Why the OCP’s New Recommendation to Step Backward from Zero Tolerance to Partial Tolerance on PPNs is Concerning

On July 2024, the Ontario College of Pharmacists (OCP) made a bold statement: closed Preferred Provider Networks (PPNs) and payer-directed care models maybe harmful to patients, and conflict with ethical principles and professional standards. OCP Board Adopts Position on Closed Preferred Provider Networks? - OCPInfo.com At that time, the College committed to a zero-tolerance stance, pledging to explore regulatory changes that would classify participation in these models as professional or proprietary misconduct.

Now, just a few months later, the OCP is walking back its commitment. New recommendations suggest regulating certain activities within these models rather than banning them outright.

december-9-10-2024-board-meeting-agenda-materials.pdf (Pages 411-500)

This shift weakens patient protections and ignores the clear example set by Quebec, where PPNs are completely banned, and patient autonomy is safeguarded through robust legal frameworks. The OCP cites concerns about “unintended consequences,” such as limiting access to specialty medications. Yet, Quebec’s success offers a proven alternative that Ontario should adopt.

What Quebec Gets Right

Quebec stands as the only province in Canada to take decisive action against the harmful impacts of PPNs. These networks are explicitly prohibited under laws that prioritize patient autonomy and protect freedom of choice in healthcare, including pharmacies.

This prohibition is grounded in:

• The Code of Ethics of Pharmacists (P-10, r.7)
• The Act Respecting Health Services and Social Services (S-4.2)
• The Act Respecting Prescription Drug Insurance (A-29.01)

These frameworks prevent pharmacists from entering into agreements or accepting incentives that steer prescriptions to specific pharmacies. By ensuring external influences like insurers or Pharmacy Benefit Managers (PBMs) cannot dictate patient choices, Quebec protects the pharmacist-patient relationship.

The Code of Ethics of Pharmacists explicitly mandates:

• Pharmacists must respect patients’ right to choose their pharmacy.
• No agreements may restrict or limit this choice.

In Quebec, the rules are clear, and they work. Patients retain full autonomy, continuity of care is safeguarded, and pharmacies are held accountable to the public—not corporate interests.

The OCP’s concerns about “unintended consequences” do not hold up against Quebec’s example. The outcomes of Quebec’s ban are intentional—and overwhelmingly positive.

Where’s the Evidence for Cost Savings?

The OCP’s justification for a softer stance includes claims of cost savings from PPNs, suggesting these networks lower premiums and improve access to specialty medications. However, the OCP’s own briefing documents, dated December 9-10, 2024, provide no evidence to support these claims.

The OCP met with Canada Life on August 15, 2024, to discuss its position on PPNs. While the details of the meeting have not been made public, it occurred during a period when the OCP was re-evaluating its stance on payer-directed care models.

september-15-16-2024-board-meeting-agenda-materials.pdf Page 38

At the same time, organizations like the Competition Bureau and the Canadian Federation of Independent Business (CFIB) have reported no measurable cost savings from PPNs. Evidence from the United States suggests that these models may increase drug costs over time, financially strain small pharmacies, and limit patient options.

Competition Bureau says preferred pharmacy networks may reduce patient choice - The Globe and Mail

Health care providers press Ontario to limit restrictive insurer-pharmacy deals - The Globe and Mail

If cost savings are being used to justify policy changes, the OCP must demand transparency and evidence from insurers and PBMs. Patients and the public deserve accountability to ensure decisions are based on facts, not assumptions.

Specialty Pharmacies: A Questionable Justification

The OCP also points to specialty medications—high-cost, complex drugs requiring specialized care—as a reason to allow payer-directed care models. However, Ontario lacks a formal designation for specialty pharmacies. All pharmacies are regulated the same way, undermining the argument for relying on PPNs to manage these medications.

Instead of deferring to industry standards, the OCP could establish its own certification process for specialty pharmacy practices. This would ensure only qualified providers dispense these medications while preserving patient autonomy.

Quebec already balances access to specialty medications with its prohibition on PPNs, showing that Ontario can do the same without compromising patient choice or continuity of care.

?Terminology Matters: The OCP’s Role as a Regulator

As Ontario’s pharmacy regulator, the OCP must lead with authority and uphold its commitment to zero tolerance for practices that compromise patient autonomy and safety. Referring to groups such as government agencies, pharmacies, insurers, and Pharmacy Benefit Managers (PBMs) as “partners” risks undermining that authority and confusing the lines of accountability. While collaboration with government bodies that share the OCP’s mandate is appropriate, entities like insurers, PBMs, and pharmacies—whose priorities could conflict with the public interest—should be treated as stakeholders, not partners. As a pharmacist, I know the College would never treat individual pharmacists as partners in regulation.

Zero tolerance should mean zero tolerance—refusing to accept language, policies, or practices that prioritize corporate interests over the public good. It means taking an uncompromising stance to ensure the OCP remains independent, focused on protecting patients, and free from influence by entities whose goals may conflict with patient care.

The College has already demonstrated its authority by changing how it refers to pharmacists from “members” to “registrants.” To regulate effectively and maintain public trust, the OCP must continue to use precise and deliberate language. Government agencies with aligned mandates can be considered partners, but other entities must remain stakeholders to reflect their distinct and often competing roles.

By committing to accurate terminology and reinforcing zero tolerance, the OCP can strengthen its leadership, reaffirm its independence, and prioritize patient safety and professional standards without compromise.

The Way Forward

The OCP must step back and refocus on its core mission: protecting patients and safeguarding their right to choose where they receive care. Quebec has demonstrated that banning PPNs is both practical and effective. The College could aim to control the operation of payer-directed care models by explicitly defining participation in payer-directed models as new grounds for proprietary and/or professional misconduct by utilizing its existing powers to set policies, codes and standards of practice.

The OCP must also demand transparency from insurers and PBMs to substantiate their claims of cost savings. Without accountability, patients and pharmacists will continue to bear the burden of payer-directed care models.

Patients and pharmacists deserve a system that prioritizes their well-being over corporate interests. The OCP still has the chance to reaffirm its commitment to zero tolerance for practices that put patients at risk. It’s time to act decisively and put patient care first

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