What do you do as a healthcare provider when you know your patient can’t afford the medicines you are prescribing? In the era of evidence-based medicine, a greater focus has been placed on ensuring that patients are prescribed the most effective treatments, but rarely do we discuss what happens when a prescription leaves the physician’s hands.
We met Doug in hospital, shortly after he’d suffered a small stroke. When we spoke, he was primarily concerned about what would happen to his family and his job if his health further deteriorated. A 45-year-old truck driver, Doug has many health concerns including diabetes, high blood pressure and high cholesterol. We already know that income is linked to health, so his poor health status is not surprising. However, while we work to dismantle those inequities, we often wrongfully assume that our universal healthcare system corrects for them.
While Doug’s family doctor prescribes medications for his multiple medical problems and even ensures she chooses the cheapest generics, like so many others in Canada, Doug doesn’t have private drug coverage and is left to pay for these medicines out of pocket. Rent, groceries and the cost of raising a family often mean that little is left at the end of the month. As a result, medications can become a secondary priority. The thought crossing both our minds when we heard Doug’s story was, “Did our health care system cause this man’s stroke by denying him access to medications?”
Doug’s story is a common one. Like him, one out of every four people in Ontario (roughly 3 million people) do not have drug coverage. Provincial catastrophic plans like Ontario’s Trillium Drug Program are only accessible to people for whom a significant portion of their household income goes towards medicines. For someone who’s average family income is $36 000 or less a year, this could mean as much as $1131 in deductibles. The increasing burden of chronic diseases such as asthma, diabetes and high blood pressure means that many medications are now essential for keeping patients out of hospital and living independently in their communities.
An incredible one in ten people in Canada report having trouble filling prescriptions because of costs, according to a 2012 study in the Canadian Medical Association Journal. This jumps to roughly 1 in 3 for people with low incomes and no insurance like Doug. Not surprisingly, patients who can’t afford their medications are more likely to suffer from adverse health outcomes, require emergency department visits and hospitalizations, and miss work. By not including medicines as part of our universal healthcare system, we have made the choice to pay for strokes but not the blood pressure medicines that could prevent them.
In most provinces, only the elderly and people on social assistance have access to public drug plans. Not only do we fail to cover our whole population as most high-income countries do, but we are also wasteful. In fact, we pay 30% more for prescription drugs than the average for OECD nations and have the highest growth in per capita drug spending.
This is in contrast to universal pharmacare, which actually saves money. A 2011 study in the New England Journal of Medicine found that providing prescription coverage to heart attack patients resulted in people taking needed medications and suffering fewer complications. As a result, costly interventions associated with complications were avoided. For us, this research is not surprising at all and is something we see with patients everyday. In Doug’s case, we did not support his access to medications and taxpayers ended up paying for the hefty tab of preventable hospital services.
In Ontario, cardiovascular complication rates in people with diabetes go down in all income levels when they reach 65 (the age at which they can access the provincial drug plan). Therefore, not only would universal drug coverage benefit patients like Doug, but everyone else as well. If we are seeing these results for patients over 65 years of age, why are we not considering such strategies for all Canadians? Too often, we stand idly as the costs of medications serve as barriers of good health outcomes for our patients. This is a real issue that leads to real consequences for all of us.
An initiative of this nature is not without its challenges, with poor media coverage, differences between various provincial plans and working with the pharmaceutical industry being just a few. However, as frontline healthcare providers, we know that it is unfair to turn a blind eye to what happens to our patients once they leave with a prescription in hand.
This is why we are attending Pharmacare 2020 in Vancouver, British Columbia this week – a national symposium to promote clarity about the future of prescription drug coverage in Canada. Over the next two days, policy-makers, academic researchers, healthcare professionals and insurance & taxpayer representatives will be discussing how these obstacles can be overcome so that we can help Canadians like Doug prevent poor health outcomes and save taxpayers money at the same time.
Had universal pharmacare already been instituted in Canada, Doug would have been able to afford his medicines and potentially avoid a stroke that could affect his ability to care for himself and his family. A national pharmacare strategy has the potential to improve equity and affordability of medicines for Doug and Canadians from all walks of life.