Public Drug Programs Research Articles

Despite Recent Reforms, Provinces Continue to Pay Too Much for Generic Drugs, Says Study

Provincial governments seeking to cut spending on generic drugs — by reducing prices to a lower percentage of the brand-name equivalent — are still overpaying for most of these drugs, according to a study from the Centre for Health Services and Policy Research at the University of British Columbia. The research was conducted by Dr. Michael Law, assistant professor at the Centre and an expert adviser with EvidenceNetwork.ca. Dr. Law focused his analysis on generic drug expenditures in Ontario, as that province has gone the furthest by reducing generic prices to 25% of the brandname cost, and so has the lowest prices in Canada. “I was interested in evaluating the real impact of the dramatic percentage reduction in Ontario, from 65% to 25%,” says Dr. Law. “Paying one-quarter of the brand price sounds like a great deal, but the numbers say other wise, when you examine whether these new prices are internationally competitive.” The study compared the 2011 prices of generic drugs on the Ontario Drug Benefit Formulary to price listings for 2 other public drug programs — the US Department of Veterans Affairs and the New Zealand government. Out of the 100 most frequently dispensed generic products in Ontario, 82 were listed on one or both of the other programs. “Among those 82 drugs, 90% of the time, they were more expensive in Canada than in the 2 comparator countries and on average, they were twice as expensive,” says Dr. Law. The largest price discrepancy was for simvastatin (10 mg), which was more than 30 times more expensive in Ontario. If the Ontario government had paid the best comparator prices for the 82 generic products, it would have saved $129 million in 2011, according to Dr. Law's study. Extrapolating to the total Ontario market, the savings would be $245 million. The traditional and arbitrary formula of setting generic prices as a percentage of brand-name prices is not optimizing savings, according to Dr. Law. The other countries use different mechanisms to achieve better pricing, he says. “If you look at New Zealand, for example, it uses contractual agreements with firms that guarantee them a certain amount of volume for a particular price and use competition to get the best price possible.” Dr. Law is encouraged by the recent commitment of Canada's premiers to have the provinces collaborate on bulk purchasing of generics. “In the generic drug market, there is genuine competition. If we can capture some of that competition then I am hopeful that the provinces will be successful in this initiative.” Canada's potential purchasing power could provide an advantage, he adds. “If you banded all the provinces together, our public programs are bigger than both of those other insurance schemes by a wide margin.” Achieving savings in the per-unit price of generic drugs could yield multiple benefits, says Dr. Law. “Governments could not only save money, they could improve coverage for people. With estimates like the one our Centre put out earlier this year — that 1 in 10 Canadians can't afford their prescription drugs — I think there's a real opportunity here to get better prices and improve coverage at the same time.”

Medication Use among Canadian Seniors

As they age, many seniors develop a progressively more complex mix of health conditions. Multiple prescription medications are often required to help manage these conditions and control symptoms, with the goal of maintaining seniors' health for as long as possible. This article explores trends in the number and types of medications used by seniors on public drug programs in Canada. Our findings suggest that a high proportion of Canadian seniors are taking several medications, highlighting the need for medication management systems focusing on this population.

An Evaluation Framework for Funding Drugs for Rare Diseases

ObjectivesFor rare diseases it may be difficult to generate data from randomized trials to support funding of a drug. Enzyme replacement therapies for diseases of inherited metabolic enzyme deficiency provide an example of this dilemma. The Ontario Public Drug Programs convened the Drugs for Rare Diseases Working Group to develop a policy for assessing these drugs. MethodsThe Drugs for Rare Diseases Working Group developed terms of reference expecting that the ideal policy product would be transparent and consistent and address unique aspects of the treatment of a specific rare condition while being adaptable to other dissimilar conditions. The perspective was that of a public payer addressing requests for funding generated for a specific drug, and included respect for the principles of “accountability for reasonableness” of Daniels and Sabin. ResultsA seven-step framework was developed and tested by using the case study of idursulfase for mucopolysaccharidosis II (Hunter disease). Estimation of clinical effectiveness was done by using decision modeling. The model developed informed funding recommendations and ultimately led to an agreement with the manufacturer allowing funding of idursulfase in Ontario. ConclusionsThis policy framework attempts to address the policy challenges of funding drugs for rare diseases. The framework will be used to assess other drugs in future and will inevitably require modification with experience. It is hoped that it may be of value to other policymakers.

