Health Committee on June 1st, 2016

[Dr. Cindy Forbes]

Thank you for that question. It's certainly an issue that is talked about in many different forums and formats in the medical profession.

I can think of a reference to some of the work we've done around senior care, and in our document on a senior strategy, we do talk about de-prescribing and some of the issues around polypharmacy. It is something that the profession is aware of and there's certainly a movement.

You may be familiar with the Choosing Wisely type of program whereby we're looking not only at the issue of prescriptions but also at how to ensure that the use of health care resources, tests, and procedures is necessary and in the patient's best interest. There is a lot of focus within the medical profession on professional education around prescribing.

I do agree that being overly controlling, from a federal government point of view, could be a problem in practice, that there does need to be some flexibility for physicians to use clinical judgment. However, at the same time, some of the formularies do look at the cost-benefit ratios and can contribute to lowering some of the costs when it comes to looking at which of the drugs gives the same value at the lowest cost.

That's often a helpful thing. I find myself being educated on a daily basis with regard to our provincial pharmacare program when a pharmacist calls and says that one drug isn't covered and that another one is much less expensive. Those things are happening on the ground every day.

One of the things that we also mentioned, though, was the concept of e-prescribing and support for electronic prescribing as well. That is something that the federal government could assist with in terms of national support. This would not only allow a national database but also allow physicians to communicate electronically with the pharmacies and to have that information on which prescriptions patients are taking.

Sometimes, as a family physician, I don't actually know all the prescriptions my patients are taking because they may come from different sources, such as the emergency room or a walk-in clinic, so I think a key component to improving pharmaceutical prescribing in Canada is to have a means of prescribing electronically so we can share data from across the country.

I hope that answers your question.

[Colin Carrie, Conservative, Oshawa, ON]

That's good.

Mr. Adams, you work with research policy and ethics. In your opinion, how big a problem is over-prescribing or prescription drug abuse, and how do you come up with a good balance between allowing a good doctor-patient relationship and also allowing government regulation and control? How do you balance that?

[Owen Adams, Chief Policy Advisor, Canadian Medical Association]

I'll have to defer to Dr. Forbes on that, sir. I'm not a clinician.

[Colin Carrie, Conservative, Oshawa, ON]

Okay.

I'm curious with regard to developing policy, because this is probably one of the questions we're going to have to answer.

What's your opinion on that, Dr. Forbes?

[Dr. Cindy Forbes]

Could you just restate that for me? I just want to be clear that I'm answering the right question.

[Colin Carrie, Conservative, Oshawa, ON]

How do you balance? How big a problem is over-prescribing or prescription drug abuse? Then how do you balance government regulation and control against the necessity of a good doctor-patient relationship?

For us looking at this issue, we might have to answer a question on how to come up with a good balance on that.

What would be your opinion about that?

[Dr. Cindy Forbes]

I think there are a couple of issues mixed in there.

With regard to prescription drug abuse, we're often referring to the opioid narcotic issue. That was a focus of our annual meeting last year in Halifax at which physicians came together to explore that issue from all sides, looking at it from the patient's point of view, from the physician's point of view, and from the addiction specialists' point of view. We recognize that it is an issue and that physicians have a role to play in trying to solve that problem.

We're looking at education for physicians; understanding other ways to manage chronic pain, which is often what leads to the initial prescriptions for opioids; and how to reduce the use of opioid prescriptions through other forms of treatment. That's one way of looking at this.

I think you're asking a really good question about balancing that, and I think it's going to require pharmacists, physicians, and patients getting together to have that discussion, but I do believe we can do that without it being too prescriptive from the point of view of government.

[The Chair, Liberal, Bill Casey]

Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair.

Thank you to all the witnesses for being here today.

Ms. Mistry, I'll start with you first. According to the Aon Hewitt 2013 Health Care Survey, the number of employers in Canada offering retirement health benefits to employees has fallen from 62% in 2002 to 49% in 2011. Another study from 2011 shows that nearly 80% of Canadian employers do not offer retiree benefits to non-union employees.

Does your organization agree with the general findings of these surveys; i.e., is it the trend that Canadian seniors are increasingly less likely to be offered retirement health benefits, including prescription coverage?

[Natasha Mistry]

Yes, and our current members will stand behind that trend.

We are seeing a decline in private coverage for seniors by their employers. The special thing about CARP members is that they're not only a group with self-interest; their concerns don't stop at senior citizens. They worry about their children's and their grandchildren's futures.

