Health Committee on May 13th, 2008

[The Chair, Conservative, Joy Smith]

Could I ask all the members to take their seats. We have a lot of witnesses to listen to today for their very important testimony. We also have some business at 12:50 p.m., so we will be going until 12:50 p.m. and then we'll go in camera for committee business.

I would like to welcome the witnesses to the health committee this morning. We're very pleased that you could make it and very pleased that you're going to give us some of your insightful comments and expertise on this important topic.

Pursuant to Standing Order 108(2) and the motion adopted by the committee on March 13, 2008, section 25.9 of the Federal-Provincial Fiscal Arrangements Act, this is our third meeting on the statutory review of the 10-year plan to strengthen health care.

Before we begin, I want to mention that we have some committee business scheduled for the end of the meeting—a steering committee report and three budgets to pay witness expenses. It is very important that we get through this business following the presentations.

The organizations that will be taking part in the first panel are the Canadian Healthcare Association, the Wait Time Alliance, the Association of Canadian Academic Healthcare Organizations, the Canadian Generic Pharmaceutical Association, and Canada's Research-Based Pharmaceutical Companies (Rx & D).

We will begin with Ms. Pamela Fralick, president and CEO of the Canadian Healthcare Association.

Pamela, could you begin.

[Pamela Fralick, President and Chief Executive Officer, Canadian Healthcare Association]

Thank you, Madam Chair.

I am going to give my presentation in English rather than in French so that it is shorter. But I am always prepared to answer questions in French.

Thank you very much for this opportunity, and congratulations to the committee for doing this review. We view the accord as one of the very fundamental pieces of the health system right now. It's important that we maintain vigilance on it.

The Canadian Healthcare Association was very active during the 2004 proceedings. We contributed, we believe, to positive outcomes of the accord, including the predictable funding and direction for setting benchmarks. This 10-year plan that we're reviewing has been instrumental in putting Canada's health care system back on track. However, the system is not yet where we need it to be. As we review the accord, we'd like to emphasize that the delivery of services is not only about access and quantity but also about safety and quality. We have four items to bring to your attention in today's session.

The first is wait times. Our Wait Time Alliance colleagues are going to speak on this in much more detail. While we're prepared to respond to any questions, at this point we'll simply emphasize two points: first, the five priorities identified in the accord are a beginning, not an end; second, appropriateness and quality of care must also be a priority, even as we address access and quality.

The second issue is health human resources. The shortage of health human resources is not just a Canadian problem; it's international in scope. It remains serious, and it points to a crisis. The pan-Canadian framework on health human resources, developed under the auspices of the FPT advisory committee on health delivery and human resources, is a strong and necessary framework. We are, however, concerned that its implementation is not receiving the attention and support from all stakeholders that it must have to succeed. In particular, Canada requires multi-stakeholder coordination of our HHR activities that transcends geographic, professional, and political boundaries in order to address the critical issues related to health human resources.

The third issue is electronic health records. EHR is pivotal for moving forward on health renewal priorities. I'd like to quote the 2004 accord, which said that the accord is committed to:

realize a vision of the Electronic Health Record through an ambitious plan and associated investment.

Canada Health Infoway investments now total $1.6 billion. However, the return on investment is estimated to have gross benefits exceeding investment dollars by an eight to one margin and to generate close to $40 billion in savings. CHA would like to reiterate its position that resources for an EHR must be allocated to allow for equitable coverage of all Canadians.

Our third point of emphasis is home care. The 2004 accord provided funding for post-acute and palliative home care. While that is a tremendously positive start, we think it is narrow and unrealistic as a view of home care in Canada. CHA continues to advocate for programs to provide both acute care replacement services and long-term home care. In the studies we reviewed, chronic home care was demonstrated to be significantly less costly than care in a long-term care facility. However, most home care is provided by informal, or unpaid, caregivers. One very impressive statistic tells us that 41% of Canadians who had to respond to home care needs within their family were forced to use personal savings just to survive. Canada's approach to home care must include continuing care as well as post-acute care.

