politics

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U niversal access to safe, affordable and appropriately prescribed medicines is an important goal of national health care systems.1 Canadians benefit from universal public coverage of physicians’ services and hospital care; how ever, an estimated 20% of Canadians are uninsured or under insured for the cost of prescription drugs used outside hospi tals.2,3 This makes Canada an outlier as the only advanced economy with a universal health care system that excludes uni versal coverage of prescription drugs.

Although the Canada Health Act ensures universal coverage of medicines used in hospitals, Canada has no national standards for the coverage of prescription drugs used in the community. The federal government provides drug coverage for select populations that account for 2% of prescription drug expenditures in the coun try.4 Provincial and territorial governments offer various public

drug plans for people of specific ages, incomes or health statuses that finance between 25% and 41% of prescription drug expendi tures in their jurisdictions.4 Private drug plans — typically obtained through workrelated extended health benefits — account for 35% of prescription drug expenditures in Canada.4 Patients finance 22% of total Canadian prescription drug expenditures out of pocket.4

Canada’s patchwork of private and public financing of medi cines creates clinical and economic problems. About 10% of Canadians report that they cannot afford to take medications as prescribed because of outofpocket costs.5 Such access barriers have been shown to result in worse health outcomes and in creased costs elsewhere in the health care system.6–9 The multi payer system for medicines also increases administration costs, creates silo budgeting within the health system and reduces

RESEARCH

Estimated effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada Steven G. Morgan PhD, Winny Li MSc, Brandon Yau BSc, Nav Persaud MD MSc

n Cite as: CMAJ 2017 February 27;189:E295302. doi: 10.1503/cmaj.161082

CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/161082res

See related article at www.cmajopen.ca/content/5/1/E137

ABSTRACT B A C K G R O U N D : C a n a d a ’ s u n i v e r s a l health care system does not include uni versal coverage of prescription drugs. We sought to estimate the effects of adding universal public coverage of an essential medicines list to existing pub lic drug plans in Canada.

METHODS: We used administrative and market research data to estimate the 2015 shares of the volume and cost of prescriptions filled in the community setting that were for 117 drugs on a model list of essential medicines for Canada. We compared prices of these essential medicines in Canada with prices in the United States, Sweden and

New Zealand. We estimated the cost of adding universal public drug coverage of these essential medicines based on anticipated effects on medication use and pricing.

RESULTS: The 117 essential medicines on the model list accounted for 44% of all prescriptions and 30% of total prescription drug expenditures in 2015. Average prices of generic essential medicines were 47% lower in the US, 60% lower in Sweden and 84% lower in New Zealand; brandname drugs were priced 43% lower in the US. Esti mated savings from universal public coverage of these essential medicines

w a s $ 4 . 2 7 b i l l i o n p e r y e a r ( r a n g e $2.72 billion to $5.83 billion; 28% reduction) for patients and private drug plan sponsors, at an incremental government cost of $1.23 billion per year (range $373 million to $1.98 bil lion; 11% reduction).

INTERPRETATION: Our analysis showed that adding universal public coverage of essential medicines to the existing pub lic drug plans in Canada could address most of Canadians’ pharmaceutical needs and save billions of dollars annu ally. Doing so may be a pragmatic step forward while more comprehensive pharmacare reforms are planned.

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Cana da’s purchasing power in the global pharmaceutical mar ket.10 As a result, pharmaceutical prices and total per capita ex penditures on pharmaceuticals are higher in Canada than in de veloped countries with comparable health care systems.10–13

Universal public coverage of prescription drugs was recom mended by the 1964 Royal Commission on Health Services (Hall Commission), the 1997 National Forum on Health and the 2002 Royal Commission on the Future of Health Care in Canada (Romanow Commission).14 These commissions, and more recent bodies of evi dence, suggest that implementing universal public drug coverage that is both comprehensive and evidence based would be the best way to ensure the accessibility, affordability and appropriateness of medicine use in Canada.15 But a variety of factors have stalled prog ress toward such universal pharmacare.16

