Diabetes Canada 2018 Pre-Budget Cnsultatin Submissin Standing Cmmittee n Finance and Ecnmic Affairs Gvernment f Ontari January 17, 2018 1
Executive Summary Tday, abut 4.4 millin Ontarians, r 29 per cent f the prvincial ppulatin, are living with diabetes r prediabetes. Over the next decade, diabetes prevalence in Ontari is prjected t increase by 30 per cent. Diabetes puts peple at higher risk f serius and cstly cmplicatins, including heart attack, strke, visin lss, kidney disease and amputatin. Sme ppulatins carry a much heavier burden f diabetes, including thse f Asian, Suth Asian, African, and Hispanic descent and Indigenus Peples. In additin t far higher prevalence f diabetes and diagnses at yunger ages, Indigenus Peples face multiple barriers t effectively prevent and manage diabetes, such as fd insecurity, limited access t prgrams and services, and a lack f prper infrastructure. Pverty, including inadequate husing, and lwer levels f educatin are als cntributing factrs. Cllectively, these challenges lead t higher rates f diabetes cmplicatins amng Indigenus Peples in Ontari. Financial cnstraints and high ut-f-pcket csts limit peple s ability t effectively manage their diabetes. A cnsiderable prprtin f Ontarians with diabetes have great difficulty paying fr prescribed medicatins and supplies. Public cverage fr diabetes medicatins, devices, supplies and services is available t sme peple but nt everybdy, and t varying degrees. The expenses assciated with disease management can be a huge burden fr peple living with diabetes t carry. Fr the 2018 Ontari Budget, Diabetes Canada urges the Gvernment f Ontari t: 1. Intrduce a renewed prvincial Diabetes Strategy that sets aggressive targets t stem the tide f the diabetes epidemic and t imprve utcmes fr peple with diabetes. 2. Address gaps in access t medicatins, devices and supplies required fr effective diabetes management by: reducing deductibles assciated with publicly funded prgrams (e.g. Trillium Drug Prgram); and ensuring adequate cverage fr supplies such as pen needles and syringes. 3. Publicly fund cntinuus glucse mnitrs fr peple with type 1 diabetes wh suffer frm severe hypglycemia and/r have hypglycemia unawareness, as recmmended in Health Quality Ontari s draft reprt. 2
1. The Call fr a Renewed Diabetes Strategy Issue: Diabetes Canada is urging the Gvernment f Ontari t intrduce a renewed prvincial Diabetes Strategy that sets aggressive targets t stem the tide f the diabetes epidemic and t imprve utcmes fr peple with diabetes. In Ontari, almst 1 in 3 peple have diabetes r prediabetes. In 2018, abut 4.4 millin Ontarians are living with diabetes r prediabetes. Over the next 10 years, diabetes rates in Ontari are prjected t increase by 30%. The direct cst f diabetes t the prvincial heath care system is apprximately $1.5 billin annually. By 2028, direct csts are estimated t be as high as $1.9 billin a year, an unsustainable amunt. Uncntrlled diabetes can lead t heart disease, kidney disease, eye disease, and lwerlimb amputatin. Depressin is als mre cmmn amng peple with diabetes than in the general ppulatin. Given the size f the diabetes epidemic, its rapid rate f grwth, and the tll it takes n individuals and families, the Gvernment must create a renewed Diabetes Strategy that sets aggressive, measurable targets t address preventin, screening and awareness, glucse cntrl and secndary preventin f cmplicatins. Over 50% f type 2 diabetes cases can be prevented r delayed. In cases that cannt be prevented, utcmes fr peple can be imprved. Type 1 diabetes is a disease in which the pancreas des nt prduce insulin. Its cause remains unknwn and it cannt be prevented. Hwever, peple with type 1 diabetes can lead lng and healthy lives with prper daily management that keeps their bld glucse levels within a healthy target range. Type 2 diabetes is a disease in which the pancreas des nt prduce enugh insulin r the bdy des nt prperly use the insulin it makes. Type 2 diabetes is caused by a cmbinatin f genetic, envirnmental and lifestyle factrs. In many cases, the develpment f type 2 diabetes can be prevented r delayed. In bth cases, intensive multifactrial interventins can significantly reduce diabetes-related cmplicatins (e.g. heart attacks) and mrtality by nearly 60%. 