Transcript Results

Disinvestment – What does
it mean in the Canadian
Context?
Industry Perspective
Lesia M. Babiak
April 11, 2016
Experience From Both Sides of the ‘Fence’
• Government
– Drug plan Manager –
Associate Director of Ontario
Drug Programs
• Industry
– Johnson & Johnson –
Government Affairs & Policy
– LifeScan – Government Affairs
– Janssen – Federal Affairs,
Market Access
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Disinvestment or Optimization, Modernization,
Reassessment
Health Care
System goals
Optimization
of use of
technology
involves
• Enhance system
efficiencies to allow
improved access to
care that is effective,
safe and offers
worthwhile benefit
• Assessment of new
technologies
• Reassessment of
established
technologies
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Reassessment Objectives
• Improving health
outcomes
• Facilitating the adoption
of technologies &
approaches offering high
value
• Supporting health system
sustainability
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Proton Pump Inhibitor – A Draconian Approach
Focused on Cost Savings That Failed
Background
• Major spend pressures, 15-20% growth annually
• Expert committee perception of misuse
• Perception of inappropriate promotion by
manufacturer
Results
• New PPI limited use criteria introduced weeks
before an election
• New limited use forms, with Ministry able to ‘audit’
prescribers
• Major backlash from physicians and pharmacists
• Limited use forms revised, eventually eliminated
• ICES analysis subsequently demonstrated PPI
usage largely appropriate
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Formulary Modernization – Focus on
Optimization of Care
Background
• Extensive effort to address a number of suboptimal use and safety
concerns
• Focus on optimization of care vs. major cost savings
• Examples:
− Flexeril – Muscle relaxant with little evidence to support usage
− Demerol – An effective narcotic in short term, long term use concern due
to metabolite accumulation
• Manufacturers provided opportunity to input over 18 month process
• Communication plan developed targeted at physicians and
pharmacists
• Flexeril delisted – Some backlash
Results
• Demerol restricted to two weeks maximum usage – No backlash
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Antimicrobial Resistance – Focus on Addressing
a Growing Concern
Background
• Incidence of antimicrobial resistance of concern in the 90’s
due to overuse of antibiotics and increased use of 2nd and
3rd line agents
• Extensive review undertaken with multiple opportunities for
manufacturers and clinicians to input
• Multi pronged approach deployed – Public Health engaged
• Extensive change management/communication plan
developed
• Communication plan targeted at physicians, pharmacists
and patients
Results
• Formulary hurdles introduced for 2nd and 3rd line agents
• Antibiotic usage dramatically changed, antimicrobial
resistance reduced
• Some backlash/resistance, no significant traction
• Unintended consequence of Ontario and restrictions of
other jurisdictions – Reduced investment in antimicrobial
R&D
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Blood Glucose Test Strips
Background
• Provincial concerns about level of spend on blood glucose test
strips (BGTS)
• CADTH launched a review, recommended disinvestment of BGTS
for Type 2 diabetes
• Consultation with stakeholders perceived to be limited, major
stakeholders, including Canadian Diabetes Association (CDA) and
others felt largely ignored, significant backlash
• Minor alterations applied to final recommendation
• CDA launched an independent assessment, published a position
which advocated for continued access to BGTS however
recommended guidelines for ‘reasonable’ levels of testing in light of
cost constraints
Results
• No provinces adopted the CADTH recommendations
• Ontario, British Columbia and Saskatchewan introduced CDA
based BGTS quantity limits
• Usage in Type 2 patients has fallen dramatically 40-50%,
overall usage decreased by over 20%
• Ontario worked proactively with CDA, BC worked proactively with
CDA and numerous stakeholders
• Backlash minimal
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Impact of Ontario BGTS Policy: 19 Month
Experience – Significant and Sustained Savings
Insulin
Insulin & Oral Agents
Oral Agents/Hypo
Oral Agents Non-Hypo
Lifestyle
Thousand
6,000
Therapy
5,000
Insulin
%
Change*
-2%
4,000
Insulin +
Oral Agents
+15%
3,000
Oral Agents/
Hypo
-44%
Oral Agents/
Non Hypo
-50%
Lifestyle
-46%
Total
-23%
2,000
1,000
Jan/12
Feb/12
Mar/12
Apr/12
May/12
Jun/12
Jul/12
Aug/12
Sep/12
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Jan/13
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Mar/13
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Jan/14
Feb/14
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Jun/14
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Dec/14
Jan/15
Feb/15
0
* Aug 2013-Feb 2015 vs. prior 19 months
Source: IMS Brogan
Legacy Medical Devices
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Minimally Invasive Hysterectomies
Background
• Hysterectomies are still the most common surgical
procedures that CDN women undergo
• CDN and international publications support least
invasive procedures to minimize complications and
recovery time
• Ottawa Hospital launched a series of initiatives in
2007 to address issue
Results
• Ottawa Hospital results significant, MIS increased
from 40.1% (2005) to 74.2% (2012)
• Decrease in mean LOS from 2.5 to 1.6 days
Reduced complications, cost savings
• Despite guidelines and publications, national figures
for open hysterectomies remain high:
Rate of open hysterectomies remain at 57%
(National Ambulatory Care Reporting System and the Discharge Abstract
Database, 2014/2015 data)
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Key Learnings
• Active engagement of stakeholders at all key stages
including
− Prioritization
− Reassessment
− Decision making
− Implementation
• Support is critical from affected stakeholders for
optimization of use
• Transparent and evidence based
• Thoughtful and effective knowledge transfer to all
stakeholders
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Key Learnings
• What should the focus be?
− Has to be worthwhile as the effort is significant
• Cost savings, maximizing value
• Safety/efficacy
− Likelihood of success should be relatively high
• Unintended consequences?
− Possible increase vs decrease in costs
− Potential impact on R&D priorities
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Key Learnings
Reassessment of evidence is just
the beginning of this journey……
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