Can an essential medicines list fix drug coverage gaps?
Take a peek in the medicine cabinet of the average Canadian home and you’re likely to find 14 prescription pill bottles. If that person is over 60, the average rises to 35 prescriptions.
But that doesn’t paint the full picture of the use of prescribed medications in our healthcare system. Although Canada has a universal health care system, we don’t have universal coverage of prescription drugs. One in 10 Canadians leave their prescriptions unfilled because they can’t afford their drugs.
Canada is the only country with universal health care that does not have a form of universal drug coverage. There is some coverage: Under the Canada Health Act, drugs administered in hospital are paid for by the public purse. Provinces also generally cover drug costs for seniors and people on social assistance. In some cases, where the cost of an approved drug is beyond reach, there are ways to apply for catastrophic coverage. Yet this leaves many people without benefits, including those who are self-employed and those who work part-time.
An “essential medicines” list includes common drugs used to prevent or treat illnesses and chronic conditions that would be covered by the public health system regardless of a person’s age or income. It could help close gaps in coverage – with some projections estimating it would cover 90 percent of prescriptions – and reduce the financial pressures that keep some patients from getting the medications they need.
Such a list is different from current publicly funded drug plans in Canada which contain many more drugs, but are only available to some people, such as those 65 years of age or older.
A recent modelling study suggested an essential medicines list could save up to $4 billion in drug costs a year, while the proposed list of essential medicines published recently in CMAJ Open might also help reduce drug errors and improve access to life-saving medications for Canadians who need them.
“It’s not a comprehensive list, but it’s the best alternative [to pharmacare] I’ve seen,” says Danyaal Raza, a family physician at St. Michael’s hospital and board member of Canadian Doctors for Medicare.
Critics, however, say an essential medicines list is a half-measure that could ultimately reduce choice for Canadian patients.
What drugs should be on an essential medicines list?
The concept of an essential medicines list is not new – since 1928, Norway has outlined a list of medicines, chosen based on their efficacy, quality, safety and cost, that must be stocked in pharmacies and whose costs are reimbursed.
More than 110 countries around the world maintain an essential medicines list, although not all are for the purpose of ensuring coverage of drug costs. The World Health Organization (WHO) list of essential medicines is designed to meet the needs of a basic health care system. Some countries, like India, keep lists to prevent drug shortages by using a medicine’s place on the list as a kind of public promise to ensure it’s stocked on pharmacy shelves.
The proposed essential medicines list for Canada is intended to provide universal public coverage of essential medicines and result in significant cost savings through bulk buying and single payer negotiations. Medicines not covered by the list would still be available, but their cost would not covered by public funders.
“A list of essential medicines increases the likelihood that patients are getting the medicines they need and also decreases the likelihood that they receive inappropriate prescriptions,” says Nav Persaud, a staff physician at St. Michael’s Hospital and one of the proposed list’s authors. (Healthy Debate’s editor, Andreas Laupacis, is a co-author on the paper.)
Persaud and his colleagues used five criteria to whittle down the WHO’s 448 essential medicines list, including duplications,medicines for conditions that are uncommon in Canada (such as malaria), ease of medication delivery (ie oral versus intravenous), items that are not medicines and medicines not prescribed by primary care physicians, such as cancer therapies.
What resulted was a list of 125 medications. The usefulness of the list was tested using data from two family practice sites in Ontario to see whether the drugs were commonly prescribed. At an inner city site, 90 percent of prescriptions were covered by the list. A suburban site saw nearly 93 percent of prescriptions covered.
Persaud sees benefits for patients, physicians, pharmacists and the health care system. Patients would be less likely to encounter drug interactions, he says, and more likely to be put on appropriate drugs with demonstrated effectiveness to treat or prevent an illness or condition.
With money no longer a barrier, patients should also be more likely to take medications that can prevent more serious illnesses – such as blood pressure drugs, which can reduce the risk of stroke.
The health care system should also be able to negotiate a lower price if there is only one drug from a class (such as statin drugs to lower cholesterol) on the list, compared with the price that can be negotiated if many different brands within a class are paid for.
Potential Cost Savings
A commonly touted benefit of an essential medicines list is cost savings, through the power of bulk buying and the savings that can be derived from having drug makers compete to put their product on the list and, consequently, on pharmacy shelves.
“There’s no public system in the world that actually costs more than Canada’s multi-payer private-public system,” says Steve Morgan, a health economist and director of the University of British Columbia’s Centre for Health Services and Policy Research.
“If you actually created a single payer public system for any medicines – whether essential or more comprehensive public drug coverage – you have the power of a single payer, which means you can drive prices down quite substantially.”
Morgan and Persaud’s recently published simulation study looked at costs and savings associated with public coverage of the proposed Canadian essential medicines list.
Using information from Sweden, New Zealand and the U.S. Department of Veteran Affairs (which maintains its own list and bulk buys those medicines for American veterans), the study showed drug prices were 47 percent lower for U.S. veterans and 60 percent lower in Sweden, compared to Canada. Canadians pay nearly five times as much for drugs as patients in New Zealand, which centralized its drug buying in 1993.