1 Ontari intrduced its first Diabetes Strategy in 2008, and its secnd in 2012. In 2008, the Gvernment f Ontari intrduced its first fur-year Ontari Diabetes Strategy, whse purpse was t reduce diabetes risk and prevalence in the prvince, prvide disease management supprt t patients, and imprve access and quality f services and care t 3
thse living with diabetes. 2 An updated strategy fllwed in 2012 that utlined the directin fr diabetes care and fcused n enhanced preventin and management appraches. In 2016, the Ministry f Health annunced $10 millin fr diabetes preventin and management within the First Natins Health Actin Plan. Hwever, the Ontari Diabetes Strategy was nt renewed. Rather than renew a strategy dedicated t diabetes, diabetes preventin and care was incrprated int the larger prvincial chrnic disease strategy. While peple may live with ne r mre chrnic disease, each ne has particular manifestatins and implicatins fr health and lifestyle. A patient-centred, diabetes-specific strategy is required t address the needs that are unique t this cnditin. Its current and prjected prevalence and cst make the diabetes epidemic impssible t ignre. It shuld nt be subsumed under a larger chrnic disease strategy. A renewed Diabetes Strategy culd make Ontari a leader in diabetes preventin and management. When develping measurable targets and utcmes, Ontari can learn frm the experience f The Jint United Natins Prgramme n HIV/AIDS (UNAIDS) establishing a 90-90-90 target t end the HIV/AIDS epidemic. Adpted in 2014, the UNAIDS 90-90-90 target set ut that, by 2020, 90 per cent f all peple living with HIV will knw their HIV status, 90 per cent f thse will receive sustained antiretrviral therapy and 90 per cent f thse will have viral suppressin. The 90-90-90 target was seen t be s effective that the same target was embraced in December 2014 fr tuberculsis. A prvincial Diabetes Strategy that incrprates a 90-90-90 target fr diabetes is urgent and imperative. The target culd mean: mre peple wh are at risk f develping diabetes wuld be aware f their status and take preventative measures, thereby aviding develping the disease. mre peple wh have diabetes wuld becme aware f their status sner, minimizing cmplicatins and maximizing pprtunities t reverse r slw the pace f the disease. mre peple living with diabetes wuld be receiving specialized cunselling and care, and thereby experiencing fewer cmplicatins and adverse health utcmes. fewer peple with diabetes wuld develp serius cmplicatins like heart disease, kidney disease r amputatins, which in turn wuld reduce significant csts t the health care system. 4
2. Access t Medicatins, Devices and Supplies Issue: Diabetes Canada urges the Gvernment f Ontari t address gaps in access t medicatins, devices and supplies required fr effective diabetes management by: reducing deductibles assciated with publicly funded prgrams (e.g. Trillium Drug Prgram); and ensuring adequate cverage fr supplies such as pen needles and syringes. The Prvince has cmmitted t intrducing a redesigned public drug prgram by 2019. The 2016 Ontari Budget stated that the new prgram will imprve lng-term sustainability while ensuring access t drugs fr peple wh need them. 3 The 2017 Ontari Budget made a bld mve frward by annuncing the OHIP+: Children and Yuth Pharmacare Prgram. Effective January 1, 2018, the prgram will prvide drug cverage fr children and yuth with OHIP under the age f 25, regardless f incme. Fr children and yuth with diabetes, this new prgram means that their families will receive funding fr insulin, ther glucse lwering medicatins and bld glucse test strips. Hwever, diabetes des nt end when peple turn 25. Peple with diabetes need timely and