Health Committee on May 14th, 2007

[The Chair, Conservative, Rob Merrifield]

Your time is up.

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

My ten minutes are gone?

[The Chair, Conservative, Rob Merrifield]

No, your ten minutes aren't, but your five are.

Mr. Fletcher, you have five minutes.

[Steven Fletcher, Conservative, Charleswood—St. James—Assiniboia, MB]

First, let me say to the Calvert sisters, I really appreciate what you had to say. I certainly can empathize that when you're injured or need help, you're not thinking about whether you're a provincial responsibility or a federal responsibility; you just want the help and you want it now.

Mr. Upshall, let me congratulate your organization on this booklet that you've handed out, Mental Illness & Addiction in Canada. It's very informative. However, due to the time, I'm going to have to focus my questions on the CMA.

In your presentation, you had a recommendation for a national formulary to harmonize the 18 different formularies. I wonder, given the reality of Canada and that much of what we're talking about falls within provincial jurisdiction, if the CMA has given any thought on how such a program could manifest itself.

Also, what would the CMA suggest to prevent a national formulary, if it's even possible, from going down to the lowest common denominator rather than the highest common denominator? And how would it be possible to change the coverage as new drugs came on? It seems as if it would be such a large monolith that it would be very difficult to change. At least now the provinces, if they want to exceed the CDR standards, have the ability to do so.

Those are my questions.

[Dr. John Haggie]

Well, in no particular order, the view of the Canadian Medical Association is that whatever drug review exists, it exists as an informative exercise based on outcomes, so it's evidence-based. The funding is a separate issue, which is a provincial-territorial responsibility, but the idea behind this is to produce a level of drugs that are generally accepted as being best in class, with some alternatives to allow for flexibility. It then becomes a separate issue as to how the provinces choose to fund those, and there are other options. You can't deal with the drug review simply in isolation, as just one fix, and we tried to allude to that in terms of the other elements we were talking about with rare drugs and catastrophic coverages. So I think you have to factor that into the mix.

How it's going to be funded is a separate issue in many respects. But we would see whatever drug review as being a lot bigger than it is at the moment, in terms of its staff and its ability to respond. We've heard from various witnesses, both today and on previous occasions, that the system is too slow and too cumbersome. That doesn't necessarily mean the system shouldn't be there; it means that perhaps it should be revised and altered in some way to make it more flexible and to make it work faster so that new drugs and first in class, which are difficult to deal with because there may not be anything with which to compare them, may need in the early stages some surrogate approach.

Ultimately what we're focused on is what happens at the sharp end with the patient. Does the patient get better with this drug in a more cost-effective, more humane way with the least side effects compared with existing treatments, or are the older treatments better?

The other thing about this, which I think people forget, is that rather than being an instructive arrangement, we as a profession would love to have access to these reviews and to this data, because by doing that and disseminating that, our physicians would be able to find the right drug for the right patient at the right time, which is what we're after.

The problem at the moment is that for most physicians in regular day-to-day practice, their main source of education on new pharmaceuticals is the lady or the gentleman from the drug company. Of course, they're not there to educate; they're there to sell. It's very difficult to get what we need, which is independent, arm's-length advice. Something like a review, funded at the federal level, would be untainted. It would be truly independent. It wouldn't have to deliver the funding, because that's a provincial responsibility. It would not be seen, by advocates for patients, as holding purse strings. Equally well, it would be at arm's length from pharmaceuticals, because it would not be open to the price deals that can be done on a provincial level.

So rather than throw out the baby with the bathwater, I think we need to change the bathwater, perhaps.

I hope that answers some of your questions. I realize I may have strayed a bit.

[Steven Fletcher, Conservative, Charleswood—St. James—Assiniboia, MB]

Yes, no problem.

[The Chair, Conservative, Rob Merrifield]

Thank you very much. Your time has gone.

Now we'll move on to Ms. Priddy. The floor is yours, and you have five minutes.

[Penny Priddy, NDP, Surrey North, BC]

Thank you, Mr. Chair.

To Ms. Calvert and Ms. Calvert, your mom did well. She raised two great activists. That's terrific. She must be really proud of what you're doing, because not everybody can pick up and decide they're going to take on a cause. Congratulations. You're doing it for all kinds of other people who don't have the voice to do it.

I have a question for the CMA, if I might. I want to be sure I've understood your presentation correctly. I think the national-provincial-territorial ministers have said something similar, that there is a need for a national formulary, correct? But there is a need for some flexibility within that, because as soon as you have a list of anything, there will be an exception to that rule, so there needs to be some flexibility within that formulary.

In terms of who does that formulary, and I've heard you say that if it's done federally it would be “less tainted”, I think was your phrase--I can't think of another one. But if it is done federally, do you think it is possible for the CDR to do that, with some revisions to CDR? I think you have been very careful; you've said that if it is the CDR to do that, then these are some things.... Do you think it's possible for the CDR to do that, with some changes?

[Dr. John Haggie]

I think the answer to that is that it depends. If you put in place an evaluation process, you will answer that question. And if CDR works, that's fine; if not, find out what's wrong with it and fix it.

[Penny Priddy, NDP, Surrey North, BC]

My second question to you would be, have you noticed a change in the approval time? I'm going to ask the same question to Dr. Laupacis. From the physicians you work with, have you noticed a change in the approval time of drugs coming back from your physicians since the CDR was in place? Are people saying it's longer, it's shorter, it's way longer? We hear data all the time, that it's six days longer than it used to be, and so on. And other people say no, it's way longer than it used to be.