Practical considerations are among obstacles to reform. Imple menting a comprehensive pharmacare program involves a number of logistical challenges: a national, evidencebased formulary needs to be delineated; prices and supply contracts need to be negotiated; and a greater share of total pharmaceutical expenditure needs to flow through the public program. Although these challenges are not insurmountable, it may be prudent to “start small” by adding uni versal public coverage of a carefully selected list of essential medica tions to the existing complement of public drug plans in Canada. A similar step toward comprehensive drug coverage for all Canadians was recommended by the 2002 Romanow Commission and the 2016 Citizens’ Reference Panel on Pharmacare in Canada.17,18

The World Health Organization (WHO) maintains a model list of essential medicines that is meant to be adapted by countries to meet the medicine needs of their populations.19,20 Medicines on resulting national lists are ones governments commit to mak ing accessible because of their importance to patient and public health.21,22 International evidence suggests that encouraging access to drugs on essential medicine lists can improve patient outcomes and lower costs.22–28

We sought to estimate the 2015 volume and cost of prescrip tions filled in Canada for medicines on, or similar to medicines on, a Canadian adaptation of the World Health Organization’s model list of essential medicines. We also sought to compare the prices of these essential medicines in Canada with their prices within singlepayer systems for pharmaceutical coverage that publish data on drug pricing: the US Department of Veterans Affairs, and the national drug coverage systems of Sweden and New Zealand. Finally, we sought to estimate the financial impli cations of adding universal public drug coverage of the essential medicines on the model list to the existing complement of public drug plans in Canada.

Methods

This is a secondary analysis of administrative and market research databases pertaining to the volume and costs of pre scriptions for the calendar year 2015.

Selection and classification of medicines The essential medicines list used in our study is the CLEAN Meds list, an adaptation of the WHO model list of essential medicines

for primary health care in Canada.29 Our analysis focused on 117 of the CLEAN Meds drugs (hereafter “the essential medicines”) that are available and sold as prescriptiononly medicines in Canada (Appendix 1, available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.161082//DC1). Although predominantly target ing primary health care needs, some medicines on the list are often prescribed by specialists (e.g., treatments for hepatitis and HIV infection, and a biologic drug for inflammatory conditions).

We used WHO’s Anatomic Therapeutic Chemical (ATC) Classifi cation System to assign medicines to mutually exclusive groups.30 This allowed us to identify other drugs for which the essential medi cines may be suitable substitutes for some patients. We used the chemical subgroups of the ATC system to define relatively close substitutes (e.g., A02BC = “proton pump inhibitors”) and the phar macologic/therapeutic subclasses of the ATC system to define broader ranges of substitutes (e.g., A02B = “drugs for peptic ulcer and gastrooesophageal reflux disease”). We further grouped medi cines into 47 broad therapeutic categories for reporting purposes.31

Data sources We used data from multiple sources, each described in greater detail in Appendix 2 (available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.161082//DC1). From IMS Health, we obtained productlevel data describing the number of and total expendi ture on all prescriptions dispensed at retail pharmacies in each province during 2015. From the National Prescription Drug Utili zation Information System database of the Canadian Institute for Health Information (CIHI), we obtained 2015 data on the number of and total expenditure on prescriptions that were paid, in whole or in part, by public drug plans in all provinces except Quebec. Because the IMS Health data included Quebec but the CIHI data did not, we estimated the public shares of prescription costs for Quebec based on average public shares for the same drug types in all other provinces combined. This may overstate the public proportion of expenditures in Quebec by 7% (Appendix 2).

Using methods described in Appendix 2, we obtained prices for the most common dosage forms of each generic drug on the essential medicines list from public formularies in Canada, the United States (US Department of Veterans Affairs), Sweden and New Zealand. Because prices of brandname drugs listed on national formularies do not include confidential manufacturers’ rebates, we obtained from the US Department of Veterans Affairs a weighted average of net prices of essential medicines available only from brandname manufacturers in Canada. We converted foreign prices for generic and brandname drugs to Canadian dollars using 2 methods: exchange rates and gross domestic product (GDP) purchasing power parities.