Socioeconomic Status and the Use of Medicines in the Ontario Public Drug Program

Residents of Ontario aged 65 years and older are covered by a provincially funded prescription drug program. The aim of this paper is to assess the extent of inequity in prescription drug use for people eligible for Ontario Drug Benefit coverage, and to explore the different possible explanations for inequities. The analyses draw on the Canadian Community Health Survey from 2005, which is linked to pharmacy and Ontario Health Insurance Plan claims data. We model the number of therapeutically different prescription drugs and the total expenditures on medications on a set of health, demographic, and socioeconomic indicators, and we calculate the concentration index of income-related inequality in medicine use. The results show that low-income individuals who have enrolled in the reduced cost-sharing program on average use more medications than those with higher income, even after adjusting for a comprehensive set of health and demographic variables. While Ontario's public drug program appears to have ensured access to medications for low-income seniors, the results of this study raise concerns about the potential inappropriateness of medication use and point to a gap in drug policy in Ontario.

Comparative Net Cost Impact of the Utilization of Romiplostim and Intravenous Immunoglobulin for the Treatment of Patients with Immune Thrombocytopenia in Quebec,

Abstract 4211 Background:Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by increased platelet destruction and suboptimal platelet production, which results in low platelet counts and mild to severe bleeding. Bleeding events may range from petechiae and purpura to severe intracranial and gastrointestinal haemorrhage. Approximately 5% of adult ITP patients suffer from a fatal bleeding event. However, the risk of severe, fatal bleeding is significantly higher for patients who are unresponsive or intolerant to current therapies, over the age of 60 years, or refractory to splenectomy. The prevalence of diagnosed cases of chronic ITP in the overall population in Canada is reported to be 20.3 per 100,000; thus, it is estimated that there are about 160,000 people in Quebec with chronic ITP.Therapeutic management of ITP include the use of corticosteroids, immunosuppressive agents, and intravenous immunoglobulins (IVIg). IVIg is an expensive and occasionally scarce blood product. Surgical management includes splenectomy. Most recently, thrombopoietin (TPO) mimetic agents such as romiplostim and eltrombopag have been used to treat ITP.Romiplostim is indicated in Canada to increase the platelet levels in adult patients with chronic immune (idiopathic) thrombocytopenic purpura: •Who are non splenectomized and have had an inadequate response or are intolerant to corticosteroids and/or immunoglobulin; •Who are splenectomized and have had an inadequate response to splenectomy.Romiplostim does not have public reimbursement in the province of Quebec. Although the public drug program expert review acknowledged the benefit of romiplostim in substantially reducing the use of IVIg, the reviewers did not recognize the use of IVIg as a maintenance therapy. The objective of this study was to conduct a net cost analysis to determine if using romiplostim instead of IVIg can result in savings to the provincial health care budget in Quebec. Methods:A net cost impact model was developed to provide a detailed analysis of the cost implications of romiplostim utilization compared with IVIg, including the drug treatment costs, costs related to the preparation and administration of medications, monitoring costs, and indirect costs such as patients' time away from usual activities or work. Expert consultation with physicians, pharmacists and nurses in Quebec was used to define treatment algorithms including all health resource utilization required when using romiplostim and IVIg. Costs were assigned to direct (e.g., drugs, medical supplies, laboratory testing, healthcare professionals' time) and indirect (e.g., productivity) healthcare resources. Results:Based on the median weekly dose (3mcg/kg) observed in the pivotal romiplostim clinical trial in splenectomised patients, the annual cost of romiplostim per patient was $47,244. The annual per patient cost of IVIg was $114,548 based on an average dose suggested by a clinical expert (1g/kg every 4 weeks and average administration time of 3.5 hours). Lower costs for drug preparation and administration ($284 vs. $1355) and less time lost from work (valued at $447 vs. $2141) were attributed to romiplostim compared to IVIg. The time attributed to monitoring was the same for both romiplostim and IVIg ($115). The total average annual per patient costs including medication, drug administration, monitoring and lost productivity for romiplostim vs. IVIg were, respectively, $48,090 and $118,159. The use of romiplostim would save, on average, about $70,069 per patient per year. Conclusion:From a societal perspective, treating ITP patients with romiplostim can provide a lower cost alternative to IVIg for the overall provincial healthcare budget. Compared with IVIg, the use of romiplostim results in lower direct costs, reduced health care resource utilization and less indirect costs. As a precious commodity, blood products must be used wisely. As stated by the expert review committee in Quebec, IVIg should remain a last resort option to treat ITP. Romiplostim can allow for improved healthcare resource allocation by reserving IVIg for use in other areas of greater need while also providing cost savings. Romiplostim also potentially improves patients' quality of life by reducing the time required for drug infusion and avoids the risks associated with IV administration. Disclosures:Pettigrew:Amgen Canada Inc.: Consultancy. Deuson:Amgen: Employment, Equity Ownership. Garces:Amgen Canada: Employment, Equity Ownership.

