Doctors find drug list too restrictive

You haven’t been feeling well and the pills you’ve been taking don’t seem to be helping. After a second visit to your doctor, you stop by the local pharmacy to have your new prescription filled.

“I’m sorry,” says the pharmacist, “but you’ll have to come back for this.”

The explanation? The new drug is in a special category of the provincial plan that covers drug needs for people 65 and older. The pharmacist must contact your busy doctor to have a special Ontario Drug Benefit (ODB) form completed. The form is required for the drugs it restricts to ‘limited use’. When the pharmacist can’t reach your doctor right away, you head for home, hoping you’ll feel well enough to come back later.

Different rules
Had you been in a hospital you’d have gotten the drug your doctor ordered. Those medications are covered by the Canada Health Act.

If you’d had the financial wherewithal to pay for the drug yourself, you could have gotten the prescription filled right away.

And if you had coverage under a private insurance plan, you’d probably also been able to get the medication.

But restricting access to certain pharmaceuticals ocrs in many provincial drug formularies across Canada. (The formularies are lists of drugs available at no charge under each province’s or territory’s drug plans.)

Dollars for drugs
While each jurisdiction attempts to provide cost-effective drugs, drug expenditures now represent the second largest chunk of health care dollars, after hospitals. It’s bigger even than the portion required for physicians’ services.

Those costs have increased due to greater demand and also as a result of newer and more expensive medications being added to the formularies.

The Canadian Institute for Health Information (CIHI) estimates that in 2000, total spending on drugs in Canada reached $14.7 billion, with $11.4 billion of that going toward prescription drugs.

Sore point with doctors
The limited use mechanism in Ontario has been a sore point with the province’s physicians. Matters came to a head early this spring when the ODB moved the antibiotic ciprofloxacin (Cipro®) to the restricted list.

Writing in the March 2001 issue of the Ontario Medical Association’s Ontario Medical Review, James Mendel and Dr. Ted Boadway (of the OMA’s health policy department) pointed out that limited use had become a primary means of “managing program costs and unrestricted drug utilization.”

Their article, “The Cipro Case: A New Formulary Restriction on the Ontario Drug Benefit Plan,” noted that the OMA disagreed with the change in Cipro’s status. It also questioned the justification for the move: the claim that restricting Cipro and other antibiotics of its class would combat antibiotic resistance.

Imposes restrictions
Cipro is prescribed for urinary tract infections and certain skin and bone infections. Giving it a limited use designation affects one group-the over-65s who get their drugs through the ODB. The general population would still have unrestricted access to the drug.

Dr. Kathryn Lockington chairs the 10,000-strong general family practice section of the Ontario Medical Association (OMA), the largest segment of the organization.

“This whole limited use process is aimed at controlling costs by imposing restrictions on our practices,” she says. “That’s the issue for family doctors, not specifically the Cipro issue.”

Lockington feels the limited use process, with its many drugs and requirement for special codes and forms, represents a load for doctors.

“It’s mind-boggling. Every new drug gets put on there. It’s a significant burden for family physicians-an unpaid burden,” says Lockington.

Doctors oppose system
The OMA surveyed family physicians last spring to determine how they felt about the limited use process. More than 70 per cent opposed the system, with 84 per cent indicating they believed it could negatively affect the health of patients.

While doctors agree controlling ever-increasing drug costs is necessary, they feel the same goal could be met through education, by providing them with feedback on drug utilization.

“We write prescriptions all day long,” notes Lockington, “but we don’t have a profile on our overall prescription pattern. We’re suggesting money could be spent more wisely by educating physicians. Send us a monthly prescription pattern so we can see if we’re off the line on what’s generally accepted.”

Lowering antibiotic use
Ultimately, the physician is in the best position to make the decision on the patient’s behalf.

“Family doctors pride themselves on their one-to-one relationships and looking after their patient’s best interest in a particular situation,” notes Lockington.

Dr. John Conly, a professor of medicine at the University of Toronto and chair of the Canadian Committee on Antibiotic Resistance, points out that restricting a drug like Cipro is only one of the strategies the provincial Ministry of Health and Long-Term Care is initiating to diminish antibiotic resistance.

“This was not about singling out a particular agent,” he says. “This was a truly principled strategic direction that was set and was accompanied by a massive educational program of brochures and information that went to all 26,000 physicians across Ontario. We believe it had a dramatic impact on appropriateness of prescribing,” he says.