Alan Cassels

Just as your doctor is pulling out his prescription pad to write a script for something that will ease your pain, he looks up and asks, “Are you on a private drug insurance plan?”

It’s a common question and innocent enough. He’s wondering if you’ve got extra coverage, maybe an extended health plan with Blue Cross or Great West, which helps pay for your prescription. Nothing could be wrong with that question, could it?

Yes, there could be. In my estimation the proper response might be a question of your own, “Tell me doctor, why is my having is private or extended medical coverage even relevant?” At the risk of sounding pedantic, I maintain that whether or not you’ve got private drug insurance is irrelevant. After he has diagnosed what is wrong with you, his job is to decide the safest, most effective and most cost effective treatment for you.

Extended health insurance plans aren’t in the business of making value-based decisions about which drugs are safe and most cost-effective (hence deserving to be covered), and which are not. They are there to ease the financial pain. In contrast, it is the policy of public medical plans to make value judgements about which drugs merit coverage. Along the way they encourage prescribing in the interests of value and effectiveness. A person’s drug insurance coverage can mean the difference between whether you get a prescription filled or not, and it also may give more access to newer medications. Sound good? Not completely! Getting faster access to a potentially more irrational and dangerous prescription often is the hidden cost you are paying for private health insurance.

For example, I examined a list of the top 20 prescribed drugs in 2007 compiled by Emergis, a company that manages drug claims for about half the private drug plans in Canada. This “Top 20 List” contains those drugs which, due to a combination of cost and volume of prescriptions, eat the lions’ share of your private insurance dollar. These top 20 drugs are the big ticket items taken by millions of people and cost you, and your drug plan, hundreds of millions of dollars.

So, what drugs are on the Top 20 List? For starters, there are five cholesterol-lowering agents on the list. Lipitor, a brand which dominates the current medical love-affair with chemically alterations of our cholesterol, tops the list. Is the widespread prescribing of Lipitor due to its being more effective, safer or more cost effective over its competitors? Not really. All the statin drugs, more or less, do the same thing but both our public and private drug plans pay for all of them, regardless of the huge differences in cost between generically-available statins and brand name drugs like Lipitor. What is most surprising, coming in at # 6 on the Top 20 List, is Crestor, the newest anti-cholesterol drug on the market. Crestor has been labelled by Worstpills.org (a site dedicated to delivering objective evaluations of prescription drugs) as “Danger Do Not Use” because it can cause kidney, muscle and liver damage. In fact, Worstpills reports that “several major U.S. insurers, including WellPoint/Blue Cross, with 16 million beneficiaries, have refused to reimburse for this drug because of safety concerns.” As far as I know, no private drug plan in Canada refuses to pay for any statin drug for safety reasons. So your doc says, “Got a drug plan? You do? Okay, here’s some Crestor”

In the “Bizarre and Unexplainable” category of their Top 20 Drugs we find Celebrex at # 15, a drug which had three sisters—all now removed from the market for a variety of safety concerns. One of these sisters, Vioxx, was at the heart of the biggest drug disaster this century and responsible for tens of thousands of deaths in the US. Why Celebrex gets so widely prescribed, even now, is a mystery. There is no evidence that it’s more effective than other anti-inflammatory drugs. Furthermore, it is more expensive than many equivalent drugs and its label warns of the risk of heart attack. So, why is it still so popular? Maybe it’s because your MD says, “Got a drug plan? Good, here’s some Celebrex…”

Also on the Top 20 List are five agents of the proton pump inhibitor (PPI) class of drugs. These five include Losec, Nexium, Pantaloc, and Pariet, all of which are used to treat ulcers and gastroesophageal reflux disease (GERD). They are all more or less equivalent in effectiveness but can vary widely in price. If you really needed one of these you could pay anywhere from $45 to $100 per month depending on which drug your doctor prescribes. In British Columbia if PharmaCare is paying for your PPI, you’ll get the cheapest one. But if you’ve got a private drug plan you can spend oodles more, and not actually buy any more health effectiveness. Your doc asks, “Got a drug plan? Good, here’s some Nexium.” The next thing you know you`re walking out of the pharmacy with a $100 prescription. Even though these drugs are very effective alarm bells recently began to ring regarding just how often they are prescribed. Earlier this year an article in the British Medical Journal reviewed evidence around the use of PPIs and concluded that only 10 percent of the people on acid suppressive therapy (PPIs) were found to have an “acceptable inclination” for these drugs. Which is to say that most of the dollars you and your private drug plan pay for those five PPIs is wasted.

Older heartburn drugs like Tagamet or Zantac, and other drugs available over the counter at a fraction of the price often get bypassed if you have a private drug plan. In reality, most people, if they altered their lifestyle or lost 10 pounds, wouldn’t need a heartburn drug at all.

The Top 20 List is a real eye-opener. It’s full of drugs that public drug plans either restrict, or won’t pay for at all. We think our private drug plan is providing good medicine and the best healthcare, but it could be just the opposite. If your doctor asks “Got a drug plan?” you might deflect him by asking his opinion of available treatments based on safety, effectiveness and cost. If there are a bunch of drugs that do the same thing, ask for the generic or the cheapest of the lot. You can always move up the chain if these don’t work. You’re not helping anyone, except the drug firms by wasting yours or your private drug plan’s money.

Albert Einstein once said, “Not everything that can be counted counts, and not everything that counts can be counted.” My health insurance corollary to this quote goes like this, “Not everything that is paid for works, and not everything that works is paid for.” Maybe this is a bit of advice worth remembering the next time that pen is poised over the prescription pad.

If you think you have been injured by a prescription drug, you should call the Canada Vigilance Program at 1-866-234-2345. You can also submit an adverse reaction report on the Med Effect Canada website (www.hc-sc.gc.ca/dhp-mps/medeff/index_e.html).