Health Committee on June 20th, 2006

[The Chair, Conservative, Rob Merrifield]

Let's call the meeting to order.

I want to start by thanking our panellists for attending and coming forward on the important issue of pharmaceuticals.

We look forward to your presentations to the committee, as the committee decides whether, perhaps in the fall, we want to look at this as a larger study to see if there is something we can do that would be productive for the committee's time.

I want to again thank you all for coming. We'll start in the order that I have.

For the committee's information, we will start with an hour and a half. We'll have the questioning, as well as the presentation time. We'll then go into an in camera session on the report of the committee on fetal alcohol spectrum disorder. There is also one motion before the committee that we'll be dealing with during the public time and perhaps an appointment position that we'll deal with at the same time. That's for the committee's information.

We'll now move on to our witnesses, and we will start.

We have Mr. Brett Skinner from the Fraser Institute, Ken Fraser from the Fraser Group, Barbara Mintzes from the University of British Columbia, and Ingrid Sketris from Dalhousie University.

Thank you again for coming.

We'll start with Mr. Skinner. You have 10 minutes.

[Brett Skinner, Director, Departments of Health and Pharmaceutical Policy Research and Insurance Policy Research, The Fraser Institute]

Thank you. And thanks to the committee for inviting me here today. It really is a pleasure to address this body. It's the first time I have addressed a parliamentary committee, so it's quite an honour. Of course, I invite your questions and answers at the end of the presentation I'm about to give.

There are three areas I would like to address, which relate directly to research being conducted by the Fraser Institute. The first one I'd like to address is the price of patented medicines and the fact that I believe it is not the cause of unsustainable health care costs in Canada. Secondly, I'd like to address issues related to the cross-border drug trade and why I believe it remains a threat to Canada's drug supply and trading relationships. And thirdly, I would like to discuss issues related to the fact that governments are rationing access to new medicines in Canada, and hopefully offer some explanations for that.

Let me begin with the price of patented medicines. The evidence indicates that average prices for patented drugs in Canada have in fact grown at a slower pace than the general rate of inflation for all other goods and services in the economy. They are therefore increasing at a slower pace than they are allowed to grow under federal price controls.

Other evidence indicates that prices for patented medicines in Canada are also lower than those in the majority of countries the federal government uses for international comparisons through the Patented Medicine Prices Review Board and are, on average, 43% below U.S. prices for identical drugs, based on research done by the Fraser Institute, which relies on a large sample of the 100 top-selling products in Canada in 2003.

There are two main reasons why drugs are believed to be accounting for a rising share of health expenditures: the introduction of expensive new medicines that are simply treatments that did not exist previously for conditions, and the increasing use of drugs to replace other forms of medical treatment.

The evidence indicates that new drugs and the substitution of drugs for other medical therapies are positive developments. Research shows that they lead to net cost savings, when all health spending is accounted for, and to significant improvements in human health.

To follow up on this, I'd like to say that if drug prices are perceived to be a problem in Canada, the problem is really with generic drug prices. Canadian prices for generic drugs are higher than international prices for identical drugs, based on PMPRB research. Based on Fraser Institute research, the difference in price is, on average, 78% higher than the U.S. price for identical drugs, based on a sample of the 100 top-selling generics in Canada in 2003.

This is significant for Canadians in terms of the cost savings that are lost. If Canadian generic drugs were priced at the international median for the same products, Canadian buyers of generic drugs would save $800 million annually. If Canadian generic drugs were priced at the even lower U.S. price levels for the same drugs--which are the lowest in the world, by the way, and are a proxy for free market prices--and if lower prices pushed our generic substitution rates to the much higher U.S. rates that we have observed, Canadian buyers of generic drugs would realize nearly $2 billion in direct annual savings and nearly $5 billion in total annual savings,

I'll move on now to the evidence I'd like to present on the cross-border drug trade. The trade remains a threat to Canada's drug supply and trading relationships, and this is because while the value of the cross-border drug trade in prescription medicines has flattened at about $0.5 billion annually, based on the most recent data from IMS Health Canada, this is largely because generics are making up an increasing proportion of the prescriptions sold. So the total volume of trade likely remains very high. More worrisome, I believe, is that political momentum for legalizing the cross-border trade is rising dramatically in the United States. Evidence indicates that the number of annual attempts to legalize the cross-border drug trade at both the state and federal levels in the United States has risen from three per year in 2002 to 84 per year as of September 2005.

