IN BRIEF
Outdated criteria for drug plan reimbursement obstruct evidence-based care hy is clinical practice lagging evidence for using cost-effective medications in Canada? Drug reimbursement decisions are not routinely updated to reflect the latest evidence, which can be bad news for patients, write the authors of an editorial in CMAJ (Canadian Medical Association Journal). “This leads some physicians to game the system to provide the best and safest treatment for their patients by saying their patients meet reimbursement criteria when they do not,” write Drs. Andreas Laupacis, senior deputy editor, CMAJ, and Ahmed Bayoumi, Centre for Urban
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Health Solutions, Unity Health Toronto. Two related research articles looking at the use of new direct oral anticoagulants (DOACs) help to emphasize flaws in the approach taken to a funding decision taken by Canada’s public drug plans. The studies found that DOACs are effective drugs with a lower risk of bleeding than warfarin, an older anticoagulant, for certain groups, and one study showed that DOACs are also more cost-effective. Yet drug plans in Canada restrict prescribing of DOACs because decisions aren’t regularly updated. However, other countries, such as the United Kingdom, have updated
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Spending more on health care But there is also a deeper reason. The provinces, and the federal government, simply may not have the data to evaluate their health care spending rigorously, even if they even wanted to. If they do have the data, they certainly keep their evaluations hidden. This is not by accident. The savvier leaders among the key stakeholders have no interest in having such data exist, because they may fear it will lead to results that could embarrass them and turn public opinion against them, possibly in ways that would reduce their incomes or autonomy. For decades, some of the most important data showing health care waste and inefficiency has looked at variations among small geographic areas – “postal code medicine.” These variations, which are the continuing subject of the Dartmouth Health Atlas, consistently show that while some parts of the U.S. spend two to three times as much on health care as others, key health indicators, such as primary care for diabetic patients and post-surgery complications, are not correlated. One recent study by leading U.S. health economists concluded that
these variations were not due to differences in patients’ needs; instead, they were most closely associated with physicians’ beliefs that were “unsupported by clinical evidence.” The specific examples they studied suggested that 12 to 35 per cent of this health care spending was unwarranted. Canadians are rightly proud that our health care sector is nowhere near as expensive or inequitable as that of the U.S. But we are not immune. One decade-old study looked at heart attack treatments in Canada and found a threefold difference across health regions with no obvious difference in post-surgical 30-day mortality. Sadly, no one has updated or extended this study, in part because the data needed are simply unavailable. We could get better value for our health care dollars if we knew more. Before the federal government signs over any more multibillion-dollar cheques to the provinces with no strings attached, Canadians deserve to know why the additional investment is needed in the first place, how it will be spent – and whether, after all this time, H our money has been well used. ■
Michael Wolfson, PhD, is a former assistant chief statistician at Statistics Canada and a member of the Centre for Health Law, Policy and Ethics at the University of Ottawa. 6 HOSPITAL NEWS NOVEMBER 2021
their recommendations in line with new evidence. “When reimbursement criteria for drugs are outdated, nobody benefits,” write the authors. “Physicians are forced into challenging choices between advocating for patients or upholding professional standards for honesty. Patients suffer because physicians who follow outdated government directives may offer suboptimal care. Health systems are seen as indifferent to high-quality evidence when making policy decisions and tolerating gaming of the system.” The editorial writers suggest several changes to allow more updated drug formularies in Canada. These could
include an automatic time for review or to update with new evidence; a process to allow groups to request a review; and regular audits by public drug plans to identify patterns showing large-scale nonadherence to restricted prescribing criteria to trigger a review. “Regular review of drugs will increase the workload and resource requirements of drug reimbursement committees. However, a regularly updated formulary is essential to having a trusted, responsive and efficient public drug reimbursement plan,” H they conclude. ■ *Outdated criteria for drug plan reimbursement obstruct evidence-based care” was published October 12, 2021.
Prescription for Northern Ontario rescription for Northern Ontario, released by the OMA, is an ambitious action plan containing 12 recommendations to address the unique health-care challenges in the north, including: • The chronic shortage of doctors, especially in specialities such as family medicine, emergency medicine and anesthesia • The profound and disproportionate impact of the opioid crisis and mental health issues, including insufficient numbers of mental health and addiction care providers, especially those who help children • The lack of high-speed internet and unreliable connectivity, which limits the availability of high-quality virtual health care • Unsafe drinking water and inadequate health-care facilities and resources in Indigenous communities Prescription for Northern Ontario is part of a larger master plan, Prescription for Ontario: Doctors’ 5-Point Plan for Better Health Care, which provides 75 provincewide recommendations for implementation over the next four years. Both road maps are the result of the largest consultation in
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the OMA’s 140-year history, which involved 110 stakeholder groups, 1,600 physicians and almost 8,000 Ontarians from 600 communities. “The OMA recognizes that the northern disparities in health care have existed for many years but the COVID-19 pandemic has made these gaps more visible and the need for solutions more urgent,” OMA President Dr. Adam Kassam said at a news conference today at the Northern Ontario School of Medicine. Northern Ontario spans almost 90 per cent of the province’s geography but had only six per cent of the population. Its distance, weather and infrastructure including reliable internet present barriers to health-care services. The health-care needs of northern Ontario are growing. A greater proportion of its population is over 65. There are more complex chronic illnesses and mental health and addictions than in other regions, and the average life expectancy is 2.5 years lower than in the rest of the province. At the same time, the number of doctors dropped from 1,715 in 2018 to 1,700 in 2019. Almost 100 generalist family physicians are needed in northern Ontario’s H rural communities. ■ www.hospitalnews.com
