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7/22/2024 I read it so you don’t have to but you probably should anyway is the TELUS Health 2024 Drug TrendsRead Now In this episode of I read it so you don’t have to but you probably should anyway is the TELUS Health 2024 Drug Trends A fan favorite event, I sadly missed the presentation because I was cohosting my company town hall. Worth it, it was legendary. Remember that 2024 is missing the data from Sun Life due to the PBM switch. Let’s get into it. My top takeaways are: The avg annual eligible drug amount per CERTIFICATE in 2023 was Canada $1262 West $905 ON $1377 Quebec $1481 Atlantic $1530 The avg eligible claim was $83.58. If we look back this number has increased quite a bit 2017 $71.74 2020 $76.63 2021 $83.45 Big post COVID jump. These is where GLP1s started to hit the market in an impactful way Going back to the avg annual eligible drug amount per cert we see the West is sooooo much lower then the rest of Canada. Pharmacare works. Remember that the eligible amount isn't what's paid, it what was eligible for reimbursement before the plan design element kicks in The impact is that clients in the east need to set aside more premium for the drug plan. This puts pressure on other parts to the plan, and makes cost containment options like biosimilar first strategy and GLP1 PA all the more appealing. Nationally generic utilization was 67.5% This is your cue to check that your clients’ plans are set up with the lowest cost alternative & a drug card. 58.7% of people made at least one claim. In 2021 it was 56.3% The avg number of claims/cert was 15.1. In 2021 it was 11.1. More people are claiming, more claims per claimant and a higher cost per claim = a lot more spent on drugs. The avg age of insured has remained almost unchanged since 2008 ranging from 41-43. This isn't a surprise when you look at who makes up the working population Specialty drugs still account for the largest position claims with 1.8% of claimants accounting for 31.2 % of claims. 16yrs ago they accounted for 10% of claims. This has begun to level out a tad partly due to biosimilars, pharmacare and partly because of the highish cost drugs that for common conditions. With the $3-9K category increasing, this pattern will begin to slowly shift. We may even see high cost specialty drugs % of overall claims drop. Drug risk is not just high cost drugs anymore, the abundance of $3-9K drugs are putting pressure on plans. The top therapeutic class is a lot of the usual suspects. But the introduction of a CF drug pushed that into the #9 spot this year. Diabetes is #1 & probably will be for some time. Inflammatory diseases are #2. This is RA, Chrome's etc and make up a good portion of the high cost specialty spend It's interesting too look at the 2008 data. This was prebiologics and a lot of the treatments we have today that are so impactful to people's lives were not available and pooling thresholds were still under $5000. In 2008 the top 5 was diabetes, depression, blood pressure, ulcers & cholesterol https://lnkd.in/gF8JVitk?  Here’s why I don’t think the federal plan has had, or will have any impact on employer paid group benefit plans.
Can you imagine an employer cancelling their 80% or 100% plan so less than half of their staff can get 40% coverage? I can imagine a mass quitting. Overall maximums paid have not been revealed. But the upper amount the government was reimbursing before this not robust plan design was reveled was $650 for the folks in the under $70,000 range. Now, for the folks with family income under $70,000, the plan is pretty good. It covers 100% and probably a maximum of $650 per year if we assume they will use the same as the 2023 payout. Honestly not great (that max will get one one cleaning with xrays), but not bad either. Perhaps worth considering cancelling benefits if you’re an employer with lower wage employees if you're confident household income meets the threshold... but how can an employer know that? Here’s the kicker and where advisor advice has been SO important. People are only eligible if they have no access to coverage. Employers who cancel their plan may not even push employees to the government plan. They may just take away COB and cause angry employees. 7/7/2023 I listened to is to you don't have to but should anyway - Obesity: The Science, Impacts and Strategies webcastRead Now In this episode of I listened to it so you don’t have to but should anyway, obesity.
I have been learning about this chronic disease recently, which is a timely learn as we in the benefits industry are navigating new entrants in the obesity pharma space. Recently I listed in on a CPBI session and a very interesting listen from the Maintenance Phase podcast. If you’re not listening to Aubrey Gordon, I highly recommend. There are my notes. Part 1 – From CPBI. Obesity: The Science, Impacts and Strategies webcast Obesity is a prevalent, complex, progressive and relapsing chronic disease characterized by abnormal or excessive body fat, that impairs health. Obesity is classified by the BMI – body mass index Because BMI does not measure body fat directly, it should not be used as a diagnostic tool. It doesn’t take into consideration different body structure. Instead, BMI should be used as a measure to track weight status in populations and as a screening tool to identify potential weight problems in individuals. Of note from the CDC, BMI does not distinguish between excess fat, muscle or bone mass. Nor does it provide any indication of the distribution of fat among individuals. Weight loss can lead to overall health improvements, but weight is not the only indicator of health.
