislative changes do not tackle the real issues associated with rising costs: transparency in price settings and optimal prescribing practices. Now is the time for drug plan sponsors to revisit their pharmacy benefit strategies.

As pharmacies and pharmaceutical manufacturers adapt to the pressure points created by drug reforms, they are using a variety of strategies to restore and maintain profitability including: increasing dispensing fees, raising prices for some generic drugs, increasing markup, reducing services or limiting the generic options available at dispensaries.

The net result for employers: lower prices for some generic drugs; higher prices for other generics; and, higher markup and increased dispensing fees for all drugs. Among Great-West Life’s clients, only 8.2% of drug spending was for generic drugs that were subject to provincial price reform. How can reforms on 8.2% of spending make up for potential higher costs on the other 91.8%?

Much has been written recently stating that drug plan costs will be lower in the short term as a fair number of blockbuster brand name drugs will come off patent in the coming months. However, some people argue that the related potential savings won’t be sufficient to offset the increases identified above and recent increases in the pooling charges from the carriers. Perhaps plan sponsors are focusing too much on the small amount spent on generic drugs (25%) instead of worrying about what is going on with high-cost biologic and other brand name drugs that currently represent a much larger share of spending and are poised to increase significantly in the future.

Plan sponsors will have to revisit their pharmacy benefit strategy. In most cases, plan designs and financial arrangements were established many years before recent, significant changes to the Canadian drug landscape. Employers need to revise their plan provisions and reassess the financial risks inherent to their drug programs.

Sponsors would do well to run some scenarios. How would your company react to news that an employee requires a $300,000 annual drug treatment for the rest of her life? Is it affordable? Is there a management process in place to make sure that any lower-cost therapeutic alternative has been investigated, that these high-cost claims have been paid at the most competitive price and that the plan is the last resource available to cover the cost of such an expensive treatment through coordination of benefits strategies? How will such a high claim impact the company’s ability to change carriers in the future, and how will a new carrier treat such a claim?

Time to update pharmacy benefit strategies
Sponsors should develop a pharmacy benefit strategy in the same way pension plan sponsors develop investment strategies—to manage the financial risks of their retirement plan.

The combined financial impact of the recent drug reforms and the growing availability of expensive specialty drugs will translate to significant cost increases in the short and long terms. It may only be a matter of time before your company’s own plan gets hit by a recurring high-cost drug claim, so preparation is key.

As a starting point to update or to implement a formal pharmacy benefit strategy, you will need a clear understanding of the drug plan coverage, the dispensing fee, ingredient price, markup structure and the pooling coverage, on either an individual or a large-amount claim basis. Talk to your carrier to better understand its current offering on clinical services, the limitations of their adjudication system (usually outsourced to a pharmacy benefits manager (PBM)), and their spectrum of pooling arrangements.

It’s also beneficial to conduct a detailed risk analysis to assess and understand the financial implications of the changing market. Many plan sponsors have focused on their plan renewal condition in the past, which is usually limited to the premium rate adjustments for the coming year. To be proactive, plan sponsors need to also examine volatility in the claims experience and the potential impact on the day-to-day operation of the company.

A pharmacy benefit strategy would do the following:

  • describe what is covered under the plan and plan limitations;
  • outline tactics to contain costs and influence responsible employee/consumer behaviours (such as dispensing fee deductibles, formularies, co-insurance, prior authorization, etc.); and
  • measure drug management programs.

Communication to employees and retirees is a critical component of the strategy. Make them aware of the value of benefits provided under their group benefits program and, most importantly, educate them on how they can impact the total company’s drug spend by adopting responsible behaviours. After all, it is their drug plan.
Barbara Martinez is principal, and Francois Joseph Poirier is partner with Mercer’s health and benefits business

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Dr. Peter Singer

The Economic Case for Universal Pharmacare

by Marc-André Gagnon

The current system for buying prescription drugs in Canada is a hybrid of multiple public and private drug plans.
This is totally dysfunctional, for many reasons. The diversity of drug plans means Canadians are covered for their drugs according to which province they live in or where they work, but not necessarily according to their medical needs.

Patients with inadequate coverage, mostly self-employed or unemployed workers, are often unable to benefit from optimal treatments. More than three million Canadians admitted not filling a prescription in the last year because of costs they couldn’t afford.

Also, Canadians pay way too much for their drugs. Canada is the world’s second most expensive country for detail prices of prescription drugs. Canada has the fastest rising drug costs among OECD countries: more than 10% per year.

Countries with universal pharmacare, such as France, the United Kingdom, Sweden, Australia and New Zealand, pay less for their drugs and their costs increase at a much lower rate.

The main reason prescription drugs are so expensive in Canada is because of the importance of private insurers. Only in the United States is a greater proportion of prescription drug costs paid for by private insurers. This private coverage is totally inefficient, and the administration fees are much higher than for public plans (8% compared with 2%).

Insurance companies are normally paid on the basis of a percentage of spending, so they have no incentive to reduce costs. For example, private plans normally make no discrimination among drugs, and gladly agree to reimburse new drugs that are more expensive than existing cheaper and better drugs.

Public plans have the resource for pharmaco-economic assessment in order to make sure that, if a drug is reimbursed, patients will get some bang for their buck. Taking into account that most new expensive medicines are “me-too” drugs (slightly modified versions of existing drugs), and that they are often shown to be no better, the current practice of not discriminating between new drugs is not a way to offer more choice to patients, but rather to make them pay more for less.

Drugs here are also expensive because of sub-optimal therapeutic choices. Drug companies spend about $30,000 per physician in Canada in order to influence their prescribing habits. Therapeutic choices are often the result of drug companies’ promotional campaigns and not of evidence-based medicine.

Among the provinces, British Columbia has benefited for many years from the Therapeutics Initiative and its ability to produce clinical guidelines and develop a culture of evidence-based medicine among physicians. B.C. has ensured that prescribing practices reflect clinical evidence instead of promotional strategy. Because of this, not only do British Columbians have the best therapeutic choices and health outcomes in Canada, but on average they pay 8.2% less per capita for their drugs. No wonder why drug companies want to abolish the Therapeutics Initiative.
Simply by eliminating the waste inherent in private insurance and by improving therapeutic choices, the implementation of universal pharmacare could save Canadians $2.9 billion per year (around 12% of total costs).
In addition to our patent policy, we have industrial policies that artificially inflate the prices of brand-name drugs. By implementing universal pharmacare and eliminating these policies, we could save $10.7 billion per year (around 43% of total costs).

I am confident that ways can be found to use this money more efficiently: for example, by improving health care and by supporting research and development through public funding.

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Dr. Peter Singer

How private drug plan sponsors can ask for—and get—more transparency and accountability from providers

by Wendy Poirier and Karen Millard

The private drug plan market is ripe for change. Recent provincial drug reforms have demonstrated that the provinces will use their volume purchasing abilities together with legislative powers to ensure costs under public plans are reduced and tightly controlled. At the same time, governments have been extremely reluctant to adopt or enforce any real price controls for private payers. With the private payer market remaining substantially unregulated, we expect to see significant cost shifting to the private sector over the next few years. It’s no shock that plan sponsors are having doubts about their ability to manage escalating drug plan costs.
The regulatory system is in flux, but there are actions plan sponsors can take today to ensure the sustainability of their programs without compromising employee health or privacy. Active plan management requires, as a first step, that plan sponsors demand more transparency and accountability from their program vendors. Most of the inefficiencies in today’s private system are exacerbated by the lack of transparency in how drug prices are set for private payers, how plan design elements are actually administered by the insurer and/or pharmacy benefit manager as well as the capability and willingness of vendors to adjust program terms and administration to fit each plan sponsor’s unique needs. Transparency and accountability are also key in helping employees become better users of their health programs and supporting healthy lifestyles. Progressive employers are stepping up to fill the gaps, using both their plan designs and better benefit communications to make plan members more knowledgeable consumers of the drugs their doctors prescribe.
Two steps for today
While change always seems daunting, we believe that there are two areas where plan sponsors should be pushing now for more transparency and accountability from their program vendors:  (1) Understanding drug plan price files; and (2) Understanding generic substitution (“least-cost alternative”) options.

