In 2016, Express Scripts Canada’s analysis of private-plan spending trends once again reflected opposing cost forces.  Factors driving an increase in drug spend have outweighed downward pressure on drug costs. At the same time, high-cost drugs and high-cost patients continued to create troubling trend acceleration.

These new medicines offer high cure rates for formerly incurable diseases, transform previously fatal diseases into chronic conditions, and provide a much greater quality of life for many Canadians. But the often staggering costs of these drugs have created unmanageable financial burdens for families and plan sponsors. More and more patients are finding they can’t afford the medications their doctors prescribe them. More plan sponsors are limiting employee access to treatment coverage in an attempt to protect plan sustainability without understanding that they have better options.

Parallel to these developments is the ageing of Canada’s population and the related increase in chronic diseases. Of greatest concern to private plan sponsors is the rising number of working-age individuals with multiple chronic conditions that require numerous treatments often prescribed by many doctors and specialists without care coordination.

The combined result of these factors is treatment complexity that, without effective intervention, overwhelms plan members and potentially leads to worsening health and more expensive therapies. These members need expert guidance at key decision points. Sponsors need to implement effective plan management solutions now, before cost increases become insurmountable.

Over the last three years, these forces—extremely high-cost drugs and the rising number of plan members with multiple chronic conditions—have garnered increasing public attention. For plan sponsors, however, the perception of urgency has been lessened by the corresponding effect of generic pricing.

We are now at a crossroads -the cost impact of patent expiries is slowing, while that of high-cost drugs and patients with multiple chronic conditions continues to accelerate.


Astonishingly, just 14% of plan members account for 72% of total plan spending.

In 2011, members with annual claims of more than $10,000 represented 18.1% of total spending; by 2016, that number had increased by 60%, up to 28.8%.

The evidence shows that individuals with total annual claims between $1,000 and $10,000, and those whose annual claims are over $10,000, need help:

  • Making treatment decisions;
  • Managing their multiple chronic conditions (an average of 5.9 and 7.3 respectively);
  • Coordinating care, provided by an average of 3.4 and 4.5 physicians respectively;
  • Managing their many medications, an average of 8.3 and 10.5 respectively.

Innovative solutions are required to help these members make better decisions to manage their overall costs and health.

In this rapidly changing environment, most Canadians simply do not have the clinical knowledge they need to determine which drug is the most cost-effective, clinically appropriate option for their treatment. The difference between the best decision and a sub-optimal decision can be tens of thousands of dollars. Express Scripts Canada’s research shows that optimizing spending on traditional maintenance drugs through pharmacy services that engage patients and influence better decisions can help fund access to new high-cost drugs.

Spending on high-cost specialty drugs (those used to treat complex, chronic conditions such as severe rheumatoid arthritis, hepatitis C and cancer) has grown from 13% of total drug spending in 2007 to 30% in 2016.

Tighter plan management and the successful completion of treatment for many hepatitis C Canadian patients moderated the specialty trend to 3.2% in 2016, a welcome respite after years of double-digit increases.

Excluding hepatitis C medications, however, the specialty category trend was 10.7% in 2016.

One out of every five dollars spent on prescription drugs in 2016 paid for medication for diabetes or an inflammatory condition.

Trend on inflammatory conditions was 11.7% primarily due to an increase in utilization including expanding indications for high-cost, anti-inflammatory medications.

The uptake of newer, more expensive diabetes drugs contributed to a trend of 13.7% in this category. But our analysis also shows that an alarming number of patients were not treated in accordance with the Canadian Diabetes Association’s Clinical Practice Guidelines, an example of an opportunity to potentially improve care while lowering
costs with tighter plan management.

There was also double-digit trend growth on cancer and attention-deficit hyperactivity disorder medications during 2016.

Biosimilars—drugs that provide alternatives to high-cost biologics that have reached patent expiration—are entering the market, but the associated cost savings is not comparable to that of generic drugs.

Cancer treatments dominate the drug development pipeline, and a continued shift from hospital-administered drugs (covered by public plans) to self-administered drugs is expected to mean more claims and higher costs in the future.


Given the number of challenges each plan member is currently facing, lightly managed plans—those that only react to claims—cannot control rising spending or help members achieve better health. But by focusing their plan management efforts on empowering these members to make more effective, informed decisions, sponsors can protect the long-term
sustainability of their drug benefit while supporting better health outcomes for employees and their families.

Tightly managed plans align drug utilization with clinical guidelines, empower members at critical decision points and provide comprehensive care to members with multiple chronic conditions. These plans leverage clinical expertise and data analytics. In addition, they incorporate synergistic management techniques, including formulary, utilization and clinical management tools to provide the best possible patient care at the lowest possible cost.