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Planning a pharmacare program for the Northwest Territories Pontus, Michael Stephen 1980

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PLANNING A PHARMACARE PROGRAM FOR THE NORTHWEST TERRITORIES by MICHAEL STEPHEN PONTUS B.A.,Carleton U n i v e r s i t y , 1969 B . S c , The U n i v e r s i t y of B r i t i s h Columbia, 1976 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES (Medicine) We accept t h i s t h e s i s as conforming to the re q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA September 1980 c Michael Stephen Pontus, 1980 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f HEALTH CARE AND EPIDEMIOLOGY The U n i v e r s i t y o f B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 D a t e SEPTEMBER 12. 1980. DEDICATION To Peggy and Jenny whose love and s a c r i f i c e s have made t h i s p o s s i b l e . ABSTRACT The Northwest T e r r i t o r i e s L e g i s l a t i v e Assembly i n March of 1979, recommended that the Government of the Northwest T e r r i t o r i e s introduce a Pharmacare program f o r Senior C i t i z e n s on J u l y 1, 1979. The Northwest T e r r i t o r i e s has a p o p u l a t i o n of 46,400 people, spread through 59 settlements and over 3,379,500 square k i l o m e t e r s . Senior C i t i z e n s account f o r 2.8% of the p o p u l a t i o n . The problem faced i n the i n t r o d u c t i o n of the program was that i t a l s o r e q u i r e d c o n s o l i d a t i o n of three e x i s t i n g programs. Rather than o f f e r a u n i v e r s a l program, the T e r r i t o r i a l Government chose a program f o r those r e s i d e n t s age 65 and over to complement the e x i s t i n g programs, s p e c i f i c a l l y the one i n the Department of Health which covers p r e s c r i p t i o n drugs f o r twelve defined i l l n e s s e s . The Government d i d so without i n t r o d u c i n g Pharmacare l e g i s l a t i o n but r a t h e r through a f i n a n c i a l a p p r o p r i a t i o n of the Finance L e g i s l a t i o n . This l e f t the f i n a l d e f i n i t i o n of p o l i c y planning and program i n t r o d u c t i o n i n the hands of bureaucrats. The planning of the program took place i n a b u r e a u c r a t i c s e t t i n g . The approach used was an incremental approach based on a comparison of the major features of the e x i s t i n g plans of B r i t i s h i v Columbia, Saskatchewan, Manitoba and Ont a r i o . The d e t a i l e d design i n v o l v e d the c o n s t r u c t i o n of a formulary, the q u a n t i f i c a t i o n and numerical i d e n t i f i c a t i o n of a l l i n f o r m a t i o n i n order that i t could be placed i n an e l e c t r o n i c data processing format to be operated on a data base i n t e r - a c t i v e system of a Hewlett-Packard 3000 computer. The con s o l i d a t e d program was s u c c e s s f u l l y implemented on J u l y 1, 1979 and has worked s u c c e s s f u l l y from that p o i n t . The report concludes w i t h an e v a l u a t i o n of the system and how i n t r o d u c t i o n of t h i s program may be of use i n the design of Pharmacare programs or other programs i n other s i m i l a r j u r i s d i c t i o n s . V ACKNOWLEDGEMENT The f i n a l i z a t i o n of t h i s thesis i s the r e s u l t of e f f o r t s by many people. F i r s t , my sincere gratitude to Dr. Anne Chrichton who has guided me through the program and t h i s t h e s i s . She has always eagerly shared her wisdom and knowledge and been a strong supporter. My thanks to Drs. C.J. MacKenzie and F.A. Morrison for t h e i r s k i l f u l and dedicated assistance i n reading my paper. Thanks i s extended as well to the s t a f f of the Department of Health and System West Consultants whose knowledge and e f f o r t s made possible the r e a l i z a t i o n of the program i n such a short time. To L i s Henry who typed the f i n a l document goes my thanks f o r her patience and d i l i g e n c e . Last but not le a s t I wish to thank my parents and Mary Ann, Larry and Kathy for t h e i r ever strong support. v i TABLE OF CONTENTS PAGE DEDICATION . , . , , . i i ABSTRACT i i i ACKNOWLEDGEMENT . . . . . . . v TABLE OF CONTENTS v i ILLUSTRATIONS . x CHAPTER PAGE 1 INTRODUCTION, . . . . . , . . . . 1 Synopsis H i s t o r i c a l Development 2 L i t e r a t u r e Review . , 12 Plan n i n g and Planning Theory. . . . 12 Pharmacare Planning L i t e r a t u r e 14 Demography • • • 16 Problem . . . . . 21 Economic Problem, • • « • * • 21 L o g i s t i c Problem 22 Summary , , 24 2 COMPARISON OF FOUR PROVINCIAL PLANS . . . . . . . 26 B r i t i s h Columbia 27 Manitoba 29 Saskatchewan 30 Ontario 32 v i i Table of Contents CHAPTER PAGE 2 COMPARISON OF FOUR PROVINCIAL PLANS A n a l y s i s . . 34 Summary 42 3 PLANNING AND DESIGN. 43 Objectives 46 E i g h t Major Deci s i o n s 47 B e n e f i c i a r i e s 48 S e l e c t i o n of Covered Drug Products 51 Cost Sharing by P a t i e n t 55 Reimbursement f o r Product Cost to Pharmacist 61 Reimbursement of Dispensing Costs by Pharmacist 63 Reimbursement Method 64 Data P r o c e s s i n g 65 C o n t r o l of Program Q u a l i t y 67 Design 69 Phases 69 Phase 1 System Study and E v a l u a t i o n 70 Phase 2 System Design 71 Phase 3 Subsystem Design 74 Formulary Subsystem 75 P r a c t i t i o n e r Subsystem 78 P a t i e n t R e g i s t r a t i o n Subsystem. . . . . . . . 79 Claims E d i t and Assessment Subsystem. . . . . 79 Management and S t a t i s t i c a l Reporting Subsystem 81 v i i i Table of Contents CHAPTER PAGE 3 PLANNING AND DESIGN Phase 3 Subsystem Design Pharmacare E f f e c t i v e n e s s Subsystem 81 P r e s c r i p t i o n V a l i d a t i o n s 82 Pharmacare System L o g i c 82 Phase 4 Production of Procedur a l Manuals . . . . 83 Phase 5 The Computer Design and Programming Phase. . . 83 Phase 6 Computer Test 84 Phase 7 System Test 84 Phase 8 Enhancements 84 Phase 9 System E v a l u a t i o n 8.4 Implementation 85 Summary 87 4 EVALUATION AND RECOMMENDATIONS . 89 E f f e c t i v e n e s s 91 E f f i c i e n c y 9Q I d e o l o g i c a l 92 Extension of P r i n c i p l e s 92 ENDNOTES 9 5 BIBLIOGRAPHY 101 APPENDICES 106 Appendix A. Reports Sequenced by R e c i p i e n t and Fu n c t i o n a l Area 106 Appendix B. Pharmacare System L o g i c N a r r a t i v e . . . . 122 i x Table of Contents CHAPTER PAGE Appendix C. Federal N o t i f i a b l e Diseases 140 Appendix D. Pharmacy P r o f e s s i o n s Ordinance 141 ILLUSTRATIONS Table T i t l e Page 1. P u b l i c Pharmaceutical Programs f o r the Aged 9 2. U n i v e r s a l Drug Programs 11 3. Comparison of Canadian P r o v i n c i a l Drug Plans w i t h P a t i e n t (Recipient) C o n t r i b u t i o n 1978 35 4. Comparison of Canadian P r o v i n c i a l Drug Plans - 65+ Ambulatory R e c i p i e n t s 1978 37 5. Comparison of Canadian P r o v i n c i a l Drug Plans w i t h F u l l Government Payment - 1978 39 6. Program Costing: Pharmacare f o r People over 65 years 66 7. Contents of Pharmacare Master F i l e s 76 Figure 1. System Concept Diagram CHAPTER 1 INTRODUCTION This t h e s i s i s an account of the development of the Pharmacare program f o r r e s i d e n t s of the Northwest T e r r i t o r i e s . The author i n h i s p o s i t i o n as C h i e f , Health Insurance Programs, developed and implemented the program described and evaluated below. The Northwest T e r r i t o r i e s has followed the r e s t of Canada i n developing programs ( P u b l i c H e a l t h , Mental Heal t h , H o s p i t a l Insurance, Medical Care) to meet the needs of the T e r r i t o r i e s . * Pharmacare i s defined as p u b l i c s e c t o r involvement i n the f i n a n c i n g of p r e s c r i p t i o n drugs. I t i s one of the s u b s i d i a r y programs brought i n to support the major i n i t i a t i v e s introduced as a r e s u l t of the Heagarty Committee's proposals i n 1943. The Committee had become i n t e r e s t e d i n the i s s u e because drugs had be-come the p r i n c i p a l form of therapy to those having medical treatment i n Canada. I t was f i r s t proposed as an a d d i t i o n to these primary programs by the H a l l Commission i n 1964. Pharmacare was introduced i n the Northwest T e r r i t o r i e s as a consolidated program i n J u l y of 1979. Three separate p u b l i c sec-t o r programs had e x i s t e d p r i o r to that date. 2 There w i l l f o l l o w a d e s c r i p t i o n of the planning and the e v a l u a t i o n of the program. Synopsis - H i s t o r i c a l Development P u b l i c i n t e r v e n t i o n i n the f i e l d of p r e s c r i p t i o n drugs o r i g i n a t e d o u t side Canada. Abel-Smith, when reviewing the comparative development of the h i s t o r y of insurance programs, notes t h a t : Pharmaceutical b e n e f i t s are normally i n c l u d e d i n compulsory insurance and p u b l i c s e r v i c e h e a l t h schemes. The u s u a l system i s f o r them to be purchased through a l o c a l pharmacist and e i t h e r the pharmacist or the p a t i e n t claims reimbursement from the s i c k fund or government. In the main s i c k fund of I s r a e l the drugs are issued through the s i c k fund. In the U.S.S.R., p a t i e n t s have to purchase t h e i r own drugs f o r use at home. In B r i t a i n , any drug may be p r e s c r i b e d f o r p a t i e n t s , through i n d i v i d u a l doctors though i n d i v i d u a l doctors may be r e q u i r e d to account f o r t h e i r a c t i o n s to t h e i r colleagues i n the area, i f t h e i r p r e s c r i b i n g appears to be "excessive". The p a t i e n t pays the standard charge of 20p f o r each p r e p a r a t i o n . In A u s t r a l i a defined " l i f e s a v i n g drugs" are a v a i l a b l e f r e e to the bulk of the population w i t h a more extensive l i s t f o r pensioners. There i s a s i m i l a r l i m i t a t i o n to " e s s e n t i a l drugs" i n Sweden. In the Netherlands doctors may not p r e s c r i b e medi-cines which are i n the experimental stage or f o r which there i s a l e s s c o s t l y s u b s t i t u t e of equal t h e r a p e u t i c value,2 Canada can t r a c e one of i t s e a r l y instances of t h i r d p a r t y involvement i n pharmaceutical b e n e f i t s to B r i t i s h Columbia where, i n 1933, the government implemented support programs f o r the 3 p r o v i s i o n of necessary p r e s c r i p t i o n drugs to s o c i a l a s s i s t a n c e cases. I t was the Heagarty Committee of 1943 that f i r s t advocated p r e s c r i p t i o n drugs as p a r t of an o v e r - a l l proposal of h e a l t h 3 b e n e f i t s . Ruderman speculates that t h i s i s due to the f a c t that members of the Canadian Armed Forces rec e i v e d drugs and came i n contact w i t h v a r i o u s types of h e a l t h insurance programs i n Southern European c o u n t r i e s , where i t was already a f a c t of 4 l i f e . Heagarty's proposals were a l i t t l e i n advance of Canadian p u b l i c conscience, more over-shadowed w i t h Canadian concerns of World War I I . The i s s u e d i d not a r i s e again u n t i l the 1950's when complaints of high drug p r i c e s goaded the Canadian p o l i t i c i a n s i n t o a c t i o n . Canada responded w i t h the f r e e e n t e r p r i s e philosophy that foresaw as l i t t l e government i n t e r v e n t i o n as possible."' Canada saw the r e j e c t i o n by the doctors of the proposed scheme i n A u s t r a l i a i n 1949. This may have i n f l u e n c e d the f e d e r a l government i n i t s d e c i s i o n not to introduce a program. The l a t e 50's 0-958) saw the i n t r o d u c t i o n of the H o s p i t a l Insurance and Diagnostic Services Program w i t h i n which pharma-c e u t i c a l costs i n a h o s p i t a l were considered a b e n e f i t . Bulk 4 purchasing and the i n t r o d u c t i o n of f o r m u l a r i e s were concepts that came to the f o r e f r o n t i n h o s p i t a l pharmacies. The American Senate Sub-Committee on A n t i - T r u s t Monopoly (1957 - 1967) chaired by Senator Estes Kefauver drew a t t e n t i o n to the monopoly powers at play i n the drug i n d u s t r y . I t pointed out that these were extremely l a r g e companies and that they were m o n o p o l i s t i c not only w i t h i n North America but g l o b a l l y . Kefauver, upon d i s c o v e r i n g the monopoly s i t u a t i o n , l e d the Sub-Committee to reach a d e c i s i o n that " i t must destroy the monopoly by i n j e c t i n g i n t o the drug manufacturing i n d u s t r y , a greater degree of p r i c e competition ".^ The f i r s t enquiry i n t o the cost of drugs i n Canada was begun i n 1958. This enquiry was spurred on, no doubt, by the Kefauver i n v e s t i g a t i o n s and the dramatic u n f o l d i n g that they undertook i n t h e i r years. The Canadian enquiry r e s u l t e d i n the f i n d i n g s of a Green Book put forward i n 1961 to the R e s t r i c t i v e Trade P r a c t i c e s Commission. The House of Commons then i n 1962 e s t a b l i s h e d a s p e c i a l committee on drug costs and p r i c e s commonly known as the Harley Committee which ran through to i t s completed document i n 1967. This committee i n i t s review of drug costs and p r i c e s , concluded that not only d i d a monopoly g s i t u a t i o n e x i s t i n Canada but t h a t i t was f o r e i g n owned. I t i d e n t i f i e d that the l a r g e s t percentage of drugs were manufactured 5 outside of Canada. I t advocated p u b l i c s e c t o r i n t e r v e n t i o n i n the form of t a r i f f s and i n c e n t i v e s to the Canadian i n d u s t r y to help develop a Canadian base. More i m p o r t a n t l y , i t c a l l e d 9 f o r strengthening of the Food and Drug Act to p r o t e c t consumers. This important l i n k a g e between consumer p r o t e c t i o n , cost and drug q u a l i t y o f f e r e d the p e r f e c t r a t i o n a l e f o r greater p u b l i c s e c t o r involvement. The Canadian approach of minimal i n t e r v e n t i o n l e d to government involvement i n q u a l i t y . The t a r i f f s and i n c e n t i v e s suggested d i d not a f f e c t the manufacturers approach. Ruderman speculates that t h i s i s a r e s u l t of economies of s c a l e that permit U.S. firm s to u n d e r s e l l Canadian made products even w i t h the t a r i f f . ^ What occurs i n t h i s i n s t a n c e i s that U.S. firm s can run o f f a d d i t i o n a l q u a n t i t i e s at minimal cost once they have met the q u a n t i t i e s that they are able to dispose of i n the United S t a t e s . At t h i s time, there a l s o appeared a great search f o r the Canadian i d e n t i t y and Canadian independence and i t spurred on the ideas of f o s t e r i n g Canadian and home grown i n d u s t r y . A patent system designed to encourage new i n d u s t r y and c o n t r o l l e d products was i n e f f e c t i v e , s i n c e only 5% of a l l Cana-dian patents are held by Canadian firms or i n d i v i d u a l s and 85% of 6 Canadian drug manufacturing i s i n manufacturing t a b l e t s from imported b a r r e l s of drugs. The H a l l Committee of 1964 which came i n t o being during the ex i s t e n c e of the Harley Committee had become i n t e r e s t e d i n the i s s u e of p r e s c r i p t i o n drugs as an insured s e r v i c e because of the enormous use of drugs i n treatment methods. Studies have shown that i n Canada p r e s c r i p t i o n drugs dispensed per c a p i t a doubled between 12 I960 and 1971. As w e l l , 70% of the drugs c u r r e n t l y being 13 p r e s c r i b e d were unknown or u n a v a i l a b l e f i f t e e n years ago. The H a l l Committee foresaw the increase i n drug usage and cost that has come about. Cost sharing arrangements e x i s t i n g at that time, appear to have conspired to remove i t from the c o n d i t i o n s agreed to i n the Medicare Act of 1967. The i n t r o d u c t i o n i n 1958 of the H o s p i t a l Insurance and Diagnostic Services Act which had marked p u b l i c s e c t o r i n v o l v e -ment i n the cost of p r e s c r i p t i o n drugs f o r i n p a t i e n t s of acute h o s p i t a l s and the Canada Assist a n c e Plan of 1966 which permitted the sharing of the cost of p r e s c r i p t i o n drugs to i n d i g e n t s , met 14 the l a r g e s t of drug c o s t s . The Medicare Act of 1967 d i d not c o n t a i n cost sharing f o r Pharmacare. Since the b a s i c f e d e r a l p o l i t i c a l philosophy has been minimal i n t e r v e n t i o n , government a c t i o n to attempt to reduce the costs of drugs d i d not focus on the manufacturing of drugs but r a t h e r t h e i r d i s t r i b u t i o n . Provinces (B.C., A l b e r t a , Saskatchewan, Manitoba 7 and Quebec) have passed l e g i s l a t i o n enabling pharmacists to choose the lowest p r i c e d drug from among equ i v a l e n t products when f i l l i n g a p r e s c r i p t i o n . The involvement of the p u b l i c s e c t o r i n the u n i v e r s a l coverage was re v i v e d by the Ontario government's i n t r o d u c t i o n i n 1970 of PARCOST ( P r e s c r i p t i o n s At Reasonable Cost). I t perhaps can be viewed as a s i g n i f i c a n t t u r n i n g p o i n t i n the p u b l i c s e c t o r involvement and the f i r s t p u b l i c s e c t o r i n t e r v e n t i o n i n the cost f a c t o r s i n c e i t i n d i r e c t l y a f f e c t e d costs of p r e s c r i p t i o n A 1 6 drugs. In a d d i t i o n , the f e d e r a l government has had i n v e s t i g a t i o n s such as the task f o r c e on the non-medical use of drugs (the LeDain Commission of 1969). In a l l a great deal of concern about the c o s t , q u a l i t y and u t i l i z a t i o n of drugs has i n v o l v e d the p u b l i c s e c t o r to an ever i n c r e a s i n g degree. The s p i r a l l i n g costs of drugs and the pro-l i f e r a t i o n of drugs has meant that subsequently, provinces have had to re-examine t h e i r p o s i t i o n s . In a short span of time, s e v e r a l provinces introduced programs f o r the aged. (See Table 1) Subsequently, B r i t i s h Columbia, Saskatchewan and Manitoba opted f o r u n i v e r s a l programs. (See Table 2) The r a p i d succession of the i n t r o d u c t i o n of these programs r e f l e c t s the high l e v e l of p u b l i c importance attached to the program and the snowball e f f e c t attached to insured h e a l t h s e r v i c e s . A l l the programs have t h e i r 8 own p e c u l i a r i t i e s r e f l e c t i n g the c o n d i t i o n s under which they were planned and operate. There i s , however, l i t t l e documentation on how the programs were planned. TABLE 1 PROVINCE Manitoba " P u b l i c Pharmaceutical Programs f o r the Aged" DATE OF IMPLEMENTATION B r i t i s h Columbia 3 A l b e r t a • 4 Ontario Nova S c o t i a Saskatchewan New Brunswick ^ Quebec ^ Northwest T e r r i t o r i e s J u l y 1, 1973 January 1, 1974 J u l y 1, 1974 September 1, 1974 October 1, 1974 September 1, 1975 (provided under u n i v e r s a l plan) October 1, 1975 January 1, 1977 J u l y 1, 1979 FOOTNOTES: 1. "Manitoba Government to Pay 80% of Senior C i t i z e n s Drug Costs" Canadian Pharmaceutical J o u r n a l 106 (September 1973): 25. 2. " B r i t i s h Columbia Introduces P r e s c r i p t i o n Program" Canadian Pharmaceutical J o u r n a l 107 (February 1974): 8-10. 3. A l b e r t a , A l b e r t a Health Care Insurance Commission, Annual Report 1974-75, p.13 4. W.R. Wensley, "Five Events I n d i c a t e Future of Health F i e l d i n Ontario" Canadian Pharmaceutical J o u r n a l 108 (January 1975): 20-24. 5. " P r e s c r i p t i o n Drug B i l l Near T h i r d Reading Stage" Canadian Pharmaceutical J o u r n a l 107 (August 1974): 34 6. "New Brunswick Pharmaceutical So c i e t y Reaches Agreement on Over 65 P r e s c r i p t i o n Drug Program" Canadian Pharmaceutical J o u r n a l 108 (October 1975): 26. 10 7. "Quebec Extends Drug Plan to A l l Senior C i t i z e n s " Canadian Pharmaceutical J o u r n a l 110 (December 1977): 38. 11 TABLE 2 UNIVERSAL DRUG PROGRAMS PROGRAM IMPLEMENTATION DATE Manitoba U n i v e r s a l Pharmacare January 1, 1975 Saskatchewan P r e s c r i p t i o n Drug Plan 2 September 1, 1975 B r i t i s h Columbia Pharmacare 3 June 1, 1977 FOOTNOTES: 1. "Manitoba Pharmacare Program Now i n E f f e c t i n P r o v i n c e " Canadian Pharmaceutical J o u r n a l 108''(February 1975): 33. 2. Saskatchewan, Department of Health, Annual Report 1975 - 1976 of the Saskatchewan P r e s c r i p t i o n Drug P l a n , p. 7. 3. "B.C. Extends Pharmacare Program to A l l Residents" Canadian Pharmaceutical J o u r n a l 110 ( J u l y 197 7): 27. 12 LITERATURE REVIEW Planning and Planning Theory G i l b e r t and Specht have i d e n t i f i e d three types of planning; r a t i o n a l , b u r e a u c r a t i c and advocacy.^ This examination i s only concerned w i t h b u r e a u c r a t i c planning. Bureaucratic planning can be viewed as the middle l i n e between r a t i o n a l planning i n t o which ideas and concepts and d e c i s i o n s are formulated on a r a t i o n a l b a s i s and advocacy planning where the emphasis l i e s i n planning f o r p a r t i c u l a r groups w i t h i n s o c i e t y w i t h as many s p i n o f f s as p o s s i b l e to p e r i p h e r a l l y i n c l u d e others. B u r e a u c r a t i c planning i s o f t e n r e f e r r e d to as "mixed scanning" 18 by E t z i o n i . I t combines the broad brush view of planning on an incremental b a s i s w i t h the -microscopic tendencies of r a t i o n a l p l anning from f i r s t p r i n c i p l e s . E c k s t e i n reviews the b u r e a u c r a t i c process i n B r i t a i n and f i n d s that what appears as l i t t l e planning from the outside i s indeed 19 methodical b u r e a u c r a t i c planning. I t c o l l e c t s data and mod i f i e s s o l u t i o n s to meet p o l i t i c a l ends. H a l l notes that there i s no e f f e c t i v e way of i s o l a t i n g planning from the p o l i t i c a l process and st a t e s that good planning i s i n e v i t a b l y c o n t r o v e r s i a l by i n t r o d u c i n g t e c h n i c a l a n a l y s i s and an e x p l i c i t value system where personal 20 judgments had p r e v i o u s l y e x i s t e d . Marmor says that planning has three stages, 1. data c o l l e c t i o n , 13 2. i d e n t i f i c a t i o n of e x i s t i n g s t r u c t u r e s - b u r e a u c r a t i c , 21 3. n e g o t i a t i n g w i t h the d e l i v e r e r s . This type of a n a l y s i s of s t a t u s enables planners to segment the process thereby being able to i d e n t i f y issues w i t h i n each segment more c l e a r l y . Lindblom recognizes that most planning i n a b u r e a u c r a t i c 22 s e t t i n g i s incremental i n nature, w h i l e Taylor i d e n t i f i e s t h i r t e e n systematic stages i n h e a l t h p l a n n i n g , only one of which i d e n t i f i e s 23 the area of incrementalism.• Reinke i d e n t i f i e s the a p p l i c a t i o n of the planning process i n t o four components, 1. the nature of the problem, 2. f a c t o r s r e l a t e d to causes, 3. plans of a c t i o n and 24 4. o b j e c t i v e s and t a r g e t s . An important planning reader by F a l u d i supports E t z i o n i ' s view of the b u r e a u c r a t i c methodology used and agrees that i t i s 25 best t y p i f i e d by the "mixed scanning" of E t z i o n i . I t i n c o r p o r a t e s the data i d e n t i f i c a t i o n as w e l l as the incrementalism or the relatedness of e x i s t i n g s t r u c t u r e s and the m o d i f i c a t i o n r e q u i r e d out of a p o l i t i c a l process. The planner recognized the incremental s i t u a t i o n necessary i n b u r e a u c r a t i c planning. Blum emphasizes that planning must be seen to be an instrument of s o c i a l change and there-for e i n t e g r a l to a l l b u r e a u c r a t i c planning must be o b j e c t i v e s and 26 t a r g e t s that r e f l e c t the unique values of the S o c i e t y . These are t r a n s l a t e d , through the methods used to o b t a i n these o b j e c t i v e s and goals, i n t o s o c i a l l y acceptable methods. 14 VJithln the pure planning l i t e r a t u r e the area of b u r e a u c r a t i c planning can be seen to have the f o l l o w i n g important f e a t u r e s : - emphasis on a review of e x i s t i n g s t r u c t u r e s - a broad brush approach to the f i e l d r e s u l t i n g i n the s e l e c t i o n of major area f o r c o n c e n t r a t i o n - a review of the major areas i n d e t a i l - the meshing of r a t i o n a l s o l u t i o n s w i t h p o l i t i c a l requirements to develop a p o l i t i c a l l y acceptable approach to the o b j e c t i v e sought. This type of approach seldom authors t o t a l l y new ideas but r a t h e r r e w r i t e s e x i s t i n g ideas i n t o a new approach which may add i n c r e m e n t a l l y to the base of proven knowledge a v a i l a b l e . Pharmacare Planning L i t e r a t u r e Planning documentation i n the area of Canadian Pharmacare insurance i s scarce. A r e l e v a n t a r t i c l e i n the area of insured Pharmacare b e n e f i t s i s by Lang, who documents the economic and p o l i t i c a l c limate that drew a t t e n t i o n to the pharmaceutical i n d u s t r y 27 and the b u r e a u c r a t i c concern.. He p o i n t s out the o r i g i n s of the involvement i n t h i r d party b i l l i n g s as stemming from cost and p r i c e concerns. Out of b u r e a u c r a t i c t e n a c i t y came the formation of a f e d e r a l committee known as the Harley Committee. I t s r e c o g n i t i o n of manipulative or m o n o p o l i s t i c s i t u a t i o n s and recommendations on i n c e n t i v e s f o r Canadian i n d u s t r y and strengthening the Food and Drug A c t , provided the stimulus to the Canadian involvement 15 i n the p r e s c r i p t i o n drug f i e l d . More r e c e n t l y , Evans and Williamson have e l u c i d a t e d the economic aspect of Pharmacare programs and v a r i o u s implementation methods that would e i t h e r change the method of Pharmacare d e l i v e r y or change the p r e s c r i b i n g and u t i l i z a t i o n 28 habxts. The 1968 Task Force on P r e s c r i p t i o n Drugs i n the United States 30 and a s i m i l a r study by M u l l e r d i s c l o s e d a wide v a r i e t y of systems a v a i l a b l e when c o n s t r u c t i n g a p l a n . T h e i r reviews were centered around the use of a formulary, reimbursements to p a t i e n t s , co-payments and peer reviews. More r e l e v a n t , however, i s the documentation of the p r o v i n c i a l plans i n e x i s t e n c e . Information concerning the p r o v i n c i a l plans i n e x istence across the country form the b a s i s of a comparative approach used to generate the major f e a t u r e s of the Pharmacare program of the Northwest T e r r i t o r i e s . Manore and Mclver have 31 3 attempted to catalogue t h i r d party programs across the country. ' A comparison of four major plans w i l l be discussed i n Chapter 2. 16 Demography The Northwest T e r r i t o r i e s covers 3,379,500 square k i l o -meters or the equivalent of one-third of Canada's land surface. It comprises a l l that part of Canada North of the 60th p a r a l l e l of North l a t i t u d e , except the portions thereof that are within the Yukon T e r r i t o r y , the Province of Quebec or the Province of Newfoundland and the Islands i n Hudson's Bay, James Bay and Ungava Bay, except those islands that are within the Province of Manitoba and the Province of Ontario or the Province of Quebec. 