Still no national drug program after 15 years of hearings, studies and agreements

One of the universal areas of agreement in Canada is the benefit of a national pharmaceutical program.

Everyone agrees a national pharmaceutical program would save money through bulk purchases of drugs. Canada has the second highest drug costs in the western world. If we had a bulk purchasing program we could use the weight of our buying power to reduce costs and it would ensure we avoided shortages of certain drugs, which have and do happen. It would also be a benefit to pharmaceutical companies because it would help them adjust their sales efforts, production and distribution so they could make more money on lower per product prices.

No one disagrees this is a good idea. In fact, in February 2003 all of Canada’s health ministers – federal, territorial and federal – agreed to a national drug policy. It was part of the foundation for the 2004 Health Accord. A national drug policy was such a good idea the health ministers agreed two more times to institute it.

A royal commission first recommended this in 1964. In 1967 and 2002 there were a national forum and another royal commission. Then, in 2003 it looked like we might act. But we didn’t. Why?

Governments agreed to it 15 years ago. No one has spoken against it, yet successive governments of all political stripes have failed to institute one.

The idea is so popular that it’s virtually spurred an industry producing annual or semi-annual schemes for a national policy.

In 2004 in support of the new National Health Accord the Romanow Commission studied it.

In June 2006 a Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceuticals Strategy said, “…Prescription drugs also constitute the fastest growing and second largest category of health care expenditure in Canada. Like governments around the world, Canada is faced with the challenge of optimizing the benefits of prescription drugs for Canadians while managing the risks and complexities associated with this rapidly evolving sector.”

“After hospital care, Canada spends more on drugs than any other major category of the health care system. Since 2000, the total public and private expenditure on prescription drugs has grown by approximately 12 per cent annually. This rapid escalation in drug costs threatens the sustainability of public drug programs.

“To ensure that Canadians continue to benefit from robust public drug coverage, public dollars must be used efficiently. By collaborating on drug price and purchasing issues, Canada’s public drug plans can encourage greater competition, increase transparency and reduce market fragmentation to ensure Canadians get the best possible prices for pharmaceuticals.”

Two of that report’s nine recommendations were:

— Establish a common National Drug Formulary for participating jurisdictions based on safety and cost effectiveness;

— Pursue purchasing strategies to obtain best prices for Canadians for drugs and vaccines;

More information is here: https://www.theglobeandmail.com/news/national/with-universal-drug-coverage-canadians-could-save-billions-study/article34141670/

In February 2017 a study in the Canadian Medical Association Journal said if the government provided universal coverage for 117 essential medicines, which accounted for 44 per cent of the prescriptions filled in Canada we would save nearly $4.3-billion.

In June 2017 a paper A Better Prescription: Advice for a National Strategy on Pharmaceutical Policy in Canada said, “Canada needs a national strategy to fulfill its obligation to ensure universal access to necessary healthcare, including prescription drugs. A 2004 attempt at a national strategy for pharmaceutical policy failed because it lacked clear vision, logical planning and commitment from federal and provincial governments. The result of uncoordinated pharmaceutical policies in Canada has been more than a decade of poor system performance.”

The Better Prescription paper, found here: http://www.longwoods.com/content/25160 says “Since 2010, provinces have been voluntarily collaborating on prescription drug pricing through a Pan-Canadian Pharmaceutical Alliance; and some provinces, most notably Ontario, have been calling for federal-provincial collaboration to establish a universal pharmacare program to make medicines more accessible to all Canadians. At the federal level, the Liberals’ 2015 election platform included promises to negotiate a new health accord and to work to make prescription drugs more affordable in Canada, promises that ended up in the new health minister’s mandate letter after the Liberals formed government in late 2015. Perhaps not surprisingly then, in January 2016, when the federal, provincial and territorial health ministers met for the first time in many years, they created a working group to explore pharmaceutical policies aimed at reducing prices, at improving prescribing and the appropriate use of drugs, and at improving coverage and access to medicines for Canadians.”

