Health Committee on May 16th, 2016

[Dr. Philip Emberley]

That's a great question, and I have to say this is not a problem that belongs to doctors. It's not a problem that belongs to nurses or to pharmacists. I think what it speaks to is that we need to have a team-based approach. It's an approach that leverages the knowledge and skills each professional brings.

I've been a pharmacist for 28 years, and I think in the last 10 years, as a profession, we have become much closer to prescribers and working with prescribers in order to optimize care. When we mention taking people off medication, it's not about that. It's about finding the optimal mix of medications that people need.

I will mention that I see seniors come in, and some of them are on so many medications they lose track of what's what and what this medication is for and what that medication is for. It becomes sometimes a toxic mix. I think there's a valuable role for pharmacists there in pulling things apart, making a recommendation where it's appropriate, and prescribing or saying, “Look, we think there's a problem here that could be addressed.” This is how we can move forward to optimize the care of the patient.

[Colin Carrie, Conservative, Oshawa, ON]

When you mention care versus cost, I remember that a few years ago Deb Matthews was concerned with the federal government because she wanted to see more opioids, the tamper-resistant type, brought in instead of the generic and easily diverted type of opioids. I believe she quoted 85% of the population of one of our first nations communities were addicted to opioids.

The concern, I think, is that it's kind of an easy thing to do, write a prescription. In some situations, how could a pharmacist work into a system to make it more appropriate, as you mentioned, with the right medication available for Canadians? How could we look at your role and your scope of practice and the importance of pharmacare with this study?

You mentioned that in some provinces you're not fully covered for giving out advice. How could we look at that to improve the entire system and the team that's involved in the entire system?

[Perry Eisenschmid]

I can start, and then Phil can embellish.

One of the biggest impediments, and many people don't realize this, is that pharmacists' compensation for those kinds of expanded services is pooled, unfortunately, under the drug plan budgets of the provincial governments. With all of this focus on cost containment and more cost containment, the unintended consequence is that provincial coffers are less able to fund the important expanded services we're talking about here.

One of the things we would put on the table for consideration is if the federal government is getting more financially involved through a national pharmacare program or other means, we need to somehow start funding those services outside of the provincial drug plan budgets, which we know are continually constrained, to make sure the medications that are being prescribed are being managed effectively.

When there is over-prescription, pharmacists see this first-hand. They see the patients wandering in with the unintended consequences of inappropriate prescribing. They are there first-hand, and if they're empowered through regulation and compensated appropriately, they would be able to step in and make the appropriate intervention.

[Colin Carrie, Conservative, Oshawa, ON]

It seems that Canadian professionals are well versed in prescribing, but it's the unprescribing.... Is this a role that pharmacists could be partnering with medical doctors on? With the opioid crisis and the huge numbers rolling through Canadians' blood systems every single year, is there any reason why we're number one in the world for this type of product? I think 25% of users, when they start on these prescribed opioids, turn to addiction.

[The Vice-Chair, Conservative, Len Webber]

Mr. Carrie, you're almost out of time. You are out of time, so if you can answer that briefly.

[Perry Eisenschmid]

I think some of these partnerships do exist today. They can and should be expanded. Your point is physicians typically prescribe a medication, and it's the pharmacists who see the patient on a regular basis as they refill those prescriptions. They are in the best position to make an appropriate intervention, I would argue.

[Dr. Philip Emberley]

Yes, it's true, we do see patients getting into trouble, and you can't strictly just stop a medication. In a lot of cases you need a systematic way of helping them to reduce.

I think a big part of what pharmacists also do, because they see their patients so often, is get a sense of when patients are getting into trouble. There are visible cues with, for example, patients refilling their medications early. You get a sense that people may be getting into trouble. I think an important role pharmacists play is to let members of the team become aware of those situations so they can intervene and provide addiction management services.

[The Vice-Chair, Conservative, Len Webber]

Thank you.

Up next we have Mr. Davies, and then Mr. Ayoub.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair, and thank you to all the witnesses for being here and sharing your expertise with us.

I have seven minutes to parse and get the unified theory of pharmacare in Canada, so I'm going to ask you if you can be crisp in your answers so I can get to as many questions as possible.

