With the call for a national, universal pharmacare plan getting louder and louder, the pressure on the Federal Government and the provinces to take action on the unfinished business of medicare has been too powerful to ignore. But it is unlikely that actual national pharmacare will come along anytime soon – especially if it requires the Federal Government to significantly lead and finance the endeavor.
While the Federal government has carefully avoided committing to leading or funding the development of a national/universal drug plan, the Federal Health Minister’s mandate letter did include a directive to engage provinces and territories to “….Improve access to necessary prescription medications. This will include joining with provincial and territorial governments to buy drugs in bulk, reducing the cost Canadian governments pay for these drugs, making them more affordable for Canadians, and exploring the need for a national formulary…”
Building the Foundations for Universal Pharmacare?
No surprise then that Minister Philpott recently announced initiatives focused on reducing drug prices. Her department is now seeking to enhance the capacity of the pan-Canadian Pharmaceutical Alliance (pCPA) to optimize bulk purchasing, and is proposing regulatory changes to the Patented Medicines Price Review Board (PMPRB) that could see modifications to the list of comparator countries against which PMPRB sets prices. The Minister has also indicated her intention to explore a national formulary. In her remarks to the Economic Club of Canada on May 16, 2017 Minister Philpott said “The development of a common formulary is a critical building block to improve equitable access, and would also improve our ability to negotiate better prices for Canadians.” She went on to discuss this common formulary saying “We could start with a smaller list of essential medicines that make up the majority of those in common use.”
What is clear now is that the Minister, when talking about a national formulary, is talking about an essential medicines list (EML) which in this case is conceived to be a limited, core list of drugs provided to patients free regardless of age or income. Her idea of an EML appears focused on common drugs used to treat chronic conditions. While the development of an EML seems to be her favoured approach to expanding universal pharmacare, it remains unclear if funding assistance for the provinces and territories is contemplated in this scheme.
The growing interest in an Essential Medicines List
Minister Philpott is not the only one talking about an Essential Medicines List. In February 2017, Dr. Nav Persaud, a family physician at St. Michael's Hospital in Toronto, and other clinicians and researchers published in CMAJ Open the results of their research to create a preliminary essential medicines list for Canada. Their work resulted in a proposed essential medicines list of 125 drugs. A few years ago Dr. Danielle Martin, a high-profile champion of national pharmacare, also suggested that pharmacare expansion could start with an even shorter essential medicines list of 20 generic drugs that are proven to help manage chronic disease. The Ontario NDP have also announced in their Pharmacare for Everyone platform that they would begin expansion of universal pharmacare through the introduction of an essential medicines list - initially covering 125 drugs.
The motivation for the development of an essential medicines list is varied. Some, like Dr. Persaud, are looking to make it easier for clinicians to prescribe the most effective, safe and appropriate medications for their patients. Dr. Martin appears to be approaching it from a societal perspective, with the goal of improving the health of the most people in the most affordable way possible. Minister Philpott, as well as the Ontario NDP, want to improve equitable access to medicines while increasing government’s negotiating power to reduce the cost of drugs.
Why have cancer medications been deemed “non Essential” by omission?
Regardless of the different motivations, what appears to be missing from all these EML models is any mention of cancer drugs. Dr. Persaud’s proposed list of 125 drugs was largely adapted from the 2013 World Health Organization (WHO) list of essential medicines. But as the focus of Dr. Persaud’s work was on drugs used in family practice, cancer drugs were excluded. Importantly, the original WHO EML of 448 items does include cancer drugs. Some are intravenous (IV) drugs, but many are also capsules or tablets. In Canada, IV drugs need not be on any proposed essential medicines list (they are already provided free because they are administered in a hospital setting), but that still leaves the take-home anti-cancer drugs. With approximately 50% of cancer drugs now being in a take-home format, an essential medicines list that does not include any take-home cancer drugs is not an essential medicines list.
As our elected leaders tackle the challenge of improving pharmacare, an understanding of societal priorities is necessary. In February 2016, the CanCertainty Coalition conducted a survey of 1,155 randomly selected Canadian residents to study attitudes towards government spending and healthcare priorities. Public priorities were clear. From a randomized list that included: education, transportation, health care, social services, the environment and “other”, health care was identified by the majority of survey participants as the most important government priority. Digging deeper into public priorities, when asked to select the most important healthcare priority from a randomized list that included: heart disease, cancer, mental health, diabetes and “other”, cancer was identified as the most important overall spending priority by the majority of survey participants. Cancer was also identified most often as the disease that presents the greatest risk to the financial future of patients and their families.
Around the world cancer is recognized as a priority health issue due to the high burden it poses in terms of loss of life, loss of productivity due to illness, and costs to individuals and healthcare systems. In Canada, this has compelled some provinces to ensure that fair and equitable access to cancer drugs is an aligned priority. As noted in the May 2014 Cancer Care Ontario Think Tank Report on Take‐Home Cancer Therapies: "In the western provinces, government recognition of the specialized clinical and administrative support requirements essential to safe, high‐quality care has led to an explicit acknowledgement that “cancer is different.” From this acknowledgment has flowed the decision to provide and fund take‐home cancer medications in a manner consistent with hospital‐administered IV treatments."While western provinces have long recognized that cancer treatments taken at home are essential components of cancer care, successive governments in Ontario and Atlantic Canada have failed to address the matters of urgency, equity and fairness in the funding and delivery of Take‐Home Cancer Therapies (THCTs).
In the mission to improve pharmacare, cancer drugs cannot be ignored
Cancer medications are essential medications. Provincial governments in Ontario and Atlantic Canada are well aware of the need to update their fragmented cancer care systems to include THCTs but have yet to take determined action to fix the problems. This must change. Ignoring the growing cracks in cancer drug funding systems across Canada will only enshrine unfairness and un-universality for a disease that will affect 50% of Canadians in our lifetimes.
With the provinces and the Federal Government active on various fronts to improve pharmacare, cancer drugs cannot be overlooked. If governments are going to be advancing a common national formulary in the shape of an Essential Medicines List, take-home cancer drugs need to be included. Better yet, as a prerequisite to the introduction of an EML, the remaining five provinces that do not yet fund take-home cancer drugs for all populations should be required to do so as an immediate priority.
Robert Bick is a health policy consultant specializing in drug access and reimbursement policy in Canada. He serves on the Board of Directors of Kidney Cancer Canada and is a co-Lead of the CanCertainty Coalition campaign.