With the new debates going, in the blogosphere, about healthcare after the Supreme Court Ruling last week I've decided to let more of my life into this blog. Generally i just think it isn't all that relative. While a strong believer of
The Personal is Political[and not just on feminist issues] my life outside the blogs has just not been relevant. However i want to discuss a two tiered part of the health system that we have that i have had personal experience with: drug coverage. And so i'm going to talk about my experience, which mirrors the experience to one extent or another of many people i know. However it is relevant
now and to what i want to say. I'm of low income and i live on provincial disability (Ontario Disability Support Program or ODSP in Ontario).
I know this got a bit long, but it's what i have to say and i think it's important. I can't think of what i could cut out. I don't expect it will make any difference to the drug situation that we currently have but maybe it can give people a more concrete idea of why a two tiered Medicare system in Canada is not a good idea. From a real example in Canada of our two tiered pharmacare system.
The picture of what can happen with two tiered pharmacare, in Canada, is not pretty. I seen blogs comments about how Sweden and France have partially privatized health care and how it works there. I have my thoughts as to
why it might works there and not here, but what i do know is that it doesn't work
here. While the Medicare coverage might be different if it were split into two tier i think what is already occurring in another part of health care (drug coverage) which is two tier is an example of where it would likely eventually go.
The easiest and most simple example of this is an Epipen. If you don't know an Epipen is a life saving device. It contains a drug that counteracts severe allergies until you (hopefully) get to the hospital. I need to carry one with me.
They stopped covering it in the Ontario Drug Benefits Progam (ODB) a number of years ago. There is a complicated system with a syringe that almost nobody but a nurse knows how to use that
is covered from what i know. I have no idea how to use it but just as importantly nobody else does. If i have a reaction a lot of folks will know how to use my Epipen even if i can't explain it. And i wear a medic alert bracelet and have a card that says i may need it. When talking about the average person helping (no medical school or nursing) with the Anaquit, forget it.
While it isn't cheap it's necessity. And it's not covered. On top of that it is close to $100 to fill one. I'm allergic to bees so often it goes unused and expires. So i do need to refill it. By the time they stopped covering it i knew enough about the drug system to get my GP to write in a Section 15 (special request) for it to be covered. It came back in record time and was good for 5 years. I've never seen (nor have my doctor's) anything come back for more than 2 years before. It's because the government knows it's essential. But they also don't want to cover the cost. At the moment i know one person without one who has more severe allergies than mine. But she doesn't have one because her doctor doesn't know how to do this and she doesn't have $100. Eventually this fact will cost someone their life, if it hasn't already.
This however is just the beginning of two tiered drug coverage (Epipens are covered on every private plan i know of).If you want to see what a two tiered system would be like the first thing you can look at is medications. It doesn't make much sense if you can see a doctor but not fill a prescription that is needed but that is the thing me and many others on disability and welfare run across all the time.
Under the current system there is a drugs benefit card. However it is not a universal drug benefit card. It is the two tiered version, what those of us that don't have insurance get. And if you have any preexisting conditions you can't buy into private insurance. The only way i would have private insurance again would be from a job.
Even people who have private insurance are not guaranteed coverage for everything except preexisting conditions. I knew someone that was manic depressive 20 years ago. She paid into a private drug insurance plan to pay for medications that she might need that weren't related to her being a manic depressive (this was a preexisting condition). But how do you define what is related. She found out how loose the rules on that were when they turned down her claim for an antibiotic. They claimed that her having a bacterial infection (from what i remember it was bronchitis or an ear infection...Something of that sort) was related to her preexisting condition of manic depression and wouldn't reimburse her. She stopped paying for the insurance because if they are going to decide those two are related they wouldn't likely cover anything for her.
The irony is that the two tierd pharmacare system has (at times) had a very negative impact on my health. This means that I'm much less likely to get back to work. I can't say for sure its the system, but it sure hasn't helped. So i'm not paying taxes.
The two tiered pharmacare system has also resulted in a number of emergency room visits. Thankfully it hasn't ended in a hospitlization yet. But it could foreseeable, if not for me than for someone else. An emergency room visit costs roughly $500. One day in a hospital ward costs $700. So it also costs the system if the two tier pharmacare results in people needing to go to the emergency room or if they have to be hospitalized.
Under the ODB system your doctor doesn't decide what prescriptions you should take. Your health card does most of the deciding with what it covers and what it doesn't cover. Your doctor then works from this list (every doctor and pharmacy is given a large binder with a list of what is covered, which also costs money). Additionally there are two types of prescription pads for ODB, one of which is for limited use drugs that the province gives to doctors. More money, although i suspect it doesn't cost all that much. It would add up when you figure its pretty much every doctor in Ontario, all personalized.
