HEAL Committee Meeting

37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Monday, October 27, 2003

·

1345

The Chair (Ms. Bonnie Brown (Oakville, Lib.))

Dr. Thomas Ward (Deputy Minister of Health, Nova Scotia Department of Health)

The Chair

Ms. Leanne Jardine (Acting Director, New Brunswick Prescription Drug Program, New Brunswick Department of Health and Wellness)

·

1350

·

1355

The Chair

Dr. Thomas Ward

Ms. Emily Somers (Acting Director, Pharmaceutical Services, Nova Scotia Department of Health)

¸

1400

Mr. Svend Robinson (Burnaby—Douglas, NDP)

Ms. Emily Somers

Dr. Thomas Ward

¸

1405

The Chair

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

Dr. Thomas Ward

Mr. Rob Merrifield

Dr. Thomas Ward

Mr. Rob Merrifield

¸

1410

Dr. Thomas Ward

Mr. Rob Merrifield

Dr. Thomas Ward

Mr. Rob Merrifield

Dr. Thomas Ward

Mr. Rob Merrifield

Ms. Emily Somers

Mr. Rob Merrifield

Ms. Emily Somers

Mr. Rob Merrifield

Ms. Emily Somers

Mr. Rob Merrifield

Ms. Emily Somers

Mr. Rob Merrifield

Ms. Emily Somers

¸

1415

Mr. Rob Merrifield

Ms. Emily Somers

Mr. Rob Merrifield

Ms. Emily Somers

Mr. Rob Merrifield

Ms. Emily Somers

Mr. Rob Merrifield

Ms. Leanne Jardine

Mr. Rob Merrifield

Ms. Leanne Jardine

Mr. Rob Merrifield

Ms. Leanne Jardine

Mr. Rob Merrifield

Ms. Leanne Jardine

Mr. Rob Merrifield

Ms. Leanne Jardine

Mr. Rob Merrifield

Dr. Thomas Ward

Mr. Svend Robinson

Dr. Thomas Ward

Mr. Rob Merrifield

Ms. Leanne Jardine

Mr. Rob Merrifield

The Chair

¸

1420

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ)

Mr. Svend Robinson

Mr. Réal Ménard

Mr. Svend Robinson

Mr. Réal Ménard

Ms. Leanne Jardine

Mr. Réal Ménard

Ms. Leanne Jardine

Mr. Réal Ménard

Ms. Leanne Jardine

¸

1425

Mr. Réal Ménard

Ms. Leanne Jardine

Dr. Thomas Ward

Mr. Réal Ménard

Ms. Emily Somers

¸

1430

Mr. Réal Ménard

The Chair

Ms. Carolyn Bennett (St. Paul's, Lib.)

Dr. Thomas Ward

¸

1435

Ms. Carolyn Bennett

Dr. Thomas Ward

The Chair

Mr. Svend Robinson

Dr. Thomas Ward

Mr. Svend Robinson

Dr. Thomas Ward

Mr. Svend Robinson

Ms. Emily Somers

Mr. Svend Robinson

¸

1440

Dr. Thomas Ward

Mr. Svend Robinson

Dr. Thomas Ward

Mr. Svend Robinson

Dr. Thomas Ward

Mr. Svend Robinson

Ms. Emily Somers

Mr. Svend Robinson

Ms. Emily Somers

Mr. Svend Robinson

¸

1445

The Chair

Mr. Svend Robinson

Ms. Leanne Jardine

Mr. Svend Robinson

Ms. Leanne Jardine

Mr. Svend Robinson

The Chair

Ms. Leanne Jardine

The Chair

Ms. Leanne Jardine

The Chair

Ms. Leanne Jardine

The Chair

Ms. Leanne Jardine

The Chair

Ms. Leanne Jardine

The Chair

Mr. Gilbert Barrette (Témiscamingue, Lib.)

Ms. Leanne Jardine

Mr. Gilbert Barrette

Ms. Leanne Jardine

Mr. Gilbert Barrette

Ms. Leanne Jardine

Mr. Gilbert Barrette

¸

1450

Dr. Thomas Ward

The Chair

¸

1455

Ms. Carolyn Bennett

The Chair

Ms. Carolyn Bennett

The Chair

Dr. Thomas Ward

The Chair

Dr. Thomas Ward

The Chair

Ms. Emily Somers

¹

1500

The Chair

Mr. Svend Robinson

The Chair

Dr. Thomas Ward

The Chair

Mr. Svend Robinson

Dr. Thomas Ward

Mr. Svend Robinson

Ms. Carolyn Bennett

Ms. Emily Somers

Ms. Carolyn Bennett

Ms. Emily Somers

Ms. Leanne Jardine

Dr. Thomas Ward

Ms. Carolyn Bennett

Dr. Thomas Ward

The Chair

---

CANADA

Standing Committee on Health

---

NUMBER 063

l

2nd SESSION

l

37th PARLIAMENT

---

EVIDENCE

Monday, October 27, 2003

[Recorded by Electronic Apparatus]

·  (1345)  

[English]

    The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good afternoon, ladies and gentlemen. It's my pleasure to welcome you to this Halifax meeting of the Standing Committee on Health as we pursue our study on prescription drugs.

    This afternoon we have representatives of both the Nova Scotia and New Brunswick Departments of Health. We'll begin with Nova Scotia, Dr. Thomas Ward, the Deputy Minister of Health, who will be assisted by Emily Somers, the acting director of pharmaceutical services.

    Dr. Ward, the floor is yours.

    Dr. Thomas Ward (Deputy Minister of Health, Nova Scotia Department of Health): Thank you, Madam Chair.

    In a brief conversation with my colleague from New Brunswick, she requested that she lead off the discussion. I think it is her fervent hope that when we both have finished, I'll get to answer all the questions. If there's concurrence, then perhaps we can proceed in that way.

    The Chair: That's fine. Go ahead, Ms. Jardine.

    Ms. Leanne Jardine (Acting Director, New Brunswick Prescription Drug Program, New Brunswick Department of Health and Wellness): Thank you, Madam Chair.

    I'm pleased to have the opportunity to make a presentation to the Standing Committee on Health as part of the study on the prescription drug situation in Canada.

    My presentation will focus on the following topics: the extent of and factors contributing to the rising cost of drugs, prescribing and utilization issues and opportunities, federal/provincial/territorial initiatives, generic drug issues, and direct-to-consumer advertising.

    It's widely reported and well known that drug costs are the fastest growing component of Canadian health care. In New Brunswick increasing drug costs affect not only the amount spent by the provincial drug program, but many individuals and families have no drug coverage at all and must pay for drugs out of their own pockets.

    The New Brunswick prescription drug program is a provincially funded program that provides prescription drug coverage to eligible New Brunswickers. It is not a universal program. Some form of universal drug coverage exists in the provinces and territories except for Atlantic Canada. Approximately 106,000 of the 750,000 residents are eligible to receive drug benefits under the program. The remaining residents either have private drug insurance or no insurance at all.

    NBPDP costs have increased from $63 million in 1991-1992 to about $103 million in 2002-2003. Several initiatives were implemented through the 1990s that reduced the rate of this growth. However, expenditures have steadily increased over the past five years an average of about 13% per year, a rate that is not sustainable indefinitely. Expenditures are forecasted to double every four to five years.

