Financial help available to make prescription drugs more accessible for more Ontarians
Prescription affordability consistently emerges as a major barrier in our work. Many patients report making difficult choices between filling their medications and paying rent or other essential expenses. Provincial drug programs and benefits exist, but are not always easy to navigate.
Some individuals eligible for provincial drug program benefits struggle to pay the related deductibles. According to Ontario Health, “the deductible for the Trillium Drug Program equals about 4% of the household income after taxes,” which can be out of reach for Ontarians living in poverty.
What difference can a financial intervention, with support, make on someone’s health?
The complexities of coverage
Canadian citizens or permanent residents tend to have OHIP. In practice, when a client has OHIP but no drug benefits/coverage, healthcare providers often refer or assist the client with applying for Ontario drug programs. Where do we send clients when they don’t meet provincial drug program criteria?
The GreenShield Cares Essential Medicines program is a drug benefit plan that provides $1,000 per 12 months in prescription drug coverage for Ontarians, with no out-of-pocket costs, co-pays, or deductibles. It is designed for those who do not have private prescription drug coverage and are not enrolled in a provincial drug program. The program aims to reduce financial barriers for those who cannot afford their prescribed medicines and fall through the cracks of our health care system. Three percent of Canadians do not have access to essential medicines. That’s 1 million Canadians without prescription drug support.
To be eligible, applicants must be employed, have a combined household net income below the program threshold, be between 25 and 64 years old, and be a Canadian citizen or a permanent resident who resides in the province of Ontario. The program does not duplicate coverage where it already exists but instead, works alongside existing programs to fill coverage gaps. For example, an age limit of 25 to 64 aligns with existing Ontario programs. OHIP+ exists for anyone age 24 or younger and the Ontario Drug Program (ODB) covers Ontarians aged 65+.
The Essential Medicines program covers the cost of many medications but may not cover all a client’s medications. A GreenShield pharmacist reviews participants medication needs and works closely with their prescribers. Medications are dispensed by GreenShield Pharmacy and shipped using many courier services at no cost directly to the patient’s home.
Coverage is available for 12 months from coverage start date. Participants can reapply to continue coverage. GreenShield sends notification 60 days in advance of their enrolment period end date to provide ample time to reapply, providing individuals continue to meet eligibility criteria. Visit the GreenShield program website for more details.
Navigating the benefits – this is where we come in
Application processes can be overwhelming, particularly for individuals balancing medication costs against other financial priorities. And although Ontarians can apply directly to GreenShield’s program, providing application and navigation support, along with ongoing follow-up is integral to favourable program and participant outcomes.
Like many social and income support programs, guidance and support can make for a more streamlined and positive experience for both participants and their health care providers. Any application process, especially for someone weighing choices about medication vs other financial choices, can feel overwhelming, confusing, and cumbersome.
Through our provincial umbrella organization, the Alliance for Healthier Communities, Access Alliance is piloting a referral process to the Essential Medicines program in our primary care services. The goal of this pilot is to support our patients’ access to the program if they are not eligible for other benefits and help them understand the program’s coverage (e.g., some of their medications may not be covered). Support for implementation includes information sessions for pilot partners, technical guides to help implement the pilot, and share best practices among partners. We’ll be evaluating what the impact of participating in the program has on their access to prescription medication and overall health outcomes.
By offering application and navigation support, and following up to track health outcomes, health promoters, social prescribers, researchers, or nursing staff can help remove the stress involved of navigating the system alone.
It’s about more than medication
The project aims to improve the overall quality of life for patients. As part of the program, we will be using a patient-reported outcome measure to determine the impact of the program on a patient’s physical and mental health status over time.
Through the pilot, we’ll also ensure that information about their coverage is captured in our medical records. Having this information can help us as primary care providers to help patients manage their medication as part of their overall care, which can be a gap. We learned more about this in our work to better understand what Seniors need to know and communicate about medications.
It’s interesting to note that determining a patient’s eligibility for existing Ontario drug programs is not always a topic of conversation and a great question to ask ourselves is, why not?
A seemingly small intervention can make a big difference for health and well-being
Perhaps one of the unintentional by-products of an intentional project like this, is that conversations about medication affordability will become more frequent and normalized, alongside providing support for patients in navigating benefit programs they can access to help reduce their medication costs.
As we progress on this interesting project, we will share both our findings and those of our Alliance partner evaluation findings regarding its impact on access to affordable medication and health outcomes. This will include examining the impact of providing short-term (12 months) access to benefit coverage, unless the patient reapplies and is reassessed for continued eligibility and participation.
An important systemic question might also be addressed by this pilot: if a targeted $1,000 intervention can stabilize the health trajectory and quality of life for Ontario’s working poor, why is this not already the national standard?
Related Access Alliance work
Understanding what Seniors need to know and communicate about medications – a health care system reality check
This joint project between the Access Alliance Research Department and the Open Door project focused on creating a new presentation for seniors about medication, medication compliance, medication use, medication reconciliation and review, why it is important to share accurate information about medication with providers, etc. We set out to build a workshop and simple tools to help seniors better understand and manage their medications. The 95 seniors we spoke to give us a health care system reality check. We learned how seniors feel about medication and their preferred relationship with health care practitioners.