Health Committee on Nov. 29th, 2016

[A voice]

All around.

[Thomas Perry]

It's all around, yes, and having been an elected person and dealing with the first very strict conflict-of-interest law in British Columbia, which arose because of obvious corruption, I got used to it. When I came back to the university, I realized that my former colleagues aren't used to the idea of declaring conflicts.

Here's a recent issue of the Canadian Medical Association Journal. With the permission of the committee, I'd happily pass it around. It is partly in French. I brought this along to read on the airplane. The lead article is about the increasing crazy prevalence of diabetes among indigenous people, but I realized that on the cover it says “Happy Januversary”, which is an advertisement for brand name Januvia, or sitagliptin, a drug promoted for the treatment of diabetes.

I'm going to be not overly specific, but someone in a very prominent position of power over me in my university has been sending out surveys about the coverage of this drug in British Columbia on Merck stationery. Is that appropriate for a doctor who is in a prominent position in a university? His predecessor with the university years ago sent out similar surveys on Merck stationery for cholesterol-lowering drugs.

This is a description of.... It's not a bad person. This is an excellent physician, but I'm saying it's an example of how pervasive the failure to recognize conflict is, and the only solution around that is really absolute independence and government, whether it be federal, provincial or territorial, insisting that we can't allow that, any more than you would allow it in Parliament here.

[The Chair, Liberal, Bill Casey]

The time is up, Mr. Perry.

What's the name of that journal?

[Dr. Thomas Perry]

This is the Canadian Medical Association Journal for November 1, 2016. I'm happy to circulate it, but I'd love to have it back because I still haven't read the article.

[The Chair, Liberal, Bill Casey]

You can't do it officially.

[Dr. Thomas Perry]

Can I do it unofficially?

[The Chair, Liberal, Bill Casey]

That's up to you.

All right. Our second round is five minutes, and we're going to start with Mr. Webber.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, Mr. Chair.

I'm going to focus a number of my questions on Linda Silas, if you don't mind.

I understand that you represent 200,000 nurses. Five of them are in the family that I married into, and all I can say is that Christmas dinners aren't very happy, because four of them are Liberal and one is an NDP. Anyway, I do get my turkey, so I'm happy.

[A voice]

Cold turkey and hot—

[Len Webber, Conservative, Calgary Confederation, AB]

Cold turkey, yes.

First of all, I wanted to question you on this research material that is going to be published that you are going to give to us, laminated, in December. I can't wait until December, Ms. Silas. I need to know now if anywhere in this report there is any information on what a national pharmacare program would cost Canadians.

You talked about the wasted billions. What about how much it's going to cost for a national pharmacare program here in Canada? Has the nurses union done any research on that?

[Linda Silas]

The nurses union hasn't done any that. We have focused on the waste. However, the CMAJ did research just two years ago on the cost, and that's where it was between $1 billion and $4 billion. There will be more, and we'll focus there.

To keep your nurses happy, I'll make sure that you get a little bag of nurses union swag for Christmas.

[Len Webber, Conservative, Calgary Confederation, AB]

Fantastic. I don't have to go shopping now. Thank you.

Mr. Davies alluded to this. He asked you if there should be one national formulary in this country, and you agreed. In fact, I did some research. I have people to do my research for me, nurses in particular, and I understand that the BC Nurses' Union opted out of the B.C. public drug formulary after initially opting in.

Do you have any comment on how unions in general, and nurses unions specifically, would respond to a national pharmacare program, including accepting a national formulary that is more restrictive than their members' access under existing private insurance coverage?

[Linda Silas]

I started this job 13 years ago, and I have to say that negotiators then weren't as much in favour of a national formulary as they are today. With health and dental, if I look at all benefits, it's about 6% of payroll.

When we look at it as negotiators, that 6% that goes towards providing health and dental and other allied services could be put somewhere else. As I said in my introductory comments, we will negotiate whatever plans. My personal plan is very poor compared to others in what I can get for chiropractic and physio. It's limited to $500 a year, compared to others that have $2,000. You negotiate what you have.

BCNU's came about with negotiations, and they changed their negotiations. They decided that instead of a wage increase, they'd put their money toward a better plan. That's their decision, as well as other unions. If I look at Unifor, the largest private sector union in this country, they associate a national pharmacare savings of $1 to $2 per hour for workers, if we would have it, because medicare is about $5 to $6 per hour.

[Len Webber, Conservative, Calgary Confederation, AB]

Interesting.

I want to get into a bit of the jurisdictional issues across the province here. I understand that through the provincial nurses' unions, you have a lot of contact with the different provinces and territories and the governments there.

From your experience, where do you understand that provincial and territories governments are with regard to pharmacare?

[Linda Silas]

They need help. There's not one province, one territory, that doesn't need help in health care. They're as frustrated as we are when they see that they have to handle this on their own. When 40% of your provincial budget is health care and more than 30% of that health care budget goes towards prescription drugs, there's a problem.