34 It stretches from the Yukon River to the A t l a n t i c Ocean and from the 60th p a r a l l e l l a t i t u d e to the Northern edge of the Continental Shelf. There are 46,400 inhabitants scattered through 59 35 settlements. Of these, eight settlements, have only 50 residents or less and are not given formal recognition. Of the 51 remaining, only one i s of c i t y status (Yellowknife), 36 the r e s t are below 5,000 i n population. Distances are great. From the c a p i t a l i n Yellowknife to the Eastern Regional O f f i c e 37 i n Frobisher Bay i s approximately 1405 a i r miles. A i r t r a v e l e i s the primary means of transportation between communities. Larger settlements have large modern commercial a i r l i n e s e r v i c e . Smaller settlements have small charter planes Northwest Territories 18 that operate on an i n f r e q u e n t l y scheduled b a s i s . The t r a v e l i s more North - South than East - West. There are three major d i s t r i b u t i o n p o i n t s , Montreal f o r the Eastern A r c t i c c a l l e d B a f f i n Region; Winnipeg f o r the Ce n t r a l A r c t i c c a l l e d Keewatin Region; and Edmonton f o r the Western A r c t i c , Inuvik and Fort Smith Regions. There are highways l i n k i n g the major and Western A r c t i c settlements to southern p o i n t s but no highways i n the C e n t r a l or Eastern A r c t i c . Weather i s an important f a c t o r i n d i s t r i b u t i o n of p e r i s h a b l e goods. Temperatures i n the areas may range from mean d a i l y average of -35°C. i n the wi n t e r i n the northern p a r t s to a high mean d a i l y o 38 average of about 17 C. i n the summer. The p o p u l a t i o n i s approximately 51% Indian and I n u i t and 49% 39 other s t a t u s . The Indian p o p u l a t i o n , numbering 7,500, i n h a b i t s 40 that part of the Western A r c t i c below or up to the tree l i n e . There are many d i a l e c t s spoken but few, i f any, w r i t t e n . The end r e s u l t i s the e l d e r s of the Indian p o p u l a t i o n cannot read or w r i t e other than the l i t t l e E n g l i s h they have learned through purchasing commercial goods. The I n u i t p o p u l a t i o n , numbering 15,000, l i v e predominantly above 41 the t r e e l i n e i n the C e n t r a l and Eastern A r c t i c . They outnumber the sta t u s Indian population of the northwest T e r r i t o r i e s by approximately two to one. In the I n u i t p o p u l a t i o n there i s one language ( I n n u k t i t u t ) but two forms of w r i t i n g (Western and S y l l a b l e s ) . E n g l i s h has become the second language f o r many although the e l d e r l y p o p u l a t i o n i s 19 o f t e n only f a m i l i a r w i t h I n n u k t i t u t . Both c u l t u r e s p r e f e r to l i v e i n small settlements from which they m a i n t a i n a high percentage of t h e i r l i v e l i h o o d through hunting, t r a p p i n g , and f i s h i n g . The "other" s t a t u s r e s i d e n t s , numbering 23,900 are p r i m a r i l y white, speaking E n g l i s h and having a higher o v e r - a l l degree of l i t e r a c y . They p r e f e r to l i v e i n the l a r g e r settlements and most of t e n work f o r the government, e d u c a t i o n a l boards, h e a l t h f a c i l i t i e s , t r a n s p o r t a t i o n i n d u s t r y or p r i v a t e mining and e x p l o r a t i o n companies. The p o p u l a t i o n i s very young, 40% i s fourteen years of age or 42 l e s s and only 2.8% i s 65 years of age or over. I t i s a h i g h l y mobile p o p u l a t i o n . In 1979, 6,000 r e s i d e n t s l e f t the T e r r i t o r i e s and 5,000 new r e s i d e n t s a r r i v e d , g i v i n g i n e f f e c t , a po p u l a t i o n change of 23%. The pop u l a t i o n a f f e c t e d by the Pharmacare program f o r se n i o r c i t i z e n s , however, when combined w i t h the supplementary programs of the Department of Health, the Indian and I n u i t program of Health and Welfare Canada, and the Indigent program from S o c i a l Services are added, the coverage extends to approximately 55% of the p o p u l a t i o n . 20 Figures from other sources ( H o s p i t a l Insurance and Medical Care) i n d i c a t e that the Indian and Unuit p o p u l a t i o n have become cognizant of the medical systems and use i t w i t h l e s s and l e s s i n t i m i d a t i o n as the younger c h i l d r e n grow o l d e r . The percentage of N.W.T. Medical Care consumed by Indian and I n u i t has r i s e n from 32% to 35% over the past three years w h i l e the h o s p i t a l u t i l i z a t i o n has r i s e n 44 from 48% to 50% over the same p e r i o d . The p o p u l a t i o n cannot be c l a s s i f i e d h i g h or low users of pharmaceuticals. The p o s s i b i l i t y that there may be d r u g - r e s i s t a n t s t r a i n s of b a c t e r i a means that p a r t i c u l a r drugs have been used i n some volume i n the T e r r i t o r i e s . There are only s i x p r i v a t e pharmacies i n the Northwest T e r r i t o r i e s (Fort Smith., Hay R i v e r , Pine P o i n t , I n u v i k , Y e l l o w k n i f e ( 2 ) ) . In F r o b i s h e r Bay, the H o s p i t a l operates a pharmacy and pharmaceuticals may be dispensed through a p r i v a t e p h y s i c i a n ' s o f f i c e . F orty of the other settlements r e c e i v e drugs dispensed by a nurse p r a c t i t i o n e r at nur s i n g s t a t i o n s . The remaining settlements r e c e i v e drugs dispensed by l a y dispensers (responsible people chosen i n t h e i r home community). 21 The Northwest T e r r i t o r i e s p r i o r to J u l y , 1979 had three separate p r e s c r i p t i o n drug programs w i t h d i s t i n c t c r i t e r i a . The a d m i n i s t r a t i o n and o p e r a t i o n of these programs had economic and l o g i s t i c problems. A Federal program operated by Health and Welfare Canada was based on ethnic s t a t u s (Treaty Indian or I n u i t ) and Indigency. The program of the T e r r i t o r i a l Government Department of S o c i a l S e r v ices was f o r a l l Indigent r e s i d e n t s of the Northwest T e r r i t o r i e s . There was overlap i n the area of indigency and d i f f i c u l t i e s arose i n d i s t i n g u i s h i n g the r e s p o n s i b i l i t y of each p a r t y . The t h i r d program was j o i n t l y operated by Health and Welfare Canada and the Government of the Northwest T e r r i t o r i e s ' Department of Health. I t was based on c o n f i r m a t i o n by a p h y s i c i a n of a r e s i d e n t having one of twelve s u p p l e m e n t a r y . i l l n e s s e s . Health and Welfare Canada handled the A d m i n i s t r a t i v e operations of the l a t t e r program. Economic Problem The p r i n c i p a l c r i t e r i a checked s t a t u s and residency. Drug q u a n t i t y , type, p r i c e or p a t i e n t e l i g i b i l i t y f o r a supplementary program could not be c l e a r l y checked against a standard. The method of i d e n t i f y i n g the e l i g i b i l i t y that e x i s t e d was too cumbersome to maintain and consequently was i n e f f e c t i v e . Payments to vendors ran from three to s i x months as forms passed through as many as three separate bodies before reaching the r e s p o n s i b l e paying agent. 22 claims forms contained more than one r e s p o n s i b l e agency which r e q u i r e d passing the form around or intergovernmental i n v o i c e s and t r a n s f e r s . P o l i c i e s were not c l e a r l y defined and the whole system was g e t t i n g out of c o n t r o l as s t a f f turnovers depleted the r e s e r v o i r of common knowledge. No method of a n a l y z i n g p r e s c r i b i n g h a b i t s , d i s p e n s i n g p r a c t i c e s , u t i l i z a t i o n h a b i t s or cost expenditures e x i s t e d . I t was not p o s s i b l e to c u r r e n t l y f o r e c a s t expenditures based on previous u t i l i z a t i o n p a t t e r n s . L o g i s t i c Problems  Vastness The vastness of the Northwest T e r r i t o r i e s and the di s t a n c e s between communities complicated the d i s t r i b u t i o n and c o n t r o l of p r e s c r i p t i o n drugs. Nursing S t a t i o n s which serve as d i s p e n s a r i e s f o r f o r t y of the communities i n the N.W.T. d i d not have a formulary. There was no consistency between Nursing S t a t i o n s as to what drugs were a v a i l a b l e . A b e t t e r method of rec o r d i n g drugs dispensed from a Nursing S t a t i o n was r e q u i r e d . Coverage The i n t r o d u c t i o n of the new program was accepted on the.basis that the e x i s t i n g programs could be c o n s o l i d a t e d w h i l e r e t a i n i n g the e x i s t i n g paying agents. The l a t t e r c r i t e r i a presented some i n t e r n a l design problems but they were overcome by the use of the eth n i c s t a t u s i d e n t i f i e r l o c a t e d i n each r e s i d e n t ' s Health Care R e g i s t r a t i o n Number. 23 These problems produced a c l i m a t e that permitted an a d m i n i s t r a t i v e e r r o r to extend the twelve i l l n e s s e s program to 67 (the S t a t i s t i c s Canada Chronic Disease L i s t , see Appendix C.) The e r r o r went unnoticed f o r a s u f f i c i e n t l e n g t h of time to make the p u b l i c f e e l a new program had been introduced. The c o r r e c t i o n of the e r r o r to that program r a i s e d the i s s u e of f r e e p r e s c r i p t i o n drugs f o r a l l r e s i d e n t s . This was f i n a n c i a l l y not p o s s i b l e and the L e g i s l a t i v e Assembly of the G.N.W.T. recommended adding a program f o r Senior C i t i z e n s . The lead time permitted was three months (March - J u l y , 1979). 24 Summary This Chapter has reviewed the s e t t i n g , past and present, i n t o which Pharmacare as an i n s u r e d b e n e f i t has been placed. The o r i g i n a l concern appears to have been w i t h c o s t s . I t spread to f u r t h e r i n v e s t i g a t i o n s of the manufacturing i n d u s t r y by Kefauver and Harlev. The nresence of nharmaceutical b e n e f i t s throueh another 17 tiroeram such as the H o s p i t a l Insurance and D i a g n o s t i c Services and the Canada A s s i s t a n c e Act kept i t , i t i s b e l i e v e d , from being introduced w i t h Medicare i n 1967, as recommended by the H a l l Commission. Continued pressure i n the e a r l y and mid-seventies r e s u l t e d i n programs f o r the aged i n some provinces and u n i v e r s a l programs i n others. The Chapter a l s o reviewed r e l e v a n t l i t e r a t u r e on the planning of p u b l i c s e c t o r programs and the l i t e r a t u r e on Pharmacare programs. The planning can best be described as b u r e a u c r a t i c or mixed scanning using an i n c r e m e n t a l i s t approach. The demography o u t l i n e d the p h y s i c a l c o n s t r a i n t s of operating i n an area w i t h a p o p u l a t i o n of 46,400, spread through 59 s e t t l e d areas, three c u l t u r e s and languages and a harsh c l i m a t e . The problems that p r e c i p i t a t e d the i n t r o d u c t i o n and subsequent design of the program such as the e x i s t e n c e of three separate programs, a d m i n i s t r a t i v e d i f f i c u l t i e s , economic and l o g i s t i c f a c t o r s were discussed. These problems made i t more reasonable to design a 25 new system that i n c l u d e d the three previous programs r a t h e r than add the Senior C i t i z e n program to the e x i s t i n g method. The program lead time f o r implementation was three months (March - J u l y , 1979). While i t was necessary to review the l i t e r a t u r e and theory i t was more important to look at the current p r a c t i c e by provinces. The choice of comparative planning (Chapter 2) can be a t t r i b u t e d to the i n f o r m a t i o n a v a i l a b l e and the time frame of the p r o j e c t . Comparative planning leads to incremental planning and design once the o b j e c t i v e s and major d e c i s i o n s are made (Chapter 3 ) . The p r o j e c t i s then evaluated and some i m p l i c a t i o n s f o r use elsewhere are put forward (Chapter 4 ) . 26 CHAPTER 2 COMPARISON OF FOUR PROVINCIAL PLANS The comparative approach h i g h l i g h t s the major features of the e x i s t i n g pharmacare programs. Once they have been d e l i n e a t e d and compared according to the same c r i t e r i a , i t i s p o s s i b l e to con s t r u c t from the data, a program that meets the needs i d e n t i f i e d by the problem. 45 M u l l e r reviewed some of the p r i v a t e drug programs i n the United States. She developed a framework f o r comparing them that c o n s i s t e d o f : 1. Reimbursement to Vendor 2. Con t r o l Costs 3. B e n e f i t D i s t r i b u t i o n 4. Q u a l i t y C o n t r o l . A f i n e r breakdown was re q u i r e d i n order to cover a l l aspects of the problem and eig h t major features were i d e n t i f i e d as key to the program planning: 1. B e n e f i c i a r i e s 2. Drugs Covered 3. Cost Sharing by P a t i e n t 4. Reimbursement of Product Costs to Pharmacist 5. Reimbursement of Dispensing Costs to Pharmacist 6. Reimbursement Method 7. Data Processing 8. Cont r o l of Program Q u a l i t y . 27 These major f e a t u r e s , considered the major d e c i s i o n p o i n t s around which the program was constructed, were the b a s i s f o r comparison of e x i s t i n g p r o v i n c i a l p l a n s . The plans chosen f o r comparison were B r i t i s h Columbia, Manitoba, Saskatchewan and Ontario. These four plans are extensive and have had a major though not v i t a l impact on the pharmaceutical i n d u s t r y . The impact i s such that a change by other j u r i s d i c t i o n s w i t h the exception of Quebec and A l b e r t a w i l l not a f f e c t the system of manufacturing and d i s t r i b u t i o n c u r r e n t l y i n p l a c e . B r i t i s h Columbia s B r i t i s h Columbia's f i r s t program was f o r r e s i d e n t s on S o c i a l 46 As s i s t a n c e i n 1933. I t expanded to i n c l u d e p r e s c r i p t i o n drugs 47 f o r a l l persons 65 and over on January 1, 1974. The program g r a d u a l l y extended to cover the handicapped and nursing'home r e s i d e n t s as w e l l as the i n d i g e n t s . In A p r i l , 1977, the "over-the-counter" component of t h i s program was discontinued due to a concern about r a p i d increases i n drug consumption by Pharmacare r e c i p i e n t s . The government introduced, however, a u n i v e r s a l program w i t h a $100 d e d u c t i b l e i n June of 1977 t o : p r o t e c t against c a t a s t r o p h i c drug expense s p e c i f i c a l l y i n c l i n e d to a i d i n d i v i d u a l s w i t h chronic i l l n e s s e s . 4 8 28 The B r i t i s h Columbia program i s a u n i v e r s a l program w i t h two groups of b e n e f i c i a r i e s . Group One (the e l d e r l y , handicapped and i n d i g e n t ) are o f f e r e d f u l l coverage. Group Two are o f f e r e d 49 80% coverage a f t e r the t o t a l expense has reached $100. The r a t i o n a l e of the $100 l i m i t may be r e l a t e d to the income tax deduction f o r medical expenditures. B r i t i s h Columbia has no formulary or r e s t r i c t i o n s on pres-c r i p t i o n drugs as a b e n e f i t other than those approved under the Food and Drug Act and those l i s t e d i n the Compendium of Pharmaceuticals • , • 50 and Specxaltxes. The amount paid to the pharmacist i s the a c q u i s i t i o n c o s t , that i s , l a i d - i n cost to the pharmacist. There i s no reimbursement f o r mark-up. The dispensing fee paid the pharmacist i s a percentage of the average fee of a group of pharmacies chosen f o r comparison. For example, pharmacists i n a p a r t i c u l a r region are compared and an average taken of the dis p e n s i n g fees."'"'" F i n a n c i n g arrangements of the u n i v e r s a l program appear to r e f l e c t the S o c i a l C r e d i t philosophy to p r o t e c t the s m a l l p r i v a t e entrepreneur. The pharmacists b i l l d i r e c t to the plan f o r f u l l y covered Group One r e s i d e n t s and the b i l l i n g i s to the p a t i e n t f o r Group Two. Group Two, i n t u r n , are provided w i t h d u p l i c a t e s of the 29 p r e s c r i p t i o n l a b e l which the p a t i e n t then attaches to a sheet that i s submitted when the amount exceeds $100 per annum. There i s no l i m i t per person and the amount reimbursed i s 80% of the amount 52 exceeding $100. The B r i t i s h Columbia Pharmacists' S o c i e t y i s paid a fee r e l a t i n g to the number of p r e s c r i p t i o n s issued i n B r i t i s h Columbia 53 to undertake a peer review on behalf of the government. Manitoba 54 The in f o r m a t i o n on Manitoba r e l i e s h e a v i l y on Manore. Manitoba f i r s t introduced a program f o r the aged i n 1973. I t c a n c e l l e d the program i n 1975 and i n s t i t u t e d a u n i v e r s a l program w i t h a d e d u c t i b l e on January 1st of that year. The program extends to a l l Manitoba r e s i d e n t s who are r e g i s t e r e d w i t h the Medicare program. There i s no g l o b a l formulary but r a t h e r a Manitoba Drug Standards and Therapeutic Formulary that l i s t s twenty-two drug e n t i t i e s f o r which there i s mandatory s u b s t i t u t i o n . To be considered a b e n e f i t the drug must be l i s t e d as a p r e s c r i p t i o n drug i n the Compendium of Pharmaceuticals and S p e c i a l t i e s . "Over-the-counter drugs are not covered. I t i s a f u l l y insured b e n e f i t f o r nursing home r e s i d e n t s of the province, A l l other Manitoba r e s i d e n t s may be reimbursed f o r 80% of the cost that exceeds $50.00. 30 The pharmacist b i l l s the drugs at usual replacement costs and the dispensing fee i s negotiated by the Manitoba Pharmaceutical A s s o c i a t i o n w i t h the Manitoba Health Services Commission. The method of reimbursement used i n B r i t i s h Columbia was f i r s t introduced i n Manitoba. A d u p l i c a t e of the container l a b e l i s attached to a form and submitted by a p a t i e n t when the sum of $50.00 has been exceeded. Saskatchewan The Saskatchewan system i s s l i g h t l y d i f f e r e n t . I t i s a u n i v e r s a l program w i t h no p r e f e r r e d b e n e f i c i a r i e s . The p a t i e n t makes a s m a l l payment toward the'cost of each p r e s c r i p t i o n . I t i s perhaps the i n f l u e n c e of a s o c i a l i s t government that i n s p i r e d the approach. Saskatchewan has a Formulary updated on a p e r i o d i c b a s i s and published semi-annually. The Formulary contents are overseen by a Formulary Committee. B e n e f i t s are r e s t r i c t e d to the Formulary. There i s mandatory s u b s t i t u t i o n , among drugs determined interchangeable, to the drug of l e a s t c o s t , unless s p e c i f i c a l l y s t a t e d otherwise by the p h y s i c i a n . S a s k a t c h e w a n has an "exception drug s t a t u s " where drugs outside the Formulary can be approved as a b e n e f i t . I t i s used i n instances when an i n f r e q u e n t l y found c l i n i c a l i n d i c a t i o n a r i s e s or the drug i s normally given i n a h o s p i t a l but i t i s given outside the h o s p i t a l 31 due to unusual circumstances. Saskatchewan's approach to cost s h a r i n g by the p a t i e n t i s d i f f e r e n t from that of B r i t i s h Columbia or Manitoba. I n B r i t i s h Columbia and Manitoba the p a t i e n t pays the f u l l amount (drug cost plus dispensing fee) and seeks reimbursement f o r 80% of the expenditures that exceed a f i x e d sum ( B r i t i s h Columbia $100, Manitoba $50). In Saskatchewan, the p a t i e n t pays a co-payment toward the dispensing fee p o r t i o n of each p r e s c r i p t i o n . The amount o f that co-payment i s reg u l a t e d by the government. For example, i f the negotiated maximum dispensing fee i s $3.22 per p r e s c r i p t i o n and the government's c o n t r i b u t i o n to the dispensing f e e / p r e s c r i p t i o n i s set at $1.00, then the maximum co-payment that a p a t i e n t could make i s ($3.22 - $1.00) $2.22 per p r e s c r i p t i o n . The presence of the Formulary and the p a t i e n t co-payment r e s u l t s i n d i r e c t reimbursement by the government of drug costs to the pharmacists and does not place the burden on the p a t i e n t as i n B r i t i s h Columbia and Manitoba. The Saskatchewan Formulary has the p r i c e s p r i n t e d i n i t . The p r i c e p r i n t e d i s the r e s u l t of guarantees of the manufacturer regarding q u a n t i t y . I t i s the maximum p r i c e on the standing o f f e r agreement. The pharmacist, however, must b i l l at a c q u i s i t i o n costs and may be audited to make sure that such i s the case."''' The pharmacist must s u b s t i t u t e the lowest cost drug i n the 32 Formulary unless the "no s u b s t i t u t i o n " i s i n d i c a t e d by the 58 p r e s c r i b e r . One argument against t h i s method i s that there may be a tendency f o r the l i t t l e manufacturers to get squeezed out of business i n which case the l a r g e r manufacturers have no competition and reach a monopoly s i t u a t i o n , thereby c o n t r o l l i n g p r i c e n e g o t i a t i o n s . The p a t i e n t c o n t r i b u t i o n toward the dispensing fee i s a d i s c r e t i o n a r y item f o r the pharmacy and th e r e f o r e induces some competition between pharmacies. As w e l l , i t r e i n f o r c e s the no t i o n of p a t i e n t ' s r e s p o n s i b i l i t y f o r t h e i r h e a l t h . The e s t a -blishment of the dispensing fee i s a negotiated r a t e between the Saskatchewan Pharmacy A s s o c i a t i o n and the M i n i s t r y of Health. I t n egotiates a maximum dispensing fee f o r the f i r s t 20,000 p r e s c r i p t i o n s by a pharmacy and a second dispensing fee f o r 59 those i n excess of 20,000. I t i s the Saskatchewan Drug Program which undertakes, through i t s automated computerized data c o l l e c t i o n and i t s review committees, the review of the pharmacists and p r e s c r i b e r s dispensing and p r e s c r i b i n g h a b i t s . Ontario The Ontario approach has been two-fold. In 1970 i t e s t a b l i s h e d PARCOST ( P r e s c r i p t i o n Drugs At Reasonable C o s t ) , a voluntary plan aimed at developing economies throughout the pharmaceutical i n d u s t r y , encouraging f a i r competition and 33 e f f i c i e n t methods of d i s t r i b u t i o n and u t i l i z a t i o n . The program i n i t i a l l y was aimed at educating and a s s u r i n g p h y s i c i a n s that lower cost drugs were of assured q u a l i t y . Pharmacies p a r t i c i p a t e d v o l u n t a r i l y and agreed to a maximum dispensing fee and to charge the cost of the drug i n d i c a t e d i n the PARCOST Comparative Drug Index which l i s t s comparable pharmaceutical products of assured q u a l i t y i n order of c o s t . ^ S u b s t i t u t i o n l e g i s l a t i o n was passed i n 1972 ensuring that the p r i c e charged w i l l be that of the lowest cost drug where interchangeable and not otherwise d i r e c t e d by the p h y s i c i a n . In 1974, the Drug B e n e f i t Program was introduced f o r s p e c i f i c i n d i v i d u a l s . I t was modified i n 1975 and 1976 so i t now i n c l u d e s : a l l r e s i d e n t s 65 years of age and over who rec e i v e o l d age s e c u r i t y , who have r e s i d e d i n Ontario f o r twelve months p r i o r and were Canadian c i t i z e n s or landed immigrants; guaranteed annual income r e c i p i e n t s and persons r e c e i v i n g f a m i l y b e n e f i t s allowance as w e l l as those under general w e l f a r e . 63 The Plan uses the PARCOST index combined w i t h the drug b e n e f i t formulary to produce a formulary code drug b e n e f i t formulary/PARCOST comparative drug index. The formulary may be supplemented when an issuance of a formal s p e c i a l a u t h o r i z a t i o n 64 to pay a drug has been given to the p r e s c r i b e r . The plan has no co-payment charges. I t reimburses the pharmacist f o r the cost of the drug at the p r i c e i n the formulary^"* enabling gains to 34 be made on bulk purchases, A dispensing fee i s set by n e g o t i a t i o n s between the Ontario Pharmacists A s s o c i a t i o n and the M i n i s t r y of 66 Health. Claims are submitted on a 20 l i n e i n v o i c e w i t h f u l l y . 6 7 automated computer assessing. A n a l y s i s Three of the four plans reviewed have much i n common, however, the fundamental d i f f e r e n c e s between having a p a t i e n t d e d u c t i b l e can be seen from Table 3. This Table i l l u s t r a t e s that i n 1978 w h i l e B r i t i s h Columbia had 2,000,000 e l i g i b l e r e s i d e n t s , only 149,000 or 7.45% took advantage of the program. The number who spent $100 and didn't c l a i m i s unknown. Manitoba which has been i n operation longer, had a 20% u t i l i z a t i o n . This can be a t t r i b u t e d i n part to f a m i l i a r i t y but more to the s i z e of the d e d u c t i b l e . The d e d u c t i b l e i n Manitoba i s one-half of what i t i s i n B.C. The p a t i e n t cost s h a r i n g or co-payment d r a s t i c a l l y reduces government expenditure. I f the o b j e c t i v e s are to provide b e n e f i t s to those i n g r e a t e s t need then i t becomes debatable whether these programs meet, that :end. B r i t i s h Columbia and Manitoba's manner of approaching the t o p i c c e r t a i n l y address those w i t h the greatest expenditure. In a d d i t i o n , both programs have f u l l coverage f o r s e n i o r c i t i z e n s , n u r s i n g homes and others f o r whom drug expenditures would be a hardship but i t i s not axiomatic that expenditures are l i n k e d to need. The program TABLE 3 COMPARISON OF CANADIAN PROVINCIAL DRUG PLANS WITH PATIENT (RECIPIENT) CONTRIBUTION - 1978 Part 1 PROVINCE TYPE OF PATIENT PAYMENT TOTAL ELIGIBLE (OOO's) TOTAL RECEIVING BENEFITS (OOO's) TOTAL Rx COST (OOO's) TOTAL PATIENT SHARE (OOO's) TOTAL GOVT SHARE (OOO's) TOTAL ADMIN' COST (OOO's) TOTAL Rx (OOO's) BRITISH COLUMBIA $100/yr +20% 2000 149 19714 15794 3655 265 2652 ALBERTA 20% Per Rx 180 N/A N/A N/A N/A N/A N/A SASKATCHEWAN $2.22 Per Rx 922 605 25900 7863 16271 1567 3360 MANITOBA $50/yr +20% 1000 202 18000 10100 7900 200 3009 ONTARIO NO PARTIAI PAY PLAN QUEBEC NO PARTIAI PAY PLAN NOVA SCOTIA NO PARTIAI PAY PLAN NEW BRUNSWICK $2.00 Per Rx 72 72 2279 644 2075 60 322 PRINCE EDWARD ISLAND NO PARTIAI PAY PLAN NEWFOUNDLAND NO PARTIAI PAY PLAN - Government of B r i t i s h Columbia/unconfirmed data/not published TABLE 3 COMPARISON OF CANADIAN PROVINCIAL DRUG PLANS WITH PATIENT (RECIPIENT) CONTRIBUTION - 1978 Part 2 PROVINCE AVERAGE FEE COST AVERAGE DRUG COST AVERAGE Rx COST AVERAGE PATIENT SHARE AVERAGE ADMIN COST AVERAGE Rx PER PERSON AVG GO PER Rx VT COST PER PERSON BRITISH COLUMBIA 3.44 3.78 7.22 5.05 .10 17.8 1.37 24.52 ALBERTA 3.45 4.01 7.46 N/A N/A N/A N/A N/A SASKATCHEWAN 2.98 3.23 6.21 2.22 .47 5.5 4.46 24.53 MANITOBA 3.20 3.50 6. 