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

1. Fertility Drugs
2. Hormone Therapy
3. Birth Control and other Contraceptives
4. Weight Loss Drugs
5. Pharmacogenomic Testing
6. Migraine
7. Vaccines

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?

1. Make the wellness program voluntary and results private. This will help with the surveillance issues and disclosing of personal info.  
2. Make the wellness program inclusive – take a beat to think about your employee population. Do you have employees living with a known physical disability or other accommodation?
3. Consider that you will 100% have employees whose personal lives and struggles and background you know little to nothing about. Think about the many invisible chronic illnesses and invisible disabilities and be mindful of how what you put in place could make these employees feel.
4. Be mindful of those living with, or in recovery from an eating disorder or a chronic illness like Crohn’s, and IBS. Food based challenges can be triggering and exclusive for this employee population.
5. Focus on more than eating and moving as wellness is about a lot more than these two items. What about smoking cessation? Quitting drinking? Health screenings? Confidential health risk assessments? Mental health? Financial health?
6. Don’t discount the value of education. Bringing health experts in to share information on identifying symptoms of common chronic illness or other health topics (not related to food and weight) is a great component of a wellness program.
7. Be mindful that when you attach rewards for completing a health behaviour you may exclude people. For example, someone allergic to ingredients in the flu shot cannot receive the reward for getting the shot and again could force them to reveal personal medical information to their employer.

 
Updating Some classic employer wellness perks and benefits that employees value:

1. The pizza lunch – instead of ordering pizza for everyone, or sandwiches for everyone, choose a location with a variety of options and let people choose their meal.
2. Free food – nothing wrong with the free fruit basket and making it easy for employees to grab a healthy snack. Improve this by adding variety like cut up veggies to the mix.
3. The beer keg – it could be time to rethink having it. Now I love a good beer don’t get me wrong and the afterwork beer can help drive work friendships and culture. But the culture around drinking in Canada is problematic and we know the negative health impacts of even a small number of alcoholic beverages per week.
4. Flu shot clinics – ensure the space where the shot is being administered is private and that the sign up list is as well.
5. Massages at work – ensure that the massage space is private and employees are not penalised for having the massage during work hours.
6. Health Risk Assessment – again ensure that the results are confidential to the employee and that the assessment is more than BMI based.
7. Renovating? Build the office to naturally support what people are doing already in their life such as having bike storage, showers and lockers to encourage active commuting. Free coffee, tea and water. Quiet rooms, with the ability to change the lighting so people can have a nice break.
8. Share the various programs built into the benefit plan and how to access them.
9. Have flexible working hours and locations so that people are able to see their health practitioners in the 9:5.
10. Be mindful of time zones. Hosting a lunch session in Ontario but have employees in BC? Don’t call it lunchtime yoga, or a lunch and learn or a lunch and whatever. 

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:

1. There is short term disability on the plan – with or without long term disability
2. There is not short-term disability on the plan, but there is long term disability on the plan

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

1. The EI sickness benefit is second payer. It does not offset the group benefit disability plan.
2. The group benefit plan is first payer (in some cases). If the EI sickness benefit is available and the group benefit plan is available then the group plan will pay and EI will top up (an unlikely situation but possible if a plan member has a low non-evidence maximum and did not apply for excess coverage).
3. The EI benefit is 55% of one’s average insurable weekly earning up to a maximum of $638 per week. This is the equivalent of an annual salary of $60,300
4. Recipients of EI pay income tax on the benefit received as this is a form of income. It is not deducted at the source and taxes will be owed upon filing the tax return.

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)

• The LTD rate is $3.00/100 of volume
• First we’ll run a $60,000 salary illustration to align with the average Canadian income assumptions made by EI. And then a high-income earner at $150,000.
• There is no NEM or that excess insurance had been applied for and approved.
• $10,000 benefit maximum
• Keeping the payment formula simple – 66.67% of monthly income and…
• Let’s forget the all-source maximum is a thing.

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:

• There is value in early intervention and disability management with the insurers. The longer a person is off work, the more challenging it is to return to work - As they say in Game of Thrones “It Is Known”.  Longer duration periods mean larger reserves and could increase the LTD rate in the long run.
• Insurers also provide resources like rehab programs, pharmacogenomics, and more to assist in the return to work. I’d also venture to say an insurers’ fraud detection is better than EI’s.
• After the 6 months, or 26 weeks is up with EI and the individual begins their application for LTD, can you imagine how difficult it will be to collect the medical information required to have your LTD claim approved? There could be an increase in declined LTD cases due to a lack of medical documentation during this time off.
• The LTD benefit in most cases pays more than EI. Again, EI is taxable and 55% (up to a maximum annual earnings of $60,300). Whereas LTD is mostly non-taxable at 66.67% or some graded formula to limit the impact of the all-source maximum. When LTD is taxable, often the benefit will be increase to 75% of earnings. Take our $60,000 earner, on LTD their benefit is $3335 a month or $769 per week. No tax owed. Compared to EI which is $638 per week and you have to pay tax on it.