Is obesity only the result of not moving enough and waiting too much? NOPE! Genetics, psychological, social economical, environmental, mediations, and social impacts are all contributing factors. It’s a complex interplay of all of these components. In reality when we’re talking about sustained weight loss (assuming that is the goal) we are talking about chronic treatment. Obesity is associated with multiple complications. It’s likely those living with obesity are also suffering with other conditions like sleep apnea, depression, anxiety, type 2 diabetes, cardiovascular disease and more. The brain plays a large roll in controlling appetite. Reducing your weight and maintaining the loss is complex as your body will try to adjust to new norms. From a relevant article: “Experts often talk about this idea as a metabolic "set point" that can be hard to adjust. Our genes, environment, and hormones all play a role in body size, and complex physiological factors that are still poorly understood can make it tough for many people to sustain weight loss “ I found this super interesting! There are a few kinds of eating –
There are new guidelines for treating obesity. It’s 700 pages long. I do believe this is the study that they break down in the Maintenance Phase podcast which I strongly recommend you listen so. It’s a great critical thinking piece! But here’s what the diagnosis of obesity looks like according to this document that has been widely adopted around the world:
Health care professionals are encouraged to :
Ultimately the what the root cause of obesity is going to dictate what intervention should be used moving forward. Challenges I see with this:
A note on weight bias, 40% of adults reported bias and stigma from family, colleagues, This can increase morbidity and mortality. There is a segment that speaks to medical nutrition. Not to be confused with diet. Diet indicates short term, but medical nutrition is a life long journey. It is meant to set up a person with something that is applicable to their core values and preferences. Plus medical nutrition is culturally sensitive and promotes healthy relationships with foods, ultimately tailoring it to the patients needs. There is also a chapter on physical activity in the report. Its important for multiple health reasons. But once someone has obesity established, we know that exercise has little impact on weight loss. Physical activity can help with other things like pain management. It’s not about weight loss. Plus, it can be used a possible preventative measure. It should not be used as the only outcomes though. Putting it all together there is a comprehensive approach in these guidelines. So after addressing the root cause of obesity, lifestyle recommendations are introduced. They can achieve 3-5% of weight loss. But the actual pillars that are the real interventions are behaviours intervention where the patient is meeting with a therapist or engaging with a counselling. There are also pharmacotherapies – there are 4 approved meds in Canada. Lastly there is surgical intervention which can achieve 30% weight loss. These interventions are not independent of each other. They can be used in conjunction. It depends on the patients needs and the root cause of obesity. How does a doctor determine if pharmacotherapies are right for a patent? Healthcare providers are advised to bring up pharmacotherapies when lifestyle interventions along with tackling the root cause have been ineffective, insufficient or unsustainable. Now here in lies the problem…. First, how often is the root cause actually being addressed and second, people don’t change their habits. This is a huge book industry on habits for a reason… Instead it’s easy to prescribe a new drug for life. It is for life becuse once a person stops taking the drug, they are likely to regain the weight. Because obesity is a chronic disease there is evidence that weight rebounding does happen and it most common in the GLP-1 drug categoey (eg Ozempic) 4 approved drug therapies for the treatment of obesity
These should always be taken with lifestyle recommendations. Pharmacotherapy can help target many of the comorbidities that are often present with obesity where weight loss is helpful such as cardiovascular disease and depression. There are not long-term studies yet. There is some data on people taking the drugs for 1-2 years. But not much past that. End. What do I need to know about the national dental program?
The federal budget highlighted the national dental care program again, providing slightly more details on the future of the plan. Let’s break it down. Currently the national dental care program offers coverage for dental for:
The family income is measured by the income of the total family, not each individual. In Canada the median family income is $90,390. Median is different from average. Median is the middle – it means that half of Canadian families make more than $90,390 and half make less. Using the median income in Canada to qualify for the plan, means half of Canadas will not be allowed to use the national dental care plan. Of the half that are able to use the plan, many will still have to pay to use the coverage. Only those with a family income of less than $70,000 will not have to pay anything for the plan. What’s being covered? (Effective Dec 1 2022) $650 per child with income under 70,000 $390 per child with income bt 70,001 and 79,999 $260 per child income 80,000-89,999 What’s next? Creating a structured list of included and excluded dental services. Right now, it’s a free for all, manual reimbursement. Health Canada is administering the plan, but a Tender for 3rd party payor is in the market, a corporation will be chosen to facilitate the claim reimbursement to the dental office at time of claim. Plans to introduce legislation that will compel employers to report existing dental coverage offered to employees through T4/T4A reporting. That seems like it’s going to be a colossal challenge and probably a mess. Expand the program to people under the age of 18, then seniors and people with a disability, eventually all Canadians. Should employers make changes to their dental program or remove their dental program? This is an individual choice, however, this writer does not recommend dropping dental in favour of this plan. Between the extremely low coverage amounts and large number of uncovered Canadians, there is little incentive to drive coverage away from employer paid dental plans and into the government plan. This plan is designed for low-income families who have no access to care. It’s not designed to replace employer paid dental plans. We hear a lot about the many generations in the workforce. But just how many are there? And what different ages make up the generations? Let’s take a look at some stats Canada data from the 2021 census so we can better understand who is in the workforce.
