Health Committee on Sept. 22nd, 2016

[The Chair, Liberal, Bill Casey]

Time's up.

Mr. Kang.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

I want to thank the panel for coming and appearing before the committee today.

My first question is for Mr. Jim Keon.

According to the Patented Medicine Prices Review Board, PMPRB, generic drug prices in Canada fell by 45% between 2010 and 2014. They continue to remain 19% higher than the international average. Why does Canada continue to have higher generic drug prices than other jurisdictions?

[Jim Keon]

Yes, the PMPRB report you refer to was from 2014. Since then, generic prices have continued to decline. You mentioned a 45% decline. The PMPRB reported that generic prices in Canada had declined more than in any other country.

I think if you take the current data, and include the fair comparison of the lower Canadian dollar than we had in 2014 with the further price reductions, then our prices now are competitive with prices across OECD countries. As I said, we are in ongoing dialogue with the provinces, and now the federal government plans as well, about what the fair price of medicines should be. We believe the prices are now equitable, and we will continue to sit down and negotiate what those prices should be in the future.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

My second question is about the effectiveness of generic drugs compared to brand-name drugs. Is it psychological? You said 100%, that generic drugs have 100% of the effect as the brand-name ones. I have come across...even my wife, she would rather go for the brand name, and me too. I have gone for the brand name. Patients have lots of concerns about using generic drugs compared to brand-name ones.

What role should there be for the generic manufacturers? Is it education? What could be done to...?

[Jim Keon]

There are, in all plans, even on the plans that specify they will only.... They're usually not called generic plans; they're called low-cost alternative plans. They will only pay for the low-cost alternative medicine. All of those plans have the ability for prescribers—doctors—to fill out and indicate adverse drug reactions. If their patient, for whatever reason, is not reacting well, they can indicate that. Most plans, if it's a recognized acceptable reason, will pay for a different medicine. That takes care of that.

In terms of the placebo effect, yes, that does occur sometimes. In the marketplace there are what are called “ultra-generics”, identical to the brand-name product, made from the same plant and sold as a generic, and the patient comes in and says it doesn't work as well. It's the same product; it's just stamped differently. If people believe it may not work as well, sometimes there's a concern.

As I said, I think that in terms of education we, the federal government, and Health Canada have a tremendous amount of material in terms of the way generics are approved. Again, 7 out of 10 prescriptions are filled with generics. Almost two million prescriptions a day are filled with generics in Canada. They do work well. Again, if there's a problem, then there is a system in place to allow a patient to switch to a different product.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Has there been any study done on patients put on the same drug without their knowing who is taking the brand name and who is taking the generic?

[Jim Keon]

Yes, it happens all the time.

The way a generic is approved is called a double-blind study. Half of volunteers are given a brand medication and half of them are given the generic. Then the doctors and nurses study the reaction in the body to that. Then later, either that weekend or in the future, the same patients are given alternate drugs. They then, again, determine the reaction of the product. If they're determined to be equivalent, then they can be approved.

As I said, they are also subject to the same good clinical and manufacturing practices. These products are considered as safe and efficacious as their comparable originator products.

[The Chair, Liberal, Bill Casey]

Go ahead, Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

I want to thank all the witnesses for being here today. I want to throw out a few questions.

Mr. Keon, maybe you could start with the answers, because I do appreciate your institutional knowledge. I think you've been coming to this committee since I've been on it, on and off since 2004.

You made a comment that I think is really important. Why are we doing this, and how do we actually define the problem? We've heard from different people that some of the statistics we're relying on are from a Canadian standpoint and haven't even been really updated since the Romanow report.

A lot of assumptions are being made. I believe Mr. Davies repeated a couple of things we've heard over and over, that 20% of Canadians don't have adequate coverage. Yet we don't really know who defines adequate coverage. He mentioned seven million Canadians walking around without coverage; they can't afford the medicines they need. We do know there are a lot of Canadians out there who don't have coverage, but they don't seem to have a problem financially covering their medication, maybe because of different financial situations they find themselves in.

If you take a look at a long-term situation, and, as I said, some of these statistics have not been updated since the Romanow report, Canada has changed a lot. Employment benefit relationships have changed greatly. We have more people working part-time. We have pensions and pension benefits that have changed. We have more seniors, as a demographic moving into a situation where maybe they have coverage now because they're a little bit older.

I want your opinion and that of the rest of the panel. Do you think the federal government should update its statistics to ensure that we have an accurate picture of the current medical benefits situation in Canada?

Also, without recent statistical evidence, do you think our recommendations could be irrelevant, albeit well-intentioned? What are your thoughts on that?

[Jim Keon]

As an organization, as a sector, we actually support more harmonization across Canada. We think widely different programs for drug coverage are not good. If medications work well in one jurisdiction, they should be working just the same in others. We actually have recommended and supported moving toward more harmonized national formularies, what drugs are covered and what drugs aren't. As people have said, right now there's a real hodgepodge. We would support more harmonization there.

In terms of people not being covered, I mean there are, as you said, a variety of programs. There are private programs and public programs. If people are really desperate, there are often programs like the Trillium program in Ontario that can cover exceptionally high costs, etc.

Absolutely, I would agree with you that a really clear database and picture of who's covered and not and in what circumstances is necessary, but in general, we would support movement toward more comprehensive and harmonized coverage across Canada.

