The Problem of Funding Education for Medical Cannabis Patients
Written on 07 July 2023
by Ruth Fisher, PhD
- The Traditional Healthcare System
- The Medical Cannabis System
- Education: Pharma vs. Cannabis
- Alternative Funding Mechanisms for Cannabis Patient Education
Using medications to treat medical conditions is complicated. Patients generally do not choose medications and dosing patterns on their own; rather, they turn to doctors and pharmacists to help them manage the process. Using cannabis to treat medical conditions is also complicated. However, neither the doctors who qualify patients for medical cannabis use, nor the budtenders who sell cannabis products, generally provide patients with effective guidance on product selection and dosing. Many organizations have emerged in the medical cannabis industry, staffed by people knowledgeable about medical cannabis, to fill this need of helping to guide patients in their use of cannabis products. Unfortunately, many of these organizations have found it difficult, if not impossible, to fund their patient education services. These providers have discovered that patients are generally not willing to pay for these types of services themselves, and alternative funding mechanisms generally do not exist to compensate educators.
Of course, for the third-party provision of medical cannabis patient education services to work, some funding mechanism must be found to reimburse providers. When approaching this problem, it’s instructive to start by examining how funding for patient education in the traditional healthcare system is managed. Once this has been established, we can determine the extent to which parallel mechanisms used in the traditional industry can be applied to the cannabis industry.
The Traditional Healthcare System
General Overview of the Patient Experience in the US
The US healthcare system generally operates as follows (see Figure 1).
Figure 1
When a patient becomes ill, she visits her doctor, who examines her and determines which types of medications would be most beneficial. The doctor, often with input from the patient, decides on a particular medication and provides the patient with dosing information, side effects, and any other guidance she needs for using that product. The doctor then gives the patient a prescription for the medication, which she takes to a pharmacy to be filled. If the patient has any other questions about using the medication, she can turn to the pharmacist. She then uses the medication and reports back to her doctor about how well it’s working. The doctor may tweak the dose or try a different medication until the patient finds relief.
Patients generally have private or public (i.e., government) healthcare insurance, in which case they pay monthly premiums to their insurance companies for coverage. When a patient visits her doctor and when she has her prescriptions filled, it is then the insurance company that pays the doctor for the office visit and the pharmacy for the prescription medications.
The doctor and the pharmacist are both licensed by the state, which means they have both established they have the medical training needed to treat patients.
Pharmaceutical companies (Pharma) develop and commercialize medications. They also provide the research and education for doctors and pharmacists that support the use of their medications. Specifically, when Pharma find a promising candidate, they take it through the FDA approval process, which establishes product safety and efficacy. The approval process involves conducting a series of studies, which, by the time the medication has been approved, creates a body of evidence upon which doctors and pharmacists draw to guide patients in product selection, dosing, and side effects.[1] After their products have received FDA approval, pharmaceutical companies provide further education to doctors and physicians – via meetings and office visits – about medication usage and dosing[2] by drawing on the studies performed during the FDA approval process.
General Overview of the Patient Experience in Canada
The traditional healthcare experience in Canada is identical in most respects to that in the US. The only relevant difference is that some healthcare is nationalized, while other healthcare is financed by private insurance (see Figure 2). Specifically, office visits are generally paid for by provincial governments, while prescription medications are generally covered by private insurance.[3] Other than that, all the dynamics described above for the US system also apply to the Canadian system.
Figure 2
Critical Points of Note about the Patient Experience
The FDA Enables All Healthcare System Activity
The FDA approval process establishes the safety and efficacy of medications, provides guidelines for their use,[4] and oversees their manufacturing, marketing, and distribution to ensure they are standardized and safe to use.[5] Most doctors will not prescribe medications for patients, and health insurance companies will not reimburse their costs, unless the FDA has approved their use. Pharmacists will generally not stock medications that doctors don’t prescribe or that patients don’t buy. And patients will generally not buy medications unless their doctors prescribe them, their insurance covers them, and pharmacists stock them. It’s clear, then, that without FDA oversight or approval medications cannot move through the healthcare system (see Figure 3).
Figure 3
Most Drug Information Is Funded by Pharma
As just discussed, the FDA approval process establishes the body of research needed by all healthcare system participants to support pharmaceutical use. Without it, doctors and pharmacists lack (most of) the guidance they need to help their patients appropriately select and dose medications to treat their conditions.
