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Fighting a war on two fronts
Rheumatologist sees two-tier system for arthritis medications.

Besides diagnosing and treating forms of arthritis, rheumatologist Dr. Majed Khraishi spends much of his time advocating for patients who can't afford their medications and have no prescription drug coverage. Arising from this experience, Khraishi says there really is a "two-tier" health system. "If you have good insurance," he said, "generally you'll have better access to drugs. If you live in St. John's, or big centres in Atlantic Canada and Canada, you have a little bit better access. But if you don't have any insurance and you are from the working poor, you are really in a bad situation. And if you are poor and covered by the Newfoundland and Labrador Prescription Drug Program (NLPDP), then you are also in a major problem." Rheumatoid arthritis and other immune system diseases like psoriatic arthritis, psoriasis, ankylosing spondylitis, crohn's disease and ulcerative colitis are very common in Newfoundland and Labrador.

At one time, Khraishi said, doctors had limited pharmaceuticals to offer these patients. But in the last six to seven years, a new group of drugs called biologics have been available, proving to be very effective and safer than some of the traditional drugs. "The problem with them," Khraishi said, "is that they are very expensive ranging from $12,000 to over $20,000 a year." And while about four of the new biologic drugs are now included in the NLPDP formulary, approval from the provincial drug program doesn't always come easy.

Khraishi said some private insurance companies require patients to have tried at least two of the older drugs first before they'll pay for the newer biologics, but the provincial drug program has a further requirement before providing any assistance to low-income earners. "They require that you not only have to fail two, but you have to fail a combination of two drugs, Methotrexate and a drug called Arava," Khraishi said, describing them as similar drugs. While these are good drugs and work well for some patients, Khraishi said there are patients who can't take Methotrexate because they develop liver problems as a side effect of the medication. "If you have liver problems from Methotrexate, any decent doctor would not put you on a drug that will cause the same problem," he said, not to mention a combination of the two drugs. As a treating physician, Khraishi said he often presents this case to the government drug program, but most often drug coverage is still refused. "They refuse to accept it and ask us to prove that this is the truth," he said. "They very rarely agree, most of the time they refuse the patient the new drug." Khraishi believes the province should have a better appeal system. He said most other provinces have an appeal process where independent physicians and pharmacists review cases where coverage has been denied. "As a taxpayer, I understand that you cannot have free access with these extremely expensive drugs for everybody, but there should be an appeal system," Khraishi said.

To his knowledge, he said, when new drugs are added to the formulary, there are also no consultations with local rheumatologists. In the meantime, Khraishi said, he watches patients suffering silently because they don't want their suffering and financial situation made public. He estimates that this applies to the majority of his patients who don't have drug insurance and can't afford the medications they need. The province's recent decision to expand its drug program to provide greater access for low-income earners was a move in the right direction, Khraishi said, but "You cannot accept in a country where we have universal health access, that there is a two-tier system."

"If you have money, you have access and can do well, but if you don't have money, you suffer and suffer."

By: Deana Stokes Sullivan
The Telegram (St. John's)
Provincial, Monday, February 5, 2007, p. A3

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