Economic Impact of Nonpersistence with Antidepressant Treatment in the Adult Population of Quebec: A Comparative Cost-Effectiveness Approach

Background Although for the great majority of indications, practice guidelines recommend that antidepressants (ADs) be used for at least 6 months, premature discontinuation is very frequent in a “real-life” setting. Previous studies have assessed the economic impact of such nonpersistence, but differences across antidepressant products remain inadequately explored. Objective To compare treatment persistence and incremental cost/persistence ratios (ICPRs) across individual new ADs (selective serotonin reuptake inhibitors and atypical ADs) as well as the associated direct health-care costs in the adult population covered by the public drug program of Quebec. Methods A retrospective cohort study was conducted in 13,936 adults aged 18 to 64 years who started an AD treatment in 2003. Persistence was defined as treatment duration of at least 6 months regardless of whether a product switch had occurred. Economic impact was assessed over the first year of treatment through drug, medical services, hospitalization, and total health-care costs. Comparisons across products were conducted using the ICPR. Results Adjusting for confounders, treatment nonpersistence ranged from 60.4% (paroxetine) to 65.1% (citalopram). The product associated with the highest total health-care costs was citalopram (CDN$2653) and the lowest was venlafaxine (CDN$2168). Fluvoxamine had the lowest mean AD costs (CDN$215) and venlafaxine (CDN$309) the highest. Conclusions Total health-care costs were similar across products except for citalopram, which was more costly. Comparisons based on the ICPR revealed that paroxetine, fluoxetine, and venlafaxine were more favorable than the other AD alternatives.

Socioeconomic Status and the Use of Medicines in the Ontario Public Drug Program

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Drug Reimbursement Policies in Canada—Need for Improved Access to Critical Therapies

Public drug programs in Canada are increasingly implementing cost management strategies. A multidisciplinary review of these strategies--specifically, the special authorization (SA) process--found that implementation of the SA practice is costly and causes inequity in access, underutilization, and delays in treatment for urgently required therapies, all potentially leading to negative health outcomes. We present potential solutions and a set of recommendations for decision-makers to base reimbursement decisions on the best clinical evidence, eliminate regional variability in access, ensure timely access to urgently required treatments, and monitor the impact of reimbursement policies on health outcomes.

Distributional consequences of the transition from age‐based to income‐based prescription drug coverage in British Columbia, Canada

In May, 2003, British Columbia transitioned from an age-based public drug program, with public subsidy primarily based on age, to an age-irrelevant income-based drug program, in which public subsidy is based primarily on household income. As one of the specific aims of the policy change was to improve fairness by increasing the extent to which payment for drugs is based on ability to pay, we measure the progressivity of pharmaceutical financing before and after the policy change in BC using Kakwani indices. Our results suggest that pharmaceutical financing became less regressive after the policy change. However, this decrease in regressivity arose primarily because high-income seniors were making greater direct contributions to pharmaceutical financing and not because low-income households were making smaller direct contributions. Our results also suggest that if the public financing of pharmaceuticals were maintained or increased, a change from age-based to income-based eligibility can unambiguously improve equity in finance. As populations in developed countries age, governments will increasingly consider reforms to publicly financed health-care programs with age-based eligibility. In assessing policy options, financial equity is likely to be a key consideration. These results suggest that income-based pharmacare can improve financial equity especially when implemented with a commitment to maintain or increase public funding for prescription drugs.

