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37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Tuesday, September 30, 2003

0905

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

Dr. André Corriveau (Chief Medical Officer, Health and Social Services, Government of the Northwest Territories)

0910

The Chair

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

0915

Dr. André Corriveau

Mr. Rob Merrifield

Dr. André Corriveau

Mr. Rob Merrifield

Dr. André Corriveau

Mr. Rob Merrifield

Dr. André Corriveau

Mr. Rob Merrifield

Dr. André Corriveau

Mr. Rob Merrifield

The Chair

Mrs. Betty Hinton (Kamloops, Thompson and Highland Valleys, Canadian Alliance)

0920

Dr. André Corriveau

Mrs. Betty Hinton

Dr. André Corriveau

Mrs. Betty Hinton

Dr. André Corriveau

Mrs. Betty Hinton

Dr. André Corriveau

Mrs. Betty Hinton

Dr. André Corriveau

Mrs. Betty Hinton

The Chair

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ)

0925

Dr. André Corriveau

Mr. Réal Ménard

Dr. André Corriveau

Mr. Réal Ménard

Dr. André Corriveau

Mr. Réal Ménard

Dr. André Corriveau

Mr. Réal Ménard

Dr. André Corriveau

Mr. Réal Ménard

0930

Dr. André Corriveau

Mr. Réal Ménard

Dr. André Corriveau

Mr. Réal Ménard

The Chair

Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.)

Dr. André Corriveau

Mr. Stan Dromisky

Dr. André Corriveau

0935

Mr. Stan Dromisky

Dr. André Corriveau

Mr. Stan Dromisky

Dr. André Corriveau

Mr. Stan Dromisky

The Chair

Mr. Greg Thompson (New Brunswick Southwest, PC)

Dr. André Corriveau

Mr. Greg Thompson

Dr. André Corriveau

Mr. Greg Thompson

Dr. André Corriveau

0940

Mr. Greg Thompson

The Chair

Mr. Greg Thompson

Dr. André Corriveau

The Chair

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

Dr. André Corriveau

Ms. Carolyn Bennett

Dr. André Corriveau

0945

Ms. Carolyn Bennett

1000

Dr. André Corriveau

Ms. Carolyn Bennett

Dr. André Corriveau

The Chair

Dr. André Corriveau

The Chair

Mr. David Bougher (Director, Pharmaceutical Policy and Programs, Ministry of Health and Wellness, Government of Alberta)

The Chair

Mr. Rob Merrifield

Mr. David Bougher

Mr. Rob Merrifield

Mr. David Bougher

1005

Mr. Rob Merrifield

Mr. David Bougher

Mr. Rob Merrifield

1010

Mr. David Bougher

Mr. Rob Merrifield

Mr. David Bougher

Mr. Rob Merrifield

The Chair

Mrs. Betty Hinton

Mr. David Bougher

Mrs. Betty Hinton

Mr. David Bougher

Mrs. Betty Hinton

The Chair

M. Réal Ménard

Mr. David Bougher

Mr. Réal Ménard

Mr. David Bougher

Mr. Réal Ménard

Mr. David Bougher

The Chair

Hon. Hedy Fry (Vancouver Centre, Lib.)

1015

Mr. David Bougher

Ms. Hedy Fry

1020

Mr. David Bougher

The Chair

Mr. Greg Thompson

1025

Mr. David Bougher

Mr. Greg Thompson

Mr. David Bougher

The Chair

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.)

Mr. David Bougher

Mr. Jeannot Castonguay

1030

Mr. David Bougher

The Chair

Ms. Carolyn Bennett

Mr. David Bougher

Ms. Carolyn Bennett

Mr. David Bougher

Ms. Carolyn Bennett

Mr. David Bougher

1055

The Chair

Mr. Greg Eberhart (Registrar, Alberta College of Pharmacists)

1100

1105

The Chair

Ms. Lori Turik (Vice-President, Public Policy, Canadian Association of Chain Drug Stores)

Mr. Jeffrey May (Director, Government and RegulatoryAffairs, Canadian Association of Chain Drug Stores)

1115

The Chair

Mr. Rob Merrifield

Ms. Lori Turik

1120

Mr. Rob Merrifield

Mr. Jeffrey May

Mr. Rob Merrifield

Mr. Jeffrey May

The Chair

Mrs. Betty Hinton

1125

Mr. Jeffrey May

Mrs. Betty Hinton

Mr. Jeffrey May

Mrs. Betty Hinton

Mr. Jeffrey May

Mrs. Betty Hinton

Mr. Jeffrey May

Mr. Greg Eberhart

The Chair

Mr. Réal Ménard

1130

Mr. Jeffrey May

Mr. Réal Ménard

Mr. Jeffrey May

1135

Mr. Réal Ménard

Mr. Jeffrey May

Mr. Greg Thompson

The Chair

Mr. Greg Thompson

The Chair

Mr. Réal Ménard

The Chair

Mr. Réal Ménard

The Chair

Ms. Hedy Fry

1140

Mr. Greg Eberhart

Ms. Hedy Fry

Mr. Greg Eberhart

The Chair

Mr. Greg Thompson

1145

Ms. Lori Turik

Mr. Greg Thompson

Ms. Lori Turik

Mr. Greg Thompson

Ms. Lori Turik

Mr. Greg Thompson

Ms. Lori Turik

Mr. Greg Thompson

Mr. Jeffrey May

Mr. Greg Thompson

Mr. Jeffrey May

Mr. Greg Thompson

Mr. Jeffrey May

Mr. Greg Thompson

Mr. Jeffrey May

Mr. Greg Thompson

Mr. Jeffrey May

Mr. Greg Thompson

Mr. Jeffrey May

1150

Mr. Greg Thompson

Mr. Jeffrey May

Mr. Greg Thompson

The Chair

Mr. Stan Dromisky

Mr. Greg Eberhart

Mr. Stan Dromisky

1155

Ms. Lori Turik

The Chair

Ms. Carolyn Bennett

1200

The Chair

Ms. Lori Turik

Ms. Carolyn Bennett

Ms. Lori Turik

Ms. Carolyn Bennett

The Chair

Ms. Lori Turik

The Chair

Mr. Réal Ménard

The Chair

Mr. Greg Eberhart

1205

The Chair

M. Réal Ménard

The Chair

Mr. Réal Ménard

1210

The Chair

Mr. Réal Ménard

The Chair

Mr. Réal Ménard

CANADA

Standing Committee on Health

NUMBER 051

2nd SESSION

37th PARLIAMENT

EVIDENCE

Tuesday, September 30, 2003

[Recorded by Electronic Apparatus]

¿ (0905)

[English]

The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good morning, ladies and gentlemen. It's my pleasure to welcome you to the second meeting of the travelling public hearings of the Standing Committee on Health as we work along in our study on prescription drugs.

This morning we have two witnesses in our first session. I'm going to beg your indulgence that we allow one of them the first half hour by himself because he has to catch a flight to get back to work.

From the Northwest Territories Health and Social Services, we have André Corriveau, the chief medical officer, who will present to us and whom we will question before we move on to the second witness.

Mr. Corriveau, the floor is yours.

Dr. André Corriveau (Chief Medical Officer, Health and Social Services, Government of the Northwest Territories): Thank you, Madam Chair.

To the members of the standing committee, good morning. Thank you for the opportunity to appear before you to present a perspective from the Northwest Territories on the important matter of prescription drugs.

I'm here on behalf of our Department of Health and Social Services. To begin with, it's important for us to mention that although the focus of your study appears to be on prescription drugs themselves, one of our main concerns in the north, in this area, relates to the supply of pharmacists. As a recruitment and retention issue, it may become a critical and limiting factor to ensuring high-quality dispensing of prescription drugs at the community level.

The apparent shortage in Canada of pharmacists, particularly hospital pharmacists, is impacting directly on small jurisdictions such as ours, as it probably does in other rural and remote parts of the country. The majority of our communities do not have pharmacy retail outlets. A significant fraction of prescription drug dispensing occurs through nurse practitioners working in health centres, with support from regional pharmacists who play an important role in terms of maintaining up-to-date formularies to provide advice and quality assurance in this area.

Furthermore, even in urban centres, a greater role could by played by pharmacists with regard to improving primary health care delivery in Canada, particularly with regard to the management of chronic disease conditions, monitoring of adverse drug reactions, and over-prescribing or direct prescribing, for example, in the case of emergency contraception.

Based on anecdotal evidence, we wonder to what extent the emergence of Internet dispensing outlets in Canada might be contributing to this current shortage of the supply of pharmacists. In any case, we do hope that the committee will not overlook this aspect of prescription drugs, albeit seeming only tangential to your main focus.

As with other jurisdictions in Canada, the rising cost of prescription drugs is another area of concern for us. It is certainly a multifaceted phenomenon that cannot be addressed with one single solution. Understanding the need for industry to expect reasonable returns on their investments, we nonetheless would like to see a more rapid introduction of generic drug competition as one means of containing the growth of prescription drug expenditures for Canadians.

In terms of better managing drug plan formularies, the NWT has been an early supporter of the newly established permanent FPT drug review process, now housed within CCOHTA, the Canadian Coordinating Office for Health Technology Assessment, with its Canadian Expert Drug Advisory Committee, CEDAC.

Given our own limited capacity to conduct assessments on many available prescription drugs, the NWT will now be able to rely on this expert committee to access objective reviews and recommendations as to the place the new drugs should have in our drug formularies.

Another area of concern for us, which also relates to drug cost in a multifaceted way, is that of direct-to-consumer advertising. I have abbreviated it as DTCA.

A recent commentary by David M. Gardner, Barbara Mintzes, and Aleck Ostry, published in the Canadian Medical Association Journal of September 2, 2003, highlights some of the issues and concerns that many of us share with regard to the practice of DTCA, which has been gaining ground in Canada almost by stealth.

Mainly, advertisements addressing the general public may be released without review by government regulators. Drug manufacturers can take advantage of loopholes and/or are unclear or perhaps overlapping on jurisdiction between the Pharmaceutical Advertising Advisory Board and the advertising standards of Canada.

Health Canada's apparent under-capacity to regulate, monitor, and respond to complaints with DTCA may be compounding the problem. DTCA creates and stimulates the uptake of new drugs that tend to be more expensive and offer only marginal benefits to standard therapies before all the unforeseen adverse effects have been documented.

The cost of DTCA ends up being passed back to consumers, both in the price itself as well as in higher insurance premiums and taxes to support pharmacare programs. Under the pretence of supporting the consumer need and right to access information, DTCA tends to present messages that seldom make reference to the illness, risk factors, alternative treatment options, and the medication's success rate or its cost-benefit ratio.

¿ (0910)

In the context of the NWT, consumers may also have a more limited understanding of the English language and be more vulnerable to the sales pitch for newer and better cures, which could add a further strain on our ability to provide the best possible care within limited resources.

Another area that we feel best warrants some attention is that of physician-directed marketing activities by drug companies. Although there may not yet be conclusive evidence that these marketing activities influence prescribing patterns, there should be no doubt that they are done at significant costs on the whole and consequently contribute to the ultimate price of prescription drugs.

Many of those activities are indeed subject to ethical pronouncements by professional groups and colleges. However, there would likely be some benefit to having such activities remain under some degree of active oversight by an independent body, such as the PAAB, for example. In this area, the same issue of the CMAJ that I quoted from earlier presents a common theory by Ray Chepesiuk, who highlights potential concerns related to the practice of distributing advertisements disguised as educational material derived from meetings or study reports for which the intended physician audience may be unaware have not been subject to independent assessments.

By the way, I did provide copies of these articles for the chair so that they could be circulated.

Adverse drug reactions represent a non-negligible proportion of overall health care costs in Canada. We feel that there is a need to strengthen post-marketing surveillance systems and activities for monitoring and reporting on adverse reactions to drugs and vaccines. We suggest that this could be integrated with other efforts to enhance patient safety that are presently occurring across Canada.

Finally, relative to large provinces, the NWT's spending on pharmaceuticals may appear to be small, but direct and indirect costs associated with prescription drugs represent a relatively significant proportion of our overall health care expenditures. Pharmaceuticals management is an area where continued pressure is having an impact on the limited resources we have to provide health care, and we're therefore thankful to this standing committee for this opportunity to be heard.

The Chair: For those who have just arrived, Dr. Corriveau has to catch a flight back to the Northwest Territories, so we're going to begin the questioning right now.

Mr. Merrifield.

Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you for coming in.

I guess the question we have to ask ourselves when you talk about direct-to-consumer advertising is whether advertising is about information or about exploitation. That is what you have to weigh.

I'm wondering if you're sensing or seeing that direct-to-consumer advertising and the spillover from the United States stations—via satellites, I would imagine—is more of a problem in the north than it would be throughout the general population of Canada, or is it just something you're alerting us to as a potential problem?

¿ (0915)

Dr. André Corriveau: I think the thing for us was to alert the committee that it's an issue that requires a little bit more investigation and that it should not be overlooked.

From our reading of the article, we tend to agree that there's been some movement in this area that hasn't really been sanctioned at this point, or that there's a grey zone in how it has been moving forward within our own country despite the regulations that should be limiting it. So we just want to make sure that this committee gives it a good hard look. I'm not trying to comment about the motives, but I think there's an issue here that we need to be wary of.

Mr. Rob Merrifield: I'm intrigued a little bit by your suggestion that you have a problem with pharmaceuticals or pharmacies trying to get enough dissenting people in the north to be able to deal with the issue of pharmacies, and that they're looking at the Internet as a potential solution to that.

Is that what you're alluding to?

