MEDICAL REFORM Newsletter of the Medical Reform Group Issue 132 Volume 24, Number 3 Winter, 2005 BLOCK FEES UNDERMINE ACCESSIBILITY TO HEALTH CARE: DOCTORS’ GROUP CALLS ON GOVERNMENT TO BAN PATIENT CHARGES Irfan Dhalla and Gordon Guyatt
he Government of Ontario longer make appointments if they re- But what is surprising, and dis- claims commitment to the Cana fused the annual fee. Everyone agrees turbing, is that the College of Physicians Tda Health Act, and ensuring that that these practices are unacceptable— and Surgeons of Ontario, a regulatory ability to pay doesn’t influence access to the important question is how to pre- body whose duty is to protect patients, care. But doctors have found a way vent them. has also endorsed block fees. Last month, around this principle and, so far, Premier It’s no surprise that the Ontario despite clear evidence that doctors con- Dalton McGuinty and Health Minister Medical Association wants to keep block tinue to violate the College’s existing block George Smitherman are letting them get fees regulated as loosely as possible. An fees policy, the College voted to contin- away with it. OMA representative has said that “Of- ue to allow doctors to charge these fees. If you are lucky enough to have fering block fees can actually improve The College’s decision comes despite its a family doctor, you may have recently the pay-as-you-go system…[They force] admission that it has neither the resourc- received an unwelcome request. The doctors to be more business-oriented.” es nor the intent to actively monitor and doctor, or more likely the doctor’s re- In fact, block fees have become so pop- enforce the administration of block fees. ceptionist, might have asked you to pay ular that a small industry has sprung up The Medical Reform Group, an a block fee—an annual payment, levied to make sure doctors are maximizing association of doctors and medical stu- in advance, for services not covered by their block fee revenue. dents who believe that all Canadians your provincial health insurance plan. should have equitable access to high-qual- Block fees are supposed to cover serv- ity health care, has been trying to persuade ices such as telephone prescription re- the College to put a stop to block fees. newals and the completion of summer INSIDE With last month’s vote, however, the camp forms. College regrettably put doctors’ interests In theory, patients can opt to pay above patients. for uninsured services on an a la carte basis Fortunately for Ontarians, under rather than en bloc. In practice, however, Releases...... 3,4,8,14 the recently passed Commitment to the Fu- most patients find it very hard to say ‘no’ Primary Care Reform...... 5 ture of Medicare Act, the provincial gov- when their doctor asks them to pay for Working Group call...... 5 ernment has the power to regulate block services in advance—even if they know fees—or ban them entirely. The MRG Steering Committee...... 6-7 they will never need those services. prefers an outright ban—with over 20 Even worse, many patients face Pharmacare...... 8-14, 19, 20 000 doctors in Ontario, monitoring the the threat of losing access to their family Guyatt Columns...... 15, 16 use of block fees would be a significant doctor if they don’t pay a block fee. One International Health--Nigeria....17-18 administrative challenge, and a waste of doctor’s patients were told that their tel- resources. Moreover, no realistic over- ephone calls would go unanswered un- sight could prevent physicians from con- less they paid up. Another doctor’s Please visit ourweb-site: tinuing to stretch the rules, and the patients http://www.hwcn.org/link/mrg patients were informed they could no (continued on page 2) Medical Reform Group, Box 40074, RPO Marlee Toronto, Ontario M6B 4K4 MedicalReform BLOCK FEES UNDERMINE ACCESSIBILITY TO HEALTH Medical Reform is the newsletter of the Medical Reform Group of Ontario. CARE (continued) Subscriptions are included with member- ship, or may be purchased separately at $50 per year. Arrangements to purchase most likely to be harmed—the poor and practice of charging large annual fees multiple copies of individual newsletters the elderly—are unlikely to complain. for extra services and preferential or of annual subscriptions at reduced There are useful actions the gov- access. Only a small number of doc- rates can be made. ernment could take short of prohibiting tors in Ontario are using the block Articles and letters on health-re- block fees. First, the government should fees policy in this way now, but little lated issues are welcomed and can be sent to
2 Medical Reform Volume 24, Number 3 - Winter, 2005 COLLEGE OF PHYSICIANS AND SURGEONS SHOULD VOTE DOWN POLICY PERMITTING PATIENT CHARGES
On November 25, the College of Under both the current and pro- According to the College, recent Physicians and Surgeons of Ontario posed policies, physicians are allowed to violations of the block fees policy include: will make a crucial policy decision charge patients for uninsured services ♦ Doctors charging block fees as a concerning “block fees”—flat fees (e.g., telephone prescription renewals, condition of being accepted into a charged in advance by doctors for completing forms for summer camp, practice services not covered by the Ontario etc.) either individually or with an annual ♦ Making patients pay for services Health Insurance Plan. The Medical flat fee. Under the flat fee policy, patients that are covered by OHIP (for ex- Reform Group is now publicly urg- often pay for services they never use. The ample, requiring payment for a spe- ing the College to ban the practice of College has proposed a new draft poli- cialist referral) charging block fees. cy that allows patients to refuse to pay ♦ Terminating patients from a prac- “The College knows that many the fee, and bans physicians from penal- tice for not paying a block fee doctors violate the existing block fees izing patients who refuse to pay the block ♦ Not responding to telephone mes- policy,” said Dr. Irfan Dhalla, spokes- fee. sages from patients who refuse to person for the MRG. “For example, “The College’s regulations might pay the block fee doctors have asked patients to pay a work in a dream world, but we live in a “Block fees benefit doctors but fee before allowing them to join their province with a severe physician short- not patients,” said Dr. Dhalla. “If the practice. Everyone agrees that this is age,” said Dr. Ahmed Bayoumi, another College does not ban block fees, they unacceptable. The College has ac- spokesperson for the MRG. “Patients are are failing their responsibility to protect knowledged that it cannot actively terribly dependent on their doctors. It is the public.”♦ monitor and enforce their block fee completely unrealistic to expect patients Released November 24, 2004 by the Medical Re- regulations. Protecting patients requires to risk upsetting their doctors saying ‘no’ form Group the College to ban block fees altogeth- to the block fee.” er.” NEARSIGHTED PHYSICIANS REJECT DEAL WITH GOVERNMENT
he Medical Reform Group be a large income gradient between prima- The government and the profes- lieves that Ontario doctors ry care doctors and specialists. The pro- sion now have a big problem. With other Thave made a serious error in fession has shown itself incapable of health workers being asked to hold de- rejecting the deal negotiated with the dealing with this problem alone. This mands for wage increases, providing provincial government. deal would have begun to redress the substantial new income to the highest “The deal was not perfect,” gradient, and potentially make primary paid workers will be very difficult to jus- said MRG spokesperson Dr. Yves care more attractive to young physicians. tify. Talbot. “For one thing, the govern- “Primary care reform has moved “The government must show its ment and OMA were making health at a glacial pace”, said another MRG resolve to retain the progressive elements policy without consulting other con- spokesperson, Dr. Ahmed Bayoumi. of the agreement the doctors have re- stituencies. But the policy they were “It’s become evident that the only way jected,” concluded Dr. Talbot. “Ulti- making, particularly the moves toward to get doctors on board is to give them mately, physicians must consider the primary health care reform, was good a financial incentive. This agreement public interest, and support the urgently policy.” would have provided that incentive.” needed restructuring of primary care.”♦ Doctors are by far the highest Released November 22, 2004 by the Medical Reform paid health professionals. Yet, there is Group.
