Cost-related nonadherence to medications and pharmacare

Canada is the only developed country with a universal healthcare system that does not cover prescription medication outside the hospital setting (Morgan, Martin, Gagnon, Mintzes, Daw & Lexchin, 2015). Canadians pay for their prescription medications either through private insurance programs or out of pocket (O’Grady, n.d.; Statistics Canada, 2016). As well, many private insurance programs pay a fixed price or percentage, which may still leave people with high out-of-pocket costs (Luiza et al., 2015); especially those needing cancer symptom management medications. Some people, including patients with cancer, report not filling prescription medications, not renewing medications or skipping doses to make the prescription last longer due to financial barriers (Angus Reid Institute, 2015; Briesacher, Gurwitz, & Soumerai, 2007). This can be defined as cost-related nonadherence, a common issue in Canada. In fact, one in 10 Canadians experience cost-related non-adherence (Morgan et al., 2015). Nonadherence to prescription medications is related to poorer health outcomes and an increased use of the healthcare system (Morgan & Lee, 2017). This paper will discuss the current policies and programs for pharmacare in Ontario, and propose solutions that oncology nurses can use to address cost-related nonadherence.

POLICIES FOR PHARMACARE

According to the 1985 Canadian Health Act, the federal government publicly funds the provincial and territorial universal health care insurance plans (Government of Canada, 2017; Morgan & Boothe, 2016). Hence, the provincial governments hold the jurisdiction on healthcare cost distribution. Hospital services (i.e., nursing care, diagnostic procedures, surgery, medication, meals), ambulatory services and home care are accessible to all Canadians at no cost (Government of Canada, 2017). However, prescription medications for non-hospitalized patients are not covered by the Canadian universal insurance plan (Statistics Canada, 2016).

The government of Ontario offers publicly funded programs to help those who cannot afford their medications and do not have private health insurance. First, the Ontario Drug Benefit (ODB) program is offered to people: a) 65 years or older in Ontario; b) living in long-term care or a special care home; c) registered in home care, the Ontario Disability Support program, or the Trillium Drug Program; or d) on social assistance (i.e., Ontario Works) (Ontario, 2017). The ODB program helps pay for medications listed on the formulary and some over-the-counter medications. Second, the Trillium Drug Program helps cover medication for people who spend between 3 to 4% after-tax income on prescription drug fees (Ontario, 2016). To qualify, the person must have an Ontario health card and not already be in the ODB program. Third, the Exceptional Access Program helps cover medications not found on the formulary of the ODB program and to receive this exceptional coverage Ontarians must be eligible for the ODB program (Ontario, n.d.). Specific to oncology patients, the pharmaceutical company may provide emergency release for access to some medications.

PROPOSED EVIDENCE-INFORMED SOLUTIONS

Although Ontario offers programs to help pay for prescription medications, not everyone can qualify to have 100% of their out-of-pocket medication costs covered, which leads to financial problems and/or cost-related non-adherence. There are some short-term and long-term solutions to consider. As a short-term solution, a systematic review by Nieuwlaat et al. (2014) of 182 randomized controlled trials suggests that healthcare professionals can support people through education and counselling to promote adherence to medication and improve clinical outcomes. For instance, oncology nurses working with patients can assess the financial needs of the patient. If need is present, oncology nurses can increase their awareness of programs to support their costs and teach the patient about their medication and its importance of use, as prescribed. Further, oncology nurses can assess the need for a medication review to potentially discontinue unnecessary medications or switch to a less costly medication. Finally, oncology nurses can advocate for patients individually and collectively. A fundamental nursing skill is advocacy for the patient (RNAO, 2015).

The long-term solution of most benefit for Canadians is universal prescription medication coverage policy (Morgan & Boothe, 2016). Pharmacare 2020 is a report developed by a team of healthcare professionals, policy-makers, academics and public interest groups that believe that all Canadians deserve prescribed medications at an affordable cost (Morgan et al., 2015). The policy goals are access to necessary prescription medications, fair distribution of costs, safe prescribing, and maximize healthcare dollars. As well, the policy recommends: a) universal coverage of prescription medications at little or no cost; b) financing at a population level; c) establishing a body to manage pharmacare that utilizes evidence in terms of drug coverage and prescribing; and d) establishing publicly accountable management and a single-payer system (Morgan et al., 2015).

BARRIERS TO IMPLEMENTING PHARMACARE

The idea of pharmacare in Canada is not new; it was first recommended in 1964 (Morgan & Boothe, 2016). Pharmacare was not implemented in 1964 for various reasons including being low on the policy agenda and Canada’s slow development of a nationwide health policy. In addition, the influence of politicians’ views, regardless of evidence, related to effectiveness and affordability interfered with implementing pharmacare (Morgan & Boothe, 2016).

MY POSITION

With the Liberal party leading Canada, we must bring pharmacare to the forefront of health policy development. I strongly support Pharmacare 2020 because of its numerous benefits to Canadians and the healthcare system, as a whole. In fact, the 1985 Canadian Health Act states an objective to “protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” (Government of Canada, 2017, c. C-6, s. 4). This objective fits with universal pharmacare. Implementing medication coverage for all Canadians would address the issue of cost-related nonadherance, improve health outcomes, and decrease use and cost to the healthcare system (Morgan & Boothe, 2016).

CONCLUSION

A Canadian universal healthcare system including prescription medication coverage is the solution to cost-related nonadherence to medications. As oncology nurses, we need to advocate for Canadians so that they can access their essential prescription medications without financial barriers and improve their health outcomes. Implementing universal coverage of prescription medications will take time; therefore, the short-term solutions, including collective advocacy for Pharmacare 2020, are necessary now.