1. Understanding the drug plan price file
The price file your PBM uses establishes the maximum reimbursement level for drug claims. This file is the means by which plan sponsors can enforce price restrictions on pharmacists, ensure plan members are not being over-charged (in dispensing fees or drug cost), and ensure you receive the benefit of provincial generic price reforms on ingredient cost. Plan sponsors should review the current arrangements in place with their insurers and/or PBMs, including the general methodology, the algorithm specific to your plan, the method and timing of updates to the pricing files and the enforcement of price file parameters. Your PBM should explain whether and how pharmacies can extra bill patients (i.e. charge them out of pocket) where the price of the drug dispensed is higher than the maximum reimbursement level set by the PBM. Plan sponsors can also examine the tracking and reporting on the pricing file (for example, generic drug pricing) or initiate an audit to review the experience price file.

2. Understanding generic substitution options 
Generic or “interchangeable” drugs are regulated to ensure that, as compared to their brand name equivalents, they contain identical clinical ingredients and provide the same level of quality, purity, effectiveness, absorption and safety. While Canadian plan sponsors include “mandatory generic substitution” (or least cost alternative) provisions as part of their plan design, these programs are often administered to cover the full price of the brand name drug (even where lower priced generics are available) where a physician had indicated “no substitution” on the prescription. There are many reasons why a physician will mark “no substitution” on a prescription. In some cases, these reasons may have nothing to do with clinical concerns and have more to do with patient preference for what the patient mistakenly believes is a better drug. To gain the full advantage of generic substitution, plan sponsors should:

  1. Confirm exactly how their program is administered, and consider revising designs to ensure that, regardless of whether the brand or one of its generics is dispensed, the plan only reimburses plan members up to the “lowest price alternative” drug on the market. This “real” mandatory generic substitution will result in an immediate reduction in claims costs with cost savings growing over time as generic prices continue to fall (in part as a result of provincial drug reforms) and, as anticipated, brand drug prices increase;  
  2. Investigate what types of appeal processes are available through their particular PBM to address situations where physicians have legitimate clinical concerns. The appeal process may include, for example, automatic approvals (after a generic is used for a trial period), manual appeal to the PBM or point of sale appeal through a preferred pharmacy provider; and  
  3. Communicate to employees on the nature, regulation and overall safety of generic drugs including information on how pharmacists substitute generics, in many cases, without patients even knowing the substitution has occurred. 

Steps for Tomorrow
Once plan sponsors and employees have experienced and seen the benefit of these two basic management techniques, they will be ready to move even further forward toward optimal pharmacy management. And moving forward is, in our view, essential for programs to remain sustainable.
A rational next step for plan sponsors is development of a specialty drug strategy that includes support to plan members dealing with severe and chronic illness. Utilization on high cost drugs including biologic and other specialty drugs is at an all time high and showing no sign of slowing down. For example, it is typical to see cost inflation trends for specialty drugs from 15% to 25% with forecasts indicating this trend will increase to 20% to 35% over the next 3 to 5 years. For most plan sponsors, about 15-20% of drug claims cost last year was driven by specialty drugs being used by just 1% of the plan member population. When properly utilized, these drugs are extremely beneficial in improving quality of life and work capacity for Canadians. Canadian plan sponsors are, however, wrestling with how to ensure their plans continue to provide valuable coverage, especially for those in greatest need, while remaining sustainable for the long term. 
When you’re ready to move from passive to active management…
Despite the fact that health cost spending has doubled for each of the past three decades, most plan sponsors have taken a hands-off approach to the drug plans they sponsor, in part because they have not had access to the tools, data or information they need to change the status quo. Changes in the drug landscape are, however, finally forcing the Canadian market to respond.

Towers Watson launched the Canadian Rx Coalition to help private plan sponsors gain the benefits of collective purchasing. Plan sponsors acting alone are more vulnerable to cost challenges than ever before. The Canadian Rx Coalition, by leveraging the combined power of employers across the country, can put plan sponsors in the driver’s seat. Group purchasing allows us to negotiate better, more accountable and transparent administrative arrangements, access better pricing arrangements, and develop more workable plan management options than would be available to plan sponsors on an individual basis.
Wendy Poirier is division leader, Health and Group Benefits, Canada, Towers Watson
Karen Millard is senior consultant, Towers Watson.

Wendy Poirier can be reached at
Karen Millard can be reached at

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Dr. Peter Singer

Digging your grave with your knife and fork

by Dr. Peter Singer

Today is my 50th birthday. A year ago, I set a goal to lose 50 pounds by today: My slogan was “50 by 50.” I never would’ve believed I could do it, but I did. I learned some lessons that may be helpful to you; those lessons also may have public policy implications.

How did I do it? I used three interlocking strategies: healthy eating, fitness and motivation. With respect to healthy eating, I kept a diary of what I ate (using a website), limited quantities and learned how many calories my body needed. I cut out starches and simple sugars – no bread, no potatoes, no beer, no sweets. I increased lean protein – eating egg whites for breakfast, for example, and discovering Greek yogurt. I ate more whole vegetables, and limited fruit. I shifted more food earlier in the day – recalling the saying “eat your breakfast yourself, share your lunch with your friend, and give your dinner to your enemy” – so as not to drive up insulin, which deposits fat, while I was asleep and inactive.

Regarding fitness, I learned that cardiovascular fitness is not enough – strength training is needed to keep the metabolic rate high beyond the time of exercise. I spent an hour a day doing exercise six days a week. On at least three of these days, I went to the gym and lifted weights; on other days, I did cardiovascular on an elliptical. I started slow, built core strength first to prevent injury, and lifted weights under supervision.

On motivation, I learned to set a goal and stick to it. I treated eating as an addiction, and kept things I shouldn’t eat out of the home. I thought of going on the elliptical not as exercise but as watching Jon Stewart or Fareed Zakaria. And I learned the critical importance of a personal trainer: He always asked me about my eating habits, and provided expert guidance on exercise so I got the most out of my time and didn’t injure myself. There were days I wouldn’t have gone to the gym had he not been there waiting.

What questions are raised for public policy from my experience? Does Canada’s Food Guide – which emphasizes grains, treats fruits and vegetables together, and may not adequately message the importance of protein – need to be revisited? Why is it that, for many Canadians, breakfast is almost all grains and sugar and little protein – and, since some of these choices may be driven by affordability, should we be looking at how our agricultural subsidies and regulatory regimes align with our national nutritional goals?

How can we get Canadians to combine cardiovascular fitness with strength training? Why can Canadians get a massage reimbursed under their extended health benefit plans but not a personal trainer? Should we extend the recently introduced Children’s Fitness Tax Credit to personal training for adults (which could also be delivered in groups to increase affordability)?

Finally, should we encourage people to set more realistic goals? My body mass index (the standard measure of weight for height) is still around 29, more than the recommended 25 (although recent Canadian evidence shows that a BMI of 28 to 30 is associated with the lowest mortality). BMI is probably too complicated, anyway; waist size may be a better measure (mine went from 42 to 32 inches).

I couldn’t be having a happier birthday today, because I’m now more likely to live to see my children grow up. And the best 50th birthday present I could get would be for these lessons to help others.

Dr. Peter Singer is professor of medicine, Sun Life Financial Chair in Bioethics, and director of the McLaughlin-Rotman Centre for Global Health, University Health Network and University of Toronto

This column first appeared in the Globe and Mail and is reprinted with permission from Dr. Singer.

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Chris von Heymann

Sustaining the specialty spend

by Chris von Heymann

If there was ever a time—and opportunity—for plan sponsors to face their fears of expensive specialty (often known as biological) drugs head on, this is it. Most plan sponsors and their advisors are aware of these products from their own experience: claims from single plan members totalling tens of thousands of dollars for novel therapies such as Remicade, Gleevec, and Rebif used to treat catastrophic conditions such as Rheumatoid Arthritis (RA), cancer and Multiple Sclerosis (MS). As a proportion of total plan spending, specialty drugs (including both those of biological origin and non-biological origin) grew from 12.9% in 2008 to 14.2% in 2009 for the average Canadian employer-sponsored drug plan, and the impact of these products is only going in one direction. Why?