    The two main factors contributing to the increase in drug expenditures are drug price--the development and introduction of new, expensive drugs, which replace older therapies--and volume--increased prescribing by physicians and utilization by patients. New drug therapies are being developed for diseases that previously had no treatment. We see shifts in prescribers' preferences for new, usually higher-cost medications, despite the availability of comparable brand name and generic alternatives. The volume of drug use is affected by the aging of the population and marketing by pharmaceutical companies to physicians and patients.

    Other factors contributing to increasing drug program costs include employee/employer groups limiting or cutting coverage, which forces patients to look to government for help, and patients receiving drugs in the community that were previously provided in hospitals.

    Although extremely expensive drugs for relatively rare conditions are often in the spotlight in the discussion about rising drug costs, moderately expensive drugs for common conditions have been the main drivers of the increase. Of the top ten drugs reimbursed by NBPDP last year, only one would be considered a high-cost drug, at approximately $20,000 per year per patient. The others are relatively moderately priced drugs used by a large number of beneficiaries. Two of the top ten have been genericized, one very recently. However, it's unlikely that this generic will be in the top ten next year, as much of the usage will have switched to another brand name product.

·  (1350)  

    The drug program has tried various measures to address utilization issues and promote appropriate prescribing. One initiative is the antibiotic prescribing profiles used to communicate usage to physicians. The profile shows population consumption rates by health region instead of by individual physicians. They were distributed two years ago. Profiles for this year will be distributed soon. The data indicate a decrease in antibiotic consumption. Of course, various factors would have contributed to this decrease.

    Another initiative is the hand-held formulary project. Many physicians have little knowledge of drug costs and often do not have easy access to cost information or the time when deciding what drug to prescribe. Better efforts to inform physicians about the true cost of medications may have an impact on prescribing habits. The project will evaluate whether providing formulary and drug cost information in this format has an impact on prescribing.

    There are several FPT initiatives in the area of pharmaceuticals management, and I would like to talk about two in particular. The first is the common drug review. The Atlantic provinces actually led the way with the Atlantic common drug review process, which started in January 2002. Our model and experience significantly contributed to the national CDR. New Brunswick has actively participated in the development of the CDR and fully supports the establishment of the national process. The common drug review, as you likely know, is a single process for reviewing new drugs and providing listing recommendations to the 19 participating federal, provincial, and territorial drug plans. The CDR consists of a critical appraisal of the best available clinical and pharmacoeconomic evidence and a listing recommendation made by the Canadian Expert Drug Advisory Committee. In the past, all jurisdictions, including New Brunswick, reviewed new drugs for consideration for coverage under their drug plans to help ensure that the drugs covered were cost-effective therapies. The CDR process will reduce duplication, maximize the use of resources, and provide access to a high level of evidence and expert advice to all the plans. This is of great value to all jurisdictions, but particularly for the smaller provinces, which have very limited resources.

    The second initiative is the Canadian optimal medication prescribing and utilization service, or COMPUS for short. It has been approved in principle, with the objective to improve appropriate prescribing and utilization, which will result in better health outcomes and improved use of drug benefit plan resources. It will have multiple functions. It will serve as an information clearing house for jurisdictions wishing to implement utilization best practices. It will critically assess the effectiveness of different best practice initiatives and also educate patients, prescribers, and pharmacists on appropriate prescribing and utilization.

    In order for drug plans to continue to be able to provide benefits, their costs must be sustainable, necessitating that drugs are prescribed and used appropriately and that the drugs used are cost-effective. Initiatives such as CDR and COMPUS will provide us with better information, which will lead to better decisions and better drug-related outcomes.

    I would now like to address several generic drug issues. Adding generic drugs to the formulary is an important way that provincial drug plans contain costs. New Brunswick streamlined its approval of generics over five years ago by accepting Health Canada's declaration of equivalence instead of duplicating the review process.

    Timely access to generic drugs is key to maximizing the savings. The Patented Medicines (Notice of Compliance) Regulations of Canada's Patent Act allow brand name companies to get an automatic two-year injunction against generic drug companies by alleging that the generic has infringed their patent. While the injunction is in place, Health Canada is prohibited from approving a generic version, which in effect extends the lifespan of the patent. Even if a generic company is ultimately found by the courts not to have violated a patent, provincial formularies and consumers have already paid additional costs for drugs during that period.

    The practice of evergreening, whereby companies list multiple patents on minor variations of their brand name drugs in order to trigger additional automatic injunctions, extends their patent coverage and further delays the availability of generic drugs. Concern regarding the practice of evergreening was raised in the Romanow report, and recommendation 41 called on the federal government to specifically review the practice of evergreening and the notice of compliance regulations. New Brunswick recognizes that there must be a balance between the rights of patent holders and the need for access to generic drugs and supports this recommendation.

·  (1355)  

    The House of Commons industry committee held hearings on the workings of the regulations in June of this year, and we look forward to the results of their review.

    The recently released study by the Patented Medicine Prices Review Board, which compared Canadian prices of multiple-source drugs to prices in nine other jurisdictions, found that the Canadian prices for generic drugs exceeded median prices in the nine other countries by 21% to 51%. This suggests that it should be possible to obtain better prices for generic drugs in Canada.

    However, it is possible that certain provincial pricing policies for multiple-source drugs could be interfering with the competitive process and keeping generic prices higher than they should be. For example, a regulation in Ontario requires the first generic entrant to be 70% of the brand name drug's price, and subsequent generics can be no more than 90% of the first generic price. It appears that companies are charging as much as they're allowed in Ontario and making that the price for all provinces. Also, many provinces set maximum allowable prices on multiple-source drugs to prevent reimbursement of brand name drugs that have generic versions. The fact that generic prices submitted by manufacturers for even the fourth or fifth entrants are equivalent to this set price raises the question as to whether this policy may also be hampering price competition.

    Although direct-to-consumer advertising of prescription drugs is prohibited in Canada, drug ads are widely seen by Canadians in U.S. magazines, on television, as well as on the Internet. The results of a recent study published in the Canadian Medical Association Journal suggest that more advertising leads to more requests for advertised drugs and more prescriptions. Direct-to-consumer advertising has the potential to increase demand for prescription drugs by encouraging patients to seek unnecessary or inappropriate treatments, which can increase the risks to their health and drug expenditures. In addition, newer drugs, for which there is often limited information about the risk/benefit profiles, tend to be advertised the most. For these reasons, we would oppose any liberalization of the current regulations.

    Consumers should have access to accurate, balanced information on drugs and other available treatments in order to participate in decisions about their health. However, this is best accomplished through government-funded, independent initiatives, such as COMPUS.

    In closing, I would like to emphasize that rising drug costs can and should be addressed by improving prescribing and utilization, and access to evidence-based drug information will provide the foundation. The provinces alone, particularly the smaller ones, cannot have a significant impact, so continued federal/provincial/territorial collaboration and cooperation are essential.

    I would like to thank the committee for the opportunity to present these views on behalf of New Brunswick, and I will be pleased to answer any questions you may have.

    The Chair: Thank you, Ms. Jardine.

    Dr. Ward.

    Dr. Thomas Ward: Thank you, Madam Chair.

    I should start by affirming the belief of Nova Scotia and our Atlantic colleagues in the concept of a publicly funded health care system. I think we are all in agreement that the future direction of our system and the Canadian system is the movement to a community-based system of health services that is very much integrated.

    We also recognize that we are faced with a population that has a growing incidence of chronic disease or, more appropriately, what could be called a growing burden of illness. It is a burden on individuals, families, communities, and governments. We are all very clear that pharmaceuticals do have a role to play in either improving or maintaining the health of Canadians.

