Health Committee on Sept. 22nd, 2016

[Dr. Jan Hux]

I'm not able to put a number to that, but certainly we know that the advances we've seen—66% reduction in heart attacks, 50% reduction in stroke and amputation—are due to the application of evidence-based therapies. We also know that people with diabetes won't take those medications if they can't afford them.

As I mentioned, many of the things we treat in diabetes are asymptomatic risk factors, like high cholesterol. A person in this condition feels no different if they skip their medication. If they're forced to choose between feeding their family and buying their statins, they will feed their family. The long-term consequences are the personal cost of amputation, blindness, heart attack, and the system cost of caring for those complications.

[Don Davies, NDP, Vancouver Kingsway, BC]

So it would be fair to say, without having numbers on it, just intuitively, that if we could expand coverage to make sure that all of those patients had access to the medication they needed, then logically, the number of complications these people experienced would be reduced.

[Dr. Jan Hux]

It would reduce the number of complications, yes.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Ms. Harris, in the CFMS briefing notes submitted to this committee, you described the contradiction between learning which medications have the best evidence for treatment and having to make prescribing decisions based on the patient's ability to pay. In your view, how frequently are doctors compelled to choose a suboptimal treatment because of their patient's inadequate prescription drug coverage?

[Jessica Harris]

I don't have a number on how often that happens, but it's very frequent. In Saskatchewan, in my personal experience, there's a drug coverage booklet, let's say, that gives the cost of each medication. You're often going back and looking to see which medication to choose. While they're all approved by Health Canada and all are evidence-based, not every one is the gold standard treatment for that medical condition. There's often a time when you're having to find a cheaper option.

A couple of weeks ago, I had a patient who had a gout attack. He was in quite a lot of pain, but he didn't have any coverage. He and his wife were both working, but his wife's drug plan was $300 a month and they couldn't afford it. When he had this gout attack and we prescribed the medication he needed, he was only able to take an ibuprofen that he had at home. He just didn't have any extra money between paycheques to go and buy the medication, even though it was $20 or $25 for the prescription.

You're working with patients on a daily basis to see what they can afford. I don't have a number for you, but it's very often.

[Don Davies, NDP, Vancouver Kingsway, BC]

It does happen. It's a real phenomenon.

[Jessica Harris]

Absolutely. It's a real phenomenon.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Mr. Keon, you've noted that, based on IMS Brogan data, only 59% of prescriptions dispensed and reimbursed by private drug coverage plans are generic drugs, compared with 74% in public drug plans. You've testified today, I think very logically, that it's desirable to increase the use of generic drugs. I think that would have good cost implications for our system.

What, in your view, accounts for the difference between public and private plans in the way they reimburse generic drugs?

[Jim Keon]

You're right that the utilization of generics in the private plans is lower. As you said, I think the benefit of generics is what we often refer to as headroom. If you save on the cost of older medications by using generics, you can then better afford the cost of some of the new medications. That's clearly what a lot of the programs do.

In Canada, we have a universal heath care system. Most employees are covered. If they're sick and they go to see a doctor, or if they have to go to the hospital, those costs are covered. If we compare that to the United States, those costs aren't covered. Often, the employee drug plans are part of a larger health care plan in the U.S. and much more expensive. I think, frankly, what we've seen is a more aggressive health management operation in the United States in the private plans. In Canada, some of the plans are not generic-only plans. In the public plan in Ontario, if a doctor writes “Lipitor”, and Lipitor is a genericized product, in all likelihood, the patient will get the generic atorvastatin at 18% of the cost, so they can fill five or six prescriptions. In many private plans, if Lipitor is prescribed, they pay for Lipitor, and simply don't require the generic. I think some of the private plans need to become more rigorous in enforcing generic-only plans.

[Don Davies, NDP, Vancouver Kingsway, BC]

Go ahead Mr. Casey.

[The Chair, Liberal, Bill Casey]

Your time is really tight.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay, I have a quick question.

Other countries in the world have universal pharmacare plans. Do you know how any of those countries that have universal prescription drug coverage deal with biologics and other sorts of innovative or expensive treatments?

[Andrew Casey]

You're entirely correct that other countries do have them. We've seen success in some, but some of them reduce their costs by just eliminating some of those therapies. They just say they're not going to pay for those therapies and take them right off, and the patients never get access to them. That's when I raise the issue that, however you define it or design it, the important part is how we design something that makes sure the patients are getting the treatments they need, but they're not limited to access.