First, the utilization of these products is increasing. Specialty drugs represent the majority of all drugs in the pharmaceutical pipeline (57% of the new molecular entities in Phase III clinical trials in the U.S. are specialty), and more people are treating a greater number of conditions with specialty products already on the market as their indications for use expand. Furthermore, utilization within given conditions is increasing, with specialty drugs being initiated earlier in therapy to more aggressively manage destructive diseases, and specialists now even trying combinations of specialty drugs to treat more difficult cases. Payers need to recognize that few physicians think about the costs of the therapies they are prescribing for plan members: according to a survey recently conducted by Emron, 42.8% of rheumatologists and 32.4% of oncologists indicated that they consider costs “rarely” or “not at all”. The only thing that matters to a physician is whether or not a patient has a plan.

Second, plan spending in a number of non-specialty areas will flatten or even decrease moving forward as legislative changes that introduce lower prices for generic drugs to both the public and the private sectors spread among various provinces, and blockbuster brand name drugs such as Lipitor and Nexium (two products which represented a combined 6.8% of total plan spending in 2009) see the introduction of their first generic alternatives. As a result of these factors, the proportion of overall plan spending attributed to specialty drugs will continue to increase.

While this may appear a daunting challenge to overcome, every plan sponsor is now in a position to approach their specialty drug spend in a proactive, strategic manner—one just has to know where to look.

STEP 1: Funding from within—finding the dollars for specialty drugs
A good portion of the funding required for future specialty claims is already being spent on inefficiencies in the 86% of the plan experience that is non-specialty. Examples of these inefficiencies include:
- excessive dispensing fees paid for suboptimal refill quantities for maintenance drugs
- cost premiums being paid for brand products with interchangeable generic alternatives due to a lack of mandatory generic substitution policies
-inappropriate utilization of narcotics and controlled drugs on a per claimant basis
- poor coordination of benefits.
All of these areas provide material opportunities for savings to offset specialty costs. Add to these, the savings to be realized through the new pricing legislation and genericization of key brand products, particularly for employers with upper pricing limits in place and/or that structure their plans to influence plan member behavior towards the most cost-effective therapies whenever possible (e.g. two-tier plans). Suddenly, the resources are there to help sustain coverage for plan members needing high-cost specialty drugs.

STEP 2: Realizing greater value from the specialty spend
Turning back to the 14% of drug plan allocated to specialty, the key is to focus on extracting more value from within this existing investment. This can be achieved through:

  1.  coverage only for approved indications and for those patients that can actually benefit from a given agent (i.e. using robust, up-to-date prior authorization criteria to confirm patient eligibility),
  2. using preferential listings and step-therapy programs (e.g. the Canadian Agency for Drugs and Technology and Health is currently undergoing its own review of the biologics used in RA) to ensure specialty drug options are cost effective,
  3. ensuring optimal specialty utilization among plan members through their enrollment in specialty drug support programs—and considering plan designs that reinforce and encourage their participation in such programs;
  4.  and finally, by ensuring appropriate outcomes via continuous monitoring and evidence of clinical benefit for continued coverage once initiated on a given therapy.

This last point is a key consideration as a number of new and innovative specialty agents only work in specific subpopulations diagnosed with a given disease, and do not work in other subtypes. It is not rational for employer-sponsored plans to be investing tens of thousands of dollars into therapies that are not providing any tangible benefit.

STEP 3: Demonstrating the returns
Finally, the major challenge that HR managers face with specialty drugs—their expense—becomes much easier to support and justify to senior management when the “expense” becomes an investment through demonstrated returns from their coverage. By integrating a group’s drug plan experience with other cost “silos” such as STD and LTD, plan sponsors can measure the cost offset or return on their spend for specialty drugs by considering the following: To what extent are specialty drugs keeping our employees at work? What are the total annual costs (e.g. drug + disability) for employees on biologics for a given condition vs. those not on such therapies?

Chris von Heymann is senior Vice President, Cubic Health Inc.

Bridging the Gap to Employers: A Call-to-Action for Pharmacy

by Chris von Heymann, senior vice-president, Cubic Health Inc.

Right around the time that I was beginning my pharmacy career, the Ontario Pharmacists’ Association released its Fee Guide for Cognitive Services. I was certain that pharmacy would adopt the Guide and secure reimbursement for the cognitive services that we had been trained to deliver. I could not have been more wrong.

Over a decade later, with few exceptions, the reimbursement model for community pharmacy is still based solely on the distribution of products rather than on the provision of clinical and consultative services. The “dispensing fee” is regarded by most payers in the private sector as an all-encompassing fee that covers all services rendered at a pharmacy.

Furthermore, while there has been much discussion and promotion of the expanded scope of practice for pharmacists within the profession itself, there have been few (if any) enhanced pharmacy services or programs developed and marketed directly to employer-sponsored drug plans.

A case in point

After we assessed the potential impact of a drug plan design change—including projected savings—for one of our 3,000-employee plan sponsor clients, that employer decided to proceed with an alternative plan design, but not before asking us a couple of interesting questions: “What kinds of programs can we reinvest those calculated savings into in order to benefit our members?” And, “Does pharmacy have any employer-specific programs that have proven returns that will benefit our members and our plan?”

Unfortunately, we could not think of a single one. What a missed opportunity for pharmacy.

The problem (from the plan sponsor’s perspective)

Pharmacy needs to take a moment and look at the world through the eyes of a Canadian employer in 2011:

  • Prescription drug claims comprise approximately three-quarters of all Extended Health Care expenses for the average plan sponsor. While the year-over-year growth in expenditures for the drug benefit has slowed since the double-digit trends in the earlier part of the decade, that growth is continuing from an already impaired starting position, and the biopharmaceutical and specialty drug pipeline is poised to continue driving plan costs higher.

  • Still recovering from the impact of the recent recession and current uncertainty with debt crises in Europe and the U.S., companies are struggling to remain competitive in the global economy, striving to preserve sales to foreign markets with our strong Canadian dollar, and possibly facing significant layoffs. At the time of writing, Research In Motion just announced the layoff of 2,000 employees – more than 10% of its total workforce.

As a result, the single mandate for the vast majority of HR professionals in charge of managing their drug benefit comes down to cost containment. How can they do more...with less?

The gap (that pharmacy needs to overcome)

As an expanded scope of practice for pharmacy unfolds across the country, and the spectrum of services community pharmacy can offer private payers and their members broadens, the question has been posed: Why aren’t private payers adopting (and paying for) these enhanced services? It all comes down to a lack of awareness, clarity and understanding:

  • What services? What exactly are “enhanced” pharmacy services, and how do they differ from the pharmacy services their plan members already receive today and/or those funded by a given provincial government (e.g. MedsCheck)? Are these enhanced services consistent across all pharmacies, regardless of chain or banner, or do they vary?

  • What cost? How much do these different enhanced services cost over and above a conventional dispensing fee? Is the cost of these additional services consistent across all pharmacies, or do they vary?

  • What value? What outcomes do these enhanced services provide from the perspective of the employer: reduced absenteeism? Reduced short- and long-term disability? Increased productivity? Reduced drug cost? Improved adherence with therapy? In other words, if an employer is going to pay more for these services, what kind of measurable returns can they expect for their investment?

The bottom line is that no employer in today’s market, struggling to get a handle on their escalating benefits costs, is going to add new healthcare services to their list of eligible benefits on blind faith alone.

The bridge

In order to bridge the gap with Canadian employers, pharmacy needs to first clearly delineate its dispensing function from its clinical and consultative services, and then to fully embrace the concept of being a strategic healthcare partner for private plans and their members, providing the following through preferred pharmacy provider arrangements:

  1. Financial solutions – These have got to be first out of the gate: only once employers realize savings on the routine dispensing and distribution of medications to their members can those savings be allocated towards enhanced clinical services and programs. Furthermore, pharmacy has to look past dispensing fees (which comprise only 10-15% of the average cost per claim in the private sector) to the ingredient cost portion of each claim as a part of any competitive offering. Employers now have clear insight into the significant ranges in ingredient costs they are paying between pharmacies for the same drug in the same province, and are looking for more competitive ingredient cost pricing structures.

  2. Clinical pharmacy solutions – With the employer’s primary cost containment mandate addressed first through financial solutions, pharmacy then has a receptive audience, and the budget through quantified savings for reinvestment, to deliver any number of specified clinical services to plan members.