Dr. André Corriveau: No, I'm sorry. I guess I didn't make myself clear. We just have anecdotal evidence that.... We're having trouble recruiting pharmacists in the north. Even though we don't have a lot of outlets, even those that we have in our three regional hospitals have had a big struggle and lots of turnover. Some of the pharmacists we lost were actually recruited by those Internet dispensing firms. We don't really know that it's a major factor, but there's an issue around pharmacist supply in Canada.

Pharmacists, we feel, have an important role to play in the management of prescription drugs overall. We can't just look at prescription drugs without looking at the people who actually make it happen or who can be of support and assistance to monitor what's going on and do adverse drug reaction monitoring and those kinds of things. For us, the issue of supply of pharmacists should not be overlooked when you look at prescription drugs. That's the point I was trying to make.

Mr. Rob Merrifield: Thank you for that clarification. I took wrongly what you were saying.

Is the whole area of addiction to prescription medication, or mistakes, let's say, in the pharmacy, something you're seeing a significant amount of? Could we get a bit of a handle on what you're seeing, either inside the hospitals or outside? Could we also have your comments about the degree to which you think the pharmacy should play a role in a checks and balances act?

Dr. André Corriveau: There is growing evidence from many industrial countries such as Australia and the U.S., and even in Canada, that adverse reactions to drugs are not an inconsequential component of our current health care cost burden in Canada. The effort to strengthen our capacity to monitor and improve the safety of prescribing also depends on not just the behaviour of the pharmaceutical industry, but our need to change our health care delivery system and involve pharmacists in it a little bit more proactively as a component of the primary health care system. That's another reason why we wanted to highlight the issue of the supply of pharmacists in Canada and their integration.

Mr. Rob Merrifield: In B.C. yesterday we were talking about the PharmaNet program they have there. Is that something you have or have looked at in the north?

Dr. André Corriveau: We don't have access to a direct link. We're struggling to improve our information systems overall for our health system, because we're very dispersed. There are issues around communications in the north concerning the types of infrastructure that could be used to develop good information systems.

Mr. Rob Merrifield: You haven't looked at that yet, then?

Dr. André Corriveau: Well, we're interested in it, but we're not there yet.

Mr. Rob Merrifield: Thank you.

The Chair: Ms. Hinton.

Mrs. Betty Hinton (Kamloops, Thompson and Highland Valleys, Canadian Alliance): Good morning.

Yesterday, as I was getting ready to come to listen to what was being presented across the country, one of the things that came to my attention from the Internet was for totally free prescriptions: “No prior prescription needed. Our U.S.-licensed doctors will prescribe your medication for free and have it shipped overnight to your door.”

You talked earlier about adverse drug reactions. I'm sure you would agree with me that having people order drugs over the Internet without any professional intervention is probably not a very good idea.

¿ (0920)

Dr. André Corriveau: I would agree with that.

Mrs. Betty Hinton: I thought you would agree. I was really quite shocked that this was happening.

With regard to the lack of pharmacists, it's not just the Northwest Territories that has that problem; I have it in my own riding, which is a major city in British Columbia. Do you have any idea—question number one—how we might be able to overcome that problem?

With regard to adverse drug reactions, obviously if people are getting drugs over the Internet we're going to have a serious problem, but the shortage of pharmacists is also causing problems, I think. I would like to hear your opinion on that, if I could, please.

Dr. André Corriveau: A lot of attention has been spent on doctors and nurses in the past several years because they're often seen as the front line of the system, but there are a lot of other people who are the backbone to that system as well—especially, I personally think, pharmacists and lab techs and other people.

We need another forum, when we look at the health human resources, to make sure we don't overlook some of those key players who may be fewer in number, to make sure we have a national approach to assessing the new requirements and creating positions or places in universities and training programs. There are often issues around remuneration and what job opportunities they have that explain why people aren't coming into the profession or why they're not staying in it. I don't have those answers.

Mrs. Betty Hinton: Is it your opinion that we do have a pharmaceutical personnel shortage?

Dr. André Corriveau: Yes, that is my opinion.

Mrs. Betty Hinton: Having come from a background where I was a pharmacy assistant in another life, I know the burden that is on pharmacists and assistants; they are front-line workers as well. Because doctors are so busy, it really falls to the pharmacists to double-check to make sure there aren't any interactions that are going to cause damage to the patient.

Do you have any thoughts on how we might encourage more pharmacists to go to university, or do you believe there's a shortage of spaces? I know there's been talk of a shortage of spaces for doctors to go through the university system. Do you find that happening with pharmacists as well, then, or is it just that there's a lack of interest on people's part to become pharmacists?

Dr. André Corriveau: I don't feel I'm able to comment at this point on the root causes, but in talking to some of the pharmacists who have left our area, some of them were offered better positions in the private sector and other people were.... But even just trying to recruit, we find that our health care system is not very proactive in identifying sectors. They spend all their energy worrying about doctors and nurses, and some of those other issues would be left to....

Mrs. Betty Hinton: To their own means?

Dr. André Corriveau: Yes, left to their own means.

Mrs. Betty Hinton: Thank you very much.

The Chair: Mr. Ménard.

[Translation]

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ): I would like to put the following idea to you. You have confirmed what several witnesses have been telling us: that there is a problem with pharmaceutical companies' promotion of the use of certain drugs.

What do you think of the idea of the committee eventually recommending the establishment of a registry within a system under which all of the drugs not sold would have to be declared? It is not yet clear in my mind if this should come under the Department of Health or the Department of Industry, but no samples or promotional material should be delivered to health care professionals, to doctors and nurses in public facilities, without the legislator and consumers being aware of the situation, given that one could think that if a pharmaceutical company distributes 6,000 samples of a given drug, it is with the expectation that the physicians who have received samples will prescribe the drug in question. One could see a link between the sale, the distribution of samples, the gift of promotional material and the faculty of doctors to prescribe the drug in question.

What do you think of the idea of having a registry to identify that which is not sold but that is part of the promotional material distributed by pharmaceutical companies?

¿ (0925)

Dr. André Corriveau: I will answer in French.

Mr. Réal Ménard: Well then, you are my idol. I will spend my holidays in the Northwest Territories.

Dr. André Corriveau: I believe it is an idea that is worth exploring. I cannot say at the outset that it would work, but the idea seems interesting and I would certainly encourage the committee to delve further into this.

Mr. Réal Ménard: Could you remind us of the population, and give us the approximate number of doctors and the names of the pharmaceutical companies that are represented within your territory? Are there branches?

Dr. André Corriveau: No, we have a drug distribution system. The population of the Northwest Territories is spread out amongst 32 communities, the population of which can vary between 18,000 people, in Yellowknife and 65 in smaller communities. We therefore have perhaps four communities with retail pharmacies and five communities with medical practices.

Mr. Réal Ménard: Do you have any indications to the effect that pharmaceutical company representatives are in operation within your territory?

Dr. André Corriveau: The representatives go where there are doctors. I cannot tell you if they visit retail pharmacies, but such is probably the case since they are in the same towns, in the same communities. So, yes, visits are made. These are representatives who come in from Alberta or elsewhere.

Mr. Réal Ménard: In fact, the main problems in your communities are common to the governments in the territories: a lack of medical personnel and difficulty in accessing first line resources. That is the reality you are faced with and you are worried given the number of drugs in circulation and the promotion carried out by the pharmaceutical companies.

Dr. André Corriveau: Indeed we are worried by the fact that with so few health care workers, when the public asks for certain drugs, we do not have as many means to monitor what goes on and there are mounting risks in our view because often a physician who is very busy will be tempted to give out a prescription instead of discussing the situation with the patient explaining to him or her that there are other less expensive and just as safe treatments available. That is therefore one of our concerns.

Mr. Réal Ménard: For comparison purposes, do you know which drug is the most prescribed in your communities? Is this information available?

¿ (0930)

Dr. André Corriveau: We do not have an information system that would give me the precise answer to your question, but we do know that prescriptions for antibiotics are higher, proportionately, than elsewhere in the country. We also know that there is a high usage of antipsychotic drugs, such as Valium.

Mr. Réal Ménard: If we were to compare your situation to that of Alberta or of Saskatchewan, for example, for the consumer, is the cost of retail drugs higher than elsewhere?

Dr. André Corriveau: It is a little higher because there are obviously transportation costs that are included as well as the operation costs of pharmacies.

Mr. Réal Ménard: Thank you.

[English]

The Chair: Thank you, Mr. Ménard.

Mr. Dromisky.

Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.): Thank you very much.

At the beginning of your presentation you made several statements pertaining to what I think was a kind of wish list regarding druggists or pharmacists and the kind of role they could play. I'm not too sure what you were driving at. It seems to me you implied that they should have additional training in order to play a more comprehensive role in the isolated communities in the north, as in any part of northern Canada where services are lacking.

We have nurses in northwestern Ontario who are practitioners. In other words, they assume some of the responsibilities of doctors in communities. Because there's a lack of doctors, some of these nurses have been trained to be practitioners in the medical field and assume some responsibilities. Is this what you're hoping will happen with druggists or pharmacists in your area, that they will play a greater role than just the dispensing of drugs?

Dr. André Corriveau: I wasn't commenting necessarily on the training, because I personally believe, having worked in several other provinces in my career as a primary care physician, that pharmacists, even with the training they've already received, are under-used in terms of their capacity to provide and enhance primary care services. In a sense, the shortages prevent us from using them to a greater extent to provide counselling to patients, and direct dispensing. Those things could be done now if we had more manpower.

You would have to ask pharmacists themselves whether they think they would need more training. From my experience, having worked in a system where we had pharmacists involved in the quality assurance mechanisms, travelling to health centres, helping the nurses in prescribing, doing their work, monitoring the system, and advising physicians, you need time to do that. If you're struggling to keep up from day to day, you don't have time to take these add-ons that are probably more critical for the quality of care you can provide.

Mr. Stan Dromisky: That leads right into my next question on your office. I have no idea how large your staff is. I don't know what kind of model you're operating under, whether it's comparable to other district health officers and administrative models and responsibilities in other parts of Canada. However, regarding your office and your set-up, I'd like to know whether there is some type of executive relationship between your department and the practising medical officers and dispensers of drugs throughout your district.

Dr. André Corriveau: It's not a direct relationship because basically I'm the only physician in this department of health. My main responsibilities are public health issues--SARS, and whatever comes up. But because I'm the only physician, because of my title, my role has evolved to provide some leadership functions within the medical community as well, which is not a very large community. In that regard, although our physicians are hired directly by our health authority--the hospital-based delivery agents in the community--I do have some influence on the debates and issues that are being addressed. So I can influence some of the organization of care, or the protocols that are being developed.

¿ (0935)

Mr. Stan Dromisky: You say you can only influence, but you cannot direct and control.

Dr. André Corriveau: I can only intervene if I feel that public health is being threatened in some way.

Mr. Stan Dromisky: You must have nurses on your staff, and so forth. If they get information pertaining to a patient who has been overdosed--in other words, the doctor has been continually renewing prescriptions, the person is already addicted, and one of your staff members discovers this--can you step into the picture and talk to the doctor about this patient who has really been heavily dosed or overdosed with medication that shouldn't be given on a regular basis?

If there's a problem out there and you know about it, what do you do about it? Do your nurses tell you? Do you tell the doctors? How much influence—the word you used—do you really have to deal with any of those kinds of problems?

Dr. André Corriveau: I don't really have a system to monitor it. My staff, as I said, are focused more on public health issues--environmental health and infectious disease control. Sometimes the public or other people will signal issues to me because of my title and the fact that they can look in the phone book and see “Chief Medical Officer”.

I do get notified of issues of this nature occasionally, and we have processes. For example, I can go to the medical director at the hospital in Inuvik and say I received a complaint about one of the physicians, or that there's a concern from one of the nurses about this or that. I can give them some advice on how to deal with it, but it's not a directed role.

We also have a formal mechanism for people to address complaints. We have a contract with a physician from Alberta, who is mandated by our minister to formally investigate complaints from the public on medical issues.

Mr. Stan Dromisky: Thank you very much.

The Chair: Thank you, Mr. Dromisky.

Mr. Thompson.

Mr. Greg Thompson (New Brunswick Southwest, PC): Thank you, Madam Chair.

I want to pick up on what Mr. Dromisky had to say about public health issues. You mentioned SARS, and so on, but I didn't hear you mention prescription drug addiction. Does that come under the guise as well of a public health issue?

Dr. André Corriveau: In my mind it does. Traditionally in Canada it hasn't been part of the core public health functions; it has been more of a mental health issue. I speak on these issues on a regular basis, because one of my roles, for example, is to highlight and publish the critical conditions or main issues for our system to address overall. So I will comment on those. But the way my office is structured and the staff I have are really focused on the traditional public health functions around environment, dumps, treating water, and prevention of communicable disease. So the core of my staff is around those issues.

Mr. Greg Thompson: How do the percentages break down in your jurisdiction of the Northwest Territories in terms of native versus non-native societies? How do those percentages play out in terms of drug addictions and problems, as you see them, if we're looking at public health?

Dr. André Corriveau: The population in the Northwest Territories overall is about 51% aboriginal and 49% non-aboriginal at the last census. But in practice, it's very unevenly divided within communities. Communities like Yellowknife and other regional centres are primarily non-aboriginal. Most of our communities are primarily aboriginal.

In our own work in looking at health status issues, we find that addictions are more correlated to economic status than to aboriginal versus non-aboriginal. There are obviously issues around other predisposing factors in aboriginal communities, like the whole issue around residential schools. But overall, when we look at this issue, it's related to economic conditions.

Mr. Greg Thompson: Okay, but that's code for saying it falls more on the native side. In other words, there's a bigger problem there, because if you look at socio-economic conditions, that's what you're talking about.

What specific recommendations could you make before this committee that we could do to help not only identify the problem but resolve that problem? I know there is probably not enough time, but are there just a few specific things we could do or recommend that could address that huge problem?