Volume 24, Number 3 - Winter, 2005 Medical Reform 3 SMITHERMAN RIGHT TO PLAY TOUGH WITH DOCTORS
he Medical Reform Group be get in upcoming negotiations with the Reform Group believes the govern- lieves the Ontario government government. ment should consider all of its op- Tshould move forward with its in- “The doctors who rejected the tions, including offering the contract itiatives to revamp the health care sys- deal are swimming against the tide of individually to the 40 per cent of doc- tem despite the Ontario Medical progressive change in health care,” said tors who endorsed it or offering the Association voting down a contract load- MRG spokesperson Dr. Yves Talbot. most transformative aspects of the ed with incentives to stimulate this vital “Primary care reform has moved at a contract to the entire profession. transformation. glacial pace. That’s in large part because “The contract had a number of “The OMA negotiators thought of resistance of the doctors, and their progressive features that would im- they had a good deal for doctors, and a rejecting the deal is just one more epi- prove patient care,” commented Dr. good deal for the people of Ontario,” sode in that resistance. It’s become evi- Guyatt. “With the cooperation of the said MRG spokesperson Dr. Gordon dent that the only way to get doctors on 40% of doctors who voted for the Guyatt. “They were right. This deal was board is to give them a financial incen- deal, the government should ensure defeated because of a highly effective tive. This agreement provides that incen- that these elements are put in place as propaganda campaign waged by a small tive, and it’s the first time we have real soon as possible.”♦ number of misguided physicians.” political will for primary care reform.” Released December 2, 2004 by the Medical Re- Doctors are the highest paid health The government has a number of form Group. professionals. As usual, this deal gave options, ranging from imposing the con- them more in the way of increases than tract against the OMA’s will to going back other health care workers are likely to to the negotiating table. The Medical SERIOUS LIMITATIONS IN HEALTH CARE DEAL
he Medical Reform Group of provincial governments have quickly ig- “Roy Romanow’s report said Ontario today made severe criti nored their targets,” Dr. Guyatt noted. that federal money must be used to Tcisms of the health care deal be- “The current agreement includes no en- buy change.” Dr. Guyatt concluded. tween the federal and provincial govern- forcement mechanisms, and no condi- This deal represents another federal ments. tions to the federal money. Why should give-away, with minimal progress to- “No national home care, no provinces pay any more attention to the ward serious health care reform.”♦ pharmacare, no serious primary care re- guidelines than they have previously?” Released September 17, 2004 by the Medical form, and no end to creeping privatiza- Equally serious is the govern- Reform Group. tion,” said MRG spokesperson Dr. ments’ silence regarding increasing pri- Gordon Guyatt. “This deal is no success.” vate pay, and for-profit delivery. The In 1997 the National Health Fo- federal government has not been enforc- rum called for national home care and ing the Canada Health Act, resulting in pharmacare programs. The Romanow the increasing proliferation of private, report and Senate Kirby reports repeat- pay-as-you go imaging and surgical fa- ed the calls. “Despite all the new federal cilities that allow patients who can pay money, in 2004 we are as far from na- to jump the queue. tional home care and pharmacare plans “Where is the federal will to en- as ever,” said another MRG spokesper- sure national standards of universal ac- son, Dr. Irfan Dhalla. cess?” Dr. Dhalla asked. “With not a The current agreement provides word from the federal government some targets in the home care and phar- about maintaining equal health care irre- macare areas, but very little extra money. spective of ability to pay, the deal does “In previous agreements, federal and nothing to halt creeping privatization.”
4 Medical Reform Volume 24, Number 3 - Winter, 2005 A NEW LIBERAL VERSION OF PRIMARY HEALTH CARE Rosana Pellizzari
rimary care reform, according mary care models in Ontario with com- plication for primary care reform was a to Liberal Party election prom munity governance are the Community sensitive issue at the public session host- Pises, is being unrolled across the Health Centres (including Aboriginal ed by the Ministry and which I attended province, despite a paucity of details. Health Access Centres) or the Commu- in Kitchener recently. The crowd con- The Tories brought us Family Health nity-sponsored “Group Health” in Sault tained mostly physicians who were gen- Networks (FHNs) and then Family Ste Marie. This means that other health uinely interested in moving forward and Health Groups (FHGs), and soon we professionals, or community partner- acquiring more resources, such as nurs- will see FHTs (Family Health Teams) ships, can submit for FHT funding. The es, Nurse Practitioners and pharmacists sprouting up across the healthcare only non-negotiable criteria for funding to facilitate the delivery of interdiscipli- landscape. In fact, our new govern- areis that the population served must nary care. Funding for FHTs is proba- ment would like to see 45 new FHTs support at least one to two full time phy- bly, for the most part, federal, as part of announced before the ends of the sicians. the post-Romanow investment in prima- 2004 fiscal year, March 31, 2005. How will the proposed FHTs ry care reform. The Association of On- Although specifics are lacking, differ from the existing menu of prima- tario Health Centres believes the FHTs Dr Jim MacLean and his team are tak- ry care delivery models? Again, details may be an opportunity for the large ing that message out to communities are sparse, but it appears certain that FHTs number of groups who have been lob- throughout the province in organized will not be as comprehensive as their bying unsuccessfully for CHC funding public sessions scheduled this month. cousins, the CHCs. Their scope will be to at least get a scaled down version of With such a tight deadline, the prov- health care, and not community devel- alternatively funded and delivered health ince is keen to negotiate contracts with opment or advocacy. They will have to care. any interested parties, including exist- roster patients, and are being billed as Deadlines for submissions are ing Family Physicians’ practices with having the flexibility to support both ur- mid-February. We’re off to the races on FHN or FHG contracts in place. ban and rural, or remote, populations. this initiative: it will be interesting to see A major difference between They will receive funding for infrastruc- both what the pick-up is, and what the the new FHT and the recently ture and information technology. final product will look like.♦ launched FHG/FHN models is the The failure of the Ontario Med- possibility of community or non-phy- ical Association-Ministry of Health and sician governance. The only other pri- Long Term Care contract and the im-
RECRUITMENT CALL—SEXUAL AND REPRODUCTIVE HEALTH ver the past year or so, we in the new years is that some smaller national picture on sexual and reproduc- have attracted a number of working groups or committees can be- tive health, there are some small windows Onew members, many of gin this process in a less formal setting, of opportunity. whom have joined the steering com- possibly in consultation with some of our This is a call for expressions of mittee. Many have enriched the steer- associate members with legal and other interest to review our existing policy on ing committee discussion, and a few expertise, then bring some of the results sexual and reproductive health. The of us have talked about the possibili- of their work to larger educational ses- group would likely work with long-time ty of taking advantage of this new en- sions as appropriate. members Rosana Pellizzari and Cather- ergy to review some issues on which Rosana Pellizzari’s recent work on ine Oliver, and involve two to three face the Medical Reform Group has been sexual and reproductive health in Costa to face or electronic meetings in 2005. active in the past, with a view to up- Rica is one example of an area where If you are interested in getting involved, dating where necessary, and educat- much work remains to be done. While contact [email protected]; ing all of our number on some of the re-election of Bush in the US has given leave a phone message at (416) 787-5246; the most persistent. Our hope in some of us cause for concern, and this or write the Medical Reform Group at launching a couple of working groups will certainly continue to cloud the inter- Box 40074, Toronto M6B 4K4.♦
Volume 24, Number 3 - Winter, 2005 Medical Reform 5 STEERING COMMITTEE 2004-05 In response to members asking who is on the current steering committee, here are short biographies of several of our more active members. If you have an interest in joining the steering committee or a working group described in the newsletter, or want to bring an issue to the attention of the Steering Committee, please contact our Administrator at [email protected].
