Peer-Reviewed Article

Canadian Trends and Projections in Prescription Drug Purchases: 2001–2023

This article has been peer reviewed.

Authors: Mina Tadrous, Ahmad Shakeri, Kaleen N. Hayes, Heather L. Neville, Joanne Houlihan, Fiona Clement, Jason R. Guertin, Michael R. Law, Tara Gomes

Abstract

Background: Comprehensive data that provides knowledge of trends in the pharmaceutical market are limited. We report historical patterns of national pharmaceutical purchases and identify factors that may influence future spending to help predict growth in national drug spending.

Methods: We conducted a time series analysis of annual prescription drug purchases across Canada between 2001 and 2020 using the IQVIA Canadian Drugstore and Hospital Purchases Audit. We report total prescription purchases and relative percentage change annually, stratified by sector (retail and hospital), and forecast annual drug spending to 2023. We also assessed recent drug approvals, policies, or legislation that may influence drug spending.

Results: Total prescription purchases for 2020 were approximately $32.7 billion, 4.3% higher than 2019 (3.8% growth in retail; 6.9% in hospital). Overall, the top 25 drugs accounted for 26.0% and 52.9% of total spending in hospital and retail sectors, respectively. Spending has grown over the last 2 decades, with annual average growth of 5.3% and 7.1% for the retail and hospital sectors, respectively. New approvals of specialty and oncology drugs and generic formulations of the top 25 drugs may influence drug purchases in 2021 to 2023.

Interpretation: We project continued growth in overall drug purchases across the entire Canadian market. Specifically, the forecast for the outpatient sector is continued moderate levels of growth in drug spending (3% to 4%), with higher rates of growth (7% to 8%) in the hospital sector. Action must be taken to curb sustained growth in pharmaceutical spending in Canada, otherwise increased costs may necessitate a shift in spending from other public budgets or to private industry and patients. The opportunity cost of continued increased spending in pharmaceuticals must also be considered.

Introduction

Total public health care spending in Canada was $265 billion in 2019, which represents 11.5% of the country’s gross domestic product.¹ Public spending on prescription drugs accounts for 6% ($15.9 billion) of national public health care expenditures, although total costs likely encompass a much larger portion of total drug spending when accounting for drug spending within the inpatient and private sector settings are included. Public spending on prescription drugs and the growing cost of prescription drugs for consumers and health systems is a leading issue for policy-makers; prescription drugs account for nearly half of total outpatient spending in Canada, and costs are increasing by 7.6% annually.^1-5. Currently, the government’s health mandate prioritizes a national Pharmacare strategy and a national drug agency.⁶ The consistent increases in drug spending are superimposed on significant changes to the health care system, including modernization of drug price guidelines by the Patented Medicines Prices Review Board. The COVID-19 pandemic has also highlighted the importance of uninterrupted access to treatments.^4,5

Current estimates of Canadian drug spending are piecemeal in nature and limited to payer-specific outpatient expenditures or surveys.^1,7-11 Little is known about drug costs across all payers, particularly when accounting for inpatient expenditures.¹ Comprehensive data that provide knowledge of current trends in the pharmaceutical market, including the anticipated impact of new molecular entities, biosimilars, and generic drugs, will assist decision-makers in planning for drug expenses and support evidence-informed policy. There is currently a gap in understanding of the full scope of drug spending in Canada and a lack of up-to-date insights on upcoming trends that may impact spending. Therefore, we report the historical trends in pharmaceutical purchases with insights on both inpatient and outpatient settings. We also report projected anticipated purchases growth for the next 3 years (2021 to 2023) and a horizon scan to identify factors that may influence future spending, including policies and new drugs, biosimilars, and generic products.

Methods

Drug Purchases and Projection

We conducted a retrospective time series analysis of annual prescription drug purchases across Canada between January 1, 2001, and December 31, 2020, using the IQVIA Canadian Drugstore and Hospital Purchases Audit. These data estimate the purchasing costs and unit volumes of all pharmaceutical products purchased by the Canadian retail and hospital sectors during that time period.¹² This audit is derived from a sample of outlets within these sectors (more than one-third of the retail sector and 86% of the hospital sector) in each province and territory; proprietary methods projected out these data to represent total pharmaceutical purchasing at the national level. We included all pharmaceutical purchasing of all dosage forms and formulations over the study period. This data includes over-the-counter drugs. Purchasing can be through a wholesaler or directly from the manufacturer; therefore, costs may include mark-ups but do not capture discounts. These data do not account for rebates or discounts given to payers as part of listing agreements. Data reflect all up-front discounts within each specific invoice and do not capture any subsequent rebates or volume discounts that could be credited to the outlets afterward. Due to the aggregated nature of the data provided, research ethics board approval was not required.