I'll just mention this one anecdotally. I met with some dentists from the northern community who gave me an example of how Health Canada works within the native community. A young native person is flown into Yellowknife for examination of badly decayed teeth. He is in a lot of pain, but they can't immediately perform any surgery or do anything. He winds up going back to the north country for two or three weeks with a huge bag full of prescription drugs to deal with the excruciating pain, when the problem could have been resolved that day or two days later.

In other words, there are some practices that are going on within the health community that you can identify very quickly, but it comes down to the bureaucracy being unwilling to deal with them and not recognizing the problems. It's very frustrating for physicians. That's just one small area they've identified as something that could be cleaned up or fixed immediately, but never has been.

Dr. André Corriveau: First of all, I would comment that you should be able to get that kind of problem resolved right away, although it may be an issue in other centres.

In terms of addictions, we don't have good evidence that prescription drugs are a major problem right now. The addiction that has been more prevalent in our communities has traditionally been related to alcohol, but there's a growing use of cocaine, illicit drugs, because--

¿ (0940)

Mr. Greg Thompson: But you had mentioned, sir--and again, I've no time, that's a problem--

The Chair: I'm sorry, Mr. Thompson, but I'm afraid you're over your time.

Mr. Greg Thompson: You had identified a couple of drugs that are basically being overprescribed or.... Wouldn't that indicate that there is a prescription drug problem?

Dr. André Corriveau: Well, there may be over-prescription of drugs among the elderly, for example, in the management of symptoms. Although they may not necessarily be addicted, they may be using more drugs than they should be. So I wasn't necessarily making a comment in an addictive-type context.

The Chair: Thank you, Mr. Thompson.

Ms. Bennett will be the last questioner, because Dr. Corriveau has to go.

Ms. Carolyn Bennett (St. Paul's, Lib.): Dr. Corriveau, you obviously have some specific issues in the rural and remote communities in the sense of health human resources. A group of us went north, and one of the messages we received was that the ability of doctors or nurses or, as you mentioned, pharmacists to be able to get out to continue medical education, or to take vacations with their families, seems to be a real deterrent in recruiting people for the north or other rural remote areas.

Is there anything you think we could do in terms of helping with this in a recommendation around being able to help pharmacists or physicians go in and out? Every time we propose something for our physicians, it seems quite clear that it wouldn't be fair if we did it just for our physicians and not for nurses and pharmacists and other health professionals as well.

So do you feel that's a deterrent for people who want to work in the north, that once they get in there there's nobody to replace them, and they're sort of stuck forever? This ranges from just taking vacations to keeping up with the data, I guess, in terms of CME or newer and better ways of dealing with certain conditions.

Dr. André Corriveau: To go back to one of my earlier comments, with regard to physicians, for example, looking almost across the country, I think the problem there has been solved. It goes back to the fact that the allied health professionals, including pharmacists, tend to be kind of overlooked or put for a later stage in terms of addressing some of those disincentives or retention kinds of issues. Even some of the federal, provincial, and territorial work that's done on health human resources tends to focus only on doctors and nurses.

So I think one recommendation that could be made is to make sure that when we develop a health human resource strategy we look at all the important pieces of the system and not just some of them, even though they appear to be, because of their numbers, somehow the more critical.

Ms. Carolyn Bennett: Is there anything we could learn by watching some of the smaller communities in terms of how health professionals work together and the role that nurse practitioners play in some of your remote communities in terms of prescribing? Perhaps when there are less drugs available, things are treated with things other than drugs. Is that...?

In terms of reassurance, in terms of the role of a social worker, the role of a proper multidisciplinary approach, do you think there are some things we could learn from the remote communities?

Dr. André Corriveau: I think so, and not just in the Northwest Territories. There are also parts of northern Quebec and Ontario, and B.C., I'm sure.

I just came back from a circumpolar health conference held in Greenland a couple of weeks ago. There's a lot of good practice going on out there, and we would like the ability to implement some of those best practices.

¿ (0945)

Ms. Carolyn Bennett: Should we be fighting for an IT system for you, where the federal government would pay its fair share?

À (1000)

Dr. André Corriveau: Well, as a territory, we'd like to see accelerated progress on the development of a health information system.

Ms. Carolyn Bennett: That would help you in your job in the sense that you could do your job much more easily if you had the data.

Dr. André Corriveau: Yes. In our case, the limiting factor often is the infrastructure in terms of bandwidth and so on to really expand our telehealth and other systems. So it's not the cost of technology per se, but the infrastructure limits that keep us at a slow pace.

The Chair: Thank you, Ms. Bennett.

Thank you, Dr. Corriveau, for coming down and rushing back. We know how busy you are, and we thank you for the work you do on a daily basis as well as your contribution to our deliberations.

Dr. André Corriveau: You're most welcome.

The Chair: Ladies and gentlemen, we'll now move on to our second witness, the director of pharmaceutical policy and programs with Alberta Health and Wellness.

Welcome, David. The floor is yours.

Mr. David Bougher (Director, Pharmaceutical Policy and Programs, Ministry of Health and Wellness, Government of Alberta): Thank you very much, Madam Chair, and thank you to the standing committee for the opportunity to discuss matters related to prescription drugs.

I want to address the committee in three areas, while first creating a context for the major challenges that are facing pharmaceutical care in Canada. I want to discuss those challenges in relation to the key stakeholders--there has been some discussion already about that--and to examine the framework for action and the need for innovative approaches in addressing the issues that have been identified.

Pharmaceutical care over the past few years has received significant attention because of the rise in costs. I would suggest there is a balancing part to that equation, which is that drugs do provide tremendous benefits for Canadians, and one of our biggest deficiencies and shortfalls is that we don't measure that value. We don't understand the benefits in quantitative terms that pharmaceuticals provide.

In 2002 Canadians spent over $18 billion on drugs, which comprised 16% of health care expenditures, and the public share of that amount has increased from 15% in 1975 to 36% in 2002. I think it's important for governments to exercise caution in seeking solutions to the cost issue, because the pharmaceutical marketplace is complex and the issues very much go beyond costs.

Policy designed to deal with costs may result in other undesirable effects, as Robyn Tamblyn from McGill University has illustrated through some of her research with respect to the impact of changes in drug programs designed for the use of seniors in the area of certain essential services. I would say there's a need for innovation and very inclusive approaches that engage all stakeholders in seeking solutions.

The challenges are four, as I would identify them. The first is the sustainability of public expenditures. In Alberta, our drug program expenditures have increased by 17.5% over the past number of years, an increase that's clearly not sustainable, but again, the other consideration is that perhaps we're spending the right amount of money, but we just need to look at how we're spending those dollars.

There are categories of drugs that are not being prescribed and used adequately, drugs for treating hypertension, for example. On the other hand, there are drugs that are being used, we believe, excessively in terms of cost-effectiveness. The cost-effectiveness issue is one of our key items, because there's a need for really strong, rigorous evidence in terms of supporting the value of drugs. There I think pharmaceuticals have the advantage over other health technologies and other services in that there's a much greater base of data and evidence to support what drugs in fact do. But we do need more cost-effectiveness analyses. The trials that result in drugs being approved for use in Canada are based on comparisons with placebos. Drugs that are approved on the basis of safety and efficacy don't really tell us very much when we're making decisions about what drugs we should be paying for in providing a benefit. How will drugs be used in the real world? We know they're safe in accordance with clinical trials, but that's the ideal setting. When drugs reach the marketplace, a number of other factors come into play.

Among the groups of drugs that have come out in the last few years are the biologics for treating rheumatoid arthritis and Crohn's disease. These drugs, which cost in the range of $15,000 to $20,000 a year, have provided tremendous benefits for many patients. But the concern we have about a new class of drugs such as this is whether or not there is long-term safety, long-term cost-effectiveness, and again, the value brought to the health system.

Primary health care is challenge number three, and the need to focus on primary care prescribing and the importance of better collaboration amongst health professionals. Pharmacists are the largest untapped resource in our health system. They have tremendous value to offer, and we need to promote systems that result in pharmacists, nurses, and physicians working more closely as teams.

The fourth challenge is information systems, the need for evidence-based decision-making, for decisions made on the basis of having the best possible evidence, and the importance of communicating drug information that is based on evidence. There are some concerns with respect to direct-to-consumer advertising. For instance, is this really informing the public? Is this providing information necessary to fully understand what the new drugs are all about?

We need pharmacies to be connected electronically with respect to medication profiles. Alberta is in the process, and has been for the last six years, of developing a pharmaceutical information network. It's not quite like British Columbia's PharmaNet, but it's a system that is in fact proceeding with the integration of these medication components into an electronic health record that will connect pharmacies and physicians throughout the province.

One of the issues we would welcome assistance on is the federal legislation that does not allow the electronic transfer of transmittal of prescriptions. There are some real barriers there, but I think on the PIPEDA legislation we're currently working with and having discussions with the federal government.

Moving on to the key stakeholders, the common objectives of stakeholders are for safe, effective, and high-quality drugs. For patients, patients want the best drugs that are available, and they want them at little or no cost. In the supplementary health insurance plans across the country the prescription drug components of those plans have been increasing, but those plans want lower costs and reduced tax burdens.

Health care professionals, physicians, want to do the best possible for their patients, and they resent many of the barriers that they see presented for patients who receive access to drugs under our public sector drug program. The pharmaceutical industry does an excellent job of research. They have shareholders to make sure they satisfy, and they have to be profitable. And governments are looking for optimal health care for the residents of their populations.

We also have governments who need to balance the areas of science and innovation and research with economic development. That's one of our challenges.

Moving on to a framework for action on primary health care, first is raising the profile of prescribing, integrating pharmacists on primary health care teams, and expanding the role of pharmacists beyond packaging and dispensing, making much better use of pharmacy assistants in the practice of pharmacy. I think the pharmacy manpower situation in Alberta is probably best described as tight. We continue to see new pharmacies opening. Certainly the impact of cross-border shopping has had some effect, but within government, we're not seeing a really critical shortage within this province.

We need national collaboration. Alberta's report of the premier's advisory council on health suggested that we need to pursue collaborative strategies to manage and contain our increasing costs, and Alberta is fully supportive of national efforts. One of those efforts is the creation of a national common drug review process, which is now in place, and establishing a national prescription drug utilization and information system to provide information to assist in policy development.

A review of generic pricing is another item on the national agenda. We pay significantly more, we believe, for generic drugs in Canada. The generic drug prices are pretty much pegged at Ontario's rate, because Ontario's process is legislated. When a new generic drug comes onto the market, it comes on and is reimbursed at a rate of 30% less than the brand name product. We need to streamline the generic listings on provincial formularies.

I want to talk about a couple of the Alberta initiatives we have been working on with industry and key stakeholders. I can give you three examples. First, the Institute of Health Economics is a unique organization, an example of partnership with industry, academia, and government. The research that is so important, involving all players, is conducted by the institute, which delivers outstanding research on health policy, economics, and outcomes.

The second example is a major project involving the drugs for treating osteoarthritis. You may be familiar with Celebrex and Vioxx, drugs approved a few years ago. These new drugs received a lot of public attention in addition to some cross-border advertising from the United States. Our expenditures for these drugs virtually took off. As a result of concerns about how these drugs are used, we're pleased that the pharmaceutical industry has invested significant dollars, a total amount of $3 million, in a project to try to understand how these drugs are in fact being used, and to develop strategies to achieve optimal care. These new drugs are not the best drugs for all patients with arthritis, and it's important to provide the information and education needed to make wise prescribing decisions. This particular initiative includes as well the Arthritis Society and professional groups of physicians and pharmacists within the province.

I've referred already to the post-marketing study with the biologics Remicade and Humira, drugs that run at $15,000 to $20,000 per year. As one of our conditions for paying for these drugs, we required and requested the companies to invest in post-marketing surveillance activities involving researchers and specialists. That work is proceeding.

Finally, on information systems, I've mentioned the electronic health record and the importance of providing prescribers and providers with the tools and information with which to make the best possible decisions. Too much decision-making goes on in isolation within the health system without comprehensive information on laboratory results and other medication use. We've moved quite far along with respect to development of the electronic health record for Alberta.

Just to conclude, we need innovation to make drugs available without bankrupting the health system. We need greater focus on primary care prescribing; on strong national collaboration; on effective partnerships with all stakeholders, including the pharmaceutical industry; and on developing the electronic health record, complete with medication profiles.

Thank you very much.

The Chair: Thank you, Mr. Bougher.

Mr. Merrifield.

Mr. Rob Merrifield: Thank you, David, for coming in. We actually go back to another life, when we had a lot to do with the health care system here in Alberta. I appreciate your coming in to talk about some of the issues.

Yesterday we found out--actually, over the last three weeks we've had witnesses come forward on this--that 50% of patients in hospitals have adverse reactions, and that most nurses, most doctors, cannot detect adverse reactions and make the diagnosis. They can't even recognize it. And we had testimony yesterday that 40% of drivers could be under the influence of some medication.

We could be doing all kinds of studies, because when we ask, “How can we verify it, and what kinds of studies are really being done?”, we find out there's not a lot happening. There are not a lot of studies looking at post-surveillance, looking at how dramatic the problem really is. Nonetheless, I think we'd have very little argument that there's a severe problem. So the degree of the problem we may not be able to pinpoint, but it doesn't really matter; I think we should be moving toward some of the solutions.

In B.C. they talked an awful lot about the PharmaNet program, which links the pharmacy and the patient, sort of, but not the physician. It's not mandatory. I understand in Alberta, through the wellness program, where you're looking at medical records following the patients, you're further along in that process.

Can you tell us a little more about how that program is working, and the timelines? I know there have been some pilot projects in the area. Perhaps you could tell us what's going on there.