Youngest to Oldest we have… Gen Z: 1997- 2012. I bet a lot of you have one of these folks at home! This generation is aged 11-26. For context, if you followed the traditional high school, university, get a job – you’re getting that job at age 20-22 depending on your post secondary. These folks are very much in the office and in the traditional post school workforce. Millennials aka GenY: 1981-1996 are middle aged now. The youngest is 27 and the oldest are 42! They are wearing the boss pants and making decisions these days. This population is also the fastest growing (immigration) with 8.6% growth numbers. They also make up the largest share of working age population (15-64). By 2029 they will become the largest generation in the country. GenX aka the forgotten generation are born between 1966 and 1980 which means they are 43-57. Baby boomers: 1946-1965 aged 58- 77 most of them are transitioning into retirement and now are less than a quarter of the total population. I acknowledge that there’s some folks older than 77 in the workforce, but the number is insignificant. There are around Million Canadians aged 77-84. Because the working aged population is defined as 15-64 there is not data on how many of these people are still working. I would venture to estimate that most are working part time and not eligible for benefits anyway. Some other generational considerations:
It’s International Women’s Day this week. What better time to consider how the employee benefit plan can support women – both at work and as dependents.
Specifically let’s target the drug plan
You have the list. Here’s the why Fertility Drugs – I’m not explaining this, it’s obvious. Hormone Therapy – is especially relevant to women in their menopause years. Menopause can be terrible and if you’re a man, I recommend learning more about it so you can better understand what the women in your life may be experiencing and in turn give better advice to your clients. Here’s a great place to start Birth Control and Other Contraceptives – again this should be obvious but it’s worth mentioning that when you remove the cost barrier from products like these you give women body autonomy. Plus, over the course of 20 years, a women can pay $6000 or more for these products. Just imagine if she could have invested that into her retirement instead. Weight Loss drugs – a hot topic these days due to Ozempic. I’m including it because even through more men are obese, historically (according to the HBM+ drug report) women account for 81% of weight loss drug users. Pharmacogenomic Testing – is Pharmacogenomics is the study of how an individual’s genes influence their response to medications. Pharmacogenomic testing can help determine how compatible a patient’s body may be to a particular drug, and helps their physician prescribe the most appropriate medication. The goal is to ensure the right drug is prescribed to deliver the most positive outcome with the fewest side effects. I’ve included this because the majority of women using weight loss drugs also use a drug for anxiety and/or depression. So let’s get them on the right drugs, at the right does out of the gate. Migraine – Again women are the largest user group of migraine drugs - Insert funny gender joke about why – People with chronic migraine literally get their lives back with these drugs. And employers regain a productive and present employee. It’s win-win. Last, vaccines – Vaccines the HPV vaccine which protects against cervical cancer is available for women of most ages now and for some reason women are more likely to develop shingles than men. Workplace Wellness Programs: they feel fun, but aren’t fun for everyone I recently discovered the Maintenance Phase podcase and listed to the Wellness at Work episode. I encourage you to listen to the episode to learn about the history of programs and how they are used in the US often to reduce insurance premiums. Honestly it’s a bit wild. I had a visceral reaction to the first minute learning about mandatory daily weigh-ins in front of all of your coworkers. I’m not talking about that here, instead I’ll share what I have learned with a focus on Canada of course. Workplace wellness is probably one of the broadest terms in the employee benefits space and when an employer claims to have a wellness program it could be as simple as posters in the lunchroom to a complex strategy with goals, objects and an ROI. When you google the definition it’s just as wishy washy “Workplace wellness is essentially any workplace health promotion activity or organizations practice or policy designed to support healthy behaviours in your workplace”. While well