Our fourth and final item for today is federal fiscal responsibility. Canadians legitimately expect to have access to comparable health services, regardless of the jurisdiction in which they reside, and the Canada Health Act commits to this. Since jurisdiction over health delivery is a provincial–territorial responsibility, some argue that the federal government should provide only the funding, without linking it to conditions or objectives. However, the federal government has a constitutional right, and some would say a duty, to use its spending power to achieve health objectives for the good of all Canadians. The people of this country rightfully expect pan-Canadian objectives to be developed and supported by all levels of government, and they are less concerned, frankly, about the ultimate source of the funding. Any move to minimize federal responsibility would have a negative impact on future pan-Canadian programs. These programs include a national pharmaceutical strategy, appropriate health human resources, and an EHR—all of which were identified in the accord. CHA would add home care to this list.

In conclusion, with respect to HHR, a strategy does exist. It needs our attention, all-stakeholder buy-in, prioritized funding, and most of all pan-Canadian coordination. With respect to the electronic health record, it is emerging in a fragmented manner that will not serve Canadians well.

To truly address patient safety and create efficiencies in the system, we must commit to a pan-Canadian HHR.

Home care—

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Fralick.

We'll now go to Dr. Lorne Bellan and Dr. Jean-Luc Urbain, from the Wait Time Alliance.

[Dr. Lorne Bellan, Co-Chair, Wait Time Alliance]

Thank you very much.

Good morning, everyone.

I'm an ophthalmologist from Winnipeg, and Dr. Urbain is a nuclear medicine physician from London, Ontario. We are pleased to be here today on behalf of the members of the Wait Time Alliance.

Our presentation today will cover three areas: the WTA's overall assessment of the implementation of the 10-year plan to strengthen health care; key barriers to making further progress in reducing wait times in these five areas and beyond; and, finally, moving ahead, the next steps government should take to ensure Canadians have timely access to quality health care.

The most recent national grades for wait times are listed in table 1 of the WTA's 2008 report card and include: in joint replacement, a B for hips and a C for knees; in radiation oncology, an A; in cataract surgery, a B; and for bypass surgery, an A.

Overall, national grades are just part of the picture in terms of assessing wait times. Therefore, the WTA has provided performance trends in the five priority areas. In some instances, where wait times are not decreasing, resources are being increased that should either lead to future wait time reductions or handle surging demand to prevent further increases in wait times.

While progress is being made to reduce wait times in the five priority areas, more can and should be done. The 10-year plan makes a number of commitments regarding wait times, including the development of access indicators, benchmarks, multi-year targets, and reporting on progress. In these areas, commitments have only been partially met, at best.

While provincial and territorial governments did adopt benchmarks in December 2005, they did not include benchmarks for diagnostic imaging nor did they honour their commitment to cardiac care. The current benchmark for bypass surgery fails to recognize the continuum of care for cardiac patients. Because of this, wait times are not being meaningfully addressed in cardiac care.

The current benchmark of four weeks for radiation therapy from “ready for treatment” until the start of treatment differs significantly from the WTA recommendation of two weeks. The benchmark also does not reflect the research evidence that found wait times for beginning radiotherapy for treatment of all types of cancers should be as short as possible.

Also, some provinces have still not indicated goals for meeting their wait time benchmarks. While most provinces are making progress, it is not equal progress across the spectrum of care, and we are concerned that some provinces may not have the necessary funding, structures, and processes in place to ensure that the reductions can be maintained.

Moving to our second area, the WTA has identified three key barriers that continue to undermine the progress being made and our ability to accurately record that progress: one, clarifying and standardizing wait time definitions and criteria among provinces; two, improving the collection and dissemination of wait time information to the public; three, lack of progress in addressing health care workforce and infrastructure capacity issues.

Governments continue to use different starting points to measure when wait times actually start. There is also huge variation in the quality of reporting by governments on wait times, and governments have not adequately addressed the most significant barriers to timely access, that being the shortage of providers and system capacity.

Dr. Urbain.

