The motivation for this piece came from thinking deeply for two years about pharmacare. The thinking proved to be circular and went nowhere.
And from a piece in the New York times today on the role of government in solving massive social problems. The private sector can’t do that without some involvement of government. It is synergistic with the private sector and government working together.
An example of this is the new Pfizer coronavirus vaccine. The US government created the Warp Speed Project and put in an advance order of US$1.95B for Pfizer vaccine. This gave Pfizer the initiative to commit dollars to research and development of the vaccine. The combination of government and private sector lead to this extraordinary success.
Here’s the problem that we have in Canada. Advanced cancer drugs and drugs for rare diseases are very expensive. Some are hundreds of thousands of dollars per patient per year. Doctors are hesitant to prescribe them. Patients miss out on the opportunity to use them. And private insurers of drug plans are, in many cases, not paying for them.
So we need a solution. This requires a creative process to generate a unique solution. And a creative solution is usually the result of a new combination that solves the problem and creates value for all the parties involved.
The real problem is the inertia that this creative solution will meet in the real world. Unless, for some unknown reason, this idea gains traction and results in an actionable plan by both government and the private sector. Activists might play a role in this process.
Here is how this plays out.
R.D. was 65 years of age. He was diagnosed with pancreatic cancer in March 2020. He had a surgical procedure called a Whipple. This removed the entire pancreas. He had a very skillful surgeon who was able to secure operating room time during the COVID lockdown. Not a trivial matter.
The pathology showed that there was micro-vascular spread. So chemotherapy started. It was challenging for R.D. Then he had targeted radiation.
R.D. asked the team at RCM Health Consultancy to organize genetic testing of his cancer. We sent tissue to a special lab for molecular profiling. This was paid for privately. The results came back showing that he would benefit from Olaparib. This is called targeted therapy. The drug targets the mutations in the DNA of his cancer. This is the approach taken at world class cancer centres like M.D. Anderson, Memorial Sloan Kettering and Dana Farber. Some cancer centres in Canada have a limited programme of this kind.
R.D. had an insurance plan that paid for prescriptions. His medical doctor wrote the script for Olaparib. And the insurance company reviewed this request and wrote back that they were going to take 9 months to review the request. That was improper. It was a breach of his contract with the insurer.
When you look at the economics of drug plans from the insurer’s perspective, it is clear. They have to conserve capital to stay solvent. They have not reserved properly to pay for these advanced cancer drugs.
So here is where the government enters the picture to solve this massive societal problem.
Dr Eric Hoskins transitioned from the Ontario government to the Federal government to introduce pharmacare for all. That did not happen.
So, for Dr Eric Hoskins and his team at the Federal government, here is a more likely playbook. The government could provide a backstop for the private insurers. This is called reinsurance.
For example, if the drug claim to the primary insurer is over $30,000, then the claim would be sent to the government for payment. Anything less than $30,000 would be paid by the primary insurer. Only a government has the deep pockets required to pay for these expensive drugs.
This would be a form of pharmacare for catastrophic drug costs. This would be an excellent example of the government working with private industry to solve a massive societal problem.
So here’s the challenge for the private sector and government to start to talk about moving in this direction before R.D. initiates his class action legal action and involves thousands of other patients and their families in this effort to fund advanced cancer drugs.
Catastrophic pharmacare can only occur if government and the private sector work together.
I invite those interested in this matter to join the converation.
Raymond Rupert patient advocate and healthcare consultant.