Statistical analysis To measure the baseline volume of prescriptions used, we com puted the total number and cost of prescriptions for the essential medicines and all other medicines in 2015. To gauge the poten tial scope of clinical needs that the essential medicines may be suitable for, we calculated the number and cost of prescriptions in the same ATC chemical subgroups and the same ATC pharma cologic subclasses as 1 or more of the essential medicines.

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We used economic modelling to estimate the total cost of prescriptions (stratified by province, therapeutic category and source of financing) under a scenario wherein universal public coverage of the essential medicines is added to the existing com plement of public drug plans in Canada. The models were based on economic frameworks developed for analyses of the determi nants of prescription drug expenditure as a function of the vol

ume of purchases made, products selected and prices paid for selected products.32,33

The economic models involved a number of pricing and utili zation parameters that we chose on the basis of Canadian and international evidence, as described in Appendix 2 and summa rized in Table 1. We report results for scenarios with all model parameters set to basecase scenario values, all parameters set

Table 1: Summary of parameters chosen for the economic models of the cost of adding universal public coverage of an essential medicines list to the existing complement of public drug plans in Canada*

Parameter Explanation Base-case scenario Best-case scenario Worst-case scenario

Direct change in the use of the essential medicines

Increased accessibility of essential medicines to Canadians who are currently uninsured or underinsured34

30% increase in utilization

12% increase in utilization

39% increase in utilization

Indirect change in the use of the essential medicines

Expected product substitutions among patients currently filling prescriptions for drugs similar to the essential medicines35

Average of 37% of such patients switch

Average of 66% of such patients switch

Average of 7% of such patients switch

Changes in prices of generic versions of the essential medicines

Expected reductions achieved with tendering and other generic pricing tools, gauged on the basis of prices in comparable singlepayer systems: United States (US Department of Veterans Affairs), Sweden and New Zealand36,37

Median comparator prices

Best comparator prices

Worst comparator prices

Changes in net prices of brandname essential medicines

Expected price reductions achieved with universal application of negotiated rebates, gauged on the basis of published estimates of prices and rebates, and average net price information for the US Department of Veterans Affairs38–40

15% lower net prices 20% lower net prices 10% lower net prices

Changes in prices of drugs not on the essential medicines list

Expected changes in the price of drugs not on the essential medicines list

No change No change No change

Standard copayment per prescription for the essential medicines

Expected copayment for standard beneficiaries, set as a maximum dispensing fee that could be lowered if pharmacies competed on price to patient

$11 or less, depending on pharmacy

Percentage of prescriptions filled by patients exempted from copayments for essential medicines

Expected copayment exemptions for vulnerable populations (e.g., older people, lowincome people, children) as a share of all prescriptions filled for the essential medicines

30% 30% 30%

Other changes in existing public drug plans in Canada

Expected changes in public coverage of drugs not on the essential medicines list

None None None

Patient savings from shopping at pharmacies with lower dispensing fees

Expected patient savings arising from pharmacies competing for business by lowering dispensing fees

Not included in estimates

Indirect reduction in government cost of extended health benefits for public sector employees

Expected government savings from reduced cost of private insurance for public sector employees, which would be equal to about 20% of total private sector savings41

Not included as government savings in estimates

Health care system savings from increased adherence to essential medications

Expected savings to the broader health care system resulting from increased adherence to essential medicines6–9

Not included in estimates

*Complete details concerning the rationale and data sources for model parameters are provided in Appendix 2 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.161082//DC1).

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to bestcase scenario values and all parameters set to worstcase scenario values.

