Ahmed’s story is one of poor coverage and high prices. But one irony of current prescription drug use in Canada is that while many people can’t afford their medicines at all, many others suffer the effects of overprescribing and inappropriate prescribing. Too much medicine can also be very bad for our health. So while we absolutely need to remove barriers to accessing needed medicines, universal pharmacare can’t be a blank prescription for the nation. We need to prescribe smarter, not just more.
Canadians are taking more prescription medicines than ever before. Some of that increase reflects real advances in the world of medicine, as in HIV and heart disease treatments, for example. But in many cases our drug-consumption increases are not actually leading to better health. So it’s critical that we design our national pharmacare program not just to increase coverage and reduce cost, but also to emphasize quality and safety.
Take my patient Abida who has an array of medical problems, many of which come with prescriptions. How could pharmacare be structured to limit the possibility that I might overmedicate her, or prescribe two medicines that interact badly with each other, or prescribe expensive drugs when less expensive alternatives are just as good (or better)?
Because medicines aren’t covered by medicare, no government or agency is responsible for ensuring that they’re appropriately prescribed. The result is that this critical element of patient safety is not overseen. Private plans will reimburse virtually any prescription, and drug marketing to doctors is heavy. Obviously, these factors do not support an environment of responsible prescribing. For example, off-label prescribing—in which a drug is prescribed for a purpose other than its approved or intended use—poses a significant risk to health. A recent study in Quebec found that 11 percent of drugs were prescribed off-label. Of these prescriptions, close to 80 percent were not backed by sound scientific evidence.
So we find ourselves in the bizarre situation where some Canadians can’t access life-saving drugs while others are the victims of overprescribing.
A national pharmacare program couldn’t fix every single thing that’s wrong with Canadian drug prescribing. But if implemented correctly, it would create a strong incentive for policy makers to encourage appropriate use of medicines.
Unlike private plans, which have little financial incentive to reduce inappropriate prescribing, a public payer covering drugs for the country will want to be sure that health care providers are prescribing based on the best available evidence. Public pharmacare could facilitate evidence-based prescribing through a national formulary that would list the best choices; it could mandate the adoption of error-reducing electronic prescribing tools; and it could generate vast amounts of data to be incorporated into life-saving prescription drug monitoring.
There is no single “silver bullet” that would fix the problem of inappropriate prescribing. Most of the solutions out there have been shown to be hard to implement and to have modest effects. But taken together, and alongside a culture shift toward more thoughtful use of medical interventions, the kinds of changes we could make with pharmacare would make a big difference.
I think about a patient like Ahmed, who has three chronic medical conditions, one of which is diabetes. There are dozens of drugs to treat diabetes on the market. How can I be sure that I’m choosing the most effective, and cost-effective, options for him?
For starters, it would help me tremendously if I knew that the list of drugs covered for Ahmed would guide me to the most appropriate treatment. A national pharmacare program shouldn’t cover every drug for every person all the time. Instead, an arm’s-length process must be established to put in place a national formulary, a list of drugs that are both economical and effective. This list is one of the best ways to guide prescribing, because physicians will want to prescribe the medicines for which their patients are covered. Therefore the list would have to be kept absolutely up to date, with the ability to remove drugs if more effective ones become available. The process must be transparent and completely free of industry and political interference. That’s a tall order, but without such independence, we can’t have faith that the decisions made are in the public interest.
Other countries already do this. For example, in the U.K., the National Health Service maintains a “blacklist” of all drugs that will not be covered or insured through the public system, as well as a “grey” list of those that should be covered only for certain conditions. The NHS makes these decisions according to evidence-based recommendations from an arm’s-length body. This process is not without controversy, in part because there is always immense pressure for the public system to pay for expensive drugs that may not have evidence to support them. But the process is transparent. That’s more than can be said for our current system.
Not everything can be solved with a formulary. What if the first-line therapies for Ahmed don’t work, or he comes in asking about newer medications that a TV commercial advised him to “ask his doctor” about? Prescribing, like so many things, is an act of habit. Most doctors develop knowledge and comfort with a small list of drugs we know well, and we prescribe them over and over. A national formulary could help us develop good habits, but sometimes we need to step outside that comfort zone. And when we do, it’s critically important that our information sources be unbiased. The reality is that many doctors in Canada continue to get their information about medications from pharmaceutical company programs designed to promote that company’s product. We’re all busy, and if a pharma rep stops by at lunchtime with free samples, a quick fifteen-minute presentation on the newest medication, and a sandwich, it’s easy to listen. Yet this type of marketing is not benign. Instead of deriding these tactics, we need to use them.
The process of academic detailing uses the same kinds of approaches employed by pharmaceutical companies to educate doctors about prescribing, but it provides unbiased information. In academic detailing programs, a health care professional such as a pharmacist or a physician educates doctors in order to help them prescribe based on the best available evidence. The process feels a lot like what drug reps do: short seminars at lunchtime, one-on-one brief conversations tailored to that doctor’s area of interest, colourful reminder cards that are left behind with key points to remember and that can be used for patient education in the office. The difference is that academic detailing is independent of any financial association with the pharmaceutical industry. These programs are usually funded by governments, research organizations, universities, or medical associations. As a result, they can focus entirely on improving patient outcomes and ensuring value for money in the health care system, not on favouring a particular company’s products.