Interestingly, most of the proposals being put forward under these attempts would legalize bulk purchases from Canadian pharmacies to supply U.S. federal, state, and local public employees, as well as recipients of social programs like Medicaid and Medicare, a group of consumers that is nearly four times larger than Canada's entire population. As a previous health minister once stated, Canada cannot be the drug store for the United States.

Evidence also indicates that the cross-border drug trade is not based on free trade principles, as some have claimed. The trade relies on Canadian government interference in the market through price controls that permanently fix the gap between U.S. and Canadian prices. But more interestingly, and perhaps more threatening to our trading relationships, cross-border pharmacies are also trading in stolen intellectual property.

Data from IMS Health Canada show that medicines that are still under active patent protection in the United States account for nearly 50% of the value of sales of Canadian generic drugs through Internet pharmacies to the United States. The data show that nearly 50% of the value of generic drugs being traded through cross-border Internet pharmacies is for active patent products in the United States.

The third area I'd like to cover is the fact that governments are rationing access to new medicines in Canada compared to other countries. Canadians are not getting timely access to new medicines. Research indicates that Health Canada approves fewer new medications than other countries, and when Health Canada does approve a drug it takes much longer to do it than in other countries. Data suggest that the common drug review process is also being used to ration access to new medicines for recipients of public drug benefits. The CDR recommends less than half the drugs it reviews for reimbursement, and the provinces approve even fewer of those drugs, even though these drugs have already been approved as safe by Health Canada and are available in other countries.

Governments across Canada are rationing access to very expensive new life-saving medicines affecting small populations but are paying for affordable health care services for everyone. A good example of this is the drug Herceptin. Last fall I did some research on this and published an op-ed that showed that eight out of 10 provinces were refusing to reimburse for the drug Herceptin. It is a very effective treatment for breast cancer, one that the FDA thought was so effective in the United States that it stopped testing it and released it to the market early to prevent thousands of women from being relegated to an early death. Yet eight out of 10 provinces were not funding it last fall, in spite of the fact that the additional expense of covering the drug would have added only 1.6%, for example, to the Ontario drug budget.

Why is this occurring?

The reason governments are rationing access to safe and effective new medicines is because public health spending is unsustainable. Even a small additional amount of spending cannot be accommodated. In seven out of 10 provinces, public health expenditures are on pace to consume more than half of total revenues from all sources available to the provinces. When I say “all sources”, I mean including federal transfers. This will be by the year 2022. It will continue on that pace if nothing changes.

Governments are under extreme spending constraints, and that's why any additional expense related to medicines is a problem. The problem is not with the price of medicines, it is with the growing utilization of medicines and the inability of governments to cover that bill because of unsustainable health care financing.

I believe the only reason that governments get away with rationing access to medicine instead of making reforms in health care is because sick people don't represent a lot of votes. The data that I had access to from the population health research unit at Dalhousie University on the medicare records for everyone in the province of Nova Scotia on an anonymous basis indicated that about 21% of the population spends zero dollars on physician services in any given year. In fact, 96% of the population spent less than $1,500 on physician services in any given year; only 4% spent more than that. What that tells you is that the distribution of illness in the population is not widespread. Very few people are sick. That tells you that sick people don't represent a lot of votes, and there's very little incentive I think for our policy-makers to resist rationing access to new technologies. Instead, rationing is a way to maintain the facade of sustainability.

That is the conclusion of my comments, and I would like to welcome your questions.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

You have presented a lot of interesting figures there. I'm sure there are going to be some good questions on that.

We'll now move to the Fraser Group, Mr. Ken Fraser. You have 10 minutes.

[Ken Fraser, President, Fraser Group]

Thank you, Mr. Chair.

Thank you for your invitation to participate in this discussion today on prescription drugs. My name is Ken Fraser, and I'm president of the Fraser Group, a firm that provides technical and market research about employee benefits and group insurance.

For clarity, we are not associated with the Fraser Institute.

Today I will provide the committee with some research findings regarding the financing of prescription drugs through public and private drug insurance programs. My colleagues--including Dr. Richard Shillington, who is with us in the audience today--and I have been studying the issues of insurance coverage and the distribution of financial costs since 1996. Hopefully the following observations from our research will be useful for the committee.

