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37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Thursday, October 30, 2003

1320

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

Dr. Joel Lexchin (Associate Professor, York University School of Health Policy and Management, Medical Reform Group)

Dr. Rosanna Pellizzari (Member of the Steering Committee, Medical Reform Group)

1325

Mr. Brad Macintosh (Member of the Steering Committee, Medical Reform Group)

Dr. Joel Lexchin

1330

The Chair

Mr. Michael Rachlis (Private consultant in health policy, As Individual)

1335

1340

The Chair

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

The Chair

Mr. Gilbert Barrette (Témiscamingue, Lib.)

1345

Dr. Joel Lexchin

Mr. Michael Rachlis

The Chair

Mr. Rob Merrifield

Dr. Joel Lexchin

Mr. Rob Merrifield

Dr. Joel Lexchin

Mr. Rob Merrifield

Dr. Rosanna Pellizzari

Mr. Rob Merrifield

Dr. Rosanna Pellizzari

Mr. Rob Merrifield

Dr. Joel Lexchin

Mr. Rob Merrifield

Dr. Joel Lexchin

Mr. Rob Merrifield

Dr. Rosanna Pellizzari

1350

Mr. Rob Merrifield

Mr. Michael Rachlis

Mr. Rob Merrifield

Mr. Michael Rachlis

Mr. Rob Merrifield

Mr. Michael Rachlis

Mr. Rob Merrifield

1355

The Chair

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

Dr. Joel Lexchin

Ms. Carolyn Bennett

Dr. Joel Lexchin

Ms. Carolyn Bennett

Dr. Joel Lexchin

Ms. Carolyn Bennett

Dr. Joel Lexchin

Ms. Carolyn Bennett

Dr. Joel Lexchin

Ms. Carolyn Bennett

Mr. Michael Rachlis

Ms. Carolyn Bennett

Dr. Joel Lexchin

Ms. Carolyn Bennett

Mr. Michael Rachlis

Ms. Carolyn Bennett

1400

Dr. Rosanna Pellizzari

Ms. Carolyn Bennett

Dr. Rosanna Pellizzari

Ms. Carolyn Bennett

Mr. Michael Rachlis

Ms. Carolyn Bennett

Dr. Rosanna Pellizzari

Ms. Carolyn Bennett

Mr. Michael Rachlis

Ms. Carolyn Bennett

Mr. Michael Rachlis

Dr. Joel Lexchin

Ms. Carolyn Bennett

Dr. Joel Lexchin

Ms. Carolyn Bennett

The Chair

Mr. Svend Robinson (Burnaby—Douglas, NDP)

1405

Dr. Joel Lexchin

1410

Mr. Svend Robinson

The Chair

Mr. Svend Robinson

Dr. Joel Lexchin

Mr. Svend Robinson

Mr. Brad Macintosh

Mr. Svend Robinson

Dr. Joel Lexchin

Mr. Svend Robinson

Dr. Joel Lexchin

Mr. Michael Rachlis

1415

Dr. Joel Lexchin

The Chair

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

Mr. Brad Macintosh

1420

Mr. Michael Rachlis

Mr. Jeannot Castonguay

Mr. Michael Rachlis

Mr. Jeannot Castonguay

Mr. Michael Rachlis

Dr. Joel Lexchin

Mr. Jeannot Castonguay

Dr. Joel Lexchin

Mr. Jeannot Castonguay

The Chair

Dr. Rosanna Pellizzari

1425

The Chair

1440

The Chair

Mr. Jean Joubert (President, ESI Canada)

1445

The Chair

Mr. Vernon Chiles (Vice-Chair of the Board, Green Shield Canada)

1450

1455

The Chair

Mrs. Anne Kothawala (President & CEO of the Canadian Newspapers Association, Alliance for Access to Medical Information)

1505

Mrs. Anne Kothawala

1500

The Chair

Mr. Rob Merrifield

Mr. Jean Joubert

Mr. Rob Merrifield

Mr. Jean Joubert

Mr. Rob Merrifield

Mr. Jean Joubert

Mr. Rob Merrifield

The Chair

Mr. Jean Joubert

Mr. Rob Merrifield

Mr. Jean Joubert

Dr. Steven Semelman (Vice-President, Health Management Operations, ESI Canada)

Mr. Rob Merrifield

Dr. Steven Semelman

Mrs. Anne Kothawala

Dr. Steven Semelman

Mrs. Anne Kothawala

Dr. Steven Semelman

Mr. Rob Merrifield

Mrs Sandra Graham (Senior Vice-President for Public Affairs of the Canadian Association of Broadcasters, Alliance for Access to Medical Information)

Mr. Rob Merrifield

Mr. Vernon Chiles

Mrs. Anne Kothawala

Mr. Svend Robinson

Mr. Rob Merrifield

The Chair

Mr. Rob Merrifield

Mr. Vernon Chiles

Mr. Rob Merrifield

Mrs Sandra Graham

Mr. Rob Merrifield

Mrs Sandra Graham

Mr. Rob Merrifield

Mrs Sandra Graham

Mr. Rob Merrifield

Dr. Steven Semelman

Mr. Vernon Chiles

Dr. Steven Semelman

Mr. Vernon Chiles

Dr. Steven Semelman

Mr. Rob Merrifield

The Chair

Mr. Rob Merrifield

The Chair

Ms. Carolyn Bennett

Mr. Vernon Chiles

Ms. Carolyn Bennett

Mr. Vernon Chiles

Ms. Carolyn Bennett

Mr. Vernon Chiles

Mr. Jeannot Castonguay

Ms. Carolyn Bennett

Mr. Vernon Chiles

Ms. Carolyn Bennett

Mr. Vernon Chiles

Ms. Carolyn Bennett

Mr. Vernon Chiles

Ms. Carolyn Bennett

Mr. Vernon Chiles

Ms. Carolyn Bennett

Mr. Vernon Chiles

Ms. Carolyn Bennett

Mr. Vernon Chiles

Dr. Steven Semelman

Ms. Carolyn Bennett

Mr. Vernon Chiles

Ms. Carolyn Bennett

Dr. Steven Semelman

Ms. Carolyn Bennett

Mrs. Sandra Graham

The Chair

Mr. Svend Robinson

Mrs. Anne Kothawala

Mr. Svend Robinson

Mrs. Anne Kothawala

Mr. Svend Robinson

Mrs. Anne Kothawala

Mr. Svend Robinson

Mrs. Sandra Graham

Mr. Svend Robinson

Mrs. Sandra Graham

Mr. Svend Robinson

Mrs. Anne Kothawala

Mr. Svend Robinson

Mrs. Anne Kothawala

Mr. Svend Robinson

Mrs. Anne Kothawala

Mr. Svend Robinson

Mrs. Anne Kothawala

Mr. Svend Robinson

Mrs. Sandra Graham

Mr. Jean Joubert

Mr. Svend Robinson

Mr. Jean Joubert

Mr. Svend Robinson

Mr. Jean Joubert

Dr. Steven Semelman

Mr. Svend Robinson

Mrs. Sandra Graham

Mr. Svend Robinson

Mrs. Sandra Graham

Mr. Svend Robinson

Mrs. Sandra Graham

Mr. Svend Robinson

The Chair

Mr. Vernon Chiles

The Chair

Mr. Jeannot Castonguay

Mrs. Anne Kothawala

Mr. Jeannot Castonguay

Mrs. Sandra Graham

Mrs. Anne Kothawala

Mr. Jeannot Castonguay

Dr. Steven Semelman

Mrs. Sandra Graham

Mr. Jeannot Castonguay

Mr. Vernon Chiles

Mr. Jeannot Castonguay

Mr. Vernon Chiles

Mr. Jeannot Castonguay

Dr. Steven Semelman

Mr. Vernon Chiles

The Chair

Mrs. Anne Kothawala

The Chair

Mrs. Anne Kothawala

The Chair

Mrs. Anne Kothawala

Mrs. Sandra Graham

The Chair

Mrs. Sandra Graham

Mrs. Anne Kothawala

The Chair

Mrs. Sandra Graham

The Chair

Mrs. Sandra Graham

The Chair

Mrs. Sandra Graham

Mrs. Anne Kothawala

Mrs. Sandra Graham

The Chair

Mrs. Sandra Graham

The Chair

Mr. Jean Joubert

The Chair

Mr. Jean Joubert

The Chair

Mr. Jean Joubert

Dr. Steven Semelman

The Chair

Dr. Steven Semelman

The Chair

Mr. Rob Merrifield

The Chair

Mr. Rob Merrifield

Mr. Svend Robinson

The Chair

Mr. Rob Merrifield

Mr. Jean Joubert

The Chair

Mrs. Anne Kothawala

The Chair

Mrs. Anne Kothawala

The Chair

Mrs. Anne Kothawala

The Chair

CANADA

Standing Committee on Health

NUMBER 068

2nd SESSION

37th PARLIAMENT

EVIDENCE

Thursday, October 30, 2003

[Recorded by Electronic Apparatus]

· (1320)

[English]

The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good afternoon, ladies and gentlemen. It's my pleasure to welcome you to the Toronto hearings of the Standing Committee on Health as we proceed with our study on prescription drugs, and we'll go right to your presentations.

