The executive director of Mount Carmel Clinic recalls the story of "Joe."
It took him three different doctors, three different stories and three different pharmacists, but the elderly Winnipegger finally scored what he needed — 300 Tylenol 3s to turn around and sell on the streets.
It's all because he was on social assistance and needed the $150 in profit. Because he was on social assistance, the province essentially paid for the drugs.
"[The province] may not notice that a particular individual is claiming thousands and thousands of dollars for medication," says Dr. Margaret Burnett.
"But we still pay, right? As taxpayers, we're financing those meds."
The result? Taxpayers are unintentionally supporting someone's addictions.
It's why some physicians say the province could cut down on those addictions if they change the way they administer drug benefits to low-income clients.
"There needs to be greater public awareness of the potency of these medications, and if taken inappropriately, they can kill full stop," said Dr. Michael Hochman, a general practitioner at a Winnipeg walk-in clinic.
"Yet [selling these drugs] can be lucrative business, especially if they don't pay for them."
Private insurance companies have the means — and the financial incentive — to weed out bogus claims for unneeded prescriptions.
"They're keeping a very close tab on how many times they have to shell out reimbursements for prescriptions," said Burnett, who is past president of the College of Physicians and Surgeons of Manitoba. "But provincial Pharmacare or welfare systems may not have the time or resources to micromanage each individual prescription."
'I'm not a babysitter'
Either way, short of putting on their private investigator hats, it can be pretty tough for a GP to sniff out these bogus patients.
"I'm not a babysitter, their parent or a detective," Hochman said.
"For me to have to step outside my office a number of times and do these extra steps to find out whether these patients are yanking my chain or lying to me, it's a lot of additional stress. It's a lot of extra time, and if you don't constantly remind yourself of the safety risks associated with these medications, it would be very easy to put the public in danger."
Nationally speaking, it's accepted that between two and 10 per cent of each health-care dollar goes to fraud. That's according to the Canadian Health Care Anti-Fraud Association.
However, it's not broken down into how much of that is patient-driven fraud. Furthermore, on a provincial level, we really don't specifically track that.
To be clear, both Burnett and Hochman say this is about more than just taxpayer dollars gone to waste. For them, it's another toxic side effect of prescription drug addiction.
But they say if that side effect was eliminated — in other words, if the province could sniff out and stop paying for the bogus prescriptions — it could go far to help reduce the number of people getting their hands on them and getting addicted to them.
There are, of course, some checks and balances in place, said Dr. Trish Caetano, executive director of the provincial drug program.
There is the Drug Program Information Network. It's a real-time database for pharmacists, Caetano said.
Very simply, every time they get handed a prescription for certain medications, they input that information into the system. If it appears that this particular patient has received an unusually high number of these — or similar — prescriptions, it "red flags" it to the pharmacist.
System has limitations
But it's not mandatory for the pharmacist to act on these red flags, and the information the database provides is limited. It doesn't reveal who prescribed the drugs, how many doctors were involved or why.
As well, if a patient is knowingly doctor-shopping, they might not use their real name. They could go to three different doctors, with three different names, so the database wouldn't be able to detect all of that one person's prescriptions.
The system does red flag what Caetano calls any "atypical prescribing pattern" that might appear at a certain clinic or with one specific physician.
For example, the system would note if a particular patient has prescriptions for three different anti-anxiety medications. That information is sent to the most recent physician on record, so he or she can review the patient's file to make certain the medications are appropriate.
Hochman said he would like to see that taken one step further — specifically with patients on social assistance. He suggested that in some cases, it should be mandated that they're allowed just one prescribing physician.
In other words, if you want the province to cover your prescriptions, you have just one physician you can go to.
To a certain extent, this is already done, said both Hochman and Caetano. Among those who have treaty cards, for example, thanks to a recent revision of Health Canada's Non-Insured Health Benefits plan, some patients already face this kind of restriction if it has been determined that they're vulnerable to a particular addiction.
But Caetano said allowing just one prescribing physician is a risky solution that could lead to mass stereotyping. Hochman agrees.
"It's very difficult because at all times you don't want to be judgmental, you don't want to discriminate and you don't want to make any assumptions about someone when they are presenting with concerns," he said. "I would hate to turn away someone who legitimately needs our help."
As well, he said it illustrates an even greater need in our medical system for better access to mental-health programs, especially for those who can't afford private options.
In other words, address the ills that cause the addictions in the first place.
That's a diagnosis Caetano agrees with.
"I think, for example, what it costs to our Pharmacare program is minimal to what it costs to the patient's health and well-being," she said.