Dr. Monika Dutt, Chair of Canadian Doctors for Medicare, was invited to present to the House of Commons' Standing Committee on Health on Monday, June 6, 2016 regarding the development of a national pharmacare program. The text of her submission is as follows. The full document with citations is also available for download.
Statement by Monika Dutt
MD, CCFP, FRCPC, MPH, MBA
Chair, Canadian Doctors for Medicare
For the HESA Regarding the Development of a National Pharmacare Program
Canadian Doctors for Medicare (CDM) was created in in 2006 in response to events in the medical profession and public policy that threatened to undermine Canada’s national commitment to equitable health care access.
As medical professionals, we are firmly committed to evidence-based health care policy reform. We advocate for innovations in treatment and prevention services to improve the quality, sustainability, and equity of our healthcare system.
A key initiative that we are focused on is the implementation of a single-payer universal national drug program or pharmacare.
We are pleased that, last January, the federal, provincial and territorial health ministers agreed to engage in a national discussion on pharmacare. Furthermore, Canadian Doctors for Medicare is grateful for the opportunity to present to the House of Commons’ Standing Committee on Health on the development of a national pharmacare program.
At a press conference following the January meeting of Canada’s ministers of health, the federal minister Dr. Jane Philpott said, “Philosophically, the concept of Pharmacare is an important one to address.” We know the practicality of universal Pharmacare resonates strongly with Canadians as well. According to a July 2015 poll conducted by the Angus Reid Institute, 91% of Canadians want a national pharmacare program. And with nearly one in four households unable to facing issues preventing access to medication, we know that this has an enormous impact on health.
But beyond philosophical alignment, popular support and improved health outcomes, this committee is considering whether or not implementing pharmacare in Canada is administratively feasible and fiscally responsible. After all, the Canadian Institute for Health Information (CIHI) estimated the total health expenditure in Canada for 2015 would “reach $219.1 billion, or $6,105 per person” and that health spending will represent “10.9% of Canada’s gross domestic product (GDP).”
Canadian Doctors for Medicare is pleased to provide evidence to the committee demonstrating that a publicly administered, single-payer system is the drug insurance model best able to provide cost management, reduce administrative expenditures, maximize health effects, and lower costs to taxpayers. This is achievable and beneficial from a fiscal standpoint. Every bit of prudent reasoning points to action, and action now, on pharmacare.
The State of Public Drug Coverage in Canada
A 2014 study found that only about 60% of Canadians are covered by private health insurance for health-care services such as prescription drugs.
Others either have no coverage or are covered by an assortment of public drug plans with different criteria depending on the jurisdiction.
Ontario alone offers six public drug programs for example that provide coverage for medication costs based on age, income, socioeconomic status, or ailment. CIHI estimated public sector spending on prescribed drugs in 2014 was $12.1 billion nationally, representing 42% of prescribed drug spending. This clumsy and pricey model falls far short of what Canadians need, and often leaves those most at risk without drug coverage.
It also translates into difficult conversations with patients daily. I can tell you about a teenage boy, whose diabetes is out-of-control because he can't take his insulin regularly -- his father does contract work in Fort McMurray and his mother works for a low-wage and no benefits — and my patient knows that his parents sacrifice to try to keep his medication access consistent. They manage, most of the time. Then he comes to me for samples the rest of the time. And you can imagine the staggering cost, both in health and in pubic funding, when these stop gap efforts fail and that boy is rushed to hospital. All because of a few dollars worth of insulin.
There are also situations that should be resolved simply: a woman in her fifties with pneumonia who didn't want to tell me that she couldn't afford the antibiotics I prescribed. She came back, in worse condition. We strategised with the pharmacist to find a cheaper antibiotic option -- but it wasn't the ideal treatment. Thankfully, she still recovered.
The lack of access to prescription medications is an urgent issue for many Canadians. In The Future of Drug Coverage in Canada, the authors reported 24% of Canadian families fail to take needed medications due to cost and about two-thirds of Canadian households have some level of out-of-pocket spending for prescription drugs. Some face exceptional costs. Five per cent (5%) of Canadian children and adults and 10% of Canadian seniors pay over $3,000 per year for drugs. But a catastrophic program that only captured them would still leave he other 19% of the households without affordable access to medications.
The current private-public mix of drug coverage programs does not work and its effects are being felt by our families, the Canadian health care system and ourselves. And patchwork solutions will still leave too many without the care they need. And that comes at a cost.
The Cost of Non-Adherence
Every emergency room doctor in Canada sees patients weekly who are there because they did not or cannot take their medications, imposing significant costs on the health care system. Not surprisingly, the negative effects of high drug costs disproportionately affect people with low incomes. Lower income people show higher non-adherence rates, and rates of non-adherence are shown to rise as costs increase, even with fees as low as $10.