Our first witness today is Michael Rachlis, a private consultant on health policy. He is presenting as an individual, although he's quite well known to most of us. Oh, you'd like Mr. Lexchin to go first.

So our first witness is from the Medical Reform Group, Mr. Joel Lexchin.

Dr. Joel Lexchin (Associate Professor, York University School of Health Policy and Management, Medical Reform Group): Actually, there are three of us from the Medical Reform Group, so Dr. Rosanna Pellizzari will start.

Dr. Rosanna Pellizzari (Member of the Steering Committee, Medical Reform Group): Thank you, and good afternoon.

For those of you who aren't familiar with the Medical Reform Group, we were formed in 1979. We're about 300 physicians and medical students. We have a reputation for defending medicare and standing up for some of the social, political, and economic issues concerning health and health status in Canada. We have given you a brief with our recommendations. We are going to highlight the three major themes we have, and I will begin.

You should have before you the abstract of an article that was published this March in the Canadian Journal of Public Health called “Children in Need of Pharmacare”. The Hospital for Sick Children, a 374-bed pediatric health care facility, established the patient amenities fund to help families with the extra costs that weren't covered by insurance associated with children's illnesses. In this article researchers analysed requests to the fund over a two-year period. What they discovered was that most of the funding was to help parents pay for drugs, that these costs were rising, and that this was despite the fact that most families had at least one working parent. The fund helped parents purchase drugs to fight cancer, mostly leukemia, seizures, renal failure, and cardiac conditions. So we're not talking about aspirins and vitamins here. The authors concluded that government plans in the wealthiest province failed to provide sufficient coverage or timely access for these children in need of treatment. These findings echo those from the Ontario bronchial inhalers study, which found that 31% of parents without drug plans delayed or did not fill prescriptions for their children's asthma because of cost.

For these reasons and more, we urge your committee to make pharmacare a goal for this and future Parliaments. As well as reducing out-of-pocket cost to Canadians and solving problems of access to needed medical care, pharmacare can control rising costs through strategies such as bulk buying, competitive tendering, and the promotion of evidenced-based, cost-efficient prescribing by physicians. As we argue in our brief, Commissioner Romanow's catastrophic drug plan is not enough. When Canada fully implemented medicare, we realized cost containment levered through powerful single payer funding. The MRG believes the introduction of a universal pharmacare program will benefit Canadians twice, by improving access and addressing current inequities and by helping to control drug costs.

· (1325)

Mr. Brad Macintosh (Member of the Steering Committee, Medical Reform Group): I'm going to now talk about promotion of prescription drugs. In Canada pharmaceutical companies spend $1.9 billion per year promoting their products, and the overwhelming majority of this money is dedicated towards physicians, be it through sales representatives' salaries or through samples. On average, doctors have 4.2 interactions with a sales representative per week, kind of an alarming statistic. Despite the fact that these doctors do not view these interactions as being credible sources of information and the interactions rarely result in discussion about safety or side effects associated with the drug, this invariably results in inappropriate prescribing. It's based on this evidence that the MRG recommends that Health Canada no longer allow voluntary self-regulation within the industry. That's the first issue that's discussed in the brief at length.

The second thing I would talk about is direct-to-consumer advertising. In the U.S. DTCA, to use the acronym, is legal and a thriving market. We can talk about that more based on the hand-out Dr. Lexchin has provided. Some $2.7 billion U.S. were spent in the year of 2001. If you just look at the top ten advertising campaigns, in 2001 they spent $1 billion on ads and earned $16 billion in sales, so it's a major market, and it's not surprising that this is something Canadians are having to deal with, both directly and indirectly. The position that we take, looking at the literature over the past 20 years, is that there's absolutely no evidence to suggest that direct-to-consumer advertising has any benefit for improving prescription patterns or improving health outcomes. We also wanted to say that recent policy statements in 1996 and 2000 by Health Canada that served to relax and weaken the Food and Drug Act only served to exacerbate this problem.

Now Dr. Lexchin is going to speak.

Dr. Joel Lexchin: The final point we want to highlight relates to information. If doctors are being bombarded by so much advertising and promotion from the pharmaceutical industry, especially for new products--those are the ones that the industry promotes the most heavily, for obvious reasons--where can doctors go to get independent sources of information in order to be able to prescribe appropriately? If you look at how much literature there is on new drugs, especially randomized control trials, which are considered the gold standard for information on how effective drugs are, there is surprisingly little when new drugs come on the market. That means doctors are forced, because of the absence of any other source, to rely on what they hear from the drug companies, which is going to be biased.

There is one untapped source of information that could be made available to doctors and to people who have to make decisions, people who produce clinical guidelines, provincial drug plan managers, and that is the clinical information that is submitted by the drug companies when they apply for approval of new drugs. However, Health Canada regards that information as confidential and will only release it with the consent of the pharmaceutical companies. That consent is rarely forthcoming. Contrast what happens in Canada with what happens in the United States. Routinely there, when a new drug is approved, the FDA posts on its website for anybody to see the FDA reviewer's comments about the information the companies have submitted. Through a freedom of information request, in the United States you can get the clinical studies that have been submitted, and they are usually released within about a two- to four-week period. The drug companies cannot veto the release of that information. Here we have the same information, the same studies. Here the companies claim that they need to protect them because they're commercial secrets, in the United States they're open and available.

Why should this discrepancy exist? Why should Canadian physicians and people in Canada who want to look for information to help guide appropriate prescribing have to go to the FDA to get that information? It should be available here, with appropriate safeguards, so that anything that identifies patients would be removed and any true commercial secrets on manufacturing techniques and stuff would also be removed. But clinical information that is submitted by the drug companies to the TPD should be routinely made available to the public once those products are approved.

· (1330)

The Chair: Thank you.

Mr. Rachlis.

Mr. Michael Rachlis (Private consultant in health policy, As Individual): Thank you very much to the committee for inviting me to speak with you today. I just have a short presentation for you, but I wanted to let you know that I'm finishing a book that's coming out in February that will have a chapter on pharmaceutical policy, and I will forward that chapter to the clerk as soon as it's gone through the final editing process.

The messages that are generally projected about prescription drugs to the public are, first, that new prescription drugs are wonder products; second, that prescription drugs are carefully regulated to ensure safety; third, that we have to rely upon the private sector for innovation, and it costs a lot of money; fourth, that drug costs are rising rapidly because we need to pay more and more for effective drug therapy; and finally, that a national pharmacare program would be unsustainable. However, I think each of these points is false.

The true situation indicates that less than 5% of new drugs are true wonders. From 1994 to 2000 only 30 of 600, or 5% of new patents granted, were for category 2 or so-called breakthrough drugs.

Second, there are safety lapses at every step of the drug delivery process. I hope, after you've forgotten all of the other presentations you've heard, Mr. Young's presentation will be burned into your mind. The Vanessa Young tragedy is a classic example of how we fail every step of the way, the approval process, the monitoring process, and even at the clinical level. The evidence indicates that this is not an aberration. University of Toronto researchers a few years ago had an article in the Journal of the American Medical Association where they concluded that adverse drug reactions were the fourth leading cause of death, causing the death of 100,000 Americans every year. These are just in-hospital adverse drug reactions. Dr. Bruce Pomerantz of the University of Toronto estimated that there would be 10,000 deaths from in-hospital adverse drug reactions in Canada. A Montreal study showed that adverse drug reactions accounted for 10% of emergency department visits by elderly people, and 20% of other patients were taking medications that had a potential for an adverse drug reaction. Another Quebec study showed that half of all seniors received a potentially dangerous prescription in just one calendar year. And an Alberta study found that over one-quarter of that province's seniors had taken a non-steroidal anti-inflammatory drug or anti-arthritic drug in the previous year; 2,600 Alberta seniors filled a prescription for two of these drugs on the same day. Drug therapy can be wonderful, but it also is a major cause of death in this country.

Third, the public sector is still responsible for most innovations: 50 of 77 anti-cancer drugs that have been approved for use in the United States were developed with help from the National Cancer Institute. Basically, our universities are still where most innovation is seeded. This is not to say the drug industry does not play a role, but it is fallacious to say that without the drug industry there is no innovation.

