Evidence of meeting #49 for Health in the 39th Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was cdr.
A recording is available from Parliament.
Conservative
The Chair Conservative Rob Merrifield
I call the meeting to order.
I want to thank you for coming. We have enough of our members here and I know that others are going to be here very shortly, so we will start very soon.
Before I introduce the witnesses for today's session on the CDR, Ms. Priddy, with your smiling face, I know you have something very good to add.
NDP
Penny Priddy NDP Surrey North, BC
Maybe we should talk about this later, but I think the executive committee was going to look at a whole work plan. Sometimes it's hard to look at the context of today without looking at that broader plan. I think we had a discussion about either the executive meeting—or bringing that back. Could you give me a bit of an update? It helps with the questioning of witnesses.
Conservative
The Chair Conservative Rob Merrifield
We will discuss that in the in camera session during the last 20 minutes we have today. We'll go through a work plan and how we want to deal with what's laid out. We'll go through it at that time.
Is that fair?
Conservative
The Chair Conservative Rob Merrifield
With that, we'd like to start with our witnesses. As I said, we will be finished shortly after five o'clock so we can get to our in camera session in time.
Christiane.
Conservative
The Chair Conservative Rob Merrifield
No. We will talk briefly about that in the in camera session. We had presenters at the last meeting on the quarantine bill and we decided to bring it back on May 2. We'll bring it back at that time.
I'd like to introduce our witnesses. We have, from the Department of Veterans Affairs, Verna Bruce. We'll start with you and introduce the other witnesses as we give them the floor.
The floor is yours. Proceed, please.
Verna Bruce Associate Deputy Minister and Chair of the Federal Healthcare Partnership, Department of Veterans Affairs
Good afternoon, and thank you.
Thank you very much, Mr. Chairman, for inviting us here today to talk about the Common Drug Review.
I'm very pleased to have my colleagues from the Department of National Defence and Health Canada with me. You will be introducing them in a few moments.
You've asked that the federal health partners appear today to give our perspective on how effective the common drug review has been thus far. In my opinion it is working very well.
As you would be aware, in November 2004 the Auditor General's report highlighted some discrepancies between federally managed drug plans. The message was that those discrepancies shouldn't have occurred if all plans were following an evidence-based process in managing their respective formularies. As a result, the federal health partners agreed to a more rigorous, evidence-based process for reviewing and modifying their formularies. The common drug review, which became operational in 2003, has been key to helping us meet this commitment.
Before I go on, I'd like to give you a quick overview of the Federal Healthcare Partnership. The partnership was created in 1994, and was originally known as the Health Care Coordination Initiative. The six permanent members are the Department of National Defence, Health Canada, Veterans Affairs Canada, the RCMP, Correctional Service Canada and Citizenship and Immigration Canada.
The role of the FHP is to identify, promote, and implement more efficient and effective health care programs. Our mission is to achieve economies of scale while enhancing equality of health care services.
As a group, the Federal Healthcare Partnership represents the fifth largest publicly funded drug plan in Canada. Our goal is to provide access to medications that evidence indicates will be the most effective in treating our various clients' conditions. In doing so, we are also accountable to ensure that those medications represent the most cost-effective benefit. To do this, we need a strong, evidence-based review process, and we do feel that the common drug review fills this need.
My presentation will consist of our evaluation of the goals of the CDR and the results of an evaluation of the CDR conducted by EKOS Research Associates. This review is, in essence, an evaluation of the common drug review from the perspective of the Federal Healthcare Partnership.
As you know, the CDR has four goals: to provide a consistent and rigorous approach to drug reviews and evidence-based formulary listing recommendations; reduce duplication of effort by federal, provincial, and territorial drug plans; maximize the use of limited resources and expertise; and provide equal access to the same high level of evidence and expert advice.
Is the CDR meeting its first goal, to provide a consistent and rigorous approach? Yes, it is. The Canadian Expert Drug Advisory Committee is an independent advisory body, with leading Canadian experts in drug therapy and drug evaluation. As such, it's a critical part of the CDR. CEDAC provides drug listing recommendations to participating drug plans, following an approach that is evidence-based and reflects medical and scientific knowledge and current clinical practice.