Is There a Tension between Clinical Practice and Reimbursement Policy? The Case of Osteoarthritis Prescribing Practices in Ontario

Reimbursement policies, such as those used to manage the public drug program for senior citizens in Ontario, focus on providing access to cost-effective drug therapies. These policies may create a dilemma for physicians who want to prescribe a particular drug to a patient, but must factor reimbursement restrictions affecting patient-level access into the prescribing decision. Information was collected from 102 physicians about prescriptions given to osteoarthritis patients (n=2,147) aged 65 years or older. Patients' access to prescribed drugs was determined from their insurance coverage and the reimbursement criteria set out in the formulary of the public Ontario Drug Benefit Program (ODBP). Starting from the assumption that physicians would follow published consensus guidelines respecting gastroprotection when prescribing NSAIDs in these at-risk elderly patients, three groups of physicians were identified from the record of their actual prescriptions. Group A physicians (n=14) prescribed non-selective NSAIDs alone to >60% of their patients. Group B physicians (n=26) prescribed an NSAID + gastroprotective agent or a Cox-2 selective NSAID to >70% of their patients. Group C physicians (n=62) were those that fit into neither category. An open-ended question was included in the study questionnaire to elicit physicians' own interpretation of what impact drug coverage had on their prescribing behaviour. No significant differences were found across groups with respect to years or type of practice, or to patient characteristics (LR=3.00, p>.2). Group C physicians were most likely to change their treatment choice in favour of restricted (limited use) drugs when patients met the criteria for reimbursement or had private insurance and therefore did not have to bear the additional cost out-of-pocket (LR=58.5; p<.0001). Most elderly at-risk patients are prescribed NSAIDs according to the prevailing guidelines. We found, however, that 40% of physicians have prescribing behaviour that favours non-evidence-based (Group A) or evidence-based (Group B) prescribing in this clinical setting irrespective of drug coverage. The remaining 60% of physicians appeared to be more responsive in their prescribing behaviour to financial constraints on patients' access to drugs. They also self-identified as most likely to change treatment if drug coverage had been different. These results have important implications for equity and quality of patient care. They also confirm that physicians' knowledge, values and self-efficacy are key determinants of prescribing behaviour and require further study to better understand how medical education and third-party policies and programs that govern pharmaceutical care are integrated into physicans' decision-making.

Case selection for statins was similar in two Canadian provinces: BC and Ontario

Objectives Though statins are fully reimbursed by the public drug programs for seniors in British Columbia (BC) and Ontario, Canada, population-based rates of statin prescription are markedly higher in Ontario. We aimed to assess whether new statin users in BC and Ontario differ in terms of their risk for future coronary heart disease (CHD) events. Study Design and Setting We collected information for 1998–2001 on demographics, outpatient prescriptions, physician visits, hospital admissions, and vital status from administrative databases to compare the proportions of new statin users aged 66 years and older who had evidence of an acute coronary syndrome (ACS), chronic CHD, neither ACS nor CHD but diabetes, or none of the above. Results Approximately 15% and 20% of BC and Ontario seniors, respectively, had filled a statin prescription by 2001. Among new statin users in the two provinces, virtually identical proportions had evidence of ACS (8%), chronic CHD (25%), and diabetes (14%), for an overall proportion of roughly 50% at high risk for CHD events. Conclusion New statin users in BC and Ontario were at similar risk for future CHD events. Poorer case selection is unlikely to explain the relatively higher rates of statin prescription in Ontario.

Drug utilization review of celecoxib in Ontario.

Cyclooxygenase (COX)-2-specific inhibitors were developed to circumvent the gastrointestinal toxicity of non-specific non-steroidal anti-inflammatory drugs while maintaining efficacy. However, the higher acquisition cost of COX-2-specific inhibitors has resulted in the implementation of a programme for cost containment in the Ontario public drug program. This programme consists of limited use (LU) criteria that need to be met for drug reimbursement of patients with osteoarthritis (OA) or rheumatoid arthritis (RA). Determining the proportion of patients eligible for reimbursement for celecoxib according to the LU criteria (based on prior treatment failure and the presence or history of serious ulcer-related gastrointestinal complications) can provide an indication of the extent of adherence to suggested guidelines. Using a patient-based survey and an analysis of the Ontario Drug Benefit Program database, the proportion of patients prescribed celecoxib who met rigorous or pragmatic definitions of the LU criteria was determined. The extent of coprescription of gastroprotective agents among patients taking celecoxib was also determined. Using the pragmatic definition, the majority of patients in the patient-based survey (53% for OA and 81% for RA) met the LU criteria. Similarly, in the database analysis, the majority of patients (76% for OA and 78% for RA) met the LU criteria. These data suggest that physician prescribing of celecoxib is consistent with the LU criteria. Concomitant prescription of gastroprotective agents in patients taking celecoxib was approximately 40%. It is recommended that further investigations be performed to determine the long-term impact of LU criteria on clinical and economic outcomes, since these criteria may also serve to restrict use in patients who may benefit from taking COX-2-specific inhibitors.