This paper tells us that in 2016 Canadians spent $30 billion on prescription drugs and $5 billion of the private spending was wasted! Further, it says that over $400 million is spent on unnecessary drugs for people over 65 and estimated that “one in six hospitalizations in Canada could be prevented if prescription drugs were prescribed and used more appropriately.“

Another paper, National Pharmacare in Canada: 2019 or bust? https://www.policyschool.ca/wp-content/uploads/2017/03/National-Pharmacare-Adams-Smith.pdf begins by saying, “It is the Canadian public policy issue that rears its head with regularity, never achieving much more than discussion, and yet never going away entirely. The issue is pharmacare, and once again it is back for discussion among academics and policy-makers, and once again it looks like the discussions will not go anywhere anytime soon. The proposal for a publicly funded pharmaceutical- coverage plan is frequently on the table in Canada, but it still is not in the cards.”

A second February 2017 paper, the Estimated effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada http://www.cmaj.ca/content/189/8/E295 “could address most of Canadians’ pharmaceutical needs and save up” to $5.83 billion annually if we covered 117 of the most prescribed drugs.

From 2006 to 2017 we have had study after study, paper and presentation after another on the benefits of universal drug coverage. Here are links to a few:

https://open.library.ubc.ca/cIRcle/collections/ubccommunityandpartnerspublicati/52387/items/1.0048260

https://www.ourcommons.ca/Content/Committee/421/HESA/Brief/BR8289787/br-external/CanadianNursesAssociation-e.pdf

http://www.pdci.ca/wp-content/uploads/2016/01/Pharmacare-Preliminary-Report-PDCI-January-2016.pdf

https://www.collectionscanada.gc.ca/eppp-archive/100/201/300/cdn_medical_association/cmaj/vol-162/issue-4/0523.htm

https://dspace.library.uvic.ca/bitstream/handle/1828/8612/Derksen_Cameron_MPA_2017.pdf?sequence=1

https://www.cma.ca/Assets/assets-library/document/en/advocacy/PD10-02-e.pdf

http://www.aims.ca/site/media/aims/Final%20-%20The%20Effectiveness%20of%20the%20Common%20Drug%20Review%20in%20Canada%27s%20National%20Drug%20Strategy.pdf

https://nursesunions.ca/wp-content/uploads/2017/07/universal-pharmacare-report-e.pdf

In 15 years we have produced at least 15 major studies on the benefits of a national drug policy. We have studied this topic to death. The benefits to people, patients and the system are clearly identified. The money to relieve the stress on the health care system is in the savings. In Nova Scotia’s case this 15 years of inaction has cost us in excess of $805 million in over-payments for prescriptions. That’s roughly half the projected cost of a replacement VG. What more do politicians, health ministers and governments need before they act?

 

 

 

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Looking south to successful new disruptors

Two of the world’s richest men may launch the biggest, positive disruption to health care in several generations.

Warren Buffet and Jeff Bezos are teaming with JP Morgan Bank to create a company to help US employees find quality care “at a reasonable cost” and tackle the “hungry tapeworm on the American economy”.

https://www.theguardian.com/technology/2018/jan/30/amazon-warren-buffett-jp-morgan-healthcare?utm_source=esp&utm_medium=Email&utm_campaign=GU+Today+main+NEW+H+categories&utm_term=262367&subid=12294947&CMP=EMCNEWEML6619I2

They’re operating in the for-profit American system, but have realized that soaring health care costs are a threat to both people and the economy.

Buffet brings a benign practicality to business. Bezos understands scale. Both understand efficiency and the need to produce results.

Their collaboration and new vision could shake up the comfortable, semi-incestuous clique of like-minded, like-educated, like-back-grounded people who manage health care. We might see a new type of results-oriented executive class introduced to health care management. And that might provide Canadian politicians with the fortitude to think outside the box when hiring executives. So instead of hiring another executive clone responding to a job description written with their particular curriculum vitae in mind, health ministers seek people with a real history of success or, failing that, demand our executives meet performance targets. Remember, in seven years Halifax hospitals have failed to meet the province’s standard for off-loading ambulance patients within 20 minutes. NS health executives have not managed to bring capital projects in on time or on budget. They have failed to recruit doctors in sufficient numbers to meet the Physician Resource Plan. They have failed to retain doctors. They have impeded doctors in taking over established practices or opening new ones. They have a history of higher-than-average administration costs, and, and, and …

Buffet and Bezos present a truly positive disruptive opportunity for western health care.