I had private insurance when i was a university student. It had a fairly low cap but luckily at the time i was able to stay under it. This was managed (at times) by my doctor giving me samples, not as samples but as the medication to take. It wasn't that she was deciding what i should take based on samples, it's that i was always close to the cap and if something
i was taking was in samples, well then it didn't go on my insurance. Of course the availability of samples can vary and the companies can try to influence doctors with samples. That was all i ever thought of samples generally before i was in need of them. Then i learned that for those on welfare, ODSP or with insurance with a low cap, it was sometimes the
only way available to get the drug that is the most appropriate. In some cases it likely does give the drug companies more say with some doctors. That ends up costing the economy and individuals, even if it doesn't end up costing the state.
I knew that coverage of drugs was limited under the provincial program but i didn't know
how limited it was until i had to use it. And i doubt many Canadians have any idea. If they did they wouldn't' be (for one thing) surprised that people end up on disability for so long. Because screw ups in what medications the government will cover have had a negative impact on my health a number of times. And i really doubt i'm the first one to have this experience.
Economically (as in to the country) the most serious time was when it looked like i might return to work but a required medication change meant that my disability got worse again. This was a few years ago. And it really did look like i might be able to work again soon. In this case the problem i ran into was generics. It is required that you take generics or pay the price difference if you have an ODB card. If you are on disability or welfare you don't have the money to pay the difference which is at least 20%.
Now i know the general view is that generics are the same as brand name and in most cases for most people they are. In my case I've only had problems with generics in one class of drugs. Otherwise i like to take generics (if i have to take anything) because it's cheaper and good for the Canadian generic maker. I filled quite a few generics when in university where i could have insisted on name brand. In fact i didn't realize there was any real difference (aside from huffing and puffing by the drug companies) until i ran into a problem.
First off generic companies are not required to provide exactly the same amount of the drug as what is listed on the pill. They are only required to get the same dosage of the medication by 7% lower or 7% higher. So the This can possibly cause the worst problem if you switch from one generic to another because then you could be looking at a 14% difference in dose, which can have a real impact. At one point a long time ago I went back and forth between one generic and another at one point not knowing this. Me and my doctor we figure out why the dosage always needed changing on and off. The difference didn't appear (in my case) to be 15%. But it was enough to cause a problem. If I'd known i just would have stayed with the
same generic.
The next thing is that "brand name" drug often come with more than just the drug in the capsule. I know of one drug where the generic has 7 different things in it and the generic has 2: the drug and the filler they put in. These backgrounds aren't copied. It's part of how they make the drug cheaper (and i believe but don't know) you can copy the drug but not the exact composition of the background. I know that the background is never copied in any case. Either because of cost or copyright I'm not sure. These background fillers can have an impact on whether a drug works, or at what dose a drug works. I learned this after i tracked down the pharmacist of a local hospital
after I'd had a few problems with generics. If you are taking more than one medication the fillers can react with each other and throw the medication that you are getting (or the effect) off by quite a bit.
I still think it makes sense to try the generic most of the time. Why pay extra money if it doesn't make any difference. And in a lot of cases it doesn't. In fact i continue to take generics for a number of things (antibiotics and migraines) but in one class they have a history of not working for me.
The first time we realized it was likely the generic that was the problem was the time i improved so much it looked like i might go back to work soon. I'm taking 50 mg of a medication and since I've started taking it i' had seen steady improvement in my health for 9 months. The drug went generic but i didn't even notice. Changed into a generic. At one point i did have a small "outbreak", or remission if you prefer, of what the medication is supposed to stop. My doctor put up the dose and the immediate problem (large) went away. But then my health started to slowly deteriorate. Neither I nor my doctor had any idea why. Eventually i noticed i was on a generic. My doctor tracked down the remission to when the drug came out in generic several months before. I ended up taking three times the dose of the super-generic (closer to the original but still different). The amount ODB saved was only 20% by dose. So they didn't save any money from the drug change at all. In fact the actual drug change lead to my cost on that medication being higher than before.
Once my doctor realized that it was clear that another drug that suddenly stopped working did so when it went into generic was also of the same class. I think at this point anyone with private insurance would go "I see a pattern. I think with drugs i'm taking specifically for this reason I'll stay with the brand names. Obviously something is off". This would be my way of dealing with it, and to take generics for everything else. Unfortunately that is not the way it works if you are one the governments drug plan.
After the second incident i did some research and my doctor did and that was when we learned the differences in generics and brand name could have an effect and were in one particular type of treatment for me
were actually having a negative effect. This information came from a specialist of specialists (my doctor is already a specialist) and by a hospital pharmacist. It was because of how blatant the change was that time that we tracked it down to the generic eventually.