The process also takes into account the economics of the new drug—that is, do the benefits of the drug warrant its cost? In many cases, new, more expensive drugs are developed to treat conditions for which there are already effective and proven pharmaceutical treatments. The CDR takes this into account when making its recommendations.
Based on this process, CDR is recommending approximately 50% of the drugs submitted to it, and we feel that this is fairly realistic. The Patented Medicine Prices Review Board itself says that only 6% of all drugs appraised between 1990 and 2003 were considered to be breakthrough drugs.
Speaking on behalf of the federal health partners, I can tell you that all partners now receive the same evidence-based recommendations for our formulary listings. As individual departments, we take those recommendations and use them as part of our decision-making process. Given our varied client groups, we do not all implement the recommendations in the same way. I believe this is a strength of the process rather than a weakness.
For example, some of the partners may authorize coverage of drugs, for an individual client, that may not have been recommended for inclusion in their formulary. In the case of the Department of Veterans Affairs, a non-formulary product might be authorized in the case of a client who has tried other available drug therapies for his or her medical condition and has not responded, or he or she may have had an adverse drug reaction. In this case, the non-formulary drug may provide some benefit, and it's done on a case-by-case basis.
This case-specific type of authorization is given to ensure that we are providing clients with the care that best meets their individual needs, when the less costly commonly used therapy is no longer effective. This flexibility allows the federal health partners to provide the most appropriate benefit that best meets the individual client's needs and, at the same time, achieve maximum benefit from the work of the CDR.
Is the CDR meeting its second goal, which is to reduce duplication of effort by drug plans? The CDR is definitely reducing duplication for the federal partners. From our perspective, it's also speeding up the process. The common drug review provides recommendations to our federal drug plans and all but one of the provincial and territorial drug plans. It has established one central body of expertise rather than each of the participants attempting to create its own review process.
Federal departments used to have to wait for decisions that were made on a quarterly basis by the Federal Pharmacy and Therapeutics Committee. As a result of CDR, the Canadian Expert Drug Advisory Committee meets and makes recommendations to us on a monthly basis. Those recommendations go directly to individual drug plans without further review. It allows us to authorize the use of new drugs much more quickly than we were previously able to. It saves time, effort, and money.
Is the CDR meeting its third goal, to maximize the use of limited resources and expertise? Again, having one body advising six federal drug plans gives all of the participants in the CDR access to leading Canadian experts in drug therapy and drug evaluation. Speaking for Veterans Affairs Canada, we would never have the means to achieve this level of advice on our own, and I don't believe many of our other partners around the table would be able to do that either. So by pooling our resources through the CDR, we're all able to provide a higher level of service to our clients. The process allows us to be more accountable with regard to the dollars spent through drug coverage.
As well, all participating drug plans are directly involved in the process. The Advisory Committee for Pharmaceuticals includes a representative from each participating province and territory, Veterans Affairs, the Department of National Defence, and Health Canada. The Federal Healthcare Partnership represents the remaining three smaller federal departments.
Finally, is the CDR meeting its fourth goal to provide all participants with equal access to the same high level of evidence and expert advice? I think we've mostly covered this point, but it bears repeating that all CDR participants receive the same high level of advice. Prince Edward Island receives the same quality of advice as larger participants like Ontario and National Defence. Without the CDR, this would not be the case.
I would now like to briefly mention an evaluation of the CDR conducted by EKOS Research Associates in 2005. It determined that federal, provincial, and territorial participants are pleased with the results of the CDR. They find it to be efficient, responsive, and timely. They believe it is providing quality reviews and recommendations.
The evaluation also raised some areas for improvement—and no process is perfect. If we aim for perfection, we will spend an awful lot of money trying to get there. But we believe the CDR is a very valuable tool that can use some tweaking, like anything else.
The areas for improvement include the need for public involvement, the need for increased transparency, the problem with delays in the uptake of CEDAC recommendations by the various drug plans, and the potential to tailor reviews to the complexity of a drug. I know that CDR is addressing these, and I'm sure they will be speaking to this either later this afternoon or later this week.