Ahmed Bayoumi PJ Devereaux health care research, recognized by over 350 publications in peer-reviewed Ahmed Bayoumi is a general in- P.J. Devereaux obtained his BSc journals. His educational work includes ternist and health services researcher in from Dalhousie University and an MD seven years as Director of the Inter- Toronto. His clinical and research inter- from McMaster University. After med- nal Medicine Residency Program. His ests focus on the health of people living ical school he completed a residency in work in dissemination of evidence- with HIV and other disadvantaged pop- internal medicine at the University of Cal- based decision-making was recog- ulations. He is committed to the concepts gary and a residency in cardiology at nized by a McMaster University of social and economic justice, which he Dalhousie University. He is currently President’s Award for Excellent in views as incompatible with capitalism. undertaking a PhD in Health Research Resource Design in 1996. Methodology at McMaster University. Dr. Guyatt was instrumental in Irfan Dhalla He holds a Canadian Institutes of Health founding the Medical Reform Group Senior Research Fellowship Award. Dr. in 1979 and has spent most of the sub- Irfan Dhalla is an internal medi- Devereaux has undertaken research com- sequent two decades as a spokesper- cine resident physician at St. Michael’s paring health outcomes and payment for son for the group. He has contributed Hospital and the Sunnybrook and Wom- care in investor owned private for-prof- to the development of MRG policy, en’s College Health Science Centre in it and private not-for-profit health care and in recent years has taken a major Toronto. He graduated as the valedicto- delivery systems. role in packaging and dissemination rian of his University of Toronto medi- of MRG approaches to health issues. cal school class in 2003. As a medical Mimi Divinsky student, he and several of his classmates Ted Haines conducted a nationwide survey of med- Mimi Divinsky is a family physi- ical students—their findings, published in cian in downtown Toronto, a Fellow of Ted Haines helps people and the Canadian Medical Association Jour- the College of the Family Physicians of workplaces solve occupational health nal, showed that medical students over- Canada and a lecturer in the Dept. of problems. While recognizing, imper- whelmingly came from privileged Family and Community Medicine at the fectly, the massive barriers posed par- families and that increasing tuition fees U of Toronto. She was, until a recent ticularly by powerful political and were adversely affecting the medical illness, medical co-director of the Sexual corporate forces, he doesn’t see why school population. Assault Care Centre at Women’s College Canadians shouldn’t have a health care Since graduating from medical Hospital. Dr. Divinsky has been active in system that protects and cares for school, Dr. Dhalla has served as an edi- the Medical Reform Group since the them, irrespective of means. That torial and research associate to the Na- group’s inception, and has played an im- would be part of the society we want. tional Advisory Committee on SARS and portant role on the Steering Committee He’s a co-chair of the Hamilton Health Public Health, published several articles since 1985. Coalition and on the administrative on inappropriate prescribing in the eld- committee of the Ontario Health erly, and currently sits on the executive Gordon Guyatt Coalition. “If the artist sees nothing committee of the Professional Associa- within him, then he should also refrain tion of Internes and Residents of On- Gordon Guyatt is a Professor in from painting what he sees before tario. He joined the Steering Committee the Departments of Clinical Epidemiol- him.” in 2003. ogy and Biostatistics and Medicine at Mc- Master University. He has made (continued on page 7) important contributions to clinical and
6 Medical Reform Volume 24, Number 3 - Winter, 2005 STEERING COMMITTEE 2004-05 (continued)
Brad MacIntosh ulations in Kingston. These include: the ronto. After attending an MRG event in unemployed; those on social assistance; Toronto, Aaron along with several other Brad MacIntosh is currently the disabled; intravenous drug users; and students was inspired to start a student pursuing his doctorate in the Depart- street youth. MRG chapter at U of T. Along with fel- ment of Medical Biophysics at the He is also active in the areas of low steering committee member Brad University of Toronto. His PhD the- Family Planning and contraception. In all MacIntosh, he currently co-chairs this stu- sis involves using Magnetic Resonance of these areas, he maintains an interest in dent group. Previous involvement in or- Imaging technology (MRI) to under- advocating for patients whose health suf- ganizations such as Amnesty International stand stroke recovery. Brad’s interests fers due to social and economic inequal- have helped foster his growing interest in health advocacy and activism gen- ity, and who are threatened by moves to in social justice, particularly within the erally focus on how biotechnology af- limit universal access to high quality pub- areas of health and human rights. Al- fects health outcomes. In addition to licly supported health care. though still searching out his career path, his interest in diagnostic imaging, Brad Aaron hopes to continue to pursue these has also been active in critical analysis Rosana Pellizzari interests and become involved in health of the pharmaceutical industry and rel- on a global level. evant Canadian policies. He has pre- Dr Rosana Pellizzari is the Medi- sented work on prescription drugs to cal Officer of Health for Perth District the Federal government and helped to Health Unit, located in Stratford, Ontario. Yves Talbot formulate a national pharmacare strat- Prior to specializing in Community Med- egy. icine, Dr Pellizzari worked as a Family Yves Talbot is Associate Professor in the Recently, Brad and other stu- Physician in Hamilton and Toronto. As a Department of Family and Community dents in health professions programs Community Health Centre physician, she Medicine and Health Administration at founded a Student Medical Reform specialized in the care of immigrant, ref- the University of Toronto and Director Group (sMRG) chapter at the Uni- ugee and HIV infected populations. She of the International Programs in the de- versity of Toronto. As Co-Chair for is past president of the Association of partment of Family and Community the sMRG, Brad is enthusiastic to find Ontario Health Centres and a former Medicine. new ways to improve and extend Chair of the City of York Board of Since 1995, he has been involved Canada’s public and universal health Health. in South America in programs of Ca- care system among a future genera- Dr Pellizzari holds academic ap- pacity Building in Primary Care. The pro- tion of health care researchers and pointments at the University of Toronto grams are aimed at training teams of professionals and the University of Western Ontario. professionals working in different cities She has worked internationally and in of Brazil, Chile and Argentina. Dr Tal- Adam Newman First Nations communities in Canada. She bot has served on the Ontario (PEC- has been a health columnist for the To- CCAR) Committee for Primary Health Adam Newman is a family phy- ronto Star and co-hosted a daily TV Care Reform and has a particular inter- sician in Kingston. He works at a Com- health show. She is active in the Medical est in the role of primary care and ques- munity Health Centre where he helped Reform Group of Ontario, and in the tions of Equity.♦ to develop Kingston’s first integrated International Women’s Health Commit- primary care nurse practitioner pro- tee of the Society of Obstetrics and gram. After spending two years as a Gynecology of Canada. staff physician in Sioux Lookout, working with First Nations people in Aaron Rostas remote and underserviced communi- ties, he has continued working with Aaron Rostas is a second year marginalized and poorly served pop- medical student at the University of To-
Volume 24, Number 3 - Winter, 2005 Medical Reform 7 PREMIERS SHOULD NOT GIVE UP ON PHARMACARE
he Medical Reform Group today money. These conditions would be the 5. Public administration. sent a letter to each of the same as those for Medicare: “These five principles work for Tprovincial premiers asking them 1. Comprehensiveness—provinces Medicare and they will work for not to give up on a national pharmacare would be required to make pharmacare too,” said Dr. Rosana plan. The physician group believes that a available all drugs on a national Pellizzari, Medical Officer of Health national drug plan is both vital and formulary deemed necessary for for the Perth District Health Unit and affordable. Canadians to access. also spokesperson for the MRG. “Under Medicare, Canadians have 2. Accessibility—provinces would “Initially some provinces will be access to doctors and hospitals but not be required to provide first- reluctant to join a national plan, but as medications,” said Dr. Irfan Dhalla, a dollar coverage (i.e., patients with Medicare, eventually all will find spokesperson for the MRG. “This makes would not have to pay a the temptation of federal dollars no sense. Many drugs are medically deductible or co-payment), impossible to resist.” necessary, and these should be covered initially for the most essential “Ralph Klein was right when he in a similar manner to physician and drugs and eventually for all drugs said the idea of a national pharmacare hospital services.” on the formulary. plan was a ‘stroke of brilliance’,” The MRG believes that the provincial 3. Universality—All residents of concluded Dr. Dhalla. “We call on him, and federal governments should share the the province should be eligible his fellow premiers and Prime Minister cost of a pharmacare program. The feds for coverage under uniform Paul Martin to use this week’s First should offer enough money to cover 50 terms and conditions. Ministers’ Meeting to make this brilliant per cent of the costs. As with Medicare, 4. Portability—For travelling idea a reality.”♦ a province would have to agree to certain residents, coverage would Released September 13, 2004 by the Medical conditions to claim its share of the extend to other jurisdictions. Reform Group.
HOW TO BUILD A NATIONAL PHARMACARE PROGRAM Bradley Macintosh, an MRG Steering Committee member, prepared this draft discussion paper as a summary of MRG discussions to date on the value of continuing to press for a National Pharmacare Program, in anticipation of the November 4th, 2004 members’ meeting in Toronto. Given the complexity of the issues the Steering Committee will return to this issue in early 2005.