    In Atlantic Canada we find ourselves particularly challenged in terms of the publicly funded pharmaceuticals programs, simply in that we are recognized as having the highest burden of illness in Canada. There's a very clear gradient that runs from the west to the east in terms of a rising burden of illness, and there seems to be a reverse gradient in terms of economic ability to pay. I would point out that as of 2001, for our double-income families in Nova Scotia, 55% of them did not have to pay taxes. That is profoundly remarkable. That gives a sense of the public's ability to participate in these programs. As with many jurisdictions, we remain today challenged with the ability to pay for these programs. We find ourselves in a continual race to catch up with other jurisdictions as the costs rise, as the burden of illness in our population rises, and as more and more of our care is appropriately moved out of the hospital sector into the community sector, a sector that is currently not recognized or funded under the Canada Health Act.

    I'm going to ask my colleague Emily Somers to speak about the challenges facing our own pharmacare program, which, I would note, covers only seniors. Our Department of Community Services covers the low-income sectors where possible.

    When Emily completes her presentation, I will speak about what I see as some of the future directions and issues.

    Ms. Emily Somers (Acting Director, Pharmaceutical Services, Nova Scotia Department of Health): Thank you, Dr. Ward.

    I thought I would just give you some background on the Nova Scotia pharmacare program, where it came from and where it is today. It was established in 1974, and it was designed to assist seniors with the high cost of medication. Of course, the Community Services program was there to help those with the lowest incomes in our society afford their prescription drugs. At the time, there were 80,000 seniors on the seniors pharmacare program, at a cost of $7 million. Though there are some smaller programs in Nova Scotia based on diseases or specific drugs, these are really the only two programs that still exist in Nova Scotia. Today we cover approximately 100 seniors under seniors pharmacare and 55,000 residents under Community Services.

¸  (1400)  

    Mr. Svend Robinson (Burnaby—Douglas, NDP): How many seniors?

    Ms. Emily Somers: We cover 100,000. The rest of the population is covered by private insurance, is not insured, or pays cash for their prescription drugs.

    Between 1974 and 1994 we were seeing annual increases of about 14% per year. We introduced a number of cost-control initiatives. At the time, we were adding any drug that came to market to our formulary. That had to stop. We put a process in place to determine whether or not we should be covering a drug under our benefit list. We also placed restrictions on the use of certain drugs. We decided that we would develop criteria for them and determine where they should be used, and then only patients who met those criteria would have access to the drugs. Also, we capped the amount we would pay for a certain amount of drugs. We introduced a maximum allowable cost policy, especially within the generic class, where we would pay only up to the cost of the least expensive generic product.

    But it was clear that wasn't enough. Small cost-control initiatives were not going to do what we needed to do to the pharmacare program because it was just growing too rapidly. So we had to look at some fundamental changes to the program. Between 1995 and today we have been trying to do things a little differently. We had to change the cost-sharing arrangement between the government and seniors. We introduced premiums into the program. We have been adjusting co-pays ever since to try to keep up with the rising cost of pharmaceuticals.

    We introduced a new formulary, and it was no longer just a list of drugs. It was additional information we thought would help physicians make better prescribing decisions. The new formulary had indicators of cost. Physicians don't always know the cost of drugs, so there were indicators of relative cost. There were indicators of first-, second-, or third-line therapy. We also introduced some treatment guidelines, which was our attempt to disseminate best practices to the physicians. We thought that if they had better information, some idea of cost and where it fit in therapy, we could help physicians with this whole issue of inappropriate use and prescribing the most cost-effective therapies.

    We also introduced educational programs for seniors. If drugs are prescribed appropriately but seniors aren't taking them as they're supposed to, then we're really back to square one. So we introduced some programs for seniors to help them understand what they were taking and why they were taking it.

    Since then, we've created a program called the drug evaluation alliance of Nova Scotia. We're now trying to identify the prescribing issues within Nova Scotia. We're developing interventions we can put in place, and then we're measuring the effect of those interventions. One of the interventions we're most proud of is academic detailing. Pharmacists and other health professionals visit physicians and provide them with evidence-based information. We believe that better information allows everyone to make better decisions.

    Regardless of all of this, our costs continue to rise. The table on the slide shows that costs of the program continue to rise every year. We are projecting them to rise to about $136 million this year.

    The biggest challenge we're facing is that drug costs are going to continue to climb. We're convinced that utilization and prices will continue to climb. It's just not sustainable. We're seeing drugs come to market with incremental improvements in efficacy and side effects at significantly higher prices. The switch to these new therapies is occurring very quickly, and it's very difficult to manage. We're seeing introductory prices of some drugs of between $20,000 and $50,000 per year per patient, a level that governments and individuals can't afford.

    We also see significant challenges to appropriate prescribing. Physicians, nurse practitioners, and other prescribers are having a really tough time. There is an overwhelming number of drugs to choose from. There's an overwhelming amount of information from multiple sources, often conflicting. There are patient pressures about the management of an illness that are inconsistent with appropriate prescribing. We see poor compliance with regard to both lifestyle and drug regimes.

    These would be the main challenges we see Nova Scotia pharmacare facing now and in the future.

    Dr. Thomas Ward: For our jurisdiction, as we move forward, there are three or four pieces that we think are issues for discussion by the federal government. There is the question about the Canada Health Act--is it modern, or should it be revisited to have some discussion about potential cost-sharing for pharmaceuticals outside of the hospital sector? We feel that is an absolute must, particularly if we are committed to a community-based system of care.

    The second thing is that there has to be a discussion at some point around the burden-of-illness concept. The February 2003 accord sees an additional $2 billion of federal funding going in, presumably to deal with the issue of catastrophic drugs. The challenge for us is to recognize that a per capita distribution of those funds across the country is not reflective of the burden of illness. It does not help Nova Scotia, compared with Alberta or some other jurisdiction. If we are to have a fair and equitable national system with national standards, a funding mechanism that recognizes the burden of illness has to be brought to the table.

    There are certainly difficult areas. We estimate that the amount of funding necessary to bring our own programs in this province up to the robustness we see in other jurisdictions would be an additional $40 million over our current expenditures. That is a huge increase for any jurisdiction, particularly one that is struggling financially to move that forward.

    We will, however, be making attempts over the next two or three years. We have committed this year to begin to reach out to some of our lower-income groups, particularly diabetics, to begin to manage those particular issues. The diabetic portion is for us one of the best examples to talk about. If you had a 23-year-old university student with diabetes who had to pay their tuition of several thousand dollars plus their room and board and find a summer job and they were independent, we would have to recognize that their test strips alone for the glucose monitor cost $500 a month. So without a drug program, they have an upfront cost of $6,000, on top of their tuition. Then they need to buy their insulin, and then they're suppose to have a proper diet. It is pretty easy to understand that on their list of priorities, the test strips required to manage their disease effectively fall to the bottom of the list. If we had a catastrophic drug program, not only in Nova Scotia but nationally, it would be meant to manage those things. That's where these programs need to be moving forward.

    Some of these issues were raised by both Mr. Kirby in terms of the Senate committee report and Mr. Romanow in terms of his report.

    I'll take you back to what I said initially. We are moving to a community-based, integrated program. There is a role for pharmaceuticals to play in the maintenance of health and the management of chronic diseases in our communities. The challenge for all of us is to figure out how we can move the agenda forward so that those who most require the assistance of a publicly funded system do in fact get it.

