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Unpacking OHIP+ What will it mean for patients?

June 14, 2017

What does OHIP+ offer children and young adults with rare disorders?

Nigel S B Rawson, PhD

Eastlake Research Group, Oakville, Ontario Canadian Health Policy Institute, Toronto, Ontario

Affordability of rare disorder drugs

“We had to turn it down and say no because of the price tag”

“There’s that feeling of helplessness: I may lose her because I don’t have enough money to save her.”

Globe & Mail, May 19, 2017

Will OHIP+ help parents like this?

What the government says about OHIP+?

Liberals “are making sure that every young person across the province has access to the medications they need to stay healthy, feel better and live full lives”

They “are easing parents’ worries, while making life more affordable for them”

Access to medicines will be improved “by eliminating financial barriers to prescribed drugs”

OHIP+ will only cover drugs in the OPDP formulary

General Benefit unrestricted use list: almost 4,000 products ― OPDP pays <$1 for 73%; <$5 for 87%; >$100 for 1.6%

Limited Use list: 940 drugs with criteria restricting access to patients with specific disease characteristics or to a defined treatment period ― OPDP pays <$1 for 48%; <$5 for 77%; >$100 for 5.8%

Exceptional Access Program: 127 drugs with detailed, frequently complex, access criteria; many are biotechnological products ― often expensive

Drugs most commonly dispensed

Children under 12 Older children & young adults

Antibiotics Antibiotics

Anti-asthma drugs Anti-asthma drugs

ADHD drugs ADHD drugs

Analgesics Antidepressants

Cough and cold remedies Contraceptives

Anti-allergens

CDR recommendations for rare disorder drugs

55 CDR recommendations for 42 rare disorder drugs submitted between 2004 and February 2016

19 submissions were for 16 drugs for rare genetic conditions

13 of the 19 received negative reimbursement recommendation

Resubmissions for two drugs led to revised CDR assessments later in 2016

8 of the submissions (42%) now have positive recommendations

Brand name Disorder treated Reimbursement recommendation

OPDP listing

Replagal Fabry disease Negative No

Fabrazyme Fabry disease Negative No

Elelyso Gaucher disease Negative No

Vpriv Gaucher disease Positive No

Zavesca Gaucher disease Negative No

Myozyme Pompe disease Positive No

Aldurazyme Mucopolysaccharidosis I Negative No

Elaprase Mucopolysaccharidosis II Negative No

Vimizim Mucopolysaccharidosis IVA Positive* No

Brand name

Disorder treated Reimbursement recommendation

OPDP listing

Kalydeco CF (G551D mutation) Positive EAP

Kalydeco CF (CFTR gating mutations) Positive No

Kalydeco CF (R117H CFTR gating mutation) Positive No

Afinitor TSC-associated renal angiomyo-lipoma

Negative EAP

Afinitor TSC-associated subependymal giant cell astrocytoma

Negative EAP

Diacomit Dravet syndrome Positive EAP

Kuvan Phenylketonuria Positive* EAP

Ilaris Cryopyrin-associated periodic syndromes

Negative No

Soliris Atypical hemolytic uremic syndrome

Negative EAP

Juxtapid Homozygous familial hyper-cholesterolemia

Negative No

Listing to access

Kalydeco/Diacomit: access usually reasonable

Afinitor: access only after surgery tried

Kuvan: harsh access criteria has led to no patient having access

Soliris: usually reserved for acute patients and those who have had a kidney transplant

BC AB SK MB ON QC NB NS PE NL

Replagal

Fabrazyme

Elelyso

Vpriv

Zavesca

Myozyme EDS ES SA ES

Aldurazyme

Elaprase

Vimizim

Kalydeco G551D SA EDS EAP SA ES ES

Afinitor TSC EAP

Diacomit SA EDS EAP ES SA ES ES

Kuvan EDS EAP ES

Ilaris

Soliris EAP

Juxtapid ES

Conclusions

Formulary chiefly limited to lower-cost generics

Children with common conditions whose parents have no current provincial or private coverage will benefit most from OHIP+

Children with rare genetic disorders for whom new innovative drugs are becoming available are unlikely to see much benefit from OHIP+

For those that do, coverage will stop at age 25

Advocacy remains essential

How do Ontario children and young adults access prescription drugs?

