Download Quebec - Canadian Skin Patient Alliance

Skin Deep
A Report Card on Access to
Dermatological Care and Treatment
in Canada – 2012
Quebec
CSPA member organizations
The CSPA is a non-profit organization made up of patient members and affiliated patient
organizations:
About Face
Alberta Society of Melanoma
Alliance québécoise du psoriasis
Basal Cell Carcinoma Nevus Syndrome Life Support Network
British Columbia Lymphedema Association
Canadian Alopecia Areata Foundation
Canadian Burn Survivors Community
Canadian Pemphigus and Pemphigoid Foundation
Cutaneous Lymphoma Foundation
DEBRA Canada, Epidermolysis Bullosa
Eczema Society of Canada
Hidradenitis Suppurativa Foundation
Scleroderma Association of British Columbia
CSPA Board of Directors
Allan Stordy, Alberta
Barbara-Anne Hodge, Manitoba
Andrew Gosse, Newfoundland
Judy Bacsu, Alberta
Preet Bhogal, Nova Scotia
Paul Francois Bourgault, Québec
Sandy Burton, Ontario
Sylvia Garand, Québec
Brooks Harvey, Alberta
Charles Jago, British Columbia
Jim Makris, Ontario
Tanny Nadon, Alberta
Karen Shipman, Ontario
Contact information
Canadian Skin Patient Alliance
2446 Bank Street, Suite 383
Ottawa, Ontario K1V 1A8
Christine Janus, Executive Director
phone: 613-422-4265
fax: 877 294-1525
cell: 613-884-3101
CSPA general office toll free 1-877-505-CSPA (2772)
www.canadianskin.ca
© Copyright 2012
All rights reserved.
Published by Canadian Skin Patient Alliance
Printed in Canada.
e02QC02
This document is excerpted
from the complete Report
Card, which can be found
online at www.canadianskin.ca.
Imagine what it’s like to live every day uncomfortable in your own skin, not just because of the physical
discomfort, pain or itchiness, but ashamed and guarded to have others see your exposed skin, afraid that people
might shy away or be uncomfortable around you.
This is a reality for a great many Canadians. Some skin patients look different and are open about their
disease, but most hide it well, so skin disease becomes something that is “in the closet.” Although it may be
thought that skin conditions are “just skin deep,” they can have a huge impact on quality of life for skin patients
as well as their families.
This report represents just a snapshot of some of the issues that affect many patients and has taken
considerable time to put together. While we’ve tried to cover many of the issues, we already know we’ve missed
some. Whether it’s funding coverage for wigs for alopecia patients, or access to treatments for hyperhidrosis, or
special drug category coverage, given that there are well over 3,000 skin diseases and approximately one third
of the population of Canada grapples with a skin condition, disease or trauma at any given time, there is much
work ahead. This is a beginning.
This Report Card was born out of a need for us—the patients—to understand where the gaps are in
access to care across the country. We have a sense that there are problems, but this report sets out a platform
from which we, the CSPA, can advocate for patients where it is needed most. This is the first time Canadian skin
patients have organized as a collective group to try to effect change.
This report is also offered as a tool to the many others who have a stake in the care of Canadian skin
patients—the doctors, nurses, medical associations and pharmaceutical companies across the country—to help
make their conversations with governments more focused and productive.
I would like to acknowledge the hard work of Christine Clarke, the past Chair of the CSPA’s Advocacy Committee, and the driver of this project, who spent countless volunteer hours in development and final
preparation of this report. Thanks to Susan Turner as the primary writer and researcher and to Christine Janus
who provided considerable input and oversight on behalf of the CSPA. We also extend very special thanks to
Dr. Evert Tuyp and Dr. Harvey Lui, the members of the CSPA’s Medical Advisory Board, the CSPA Board of
Directors and the representatives of other affiliated patient organizations who all stand with us in our goals to
improve the situation for skin patients in Canada.
I thank you for taking the time to read this report, and we look forward to working with the different
levels of government to make progress in treatment and care for all skin patients in Canada.
Whether you live in Kinkora, PEI, or Victoria, BC, we hope that by working with other stakeholders
and decision-makers in Canada’s complex health system, we can together use this Report Card to improve your
access to dermatological care and treatment.
Allan Stordy, CSPA President
Summary of the CSPA’s position
1. Skin patients should have access to a dermatological care within an acceptable wait time
regardless of where they live in Canada. We believe that Canadians seeking treatment for
medical skin disorders should not have to wait longer than five weeks to see a dermatologist—the national median wait time reported in 2001. While we recognize that it is not
possible for all dermatology services to be available within commuting distance of all
Canadians, we believe that phototherapy—the mainstay of treatment for many medical
skin conditions—should be available to every Canadian, either in a clinic or as an insured
service at home for those Canadians who cannot access a clinic.
2. Medical procedures should be insured services for all patients with a medical skin disorder.
Treatments for diseases such as vitiligo, a pigmentation disorder with serious social and
psychological impacts, need to be covered by the public health system.
3. All drugs that are considered the standard of care should be funded without restrictions.
Dermatologists need access to the broadest range of alternative medications. A medication
that works for one patient may not work for another. In many skin diseases, the body can
build up a tolerance to a “tried and true” medication over time and thus new ones need to
be available. Also, some skin patients are particularly susceptible to side effects of drugs.
Since these diseases are chronic, a patient’s quality of life can be affected dramatically by
drugs that are poorly tolerated, less effective or that require the patient to go to unreasonable lengths to administer.
4. Patients with rare skin diseases should have access to a medication or medical procedure
for which there is reasonable evidence of efficacy, regardless of its regulatory approval
status. By definition, the number of patients with a rare disease is too small to allow for
the same levels of scientific evidence that are achievable for treatments for more common
diseases. In practice, this means that Health Canada will have insufficient evidence to prove
that a treatment is effective and safe in patients with rare diseases, according to its normal
standards. Drug review committees will also lack a high standard of evidence on which to
base a funding decision. In these situations, a lower level of evidence should be accepted for
decisions concerning the clinical application, funding and availability of promising treatments for rare skin diseases.
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Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Contents
Summary of the CSPA’s position......................................................................................................................... ii
Executive Summary
Issues..............................................................................................................................................................xix
Recommendations.........................................................................................................................................xx
Improve access to dermatological care...............................................................................................xx
Improve access to medical procedures...............................................................................................xxi
Improve access to medications...........................................................................................................xxi
Introduction
About the Canadian Skin Patient Alliance (CSPA).................................................................................. xxiii
Prevalence of skin diseases in Canada...................................................................................................... xxiii
Burden of skin diseases...............................................................................................................................xxiv
Reasonable access to care and treatment..................................................................................................xxvii
About the Report Card............................................................................................................................ xxviii
How performance was graded................................................................................................................. xxviii
National
Issues and Actions..........................................................................................................................................CA-2
Where are the gaps?..................................................................................................................................CA-2
Who is at risk?...........................................................................................................................................CA-3
What the CSPA is doing............................................................................................................................CA-3
Detailed Tables...............................................................................................................................................CA-4
1. Access to dermatological care...............................................................................................................CA-4
How does Canada’s performance rate?..........................................................................................CA-4
Long wait times..........................................................................................................................CA-4
Low and steadily declining numbers of dermatologists..........................................................CA-7
Lack of access in rural and remote areas...................................................................................CA-7
Need for more dermatology nurses..........................................................................................CA-9
Need for more Mohs surgeons................................................................................................CA-10
How have governments responded?.............................................................................................CA-10
Training new dermatologists...................................................................................................CA-11
Remuneration..........................................................................................................................CA-11
Outreach to rural and remote communities..........................................................................CA-12
CSPA recommendations to improve access to dermatological care...........................................CA-13
2. Access to medical procedures.............................................................................................................CA-14
What is the situation today?.........................................................................................................CA-14
Phototherapy............................................................................................................................CA-14
Access to vitiligo treatments....................................................................................................CA-17
Access to specialized treatments..............................................................................................CA-17
CSPA recommendations to improve access to medical procedures...........................................CA-18
3. Access to medications.........................................................................................................................CA-18
Number of standard-of-care drugs funded............................................................................CA-19
Restricted access to standard drugs.........................................................................................CA-20
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Contents
Funding status of medications to treat skin diseases.............................................................CA-21
Lack of policies for rare skin diseases.....................................................................................CA-25
Drug review delays...................................................................................................................CA-26
CSPA recommendations to improve access to medications.......................................................CA-27
Quebec
Key issues.................................................................................................................................................. QC-1
Recommendations................................................................................................................................... QC-1
Detailed Tables.............................................................................................................................................. QC-3
1. Access to dermatological care ............................................................................................................. QC-3
What is the situation today?.......................................................................................................... QC-3
Long wait times......................................................................................................................... QC-3
Large but falling numbers of dermatologists.......................................................................... QC-5
Lack of access in rural and remote areas.................................................................................. QC-6
Need for more dermatology nurses......................................................................................... QC-6
How has the Government of Quebec responded?........................................................................ QC-7
Training new dermatologists.................................................................................................... QC-7
Remuneration........................................................................................................................... QC-8
Outreach to rural and remote communities........................................................................... QC-8
CSPA recommendations to improve access to dermatological care in Quebec.......................... QC-9
2. Access to medical procedures ............................................................................................................. QC-9
What is the situation today?........................................................................................................ QC-10
Phototherapy........................................................................................................................... QC-10
CSPA recommendations to improve access to medical procedures in Quebec........................ QC-11
3. Access to medications ....................................................................................................................... QC-11
What is the situation today?........................................................................................................ QC-12
Number of standard-of-care drugs funded........................................................................... QC-12
Restricted access to newer medications................................................................................. QC-12
Funding status of medications to treat skin diseases in Quebec............................................... QC-13
Lack of policy for rare skin diseases....................................................................................... QC-18
CSPA recommendations to improve access to medications in Quebec.................................... QC-19
Appendix 1
Information Sources ...................................................................................................................................A-1
Dermatologist fees.............................................................................................................................A-1
Medications........................................................................................................................................A-2
Appendix 2
Methodologies for assessing access to dermatological care.......................................................................A-3
Benchmarks for access to dermatological care.................................................................................A-3
Rationale.............................................................................................................................................A-3
Measuring supply...............................................................................................................................A-4
Calculation of FTEs......................................................................................................................A-4
Measuring demand............................................................................................................................A-5
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Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Contents
Table and Figure List
Introduction
Table 1: The CSPA Report Card Scoring Method...........................................................................................xxx
National
Table 1: How is Canada performing?............................................................................................................CA-1
Table 2: Overall performance ratings on access to dermatological care......................................................CA-4
Table 3: Median wait times in weeks for routine consultation....................................................................CA-5
Figure 1: Lack of Accessibility of Dermatologists.........................................................................................CA-6
Figure 2: Median Wait Times for Dermatologist Consultation...................................................................CA-7
Figure 3: Distribution of Dermatologists in Canada...................................................................................CA-8
Figure 4: Urban concentration of dermatology practice.............................................................................CA-9
Table 4a: Ratios of dermatology nurses to dermatologists........................................................................CA-10
Table 4b: Ratio of dermatology nurses to dermatologists, by province....................................................CA-10
Figure 5: Dermatologists in Training..........................................................................................................CA-11
Table 5: Comparison of dermatologist fees by province and territory.....................................................CA-12
Table 6: Performance ratings on access to medical procedures.................................................................CA-14
Table 7: Phototherapy clinics in Canada (estimated, 2006).......................................................................CA-15
Figure 6: Locations of Phototherapy Clinics in Canada 2006...................................................................CA-16
Table 8: Professional fees for a narrow-band UVB phototherapy session by jurisdiction.......................CA-16
Table 9: PUVA phototherapy as an insured service for vitiligo patients...................................................CA-17
Table 10: Availability of specialized dermatology services by province....................................................CA-18
Table 11: Performance ratings on access to medications...........................................................................CA-19
Table 12: Funding status by province of medications to treat psoriasis....................................................CA-21
Table 13: Comparison of Special Authorization criteria for biologic medications for psoriasis.............CA-22
Table 14: Funding status by province of medications to treat eczema......................................................CA-22
Table 15: Funding status by province of medications to treat and prevent viral skin infections............CA-23
Table 16: Funding status by province of medications to treat skin cancers..............................................CA-24
Table 17: Funding status by province of medications to treat rare skin diseases......................................CA-25
Quebec
Table 1: Performance of Quebec on access to dermatological care ........................................................... QC-3
Figure 1: Wait Times for Dermatologist Consultation in Quebec............................................................. QC-4
Figure 2: Lack of Accessibility of Dermatologists in Quebec...................................................................... QC-5
Table 2: Ratios of dermatology nurses to dermatologists........................................................................... QC-6
Figure 4: Dermatologists in Training in Quebec ........................................................................................ QC-7
Table 3: Relative remuneration for dermatologist office visits................................................................... QC-8
Table 4: Performance of Quebec on access to medical procedures.......................................................... QC-10
Table 5: Performance of Quebec on access to medications...................................................................... QC-11
Table 6: Funding status of medications to treat psoriasis in Quebec....................................................... QC-13
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
v
Contents
Table 7: Funding status of medications to treat eczema in Quebec......................................................... QC-15
Table 8: Funding status of medications to treat viral skin infections in Quebec..................................... QC-16
Table 9: Funding status of medications to treat skin cancers in Quebec................................................. QC-17
Table 10: Funding status of medications to treat rare skin diseases in Quebec....................................... QC-18
Appendix 1
Table 1: Dermatologist fees...............................................................................................................................A-1
Table 2: Formulary sources...............................................................................................................................A-2
Appendix 2
Table 1: Benchmarks for access to dermatological care..................................................................................A-3
Figure 1: Factors affecting supply and demand for medical dermatology services.......................................A-4
Table 2: Forecasting the growth of demand for dermatology services...........................................................A-5
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Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Executive Summary
Many millions of Canadians suffer from skin disorders. At any time, approximately half
of the population is grappling with a skin condition, disease or trauma. Some of these
are life-threatening, while others reduce the quality of life for patients and their families.
Although there is often no permanent cure for these diseases or traumas, there are many
effective forms of treatment that improve a person’s ability to live a normal, healthy life.
This CSPA Report Card provides an assessment of the performance of three primary
areas of the Canadian health-care system:
1. Access to dermatological care;
2. Access to medical procedures;
3. Access to medications.
The CSPA Report Card covers five categories of common skin conditions and two rare
diseases. Since there are over 3,000 different skin diseases, we selected a representative few in order to reveal the problems that are experienced by most patients needing
dermatological care in Canada.
Overall, Canada receives a failing grade for access to dermatological medicines, care and
treatments. While some provinces deserve credit for investing in new specialized treatments for skin diseases, the basic needs of most of Canada’s skin patients are not being
met.
Issues
The CSPA Report Card reveals the following key findings:
• First, patients wait too long for routine appointments—on average, at least twice as
long as the benchmark median wait time of five weeks. Fifty per cent of patients wait
longer than 12 weeks following referral from their family doctor.
• Importantly, the availability of a primary form of treatment for many skin diseases—phototherapy—is severely lacking and increasingly difficult to obtain. Consequently, provincial governments are paying higher costs in other forms of treatment because of these shortages.
• Furthermore, not all medications deemed to be the standard of care are covered by
government formularies. Access to newer medications, which could provide patients
with improved tolerability and quality of life, are usually restricted. They can also
sometimes require patients to undergo months or years of treatment with drugs
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Executive Summary
having poorer effectiveness and/or high levels of side effects. Too often, dermatologists know that a better treatment exists that would greatly improve their patients’
conditions and quality of life, but they cannot prescribe them because they are not
covered under provincial formularies.
