Doubts raised over pharmacy testing
Doctors cite concerns over safety and cost of drugstore COVID screening as demand soars
Three weeks after Ontario pharmacies started testing for COVID-19, doctors are questioning the costs of a “problematic” program they say was introduced with little transparency and ill prepared to meet soaring demand.
Select pharmacies across the province started doing asymptomatic COVID testing Sept. 25, and Premier Doug Ford has touted the new system as a way to “help expand testing to more people.”
But some symptom-free people who need testing — like essential caregivers with loved ones in nursing homes — say it’s still taking hours or even days of effort to find a nearby appointment, only now they’re calling multiple drugstores instead of testing centres.
And physicians are raising concerns over the safety and cost of Ontario’s pharmacy testing plan, which is shipping specimens to labs in the United States and reimbursing pharmacists at least $42 per test — more than what doctors and COVID assessment centres are getting per swab, according to several physicians.
“We need to make sure testing is accessible, but the actual implementation of pharmacy testing is problematic on a number of fronts,” said Dr. Camille Lemieux, medical lead at the COVID assessment centre at Toronto Western
Hospital. “I feel like the pharmacy (plan) was kind of like chewing gum stuck on the side of something; oh, let’s just add this on.
“For a six-month period of preparedness, there is remarkable chaos. I don’t understand how we got to this point in
October 2020. I really don’t.”
Ontario has been testing asymptomatic people since late May, when provincial labs were testing below capacity and Ford urged “everyone possible” to get swabbed, even if they weren’t showing symptoms.
But public health data has since shown that broad as ymptomatic tes ting in Ontario has turned up very few positive cases while using up significant resources.
“For a six-month period of preparedness, there is remarkable chaos. I don’t understand how we got to this point in October 2020. I really don’t.”
Dr. Camille Lemieux Toronto Western Hospital
And in September as infection rates began to rise — and the province’s testing backlog ballooned — there was intense pressure to fix the snaking lineups at testing centres and shift resources away from low-yield asymptomatic tests.
Under the province’s latest testing guidelines, only asymptomatic people in targeted groups are eligible for pharmacy testing; for example, caregivers with loved ones in nursing homes, or people who need a negative test to travel.
Shifting these tests to pharmacies was “part of the government’s commitment to expand access to COVID-19 testing,” the health ministry told the Star in a written statement. As of Oct. 6, Ontario pharmacies had collected a total of nearly 13,000 COVID samples, with an average turnaround within four days, according to the province.
“To ensure the province is well prepared to manage testing volumes, the province continues to expand the capacity of our lab network, including working with all of our health system partners to process more tests and achieve provincial testing targets,” the statement said. “We continue to work with pharmacy industry associations and Ontario Health on the optimal delivery approach for this new program.”
But critics wonder why the province is turning to pharmacies instead of expanding existing testing centres or funding community practices to test for COVID.
One question is whether pharmacies can adequately meet soaring demands. The province has “set a threshold for now of 20 tests per day” at each participating pharmacy, according to Justin Bates, CEO of the Ontario Pharmacists Association. As of Friday, 139 pharmacies across Ontario had started offering the tests, according to the ministry of health.
COVID assessment centres are set up to do hundreds of swabs every day, however. In September, before the province’s move to appointment-only testing, Trillium Health Partners was averaging 1,200 swabs per day at its two assessment centres.
And in a health emergency with urgent funding needs, some doctors question the province’s decision to spend money on pharmacy testing, most of which will flow toward drugstores owned by two corporations.
The vast majority of participating pharmacies are Shoppers Drug Marts — a Loblawsowned chain where store owners operate much like franchisees — and Rexall, owned by pharmaceutical giant McKesson.
“We are proud to be a part of the solution for our communities and will continue to work with provincial governments to support testing in any way we can,” a representative from Loblaws said in an email.
The Ontario Pharmacists Association had been urging the province for months to follow the lead of other jurisdictions like Alberta, which introduced pharmacy-based COVID testing in early July, according to Bates.
He said COVID testing is “not a money maker,” especially for independent pharmacies providing the service at a loss. But he said his association saw an opportunity to not only relieve the burden on testing centres, but “showcase our value to the system,” during the pandemic and beyond.
The association pushed for regulatory changes allowing Ontario pharmacists to swab for COVID and, they hope, to offer the rapid tests recently approved by Health Canada, which can produce results in 15 minutes.
These changes pave the way for pharmacists to expand their scope of practice even post-COVID, when Bates envisions pharmacies offering “point of care” rapid tests for everything from HIV to strep throat.
“We need all health-care providers to be stepping up,” Bates said. “This is the time to ensure we are working together as health-care providers in the best interests of our patients.”
Lemieux said she is in “complete support” of expanding access to COVID testing, including to pharmacies and other community settings. But she questions whether drugstores have the infrastructure to safely handle high volumes of COVID tests. She’s troubled by the idea of potentially infectious people crowding “next to the person who is buying the soap.”
Lemieux is also struggling to understand why the government is shipping samples to the U.S. for processing and reimbursing pharmacists $42 a test — more than the $38 per swab she says her COVID assessment centre receives from the province to test people who are symptomatic.
The health ministry said funding models differ between assessment centres and pharmacies, and many variables affect cost. The $42 reimbursed to pharmacists covers screening and swabbing; at assessment centres, the $38 is also for “assessment and swab collection” but test kits and lab processing add an estimated $47.50 on average, the ministry said.
But the province did not respond to questions about the cost of processing samples collected by pharmacies and shipping them to the U.S., where the lab work is being contracted out to the company Quest Diagnostics.
“Paying pharmacies more than physicians has just left such a bitter taste in our mouths, after everything we’ve gone through in the past six months of stress and overwork and PTSD for some people,” Lemieux said.
