About 20 years ago while still in pharmacy school, I listened to a professor to discuss the fate of National Pharmacare in Canada as it was recommended in the National Forum of Health in 1997. He said at the time, it was never going to happen and went on to cite many reasons. I didn’t understand the reasons then and still don’t now. But I know it’s complex and affects many stakeholders including employers, insurance companies, pharmaceutical industries as well as clinicians, consumers and government both provincially and nationally. It’s been 20 years and the discussion of National Pharmacare has not disappeared but little has progressed either.
Recently, the discussion to develop a National Pharmacare has re-emerged once again in Canada. It is mainly motivated by the escalating drug costs. Many have questioned why Canada does not have a National Pharmacare when many other developed countries do. Why our drug coverage systems across Canada are so disjointed and illogical? Why we have allowed each provincial jurisdiction to administer its own drug plan without some coherence or plan to unit into a single national plan.
Wouldn’t it be simple if we have one national drug formulary for all Canadians to follow, one process to apply for special authorization for specialty medications and one system to collect data for research and analysis to understand the prescribing patterns and drug utilization trends – not to mention the single most important reason to have immense negotiating power of pricing with manufacturers to contain the escalating drug expenditures for Canada?
Dr. Steven G. Morgan, a professor at the School of Population and Public Health of University of British Columbia has studied and researched on a national strategy of pharmaceutical policy and has written a number of articles on this topic. In his publication The Future of Drug Coverage in Canada, he discusses there are four key policy goals that are important to address for Canadians:
- Access: universal access to necessary medicines
- Fairness: fair distribution of prescription drug costs
- Safety: safe and appropriate prescribing
- Value for Money: maximum health benefits per dollar spent
The report also explores a vision of a public drug plan with the following policy recommendations:
- Provide universal coverage of selected medicines at little or no direct cost to patients through Pharmacare.
- Select and finance medically necessary prescription drugs at a population level without needs-based charges – such as deductibles, coinsurance, or risk-rated premiums – on individuals or other plan sponsors (e.g., businesses)
- Establish a publicly accountable body to manage Pharmacare, one that integrates the best available data and evidence into decisions concerning drug coverage, drug prescribing, and patient follow-up.
- Establish Pharmacare as a single-payer system with a publicly accountable management agency to secure the best health outcomes for Canadians from a transparent drug budget.
So perhaps we are moving once again toward a National Pharmacare. It will be a major undertaking for each province to adapt. Looking at our own Ontario Drug Benefits Program, here are few of my personal thoughts I wish we can learn from, if and when we move into a new system for drug reimbursement:
- List medications based on best practices and treatment guidelines, not based on manufacturers’ requests. There are many drugs that are safer at lower dosages and are not expensive but not covered because for whatever reason(s), the manufacturers have not made a submission to add them into the formulary. (e.g., Doxepin 3mg and 6mg, Fentanyl 12.5mcg/hr patch)
- Have prescribing restriction on all harmful drugs, not just expensive drugs. It annoys me to see that physicians can easily and freely prescribe benzodiazepines for insomnia but they have to fill out forms and forms to prescribe vancomycin for someone who is suffering an episode of C difficile associated infection.
- Stop changing the decision on what brand drug to reimburse – this is confusing for consumers when the appearance of their medications keep changing and difficult for pharmacies to keep the right brand in the inventory. It actually is a risk factor for medication errors. So once a brand is negotiated, stick with it for at least few years before we decide to make friend with another brand.
- Don’t discriminate against over-the-counter medications. One ridiculous example is that we do not pay for low dose aspirin (80mg) in our formulary but opt to pay for the regular dose aspirin 325mg or 650mg. Given aspirin is rarely used for pain and indicated as an antiplatelet agent of which low dose is equally effective but safer, we should opt to pay for the low dose aspirin instead. I understand many drug plans do not cover for over-the-counter medications. But why would we pay for higher dose aspirin that may increase the risk of bleed (and potentially costing the system more money with hospitalization for GI bleed) when patients can be on low dose aspirin instead. Fix the system so that there is a way to reimburse over-the-counter medication if it makes clinical sense and safer for the public.
So these are just some of my random thoughts on our current drug reimbursement system in Ontario. I will be watching in the next 20 years to see if we will indeed have a National Pharmacare in Canada, or according to Dr. Steven Morgan, we hope to have it by 2020.