• Patients with rare skin diseases do not have access to promising treatments. Canada
lacks an “orphan drug” policy to promote research into new medications. In addition, most jurisdictions that do not have special exemptions and emergency drug
release programs for other rare diseases currently do not apply them to most rare
dermatological diseases.
There is great disparity across the country regarding the availability of dermatological
care and treatment and the quality of services in each jurisdiction. The CSPA Report
Card provides details about the status of dermatological care provided in each jurisdiction.
Little is being done to improve access to dermatological care, either by increasing access
for Canadians living outside urban centres, by supporting the use of other health professionals such as dermatology nurses to work alongside dermatologists or by expanding
the number of training places for dermatologists. Likewise, while access to specialized
treatments is increasing, the disappearance of basic services such as phototherapy and
the cumbersome and sometimes unreasonable restrictions on newer medications remain
problematic.
Recommendations
Responsibility for addressing the issues outlined in this report is shared between federal,
provincial and territorial governments; medical colleges, schools and professional associations; dermatologists; and patients. The CSPA invites all stakeholders to be part of
a concerted effort to improve access to dermatological care and treatment for all Canadians.
The CSPA calls on the federal, provincial and territorial governments to take the lead regarding the following recommendations, in collaboration with dermatology professionals and patients. Further details about each recommendation are found in the relevant
sections of the report.
Improve access to dermatological care
1. Reduce wait time for routine consultation by a dermatologist to five weeks within
the next three years. Options for achieving this goal may include:
• Creation of a plan to achieve a minimum ratio of one full-time medical dermatologist for every 65,000 people;
• Examining systems of remuneration for medical dermatology services;
• Creating billing codes for the services of trained dermatology nurses.
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Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Executive Summary
2. Require that basic dermatological care is provided within reasonable commuting
distance for 90 per cent of residents by dermatologists and/or dermatology nurses
under the supervision of dermatologists in all provinces and territories. Options for
achieving this goal may include:
• A roundtable discussion in 2012 initiated by the Federal Ministry of Health to remove the factors limiting the use of teledermatology services in rural and remote
regions;
• Creation of a plan to expand outreach visits by dermatologists or dermatology
nurses under the supervision of a dermatologist.
3. Prepare and plan to meet current and future demands for dermatological services
based on expected dermatologist retirements, population growth and the rising incidence of skin disease. Options for achieving this goal may include:
• Expanding the number of dermatology training places;
• Ensuring that systems of remuneration support the recruitment and retention of
medical dermatologists.
• Ensuring that systems of remuneration support the recruitment and retention of
trained dermatology nurses to work under the supervision of dermatologists.
Improve access to medical procedures
1. Ensure that every skin patient has access to phototherapy by providing a clinic in
every publicly funded hospital and by including home phototherapy as an insured
service for patients who cannot access a clinic.
2. Fund medical procedures for vitiligo as for other dermatological conditions.
3. Provide specialized dermatological procedures, such as Mohs surgery, plasmapheresis and photopheresis, within reasonable travelling distance for patients.
Improve access to medications
To all provincial, territorial and federal drug programs:
1. Fund all drugs deemed to be the standard of care without restrictions and without a
time-consuming application process, allowing physicians, together with their patients, to make the decision about which therapies are appropriate.
2. Fund anti-viral medications for herpes simplex infections, and HPV vaccinations for
boys.
3. Move swiftly to provide coverage for new skin cancer drugs currently in the regulatory approval pipeline, in order to save the lives of Canadians.
4. Develop policies for rare diseases and provide coverage for promising and effective
treatments for skin patients with rare or orphan diseases. For jurisdictions where orphan drug policies exist or where there are special exemptions and emergency drug
release programs, expand the existing access to cover rare dermatological diseases.
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
xxi
Executive Summary
Rare skin diseases can profoundly affect lives and need to be considered serious and
therefore warrant these considerations.
To the federal government:
1. Take a leadership role and develop and implement a national “orphan or rare disease” policy to encourage the introduction of new drugs to treat rare skin diseases,
as well as set into place mechanisms so that Canadians, wherever they live, can gain
access to treatments that help them.
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Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Introduction
Many millions of Canadians suffer from skin disorders—some of which are life-threatening, while others severely reduce the quality of life for patients and their families.
Although there is often no permanent cure for these diseases, there are many effective
forms of treatment that improve a person’s ability to live a normal, healthy life.
Yet, there are deficiencies and disparities regarding access to dermatological care and
treatment across the country. Some effective treatments are not funded by governments,
and not all Canadians have access to the same level of care. Long wait times and a shortage of dermatologists threaten the ability of patients to receive the medical attention they
need. This CSPA Report Card was written to measure and expose how well skin patients
are able to access a reasonable level of dermatological care and treatment. Its findings
will serve as a foundation for the advocacy work of the Canadian Skin Patient Alliance,
its affiliates and other stakeholders. As the CSPA Report Card is updated in future years,
Canadians will be able to track our progress in improving patients’ access to effective
care and treatment for skin diseases.
About the Canadian Skin Patient Alliance (CSPA)
The Canadian Skin Patient Alliance (CSPA) is an umbrella organization representing
the collective interests of its member groups and the millions of Canadians who grapple
with dermatological conditions—diseases of the skin, hair and nails. Founded in 2007,
the CSPA provides education, information and an online support community, as well as
opportunities for Canadian skin patients to create and join local support groups.
Advocacy is one of the CSPA’s primary missions. As such, the CSPA Report Card presents
a set of facts to draw attention to the urgent needs of skin patients and pinpoints those
areas that must change. The Report Card enables advocates to discuss with their governments and other stakeholders how improvements can be made that will help Canadian
skin patients and their families to participate fully in their home, community and working lives.
Prevalence of skin diseases in Canada
Clinical experts have identified more than 3,000 types of skin disorders—some quite
rare, such as cutaneous T-cell lymphoma, and others quite common, like psoriasis, which
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
xxiii
Introduction
affects one in 50 Canadians.1 It is estimated that over half of the Canadian population
suffers from a skin condition,2 many of whom are young and will continue to experience
some level of disability for decades.
As it would be impossible to address every issue associated with access to care and treatment for each skin disease, we have selected five common and two rare diseases for the
Report Card as representative of the array of skin disorders and issues related to their
treatment. These representative disorders are:
• Psoriasis: an autoimmune disease causing mild, moderate or severe skin lesions;
• Eczema (also called atopic dermatitis): red, scaly, intensely itchy skin patches aggravated by contact with irritants;
• Vitiligo: patchy depigmentation of the skin due to localized depletion of melanin;
• Skin cancers: malignant melanoma, basal cell carcinoma and squamous cell carcinoma;
• Viral skin infections: herpes simplex (cold sores, genital warts), herpes zoster
(shingles) and human papilloma virus (ano-genital warts);
• Rare skin disorders: cutaneous T-cell lymphoma (a type of cancer), and pemphigus
(an autoimmune disease causing severe blistering of skin and mucous membranes).
Burden of skin diseases
Research shows that the burden of skin diseases is high in Canada—both in terms of
health outcomes and in social and economic costs.
The impact of skin disease across Canada is immense—not
only from a economic point of view but also from the
psychological impact on patients and their families. Many
Canadians at some time in their lives experience some type of
skin disease. A report such as this highlighting the lack of access
to dermatologists and medical treatment and many newer and
investigational drugs is so important to effecting change.
— Dr. Denise Wexler, President of the Canadian
Dermatology Association
Psoriasis affects approximately one in 50 Canadians, and its treatment costs more than
$30 million annually.3 In addition to its economic impact, the disorder also exacts
1. Canadian Guidelines for the Management of Plaque Psoriasis, June 2009.
2. Rea JN et al. Skin disease in Lambeth. A community study of prevalence and use of medical care. Br. J.
Prevent. Soc. Med. 30,107-114 (1976).
3. Ontario Health Technology Assessment Series 2009;9(27).
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Introduction
a heavy emotional and social toll. Psoriasis patients suffer from a variety of psychosocial burdens, including stigmatization, stress, depression, and other psychosocial
co-morbidities,4 even suicidal ideation.5 In Canada, the rate of associated medical and
psychological problems is reported to be up to four-fold higher than in the general
population. One-third of Canadians with psoriasis describe their disease as a substantial
problem in their daily life.6 Furthermore, patients report reduced income and increased
unemployment at levels that increase with psoriasis severity.7 New treatments have been
found to improve patients’ productivity,8 yet these are often difficult to obtain for reasons
that are discussed in this report.
Atopic dermatitis affects up to one in five children9, and the disorder can have a substantial impact on the quality of life of patients and their families. Approximately 80 per
cent of children with atopic dermatitis experience sleep disturbance, leading to daytime
behavioural problems and difficulties in performing daily activities. Atopic dermatitis
has been estimated to cost the Canadian economy $1.4 billion each year.10
Vitiligo affects approximately one per cent of the population globally and is particularly
a problem for pigmented races. Approximately three-quarters of vitiligo sufferers find
their appearance moderately to severely intolerable.11
Melanoma can progress rapidly and is often fatal if caught too late. In 2011, the Canadian Cancer Society estimated there would be 74,100 new cases of non-melanoma skin
cancer (basal cell and squamous cell carcinomas), 5,500 new cases of melanoma and
950 deaths due to melanoma.12 Patients with a recent diagnosis of melanoma exhibit the
same high levels of psychological distress reported by other cancer patients.13 Skin cancers are estimated to cost the Canadian economy over $500 million annually.14
Many skin conditions are caused by a virus. Three strains of herpes virus—herpes
simplex viruses (HSV-1 and HSV-2), and herpes zoster virus—are estimated to affect
4. Kimball AB et al. The psychosocial burden of psoriasis. Am J Clin Dermatol 2005;6:383-92.
5. Gupta MA et al. Suicidal ideation in psoriasis. Int J Dermatol 1993;32:188-90.
6. Lynde CW et al. The burden of psoriasis in Canada: insights from the psoriasis knowledge IN Canada
(SKIN) survey. J Cutan Med Surg 2009;13(5):235-52.
7. Mahler R et al. The burden of psoriasis and barriers to satisfactory care: results from a Canadian
patient survey. Cutan Med Surg 2009;13(6):283-93.
8. Reich K et al. Infliximab treatment improves productivity among patients with moderate-to-severe
psoriasis. Eur J Dermatol 2007;17(5):381-6.
9. Su JC, Kemp AS, Varigos GA, Nolan TM. Atopic eczema: its impact on the family and financial cost.
Arch. Dis. Child. 1997;76:159-162.
10.Barbeau M and Lalonde H. Burden of Atopic dermatitis in Canada. International Journal of
Dermatology 2006;45:31-36.
11.Salzer BA and Schallreuter KU. Investigation of the personality structure in patients with vitiligo and a
possible association with impaired catecholamine metabolism. Dermatology 1995;190:109-115.
12.Canadian Cancer Society. Canadian Cancer Statistics 2011.
13.Fawzy F et al. A structured psychiatric intervention for cancer patients. I. Changes over time in
methods of coping and affective disturbance. Arch. Gen. Psychiatr. 1990;47:720-725.
14.Canadian Partnership Against Cancer. Economic Burden of Skin Cancer in Canada: Current and
Projected. February 2010.
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Introduction
two-thirds of the Canadian population. Cold sores on the lips and around the mouth
are the most common manifestation of HSV-1 infection, whereas genital sores are associated with HSV-2. Herpes zoster virus, more commonly known as “shingles,” affects
another seven per cent of the population. In addition, human papilloma virus (HPV)
affects more than one in six Canadians. Skin diseases caused by HPV, such as ano-genital
warts, have been estimated to cost $418 million in the U.S. and so can be expected to cost
$40 million or more in Canada.15 In addition, there is a link between HPV and cervical
cancer—once again an instance where a skin disease is implicated in wider and deadlier
outcomes.
The impact of rare skin disease on the lives of patients is extraordinary. In addition to
the stigma of having a skin disease, the inability to access medications, treatments or care
can be devastating.
Skin diseases are not just superficial.
The huge psychological and social burden of skin disease cannot be ignored. While we
have not dealt with them specifically here, there are several issues that governments must
acknowledge and address.
Treatment for skin disease must look beyond the physical and address the often more
devastating psychological issues that cause patients to hide, to isolate themselves, to feel
untouchable—like the lepers of biblical times. Three examples of actions that would
signal a willingness to understand and help:
• Governments should provide ready and easy access to a variety of psychological
services and support programs for those with visible skin diseases. More teens with
acne, for example, suffer from depression than do their unblemished peers. Statistically more likely to commit suicide, they would benefit greatly from support groups
and/or counselling.
• In recent studies, psoriasis patients had a 39 per cent increase in the risk of a clinical diagnosis of depression, a 31 per cent increase in the risk of anxiety and a 44
per cent increase in the risk of suicidality.16 Patients with a great many skin diseases
carry with them the burden of looking different and feeling uncomfortable in their
own skin. An acceptance that counselling is part of an accepted treatment paradigm
for visible skin conditions, diseases and traumas (like burns) would surely help.
• Governments should cover wigs for patients with alopecia areata—these are covered
for chemotherapy patients but, inexplicably, not for people who permanently lose
their hair through a skin disease.
15.Hu D, Goldie S. The economic burden of noncervical human papillomavirus disease in the United
States. Am J Obstet Gynecol 2008;198:500.e1-500.e7.
16.Gupta MA, 1998.
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Introduction
Reasonable access to care and treatment
Canadians believe they enjoy one of the best health-care systems in the world. The Canada Health Act guarantees all Canadians reasonable access to medically necessary services. Surely patients with medical skin conditions should also expect to have reasonable
access to the care and treatment they need.
Some governments across Canada have taken the first steps to improve the health outcomes of skin patients by:
• Promoting skin cancer prevention through legislation and awareness programs;
• Providing funding for some of the effective medications and medical procedures
needed;
• Planning to meet current and future needs for dermatology services.
However, many challenges remain. For example:
• Most skin patients must wait several months for a routine appointment to see a
dermatologist;
• In most regions, long wait times reflect a dire shortage of dermatologists and dermatology nurses;
• Canadians who live outside urban centres have little or no access to dermatological
care;
• Many jurisdictions appear not to have planned to replace the 20 per cent of dermatologists who are expected to retire in the next five years;
• There is a critical and growing lack of phototherapy clinics, resulting in patients going without effective treatments and placing an unnecessary burden on drug budgets
for expensive biological therapies, which are the only alternative;
• New medications are being introduced every year that are more effective but usually more costly than existing therapies. Public drug programs are slow to respond
to cover new drugs and often impose cumbersome and sometimes unreasonable
restrictions or deny funding;
• The situation is especially acute for patients with rare skin diseases. Few provinces
have policies to fund drug treatments for specific patients with rare diseases for
which the level of evidence will never be sufficient to meet the criteria for drug
funding approvals. Even though some provinces do have policies or exemption
procedures in place, it is difficult or impossible to get coverage for rare skin diseases
because skin disease is not typically viewed as being “important” or “urgent” or “lifethreatening.”
The CSPA recognizes that governments cannot afford to fund all available treatments,
nor can the numbers of dermatologists be increased quickly with ease. The CSPA’s
position on these issues reflects the premise of the Canada Health Act which promises
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Introduction
“reasonable access to health services without financial or other barriers17.” This Report Card
defines reasonable access for patients against standards of care determined by accepted
health-care benchmarks.
About the Report Card
This is the first issue of the CSPA Report Card. It was developed to give voice to the rising frustration of the millions of Canadians with skin disorders about the unacceptably
low and, in many areas, deteriorating availability of dermatological care and treatment
they receive through the publicly funded health system.
The 2012 CSPA Report Card assesses only public drug programs. Although many Canadians are covered by private insurance for the costs of drugs, and sometimes medical
equipment and travel expenses, there are thousands of different plans, making assessment of them beyond the present scope of the CSPA’s research capabilities.