In conclusion, governments have a legitimate role in ensuring that public resources are appropriately used. For drugs that are publicly reimbursed, this includes verifying they are of good value relative to their benefits over existing therapies. Internationally, all OECD countries except the United States and France have adopted some type of post-licensure review of therapeutic benefits and cost-effectiveness.
So again, the common drug review is working very well. The federal health partners are pleased with it and look forward to continuing to contribute to, and benefit from, this invaluable process.
Thank you.
Conservative
The Chair Conservative Rob Merrifield
Thank you very much for your comments. We will reserve questioning until all of the panel has had an opportunity to present.
We will now move to the Department of Health and Ian Potter, who has been here before. Ian, the floor is yours, and if you would introduce your colleagues, that would be great.
Ian Potter Assistant Deputy Minister, First Nations and Inuit Health Branch, Department of Health
Thank you, Mr. Chairman, and members.
Thank you on behalf of Health Canada for the opportunity to speak to the committee on the topic of the Common Drug Review.
I'm joined by my colleagues Abby Hoffman, the executive coordinator of pharmaceutical management strategies for Health Canada; and Scott Doidge, the manager of pharmacy for the non-insured health benefits program.
Committee members may recall that Health Canada’s first nations and Inuit health branch operates a program for registered first nations and Inuit called the non-insured health benefits program, or NIHB. This program provides a limited range of medically necessary health benefits to approximately 790,000 eligible clients. These benefits include pharmacy and dental services, glasses and other vision care aids, and transportation to access medically required services. The NIHB program plays an important role in Health Canada’s goal of closing the health gap between first nations and Inuit and other Canadians.
Approximately 80% of our clients are low-income earners. They experience a higher disease burden than the national average. For many of them, NIHB is the only available supplementary health benefit program they have.
NIHB is the largest federal non-employee drug benefit program with expenditures of $368 million in the year 2006-07.
Last year, NIHB processed over 13 million pharmaceutical benefit claims. In total, over 500,000 different first nations and Inuit clients claimed the benefit.
In managing this benefit, NIHB maintains a drug benefit list, or a formulary, to determine whether and how to fund pharmaceutical benefits. There are approximately 6,000 distinct products reimbursed under the program. Drug products on the NIHB drug benefit list are categorized as either open—that is, no restrictions if there is a valid prescription—or limited use. Other drugs are reimbursed on a case-by-case basis. The drug benefits list changes on a constant basis to reflect the availability of new drugs, new uses for old drug products, or generic versions of brand name products. Last year, the non-insured health benefits program made more than 600 changes to the drug benefit list.
Almost every day, new strengths or formulations of existing drug products are approved by Health Canada. Manufacturers often change, and generic versions of brand name medicines come to market. To provide advice on existing drugs in our formulary, NIHB looks to an independent expert advisory committee, the Federal Pharmacy and Therapeutics Committee. The committee provides clinical advice to all six federal plans and informs decisions related to delisting and to listing of new uses for drugs. The membership of this independent expert advisory committee includes practising physicians and pharmacists from the community and hospital setting, and it includes three first nations physicians.
The NIHB program also has a Drug Use Evaluation Advisory Committee to provide expert independent advice on appropriate utilization and client safety with respect to drugs listed in the NIHB formulary. This committee reviews utilization trends of certain drugs or classes of drugs and, where appropriate, refers issues of concern to the program. For instance, as a result of safety issues and concerns about potential misuse, NIHB changed the benefit status of Duragesic, a long-acting opioid patch, from open benefit to limited use.
For drug products that are new chemical entries on the Canadian market or for a new combination of existing products, the NIHB program follows the recommendations of the federal-provincial-territorial common drug review. Since 2003, the common drug review has reviewed 68 new prescription drugs. Of the 32 drugs recommended by the common drug review, NIHB has listed or will reimburse the cost of all these drugs for our clients. Twenty-five of these drugs are listed on our benefit list and seven are available on a case-by-case basis.
NIHB always assesses the recommendations made by the common drug review against the mandate of our plan and the unique needs of our first nations and Inuit clients. Given the unique needs of our clients, some exceptions are warranted. That is, they may not be reasonable in the general situation, but they make sense for our clients.
