Health Committee on Dec. 1st, 2016

[Don Davies, NDP, Vancouver Kingsway, BC]

Great. Thank you.

Monsieur Doiron.

[Michel Doiron]

I guess we've learned a few things, and if I had any recommendations, one would be good monitoring. We've learned to make sure there are no counter effects. The other thing is to make it evidence-based, ensure that whatever is coming out is evidence-based. I think the OAG talked about that and I take that as very important, as well as understanding where the cost and the cost drivers are, and maybe at the end, the cost savings.

The other thing is that we're using a term more and more in the department to “go low and go slow”, to ensure that when you're starting with your prescriptions and the approvals and that, you start slowly and at lower levels. I think marijuana caught us maybe a little by surprise. When the regulations changed, we were perhaps a little slow to react to that. We went from no more than a couple of grams a day and 100 veterans using it, to 3,000 using it within a year or 18 months.

That's where I would go. Make sure you have the data, the evidence, and then know where the cost drivers are.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Monsieur Perron, or Mr. Doidge.

[Sony Perron]

I would mention rigorous, evidence-based formulary management. This is fundamental in managing a plan. You will always have challenges meeting everybody's expectations, but the science and the evidence about the cost-effectiveness and the relative effectiveness of various products is something that needs to be done rigorously. I think it's fundamental. Whether it is a regional, employee-based, or group-based plan, this is fundamental.

[Don Davies, NDP, Vancouver Kingsway, BC]

Mr. Ferguson, do you have any thoughts?

[Michael Ferguson]

I think they both mentioned the things we covered off in our audit in terms of it being evidence-based and the monitoring, and that type of thing. That's all very critical in the actual set-up of the program. However, there is the first step of making sure you understand what the demand is going to be. When you make this big change in the model, what is the demand that will be coming from the citizens? What is the cost estimate going to be? What is the inflation? What's going to happen when there is another big drug that costs $1 million a year, or whatever? If there is a large demand for it, how are all those things going to be managed?

I think there are two aspects. There is understanding the mechanics of managing this type of program, but there is also a matter of stepping back and saying, if you're going to take something this broad in scope, it's not necessarily just going to be exactly what Health Canada is offering or what Veterans Affairs is offering. It will probably come along with a different set of expectations. I think understanding what those are going to be and what impact those things could have on the program and the satisfaction of the people trying to access the program is something that would need some attention as well.

[Don Davies, NDP, Vancouver Kingsway, BC]

Those are wise words, but if I might say, these are exactly issues we deal with today. Every insurance plan of every type, whether it's private insurance or any government department, is dealing with exactly those issues today.

[Michael Ferguson]

It is exactly those types of issues today, but of course, when you put it into one program, you now only have the one place to deal with that. You're right that they're the same issues that exist today, but they're not issues that the federal government has today. Some departments do have them, but only to a small percentage. When the federal government has to take on all those issues, it needs to understand what it's taking on.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay, thank you.

I just want to drill down in my last question to first nations and Inuit. In the last six months we have heard some stories of particular problems in health care delivery, timely and adequate health care delivery to first nations, particularly first nations children. Certain doctors have testified about or have gone public with there being certain barriers to getting treatment and medications to first nations clients, barriers that don't exist, say, for non-indigenous people.

Mr. Perron, do you have any comments on that?

[Sony Perron]

Yes. I cannot talk about all of them, but I think some of the comments come about from the situation where we are requiring, as a department, additional information from the prescribing physician as to why he or she is going with this prescription. It goes back to the CADTH recommendation that says, okay, this product should be used as a second-line or third-line therapy or should only be used if there is an allergy to that kind of product.

As a payer, our responsibility is to go back to the physician and say, “We have received that script to be paid by that pharmacy. Could you please confirm the reason you went with this product? Is it because the person has already tried the first-line or second-line therapy, or is there an allergy element?” There are criteria and we ask the physician to answer these kinds of questions.

[Don Davies, NDP, Vancouver Kingsway, BC]

Are you satisfied that's not interfering, though, with the actual treatment?

[Sony Perron]

If the response of the physician points toward the criteria, we are going to authorize the treatment. If not, then we'll ask why they are not trying the first line and second line.