Details about the information, sources and methodology used to produce the CSPA Report Card are provided in the appendices.
How performance was graded
Performance grades were decided by the CSPA based on our positions, on clinical practice guidelines and, where the latter do not exist, on historical precedent and on the
judgement of a panel of dermatologists about what constitutes an acceptable standard of
care.
At this time, there are no published benchmarks that define the point at which patients
experience harm from lack of access to dermatological care and treatment. The Report
Card uses benchmarks obtained from published, historical, calculated or best-practice
sources wherever possible. These benchmarks are described below and explained in further detail in each section of the Report Card.
17.Canada Health Act. Available online: http://laws.justice.gc.ca/Search/Search.aspx?txtS3archA11=ACCE
SS&txtT1tl3=%22Canada+Health+Act%22&h1ts0n1y=0&ddC0nt3ntTyp3=Acts.
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Introduction
The following method was used to establish overall grades for each jurisdiction the CSPA
assessed:
1. Performance measures within each section were assigned the following weights:
Rating
Score
Excel:
5 points
Pass:
4 points
Needs Improvement:
2 points
Fail:
0 points
2. The ratio of total points for each section to total available points was then calculated.
3. The overall grade was assigned and colour-coded based on these ranges:
Rating
Score
Excel
> 75%
Pass
51–75%
Needs improvement
35–50%
Fail
< 35%
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Introduction
The following scoring method was used:
Table 1: The CSPA Report Card Scoring Method
Performance
Measured:
Measurement Performance
Benchmark
Scoring Range
Access to
dermatological
care
Wait time for
non-urgent
consultation
5 weeks
(2001 national median wait
time)
•
•
•
•
Excel: < 5 weeks
Pass: 5-6 weeks
Needs improvement: 7-12 weeks
Fail: > 12 weeks
Increase in
number of
new full-time
dermatologists
6.2% annual increase
(Replacement rate for retiring
dermatologists plus increased
demand due to rising
incidence of skin disease)
•
•
•
•
Excel: > 6%
Pass: 4-6%
Needs improvement: 2-3%
Fail: < 2%
Ratio of trained
dermatology
nurses to
dermatologists
0.5 dermatology nurses per
dermatologist
(national best practice)
•
•
•
•
Excel: > 0.5
Pass: 0.4-0.5
Needs improvement: 0.2-0.3
Fail: < 0.2
Number of
phototherapy
facilities per
population
Ratio of one phototherapy
facility per 65,000 population
(Royal College of Physicians &
Surgeons)
•
•
•
•
Excel: < 65,000
Pass: 65,000 to 70,000
Needs improvement: 70,000 to 150,000
Fail: > 150,000
Access to
phototherapy
facilities
Percentage of population
having access to a
phototherapy facility
within commuting distance
(including insured home
phototherapy)
•
•
•
•
Excel: > 95%
Pass: 85-95%
Needs improvement: 65-84%
Fail: < 65%
Procedures for
vitiligo
Phototherapy is an insured
service and is accessible.
• Excel: Phototherapy is an insured service and is
accessible by > 95% of population.
• Pass: Phototherapy is an insured service and is
accessible by 85-95% of population.
• Needs improvement: Phototherapy is a
restricted service and/or is accessible by 6584% of population.
• Fail: Phototherapy is not an insured service
and/or is accessible by < 65% of population.
Specialized
procedures
Availability in the province of:
• Mohs surgery
• Plasmapheresis
• Photopheresis
• Excel: All 3 procedures available in the
province.
• Pass: All 3 available
• Needs improvement: 1-2 available
• Fail: None available
Number of drugs
for common
skin diseases on
formulary
All drugs deemed the standard • Pass: 90% or more drugs on formulary
of care are on formulary
• Needs improvement: 60-89%
(lower “pass” rate reflects time • Fail: < 60%
needed to review new drugs.)
Access to
medical
procedures
Access to
medications
xxx
Restrictions on use Number of funded drugs
of drugs
having no restrictions
(lower “pass” rate reflects
restrictions for reasons of
patient safety)
•
•
•
•
Excel: > 90% unrestricted
Pass: 80-89%
Needs improvement: 60-74%
Fail: < 60%
Policy on drugs for Policy in place and applies to
rare diseases
skin patients
• Pass: Policy in place and applies to skin
patients
• Needs improvement: Policy in place but does
not apply to skin patients
• Fail: No policy in place
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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National
Canada receives a failing grade overall for access to dermatological care and treatment.
While some provinces deserve some credit for investing in new specialized treatments
for skin diseases, the basic needs of skin patients for timely access to appropriate services
are not being met. There is great variability among jurisdictions in the quality of services provided. The overall performance assessment shown in Table 1, below, masks some
positive highlights and glaring deficiencies that are apparent only on viewing the individual provincial reports.
Table 1: How is Canada performing?
Access to
Dermatological Care
Access to Medical
Procedures
Access to Medications
Canada
Fail
Fail
Fail
British Columbia
Fail
Needs improvement
Fail
Alberta
Fail
Fail
Fail
Saskatchewan
Fail
Fail
Fail
Needs improvement
Fail
Fail
Ontario
Fail
Needs improvement
Needs improvement
Quebec
Fail
Fail
Needs improvement
Needs improvement
Fail
Fail
Prince Edward Island
Fail
Fail
Fail
Nova Scotia
Fail
Fail
Fail
Newfoundland and
Labrador
Fail
Fail
Fail
Yukon
Fail
Fail
Fail
Northwest Territories
Fail
Fail
Fail
Nunavut
Fail
Fail
Fail
Non-Insured Health
Benefits*
N/A
N/A
Fail
Manitoba
New Brunswick
National
*N
on-Insured Health Benefits is a federal program that covers the costs of medications, medical supplies and medical travel, within
certain restrictions, for registered First Nations and Inuit beneficiaries.
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Issues and Actions
Where are the gaps?
There is a looming crisis in access to dermatological care and treatment for the many
millions of Canadians who rely on these services. Canada’s publicly funded health-care
system, while it offers substantial benefits, falls short in each of the three areas where performance was measured:
1. Access to dermatological care:
• Wait times for a routine appointment with a dermatologist is perhaps the most
glaring gap. Half of patients wait at least 12 weeks on referral from their family
doctor. In some areas of the country, the median wait time is 23 weeks;
• Support for trained dermatology nurses is low to non-existent, yet these allied
health professionals could play an important role in reducing wait times;
• The number of new dermatologists is not increasing fast enough to meet future
demands for dermatology services.
2. Access to medical procedures:
• Phototherapy, which is a mainstay of treatment for many common skin diseases,
is being eliminated by many hospitals and dermatology clinics due to budget
constraints. Skin patients without access to phototherapy services must purchase
home phototherapy units at their own expense or take costly medications (often
at the expense of governments) as the only alternative treatment;
• Phototherapy and other treatments for vitiligo, a pigmentation disorder with high
psychological, social and economic impacts, are not funded in many provinces.
3. Access to medications:
• Not all medications deemed the standard of care are covered by government formularies;
• Access to newer medications, which offer patients improved tolerability and quality of life, are restricted and require patients to undergo months or years of treatment with drugs having high levels of side effects and poorer effectiveness;
• Medications and treatments for melanoma and skin cancers are either not covered or only covered with restrictions for far too many Canadians. Promising
new treatments for melanoma are in the regulatory pipeline and will need to be
covered expeditiously to save lives;
• Patients with rare skin diseases lack access to promising treatments. Canada does
not have a national “orphan disease” policy to encourage the introduction of new
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drugs for rare diseases, and virtually all provinces lack policies or programs that
fund drugs that are effective for Canadians with rare skin diseases.
Who is at risk?
While all Canadians with skin conditions are affected by these gaps, a few groups of patients are at particular risk. For example:
• Skin patients requiring phototherapy treatments are increasingly at risk because of
phototherapy clinic closures and the need to travel long distances to receive treatments several times a week;
• Atlantic Canadians and residents of Saskatchewan have much longer wait times
and less access to medical procedures. Residents of the three territories are entirely
dependent on outreach services from neighbouring provinces;
• Canadians living outside urban areas are increasingly vulnerable to shortages of
dermatologists and to the expenses of travelling to receive necessary treatments;
• Canadians without private insurance do not have the benefit of prompt and broad
access to medication that is generally provided by employer-sponsored drug plans.
What the CSPA is doing
The Canadian Skin Patient Alliance has been advocating for improvements to the healthcare system since 2007. Our advocacy campaigns have focused on the shortage of dermatologists in Canada as well as on access to newer and effective treatments and medications.
National
The CSPA also contributes funds for research about skin diseases, which will help to
build an evidence base to determine the most effective treatments. Through meetings,
newsletters and publication of our quarterly magazine we educate Canadians, make patients aware of their treatment options and raise awareness of access issues. We continue
to lobby governments for access to specific new treatments for the patients we represent.
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Detailed Tables
The tables in this section compare access to dermatological care and treatment in each
province and territory, and by the federal Non-Insured Health Benefits (NIHB) program.1
1. Access to dermatological care
Access to dermatological care was assessed by measuring three indicators: wait times, increases in the number of dermatologists over the past five years, and the ratio of dermatology nurses to dermatologists.
Although median wait times for a non-urgent consultation is the most important measure from the patient’s perspective, additional information may help to inform policy
directions. For this reason, we also calculated the number of full-time medical dermatologists in each jurisdiction and examined steps taken by governments to improve access,
such as expanding training positions and providing outreach services.
How does Canada’s performance rate?
Canada falls far short of the CSPA’s benchmarks on access to dermatological care.
Table 2: Overall performance ratings on access to dermatological care
CDN
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
YT
NT
NU
Fail
Fail
Fail
Fail
NI
Fail
Fail
NI
Fail
Fail
Fail
Fail
Fail
Fail
Legend: NI = needs improvement
Long wait times
Canadians wait far too long for a consultation after they have been referred by their
family doctor.
The benchmark for wait times is five weeks for an initial, non-urgent consultation with
a dermatologist. This measure was chosen to reflect the need for patients with debilitating conditions to obtain timely treatment that may allow them to return to their daily
lives without detrimental effects to their health, work, psychological state and social
functioning. This benchmark is based on the national median wait time reported by the
Canadian Dermatology Association (CDA) Workforce Survey in 2001.
An independent survey, conducted in February-March 2011, and sponsored by the
CSPA, showed that patients wait an unacceptably long time for an initial appointment.
1. The Non-Insured Health Benefits program covers registered First Nations and Inuit.
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The median wait time was 12 weeks for any Canadian skin patient. Furthermore, onefourth of patients must wait 23 weeks, or nearly six months, to be seen. As Table 3,
below, reveals, none of the provinces came close to reaching the recommended five-week
benchmark:
Table 3: Median wait times in weeks for routine consultation
BenchMark
CDN
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
Median wait
time (weeks)
for routine
consultation
5
12
10
8
14*
14*
12
18
23*
n/a
23*
23*
Performance
Grade
Pass
NI
NI
NI
Fail
Fail
NI
Fail
Fail
Fail
Fail
* Wait times data for Saskatchewan, Manitoba and the Atlantic provinces were combined due to the small number of responses in
each individual province.
The problem of wait times may also extend to appointments to investigate a possible
diagnosis of skin cancer. In a national survey conducted in 2011, the Melanoma Network
of Canada reported that 55 per cent of patients had to wait longer than the accepted
benchmark of two weeks2 to be seen by a dermatologist.3
National
Many physicians concur with the CSPA’s findings that there is a lack of access to dermatologists. In fact, Canadian dermatologists report that they are nearly twice as difficult
to access compared to other specialists. In the 2010 National Physician Survey,4 doctors
were asked to rate their own accessibility to their patients. Figure 1 shows that 38 per
cent of them said their accessibility was either “poor” or “fair.” As the figure reveals, in all
provinces surveyed, dermatologists were considerably more difficult to access.
2. Suneja T, Smith ED, Chen GJ, et al; Waiting times to see a dermatologist are perceived as too long by
dermatologists. Arch Dermatol. 2005;137:1303-1307.
3. Samuel Hetz, in partnership with Melanoma Network Canada. Survey conducted January – March
2011.
4. 2010 National Physician Survey. The College of Family Physicians of Canada, Canadian Medical
Association, The Royal College of Physicians and Surgeons of Canada.
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A greater percentage of dermatologists report they are difficult to see
compared with other specialists.
60%
50%
40%
30%
20%
10%
All Specialists
Dermatologists
tia
No
va
S
co
ec
eb
Qu
rio
ta
On
ba
M
an
ito
ta
Al
be
r
B.
C
.
0%
Ca
na
da
Percentage of doctors rating their access as poor or fair
Figure 1: Lack
Lack of
of Accessibility
Accessibility of
of Dermatologists
Dermatologists
Source: National Physican Survey 2010
To make matters worse, wait times are steadily increasing, as shown in Figure 2, which
is a comparison of data from three surveys conducted over the past 10 years against the
CSPA recommended benchmark wait time of five weeks.
The Canadian Dermatology Association (CDA) 2001 Workforce Survey reported a
national median wait time of five weeks for a routine dermatologist appointment. In
2006, the CDA reported that wait times had doubled to 10 weeks. The 2011 CSPA survey
showed that wait times had further increased to 12 weeks. Although caution should be
used in comparing data from different sources, the trend toward worsening wait times is
clear. (Note: This negative trend may actually be understated, as the CDA survey examined time to the third-next appointment, whereas the CSPA survey measured time to the
next available appointment.)
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Figure 2:Median
MedianWait
WaitTimes
TimesforforDermatologist
DermatologistConsultation
Consultation
14
12
Weeks
10
8
6
Benchmark
4
2
0
2001 (CDA)
2006 (CDA)
2011 (CSPA)
Low and steadily declining numbers of dermatologists
One reason for long wait times may be the shortage of dermatologists. The benchmark
ratio of one dermatologist for every 65,000 people was chosen based on the recommendations from the Royal College of Physicians and Surgeons of Canada.5 In seven of 10
provinces, the number of full-time dermatologists is insufficient to achieve the benchmark. In fact, in Saskatchewan, one dermatologist provides services to over 250,000
people.
In addition to the current shortage of dermatologists in most of Canada, a major concern is that the number of dermatologists being trained will not keep up with expected
retirements and increased demand for services in the future. The average age of dermatologists in Canada is 55, and more than one in five is already over age 65.6
The number of full-time-equivalent dermatologists needs to increase at an annual rate
of 6.2 per cent in order to replace retirees and to meet future demands for services due
to growth in the population and rising incidence of skin disease (see Appendix 2). In the
five-year period ending in 2008-09, the number of full-time dermatologists had risen at a
rate of only 0.8 per cent annually7—far from meeting the required rate of growth.
Lack of access in rural and remote areas
National
The shortage of dermatologists is even more acute in rural and remote areas of Canada.
As shown in Figure 3 below, the concentration of dermatologists is largely in southern,
urban centres. No dermatologists are based in the territories or in the northern parts of
most provinces.
5. Royal College of Physicians and Surgeons of Canada. National Specialty Physician Review. July 1988.
6. Canadian Medical Association 2010.
7. National Physician Database 2004-05 to 2008-09.
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Figure 3: Distribution of Dermatologists in Canada
One dot represents one physician (N = 510).
Dots may overlap for the same geographic location.
Source: Geographic Distribution of Physicians in Canada: Beyond How Many and Where. Canadian Institute for Health Information
(CIHI) 2005.
Although many dermatologists provide outreach services to smaller communities, Figure
4 shows the discrepancy between citizens residing outside urban centres and the level
of outreach provided. According to the 2006 census, 20 per cent of Canadians reside in
a rural or remote area; however, according to the Canadian Dermatology Association’s
2006 Workforce Survey, only eight per cent of dermatologists’ time is spent practising
outside urban areas. This means that a Canadian living in a rural or remote community
is less than half as likely to be able to receive care from a dermatologist than is someone
living in an urban area.
