Re: Pharmacare changes are fair

The neoconservative rhetoric of our time is becoming too much for me. “Fair Pharmacare?” To me the title says—“they must be hiding something.” Such a title wants you to disregard continuity, careful progress, and memory of the past.

In her editorial in the April 2003 BCMJ (45[3]:114-115), Dr Heidi Oetter states that “reference-based pricing and special authority forms have… resulted in poor medication choices for patients….” Are you sure about that? Which drugs in the program are poor choices? How will “Fair Pharmacare” affect the choice of drugs?

The former Pharmacare program was inclusive—all seniors had an equal stake. The deductions and limitations were based on how sick you were, not whether you could pay. That allowed the process of drug scrutiny for inclusion in the program to carry more weight. Dr Oetter suggests a competitive bidding process for medical supplies. This was what was essentially going on for drugs. Consider for example the decision of Pharmacare for M-Eslon to be the long-acting morphine of choice for the province over other preparations.

But now you remove some people’s stake in the process. If you have a higher income you’re going to be paying for your own drugs anyway. What do you care if a process of competitive bidding goes on if you’re not contributing to the program? What’s to stop the price of drugs in BC from becoming as expensive as in the US if the majority of people are just going to be paying for them outright? How much will the exclusion of those with cash and the lack of drug scrutiny only serve the increase prices for the public system?

Despite clear evidence that it is not the total amount that is spent on health care that makes a difference in general health, but rather how the health dollars are distributed (the glaring example being the US system), the BC government will happily watch as the per capita spending on drugs increases. As such, this exclusive policy will corrode our collective well-being in the face of what is actually an increase in the total monies for drugs. We all know where that increased money is going to go. No wonder we haven’t heard any opposition to this new program. Oh well, I guess fair is fair.

—Donald J. Young, MD
Vancouver

Dr Oetter responds

In Dr Young’s letter, he asserts that the old way of defining Pharmacare benefits was fairer. He is correct that all seniors had an equal opportunity for the benefit. But I will disagree with him about the fairness of defining a benefit based solely on age. It is a choice: as a society we can have the benefit made available based on a financial criterion or an age criterion. One choice would have a positive impact for people with lower incomes, the other a positive impact for those with higher age. Given the tough choices that have to be made in health care, both groups cannot be offered the benefit simultaneously. I happen to believe the financial test to be fairer. I guess we will agree to disagree. As a footnote, the financial test based on taxable income is also one that I can support. I would abhor a process that determined financial eligibility based on an asset test.

Dr Young also challenges the concept of competitive process for medications or supplies being affected by whether purchases are made by individuals (private) or Pharmacare (public). I believe that competition for “preferred” status that would result in sharpening of prices can be achieved with either form of payment.

The issue of reference-based pricing continues to be a problem. While I could choose from many examples, I will highlight just one: the medications available for management of osteoporosis provide less-than-satisfactory choices for my patients.

—HMO