Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 





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Now is Not the Time for National Pharmacare

A recent CMAJ article by UBC's Steve Morgan PhD, and Danielle Martin MD and others entitled "Estimated cost of universal public coverage of prescription drugs in Canada" is making the rounds.

The Toronto Star picked this up and is now spreading the word about how affordable a National Pharmacare program could be stating potential savings of $7.3 Billion. This is misleading to say the least.

The abstract from the CMAJ publication includes as background that,

"With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs."

What the authors conveniently leave out is that Canada is the only developed country in the world that has a single payer health care system for medically necessary care. It is no surprise that it does not have universal public drug coverage. It can't even afford to meet demand for what it has already created let alone add other programs. The "game changer" CMAJ study conclusion is flawed on multiple levels.

First, let us acknowledge that despite many tens of billions of additional federal dollars in recent years, timely access to care in Canada is ranked last in comparison to many developed countries. The better performing systems are from countries with Hybrid systems that have universal medical care through a combination of  private and public funding mechanisms and which also have publicly funded pharmacare programs and even dental and eye care. 

Until Canada allows provincial health systems to evolve to hybrid systems using combination funding mechanisms, a National Pharmacare program is unaffordable, not because of the cost of the medication necessarily but because of the burden of single payer health care delivery.

It is not unusual for government programs to exceed their anticipated costs and for any savings promised to be elusive. We can look at the cost of Canada's former Long Gun Registry that was anticipated to cost 2 million and which reached 2 billion. Look at the cost of eHealth in Ontario and Canada to understand how programs that start out with predicted costs begin to balloon and cost many billions more than anticipated without even being completed.

Creating an ongoing National Pharmacare program that creates dependency but that can then have no end is a recipe for creating costs that are not affordable despite what some economists and well meaning physicians say. Once it is created, there can be no going back. Unlike the  Long Gun Registry, closing down a pharmacare program and cutting off medication to patients that have grown to expect it is a very different situation.

Look also to Quebec's experience with its publicly funded pharma program. Despite touting its universal public drug coverage for its citizens, Quebec has robbed its medical system to cover its pharmaceuticals. While the shift is not transparently done, it is at least clear that Quebec has difficulty affording access to quality medical care as its citizens swarm Ontario hospitals and MDs for access to care. There are always trade offs.

Other programs in Quebec were expected to save dollars by creating public coverage but did not. Several years ago a CMAJ article suggested cost savings from a publicly funded In-Vitro Fertilization program and yet cost savings did not materialize. In fact, the popularity of this program soared and costs with it so much so that recently Quebec women were encouraged to go about pregnancy "the natural way" with focus for at least three years!

The accuracy of predictions by the CMAJ and some well-meaning medical doctors is suspect. One Toronto-based MD wrote a few years ago that maintaining Canada's single payer system was no problem, our rising GDP was going to save the day. This is a sober reminder that not all of what we believe is predictable is truly predictable. It is a cautionary example of how a more cautious and thoughtful approach to health care is required so that politicians do not promise what cannot be delivered despite the best of intentions. Creating a dependency on entities that cannot be sustained is irresponsible.

Dr Danielle Martin, one of the authors of the study claims that it is with "certainty" that specific claims of cost savings can be made. I caution Dr Martin that in a world that is increasingly unpredictable, speaking in certainties may sound confident but can also be ultimately misleading.

However, there are many other issues with the report that should be identified.

The authors of this study may defend their report citing that savings can be had in a National Pharmacare program through the following mechanisms:

1. Increased use of Generic medications

2. Lower Generic prices generated through bulk purchasing

3. Lower Brand Name prices through economies of scale in price negotiations.

These premises are flawed.

Consider the drug shortages that have resulted in part from governments favouring generic drugs. The pharmaceutical industry is in upheaval responding to new realities in different ways by altering its assembly lines and looking to rebalance profitability. Only people with little insight into complex systems would believe that prices can be driven down through bulk purchases without some resulting compensatory response.

