Market Access: Reimbursement

Video Transcript:

The reimbursement environment is a mixed market. So governments pay about 40% of the costs, private insurance companies pay about 40% of the costs usually on behalf of employers, and individuals pay about 20% of the costs, but that's not a cash market. That's a market where people are paying premiums, deductibles, copays, towards both public and private plans.

There are two main systems for payers in Canada, the public and the private system. The public system is governed more on an HTA, or Health Technology Assessment basis, where you have 2 major agencies that deal with that – CADTH provides recommendations to all the provinces except Quebec. INESSS provides recommendations to Quebec. 

CADTH looks at thing from health technology perspective on the health systems side. In other words, will the drug provide some value with regards to hospitalisations, or physician visits?

INESSS does the same, it also adds the societal perspective, which means they look at what the impact might be on the patient costs and/or the caregiver costs.

The private market, the payers there are really the employers and they're interested in making sure their employees can be back at work at a reasonable time. And also it's a tax efficient way for them to provide compensation.

There are a number of specific steps that companies need to follow to obtain reimbursement in Canada. The main thing to think about is that there are a number of submission requirements for all the payers, and they're slightly different for public payers, then private payers. You have to follow the administrative documents that have to be filled out properly, and then you have to provide a good clinical story and an economic story. These things are changing all the time so it's always good to have an agency like Innomar to help you through those particular steps at each juncture.

We always say earlier is better to have your reimbursement processes underway. Many clients that we're dealing with think of them in sequential fashion. In other words, they do the regulatory work first, and then the reimbursement work. And certainly regulatory is important, but we find that if you do your reimbursement work around the same time as a Health Canada submission, you're going to be better off, because you can make your submission to the payers 6 months prior to your regulatory approval which might take as long as a year when the file is in place. So it's always important to stay on top of these things and prepare earlier because time is money.

It can take as long as a year or more to get a drug reimbursed in Canada. And so you have to think of the different steps. So the Health Technology Assessment, or HTA process, can take up to 6 months. Then there's usually a negotiation process that takes place after that, and that'll take another few months. And then there's a listing process on the formularies which can take another few months. So you can see how the time can quickly add up. So the earlier you start and getting the file into the payers the better off you're going to be, which is why we always say start early.