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Urban
concentration
of of
dermatology
practice
Figure 4:
Urban
concentration
dermatology
practice
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Dermatologist time
Canadian population
0%
Urban
Rural + remote
Sources: CDA Workforce Survey 2006, Statistics Canada
Need for more dermatology nurses
Long wait times for dermatological care could be alleviated by employing other health
professionals to work alongside dermatologists. Trained dermatology nurses are being
used effectively in other countries to assist busy dermatologists by screening patients and
overseeing their treatments.
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Tables 4a and 4b, below, reveals that, on average, one dermatology nurse is employed for
every five dermatologists in Canada. In the United Kingdom, there are four dermatology nurses or dermatology nurse practitioners for every five dermatologists, reflecting
a team-based approached to providing care.8 In the U.S., 30 per cent of dermatologists
reported that they used a dermatology nurse or a dermatology nurse practitioner in their
practices.9 The CSPA’s recommended benchmark ratio of 0.5 is based upon the best practice ratio found in Nova Scotia, an achievable goal for many other jurisdictions.
8. An audit of the provision of dermatology services in secondary care in the United Kingdom with a
focus on the care of people with psoriasis. British Association of Dermatologists and the Royal College
of Physicians and Surgeons 2008.
9. Resneck, JS Jr et al. Who else is providing care in dermatology practices? Trends in the use of
nonphysician clinicians. Journal of the American Academy of Dermatology 2008;58(2)211-216.
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Table 4a: Ratios of dermatology nurses to dermatologists
Benchmark
Canada
U.K.
U.S.
0.5
0.2
0.8
0.3
Nova Scotia leads the country in its employment of dermatology nurses but Quebec and
Newfoundland and Labrador lag. Prince Edward Island currently has no dermatologist
and so may not be able to support a dermatology nurse position.
Table 4b: Ratio of dermatology nurses to dermatologists, by province
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
0.2
0.3
0.3
0.2
0.3
0.01
0.2
0.0
0.5
0.1
Source: Canadian Dermatology Nurses Association, 2010
This limited analysis suggests that Canada may not have capitalized on an opportunity to make more efficient use of dermatologists’ time through the utilization of trained
dermatology nurses. Billing codes that encourage dermatologists to hire dermatology
nurses with specialized training and skills to assist in the treatment of many skin conditions will help to address long wait times.
Need for more Mohs surgeons
Dermatologists trained in Mohs micrographic techniques are able to perform more
complex but minimally invasive surgeries that almost completely remove various types
of skin lesions, including cancers.
According to the Canadian Association of Mohs Surgeons, there are currently 19 accredited Mohs surgeons in Canada. Long wait lists appear to indicate that more Mohs
surgeons are needed. Of the16 Mohs surgeons who responded to a request for information, half indicated that their wait list was four months or longer for most procedures
and two to three weeks for skin cancers.10 Those contacted stated that the number of
Mohs surgeons needs to double across the country.
How have governments responded?
Some provincial and territorial governments have taken steps to improve access to
dermatological care. Strategies include increasing the number of training places, negotiating dermatologist fees that encourage the practice of medical dermatology within their
jurisdiction, and/or improving outreach services. However, these actions generally have
fallen short of what is needed to achieve the level of access that Canadian skin patients
need and deserve.
10.Personal communication from Dr. Evert Tuyp, dermatologist, British Columbia.
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Training new dermatologists
Training new dermatologists is essential to replace retirees and to meet the growing
demand for services. There are currently 104 dermatologists in training (excluding visa
students) of whom only 12 are expected to enter into practice in 2011 (including visa
students).11 This addition amounts to only 2.5 per cent of the current full-time medical
dermatologists, whereas a growth rate of 6.2 per cent (or a minimum of 32 new entries
per year) is needed. In fact, the current rate of new entries is insufficient even to replace
the expected numbers of retirees.
On the upside, the number of dermatology training places has been increasing steadily
over the past five years. Since dermatology training is a five-year program, the numbers
of new dermatologists will be expected to rise beginning in 2012-13. Nevertheless, even
higher numbers of dermatology training places are needed to meet future demands for
services.
Dermatologists
in Training
Figure
5: Dermatologists
in Training
120
100
80
60
40
In training
(ministry funded only)
20
Estimated practice
entries (all)
0
2006-07
2007-08
2008-09
2009-10
2010-11
Source: Canadian Post-MD Educational Registry
The CSPA recommends that a minimum goal of 35 new practice entries should be set
until all provinces reach the recommended benchmark of one full-time medical dermatologist for every 65,000 people. Filling these new places should not be a problem since
there is strong interest in dermatology among medical school graduates. In 2011, only 59
per cent of first-year medical residents wishing to specialize in dermatology were able to
be placed in training programs.12
National
Remuneration
A potential cause of the shortage of dermatologists (including Mohs surgeons) may be
related to remuneration for medical services. Jurisdictions with comparatively low fees
11.Canadian Post-MD Educational Registry (CAPER) 2010-11.
12.Canadian Resident Matching Service, 2011.
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are at risk of diminishing numbers of dermatologists because those specialists may locate
elsewhere and/or devote increased time to cosmetic services. Although fees are not the
only, or even the most important, reason for a dermatologist to practise in a certain area,
an unrealistically low level of remuneration may limit the amount of time a dermatologist can afford to spend delivering insured services, which may dissuade medical students
from entering the specialty.
Table 5, below, depicts the fee payments for consultations and repeat visits used as indicators of overall remuneration. Provinces and territories whose fees were 20 per cent
greater or less than the interprovincial average are highlighted. The comparison reveals
that British Columbia may be at risk of losing dermatologists, whereas New Brunswick
and the territories appear better positioned to recruit and retain dermatologists.
Table 5: Comparison of dermatologist fees by province and territory
Appointment Type
Prov.
Avg.
BC
AB
SK
MB
ON
QC
Fee per comprehensive
consultation
$78.99
$59.66
$69.03
$78.20
$64.45
$70.25
$62.20
Fee per repeat office
visit
$29.77
$22.55
$39.68
$30.20
$28.30
$21.40
$25.80
Appointment Type
Prov.
Avg.
NB
PE
NS
NL
YT
NT
Fee per comprehensive
consultation
$78.99
$102.95
$85.00
$119.60
$78.51
$108.30
$116.70
Fee per repeat office
visit
$29.77
$37.70
$33.00
$29.90
$29.16
$75.50
$63.65
Legend:
20% or more above provincial average
within +/– 20%
> 20% below
Outreach to rural and remote communities
None of the provinces has a requirement to maintain a minimum level of dermatology
services no matter where its citizens reside. For many of the 20 per cent of Canadians
who live outside an urban centre, outreach services are the only way they can access
dermatological care.
As mentioned earlier, dermatologists report that only eight per cent of their time is spent
practising outside urban centres—much less than is needed. Given that there is already
a shortage of dermatologists in eight out of 10 provinces even in the urban centres, the
problem in rural areas becomes more dire.
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Teledermatology is one option to increase services in rural and remote areas. Assessments of the utility of teledermatology generally recommend that this technology be
used to supplement rather than replace in-person care.13 14
Provincial governments and dermatologists have used this technology to varying degrees.
All provinces (except Prince Edward Island) have the available equipment and (except
Quebec) include teledermatology consultations in their fee schedules. Yet some dermatologists interviewed for the CSPA Report Card said that it is seldom used in practice.
The CDA Workforce Survey reported that in 2006 only one in 12 dermatologists used
teledermatology, and only for an average of three hours per week. Overall, this amounted
to only one-tenth of one per cent of all dermatologists’ time, suggesting that there is potential to expand these services. Dermatologists in Edmonton have developed their own
program, which is growing in use by family physicians and which might serve as a model
in other centres.
Although dermatologists would like to make more use of the technology, liability issues
have been mentioned by some as a concern where physical examination by a trained
specialist plays a key role in diagnosis. Remuneration and ease of use of the technology
are other issues. Until these issues are resolved it is unlikely that this important tool can
achieve its potential to improve the quality of care and reduce costs of outreach services.
CSPA recommendations to improve access to dermatological care
The CSPA calls on federal, provincial and territorial governments to take the lead and to
work in collaboration with dermatology professionals and patients to do the following:
1. Reduce wait times for routine dermatology consultations to five weeks within the
next three years. Strategies may include:
• Developing a plan to achieve a minimum ratio of one full-time medical dermatologist per 65,000 population;
• Supporting the hiring of trained dermatology nurses by dermatologists by creating billing codes for their services.
2. Require that basic dermatological care is provided within reasonable commuting
distance for 90 per cent of residents by dermatologists or dermatology nurses under
the supervision of a physician. Options for achieving this goal may include:
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• In 2012, the Ministry of Health to initiate a roundtable discussion that examines
and finds solutions for the limiting factors associated with the use of teledermatology services in rural and remote regions;
13.Ndegwa, S et al. Teledermatology services: rapid review of diagnostic, clinical management, and
economic outcomes. Canadian Agency for Drugs and Technology in Health (CADTH). Technology
Report. Issue 135 October 2010.
14.Louise Gagnon. Remote viewing: teledermatology increases access to specialists in Canada.
Dermatology Times August 1, 2008.
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• Create a plan to expand outreach visits by dermatologists or dermatology nurses
under the supervision of a dermatologist;
• Prepare to meet future demands for dermatological services, based on expected
dermatologist retirements, population growth and rising incidences of skin diseases;
• Expand the number of dermatology training places by 35 to achieve an overall annual increase in numbers of dermatologists of 6.2 per cent;
• Ensure that systems of remuneration support the recruitment and retention of
medical dermatologists.
2. Access to medical procedures
Access to medical procedures was assessed according to whether they are funded and
available within reasonable distance from where Canadians live.
Canada falls far short of the CSPA’s benchmarks for providing access to dermatological
procedures, primarily because of the low and declining availability of phototherapy
facilities across Canada.
Table 6: Performance ratings on access to medical procedures
CDN
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
YT
NT
NU
Fail
NI
Fail
Fail
Fail
NI
Fail
Fail
Fail
Fail
Fail
Fail
Fail
Fail
Legend: NI = needs improvement
Access to medical procedures was assessed according to the following factors:
What is the situation today?
Phototherapy
Phototherapy, including psoralen/ultraviolet A (PUVA) and broad- and narrow-band
UVB treatments, is a widely used, effective and non-invasive treatment for several skin
conditions, including psoriasis, acne, eczema, vitiligo, itchy skin, lichen planus, granuloma annulare and certain rare skin diseases. In some cases, it represents a cost-effective
alternative that may also alleviate or slow the need for more expensive treatments or
medications.
While there is no definitive source of information about how many phototherapy clinics
are operating in Canada, based on information from multiple sources it is estimated that
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in 2006 there were over 100 locations across the country.15 The benchmark chosen for
the CSPA Report Card is one phototherapy clinic for every 65,000 people, mirroring the
standard for dermatologists. Access to phototherapy was also evaluated according to how
far patients must travel to receive treatment. A passing grade requires that at least 85 per
cent of the population can obtain phototherapy treatments within commuting distance.
Currently, all phototherapy clinics are located in urban centres, as shown in Figure 6.
There are no phototherapy clinics in Prince Edward Island or in the three territories, and
only one is located in Manitoba. Since treatments are required two or three times a week,
it is impractical for many Canadians to travel to a phototherapy clinic. Instead, some
patients could opt for home treatment; however, the cost of purchasing the equipment is
not currently covered by any province or territory, nor by many private insurers.
Table 7: Phototherapy clinics in Canada (estimated, 2006)
British Columbia
21
New Brunswick
5
Alberta
14
Prince Edward Island
0
Saskatchewan
3
Nova Scotia
7
3
1
Newfoundland and Labrador
Ontario
30
Yukon Territory
0
Quebec
29
Northwest Territories
0
Nunavut
0
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Manitoba
15.Compiled from: Canadian Dermatology Association list of dermatologists providing courtesy UVA/B
treatments for travellers; Koo, M et al. Phototherapy services in Canada (poster presentation) 2006;
personal communication from Bruce Elliott, President, Solarc Systems Inc., Barrie, Ontario.
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Figure 6: Locations of Phototherapy Clinics in Canada 2006
Moreover, patients and dermatologists have increasingly reported the closure of phototherapy clinics. Hospital-based facilities, which are funded from global budgets, have
closed in some areas due to cost pressures. In these centres, phototherapy is typically
provided by physiotherapy departments where most other treatments tend to be less expensive to provide. As a result of the closure of hospital units, phototherapy clinics based
in dermatologists’ offices cannot keep up with demand.
Many dermatologists interviewed for the CSPA Report Card commented that the fees
for providing phototherapy are insufficient to cover the costs of equipment, staff and
facilities. For example, the cost of a set of UVB light bulbs is $3,000 and these must be
replaced every six to 12 months. Table 8, below, shows the fees paid for a narrow-band
UVB phototherapy session in each province.
Table 8: Professional fees for a narrow-band UVB phototherapy session by jurisdiction
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BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
$19.94
$20.42
$13.90
$27.75
$7.85
$17.40
$33.35
$20.00
$29.90
$9.60
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It makes little sense that phototherapy, a relatively inexpensive therapeutic option for
several skin diseases, is not better supported. In situations where dermatologists cannot
offer this procedure, they must often resort to prescribing treatments that have a much
greater overall cost to the public health-care system.
Access to vitiligo treatments
Not all medically necessary dermatological procedures are funded by provincial and
territorial governments. To assess performance in this area, we examined phototherapy
repigmentation procedures for vitiligo, a condition in which the skin loses pigmentation in patches due to loss of melanin. Although the condition does not directly threaten
long-term health outcomes, the psychosocial effects can be severe, resulting in significant
social and economic impacts for patients.
As shown in Table 9, below, four provinces consider this procedure to be cosmetic, rather
than medically necessary, and do not fund it for vitiligo patients. In addition, although
phototherapy is an insured service in the six remaining provinces, it is inaccessible to
many patients due to the shortage of phototherapy units. To achieve a passing grade for
access to vitiligo treatments, phototherapy must be both an insured service for vitiligo
patients and accessible to at least 85 per cent of the population. Advanced treatments,
such as excimer laser repigmentation, are reportedly very effective but are currently unfunded in Canada.
Table 9: PUVA phototherapy as an insured service for vitiligo patients
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
Yes
No*
No
Yes
Yes
Yes
No*
No
Yes
Yes
*D
ermatologists interviewed for this report noted that psoralen is difficult to obtain for vitiligo patients, although it is listed as a
general benefit on the provincial formulary.
Access to specialized treatments
The benchmark used to evaluate access to specialized treatments was the availability
within the province of three services: plasmapheresis, photopheresis and Mohs surgery.
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Not all provinces, and no territories, provide specialized dermatological treatments. Although plasmapheresis is available in all provinces, other procedures such as photopheresis (for the treatment of cutaneous T-cell lymphoma) are not available in six provinces
or in any of the territories. Similarly, Mohs surgeons are located in only six provinces.
(Dermatologists trained in Mohs micrographic techniques perform highly effective tissue sparing surgeries for the most complex skin cancers with the highest cure rates and
the lowest rates of recurrence.)
Patients living outside these areas must travel to receive treatment, often at their own
expense. For repeated treatments, this can be very costly. Wherever possible, specialized
treatments should be located within reach of skin patients, no matter where they live.
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Table 10: Availability of specialized dermatology services by province
Treatment
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
Mohs micrographic
surgery
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
No
Plasmapheresis
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Photopheresis
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
CSPA recommendations to improve access to medical procedures
The CSPA calls on the federal, provincial and territorial governments to take the lead,
working in collaboration with dermatology professionals and patients, to:
1. Ensure that every skin patient in Canada has access to phototherapy.
• Provide a phototherapy clinic in every publicly funded hospital;
• Include home phototherapy as an insured service for patients who cannot access a
clinic.
