Defending Healthcare: A Different Perspective

Positive Living I recently read an article under the banner “Fighting Words” entitled “Defending healthcare“.  The authors in that article threw down an interesting jingoistic saying.

Right now, there’s a legal attack before the courts that could turn Canada’s medicare system into the type of system found in the United States.

I understand the authors’ desire to inflame passions and press forward with their point, but of course I thought of the benefits that the US system has over the Canadian system when it comes to those that Canada deems to be “medically inadmissible”. The Canadian Healthcare system covers most people in Canada but in exchange for this universal coverage the Canadian system systematically refuses anyone with certain medical conditions entry into the Canada.  Indeed, the very disease of most interest to the authors and readers of this magazine (HIV positive people) is the one disease that Citizenship and Immigration Canada refuses as a matter of policy. I’m sure there are folks who understand that the written policy is to perform an individualized assessment of people.  But pragmatic experience in helping people with medical issues has taught me that in fact HIV is one of those conditions that are refused as a matter of course. Thus, while the authors view their healthcare system as being a wonderous thing, my perspective is that is is the fundamental justification of a morally bankrupt system intent on classifying anyone with HIV (or Down’s Syndrome, etc.) as being an unmitigated drain on society. The US system does not discriminate in this fashion.  The US immigration system is not tied into the costs of the US healthcare system.  The Canadian immigration system is. And it continues to get worse.  Essentially, anyone immigrating to BC would automatically be excessive demand because the province pays for all drugs (albeit in exchange for your agreement to enter the UBC research study.) Once Canada permits pre-exposure prophylaxis (PReP) not only can a disease condition be used to refuse someone entry into Canada, but even being at high risk could theoretically be used to justify the same thing. While I don’t post too much here anymore, I continue to communicate with people trying to find their way through the medical inadmissibility system.  Recently I communicated with someone who was given a fairness letter without any cost estimates at all. Just the blanket assertion that their treatment was expensive and paid for by the public healthcare system. I must admit, I was incensed at it.  Why?  Because the persons treatment was the only treatment that doesn’t exceed the threshold.  It’s all generics (Neverapine, Lamivudine and Zidovudine).  Using the Quebec published numbers, the cost was something like CAD$2,500 per year. So much for “individualized assessment”.  Hence my claim that, like it or not, it leads to systematic refusal of people with specific health conditions.  Like HIV. If you want a better health care system, stop using it to discriminate against people that want to come here but cannot because they might use it.  At least come up with some mechanism that balances inputs from outputs. In the meantime, pardon me for disagreeing with this blanket rosy self-congratulatory claim of superiority.  It rings hollow.


BC And Drug Coverage (Revisited)

Canada's Source for HIV and Hepatitis C information


In my previous post about prescription drug coverage in British Columbia I did not really go into detail about the evidence supporting my argument that the province does not cover drug costs for HIV specifically.

In this post I’d like to rectify this oversight.

First, each province has a governmental website dedicated to explaining the coverage provided by provincial health care. In BC, it is Fair PharmaCare that provides coverage for some prescription medications. The BC website includes a drug formulary that describes the drugs covered by the provincial plan.  British Columbia has a separate panel that actually reviews drug information as part of the process of being added to this formulary and after careful scrutiny recently that program has been renewed.  While I did not check every single drug for HIV available, I checked those that are commonly prescribed (e.g., tenofovir, efavirenz, raltegravir, ritonavir) and the once-per-day treatment options (Atripla, Complera, and Stribild).  None of them are listed in their formulary.  Further, that formulary explicity states that they do not describe drugs covered by the BC Centre for Excellence in HIV/AIDS. This group is a non-governmental research group with funding from a variety of sources, including the provincial government.  The web page for the therapeutic care given explicitly states:

The Drug Treatment Program (DTP) is an innovative research and treatment program designed to ensure that all medically eligible persons living with HIV in British Columbia have access to free antiretroviral therapy.

Established in 1992, the DTP currently provides nearly 5,500 patients with access to life-saving drugs.

One of the foundational programs of the BC-CfE, the Drug Treatment Program is funded by the provincial government (PharmaCare) to distribute anti-HIV drugs based on guidelines generated by the Therapeutic Guidelines Committee. Information from all participants is entered into a database, providing data for clinical and virological outcome studies of patients receiving antiretroviral therapy.  This database acts as a registry of all HIV-treating physicians in the province, as well as an “early warning system” to alert government about the trajectory of the disease.

Thus, the data from patients working through this program is used to further the research goals of this group.  While one could claim (as CIC does) that this constitutes “free drugs” in fact it does so for the express purpose of using the participants as guinea pigs in the research being done by this organization.

