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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Health Care System goals

• 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

Optimization of use of technology involves

Disinvestment or Optimization, Modernization, Reassessment

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

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Background • Major spend pressures, 15-20% growth annually• Expert committee perception of misuse• Perception of inappropriate promotion by

manufacturerResults• 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

Formulary Modernization – Focus on Optimization of Care

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• 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

Back-ground

• Flexeril delisted – Some backlash• Demerol restricted to two weeks maximum usage – No backlashResults

Antimicrobial Resistance – Focus on Addressing a Growing Concern

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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 patientsResults• 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

Blood Glucose Test Strips

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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

Impact of Ontario BGTS Policy: 19 Month Experience – Significant and Sustained Savings

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1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

Insulin Insulin & Oral Agents Oral Agents/Hypo Oral Agents Non-Hypo Lifestyle

Therapy%Change*

Insulin -2%

Insulin + Oral Agents

+15%

Oral Agents/Hypo

-44%

Oral Agents/Non Hypo

-50%

Lifestyle -46%

Total -23%

* Aug 2013-Feb 2015 vs. prior 19 monthsSource: IMS Brogan

Thousand

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Legacy Medical Devices

Minimally Invasive Hysterectomies

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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)

Key Learnings

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• 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

Key Learnings

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• 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

Key Learnings

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Reassessment of evidence is just the beginning of this journey……