2. Add sufficient numbers of Mohs surgeons to achieve wait times of 28 days in keeping with the national wait times benchmark for cancer radiotherapy. Encourage the
location of new Mohs surgeons to reach the maximum number of Canadians.
3. Access to medications
The CSPA believes that all drugs that are considered the standard of care in the treatment
of skin diseases should be covered by government drug programs without restriction.
These include drugs that have received Health Canada approval as well as promising new
treatments for rare skin diseases, which are very unlikely to be submitted for marketing
authorization.
To measure performance in this area, we examined the formulary listings of medications
that are considered the standard of care for five common skin diseases. The percentage of
funded drugs was measured, as well as whether they were made available with or without
restrictions. In addition, we assessed the policies adopted by governments to facilitate access to medications for rare skin diseases.
The following three benchmarks were used to evaluate access to medications:
• Ninety per cent or more of a list of standard-of-care drugs are covered. The CSPA’s
position is that 100 per cent of drugs are covered and this lower benchmark allows
for the time needed by drug programs to review new drugs;
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• At least 80 per cent of drugs are available without restrictions. The CSPA’s position is
that 100 per cent of drugs should be available without restriction. We recognize that
some restrictions currently exist because of past best practice protocols;
• The jurisdiction has implemented a policy on rare diseases that allows, for specific
patients, funding for unapproved drugs that have been proven effective in the particular “orphan” indication. Where they exist, it is noted whether or not the exemption policies cover skin diseases.
As Table 11, below, reveals, Canada falls short of the CSPA’s benchmarks on access to
medications
Table 11: Performance ratings on access to medications
CDN
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
YT
NT
NU
Fail
Fail
Fail
Fail
Fail
NI
NI
Fail
Fail
Fail
Fail
Fail
Fail
Fail
Legend: NI = needs improvement
Nationally, Canada fails to provide adequate access to medications for several reasons:
1. Not all medications considered the standard of care to treat skin conditions are
funded in every jurisdiction. This is a concern for all diseases, but especially for
drugs used to treat skin cancers.
2. Where newer drugs are funded, there are often cumbersome and sometimes unreasonable restrictions on their use, which pose barriers to access and waste scarce
dermatologist time.
3. Canada lacks an “orphan drug” policy to encourage development of drugs for rare
skin diseases, as well as provincial and territorial mechanisms or policies to fund
promising medications for rare skin diseases.
Number of standard-of-care drugs funded
The number of standard-of-care drugs funded falls well below the benchmark of 90 per
cent of standard-of-care drugs for the treatment and prevention of common skin diseases.
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For those drugs that are not covered by the provincial formulary, unless a patient has
private insurance, they must pay out of pocket. As mentioned earlier in the Report
Card, skin patients are often intolerant to side effects of drugs or need alternatives when
medications lose effectiveness over time. For this reason, they need access to the widest
possible range of choices. To deny access to patients to medications considered to be part
of the standard of care can be to deny them a life without pain, itch, disfigurement, discomfort and/or shame. To deny medications to patients with melanomas or skin cancers
is unimaginable, and yet is the case for many Canadians, depending upon where they
live. Each provincial and territorial section has tables that detail which standard-of-care
medications are not covered for the seven conditions we cover in the Report Card.
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Restricted access to standard drugs
Newer drugs, which may offer patients enhanced clinical benefit and improved quality of
life, are more likely to be restricted than older drugs. (Details on the restriction criteria
can be found in the provincial sections of the Report Card.) No jurisdiction comes close
to meeting the benchmark of 80 per cent of unrestricted drugs.
Restricted access criteria can be stressful for patients. Most jurisdictions require that
a patient first try to see improvement in their skin condition on a succession of older
drugs, some of which may offer fewer clinical benefits and in some cases even have toxic
side effects, before coverage will be allowed for a newer medication.
When dermatologists believe that the best therapeutic option for their patient is one of
the newer restricted-access treatments they must make special applications to provincial
drug programs showing that the patient has tried and failed several older therapies. The
administrative burden imposed on already overworked dermatologists to repeatedly
complete and submit these applications on behalf of their patients is very time consuming. While most dermatologists will repeatedly go to bat for their patients, it would not
be inconceivable that some might not even mention the option of a more effective but
restricted treatment option to a patient, simply because they either have too little time
to process the paperwork, or in some provinces, no faith that an application will be accepted even if submitted.
A key example is the current dilemma faced by psoriasis patients in Canada whose doctors wish to prescribe biologic medications for them. Depending on where the patient
lives, even if they are covered, the dermatologist must provide evidence that the patient
has tried at least two and in some jurisdictions, three different therapies that either
haven’t worked for them or have had significant side effects that warranted stopping the
treatment.
Children or adults with eczema can lead difficult lives. Special access requirements can
force those affected into regimens with super potent topical steroids before newer options are made available, and then sometimes only if other conditions are met.
Metastatic melanoma moves swiftly and will claim almost 1,000 Canadians this year. It
is one of the few cancers that are on the rise. In the case of medications for skin cancers,
restricted access can sometimes have devastating effects.
Treatment delayed is often treatment denied, especially for a
disease like metastatic melanoma
— Dr. James Walker, dermatologist in Ottawa
Restrictions may make sense for provinces and territories trying to limit the amount of
money spent on medications, but the cost on human lives of these strategies is undeniably
high. When a patient is put on a medication that isn’t the right one, there can be a sense of
failure or hopelessness. Surely, the decisions on which medications and treatments are best
for a patient should be made by the dermatologist in consultation with the patient, and not
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by government decision-makers who never see patients nor hear their stories.
Funding status of medications to treat skin diseases
The remaining tables in this section of the CSPA Report Card describe the funding status
of drug treatments that are considered the standard of care for five common skin conditions and two rare skin diseases. The lists of drugs are not exhaustive but represent common classes of medications used in the treatment of the disease in question. Selections
were based on clinical practice guidelines, where these exist, and on recommendations
from dermatology professional associations and patient organizations. The lists were further validated during interviews with dermatologists. The tables present the listing status
of drugs as of July 31, 2011.
Table 12: Funding status by province of medications to treat psoriasis
Psoriasis
Drug:
calcipotriol
(Dovonex®)
calcipotriol +
betamethasone
(Dovobet®)
calcipotriol +
betamethasone
(Xamiol®)
calcitriol cream
(Silkis®)
tazarotene
(Tazorac®)
cyclosporine
(Neoral®)
acitretin
(Soriatane®)
adalimumab
(Humira®)
etanercept
(Enbrel®)
infliximab
(Remicade®)
ustekinumab
(Stelara®)
AB
SK
MB
ON
QC
NB
PE
NS
NL
YT
NIHB
Full
Full
Full
Full
SA
Full
Full
Full
SA
Full
Full
Full
No
Full
Full
No
Full
SA
No
No
No
No
No
No
Full
Full
Full
No
Full
SA
SA
SA
SA
SA
No
No
No
No
No
No
SA
Full
No
No
No
No
No
No
Full
Full
Full
SA
No
No
No
No
SA
SA
Full
Full
SA
SA
SA
SA
SA
Full
SA
No
SA
SA
Full
No
Full
Full
SA
Full
Full
Full
Full
SA
Full
Full
SA
Full
SA
SA
SA
SA
SA
SA
SA
No
SA
SA
No
SA
SA
SA
SA
SA
SA
SA
SA
No
SA
SA
No
No
SA
SA
SA
No
No
SA
SA
No
SA
SA
No
No
SA
SA
SA
No
SA
SA
SA
No
SA
SA
No
SA
no restrictions
restrictions
not funded
not Health Canada-approved
National
Legend:
BC
Abbreviations: S A = Special Authorization (also called “Limited Use” and “exceptional drug status”)
NIHB = Non-Insured Health Benefits. Covers registered First Nations and Inuit. Formulary also used by NT and NU.
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In addition to these drugs, topical corticosteroids and methotrexate are funded in all
provinces and territories for the treatment of psoriasis.
Table 13: Comparison of Special Authorization criteria for biologic medications for psoriasis
Standard:
BC
Baseline
PASI score
PASI
> 12
DQLI
>/=10 or
significant
involvement
of exposed
areas or BSA
>10%
Prior
therapy
x
AB
SK
MB
PASI
not
PASI
>/=10 stated >/=10
x
not
stated
ON
QC
PASI
>/=10
PASI
>/=15
x
DQLI
>/=15
x
MTX
MTX
MTX,
MTX
or
+
CS
+
CS
+/or
CS
CS
+
photo
+
+
photo photo photo
NB
NS
NL
NIHB
not
not
not
not
stated stated stated stated
x
x
x
x
2 of:
Several
MTX
MTX
MTX
MTX
of: 3 or MTX, CS,
+
+
+
&/or
more acitretin
CS
CS
CS
CS
+
topical
+
+
+
+
photo photo photo photo photo
agents
or photo
or 2 of:
MTX, CS,
acitretin
Legend: x = standard (as shown in the first column)
Abbreviations: PASI = Psoriasis Area Severity Index
DQLI = Dermatology Quality of Life Index
BSA = Body Surface Area
MTX = Methotrexate
CS = Cyclosporine
Photo = Phototherapy
Table 14: Funding status by province of medications to treat eczema
Eczema
Drug:
tacrolimus
(Protopic®)
pimecrolimus
(Elidel®)
alitretinoin
(Toctino®)**
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
YT
NIHB
SA
SA
SA
SA*
SA
SA
SA
SA
SA
SA
SA
SA
SA
No
SA
SA*
SA
SA
No
No
No
No
SA
SA
No
No
No
No
No
No
No
No
No
No
No
No
Legend: * Approved on a case-by-case basis
** Approved by Health Canada in April 2011. Still under review.
Legend:
no restrictions
restrictions
not funded
not Health Canada-approved
Topical corticosteroids and antibiotics for secondary infections are also funded in all
provinces and territories for the treatment of eczema.
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Table 15: Funding status by province of medications to treat and prevent viral skin infections
Viral Skin Infections
Drug:
BC
AB
SK
MB
ON
QC
NB
Genital herpes and herpes zoster treatment:
acyclovir
Full Full Full Full
No
Full Full
(Zovirax®)
valacyclovir
Full Full Full Full
SA
Full Full
(Valtrex®)
famciclovir
Full
No
Full Full
SA
Full Full
(Famvir®)
Herpes labialis (cold sores) treatment:
acyclovir cream
Full
No
No
Full
No
No
No
(Zovirax®)
Herpes zoster (shingles) prevention:
herpes zoster
vaccine
No
No
No
No
No
No
No
(Zostavax®)
Human papillomavirus (HPV) prevention of ano-genital warts:
HPV vaccine
(Gardasil®) –
Full Full Full Full Full Full Full
girls
HPV vaccine
(Gardasil®) –
No
No
No
No
No
No
No
boys
Legend:
PE
NS
NL
YT
NIHB
Full
Full
Full
Full
Full
Full
Full
Full
Full
Full
Full
Full
Full
Full
Full
No
No
No
No
Full
No
No
No
No
No
Full
Full
Full
Full
Full
No
No
No
No
No
no restrictions
restrictions
not funded
not Health Canada-approved
Zostavax®, a preventive vaccine against herpes zoster, is not publicly funded in any
jurisdiction. Dermatologists interviewed for this report unanimously stated that the vaccine should be funded for seniors, who are most vulnerable to acquiring this painful and
debilitating condition.
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Public health programs exist in all provinces and territories for voluntary vaccination of
girls with Gardasil®. Although the primary intent of these programs is to prevent cervical
cancer caused by HPV, prevention of ano-genital warts is also accomplished by vaccination. There are at present no publicly funded programs to vaccinate boys, and dermatologists report this to be a clear need. Gardasil® is approved for use in females aged 9-45
and males aged 9-26.
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Table 16: Funding status by province of medications to treat skin cancers
Skin Cancers
Drug:
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
YT
NIHB
SA
No
Non-melanoma skin cancers:
imiquimod
(Aldara®)
No
SA
No
SA*
SA*
SA
SA
Full
SA
SA
aldesleukin
(Proleukin®)
No
No
No
SA
Full
No
No
No
No
No
interferon alfa
2b (Intron A®)
Full
No
SA
Full
SA*
Full
Full
SA
SA
SA
Melanoma:
N/A† N/A†
No
Full
Legend: * Funded on a case-by-case basis.
† Infused drug, for hospital administration only
Legend:
no restrictions
restrictions
not funded
not Health Canada-approved
Several drug options exist for the treatment of non-melanoma skin cancers—basal cell
carcinoma and squamous cell carcinoma—and actinic keratosis, which is a pre-cancerous lesion of the skin. The drug 5-fluorouracil (Efudex®) is funded in all provinces.
Imiquimod, a standard therapy for basal cell carcinoma, is surprisingly not covered in all
jurisdictions. Even in those provinces that provide restricted access to imiquimod, special
authorization criteria require that patients are first treated with 5-fluorouracil and cryotherapy before approval will be given.
Melanoma is an aggressive cancer that can quickly claim the lives of those who are diagnosed. Although less common than other types of skin cancer, melanoma is responsible
for 75 per cent of deaths from skin cancers. Drugs play an important supporting role in
eliminating the primary tumour and preventing its spread to other organ systems. Medications for the treatment of melanoma that are funded in all provinces include dacarbazine
(DTIC®), lomustine and tamoxifen. Beyond these options, individual provinces follow
their own treatment protocols, although most tend to follow those of British Columbia,
Ontario or the National Comprehensive Cancer Network (NCCN) in the United States.
It is of particular concern that beyond these these medications, aldesleukin and even
interferon alfa 2b are either only available by special access or are not at all funded
in many jurisdictions. Requiring the filing of special access paperwork to gain access to
a medication for a melanoma patient adds undeniable stress and delays during a time
when neither is welcome.
This gate-keeping approach, when Canadian lives are at stake is disconcerting. Two new
treatments—vemurafenib and ipilimumab—were recently approved in the United States
and are under review by Health Canada. The dermatologists and oncologists who are
Canada’s experts in melanoma are optimistic that these will give patients diagnosed with
melanoma substantially better odds than ever before. The CSPA calls on provincial govCA-24
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ernments to move swiftly to cover these treatments once they receive marketing authorization in Canada.
Lack of policies for rare skin diseases
Many Canadians living with a rare skin disease are in a unique situation. Generally, drugs
without prior Health Canada approval for their particular disease are not listed on the
formularies of public or private drug programs. For economic and practical reasons,
drug companies are reluctant to undertake clinical trials for drugs with very few potential patients. For most rare diseases, therefore, it is very unlikely that promising drugs will
ever receive marketing authorization.
For someone with a debilitating or even life-threatening rare disease the situation is
critical. The two diseases depicted in Table 17, below, are typical of this predicament.
Pemphigus is a group of autoimmune diseases of the skin and/or mucous membranes in
which the skin cells become separated from each other, causing widespread burn-like lesions or blisters that do not heal. It can be fatal if left untreated as the blisters spread and
become infected. Cutaneous T-cell lymphoma is, as the name suggests, the manifestation
on the skin of a systemic cancer.
Table 17: Funding status by province of medications to treat rare skin diseases
Rare Skin Diseases
Drug:
BC
AB
SK
MB
ON
QC
NB
PE
NS
NL
YT
NIHB
IVIG (intravenous
immunoglobulin Full
G)
Full
Full
Full
Full
Full
Full
Full
Full
Full
Full
N/A
rituximab
(Rituxan®)†
No
No
No
No
No
SA*
No
No
No
No
No
No
cyclosporine
(Neoral®)†
No
No
No
No
No
SA*
No
No
No
No
No
No
mycophenolate
(Myfortic®)†
No
No
No
No
No
SA*
No
No
No
No
No
N/A
Pemphigus:
Cutaneous T-cell lymphoma:
vorinostat
(Zolinza®)
No
No
No
No
No
SA*
No
No
No
No
No
No
bexarotene
(Targretin®)‡
No
No
No
No
No
SA*
No
No
No
No
No
No
Legend:
National
Note: Intravenous immunoglobulin G (IVIG) for the treatment of pemphigus is covered through the Canadian Blood Services and
Héma-Québec for all provinces and territories.
