The changes announced by B.C. Health Minister Josie Osborne follow reporting by The Globe and Mail on pharmacies paying kickbacks to patients to maximize the amounts the businesses can bill the province’s publicly funded drug plan.Rich Pedroncelli/The Associated Press
British Columbia will change the fee structure for pharmacies that dispense addiction medications, to remove the financial incentive for predatory pharmacies accused of paying vulnerable patients prohibited kickbacks for their prescription business.
The province will also revert its prescribed alternatives (“safer supply”) program to a witnessed-only model, meaning that a health care provider must observe a patient ingesting the medication, and it cannot be taken off-site.
The changes, announced Wednesday by Health Minister Josie Osborne, follow reporting by The Globe and Mail on pharmacies paying kickbacks to patients to maximize the amounts the businesses can bill the province’s publicly funded drug plan.
Ministry of Health documents leaked by the BC Conservatives earlier this month stated that about 60 pharmacies in the province have been accused of paying patients kickbacks, and that a “significant” portion of the prescribed opioids were being diverted.
The issues, separate but related, together create a lucrative system of fraud and exploitation. Low-income patients with substance-use disorders are incentivized to lie to their health care providers to receive a maximum of three daily-dispense medications, which bad-actor pharmacies require in exchange for the full kickback, commonly reported as $50 a week, The Globe’s investigation found.
Medications with street value, such as hydromorphone, are either used as directed, sold for cash or exchanged for illicit substances. Those with little to no value to the patient, such as daily-dispense ibuprofen, are often discarded, at a cost to PharmaCare. Meanwhile, predatory pharmacies profit and the diverted medications are trafficked “provincially, nationally, and internationally,” according to the leaked Ministry of Health documents.
Just last week, Prince George RCMP observed two people allegedly engaged in drug trafficking outside of a pharmacy, seizing suspected fentanyl, methamphetamine, cocaine, methadone and 700 pills of what appeared to be prescription hydromorphone, the most commonly prescribed medication under the prescribed alternatives program.
Ms. Osborne said the Ministry of Health took action after “allegations, stories and anecdotes” surfaced last year, striking a special investigation unit consisting of former RCMP officers in June and creating a working group with police and the Ministry of Public Safety. The documents leaked earlier this month were part of a presentation from the special investigation unit used to train more than 250 RCMP officers on how to identify illegal activity at pharmacies, the minister said.
“Investigations are under way now with the Ministry of Health, working with the College of Pharmacists of BC and law enforcement, and if there is evidence of wrongdoing, we will take action to shut down a pharmacy and refer the case to police where it’s appropriate.”
Ms. Osborne said she had not discussed the changes with Provincial Health Officer Bonnie Henry, who has been leading the prescribed alternatives program.
The minister said the change in pharmacies’ fee-for-service payments would relate to dispensing prescribed alternatives and opioid agonist treatments, such as methadone, but did not provide details on exactly how. The Ministry of Health was unable to provide an answer on Wednesday.
The Globe previously reported that pharmacies charge a dispensing fee for each prescription, and these fees make up a significant portion of their overall revenue. For patients on income assistance or with First Nations health benefits, a pharmacy can bill PharmaCare for up to $10, for each of up to three medications, per patient per day.
For methadone, the most commonly prescribed medication for opioid-use disorder, the program also pays pharmacies an “interaction fee” of $7.70, on top of the dispensing fee, for the pharmacist to witness the patient ingesting it. This means that a single methadone patient could bring in up to $13,760 a year in pharmacy fees for multiple medications. A pharmacy with a few hundred such patients can bill PharmaCare for millions of dollars a year.
The BC Centre on Substance Use is tasked with updating the clinical guidance on prescribed alternatives. Co-medical director Paxton Bach said Wednesday that it is important for public-health policy to be informed by data and evidence collection, and that the change appears to be in response to emerging information related to the original policy’s unintended consequences.
“Existing clinical guidance provides direction to support clinical assessments and ongoing monitoring that consider individual and public health benefits and risks when offering prescribed alternatives to toxic, unregulated drugs,” Dr. Bach wrote in an e-mail to The Globe.
“Updated guidance will have to reflect this new policy direction and the reasons behind it, while also recognizing that this change may be significantly destabilizing for some who are benefitting from medications that stabilize them and allow them to return to work and to their communities.”
At its peak in March, 2023, 4,945 people were prescribed an opioid as part of the prescribed alternatives program. As of December, 3,665 clients had been prescribed an opioid – a 26-per-cent reduction.
Wednesday’s announcement came shortly before the first Question Period of the legislative session. Elenore Sturko, the BC Conservative critic for justice and public safety, welcomed the decision to return to witnessed ingestion but noted that she raised the issue of diversion two years ago. BC Conservative Leader John Rustad called for a public inquiry into the matter, saying the NDP government played down the issue until his party leaked the Ministry of Health documents.
Premier David Eby defended his government’s actions, saying there are criminal investigations under way now because of the ministry’s probe.
With a report from Justine Hunter