Further, this group limits the therapeutic options that are available to participants.  In this published list a surprising number of drugs listed are subject to restrictions.  For example, my own doctor said the therapeutic option he recommended would not be approved by the Centre for Excellence – and normally he can’t prescribe this specific therapy precisely because it won’t be approved.  When I looked at that list, all but one of the drugs he prescribed to me are listed as “Certain restrictions apply”.

So “free” can also mean “therapeutic options in the best interests of the research group, not the patient”.  That’s the nature of a research study – it’s primary focus is in collecting information about the subject under study.  But I suspect most patients want to pick the best therapeutic option for them personally, not the one that forwards the interests of a research study or group.  Of course, some people do choose to enroll in research studies (e.g., clinical trials) in exchange for something: lower costs, otherwise unavailable therapeutic options, etc.

As an aside, notice that all the Centre for Excellence web pages are actually maintained by the University of British Columbia.  While that’s a public educational institution, it’s not one that is generally associated with the provincial health care system and operates as an independent organization.

So, for anyone else facing this situation in the future, do your homework. Regardless of the province where you intend on landing, don’t assume that the medical officer knows the provincial rules.  It’s quite possible that he or she is just making it up, based upon her or his own misconceptions.  For example, in my case the medical officer stated:

This applicant’s medical condition is likely to require treatment that is expensive and publicly funded in B.C.  Although he has private insurance, antiretroviral medications are covered 100% by the provincial drug plan in the Province of Britsh Columbia with no payment from private insurance.

She completely misunderstood the BC plan.  It isn’t funded by the provincial drug plan directly.  It’s funded indirectly through a research study: you must accept loss of privacy and you must be willing to accept treatment options that advance the research effort and are not necessarily the best options for you as a patient.  In my case I had private insurance to cover the best therapeutic option.  Why would I choose an option that wasn’t best for me?

From my interactions with others caught in this quagmire of excessive demand, it really does seem clear to me that it’s more about reinforcing biases against people with disabilities, despite Canada’s obligations to the contrary.  Ah, but that’s topic for another blog post.

New Medical Information on CIC Website

CIC Logo
CIC has been reorganizing their website so that the old medical procedures manuals have been replaced.  The new layout is more complex to navigate (it’s a website instead of an operational manual) but there are also substantive changes to the information and material.

For anyone trying to understand more about the medical evaluation process, it’s important to become very familiar with this information.

Personally, I’m glad that some of this wasn’t in place for the processing of my own application – it would have added months onto the process (there are procedures for sponsor notification in some cases and requiring the sponsor agree to continue the sponsorship in spite of the medical condition.)


The Best Laid Plans…

Note:  I originally wrote this post on 11 October.

Yesterday afternoon I was excited to find that the USPS tracking website was now showing information for the prepaid Express Mail waybill for my passport – and presumably the holy “Confirmation of Permanent Residency”.

So I jumped into action – I wrote an e-mail to the folks in the US, alerting them to the incoming package and providing directions on sending it me here in Canada.  I discussed my plans for heading down to the US tomorrow in order to complete the “landing” process – this is the change in status from foreign national to permanent resident.  It’s really just a paperwork thing, but it’s the end-point of this entire process.

At  2 pm today – 5 pm ET  where my company’s offices in the US are located – I heard from them that the package never arrived.  So much for the “guaranteed delivery by 3 pm”.  But the last entry in their tracking system is:

Dispatched to Sort Facility       LOS ANGELES CA 90071                   10/10/12  6:52pm

So, basically, they haven’t seen it since yesterday evening – but USPS tracking is notoriously unreliable, though Express Mail is their best service offering.  This clearly illustrates why one can never count on anything in this process going “as expected”.  In all fairness, I would normally have used FedEx, given the choice, but there were exactly two options available to me: first class mail or Express Mail to a US address.

At any rate, I’m hoping that they find it between now and tomorrow.  Lurking in the back of my head is the “ugh, what if they LOSE it”.  It’s only my passport and that incredibly precious immigration document.  The passport can be replaced, but I have this fear that the only way to replace that immigration document will be to go through the whole process all over again.

So close to the end….


Three months and counting

Cat waiting outside of mouse hole

Three months and counting

As I write this, I realize that it will be three months since my file was sent to the court for a decision.  Thus, my case now seems to stretch into an unusual category, since this time of extended delay seems, from what I can tell, to be remarkably unusual.

Companioni took three weeks to decide (and review was granted).  Another case of someone I know took two months for a denial.  Ovalle took just under a month to decide (and review was again granted).  While I’m sure there are other cases that wait three months for a decision on the application, I have not found one.  This leaves me in the peculiar position of wondering why it is taking so long to actually make a decision.  Part of me wonders if the Court is waiting to see if CIC makes a decision on my other application (thus allowing the Court to wriggle out of making a decision that is unlikely to be popular, regardless of what they decide.)