he introduction of a national The MRG has long since power, which would result in universal pharmaceutical supported the idea of a national decreased costs. This would Tprogram, known as pharmacare, pharmacare program. The Canada particularly benefit small provinces dates back to the 1964 Royal Health Act (CHA) ensures that all and territories. The federal Commission on Health Services by Canadians have access to health services. government is in a better position Justice Emmett Hall (Canada, 1964). However, the Act does not include to control drug cost though Nearly four decades later, in 1997 a pharmaceuticals as an integral component monopsony buying power. National Forum called for a universal of the publicly funded health care Between 1987 and 2001, Pharmacare program, which the Liberal system. This means that access to prescription drugs rose from 7 per government endorsed at the time, but medications varies across socio-economic cent to 12 per cent of total health continues to evade. Recent events levels and across provincial and territorial care expenditures (Lexchin, 2003). surrounding the First Ministers meeting jurisdictions. According to a recent report, in Sept 2004 have put the idea of prescription drug spending is pharmacare back on the radar, this time Requirements for National forecast to have reached $14.6 with a unanimous endorsement by Pharmacare billion in 2002 (CIHI 2003). In Provincial and Territorial leaders. 1. Single payer–A single drug countries like Australia and New purchaser affords bulk purchasing (continued on page 9)
8 Medical Reform Volume 24, Number 3 - Winter, 2005 HOW TO BUILD A NATIONAL PHARMACARE PROGRAM (continued)
Zealand, where national pharmacare reducing costs. For example, this program would extend and invigorate programs are in place, prescription strategy allows the government to the CHA. As more provinces sign on to drug expenditures are well below the select a drug that has equivalent a national program, the federal Canadian numbers. For instance, effectiveness but is not on patent and government will be in a position to compared to Australia, Canadian thus cheaper. A national reference encourage remaining provinces to follow prices in 2000 for new innovative based pricing would extend from the suit, such as by withdrawing funding for products were 9 per cent higher success observed in British Columbia. violations of conditions.♦ (AusInfo 2001). In New Zealand, the drug budget is managed by the 4. First dollar coverage– References Pharmaceutical Management Agency Governments paying for the first 1. AusInfo (2001). Productivity (PHARMAC). The use of a variety of dollar for every prescription ensures Commission. International measures including reference based that all Canadians have access to drugs pharmaceutical price differences. Research pricing and tendering has allowed independent of socioeconomic status. Report, AusInfo. Canberra. 2. Canada 1964. Royal Commission on New Zealand to cut its projected drug Initially, it may be appropriate to Health Services. Ottawa: Queen’s Printer. bill by almost 50 per cent (Pharmac introduce a maximum deductibles and 3. CIHI (2003). Drug Expenditure in 2003). co-payments. As cost containment Canada, 1985-2002 (accessed electronically strategies begin to take effect, the from www.cihi.ca): 156. 2. A national drug formulary– An proportion of government coverage 4. Lexchin, J. (2003). Intellectual Property independent body of pharmaceutical can be expanded without incurring Rights and the Canadian Pharmaceutical and health policy experts would create significant additional costs. markeplace: Where Do We Go From a list of necessary drugs that all Here? Ottawa, Canadian Centre for Policy Canadians should have access to. This 5. Public Administration–A Alternatives. list would be kept current and adjusted National Drug Agency, organized by 5. Lexchin, J. (1998). “Improving the appropriateness of physician based on the latest scientific evidence. the federal government, would consist prescribing.” Int J Health Serv 28(2): 253- Thus, annual revisions to the list of physicians, pharmacists and health 67. would occur. A national formulary policy experts, similar to New 6. Pharmac (2003). Pharmaceutical would encourage sensible, cost- Zealand’s PHARMAC. Management Agency. Annual Review effective and safe use of medicines. Provinces like Saskatchewan and 2002. Available at www.pharmac.gov.nz. Manitoba have experimented with Wellington. 3. Reference based pricing– universal and income-based pharmacare, 7. Romanow, R. (2002). “Commission on Selecting the cheapest drug from a list while Alberta has passed laws that the Future of Health Care in Canada. of drugs that have identical therapeutic facilitate generic drug competition. A Building on values: the future of health application is an effective means of comprehensive and national pharmacare care in Canada. Final report. November 2002.” EXPERTS DISCUSS NATIONAL PHARMACARE: REPORT OF FALL 2004 MEMBERS’ MEETING The members' meeting presented a panel discussion featuring Dr. Joel Lexchin, professor of health policy at York University and emergency physician at the University Health Network, and Armine Yalnizyan, consulting economist and community-based activist; she was the first recipient of the Atkinson Foundation Award for Economic Justice; she is a public commentator on public finance issues in general, and a specialist on issues of health care financing.
rmine Yalnizyan began her on Health, 2001—Romanow and strategy needs to be found to fund drugs presentation to the meeting by Kirby). Each group has produced more comprehensively. Aobserving that several groups essentially the same result: -- because of The most recent experience of have reviewed drug costs (1964—Hall the (rising) share of drug costs in the the federal-provincial-territorial meeting Commission, 1987—National Forum provision of health care in Canada, a (continued on page 10)
Volume 24, Number 3 - Winter, 2005 Medical Reform 9 EXPERTS DISCUSS NATIONAL PHARMACARE: REPORT OF FALL 2004 MEMBERS’ MEETING (continued) in September in which the provinces very and larger tactics available which would She also observes that in a staged directly brought this issue to the table have some effect on the gross cost of implementation process [where, for marks yet another opportunity. Yalnizyan drugs:. None of these are new, and have example, access would be available also noted a commitment at the 2000 been dealt with in greater and less detail first to certain categories of users or federal-provincial-territorial agreement by recent task forces and commissions: for specified categories of drugs], the on health to move toward a Common ♦ Bulk buying: volume brings potential of reinvesting savings Drug Review, which appears not to have economies of scale—this is of realized from bulk purchase could moved significantly since then. particular interest to smaller provinces, support further enhancements or Although the provinces and as it could increase their clout in the extensions of the program. territories have moved on to other issues, market place Yalnizyan noted that although Yalnizyan is convinced that there is a ♦ Creation of a national formulary or private drug benefit providers have receptiveness and more generally an streamlining of provincial formularies traditionally kept below the radar interest at the policy level to deal with to get the most effective and cost- screen, many large employers are this, though not necessarily in the manner effective drugs easily available and beginning to look for alternatives to proposed by the premiers. She limit or minimize administration costs annual increases in benefit plan costs. recommends we consider a strategy which are currently reproduced in each She thinks they can be persuaded to which keeps this issue on the agenda by province—can begin to approximate trade these employee benefits for working first on developing consensus the single payer situation we have with higher taxes. A relatively coordinated with health care workers at the very local physician care and hospital services switch to add the ‘savings’ from level, takes this to provincial parliaments ♦ Direct contracts with suppliers on private benefit plans to the personal and then to the federal level. She has new drugs would generally be worth income tax could complete the picture offered to assist in development of the supplier’s energy given the likely without significant changes for the campaign materials and advise on market to be accessed average taxpayer. meeting strategies where appropriate. ♦ Improve patent legislation to reflect Yalnizyan added, Pharmacare According to Yalnizyan, drug costs the real research and development is smart because it can restore fairness are the single largest cost driver currently costs of useful drugs. to our system at little or no cost to in 2003, they accounted for $16 billion As for strategy, Yalnizyan believes individuals. While the waiting list issue in expenditures in 2003, of which that an effort begun by physicians in has temporarily knocked pharmacare $7.6billion was spent in public programs Ontario and British Columbia could have off the media stage, she is eager to (provincial and federal drug benefit plans. great rewards. Ontario spends $2 billion work with physician activists who she This figure has tripled since 1991. for an Ontario Drug Benefit Plan for thinks can play a central role in In February 2003, the Federal- seniors, disabled and long-term social restoring the issue to the attention it Provincial-Territorial Health Accord set assistance recipients, a situation which has deserves. She notes that none of the aside $1.6 billion in a 5 year fund to significantly affected their ability to federal-provincial-territorial meetings reform catastrophic drugs and primary contain costs in this part of the health over the past 5 years have significantly care. Almost nothing has been done, budget. spent what was committed to address except that Nova Scotia has raised co- Yalnizyan believes the most any of the major Romanow issues— payments and the government of British efficient way to proceed is to have the pharmacare, home care or primary Columbia has largely abandoned federal government take responsibility for care. Moreover with projected reference-based drug pricing. The a national pharmacare program. They, surpluses as far ahead as the eye can commitment on drugs was renewed in not the provinces, can make the best deal see, we should concentrate on making September 2004 with a commitment to for the country. In addition, because of the general economic and practice collaborate on improving the drug their jurisdiction over patents, and which arguments for a national program and purchasing process. they have used successively to favour leave the detailed financial strategy until Beyond the purchasing process, and drug manufacturers rather than drug we have recuperated the level of a discussion of prescribing practices, purchasers, they have actually ended up political interest of early September, which was dealt with in more detail by off-loading additional costs to the secure in the knowledge that adequate Joel Lexchin, Armine reminded the provinces who are the largest purchasers. funding can be found immediately to audience of a number of other smaller (continued on page 11) 10 Medical Reform Volume 24, Number 3 - Winter, 2005 EXPERTS DISCUSS NATIONAL PHARMACARE: REPORT OF FALL 2004 MEMBERS’ MEETING (continued) make a significant difference. She 1975 and 1999, 117 subsequently had that the national drug procurement believes this strategy needs to begin drug alerts posted or were completely program includes an expanded role for with provinces—BC and Ontario are withdrawn, when they were shown to pharmacists and pressure for a shift in key and currently closer than many have adverse effects. physician payment from fee for service. others ideologically to making such a Another issue, which appears to He thinks more education will be critical decision, and that a lobby at the have inspired the Ontario Health Minister if the government is serious about provincial level in the next couple of in his recent negotiations with the OMA, changing prescribing patterns, although months can renew the issue by federal relates to prescribing practices of he noted that the Australian drug agency budget time. physicians. The literature is replete with is set up as an independent agency and The second panelist, Joel examples of inappropriate prescribing, better accepted by physicians than one Lexchin, addressed more of the clinical and Lexchin has great concerns that the imagines a directly government-operated and practice issues relating to the heavy advertising of new drugs and the agency might be. current trend of escalating drug costs. increase in direct to consumer advertising In the question period follow- His presentation began by focusing on to which we are subjected adds to the ing the presentations, Yalnizyan recog- addressing the reality of innovation in potential for added risk to patients. He nized the central role of physicians in pharmaceuticals, citing a French counselled prohibition of direct to leading the charge among health care review of 2,700 new preparations, consumer advertising (an MRG position workers with a focus on appropriate among which the reviewers identified for some years) and a system of prescribing. She indicated that more of 7 products with genuinely innovative controlled listing of new drugs for a the business sector—employers who therapeutic uses. period beyond the current drug approval provide benefit plans—are increasingly He also noted that the limits. While this latter strategy is seeing the plans and the escalating costs process for drug approvals is not complicated in a multiple-payer system, of providing them a nuisance. Likely the foolproof, given that initial testing it could also work in a single payer system, only business sector to be averse to a more tends to be based on relatively short where a single database could monitor clear and accountable national role in drug term use. To support this point, he use and adverse effect patterns. procurement are pharmaceutical manu- ♦ noted a report which found that of Lexchin also reported on his facturers. 548 new drugs introduced between recent studies in Australia where he noted
THE PHARMACEUTICAL BENEFITS SCHEME: A UNIVERSAL SCHEME Medicare Fact Sheet 10 of The Doctors Reform Society of Australia, first published in winter 2001, and reproduced with permission.