 
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:

• The EI benefit pays more than the LTD.
• This is the big one – someone has to tell EI to stop making payment!

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. 

1. Page 6 and 7 of the report have client friendly drug terminology that’s an easy sharable item. Maybe if someone asks HBM+ they will make this into a client sharable PDF. Or even social medial sharable images. Hint hint.
2. Biosimilar use is growing and there is a huge opportunity for plan sponsors who prioritize biosimilar use to save on drug costs. We can look to BC for proof in the pudding. BC
3. Proactively helping employees live a healthy lifestyle can save employers a ton on drug claims. Overall health expenditures for claimants with diabetes reached $469 million in 2021 with an average claimant cost of approximately $3,321. I’m typing that again. With an average claimant cost of $3,321. As an employer, if you can prevent even just one employee from developing type 2 diabetes, it will have a significant impact on your drug claim costs. Plus, the costs saved from all the other stuff connected to a person having diabetes. But as pointed out recently by the New York times, there is no device or drug powerful enough to counter the effects of poverty, pollution, stress, a broken food system, cities that aren’t walkable and inequitable access to healthcare.
4. Drug costs aren’t bad, you’re helping people take their lives back. Migraine drugs are a great example of this.
5. CF drugs are a plan killer but incredibly meaningful to the lives of the people who need them.
6. Something about digital pharmacy
7. The $5000-$9999 drug cost interval had year over year growth of 17.1% this is a cost sustainability killer category.
8. Due to there being 40% more claimants (taking new biologics like Aimovig, Ajovy, Emgality) total migraine drug cost jumped by 53% These drugs fall into the $5000-$9999 drug cost interval.
9. Society has had a hugely negative impact on women’s body image, and we see a direct result of this with women over age 24 make up 81% of the claimant population and 45% also using drugs for mental health
10. If you want to support women in the workplace offer digital pharmacy, migraine drugs and Lifestyle drugs.

Download your own copy of the report here

6In this addition of I read it so you don’t have to but probably still should is the hbm+ Drug Trends and Strategic Insights report. You know I love a good drug report and hbm+ shares insights to help guide conversations with employers about their employee benefit plan.
 
Before I get into my recap here’s my top 3 takeaways for those of you who can’t be bothered to read for 8 minutes. And if you click here, I drop my top 10.

1. Page 6 and 7 of the report have client friendly drug terminology that’s an easy sharable item. Maybe if someone asks hbm+ they will make this into a sharable PDF. Or even social medial sharable images. Hint hint.
2. Biosimilar use is growing and there is a mega opportunity for plan sponsors who prioritize biosimilars to save on drug costs. We can look to BC for proof in the pudding.
3. Proactively helping employees live a healthy lifestyle can save employers on drug claims. But as pointed out recently by the New York times, there is no device or drug powerful enough to counter the effects of poverty, pollution, stress, a broken food system, cities that aren’t walkable and inequitable access to healthcare.

 
Getting into the recap – I took 71 pages down to 6 pages. You can do it! This data is drug costs adjudicated by hbm+
 
Year over year growth in drug spend has increased 42.8% since 2017 with total drug costs rising from $1.4B to $2.0B that’s B for billion.
 
Part of this increase is due to the number of claimants increasing from 1.9M to 2.1M. The rest is due to the number of claims per claimant rising to 14.2 in 2021 from 11.9 in 2017 as well as the cost per claim increasing. However, the cost per claim has only increased by 6.25% since 2017 where it was $64. In 2021 it’s $68. For those who want to do that math 2.3 claims x $4 = and extra $9.2 per person.
 
Specialty drugs make up 0.64% of claims. Pharmacare provinces like BC, Sask and MB are well below average with ON leading the way in spend here.
 
As per usual, a small number of claimants make up a disproportionately large share of overall spend.
 
I think we’ll see this small number increase as more higher cost treatments becomes available for regular conditions. Right now, the top 5% of spenders have an average annual claim cost of $10,538. We could see this creep into the top 8% or 10%. The bottom spenders clock in only $466 of annual spend. We’ll see that number creep as well.
 