Legend: * Funded on a case-by-case basis
† Not approved by Health Canada for this indication
‡ Not approved by Health Canada, but may be available to patients who apply to Health Canada’s Special Access
Programme
no restrictions
restrictions
not funded
not Health Canada-approved
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
CA-25
National
The options for treatment with a drug that has been shown to be effective for a rare skin
disease are few or non-existent unless the patient is in a financial position to pay for
his or her medications. In Canada, physicians are allowed to prescribe a drug if there is
evidence that it may be helpful and if the risks of harm do not outweigh the expected
benefit.
Unlike many other developed countries, Canada does not have an “orphan drug” policy
to encourage development of drugs for rare diseases. Nor is there a consistent national
model for funding drugs to treat rare diseases.16 This is identified by dermatologists as a
critical need. Alberta has developed a formal policy for rare diseases; however, it does not
apply to skin conditions. Ontario and Quebec conduct case-by-case reviews to consider
the merits of promising therapies for individual patients. Policies and practices for rare
diseases need to be developed that are transparent and consistent across Canada, and
skin diseases, because of their serious nature, need to be included.
In the meantime, access to special exemptions and emergency drug release programs
needs to be expanded to include rare skin diseases.
Drug review delays
Several dermatologists interviewed for the CSPA Report Card object to the long delays
by some provincial governments in reviewing and deciding upon whether to fund new
drugs. For example, British Columbia was the second-last province to approve biological
drugs for the treatment of psoriasis, years after they were funded by private insurers and
available in other provincial drug programs (Prince Edward Island and Yukon still have
not yet funded this class of medications for psoriasis).
These delays in approvals can effectively be considered denials, especially in the cases
of those diagnosed with skin cancers, where their time can be measured in days and
months. Also, bureaucratic explanations for long delays in getting medications that alleviate suffering, mean very little to the eczema, psoriasis, pemphigus patients and others
who may be so debilitated by their disease that they cannot leave their homes to work or
go to school.
Although time-to-decision statistics were not collected for this report, this information
would reveal just how long skin patients must wait for new treatments following their
approval by Health Canada. The CSPA will include time-to-decision data in its future
reports and encourages funding bodies to approve submissions in a timely manner.
Canadians with serious skin conditions cannot afford to wait years for a new drug to be
funded.
New drugs for the treatment of melanoma are currently under review in Canada. We
urge Health Canada to make these drugs a priority and also urge the provinces to add
these life-saving medications to their formularies without delay.
16.Lisa Priest. National drug policy for rare diseases has fallen between the cracks. The Globe and Mail,
April 05, 2011.
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National
CSPA recommendations to improve access to medications
To all provincial, territorial and federal drug programs:
1. Fund all drugs deemed the standard of care without restrictions and without timeconsuming application processes. Let the physicians together with their patients
make the decisions about which therapies are appropriate.
2. Move swiftly to provide coverage for new skin cancer drugs currently in the regulatory approval pipeline, in order to save the lives of Canadians.
3. Develop national and provincial/territorial policies for rare diseases and provide
coverage for promising treatments for patients with rare skin diseases. Immediately expand access to special exemptions and emergency drug release programs to
include rare dermatological diseases. Skin diseases are indeed considered serious
enough to warrant these considerations.
To the federal government specifically:
1. The federal government should develop and implement a national “orphan drug”
policy to encourage the introduction of drugs for rare diseases in all jurisdictions
and should include all rare skin diseases in the policy.
Based on the information we have gathered, Canada receives a resounding “fail” with
respect to access to dermatological care and treatment. Canadians wait far too long to
receive care. Access to treatments is severely limited. Access to and coverage for a plethora of effective medications is cumbersome, time-consuming and in many cases nonexistent.
National
The CSPA therefore calls on the Government of Canada to work with each of the provinces and territories in order to fulfill the promise of the Canada Health Act of reasonable access to care.
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
CA-27
Quebec
Quebec
Access to:
Grade
Dermatological
care
Fail
Medical
procedures
Fail
Medications
Needs
improvement
Key issues
1. Despite having a large number of dermatologists relative to the population, patients
in Quebec experience long wait times for routine appointments.
2. Lack of access to phototherapy. While the Quebec government has succeeded in
providing specialized dermatology treatments in tertiary care centres, the workhorse
of dermatological treatment—phototherapy—is not available to one out of five
Quebeckers.
3. Unreasonable and time-consuming restrictions on the use of newer drugs pose
barriers to access and waste scarce dermatologist time.
4. Melanoma patients need access to all Health Canada-approved treatments in a
timely manner. Currently Quebec does not cover all treatments considered to be
part of the current standard of care. These and new treatments in the regulatory
pipeline must be covered expeditiously to save lives.
Recommendations
Quebec
The Canadian Skin Patient Alliance recommends that the following actions are taken by
the Government of Quebec, in collaboration with dermatologists and other health professionals, and in consultation with skin patients.
1. Improve access to dermatological care:
a. Reduce wait times for routine dermatology consultations to five weeks within the
next three years. Strategies may include:
• Determining and addressing the reasons for long wait times;
• Creation of billing codes for the services of trained dermatology nurses working under the supervision of a dermatologist.
b. Require that basic dermatological care is provided within reasonable commuting distance for 90 per cent of residents by dermatologists or dermatology nurses
under the supervision of dermatologists. Options for achieving this goal may
include:
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Quebec
• In 2012, the Ministry of Health initiate a roundtable discussion that examines
and finds solutions for the limiting factors associated with the use of teledermatology services in rural and remote regions;
• Creation of a plan to expand outreach visits by dermatologists or dermatology
nurses under the supervision of a dermatologist.
c. Plan to meet future demands for dermatological services:
• Increase the number of dermatology training places to achieve a new practice
entry rate of nine per year.
2. Improve access to medical procedures:
a. Ensure that every skin patient in the province has access to phototherapy by:
• Providing a phototherapy clinic in every publicly funded hospital;
• Including home phototherapy as an insured service for patients who cannot
access a clinic.
3. Improve access to medications:
a. Fund all drugs deemed the standard of care without restrictions and without
time-consuming application processes. Let the physicians together with their patients make the decisions about which therapies are appropriate.
b. Fund anti-viral medications for herpes simplex infections, and HPV vaccinations
for boys.
c. Move swiftly to provide coverage for new skin cancer drugs currently in the regulatory approval pipeline, in order to save the lives of Quebeckers.
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Quebec
Detailed Tables
1. Access to dermatological care
Quebec rates a failing grade on access to dermatological care. Despite having the largest
number of dermatologists in Canada on a per-population basis, it has long and growing
wait times. Little has been done to improve the situation and problems are expected to
worsen in future years.
Table 1: Performance of Quebec on access to dermatological care
Measure:
Quebec
Benchmark
Grade
Wait times (median)
18 weeks
5 weeks
Fail
Increase in number of
new dermatologists
-1.5% annual growth
6.2% annual growth
Fail
Ratio of dermatology
nurses to
dermatologists
0.01
0.5
Fail
What is the situation today?
Long wait times
Quebeckers wait far too long for a dermatologist consultation after they have been referred by their family doctor.
The CSPA considers five weeks to be the benchmark for wait times for non-urgent
consultations. This measure was chosen to reflect the need for patients with debilitating
conditions to obtain timely treatment that may allow them to return to their daily lives
without detrimental effects to their health, work, psychological state and social functioning. Five weeks was the national median wait time in 2001, as reported by the Canadian Dermatology Association (CDA) Workforce Survey. It is also a realistic standard,
since wait times at this level were achieved in 2001 in Quebec.1
Quebec
Fail
A survey conducted independently on behalf of the CSPA in February-March 2011
showed that half of Quebeckers wait at least 18 weeks for an initial consultation with
a dermatologist. One-quarter of patients must wait 24 weeks or longer for an appointment. The wait time for Quebec dermatologists ranged from one week to a full two years.
And wait times are growing progressively worse, as shown in Figure 1, below. The CDA
reported that the five-week wait time in its 2001 Workforce Survey had more than
doubled to 12 weeks by 2006. By 2011, the CSPA survey reported that wait times had
again increased to 18 weeks. Although caution should be used in comparing data from
1. Canadian Dermatology Association Workforce Survey 2001.
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Quebec
different sources, the trend toward worsening wait times is clear. The situation may
actually be understated. The CDA survey examined time to the third-next appointment
whereas the CSPA survey measured time to the next available appointment.
Figure 1:Wait
WaitTimes
TimesforforDermatologist
DermatologistConsultation
ConsultationininQuebec
Quebec
20
18
16
14
Weeks
12
10
8
6
Benchmark
4
2
0
2001 (CDA)
2006 (CDA)
2011 (CSPA)
Remarkably, the CSPA survey also revealed that 36 per cent of dermatologists contacted
were not taking new patients. Although this finding is inexplicable, and was not seen
elsewhere in the country, it points to a possible reason why wait times are so long, especially considering that Quebec has the second-highest number of dermatologists per
capita in Canada.
Physicians concurred with the wait times survey findings. In fact, dermatologists in
Quebec report that they are twice as difficult to access compared to other specialists. In
the 2010 National Physician Survey,2 doctors were asked to rate their own accessibility on
behalf of their patients. Figure 2, below, shows that 49 per cent of dermatologists in Quebec said that their accessibility was either “poor” or “fair.” Only 22 per cent of doctors
said that access was “poor” or “fair” to all specialists combined, including cardiologists,
neurologists, surgeons and others.
2. 2010 National Physician Survey. The College of Family Physicians of Canada, Canadian Medical
Association, the Royal College of Physicians and Surgeons of Canada.
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Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Quebec
Percentage of doctors rating their access as poor or fair
Figure 2: Lack
LackofofAccessibility
AccessibilityofofDermatologists
DermatologistsininQuebec
Quebec
A greater percentage of dermatologists report they are difficult to see
compared to other specialists
60%
50%
40%
30%
Dermatologists
20%
10%
All Specialists
0%
Source: National Physican Survey 2010
The issues presented below may provide policy directions to reduce dermatology wait
times in Quebec.
Large but falling numbers of dermatologists
Quebec
According to provincial billing data for 2009-10, there were 171 medical dermatologists
actively practising in Quebec, excluding full-time cosmetic dermatologists, researchers and teachers. A total of 181 full-time medical dermatologists were calculated to be
available in Quebec. (Some dermatologists worked more than a standard full-time work
week. See Appendix 2 for calculations). This means that each full-time dermatologist
served 43,736 people—a number 33 per cent lower than the Canadian benchmark of
65,000.3
The lack of correlation between the ample supply of dermatologists and long wait times
in Quebec cannot be explained by the available data. Further investigation is warranted
to determine whether other factors, such as higher demand, are responsible for these
delays. Root causes of long wait times need to be determined and addressed. Anecdotal
evidence suggests that low clinical service remuneration rates for Quebec dermatologists, coupled with a high demand for cosmetic services, are reducing the amount of time
available for medical services.
Despite the robust supply of dermatologists, the situation is worsening: over the fiveyear period ending 2008-09 the number of full-time dermatologists decreased by 1.5 per
cent.4
3. Analysis of provincial billing data (see Appendix for methodology).
4. National Physician Database (CIHI).
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Quebec
Specialized dermatological care is available in Quebec in large urban centres. There are
six accredited Mohs surgeons in the province—the highest number relative to population in the country. Wait lists for Mohs micrographic procedures are currently between
one and two months (although two to three weeks for skin cancers)—among the shortest in Canada.5
Lack of access in rural and remote areas
In rural and remote areas of Quebec the shortage of dermatologists is worse. Only two
cities in the northern part of province have a dermatologist6, and patients living outside
urban centres must travel long distances to receive dermatological care. Twenty per cent
of Quebeckers live in rural or remote communities. Yet, according to the CDA Workforce
Survey of 2006, dermatologists spent only seven per cent of their time outside urban
areas.
Need for more dermatology nurses
Access to dermatological care and long wait times could be alleviated by employing
other health professionals to work alongside dermatologists. Trained dermatology nurses
are being used effectively in other countries to assist busy dermatologists by seeing and
screening patients, and by overseeing treatments under the supervision of a physician.
In British Columbia, rheumatologists can make use of specific billing codes that can be
applied to the services of trained rheumatology nurses in clinical settings. Similarly provincial health funding in Quebec to cover the costs of using trained dermatology nurses
in dermatologic practices would make better use of dermatologists and provide better
patient care. The best practice precedent exists and it similarly should be expanded to
include dermatology nurses across the country.
There are only two dermatology nurses in Quebec—by far the lowest proportion in
Canada, as shown in Table 2, below.7 In the United Kingdom, there are four dermatology nurses or dermatology nurse practitioners for every five dermatologists, reflecting a
team-based approached to providing care.8 In the U.S., 30 per cent of dermatologists said
they used a dermatology nurse or a dermatology nurse practitioner in their practices.9
Table 2: Ratios of dermatology nurses to dermatologists
Benchmark
Quebec
U.K.
U.S.
0.5
0.01
0.8
0.3
5.
6.
7.
8.
Information obtained by Dr. Evert Tuyp, August 2011.
CIHI 2005
Canadian Dermatology Nurses Association
An audit of the provision of dermatology services in secondary care in the United Kingdom with a
focus on the care of people with psoriasis. British Association of Dermatologists and the Royal College
of Physicians and Surgeons 2008.
9. Resneck, JS Jr et al. Who else is providing care in dermatology practices? Trends in the use of
nonphysician clinicians. Journal of the American Academy of Dermatology 2008;58(2):211-216.
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Quebec
This limited analysis suggests that Quebec, and Canada as a whole, may not have capitalized on an opportunity to make more efficient use of dermatologists’ time through the
utilization of other health professionals.
The CSPA is willing to organize a forum of dermatologists, other health professionals
and governments to systematically explore the possibilities of innovative practice models
as a means to improve dermatology services to patients.
How has the Government of Quebec responded?
The Government of Quebec appears to have taken steps to improve access to dermatological care, mainly by increasing the number of training positions. However, there
remain significant gaps that need to be addressed.
Training new dermatologists
Training of new dermatologists is essential to replace retirees and to meet the future
demand for services. There are currently 41 dermatologists in training (excluding visa
students) at four universities in Quebec.10 Most, but not all, trainees originate from the
province and might potentially practise in Quebec upon certification.
The number of trainees has been rising steadily over the past five years, as Figure 4,
below, shows. Since dermatological training is a five-year program, there is a lag time
before trainees emerge as practising dermatologists. Given the trends shown, the number
of new dermatologists in Quebec may soon grow and reverse the current declining trend.
Figure
4: Dermatologists
in Training
in Quebec
Dermatologists
in Training
in Quebec
(ministry funded only)
Quebec
45
40
35
30
25
20
15
10
5
0
2006-07
2007-08
2008-09
2009-10
2010-11
Source: Canadian Post-MD Educational Registry
On average, 10 new dermatology residents enter a training program in Quebec each
year; however only four trainees are expected to enter into practice in 2011. Even if these
graduates remain in the province, this addition amounts to only a 2.6 per cent increase
in the number of dermatologists—insufficient to replace expected retirements and prepare for rising future demand for dermatology services. As mentioned above, a growth
rate of 6.2 per cent is needed to keep pace. This means that at least nine new entries are
10.Canadian Post-MD Educational Registry (CAPER).