  3. Measured outcomes & routine progress updates – By ensuring that a given employer has the necessary baseline analytics in hand prior the implementation of enhanced clinical services, pharmacy has the ability to measure very specific utilization parameters and outcomes for that employer on an ongoing basis post-implementation in order to clearly demonstrate the value and return on investment for those services. Not only is this step required to demonstrate the outcomes for the given employer, it is essential for pharmacy to have these measured outcomes in hand for marketing its services to other stakeholders.

With this strategic approach to delivering expanded services to the private sector, pharmacy may finally be able to demonstrate the tangible value of expanded clinical services for employers, and get the ball rolling for a sustainable reimbursement model for these non-dispensing functions.

Chris von Heymann is senior vice president at Cubic Health, Inc., which provides companies with information and solutions based on the integration of plan-specific drug claims data with their proprietary analytics systems and reporting applications.

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Mike Lee


Mike Lee
Vice President Human Resources, Moosehead Breweries Limited (Saint John, New Brunswick)

Michael Lee joined Moosehead Breweries Limited, Canada’s oldest independent brewery, in 1999. In 2006, Mike represented one of seven employers participating in Inspire at Work, an asthma self-management program in the workplace. The program realized a return on investment of $4.24 for every dollar spent. Mike is a graduate of the University of New Brunswick with an honours BBA degree. He holds a Certificate in Employee Benefits from Humber College and is also a Canadian Human Resource Professional (CHRP).

* View Expert Q&A with Mike, see Question 1 below.

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Bruce Fraser


Bruce Fraser
Manager Disability & Wellness, Sobeys Inc. (Stellarton, Nova Scotia)

In 2000, Bruce joined Sobeys Inc., one of Canada’s two national retail grocery and food distribution companies, which operates more than 1,300 corporate and franchised stores in all 10 provinces. After leading the group benefits department for over seven years, he is currently responsible for governance and integration of occupational and non-occupational disability claims management for Sobeys. He also manages the alignment of national wellness initiatives.

Bruce is a graduate of Acadia University with a Bachelor of Science and Certificate in Applied Science. In over 16 years in the industry he’s earned the RHU, GBA, CMS and CEBS designations.

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Jennifer Kim


Margaret Brna, B.Sc. Pharm.
Manager Pharmacy Professional Affairs, Shoppers Drug Mart

Margaret Brna has practiced pharmacy in various settings, including community pharmacy, pharmaceutical industry and retail pharmacy corporate office. Her experience includes consumer health marketing as well as development of health educational programs. In her current position with Shoppers Drug Mart corporate office, she is responsible for the development of fee-based cognitive services and manages customized health programs for the private sector under the HealthWATCH for Business brand.

* View Expert Q&A with Margaret, see Question 3 below.

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David Alter


David A. Alter, MD, PhD, FRCPC
Chief Scientific Director, INTERxVENT Canada

In addition to his position at INTERxVENT Canada, David is associated with the Division of Cardiology and The Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto and The Toronto Rehabilitation Institute, Cardiac and Secondary Prevention Program. He is also an Associate Professor of Medicine at the University of Toronto. David’s research interests extend across many disciplines, including the examination of chronic vascular disease management and the evaluation of regionalization and/or decentralization of specialized cardiac services. Recently, he launched several pilot projects to measure the health and economic outcomes of disease management in the workplace.

*View Expert Q&A with David, see Question 1, Question 2, Question 3 and Question 4 below.

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Sal Cimino


Sal Cimino, B.Sc.Phm.
Manager, Pharmacy and Professional Services, Green Shield Canada

In 2001, after working as a hospital and community pharmacist and co-owner of three pharmacies, Sal Cimino became the resident pharmacy benefit consultant at Green Shield Canada. The department is charged with all facets of drug claims including, but not limited to, drug evaluations, formulary design/maintenance, drug pricing and drug policy. The department also serves as a liaison to the pharmacy community, the pharmaceutical industry and associations and regulatory bodies. Sal, who has his Bachelors degree in Science and Pharmacy, is currently a Director of the Board of the Essex County Pharmacists Association and a member of the Canadian Pharmacists Association and the Ontario Pharmacists’ Association.

*View Expert Q&A with Sal, see Question 1, Question 2 and Question 3 below.

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Barbara Martinez


Barbara A. Martinez Senior Associate, Mercer Health & Benefits Toronto, Ontario

Barbara Martinez helps organizations in both the private and public sectors manage their prescription drug benefit programs. Her background in pharmaceutical sales/marketing, government affairs and professional services has equipped her with extensive knowledge of the prescription drug, regulatory and drug approval process in Canada from both a government and private drug plan perspective. Barbara is a guest lecturer at the University of Toronto’s College of Pharmacy on the issue of direct-to-consumer advertising of prescription drugs and a frequent contributor to the work of the Canadian Pharmacists Association and the Ontario Pharmacists’ Association. She has spoken at conferences and as part of panel discussions to both the pharmacy and plan sponsor audiences.

* View Expert Q&A with Barbara, see Question 1, Question 2 and Question 4 below.

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Lyle Hargrove


Lyle Hargrove Director, Health and Safety Training Fund Canadian Auto Workers

Lyle Hargrove develops health and safety training programs for the workplace, including educational videos, for the auto sector of CAW. He is the coordinator for several workplace wellness programs, including “Brake for Health” with General Motors and other disease-management initiatives with Daimler Chrysler and Ford. Lyle joined the Occupational Health Clinics for Ontario Workers Board in 2001, becoming Chair 2002.

* View Expert Q&A with Lyle,see Question 1, Question 2 and Question 3 below.

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Expert Q&A

Question 5: "I'm the benefits manager for a company with 2,000 employees. Like many other employers, we'd like to promote better health among our employees to help control our drug plan and disability costs. Our resources are limited so we're wondering where we would get the biggest bang for our bucks. Should our priority be on people at risk of chronic disease to try to prevent future illness? Or should we try to make people who are already unhealthy healthier? Can we do both?"

Sal Cimino
It might be a bit premature to determine where you will get the most bang for your buck, without first focusing on data collection, analysis, and interpretation. Otherwise—like the expression "you don't know what you don't know"—you will not have the solid foundation you need to make insightful decisions that will result in the best cost-benefit scenario.

Your first step should be to take a step back, and take a closer look at your employee group. For example, at Green Shield Canada, we use what we refer to as Benefit Insight® reports to help our clients put their plan experience under the microscope. This gives them a solid understanding of employee health and acts as the foundation for making insightful decisions.

To help identify problem areas, you might want to look at benefit utilization reports that flag fluctuations in usage within benefit categories. Also, take a look at reports that highlight drug categories where total claims exceed predetermined values and year-over-year variances exceed set values. Another insightful report would be one focused on medical conditions and chronic diseases, because it can examine claims patterns to identify issues that could potentially develop into serious medical conditions.

You can also compliment this kind of data by getting an outside, bigger picture perspective: for example, take a look at reports that benchmark claims utilization data against a database of similar organizations within an industry or province, as well as reports that provide information about industry trends like how the introduction of a new drug may impact usage patterns and health outcomes. Once you have all of this data at your fingertips, you can give it to your EAP and disability carriers so that they can coordinate the data to do a number of things that will have a positive impact on your organization, such as:
• benchmarking leading indicators where disabilities may occur,
• examining the experience from a holistic perspective, and
• verifying employee compliance.

This wealth of data will help you realize the best value for your efforts, regardless of whether you end up focusing on disease management or health promotion and prevention strategies. Data collection and interpretation shifts your knowledge base from the position of “you don’t know what you don’t know” to “knowledge is power.” Now, armed with a clear picture of your employee group—everything from health status to drug usage to spending patterns—you can make informed decisions about where to focus limited resources.

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Bruce Fraser
Congratulations for taking a most important step—you’ve identified the problem and articulated two viable approaches to addressing it.

I would suggest you begin by understanding your drug and disability cost drivers. If you don’t understand these drivers (your plan members’ most common and costly disease states) you can’t make the best use of those limited prevention resources. Looking at how your costs have trended over the past few years (and continuing to track them into the future) will help show which chronic diseases are a growing problem and could provide your best return for the efforts you make in prevention both now and in the future.