[Dr. Jean-Luc Urbain, Co-Chair, Wait Time Alliance]

Thank you very much.

Being able to document progress in reducing wait times for access to health care in the five key areas listed in our brochure is encouraging. But it is not reasonably possible to limit access to health care to only five areas. Taking care of the medical needs of Canadians requires us also to deal with and evaluate access to other specialties such as emergency care, psychiatric care, plastic surgery, gastroenterology, pain management, gynecology and obstetrics.

The entire medical profession in Canada is well aware of the complexity of Canadian health care. We are all equally convinced that, in the 21 ^st century, Canadians deserve to have quick and easy access to the health care system. We also firmly believe that this goal is perfectly realistic.

[The Chair, Conservative, Joy Smith]

Thank you so much.

Next is the president and CEO of the Association of Canadian Academic Healthcare Organizations, Jean Bartkowiak.

[Jean Bartkowiak, President and Chief Executive Officer, SCO Health Service, Association of Canadian Academic Healthcare Organizations]

Thank you, Madam.

I am Jean Bartkowiak and I am President and Chief Executive Officer of the SCO Health Service here in Ottawa. I am joined by Dr. Arthur Slutsky, Vice President of Research at St. Michael's Hospital in Toronto.

We represent the Association of Canadian Academic Healthcare Organizations, which is the national voice of research hospitals, academic regional health authorities, and their research institutes in Canada.

You have received a copy of our written submission. For purposes of ACAHO's remarks, we shall speak to the three policy issues related to capacity-building and the 2004 health accord: health human resources; information and communications technology; and health research and innovation.

Wait times are the barometer by which Canadians perceive the performance of the health system. Their very existence is closely linked to a range of other policy issues. The health accord has contributed to a number of pockets of success where progress is being made when it comes to wait times and others where more work is required. This has been noted in the association's two reports on wait times, called Wait Watchers and Wait Watchers II, which identify a number of strategies to improve patient flow-through in the system.

That said, there are other areas where direct net investments are needed. One critical area is the training, recruitment, and retention of health providers. The lack of available family physicians, specialists, nurses, or lab technicians has a direct impact on the availability of health services. Limited operating revenues for teaching hospitals or regional health authorities can also impact on the number of surgical suites, as can restricted capital budgets limit the number of diagnostic and therapeutic equipment in use.

If the prime objective of the health system is to ensure that Canadians have timely access to quality health care services, there are growing concerns that the current and future supply of health care professionals, be it physicians, nurses, pharmacists, physiotherapists, technicians, and others is not able, now or into the future, to meet the demand for health services.

While the 2004 health accord introduced a wait times reduction fund, the reality has been that moneys from this fund have already been transferred to the provinces and territories on an equal per capita basis for day-to-day operations of their health systems, based on specific provincial priorities, not necessarily aligned to a pan-Canadian perspective. Now is the time for renewed strategic investment in a shared national policy that will have a measurable and direct impact on wait times across the country.

More can and should be done to establish a pan-Canadian solution that focuses on graduating more health care professionals across the country. ACAHO is strongly supportive of the proposal by the Health Action Lobby to establish a five-year, $1 billion health human resources infrastructure fund. The essence of the fund is for the federal government to work with the provinces and territories to develop the necessary capacity to train the next generation of health care professionals. A copy of the proposal has been left with the clerk.

In addition to human resources, investments in information and communications technologies can have a more powerful and transformative impact on the overall organization, delivery structure, and performance of the health system. Not only can electronic health records improve the efficient exchange of patient information, minimize the duplication of diagnostic tests, and improve health outcomes and patient safety, they can also be a significant driver of how providers organize themselves and work together to provide care. ACAHO would encourage all levels of government to consider the additional investment that Canada Health Infoway requires and its significant payback to the system and to Canadians.

I will now ask my colleague, Dr. Slutsky, to make some closing comments on health innovation.

[Dr. Arthur Slutsky, Vice-President of Research, St. Michael's Hospital, Association of Canadian Academic Healthcare Organizations]

Thank you.