Their findings indicate that universal coverage of drugs on the essential medicines list would save an estimated $4 billion a year for patients and private insurers, but cost governments an extra $1 billion on top of the $5 billion they currently spend on drug coverage programs.
“Taxpayers need to find $1 billion in premiums or taxes, but in exchange, consumers, unions and employers save $4 billion. It’s a 4-for-1 return on investment,” Morgan says.
How would the list be maintained?
Determining whether a drug belongs on the list wouldn’t be that different from the processes that are currently in place to evaluate drug coverage, Raza says. Right now, CADTH, an independent, non-profit organization, conducts a review of new drugs and uses evidence to develop recommendations about which drugs should be paid for from public funds.
Right now, the proposed list is confined only to drugs prescribed by primary care physicians. Expensive drugs such as those for cancer, and biologic drugs for diseases like rheumatoid arthritis and inflammatory bowel disease would still need to be publicly paid through some other mechanism.
“It wouldn’t be a whole lot different than what we do now,” Raza says. “If patients come in and they need a drug they don’t have coverage for, we’ll explore alternative options, different forms of insurance or compassionate programs from a pharma company. It wouldn’t really change the process that we have now when it comes to issues of cost of medication.”
Persaud says most drugs in a particular class are similar in terms of their benefits and harms. Where there’s little to distinguish them, the choice for an essential medicines list could be based on which drug has been studied the most. He says an essential list can be surprisingly stable because genuine breakthroughs are relatively rare. Evaluating a new drug shouldn’t cause delays in access, he says. “If anything, it should be faster because you’re able to do better comparisons,” he says. “You’re just comparing a new drug to what’s on the list.”
However, Alistair Bursey, a pharmacist in Fredericton, New Brunswick and board chair of the Canadian Pharmacists’ Association, says a list containing only one drug in a class is a poor substitute for comprehensive pharmacare and may limit drug access.
“[An essential medicines list] wouldn’t come close to covering what Canadians need, and if we’re putting patients at the centre here, we need to cover that gap that we have in this country for patients who do not have comprehensive coverage for medicines,” he says.
Yanick Labrie, a Montreal-based health economist with the Fraser Institute, agrees.
“It’s a good thing to identify efficient drugs, drugs that we would want to see available in Canada and reimbursed by the public drug plans, but why would we want to have a limited number of medicines on that list?” Labrie says. “What we would want to have is an expanded list, even if you don’t see it as the most efficient drugs of all, it’s important that patients and prescribers have options, have choice.”
An essential medicines list wouldn’t limit access, Persaud says, just coverage.
“If there is really a reason to have more than one medication from a class, then the essential meds list should have more than one. Also, some lists in other countries have provisions for exceptional cases so that another medication can be provided,” he says.
With the current system, “from the perspective of patients, there’s a false perception of increased choice,” Persaud says. “There’s this idea that it’s better to have, say, 11 different statins. But in reality, patients are not given any choice. No one says ‘here is the list of statins, here’s a table explaining the risks and benefits of each.’”
Patients are usually prescribed the medication that their physician is familiar with, and that’s often the result of marketing, Persaud says, not necessarily based on the latest scientific research on safety or efficacy.
For Bursey, an essential medicines list may leave some people who have reactions or side-effects to a drug without access to the medication they need. It may also keep people from accessing competing drugs that could better treat their illnesses.
“I want to be able to treat my patient with the best medicine possible to get their condition under control and meet their [health] targets,” he says. “The key to us is to have that arsenal, that repertoire.”
The list also doesn’t address the issue of under-insurance, Labrie notes. “Many drugs are not insured, their costs are not fully insured. There are deductibles or co-pays. This is the problem. It’s not the fact that a large part of the population are not insured,” he says.
The politics of implementing a list
There are still many hurdles to clear before an essential medicines list could be implemented in Canada. Some of them are related to infrastructure, such as e-prescription services and databases to monitor drug safety and efficacy, but a favourable political landscape is perhaps the most critical.
Right now, both Morgan and Persaud acknowledge there seems to be little political will at the federal level, even though a standing committee on health has received positive submissions on pharmacare and a national citizens’ panel has submitted a report advocating for a universal, mandatory public drug insurance system for all Canadians, with an essential medicines list as a first step.
Provinces alone or in partnership could conceivably also forge ahead with creating their own lists. Ontario Health Minister Eric Hoskins has certainly advocated to put access to medications back on the political agenda.
Raza says with 3.5 million Canadians currently unable to fill needed prescriptions, it’s time for a solution.
“It’s a problem that’s getting worse,” he says. “Jobs are becoming more part-time, more contract, more precarious. Not as many people have employment-related benefits. This problem, as bad as it’s been, it’s only going to get worse. The longer we wait, the worse the problem is going to get.”