    Thank you.

¸  (1405)  

    The Chair: Thank you very much.

    We'll move to the question-and-answer period, and we'll begin with Mr. Merrifield.

    Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you for sharing your views.

    I have a few questions. I'd like to start with your last comment with regard to the $2 billion for the catastrophic drug program under the accord. I didn't quite catch your rationale behind saying all provinces wouldn't be treated equally or fairly, that Nova Scotia would be disadvantaged compared with, say, Alberta. How would that work?

    Dr. Thomas Ward: The current health reform fund, of which the catastrophic drug component is one of three pieces, is distributed nationally on a per capita basis. The comment I would make is for a jurisdiction that has a low burden of illness per capita versus a jurisdiction that has a very high burden of illness per capita, my expectation is that the people who have a disease are the ones who require the medication, and the funds should be distributed reflective of that burden of illness, not reflective of the per capita basis of the population.

    Mr. Rob Merrifield: So it's not the per capita thing you argue with. Is it the demographics or the standard of living?

    Dr. Thomas Ward: It's a combination that really is reflective of the amount of illness, that burden of chronic disease and requirements for medication, within a province or a particular region.

    Mr. Rob Merrifield: Would that be a complex thing to determine? Would it change all the time? It would be hard to know.

¸  (1410)  

    Dr. Thomas Ward: My sense is that there are opportunities to do that. In this jurisdiction we have looked at trying to understand the situation. We have a similar gradient, in that the people in our jurisdiction who seem to be the healthiest reside in the Annapolis Valley, and then as we head up toward the Cape Breton area and the northeast, the burden of illness rises quite dramatically. We have looked at a number of indicators that are reflective of that. We've looked at the utilization of hospital services, which we believe is a proxy for illness. We found that it is income and education related. There's a mobility factor, which Stats Canada now includes. That's a five-year look at changes in population bands. We have found an extremely high correlation with five factors. Our sense is that it would not be unreasonable to at least look at that type of approach to this.

    As we begin to think about the shift we're seeing in terms of the CHST and the discussions taking place now that at the end of this accord there will be a Canada health tax, CHT, is it not time to at least raise the idea or consider that perhaps that CHT should be reflective of illness?

    Mr. Rob Merrifield: Getting back to the catastrophic drug program, what number would you be recommending as a province to be classified as a catastrophic amount?

    Dr. Thomas Ward: The majority of discussions at the FPT level are around semantics and definition as a beginning point. There are three components with regard to catastrophic: defining catastrophic, reasonable, and undue financial burden. Taking those pieces in reverse order, on the undue financial burden, both Mr. Kirby and Mr. Romanow were very clear about participation by the individual in some form of a co-pay. That could be a sliding scale based on previous year's income tax or a set level. There are different approaches across the country. I think that the catastrophic and reasonable parts will be harder to define, although I suspect that we can get there. The conversation is ultimately going to be around what provinces think is reasonable and where you start and stop on that.

    Mr. Rob Merrifield: I understand, but I was asking whether as a province you were recommending a certain number.

    Dr. Thomas Ward: We will be participating in the national process. Under the Advisory Committee on Information and Emerging Technologies, there is an FPT process to deal with the first stage, which is looking at those particular definitions.

    Mr. Rob Merrifield: Getting back to your own pharmacare program for seniors, you introduced a premium in 1995, as you were saying. Is that a yearly premium or a per-prescription premium?

    Ms. Emily Somers: It's an annual premium, and it is in addition to the co-pay. There are some income cut-offs. If you are below a certain income, there is no premium. If you're between two incomes, it's a sliding scale. Then there's the full premium for the seniors above that. It's an annual premium that has to be paid every year. It's in addition to co-pays per prescription.

    Mr. Rob Merrifield: You have the copayment as well.

    Ms. Emily Somers: Yes.

    Mr. Rob Merrifield: What kinds of changes have you seen in access and utilization since you introduced these?

    Ms. Emily Somers: When we introduced the premium, there was a lot of confusion among seniors, and there would have been a dip.... Is that what you mean, the change in the number of seniors joining the program and the change in accessing drugs?

    Mr. Rob Merrifield: It wasn't just more finances coming in, was it? Was that what you saw, or did you see a different pattern with regard to utilization?

    Ms. Emily Somers: We continued to see an increase in utilization. We had introduced these because we had already begun to see increases in utilization and in the price of drugs. We had to introduce some kind of cost sharing that was manageable for seniors and government. We have continued to increase the amount both government and seniors are paying, and it continues to grow significantly.

    Mr. Rob Merrifield: You said the premiums have increased as well.

    Ms. Emily Somers: Premiums were introduced in 1995, and they have increased as well since that time.

¸  (1415)  

    Mr. Rob Merrifield: What are they now?

    Ms. Emily Somers: The numbers?

    Mr. Rob Merrifield: What is a premium? How much?

    Ms. Emily Somers: An individual senior pays $336 per year if they are above a certain income amount.

    Mr. Rob Merrifield: What is it if you are under that?

    Ms. Emily Somers: If your annual income is below $20,000 per year, I think it is, there is no premium, and there's a sliding scale from about $20,000 to $26,000, where you pay some portion of the $336.

    Mr. Rob Merrifield: You mentioned direct-to-consumer advertising as being a problem. Have you seen it being abused? We have a law in the country that says it's illegal, but nobody is monitoring it. I'm wondering if you've seen abuses of that law. Have you aggressively pursued action against the advertisers because of that?

    Ms. Leanne Jardine: Yes, we have seen that, but no, we have not pursued the advertisers. Is that what you asked?

    Mr. Rob Merrifield: Do you see the law not being complied with?

    Ms. Leanne Jardine: We have spoken to Health Canada, as opposed to the advertisers, about the enforcement of that.

    Mr. Rob Merrifield: Because it's a federal law, you report it to the federal government. I'm wondering if you've pursued that with the federal government.

    Ms. Leanne Jardine: In discussions on direct-to-consumer advertising, yes. However, those discussions took place several years ago. There haven't been any discussions recently between our province and Health Canada on that topic. My understanding is that they have been looking at it for the last number of years. But as far as us going to them recently is concerned, no, we have not.

    Mr. Rob Merrifield: Are you going to them just to discuss the problem or to have the law tightened, to say we have a problem here and it has to stop?

    Ms. Leanne Jardine: Several years ago when the discussions were active, New Brunswick participated in the federal/provincial/territorial committee that recommended that the regulations not be made looser than they currently are and that Health Canada consult with the drug plans if there were to be any changes with regard to direct-to-consumer advertising regulations.

    Mr. Rob Merrifield: If I can interpret what you just told me, then, it's not that you are finding abuses here and blowing the whistle on those, it's that you're looking at it more from a policy perspective.

    Ms. Leanne Jardine: Yes.

    Mr. Rob Merrifield: Therein lies the problem. In Canada we have a law, and unless you blow the whistle, it actually doesn't come into play.

    Dr. Thomas Ward: I think the pragmatic reality is that the majority of jurisdictions have just given up at a certain point in time. If you keep sending letters--

    Mr. Svend Robinson: To Health Canada.

    Dr. Thomas Ward: --yes--and nothing happens, it's a waste of time.

    Mr. Rob Merrifield: Have you ever had any responses from Health Canada?

