Transcript A Decade of Outcomes-Based Drug Coverage in British Columbia

A Decade of Outcomes-Based
Drug Coverage in British Columbia
Steve Morgan, Ken Bassett,
Barbara Mintzes, and Jim Wright
University of British Columbia
THE
COMMONWEALTH
FUND
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Context: BC
• British Columbia
– 4.1 million residents (3rd largest province)
– ‘Domestic’ Rx Industry  generic & biotech
• Health Coverage
– Universal, public insurance for medical and
hospital care
• Rx Coverage:
– Mix of private/public/uninsured
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Context: BC PharmaCare
• Tax-financed public drug benefit plan
• PharmaCare covered
– Social Assistance Recipients
– All Seniors
– Residents with catastrophic costs
– Residents with specific diseases (HIV, Cancer…)
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Context: Cost Crises of 80s and 90s
1.2%
Drug Spending in Canada as % of GDP
1.0%
0.8%
0.6%
0.4%
0.2%
0.0%
1933
1943
1953
1963
1973
Medical & Pharmaceutical Products
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1983
1993
Retail Rx
Source: CIHI and Statistics Canada
How Cost Crisis Played Out in BC
• 1993 review of PharmaCare
• Appointment of new Executive Director
• Management aware of:
– Cost-sharing research from US
– Cost-impact research done locally
• Decision:
– Limit subsidy based on evidence
– Establish process to review evidence
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The Therapeutics Initiative
• Multi-disciplinary group at UBC
– Supported by 5-year grant from Ministry
– Small core staff
• Mandate:
– review all products for listing
– promote rational drug therapy
– advisors to Ministry staff
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Genesis of Coverage Framework
• 1994 review of nitrate drugs
– $3.8M/yr spent on one SR product
– Cost 10 times per dose as alternatives
– no evidence to distinguish SR efficacy,
effectiveness, compliance, or side effects
• Manufacturer Criticisms
– Failed
– Engage partners in dialogue
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Evidence Standards
• Evidence of high standard
– Blinded RCTs
– Comparative
– Published
• Outcomes approach
– Total morbidity/mortality impact
– ADRs = part of outcomes
– Surrogates must be rationalized
– Amenities must yield outcome benefit
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Implementing Framework
• Reference Drug Program
– Applied reference based subsidy to 7
classes
– Regular reviews for new evidence of
comparative “outcome advantages”
– Generous exemptions + market freedom
• Rigorously Assessed
– Data provided to external research teams
– Savings > $12M annually
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Simple Econ of Outcomes Approach
Higher
Cost
Avoid
Waste
Tough
Choices
Worse
Outcomes
Better
Outcomes
Tough
Choices
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Promote
Savings
Lower
Cost
Critical Balance
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Key Ingredients
• Leadership: committed to EBDM
• Communication: ongoing, two-way
• Credibility: standards of evidence and
standing of advisors
• Transparency: Communicating process,
evidence, and rationale avoids backlash
• Necessity…
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Thank you
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