Diabetes, in particular had a different dynamic in the two categories; it represented the second-largest share of drug costs in the top 5% claimant group, compared to the tenth-largest share in the top 1% group. This was due to the high prevalence of the disease, paired with an escalating cost of treatment per patient driven by utilization of newer drugs.
 
I’m breezing over some of the next data sets as it reinforces the data from TELUS Health and Express Scripts. The share of generic drugs could be higher. There’s room for improvement. The top therapeutic classes are RA/Crohn’s, MS, Diabetes, we’re seeing a huge increase in ADHD drugs (for adults). Mental Health drugs are prevalent and Cancer drugs have new treatments enroute. Due to the pandemic, we saw claims for pain meds and infections drop.
 
An important topic and something that drug usage can give a client good insight to is employee mental health. The report shows that anxiety/depression prevalence rate by age group in 2021 was over 25% across the board for people aged 25-64. A clear indication that proactively providing mental health resource should be top priority. But not only providing them, but also communicating that they are there, what they are for and how employees and their families can access them. Beyond that, creating a psychologically safe workplace and tackling the root cause of mental health issues is important for employers. Burnout, workloads, culture etc. are all under the microscope.
 
Specialty drug spend growth slowed down a bit compared to previous years, but it’s not time to be complacent. In a 2021 report by the Patented Medicines Price Review Board (PMPRB), 31 late-stage new medicines were identified based on their potential to significantly impact the Canadian health care system, with some of these medicines potentially offering breakthroughs in treating previously unmet needs or having the potential to treat large patient populations - five new medicines are forecasted to reach annual global revenues over $1 billion by 2027.
 
Biologic drugs are the main contributors within the specialty drug category accounting for 66% of the cost.
 
But guess what? There’s a way to reduce spend in this category. Biosimilars. Since 2014, more than 29 biosimilar products have been approved and marketed in Canada. Biosimilars present comparable safety and efficacy to their originator products but at a significantly lower cost with many of these drugs costing a fraction of the original biologic drug.
 
Biosimilar transitioning policy under provincial health care plans have now been launched in British Columbia, Alberta, New Brunswick, Quebec, Northwest Territories, and Nova Scotia. (Sask just announced) These policies have driven biosimilar adoption but due to the timing of implementation, there are dramatic differences in biosimilar penetration across the country, with a strong west-to-east gradient.
 
Moving away from specialty drugs, the two fastest growing claimant-cost-interval categories in 2021 were the $1,000–$1,999 and the $5,000–$9,999 intervals. Take notice of the 17.1% growth in the $5000-$9999 category. This claim category can have significant impact on plan experience and long-term plan affordability as is it below most pooling thresholds.
 
Traditional tools, such as prior authorization, continue to be an essential element of drug plan management, but equally important are disease-based case management approaches. In a case management framework, claimants with specific chronic diseases, such as high cholesterol and diabetes, work with a case manager one-to-one to manage all aspects of their disease, including medication adherence, diet, and exercise among others. Ensuring that drugs in these categories are not used for off label conditions is also an area to focus.
 
I want to highlight two categories in this spend category – migraines and elevated cholesterol.
 
Migraines: Due to there being 40% more claimants (taking new biologics like Aimovig, Ajovy, Emgality) total migraine drug cost jumped by 53% These drugs fall into the $5000-$9999 drug cost interval.
 
Elevated Cholesterol: Total drug cost for elevated cholesterol medications grew by 16.5% due to an increase in Praluent and Repatha. This noticeable growth was mainly thanks to greater claimant utilization, which increased by 17% from the previous year.
 
While the cost to migraine management is high, the benefit can easily outweigh this cost. Employees who suffer from migraine will get their life back. They will be more productive; they will be less absent.
 
Total costs for claimants in the $1,000–$1,999 cost interval grew by 19% over the past five years due to consistent double-digit claimant growth. Diabetes is the significant cost driver accounting for 57% of the total drug-cost growth in 2021. This increase can be attributed to the greater expenditures for Ozempic, which rose by 67%
 
It’s important to note that drugs like Ozempic are sometimes used off label (when a doctor prescribes a medication for use that is not approved by health Canada) for weight loss. Employers wanting to limit off label use for this drug category can use prior authorization as a tool.
 
Enough of looking into the rear-view mirror! Let’s get into the emerging trends
 
hbm+ has identified the following emerging trends: digital pharmacy. Diabetes, (I’d call this a continuing trend), Obesity, Cystic Fibrosis, and the Drug Pipeline.
 
