Health Committee on Dec. 1st, 2016

[John Oliver, Liberal, Oakville, ON]

It wouldn't matter. If there were a universal pharmacare program, it wouldn't matter where they had the injury from.

[Michel Doiron]

It would, because the pharmaceutical part is a very small component. There are disability awards, disability pensions, and other treatments that are not medication, which all fall under that area.

[John Oliver, Liberal, Oakville, ON]

Thank you. I understand that.

[The Chair, Liberal, Bill Casey]

Okay, time is up.

We're going to five-minute rounds now, but the chair has to leave. I'm going to table our fifth report on Bill C-233, and I think that's quite an accomplishment for us. I'm tabling that this morning. When I table it, I'm going to say that every party had amendments that we think strengthened Bill C-233.

I'm going to turn the chair over to Mr. Webber, and I'll go to table Bill C-233.

I want to thank our guests. I'm sorry I'm going to miss the rest of this. It's very interesting, and you're bringing new perspectives that we hadn't heard. Anyway, I have to go.

[The Vice-Chair, Conservative, Len Webber]

Dr. Carrie is up now.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, and we'll miss you.

First of all, I'd like to thank our witnesses today.

I actually have a whole bunch of questions. I'd love to have more than five minutes, but the reality is that if we're going to be moving to a national pharmacare program, the rationale behind that is to decrease costs and have better coverage, but some of the evidence—even Mr. Ferguson's point 9—is that when government runs things, sometimes that's not exactly what we end up getting.

We've defined pharmacare. Some of the activists, unions, and groups that have come in front of us say it's a government-run, single-payer monopoly that would entirely replace Canada's current pluralistic system of federal-provincial-territorial publicly funded, government-run drug plans, and the employment-based private drug plans. One of the problems with setting this up is that a lot of the data we have is extremely old. What I'm concerned about is the cost to the taxpayers in the immediate costs, if you're moving toward this.

Mr. Ferguson, in your point number nine today, you said that you “noted recurrent problems with government programs that are not designed to help those who have to navigate them and that focus more on what civil servants are doing than on what citizens are getting”, that it is “critical for the government to understand that its services need to be built around citizens, not process” and that you “encourage the government to think at the design stage of how a pharmacare program could deliver services that work for Canadians.”

You gave an example, I think in point number four, about inefficiencies and it being two years before things are actually looked at.

I'm really concerned. We don't really know at this stage of the game how many Canadians are insured, uninsured, or under-insured. We don't know how access to newer treatments and drugs would be affected. We've seen in other countries that have national pharmacare that innovative drugs can be restricted. Under realistic assumptions, we don't even know how much cost is going to be shifted to the taxpayers under pharmacare, and we don't know indirect economic costs, for example, job losses, private sector job losses, or takeover of the private sector. We don't know what the NAFTA implications would be, how other countries are really doing this, and what we have in the pipe right now that's working very well.

My first question for you, Mr. Ferguson, would be this. The federal government only covers 2.1% of total prescription drug expenditures in Canada. How is it being done? Is it being done efficiently by the government right now? If we extrapolated that 2% to 100%, do you think the costs would be huge?

What are your thoughts on this? Maybe you can't even answer that question.

[Michael Ferguson]

Perhaps I can provide a bit of perspective.

I think we heard in the opening statement from the Department of Health that some drugs can be extremely expensive for individuals. If you look at the opening statement from Veterans Affairs they commented on the fact that in 2015-16 they covered 48,000 veterans at a cost of $91.6 million. It's a very small program in terms of the overall coverage of prescription drugs. When we did the audit in 2014-15 they were covering 51,000, so the number of veterans they were paying for has decreased from 51,000 to 48,000, a decrease of 3,000, but the costs have gone from $80 million to $91.6 million.

A lot of that, as we have seen, has been the increase in the use of marijuana for medicinal purposes. Nevertheless, if you pull that out I think you can see that the incremental inflationary cost of prescription drugs can often be much higher than just normal inflation. Again, if you look at 2014-15 at the information we have in the audit, again, the average cost per person to Veterans Affairs was almost $1,600. The numbers we heard from Health Canada would probably put their average somewhere around $800 or something like that per individual. I may be wrong on that. That was my quick math.