Fourth, increases in drug costs are mainly due to inappropriate prescribing. Once a year we hear of studies that thousands of Canadians are dying because of inappropriate prescribing. The other 364 days of the year we fret about not having enough money to buy the drugs people need. We have to recognize that if we could do something about the inappropriate prescribing of drugs in this country, we could cover everyone. We prescribe new drugs when older drugs are more effective, and we prescribe drugs when no drugs are really warranted at all. This is for three reasons.

Drug companies' marketing practices overwhelm doctors' lack of knowledge and training in pharmacology. Solo fee-for-service doctors working in Canada are the easiest prey for drug company marketing. Direct-to-consumer advertising, as a friend of mine would say, would be like the crack cocaine of drug marketing. It would take the problems we have that have killed people like Vanessa Young and would kill thousands of others. If you really feel that we should be providing more unbiased information to the public on drugs, which I think we should, then levy a small tax on each prescription and use that money to fund it. We cannot pretend that we will be uninfluenced by the promotion if the drug companies fund it.

Second, patients do not have easy access to non-drug therapies. Many disorders can be treated safely with non-drug therapy: mild hypertension, mild to moderate depression, most back pain problems. But the problem here is that physicians are not often aware of the issues. Furthermore, physicians, again, tend to practise by themselves. They don't have social workers to do counselling, they don't have physiotherapists to do the musculoskeletal treatment, they don't have other professionals who could provide these non-pharmaceutical therapies.

Finally, pharmacists are the experts in medication, but outside hospitals, they typically work in isolation from doctors and other professionals.

· (1335)

My fifth point is that a national pharmacare program would be sustainable. In fact, drug costs are unsustainable because we do not have a national pharmacare program. As Joel and the others have mentioned, we could save a considerable amount of overhead from our drug costs if we had a public plan. That's the reason we have a public insurance plan for doctors in hospitals. As Justice Emmett Hall noted, it would be cheaper to administer to a single payer plan.

We should also take a number of actions to improve the appropriateness of prescribing. First, we need better use of non-pharmacological therapies, and second, we have to utilize pharmacists in a much better way. Physicians and pharmacists can practicse in the same community for 30 years and only spend ten minutes on the phone talking about professional issues. Pharmacists are a very unused resource. In hospitals pharmacists are appreciated now. We do have more multidisciplinary teams in hospitals. Outside hospitals we still don't have good teams, which is why we haven't talked about primary health care for many years.

There are three tactics I can recommend here. One is academic detailing. This started in North Vancouver, now it's spread to Alberta. Saskatchewan and Nova Scotia have major academic detailing plans in place, where pharmacists and sometimes other professionals go into doctors' offices using the same tactics the pharmaceutical representatives use themselves. They educate physicians on prescribing. A study in North Vancouver has shown that for every dollar spent on that program, they save two dollars, because of better prescribing.

We need to integrate pharmacists into primary health care settings. We have some examples of consulting pharmacists spending time in doctors' offices. There are almost no examples of the multidisciplinary clinics we've been talking about for 30 years, where you have physicians not paid on fee-for-service, so they don't have the incentive to write that prescription, get the patient out of the office, working with non-physician providers like social workers, nurse practitioners, physiotherapists, and others, and with pharmacists.

If you're going to be in Vancouver, the two best examples I know of in this country are at the Reach and the Mid-Main community health centres in Vancouver. As a quick story about one of them, Susan Troesch, a pharmacist at the Mid-Main centre, had been a practising pharmacist for 30 years. She got bored with what she described as plugging and cranking, filling prescriptions and then giving change. She longed for meaningful interaction with the doctors and other professionals she treated her patients with. A few years ago she started volunteering at the Mid-Main centre, and she's now there on a half-time basis, because of limited funding; she'd be there full-time with more funding. She works with all the other professionals, and she also sees personally 15 patients a day. Some need regular monitoring for things like anticoagulant therapy, but there's a very interesting story I think you should also remember.

A patient she told me about, Mildred, was a 75-year-old lady who had been referred to Susan because the home care nurse was worried about how somnulent she was. It turns out that she recently had a car accident; she fell asleep at the wheel and hit a garbage truck on the way to the bank. When Susan started to see her, Mildred was so sleepy that she could barely finish her sentences. She was taking painkillers on a regular basis, but she waited until the pain was unbearable, and then took far too much. She took three different benzodiazepines, as well as three different antidepressants. To make a long story short, after Susan worked with her, Mildred woke up, and now is just doing wonderfully. Given that at least 20% of elderly Canadians are taking benzodiazepines and are probably hooked on them, we can't count the thousands of car accidents and other problems or the lives that are being lost by people who are sleeping their remaining days away.

A final tactic to make drug therapy more affordable is to reduce the cost of medication expense. As the others have mentioned, tendering of drugs would save a lot of money. I think Joel has estimated that Ontario could save over $50 million a year by simply tendering for multi-sourced drugs, and B.C.'s reference-based drug pricing is estimated to save them over $40 million a year.

· (1340)

My final point is that this area, I don't have to tell you, is riddled with conflict of interest. I don't know if we're the few people in the country who haven't experienced the pharmaceutical company largesse. I've experienced a little bit of it. I hope you won't feel that this is pedantic of me, but with all the pressure you've got from all the industry sources, including many of the other groups that are not officially industry groups, but act as industry groups, who are presenting to you, you need to remember that your job is to protect people like Mildred and to make sure there are no more Vanessa Young tragedies in this country.

Thank you very much.

The Chair: Thank you, Dr. Rachlis.

We'll proceed right to the questioning. Mr. Merrifield, Mr. Barrette has to leave at exactly two o'clock, and I'm wondering if you would mind if he went first.

Mr. Rob Merrifield (Yellowhead, Canadian Alliance): No, not at all.

The Chair: Mr. Barrette.

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

Thank you, all, for coming to see us.

You're not the first ones; we've heard quite a few times about pharmacare. According to you, who should take the leadership, and how should it be financed?

· (1345)

Dr. Joel Lexchin: Pharmacare, in my view, should be financed the way the rest of medicare is financed. Doctors' visits and hospital costs are paid for through general taxation revenue. The additional public expense would not be small; we're looking at expenditures currently in Canada of around $12 billion a year for prescription drugs. Through a public plan, you would probably save between 8% and 10% of those costs, even allowing for increased utilization. Those savings would come about from a number of things.

First, administrative costs would drop. Administrative costs of private plans run about 8% a year, compared with 2% to 3% in large public plans, like those of Ontario and Quebec. So you would save money from that. Second, you would save money through having a single buyer for prescription drugs. In Australia they have the pharmaceutical benefits scheme, and a recent study from there compared Australian prices for new patented medications with Canadian prices and found that Australian prices were about 10% lower, on average, than Canadian prices. So you could save money through buying power.

If you look in our brief, we show you what can be done. In New Zealand the agency PHARMAC manages the drug budget, and they think that over the period of time that PHARMAC has existed, they have cut spending on prescription drugs by about half because of tactics they've used, such as tendering where there are a number of sources, referenced-based pricing, telling companies they could get a new drug listed, but they had to drop the price of an existing drug that was already being listed--a variety of tactics like that.

So pharmacare, overall, would save on the total pharmaceutical budget, and it would also ensure that people have access. Currently, the estimates are that 3% of Canadians are uninsured for drugs, which means they have to spend more than 4.5% of their annual income on prescription drugs, and that around 11% are underinsured. A single public plan would deal with both of those things and would probably result in savings downstream from hospital and physician costs.

Mr. Michael Rachlis: If I could just tag something onto that, there would be initial costs, as Joel has mentioned, but there would also be huge savings, to industry in particular, which is currently paying a lot of the costs for drugs. There would be savings for some individuals as well. We need to remember the way medicare was originally financed. By putting in public money, it replaced private money, allowed taxes to be raised. In fact, companies that at present have generous drug plans, with a public plan, may end up paying less in increased taxes than they're now paying for their drug plans.

The Chair: Thank you.

We'll go now to Mr. Merrifield.

Mr. Rob Merrifield: To pick up on what was just said, that's all with the assumption that the demand for drugs would stay where it is.

Dr. Joel Lexchin: No, the figures that I've looked at show that even with increased demand--

Mr. Rob Merrifield: But you don't know where the demand is going to go. That's a hypothetical we've asked many witnesses about.

Dr. Joel Lexchin: You can estimate by looking at what happens in provinces when people turn 65 and they become eligible for the public drug plans. You can estimate from the United States, where people are covered under Medicaid. There are ways of estimating what the increased demand would be.