Mr. David Bougher: If I could comment first on what we have as a relatively passive reporting system in surveillance for adverse reactions, it's an area I know Health Canada is strengthening, but we do know adverse effects have a significant impact on the use of health care resources. You're absolutely right that connecting health providers with the right information and allowing them the opportunity to provide feedback on the effects they see drugs providing to patients is going to be a key part of our system.

In answer to your specific question, the Wellnet initiative, which is Alberta's information system development, has now moved into the electronic health records phase, overseen by a governance body, and its implementation is proceeding fairly quickly. I'm on the electronic health records data stewardship committee that is overseeing the use, disclosure, and access to data, and there are a lot of issues. I think the key to the success of Alberta's approach is the inclusion of the stakeholders. The physicians representing the local associations, the pharmacists, and the health regions are all participating as stakeholders in the development of this system, and that's important to achieve buy-in and support for active use of the system.

Mr. Rob Merrifield: What kind of timeline are we on?

Mr. David Bougher: I believe over the next year is the timeline for the actual implementation.

À (1005)

Mr. Rob Merrifield: Okay.

Something I wasn't aware that you mentioned is that there is a federal law against medical records going through the Internet.

Mr. David Bougher: There is legislation at the federal level that does not allow electronic prescribing, and I can't speak to the details of that legislation.

Mr. Rob Merrifield: Do you see that as a hindrance to moving forward?

À (1010)

Mr. David Bougher: I think if physicians can be connected, so that the prescribing doesn't have to be handwritten, and if it can be done electronically, it provides a number of advantages from the point of view of accuracy and interpretation.

Mr. Rob Merrifield: And this is federal legislation.

Mr. David Bougher: It's federal legislation.

Mr. Rob Merrifield: I wasn't aware of that, but that's certainly something we should address as a committee. What is amazing to me is that we have federal legislation on something that is developing and moving forward. I can see legislation in the past, but that's being discussed so as to be able to hold the hands of technology as we move forward till we put these safeguards in place. Maybe we've evolved--

The Chair: Thank you, Mr. Merrifield.

Ms. Hinton.

Mrs. Betty Hinton: I found what you had to say very interesting. Some things were a little disturbing. I was unaware that they were spending $18 billion a year on drugs and 36% of that was paid by the public. That's a fairly large chunk of money.

I'm just going to ask you, from a professional standpoint, if you would agree or disagree with this particular statement. Personally, I agree with you that there is a very significant role for antibiotics, and I think they've saved an awful lot of lives, but would you agree or disagree that the key element we're probably missing in this country with the public is their own ability to build up their immune systems so that they're not as reliant on prescription drugs? From my experience, what happens with the prescription drug is that although it does what it's supposed to do, kills off a specific infection, it doesn't have the ability to pick and choose which infections it does kill off, so it kills off everything and leaves you open to the next bout of whatever comes along. Would you agree with that statement, or am I off the mark there?

Mr. David Bougher: There's a great deal of concern with the appropriate use of antibiotics, because they're not effective against viruses, and throughout the country there have been different initiatives. Alberta's has been “Do Bugs Need Drugs?” That initiative has been focused on educating. It goes into classrooms and into homes to educate the public that you don't need an antibiotic every time you get sick. I think it's been successful, because the statistics we've seen and industry has shared with us indicate that the use of antibiotics has probably dropped; it's one of the categories of drugs that has declined. We think that's positive, because the concern is with the development of resistance to antimicrobial agents and, as you say, the broad impact of these drugs on patients. Appropriate use of these drugs is one of the key issues in the whole pharmaceutical area.

Mrs. Betty Hinton: I also believe--this is a personal point of view and I've used it myself--hand washing is probably one of the best preventions of germs, and therefore you don't need an antibiotic. I personally haven't taken an antibiotic in 25 years. Your body has the ability to recover from a lot of things without having to take that. But what I've witnessed personally is the number of young children who seem to be getting more and more prescriptions at an earlier and earlier age, and they end up being less healthy by the time they're, say, 10 or 12 years old. Is that accurate, or again, am I not observing the right group?

Mr. David Bougher: I can't confirm that. I don't know through any research whether that's true or not. It may be, but I just don't know.

Mrs. Betty Hinton: Thank you.

The Chair: Mr. Ménard.

[Translation]

M. Réal Ménard: Welcome.

I have three short questions for you. You mentioned the idea of a new basis for comparison. When a notice of compliance is granted by Health Canada, there is obviously a clinical monograph and the research drug is compared with a placebo. A number of witnesses believe that this comparison should not be done in this way. In their opinion, we should be comparing the research drug with an already existing drug.

Are you in favour of that idea?

Secondly, I believe that Alberta participated in the federal-provincial-territorial task force on the evaluation of the cost of drugs. We were given three cost indicators. You are familiar with them: 50% for the increase; 18% for the fact that these are drugs that present very few new therapeutic effects, etc.

Has Alberta done any specific studies that you might share with us with regard to the reasons underlying the cost of drugs?

I did not fully understand what you said about new generic drugs. You said that you rely on Ontario rates as far as reimbursement is concerned. I would like to hear you explain that further. Those are my three questions.

[English]

Mr. David Bougher: Those are three excellent questions. One of our concerns with respect to clinical trials is that placebos are used as a comparison, so we don't have a really good standard of comparison. If a new drug is better than a placebo, it can be approved for use in Canada, as long as it meets the safety requirements. Head-to-head trials, trials comparing drugs to existing products, would be much preferred and would inform us a lot better with respect to the value this new drug brings. It's expensive, but it's the direction we need to move in.

As to analyses of costs of drugs and studies, we know what cost drivers are pretty well. Several categories are near the top, and in some of those cases it's good, because anti-hypertensives and drugs to lower cholesterol are important and valued products. In other cases, drugs for treating infections, antibiotics, as well as some of the drugs such as the proton pump inhibitors and drugs such as Losec, which are very effective...we're just not sure we should be paying for the amount of use of products like this. There are a lot of people on these drugs. I don't believe they were intended to be used for long periods of time. So we know what the cost drivers are. The bigger challenge we have is how we manage the use of these products appropriately to target patients who are going to get the most value for drugs.

[Translation]

Mr. Réal Ménard: With regard to costs, there is not agreement. For example, the pharmaceutical industry challenges the numbers. We are being told that it is in the two years following the introduction of a drug that the costs go up and that only 10% of these new drugs presenting new therapeutic effects are given a notice of compliance by Health Canada. There is therefore disagreement here. We have the cost drivers, but there is no agreement as to their relative and absolute importance.

Your Department of Health participated as such in the federal-provincial-territorial task force, but you have not done any in-house study that you could table with the committee. That is my understanding.

[English]

Mr. David Bougher: The federal-provincial work, you're right, has identified the cost drivers, and reports have been released through the Patent Medicine Prices Review Board with respect to what those results are. Those are interesting results that are publicly available.

Your third question was with respect to generic drugs, and I mentioned Ontario. Ontario sets the benchmark with generic drugs by requiring that the cost of a new drug entering the market be reimbursed at 30% less than the brand name product. There's no relationship to the cost for the generic company to develop and manufacture that drug, so we are in need of finding creative ways, other than encouraging Ontario to legislate 40%--

[Translation]

Mr. Réal Ménard: Why Ontario? This is the first time I am hearing this and I would really like to see some research into this. I do not know if my colleagues were aware of this. You are saying that for generic drugs, provinces such as yours, Alberta, base themselves on the price set by Ontario. Why Ontario and why is it? I would like to better understand this.

[English]

Mr. David Bougher: Ontario's approach is very highly regulated with respect to how decisions are made on coverage under their drug programs. In fact, they go through the entire system, and I think they have to be approved at the highest level with the Ontario government. So they're at one end of the spectrum with respect to the approval that's required; they're very highly regulated and legislated. If you move to British Columbia, it's virtually the opposite. Decisions are made within the ministry unless it's a drug that has a very high-cost impact, in which case it would need to go to their finance people. I think what you're seeing is variation across the country in the way in which new products are treated and what the rules are for paying for them through public sector drug programs.

The Chair: Thank you, Mr. Ménard.

Ms. Fry.

Hon. Hedy Fry (Vancouver Centre, Lib.): Thank you very much, Madam Chair.

I want to thank you for an excellent presentation. You covered all the bases nicely. The issue you brought up that really interests me is one on which we have heard so far from everyone I have asked at least. Hopefully, I'll get an answer one day. It is about cost-benefit analysis, and you talked about that. You said one needs to see what the rising cost of drugs is, and there is the matter of benefits that decrease other costs. I've been told so far that there really hasn't been any such work done and that the work done in the U.S. hasn't really been done in a manner that would give you the direct cost benefit. The work done so far has talked about cost-effectiveness somewhat, but we're not doing the right analysis. So I'm glad you mentioned that.

The other one that interested me is also one I keep coming back to: post-market surveillance. Do you do post-market surveillance here as a government, and if you do, because I know there are provincial, territorial, and federal jurisdictions at stake here, how do you see the governments coming together to collaborate on post-market surveillance initiatives? Do you think it should be mandatory for physicians, nurses, and pharmacists to report adverse effects?

À (1015)

Mr. David Bougher: To answer your second question first, the federal government is responsible for the post-marketing surveillance, which is a relatively passive approach, a voluntary approach, to the reporting of adverse events. Health Canada has created a marketed health products directorate, which we are looking forward to working with in regard to strengthening the role and the reporting of adverse events. I'm not sure how possible it would be to implement a mandatory approach. I think we have to provide the right incentives and the systems to encourage much more complete reporting of adverse events. So I think that's a key strategy for the future. It needs to be done in collaboration with the provinces and territories as well as the federal government.

If I can go back just for a moment to the post-marketing, we call it pharmacal vigilance and pharmacal surveillance for the new biologic agents. Health Canada is participating in this research study. We believe that Health Canada should take a much stronger leadership role in this area in the country, and we encourage them to do that. I think they plan to make that role more active.

Ms. Hedy Fry: It would seem to me that if there is a very high incidence of morbidity, which costs the health care system--we're now talking about cost drivers coming from reactions to drugs--it would be almost essential to have some sort of reporting to say that one knows what the incidence of morbidity is as a result of the use of drugs.

I have two questions I want to ask. Ms. Hinton talked earlier on about the cross-border electronic prescription refill. I practised as a physician in British Columbia for 23 years. I could not write a prescription for a friend in Alberta. We don't do that across provinces here. How is it possible to have a physician in the United States write a prescription that is valid here in Canada? Are there any rules governing pharmacists? Do the pharmacist colleges have rules? Does that fall under any jurisdiction? It seems to me to be a very strange thing. It seems to me to be bad medicine as well, if you don't mind my saying so. The patient will eventually pay, not with dollars but with all sorts of drug reactions and problems and not knowing exactly what is wrong with the patient and nobody here to follow up. Where does the responsibility of the pharmacist lie in filling out that prescription for someone in a totally different jurisdiction? That's the first question.

The second question is, does Alberta pay for access to medication for HIV/AIDS and for some of the new drugs?

À (1020)

Mr. David Bougher: That's a simple question. Yes, we cover drugs for HIV, as we do for a number of specialized diseases, including transplant patients and cancer. We don't cover them through our public drug program but through specialized services through two of the major health regimes.

With regard to cross-border shopping, governments are concerned about what's going on. However, I would say that the regulatory bodies of pharmacy and medicine have the responsibility for ensuring that standards are met. We would be reluctant to start telling the College of Physicians and Surgeons, for example, how to do their job. However, we're very interested in what's going on.

In answer to your question with regard to the authorization of prescriptions, as I understand it, there are two ways that these prescriptions are legitimized in Canada. In one case, there are quite a few physicians in the United States who have dual licences and who are in fact licensed in a jurisdiction in Canada. There's one company in particular that exploits that opportunity. I think the other way is through having prescriptions countersigned, having a process available within the particular jurisdiction in Canada, which then validates or provides the authorization for the prescription to be filled.

The Chair: Thank you, Dr. Fry.

Mr. Thompson.

Mr. Greg Thompson: Thank you, Madam Chair.

Some of the numbers you have mentioned don't surprise some of us. You're talking about the $18 billion a year spent. One of the things that does scare us, although we know it has happened, is you're talking about a 17% increase on average over the last number of years, and that's growing exponentially. Where does it end? We've talked about what those solutions might be to that price problem. You're suggesting they can't be simplistic. In other words, it's a very complicated equation to solve. You can't identify one area and that one thing will fix it.

You went on to talk about the innovation within the industry—some of the things that could happen at various levels. You did mention the pharmaceutical industry. I think you're saying they act quite responsibly. Now I'm paraphrasing obviously; I'm not quoting. But you were talking about their being beholden to their shareholders in the sense that they perform well, because they are responsible to their shareholders. I guess you're replying that's a good thing, and I'm not arguing with you on that.

One of the things that I want to comment on is whether that relates to patent protection, where in fact the drug companies are beholden to their shareholders at the expense of an awful lot of people—in other words, that 20 years of protection they have given.

You did talk about drug prices. You didn't talk about patent drugs, but you did mention generic drugs. You didn't mention the monopoly that is being exercised in this country by two major generic drug companies. Is there any cross-ownership in drug companies and the drug stores, if you will? That's a question I don't know the answer to.

Anyway, you're talking about innovation, different delivery systems, and so on. I'll go back again to those simplistic solutions and that there don't appear to be any out there. We want a cure.

One of the things you did mention as well was the safety and efficacy of the drugs. You're saying there is not a problem there, and I think I would agree with you in the big picture. But you're saying there is a problem in terms of how they're used in the real world. I think most of us would agree with you there as well.

It's a wide range of comments, Mr. Bougher. I'll just let you take the floor and maybe you can respond to some of them.