Trend #1 Digital Pharmacy - several new digital pharmacy start-ups entered the Canadian marketplace, including PocketPills, Pillway, Mednow, Health Depot, and others. Digital pharmacies rely on the same model of drug distribution as “mail-order” pharmacies, but they elevate the patient experience to a much higher level, including connections through web and mobile applications combined with home delivery of medications.
 
The number of claims for non-specialty medications obtained through digital pharmacies grew 55.8% in 2021.
 
Delving a bit deeper into the dynamics of the traditional versus digital pharmacy models reveals some interesting trends:

• First, digital pharmacies charge lower dispensing fees than their traditional counterparts – on average under $8 per prescription compared to $9–$11 for traditional pharmacies.
• Second, digital pharmacies tend to dispense larger quantities (days’ supply) of medications compared to traditional pharmacies – on average 54 days per claim compared to 36−51 days for traditional pharmacies

 
Caution rant incoming: I need to add some colour here. The disp fee is not the be all end all to lower costing drugs. The dispensing fee makes up just one of many parts of thee and cost of the drug. Some carriers, namely the blues and Sun life have drug look up tools. Here’s the Pacific Blue Cross tool. These tools will tell you the whole cost of your drug at different pharmacies.
 
I use a digital pharmacy and my drugs actually cost more through the digital pharmacy than they would if I walked down the street to my local brick and mortar pharmacy. And they cost WAY more if I felt brave or wanted a $1.50 hot dog and went to Costco. But I don’t use the digital pharmacy to save money. I use the digital pharmacy because it’s convenient and it saves me time.
 
I’m telling you this because there are coinsurance incentives out there that drive plan members to use a digital pharmacy in exchange for a higher reimbursement level. I.e., go to brick and mortar pharmacy drugs reimbursed at 80%, go to digital pharmacy and get reimbursed at 90%. Despite a maybe lower dispensing fee, the additional 10% reimbursed could mean that overall drug claims increase, causing rates to increase more than if that program was no in place. Good drug analysis of the top DINs and discussion around the possibility of claims increasing with a program like this is necessary so employers understand the pros and cons. Digital pharmacy is not a miracle cost saver. End rant.
 
Back to our program. 

It is interesting that digital pharmacies are dispensing a larger quantity compared to brick and mortar. This will over time slightly reduce the number of times a drug is dispensed. It could possibly increase drug adherence, or it could increase wastage.  ON has the largest concentration of digital pharmacy uptakes, followed by Quebec and BC.
 
The report goes on to say that maintenance medications for chronic disease are an ideal category for distribution through digital pharmacies given the predictable nature of dispensing, compared to medications used to treat acute conditions which are often required on short notice.
 
The top disease states among patients utilizing digital pharmacy are:

• Anxiety/depression (this makes so much sense – you don’t have to leave the house; low barrier access is a really good thing here)
• Hypertension
• Birth Control (this indicates to me that women are early adopters! And they probably like the auto refills).

 
Onto Diabetes, trend #2
 
The number of claimants taking diabetes medication has been on the rise for years. That’s why I flagged this as an ongoing trend, vs an emerging trend. An estimated 141,000 claimants were using at least one diabetes medication in 2021,
 
Diabetes prevalence rate has increased. Overall health expenditures for claimants with diabetes reached $469 million in 2021 with an average claimant cost of approximately $3,321.
 
I’m typing that again. With an average claimant cost of $3,321. As an employer, if you can prevent even just one employee from developing type 2 diabetes, it will have a significant impact on your drug claim costs. Plus, the costs saved from all the other stuff connected to a person having diabetes.
 
The effort put into keeping employees healthy is worth it.
 
The report goes into detail on the spend in different diabetes drug and treatment classes. I will recap only this: While the mainstay of treatment for diabetes remains metformin, there are a variety of new medication classes that have been introduced in the market over the past 10 years. In particular, the SGLT-2 inhibitors and GLP-1 receptor agonists medication classes have risen dramatically in utilization. These drugs cost significantly more than tried and true metformin.
 
If anyone is curious about the Diabetes Canada guidelines around drugs, prevention, physical activity etc. you can find it here.
 
Traditionally patients have relied on test strips to monitor blood glucose, but highly convenient continuous glucose monitoring (CGM) and flash glucose monitoring (FGM) devices have been introduced on the market. They are obviously becoming more popular and do come with a heftier price tag.
 
The average claimant cost of CGM/FGM devices reached nearly $2,000 in 2021, which was more than six times the average test-strip claimant cost. Younger claimants made up a significant portion of the CGM/FGM diabetes claimants – about 40% of the CGM/FGM claimants were less than 45 years old,
 
Diabetic patients typically suffer from additional comorbidities. In particular, 47% of diabetic claimants’ total health expenditures were for medications to treat non-diabetic conditions. On average, each claimant spent $1,558 on non-diabetic medications.
 