he Australian Pharmaceutical ly endorsed this approach as a useful tralian drug prices being substantially low- Benefits Scheme (PBS) com mechanism to ensure equity of access to er than the OECD average while still re- Tmenced over 50 years ago. At necessary drugs. taining general access to a comprehensive that time, there was concern that many Our PBS has evolved from a range of medicines. This has been good people could not afford expensive but scheme that fully subsidised a small for Australian consumers but it has attract- valuable new drugs such as penicillin. number of drugs to one that partially sub- ed determined opposition from the inter- A Pharmaceutical Benefits Advisory sidises about 650. The cost of the PBS national pharmaceutical industry. Committee (PBAC) was set up; they rec- has escalated and patient co-payments, ommended that a limited list of life brand premiums and other strategies have Escalating PBS Costs saving or disease-preventing drugs been used to transfer some of the cost to In 1948/1949 the PBS cost the Federal should be made available on prescrip- consumers. Government $298,074. It took 40 years tion free of charge, the costs to be paid The PBS purchases about 90 per for the costs to reach a billion dollars but for by the Federal Government. The cent of all prescription medicines. This more recently costs have been rising far World Health Organization subsequent- near monopoly power has resulted in Aus- (continued on page 12)
Volume 24, Number 3 - Winter, 2005 Medical Reform 11 THE PHARMACEUTICAL BENEFITS SCHEME: A UNIVERSAL SCHEME (continued) more rapidly. In 1999/2000 the PBS cost 1999 compared to 1998. Doctors wrote policy. They advocated independent in- the government $3.45 billion, an increase 34.2 per cent more prescriptions in 1999 formation; drug audits and targeted ed- of 16 per cent on the previous year. The than in 1998 for the top 25 DTCA drugs. ucation aimed at both consumers and 2001 budget papers estimated PBS ex- Doctors wrote only 5.1 per cent more health providers. PHARM was success- penditure for 2000/01 to be $4.26 billion, prescriptions for all other prescription ful both in gaining small amounts of a 22 per cent increase on the previous year. drugs. funding for QUM projects and in prov- There are several reasons for es- ing that certain strategies worked. calating PBS costs. National campaigns Changes to the PBAC Government then set up a Na- have improved drug treatment of asth- Over the past few years, individual phar- tional Prescribing Service (NPS) in ad- ma, depression and elevated blood cho- maceutical companies have taken legal dition to PHARM. The NPS works lesterol levels. Hospitals have limited action over PBAC decisions to deny list- with Divisions of General Practice and supplies of drugs to patients when dis- ing of drugs such as the erectile dysfunc- has primarily focused on educating pre- charged and have privatised outpatient tion treatment sildenafil (Viagra). They scribers. For an expenditure of about clinics and pharmacies. have successfully lobbied the Federal $5 million per annum they have dem- But the major cause of increased Health Minister to replace PBAC mem- onstrated improvements in prescribing PBS costs has been the growth of new, bers judged antagonistic to pharmaceuti- worth about $15 million per annum. more expensive medications. Their pre- cal industry and have succeeded in getting While NPS activities are undoubtedly scription has not always accorded with clin- a former industry lobbyist appointed to worthy, the savings achieved represent ical best-practice guidelines. Many of the the committee. less than 2 per cent of the $800 mil- prescriptions written for these drugs are Minister Wooldridge has argued lion annual increase in the cost of the for uses that have not been approved by that these changes to the PBAC have re- PBS. the PBAC as cost-effective. In many cas- sulted in a better committee. Critics see The 2001 federal budget pro- es the PBS is paying a price for these ex- this move as the latest pro-industry initia- vided another 4 years funding for the pensive medications that is far higher than tive of the Federal Government. They NPS (at the same level) and also allo- would be justified by the health benefit argue that adding a former industry lob- cated $14.6 million (over four years) achieved. byist to the PBAC is akin to placing the for “a consumer education strategy”. One of the main drivers for in- defendant on the jury. They claim it is like- The challenge for government and op- creasing pharmaceutical costs is industry ly to inhibit free debate among independ- position is to re-examine existing strat- marketing. According to the industry’s own ent experts and could result in more costly egies and structures and formulate figures, manufacturers spend up to one- drugs (with more marginal benefits) being better ways of ensuring the sustaina- third of sales revenue on marketing, twice added to the PBS. bility of the PBS. as much as they spend on research. A clash This, in turn, would lead to an The Friends of Medicare Al- occurred in 2000-2001 over direct-to-con- even greater PBS cost blow-out that the liance believes such strategies should sumer advertising (DTCA) of prescription government would inevitably pass on to include removing the former industry drugs. The Australian Pharmaceutical consumers via higher co-payments, de-list- lobbyist from the PBAC, more rigor- Manufacturers Association (APMA) is lob- ing “less-essential” drugs and other strate- ous PBS price / volume negotiations, bying the Federal government to remove gies. The end result would be a U.S. style more independent information, audit current restrictions on DTCA of prescrip- pharmaceutical system where poorer citi- and other decision support functions tion drugs. The U.S. experience shows why. zens could no longer afford necessary incorporated into prescribing software, In 1999, U.S. pharmaceutical drugs. less pharmaceutical promotion (espe- companies spent $US 1.8 billion on DTCA. cially resisting DTCA), and budget hold- This was a 40 per cent increase over 1998. Sustaining Equity and Access in the ing or other forms of clinical $1.1 billion was spent on television ads, a PBS governance to encourage physicians to 70 per cent increase over 1998. Forty one Over the last 10 years a variety of strate- prescribe more cost-effectively. percent of DTCA spending was concen- gies have been employed in Australia to We also believe that new struc- trated on ten products. The top-selling 25 try to improve medicinal drug use. tures are required and that PHARM, DTCA drugs accounted for 40.7 per cent The Pharmaceutical Health and the NPS, the PBAC and related bodies of the total increase in retail drug sales Rational Use of Medicines (PHARM) should be rationalised and reorganised. between 1998 and 1999 (i.e. $7.7 billion Committee recommended a quality use of of the $17.7 billion increase). There was a medicines (QUM) policy as the final inte- (continued on page 18) 19 per cent increase in retail drug sales in grating arm of national medicinal drug 12 Medical Reform Volume 24, Number 3 - Winter, 2005 INTRODUCING MEDICARE’S NEWEST CHILD: NATIONAL PHARMACARE Brad MacIntosh
rescription drugs continue to Prescription Drug as a Percentage of Total Health Expenditures7 play a larger part of health care Pin Canada. Year after year, the number of prescriptions increase: in 2003 retail pharmacists dispensed over 350,000,000 prescriptions1. Roy Ro- manow’s reported the average Cana- dian has 10.1 prescriptions per year2. This alarming number would lead you to believe that the average Canadian is able to afford their prescription drug costs. For the most part, this is true. Across Canada, drug coverage is a hodge-podge mixture between private and public plans. Although comprehensive data is hard to come by, a pharmaceutical policy expert, Dr. Joel Lexchin explains in 1995, 88 per cent of Canadians had not add to the clinical uses offered by while private expenditures were 35 some sort of coverage: 62 per cent previously available products5. per cent by insurers and 18 per had private insurance, 19 per cent were Other countries, like Australia cent out-of-pocket expenses9. covered under public provincial plans, and New Zealand have been successful and 7 per cent were covered by both at containing costs. For example, the use 2. Cost Containment is possible – 3 private and public sources . The 12 per of a variety of measures including ref- Large provinces like Alberta and cent of Canadians that have no drug erence based pricing and tendering has Ontario already reap the benefits coverage either do not fill prescrip- allowed New Zealand to cut its project- of buying drugs in bulk, much like tions or incur out-of-pocket expens- ed drug bill by almost 50 per cent6. how Shoppers Drug Mart is able es. Based on these statistics it is to “leverage its cost base and in- Prescriptions drug costs make reasonable to ask “do we need a new crease profitability”10. By extend- up a larger piece of the health care prescription drug plan in Canada?” ing bulk-purchasing to a national expenditure pie, not only because of Economist Armine Yalnizyan explains scale, smaller provinces would the increased number of prescriptions, now is the time to expand coverage, to also enjoy benefit, resulting in re- but also due to increased cost per drug. a more equitable and cost-effective sys- duced drug costs across Canada. Newer drugs are more expensive, al- tem: “One way or another Canadians though they tend to be no more ef- pay their own drug bills, whether through 3. Unequal out-of-pocket expens- 4 fective and less safe . For example, the insurance, taxes or out-of-pocket”8. So es – A 1996 report documented a French drug bulletin, Prescrire Inter- is there a better way to pay for pre- glaring disparity between low-in- national, has recently published sum- scription drugs? come and high-income groups mary statistics on almost 2500 new when it comes to out-of-pocket preparations or new indications for Pharmacare makes financial sense drugs expenses between 1964 and existing drugs that it evaluated be- 1. You are paying anyway – Over 1990. Low-income groups who do tween 1981 and 2001. In that time the past decade, the breakdown in not qualify for welfare benefits, nor period it rated just 76 (3.0 per cent) as how drugs get paid for has been have a private insurance benefit major or important therapeutic gains fairly consistent: In 2003, 47 per program, pay seven times that of while close to 1600 were assessed as cent of the $16 billion drug expen- high-income groups, as a function being superfluous because they did ditures came from public dollars, of total family expenditures11. (continued on page 20) Volume 24, Number 3 - Winter, 2005 Medical Reform 13 MESSAGE TO PREMIERS ON THE EVE OF FEDERAL-PROVINCIAL-TERRITORIAL MEETINGS On September 13, 2004, Steering Committee member Rosana Pellizzari sent a copy of the following letter of encouragement to Premier McGuinty and each of the provincial and territorial leaders.
