Speciality drugs

Patients’ care pathway fragmented due to prohibited commercial practices

Since the 2000s, increasing numbers of patients have been prescribed so-called specialty drugs. Most of these treatments are very expensive, and some can require specific types of care or management, including ensuring that the drugs are properly administered (e.g., if they must be injected).

For many of these prescription medications, manufacturers have established patient support programs (PSPs) to make it easier for patients to obtain refunds or financial assistance when they need it, or to provide therapeutic follow-up services.

However, some prohibited practices, which violate patients’ rights, have become entrenched over the years.

In fact, when they are prescribed their medication, a patient is often in a highly vulnerable state, and is referred to a so-called speciality pharmacy by the PSP, which has preferential relationships with a select number of pharmacies and other third parties, despite the fact that this is prohibited under current laws and regulations. No one can impose a choice of pharmacy or pressure a patient: manufacturer, infusion clinic, physician, pharmacist, insurer or employer.

Preventing fragmentation of care

If you are receiving a specialty drug from another pharmacy, tell your usual pharmacist about it. This is especially important to make sure that your file is analyzed in full, which includes checking for drug interactions and side effects.

Pharmacists are expanding their range of services to manage the entire pharmacological therapy of their patients, or at least to coordinate it by having access to the complete file. This makes the process much smoother for the patient and ensures better care coordination.

“With my regular pharmacist I get much more personalized service, because they are familiar with my overall health situation and my entire history. My pharmacist is the one I can consult if I need antibiotics because of my immunosuppressed condition, or when my blood pressure is too high. People like me who have to live with a chronic disease and are in a highly vulnerable state can maintain control over their therapy and their lives, regardless of what some groups or individuals may say. And that starts with making our own choice of the pharmacy where we want to get your medication.” – Isabelle, who is living with two autoimmune disorders, including Crohn’s disease

“The fragmentation of patient care is totally illogical. Québec’s 7,000 pharmacists and their teams also have the capability and the skills to properly serve their patients. They have a strong presence in all regions and are easily accessible, right in people’s neighbourhoods. We help patients every single day, and we are the ones who are there to meet their every need, large or small.”
– Judith Choquette, owner-pharmacist, Longueuil

A unique model that benefits patients

In Québec, pharmacists have an exclusive ownership right that allows them to own and manage their own pharmacy. This exclusive right is a protective mechanism that ensures patients’ interests remain at the heart of pharmacists’ decisions.
By guaranteeing pharmacists’ professional independence, it promotes broader territorial representation, making it easier for the population across Québec to access a frontline healthcare professional. Several provisions of the law and the pharmacists’ Code of Ethics contribute to making Québec’s pharmacy model one of the most advanced and advantageous for patients.
The 1,900 pharmacies located throughout Québec are therefore a cornerstone of the healthcare network. There are 7,000 pharmacists (4,900 women and 2,100 men) working at the heart of communities, serving patients. These accessible professionals, experts in medication, have developed their practice around patients’ needs.

Business practices that harm network development

Unfortunately, prohibited commercial practices between a handful of so-called speciality pharmacies and certain patient support programs create closed circuits that prevent community pharmacists from fully playing their role and serving patients effectively.
To remain open and accessible, pharmacists must organize their services based on patients’ evolving needs. And specialty medications are therapies that are rapidly growing!
It is therefore essential that community pharmacies in Québec have unrestricted access to specialty products, which represent the future of drug therapies. No pharmacy, wholesaler, manufacturer, or patient support program should interfere with pharmacists’ work or with patients’ right to choose their pharmacist.

Frequently asked questions

What is a specialty drug?

Specialty drugs are generally prescribed to treat complex and chronic diseases and illnesses, including some rare conditions. They may require specific management and follow-up. They also tend to be expensive.

What is a patient support program (PSP)?

If you’re taking a specialty drug, you’ve probably been in contact with a patient support program (PSP). PSPs are set up by drug manufacturers to offer support and services in the area of treatment management, as well as help with financial aspects, like insurance and financial assistance.

It is often through a PSP that a manufacturer makes available free doses of drugs, frequently referred to as compassionate doses. The manufacturer cannot distribute doses of medication directly to a patient; a pharmacy must be involved in the process of providing the drug.

Be careful: Many PSPs direct patients to partner pharmacies to obtain free doses. This is a prohibited practice.

Is a PSP allowed to refer me to a designated pharmacy or so-called specialty pharmacy?

Your pharmacist can send a request to the PSP for your compassionate doses to be provided through your usual pharmacy.

You can also obtain a refund for your medication under your group insurance coverage at any pharmacy.

If a PSP representative tells you that you will not be able to obtain an insurance refund if you choose a pharmacy other than the one they designate, or if a manufacturer or wholesaler tries to make it difficult for your pharmacist to order your drug, these may be prohibited practices.

Does my usual pharmacist have the required competencies to manage my treatment?

All pharmacists receive the same university training qualifying them to practice their profession in Québec. Each of them has the necessary knowledge and right of practice to assess the full range of a patient’s drug therapy and ensure that it is properly monitored and managed.

Therapies are constantly evolving, and always have been, and pharmacists take continuous training to respond and adapt to these changes (indeed, this falls under their professional responsibility).

Warning: To persuade patients to deal with a designated pharmacy, often called a “specialty” pharmacy, some PSPs and other parties promote myths that can be a source of doubt for patients. For example, they discourage them from going to their usual pharmacist by undermining their confidence in their abilities or suggesting that their care journey will be more complex (e.g., maintenance of a cold chain).