When you take that number and multiply it by the number of people who would be covered you get a very large number. Some offsets to that would have to be figured in. What are the other programs that would no longer have to exist, what are they paying for, and where are they getting their money? Understanding the costs of this type of program and the offset costs that could go toward it would be prudent, as well as understanding the cost pressures.

I think in the audit that we have here that's something we said is very important in these types of programs: being able to monitor those cost pressures and being able to put in place cost-effectiveness strategies. Also, these would be strategies to know up front how the program is going to react when a new, expensive drug comes on the market and there's a lot of demand.

[Colin Carrie, Conservative, Oshawa, ON]

You mentioned prudence—

[The Vice-Chair, Conservative, Len Webber]

I'm sorry, Dr. Carrie, your time is up.

I hate to cut you off, being a colleague. Unless we have unanimous consent around the table to allow you to continue—

[Colin Carrie, Conservative, Oshawa, ON]

I wanted to know if we need good data before we do this because it's a huge cost. Can we afford it?

[The Vice-Chair, Conservative, Len Webber]

Perhaps Mr. Ferguson could answer those questions in writing.

We'll have to move on to Mr. Ayoub.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you, Mr. Chair. Even though we are not colleagues, it is nice of you to give me the floor.

Let's talk about first nations. We have not talked a lot about them, but there are significant concerns.

It appears that the non-insured health benefits program is the responsibility of some first nations, such as the Mohawk community of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta. They must manage the drug delivery component of the program themselves.

Can you give us a little more information about how the management is carried out and the reason for this, please?

[Sony Perron]

Thank you.

One of the guiding principles of our health intervention with first nations and Inuit is to ensure that the nations themselves have the greatest possible control over their health services, whether it be delivery, organization or design. Across the country, a number of nations have taken over parts of the program, with far more autonomy. The two examples you mentioned are more at the community level.

On a larger scale, British Columbia now has a health agency that manages that type of service. This covers the 200 first nations in the province. The agency has the flexibility to change the program if it wants to. The Inuit of Nunatsiavut also have an arrangement of this kind. This sort of change is allowed.

However, it is important to be careful with smaller public insurance plans. The fact that many clients are asking for very expensive drugs—such as the ones I mentioned earlier—can very quickly put the plan at risk. The risks are higher for those plans. Mechanisms must therefore be found to support first nations and organizations that assume those responsibilities. We must ensure that they do not become financially fragile because of new drug claims that they cannot afford. We are working closely with those organizations to ensure that the model remains viable.

In some cases, our department continues to provide support services. For instance, in the case of our British Columbia partners who have taken over the program, the department continues to process some of the claims as a service provider at this time. We expect the organization to transfer the management of its pharmacy program to the provincial program over the next few years.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

You’re talking about the British Columbia program?

[Sony Perron]

Yes. If you're interested, I can explain how alignment with provincial programs is beneficial.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

I’m also interested in cost control, of course.

We are talking about 824,000 first nations members, an expenditure of $422 million and an increase of 1.4% year after year.

Can you tell me what is causing that increase?

Do you have any data on that?

What control methods are used to ensure that first nations’ needs are being adequately met and that they are as independent as possible while being provided with special assistance?

[Sony Perron]

I'm going to start the answer, and then I'll ask my colleague to add more details.

We have an annual, multi-year mechanism that allows us to monitor our costs and know what they are associated with, in order to predict future costs. In addition, we examine whether the demand for drugs is similar for other public and private plans.

In order to project future costs, take action and make good decisions, we are studying the prevalence of certain diseases in the population we serve. Yes, the profile of its needs is often different.

After a period of relatively moderate growth in drug costs, we are now seeing an increase. This is happening this year and will continue over the next few years. This is mainly due to the new therapies on the market. For example, last year or two years ago, new hepatitis C therapies have emerged and this has had a significant impact on our public plan as well as a number of other plans across the country.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Does the use of fentanyl and other opiates have an impact on statistics?

Are you able to keep track of prescriptions like that?

[Sony Perron]

Yes. In my presentation, I briefly talked about the work we have done over the past 10 years on drug safety.

