The missing claimants of the pandemic: Who went without claims in Canada during the first two years of the COVID-19 pandemic and what does it mean for public and private drug plans?

Presented at ICPE 2023, August 23-27, 2023

Étienne Gaudette, PhD, and Yvonne Zhang, MA

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Introduction

Background and objectives: This study aims to draw attention to the sharp swings in the number of claimants observed in 2020 and 2021 in Canada, and to examine whether the “missing claimants” of the COVID-19 pandemic could impact drug claims and spending for years to come.

Approach: We analyze data from public and private drug plans since 2015, investigating the changes in the number of claimants in 2020 and 2021 relative to 2015–2019 trends by public/private plan, age group, and spending level. We also document the therapeutic classes that saw the greatest shifts in the number of claims filed. This research expands on an analysis focused on 2020 data published in 2022.Footnote 1 For more detail, see Data section below.

Data

Public drug plans: Annual aggregates from publicly financed drug benefit programs affiliated were compiled with the National Prescription Drug Utilization Information System (NPDUIS) database, which represent approximately 7 million publicly covered active beneficiaries. Public drug plans from British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland were included in the analysis.

Private drug plans: Aggregated annual data from the IQVIA Private Drug Plan database were used for the analysis. This database houses adjudicated prescription claim-level data collected from a large sample of Canadian pay-direct private drug plans representing all provinces and territories, and was estimated by IQVIA to represent 85.7% of the Canadian private pay direct insurance market in 2020. In 2021, IQVIA reported changes in the data provided by one plan administrator, resulting in a decline in the capture rate to 79.9% over all provinces in that year. Private claimants and claims data were thus adjusted by a factor of 0.857 / 0.799 = 1.0726 in that year.

Definitions: Claimants are individuals with at least one prescription drug claim accepted for reimbursement during a given year. “Missing claimants” refer to differences between the projected number of claimants in 2020 and 2021, based on pre-pandemic trends from 2015–2019, and the actual number of claimants observed during these two years. Pre-pandemic trends were estimated for all groups using second-order polynomial regressions for years 2015 to 2019. Public plan annual data were aggregated at fiscal years (Apr. to Mar.), while private plan data were available at calendar years (Jan. to Dec.). Therapeutic classes are defined based on the second level of the World Health Organization’s Anatomical Therapeutic Chemical classification system.

Exclusions: Because design changes impacted public plan eligibility of Ontario claimants under 25 during the study period,Footnote 2 they were excluded from Figure 1 to Figure 3. For the same reason, Ontario claimants by spending level and Ontario claims were excluded from Figure 4 and Figure 5, since they were not disaggregated by age group for private plans and were impacted by the eligibility changes. Claimants with an unknown age group were excluded from Figure 2. Claims for vaccines were excluded from public plan data in all analyses because of differences in their reporting by jurisdiction.

Results

1. Claimants greatly declined in 2020 and remained over 1M below trend in 2021

Figure 1: Drug plan claimants, 2015 to 2021

Figure 1 - Text version
Figure 1
  2015 2016 2017 2018 2019 2020 2021
Observed claimants 16.0 16.4 17.0 17.5 18.0 17.1 18.1
Pre-pandemic trend - - - - 18.0 18.6 19.3
Missing claimants - - - - 0.0 1.5 1.2

Figure 2: Missing claimants by plan type

Figure 2 - Text version
Figure 2
  Private plans Public plans
2020 1,242,000 305,000
2021 795,000 377,000

Note: For reference, private and public plans included in the analysis counted 11.8M and 5.3M observed claimants in 2020, respectively.

2. Who were the missing claimants?

Figure 3: Missing claimants by spending level and plan type

Public plan claimants

Figure 3 - Text version
Figure 3 - public
Spending level 2020 2021
Under $5,000 152,300 250,200
Over $5,000 -1,600 -1,300

Private plan claimants

Figure 3 - Text version
Figure 3 - private
Spending level 2020 2021
Under $5,000 823,100 635,400
Over $5,000 -6,700 -14,900

Figure 4: Missing claimants by age group and plan type

Public plan claimants

Figure 4 - Text version
Figure 4 - public
Age group 2020 2021
Less than 25 57,300 61,900
25 to 64 114,100 115,100
65 and older 134,000 200,100

Private plan claimants

Figure 4 - Text version
Figure 4 - private
Age group 2020 2021
Less than 25 326,400 346,800
25 to 64 859,900 558,300
65 and older 79,900 -79,700

3. Some therapeutic classes saw important declines in claims

Figure 5: Therapeutic classes with the greatest declines in claims for public and private plans

Public plans

Figure 5 - Text version
Figure 5 - public
Therapeutic class Percent change from 2019 to 2020 Percent change from 2019 to 2021
Ectoparasiticides, including scabicides, insecticides and repellents -21.8% -31.2%
Antibacterials for systemic use -21.2% -8.0%
Antimycobacterials -15.2% -12.1%
Stomatologicals, mouth preparations, medicinal dentifrices etc. -16.6% -3.4%

Private plans

Figure 5 - Text version
Figure 5 - private
Therapeutic class Percent change from 2019 to 2020 Percent change from 2019 to 2021
Cough and cold preparations -61.4% -85.5%
Ectoparasiticides, including scabicides, insecticides and repellents -45.6% -57.2%
Vaccines -26.2% -46.8%
Antiprotozoals -31.3% -34.3%
Antibacterials for systemic use -29.1% -35.4%
Corticosteroids for systemic use -13.9% -10.4%
Otologicals -10.7% -12.7%
Antibiotics and chemotherapeutics for dermatological use -12.3% -11%

Note: Declines shown are relative to 2019 claims. Classes shown had 10,000+ annual claims on average during the pre-pandemic (2015–2019) period, had declines greater than 10% in 2020 or 2021 relative to 2019 levels, and had declines relative to the pre-pandemic trend greater than 1.96 times the standard deviation observed during the pre-pandemic period.

Conclusions

With the onset of the COVID-19 pandemic, over 1M fewer Canadians filed drug plan claims in 2020 and 2021 than expected based on pre-pandemic trends. A decline in claimants was found in both public and private drug plans. Groups of claimants showing the greatest declines were those with lower spending levels and privately covered adults aged less than 65.

Despite a partial rebound in 2021, the number of claimants in both types of plans remained well below historical trends, possibly foreshadowing further rebound in the coming years.

Limitations

All analyses performed are observational and cannot inform about the causal effect of the COVID-19 pandemic. Two public plans were not included in the analysis: the Régie de l’Assurance Maladie du Québec is not included in the NPDUIS data and data for the Non-Insured Health Benefits program were not available for fiscal years 2020-21 and 2021-22. Private plan data for year 2021 were adjusted to account for an exogenous change in data capture (see Data section) and may be considered preliminary pending revisions from the data supplier. No data were available to study public and private drug plan enrollees during the period. For that reason, the analyses could not distinguish between changes due to eligibility/enrollment (e.g., because of job loss) and those attributable to utilization.

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