Mr. Rob Merrifield: I don't want to spend our time arguing about that, because we'll have a difference of opinion. That's fair enough, but that's not where I would like to go with the questioning.

I am curious as to how your organization differs from the Canadian Medical Association. You say you represent 300 doctors, and I'm wondering where your role is different.

Dr. Rosanna Pellizzari: We're a voluntary group of physicians.

Mr. Rob Merrifield: Do you work hand-in-glove with them or on a different wavelength?

Dr. Rosanna Pellizzari: Many of our members belong to the Canadian Medical Association or the Ontario Medical Association. Those are professional associations, we're not a professional association, we are an advocacy group.

Mr. Rob Merrifield: Okay.

One of the things that amazes me is this. I'm not sure about it. I think you've given me the answer, but clarify if I've got it wrong. A pharmacist in the last group of witnesses said that when a new product comes out of Health Canada, he has a directory on what their recommendations are, the benefits as well as side effects. Are you telling me the physicians do not have that information?

Dr. Joel Lexchin: No. When a new drug is approved, there is something that accompanies it called the official product monograph. This is a summary of the information that is produced by the drug companies, but approved by the TPD. That's available with drugs, but it's only a summary of the information. It doesn't give you the clinical studies that have been done, and it also is not comparative. If you look at that information, it's specific to the particular drug, it doesn't compare that drug to other drugs that may be available for the same problem. That kind of clinical information is crucial. If you want to treat hypertension, there are probably 40 different medications you can choose from. If you don't have comparative information as to which drug is the most effective in which population, which drug is the safest, which drug reduces morbidity and mortality the most, then it's like a crap shoot.

Mr. Rob Merrifield: You don't get that information from Health Canada when they approve, is that what you're saying?

Dr. Joel Lexchin: The clinical trials the companies submit that may have that information are confidential and will not be released unless the companies allow it. All that's released is the official product monograph, which just deals specifically with the individual drug.

Mr. Rob Merrifield: But Health Canada would have that information.

Dr. Rosanna Pellizzari: If I may respond as a practising physician, that is not something that would be available to us. What we would have access to is published trials, for example, in peer review journals. But part of the problem with the approval process is that these are often based on very small numbers. The pre-marketing trials can involve hundreds or even thousands, not enough to know really the full impact of that drug, and it isn't until post-marketing, when we start prescribing that drug, that we actually start seeing some of these adverse effects. That is why we feel that this licensing should be an interim licensing, that there should be post-marketing surveillance before there is final approval given to a product.

· (1350)

Mr. Rob Merrifield: And that's why we're seeing 20% of them hold back.

That also leads us to the responsibility of the physician, as well as the pharmacist, to make sure adverse reactions are being reported. We know only 10% are, and that's probably a high number. So what would change in your practice to give you the proper incentive to make sure that happens?

Mr. Michael Rachlis: The Vanessa Young case is a very good example of that--or a bad example. The drug was not supposed to be prescribed to children younger than 16, and she was 15. Doctors weren't supposed to prescribe it to patients with bulimia or other vomiting disorders, which she had. Janssen-Ortho wrote a warning letter to all Canadian physicians four months before she died.

We have failures all the way through this process. I would feel a lot more comfortable if my parents were getting their prescriptions from a doctor at the Mid-Main health centre, because that doctor isn't on fee-for-service and does not have an incentive to grind patients through the office. The doctor is working with other professionals, such as social workers. So if my mother were anxious, there would be another remedy besides just a drug. Finally, there's a pharmacist there who is working intimately with all the other staff to make sure these issues are brought up. I don't think any of us can have any confidence whatsoever that we or our families are getting the therapy we deserve unless there are those fundamental changes in the delivery system. That's the best hope to reduce the cost of drugs too.

Mr. Rob Merrifield: No one has really talked about that. I wouldn't argue with what you're saying. I think you're probably on the right track with some of the solutions.

I certainly do appreciate some of the things you've reaffirmed that we've heard from other witnesses, with regard to 20% to 30% of our seniors being addicted to benzos, for example. We've heard this from other witnesses as well. What really astounds me is what I challenged the pharmacist, the last witness, on, who suggested that when he sees a misprescribing happening, if it doesn't follow the guidelines in the book, Health Canada's guidelines, he reports it. How do you have 20% of our senior population addicted to a product that is recommended by Health Canada to only be used for 7 to 14 days? They're on them for years.

Mr. Michael Rachlis: Now you're getting to where we really need to go with these issues. There's a whole series of issues that are important related to patent, but the real issue in pharmaceuticals, as well as in the rest of our health system, is quality. If we could improve the quality of care our health care system delivered, we would automatically reduce costs. In this area we have very poor quality care, and we don't typically like to talk about it.

Mr. Rob Merrifield: Yes, I would agree. That's what led to the study we're embarking on. Unfortunately, sometimes we get sidetracked into dealing with patent law, which is more to do with industry than with the adverse effect, which is something we can focus on. If we do this broad brush thing, we'll probably end up going nowhere.

Mr. Michael Rachlis: If I can add, I think it is important not to vilify individuals in this. When we have a problem as widespread as this across the country, it's not the fault of individual physicians or individual pharmacists. The individual physician or individual pharmacists can do very little to grapple with this issue.

You have patients who may have been taking a drug for years coming into a doctor's office saying “I need it”. It takes so long for the doctor to explain why that isn't the case. Very few doctors are working with people like Susan Troesch, who can help wean someone off these drugs.

As for the pharmacists, if they questioned every prescription they thought bore a question, they would not have time to dispense a half a dozen prescriptions a day.

Mr. Rob Merrifield: I appreciate that, and I think you're absolutely right on it. I hope your book will address it. You're leading the way, you might say, because it's an overlooked area, which we have certainly heard of from the witnesses who have come forward.

We need to do a lot more work in this area. Seriously, when you look at 10,000 deaths per year within our facilities because of inappropriate use of medication, we have a serious problem.

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The Chair: Dr. Bennett.

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

I just have a few quick follow-up questions.

Joel, the FDA's approach is to have everything up and transparent, but if you were going to write the rules for Canada, would you want them to have to come with the equivalent of the U.S. Freedom of Information Act, or should they just be on the net?

Dr. Joel Lexchin: Well, they should be on the net. But I mean, the clinical trials should be routinely posted. Failing that, the second best option is that they should be available here in Canada via access to information requests.

But yes, you're right, in the same way they routinely put the reviewer's comments on the website in the U.S., they should also be putting the clinical trials on the website.

The U.S. has a much more transparent and much more open system in their approval process than Canada has, so that most drugs in the approval process go to expert committee hearings. These committee hearings are held in public. There's an opportunity at the start of the meeting for any member of the public to make a presentation, and any information the expert committees get is also available to anybody else who wants to look at it. So the U.S. has a much more transparent system. There are still mistakes in the U.S. system; there are always going to be mistakes, but at least you have some understanding of why those mistakes are being made, and you can have a better idea of how to correct them.

Here, what you're dealing with is a system where the public is taking on faith that the TPD is doing a good job. It may well be doing a good job, but we just don't know it, because we can't see how that decision-making process is going on. And when you couple that lack of transparency with the fact that between 50% and 70% of the costs of running the TPD are now coming from cost recovery, or user fees from the drug companies, you create an enormous perception, whether it's true or not, of conflict of interest.

If you can't actually get the information to see what's going on, it leads people to believe the worst about how the TPD is functioning,

Ms. Carolyn Bennett: On quality, I think that a lot of us feel that information is good. But where are we on this second phase of the Canadian Health Network in terms of getting clinical guidelines up and posted, such that not only physicians but also patients can see what the optimal treatment of hypertension is and can go back and ask, “How come you're giving me this expensive thing, instead of the cheap one that works?”

Dr. Joel Lexchin: In terms of guidelines—

Ms. Carolyn Bennett: But what's the cottage industry of guidelines? What guideline does somebody look at? I mean, some of them are produced by the industry, right?

Dr. Joel Lexchin: That's right.

Well, one of the things that's been recommended in the United States, which has been implemented to some degree, is independent centres for prescription drug information. They were recommended and partly implemented—

Ms. Carolyn Bennett: Maybe the CHN could do something like that.

Dr. Joel Lexchin: So what you need are—

Ms. Carolyn Bennett: I need to know, because the chair is so strict.... Does Quebec have a better set of guidelines for the relationship between physicians and drug detailing, and is there a...?

Dr. Joel Lexchin: No. The promotion practices....

Ms. Carolyn Bennett: In terms of guidelines or something? No?

Mr. Michael Rachlis: In Quebec there are a couple of things that are different. One is that in Quebec pharmacists can get paid for providing a cognitive service.

