Health Committee on Dec. 1st, 2016

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Mr. Doiron, are veterans generally happy with the coverage they get? Again, in your experience, do you feel that Veterans Affairs Canada is providing a broad enough formulary to cover the needs of veterans, and providing that service to them in a reasonably efficient way?

[Michel Doiron]

I would echo my colleague's comment, and the answer is yes. I think our formulary is very wide. We have made some changes following the OAG.... We've brought in more professionals to manage our formulary. We've hired a pharmacist, and our committee is now chaired by a doctor, so we understand more about the complexity of the drugs than we did before, because it's not only now an administrative.... We've actually brought the health professionals to the table—the pharmacists, in particular—to provide us with in-depth knowledge of one drug versus another.

Yes, our formulary is quite wide. Our biggest challenge is often the provinces, because each province has a different formulary, or doctors may prescribe a different drug for different things. It's keeping up with their changes in prescriptions. I have exactly the same comments as Mr. Perron when it comes to that, but I think we do have a pretty large formulary.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'm done.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Mr. Oliver, you have seven minutes.

[John Oliver, Liberal, Oakville, ON]

Thank you very much. Thanks for the various testimony that we've heard.

To begin, I heard both from Veterans Affairs and Health Canada that you work with CADTH. You take the Canadian Agency for Drugs and Technologies in Health and their common drug review, but then you put it through your own sort of drug benefit review lens, which would change it.

I'm thinking about a national program. We'd heard from CADTH that they felt they were in a position to help to define a formulary. You feel that you need to redefine what they're doing. Could you help me understand what kind of criteria you would apply that CADTH doesn't apply?

[Sony Perron]

I think we are not redefining. I would qualify that we refine what is being given to us by CADTH. For example, a large portion of the population we serve lives in remote, rural, and isolated locations. Sometimes the criteria that have been designed by CADTH will apply to Canada, in general, and mostly urban or suburban areas.

When it comes to populations that live at a distance, we sometimes have to change and decide to do coverage differently, because the likelihood that this patient can come back the week after to see the physician to try a second therapy might not work. Sometimes we have to change the rules a bit to accommodate the reality of the population we try to serve and the geographic distribution of the population.

Maybe Scott can give a partial example because I think this could be better illustrated.

[Scott Doidge]

I think the route of the administration of a drug sometimes becomes important, so to Sony's example, if a drug is administered intravenously and there's an alternative product that can be self-injected, that's something that we might take into consideration in looking at a category.

[John Oliver, Liberal, Oakville, ON]

Going from an open benefit to a limited-use benefit, do you have other criteria that you're applying in addition to only the clinical application of the pharmaceutical? In your DBL you said there was an open benefit, a limited-use benefit, and then there's an exception, so for the limited-use benefit, is someone applying some kind of criteria in addition to the clinical performance of the drug?

[Scott Doidge]

The limited use and exception criteria for coverage are actually built around what CADTH says a drug's place in therapy is. We don't add net new criteria to those kinds of products. If CADTH says pay—

[John Oliver, Liberal, Oakville, ON]

So CADTH does that. Other than the geographical issues, the CADTH recommendations on formulary are what you accept.

[Scott Doidge]

Except for a very limited handful of circumstances.

[John Oliver, Liberal, Oakville, ON]

Is that true for Veterans Affairs as well?

[Michel Doiron]

Yes, it is. It's not so much the remote locations of our veterans, it's more that the injuries suffered by the veterans sometimes need us to veer a bit. As an example, we know that veterans have a lot of issues with mental health. PTSD is what everybody says, but we should actually call it mental health because it's a full spectrum. Sometimes we will make a drug more available, or treatment benefits more available to help, because we have a full suite of services in mental health for our veterans that not many Canadians may have, and that includes certain medications.

Typically, the recommendations we get from the committee is what we follow, as my colleague—

[John Oliver, Liberal, Oakville, ON]

Just on that, recommendation 4.12 from the Auditor General said that other than following CADTH there were 17 committee decisions that he couldn't find adequate evidence for, for clinical review, so you must be applying other criteria besides CADTH.

[Michel Doiron]

Yes, we look at the need of the veteran outside of what CADTH has provided us. In those 17 cases, it's because we did not track the decision-making, but the committee had met and had discussed. That's why, as I mentioned earlier, we brought the health professionals to the table, the pharmacists and the doctors that we have internally, to help us refine those requests, or refine those...I won't say exceptions, but those categories.

[John Oliver, Liberal, Oakville, ON]

It sounds a bit like your drug benefit process is related more to the adjudication process than it is to...because you're not really providing a universal coverage. You're providing for veterans from certain classes, categories, or service-related injuries.

[Michel Doiron]

Yes, but I would not say it's based on adjudications only. It is based on the needs of the veterans and the injuries they have suffered. That is determined by adjudications often, but not always. In the case of PTSD, we provide a lot of services to our operational stress injury clinics, where we have psychiatrists and psychologists who provide help, and that is outside the adjudication process.

[John Oliver, Liberal, Oakville, ON]

Thank you.

I'm going to keep us moving along here. I only have seven minutes.

I'm also looking at the cost of administration. I think Veterans Affairs uses Blue Cross to administer. I don't know whether Health Canada uses a third party to administer their funds. What is the admin fee associated with that? There's the cost of the actual medication and then there's a percentage that Blue Cross or others would charge for the administration of that. What's your percentage?

[Michel Doiron]

I will have to get back to you with the answer to that. I don't know it right off the top of my head and I'd rather not give you a wrong answer. They administer all our POCs. There is an administration fee, but it states on the contract—

[John Oliver, Liberal, Oakville, ON]

Mr. Doiron, if you went to a single-payer versus multiple third-party payers, that's a savings that we'd see across the system for private insurers and public people who are using third-party insurers. In Health Canada, do you have an administration arm for that?

[Scott Doidge]

We have one for the program, including all the benefits that Sony described at the start of the testimony, so for all of our benefits our admin cost ratio is 5%. That includes all the salaries of Health Canada employees, plus the contract payments, and our contract is with Express Scripts Canada.

[John Oliver, Liberal, Oakville, ON]

Thank you.

If we could get the cost of your Blue Cross administration fee for veterans, that would be worthwhile receiving.

[Michel Doiron]

Yes, sir. We will follow up on that. Thank you.

[John Oliver, Liberal, Oakville, ON]

I have less than a minute left.

The adjudication must cost something as well. If there were a national formulary, a national pharmacare program, veterans wouldn't need to be adjudicated. They would receive drug benefits as required, as any other Canadian would, regardless of the class of veteran or whether it was injury-related, so the whole cost of adjudication, the whole cost of.... I would potentially say the same thing about indigenous people, that they would fall under the same category.

Do we have any guesstimate of the cost of administration of these separate programs that would fall under a universal benefit?

[Michel Doiron]

Sir, there would be no savings on adjudications because, we have to be clear, when they do the adjudication process to determine if the injury was related to service—