Position statement

Health care in Ontario should focus on global, not local, cost savings — as well as patient quality of life

The Ministry of Health and Long-Term Care needs to deal with the rising costs of drugs in a comprehensive and context-sensitive way. Giving the Exceptional Access Program (EAP) a mandate — whether written or implicit — to cut costs locally by denying patients coverage for biologics is counterproductive. The current system, in which the EAP frequently denies coverage for patients already on biologics, is not only dangerous for those patients’ health and well-being, but is inherently unfair: it not only kicks sick patients while they are down, but it discriminates against patients who have neither the know-how, energy, or education to beg for consideration from MPPs, newspapers and the Ontario Ombudsman. The issue needs to be addressed at a broader level so that cost-savings at the EAP don’t spill over into increased costs in other areas of the health care system through increased rates of hospitalization and surgery, or into the Ministry of Community and Social Services via patients going on disability (the Ontario Disability Support Program, ODSP).

Recommendations

The EAP should move towards a system where patients already on biologics face minimal barriers for approval for continuing on the medication that works for them. Harmonizing the EAP’s guidelines for patient eligibility for biologics so that they are in line with the best medical evidence, as determined by specialists in the diseases the biologics are used to treat (e.g. the Canadian Association of Gastroenterology for Crohn’s disease) would be a great first step. (More on that here). The EAP’s yearly reviews should also be reduced in frequency for patients whose conditions are stable — this will reduce paperwork for the EAP and for doctors, reducing delays at both ends. Also, the EAP should promptly refund patients for treatments that patients pay for out of pocket while waiting for EAP paperwork to be processed.

Biologics are not going away. They are effective, and the conditions they are used to treat are not preventable (e.g. Crohn’s, rheumatoid arthritis, ankylosing spondylitis). The Ministry of Health and Long-Term Care, Trillium Drug Program, and EAP should look elsewhere for cost containment, as suggested by insurance companies (which also have a large stake in containing drug costs). Improving public health by moving to reduce the incidence of lifestyle-related conditions, such as obesity and heart disease, would lower drug costs because of the sheer number of people on medication for these largely preventable conditions. Lower-cost biologic drugs are also on their way to entering the market in the near future, and this will spur price competition that will lower the cost of biologics overall (though, admittedly, not by a huge margin).

Ultimately, it is much better to have patients controlled on medicine that works than to deny them coverage and have them missing work, getting hospitalized, having surgery, going on disability, etc. Keeping patients well and at work should not be left out of the cost-of-biologics equation, as the director of the pharmacy division of Green Shield pointed out. I would rather be a productive member of society than be on disability, and it also costs less overall. What’s not to like about that?