Considering the plan member experience

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At a time when all stakeholders are struggling to keep pace with rapid and important changes in the space, leading benefit advisors from across Canada highlight common challenges, provide insight, and discuss best practices that will allow the provision of comprehensive and sustainable health benefit plans

MAPOL AND H3 CONSULTING co-hosted a meeting with 12 leading benefit advisors from across Canada, who collectively manage life and health plans for hundreds of employers. The event was sponsored by five pharmaceutical manufacturers. The purpose of the meeting was to exchange information and ideas on how plan members experience their benefit plans in three key areas – fertility, vaccines, and the effects of drug-claim pooling on access to high-cost drugs. National pharmacare was also discussed, given its potential to disrupt drug benefits in the mid-term. All topics generated significant and insightful discussion.

Among the 100 advisors surveyed by H3-Mapol, 50 percent said fertility coverage would help their clients attract and retain employees. Apart from potential cost, advisors also reported that many clients were unaware of this unmet employee need.

Fertility costs can range from several thousand dollars for genetic testing and egg freezing, to significantly more as age, the number of cycles, and the complexity of underlying health issues increase

Dr. Marjorie Dixon, Anova Fertility

The survey was developed to assess the opinions and priorities of benefit advisors on two therapeutic areas, plus national pharmacare and rare-disease drugs. We are unaware of any previous attempts to capture this information from this crucial audience. In October 2023, 100 benefit advisors from across Canada responded to 31 questions with their own views and those of their employer clients. On average, they had 21 years of experience as a benefit advisor and managed 111 clients. Hundreds of comments indicated strong engagement with the topics. Key findings:

As employers examine their health benefit plans through the lens of diversity, equity, and inclusion (DEI), some issues may emerge that were not considered in the original plan design. One example is fertility treatments. Not only has family composition changed; so too have paths to creating families.

Infertility has been defined (in part) as “the inability to achieve a successful pregnancy based on a patient’s medical, sexual and reproductive history; age; physical findings; diagnostic testing; or any combination of those factors. The broader 2SLGBTQIA+ community and single-by-choice individuals are examples of new family models who need access to surrogacy, adoption, donors, and other services. Within the general population, one in six individuals between the ages of 25 and 44 struggles with fertility. Many plans don’t fully cover fertility drugs and adjunct treatments and services. Mapol's research revealed that almost half (47 percent) of Canadian employers provide limited coverage for fertility medications, although the median benefit ($6,000) is well below typical costs. Only 2 percent of the 47 percent also provide coverage for related procedures. This is inconsistent with DEI principles, and updated plan language and support are needed. Note that improved fertility benefits may also mitigate other health concerns. Fertility benefits position your organization as an attractive choice in a competitive labour market. In addition to benefit principles, employers need to identify all their compensation priorities, including affordability. Fertility costs can range from several thousand dollars for genetic testing and egg freezing, to significantly more as age, the number of cycles, and the complexity of underlying health issues increase. Plan design needs enough flexibility to meet needs that can vary quite a bit between patients.

Fertility challenges affect several unexpected demographics such as young people, single-by-choice individuals, and heterosexual couples. Often, members of the 2SLGBTQIA+ community need access to fertility care, including donor sperm, ova or embryos, or surrogacy. Fertility coverage is likely to be particularly important to millennials, ages 25 through 44, who are building a family. This demographic group now comprises 43 percent of the labour force.

Although earlier research indicates about two-thirds of employers provide coverage for vaccines, the quality varies significantly

Pavithra Ravinatarajan, Pavithra Consulting

Employers engaged in improving the health and well-being of their workers often use in-person or web-based educational sessions or materials or expert online health libraries produced and vetted by third parties. However, discussions on adult vaccines such as those treating

Plan sponsors, advisors, and insurers often do not fully understand how plan members and patients experience their health benefit plans. The meeting’s goal was to surface those member experiences and provide advisors with insights and resources to address them. The extensive national survey helped identify key advisor concerns, notably high-cost drugs, claim pooling, and national pharmacare. These are complex, complicated, and evolving issues on which many advisors want more education, beyond what insurers have traditionally provided. Three therapeutic presentations described unmet plan member needs concerning access to fertility treatments and vaccines. Advisors were reminded about limited and uneven provincial coverage across Canada. More education would help them to identify emerging treatments and the broad, environmental forces acting on drug and other benefit decisions. Advisors noted legacy decisions have limited the coverage for fertility drugs and procedures, as well as vaccines, despite greater diversity in workforce needs, goals, and priorities. While previous generations focused elsewhere, the cohort aged 25–44 – which now composes more than 40 percent of the labour force – is most likely to appreciate fertility benefits. Ironically, fewer than half of employers provide this coverage. In addition, limits on vaccine benefits frustrate plan members as well as organizations that want to improve the health and well-being of their workforce. With employers understandably focused on their business operations and strategic goals, leading advisors see an opportunity to increase their value. Improved health data and education would allow them to be more proactive and holistic with their clients. For example, addressing mental health must also consider other health issues that affect a person, such as infertility or acute disease, all of which can seriously impair mental health and drive workplace absence and presenteeism. Policy issues like pharmacare and protection against catastrophic drug-claim costs follow a similar path. In addition to a new federally funded dental plan, important federal pharmacare legislation is expected early in 2024 that may eventually change workplace drug plans. While branded specialty drugs are now being replaced by lower-cost biosimilars in most provinces, rare-disease drugs continue to grow rapidly in average and overall cost. Policy issues are very relevant but are not often assessed for drug plan impacts. Here again, advisors wanted more information so they can effectively advise and advocate for their clients. In summary, leading benefit advisors are struggling to keep pace with rapid and important changes that affect sponsors and members of health benefit plans. Their advice – and request – is to commensurately improve their access to data, information, and insights so plan sponsors continue to provide comprehensive and sustainable health benefit plans. H3 Consulting and Mapol sincerely thank these advisors for their time and tremendous insights, and the event sponsors for their interest in understanding the issues and opportunities of the private drug insurance market.