Ms. Carolyn Bennett: But in terms of the relationship of the detail people from the pharmaceutical business--

Dr. Joel Lexchin: No, it's the same across Canada.

Ms. Carolyn Bennett: Okay, because I think John Godfrey had asked something about that.

Mr. Michael Rachlis: Some institutions have different approaches. Of course, McMaster University has been well known for taking some different approaches in terms of access by pharmaceutical representatives.

Ms. Carolyn Bennett: In the pharmacare piece, Rosanna, Australia gave people a drug plan for their first year off welfare. I think what has happened is that no matter how much reassurance somebody like Joel gives us, everybody thinks it's a very big bite to take off all pharmacare.

Do you think it could be something that you would have just for kids, the way we don't pay GST on kids' clothing? You could get pharmacare for kids as a first step, and then for your first year off welfare. Or is everybody saying it has to be all in there or not at all?

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Dr. Rosanna Pellizzari: I think there are probably many ways to phase it in, but I think the lessons we learned from medicare when we introduced public insurance for hospitals and physicians is that the single payer is very powerful and it's very efficient administratively. So there are cost savings in how you do it.

Doing it piecemeal really threatens the potential to realize those cost savings. So again, I think history has taught us in Canada that the way to do it is to do it universally.

Ms. Carolyn Bennett: And on patient information, instead of a tax on every prescription, what if there was...? You're saying that even if it was a pool of R and D money that was sent to do disease-specific patient--

Dr. Rosanna Pellizzari: Health education.

Ms. Carolyn Bennett: --health education, do you still think that's tainted?

Mr. Michael Rachlis: Why don't we just give them less money by having better-quality prescribing and fund it ourselves? It always seems to me we're like the queen--we don't travel with our own money. We're always looking to the drug industry to pick it up.

Quality prescribing in this country would save so much money. We could fund this ourselves. I said put a levy on each prescription just to show how practically it could be done.

Ms. Carolyn Bennett: In the information technology piece, which I think everybody on the committee understands, even with the information we do have in terms of what we are paying out of drug benefits, we're not mining the data; we're not doing anything with that information. Would that be something you would see going into CIHI, a patient safety institute, a drug agency? How would you be measuring the quality of prescribing?

Dr. Rosanna Pellizzari: As somebody in primary care, I'd say there is the potential to do audit and feedback with physicians around prescribing patterns. Joel and I have co-edited a drug formulary that's evidence-based, and it does give you cost, so you could use that as a gold standard to go back and look at. For example, for uncomplicated hypertension, what have you been prescribing? Because the best way to change behaviour--and I'm talking as a prescriber--is to give me the feedback and to build in the right incentives for me to want to prescribe better.

Ms. Carolyn Bennett: Would you want every physician in the country to get a report card once a year of their prescribing habits?

Mr. Michael Rachlis: Yes, but again, I think the quality literature tells us that kind of information hardly makes any behavioural change. If you really want to change--

Ms. Carolyn Bennett: It says on our billings, though, doesn't it?

Mr. Michael Rachlis: But if you really want to make change, you change structure, you re-engineer. We've been talking for decades about non-fee-for-service paid physicians and working with other professionals, including pharmacists. What's wrong with that model? We all want our parents to be going to places like that. Let's do it.

Dr. Joel Lexchin: There are studies that support that. There are at least a couple of studies in Canada that show that doctors on salary do a better job of prescribing than doctors on fee-for-service.

Ms. Carolyn Bennett: I asked that question at the beginning, and no one.... Can you show us?

Dr. Joel Lexchin: Yes.

There was one done in Montreal, where they trained unemployed actors to simulate tension headaches. They chose tension headaches because there are no physical findings associated with them. It's all history, so it's easy to fake. Then these people went to doctors who worked in CLSCs, community health centres, on salary, and they went to group practices where doctors were on fee-for-service, and the CLSC doctors prescribed better.

There was a more recent paper that looked at prescribing in Newfoundland, doctors on salary versus doctors on fee-for-service, and it looked at antibiotic prescribing. The doctors who were on salary prescribed fewer antibiotics, controlling for all the other factors around the characteristics of the patients.

Ms. Carolyn Bennett: It's what we've thought, but that's good that there's a study.

The Chair: Thank you, Dr. Bennett.

Mr. Robinson.

Mr. Svend Robinson (Burnaby—Douglas, NDP): I want to thank the witnesses for your evidence, but more importantly, to thank you for your ongoing work to ensure that we have a health care system in this country that isn't driven by the pursuit of massive corporate profit and is instead driven by the best interest of Canadians and health outcomes.

The more I listen to witnesses over the course of this study, the more concerned I am that we really have to get at the root problem here--and I made this point this morning--which is the extent to which, instead of focusing on health care, we have a system that at all levels is pervasively driven by corporate interests. And we see that in clinical trials, we see it in post-market surveillance, we see it in the push for direct-to-consumer advertising, and on and on--and with obscene levels of profit.

We heard in Quebec City, a couple of days ago, about the after-tax return to the nine largest multinational pharmaceutical companies being in excess of 40%. And basically, the system we have now is a system in which we have to bribe pharmaceutical companies, because they say if we don't give them 20-year patent protection, we're not going to get the research done. Frankly, the more I see, the more I think we should just say we're going to do the research ourselves; we're going to fund it publicly and we're going to do it based on health priorities. In fact, in 1963 there was a fascinating study done by the Restrictive Trade Practices Commission, which you may be familiar with, that said forget patents and publicly support research.

I don't think I'm going to convince my colleagues of that one, but I think we do have to start looking at some pretty radical alternatives. When we have a study like this, about how kids in poor families are just not getting access to the drugs they need, there's something very wrong in a country like Canada when that is happening, with a $7 billion surplus. Don't tell me we can't afford it. We can. It's about priorities.

In your brief, and I'm referring now to Dr. Lexchin, you made reference to Norway having a policy in place until the mid-1990s under which new drugs were approved only if they could be shown to have an advantage--and I assume that's not just a cosmetic advantage, but a real advantage--over existing drugs. We don't have a lot of time to go into all of the details of that, but I wonder if you could tell us a bit about that. Is there something you could point our researchers to?

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Dr. Joel Lexchin: From 1928 to 1996, Norway had what was called a medical-needs clause in its drug approval process. In order for the Norwegian regulatory authorities to approve a new product, the product had to be shown not only to be safe and effective—and be manufactured under good quality conditions, the way drugs are in Canada—but also to be better in some way than existing products, better either in the general population or in sub-population groups, meaning either more effective or safer in those groups.

By the mid-1990s, Norway had around 1,100 prescription medications on its market, versus probably an estimated 5,000 in Canada. So there was a significant difference. But if you looked at surveys done of Norwegian physicians around a couple of specific drug categories, there was no perception on the part of the majority of doctors that they were suffering because they had fewer choices in non-steroidal, anti-inflammatory arthritis drugs, or fewer choices in beta blockers, a class of drugs that treats high blood pressure.

Also, if you look at health statistics in general, the Norwegian population is just as healthy as, or perhaps even better off than, the Canadian population.

Beyond a certain number of products, what you're really getting is just confusion: confusion on the part of the public; confusion on the part of physicians who have to do the prescribing; and confusion on the part of payers who have to sort out which of the 16 or 18 non-steroidals they should put on their drug benefit plan. So there certainly is room for doing that kind of thing.

Norway only abandoned its medical-needs clause because it decided to harmonize its drug regulations with those of the EU.

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Mr. Svend Robinson: Thanks very much.

Perhaps our researchers could also get us some information on that.

I just have a quick question in one other area. We're in Toronto, and I think two of the most glaring examples of the abuse of corporate power with respect to pharmaceuticals and their relationship with academe here in Toronto are Nancy Oliveri and David Healy.

The Chair: Who was the second one?

Mr. Svend Robinson: David Healy, Eli Lilly, Prozac.

Dr. Lexchin, you're at the University of Toronto?

Dr. Joel Lexchin: Some of the time, yes.

Mr. Svend Robinson: Some of the time. Okay.

Mr. Macintosh, where are you studying?

Mr. Brad Macintosh: The University of Toronto.

Mr. Svend Robinson: You're at the University of Toronto.

I'd be interested to hear, Dr. Lexchin or Dr. Pellizzari, if you could maybe just update us on whether there has been any improvement with respect to this whole issue of corporate influence in the academic setting driving priorities in research, for example. And could you share with the committee any changes there have been?

One of the big concerns I had about that was the really quite appalling lack of response of Dr. Oliveri's and Dr. Healy's colleagues. Arthur Schafer did a study just recently, which I thought documented this pretty eloquently, calling for total sequestration. I support that. But has there been any improvement at all?

