CMPA to net Rx writers: you're on your own

Everyone's tied in a knot over cross-border web scripts except the companies selling the product -- and the docs writing the slips with both hands

By Robb Beattie

Providing cheaper Canadian drugs to American patients has grown into a billion-dollar business. At the same time, the doctors who sign Internet prescriptions at $15 a pop are increasingly isolated. A National Review of Medicine poll conducted last December showed that fully 91% of physicians considered the practice either "unacceptable" or "borderline." In February, the Canadian Medical Protective Association (CMPA), which provides malpractice coverage to virtually all practising physicians in the country said it would no longer represent physicians who were sued by an American patient for whom they'd signed an Internet prescription.

"I don't know if our statement will stop doctors from engaging in the practice," says Dr John Gray, Executive Director of the CMPA. "We've been issuing progressively more pointed warnings over the last two years, first telling doctors that it put them at risk of being sued or investigated by their college. Then last year we said we might not assist if they encountered medical-legal difficulty. And now, we've stated we categorically will not assist, whether the legal action is brought against the physician in the US or Canada."

The CMPA's latest position was taken on the basis of provincial college rulings that prescribing over the Internet without seeing a patient does not meet the standard of care. "The colleges have defined very clearly what is an appropriate circumstance for physicians to renew or cosign a prescription for a patient, and what isn't," states Dr Gray. "When a snowbird asks for a prescription to be renewed by a Canadian doctor with whom they have an existing relationship, that's acceptable.... Similarly, the colleges deem it acceptable for a physician to renew a prescription for a patient who isn't their own personal patient, but part of their call group."

The conditions that must be present in order for a doctor to issue a prescription include knowledge of the patient's condition, examination, opportunity for follow-up and for questions to be asked. Clearly with Internet prescribing, these conditions can't be met.

EXPONENTIAL GROWTH
Despite objections from medical and pharmacy associations -- and polls that show that Canadian doctors are overwhelmingly opposed to the practice, Dr Gray says the number of prescriptions issued in Canada for US patients is growing exponentially. Just how many doctors are signing these prescriptions remains somewhat mysterious. A handful have been sanctioned by their provincial college but to date no licenses have been revoked and no lawsuits have yet been reported by the CMPA -- it cannot comment on open cases and most take three to four years to close.

Dr Durhane Wong-Rieger, Chair of the Consumer Advocare Network and President of the Anemia Institute, doesn't believe that the medical associations and colleges can curb Internet prescribing without the government actively behind them. "Unfortunately, government is looking at the revenue side of the equation," says Dr Wong-Rieger, "and is not looking for effective ways to stop it. They were far more effective when it came to stopping the re-importation of cigarettes." She worries about the threat Internet prescribing poses to the supply of drugs in Canada. "A number of major US-based drug companies have already limited their shipments to Canadian pharmacies to what they view as Canadian need," she says. She even goes so far as to suggest that companies "will not tolerate Canadian pricing practices if the situation continues."

More serious, perhaps, is that supply pressure is also encouraging Internet pharmacies to purchase drugs from countries which do not have mutual recognition agreements with either Canada or the US for pharmaceutical good manufacturing processes. "If these drugs are making their way into Canada and on to the US, there's nothing stopping them from being sold in Canada as well," says Dr Wong-Rieger. "Government has already said it doesn't have the resources to conduct on-the-ground inspections of pharmacy drugs." She cites a recent FDA report finding that 80% of the drugs they intercepted en route to American patients were from Canadian pharmacies and more than 50% of these drugs were not what they were labelled to be.

She speaks regularly to American mayors and state governors on the issue and says they recognize that their professed interest in buying drugs from Canada is little more than a political ploy to deal with drug costs and get Washington to provide better coverage for their citizens.