The cost of diabetes goes beyond drugs. Outside of the top five EHC services, diabetes medication claimants had much higher levels of spending and much higher prevalence rates than non-diabetes medication claimants on lancets, stockings, optometric diagnostic services, and braces. Greater use of these services is likely due to diabetes-related complications.
 
Trend #3 Obesity.
 
Obesity is a chronic disease typically characterized by accumulation of excess body fat which can have a negative impact on overall health and quality of life. There is a very strong genetic component to obesity with an estimated 70-80% of body mass index (BMI) determined by genes. About one in four Canadian adults are obese, with a higher prevalence among males than females.
 
There is widespread misunderstanding of obesity today, with a common belief that it is purely due to lifestyle factors such as diet and lack of exercise. Unfortunately, this misunderstanding translates into how private drug plans consider obesity treatments, and in particular, anti-obesity drug therapies. Historically, these drug therapies were lumped with smoking cessation and infertility, into a category called “lifestyle drugs.” The underlying philosophical assumption has been that these conditions are due to life decisions made by individuals, and as such, the treatments for those conditions should not be reimbursed through benefit plans.
 
There exists an opportunity to streamline the coverage of these drug therapies to coincide with today’s more modern understanding of obesity.
 
From a drug therapy perspective, there are four Health Canada approved treatments: Xenical, Saxenda, Contrave, and Wegovy. Notice that Ozempic is not on this list.
 
Utilization of obesity medications has escalated substantially in recent years, including a 29% increase in claimants in 2021. The average claimant cost is $1800 and women over age 24 make up 81% of the claimant population. There’s a whole lot you can unpack about the impact of society on women in that stat. We won’t go there today.
 
Again, a lot of societal impact here that you could unpack. In looking at comorbidities among obesity medication claimants, mental health was the condition with the highest prevalence rate. Nearly 45% of the obesity medication claimants also used mental health medications in 2021.
 
Trend #4 Cystic fibrosis (CF)
 
CF is a genetic disease that occurs when a child inherits two defective copies of the gene responsible for CF, one from each parent. It is a multi-system disorder that produces a variety of symptoms including persistent cough with productive thick mucus, frequent chest infections, which may include pneumonia, and bowel disturbances among others. Traditionally, CF was treated mainly with supportive therapies, but over the last decade, a number of drug therapies were approved that treat the underlying cause of the disease,
 
The larger CF population, combined with the $306,000 annual treatment cost invites questions about the affordability and sustainability of private drug plans in light of this and other ultra-high-cost drug therapies. There were a total of 100 claimants that used these CF treatments in 2021 with the total drug cost of $14 million.
 
Almost there! Trend #5 the Drug Pipeline.

• Obesity has some good stuff happening that will cost about $5000 a year.
• COVID-19 related therapies are being developed. Private drug plans are largely shielded from the cost of these drugs…. For now.
• Alzheimer’s Disease  - the report shares that over 747,000 Canadians are living with this disease or another form of dementia. They acknowledge the ongoing controversy around Aduhelm (Read this and then google Aduhelm for all the details). Long story short, Aduhelm will not be available in the Canadian marketplace.

 
And that’s the recap.  
You can download a copy of the report here

I read it so you don’t have to but should anyway– Striving for balance, advocating for change – The Deloitte Global 2022 Gen Z and Millennial Survey

This survey connects with respondents around the globe to gauge their views about work and the world around them. Let’s dig in!
_________________________________________________________
The recap is that people feel burnt out but are still pushing - taking on second jobs and pushing for more meaningful and flexible work. The executive summary is excellent and a really quick read – if you read anything read that.

This year’s survey found that Gen Zs and millennials are deeply worried about the state of the world and are fighting to reconcile their desire for change with the demands and constraints of everyday life. They are struggling with financial anxiety, while trying to invest in environmentally sustainable choices. And they are pushing their employers to be more proactive in the fight against climate change.
 
The report is broken into 4 categories:

1. Struggling with the cost of living and financial concerns
2. The great resignation signals a breaking point and an opportunity to reassess how we work
3. Prioritizing sustainable choices and environmental action by employers
4. Workplace mental health continues to be a challenge

 
Aligning with Gen Zs’ and millennials’ values is key. Nearly two in five say they have rejected a job or assignment because it did not align with their values. Meanwhile, those who are satisfied with their employers’ societal and environmental impact, and their efforts to create a diverse and inclusive culture, are more likely to want to stay with their employer for more than five years.
 
