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Health as if everybody counted blog

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So you think you have free health care?

Posted by guest blogger Sarah Giles
guest blogger Sarah Giles
Sarah Giles is a family physician with an interest in remote and rural medicine.
User is currently offline
on Tuesday, 09 October 2012
in CHNET-Works!

Many doctors do not openly discuss the social determinants of health. It's the dirty little secret of Canadian medicine: income makes a huge difference to your health. In the land of "free" health care, living in poverty is still going to have the biggest effect on a patient's health.

At the recent Canadian Medical Association annual meeting in Yellowknife, doctors finally seemed to acknowledge the poverty=poor health situation. Why has it taken so long for doctors to acknowledge the problem? A cynic might say that it is because the vast majority of doctors come from privileged backgrounds, have an income in the top 5% of Canadians, and generally don't care about or understand the poor. A more forgiving person might argue that, coming from such privileged backgrounds and having little to no formal teaching on the subject, many doctors are unaware of the devastating impact of poverty on their patients. And, in fairness, some doctors do not get much exposure to the poor.

A wise physician once told me: "If you don't know your patient's financial situation, you don't know your patient." Truer words have never been uttered. Yesterday I saw a wheezing little boy in clinic. He is a known asthmatic who had not taken his puffers in 3 months. It would have been easy to dismiss the mother as lazy and "non-compliant". Instead, the aunt (who recently gained custody of the little boy), explained to me that she was now looking after 4 children and could not afford the insurance co-pay on these potentially life-saving medications. She didn't qualify for income support and she had insurance – but she still couldn't afford the medications. So much for universal health care.

Patients with low socioeconomic status face a number of challenges within our system. For the homeless, the first challenge is getting a health card. You need a fixed address to get one and then the organizational skills to hold on to it and renew it every few years. Small wonder that the homeless go to the ER more than almost any population – that's the only place they will be seen without a health card.

Let's say that you are on income support or disability. Your health should be good, right? You likely have housing, get your meds covered, and can even access some allied health resources. But can you afford to eat? Studies show that, actually, in Ontario you can't afford to eat a healthy diet on income support. And, even if you could, you likely live in an area where there are lots of expensive "convenience" stores but very few places to buy fresh produce or healthy foods with a short shelf-life. It's much easier to buy crappy food than anything with nutritional value. So, you put on some weight and develop diabetes. Your meds are covered but since your family doctor isn't part of one of those fancy health teams that you get in rich neighbourhoods, you can't access a dietitian because you Community Health Centre hasn't been able to fill the position and all of the other dietitians charge $70 per hour to tell you what you already know – eat better (more expensive and inaccessible) food.

giles-guest-blog-pic-1 giles-guest-blog-pic-2
Healthy foods are available in some low-income neighbourhoods,
but often "it's much easier to buy crappy food."
Photos: T. Schrecker

Now let's pretend that you have developed crippling insomnia. You can't sleep. You got fired from your last job for falling asleep during the day because you couldn't sleep at night. You are now on income support but that's going to run out soon. You are sure you could get back into the work force if you could just sleep six hours per night. You have tried trazodone and amitriptyline – the infamously ineffective sleep aids – but they didn't work. Your doctor now gives you an option: try zopiclone – a sleep aid that works and has little addictive potential – or try clonazepam – a highly addictive benzodiazepine that requires higher and higher doses as your body becomes habituated to it and a drug with considerable street value. The choice is obvious, you want zopiclone. Unfortunately, the provincial formulary will only cover the highly addictive medication with a street value. Zopiclone will cost you at least a dollar a day – a dollar you don't have.

Nobody ever claimed that life was fair. It is intuitively obvious that the more money you have, the more access you have to goods and services. But should money make such a difference that it can determine how healthy you will be or how long you will live? If we, as Canadians, want to continue to be proud of our "universal" health care, we need to make some changes.

Provincial and non-insured health benefits (NIHB) formularies are set by a bunch of experts sitting in a room. The formulary, to those of us in practice, seems to be arbitrary. There is no explanation as to why one drug is covered and another is not. Recent drug shortages have made life even more difficult as drugs that I would commonly substitute in for a short drug are often not on formulary (for instance, amitriptyline is covered but we couldn't get any; gabapentin is not covered for anything other than seizures so I had nothing to give my patients with neuropathic pain). I'm not sure why we need ten drugs in one category covered when we could have three instead, buy in bulk, and use those savings to incorporate other drugs into the formulary.