On rare occasions, the NIHB program will list a drug that is not recommended by the common drug review if a client-specific analysis warrants it. For example, to ensure access to oral contraceptives for a high proportion of clients in our program who are of child-bearing age—and our clients are mostly young—NIHB listed a birth control product in the formulary that was not recommended by the common drug review panel. In this case, our pharmaceutical committee reviewed it, looked at the specifics of our clientele, and said that there was a benefit to our clientele and that it should be available.
Through the work of the common drug review process, the NIHB program has been able to eliminate the backlog of new drugs awaiting review.
As a national program that delivers its benefits in ten provinces and three territories, the NIHB program has benefited from increased consistency in listing across jurisdictions, and clear objective standards.
We are also able to make faster decisions on new drug listing, reducing the amount of time to list a drug product by approximately 25%, from an average of 500 days from the day a product receives its marketing authorization to 334.
Because NIHB pharmacy professionals now spend less time reviewing drug submissions, the program has been able to concentrate on other key tasks that have led to important program enhancements, including measures to improve client safety.
Given the interest the committee has shown in the past about NIHB's work to improve safety, I have taken the liberty of circulating a publication called a “Report on Client Safety”, which highlights some of the improvements, for your information.
I have taken the liberty of circulating, in advance of this meeting, a publication called a Report on Client Safety which highlights some of these improvements for your information.
Thank you very much. Merci.
Conservative
The Chair Conservative Rob Merrifield
Thank you very much for your presentation.
Now we'll hear from the Department of National Defence. We have Lieutenant-Colonel David Cecillon. I probably messed that name up, but you can correct that for me. Carry on with your presentation, please.
Lieutenant-Colonel Dave Cecillon Pharmacy Policy and Standards, Department of National Defence
Thank you.
I am the senior clinic pharmacist in the Canadian Forces, and I am responsible for the administration and management of our drug acceptance centre, which is basically our drug plan. On behalf of the Chief of the Defence Staff and the director general of health services of the Canadian Forces, I would like to thank you for this opportunity to speak to you today on the common drug review.
As you may already know, the Constitution Act of 1867 assigns the sole responsibility for all military matters to the federal authority. Subsection 91(7) of the Constitution Act serves as the constitutional basis for the Canadian Forces health care mandate. In addition, the Canada Health Act specifically excludes Canadian Forces members from its definition of insured members, as do the public service health care and dental plans.
The director general of health services of the Canadian Forces is responsible for providing comprehensive health services to all regular and reserve members, as dictated by the conditions of employment, as well as anyone else, as determined by the minister. In all cases, despite this exclusion, the Canadian Forces health services must abide by the principles set forth in the 1984 Canada Health Act.
In April 2000, the Canadian Forces initiated an evidence-based medicine approach to managing its drug formulary, with the goal of improving health outcomes in Canadian Forces members. This program is based on three key principles: operational readiness, fairness, and equality.
With the creation of the common drug review process in 2003, the Canadian Forces and other federal health care partners determined that the common drug review offered significant benefits, and therefore we decided to willingly and actively participate in the common drug review process. At present, I am the Canadian Forces representative on the common drug review's Advisory Committee on Pharmaceuticals, and an observer at the Canadian Expert Drug Advisory Committee.
For the Canadian Forces, the common drug review has eliminated duplication, decreased time to review and make listing decisions on new chemical entities, and enabled the Canadian Forces and the Federal Pharmacy and Therapeutics Committee to address other pressing federal drug benefit plan issues. For the most part, the Canadian Forces has complied with the recommendations of the common drug review. However, as per the data you were previously provided with, there are variances, and many of these variances can be attributed to our vastly different patient population, as well as our mandate.
For instance, the membership within the Canadian Forces is approximately 85% male. They range in age from 17 to 60 years old, and they are relatively healthy compared to the Canadian population. Given the Canadian Forces health services group mandate to provide health care to its members in Canada and on operations, it is easy to see that our conditions of service have a direct effect on our drug benefit listing decisions. We must be able to overcome the limited load and resupply capabilities associated with deployed operations. We must also take into account product stability concerns based on each theatre of operations. Rest assured that careful consideration is given to every listing decision in order to ensure that we can maintain our operational capabilities.
