About Dr. Hoskins’ drug benefit

Dr. Hoskins’ recent drug insurance proposal was considered “bold and clever”. Overall, I agree. The 171-page scientific report of the Advisory Council on the Implementation of a National Pharmacare Program responds to a well-established need to expand pharmacare to include all Canadians. However, it neglects or avoids some rather important topics.
E bout 10 to 20% of Canadians are uninsured or have inadequate coverage for essential prescription medications; therefore, they may neglect to take essential medicines. The remaining population is covered by an amalgam of 100 public plans and more than 100,000 private plans, most of which provide for various quota deductibles and annual ceilings. The problem is exacerbated by the aging of the population and the growing number of workers in temporary positions with limited drug coverage. Drug costs are rising rapidly, from rare diseases to immunotherapy to biologics and even common medications like insulin.

According to a report from the Patented Medicine Prices Review Board, in 2016, average generic drug prices compared to Canada were approximately 74% in France, Germany and the UK, 62% in Canada. Australia and only 39% in New Zealand; the same drug can be 10 times more expensive in Canada than in New Zealand.

The question is whether it is possible, desirable and cost-effective to replace all existing private and work plans and to establish a new federal bureaucracy.

Dr. Hoskins’ report lists “comparator countries” – Australia, France, Germany, the Netherlands, New Zealand and the United Kingdom.

Almost everywhere, the delivery of health care is nationalized. In contrast, in Canada, the Constitution states that health is a provincial or territorial jurisdiction.

Can Justin Trudeau join all the provinces if he is concerned about conflicts over carbon taxes, pipelines, etc.? Dr. Hoskins acknowledges (at page 66 of the report) that as the will of jurisdictions varies, it will take time before all provinces and territories are ready to participate. This reality certainly applies to Quebec, which already has a universal comprehensive drug plan (which, however, costs $ 200 more per person compared to Canadians in other provinces) (page 34), and its own organization, the INESSS (page 68), to evaluate drugs and recommend to the government which drugs to include in the public plan.

Ontario could also protest. The Liberal government expanded the coverage of its health insurance plan on January 1, 2018 to include people aged 24 and under (Health Insurance Plus). On April 1, 2019, the Conservative government of Doug Ford, in its plan to reduce the deficit, limited protection to children and youth who did not already have a private drug plan.

All of this could undermine the goal of reflecting all the principles of the Canada Health Act (page 11) so that “the benefits of the national drug plan must be transferable in all provinces and territories when people are traveling or moving.

It is interesting to note that throughout the report, Dr. Hoskins insists that (page 22) “The Council recommends that the federal government enshrine the principles and national standards of pharmacare in a federal law, separate from the Canada Health Act … “” The inclusion of pharmacare in the Canada Health Act (page 97) may impose limits on the plan because the Act does not allow for the imposition of such as the quotas we have recommended. “Above all (page 98),” we are also concerned that the amendment to the Canada Health Act (…) will create pressures to bring other changes “.

Why does Dr Hoskins want his program to be separate? Several reasons are possible. While acknowledging that excessive user fees may be a barrier to access, he noted (at page 12) that: “They are nonetheless a standard feature of virtually all insurance plans. drugs in Canada and abroad, and we recommend them, but with strict limits: drugs on the list of essential drugs would be matched by a share of $ 2, while the share of other drugs drugs would be $ 5 (…) no household would pay more than $ 100 a year.

In addition (page 22), “the Council recommends that private insurers be authorized to cover quotas and drugs that are not on the national list of insured drugs”.

Dr. Hoskins does not mention that all comparator countries also have mixed public and private systems of health care delivery. These systems are financially viable and have shorter waiting times thanks to certain user fees and private coverage of certain doctor services also covered by the public system. All of this is prohibited by the Canada Health Act.