[Colin Carrie, Conservative, Oshawa, ON]

Does anybody else what to comment on statistical, like Mr. Casey and then Madam Hux?

[Andrew Casey]

You raised for our industry the most important question. Before we talk about what pharmacare is, we are designing something for a problem when we don't really know exactly what the problem is. Is it a coverage issue? Is it an access issue? Is it a combination of both? If somebody presents with the symptoms of a heart attack, you don't immediately cut them open and take a look at the heart. You try to figure out what really is going on in that person. We would do similarly. I think we should take a look and figure out what those numbers are.

The Romanow commission did a lot of great work, but that was almost 20 years ago. What do the statistics bear out? Where is the challenge? What is the opportunity here? Once we have a better handle as to what we are trying to address, then I think the solution will become a bit more evident.

[Colin Carrie, Conservative, Oshawa, ON]

Jan.

[Dr. Jan Hux]

Whether by research or by training, I'm never going to argue against the value of having better and more current information. However, I am confident that any study you would do would find that people living with diabetes face significant barriers to accessing their medication, just as Ms. Harris indicated. We did a study in 2015 asking people about their ability to access medication, and 23% of people living with diabetes said they couldn't take their medications as prescribed because they couldn't afford them. We know that diabetes is not an equal opportunity disease. It clusters in low-income communities, and so a disproportionate burden of this very expensive illness is borne by people who can't afford to manage it.

[Colin Carrie, Conservative, Oshawa, ON]

That's specifically for diabetes. I think what you said is absolutely true.

[The Chair, Liberal, Bill Casey]

Your time is up.

[Colin Carrie, Conservative, Oshawa, ON]

Darn. Okay.

[The Chair, Liberal, Bill Casey]

Dr. Eyolfson.

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

Thank you all for coming.

I have a very quick comment to Ms. Harris.

Thank you. I know how busy it is to be a medical student. I graduated in 1993, and for you to have the time to do this with your studies is a tremendous accomplishment.

Regarding the heartbreaking story that you told, I'll tell you that after 20 years of medical practice, you will see that on a weekly if not a daily basis depending on your practice, which is one of the reasons I am now in this new career.

In regard to diabetes, this is something I've been using in many of my examples, and again, from my practice. I practised emergency medicine in an inner-city hospital. There was a very poor population and a high number of aboriginal patients. We know the rate of diabetes in that population. I see the costs of non-compliance; they are acute. I know that people with severe DKA, diabetic ketoacidosis, will often end up in the intensive care unit, and we know how expensive that is. Then add in amputations, heart attacks, strokes, and dialysis.

I may be asking a question that has already come to you in a different way. Just in relation to this disease, if you look at what non-compliant patients, the ones who are non-compliant because they can't afford it, are costing the system in medical costs compared to what it would cost to make sure that everyone had their medication paid for by a universal system, would there be a balance? Would it still be costly to be supplying everyone with their insulin, or would that be more or less offset by these savings to the system?

[Dr. Jan Hux]

I don't have specific numbers to answer the question of whether paying for the drugs would be cheaper than paying for the complications, but we do have some really interesting evidence in regard to the benefit of universal access. Dr. Gillian Booth from St. Michael's Hospital in Toronto did a fascinating study where she looked at the benefit of turning 65 in Ontario. Generally, health outcomes are known to worsen after the age of 65, due to the impact of retirement and the change in lifestyle. However, what she looked at was the socio-economic gradient. For low-income people under the age of 65, many of whom can't afford their medication, there was a dramatically higher rate of complications, such as amputation, stroke, and heart attack. That gradient almost completely disappeared when people turned 65 and had access to universal coverage.

She has not completed it yet, but we have commissioned her to do an economic analysis to answer your question: would the cost savings from those adverse events outweigh the cost of paying for the medication? It is a great question.

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

Okay, thank you.

Mr. Keon, I appreciate what you are saying about whether we should be doing this because it is the right thing to do or because it would save money. I agree that we should be doing it because it is the right thing to do, to make sure that everyone can afford medication. As you say, if there is a case that we are not going to save a lot of money by the federal bulk buys versus the provincial bulk buys, the math may bear that out.

Do you think it is fair to say that we are looking at savings not because we are doing it to save money, but to show that the money we save in better outcomes might offset the costs of investing in that? Would it be a fair assumption that this would be one of the end points we should look for?

[Jim Keon]

As I said, we support the idea of all Canadians having access to the necessary medication. I think that is very important. As most people on the panel have said, it clearly does lead to savings elsewhere in the system. Again, our sector provides headroom for that so that new medications can be afforded.

I would make one comment on it, because there have been a few questions about quality and safety. The way drugs are approved in Canada is the same as the way they are approved in the United States by the Food and Drug Administration, and in Europe by the European Medicines Agency. Generic medicines are subject to the same standards. This is internationally accepted science.

After patents, our role is to provide protection for the new innovative medicines, which are often very expensive. Even the PMPRB has acknowledged that it hasn't always done a terrific job in controlling prices in Canada.

After the patents expire, you have good-quality medicines. The science is there. They should be used to help broaden access to medicines for all Canadians.

[The Chair, Liberal, Bill Casey]

Time is up.

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

I just want to reiterate that, from my medical experience and knowledge, I would not find a physician or a scientific publication that disagrees with you on that.

[The Chair, Liberal, Bill Casey]

Mr. Davies, you have three minutes.