À (1025)

Mr. David Bougher: Thank you.

My first comment will be that I'm not aware of any ownership relationships between generic companies and pharmacies, although we do know there are special arrangements that some of the generic companies have with pharmacies, and that there are probably discounts being provided in some form to pharmacies, which we have no way of in fact determining or identifying. That's one of our real dilemmas.

We have done the simple things with respect to management costs, generic drugs, formulary. We have an enormous challenge now with respect to the direction of our costs. I said earlier that we may be spending enough money. Maybe our expenditures are at the right level. We just don't know what we're getting in value and we need to measure. We need to do post-marketing studies on cost-effectiveness, telling us how cost-beneficial, how cost-effective these products are. We know they benefit many, many people.

Mr. Greg Thompson: I don't want to get you off track here, but one of the questions I'm intrigued by is generic drug companies. Obviously drug companies, patent or otherwise, are very much international. They know no boundaries, if you will, in terms of investment and the flow of money across borders and so on. It seems to me that basically two generic drug companies have a monopoly in this country. Why doesn't that influx of cheaper generic drugs in America flow this way? Our cheaper patent drugs flow that way, but there doesn't seem to be any cross-border trade in terms of generics.

Mr. David Bougher: I'm not sure, other than the market in Canada is relatively small and there probably are some restrictions with respect to generic drugs flowing into Canada. We have not investigated the feasibility of that. But generic prices in the United States are extremely variable as well. I suppose one of the strategies to consider would be exploring the drugs that are available in the United States. I think there are some laws that prohibit bringing generic drugs into Canada that would be problematic for us.

The Chair: Thank you, Mr. Thompson.

Mr. Castonguay.

[Translation]

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.): Thank you, Madam Chair.

Thank you for your presentation. You have mentioned several times the need for national cooperation between various players and regions of the country.

Could you elaborate on this and give us a few examples of practical things that could be done right away in order to encourage and support this type of national cooperation? What would the role of the federal government be in this regard?

[English]

Mr. David Bougher: There has been a lot accomplished at the national level to date, and there are some initiatives that have already been developed. There's one in particular that is termed the “best practices initiative”, which provides a clearing house and a system for sharing information across the country on what has worked well in other parts of the country. The impact is on the utilization of drugs, the appropriate use, and it identifies some of those best practices that can be shared and developed elsewhere in the country. The federal government has in fact committed some significant dollars over the next few years for the implementation of this initiative, and it's going to the deputy ministers for approval in December.

There has been a strong relationship between the provinces, the territories, and the federal government on pharmaceuticals. Pharmaceuticals management has been a key initiative, giving what I consider some positive results in terms of what has been accomplished, and we're pleased with that.

[Translation]

Mr. Jeannot Castonguay: I heard you say that these are things that are already being done within your department. However, you mentioned several times the need for greater cooperation.

Could you suggest other areas that need to be dealt with in order to improve the delivery of services and get a better return on the investment?

À (1030)

[English]

Mr. David Bougher: I have no specific additional examples of what is currently proceeding. I mentioned the national prescription drug utilization information system and the best practices initiative. I think the area of post-marketing surveillance is one where we are looking forward to a strong role by the federal government with respect to the coordination and implementation of initiatives.

The pharmaceuticals management agenda has been a busy one, a very active one, and I think we've explored as many opportunities as possible for the federal government. I suppose the role of Health Canada is something that comes up from time to time in terms of their regulatory role; there's the declaration of interchangeability, for example, with generic drugs. These are matters that have been seen to be outside the scope of the federal government and have not been actively pursued.

The Chair: Thank you, Mr. Castonguay.

Ms. Bennett.

Ms. Carolyn Bennett: Thank you.

I'll just follow up on that in terms of what is national or pan-Canadian collaboration on these things that seem to involve the Ministry of Health, in terms of who has to actually pay for these things, and in terms of what is appropriate treatment.

There was a recommendation in the Romanow report calling for an independent drug agency. Do you think that would help get around some of these things in terms of maybe a common formulary to work towards the post-market surveillance, where provinces could work together in a collaborative way with the federal government at the table as an equal partner? What would be the accountability structure for Canadians with such an agency, and what do you see as the pros and cons?

The first question would be, when you talk about implementation within a year, would that be 100% of Albertans on an electronic health record?

Mr. David Bougher: No. It's voluntary, but there will be a lot of inducement and encouragement for practitioners to join in this electronic health record system.

With respect to a national agency, it's not a new concept. It's good in theory and it has a lot of merit. Much of what would be performed or would be the functions of an agency are currently being carried out through the Canadian Coordinating Office for Health Technology Assessment, or CCOHTA. I think it's the size of the agency that is a little bit daunting in terms of pulling all of these things together. I'm not sure how closely it's being looked at. I can't speak to that from the federal government's perspective, obviously. The individual components are being carried out by different organizations.

If you start to consider a national formulary, then that takes away from regional and individual provinces' and territories' priorities in terms of coverage. I'm not sure, but if we're moving to some form of pharmacare, it's difficult to get that kind of agreement.

Ms. Carolyn Bennett: I guess we were hoping there would be an opportunity to see some things done in common, and then obviously there's no choice, much the way the new formulary has begun to evolve, where you actually share the information, because everything is not done thirteen times, right? There would be a common database for cost-effectiveness, and for some of the questions that are out there, the provinces wouldn't have to do it. If you've done a great job for Alberta, then every other province doesn't have to repeat it.

Mr. David Bougher: That's correct, and the objective of the common drug review that has been created at CCOHTA is to do some of those things, to collect and share information and to have one national committee to evaluate the evidence for drugs and to make recommendations to drug plans across the country with respect to which drug provides the best value.

Ms. Carolyn Bennett: What did you call that?

Mr. David Bougher: The common drug review. Ministers recently announced a national Canadian Expert Drug Advisory Committee, with representation across the country to carry out that function.

À (1055)

The Chair: Thank you, Ms. Bennett.

On behalf of the committee members, may I thank you, Mr. Bougher, for coming and representing the Government of Alberta to us as we continue with our deliberations. Thank you very much.

Ladies and gentlemen, just before you take a break, I want to be made aware by probably just after lunch as to your intentions about tomorrow. I understand some people might have to rush back to Ottawa. I would like to know who will be in attendance tomorrow and Thursday, so if you could come back and alert me to that, I'd be very grateful.

We will take a short adjournment.

The Chair: We're called back to order, ladies and gentlemen.

Welcome to our new set of witnesses, representing the Alberta College of Pharmacists and the Canadian Association of Chain Drug Stores. We'll begin with the College of Pharmacists, and the representative is the registrar, Mr. Greg Eberhart.

Mr. Eberhart.

Mr. Greg Eberhart (Registrar, Alberta College of Pharmacists): Thank you, and good morning to you, committee members. I welcome the opportunity to make presentations for this most timely discussion about the cost and utilization of drugs within Canada.

My name is Greg Eberhart and I am the registrar of the Alberta College of Pharmacists. We are responsible for regulating pharmacists, pharmacies, and drug scheduling in the province of Alberta. We have a membership of over 3,100 pharmacists who practice in over 800 community-based pharmacies and in approximately 150 publicly funded institutions. Our mandate is focused on public protection and the safe and effective use of drugs through quality pharmacist practice.

This morning I'd like to address three issues that were outlined in the invitational letter, those being the monitoring of adverse effects and prescribing practices, direct-to-consumer advertising, and international comparisons. I will take the liberty of addressing these in reverse order.

The price of patented drugs in Canada is at the mid point, we feel, within those of international nations. The price of many generic drugs within Canada is substantially greater than that of our U.S. neighbours. U.S. public policy, drug prices, and favourable financial exchange rates have attracted U.S. consumers to seek prescription drugs in Canada. This is a joint problem of medical licensing organizations, pharmacy regulatory organizations, provincial governments, and the federal Minister of Health.

It is beyond our mandate as a college to address issues of economics or drug product supply and demand. However, we are committed to bringing information about such trends to the attention of the appropriate authorities. We received testimony that the sale of drug products licensed in Canada to the U.S. may be affecting drug product availability in Canada. We have further been advised that this emerging industry is affecting the availability of pharmacy manpower to serve Canadians in certain geographic regions. Additionally, there's speculation that should these trends continue, the cost and access to some prescription medications by Canadians will be affected.

In response to similar concerns, the New Zealand government enacted legislation controlling the export of drug products licensed for sale in New Zealand. Despite these factors, our primary concern as a college is that pharmacies responding to this demand are functioning in a quasi-unregulated environment. The jurisdiction is unclear.

The governance of professional conduct is a privilege granted by provincial governments to individual professions such as ours and does not provide for the regulation of such practices in international jurisdictions. Provincial pharmacy regulatory authorities are restricted to governing within Canadian and provincial jurisprudence and therefore are legally unable and not resourced to conduct investigations internationally.

The use of electronic pathologies that facilitate the delivery of health care has no boundaries. Therefore, jurisdictional challenges abound.

I'd like to refer to a report that has either recently been released or is forthcoming and covers the national initiatives for telehealth frameworks and guidelines. I refer specifically to section 6.2.6, which addresses global and international telehealth. Among the recommendations, it states that federal and provincial governments' ministries of health could work with complementary international authorities to negotiate necessary international agreements to support the regulatory processes important for public protection and accountability.

In the conclusion of my submission, I'd like to provide you with the following recommendations. First, that the federal Minister of Health work with federal and provincial authorities to determine the potential long-term effect on the Canadian health system as the result of the cross-border international sale of prescription drugs.

Second, should federal and provincial policy continue to prevent the international sale and distribution of drug products licensed in Canada, negotiations should be initiated with international authorities to establish the necessary agreements to clarify jurisdiction and ensure consumer safety.

Next I would like to address the issue of direct-to-consumer advertising. This, again, is a timely discussion as the issue has been elevated on the agenda of our international neighbours. Our college supports the importance of informed consumers and the principle of consumer choice. These are cornerstones to client-directed rather than health-professional-directed care and were outlined in both the Romanow and Kirby reports.

Á (1100)

Direct-to-consumer advertising includes the use of multiple media, and while it's not often considered, it includes packaging and labelling. Informed consumers rely on accessible, objective, balanced, understandable, and unbiased information. Direct-to-consumer advertising is typically product focused and seldom meets these qualities. Often it portrays unhealthy lifestyles as a means of creating demand for the advertised product.

My recommendation to the committee is that Health Canada develop new strategies that better control direct-to-consumer advertising to ensure it is balanced, objective, and unbiased. Direct-to-consumer advertising should not be permitted to encourage unhealthy lifestyles.

Last, I would like to address the issue of monitoring adverse effects and prescribing practices. First I'll speak on the monitoring of adverse effects.

The monitoring of adverse effects is a subcomponent of the massive drug scheduling and licensing process and is a federal responsibility. This process can be improved through integrated technologies. Health providers should be able to submit online or be able to easily access updated information online. Information must be presented in a clear and relevant manner. Again, my recommendation is that Health Canada make adverse drug effect reporting processes more accessible and usable with integrated computer technologies. Opportunities will abound in the future as our provinces develop integrated health systems to assist their practitioners in the care of their public.

The monitoring of prescribing practices is something that is provincial in scope; however, federal-provincial-territorial partnerships are necessary to advance evidence-based approaches. We applaud federal grants that have recently been provided to support patient safety initiatives.

The aspect of monitoring prescribing practices requires long-term strategies that are time and resource intensive. Monitoring must be supported by intervention and is a change management process. Intervention should be educational wherever possible. The focus should be on proper drug use, not just on prescribing.

I recommend to you that Health Canada provide ongoing support with pan-Canadian initiatives to support proper drug use and patient safety through best practices and evidence-based medicine.

I welcome any questions you may have.

Á (1105)

The Chair: Thank you, Mr. Eberhart.

Our second presenter will be from the Canadian Association of Chain Drug Stores, the vice-president, public policy, Lori Turik. She will be assisted by the director of government and regulatory affairs, Mr. Jeff May.

Ms. Turik.

Ms. Lori Turik (Vice-President, Public Policy, Canadian Association of Chain Drug Stores): Madam Chair, members of the committee, thank you very much for this opportunity to present to you on such an important and critical issue to Canadians.

The Canadian Association of Chain Drug Stores is a national association that represents 22 retail chain members. We represent traditional chain drugstore members, members who are mass merchandisers with pharmacies, as well as grocery chains with pharmacies. Among them they operate over 60% of the pharmacies in Canada. They operate across the country and provide up to 75% of all prescription drugs nationally.

Every day over 8 million Canadians visit a pharmacy. There's tremendous opportunity that may be untapped, which we would argue is underutilized in our health care system today because the interactions between pharmacists and pharmacies are not being integrated with the health care system to the extent they could be.

In addition to reaching out to 8 million Canadians a day, we also employ over 80,000 individuals--60% of pharmacists who work in Canada.

In Canada there has been a tendency for government, in our opinion, to examine rising drug costs in isolation or in a silo, rather than looking at the issue broadly across the system, looking at the cost-benefit of medications in the system and the impact they may have on the health and well-being of Canadians today, where they may in fact reduce the more expensive and costly health care services we're providing and may in fact reduce the extreme pressures on a limited resource of health care professionals. We would definitely support, as we've heard today, additional research in this regard.

There is a clear interrelationship between pharmacies, pharmacists, and manufacturers in the industry. In addition to the interrelationship between the manufacturers of products, both Rx and generic, there is an interrelationship with the entire supply chain. Obviously, any changes in regulations or pricing have a direct and deliberate impact on pharmacies, pharmacists, and, most importantly, on the care that is provided to Canadian citizens. Thus it is very important for the committee to consider the pricing of drugs and the regulations that are put in place for distribution in that context.

