Pharmacare Flashcards
Unlike most hospitals and physician services, prescription drugs are not included in Medicare. What is the exception?
Hospital-based medications
Most Canadians have some form of coverage through a variety of payers. Such as? (4)
- Federal Drug Programs (Public)
- Non-Insured Health Benefits (NIHB), Veteran Affairs, National Defense, RCMP, Citizenship and Immigration, and Correctional Services - Worker Compensation Boards (Public)
- Provincial Drug Plans (Public)
- Private Insurance
- For-profit and Not-for-profit
Approximately __% of Canadians have insufficient or no drug coverage
20
“In the past five years, was there a time you decided not to fill a prescription b/c of the cost?” What to know about this?
The lower your income and education level, the more likely to answer yes to the question. A lot of people with higher income tend to have better coverage too.
What is “risk/experience rating” in terms of private drug coverage? (2)
- 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. - Insurers are incentivized to only cover those least likely to access insurance benefits:
- Risk selection (i.e. cream-skimming)
Explain what’s going on with pre-existing conditions and accessing private drug coverage
Common feature of many private drug plans.
Decline coverage for targeted conditions to avoid costs associated with high-risk groups and individuals or charge prohibitively high premium costs that effectively exclude people with the condition
What is “community rating” in terms of private drug coverage? (2)
- All individuals can participate regardless of risk or pre-existing conditions with total costs offset by premiums paid by the group.
- Assuming people meet other criteria such as age or group affiliation. - Common feature of public plans (also seen with most private group plans) in Canada.
- The healthy and wealthy subsidize the sick and the poor by paying a higher proportion of plan costs while receiving a lower proportion of benefits.
What are some critiques of the current drug coverage system? (4)
- Incomplete coverage
- Medically necessary but not publicly funded - Inconsistent coverage within and across jurisdictions
- Only certain groups covered
- Groups/amount of coverage varies across provinces - Coverage/access not based on need
- In SK, under 14 and most seniors pay $25 maximum - Uncoordinated due to competing goals of public and private plans
- Maximize coverage vs. maximize profits
What are 3 funding options for drug coverage?
- Medicare model (or something like it)
- Cover all Canadians and replace all existing government and private insurance plans - Expand public payer role in current system
- Cover those Canadians not currently covered through an existing government or private plan. - Status quo
- Ensure all Canadians are adequately covered against extreme financial risk (catastrophic drug coverage)
How is Canadian Medicare defined?
A public-funded single-payer system that provides…services
deemed medically necessary, without financial cost to insured persons.
Based on the CHA, the drug plan should be universal, comprehensive, and accessible. Should know what those 3 terms means
- Universal - available to all residents under equal terms and conditions
- Rules out risk-based premiums - Comprehensive – medically necessary
- Restrictions based on an evidence-based formulary - Accessible - no user fees for covered drugs
- Available free-of-charge to patients
With the Medicare model, what if the patient wants a drug therapy option not on the formulary?
If deemed “not medically necessary” then not covered by Medicare
- The individual can pay themselves or through insurance if they really want it though
What is MedicareLite? (4)
Universal public plan with patient cost sharing:
1. Deductible
- Pay up to a maximum before public payments
2. Co-insurance
- Pay percent of the cost of each Rx
3. Copayment
- Pay set amount per prescription
4. Prescription Fee
- Pay the professional fee; the drug is “free”
What is the Pan-Canadian option for drug coverage? (3)
- A new public plan as the default option.
- Insurance mandatory; whether a private or public plan the choice of the individual based on features and cost. - People can keep their current plan; whether public or private.
- Don’t fix what ain’t broke. - Those opting for private not covered by the new public plan.
- Can switch but only at fixed times (e.g. annually).
What are 2 attractive features of the Pan-Canadian option for drug coverage?
- Everyone has some level of coverage
- Better than current system - No radical restructuring
- Limited impact on insurance industry
- Limited impact on government budgets
What are 2 concerns of the Pan-Canadian option for drug coverage?
- Risk of Cream-skimming
- Only sick and poor in public plan – higher costs to taxpayers - Public option may be too attractive
- Shift from private to public - higher costs to taxpayers
What are the incentives to opt out of the public plan in the Pan-Canadian option for drug coverage? (2)
- Financial: Tax refund
- Subsidies to make private insurance less expensive and increase probability of being the selected option to reduce the public cost - Perceived or real quality difference
- Usually around issues of choice, access to medicines with better side effect profiles, and “life-style” medicines
What is the Private Insurance model of drug coverage? (2)
- 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.
- Reduces the risk of cream skimming
- Potential to lower costs through competition among private insurers
What does maintaining the status quo mean in terms of Canadian drug coverage? (2)
- Keep current system with catastrophic coverage for all.
- The federal government provides catastrophic drug coverage, subject to a deductible, to:
- Eligible registered First Nations people and recognized Inuit under the Non-Insured Health Benefits (NIHB) Program.
- Federal public service employees; members of the Canadian Forces and the Royal Canadian Mounted Police; members of Parliament, federal judges, and Canadian veterans receive coverage under the Public Service Health Care (PSHC) Plan.
What is a pro and con of maintaining status quo for drug coverage?
Pro = Minimal impact on current system with incremental costs to public funders
- Based on economic impact (% of income) (>3.4% of income in Saskatchewan)
Con = However, high out-of-pocket costs amount to a tax on the sick and burdens the poor disproportionately
What is recommendation 2 from the 2018 pharmacare now document?
That the Government of Canada amend the Canada Health Act to include drugs prescribed by a licensed HCP and dispensed outside of hospitals in accordance with a common voluntary national formulary, as part of the definition of an “insured health service” under the Act
What is recommendation 3 from the 2018 pharmacare now document?
That the Government of Canada provide additional funding to provinces and territories through the Canada Health Transfer to support the inclusion of prescription drugs dispensed outside of hospitals as an insured service under provincial and territorial public health insurance programs under the Canada Health Act
Who are the political constituents of Pharmacare? (5)
- Physicians
- Retail pharmacy
- Big pharma
- Private insurance
- The public