Look at recent concerns over generic drug manufacturer quality issues to understand where this kind of bulk buying will lead us. A National Pharmacare program that relies on "best prices" has potential to also rely on lower quality products without the choice that patients currently have. It also has the potential to reduce access to brand name medications which in turn creates changes in the pharmaceutical industry that are unpredictable. What effect on production will occur? What shortages will result? It's anybody's guess.

One of the other major flaws with this report is that it uses past information to predict the future. This may seem like a standard approach to health economists or to people who do not study major scientific and medical changes such as Genomics or Epigenetics but anticipating future developments is important to understanding the viability of any potential National Pharmacare program. Although specifics may not be predictable, it is clear to see that on the horizon there are many new life altering and life saving drugs. It is arguable that this is the very reason why a National Pharmacare program is needed but until economic conditions have improved, assuring the viability and sustainability of such a program is dubious at best despite the claims of cost savings in the CMAJ study.

It must be noted that many more expensive medications for rare diseases are in the pharmaceutical pipeline. Expensive immunologics and biologics are being developed and have promise for many people. Adding these to many new and expensive medications for cancer as a chronic disease and medications for age related diseases such as macular degeneration, it will be difficult to avoid the lobbying for coverage of more and more medications.

Once again, we will have created a program that creates dependency on public funding and it will distort access to medication as private options become limited or are passed up by patients. A National Pharmacare program that identifies medications it will include based on cost savings will have repercussions when patients are denied coverage due to cost and who have not purchased private coverage, much the way the public health care system fails patients who were led to depend on it and then who are denied access to the care or procedure based on excessive cost to government.

It is not uncommon for patients who have been denied public coverage of a medication for their cancer to have it funded through their private drug plan. A National Pharmacare program has potential to create an expectation by patients that their pharmaceutical needs will be met. This is as unfair as what has been created in our government funded health care system. Funded care may exist, but it may not exist for you despite the fact that you have paid into the system.

Now is not the time for a National Pharmacare program. The CMAJ study makes assumptions that future pharmaceutical demand can be assessed in a snap shot of today and of previous years. This is simply not the case. The affordability of universal public coverage of prescription drugs is currently not possible despite the best efforts of well-meaning individuals to present it as such. Once there is a Hybrid system for medically necessary care in Canada, this discussion could be revisited.



Reader Comments (467)

In a way now is the ideal time to develop a national pharmacare programme. There is no money and production is off-shore.

I look forward to government coming up with a solution that is not fanciful or magical in nature. I anticipate the same as in auto manufacturing, massive infusion of tax money to subsidize an innately globally uncompetitive industry. Public support of private industry; that's worked so well before.
March 17, 2015 | Unregistered Commentereklimek
"ideal time to develop a national pharmacare programme. There is no money.."
Please explain this logic eklimek.
Please don't tell me you really believe it will "save" billions of dollars...
There are two rationales for saying this.

1. There is an unmet need and if government has a plan, show me.

2. There is no money, and the ideal moment is past. If there is a time, its still now.
March 17, 2015 | Unregistered CommenterEklimek
You are sounding like you have fallen down the rabbit hole...

Sometimes, one just needs to cry.You just need a big cry.

1. Canada does not have a national medicare system. It has 13 (at least) independent health care systems, all providing different services. Many of us have advocated for a national plan. WE DO NOT HAVE ONE. If we wish to have a national plan, do it. For those who advocate to add a national pharma-care program, since we don't have a national health care plan, stop the wasted politics. First, spend your time, advocating for a national health care plan, providing equal services in each province and territory Since that doesn't exist., advocate for for that. Once you obtain that, move ahead. Stop avoiding the issue. Canada does not have a national health care system, with assured care of equitable value, across all the political jurisdictions.
2. Most will argue for fairness and equal access. Stop pretending it exists. It does not. It does not exist, because Canada doe not have a national health care system. If it did, the native Canadians won't have a mortality rate will into the third world statistics. Fix what exists, don't advocate for more inequality.

Many of us are tired. Stop avoiding the truth. Canada does not have a "nationalized" health care system. The ad-vocation for national Pharmacare system is dishonest. We live in a federated system, not a national republic.

