Honourable George Smitherman
Minister of Health and Long-Term Care
10th Floor, Hepburn Block
80 Grosvenor Street
Toronto, ON M7A 2C4
August 11, 2006
Dear Minister Smitherman:
As the professional association for registered nurses in the province, the Registered Nurses’ Association of Ontario (RNAO) is gravely concerned about the proposal before you on cancer drugs not funded by the government.
You have received a proposal that patients be allowed to buy non-government funded cancer drugs, and pay to have those drugs administered by public hospitals. This proposal appears in the Report of the Provincial Working Group on the Delivery of Oncology Medications for Private Payment in Ontario Hospitals [PDF - 138 KB]. At risk are three key principles:
- Equitable access to health care based upon need
- Ethical working conditions for nurses
- Sustaining and strengthening Medicare
The range of treatment options available in our public hospitals must be based on medical need, rather than on a system of privilege. Allowing patients to pay for drugs and treatment service is a significant step towards establishing and normalizing a two-tier hospital infrastructure. The B.C. Cancer Agency does not allow this practice in its cancer hospitals, in light of the Canada Health Act.
Registered nurses do not want to work in a system that provides differential access to health care, determined by a patient’s ability to pay rather than the care they require. These proposed changes benefit only the most affluent. Since drugs that are currently inaccessible because of cost to the public system would remain unfunded, these expanded treatment options would remain out of reach for vast majority of Ontarians. RNs would be placed in a most difficult ethical position: patients with identical diagnoses in the same hospital would receive different care due to their individual access to resources. This clearly violates nurses’ ethical code, and runs counter to the principles and spirit of both the Canada Health Act and Ontario’s Commitment to the Future of Medicare Act. The private-pay and universal access environments are not compatible.
We understand that the Provincial Working Group was charged with the task of developing a framework for administering unfunded oncology medications. We propose, however, that the report would have addressed a greater, overarching concern by asking instead: in a context of rapidly changing technology, how do we best serve the needs of people requiring complex treatment while maintaining the fundamental values of the Canada Health Act?
Instead of implementing private-pay arrangements in hospitals, RNAO proposes the following steps to benefit all Ontarians, including cancer patients:
- Develop a pharmacare program governed by the five principles of the Canada Health Act
Ontarians should receive first-dollar coverage for essential pharmaceuticals. Prescription drugs should be part of a health-care system that must cover essential medical and hospital services by law. Medically necessary cancer drugs would be included.
- Use government purchasing power to negotiate lower pharmaceutical prices
Bill 102, the Transparent Drug System for Patients Act, seeks to control pharmaceutical prices. The cost of drugs has risen sharply in recent years, consuming a growing share of the health-care budget. The government should use the Act and any other tools at its disposal, including its purchasing power, to secure more sustainable drug prices.
- Expand public provision of currently unfunded, effective medications by enhancing government affordability
Given budgetary constraints, there will always be effective medications (for cancer and other diseases) which do not meet the cost-benefit threshold. However, the government may be able to negotiate more favorable terms that could allow more of these effective medications to cross the public affordability threshold. Ideally, drugs that remained unfunded would provide very little net benefit over funded drugs. More generally, the government ought to develop a strategy to pay for all essential health-care services. This is the best protection of the single-tier system; whenever essential services are not covered by public health insurance, they will be paid for privately and only accessible to those who can afford them. Ontario only publicly paid for 67.2% of health-care expenditures in 2005 -- less than any other province in Canada, and a significantly smaller share than the 75.3% of health-care expenditures the province paid in 1975.
- Fund effective but unfunded cancer drugs under the Trillium Drug Program
If unfunded cancer drugs are safe and effective, and if they offer significant benefit over funded drugs, the government should make those drugs eligible under the Trillium Drug Program. The Trillium Program should change from a reimbursement program to one which makes direct payments, so that access is unimpaired by ability to pay.
- Maintain full rigor of pharmaceutical testing
If the public system is pressured to expand access to new or experimental drugs, it must not cut any corners in testing. Ontario must continue to rigorously evaluate the evidence about new cancer drugs.
The delivery of for-pay cancer medication services in hospitals would contravene the principles of the Canada Health Act and would put hospital RNs in an unethical position. Rather than compromise Ontario’s hospital environment, RNAO urges the government to take the above steps to improve access to pharmaceuticals within the publicly-funded system.
Minister, we would be pleased to discuss this critical concern with you at your convenience.
Doris Grinspun, RN, MSN, PhD (cand) O. Ont.
Executive Director, Registered Nurses’ Association of Ontario
cc: Premier Dalton McGuinty
Robert Bell, President and CEO, University Health Network, co-Chair of Provincial Working Group on the Delivery of Oncology Medications for Private Payment in Ontario Hospitals
Robert Devitt, President and CEO, Toronto East General Hospital, co-Chair of Provincial Working Group on the Delivery of Oncology Medications for Private Payment in Ontario Hospitals
Terrence Sullivan, President and CEO, Cancer Care Ontario, Resource Person for Provincial Working Group on the Delivery of Oncology Medications for Private Payment in Ontario Hospitals