There is an appeals process. But the kicker is that the government requires that
you show them that the generic doesn't work. So your health needs to deteriorate before you can have it improve. So you need to get ill from a change before you can successfully appeal. I've had problems with three generics from one class of drugs. Luckily I'm not taking anything that will become generic soon from that class of drugs. Because I'm stuck in the position of having to get sick to possibly (and this is in no way guaranteed even through the appeals) get the brand name drug. Once it is clear there is one area where it's causing problems if a drug from that class changes you are in a very frustrating spot. What do you do? It hasn't come up again recently but it is a real question for the future if i'm not at a job with a drug plan.
This is not the first trouble i ran into. I took a slow release version of one drug. I had tried the alternates and the side effects were too severe. When i needed to get my drugs through ODB i ran into a problem. They don't cover slow release drugs if it is possible to get the original. Whatever the cost difference. In my case there was virtually no cost difference. The slow release was considered the standard by now and it was competing with a slow release version of one of the other drugs that was similar. It still took a long time (over six months) to get a Section 15 to cover the slow release pill. In the meantime i was stuck.
I've had other problems with getting the right medication even on appeal. One memorable time was when they turned down my appeal for over a year saying i should take a similar effect drug from another class which was cheaper. The thing was I'd already tried that with 5 drugs from the similar class and my doctor wrote this back to them. They didn't work for me. Not everything works for everyone the same. My appeal was approved after i asked a pharmacist the best way to write an appeal (while being totally honest). He said that instead of writing i had tried other pills from the other class my doctor should list off the name of every other one i had tried. The appeal was successful. But it took over a year. And the way my body treated the two classes of drugs different didn't change. They just got it written in a way that made sense to them.
This is what happens when you have a two tier system. Not right away but sooner or later. In this case it's a two tier system as to what drugs will be covered (despite what your doctor might think or experience that shows three times in one area the generics are a problem). I continue to like to take a generic when it's outside that area because i want the companies to do well. But it's hard when the one's in that class go generic because of the bad experiences. None of them now are likely to go generic for another two years. Which is good news for me because we can work on getting the right combo again (although not with the drugs that worked before because they aren't covered). But maybe we will find it elsewhere.
Two tiered systems don't lead to health. Tell everybody they had to go on the provinces drug plan and there would be changes very fast. The hospitals pharmacist, the specialist they all know that in some cases generics can cause problems, often if one in a drug class causes problems for a person another in the same class will. Once you are up to three problems having occurred in one class (where i am now)it's actually quite likely there will be problems with another generic. The best suggestion medically (according to my doctor and pharmacist) is to not try any more generics in that classes and to continue taking generics where you've never had a problem.
I would guess that for most of you this would be the first time you have heard of this problem with generics. Or the problem with getting an Epipen. It's predictable that the more complaints and the louder the faster a problem will be solved. If it is a problem only for people on welfare or disability it's even harder. First the group effected is smaller and second it's poor. Unfortunately it is the middle class that tends to get listened to when they complain. The rich can afford to go elsewhere (the US for surgery for example). People who are poor are often ignored and they may have less skills in dealing with bureaucracies. Poor people and people with disabilities are a group with very little clout
When it comes to medications people who have private coverage or more money can afford to take what is best for them and if there is a problem there is no complaints that are heard. They just move on to what worked before and (for example in my case) wouldn't get any more generics in the class i seem sensitive too.
Personally i don't generally mind that what anti-biotic i take is partially decided by the government because the one's they suggest work. I can understand trying to limit costs but what they are doing at the moment is just costing everyone. Me, their tax incomes, any hospital costs; it ends up costing everyone more.
As drugs become more important in health treatment and prevention this is going to become a larger problem. I'm not sure i could say what the exact solution is. Ideally it would be everyone being able to fill what prescription their doctor writes. But the failsafes in the system don't even work properly. A reasonable appeal doesn't take 6-9 months. And in fact on the one with the 50mg i've not had a successful appeal and its been almost two years. My doctor's office and the province just keep on bouncing it back and forth between them
There is a final point I'd like to add. When my doctor writes for an appeal it takes time. That time is not covered by OHIP. She is entitled to charge me for it. In my case she doesn't. With people with insurance she will tend to charge for writing letters. This is work however and work that the government is requiring. If you have a doctor not willing to take the time to write without money there becomes yet another barrier. The cost of having anything written. Even if it is for an Epipen that could save your life.
This is what two tiered health care would eventually end up looking like in Canada. I think what the two tiered system of drugs in Canada is, likely predicts what two tiered health in Canada would be. If we can't provide coverage for the drugs people need it cost everyone.
And this is not even keeping track of whole bunch of people who can see a doctor but not afford to even fill the prescription the doctor gives them at all and who have absolutely no coverage at all. If they miss more work it costs society. If they end up in a hospital it costs society. And of course it costs them personally too. But getting that recognized when it's a smaller segment of society is hard. Universality of programs means everyone is stuck with what they deliver. And it is the best way to put pressure on a social program system to perform effectively.
P