A good analogy might be the pebble in the pond analogy, where you actually drop a pebble into a pond and it has an impact on the pond environment itself, on those who are dependent on the pond, and also on the shore. In fact, we would say what you're doing here today is looking at the broader context of the ecosystem in general.

We would all agree that medications are essential for health, and when used effectively these therapies save lives, reduce disability, and improve the quality of life for Canadian citizens. They not only contribute to the health of our society, but also to our economy as a whole.

The cost of medications, I think we would agree, has been steadily increasing, and this is a result of our aging population and the development of new products that are more costly and more complex, such as biologics. We also would agree that medication is an essential element of our health care system today, and that this needs to be considered not only in terms of its benefits, but in terms of how we can maximize the value of medications for our citizens and get the best value for our investment.

In relation to the work of the committee, what we would like to speak to primarily and specifically is that the federal government does hold the key. It holds the key to solutions, in terms of the approval process and the impacts those have on the cost of medications. It holds the key to the regulatory framework that has an impact on how we access our medications and how they are provided to our citizens. It holds the key to investment in research and information technology that is essential for providing care across the spectrum of pharmacists, physicians, and the patients themselves.

The government has been investing very heavily in areas such as primary care reform, and pharmacists could and should be a bigger part of that initiative. Government also holds the key for support for innovation, for research, and for work in the area of health human resources. All of these things really do impact on Canadian citizens.

Jeff will speak to how pharmacies and pharmacists can be integrated into the system in a much more effective way that will improve value on investments and reduce waste in the system overall.

Mr. Jeffrey May (Director, Government and RegulatoryAffairs, Canadian Association of Chain Drug Stores): Thank you, Lori.

Thank you very much for the opportunity to speak with you today.

In the broadest context, one has to consider pharmacy and drug use management services such as compliance programs, monitoring medication outcomes and interactions, and medication review with physicians. These are not fully incorporated into our primary health care system. Moreover, the public and private plans that pay for prescriptions and pharmacy services do not recognize or compensate these professional services. Health professionals and patients are not taking full advantage of pharmacy services.

The soon to be released CACDS POLLARA poll shows that only 40% of Canadians use the traditional medication-related pharmacy services, such as advice about medications, drug interactions, and side effects. There is a major opportunity to increase awareness of the pharmacists' role, and we must create an environment in Canada that enables and supports access to these free services.

We believe there are three key steps to utilizing pharmacy services optimally for drug use management, hence promoting health and wellness.

First, there must be a framework for pharmacy services that clearly defines the medication services pharmacists provide, that maximizes their current scope of practice with consistent standards, and that maximizes their interaction with other health care providers.

Second, we must improve information exchange between health care providers, indeed with government and policy-makers, to monitor and evaluate patient response to medication.

Third, we must have a health care environment to promote and enable access to these services.

Through the Canadian Association of Chain Drug Stores and our pharmacy committee we have developed a white paper on the integration of pharmacy services into primary care, which we could certainly make available to the committee.

We've been educating policy-makers on this role, and we're developing pilot programs and initiatives to demonstrate the benefits of this integrated service as part of primary care reform, focusing on drug use management, collaboration, and information sharing. Federal funding for primary care innovation must be explicitly targeted toward pharmacy-based integration into primary care services, focusing on proper drug use management.

With respect to misuse, abuse, addiction, and proper drug utilization, there is a need for greater collaboration and information sharing, as I've said. This need is to identify and mitigate drug abuse and addiction and to promote better decision-making and monitoring on behalf of health care professionals. The use of information technology and electronic health records would facilitate this exchange; reduce the human cost of misuse, abuse, and addiction; help information technologies and regulatory frameworks that allow pharmacists and other members of patient care teams to access the complete medication record; and have the ability to expose unusual drug use patterns and to track misuse or abuse.

Community pharmacies already use electronic medication records that include comprehensive information about the medications patients are taking. These systems are currently connected to every provincial and territorial drug plan and all private drug plans for adjudication. Chain pharmacies across Canada have knowledge and experience in utilizing health information networks for claims adjudication, drug utilization review, and medication management, and combined with community pharmacies' information technology infrastructure, these put together can provide the foundation for the electronic health record.

Experience with the Alberta Wellnet EHR initiative and pilot programs, the MOXXI initiative in Montreal, and B.C.'s PharmaNet system show that this is a great foundation upon which to work.

In the area of misuse, abuse, and addiction in the general population, the community pharmacies' information technology network is also an important mechanism to ensure orderly management and protect against drug diversion. Electronic ordering of prescription and non-prescription medication offers greater protection from information tampering and potential product diversion. Discussions are ongoing with Health Canada about this issue.

Governments must begin also to differentiate between the rising cost of pharmaceutical products and pharmacy services and make a strategic investment that will ensure the best value for dollar spent. Investing in pharmacy services information systems and technology that will promote and enhance exchange of information will have a significant impact on rising costs of prescription drugs.

Also, in community and chain pharmacies we're concerned about how pricing changes will impact patient access. Lack of access places a tremendous burden on society, contributing to poor health, disability, and lost productivity, and it results in cost shifting to more expensive areas in the health system.

All of these initiatives are contingent upon adequate supplies of pharmacists within the health care system and adequate supplies and access to drugs. Time spent on administration by pharmacists is time taken away from the patient and from drug use management services. There has been a shortage of pharmacists in Canada. We have a 10% shortage in both community and hospital practice. It is essential that changes in the system do not negatively impact on the availability of pharmacists to provide better patient care.

In conclusion, by enabling community pharmacists to practice to their full potential and by taking advantage of the full scope of pharmacies' expertise, information technology infrastructure, and resources, we can manage drug costs and improve the health and quality of life of Canadians.

We'd be pleased to respond to questions you may have about these or other issues.

Thank you.

Á (1115)

The Chair: Thank you, Mr. May.

We'll move on to the second part of our inquiry, and we'll begin the questioning with Mr. Merrifield.

Mr. Rob Merrifield: Thank you for coming in.

I'd like to start with the pharmacists.

Number one, you're saying more resources would help to bring you into the continuum of health. We heard this yesterday as well. In fact, the suggestion was if we give you the resources, you would help with the consultations and recommendations in terms of what medications should be given.

I'm wondering how you square that with the idea that right now you have a lot of concern that physicians are being controlled by pharmaceutical companies in terms of their prescribing habits. How do you think you could convince Canadians to be confident that you wouldn't be part of that same play, in the sense that your entire business is dependent upon the amount of product you move and sell?

Can you tell me how you plan to get around the suspicious nature of man in this area?

Ms. Lori Turik: That's an excellent question.

Of course, pharmacists, at this point in time, don't prescribe medication, so they don't have an impact on the demand the public has for a particular product. They do dispense product and they can play a very significant role in managing medication use, which would provide the best therapeutic impact, I believe, for the public and would significantly reduce waste in the system.

A lot of dollars are being paid by both our government and our third-party plans, as well as by individuals, for medication that's not being used to its best and prescribed intent. I understand in Alberta there has been a study done that showed approximately 30 metric tonnes of unused medication had been collected annually. That is medication that's not being used to its best advantage and has been paid for by one of these plans.

In addition to that, we know if we do invest in pharmacy services.... There have been a number of studies. There was a recent one in 2003. It is a U.S.-based study, through the American Journal of Managed Care. It demonstrated that when $1 million was spent on ensuring access to pharmacy services for medication management and counselling, for every 4,000 beneficiaries there was reduced morbidity, reduced mortality, reduced visits and admissions to emergency rooms, and reduced pressure on physician services.

Statistics Canada has said that 19% to 28% of hospital admissions for people over 50 are the result of some form of drug interaction. These are things that we believe could be avoided or reduced.

Á (1120)

Mr. Rob Merrifield: What do you do right now when you have an individual who is either having an adverse reaction to medication or is under suspicion of being addicted to prescription medication?

Mr. Jeffrey May: The relationship between physician and pharmacist, particularly if you look at the role of the pharmacist in providing ongoing monitoring, supporting the physician who prescribed the medication.... When patients come in for refill medication, it allows for an opportunity for discussion between the pharmacist and the individual about how the medication is working, if there are adverse effects that have been experienced, or side effects. The pharmacist can provide information on how the patient can manage those things. If there are significant concerns about the information that is taken from the patient or concerns about the patient's health, the issue is communicated directly to the physician, and very often there are regular conversations between pharmacists and physicians. In some cases, adverse effects and side effects can be easily managed by changing how a medication is taken and when it's taken, but in many cases when there is a more serious event there is a discussion between the pharmacist and the physician.

Mr. Rob Merrifield: I understand the wellness program will have the medical records also falling within the program, let's say, an alert to medical reactions, drug reactions will be within the program itself and will alert physicians, and this could be a third party. Is that true? Do you see that working as well?

Mr. Jeffrey May: The current situation with health information and medication records within pharmacies and physicians is so siloed. You may have a patient who patronizes one, two, or more community pharmacies and then that patient record is isolated at the pharmacy at which the drug is dispensed. Other clinical information that the pharmacist may have gathered from the patient rests in that pharmacy. The wellness system and the EHR system in Alberta allow for that type of information to be placed into the database, if you will, and that information can be accessed by other pharmacists, should the patient choose to use multiple pharmacies, or by other physicians, and that broader-based sharing of information in a very fulsome way--not just looking at a drug that was dispensed on a certain day but also looking at it with respect to adverse effects or concerns the patient may have or when a medication was started or stopped--is a very positive step forward in terms of health IT and also being able to care for patients better and make better decisions about prescribing, and also to deal with ongoing monitoring of patients to prevent adverse reactions.

The Chair: Thank you, Mr. Merrifield.

Mrs. Hinton.

Mrs. Betty Hinton: I have a series of questions. I'll ask them all, if you don't mind, and then I'll wait for the answers.

Have you been threatened by drug companies with loss of access to any pharmaceuticals because of Internet cross-border prescriptions?

My second question is, can they do it? Can they cut it off, or is it sabre-rattling?

My third question is, can you estimate the volume per year and the dollar figure of what that costs the industry in Canada? For those pharmacists who are doing that in this country--there are several pharmacists, apparently, who are doing the cross-border thing--is there not a self-policing mechanism within your association to prevent that practice? That's another question

Also, is the dispensing fee still the only--I hate to use the word “profit” because it's not profit--means of meeting your overhead because the drug costs are so controlled, or has this changed over the last few years?

The last thing I want to mention to you, Mr. Eberhart, is you referred to advertising on television. My understanding from the past few years is that that is prohibited, but there is an advertisement on television that is very specific. It is directed towards men and it labels the name of the product. It comes up on the screen and there's no guessing that it is Viagra. I wonder how you feel about that and if there's anything that can be done to prevent it.

Á (1125)

Mr. Jeffrey May: Perhaps we could take the first piece in terms of assets related to the practice of international pharmacy services and the issue of loss of access. To date, we have not--I would say I'm speaking on behalf of the members of CACDS--been threatened per se by a loss of access to drugs in Canada. We do know there are examples of drugs that have been approved by the FDA in the U.S. and have received their notice of compliance by Health Canada and the drug is released in the U.S. and not in Canada. And there are examples of the situation being reversed.

It really is only left up to speculation as to why a drug is not released in Canada. There are obviously many motivations from the pharmaceutical industry, but to say that we have been threatened by access or have been in a situation where we're going to be cut off, we haven't got to that point. We do recognize the concerns of the pharmaceutical industry on this issue, though.

In terms of cost, the best estimate in terms of the value of Canadian drugs going across the border to the U.S, which you will understand is very difficult to measure, is that common estimates from groups such as IMS Health place the value at about $1 billion Canadian.

Mrs. Betty Hinton: Is that $1 million?

Mr. Jeffrey May: That was $1 billion.

Maybe, Greg, I could turn it over to you for the regulatory issues.

Mrs. Betty Hinton: How about the rattling sabres issue, or can they actually cut you off if they choose to do so?

Mr. Jeffrey May: Do you mean cut us off in terms of access?

Mrs. Betty Hinton: Yes.

Mr. Jeffrey May: I think the issue goes to the trade agreements between the pharmaceutical industry and pharmacies. Any pharmacy that purchases medication from the pharmaceutical industry has to sign a contract that basically deals with the terms of trade. One of the specifications in those contracts is that you will not export the drug outside of Canada, and the vast majority of pharmacies do comply with that.

The pharmaceutical industry has indicated that they will protect the supply of drugs to the best of their ability for Canadians.

Mr. Greg Eberhart: On the question of self-policing, as self-regulating professions we work within a system, and our specific responsibility is with respect to the practice of pharmacists.

Notwithstanding that, when we do become involved in an investigation often we need to work with other colleges such as medicine. There are issues within this process, and particularly when you get into international jurisdictions you run into some conundrums in and around information sharing.

But more specifically, and of greatest concern to us...for example, in Alberta, we currently have a number of investigations under way. If it was determined through those investigations that some type of punitive measures were necessary, we do not have the jurisdiction to complete the investigation in an international jurisdiction, nor do we have the jurisdiction to subpoena witnesses from an international jurisdiction.

That is why I referred to the report from the national initiative for telehealth, which has just undertaken a two-year study of the evolution of telehealth and what it means to the electronic world and the delivery of health care. Specifically, it's been recognized by that group, which was multidisciplinary in nature, that there is a role for the federal government and provincial governments to define a jurisdiction and create the necessary agreements so that if health care is going to be delivered into the international marketplace, patient safety can be addressed effectively.

The Chair: Thank you, Mrs. Hinton.

Mr. Ménard.

[Translation]

Mr. Réal Ménard: Thank you. Your testimony is very useful, especially since physicians' associations as well as those of pharmacists maintain, when we discuss with them, that they are not responsible for costs. So it seems very difficult to pinpoint who is responsible for these costs. I have three questions for you.

