CATIE News

• Researchers find 22% of prescription drug spending in Canada is out of pocket
• Cost of drugs leaves many Canadians cutting back on medication and essentials
• Cost-related non-adherence increases health complications and healthcare burden

Canadian public health insurance plans pay for hospital and physician services that are considered medically necessary. However, prescription drugs are another matter. According to a team of researchers at universities in British Columbia and Ontario, the cost of prescription drugs in Canada is covered by “a mix of public and private insurance plans and out-of-pocket payments by patients.”

Out-of-pocket payments can occur for the following reasons:

• a person lacks drug coverage
• drugs may not be covered by an insurance plan
• they first need to spend a certain amount of money on medicines before insurance coverage takes effect (this initial personal outlay is called a deductible)
• most drug plans offer only partial coverage of the total costs of drugs

In a recently published study, the research team found that out-of-pocket prescription drug spending by Canadians is “substantial.” The researchers stated that in 2014 the figure spent by Canadians was $6.5 billion, or 22% of the money spent on prescription drugs in Canada that year.

Researchers have found that due to out-of-pocket prescription drug costs “many Canadians skip doses or reduce dosages, delay refilling prescriptions or do not fill prescriptions at all to reduce their drug costs—a phenomenon known as cost-related non-adherence.” Furthermore, the researchers found that people who were affected by the costs of prescription medicines sometimes had to reduce spending on basic necessities such as food and heating so that they could spend money on medicines. People who could not afford prescription drugs were found to be at increased risk for medical services—additional visits to a doctor and hospital emergency room—that may not have been necessary had they been able to obtain their prescription medicines.

Study details

The study team collaborated with Statistics Canada and developed questions about out-of-pocket prescription drug costs and their impact on people’s lives. A total of 28,091 people responded to the survey (as part of a broader survey by Statistics Canada) in the first half of 2016. This sample of people was considered representative of the population in Canada.

Results

Researchers found that about 8% of participants disclosed cost-related non-adherence in the past year. People at highest risk for cost-related non-adherence were likely to have the following profile:

• female
• aged 18 to 44 years
• have a low income
• lacked prescription drug coverage

Indigenous people were generally twice as likely as other people to disclose cost-related non-adherence.

Participants from the province of Quebec generally had the lowest rate of cost-related non-adherence, while British Columbia had the highest rate.

Conditions

Prescribed drugs for the following conditions were forgone by the following proportions of participants because of their cost:

• depression, anxiety or other mental health issues – 21%
• arthritis or chronic pain – 16%
• heart disease, abnormal cholesterol levels or high blood pressure – 16%
• infections – 15%
• gut problems (including ulcers, heartburn and bowel disease) – 11%
• asthma or chronic obstructive pulmonary disease – 10%
• diabetes – 8%
• cancer – 1%

(Percentages do not total 100%, as we did not list all conditions.)

The researchers found out that “the out-of-pocket cost of the most recent forgone prescription varied, with half of prescriptions costing $51 to $200. Notably, nearly one-third of those who reported cost-related non-adherence reported that their most recent forgone prescription would have cost $50 or less.”

Consequences for the healthcare system

Based on their survey results, the researchers estimated (by extrapolating their figures to the broader Canadian population) that 375,461 Canadians who engage in cost-related non-adherence developed new health complications or had worsening symptoms of existing health problems. In turn, this change in their health caused them to “use health care services they would not have needed otherwise.”

According to the researchers, this additional use of health services included the following:

• 303,341 people who reported an additional visit to the doctor
• 93,295 people who reported an additional visit to a hospital emergency room
• 26,423 people who reported an additional hospital stay

Making difficult choices

The researchers found that in some cases people who faced out-of-pocket costs for prescription drugs decided to reduce their spending on other areas of their budget. Extrapolating to the larger Canadian population, the researchers estimated that the following numbers of Canadians reduced spending in the following areas:

• spending less on food – 726,706 people
• spending less on other health care – 238,611 people
• spending less on heating their home – 238,178 people

Implications from the present study

The findings from this study have implications for different parties in the healthcare system. Here are the suggestions that the researchers made for prescribers:

• “Consider whether patients can afford their medications.”
• “Consider asking patients if they are making trade-offs” when deciding to pay for medicine, and, as a result, cutting back on food or other necessities.
• “Be aware of the higher potential for cost-related non-adherence and related trade-offs in female patients, Indigenous persons and those with poorer health status.”
• “Be aware that cost-related non-adherence is not limited to expensive medications.”
• “Be aware that the decisions patients make are likely very individual.”
• “Consider that drugs for mental health conditions were the most commonly reported drug class for cost-related non-adherence and be particularly cognizant of cost with patients with these disorders.”

Here is the suggestion that the researchers made that is relevant for health policy analysts and others working in health systems (hospitals and clinics) as well as departments and ministries of health:

“Changing clinical systems to support discussions with patients, with comparative information on drug costs, would also likely help physicians consider what to prescribe, with a view to minimizing the negative effects of cost-related non-adherence.”

Although the researchers acknowledged and detailed some of the problems faced by Indigenous people when trying to access health care, they were unable to provide specific recommendations. They said that many of the barriers faced by Indigenous people are “structural” in nature and could not be addressed by the study, as it was not designed to explore these problems. Hopefully, other research teams will collaborate with Indigenous people to plan studies designed to uncover the specific barriers faced by this population. Such work would lead to the development of strategies to overcome the barriers.

                                                                                                                                                                —Sean R. Hosein

REFERENCE:

Law MR, Cheng L, Kolhatkar A, et al. The consequences of patient charges for prescription drugs in Canada: a cross-sectional survey. CMAJ Open. 2018 Feb 5;6(1):E63-E70.