Quebec Panel
On Tuesday, June 13, 2017, the Canadian Association for Healthcare Reimbursement (CAHR) held the Market Access 201 conference in Toronto. The theme for this conference was Parallel or Intersecting Paths, the Future of Public and Private Reimbursement in Canada which consisted of five fascinating panels focusing on key topics of interest to the Canadian pharmaceutical stakeholders. Over the coming weeks, MORSE will be releasing summaries for each panel to share key learnings from this conference. This issue will focus on the Quebec panel discussion.
Session Topic: Quebec
Description: A number of important changes are emerging in Quebec over the coming months (e.g. INESSS will be changing its framework for evaluation and issuing guidelines on biosimilars). In addition the implementation of Bill 92 will restrict the use of co-pay cards which may have significant impact on patient assistance programs in that province. This panel discussed the upcoming changes in Quebec and their implications on the industry and the healthcare system.
Speakers:
Adrienne Blanchard, Founder, Blanchard Law
Lyne Duhaime, President, ACCAP-Quebec
Sebastien Dao, Managing Principal, Synergyx Consulting Inc. (MODERATOR)
Summary:
Sebastien Dao, Managing Principal, Synergyx Consulting Inc.
We did extend invitations to individuals to the government but they are working on new regulations including new amendments on Bill 92 which will come out at the end of the month. And new bills the Minister will present. INESSS is also very busy working on new guidelines. They did publish some new guidelines 2 weeks ago as well.
History on Quebec
- Quebec drug insurance program was created 20 years ago
- June 1996 Act was passed and implemented in January 1997
- Public and private drug plan form the Regime
- The objective behind the public drug plan is to provide reasonable and fair access to drugs
- The coverage is defined by the drugs listed in the “Liste de medicaments” there are general benefits and exception drugs
Universal drug coverage
- 56% of Quebec population is covered with a private drug plan
- Employer provides a private drug plan
- The other 44% are publicly covered
- Types of beneficiary includes under 18 (however, this is different from the Ontario based program), in adherent (no access to private plan) and seniors
Drug Policy
- 2007 — 4 main objectives
- Ensure access to drugs
- Establish fair and reasonable prices
- Promote optimal use of drugs
- Maintained a dynamic industry
- 34 new regulations were proposed however, only 29 made it to the policy
- There was a regulation to include evidence development
- Financial risk sharing agreements with manufacturers only recently came into effect
INESSS
- Created in 2011
- Makes recommendations to the Minister of Health considering:
- Therapeutic value
- Fair price
- Cost-effectiveness
- Impact on health of Quebec population and health system and social services
Power is very centralized to the Minister of Health
- Minister of Health in center with INESSS as an independent advisor, RAMQ is a program administrator and the Ministry of Health sets the policies
- Very different responsibilities and roles
- INESSS only evaluates fairness of price
- Product listing agreements are the responsibility of the Ministry of Health
20 years later how are they performing….
- 8 billion dollars on public and private drug plans
- Prices vary between public and private drug plans
- Insurance premiums are not proportional to revenues of insured people
- Drug formulary has never been thoroughly reviewed
- Very concerned about inappropriate use of drugs
- Quebec is not benefiting from lower cost of drugs
Quebec Health System Reforms
- 5 main drivers
- Generate savings
- Maintain the sustainability of the health care system
- Return to a balanced budget 2015 – 2016
- Increase efficiency of the health care system
- Encourage optimal use of drugs
- Generate savings
- Abolishment of BAP 15, freeze on price increase, Maximum Price Payable, restrictions on conditions for the use of no substitution, Quebec joins pCPA
- Bill 81
- Tendering
- Since then the Minister has negotiated with generics and the deal is concluded
- Quebec wants to benefit from lower prices
- Joining pCPA to benefit from deals with generics
- Tenders are already being used in hospitals
- List of drugs for tenders not yet determined potential savings not evaluated
- Biosimilars
- Set preferential reimbursement
- Restricted for Remicade continued reimbursement < 18 years with CD or juvenile rheumatoid arthritis treated with Remicade prior to Feb. 2017
- Efficiency
- INESSS is working with the new evaluation framework
- Therapeutic value
- Fair price
- Cost-effectiveness
- Efficiency: effectiveness in real-world settings
- INESSS is working with the new evaluation framework
- Pre-NOC evaluation
- Drug is indicated for the treatment of a serious health condition
- Available clinical evidence suggests that the drug significantly improves patients’ health
- INESSS Evaluation framework
- Expected Q2, 2017
- Submission review fees to be announced in Q3, 2017
- Optimal Use
- Glucose test strips
- Proton pump inhibitors
- Quebec made surplus in 2016
- Instead of reinvesting they are using the money to reduce the debt
- Lower income tax however, only 2% increase in health
- More new legislations are expected to reduce costs
Adrienne Blanchard, Founder, Blanchard Law
Legal update on Quebec’s Bill 92 which amends six different acts and affects many players. The Bill became law in December 2016 which broad ranging amendments to the Act.
