Doctors have no idea how much drugs cost — a Toronto physician wants to change that
|Toronto Star 26 Mar 2018 at 08:25|
When Shelley Wigham suffered a heart attack last summer, she was prescribed various cardiac medications. But the 64-year-old widow never took them.
She doesn’t have a drug plan, was already paying $125 a month for meds to treat depression and high blood pressure, and, despite juggling two jobs, couldn’t afford to tack $300 onto her already pricey pharmacy bill.
“I was a mess,” recalls Wigham, who did not tell anyone money was tight. “I was embarrassed. It’s a dirty little secret. Nobody wants to admit they can’t afford their drugs.”
She hoped the heart attack was a one-off. It wasn’t.
Last month, Wigham had another heart attack. At the hospital, she told doctors she had not taken the meds because she couldn’t afford them. Three days later, she was discharged with a prescription for the same costly drugs.
“Doctors don’t have access to drug costs, so they were disempowered to talk to her,” says her family physician, Dr. Iris Gorfinkel. “They’re managing a heart attack, but not managing the primary problem, which is that she can’t afford the drugs.”
That’s why Gorfinkel is spearheading an initiative urging the province to mandate drug cost transparency — having prices pop up in the electronic medical record (EMR), so when doctors and nurse practitioners are writing prescriptions, they can discuss affordability with patients.
Right now, when doctors write prescriptions, they see the name of the drug, but not the price. This means patients may be prescribed more expensive meds when there are equally effective and cheaper alternatives. As a result, people can experience sticker shock at the pharmacy, leading some to forgo their meds and become sicker, contributing to downstream health-care costs.
Gorfinkel’s initiative is gaining traction. The Ontario Medical Association , representing 33,000 practising physicians, the , representing 3,300 nurse practitioners, and the Ontario Pharmacists Association , representing more than 10,000 pharmacists, pharmacy students and pharmacy technicians, support the idea. And an online petition has more than 5,400 signatures.
She’s met with government officials who appear to support the idea, yet Gorfinkel says there’s “tremendous inertia” at the health ministry to implement it.
When reached by the Star, the says it is considering the option. Currently, no jurisdiction in Canada has real-time access to drug costs in electronic form.
“The province is exploring and prioritizing a large number of potential enhancements to provincial standards for Electronic Medical Records, in addition to the inclusion of drug pricing information,” Laura Gallant, press secretary for Health Minister Dr. Helena Jaczek, said in an email. “Other opportunities include integration with provincial immunization systems, electronic consultation and referral systems, and home and community care information, and the Ministry is working with its partners to develop a long-term approach to sequence these enhancements.”
But proponents of the plan say now is the time to act, as EMR systems currently are being updated and better integrated into the health-care system.
The impact would be huge, health critic France Gélinas says. The NDP MPP for Nickel Belt says drug cost transparency is “crucial” for physicians and long overdue.
“Does the technology exist? Absolutely. Will it save the health-care system money? Yes, absolutely.
“Is this something that has been talked about that has the potential to be a game-changer? Yes, absolutely.”
Last month, after Gorfinkel received Wigham’s discharge summary from the hospital, she spent two hours on the phone with a pharmacist figuring out drug prices and which of Wigham’s seven medications — prescribed by herself, a psychiatrist and a cardiologist — could be switched for cheaper versions. Gorfinkel was shocked to discover she had prescribed a brand-name drug for high blood pressure, that costs $170 for a three-month supply, when a generic version is $35. Gorfinkel shakes her head, saying she failed Wigham.
“If I give a prescription, I owe that patient an explanation of how much a drug costs,” she says. “A standard of care is not actually met if I’m not making sure that the patient can afford that drug.”
How much patients pay can vary by the pharmacy, but Gorfinkel wants doctors to see the Ontario Drug Benefit (ODB) formulary price. That’s how much the province pays for prescription drugs for those covered by the ODB program — this includes people older than 65, younger than 25 and those receiving financial assistance through Ontario Works and Ontario Disability Support Program. Because the province buys in bulk, it pays less for meds than private insurers and those without coverage. But at least it gives doctors a ballpark figure.
In Wigham’s case, Gorfinkel was able to get her patient’s monthly costs for medication down to $200, which she’s now able to manage thanks to a loan from a friend.
