What should reform of PPNs in Ontario look like?

As Ontario considers restricting preferred provider networks (PPNs), pharmacy experts warn against taking an overly simplistic approach.The proliferation of PPNs across Ontario's pharmaceutical distribution system in recent years has become a highly contentious issue for pharmacy professionals, spurring the Ontario finance ministry to launch a 60-day period calling for public comment on PPN agreements last August. The discussion so far has often seen the issue as pitting insurance providers’ bottom lines against the best interests of medical practitioners, and their patients. However, formal comment so far shows that while pharmaceutical professionals are generally in favour of some form of political intervention, opinions vary widely on how. Michael Nashat, executive director of the independent pharmacy advocacy network OnPharm-United, called for a complete ban of PPN networks in an interview with Pharmacy Practice + Business.“There needs to be a distinct rule between the role of the payers and the role of healthcare providers,” said Nashat. “Eliminating PPNs eliminates the requirement or the need to do backroom deals between payers and healthcare providers.”Nashat emphasized how PPNs can direct vulnerable or marginalized patients away from pharmacists they may have chosen for specific reasons.“There's a lot of those [patients] in Canada, especially in the GTA, that have to be directed to a pharmacy that might not understand their language, faith, how they take medications, or whether they're fasting and they chose a pharmacist initially that met those criteria for them,” said Nashat.For its part, Neighbourhood Pharmacy Association of Canada (Neighbourhood Pharmacy) supported the Ontario government's inquiry into PPNs, but cautioned that changes to legislation should be underpinned by a thorough understanding of why PPN agreements have been proliferating in the first place. To some degree, pharmacies are at the mercy of how PPNs have been arranged thus far, said Shelita Dattani, senior vice-president of Pharmacy Affairs and Strategic Engagement for the Neighbourhood Pharmacy, told Pharmacy Practice + Business.“It's not really a system that we've designed, it's a PPN design,” she said. “And pharmacy in that ecosystem needs to continue to be able to be viable and be able to . . . compete based on service.”Neighbourhood Pharmacy proposed several factors needed to fully represent Ontario’s pharmaceutical ecosystem that were overlooked during this initial consultation period.Neighbourhood Pharmacy pointed out that as the jurisdiction with the lowest dispensing fees in Canada, Ontario pharmacists are increasingly struggling to cover rising operating costs through drug markup rates. This was one example of how the long-term economic vitality of the sector is already in danger. That, the association stressed, needs to underpin any legislative response.Further, the association cautioned against use of reductionist language. By limiting the discussion of PPNs to generic terms such as “open, closed, mandatory or voluntary,” Neighbourhood Pharmacy argued the ministry has limited the perception and the scope that PPN serves within the pharmaceutical distribution system.Neighbourhood Pharmacy cited an example relating to Health Canada protocols that require the manufacturers of complex medications to ensure their distributors are able to provide a higher standard of care when dealing with their patients. According to Neighbourhood Pharmacy, the use of a closed distribution network was the only avenue available to manufacturers in order to comply with these protocols.As well it said, patient support programs, healthcare services that offer specialized medical care and financial assistance programs for patients with specialized medications, should play into the conversation. “We want pharmacists to be able to sustain [themselves] and not feel like their value has to be commoditized based on cost alone but that their value comes from the clinical services that they provide,” said Dattani. The Ontario government has promised to hold future consultation periods before introducing any new legislation, if the finance ministry determines that regulating PPNs is in the public's best interests.

What should reform of PPNs in Ontario look like?

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