Health Committee on June 6th, 2007

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Mr. Chairman.

I have four questions, and I'll state them first and leave the remaining time for you to answer them.

Number one, in previous testimony before this committee, one of the things I heard presented was that one of the motivating factors or aspects of the creation of CDR was to bring together some more national standards and commonality in decisions. I wanted to know your opinion about if that's been achieved at this point, or if there's been progress towards that.

Number two, are there other examples internationally that you know of where there are two layers of review like this in the drug approval process?

Number three, when this process was created, was there a sense that decisions previously made by provincial bodies were inadequate or weren't based on enough information and that there was a lack of process? Are there any examples of decisions previously made that gave, I guess, cause for concern?

And my last question is that in many organizations—and it sounds, Mr. Wright, as if you've been involved in many—there is a tendency to do evaluations or independent reviews; it's a common business practice. Do you think the CDR would be well served if they took the opportunity or occasion to have an independent review to examine opportunities for improvement or changes?

[John Wright]

If I can, Mr. Chair, I'll take a stab at this. In Saskatchewan there's a famous phrase, “What the deputy minister meant to say”—and Dr. Sanders, I'm sure, will use that in a few minutes!

[Voices]

Oh, oh!

[John Wright]

With respect to an evaluation, Mr. Chair, we just undertook a very extensive evaluation back in 2005. It had a series of excellent recommendations, including recommendations about transparency, such that we added, for example, two public reps to the board. Certainly, I'm not sure another independent review would be required. There's been an awful lot of discussion here and a lot of good work by the committee members and the analysts, and others, I'm sure, and I'm looking forward to the final report. I think there's an awful lot of good work we can do going forward, rather than having a reflective independent review. That would be my perspective on the first item.

With respect to national standards, the CDR has actually brought things together in a number of ways. Using Saskatchewan as an example, we had our own groups that would do evaluations—mostly on the clinical effectiveness side of the equation. Saskatchewan is not a big province, nor is New Brunswick, nor is Manitoba, nor are others, and we couldn't bring the cost-effectiveness and economic analysis together. By pulling CDR to a national framework, we've achieved economies of scale in our ability to tap into national resources, and that's been very, very useful for the provinces and is leading us closer, I think, to that goal of a national pharmaceutical program, which could have a common formulary.

With respect to the two layers, I'm just going to comment that Canada is unique, let us not forget, as health care is the responsibility of the provinces. In many other countries, like the U.K., health care is the responsibility of the national government as well. Dr. Sanders will correct me, but I think that's in part why we have this two-layer bit of business here.

You mentioned what went on in the past and whether there were inadequacies, and so on. I can't speak to any of those, but I do know that with the economies of scale we've achieved, the quality of the review has now improved—certainly from Saskatchewan's perspective and, I'd like to think, from the perspective all provinces and territories, because that's why we're all participants in this.

[Dr. Jill Sanders]

I just want to clarify. The two layers you're referring to are the regulation of drugs and then the reimbursement. Those are the two layers? That's what I was checking on. Yes, you were talking about two different layers, I think.

Having two layers that deal with regulation and reimbursement is pretty standard practice across the world. Regulation gives permission to market and sell a product, which a citizen may buy, and that is separate from any system that has publicly funded drugs, whereby those paying for those publicly funded drugs would have a system in place to determine which of those that are marketable they will pay for. That's standard in any publicly funded health care system, yes.

[The Chair, Conservative, Rob Merrifield]

Thank you.

Carolyn Bennett.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thanks very much.

Thank you for coming back, because I think we had a few questions that came, as you could tell, from the hearings. I think the committee wants to go forward, not backwards. I don't think anybody wants to see the kind of collaboration Mr. Wright has talked about going backwards; we want to go forward.