Dr. Joel Lexchin: There have been some improvements. The University of Toronto renegotiated its agreements around contract research with the teaching hospitals. But that really only gets to a small portion of the problem; the problem is much deeper than that.

Currently, the pharmaceutical industry is the single largest direct funder of medical research in both Canada and the United States, meaning that corporate priorities are the ones that are driving the direction of medical research. So you can take an example like sexually transmitted diseases. If you want to study an antibiotic for treatment, chances are you won't have any problem finding a drug company that's willing to fund that kind of research. On the other hand, if you want to look at how to change sexual behaviour among teenagers to stop them from getting STDs in the first place, no drug company's going to fund that kind or research, because there's no drug involved in it.

So having drug companies funding the majority or plurality of research in Canada really focuses medical therapy in a particular direction.

Mr. Svend Robinson: Could I just interrupt you for one second?

One of the other examples that we heard in Halifax was Dr. Allan Abbass, at Dalhousie University, who specializes in brief psychotherapy for things like depression, anxiety disorders, and so on, which in fact encourages people not to use drugs. That kind of stuff, I guess you would agree, would not be financed by drug companies.

Dr. Joel Lexchin: No, and it's quite understandable. Why would they? Their job isn't to do that; their job is to make money.

Mr. Michael Rachlis: If I could just add, I think it's really, really important here that you focus on the conflict of interest throughout this whole issue.

There's a very good article by some sociologists published in July of this year in the Journal of the American Medical Association. It's called “A Social Science Perspective on Gifts to Physicians from Industry”. It itemizes how our current understanding and mechanisms to deal with conflict of interest are completely inadequate.

We assume, for example, that the biasing effect of accepting gifts can be treated as a matter of deliberative choice. But these sociologists go through a wealth of sociological literature that has almost never penetrated this debate. They conclude, first, that individuals are unable to remain objective, even when they're motivated to be impartial, which demonstrates that self-serving bias is unintentional. Second, individuals deny and succumb to bias, even when explicitly instructed, which suggests that self-serving bias is unconscious. And third, the study showed that self-interest affects choices indirectly, changing the way individuals seek out and weigh the information on which they later base their choices, when they have a stake in the outcome.

You have the richest groups in society trying to influence what you're doing to protect the health of Canadians. I think the only way we can ensure that bias doesn't operate is to make sure it doesn't exist. That means not funding drug approvals from the industry; not funding anything at all to do with information to patients by the industry; completely banning any of the current promotions to doctors; and throwing the coldest of water on any plans for direct-to-consumer advertising.

Direct-to-consumer advertising is the most dangerous threat to the health of Canadians that I can imagine. We already have a huge problem with thousands of people being killed because of poor prescribing; yet somehow if we approve that advertising, we are going to open up that problem to way more people.

So I think it's really important that we put a huge ring fence around this conflict of interest, and we prevent any possibility of it occurring.

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Dr. Joel Lexchin: If you look on the last page of the three-page handout we gave you today, what you'll see there is the number of prescriptions that are written for new drugs that have been heavily promoted through direct-to-consumer advertising. The problem with new drugs, aside from costs--and I'll talk about costs later--is that when they hit the market, they have been tested on maybe 5,000 or 6,000 people. That means any side effect that occurs less frequently than one in 2,000 won't have been seen. Sometimes those side effects will be trivial, but other times they will be very significant.

What they're doing in the United States and what's being talked about here is allowing companies to heavily promote drugs we know the least about in respect of their safety profile. That's a recipe for disaster from a health point of view. If you look at the first two graphs there of changes from year to year in drug expenditures in Canada and the United States, you'll see they were roughly similar, going up between 1975 and the mid-eighties, levelling off between the mid-eighties and the early nineties, and then taking off again in the United States around 1992, 1993, whereas in Canada it stayed levelled off. The third page shows you why. The new drugs, the ones being heavily promoted, the ones we know the least about in regard to safety, are the ones that are driving drug expenditures significantly in the United States. So whereas in Canada the year-to-year increase in spending has levelled off at about 8%, in the United States it's at about 12% per year and still rising. Allowing direct-to-consumer advertising and allowing that kind of corporate influence on how patients get information is a recipe for pure disaster in both financial terms and, more importantly, in health terms.

The Chair: Thank you.

Thank you, Mr. Robinson.

Dr. Castonguay.

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.): Merci, madame la présidente.

I understand that you don't support the DTCA, and you're not the first. With a few exceptions, most of the witnesses don't support this now. It is a reality that it is done in the United States, it is a reality that I can tap the Internet, I can turn the TV on. Canadians are exposed to that type of information, maybe not to the extent that they would be if we were to go with the DTCA in Canada, but I believe more and more people will be exposed to that. Is there anything we should be doing at this time to educate the Canadian public that there are dangers in this, that you have to be very careful when you're exposed to that type of information, or should we just forget about it? My concern is that a few years down the road, let's face it, we are exposed to that type of advertising, promotion, or whatever. So I woud like to have your opinion on this. Should we be doing something at this time?

Mr. Brad Macintosh: I was going to say that we can start by cleaning up our own back yard. It's true that Canadians are exposed to direct-to-consumer advertising through various media, and we describe in the brief how there are lots of examples where the fact that it's illegal is not enforced in Canada at all. We have lots of examples where commercials run for several months. In women's magazines there are prescription drugs catering to women that are advertised for quite a long period of time without being punished.

Sure, we can address ways to try to reduce the amounts that we get from outside sources, one of which would be a progressive series of fines or penalties: the first time there is exposure, you can give a slap on the wrist, and as a campaign continues, you can progressively increase fines and then have a ban on that product or what have you. But the fact that the Food and Drugs Act rules are not being enforced is probably where you want to start.

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Mr. Michael Rachlis: I agree with that. And I would quickly make the point that when people make the argument that they allow it in the U.S. and we're starting to see some of it here through the U.S., so let's just open it up here, my rebuttal is that it's the same thing as saying that after I've yelled at my kid, I should beat the heck out of him. If something wrong is happening, like DTCA in the U.S., we should do what we can to protect ourselves from it, but it is not an excuse to do something wrong in our own country

Mr. Jeannot Castonguay: I don't mean that we should do it here.

Mr. Michael Rachlis: I know, but I'm just saying--

Mr. Jeannot Castonguay: Tell us, is there any positive thing we can do to prevent the influence?

Mr. Michael Rachlis: One other quick thing is that most provinces now have nurse information help-lines, Ontario has, and they're already providing a lot of advice about pharmaceuticals inadvertently. We could be looking at adding pharmacists to those help-lines, so that they could directly deal with people who have concerns or questions about pharmaceuticals.

Dr. Joel Lexchin: Also, currently, Canada is one of the few countries that do not make it mandatory that when you get a prescription, there's patient information with it. Pharmacies that do it do it voluntarily. That information is usually produced by commercial entities. It's not the same. If you go to your Shopper's Drug Mart in Toronto, and then go to a different chain in Toronto, chances are you'll get completely different pamphlets. So one of the things we need is to make it mandatory that there be patient information, leaflets given out, with a low literacy level, in different languages if necessary, so that when people get a prescription, they get objective information.

Second, in Australia the government has funded a national consumer service that deals with prescription medications. They're giving them, I believe, in the range of $3 million or $4 million a year to develop educational strategies to teach people about safe and proper use of medications and to get out information that's appropriate for those people.

So we can take all those steps here in Canada.

Mr. Jeannot Castonguay: We could and we should.

Dr. Joel Lexchin: We should.

Mr. Jeannot Castonguay: Thank you.

The Chair: Thank you very much.

I have one thing I'm concerned about, the fact that pharmaceutical companies do not submit for approval in Canada nor have any desire to bring to market drugs they have that are efficacious, but for which we might only have, say, 100 patients in the whole country. I wonder if you've ever thought about tying a drug approval of a product, say, they're bringing that has a big market, to their bringing forward the other drugs they have no desire to market here. In other words, it seems to me they're the tail that's wagging the dog here. How do we get them under control? Has anybody ever thought of that mechanism for at least getting some of these things, so that we don't have to pay all this money to import it from France and all this sort of thing through the special access system?

Dr. Rosanna Pellizzari: I think that's a creative idea that should be pursued. We see evidence of it elsewhere because of our size and because we are into large market. We came up against this with West Nile virus this past year, in that many of the safer, less toxic products that were used in the States were not even registered in Canada. The manufacturers didn't bother to apply, because our markets are small. Again, I think it's a fascinating thought and has a lot of merit to it. Anything we can do to get safer, necessary products here I think would be worthwhile.

