User:Oceanflynn/sandbox/Express Scripts Canada

Express Scripts Canada established in 1996, with its headquarters in Mississauga, Ontario, is a registered business name of ESI Canada (Express Scripts Inc), an Ontario partnership indirectly controlled and indirectly owned by St. Louis, Missouri-based Express Scripts Holding Company—the largest pharmacy benefit management (PBM) organization in the United States. Express Scripts Canada is a Pharmacy Benefit Management (PBM) service that also offers claims processing, benefit-plan design consultation and home prescription delivery services focusing on maintenance medications—any medication the patient will be on for three months or more— which represent about 60 per cent of prescriptions sold today. ESC processes "over 100 million drug, dental and other health care claims each year in Canada."

History
ESC was launched in 1996. In their 1998 report to investors Express Scripts, Inc. (NASDAQ:ESRX)—Express Scripts Holding Company—reported that the enrollment in Express Scripts’ programs in Canada had grown to "1.1 million lives." Express Scripts Holding Company "operates its business through two segments: Pharmacy Benefit Management (PBM) and Other Business Operations. The Pharmacy Benefit Management segment provides domestic and Canadian retail network pharmacy management, home delivery pharmacy services, benefit design consultation and drug utilization review. ES's Other Business Operations segment provides distribution of pharmaceuticals and medical supplies to providers and clinics, scientific evidence to guide the safe, effective and affordable use of medicines."

Since 2009 Express Script has had a contract with Health Canada's Non-Insured Health Benefits (NIHB)—a "national program that provides coverage to eligible registered First Nations and recognized Inuit."

Starting in 2011 ESC began offering their PBM service to insurance carriers, such as Desjardins, Manulife, Empire Life Insurance Company, third‐party administrators, plan sponsors/employers-Canadian Pacific, Canada Post,  Home Depot, and the public sector—Health Canada (NIHB). The offer management of group benefit plans.

By 2012 Express Scripts Canada had received regulatory approval to open four central pharmacies in each of "Ontario, British Columbia, New Brunswick and Manitoba to serve all of Canada except Quebec." They are fully licensed and accredited in Canada. "In July 2012, Express Scripts Pharmacy Central Ltd. was granted a licence to operate a pharmacy in the province of Manitoba by the Manitoba Pharmaceutical Association (MPhA). As such it abides by and is fully compliant with the laws and regulations established by the MPhA." The Burnaby-based central pharmacy serves plan members in British Columbia and Alberta since it was granted accreditation by the College of Pharmacists of British Columbia in 2012.

Insurance companies such as Manulife, Desjardins began to offer Express Script's "Pharmacy Benefit Management (PBM) service and home delivery of maintenance prescription medications.

Express Scripts Canada has a central dispensing pharmacy service with home delivery of prescription medications.

By 2013 Express Scripts Canada's major clients included Canadian Pacific, Canada Post, SCI Logistics, and the retired teachers for the Ontario Teachers Insurance Plan. Express Scripts Canada is a "registered business name of both ESI Canada and Express Scripts Canada Services, each an Ontario partnership."

Manulife uses ESC as their pharmacy benefits manager and depends on ESC research (ESI) to develop their Manulife Managed Formulary (MMF).

""According to our pharmacy benefits manager, Express Scripts Canada® (ESC), generic drugs cost between 25% and 85% less than brand name medications. To maximize the savings potential of the formulary, the MMF applies generic pricing. Generic substitution ensures that coverage is limited to the price of the lowest-cost alternative.""

- Manulife

In 2014 the Empire Life Insurance Company signed an agreement with Express Scripts Canada to provide pharmacy benefit management services to its group customers.

NIHB
Health Canada's Non-Insured Health Benefits (NIHB)—a "national program that provides coverage to eligible registered First Nations and recognized Inuit." uses ESI's "integrated pharmacy benefit management (PBM) services to insurers, third-party administrators, plan sponsors and the public sector, including health-claims adjudication and processing services, Home Delivery Pharmacy Services, benefit-design consultation, drug-utilization review, formulary management, and medical and drug-data analysis services."

"Non-Insured Health Benefits directorate, claims for medical supplies and equipment, pharmaceutical drugs, and dental services for all eligible First Nations and Inuit in Canada are processed through the national Health Information and Claims Processing System (HICPS)." In 2009 "Express Scripts Incorporated (ESI) Canada, a Toronto-based claims processor, assumed responsibility for managing HICPS.