Redefining parenthood: Making fertility benefits inclusive through DEI

Published Mar. 06, 2024

Chris Bonnett, MHSc, PhD, Principal, H3 Consulting

Benefit advisor survey results

The most important drug plan issues were high-cost biologic and specialty drugs (66 mentions), claim pooling offered by insurers (60), and national pharmacare (55). Transitioning to a fully public drug plan would have a material effect on advisor revenues. Most advisors expected no change to drug coverage (76), with roughly equal numbers expected to improve coverage (12) or reduce or eliminate coverage (11). To sustain drug plans, advisors expected more plan maximums (69) and higher cost-sharing with members (53). Improved risk-sharing and pooling is needed (50), and exclusions for high-cost or rare-disease drugs are expected (50). Generally, respondents were unsure about their clients’ coverage for fertility drugs, vaccines, and rare-disease drugs. Most understood the impact of skills shortages and the importance of promoting good health; however, most advisors believed that expanded coverage was unlikely. There was a wide range of perceptions, positive and negative, of both fertility and vaccine coverage. Most advisors stated it was time to update (improve) coverage in both areas. Some advisors believed governments should cover these benefits and that they might be costly. Both national pharmacare and the national rare-disease drug strategy elicited concern about client and business risks. Advisors wanted better information and education, reflecting greater complexity and challenges in managing benefit plans.

Sponsor: EMD Serono

Dr. Marjorie Dixon, medical director and CEO, Anova Fertility

Sponsor: Ferring

Carolynn Dubé, Fertility Matters Canada, and Erin Fordham, Alta Vista Planning Partners

Fertility benefits: Why they matter and the plan member experience

Creating a family in Canada is expensive. The average cost of in vitro fertilization (IVF) is $20,000. For surrogacy, the cost starts at $60,000, and fertility preservation (egg freezing) costs about $8,000. Finances aside, not everyone is prepared to undertake the emotional turmoil of treatment. Some costs are partially covered by provincial plans in Ontario (IVF), Quebec (IVF and tax credit), and New Brunswick ($5,000 one-time grant). Other jurisdictions may provide a tax credit (Manitoba and Nova Scotia, up to $8,000 annually) or a subsidy (Prince Edward Island, up to $10,000). Newfoundland and Labrador provides $5,000 per IVF cycle, for up to three cycles. No coverage is available in western Canada. For many people, workplace benefits are the only way to make fertility affordable. This is an important discussion to have with employers, and another place where good data and expert advice will support good decisions.

Sponsor: GSK Canada / Pfizer Canada

Pavithra Ravinatarajan, RPh, Pavithra Consulting

Modernizing plan designs and optimizing vaccine coverage

Sponsor: Mitsubishi Tanabe Pharma Canada

Philippe Laplante, FCIA, FSA, Principal, Eckler

QDIPC Overview: Pooling across Canada – administration, cost, and differences

Discussion

The steady growth in specialty drugs and explosive growth in the cost of drugs for rare diseases (DRDs) have led to concerns about how effectively drug-claim pooling is protecting plan sponsors. Pooling removes or lessens risk from one employer’s drug plan since the insurer will spread it across many employer clients. Another form of pooling is risk-sharing, where market risk is redistributed across many insurers. In Canada, there is one pooling and risk-sharing mechanism in Quebec and another everywhere else. The overall goal is to reduce the volatility of drug-claim costs, which can vary significantly among employers and over time within one plan. The Quebec Drug Insurance Pooling Corporation (QDIPC) was established in 1997 and applies to Quebec plan members. It is a mandated, lightly regulated model that covers all private plans with up to 6,000 employees across Canada. In contrast, the risk-sharing model used everywhere else applies only to recurrent claims from fully insured plans, which are typically used by small employers. Each year, QDIPC provides recommended pooling charges according to the number of covered employees and the maximum pooling threshold. Insurers independently determine their pooling charges. This table provides a useful benchmark for advisors across Canada, allowing them to compare pooling

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Mapol Inc. is the pharmaceutical industry's leading market access expert on private and public payer drug plans in Canada. With over 100 years of combined experience within both the pharmaceutical and payer industries, our products and services are tailored to meet the needs of those working for pharmaceutical manufacturers in the areas of market access and product reimbursement.