 

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The hidden costs of the doctor shortage

More and more doctors, specialists, surgeons are speaking out about the hidden costs of the shortage of family physicians in the province.

On the first work day of 2018 vascular surgeon Dr. Gerry MacKean said a complaint at a meeting of specialists was how all were being asked to step outside their medical specialties to supply the basic care normally provided by family physicians. This included writing prescriptions. Dr. MacKean knows his specialty, but he isn’t a general practitioner, isn’t up on certain pharmacology and is uncomfortable with some of the care requests being made of him. His colleagues feel the same. It’s also an expensive stop-gap measure that diverts him from more urgent cases that need his specialized knowledge.

Then Dr. Kirk Magee, interim head of emergency medicine at the Queen Elizabeth II Health Sciences Centre, added his observation about the impact of the shortage of family physicians. The shortage is driving more people to treat ERs as a type of walk-in clinic.

According to Dr. Magee 14 percent of patients visiting the Halifax Infirmary ER are orphaned patients seeking basic medical care. As many as half of the people using the ER are seeking a prescription top up.

According to the Nova Scotia Health Authority’s website, 561,516 people visited provincial ERs in the previous year. An earlier report said that 48 percent of ER visits were not medical emergencies, they were people seeking walk-in care that normally would be provided by a family physician. That means 269,527 visits were not an emergency.

This is a waste of resources, a great waste of individual’s time and a massive financial hit. The Legislature’s Public Accounts committee have been told it costs approximately $200 per ER patient. Provincial doctors say that $200 figure doesn’t include the supporting costs: like nurses or operating the facility.

Using the $200 figure means that the 269,527 non-emergency ER visits cost $53,905,400. If those patients were seen by a doctor in his or her office, the doctors would have billed an average of $31 per appointment or $8,355,337. In short, the system is wasting $45,550,063 delivering care in this format. Furthermore, since writing prescriptions isn’t a billable fee for family physicians in private practice, writing ER prescriptions is an additional $3.5 million payout. I’ve said it before, it’s not a matter of money, it’s management. If we had more family physicians the pressure would be off ERs and specialists, and the population would be healthier.

This is reminiscent of the telephone changes made in the provincial civil service in the 1990s. Efficiency experts decided a new system would cut connection charges and reduce the need for support staff across the civil service. As a result, people in the $25,000-a-year range were eased out and positions eliminated. The result was that senior executives found themselves performing the work of people paid a third or a quarter of their pay and the work they were hired to perform was impeded. Sounds a lot like health care today.

 

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Who to trust?

The Nova Scotia Health Authority has trouble communicating what they’re doing. Auditor General Michael Pickup made that point in the fall. It’s worth remembering that in 2011 former Auditor General Jacques Lapointe, having studied the problems with the cost overruns of the Truro hospital, recommended “The Department of Health and Wellness should put a process in place to ensure only complete and accurate information is presented to Cabinet.”

The former AG determined that inaccurate information was presented to justify the construction of a new hospital. And here we are almost a decade later and we’re still questioning the veracity of health executives.

It seems that after each appearance by an NSHA representative before the Legislature’s Public Accounts Committee their testimony is questioned.