3. Show a plan. Each jurisdiction will give up its powers and differ to a national plan, against the existing laws, assuring central purchasing and distribution mandates, that violate provincial and territorial laws, and it will be "cheaper" because the "central" rationing system is better.

Sometimes, the best response to poor policy suggestions is just "how poor can your proposal be" given reality, and the intent of local control.

Like many, even I tire of, if only we centralize more,it will get better.

Funny, the Premier in Ontario, about beer access, is saying we need to centralize less, to provide superior service and better product!
March 17, 2015 | Unregistered CommentermovingforwardOntario

Not news to those providing services.

This appeared in the Canoe chain of newspapers on Feb 26th 2009.
Get angry about health system
March 17, 2015 | Unregistered CommenterEklimek
You point out the hypocrisy of the Pharmacare justifiers mfO.

We can't provide health care equitably or universally in reality and somehow a National Pharmacare program is going to save billions. Just imagine the layers of bureaucracy. Shudder.
March 17, 2015 | Unregistered CommenterMerrilee Fullerton

But the main point is missed. We, as a society, have agreed health care is a provincial/territorial issue. Tha calibre of services is local, not federal.
March 18, 2015 | Unregistered CommentermovingforwardOntario
Great post, Merrilee! Excellent comments, too.

It might be worth acknowledging that we agree on ends, but not means. We all want patients to have access to the highest quality medications at the lowest possible prices. We debate about how to achieve that end. Statists put their faith in government. Past failures just increase their conviction that we still haven't given government enough support to succeed.

We might also discuss the difference between leadership and management. It seems government cannot lead without managing. If they could, we might trust them to help coordinate new offerings.

Thanks again for sharing your passion. You write really well!


March 18, 2015 | Unregistered CommenterShawn Whatley
"Past failures just increase their conviction that we still haven't given government enough support to succeed. "-Shawn Whatley

"Their"? Meaning government?

I do not hold the belief that government needs more MD support. It needs to get out of the way of more significant structural health care innovation.
Gov't can regulate, it can guide , it can fund pilot projects but it needs to stop obstructing access to care that patients want and need and that physicians can safely provide to informed patients.

So I don't quite understand the concept that government needs more support. Or did I misunderstand?
March 18, 2015 | Unregistered CommenterMerrilee Fullerton
To be honest, I don't necessarily want my medications at the lowest possible price . I don't choose a roofer or an electrician based on lowest possible price. I want a quality product for which I can depend on knowing the origin, contents and quality.
I don't want a second rate product from a producer that can't be relied upon to follow quality controls.

Just recently I had to request a brand name allergy eye drop because the generic that was substituted was not nearly as effective. I did not even realize I was using a generic drop until I had to use more if it then I realized it was a generic.

That may not be the result for everyone but it was enough for me to realize "you get what you pay for" in some cases.
March 18, 2015 | Unregistered CommenterMerrilee Fullerton
Thanks for asking for clarification!

I said, "Statists put their faith in government. Past failures just increase their conviction that we still haven't given government enough support to succeed."

I refer to 'statists' throughout. Many people believe that a forced collectivism will eventually work, somewhere, sometime, if only we can find the right leaders. All the collectivist failures throughout history do not count as proof against a failed ideology, for the statist. They insist collectivism/socialism/communism has not succeeded because we have not tried hard enough.

Sorry for not making that clear.

I still stand with my 'highest quality at the lowest price' comment. If you pay low for lower quality, it just supports what I said initially. Paying more for the highest quality that can be purchased more cheaply in the same market is just stupid. Of course, I understand 'quality' to include all descriptors of a product or service, not just efficacy.

Again, great post!


March 18, 2015 | Unregistered CommenterShawn Whatley
Thanks for clarifying and I agree.
There are people in high places who think they know best for everyone else and want to force their belief system on others -- in health care too. That typically leads to problems.
March 18, 2015 | Unregistered CommenterMerrilee Fullerton
I thought you might enjoy this piece on "Clinical Man":

I have decide not to rant re: national pharmacare. A poor philosophy based on no fact., or understanding of legal rules.