The reimbursement for pharmacists is even more puzzling given that they’re doing more shallow nasal swabs, rather than the deeper, more sensitive, nasopharyngeal swabs used at COVID assessment centres, said Dr. Lisa Salamon, an emergency room physician and Toronto district chair with the Ontario Medical Association.
At her busy assessment centre in Toronto, Salamon makes $170 hourly during the week, which she bills OHIP as a COVID-19 “sessional” fee. Before the shift to appointment-only testing, Salamon saw 50 patients an hour on a busy day — working out to about $3.40 per patient.
Although community doctors haven’t been supported to test for COVID, some are scrounging together the swabs and PPE to test their own patients. But there is no OHIP code for assessing and swabbing for COVID, and the most a family doctor could bill is less than what pharmacists are being compensated, Salamon said.
Many doctors who had to shut their doors during lockdown have struggled financially and would have welcomed the chance to provide COVID testing, said OMA president Dr. Samantha Hill. She said the province didn’t consult the OMA and she learned in the media about testing in pharmacies.
“I wonder about the fact that a general practitioner will get $30 to $35 for managing a complex patient in their office, whereas a pharmacist is getting $42 to swab an asymptomatic patient,” Hill said. “When it comes to public health care and public spending, are we getting the biggest bang for our buck?”
Bates said doctors can’t offer the same degree of accessibility as Ontario’s 4,600 pharmacies, which remained open while many doctors’ offices went virtual.
He said the funding models for pharmacies and health-care providers are “apples to oranges” and the money reimbursed to pharmacists is meant to offset costs like PPE, technology, labour and sanitation — a fee model aligned with what Alberta is paying its pharmacists, he said.
In Ontario, samples have to be delivered by refrigerated trucks, and pharmacists are currently paying courier fees out of pocket, Bates said. He said the province didn’t want to exacerbate the capacity issues plaguing the provincial lab system so created a separate system for pharmacy samples, which are delivered to a central depot and contracted out for processing in the U.S.
“This is one of the complexities of program that’s a challenge for independents, because they don’t have the scale to operationalize this in the same way.”
Scarborough pharmacist Akil Dhirani is one of the few independent owners currently offering COVID testing at his store, Village Square Pharmacy, part of the Guardian retail banner under McKesson Canada.
Dhirani says he was happy to volunteer when the province issued a callout. His pharmacy is now doing about 20 tests a day, with appointments booked for the next few weeks; he has yet to uncover a positive case in the 200-plus people tested so far.
But Dhirani said he loses money every day on shipping costs, even though the government is reimbursing him up to $20 per day for delivery expenses. He is also paying for PPE, twice-weekly deep cleanings, a security guard who can take temperatures, and staffing to handle bookings and the phone — which initially rang “every five to 10 seconds.”
Dhirani wants to continue this service but would like to see more reimbursement from the government to break even.
“It’s something that we felt we wanted to give back to our community in Scarborough,” he said. “It’s definitely not going to make you a millionaire.”
Dhirani said he and his team received online training provided by McKesson Canada, which took a couple of hours. He said every patient that comes in for testing is screened by phone, temperature-checked at the door, and swabbed in a room separate from the pharmacy, with “fairly aggressive” sanitizing protocols.
“When the actual testing would take place, it’s five seconds in each nostril,” Dhirani said. “The exposure is minuscule, a lot less than what you would see if you went to Costco or Ikea.”
But physicians like Salamon say infection prevention and control practices are incredibly strict at COVID testing centres and she has a hard time imagining hundreds of drugstores maintaining similar standards. She worries symptomatic people will come to pharmacies, confused about testing criteria or simply unaware they have symptoms.
That could potentially cause exposure where “people are coming for flu shots, coming to shop, and frail people are coming to pick up prescriptions.”
One Mississauga resident said he never felt nervous at his local pharmacy until COVID testing started. He needs to regularly pick up medication because he is diabetic and his wife has a chronic illness.
Adam, who asked to withhold his surname because he works in the pharmaceutical industry and worries about professional ramifications, said that when he recently picked up his prescription, he found himself next to “no fewer than six people waiting for their COVID test.”
“On top of that I had to wait for at least 20 minutes to get to the counter,” he said. “I watched a staff that looked completely overwhelmed trying to fill prescriptions, deal with questions, and complete the COVID (tests) and flu shots in the consultation room that they were using.
“I fear that this plan to have pharmacies complete these tests did not take into account the multiple high-risk people that rely on the pharmacies on a regular basis, and that there will be a greater risk of contracting COVID while getting needed medicine.”
Dr. Lesley Barron, a general surgeon in Georgetown, was also perturbed by her recent visit to a pharmacy, where she was tested for COVID in order to visit her mother in long-term care.
After walking through the main entrance, she waited next to other customers until her name was called. She did not see anybody clean the testing room after the previous patient left and she walked in.
“I guess you could argue you don’t need aggressive protocols with asymptomatic testing,” she said. “But in an assessment clinic, every chair and handle would be wiped down after everybody came in to get their swab done.”
Barron would know; she works at an assessment centre. But even though the centre is within walking distance of her home, she still had to drive 30 kilometres to the nearest pharmacy with a timely appointment.
Ultimately, it took Barron eight days to get the asymptomatic test result she needed.
“The whole system is really frustrating to navigate, and I’m someone who works at a COVID assessment centre,” she said. “I don’t see good things coming with this second wave. It’s very, very scary when we knew it was coming and we still can’t get it right.”
“It’s something that we felt we wanted to give back to our community in Scarborough. It’s definitely not going to make you a millionaire.” AKIL DHIRANI PHARMACIST