Putting an end to the open bar

The federal election campaign demonstrates once more how the concept of a public drug plan is gaining ground. It has reached election issue status. Its progress in the last few years is such that opponents now prefer influencing the system to be implemented by the government rather than suggest that we should maintain the status quo.

Last June, the Canadian provinces and territories ratcheted up the pressure on the federal government to facilitate the implementation of a health insurance aimed at increasing drug safety and better controlling costs. Favourable editorials and articles have started to appear in the last year in many important newspapers.

Among those who oppose government intervention, the Institut économique de Montréal (IEDM) published this month an economic study designed to warn against universal coverage. Its author, Yanick Labrie, states that in countries with a universal public plan patients pay a greater share of the spending out-of-pocket and claims that controls for drug spending “probably have a role to play in the lower survival rates for various cancers in the United Kingdom” (p. 2).

These arguments simply do not hold water. Canada has among the highest per capita drug costs in the world (costs in the US are even worse if you want a silver lining). The proportion of out-of-pocket spending by patients is higher in countries with universal public plans not because they pay more out-of-pocket, but because total costs are lower. For instance, Danes pay out-of-pocket an average 35% of $289 in total annual costs (i.e. $101) whereas Canadians pay 26% out of an annual total of $692 (i.e. $180). Nonetheless, Canadians are better off because they pay a smaller share (26% vs. 35%) according to the IEDM’s logic.

The issue of cancer remission rates is extremely complex and cannot support the idea of the Canadian plan’s superior nature. Variations in remission rates do not depend on the level of cancer drug coverage, but mainly on the various countries’ screening programs. A higher remission rate is not necessarily a good thing. Large-scale screening does detect more cancers, leading to more cancers being treated, but many forms of cancer develop very slowly and do not affect patients’ quality of life (unless they reach 130 years of age). In fact, more and more, researchers are finding that some large screening campaigns have done more harm than good. Of course, they increase remission rates by treating cancers that would not have been damaging to the detriment of patients who experience, often unnecessarily, the stress and side effects related to these treatments.

Emphasizing remission rates is therefore problematic. Let’s mention that since 2010, the UK (the IEDM’s example) has created a fund to reimburse cancer drugs without evaluating whether or not their price is justified by their therapeutic value. Following the IEDM’s logic, we could expect a stark increase in remission rates since 2010, but it was not the case.

The additional $2 billion in spending to increase access to drugs are considered to have been a huge waste for patients (and an equally huge profit for pharmaceuticals). The fiasco lead to a working group being set up to improve outcomes in the fight against cancer in the UK. It came up with a series of recommendations, ranging from prevention to renewing radiology equipment, but access to drug therapies was not identified as being part of the problem.

In any case, using the example of cancer remissions in the UK to boast the virtues of the Canadian plan participates in a twisted and irresponsible rationale. Mr. Laurie is giving the impression that greater prescription drug consumption is necessarily a good thing and that Canada should probably think of itself as a champion because, here, per capita drug spending is at its highest.

However, more pills do not mean better health, and it could even often mean the reverse. Indeed, doctors are worried about increasing overdiagnosis and overtreatment. Not only is excessive medication intake a problem in and of itself, but it currently means, at the other end of the spectrum, sacrificing preventive policies and chiefly global public health impact assessments, the poor cousin within the current healthcare system.

The Canadian system has the advantage of covering everyone without exception, but it works just like an open bar and turned out to be so expensive in Quebec that its sustainability is in jeopardy. The Quebec model, so profitable to private insurers, is no example and it should also change. Therefore, that which IEDM calls “rationing” in its last publication is first and foremost a policy designed to put an end to waste. It will make it possible to better choose and use prescription drugs at a time when it has become urgent to put some order into the plan.

Guillaume Hébert is a researcher with IRIS, a Montreal-based progressive think tank.

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