Health Committee on May 14th, 2007

[Dr. Andreas Laupacis]

There is an appeal process now. I've observed that every time, with maybe one or two exceptions, we recommended that a drug not be funded, it was appealed, and we reviewed that appeal.

I would agree that the appeal should be more transparent and open, but that would mean the pharmaceutical companies would have to agree to allow all the information they submit to the CDR, which they frequently ask us to keep confidential, be open and public. I would be very supportive of that.

[The Chair, Conservative, Rob Merrifield]

On that, for the committee, the appeal process now is appealing to the same body that approved the decision the first time?

[Dr. Andreas Laupacis]

Exactly, yes.

[The Chair, Conservative, Rob Merrifield]

If you were to recommend an appeal process to the committee that would be appealing to another group, who would that be, and how would that look?

[Dr. Andreas Laupacis]

That's an interesting question. I guess the question is what one is appealing. Is one appealing that the CDR got the science wrong? The CMA reps have almost been implying that the science is going to be clear-cut, and it ain't. Sometimes it's really clear-cut that a drug is fantastically effective and safe. Other times it's clear-cut that it's not. And a whole bunch of times we don't know. We don't know how this drug is going to work in the real world, because Health Canada only needs six months of data and this antidepressant is used for six years, etc. I want to make that point, that science isn't going to solve all this.

There's a values process, which is why I personally pushed very hard to add public members to the CEDAC committee. I thought it was really important to have. We can argue whether two may not be enough and whatever.

So there's the science part and there's a values part. Is this drug really good enough value for money to justify putting on the formulary, given the other things we could spend health care dollars on?

I would agree that in general it would be reasonable to appeal to another body, but you would want to appeal to another body that's using the same principles as CEDAC uses. My understanding is that Hungary does that; they have a second group that hears appeals that is similarly constituted to their first group.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Now we'll move on to Madame Beaumier.

[Colleen Beaumier, Liberal, Brampton West, ON]

Thank you.

I think the number one concern we hear from most people is that CDR does not approve drugs fast enough. I notice that in recommendation number one, Mr. Upshall is saying that the drugs for mental health don't have the same priority as those for, say, cancer and physical health. I think we can all acknowledge that many times mental health is just as deadly as cancer or diabetes or any of these other terminal illnesses.

Are we short-staffed? Is that why there are backlogs? Should there be different decisions, whereby drugs for mental health are perhaps measured in a different kind of way for approval? I understand that you need families and communities involved, because when someone is suffering from mental health it affects not only the patient; it affects the family and oftentimes the entire community. Should we have different divisions? I think we all recognize that we have to get these things processed faster, and with the advances of science, drugs are coming on, new ones are coming quicker and quicker, and they're piling up.

So I'm just wondering what the solution for this is, because everyone wants their area to be prioritized.

[Dr. Andreas Laupacis]

First of all, I fully agree. I work at St. Michael's Hospital, which is an inner-city hospital in Toronto, and there are a lot of homeless folks around St. Mike's, many of whom have mental illnesses. My dad died of dementia, so I'm fully aware of the devastating effects of mental illness. I guess my comment about the cancer review that's been set up--the name of which I've forgotten--is that I don't think, in terms of the principles of how we make decisions about which drugs should be funded, that we should be differentiating between trying to treat cancer and mental health and then arthritis. Clearly some of these disorders kill people, and others affect their quality of life. We have to try to make sure we are treating all of these as importantly and equally as we can.

I don't have all the information on the CEDAC drugs before me that we reviewed, but I can remember a couple of mental health drugs, and we processed those exactly as we did the other drugs. So I don't think, at least from a CDR perspective, it's a matter of somehow speeding up the mental health drugs process compared to that for others. If there's a sense that the whole system is too slow, then we should talk about that, but I certainly don't think there's any discrimination, at least from where I sit, against drugs for mental health.

[Colleen Beaumier, Liberal, Brampton West, ON]

Thank you.

Mr. Upshall.

[Phil Upshall]

I just have a couple of quick comments.

With regard to terminality of mental illnesses, Mood Disorders Canada has a website that counts suicides. To date, since the turn of the century, 30,000 Canadians have committed suicide, all of whom, or a vast majority of whom, have been impacted by serious and difficult mental illness. So it does kill. Mental illnesses do kill.