Critically, almost all studies available for FDA-approved medications have been funded by the pharmaceutical companies who develop and manufacture products. The funds needed to finance studies on a medication’s safety and efficacy come from the expected future sales of that product once it becomes FDA-approved. Furthermore, as already discussed, pharmaceutical companies also finance the conferences and office visits for doctors and pharmacists to educate them about that medication, since doing so encourages doctors and pharmacists to prescribe that medication to patients.[6] In short, almost all the information available to doctors and pharmacists about a medication generally comes from the manufacturer.
Medications Are Standardized
As discussed above, the FDA oversees all over-the-counter and prescription pharmaceutical (drug) supplies in the US. The FDA has stringent requirements on the manufacture, distribution, and sale of drugs, and as a result, drugs are fully standardized across time and space.[7] That is, a Tylenol or Lipitor pill taken today in Kalamazoo, Michigan is exactly the same as the Tylenol or Lipitor pill taken last year in Kansas City, Missouri. This standardization has three important implications.
First, when a doctor prescribes Lipitor to a patient, the doctor knows the patient can go to any pharmacy in the US, hand the pharmacist her prescription, and she will get a bottle of Lipitor pills, where each pill contains the exact compounds the doctor intends the patient to take and expects will treat the patient’s condition.
At the same time, when a doctor prescribes Lipitor to a patient, the doctor knows that neither the patient nor the pharmacist has any (or only very limited) discretion in being able to change the medication the pharmacist gives her. In other words, the doctor knows the patient will leave the pharmacy with exactly the medication the doctor prescribed.
Finally, Lipitor is a mass-market, one-size-fits-all, product. The same exact formulation (compound) is used by millions, if not tens of millions, of people in the US alone, regardless of any differences in patients’ system makeups, comorbidities, lifestyles, etc.
The Medical Cannabis System
General Overview of the Patient Experience in the US
The US medial cannabis system generally operates as follows (see Figure 4).
Figure 4
A patient visits a doctor who provides her with certification indicating she has a condition that qualifies for medical cannabis use in that state. The patient then submits the appropriate documentation to the state and pays the requisite fee, after which she receives her medical cannabis card. She then goes to a dispensary that’s licensed to sell medical cannabis, where she buys her cannabis. If she has questions about product selection or use, she can ask the budtender for advice.
Health insurance generally will not reimburse for medical cannabis-related visits to the doctor or for cannabis products, so the patient must pay for the doctor visit and all cannabis products out-of-pocket.
The doctor who certifies that the patient qualifies for medical cannabis use generally does not provide (much) guidance to the patient about product selection or dosing, since he generally has little-to-no education about medical cannabis. Likewise, the budtender from whom the patient buys her cannabis has generally not been licensed in either medicine or in medical cannabis. So, while the budtender may offer advice on product selection and dosing, he probably has no formal training on the matter. It’s generally up to the patient to select a product and determine dosing for herself.
General Overview of the Patient Experience in Canada
The medical cannabis patient experience in Canada differs in two ways from that in the US (see Figure 5). First, some medical cannabis activity is covered either by government or by private insurance. Specifically, the Canadian government (Veterans Affairs Canada) pays for medical cannabis use by military veterans,[8] and some private health insurance companies cover medical cannabis use for select patient conditions.[9] The other difference between the US and Canada is that while medical cannabis patients in the US are free to purchase cannabis products from any licensed dispensary, medical cannabis patients in Canada must register with a single Licensed Producer and then purchase all their cannabis products from that select producer.
Figure 5
Critical Points of Note about the Patient Experience
Information Is Largely Absent for Medical Cannabis
Because cannabis is not regulated by the FDA, the body of research that normally exists to guide doctors and pharmacists in the traditional system in determining the appropriate products and dosing for patients is largely absent from cannabis. In the traditional system, it is the medication providers who fund education for doctors and pharmacists. However, in the cannabis system, the cannabis product providers don’t have the same incentives to fund education for doctors and budtenders (more detail to follow). At the same time, neither doctors who certify patients for medical cannabis use nor budtenders who dispense cannabis products to medical patients have the incentive to invest in gaining the knowledge needed to guide patients (more detail to follow). In short, the information infrastructure that supports education for traditional pharmaceuticals is almost entirely absent from the medical cannabis system.