For example, in April 2017 Dr. Bob Martel, a palliative care doctor from Richmond County, took issue with a statement from NSHA CEO Janet Knox that paramedics can offer in-home palliative care to 1,000 patients who have signed up for the service. Martel wrote, “On the surface, this statement is factually correct, but is misleading in that it leaves the impression with political officials interviewing Ms Knox that these paramedics are offering palliative care services to 1,000 patients. The number refers to the patient population registered as special palliative patients with Emergency Health Services over the last two years. What it really means is that EHS will respond to calls from these patients and their families in a different way: no lights and sirens, more sensitivity around issues of resuscitation and on occasion, administer bridging pain and symptom relief to patients who do not have access to their regular physician or palliative care practitioner. … This program is neither meant to provide primary palliative care nor is it qualified to assess or administer comprehensive palliative care. … It is too bad that Ms Knox was not challenged on this point as it appears that she successfully conveyed that all is well in palliative care …”

http://thechronicleherald.ca/editorials/1457478-opinion-paramedic-program-is-not-true-palliative-care

Now Herald columnist Jim Vibert questioned the information provided by – or left unsaid – by Rick Gibson, NSHA’s senior medical director, who appeared before the Public Accounts Committee in December. Vibert writes, “Gibson told MLAs the authority now has what it needs to plan for future doctor requirements across the province … But even as he was speaking, the NSHA was issuing a tender “for a more robust data system to better track and report on physician information, including credentialing, privileging and recruitment”.”

Vibert continues, “No mention was made of the tender at the committee, and members could be excused for coming away with a sense that at least the NSHA is working from good information, when it is in fact just going about the process of buying better data.”

It was, as Vibert says, not a complete picture. I am reminded of the line from A Few Good Men, where an angry Jack Nicholson screams, “You can’t handle the truth!” Is that what the NSHA executive feel about the right of the public and politicians to know about the state of our health care system?

Are Nova Scotia health executives too cute with details or uncomfortable with facts? As Vibert says, “Say what you will about the health authority – and I have – they are good at teaching us who to trust.”

http://thechronicleherald.ca/opinion/1536671-vibert-haruspicy-isn’t-revealing-the-fate-of-health-care

 

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Replace the NSHA leadership

It has come to this. James Moir, a former president of Maritime Medical Care and former chairman of the QEII Health Sciences Centre, has called for the government to fire the leadership of the Nova Scotia Health Authority.

The delivery of health care in Nova Scotia has reached a point where we are moving from insider conversations, measured statements, calls for study and other platitudes to putting our names to public calls to fix the system by firing of those who failed to deliver.

Read Moir’s comments here:

http://thechronicleherald.ca/opinion/1535593-opinion-fire-health-care-kingpins-they’ve-failed-miserably

The government was bold enough to change the system, and now we need that same boldness to fix the remaining impediment to success.

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Nova Scotia’s doctor deficit

Kevin Chapman with Doctors Nova Scotia told CBC’s Information Morning host Don Connolly that there are currently vacancies for 70 family physicians in the province. That’s as of December 18.

Using quick shorthand we can get a better idea of how many people are without a family physician. As a rule of thumb, most solo or dual-practice family physicians in Nova Scotia have 2,200 patients. For some longer-practicing physicians’ (the ‘old school doctor’) file numbers creep past 3,000.

Working with the basic of 70 vacancies x 2,200 = 154,000 patients without a family doctor.

Under the Nova Scotia Health Authority’s collaborative care practice model doctors will have an average patient load of 1,400. In which case 70 x 1,400 = 98,000 people without a physician.

In either scenario the 42,000 names on the NSHA list of patients waiting for a physician is a grossly understated fiction.

And what happens to people without a family physician? Their only alternative is to treat hospital ERs as a walk-in clinic. And in 2015-2016, 48 percent of ER visits in Nova Scotia were for non-emergencies. Using an ER for medical care is not good for patients. It focuses on the current concern, doesn’t develop a relationship with a medical professional who can help develop a long-term care plan and catch abnormalities before they become dangerous, and expensive. Forcing people to use the ER as their primary contact for care illustrates the level of failure of care.

The NSHA’s inaction on physician recruitment is shoving the system to a fiscal breaking point. How much longer can we afford an executive who fail to produce better patient outcomes?

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Questioning the costs and care of CCCs

The Nova Scotia Health Authority is advertising for health care professionals to join the collaborative care practices.

Is this a real request or a public relations move to mute some of the Auditor General’s criticisms about the NSHA’s secrecy, lack of transparency and poor communications?

If the NSHA needs to reach physicians, nurses and other professionals, it has only to reach out to their associations, regulatory boards and colleges. This ad, it would seem, is more about looking busy and active than being productive.