    Ms. Leanne Jardine: Only through the FPT process, and it was an information process they were looking at. But not with regard to any complaints that may have been laid or any of the alleged abuses that have come out in the media.

    Mr. Rob Merrifield: Thank you.

    The Chair: Mr. Ménard.

¸  (1420)  

[Translation]

    Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ): Thank you. I apologize if I sometimes look like I'm dozing off, but I have a bit of a cold and I'm taking some medication. Nevertheless, I'll try to ask you some good questions.

    Mr. Svend Robinson: Did you take a generic drug?

    Mr. Réal Ménard: Here's what I took, Mr. Robinson. What do you think about that?

    Mr. Svend Robinson: I see.

    Mr. Réal Ménard: In your presentation, Ms. Jardine, you mentioned rising costs. Committee members have seen the summary of the federal-provincial-territorial committee studies, and I'm intrigued by something you said in the course of your explanations. You refer to “marketing” and to “manoeuvres de couloir”. What exactly do you mean by that? At last that's what the French translation says. You'll find it one page 2, on your second slide. You list the registration of new drugs as one factor tied to rising costs, along with increased use, marketing and “manoeuvres de couloir”. We know all about backdoor manoeuvring in parliamentary circles, but could you explain to me what this means in terms of the pharmaceutical industry?

[English]

    Ms. Leanne Jardine: I don't recall using the term “backdoor” or suggesting that.

    Mr. Réal Ménard: That's speculation.

    Some hon. members: Oh, oh!

    Ms. Leanne Jardine: What I refer to there is how the pharmaceutical industry sells their drug by direct-to-consumer advertising for the patient side. The marketing is directly to physicians in their offices by pharmaceutical representatives and also directly to health professionals in health professional journals. The marketing is the practices of selling.

[Translation]

    Mr. Réal Ménard: I see. Some witnesses recounted how large pharmaceutical companies invested $20,000 per physician in an effort to convince them to prescribe their particular brand of drug. The influence-peddling is very real. In some respects, these pharmaceutical companies behave liked pill pushers. Should we be recommending that either the Patented Medicine Prices Review Board or Health Canada—I'm not sure which it should be—be required to keep a register of all drug samples in circulation? That way, all unsold drug samples would have to be reported to Health Canada. If a pharmaceutical company distributes 300 samples of a particular drug to physicians, I imagine it expects these physicians to actually prescribe that drug. Would you be in favour of this type of register, along with mandatory reporting of all samples distributed by pharmaceutical companies?

[English]

    Ms. Leanne Jardine: Are you asking whether having a registry of the samples would help in determining the volume that was distributed to physicians and that somehow you could correlate that with prescribing increases?

¸  (1425)  

[Translation]

    Mr. Réal Ménard: I'm asking whether you believe a register would help alleviate the problem of influence-peddling by pharmaceutical companies. The basic assumption is that a correlation exists between the samples distributed and the prescribing of the drugs by physicians. Right now, it's all rather nebulous. Companies give gifts to physicians, invite them to conventions and distribute drug samples, but all of this activity is hush-hush. I've been thinking about this idea for some months now and I hope to convince my colleagues to support me. Should such a register be the responsibility of Health Canada or of the Patented Medicine Prices Review Board? I can't answer that question yet, but do you think we should put forward this recommendation?

[English]

    Ms. Leanne Jardine: It might be helpful.

    One challenge I would see is that a lot of the samples that are distributed are never used and end up being discarded because they go out of date. Personally, I don't think the current sampling process is a good way to go. Something should be done about the sampling process itself. One of the patient safety issues that comes up is patients receiving expired samples or taking home samples and using them at a later date, and they are not tracked on the patient's drug profile at a pharmacy.

    Several initiatives have come up over the years to get rid of sampling altogether. While that has a lot of benefits, there might be a downside for very low-income people. Sometimes physicians give samples to people who do not have the means to afford the drugs themselves and are not eligible for drug programs.

    I would be more in favour of changing the sampling process so that the samples patients get could be captured by the pharmacist on their drug profile, rather than have a registry. As I said, a lot of samples aren't used.

    Although you might get a general idea about the volume of samples for drug X and how it increases the drug prescribing for that particular product, I don't think it would be all that accurate to have the registry.

    Dr. Thomas Ward: In terms of those types of issues, I think it is fair to recognize upfront that there's not congruence between the goals of the pharmaceutical manufacturers and a publicly funded health care system. One presumes that the pharmaceutical manufacturers have some interest in providing a reasonable rate of return to their shareholders, whereas for the publicly funded health care system, I presume we are trying to provide to the public, who's paying, the maximum benefit for the least amount of dollars. In spite of any campaigning otherwise, that's a pretty basic fact.

    The issue about how drug companies bring drugs to the market is a challenge for all of us. Awhile ago we had an issue around Remicade, which is an anti-inflammatory. It was provided to a large number of researchers in academic centres. Patients were on trials for some time. Toward the first part of September, most of the deputy ministers received a letter from the manufacturers suggesting that they would be stopping the drug trials at the end of the month and that we should all want to pick up this drug. Remicade is quite expensive. I think the interesting thing with regard to Remicade is that it has now been shown to have some very powerful side effects, and it is certainly not the first drug of choice as an anti-inflammatory.

    We in our jurisdiction had a recent issue with regard to a new low-cost proton pump inhibitor, which is a nice way of saying an antacid. It came to the market, and through our pharmacare program we sent a letter to our family practitioners suggesting that they choose that as the first drug of choice, rather than going to a higher-cost PPI, such as Losec. We created a firestorm. We had presidents of drug companies writing us and wanting to see the minister. It was all about a very simple thing that would have saved the public money. The view of the drug companies was that we can't do that. My view is we're paying for it, so of course we can do it.

    With regard to the issue you raised about some of the benefits physicians receive in terms of educational programs and all the rest of it, if it's truly a benefit, then perhaps if it were made a taxable benefit, it might create some sense of worth in it. Let's be frank, there are some options there.

    The last piece is just the massive number of pharmaceuticals. Health Canada usually approves 100-plus medications annually. Last year one of them was a new class. The others were 100 versions of the previous drugs. If you read all the drug companies' material, somewhere in the midst of all of the proton pump inhibitors, one of them has to be the best. We can't have 27 best. There are difficulties in this, and the real issue is how one sorts their way through these particular pieces.

[Translation]

    Mr. Réal Ménard: Are you relatively satisfied with the mandate and role of the Patented Medicine Prices Review Board? For example, if we were to recommend that the role of the PMPRB be expanded to include the reviewing of generic drug prices, would you be amenable to such a proposal? Do you think we need to include, for comparison purposes, more countries when we attempt to determine what is, or is not, a reasonable price? Some witnesses indicated to us that we should be comparing Canada with Australia and New Zealand, two countries with interesting drug policies. How do you view the role of the PMPRB?

[English]

    Ms. Emily Somers: We feel that PMPRB has been very effective in keeping the price of patented medicines within the median of the seven comparative countries. However, we have seen increases in the cost of single-source generic products and multiple-source products. So we feel that PMPRB may be the right organization to start looking at generic products to see if we can't do better. If you look at where our generic product prices are going, you'll see that they're actually quite far above the median of the seven comparative countries. So we would be supportive of that as well.

    With regard to the basket of countries, we've talked about this forever. We need to take a look at that basket of countries. I know that New Zealand and Australia have been talked about a lot, but there could be other countries. We just need to re-examine that to see if we shouldn't be putting together a new mix of countries.