Sometimes, false information, and it sources, just need to be pointed out. The world is not flat, and Canad does not have a national system.
March 18, 2015 | Unregistered CommentermovingforwardOntario
Thanks for your perspective +/- rant!
March 18, 2015 | Unregistered CommenterMerrilee Fullerton

Yes, a very well written post.

As you can see, the push for national pharmacare does not come from pharmacists or the CPhA or any provincial pharmacy association. Your concerns are precisely why pharmacists, in general, do not support pharmacare.

We are the closest to the situation, so you would think pharmacists would be advocating for national pharmacare but we know what the layers of bureaucracy are like already, the billing nightmares, the formulary capping, IT and computer issues, not to mention the quality, accessibility and pricing issues of drugs you have identified. Pharmacists suspect utilization will increase and wastage will occur...and what will happen to the current federal pharmacare program? Will employees no longer provide benefits?

The position statement on national pharmacare from CPhA is very guarded
March 18, 2015 | Unregistered CommenterOutPatientPharmD
As the ideologues struggle to preserve the idea that the current system serves patients well, others struggle more with the day to day issues. It is building for yet another "national" review too review how well the last national review did.
March 19, 2015 | Unregistered CommentermovingforwardOntario
"Beyond its dwindling but still politically powerful defenders, no one really still buys the apophthegm about Canada’s single-payer health-care system being superior to any other. But politicians remain too scared by voters or outgunned by lobby groups to tamper with the model.

Yet, were you designing a universal health-care system from scratch, with the twin goals of equity and efficiency in mind, you would never look to Canada."
March 19, 2015 | Unregistered CommenterCanary in a Coal Mine
Let's get it over with.

Nationalize all health care service, place them under a "super board", then put in place a guaranteed income system. All will be fine!
March 19, 2015 | Unregistered CommentermovingforwardOntario
Coming up the balance the LIHN budget time. April 1 will reveal a pretty hefty number of FTE reductions. It seems the current government's plan is to do a quiet 100,000 job reduction. The OHIP reductions is starting with about 10,000 positions not being funded.
March 19, 2015 | Unregistered CommentermovingforwardOntario
The current Globe poll shows that 76% of readers support a national drug plan.

The CBC tonight is pushing hard with Danielle Martin for a national plan.

Who is going to pay?
March 19, 2015 | Unregistered CommenterCanary in a Coal Mine
I didn't see the panel.
It would be the usual CBC flavours:
Dr Martin, a St Mike's or other Toronto based researcher, the Union guy and one other miscellaneous filler.., and Wendy Mesley (sp?)

Of course the public wants more fee stuff! Why wouldn't they? It falls from the sky.
March 19, 2015 | Unregistered Commenterrealist2
Central knows it has unlimited taxation authority. Payment is not an issue, assuning the provincial gdp grows enough. The last 8 years have been discouraging. An Ontario plan might succeed but in the end widens inequity. However it gets votes!
March 20, 2015 | Unregistered CommentermovingforwardOntario
If they pay as they can, they are completely unstoppable.
March 20, 2015 | Unregistered CommentermovingforwardOntario
Infrastructure, guidelines, and rationing

As we head for more rationing, more guideline care, and shifting inequality, we should begin adjusting the liability response, as has been mentioned many times by DrK. Until nor, errors in diagnosis have hit the provider. We need to move to "no fault" position.

You get seen, the rules established by central are followed, but you have disease but failed to get diagnosed by the guidelines and the rationing. Instead of it going through the courts, you should be compensated by the state directly through a compensation tribunal. Sine, as we build the new pooled state system, we should beginning "socializing" the risk back to the state, and off the compliant providers.

All we are doing are rebuilding the inequality system. Now if you get hurt, we acknowledge it is the systems design that caused the issue, and the system directly compensates you.