70 4.01 .07 14.9 2.69 40.09 ONTARIO NO PARTIAI PAY PLAN QUEBEC NO PARTIAI PAY PLAN NOVA SCOTIA NO PARTIAI PAY PLAN NEW BRUNSWICK 3.25 5.09 8.44 2.00 .18 4.5 6.44 29.65 PRINCE EDWARD ISLAND NO PARTIAI PAY PLAN NEWFOUNDLAND NO PARTIAI PAY PLAN P. T i d b a l l - Government of B r i t i s h Columbia/unconfirmed data/not published TABLE 4 COMPARISON OF CANADIAN PROVINCIAL DRUG PLANS - 65+ AMBULATORY RECIPIENTS - 1978 ! PROVINCE DESCRIPTION OF PAYMENT TOTAL NUMBER ELIGIBLE (OOO's) TOTAL RECEIVING BENEFITS (OOO's) TOTAL Rx (OOO's) AVERAGE Rx PER RECIPIENT AVERAGE FEE COST AVERAGE DRUG COST AVERAGE Rx COST AVERAGE Rx RECIPIENT PAYMENT AVG PER Rx GOVT COST PER RECIPIENT BRITISH COLUMBIA GOVERNMENT 100% 270 *270 2916 10.8 3.44 3.78 7.33 N i l 7.22 77.98 ALBERTA PATIENT PAY 20% Rx 180 N/A N/A N/A 3.45 4.01 7.46 1.50 N/A N/A SASKATCHEWAN PATIENT PAY $2.22/Rx 104 85 1080 12.7 2.98 3.23 6.21 2.22 3.99 50.67 MANITOBA PATIENT $50/YR+20% N/A N/A N/A N/A N/A N/A N/A ONTARIO GOVERNMENT 100% 800 600 11100 18.5 2.84 3.19 6.03 N i l 6.03 111.55 QUEBEC GOVERNMENT 100% 518 *518 10732 20.7 2.70 2.94 5.64 N i l 5.64 116.74 NOVA SCOTIA GOVERNMENT 100% 83 77 1453 18.8 3.13 4.92 8.05 N i l 8.05 151.34 •:NEW BRUNSWICK GOVERNMENT 100% 70 65 963 14.8 3.35 5.09 8.44 N i l 8.44 124.91 PRINCE EDWARD ISLAND NO PLAN NEWFOUNDLAND NO PLAN * Estimated only P. Tidball/Government of B r i t i s h Columbia/unconfirmed data/not published TABLE 5 COMPARISON OF CANADIAN PROVINCIAL DRUG PLANS WITH FULL GOVERNMENT PAYMENT - 1978 Part 1 PROVINCE TYPE OF RECIPIENT TOTAL ELIGIBLE (000's) TOTAL RECEIVING BENEFITS (000's) TOTAL BENEFIT COST (000's) TOTAL ADMIN COST (000's) TOTAL GOVT COST (000's) TOTAL Rx (000's) BRITISH COLUMBIA 65+ S.A. 387 *387 30830 500 31330 4720 ALBERTA S.A. 46 *46 N/A N/A N/A 772 SASKATCHEWAN S.A. 39 26 2258 164 2422 348 MANITOBA NO FULLY PAID PLAN **ONTARIO 65+ S.A. 1200 896 99950 4445 104395 16576 QUEBEC 65+ S.A. 984 *984 91850 N/A 91850 16285 NOVA SCOTIA 65+ 83 77 11790 365 12155 1453 NEW BRUNSWICK 65+ 70 65 8119 174 8293 962 PRINCE EDWARD ISLAND NO FULLY PAID PLAN NEWFOUNDLAND NO FULLY PAID PLAN Assumed Estimated Only TABLE 5 COMPARISON OF CANADIAN PROVINCIAL DRUG PLANS WITH FULL GOVERNMENT PAYMENT - 1978 Part 2 PROVINCE AVERAGE FEE COST AVERAGE DRUG COST AVERAGE Rx COST AVERAGE ADMIN COST AVERAGE Rx PER RECIPIENT AVG GOVT COST PER Rx PER RECIPIENT BRITISH COLUMBIA 3.44 3.08 6.52 .10 12.2 6.62 80.76 ALBERTA 3.45 4.01 7.46 N/A N/A 7.46 N/A SASKATCHEWAN 2.98 3.23 6.21 .47 13.4 6.68 89.51 MANITOBA ONTARIO 2.84 3.19 6.03 .27 18.5 6.30 116.55 QUEBEC 2.70 2.94 5.64 N/A 16.5 5.64 93.06 NOVA SCOTIA 3.13 4.92 8.05 .25 18.8 8.30 156.06 NEW BRUNSWICK 3.35 5.09 8.44 .18 14.8 8.62 127.57 PRINCE EDWARD ISLAND NO FULLY PAID PLAN NEWFOUNDLAND NO FULLY PAID PLAN 1 40 of Saskatchewan w i t h t r e b l e the u t i l i z a t i o n of Manitoba and quadruple the u t i l i z a t i o n of B r i t i s h Columbia, has only o n e - t h i r d more i n expenditure. In f a c t , Saskatchewan per c a p i t a i s almost i d e n t i c a l to B r i t i s h Columbia. The l a c k of a formulary may be the reason that the t o t a l cost i s high i n B r i t i s h Columbia. An important feature i s s u b s t i t u t i o n a b i l i t y of interchangeable drugs. Saskatchewan, Manitoba and Ontario make i t mandatory. B r i t i s h Columbia without a formulary cannot make i t mandatory. The best combination of approaches t h e r e f o r e , l a y i n g aside such p o l i t i c a l things as the p r o t e c t i o n of small pharmacies which i s b u i l t i n t o the B r i t i s h Columbia program, appears to be a formula w i t h f i x e d maximum cost s such as Saskatchewan and Ontario but r e q u i r i n g a c q u i s i t i o n costs to be submitted. Other r a t i o n a l f e a t u r e s are; mandatory s u b s t i t u t i o n f o r interchangeable drugs to the lowest cost drug and a negotiated dispensing fee combined, w i t h a d e d u c t i b l e of $100. These fe a t u r e s would give the program c o n t r o l a v a i l a b l e to Saskatchewan w i t h the assurance to governments that they are spending funds on those who would c l a s s i f y as needy. But u n i v e r s a l programs r a t h e r than s e l e c t e d b e n e f i c i a r y programs, have not j u s t i f i e d themselves. I f one compares the average c o s t / p r e s c r i p t i o n per person b e n e f i t i n g from the B r i t i s h Columbia program to the average cost per p r e s c r i p t i o n of the number of persons from the Saskatchewan program, one a r r i v e s at a r a t i o showing that B r i t i s h Columbia covers the 41 p r i m a r i l y high users w h i l e Saskatchewan covers the high and the low users. Therefore, i n Saskatchewan's case, there i s a greater t r a n s f e r of wealth but not n e c e s s a r i l y to a l l those who need i t . The approaches of Saskatchewan and Ontario by d i r e c t reimburse-ment to pharmacies, i s the most r a t i o n a l f o r t h e i r systems. B r i t i s h Columbia though, e x h i b i t s the best approach f o r peer review. Given a l l t h i s , the N.W.T. should have produced the i d e a l r a t i o n a l p l an but b u r e a u c r a t i c planning cannot be e n t i r e l y r a t i o n a l , i t i s encumbered by e x i s t i n g p o l i t i c a l , economic and a d m i n i s t r a t i v e i d i o s y n c r a c i e s . Therefore, the p l a n produced f o r the N.W.T. achieves some of the r a t i o n a l f e a t u r e s of the e x i s t i n g plans but then goes beyond them i n other areas and f a l l s short i n some others. I t may, however, be termed as an incremental approach, b u i l d i n g on the knowledge of the e x i s t i n g programs and features which have worked w e l l f o r them and viewing the f i e l d r e l a t i v e to the Northwest T e r r i t o r i e s i n implementing something which w i l l meet the p e c u l i a r i t i e s of that j u r i s d i c t i o n and i t s extensive p o p u l a t i o n spread and method of supply and d i s t r i b u t i o n . 42 Summary This Chapter has e x h i b i t e d some of the fundamentals of bu r e a u c r a t i c planning and provided d e t a i l on comparisons of e x i s t i n g p r o v i n c i a l programs. B u r e a u c r a t i c p l a n n i n g or mixed scanning i n v o l v e s f i r s t a broad view of the f i e l d f o l l o wed by the s e l e c t i o n of c r i t i c a l f e a tures to be fol l o w e d . The i n i t i a l features chosen were eig h t major components that the planner f e l t were required to introduce a Pharmacare program. Secondly, b u r e a u c r a t i c planning i n v o l v e s a review of e x i s t i n g s o l u t i o n s to s i m i l a r problems. This was done by a comparative review, along the l i n e s of e i g h t major f e a t u r e s , of the fou r major p u b l i c p r e s c r i p t i o n drug programs i n Canada. The review and subsequent a n a l y s i s demonstrate that there are many approaches each chosen to meet p o l i t i c a l ends or o b j e c t i v e s . T h i r d l y , b u r e a u c r a t i c planning i n c l u d e s the s e l e c t i o n of o b j e c t i v e s and the incremental approach to be used i n moving from the e x i s t i n g s i t u a t i o n to the new one. This w i l l be the subject of the next Chapter on planning and design. 43 CHAPTER 3 PLANNING AND DESIGN This Chapter discusses the planning used by the planner i n order to put i n place a Pharmacare program. I t discusses the s e l e c t i o n of the c r i t e r i a used to put the program i n place and f o l l o w i n g t h a t , an extensive review of the design procedure. The problem f a c i n g the planner i s one that i s not new. In the days of t i g h t f i n a n c i a l r e s t r a i n t , there i s need to c o n s o l i d a t e and r a t i o n a l i z e s e r v i c e s and a d m i n i s t r a t i o n as much as p o s s i b l e . In t h i s i n s t a n c e , the Northwest T e r r i t o r i e s ' c o n s o l i d a t i o n of three programs and r a t i o n a l i z a t i o n of the a d m i n i s t r a t i v e procedures was able to add a new category of b e n e f i c i a r i e s and o f f e r a new program without extensive a d m i n i s t r a t i o n c o s t s . P l a n n i n g The mandate given the Department of Health was to c o n s o l i d a t e the programs and introduce a Senior C i t i z e n ' s program. This mandate was not given i n the form of l e g i s l a t i o n but r a t h e r through an a p p r o p r i a t i o n of the F i n a n c i a l L e g i s l a t i o n . The planning was therefore l e f t i n the hands of the bureaucracy. Planning S t r u c t u r e Once the mandate had been c l e a r l y documented and the parameter of funding i d e n t i f i e d i t became necessary to e s t a b l i s h a f i r m planning s t r u c t u r e i n p l a c e . The s t r u c t u r e had c l e a r l y defined 44 r u l e s . P a r t i c i p a n t s had to be cognizant of the l i m i t s of t h e i r d e c i s i o n c a p a b i l i t y and a c l e a r l y understood jargon and procedure f o r communication between the groups was put i n p l a c e . No where d i d t h i s become more apparent than i n the f i e l d of computing. The pyramidal s t r u c t u r e e s t a b l i s h e d f o r the implementation of t h i s program was: P a r t i c i p a n t s / I n p u t M i n i s t e r | - Government STEERING COMMITTEE P u b l i c P r o v i d e r s P h y s i c i a n s PROJECT TEAM •••— I n t e r n a l Government De I " " " """ I n t e r n a l to Department The terms of reference of the S t e e r i n g Committee were: 1. P o l i c y d e c i s i o n s w i t h i n parameter of Executive mandate. 2. F u n c t i o n a l guidance. 3. E s t a b l i s h i n g terms of reference, o b j e c t i v e s and goals f o r sub-group(s). 4. Accountable to the M i n i s t e r f o r a l l design and implementation cos t s . 5 . S i g n - o f f on Systems design. 6. Determine i n f o r m a t i o n requirements. 45 During the i n i t i a l steps i t was necessary f o r the Committee to meet three times a week to i d e n t i f y the scope, tender documents, i n t e r v i e w and s e l e c t c o n s u l t a n t s , d e f i n e p o l i c y and e s t a b l i s h working groups. P r o j e c t Team The p r o j e c t team's terms of reference were: 1. I n t e r p r e t p o l i c y d e c i s i o n s i n t o systems design. 2 . Recommend changes where necessary. 3. I n t e r f a c e w i t h an o p e r a t i o n a l group of u s e r s . 4. Prepare necessary computer system documentation. The p r o j e c t team leader sat i n on a l l S t e e r i n g Committee meetings but without a vote. The system of communication decided upon was c a l l e d 68 P.R.I.D.E. ( P R o f i t a b l e Information by DEsign). This i s a p r e c i s e method of communication that f o r c e s the user, the designer and the manager to d i s c u s s , d e f i n e , agree and s i g n o f f a l l major areas at pre-ordained stages. I t has i t s own jargon. I t i s one of s e v e r a l communication systems a v a i l a b l e , however, the important f a c t i s that some methodology of communication was defined and adhered t o , to the l e t t e r by a l l p a r t i e s concerned. Once the d e c i s i o n s t r u c t u r e was i n p l a c e , and the method of communication s e t , then the next stage was a statement of o b j e c t i v e s and broad p o l i c y d e c i s i o n s . 46 As Eckstein notes, i t i s the task of the planner somehow to translate "values" with a l l t h e i r ambiguities and inconsistencies i n t o a consistent, r a t i o n a l l y calculated and - not le a s t -69 p o l i t i c a l l y defensible system. Objectives The choices of goals and c r i t e r i a involve value judgments. Value judgments cannot, by t h e i r nature, be s t r i c t l y r a t i o n a l judgments because they seek to serve many objectives, not a l l of which are r a t i o n a l . The objectives of the drug insurance program can be viewed i n three categories: 1. Effectiveness - the r a t i o n a l use of drugs to achieve and maintain the best possible health. 2 . E f f i c i e n c y - the cost of the program must be kept under co n t r o l and to the lowest reasonable l e v e l . 3 . I d e o l o g i c a l - the program should benefit e s p e c i a l l y those with the greatest drug costs and the l e a s t f i n a n c i a l a b i l i t y to meet these costs. The objectives are targets and i t was the task of the planner to chart the path to those objectives. This was done by i d e n t i f y i n g the c r i t i c a l d e c i s i o n areas. This type of approach i s perhaps best categorized by the 47 term "mixed scanning" as o u t l i n e d by E t z i o n i . E t z i o n i ' s approach was a p p l i e d to the f i e l d of study, i n t h i s case Pharmacare, and we i d e n t i f i e d the major f e a t u r e s . This being accomplished, a review of the major p o i n t s of the f e a t u r e s , then f o l l o w e d . I t i n v o l v e d a comparative approach. I t r e q u i r e d s e l e c t i n g , a s s e s s i n g and r e f i n i n g the options u n t i l the e i g h t d e c i s i o n s were not only i n t e r n a l l y c o n s i s t e n t but o f f e r e d an e f f i c i e n t and f l e x i b l e program. Eight Major Decisions The fundamental p o i n t s of the program were determined to be the f o l l o w i n g e i g h t : 1. B e n e f i c i a r i e s . 2 . S e l e c t i o n of Drugs Covered. 3. Cost Sharing by P a t i e n t . 4. Reimbursement f o r Product Cost to Pharmacist. 5 . Reimbursement of Dispensing Cost by Pharmacist. 6. Reimbursement Method. 7. Data Processing. 8 . C o n t r o l of Program Q u a l i t y . Each of the major d e c i s i o n p o i n t s had s e v e r a l options. I t was necessary to choose one or a combination of them to t a i l o r the plan to the Northwest T e r r i t o r i e s . 48 1. B e n e f i c i a r i e s The f i r s t major p o l i c y d e c i s i o n was the s e l e c t i o n of bene-f i c i a r i e s . Once the subject,having pharmaceuticals as an i n s u r e d benefit,was breached, then there were s e v e r a l o p t i o n s . At one end of the spectrum was the option to i n s t i t u t e a u n i v e r s a l , comprehensive program. This was not f i n a n c i a l l y p o s s i b l e . At the other end was "no coverage" which was not p o l i t i c a l l y p o s s i b l e . I t was necessary t h e r e f o r e , to s e l e c t groups of b e n e f i c i a r i e s . Normally, the s e l e c t i o n of groups would be based on some fundamental c r i t e r i a , e.g. e i t h e r age, i l l n e s s or f i n a n c i a l need. In t h i s case, there were fo u r major c r i t e r i a : 1. E t h n i c s t a t u s . 2. F i n a n c i a l need. 3. I l l n e s s . 4. Age. The f i r s t three were c r i t e r i a already i n place i n e x i s t i n g programs. The f o u r t h was added as the new program by the l e g i s -l a t i v e assembly. E t h n i c Status The f i r s t major group i s the Status Indian and I n u i t . A l l Status Indians and I n u i t by v i r t u e of t h e i r e t h n i c s t a t u s , r e c e i v e p r e s c r i p t i o n medication l i s t e d i n the N.W.T. Formulary, f r e e of charge. This represents approximately 50% of the p o p u l a t i o n , numbering 22,500. 49 Indigent, I l l n e s s The second major group i s the i n d i g e n t . Residents of the Northwest T e r r i t o r i e s and t h e i r dependents c e r t i f i e d as i n d i g e n t by a Welfare O f f i c e r , r e c e i v e p r e s c r i p t i o n medication l i s t e d i n the N.W.T. Formulary, f r e e of charge. This coverage extends to approximately 660 people, or 1.4% of the p o p u l a t i o n . The t h i r d major group are the r e s i d e n t s of the Northwest T e r r i t o r i e s , w i t h one or more of these twelve s p e c i f i c i l l n e s s e s : Cancer P e r n i c i o u s Anemia Tuberculosis Phenylketonuria C y s t i c F i b r o s i s Veneral Disease Chronic Psychosis Diabetes C o e l i a c Disease Rheumatic Fever E p i l e p s y Rheumatoid A r t h r i t i s The r e s i d e n t s w i t h one or more of these twelve i l l n e s s e s represent approximately 1,300 people or 2.7% of the p o p u l a t i o n . Funds were not a v a i l a b l e to cover the outstanding 55 i l l n e s s e s l i s t e d on the Chronic Disease L i s t . Therefore the twelve were chosen according to what had been p r i o r f e d e r a l p r a c t i c e across the country. The o p t i o n a v a i l a b l e i n determining b e n e f i c i a r i e s was to extend coverage to a l l r e s i d e n t s or to another segment of the yet uncovered group. • F u l l extension was too expensive. Of the remaining p o p u l a t i o n (other s t a t u s and non-indigent) the age grouping of 65 and over had been i d e n t i f i e d by Adamson as being the most frequent users of ... 71 medicine. 50 The end r e s u l t i s a mixture of b e n e f i c i a r y o p t i o n s . I t i s a u n i v e r s a l p l a n f o r r e s i d e n t s of p a r t i c u l a r status (Treaty Indian and I n u i t ) . For the r e s t of the p o p u l a t i o n , i t i s s e l e c t i v e on the ba s i s of three q u i t e d i f f e r e n t c r i t e r i a (age, indigency and i l l n e s s ) . The s e l e c t i o n of these groups removes economic b a r r i e r s to high users on low income. In r e l a t i o n to c l i n i c a l b e n e f i t s that are re c e i v e d , increases i n expenditures are moderate. The b e n e f i c i a r y l i s t i n g was to be a s u b - f i l e of the Medical Care H o s p i t a l i z a t i o n f i l e of the Northwest T e r r i t o r i e s . This was p o s s i b l e due to the c o n s t r u c t i o n of the Medicare R e g i s t r a t i o n Number. There i s a unique number f o r each r e s i d e n t and w i t h i n that number i s coded the person's e t h n i c s t a t u s . The f i l e can a l s o be cross l i n k e d to age and i l l n e s s to create the necessary master b e n e f i c i a r y f i l e . O bjectives S a t i s f i e d by B e n e f i c i a r y L i s t i n g The s e l e c t i o n of the mixed o p t i o n s a t i s f i e d many o b j e c t i v e s . The need of the Federal Government to be able to d e l i v e r a program to a l l Indians and I n u i t i s s a t i s f i e d . The need of the T e r r i t o r i a l Government's Department of S o c i a l S e r v i c e s , to d e l i v e r i t s welfare program i s s a t i s f i e d . The need of the T e r r i t o r i a l Government's Department of Health to d e l i v e r i t s program f o r twelve i l l n e s s e s and sen i o r c i t i z e n s has been s a t i s f i e d . With t h i s e xtensive b e n e f i c i a r y l i s t i n g , the major areas are covered without the i n t r o d u c t i o n of a u n i v e r s a l p l a n . By i n c o r p o r a t i n g a l l b e n e f i c i a r i e s i n t o one program, i t s a t i s f i e d the need to come 51 to g r i p s w i t h the amount of money being spent on p r e s c r i p t i o n programs and a d m i n i s t r a t i o n . Use of the Medicare R e g i s t r a t i o n f i l e to c o l l e c t ages permitted the i n t r o d u c t i o n of the system without much p u b l i c i n t e r r u p t i o n . 2 . S e l e c t i o n of Covered Drug Products The Use of Formularies - Pharmacists, Product S e l e c t i o n P o l i c y d e c i s i o n on the use of a formulary was derived from a requirement to meet two o b j e c t i v e s , f i r s t the a v a i l a b i l i t y of drugs, second the program c o s t s . A v a i l a b i l i t y of Drugs The N.W.T. i s comprised of many settlements w i t h s m a l l p o p u l a t i o n s . I t i s not p r a c t i c a l to expect that each one of these settlements would be able to s t o c k a f u l l spectrum of drugs and keep up to the compendium of pharmaceuticals and s p e c i a l t i e s . Programs of o r d e r i n g , shipment, storage, tra n s p o r -t a t i o n and r e - o r d e r i n g are immensely compounded by the great d i s t a n c e s and weather. The spectrum of dispensers can range from a p r i e s t w i t h some i n s t r u c t i o n s a c t i n g as a l a y dispenser, to a n u r s e - p r a c t i t i o n e r , to a q u a l i f i e d pharmacist. The f a c t that many communities are v i s i t e d by t r a v e l l i n g s p e c i a l i s t s brought i n from the South l e d to drugs being requested that they p r e f e r r e d . There was no consistency i n s p e c i a l i s t s v i s i t i n g an area. As w e l l , there was a need f o r a method of determining q u a n t i t i e s dispensed i n order to prevent abuse. 52 C o n t r o l The second o b j e c t i v e met by the use of a formulary i s program c o n t r o l . By c o n t r o l l i n g the drugs which are l i s t e d as a b e n e f i t , the program can be molded toward more r a t i o n a l p r e s c r i b i n g . C o n t r o l of drugs l i s t e d as a b e n e f i t can mean the e x c l u s i o n of high p r i c e d drugs of no known added t h e r a p e u t i c v a l u e . Consistent w i t h a l l plans across Canada, over-the-counter drugs have been r u l e d out as a b e n e f i t . The r a t i o n a l e behind t h i s i s that they do not r e q u i r e a p r e s c r i p t i o n and t h e r e f o r e , can be ordered at pleasure and subsequently, there i s no c o n t r o l . A review of the p r o v i n c i a l programs i n d i c a t e d that b a s i c a l l y , three options were a v a i l a b l e . One, no formulary - B r i t i s h Columbia, A l b e r t a , Nova S c o t i a , P r i n c e Edward I s l a n d and Newfoundland. Two, p a r t i a l formulary - Manitoba. Three, formulary - Saskatchewan, Ontari o , Quebec and New Brunswick. The o p t i o n of a formulary was chosen a f t e r the comparison of the c l i n i c a l and economic impact of the op t i o n s . The formulary o f f e r e d the maximum amount of c o n t r o l i n determining drugs dispensed i n the Northwest T e r r i t o r i e s outside of a p r i v a t e pharmacy. I t al s o o f f e r e d a measure of c o n t r o l of drugs stocked i n the p r i v a t e pharmacist's since approximately 50% - 53% of the pop u l a t i o n i s a f f e c t e d . Selected drugs from the formulary were used to construct a Nursing S t a t i o n Formulary and Lay Dispenser Formulary, The 53 r a t i o n a l e being that they s e r v i c e d a sma l l e r area and t h e r e f o r e d i d not need as wide a s e l e c t i o n . The drawbacks of a formulary are the continuous maintenance, the arguments w i t h manufacturers and complaints by ph y s i c i a n s about r e s t r i c t i n g t h e i r method of p r a c t i c e . I t was f e l t , however, th a t the economic b e n e f i t s and c o n t r o l outweighed the problems a s s o c i a t e d w i t h a formulary. The d e c i s i o n to have a formulary required the establishment of a mechanism to keep the formulary up-to-date. The mechanism chosen was a Formulary Advisory Committee comprise'd o f : 1. A s p e c i a l i s t i n i n t e r n a l medicine. 2. A general p r a c t i t i o n e r . 3 . The medical programs o f f i c e r (a p h y s i c i a n ) of Health and Welfare Canada. 4. A r e p r e s e n t a t i v e of the N.W.T. p r i v a t e pharmacists. 5 . A pharmacist from one of the N.W.T. h o s p i t a l s . 6. A r e p r e s e n t a t i v e of the Department of Health who ch a i r s the meetings. 7. A s e c r e t a r y to the Committee from the Department of Health. The terms of reference are: 54 1. A d v i s i n g the Department of Health, on i s s u e s r e l a t i n g to the N.W.T. Formulary f o r the Pharmacare Program f o r Senior C i t i z e n s ; 2. Ro u t i n e l y review the contents of the Formulary; suggest a d d i t i o n s , d e l e t i o n s and other amendments; 3. Make recommendations regarding the th e r a p e u t i c e f f e c t i v e -ness of drug s e l e c t i o n s ; 4. Make recommendations regarding the o v e r a l l p o l i c i e s r e s p e c t i n g the content of the Formulary; 5. A d v i s i n g the Department of Health on matters of p r o f e s s i o n a l review of a pharmacists a c t i v i t i e s . The Committee meets on a r e g u l a r monthly b a s i s to review a l l matters p r o p e r l y addressed to i t . Communication from the Committee goes by way of an I n f o - B u l l e t i n by the Department of Health to a l l p r o f e s s i o n a l s and i n t e r e s t e d consumer groups. S u b s t i t u t i o n Coincident to the d e c i s i o n on a formulary, i s the d e c i s i o n on s u b s t i t u t i o n (mandatory or voluntary) of drugs which are deemed interchangeable. S e v e r a l f a c t o r s l e d the planner to opt f o r a volu n t a r y s u b s t i t u t i o n . The f i r s t was that research on p a r t i c u l a r drugs was not conducted i n the Northwest T e r r i t o r i e s . The Formulary Committee e s t a b l i s h e d to administer the formulary had to r e l y on Federal and P r o v i n c i a l research so i t could not say d e f i n i t i v e l y that one drug i s e q u a l l y interchangeable w i t h another. The second reason was the l a c k of supporting l e g i s l a t i o n f o r 55 this type of a c t i v i t y . The t h i r d was that the method f o r payment fo r drugs prescribed was not a f i x e d value per drug f o r a long period ( i . e . one year) rather i t was based on the wholesale drug p r i c e which fluctuated from time to time. Objective Resolved by use of a formulary The use of a formulary met the objective of control necessary to exercise responsible spending of public funds. 3. Cost Sharing by Patient The t h i r d major p o l i c y decision i n formalizing the role of the Government i n t h i s project deals with cost-sharing by patient (User Fees). To properly present the p o s i t i o n of the Northwest T e r r i t o r i e s , i t i s necessary to digress a l i t t l e into the d e f i n i t i o n and concept of User Fees. The comments and ideas i n t h i s s e c t i o n were influenced by material prepared by Barer, Evans and Stoddart,^ 73 Evans and Williamson, the Ontario Council of Health's report 74 75 on User Charges f o r Health Services and Soderstrom. D e f i n i t i o n User Fees are charges imposed on people who use the Health Care System, proportionate to the amount they use i t , e i t h e r by charges imposed at the time of use, or assigned subsequently on the basis of use. 56 Common Types of User Fees  Co-Insurarice The p a t i e n t i s required to pay a c e r t a i n percentage of a l l costs i n c u r r e d on h i s b e h a l f . Deductible Requires that the p a t i e n t pay 100% of a l l b i l l s i n a given p e r i o d to some maximum amount beyond which insurance b e n e f i t s are p a i d . Per Service Charge Requires that the p a t i e n t pay a f l a t charge which may or may not be r e l a t e d to the a c t u a l charge of p r o v i d i n g the s e r v i c e . There are two b a s i c arguments p o s t u l a t e d as to why User Fees should be introduced, i . Cost Containment The recommendation of User Fees i s o f t e n based on the presumed exis t e n c e of p a t i e n t abuse of the system. Proponents argue that User Fees w i l l make p a t i e n t s aware of the cost of p r o v i d i n g care so t h a t u t i l i z a t i o n o f f r i v o l o u s or unnecessary s e r v i c e s w i l l decrease. There i s l i t t l e evidence to suggest that p a t i e n t s are the primary generators of m a r g i n a l l y needed care f o r p a t i e n t s have only a l i m i t e d r o l e i n e f f e c t i n g t h e i r u t i l i z a t i o n of h e a l t h s e r v i c e s ; i . e . p h y s i c i a n s have the c r i t i c a l r o l e i n v i r t u a l l y a l l treatment d e c i s i o n s . For User Fees to reduce the o v e r - a l l cost of h e a l t h care, four major assumptions would have to be s a t i s f i e d : (a) P a t i e n t s must be s e n s i t i v e to p r i c e s i n making d e c i s i o n s about h e a l t h care use. P a t i e n t i n i t i a t e d 57 h e a l t h system contacts must f o l l o w i n response to the user charge. (b) P r i v a t e insurance must not step i n and provide coverage f o r the user fee. High l e v e l s of d i r e c t charges would presumably be necessary to achieve d e t e r r e n t s . Since t h i s would increase the f i n a n c i a l r i s k to which the i l l are exposed, the purchase of supplemental p r i v a t e insurance and the p r o v i s i o n of government s u b s i d i e s to the poor and aged would be encouraged, i f d i r e c t charges were h i g h , i t would not be p o l i t i c a l l y f e a s i b l e to ban p r i v a t e insurance. I f d i r e c t charges are i n s u r e d p r i v a t e l y , the deterrent e f f e c t i s n i l . (c) P r o v i d e r s of h e a l t h care must not react to the user charge i n such a manner as to a f f e c t any reduced u t i l i z a t i o n . P h y s i c i a n s possess s i g n i f i c a n t power to i n f l u e n c e u t i l i z a t i o n d i r e c t l y and the concept of s u p p l i e r - induced demand i s now w i d e l y accepted by h e a l t h economists. i i . User Fees as a Source of Revenue With the i n t r o d u c t i o n of the User Fee, some of the r e s p o n s i -b i l i t y f o r h e a l t h care f i n a n c i n g i s shipped back to the p r i v a t e s e c t o r . This i n j e c t i o n of p r i v a t e funds can lead to an en l a r g e i n g of the funds a v a i l a b l e f o r h e a l t h care r a t h e r than e f f e c t i n g cost r e d u c t i o n . O v e r a l l h e a l t h care costs could be reduced i f User Fees lead p a t i e n t s to seek out more e f f i c i e n t , lower cost forms of d e l i v e r y . This process would hinge on two important c o n d i t i o n s : 58 (a) There must be p r i c e v a r i a t i o n between s u p p l i e r s . P r o v i d e r charging behaviours must be t r u l y independent, open and a d v e r t i s e d . There must be no c o l l u s i o n between h e a l t h p r o v i d e r s to e s t a b l i s h uniform charges; and (b) P a t i e n t s must be able to judge s e r v i c e q u a l i t y and r e s o r t to a rough judgment of q u a l i t y by p r i c e . Since the s i n g l e outstanding c h a r a c t e r i s t i c of the h e a l t h care market i s the i n a b i l i t y of the consumer ( p a t i e n t ) to judge the need f o r s e r v i c e or the q u a l i t y of s e r v i c e , there must be some i n t e r v e n t i o n by a t h i r d p a r t y , to provide an adequate l e v e l of i n f o r m a t i o n . Regulatory mechanisms may have to be e s t a b l i s h e d to ensure that adequate q u a l i t y and s a f e t y standards e x i s t f o r the s e r v i c e s provided. Saskatchewan's p o s i t i o n on charges i s the c l e a r e s t example of a d i r e c t charge s a t i s f y i n g these c o n d i t i o n s . The P l a n covers the f u l l i n g r e d i e n t costs of the drug ( p a t i e n t s g e n e r a l l y are not able to evaluate t h e i r own need f o r a p a r t i c u l a r drug nor are they aware of the r e l a t i v e merits of one drug over the o t h e r ) , but not the d i s p e n s i n g f e e . Pharmacies are allowed to a d v e r t i s e t h e i r d ispensing fees so that the p a t i e n t s have s u f f i c i e n t i n f o r m a t i o n to choose between dispensers on the b a s i s of t h e i r r e l a t i v e p r i c e s . To the extent that the dispensing fees create competitive pressures, lower p r i c e pharmacies w i l l be able to expand t h e i r market share at the expense of higher p r i c e d , l e s s e f f i c i e n t dispensers. The existence of the N.W.T. Formulary 59 provides the r e g u l a t o r y mechanism ensuring q u a l i t y and s a f e t y standards, which the p a t i e n t i s unable to judge. The systems of B r i t i s h Columbia and Manitoba do not allow f o r the second f a c t o r s i n c e they do not have f o r m u l a r i e s . As discussed e a r l i e r , the two b a s i c arguments p o s t u l a t e d f o r the i n t r o d u c t i o n of User Fees are: (1) To c o n t a i n h e a l t h care expenditures by reducing unnecessary u t i l i z a t i o n ; and (2) To provide an a d d i t i o n a l source of revenue. In the Northwest T e r r i t o r i e s , s p e c i a l circumstances suggest that the i n t r o d u c t i o n of User Fees f o r h e a l t h s e r v i c e s would not achieve e i t h e r of these o b j e c t i v e s . Status Indians and I n u i t who make up 50% of the N.W.T. popula t i o n would be excluded from d i r e c t charges. Even w i t h i n the "other" p o p u l a t i o n , the low income and aged would have to be excluded f o r economic reasons. By reducing the number of r e s i d e n t s e l i g i b l e f o r paying User Fees, the p o t e n t i a l f o r User Fees to generate a d d i t i o n a l revenue i s s e r i o u s l y reduced. There would be no guarantee that s e r v i c e s deterred by a User Fee, would be those l e a s t m e d i c a l l y necessary. I f people were being deterred from necessary medical care, t h i s would contravene the equal access o b j e c t i v e s on which u n i v e r s a l h e a l t h 60 insurance i s based. The a d m i n i s t r a t i v e machinery necessary to c o l l e c t User Fees f o r h e a l t h s e r v i c e s i n the Northwest T e r r i t o r i e s does not c u r r e n t l y e x i s t . Consequently, a mechanism would have to be e s t a b l i s h e d a t considerable expense. Even then there would be no guarantee that p a t i e n t s would comply w i t h the User Fee r e q u i r e -ments and pay t h e i r b i l l s . U n c o l l e c t i b l e s were a se r i o u s problem f o r h e a l t h care providers before the advent of u n i v e r s a l h e a l t h insurance. The coupon system of Manitoba and B r i t i s h Columbia was r u l e d out as w e l l because of a d m i n i s t r a t i v e d i f f i c u l t i e s a r i s i n g from language problems. In the Northwest T e r r i t o r i e s , there are s i x d i a l e c t s of Indian languages and two manners of speaking the I n u i t language. For the e l d e r l y , t h i s would be such an a d m i n i s t r a -t i v e burden, that many i n d i v i d u a l s would lo s e t h e i r b i l l s or ne g l e c t to submit a claim. The Northwest T e r r i t o r i e s chose not to r e q u i r e a User Fee. I t opted, however, to have the system designed such that i t could accommodate s e v e r a l forms of User Fees i f introduced i n the f u t u r e . Objectives Resolved by o m i t t i n g any co-payment This d e c i s i o n r e s u l t e d i n a compromise of the o b j e c t i v e . The o b j e c t i v e was to reduce costs to government as w e l l . This d e c i s i o n , however, permitted a l e s s c o s t l y a d m i n i s t r a t i o n w i t h 61 fewer problems. I t was considered that the revenue gained or expenditure saved was indeed equalled by the a d m i n i s t r a t i v e expenditure saved. 