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The Chair: It seems you're not the only group to cause us to question what's going on. I think you can be comforted by the fact that most of us are pretty uncomfortable with some of the things that are going on, the conflict-of-interest situation in the drug approval process, the signing of confidentiality agreements from people who understand some of the adverse effects that are happening and are not allowed to say anything.

In my view, the over-medicalization of people's illnesses, mood disorders, etc.... It's really good to know there are people out there who know there's not a pill for every ill and that there are other kinds of therapies that might be more appropriate. It's very hard to sell that idea. There seems to be this growing over-medicalization of society, and a set of expectations, but maybe if we completely ban direct-to-consumer advertising and raise the fines to be very substantial, we would begin to erode that culture that is developing in our country.

In any case, on behalf of all the committee members, I would like to thank you very much, not just for your presentations today but for the work you do at the Medical Reform Group and the work that Dr. Rachlis has done over the years. I did take note of what I call your favourite hobby horse, which is changing the system of practice in this country from fee-for-service. I remember years ago a great presentation you made on that, and I still believe in it. I don't know if that gives you any hope. In any case, thank you very much.

We'll adjourn for a few minutes.

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The Chair: We'll come back to order, ladies and gentlemen.

Welcome to our hearing. We'll move directly to the presentations you have prepared.

We'll hear first from ESI Canada, Jean Joubert, president, and Steven Semelman, vice-president, health management operations. The floor is yours.

Mr. Jean Joubert (President, ESI Canada): Thank you, Madam Chair.

Good afternoon to all members of the committee, ladies and gentlemen. Thank you for the opportunity for me to present here this afternoon.

My name is Jean Joubert. I am president of ESI Canada. Dr. Steve Semelman is with me here this afternoon; he is vice-president, health management operations, and is responsible for our research work.

ESI Canada is the largest private payer of drugs, paying some 40 million claims in 2003. We are the third largest payer of prescription drugs, after the Ontario and Quebec provincial drug plans. We manage for our clients $1.5 billion in drug costs. Our customers include six out of the top eight group insurers, covering six million Canadians.

The key message I would like to present to the committee is as follows. Our observations show a persistent increase in costs year over year. The trends observed over the past several years will continue to prevail over the next decade. We believe there are ways to curtail the impact of these trends. While there is no magic bullet, we will suggest some solutions that can go a long way in reducing the impact of these increases.

First let me provide you with the key elements of our drug trends research. Overall prescription drug costs to our clients have increased 42% in the last four years, 22% in 2002 alone. There are key factors that have generated these increases. First, we notice a significant increase in the use of prescription drugs. One of the main contributing factors is the aging of the Canadian population. The covered population between 26 and 30 years of age use four prescription drugs per year, at an annual cost of $144. This consumption grows to 14 prescriptions per year between 61 and 65 years of age, for an average cost of $622. As we grow older we take more drugs and more expensive drugs.

Second is the impact of new drugs. In 2002, 23% of the costs to our customers were for drugs not on the market five years earlier. These new drugs, on average, are much more expensive than those they replace.

Third is the therapeutic mix. We observe a trend toward the use of new therapies when older equally effective therapies would result in the same outcomes.

The few numbers mentioned here are just the tip of the iceberg. You can consult our more detailed findings on our website. As well, you have a summary of this presented to you in a hard copy.

Looking forward, we don't see any easing of these trends. Considering the demographic evolution and the new drugs under development, we forecast the trends to accelerate further, with the total annual cost to reach $30 billion in 2010, from $14 billion in 2000. We can ask ourselves, to what extent is the covered population getting improved benefits from these additional investments to their health?

So far I have provided you with observations. Now I would like to provide an opinion as to what we can do about this.

Our clients are worried about these trends. Where will it stop? Do we have enough money to cover all these increasing costs? What choices will have to be made, and who will have to make them?

Without getting into the details, there are two key ideas we would like to present to the committee. We recognize that options exist in the selection of drug therapies for the physician, pharmacist, and patient. We also recognize that patients have a greater influence on choice of drugs than they had before. From the Internet and direct-to-consumer advertising, patients know more about drugs and ask for them from their physician. This leads us to believe the control of the consumption of drugs will come from a more informed population. We will have to elevate our efforts at educating Canadians about the prescription drugs they use.

Together with better information, a key strategy will be a more proactive approach to encourage patients to help make better choices, such as the use of generics where possible, and rewarding them for making good decisions about their prescription drugs.

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According to our analysis, total costs to plan sponsor are always reduced when the patient's share of the cost is set as a percentage of the total cost. More sophisticated plan designs will need to be considered, and the technology exists to support them.

The second element I would like to bring to your attention is electronic prescribing. Between the pharmacists and us, the payers, the existing technology gives us the opportunity to provide value. Right now, information to the pharmacist at the point of sale is in real time and has the potential to influence the selection. We could have more efficiency if the link from the physician to pharmacy would also be electronic and in real time.

Currently in Canada it is illegal to send an electronic signature. But we are aware of studies in the U.S. and other countries showing the cost-benefit of electronic prescribing, such as improved prescribing at the point of care from better information in the patient file, in addition to cost-effective alternative therapies; savings to the overall health system from a reduction in the number of errors from interpreting physicians' handwriting; increased productivity for both pharmacist and physician from the elimination of numerous phone calls after the fact to modify a prescription. Overall, electronic prescribing gives the physician better patient information at time of care and influences the selection of a more cost-effective solution. We would welcome and support initiatives to introduce electronic prescribing in Canada.

In conclusion, ladies and gentlemen of the committee, I would like to reiterate our forecast that drug costs will continue to increase. We believe that opportunities exist to curtail the cost increase by involving the consumer in the decision-making process. We also support the introduction of electronic prescribing in Canada as a means of improving the efficiencies and the safety of drug retailing.

We thank you for your attention.

The Chair: Thank you, Mr. Joubert.

We'll move on to Green Shield Canada and hear Mr. Vernon Chiles, who is vice-chair of the board. Mr. Chiles.

Mr. Vernon Chiles (Vice-Chair of the Board, Green Shield Canada): Thank you very much, Madam Chair.

It's a pleasure to be here from Sarnia. I live in Sarnia, although I work with Green Shield, which is based in Windsor, and we have offices in Toronto.

Green Shield is a not-for-profit health benefits administrator. We serve employer groups, from large groups such as General Motors to smaller employers, and also public sector groups such as school board employees, university employees, municipal employees, and so on. We administer claims for some 1.1 million Canadians.

We also develop, administer, and maintain, on behalf of the Ministry of Health and Long-Term Care, the Ontario health network system that adjudicates 50 million claims per year on behalf of 2.4 million Ontario citizens. These are seniors or people who are on social assistance or are part of the catastrophic drug plan in Ontario, which is called the Trillium drug program.

Today's submission is presented on our own behalf and also on behalf of our clients, who are employers and subscribers--the employees--who share with us a common interest in having access to quality drug treatments.

In the package of material you have an executive summary in English and French and the main brief that we have submitted. As well, we did a major study in 2002 covering a five-year period of drug costs, from 1997 to 2001. That has been filed with the clerk, and I think the committee chair has a copy. As well, there is an eight-page summary of that larger study.

I just want to list a few facts from the study to set the stage for what we want to recommend. The drug cost over that period of time, five years, rose annually, per claim, 7.4%, which is 3.7 times the rate of inflation. The primary reason for the increase is the changing mix of drugs, with new or more costly drugs replacing older less costly drugs. As we heard from the previous presenters, new drugs are accepted rapidly, and in this study, by 2001, 46% of total costs were represented by drugs that were marketed in 1997 and later.

We also broke out patented drugs, and patented drugs comprise an ever-increasing share of total drug costs. When the latest Patent Act changes went into place in 1993, 44% of all drug costs were for patented drugs. In 2001 it was 65%.

The average generic drug claim costs 31% that of a brand claim, and over the period of time pharmacists' fees were relatively flat. By 2001, on the average claim, 17% of the total average prescription charge was the pharmacist's fee.

The market for prescription drugs lacks the normal market controls on prices and costs because consumers can't make the choice of a drug without the help of a professional intermediary. As well, most consumers have either a public or a private sector drug plan and are relatively unconcerned about costs. Therefore, we have mechanisms, and we have to have mechanisms in place, such as the patent review board and public and private plans that exert some controls.

Manufacturers understandably oppose public and private sector policies such as restrictive formularies that may restrict or delay access to prescription drugs.

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Manufacturers attempt to retain market share in a number of ways. I want to focus on one in particular, which is the patent extension strategies related to the NOC link regulations. We submit that these regulations should be either rescinded or modified to maintain the intent of the Patent Act changes of 1993, which was to give 20-year patent protection.