90% are making some effort to reduce their own impact on the environment and many are willing to pay more to make sustainable choices. They want businesses, and their own employers, to do more. Only 18% of Gen Zs and 16% of millennials believe their employers are strongly committed to fighting climate change. Gen Zs and millennials want to see employers prioritize visible climate actions that enable employees to get directly involved,
Employers do seem to be making progress when it comes to prioritizing mental health and well-being in the workplace. More than half agree that workplace well-being and mental health has become more of a focus for their employers since the start of the pandemic. However, there are mixed reviews on whether the increased focus is actually having a positive impact.
 
The cost of living is the top concern among Gen Zs and millennials followed by climate change. After that, top concerns change between the two generations. The younger cohort are concerned by unemployment, mental health, and sexual harassment. Personally, I’m glad to see sexual harassment on the list as is shows a lack of tolerance for historical bad behaviour and makes me hopeful for systematic change in this space. Millennials are concerned about their healthcare and disease prevention. This is a signal to employers, and something that the employee benefit plan can tackle.

With large portions of these generation taking on second jobs and with 47% living paycheck to paycheck it’s not a surprise that burnout is high. 26% and 31% are not confident they will be able to retire with financial comfort. There is an opportunity for employers to make these generations feel more secure by offering a Group RRSP program with contribution matching or a Tax free spending account where they can use the funds to repay student loans.
Respondents also shared that working remotely has helped them save money.

The way things were, is not the way things are.
Loyalty to the employer is waning.
"would like to leave their jobs within 2 years"

• 40% of Gen Zs
• 24% of millennials
• only 23% of Gen Z plan to stay in job for 5 or more years.
• education, training and internal opportunity for growth and promotion are key to retention

 
Public facing industries are especially at risk for high turnover and industries such as consumer and retail are already experiencing labour shortages. But what can employers do to attract and retain talent?

When people feel their voices are heard, they tend to feel more connected and loyal to their organizations.
 







​You can’t EAP your way out of burnout: 53% of Gen Zs and 51% of Millennials agree that their organization talks more about mental health now, but this has not resulted in any meaningful impact on employees. Only about 1/3 said they would not feel comfortable speaking openly with their direct manager about feeling stressed or anxious or about other mental health challenges
 
If you’re not addressing the core issues of burnout – work loads, feeling of purpose and feeling valued, no amount of mental health communication will help. When most respondents top source of stress is financial, employers need to do more than offer a few mental health resources. They should assess if their total compensation packages are meaningful
 
One of the most direct actions organizations can take to address wealth inequality is to focus on supporting their own people. By understanding employees’ priorities, organizations can align benefits and compensation accordingly. Low hanging fruit could be increasing the employer paid portion of the group benefit plan or adding a healthcare spending account.
 
Another key factor is focusing on closing the pay gap, which will include working to ensure that women and minorities are represented at all levels, and that they have equal opportunities to grow.
 
End.

Risks in employee benefits – what is the cost of doing nothing and why is no one updating their employee benefit plan? (This is a long one!)

Let’s talk A little about change, everyone’s most beloved activity.

Doing nothing is easy. Doing nothing is all about change. And Not changing seems easy.
Historically in the benefits biz, change has been driven by outside forces. not by innovation from within. Pharma manufacturers releasing high cost drugs for rare disease, pharma releasing high cost drugs for less rare disease. Employer pressure in Alberta for more tools to compete for employees. Supposed disrupters, COVID, consolidation, government policy, the list goes on. COVID for example has pushed the insurance digital revolution forward at least 5 years.

External change drivers are a risk as it puts the group benefits industry in a position where it’s reacting. We’re passengers in the change vehicle instead of drivers. Group Benefits Insurers and group benefits advisors need to become drivers and I think we are seeing the beginnings of this.

Back in 2016 when Canada Life was still GWL, they told the people attending the Benefits Canada’s Face-to-Face Drug Plan Management Forum the 90% of their clients hadn’t changed the design of their drug plan during the last 10 years. I guarantee you, six years later that this stat is unchanged.

Don’t believe me? Here are a few more stats. The Gallagher Driving Data with Decisions Survey found that 62% of plan sponsors have no plans to make updates to their benefits programs. Let’s give that more weight. In a weird coincidence, the 2022 Benefits Canada Survey also found that 62% of employers made no changes to their benefit program. And of those who did, 7% reduced their benefits.

Why is this? Why aren’t employer making simple updates to their benefits program? Why as an industry are we letting outsiders drive change?