4. Reimbursement f o r Product Cost to Pharmacist Two f a c t o r s are covered i n determining the f u l l r e t a i l p r i c e of a p r e s c r i p t i o n . One i s the product cost - the cost at the wholesalers'or manufacturers' l e v e l . The second i s an added percentage mark-up or a f i x e d p r o f e s s i o n a l f e e . I n some cases, a combination of percentage mark-up and p r o f e s s i o n a l fee i s used. The p r o v i n c i a l review i n d i c a t e d that the spectrum of reim-bursement f o r product cost could range from a c q u i s i t i o n cost (meaning l a i d - i n p r i c e to the s t o r e , B r i t i s h Columbia) to customary replacement costs ( s u p p l i e r ' s p r i c e p l u s the wholesaler's mark-up), to f i x e d p r i c e s ( p r i c e s f i x e d f o r a pe r i o d of time - Saskatchewan). The Northwest T e r r i t o r i e s ' s i t u a t i o n centred around the simplest method of i d e n t i f i c a t i o n of cost both by the pharmacist and the Program. The Program i s not la r g e so i t was not a d m i n i s t r a t i v e l y wise to tender as Saskatchewan does. The Program d i d not have s u f f i c i e n t competing pharmacies to f o l l o w the f r e e market concept of B r i t i s h Columbia but i t wished to o f f e r the pharmacists some p r o t e c t i o n . The d e c i s i o n reached was to take the wholesale p r i c e ( l a i d - i n to the wholesaler) of the company that s u p p l i e d the m a j o r i t y of the 62 p r i v a t e entrepreneurs and permit a percentage mark-up of the wholesale plus a d m i n i s t r a t i v e and t r a n s p o r t a t i o n c o s t s . The r e s u l t was a wholesale (microfiche) p r i c e plus a mark-up dependent upon l o c a t i o n of the dispensing f a c i l i t y . The mark-up ranges were from 25% to 35%. The weakness inherent i n the mechanism i s that each time a product cost r i s e s , there i s a w i n d f a l l b e n e f i t to the pharmacies r e s u l t i n g from the percentage markup. This permitted a s i m p l i s t i c p r i c i n g system. Both the pharmacists and the Plan r e c e i v e d the m i c r o f i c h e from the whole-s a l e r p l u s the normal up-dates. Quantity p r i c e s put i n t o the system are f o r the more commonly dispensed s i z e s . The pharmacists may buy higher volume and r e c e i v e a lower p r i c e from the whole-s a l e r and t h e r e f o r e , enjoy a surplus against the program but instances are so few that i t i s compensated f o r by t h e i r r i s k - i n c a p i t a l o u t l a y . The q u a n t i t i e s purchased by the Northwest T e r r i t o r i e s are not s i g n i f i c a n t i n the volume of business w i t h e i t h e r the manu-f a c t u r e r or the wholesaler, t h e r e f o r e the p r a c t i c e does not act as an i n c e n t i v e f o r the manufacturer or wholesaler to r a i s e h i s p r i c e s i n o r d i n a t e l y , since they s t i l l must compete on the l a r g e southern p r i v a t e market. Objective met by the p r i c i n g system The o b j e c t i v e of a c h i e v i n g a s i m p l i s t i c system was met. I t d i d away w i t h extensive research, tendering, b a r g a i n i n g and 63 a u d i t s of a c q u i s i t i o n c o s t s . With v o l u n t a r y s u b s t i t u t i o n of the lowest cost interchangeable i n t h e i r i n v e n t o r y , i t permits f l e x i b i l i t y on behalf of the pharmacist. 5. Reimbursement of Dispensing Costs by Pharmacists The o b j e c t i v e of the Department i n t h i s area c o i n c i d e s w i t h that pointed out by the H a l l Commission. That i s , that there be f a i r and reasonable compensation to the pharmacist. F a i r and reasonable compensation i s l i n k e d to v a r i o u s o r b i t s of comparisons. Two fundamental options were a v a i l a b l e to the Northwest T e r r i t o r i e s : 1. To base the dispensing cost as a percentage mark-up of drug c o s t s ; or 2. To base dispensing c o s t s on a f i x e d p r o f e s s i o n a l fee. Pharmacists are p r o f e s s i o n a l , t h e r e f o r e p r e s c r i p t i o n drug coverage must extend beyond the r o u t i n e dispensing. A range of pharmaceutical s e r v i c e s should be o f f e r e d . Some of these s e r v i c e s are: 1. Keeping a p a t i e n t p r o f i l e that i n c l u d e s a l l e r g i e s , i f known, and p a t i e n t drug r e a c t i o n s , i f known. 2. A d v i s i n g the doctor of c o n t r a - i n d i c a t i o n s where p r e s c r i p t i o n s c o n f l i c t . 3. Appropriate c o n s u l t a t i o n on the use of drugs w i t h the p a t i e n t when dispensing. 4. Cautioning the p a t i e n t against overdosage or what to do i f the p a t i e n t f o r g e t s to take the drug. 5. A l e r t i n g the p h y s i c i a n i f i t appears that the p a t i e n t may be s t o c k p i l i n g drugs. 64 For t h i s type of a p r o f e s s i o n a l s e r v i c e , there should be adequate compensation. The d e c i s i o n taken was to pay a f i x e d p r o f e s s i o n a l fee f o r each p r e s c r i p t i o n dispensed. This fee would be negotiated annually. An h i s t o r i c a l precedent had been set i n t h i s instance but the d e c i s i o n i s supported by the argument that r e g a r d l e s s of the product dispensed, the p r o f e s s i o n a l advice should be complete. Product cost i s more r e f l e c t i v e of patents, marketing and newness to the market; t h e r e f o r e i t has l i t t l e bearing on p r o f e s s i o n a l advice. The fee negotiated provides a f a i r and reasonable payment f o r s e r v i c e s rendered. I f the extent of the s e r v i c e i s counting p i l l s , then i t deserves l e s s compensation. The s i n g l e d i s p e n s i n g fee r a t e f o r each p r e s c r i p t i o n i s a simple, easy method to monitor. Co-incident w i t h t h i s runs a minimum p r e s c r i p t i o n period depending on the drug dispensed. Drugs were c a t e g o r i z e d as to whether there should be a 34, 60 or 90 day q u a n t i t y dispensed. 6. Reimbursement Method The procedure by which a h e a l t h b e n e f i t i s paid f o r i s o f t e n thought to be l i n k e d to u t i l i z a t i o n . I t has been speculated that i f the p a t i e n t paid and was reimbursed, then he would understand the cost of the s e r v i c e and the u t i l i z a t i o n would be l e s s t h a n . i f he never saw the b i l l . 65 A review of the p r o v i n c i a l plans found that the u n i v e r s a l programs of B r i t i s h Columbia and Manitoba worked w e l l because of reimbursement to p a t i e n t . Saskatchewan's reimbursement to pharmacists worked e q u a l l y w e l l . The d i f f e r e n c e between these plans was a f u n c t i o n of the method of User Fees. The d e c i s i o n i n the Northwest T e r r i t o r i e s was to reimburse the pharmacist w i t h the o p t i o n of reimbursing the p a t i e n t . T h i s , i t f e l t , would r e s u l t i n a lower a d m i n i s t r a t i v e cost because there would be fewer number of claimants. The cash i n t e r e s t value forgone by the method i s estimated at l e s s than 1/10 of 1%. The o p t i o n i s meeting the s i m p l i s t i c turnaround r e q u i r e d . The average time between the date of s e r v i c e and the date of r e c e i p t of i n v o i c e i s to be estimated at ten to twenty days (most pharmacies p r e f e r to b i l l weekly or b i - w e e k l y ) . The average time between the date of r e c e i p t and date of payment i s estimated at ten to fourteen days, making the turn-around time w i t h i n reasonable business l i m i t s . The Program p r e s e n t l y pays weekly. This does not sev e r e l y impact on the cash management of the Program si n c e sums are not l a r g e . Table 6 i n d i c a t e s the estimated cost of the Program f o r Senior C i t i z e n s . 7. Data Processing The Northwest T e r r i t o r i e s by comparison with the provinces TABLE 6 Program C o s t i n g : Pharmacare f o r P e o p l e Over 65 Yea r s PART ONE - C o s t D e t e r m i n a t i o n A v erage C o s t P e r P r e s c r i p t i o n ( A l b e r t a ) LESS: D i s p e n s i n g Fee Average Drug C o s t Per P r e s c r i p t i o n PLUS: 25% NWT c o v e r a g e I n f l a t i o n ( e s t . 10%) PLUS: NWT D i s p e n s i n g Fee Average C o s t P e r P r e s c r i p t i o n PART TWO Es t i m a t e d Useage P o p u l a t i o n o v e r 65 y e a r s E s t i m a t e d A c t i v e U s e r s (80%) E s t i m a t e d Number of P r e s c r i p t i o n s (one s c r i p t p e r p e r s o n per month) TOTAL COSTS 19 78- 79 1979-80 $ 7. 43 $ 7 . 43 3 . 3 . 45 98 3.45 3.98 * 1 . 00 1.00 .50 4 . 98 5.48 * 3. 70 3.95 $ 8. ,68 $ 9 .43 * 1,340 1,072 1980-81 1,410 1,128 12,864 13,536 X 9.43(+8%) X 10.19 $121,308 $137 ,932 NOTES: 1. N.W.T. a v e r a g e c o s t p e r p r e s c r i p t i o n n ot a v a i l a b l e however l i k e l y f o l l o w s A l b e r t a t r e n d s . 2. E s t i m a t e of 10% a c t u a l drug c o s t i n f l a t i o n . 3. E s t i m a t e of $3.95 d i s p e n s i n g fee used w h i l e a c t u a l to be n e g o t i a t e d . 4. E s t i m a t e t y p i c a l o f o t h e r p r o v i n c i a l e x p e r i e n c e s . E s t i m a t e of one p r e s c r i p t i o n p e r month per p e r s o n . 5. Average c o s t of $9.43 i n v o l v e s lower c o s t i n g drugs a c r o s s s p e c t r u m when e l d e r l y t y p i c a l l y r e q u i r e the h i g h e r c o s t i n g d r u g s . E s t i m a t e i s 8% i n c r e a s e i n c o s t s between 19 79-80 to 19 80-81. SOURCE: Department of Health, G.N.W.T. estimate, June, 1977 67 handles a sm a l l number of claims f o r Pharmacare, A d e c i s i o n therefore was required as to whether to run the system on a manual b a s i s or to set i t up on e l e c t r o n i c data p r o c e s s i n g , A manual system costs l e s s to set up and i f i t i s not necessary to monitor the program e x t e n s i v e l y or to use the informat i o n f o r planning purposes, then the system i s fundamentally sound. The e l e c t r o n i c data processing or computing system re q u i r e s a more extensive and elaborate set up but costs l e s s to operate and gives f a r greater c a p a b i l i t i e s f o r future expansion and c o l l a t i o n of in f o r m a t i o n . The d e c i s i o n the T e r r i t o r i e s was made to introduce e l e c t r o n i c data processing i n order to have c o n t r o l of the system, a c a p a b i l i t y of fu t u r e expansion and f l e x i b i l i t y i n combining the in f o r m a t i o n a v a i l a b l e . Data processing i s accomplished through an o n - l i n e i n t e r a c t i v e system t e r m i n a l l i n k e d to a computer at a c e n t r a l government l o c a t i o n . The system does a pre-audit as claims are entered. The volume i s handled by one person whose volume could double or t r i p l e without making i t necessary to increase s t a f f . Information i s immediate f o r assessment and r e c a l l i n g c l a i m s . There.is a maximum of 24 hours f o r standard turn-around report documents. Report i n f o r m a t i o n i s up to the date of the report request. There i s no time l a g i n reports or payments. 8. C o n t r o l of Program Q u a l i t y One of the e s s e n t i a l features of p u b l i c programs i s c o n t r o l . 68 There are e s s e n t i a l l y two o p t i o n s ; no c o n t r o l and c o n t r o l through review. Some provinces such as B r i t i s h Columbia and A l b e r t a t u r n review over to the Pharmaceutical S o c i e t y and pay them a fee per p r e s c r i p t i o n to assess and d i s c i p l i n e problem pharmacists. There are few p r i v a t e pharmacies and t h e r e f o r e t h i s approach f o r review i s not p r a c t i c a l i n the Northwest T e r r i t o r i e s . Review and d i s c i p l i n e has become a f u n c t i o n of the Northwest T e r r i t o r i e s Formulary Advisory Committee, a Committee whose primary f u n c t i o n i s m a i n t a i n i n g the master l i s t of drugs that are termed a b e n e f i t under the program. The review l a c k s t e e t h i n l e g i s l a t i o n , but can d i s c i p l i n e a pharmacist by c a n c e l l a t i o n of h i s c o n t r a c t w i t h the Program or by asking f o r an independent review by a p r o v i n c i a l a s s o c i a t i o n . I f the a c t i o n of the pharmacist i s n e g l i g e n t or f r a u d u l e n t , then there are p r o v i s i o n s through the courts to proceed f u r t h e r . Eight d e c i s i o n f e a t u r e s The e i g h t major d e c i s i o n s set the framework on which the Program was to be b u i l t . Information regarding the v a r i o u s options had come about as a r e s u l t of the l i t e r a t u r e review and comparative review of e x i s t i n g p r o v i n c i a l Pharmacare programs. I t a l s o was necessary to b u i l d upon some of the features of the previous three Northwest T e r r i t o r i e s programs and the planning t h e r e f o r e could a l s o be c l a s s i f i e d as incremental. Once the framework was s e t , i t provided the broad s p e c i f i -6 8 a There are e s s e n t i a l l y two options; no con t r o l and control through review. Some provinces such, as B r i t i s h Columbia and Alberta turn review- oyer to the Pharmaceutical Ass o c i a t i o n and pay them a fee per p r e s c r i p t i o n to assess and d i s c i p l i n e problem cases. There are few- private pharmacies and therefore t h i s approach f o r review i s not p r a c t i c a l i n the Northwest T e r r i t o r i e s . Review and d i s c i p l i n e has become a function of the Northwest T e r r i t o r i e s Formulary Advisory Committee, a Committee whose primary function i s maintaining the master l i s t of drugs that are termed a b e n e f i t under the program. The review lacks teeth i n l e g i s l a t i o n , but can d i s c i p l i n e a pharmacist by c a n c e l l a t i o n of h i s contract with the Program or by asking f o r an independent review by a p r o v i n c i a l a s s o c i a t i o n . I f the action of the pharmacist i s negligent or fraudulent, then there are provisions through the courts to proceed further. The eight major decisions set the framework on which the Program was to be b u i l t . Information regarding the various options had come about as a r e s u l t of the l i t e r a t u r e review and comparative review of e x i s t i n g p r o v i n c i a l Pharmacare programs. It also was necessary to b u i l d upon some of the features of the previous three Northwest T e r r i t o r i e s programs and the planning therefore could also be c l a s s i f i e d as incremental. Once the framework was set, i t provided the broad s p e c i f i -69 c a t i o n s f o r design by the computer programmers.. As the design progressed changes of a s m a l l e r nature were c o n s t a n t l y made to achieve a workable product. Design The procedure used i n Design followed a systematic approach known as PRIDE ( P R o f i t a b l e Information by DEsign). This type of approach attempts to bridge the c r e d i b i l i t y and communication gap that a r i s e s between the user and the designers during systems design. I t proposes s p e c i f i c t h oughtful documentation to e l i m i n a t e the t r i a l and e r r o r methods. While the d e t a i l e d p lanning here i s concerned w i t h Pharmacare, the approach i s a p p l i c a b l e to a l l p r o j e c t s and a l l p r o j e c t s pass through the same phases of design but the order of these phases i s l o g i c a l and p r e d i c t a b l e . Phases This report w i l l not deal w i t h a l l the f i n i t e d e t a i l s , r a t h e r , i t w i l l o u t l i n e the major features and give some d e t a i l s about them. The design was broken i n t o nine phases, of which seven are required t o put the system i n t o o p e r a t i o n , the phases are: 1. System Study and E v a l u a t i o n . 2. System Design. 3. Subsystem Design. 70 4. A d m i n i s t r a t i o n Procedure and Computer Procedure Design. 5. Program Design. 6. Computer Program Test. 7. System Test. 8. System Enhancement. 9. System A u d i t . Phase 1 - System Study and E v a l u a t i o n This phase in v o l v e d the development of the scope of the p r o j e c t by s e t t i n g up the boundaries. The scope was the design, development and implementation of a Pharmacare program f o r e l i g i b l e Northwest T e r r i t o r i e s ' r e s i d e n t s which encompassed the e x i s t i n g programs p l u s the a d d i t i o n of the new s e n i o r c i t i z e n s ' program. Included i n the scope were d e t a i l s of p o p u l a t i o n to be served, users, p r o v i d e r s and t h e i r i n t e r a c t i o n w i t h other agencies and i n d i v i d u a l s . Phase 1 a l s o i ncluded d e f i n i n g the requirements of the users on such matters as c o n f i d e n t i a l i t y and in f o r m a t i o n r e p o r t s . The program scope was then defined i n terms of f u n c t i o n . The four major f u n c t i o n s are: 1. R e g i s t r a t i o n of v a i l d pharmacists, h o s p i t a l s and nursing s t a t i o n s authorized to dispense drugs to r e s i d e n t s of the Northwest T e r r i t o r i e s : e l i g i b l e Northwest T e r r i t o r i e s r e s i d e n t -71 Indians and I n u i t , i n d i g e n t , 12 supplementary i l l n e s s e s , and age 65 years and o l d e r . 2. Processing and Reimbursement of v a l i d claims submitted f o r drugs dispensed to e l i g i b l e Northwest T e r r i t o r i e s r e s i d e n t s . 3. A n a l y s i s of drugs dispensed to Northwest T e r r i t o r i e s r e s i d e n t s under each of the programs. P a t i e n t h i s t o r i e s i n c l u d e these drugs dispensed under the h e a l t h programs and provide f o r i n t e g r a t i o n w i t h e x i s t i n g p a t i e n t h i s t o r i e s accumulated under Medicare and the T e r r i t o r i a l H o s p i t a l Insurance S e r v i c e s . 4. A d m i n i s t r a t i v e and f i n a n c i a l procedures w i t h i n the Government of the Northwest T e r r i t o r i e s to ensure accuracy and a u d i t a b i l i t y of the Pharmacare program. 5. S t a t i s t i c a l and management reports to f a c i l i t a t e management and c o n t r o l of the Pharmacare program. The end of the phase r e s u l t e d i n a systems approach to the p r o j e c t . Phase 2 - System Design This phase defines the systems approach i n t o subsystems and prepared systems f l o w charts and l o g i c and data management d e s c r i p t i o n s . Figure 1 shows a broad overview of the component system. FIGURE 1 SYSTEM CONCEPT DIAGRAM N.W.T. PHARMACARE 1979 ^REGISTRATION / OF NEW / ^PHARMACISTS & PHARMACIES/ PRACTITIONER MASTER UPDATE FORM PHARMACY NURSING HOSPITALS OUT OF STATION FEDERAL & PROVINCIAL TERRITORY *• DEPT. OF HEALTH MEDICAL SERVICES SOCIAL SERVICES 73 From a s i m p l i s t i c view there are master f i l e s which contain i n f o r m a t i o n against which claims are assessed. The in f o r m a t i o n i n the master f i l e s must be con s t a n t l y updated. ( P a t i e n t R e g i s t r a t i o n , Formulary, Drug P r i c e s and Dispensers' R e g i s t r a t i o n ) . These f i l e s are al s o l i n k e d to p r i n t subsystems so that hard copies of any of the master f i l e s can be e d i t e d or p r i n t e d a u t o m a t i c a l l y from the computer i n the format to be d i s t r i b u t e d to the p u b l i c . The second major set of f i l e s r e volves around the c l a i m assessment area. I f a cl a i m i s v a l i d and passes the e d i t s throughout i t i s accepted by the computer and held i n the cumulative pay f i l e that i s a c t i v a t e d once a week. I f the cla i m i s i n v a l i d f o r a c e r t a i n set of e d i t s , i t i s refused o u t r i g h t . But i f the cl a i m f a i l s to pass only one or two l e s s e r e d i t s , i t shunts i t i n t o a c l a i m in-process f i l e which i s p r i n t e d out d a i l y . An assessment c l e r k reviews the in-process f i l e and f o l l o w s up on the c o r r e c t i v e a c t i o n r e q u i r e d . The c l a i m , once c o r r e c t e d , can be released back i n t o the system and through to the pay f i l e . The t h i r d major set of records are s t a t i s t i c a l f i l e s . These f i l e s are set up on a data base system. F i l e s are created when claims are accepted, as va r i o u s p o r t i o n s of the i n f o r m a t i o n on the c l a i m goes i n t o v a r i o u s f i l e s which can then be recompiled i n t o s t a t i s t i c a l reports or re-assembled i n any combination thereof. These f i l e s are provided as a r e s u l t of s t a t i s t i c a l and management reports requested. These reports are o u t l i n e d i n d e t a i l i n Appendix A . 74 The s t a r t i n g p o i n t f o r the system i s the completion of c l a i m page by the va r i o u s dispensers. The cl a i m page i d e n t i f i e s the dispenser and the d e t a i l s of the p r e s c r i p t i o n drug i s s u e d . The claim page i s completed by a l l dispensers and submitted d i r e c t l y to the Department of Health. Upon r e c e i p t by the Department of Healt h , pharmacy claims are subjected to a comprehensive s e r i e s of e d i t s and v a l i d a t i o n s on a weekly frequency designed to determine e l i g i b i l i t y of the p a t i e n t and v a l i d i t y of the s p e c i f i c c l a i m . A l l v a l i d claims r e s u l t i n a cheque being i s s u e d to the dispenser w i t h a supporting statement of account e x p l a i n i n g the nature of the payments. In a d d i t i o n to the primary claims e d i t and assessment subsystem, support subsystems have a l s o been constructed, t o : 1. Produce a s e r i e s of management in f o r m a t i o n and s t a t i s t i c a l r e p o r t s . 2 . R e g i s t e r e l i g i b l e r e s i d e n t s w i t h the Pharmacare program. 3. R e g i s t e r pharmacists. 4. Create and update the formulary f i l e . Phase 3 - Subsystem Design A design philosophy of f l e x i b i l i t y and e x p a n d a b i l i t y has been followed to f a c i l i t a t e the subsequent expansion of the i n i t i a l Pharmacare program. The key system f i l e s are designed to provide a comprehensive h i s t o r i c a l data base t h a t i s the b a s i s f o r a unique s t a t i s t i c a l report or management e n q u i r i e s . 75 The Pharmacare design f u l l y addresses the concept of on demand - demand r e p o r t i n g and as such, u t i l i z e s a report generator system to s a t i s f y t h i s need. The system approach and concepts that had Been developed possess s u f f i c i e n t growth p o t e n t i a l to permit the handling of f a r greater volumes of t r a n s a c t i o n s w i t h no s i g n i f i c a n t i n c r e a s e i n s t a f f or computing power. The Pharmacare system d i r e c t l y depends on the f o l l o w i n g key data base components: 3.1 Formulary Subsystem A comprehensive f i l e of a l l drugs l i s t e d i n the Formulary and t h e i r r e l a t e d drug i d e n t i f i c a t i o n numbers (D.I.N.) i s s u e d by the Federal Government, designed to provide an index of v a l i d drugs and a p r o f i l e of i n d i v i d u a l D.I.N.'s i n terms of cost and d e t a i l s p e c i f i c a t i o n s . Unit drug costs are not included i n the N.W.T. Formulary that i s d i s t r i b u t e d to the various pharmacists. The Formulary f i l e contains u n i t drug costs to be updated monthly ( i f necessary) and a percentage upcharge to the base drug u n i t cost that can be added to an i n d i v i d u a l pharmacy. D e t a i l s of the Formulary f i l e and i t s contents are i n Table 7. 