Health Committee on June 1st, 2016

[Dr. Cindy Forbes]

It's nice to see you.

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

We've been listening to various points of view on the development of pharmacare. We've heard that a couple of different stakeholders dispute some of the findings of the Canadian Medical Association studies, particularly the Morgan study's findings on monetary impact. What is your response to the Morgan study's criticisms of the costs?

[Dr. Cindy Forbes]

I am going to defer to Mr. Adams.

[Owen Adams]

Let me say first that Steve's study was published in the Canadian Medical Association Journal. There's a firewall between us and them, so you should note that. I've certainly reviewed Steve's study. Like the assumptions, the methodology is very clearly specified. To some degree, it's benchmarking what would happen if you could reduce costs to a certain level. It's not unlike the findings of Marc-André Gagnon's study out of Carleton, in 2010. We've referred to both of those in our brief. I think it was carefully done.

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

All right, thank you.

Would you be able to comment on the potential savings within households and to the private sector—such as insurance agencies—if there were a universal pharmacare system? Do we have any idea of the scale of potential savings?

[Owen Adams]

We know that average out-of-pocket household spending was $408 in 2014, according to Statistics Canada. I'm not familiar with good estimates in terms of what the overall administrative savings would be from that, whether from the provincial plans or private plans. I don't really know that

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

Sure. Okay.

I have an idea intuitively that this would be the case, but I don't have the data to actually say this.

Do we have an idea of the costs to the healthcare system of non-compliance due to decreased cost? I apologize to the committee, because they've heard me give this example many times.

If someone can't afford their insulin, what are the immediate costs for every occurrence of diabetic ketoacidosis, the cost of a heart attack, the cost of them going on dialysis? Do we have any idea of the savings, the potential downstream savings, to the health care system if everyone could afford their medications?

[Dr. Cindy Forbes]

I think the answer is that we don't have that information. I think that would be very useful information. I'm not sure whether it's even possible to gather all that information. I know from my own experience that patients don't often reveal that they're not taking their medications. They may not want me to know that they can't afford them. From that point of view, it's really difficult to know whether the outcome had to do with them not taking their medications or not. We have asked ourselves that same question, namely whether that evidence does exist, and we haven't seen it.

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

Thank you.

You talked about optimal prescribing as being a part of this. I couldn't agree more. We are privileged in the hospital environment, at least in Manitoba. We have a computer readout through an integrated system with the pharmacies. If someone comes to the emergency department, we print out a list of every medication they've been prescribed in the last six months, so we know what they're on.

Would a national pharmacare system help with the surveillance and guidance of physicians in their prescribing practices?

[Dr. Cindy Forbes]

I think it could. When we talk about getting the provinces and territories together with stakeholders, along with the federal government, to look at a pharmaceutical strategy, determining how it could best occur would be part of that. I believe that it definitely could help with that on many different levels. I mentioned e-prescribing, but there is also education around the choice of the medications that are on the formulary, allowing feedback on which drugs are covered as time goes on, and allowing some choice, which I've also heard from others.

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

All right. Thank you.

Mr. Harrington, we talked about the use of over-the-counter medications. Of course, they do much different things from a lot of the prescription medications. Antibiotics aren't over-the-counter. Cancer drugs aren't over-the-counter. Has there been any data showing any improvement in morbidity or mortality associated with the use of over-the-counter medications among consumer health products?

[Gerry Harrington]

That's a tough question to answer. I mean, generally speaking, where you have two products in the same therapeutic category, one on prescription and one available without a prescription, we know from the standards that Health Canada uses to approve these drugs that the risks are generally lower with the OTC version.

But to extrapolate from there to a better outcome, I don't think there's data out there that would necessarily support that. We do have data in terms of outcome satisfaction from the individuals who use these products. There have been studies done, in a number of Rx-to-OTC switches, saying that outcomes tended to be the same as when the product was available as a prescription drug. I couldn't speak to any sign of an improvement through a switch.

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

Okay. Thank you.

I'll go back to you, Dr. Forbes. We've heard about the current patchwork we have, a system with private coverage, public coverage, non-coverage, with a lot of physicians spending time doing workarounds. I think you and I are very familiar with what has to be done.

Are you getting a sense of how your members are dealing with that, or of how much time they are dealing with all these workarounds they have to perform? Do you have any idea of the amount of time and resources physicians are putting into these workarounds to make sure their patients can afford their medications, or to get them when they can't afford them?

[Dr. Cindy Forbes]

I'm not sure if we're talking about workarounds in the same sense. The workarounds I'm familiar with are usually me filling out special authorization forms or special requests for things that aren't covered, which is paperwork.

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

That counts.

[Dr. Cindy Forbes]

Yes, that counts. There's definitely an administrative burden, and a burden on physician time, in dealing with the exceptions, which sometimes seem to be the rule. I would hope that the vision of a national pharmacare program would not be based around increasing the administrative burden on physicians, because that would not be a success, to my mind. There's also the administrative burden, or the complications or barriers, let's say, for patients who often have to submit a lot of claim forms. Sometimes they're complicated, and it's often difficult for people to complete them on their own.

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

Thank you.

[The Chair, Liberal, Bill Casey]

That completes round one.

We'll now go to round two. These will be five-minute question periods.

Ms. Harder.

[Rachael Thomas, Conservative, Lethbridge, AB]

Thank you very much.

My first question I will direct to Gerry and Kristin.

I understand that your organization deals solely with the supply side of the industry. Is that correct? I'm hoping you can explain for us some of the existing hurdles that products face in order to get onto the public formularies that exist. What are some of those hurdles compared with the ones on private insurance formularies?

[Gerry Harrington]

I would have to say, right off the top, that since about the mid-1990s, virtually all major formularies, primarily in the public plans, have cleared out non-prescription medicines from the plans. This was a movement that took hold around 1990-91. I think at this stage there are very few formularies.... I think the NIHB is one of the few major drug plans that still reimburse non-prescription medicines.

[Rachael Thomas, Conservative, Lethbridge, AB]

Okay.

[Gerry Harrington]

That's a pretty big hurdle.

[Rachael Thomas, Conservative, Lethbridge, AB]

Would you then be advocating for non-prescription drugs to be considered under a public pharmacare program?

[Gerry Harrington]

Generally not. I think we may be evolving in a direction where that becomes more likely further down the road. We see a lot of jurisdictions in which the kinds of things that are switching to non-prescription status are things that you may want to include on a plan.

[Rachael Thomas, Conservative, Lethbridge, AB]

Right.