Provincial and NIHB formularies need to help doctors decrease addictions to opioids and benzodiazepines. They could do this by covering medications that are currently believed to be less addictive. For instance, I can prescribe OxyNeo (the new version of Oxycontin) until the cows come home but prescribing a long fentanyl patch or long acting codeine requires special forms. Doctors can prescribe massive doses of narcotics but need a special license to prescribe the meds required to help people break their addictions (Suboxone and methadone). Certain non-steroidal anti-inflammatory drugs (NSAIDs) require special permission but massive doses of benzodiazepines don't raise flags in the system. Private insurance fills these gaps for many patients, but creates a two-tiered system.

When poor people get injured their lack of access to out patient allied health services (such as physiotherapy) and non-addictive medications decreases their chances of returning to the work force. If outpatient allied health services were easily available to patients, they would be able to get off of income support faster and be less likely to remain in chronic pain.

Imagine if the thousands of people off work for mental health reasons were able easily to access free psychological help? In Ottawa, the going rate for a psychologist is $160/hr. I know of very few people who can afford this. If they could afford it, many people could remain in the work force or stay off of the streets. Instead, we rely on NGOs to provide care that should really be universally available.

In short, I'm sick of being a doctor who sees such discrepancies in the availability of care, medication, and overall health status between the poor and the rich. I am glad that the CMA is finally taking note of the problem – but how are we going to address it? Having the current Canadian government pull the social safety net out from under those who have the most precarious balance is not going to help matters. Is it only a matter of time before I recommend that patients find a way to get sent to jail so that they can get the medication, rehab, and care they require? There has got to be a better way.

Affordability of medications: (re)discovering the obvious

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 17 August 2012
in CHNET-Works!

In an earlier posting, I mentioned research by Canada's Dennis Raphael, among others, on the difficulty of managing diabetes on a low income. The cost of a healthy diet is a major part of the problem; another is the cost of medications. In Ontario, prescription medications outside hospital are covered by public health insurance only for people over the age of 65 and for those on extremely low incomes. A new study by researchers at the University of Toronto (1) points out that this may be having a substantial impact on the health of people with diabetes.

We already knew that mortality among high-income Ontarians with diabetes has been declining faster than it has among those with low incomes, leading to a widening equity gap. Starting with a health records database including almost all Ontarians with diabetes and using median household incomes in the Statistics Canada dissemination area where they lived as a proxy for an individual's own income, the researchers found that the socioeconomic gradient for death, acute myocardial infarction (AMI) and stroke is substantially steeper among people under 65, who either pay out of pocket for their medications or rely on private insurance, than it is among those 65 and over whose prescription drugs are covered. "[A]s many as 5,000 deaths and nearly 2,700 AMIs or strokes could have been avoided among younger and middle-aged adults with diabetes if the gap between wealthier and poorer individuals had been identical to that seen among older groups. "

affordability-car-accident-If we could eliminate vehicle accidents as a cause of death in Ontario, wouldn’t we give it a shot?
Photo: Sean Whaley/Nevada News Bureau, reproduced under a
Creative Commons Licence 3.0.
To put that figure of 5,000 into perspective, that's the total number of people who died in Ontario motor vehicle accidents from 2002 through 2007, the years covered by the new study. If we could eliminate such accidents as a cause of death in this province, wouldn't we do it? And since the study looked only at the portion of the population with one disease, the overall toll of avoidable illness and death associated with lack of universal public insurance for prescription medications ("pharmacare") is almost certainly higher.

Lack of pharmacare kills, in other words. Nothing is especially new about this realization. The new study cites previous research on the problem of drug costs for diabetics ... and it's now been more than a decade since a landmark study by Robyn Tamblyn and colleagues showed that emergency department visits and hospital admissions increased, and use of essential medications decreased, after Québec introduced co-payments in its public drug coverage for senior citizens.

Pharmacare is not just an equity issue; it's also an efficiency issue. The market power available to a single public purchaser could be important tool for cost containment. Indeed an important analysis published in the fall of 2010, which appears to have sunk without a trace, suggested that the lack of pharmacare is one of the reasons that prescription drug costs in Canada have been growing faster than in most other OECD countries, and argued that national pharmacare would reduce drug costs by 11.7 – 42.8 percent relative to current practice.

Failing to provide public insurance coverage for prescription drugs outside hospitals doesn't save money. It simply means that fewer costs are borne by the public treasury, and more by private insurers or people who may not be able to pay out-of-pocket, sometimes with fatal consequences.

At least under the current national government, there seems no hope for a federally initiated program. Ontario is one of the few provinces that are probably large enough to go it alone; a consortium of smaller provinces could do the same. Until that happens, the avoidable illnesses and deaths will continue, and we who are concerned with equity should laugh hollowly at all official claims that health policy is evidence-based.

(1) Unfortunately, full text is not available for open access

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