The Benefits Connexion Podcast

Back to the Future! CLHIA’s perspective on a journey through the pandemic and beyond

Connex Health

Joining Denise Balch for this podcast is Joan Weir, recently appointed Vice President, Group Benefits, at the Canadian Life and Health Insurance Association (CLHIA). 

Joan and Denise will explore key areas of change in employee benefits:

  • The insurance industry response to COVID-19 and the aftermath, including insights into long COVID and COVID-related disability trends
  • The CLHIA Fact Book 
  • CLHIA and drugs for rare diseases
  • Pharmacare and new data on the uninsured
  • Publicly funded dental benefits
  • Paramedical benefit trends
  • Prior authorization and an electronic submission solution
  • Pharmacy claim standards
  • Vision care beyond vision correction – closing the gaps on diagnosing disease
  • Vaccines and their place in group benefit plans

Hear directly from CLHIA on these important developments in group benefits that will affect plan sponsors.

This podcast is free. Thank you to our season sponsors for the Benefits Breakfast Club for making this podcast possible.

Find out more information on upcoming podcasts and webinars at www.connexhc.com.

Denise Balch:

My name is Denise Balch. I'm the president of Connex Health and I'd like to welcome everyone to the next in our podcast series with industry leaders. My guest today is Joan Weir, who is the recently appointed Vice President of group benefits for the Canadian Life and Health Insurance Association (CLHIA), a voluntary trade association with member companies that account for 99% of Canada's life and health insurance business. In her role, Joan is responsible for analysis on industry issues, policy strategy development, and to build consensus on concerns important to remember companies. An important part of the health portfolio is working with industry, including with national healthcare associations, as well as with provincial and federal payors on benefit programs, specifically on best practices, strategy, advocacy, and sustainability. Joan has been with CLHIA for more than seven years, starting originally as the director of health and disability policy, she also brings over 20 years of benefits management experience and expertise to her position at CLHIA having worked for insurers and administrators on both private and public sector programs, notably with first Canadian Health and Health Canada, on the NIHB program, and most recently with Medavie Blue Cross. So Joan, welcome, and thanks for being here today. The last time we spoke was at our very first podcast recording almost three years ago at the very beginning of COVID lockdown, and we largely that time talked about out of country travel, but, today we're going to talk about that and so much more. So perhaps we can start with an update on how the insurance industry responded to COVID-19, and then the aftermath, which of course we're still dealing with.

Joan Weir:

Sure. Well, first of all, thank you for having me, Denise, I really appreciate the opportunity to get caught up with you on a whole bunch of different issues. So on your first one there with respect to COVID-19, you know, it did start as a travel insurance issue, and it's continued to be such over the past - well, it continues today. It has changed because now we have travel ongoing, we've enlarged that and most people are traveling. But the concerns still continue with cancelled flights, with baggage that's been lost, and particularly here in Canada, we've been grappling with that. And so the insurance industry continues to grapple with those kinds of claims. So that continues. On the other sides, you know, we had the health and dental clinic shutdown back in 2020. Just want to mention a stat with the dental side of things, because on the dental side of things, they never fully recovered in 2020. Although clinics reopened in May timeframe, people didn't go back for their dental care in 2020. Well, they did in 2021. And the stat is that's fully recovered now. And so it hit a new high of- I think it was $9.2 billion - paid out for dental care. And then the last point I'd say is, you know, pretty much we're back to operating normally or as we had in the past, we did see an impact on life claims in 2020 and 2021. Which stands to reason. But that's one impact. We did see. And then the last point I'll make here is that we hear a lot in the media about long COVID, long haul COVID, and disability claims. And just to say that we as an industry are not really seeing in that impact- sure, there are claims out there for long haul COVID and, you know, as we know, it's very difficult to really diagnose it. It's a whole range of symptoms that can look like other symptoms of other diseases. But we haven't seen that impact.

Denise Balch:

That's about the only good news I've heard on the disability front for years. Of course, mental health has been significantly on the rise, but that's not normally associated with long COVID.