Originally thought it was aimed at cards, but the stated purpose is to increase transparency, competition and reduce costs. An intermediary has two parts to the definition including banners and chain drug stores. This imposes obligations on any person who intervenes on the supply chain or marketing which is a very broad definition. I have not been able to get clarity on who is scoped in that definition.
The new section of the act has a series of prohibitions for dealings within the supply chain such as a manufacturer cannot enter an exclusive supply deal and that provision is in force. You also can’t pay or reimburse a person covered under the public plan. This could affect co-pay cards and patient support programs however, this is not in force. Humanitarian payments may occur but the definition is not clear.
It is also prohibited to limit supply to a restricted number of pharmacies unless allowed by Health Canada. Cannot discriminate in supplying to pharmacists. You cannot have an exclusive agreement with pharmacy but can have preferential.
It is prohibited for manufacturers, wholesalers or intermediaries to directly or indirectly receive benefit, discount or additional profit margin. There are no add on benefits it is just the sale price and this in force.
It prevents a manufacturer from providing benefits of an author of a prescription or a senior resident manager. However, what is the definition of a benefit? If a physician is infusing a drug then if they are paid is that a benefit? Provision regarding several questions surrounding patient support programs.
There are also new powers of the Minister and he can delist products from the list.
Lyne Duhaime, President, ACCAP-Quebec
In Quebec, we have a universal plan. Drug costs continue to increase in Canada but in Quebec there are different elements. More prescriptions, low use of generics, no agreements with pharma, no agreement with pharmacists.
The reality is in Quebec as an employer the plan must cover prescription drugs and all drugs on the formulary must be covered. Those employees will get more prescriptions than in other provinces. Drugs are expensive and as a private payer you need to pay the price on the list. Pharmacists are charging more to private payers. The difference is about $450 million per year to compensate for what the pharmacists believe that the government fees are not sufficient.
Bill 92 will be helpful… As of September 15, 2017, the pharmacist will have to list on the invoice the professional fees, the drug cost and the wholesale profit margin. The professional fee is the dispensing fee, the margin. Important to private payers, which means employers and employees, and it does not mean the price is less but there will be a tool to try and control prices.
They are still in a battle with pharmacists; 2017 is a pivotal year as a breach in the deadlock. There are tools to inform patients about the costs of the drug and differences between pharmacies. Before October the Minister of Health must publish a report that determines the difference between public and private plans. In 2013 the difference was about 17% and this report will be filed this fall. Really want to use this opportunity to change things and be more comparable to what happens outside of Quebec. Hopeful that the situation will improve.
QUESTIONS
What is the communication plan to talk to consumers about the change that will occur in September and what kind of push back do you expect?
LD: We developed communication tools for our members. We are working with members and preparing the communication tools and will also work with the media. This will be very important since the public will have questions.
Some CLHIA members are negotiating with pharmaceutical companies, how do they plan to work to harmonize the process?
LD: The key message is to join the pCPA and in terms of drugs we are partners of governments.
MORSE thanks our Reimbursement Strategist, Avery Hughes, for diligently preparing these summary notes during the conference. This summary is not an official transcript of the presentations/ discussions – as such, it may contain some errors/omissions/misinterpretations. Please contact the CLHIA, Adrienne Blanchard or Sebastien Dao if you would like additional information or clarification on this topic.
Summary of Quebec Panel discussions from the June 13, 2017 CAHR 201 conference. Share on X
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