[Colleen Beaumier, Liberal, Brampton West, ON]

By the turn of the century, do you mean the year 2000?

[Phil Upshall]

Yes. Some 4,000 Canadians a year kill themselves, and we don't care. That's roughly 150--I forget; I did the calculation last week--Boeing 747s crashing, and that's just suicides. Our jails are full of people with mental illnesses. Far more people are in jails than are in hospitals or on the street with mental illnesses. As the Honourable Justice Ted Ormiston will tell you, when he was in charge of the Canadian mental health court, he was the biggest warehouser of people with mental illnesses.

When I talk about access to medications, I mean access to medications for people with disabling mental illnesses. Medications are very frequently our canes, our wheelchairs, our curb cuts. So when we talk about cost of medications, I talk about the cost to society of not making the medications available, and that goes far beyond health care costs. I understand restricting the calculation of costs to health care, but even in the costs of health care, the medications for people with mental illnesses are frequently at the low end of the cost scale, and certainly nowhere near where immunosuppressant drugs are or where cancer drugs are. The bang for the buck for readily available mental illness medication is quite great.

I think maybe in the new CDR you might want to consider a fast-track process for medications that have been approved and used around the world, that are safe and facilitate recovery quickly. I don't know. There are some scientific issues, and others, but there has to be a way to get our medications to us more quickly.

[The Chair, Conservative, Rob Merrifield]

Thank you.

Mr. Brown.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Mr. Chairman.

I have a few questions today. The first is a general question for whoever is able to answer it.

The thing I struggle with, and an argument I haven't seen presented yet, is how the CDR doesn't contain overlap. We've heard a lot of rationalizations throughout these hearings about how there is an overlap. If we bring up a particular case, there's always a reason it was delayed. But if you look at the structure of this, the very base of it, we have two different decision bodies. We have the provincial aspect of it and we have the national aspect with the CDR.

How is that not inherently an overlap? How is that not inherently two groups doing the exact same job?

It gives you the impression that there are certainly going to be some delays. I hear many stories like the moving story we've heard from the Calverts. It's very sad that we have doctors within our community—not just in my riding but, I'm sure, around the country—who are saying, cross your fingers, hopefully the CDR will approve this.

I want to know what the root of the problem is. We shouldn't be crossing our fingers. If the problem is not overlap, if the problem is not two groups doing two things and making it longer, what is the problem? That's something I'd like to probe into. Is the problem that it takes so long because there's a lack of resources, a lack of staff? What is it? I've never heard that brought up.

One thing I did hear brought up by proponents of the CDR was that it helped bring national standards, helped bring uniformity to the process and more commonality amongst the provinces. They said that was one of the reasons it was set up a few years ago. But if you look at where we are today, we are seeing cancer drugs rejected by the CDR and approved in certain provinces. We saw an example of that in British Columbia. If the point of it was to get a set standard, that hasn't been achieved.

I know I've said a few things, but feel free to comment.

[Dr. Briane Scharfstein]

One observation, perhaps, is that we would have seen the processes as being quite distinct. At the national level you would have a process that would simply provide the objective information—the best evidence, using recognized and acknowledged experts up front, so that you wouldn't argue later about having the right expert—transparently. It would basically provide objective information—this is drug A, and it does X, has X benefit, and X cost—and perhaps give some sense of how much more or less that would be than other therapies that may also do the same thing.

Each jurisdiction that funds, then taking that objective information and hopefully not repeating or challenging that exercise, or if it does, doing it once, transparently, would then decide whether they wanted to pay for it or not, but not once again reinvent the process and say they've come to a different conclusion as to what this drug actually costs or what its benefit is.

So we would see them as quite distinct and not necessarily duplicating. If they are duplicating, then maybe there should be some reconsideration. The extent to which the national process, so to speak, gets into the business of deciding whether it should be covered or not is probably duplicating the provincial job and ought not to. It ought to be more objective.

[Phil Upshall]

The cynic in me tells me the reason there's overlap—it's been created by some very intelligent deputy ministers and others—is to save initial money in the provincial health care budgets. The longer you can delay an approval, the less likely you are to have to pay for the drug. That's a cynical approach. It may well be that I'm wrong in my cynicism.