Joan Weir:

No, but you're right. I think the fact is that about 50% of claims are primarily mental health now, and of course, many of the rest of them that are maybe cancer or stroke or otherwise have a mental health component of them as well. So it definitely is a huge impact on the industry.

Denise Balch:

No, for sure. And just as an aside issue, just going back to travel for a minute and I know that you traveled this summer and I've got a flight my first flight coming up in the last few years and you're still a little bit anxious. But now I have a group travel coverage plan but have had the rates for those gone up? Have we seen, you know, that insurers have had to increase rates because of the increased claim payout?

Joan Weir:

Well, my thinking is probably not because associated with the increased claim payout for travel that travel claims such as baggage and trip cancellation and all of that - there has been a corresponding decrease in the medical side of claims because people weren't traveling during that period. So, a bit of an offset there.

Denise Balch:

Okay, okay. Well, that's good news. Good. Now, when we were prepping for this call, and we were sort of going through, oh, you know, what are we going to talk about, what's new, you mentioned that CLHIA has just published new industry data, but you didn't tell me much about it. So, I'm looking forward to hearing all about it on this call. So maybe you can tell us about the trends you're seeing.

Joan Weir:

Yes. So we publish our data once a year, it's collected from all of our members. So it's the industry's data across Canada, you will find it if you just go on to the CLHIA website and look for the Fact Book. And this year, the stats are quite interesting, because we cover more Canadians than ever before, we now cover 27 million Canadians for health alone. And if you add in some other products, 29 million Canadians have some kind of insurance with members. We paid out a record 30.4 billion in health claims, that's in 2021. And a lot of that is the recovery of the dental piece that I had mentioned previously. But also we're seeing, as we talked about a little bit, a huge increase in mental health claims. So that's that extended health care benefit where you can access the services of psychologists or social workers, it was, in 2021, 580 million paid out. And that's 45%, more than 2020 and 75%, more than 2019. So really seeing the hit there. And that actually doesn't include any of the the money that comes to from EAP programs, any of the benefits from that, or from other programs like iCBT, or even from disability rehabilitation, it doesn't cover any of that. So this is purely accessing the extended health care benefit. And, you know, we've grown as an industry, we over this past couple of years added 5000 jobs to the insurance sector. So we continue to be one of the biggest sectors within industry in Canada. So really interesting stats, everything seems to have recovered. And we'll see what 2022 brings.

Denise Balch:

2023, or I guess 2022 report because it's retrospective. Right? So 2023 report talks about 2022. Well, that's great. And it's good to know that that's available publicly, and that it's on your website, and just look for the Fact Book. So that's great, I'll make sure that we download that you put that into our resource library for our members. So that's great. So you mentioned increase in spend under extended health. So I'd like to kind of dig into that, as well as a few other things that we talked a little bit about in our prep. One of the things that is I think of concern, and on a lot of people's minds these days, whether they're a patient or physician or an advisor or insurer, is the situation with rare diseases. And we know that, you know, there's more and more drugs that are coming out that are, I would say, beyond the specialty drugs. These are literally drugs for rare diseases, rare disorders, that can be in the hundreds of 1000s. So maybe you can give us an update on the work that CLHIA is doing in this space.

Joan Weir:

Yes, for sure. Well, the drugs for rare disease, as you mentioned, Denise, the pipeline is full of expensive drugs, and particularly for rare diseases. The Canada drug agency and the new agency that overseeing this work has spent the better part of I'm going to say two years consulting with industry and that includes with us, and pulling together a framework or a strategy, because the rare disease space can be complicated because you have drugs that are expensive, but drugs also that maybe don't have as much evidence to support their use. So one of the new tasks that's coming out of CADTH, if they've been tasked with doing this, is to develop a committee that's going to look at real world evidence, as they call it, which is evidence that's built after somebody starts taking a rare disease drug. So it's built into a database. And evidence is collected for that drug, sometimes it means the drug needs to be funded further, sometimes it means not. So that real world evidence committee is something we're hoping to be part of. So that's one of the outreaches we're doing is presenting to CADTH very soon on where and what types of evidence private insurers keep, and how that can be shared with privacy rules in place, how that can be shared into a database that is mutually administered, I guess, by private and public payers. So there's that piece of it.