You can limit access and save yourself a lot of money, just like I could say to you that I could save you a lot of money by telling you not to have any food in your fridge for a year. You'll save a lot of money, but there'll be consequences of not being able to eat for a year. It's the same thing when it comes to health care. If you are not getting access to certain therapies, there will be consequences to that, but you will save money though.

[The Chair, Liberal, Bill Casey]

Ms. Sidhu.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you all for coming here, and sharing this valuable information.

As a diabetes educator, I know how untreated diabetes leads to other health problems, and it can cause a burden on the health care system.

My question is for Ms. Hux.

Can you talk more about costs associated with managing type 1 and type 2 diabetes? I heard a lot about the challenges of insulin and insulin pumps. In your view, how should it be designed to meet the needs of the general population?

[Dr. Jan Hux]

You're correct that the cost of managing type 1 diabetes is often very burdensome. Type 1 accounts for less than 10% of cases in Canada, and almost always onsets at a young age, and families are frequently burdened by these costs.

Not only is there that complication, but in a situation where an insulin pump is not publicly reimbursed, families are often forced to choose between an optimal therapy and a suboptimal therapy of frequent daily injections. Thanks in part to advocacy on our part, and insight on the part of government now, we do have pump programs in all provinces, but they have age restrictions in some provinces.

We see young people who have an opportunity to go for a great job internship in another province, but if they leave Ontario, they lose coverage for their pump and the crippling cost that would be involved may make it prohibitive. They're being asked to forgo a treatment that will give them excellent blood glucose coverage, and face the attendant threat of future loss of vision, kidney function, and amputation. It seems to us to be unfair to have that kind of patchwork system. The out-of-pocket costs can be very burdensome, especially for a new grad who's working in an internship or a poorly paid position. It can be thousands of dollars a year. Those costs in some cases can be shared by families, but when those individuals pass the limit for coverage on their parents' plan, that has to be borne differently, and it often leads to suboptimal choices.

I talked earlier about the fact that in type 2 diabetes, and particularly the management of risk factors for diabetes, patients are asymptomatic. In type 1 diabetes, insulin is a life-saving therapy. Skipping the medication will rapidly lead to potentially fatal consequences, and certainly a trip to the emergency department.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

I want to echo Ms. Harris. I heard, especially in the diabetes population, that generic drugs are not working the same as brand-name drugs. I want to ask Ms. Harris about this, and after that, Ms. Hux.

[Jessica Harris]

Are you asking about my experience with generics?

[Sonia Sidhu, Liberal, Brampton South, ON]

Are generics working less well with the diabetes population?

[Jessica Harris]

As a medical student still, I'm not prescribing medications yet. We work with physicians and are involved in that management process. But as Mr. Keon mentioned, patients are using generics every day, Lipitor, atorvastatin. As evidence shows, generic medications are equivalent to brands. I haven't had the experience of a patient coming in and saying, “This generic medication isn't working for me”.

That's my experience. That hasn't happened.

[Sonia Sidhu, Liberal, Brampton South, ON]

Dr. Hux, just on the diabetes population and epilepsy patients.

[Dr. Jan Hux]

I would agree with Mr. Keon that, in order to be licensed, the drugs have to be proven to be equivalent. Why a patient's experience might differ, I cannot comment on an individual case.

For drugs to be licensed, we do randomized control trials in which hundreds of patients are randomly assigned to a treatment so we can know the changes that they experience are, in the end, due to the drug. If you only have one individual, you don't know what the trajectory of their illness would have been. Changes in their symptoms and experience may have occurred independent of the change of a drug. We rely on the research evidence that suggests these generic medications are equivalent. I'm certainly not aware of people having an inferior experience that can be directly attributed to the use of generic drugs.

[Sonia Sidhu, Liberal, Brampton South, ON]

I know there are other jurisdictions where insulin is declared a life-saving drug and anyone can access it. If a pharmacare program across Canada would do that, can you point to some other jurisdictions that have good insulin access?

[Dr. Jan Hux]

I am familiar with the notion of listing insulin as a life-saving drug and making it free, but I can't speak to the experience in specific jurisdictions that have done that.

Again, insulin is needed every day for someone with type 1 diabetes to avoid a fatal complication called diabetic ketoacidosis, as you know. Adequate doses of insulin are needed consistently to prevent long-term complications. So it's both short-term gets some, at least, and long-term gets adequate doses in order to forestall those long-term complications. Making access free would surely improve the appropriate and adequate utilization of insulin.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

Can you describe the barriers people with diabetes face in accessing new drug treatment, cost being one, and are there any other barriers?