Your current carrier(s) will be a great data resource to start with. They should be able to provide you with metrics on which disease states are most prevalent in your employee population, and let you know which of those are most costly. Using your Drug Utilization Reviews (DURs), your extended health care (EHC) claims (these may not be high ticket items on your plan, but they do contain a wealth of information about your employees’ claiming and illness patterns) and your disability claims diagnosis metrics, your carrier should be able to see what drives these costs in your benefit plans. Privacy laws prevent an employer from doing this kind of analysis, but your carriers are uniquely positioned to conduct individual employee analysis to find patterns of use and cost connections among your plan members. This provides you with accurate meaningful data regarding what issues you should target for prevention. Most of this valuable data should be available to you at little or no cost.

Once you better understand what is causing your employees to be ill or off work, and what is costing your various plans the most money, you can better determine which initiatives align best with the issues your employees face (and the ones which your data shows will become more prevalent in your future workforce!). Decisions on how to target prevention will be based on the unique makeup of your workforce and industry, and influenced by other factors such as access to technology for your employees, whether you are in one physical location or scattered among many business sites, and what existing communication methods your company has available.

From a purely financial standpoint, it makes sense to target your least healthy employees first. They are most likely to have more drug and disability claims in the present and near future. It also helps to be able to generate some shorter-term returns to demonstrate the benefit of prevention and intervention and to generate funds to apply to longer-term efforts.

If your budget is extremely tight, one approach that costs very little is to simply communicate to your employees exactly what your company’s biggest claim cost drivers are. State what your top four or five disease states (or illnesses) account for in percentage and real dollar terms out of your overall health plan and disability costs. Whenever possible, illustrate which of these disease states may be under an individual’s control to change—such as smoking, high blood pressure, obesity or lack of exercise. It may be easier to believe one can effect change when these drivers and costs are reduced to behavioral issues that one may see as something to personally take charge of in one’s own life. Awareness is a first step to action.

There are also many prevention resources available to you at low cost. Provincial and National Health Departments have many targeted programs and information resources available. If your company has an EAP, you could work with that provider to ensure your program provides supports targeting the most costly issues affecting your employees’ health. They can also assist you with communication and promotion of these support services. Many national societies that target disease states, such as the Lung Association, the Heart and Stroke Foundation, the Canadian Mental Health Association and the Canadian Diabetes Association, can be invaluable resources for an employer who wants to provide information and support resources to employees.

By taking advantage of these low cost starting points you can build some momentum and your business case for greater investment by your company to reap those ROI rewards in the future. Good luck!

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Question 4: "I'm the the human resources manager for a medium-sized employer. Until the current economic crisis hit, we had been planning to implement a disease management program for our employees as a long-term strategy to cut disability and drug plan costs. But a strong directive from the head office has instructed all departments, including HR, to cancel all pending programs and to find ways to reduce spending “immediately.” Should I make the argument that promoting employee wellness will pay off in the long run, or should I put the disease management program on the back burner and focus on short-term strategies for lowering drug plan costs? What are my options?"

David A. Alter
The effects of economic peril are far-reaching. The challenges regarding priorities, resources, and activities are always difficult, whether it be for individuals, government, or employers. Employers must approach this pragmatically, and decide how and where they are to most appropriately invest, within the framework of their own fiscal realities.

That said, employers (small, medium, or large size) must understand the health implications of economic downturn. Available evidence suggests a close inter-relationship between economy, stress, and health. Evidence has demonstrated that individual psychological distress, health-seeking tendencies, and adverse lifestyle behaviours all increase during times of economic downturn. Indeed, a recent Desjardins Financial Security National Health Survey examined the perspectives of 1,062 Canadian employees between March and April 2009, and determined that psychosocial stress has increased 33 percent over the past year, with nearly one-third of all employees experiencing significant anxiety, sleep impairment, headaches, and other generalized nonspecific health complaints. During this economic recession, employees have been working longer hours, are less satisfied, and are finding it difficult to balance work, life, and health.

Recent evidence also suggests that many employers are actually increasing their investments in health during this economic recession. Such investments are likely to pay dividends with improved rather than deleterious cost-effectiveness ratios. Why? The answer lies with the likelihood that employees’ baseline risks are higher during the current economic climate. Higher baseline risks yield higher absolute expected benefits and lower numbers needed to treat to avoid adverse health outcomes. The investment returns associated with health and wellness or disease management programs during economic downturn are also likely to be broadly manifested to include favorable effects on health claims, drug costs, absenteeism, presenteeism, short-term disability and employee engagement—metrics which have already been well demonstrated from such programs during times of relative economic prosperity.

If employers are to invest into employee health, wellness, and disease management programs, the key message is that such programs must be accompanied with appropriate benchmark metrics and evaluation. Program surveillance becomes essential, so that the mental, physical, and behavioural health attributes of employees are documented, refined and targeted for interventions appropriately.  Employers may want to consider programs that allow for broader flexibility in content—those that address health promotion, medication management issues, diseases, and productivity. Employers and health human resource teams may want program delivery to vary in intensity depending on health, productivity, or disability metrics; programs that track behavioural compliance in real time, allowing for the selective targeting of individuals whose behaviours are most modifiable, will maximize returns-on-investment resulting from such intervention.

One’s personal investment and commitment into health cannot be driven or dictated by economic cycles, but instead, must remain consistent and impervious to environmental challenges. An employer's investment into their company’s health should be viewed as no different. Ignoring health during economic peril may only magnify the adverse effects of the company’s health over time (financial, cultural, and medical).

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Barbara A. Martinez
Focusing on short-term strategies to lower drug plan costs is definitely one way to attain this objective. Proven ways are those used by provincial public drug plans, including placing limits on the list of eligible drugs, limiting the eligible cost to the price of generics, using pre-authorization for certain expensive drugs, and favoring therapeutic substitution. For important pressing cost reductions, an employer could be more adventurous and consider eliminating their company's subsidy toward dependents’ dental coverage for at least one year.

But why conclude that you need to choose between short and long term goals? Under this theme you could, for example, educate employees on stretching their healthcare dollars, inform employees on the relative cost of services available under provincial health plans and in private clinics, and promote the use of the health risk assessments (HRA) offered by your carrier at no cost. The employer could take further action on heath and wellness spending on a regular basis and build a momentum. For example if the HRA were promoted, the employer could report the results of the HRA and select interventions accordingly.

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Question 3: "I represent a client with 2,500 employees in several provinces. We love what we’re hearing about disease management in the workplace, we’ve seen the studies that show a positive ROI, but we just don’t have the resources. Today’s economic environment makes internal funding even less likely. Is there anything we can do, aside from putting this back in the ‘pending’ file for another year or two?"

Lyle Hargrove
Disease management in the workplace is so important that when resources are scarce we must be innovative in how we get disease management and education to our workers. In the short-term, we can get our HR people to contact health organizations in the community that are already funded by other sources, such as regional health units, the Heart and Stroke Foundation and the Canadian Diabetes Association. These organizations have educational materials and are more than happy to come into the workplace to help educate workers about different health conditions. In the longer term, when times and resources permit, you need a good comprehensive wellness program with a strong commitment from both management and workers that will make your wellness program successful and give you a good return on investment.

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David A. Alter
Yes there are options. The key here is to take a long-term perspective on your organization’s health strategy. Once the blueprint has been established, its implementation can begin with smaller, simpler, less expensive steps. For example, simple health promotional activities themselves draw awareness to health, wellness, behaviours, and disease complications – awareness initiatives are essential to the successful execution of health-related interventions in the workplace.

Such health promotion initiatives may begin with the dissemination of publicly accessible educational materials related to health, risk, prevention, and screening activities. The vehicles for disseminating such materials may include lunch-and-learn seminars with a health professional. Others may embark on organizational healthy workplace initiatives (community-wide walkathons, team sports, etc.). The intent here is to begin undertaking a process of culture change within your workplace environment.

