Talk of a national pharmacare plan has been going on for at least the last two decades in Canada, yet we have seen little, if any, progress to date. But when it was announced last month that Eric Hoskins, former provincial health minister in Ontario, had taken on a new role as chair of a federal government advisory council on a national pharmacare plan, I felt hopeful for the first time that the idea may actually come into fruition. I am excited at the prospect of Canadians finally being able to have access to essential medicines soon.
But implementing a national pharmacare plan is no easy task—it must begin with the federal government having multiple dialogues with the 10 provinces and three territories on how to consolidate a patchwork of systems and infrastructures of prescription coverage. And it must tackle the challenging questions of who will pay for what, and which medications should be covered.
As a pharmacist who has seen how prescribing is done in real life and how patients suffer from sub-optimal drug therapies, here are 10 things I hope the new national pharmacare plan will take into consideration:
1) Establish a list of essential medicines
In fact, a preliminary such list was recently developed and can be used as a foundation for discussion. (Editor’s note: Healthy Debate editor-in-chief, Andreas Laupacis, was a co-author of this study.) For medications not on this list, patients can decide to pay through other means, such as private insurance or out of pocket. As for specialty medications such as oncology drugs or biologics for rare diseases, there must be a mechanism for special coverage considerations. Perhaps physicians could apply for funding in cases where the patient has met specific clinical criteria and where there are no other treatment alternatives. This structure will ensure that there is adequate access to expensive medications as well as sufficient control on appropriate prescribing and cost containment.
2) Negotiate pricing to prevent drug shortages
It will be important for a national pharmacare plan to have strong negotiating power on drug prices. But equally important is the ability to impose mandatory requirements to avoid shortages of essential medicines. If there is a drug shortage due to some unforeseen circumstances, then there must be a mechanism in place to resolve it as quickly as possible. After all, what good is it that we can negotiate a price of $0.10/tablet of spironolactone if there will be a drug shortage for the next 12 months? Drug shortages often force pharmacies to order from more expensive suppliers, and the cost differences are likely to be passed onto the patients.
3) Reconcile differences in medication coverage across Canada
This will likely be the most challenging aspect of implementing national pharmacare. For example, an oncology medication is often first covered by BC Cancer Agency while the rest of the country is still reviewing evidence for the medication. Likewise, many provinces on the East coast may never consider the same medication for public coverage, given their limited budget. How do we reconcile these differences? Some people will inevitably be disappointed if non-essential medications do not receive continued coverage, or if they’re asked to switch to a less expensive alternative. A national pharmacare plan must ensure similar access to drugs across Canada.
4) Be inclusive with coverage
Coverage should not be limited to prescription medications—if an over-the counter medication or supplement is clinically necessary and supported by sound evidence, it should be part of the national pharmacare plan. I am often frustrated when patients will not take vitamin B12 for pernicious anemia, vitamin D for bone health, or over-the-counter eye drops for severe dry eyes, because these medications are not covered.
5) Cover all strengths and formulations of the same medication
Another of my pet peeves is that we sometimes resort to prescribing a higher strength of medication because the lower strength is not covered, resulting in possible adverse effects for the patient. An example is the fentanyl patch—it is available at 12mcg/hr, but in Ontario, the provincial drug plan will only pay for a 25mcg/hr patch, simply because the manufacturer has decided not to submit a lower strength for coverage consideration. Why should the manufacturer decide what strengths are available for coverage? Liquid formulations of medications are particularly important for young children who are unable to swallow tablets. Yet many provincial drug plans omit these formulations. Clinicians should not need to keep tabs on what strengths or formulations are covered—they need to focus on knowing what medications are appropriate to prescribe. If a medication is cost-effective for a condition, a national pharmacare plan should cover all appropriate strengths and formulations.
6) Ensure an independent governing organization for evidence review
The Canadian Agency for Drugs and Technologies in Health (CADTH) is charged with providing an unbiased review of clinical evidence as well as pharmacoeconomic data in order to recommend whether a new medication should be listed for coverage by provincial drug plans. CADTH must continue to ensure objective review of evidence and ensure that new medications with established clinical benefits can be listed in a timely manner on the national pharmacare plan. Likewise, the organization should review any safety concerns that have emerged about a medication and consider de-listing or placing restrictions on coverage criteria as appropriate. For example, high-dose opioids were recently de-listed by the Ontario Drug Benefits Program. What about long-term use of benzodiazepines for insomnia? There needs to be mechanisms in place to ensure that medications are appropriately prescribed so that a national pharmacare plan is accountable to the public.
