Health Committee on April 23rd, 2007

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

Go ahead, Mr. Potter.

[Ian Potter]

I think that if they conclude their reviews in a shorter period, the total time between the drug's coming on the market and the drug's being listed in our program would be reduced.

As I said, we are trying to reduce the amount of time that we spend looking at our particular population and seeing if it is apropos or if there are some differences. Very minor changes are made between the recommendations in CDR and what we do in terms of listing. We build on after they approve, so if they reduce their amount of time, the total time will go down.

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

How can you make that claim, Mr. Potter, when Ms. Bruce stated in her opening remarks that delays in the uptake of CEDAC recommendations by the drug plans was one area in which improvement was warranted?

If a problem already exists, how can you think that if the review process were accelerated, you would be better able to keep pace, when you're already having trouble doing that?

[Ian Potter]

I am not sure if I understood the difference between my position and Ms. Bruce's position. I think we're saying there is a period of time that the CDR does work and there's a period of time afterwards that each department looks at it and their drug plans to see if it's appropriate to list in their special circumstance.

I don't think the volume is so huge that it will make a big difference, but it may, depending on the size of your program. We have a fairly large program. I think we spend almost $370 million a year on drug benefits, so compared to others, we may have more capacity.

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

Do you reassess each product submitted for review, whether it was recommended or not?

[Ian Potter]

We do not reassess the work that the common drug review has done. What we do look at is certain decisions they make based on parameters that they set out quite clearly. Some of them are things like the cost of the drug. Some of them are looking at alternatives.

For example, I talked about the situation in which we were looking at a long-term insulin drug, Lantus. It has the possibility of replacing the need for an insulin pump. Our program covers both. It is very expensive if a patient has to move to an insulin pump, and while it may not be of value in the general population, in our particular population, because of its isolation and the cost of servicing that clientele, it was deemed by our pharmacists and physicians to be a valuable drug for a few cases in which they may not need an insulin pump but do need a longer-acting insulin.

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

In that case, do you really need the committee to make recommendations, or would a number of pharmacological analyses suffice, given that you do question whether or not the product is good for your own clients?

[LCol Dave Cecillon]

From DND's perspective, yes, we do need the analyses. It is a recommendation and it is based on a pharmaco-economic analysis that takes an uptake of the drug in each jurisdiction. Because we have various jurisdictions with quite a varying population, that uptake may not be the same as what CDR has looked at.

We're not a province. We don't have the population of a province, so it may not impact us financially as much as it would one of the provinces; therefore, given our individual mandates, we have to determine whether we can afford it within our resources.

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

So then, you don't really need a recommendation, but rather more work on the process leading up to the recommendation.

[LCol Dave Cecillon]

No. We do need the recommendation, because the recommendation includes the pharmaco-economic analysis. What we need to do is individualize that for our program, bring it to our deputy minister or whoever, and let them make the decision on whether we will fund it.

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

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for that.

Patrick Brown.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Mr. Chairman.

My concerns are similar to those of Mr. Batters about patient access. Since I wasn't here when the common drug review came about, was there a reason why some people felt that drugs were being approved prematurely? Are there any examples of mistakes that happened in the system without the CDR?

Second, what is the point of the CDR if the provinces are approving drugs that are not recommended by the CDR? Can you explain what benefits may arrive from having those conflicting positions?

Third is a local issue I had in my riding. A constituent came into my office to tell me that her mother was suffering from cancer. The physician said that Iressa would be helpful, and my constituent wanted to know why the CDR hadn't approved it. It's very difficult when a constituent is very upset, when dealing with a loved one, by what she believes is red tape and incredible slowness on behalf of the federal government.

I understand that some of the provinces approve that drug, so why would some provinces say it's good enough for their patients when the CDR is saying it isn't? It just seems we get so many mixed signals out of this system.

Could you provide some light on this?

[Verna Bruce]

I can take the first question, but the common drug review people should speak to the provincial matter. I have no knowledge there, and I don't think any of us do. Others can speak to the cancer drugs.

