Health Committee on April 25th, 2007

[Dr. Ed Hunt, Chair of the Board of Directors, Canadian Agency for Drugs and Technologies in Health, and Assistant Deputy Minister, Department of Health and Community Services, Government of Newfoundland and Labrador, Conference of Deputy Ministers of Health]

The Conference of Deputy Ministers actually appoint auditors at their annual meeting each year. This past February, in fact, they appointed the auditors. The auditors are accountable to the Conference of Deputy Ministers. I'm not sure who it is this year, but—

[Dave Batters, Conservative, Palliser, SK]

Okay, thank you.

Dr. Sanders, on the bottom of page two of your submission you note that formulary listing decisions are “entirely within the authority of the jurisdictions, and the CDR has no role in, or influence on, the nature...of [these] decisions by drug plans”. Why, then, are Canadian taxpayers paying so many hard-earned dollars to support a body that admits it has no influence or role at the end of the day?

[Dr. Jill Sanders]

Perhaps that was worded in a way that was misleading, and I apologize for that. The intention of that statement was to inform the committee that the CDR makes recommendations and not decisions. Those recommendations inform decisions, but the decisions are entirely the responsibility of the jurisdictions that make them.

I apologize if the wording of that statement is misleading.

[Dave Batters, Conservative, Palliser, SK]

It's maybe not misleading, because in the last meeting we had regarding this topic, we noted multiple negative recommendations that were covered by some public plans and multiple positive recommendations that were not covered. So it is puzzling, to say the least.

I want to pick up a little bit on the comments of my colleague Mr. Malo, specifically regarding Lantus. Health Canada has provided access to Lantus for federal drug plans, as have Ontario and Quebec.Lantus costs between $63 and $70 per month. According to Health Canada's Mr. Potter, who was here last meeting, Lantus can be a substitute for much more expensive insulin pumps, which cost around $5,000 for the equipment and $200 per month for the insulin.

If you're a patient in Ontario or Quebec, you have access to Lantus. Why does the CDR deny access to Lantus for other Canadian patients? It seems to be that we're going down a road of two-tier health care, where it really depends upon which province you live in. Can you explain to me why the CDR has not approved Lantus?

[The Chair, Conservative, Rob Merrifield]

Go ahead.

[Dr. Braden Manns]

I can talk about the CDR due process that Lantus went through.

When that medication was reviewed, one of the advantages of the CDR reviews, which we did not have when we reviewed these medications in Alberta and I am not sure whether Quebec has—Quebec could answer that—is that companies are compelled to send unpublished information to us. The majority of the information we reviewed around Lantus, whose comparator was another NPH insulin, was actually unpublished. We were not able to state that in our recommendations, because of proprietary issues. But the body of evidence available to physicians and to the makers of clinical practice guidelines is not the same body of evidence as we reviewed.

Ontario has made a recommendation that—Ontario has different policies in place by which they can fund pharmaceuticals. Ontario does not list Lantus on their formulary but has it available under individual clinical review.

We make recommendations to the provinces. All of the provinces have different policy options available for restricting the use of medications, and they've taken their right to restrict this very aggressively, with an individual clinical review mechanism.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

[Dave Batters, Conservative, Palliser, SK]

Thank you, Mr. Chair.

[The Chair, Conservative, Rob Merrifield]

We'll now move on to Madame Gagnon.

[Christiane Gagnon, Bloc, Québec, QC]

I would like to go back to the table on research and development. Dr. Sanders, you said that this was not a rigorous study and that we had to consider variables in other provinces or countries, variables such as the national price. New Zealand has another approach when negotiating the price of drugs. In addition, some of these costs are reimbursed by insurance policies.

We may criticize the statistics that have been presented, but the fact remains that they are somewhat troubling. For example, in British Columbia, only 15% of the drugs are recommended for reimbursement whereas in Quebec the percentage is 62%.

With respect to new products, you said that this was about effectiveness and cost. Does that mean that Quebec allegedly reimburses expensive medication which does not necessarily provide greater effectiveness? If that's the case, you're better off using a product already available on the market. I believe one of you said that the new medications offered to patients were hardly more effective. I would like to know what you do not like about the research and development statistics. You have certainly read them, given that you criticize them in your statement, Ms. Sanders.

As for the list of approved drugs, I would like to know, in particular, whether those who have the highest acceptance rate—and that would be Quebec—pay much too much, given the effectiveness of these products. Is that what you meant?

