Ontario’s Health Minister is promising to look into the practice of pharmaceutical companies paying fees to physicians who provide expensive IV medications in their offices after The Globe and Mail revealed the arrangement in an investigation of one of the most lucrative drugs in Canadian history.
The paying of per-infusion fees to doctors is “something that we are certainly looking at very carefully within the ministry right now,” Christine Elliott said on Monday. “I believe that it’s important that people who need access to certain medications are going to get them under the prescribed rules. That’s why we have those rules in Ontario.”
The Globe reported on Saturday that Janssen, a unit of the pharmaceutical giant Johnson & Johnson, pays doctors $275 every time patients in their offices receive a two-hour infusion of a drug called Remicade, which treats Crohn’s disease, ulcerative colitis, rheumatoid arthritis and other autoimmune disorders. (Janssen declined to confirm the amount of the fee, calling it confidential.) The makers of other infused drugs pay such fees as well.
Janssen says the payments are intended to cover overhead, including the salaries of the nurses who usually start the IVs and monitor the infusions. But some pharmaceutical policy experts warn the fees could influence doctors to prescribe infused drugs over alternatives that patients can self-inject or swallow at home.
Janssen and Pfizer, another drug maker that pays a $275 fee to doctors for a cheaper alternative to Remicade, say Canada’s public health-care system has left them with no choice but to foot the bill for the administration of infused drugs provided in doctors' offices. The health ministry in one province, Ontario, disagrees; officials there say doctors can bill $54.25 to the Ontario Health Insurance Plan (OHIP) for supervising Remicade infusions, even if the work is delegated to a nurse.
In Ontario, a 2004 law called the Commitment to the Future of Medicare Act prohibits third parties, including drug companies, from paying doctors to perform medically necessary services covered by OHIP. The law has never been enforced.
“The idea of a firm paying these extra fees directly to the providers does create a potential conflict of interest that can be concerning," said Steve Morgan, a professor in the department of population and public health at the University of British Columbia. “The remedy would be a public fee for administering a treatment for the patient’s need.”
Teresa Pavlin, a spokeswoman for Janssen, wrote in a statement last week that the company would welcome Ontario making it clear to doctors that infusion services provided in their offices are, in fact, publicly covered. However, she also said the company has begun to phase out the sponsoring of infusions inside doctors' offices because it has enough capacity through the drug-company-sponsored private clinics, where 90 per cent of Remicade infusions already take place.
The paying of infusion fees to doctors is just one of the tactics that The Globe uncovered during a 10-month investigation into the marketing and promotion of Remicade, Canada’s top-selling drug by revenue. The probe revealed how a fractured system of paying for prescriptions through more than 100 public and 100,000 private insurance plans contributes to Canada spending more per capita on prescriptions than any country except the United States and Switzerland.
Creating a coherent national system to pay for drugs could plug some of those gaps, according to Eric Hoskins, the former Ontario health minister who is now leading an advisory council on implementing national pharmacare. The council is expected to present its recommendations this spring.
Patients and governments alike experience “a tremendous amount of frustration,” because there are no consistent standards for how medications are covered from place to place and plan to plan, said Dr. Hoskins, who is also a family physician.
That lack of co-ordination is partly to blame for Canada missing out on the savings offered by biosimilars, a cheaper class of drugs that mimic – although not perfectly – biologic drugs manufactured in living cells, Dr. Hoskins added.
“Compared to other jurisdictions, we’re way behind,” he said. “What I see there is a tremendous opportunity.”
Remicade is the first blockbuster biologic drug to lose its patent and face competition from biosimilars with sticker prices about half that of Remicade. Canada’s drug-pricing regulator predicts the biosimilar versions of Remicade could save the system between $91-million and $514-million a year, but not if the copycat drugs can’t get a foothold here.