Denise Balch:

That's fantastic, because that's been an ongoing, you know, critique of CADTH inn the past, that we're not looking at real world evidence that is applicable to the private sector and plan sponsors, and their plan members.

Joan Weir:

Exactly. And I think over time, in the last year, as we've met with them a number of times, they've come to realize that that the information private insurers need is more around productivity and more around, you know, absenteeism from work, making things easier for employees to remain at work and to remain healthy. And so I think that they're seeing the private and public perspectives or maybe complimentary, at that point in time. Yeah, so the one thing I did want to say to the audience about rare disease is, we fully expect and want to be part of the table, part of sharing the funding model, whatever that's going to look like, but also in all of the decision making points. So you know, part of this committee is one step. But there are also other - there's a formulary committee, for instance, that will need to be developed, in order to, I guess, put in place, a formulary of rare disease drugs that is that most or all payers will follow. So that's another piece of it that has not yet started, to my knowledge, but we've put forward that we want to be part of all of the decision making points.

Denise Balch:

Yeah. I think that's another really important point, having that sort of common formulary between payers, I think, will be something that's going to be really valuable, because it is very complex, it's complex enough for an advisor if they're moving plans from one carrier to another. But it's also, even if they don't move, sometimes it's really hard to know, when a drug is going to be covered, particularly a rare disease drug. So that can be that can be tough. So this would be very helpful.

Joan Weir:

Yeah, it would be, and I don't know if I've shared this data point with you before, but we measured how much spend we already do in the rare disease space. We did this work in 2021. So it's 2020 data, and the figure is 650 million was spent in that year on rare disease drugs for 15,000 Canadians who benefited from that.

Denise Balch:

And what is the threshold that moves a drug beyond say, a specialty drug to a rare disease drug? Is there a dollar threshold? Or is it more disease or condition based, diagnosis based?

Joan Weir:

Yeah, well, when we did our data, we had certain conditions around it, and a dollar threshold was part of that. But one of the holdbacks that we've got with working with rare disease with private and public plans together is we really don't have a definition of what that is yet. I think what Health Canada is looking at is a dollar threshold. So in other words, how would we work jointly to fund these drugs, there would be a dollar threshold that private and public payers would pay out and then over that threshold would either be shared with the federal government or the federal government would pick it out, but we don't know what that final model is yet.

Denise Balch:

Okay. Good to know. That's great. Well, it sounds like there's progress being made, and I'm sure that people will be really happy to hear that. The next thing that I know has been, you know, pre-COVID looming, and we have had some stops and starts, is pharmacare. Maybe you can shed some light on where the focus is right now on that.

Joan Weir:

Yes. So one of the things we undertook this year in 2022, was participating in redoing a gap report that we did before with Innovative Medicines Canada and the Conference Board. So this is, if you Google, Gap Report Conference Board, you will find the publication that went out just, I'm going to say, August timeframe. And really it was to take a look at where is and what is the gap for the uncovered for prescription drug plans. And we found that 1.1 million people don't have a prescription drug plan. So there's the gap, and that is 2.8% of Canada's population. So it's a very miniscule number of people that don't have coverage. But we do think that, of course, these people should have some kind of coverage. And so that's the gap measured. Now, what do we do about it? You know, we believe that CLHIA that all Canadians should have access to equitable coverage. And we really support the government's efforts to develop a formulary that could be funded to fill this gap. We don't know how that's going to happen. But we do know that the government – the federal government – through their NDP agreement, has said that one of the cornerstones they will do is they will make sure that there is a pharmacare act, published in 2023. So that's coming up pretty soon. We haven't seen any work start on it yet, and we don't really know what will be included. But I guess that's a 'to see or to come' part of it for 2023.