This was actually in response to a report by the previous auditor general. According to that report, the population we serve had wide access to drugs that lead to addiction problems. There was also a problem with the duplication of prescriptions. We have implemented several measures over the past number of years to try to contain the problem, which is not limited to the population we serve across the country. The profile is very different from one province or territory to another. The fact that our program is national and we have clients in every part of the country allows us to see how things are progressing. It is strongly related to the way doctors write prescriptions.

However, I would say generally that the last decade has created an environment in which people are exposed to drugs that can lead to addiction problems. We have implemented control measures. The non-insured health benefits program was one of the first programs to remove certain drugs from the list and to establish dosage limits. In an attempt to contain the problem, we contact the physicians who have prescribed the medication and inform them of any concerns about the dosage. This is not really a matter of cost management, but rather a matter of patient safety.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Mr. Chair, thank you for the extra time you’ve given us.

[The Vice-Chair, Conservative, Len Webber]

I'm very good at treating you well, all of you.

We'll move on now to Ms. Harder. You have five minutes.

[Rachael Thomas, Conservative, Lethbridge, AB]

My question is for Mr. Ferguson.

You make a point in number nine of your summary report here. You've actually cautioned us, it would appear, with regard to moving forward with a pharmacare program and making sure that we're taking into account delivery and the people, rather than looking at just the process.

I would ask you to reflect on a couple of things. First, what data is needed in order for us to move forward with a national pharmacare program from an educated standpoint, and with a delivery model that is going to be helpful rather than hindersome?

Second, what is the cost that would be associated with a pharmacare program?

Third, what would the impact be on choice be if we were to move forward with a pharmacare program?

[Michael Ferguson]

I'm not actually sure that I can answer a lot of those questions, but I can certainly speak to the comment that I made.

Again, it's something that we see over and over again in a number of our audits. Some programs are sort of putting the focus on the process, rather than on the individual.

I think the point of my comment simply is that, as you move forward with this, make sure that the point of view of the person receiving the service is considered important. I don't think that's just going to be a matter of just saying that people will want this type of a program. That may very well be true, but what is the cost going to be? How is that cost going to be covered? What will those cost offsets be? I think that's all important information to understand. The different steps in the process are also important to understand, but they need to be understood from the point of view of what the impact is going to be on the person receiving it.

I can't get down into the specifics of all of the types of data. I think that, with the information that Health Canada and Veterans Affairs have given, if you do a quick calculation, it gets to a fairly large number. However, there may very well be some offsets to that number because there are a number of different programs in this field already. If they don't have to exist, are there some cost savings there that could be put towards this?

Then I think the other thing to be very careful of is, again, the fact that often in these types of programs it's not just a matter of the cost increase by the regular consumer price index or anything like that. The way that inflation in the health field can be significantly larger than in other fields is something that any government taking on a project of this scope would have to understand. They need to understand how they're going to deal with those types of cost pressures in the future, as well.

[Rachael Thomas, Conservative, Lethbridge, AB]

Thank you very much.

My next question is also for you, and its in regard to the opioid problem or crisis that we just saw arise. You mentioned that, briefly, in your comments. You alluded to the fact that accountability was needed and that this problem actually went unchecked for a little too long. If we were to move forward with a national pharmacare program, what accountability is needed in order to make sure that there isn't an abuse of pharmaceuticals?

[Michael Ferguson]

I think maybe I'll reflect on something like the use of marijuana for medical purposes that was in the audit we did related to Veterans Affairs. Again, I think we've heard a little bit about that this morning.

That understanding of some of the prescribing practices.... We identified that Health Canada had talked about the types of situations were perhaps marijuana for medical purposes would not necessarily be the right choice, such as for people with bipolar disorder or people with depression. There were about 300 veterans, I believe, who had received prescriptions for antidepressants, as well as prescriptions for medical marijuana. That's an indication that it might not be consistent.

Similarly, in one of the years, we identified that 29% of the prescriptions for marijuana for medical purposes were provided by one physician.

Understanding the usage, understanding when there's incompatible drug usage, and even understanding, sometimes, what some of those prescribing patterns are, that's all part of the monitoring that's important for this type of a program.