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In case you missed it – Common Strategies for Employee and Public Health Benefits

In case you missed it -  Common Strategies for Employee and Public Health Benefits

Consider the interests of all parties (i.e., plan sponsors, employees and government) and engage them to create wins.  This was the theme for our CBPI lunch session on May 19th, presented by Steven Long of S. C. Long Consulting Ltd., and Shandy Reed, Division Manager - Health Strategies & Stakeholder Engagement, Alberta School Employee Benefit Plan (ASEBP).


There are common perceptions that government health programs have not been very innovative and have offloaded costs onto the private sector.  Steve says this is not entirely true. For example, Alberta pharmacists have the broadest scope of pharmacists in Canada and plan sponsors should be taking advantage of these services to help their employees better manage chronic disease. Medication management and adherence are keys to improving overall health outcomes. Patients see pharmacists five times more often than they see their physicians, so it makes sense that Pharmacists should be playing a bigger role in patient care. Alberta residents with chronic health conditions and other risk factors, who are taking multiple medications may be eligible for a comprehensive annual care plan and/or a standard medication management assessment.  However, Steve acknowledges that the new pharmacists’ role is a cultural shift for patients, physicians and pharmacists, so it will take time for all parties to adopt to this new health management strategy. 


While there has been some government offloading of services to the private sector, Steve says the split of spending between the public and private sectors has remained relatively consistent at approximately 70%/30% respectively, since the late 1990’s.  As of 2013, the cost of healthcare in Canada was $6,105 per person or approximately 10.9% of GDP, which is relatively on par with many other OECD countries, but much lower than the U.S., which spends a whopping 17.1% of GDP on healthcare.


Steve said that the Alberta government doesn’t want residents to fall through the cracks.  As overall drug plan maximums to combat rising drug costs have become more prevalent, employees whose drug costs exceed these plan maximums can obtain coverage under the Alberta non-group drug program. While there is also a $25,000 annual maximum under the Alberta non-group plan, Steve says patients approaching this maximum can often appeal to have the limit waived.


Health benefits are a tool for achieving and maintaining good health; and achieving good health and using the plan effectively is a shared responsibility between plan sponsor, plan members and insurer, says Shandy Reed.  The ASEBP’s use of predictive modeling has indicated the party is over in terms of relatively flat drug inflation that the plan has enjoyed over the past several years.  Most of the factors that contributed to lower drug inflation such as generic reform and the patent cliff have largely come to an end. To help stem the tide of future inflation, the ASEBP has been focusing on diabetic plan members, particularly the 42% or so that are generally non-adherent to their required drug treatment.  They have also implemented tighter controls for reimbursement of high costs drugs through an enhanced special authorization program (ESA). Under the program, there are three possible outcomes:  Approved - for a specified period of time & then clinically reviewed; Conditionally Approved - for specialty therapy but the specific drug and/or dosage regiment does not qualify and needs to be changed; or DECLINED – member does not meet evidence-based criteria for any form of specialty drug coverage at current point in time.  Under the ESA program, only two out of 10 Hepatitis C prior-authorized drug claim submissions were approved as written. Of the remaining eight claims, four required substantial modification to medication and/or regimen before approved; and four submissions did not meet criteria for approval, resulting in several hundred thousand dollars in savings to the plan.


Steve says plan sponsors should be asking themselves the following questions:


1. What is your benefits plan strategy? Are benefits a cost or an investment?

2. Do you have a Benefits Health Charter? Could it change the way you think about and manage your benefit plan?

3. How well do you communicate benefit changes and gain insights from your members? Does your plan have use mobile apps to support effective use of medications?

4. What does your health claims data tell you about the health of your plan and of your covered members?

5. Are you focusing on the right part of your benefit plan spend – the 90% of health claims?

6. Is your plan leveraging the efforts of Alberta Health and other government actions? Can you build on these initiatives?

7. Do you have an open drug formulary or a managed drug formulary?

8. Does your organization believe it is time for a new level of benefit plan management transparency and responsibility?


Steve also indicated that the Alberta Health Minister’s mission is for Albertans receive the right health care services, at the right time, in the right place, provided by the right health care providers and teams.  Plan sponsors must take an active role in plan management and integrating strategies and solutions with government programs where feasible.

- Kenneth MacDonald  

Please visit our WordPress Blog for a copy of the presentation

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