What keeps coming back to me is, are we doing this upside-down? I was a family doctor, and I have great sympathy for the Best Medicines Coalition because it really did come together from a couple of groups that knew, because of their unbelievable networks, whether it was HIV/AIDS or cancer, that people were getting drugs in other places around the world that they weren't getting access to. This came from a real patient empowerment, networking, self-help approach, in terms of, “How come they can get this in Buffalo and I can't get it, and it may save my life?” The story around the kidney cancer drug upset us. That obviously was something about which the community felt very strongly.

If we were really going to move to a formulary, which is where we want to be, and with the way we would make these decisions, wouldn't we start with clinical guidelines first and then defy any government to not pay for something that's on a clinical guideline? This is about patient empowerment and saying the best drug for this is that. I would have assumed that the kidney cancer drug, Nexavar, or whatever it was, would have ended up in a clinical guideline if you asked a bunch of kidney cancer doctors what to do.

From the empowerment of patients who know what's happening around the world now, from the Internet, to actually pushing the medical profession to get going on clinical guidelines, to then making your jobs easier--because if it were in a clinical guideline, surely when the people who know the most about these diseases.... Now we have some stupid extra cancer system, and we're worried that everybody else is going to want a separate system if we don't get this right. It has to be what's best for patients and what brings Canadians in line internationally.

I'd like to hear a plan for going forward. How do we get the clinical guidelines? Also, how are you planning to involve--

[The Chair, Conservative, Rob Merrifield]

Your time is up.

[Christiane Gagnon, Bloc, Québec, QC]

You've had your five minutes.

[Carolyn Bennett, Liberal, St. Paul's, ON]

This is not funny.

It is the reason we're doing this.

[The Chair, Conservative, Rob Merrifield]

Yes, but we need a question fairly soon.

[Carolyn Bennett, Liberal, St. Paul's, ON]

What I want to know is the plan for going forward and the plan for involving citizens and informed stakeholders like the physicians working in these special diseases.

[The Chair, Conservative, Rob Merrifield]

Okay.

[John Wright]

Let me try it very quickly at a high level, and then Dr. Sanders can pick up from there.

With respect to the clinical effectiveness, there are about 400 oncology drugs in the pipeline right at the moment, and each one of these has an approximate cost for treatment of about $50,000 per patient. You work out the numbers, and in a little province like Saskatchewan, if you approved all of these clinically, it'd be about $600 million a year incremental cost. We have to consider not just the clinical effectiveness but also the cost-effectiveness on this.

With respect to the go-forward game plan, there really is a great plan out there. The foundation currently is the CDR. It is CADTH, it is the CDR. Again, when I was here last time, we talked about the national pharmaceutical strategy. Saskatchewan is working on the common formulary. B.C. is working on expensive drugs for rare diseases. Alberta and Manitoba are working very closely on a catastrophe program. We've set up a new oncology review process, piggybacking off the Ontario system as a pilot for many of the provinces, given drugs that have come on, which have been very expensive, and we're not certain about their cost-effectiveness.

So the game plan at the end of the day would be, from the perspective of many provinces, let's have a national pharmaceutical system, number one. Number two, let's have the common drug review and let's incorporate oncology drugs into that review.

[Dr. Jill Sanders]

First of all, Dr. Bennett, I understand that the patient-based care is different from population-based care, and that is something that we have to be clear on. The decisions made around reimbursement must be population-based, not individual patient-based, as you know.

But the first point that occurs in CDR is clinical effectiveness. That is the first barrier, the first gate that a drug must pass before entering into the cost-effectiveness phase, if you like. At the cost-effectiveness phase, the CDR is asked to comment on cost-effectiveness. And as Mr. Wright has said, it is up to the provinces to decide either with a yes on affordability within that province, or on a no, that actually they can't afford it. But this comes back to sustainability.

The most recent statistics from CIHI, the Canadian Institute for Health Information, indicate that health care costs went up by between 55% and 60% between 1999 and 2006. But drug costs, in the same period of time, went up by 110%, so the percentage increase of drug costs over health care costs doubled.