intentioned, I learned that wellness programs are often problematic and even harmful. Let me explain. First, in a lot of cases, workplace wellness = surveillance. Think about the data being tracked - from your location to your activity and even your routine. Employees end up sharing private information about their life outside of work hours (that’s none of anyone’s business) during many classic wellness challenges. Second, with fitness challenges like 10,000 steps, you’re asking employees to participate in workplace activity outside of work hours and your activities outside of work now play into they way you are assessed at work. This becomes even more problematic when you consider a huge number of people cannot participate in the challenge due to life responsibilities and that employee may be forced to share this private information they did not want to share with their boss or colleagues. For example, many people will not be able to or want to participate in the challenge for many reasons. Imagine someone working a second job, or someone living with a disability, or someone caring for an aging parent, someone caring for their children, someone in a long distance relationship, someone with a chronic condition. Imagine a colleague casually asking why you’re not participating in the challenge – “come on! It will be fun” they say – forcing the employee to reveal they have XYZ that doesn’t allow them to participate or be judged if they don’t reveal a sufficient “excuse” for not taking part. Third, in a rewards-based program, selection bias is real. People who are already doing the activities are rewarded for behaviour they already do, and the program doesn’t encourage those who are not to begin these activities and participate. Fourth, wellness programs may create and emphasize stigma. “Take the stairs when possible” seems innocent enough, but as the podcast says, “the idea that if fat people just took two flights of stairs they wouldn’t be fat is outrageous”. Obesity is after all a complex illness and we are learning not necessarily related to calories in, calories out. This also makes people feel bad for using the elevator and can drive bullying or a culture where people are judging each others health behaviours and how they look. Bonus – Wellness is often connected to being thin. But there is much more to a healthy body than weight and often one’s weight is not an indicator of their health. It’s worth mentioning that it does seem like having some form of workplace wellness is worth it for employers. Year over year, the Benefits Canada Healthcare Survey finds that employees who have a wellness program at work are more likely to report their benefit plan as quality that the plan meets their needs. The survey also find that employees who view their benefit plan as quality, are more likely to be satisfied with their job. What can you do to make your workplace wellness program feel fun AND be fun for everyone?
Updating Some classic employer wellness perks and benefits that employees value:
Primary care is rapidly degrading and for many finding a family doctor is like winning the lottery. Here's a link to an interesting Twitter thread on this topic.
Virtual care is a valuable component to primary care and is helping to fill the gap, but it’s only used for a handful of things. It’s not meant as a replacement for in person care.
Unfortunately Virtual care has taken a beating recently when our most populated province reduced the fee paid for virtual care visits from $37 to $15. This made the care model not financially feasible for some operators and they were forced to close. While some others now charge a subscription fee making the service inaccessible to many Canadians who can’t afford to pay the fees. I wonder if I’m the long term this will be a net positive as the lower fees will encourage some doctors to return to an in person practice, vs doctors who were taking on extra hours via virtual visits no longer seeing this as a valuable use of time. It feels like some of the virtual care shine is wearing off. I hope this isn’t the case as it’s an extremely valuable service, and one that I personally use and benefit from. Or perhaps we are just at the beginning. There are a lot of smart minds in that space. I think there’s more to discover around how virtual care can be used and incorporated into primacy care, especially within the preventive care space. I hope the primary healthcare evolution will be an innovative and exciting one to watch. In November the Federal Government announced that they will extend the EI Sickness benefit period to 26 weeks from 15 weeks as of December 18, 2022.