We describe total prescription medication purchases across Canada annually (using calendar years) over the study period, stratified by sector (retail versus hospital), and the calculated annual growth in purchases as the relative percentage change from the previous year. We used exponential smoothing models to forecast annual pharmaceutical purchases in 2021 to 2023. Costs are reported as nominal annual costs. Nominal costs were used for projection models; however, for a sensitivity analysis, we inflated the annual costs before 2020 to 2020 values using the all-items consumer price indexes.¹³ We also identified the 25 medications with the highest total purchases in calendar year 2020 in the retail and hospital sectors.

Horizon Scan

Environmental scans for national drug pipeline reports were conducted to estimate the therapeutic areas that will have major impacts on pharmaceutical spending in the next 3 years.^14-17 Medications approved by Health Canada in 2020 and the first quarter of 2021, as well as generic drugs and biosimilars currently under review, were examined for potential budget impacts.^14,18 The US Food and Drug Administration (FDA) new drug approvals in 2020 and early 2021 were also reviewed to identify drugs that may soon enter the Canadian market.¹⁹

The list of new and upcoming therapies was reviewed by a team of pharmacists and drug policy experts. Drugs with potential high impact on future spending (via upward pressure or downward pressure) were flagged based on the prevalence of the indication, current medication use in the therapeutic area, cost, and public plan reimbursement recommendations by CADTH. Based on the drugs with highest potential for impact, a consensus recommendation was made by authors on whether the projected spending might be more likely on the high, middle, or low end of the projected confidence interval (CI) range for the next 3 years.

Results

Historical Trends in Prescription Purchases

Figure 1 and Figure 2 illustrate the trends in Canadian prescription drug purchases from 2001 to 2020 in the retail and hospital sectors, respectively (values accounting for inflation can be found in Appendix 1, Figure 4 and Figure 5).

Figure 1: Total Medication Purchases in Canada for the Retail Sector From 2001 to 2020

Note: The grey zone illustrates forecasted purchases in the retail sector (solid line) with 95% confidence interval estimates (dashed lines) for the years 2021 to 2023.

Figure 2: Total Medication Purchases in Canada for the Hospital Sector From 2001 to 2020

Note: The grey zone illustrates forecasted purchases in the hospital sector (solid line) with 95% confidence interval estimates (dashed lines) for the years 2021 to 2023.

Overall Spending

In 2020, total prescription purchases in Canada grew 4.3% from the previous year, reaching $32.7 billion (compared with $31.4 billion in 2019). The retail sector accounted for 85.1% of prescription purchases in 2020 ($27.8 billion), and the hospital sector accounted for 14.9% ($4.9 billion). Retail and hospital purchases in 2020 increased by 3.8% and 6.9%, respectively, from 2019. Figure 3 illustrates the trends in annual change in purchases across both sectors. Over the entire time period (2001 to 2020), the average annual growth was 5.3% for the retail sector and 7.1% for the hospital sector.

Figure 3: Annual Growth in Drug Purchases From the Previous Year for Retail and Hospital Sectors From 2002 to 2020

Note: The grey zone illustrates forecasted annual growth for 2021 to 2023.

Retail and Hospital Spending

In the retail sector, total drug purchases increased by 165% over the study period, from $10.5 billion in 2001 to $27.8 billion in 2020. In the hospital sector, total drug purchases grew 264% during this time, from $1.3 billion in 2001 to $4.9 billion in 2020. Among retail purchases, the average annual growth was higher in earlier years (6.7% between 2001 and 2011) compared with 2012 onward (3.8% between 2012 and 2020), with 2011 representing the only year with a decrease in annual purchases (−2.9%).

Among hospitals, the average annual growth was similar to the retail sector between 2001 and 2011 (6.5%) but continued to grow more quickly between 2012 and 2020 (7.8%); no year had a decrease in annual purchases. Compared with 2019 spending, purchases for hospital-administered drugs grew 12.7%, 18.4%, and 6.9% in 2018, 2019, and 2020, respectively. In comparison, prescription purchases in retail experienced a smaller positive growth of 3.4%, 5.2%, and 3.8% in 2018, 2019, and 2020, respectively.