American Society of Reproductive Medicine, 2023, https://www.asrm.org/practice-guidance/practice-committee-documents/denitions-of-infertility/. Canadian Fertility and Andrology Society (CFAS), 2023 poster. Mapol Inc. news release, November 20, 2023. Statistics Canada. Labour force status by age and gender: Canada, provinces and territories, census divisions and census subdivisions. Table 98-10-0485-01. Calculated from ages 25 to 44 as a percent of total “in the labour force.” Op cit. CFAS 2023 poster. Between 2018 and 2022, “catastrophic” drug-claim costs, defined as at least $300,000 annually, experienced a 400 percent increase.

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H3 Consulting provides a unique combination of deep knowledge of the private payer community, health benefit plans, and prescription drug policy with advanced research and communication abilities in three key areas: 1. Prescription drug policy for private and public payers 2. Workplace health strategy and chronic disease management 3. Private drug insurance market access that identifies value from all perspectives

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Advisor A

Experts' advice on improving benefit plans

“We don’t get a lot of information on the cost of drugs, vaccines, and fertility benefits. As an advisor, [I don’t] have enough information to educate our clients”

Advisor B

“Clear, easy to understand data [are] key. Cost projections [from insurers] would also be helpful”

Sandra Ventin, Gallagher

“We are seeing new interest in plan sponsors adding fertility and erectile dysfunction coverage plus gender affirmation coverage when they approach their plan from a DEI lens. The dated lifestyle drug category wording is being replaced with modern, inclusive language – which we applaud and continue to support”

Shannon Hughes, Captivate Benefits

“Another way we can add value and help the ROI for benefit plans is letting plan members know they have coverage for vaccines”

Gavin Mosley, CEO, GroupBenefitz

“I would prefer to just include vaccine coverage right from the beginning. Make it standard, or at least discuss prevention at every renewal. Given the value, why do we even ask if this should be optional?”

human papillomavirus (HPV), respiratory syncytial virus (RSV), and shingles may need different approaches. Communications may need to be more specific and adhere to a seasonal schedule, e.g., flu and RSV vaccines in the fall. As well, there is a misunderstanding that provincial plans provide all necessary immunizations. Apart from provincial differences in what they cover, employers have an important role to play in ensuring affordable access. Worksite vaccine clinics, staffed by regulated professionals such as pharmacists, nurses, or nurse practitioners, can be very effective by administering recommended vaccines, providing advice and even incentives, and thereby reducing hesitancy. This is a complementary approach to reminding parents that childhood immunizations for measles, rubella, diphtheria, tetanus, and pertussis are also recommended and, in fact, required by school boards. Although earlier research indicates about two-thirds of employers provide coverage for vaccines, the quality varies significantly. Most plans in that study provided $500 or more annually for vaccines, although many plans provide smaller amounts that may be inadequate to encourage access. Some benefit plans require that all eligible expenses must treat an illness rather than prevent it. Curiously and paradoxically, some of those plans still stated that vaccines were eligible, indicating that contracts need to be carefully reviewed and updated as needed. Vaccines may be classified as “lifestyle” drugs, and therefore excluded. Given their efficacy and very limited potential for abuse, this is no longer appropriate.

charges for their clients with those deemed reasonable in Quebec. An important question is whether the Quebec model could be used across Canada. This may increase the risk spread and moderate drug-claim costs, which are especially important to smaller or low-margin employers. Without improvement, some employers may abandon their health plans and shift risk and costs to the provinces. Data are difficult to find and compare because of different pooling models and reporting in Quebec and elsewhere in Canada, as well as claim control standards that vary by insurer. There are no aggregate claims data publicly available to track the growth of DRDs in private plans.

Back Row: Gordon Polk (Mapol Inc.), Peter Ma (Mapol Inc.), Carolynn Dubé (Fertility Matters Canada), John McGrath (ZLC Financial), Carolyne Eagan (Benefits Alliance), Philippe Lagacé (Mercer Marsh Benefits), Dave Patriarche (Mainstay Insurance Brokerage Inc.), Erin Fordham (Alta Vista Planning Partners Inc.), Jean-Philippe Bernard (Normandin Beaudry), Sandra Ventin (Gallagher), Tahir Feroz (Ferring Canada), Corinne Razem (Mapol Inc.), Chris Bonnett (H3 Consulting) Front Row: Sue-Lee Pring (Mapol Inc.), Sacha Morcos (GSK), Christine Than (Aon), Gavin Mosley (GroupBenefitz), Chris Pryce (Human Capital Benefits), Sally Chen (EMD Inc., Canada), Jenev Portelance (Pfizer Canada), Pavithra Ravinatarajan (Pavithra Consulting Inc.), Shannon Hughes (Captivate Benefits), Philippe Laplante (Eckler), Louise St-Onge (Mitsubishi Tanabe Pharma Canada), Cheryl Kane (Hub International)