This is not wishful thinking; other countries are implementing academic detailing and other measures to improve the appropriateness of prescribing. Under its national pharmacare program, the New Zealand government tackled the issue through several different approaches. Its first national awareness campaign—Wise Use of Antibiotics—is an annual promotion aimed at reducing inappropriate prescriptions of antibiotics for colds and flu. A mix of public education tools like posters, pamphlets, campaign prescription pads, and practice commitment posters were used to guide decisions around when these medications are actually necessary. The campaign—targeted at patients and health care providers alike—has been successful, leading to a marked decline in the use of drugs that are so often prescribed inappropriately during cold and flu season.
Once I make my decision about what to prescribe for Ahmed, it’s important that I not make a mistake. If I reach for a pen, the risk of a safety problem is much greater. I might prescribe the wrong dose, or something that interacts with another medicine he’s taking. So one of the hopes we should all have for pharmacare is that it will support the implementation of electronic prescribing across the country. E-prescribing allows me to write and send prescriptions to Ahmed’s pharmacy electronically instead of using handwritten or faxed notes or calling in prescriptions. The e-prescribing program I currently use warns me about potential allergic reactions and drug interactions that could put Ahmed at risk. E-prescribing can also decrease prescription errors that result from bad handwriting or cryptic faxes.
Finally, if Ahmed does end up on a newer medication, he would be part of the large group of people who can help us learn about the effects of that medicine over time. The data available through a national pharmacare program could allow us to follow and better understand patient experiences with medications. Data collection on this scale has the potential to provide transformative insight into the effectiveness of drugs, their side effects, factors that change prescribing habits, and many other questions. Providing feedback to doctors about how our prescribing practices compare to those of our peers has also been shown to be a modestly effective way to improve the appropriateness of prescribing over time, so that if my go-to choice for Ahmed isn’t the ideal choice, I can learn to do better.
All the evidence points to pharmacare filling a real gap in Canadian health care, yet despite decades of recommendations by Royal Commissions and calls from provincial politicians, we seem to be stuck. Why?
Part of the issue has been that although pharmacare would clearly save money for society as a whole, it would shift the burden of paying for medicines from the private sector to the public sector—from out-of-pocket spending and insurance premiums to taxes. The incremental cost to public plans isn’t as big as some politicians worry it would be, but it’s not zero.
How much would pharmacare cost? A research study I was involved in, led by Professor Steve Morgan at the University of British Columbia and published in 2015, quantified the costs. We found that the annual savings to employers, unions, and private citizens would be $8.2 billion. Governments wouldn’t have to invest anywhere near this amount, because they can get much lower prices than we currently do. Depending on whether we achieved prices similar to the best- or to the worst-performing countries, the additional cost to governments would likely be on the order of $1 billion per year. This estimate doesn’t take into account any of the savings we should expect to see in the health care system as a result of people taking their medicines as prescribed. It doesn’t assume cancellation of the tax subsidy for private insurance. And it doesn’t assume any improvement in the overprescribing and inappropriate prescribing that currently take place. (Taking any of these factors into account would make the program even more affordable.) It is solely an estimate of how much more our public payers would need to spend in order to cover everyone if we got better prices for our drugs. Divide those costs among thirteen provinces and territories plus the federal government, and pharmacare starts to feel affordable.
In recent years, many governments have focused on downsizing their role and balancing the budget. So the social objective of equitable access to medicine and the political objective have appeared to diverge. Given the federal–provincial division of powers, it’s also been easy for the provinces and the federal government to point fingers at each other in discussions about whose job it should be to solve the drug problem in our country. Public support for national pharmacare is high, but despite the strong economic and moral case, this Big Idea will require political courage.
Apart from the price tag, governments are pressured by organized interests. The pharmaceutical industry, private insurance companies, and small and large pharmacies would all likely see their profit margins shrink. These economic powerhouses exert tremendous political influence. Yet the alternative—maintaining the status quo—is harming the health of millions of Canadians and hampering our economic prosperity.
The savings from universal public pharmacare don’t materialize out of nowhere. As the renowned Canadian economist Bob Evans has observed, every dollar of health care spending is a dollar of somebody’s income. With any major policy change there are winners and losers. The winners under pharmacare would be Canadian patients, especially those who are currently uninsured or under-insured, and Canadian businesses. The losses would be reduced profits for pharmaceutical companies, private insurance companies, and pharmacies.
These groups are all entitled to advocate for their interests. But we need to decide as a nation if we’re comfortable underwriting their profits at the expense of the health of our population and the sustainability of our health care system. Every other industrialized country in the world has managed to structure systems that strike a better balance than ours.
Major change in Canadian health care is rare, but it isn’t impossible. If people want politicians to do something, they have to demand it. No amount of economic analysis, policy doomsday predictions, or international shaming will cut it. Until the phones of the nation’s constituency offices start to ring off the hook, change will come slowly, if it comes at all. I wish that more people had time to devote to advocacy for their own legitimate interests. But as more Canadians begin to realize that they’re being ripped off by unnecessarily high prices, as more middle-class people face outrageous costs and bureaucracy to have their medication needs met, and as more doctors get fed up spending their time working around a system that is fundamentally broken, something will shift. Provincial and federal ministers of health are in active discussions about this issue at the time of writing; I hope their efforts will not stop short of the goal.
It doesn’t happen very often in the world of public policy that the right thing to do is also the less expensive thing to do. The economic and health case for pharmacare is clear. If access to care in Canada is to be based on need, not ability to pay, there is no justifiable reason to continue excluding prescription medications from our public plans.