Provincial patchwork limits drugs
You and your cousin Bernie share the family weaknesses: a fondness for greasy fast foods and a dicey ticker. Somehow, you’ve both managed to control the junk food addict within, and your doctors have prescribed medication to keep your cardiovascular systems functioning reasonably well. But when Bernie goes to his pharmacy, half the country away from yours, he goes home with a newer, more effective drug than the one you pick up.
Both over 65, you and Bernie are covered by provincial drug plans. Unfortunately, in Canada, all provincial drug plans are not created equal.
About 85 per cent of Canada’s population is covered to some extent by a drug plan. While some are covered by private insurers through employment and others purchase private coverage independently, most people 65 and older, and people on welfare, receive drugs through provincial or territorial drug benefit plans.
A look at a comparison of those plans, prepared by the Canadian Pharmacists Association, illustrates the complexity of drug coverage in Canada. Some provinces charge a premium for coverage; many charge a deductible plus a co-payment which may vary with income; most pay for certain expensive drugs reired by people struggling with catastrophic illnesses.
Drugs approved at the federal level by the Health Protection Branch (HPB) are not automatically available for provincial drug plan beneficiaries across the country. Inequitable access to prescription drugs is a fact of life in Canada.
Expenditures for drugs under these government plans will inevitably rise as more and more people reach the age of eligibility. In an effort to maintain some control over spending, each jurisdiction has developed a formulary or listing of the drugs available under their drug benefit plan, and new drugs are added only after careful scrutiny of their effectiveness, particularly in relation to their added cost. (New drugs usually cost more than older drugs already listed.) New additions may be classed as "full" (without any restrictions) or "restricted," in which case the drug will only be available under certain conditions.
Increasingly, provinces are requesting a pharmoaco-economic analysis from manufacturers who have submitted a drug for listing on a provincial formulary. This takes into account the money saved when an expensive, but effective, medication reduces physician visits or hospital stays, for example.
Provinces attempt to control rising drug costs through strategies such as price freezes. Ontario has not allowed price increases in the drugs it lists since 1993, and because Québec has a policy that does not allow prices to be higher in Québec than elsewhere, prices on the same drugs are also frozen in its formulary.
Costs are also minimized through the use of generic substitution. Most provinces only allow changes to this policy if the doctor clearly states on the prescription that there should be no substitution. However, in some instances, the patient could end up paying the difference between the cost of the required drug and its generic form, unless the patient has had a drug reaction caused by the substituted form. CARP’s President, Lillian Morgenthau, has steadfastly opposed any policy requiring a patient to suffer a reaction before a drug ordered by a doctor is allowed.
Limiting coverage of drug costs to a provincial formulary in effect tells doctors what drugs they will prescribe. If necessary, doctors can request access to a particular drug for a patient. This requires the doctor to take the time to write a letter to the province indicating the need for the special authorization. Since 1994, such requests have risen in Ontario from 1,100 to 11,000 in 1997, and patients are no doubt waiting longer for authorization.
While British Columbia electronically lists the drugs covered by its provincial plans, other provinces publish their formularies in conventional print form which requires much more time to alter.
Ontario has not published a new formulary since August 1997. While the province is planning a move to quarterly formularies, the process must first be developed. This requires tripartite negotiations between drug program managers, the government and pharmaceutical companies.
Provincial reluctance to add new and expensive medications to their drug plan coverage is affecting seniors in Canada. Following approval at the federal level, even breakthrough products — new medications offering significant improvement over currently available drug therapies — may not be added to provincial formularies at all. Some may be added after many months, and an increasing number are listed with limitations on use. B.C. residents are waiting an average of 222 days for these new products, while people in Alberta and Ontario are waiting approximately 500 days before the drugs are covered by their drug benefit plans.
Follow your cousin Bernie’s example if you need a variety of prescription drugs to maintain your health, and are contemplating a move to another part of Canada. He did some research before he moved. After all, you’ll find those greener pastures may not look as lush if you’re suddenly expected to pay for the medication you know you tolerate well — and have been receiving under a provincial drug benefit plan.