    We probably need to do something about the introductory prices of drugs. There may be something PMPRB can do to keep a downward pressure on them. Right now they use the term “non-excessive”. Maybe we need to move to something like “reasonable” instead of “non-excessive”. But we do see that PMPRB could probably play a much greater role in helping us with drug prices.

¸  (1430)  

    Mr. Réal Ménard: Thank you.

    The Chair: Thank you, Mr. Ménard.

    Ms. Bennett.

    Ms. Carolyn Bennett (St. Paul's, Lib.): Thank you very much.

    I was quite intrigued by the burden-of-illness issue. I don't know what the reality of your life is, but it may be that most of your healthy people are moving to central Canada or something. How do you square that off with what we know we have to do in prevention? If we had a funding formula around the burden of illness, how would we be incenting funding for prevention? There was the discussion paper in Britain where it spoke about whether you should put tobacco cessation products on a formulary and make rules such as people only get it once, when we know that it takes eight times for people to stop smoking. How do we deal with the reality of the burden of illness and then incenting people to try to keep people well?

    Dr. Thomas Ward: The issue about keeping well is the fundamental issue around primary health care reform. Presumably, it is a re-engagement of Canadians in a process in which they take a growing responsibility for their own health. I do not think that as a country we have spent enough time investing in that type of work. We are quite happy to put half a billion dollars a year toward the Canadian Institutes of Health Research, which are primarily looking at disease mechanisms or finding a better magic bullet for diseases, when we should be spending as much money on how we engage those particular communities.

    As we are gaining more knowledge and moving away from the traditional medical model to a population health model, a lot of good work is being done in the world, such as in the OECD countries around their issue of approaching the broader determinants of health. I think that's something we should be looking at nationally. When you look at a jurisdiction such as Denmark, in which there are no long-term care facilities--they have a community-based model of care for seniors--you'll see there are lessons that we somehow have failed to transfer either to our public system or, more importantly, to the policy arena. We spend a lot of time talking about knowledge transfer from the research lab to the bedside. We need to talk about knowledge transfer from the research lab to the policy arena, not only provincially but nationally.

    On the issue of how you balance those pieces, it is really when we begin to think more about the role of social housing and pharmaceuticals in maintaining families and individuals in the community in a way that they can care for themselves or their spouses. I think that is where we should be focusing.

    Is it going to be a difficult national debate? Absolutely. As a nation--this is strictly a citizen's viewpoint--at some point in time we are going to have to go through the debate that virtually every other publicly funded jurisdiction has gone through, and that is around the question, what can the average Canadian citizen realistically expect from their publicly funded health care system? If the answer is everything, then we need to change our model. If we're of the view that it will have some boundaries to it and will require greater public participation, then I think we should get focused on doing that and on doing that now.

    I think that for some sectors of the population in the country, we have really missed the boat. Let us be frank that when it comes to our relationship with and care of first nations communities in this country, they are basically third world countries. In our province the average life expectancy for a male is about 77 years. For members of our Mi’kmaq community on the Eskasoni Reserve, it's 47 years. That's like Africa. That's ridiculous. We do recognize that there is a huge problem of childhood and adolescent poverty and the need for some support with medications and care, which means being able to have decent meals and housing. I do think we have to have a conversation about trying to balance those pieces.

    There is the growing population of single parents, particularly mothers with children, and, remarkably, for some jurisdictions, such as our own, there is a new and very challenging population, and that is a lot of elderly women who have spent their lives caring for their husband, who has now died, a rising population of women over the age of 85 who are absolutely destitute and can't afford anything.

    We do need to have a conversation about how we balance these pieces. Ultimately, for any government the role will be, is it medication, social housing, or buying yet another MRI to find more disease?

¸  (1435)  

    Ms. Carolyn Bennett: Someone suggested a drug agency. Do you think that's something you in Nova Scotia would support?

    Dr. Thomas Ward: I certainly think it's worth a conversation.

    The Chair: Thank you, Ms. Bennett.

    Mr. Robinson.

    Mr. Svend Robinson: It's worth a conversation. That's a rather equivocal statement. If I were trying to understand whether Nova Scotia supports the recommendation for a national drug agency and, I might add, a national formulary as well--those are two of the half dozen recommendations on prescriptions drugs.... Is Nova Scotia's position that there should be a conversation?

    Dr. Thomas Ward: Our answer is that we think it would be a very good idea. The question is, is there an appetite on the part of the federal government to move that discussion forward?

    Mr. Svend Robinson: Fair enough, but your position is that it should be moved forward.

    Dr. Thomas Ward: We have a national health care system in theory. What we actually have are 14 different health care systems--ten provinces; three territories; and the federal government's commitment to first nations, the armed forces, and the RCMP. There are 14 different programs, when we should have one.

    Mr. Svend Robinson: I just wanted to comment before asking a couple of questions. On the whole issue of per capita, I'm with you absolutely on that. If you needed any example of the injustice of a per capita formula, of course it was with regard to the treatment of the three northern territories in the most recent health accord. Fortunately, through a lot of sustained pressure and the support of the provinces, we were able to recognize that there are some fundamental distinctions. I was in Iqaluit earlier this year. The statistics with regard to childhood respiratory illnesses in the first year for Nunavut are devastating, the highest in the world, actually. Something like 60% of all the kids up there have to see a doctor because of respiratory problems in their first year of life. So per capita is a huge problem, and I'm glad to hear you mention that.

    We heard earlier today what I thought was quite compelling evidence from Dr. Allan Abbass, who is the director of the Centre for Emotions and Health at Dalhousie University. He talked about how not nearly enough work is being done in terms of looking at alternatives to just more drug pushing and use of medications. One example is the whole issue of brief psychotherapies for emotion-driven disorders, such as depression, anxiety, eating disorders, and so on. It would save a lot of money and is quite efficient, and yet, according to Dr. Abbass, it lacks support. He's here in Nova Scotia. I want to ask whether this is something the health ministry in Nova Scotia is prepared to look at in terms of some support. Are you aware of it?

    Ms. Emily Somers: Within pharmacare we focus on drugs. We look at alternative drug therapies, and occasionally we look at alternatives to taking drugs. But I'm not aware of this issue.

    Mr. Svend Robinson: I think it's a real concern. Maybe Ms. Jardine would like to comment on this. Perhaps it's different in New Brunswick. The point he's making is that it's all well and good to look at alternative drug therapies, but where there are viable alternatives that don't involve the use of medication, we should be looking at them as well. Are you prepared to meet with Dr. Abbass to look at the possibility that this may be something worth exploring and supporting?

¸  (1440)  

    Dr. Thomas Ward: We'd be quite happy to meet with Dr. Abbass and speak to him about that and any other program. We do suffer from one little jurisdictional hiccup, and that is that the Department of Health has responsibility for the seniors population. Community Services is our partner with responsibility for a large portion of the population, those below the age of 65. I'd be quite happy to undertake that. I will invite my colleagues from Community Services to the table to have the conversation.

    Mr. Svend Robinson: I appreciate that.

    You made a statement, Dr. Ward, that was quite shocking. You were basically saying we've given up in terms of getting the federal health department to explore and enforce the law, which is really all we're talking about at this point. Could you elaborate on that? You're one of the veterans among the deputy ministers of health in Canada. To what extent has this been an issue at FPT meetings? To what extent have provinces and territories urged the federal government to take some action on this? Conversely, what are you hearing from the federal government about possibly opening up more direct-to-consumer advertising?