Results

Baseline volume and cost of prescriptions In 2015, Canadians filled an estimated 568.4 million prescriptions at retail pharmacies, at a total cost of $26.2 billion (Table 2). A to tal of 377.5 million of the prescriptions were publicly paid, at a total cost of $10.8 billion. The essential medicines accounted for 44% of all prescriptions and 30% of the total cost. They ac counted for a slightly higher share (50%) of publicly paid pre scriptions and an approximately equal share (31%) of the total expenditure on publicly paid prescriptions.

The essential medicines accounted for 50% or more of pre scriptions from 15 broad therapeutic categories, including highprescriptionvolume drug classes (e.g., drugs for chronic obstructive pulmonary disease and asthma, drugs for ulcers and gastroesophageal reflux disease, noninsulin diabetes medi

cations and antibiotics). (Results by drug category are available in Appendix 1.) There were no essential medicines listed for 7 treatment categories: hepatitis C, bladder control, infertility, macular degeneration and receptorpositive cancers (endo crine therapies).

Greater shares of prescription volumes and expenditures were accounted for by the essential medicines combined with drugs that were either chemically or pharmacologically similar to them. Medicines from ATC chemical subclasses that had 1 or more of the essential medicines within them accounted for 77% of total pre scriptions filled and 63% of total prescription expenditures. Medi cines from ATC pharmacologic subclasses with 1 or more of the essential medicines within them accounted for 90% of total pre scriptions filled and 83% of total prescription expenditures.

Foreign prices of essential medicines Table 3 summarizes our comparison of the relative price of generic versions of the essential medicines in Canada and in comparable countries. We were able to find comparator generic

Table 2: Shares of prescription volume and expenditure accounted for by the essential medicines and other drugs in the same chemical and pharmacologic subgroups in 2015, by province*

Variable

Province; share of prescription volume or expenditure, %†

All BC AB SK MB ON QC NB NS PEI NL

Total prescriptions, millions 568.4 49.9 41.7 14.9 15.2 186.8 225.9 11.4 12.2 1.9 8.5

Essential medicines 44 48 43 43 44 44 43 44 43 47 43

Essential medicines and other drugs in same chemical subgroups

77 77 74 76 76 76 79 75 75 78 76

Essential medicines and other drugs in same pharmacologic subgroups

90 89 88 88 89 91 91 88 88 90 89

Publicly paid prescriptions, millions 377.5 31.8 14.0 7.0 7.2 147.9 155.6 5.2 4.3 0.9 3.7

Essential medicines 50 53 50 47 49 52 48 50 48 55 46

Essential medicines and other drugs in same chemical subgroups

83 82 78 79 80 82 86 78 79 84 78

Essential medicines and other drugs in same pharmacologic subgroups

94 94 88 91 92 94 96 90 90 93 89

Total expenditure, $ billions 26.2 2.6 2.6 0.7 0.8 10.1 7.4 0.7 0.8 0.1 0.4

Essential medicines 30 33 31 35 31 28 29 32 32 36 32

Essential medicines and other drugs in same chemical subgroups

63 65 63 70 66 60 64 65 67 72 68

Essential medicines and other drugs in same pharmacologic subgroups

83 87 83 87 85 82 82 82 86 86 84

Public expenditure, $ billions 10.8 1.0 0.8 0.3 0.3 4.8 3.0 0.2 0.2 0.0 0.1

Essential medicines 31 33 31 34 28 30 30 36 35 46 35

Essential medicines and other drugs in same chemical subgroups

61 65 61 70 65 59 62 66 69 80 70

Essential medicines and other drugs in same pharmacologic subgroups

82 91 78 87 84 81 82 82 86 89 83

Note: AB = Alberta, BC = British Columbia, MB = Manitoba, NB = New Brunswick, NL = Newfoundland and Labrador, NS = Nova Scotia, ON = Ontario, PEI = Prince Edward Island, QC = Quebec, SK = Saskatchewan. *Calculations are based on data from IMS Health and the National Prescription Drug Utilization Information System database of the Canadian Institute for Health Information (see Appendix 2 for details, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.161082//DC1). †Unless stated otherwise.