76 TABLE 7 CONTENTS OF PHARMACARE MASTER F I L E S PATIENT REGISTRATION F I L E CONTENTS - as i n M e d i c a r e - D r u g R e i m b u r s e m e n t E l i g i b i l i t y Code ( a g e , i n d i g e n t , SHP) - D r u g R e i m b u r s e m e n t E l i g i b i l i t y D a t e s (by e l i g i b i l i t y c o d e i n c l u d i n g r e p e a t s f o r p a s t e l i g i b i l i t y p e r i o d ) - a c t i v i t y f l a g by E l i g i b i l i t y Code REGISTERED PRACTITIONER MASTER F I L E CONTENTS - as i n M e d i c a r e - D i s p e n s i n g Fee DRUG HISTORY F I L E CONTENTS - D a t e o f R e c e i p t - C u r r e n t P a t i e n t R e g i s t r a t i o n Number - P r e v i o u s D u p l i c a t e P a t i e n t R e g i s t r a t i o n Number - C l a i m Number - P a t i e n t B i r t h D a t e - D a t e o f D i s p e n s i n g - D a t e o f Payment - D i s p e n s e r Number - P r e s c r i b e r Number - Mode of Payment ( f u l l , p a r t i a l , n i l ) - U n i t C o s t ( F o r m u l a r y / S u b m i t t e d / A p p r o v e d ) - New or R e p e a t P r e s c r i p t i o n - S u b s t i t u t e o r no Sub. P r e s c r i p t i o n - DIN E x c e p t i o n S t a t u s o r F o r m u l a r y - Q u a n t i t y ( S u b m i t t e d / A p p r o v e d ) - D r u g C o s t ( S u b m i t t e d / A p p r o v e d ) - D i s p e n s i n g Fee - T o t a l C o s t P a i d - ASHP C l a s s i f i c a t i o n - A c t i v e I n g r e d i e n t s - S t r e n g t h - R o u t e - Form N.W.T. P h a r m a c a r e S y s t e m M a n u a l , 1979 77 - M a n u f a c t u r e r - N a r c o t i c I n d i c a t o r - E x p l a n a t o r y Codes - A s s e s s m e n t Codes - A d j u s t m e n t Codes - Age - D u r a t i o n Days ( B e f o r e / A f t e r ) - S u b s t i t u t e d ( D I N / U n i t C o s t ) - D r u g R e i m b u r s e m e n t E l i g i b i l i t y Code - S e t t l e m e n t Code - D a t e of P r o c e s s i n g - E q u i v a l e n t Group number FORMULARY F I L E CONTENTS - D r u g I d e n t i f i c a t i o n Number - M a n u f a c t u r e r code - D r u g Name - R o u t e of a d m i n i s t r a t i o n ( e . g . o r a l ) - Form ( t a b l e t , c a p s u l e , e t c . ) - A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s C l a s s i f i c a t i o n s - E f f e c t i v e D a t e , U n i t P r i c e ( r e p e a t e d f o r p a s t P r i c e c h a n g - Q u a n t i t y Minimum/Maximum - DIN D i s p e n s i n g Fee ( S t a n d a r d , 0, o r $1 f o r i n s u l i n -u s e d f o r 100% d r u g c o v e r a g e e.g., w e l f a r e ) - E x c e p t i o n D r u g S t a t u s I n d i c a t o r - N a r c o t i c I n d i c a t o r - D u r a t i o n L i m i t s - D u r a t i o n Q u a n t i t y - A c t i v e I n g r e d i e n t s (7 d i g i t C a n a d i a n D r u g I d e n t i f i c a t i o n Code) - S t r e n g t h s X.XX ( r e p e a t e d once p e r a c t i v e i n g r e d i e n t ) - I n v a l i d Sex CM o r F) - Minimum and maximum age l i m i t s - E x p l a n a t o r y C o d e s : Z6 - c o m p o u n d i n g Z9 - c r e a m s , o i n t m e n t s and s o l u t i o n s - S u b s t i t u t e DIN f r o m i n t e r c h a n g e a b l e d r u g g r o u p - S u b s t i t u t e DIN U n i t P r i c e - DIN n o t s u b j e c t t o a u d i t i n d i c a t o r - S u p p l e m e n t a l H e a l t h P r o g r a m C o d e s ( r e p e a t e d p e r SHP) - E q u i v a l e n t g r o u p number N.W.T. P h a r m a c a r e S y s t e m M a n u a l , 1979 78 3.2 P r a c t i t i o n e r Subsystem The subsystem contains a p r o f i l e of a l l pharmacies that s e r v i c e e l i g i b l e N.W.T. r e s i d e n t s . The data base contains p r a c t i t i o n e r i d e n t i f i c a t i o n data and other s p e c i f i c data elements r e l a t e d to p r a c t i t i o n e r e l i g i b i l i t y (both dispenser and p r e s c r i b e r s ) . This i n f o r m a t i o n i s based upon and i n t e g r a t e d w i t h the N.W.T. Medical Care Doctor R e g i s t r a t i o n System. The Pharmacare program provides f o r a v a r i a b l e d i s p e n s i n g fee f o r each r e g i s t e r e d pharmacy. The Pharmacare program also incorporates a s e l f - c h e c k i n g p r a c t i t i o n e r number w h i l e remaining compatible w i t h the e x i s t i n g doctor r e g i s t r a t i o n f i l e i n Medicare. This s e l f - c h e c k i n g r e g i s t r a t i o n number enables grouping of cheques and statements of account (e.g. pharmacists w i t h i n a pharmacy). The Pharmacare program provides f o r out of t e r r i t o r y pharmacies to be r e g i s t e r e d f o r reimbursement, and f o r drug costs i n c u r r e d out of t e r r i t o r y to be reimbursed d i r e c t l y to e l i g i b l e r e s i d e n t s . P r o v i s i o n i s made to reimburse out of t e r r i t o r y pharmacies not r e g i s t e r e d w i t h Pharmacare on an i n d i v i d u a l c l a i m b a s i s , (maximum or Formulary p r i c e ) . 79 . 3 . 3 P a t i e n t R e g i s t r a t i o n Subsystem Pharmacare r e l i e s on the p a t i e n t r e g i s t r a t i o n f i l e of the Medicare and H o s p i t a l Claims system. The cur r e n t f i l e i s supple-mented by an e l i g i b i l i t y f i l e to p r o p e r l y track which r e s i d e n t s are e l i g i b l e f o r what s p e c i f i c coverage, at what p a r t i c u l a r time i n t e r v a l . The primary o b j e c t i v e of t h i s f i l e i s to ensure that only e l i g i b l e r e s i d e n t s r e c e i v e b e n e f i t s of the Pharmacare program. Pharmacare has the same residency requirements ( e f f e c t i v e a r r i v a l plus three months, expires departure plus three months) as the Medicare and H o s p i t a l programs. Claims w i l l not be pro-cessed f o r dispensing dates outside of the e l i g i b i l i t y p e r i o d s . 3.4 Claims E d i t and Assessment Subsystem A l l drug claims that pass the Pharmacare e l i g i b i l i t y and v a l i d i t y checks are approved f o r payment and added to a drug h i s t o r y f i l e which provides a complete p r o f i l e of completed s e r v i c e s . I t i s the focus of a l l management and s t a t i s t i c a l r e p o r t s . This subsystem inc l u d e s the pr e p a r a t i o n of cheques and statements of account f o r the pharmacies, the p r e s c r i p t i o n v a l i d a t i o n statement to be v a l i d a t e d by the drug r e c i p i e n t , and the r e - e n t r y of the claims and process of assessment. A d m i n i s t r a t i v e procedures f o r the pharmacies i n c l u d e the use of a c l a i m page as a d a i l y sheet and requests to submit 80 claims to the Department of Health on a bi-weekly or a monthly b a s i s as t h e i r business volumes r e q u i r e . There i s a pharmacist's agreement and h i s statement of account i n d i c a t e s as w e l l that the pharmacy i s re s p o n s i b l e f o r re s u b m i t t i n g claims r e j e c t e d by the Pharmacare program. Allowance was made l a t e r to i n c l u d e r e s i d e n t payments of a p o r t i o n of the cost of each p r e s c r i p t i o n . The options to be considered are p a t i e n t payment of a percentage (0% - 100%) or a f i x e d d o l l a r amount of each p r e s c r i p t i o n up to a d o l l a r l i m i t f o r p a t i e n t payments i n each calendar year. When t h i s l i m i t (to be determined) i s exceeded, the percentage of f i x e d d o l l a r payment i s changed f o r the remainder of the year f o r that p a t i e n t . The Pharmacare program w i l l provide f o r v o l u n t a r y s u b s t i t u -t i o n w i t h i n e q u i v a l e n t drug groups f o r a l l dispensers unless the • pharmacist i n d i c a t e s no s u b s t i t u t i o n on the c l a i m . P r o v i s i o n i s made f o r exception drug coverage f o r a s p e c i f i c p a t i e n t , s p e c i f i c drug i d e n t i f i c a t i o n number, s p e c i f i c pharmacy, p r e s c r i b e r and time frame. An automatic claims r e c y c l i n g system i s provided to enable the Pharmacare Assessment C l e r k to co r r e c t the data i n e r r o r where p o s s i b l e and to respond to dispenser queries regarding the st a t u s of claims i n process (under assessment). 81 The pharmacists are r e q u i r e d to enter the p r e s c r i b i n g p h y s i c i a n ' s Medicare r e g i s t r a t i o n number on the Pharmacare c l a i m page. Claims are r e j e c t e d and returned to the pharmacy i f a v a l i d p h y s i c i a n number i s not submitted. 3 . 5 Management and S t a t i s t i c a l Reporting Subsystem The drug h i s t o r y f i l e i s analyzed on a monthly, q u a r t e r l y and annual b a s i s . These reports provide the b a s i s f o r cost p r o j e c t i o n s , reviewing a pharmacy's a c t i v i t i e s , a p r e s c r i b e r ' s a c t i v i t i e s or the Department's own i n t e r n a l a c t i v i t i e s . Examples of the extensive reports are i n Appendix A. 3 . 6 Pharmacare E f f e c t i v e n e s s Subsystem This subsystem c o l l e c t s data from the weekly p a t i e n t r e g i s t r a t i o n and claims e d i t and assessment subsystems and on a monthly b a s i s w i l l produce Pharmacare e f f e c t i v e n e s s r e p o r t s . Examples are found i n Appendix A. These reports d e t a i l the p r e s c r i b i n g h a b i t s by p h y s i c i a n s , the dispensing h a b i t s by pharmacies and n u r s i n g s t a t i o n s , the u t i l i z a t i o n by p a t i e n t and community and costs by p a t i e n t , community, region and the t o t a l Northwest T e r r i t o r i e s . These reports then provide a method of checking f o r drug q u a n t i t i e s dispensed i n the nursing s t a t i o n s which was not p o s s i b l e before. The reports a l s o permit an a n a l y s i s of drug usage by drug that d e t a i l s the q u a n t i t y and community where the drug i s 82 being used. This i s to enable monitoring of p r e s c r i b i n g h a b i t s to guard against the development of drug r e s i s t a n t s t r a i n s of b a c t e r i a . 3.7 P r e s c r i p t i o n V a l i d a t i o n This subsystem c o l l e c t s data from the p a t i e n t f i l e s and produces r e p o r t s f o r d i s t r i b u t i o n tb p a t i e n t s to have them v a l i d a t e the drug, date r e c e i v e d , dispenser and l o c a t i o n . I t a l s o acts as a method of p u b l i c i n f o r m a t i o n . Pharmacare System L o g i c The Pharmacare System i s made up of f i v e subsystems, namely: 28-01 Formulary P r i n t 28-02 Master F i l e Maintenance 28-03 E d i t and Assess Claims 28-04 Payments 28-05 Management Reports These subsystems are i n t e r r e l a t e d through a common Data Base c o n s i s t i n g of master f i l e s , namely: FD28010 DIN Formulary FD28020 P a t i e n t E l i g i b i l i t y FD28030 Supplementary Programs FD28040 Drug H i s t o r y FD28050 Performance Stats FD28213 Batch Imbalance Recycle FD28214 Claims-In-Process Recycle FD28370 Formulary P r i n t FD24003 P a t i e n t R e g i s t r a t i o n FD24004 Doctor (Dispenser) R e g i s t r a t i o n FD28035 Dispenser Fee FD28310 Refused Claims FD28360 V a l i d Claims The subsystems are designed i n a data base mode that permits the a d d i t i o n of new programs, f i l e s or data i n a modular f a s h i o n . 83 This means that a system change does not r e q u i r e the r e w r i t i n g of the system each time. Appendix B provides, an a d d i t i o n a l source of in f o r m a t i o n on the subsystem. PHASE 4 - PRODUCTION OF PROCEDURAL MANUALS The d i s t i n c t i o n i s made between p o l i c y and procedure. Since much of the work w i l l be undertaken by people who are not expected to i n t e r p r e t p o l i c y ; s t r i c t , simple, c l e a r procedures must be defined i n a step-by-step manner. This s e c t i o n of the p r o j e c t d e a l t w i t h a step-by-step production of procedure manuals i n which there was no room f o r p o l i c y d i s c r e t i o n . Areas of p o l i c y d i s c r e t i o n are handled by another branch of the Department o f Health. The production of the procedural manuals f o r p r e s c r i b e r s and dispensers maintains boundaries on the judgment expected by the people doing the assessment and provides assessment on a standard and uniform b a s i s . I t al s o documents the steps of the claims through the system and thereby enables people to trac e p a r t i c u l a r claims which appear l o s t . PHASE 5 - THE COMPUTER DESIGN AND PROGRAMMING PHASE Once the users requirements have been defined; the parameters have been defined; the c o n s t r a i n t s on the system have been defined and the hardware has been defined, the a c t u a l programming or e s t a b l i s h i n g of the system i s then put i n t o place on computer. This then has the e f f e c t of s t r i c t t e c h n i c a l g u i d e l i n e s much as are evident i n a r c h i t e c t u r a l and engineering f i e l d s . 84 PHASE 6 - COMPUTER TEST Phase 6 i s a t e s t phase of the computer d e t a i l and the programs designed i n Phase 5. This t e s t i s to see that each i n d i v i d u a l f u n c t i o n i n g step i s ope r a t i n g . PHASE 7 - SYSTEM TEST Phase 7 i s an o v e r - a l l system t e s t of the whole system which i n c l u d e s manuals, procedures, documents, paper flow, storage and p u b l i c i n f o r m a t i o n . A step-by-step system t e s t i s conducted over a period of time before documents are a c t u a l l y signed o f f . The system i n c l u d e s a procedure at the end of each phase that the user and the designer must s i t down, read the documents, know that they have both understood them and s i g n them o f f as being understood and acceptable. Phase 7 i s the formal s i g n - o f f of the system and acknowledges acceptance of the system. PHASE 8 - ENHANCEMENTS Phase 8 deals w i t h enhancements i d e n t i f i e d as necessary f o r the p r o j e c t a f t e r the system has been s t r u c t u r e d i n t o design. These enhancements are then incorporated i n fu t u r e production and program changes. PHASE 9 - SYSTEM EVALUATION Phase 9 deals w i t h a system e v a l u a t i o n . I t i s t h i s phase of the program i n which an e v a l u a t i o n as to whether the program design has met the o b j e c t i v e of the system. 8 5 The system design u l t i m a t e l y takes i t s s t r u c t u r e from the values of the Government. The values are t r a n s l a t e d i n t o o b j e c t i v e s and the o b j e c t i v e s s t a t e d i n terms of f u n c t i o n a l d e c i s i o n s . From each f u n c t i o n a l d e c i s i o n , various subsystems are designed to i n t e g r a t e i n t o one comprehensive system. The Pharmacare program of the Northwest T e r r i t o r i e s i s unique i n that i t uses a c l a i m i n process c y c l e . I t as w e l l i s e s t a b l i s h e d on a data based system that allows f o r maximum f l e x i b i l i t y when compiling i n f o r m a t i o n f o r a u d i t s , c o n t r o l s or other s e l e c t i v e r e p o r t s . IMPLEMENTATION With the i n t r o d u c t i o n of the program the government f e l t i t had met i t s p o l i t i c a l commitment of o f f e r i n g a r e l i e f from the cost of pharmaceuticals to s e n i o r c i t i z e n s and at the same time, c o n s o l i d a t e d and r a t i o n a l i z e d a government s e r v i c e . The bureaucracy was pleased having met i t s o b j e c t i v e of a d m i n i s t r a t i v e s i m p l i c i t y w i t h what was f e l t to be s u f f i c i e n t c o n t r o l . The extent of the i n f o r m a t i o n and ease of r e t r i e v a l of va r i o u s combinations made i t a much simpler task to account to the p u b l i c . The presence of the Formulary Advisory Committee l i n k e d the p r o f e s s i o n a l s of the Northwest T e r r i t o r i e s to the program and o f f e r e d greater c r e d i b i l i t y to ac t i o n s taken. The s e r v i c e d e l i v e r e r s now had f o r the f i r s t time d e f i n i t i v e 86 g u i d e l i n e s on acceptable and non-acceptable b e n e f i t s , a standard p r i c i n g format, a standard submission format, only one agency to dea l w i t h and a much s u p e r i o r turnaround time f o r the payment of t h e i r i n v o i c e s . D e t a i l e d a d m i n i s t r a t i v e manuals were prepared f o r p r e s c r i b e r s , dispensers and n u r s i n g s t a t i o n s and h o s p i t a l s w i t h i n s t r u c t i o n s as to a l l phases of the operation and t h e i r r o l e i n i t . A systematic r e p o r t i n g procedure f o r the nursing s t a t i o n s , already i n p l a c e , now had boundaries as a r e s u l t of the c r e a t i o n of the nur s i n g s t a t i o n s and l a y dispensers' f o r m u l a r i e s . This enabled the proper o r d e r i n g of drugs which then eased t r a n s p o r t a t i o n problems. The c o n t r o l a v a i l a b l e enabled the monitoring of dispensing h a b i t s i n the n u r s i n g s t a t i o n s and l a y dispensers area. Consumers were then advised of the program and the procedures r e q u i r e d , i f any, to ensure they were on the b e n e f i c i a r y l i s t i n g s . They were a l s o advised of the presence of a Formulary Advisory Committee made up of three p h y s i c i a n s , two pharmacists, and chaired by the Department of Health to whom requests f o r a d d i t i o n s to the b e n e f i t l i s t i n g could be made. This s a t i s f i e d the need f o r input e x t e r n a l to the bureaucracy. Contacts were l i n k e d w i t h wholesale supply houses to maintain c u r r e n t p r i c e l i s t i n g s . The Department l i n k e d i t s e l f to the Drug Q u a l i t y and Assessment Services of the Fede r a l Department of Health and Welfare. I t a l s o l i n k e d i t s e l f to the Saskatchewan Formulary S e c r e t a r i a t to r e c e i v e advice on t h e i r a d d i t i o n s and 87 d e l e t i o n s . Information dissemination and l i n k a g e became the themes f o r the f i r s t few months of the program. SUMMARY This Chapter has o u t l i n e d the planning and design procedures undertaken to b r i n g the program on stream. I t has f o l l o w e d the progression from a comparative review of e x i s t i n g plans (Chapter 2) to the statement of the three o b j e c t i v e s and e i g h t broad p o l i c y d e c i s i o n s which provided the b a s i c s t r u c t u r e f o r design. The design followed a p r e s c r i b e d methodology of nine phases, seven of which were required p r i o r to implementation. I t i n v o l v e d the e s t a b l i s h i n g of committees, p r o j e c t teams and d e t a i l e d d i r e c t i o n of a d m i n i s t r a t i v e and computing requirements. The design d e t a i l i n v o l v e d s t r u c t u r i n g the system to be processed on a Hewlett Packard 3 0 0 0 Computing System w i t h minimal manual assessment or f i l i n g . The program design s a t i s f i e d the o b j e c t i v e s of p o l i t i c i a n s , p r o f e s s i o n a l s and the p u b l i c . I t required extensive documentation i n c l u d i n g the c o n s t r u c t i o n of a Formulary and a d m i n i s t r a t i o n manuals f o r assessment, p r e s c r i b i n g and d i s p e n s i n g . But the key component of the design was i t s f l e x i b i l i t y . The design permits a d d i t i o n s , d e l e t i o n s and changes to programs, even an allowance f o r a p a t i e n t co-payment system i n the f u t u r e without d i f f i c u l t y . 88 I t was designed on time, w i t h i n budget and w i t h a high degree of user s a t i s f a c t i o n . 89 CHAPTER 4 EVALUATION AND RECOMMENDATIONS System design i s always subject to c o n s t r a i n t . I t labours under the c o n s t r a i n t of p o l i c y d e c i s i o n s , computer hardware, manpower, expense, i n f o r m a t i o n and knowledge. The great e s t mechanism of se l f - d e f e n c e f o r t h i s system therefore i s f l e x i b i l i t y and r e s i l i e n c y . F l e x i b i l i t y i n order to permit the system to adapt to changes. R e s i l i e n c y so that the removel of one part does not destroy the whole. This Chapter reviews the c o n s t r a i n t s placed on planning the system, and where they have kept the plan from meeting i t s o b j e c t i v e s to date. I t concludes w i t h recommendations f o r f u t u r e expansion of the program. The system must be evaluated according to i t s o b j e c t i v e s . The main o b j e c t i v e s , as st a t e d i n Chapter 3 were: 1. E f f e c t i v e n e s s : the r a t i o n a l use of drugs to achieve and maintain the best p o s s i b l e h e a l t h . 2 . E f f i c i e n c y : the cost of the program must be kept under c o n t r o l and to the lowest reasonable l e v e l . 3. I d e o l o g i c a l : the program should b e n e f i t those w i t h the great e s t drug costs and the l e a s t f i n a n c i a l a b i l i t y to pay. 90 E f f e c t i v e n e s s "The r a t i o n a l use of drugs to achieve and maintain the best p o s s i b l e h e a l t h . " The program attempted to meet the o b j e c t i v e o f e f f e c t i v e n e s s through the use of a formulary, v o l u n t a r y s u b s t i t u t i o n and the assessment r u l e s on d u r a t i o n l i m i t s . In a d d i t i o n , there i s a s e r i e s of reports that permit the program to check f o r p r e s c r i b i n g , dispensing and u t i l i z a t i o n a b n o r m a l i t i e s . The Formulary Advisory Committee d i s t r i b u t e s b u l l e t i n s on new drugs or drugs removed from the market. These b u l l e t i n s serve as combined assessments and in f o r m a t i o n on p r e s c r i b i n g h a b i t s . The review f u n c t i o n of the committee has not been necessary to date but i s capable of reviewing bad p r e s c r i b i n g h a b i t s . The f a c t that p h y s i c i a n s may request a drug on exception s t a t u s s i m i l a r to Saskatchewan, puts t h e i r p r e s c r i b i n g h a b i t s a u t o m a t i c a l l y before the committee and over the long term, should have an i n f l u e n c e . Confirmation of the achievement of t h i s o b j e c t i v e w i l l not be known f o r some time. E f f i c i e n c y "The cost of the program must be kept under c o n t r o l and to the lowest reasonable l e v e l . " The program by i t s very c o n s t r u c t i o n has achieved a l a r g e degree of a d m i n i s t r a t i v e e f f i c i e n c y . I t has solved many, i f not a l l , of the a d m i n i s t r a t i v e problems of the three separate systems 91 i d e n t i f i e d i n Chapter 2. The system can be handled by one c e n t r a l agency. The e d i t s and assessments are programmed i n t o the computer so that checks are made on every aspect of the i n v o i c e . The assessment r u l e s are d e f i n e d . Rates are known and programmed i n . The turnaround time from r e c e i p t of i n v o i c e to date of payment i s l e s s than one month but s t i l l w i t h i n good cost management p r i n c i p l e s . P a t i e n t e l i g i b i l i t y i s recorded and checked by computer against each c l a i m . Methods of a n a l y z i n g p r e s c r i b i n g , d i s p e n s i n g and u t i l i z a t i o n are i n e x i s t e n c e . The l e a s t e f f i c i e n t aspect of the system i s the Formulary maintenance. I t i s a heavy a d m i n i s t r a t i v e workload. The Committee must r e l y upon research from Ottawa, the Ontario Government and the Saskatchewan Government. I t means r e v i s i o n s to the formulary on a r e g u l a r b a s i s . The Formulary Committee does not have l e g i s l a t i o n to support i t and the l e g a l s t a t u s of i t s d e c i s i o n to i n c l u d e or exclude a drug i s u n c e r t a i n . L e g i s l a t i o n w i l l be d r a f t e d , however, but u n t i l that time, the s i t u a t i o n i s un c l e a r . In c o n c l u s i o n , though, i t s m e r i t s l e a d i n g toward more r a t i o n a l p r e s c r i b i n g , f a r outweigh the heavy a d m i n i s t r a t i v e burden. The ex i s t e n c e of the formulary f o r nursing s t a t i o n s has permitted b e t t e r scheduling of drug a d m i n i s t r a t i o n and eased the l o g i s t i c problem of d i s t r i b u t i o n p r e v i o u s l y i n e x i s t e n c e . The c e n t r a l i z a t i o n of one body n e g o t i a t i n g the r a t e s and dis p e n s i n g fees f o r a l l three agencies removes the p o s s i b i l i t y of p l a y i n g one 92 agency against another. I d e o l o g i c a l "The program should b e n e f i t e s p e c i a l l y those w i t h the greatest drug co s t s and the l e a s t f i n a n c i a l a b i l i t y to pay those c o s t s . " The program has met the o b j e c t i v e of the t r a n s f e r of wealth to another s p e c i f i c group i n s o c i e t y , r e s i d e n t s s i x t y - f i v e years of age and over. I t d i d not, nor was i t the mandate of the p r o j e c t to do so, to r e s o l v e the problem of double standard that e x i s t s due to funding agencies. A l l Treaty Indian and I n u i t r e c e i v e a l l p r e s c r i p t i o n drugs i n the Formulary as a f r e e b e n e f i t . "Other" st a t u s people must pay unless they are Indigent, or over s i x t y - f i v e years of age or have one of the twelve s p e c i f i c i l l n e s s e s . On the b a s i s of the agreed o b j e c t i v e s and the a d m i n i s t r a t i v e problems to be solved the p r o j e c t was an u n q u a l i f i e d success. I t i s f u n c t i o n a l , e f f i c i e n t , s i m p l i s t i c and i s r e c e i v e d w e l l by the p u b l i c and the p r o f e s s i o n a l s , E x t e n t i o n of P r i n c i p l e s The planning method and the f i n a l system design i s such that the p r i n c i p l e s can be extended to other j u r i s d i c t i o n s and even other f i e l d s of insured b e n e f i t s . Other j u r i s d i c t i o n s of s i z e s up to 500,000 would be able 93 to i n c o r p o r a t e the system as i s w i t h the c o n f i r m a t i o n of one item, that being the p r i c e of the drug i n g r e d i e n t s . Once above the l i n e of 500,000 i t would be necessary to modify the data entry to r e c e i v e submissions from computer tapes or employ a l a r g e number of keypunch operators. The system i s designed such that any j u r i s d i c t i o n could use i t once they ha-ve i d e n t i f i e d the b e n e f i c i a r i e s . While the a p p l i c a t i o n of the system i n t h i s i nstance was a Pharmacare program, i t could w e l l have been a d e n t i c a r e or medical care program. The u n d e r l y i n g p r i n c i p l e i s the q u a n t i f i c a t i o n and numerical d e f i n i t i o n of a procedure. Using the example of d e n t i c a r e , one would only have to define each procedure, then code i t and p r i c e i t . The codes and p r i c e s and r e l e v a n t assessment r u l e s could be entered i n a matter of hours and the system o p e r a t i o n a l . Fundamental p r i n c i p l e s may a l s o be a p p l i e d elsewhere. The c l a i m in-process c y c l e was a p p l i e d to the Medical Care, H o s p i t a l Care and P u b l i c Health Information as part of the new Health Information System designed by the Department of Health i n 1979. I t i s being a p p l i e d to a computerized system f o r r e c o r d i n g court cases and t h e i r completion. The use of a data base system has been a p p l i e d to the Health Information System of the Department of Health as w e l l but i s e q u a l l y v i a b l e f o r any system that must st o r e a l o t of data, however, only r e q u i r e b i t s and pieces when r e t r i e v i n g . For example, a student record system or a r e n t a l 94 accommodation system. The Pharmacare p r o j e c t B e n e f i t e d not only the Department of Health but al s o the whole h e a l t h f i e l d i n Canada because from that system were t r a n s f e r r e d the p r i n c i p l e s that make the new Northwest T e r r i t o r i e s Health Information System (implemented A p r i l 1, 1980) the most comprehensive and i n t e g r a t e d i n Canada. 95 ENDNOTES Canada, Royal Commission on Health S e r v i c e s , V o l . 1, J u s t i c e Emmett H a l l , Chairman (Ottawa: Queen's P r i n t e r , 1964), pp. 41 - 45. Br i a n Abel-Smith, "The H i s t o r y of M e d i c a l Care" i n Comparative Development i n S o c i a l Welfare ed. E.W. M a r t i n (London: George A l l e n and Unwin 1972). 3 Canada, (Heagarty) Health Insurance. Report of the Advisory Committee on Health Insurance, Ottawa: King's P r i n t e r , 1943. 4 Personal i n t e r v i e w w i t h Peter Ruderman, J u l y 15, 1980. ^ Ronald W. Lang, The P o l i t i c s of Drugs, (Lexington, Massachusetts: Saxon House/Lexington Books, 1974) p. 4. ^ Lang, p. 13. ^ Lang, p. 129. g Canada House of Commons, S p e c i a l Committee on Drug Costs  and Drug P r i c e s by Harry C. Harley (Ottawa: Queen's P r i n t e r 1967) p. 9. 9 Canada House of Commons, p. 51. ^ Personal i n t e r v i e w w i t h Peter Ruderman, J u l y 15, 1980. ^ Lang, pp. 25 - 27. 12 Eugene Vayda, "Use of Medications: A Growing Concern" Canadian-Medical A s s o c i a t i o n J o u r n a l , CXIV (February 21, 1976), p. 287. 