Such initiatives must occur with frequency, and must include the full commitment and active participation by all, from senior management downward. While such initiatives are not designed to alter the long-term behaviours, health or wellness of employees per se, organizational culture, excitement, and commitment is a prerequisite to the long-term success of any employee health and wellness comprehensive intervention (regardless of how costly the intervention is). Simple small-step initiatives may also have a positive impact on employee engagement, so returns with minimal investment may be eminently feasible.

The next step, while still largely affordable, may include the administration (through an independent third-party) of confidential health risk assessments to your employees. When doing so, you must ensure that the health risk assessment process allows for the quantification of biological and behavioral risk (indeed, most do). Health risk assessments do vary in complexity, accuracy, and comprehensiveness, so some due diligence may be required. Publicly-accessible health-risk assessments can serve as a start, but an organization will still require an independent third party to analyze the results and generate aggregate reports and interpretation. The quantification of risk through the use of health risk assessments not only serve to justify the need for the application of more comprehensive personalized health and wellness programs (assuming your employees risk-profiles warrant such intervention), but also help shape the program composition and intensity needed to maximize the health, wellness, productivity, and drug-utilization benefits.

As with the implementation of your overall organization’s health strategy, the implementation of personalized health, wellness, and disease-management interventions once employee risk profiles are known, may occur in a scaleable fashion. The implementation may range from highly affordable self-help educational programs (with or without group counseling sessions), to costlier but more comprehensive, effective fully-mentored interventions which allow for personalized one-on-one counseling using certified health care professionals. ROI evaluations are encouraged especially when implementing costlier programs, in order to ensure that any estimated “value for money” benefits are indeed realized within your organization.
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Sal Cimino
Faced with the challenge of limited resources, one of the best strategies to try to free up funds is to examine your organization’s drug cost budget allocation. Each year organizations typically allocate increased spending on drugs. This budget increase may in fact represent ‘hidden funds’ – funds that could be re-allocated to wellness initiatives.

The funds budgeted for drug cost increases may possibly be an avenue for accessing hidden funds, as over the last few years drug costs have remained stable due to the introduction of generics, patent expirations and other factors. This pricing trend is expected to continue until at least 2010. As a result, you could consider re-allocating these funds to wellness initiatives like health risk assessments (HRAs) and smoking cessation programs that provide a solid return on investment in terms of reducing drug utilization and improving employee health.

The HRA is an especially worthwhile investment because it provides baseline information about your employee population that can then become the foundation for your wellness strategy. This enables you to confidently plan your wellness strategy so that resources are not only dedicated to the right areas/initiatives, but also are not wasted on low cost/benefit scenarios.

In addition, the more advanced HRAs provide additional value by going beyond health status reporting by also incorporating ROI calculations. For example, in addition to evaluating health data provided by its users, Green Shield Canada’s HRA also tracks and assesses corporate spending on health-related benefits, such as paramedical costs, drug utilization, etc.

With limited resources, in addition to investing in an HRA, depending on your employee group’s issues, another cost effective investment is in smoking cessation programs. Research indicates that smoking cessation programs can play a significant role in decreasing health claims for high cost, high utilization drugs for illnesses such as lung cancer, coronary artery disease, stroke, emphysema and chronic bronchitis.

Research also indicates that the most successful smoking cessation programs include the use of smoking cessation products combined with counseling, so the ideal is to find a program that includes these elements. For example, Green Shield Canada recently administered an innovative smoking cessation program for one of its clients that extended the employees’ benefits package to include coverage for nicotine replacement therapy products combined with coverage for pharmacist counseling services. Rather than having to put your wellness plans “in the ‘pending file’ for another year or two,” consider developing a business case for re-allocating resources to focus on investing in just a couple of key tools like an HRA and possibly a smoking cessation program. You are likely to find that the business case will speak for itself in illustrating how even limited resources can go a long way in delivering a significant return on investment.

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Margaret Brna
Take advantage of various not-for-profit health organizations such as Heart and Stroke Foundation and the Diabetes Association to gain access to educational programs, services and publications that are often offered free of charge. Services range from provision of speakers for educational sessions, print educational information, lists of local resources and healthcare professionals, and comprehensive websites with objective and easy to read information on managing health conditions. The mandate of many of these organizations is to create public awareness and to share their educational resources, so they may welcome a partnership with your company to deliver some programming.
 Create awareness of publicly-funded programs among your employees. Contact your local Public Health Unit as they have expertise and resources available through publicly funded programs. In Ontario, employees are also eligible to take advantage of the MedsCheck program through community pharmacies. It is a medication review program funded by the Ontario government for individuals taking three or more chronic medications. This is a solid first step towards engaging an employee in disease management. Participating in it can help employees gain a better understanding of their therapy, expected benefits, clarify how to properly take all medications and help to prevent drug interactions with over-the-counter medications or natural supplements. To take advantage of this program, an employee can contact his local pharmacy or an employer can set it up with a corporate pharmacy chain.

Various pharmaceutical manufacturers, independent pharmacies and pharmacy chains have recognized the business opportunity of helping organizations improve results through collaboration with pharmacists on delivery of disease management programs in the workplace. Rexall Network as well as Shoppers Drug Mart (under the HealthWATCH for Business brand) offer many types of programming to meet various employers’ needs and budgets. Contact them for more information.

While chronic diseases affect a relatively small proportion of employees, the cost to a corporation is high. These may be individuals with diabetes or cardiovascular disease who would truly benefit from disease management, but effective programming often requires resources, which are limited in many corporations. Newer options for more turn-key workplace health and disease support programs are emerging, and they will likely become widely available to corporations in the next few years.

If developing a disease management program for a chronic condition is not within a company’s budget, start small by targeting common conditions that can be typically managed by the employee. Examples of these conditions are seasonal allergies (allergic rhinitis), menopause symptoms, migraines, arthritis and gastrointestinal disorders. The employees may often self-medicate for these conditions, trying to treat the symptoms, without investigating the causes. Provision of education to help employees treat the condition more effectively (through appropriate and efficient utilization of the correct medications) may drastically improve their symptoms and make them more productive employees who don’t need to take days off in order to deal with their bothersome symptoms. 

Set up a health resource library by sourcing educational pamphlets (from any of above mentioned organizations) and create a resource sheet of reliable and unbiased health websites. Utilize the company lunch room or other suitable area that all employees can access as the health library. An employee, who has access to even the most basic health information is already in a better position to manage his or her health.

In summary, if the organization is not quite ready to invest in a comprehensive disease management program, consider taking small steps towards employee health empowerment and education.

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Question 2: "Workplace support programs for people with chronic diseases sound good in theory, but realistically why would employers make that kind of investment? Aren't we talking about a relatively small proportion of employees? Isn't it up to healthcare providers to do more for them, and for employees to be more responsible?"

Lyle Hargrove
It is more important than ever for employers to have workplace support programs for workers with chronic diseases. Although they may represent a small portion of the workplace, workers with chronic diseases are most likely long-time employees of the company. These workers have played a major role in the success of the company over the years and may feel they have made the company a lot of money when they were healthy and have earned the respect of their employer. They feel that the corporation should look after them in their time of need.

In most cases of chronic disease the workplace has contributed to the worker’s illness. Many workers work with a lot of chemicals and materials that are carcinogenic or known to cause cancers. Workers suspect that these chemicals will cause them harm, but don't have scientific evidence to prove that they do. But I believe that employers have an obligation to support these workers.

Healthcare providers certainly need to play a part, as well, since a lot of time the employer doesn't do enough and healthcare providers need to make sure that workers get the care they need. The worker also needs to play a part and can make a difference in their own health by doing the things that keep the body strong when they encounter illness. Workers need to take ownership of their own health. Having said that, however, the number-one party in terms of responsibility is the employer.
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David A. Alter
While it is true that chronic diseases affect a relatively small proportion of employees, they account for a disproportionate degree of health- and cost-related consequences to a corporation. In this regard, the health-related consequences of chronic disease in the workplace setting mirror that in the population as a whole, where 70% of healthcare-related expenses are consumed by only 30% of the population – most of whom have chronic diseases. Indeed, absenteeism in Canada costs employers nearly $16 billion annually. Studies have determined that improving the health and outcomes among employees with chronic diseases have significant economic advantages to corporations, through improvement in productivity, and through more appropriate and efficient utilization of medications. 