Denise Balch:

Well, as one of those 1.1 million, I'll be very interested to see what happens. Well, that's good news. And I guess the only thing that – and I'm sure that this is going to be discussed or has been examined, is that, as you know, there is has been some trend towards drug caps, particularly for smaller group plans, or for group plans with a lower smaller number of members. And so is that something that's been examined? Are you aware whether that's been looked at as well?

Joan Weir:

I'm going to say, no, we haven't examined it. We're aware of that trend, you're right - small business, small employers who can't afford to get that million dollar claim. And I guess caps have been a way to do that. I've seen a rise in healthcare spending accounts, that's another way to do that. And stop loss is probably the other way, and certainly have seen growing dollar amounts for stop loss. So it's a concern, especially for the small employer.

Denise Balch:

Yeah. So it's something that I'm sure will be discussed and brought up again. Yeah. And the big elephant in the room dental benefits. Now that the dentist calendars are all full, which I can attest to as well, because trying to get into see my dentist has been totally brutal. But I'm one of those people that pretended that dental care wasn't a necessity during COVID.

Joan Weir:

Yeah, that did happen. For sure. Yeah, the Canada dental benefit. So that was, I think, a surprise to all of us, and it came out of this NDP-Liberal agreement, just a few thoughts about it, or how it's structured. It is for the uninsured. So the federal government has now made it clear that anybody with dental benefits, or having access to dental benefits, is not eligible for this program at all. So it's uninsured. It's based on family income must be below 90,000 per year, they're going to start off with children under the age of 12. Interesting that they will have to apply for it through the Canada Revenue Agency, which kind of mimics how we rolled out CERB and all of the other benefits for the pandemic. But quite a bit of information will need to be given over to CRA including who the dentist is, when the dental appointment is taking place, how much on the employer side of things, that person needs to attest that they don't have dental benefits, and they need to give the name of their employer. I suppose that at some point CRA could audit some of this stuff. But the initial benefit is going to be 650 per year. So that's 2022 this year and next year, per child, to be paid out directly to the parents. On the further program down the line to get to the rest of the uninsured, they'll be gradually added in - people with disabilities, and eventually everybody will be eligible for it who doesn't have insurance. And with the way the government looks to be going down the road with this is they issued an RFI this year for a payer. And so that could be an insurer or it could be a third party administrator. And the word is that they will issue the RFP, next year, so early next year. So this looks to be a federal program that will be administered by a third party, and at that point in time, we'll know more about it, and what benefits might be covered and that sort of thing.

Denise Balch:

Oh, I thought when you said that, you have to apply through Canada Revenue Agency, I was thinking, Oh, well, I guess that's one way not to lay any people off that were involved in the CERB, but maybe not so if they're getting somebody else to administer it.

Joan Weir:

Yeah, I think they're administering only that piece of it, the eligibility piece, because insurers don't look at income for eligibility, right? They don't collect that information. So that would be a piece of it that would have to be done by the federal government. So this is the start of that.

Denise Balch:

So there'll be the gatekeeper basically. Okay. Interesting. Well, we'll look for more on that. I'm sure there'll be lots more. You mentioned going back to one of your first comments was that with COVID, we saw a big increase in healthcare spend on the extended health plans. Paramedical has been kind of a bane of the advisor and plan sponsor existence, particularly in massage therapy benefits in the last sort of five plus years. Can you speak to that at all? Is there anything happening in that area to address that?

Joan Weir:

For sure, we saw the massage therapy benefit increased again this this year. So it does seem to be a trend. Whereas physiotherapy and chiropractic seem to be relatively stable, going up a little bit but relatively stable. Are there concerns with that? I think each insurer, each employer is looking at their benefits to see maybe what limits they might put on, or whether massage therapy might be funded or a different way to look at massage therapy. I know that benefit plans are there for medical necessity, and presumably there's medical necessity in these types of pain benefit payments. But but that would be at each insurer and each employer level. So at that point, yeah, I don't know what else might come down the road on that.