Many people make hard choices, such as whether to pay the rent, buy food, or buy medicines. Not only is the cost of drugs a factor, but high dispensing fees, copayments, and deductibles must also be considered. High costs have a significant impact on adherence and, with it, on health and overall health care costs. Likewise, researchers have found that reducing financial barriers to medication increases the consistency with which patients purchase and take their medicines as prescribed.
Peer reviewed studies from the U.S. and Canada have demonstrated the meaningful health benefits and significant cost savings from more consistent use of medications.
In the U.S., Dr. Niteesh K. Choudhry noted that adherence to medications prescribed after myocardial infarction is poor. His team enlisted patients who had been discharged recently from the hospital for a heart attack in a study. They were split into two groups: 1) one group had their medications fully paid for at no cost, and 2) the second group maintained their usual coverage.
They found the rates of total major vascular events or were significantly reduced in the full-coverage group, with a significant reduction in the number strokes and an 11% decline in other vascular events in the full coverage group compared to the usual coverage group. Rates of adherence were 4 to 6 percentage points higher in the full-coverage group. Significantly, the total health care costs fell by $5,700 USD per patient on average for the full coverage group.
Dr. Irfan Dhalla applied this study in Ontario and examined the costs and benefits of providing free medications to myocardial infarction patients who do not have private insurance and do not qualify for sufficient public coverage. They found providing free medications to prevent illness after a heart attack produced better health outcomes at lower average costs than the current system.
Patients unable to take their medication often experience decreased quality of life. What’s more, their lack of access is stressing the public purse since untreated conditions lead to increased healthcare provider visits and hospitalizations.
In the United States, between $100 and $300 billion of avoidable health care costs have been attributed to medication non-adherence, for example. Studies indicate that in Canada 6.5% of hospital admissions are the result of nonadherence to medications. The total cost of non-adherence in Canada is estimated between $7 billion and $9 billion per year.
The Weight of the Evidence
Within two weeks of this government’s mandate, a group of 331 health professionals and academics signed an open letter addressed to Prime Minister Justin Trudeau urging him to put Pharmacare at the top of the Canadian health care agenda. Garnering consensus of this magnitude is often a difficult undertaking; however, in this case the letter had signatories from every province including: physicians, pharmacists, and nurses; professors from 34 universities across Canada; 10 recipients of the Order of Canada; and 11 Canada Research Chairs.
These experts, like Canadian Doctors for Medicare, were swayed by a case based on strong, data-driven evidence in favour of implementing Pharmacare.
We realize the committee has been presented with much of this research, and also with rebuttals. We encourage the committee to consider the research on all sides of the issue; however, we also urge members to consider the source and quality of research.
For instance one recent paper challenged the accuracy of an article, published in the Canadian Medical Association Journal and praised by the Canadian Institute of Health Research. The CMAJ article demonstrated the impressively low cost of implementing pharmacare. The paper criticizing it was not submitted to a peer-reviewed journal, where a baseline for research standards can be met. In addition, several sections in the report make contradictory claims about costs. We have attached our analysis of that paper, which we shared earlier this year with the Minister, and encourage the committee, as we did the Minster, to receive all the evidence, but weight its credibility carefully.
Canadian Doctors for Medicare welcomes courageous conversation especially on topics of national importance such as pharmacare, but debate grounded in reason and evidence is much different than one resting on special interests and hyperbole.
And the evidence is clear.
According to the health economist Steven Morgan from School of Population and Public Health at the University of British Columbia, universal public drug coverage would reduce total spending on prescription drugs in Canada by about $7.3 billion. The private sector would save about $8.2 billion.
According to this analysis, costs to the government would increase by about $1 billion and most of the projected increase in government costs would arise from a small number of drug classes.
Given the cost of medication non-adherence in Canada is estimated well over $1 billion annually, it is likely governments would recoup even these limited costs and more. To quote Dr. Morgan:
“Pharmacare is achievable and financially sustainable. Every comparable universal health care system in the world proves that this is the case, because they all provide better access to medicines for less than Canada now pays.”
With those economic realities, it is no surprise that, in the last week alone, both the Federation of Canadian Municipalities and the BC Chamber of Commerce formally adopted policies calling for action on Pharmacare. Support for prompt action on pharmacare is literally growing broader by the day.
Canadian Doctors for Medicare joins those groups and hundreds of others in advocating for prompt implementation of a national drug coverage program because we see firsthand the consequences that gaps in drug coverage have for our patients’ health. Canadians without drug coverage are continually faced with the choice of paying out of pocket for costly medications or skipping their treatment. We see them in our clinics every day. Every day governments delay we see more of them. And every time they return – with issues that could have been prevented by taking their medications as prescribed – the public health care system incurs increased health delivery costs.
These personal and system repercussions are avoidable. The cost of not implementing pharmacare is too high in terms of health and the public purse. We urge the government to work collaboratively with the provinces and territories and provide pharmacare to Canadians immediately.