So I'm wondering if you've had any feedback from all of your counterparts across the country about whether indeed it's taking what they perceive as a longer period of time.

[Dr. John Haggie]

I will just speak on a very local basis, and perhaps I'll let Briane Scharfstein answer the more national question. On a local basis, our problem is on a provincial level, with trying to get what we call special authorizations in the province.

[Penny Priddy, NDP, Surrey North, BC]

Yes, I'm familiar with that.

[Dr. John Haggie]

And the difficulty there is that there's a feeling amongst physicians that this is an economic rationing exercise rather than necessarily one that's focused on outcomes, because the data just don't seem to be there to support the outcome issue.

But perhaps Briane has a better national perspective.

[Dr. Briane Scharfstein, Associate Secretary General, Canadian Medical Association]

Just quickly, I think Dr. Laupacis made the point that for the front-line practitioners, they don't understand the process, nor do they wish to. What they understand is that drugs become available in a variety of ways, they become aware of it, and then there's a long time before they're able to write a script that's covered. And whether it's tied up at CDR or the lack of integration with other processes--the original approval process, other testing, monitoring, etc.--they're not aware. So I don't know that for the average practising physician it's necessarily that specific process, but the entire process seems somewhat complex and difficult to understand.

I would like to make a quick comment as well on the doability of a national formulary. It's interesting, if you think of it, that we have the equivalent of a national formulary for physician care. We seem to be able to manage that in the context that all physician services are covered under similar terms and conditions, and in fact the cost of physician services in Canada is actually less than the cost of pharmaceuticals now. So I think if there's a will, there's certainly a way, and we've shown that.

I would make another supplement to John's answer to the question of supporting a national formulary. The degree to which the provinces have variability in their formularies, I think, does compromise its integrity, at least in the eyes of the physicians. If there's great variability in what's covered, you begin to question the science that's used to make those decisions. And we're looking for a scenario where in fact the CDR process would be seen as infallible, would be the gold standard. You would trust it implicitly as a way to influence prescribing behaviour, and we'd like to see that. When it becomes used as a tool to ration or to manage the drug budget, our view is that it does compromise, then, its integrity to some extent, and it would be nice if it could be avoided so that you could trust the science, I think.

[Penny Priddy, NDP, Surrey North, BC]

Thank you.

Dr. Laupacis, you made a comment--

[The Chair, Conservative, Rob Merrifield]

Your time is gone, I'm sorry. But it was a very good try.

[Penny Priddy, NDP, Surrey North, BC]

But maybe it will come back--

[The Chair, Conservative, Rob Merrifield]

Yes, possibly.

[Penny Priddy, NDP, Surrey North, BC]

--about the five months and what we hear is 735 days. But surely you'll speak to that later.

[The Chair, Conservative, Rob Merrifield]

Yes, I'm sure we will.

Thank you, Ms. Priddy.

We'll now move on to Ms. Davidson.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Thank you, Mr. Chair.

Thanks to each of the presenters who have been here. My special thanks to Michelle and Sarah for having the fortitude to come and tell us their story and to advocate for others, to help them.

My first question would be to Mr. Upshall. You talked about a lack of expertise in the CDR when you're looking at drugs that are needed for your particular area. Are there drugs available in other countries that are not available in Canada because of this? Are some of the drugs that are being reviewed basically by CDR and rejected being picked up by the provinces? Are they being approved at the provincial level? Or are we as Canadians just not having the use of the drugs that other countries are having?

[Phil Upshall]

In many cases, we don't have access to the drugs that our community has in other countries. I can't tell you why that is, other than that it's probably a combination of the CDR process and the lack of will in the provincial formularies to fund the availability of these medications.

The other issue is timeliness. It does take longer in Canada to have these drugs reviewed and approved than it does elsewhere.

I would like to point out to you, as well, that our community is very globally integrated. People in Canada who have mental illnesses are in communication with other people in other countries who have mental illnesses through other advocacy groups and on the net. Very frequently--and I think the medical profession will agree with this--patients ask the doctor if they can be prescribed this medication.

Particularly when it comes to medications for people with mental illnesses, they are not as precise or targeted as other medications are. It's absolutely essential to have a menu of medications available as early as possible. I think, again, we all know that the earlier the intervention in a mental illness situation, the less harm can be done, the more likely recovery is, and the more likely the return to being good taxpaying citizens.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Thank you.

To the CMA, one of the points you made was that there should be a process for appealing the review's decisions. What would that process look like?

[Dr. John Haggie]

I have no preconceived ideas. I think you would need to involve the individuals concerned and perhaps make sure that whatever.... The prime thing is that it has to be transparent. It has to be visible to all.

I think these appeals have to be along the same lines as the drugs and the mechanisms that CDR, or whatever it's called, will use. So it has to be outcome-based, it has to be based on some scientific evidence, and it has to be open for everyone to see. I think one of the problems with the whole process is that it's the black box; you just don't know what's gone on inside.

Other than that, as long as you adhere to the principles we've laid out, I don't think I would prescribe any form. I think it will follow the function that's laid out.

[The Chair, Conservative, Rob Merrifield]

Dr. Laupacis, are you interested in answering any of that, on an appeal process, since you are the chair?