At present we have four listing categories: list, list with criteria, do not list, and not a benefit. Should a member have tried all the benefit items and failed to demonstrate an improved outcome, a request for a non-benefit list item can be made to the Canadian Forces health services group directorate of health service delivery spectrum of care committee for adjudication on a case-by-case basis.
In conclusion, I hope I've been able to highlight the differences between the Canadian Forces membership and the rest of the Canadian population. In addition, like my colleagues before me, I must reiterate that the common drug review is working very well and has allowed us to reallocate many of our already scarce resources to other pressing drug benefit list matters.
Thank you.
Conservative
The Chair Conservative Rob Merrifield
Thank you very much. That gives a perspective to the committee, from the witnesses before you, on the federal use of the common drug review.
We'll start questions with Ms. Bonnie Brown.
Liberal
Bonnie Brown Liberal Oakville, ON
Thank you, Mr. Chair.
Welcome to all the witnesses.
I believe Ms. Bruce said that all the participants in the CDR have access to leading Canadian experts in drug therapy and drug evaluation. Considering the plethora of agencies, groups, and committees that are part of it, I would ask Ms. Bruce this: which experts do you listen to out of those 14 groups? The committees listed in our report are CDR, CADTH, CDAC, ACP, FHP, FDVC, FPT, FDBC, not to mention the six plans, one of which is assigned to each federal department. I think that comes to about 14 different things.
Associate Deputy Minister and Chair of the Federal Healthcare Partnership, Department of Veterans Affairs
I'll speak to it generally from a management perspective, and if you have technical questions, I'll defer to the people who have the technical expertise.
Simply put, for me, as a person responsible for delivering drug plans to veterans, and with my hat on the Federal Healthcare Partnership, there are three critical things. One, you need to know that a drug is safe, and that would be Health Canada.
Liberal
Bonnie Brown Liberal Oakville, ON
Excuse me, that's going around my question. My question is, considering there are competing committees of experts, which one do you listen to?
Associate Deputy Minister and Chair of the Federal Healthcare Partnership, Department of Veterans Affairs
We listen to CDR in terms of getting the advice on whether or not a new drug is worth the money it's going to cost.
Liberal
Bonnie Brown Liberal Oakville, ON
Since the arrival of the CDR, to your knowledge has anything else been dismantled at Veterans Affairs? In other words, this is costing a lot of money, and I wonder what was there before and did any of that fold down to accommodate the CDR.
Associate Deputy Minister and Chair of the Federal Healthcare Partnership, Department of Veterans Affairs
Speaking for Veterans Affairs, we have an internal committee—we still have it—but in the past it would have spent hours and hours trying to chase down medical reports and research reports. They don't have to do that anymore, because we take that information from CDR. Our committee can then take that information and make a decision about whether or not it's a benefit that would make sense to list for veterans.
Liberal
Bonnie Brown Liberal Oakville, ON
I can see that you're pretty happy with it and I can understand why. You may not think these numbers are accurate, but an outside report said that 27 drugs got positive formulary listing recommendations, and the government currently reimburses all 27 drugs under the veterans' drugs benefit plan.
I wonder what expert you're listening, because it said that 25 drugs got negative recommendations, and despite that, the federal government provides coverage for all 25 drugs to veterans. What it means is that regarding every drug that's submitted, somehow or other you have access to it for your client group.
Associate Deputy Minister and Chair of the Federal Healthcare Partnership, Department of Veterans Affairs
There is an error in the listing in terms of the drugs that are not approved. We do not list them on our formulary, but we will, on a case-by-case basis, take a look at whether or not a veteran who's tried everything else without a positive result could benefit from the ones that aren't listed.
Liberal
Bonnie Brown Liberal Oakville, ON
They could get anything that got a negative recommendation if someone in your shop thinks they really need it?
Associate Deputy Minister and Chair of the Federal Healthcare Partnership, Department of Veterans Affairs
It would have to have a very high level of rigour, and not just from people in our shop, but from the physicians involved as well. There would have to be documented evidence that existing medications are not working.