Remember: no one involved in a patient’s care can claim that their usual pharmacist is not capable of providing the same level of care as a pharmacy designated by a PSP.

Does my usual pharmacy have the necessary resources (e.g., delivery system, refrigerator, injection service) to handle specialty drug service?

Pharmacies meet all of the strict standards of practice imposed by the Ordre des pharmaciens du Québec. They all have standards for storage of medications and “cold-chain maintenance,” labelling standards, product preparation standards and more.

Why is it better for me to go with my usual pharmacy for my treatment?

It is in your interest as a patient for your drug therapy to be fully managed by their usual pharmacy, if that is your choice.

This is especially important to make sure that your file is analyzed safely and comprehensively, which includes checking for drug interactions, as well as to adapt the support and guidance needed throughout your treatment.

The information in someone’s Dossier Santé Québec (DSQ) file is no substitute for the relationship established between a patient and their pharmacist. In addition, free (so-called compassionate doses are often not entered into the DSQ, which poses a problem in terms of patient safety.

The advantage of community pharmacists is that they know their patients and their complete health status—especially when a particular patient has a health condition requiring multiple follow-ups and extra support and guidance.

For example, a patient living with a chronic illness should go to see their usual pharmacist if they need an antibiotic because of their immunosuppressed condition, if their blood pressure is too high, or if they experience other side effects that need treatment. It makes no sense to shuffle a patient around for no reason if their case can be managed globally and effectively by their usual pharmacy.

Is there a recognized “specialist” title connected with management of specialty drugs?

No. There is no recognized specialty connected with management of specialty drugs. The pharmaceutical services involved in the case of specialty drugs are not reserved for a specific category of pharmacist. Every pharmacist has all the knowledge and skills needed to provide these medications and handle the complex follow-up required.

Which illnesses are most likely to require treatment with specialty drugs?

Specialty drugs may be prescribed to treat chronic or complex diseases, including some rare conditions. Examples of conditions and diseases that may require a patient to take specialty drugs include Crohn’s disease, ulcerative colitis, cancer, lymphoma, myeloma, rheumatoid arthritis, atopic dermatitis, macular degeneration, psoriatic arthritis, ankylosing spondylitis, rheumatoid arthritis, plaque psoriasis, multiple sclerosis, leukemia, adenocarcinoma, cystic fibrosis, lupus erythematosus, melanoma, carcinoma.

If you would like more information about patient support programs or financial assistance, an explanatory brochure is available here.

Let’s help ensure that the local pharmacy network survives

Did you know that a small group of individuals, alongside certain pharmaceutical industry players (certain manufacturers and their patient support programs), are engaged in non-compliant strategies that are contrary to the Act Respecting Prescription Drug Insurance and the Code of Ethics of Pharmacists and that allow them to control the majority of the specialty drug market?

That’s right: there are six so-called specialty pharmacies currently sharing 40%* of the specialty drug market in Québec. This situation is jeopardizing the survival of Québec’s pharmacy network, making the patient care pathway more complex and funnelling the resulting profits to a handful of pharmacists. And yet those profits could be of benefit to the overall community pharmacy network, helping to maintain or improve frontline services provided to patients.

With the Government of Québec preparing to further expand pharmacists’ scope of practice in frontline care through Bill 67, it is important to safeguard the vitality of the local pharmacy network as we know it today, as it has a presence in all of the province’s regions and communities.

*Patients covered by the RAMQ for the year 2023–2024

Class action

In response to the unlawful and wrongful commercial practices being perpetrated by certain groups and individuals, the Association québécoise des pharmaciens propriétaires (AQPP) has filed an application for authorization to institute a class action against 10 of its pharmacist members and the pharmacist owners of six pharmacies, three patient support program (PSP) managers and three private infusion networks. To learn more, go here.

Are you affected by this situation? Share your story!

I am a patient or a relative of a patient

Are you taking a specialty drug? Were you able to freely choose the pharmacy responsible for your treatment? Do you feel that you were pressured by a third party? Please share your experience with us.

Consulter la politique de confidentialité de l’AQPP.

I am a health professional or a worker involved in a patient’s care journey

Are you a health professional (community or institutional pharmacist, prescriber, nurse) or other worker involved with patients? Do you have something to share about the management of a specialty drug?

Consulter la politique de confidentialité de l’AQPP.

To report a situation

Anyone wishing to report a situation where laws and regulations are not being upheld and they are pressured into obtaining a service from a pharmacy they have not chosen may reach out to their pharmacist or the RAMQ using the following contact information:

WEBSITE

Report wrongdoing (a person or situation) | Régie de l’assurance maladie du Québec (RAMQ) (gouv.qc.ca)

Visit the “Reporting Wrongdoing” section of the RAMQ website, accessible at the bottom of any page of the site, under “Your rights.”

TELEPHONE

1 877 858-2242

Régie de l’assurance maladie du Québec – Dénonciation

C.P. 6600, succ. Terminus

Québec (Québec) G1K 7T3

[1]. Such actions are contrary to the Code of Ethics of Pharmacists (Chapter P-10, R. 7) and the Code of Ethics of Physicians (Chapter M-9, R. 17, Sec. 27), and also violate the Health Insurance Act (Chapter A-29, Sec. 2).