Chris Bonnett, MHSc, PhD (Cand.)

H3 Consulting / hthree.ca

CORD / Toronto / June 14, 2017

In ten minutes…

1. Special drug coverage for children and young adults across Canada

2. Estimates of coverage in Ontario: provincial and private drug plans

3. Potential therapeutic classes relevant to children and young adults

4. Considerations and questions

5. Paying for drugs: OHIP+ conclusions

Provincial Special Drug Coverage Children and Young Adults

Prov Special Drug Programs Eligibility Notes

BC None

AB Child Health Benefit Low income (< $26,023, +); < age 19/21

SK Children’s Drug Plan, Insulin Pump (IP)

CDP: $25 per drug; < age 15. IP: < age 26.

MB Insulin Pump < age 18.

ON OHIP+ (proposed) Universal < age 25; ODB+EAP drugs; no cost

QC None

NB Growth Hormone Deficiency (GHD) < age 19; 20% up to $20/drug, up to $500/family/yr.

NS Insulin Pump < age 25

PEI GHD; Immunization; IP GHD, Imm: < age 18. IP: < age 19.

NL Select Needs Plan; IP SN: GHD up to 18. IP: < age 25.

Sources: (1) Clement FM, et al., 2016. Canadian Publicly Funded Prescription Drug Plans, Expenditures and an Overview of Patient Impacts. University of Calgary, School of Public Policy. https://obrieniph.ucalgary.ca/system/files/comparison-of-canadian-publicly-funded-drug-plans-for-alberta-health-feb-1-2016.pdf. (2) Provincial government websites.

Public: Unclear

Government drug spending (2014, ages 0 – 24): $146,005,000 1

Incremental provincial drug spending: $319,000,000 Proposed annual drug spending (2018): $465,000,000 2

Total ON Beneficiaries (ages 0 – 24): 3,914,000 3

Percent of total population (13,448,000): 29 3

Per capita (ages 0 – 24): $119 (2018, implied) OPDP Coverage Estimates 4

ODB Programs 3.94 mm (28%) • Beneficiaries (ages 0 – 19) 400,000 eligible • Beneficiaries (ages 0 – 24) 244,000 (60%) claim

Other public 0.24 mm (2%) Private insurers 7.74 mm (55%) Uninsured 2.24 mm (16%) Total 14.16 mm (105% of population)

Sources: (1) CIHI NHEX 1975-2016 Open Data. (2) Ontario government News Release, May 23, 2017. (3) Statistics Canada, 2016 Census. (4) 2015/16 Report Card for the Ontario Drug Benefit Program. Private insurance coverage is unreliable.

Private: We know even less

• Typical private drug plan prescription drug coverage is for children to age 18, except age 23 or 25 if a full time student, or if physically or mentally incapable of self-support. 1

• Most plans reimburse 100%, 80% or 90% of a much broad(er) formulary,2 though few have limits on out-of-pocket spending.

• Current private drug spending for ages 0 to 24: unknown.

• Telus Health, ages 0 – 29: 3

• 30.7% of claimants account for 12.4% of total eligible costs.

• OHIP+ may save 8% to 11% of drug claims, defer other cost controls. 4

Notes: (1) There are over 100,000 private health plans, and many variations on eligibility for both members and drugs. (2) PDCI Market Access reported that their database of private drug plans reimbursed 3,300 more DINs than the ODB formulary. See Pharmacare Costing in Canada, March 2016, p.21. (3) Telus Health, 2016 Data Trends. (4) M. Sullivan, Cubic Health, LinkedIn blog May 1, 2017; F. Naranjo, Collins Barrow, quoted in Cdn HR Reporter, May 23, 2017

Top 10 Therapeutic Classes Children and Young Adults

Class Rank / Name Avg. Cost

$ per script Notes

2 Diabetes 80 Metformin only generic in top 10; 14% trend

4 Depression 41 Higher use offset by lower cost generics

5 Asthma 73 Most products brand only; generic fill 35%

6 Infections 33 Rank 3rd in utilization; -8% trend

9 Cancer 503 Biggest pipeline; 12% trend

10 ADHD 96 Mostly generic, but 14% trend

11 Multiple sclerosis 1,847 Most often diagnosed in young adults

41 Rare diseases 4,686 Few products currently, but 42% trend

48 Cystic fibrosis 3,216 Orkambi® could benefit 50% @ $260,000/yr

Source: Express Scripts Canada, 2016 Drug Trend Report. http://www.express-scripts.ca/knowledge-centre/drug-trend-reports. Rank is by annual claim cost.

