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Canadian MDs help US "drug refugees" bypass high prices
Drug prices may not have been an issue in the campaign leading up to Canada's Nov. 27 federal election, but they were front and centre when the US held its presidential election 3 weeks earlier. People like Bill and Kitty McHugh were the reason. The Narberth, Pa., couple are currently spending enough on prescription drugs every year to buy a new car. Their annual cost — roughly Can$22 000 — helps explain why the couple made an 11-hour, 900-km bus trip to Kingston, Ont., in October to have prescriptions filled. Bill McHugh says it was time well spent. A 3-month supply of drugs for him and his wife — she had a lung transplant 8 years ago — cost Can$5517 in Philadelphia. The price in Canada (Table 1) was 52% lower, at Can$2631. He says one of the pills, the antifungal itraconazole, costs the equivalent of a movie ticket per pill, and his wife takes 4 per day. The McHughs ended up in Kingston because of the convergence of social activists in Pennsylvania and physician activists in Ontario. Alisa Simon, who is in charge of health issues for the advocacy group Citizens for Consumer Justice, organized 2 bus trips from eastern and western Pennsylvania, with one going to Kingston and the other to Hamilton. On this end, physicians from the Medical Reform Group wrote prescriptions for the American drug refugees. "There's a fairly simple reason for the higher costs down here," Simon said in an interview from her Philadelphia office. "In the US, we simply tell the drug companies to charge what they want — there's no negotiating." Simon said that if results of the bus trip to Canada were spread over an entire year, the 37 participants would have saved Can$112 500 annually by buying their drugs here. Before the bus passengers could do that, however, they had to get prescriptions from a Canadian doctor. About half of the visitors to Kingston were seen by Dr. Adam Newman, a local family physician who belongs to the Medical Reform Group. "We did this for free," says Newman, "but I know that one doctor contacted by Citizens for Consumer Justice said he would charge $30 per patient and another doctor said $80. For me, it was a one-time thing to help publicize the situation in the US." Jeff Trewhitt heard a litany of complaints against high drug prices during the US election campaign, but he does not apologize for them. Trewhitt, a spokesperson for the Pharmaceutical Research and Manufacturers of America, says his industry is getting bad press in the US because the focus is always on drug prices and not on the real problem — the fact that elderly Americans have no government-sponsored drug coverage unless they are in a hospital or nursing home. Trewhitt agrees that prices are higher in the US — "most other nations have government-mandated price controls and we do not" — but also points out that the US has the world's most innovative drug industry. According to Trewhitt, it takes the combined strength of all Western Europe and Japan to match US innovation. He also hinted that countries like Canada simply ride American coat-tails, all the while criticizing high American prices but more than happy to use the new drugs these high prices help to produce. "We still have marketplace incentives, and these are essential when you consider that it costs [Can$750 million] to bring a new drug to market." The economic arguments may sound solid, but they hold little sway with Karen Nicholls of Scranton, Pa. Nicholls, who is in her mid-50s, receives disability payments and a small pension because of a work-related injury. She had 11 prescriptions filled during October's bus trip to Kingston, and says the Can$1350 she paid for a 3-month supply would have provided a 1-month supply in the US. "Sometimes it comes down to prescriptions or food," says Nicholls, "and sometimes people play games. They will take their pills only 3 days a week to make them last longer. As for me, my doctor has been very good by giving me samples, and that has got me through."
The story is much the same for 58-year-old Caroline DaCosta of Mercer, Pa., who participated in the bus trip to Hamilton in August. "This issue affects a huge number of people," she says. "I live in an upscale area, and you'd be surprised how many people have no [drug] coverage. Either they can't afford to buy it or they can't get it because of pre-existing conditions. I have Medicare [it provides medical coverage to the disabled and those over 65] but it doesn't cover drugs, so I go begging for samples. It was sad to hear the stories I heard on that bus trip, with so many people having to decide between food and drugs."
But Trewhitt argues that his industry is simply a victim of its own success. When the US Medicare program was being launched 35 years ago, drug coverage wasn't an issue because the number of new drugs under development was small. "Ten years ago there was no treatment for Alzheimer's disease. Now there are 3 drugs on the market and 23 more in clinical trials. This means that patients have all of these additional choices, but there is still no coverage."
Trewhitt said the industry agrees that change is needed, but that change should involve insurance coverage, not pricing restrictions. "Put it this way," he says. "In Canada, price controls are in the range of 25% to 40%. If you're taking a heart drug that costs $100 a month, that means you're still paying $60 to $75 to fill your prescription, and many of these people still can't afford that. The answer is improved coverage."
Simon says Americans will face a difficult battle in changing the system. Politicians, she says, are often deaf to their pleas because the pharmaceutical industry spends more on lobbying than any other group. And that lobbying wins the attention of a lot of politicians.
However, she thinks they may now be forced to listen. "Eighteen months ago no one talked about this issue, and now they can't stop talking." She added that the price of prescription drugs was a key election issue that helped the Democrats win some tight races.
As for the future, Simon says: "That's it for the bus trips. Now we're going to focus on solutions." — Patrick Sullivan, CMAJ Be cautious when prescribing to Americans, doctors warned
Should more Canadian doctors be helping American patients buy cheaper drugs in Canada? The College of Physicians and Surgeons of Ontario and Canadian Medical Protective Association (CMPA) have both issued warnings on the topic. Dr. John Carlisle, the college's deputy registrar, says that under Canadian law it is improper for a physician to write a new prescription or countersign one without taking appropriate steps to reach a diagnosis, formulate a treatment plan, provide the necessary information and obtain consent. "What may, on the surface, seem like a simple transaction ("just sign here") with a favourable financial incentive for you can go sour if civil litigation or a regulatory complaint occurs," Carlisle wrote in a recent issue of the college's Members' Dialogue. He says care provided to visiting Americans "should meet the same high standards as that provided for our citizens."
Meanwhile, the CMPA warns that a Canadian physician who is sued in the US over a service provided in Canada will not be eligible for the association's help if the service provided was solicited through advertising or other means. Coverage will be provided if the suit is launched in Canada.
Dr. Adam Newman, who helped write prescriptions for a busload of American patients who came to Kingston, Ont., last October, didn't seek legal advice before meeting them. Instead, he had them sign a waiver that had been drawn up for the Medical Reform Group by a lawyer. "The CMPA says it won't defend doctors who are sued in the US," says Newman, "so the waiver says that if anyone brings action against me, they have to do it in Canada."
He says the most common prescriptions he wrote were for ACE inhibitors and calcium-channel blockers. "The patients had either a letter from their physician detailing their conditions or they brought their prescriptions with them," he said. "The experience was entirely different from what I'm used to. For one thing, I feel a bit of a failure if I have a patient taking 9 different medications. As for seeing them, I made clear that I wasn't trying to be their family doctor. I simply told them, 'This is what your doctor says you can take.' "
Copyright 2001 Canadian Medical Association or its licensors |