Two years ago, we were paying more for prescription drugs than we were paying for doctors in this country. That's a problem. They need help, but they know they can't do it by themselves. They need federal leadership on this, and we're hoping that the to-do list of next steps will be done by this committee.

[The Chair, Liberal, Bill Casey]

Dr. Eyolfson, you have five minutes.

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

Thank you very much.

Thank you to everyone for coming.

Dr. Perry, I loved your description of yourself as a recovering politician. I've been referring to myself as a “recovering ER doc”. It was my experience, the things that we couldn't help in the department, that pretty much got me thinking of doing this.

Like Ms. Silas, I am acutely aware of the effects of what happens when people can't afford their medications. Most of my career was in an inner-city hospital, with lots of poverty. People were coming in life-threateningly ill because they couldn't afford their insulin. Some were ending up on dialysis because they chronically couldn't afford their insulin. It was these sorts of things.

I know there is a good opportunity for improved outcomes and increased health care savings. We talk a lot about savings to the health care system. Someone pointed out that we shouldn't be talking about how much we save but about how it's the right thing to do. I am the first to agree with that. However, we do have a publicly funded system that has only so much money. We have to make a case that it is cost-effective, and from the testimony I heard today, it sounds as though it is, in fact. It sounds like the savings to the health care system would to a great extent offset the cost of putting this in.

I just wanted to confirm what you said, Ms. Yale, about how patients should have the choice of what works best. On the choice of medication, would you agree that if it's a more expensive medication, there should be evidence that this more expensive drug is more effective, has fewer or comparable side effects, and there should be good scientific evidence to support that?

[Janet Yale]

Absolutely. A lot of the comments that have been made have been about how you create that evidence base through an independent assessment as to which ones are more effective than others. My point was simply that some of the new biologic therapies are not perfect substitutes for each other. They're biologic formulations. The issue is that what works for one person may not work for another. Even when someone gets on an effective treatment regime, it may stop working for them after a number of years, so the issue isn't that they're perfect substitutes, in which case you could do, as you say, that evidence-based assessment. The question then becomes how we ensure, through that evidence base, that we understand the indications for which some drugs are appropriate, rather than simply listing one drug in a class. That was my fundamental point. Absolutely, it should be evidence-based in all cases.

What's making it more complicated now is that as with chemical compounds, we came up with generic substitutes. With biologic formulations, what are called “biosimilars” are coming to market, which are generally speaking much less expensive than the originator drug. For Remicade, which has been in existence for some time, there's a new drug called Inflectra that has now come to market. The big questions are, one, does the less expensive drug become the drug of choice when prescribing for new patients, and two, do people who are on a good treatment regime with the originator drug get forced to switch?

In the absence of evidence, and to your point, our position is that people shouldn't be forced to switch, but we do need better evidence as to the relative efficacy of these alternative treatment regimes.

I hope that's helpful.

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

Thank you. Yes.

This is borderline off topic, Dr. Coyle, but I appreciated your comment about medical technology in general. In my obstetrical training I've known what most obstetricians would agree with me on today—namely, that routine ultrasounds in pregnancy have never been shown to make any difference in outcomes in pregnancy.

People think about that. I get raised eyebrows. I sometimes get people angry when I say that, but in fact they've never been shown to improve outcomes in pregnancy. We have to make a case in terms of the evidence. Think of the potential money saved to the health care system if we stopped doing something that isn't helping. I think we need to consider that with all our drugs, with all our more expensive drugs.

Dr. Perry and Dr. Coyle, I don't know if you're aware, but there is some evidence coming up on the medication class that seems to be the number one money-maker for industry right now, and that is statins. There appears to be some evidence that this entire class of drugs may not in fact improve outcomes.

[The Chair, Liberal, Bill Casey]

He just needs a short answer.

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

Yes, I just need a short answer.

Do you think we should start reviewing the evidence on these medications that are taking up a huge part of our spending?

[Dr. Thomas Perry]

Well, it's a good example of an area where conflict of interest gets in the way of a real understanding and science. Our academic group still feels that statins in secondary prevention for people who already have had heart disease or stroke probably have—

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

Absolutely, yes. I was talking about primary prevention. That was my mistake.

[Dr. Thomas Perry]

In primary prevention, for someone like me, for example, who has relatively high cholesterol but is otherwise fit, we think that the overall harms may well exceed the benefits.

There's no question. I'm sure you've seen this as well, as has Dr. Carrie, probably. Anyone who has been in clinical practice with their eyes open, including the nurses here, will know that statins frequently cause very severe muscle damage, weakness, and pain.

The official experts, even in Britain at Oxford University, still insist this is exceptionally rare. They're completely out to lunch on that. The reason they are out to lunch turns out to be the way they define muscle disease, or myopathy, with a crazy elevation of the CK. If you or I have statin myopathy but don't have a CK at least 10 times the upper limit of normal, according to them we don't have anything wrong with our muscles, even if I can't walk back to my hotel today.

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

Thank you very much.