Denise Balch:

Fair enough. You can't be all things to all people. Before we started recording, I mentioned that there was quite a bit happening, at least from my perspective, in the work that I'm doing on electronic Prior Authorization and trying to work with stakeholders to improve the actual process and get it online. Do you have any updates on that or on pharmacy in general?

Joan Weir:

Yeah, for sure. EPA, electronic Prior Authorization is, you know, it's growing in importance. We have a very manual process with paper and that sort of thing, and we know that. So it's top of mind. But I'm going to say that we as an industry aren't addressing it. So I'm not aware of any individual insurers that are - they may be doing some pilots with various PBMs as an example, but at this point in time, there's no industry effort to go down that road. But, I would like to say to you in the audience that we do have some effort in a plan for the pharmacy claims. Electronic service, so pharmacy claims standard. So we've established a joint working group with Canadian Pharmacists Association, as well as Neighbourhood Pharmacies. And the three organizations are working together collaboratively to get the right technical people to the table to build upon some work that was done in 2015. The pharmacy standard itself hasn't been updated for, I'm going to say, at least a decade, probably longer than that. And a lot of new things

are on the table:

pharmacy services, for instance. They are new since the last time the the standard came into place. So that's something we have to look at updating. Plus, there's many other things that need to be updated. And we know that this standard is also used by public plans – many of the public plans, not all of them. So we're reaching out to them to make sure that they have their say into what it is they need to have as well. So we're at the point where we've got a plan. We have a contractor in place and we're planning to have the work done, probably by no later than mid next year, 2023. With that, adjudicators will need to then take that work and build it into their systems. So, good news, because we've had starts and stops with pharmacy. But we seem to be going forward now with a real path and real agreement between the organizations.

Denise Balch:

Definitely, in my discussions with pharmacists, and we've had some podcasts with pharmacists as well, those pharmacy standards definitely is something that they identify that that needs some updating. So it's great to hear that. You know, no wonder your calendars pretty busy, because there's a lot on the go. But it's I think the other thing that's resonating with me is there's a lot of public private collaboration now, I think, probably more than there has been in the past. And it's really nice to hear, because often there's a criticism that, you know, the public does their thing over here, and the private does their thing over here, and they don't really sort of pay attention to each other, and that creates sometimes more challenges, but it's great to hear about the collaboration on so many fronts that's taking place.

Joan Weir:

Yes, and I would just build on that to say it is so many fronts, because it's the pharmacy front, but it's also mental health, we've had many discussions with a few different provinces, as they look to build their mental health care capacity, they want to understand what it is we deliver. So, lots of cooperation.

Denise Balch:

Yeah, it's really good to hear. And I've got a couple more questions before we close off. And one of them, it's on vaccines, but it really speaks also to the larger trend towards prevention, because of course vaccines are part of that prevention toolbox. And while traditionally, they've been the domain of the public sector and public health plans, there are more vaccines available now that are either only covered for people of over a certain age or under a certain age, so it's created a gap in vaccine care. So is this another area that your members and the CLHIA have been looking at? And is there an awareness or a recognition of the need for, you know, for the place for coverage of vaccines and group plans?

Joan Weir:

Yes, so I'll start by saying that, yes, employers, with this very tight job market, are really looking to attract and retain talent. And, to my knowledge, and based on some information coming out of a recent Benefits Canada survey, employers are really looking at their benefits plan to attract and retain these employees, this top talent, and are looking at all kinds of different benefits to bring on. So one of them would be vaccines. Now, anybody who has a healthcare spending account today will be able to put vaccines through there. So that's one place to put it. But there's also the pharmacy services, there's a few vaccines that are covered through there. I'm aware of travel vaccines being covered. So that's another area, and just expanding beyond vaccines. I'm seeing benefit plans out there with really interesting and innovative add ons, for instance, benefits for transgender people. So that's another thing. Indigenous benefits. So we're seeing lots of creativity and, you know, a little bit more diversity and equity and inclusion within benefit plans. I think if you look at the Public Service plan that is going into effect next year, it's already up at their website, you will see very innovative offerings, they do have transgender, they also have lactation consultants, fertility benefits, really interesting benefit plans, but we're seeing that more than just a public service. It's entering into a lot of employer plans. So vaccines are absolutely part of that as prevention.

