Health Committee on April 25th, 2007

[Dave Batters, Conservative, Palliser, SK]

Thank you very much, Mr. Chair.

Thank you to the witnesses for appearing before us today.

Dr. Saunders or Mr. Tierney, you've heard the criticisms of CDR. Some people will claim it's a barrier to patient access to new drugs; that it's an exercise in cost containment, and not what is best for patient health; that there's a lack of accountability and transparency. I'd like to ask whichever one of you wants to respond, and I've relatively short questions. If you could give me relatively short answers, that would be wonderful, because I only have five minutes.

Wouldn't open door meetings increase the transparency of the CDR, and what would be the disadvantages of having open door meetings?

[Dr. Jill Sanders]

The first step toward the transparency with regard to the content of meetings will be the publishing of the minutes of the CEDAC meetings, which is going to happen this year, and that's part of this year's initiatives.

As for opening the doors, there's a cost to that. Opening the doors entirely may be a good idea. We need to discuss that with the owners of the process. They need to make that decision, because there will be some cost and process implications.

[Dave Batters, Conservative, Palliser, SK]

Is that something you'd commit to discussing among yourselves in the future? That is one of the big criticisms of CDR, and perhaps this could make it go away, but let the public come. Let those who are critical come, and maybe it'll alleviate a lot of the concerns.

[Dr. Jill Sanders]

In my presentation I spoke to some aspects—that we may look at the conduct of the meetings. In that, I mentioned a couple of examples: one might be attendance at the meetings, one might be presentations to CEDAC by certain groups. It may go beyond attendance is what I'm saying.

[Dave Batters, Conservative, Palliser, SK]

You know what I'm talking about, though.

[Dr. Jill Sanders]

Yes, I know exactly what you're talking about. We need to look at it with our owners and with respect to the costs associated.

[Dave Batters, Conservative, Palliser, SK]

Thank you.

This is to Mr. Nakagawa.

The CDR touts evidence-based decision-making. Why is it that other countries, such as Sweden, Switzerland, and the U.K., are approving much greater access—more than 50% more—to innovative medicines for their citizens? Given that they are reviewing the same drugs, the same science, the same evidence base, why is the CDR blocking access to these same innovative therapies for Canadians?

I'm going to go a little further. Why are patients in Quebec provided with greater access to more innovative medicines in less time than those on a CDR-participating plan? And if I may say so, sir, you're explanation that somehow the science may be viewed differently in Quebec is baffling, at best.

I'll give you a chance to respond to all that.

[Robert Nakagawa]

First, I really don't have a thorough understanding of the processes, of the way that other countries—I think you mentioned Sweden and perhaps others?

[Dave Batters, Conservative, Palliser, SK]

Switzerland and the U.K.

[Robert Nakagawa]

I don't know what their process is for reviewing the evidence and the rigour that they apply. I can tell you, though, that I am extremely comfortable with the process that the common drug review applies. It is very similar to the process that British Columbia has applied and continues to apply for the new indications for old drugs, and it's one that meets the standards internationally that are applied by the Cochrane Collaboration.

It's hard for me to know why there are differences that exist when I don't have a good understanding of the details of how those countries go about doing their process. If they did things in the same way as we used to do them before we undertook critical appraisal, I can understand that they would come to different conclusions.

[Dave Batters, Conservative, Palliser, SK]

What about the difference, though, within this great country? Why do Quebeckers have more access to innovative medicines in less time? I'll give you an opportunity to explain your previous comment that maybe the science has been viewed differently in the province of Quebec.

[Robert Nakagawa]

I will actually say that part of it is similar to my response for other countries. I don't know the detail of how they go about their process, so in comparison I can't give you the answer. I can tell you that when experts look at the same literature there often are different views that come to the fore and decisions that are made, based on those perspectives.

If they applied the same rules of evidence that the common drug review uses and those that are applied by the Cochrane group and by British Columbia, I expect they would come to the same conclusions. I just don't know that they have done that.

[Dave Batters, Conservative, Palliser, SK]

That's very dicey ground, sir. We have excellent scientists in the province of Quebec—fantastic medical professionals.