Canada does not have a comprehensive national program or policy infrastructure around insuring the cost of pharmaceutical therapies. Despite this, a substantial system of drug insurance has evolved that does in fact provide the great majority of Canadians with reasonable financial security with respect to drug expenses.

There are, however, significant regional variations and disparities in this system of coverage. The most significant gap lies in Atlantic Canada. We estimate that approximately 25% of the population there would suffer financial hardship should they need expensive medications. In the case of truly catastrophic health needs, these Canadians would probably face the loss of their homes and be destitute. We have had such cases reported in the media.

Most of the regional variations are due to differences in publicly financed social insurance drug programs. Private drug plans, mostly sponsored by employers and labour unions, cover approximately 58% of the population, with minor provincial variations.

Drug expenses represent a significant financial exposure for all Canadian families. It's not uncommon for a family's drug expenses to exceed $10,000 or $20,000. Although it is rare, we have seen expenses exceed $250,000.

Many social programs and the federal tax system use a threshold of 3% or 4% as a measure of financial stress with respect to medical care costs. Using this threshold of 3%, four million Canadians require drugs that cost in excess of 3% of their family income. This includes 51% of those who are over age 65 and 8% of those who are younger than age 65. These numbers are before any reimbursement from drug plans. This group of individuals, with high drug expense needs relative to income, account for 66% of all drug spending outside of hospitals.

If we define the catastrophic drug expense to be the portion of the drug expense that is in excess of 3% of income, then 42% of all drug spending would be categorized as catastrophic. Our research shows that 89% of Canadians are protected from catastrophic drug expense by public and private insurance programs. Another 9% of the population has substantial but incomplete coverage. This leaves 2% of the population with no coverage whatsoever. They would be exposed to financial ruin in the face of severe drug expenses.

In conclusion, I would ask that the committee understand that access to the health benefits that can be derived from prescription drugs rests in large part on access to the financial mechanism of public and private drug insurance programs, particularly for those individuals with high needs relative to income. Maintaining and improving this system of drug insurance is a necessary part of ensuring that all Canadians--no matter where they live, or the level of their income, or the status of their health--have access to appropriate and timely medical treatment.

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for your testimony. Actually, we look forward to further reports on catastrophic drug coverage, but that was very interesting testimony.

We'll now move to Barbara Mintzes from the University of British Columbia. You have 10 minutes.

[Dr. Barbara Mintzes, Centre for Health Services and Policy Research, University of British Columbia]

Thanks very much for inviting me to speak to you today.

The focus of my remarks is going to be on direct-to-consumer advertising of prescription drugs. In the health committee's April 2004 report, “Opening the Medicine Cabinet: First Report on Health Aspects of Prescription Drugs”, this was one of three key issues addressed.

The recommendations of that report were to maintain the prohibition on direct-to-consumer advertising in the Food and Drugs Act and that Health Canada put additional resources into enforcement and bring in active surveillance, corrective actions if there are problems, sanctions against companies that are illegally advertising drugs, and to report annually. The committee also recommended that independent information be made accessible to the public and be publicly financed.

The other thing the report highlighted was the issue of reminder advertising. These are branded ads like the Viagra ads you see on TV, which state the brand but not the indication.

The report--with which I would agree--states there is no justification from a public health perspective in allowing reminder advertising. It suggested that the 1978 price advertising clause that has been interpreted since November 2000 to allow this type of advertising be rescinded because nobody is advertising prices anyway--if I can summarize the report.

So what has happened since April 2004? I would say the recommendations made by the committee are, if anything, much more pressing today, or more pressing than they were, for three main reasons.

One reason is that following the global withdrawal of the arthritis drug Vioxx, the idea of a large-scale public health disaster coming out of a heavily advertised drug is no longer hypothetical; it has actually happened.

Second, we've seen a continued growth in reminder advertising and unbranded, disease-oriented advertising in Canada with no apparent regulatory response.

And third, we now have a charter challenge by CanWest MediaWorks, which is challenging that the Food and Drugs Act prohibition is an infringement on their freedom of expression.

I will give you a couple of examples of unsafe and unnecessary medicine use that's been stimulated by advertising. When the global withdrawal of the arthritis drug Vioxx occurred in September 2004, at that point Merck & Co., Inc. had spent more than $500 million U.S. advertising this product to the U.S. public. Vioxx is no more effective for arthritis symptoms than alternative arthritis drugs. It's costlier. In British Columbia we've probably prevented harm very effectively because we did ration access to a greater extent than other provinces.