Ms. Ashley, I'm going to start with you. Can you provide the committee with an example of an outcome of cost-related non-adherence to prescriptions that some of your member nurses have to deal with? In other words, give me an example of what happens when a patient doesn't have access to pharmacare and how that costs our system more.

[Lisa Ashley]

I can't give you a monetary cost, but I can certainly give you the life costs that make a difference. If a senior with multiple chronic conditions is unable to afford their medication, they are going to end up in an emergency department with a stroke. They may end up having falls because they haven't had the right medication to control that, so they will end up in the emergency department and then they will end up in a long-term care facility and not be able to be at home.

[Don Davies, NDP, Vancouver Kingsway, BC]

Do your members see that kind of example?

[Lisa Ashley]

Yes.

[Don Davies, NDP, Vancouver Kingsway, BC]

In your submission you recommend mandatory generic substitution, which you also mentioned in your remarks. Some witnesses have come before this committee and warned us that measures like that—and in fact a universal pharmacare system itself—would restrict choice for patients and potentially undermine access to quality therapies.

What is your response to those criticisms?

[Lisa Ashley]

Certainly there is the opportunity for the team approach, and the way something is created will actually make a difference. While we may have a difference of opinion about how to get to the bottom line in what we're talking about, I think the bottom line consistently is to ensure that patients have access to medications they can afford.

[Don Davies, NDP, Vancouver Kingsway, BC]

Ms. White, in a previous meeting we heard a witness state that unions and union members are opposed, or may be opposed, to a national public drug plan, instead preferring the coverage they have under private work-based plans. As an organization that works closely with unions and unionized workers, would you agree with that statement?

[Julie White]

I saw that comment. It made me smile, because in the Canadian Health Coalition, we have a huge amount of support from the union movement, and that includes all the big unions. I could list them off, but to save space, I won't.

It's not just that the unions themselves are in favour. We have many union members who come to our annual lobby of MPs to talk to MPs about the importance of a prescription drug plan. I'm not saying there are no union members out there who might have 100% coverage who wonder what might happen under a public plan. There may be.

What I tend to say to them is “It's fine for you to have coverage, but does your whole family have coverage? Do your grown children have coverage? Do your grandkids have coverage?” I think it's entirely wrong to suggest that unions are not interested in a national public plan. That is what they are struggling for.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Ms. White, some witnesses have also recommended that the committee look at the Quebec model, which has a public floor for those who have no coverage and then it retains a private system paid for by employers for coverage above that.

Does your organization have any position on the Quebec model, or would you instead prefer a single-payer first-dollar universal system?

[Julie White]

I would prefer the latter. My remarks tended to say that these are the kinds of problems you're going to have if you try to integrate some kind of work-based model like the one in Quebec with the public system, which just picks up the outliers who aren't covered with a workplace plan. You're going to have all those increased costs that workplace plans entail, and you're going to have a lack of general coverage for the population and a lack of capacity to negotiate the prices of drugs with pharmaceutical companies, so you're going to be looking at a much more expensive system with results that are not as good.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Ms. Ashley, does the Canadian Nurses Association have a position on the Quebec model, or do you instead prefer a single-payer first-dollar universal system?

[Lisa Ashley]

I would have to check on that.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Mr. Eisenschmid, I'm not sure I got this correct, but I think I did. You suggested that a universal pharmacare system would take time to implement, which is logical, but if I heard you correctly, you suggested that the process of implementing it would leave some patients without coverage.

I'm just wondering about the source of that statement. Do you have data on that? Is that inevitable? Could we not build a universal pharmacare system and make sure that Canadians are covered while that process is taking place, or do you think it is inevitable?

[Perry Eisenschmid]

You could. In terms of the development of the ultimate program, what we're commenting on is more the reality of how long it takes to get such a comprehensive fundamental change in our coverage. It's going to take some time, and in the meantime, shouldn't we look for ways to make sure the gap isn't maintained? It's more of a temporary situation.

[Don Davies, NDP, Vancouver Kingsway, BC]

I see. Okay.

Ms. Côté, I believe your organization does not have a particular system that you're advocating. Is that correct?

[Connie Côté]

That's correct.

[Don Davies, NDP, Vancouver Kingsway, BC]

Has your organization expressed any concerns with Canada moving to a single-payer, first-dollar system to ensure universal coverage for Canadians?