Denise Balch:

Yeah. So it's positioned pretty well for that. So that's good to hear. Because, you know, certainly as someone who's getting older, and we all are, but of a certain age, there are vaccines that are recommended but not necessarily reimbursed privately, so, certainly I pay extra attention to those. The last one I wanted to touch base with you on before we close out for today, and it actually goes to the comments that you just made made about attracting and retaining employees and plan members, and also prevention, is vision care. You know, I admit my bias because I'm doing some work on this. And I have been doing some work with the Canadian Association of Optometrists. Because vision care plans have remained relatively unchanged. I mean, when, when comprehensive exams were delisted from the provincial plans for adults, then group plans pick them up. But as the technology and the screening for serious eye diseases that can lead to blindness, as that technology has developed, the group plans really haven't kept pace. So can you tell us if there's much of an appetite for really looking at a benefit like vision to, again, increase those sort of preventative and early diagnostic tools that are available?

Joan Weir:

Yeah, I think, yes, vision care plans have really been focused on vision correction, and that's been the case for decades. But you're right, technology has improved, and even the ability in an optometrist office to have a retinal scan or some other type of diagnostic tool that can diagnose disease, can help with that. I think it's really important, and I am seeing insurers and employers who are interested in that. It needs to be an education piece of it, because for the most part, employers probably wouldn't focus on their vision care plan, or probably wouldn't focus on, although it's a highly, highly valued benefit, vision care, might not know the extent of how much things have changed in the optometrist's office. So I do believe we're seeing employers and insurers who are interested in looking at ways to tweak that benefit so there's more of a preventive aspect to it.

Denise Balch:

Yeah, that sounds good. And to me, some of the things that we talked about, like vaccines and and allowance for vision, diagnostics, and, you know, addressing directly some of the trends that we see in paramedical benefits that maybe are pushing the boundaries of whether something is actually medically necessary. I think we're seeing, maybe for the first time in years, an adjustment in the benefits plan environment and a re-examination of our benefit plans to make sure that, as you said, they're not only attracting and retaining, but they're also adding that prevention and management and early diagnosis and opening up opportunities for those changes.

Joan Weir:

Yeah, I would agree, I think this is the first time I have ever seen so much creativity and innovation in benefit plans. So I think definitely the appetite is there.

Denise Balch:

And I think, you know, in some ways, I mean, obviously COVID was devastating in so many ways, but boy oh boy did the payers and insurance companies boogie on making those virtual care agreements with providers, and if they were kind of sitting in a corner, really bringing them to the forefront of their marketing communications to plan sponsors and plan members. So I've got to pat them on the back there. For an industry not known to ever move quickly, they sure did a good job at responding.

Joan Weir:

Yes, agreed. It was an interesting time. And yeah, quick responses. But every industry had to do that.

Denise Balch:

Well, yeah. So there's no excuses, the industry can do it when it wants to. So there's the challenge to keep it up. There's lots to catch up on. So I know we have limited time today. But I would like to just take an opportunity to thank you so much for the insights that you've provided to me today and to our listeners, when we are able to share this podcast in the very near future. And I would encourage folks to, you know, visit the CLHIA site regularly because you've got lots of good stuff on there, and you're always adding to it. And I know that you have conferences and events that go on as well that are open to people working in our industry. And so I would definitely encourage them to take advantage of the services that you offer. And thanks once again for being here today. It's been very, very interesting having our discussion.

Joan Weir:

Well great, thank you very much Denise for inviting me. I've enjoyed our conversation.

Denise Balch:

And we won't leave it till almost three years the next time we'll have to do this on an annual basis. Great.