I'm the vice-president of research at St. Michael's Hospital in Toronto, home of the new Li Ka Shing Knowledge Institute.

The 2004 health accord recognized the value of health research and innovation in at least three ways: first, improving the health of Canadians; second, the impact of research on improving the cost-effectiveness of health care services; and third, producing world-class discoveries to leverage economic benefit as well as health gains, as recognized in the government's S and T strategy.

While significant investments in health research have been made by the federal government—for example, CIHR, Canada Research Chairs, and CFI—we must continue to sustain the momentum that has been created so that we can continue to participate in the benefits that come from future world-class research findings. We are on the threshold of a biotechnology revolution, and ACAHO is concerned that any retrenchment in funding would have serious consequences on our ability to attract and retain world-class researchers and to advance discovery and innovation.

Let's not go backwards. We do not want Canada to fall—

[The Chair, Conservative, Joy Smith]

Mr. Slutsky, I'm sorry to cut you off, but it's five minutes per organization.

[Dr. Arthur Slutsky]

I understand.

[The Chair, Conservative, Joy Smith]

We now have Mr. Keon. Mr. Keon is the president of the Canadian Generic Pharmaceutical Association.

[Jim Keon, President, Canadian Generic Pharmaceutical Association]

Thank you, Madam Chair.

The Canadian Generic Pharmaceutical Association is the national association that represents Canada's generic pharmaceutical industry.

Generic drugs are low-cost versions of brand-name drugs. They are produced by a number of manufacturers once the patents expire on the brand-name versions.

There are no differences in quality, purity, effectiveness, or safety between generic drugs and brand-name drugs. All drugs sold in Canada must be reviewed and approved by Health Canada. Each product, brand name or generic, must meet the strict regulations and standards established by the Food and Drugs Act.

Canadian generic pharmaceutical companies are proud of our contribution to affordable health care in Canada. In Canada the use of lower-cost generic prescription medicines saves governments, employers, and consumers almost $3 billion every year.

We're going to talk today about the national pharmaceuticals strategy. In September 2004, CGPA congratulated first ministers on their national pharmaceuticals strategy. We are, however, disappointed that this initiative does not appear to be moving forward, and we urge all governments, federal and provincial, to continue to take action on the NPS priorities.

I would like to highlight the current status of two NPS priorities this morning: generic drug pricing and faster access to non-patented medicines.

Regarding generic prices, many members of this committee may be familiar with the Competition Bureau's generic drug sector study, which was published in October 2007. In Canada, generic drugs fill fully 49% of all prescriptions, yet account for only 21% of the $19 billion Canadians spend annually on prescription medicines. Despite this, there has been some evidence that the retail prices paid for generic drugs in Canada are higher than the prices paid in other jurisdictions. This was of great concern to the generic pharmaceutical industry and other stakeholders, and the Competition Bureau report represents the first comprehensive analysis into the reasons why.

The study confirms that the generic pharmaceutical sector is highly competitive. When a product comes off patent, there are generally multiple generic entrants competing for a share of the market. In some cases, seven or more different companies will develop a generic version of a single product.

The problem is that while the industry itself is highly competitive, there are other elements of the provincial market frameworks for generic drugs that may prevent the full savings generated by this competition from reaching end payers.

I am pleased to advise this committee that some provinces have already reviewed and made enhancements to their market framework for generic drug products. CGPA was pleased to work with the provinces of Ontario and Quebec to achieve savings of 20% to 25% on the price of generic products and is actively working with other provinces to reduce their prescription drug costs.

With these changes, there is little doubt that retail prices for generic drugs in Canada will be in line with other jurisdictions in the OECD, and this will be reflected in future international surveys. Generic drugs save the health care system billions of dollars each year and are now a better value than ever.

The second element I want to talk about is faster access to non-patented medicines. With respect to this NPS priority, several provinces, including British Columbia, Saskatchewan, Ontario, Quebec, Newfoundland and Labrador, and Prince Edward Island have taken measures to speed up the listing of generic medicines on their drug benefit formularies to increase their savings. Other provinces, such as New Brunswick and Nova Scotia, already have efficient systems for listing generic medicines on their drug plan formularies.