Cannabis Is Not Standardized
Unlike with traditional therapeutics, most cannabis products are not standardized across time and space. Cannabis flower and cannabis products made with whole plant extracts vary in composition from sample to sample. Furthermore, the availability of cannabis products varies, not only from dispensary to dispensary, but also within dispensaries over time.
The standardization of traditional therapeutics both in composition and in availability across pharmacies enables two important dynamics in the traditional healthcare system. First, both doctors and patients know that therapeutics will be consistent in formulation, no matter where or when the products are purchased. This is essential, because once patients find particular products that help address their conditions, they want continued access to those same formulations over time and space.
And second, standardization and ongoing availability of formulations enables doctors to prescribe particular therapeutics for their patients and know that when patients visit any pharmacy, (i) patients will be able to access the prescribed therapeutics, and (ii) patients will leave the pharmacy with the prescribed therapeutics. Because cannabis products are not standardized, cannabis doctors have no assurances that either of these factors will hold true. In fact, in many cases patients cannot find the products their doctors recommend, and even if they do, they’re not required to adhere to their doctors’ recommendations, so they may not end up buying them. In either case, patients often don’t end up using the products best suited to their needs.
Cannabis Is Personalized Medicine
The cannabis products that best address patients’ particular needs vary tremendously across patients. Finding the best product is often an iterative process for patients. While finding the right therapeutic in the traditional system can also involve an iterative process, the number of choices is generally much more limited. Both cannabis doctors and their patients generally need at least a basic understanding of medical cannabis to navigate through all the possibilities and find the best products to suit patients’ individual needs.
Patients Have Much More Discretion with Cannabis
In the traditional healthcare system, doctors prescribe medications for patient use. Patients can choose either to use or to not use that medication, but a patient is not able to use the prescription to get a different medication. In contrast, in cannabis, doctors qualify patients for medical use, but once patients are qualified, they are free to use any cannabis product they choose. Even if a doctor recommends a particular cannabis product, patients are still free to reject the doctor’s recommendation and use whichever product they want. In short, patients have much more discretion with both product selection and dosing in cannabis than they do with traditional prescription medications.
Of course, greater amounts of patient discretion in cannabis can be both frightening and empowering. Regardless, the successful use of medical cannabis requires that education be available for both doctors seeking information to guide patients who want their help, as well as for patients seeking empowerment to contribute to, if not drive, their own care.
Education: Pharma vs Cannabis
As discussed above, in the traditional healthcare industry pharmaceutical companies generally provide the education needed by doctors and pharmacists to guide patients in the use of prescription medications. Perhaps, then, the medical cannabis industry should be looking to the providers of medical cannabis products to provide medical cannabis doctors, if not also patients, with information on product use? Probably not. There are clear reasons why Pharma voluntarily educate providers about medications, but these reasons do not carry over into the medical cannabis industry.
Pharma Provide Education Voluntarily
Pharma’s education programs for doctors and pharmacists contain the following characteristics.
Research Is Readily Available: Most of the research Pharma uses as the basis for their education programs comes from studies they’ve already conducted in preparation for and/or during the course of the FDA approval process. That is, the most difficult, expensive, and convincing component of their educational programs has already been generated. Pharma’s education programs are simply exercises in providing awareness of information already in existence. The costs of Pharma’s educational programs are therefore relatively low.
Medications Ae Standardized: Medications are standardized across time and space. As a result, assuming no new information comes to light, a study performed on a particular medication will continue to be relevant for any and all use of that medication. That is, a single study can support potentially large volumes of use (across time and space) for the medication at issue. This makes the costs of supporting education for particular medications relatively low.
Education Is Tied to Differentiated Products: The education Pharma provides doctors and pharmacists is information that is tied very closely to highly differentiated products that cannot be easily reproduced by competitors. In other words, the information provided is relevant for very specific products with relatively little spillover in relevance to other products. This enables Pharma to extract most of the value it creates from its education programs, which increases the efficiency of education programs.
Education Targets Sales Drivers: The education provided by Pharma targets those individuals (doctors and pharmacists) who drive (i.e., prescribe) large amounts of use.[10] This makes the returns on supporting education for particular medications relatively high.
Medications Generate Large Profits: The education provided by Pharma tends to focus on specific products that generate large profits, either through high sales volumes or high margins.[11] This makes the returns on supporting education for particular medications relatively high.