affrdable access t prescribed medicatins, devices and supplies t ptimally manage their disease and avid serius and cstly cmplicatins. T keep bld glucse under cntrl and prevent r manage cmplicatins, many peple with diabetes take multiple medicatins: 32% f Canadians reprted taking three t fur medicatins, 40% reprted taking five t nine, and 12% reprted taking 10 medicatins r mre. 4 Ontari has taken imprtant steps t imprve access t needed medicatins, devices and supplies, such as expanding cverage fr insulin pumps and supplies t all eligible residents with type 1diabetes in 2008. In spite f this, many peple still struggle with the high ut-fpcket csts f managing their disease. Cverage fr supprt prgrams depends n incme, and Ontarians under 65 with diabetes can experience severe financial cnstraints frm high deductibles. Fr example, fr mst peple wh qualify, the deductible fr the Trillium Drug Prgram equals abut 3 t 4% f husehld incme after taxes. 5 Peple then pay up t $2 fr each drug, per persn, that is filled r refilled. Drug therapy must be accessible t ensure prper diabetes management. In Ontari, public cverage fr drug therapy t treat diabetes varies based n a persn s incme level and prescribed therapy the level f cverage impacts ut-f-pcket csts. 5
Fr peple with type 1 diabetes wh meet medical criteria fr insulin pump therapy and chse t use an insulin pump, sme, but nt all, f their expenses wuld be cvered under Ontari s insulin pump prgram. They may still need t pay $500 $1,700 a year f their wn mney. Peple with type 2 diabetes living in Ontari have very limited assistance frm the prvincial gvernment. A 55-year ld individual with type 2 diabetes earning $40,000 t$80,000 annually may need t pay the full cst fr prescribed treatment at an estimated $1,900 per year. At a lwer incme (e.g. $20,000), Ontarians with type 2 diabetes may still need t pay ver 80 per cent f their expenses. When peple with type 2 diabetes reach 65 years f age, many expenses are cvered by the Ontari Drug Benefit prgram (ODB), hwever nt all needed medicatins are insured by ODB and sme are verly restricted. The annual deductible fr ODB is $100 fr single senirs with an annual incme f apprximately $19,300 r senir cuple with an annual incme f apprximately $32,300. The c-payments are currently $6.11 per drug. Diabetes is a cstly cnditin, even when peple are eligible fr varius prvincial supprt prgrams. That is why Diabetes Canada urges the Gvernment f Ontari t reduce deductibles assciated with publicly funded prgrams t make medicatins, devices and supplies less expensive and mre accessible. Pen Needles and Syringes: Public cverage des nt adequately cver annual csts Eligible individuals may receive up t $170 annually in public cverage fr pen needles and syringes t administer insulin thrugh the Gvernment f Ontari s Assistive Devices Prgram, Ontari Wrks and the Ontari Disability Supprt Prgram. Hwever, fr peple wh test fur times daily, the annual cst fr pen needles and syringes is clser t $500 t $600 -- if they use a needle r syringe nce nly, as is recmmended by medical prfessinals. The cst t the individual may be higher r lwer depending n the treatment regimen, the type f needles r syringes used, where they are purchased and whether they have public r private cverage. Diabetes Canada urges the Gvernment f Ontari t raise the cverage fr pen needles and syringes t cver the annual csts fr peple with diabetes. 6