This is a disturbing trend, yes.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Dr. Forbes, it's good to see you again.

I'm going to juxtapose two things for you. In a 2010 policy paper entitled “Funding the Continuum of Care”, the Canadian Medical Association recommended that governments establish a program of comprehensive prescription drug coverage to be administered and reimbursed through provincial and territorial drug coverage plans and private prescription drug plans.

From my research, in August of 2015—maybe it was in Halifax, but I'm not sure—your members adopted a resolution in support of “the development of an equitable and comprehensive national Pharmacare program” at your annual meeting.

I'm trying to make those two jibe. Is it the current policy of the CMA to go for universal national coverage for prescriptions?

[Dr. Cindy Forbes]

The current policy is that we want all Canadians to be able to access necessary prescription medications. You're asking about what we see as the actual funding model for that. We have recommended that there be a federal sharing of that cost and we've actually costed it out through a study with the Conference Board of Canada, looking at it from the point of view of no individual having to pay more than $1,500 a year or 3% of their annual earnings. That is one example we have proposed of what we're talking about as a shared model.

The remainder of the funding could come from private plans or from provincial plans. It's really just a demonstration of one model that could work and could be a step towards a universal federal plan. This would be something that could still happen in the future. We have suggested this model of a shared plan between the federal government and private or provincial plans because it is completely scalable. The question of how much this is going to cost, I know, is huge. It would be possible to set that limit at a lower amount or at a higher amount, whether it be $1,500 or $2,000 or $5,000. That is something the government could decide, along with the percentage—whether it's 3% of annual earnings or not. We really felt that it might be a way of initiating this type of federal involvement in payment with some safety parameters around it, such that you would have the ability to scale it up or down.

[Don Davies, NDP, Vancouver Kingsway, BC]

Would the—

[Dr. Cindy Forbes]

Excuse me, but I'm just going to ask whether Owen...because this is something he can—

[Owen Adams]

No, that's fine.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'm just trying to determine whether the CMA would be opposed to a universal public pharmacare plan.

[Dr. Cindy Forbes]

No, we would not be opposed to that, if that was your question. That was a long answer, then.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thanks.

My colleague asked you about prescribing practices, and you had some interesting testimony, I thought. In “Pharmacare 2020: the Future of Drug Coverage in Canada”, Professor Steve Morgan and colleagues argued that

A single, universal formulary would also better guide prescribing than professional education alone and would likely improve the quality and safety of care received by patients.

You talked about the assistance that formularies give to physicians practising. Can you describe what impact formulary listing decisions have on prescribing practices? Is Dr. Morgan onto something there?

[Dr. Cindy Forbes]

I think certainly it can be very beneficial. I'm familiar with the situation in Nova Scotia, where I work. The formulary is determined by a committee that looks at evidence. They look at cost and they look at value. The fact that the formulary has been developed with these in mind gives us confidence that those things have been considered and provides a template for physicians to understand which prescriptions provide the best value for their patients.

There are times when we may wish to prescribe medications that aren't on the formulary, that aren't covered. Sometimes the reasons are very individual for a patient. Cost is always something we bear in mind, but it's one factor when deciding what medication to prescribe. Sometimes it has to do with compliance. Sometimes it has to do with the ease of use of a device or something like that, that we may choose a medication that isn't on the formulary. Then it becomes a discussion with patients as to whether they can afford it or not; it complicates things.

[Don Davies, NDP, Vancouver Kingsway, BC]

How am I for time, Mr. Chair?

[The Chair, Liberal, Bill Casey]

You have 17 seconds.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'll be quick, then.

Mr. Harrington, do you know whether in any other country with universal public pharmacare there has been an increase in patient use of prescription medicines at the expense of over-the-counter medications? I know that's one of your concerns. Can you point us to a jurisdiction in which that has happened?

[Gerry Harrington]

No, I can't, because we haven't seen that transition any time recently. The main point I would make is that the fact that we lag behind all those jurisdictions in terms of the switch process may have something to do with the fact that we don't have national pharmacare. In other words, the consequences don't accrue to government, because there isn't a national pharmacare program that is paying for all those extra prescriptions.

Again, our concern.... It's not so much that we're concerned about it as that we think there's an opportunity to make pharmacare more affordable.

[The Chair, Liberal, Bill Casey]

Thank you.

Dr. Eyolfson, go ahead, please.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Mr. Chair.

Thanks, everyone, for coming.

Dr. Forbes, as Don said, it's good to see you again.