Thank you, Mr. Chair.
I'm the previous chair of the Canadian Expert Drug Advisory Committee, which I'll refer to as CEDAC. This committee recommends to the drug plans participating in the common drug review which drugs should be funded and which should not.
I'm also a practising physician and a researcher, and like all of you, my family and I use the services of the health care system.
In previous hearings, you've heard from many others about the common drug review. Therefore, I'll proceed directly to answer the specific questions you posed to me and will not review the CDR. I'll conclude with a couple of remarks that I personally feel are important.
You first asked about the effectiveness of the CDR. As you know, the CDR performs a thorough independent review of all relevant available information on the benefits, the harms, and the cost-effectiveness of the new drugs it considers. A summary of the reviews are publicly posted on the CDR website. While I was chairing the CEDAC for three years, the accuracy of those reviews was almost never challenged; and the importance of the independence of those reviews, I believe, can't be overstated.
Your second question was about duplication. The CDR provides one national review of the available evidence about a new drug. However, in our federal system, the final decision about drug reimbursement does lie with each jurisdiction. To my knowledge, the vast majority of jurisdictions, except the CDR, do not conduct their own independent evaluations, and over 90% of the time, CEDAC's recommendations are accepted. Thus, I don't think duplication is a bigger issue than it was before the institution of the CDR.
However, in some provinces there are delays of many months between CEDAC making a recommendation about funding and the province's final decision. In my opinion, that's an unacceptable delay, and the time between the CEDAC recommendation and a jurisdictional funding decision should not be more than a couple of months.
The third issue you asked me to address is transparency. To my knowledge, the CDR is the only drug reimbursement committee in Canada to make the reasons for its recommendations publicly available on its website. For this degree of transparency, the CDR deserves credit. While I fully support calls for greater transparency in the CDR process, the fact is that greater transparency is needed in the whole drug evaluation system. In general, the entire drug evaluation process in Canada is, in my opinion, a transparency free zone.
So let's have transparency and make the protocols of all studies of a drug publicly available, so that anyone can compare the protocol with the study results reported later.
Let's make the pharmaceutical companies' submissions to Health Canada, which contain detailed information about their drugs' benefits and harms, publicly available. Aren't Canadians who will consume and pay for those drugs entitled to this information?
Let's make Health Canada's review of the pharmaceutical companies' submissions publicly available. Aren't Canadians entitled to know what their publicly funded regulator thinks about companies' submissions?
Let's have transparency, as we just heard, about the relationship between the pharmaceutical companies and disease-oriented groups and those who develop clinical practice guidelines.
Let's have transparency about the agreements that various jurisdictions and pharmaceutical companies negotiate on the price paid for a drug, and on any rebates or arrangements negotiated.
And yes, let's make the CDR process much more transparent. Let's make public the drug companies' submissions to the CDR, and the CDR reviews and the minutes of the CDR meetings.
The next thing you asked me about was public input. It's absolutely true that the public has had little direct input into the CDR process—although two public members have recently been added to CEDAC, which I think is an important step. Increasing the transparency of the whole drug review process, which I've just called for, will in and of itself increase public involvement. However, I also believe there needs to be greater public input into the CDR. This can be done in many ways, including public submissions, the opportunity for the public to appeal a CEDAC recommendation, and forums for CEDAC and the public to discuss CEDAC recommendations. I think it's important to engage the public in the whole drug evaluation process, rather than only obtaining its input on decisions about individual drugs.
I've been asked to comment on the joint oncology drug review. This has been established since I left my position as chair of CEDAC; therefore, I can't make an informed comment. However, whatever reimbursement process is established for cancer should use the same principles used for other diseases and other drugs. Patients with heart failure, a condition with a high risk of death, should not be treated differently from patients with cancer.
Let me now turn to two other issues that I think are very important.
The first relates to the fragmentation of the whole drug evaluation process in Canada. There is virtually no integration between those who make decisions about whether a drug can be sold in Canada, which is Health Canada; those who establish the maximum price of a drug, which is the Patented Medicine Prices Review Board, or the PMPRB; and those who decide whether a drug will be publicly funded, and that's CEDAC or the CDR, and eventually the federal-provincial-territorial drug plans.
Let me give you one example. Both the PMPRB and CEDAC are interested in the price charged for a drug. The PMPRB sets the maximum price that can be charged for a drug in Canada, based upon the price charged in seven other countries, which often has nothing to do with the benefits of the drug. CEDAC makes its recommendations based upon a drug's cost-effectiveness, but has absolutely no input into the maximum price established by the PMPRB and has no authority to negotiate price. The CDR is a relatively small component of the whole drug evaluation system in Canada, and I would respectfully urge you as a committee to look at the whole system.
The final issue I wish to discuss is the price of drugs. As you know, cost-effectiveness, or value for money, is the main criterion that CEDAC uses to guide its recommendations, and here I'd make the very strong point that CEDAC does not just look at which drug is the cheapest; it looks at benefits and costs, and benefits include non-drug benefits such as avoidance of heart attacks and the future avoidance of hospitalization, etc.
Cost-effectiveness is affected by two factors. The first is how beneficial a new drug is compared with existing therapies. Even a very expensive drug is cost-effective if it is safe and provides a very large benefit.
The other factor that markedly affects a drug's cost-effectiveness is its price. In the last ten years there has been a massive increase in the price of drugs without, generally speaking, a massive increase in their benefits. Only a few years ago, I thought that a drug that cost $1,000 a year was expensive. Now the average drug submitted to CEDAC costs about $5,000 a year--that's the average drug--with a number costing more than $20,000 a year. These drugs in general don't cure disease, and in many instances their benefits are actually quite modest.
In my opinion, the single most important factor limiting access to drugs is skyrocketing drug prices, with no apparent end in sight. Skyrocketing prices are making some drugs unaffordable, and I would point out that the common drug review does not have the authority to negotiate price; CEDAC is simply provided a price by the pharmaceutical company and essentially told to take it or leave it.
We all know that access to quality of care is an important issue in our health care system. In many parts of Canada, patients with arthritis of the knee are waiting in severe pain and immobility for many months before they are able to benefit from a knee joint replacement. Joint replacements are among the most dramatically effective interventions in medicine. One joint replacement costs about $11,000 to $13,000, and its benefits last for decades; contrast that with the greater costs and less impressive benefits of some of the drugs considered by CEDAC.
My point is not that joint replacements are always better than drugs--that's clearly not the case--but as parliamentarians, you are aware that the resources available for health care are limited, and difficult choices about what we can afford and what we cannot afford are being made every day. I would suggest that the CDR and the drug plans are not in the business of purchasing drugs; as one component of the health care system, they are in the business of purchasing health outcomes. It is incumbent upon the pharmaceutical industry to ensure that the outcomes provided by drugs are at least competitive with the outcomes that can be purchased by similar investments in other parts of health care.
Thanks very much for the opportunity to address you today.