Of course, nothing seems to be moving when it comes to the Canadian government and any of my applications.  At the beginning of July, the GCMS notes for my request to Seattle (for the TRP – in order to definitively settle the question of admissibility or not) indicated that Seattle had still not started processing my application.  Given that they quoted a three to six month application time frame (and it’s now at five months) I’m now wondering if even six months is a realistic number.

Heck, I’m still waiting to hear from CIC with respect to my request to withdraw the sponsored spousal application (indeed, that hurt to do – I put it off until May, but I didn’t seem to have much choice in the matter.)  Knowing my luck, they’ll finally match the withdrawal letter with the file the dayafter the Court declines to grant my judicial review application.

The final looming deadline is that my current work permit expires on September 3, 2012.  That means that in about a month’s time I will need to gather up all the paperwork for it and submit a renewal. Of course, my hope had been to have a TRP by then so I could apply for the renewal of both the work permit and the TRP at the same time – but that really only worked if I had the TRP by June.  At this point, even if i did get the TRP, I seriously doubt I could get a renewal of the work permit and the TRP prior to September 3, 2012.  Of course, an inland application for a work permit is automatically canceled if you leave Canada after the expiration of the first work permit and prior to the granting of the second (new) permit.

The inland work permit application differs from the outland application in one critical area.  The inland permit renewal asks if you have any “serious medical conditions” and while I wouldn’t think of an asymptomatic disorder to be “serious” I’ve been assured by my attorney that CIC considers it to be one and that I must answer yes.  The outland permit renewal asks if you have any serious medical conditions that require treatment other than prescription medications and the answer for that in my case is “no”.  Indeed, my attorney told me that he was involved in the drive to change the rules (and specifically this field of the form).

So I’m not quite at the point where I have to prepare for the work permit renewal.  But I’m already thinking about it.

In the meantime, it’s now been three months, no decision.  Perhaps there will be a decision tomorrow – or not.  Only time will tell.

The least expensive treatment option

One of the most difficult parts of formulating a response to the fairness letter in my particular case was even determining what the actual costs are to the Canadian Government.  It took me a while to find a source for such information, but it turns out that the Government of Quebec publishes a complete list of what they are willing to pay; my understanding is that this in turn is based upon the actual negotiated prices of the Canadian Government.  The liste de médicaments provides exactly this information.

By using this information I have been able to find what would be the least expensive option for treating an HIV infection in Canada at the present time.  While not the “preferred first line” treatment, it is still listed as a valid first line treatment and thus should be an option for anyone arguing the fairness letter.

Specifically, the combination of lamivudine, zidovudine and nevirapine (also known as Combivir and Viramune) now involves two drugs that are off patent (zidovudine and nevirapine) in Canada as well as the third (lamivudine) for which the patent expires June 2, 2012 (it is already off patent in the United States).

The current cost (as I write this) according to the Quebec price list is:

Zidovudine (100mg x 3) twice per day = $6.32/day

Lamivudine 150 mg twice per day = $9.30/day

Nevirapine 200mg twice per day = $2.47/day

Total cost per day = $18.09/day

$542.70 per month.  At $6,512.40 per year, this is above the maximum allowed, albeit only slightly over that limit.  With the impending generic status of Lamivudine, I would expect those prices to fall so they are below the threshold.

For a comparison, I used an online Canadian pharmacy (based in Quebec) to determine the price of generic equivalents.(Canadian Family Pharmacy – Your Cart)

Canadian Family Pharmacy

Canadian Family Pharmacy

It is a bit of a challenge to put this all together cleanly, but let’s go through the math:

Zidovudine is $4.56/day

Lamivudine is $2.00/day

Nevirapine is $3.40/day

Total per day: $9.96.

That’s $298.80 per month for this treatment option.  I did not combine the first two drugs together because that combination is covered by a patent still (“Combivir”) that has not yet expired.  However, my point is that all of these drugs are available as generics staring June 2, 2012.  This is a Canadian based company selling these drugs.  Note that this company will not ship products to Canada.  This is due to the Canadian rules that these drugs may not be imported (they are “Schedule F”) but for the purposes of computing the cost of generics, this is a reasonable place to start – if the government wishes to disagree, they can but they would need to be in a position to explain how they reached their conclusion.

Bottom line: if you find yourself arguing against a fairness letter due to your HIV positive status, obtain a letter from your doctor indicating that this combination is an acceptable starting therapy for you.  Then use this cost analysis to point out that the total cost of treatment is now under $3600 per year.  Even with periodic testing, your total costs will be well under the current limit (just over $6000 per year).

I didn’t make this argument because the emphasis by CIC in the past was on insurance.  Their response to me was “your insurance doesn’t matter, all that matters is the total cost of treatment, which is paid for by the provincial government”.  If I had known insurance didn’t matter, I’d have focused on costs.  Hopefully, if you find yourself in the same situation you can avail yourself of this argument.

Good luck!