The first study to show an increase in heart attack risk was published in late 2000. So for four additional years, Merck continued to advertise this drug heavily to the U.S. and New Zealand public, where direct-to-consumer advertising is legal, and elsewhere to health professionals.

Dr. David Graham, who is a senior official with the U.S. FDA, used drug use data in the U.S., plus the results of clinical trials, to estimate how many people had been harmed. He estimated approximately 40,000 deaths from heart attacks as a result of Vioxx use would otherwise not have occurred. One of the questions I wondered about was how many of those were stimulated by advertising. I did a bit of a back-of-the-envelope analysis of this, looking at advertising spending versus total sales and then market research data on returns on investment on direct-to-consumer advertising. If you take the blockbuster returns--which Vioxx definitely was--you have about 16,000 of those 40,000 deaths that would have occurred as a result of excess sales stimulated by advertising. That's a rough estimate, but it certainly gives you some idea that there is a cause for concern in the rapid escalation of the use of newer drugs.

The other issue that's of concern with direct-to-consumer advertising is the promotion of unnecessary medicine use for everyday life problems--the medicalization of life.

In 2005 there was a 60% increase in sleeping pill use in the U.S. Why is this? Is there suddenly an epidemic of sleeplessness in the U.S.? Well, no. What's happened is that two sleeping pill manufacturers have been vying for market share and have been very heavily advertising their products to the public. Sepracor spent $270 million U.S. advertising Lunesta to the public. Ambien was advertised to the tune of $90 million U.S.

We know that the continued use of sleeping pills can lead to a risk of dependency, an extra risk of falls and fractures in the elderly, and traffic accidents. There have also been systematic reviews of the clinical trial evidence on these drugs. There's no difference in the direction or the magnitude of effects with the newer versus the older products. You're looking at a situation where, for a person over 60, use for more than five consecutive days is more likely to lead to harm versus benefits.

As a general overview, these are a couple of examples. I could go on, but I won't.

In the U.S. the industry brought in voluntary guidelines about a year after the Vioxx disaster. The most concrete change was that they have agreed not to run any reminder advertisements anymore on television in the U.S.

What's happening in Canada? Well, we've seen an increase in advertising, and the same companies are running reminder advertisements in Canada without any kind of regulatory response. We've certainly seen no reduction in the volume of made-in-Canada ads, no change following the committee's recommendations, no change post-Vioxx, no change after the U.S. voluntary industry guidelines, and no improvement in enforcement.

If I can give you an example, I was involved in a complaint with a women's health organization, Women and Health Protection, about a televised advertising campaign for Celebrex. Celebrex is a very similar drug to Vioxx and is in the same class. There's evidence of increased heart disease risks with Celebrex as well. Health Canada has put out a safety advisory as a result, telling physicians to prescribe it with caution, at a low dose, and for a short period of time.

We submitted our complaint to the Minister of Health and to Health Canada on March 14. We saw no evidence of any kind of regulatory response, and we haven't even had the courtesy of a response to that complaint.

What's happening from a regulatory perspective?

There was a complaint in 2005 about an ad campaign for Xenical, an obesity drug. This was not a brand ad campaign, but it was being advertised to women who wanted to lose a few pounds, a use that it's never been approved for. On the complaint that we submitted to Health Canada at that point, we did get a response, which said that it was perfectly legal because the brand had not been mentioned and the company had not been mentioned. From a public health perspective, we certainly haven't seen a shift in the regulatory response to these kinds of advertising.

The other thing that has happened is that we've seen ads, for example, like the TV ads for Celebrex, which would be illegal in the U.S. on public health grounds because this is a product with what's called a “black box warning” of serious safety risks. Reminder advertising is not allowed for drugs with black box warnings in the U.S. because of safety concerns. Although our law is more strict, we have had such a lax approach to enforcement that we're actually seeing things happening in Canada that are not allowed in the U.S.

The other major change is the challenge to the Food and Drugs Act prohibition by CanWest, which I would like to briefly highlight. This is a challenge by our largest media company on the grounds that the prohibition is an infringement on their freedom of expression. Yes, I can see a grin about that.