am writing on behalf of the Medical Reform Group of Ontario, an association of physicians and medical students in Ontario with a history of defending Medicare that now stretched back 25 years. On Tuesday, September 14th you and Iyour provincial counterparts from across the country will have Pharmacare on your agenda. We believe, as you do, that a National Pharmacare program is vital if Canadians are to access the prescribed drugs that have become such an essential part of medical care. We applaud your recent effort, in Niagara on the Lake, to put Pharmacare on the agenda for your negotiations with our federal government. In response to your advocacy, we offer, Premier, a caution, that a national drug program funded exclusively by the federal government carries excessive risks, including that of marginalizing Ottawa’s role so that the future of our public health care system is put into jeopardy. Instead, we urge you to consider a cost-shared program in which the federal govern- ment will provide 50 per cent of the funding in return for provincial, and territorial, compliance with the following condi- tions: - Universality - First Dollar Coverage - Portability - Public Administration - The establishment of and adherence to a National Formulary - Uniform terms and conditions, such as Reference Based Pricing Making Pharmacare a reality for all Canadians would be a truly significant and historic feat. It is within your grasp. On behalf of all the Canadian people, we wish you success in your meetings this week, and we look forward to all the ways in which you will make our health care system stronger, more effective, and sustainable.♦
Rosana Pellizzari, MD, CCFP, MSc, FRCPC Steering Committee Member
THREATS TO ACADEMIC FREEDOM SHOULD WORRY PUBLIC
he Medical Reform Group of On The CAUT report highlights the “The report proposes much tario today noted the serious impli increasing threats to the academic free- needed solutions to these growing prob- Tcations of a Canadian Association dom of doctors working in university set- lems,” said another MRG spokesper- of University Teachers (CAUT) task force tings. The case of Nancy Olivieri, who son, Dr. PJ Devereaux. “Doctors who report highlighting threats to academic faced persecution not only from the drug are threatened need arbitration proce- freedom among clinical faculty in health industry but from the University of To- dures that protect them. They need sciences centres, and proposing solutions. ronto after she identified the dangers of a backing and support when attacked by “When doctors exposing the dan- drug she was studying, is the most promi- powerful institutions.” gers of drugs face intimidation and legal nent. The report notes that the CAUT has “The five academic physicians and sci- action, the public should be concerned,” received an increasing number of com- entists who authored this report are is- said MRG spokesperson Ahmed Bayou- plaints from clinical faculty who face loss suing a wake-up call,” Dr. Bayoui mi. “When doctors who highlight limita- of jobs, income, or opportunities as a re- concluded. “When clinical faculty can’t tions in clinical care face loss of hospital sult of behaviour that institutions see as speak out on behalf of their patients, privileges, the public must realize that pa- threatening to their interests. the public should be worried.”♦ tient care is threatened.” Released November 18, 2004 by the Medical Reform Group. 14 Medical Reform Volume 24, Number 3 - Winter, 2005 MEDICARE CRITICISMS SIMPLISTIC
moking rates are much higher in ing is public, the rest private. Among 30 and the means, to control spending. Per- France than Canada. The French industrialized countries, 18 have higher haps the most informative comparison Shave lower rates of coronary proportions of public versus private is to look more closely at how private artery disease than Canadians. So, to funding—that is, public funds pay for and publicly funded systems actually cut coronary risk, Canadians should over 71 per cent of expenditures. All but work. Because getting seriously ill involves increase their smoking, right? one of these 18 countries spends less of gigantic costs, private insurance imme- That’s ridiculous, you say. Just their GDP on health than Canada. So diately springs up in user-pay systems. because two countries differ on two perhaps we could get more efficient by Private insurance companies attributes — smoking and coronary increasing, rather than decreasing, our must develop insurance packages, mar- artery disease — doesn’t mean that ratio of public to private expenditures. ket those policies against the competition, one causes the other. Unfortunately, The next step in a more sophis- explain the policies to potential users, participants in health-care debates ticated analysis is to consider the entire evaluate applications for insurance, assess sometimes rely excessively on simplis- spectrum of industrialized countries. The claims, and still satisfy their investors with tic cross-national comparisons. latest international figures show that a profits in the order of 10 per cent. Take a for-instance. The Fra- cluster of 12 countries spend between Public health-care plans, like our ser Institute, a right-wing think tank, 8.6 and 11.1 per cent of their GDP on medicare, bear none of these costs. This points out that many countries allow health. Canada is in the middle of this explains why private insurers, which user fees and private insurance for pack, at 9.7 per cent. The United States, dominate the U.S. system, have overhead physician and hospital care. Some of at 13.9 per cent, spends far more than costs averaging 11.7 per cent. That com- these countries spend less on health any other country. pares to 3.6 per cent for U.S. Medicare, care than Canada, while remaining Americans have a lower life ex- and 1.3 per cent for provincial health competitive in health outcomes. pectancy than Canadians, a higher infant plans in Canada. It explains why the U.S. Therefore, they argue, if we aban- mortality rate, and worse outcomes in a spends 31 per cent of its health-care doned the Canada Health Act and al- wide variety of specific health problems, dollars on administration, while Canada lowed user charges for medically from asthma to hepatitis. Their higher spends only 17 per cent. necessary physician and hospital serv- expenditures don’t translate into better When the National Health Fo- ices, our performance would im- health. rum of 1997, the Kirby Senate report, prove. What distinguishes the U.S. sys- and the Romanow Commission studied But just as we don’t know tem from the others? The U.S. has by far our system carefully, they each recom- whether France’s lower coronary risk the lowest proportion of publicly fund- mended enlarging the scope of publicly happens because of, or in spite of ed health care, only 44 per cent. If pri- funded health care. That’s because a dis- smoking, we can’t be sure whether our vate pay were a good thing, why is the passionate look at the evidence that health-care problems are because of American performance so disastrous? avoids simplistic cross-national compar- the Canada Health Act, or despite it. Because there is so much varia- isons shows that public payment — A more sophisticated analysis can help. bility in health systems, and in determi- whether for physician and hospital serv- First, let’s get the question nants of health, we still need to move ices, for drugs, or for home care — pro- straight: What is the best way of fund- beyond between-country comparisons vides better value for money.♦ ing our health care? Through the public of overall costs and overall health. First published October 4, 2004, as one of Dr. purse, from taxes; or privately, One additional source of evi- Gordon Guyatt's monthly columns in the through insurance companies and dence is a within-country comparison Winnipeg Free Press out-of-pocket expenditures? examining different aspects of Canadi- Next, we need to widen our an health care. In the last decade, costs scope beyond physician and hospital of the publicly funded parts of the Ca- services, and consider all health serv- nadian system — physician and hospital ices. In areas such as drugs, home care services — have remained stable. Costs and eye care, Canada relies more on in the privately funded areas, particular private funding than do most indus- pharmaceuticals, have exploded. These trialized countries. The result is that 71 results suggest that when governments per cent of Canada’s health-care fund- fund services, they have the motivation,