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Quebec
needed each year. Due to the long training program, it may be another four or five years
until this level of new entries is achieved.
Remuneration
A potential root cause of long wait times in Quebec may be related to remuneration for
medical services, which in some practices compete for time dedicated to cosmetic services. Although fees are not the only, or even the most important, reason for a dermatologist to practise in a certain area, an unrealistically low level of remuneration may limit
the amount of time a dermatologist can afford to spend delivering insured services and
may dissuade medical students from entering the specialty.
In Table 3, below, fee payments for consultations and for repeat visits were used as indicators of overall remuneration. Fees in Quebec were generally lower than the provincial
average. Compared with other provinces, Quebec may be less able to recruit and retain
dermatologists.
Table 3: Relative remuneration for dermatologist office visits
Appointment Type
Prov.
Avg.
QC
Percentage
Fee per comprehensive
consultation
$78.99
$62.20
79%
Fee per repeat office
visit
$29.77
$25.80
87%
Legend:
20% or more above provincial average
within +/– 20%
> 20% below
Outreach to rural and remote communities
As mentioned earlier, dermatologists in Quebec spend only seven per cent of their time
outside urban centres, yet 20 per cent of population resides in rural areas.11 The province
sets no requirement that a certain minimum level of dermatology services must be available regardless of where people live.
Teledermatology may assist in expanding outreach to northern and rural parts of the
province without the time and monetary costs of in-person travel. Yet, there are indications that this technology may be underutilized. Although Quebec, a pioneer in developing this technology, has the requisite equipment, dermatologists interviewed for
the Report Card said that it is seldom used in practice. Although they would like to make
more use of teledermatology, liability issues are a concern where physical examination by
a trained specialist plays a key role in diagnosis.
Physician fees also play a role in the utilization of teledermatology in Quebec. Unlike
other provinces that include teledermatology fees in the regular fee schedule, in Quebec
11.Statistics Canada, 2006 census.
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Quebec
the fees are negotiated between each regional health authority and institution. While
dermatologists have been trying to change this situation for a number of years, the issue
has not yet been resolved.12
Until these issues are addressed it is unlikely that teledermatology can achieve its potential to improve the quality of care and reduce costs of outreach services.
CSPA recommendations to improve access to dermatological care in Quebec
The CSPA calls on the Government of Quebec to collaborate with dermatology professionals and medical schools to:
1. Reduce wait times for routine dermatology consultations to five weeks within the
next three years. Strategies may include:
• Determining and addressing the reasons for long wait times;
• Creation of billing codes for the services of trained dermatology nurses working
under the supervision of a dermatologist.
2. Require that basic dermatological care is provided within reasonable commuting
distance for 90 per cent of residents by dermatologists or dermatology nurses under
the supervision of dermatologists. Options for achieving this goal may include:
• In 2012, the Ministry of Health initiate a roundtable discussion that examines and
finds solutions for the limiting factors associated with the use of teledermatology
services in rural and remote regions;
• Creation of a plan to expand outreach visits by dermatologists or dermatology
nurses under the supervision of a dermatologist.
3. Prepare to meet future demands for dermatological services, based on expected
dermatologist retirements, population growth and the rising incidence of skin disease.
Fail
Quebec
4. Continue to expand the number of dermatology training places to achieve at least
nine new practice entries per year.
2. Access to medical procedures
Access to medical procedures was assessed according to whether certain common and
specialized procedures are funded and whether they are available within reasonable distance from where Quebeckers live.
12.Jean-Paul Fortin. Telehealth in Quebec: a lot of catching up to do. Le Spécialiste 2009;11(2).
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Quebec
Table 4: Performance of Quebec on access to medical procedures
Measure:
Quebec
Benchmark
Grade
Number of phototherapy
facilities
1:270,000 population
1:65,000 population
Fail
Distance to phototherapy
facilities
Less than 80%
>85% population has
population has access
access
Needs improvement
Procedures for vitiligo
Phototherapy
repigmentation
insured but not
always accessible
Phototherapy
repigmentation
insured and
accessible
Needs improvement
Specialized procedures
Two out of 3
specialized
procedures available
in province
Mohs surgery,
plasmapheresis
and photopheresis
insured and available
in province
Needs improvement
The Quebec government deserves credit for providing access to Mohs micrographic
surgery, which is not available in every province. Also, Quebec funds phototherapy for
the treatment of vitiligo. However, this is inconsequential if phototherapy is inaccessible
by patients.
Most crucially, the province needs to improve access to phototherapy for all skin patients. This service is currently inadequate both with respect to the number of centres
and their location throughout the province. For patients without access to a clinic, home
phototherapy treatments should be an insured service.
What is the situation today?
Phototherapy
Phototherapy, including psoralen/ultraviolet A (PUVA) and broad- and narrow-band UVB
treatments, is a widely used, effective and non-invasive treatment for several skin conditions, including psoriasis, acne, eczema, vitiligo, itchy skin, lichen planus, granuloma annulare and certain rare skin diseases. In some cases, it represents a cost-effective alternative
that may also alleviate or slow the need for more expensive treatments or medications.
While there is no definitive source of information on how many phototherapy clinics are
operating in Quebec, based on information from multiple sources, it was estimated that
in 2006 there were 29 locations in the province, all of which were located in major urban
centres.13 The number of clinics is inadequate to serve the needs of the population: four
times this number are required. Also, residents in the eastern and northern regions must
travel long distances to receive phototherapy—an impractical requirement for patients
who need treatments several times a week. Home phototherapy is not an insured service
13.Compiled from: Canadian Dermatology Association list of dermatologists providing courtesy UVA/B
treatments for travellers; Koo, M et al. Phototherapy services in Canada (poster presentation) 2006;
personal communication from Bruce Elliott, President, Solarc Systems Inc., Barrie, Ontario.
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Quebec
in Quebec, although providing this option would mean that 100 per cent of residents
had access to this treatment.
Patients and dermatologists across Canada have increasingly reported the closure of
phototherapy clinics. Hospital-based facilities, which are funded by global budgets, have
closed in some areas due to budgetary pressures. Phototherapy clinics based in dermatologists’ offices cannot keep up with demand and are poorly remunerated.
CSPA recommendations to improve access to medical procedures in Quebec
The CSPA is calling on the Government of Quebec to take the lead, in collaboration with
dermatology professionals and patients, to:
1. Ensure that every resident of Quebec has access to phototherapy by:
• Providing a phototherapy clinic in every publicly funded hospital;
• Including home phototherapy as an insured service for patients who cannot access a clinic.
3. Access to medications
The CSPA believes that all drugs that are considered the standard of care in the treatment of skin diseases should be covered without restriction. These include drugs that
have received Health Canada approval and those that have been shown to be effective for
the treatment of rare skin diseases but that have not been, and are very unlikely to be,
submitted for marketing authorization.
Table 5: Performance of Quebec on access to medications
Measure:
Quebec
Benchmark
Grade
Number of selected
standard-of-care drugs
listed
78%
90%
Needs improvement
Unrestricted drugs (of
listed)
50%
80%
Fail
Policy in place and
applies to skin
diseases
Policy in place and
applies to skin
diseases
Pass
Policy on medications for
rare diseases
Quebec
Needs
improvement
Quebec lists on its formulary a moderate proportion of drugs deemed the standard of
care for several skin diseases. A large number of these, however, are accompanied by burdensome restrictions. The Government of Quebec deserves credit for putting in place a
mechanism to allow patients with rare skin diseases to access medications that have been
shown to be effective but that have not been approved for that particular indication by
Health Canada.
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Quebec
What is the situation today?
Number of standard-of-care drugs funded
Our analysis showed that Quebec funds 78 per cent of standard-of-care drugs for the
treatment and prevention of several common skin diseases—below the CSPA benchmark
of 90 per cent. These medications are noted in the detailed tables below.
For those drugs that are not covered by the provincial formulary, unless a patient has private insurance, they must pay out of pocket. Access to critical medications that is denied
completely can have devastating results for skin patients and their families. It is indeed
concerning that patients don’t have access through the formulary to drugs considered to
be part of the standard of care for several of the skin diseases we looked at for this report.
A new treatment for eczema isn’t covered in Quebec even though it has had Health Canada approval since April 2011. A widely used topical treatment for psoriasis isn’t covered
in Quebec, while it is covered in eight other jurisdictions across Canada.
Restricted access to newer medications
Only 50 per cent of funded drugs were available without restriction (termed “médicaments d’exception” in Quebec). Access to newer drugs, which may offer patients enhanced clinical benefit and improved quality of life, is more likely to be restricted than
for older drugs.
Eczema can be a very debilitating disease, and yet coverage is restricted for two topical
immunomodulators for eczema patients in Quebec, making these medications more difficult to access. Two single-application-per-day topical treatments for psoriasis are also
on the restricted list, even though these are cost effective alternatives to some systemic
protocols, themselves médicaments d’exception. When a provincial formulary imposes
rigorous restrictions to access it can mean that some patients simply don’t get the treatment they need.
For example, to obtain biological products indicated for psoriasis, patients must first
try to see improvement in their skin condition on a succession of treatments and drugs
before the drug program will allow a newer medicine to be used. Quebec requires that
the patient first try three treatments: phototherapy, plus two of the following three drugs:
methotrexate, cyclosporine and acitretin. Some of these drugs have toxicities that some
patients are unable to withstand and have a limited duration of use. Since almost all
patients with severe psoriasis will eventually be candidates for treatment with a biologic
drug, it raises the question of why governments force skin patients to undergo these
unpleasant and potentially dangerous protocols before being allowed access to newer and
potentially more effective treatments.
Quebec’s criteria for biological drugs are the most rigid in Canada. Beyond the requirement for not being able to tolerate two other systemic treatments to be eligible for consideration, a patient must have a Psoriasis Area Severity Index (PASI) of 15 or greater—
far higher than the usual score of 10. Even Third World countries will cover biological
drugs in patients with a PASI of 10.
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Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Quebec
The Dermatology Quality of Life Index (DLQI) must also be 15 or more—again, much
higher than the level of 10 generally required by other provinces.
Another consideration is that dermatologists must complete application forms on behalf
of their patients, a process that must be repeated, in order to qualify to obtain restricted
medications. Dermatologists interviewed for this report found the process frustrating
because of the paperwork involved, both on the initial submission and on the frequent
occasions when the application was rejected. This time-consuming procedure adds a
significant burden to dermatologists whose time is already stretched.
So, while on paper it appears as though psoriasis patients have access to these new medications, it would seem that in Quebec, ‘médicaments d’exception’ generally means no
access. Given that psoriasis affects almost two per cent of the population, these decisions
affect a great number of Quebeckers.
Whether the disease is psoriasis, eczema, melanoma or any other, skin patients are often
intolerant to side effects of drugs or need alternatives when medications lose effectiveness over time. For this reason, they need access to the widest possible range of choices.
Funding status of medications to treat skin diseases in Quebec
The tables below show the funding status of drug treatments that are considered the
standard of care for five common skin conditions and two rare skin diseases. The lists
of drugs are not exhaustive but represent common classes of medications used in the
treatment of the disease in question. Selections were based on clinical practice guidelines,
where these exist, and on recommendations from patient organizations and dermatology
professional associations. The lists were further validated during interviews with dermatologists. The tables present the listing status of drugs as of July 31, 2011.
Quebec
Responsibility for funding medications is divided among two agencies in Quebec. The
Régi de l’assurance maladie du Québec (RAMQ) covers drugs administered at home and
some drugs provided in hospitals, whereas immunizations are a Public Health responsibility.
Table 6: Funding status of medications to treat psoriasis in Quebec
Psoriasis
Medication:
calcipotriol
(Dovonex®)
calcipotriol +
betamethasone
(Dovobet®)
calcipotriol +
betamethasone
(Xamiol®)
Listing
Status
Pre-Authorization Criteria
Full
N/A
SA
For treatment of psoriasis where calcipotriol is ineffective or poorly
tolerated
SA
For treatment of psoriasis where calcipotriol is ineffective or poorly
tolerated
continued . . .
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
QC-13
Quebec
Psoriasis
Medication:
calcitriol cream
(Silkis®)
tazarotene
(Tazorac®)
cyclosporine
(Neoral®)
acitretin
(Soriatane®)
Listing
Status
Full
N/A
No
Full
N/A
Full
N/A
SA
For treatment of persons suffering from a severe form of chronic
plaque psoriasis:
• in the presence of a score greater than or equal to 15 on the Psoriasis
Area and Severity Index (PASI) or of large plaques on the face, palms
or soles or in the genital area; and
• in the presence of a score greater than or equal to 15 on the
Dermatology Quality of Life Index (DQLI) questionnaire;
AND
• where a phototherapy treatment of 30 sessions or more for three
months has not made it possible to optimally control the disease,
unless the treatment is contraindicated, not tolerated or not
accessible or unless a treatment of 12 sessions or more for one month
has not provided significant improvement in the lesions;
AND
• where a treatment with two systemic agents, used concomitantly
or not, for at least three months each, has not made it possible to
optimally control the disease. Except in the case of serious intolerance
or a serious contraindication, these two agents must be:
• methotrexate at a dose of 15 mg or more per week;
OR
• cyclosporine at a dose of 3 mg/kg or more per day;
OR
• acitretin at a dose of 25 mg or more per day.
The initial request is authorized for a maximum four months.
When requesting continuation of treatment, the physician must
provide information making it possible to establish the treatment’s
beneficial effects, specifically:
• an improvement of at least 75% in the PASI score;
OR
• an improvement of at least 50% in the PASI score and a decrease of at
least five points on the DQLI questionnaire;
OR
• a significant improvement in lesions on the face, palms or soles or
in the genital area and a decrease of at least five points on the DQLI
questionnaire
adalimumab
(Humira®)
etanercept
(Enbrel®)
infliximab
(Remicade®)
ustekinumab
(Stelara®)
Pre-Authorization Criteria
continued . . .
QC-14
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Quebec
Psoriasis
Medication:
ustekinumab
(Stelara®)
(con’d.)
Legend:
Listing
Status
SA
Pre-Authorization Criteria
Requests for continuation of treatment are authorized for a maximum
of six months.
Authorizations for adalimumab are given for an induction dose of 80
mg, followed by a maintenance treatment beginning the second week
at a dose of 40 mg every two weeks;
Authorizations for etanercept are given for a maximum of 50 mg, twice
per week;
Authorizations for infliximab are given for a maximum of 5 mg/kg in
weeks 0, 2 and 6 and then every eight weeks.
Authorizations for ustekinumab are given for a dose of 45 mg in weeks
0 and 4, then every 12 weeks. A dose of 90 mg may be authorized for
persons whose body weight is greater than 100 kg.
no restrictions
restrictions
not funded
not Health Canada-approved
Abbreviations: Full = full benefit for eligible residents
SA = special authorization (called “exceptional medications” in Quebec)
N/A = not applicable
In addition, topical corticosteroids and methotrexate are funded in all provinces and territories for the treatment of psoriasis.
Table 7: Funding status of medications to treat eczema in Quebec
Eczema
Medication:
Listing
Status
Pre-Authorization Criteria
For treatment of atopic dermatitis in children, following failure of a
treatment with a topical corticosteroid;
SA
pimecrolimus
(Elidel®)
SA
For treatment of atopical dermatitis in children, where a topical
corticosteroid treatment has failed
alitretinoin
(Toctino®)
No
Approved by Health Canada April 2011
Legend:
Quebec
For treatment of atopical dermatitis in adults, following failure of
at least two treatments with a different topical corticosteroid of
intermediate strength or greater, or following failure of at least
two treatments on the face with a different low-strength topical
corticosteroid
tacrolimus
(Protopic®)
no restrictions
restrictions
not funded
not Health Canada-approved
Abbreviations: SA = Special Authorization
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Quebec
Topical corticosteroids and antibiotics for secondary infections are also funded in all
provinces and territories for the treatment of eczema.
