Evidence of meeting #51 for Health in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was system.
A recording is available from Parliament.
NDP
Don Davies NDP Vancouver Kingsway, BC
Thank you, Mr. Chair.
Mr. Golja and Ms. Wallström, thank you so much for being with us here today.
As you are probably aware, one of the goals of our committee study is to explore how we can provide universal pharmaceutical coverage for Canadians, which we don't have now.
My first question is a simple one, and it may be obvious.
Maybe we'll start with you, Ms. Wallström. Is one of the goals of your system to provide universal coverage for all Swedes?
Director General, Dental and Pharmaceutical Benefits Agency
Yes, I would say it is.
NDP
Senior Policy Advisor on Pricing and Reimbursement of Pharmaceuticals, Department of Pharmaceutical Affairs and Medical Technology, Dutch Ministry of Health, Welfare and Sports
Yes, it is.
NDP
Don Davies NDP Vancouver Kingsway, BC
Okay.
Ironically, it has been estimated in Canada, depending on who you talk to, that we pay between the second highest and the fourth highest drug prices in the world, while at the same time not providing universal coverage.
I would like to ask each of you where each of your respective countries fit in terms of, say, the world, or perhaps the EU or the OECD, in terms of drug costs.
Ms. Wallström, maybe I'll start with you.
Director General, Dental and Pharmaceutical Benefits Agency
We have a relatively high expenditure on health care costs in Sweden, but we also have a good ratio between the quality of the medical results and the resources we put in.
When it comes to the pharmaceutical part of the health care spending, it's average on a European level. When it comes to prices, we have slightly over-average prices within the European Union. When it comes to products on patent, those without competition, and when it comes to products off patent, those with generic competition, together with the Netherlands we have among the lowest prices in Europe. Overall, I would say we're average.
Senior Policy Advisor on Pricing and Reimbursement of Pharmaceuticals, Department of Pharmaceutical Affairs and Medical Technology, Dutch Ministry of Health, Welfare and Sports
I would say the same. We're slightly above average when it comes to total expenditure on health care. In the European Union when it comes the monopoly products, looking at the external reference price of these products, I would say that our prices are average within the European Union. Also, as Ms. Wallström said, our generic prices are among the lowest in Europe.
Don Davies NDP Vancouver Kingsway, BC
Now I'm going to try to delve into why that is.
Maybe I'll start with you, Mr. Golja. It sounds as though you're managing to provide universal coverage for your citizens and you are keeping control of costs pretty well. What do you attribute that to? How are you able to do it? What is the factor that is accounting for that success?
Senior Policy Advisor on Pricing and Reimbursement of Pharmaceuticals, Department of Pharmaceutical Affairs and Medical Technology, Dutch Ministry of Health, Welfare and Sports
I think it's a combination of the responsibilities and the drivers in the system. You could say that trying to regulate the market to have obligatory insurance with obligations for insurance companies but also incentives for them to keep their premiums at an affordable level while also providing for the care of their patients drives them to find the lowest price in the market.
As a result of prescribers' being contracted, when it comes to the prescription of generics according to set guidelines, the parties involved all have an incentive and benefits to keep the financial burden on the system as low as possible. It's a balance—the market balance, you could say.
NDP
Director General, Dental and Pharmaceutical Benefits Agency
I would say that the efficient system for generic competition is an important basis. It creates headroom for innovation, and that leaves us in a good place when it comes to our relatively high, I would say, willingness to pay for new pharmaceuticals that bring added value. Having the value-based approach and trying to develop our decisions on our follow-ups in such a way as to pay for performance or pay for results and link that to our developed real world data work has also, I think, helped.
Also, as my colleague said, it's the combination of both, and it's also due to our collaborative framework for dialogues with the county councils and the pharma companies.
NDP
Don Davies NDP Vancouver Kingsway, BC
One fear we hear expressed about Canada's moving towards a universal system is this: some people warn—I think primarily industry representatives—that Canadians may face a lack of choice in getting the drugs they really want or need.
Do you have that experience in your countries, in Sweden and the Netherlands? Are you able to make sure that your patients get the actual medication they need and want within a universal system?
Ms. Wallstrom, you may go first.
Director General, Dental and Pharmaceutical Benefits Agency
In the Swedish system, all doctors are working for the county councils. There are no doctors who are totally private. There is thus a whole system that links one to another when it comes to choice and access.
I would say that in the few situations we experience in which we haven't been able to reach reimbursement status for new important pharmaceuticals, it has been possible for the Swedish system to handle the situation. So far it has also been possible for the political system to stand up for doing so. This also means that these are exceptions from the usual situation, such that it's possible for us to anchor our decisions with the prescribers and with the rest of the county councils and the health care system.
NDP
Senior Policy Advisor on Pricing and Reimbursement of Pharmaceuticals, Department of Pharmaceutical Affairs and Medical Technology, Dutch Ministry of Health, Welfare and Sports
I agree with what was said. In our system we have the freedom of choice for the prescriber; there are thus plenty of options for the prescriber to prescribe whatever he or she feels is necessary for the patient.
It's not as if there have been companies leaving the markets, with the system freed up with generics and given our ability to tender and various insurance companies participating in the tender. Even in the generic space, several providers are engaging in competition.
When it comes to new products, the Netherlands seems to be relatively early in the launch sequences of companies, and we haven't yet had shortages of new products not yet introduced into the Netherlands.
I don't feel that patients are missing out on products they should have had.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Thank you, Chair.
Thank you both, Ms. Wallström and Mr. Golja, for joining us today.
Ms. Wallström, first, could you please tell us whether bulk purchasing of medicines is a part of your policy, and, if so, can you please explain what difference that makes to the cost of prescription medications that individuals face?
Director General, Dental and Pharmaceutical Benefits Agency
You mean that if the volume is higher, the prices are low? Well, not specifically, but, of course, the health technology assessment is based on a model in which a larger patient population often gives a larger value. In that sense, the price should be lower. But in our decision-making, it's more of an implicit factor, I would say, with the exception of the generics, of course, which involve another kind of decision-making.
Liberal
Sonia Sidhu Liberal Brampton South, ON
To determine which medications will be covered by your health care system, could you please explain how you protect these formulary decisions from political perspectives? It is not affected by your political perspective? It's not affected by the system?
Director General, Dental and Pharmaceutical Benefits Agency
I really beg your pardon, but I need to understand better what—
Liberal
Sonia Sidhu Liberal Brampton South, ON
Can you explain how you protect these formulary decision to purchase the medications? Are the decisions not affected by the political system?
Director General, Dental and Pharmaceutical Benefits Agency
It's the TLV, which is an independent agency, that makes the decisions, and our decision-making is based on legislation and the Act on Pharmaceutical Benefits, and, of course, I am appointed by the government, but I'm not political. That's more or less the Swedish system for a major part of the decision-making like this, and we are independent when it comes to our relationship with the ministry and the government.
Liberal
Sonia Sidhu Liberal Brampton South, ON
I understand that even with the drug benefit scheme, individuals face copayment for their medications, which causes some people to skip doses or not refill their prescriptions. We have that problem in Canada, where 20% of people sometimes cannot afford medications. Can you comment on whether you have seen a decrease in this kind of activity since implementing the drug benefit scheme?
Director General, Dental and Pharmaceutical Benefits Agency
There are a number of patients at this point who for economic reasons do not get their medicines, and the government has made some reforms targeted to certain patient groups, for example, contraceptives for young women. A recent example is all the pharmaceuticals within the pharmaceutical benefits scheme for children and young adults up to 18, which are with no copayments at all. So the government has made some changes in the high-cost thresholds in order to avoid some of these problems.
