National pharmacare Programme

A National Pharmacare Programme for Canada?

Prescription drug costs are in danger of bankrupting Canada’s Medicare. That may be hyperbolic, but certainly they are siphoning too many dollars away from other services.  Last year in Canada prescription drugs cost a total of $30 billion. They have quadrupled in the past 20 years.  That is an increase of 8% per annum over inflation.  It was in 1997 that prescription costs outstripped total physician cost to Medicare.  This is a problem that cannot be ignored;  there will be no one simple solution, but a major consideration will be a national Pharmacare programme.

When Tommy Douglas first established Medicare in Canada in 1962 his intention was to have an all-encompassing programme. He reluctantly had to make compromises because of an impending election; the result, 50 years later, is a Medicare system that covers hospitals and physicians and little else.

Since then the Hall commission (1964), and the Romanow report (2002) have emphasized that prescription costs should become part of the Canadian health system. In fact Canada is the only developed country in the world with a national health care program which does not include prescription drugs.

The result is a hodgepodge of different payers. Private insurance companies pay about 36%, public insurance plans pay about 42%, and the public bears 22%.

This leads to inefficient replications of administration of these disparate paying agencies. A less obvious consequence is that there is no authoritative body to negotiate reasonable drug prices.

It is estimated that if there were one single paying agency across the nation then 10% could be saved on private company administrations, 10% on the public administrations and 10% on renegotiated drug prices. This is for a total of 30% of $30 billion.  $10 billion.  No small change.

A single agency dealing with prescription drugs will be able to negotiate substantial savings. As an example let’s look at atorvastatin (Lipitor). A year’s supply of the brand-name drug in Canada costs at least $811; in New Zealand, where a public authority negotiates prices, a year’s supply of the brand costs just $15. Even the generic version of Lipitor costs at least $140 in Canada,

Another driver of these escalating costs is the price of new drugs. These are promoted strongly to both the public and to physicians.  Physicians may feel that failure to use new medications will put them at risk of malpractice. Quite the contrary.  New drugs are not always better.  As an example, remember rosiglitazone (Avandia) and cerivistatin (Baycol)?

Another cause, which we can all address, is polypharmacy. It is easier to start a prescription than it is to stop one.  As physicians, we are the ones that write these prescriptions and so we should look at our prescribing habits.  In order to do this we need good evidence on which to confidently base therapeutic decisions.  A national Pharmacare program must do more than simply administer payment for prescription drugs;  it should also promote evidence-based education for physicians.

British Columbia’s drug costs are lower than the national average, due in no small part to the University of British Columbia’s programme Therapeutics Initiative.  Once I got over my prejudice of ‘yet one more restriction on my practising medicine’, this has turned out to be a valuable objective look at the evidence concerning new and established medications, and to a lesser extent physicians’ prescribing practices. (a hands-on practical offspring of TI can be found in iTunes – Best Science Medicine podcasts)

Finally, as a simple matter of arithmetic, if a medication dose can be safely halved, so will the cost. An example is Ezetimibe (Ezetrol) — 1/40th of the recommended 10 mg dose results in 50% of the full therapeutic effect.  A pill cutter could safely reduce the dose and the price to one quarter.

The cost of the prescriptions which we write remains occult. I have searched diligently and I am unable to find a website with the price of drugs commonly prescribed in Canada.  With the adoption of the EMR I wonder if it is possible that the price of prescriptions could appear when a electronic prescription is written.  Give physicians the information to enable them to make clinically and fiscally responsible decisions.

 Further reading on a national Pharmacare is covered in an excellent paper Pharmacare 2020, prepared by a group of academics from universities around the world.

 

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