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What’s pharmacare and why should it matter to breast cancer patients?

It’s just the start of 2019 but we’re already thinking about fall and the federal election it brings with it. Last year, there was a lot of talk about the establishment of a national pharmacare plan. The federal government assembled a working group to study the best way a system like this would work in Canada. It suddenly became the talk of the town in the health policy community and we all anticipate that it will be a key issue in the upcoming election this fall. But what is it and why does it matter to the breast cancer community? And most importantly, how will current access issues facing Canadians be addressed?

Here in Canada, we are known for our public health care. We can go to a hospital and not worry about how we are going to pay for it. The same cannot be said for prescription drugs, unfortunately. We are the only developed country that has a publicly funded healthcare system without a publicly funded pharmacare system1. Most Canadians rely on private insurance plans, usually provided by their employers, to cover the costs of their medications. But still, 1 in 10 Canadians can’t afford their prescriptions2.

Things get a more complex when it comes to cancer treatments. Most Canadians think that because we have publicly funded healthcare that cancer treatment will be covered for them, but this isn’t always the case. Since our healthcare system is administered by the provinces, access to treatments for cancer is inconsistent.

Here are the biggest issues facing cancer treatment today in Canada:

  1. Equity
    Every province has a public drug formulary or a list of drugs that they will fund if you meet certain eligibility criteria (which we discuss in more depth below). Some provinces offer a robust and comprehensive list of cancer treatments while other provinces offer only a few treatments they deem are essential. With cancer treatments becoming more and more personalized and costly, public formularies are becoming more restrictive with their allowance of these drugs on their lists. This means that a treatment available in one province may not be available in another.
     
  2. Delays
    New treatments are vital in extending the lives of Canadians living with metastatic breast cancer. For many metastatic patients, having new treatments available to them when they’ve exhausted the current standard treatments can greatly improve their length and quality of life. But it can take anywhere between 2 to 4 years for these new treatments to be added to the public formularies mentioned above3. And sometimes, often smaller provinces, don’t add them at all.
     
  3. Eligibility
    We mentioned earlier, that eligibility is required to receive access to drugs on provincial public formularies. These criteria also vary from province to province.
  • Drug formats: Let’s start by saying that all cancer therapies listed on public formularies that are administered through an IV in a hospital setting are available to patients. For some provinces, like BC and Manitoba, how your treatment is administered makes no difference. If your treatment is an oral medication (a capsule or a pill for example), it’s covered; if you require IV administration in a hospital, it’s covered. But for many other provinces, like in Ontario and Atlantic Canada, only IV treatments administered in a hospital setting are covered, requiring many patients to pay out-of-pocket or through private insurance for their oral take-home treatment. More and more, new treatments are moving away from IV administration and are only being offered in pill form.
  • Age: For all provinces, seniors over the age of 65 have access to public drug plans and whatever drugs are listed on the public formularies, regardless of format. Many provinces now offer the same for children. But for the rest of the population, patients are often not covered publicly for their treatments administered outside the hospital or for any support medications they may require.
  • Line-setting: For metastatic patients who are waiting for access to new treatments, line-setting is a big deal. Metastatic patients go through various lines of therapy; when the 1st line of therapy stops working they move on to the 2nd line, and so on. When a new treatment is approved and publicly funded, it is often only funded in specific line-settings. If a patient has been waiting for this approval and their cancer has progressed passed the approved line-setting, then they are often ineligible for the funding they’ve waited so long for.  
  1. Un- or under-insured
    Many Canadians today are un-insured or under-insured. With the rising cost of medications and the restrictive nature of public plans many un-insured patients face crippling financial impacts or are forced to forgo life-saving treatments. More and more, private insurance plans are implementing strict reimbursement guidelines making plans inadequate for an insured patient and treatment needs.
    Many provinces offer catastrophic drug coverage plans to help alleviate some of these burdens and barriers for Canadians facing high prescription drug costs. But these plans vary by province and require added thresholds in order to qualify. They add an additional burden for patients requiring public assistance during a time of heightened stress, anxiety and vulnerability.

It’s our hope that a national program for prescription drug coverage address and resolve these current issues that so many Canadians face when undergoing cancer treatment. As discussions for pharmacare continue to ramp up, CBCN will continue to address these issues to ensure that those with unmet needs are provided for and that the implementation of a national pharmacare program benefits all Canadians facing a cancer diagnosis.

Photo by Danielle MacInnes on Unsplash