Volume 24, Number 3 - Winter, 2005 Medical Reform 15 HMOS DRIVE UP U.S. HEALTH COSTS
merican lawmakers have recent When practices are investor- the U.S. will be moving into Canada ly been outraged to find that re owned, the dynamic changes. Managers if we expand for-profit health care. Acruiting large corporations to of health care corporations are respon- Roy Romanow, whose Com- deliver publicly funded health services to sible to the investors, not the patients. mission report remains the most au- the elderly has substantially increased Their first responsibility is to deliver a thoritative overview of the Canadian costs. profit margin, typically about 10 per cent. health care system, has endorsed the They shouldn’t have been sur- In health care, for-profit firms McMaster findings. Since he released prised. also have much higher administrative his report in November 2002, Ro- Medicare is the name of the US costs than centrally administered public manow has continued to criss-cross health care program for seniors. It oper- programs. For instance, American HMO the country seeking evidence that in- ates very similarly to our Medicare, pay- Medicare companies have 15 per cent vestor-owned for-profit delivery is ing health-care providers for delivering overhead, in comparison to 3 per cent less costly, or delivers better care. He services to the program’s beneficiaries. in traditional fee-for-service Medicare. keeps coming up empty, and his wor- Also similar to Canada, those providers The investor-owned firms’ have a final ries about for-profit delivery contin- have until recently been hospitals and additional burden. Their executive sala- ue to grow. small groups of physicians receiving fee- ries and bonuses are approximately 10 Indeed, when examined crit- for-service payments. fold higher than the not-for-profit health ically, Canadian experiments with for- But recent changes in Medicare care organizations. Independent physician profit care have not brought good have opened the market to large inves- practices needn’t worry at all about pay- news. A for-profit clinic for cancer tor-owned private for-profit Health ing executives. radiation therapy cost $500 more per Maintenance Organizations (HMOs) that No wonder corporate health care patient than the not-for-profit alter- have gained about 10% of the market. delivery costs more. native. Winnipeg’s Pan Am sports Their promise was the same one we of- These latest developments in the medicine clinic reduced costs when it ten hear from advocates of private for- US are consistent with a series of studies moved from for-profit to not-for- profit care in Canada: better service for produced by our research team at Mc- profit status. lower cost. Master University. The first two studies While we still have relatively Unfortunately, that’s not the way showed higher death rates in investor- little investor-owned private for-profit it worked out. The Medicare Payment owned private for-profit hospitals com- care, the sector is growing. It includes Advisory Commission, an independent pared to private not-for-profit hospitals, nursing homes and, in some provinc- federal panel, has informed congress that and in outpatient for-profit dialysis clin- es, home care companies, for-profit the companies are costing the system an ics compared to not-for-profit clinics. MRI facilities, and surgical facilities. average of 7 per cent more than the ex- The results of a third study, published Governments in several provinces are isting system. That would add up to $50 this summer, showed that health care enthusiastic about expanding investor- billion of extra payments over the next costs payers 19 per cent more at for- owned for-profit delivery. 10 years. profit versus not-for-profit hospitals. Will we continue with this The American experience illus- These results come from the U.S., foolish experiment until we face the trates the importance of getting beyond but are likely applicable to the Canadian American lawmakers’ situation: a Can- knee-jerk reactions to private health care scene. Investigators conducted the orig- ada-based study telling us that inves- delivery, and asking “what kind of pri- inal studies over a period of more than tor-owned for-profit health care costs vate”? Your family doctor, and any spe- 20 years in which the U.S. health care sys- more and delivers less? And then face cialists you need to visit, probably work tem changed radically. The consistency the enormously challenges of mov- in a practice setting with a few other of the findings suggests that they apply ing back to not-for-profit delivery. doctors. These practices are usually “pri- to a wide variety of administrative and Hopefully, we will choose to avoid the vate” and some might characterize them reimbursement structures. Many of the waste, and poorer health outcomes, as “for-profit”. Certainly, the doctors studies focus on publicly funded pro- of investor-owned for-profit care.♦ need to pay their own salaries, and those grams. In this way, they mimic the Cana- First published November 2, 2004 as one of Dr. of their administrative and nursing staff. dian situation: our choice is whether to Gordon Guyatt's regualr columns in the Win- The physicians, however, are in control invest our public dollars in for-profit or nipeg Free Press. of the practice decisions and have direct not-for-profit delivery. Finally, the same relationships with their patients. large corporations that were studied in 16 Medical Reform Volume 24, Number 3 - Winter, 2005 HEALTH CARE CRISIS IN NIGERIA Anthony Okwuosah
he health care crisis in Nigeria Brain drain remains a very big are served one of the worst health dish- is aptly captured by the medi problem with many of our best brains es available on the planet earth. Every Tcal advisory on the US embas- frustrated out of the country. Nigeria is segment of Nigerian society shares cul- sy web site. It states, inter alia, that “ estimated to have about 10 physicians pability for this sad state of our health the quality of government medical per 100,000 population while Canada care. facilities is unacceptable by US stand- and the US have 229 and 250 respec- The government, of course, bears ards”. It also further states that the tively. the greatest responsibility for this state quality of healthcare providers rang- HIV/AIDS continues to be a of affairs by chronically under funding es from poor to fair and that most problem and NACA (National Action the health care sector, appointing wrong physicians and nurses do not meet US Committee on AIDS), NASCAP (Na- leaders for the sector, implementing con- standards of training. The blood sup- tional AIDS/STD Control Program) flicting policies, programmes and guide- ply is not safe and blood-banking serv- and their international partners continue lines, and fueling corruption. Corruption ices are unacceptable. National to advocate abstinence and safe sex as is not exclusive to the government; rath- Disaster management is not effective panacea to the near exclusion of improv- er it pervades the whole system from or functional. ing the safety of our health care, espe- top to bottom, employers to employ- As damning as these statements cially medical injections and blood ees, care providers to the general public are, they are in reality understating the transfusion services. The immunization and the Nigerian society at large. The rot in the Nigerian healthcare system. services should be commended for their government has also woefully failed in The health indicators show a life ex- efforts at making immunization injections the duty of setting standards and regu- pectancy at birth of less than 50 years safe. Also to be commended are the lating practice. and the probability of a Nigerian born untiring efforts of NAFDAC (National The next culpable group are health child dying before age 5 is 182 per Agency for Food and Drug Administra- care workers themselves who spend val- 1000 live births. Nigeria’s total health tion and Control) in controlling the un- uable energy, resources and time in inter- expenditure as a percentage of GDP dying scourge of fake and adulterated necine squabbles on leadership of the has been consistently under 4 per cent. drugs. sector. In the private sector, the cadres Immunization coverage remains low The international covenant on abandon their roles and rather devote with DPT3 for 2003 at 25 per cent as Economic, Social and Cultural rights themselves to providing services they are accessed from the WHO website on (ICESCR) prescribes the right to the not trained to provide. The doctors fail August 20th, 2004. highest obtainable level of health for all. to collect consultation fees but instead Tertiary hospitals are a shadow It specifically requires States to take steps vend medications to patients with the of their former glory with decayed necessary for “the prevention, treatment attendant conflicts of interest. They dis- infrastructure while primary health care and control of epidemic, occupational pense medications available in their units are overgrown with weeds and and other diseases.” The Committee of stocks or ones that are most likely to give overrun by rodents and snakes with ECOSOC (Economic, Social and Cul- them the greatest financial reward. Phar- staff doing other business and show- tural Rights) charged with monitoring macists, nurses