Surviving niche busters: Main strategies employed by Canadian private insurers facing the arrival of high cost specialty drugs. Issue 12 (December 2018)

• Record Type: Journal Article
• Authors: Charbonneau, Mathieu; Gagnon, Marc-André
• Is Part Of: Health policy. Volume 122:Issue 12(2018)
• Page Start: 1295
• Page End: 1301
• Publication Date: 2018-12
• Subjects: Prescription drugs -- Technology -- High-cost [N03.880.502] -- Insurance -- Pharmaceutical services [N03.219.521.576.343.575] -- Health benefit plans -- Employee [N03.219.521.576.343.290] -- Health care reform [N03.349.285]; Medical education -- Periodicals; Medical policy -- Periodicals; Delivery of Health Care -- Periodicals; Education, Medical -- Periodicals; Health Education -- Periodicals; Health Planning -- Periodicals; Public Policy -- Periodicals; Enseignement médical -- Périodiques; Politique sanitaire -- Périodiques; Medical education; Medical policy; Periodicals; Electronic journals; Electronic journals; 362.1
• DOI: 10.1016/j.healthpol.2018.08.006
• Languages: English
• ISSNs: 0168-8510

Abstract

Highlights: Canadian private health insurers are reluctant to comprehensively control costs. Facing high-cost specialty drugs, insurers implement three categories of strategies. Insurers use cost transfers and set case management and assessment programs. The insurance industry established guidelines and a catastrophic pooling agreement. The insurance industry lobbies for public catastrophic coverage. Abstract: The Canadian patchwork system of prescription drug coverage and the employer sponsored private health benefits group plans appear vulnerable to cost growth due to insufficient balance of power between fragmented public and private buyers, and pharmaceutical manufacturers. The emergence of "bad" insurance risks caused by new and very expensive treatments featuring high cost specialty medicines – also known as niche buster drugs – exposes this vulnerability. This study fills a gap in knowledge by seeking to better understanding how Canadian private insurers face the arrival of specialty pharmaceuticals. It completes an overview of a body of grey literature composed of publicly available online articles from the employment benefits and group insurance consulting and administration industry; online documents from group benefits sector conferences; and online or on demand materials from Canadian life and health insurers. Claims for high cost specialty drugs generate new bad insurance risks that Canadian health insurers attempt to mitigate through isolated corporate initiatives, industry-wide strategies and calls for universal, public catastrophic coverage. The outcomes of these strategies are limited cost-control measures as well as risk and cost transfers onto plan sponsors, patients and provincial public programs.