Taxes will be going up, as the new system gets built.
March 20, 2015 | Unregistered CommentermovingforwardOntario
Would a " no fault" system eradicate the need for CMPA....again a saving for the government?
March 20, 2015 | Unregistered CommenterAndris
CMPA would be unneeded to solve guideline or rationed issues. If followingpublished standards, any misses would be covered by tribunal. CMPA would remain for Issues of negligence.
March 20, 2015 | Unregistered CommentermovingforwardOntario

I think you suggest the bar set by "guidelines" is to be used as a minimum or floor from which to judge practice.

As currently constituted recommendations represent an ideal or target to be achieved. The bar moves as new information is revealed and is influenced by the desire to improve outcome. It is not a designated standard.

Cases are still assessed as what is expected from the reasonable practitioner in similar circumstances.
March 20, 2015 | Unregistered Commentereklimek

You argue using the old "do the best you can" standard. It is changing to do what the state has approved. Within the decade, most providers will shift to, we did what we were told to do, with the rationed funds.

The judicial system will be legislatively controlled, to recognize finincial restrictions in a centrally driven system.
March 20, 2015 | Unregistered CommentermovingforwardOntario
I enjoyed the 'Clinical Man' post you shared above. Thanks!
March 20, 2015 | Unregistered CommenterShawn Whatley
As we go at it:

Is it that we have a shortage of resources being spent in health care in Ontario, or are we misspending it?

If it is a shortage of resources, add more money.

If it is misspending of the public pool, fix it.

Central has established, by reducing the money flowing in, the issue is misspending.

What is the real problem?
March 21, 2015 | Unregistered CommentermovingforwardOntario
Good questions Mfo.

So where is the data showing the age-adjusted health care spending per capita over the last two decades. My guess is were spending the same or slightly more.

And individual tax as a percentage of income? Up?

And personal tax as percentage of total tax revenues. Up?

And corporate tax as percentage of tax revenues. Down?

With regards to health care specifically we see the pie graphs with physician incomes, hospitals, drugs, but rarely do we see the cost spent on administration of the system. I suspect that is one of the real problems,...layers and layers of bureaucrats all with DB pensions drawing on the shrinking pool of revenues.

On the CBC last night was an interview with the director of the film "The Price We Pay" which portrays the problem as offshoring of taxes by large corporations not paying their fair share of taxes. If this is a real problem then let's fix that too.

The irony of the one percent claim is that pair up any of the following two professions in Ontario physician, teacher, firefighter, police officer, nurse practitioner, hydro worker, hospital administrator, etc. and you will have a family in the top one percent.
March 21, 2015 | Unregistered CommenterCanary in a Coal Mine

It is all about obtaining power to control the money. We are socializing the power base, and actually creating more inequality as we learn, all groups misuse power. We have created legislation to minimize that, but now are seeing legislation create to "abuse" groups.
March 21, 2015 | Unregistered CommentermovingforwardOntario
Mfo we saw what happened with the OPP interfering in the last election. Sure it may have been the corrupt OPPA but I think their tactics foreshadow of what is to come in the future. Firefighters and police campaigning door to door for the incumbent party in order to ensure their lifestyles are maintained.

We have so many workers now dependent on the government for their livelihoods that the chance of any opposition party winning power is becoming more and more remote. With such a large proportion of the population dependent on rich public sector jobs who is going to vote for a party that promises to cut public sector jobs even if that is one of the solutions required to revitalize the province for future generations?
March 21, 2015 | Unregistered CommenterCanary in a Coal Mine

That's how politics works. You find the right mixture of silo groups you can pander to, and feed them stuff they want. It works well in growing economies. Ours hasn't grown enough in the last 9 years, which why the first two easy groups got targeted, the globally wealthy got their income surtax, and next the doctors took their first hit. Next is likely the Universities and their very generous benefits . If the economy doesn't pick up, over the federal dump of money doesn't arrive, more groups will get targeted. Soon expect to see "means" testing of the well off, for surcharges to use public facilities.

