Beyond Pharmacare

It's more bubbling under the surface than being a headlining issue, but national Pharmacare is steadily becoming a major point of conversation within the medical community. Most countries with universal healthcare include some form of provision of pharmaceuticals, if not outright coverage - Canada is the notable exception. As such, Canada has now become a patchwork collection of private insurance, industry-provided samples or give-aways, public welfare programs, and out-of-pocket purchases in order to provide these drugs to patients. It's not a particularly efficient approach, with high costs for patient health, economic prosperity, or even balance sheets for government agencies.

What gets lost in the conversation is that when it comes to healthcare coverage in Canada, it's not just drugs that get the short end of the stick, it's most therapeutic interventions. Big, hospital-based treatments - surgeries, inpatient stays (including medication), dialysis, etc - are still covered, but non-pharmaceutical outpatient therapies rarely get adequate funding. The two that spring to mind most readily are physiotherapy (PT) and mental health therapies, notably Cognitive Behavioural Therapy (CBT). PT is a main component of treatment for most non-critical musculoskeletal injuries and in many cases, may be the only or main component to effective treatment. CBT is the first-line treatment for most cases of anxiety (which is exceedingly common) as well as a component in many other mental health treatment plans.

There are now some funded programs for both PT and CBT, but they naturally have long wait-lists. As a result, the rest falls on private insurance and out-of-pocket spending. The concern, as with medication, is cost. PT and CBT both involve having a qualified healthcare provider spend significant time with a patient. In-person contact is expensive and the public healthcare system is understandably hesitant to provide coverage, particularly if these treatments need to go on for some time.

In most cases though, neither PT nor CBT should go on for an extended period of time. PT and CBT have primary benefit when they teach patients exercises or skills to deal with their conditions. A single PT appointment may be enough in mild cases. CBT requires a few more, but a short course is often sufficient if the patient is compliant and motivated. There's always the possibility of therapy needing to go on longer than intended - but the same can be said of medication.

I'm very hopeful that Pharmacare becomes a reality - I've already seen far too many patients struggle with getting necessary or helpful medications. No doubt more fail to get important medications without their healthcare providers being aware, as research on compliance with medications in the setting of economic difficulties makes absolutely clear. Yet, as coverage for medications expands, I do worry about these outpatient-based, non-pharmaceutical therapies falling by the wayside, especially when these interventions are often more effective than pharmaceutical alternatives. Looking towards my future practice, I find myself taking a decidedly "drugs if necessary, not necessarily drugs" attitude. I want a public insurance system that supports such an attitude.