Considerations and Questions

General

1. Who are “most in need and least able to pay”? 1

2. No detail / certainty on estimated cost. What assumptions?

3. Will impacts (intended and not) of new drug coverage be measured?

Private Drug Plans

1. Insured plans will not see immediate cost reductions; ASO will. 2

2. Young plan members are usually low cost; rates may increase for others.

3. Will some employers exclude members under age 25, even though it’s unclear what OPDP formulary won’t cover?

4. Unknown future costs: Could Employer Health Tax be increased? 3

Notes: (1) 2017 Ontario Budget. http://www.fin.gov.on.ca/en/budget/ontariobudgets/2017/. (2) Insured plans (pooled or experience-rated) are typical for smaller employers (<50 to 100 employees). ASO (Administrative Services Only) plans are self-insured by larger employers. (3) 2017 Budget (Table 6.14) estimates EHT revenue at $5.9 billion for 2016-17.

OHIP+ Conclusions

1. OHIP+ coverage is unique in Canada. Other provinces have specific targets: low income families or certain diagnoses. Some have co-pays. Quebec offers consolidated, consistent universal coverage model.

2. Budget speaks of those in need, but message then changes to equity and supporting notion of universal pharmacare. Immediate purpose and longer-term goals are unclear.

3. Quick implementation means consultation may be welcomed…or discouraged so that Ministry can meet its deadline…but something will have to be implemented before the 2018 election.

4. A welcome surprise to employers. Biggest impact will be on ASO plans with large, recurring claims….but some employers could choose to eliminate coverage for Ontario plan members under age 25.

How do Ontario children and young adults access prescription drugs?

Chris Bonnett, MHSc, PhD (Cand.)

H3 Consulting / hthree.ca

CORD / Toronto / June 14, 2017

In ten minutes…

1. Special drug coverage for children and young adults across Canada

2. Estimates of coverage in Ontario: provincial and private drug plans

3. Potential therapeutic classes relevant to children and young adults

4. Considerations and questions

5. Paying for drugs: OHIP+ conclusions

Provincial Special Drug Coverage Children and Young Adults

Prov Special Drug Programs Eligibility Notes

BC None

AB Child Health Benefit Low income (< $26,023, +); < age 19/21

SK Children’s Drug Plan, Insulin Pump (IP)

CDP: $25 per drug; < age 15. IP: < age 26.

MB Insulin Pump < age 18.

ON OHIP+ (proposed) Universal < age 25; ODB+EAP drugs; no cost

QC None

NB Growth Hormone Deficiency (GHD) < age 19; 20% up to $20/drug, up to $500/family/yr.

NS Insulin Pump < age 25

PEI GHD; Immunization; IP GHD, Imm: < age 18. IP: < age 19.

NL Select Needs Plan; IP SN: GHD up to 18. IP: < age 25.

Sources: (1) Clement FM, et al., 2016. Canadian Publicly Funded Prescription Drug Plans, Expenditures and an Overview of Patient Impacts. University of Calgary, School of Public Policy. https://obrieniph.ucalgary.ca/system/files/comparison-of-canadian-publicly-funded-drug-plans-for-alberta-health-feb-1-2016.pdf. (2) Provincial government websites.

Public: Unclear

Government drug spending (2014, ages 0 – 24): $146,005,000 1

Incremental provincial drug spending: $319,000,000 Proposed annual drug spending (2018): $465,000,000 2

Total ON Beneficiaries (ages 0 – 24): 3,914,000 3

Percent of total population (13,448,000): 29 3

Per capita (ages 0 – 24): $119 (2018, implied) OPDP Coverage Estimates 4

ODB Programs 3.94 mm (28%) • Beneficiaries (ages 0 – 19) 400,000 eligible • Beneficiaries (ages 0 – 24) 244,000 (60%) claim

Other public 0.24 mm (2%) Private insurers 7.74 mm (55%) Uninsured 2.24 mm (16%) Total 14.16 mm (105% of population)

Sources: (1) CIHI NHEX 1975-2016 Open Data. (2) Ontario government News Release, May 23, 2017. (3) Statistics Canada, 2016 Census. (4) 2015/16 Report Card for the Ontario Drug Benefit Program. Private insurance coverage is unreliable.