Indeed, the objective of workplace support programs is to prevent the disabling and costly complications of chronic disease. Workplace support programs include employee assistance programs and therapeutic lifestyle and disease-management programs (sometimes referred to as workplace “health and wellness programs”). The effectiveness of such programs are achieved by not only managing employees with chronic disease more effectively, but by preventing diseases and their associated complications from the outset.

Workplace support programs have evolved significantly in recent years. New and emerging programs now span the entire spectrum of disease, from “asymptomatic, pre-disease-states” to chronic diseases and their complications. Newer health and wellness programs incorporate employee health screening questionnaires (termed a “health risk assessment”). Health risk assessments are used to stratify employees into high, medium, and low-risk status. Those at highest risk would require management of specific disease-related complications, while those at lower degrees of risk may warrant specific lifestyle interventions in hopes of preventing disease. 

The rationale for screening all employees is two-fold. First, available evidence has demonstrated that a sizable proportion of the population has risk factors for disease, and don’t even know it. The consequences of unrecognized disease in the workplace can be devastating, and may include disability, depression, and death. Second, employee health screening initiatives allow for, and provide targeted programs to, those employees most in need of intervention. Indeed, recent Canadian guidelines advocate for the use of health risk assessments for every male over the age of 40 and every female over the age of 50 years of age (or who is postmenopausal). Therefore, the use of employee screening assessments in the workplace is consistent with consensus guideline-supported screening initiatives in the general population. Given significant variations in the health and behaviors of individuals, effective health and wellness programs must be tailored to the individual needs of employees. Such programs have demonstrated dramatic improvements in health, behaviors, drug utilization, work-related productivity, and costs.

While it is true that healthcare providers devote significant time to the management of patients with chronic diseases, the availability and supply of physicians are diminishing rapidly, as the prevalence and burden of chronic diseases rise. This combined with the escalating costs of pharmaceuticals and other medical technologies have led many policymakers to question the sustainability of Canadian healthcare system. Even where chronic disease management is provided in “usual-care-type” clinical settings, available evidence suggests that the quality of care is suboptimal in many cases. The delivery of preventive care services in usual-care clinical settings is even poorer than the delivery of chronic disease-management services, as evidenced by a recent Commonwealth survey which determined that the provision of lifestyle counseling in Canada was among the poorest worldwide. Currently, government funding for chronic disease-management and therapeutic lifestyle programs is minimal to nonexistent. Through the promotion of self-management, the provision of services in home-based settings, and mechanisms which close the loop between the employee and their physicians, therapeutic lifestyle and disease-management programs are being looked upon as potential solutions to the growing costs and sustainability challenges facing Canada’s healthcare system.

Should employees shoulder some of the responsibility of their own management? In the end, we are our own best health advocates. Effective workplace support or health and wellness programs empower employees to take control of their own health. The extent to which the employer invests in workplace health will depend upon the investment returns realized through improvement in health outcomes, health-seeking behaviors, productivity, and drug utilization.

In summary, while chronic diseases inflict only a minority of a workplace, their health and economic implications in the workplace and greater population are significant. Workplace support programs often necessitate greater focus among employees with chronic disease. However, newer programs with expanded scope in the workplace environment allow for the screening and targeting of interventions to those employees at risk for diseases and their complications. Healthier employees make for healthier corporations and healthier businesses. Accordingly, such programs are rapidly emerging and are expected to proliferate within the workplace setting over the next several years.
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Sal Cimino
Employers are making this kind of investment because it is good for their employees’ health and, in turn, good for the long-term health of their organization and their bottom line. Some of the issues driving this trend towards increased employee wellness programs, making them a necessity rather than just a “perk” are: 

  • 8 out of 10 Canadians have at least one risk factor for cardiovascular disease.
  • Approximately 48% of Canadians are defined as overweight or obese and obese adults have a greater risk of developing arthritis, diabetes, heart disease and stroke, high blood pressure, cancer, gallbladder disease, gout, and breathing problems.
  • 1 in 5 Canadians will suffer from mental illness at some point in their lives.
  • Over half of working Canadians report high stress levels and work-related stress/strain that have been linked to a variety of health issues, including mental illness and substance abuse, cancer, infections, increased risk of injuries and heart and back problems.
  • Adults who suffered high stress had higher odds of developing a number of chronic conditions in later years, including arthritis and rheumatism, back problems, chronic bronchitis or emphysema, and stomach or intestinal ulcers. For men, they also included heart disease, and for women, asthma and migraine.
  • One in 20 Canadians have diabetes and this is expected to double by 2016.
  • Rates of asthma, hypertension, heart disease and stroke are higher in a diabetic population.

There is a shortage in family doctors across Canada and more and more services have been de-listed from provincial health plans, resulting in individuals not getting their needs met from government-sponsored health plans. In addition, the aging population combined with longer lifespans means greater demands on an already over-burdened health care system.

The reality is that employers are experiencing the pressure of illness more than ever before, realized through benefit usage, absenteeism, disability rates and productivity losses. The bottom line is that an ill employee costs the organization in many ways, and public health care is not addressing these needs.

The ideal is that everyone takes responsibility for his/her own health. However, many people do not take responsibility for themselves and their well-being. Often people do not engage in preventive behaviours until they feel the impact of not doing so because a certain activity or lack of activity “catches up with them.”

Ultimately the organization will carry much of the burden of chronic illness. Hence programming supported by the workplace is critical for reducing future risk factors. Workplace programs provide greater convenience, ease of access, reduced cost, peer support and a positive culture – all of which offer greater opportunities for participation and increased health-related behaviour change.

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Barbara A. Martinez
Chronic disease is a major cause of death and disability in Canada. One needs only to look at disability and health plan trends to see the cost and human impact of serious, chronic illnesses. Further, the World Health Organization projects that death due to chronic diseases in Canada will increase by 15% from 2005 to 2015. Death due to diabetes alone is expected to increase by 44% in Canada. These pressures are even more significant given the aging workforce and the skill shortages that employers are experiencing.

The healthcare system and providers cannot do enough to help patients understand and manage their chronic conditions. It is time for employers in Canada to recognize that they have an important role to help employees take control of their care. These programs are about empowering and arming employees with the right tools and not about taking over the responsibility for their care. Education and supports to navigate within a strained health care system are needed now more than ever.

A disease management program is a fundamental component of any robust, targetted and successful workplace health and productivity strategy. The cost of supporting these programs do not need to be excessive with available technologies and a robust program. The return on investment for disease management programs is well documented in the US. The challenge is to identify the right program structure for a Canadian context.

It is time for employers to wake up to the reality that the perfectly healthy employee represents a shrinking portion of their workforce and people with chronic illnesses make substantial contributions to the workplace. With the right combination of incentives, program offers, and communications, employers can influence behaviours.

Most importantly, demonstrating commitment to employee health and well-being across the full employee population contributes to gaining employees' recognition of the value proposition that employers offer. If an employer doesn't demonstrate that they care about their employees who are ill – how can they ever convince "healthy" employees that they care?
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Question 1: I represent an employer with 1,500 unionized employees. Our next round of contract talks begins in about 18 months. What can I do to lay the groundwork for workplace wellness programs, such as voluntary onsite employee health screenings? Senior management still needs to be sold on this as well, though they’ve at least given me the green light to try and build a business case.

Barbara A. Martinez
Workplace wellness programs are an emerging trend in group benefit plans in Canada. Many employers are starting to introduce proactive wellness features such as education, information and incentive programs around health, diet, nutrition, exercise and how lifestyle choices may influence employee health. Unlike traditional plan benefits, which focus on treating illness, the premise behind wellness programs is that the prevention of illness will lead to an increased number of employees that are healthy, productive and at work. Wellness programs are gaining traction due to their potential to save costs and to attract and retain employees.

Wellness initiatives require more than a change in the benefit plan. For most organizations they mark a change in the corporate culture. Wellness is a long-term commitment that requires management cooperation and support, mentoring and encouragement, plus the funding and tools to enable employees to make healthier lifestyle choices. The benefit plan design will need to be aligned with the wellness objectives, structured to reward the desired employee behaviour, well communicated to all parties, and include measurements of the results.