This is not complex to figure out, it is how all societies function.There is a lot of "wealth" in the boomers retiring that can be obtained. This is about power and wealth transfer to maintain power, so the system doesn't change for those who have the power. It is not about healthcare.
March 21, 2015 | Unregistered CommentermovingforwardOntario

Like many, I avoid social media as much as I can.mI'm most impressed at how quickly your comments about profit, are attacked by those who believe single payor health care is free and good because there is no profit. We hadthat discussion here years ago. Private systems take capital and redistribute that capital investment through dividends to all those who invest. Anyone with resources can invest. Public systems take capital from all, and return that investment by access to wanted services, and also restricted profit for those public members who are deemed members, excluding all others from the restricted benefits.

Clearly what is going on, is just an ideological struggle to restrict resources to those in the system. It does want to make you cry. The absence of economics in the real world, is frightening. Better hope the GDP picks up or some of these folks may find out about "greek" austerity pain.
March 21, 2015 | Unregistered CommentermovingforwardOntario

My sympathies to the twitter attack you are taking. It seems you've hit some ideological button arousing all those with an utopian agenda, based on they being in control.
March 21, 2015 | Unregistered CommentermovingforwardOntario
The likely upcoming groups for more tax revenue:

1. Up the surtax on family incomes greater than 150,000.00
2. Means testing retirees to access public services: More that $100,000 in retirement and you pay an access fee, for all public services.
3. Provincialize the public servant defined benefits pension plan, and the upcoming ORSP, and borrow against those principal assets.There are lots of assets around. Central merely has to get at them.
March 22, 2015 | Unregistered CommentermovingforwardOntario
Thanks Canary...I haven't bought today's NYTimes as yet....but I will spread its contents.

I have always stated that paper based practices will become more valued by the public even as the powers that be try to impose EMR and eradicate we supposed paper utilizing Luddites .

Denmark has all the EMR that the powers that be dream of,,,,but Danish outcomes are not superior to Canada's.
March 22, 2015 | Unregistered CommenterAndris
So I hear Bell's X Wave is being shut down. Bell purchased X Wave EMR from Bell Alliant in 2010 for forty million dollars in order to scoop all the government cash floating about the system for EMR subsidies. They sold a second rate EMR to many physicians in this province who are now required to find a new vendor and pay a fee to have the information transferred.

Just wait until the monthly service fee subsidies come to an end this ?year and many of these two-bit EMR software companies will close up shop leaving more docs high and dry. At least then we will find out the true cost of an EMR purchase and ongoing service fees.

A year after the EMR subsidies in Ontario end will be the time to start looking at which systems one might consider for implementation. We'll be sure to consider a system that the government will not be able to snoop into.
March 22, 2015 | Unregistered CommenterCanary in a Coal Mine reminds me of a Warren Buffet's quote " you don't know who is swimming naked until the tide goes out".

Happily I'm a landlubber where EMR is concerned.
March 22, 2015 | Unregistered CommenterAndris
Dementia is horrifying and on the rise ....but not sexy.

Looking after demented parents is an increasing struggle for our generation ...the CCAC is inadequate and seems to fall apart on weekends when the ' regulars' are off...private care workers have to be increadingly hired ( and privately paid for) ....God knows how those without children and famillies cope, their dementia going unrecognized for far longer than those with children.
March 22, 2015 | Unregistered CommenterAndris

mfO, thanks for the sympathy although it is not necessary.
March 22, 2015 | Unregistered CommenterMerrilee Fullerton
One is judged by one's drives them nuts when one responds to them courteously.
March 22, 2015 | Unregistered CommenterAndris

It is interesting to watch the ideology. Certainly facts, and understanding of economies, doesn't appear part of the agendas.
March 22, 2015 | Unregistered CommentermovingforwardOntario
Looks like birds of a feather flock together,...CDM, RNAO, and OPSEU.

I wonder if Grinspun's 5 year stint in the USA as a nurse was influential in her rabid opposition to developing a hybrid medical system in Canada something every other country in the world seems to have permitted without inducing an existential crisis?
March 22, 2015 | Unregistered CommenterCanary in a Coal Mine

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