Health Committee on Dec. 1st, 2016

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

My only concern is that they don't have to go in circles to get their coverage. That's what really bothers me. Even in my constituency I hear some veterans, and they are in tears. They say that sometimes they are running into a brick wall. That's why I'm passionate about this, and that's why I'm bringing this up.

[Michel Doiron]

Thank you.

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

Am I done?

[The Chair, Liberal, Bill Casey]

Mr. Webber, you're up.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, Mr. Chair.

I appreciate everyone's being here today and presenting to us. Thank you.

I read here a paragraph from the Office of the Auditor General. He said, “A well-defined approach to monitoring drug utilization is also important.” He went on to say:

Particular attention should be paid to the utilization of some high-risk drugs which need to be adequately monitored in order to understand the trends and their use.

My question to the Department of Veterans Affairs is about a concern I have with the reported high use of medicinal marijuana within the Veterans Affairs department. First of all, to be covered, medicinal marijuana obviously must be on your drug formulary.

Can you give us some specifics on that particular drug—the stats, perhaps, on the increase from the years before? Also, are other drugs being less utilized because of the high increase of medicinal marijuana? If you can answer those, that would be great.

[Michel Doiron]

Thank you for the question.

First, cannabis or marijuana for medical purposes is not on the formulary because it is not a prescription drug. It's not considered a drug, and it doesn't have a PIN. It doesn't have those criteria, so it's not on our formulary.

The OAG rightly identified the fact that we were paying a lot of money for marijuana and that the department should look into it, and Minister Hehr came out very clearly saying that we need a reimbursement policy for this. I think the committee will be happy to know that the reimbursement policy was announced and is being implemented now, as of November 22, whereby we will limit the amount to three grams per day, down from 10 grams, which was the limit before. In addition, we will cap the amount that we pay per gram to $8.50 per gram.

Now, I want to stress that it is not a prescription for marijuana, but a script, and Veterans Affairs does not provide scripts. We will pay, but it's the professional health care professionals or the doctors who work with the veterans who make the determination whether marijuana for medical purposes is the right substance to use.

The department in 2007 decided to pay for palliative clients based on compassionate grounds. Over the years, that use has gone up. In 2013-14, we had 112 clients, which is not very many. Then the courts made certain decisions, and some of the regulations surrounding the distribution or the availability of medical marijuana were changed.

We finished 2015-16 with just over 1,700 veterans using marijuana for medical purposes. This year, in the first six months there are just over 3,000. As you can see, there's been a pretty significant increase, and it is not due to Veterans Affairs providing the scripts. I want to be very clear. It is more and more doctors and health professionals deciding that our veterans could have some use for it. Now, we are very concerned with the health and well-being of our veterans, and hence the minister came in with the new requirements.

To answer your questions about a decrease in other areas, we did a review about six months ago, following the OAG's visit, of whether there was—because we were hearing anecdotal evidence that there was—a decrease in opioids, or benzanines, or such medications. The review at the time did not demonstrate that. It demonstrated that our numbers are staying pretty consistent in that area, but that the use of marijuana was going up.

Now, if you look at our public reports, you will say, “Well, sir, your numbers are going down for opioids”. That is not because of the people using marijuana. We compared people using marijuana and people using opioids. Our veteran population is decreasing; we now have 670,000 veterans. Therefore, the use of opioids, benzanines, and other medications is decreasing because of the decrease in the number of veterans.

We actually did a correlation between veterans using marijuana and veterans using other drugs to see whether, in that population, there was a decrease, and at that moment there was nothing of any significance.

I hope I've answered all your questions, sir.

[Len Webber, Conservative, Calgary Confederation, AB]

Yes. Thank you so much.

I don't know how much time I have left, but I quickly want to ask the first nations and Inuit health branch a question.

Do you see a significant increase in the use of medicinal marijuana in your department?

[Sony Perron]

As my colleague from Veterans Affairs mentioned, medical marijuana is not a prescription drug in Canada. The policy of the program is to cover only prescription drugs, so as a result we've had no coverage for medical marijuana in past years.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you.

[The Chair, Liberal, Bill Casey]

You still have some time.

[Len Webber, Conservative, Calgary Confederation, AB]

I still have time? Oh boy. Okay. I'm not used to having seven minutes, Mr. Chair. Maybe we'll just sit and look at each other.

[The Chair, Liberal, Bill Casey]

No, we won't do that. We'll move to Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Can I have some of those minutes? Thanks.

Thank you to all the witnesses for being here today.

My first question is for the Auditor General. I apologize if you've covered this. Are the six departments that provide coverage participating in a common bulk-buying program for all of their drugs? Do we know that?

[Michael Ferguson]

Actually, probably the department would be in a better position to answer that.

Again, the audit that we're presenting to you today was just on Veterans Affairs, so I think the departments could give you a better idea of what they're doing in terms of bulk purchasing.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay.