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prices for matching dosage forms of 63 of the essential medicines (Appendix 3, available at www.cmaj.ca/lookup/suppl/doi:10 .1503/cmaj.161082//DC1). Using 5year average exchange rates to convert currencies, and weighting products according to Canadian sales volumes, we found that generic versions of the essential medicines were priced 47% lower in the US, 60% lower in Sweden and 84% lower in New Zealand. Results were similar when we used GDP purchasing power parity to convert curren cies: 53% lower in the US, 56% lower in Sweden and 84% lower in New Zealand. Several highvolume medicines (including atorva statin, pantoprazole, amlodipine, amoxicillin and clopidogrel) were priced at least 70% below Canadian prices in 2 or more comparator countries (Appendix 3).

From the US Department of Veterans Affairs, we obtained a weightedaverage of relative prices for 16 brandname drugs that accounted for 91% of Canadian expenditures on all of the essential

medicines available only from brandname manufacturers in Can ada. Net of manufacturer rebates, brandname drugs in the US were priced 43% below Canadian list prices using exchange rate conversions and 49% below Canadian list prices using purchasing power parities. We nevertheless used more conservative estimates of price changes in our economic models (Table 1 and Appendix 2).

Cost of universal coverage of the essential medicines For Canada and each province separately, Table 4 lists the esti mated change in total (private and public) expenditure on all prescriptions filled in retail pharmacies under our scenarios for adding universal public coverage of the essential medicines to the existing complement of public drug plans in Canada.

We estimated that the total expenditure on prescription drugs in Canada would fall by $3.04 billion (range $743 million to $5.46 billion; 12% reduction) under such an expansion of public

Table 3: Expenditure-weighted averages of the relative price of generic versions of the essential medicines in Canada and specified comparator countries, May–July 2016

Variable United States Sweden New Zealand

Total no. of essential medicines with 1 or more generic equivalent in Canada and comparator country

55 29 51

Total expenditure on prescriptions for brandname and generic versions of essential medicines with 1 or more generic equivalent in Canada and comparator country, Can$ billions

2.98 2.51 3.22

Expenditureweighted average relative price of generic versions of essential medicines, comparator country relative to Canada, %

Using 5year average exchange rates to convert currencies 53 40 16

Using GDP purchasing power parities to convert currencies 47 44 16

Note: GDP = gross domestic product.

Table 4: Estimated change in total (private and public) expenditure on all prescriptions filled in retail pharmacies with the addition of universal public coverage of essential medicines on model list, by province

Province Population in 2015, millions

Actual expenditure in 2015, $ millions

Estimated change in expenditure with addition of universal public coverage of essential medicines, $ millions (%)

All model parameters set to base-case scenario values

All model parameters set to best-case scenario values

All model parameters set to worst-case scenario values

All 35.7 26 204 –3043 (–12) –5458 (–21) –743 (–3)

British Columbia 4.7 2649 –320 (–12) –562 (–21) –93 (–4)

Alberta 4.2 2580 –238 (–9) –456 (–18) –35 (–1)

Saskatchewan 1.1 728 –75 (–10) –134 (–18) –20 (–3)

Manitoba 1.3 775 –90 (–12) –162 (–21) –22 (–3)

Ontario 13.8 10 148 –1282 (–13) –2238 (–22) –359 (–4)

Quebec 8.3 7364 –804 (–11) –1482 (–20) –158 (–2)

New Brunswick 0.8 662 –84 (–13) –141 (–21) –30 (–4)

Nova Scotia 0.9 762 –87 (–11) –153 (–20) –25 (–3)

Prince Edward Island 0.2 96 –12 (–12) –20 (–21) –4 (–4)

Newfoundland and Labrador 0.5 440 –47 (–11) –86 (–19) –10 (–2)

