Medication access via hospital admission

Canadian medication policy

Public funding for medications was recommended by the Hall Commission of 1961, which called for the implementation of a publicly funded health care system.⁷ The 1984 Canada Health Act established the criteria and conditions for insured health care that covers all Canadian residents. This includes “hospital services” encompassing “drugs, biologicals and related preparations when administered in the hospital.”⁶ The Canada Health Act categorizes outpatient health services, such as physician consultations, as insured services, but these do not include medications for outpatients. Thus, medications that are publicly funded during hospital admission become financial burdens to patients who are not admitted to hospital. There is no clear definition of essential medical services, so provinces and territories have considerable leeway in deciding what is publicly insured.

Saskatchewan implemented publicly funded medications for outpatients between 1975 and 1987; at the time, most medications were taken for short durations for acute conditions.⁸ The 1997 National Forum on Health recommended publicly funded prescription medications.⁸ Quebec mandated medication coverage in 1997, requiring those who did not qualify for social assistance to purchase private insurance, and set a cap for the total amount paid by each person for coverage and for fees related to medications per year.⁹

Access to medications without charge is currently provided to certain outpatients based on income and age; provincial or territorial programs provide medications at no charge or with a small deductible to patients receiving social assistance, to those who meet certain income criteria, and to older adults.^2,10 Some provinces provide “catastrophic coverage” for medications by tying deductibles to household income. Despite these programs, millions of Canadians do not take medications because of the cost.³

Professional roles of physicians

One of several international efforts made to articulate the principles of medical professionalism is “Medical Professionalism in the New Millennium: A Physician Charter,”¹¹ an American and European collaboration endorsed by the Royal College of Physicians and Surgeons of Canada. The charter stipulates the “primacy of patient welfare” as its first fundamental principle and that “administrative exigencies must not compromise this principle.”¹¹ Providing medication through hospital admission is an example of overriding “administrative exigencies” for the welfare of patients. The charter also recognizes the important public role of physicians in supporting “wise and cost-effective management of limited clinical resources,” but it ties that with an obligation to “promote justice in the health care system, including the fair distribution of health care resources.”¹¹ Through temporary hospital admission, physicians who provide medication to lower-income patients are “work[ing] actively to eliminate discrimination in health care,”¹¹ just as the charter advocates.

The Canadian Medical Association’s Code of Ethics also combines the notion of primary commitment to patient welfare with physicians’ responsibility to promote equitable access to health care resources among patients.¹² The CanMEDS roles of the Royal College emphasize that physicians have a fiduciary duty toward patients and should advocate on behalf of patients by responding to individual patient health needs and issues as part of patient care.¹³ One could even argue that if a physician believes a patient cannot afford an essential medication, the physician has a fiduciary duty to ensure the patient receives the required medication through any available legal means, including temporary hospital admission.

Some provincial standards also support this position. According to the College of Physicians and Surgeons of Ontario, physicians have a legal, professional, and ethical duty to accommodate individual patients, as “each person has different needs and requires different solutions to gain equal access to care.”¹⁴ The College of Physicians and Surgeons of British Columbia outlines similar standards, declaring that “appropriate access to medical care is a core value of Canadian society, and this access should be equally available to all patients, including those in vulnerable and marginalized populations.”¹⁵ Providing medication through hospital admission addresses the unique needs of lower-income patients and therefore ensures fair access to care.

Physicians can use hospital admission to promote the well-being of patients in other scenarios in which there is no direct medical indication. For example, when encountering a victim of acute intimate partner violence, the Society of Obstetricians and Gynaecologists of Canada asks physicians to consider hospital admission or a delay in discharge if there is serious danger.¹⁶

Legal and financial implications

Admitting patients to hospital for the purpose of medication access will not affect the health, safety, or legal rights of others. These patients will not occupy beds, and thus will not affect other inpatients or incur additional costs besides their medications. Although these admissions might affect other hospital staff, the extent of such an effect is uncertain and should be measured to determine its scale.

While it is within provincial laws for physicians with hospital admitting privileges to decide which patients should be admitted based on the required level of care, both patients and physicians might still be reluctant to participate in this practice. Using a legal “loophole” could be viewed as dishonest. Patients might fear repercussions from the government and physicians might fear sanctions from regulatory bodies.

For hospitals that allow patient admission in order to provide medications, patient per diem costs will drop while total expenditures will increase. Global budgeting continues to be the predominant method for funding hospitals in Canada¹⁷; consequently, hospitals with increased expenditures that deviate from historical budgets are disadvantaged. While decreased patient per diem costs will make the hospitals appear more efficient, hospitals will ultimately seek to recoup the added expenses from the provincial and territorial governments that have decided not to fund outpatient medications.

The provincial and territorial governments receive equal, per capita funding for health care from the federal government through Canada Health Transfer payments. Canada Health Transfer payment levels are set to grow at 6% until 2016 to 2017, after which they will grow in line with a 3-year moving average of the nominal gross domestic product.¹⁸ Providing medications to outpatients on a limited basis, without making any other changes, would increase provincial and territorial health expenditures, which might strain relations between hospitals and provincial and territorial governments.

This is why, in the long run, a coordinated pharmacare strategy will be necessary; pharmacare will also increase government spending, but it will avoid such a strain. It is also estimated that, on the whole, a publicly funded and carefully monitored pharmacare program should reduce total spending on prescription drugs in Canada by $7.3 billion.¹⁹

Pharmacare and human rights

A coordinated pharmacare strategy that ensures equitable access to essential medicines is a human rights issue. The United Nations Committee on Economic, Social and Cultural Rights considers equitable access to essential medicines to be a component of the right to health, recognized by the International Covenant on Economic, Social and Cultural Rights, of which Canada is a signatory.²⁰ The World Health Organization has also emphasized the human rights component of access to medicines.¹ Even if the International Covenant on Economic, Social and Cultural Rights is not directly enforceable in Canada, equitable access to potentially life-saving medication can be seen as required under the Canadian Charter of Rights and Freedoms provisions related to equality and to life, liberty, and security of person.

For all these reasons, we endorse the call for a publicly funded pharmacare program. However, in the interim and in the absence of human rights–promoting governmental action, we urge clinicians to respect their fiduciary and human rights–related obligations to patients by using all available legal means to provide people with essential medications.