When deciding on reimbursement criteria for pharmaceutical products, it’s understandable that makers must take a hard look at cost-effectiveness. After all, health expenditures, which are on the rise, must be managed within our public system.

Yet the emphasis on cost-benefit analyses, the lens through which we view public coverage, often leaves gaps in appropriate care options for Canadians.

Often, when new and innovative therapies emerge, the focus of decision making can centre on cost-effectiveness, rather than clinical effectiveness.

As a result, access to medicines can be uneven across Canada, depending on the decision-making process in each jurisdiction.

This problem isn’t new. But if we’re going to evaluate drug reimbursement in large measure on the basis of cost, let’s make sure we factor in all the costs.

For instance, taking the example of osteoporosis, let’s say Drug A is publicly reimbursed and works well for Patient X. That’s cost-effective. But what about Patient Y, who’s vulnerable because Drug A doesn’t work for him? What happens if Patient Y goes on to break a hip, is hospitalized, requires surgery, and time to rehabilitate? How does that now play into the cost-benefit analysis of Drug A?

Or consider the case of a 50-year-old woman with osteoporosis, who manages the household, is a working mother, and is the primary caregiver for an elderly parent. For whatever reason, she either can’t take the approved osteoporosis drugs that are currently covered, or they aren’t effective for her. So there’s a high likelihood that she’ll eventually break a hip. Any fall could do it.

What happens now? Well, not only is the woman affected; so is her entire family. The household can’t run as effectively with her out of commission. While off work, her income might suffer. Certainly, her ability to care for her own parent is hampered.

Those impacts might not be health care costs, but they are societal costs. And one way or another, we do pay for them.

The question is this: how do we account for such a scenario when using traditional health technology assessment (HTA) principles to make reimbursement decisions?

We simply must find a way to factor in these issues and other qualitative measures to complement the traditional HTA.

Without question, this is complex. For example, a drug could be less expensive, but might not be as effective from a clinical perspective. So how do we assess the long-term effects and costs of a disease, of which drug costs are merely one element?

There have been some promising developments. For instance, there’s now a vehicle in place to allow patient input into the Common Drug Review (CDR), which provides formulary listing recommendations to the publicly-funded drug plans in Canada. But it’s too early to tell how much the patient experience will influence those recommendations.

The reality is that healthcare costs will only increase as the Canadian demographic ages. The toll of chronic diseases and related conditions will also continue to grow. Yes, we need to rein in costs. But we need to paint a fuller picture of what certain decisions really cost us.

Dr. Famida Jiwa is President and CEO of Osteoporosis Canada (www.osteoporosis.ca).