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coverage. The percentage reduction in total expenditure was about equal across the provinces: ranging in the base scenario from a 9% reduction in Alberta to a 13% reduction in Ontario and New Brunswick. All economic scenarios included a total of more than $6 billion in pharmacy dispensing fees, equivalent to more than $210 000 per pharmacist practising in the community set ting in Canada.42

For Canada as a whole, Table 5 summarizes our estimates of the change in public and private expenditures on all prescrip tions filled in retail pharmacies under our scenarios with the addition of universal public coverage of the essential medicines. We estimated that the incremental government cost of adding universal public coverage of the essential medicines would be $1.23 billion per year (range $373 million to $1.98 billion; 11% reduction). The incremental private sector savings from such coverage was estimated at $4.27 billion per year (range $2.72 bil lion to $5.83 billion; 28% reduction). Total public expenditure on the essential medicines was estimated at $6.14 billion (range $5.6 billion to $6.6 billion); total public expenditure on medicines not on the essential medicines list, yet currently covered under existing public drug plans, was estimated at $5.85 billion (range $5.53 billion to $6.13 billion).

Almost half of the estimated total national savings from add ing universal public coverage of the essential medicines ($1.50 billion) came from 7 therapeutic categories of medicine commonly prescribed in primary care: acidreducing drugs, cholesterol medicines, antihypertensives, antipsychotics, anti biotics, antidepressants, and gabapentin and related drugs (Appendix 1). In contrast, about half ($628 million) of the incre mental cost to government of covering the essential medicines stemmed from increased public expenditure on just 1 drug: adalimumab (Humira).

Interpretation

We found that nearly half (44%) of all prescriptions filled at re tail pharmacies in Canada in 2015 were for 117 drugs on a model essential medicines list for Canada (the CLEAN Meds list29). An additional 33% of prescriptions filled were for drugs from the same chemical subclasses as 1 or more medicine from the essential medicines list. We estimated that adding universal public coverage of the essential medicines to the ex isting complement of public drug plans in Canada would save

patients and private drug plan sponsors $4.27 billion per year (range $2.72 to $5.83 billion; 28% reduction). The incremental government cost of adding such coverage was estimated at $1.23 billion per year (range $373 million to $1.98 billion; 11% reduction). These estimates do not include indirect govern ment savings from reduced cost of private drug coverage for public sector employees, patient savings from shopping at pharmacies with low dispensing fees, or reduced demands on the health system stemming from increased adherence to essential therapies.

Our modelling produced financial results similar to those found in the actual implementation of a limited formulary in Sweden. Adherence to the Swedish “Wise List” in Stockholm pri mary care sites saved 28% annually (€10 million or Can$14.5 mil lion).43 If our economic models were set up to exclude the cost impact of increases in utilization resulting from insuring previ ously under and uninsured people (which was not a factor under Sweden’s universal system of drug coverage), they would pro duce estimated net savings of 23% ($3.7 billion) within the drug classes directly affected by the essential medicines list modelled for Canada.

Our findings are also consistent with a previous study that estimated a comprehensive public drug plan could reduce total annual pharmaceutical expenditure in Canada by $7.3 billion using data from the 2012/13 fiscal year.41 If our results were scaled to include savings for drugs not on the essential medi cines list, the basecase scenario estimates of total annual sav ings would be between $6.9 billion and $10.1 billion using data for the calendar year 2015.

Reflecting the incremental approach to policy development modelled here, our present estimates of the public cost of adding universal public coverage of essential medicines to the existing complement of public drug plans in Canada are lower than the previous estimates of the public cost of a universal, comprehen sive public drug plan. The estimated gross cost to governments (excluding indirect savings on public sector employee benefits) is $1.2 billion for coverage of essential medicines in 2015, as com pared with the estimated $3.4 billion for comprehensive public drug coverage in 2012/13.41

Limitations As a simulation study, our analysis is necessarily based on assumptions concerning changes in drug utilization, product

Table 5: Estimated change in public and private expenditure on all prescriptions filled in retail pharmacies with the addition of universal public coverage of essential medicines