The ODB prices are available on a government website, but the site is “very cumbersome,” Gorfinkel says from her office at Yonge St. and Davisville Ave. But in a busy practice, doctors don’t have time to navigate an online database or call up a pharmacist to do price checks, she says. Some doctors and nurse practitioners may know approximate prices of frequently prescribed drugs, but there are about 10,000 drugs on the market.
“Right now, we don’t know cost; we don’t even know relative cost. There’s a complete lack of knowledge … That’s frightening.”
She recalls once prescribing a patient a brand-name anti-depressant, which cost about $280 for a three-month supply. He didn’t have a drug plan and skipped the meds, which exacerbated his depression. He eventually confided in Gorfinkel that cost was a concern and was switched to a different generic drug that cost about $50.
Another patient, a 26-year-old university student, went to Gorfinkel seeking a birth-control pill and was prescribed a brand-name drug. She had no insurance, and when she got to the pharmacy, she learned a three-month supply was about $90, which was too costly, so she didn’t get it. The woman became pregnant and had an abortion.
Ending up with an unwanted pregnancy resulted in numerous costs to the health-care system. There were visits to her family doctor, blood work, counselling, and the abortion. And, says Gorfinkel, “the emotional costs are tremendous. I don’t think a person can put a price on that.”
After that ordeal, Gorfinkel prescribed a different generic birth-control pill that cost $30.
Hoda Mankal, a nurse practitioner and spokesperson for the Nurse Practitioners’ Association of Ontario, supports the initiative. She works at a community health centre in Ottawa where many patients have no insurance.
“Too often, we hear of patients splitting pills or taking a dose every other day trying to ration the medication they have, or maybe forfeiting the purchase of something else — a household item or food — to be able to afford the medication,” Mankal says.
A recent study found for many Canadians, cost is a barrier to obtaining prescription medicines. The study published in the Canadian Medical Association Journal found that about 1.4 million Canadians in 2016 cut spending in other areas — such as food, heat, and transportation — to afford their drugs. About 1.7 million Canadians didn’t fill prescriptions because they couldn’t afford them. As a result of that, 303,000 people reported seeing their family doctor, 93,000 ended up in emergency, and 26,000 were admitted to hospital.
According to provincial legislation, pharmacists are supposed to replace a brand-name prescription with a generic version of the exact same product, if it exists —unless the patient, prescribing doctor or nurse practitioner, or private drug plan specifies otherwise. Pharmacists can’t substitute one drug for another that has a different molecular makeup.
Allan Malek, the executive vice president and chief pharmacy officer for the Ontario Pharmacists Association, says the lack of awareness of drug costs, among prescribers and patients, is “an age-old issue.”
“Pharmacists would love to get out of that conversation of price and (drug plan) coverage and what’s cheaper,” he said. “We spend more time on that than we do on talking about the actual medication and how it works and why it’s important.”
Gorfinkel says making drug costs transparent extends beyond generic versus trade medications. It’s about trying to choose the best affordable option from several choices within a drug category.
Helen Stevenson agrees. The former assistant deputy minister of health who is now the CEO of the Reformulary Group — it works with companies to ensure drug plan sustainability — applauds the move and wants it to go even further by updating EMR systems to include the price for comparable drugs as well.
Stevenson says having drug prices pop up in the EMR for a particular drug isn’t very useful if a doctor doesn’t know what other comparable drugs treat the same condition, she says. For example, there are many sleeping pills on the market, which all pretty much work the same way. The approximate monthly cost for generic doxepin is $7, for generic zopiclone is $14, and brand name Silenor is $36, she says. If a doctor looked up the price for the $14 drug, they might not even know that there is another that costs half.
“If you could have both, that would be the magic, the golden ticket.”
So, what’s the holdup? Health critic Gélinas believes a big part of it is money. In a cash-strapped health-care system, where hospitals are grappling with flatline budgets, she says investing in an outdated information-technology system has been put on the back burner.
But implementing prices into electronic records is pretty straightforward from a technical perspective, according to OntarioMD , a provincial agency that manages and certifies EMRs. And, the timing is right. That’s because OntarioMD currently is integrating into EMR systems something called the digital health drug repository, which will list a patient’s medical history, including all the drugs taken.
Yet, it can’t implement Gorfinkel’s proposal without a green light from the ministry.
“Making the formulary available in conjunction seems like a logical parallel, or next step,” says Sarah Hutchison, the CEO of OntarioMD, adding she doesn’t think it would be a costly undertaking. “The timing is really good and the opportunity is right in front of us.”