Addressing inequities in cardiovascular drug access

A new study assessing provincial and territorial variations in reimbursement criteria of drug coverage for patients covered by Canada’s public pharmacare programs for two common cardiovascular conditions revealed significant inequities and deficiencies in access to medications and treatment. The article appearing in the Canadian Journal of Cardiology, published by Elsevier, exposes the complexities of the Canadian drug review process and makes a case for a unified framework to improve the present infrastructure, moving towards ensuring the best care for patients with cardiovascular disease.

Canada has been praised for its universal healthcare system and low drug prices, yet it is the only country with universal healthcare that does not provide global coverage for prescription medications. Only a third of Canadians are eligible for publicly funded drug plans. Current Canadian drug review decisions are complex, and coverage decisions vary widely across the country. Reimbursement decisions are often discordant with Canadian guidelines, resulting in an inability to provide guideline-recommended cardiovascular evidence-based care.

“Can the Present Canadian Health Care System Provide Evidence-Based Pharmacare? Consideration of Two Important Cardiovascular Clinical Contexts” compared all provincial drug formulary reimbursement criteria for medications recommended to treat heart failure with a reduced ejection fraction and antiplatelet therapies in acute coronary syndromes, two common cardiovascular conditions, based on the most recently updated Canadian Cardiovascular Society (CCS) guidelines. The study assessed whether reimbursement criteria were concordant with listing recommendations from the Canadian Agency for Drugs and Technology in Health (CADTH) and with CCS cardiovascular therapy guidelines.

Commenting on the findings of the study, co-lead investigator Morgane Laverdure, MD, Division of Cardiology, University of Ottawa Heart Institute, says, “Our study showed that CADTH recommendations were only followed 33% of the time in the 24 medications reviewed, and that almost a quarter of reimbursement approvals (23%) were discordant with Canadian guidelines. Furthermore, novel drugs disproportionately carried the highest discordance with evidence. No systematic process exists for formulary updates based on new evidence, changes in guidelines, or drug pricing.”

In an accompanying editorial “Bureaucratic Dissonance and Inertia: Barriers to the Effective and Equitable Implementation of Cardiovascular Guideline-Directed Medical Therapy in Canada,” Jafna Cox, BA, MD, FRCPC, FACC, Dalhousie University, and Division of Cardiology, Queen Elizabeth II Health Sciences Centre, notes, “Canada’s publicly funded healthcare system is not a monolithic entity. All 13 provinces and territories have their own healthcare insurance plans, with unique priorities. But the federal government has set national standards on key aspects of care through the Canada Health Act. These include comprehensiveness, universality, portability, and accessibility. Whereas patients in some provinces (or regions within provinces) might experience relative delays owing to resource constraints, all residents of Canada ultimately have reasonable access to medically necessary physician and hospital services without out-of-pocket costs. Access to prescription drugs is entirely another matter, and many Canadians are likely unaware of the implications.”

The study identified several key findings:

• There is substantial redundancy with multiple tiers of agencies in drug approval processes across provinces and territories.
• Despite the initial common Health Technology Assessment in all provinces but Quebec, there are significant interprovincial variations in final drug reimbursement approvals.
• There are no protocols in place in any province to permit timely updates of formularies to account for novel evidence in cardiac drugs or change in pricing.
• 23% of all formulary decisions in the study are discordant with guideline-based recommendations.
• Formularies are also discordant amongst themselves, highlighting the complex and inconsistent process for reimbursement decisions.
• Based on the two commonly encountered cardiovascular scenarios in this study, no current drug formulary permits complete evidenced-based cardiovascular care.
• The Non-Insured Health Benefit federal plan and the Quebec plan, the only one not relying on CADTH’s recommendations, were the two plans most concordant with current CCS and its affiliate societies’ guidelines and best evidence.

Dr. Cox comments, “Wherever we live in Canada, we pay similar taxes in the expectation of receiving comparable healthcare. While this is largely the case concerning physician and hospital services, Laverdure and coauthors have clearly shown that drug coverage is entirely another matter. Not only can access to basic guideline-directed medical treatment become restricted for especially older and lower income patients dependent on public drug plans, there are clear inequities across the country depending on the plan providing drug coverage.”

Provinces use different criteria to determine which patient populations are eligible for public drug plans. Most provinces rely on income-specific and/or age-specific eligibility. Some provinces also include disease-specific eligibility, for example, allowing patients in palliative care to be covered regardless of their age or socioeconomic status.

Co-lead investigator of the study Derek Y.F. So, MD, Division of Cardiology, University of Ottawa Heart Institute, concludes, “The current system leads to significant inequities, with Canadians residing in different provinces having varied access to different evidence-based medications and treatment. While solutions are being explored, the limited and inconsistent provincial drug formularies may compromise the health of many Canadians, especially for the most vulnerable groups relying on publicly funded drug plans. Future plans for universal pharmacare should consider timely and systematic triggers for updates of formularies to account for novel evidence. A simplified and consistent process can ensure that the same patient populations are covered and have access to the same medications regardless of their place of residence. By enabling access to evidence-based medications, the health of Canadians can be better addressed.”

Dr. Laverdure adds, “The situation of fragmented pharmacare within the same country is not unique to Canada. Indeed, several other countries such as Sweden and Norway have a similarly decentralized healthcare system with strong regional control over services. The findings of our study, as well as the potential solutions explored, can therefore be of interest for other international jurisdictions.”