Source of finance Actual expenditure in 2015, $ millions

Estimated change in expenditure on all medicines with universal public coverage of essential medicines, $ millions (%)

All model parameters set to base-case scenario values

All model parameters set to best-case scenario values

All model parameters set to worst-case scenario values

Public 10 760 1229 (11) 373 (3) 1979 (18)

Private 15 444 –4272 (–28) –5831 (–38) –2721 (–18)

Total 26 204 –3043 (–12) –5458 (–21) –743 (–3)

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substitutions and prices. We have based our assumptions on available evidence and direct price comparisons described in the Appendix 2. To account for the range of possible outcomes, we present results with all parameters set to bestcase scenario values and all parameters set to worstcase scenario values.

We were unable to compare netofrebate prices in Canada with those in each of the comparator countries in this study. However, from the US Department of Veterans Affairs, we obtained an estimate of the weightedaverage netofrebate prices for essential medicines available only from brandname manufacturers in Canada. Those prices were 43% lower than Canadian list prices, which suggests that our assumptions about possible changes in net brandname prices for the essential med icines are conservative (Appendix 2).

Finally, we modelled the implications of just one example of an essential medicines list that could be used as a first stage of pharmacare reform for Canada. Changes in the number and type of drugs included on the list will affect financial impacts of expanding drug coverage in this way. Provided that the list in cludes 1 or more generic drugs from the highvolume chemical subclasses of medicines that account for most medication use in Canada today (as the CLEAN Meds list does), the financial im pacts of coverage of such treatment types will be similar to those modelled here. Expanding coverage to include additional therapeutic categories will broaden the extent of needs met and savings potential from the universal public system, but it will also increase the incremental costs to government of such a program, which would bring this incremental approach to phar macare development closer to the comprehensive approach modelled previously.41

Conclusion Commissions on the Canadian health care system have repeat edly concluded that universal, comprehensive public pharma care is the most equitable and efficient means of achieving access to appropriate and affordable care for all Canadians. Our study showed that adding universal public coverage of a model list of essential medicines to the existing complement of public drug plans in Canada could address most of Canadians’ pharma ceutical needs and save billions of dollars annually. Doing so may be a pragmatic step forward while more comprehensive pharma care reforms are planned.

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Competing interests: None declared.

This article has been peer reviewed.

Affiliations: School of Population and Public Health (Morgan), University of British Colum bia, Vancouver, BC; Faculty of Medicine (Li), University of Toronto, Toronto, Ont.; Faculty of Medicine (Yau), University of British Colum bia, Vancouver, BC; Department of Family and Community Medicine (Persaud), University of Toronto, Toronto, Ont.

Contributors: Steven Morgan and Nav Per saud conceived of the study. All of the authors contributed to the study design. Nav Persaud and Winny Li obtained research data. Winny Li, Brandon Yau and Steven Morgan con

ducted the analysis. All of the authors contrib uted to the interpretation of results. Steven Morgan and Nav Persaud drafted the paper. All of the authors revised the manuscript for important intellectual content, approved the final version to be published and agreed to act as guarantors of the work.

Funding: This study was funded in part by a PSI Graham Farquharson Knowledge Transla tion Fellowship from the Physicians Services Incorporated Foundation, by an IMPACT Award from the Ontario SPOR Support Unit and by an operating grant from the Canadian Institutes of Health Research (grant no. DCO150GP). Funding agencies had no role in the study design, analysis or preparation of the paper.

Acknowledgement: This study is based in part on CompuScript data (January through December 2015) obtained under license from IMS Health Canada Inc. The statements, find ings, conclusions, views and opinions con tained and expressed herein are not necessar ily those of IMS Health Canada Inc. or any of its affiliated or subsidiary entities.

Disclaimer: Nav Persaud is an associate editor for CMAJ and was not involved in the editorial decisionmaking process for this article.

Accepted: Jan. 13, 2017

Correspondence to: Steven Morgan, [email protected]