Potential change to Quebec’s drug insurance plan a worry

It’s not something we think about often, but public drug insurance does not cover all treatments.

Quebec’s drug insurance plan, the most generous among provincial public plans, covers just over 8,000. With private plans, almost 13,000 are covered. While these are impressive numbers, many drugs are still not covered by insurance. Some have yet to jump through all the hoops required to be covered, while for others, the request for coverage has been refused.

Whatever the reason, this nonetheless represents a roadblock for Quebec patients whose health depends on access to these drugs to treat their ailments. In 2005, the Quebec government recognized this and adopted a special “exceptional patient” measure. The idea was to add some flexibility for cases that don’t tick all the boxes at the Régie de l’assurance maladie du Québec (RAMQ).

The measure allows, on a doctor’s recommendation, exceptional insurance coverage for drugs that have not been added to the RAMQ’s list of medications, as long as these have been deemed safe and effective by Health Canada.

The process is rigorous, notably requiring the doctor to show that treatments already covered are not an option for the patient, whether because of a lack of effectiveness, an allergy, or some other reason.

Though the measure is not well known, between 20,000 and 40,000 requests for exceptional coverage have been approved each year over the past decade, helping many thousands of Quebec patients.

Unfortunately, amid the government’s efforts to find savings in its health budget, some patient-rights groups have expressed concern that the program might be put on the chopping block.

It would not be the first time that such a mechanism was eliminated.

While civil servants might see it as one line too many in the budget, the exceptional patient measure helps keep our health care system from becoming more dysfunctional than it already is. The health minister must leave it alone.

In 2023, buried in Bill 15’s reform of the health system, the Coalition Avenir Québec government tightened access to the “specific medical necessity” measure, which has the same effects as the exceptional patient measure, but within the hospital system.

After this modification, patients lost access to the measure in cases where Quebec public health authorities do not recognize the therapeutic value of a drug, even though Health Canada recognizes it. (An exception exists if delays in taking the drug would lead to a “rapid and irreversible” deterioration of the patient’s health.)

Take the example of someone suffering from a rare, degenerative disease. If this patient’s life is not in imminent danger, their health deteriorates slowly, over a period of several years. For this patient, a new drug arriving on the market can represent the hope of a few more years of being able to enjoy life, or even the hope of arresting the progression of the disease. Yet, if Quebec public health authorities render a verdict different from Health Canada’s regarding the therapeutic value of the drug, this patient today is deprived of access to the medication within the hospital system, due to Bill 15’s modifications.

Patient-rights groups like the Alliance des patients pour la santé are sounding the alarm for fear that the Quebec government will give the exceptional patient measure the same treatment, thereby restricting access to these drugs.

In so doing, the government would eliminate an important lifeline for tens of thousands of patients. And for what? In the Health Ministry budget, the measure represents less than one per cent of spending.

And this is a measure that helps reduce financial pressure on other parts of the health system.

By slowing the breakdown of an organ, for example, drugs accessible thanks to the exceptional patient measure allow certain transplants to be postponed. They avoid costly operations and stays in long-term care facilities.

While civil servants might see it as one line too many in the budget, the exceptional patient measure helps keep our health care system from becoming more dysfunctional than it already is. The health minister must leave it alone.

Emmanuelle B. Faubert est économiste à l’IEDM et l’auteure de « La mesure du patient d’exception: une soupape permettant aux malades québécois d’obtenir des médicaments novateurs en cas de besoin ». Elle signe ce texte à titre personnel.