The other comment I have is that Health Canada and all the provinces have what's called a patient-centred approach. Everyone talks about the patient-centred approach. The patient ain't at the centre of anything I've seen in this process. I think it's about time the patient got to the centre as expert, as adviser, and as the person who says I want or need this drug.

I think you have to go back to the bureaucrats and ask them how many bureaucracies they have to create in order to make a drug available.

I agree, there needs to be one national organization, but I think it has to be able to take some recognition of what's gone on in other major countries when they've processed the medications. We need to have deep investigation, but I don't think we have to reinvestigate. I think that adds significant cost to the pharmaceutical companies, and significant delays.

Those are my comments, for what they're worth.

[The Chair, Conservative, Rob Merrifield]

Thank you very much. Your time is gone.

We have one more questioner. This part of the meeting is actually supposed to stop at 5 o'clock, so we'll allow Ms. Kadis a few minutes to ask her questions.

[Susan Kadis, Liberal, Thornhill, ON]

I appreciate that, Mr. Chair, and all the presentations.

I'm particularly interested in what I guess is a bit of a running theme, and that is the issue of whether our investment in our current research in potential breakthrough drugs—new drugs for new and sometimes rare diseases, as well, and others—is actually benefiting Canadians. In other words, in terms of the disconnect that I'm hearing or perceiving from some of our witnesses, previously and today, between the drugs that are recommended for approval by the CDR and the people accessing those drugs, and the money that's being put into the investment and the research to ensure that we have these new, innovative drugs available, do you believe that there is a disconnect? That's something that I am picking up.

[Dr. Briane Scharfstein]

I'm not quite sure I get your question, in terms of what the disconnect is that you're perceiving.

[Susan Kadis, Liberal, Thornhill, ON]

We're investing so much in research in Canada. We have for the last several years. The issue is, is that being factored in enough? Are Canadians benefiting from that? Or is it getting stonewalled when it hits the recommendation level, such as at the CDR?

[Phil Upshall]

Perhaps I could just make a very quick comment.

Canadians fund $700 million, $800 million, $900 million of research through CIHR. Very, very little of it goes to clinical trials, very little of it. Most of it is basic, although we're trying to move them forward. The vast majority of clinical trials are undertaken by pharmaceutical companies outside of the federally funded research activities. They're solely oriented to the marketplace.

To my knowledge, pharmaceutical companies are going to work on drugs that are going to be available and be demanded. A number of disease groups that I'm aware of don't have the advantage of the kind of research that would be available to them if we had a level playing field in research.

I would urge you to ask Dr. Bernstein to come and provide you with the advice of our research community as to what can be done--Dr. Bernstein is the head of the CIHR, an institute I'm used to--and Dr. Rémi Quirion, who could also provide you with some excellent advice.

[The Chair, Conservative, Rob Merrifield]

He has been to committee so many times, we call him Alan.

[Dr. John Haggie]

I think you have to bear in mind the comments of Mr. Upshall about research and pharmaceuticals. We had some data presented to the CMA by an expert in genomics that suggested that the biological companies had three main areas of interest in their research programs that they were expending a vast amount of money on. One was hypertension, the treatment of high blood pressure. The other two were male pattern baldness and obesity. You can make of that what you want, but I think it's difficult to know sometimes what the results of pharmaceutical company research really are in terms of the amount of value they get for the money that they expend, because a lot of that data is proprietary and never sees the light of day.

I'm not sure that I can answer your question. I'm not sure anybody but the pharmaceutical company could answer that.

[The Chair, Conservative, Rob Merrifield]

Our time has gone. I really hesitate.... You're okay? Good. He wanted to talk me into going another round, and once we get into that, we're in serious trouble.

We'll call this part of the meeting over.

We want to thank you very much for coming. Your presentations to the committee will be valuable as we sit down to draft up our report. Thank you very much for coming and sharing with us.

With that, we'll call this part of the meeting over. Then we will clear the room to a degree, whoever wants to. It's still public, so don't feel you have to leave at this point.

Then we'll deal with a notice of motion that has been presented by Ms. Brown.

Thank you very much. We'll pause for two or three minutes.

[The Chair, Conservative, Rob Merrifield]

I call the meeting back to order. I ask members to take their seats and we will move on.

We'll start with Ms. Brown's notice of motion. She presented a notice of motion and we will ask her if she is prepared to move that motion.