In contrast, however, the federal government has not done its part to help achieve the first ministers' directive. In fact, new delays have been introduced in the three and a half years since this strategy was created, further slowing access to cost-saving generic medicines.

In October 2006 regulatory changes were made to the patented medicine notice of compliance regulations to limit the practice of evergreening of drug patents by brand-name companies. These tactics unfairly kept generic competition off the market and forced Canadians to pay monopoly prices much higher than they should have.

Unfortunately, the October 2006 changes also introduced a new data exclusivity regime, which gives brand-name drug companies an eight-year ban on generic competition. This is three years beyond our international trade obligations under NAFTA and TRIPS and puts our member companies at a disadvantage compared to their U.S. competitors, who are subject to just five years of data exclusivity. These extended monopolies also add more than $100 million to Canada's prescription drug bill each year.

There is yet another new development that is threatening timely access to generic medicines. The Government of Canada recently published proposed amendments to these same regulations that would overturn and override its Supreme Court of Canada ruling and reopen the evergreening loopholes that allow brand companies to abuse the patent system and unfairly delay generic competition.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Keon. There will be time for questions. My apologies, but you are over five minutes.

We'll now go to Mr. Russell Williams, the last of our first panel. Thank you.

[Russell Williams, President, Canada's Research-Based Pharmaceutical Companies (Rx, & D)]

Thank you very much.

I am proud to represent the companies who conduct research and make discoveries in order to save lives and improve our health system.

We are very proud that we are in the business of improving and saving lives. Our organization invests over a billion dollars in research and development and is the largest single source of health research in the business sector.

We are looking at an aging population when we look at our health care system, and we believe that optimal utilization of innovative medicines is part of the solution. New medicines and vaccines help reduce surgery, hospitalization, and wait times, and improve patient outcomes, which I think is our goal. Various diseases, such as leukemia, 30 years ago were almost fatal. Now 80% of children stricken by this form of cancer are alive five years later. Too many Canadians will die of cancer this year. I find that totally unacceptable when we have in our research 750 new medicines that we are studying to treat, cure, and prevent cancer. Chronic diseases like diabetes and infectious diseases require research to make discoveries.

We are looking at 338 medicines and vaccines in development. We've invested in this country in terms of research and vaccine both in Toronto and Quebec. Innovative medicines are 10% of the health care cost.

We represent only 10%, but when one dollar is invested in innovative medicines, the resulting saving is seven dollars.

One dollar invested means seven saved.

If you look at the Pitney Bowes study, they experimented and actually decided--against normal thinking about restricting and cost containment strategies--not to limit choice but to encourage more choice. Pharmacy costs went down 7%. The emergency department went down 26%, and overall diabetes decreased by 6%. That's phenomenal.

We have contributed to trying to share information through our program, “Knowledge is the best medicine”, in which 3.5 million Canadians have actually shared. Canadians must have access to the power and benefits of innovation in a timely way.

The issue of wait times is one that I believe very much we have to deal with. Despite Health Canada's efforts, their approval times are still long. Provincial governments range between 9% and 37%, in P.E.I. and Quebec, in terms of listing products. Innovative medicines, we very much believe, save money, reduce wait times, lower overall costs, and improve outcomes without compromising safety. We need the right medicine at the right time for the right patient.

My recommendation would be that we include access to innovative medicines as one of the targets for the 10-year plan, so it affects the other wait times.

But I must comment on the last presenter's comments. The new regulations do not in any way, shape, or form add any delay. The companies that the last presentation represented are, I believe, twisting the truth. There are regulations that protect intellectual property. They do not result in any increase of patents. They do allow for better research. It is fear mongering, and it does not deal with the essence of what we are trying to develop here--to have a research-based community that is strong and vibrant. He also neglected to mention that generics were forced by law to reduce their prices. They were considered the most overpriced, most expensive in the world. This is an area that we must deal with.