At this point, most, if not all insurance carriers have share an update on this. Some with helpful tools. But mostly the updates are light on advice and but there seems to be a need for more. This is because there’s not a set you have to do ABC. The plan sponsor’s decision to change or not change their disability benefits is unique to each organization and decision makers are looking to their group benefit advisor for, well, advice. We have two scenarios to consider:
Let’s get the easy one out of the way first. Short Term Disability Should an employer make changes to their disability plan if there is short term disability being offered – this is either as a stand alone or in conjunction with long term disability. Right now - no. Hang tight for further information. Why you ask? What about the EI rate reduction program? The Feds plan to make changes to the EI rate reduction program and further information will be coming at some point in 2023. Right now there is no obligation to update your plan. You will remain EI rate reduction eligible. Employers who change their program now, will likely end up making changes again in the near future. Before we get into Long Term Disability, first a quick level set is required
I said the EI sickness benefit is first payer twice because it’s an important factor in this decision to change or leave unchanged the LTD. It’s also the reason why the EI rate reduction program exists. Now that we’ve had an EI refresher, we’re ready to discuss LTD In most plans, the LTD is a non-taxable benefit where the plan member/employee pays the premium. Working under this assumption, let’s first tackle the big reason why an employer would choose to aligned the LTD waiting period with the EI payout period. Note 26 weeks is the equivalent of 6 months or 182 days. But, EI has a 7 day waiting or elimination period. So when calculating the LTD waiting period to align with EI this should added, equaling 189 days. The first reason organizations will consider extending the waiting period is SAVINGS! The rate paid for the LTD plan will (probably) be reduced if you change the waiting period aka elimination period from 112 or 120 to 26 weeks (plus 1 week for the elimination), aka 189 days. And who doesn’t like to save money? But how much money are we talking about here? Spoiler alert, not a lot. While I try to be unbiased and neutral here, my opinion is this is not a good reason to change the plan. Let’s look at the math. Assumptions for this illustration: (don’t be a picky panda, this is just quick math to show you why it’s not a lot of savings)
And now the big assumption, this change will warrant a 10% reduction to our $3.00 rate. I’ve seen quite the spread on the require rate reduction, but 10% is an easy number for an illustration, and I prefer to look at a worse case scenario instead of having rose coloured glasses on. First $60,000 – what will an individual employee save with a 10% rate reduction? $3.00 x 10% = $0.30 New LTD rate is $2.70 ($3.00 - $0.30 = $2.70) $60,000 x .667 / 12 = $3335 of monthly benefit Cost of LTD at $3.00: 3335 x 3 /100 = $100.05 Cost of LTD at $2.70: 3335 x 2.70 /100 = $90.45 Monthly savings is $9.60 (100.05 – 90.45) Savings per pay assuming biweekly pay schedule is $4.43 I know that life is expensive these days, and I know people are looking for ways to save money. But this isn’t it. $9.60 per month is not a meaningful amount. Are some people struggling to the point that this amount would help? Yes, I’m sure there are. But overall, $4.43 isn’t going to be noticed on one’s paycheck. Second $150,000 - what will an individual employee save with a 10% rate reduction? $3.00 x 10% = $0.30 New LTD rate is $2.70 ($3.00 - $0.30 = $2.70) $150,000 x .667 / 12 = $8338 of monthly benefit Cost of LTD at $3.00 8338 x 3 /100 = $250.14 Cost of LTD at $2.70 8338 x 2.70 /100 = $225.13 Monthly savings is $25 Savings per pay assuming biweekly pay schedule is $11.53 In this scenario, the savings are slightly noticeable at $25 per month. But $25 a month still isn’t significant, especially when your individual income is $150,000. Now that the math is out of the way, what other reasons are there to keep the LTD as is with a 112 or 120 day waiting period:
Last up, let’s make the case to change the LTD waiting period to 182 days. Besides the small cost savings, there are two significant scenarios to consider:
It is possible that for some group benefit plans, EI offers a higher benefit amount. This will be employers with the bulk of employees at a salary much less than $60,300 (remember we have to take into account the LTD benefit percent is higher than EI and there is no tax owed). OR you have a group where the NEM is low and no one, or mostly no one has applied for excess coverage. Small Businesses – I’m looking at you! LTD NEM’s on groups with less than 10 lives could be as low as $1000 - $1500. $1000 a month, is a lot less than $638 a week. Group Benefit Advisors, this is a great time for proactive communication to plan members to encourage them to apply for their excess coverage. Imagine how defeated an employee, who is struggling with a disability, would feel when they have applied for LTD, they think they have $3000 of coverage, only to find out it’s actually half of that. The good news here is, EI could top up these individuals to the weekly maximum. If you don’t change the LTD waiting period to align with EI, there will be about 3 months of overlap between EI and LTD. Since LTD is the first payer, the disabled individual will need to let EI know of this source of income when approved. If they do not notify EI, EI will continue to pay the disabled person which will create an overpayment. This overpayment is not a gift from the government. It will need to be paid back with interest when the individual files their taxes or when the government becomes aware of the overpayment. Which ever happens first. This situation will happen. But I think it will be infrequent for a number of reasons. First when you’re on EI you have access to the portal to update your situation, and you’re generally in contact with them. So there are natural opportunities for updates. Second, the insurance carriers will put protocols in place to help prevent this situation. At Equitable Life for example, their case managers will let employees know that they need to inform EI of their disability payments, plus they will include this info in the letters sent to the employee. I’m sure other insurers are putting similar protocols in place and over time this will become smooth sailing. This is also an opportunity for the group benefit advisor to help their clients put their own disabled employee communication protocol in place. What other reasons are you discussing to change or not change? I love nothing more than a good top ten list and I also love a good drug report. So, I combined the two! Presenting my top ten takeaways from the 2022 hbm+ Drug Trends and Strategic Insights Report. You can reap my full recap here. Following drugs trends are important as drugs drive the majority of the claims cost in an employee benefits program.
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