and laboratory scientists ing up at month end for wages when adherence to ICESCR in 2000 in its are all consulting, diagnosing and pre- available. The Pentecostal and Sabbath General Comment 14 explains that the scribing, without adequate training. churches are convincing the people right to health at all levels consists of these Half-illiterate business men in Idu- that the causes of high rates of mor- interrelated and essential elements: ap- mota, Mushin, Onistha Bridgehead, Aba tality and morbidity are demons, an- propriateness (cultural, social, and scien- and Kano, without the education and cestral spirits, poisons, curses and tific), high quality, and acceptability. It ethical indoctrination of our pharmacists, other supernatural sources. Our peo- does not insist on uniform standards for have taken over the importation of med- ple from Aso Rock down to the shan- all societies but aims at the highest level ications and sundry health supplies result- ties of Badia are becoming more attainable for each society. Nigeria, the ing in the flooding of our system with superstitious, resorting to prayers self-styled “Giant of Africa”, should fake and adulterated products. The phar- while non-praying Europe and the US then aspire to be the giant in health in macist also contends with the scourge of continue to enjoy better health care Africa at the very least. However, the the patent medicine vendors, many of and prosperity. reality is that the generality of Nigerians (continued on page 18)
Volume 24, Number 3 - Winter, 2005 Medical Reform 17 HEALTH CARE CRISIS IN NIGERIA (continued) whom are called “doctors” by their pa- trician to change his bulb, carpenter to retain our doctors, nurses and other trons. It is common to see even well- fix his door, painter to paint his child’s health care professionals in the coun- educated persons walk into a patent room but when ill, he treats himself. He try.♦ medicine store, illegally stocked with eth- becomes the expert who decides on the Dr Anthony Okwuosah is director of the ical products and restricted medications, test to carry out (typically, the Widal re- Medical Rehabilitation Centre for Trauma to consult a primary school drop out for action and tests for the malaria parasite) Victims, the Project of Rights Relief Reha- medications to use for their ailments. The and goes ahead to prescribe medications bilitation Reconciliation Services, Lagos, Ni- attendant, trained in the art of “mixing” for himself. geria. Dr Okwuosah is participating in by a master he previously served, duti- International NGOs contribute to research on injection safety with Dr Berna- fully doles out a variety of painkillers, this bad scenario by creating vertical pro- dette Stringer, principal investigator, of the anti-malarials, multivitamins and antibi- grammes with skewed incentives, poor- University of Western Ontario. Ted Haines, otics to his patrons. ly articulated sustainability strategies and MRG steering committee member, is a co- Laboratories are also busy churn- shoddy, unplanned and unannounced investigator. ing out questionable results using ques- sudden exits. They reappear sooner than tionable reagents and antiquated systems. later with fresh programmes that have Medications and reagents meant to be little or no connection to their previous kept in well-regulated environments are programmes. AUSTRALIAN PBS left in unmonitored refrigerators to the There is no magic bullet that can vagaries of irregular power supply. Poor solve the Nigerian health sector. How- (continued) staffing is also a major problem in the ever, curbing and minimizing corruption private sector with the use of ill-trained is perhaps the most important step gov- References auxiliaries and other attendants. ernment can take to restore hope to our Supporting references, links to policy doc- In the public sector with better people. uments, PBS statistics, media debates and staffing, poor work culture results in staff Important also are increased and related sites such as QUM and the NPS can only putting in a fraction of the time they sustained funding and appointment of be found at www.phaa.net.au ♦ are supposed to and only half-heartedly qualified and competent people to head Rickard, M., The Pharmaceutical Bene- rendering the service when they do. Lab- our health and para-public institutions fits Scheme: Options for Cost Control. oratory tests of doubtful benefit such as with clearly stated time frames and meas- 2002, Current Issues Brief no. 12 2001- Widal reactions are commonly used. In- urable targets expected of them. No ex- 02, Social Policy Group, Parliamentary jections are overused and basic precau- cuse should be acceptable for failure to Library: Canberra.—focus on debate tions to make them safe for the patient, achieve the targets within the stated time about sustainability, argues that al- the health worker and the community are lines. Policies and guidelines should be though increasing, keeps costs down in not taken. Blood transfusions are being enunciated and widely disseminated up other sectors; Australia compares very favourably with other countries given with dubious, if any, screening due to provider levels. These regulations, Schofield, D., Re-examining the Distri- to near inexistent regulation and enforce- policies and guidelines should be strictly bution of Health Benefits in Australia: ment of existing legislation. enforced at both governmental and pri- Who Benefits from the Pharmaceutical Nigerian society is also to blame. vate sector levels. Benefits Scheme? National Centre for Our people are busy looking for guar- National health insurance schemes Social & Economic Modelling (NAT- anteed cures which modern medicine should be accelerated and greater aware- SEM), 1998: Canberra. Ref to benefits to fails to give. A plethora of alternative ness created. The pitfalls of privately fi- marginalized and vulnerable Practitioners and healing ministries hap- nanced and operated health insurance, Transcript, Australian benefits scheme pily guarantee our ever so gullible peo- which is overused and abused, should upsets US drug companies. 7.30 Report, ple with miracle cures. The average be remedied. Australian Broadcasting Corporation (ABC) 27 February, 2001, http:// Nigerian differs from his western coun- Improvement in our economy www.abc.net.au/7.30/s252447.htm. US terpart in a very simple way. The west- and a reduction of the people’s poverty public health people on advantages of erner fixes his broken door, paints his level will, of course, positively affect our Aus. PBS house, and does most minor repairs on health. This will add an incentive to help his appliances but goes to see a doctor when he is ill. The Nigerian calls an elec-
18 Medical Reform Volume 24, Number 3 - Winter, 2005 INTRODUCING MEDICARE’S NEWEST CHILD (continued)
Lexchin. A National Pharmacare Plan: 6 Pharamac (2003). Pharmaceutical Management 9 CIHI (2003). Drug Expenditure in Combining Efficiency and Equity. Ottawa : Agency. Annual Review 2002. Available at Canada, 1985-2002 (accessed electronically Canadian Centre for Policy Alternatives, March www.pharamac.gov.nz. Wellington. from www.cihi.ca): 156. 2001, at (available at www.policyalternatives.ca). 7 CIHI (2001). National health expenditure 10 Shoppers Drug Mart Corporation, 2003 4 Cross, J., H. Lee, et al. (2002). “Postmarketing trends, 1975-2001, report: executive summary. Annual Report, page 21. drug dosage changes of 499 FDA-approved Ottawa. 11 Lexchin, J. (1996). “Income class and new molecular entities, 1980-1999.” 8 Yalnizyan, A. (2004). “Accepting the Pharmacare pharmaceutical expenditure in Canada: Pharmacoepidemiol Drug Saf 11(6): 439-46. Prescription”, Canadian Healthcare Manager, Sept. 1964-1990.” Can J Public Health 87(1): 46- 5 Prescrire (2002). Drugs in 2001: a number of 50. ruses unveiled, Prescrire International 11: 58- 60.
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Volume 24, Number 3 - Winter, 2005 Medical Reform 19 INTRODUCING MEDICARE’S NEWEST CHILD: NATIONAL PHARMACARE (continued)
3. Improving prescribing patterns – A national body would be more effec- Canadian Public & Private Drug Expenditures tive at instituting mechanisms to im- in $ billions: 2003 (CIHI report) prove health outcomes. A national body could create incentives to im- Insurers, 5.576, prove prescribing patterns by doc- 35% tors, or contract pharmacist to act as Public, 7.5505, 47% consultants to advise patients in a community oriented setting are two good examples.♦
Out-of-pocket, (Endnotes) 2.881, 18% 1 IMS Health, Compuscript, 2003, Drug Monitor. URL: www.imshealthcanada.com (accessed Dec 5, 2004). Pharmacare would improve health 2. National monitoring– Pooling databases 2 Romanow, R. (2002). Commission on the outcomes from across provinces and territories Future of Health Care in Canada. Building 1. Creating a National Drug Formulary to a centralized location would minimize on Values: the Future of Health Care in – A national body that selects drugs the risk of adverse drug reactions, since Canada. 3 that are available to all Canadians en- larger sample sizes are more sensitive William M Mercer, Ltd. Supplementary Health and Dental Programs for Canadians: sures safety and cost-effectiveness of to side-effects. Monitoring at a nation- Assessment of Coverage and Fairness of Tax commonly prescribed drugs. al level would also provide demograph- Treatment, November 1995, cited in J ics on under/over-use of certain drugs. (continued page 19) Medical Reform Group Box 40074 RPO Marlee Toronto, Ontario M6B 4K4
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20 Medical Reform Volume 24, Number 3 - Winter, 2005