Exploring Community Pharmacy Practice in Canada
Key takeaways:
Canada has a decentralized system of healthcare delivery and provincial insurance. It’s funded through the federal and provincial governments. And it’s collectively referred to as Medicare.
Private insurance is available to cover services not mandated by the federal government. These include prescription drugs, vision, and dental care.
Although it varies by province, pharmacists in Canada have broad authority. And in many cases, they can give vaccines, prescribe medications, order and interpret lab tests, and offer medication reviews.
Community pharmacies are those that dispense medications to patients who aren’t hospitalized or in nursing facilities. This series explores how community pharmacy practice differs around the world. In doing so, it gives us the opportunity to view our own system in a new light and possibly find opportunities for improvement.
We’ve covered the globe, exploring the practice of pharmacy in countries across continents, from Japan and Australia to Argentina and Finland. Here, we’ll look at community pharmacy practice in our next door neighbor, Canada.
To help me better understand the Canadian system, I’ve interviewed Rheya White, BSc (Pharm), a pharmacist and also a practice consultant and practice site assessor with the Newfoundland and Labrador Pharmacy Board.
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How Canada’s pharmacy system works
Health insurance
Health insurance in Canada is offered primarily through a public system termed Medicare. This is not to be confused with Medicare in the U.S., which mainly insures individuals over the age of 65.
Medicare is funded by the federal government in accordance with the Canada Health Act. And it is also funded by each provincial government. Every year, the federal government gives each province funding through the Canada Health Transfer. Funding is offered on an equal, per-capita basis.
Importantly, some medical services not mandated to be covered by the federal government, including prescription drugs, dental services, and vision services. This means not all Canadians in all provinces will be insured for those services through the government.
For these services, including prescription drugs, private insurance is available and offered by many employers. Like the U.S., benefits will vary largely depending on the employer. There are also various public programs, similar to the U.S., to cover certain populations. Examples include for the Canadian Armed Forces and the non-insured health benefits for First Nations and Inuit citizens.
Finally, provinces like Newfoundland and Labrador offer added prescription drug coverage to certain people who need extra help paying for their medicines. These include those with low incomes, those over the age of 65, and those with high prescription drug needs.
Outcomes
Canada’s annual healthcare spending in 2021 was $8,019 CAD ($6,157 USD) per person, or 12.7% of GDP. For comparison, in 2020, the U.S.’s healthcare spending was $12,530 per person, or 19.7% of GDP, according to the Centers for Medicare & Medicaid Services.
Canada’s under-5 mortality rate, a key indicator of health system performance, was 5 per 1,000 live births in 2020. This is somewhat lower than the U.S., which had a rate of 6.3 per 1,000 live births the same year.
Canadians also live longer than Americans on average. Life expectancy in Canada, another key indicator of health system performance, was 82 years in 2020, compared to 77 years the same year in the U.S.
Pharmacy regulation
Health Canada is the primary regulatory body. They are responsible for drug and device approvals and regulation, assisting with continuous improvement of the healthcare system, and conducting health science and research.
Drug pricing
After a drug is approved, the pricing is set by the Patented Medicine Prices Review Board. Prices are also reviewed twice annually through the life of the patent.
Drug pricing review consists of two major parts:
Scientific review: During scientific review, the panel of experts assesses the amount of improvement over existing therapies the new drug has. The drugs used for comparison are recommended by the Human Drug Advisory Panel. The difference in improvement over comparator drugs is used to find out the new drug’s maximum average potential price. This price is a ceiling price. So, manufacturers are allowed to charge less, but not more.
Pricing review: The board conducts ongoing pricing reviews to ensure compliance.
Daily pharmacy practice in Canada
Canada has both chain and independent pharmacies, although according to Ms. White there aren’t many independents and most that exist are part of a franchise.
Prescriptions are billed electronically. And, patients either have provincial insurance, private insurance, or pay cash. For provincial insurance, the pharmacy can bill the claim using the patient’s personal health number, which Ms. White notes makes the billing process simple and easy. She also feels that private insurance is fairly easy to bill, as long as the patient brings their insurance card to the pharmacy.
For patients insured with a provincial plan, like BC PharmaCare, pharmacies also electronically send information to the provincial electronic health record, like that of Ontario. The patient — and other healthcare providers — can access those records so they have a full picture of the patient’s health history.
Coverage varies depending on the insurance plan. But even if a drug is not initially covered, it might be eligible through a special authority, similar to a prior authorization. Ms. White notes that, in some cases, this authority will go through automatically. This is because the system can determine from prior fills a patient has failed a medication.
While the scope of practice for pharmacists varies by province, pharmacists in most provinces can:
Administer vaccines and injectable drugs
Prescribe drugs for smoking cessation, minor ailments (like acne, hemorrhoids, and diaper rash), and in an emergency
Renew or extend prescriptions to maintain continuity of care
In Alberta, pharmacists can also prescribe independently. And in many other provinces, pharmacists can prescribe if a collaborative agreement is in place.
Finally, many provinces allow pharmacists to order and interpret lab tests. Ms. White notes that medication reviews, like Medication Therapy Management, are also common.
Misconceptions of Canadian healthcare
Because the U.S. system is compared to Canada’s system often, there are a few misconceptions worth discussing.
Socialized medicine
While Canada does have a publicly funded, universal healthcare system, it is not socialized medicine.
Socialized medicine is a term not used widely outside the U.S. And it most often refers to the government paying for healthcare but also owning and operating healthcare facilities and employing healthcare professionals. The term is also not used in health economics, but most resembles the Beveridge Model.
The most widely discussed example of this type of healthcare is the National Health Service. But, it’s important to note that even in the U.K. the government does not own all healthcare facilities. This is because both pharmacies and general practitioner clinics are usually privately owned. It’s also important to note that the U.S. does, in fact, already use what could be referred to as socialized medicine for some of its residents. Two examples are the Veterans Affairs system and the Indian Health Service.
In Canada, by contrast, a system of mostly private facilities and provincial insurance systems delivers healthcare funded by the government. Unlike the U.K., the Canadian government does not own the majority of the country’s healthcare facilities.
Wait times
In Canada, long wait times are another common issue. In this case, there is some truth to it. This is because Canadians often need to wait a long time for elective procedures. The Canadian Institute for Health Information, for example, cites benchmark wait times for a knee and hip replacement at 182 days and cataract surgery at 112 days. Even with these long wait times, before COVID only around 3 in 4 Canadians were given the procedure within this time frame.
While data for the U.S. is not widely available, a recent OECD report looked at wait times in other countries, including developed countries. In New Zealand — the country with the lowest wait times in the report — the wait time was 48 days for cataract surgery, 80 days for knee replacement, and 71 days for hip replacement.
But, Canadians with urgent needs will be treated. The Canadian Institute for Health Information also noted that 85% of Canadians received hip fracture repair within 48 hours. And, 97% received radiation therapy within 4 weeks. Both of which are within the recommended time frames in Canada.
The bottom line
Canada’s healthcare is a publicly funded system with services delivered by mostly private facilities. Private insurance plays a role in filling the gaps and offering coverage for services not required to be covered by the federal government. So, pharmacists have been given a lot of authority. And in many ways, community pharmacy practice is like pharmacy practice in the U.S.
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