    Dr. Thomas Ward: The FPT arena has been challenged in the last number of years in that what I believe would be the normal business of deputy ministers across the country has been overtaken by a couple of issues. Certainly, the blood issue caused the normal work that should have been done to be put aside, and every meeting was consumed by that. We went through about a year when we were getting back on track. Then we hit the accord in 2000, and we were back on track leading up to February 2003. I've tried to look at a way to streamline or utilize advisory committees to the Conference of Deputy Ministers, which are really advisory on the policy side about how these things might move forward.

    Suffice it to say that every ministry of health is tasked at the current time with just finding the staff. One of the remarkable things that has happened across the country as health care reform has occurred is that everybody has been pretty clear that there has been too much administration, so cut, cut, cut. When you are down to having only a few managers left, you really don't have the research and policy capacity--

    Mr. Svend Robinson: Back to direct-to-consumer advertising, how does that impact on that?

    Dr. Thomas Ward: Mr. Robinson, when I go to a meeting, it's not at the top of my list of big items. I might get an opportunity to pass on a note to the federal deputy or one of the ADMs to say it's still a problem. But I would suspect that from their viewpoint, they're also under a bit of stress in Ottawa at the current time.

    Mr. Svend Robinson: But you do continue to raise this as a concern.

    Ms. Emily Somers: As Leanne mentioned earlier, there were consultations around this several years ago, and we presented our point of view on direct-to-consumer advertising. I think there were actually two or three different consultations. Maybe we're all too patient, but we're still waiting for the outcome of that consultation.

    Mr. Svend Robinson: So there has been no public outcome.

    Ms. Emily Somers: No, there hasn't. What Dr. Ward says is true. We're all consumed with other issues. We thought something was going to happen in this area, but it hasn't. As far as us starting to hammer away again at this issue is concerned, we've been waiting for something to be published as a result of the consultations that were held several years ago.

    Mr. Svend Robinson: That's certainly something we can follow up on.

    Do I have time for one very quick final question?

¸  (1445)  

    The Chair: Yes.

    Mr. Svend Robinson: To Ms. Jardine, we did hear evidence earlier today from New Brunswick. Dr. Margaret Dykeman, from the Community Health Clinic in Fredericton, stated in her brief “...no tracking system currently exists in New Brunswick to record and report the number of narcotics that any one individual can access”. I wonder if you can comment on that, whether anything is being looked at to put that kind of tracking system in place. B.C. has PharmaNet, which works very well. I'd be interested to hear from our witnesses whether they're looking at a similar concept in their jurisdictions.

    Ms. Leanne Jardine: We have a tracking system, and we collect data on our beneficiaries under the New Brunswick prescription drug program. We're not a universal program. We don't have the legislation or jurisdiction to track usage of narcotics for anyone other than our beneficiaries. If we were to track it for all residents, we would need that legislation in place. Further to that, we would need a system, which costs a lot of money. So two things would have to happen: the ability and the jurisdiction to collect the information and then the system in order to do it. We are looking at various options, but it has been in the context of the development of our one patient/one record electronic health record. That is somewhat long term. We are also looking at it with regard to our work on providing catastrophic drug coverage more broadly in New Brunswick, and a system will be needed in the event that is put in place. So no, it doesn't exist in New Brunswick. Yes, it would be wonderful to have a system like B.C.'s. But at the present time we don't.

    Mr. Svend Robinson: You need government to bring it forward.

    Ms. Leanne Jardine: And it would take a lot of funding and resources.

    Mr. Svend Robinson: How about Nova Scotia?

    The Chair: Leanne said something I want clarification on. You said you don't have the money to create the system. You also said you don't have jurisdiction. But don't you license your doctors who write the prescriptions and your pharmacists who dispense them?

    Ms. Leanne Jardine: The jurisdiction is with regard to collecting personal information on patients.

    The Chair: Are you saying people who are on social assistance, for example--

    Ms. Leanne Jardine: We collect that data--

    The Chair: --don't have the same rights as citizens who aren't on social assistance?

    Ms. Leanne Jardine: No, not even close.

    The Chair: If you can collect personal data on people who are on social assistance, why can you not collect personal data on people with, say, private insurance?

    Ms. Leanne Jardine: The ability to do that is contained in the Prescription Drug Payment Act, which was written in 1975.

    The Chair: So the act says if the province is providing the payment for the prescription, we can collect the data.

    Ms. Leanne Jardine: Yes.

    The Chair: It seems that there are two classes of citizens. That's something I didn't know went on.

    Mr. Barrette.

[Translation]

    Mr. Gilbert Barrette (Témiscamingue, Lib.): Thank you, Madam Chair.

    You stated that you provide assistance to low-income individuals through community services. Are these services dispensed at the municipal, regional or riding level?

[English]

    Ms. Leanne Jardine: Our drug program is a central provincial program.

[Translation]

    Mr. Gilbert Barrette: You're referring to the program for low-income individuals, are you not?

[English]

    Ms. Leanne Jardine: The drug program piece is. Family and Community Services to access assistance is regional. But the drug program is a centrally administered provincial program.

[Translation]

    Mr. Gilbert Barrette: Must these individuals pay a fee, or are 100 per cent of the costs covered?

[English]

    Ms. Leanne Jardine: For Family and Community Services clients, adults pay $4 per prescription, and children under 18 pay $2 per prescription. But there is a maximum of $250 annually per family.

[Translation]

    Mr. Gilbert Barrette: My next question is for Dr. Ward.

    As Deputy Minister of Health, surely you've discussed with your minister the type of federal government initiatives that could be part of a Canada-wide program. Do you think individuals should receive a certain amount that they could do with as they please, or do you think funds should be allocated specifically for drugs? Or, do you think the government should be investing in some form of Canada-wide program, an option I think many people prefer?

¸  (1450)  

[English]

    Dr. Thomas Ward: There are two parts to that question. One of them very clearly is the issue of accountability for public money, whether it comes from the province, the municipality, or the federal government. It is very clear that one of the driving forces within the system of public governance in this country at the current time is a growing interest on the part of the public in value for money for anything. If we were to receive money from the federal government to support a catastrophic drug program, I would be more than pleased to report on how that money was being spent. I have no difficulty with that whatsoever. It is the public's money. They have a right to know.

    With regard to a national drug program funded by the federal government, my sense is that the majority of jurisdictions would be very keen to see that happen. It would certainly allow some levelling in the sense of at least recognizing on a national basis the burden-of-illness piece.

    I suspect that we would run into some difficulties at that level in two areas. At the current time the federal government is the regulator for medications, new pharmaceuticals or chemical agents, and you cannot make decisions around who should get what and be the person approving it. There's a fundamental conflict problem with that. That's one piece. It would put the federal government in some difficulty in that it may well find itself the target of many provinces in this respect, and I may end up leading the charge. If they do put a ceiling on the medications or types of medications and say this is what the national program covers, this is our concept of a reasonable catastrophic program, there would be some challenges. Many of the new medications we are now seeing, particularly for some very rare diseases.... We are receiving some signals from the pharmaceutical industry that we may see a medication coming out that could cost us as much as $600,000 per year per patient. Those are costs that become fundamentally a huge issue for a government that is struggling day to day.