In Canada, the Patented Medicines Prices Review Board regulates the cost of drugs at the manufacturing level. Therefore, the price of Viagra coming from the manufacturer cannot exceed the increase in the Consumer Price Index.

I would like to know how a pharmacist who manages his own store, whether in Edmonton, Toronto, Calgary or Vancouver, establishes his profit margin when selling a drug? You buy from manufacturers and you sell to consumers, therefore you are retailers of drugs. How is the profit margin established?

Next, are you entitled to suggest a generic product when filling a prescription if you are assured that the generic will achieve exactly the same outcome?

Finally, do you have any specific recommendations to suggest to us regarding the cost of medication? If I have some time left, I will get back to the issue of advertising. The ads for Viagra are not illegal. They might be questionable an ethical point of view, but nevertheless under the Food and Drug Act, it is permissible to advertise a drug as long as the ad does not make any mention of disease.

The TV ad for Viagra, which depicts a giddy gentleman who, we are given to presume, has just spent a wonderful night, does not talk about impotence. Therefore it is not illegal. But that is another story to which we might get back later.

I would like merely to know how you establish your profit margin because some people within the system maintain that pharmacists are those who make the most money.

Á (1130)

[English]

Mr. Jeffrey May: Thank you very much for those questions. I think the issues around the economics of community pharmacy are not well understood generally in Canada.

Perhaps I could highlight some of the key points in terms of how the product gets delivered and how payment is part of that system.

First of all, costs generally are defined by provincial formulas. Once they're established by the PMPRB, primarily on the brand side, provincial governments establish the cost of generic drugs. That's the cost that typically pharmacies pay for it.

There is also a cost built in the system for distribution, that is, to get the drug from the manufacturer to the pharmacy through a wholesale mechanism or some type of a distribution centre logistics-type mechanism, and there are small costs that are built into the system, a small percentage, which varies across Canada, but it can be anywhere from--

Mr. Réal Ménard: You have to be more specific. These are from the sales.

[Translation]

What is that cost? Give us a specific example of a drug and of the chain of intermediaries.

Let us take Viagra as an example, so as not to let that subject drop! Describe the evolution of its cost all the way from the factory until the consumer pays when filling a prescription.

[English]

Mr. Jeffrey May: Thank you. I think that's probably the best way to deal with the question, because I can speak in generalities forever.

I don't know the exact market price for that drug, but let's say it is established at $100 for a standard supply. The pharmacy will purchase that drug at, say, $107, given that there is a wholesaler up-charge. Some provincial formulators recognize that $107 price; some recognize a slightly lower price, particularly in the province of Ontario.

The cost to the patient, then, is determined, really, by three factors: the cost of the drug, an allowable markup that is defined by each province and its drug plan, and the fee. The markup in fee typically averages in Canada $10 to $12. There's a high level of deviation from that. If you look at the province of Ontario, the fee is $6.54; in the province of Quebec it's very similar.

The provincial drug program typically sets a standard fee that can be charged in each province. Some private sector drug programs do not fall under the jurisdiction of a provincial drug program, and higher fees may be charged. But if you go right down to the average, taking the cost of the drug from the manufacturer as $100 and adding an additional cost for the distribution of the drug through manufacture to the pharmacy, the pharmacy may be allowed to charge a markup that typically can range from a dollar figure of 50¢ to a percentage of 10%.

Á (1135)

[Translation]

Mr. Réal Ménard: I understand that pharmacists are not always owners of their business and the owners are not always pharmacists.

So does the pharmacist decide to add a dollar or a dollar fifty to the price? We know that the board regulates and that the province determines the cost to be reimbursed but the profit margin of the pharmacist, which is about a dollar—in this regard, this part of your presentation is definitely the most conservative—is it discretionary or is it regulated?

[English]

Mr. Jeffrey May: The markups that are within the system are primarily defined across Canada by the provincial drug programs.

Mr. Greg Thompson: That's not correct. That's absolutely incorrect.

The Chair: It's not your turn.

Mr. Greg Thompson: I'm just discouraged listening to this type of nonsense.

The Chair: Well, when it's your turn, you'll be able to make these points. I'll be happy to hear them.

Mr. Réal Ménard: I just want to get a better understanding, because we just have one life, and we want a good life and to have a better understanding. Maybe I could share my time with him.

The Chair: Are you ready to move your time along? Actually, Mr. Thompson is not next anyway, so it would go to Ms. Fry.

Mr. Réal Ménard: But if he can share some information for all—

The Chair: He will when it's his time, Mr. Ménard. Are you finished? Actually, your time is up anyway.

Ms. Fry, you're next.

Ms. Hedy Fry: I have a question for the college, and it has to do with a cross-border issue again. This is an issue I'm really concerned about, and I think we should be, in terms of costs, access—all of the things we are looking at in this study. You said the college really didn't have any responsibility per se in the face of that kind of cross-border initiative because it was an international issue. But what about, for instance, some sort of punitive measure you could inflict on pharmacists who do this because you think it's a bad and unethical practice? Is there something you can do in that way?

The question also is, what is the responsibility of the Canadian pharmacist who moves drugs cross-border in case of an adverse reaction by the person in the United States? Is there a liability issue for pharmacists here?

Third, what is the status of a prescription drug that has moved across from a pharmacist here with a patient when it's an opiate prescription? How does that contravene, or does it contravene, the transportation of opiates across the border? I just wanted to know if that has anything to do with it.

In a second I'll let you answer. I just wanted to go to Lori and Jeff. I wanted to follow up a little bit on the issue of.... You've talked very clearly about the role of pharmacists and expanding the role of pharmacists. As a family physician, I can't agree with you more. I think there needs to be a lot more collaborative work done between the physician and the pharmacist with regard to the patient because of the fact that they both have direct contact with the patient concerning medication—and I don't have a problem with that and I think it should be expanded.

How do you see pharmacists being reimbursed for expanding that role? Do you believe the role should include direct prescribing by the pharmacist? If so, my big question would be, what is the liability of the pharmacist with regard to prescribing?

And I hearken back to the question: what are your incentives from any particular pharmaceutical company for selling their drugs? If you, for instance, sell a quantity of the drugs, do you get deals such as if you buy one, you get two free, or if you sell 2,000 pills, you get 500 free? I cannot think of any other profession that has more to gain—other than the pharmaceutical industry itself—from the movement of drugs to sway some patients to a company, because you make money selling drugs. That's what you do, whether it's over-the-counter or prescription drugs.

My question is, if you intend to expand your role, how do you keep some sort of ethical regulation around that?

Á (1140)

Mr. Greg Eberhart: First of all, I'd like to go back to the opening part of your question. It's not that we don't have a responsibility; we have limitations on our responsibility. When you look at self-governance, we have responsibility for registering pharmacists and pharmacies. We deal with the monitoring of their practices—that is, the establishment of standards, the monitoring of their competencies, and their adherence to those standards. We also have a responsibility to deal with complaints resolution.

In the case of licensing pharmacies, it is very infrastructure-oriented. That is to say, if a pharmacy meets certain size requirements and has the appropriate equipment in place, they receive a licence—again, providing they are under the jurisdiction and management of a pharmacist.

The challenge we are faced with is not that we do not have a role in this equation; it's just that we cannot fulfil our absolute responsibilities because of jurisdictional issues and the lack of clarity around the jurisdictional issues. Therein lies the responsibility of the provincial and federal governments, particularly when you move into the international marketplace.

The second question was around liability. We believe it will come down to a court of law. When something happens and a product has been marketed in Canada and been licensed for sale in Canada and a pharmacist has made the decision to provide it to an American citizen, I think the jury is out as to where the liability lies. We've heard different arguments in this vein—that is to say, whether the distribution occurred in the United States, or did it occur in Canada? That's a legal argument I can't give you an answer to until we're confronted with the challenge.

Ms. Hedy Fry: Transportation of narcotics.

Mr. Greg Eberhart: Transportation of narcotics. To our knowledge, at this point in time I am not aware of any Canadian pharmacy that is transporting or selling narcotics/opiates to American customers. Most of them that I am aware of are very clear that these are very specific scheduled drugs that are provided and they do not end up in that particular marketplace.

I'd like to take the liberty, prior to passing it on to my colleagues, to comment on the issue of prescribing. This is something that's very much in the forefront in Alberta, which our colleague is currently leading as he works the advent of new health professional legislation here. We will be making presentations to our health professional advisory committee near the end of November in and around the role of pharmacies and prescribing drugs.

We have developed a model to try to define and describe what is meant by pharmacist prescribing. I would emphasize that pharmacist prescribing is very unique as compared to that of other health professionals, because of where pharmacists are positioned in the health system. The model we've developed is divided into three categories. It talks about prescribing for the purposes of primary care; it talks about prescribing for the purposes of adjusting and continuing therapy to ensure compliance and appropriate drug outcomes; and, thirdly, it talks about comprehensive drug therapy management.

To speak to each of those categories very briefly--

The Chair: Actually, Ms. Fry's time is already up. Perhaps you can put it into another answer.

Mr. Thompson.

Mr. Greg Thompson: Thank you, Madam Chair.

I noticed your paper here, by the Canadian Association of Chain Drug Stores, and I was here to hear most of that presentation. It's pretty self-congratulatory. I don't see too many criticisms of the pharmacists in this glowing overview, if you will. And I notice on page 1 of 8--I'm quoting from your report:

Study after study shows that Canadians highly value their pharmacy. The pharmacist has been ranked the most trusted of all professionals (Ipsos-Reid 2002).

Does that put you slightly ahead or behind politicians and used car salesmen? I say that because when you get talking about the price of drugs and the profit margins, I don't think you're being as forthright to this committee or the public as you should be.

It's hard to believe that the profitability, when you're going into a drug store.... Basically, you're telling us you're going into an institution that sells more items than a hardware store, so you can't convince me that the pharmacists in a lot of cases, especially with the associations you have, are actually the owners of the business, if you will. You can't convince me that they're making more on a box of chocolates than they are on Viagra, for example. It's typical markup on some of those consumer items.

So how does the profitability of the drug store break down on that other wide range of items, from claw hammers to screws and a box of chocolates? How does that fit into the profitability range of some of the drugs you're dispensing?

My other question is in terms of the wide range of discretion you have as pharmacists, whether you're prescribing a drug that's a patent drug, one that's come off patent, generic versus brand name, and how much discretion you exercise there. This morning, for example, we heard from Mr. Bougher from the Alberta government, the pharmaceutical and policy programs director, talking about categories of drugs that are not being prescribed and some that are being overprescribed. There's a wide range of drugs that you prescribe and don't prescribe.

So how much discretion is there when, for example, the doctor sends in a prescription? Do you have the ability to move that around within a range of products? That is one of the questions. And how much does that impact on your profitability? In other words, you very seldom meet a pill you don't like, provided that the profit range is greater than the other one. How much does that impact on your decision-making when you're dispensing that drug, or is it totally up to the doctor?

Maybe you could address some of those points.

Á (1145)

Ms. Lori Turik: The pharmacy sector is a highly regulated industry--

Mr. Greg Thompson: We know that, but just get to the point. I don't want to hear any of the in between. I only want to get to the point of the profitability and how much discretion you have. Don't give us the overview. We've had that.

Ms. Lori Turik: Okay.

We don't control prices. We are paid from the formularies for three components that we've discussed--

Mr. Greg Thompson: Whether it's a drug plan or off drug plan?

Ms. Lori Turik: Both, yes.

Mr. Greg Thompson: So that would apply.... For example, if someone who goes in is on a drug plan, the charge of that product does not vary. In other words, if I go in and I'm on a drug plan, I'm charged x amount because that's all the drug plan is going to pay. Then Mr. Ménard comes in and he doesn't have a drug plan. Is he charged the identical price? Is that correct?

Ms. Lori Turik: We're reimbursed on the basis of--

Mr. Greg Thompson: No, I'm not talking about reimbursement. When you're paid over the counter by this man, versus myself for whom you're being paid by a drug plan, is he actually charged the same price? In other words, his drugs cost him $50 and he's paying for them over the counter. I'm going through a drug plan. Typically, the drug plan will pay you less. Is that not right?

Mr. Jeffrey May: I think the best answer is that there is variability in reimbursements from drug plans--

Mr. Greg Thompson: Okay, there you go. Strike down that code, please. I don't like code words. In fact, when I'm looking through the report, you double speak and you speak in code all through this report.

In fact, if you go down to patent drugs, for example, there's another example of code, Madam Chair. On page 6 of 8:

We believe it is essential that the Canadian government works with the pharmaceutical industry to ensure effective incentives to stimulate pharmaceutical R&D and enable Canadians to have timely access to innovative therapies.

Effective incentives. Does that mean you support 20-year patent protection, 30-year, 40-year? What's that telling us?

Mr. Jeffrey May: Might I go back and answer the question about variability and price?

Mr. Greg Thompson: Well, please explain variability, but don't go through this code language.

Mr. Jeffrey May: I will not, sir.

If you come with a prescription and you are a beneficiary, for example, in the Ontario drug benefit program, typically, if it's a $100 drug, you will pay $116.54. If you are a member of a privately paid drug program in the province of Ontario, that charge may be toward $120.

Mr. Greg Thompson: Maybe or is?

Mr. Jeffrey May: It's variable. Different pharmacies have different fees. That's one of the realities of doing business.

Mr. Greg Thompson: So there is a range within pharmacies. There's a level of discretion that you can exercise in a typical pharmacy.

Mr. Jeffrey May: That's right. Government programs and--

Mr. Greg Thompson: The possibility is very dependent on the individual pharmacy. That 10% number you quoted Mr. Ménard might be active for some but not active for others. Would that be correct?