3. Cntinuus Glucse Mnitring Systems Issue: Diabetes Canada recmmends that the Gvernment f Ontari publicly fund cntinuus glucse mnitrs fr peple with type 1 diabetes wh suffer frm severe hypglycemia and/r have hypglycemia unawareness, as recmmended in Health Quality Ontari s draft reprt. Hypglycemia can be a life-threatening cmplicatin f diabetes. Lw bld sugar (hypglycemia) ccurs when there is t much insulin relative t the amunt f sugar in the bldstream. It is ften characterized by symptms such as trembling, anxiety, difficulty cncentrating and dizziness. When a persn experiences and can crrectly identify symptms f hypglycemia, he/she can treat him/herself t bring bld sugar back t a healthy, safe level. In sme severe cases, hwever, a persn may lse cnsciusness and require assistance with treatment frm smene else. Hypglycemia can cause cnfusin, seizure and/r cma. It can lead t accidents that may cause serius harm. Hypglycemia is particularly dangerus when individuals are asleep, unable t recgnize the symptms f hypglycemia and therefre have n warning r pprtunity t treat it. Mnitring bld sugar levels is essential t preventing hypglycemia. Diabetes Canada s 2013 Clinical Practice Guidelines recmmend that peple with diabetes test t ensure their bld sugar levels remain within the target range, which helps t prevent cases f severe lw r high bld sugar. Hwever, there may nt always be an bvius cause fr severe bld sugar lws, despite ptimal use f insulin therapy and cnventinal bld glucse mnitring with test strips. Symptms d nt always accmpany hypglycemia in all peple. Sme, like yung children fr example, may nt be able t recgnize r cmmunicate the symptms f hypglycemia, r it may ccur during sleep. Hypglycemia unawareness can cntinue int adulthd. In specific instances, cntinuus glucse mnitring (CGM) systems may help peple with diabetes stay within their target bld sugar range and prevent lw b ld sugar episdes. If used cnsistently, CGM has the ptential t prevent life-threatening emergencies. With CGM, a small sensr is inserted under the skin t measure a persn s bld sugar levels every few minutes. The readings are then relayed t a device, which can be read by the persn, caregiver r health care prvider, even remtely. 7
These data help peple with diabetes recgnize when their bld sugar is lw s they can treat it. They als help them t identify when their bld sugar is trending dwn, which allws fr apprpriate, timely actin t be taken t avid hypglycemia. Currently, public funding fr CGM systems is nly available fr peple wh have access t the Ontari Disability Supprt Prgram. All thers must pay the entire cst ut-f-pcket. CGM systems typically range in price frm $3,000 t $6,000 a year. Many peple cannt affrd this cst. The cst can vary between manufacturers and is based n the cmpnents f the system and the frequency with which equipment needs t be replaced. A Health Quality Ontari draft reprt prvides sme recmmendatins t the gvernment. In its draft reprt released in Octber 2017, the Ontari Health Technlgy Advisry Cmmittee (OHTAC) recmmends publicly funding cntinuus glucse mnitring in patients with type 1 diabetes wh are willing t use cntinuus glucse mnitring fr the vast majrity f the time and wh meet ne r mre f the fllwing criteria: severe hypglycemia withut an bvius precipitant, despite ptimized use f insulin therapy and cnventinal bld glucse mnitring. inability t recgnize, r cmmunicate abut, symptms f hypglycemia. OHTAC estimates the cst t the prvince t supprt thse wh are currently using this technlgy culd be as lw as $8.5 millin ver five years. T make the technlgy available fr peple wh are ften unaware they are having a lw bld sugar episde, the cst culd rise t $82.5 millin ver five years. The call fr public input clsed n Nvember 1, 2017, and Health Quality Ontari is currently reviewing the feedback. 1 Diabetes Canada. Diabetes: Canada at the Tipping Pint. Charting a New Path. 2013. Available frm: https://www.diabetes.ca/cda/media/dcuments/publicatins-and-newsletters/advcacy-reprts/canada-at-the-tipping-pintenglish.pdf 2 Ministry f Health and Lng-Term Care. (2016). Ministry Plans: 2016-17 Published Plans and 2015-16 Annual Reprts. Trnt, Ont: Ministry f Health and Lng-Term Care. Retrieved frm http://www.health.gv.n.ca/en/cmmn/ministry/ publicatins/plans/ppar16/. 3 2016 Ontari Budget, 118. 4 Statistics Canada. 2011 Survey n Living with Chrnic Disease in Canada. Custm data request. 5 Gvernment f Ontari. Get Help with Prescriptin Drug Csts. https://www.ntari.ca/page/get-help-high-prescriptin-drugcsts#sectin-4 8