96 13 Alexander R.P. Walker, "Too Many P i l l s " , Canadian Medical A s s o c i a t i o n J o u r n a l CXV (September 4, 1976), p. 382. Maurice L e C l a i r "The Canadian Health Care System" i n N a t i o n a l Health Insurance: Can We Learn from Canada? ed. Spyros Andecopolous (New York: John Wiley & Sons, Inc., 1975) pp. 28 - 34. ^ Canada, Royal Commission on Health S e r v i c e s , p. 16 Harold J . Segal, "Changes i n Pharmacy P r a c t i c e : Ontario's PARCOST Program", Canadian Pharmaceutical J o u r n a l , 106 (November, 1973) pp. 1 6 - 2 1 . ^ N e i l G i l b e r t , Harry Specht, Dimension of S o c i a l Welfare  P o l i c y , (Englewood C l i f f , New Jersey, P r e n t i c e - H a l l 1974) pp. 185 - 199. 18 A m i t a i E t z i o n i , "Mixed Scanning: A 'Third' Approach to D e c i s i o n Making", A Reader i n Planning Theory ed. Andreas F a l u d i (Toronto: Pergammon Press, 1973) pp. 217 - 229. 19 Harry E c k s t e i n , "Planning: The N a t i o n a l Health S e r v i c e " P o l i c y Making i n B r i t a i n ed. Richard Rose (MacMillan and Co., 1969) pp. 225 - 237. 20 Thomas L. H a l l , "The P o l i t i c a l Aspects of Health P l a n n i n g " Health Planning Q u a l i t a t i v e Aspects and Q u a n t i t a t i v e Techniques ed. W i l l i a m A. Reinke (Baltimore: Waverly Press, 1974) pp. 73 - 95. 21 T.R. Marmor, The P o l i t i c s of Medicare (Chicago: A l d i n e P u b l i s h i n g 1973) pp. 97 - 106. 22 Charles E. Lindbloom, "The Science of 'Muddling Through'", A Reader i n Planning Theory, ed. Andreas F a l u d i (Toronto: Pergammon Press, 1973, pp. 151 - 170). 97 23 C a r l E. T a y l o r , "Stages i n the Planning Process" Health Planning Q u a l i t a t i v e Aspects and Q u a n t i t a t i v e Techniques ed. W i l l i a m A. Reinke (Baltimore: Waverly Press, 1974) pp, 2Q - 34. W i l l i a m A. Reinke "Overview of the Planning Process" Health Planning Q u a l i t a t i v e Aspects and Q u a n t i t a t i v e Techniques, ed. W i l l i a m A. Reinke (Baltimore: Waverly P r e s s , 1974) pp. 53 - 72. 25 Andreas F a l u d i , A Reader i n Planning Theory (Toronto: Pergammon Press, 1973) pp. 231 - 297. 26 Henrik L. Blum, Planning For H e a l t h , (New York: Human Sciences Press, 1974) pp. 1 5 - 3 7 . 27 Lang, pp. 19 - 52. 28 R.G. Evans, M.F. Williamso n , Extending Canadian Health Insurance: Options f o r Pharmacare and D e r i t i c a r e , (Toronto: U n i v e r s i t y of Toronto Press, 1978) pp. 61 - 107. 29 U.S. Department of He a l t h , Education and Welfare, O f f i c e of the Secretary, Task Force on P r e s c r i p t i o n Drugs, Current American and Foreign Programs (Washington, D.C: U.S. Government P r i n t i n g O f f i c e , 1968). 30 C. M u l l e r , "Drug B e n e f i t s i n Health Insurance", I n t e r n a t i o n a l J o u r n a l of Health Science 4 (No. 1, 1974): 157 - 170. 31 Nancy Mclver and D.A. Manore, " T h i r d P a r t y Programs Across Canada", Canadian Pharmaceutical J o u r n a l 108 (March, 1975): 19 - 22. 32 D. A. Manore, "T h i r d P a r t y Payment Programs from East to West", Canadian Pharmaceutical J o u r n a l 109 (March, 1976): 15 - 18. 33 H.J.F. Gerein, Community Planning arid Development i n  Canada's Northwest T e r r i t o r i e s , ( Y e l l o w k n i f e : Government of the Northwest T e r r i t o r i e s , 1980) p. 15. 98 34 Northwest T e r r i t o r i e s Act, Revised Ordinances of the  Northwest T e r r i t o r i e s , (Ottawa: Queen's P r i n t e r , 1974) Se c t i o n 2, a and b. 35 Northwest T e r r i t o r i e s , Department of Planning and Program E v a l u a t i o n , P o p u l a t i o n Estimates, ( Y e l l o w k n i f e : Government of the Northwest T e r r i t o r i e s 1979) p. 26. 36 „ Gerem, p. 41. 37 Northwest T e r r i t o r i e s , Department o f Economic Development and Tourism, E x p l o r e r ' s Guide ( Y e l l o w k n i f e : Government of the Northwest T e r r i t o r i e s , 1980) p. 71. 3 8 Gerein, p. 20. 39 Northwest T e r r i t o r i e s , Department of Planning and Program E v a l u a t i o n , p. 26. 40 „ . . . . e Gerein, p. 45. Gerein, p. 45. 42 Northwest T e r r i t o r i e s , Department of Planning and Program E v a l u a t i o n , p. 26. 43 Northwest T e r r i t o r i e s , Department of Health , " R e g i s t r a t i o n F i l e , 1979", unpublished. 44 Northwest T e r r i t o r i e s , Department of He a l t h , "Med 730 S e r i e s " unpublished. 45 M u l l e r , p. 158. 46 B r i t i s h Columbia, M i n i s t r y of Human Resources, unpublished notes by P. T i d b a l l . 47 Correspondence, M i n i s t e r of Human Resource's to a l l e l i g i b l e r e s i d e n t s , October 15, 1973. 99 ^ B r i t i s h Columbia, Department of Human Resources " U n i v e r s a l Pharmacare" news r e l e a s e , Nanaimo: May 12, 1977. 49 B r i t i s h Columbia, Department of Human Resources, " U n i v e r s a l Pharmacare", p. 2. ^ B r i t i s h Columbia, M i n i s t r y of Human Resources, unpublished notes by P. T i d b a l l . B r i t i s h Columbia, P. T i d b a l l , unpublished notes. 52 B r i t i s h Columbia, M i n i s t r y of Human Resources, l e t t e r to p h y s i c i a n s , May 12, 1977. 53 B r i t i s h Columbia, P. T i d b a l l , unpublished notes. 5 ^ D.A. Manore, "Third P a r t y Programs from East t o West" Canadian Pharmaceutical J o u r n a l 109 (March, 1976): p. 17. 55 Saskatchewan, Department of Health , Formulary (Regina: Government P r i n t e r s , 1980) p.v. 56 Saskatchewan, Department of Health, Annual Report 1975 - 76 of the Saskatchewan P r e s c r i p t i o n Drug P l a n , p. 8. Saskatchewan, Formulary, p. i x . 58 Saskatchewan, Formulary, p. i x . 59 Saskatchewan, Department of Health, Annual Report 1975-76 of the Saskatchewan P r e s c r i p t i o n Drug P l a n , p. 9. 60 Ontari o , Drug B e n e f i t s , (n.p.n.p. 1976), p. 6. 61 Ontari o , M i n i s t r y of Health , Drug B e n e f i t s Formulary, No. 13 (Toronto: Queen's P r i n t e r , 1980) p.v. 6 2 Ont a r i o , Drug B e n e f i t s , p. 7 Ontario, Drug B e n e f i t Formulary, p.v. 64 Ontari o , Drug B e n e f i t s , p. 11. ^ On t a r i o , Drug B e n e f i t s , p. 6. 100 66 Ontario, Drug B e n e f i t s Formulary, p. v i . ^ Ontar i o , Drug B e n e f i t s , p. 12 68 M. Bryce and A s s o c i a t e s , P r o f i t a b l e Information by Design, (n.p. n.p. 1976). 69 Harry E c k s t e i n , p. 226. ^ A m i t a i E t z i o n i , p. 224. 7 1 Karen Anne Adamson, Dorothy L. Smith, " N o n - P r e s c r i p t i o n Drugs and The E l d e r l y P a t i e n t " , Canadian Pharmaceutical J o u r n a l (March, 1978): 4 - 9 . 72 L. Barer, R.G. Evans, G. Stoddart, C o n t r o l l i n g H e a l t h Care Costs by D i r e c t Charges to P a t i e n t s : Snare or Delusions, (Toronto: Ontario Economic C o u n t i l , 1979). 73 Evans, pp 47 - 49. 74 Robin F. Badgley, R. David Smith, User Charges f o r Health  Services,(Toronto: Ontario C o u n c i l of H e a l t h , 1979). ^ Lee Soderstrom, The Canadian Health System (London: Croom Helm L t d . , 1978), pp. 174 - 184. 101 BIBLIOGRAPHY Abel-Smith, B r i a n . "The H i s t o r y of Medical Care i n Comparative Development i n S o c i a l Welfare. Ed. E.W. M a r t i n . London: George A l l e n and Unwin, 1972,pp. 228 - 229. Adamson, Karen Anne and Dorothy L. Smith. " N o n - P r e s c r i p t i o n Drugs and the E l d e r l y P a t i e n t " Canadian Pharmaceutical J o u r n a l , March (1978) pp. 4 - 9. Badgley, Robin F. and David Smith. User Charges f o r Health S e r v i c e s . Toronto: Ontario C o u n c i l of He a l t h , 1979. Barer L., R.G. Evans and G. Stoddart. C o n t r o l l i n g H e alth Care Costs by D i r e c t Charges to P a t i e n t s : Snare or Del u s i o n. Toronto: Ontario Economic C o u n t i l 1979. Blum, Henrick. Planning f o r Health. New York: Human Sciences Press, 1974. pp. 15 - 37. B r i t i s h Columbia. M i n i s t r y of Human Resources, Correspondence to a l l E l i g i b l e Residents, October 15, 1973. B r i t i s h Columbia. M i n i s t r y of Human Resources, Correspondence to a l l P h y s i c i a n s , May 12, 1977. B r i t i s h Columbia. M i n i s t r y of Human Resources, Pharmacare Program, unpublished notes, P. T i d b a l l . B r i t i s h Columbia. M i n i s t r y of Human Resources, news rel e a s e " U n i v e r s a l Pharmacare", Nanimo, May 12, 1977. Bryce, M. and A s s o c i a t e s , P r o f i t a b l e Information by Design, n.p. n.p. 1976. 102 B i b l i o g r a p h y Canada, House of Commons, S p e c i a l Committee on Drug Costs and Drug P r i c e s , Harry C. Harley, Ottawa: Queen's P r i n t e r , 1967, p. 9. Canada, Royal Commission on Health S e r v i c e s , J u s t i c e Emmett H a l l , Chairman, V o l . 1. Ottawa: Queen's P r i n t e r , 1964. pp. 4 1 - 4 5 . E c k s t e i n , Harry. "Planning: The N a t i o n a l Health S e r v i c e " , P o l i c y Making i n B r i t a i n . Ed. Richard Rose, MacMillan and Company, 1969, pp. 225 - 237. E t z i o n i , A m i t a i . "Mixed Scanning: A 'Third' Approach to D e c i s i o n Making", A Reader i n P l a n n i n g Theory. Ed. Andreas F a l u d i , Toronto: Pergammon Press, 1973. pp. 217 - 219. Evans, R.G. and M.F. Williamson, Extending Canadian Health Insurance: Options f o r Pharmacare and Denticare, Toronto: U n i v e r s i t y of Toronto P r e s s , 1978. F a l u d i , Andreas. A Reader i n Planning Theory, Toronto: Pergammon Press. 1974. Gerein, H.J.F. Community Planning and Development i n Canada's Northwest T e r r i t o r i e s . Y e l l o w k n i f e : Government of the Northwest T e r r i t o r i e s . 1980. G i l b e r t , N e i l and Harry Specht, Dimensions of S o c i a l Welfare P o l i c y , Englewood C l i f f , New Jersey: P r e n t i c e - H a l l , 1974. H a l l , Thomas L. "The P o l i t i c a l Aspects of Health P l a n n i n g " Health Planning: Q u a l i t a t i v e Aspects and Q u a n t i t a t i v e Techniques. Ed. W i l l i a m A. Reinke. Baltimore: Waverley Press, 1974. pp. 73 - 95. 1 0 3 Bibliography Lang, Ronald W. The P o l i t i c s of Drugs. Lexington, Massachusetts: Saxon House/Lexington Books, 1974. L e C l a i r , Maurice. "The Canadian Health Care System" i n National Health Insurance: Can We Learn From Canada? Ed. Spyros Andreopolous. New York: John Wiley and Sons Inc. 1975, pp. 28 - 34. Lindblom, Charles E. "The Science of Muddling Through" i n A Reader i n Planning Theory. Ed. Andreas F a l u d i . Toronto: Pergammon Press, 1973. Manore, D.A. "Third Party Payment Programs from East to West" Canadian Pharmaceutical Journal, 109 March (1976), pp. 15 - 18. Marmor, T.R. The P o l i t i c s of Medicare. Chicago: Aldine Publishing, 1973, pp. 97 - 106. Mclver, Nancy and D.A. Manore, "Third Party Programs Across Canada", Canadian Pharmaceutical Journal 108, March (1975), pp. 19 - 22. Muller, C. "Drug Benefits i n Health Insurance", International Journal of Health Science 4 (No. 1 1974), pp. 157 - 170. Northwest T e r r i t o r i e s , Revised Ordinances of the Northwest T e r r i t o r i e s , Ottawa: Queen's P r i n t e r , 1974. Northwest T e r r i t o r i e s , Department of Economic Development and Tourism, Explorer's Guide, Yellowknife: Government of the Northwest T e r r i t o r i e s . 1980. 104 B i b l i o g r a p h y Northwest T e r r i t o r i e s , Department of Healt h , " R e g i s t r a t i o n F i l e Reports 1979, n.p. Northwest T e r r i t o r i e s , Department of Healt h , "Med. 730 Report Se r i e s 1979, n.p. Northwest T e r r i t o r i e s , Department of Planning and Program E v a l u a t i o n , P o p u l a t i o n Estimates, Y e l l o w k n i f e : Government of the Northwest T e r r i t o r i e s , 19 79. Ontari o , M i n i s t r y of Heal t h , Drug B e n e f i t s , Toronto: Queen's P r i n t e r , 1976. Ontario, M i n i s t r y of Health, Drug B e n e f i t s Formulary, Toronto: Queen's P r i n t e r , 1980. Reinke, W i l l i a m A. "Overview of the Planning Process" i n Health P l a n n i n g : Q u a l i t a t i v e Aspects and Q u a n t i t a t i v e Techniques. Ed. W i l l i a m A. Reinke, Baltimore: Waverley Press, 1974. Saskatchewan, Department of Healt h , Annual Report 1975 - 76 of the Saskatchewan P r e s c r i p t i o n Drug P l a n . Regina: Government of Saskatchewan. Saskatchewan, Department of Healt h , Formulary. Regina: Government of Saskatchewan, 1980. Segal, Harold J . "Changes i n Pharmacy P r a c t i c e : Ontario's PARCOST Program". Canadian Pharmaceutical J o u r n a l 106 November (1973) pp. 16 - 21. 105 B i b l i o g r a p h y Soderstrom, Lee. The Canadian Health System. London: Croom Helm L t d . 1978, pp. 174 - 184. Taylor, C.E. "Stages i n the P l a n n i n g Process" H e a l t h Planning: Q u a l i t a t i v e Aspects and Q u a n t i t a t i v e Techniques, Ed. W i l l i a m A. Reinke. Baltimore: Waverley Press, 1974. pp. 20 - 34. United S t a t e s , Department of H e a l t h , Education and Welfare, O f f i c e of the Secretary, Task Force on P r e s c r i p t i o n Drugs, Current American and Foreign Programs, Washington, D.C: U.S. Government P r i n t i n g O f f i c e , 1968. Vayda, :Eugene, "Use of Medications: A Growing Concern", Canadian M e d i c a l A s s o c i a t i o n J o u r n a l , CXIV February 21, 1976. Walker, Alexander R.P. "Too Many P i l l s " Canadian Medical  A s s o c i a t i o n J o u r n a l , CXV September 4, 1976. 106 APPENDIX A REPORTS SEQUENCED BY RECIPIENT AND FUNCTIONAL AREA P a t i e n t R e g i s t r a t i o n P r o c e s s i n g A n a l y s i s none cheque S t a t e m e n t of A c c o u n t P r e s c r i p t i o n V a l i d a t i o n S t a t e m e n t P r e s c r i b e r R e g i s t r a t i o n P r o c e s s i n g A n a l y s i s F o r m u l a r y none none D i s p e n s e r R e g i s t r a t i o n P r o c e s s i n g A n a l y s i s F o r m u l a r y cheque S t a t e m e n t of A c c o u n t Drug C o s t V a l i d a t i o n R e p o r t D epa rtme n t of H e a l t h D i r e c t o r - R e g i s t r a t i o n - P r o c e s s i n g - A n a l y s i s none none P h a r m a c a r e E f f e c t i v e n e s s R e p o r t C h i e f H e a l t h I n s u r a n c e B r a n c h - R e g i s t r a t i o n - P r o c e s s i n g - A n a l y s i s F o r m u l a r y P h a r m a c a r e E l i g i b i l i t y none P r e s c r i b e r P r o f i l e P r e s c r i b e r D e t a i l e d P r o f i l e P r e s c r i p t i o n F r e q u e n c y P r o f i l e D i s p e n s e r P r o f i l e D i s p e n s e r D e t a i l e d P r o f i l e D rug Usage P r o f i l e D r u g Usage D e t a i l e d P r o f i l e Drug C o s t V a l i d a t i o n R e p o r t s Movement P r o f i l e D e m o graphic A n a l y s i s D e t a i l e d D e m o g r a p h i c A n a l y s i s 107 C l a i m s A s s e s s m e n t C l e r k - R e g i s t r a t i o n -- P r o c e s s i n g - A n a l y s i s P a t i e n t E l i g i b i l i t y E r r o r and A u d i t L i s t DIN F o r m u l a r y E r r o r and A u d i t L i s t . B a t c h I m b a l a n c e Update R e p o r t B a t c h I m b a l a n c e E r r o r R e c y c l e C l a i m s In P r o c e s s U p d a t e R e p o r t C l a i m s In P r o c e s s E r r o r R e c y c l e S u p p l e m e n t a l H e a l t h Program E r r o r and A u d i t L i s t S t a t e m e n t of A c c o u n t D e t a i l e d P a t i e n t H i s t o r y P r e s c r i p t i o n V a l i d a t i o n S t a t e -men t Pep artmen t of F i n a n c e - P r o c e s s i n g - Cheque R e g i s t e r 108 REPORT NAME: P r e s c r i p t i o n V a l i d a t i o n S t a t e m e n t PURPOSE: To p r o v i d e T e r r i t o r i a l r e s i d e n t s and t h e D e partment of H e a l t h w i t h a method t o v a l i d a t e t y p e and q u a n t i t y of d r u g s d i s p e n s e d . INFORMATION REQUIREMENTS: A s t a t e m e n t w i l l be p r o d u c e d w h i c h would be f o r w a r d e d t o t h e i n d i v i d u a l d r u g r e c i p i e n t f o r r e v i e w , c o r r e c t i o n i f n e c e s s a r y and r e t u r n to the D e p a r t m e n t o f H e a l t h , i f c o r r e c t e d . T h i s r e p o r t would i n c l u d e : - amount r e i m b u r s e d on b e h a l f of r e c i p i e n t - p a t i e n t name and a d d r e s s - d i s p e n s i n g d a t e - name o f d r u g d i s p e n s e d - q u a n t i t y d i s p e n s e d - name of p r e s c r i b e r - name of pharmacy - p r e s c r i p t i o n v a l i d a t i o n s t a t e m e n t number DISTRIBUTION: To t h e p a t i e n t FREQUENCY: Q u a r t e r l y REMARKS: Copy to the D epartment of H e a l t h , P h a r m a c a r e C l a i m s A s s e s s m e n t C l e r k . 109 REPORT NAME: F o r m u l a r y PURPOSE: To p r o v i d e p h y s i c i a n s , p h a r m a c i s t s , h o s p i t a l s and n u r s i n g s t a t i o n s w i t h i n f o r m a t i o n r e g a r d i n g d r u g s c o v e r e d by t h e P h a r m a c a r e P r o g r a m . INFORMATION REQUIREMENTS: A F o r m u l a r y w i l l be p r o d u c e d i n c l u d i n g t h e f o l l o w i n g i n f o r m a t i on: - t h e r a p e u t i c c l a s s i f i c a t i o n number and name ( i n c l u d e s n a r c o t i c and c o n t r o l l e d d r u g i n d i c a t o r s ) - d r u g i d e n t i f i c a t i o n number - d r u g g e n e r i c name - d r u g s t r e n g t h and d o s a g e - i n t e r c h a n g e a b l e d r u g g r o u p i n d i c a t o r - a c t i v e i n g r e d i e n t names - s t r e n g t h s of a c t i v e i n g r e d i e n t s - d r u g b r a n d name - m a n u f a c t u r e r i d e n t i f i c a t i o n - d a t e o f r e v i s i o n DISTRIBUTION: A l l p h a r m a c i s t s , h o s p i t a l s , n u r s i n g s t a t i o n s , d e n t i s t s and p h y s i c i a n s r e g i s t e r e d w i t h P h a r m a c a r e . FREQUENCY: On demand REMARKS: F o r m a t w i l l be a p h o t o — r e d u c e d t o i n a b i n d e r w i t h c o m p u t e r p r o d u c e d r e p o r t , 8 1/2 X 11 and d i s t r i b u t e d r e p l a c e a b l e p a g e s . H Q REPORT NAME D r u g C o s t V a l i d a t i o n PURPOSE: To r e d u c e t o t a l d r u g c o s t s by i d e n t i f y i n g d i s p e n s e r s s u b s t a n t i a l l y a bove a v e r a g e c o s t s INFORMATION REQUIREMENTS: A r e p o r t w o u l d be p r e p a r e d by p h a r m a c y l i s t i n g a l l DIN's whose a v e r a g e c o s t p e r u n i t d i s p e n s e d by t h i s p a r t i c u l a r p h armacy was s u b s t a n t i a l l y h i g h e r t h a n a v e r a g e c o s t s p e r u n i t a c r o s s a l l p h a r m a c i s t s . ( D r u g s d i s p e n s e d by H o s p i t a l s and N u r s i n g S t a t i o n s w i l l n o t be i n c l u d e d i n c a l c u l a t i o n o f a v e r a g e s . ) The p h a r m a c i s t w i l l be r e q u e s t e d t o v a l i d a t e h i s a c q u i s i t i o n c o s t s f o r t h o s e DIN's s e l e c t e d , by s u b m i t t i n g c o p i e s o f h i s p u r c h a s i n g i n v o i c e s t o t h e D e p a r t m e n t o f H e a l t h . The r e p o r t - pharmacy - D I N w o u l d name , l i s t : a d d r e s s numb e r DISTRIBUTION: To t h e P h a r m a c y s e l e c t e d FREQUENCY: Quar t e r l y REMARKS: Copy t o t h e D e p a r t m e n t o f H e a l t h I l l REPORT NAME: S t a t e m e n t of A c c o u n t and Cheques PURPOSE: To r e i m b u r s e d r u g d i s p e n s e r s f o r d r u g c o s t s and d i s p e n s i n g f e e s c o v e r e d by t h e P h a r m a c a r e P l a n , and t o r e i m b u r s e e l i g i b l e T e r r i t o r i a l r e s i d e n t s f o r e l i g i b l e d r u g s p u r c h a s e d d i r e c t l y by them. INFORMATION REQUIREMENTS: A payment a d v i c e i s p r o d u c e d f o r any c l a i m s s u b m i t t e d t o P h a r m a c a r e . F o r c l a i m s r e s u l t i n g i n payment o f amount c l a i m e d , p a r t i a l payment or a l l p a y m e n t , t h e f o l l o w i n g i n f o r m a t i o n i s p r e p a r e d : - d i s p e n s e r number - c l a i m number - d a t e o f d i s p e n s i n g - p r e s c r i p t i o n number - p a t i e n t r e g i s t r a t i o n number - d r u g i d e n t i f i c a t i o n number - u n i t c o s t - q u a n t i t y - d i s p e n s i n g f e e p a i d - t o t a l c o s t p a i d - a v e r a g e days d u r a t i o n ( d i s p e n s e d t o r e c e i p t t o p a i d ) F o r c l a i m s w h i c h c a n n o t be p r o c e s s e d by P h a r m a c a r e due t o e r r o r s i n s u b m i s s i o n , t h e above i n f o r m a t i o n i s p r i n t e d as c o m p l e t e l y as p o s s i b l e , w i t h i n f o r m a t i o n e n t e r e d i n e r r o r h i g h l i g h t e d w i t h e x p l a n a t i o n s f o r p o s s i b l e r e - s u b m i s s i o n by t h e p h a r m a c i s t . F o r c l a i m s which, a r e u n d e r g o i n g m a n u a l a s s e s s m e n t and have been n e i t h e r r e j e c t e d n o r a p p r o v e d , P h a r m a c a r e , t h e c l a i m number and a s s e s s m e n t r e a s o n a r e l i s t e d . T h i s r e p o r t w i l l e n a b l e t h e p h a r m a c i s t s t o e a s i l y r e c o n c i l e c l a i m s s u b m i t t e d t o P h a r m a c a r e and t o e n s u r e he i s r e c e i v i n g c o m p l e t e and a c c u r a t e r e i m b u r s e m e n t f o r d r u g s d i s p e n s e d . DISTRIBUTION: To o r i g i n a t o r of t h e c l a i m FREQUENCY: W e e k l y 112 REMARKS:. F o r a n i l p a y m e n t , c h e q u e p r i n t i n g i s s u p p r e s s e d and a payment a d v i c e p r o v i d t h e d e t a i l s o f c l a i m s p r o c e s s e d . 113 REPORT NAME: P h a r m a c a r e E f f e c t i v e n e s s PURPOSE: To p r o v i d e t h e s e n i o r management of t h e D e p a r t m e n t o f H e a l t h w i t h i n f o r m a t i o n m e a s u r i n g t h e v o l u m e o f c l a i m s p r o c e s s e d , and m e a s u r e s o f s y s t e m ' s e f f e c t i v e n e s s . INFORMATION REQUIREMENTS: A r e p o r t w o u l d be p r o d u c e d l i s t i n g : - t o t a l number of c l a i m s r e c e i v e d , r e j e c t e d , a p p r o v e d f o r payment - a v e r a g e d u r a t i o n f r o m d a t e o f d i s p e n s i n g , t o r e c e i p t - a v e r a g e d u r a t i o n f r o m r e c e i p t t o d a t e o f payment - number o f T e r r i t o r i a l r e s i d e n t s r e g i s t e r e d w i t h t h e D e p a r t m e n t o f H e a l t h - number and p e r c e n t a g e e l i g i b l e f o r d r u g r e i m b u r s e m e n t v i a e a c h S u p p l e m e n t a l H e a l t h P r o g r a m o r age - p e r c e n t a g e o f above e l i g i b l e r e s i d e n t s s u b m i t t i n g d r u g c l a i m s t h i s month, q u a r t e r and YTD. - p e r c e n t a g e r e j e c t r a t e by e x p l a n a t o r y c o d e . DISTRIBUTION: D i r e c t o r , D e p a r t m e n t o f H e a l t h FREQUENCY: M o n t h l y REMARKS: 114 REPORT NAME: P r e s c r i p t i o n F r e q u e n c y P r o f i l e PURPOSE: To p r o v i d e t h e i n f o r m a t i o n r e q u i r e d t o i d e n t i f y p o t e n t i a l a r e a s o f e x c e s s i v e d r u g u s e . INFORMATION REQUIREMENTS: A r e p o r t w o u l d be p r o d u c e d l i s t i n g a l l p a t i e n t s r e c e i v i n g more t h a n f o u r p r e s c r i p t i o n s i n e i t h e r o f t h e l a s t two q u a r t e r s and t h i s r e p o r t w o u l d i n c l u d e : - d a t e d i s p e n s e d - p a t i e n t name and r e g i s t r a t i o n number, s e t t l e m e n t code - p r e s c r i p t i o n number - new o r r e p e a t p r e s c r i p t i o n - p r e s c r i b e r number - pharmacy number - DIN - q u a n t i t y d i s p e n s e d - ASHP c l a s s i f i c a t i o n - a c t i v e i n g r e d i e n t , s t r e n g t h - d u r a t i o n d a y s - d r u g r e i m b u r s e m e n t e l i g i b i l i t y c o d e DISTRIBUTION: C h i e f , H e a l t h I n s u r a n c e B r a n c h , D e p a r t m e n t o f H e a l t h FREQUENCY: Q u a r t e r l y REMARKS: S p e c i f i c S u p p l e m e n t a r y H e a l t h P r o g r a m s n o t s u b j e c t t o p r e s c r i p t i o n f r e q u e n c y a n a l y s i s . a r e 115 REPORT NAME: Movement P r o f i l e PURPOSE: To i d e n t i f y T e r r i t o r i a l R e s i d e n t movement p a t t e r n s . INFORMATION REQUIREMENTS: A r e p o r t w o u l d be p r o d u c e d s h o w i n g : (a) - d i s p e n s e r name, number - number o f p a t i e n t s p r e s c r i b e d t o ( o r p r e s c r i p t i o n s ) by s e t t l e m e n t code ( a ) - s e t t l e m e n t c o d e , d e s c r i p t i o n - number o f p r e s c r i p t i o n s by d i s p e n s e r DISTRIBUTION: C h i e f , H e a l t h I n s u r a n c e B r a n c h , D e p a r t m e n t of H e a l t h FREQUENCY: Q u a r t e r l y REMARKS: 116 REPORT NAME: R e s i d e n t s e l i g i b l e f o r P h a r m a c a r e PURPOSE: To l i s t w h i c h T e r r i t o r i a l r e s i d e n t s a r e e l i g i b l e f o r r e i m b u r s e m e n t of d r u g s u n d e r e a c h o f t h e S u p p l e m e n t a l H e a l t h P r o g r a m s . INFORMATION REQUIREMENTS: A l i s t i n g w i l l be p r o d u c e d i n c l u d i n g t h e f o l l o w i n g i n f o r m a t i - r e g i s t r a t i o n number - s e t t l e m e n t c ode - b i r t h d a t e - e f f e c t i v e d a t e - e x p i r y d a t e - s e x - d r u g r e i m b u r s e m e n t e l i g i b i l i t y code ( s e n i o r c i t i z e n , s u p p l e m e n t a l h e a l t h p r o g r a m , o t h e r ) DISTRIBUTION: D e p a r t m e n t of H e a l t h FREQUENCY: On demand REMARKS: 117 REPORT NAME D i s p e n s e r P r o f i l e PURPOSE: To p r o v i d e management o f t h e D e p a r t m e n t o f H e a l t h w i t h t h e i n f o r m a t i o n r e q u i r e d t o manage and c o n t r o l t h e c o s t s and methods of d i s p e n s i n g d r u g s u n d e r t h e P h a r m a c a r e P r o g r a m . INFORMATION REQUIREMENTS: A r e p o r t i s p r o d u c e d t o m o n i t o r p a t t e r n s o f d r u g s d i s p e n s e d ( v o l u m e s and c o s t s ) f o r e a c h d i s p e n s e r ( p h a r m a c i s t , n u r s i n g s t a t i o n , h o s p i t a l , a l l p h a r m a c i s t s ) . T h i s r e p o r t w i l l show i n f o r m a t i o n f o r y e a r - t o - d a t e f o r t h e c u r r e n t y e a r and i n c l u d e t h e f o l l o w i n g : t h e m o nth, p a s t y e a r , q u a r t e r and and w o u l d number o f p r e s c r i p t i o n s number o f p r e s c r i p t i o n s i n i n t e r c h a n g e a b l e g r o u p s number of no s u b s t i t u t e p r e s c r i p t i o n s p e r c e n t a g e no s u b s t i t u t e p r e s c r i p t i o n o f i n t e r c h a n g e a b l e p r e s c r i p t i o n s . d r u g c o s t s d i s p e n s i n g f e e s t o t a l amount p a i d a v e r a g e c o s t p e r p r e s c r i p t i o n DISTRIBUTION: To C h i e f , H e a l t h I n s u r a n c e B r a n c h , D e p a r t m e n t of H e a l t h FREQUENCY: M o n t h l y REMARKS: A d e t a i l e d r e p o r t o f a l l p r e s c r i p t i o n s d i s p e n s e d by a p a r t i c u l a r p h a r m a c i s t o r s t a t i o n c o u l d be p r o d u c e d on demand. 118 REPORT NAME: P r e s c r i b e r P r o f i l e PURPOSE: To p r o v i d e management o f t h e D e p a r t m e n t o f H e a l t h w i t h t h e i n f o r m a t i o n r e q u i r e d t o manage and c o n t r o l t h e c o s t s and methods o f p r e s c r i b i n g d r u g s u n d e r t h e P h a r m a c a r e P r o g r a m . INFORMATION REQUIREMENTS: A r e p o r t i s p r o d u c e d t o m o n i t o r p a t t e r n s o f d r u g s p r e s c r i b e d by p h y s i c i a n s r e g i s t e r e d w i t h t h e D e p a r t m e n t o f H e a l t h P h a r m a c a r e P r o g r a m . T h i s r e p o r t w i l l show i n f o r m a t i o n f o r c u r r e n t m o n t h , q u a r t e r , and y e a r - t o - d a t e , and w o u l d i n c l u d e : * - number o f p r e s c r i p t i o n s - p e r c e n t new - number of p r e s c r i p t i o n s i n i n t e r c h a n g e a b l e g r o u p s - p e r c e n t a g e o f no s u b s t i t u t e p r e s c r i p t i o n s DISTRIBUTION: To C h i e f , H e a l t h I n s u r a n c e B r a n c h , D e p a r t m e n t o f H e a l t h FREQUENCY: M o n t h l y REMARKS: A d e t a i l e d l i s t i n g o f a l l d r u g s p r e s c r i b e d by a p h y s i c i a n c o u l d be p r o d u c e d on demand. 11.9 REPORT NAME: D r u g Usage P r o f i l e PURPOSE: To p r o v i d e management of t h e D e p a r t m e n t o f H e a l t h w i t h i n f o r m a t i o n r e q u i r e d t o manage and c o n t r o l t h e c o s t s and t y p e s o f d r u g s c o v e r e d by t h e P h a r m a c a r e P r o g r a m . INFORMATION REQUIREMENTS: A r e p o r t i s p r o d u c e d t o m o n i t o r v o l u m e s and c o s t s r e s u l t i n g f r o m d r u g u s a g e by T e r r i t o r i a l r e s i d e n t s . I n f o r m a t i o n w i l l be s u m m a r i z e d by D r u g I d e n t i f i c a t i o n Number, as w e l l as T h e r a p e u t i c C l a s s i f i c a t i o n , and w o u l d i n c l u d e : - number of p r e s c r i p t i o n s - p e r c e n t a g e o f new p r e s c r i p t i o n s - p e r c e n t a g e o f n o - s u b s t i t u t e p r e s c r i p t i o n s - t o t a l d r u g c o s t p a i d - a v e r a g e c o s t p e r p r e s c r i p t i o n - number o f u n i t s d i s p e n s e d - a v e r a g e c o s t p e r u n i t d i s p e n s e d DISTRIBUTION: To C h i e f , H e a l t h I n s u r a n c e B r a n c h , D e p a r t m e n t of H e a l t h FREQUENCY M o n t h l y REMARKS A d e t a i l e d l i s t i n g o f a l l p r e s c r i p t i o n s by p r e s c r i b e r f o r a d r u g o r a t h e r a p e u t i c c l a s s i f i c a t i o n c o u l d be p r o d u c e d on demand, i n c l u d i n g r e p o r t s on d r u g s d i s p e n s e d as p a r t o f e a c h o f t h e S u p p l e m e n t a l H e a l t h Programs: o r E x c e p t i o n D r u g S t a t u s . 