Who writes your prescriptions?

I always thought it was my doctor who diagnosed my problem, decided on the appropriate drug and wrote a prescription. Boy, was I wrong.

Apparently, there are a great many people telling our doctors what they can and cannot prescribe and when. The latest group to be added to the mix is the Common Drug Review. The CDR is an inter-provincial panel that reviews drugs for purchase and use in situations where the provinces pay for drugs – i.e., for the most vulnerable among us, the elderly, those in hospital, and those unable to afford private drug plans of their own.

The CDR was intended to streamline the process of approval of drugs for purchase by governments in Canada by creating a single window for review. Unfortunately, once Health Canada certifies a drug as safe for use, it is then reviewed not only by the CDR but by the old provincial approval systems (they never went away), and in many cases by further approval committees at the health district and hospital levels, and by independent agencies that oversee drug plans for veterans, public servants and the military (among others).

The result is a great deal of duplication and a continued lack of consistent drug coverage. Veterans, politicians and public servants, for instance, have quite broad formularies (a list of drugs the specific drug plan will pay for) compared to the rest of us. Similarly, the province of Quebec will cover many drugs not available under provincial plans elsewhere in Canada.

Of the 53 drugs that were reviewed by the CDR between 2003 and 2006, 53 per cent were rejected. Quebec, which does not participate in the CDR, rejected only 38 per cent. That translates into 11 new drugs paid for by the government of Quebec that are not paid for elsewhere in Canada because of the efforts of the CDR.

Now, remember, you can pay for ALL of these drugs privately if you wish because all of them have been approved for use by Health Canada.

Yes, that means they have gone through clinical trials and have been approved as safe for human consumption and as having positive and demonstrable effects in the treatment of specific diseases. But in 53 per cent of the cases, public servants decided that the most vulnerable among us should not have access to these drugs. That decision was made because the cost of those drugs to the provincial treasury outweighed the benefit they delivered to affected patients.

Or, at least, we think that was the reason. You see, you and I have no right to know what evidence was considered, what questions were asked, what experts were consulted, or what trade-offs were made when these decisions were reached. That lack of accountability arises because, while it provides this service for the federal and provincial governments, and our tax dollars pay for it, the CDR is technically a private, not-for-profit entity and does not report to you, or to anyone, and is not covered by freedom of information laws.

Let’s be clear. These are hard decisions, decisions that have to be made. But they must be based on the best available evidence and the most accurate definition of total system cost available. They must be made promptly and in a dependable, transparent manner. They cannot be made behind closed doors or in a manner that results in their veracity being in any way in doubt. We must demonstrably account not only for the short-term savings by refusing certain drugs, but the long-term potential costs of other treatments that will be necessary in the absence of those drugs.

Consider private drug plans. Private plans make use of generic replacement stipulations, for example, that allow them to reduce costs and cover more services – a good thing. But normally, if your doctor makes the case that only the brand name medication will work for you, then they allow for that. Simply put, it is better for the insurance company to pay a higher price now rather than risk that you will get sicker and need more – and more expensive – care later on.

This is something the CDR should be considering next time the news is full of stories about bed shortages and staffing challenges: Health is an interconnected system and the cash all comes from one source. Saving on drugs today generally means more spending on doctors, nurses and hospitals tomorrow.

Charles Cirtwill is the acting president of the Atlantic Institute for Market Studies, a non-partisan public policy think tank based in Halifax.