In addition, Dr. Hoskins does not want us to invite comparisons with the services covered by the CHA and the projected ongoing federal contribution. It should be remembered that when the CHA was adopted in 1984, the idea was to establish an equal cost-sharing agreement between Ottawa and the provinces and territories. A peak of only 36% was reached in 1976-1977, but the proportion has now fallen to about 21%. The Canada Health Transfer is per capita, regardless of the needs of an aging population in regions such as the Atlantic provinces. Dr. Hoskins proposes to narrow the gap between the needs of each province and its current expenditures. Thus, the transfer of drug insurance would be $ 794 per person for Newfoundland and Labrador and $ 759 for New Brunswick,

Dr. Hoskins acknowledges the reluctance of most provinces and territories to sign an agreement without guaranteed federal funding (page 94), ie. that the federal government could not “make changes to the agreement without the agreement of the provinces and territories”. Later, he reiterates this argument by emphasizing that “the mechanism must be governed by a common decision-making ethic. One party should not be able to make unilateral changes to the agreement. ”

I totally agree, but I find it ironic, since in April 2015, as Ontario’s Minister of Health, Dr. Hoskins unilaterally reduced (sometimes 30 to 50%), revised or completely removed more than 400 doctor’s fees.

How should we proceed? First, the mechanism to fill the gaps in pharmacare should be implemented at an initial cost of $ 3.5 billion per year. Very expensive drugs for rare diseases should be covered for all Canadians.

What should be done about people already covered by private and public insurance plans? In 2017, there was a total expenditure of $ 29.8 billion in prescriptions; $ 13.4 billion came from public plans, $ 11.5 billion from private plans and $ 5 billion from direct payments.

With massive purchases from the Pan-Canadian Pharmaceutical Alliance, drug prices are expected to decrease, resulting in savings of $ 100 per year in drug and business plan premiums, and $ 750 per year per employee. In other words, businesses would save more than $ 15 billion in insurance costs, and families would save more than $ 5 billion in out-of-pocket expenses. However, the marginal cost for Ottawa would be at least $ 15.3 billion a year by 2027. This expense comes at a time when the federal deficit is already at about $ 20 billion a year!

It is very surprising that Dr. Hoskins is making little effort to recover some of the business savings. He argues (at page 15) that “(business owners) will have the financial flexibility to provide other social benefits to their workers (for example, mental health and wellness services, physiotherapy, dental and vision care) to help employees benefit from savings by increasing their wages or investing in their businesses. ” He continues (at page 154) that “the consultations suggest that it is likely that the compensation of many employees will increase, either in the form of additional benefits, or in the form of increased wages and salaries”. Once again,

Dr. Hoskins also proposes tighter regulation of pharmaceutical industry funding for health care professionals. He suggests (at page 80): “A good starting point would be to follow the example of the United States and Europe, which requires pharmaceutical companies to publicly disclose payments to health facilities, health professionals and patients “.

Permettez-moi de proposer une deuxième étape: une surveillance beaucoup plus étroite des ristournes illégales sur les ventes de médicaments génériques. Une interdiction complète des ristournes directes et indirectes sur les médicaments génériques aux pharmacies est entrée en vigueur en Ontario en 2013; le Québec est la seule autre province ayant des restrictions semblables. Pourtant, d’après un reportage de l’émission Fifth Estate diffusée sur CBC le 13 janvier 2019, la pratique se poursuit, ce qui peut alourdir considérablement le fardeau financier des patients, du public et des régimes d’assurance privés.

Dr. Hoskins is vague in his explanation of how his new program would be funded. To avoid tax increases and worsening debt, Ottawa should look at ways to raise additional revenues, including the promotion of medical tourism. It could also look at the effective mixed regimes of the comparator countries and draw inspiration from them. It should then amend and modernize much of the Canada Health Act.

Dr. Hoskins’ report and a total re-evaluation – after 35 years – of the Canada Health Act should be on the agenda of the First Ministers’ and Territorial Leaders’ Meeting in Saskatoon from July 9 to 11 for the Council of the Federation.

Dr. Hoskins’ proposals are indeed “bold and clever”. Most Canadians expect an excellent universal health care system, which will soon include pharmacare. Nevertheless, they must know exactly how this system will be financed. As John Ivison concluded (National Post, June 13, 2019), it is obvious that when you get something for free, it’s just that you have not received the invoice yet.

Dr. Charles S. Shaver is a native of Montreal. He is a graduate of Princeton University and Johns Hopkins School of Medicine. He is past president of the General Medical Practice Section of the Ontario Medical Association.

The opinions expressed in this article are his.

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