The first ever pharmacist invited to the national pharmacare file

These days, when I find myself in increasingly privileged positions with a seat at decision-making tables, I look around and ask: who’s missing?To his credit, the former Minister of Health, Mark Holland, upon the passing of Bill C-64, the “Act Respecting Pharmacare,” must have asked this question. The Bill, which mandated the formation of a committee of experts to determine the administration and financing of a national pharmacare program, added the voice of pharmacy practice and Indigenous health expertise that has been missing in the history of this file. I presumed it was my intersection of pharmacy practice expertise and my commitment to health equity. Either way, In the 20-year history of the pharmacare file, I was the first-ever pharmacist appointed to a reporting committee.At least that was how I justified my acceptance as I stepped into the wave of responsibility that came with Health Canada's invitation to participate in the Pharmacare Committee of Experts. I knew how the pharmacy sector ‘felt’ about pharmacare. I know the panic it incites among colleges and stakeholders. Pharmacare acknowledges the exponential and unfettered growth of drug costs impacting Canadians, and the inherent health access inequities and health systems sustainability risks that it imposes. Pharmacare represents a cost-containment measure.Drug pricing impacts the entire pharmacy sector, in part due to transactional models that tie drug costs to the safe and effective delivery of medicines. As an authentic participant, I had to believe that we were proceeding with National Pharmacare and acknowledge the importance of pharmacy systems oversight to protect pharmacy distribution, operations or professional services. With the administrative nightmares pharmacy professionals navigate for patients every day, there is a strong sense of apprehension about “one more” poorly designed drug plan enforced upon Canadians and their health teams. I knew there were risks to my participation, personally and professionally, but obligation compelled me. We needed a pharmacist at that table, so I showed up with humility, respect, and openness. This article will share the report in my own voice and in kinder language, as I call upon my pharmacy colleagues to continue to ensure we are invited to contribute to medicines policies impacting our patients.Cost-containment of drug costs has had negative impacts on the entire pharmacy sector, in part due to transactional financial models that inherently tie drug costs to the safe and effective delivery of medicines. The pharmacy practice ecosystem, like most sectors, has faced significantly increasing costs in meeting best practices, including new or changing health regulations and standards, maintaining infrastructure and adapting practices that improve the health and safety of patients in the delivery of medicines. Pharmacists have added immense value to primary care services and access, while bearing the administrative and operational burden of health and safety regulatory standards and navigating unfair and complex drug coverage standards for patients. There is minimal, reduced, or no funding supporting these expanded responsibilities. Distributors face increasingly complex drugs to ship, including a wave of biologic medications and popular refrigerated items, such as new weight loss drugs, which require significant infrastructure investments and procedural standards. Distributors and manufacturers, too, must adhere to increasingly vital standards in the transport and monitoring of temperature-sensitive medicines and controlled drugs like opioids.Pharmacy distribution and services alike are failing in their intentions to serve remote and rural communities in one of the most geographically remote countries in the world. Through robust consultation with this sector, the Pharmacare Committee of Experts clearly heard that this ecosystem was at a breaking point, and that a cost ceiling imposed by pharmacare, intended to increase access to medications, would have a potentially disastrous impact on their capacity to deliver on that right. It took trusting a pharmacist with a seat at the table to deliver a report that advocated for sustainable pharmacy reimbursement models, distribution support, and funding models that acknowledge the increased costs, and equity challenges of geographically remote communities.The pharmacy sector has been facing a critical crossroads for some time. If the costs of drugs continue to soar, we will face the same dilemma as the impact of cost-containment strategies: the systemic underfunding of pharmacy services and distribution. We are seeing this already in the rolling back or limitation of dispensing fees and funded services within provincial budgets which consider distribution and drugs in the same exponentially growing share of health care costs.As I sat at the table of experts, learning and listening with humility, I heard the story of ‘why pharmacare’. We heard from politicians, lawyers, experts, researchers, and stakeholders, all with immense knowledge in health policy, financing, and patient equity, who not only provided evidence of pharmacare as a solution, but the solution. I was able to reflect on the real costs of our current medicine delivery system, both human and financial. It is heartbreaking to know that families are unable to afford life-saving medicines. I have witnessed this firsthand as a community pharmacist and experienced the ethical harm of standing between a patient and the one thing they need to get better, with a barrier of cost. Métis communities have no drug coverage at all, and our Elders share stories of hitchhiking to chemotherapy appointments, sharing medicines between family members, sacrificing food for the medicines, and medicines for food.The administration costs of private insurers, meaning what they charge for their operation of the drug plan, are sometimes ten times