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On May 5th 2010, Carol Mitchell, M.P.P. for Huron-Bruce sent a form letter addressed to her constituents in response to the proposed cuts to frontline healthcare. The following letter is a reply from Adam McDowell, pharmacist at Michael’s Pharmasave #605 in Bayfield, Ontario.

May 11th, 2010 Carol Mitchell, M.P.P. for Huron-Bruce 49-51 Albert Street, P.O. Box 1794 Clinton, ON N0M 1L0 Phone: 519-482-5630 Fax: 519-482-3149 Dear Carol Mitchell: I had an opportunity to read the letter that you sent to your constituents on May 5th, 2010. I thank you for taking the time to publicly respond to the cuts to pharmacy funding, but it’s unfortunate that your letter does not address many of the concerns that are being raised by area pharmacists and our customers. In addition, your letter is rife with misleading information when it comes to your price comparison chart. I’m not sure if you and your team prepared this chart yourselves, or if you just copied it from Deb Matthews and her team. Either way, it is very misleading to the general public who do not understand the provincial formulary and it’s unfortunate you did not research any of the information in this chart before sending it to your constituents. I am going to address these points and I’ll be sure to have a copy of this letter on hand in the pharmacy should any of our customers bring in your letter looking for my thoughts. I’m going to start with your drug price comparison chart. The chart is titled “4 generic drugs in 5 other countries…” and yet the first drug listed is enalapril. Perhaps it will surprise you to know that Ontario does not pay for any generic enalapril; only the brand name Vasotec. The price listed in the chart ($0.4279 for 5mg and $0.5142 for 10mg) is for brand name Vasotec, not generic enalapril. Generic enalapril is not covered under our provincial formulary at all. Maybe if your government had not made a lucrative deal with Merck Frosst to have Vasotec as the exclusive listing of enalapril on the provincial formulary, the generic drug manufacturers (Apotex, Novopharm, Cobalt, Genpharm, Pharmascience, Ratiopharm, Sandoz, and Taro – all of whom have a generic equivalent available) would have an opportunity to supply a generic equivalent at a much lower price. It’s your government that is not allowing the public access to these generics.


Moving along the chart, I’m wondering why we are making comparisons to other countries, including the United States, rather than looking at the other provinces in our own country. Since when has the health system in the United States been regarded as exemplary? By making these comparisons, I suppose the McGuinty government is saying that our health system here in Ontario should be more like the United States. I would challenge you to ask any of your constituents which health system they would prefer: ours, or that of the United States. I believe the reason you and your government have had to look outside of the country for price comparisons is because our generic drug prices here in Ontario are actually LOWER than other Canadian provinces. Let’s take a look at my hometown province of Nova Scotia, using the same drugs and strengths as in your letter: Drug Enalapril 5mg Enalapril 10mg Gabapentin 300mg Metformin 500mg

Ranitidine 150mg

Ontario $0.4279 (brand price) $0.5142 (brand price)

Nova Scotia $0.6417

Comments Ontario is lower

$0.7712 Ontario is lower $0.6555 (For Pharmacare recipients) $0.6130 $0.4865 Ontario is lower $0.5211 (For Pharmacare recipients) $0.1216 $0.0965 Ontario is lower $0.1033 (For Pharmacare recipients) You list the price for generic ranitidine 150mg as $0.4042, which is correct. Fortunately for Ontarians, they don’t have to pay that much since brand name Zantac 150mg is only $0.1800 and this is the price listed on the provincial formulary. This is also the same price Nova Scotian’s pay. You are blatantly misleading the public into thinking that they pay 40 cents per tablet for ranitidine when they only pay 18 cents.

Source: Nova Scotia Pharmacare Reimbursement List – January 14th 2010. Accessed online May 5th, 2010: http://www.gov.ns.ca/health/Pharmacare/pubs/Reimbursement_List.pdf

How about Alberta? Drug Enalapril 5mg Enalapril 10mg Gabapentin 300mg Metformin 500mg Ranitidine 150mg

Ontario

Alberta

Comments Since Ontario pays only for Vasotec, a $0.4935 for generic $0.4279 drug-drug comparison means Alberta $0.8813 for Vasotec pays 2.06 times more per tablet. $0.5932 for generic Again, a drug-drug comparison means $0.5142 $1.0592 for Vasotec Alberta pays 2.06 times more. $0.4865 $0.6092 Alberta pays 1.25 times more. $0.0965 $0.1216 Alberta pays 1.26 times more. Alberta pays $0.4042 for generic ranitidine, and $0.1800 for brand Zantac, just like Ontario. Just like Alberta, nobody in Ontario would pay $0.4042 for generic ranitidine since Zantac is interchangeable and less expensive.