Private: We know even less

• Typical private drug plan prescription drug coverage is for children to age 18, except age 23 or 25 if a full time student, or if physically or mentally incapable of self-support. 1

• Most plans reimburse 100%, 80% or 90% of a much broad(er) formulary,2 though few have limits on out-of-pocket spending.

• Current private drug spending for ages 0 to 24: unknown.

• Telus Health, ages 0 – 29: 3

• 30.7% of claimants account for 12.4% of total eligible costs.

• OHIP+ may save 8% to 11% of drug claims, defer other cost controls. 4

Notes: (1) There are over 100,000 private health plans, and many variations on eligibility for both members and drugs. (2) PDCI Market Access reported that their database of private drug plans reimbursed 3,300 more DINs than the ODB formulary. See Pharmacare Costing in Canada, March 2016, p.21. (3) Telus Health, 2016 Data Trends. (4) M. Sullivan, Cubic Health, LinkedIn blog May 1, 2017; F. Naranjo, Collins Barrow, quoted in Cdn HR Reporter, May 23, 2017

Top 10 Therapeutic Classes Children and Young Adults

Class Rank / Name Avg. Cost

$ per script Notes

2 Diabetes 80 Metformin only generic in top 10; 14% trend

4 Depression 41 Higher use offset by lower cost generics

5 Asthma 73 Most products brand only; generic fill 35%

6 Infections 33 Rank 3rd in utilization; -8% trend

9 Cancer 503 Biggest pipeline; 12% trend

10 ADHD 96 Mostly generic, but 14% trend

11 Multiple sclerosis 1,847 Most often diagnosed in young adults

41 Rare diseases 4,686 Few products currently, but 42% trend

48 Cystic fibrosis 3,216 Orkambi® could benefit 50% @ $260,000/yr

Source: Express Scripts Canada, 2016 Drug Trend Report. http://www.express-scripts.ca/knowledge-centre/drug-trend-reports. Rank is by annual claim cost.

Considerations and Questions

General

1. Who are “most in need and least able to pay”? 1

2. No detail / certainty on estimated cost. What assumptions?

3. Will impacts (intended and not) of new drug coverage be measured?

Private Drug Plans

1. Insured plans will not see immediate cost reductions; ASO will. 2

2. Young plan members are usually low cost; rates may increase for others.

3. Will some employers exclude members under age 25, even though it’s unclear what OPDP formulary won’t cover?

4. Unknown future costs: Could Employer Health Tax be increased? 3

Notes: (1) 2017 Ontario Budget. http://www.fin.gov.on.ca/en/budget/ontariobudgets/2017/. (2) Insured plans (pooled or experience-rated) are typical for smaller employers (<50 to 100 employees). ASO (Administrative Services Only) plans are self-insured by larger employers. (3) 2017 Budget (Table 6.14) estimates EHT revenue at $5.9 billion for 2016-17.

OHIP+ Conclusions

1. OHIP+ coverage is unique in Canada. Other provinces have specific targets: low income families or certain diagnoses. Some have co-pays. Quebec offers consolidated, consistent universal coverage model.

2. Budget speaks of those in need, but message then changes to equity and supporting notion of universal pharmacare. Immediate purpose and longer-term goals are unclear.

3. Quick implementation means consultation may be welcomed…or discouraged so that Ministry can meet its deadline…but something will have to be implemented before the 2018 election.

4. A welcome surprise to employers. Biggest impact will be on ASO plans with large, recurring claims….but some employers could choose to eliminate coverage for Ontario plan members under age 25.

Durhane Wong-Rieger, PhD

President Canadian Organization for Rare Disorders

June 2017

OHIP+

What Patients are Saying

Durhane Wong -Rieger, PhD

President Canadian Organization for Rare

Disorders

J u n e 2 0 1 7

OHIP+

What Patients are Saying

31

Unpacking OHIP+ What will it mean for patients?

June 14, 2017