An Ontario teacher is asking the province’s pharmacy regulator to take disciplinary action against the operators of MemberRx, a pharmacy created to exclusively serve the Ontario Teachers Insurance Plan, saying it harms patients by taking away their ability to choose where to go to fill their prescriptions.
High-school teacher Amy Miller received a notice from OTIP in March that MemberRx would be the exclusive provider for certain specialty medications. This meant that people covered by OTIP would be forced to pay out of pocket for those drugs if they received their prescriptions from any other pharmacy.
Now, in a formal complaint submitted to the Ontario College of Pharmacists through her lawyers, Ms. Miller argues the deal between OTIP and MemberRx is damaging to teachers who are covered by the plan.
Ms. Miller has a form of arthritis characterized by painful inflammation of the spine, and manages her condition with Humira, a drug she says is “life-changing.” The injections cost more than $30,000 per year. She objected to the switch to MemberRx, telling OTIP that she works with a pharmacist she trusts. The insurer granted a “one-time” exception to cover upcoming doses of her medication, but those doses will run out by the end of September.
She appeared before the College last month to discuss the issue, and on Aug. 23, her lawyers filed a professional-misconduct complaint with the College, naming MemberRx and three of its directors.
The complaint argues that MemberRx is no different from a “preferred provider network” or PPN, a type of deal that has been subject to growing scrutiny and criticism across the industry. PPNs commonly involve deals in which pharmacies provide drugs at a lower cost to insurance plans, in exchange for members of those plans being directed to fill prescriptions through that pharmacy. But the financial details of those deals is opaque.
PPNs came into the spotlight earlier this year when Canada’s largest insurer, Manulife Financial Corp. MFC-T, cancelled a deal with Loblaw Cos. Ltd. L-T, after public backlash over a requirement for plan members to fill specialty medications through Loblaw-owned pharmacies, including Shoppers Drug Mart. Pharmacy regulators across the country have been considering whether to restrict such deals, and last week, the Ontario government launched a consultation seeking input on whether to limit insurers’ use of PPNs as well.
“Complaints are a confidential process, however we can confirm that the College has received several recent complaints related to PPNs or payer-directed care models,” Ontario College of Pharmacists spokesperson Dave Bourne wrote in an e-mailed statement on Tuesday.
OTIP and MemberRx have argued their pharmacy is different from a typical PPN, because the pharmacy has “no profit motive,” directing any proceeds it generates back into improving coverage for members. MemberRx was set up for OTIP by Cubic Health, a Toronto-based consultancy. Cubic Health manages some of MemberRx’s operations, such as payroll and hiring, and charges OTIP a fee for its services.
Ms. Miller’s complaint argues that this constitutes a conflict of interest, because the pharmacists who sit on MemberRx’s board “receive financial benefits from Cubic as a direct result of the exclusivity arrangement between MemberRx and OTIP.” The complaint states that this financial interest is in conflict with their duty to provide patients with “quality care.” The deal has affected “multiple patients” across the province, according to the complaint.
The document also notes that Ms. Miller was not aware of the business relationship between OTIP and MemberRx, and that teachers were only informed that OTIP had chosen the pharmacy as its exclusive distributor for certain drugs.
It also argues that the deal threatens “fragmentation” for patients who may have some specialty medications only covered through MemberRx, and others that they may fill elsewhere – meaning they do not have a single pharmacist overseeing their care.
Ontario’s Healthcare Consent Act requires pharmacists to obtain consent before treating people, and that the consent must be informed and provided voluntarily. Ms. Miller’s complaint notes that OTIP’s use of MemberRx does not meet this standard, because she was not aware of the business relationship between OTIP and MemberRx, and because the switch is not voluntary.
“Consent would be provided under duress after being threatened by OTIP and MemberRx that the Complainant would lose coverage for the treatment of a debilitating and painful condition, which they could not afford to treat without insurance,” the complaint states.
The College is required to notify registrants of complaints within 14 days of filing. Cubic Health chief executive officer Mike Sullivan declined to comment on Tuesday, telling The Globe and Mail in an e-mail that he had not yet received the complaint from the College.
All complaints submitted to the Ontario College of Pharmacists are subject to an investigation, reviewed by a panel known as the inquiries, complaints and reports committee. The committee then decides whether to take further action, such as providing recommendations to a pharmacist on how to improve their practice, mandating they take educational courses, or in more severe situations, refer the case to the College’s discipline committee for a hearing.
“In Amy’s situation, we would be hopeful that these allegations would be referred to the College’s discipline committee which could then review this situation and adjudicate these concerns properly,” Ms. Miller’s lawyer Aly Haji said in an interview.
The complaint argues the operations of MemberRx qualify as “disgraceful, dishonourable and unprofessional conduct.” It also notes that the discipline committee has found professional misconduct in the past related to a pharmacist’s involvement in a closed PPN.
The College reprimanded a registrant in August of last year, noting in its decision that her involvement in the PPN had interfered with a patient’s “right to choose a pharmacy and/or pharmacy professional.”