The book Stop Selling and Start Leading nicely lays out this journey. I’m going to use the term buyer now. The buyer is different depending on the context. As an insurer, the advisor is the buyer, maybe the plan sponsor too. For an advisor the plan sponsor is the buyer. You perhaps you’re reading in the context of being the buyer.

When we sell, and when we propose options to people what we’re doing is asking them to change. We all have a limited amount of bandwidth which means we need to factor in which actions are worth doing. This is part of why the status quo is so appealing.

Thinking about the change journey, First the buyer will need to convince others inside her organization about the choice. That may involve conflict, debates, tradeoffs, promises and uncomfortable questions. 

Next the buyer will need budget approval. that choice to allocate a portion of it to your solution means foregoing some or all of something else. This means saying no other others who are advocating for those resources. It may mean severing ties with another vendor who also has a relationship and history with the company.

Once everyone is convinced and the budget is approved, there’s even more work to do. The buyer must coordinate or delegate all process, staff training, alignment, and set up.

The buyers decision will be scrutinized. And they will have to deal with push back and complaints that come with change. All this requires the buyer to take risks, to dedicate time and energy to the change and to disrupt other work. 

No one makes those kinds of sacrifices unless they feel competent, confident and committed. We need to create the conditions for buyers to feel supported and enabled.

How does one accomplish this? By Being available, being responsive and being respectful.

Be available – you’re the quarterback between the client and the implementation team. Educate, explain and answer questions. Keep everyone connected. Set expectations early and check in on them often. The buys needs to absolutely understand what is going on.


Next Be responsive. If the buyer has concerns or doubts, don’t take them lightly.  Confidence gaps can derail a project.  Listen closely to pick up subtle clues
Last, be respectful – two way dialogue that allows your buyer to participate in creating what they want so they will have a sense of ownership.

People embrace new behaviors when the current behavior is really not working for them. The status quo becomes so uncomfortable that you feel compelled to break the inertia and try something new. 

We can get people to embrace new behaviours by offering a unique perspective on their business. Our insights have to be so compelling that the client is willing to go through the pain of change. Because we are selling change.
The goal isn’t to convince a buying group to buy a solution. It is to persuade them to change their behaviors.  
 
I think we understand why people don’t change. What are the risks of not changing? It comes down to money and time. Money First. It’s simple you’re spending more money than you have to because of:

• Employee Turnover – if the plan isn’t relevant to employee’s current needs it’s just one more reason for them to loop for a new job. The cost to replace an employee can range from 90% to 200% of the employee’s salary.
• Drugs - paying for drugs the province can, paying too much for drugs (i.e. brad vs generic and more expensive drug when a lower cost one will work, or a drug being used for something other that it’s indicated use – ie botox for cosmetics instead of migraine)

What about the risk of losing money? Group Benefit advisors could be at risk of losing a client if you’re not at a minimum reviewing client plans, financial arrangements and then advising them on updates. In the drug space alone there’s lots to be reviewed and discussed.
 
Time. It’s likely that you’re using up precious bandwidth and spending time doing things you don’t have to

• Yup employee turnover makes the list again. A massive amount of time goes to posting job ads, interviews, and retraining. Now don’t take my training comment the wrong way, I’m a big believer in continuous learning and improvement and growth. But high turnover means you have employees putting their time to training new hires instead of upskilling and doing their jobs. You’re laso increase the risk of employee burnout and productivity loss.
• I bet that paper is costing a lot of people time. If you’re still with an insurer who has not embraced modern new hire enrolment, claim submission and more it’s time to make a change.
• Bad service is one of the worst time wasters of all. Service and the user experience should be a major consideration when choosing a group benefits provider.

 
While we’re on the topic of risk and change I’ll leave you with a few other risks to ponder.

• A lack of communication – for the plan sponsor it’s a liability. When does the duty of care kick in? If people don’t know what benefits they have they cant use them. Think of a CI claim never submitted. There’s lots of other nitty gritty plan offerings that are under utilized like iCBT being claimed. Or pharmacogenomics. If people don’t use their benefits when they need them, they could become seriously ill or maybe even disabled.
• New entrants into the market - who will they be, how will they shake things up?
• Risks we don’t know about because we cannot fathom that it exists. Imagine telling someone about crypto currency or NFTs in the 1990’s.  Imagine describing social media to someone in the 80’s. This means there are also solutions we don’t know about or are not using. Think the HSA before League entered the market.

 
 End.

