Working Together for Better Health Benefits

Express Scripts Canada

A subsidiary of its parent company, Express Scripts in the United States, the Canadian branch has been in operation for nearly 17 years. President Michael Biskey explains that the organization has traditionally adjudicated health benefit claims such as drug, dental, medical supplies and equipment claims. “When a company decides to provide a benefit to their employee base, say a drug benefit for example, it is essentially administered by its insurance company who has asked us to adjudicate the claims,” he says. “We make sure the patient is covered by a health plan through the employer, then we figure out what they owe versus what the company pays.

“We decided to take a look at how to implement better drug plans here in Canada,” Mr. Biskey continues. “What we now do is work hand in hand with an employee of a company that happens to need drugs from a plan. We help them to understand their plan better and to use their benefits more effectively.”

Clients are often prescribed newer high cost medications or treatments that do not generate any additional health benefits over established lower cost therapies, Mr. Biskey explains, “We work with you and your doctor to establish perhaps a less expensive medication with the same results. People are quite often prescribed medications that are too expensive and the doctor has no inside information on drug costs and on the patient’s status as far as what their drug plan pays and what they are supposed to pay.” He adds that, “often the patient does not even know what their drug benefit plan encompasses and so what we do is bring all that information together in one place. We help the patient to understand what their choices are and of course we are here to help them make the best choice. We don’t do anything unless both the patient and physician collectively agree to the outcome.”

Patients enrol in the Express Scripts service through the company’s website or over the phone via its toll free number; the process typically takes just five to ten minutes. Once enrolled, the patient’s physician can either fax the prescription to an Express Scripts pharmacy, or the patient can mail the hard copy of the prescription if there isn’t one nearby. The company then works with the patient and physician to ensure they have the most affordable effective medication. Mr. Biskey explains, “We tend to use the pharmacy for maintenance medications, meaning daily medications that are needed day in and day out over the long term.”

Express Scripts Canada has quickly become known as a game changer in Canada’s health insurance industry, serving such major clients as Canadian Pacific, Canada Post, SCI Logistics, and the retired teachers for the Ontario Teachers Insurance Plan. Mr. Biskey reflects that, “The reason we are so successful is because we actually provide a better drug benefit service for the employees at a lower cost for the employer and for the employee. When the employer saves money, we make money.”

He adds, “Ultimately there are no competitors doing what we are doing. We help the patient and their physician make better decisions considering their therapy options and the patient’s drug benefit plan.” Express Scripts Canada maintains a competitive edge in business by keeping up with the most modern techniques and technological possibilities in the industry.

While the Canadian branch maintains a positive relationship with its parent headquarters in St. Louis, Missouri, each subsidiary is managed separately, enabling Express Scripts Canada to learn and adapt to the optimal procedures to use north of the border. “Whether benefit or drug plan, we are going to apply the same best practises,” says Mr. Biskey. “Everything is done in Canada; we just leverage the best ideas from the United States.”

Express Scripts employs a team of licensed pharmacists that work together with its patients along with clinicians who take part in the analysis of benefit plan design. “We basically provide a pharmacy service with licensed Pharmacists in Ontario and participating provinces that help the patients and their physicians make those difficult decisions,” Mr. Biskey explains. The company works together with the employer and the insurance company to manage the drug benefits and provides advanced communication materials and technologies to communicate with clients at the start of the benefit year to explain what their plan covers.

The company also goes the extra mile to provide its clients with top-of-the-line service, including a rigorous training regime for its employees and free home delivery for prescriptions. Temperature sensitive medications, such as insulin or eye drops, are shipped with freezer packs, and all deliveries are packed in discreet boxes to preserve the patient’s privacy.

One of Express Scripts’ missions is to reduce waste that occurs when medications are not used properly. Mr. Biskey explains that there are two kinds of waste in the industry, the first being a drug-mix waste which occurs when the patient is taking a higher cost medication when there is a lower cost medication available that delivers the same results. A channel waste occurs when the patient uses a pharmacy with higher dispensing fees or when a client gets their prescription filled more often than they may need.

“Express Scripts Canada does the most in-depth research in the country for use of drug benefits,” shares Mr. Biskey. “In fact, hundreds of people come after us each year for the research we do.” The company evaluates what private plans are spending the most money on, comparing the number of prescriptions as well as costs for various prescriptions. “In terms of what are the most prevalent types of prescriptions that we do adjudicate, the top three are [for] high blood pressure, antibiotics and depression,” notes John Herbert, head of the Research Department. “On the cost side of things, the most costly conditions in Canada would include the above conditions but also inflammatory conditions. Conditions such as rheumatoid arthritis, Psoriasis and Crohn’s may have a small percentage of affected individuals but the spending is high to treat these conditions.”

Some biopharmaceuticals are also distributed by Express Scripts Canada. Mr. Herbert adds, “Higher cost biological drugs are often injected or infused. These drugs are derived from a living organism and not synthetically made from chemicals so they can get quite expensive.”

Express Scripts’ record of environmental responsibility has also made the company stand out. While health claims adjudication might not seem like a business with a large carbon footprint, Express Scripts goes to great lengths to reduce its paper consumption and ensure all its deliveries in a given day occur in a single trip. “The service itself means people do not have to leave their homes as much and therefore saves time and money,” explains Mr. Biskey. “We are able to move to a 90 day supply option and ship directly to people’s homes so they do not end up having to pay extra dispensing fees at the pharmacy.” It also means the client no longer has to make a special trip, driving to the pharmacy.

Currently, Express Scripts Canada is working on additional best practices that will optimize therapies for patients and the company is continually making strides to help its clients adhere to medications when they need them most. Describing one of the company’s current development plans, Mr. Biskey says Express Scripts “will be improving on the current drug formularies and other tools to help the patient determine and move to lower cost, clinically effective drug alternatives.”

As drug costs continue to rise while companies are still faced with the need to provide the best possible health benefits to their employees, innovative services like Express Scripts help businesses enhance their existing employee benefits at a lower cost, resulting in overall better service for everyone.

December 19, 2018, 3:07 AM EST