""Until 2009, the contractor was responsible for subcontracting a third party to operate the HICPS, the system that processes claims. Given that the contracted firms are also responsible for processing claims for most private insurance companies, Health Canada’s rationale for contracting-out these services is that the firms’ capital and labour resources can be used more efficiently in the context of claims processing, thereby offering lower administrative costs...In Nunavut’s case, there are several challenges associated with this system. First, for providers serving smaller communities on a scheduled basis, adequate infrastructure necessary for accessing broadband internet is often absent or severely lacking.[178] As a result, the ability to submit claims online and receive confirmation for approval is sometimes constrained. NIHB administrators have attempted to mitigate these challenges by allowing providers to receive approval over the phone... However, if telephone services are interrupted, or delays occur in receiving confirmation over the telephone, providers may proceed with the procedure, later receiving notification that the claim was rejected. Importantly, under the terms and conditions for the NIHB program, the provider is responsible for absorbing this cost, a clear barrier to recruiting dentists to remote communities.""

- Moeller 2013:71-2 MA thesis

NIHB also contracted ESI with dental services,

""[N]inety per cent of services offered to eligible beneficiaries, claims are submitted to a contracted third party – Express Scripts Canada (ESI) since 2009 – who are then responsible for payment and flagging of any irregular bills. The processing of claims generally takes longer than most private insurers, and the auditing process is considered invasive and time-consuming by dentists. Furthermore, the contract which NIHB requires dentists to sign contains a termination clause that allows ESI Canada, in consultation with Health Canada, to unilaterally terminate a dentist from the plan. These administrative conditions may compound the already challenging environment for attracting and retaining dentists in Nunavut.""

- Moeller 2013:131 MA thesis 2

""The system as it exists today. I argue that, while the current system offers useful checks and balances for ensuring that patients are not over-treated by dentists and that inappropriate claims submitted by providers are identified and recovered, the claims processing system nevertheless presents barriers for delivering the most effective care to patients, particularly in Nunavut’s case.""

- Moeller 2013:70 MA thesis

Strategies
ESC uses strategies developed by its American parent company Express Scripts. They economize by using lower cost generics by default, in consultation with individual doctors who write the prescriptions. They only offer an online home delivery pharmacy that dispenses prescriptions. They focus on 'maintenance prescriptions'—any medication the patient will be on for three months or more— which represent about 60 per cent of prescriptions sold today. Other prescriptions for acute conditions, for example antibiotics are still dispensed by the member's local pharmacy under the sponsor's insurance. They fill prescriptions for 90-day supply by default and with an automatic refill service which means only one dispensing fee and less administration. They claim this saves the environment by limiting the number of trips to the local pharmacy. They use a behavioral science advisory board to implement their patented consumerology which includes methods to "activate good intentions." According to Forbes, once a sponsor or employer partners with ECS's PBM, they "entice," "nudge", or "[push] consumers to either move to home delivery of maintenance drugs or make a deliberate decision not to." Once ESC's PBM are managing the sponsor's group benefit plan, the sponsor/employer inform employees that from a specified date forward the employee/beneficiary "will 100% of the cost for maintenance medication out-of-pocket" and they will not be reimbursed if they choose to not enroll as a ESC Pharmacy member. By eliminating the services of the local pharmacist and offering only online consultations with pharmacists, they claim they also cut costs.

Instead of patients ES refers to plan members of management of a group benefit plan.

""Its strategy is to entice members of plans that sign on with it for other management services to buy from its home delivery pharmacy their “maintenance” prescriptions: those used repeatedly for chronic conditions such as asthma and diabetes, together representing about 60 per cent of prescriptions sold today... In its U.S. home base, Express Scripts’ pharmacy sells expensive specialty drugs and observers believe it’s just a matter of time before the firm expands to those drugs also in Canada, threatening one of the most lucrative businesses of drugstores.""

- Globe and Mail 2012

Prior authorization of benefits (PBA)
ESC may require prior authorization of benefit (PAB) from a doctor for certain drugs for very specific medical conditions. ESC claims the PAB "provides a safe and affordable pharmacy benefit." The decision to cover the medication is "primarily based on Health Canada approved indication(s) and on supporting evidence-based medicine."

Generics
Insurers and sponsors faced with the patent crisis-when the patent for over 35% of drugs purchased in 2009 will expire between 2010 and 2014, looked to adopting measures that would favour generic drugs. "

On "average generic drugs cost 25 to 50% less than brand-name drugs."

