Originally published in The Ottawa Citizen December 11, 2001

In Ontario there are two drug programs designed to reduce the burden of medication costs: The Ontario Drug Benefit Program (ODB) and the Trillium Drug Program (TDP). The ODB covers the cost of medications for seniors, welfare recipients and the disabled. The TDP, a co-payment plan varies with an individual’s or family’s income.

Within the ODB there is a substantial list of medications that require the use of the Limited Use form. As the name implies, “Limited Use” is designed to control the use of newer more expensive medications. A patient becomes eligible to receive these medications if they “qualify” for them. Another component is the Section 8 reserved for medications covered only if it is critical to the patient’s survival. Bureaucrats decide on the use criteria. It frequently drives both physician and patient to frustration.

For example, Avandia and Actos are new medications used in the treatment of Type 2 (non insulin dependent) diabetes. They too are designed to control blood sugar but also have the advantage of promoting kidney protection, heart disease risk reduction and improved cholesterol profiles. Some patients are able to reduce the dose of their other diabetes medications. With early use especially in the younger diabetic, the risk of the diabetic complications can be reduced. However, these are Section 8 medications. Unless the patient has failed to have their blood sugar controlled with the other available medications, the cost will not be covered.

For the treatment of osteoporosis only one drug is covered: Didrocal. It maintains bone density in the hip and spine. More efficacious “Limited Use” medications like Fosamax or Actonel are available but cannot be used until there is proof that Didrocal was ineffective. If, while using Didrocal, you suffer a new osteoporosis fracture after a year or your bone mineral density has decreases by more than three percent over two years or you experience intractable side effects, then you can be prescribed Fosamax or Actonel.

Fracture repair and rehabilitation costs more than the medication. Consider the suffering and affect on quality of life. Hip fractures in the elderly can be fatal. Physicians are in the business of providing the best possible care for their patients. It is frustrating when there is a better medication for your patient but you cannot prescribe it. People have to experience uncomfortable side effects, suffer a grievous injury or demonstrate that the medication is ineffective before being eligible for coverage.

The issue is long term versus short term cost savings. We are aware of the increasing utilization of hospital-based care. Is it not better to invest in treatments that can potentially reduce future utilization? If we can keep someone away from diabetes-induced kidney disease, dialysis, heart disease, heart attack and amputation, is it not in everyone’s best interest to invest in their continued well being?

The cost of developing a new medication varies between 500 million and one billion dollars. On average one new drug is developed for every 5000 tested. It takes about ten years to bring a drug to market. Pharmaceutical companies must have a return on their investment but not to abuse their position. Why is there great cost disparity between the United States, Canada and Latin America for the same medications? Should not pricing be standardized worldwide? As much as I support the efforts of our pharmaceutical companies, they must be reasonable. What is an acceptable return on their investment? There has to be a balance between profits and humanitarianism. Despite popular belief, doctors are in cahoots with pharmaceutical companies. Most of us treat patients with medications that we ourselves would use under similar circumstances. Sometimes that involves prescribing a more expensive non-covered medication.

As it stands our healthcare system unsustainable. By 2020, Ontario’s elderly population will increase by 70% while the total population will increase by 25%. We cannot afford to cover the total cost of these medications. We can choose to use less expensive drugs for our health problems or opt to choose newer and perhaps more efficacious treatments but pay for them.

In Quebec, patients have a co-payment plan wherein the government covers the basic cost of medications and the patient pays the difference. A sliding scale based on income could reduce the burden for those less capable of paying for their medications.

The definition of who qualifies for complete coverage will have to change. It is not a palatable choice but we are forced to consider it. The sooner that government admits that it cannot afford the current healthcare system the better. Expecting governments to pay for everything is not an option anymore. It means applying for supplemental medication insurance with government providing coverage for the inexpensive basics. Those that can afford insurance can reduce the burden on the system so we can help the less fortunate. We have to be proactive, responsible and not wait for bureaucrats to fix it.

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© Dr. Barry Dworkin 2003