Some pharmacists have resumed the practice of offering prohibited cash incentives in exchange for patients’ prescription business, despite media and government scrutiny last spring that forced a temporary halt to the kickbacks, say pharmacists in a letter to British Columbia’s Health Minister.
The letter to Health Minister Josie Osborne and College of Pharmacists of B.C. registrar Suzanne Solven, obtained by The Globe and Mail, is signed by 10 professionals who identify themselves as concerned pharmacists practising in Vancouver’s Downtown Eastside. The letter pleads for urgent intervention in the matter. It said the kickbacks not only undermine the integrity of their profession but pose significant risks to vulnerable patients and public health.
“Approximately eight months ago, media reports highlighted allegations of pharmacies offering incentives to attract prescriptions, prompting your swift response in forming a special investigation panel,” said the Nov. 26 letter, which added that many pharmacists provided the college with detailed information about illegal activities.
“The situation temporarily improved when investigations were perceived to be under way; however, six months later, the unethical practices have surged, with devastating consequences for ethical businesses and patient safety,” the letter says.
The Globe spoke with two of the signatories and is not naming them because they said they fear for their personal safety and are concerned about professional repercussions.
The Globe reported last March that numerous B.C. pharmacies were accused of paying patients prohibited cash incentives – typically around $50 a week – to fill their prescriptions at the pharmacies’ locations and recruit others to do the same, maximizing the amounts the pharmacies can bill the province’s publicly-funded drug plan. The pharmacies appeared to target low-income patients with substance use disorders who are on opioid agonist therapies such as methadone.
Pharmacies charge a dispensing fee for each prescription, and these fees make up a significant portion of their overall revenue. For patients on income assistance and with First Nations health benefits, a pharmacy that is enrolled with BC PharmaCare can bill the publicly-funded program for up to $10 for each of up to three medications, per patient, per day.
For methadone, the most-commonly-prescribed medication for opioid use disorder, the program also pays pharmacies an “interaction fee” of $7.70, on top of the dispensing fee, for the pharmacist to witness the patient ingesting the medication. This means that a single methadone patient could bring in up to $13,760 a year in pharmacy fees for multiple medications. A pharmacy with a few hundred such patients can easily bill PharmaCare for millions of dollars a year.
The Globe spoke to 28 doctors, nurses, pharmacists, patients and social service providers as part of its investigation. Among them, two doctors, two pharmacists and several patients independently revealed the name of dozens of pharmacies alleged to offer kickbacks, including locations in Vancouver, Burnaby, Surrey, New Westminster and Victoria. A Globe journalist also witnessed a pharmacy delivery man paying a patient a $50 kickback.
In May, the Health Ministry sent a letter to Vancouver-area pharmacies warning that offering such inducements could result in a fine of up to $200,000 and/or six months imprisonment. As an apparent result, pharmacies began cutting off the payments.
But the letter writers urged the ministry and the college to intensify investigations, increase oversight of pharmacy operations in the Downtown Eastside, implement stricter accountability measures for non-pharmacist employees who influence operations, provide updates on its investigations and meet with concerned pharmacists.
The Globe asked B.C.’s Ministry of Health on Jan. 6 about Ms. Osborne’s response to the letter, the special investigation panel and its work to date, and whether any pharmacists or pharmacies have been subject to disciplinary action. The Ministry refused to answer all questions, citing an active investigation.
Asked by The Globe about the status of investigations at an unrelated news conference this past Monday, Ms. Osborne said her government expects all pharmacies to adhere to B.C. regulations and that her ministry would follow up with more information, which it did not.
The College of Pharmacists of B.C. confirmed to The Globe on Jan. 8 that it had received the group’s letter but said it could not answer further questions.
“These situations are complex and must be meticulously handled,” said a statement provided by public information and engagement lead Lesley Chang. “Unfortunately, we cannot share more without compromising our investigations and processes.”
The college and ministry responded to the pharmacists group on Jan. 17 and on Jan. 22, respectively, reiterating that action was being taken but providing no details, according to correspondence viewed by The Globe.
Some pharmacists say it is challenging to stay in business without paying incentives when so many others do. The November letter said patients frequently ask about payments and threaten to transfer pharmacies, creating safety and ethical concerns.
“We firmly believe that inaction on these issues will compel ethical pharmacies to either close their doors or resort to unethical practices to survive,” the letter said. “This not only erodes the profession’s integrity but also endangers patients and perpetuates the cycle of addiction and exploitation in our community.”