In short, the discussion makes it clear that Pharma education is a highly tailored endeavor, which involves (i) using highly specific information (studies) (ii) they’ve already invested in generating, while (iii) targeting campaigns to focus on those individuals most likely to drive sales (iv) for very specific and uncopiable products (v) that have the potential to generate large profits for the company. Taken together, these five factors enable Pharma to generate and extract large returns on their investments in education programs.
Parallels with Cannabis Cultivators/Brands?
Few, if any, of these five factors that characterize Pharma’s education programs – and that make them profitable for Pharma to voluntarily provide – are generally present in cannabis.
First, with the exception of research on cannabis pharmaceuticals (e.g., Sativex or Epidiolex), research establishing the safety and efficacy of cannabis products is generally scarce, and it’s tied to specific cannabinoids (generally isolates), not cannabis products (which generally contain combinations of compounds). Cannabis growers or brands can tout the benefits of their products to sellers (and buyers), but without studies to reference establishing efficacy, it may be a hard sell.
Second, particular cannabis cultivars can vary tremendously as to exact contents (i.e., profile of compounds) across time and space. The relatively large variation in the contents of most cannabis products over time makes it difficult to link research (again, generally conducted on isolates) to specific cannabis products (which not only contain combinations of compounds, but also whose compositions may vary over time). There are simply too many variables in most cannabis products for any one study to have broad applicability.
Third, most cannabis products are not highly differentiated or uncopiable. As a result, information provided for one product can often be applied to other products as well. This makes it difficult for the education provider (grower or brand) to capture enough of the benefits of the education he’s providing (in terms of higher product sales), without having too much of the benefits spillover into competing products (see Figure 6).
Figure 6
The fourth issue, the focused or dispersed nature of sales across outlets, may be similar to Pharma in some cases. For example, small suppliers may focus sales on a limited number of outlets, in which case, it might be relatively easy to concentrate education efforts on those select outlets. On the other hand, larger suppliers, may have more dispersed sales, which could make the provision of education across outlets a more costly endeavor, especially if individual outlets do not sell enough of the growers’ product to make the provision of education worthwhile.
The fifth issue, the potential profitability of single cannabis products, like the fourth issue, may have both similarities with as well as differences from Pharma. The important factor here is the profitability of product sales at particular outlets. Growers or brands that generate large sales at specific outlets may indeed benefit from providing education to those outlets, but this may not generally be the case.
In short, the factors that make it profitable for Pharma to voluntarily provide education to physicians and pharmacists for guiding patients in their use of medications do not apply to cannabis. As a result, the medical cannabis industry cannot rely on growers/brands to provide the education that budtenders and patients need to guide patients in their cannabis use.
Alternative Funding Mechanisms for Cannabis Patient Education
As described above, in the traditional healthcare system the doctors who treat patients are generally responsible for guiding patients in their selection and use of medications. In the medical cannabis system, however, doctors who qualify patients for cannabis use generally do not have the knowledge needed to guide patients. A possibility, then, is to require doctors who wish to qualify patients for cannabis use to become knowledgeable about medical cannabis so they will, in fact, be able to guide patients.
This proposition would not improve the situation. While there are currently many programs for training doctors to care for cannabis patients, there are hurdles other than simply lack of knowledge that are currently preventing more mainstream doctors from guiding patients in their cannabis use, particularly cannabis’s Schedule I status and it’s lack of FDA approval (for a more detailed explanation, see my previous blog, Why Most Doctors Are Reluctant to Recommend Medical Cannabis). The existence of these hurdles suggests that requiring qualifying doctors to also guide patients would lead many doctors who currently qualify patients to stop doing so, because they cannot or will not also guide patients in their cannabis use. This would simply reduce patients’ access to medical cannabis, which would certainly not improve the current situation.
Another possibility would be to require sellers of medical cannabis products (i.e., budtenders/dispensaries) to also guide patients in their use. There are currently a smattering of budtenders and other dispensary personnel who are providing these services. Forcing all medical cannabis budtenders to be certified in cannabis would raise prices to medical users (since certified budtenders command higher wages) and perhaps also decrease availability of supply (since some medical dispensaries may instead simply transition to the adult use sector). So, then, this alternative would have the same effect as the previous one of limiting access to medical cannabis products.