[The Chair, Conservative, Rob Merrifield]

Madam Gagnon, what study are you referring to from which you're getting your information?

[Christiane Gagnon, Bloc, Québec, QC]

I was referring to the study distributed to us when we heard the testimony of the industry and research and development representatives. They submitted some tables.

For example, we could also criticize the number of days it takes to assess a product. If we consider the number of products that are assessed, the average is very high when it comes from you—

[The Chair, Conservative, Rob Merrifield]

Do we have that information, or is this information you have? We don't have it?

[Christiane Gagnon, Bloc, Québec, QC]

No, I'm not the only one who has it; you have it. They came here and submitted it to us. Unless I'm the only one who received it, but that would surprise me. No, you have it, Mr. Chairman. It was the day when I chaired the meeting, I believe.

[The Chair, Conservative, Rob Merrifield]

Okay, that's fine. As long as our researchers have the information, we'll look after that later.

Go ahead with the answer.

[Christiane Gagnon, Bloc, Québec, QC]

We are not here to take sides. We are here to examine the documents and hear the various testimonies, in order to try to understand how things work.

We have statistics, averages regarding the number of days it takes, for instance, to approve medication, to analyze it, and there are some disturbing gaps.

[The Chair, Conservative, Rob Merrifield]

Fair enough.

[Dr. Jill Sanders]

I'll give part of the answer, and then I'm going to turn to Dr. Manns.

Part of the answer with respect to my concerns with that study has to do with comparing apples and oranges. Aside from the science, the decisions are often based around other factors. Some of those factors have to do with affordability, and in that factor we have to consider co-payment made by patients.

Where we see a drug listed, we need to fully understand—and it is confusing, quite frankly—because on the face of it, if we look at the tables, and we're not given that information, we wouldn't know that there are differences within the plans being compared, where listing a drug doesn't tell you the whole story.

In some countries there is co-payment by the patient. In other countries you must pay an additional health insurance dollar to get coverage for drugs, and then you get into that drug plan. Those are the decisions being made. It is complex. We're trying to help as well.

What I am trying to say is that the study doesn't highlight these differences between the plans, and therefore it doesn't highlight the differences around those reimbursement decisions. That is where I have trouble with the statistics as they are presented.

[Christiane Gagnon, Bloc, Québec, QC]

I would just like to have some clarification.

Regardless of whether it's paid by insurance, an individual or the state, in the final analysis, this is about the cost of a particular drug. For instance, in British Columbia, 15% of the products are included on the list of drugs that are refundable whereas in Quebec, the figure is 62%. That means that Quebec is paying too much for drugs that are not very effective. We don't have labels indicating who pays for what, but that is not what I see when I read the table. I think it's perhaps the individual or private insurance that pays, or both.

Finally, if I understand the logic, regardless of whether or not you are recommending a product for approval, on the whole, someone is paying too much for medication that is really not effective. That is what I am interested in. Regardless of who pays, in the final analysis, someone is paying too much for medication that is not very effective when in fact he or she could have had another medication that is just as effective but less costly.

In New Zealand, that's how things work.

[Dr. Jill Sanders]

I'm sorry, are you referring to the price of the drugs or the number of drugs listed? Is it the price of the listed drugs or the individual drug prices in the study?

[Christiane Gagnon, Bloc, Québec, QC]

I'm saying that when you make your recommendations, you always consider the effectiveness in terms of what it provides in addition. But when you do your analysis, you also take the cost into account.

Consequently, there is a tremendous gap if 62% of the products are approved in Quebec for reimbursement whereas British Columbia approves only 15%. That means that Quebec is reimbursing too much money for drugs, especially since you are saying that there may be other medications that are just as effective but less costly.

[The Chair, Conservative, Rob Merrifield]

Okay, I think we have the gist of it.

[Dr. Jill Sanders]

May I have one more stab at this?

I can't fully answer the question, but that study was based on a snapshot in time.

[The Chair, Conservative, Rob Merrifield]

Go ahead.

[Dr. Jill Sanders]

I don't know what snapshot in time, I don't know what basket of drugs was being studied, so we have to be careful.

This is what we're saying about looking at any statistics. We have to look at the baskets being compared. It may not be the same basket that goes through the common drug review. To be frank, I don't know what the basket is in the 62% and the 15%, because what we heard from Mr. Nakagawa was that they are following all the recommendations.

So it is confusing.