Online pharmacy
While Express Scripts claims to not be an online pharmacy, request for prescription transfers, renewals and refills are made online, by phone at a toll-free number or by mail. and the Globe and Mail described them as "new online home delivery pharmacy." ESC launched their online prescription manager for Pharmacy Benefit Management members in November 2011. The launch was announced on the Canadian Healthcare Network as a new business model,

""Express Scripts Canada has introduced a new business model targeted at Canadian drug plan sponsors and touted as a way to better control costs of prescription drugs and improve health outcomes. Home delivery of maintenance prescription drugs is part of the newly expanded pharmacy benefits management offerings. Express Scripts claims that by using proprietary behavioural economics research-based practices, the mail order and auto refill service will improve adherence and health outcomes.""

- Canadian Healthcare Network 2011

Electronic claims
Desjardins Insurance's, which is part of Desjardins Group, one of Canada's five largest life insurers serving over five million people in Canada, uses Express Scripts Canada as their "electronic claims processing partner" to service an "extensive network of providers representing 100% of pharmacies across Canada."

Pharmacy benefit management (PBM)
PBMs act as intermediaries between the payor—insurer and sponsors, usually corporations, businesses and/or employers with group benefit programs—and the consumer in the health-care system. "They make money through service fees from large customer contracts for processing prescriptions, operating mail-order pharmacies, and negotiating with pharmacies and drug makers." More than half of the $263-billion PBM market in the US in 2014, was held by CVS Health and Express Scripts Holding Co. They use scale to negotiate with drug manufacturers. Because ESRX is the largest PBM in the US, they have "more bargaining power against drug makers manufacturers, pharmacies, and wholesalers. ESC operate on the side of pharmacy not doctors and/or hospitals. ESC acts as PBM to insurers—such as Manulife, Desjardin and Empire Life Insurance Company—offering services to its group customers, the sponsors or employees—such as CP, Canada Post and Home Depot. ECS aligns its interests with these insurers and employer/sponsors. Becoming a member of ECS Pharmacy is not an option for employees or beneficiaries. They must enroll for ECS's home delivery pharmacy for their 'maintenance' prescriptions—any medication the patient will be on for three months or more— —for example, medications used "repeatedly for chronic conditions such as asthma and diabetes." As maintenance medications represent about "60 per cent of prescriptions sold today" this affects many individual insurance beneficiaries. There is a a hefty penalty if individual employees, for example, do not act quickly and become a ECS 'member'—they are warned (usually by their employer's Human Resources department) that they will pay have to for 100% of their own maintenance medication if they do not enroll either on-line or by phone by a specified date. ECS calls these warnings, a nudge based on the cosumerology, a brain child of the parent company's behavioral science advisory board.

Insurance companies hire Express Script to adjudicate claims such as drug benefits offered by an employer. Express Script Canada use Express Script's approach called Consumerology®, a "convergence of the behavioural sciences and health care" to lower costs. In an article published in Forbes reporting on the annual meeting of the Society for Medical Decision Making held in Chicago in 2011, journalist Michael Millenson quoted Kit Sundararaman who described how Express Script uses a behavioral science advisory board to help implement “consumerology." The goal is

""to help our members make better choices" ... [to be more adherent to therapy, to choose]..."better channels for receiving drugs" ...[the less costly pharmacy network or home delivery]...[and to make a better brand-generic decisions]..."You can’t assume that people are doing what they want to be doing...Humans are wired for inattention and inertia, not engagement and choice. It’s not thinking about pharmacy benefit.""

- Kit Sundararaman, PhD, Express Scripted quoted in Forbes

Millenson questioned the way in which Express Scripts "pushed consumers to either move to home delivery of maintenance drugs or make a deliberate decision not to." One of the sessions called "From a Nudge to a Shove: How Big a Role for Shared Decision Making?" was exemplified by one questioner who asked, "What about nudging the elderly lady to choose home delivery of drugs when dressing up to go see the pharmacist is a regular part of her life (as one questioner suggested)? What is the balance between personal freedom and societal obligations?" What Express Scripts called 'activating good intentions' researchers conceded that "these approaches seem to edge near the line separating empowerment from entrapment."

Shipping and delivery
Medications are delivered by mail. Express Script Canada deals mainly with maintenance medications and mails a 90 day supply with a dispensing fee. Express Scripts Canada will send medications as an "expedited parcel mail through Canada Post – at no charge – in tamper-resistant packaging" in a discreet, unmarked package that protects privacy. Home Depot for example encourages employees to use the Canada Post's FlexDelivery through which a patient can pick up their packages free of charge from any post office.