that of public plans. With hundreds of uncoordinated insurance plans and associated formularies, the costs of medicines are negotiated in small batches with insignificant impact on the pricing that reaches Canadians. There is no standardization of what is covered based on health data, and formularies are not supporting best practices in prescribing, let alone health equity needs. The costs of the drugs are minimally negotiated; instead, the costs are passed along to employers and employees through premiums. Health economists, health equity researchers, and international models have exhibited that private insurance dominance significantly limits oversight and leads to excessive inefficiency in drug costs. Health insurance has a multitude of important roles, and it will persist even in the implementation of robust public drug coverage. Like all participants in the health sector, the insurance industry is validated by the good it contributes, and will adapt, like the rest of us, to serve patient-led needs and values.A federal investment in pharmacare represents a significant opportunity to finally have oversight on the existing investments Canadians make every day in medicines. The Pharmacare Committee of Experts’ report describes a system carefully constructed from uniquely Canadian-made principles and co-developed with the system's participants. This included meaningful contributions from pharmacists, industry, distributors, and researchers. It represents the required integration of the funding of medicines into a national medicines strategy, one that includes Canadian-made prescribing guidelines, environment and climate considerations, as well as monitoring and innovations in supply-chain disruptions to navigate an increasingly geopolitical and environmentally unstable world.We currently purchase our health data from an American company. Our drug pricing and access can be significantly impacted by policies and challenges in other countries. We live in a state of uncertainty, which is missing a collaborative strategy to navigate upcoming challenges with transparency, innovation and full stakeholder participation. The pharmacy sector itself contributes to this lack of transparency, with hidden generic rebates. Small community pharmacies do not have negotiating power to meaningfully benefit from generic rebates, whereas large pharmacies driving bulk distribution contracts can benefit from an inequitable share. If we reflect on this knowledge, we can see that the discrepancies in reinvestment in the pharmacy services and care of Canadians are not uniform, and that these rebates do not reflect a principled effort which invests in the servicing of Canadians. They also reinforce the transactional care dynamic, where more means more, except when it comes to patient care.This committee experience was a deep dive into the complexities of health jurisdictions and their often combative structures. The provincial and federal governments have complex relationships, and often stand in opposition regarding health systems delivery. Provinces are primarily responsible for administering and delivering healthcare, while the federal government sets national standards through the Canada Health Act, provides funding via the Canada Health Transfer, and regulates specific areas like pharmaceuticals and products for sale. Federal responsibility also includes providing healthcare for specific groups like First Nations, Inuit, veterans, and federal inmates. Forming any sort of agreement between these entities, including the bilateral agreements which have founded the delivery of contraceptive and diabetes medicines funding through Bill C-64, creates a barrier to the national implementation of any medicines strategy.One would assume that any provincial government would agree to accepting additional medicines funding, and yet, when they are required to agree to a small share of the costs within a system outside of their design, many have chosen to opt out over cost-sharing, principles, or other factors. The committee decided to focus on the rights of Canadians as our guiding principles and recognized that the participation of the provincial governments was a barrier to the principle of universality. Given that this was a national investment, and that gaps between jurisdictions, including those created in the delivery of Indigenous health, create the most significant harms, building federal leadership into pharmacare was a critical first step.The pharmacare report will introduce a system that has the federal government investing in the first phase of pharmacare entirely. An investment that will be tested by essential medicines funding, without co-pays, available free to all Canadians, everywhere. I want to acknowledge that this is not the vision of pharmacare that many patient and professionals groups had, and that the committee shared fears that phase one would ultimately end up being the final phase. The fact is, both jurisdictional disputes and skepticism about the projected savings of pharmacare have served to halt the program's realization for over 20 years. At this moment in time, with geopolitical pressures and the sustainability of our health systems increasingly in the hands of global influences, progress on this strategy needs a bold and balanced approach.The report will highlight that through investing in universal access to essential medicines, the drug plans of other jurisdictions or populations, including provinces and the Non-Insured Health Benefits Program (NIHB), will experience cost savings. The cost savings themselves become an invitation for forming good relationships, where the savings become a mechanism for investing in the distinct and jurisdictional gaps in service and medicines delivery. The report recommends that savings be reinvested in health, aligning with the priorities and unique needs of those served within the jurisdiction.From the paternalism, dehumanization, and isolation of Residential Schools