Something exciting seems to be gaining momentum – that the talk of a National Pharmacare may actually transpire into a reality. Eric Hoskins, our former provincial health minister in Ontario, has taken on a new role to chair a Federal Government Advisory Council for a National Pharmacare Plan.
I think Eric Hoskins has a track record of getting things done – we can all criticize how well they are done but they are done. He has implemented few initiatives to deal with the ongoing opioid crisis in Ontario; he has broadened access of Naloxone to the public by making it available at no cost and without a prescription in Ontario. He has changed the coverage criteria for Suboxone to general benefits so that primary care physicians can prescribe them for patients who have opioid dependence (without referring to an addiction specialist). He has implemented OHIP Plus for prescription coverage for children and youth under the age of 25.
But implementing a National Pharmacare Plan is no easy task – he will have to begin the dialogues with 10 provinces and 3 territories on how to consolidate a patchwork of systems and infrastructures of prescription coverage for a National Pharmacare Plan.
As a pharmacist who has seen how prescribing is done in real practice setting as well as how patients suffer from sub-optimal drug therapies, here are 10 things I wish the new National Pharmacare Plan will take into considerations:
- Establish a list of essential medicines for national drug coverage – there are drugs that are absolutely essential and there are drugs that are “nice to have”. Figure out and decide on a list of essential medicines so that we have high priority to target them for national drug coverage. The World Health Organization has a list that may be a good starting point.
- Negotiate pricing wisely to prevent drug shortages – A big part of the national pharmacare plan is to have strong negotiating power. I hope we can take advantage to ensure manufacturers have mandatory requirements to ensure there will be no drug shortages of these essential medicines. Or if there is a drug shortage due to some unforeseen circumstances, then there must be a mechanism in place to resolve it as quickly as possible. After all, what good is it that we can negotiate the manufacturer to charge us a penny per tablet of Aspirin if there will be a drug shortage for the next 6 months.
- Reconcile differences in medication coverage across Canada – This will be a challenge when medications have different coverage status across Canada. For example, an oncology medication is often always first covered by BC Cancer Agency in British Columbia when the rest of the country is still reviewing evidence for the medication. Likewise, many provinces on the East Coast may never consider the same medication for public coverage given their limited budget. But how do we reconcile these differences as we move forward to a National Pharmacare Plan? This will likely be the most challenging aspect of implementing a National Pharmacare Plan. Some individuals will inevitably be disappointed if they will be told their medications may not receive continued coverage, especially if alternative options are not always available or appropriate.
- Be inclusive with Coverage – Coverage should not be limited to prescription medications – if an over-the counter medication / supplement is indicated and warranted based on clinical evidence, they should be part of the Pharmcare plan. I am often frustrated to realize that patients will not take their Vitamin D for bone health or over-the-counter eye drops for severe dry eyes because they are not part of the drug coverage plan.
- Cover all strengths and formulations of the same medication – Again, one of my pet peeves is that we may resort to prescribing a higher strength of a medication because the lower strength is not covered, resulting in possible adverse effects for the patient. An example is Fentanyl Patch – it is available as 12mcg/hr patch but our provincial drug plan will only pay for 25mcg/hr patch, simply because the manufacturer has decided not to submit a lower strength for coverage consideration. Why should the manufacturer decides what strengths are available for coverage? Liquid formulations of medications are particularly important for toddler and children as they are unable to swallow tablets yet. So ensuring liquid formulations are part of the National Pharmacare Plan is very important, especially for medications commonly prescribed for the younger population.
- Ensure an Independent Governing Organization for Medication Review – We already have CADTH in place to provide unbiased review of clinical evidence as well as pharmacoeconomic data to put forth recommendations for whether a new medication should be covered by provincial drug plans. This independence must continue to exist to ensure objective review of evidence to support best practices.
- Be Transparent about Drug Costs to Prescribers – one of the issues with rising drug costs is that prescribers often do not have direct and easy access to how much medications cost. Often they are surprised when their patients return to their offices, either indicating they cannot afford the medications or they are not taking them due to cost concerns. Ideally, the cost of medication should be easily accessible to prescribers either by having this information available in the electronic medical records or a user-friendly formulary that is available online. For the record, the Ontario Drug Formular is online but prescribers often don’t understand how to use it to estimate drug costs.
- Incorporate Pharmacist in Primary Care – I am not trying to sell the role of pharmacist; but really if a pharmacist can review medications and collaborate with physicians and useful recommendations are implemented, it will reduce pill burden for patients, save on medication costs and help to ensure patient’s therapies are optimally prescribed. The premise of a National Pharmacare Plan is to save on drug costs. Pharmacists can do just that by ensuring patients are only on appropriate medications.
- Funding & Research on Deprescribing Guidelines – Our escalating drug costs are out of control because we only have guidelines to advise us on when to start treatment. But we also need guidelines on when to stop treatment. That is exactly why we should continue to fund research on developing deprescribing guidelines. They are very helpful to clinicians and ultimately help our health care system to save on drug costs.
- Listen to stakeholders. – Finally, it is no easy task to implement a National Pharmacare Plan. However, listening to stakeholders is important. Being flexible is important. The National Pharmacare Plan needs to grow with the population it is designed to serve and our population may change over time so mechanism must be set up so that we can change according to the needs of the Canadians.
I wrote a post over a year ago about the National PharmaCare Plan. I was skeptical and still am but I do hope that something fruitful will come out of this Advisory Council on National Pharmacare Plan.
What are your thoughts on the National Pharmacare Plan? Thank you for reading my post.