Specialty drugs
Express Scripts Canada distribute specialty drugs—"higher cost biological drugs that are often injected or infused" and are derived from a "living organism and not synthetically made from chemicals." Express Scripts Canada Pharmacy mails temperature sensitive medications, such as insulin or eye drops in freezer packs.

Specialty drugs represent only "2% of claims but continues to grow as a percentage of total drug spending, steadily increasing from 13.2% in 2007 to 26.5% in 2014."

Patient - physican - pharmacist - province
Express Scripts Canada provides a pharmacy service with licensed pharmacists in Ontario and participating provinces. Pharmacists are on call to consult with individual patients 24 hours a day seven days a week. Maintenance prescriptions are filled up to a 90 day supply with a $9 dispensing fee. Express Scripts works with patients and their doctors "to choose safe, approved, lower-cost medications, where possible." Once a patient becomes a member, Express Scripts will have access to a patient's personal health and medication information.

Pharmacy Network Management
"Express Scripts Canada maintains contracts with virtually all Canadian pharmacies, including chains and independents" allowing them "to reduce costs for insurance carriers, third-party administrators and the public sector by arranging for bulk payment of the pharmacy providers."

Formulary Management
Express Scripts creates, updates monthly and uses a drug formulary—preferred list of drugs—Express Scripts Canada has a number of drug plans for employers to lower costs through managed tiered formularies to determine which prescription medications should be covered by their plan. This also includes a Dynamic Therapeutic Formulary (DTF) which is two-tiered—consisting of "a defined list of drugs that are reviewed on a monthly basis." If a more inexpensive alternative—a generic for example—becomes available it can replace the more expensive drug. For example if a patient that has been using synthroid for years may be forced to switch to Armour or levothyroxine.

Manulife uses ESC as their pharmacy benefits manager and depends on ESC research (ESI) to develop their Manulife Managed Formulary (MMF).

Express Script's Annual Drug Trend Report
In their 1999 report ES predicted that drug expenditures—which had been rising ever since they published their first report in 1993—would decline because of a decrease in price inflation. In 1999 the per member per year (PMPY) Average Wholesale Price (AWP) annual growth increased by 17.4%. They argued that payers or sponsors should adopt plan designs that encourage "more cost-conscious consumer behavior," that would result in a "decline in drug utilization." They anticipated that these plan designs would "encourage the use of less expensive but therapeutically efficacious products" and this would be "reinforced by physician online prescription writing."

In 2012, as drug prices declined pharmacies in Canada compensated by "increasing drastically the dispensing fees for private plans. Similar tactics appear to be in place in the Western provinces and the territories where average dispensing fees for private plans increased up to 5.5% from 2011 to 2012."

According to Express Scripts Canada (2013), "private drug plans wasted $5.1 billion in 2012 because they either reimbursed medicines that were more expensive without providing additional therapeutic value, or because they paid unnecessary dispensing fees."

According to Express Scripts Canada's 2015 "Drug Trend Report" speciality drugs for chronic, complex conditions such as cancer and hepatitis C — "grew at alarming rates in 2014." The report also found that "Spending on traditional prescription drugs - those used to treat common conditions such as high blood pressure - declined by 0.3 %. This slight downward trend is driven by lower generic prices resulting from pan-Canadian Pharmaceutical Alliance pricing agreements, as well as an increase in the availability of generic options due to patent expiries."

"According to Express Scripts Canada, average generic drug prices have fallen 28% since 2010." Express Scripts Canada’s 2015 Drug Trend Report—"based on drug claim data for more than seven million Canadians—found that the cost associated with specialty drugs continued to rise in 2014, seeing growth of around 12%."

Complaints
When Canadian Pacific partnered with Express Scripts in 2012 for most of its 14,000 Canadian employees, they stopped drug benefit coverage of its "unionized plan members if they [bought] their maintenance prescription drugs elsewhere." The Teamsters union which represents about 3,500 CP maintenance employees listed a number of complaints such as "problems getting drugs, including insulin, shipped to them on time, forcing them to pay out of pocket for the prescription at a local pharmacy" and "getting through to the Express Scripts hotline can be time-consuming." Judy Au, CP’s human resources director denied there were problems. In 2012 CP estimated that it would save "at least $1-million over three years on an annual $5.2-million spending on maintenance drugs from using Express Scripts."