The business case for wellness rests on a cost-benefit analysis that is not always easy to articulate. It can be difficult to ensure you have the right information for the cost side of the equation, and the necessary broad-based research information on the benefit side. For employers the analysis starts with understanding their absentee rates and the reasons why employees are absent. Plan sponsors also need to look at what is driving health care costs, particularly prescription drugs. Wellness programs that target the source of health-related absenteeism and growing health care costs can then be implemented and measured for improvements in productivity, time at work, and plan cost reductions.

In a union environment it is important that plan changes are made in collaboration with the union as its ongoing support will be critical to the success of the program. As plan members tend to favour initiatives aimed at improving health, the introduction of a wellness program creates the opportunity for a win-win situation for all parties.

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Mike Lee
You are in a great position for developing the groundwork for workplace wellness with 18 months until expiration of the CA. But you will need to start today!

There are two things you need to start at right away, and both will be beneficial in developing your case for the union as well as management. Both involve the gathering of information. First, get going on developing some relevant metrics. Data is king in any undertaking, and the more facts you have, the greater your arguments. Get a hold of your major medical carrier, and get some statistics on drug utilization. What are the top disease conditions? Are they preventable through early detection and interventions? What are the costs of these medications? Absenteeism reports are your next source of information. How many employees are on LTD? What are the causes of disability? Again, can these causes be attributed to manageable disease states? How much do you have tied up in disabled life reserves?

The second opportunity for success is to see what is happening in current employee-based committees such as EAP, safety, and any other employee committees. Are there any wellness-related issues on their agendas? If there aren’t, could you introduce some? Once you have the data and have made wellness an area of interest for other committees, it’s time to put forth an offer to the union to strike up a committee before negotiations to present your concerns about what you have discovered. Seed some ideas, and let them germinate.

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Lyle Hargrove
I suggest you meet with the local union leadership and Health & Safety committees, as well as any other workplace committees (e.g., substance abuse, union counsellors and human rights) to educate them on the possibilities and benefits of wellness programs. A Wellness Fair in the workplace can really help build awareness. Invite all levels of management to participate so they can see the benefits of a wellness program using the community expertise. We’ve done Wellness Fairs with screening clinics for blood pressure and cholesterol readings and for diabetes.

Last but not least, set up regular meetings with the bargaining committee for the union over the 18 months leading up to contract deadline to make sure they understand that wellness is an important issue to their members and they are not to leave the table without money to implement a comprehensive wellness program.

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David A. Alter
Workplace wellness could be offered as incremental benefit programs to employees.  Such programs could be positioned as a win-win for both union and management. As contract talks are set to begin in 18 months, the timing is ideal to begin thinking about such programs, as they could be launched along with other benefit plans.

There are many possible employee workplace wellness initiatives to choose from. When building a case for wellness workplace initiatives, the first and most important task is to choose the right program. Not all programs are the same. You want to ensure that the health and wellness programs you are exploring are credible and scientifically validated, and have a proven track record in the workplace. As companies become increasingly aware of the importance of wellness, many small “health and wellness” start-ups will be creating and pitching wellness programs to profit from the growing market. But in reality, the creation of health and wellness programs is complex, and the stakes are high. There is little room for error, given their impact on people's lives. And there are many places where health and wellness programs can go wrong. So it's important to go with well-established, time-tested programs. Surprisingly, only a minority of health and wellness programs have actually published improvement in health and outcomes in peer-reviewed scientific journals. As with the pharmaceutical and biotechnology products, health and wellness programs must have committed extensively to research and development. Without proven scientific evidence, the benefits of a workplace wellness program will be undermined.

Health and wellness programs come in various sizes and shapes. Their content and composition also varies. Some programs offer only health screening questionnaires (e.g., health risk assessments) and/or generic “self-help” education materials. Others provide more individualized, comprehensive programs with one-on-one health coaching by certified medical personnel. Costlier, fully mentored programs are generally more effective at improving health outcomes than non-mentored programs. Given potential variations in quality, health coaches should be certified trained personnel; one-on-one mentoring should follow standardized protocols so that the quality of counseling is consistent from corporation to corporation; and quality control mechanisms should also be in place. 

The selection of the ”best program” helps build the case for employee health and wellness. Once you are assured that you have selected the correct program, the idea must now be sold to employees and to senior management. While both of these groups may share in their goals for improvement in health, wellness, stress- and disease-management, subtle differences in goals and perceptions may exist. For example, employees will need to understand the pros and cons of participation; employees will need to be reassured that the program is voluntary, and that the health information that is being collected is essential for program delivery and will be strictly confidential. Neither senior management nor human resources should have access to individual employee data. In this regard, health and wellness programs are not dissimilar to employee assistance programs. Unlike employee assistance programs, health and wellness programs focus on self-management so that employees learn how to best care for their own health, lifestyles and disease-related complications. 

Some programs offer incentives and rewards for participation and completion. Some health and wellness programs offer the opportunity to create a positive culture change ("a buzz") within a corporation. These are all positive attributes which, if presented effectively, can be looked upon extremely favorably by employees.

While the entire corporation will share in these positive attributes, senior management will need to understand the business case associated with implementation of health and wellness programs. If they are to invest in such programs, what are the benefits to the company? Employers and senior management will need to have a clear understanding of what resources they will need to have in place to create a successful and sustainable health and wellness program. Generally, an individual from senior management or human resources will need to champion the program and act as a wellness coordinator for their corporation. Employers and senior management may want evidence that the health outcomes, productivity and the satisfaction of their employees have improved with the program. In this regard, some programs allow for aggregate longitudinal reporting, which can track the productivity, drug utilization, health and cost-implications to their corporation as a whole. Others will quantify the return on investment related to health, drugs, and productivity to the corporation.
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Sal Cimino
Over the past several years a lot of information has emerged recognizing the solid cost/benefit of initiating wellness programs. Although organizations may not implement rigorous outcome analysis, more organizations are beginning to introduce workplace wellness programs or expand existing initiatives.
There are several reasons why there is more emphasis on workplace wellness these days. Shortages in government sponsored health care initiatives including physician shortages mean that employees will get fewer services provided in the community, thus increasing the burden on the employer. Research indicates that the number of health risks an individual possesses directly relates to the medical costs that they generate and rates of absenteeism. Increased health issues appear as absenteeism, presenteeism or reduced productivity levels. Stats Canada has shown that absenteeism is on the rise (7 days in 2001 to 7.5 in 2004).
A compelling argument for health promotion/wellness programs is to raise awareness of the cost of doing nothing. The following statistics reveal the positive impact to the bottom line of helping even one at-risk individual:


Cost employers $3,396 more per year (Source: Conference Board of Canada, 2006)

Mental Illness

Costs employers $10,000 per individual for treatment and wage replacement costs (Source: Global Business and Economic Roundtable)
Depression is now the fastest growing category of days lost to disability in Canada. Employers assume 55% economic burden of depression in absenteeism and lost productivity (Source: J of Clinical Psychiatry, 54:415-418)


Obese adults incur annual medical expenditures that are 36% higher than those of normal weight (Source: Health Affairs, 2002)


Incur medical costs two to three times higher than non-diabetics
Direct costs for diabetes medications and supplies can be up to $15,000 per year per person (Source: Canadian Diabetes Association)

Cardiovascular Disease (CVD)

CVD is the leading cause of death in Canada.
8 in10 Canadians have at least one risk factor for CVD (Source: Canadian Population Health Study 2000)
Nearly 6% of Canadian adult population currently reports heart problems

Sleep Disorders

Sleep deprivation has been linked to accidents, stress, obesity, pain conditions and numerous health conditions


In addition to the above information, the added value of enhanced company image, the ability to attract and retain employees and improved engagement and satisfaction scores is an important aspect of a business case for workplace wellness programs.
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2. Clinical medication review by a pharmacist of patient on repeat prescriptions in general practice: A randomised controlled trial. Zermansky AG, Petty DR, Raynor DK, Lowe CJ, Freemantle N, Vail A. Health Technology Assessment 2002; Vol. 6: No. 20
3. Medication reviews in the community: results of a randomized, controlled effectiveness trial. Sorensen L, Stokes JA, Purdie DM, Woodward M, Elliott R, Roberts MS. Br J Clin Pharmacol 2004 Dec; 58(6): 648-64.

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