Could Quebec’s public drug plan work for national pharmacare?

Quebec’s universal pharmacare program offers better drug coverage and quicker approval for new drugs coming to market than the rest of Canada, according to a new study by the Fraser Institute.

Looking at drugs approved by Health Canada between 2008 and 2017, the report found Quebec went on to cover 33.4 per cent of them, compared to an average of 26.5 per cent in the rest of Canada.

It also takes Quebec far less time to begin covering drugs approved by Health Canada, at an average of 477 days in comparison to an average of 674 days in other provinces. Quebec’s formulary, which covers more than 8,000 prescription drugs, is also more generous than other provinces, giving patients access to a wider range of drug options than they might get in another province. As a comparison, the report noted Ontario’s Drug Benefit formulary covers 4,400 drugs.

Read: Lessons for Canada from pharmacare systems around the world

“I think [Quebec’s plan] is an achievement,” says Yanick Labrie, the report’s author and a senior fellow at the Fraser Institute. “When you look at the access to medication, in Quebec we’re doing a much better job than the rest of the country.”

Quebec’s public-private system has helped keep patients’ risk of catastrophic drug costs low, says Labrie. As of 2009, just 0.2 per cent of the population faced drug costs that were higher than nine per cent of their income, in comparison to 1.1 per cent in the rest of Canada.

Quebec’s pharmacare system, established in 1997, provides a minimum level of drug coverage through the public plan for people aged 65 and older and who receive social assistance, as well as for Quebecers ineligible for private insurance with an employer. Private plans must offer at least the same coverage as the public plan, though often offer more.

Currently, 57 per cent of Quebec’s population, or 4.7 million people, are covered by private plans, and the remaining 43 per cent fall under the public plan.

Read: A primer on the parliamentary report on pharmacare and its impact on the benefits industry

Labrie says Quebec’s model could be an effective solution to the question of what a national pharmacare system should look like. “The reason I studied the Quebec model was I wanted people to know the type of achievements you could expect [from] a so-called fill-in-the-gap approach,” he says. “There is a large portion of the population currently insured by their employer . . . and do you want to get rid of that type of drug plan that people appreciate? I don’t think it would be a solution. You have to cover people who are currently either underinsured or have no insurance at all, but I don’t think you need to have a complete overhaul of the system to do that.”

Suzanne Lepage, a private health plan strategist, agrees it’s a viable option. “It provides an opportunity for public and private to co-exist, which is important, and it also allows for employers to provide a minimum level of coverage as mandated by the government, but then they can offer better coverage,” she says. “I think what we want to be able to see going forward is that not everyone’s brought down to the lowest common denominator, which was what universal pharmacare would offer, but allows employers to offer equal to or better coverage as needed.”

Allowing for private plans within a universal pharmacare model, as in the Quebec system, provides employers with the option to tailor coverage to their business needs, says Lepage. “One of the biggest distinctions between public and private drug plans is when public drug plans evaluate drugs, generally speaking, . . . they don’t consider the importance of keeping employees healthy and productive at work. That’s not part of their mandate.”

Read: Industry responds to expert panel’s pharmacare report

In its final report, the expert panel on national pharmacare said it considered Quebec’s model but ultimately decided the advantage it presented was outweighed “by the longer-term efficiency and sustainability of a single-payer model.”

The Fraser Institute’s report noted the Quebec government is expected to pay $3.3 billion for public coverage in 2018-19, and patients covered under the public plan are expected to pay an additional $921 million in annual premiums, coinsurance or monthly deductibles. The most an individual on the public system pays is $93.08 per month, or $1,117 annually. Low-income seniors, people who receive social assistance, those with serious disabilities and children covered under the public plan receive full coverage with no premiums.

Private plans in Quebec, according to the report, are expected to pay a little over $5 billion on prescription drugs in 2018-19. The province also has a maximum annual contribution level for people covered under public plans, which must be equal to or lower than the public plan.

Critics of Quebec’s system have decried the rising costs of the public plan. Indeed, the report found prescription drug expenses are higher in Quebec than most other provinces, at $1,140 per capita as of 2016. In contrast, drug costs in British Columbia were $799 per person.

Read: Sanofi survey finds plan sponsors, members misunderstand private drug plans

However, looking at the full picture, says Labrie, while drug spending in Quebec is higher, overall health costs are lower. The province paid $6,159 per capita in overall health-care spending in 2016, the lowest in the country.

“There’s a substitution of treatments,” he says. “People are now taking medication instead of going to the hospital.”

He also cites a few other factors at play. Increased access to drugs and a generous formulary have helped drive the number of prescriptions higher, and Quebec’s aging population has likely played a role as well — according to Statistics Canada, 18.5 per cent of Quebecers were aged 65 and older as of 2018. The number of prescriptions per insured has also tripled since 2000, according to the report, while the total cost per prescription has dropped 40 per cent.


Read: What are the implications of pharmacare reform for private drug plans?