I’m in the middle of moving from Nova Scotia to Prince Edward Island and all that entails. I am aware that we’re fiercely proud of our provincial cultural differences here in the Maritimes (try debating who has the best lobster) so I expect a few things to be different, but not necessarily pharmacare. After all, it is the “Canada” Health Act and the universe in universal health care is supposed to be the entirety of Canada. This got me thinking of some of the more interesting contradictions in how pharmacare rules and practices have varied across provincial boundaries. This is somewhat of a current to rear-view mirror look. I am more hopeful on potential changes for the future.
My favourite cross-border pharmacare contradiction remains how Quebec and Ontario ruled differently on generic substitution for the drug Concerta when it lost its patent back in 2010. Before going there, I feel compelled to take a minute to go over the difference between “bioequivalent”, “interchangeable”, and “identical” as they relate to generic drugs. If you already know this, then skip ahead but recognize that you are in the minority. Just ask my former pharmacist who chose to stare me down and insist that their store-branded Ibuprofen was “identical” to Advil.
Health Canada holds the definition for when a generic drug is “bioequivalent” to the original brand drug. The heart of that definition is that the active ingredients of the drug must be identical. Well … not quite. If you want to get specific, the active ingredient must be between 80% and 125%. As a colleague of mine so startlingly put it, if it were your daughter on a generic birth control pill, you’d probably like to get the 125% of the range and hope you don’t get 80%. The generic drug can then be different in all kinds of other ways: fillers, colour, shape, coating, release mechanisms, etc., not to mention manufacturing quality. So, a generic drug is not “identical” to the original brand. Nor are two difference generics “identical” to each other. Unlike where a federal agency (Health Canada) determines the scientific bioequivalence, each province then determines “interchangeability”. This is because interchangeability is as much a financial decision as it is a scientific one. When a drug is declared interchangeable, it effectively means that the government will only pay the generic price, regardless of whether you get the generic or the original brand dispensed. Thus ends the tutorial.
Back to the ADHD drug Concerta. When Concerta lost its patent protection in 2010, Ontario declared generic methylphenidate ER to be interchangeable with Concerta whereas Quebec did not. This is not the first time that provinces have not been aligned on interchangeability but what makes me scratch my head on this one is that there was a lot of considered debate on whether the generic methylphenidate ER was “as good as” brand Concerta. Yet two provinces that share a border literally came down on opposite sides of the fence. A parent in Gatineau with a child who had been responding well to brand Concerta could carry on as usual whereas a parent living across the river in Ottawa would either have to shell out more money to stay on the brand or take a chance with the generic.
The irony of the Concerta story is that Quebec decided to continue to reimburse the brand. This from a province that distinguishes itself from other provinces in its approach to pharmacy ownership, pharmacy allowances, and patient choice cards. Allow me to elaborate.
A pharmacy allowance is often called a “kickback” as it is a payment made by a generic drug manufacturer to a pharmacy owner for dispensing a generic drug. This practice was at the heart of the generic reform that happened circa 2010 in Ontario and then across Canada with the result that now, in almost all provinces, pharmacy allowances have been banned … but not in Quebec. Quebec never quite got there and maintained a 15% cap on allowances that could be paid. Then in April of 2016, Quebec proposed new legislation to get rid of the cap entirely over a 3-year period, resulting in unlimited kickbacks. Couple that with the fact that pharmacies must be owner-operated in Quebec and does this not create a conflict for a pharmacist there to have an unbiased discussion with a patient on the decision to substitute a generic drug? Maybe the current move in Quebec to ban “frais accessoire” from physicians will set a precedent for change on this position on pharmacy allowances.
Like BC, Quebec has also taken the position of banning points from “fidélité” (loyalty) programs for prescription drugs but the college of pharmacists there (the “OPQ”) has taken the extra step of implying that patient choice cards, that pay the difference between the brand and generic, are also loyalty programs. This is a clever inference that has pharmacists in Quebec scared to accept patient choice cards and even worse, other payment cards for things like samples and patient assistance for high cost drugs. Sorry about the long path to get here but remember that parent in Ottawa? Well, he/she could use a patient choice card for Concerta and stay on the brand just as if they were living in Quebec. But a patient in Quebec who wants to stay on the brand for Lyrica, by example, doesn’t seem to have that choice because Quebec has deemed Lyrica to be interchangeable and, due to a confusing position taken by the OPQ, pharmacies in Quebec often won’t accept patient choice cards.
To sum up, I think some differences in pharmacare across provincial boundaries are to be expected, especial since the funding for pharmacare is managed provincially. But I’ve thought too hard about the examples I’ve laid out and can’t really make sense of the rationale for the contradictory decisions taken by the different provinces. I remain bullish though on the winds of change that may result in more provincial alignment and legislation that puts the patient first.
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