Mr. Jeffrey May: Yes. The contracts we have with drug programs establish the maximum allowable price we can charge. Pharmacies, depending on the nature of their business and their position within the marketplace, can choose to charge underneath that, and that results in the variability in the marketplace.

Á (1150)

Mr. Greg Thompson: Some of these prescriptions I've been, I suppose, the beneficiary of, in being able to take in the sense of the cure.... I can remember my wife going into the pharmacy and a five-day supply cost $1,500. So when you're talking 10% on $1,800, you're talking about a chunk of change, aren't you?

Mr. Jeffrey May: Yes.

Mr. Greg Thompson: That's more commission than a used car salesman would make on a junker, isn't it?

The Chair: I'm afraid your time is finished. There is no time for the answer, but perhaps Ms. Bennett could pick up either your thoughts or Madam Fry's.

Mr. Dromisky.

Mr. Stan Dromisky: Thank you very much.

We know the holy dollar controls just about everything, don't we? A common thing about advertising...I have to use this analogy: soap is soap is soap. When Tide comes out they say “This is the best soap”. Then some retrofitting takes place. They might add something. But there isn't any change. Soap is soap is soap. When you look at the molecular viewpoint, you can't really change it. You add things to it.

The same thing happens in the drug industry. You have basically spent millions and millions of dollars. A drug is created. It is very effective. Then the drug companies go ahead and some retrofitting takes place. You make a slight little change in whatever the competition might be for that drug. Then they advertise how wonderful it is: it's far greater and it's better--and it costs more.

In the pharmacies, all the pharmacists...I don't know what kind of counselling takes place. There's really no difference between the two. Do you tell your patients that this is as good as the old one? Are you allowed to do something like that? Is there some other ethical guideline, or do you just keep your mouth shut and simply push the one that's the most expensive one?

Mr. Greg Eberhart: Pharmacists have a responsibility to counsel patients, not only with respect to what they might expect from the drugs and how to use the drugs, and related to that the disease states for which they're being treated, but the patient needs to understand what they're taking and what to expect in order to get the outcomes we try to achieve.

Part of that discussion leads us into the monitoring process. Typically, if a patient visits a physician, a diagnosis is provided, and a decision is made to treat with a drug, the pharmacist will provide the counselling as I have described. Once the monitoring process begins, if the patient responds with adverse effects or other anomalies of concern, it's usually at that stage that the pharmacist will make recommendations, be it within a chemical class or otherwise, for change to occur.

In the first instance—that is, at the first point of entry, and it may be when that original prescription is received—the pharmacist may provide recommendations or may discuss with the patient the consideration of an alternative based on cost. Usually it's not on effect in that first instance, because they will respect the decision of the physician in the first instance. Modification will occur as monitoring occurs.

Mr. Stan Dromisky: Okay. Very good.

My second question is for the chains. If I produce pork and beans and want to market it in the Safeway supermarkets, I'm going to have to pay for so many inches of shelf space in order to have that product there. Using that concept, I'm wondering if the same kind of thing happens in a chain that has, let's say, a thousand drug stores across the country in dealing with the two arms of the pharmaceutical industry. I have a thousand drug stores; I'll push this drug or I'll push this product, whether it's prescribed or not, for a certain price. We can call it a kickback, we can call it payment underneath the table, or it could be part of a sponsorship program or something. I don't know what you would call it, but I'm wondering if there are agreements of this nature with the large drugstore chains we have across this country to increase their margin of profit for the stockholders.

Á (1155)

Ms. Lori Turik: As a national association we don't comment on the commercial activities of our members. But that having been said, and given the discussion that's been around the table, professional allowances are a common business practice that take place in all business dealings in this country. They are also used as a common business practice not only in the private sector but also in groups such as hospitals for long-term care and in not-for-profit situations.

So in reality there are certainly professional allowances that are provided, but they're not just provided to pharmacies; they're also provided within the private sector not-for-profit area and within the health care sector itself. We hear about these professional allowances as well for physicians, and I know there's been some reference to that also.

We believe that in fact pharmacies need to be compensated fairly for the services they provide. Currently, we believe that not all of the services pharmacies are providing are being compensated through the drug benefit plan, that in fact the professional allowances being used by pharmacies are going to provide direct patient care and professional educational services for pharmacists.

If as a government one chooses to change the prices, one chooses to change the distribution payment, one chooses to change the markups we've talked about, one needs to consider and factor in all of the costs the pharmacy has as a business to provide those services in the best interest of patient care.

The areas where these professional allowances are going are to provide services such as clinic days, educational services for pharmacists, investment in information technology, so that in fact you can exchange information directly between pharmacies and the provincial governments, so that you can start to create a database of information for purposes such as medication misuse or abuse, or for diabetes and asthma care programs that are being provided. In reality these are a legitimate business practice.

I can't comment on what might be the reasonable profit margins of any company, but when one looks at pricing and regulation and distribution and costs, one needs to take into consideration the impact that will have on the provision of patient care as a whole.

The Chair: Thank you, Mr. Dromisky.

Ms. Bennett.

Ms. Carolyn Bennett: Thank you very much.

I think there's no question that there are pharmacies where businessmen try to make a profit and there are special relationships with the suppliers of their product. I remember the drug reform secretariat in Ontario when we sat on the Subcommittee on the Expanded Role of Pharmacists, back in the days when pharmacare made your pharmacy a consultant to help Canadians better understand their drugs or how they could better manage their condition. There has been a blending of these two, which has meant that the pharmacies do have to sell their hair colour products, and the whole front end of the store is confused with the person at the back. A guy in a pharmacy in Sault Ste. Marie who thinks of it as a consulting office, where the patients come in and privately discuss their condition with them, is very different from the guy who is in the office up on top looking for shoplifters, or whatever the reason is for those offices up on high. Borrowing Stan's point, I think this is something we have to work on if we're going to bring the pharmacists in as an important member of the health care team.

I was surprised to see in the drugs program the alarm raised on a national drug agency. I think most people think that for every province to do the drug reviews and all of those things.... What I've heard is that needs to be done collaboratively. With the Alberta director of pharmaceutical policy and programs talking about the importance of national collaboration, I'm not sure why creating a structure around that would raise alarm bells for you.

I don't quite see how you reach the conclusion that medications should only be available if they are deemed cost-effective. I don't know why that would be a bad thing. But it's clearly good for provinces to share best practices. The federal government is the fifth biggest provider of health care in this country, with all that we do with aboriginals, veterans, and whatever. Even in your example of what's happening in the armed forces, it looks as if there's a lot to be said for the role of pharmacists and some collaboration on best practices. If there were a move toward a drug agency and a role for post-market surveillance in a coordinated way, what exactly would be your concern?

Â (1200)

The Chair: You have about a minute and a half to answer.

Ms. Lori Turik: We definitely support the process of common drug reviews if it achieves the goals it sets out to achieve, which are to improve efficiency, consistency, and transparency in the process. I think it's a new process that's being undertaken, and it's highly supported by both provincial and federal governments. We're very optimistic and hopeful that it will achieve those goals.

In terms of post-surveillance monitoring, we would be very supportive of that. In fact, we would argue that there's a very clear role for the federal government to play in supporting an initiative for information technology expansion that would allow for the data to be captured both from physicians and pharmacies to assist in that regard. So from a perspective of cost-effectiveness, we're in agreement.

Ms. Carolyn Bennett: A secretariat that would fulfil both of those roles--is there a problem with that in terms of...?

Ms. Lori Turik: As long as it actually achieves the goals it sets out to achieve, does not increase administrative burdens, which are quite heavy on the industry as a whole now, and expedites the process, we would be very supportive of that taking place. We're optimistic, and we're waiting to see the results of that.

Ms. Carolyn Bennett: The curious thing is, how come there are 13 places we have to go? I don't know why you guys wouldn't think that that would be the right thing.

The Chair: You are not at five minutes yet. Other people have had more than six, because those answering had the floor at the moment the five minutes ticked by. But right now we're at five minutes, Ms. Bennett, and I will allow one answer.

Ms. Lori Turik: In answer to your question, we do support the common drug review process if it achieves the goals it established.

The Chair: I've had two requests. Mr. Ménard has a point of order, and Mr. Merrifield and somebody else have asked to have Mr. Eberhart continue with his three points that he was in the middle of.

Mr. Ménard, would you let Mr. Eberhart finish before your point of order?

Mr. Réal Ménard: Yes.

The Chair: Thank you very much.

Mr. Greg Eberhart: In Alberta we have new health legislation introduced. Our colleagues will be proposing that pharmacists be enabled to prescribe drugs. We have developed a model that has three categories. Those three categories can be defined as primary health care, continuing and adjusting drug therapy for the purpose of ensuring compliance and appropriate outcomes, and comprehensive drug therapy management. This model has been introduced in the context of pharmacists making decisions within a collaborative health scheme environment. We emphasize, and this is the foundation of the whole discussion, pharmacists not working autonomously, but working with other health professionals. The purpose of the proposal is to increase accessibility and opportunity for clients. It respects the privilege of clients making personal choices as to where and how they secure health services.

Just to briefly describe the three categories, I'll discuss them in reverse order. Comprehensive drug therapy management is a situation where a patient suffering from a chronic condition would visit a physician and a diagnosis would be made. The physician, in prescribing a drug therapy, would refer the patient to the pharmacist for the ongoing monitoring and management of the patient. The pharmacist, through their knowledge and competence, would be enabled to monitor the effects of the medication and adjust the therapy where necessary. That may mean increasing doses; it may mean decreasing doses. In some situations it may mean prescribing other medications. An excellent example of this today is the management of anti-coagulation, where pharmacists are working as physicians, exactly as I've described, to manage a patient who requires therapy.

The second scenario is one most of us would relate to in community-based practice, where a patient visits a physician, a diagnosis is made, and treatment is initiated, possibly along with a number of refill medications. The first decision the pharmacist needs to make is whether the medication is appropriate for the patient. Is it in the right dosage form? Is it the right strength? Does it have the right instruction for use? Periodically, changes to those types of instructions need to be made, and we're proposing that pharmacists be enabled to apply their skills, knowledge, and competence and do that without having to refer back to the physician. We also believe in those situations pharmacists should be able to therapeutically substitute medications in the interest of both cost and effectiveness, in the interest of minimizing adverse effects the patients might experience. We also believe pharmacists should be able to prescribe medication to continue the therapy if a refill has run out, or if somebody has lost their medication, or if somebody is travelling and has left their medication at home. These are scenarios pharmacists face on a day-to-day basis. Again, the purpose is not to take over from the physician, but to fill gaps within the system to accommodate accessibility and to minimize costs.

In the first instance we talk about pharmacists prescribing drugs for the purposes of lifestyle changes, e.g., smoking cessation therapy. We talk about pharmacists prescribing medication to assist patients in emergency situations. One that is now commonly practised across Canada is the prescribing of emergency contraception. Alternatively, we might have a patient who presents himself to the pharmacist who is asthmatic, is wheezing, and the pharmacist is familiar with the previous treatment protocol. The pharmacist would then be able to provide him with the appropriate medication to see him through. The third instance under category one speaks of a pharmacist having an expanded drug armamentarium to treat conditions they are already assessing. For example, patients commonly see a pharmacist as the first point of access to the system, and the pharmacist assesses them for information, recommends ASA, recommends ibuprofen. We're suggesting that there are other drugs that may not have the same adverse effect on a patient-specific basis that the pharmacist might consider. Or it might be a situation of dealing with seasonal conditions, where the pharmacist again has the appropriate information to make a decision to provide the appropriate therapy.

Â (1205)

I'd like to emphasize, in closing, that when we look at this model we are talking about pharmacists working at many different points in the health system; we're talking about many pharmacists, many patients, many drugs. The foundation for the legislation in Alberta, just like we see in medicine, just like we see in nursing, is that the limitations on any given health professional are based on their individual competencies, skills, and knowledge. Physicians have vast knowledge in diagnosis. They receive limited training in and around drugs. Pharmacists are exactly the opposite: they receive a vast amount of knowledge about drugs, but a limited amount of training around the diagnosis. And there's an interface there that's similar with respect to theirs.

The Chair: I know this has been terribly interesting, and we might want to question Dr. Eberhart, but I will remind you that moving backwards from the end of day, when our flight is overbooked and we have to get there in time to get everybody on the plane, back to our afternoon witnesses, we now have 60 minutes to check out and have lunch, etc. So I think I'm going to thank these witnesses, and if you want to speak to them, please, do it privately at the end of this session.

Thank you.

[Translation]

M. Réal Ménard: I have a point of order.

[English]

The Chair: On a point of order, sorry.

[Translation]

Mr. Réal Ménard: Since we will not have time for a second round of questions with our guests, I want to make sure documents will be tabled and a research report produced. I want to know exactly the chain of intermediaries you mentioned and I would like your association to remain in contact with our researcher in order for us to get a copy of the documents and a report distributed to all members on how these things work for our information when the time comes to write our report.

Maybe we need to consider the possibility of having the association appear again in Ottawa, Madam Chair. Pharmacists play such a major role that they might have to come back before us in Ottawa in order for the committee to get a better understanding of how their industry works.

Â (1210)

[English]

The Chair: Mr. Ménard, I'm sorry, who is it you wanted to have come to Ottawa?

[Translation]

Mr. Réal Ménard: The Canadian Association of Drug Store Chains.

[English]

The Chair: The Canadian Drug Association? You want to hear from them again, do you?

[Translation]

Mr. Réal Ménard: Yes, and I would like to have a research report that would fully document what provinces pay to them and the regulations that they are subject to, in order to have a full grasp of the chain of intermediaries.

[English]

[Technical difficulty--Editor]

The chair: Meeting is adjourned.