Drug Purchase Forecast for 2021 to 2023

We forecast a yearly increase (all sectors combined) in pharmaceutical purchases of 4.2% to 4.6% in each of the years of 2021 to 2023 (Figure 3). We project that purchases for hospital-administered drugs will increase annually by 7.2% to 8.5% for the 2021 to 2023 period and increase 3.6% to 3.9% in the retail setting. In terms of absolute growth, the forecasted percent increase for 2023 translates to $31.1 billion (95% CI, $27.3 billion to $34.9 billion) for retail purchases and $6.1 billion (95% CI, $5.3 billion to $7.0 billion) for hospital purchases (Figure 1 and Figure 2).

Top Drugs Overall

Table 1 provides the top 25 drugs by spending in retail and hospital settings across the country for the year 2020. Infliximab ($1.2 billion), adalimumab ($970.1 million), and ustekinumab ($527.8 million) were the top 3 drug purchases in the retail setting, while pembrolizumab ($361.6 million), nivolumab ($253.0 million), and daratumumab ($218.0 million) were the top 3 in the hospital setting. Overall, total spending by the top 25 drugs in both markets accounted for $9.8 billion ($7.2 billion in the retail sector and $2.6 billion in the hospital sector), which accounted for 26.0% and 52.9% of total spending in the retail and hospital sectors, respectively. Only 2 drugs were in the top 25 of both lists: the vascular endothelial growth factor-A antagonist aflibercept was ranked number 4 in retail spending and number 20 in hospital spending and the kinase inhibitor ibrutinib was ranked number 17 in retail spending and number 7 in hospital spending.

Table 1: Top 25 Drugs by Spending in the Retail and Hospital Sectors for the 2020 Calendar Year

Horizon Scan

The drugs that are anticipated to have the highest impact, either via upward or downward pressure, are listed in Table 2. A complete list of drug approvals for Health Canada and the US FDA in 2020 and early 2021 are presented in Appendix 1 (Table 3 and Table 4). In this section, we also summarize the major themes related to new and upcoming therapies in Canada and highlight those we believe may have the largest impact on spending growth.

Potential for Upward Pressure

In oncology, 3 new drug approvals are expected to dominate this category due to either disease prevalence (B-cell lymphoma and multiple myeloma) or lack of other treatment options (small-cell lung cancer).

Table 2: Selected Drugs and Biologicals That Have Received Health Canada and/or FDA Approval in 2020 and Early 2021 and Are Expected to Affect Drug Spending

Outside of oncology, recent or upcoming therapies for migraine, diabetes, and weight loss will likely have the largest impacts because of the high disease prevalence in the population. Calcitonin gene-related peptide (CGRP) receptor antagonists (CGRP-RAs) for the prevention of chronic migraine are expected to greatly impact budget spending. Two recently approved CGRP-RAs, fremanezumab and eptinezumab, join erenumab and galcanezumab in this class. Erenumab and fremanezumab were both recommended for reimbursement by CADTH in July 2020 and April 2021, respectively. Another CGRP-RA approved for use in the US, rimegepant, has the potential to increase costs for the acute treatment of migraine but it is not currently under review by Health Canada.

A new indication of weight loss was approved for the injectable glucagon-like peptide-1 (GLP-1) receptor agonist liraglutide in February 2021, which was previously approved for the treatment of type 2 diabetes mellitus. This broadened indication will likely increase liraglutide’s utilization and the broader appeal of GLP-1 receptor agonist therapies. Injectable semaglutide is presently ranked number 7 for retail; the oral dosage form was approved in April 2020, which may also have high uptake. Remdesivir, approved in late 2020 for the treatment of pneumonia secondary to COVID-19 infection requiring supplemental oxygen, will likely have sustained use in Canada due to the ongoing pandemic and increased supply from the US. For rare indications, recently approved therapies for cystic fibrosis, multiple sclerosis, and spinal muscular atrophy will likely exert upward pressure due to high annual costs and few other treatment options. Indeed, Ontario and other provinces added the medication to its public drug formulary shortly after the Notice of Compliance for elexacaftor-ivacaftor-tezacaftor in Canada in June 2021.