120 REPORT NAME: Demographic A n a l y s i s PURPOSE: To provide management of the Department of Health with the i n f o r m a t i o n r e q u i r e d to budget and monitor costs a s s o c i a t e d with drugs dispensed under the Pharmacare Program i n each settlement and r e g i o n . T h i s r e p o r t would a l s o permit a n a l y s i s of drug usage p a t t e r n s by t h e r a p e u t i c s u b c l a s s i f i -c a t i o n w i t h i n settlements and r e g i o n s . INFORMATION REQUIREMENTS: A r e p o r t i s produced to monitor costs and volumes of drugs dispensed by settlement and r e g i o n . The r e p o r t w i l l show in f o r m a t i o n f o r the month, q u a r t e r , and year to date, and would i n c l u d e : s - region number - settlement number - t h e r a p e u t i c s u b - c l a s s i f i c a t i o n - number of p r e s c r i p t i o n s - drug cost - d i s p e n s i n g fee - t o t a l cost paid DISTRIBUTION: To C h i e f , Health Insurance Branch, Department of Health FREQUENCY: Monthly REMARKS: A l i s t i n g of drugs dispensed by Drug I d e n t i f i c a t i o n Number could be produced f o r each, settlement or r e g i o n on demand 121 REPORT NAME: R e - S u b m i s s i o n o f R e j e c t s PURPOSE: To p r o v i d e t h e P h a r m a c a r e A s s e s s m e n t C l e r k w i t h t h e i n f o r m a t i o n r e q u i r e d t o m a n u a l l y a s s e s s and c o r r e c t t h e c l a i m s q u e s t i o n e d by t h e P h a r m a c a r e S y s t e m . INFORMATION REQUIREMENTS: F o r e a c h c l a i m q u e s t i o n e d by t h e P h a r m a c a r e S y s t e m , a r e p o r t w i l l be p r o d u c e d w i t h t h e f o l l o w i n g i n f o r m a t i o n : - p h a r m a c i s t number - c l a i m number - d a t e o f d i s p e n s i n g - p r e s c r i p t i o n number - r e g i s t r a t i o n number - p r e s c r i b e r number - q u a n t i t y c l a i m e d - d r u g i d e n t i f i c a t i o n number - u n i t c o s t - d i s p e n s i n g f e e c l a i m e d - t o t a l c o s t c l a i m e d - e x p l a n a t i o n c o d e s d e t a i l i n g r e a s o n s f o r a s s e s s m e n t DISTRIBUTION: P h a r m a c a r e C l a i m s A s s e s s m e n t C l e r k , D e p a r t m e n t o f H e a l t h FREQUENCY: On a r u n b a s i s REMARKS: A d e t a i l e d p a t i e n t h i s t o r y o f c l a i m s p r o c e s s e d can be p r o d u c e d on demand i f r e q u i r e d i n t h e a s s e s s m e n t p r o c e s s . T h i s f i l e w i l l c o n t a i n p r e s c r i p t i o n s f l a g g e d as 101-110% of F o r m u l a r y F i l e C o s t f o r a p r e s c r i p t i o n . 122 APPENDIX B PHARMACARE-SYSTEM LOGIC NARRATIVE The P h a r m a c a r e System i s made up of f i v e sub s y s t e m s , namely: 28- 01 F o r m u l a r y P r i n t 28- 02 M a s t e r F i l e M a i n t e n a n c e 28- 03 E d i t and A s s e s s C l a i m s 28- 04 P a y m e n t s 28- 05 Management R e p o r t s T h e s e sub s y s t e m s a r e i n t e r r e l a t e d t h r o u g h a common D a t a Base c o n s i s t i n g of m a s t e r f i l e s , n a m e l y : FD28010 DIN F o r m u l a r y FD28020 P a t i e n t E l i g i b i l i t y FD28030 S u p p l e m e n t a r y P r o g r a m s FD28040 D r u g H i s t o r y FD28050 P e r f o r m a n c e S t a t s FD28213 B a t c h I m b a l a n c e R e c y c l e FD28214 C l a i m s - I n - P r o c e s s R e c y c l e FD28370 F o r m u l a r y P r i n t FD24003 P a t i e n t R e g i s t r a t i o n FD24004 D o c t o r ( D i s p e n s e r ) R e g i s t r a t i o n FD28035 D i s p e n s e r F e e FD28310 R e f u s e d C l a i m s FD28360 V a l i d C l a i m s DIN F o r m u l a r y c o n t a i n s t h e p e r t i n e n t i n f o r m a t i o n a b o u t t h e DIN's ( D r u g I d e n t i f i c a t i o n Numbers) t h a t a r e e l i g i b l e f o r r e i m b u r s e m e n t as e s t a b l i s h e d by t h e D e p a r t m e n t o f H e a l t h F o r m u l a r y A d v i s o r y C o m m i t t e e , f o r e x a m p l e , t h e a c c e p t e d u n i t c o s t of t h e DIN, r e s t r i c t i o n s o f d i s p e n s i n g , t h e s u p p l e m e n t a r y p r o g r a m s f o r w h i c h r e i m b u r s e m e n t i s e l i g i b l e , e t c . 123 P a t i e n t E l i g i b i l i t y - c o n t a i n s t h e p a t i e n t r e g i s t r a t i o n numbers o f t h o s e p e r s o n s who h a v e been c e r t i f i e d e l i g i b l e f o r d r u g r e i m b u r s e m e n t and t h e p r o g r a m ( s ) and e f f e c t i v e d a t e s o f e l i g i b i l i t y a g a i n s t w h i c h r e i m b u r s e m e n t amounts a r e v a l i d a t e d . S u p p l e m e n t a r y P r o g r a m s - c o n t a i n s t h e p a t i e n t r e g i s t r a t i o n and e f f e c t i v e d a t e s o f e l i g i b i l i t y d u r i n g w h i c h d r u g r e i m b u r s e m e n t i s v a l i d . D r u g H i s t o r y - c o n t a i n s t h e H i s t o r y d a t a w i t h r e s p e c t t o p a t i e n t r e g i s t r a t i o n n u m b e r s , d a t e s , e t c . f o r a l l c l a i m s v a l i d a t e d and p a i d i n t h e s y s t e m . P e r f o r m a n c e S t a t s - c o n t a i n s s y s t e m p e r f o r m a n c e s t a t i s t i c s by week o r day of a l l c l a i m s p r o c e s s e d i n c l u d i n g r e f u s a l s f o r management r e p o r t P h a r m a c a r e P e r f o r m a n c e R e p o r t (OD28422). B a t c h I m b a l a n c e R e c y c l e - c o n t a i n s t h e c l a i m s i n b a t c h e s as t h e y were k e y e d o n t o t h e f i l e w h i c h d i d n o t b a t c h b a l a n c e . T h i s a l l o w s f o r c o r r e c t i o n o f t h e i m b a l a n c e c o n d i t i o n w i t h o u t h a v i n g t o r e k e y t h e e n t i r e b a t c h . C l a i m s - I n - P r o c e s s R e c y c l e - c o n t a i n s t h e c l a i m s w h i c h d i d n o t p a s s t h e e d i t f o r r e a s o n s t h a t a r e p r o b a b l e k e y i n g o r t r a n s c r i p t i o n e r r o r s or a r e p o t e n t i a l d u p l i c a t e s w i t h r e s p e c t t o t h e H i s t o r y F i l e . T h i s a l l o w s f o r c o r r e c t i n g an 124 i n d i v i d u a l c l a i m w i t h o u t h a v i n g t o r e f u s e i t and r e - e n t e r i t . R e f u s e d C l a i m s - c o n t a i n s a l l c l a i m s t o be r e f u s e d on t h e S t a t e m e n t o f A c c o u n t . V a l i d C l a i m s - c o n t a i n s a l l c l a i m s v a l i d a t e d and t o be r e i m b u r s e d on t h e S t a t e m e n t o f A c c o u n t . F o r m u l a r y P r i n t - c o n t a i n s t h e p r i n t a b l e F o r m u l a r y , a w o r d - p r o c e s s i n g f i l e , w h i c h i s u p d a t e d and p r i n t e d f o r r e f e r e n c e p u r p o s e s f o r p r e s c r i b e r s and d i s p e n s e r s . P a t i e n t R e g i s t r a t i o n - c o n t a i n s a l l r e g i s t e r e d r e s i d e n t s o f t h e N.W.T. T h i s f i l e i s r e f e r e n c e o n l y and i s m a i n t a i n e d i n t h e MEDICARE S y s t e m . D o c t o r ( D i s p e n s e r ) - c o n t a i n s a l l t h e r e g i s t e r e d d o c t o r s , d e n t i s t s , n u r s i n g s t a t i o n s , and d i s p e n s e r s f o r t h e N.W.T. T h i s f i l e i s r e f e r e n c e o n l y and i s m a i n t a i n e d i n t h e MEDICARE S y s t e m . D i s p e n s e r Fee F i l e - c o n t a i n s d e t a i l s on d i s p e n s i n g f e e f o r e a c h p h armacy as a f i x e d f o l i a r amount p e r p r e s c r i p t i o n , ( e g . $ 3 . 9 5 ) , a m a t e r i a l c o s t u p g r a d e p e r c e n t a g e , ( e g . a d d i t i o n a l 10% f o r I n u v i k ) , o r a p e r c e n t a g e , ( e g . f o r OTC's). 125 Due t o t h e c o n f i d e n t i a l n a t u r e o f s e v e r a l r e p o r t s , t h e d a t a w i l l be p r i n t e d and e n t e r e d a t t h e D e p a r t m e n t of H e a l t h by a u t h o r i z e d p e r s o n n e l o n l y v i a a t e r m i n a l . The I n p u t s t o t h e s y s t e m c o n s i s t o f I D 2 8 0 0 1 DIN F o r m u l a r y ACD ( A d d , Change ID28002 P a t i e n t E l i g i b i l i t y ACD ID28003 S u p p l e m e n t a r y P r o g r a m ACD ID28004 D i s p e n s e r Fee ACD ID28111 New C l a i m s B a t c h H e a d e r ID28112 New C l a i m s Document ID28113 B a t c h I m b a l a n c e ACD ID28114 C l a i m s - I n - P r o c e s s Changes ID28370 F o r m u l a r y P r i n t ACD ID28410 Cut O f f D a t e ID28500 P a r a m e t e r L i s t D e l e t e ) The P h a r m a c a r e P r o g r a m w i l l u t i l i z e t h e c u r r e n t M e d i c a r e r e g i s t r a t i o n p r o c e d u r e s f o r T e r r i t o r i a l r e s i d e n t s , d o c t o r s , h o s p i t a l s and n u r s i n g s t a t i o n s , as w e l l as a d d i t i o n a l p r e s c r i b e r s ( d e n t i s t s ) . P h a r m a c a r e w i l l p r o v i d e f o r r e g i s t r a t i o n o f d r u g d i s p e n s e r s ( p h a r m a c i s t s , n u r s i n g s t a t i o n s and h o s p i t a l s ) . An a d m i n i s t r a t i v e p r o c e d u r e w i l l e n a b l e t h e D e p a r t m e n t o f H e a l t h P h a r m a c a r e A s s e s s m e n t C l e r k t o r e g i s t e r ( I D 2 8 0 0 4 ) new d i s p e n s e r s v i a P h a r m a c a r e ( i n c l u d i n g i n d i v i d u a l d i s p e n s i n g f e e - i n i t i a l s t a n d a r d o f $3.95 - , o r a p e r c e n t a g e u p c h a r g e a l l o w a b l e on d r u g m a t e r i a l c o s t s f o r OTC d r u g s d i s p e n s e d ) and t o u t i l i z e t h e c u r r e n t M e d i c a r e r e g i s t r a t i o n p r o c e d u r e s f o r t h e new p r e s c r i b e r s ( d e n t i s t s ) . I n a d d i t i o n t h e P h a r m a c a r e A s s e s s m e n t C l e r k c a n add D r u g s t o t h e F o r m u l a r y f i l e v i a I D 2 8 0 0 1 b a s e d upon i n s t r u c t i o n s f r o m t h e F o r m u l a r y A d v i s o r y C o m m i t t e e and t h e D i r e c t o r o f t h e D e p a r t m e n t of H e a l t h . S u p p l e m e n t a r y P r o g r a m s 126 can be c o n t r o l l e d v i a ID28003 and t h e P a t i e n t E l i g i b i l i t y f o r t h e SHP v i a ID28002 as d e t a i l e d i n t h e M a s t e r F i l e M a i n t e n a n c e Sub S y s t e m 02. The DIN F o r m u l a r y F i l e ACD ( I D 2 8 0 0 1 ) w i l l a l s o c a u s e t h e p r e p a r a t i o n o f t h e F o r m u l a r y P r i n t ACD ( I D 2 8 3 7 0 ) w h i c h w i l l e n a b l e Sub S y s t e m 01 F o r m u l a r y P r i n t t o p r o d u c e new F o r m u l a r y p a g e s f o r d i s t r i b u -t i o n t o d i s p e n s e r s and p r e s c r i b e r s . D i s p e n s e r s w i l l c o m p l e t e t h e New C l a i m s Document ( I D 2 8 1 1 2 ) and f o r w a r d them f o r r e i m b u r s e m e n t t o t h e D e p a r t m e n t o f H e a l t h w here t h e P h a r m a c a r e A s s e s s m e n t C l e r k c r e a t e s t h e New C l a i m s B a t c h H e a d e r ( I D 2 8 1 1 1 ) and I n p u t s t h e new t r a n s a c t i o n s i n t o t h e s y s t e m v i a a d i s p l a y s t a t i o n . Sub S y s t e m 03 E d i t and A s s e s s C l a i m s w i l l r e f u s e c l a i m s ( F D 2 8 3 1 0 ) , a u t h o r i z e payment ( F D 2 8 3 6 0 ) , and h o l d q u e s t i o n a b l e C l a i m s -I n - P r o c e s s ( F i l e FD28214) f o r c o r r e c t i o n and r e - e n t r y v i a t h e C l a i m s - I n - P r o c e s s c h a n g e s f o r m ( I D 2 8 1 1 4 ) . The P h a r m a c a r e A s s e s s m e n t C l e r k w i l l a c t i v a t e Sub S y s t e m 04 - P a y m e n t s v i a c r e a t i o n o f a C u t O f f D a t e I n p u t Document ( I D 2 8 4 1 0 ) w h i c h w i l l r e s u l t i n c h e q u e s t o d i s p e n s e r s , S t a t e m e n t s o f A c c o u n t t o d i s p e n s e r s and t h e D e p a r t m e n t of H e a l t h , a cheque r e g i s t e r r e p o r t (OD28470) and t a p e (FD28470) t o t h e D e p a r t m e n t of F i n a n c e . A t month end upon c o m p l e t i o n of t h e p a y m e n t s Sub S y s t e m 04, t h e D e p a r t m e n t of H e a l t h w i l l s e l e c t a P a r a m e t e r L i s t ( I D 2 8 5 0 0 ) w h i c h w i l l c a u s e t h e p r i n t i n g o f s e l e c t e d 127 M a n a g e m e n t R e p o r t s i n S u b S y s t e m 128 PHARMACARE - SUB SYSTEM 01 FORMULARY PRINT NARRATIVE The DIN F o r m u l a r y ACD ( I D 2 8 0 0 1 ) w h i c h u p d a t e s t h e DIN F o r m u l a r y F i l e (FD28010) i n t h e M a s t e r F i l e M a i n t e n a n c e Sub S y s t e m w i l l be u s e d t o t r i g g e r t h e c r e a t i o n o f t h e F o r m u l a r y P r i n t ACD ( I D 2 8 3 7 0 ) w h i c h i s u s e d t o u p d a t e t h e F o r m u l a r y P r i n t F i l e ( F D 2 8 3 7 0 ) . The o u t p u t i s t h e F o r m u l a r y B i n d e r of 8 1/2 X 11 pa g e s (OD28350). C o m p l e t e s e t s were p r e p a r e d d u r i n g J u n e , 1 9 7 9 , and d i s t r i b u t e d t o a p p r o p r i a t e d o c t o r s , d e n t i s t s , n u r s i n g s t a t i o n s and h o s p i t a l s ( f o r u s e as a p r e s c r i b e r ) and t o p h a r m a c i s t s , n u r s i n g s t a t i o n s and h o s p i t a l s ( f o r u s e as d i s p e n s e r s ) . S u b s e q u e n t u p d a t e s t o t h e F o r m u l a r y b i n d e r w i l l be p r e p a r e d m o n t h l y on an i n d i v i d u a l page b a s i s as r e q u i r e d . T h e s e c h a n g e d p a g e s ( i n d i c a t i n g d a t e o f r e v i s i o n ) w o u l d t h e n be d i s t r i b u t e d t o F o r m u l a r y b i n d e r h o l d e r s as r e p l a c e m e n t p a g e s . 129 PHARMACARE - SUB SYSTEM 02 MASTER F I L E MAINTENANCE NARRATIVE The p u r p o s e of t h i s sub sys t e m i s to m a i n t a i n t h e c u r r e n c y of t h e v a r i o u s m a s t e r f i l e s u s e d by t h e PHARMACARE s y s t e m . E s s e n t i a l l y t h r e e m a i n t e n a n c e p r o c e d u r e s f o r each m a s t e r f i l e a r e p e r m i s s a b l e , namely: ( i ) a d d i n g a new r e c o r d to t h e f i l e b e i n g u p d a t e d , ( i i ) c h a n g i n g s p e c i f i c d a t a e l e m e n t s of a s p e c i f i c r e c o r d or t h e f i l e b e i n g u p d a t e d and, ( i i i ) d e l e t i n g an e x i s t i n g r e c o r d f r o m t h e f i l e b e i n g u p d a t e d . Note : A d e l e t e c o n s i s t s of t e r m i n a t i n g a r e c o r d f r o m b e i n g v a l i d by d a t e c o n t r o l as opposed to p h y s i c a l l y d e l e t i n g the r e c o r d f r o m t h e f i l e . The f i l e s t h a t a r e m a i n t a i n e d i n t h i s sub s y s t e m a r e : 13Q ( i ) DIN f o r m u l a r y F i l e ( F D 2 8 0 1 0 ) , ( i i ) S u p p l e m e n t a r y P r o g r a m F i l e ( F D 2 8 0 3 0 ) , ( i i i ) P a t i e n t E l i g i b i l i t y F i l e ( F D 2 8 0 2 0 ) , and ( i v ) D i s p e n s e r Fee F i l e ( D 2 8 0 3 5 ) . DIN F o r m u l a r y F i l e : c o n t a i n s t h e p e r t i n e n t I n f o r m a t i o n a b o u t a l l t h e DIN's ( D r u g I d e n t i f i c a t i o n Numbers) t h a t a r e e l i g i b l e f o r r e i m b u r s e m e n t u n d e r t h e PHARMACARE P r o g r a m . S u p p l e m e n t a r y P r o g r a m F i l e : c o n t a i n s t h e p r o g r a m s ; eg, S e n i o r C i t i z e n s , D i a b e t e s , e t c . , t h a t a r e e l i g i b l e f o r d r u g r e i m b u r s ement. P a t i e n t E l i g i b i l i t y F i l e : c o n t a i n s t h e p a t i e n t r e g i s t r a t i o n numbers of t h e p a t i e n t s who a r e e l i g i b l e f o r r e i m b u r s e m e n t , t h e p r o g r a m ( s ) f o r w h i c h t h e y a r e e l i g i b l e and t h e t i m e p e r i o d f o r w h i c h t h e e l i g i b i l i t y i s v a l i d . D i s p e n s e r Fee F i l e : c o n t a i n s i n f o r m a t i o n on t h e s t a n d a r d d i s p e n s i n g f e e f o r e a c h d i s p e n s e r ( i n i t i a l l y a l l $3.95) a n d / o r p e r c e n t a g e u p c h a r g e a l l o w e d on OTC d r u g s as a p r e s c r i p t i o n f e e , and t h e p e r c e n t a g e u p c h a r g e a l l o w e d on a l l d r u g a c q u i s i t i o n c o s t s ( i n i t i a l l y I n u v i k o n l y a t + 8 % ) . The i n p u t s t o t h e M a s t e r F i l e M a i n t e n a n c e Sub S y s t e m o r i g i n a t e as f o l l o w s : DIN F o r m u l a r y ACD ( I D 2 8 0 0 1 ) p r e p a r e d by t h e A s s e s s m e n t C l e r k upon i n s t r u c t i o n s f r o m t h e D i r e c t o r o f 131 H e a l t h , i n t u r n b a s e d upon r e c o m m e n d a t i o n s o f t h e F o r m u l a r y A d v i s o r y C o m m i t t e e . P a t i e n t E l i g i b i l i t y ACD ( I D 2 8 0 0 2 ) p r e p a r e d by t h e A s s e s s m e n t C l e r k t o r e g i s t e r i n d i v i d u a l r e s i d e n t s f o r a S u p p l e m e n t a r y H e a l t h P r o g r a m ( o t h e r t h a n S e n i o r C i t i z e n s w h ere M e d i c a r e d a t e o f b i r t h e n a b l e s e l i g i b i l i t y ) f o r a s p e c i f i c t i m e p e r i o d , or t o r e g i s t e r an i n d i v i d u a l f o r E x c e p t i o n D r u g S t a t u s . A u t h o r i z a t i o n i s b a s e d upon p h y s i c i a n s c e r t i f i c a t i o n t h a t t h e d i s e a s e c o n d i t i o n e x i s t s . S u p p l e m e n t a r y P r o g r a m ACD ( I D 2 8 0 0 3 ) p r e p a r e d by t h e A s s e s s m e n t C l e r k t o add cha n g e o r d e l e t e SHP's upon i n s t r u c t i o n s f r o m t h e D i r e c t o r o f H e a l t h . D i s p e n s e r F e e ACD ( I D 2 8 0 0 4 ) p r e p a r e d by t h e A s s e s s m e n t C l e r k t o m o d i f y d i s p e n s i n g f e e s f o r e a c h d i s p e n s e r b a s e d upon i n s t r u c t i o n s f r o m t h e D i r e c t o r o f H e a l t h . E a c h o f t h e above I n p u t Documents i s v a l i d a t e d a g a i n s t t h e a p p r o p r i a t e m a s t e r f i l e s p r e v i o u s l y n o t e d and O u t p u t Documents r e s u l t t o c o n t r o l t h e v a l i d i t y o f t h e d a t a . T h e s e o u t p u t s go t o t h e A s s e s s m e n t C l e r k : OD28010 OD28020 OD28030 0D28035 DIN F o r m u l a r y E r r o r and A u d i t P a t i e n t E l i g i b i l i t y E r r o r and A u d i t S u p p l e m e n t a r y P r o g r a m E r r o r and A u d i t D i s p e n s e r Fee E r r o r and A u d i t 132 PHARMACARE - SUB SYSTEM 03 EDIT AND ASSESS CLAIMS NARRATIVE The p u r p o s e of t h i s sub s y s t e m i s t o e d i t and a s s e s s c l a i m s s u b m i t t e d f o r r e i m b u r s e m e n t . The c l a i m s a r e c r e a t e d d a i l y by t h e d i s p e n s e r ( I D 2 8 1 1 2 ) and b a t c h e d r e g u l a r l y by t h e A s s e s s m e n t C l e r k ( I D 2 8 1 1 1 ) f o r i n p u t t o t h e s y s t e m and a r e d e t e c t e d and f l a g g e d w i t h t h e a p p r o p r i a t e e r r o r m e s s a g e ( s ) . T h i s a l l o w s t h e A s s e s s m e n t C l e r k t h e o p p o r t u -n i t y t o c o r r e c t w i t h o u t r e s u b m i t t i n g ( r e - k e y i n g ) t h e e n t i r e r e c o r d (OD28113, 0D28114, OD28213, 0D28214, and I D 2 8 1 1 3 , I D 2 8 1 1 4 ) . The e d i t i n g c o n s i s t s of c o m p a r i n g s u b m i t t e d d a t a e l e m e n t s s u c h as (1) p r e s c r i b e r no. t o t h e P r e s c r i b e r ( D o c t o r ) F i l e (FD24004) f o r a m a t c h , (2) t h e DIN number t o t h e DIN F o r m u l a r y F i l e (FD28010) f o r a m a t c h , (3) t h e p a t i e n t r e g i s t r a t i o n no. t o t h e P a t i e n t R e g i s t r a t i o n M s t r (FD24003) f o r a m a t c h as w e l l as t o t h e P a t i e n t E l i g i b i l i t y F i l e (FD24003) t o e n s u r e e l i g i b i l i t y u n d e r a v a l i d s u p p l e m e n t a l p r o g r a m and f i v e s t a n d a r d n u m e r i c a l t y p e d a t e c h e c k s . I f t h e c l a i m i s e d i t e d c l e a n i n a l l c a s e s i t i s t h e n 133 a s s e s s e d . A s s e s s m e n t c o n s i s t s p r i m a r i l y o f v e r i f y i n g t h a t i t i s n o t d u p l i c a t e d i . e . t h a t t h i s c l a i m has n o t b e e n e n t e r e d and p a i d b e f o r e . Two c o n d i t i o n s c o n s t i t u t e a d u p l i c a t e (1) t h a t w i t h i n t h e same week t h e c l a i m has been e n t e r e d t w i c e - d e t e r m i n e d by c o m p a r i n g t o t h e D r u g H i s t o r y F i l e (FD28040) o r (2) t h a t t h e c l a i m a p p e a r s as s u s p e c t i . e . n o t c h a r a c t e r by c h a r a c t e r d u p l i c a t e s b u t s i m i l a r i t i e s b e t w e e n i t and a r e c o r d on t h e D r u g H i s t o r y F i l e (FD28040) w h i c h m i g h t i n d i c a t e f e e s p l i t t i n g . The f i r s t c o n d i t i o n c a u s e s r e f u s a l w h i l e t h e s e c o n d c o n d i t i o n c a u s e s t h e new c l a i m t o be p u t i n t h e P r o c e s s F i l e (FD28214) f o r m a n u a l a s s e s s m e n t . I n P r o c e s s r e c o r d s c a n be " f o r c e d t h r o u g h " w i t h v a l i d f o r c e c o d e s a p pended t o t h e r e c o r d o r c l a i m by t h e a s s e s s -ment c l e r k t o o v e r r i d e c e r t a i n e d i t i n g c o n d i t i o n s w h i c h w o u l d o t h e r w i s e c a u s e r e f u s a l . O u t p u t f r o m t h i s sub s y s t e m i s e s s e n t i a l l y two r e p o r t s C D B a t c h I m b a l a n c e R e c y c l e (0D28213) and (2) C l a i m s I n -P r o c e s s R e c y c l e (.OD28214) w h i c h a c t as c o n t r o l d o c u m e n t s t o f a c i l i t a t e e r r o r r e c y c l i n g . 134 PHARMACARE - SUB SYSTEM 04 PAYMENTS NARRATIVE The p u r p o s e o f t h i s sub s y s t e m i s t o p r o d u c e t h e S t a t e m e n t o f A c c o u n t (OD28300) , Cheque R e g i s t e r (OD28470) , Cheque R e g i s t e r T a p e ( s ) (FD28470) and Cheques (OD28310). A l l e d i t i n g and a s s e s s i n g i s c o m p l e t e d and t h e t e m p o r a r y f i l e s t h a t were c r e a t e d d a i l y as a r e s u l t of SS03 i . e . R e f u s e d C l a i m s ( F D 2 8 3 1 0 ) , V a l i d C l a i m s (FD28360) and t h e C l a i m s - I n - P r o c e s s (FD28214) a r e merged t o p r o d u c e a c o n s o l i d a t e d S t a t e m e n t o f A c c o u n t d e t a i l i n g t h e s t a t u s o f c l a i m s f o r e a c h d i s p e n s e r . A t t h i s s t e p t h e R e f u s e d C l a i m s F i l e i s p u r g e d o r r e i n i t i a l i z e d t o n u l l - f i l e s t a t u s , t h e V a l i d C l a i m s i s p r i n t e d as c h e q u e s , and cheque r e g i s t e r , and a c h e q u e r e g i s t e r t a p e i s c r e a t e d f o r t h e D e p a r t m e n t of F i n a n c e . S u b s e q u e n t l y , t h e V a l i d C l a i m s F i l e i s p u r g e d o r r e i n i t i a l i z e d t o n u l l - f i l e s t a t u s , and t h e C l a i m s - I n - P r o c e s s i s r e t a i n e d f o r e r r o r r e c y c l i n g . P r i o r t o p u r g i n g t h e V a l i d C l a i m s F i l e , t h e s y s t e m c o u l d be e x p a n d e d l a t e r t o i n c l u d e p r i n t i n g s u m m a r i e s o f 135 d r u g c o s t s r e i m b u r s e d f o r e a c h S u p p l e m e n t a r y H e a l t h Program f o r c o s t r e c o v e r y p u r p o s e s ( e g . I n d i a n and Eskimo f r o m th e D e partment of N a t i o n a l H e a l t h and W e l f a r e , I n d i g e n t s f r o m S o c i a l S e r v i c e s e t c . ) . T hese r e p o r t s have n o t been i n c l u d e d as p a r t of t h e c u r r e n t P h a r m a c a r e Program. 136 PHARMACARE - SUB SYSTEM 05 MANAGEMENT REPORTING NARRATIVE The C l a i m s E d i t and A s s e s s m e n t Sub S y s t e m v a l i d a t e s d r u g r e i m b u r s e m e n t c l a i m s and a u t h o r i z e s them f o r payment. T h e s e v a l i d c l a i m s a r e t h e n added t o t h e p a t i e n t D r u g H i s t o r y F i l e w h i c h w i l l c o n t a i n t h e l a s t f i f t e e n t o t w e n t y -s e v e n months h i s t o r y o f d r u g s d i s p e n s e d t o a p a r t i c u l a r p a t i e n t . The p a t i e n t D r u g H i s t o r y F i l e w i l l be u p d a t e d d u r i n g e a c h payment r u n ( w e e k l y ) . E a c h month, a copy o f t h e c u r r e n t p a t i e n t D r u g H i s t o r y F i l e w i l l be t a k e n (FD28040) and r e t a i n e d f o r s u b s e q u e n t e n t r y t o t h e Management R e p o r t i n g Sub S y s t e m 28-05. The D e p a r t m e n t o f H e a l t h w i l l c r e a t e a P a r a m e t e r L i s t ( I D 2 8 5 0 0 ) w h i c h w i l l c o n t r o l t h e s e l e c t i o n and p r i n t i n g o f t h e r e p o r t s d e t a i l e d b e l o w . The P a t i e n t D r u g H i s t o r y F i l e w i l l be s o r t e d i n t o t h e a p p r o p r i a t e s e q u e n c e s , and t h e management r e p o r t s p r o d u c e d as p e r t h e I l l u s t r a t i v e O u t p u t s a t t a c h e d i n a s u b s e q u e n t s e c t i o n of t h i s r e p o r t . The s o r t i n g and p r o c e s s i n g s e q u e n c e s a r e as d e f i n e d i n 137 t h e a t t a c h e d s y s t e m f l o w c h a r t s f o r Sub S y s t e m p a r a m e t e r d e t a i l s f o r e a c h r e p o r t i n c l u d e t h e 28-05. The f o l l o w i n g : 0D28401 - P r e s c r i p t i o n F r e q u e n c y P r o f i l e - p r o v i d e s f o r p r i n t i n g t h e d e t a i l s of p r e s c r i p t i o n s f o r any p a t i e n t r e c e i v i n g more t h a n N ( v a r i a b l e , i n i t i a l a s s u m p t i o n i s 4) p r e s c r i p t i o n s i n a f i s c a l q u a r t e r y e a r . 0D28403 - Movement P r o f i l e s - s u m m a r i z e s a l l p r e s c r i p t i o n s OD28404 w i t h i n a q u a r t e r y e a r by s e t t l e m e n t and d i s p e n s e r , o r by s e t t l e m e n t and p r o g r a m . OD28407 - D i s p e n s e r P r o f i l e s - i f u n u s u a l d i s p e n s i n g OD28409 p a t t e r n s a r e d e t e c t e d as a r e s u l t o f t h e m o n t h l y D i s p e n s e r P r o f i l e (OD28407) summary s t a t i s t i c s o r a n o t h e r management r e p o r t , a d e t a i l e d d i s p e n s e r l i s t i n g (OD28409) c a n be r e q u e s t e d by s p e c i f y i n g d i s p e n s e r number, and b e g i n n i n g and end d a t e s . OD28411 - P r e s c r i b e r P r o f i l e s - I f u n u s u a l p r e s c r i b i n g OD28413 p a t t e r n s a r e d e t e c t e d as a r e s u l t o f t h e m o n t h l y P r e s c r i b e r P r o f i l e (OD28411) summary s t a t i s t i c s o r a n o t h e r management r e p o r t , a d e t a i l e d p r e s c r i b e r p r o f i l e (OD28413) c a n be r e q u e s t e d by s p e c i f y i n g p r e s c r i b e r number and a b e g i n n i n g and end d a t e . 138 0D28415 - D r u g Usage P r o f i l e s - a m o n t h l y D r u g Usage OD28417 P r o f i l e (OD28415) w i l l be p r o d u c e d f o r s e l e c t e d p r e s c r i b e r s , d i s p e n s e r s and e l i g i b i l i t y c o d e s . D e t a i l s on p r e s c r i p t i o n s f o r s p e c i f i c p r e s c r i b e r s , S u p p l e m e n t a r y H e a l t h P r o g r a m s , o r D i s p e n s e r s c a n be r e q u e s t e d (0D28417) as r e q u i r e d . OD28419 - D e m o g r a p h i c A n a l y s i s - summary s t a t i s t i c s on OD28420 d e m o g r a p h i c d r u g c o s t s (OD28419) a r e p r o d u c e d on a m o n t h l y b a s i s by t h e r a p e u t i c c l a s s i f i c a t i o n . On demand a l i s t i n g o f p r e s c r i p t i o n d e t a i l s by DIN f o r a s p e c i f i c s e t t l e m e n t f o r a s p e c i f i c t i m e p e r i o d c a n be p r o d u c e d (OD28420). 0D28422 - P h a r m a c a r e P e r f o r m a n c e - i n f o r m a t i o n i s g a t h e r e d f r o m a number of c o m p u t e r p r o c e d u r e s i n t o a p e r f o r m a n c e s t a t i s t i c s f i l e (FD28050) w h i c h i s i n p u t t o t h e s u b j e c t r e p o r t on a m o n t h l y b a s i s . OD28424 - D r u g C o s t V a l i d a t i o n - p h a r m a c i s t s whose a v e r a g e DIN u n i t c o s t s e x c e e d s y s t e m a v e r a g e s by a s p e c i f i e d p e r c e n t a g e w i l l be i d e n t i f i e d f o r a u d i t s of d r u g a c q u i s i t i o n c o s t s . T h i s r e p o r t (0D28424) r e q u e s t s c o p i e s of i n v o i c e s t o v a l i d a t e d r u g c o s t s . 