The other issue is whether these collaborative care practices are the panacea the NSHA would have us believe they are. Or are they just about a different type of bloated bureaucracy?

Four years ago I was invited to attend a medical information day by the Minister of Health. At that day we heard medical students say they wanted to collaborate in a family practice. What I heard said was this next generation of doctors wanted practice partners. They wanted someone to share the work with, to bounce ideas off, to help keep up with medical advances, and to cover for holidays and sick days. The impression was that new doctors wanted to work with two or three others. I did not hear anything along the line of the collaborative care centres/practices the NSHA is promoting. It could be that an aversion to commit to a solo practice – which students say is not presented as an option in medical school – has been misunderstood by the bureaucrats who embraced the idea of over-building a response. A doctor opening a solo practice doesn’t give the ribbon-cutting photo ops of a clinic opening.

Students didn’t say they wanted this and many of the experienced physicians, surgeons and specialists question this model of care delivery. The feeling is that CCCs are an expensive way to deliver care to fewer patients. Below are the detailed questions and concerns of long-time Yarmouth County family physician Dr. Peter Loveridge, MB, BS, DMRD, FRRMS, who lectures in family medicine at Dalhousie University.

This is a copy of a letter Dr. Loveridge wrote to the Doctors Nova Scotia newsletter in response to an article. He asked helphealthcare to share it. It has been lightly edited for clarity to a lay reader.

The Editor, Doctors NS magazine

I am not sure if DostorsNS is set up for comments, but I would like to comment on the article highlighting … collaborative practice. I am a rural doctor who has worked in Yarmouth County for more than 40 years. The article does not give a balanced view of this approach, and leaves many really major problems unaddressed. In replying to this I did take the trouble to go through the 29 pages of “strengthening the primary care system…”, a rather turgid read full of bureaucratese and jargon.

I write entirely as a remote rural doctor. I have nothing to say about urban practice, though it seems now that the inhabitants of HRM are now experiencing the same problems we have had to deal with for decades. I will use the HA example of serving a population of 10,000 people, though the geography of rural NS rarely leads itself to such neat packages.

In the bad old days of 20 years ago, such a population would have been served by a group practice of 4 doctors. (Five if you were lucky and 2 or 3 if you weren’t.) The docs paid for everything out of their (usually) FFS earnings. There would be 3 ancillary staff (+/- 1) and they did all the managing of the practice. Usually one of the senior physicians would have some management oversight. Didn’t much matter about the details, as no-one other than the physicians was responsible for payment of the overheads. The practice would receive about $250k per physician in fees, sometimes in a high volume practice a bit more; in a practice with a lot of elderly, multi-morbidity patients, a lot less. Hospital in-patient coverage, ER coverage, nursing homes, surgical assists, and obstetrics, often in collaboration with other practices, was almost universal. Works out to a cost to the taxpayer of about $100/year/patient.

Now, consider the NSHA’s obsession with collaborative care centres and supposed medical homes, each one serving about 10k patients. Sorry, the geography doesn’t work. My municipality, population just under 8k is 2/3rds the size of Luxembourg. The two population centres are a 45-minute drive apart, and it’s an hour-and-a-half from one end to the other on a good day. The unfortunate people in Weymouth (Digby County) are expected to get service in Digby, a 45-minute drive on the only unimproved section of highway 101. Westport, where previous governments managed to maintain a physician presence for at least 50 years and maybe longer, face an hour-and-a-half drive and two ferry crossings. Try doing this in February with a northwesterly gale and blowing snow – these times can be tripled. The people in Westport, a prosperous fishing community which contributes mightily to the GPP, are not amused. Administrators in the NSHA give every impression of having zero understanding of this problem and are not interested in getting enlightened.