If you think about it, as a media company, they can run any editorial content they would like to on prescription drugs and any TV program they would like to on prescription drugs. What they are prohibited from doing is selling advertising space to prescription drug manufacturers. This is really a case that has everything to do with trade, competition, and lucrative advertising contracts.

Given my concern, from the outside, and having been concerned about the shift in response to enforcement of the law, what I would like to ask is whether adequate resources are being put into defending the law against this case. That's certainly a question for the committee.

In conclusion, I would like to say that the committee's recommendations are as valid as ever, but the real question is, what can be done to implement them?

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Your testimony reminds some of us of some of the testimony we heard during that time period and the subsequent study that came from it. It's very valid today as well. Your point is well taken. Some of the questions that were asked under that study may still be just as valid.

Let's go on to our last presenter, from Dalhousie University, College of Pharmacy, Ingrid Sketris. You have 10 minutes.

[Dr. Ingrid Sketris, Professor, College of Pharmacy, Dalhousie University]

Thank you.

I would like to thank you for providing me with the opportunity to come and speak to you. I'm a pharmacy professor with the CIHR/CHSRF-funded chair in drug use management at Dalhousie, and I've been there for 25 years.

I'm going to talk about goals of pharmaceutical policy. Then I'm going to give you two cases, one of inappropriate drug use and another of drug use where you could have a more efficient system. Finally, I'm going to talk about selected medication management strategies.

Jacobzone from the OECD defined the goals of pharmaceutical policy as improving health, fostering efficiency, improving cost-effectiveness, obtaining best value for money, preserving equity, and other--industrial policy. As Canadian jurisdictions set and refine their goals related to pharmaceutical policy, we need to determine how well they are performing against the goals, and have systems to measure them.

My first case illustrates the identification of an unsafe drug in the general population. In the 1980s, evidence was generated to show that Chlorpropamide, a drug for diabetes, was less safe than alternatives for the treatment of diabetes. It could cause low blood sugar, sometimes causing coma and hospitalization.

The Drug Evaluation Alliance of Nova Scotia funded a program to decrease Chlorpropamide use, and all seniors were switched to more appropriate therapy. But look at the time it took. The evidence came out in the 1980s, but in 1995 we still had 1,500 seniors in Nova Scotia receiving the drug. We put together an intervention that took people off the drug. In 2003, eight out of ten provincial pharmacare programs still funded the drug. In 2004, the Auditor General of Canada discussed the Beers criteria, which suggested this drug should never be used in seniors, and in 2005 there was a CBC radio show on the Beers criteria.

The key message is that even once the evidence is in, it can take a very long time to change habits and ingrain practices to adopt better practices. There needs to be a systematic approach to monitoring drugs after they are marketed in Canada, especially in susceptible populations such as children and seniors. Real-time electronic clinical decision support systems need to be developed to alert physicians to drug disease, drug interaction, and other problems.

On the next slide you'll see pictures of a mask that's used for asthma, and puffers. About three million people in Canada have asthma and bronchitis, so this is an important therapeutic area. The masks, or wet nebulization, are more costly, less efficient, less portable, have more bacterial contamination, and are less convenient. The puffers, which are supported by Canadian and international guidelines, have equal efficacy and cost about one-tenth as much.

In Nova Scotia we were paying about $2 million for the masks, and then the Drug Evaluation Alliance of Nova Scotia did an intervention that decreased the use of masks considerably. In just two years the DEANS group got patients switched from masks to puffers, which saved the government about $1 million per year and gave patients a simpler, more convenient approach. It was better for the patient, easier to provide, and it saved money.

The point of these two examples is to illustrate that there's room to improve the quality of medicines used and the cost-efficiency in the pharmacare program.

I would next like to talk about strategies that could be used to improve medication use. There are many stakeholders in pharmaceutical policy, and there need to be more opportunities in Canada where stakeholders can be brought together.

In Australia there's a national strategy on the quality of use of medicines. The Australian pharmaceuticals advisory committee is a representative council with about 30 members from diverse groups. So it includes the brand-name and generic drug industries, doctors, social workers, physicians, nurses, and journalists. They look at trying to set goals for the quality use of medicines in the country and how the various players can help implement those goals.

The next slide is on strategies for government. In Canada there are 19 federal, provincial, and territorial pharmacare programs. They differ in eligibility requirements, the drugs they provide, co-payments, and methods they use to manage programs. They use a mixture of legislative, financial, and educational approaches. These plans need to continue to work together to learn from each other and other countries on what works, what doesn't work and why, and what the trade-offs are.