0D28405 - P h a r m a c a r e E l i g i b i l i t y - d e t a i l s p a t i e n t e l i g i b i l i t y 139 f o r e a c h s e t t l e m e n t f o r e a c h SHP. T h i s r e p o r t w i l l i n c l u d e s p e c i a l c o n f i d e n t i a l i t y p r o c e d u r e s . OD28426 - P r e s c r i p t i o n V a l i d a t i o n S t a t e m e n t - r e q u e s t s d r u g r e c i p i e n t s t o v a l i d a t e t h e a c c u r a c y o f r e c e n t d r u g c l a i m s p r o c e s s e d by P h a r m a c a r e . OD28428 - P a t i e n t H i s t o r y D e t a i l - p r o v i d e s t h e D e p a r t m e n t of H e a l t h w i t h p r e s c r i p t i o n d e t a i l s f o r a s p e c i f i c r e s i d e n t . T h i s r e p o r t w i l l i n c l u d e s p e c i a l c o n f i d e n t i a l i t y p r o c e d u r e s . 140 Appendix C Diseases on federal list Diarrhoea of the newborn, epidemic (009.1) Diarrnee epidemique du nouveau-ne DtpMhrrla (0.12) Diphtertr Dvsi'nlrry, luclllary (HIM) Uyi^nlrne liacilldlre Fnccplialim, western equine (062.1) Encephalite equine occidental Food poi^ oninji. bacterial -- Intoxication alimentaire (bacteriennc): (a) Staphylococcal 1005.0) A staphylococci (b) Botulism (0"5.l> Ikuiilismc Hepatitis, infectious (including serum hepatitis) - Hepatite infectieuse (y comptii scriquc): (a) Hepatitis, infectious (070) Hepatite infectieuse (b) Hepatitis, wruni (999.2) Hepatite serique Measles (0S5) Roupeolc Meningitis, isrpiL. due to enteroviruses - Mcninjtitc ascptique a enterovirus: (i) ( ns*:u k i . - vim, CM V0) Due an* virus c«ssackie <l<) I ( I K ) vim* I) Dm- „„* vims I ( I K ) It) NiH tpviihi-il UMViJ) Sims precision Meningococcal infections (036) Infections a meningocoqucs Rubella (German measles) (056) Rubcole Salmonella infections, other - Autrci infections a salmonella: (a) With mention of food as vehicle (003.0) Avec mention de coinage alimentaire (b) Without mention of food as vehicle (003.9) Sans mention de contage alimentaire Streptococcal sore throat and scarlet fever (034) Angine a strep tocoques et tcarlatine Tuberculosis 1010-019) Tuberculose Typhoid and paratyphoid fever - Fievre typhoide et pita typhoide: (a) Typhoid (001) Typhoide (b) Paratyphoid <00I) Para typhoide Whoop1 ing cough (033) Coqueluchc Venrrcal tiiscasrs • M.itLidiet vencrienncs: (iurun KI I'.II in It's lions liif'eciioni Bomicocciiiues: Genitourinary ( I W M . O . 0«H.l) De 1'apparell iemiourinatre Gonococcal miction of eye (098.2) Do I'oeil Other (098.J-0YH.9) Autrcs Syphilis: Congenital (090) Congcnitalc Acquired - Acquire: Farly syphilis symptomatic (091) Syphilis rcccntc symptomatique: Primary (091.0. 091.1) Primuire Secondary (091.2. 091.3) Secondare O I I K - I and unspecified (091.8. 091.9) Autres et sans precision Latent syphilis-1092. mb, 097.1) Syphilis latente Laic vyptulls • S> philis tardive: Cardiovascular sy phili- (093) Syphilis cardio-vasculairc Syphilis ul central nervous system (094) Syphilis ncrvcuse Other foims ol tale syphilis with symptoms 4095) Autrcs formes de syphilis tardive, symptomatique Other and unspecified (097.0, 097.9) Autres et sans precision Chancroid (099.0) Chancre mou Lymphogranuloma venereum (099.1) Lympliopranulomatosc vencrienne Granuloma inguinale (099.2) Granulome inguinal Rare di*«\iscs M.iljilies rare*: AmnclM.iM* |»iW») An.ibL.u-Anthras I I I " ) t I M I I H I H l l r i u c l l o M v lii.'M lltn.cllose ( holitii inoi'K l.oln.i 1 .pro*\ Ul tin I epic M.il.in.1 (OH4) I'.ihiilisme Pb^ne tli.Mli I Y M C Poliomyelitis HWO. 04 3) Poliomyclile Psittacosis (ornithosis) i073) Psittacosc (orrtithose) Rabies (071) Raft-Relapsing lever. Ionse-borne (088.0) Fit-vie recurrenle a poux Rickettsial infections - Rickeltsiosvi: Louse-borne typhus (ORO) Typlius vpidemlquc a poux Rocky Mouituin spotted fever (082.0) Fievre pourprcc des Montajnes Rochcusej . . O-t"even0«1.l> 1-icvreQ Snullpos, t050» Variok-Tetanus(037) Tcldiiot Trichinosis (I 24) Tnchinose luUracmw (0:n Ttil.ircm-ir Yellow levet (060) licvie jaunt SOURCE: Publication #82-201 Annual Report of Not i f i a b l e Diseases 1978 Edi t i o n , S t a t i s t i c s Canada, Ottawa, March 1979, p.9. SOURCE: Northwest T e r r i t o r i e s  Ordinances Queens Pr i n t e r s , Appendix D. Ottawa, 1974 Pharmacy Chap. P-7 CHAPTER P-7 AN ORDINANCE RESPECTING PHARMACY S H O R T T I T L E 1. This Ordinance may be cited as the Pharmacy Ordinance. Shon title R.O.,c.77,s.l; 1964(l»,),c.ll,s.2. I N T E R P R E T A T I O N 2. In this Ordinance Definitions (a) "dentist" means a dentist under the Dental Profession Ordi- -demur nance; (f>) "medical practitioner" means a medical practitioner under •medic»i the Medical Profession Ordinance; pracutioner-(c) "merchant" means a person licensed as a merchant under "merchint" the Business Licence Ordinance or pursuant to a by-law of a municipality established under the Municipal Ordinance; {d) "narcotic" means any substance included in the Schedule to "narcotic-the Narcotic Control Act (Canada) or anything that contains any substance included in that Schedule; (e) "nurse" means a person who is registered under the law of -oune" any province to practise the profession of nursing; (/) "pharmaceutical chemist" means a person who is entitled to "ph«rm«ceutic.i practise the profession of pharmaceutical chemist under this c l l c m i"" Ordinance; (g) "register" means the Pharmaceutical Chemists Register re- -register" ferred to in section 3; (A) "veterinary surgeon" means a veterinary surgeon under the -veterinary Veterinary Profession Ordinance. R.O.,c.77,s.2; luigeon-1960(2,"i),c.7,s.l; 1963(2"d),c.21,s.l; 1964(l"),c.l l,s.3. R E G I S T R A T I O N A N D L I C E N S I N G 3. The Commissioner shall keep a register called the Phar- Pharmaceutical maceutical Chemists Register, and shall enter therein the names, chomu« Register addresses and qualifications of all persons who are, pursuant to this Ordinance, entitled to be registered in the register and he may issue licences to such persons. R.O.,c.77,s.3. 1405 142 Chap. P-7 Pharmacy Qualifications for registration Registration fee Registration certificate Licence fee 4. (1) A person who (a) on the 12th day of December 1953, was entitled by law to practise the profession of pharmaceutical chemist in the Territories, (6) produces to the Commissioner a certificate under the hand of the proper authority that he has the right to practise the profession of pharmaceutical chemist in any province, in the United Kingdom or in any part of Her Majesty's dominions and satisfies the Commissioner that he is the person named in the certificate, and is a suitable person, or (c) is a medical practitioner, and who. pays the fee required by this Ordinance is entitled to be registered in the register. (2) Every person who applies for registration in the register shall, with his application for registration, pay the Commissioner a registra-tion fee of fifty dollars. R.O.,c.77,s.4. 5. The Commissioner may issue a registration certificate in Form A of Schedule E to a person who under section 4 is entitled to be registered in the register and is so registered and the registration certificate shall show that the person is registered. R.O.,c.77,s.5. 6. Every person who is registered in the register shall pay to the Commissioner, at the time his name is entered in the register and subsequently on or before the 31st day of March in each year, an annual licence fee in the sum of ten dollars. R.O.,c.77,s.6. Validity of licence Expiration of licence 7. No licence is valid unless (a) the licence fee in respect of the year for which the licence is issued has been paid, and (b) the holder of the licence has been registered pursuant to section 3. R.O.,c.77,s.7. 8. A licence expires on the 31st day of March next following the day upon which it came into force. R.O.,c.77,s.8. Temporary licence TEMPORARY LICENCES 9. (1) The Commissioner may grant a temporary licence to prac-tise the profession of pharmaceutical chemist for a period specified by the Commissioner not exceeding six months and upon such other terms and conditions as the Commissioner may specify in the licence to any person who (a) produces to the Commissioner a certificate under the hand of the proper authority that he has the right to practise the 1406 143 Pharmacy Chap. P-7 profession of pharmaceutical chemist in any province of Canada, England, Scotland, Northern Ireland, New Zea-land, or Australia and satisfies the Commissioner that he is the person named in the certificate, and is a suitable person; and (b) pays a fee of ten dollars. (2) Notwithstanding anything in this Ordinance, a person who idem holds a temporary licence issued pursuant to subsection (1) may practise the profession of pharmaceutical chemist in the Territories as though he were registered and licensed under this Ordinance subject to the terms and conditions of the said temporary licence and subject to this Ordinance. 1969(2nd),c.24,s.l. PRACTICE OF PHARMACEUTICAL CHEMISTRY 10. Subject to section 18, no person is entitled to practise the Practice limited profession of pharmaceutical chemist nor to recover a fee, reward or {? h n ° ' ^ r a 0 1 remuneration for medicines, materials or appliances provided by him in practising the profession of pharmaceutical chemist unless he holds a licence under this Ordinance at the time the medicines, materials or appliances are provided. R.O.,c.77,s.9. 11. A person who holds a licence is entitled to practise the Licensee-* right profession of pharmaceutical chemist in the Territories and to bring |° j 1 ™^* ^ an action for the recovery of reasonable charges for any medicines, ° o v e r c e s materials or appliances supplied by him. R.O.,c.77,s.lO. OFFENCES AND PENALTIES 12. (1) A person who is not the holder of a licence and who Offences Tor unlicensed (a) publicly or privately for hire, gain or hope of reward prac- practice tises the profession of a pharmaceutical chemist; (b) appends to his name the title pharmaceutical chemist, dis-pensing chemist, druggist, dispensing druggist, or apothe-cary or any word indicative of any such title or uses any substitution or abbreviation thereof; (c) holds himself out in any way to be a duly qualified phar-maceutical chemist; or (d) assumes any title or description implying, or designed to lead the public to believe, that he is duly qualified to practise as a pharmaceutical chemist; is guilty of an offence. (2) A person who violates any provision of this Ordinance is offence and guilty of an offence, and liable on summary conviction to a fine not P e n a i t y 1407 144 .Chap. P-7 Pharmacy Merchant prohibited by Commissioner from selling Schedule C poison Time for prosecution Onus of proof exceeding one hundred dollars or to imprisonment for a term not exceeding six months, or to both fine and imprisonment. (3) Notwithstanding anything in this Ordinance, where a mer-chant is convicted of an offence under this Ordinance, the Commis-sioner may make an order prohibiting that merchant from selling a substance listed or described in Schedule C. R.O.,c.77,s.ll; 1960(2nd),c.7,s.2; 1963(2nd),c21,s.2. 1 3 . In the case of an offence under this Ordinance a complaint shall be made, or the information laid, within one year from the time when the matter of the complaint or information arose. R.O.,c.77,s.l2. 1 4 . In a prosecution for an offence under this Ordinance the onus of proof that the person against whom the charge is laid is the holder of a licence is upon the person against whom the charge is laid. R.O..C.77.S.13. INVESTIGATION AND REMOVAL Removal for non-payment of fees Extension of time Reinstatement 1 5 . (1) Subject to subsection (2), the Commissioner shall remove from the register the name of a person registered therein who fails to comply with the provisions of this Ordinance with respect to licence fees and the licence issued to that person is invalid until such time as he is again registered in the register. (2) Where reasons satisfactory to the "Commissioner are ad-vanced to him as to why the licence fee has not been paid at the required time or within the required period, the Commissioner may grant an extension of time for payment of fees before striking the name of a person off the register but he shall in no case grant an extension of time exceeding sixty days. (3) A person whose name is removed from the register pursuant to subsection (1) is entitled to have his name restored to the register if he pays a fee of ten dollars in addition to the fee in respect of which his name was removed from the register. R.O.,c.77,s.l4. Board of Inquiry Meaning of improper conduct 1 6 . (1) The Commissioner may appoint two or more persons to act as a Board of Inquiry for the purpose of investigating any com-plaint made against a person practising as a pharmaceutical chemist with respect to an alleged contravention of this Ordinance or any complaint or malpractice or infamous, disgraceful or improper con-duct on the part of a person practising as a pharmaceutical chemist. lm-(2) Without restricting the generality of the expression proper conduct" a pharmaceutical chemist is guilty of improper con-duct who 1408 1 4 5 Pharmacy Chap. P-7 (a) is convicted of an offence against an Act of the Parliament of Canada or an Ordinance of the Territories relating to the sale of narcotics; or (b) is shown to be addicted to the excessive use of intoxicating liquors or narcotics. (3) A Board of Inquiry appointed pursuant to subsection (1) may Powers of Board make rules and regulations under which the inquiry is to be held, and has power (a) to summon and bring before it any person whose attendance it considers necessary to enable the Board properly to in-quire into the matter complained of; (b) to swear and examine all such persons under oath; (c) to compel the production of documents; and (d) to do all things necessary to provide a full and proper in-quiry. (4) A Board of Inquiry shall, after investigation of a complaint Finding of Board pursuant to this section, make a finding and shall immediately report its finding to the Commissioner. (5) A majority of the members of a Board is a quorum and a Quorum finding by a majority of a Board upon any matter is final. (6) Every person who Offence (a) fails, without valid excuse, to attend an inquiry as required under this section, (b) fails to produce any document, book or paper in his posses-sion or under his control as required under this section, or (c) at any inquiry under this section (i) refuses to be sworn or to affirm, or to declare, as the case may be, or (ii) refuses to answer any proper question put to him by the Eoard of Inquiry, is guilty of an offence. R.O.,c.77,s.l5. 1 7 . (1) Where a pharmaceutical chemist has, after due inquiry, been adjudged by a Board of Inquiry to have been guilty of a contra-vention cf this Ordinance or of malpractice or infamous, disgraceful or improper conduct, the Commissioner shall strike his name off the register and suspend or cancel his licence to practise. (2) A pharmaceutical chemist whose name has been struck off Reinstatement the register and whose licence to practise has been suspended or cancelled may be reinstated on the register, his licence renewed and his rights and privileges thereunder restored in such manner and upon such conditions as the Commissioner in his discretion may decide. R.O.,c.77,s.l6. Cancellation of licence after finding by Board of Inquiry 1409 146 Chap. P-7 Pharmacy APPLICATION Application 18. Nothing in this Ordinance shall be deemed to prohibit or prevent (a) a medical practitioner from exercising a privilege conferred by any Ordinance relating to the practice of medicine and surgery in the Territories; (b) any person from supplying goods of any kind to a phar-maceutical chemist, medical practitioner, dentist or veteri-nary surgeon; (c) a medical practitioner, dentist, veterinary surgeon or a nurse acting under the supervision or direction of a medical practi-tioner or dentist from supplying a patient with such medi-cines as he may require; (d) an executor, administrator or trustee of the estate of a deceased pharmaceutical chemist from continuing the busi-ness of the deceased if the business is bona fide conducted by a pharmaceutical chemist; or (e) a person employed as a pharmacist by the armed forces of Canada or by a visiting force as denned in the Visiting Forces Act (Canada) from practising as a pharmaceutical chemist. R.O.,c.77,s.l7; 1960(2nd),c.7,s.3; 1964(l5t),cll,s.4. POISON storage of 19. A. substance described in Schedule A or B, when in the substances listed possession of a pharmaceutical chemist, shall be stored in a place in Schedule A or 8 (a) that is used only for that purpose; (b) that is kept securely locked at all times; and (c) to which only a pharmaceutical chemist has access. 1963(2nd),c.21,s.3,"18". Prohibition 20. No person shall supply to any person any of the substances described in Schedules A to C except as authorized by this Ordinance. 1963(2nd),c.21,s.3,"19"; 1964(l5t),cll,s.5. Sale of substance 21. A pharmaceutical chemist may supply a substance described listed in i n Schedule A to Schedule A (fl) a medical practitioner; (6) a veterinary surgeon; (c) a dentist; or (d) a person who has in his possession a prescription signed by one of the persons listed in paragraphs (a) to (c). 1963(2nd),c.21 ,s.3,"20"; 1964(1 s,),c. 11 ,s. 6. 1410 147 Pharmacy Chap. P-7 22. (1) Subject to subsection (2), a pharmaceutical chemist may, Prescriptions on the oral request of a medical practitioner, veterinary surgeon or o r d e r e d orall>' dentist, supply to that person or to a person named by him a substance described in Items 1 to 7 of Schedule A. (2) Before supplying any substance referred to in subsection (1) Preliminary-pursuant to an oral request a pharmaceutical chemist shall requirements (a) take reasonable precautions to satisfy himself that the per-son making the oral request is a medical practitioner, veteri-nary surgeon or dentist and that the person to whom the substance is delivered is the person who requested it or for whom it was requested; and (6) enter in a register kept exclusively for the purpose (i) the date and number of the prescription, (ii) the name and address of the person requesting the substance, (iii) the name and address of the person for whom the substance is requested, (iv) the name and quantity of the substance supplied, and (v) the directions for the use of the substance given with it and any directions respecting the refilling of the pre-scription. 1966(2nd),c.l8,s.l. 23. A pharmaceutical chemist may supply a substance described supply of in Schedule B tO substance listed in Schedule B (a) any person described in paragraphs 21(a) to (d); or (b) any person if before supplying the substance he enters in a register kept exclusively for the purpose . (i) the date on which he supplies the substance, (ii) the name and amount of the substance, (iii) the declared purpose for which the substance is re-quired, (iv) the price paid, if any, and (v) his signature, and the person to whom the substance is supplied signs his name and address to the entry. 1963(2nd),c.21,s.3,"21"; 19640s,),c.ll,s.7. 24. A pharmaceutical chemist or a merchant may supply to any Supply of person a substance described in Schedule C if before supplying the """" " substance he enters in a register kept exclusively for the purpose (a) the date on which he supplies the substance, and (b) the name and the amount of the substance, substance listed in Schedule C 1411 148 C h a p . P-7 Pharmacy and the person to whom the substance is supplied signs his name and address to the entry. 1963(2nd),c.21,s.3,"22"; 1964(lJt),c.ll,s.7. Poison noc to be 25. Notwithstanding anything in this Ordinance, no person shall suppliedUo supply a substance described in Schedules A to D to a person certain persons (a) of whose identity he is not reasonably assured; (jb) who is not of the age of sixteen years; or (c) of whose understanding of the dangers inherent in the use of the substance he is not reasonably certain. 1963(2nd),c.21,s.3,"23"; 1964<lst),c.l l.s.8. How pojions to 26. Every substance described in Schedules A to D supplied be labelled otherwise than pursuant to a written prescription signed by a medical practitioner, dentist or veterinary surgeon shall, prior to delivery, be labelled with (a) the common name of the substance, (6) the design of skull and cross-bones, and (c) the word "POISON" in largo, bold type. 1963(2Bd),c.21,s.3,"24". Commissioner 27. The Commissioner may alter, add to or remove from the list may alter Qf substances listed and described in Schedules A to D. Schedules A to 1 9 6 3 (2«l) t C.21,s.3,«25". Schedule A 1. Apomorphine and its preparations. 2. Curare and Curarin. 3. Hydrocyanic (Prussic) Acid. 4. Hyoscine and its preparations. 5. Physostigmine, its alkaloids and preparations. " 6. Picrotoxin. 7. Valerian and its preparations. 8. All drugs listed in Schedules F and G of the Food and Drug Act 9. All drugs listed in the Schedule of the Narcotic Control Act except solid preparations containing Vfc grain or less of co-deine per tablet or capsule in combination with other medici-nal ingredients in doses not exceeding those of the British Pharmacopaeia and generally recognized as safe medication. R.O.,c.77,Sched.A; 1960(2nd),c.7,s.6; 1963(2nd),c.21,s.4. Schedule B 1. Acetanilid in doses in excess of 1 grain. 2. Aconite and its alkaloids, compounds and preparations ex-cept preparations for use in the control of plant diseases or 1412 149 Pharmacy Chap. of pests and predators of plants and animals or of animal pests and when clearly labelled as for such purposes. 3. Poisonous vegetable alkaloids, not otherwise specifically mentioned elsewhere in Schedules A to D, and their salts and poisonous derivatives. 4. Amyl Nitrate. 5. Inorganic and organic compounds containing in excess of 1% of antimony calculated as SbjOj, except preparations for use in the control of plant diseases or of pests and preda-tors of plants and animals or of animal pests when clearly labelled as for such purposes. 6. Inorganic or organic compounds containing in excess of 0.-01% of arsenic, calculated as AS2O3, except preparations for use in the control of plant diseases or of pests and preda-tors of plants and animals or of animal pests when clearly labelled as for such purposes. 7. Atropine, its salts and preparations. 8. Belladonna, its preparations and compounds except Bel-ladonna plaster. 9. Barium Salts, other than the Sulphate. 10. Cantharides and Cantharidin and their preparations except preparations for use as fly blisters and hair compounds. 11. Chloroform. 12. Colchicine and its preparations. 13. Conium, its preparations and compounds. 14. Croton Oil. 15. Digitalis and all allied substances having a distinctive action on the heart, in concentrations having in excess of one unit of activity per 30 grains. 16. Ether (pure). 17. Elaterin. 18. Emetine and its salts and preparations containing in excess of 1.0% of Emetine or its salts. 19. Ephedrine and its alkaloids and preparations containing in excess of 1.0% of Ephedrine or its alkaloids. 20. Euphorbium. 21. Gelsemium and preparations containing in excess of 0.1 % of its alkaloids. 22. Hyoscyamus and its preparations. 23. Mercury and its salts. 24. Mydriatic Alkaloids, their sources and salts and prepara-tions containing in excess of 0.15% of mydriatic alkaloids, their sources or salts, calculated as hyoscyamine. 25. Nux Vomica and its preparations. 26. Oil of Savin. 27. Potassium Cyanide and all other metallic cyanides. 28. Strychnine its salts and preparations except preparations for use in the control of plant diseases or of pests and predators of plants and animals or of animal pests when clearly la-belled as for such purposes. 1413 150 Pharmacy 29. Thallium Compounds. 30. Alkaloids of Veratrum, and preparations containing in ex-cess of 1.0% veratrine. 31. Yohimbe and its alkaloids. 32. Any other substance the medicinal dose of which is less than 0.5 grains or the toxic dose of which is less than 3 grains. 0.,c.77,Sched.B; 1963(2nd),c.21,s.4. Schedule C 1. Acid Acetic Glacial. 2. Acid Chromic. 3. Acid Hydrochloric in concentrations in excess of 10% HCl. 4. Acid Hydrofluoric and Alkali Fluorides. 5. Acid Nitric in concentrations in excess of 10% H N O 3 . 6. Acid Oxalic and all oxalates. 7. Acid Picric in concentrations in excess of 5.0% CsHjOH (N02). 8. Acid Phosphoric in concentrations in excess of 10% H 2 P O 4 . 9. Acid Sulphuric in concentrations in excess of 10% H2SO4 10. Copper salts, excluding the sulphate. 11. Cresol and preparations containing in excess of 5% of cresol. 12. Creosote. 13. Denis Root. • 14. Ether (commercial). 15. Formaldehyde. 16. Hellebore. 17. Iodine and its preparations except tinctures containing not more than 1Vi% iodine. 18. Jaborandi and its alkaloids and preparations containing in excess of 0.025% of its alkaloids. 19. Lead Salts and their preparations except red and white lead, lead chromate, lead plaster and preparations for use in the control of plant diseases or of pests and predators of plants and animals or of animal pests when clearly labelled as for such purposes. 20. Lobelia and preparations containing in excess of 0.1% of its alkaloids except asthma cigarettes and fumigants. 21. Nicotine, other than in tobacco and in preparations for use in the control of plant diseases or of pests and predators of plants and animals or of animal pests when clearly labelled as for such purposes. 22. Nitrobenzene and admixtures containing in excess of 0.1 % of C«HsN02 except soaps. 23. Oil of Cedar. 24. Oil of Bitter Almonds unless deprived of hydrocyanic acid. 25. Oil of Pennyroyal. 26. Oil of Tansy. 1414 151 Pharmacy 27. Phenol (Carbolic Acid) and preparations containing in ex-cess of 5% of phenol. 28. Phenylene Diamines and homologues thereof. 29. Phosphorus in a free state. 30. Potassium Bichromate. 31. Potassium Hydroxide. 32. Potassium Permanganate. 33. Sabadilla Seeds. 34. Santonin. 35. - Silver Salts. 36. Sodium Hydroxide. 37. Stavesacre Seeds. 38. Zinc Salts except the oxide and carbonate. 39. Any substance the medicinal dose of which is less than 5 grains or the toxic dose is less than 30 grains. 1963(2nd),c.21,s.4; C.O.,23-65. Schedule D 1. Poisonous preparations for use in the control of plant dis-eases or of pests and predators of plants and animals or of animal, insect or plant pests. 2. Turpentine and other solvents not otherwise specified in these schedules. 3. Chloride of Lime. 4. Poisonous chemicals used in connection with photography. 5. Methyl Hydrate (Wood Alcohol) except when supplied in containers which state the use to which the substance is to be put. 6. Carbon Tetrachloride except when supplied in containers which state the use to which the substance is to be put. 7. Ammonia in concentrations is excess of 10% NH3 except when supplied in containers which state the use to which the substance is to be put. 8. Iodine and its preparations except tinctures containing not more than 2Vi% iodine. I963(2nd),c.21,s.4; C.O.,23-65. Schedule E FORM A REGISTRATION CERTIFICATE TO ALL TO WHOM THESE PRESENTS SHALL COME OR WHOM THE SAME MAY IN ANYWISE CONCERN: , of. has qua-lified for registration in the Pharmaceutical Chemists Register pursu-ant to the Pharmacy Ordinance and that pursuant to and under the authority of the said Ordinance I have authorized him, the said , to be registered therein. 1415 152 Chap. P-7 Pharmacy GIVEN UNDER MY HAND AND THE SEAL OF THE NORTH-WEST TERRITORIES AT this..... day of. . , 19 . . . (Seal) Commissioner. R.O.,c.77,Schedule C; 1963(2nd),c.21,s.4. QUEEN'S PRINTER FOR CANADA OTTAWA. 1974 BILL C - 80(1) A BILL TO AMEND THE PHARMACY O R D I N A N C E The Commissioner of the Northwest T e r r i t o r i e s , by and with the advice and consent of the C o u n c i l of the s a i d T e r r i t o r i e s , enacts as f o l l o w s : 1. Paragraph 12(1)(b) of the Pharmacy Ordinance i s repealed and the f o l l o w i n g s u b s t i t u t e d t h e r e f o r : "(b) appends to h i s name or uses the t i t l e pharmaceutical c h e m i s t , pharmacist, d i s p e n s i n g c h e m i s t , d r u g g i s t , d i s p e n s i n g d r u g g i s t , apothecary, h e r b a l i s t or a n y word i n d i c a t i v e of any such t i t l e or 'any s u b s t i t u t i o n or a b b r e v i a t i o n t h e r e o f ; " . 1416 

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