I would say physicians are busy people. They want to do good for their patients, and sometimes they may feel this is pressure on them, but all plans in Canada have a certain level of, I would say, limited use where you go back to the physician to ask for evidence.

As I've mentioned before, this is a small percentage. Ninety-six per cent of the claims we receive for drugs are paid at the counter of the pharmacy. The patients show up at their pharmacy, pharmacists fill the prescription and send us the bill, and the client leaves with the drugs. It's 96%.

There is a small percentage, and we are trying to look at opportunities all the time to change our status or refine our criteria to avoid having to go back to the physician, but sometimes it is the result of a client safety situation so we will go back to the physician and ask, “Could you please explain, because we see a problem?” There might be contraindications about the two prescriptions the patient is on. We have the information. It would not be responsible to not act on that.

Most of the time we get the answer, and we process that in half a day because all this is done electronically between the pharmacy desk, our drug exception centre, and the physician's office, and we try to expedite the process. We have put a higher scrutiny on children more recently because there seemed to be a sensitivity there to make sure our rules are up to date.

The other reality is that, since we are operating in 13 jurisdictions, the fact that some provinces use different processes is a bit confusing for people on the ground sometimes. This is because most of their clients will be covered by the provincial plan, for example, and an odd case will be covered by us, and they are not totally aligned or knowledgeable about our processes.

This is one of the challenges of being a very large plan distributed across the country. We are small everywhere, so we cannot really influence the practice. We have to learn about that all the time.

There was an issue in one of the provinces recently about one product. We were hearing an ongoing complaint about the fact that we denied coverage of that. It was only in that province because suddenly the provincial plan started to cover this product, and physicians started to prescribe that product there, and we were not aligned with them. There is a due diligence that we have to try to learn about what is changing in the provincial formularies so that we can take that into account in the way we administer products.

[The Vice-Chair, Conservative, Len Webber]

Okay. Great.

I'll have to cut you off there, Mr. Davies.

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

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Chair.

Thank you to all the witnesses for your testimony.

I want to share my time with John.

My question is for Veterans Affairs. What step does the department need to take to improve its ability to monitor drug utilization so that veterans can have more access to proper services?

[Michel Doiron]

Thank you for the question.

We've taken steps. I think the issue with Veterans Affairs is not more services. I do want to be clear. I think veterans can get the drugs they need if they are prescribed by a treating physician. Our processes are quite quick as long as it's service-related or you fall within some of the criteria.

We do have to take steps, and we are taking steps, to improve the monitoring and the management of our formularies to ensure that the right drug is available to the veteran at the right time. Those are some of the things that were highlighted by the OAG, and we have undertaken to do this. Most of it we're trying to do by the end of this fiscal year.

As I mentioned earlier, we have hired a pharmacist, and the pharmacist, a professional in medication, is reviewing the formulary and making sure that it's the right drug and that there are no contraindications. A lot of stuff that Mr. Perron talked about is there. This committee now is also chaired by a doctor, a medical physician who understands what another doctor may have prescribed and has a better understanding.

The other thing we've taken a lot more interest in, if I can use that terminology, is the whole area of opioids and benzodiazepines to make sure, as we get more into this and as we're advancing it, that we're not creating issues out in the field that other health professionals have to....

The third and the last one would be marijuana, the reimbursement policies put out a couple of weeks ago for marijuana. There's a lot more monitoring for that and closer associations with the various people in the industry.

I want to emphasize that the veteran can get drugs, and it's quite quick. It is very good as long as it's service-related or you fall within one of the criteria. A lot of the work we're doing presently is making sure our programs are being well managed and are meeting the needs.

[Sonia Sidhu, Liberal, Brampton South, ON]

I am saying that because I went to a round table discussion with veterans and I heard stories. Can you give me the data about the time frame for the mental health, how long it took to access treatment procedures, or about the big trail of papers that they have to fill out?

[Michel Doiron]

On mental health, the department has an incredible suite of services related to mental health. We have over 4,000 mental health practitioners coast to coast to coast on contract with us. If a veteran needs help and if we don't have our OSI clinics there, they can get to the services.

