Outpatients may have to pay for some treatments now covered in Alberta

Alberta Health Services is considering changes that would download the cost for certain medications and treatments onto patients. 

The proposed new program is outlined in confidential documents sent to CBC News by an AHS employee. CBC has agreed to protect their identity because of the potential for repercussions on them and their employment. 

The Standardizing Access to Medications for Ambulatory Patients (STAMP) program would set parameters for when AHS would absorb the cost for certain treatments and when they would be passed on to patients. This means some drugs would cease to be offered for free to patients for administration in hospitals. 

Instead, they would have to buy the medications at a pharmacy and, in some cases, also pay a clinic for the infusion procedure. The documents say STAMP would save AHS an estimated $2.3 million a year as "these costs will be transitioned to ambulatory patients and/or their insurance plans." 

Ambulatory patients (sometimes referred to as outpatients) are people who are not formally admitted to hospital but who receive care there. They are often treated in specialty and infusion clinics or emergency departments. 

The treatments under consideration for STAMP include those used during the treatment of cancer or Crohn's. The bulk of the savings AHS is considering could come from redirecting iron, calcium and magnesium infusions to clinics, as well as non-cosmetic Botox injections. They are often utilized for fibromyalgia, breast and bone marrow cancers, skeletal issues like Paget's disease and osteoporosis, and spasticity associated with brain injuries, cerebral palsy or multiple sclerosis.

If the program is approved, many patients with those illnesses could be responsible to pay for their own medications as well as the associated costs to have them administered. 

AHS declined CBC News's request for an interview. Officials did not respond to specific questions about the program but did provide a statement. 

"The process under consideration would be for cases where there is no urgent medical need for a medication to be administered in a hospital or AHS/Covenant Health clinic. Those patients would potentially be referred to a more appropriate community setting, such as a family physician's office, pharmacy or other clinic, if available in their local area," spokesperson James Wood said. 

The documents say the implementation period was originally set to occur in March, before the pandemic hit. Wood stressed no final decision has been made on the program but would not elaborate on when it could be expected.

"Albertans will always continue to receive the medications they need — that will not change. We will also ensure that patients continue to have their medications administered. The new process under discussion would simply allow this to occur in a different health-care setting, and would ensure consistency of any fees associated with this service," Wood added.

CBC News also reached out to the health minister, whose office said it is an AHS initiative and was not developed by the minister's team.

Long-term costs versus short-term savings

The AHS employee who obtained the paperwork is concerned that thousands of Albertans will flood the limited number of qualified clinics, causing backlogs in the system, financial strain on patients and ultimately resulting in more people needing elevated medical intervention in hospitals. 

They estimate that transitioning to STAMP will actually cost more money in the long run. For example, they said that a single iron infusion costs about $150 and most patients need three treatments a year. Without those doses, iron-deficient patients often end up in the emergency room, where treatment to save them costs upwards of $6,000. 

The employee worries that people without adequate insurance or who are too poor to pay for treatments will skip their infusions and end up needing that costly life-saving intervention. 

AHS says no patient will be denied care. In order for treatment to be covered, AHS would require the medication to be used to treat an emergency or stabilize acute symptoms, or to be a drug required to be administered in a hospital. Patients could also have their medications administered in hospital if there is no appropriate alternative setting.

The documents say if the program is approved, AHS clinics would be limiting their stocks of the affected medications to encourage patients to provide their own. Limited doses would continue to be stored for emergencies. 

The external communications plan for STAMP, included in the leaked documents, says the program is to be pitched as standardizing care so that all patients "have the same access to care across Alberta."

Currently, there is no set model for giving ambulatory patients medication. The AHS documents say this causes "patient frustration and a lack of confidence in the system." 

If STAMP is implemented, AHS medical staff in hospitals and clinics will be the ones informing affected patients that they're required to pay for their own drugs going forward. The staff will be instructed to encourage patients to find private insurance that includes drug coverage. 

The challenges of private insurance

Sandra Azocar, executive director of Friends of Medicare, said implementing the STAMP program is unnecessary and would create inequalities in Alberta's health-care system.

"There's no way that insurance, private insurance … is going to cover pre-existing conditions," she said, adding she's concerned about AHS relying on private health care for drug delivery. 

"The standardization of care can be done without offloading the cost to patients and their families. So it is just simply a cruel move." 

The standardization of care can be done without offloading the cost to patients and their families. So it is just simply a cruel move.- Sandra Azocar, Friends of Medicare

It's a concern shared by NDP health critic David Shepherd. 

"We're really gambling with people's health for the sake of a few dollars. I think that's unconscionable," he said. 

"I recognize the value of equalizing these systems across the province of Alberta, but then let's try to do that by treating everybody equally well, not equally badly."

Azocar says if STAMP is introduced, AHS could find itself in the courts to test if the program meets care standards set out in the Canada Health Act.