Do either of the officials from Health Canada or Veterans Affairs know if the six departments are coordinating bulk buying of their drugs?

[Sony Perron]

I will ask Scott to talk about our participation in the pharmaceutical procurement alliance.

[Scott Doidge, Director General, Non-Insured Health Benefits, First Nations and Inuit Health Branch, Department of Health]

For about the past year we've been participating with our provincial and territorial counterparts through the pan-Canadian pharmaceutical alliance. We are representing the other federal departments at that alliance, so when agreements are negotiated through that consortium, we do provide those agreements through our federal counterparts. Then it's up to the departments to choose whether or not to enter into those product-listing agreements.

[Don Davies, NDP, Vancouver Kingsway, BC]

As all the witnesses know, this committee is studying the potential for a universal national pharmacare program of some type. What I'd like to know is whether it is a fair comment—if I'm understanding this properly—to say, with Veterans Affairs and with Health Canada, with respect to first nations and Inuit peoples, you effectively have a universal pharmacare program for veterans, and there's a universal pharmacare program for first nations and Inuit people. Is that a correct description of what is presently the case within those cohorts?

[Sony Perron]

I think what I can say for the first nations and Inuit is that the program is universal for all first nations and Inuit in Canada, with the exception of first nations living in British Columbia, because this portion of our activity has been devolved to a first nation institution.

There are small pockets in Canada where first nations under self-government or Inuit under self-government have taken on this program, but generally speaking, you're right to say that it's universal coverage for drugs for all first nations and Inuit. In particular, the program, because of the economic conditions of the populations we serve, has no copayment, no deductible, and no income testing. It's for all of them as status.... There are some rules in terms of the formulary that I mentioned in my introductory remarks, which we are applying, but otherwise, this program can cover really high-cost products, and there is no maximum limit if this is medically required.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Mr. Doiron.

[Michel Doiron]

We don't usually say that it's a universal program. I want to be careful. Ours is based on the needs of the veteran. However, once the need has been identified and they meet the eligibility criteria, then every veteran has access to the same formulary. In that sense, that would be universal, but it has to be service-related, or you have to be in a certain category. Once we deem it to be service-related or you're in that category, then we use the same formulary, and again, there is no cap, as my colleague said, no top. We ensure that you get the medication you're entitled to.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay. The reason I ask that question is that we're not reinventing the wheel here at this committee. Many countries have universal hospital and physician coverage and also have some form of universal drug coverage. We also have, of course, the U.S. veterans association, and I think your two departments are examples of where we already are providing some form of universal coverage for a defined group of people. What I'm trying to delve into now is what lessons or advice you might give this committee, from your experience, about how we might be able to set up such a system that covers all Canadians.

Maybe I'll start with you, Mr. Perron, focusing particularly on the formulary. Is the formulary broad enough, in your experience, in covering your cohort? Is the administration of the program efficient and effective, in your view?

[Sony Perron]

Thank you for the question.

I think some of the principles that the Auditor General of Canada mentioned in terms of what we should look at when we look at formulary management are principles that we try to adhere to. It needs rigour. Evidence is changing all the time. It needs to rely on expert advice. This is why we are looking at the common drug review process, and the expert group that supports that is giving us the first input about what we should do when a new drug comes on the market, or when new theoretical value is identified for a drug and we need to take that into consideration. I think the rigour in formulary management is essential.

Alignment with other plans is also very important, so that you don't get into a situation where patients going to see a physician receive a certain type of prescription from one physician, and because another kind is covered by someone else, they will receive a different kind of prescription. In fact, it's really difficult for the prescriber to know what is covered in one plan and in the others, so a certain alignment is good.

I think we have made progress. When I say we, it's not necessarily Health Canada only. I think, generally speaking, in Canada we have made progress in the last few years in some alignment that makes it easier for the prescriber, for the pharmacists who deliver, and for the client, of course, to access what they need. There is more progress that can be done. I would think rigour in this is important.

There are also specialized drugs that emerge. Cancer therapy that used to be delivered in hospitals now is often dispensed at the pharmacy desk, and people leave with this for home. These are new areas where we have to refine our process all the time because it's not static. The pharmaceutical offer is changing all the time. We need to have the capacity to adapt to these new realities and changes in the health system because the patients are also facing that. Therefore, the plans always need to be evolving.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you for that. I think that's jibing with a lot of evidence we're receiving from many of the witnesses.

On a very general question, do you feel that the program you're administering is able to provide a broad enough formulary to cover the cohort that you're covering in a reasonably efficient way?

[Sony Perron]

Yes. This is our objective. I would say it never ends. We need always to refine and re-evaluate and assess the trends. I think we mentioned opioids before. For a number of years we were closing our eyes to this problem and we were just paying for the drugs that were prescribed because we relied on the physicians to do the prescriptions, but it caused a public health problem in Canada. We have a role to play in trying to curb that going forward.