Potential for Downward Pressure

Several generic formulations and biosimilars for frequently used therapies will likely place robust downward pressure on spending. Biosimilar formulations for adalimumab (number 2 in retail spending) were approved by Health Canada in late 2020. Next, there are recently available or forthcoming generic formulations of the direct-acting anticoagulants apixaban (number 5 in retail spending) and rivaroxaban (number 11 in retail spending). Generic formulations for several oral therapies for type 2 diabetes mellitus are expected, of which the dipeptidyl peptidase-4 inhibitor sitagliptin (number 21 of top 25 retail medications; number 6 in combination with metformin) will have the greatest potential effect. Finally, in oncology, the generic drug bendamustine (approved February 2021) is anticipated to decrease spending given its ranking in the top 25 drugs list (number 21 in retail).

Interpretation

Spending on pharmaceuticals has grown considerably over the last 2 decades in Canada, leading to a total market size of nearly $33 billion in 2020. With an annual average growth in spending of 5.3% and 7.1% for the retail and hospital sectors, respectively, this equates to absolute spending increases of $1 billion each year and is outpacing overall market inflation. The expansion is likely largely driven by new product approvals, higher market entry prices for new drugs, and growing utilization. Thus, we anticipate continued increases in these sectors, with greater growth in the hospital sector. As the number of new therapies continues to grow, important decisions on the opportunity cost of continued growth in spending in pharmaceuticals will need to be considered.

Major shifts in available therapies identified in the pipeline are likely to impact the degree of change in spending in the coming years. Overall, we believe the growth of spending will be on the lower end of the predicted range in the outpatient retail setting due to new generics or biosimilar formulations of several of the top 25 therapies, including adalimumab, 2 direct-acting anticoagulants, and dipeptidyl peptidase-4 inhibitors. However, the impact of adalimumab costs will depend on increased biosimilar uptake in Canada. Presently, most Canadian provincial public drug plans require biologic-naive patients to initiate a biosimilar formulation when available; however, British Columbia, Alberta, and New Brunswick mandate switching to biosimilars for most patients currently on therapy.²⁰ Other provinces are anticipated to follow suit for mandated switching among all patients. These policy and regulatory changes, including those within the Patented Medicines Prices Review Board, may mitigate this projected growth and encourage the addition of more biosimilars to the Canadian market, yet their impact on overall cost growth remains unknown.^21,22 The impact of biosimilar uptake is particularly important to understand given that the top 25 drugs in terms of retail and hospital spending have several biosimilars on or about to enter the market. With a number of public and private payers moving toward mandatory switching, we anticipate greater uptake over the coming years across Canada. Finally, despite this downward pressure, CGRP-RA therapies have particular potential to be “blockbuster” retail pharmacy drugs due to the prevalence of migraine and the recent CADTH recommendations for public drug plan reimbursement.²³

We are among the first to quantify drug spending within the hospital sector. There are well-developed pan-Canadian processes to support cost-efficient formulary development within the outpatient setting. However, the process within the hospital setting is inconsistent. Our findings suggest that greater support is needed within the hospital sector in the context of overall drug purchases growth because it accounts for 15% of total national spending. The degree of growth on the inpatient side is less certain; based on the horizon scan, it is likely that spending will be in the moderate to high end of the prediction range because oncology therapies, either novel agents for rare conditions or new indications for existing treatments, will likely increase spending. Conversely, biosimilar formulations for enoxaparin and rituximab, in conjunction with generic formulations of bendamustine, lenalidomide, and abiraterone, may help to curb spending.

Our analysis has limitations that warrant discussion. First, we do not have information on the confidential rebates that manufacturers provide to public and private drug plans or to hospital purchasers. These discounts can be substantial; for example, negotiations on brand name medications through the pan-Canadian Pharmaceutical Alliance resulted in $1.24 billion in savings to public payers in 2017–2018.²⁴ Our results represent the total spending in the current drug system, and we do not anticipate major differences in the proportion of rebates to total spending in recent year. It is also unknown if the level of rebates differs between the hospital and outpatient setting. Moreover, many rebates are re-invested by public payers by paying for future drug spending. Importantly, rebate structures and rising prices have important consequences on patient co-pays depending on payment method and plan structure.²⁵ Second, our data had no information on how payment for these medicines was distributed among payers (i.e., public insurance, private insurance, or out-of-pocket), but instead characterizes global spending and future impact to all payers. Lastly, because IQVIA has a robust process to update and verify data, the data we used in this analysis could be revised in the future. Such revisions are likely minor and would not influence the trends and projections that we have reported.