    With regard to agents, there are a couple of areas in which we have not had a conversation. One is the issue of blood products and synthetic blood products. For the intravenous gamma globulins or fractionated blood products, internationally the costs are increasing by 40% per year. These should be controlled like medications, from my viewpoint. There are synthetic compounds, such as synergist. It is an agent to treat children so they will not get respiratory syncytial virus, a disease that can be very lethal, particularly in the first nations community or in children who are chronically ill, such as children with chronic heart or lung disease. We currently cover about 100 children a year in this province at a cost of $700,000.

    With regard to the area of genomics, the new gene therapies, do they not fall into this category? Does there not need to be some sort of national program or some controls on it? Even as of today we are having problems with the issue of gene patenting and other pieces, which health departments are pushing Industry Canada to deal with. They could have huge cost implications for us as a country.

    I would say that it is not just about what we do today. The committee needs to cast its view toward some of the things for the future. I do think that the discussions you're having need to be broadened to some extent.

    The Chair: Mr. Barrette, you've raised a point the committee has tried to get some information on in previous studies, and that is patents for genes, gene therapies, etc.

    I'd like to go back to this issue of direct-to-consumer advertising. You've probably seen the ad on TV for Twinrex, a vaccination to have prior to going south for fear you'll get hepatitis A or B. They advertise what might happen to you. They advertise what you have to buy. The committee inquired about that, wondering why it was allowed to be advertised on television. It was because it is a biologic.

    Having heard your comments a minute ago, do you think we should move toward banning direct-to-consumer advertising of products that are either biologic or genomic if they are to address a disease state or prevent a disease state? In other words, as the therapy--

¸  (1455)  

    Ms. Carolyn Bennett: If Health Canada had the money to do that.... That prevents a whole bunch of diseases from coming back--

    The Chair: Actually, it could be advertised without naming the precise product. The pharmaceutical manufacturers are restricted to an ad that might portray a condition and suggest that it's very dangerous to have that condition and that anybody who is having those symptoms or who might be exposed to that disease should ask their doctor--

    Ms. Carolyn Bennett: It's a vaccine.

    The Chair: But there may be others who design a vaccine, a treatment--

    Dr. Thomas Ward: On the issue of biologics and immunization or vaccination, the greatest benefits we've seen in terms of health care in the last century have been related to vaccinations in the management of infectious diseases. That's where the biggest--

    The Chair: But up until now it has been governments. A provincial government puts out an ad saying time to get your flu shot, time to do this, time to do that, as opposed to a company.

    Dr. Thomas Ward: I think that is based very clearly on preventing illness in the patient population.

    On the issue of genomics, I think the challenge as we move forward will be the cost-benefit issue. Do these changes actually improve patient outcomes on longevity?

    The patent piece is a huge problem. I'm sure you're aware of what happened in Ontario. BRAC1 and 2, which are the markers for a higher incidence of breast cancer, have been patented by a firm in Utah. When the Ontario government went to a different test, that firm took it to court saying we have the copyright on these genes. That's ludicrous.

    The federal government and Industry Canada need to get their mind around the fact that we have to manage these pieces. If that's not done and somebody comes up with a gene therapy that fixes some type of cardiac disease or some underlying genetic lung disease, which very clearly could save the systems multiple millions of dollars over time from investment, and they hold the patent, as do drug companies today, they may say the cost of this drug for this gene is $100 million. When it comes to the future, we're really talking about balancing the need of a publicly funded system to improve and maintain the health of the population against recognizing that developers of chemical compounds, genetic compounds, or biologics do have a requirement to receive some recompense for their studies. But again, it's a matter of balancing that against how many of those we need.

    The Chair: I want to hear part 2 of your story with regard to sending a letter to prescribing physicians about preferring one drug over another, one drug being much cheaper than the other, and then getting all the phone calls from the pharmaceutical companies. Did you win that battle, or did the politicians cave in to the pharmaceutical companies?

    Ms. Emily Somers: The policy did not change. There was a slight modification to the policy, but it was implemented pretty much as announced. Just to make it perfectly clear, there were two pieces. We were going to switch people to this lower-cost therapy, and all new patients would have to take this lower-cost therapy. We decided to drop the switching piece. If people were stabilized on something, we would leave them on it. But all new patients needed to start on the lower-cost therapy. That seemed to be a middle of the road....

¹  (1500)  

    The Chair: A compromise. It's quite amazing, though, that these companies would phone the provincial department and throw their weight around, is it not?

    Mr. Svend Robinson: They do that all the time.

    The Chair: I know they do.

    Dr. Thomas Ward: That is not unusual.

    The Chair: I wasn't suggesting that it was unusual.

    Mr. Svend Robinson: Keep talking about it. Keep going.

    Dr. Thomas Ward: You've heard from everybody else about the issues. I don't think there's anything new under the sun. They're into heavy-duty marketing and heavy-duty arm-twisting.

    Mr. Svend Robinson: And lobbying.

    Ms. Carolyn Bennett: If there are 22 dishwasher detergents on the market, there are only so many dishwashers, and you only need so much soap. If you approve x number of proton pumps and you explain to physicians which is the cheapest and which works just as well or that there must be some practice guidelines on this, why does it cost more? That's something I still don't understand, why more of them are approved if the doctors are only going to prescribe one.

    Ms. Emily Somers: Are you asking why the addition of a new drug to a category might all of a sudden cost more?

    Ms. Carolyn Bennett: Yes.

    Ms. Emily Somers: Often, when a new drug comes to market, the market grows all of a sudden. People who have failed similar therapies in the past will be tried on this new product. With the COX-2 inhibitors, which just came to market, we saw the market grow hugely, because it was a new category of drug, and people who had failed previous therapies were tried on it. So that does happen when new drugs come to market.

    Ms. Leanne Jardine: The other thing it does is increase the noise in the marketplace, because there are more companies with a message about their drug in that category. There might have been two, and now there are ten. The noise in the marketplace to sell those products is increased that much.

    Dr. Thomas Ward: One of the challenges in the system is to recognize and understand that a fair amount of research, particularly the phase 3 and 4 clinical trials, is funded by drug companies. They are an economic presence in terms of the support of academic institutions.

    There are two pieces that are important in this, at least from my viewpoint. One of them is that how studies are approached tends to be taking the eighth generation cephalosporin and comparing it with the success of the ninth generation cephalosporin without having the discussion as to whether or not the ninth generation cephalosporin should go back and replicate the trial that compared penicillin with the first generation cephalosporin.

    Ms. Carolyn Bennett: For strep throat. It should come back to what it was doing.

    Dr. Thomas Ward: It should come back to what I would describe as that classic clinical piece. A recent article in the New England Journal of Medicine or The Lancet showed that hydrochlorothiazide, the core diuretic of 25 years, was as effective as most of the high-end pieces as the first-line defence against congestive failure.

    There is a glimmer of hope in that the editors of the five or six leading medical journals in the world have now agreed to print what they believe are important clinical trials in which there are negative results; that is, the new high-end medication is studied against the other medication, and there is no proven benefit. We have never seen that before. Why would you publish a negative study in a scientific journal? I think the answer is that somewhere along the line, those studies do have to be published.

    So I think there are important pieces, but there's room for improvement.

    The Chair: We'd love to continue this conversation. It has been most interesting. But because of our travel plans, we have to shut it off.

    On behalf of the members of the committee, I want to thank you very much for coming. I also want to thank you for the work you do as you struggle with these issues on a daily basis. We reserve the right to come back and ask you questions via the telephone or e-mail. Thank you for your expertise and for your work.

    The meeting is adjourned.