I'm not making a judgment call on those numbers, but they're reality numbers that the provinces have to deal with. And yes, there may be savings elsewhere in the system from certain drugs, and we understand that, and so do the decision-makers, but in looking at the sustainability of the system, these are all matters that must be considered.

However, getting back to the common drug review, our job is to look first at patient outcomes. And with respect to the drug that you're referencing, it was the patient outcomes that were in question.

[The Chair, Conservative, Rob Merrifield]

Okay. Thank you.

[Dr. Jill Sanders]

Finally, perhaps I may comment on the joint oncology drug review. As Mr. Wright has indicated, it won't stay a separate system or a separate process. For now, the provinces were looking for something to get started with, and that was an efficient way of having a pilot, and it's a one-year pilot. At the end of the pilot, the deputy ministers will decide, and the common drug review, or CADTH, is one of the options where that process may go. So it will take away the two....

[The Chair, Conservative, Rob Merrifield]

Thank you.

Monsieur Malo.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Thank you, Mr. Chairman.

Dr. Sanders, a few moments ago, in your opening statement, you recognized that the process could be changed or improved. You said that we should work together to make these improvements and address these situations in a less antagonistic way.

I was just wondering how you would like all stakeholders to think more serenely and positively about these things, when you said in your statement that what other witnesses had told us was wrong, and that you wanted to set the record straight. I am convinced that if we were to call back the people who already appeared before us, they would perhaps also say that you are wrong.

Given everything we have heard so far about the drug review process and the process to recognize their effectiveness, we get the feeling that it will be difficult to find a common ground. I am simply wondering what solutions you have in mind to get everyone to pull in the same direction to provide patients in need with the best possible drugs, since they are probably the ones who are suffering the consequences of these disputes, arguments and misunderstandings.

[The Chair, Conservative, Rob Merrifield]

Do you have a question?

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Yes, I asked my question.

[Dr. Jill Sanders]

We, as a matter of course, do meet with patient advocacy groups. As a matter of course, we meet with industry and industry groups. So the process is already in place; it was started at the beginning for CDR. At the very beginning of CDR we had consultation sessions with both those groups, and we continue to talk to those groups.

There is a place for input from everywhere, but I feel I'm compelled to point out for the committee that the stakes for the industry are huge. The amount spent in Canada on drugs is over $20 billion. On prescription drugs alone, it's $17 billion. The stakes are huge. We all play different roles and we all play those roles to the best of our abilities, but we have to recognize we do have groups with very large stakes in this process.

[The Chair, Conservative, Rob Merrifield]

Okay.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Can someone tell me what role ordinary Canadians should play in this process? Is there room for them? If so, should they play a bigger or a smaller role? Because, after all, ordinary Canadians are the ones who take their medication every day.

[Dr. Jill Sanders]

Perhaps you'll excuse me for a second. I sometimes bemoan the fact within our organization that millions of people watch Canadian Idol, but if we were to have a show that sought the opinions of all Canadians on their opinions around health care decisions and societal values, we probably wouldn't get even 5,000 people voting or even watching it. That it's a challenge is what I'm telling you.

Yes, I believe that societal values are something we'd all like to understand better. They move, they change--and I just mentioned willingness to pay, willingness to risk. All of these things are crucial elements, and capturing some measure into the process is tricky. We have two members on CEDAC who are public members or non-expert members chosen for being non-expert. But do two people represent the public? No. If we had a committee of 30, would that represent the public? No, not really. So it is tricky.

So where does the rubber hit the road? Well, it actually hits the road in the provinces, where the decision...and this is where Mr. Wright and his department do hear from the public on quite a significant level, I believe. So it happens through another way. We don't have a process where we can engage millions of Canadians to find out how they would act or behave or vote in a certain situation. However, we do know through the feedback, and deputy ministers then guide us with that information they hear from the public.

Do you want to add to that?