Strategies are also needed to provide doctors, pharmacists, and other health professionals with tools to make good choices. Close to 400 million prescriptions per year are written by Canada's 60,000 physicians, and dispensed by Canada's 29,000 pharmacists, so a strategy that comes from Ottawa can't help all of those physician, patient, and doctor interactions. We also need tools to give to those individuals.

We also need strategies that target health organizations: the health delivery sector, information technology, drug utilization, and post-marketing surveillance. There are over 22,000 drugs on the Canadian market and an estimated 7,000 drug interactions. Busy physicians cannot keep all this information in their heads. They rely on a small set of drugs they know well. Both electronic health records and clinical decision support systems can help them take care of patients, especially when they are unfamiliar with drugs or new drugs.

Finally, I couldn't be a researcher without saying that research is important, so the pharmaceutical system in Canada needs a strong research underpinning. It's critical to understand the theories related to physician prescribing behaviour. Synthesis of the best international evidence provides useful information from Canada. New knowledge about drug effects and their use is needed, and this needs to be communicated to the decision-makers and practitioners. A strong network of post-marketing surveillance is needed to determine safety and effectiveness under real-world conditions.

In summary, do not expect that one policy will have huge breakthroughs in cost containment. Continuous improvement matters, to improve outcomes for patients and cost-effectiveness. As baby boomers age, it is ever more critical to put in place systems to manage the pharmaceutical system for sustainability.

Thank you for your attention.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for your testimony.

We'll move to questioning. We'll start with the official opposition for ten minutes.

[Ruby Dhalla, Liberal, Brampton—Springdale, ON]

Thank you very much to all of you for your comments. They were very informative and helpful in this important area. Many of you have done a tremendous amount of work, so the information you have provided is going to help many members on this committee.

I want to ask you a question on the national pharmaceutical strategy. During the first ministers conference in 2004, it was stated that a report had been brought forward by the Ministers of Health in consultation with various stakeholders on this strategy. I believe that report is due in the next ten days, and as of this date, none of us has seen that report. In talking to stakeholders, I don't know anyone who has been consulted.

As individuals with a tremendous amount of experience in research in this particular area, have you been consulted by Health Canada or any of the other individuals involved in putting that national pharmaceutical strategy draft report together?

[Brett Skinner]

I haven't been invited to speak to Health Canada, to my knowledge anyway.

[Ruby Dhalla, Liberal, Brampton—Springdale, ON]

Maybe in the next ten days...?

[Brett Skinner]

Maybe.

There are a few things I would like to say about the national pharmaceutical strategy. First, I believe it's unnecessary. The distribution of catastrophic drug expenses in the population is quite small. If we look at the data presented by Ken, for instance, there is a small percentage of people with catastrophic drug expenses. If we ask ourselves what percentage of that group lacks the income and insurance coverage to pay for those drugs when they reach a catastrophic level, it's an even smaller percentage.

Secondly, the national pharmaceutical strategy seems to be based on a desire by the provinces to escape responsibility for the rationing decisions they're making and upload it to the federal government, or at least to a quasi-national government agency like the CDR--common drug review--for instance.

So I believe it's unnecessary and a way for governments to avoid accountability for decisions they take on rationing. For those reasons, I would not be in favour of pushing forward with a national pharmaceutical strategy.

[Ruby Dhalla, Liberal, Brampton—Springdale, ON]

I can see that Barbara and Ingrid want to jump in.

[Dr. Barbara Mintzes]

I certainly haven't seen the final document or the final plans that are coming out. There was a broad consultation meeting that Health Canada held in September--or something of the sort.

[Ruby Dhalla, Liberal, Brampton—Springdale, ON]

No one has been consulted, apparently, since the last go-round.

[Dr. Barbara Mintzes]

I haven't been consulted more recently.

My understanding is that many of the issues that Ingrid Sketris has just raised in terms of needing to put many more resources into post-market surveillance and to ensure that there is a less piecemeal process in place in terms of supporting better quality use of medicines and better quality prescribing is something you'd expect out of a national pharmaceutical strategy. So I can say what I would hope would be in there.

I don't know if you have a....