[Robert Nakagawa]

They have extremely good scientists. What I don't know is that they've applied the same rules of evidence as others have, and in particular ours.

[Dave Batters, Conservative, Palliser, SK]

Sir, you know a lot more about this than I do, but either you have morbidity data or you don't.

I'm going to move on, Mr. Chair, if I have a little more time.

[The Chair, Conservative, Rob Merrifield]

Your time is pretty well gone.

[Dave Batters, Conservative, Palliser, SK]

Pretty well, but it's not gone, right?

[The Chair, Conservative, Rob Merrifield]

It actually is over. I'll let you come into another round, because I think you're going to ask for that at any rate.

[Dave Batters, Conservative, Palliser, SK]

Thank you, sir.

[The Chair, Conservative, Rob Merrifield]

Let's go on to Mr. Malo.

The floor is yours.

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

Thank you, Mr. Chairman.

You are probably aware of the fact that last Monday we met with officials from various federal departments responsible for carrying out the recommendations. The impression I get is that of a buffet. Some drugs are recommended and others not. On the other hand, some are covered across the board. In other cases, some are and some aren't. From what we've been told it appears that those choices depend on the clientele in question.

Mr. Potter, the assistant deputy minister responsible for first nations and Inuit health, told me, when I asked him about Lantus, a drug for diabetes, that this particular drug was eligible. However, it isn't under other programs.

I would like to ask Mr. Nakagawa about this, because he deals directly with British Columbians.

Do people in your province know that if they were Inuit, if they lived in another province, they might have access to a drug that could improve their health? Or, are they, rather, kept in the dark about these drugs? Why would these drugs be available to some people and not others, for example those in your province?

[Robert Nakagawa]

In answer to your question about whether British Columbians are aware of the different drugs that are available within each of the jurisdictions and whether, if I were in British Columbia, British Columbians are aware that a drug might be not available in British Columbia and would be available in Alberta, as an example, I don't know whether the average British Columbian is acutely aware. I think they would only become aware of this if the circumstance were that they went to their physician, received a prescription for a drug, found out that it was not funded, and had a subsequent discussion with their physician and found out that there was nothing else available.

What I think happens most commonly is that they might find that a drug would not be provided, then would have a discussion with their physician, who would then say the choice was theirs whether to pay for this drug as an individual or through their third-party payer or another insurance plan; or that they could use another drug, perhaps within that same class, that is covered by the province.

In British Columbia, as we look across the different drugs that are covered, we have a very broad range of drugs, so that within each of the therapeutic categories there's always something available that's publicly funded.

So I think the patient may not be aware of differences. That being said, what the common drug review does is provide for more consistency across the country in drug listing decisions.

As we look at the recent decisions and see this high degree of correlation between what the common drug review is recommending and what provinces are actually accepting and implementing, we're seeing that there are more commonalities now than there ever have been; there are fewer differences between provinces.

For the most part, the drugs that are coming onto the market now are not all wonderful therapeutic innovations. I wish they were, but fully two-thirds of them are not significant advances in therapy.

So we see there's consistency across the country now more than ever.

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

Thank you, Mr. Nakagawa.

Ms. Sanders, in your presentation, you said something that is very serious in my opinion. It pertains to the following:

While we recognize that there will always be tension between the pharmaceutical industry and CDR, [...]

So that means that there will always be a completely irreconcilable difference between what the industry wants and what the various legislatures or CDR partners want. Your opinion on the matter is very harsh. Could you explain why this is irreconcilable?

[Dr. Jill Sanders]

I think I used the word “tension”, and the word “tension” is the one I would still apply to the situation. There will always be a tension, because the mandate of private industry is to gather return on investment and profits. Our mandate is to perform scientific, rigorous work based on the data, and the data is often provided by the industry, but not in its entirety.

As I said earlier, the cost-effectiveness work is done following clinical effectiveness. Sometimes the data are insufficient, and sometimes we draw conclusions, as is clear in our recommendations, that are not satisfying to the industry.

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

Do you think, as our chair was suggesting—

Mr. Chairman, I'm talking about you.