We have to realize that our programs are based on need and based on the service relationship. Eligibility is very complex and we're trying to facilitate that, but generally speaking those are the two areas, and there's a series of services available. We actually pay for psychologists and psychiatrists. We actually pay the provinces to run our OSI clinics that are dedicated to our proud men and women in uniform, and to the RCMP, who can get their services.

Is there a wait time? Yes, sometimes in a certain clinic you may have to wait a week or 15 days to see a psychologist. If you try to see a psychologist in many parts of this country.... I know that there are even some provinces where psychiatrists are at a premium and it will take you a year to see one. With us, it's about 15 days. Some veterans do think it's too long to wait 15 days.

We have to understand, though, if they are in a crisis, the service is immediate. We work with the hospitals, with the doctors, with the professionals.

I think what they're referencing is that when they put in a claim with us, the whole adjudication process that I talked about earlier.... We will get them in for PTSD quickly, but the entire process will take 16 or 17 weeks. They need medical diagnostics. We're not doctors, but a doctor has to say, “You have PTSD”, or “You have a bad knee”. We cover everything.

The OAG did highlight the timelines it takes to get there, and we're working on accelerating that. I believe, without having been at that round table, that some of the comments about waiting are not so much about the treatment, it's about the adjudication process that comes with treatment but also comes with disability awards, which come with disability pensions, which come with other services. I know there is a real frustration in the veteran community surrounding some of those timelines.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

[The Vice-Chair, Conservative, Len Webber]

I'm sorry, you're out of time.

We have to move on to Ms. Harder. You have five minutes.

[Rachael Thomas, Conservative, Lethbridge, AB]

Thank you.

I will also be sharing my time with my colleague.

I have two questions, one for the Department of Health and one for the Department of Veterans Affairs. It is the same question, and that is, what are the key cost drivers you are facing within your department on pharmaceutical coverage?

Perhaps we can start with Mr. Doidge.

[Scott Doidge]

Sure. Our current projected growth rate for this fiscal year is about 8.3% in our pharmaceutical benefit, and that's up from previous years where we were quite a bit lower than that.

In our plan, one of the main drivers of growth is always new clients accessing the benefits. Population growth among first nations and Inuit is nearly double the Canadian growth rate, so we have a strong underlying population effect.

What we're dealing with right now in terms of drug coverage is that we have strong growth in our hepatitis C medication coverage. We're up about 30% on that. Opioid addiction therapies—drugs like buprenorphine, under the brand name of Suboxone, or methadone—are up significantly, as are biologic medications—drugs for rheumatoid arthritis, Crohn's disease—as Sony mentioned in his opening remarks.

With oral chemotherapy, it was noted that we're seeing a shift from hospital-based chemotherapy coverage to drugs that are now in tablet format and they're coming into our reimbursement environment, so we're seeing a significant growth in terms of our payment of oral chemotherapy. For infectious diseases such as HIV/AIDS medication as well, as more clients are diagnosed they're put on drug regimes that can cost $10,000 to $15,000 annually.

Those are the types of examples in which we're seeing growth pressure.

[Rachael Thomas, Conservative, Lethbridge, AB]

Thank you very much.

[Sony Perron]

If I could add one thing, from a public health perspective, the fact that people are accessing these drugs, getting treated, and getting cured is very good news. It comes with a cost, though.

[Rachael Thomas, Conservative, Lethbridge, AB]

That's a good point.

Thank you very much.

I have the same question for Veterans Affairs.

[Michel Doiron]

Thank you for the question.

Some of the same points were raised by Mr. Doidge, but some are a little different, because for us it's a change in demographics.

For a long time, Veterans Affairs had an older cohort of veterans, but since the war in Afghanistan and some of the peacekeeping missions before that, the average age of our veterans has gone down and the needs of the veterans have changed.

The newer, younger veterans have different injuries we have to treat, and some of the medications used to treat some of these new injuries are a lot more expensive than some of the traditional medication we may have used in the past.

A lot of our changes.... Although the demographics are going down—we had over 700,000 veterans and now we're around 670,000—the needs are more complex, the medications they are using are different, and the costs of those medications are going up. Like I said, some of the injuries and illnesses we are seeing are a lot more complex than they were with some of our previous veterans.