Concerns
Independent pharmacies are concerned that Express Scripts Canada will "drain business from them and limit patient choice." A Toronto pharmacist noted that, "A lot of pharmacists like myself are seeing this as a trend, and there’s nothing we can do to stop it but find some way to draw attention to it." Pharmacy groups warn that the Express Script's online pharmacy "market clout (it’s estimated to have nearly a third of the U.S. prescription market) will limit competition" in Canada as well.

Pharmasave pharmacist Ryan Haggarty explained how ESC clients would have their maintenance medications provided to them via a "delivery from ESC’s central pharmacy in Winnipeg."

""The first, and perhaps biggest ethical issue is that ESC has forced its beneficiaries into this service. To continue receiving drug benefits, they must accept the terms and conditions laid out by ESC...The patient that I spoke with expressed his outrage regarding this ultimatum, as neither he nor his fellow employees were given the option to opt out of using the central pharmacy without losing their drug benefits.""

- Pharmasave pharmacist Ryan Haggarty

Haggarty questioned how a "mail order system operating out of one province [can provide] services to clients in another province."

""Being that pharmacy laws and regulations differ (sometimes significantly) from province to province, by providing dispensing services to clients outside of its home province, I question how this pharmacy can function within the laws of each individual province... In Saskatchewan, we have the Pharmaceutical Information Program (PIP), on which all prescriptions filled in the province are captured for health care professionals within the circle of care to view when necessary. With prescriptions being filled outside of Saskatchewan, they do not appear on PIP. Some provinces have similar systems in place, but I am speaking only for Saskatchewan here. There are a number of situations where this becomes problematic, and potentially very dangerous.""

- Pharmasave pharmacist Ryan Haggarty

Provincial laws vary for example in maximum dispensing quantities. Saskatchewan has its own unique Prescription Review Program which "dictates what information must appear on prescriptions for controlled and targeted substances."

NIHB also contracted ESI with dental services and the impact on Nunavut has been positive in terms of administrative costs and negative in terms of barriers to effective care for patients.

""[N]inety per cent of services offered to eligible beneficiaries, claims are submitted to a contracted third party – Express Scripts Canada (ESI) since 2009 – who are then responsible for payment and flagging of any irregular bills. The processing of claims generally takes longer than most private insurers, and the auditing process is considered invasive and time-consuming by dentists. Furthermore, the contract which NIHB requires dentists to sign contains a termination clause that allows ESI Canada, in consultation with Health Canada, to unilaterally terminate a dentist from the plan. These administrative conditions may compound the already challenging environment for attracting and retaining dentists in Nunavut.""

- Moeller 2013:71 MA thesis 2

""The system as it exists today. I argue that, while the current system offers useful checks and balances for ensuring that patients are not over-treated by dentists and that inappropriate claims submitted by providers are identified and recovered, the claims processing system nevertheless presents barriers for delivering the most effective care to patients, particularly in Nunavut’s case.""

- Moeller 2013:70 MA thesis

""By signing on as a provider with the Program’s claims processor (ESI Canada), dentists are subject to the terms and conditions of the twenty page Dental Claims Submission Kit which contains legal wording. Several dentists who were interviewed for this thesis confirmed that no other insurance plan in Canada requires this extent of a contractual commitment...Under the terms and conditions of the Dental Provider Enrolment Form required for claims to be processed by ESI, the provider must “submit to and assist in any audit conducted by Express Scripts Canada of claims submitted through the NIHB program.” The impacts of this obligation are compounded for providers in Nunavut, as one individual suggests: “…if you [the provider] do not cooperate with [the auditor], they [NIHB] can remove your billing privileges for that segment of the population, which in [the case of Nunavut’s providers] would be a significant portion of somebody’s income. Dentists on an individual basis, or even [regional] dental associations, do not have the financial wherewithal or the political capital to fight the NIHB and the federal government in court.""

- Moeller 2013:81 MA thesis

""[T]he desk audit and the on-site audit programs require dentists to provide auditors with patients’ personal health information, which may create legal and moral hesitations for dentists. The ability for NIHB authorities to unilaterally terminate the billing privileges for dentists who fail to comply leaves providers relatively powerless to contest this policy. Importantly, these elements create an environment which hampers the attraction and retention of the most-qualified and committed providers for Nunavut’s population.""

- Moeller 2013:83 MA thesis