Pharmacare Flashcards
How much of prescribed drug spending is publicly funded in Saskatchewan?
51% of costs are covered by the public payer in Sask
How much of prescribed drug spending is publicly funded in Canada?
43% of costs are covered by the public payer across Canada
What are the largest categories of payers that provide drug coverage?
- Federal Drug Programs
- Worker Compensation Boards
- Provincial Drug Plans
- Private Insurance
Unfortunately, approximately 20% of Canadians have insufficient or no coverage
What are some federal drug coverage programs?
NIHB
Veteran Affairs
National Defence
RCMP
Citizenship and Immigration
Correctional Services
What is risk rating in terms of accessing private drug coverage?
Common feature of private drug plans
To mitigate costs and secure profits, insurance premiums are based on the history of the individual or group and expected future claims
More likely to get reasonable coverage if you are young and healthy (cream-skimming)
What is community rating in terms of drug coverage?
All individuals can participate regardless of risk or pre-existing conditions with total costs offest by premiums paid by the group
ex. Over 65 and resident of Canada are eligible for Senior’s Drug Plan
Common feature of public plans and most private group plans
What are some critiques of the current system of drug coverage?
- Incomplete coverage (medically necessary, but not publicly funded)
- Inconsistent coverage within and across jurisdictions (only certain groups covered, and amount covered varies by province)
- Coverage/access not based on need (In SK, under 14 and most seniors pay $25 max per drug)
- Uncoordinated due to competing goals of public (maximize coverage) and private plans (maximize profits)
Whare are the three principles of pharmacare (Medicare model)?
Universal (rules out risk-based premiums)
Comprehensive (restrictions based on an evidence-based formulary)
Accessible (available free-of-charge to patients)
Under the Medicare model of pharmacare, what happens if a patient wants a medication not on the formulary?
The drug is likely not useful, or more likely it is excessively expensive and is not a good value based on CEA
Patient can either pay out of pocket or rely on private insurance
What is the basic principle of MedicareLite model of drug coverage?
Universal public plan with patient cost sharing (deductible, co-insurance, copayment, prescription fee)
What is the role of private insurance in a MedicareLite model of drug coverage?
Private insurance allowed for costs not covered by the public plan (financial barriers to access would be explicit to federal policy)
Review slide 19 for cost analysis of Medicare and MedicareLite models of drug coverage compared to status quo
What are some characteristics of the Pan-Canadian option for drug coverage?
Expand public role in current system
Insurance is mandatory, either private or public plan. The choice of the individual is based on features and cost
People can keep their current plan, either public or private
Can switch between public or private, but only at fixed times to prevent double dipping
What are some attractive features of the pan-Canadian option for drug coverage?
Everyone has some level of coverage (incremental improvement)
No radical restructuring of insurance industry and government budget
What are some concerns associated with the pan-Canadian option for drug coverage?
Risk of cream-skimming (only sick and poor in the public plan, see taxpayer costs increase over time)
Public option may be too attractive, lots of people switch to public plans (higher cost to taxpayers)
What are some incentives for patients to use private plans instead of the public plan in the pan-Canadian model of drug coverage?
Tax refund on private insurance costs to encourage private plan use
Perceived or real quality difference (issues of choice, access to medicines with better side effect profiles, and lifestyle medicines)
Which jurisdictions in Canada follow the pan-Canadian model for drug coverage?
Quebec and PEI
What does drug coverage look like for residents of Quebec?
Pan-Canadian model
Public options for senior, low income, and uninsured (monthly premium, deductible, and co-insurance)
Private insurance required for those not covered by a public option (reduced cream-skimming)
What are some concerns with the Quebec drug coverage model?
Private plans are generally inaccessible to low-income pts. and tend to provide better coverage for healthier groups at lower cost
Reduced access to some drugs for some groups unable to get private insurance due to higher private costs
What does drug coverage look like in PEI?
pan-Canadian model
Out-of-pocket costs are capped to $20 per Rx and remainder is covered by the public plan for all uninsured patients under 65 yo
Only pays for generic drugs, leaves out innovator products (no additional coverage for newer and potentially more effective therapies)
Review slide 27 for analysis of Medicare, MedicareLite, and pan-Canadian model for drug coverage
What is the private insurance model for drug coverage?
Compulsory program with private plans rather than a public plan providing coverage for uninsured
Private insurers required to offer all residents a basic prescription drug plan for all drugs listed in provincial formulary
What are some positive qualities of the private insurance for all model?
Reduces the risk of cream-skimming
Potential to lower costs through competition among private insurers
What are the characteristics of the status quo drug coverage plan?
Catastrophic drug coverage for all
When drug costs exceed a certain percentage of income, the federal or provinical governments cover the remainder
ex. Special Support in SK