and Indian Hospitals comes reconciliation movements with Indigenous-led education and health systems that invite in families, culture, autonomy, consent and respect. For me, pharmacare was a chance to evaluate everything that was wrong with Indigenous access to medicines, and start building towards the opposite. First Nations and Inuit patients with status receive drug coverage through the Non-Insured Health Benefits (NIHB) program. Through this federally funded program, which a private insurer administers, patients have experienced an extension of the health system rooted in racism, stigma, ongoing segregation, a legacy of underfunding and policy harms. This plan, its policies, and its evaluation do not exist within a co-creation framework that honours the distinct and sovereign rights of Indigenous Peoples. It excludes non-status First Nations and Métis patients. It asks, only after a policy is implemented, how it might cause harm. It does not consider the unique historical, geographical, and social circumstances of Indigenous peoples in its decisions about drug coverage. It underfunds pharmacies in the administration of the plan, with one of the lowest reimbursement rates for dispensing fees, compounding fees, and includes no coverage of medication reviews or pharmacy services. Pharmacare would need to be an agent of change that would build towards health sovereignty, without disrupting existing systems and nation-to-nation relationships.Ultimately, NIHB is an application of the health rights and agreements made between the Crown, the Canadian government and Indigenous peoples. It is one that must be respected and upheld, and the decisions regarding the NIHB program should be held with the rights holders themselves. The committee's experience with Indigenous consultation, within the timelines available to this report, was not robust enough to speak on behalf of the needs of Indigenous Peoples. Pharmacare must not disturb or replace existing relationships with the federal government, nor could it be implemented specifically for Indigenous Peoples without their consent and evaluation. Pharmacare represents an opportunity for a co-creation framework, one that invites the perspectives of the people, systems leaders, and best practices that will drive diverse evaluation and iterative delivery of a valuable investment. It serves as a mechanism for other governments to apply the inherent drug expenditure savings to their own populations' sovereign and distinct needs.Investments in care and dispensing of medicines are particularly needed in remote communities, and a renewed system will make space for sovereign Indigenous health systems to develop and flourish. These same changes will strengthen culturally appropriate care for Indigenous Peoples and reduce factors of systemic racism in access to medicines. Reinvestment and recognition of access costs for geographically remote communities is a firm recommendation in the report. This is an opportunity to enhance clinical and professional standards based on best practices, evidence, and the unique needs of Canadians.Pharmacare represents an opportunity to inject Canadian values, risk management, and solutions to current and future challenges facing the health of Canadians. The extensive financial investments in medicines would be much more informed, adaptable, and agile to drastically changing landscapes. Pharmacare could assess and invest in supply chain challenges, address the environmental impact of medicines, and ensure access to geographically underserved areas and regions facing environmental disasters. The program addresses the inefficacy of transactional drug funding in the servicing and care of Canadians, one which has underfunded pharmacy and distribution services and limited access to primary care and medical supplies in underserved communities.We pharmacists proudly share our history of being ranked among trusted health professionals, yet I learned through this work that the pharmacy sector does not hold that same level of trust. Personally, I am unwilling to accept that. I have advocated on behalf of pharmacists my entire career because I know my community. I know the hearts and intentions of those professionals, clinicians, researchers, innovators, stakeholders, and industry who have dedicated themselves and their excellence to the healing and well-being of Canadians. However national pharmacare proceeds, pharmacists and pharmacy sector stakeholders must be at the centre of the design, implementation, evaluation and innovations of national medicines investments and strategies.My participation on this committee led to guidance within the pharmacare framework to start small, with full stakeholder participation, in a co-creation and discovery framework, recognizing that cost containment alone does not represent enhanced access. To be participants in the systems changes that will define the future of the pharmacy sector, we must be transparent, collaborative, and cooperative. We must acknowledge our own contributions to truth, to harm, to inequity, and to self-preservation, and honour this invitation with stewardship, accountability, participation, and a shared purpose of building a lasting system that will serve and evolve with the needs of generations to come.We have much work to do to shape and inform all that this report was meant to deliver. I know that pharmacists will be vital leaders in this work, no matter how it proceeds, and in so doing, will make Canadians proud.Amy Lamb, BSP, is a committee member of the Pharmacare Committee of Experts and executive director of the Indigenous Pharmacy Professionals of Canada.This article reflects my own views. For insights and perspectives from the government, other committee members, or stakeholders, don't hesitate to get in touch with the relevant representative.Read the report here.

The first ever pharmacist invited to the national pharmacare file

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