On why we got into the common drug review, previously each department tried to figure out, every time a new drug came on the market, even though it was a lot more expensive, whether it was actually going to provide that much greater benefit for the people to whom we were dispensing the drugs. So we were trying to do it ourselves.

There is not a bottomless pit of resources to do that. It requires a lot of professional expertise—doctors and pharmacists—and they're in high demand. So the view of the partner departments was that rather than each of us trying to build our own drug review process, if we went in it together we could end up getting something that would probably cost less in the long run, we wouldn't be duplicating the same work six times, and it would make it easier for everybody.

So from a user's perspective, that's basically why we got into the common drug review.

[Ian Potter]

We've seen improvement in the quality of work that's been done since the common drug review, and we've seen efficiencies in having one expert panel deal with it. We've reduced the amount of work we do on reviews of new drugs. We have seen the time period go down between when a drug enters the market or is approved by Health Canada for sale in Canada, and when it gets listed as a benefit on our program. We have seen benefits from it.

You'd have to ask the CDR about it, but my impression is that there is more commonality between drug plans now than there was in the past.

[Patrick Brown, Conservative, Barrie, ON]

Is anyone able to comment on the case of the cancer drug being available in British Columbia but being turned down by CDR?

[LCol Dave Cecillon]

I can't comment on the individual provinces, but based on my attendance at CDR and the recommendations, each province has its own mandate and exercises it based on the recommendation. If one province feels it has the funding to pay for a drug that wasn't recommended based on cost alone—which some of them might be—it can do so.

[Patrick Brown, Conservative, Barrie, ON]

So the explanation is that British Columbia decided it could pay for it, but CDR viewed that drug as being too expensive.

[LCol Dave Cecillon]

I'm not saying that. CDR makes its recommendation, and the provinces can determine whether or not they can fund the drug, based on their mandates. So it's not a matter of whether the decision is CDR's or not. Each provincial mandate allows the province to determine if it can pay for it or not.

[Patrick Brown, Conservative, Barrie, ON]

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

If the committee would allow me, I have a couple of questions just to clear it up for the committee.

It makes perfect sense. You want efficiency. You want to have one board examining these products so you don't have to duplicate it in each of your portfolios or areas. But we have before us three different departments of the federal government, all with three different formularies, all using the CDR and saying it's appropriate. The explanation you gave as to why they're not uniform is that the populations you're trying to accommodate are different. That sort of makes some sense. But it's physicians who prescribe the medication, and there are some in the Canadian armed forces who are female who might use the same birth control...whereas the first nations say they need a different product. Or there is even the insulin pump.

I guess where I'm coming from is that I have a difficult time understanding, even if it's not prescribed very often, why it would not be on a formulary as being acceptable, when it's a federal government department.

[LCol Dave Cecillon]

With respect to DND, the product that was alluded to by Mr. Potter is a regular benefit on our drug plan, and we do have that. That was the Evra patch.

[The Chair, Conservative, Rob Merrifield]

Okay. Then why is your formulary not identical to Mr. Potter's?

[LCol Dave Cecillon]

Again, based on our patient population, and I also alluded to it in my opening remarks with respect to our need to deploy, we have a limited list capability, which means that we can't take every single drug. We just don't have the capacity to move them. The other thing is that we have stability concerns in our operations. If you take a patch into a cold area compared to a very warm area, the kinetics of the drug, or the absorption of the drug, varies, and therefore we have to take that into account. So there are many factors that we look at.

The other thing is that we have primarily a healthy, younger population, and he has a varied population with pediatrics and geriatrics, which we don't have. So you wouldn't find many of the Alzheimer's drugs on our benefit list. You would not find drugs for some cardiovascular diseases, unless a patient has that condition, when we would do it on a case-by-case basis, as Bruce has said. We also look at the individuals and we tailor the therapy to them. It doesn't mean it's not a regular benefit; it means that not everyone can access it.

[The Chair, Conservative, Rob Merrifield]

I understand all of that. But it's not the formulary that prescribes it; it's physicians. It's specific, patient by patient. All the formulary does is allow you the ability to use it or not. So I guess that's where my problem is with three federal departments, all with different formularies, albeit, I understand, with different clientele. Nonetheless—