In this  past post I shared the Benefits Canada Healthcare Survey findings that employees who view their group benefit plan as quality are most likely to report also being satisfied with their job. The group benefits survey also finds that employees who are healthy are also more likely to find their group benefits meet their needs and also repot being satisfied with their job.

The group benefits survey also finds that employees are looking to their employer to support their physical, mental and nutritional health.

But who is responsible for employee health?

Employees seem to think their employer is. And a case can be made that it’s in an employer’s best interest to keep employees healthy.

One must acknowledge that personal health is always to some degree the responsibility of the individual. But as individuals the info we receive (and “research”) is often conflicting and confusing. Again employees look to their employer to vet vendors and information so they can consult trusted sources without hours of googling.
 
What about the government? Aren’t they responsibly for healthcare? Well yeah. The federal government made it their job to keep us healthy with the Canadian Health Act but have failed to live up to that promise. With family physician access akin to winning the lottery in some cities, wait times for specialist getting longer and longer, emergency centers closing and some people unable to afford drugs or dentalcare without an employee benefit plan, the burden of healthcare is for better or for worse seemingly shifting (shifted?) to the employer.
​
If employers have by de facto become responsible for keeping working Canadians healthy, the next question is can they afford to continue to do so? And how will group benefit plans evolve to solve this?

This isn't a group benefits blog post. It's more of a work perk, culture, burnout, examining why society is clinging to a work structure that's no longer working.  I suspect it has a lot to do with not wanting to change and internal bias.  I did a blog post about risk and change that applies to this situation. 

We’re at a space in time where the classic 9-5 is being revaluated. Are there better ways to work? One of the ways being tested around the world is the 4 days workweek. Most think of this as a 32 hour week, not 40 hours condensed into 4 days. But that is an option being tested and applied as well. There’s other ways to rethink the 9-5, flexible working hours is one. But here I recap some of the findings on the 4 day week.

Recently in the news was an update on the worlds largest trial of a 4-day workweek. Back in June over in the UK, over 3300 workers across 70 companies are taking part in the trial that gives workers 100% ay for logging 80% of their normal hours.

Previous to this, Unilever, Panasonic, and Microsoft all did their own trials with great success. Microsoft said it’s experiment saw productivity surge 40% Iceland famously trialed the 4 day workweek with over 2500 public sector workers and it was an overwhelming success. the results found that a reduction of working hours maintained or increased productivity across all sectors in the economy. The findings also indicated improved wellbeing and work-life balance among workers.

In 2018 a trial at Perpetual Guardian in New Zealand found engagement levels rose between 30 and 40 percent, work-life balance metrics rose by 44 percent, empowerment by 26 percent
Why try this?

1. You help employees have a better life
2. You help increase gender equality by enabling a better distribution of caring responsibilities between parents and guardians.
3. You help yourself as the company drive better productivity
4. You help the environment (less commuting) and in the GenZ/Millennial post we saw how important this is. 

The early verdict is in – it’s a life changer.  People are rested and engaged, and companies aren’t losing productivity or profit.  One participant said “I don’t want to prejudge the outcome of the pilot, but I'd be surprised if we got to the end of this and said,  - right let's go back to our old way of working”.

4 Day Week Global is a not-for-profit community that provides a platform for people interested in supporting a 4 day week as part of the future of work. Some of their findings include

1. 63% of business found it easier to attract and retain talent
2. 78% of employees are happier and less stressed.

In the service industry, fast-casual restaurant chain Dig started its own pilot of a four-day workweek in September 2020 and announced after 18 months that they were implementing the schedule full-time.

This doesn’t come without any headaches – you of course have change management to deal with. Beyond that, figuring out the best new scheduling pattern will take some trial and error. You also need to consider what to do with employees who were already working on a reduced schedule. You also have to balance the pressure to perform in a shorter amount of time and the ability to track productivity changes… or do you?

It’s also not a miracle fix. If burnout is a problem, it probably still will be. If you don’t address the core of the issue (in burnout’s case that’s complex – flexibility, feeling valued, the literal workload) a shorter work week won’t solve the problem.

If you do want to try this 4 Day Week Global recommends:

• Give clients a heads-up that you are introducing a flexible working week and an assurance that there will be no drop-in client service.
• Plan for staff to take different ‘rest days’ to ensure clients and customers always have access to key personnel during standard business hours.
• Be clear that the policy has to benefit shareholders as well as employees.
• Understand that there are better ways to work than the traditional nine-to-five work week.
• Don’t introduce a flexible working week just to look good.
• Be consistent in your messages to staff and clear that staff must meet, or exceed, performance expectations.

Here's the recap on the large study happening now from CTV News