Source: Alberta Health and Wellness Drug Benefit List – Effective April 1st, 2010. Accessed online May 5th, 2010: https://www.ab.bluecross.ca/dbl/pdfs/ahwdbl_april_list.pdf


Isn’t it interesting that every price in Nova Scotia and Alberta for the examples above are either the same (in the case of ranitidine) or higher than what Ontario pays? Generic prices are actually lower in Ontario than elsewhere in Canada and that contradicts the government’s statement that generic prices are higher in Ontario than anywhere else. So, to try and prove their point, the government needs to reference three out of the fifty states in the US, go halfway around the world to New Zealand, and three European countries to find lower drug prices than Ontario. And even then they can’t represent it properly (i.e. neglecting that Zantac brand is available cheaper than generic ranitidine, and that generic enalapril is not even a benefit in Ontario). Your letter fails to address to your constituents why brand name drugs like Vasotec get an exclusive listing on the provincial formulary, even when generics are available. You fail to mention that brand name companies like Merck Frosst pay the government incentives for listing their products and/or receiving exclusivity on the formulary (like Vasotec). I addressed this very issue in my previous letter to you, referencing a letter from Rx&D’s Russell Williams seeking to keep such information confidential. You fail to inform the public that brand name drugs actually make up 70% of the average consumer’s prescription bill and that nothing is being done with current legislation to address brand name prices. You letter fails to mention that brand name companies like Pfizer have actually increased their prices. Your letter fails to mention that if brand name drug prices were addressed and lowered, generics would automatically decrease since they are priced on a percentage basis. This would in effect lower 100% of the drug costs in Ontario, rather than just the 30% made up by generics. You write in your letter about eliminating the professional allowances paid to pharmacies, but fail to mention why these allowances exist in the first place, and that the government has been regulating and auditing them since 2006. The allowances have been needed to fill the massive funding gap left behind after years of the government under-funding pharmacy services. A 56cent increase in dispensing fee over the last 20 years can hardly be seen as the “government recogniz[ing] and appreciat[ing] the valuable contribution that Ontario’s pharmacists make to patient care.” You also fail to mention how these professional allowances were used by pharmacies and what services they funded. I’m sure your constituents would be interested to know that services they get “for free” are actually paid for by these professional allowances (e.g. delivery of medication, blood pressure monitoring, counseling on over the counter medications, contacting doctors and insurance plans on patients’ behalves, etc.). By only referring to the allowances as a $750 million dollar annual payment to Ontario’s pharmacies without explaining why it was needed and how it was used, you’re only propagating the negative stigma that the government has attached to these allowances and the pharmacies that use them, which is just wrong. Like all pharmacists, I have said many times that I do not agree with a funding model where professional allowances are used. However, to eliminate these allowances as quickly and drastically as the government is proposing, and only replacing it with one-third of that amount, you cannot expect the level of services to stay the same. It does not take a mathematician or even a simple calculator to see that removing $750 million and only replacing it with a total of $244 million ($100 million additional funding + an estimated $124 million in increased dispensing fees + $20 million for rural funding, according to your letter) doesn’t add up.


You mention that the government has “proposed reforms that would compensate pharmacists for additional clinical pharmacy services they provide,” but fail to mention to your constituents that the government has not said what these services will be, who will qualify, and how they will be compensated. Like I said to you at our meeting, the government is being very clear about what they want to take away and yet has no specific answers about what they plan to give back to the public. Your letter also fails to address the problem we are currently facing with new pharmacy graduates needing a place to train before they become licensed. We were actually just forced to lose our pharmacy intern we had lined up for the summer in Bayfield – an act that Deb Matthews has referred to as “despicable” and “shortsighted.” What does she expect? These interns cannot work for free; the government is not going to pay them, so where is the money supposed to come from? These internships were arranged before the government made their announcement, so how can a pharmacy be expected to keep their commitment to their intern at an agreed upon salary when all of a sudden they’re losing $200,000-$300,000 a year? The only thing that is shortsighted here are the drastic and reckless cuts to frontline healthcare proposed by the Liberal government. I asked you in our meeting on April 30th if you thought these cuts were right and you said “I don’t think right is the right word.” And yet in your letter to your constituents you refer to the proposed cuts as “the right thing to do” and “the fair thing to do.” I would have thought that after meeting with myself and other area pharmacists, and receiving postcards and letters of concern from the public, you could have really taken the time to address the issue as it pertains to your constituents in your riding. But unfortunately you could only copy and paste the same quotes and misleading numbers that have been reiterated by the McGuinty government since day one of the announcement. I would have expected more from my MPP. Sincerely,

Adam McDowell, BSc. Pharm Staff Pharmacist Michael’s Pharmasave, Bayfield, ON


Response to Carol Mitchell's Letter