Conclusion

We predict continued moderate growth in overall drug purchases across the entire Canadian market. Specifically, we expect the outpatient sector to continue to experience moderate levels of increased growth in drug spending by 3% to 4% annually from 2021 to 2023. We anticipate the inpatient setting to continue to have higher rates of growth in the range of 7% to 8% per year. Given a fixed social budget, increases in pharmaceutical spending will, by necessity, lead to decreases in other public budgets, increased shifting of spending from the public budget to private industry or directly to patients, or increased revenue requirements for the government. The opportunity cost of continued increased spending in pharmaceuticals must therefore be considered.

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Appendix 1: Additional Figures and Tables

Figure 4: Total Medication Purchases in Canada for the Retail Sector From 2001 to 2020

Note: The grey zone illustrates forecasted purchases in the retail sector (solid line) with 95% confidence interval estimates (dashed lines) for the years 2021 to 2023. Blue line = non–inflated-adjusted purchases; orange line = inflated-adjusted purchases.

Figure 5: Total Medication Purchases in Canada for the Hospital Sector From 2001 to 2020

Note: The grey zone illustrates forecasted purchases in the hospital sector (solid line) with 95% confidence interval estimates (dashed lines) for the years 2021 to 2023. Red line = non–inflated-adjusted purchases; green line = inflated-adjusted purchases.

Table 3: Health Canada Drug Approvals Between January 1, 2020, and October 21, 2021

NOC = Notice of Compliance; NOC/c = Notice of Compliance with conditions.

Table 4: FDA Drug Approvals Between January 1, 2020, to March 15, 2021

CMC = Chemistry, Manufacturing and Controls; NDA = new drug application; NSCLC = non–small-cell lung cancer.

Appendix 2: Author Information

Corresponding Author

Mina Tadrous

Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto ON

mina.tadrous@utoronto.ca

Author Affiliations

Mina Tadrous, PharmD, PhD^1-3; Ahmad Shakeri, MSc¹; Kaleen N. Hayes, PharmD, PhD^4,5; Heather L. Neville, BSc Pharm, MSc⁶; Joanne Houlihan, BSc Pharm⁷; Fiona Clement, PhD^8,9; Jason R. Guertin, PhD^10,11; Michael R. Law, PhD¹²; Tara Gomes, PhD^1,3,13

¹ Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada

² Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada

³ ICES, Toronto, Ontario, Canada

⁴ Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

⁵ Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA

⁶ Queen Elizabeth II Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada

⁷ Nova Scotia Cancer Care Program, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada

⁸ Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

⁹ O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada

¹⁰ Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Quebec City, Quebec, Canada

¹¹ Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada

¹² Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada

¹³ Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada

Author Disclosures

Dr. Gomes received salary support through a Canada Research Chair in Drug Policy Research and Evaluation. Dr. Gomes reports grant funding from the Ontario Ministry of Health. Dr. Law received salary support through a Canada Research Chair in Access to Medicines. Dr. Guertin holds a research career award from the Fonds de recherche du Québec–Santé (FRQS) (Award #266460). Dr. Law has consulted for Health Canada, the Health Employees’ Union, and the Conference Board of Canada, and provided expert witness testimony for the Attorney General of Canada and the Federation of Post-Secondary Educators. Dr. Tadrous has consulted for CADTH and Green Shield Canada. Dr. Hayes received doctoral stipend support from the Canadian Institutes of Health Research during the conduct of this work.

Acknowledgements

All authors were involved in the design, interpretation of results, writing, conceptualization of recommendations, and revision of the manuscript. MT was involved in the implementation of the study and had full access to all data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis. MT is the guarantor of the content of the manuscript, including the data and analysis.

This research was conducted through a gift of data from IQVIA Canada. The statements, findings, conclusions, views, and opinions contained and expressed in the report are based in part on data obtained under license from IQVIA, Canada Inc. concerning the following information service(s): IQVIA’s Canadian Drugstore and Hospital Purchases Audit, data period January 1, 2001, and December 31, 2020. All Rights Reserved. The statements, findings, conclusions, views, and opinions expressed herein are not necessarily those of IQVIA Canada Inc. or any of its affiliated or subsidiary entities.