Table 8: Funding status of medications to treat viral skin infections in Quebec
Viral skin infections
Medication:
Listing
Status
Pre-Authorization Criteria
Genital herpes and herpes zoster treatment:
acyclovir
(Zovirax®)
Full
N/A
valacyclovir
(Valtrex®)
Full
N/A
famciclovir
(Famvir®)
Full
N/A
Herpes labialis (cold sores) treatment:
acyclovir
ointment
(Zovirax®)
No
N/A
Herpes zoster (shingles) prevention:
herpes zoster
vaccine
(Zostavax®)
No
N/A
Human papillomavirus (HPV) prevention of ano-genital warts:
HPV vaccine
(Gardasil®) –
girls
Full
N/A
HPV vaccine
(Gardasil®) –
boys
No
N/A
Legend:
no restrictions
restrictions
not funded
not Health Canada-approved
Zostavax®, a preventive vaccine against herpes zoster, is not publicly funded in Quebec.
Dermatologists interviewed for this report unanimously stated that the vaccine should
be funded for seniors, who are most vulnerable to acquiring this painful and debilitating
condition.
Public health programs exist in all provinces and territories for voluntary vaccination of
girls with Gardasil®. Although the primary intent of these programs is to prevent cervical
cancer caused by HPV, prevention of ano-genital warts is also accomplished by vaccination. There is at present no publicly funded program in Quebec to vaccinate boys and
this is felt by dermatologists interviewed for this report to be a clear need. Gardasil® is
approved for use in females aged 9-45 and males aged 9-26.
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Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Quebec
Table 9: Funding status of medications to treat skin cancers in Quebec
Skin cancers
Medication:
Listing
Status
Pre-Authorization Criteria
Non-melanoma skin cancers:
imiquimod
(Aldara®)
• For treatment of external genital and peri-anal condylomas, as well as
condyloma acuminata, upon failure of physical destructive therapy or
of chemical destructive therapy of a minimum duration of four weeks,
unless there is a contraindication
SA*
• The maximum duration of the initial authorization is 16 weeks. When
requesting continuation of treatment, the physician must provide
evidence of a beneficial effect defined by a reduction in the extent
of the lesions. The request may then be authorized for a maximum
period of 16 weeks.
aldesleukin
(Proleukin®)
No
N/A
interferon alfa
2b (Intron A®)
Full
Melanoma:
*Although listed as an Exceptional Access medication, Aldara® was reported by dermatologists interviewed for this report to be
very difficult to obtain.
Legend:
no restrictions
restrictions
not funded
not Health Canada-approved
Abbreviations: Full = full benefit for eligible residents
SA = special authorization (called “exceptional medications” in Quebec)
N/A = not applicable
In addition, dacarbazine (DTIC®) is funded in Quebec for the treatment of melanoma,
as is 5-fluorouracil (Efudex®) for the treatment of actinic keratosis.
Quebec
Melanoma is an aggressive cancer that quickly claims the lives of those who are diagnosed. It is of particular concern that aldesleukin, which is recommended for the treatment of melanoma by Cancer Care Ontario, is not funded in Quebec. The CSPA urges
the Quebec government to add this treatment to its formulary quickly, in order to grant
another treatment option to Quebeckers battling this deadly skin cancer.
Dermatologists and oncologists have long lamented that existing covered treatments
do little to extend the lives of melanoma patients. Two new treatments—vemurafenib
and ipilimumab—were recently approved in the United States and are under review by
Health Canada. The CSPA calls on the Government of Quebec to move quickly to cover
these treatments once they receive marketing authorization in Canada.
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
QC-17
Quebec
Table 10: Funding status of medications to treat rare skin diseases in Quebec
Rare skin diseases
Medication
Listing
Status
Pre-Authorization Criteria
Full
Covered by Héma-Québec
Pemphigus:
IVIG (intravenous
immunoglobulin G)
rituximab
(Rituxan®)†
Case by
Not approved by Health Canada for this indication
case
cyclosporine
(Neoral®)†
Case by
Not approved by Health Canada for this indication
case
mycophenolate
(Myfortic®)†
Case by
Not approved by Health Canada for this indication
case
Cutaneous T-cell lymphoma:
vorinostat
(Zolinza®)
Case by
N/A
case
bexarotene
(Targretin®)
Not approved by Health Canada for this indication. May be made
Case by
available to qualifying patients through Health Canada’s Special Access
case
Programme (SAP)
Legend:
no restrictions
restrictions
not funded
not Health Canada-approved
Lack of policy for rare skin diseases
Many Canadians living with rare skin diseases are in a unique situation. Public and
private insurers generally do not list drugs without prior Health Canada approval on
their formularies. For economic and practical reasons, drug companies are reluctant to
undertake clinical trials for drugs with very few potential patients. For most rare diseases,
therefore, it is very unlikely that promising drugs will ever receive marketing authorization.
For someone with a debilitating or even life-threatening rare disease the situation is
critical. The two diseases depicted in Table 10, above, are typical of this predicament.
Pemphigus is a group of autoimmune diseases of the skin and/or mucous membranes in
which the skin cells become separated from each other, causing widespread burn-like lesions or blisters that do not heal. It can be fatal if left untreated as the blisters spread and
become infected. Cutaneous T-cell lymphoma is, as the name suggests, the manifestation
on the skin of a systemic cancer.
Quebec’s pharmaceutical policy, launched in 2009, outlined its approach to rare metabolic diseases. According to dermatologists interviewed for the Report Card, the government will review requests for unapproved drugs for skin diseases on a case-by-case basis
QC-18
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Quebec
for patients who have no other alternatives. We hope to confirm that rare dermatological
diseases will be deemed on par with others and that patients suffering with them will
merit due consideration.
CSPA recommendations to improve access to medications in Quebec
The CSPA calls on the Government of Quebec to:
1. Fund all drugs deemed the standard of care without restrictions and without timeconsuming application processes. Let the physicians together with their patients
make the decisions about which therapies are appropriate.
2. Fund anti-viral medications for herpes simplex infections, and HPV vaccinations for
boys.
Quebec
3. Move swiftly to provide coverage for aldesleukin as well as the new skin cancer drugs
currently in the regulatory approval pipeline as they become available, in order to
save the lives of Quebeckers.
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
QC-19
Appendices
Appendix 1
Information Sources
In addition to the sources of information listed in the footnotes to the Report Card, the
following resources were used.
Dermatologist fees
Table 1: Dermatologist fees
Codes used:
Province
Source
Consultation
Repeat Visit
British
Columbia
Medical Services Commission.
June 2011
00210 Consultation
00207 Subsequent
office visit
Alberta
Alberta Health Care Insurance
Plan Schedule of Medical
Benefits. March 2011
03.08A Comprehensive 03.07B Repeat
consultation
consultation
Saskatchewan
Payment Schedule for Insured
9F Consultation
Services Provided by a Physician.
April 1, 2011
7F Follow-up
assessment
Manitoba
Physician’s Manual. April 1, 2010
8550 Consultation
8530 Subsequent visit
Ontario
Schedule of
Benefits. July 1, 2011
A025 Consultation
C022 Subsequent visit
Quebec
Manuel Des Médecins
Spécialistes (no 150). Mars 2011
09249 Consultation
09182 Visite de
contrôle
(Unit values 1.45)
Code 125 Major or
regional consultation
Code 121 Other office
visit
New Brunswick Schedule of Fees of the New
Brunswick Medical Society. April
2010.
Prince Edward
Island
Master Agreement Between the 0360 Consultation
Medical Society of Prince Edward
Island and the Government of
Prince Edward Island. April 1,
2007 – March 31, 2010
0313 Limited office
visit
Nova Scotia
MSI Physicians Manual. May 2011 03.08 Comprehensive
consultation
03.03 Subsequent visit
Newfoundland Medical Payment Schedule.
and Labrador
April 1, 2009
101 Consultation
115 Specific
reassessment
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Appendix 1
Medications
Information on funded medications was retrieved from published government drug
program formularies and is effective July 31, 2011. Drug program managers were invited
to validate the information.
Table 2: Formulary sources
Jurisdiction Source
BC
Online search of BC Pharmacare formulary (August 10, 2011)
www.health.gov.bc.ca/pharmacare/benefitslookup/faces/Search.jsp
No response received to request to validate information
BC Cancer Agency Chemotherapy Protocols and “Protocol by Drugs Index August 2011”
www.bccancer.bc.ca/HPI/ChemotherapyProtocols/default.htm
AB
Online search of Alberta Health and Wellness formulary (August 10, 2011)
https://www.ab.bluecross.ca/dbl/publications.html
Validated by Alberta Health and Wellness January 2011
SK
Online formulary search (August 10, 2011)
http://formulary.drugplan.health.gov.sk.ca/
Validated by Saskatchewan Pharmacare February 2011
Cancer drug coverage validated by Saskatchewan Cancer Agency, April 2011
MB
Online formulary search (August 10, 2011)
http://web6.gov.mb.ca/eFormulary/
Validated by Manitoba Pharmacare February 2011
ON
Online search of Ontario Public Drug Programs formulary (August 10, 2011)
www.health.gov.on.ca/english/providers/program/drugs/odbf_eformulary.html
Referenced Exceptional Access Program document “Drugs Not Considered for Reimbursement.
June 4, 2010”
Validated by OPDP February 2011
Online search of Cancer Care Ontario chemotherapy protocols (August 10, 2011)
www.cancercare.on.ca/cms/one.aspx?portalId=1377&pageId=10760
QC
List of Medications, August 3, 2011
List of Medications – Institutions, July 6, 2011
RAMQ declined to validate the information February 2011
NB
New Brunswick Prescription Drug Program Formulary, June 2011
Validated by NBPDP, February 2011
PE
PEI Pharmacare Formulary (no date) and updates to June 2011, retrieved August 10, 2011 at:
http://healthpei.ca/formulary
Validated by PEI Pharmacare February 2011
NS
Online search of Nova Scotia Pharmacare formulary:
www.gov.ns.ca/health/Pharmacare/formulary.asp
Search of Systemic Therapy list of Cancer Care Nova Scotia:
www.gov.ns.ca/health/cancer_drugs/
No response received to request to validate the information January 2011
NL
NLPDP Coverage Status Table, July 2011. Special Authorization Criteria July 2010.
Information validated by NLPDP January 2011.
YT
Yukon Drug Programs Formulary, July 2010.
No response received from Yukon Drug Programs to request to validate information January 2011.
NT
NU
NIHB
A-2
NT uses the NIHB formulary (see below).
NU uses the NIHB formulary (see below).
NIHB formulary 2010 and updates to Spring-Summer 2011.
Information validated by NIHB in February 2011.
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
Appendix 2
Methodologies for assessing access to
dermatological care
The following methodologies show the approach to developing measures and benchmarks for the “Access to dermatological care” sections of the Report Card, and provide
details of how the measurements were calculated.
Benchmarks for access to dermatological care
In summary, the following benchmarks were used to assess access to dermatological care.
Table 1: Benchmarks for access to dermatological care
Measurement
Benchmark
Wait times
4 weeks
Population per dermatologist full-time equivalent
65,000
Annual rate of growth in dermatologist numbers required to meet rising
incidence of skin diseases (2.8%) and replace retirements (3.4%)
6.2% per year
Rationale
From the patient’s perspective, wait times for a dermatology appointment are the key
measure of access to dermatology care. For this report, a median wait time of four weeks
for a non-urgent consultation was chosen as a benchmark. Four weeks reflects the need
for patients with debilitating conditions to obtain timely treatment that may allow them
to return to their daily lives without detrimental effects to their health, work, psychological well-being and social functioning. This is a realistic level since it was achieved in
2001.1
Merely measuring wait times, however, is not sufficient. There must also be an understanding of the underlying causes of long wait times in order to suggest actions to
improve the situation. A simple supply-demand model, shown below, captures the
approach taken in this report card to assess the various factors that contribute to wait
times.
1. Canadian Dermatology Association Workforce Survey, 2001.
Canadian Skin Patient Alliance · Skin Deep: Report Card on Access to Dermatological Care and Treatment in Canada 2012
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Appendix 2
Factors Affecting Supply and Demand for
Figure 1: Factors affecting
and demand
for medical dermatology services
Medicalsupply
Dermatology
Services
Demand
• Population growth
• Decrease incidence
• Treatment seeking
Supply
Medical dermatology FTEs per population
• Growth rate (trainees, retirements)
• Remuneration vs. cosmetic
• Practice models
Measuring supply
Full-time equivalents (FTEs) were calculated based on fee-for-service billing information provided by provincial governments. This captures medical services and omits other
activities such as cosmetic procedures, research and teaching. This measure indirectly
accounts for the number of hours worked and the number of patients seen per dermatologist.
The methodology used to calculate FTEs was developed by Dr. Evert Tuyp2 who kindly
obtained and analyzed provincial billing data to include in the model used in the Report
Card. This approach modifies the methodology used by the National Physician Database
(CIHI) by applying tailored income breakpoints that more accurately reflect the economic realities of dermatology practice by factoring in overhead expenses.
Calculation of FTEs
1. From the 2009-10 provincial billing data, extract the number of dermatologists who
billed above a threshold of $150,000. This represents a minimum income for fulltime fee-for-service practice.
2. The $150,000 breakpoint income was grossed up by a fixed percentage of dermatologist overhead costs (44.8 per cent) to achieve a revised lower limit of $271,781.
3. Physicians billing between one and two times the lower limit of $271,781 were
counted as one FTE.
2. Tuyp E. Full-time equivalent (FTE): a critique of its use in allocation and remuneration. Submitted for
publication.
A-4
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Appendix 2
4. Partial FTEs were calculated for dermatologists billing less than $271,781.
5. For dermatologists who billed greater than twice the lower limit (i.e., $543,562),
this amount was subtracted and the remainder divided by $543,562.
6. FTEs were summed by province.
A benchmark of one FTE per 65,000 Canadians was used in this report. This number is based on the ratio existing in 2001 when wait times averaged four weeks. It is
about double the proportion of dermatologists in Western Europe (one per 30,300
population)3 and the United States, where one per 33,000 population has been identified
as appropriate.4 Clearly, the CSPA would like Canadians to enjoy the same standards of
care as their American and European neighbours, but for now a more reasonably attainable goal is twice their ratios.
In addition to measuring system performance according to today’s needs, the adequacy
of actions taken by governments and others is also assessed, according to whether they
have prepared to meet future demands. Based on the Canadian Dermatology Association Workforce Survey of 2006, it was estimated that retirements will deplete the current
dermatologist ranks at a rate of 3.4 per cent annually. Therefore, new practice entries
must at equal or exceed this rate to avoid losing ground.
Measuring demand
Future demand is benchmarked as a rate of growth in demand for services. The major
factors that contribute to demand are outlined in the table below. Since data are not
available to measure incidence trends in every skin disease, an overall level of growth was
estimated conservatively at 2.8 per cent. Similarly, although we know that the Canadian
population is better educated and informed about health, there are no figures measuring
trends in seeking treatment for skin diseases.
Table 2: Forecasting the growth of demand for dermatology services
Factor influencing demand
Annual growth rate
Population growth
0.8%
Skin disease incidence:
2.0% (estimated)
• Psoriasis
Increasing
• Atopic eczema
Increasing
• Melanoma skin cancers
2%
• Nonmelanoma skin cancers
3%
Estimated total annual growth of demand
for medical dermatology services
2.8% (minimum)
3. Wound Management Decision Support Database. Frost & Sullivan’s Healthcare Practice. 2004;2(12).
4. Krasner M et al. Dermatologists for the nation – Projections of supply and demand. Arch
Dermatol. 1977;113(10):1367-1371.
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