CPhA urges regulation as survey shows insurer practices disrupt care and restrict choice
Nearly 3 million Canadians have switched pharmacies because their insurance company recommended it, according to new survey data released by the Canadian Pharmacists Association (CPhA).
The findings highlight how insurer and pharmacy benefit manager (PBM) practices are influencing patient choice and straining pharmacy operations.
The survey also found that 86 percent of Canadians believe they should be able to fill prescriptions at any licensed pharmacy, regardless of their insurance provider.
CPhA said these results underline the urgency of addressing insurer-driven restrictions that affect both patients and pharmacists.
Annette Robinson, chair of CPhA, said, “Pharmacies play a critical role in patient care.”
She added that pharmacists are increasingly weighed down by administrative requirements and explained that the proposed legislation provides a blueprint for policymakers to help them focus on patients rather than paperwork.
CPhA is calling on governments to regulate PBMs and insurers through template legislation it has developed.
The framework is designed to improve transparency, safeguard patient choice, and reduce administrative burdens.
The proposed measures include protecting patient choice by prohibiting requirements that force patients to use specific pharmacies, ensuring fair audits by limiting frequency and conflicts of interest, requiring advance notice, restricting recoupment practices, and establishing clear appeal processes.
It also calls for banning administrative fees imposed by PBMs for electronic claims submissions, adjustments, or related transactions.
Survey results show that 36 percent of pharmacists face multiple patient conflicts daily when handling third-party payer claims.
In addition, 75 percent spend at least 5 hours weekly on such claims, and nearly 20 percent dedicate more than 15 hours.
CPhA reported that 81 percent of pharmacies experience moderate to significant workflow disruptions because of these tasks.
While 71 percent of pharmacies do not participate in preferred provider networks (PPNs), 75 percent report being required by third-party payers to direct patients to pharmacies within these networks.
“These findings make clear that insurer-driven red tape is not a minor inconvenience,” Robinson said.
She added that the data shows urgency, noting that pharmacists are spending hours on paperwork instead of with patients and that Canadians are being steered away from their pharmacy of choice. Robinson explained that this is why their template legislation is needed.
CPhA said the message from pharmacists is direct: insurer practices should not interfere with patient care.
Protecting patient choice and reducing unnecessary administrative barriers will ensure pharmacists can deliver timely, patient-centred services.