[Dr. Ingrid Sketris]

I attended the Health Canada meeting in the fall around drug safety and effectiveness, and it's produced a report. I think it talks about the need for a system after the drugs come on the market, to monitor it. It had numerous stakeholders there, people from industry, a number of people from patient groups, and so on.

There were briefings on the national pharmaceutical strategy across the country. There was one in Atlantic Canada, in Newfoundland, that I was invited to attend, but I was unable to attend.

The co-chairs of the part that deals with drug safety and effectiveness have been trying to work with academics, and they have a number of consultation papers coming out. I haven't seen them, but I know they have been working hard in that area.

[Ruby Dhalla, Liberal, Brampton—Springdale, ON]

Aside from that particular area, no one else has been consulted?

Ken.

[Ken Fraser]

We've had inquiries from Health Canada regarding the capabilities of our research models, but that's the extent of it. We have not provided any input into Health Canada.

[Ruby Dhalla, Liberal, Brampton—Springdale, ON]

Brett, you mentioned something in your response to me, and I was taking a look at your report as well in regard to access to medications in terms of the involvement of the CDR, and the provinces basically utilizing it, I would say, perhaps as an excuse to avoiding the responsibility for their particular rationing choices.

Barbara touched upon having this piecemeal solution across the country: someone who lives in P.E.I. can't get access to a drug versus someone who lives in British Columbia who can, or if someone lives in Winnipeg, they may not get the best type of drug. We have to start creating equality regardless of where Canadians live. From your experience and the work you've done, how would you see, in terms of moving forward, that we can create some sort of equalization across the country in this respect?

[Brett Skinner]

The best way to do that I think is to incentivize interprovincial policy competition. When residents of P.E.I. see that their neighbours in a different province get better access to drugs than they do, they should pressure their governments to do something about it.

Health care is a jurisdiction of the provinces, and I believe it should remain this way, because there is a lot of value to that interprovincial policy competition.

I think what we're talking about here are governments that are attempting to hide behind the facade of sustainability when in fact health care finances are not sustainable. They're doing that by rationing access instead of reforming health care, by doing some of the things that are done in other countries, such as allowing user fees for publicly funded services, allowing the development of parallel private health insurance, for instance.

Drug insurance in this country is actually operating very well at the private sector level. The only problem is that some people do not have employment in order to obtain it, or they lack the income to obtain it.

Our public program should be identifying people who have catastrophic expenses and who also lack the income or insurance to cover those expenses, which is a very small percentage of the population, and it's a population that's amenable to sustainable insurance approaches.

So I would recommend something entirely different from a national program.

[Ruby Dhalla, Liberal, Brampton—Springdale, ON]

I have just one last question in regard to that. Quebec has set up a model that has worked very well for the individuals living in Quebec, which ensures, basically, that every single resident gets access to the pharmaceutical medications they require.

You mentioned individuals not having access--either the ones who are unemployed or the ones who don't have coverage--but there are also many women entrepreneurs, as an example, who don't have health insurance plans.

What are your thoughts, perhaps just generally to the whole panel here, with regard to the Quebec model?

[Brett Skinner]

I'd like to address that first. The Quebec model is very similar in many ways to the Swiss health insurance model, as it achieves universal coverage through a mandatory purchase requirement similar to, let's say, Ontario auto insurance. If you want to drive a car, you have to buy auto insurance. If you want to live in Switzerland, you have to buy health insurance. And in Quebec, you have to buy drug insurance.

For those people who lack the income to participate in a private market there is either a subsidy or a public insurer in which they are enrolled.

That's a way of achieving universal health insurance or drug insurance coverage that preserves all of the benefits of competition and private delivery of insurance products, and I think it's a much better model than what the other provinces are following.

In fact, it's very interesting to note that Quebec, among all the provinces, has approved far more drugs than have been submitted for review to the CDR than even the CDR itself, and than all other provinces as well. In fact, Quebec spends more on drugs as a percentage of its total public health expenditures than any other province, and yet health expenditures as a total are growing slower in Quebec than in all the other provinces.

That is consistent with research from Frank Lichtenberg, out of Columbia University, who has done significant work showing that medicines have a positive technological substitution value, so that more spent on medicines can lead to net cost savings on other health spending elsewhere. His figures show a dollar spent on new drugs, for instance, can save up to seven dollars on non-pharmaceutical health care spending.

[The Chair, Conservative, Rob Merrifield]

Madam Demers, you have five minutes.