When you talk about generosity in this country, there is in fact a pricing regime in which governments are paying too much for generics, and yet the PMPRB shows in our pricing that it's 8% below international means.

We must find a solution together. We must tell the truth when we are discussing the matter.

There is no change in these amendments that would adversely affect any Supreme Court decision. In fact, what these amendments are trying to do is clarify the intent of Parliament back in 2006 to make sure on one hand that we have innovative medicines and on the other that we have protected an IP regime that is world class.

Furthermore, again, data protection, which the member just mentioned, is compared to that in Europe, which has 11 years of data protection. Canada rightfully moved for eight years, and they should be congratulated. Canada is currently moving on trying to correct a loophole that the generics are trying to profit on, which is not in the will of Parliament, and they are trying in fact to stop this loophole, this windfall that they have now found, and improve and protect what was decided upon in 2006. This should be encouraged and it should be protected.

Merci beaucoup.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mr. Williams.

We'll now go to our questions. Usually we have a seven-minute round, but we're going to have a five-minute round to allow more questions, because of the two panels.

We'll begin with Mr. Thibault.

[Robert Thibault, Liberal, West Nova, NS]

My point is very quick, so I'll ask for a short answer, if possible.

Madam Fralick, when I look at the scorecard from the Wait Time Alliance, the scores aren't great. They don't show a marked improvement over the previous year, but there are areas of improvement.

Are you an optimist or a pessimist, or a guarded optimist, when looking at the achievements of the 10-year plan with respect to wait times?

[Pamela Fralick]

I am an optimist by nature, and in this specific case, very much an optimist. And I thank you for the opportunity to remind the committee, and the others here, of the tremendous successes we have had.

My concern lies in any sense of complacency, that we have done enough. To me, this speaks to the most basic values of Canadians.

[Robert Thibault, Liberal, West Nova, NS]

Thank you.

I will get back to that. We only have five minutes.

Dr. Urbain, when you were discussing wait times in your presentation, you mentioned that other surgical procedures or treatments run the risk of being adversely affected. Can we see that that trend yet?

[Dr. Jean-Luc Urbain]

It can be seen directly and indirectly. The associations I mentioned have said that they want to be part of the Wait Time Alliance because of the implications for their specialties. If you go to see a doctor, you do so as a person and not just as a heart, a brain, a liver or a spleen. I feel that we must tackle health care as a whole.

[Robert Thibault, Liberal, West Nova, NS]

Thank you.

Perhaps I'll ask this of Dr. Bellan. You mentioned a lot of other areas, as have other people, in which we should be working more or making a greater effort. Do you think we need to add more money to that $42 billion in the 10-year program, or can adjustments be made within that $42 billion so that we reach that national objective?

[Dr. Lorne Bellan]

It's hard for me to answer that, because I don't know specifically how much each province has used of the money allocated to it. If they still have leftover capital, they may be able to allocate it to new areas.

I think even if new money were required, the experience that has been gained from the money that's been administered, or given out, so far is probably going to lead to less relative costs for any incremental increase in the future, compared with the first steps.

[Robert Thibault, Liberal, West Nova, NS]

Mr. Bartkowiak, you spoke to that subject. It sounded like you were asking for more money.

[Jean Bartkowiak]

Yes, absolutely. Here is the problem that we face at the moment. Although we have the resources to provide the services, we are unfortunately facing a significant shortage of health professionals. We are trying to recruit them, but we do not have the nurses, the doctors and the other professionals needed to provide the services, not just right in the hospital, but also during recovery and at home. It is a serious problem.

Some teaching institutions are now increasing the number of professionals they are training, but it is not enough. I am sure that the other group will bring it up today. We have a significant human resources problem in the health care field. That is why we are proposing strategic investment designed to train health care professionals in Canada.

[Robert Thibault, Liberal, West Nova, NS]

Thank you. I have to stop you because I have another question to ask the other witness about drugs and medications, before we move to the next panel.

Do I have 10 minutes left?

[The Chair, Conservative, Joy Smith]

You only have about a minute.