Good afternoon and thank you so much for inviting me to join you.
My name is Danielle Martin. I am a practising family physician and I'm also a hospital administrator. I'm the vice-president of medical affairs and health systems solutions at Women's College Hospital in Toronto. I'm also an assistant professor at the University of Toronto.
I want to speak to you today mostly as a practising family doctor, but also as someone who is trying to help run a hospital and organization in the Canadian health care system, someone who is working to try to make care better for patients on the ground every day. I'd like to share with you what I see from my own vantage point about what the problem is that needs to be fixed with respect to pharmaceutical policy in Canada. It is that our current patchwork system is letting many groups, not just a single group, but many groups of Canadians fall through the cracks. It encourages and provides incentives to make bad prescribing choices. It is forcing doctors and other health care workers to engage in what can only be described as crazy workarounds to try to get our patients the basic health care that they need.
As the committee now knows—and I know you're up to date on these basic statistics—more than 50%, probably somewhere around 60%, of Canadians are covered by private drug insurance, usually through their employers or the employers of their spouses or parents. In those private plans, by and large, whatever a physician prescribes or another provider prescribes to a patient with private coverage will be covered. This is what's known as an open formulary drug plan. The majority of private drug plans function in this fashion. They make absolutely no attempt to base their coverage on medical evidence until an individual's spending on drugs gets into the many thousands of dollars annually. As a physician, if I write a prescription for a patient, their private plan will nearly always cover it.
Now that might sound good to you. I know it sounds good and you will probably hear people present to your committee over the coming days who will try to convince you that it is good, but in fact, it's not. It's not good for health, and it's not good for the economy. Why? Such open formulary plans give licence to doctors and other providers to prescribe more expensive medicines when less expensive ones are just as good or even better. This results in high costs for no reason and is one of the many drivers for the high costs that you've heard described by Steve and others.
Eventually, of course, those costs are passed on to Canadians, either directly or indirectly. Open formulary plans also encourage what's known as off-label prescribing, which leads to doctors writing prescriptions for cases where the drugs are not medically proven to work, and they fail to provide any guidance to patients or to prescribers about what the most appropriate drug choice is for a given condition.
This leads to a culture of over-prescribing and inappropriate prescribing that has real effects on the health of Canadians every day and leads to statistics of the kind we know. For example, one in five Canadian seniors today takes a drug on the Beers list, which is a list of medications that should almost never be prescribed to people over the age of 65 because the risks outweigh the benefits.
Indeed, private insurance plans have no incentive to reduce inappropriate prescribing. In fact, the incentive is just the opposite, because the more prescriptions we write, the more money they make.
Now the fact that many people depend on those employer-based drug plans also causes problems in the job market. A parent whose child has diabetes or whose spouse has cancer cannot afford to lose his or her employer-based insurance, and that traps people in jobs that may not be right for them.
Importantly, many Canadians who are working—the self-employed, people who work on contract, people who work part-time, and people who work in small businesses—do not have private coverage. It isn't only the working poor. The changing nature of work in Canada means that the issue now extends well beyond the nannies and taxi drivers of the nation, although we should of course be concerned about the nannies and the taxi drivers of the nation. In my own practice, I see lots of self-employed consultants and others with medium to high incomes who don't have drug coverage. As you will know from interactions with your own constituents, precarious work is on the rise in the Canadian economy. More and more people are working on serial contracts and in more than one job, and there are fewer long-term jobs with a single large employer.
As our economy shifts into an age where old models of employment become increasingly rare, old models of benefits are also disappearing. It's important to understand that many middle-class Canadians either don't have good drug coverage or are at risk of losing their drug coverage in the modern Canadian economy.
That's the private drug plans. They're not working well for Canadians.
Now let's talk about our public insurance plans. Every province, and also the federal government, runs at least one public drug plan, but most Canadians with jobs are excluded from public plans, despite the fact that they may not receive coverage through their employer, unless their costs become what is known as “catastrophic”. As you know, those catastrophic plans are supposed to kick in to save people from having to mortgage their homes in order to pay for their drugs. It is really important to understand how unhelpful catastrophic drug coverage is for the patients in my practice and practices across the country: people living with diabetes, high blood pressure, asthma, chronic heart disease, and chronic lung disease. To give you an example, in Ontario, where I live, on an income of $20,000 annually, a patient would need to spend $800 out of pocket before her coverage would kick in. This requires an upfront cash outlay that a person living on $20,000 a year simply can't afford, so what happens is that people just don't fill their prescriptions. For people who can't afford those catastrophic deductibles of 3%, 5%, 10%, or 12% of their income, having access to catastrophic drug coverage is equivalent to not having any drug coverage at all. In that context, it should not surprise any of us that one in five Canadian households now reports that someone in the household does not fill a prescription due to concerns about costs.
The impact is not only on patients, but it is also on the practice of medicine and on clinical practice across the nation. The reality is that every day in your communities doctors are doing things they shouldn't have to do in order to get medicine for their patients. We are allowing ourselves to be lobbied by pharmaceutical reps in order to get a few boxes of drug samples. We are prescribing an alternative to the drug that is actually needed by our patient, so that he can afford to fill the prescription. We are admitting people to hospital so we can give them treatments that they can't afford to take at home. We are wasting time begging companies to give our patients compassionate access to a drug they can't afford. Sometimes we just buy our patients' medicine ourselves, and sometimes the pharmacists do the same. Sometimes we just advise them that they should go on social assistance so that they can get the drug card they need.
It is abundantly clear to those of us who work in it that our current system, one in which private insurance drives unnecessarily expensive prescribing and huge numbers of Canadians go without their medications, is fundamentally flawed. Given the importance of medicine in modern-day clinical practice, the ongoing exclusion of prescription medicines from our publicly funded health care system makes no logical sense. Instead, we need a national pharmacare program with five key elements.
First, every single Canadian must be covered by a public plan. Just as we have done for doctors and hospitals, essential prescription medicines must be accessible to everyone.
Second, not every medication should be covered for every person. We need to devise an open, transparent, and evidence-based process, one that is at arm's length from government and free of industry influence and political interference, to make our decisions about what to cover.
Third, copayments should be extremely low or zero, especially for low-income people, because there is very strong evidence that even very small copayments can prevent low-income people from filling their prescriptions.
Fourth, governments must band together to purchase all drugs for the nation. Even the pCPA, with its limited success thus far, has failed to get the kinds of savings on drug prices that other countries get, because even with the federal government participating, public plans represent only 40% of the market for drugs in Canada.
The fifth and final element of a well-designed pharmacare program is an emphasis on reducing over-prescribing and improving quality and safety. This critical job cannot be left to private insurance companies or to pharmaceutical companies, which neither are accountable to the public nor have any kind of incentive to decrease rather than increase prescribing.
As I close, I would like to say that a national pharmacare program does not need to involve a full uploading of all provincial jurisdiction over drug plans in order to be successful. A co-operative effort, convened by the federal government, could be achieved without any constitutional hassle and without sticking the federal government with the whole bill. The tasks involved in pharmacare are discrete and could be shared between the federal government, the provinces, and the territories to achieve the five elements I have just outlined.
Canadians are rightly proud of the principle that our universal public health care system should base access to care on need rather than ability to pay. Until we deal with the lack of national pharmacare in this country, I am sorry to say that I don't believe we are living up to that principle.