So, consider the unaddressed problem with all this talk: the money. Here is at least a realistic yearly estimate of running the cost of such a place:
4-5 doctors – $1 million
2 NP’s – $260k
2 practices nurses – $160k
2 adaptive team members (the NSHA’s jargon, don’t really know what it means) – $160k
6-8 clerical staff – $250k
management – $100k

Then the rent or capital cost of a building holding a minimum of 17 health care professionals and its maintenance, utilities, supplies, insurance, etc. That’s a $2.5 million capital cost and $200k maintenance as a very conservative estimate. If the non-physician staff are unionised, you can add at least 30% to the costs.

This works out to about $2.6 million a year (building cost amortised over 20 years, but being it the government, in all probability it is higher than this), and an annual cost per patient of $260, more than double the cost of a traditional group practice.

If you, as a rural doctor really want the bile to raise in your gorge, you can read this last spring’s article in the Halifax paper about the DFM clinic in Spryfield. Here, 10 physicians, 14 residents and at least 12 other clinical staff manage to look after 4200 patients, and no, they can’t possibly manage any more. Patients are not guaranteed that they can see “their own” doctor, the concept is discouraged. Dalhousie family medicine is anything but transparent with disclosing finances, but a very conservative estimate of the costs works out to about $1400/patient/year. No mention is made of things like ER shifts, nursing homes, obstetrics, etc. I truly despair about what training the residents would get, it is not in the real world.

It is often stated that new doctors want to go into turnkey operation where they do not have to be small business owners. This may be true, but when these same people go into a CCC and find out they are subject to the whims of an (appointed) manager … this begins to pale rapidly. My kingdom is pretty humble, but at least I am the King, and if I need a new fax machine I just order it. I do not have to put in a requisition, wait for three quotes, and if the manager deems it important enough, wait two months for it to arrive. There may be some merit in joining a well run CCC, but joining a bad one, which outnumber the good one by two to one, is a nightmare, I’ve been there.

Of our first 10 residents graduating from our program, only one is in a CCC. 3 left the province, 2 to do ER, one to a rural community in BC, 3 to Shelburne (not a CCC) one to Yarmouth, one to Clare, one to Dartmouth, and one to Cape Breton. After 10 years of post secondary education most docs want to be their own master and actually don’t want to be employees in name only with none of the benefits. Though the CCC, which our one resident is in, is the best run one in our district, she is not happy. She wants to work half time as she has a baby, and the CCC is not flexible enough to charge her part time expenses. Another young doc (not a recent graduate) left the place as he worked mostly in ER’s and they couldn’t accommodate him either. I will refrain from commenting on the other places, though I did survive 6 weeks in one. …

Now, I will have a brief word about nurse practitioners. I don’t have a problem with the concept, in fact, when I was a resident, many decades ago and across an ocean, we had such creatures (we didn’t call then that), as we did when I first came to Pubnico 44 years ago. But community NP’s in western NS work from 9-4 Monday-Thursday. It is rare they see more than 10 patients a day and an average is 7. Most family physicians see at least 30 patients a day, 5 days of the week. I’m sure you have seen on the news the case of the young lady in Lockeport who couldn’t get a diagnostic mammogram.. The small print stated she had 5 NP’s in 4 years and the service had been withdrawn from their community, leaving her high and dry. The reality is that if a 4 person group practice, because of retirement, moving away or death, is replaced by a 3 doc + 1 NP practice, the remaining docs will have their workload increased by 30%. This may well make the practice unsustainable. If you think NP’s are going to do the extended hours, weekends, ER shifts, surgical assists, hospital inpatients and the like, you are dreaming. There also has to be consideration of the costs of an NP. NP’s earn about $110k/year, but their benefits raise this to about $130k/year. They have to have support staff and an office. This cannot be done for less than $50k/year, so the total annual cost is $180k. Given the limited number of patient encounters, the cost per encounter is close to $100. The corresponding cost for a family doctor is $32, or a bit less than $40 if the patient is over 65. This does not make economic sense, but any mention of this is considered to be hostile to nurses. It is time for realistic talk here.

The bottom line of all this is that the traditional solo or group practice is a very cost effective way of delivering care. Practices have always collaborated, it is just that government haven’t controlled it. Everything else costs at least twice as much, and there has not been a single credible plan as to how this is going to be funded.

Peter Loveridge

 

 

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