Of course, government could directly fund patient education by drawing on taxes collected from cannabis activity. This is not an ideal situation, since all government tax collections are presumably already earmarked for other causes, which means government would have to increase the current tax rates on cannabis activity, which are already too high. At the same time, there's no promise that such funds would be used effectively.
There is only a single long-term solution I can think of that would effectively fund guidance for medical cannabis patients in the US, coincidentally, while also expanding access: convince health insurance companies to fund patient guidance, that is, reimburse for the services of medical cannabis education providers. Many medical cannabis users find that cannabis not only improves their symptoms, but that it also enables them to decrease, if not eliminate their use of other medications.[12] In other words, using cannabis reduces patients’ healthcare spending, which, in turn, decreases the costs to health insurers of insuring medical cannabis patients. Certainly, patients are more likely to use cannabis effectively if they have proper guidance from knowledgeable providers. It follows that health insurers have a financial incentive to reimburse both patient guidance services as well as medical cannabis products. Yet, there still remains the hurdle that, with very few exceptions, cannabis products are not FDA-approved, and health insurance companies have historically refused to cover most unapproved medications.[13]
In Canada, however, where provincial governments cover patient costs for office visits, while private insurance covers the costs of medications, the same health insurance mechanism as that in the US exists for funding patient education in cannabis may not work. More specifically, the optimal cost savings would only be realized if both sets of payers participate, and any cost savings would be divided between the two sets of payers. This co-dependence would probably create a reluctance by each payer to participate. So, it seems that the only way to finance cannabis education services in Canada is to convince provincial governments to cover these services alongside more traditional healthcare services.
References
[1] Development & Approval Process | Drugs. (2022, Aug 8). US Food & Drug Administration. https://www.fda.gov/drugs/development-approval-process-drugs
[2] Drug Policy 101: Pharmaceutical Marketing Tactics. (2020, Jan). Kaiser Permanente Institute for Health Policy. https://www.kpihp.org/wp-content/uploads/2020/02/drug_policy_pharmaceutical_marketing_101_FINAL.pdf
[3] Canada's health care system. (2023, Apr 4). Government of Canada. https://www.canada.ca/en/health-canada/services/canada-health-care-system.html
[4] Development & Approval Process | Drugs. (2022, Aug 8). US Food & Drug Administration. https://www.fda.gov/drugs/development-approval-process-drugs
[5] Current Good Manufacturing Practice (CGMP) Regulations. (2023, May 19). US Food & Drug Administration. https://www.fda.gov/drugs/pharmaceutical-quality-resources/current-good-manufacturing-practice-cgmp-regulations
[6] Drug Policy 101: Pharmaceutical Marketing Tactics. (2020, Jan). Kaiser Permanente Institute for Health Policy. https://www.kpihp.org/wp-content/uploads/2020/02/drug_policy_pharmaceutical_marketing_101_FINAL.pdf
[7] Current Good Manufacturing Practice (CGMP) Regulations. (2023, May 19). US Food & Drug Administration. https://www.fda.gov/drugs/pharmaceutical-quality-resources/current-good-manufacturing-practice-cgmp-regulations
[8] Cannabis for Medical Purposes. (2023, May 30). Government of Canada. https://www.veterans.gc.ca/eng/about-vac/research/research-directorate/publications/reports/cmp
[9] Insurance Coverage for Medical Cannabis. Medical Marijuana Consulting. https://medmc.ca/resource/insurance-coverage-for-medical-cannabis/
[10] Big Pharma Targets High Prescribing Doctors. (2015, Dec 1). Yahoo! News. https://www.yahoo.com/news/big-pharma-targets-high-prescribing-doctors-183048952.html
[11] Emily Alagha and Adriane Fugh-Berman (2022, Nov 7). Pharmaceutical marketing: the example of drug samples. Journal of Pharmaceutical Policy and Practice. https://joppp.biomedcentral.com/articles/10.1186/s40545-022-00479-z
[12] Mark Bicket, Elizabeth Stone, Emma McGinty (2023, Jan 6). Use of Cannabis and Other Pain Treatments Among Adults With Chronic Pain in US States With Medical Cannabis Programs. JAMA Network.https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800119
[13] Elizabeth Davis (2022, May 27). Why Isn't This Prescription Drug on My Health Plan's Drug Formulary? Very Well Health.https://www.verywellhealth.com/why-isnt-my-rx-drug-on-my-health-plan-drug-formulary-1738477