7) Be transparent about drug costs to prescribers
One of the issues with rising drug costs is that prescribers often do not have direct and easy access to information about how much medications cost. While implementing a national pharmacare plan would remove most of the cost barriers to essential medicines, prescribers would still be responsible to select the most cost-effective treatment options for their patients. If a medication is not listed, the cost should be clear to physicians and patients when it is prescribed. Currently, a patient only finds out how much a medication costs at the pharmacy. Ensuring transparency of drug costs will help prescribers select the most cost-effective treatments, thereby helping to keep the national pharmacare plan sustainable.
8) Incorporate pharmacists in helping patients manage their medications
Pharmacists have been shown to have the potential to reduce drug costs in various settings—from intensive care units to antibiotic stewardship and infectious diseases. It is time to integrate them in primary care. If a pharmacist can collaborate with physicians to review medications with patients, they can help improve appropriate prescribing, save on medication costs and help ensure that patients receive optimal care through education and close monitoring. Pharmacists can also support transitional care, liaise with community pharmacists and foster an environment for safe medication practices.
9) Integrating de-prescribing guidelines
Our escalating drug costs are out of control because although we have guidelines to advise us on when to start treatments, we don’t typically have them for when to stop. Polypharmacy not only drives up the drug costs, it is also responsible for many adverse health outcomes. We have recently developed de-prescribing guidelines on proton pump inhibitors, benzodiazepines as well as antipsychotic use in dementia. But we need more, specifically for the geriatric population where medications that were started years ago are no longer necessary or may become harmful. Our system needs to rethink how to incorporate de-prescribing into routine clinical practice. For example, there could be a requirement introduced that a patient with dementia who has been on an antipsychotic for more than three months must be reviewed by a pharmacist for appropriateness in order to receive continued coverage.
10) Listen to stakeholders
Consultation with clinicians, patients, the pharmaceutical industry and other employer-sponsored private insurance is absolutely imperative in developing a national pharmacare plan. It is also important for those creating a national plan to remember the bias of the pharmaceutical industry. The industry may argue that a national plan would slow down their ability to bring innovative medications to the market, but most of the negotiation will apply to generic medications, as opposed to new ones. Still, having a mechanism to listen to all stakeholders will help ensure that the national pharmacare plan will grow and adapt to the changing needs of the population.
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Thanks for this, Cynthia. Working in pediatrics, the implementation of OHIP+ has provided a glimpse into what might work for universal pharmacare.I think it works well for those who had no drug coverage prior to implementation, but it has been problematic for those on “off-label” high-cost medications that were previously covered by private insurance along with patient assistance programs. And I entirely agree with the need to cover all strengths of a drug. We have a patient who needs to take thirty 2.5 mg Methotrexate tablets once a week because the 10 mg tablets aren’t covered by ODB. It complicates medication adherence and compromises patient safety.
Terrific wish list! I would only add that, as pharmacists become better integrated into primary care settings, it would be ideal if existing (and future) community-based medication review programs (such as MedsCheck in Ontario) were likewise better integrated with the primary care providers on whose shoulders falls the near-impossible task of managing the ever-growing number of meds being consumed.
Oh, and it would also help if the work of Dr. Hoskins and the national pharmacare advisory council was not already being undermined by the federal Finance Minister. This should not be too much to ask.
Finance Minister Morneau’s comments were largely consistent with the initial Terms of Reference set by the Privy Council. The Advisory Council would advise the Ministers of Health and Finance “on how to best implement national pharmacare in a manner that is affordable for Canadians and their families, employers and governments.”
A helpful article that identifies some important considerations. Pharmacists clearly have an important role to play. Recognizing every group has their needs and biases, I think all stakeholders (point 10) can play a constructive role.
So much of what national pharmacare will become depends on what problems we’re trying to solve. The need for common definitions and discussion on many contentious issues, such as principles, policy goals, scope of coverage, a role for private insurance and funding is already clear. Unfortunately, it seems as if positions are hardening even before Council members have been named and the terms of reference set. If we can’t find common ground quickly, the window will close and pharmacare will be back on the shelf.
Develop a system whereby dosing can be done without wasting medications of the wrong dose–complex challenge but anyone who is being titrated on a medication understand how much waste can occur.
Well stated!!
Good article. I would add that there should be some opportunity for flexibility. Some patients can not tolerate a particular drug, but may do very well on another drug from the same class (eg., proton pump inhibitors, beta blockers, cholesterol lowering agents). Patients should have options within drug classes, managed by their MD.