The Patent Medicine Prices Review Board restricts price increases to the rate of inflation. When it comes to new drugs, which it calls category 3 drugs, those with little, no, or moderate improvement, the act specifically states that the board must consider the prices of other medicines in the same therapeutic class.

The board has, since its inception, interpreted this to mean that when it is determining a maximum non-excessive price, the price of that new drug must not exceed the price of the highest-priced comparator in that class. So as new drugs gain market share by replacing older drugs, this policy has the effect of raising costs in the class toward that of the highest-priced one in the class.

It would be our recommendation that the Minister of Health, to whom the PMPRB reports, should require the board, in making these determinations of non-excessive prices, to consider the range of comparators in the therapeutic class. There may be different mechanisms, whether they use average, median, and so on, but they should follow the spirit and the letter of the act and consider the range of comparators and not simply the highest-priced comparator.

On the issue of direct-to-consumer advertising, your committee has heard a lot about that. We are very concerned that consumers need balanced information on drugs, but we distinguish between advertising and information. Advertising is designed to promote products and inherently has a bias in favour of the product being promoted. We also note in more detail in the brief that there is a regulation in the Food and Drugs Act that allows drug name, price, and quantity to be advertised. It is because of this regulation that we see a lot of advertising about product name, with associated graphics, without any indication of its use.

That regulation was put in place about 25 years ago. The purpose of the regulation was to encourage price competition on prescriptions among pharmacies. Pharmacies do not use that regulation. Since that regulation went into place, we've had provincial plans that define drug costs and limit and require pharmacies to post their fees and reveal them, so the intent of that legislation is being dealt with at the provincial level.

In our view, that regulation is obsolete with respect to the purpose for which it was passed. However, it is a regulation that is being used to allow promotion of products without mentioning their use. We feel that repealing that regulation would be of some assistance.

The previous speakers alluded to the networks that connect plan payers, whether public or private, and pharmacies that adjudicate claims in real time and deal with drug utilization and drug interaction issues. We would also support the expanded use of these networks and electronic prescribing.

A lot of things can be achieved that way. Formulary coverage issues are dealt with, prescribing guidelines can be incorporated into them, there may be interactive systems that will deal with collecting adverse drug reaction information, and patterns of use may be studied. We feel that using these networks and building upon what is already in place can be a great tool in terms of improving the quality of pharmacotherapy.

I will stop there. I may have gone a little over time.

I look forward to questions.

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The Chair: Thank you very much.

Our next presenters represent the Alliance for Access to Medical Information. We have Ms. Anne Kothawala, the president of the Canadian Newspaper Association, and Sandra Graham, the senior vice-president, public affairs, of the Canadian Association of Broadcasters.

Go ahead, please.

Mrs. Anne Kothawala (President & CEO of the Canadian Newspapers Association, Alliance for Access to Medical Information): Thank you, Madam Chair and members of the committee, for the opportunity to appear before you.

We know the scope of your prescription drug study is broad, but we are here to speak specifically about DTCA. The reality is that DTCA is already here. The magazines we've flagged for you are in doctors' offices across this country. Canadians are reading them in vast numbers. Canadians are exposed to U.S. ads. The problem is that this is American advertising. We agree, some of these ads, in fact many of them, are misleading and irresponsible. That's why we don't want American DTCA. Canadians are rightly confused, and they deserve better. We all agree that there's a problem: American ads are misleading. However, unlike our opponents, we have a workable and practical solution developed by Canadians for Canadians. Frankly, I couldn't help noticing that the previous presenters dodged the question of what we can do to prevent U.S. DTCA. They want to bury their heads in the sand.

We know that you, as members of Parliament, care about what Canadians want. I hope, based on what I heard in the last presentation, that your minds are not made up already regarding DTCA in Canada. Please make sure you listen carefully to what Canadians feel they want and rightly deserve. We've actually taken the time to find out where Canadians are on this issue, and they want Canadian DTCA. You have also rightly encouraged Canadians to take a more informed and active role in their own health care decisions. As media organizations, we are committed to providing, increasing, and protecting public access to fair and balanced information in all fields. DTCA is no exception.

Do we stand to benefit from this financially? Absolutely. More advertising revenue translates into more money available to invest in Canadian information and Canadian stories. The reality is that Canadians are getting this information already. They are turning increasingly to unregulated sources of information, like the Internet, and to U.S. media, because frankly, there is a void. Balanced, regulated, accurate, made-in-Canada DTCA is part of the solution.

Our Ipsos-Reid survey, released today, confirms this. There is total confusion out there. Some 57% of Canadians believe prescription drugs can already be advertised directly to consumers.

An hon. member: Can we have a copy of this survey you've made reference to? Are you circulating it?

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Mrs. Anne Kothawala: I can circulate our press release that summarizes the findings.

An hon. member: But it's the questions that--

Mrs. Anne Kothawala: Yes, we can provide those; it's not a problem.

An hon. member: Good, thank you. Sorry to interrupt, but I just wasn't sure if we had that

Mrs. Anne Kothawala: It's on our website and on the Ipsos-Reid website, but we'll be happy to provide all the questions and answers.

Just this morning, in fact, the Seniors Alliance confused the American DTCA for Claritin, which in the United States is a prescription drug, with the fact that it's an over-the-counter drug in Canada. So there is a lot of confusion out there.

Quelles sont les autres constatations du sondage Ipsos-Reid? Près des deux tiers des Canadiens croient que la PDC devrait être permise, et cela sans même qu'il soit question de règlements, de conditions ou de quelqu'autre élément de la solution canadienne. Spontanément, ils affirment appuyer la PDC. Naturellement, cet appui augmente en flèche, jusqu' à 85 p. 100, si la publicité doit être conforme à la solution canadienne, que je vais décrire brièvement.

¹ 1500

C'est un élément crucial. Depuis deux ans, nous y avons consacré beaucoup de temps. Nous avons rencontré des médecins, des groupes de patients, des pharmaciens, des infirmières et des administrateurs d'hôpitaux. Nous leur avons demandé leur avis pour nous aider à concevoir une solution canadienne qui tient compte des réalités du système de soins de santé canadien. Les Canadiens accordent un immense appui à la solution canadienne. Je le répète, nous ne voulons pas de la PDC en provenance des États-Unis.

Alors, voici les grandes lignes de la solution canadienne, ou de ce qu'elle pourrait être, car nous sommes réceptifs aux suggestions. Cette liste n'est absolument pas exhaustive. Nous disons que la PDC sera examinée par un organisme indépendant. La PDC sur les nouveaux médicaments ne paraîtra pas avant six mois. Elle informera les Canadiens sur la maladie dont il est question et sur les autres traitements existants. La PDC présentera des sources de renseignements impartiales. Elle fera état des effets secondaires importants, et elle inclura la mention « consultez votre médecin ».

Les opposants à la PDC soutiennent qu'elle fera augmenter la demande et les coûts. Pour ce qui est de la demande, je rappelle que nous avons pris le temps d'interroger les Canadiens, et que seulement 16 p. 100 ont signalé qu'ils avaient demandé à leur médecin une ordonnance pour un médicament qu'ils avaient vu annoncé. Les médecins croulent sous le travail et nous y sommes sensibles. C'est une raison de plus pour laquelle ils devraient souhaiter que leurs patients soient informés. Pour l'instant, ces derniers sont mal informés, et cette question de la publicité américaine prouve qu'ils sont mal informés. Souvent, ces publicités portent sur des médicaments qui ne sont même pas homologués au Canada, ou qui y portent un nom différent. La situation actuelle cause toutes sortes de problèmes.

Du point de vue des coûts, les Canadiens acceptent avec raison que le médecin continuera d'être le protecteur du public. Ils reconnaissent donc que les coûts n'augmenteront pas nécessairement. Il serait tout à fait irresponsable, à une époque où l'information ne connaît aucune frontière, de demander au gouvernement d'empêcher les Canadiens d'obtenir de l'information pondérée et réglementée sur leur propre santé. Mesdames et messieurs, c'est exactement ce que les opposants à la publicité vous demandent de faire. Les déclarations alarmistes comme « la PDC tuera des milliers de Canadiens », qui ne reposent sur rien, ne font qu'envenimer la situation.

Nous croyons que notre recommandation est pratique et applicable. Puisque le comité permanent a recommandé, en 1998, que les règles sur la publicité soient révisées, que cette révision a été annoncée par le ministre le 9 juin, et que ce processus de renouveau législatif—qui traitera de la réglementation de la publicité sur les médicaments d'ordonnance et en vente libre—a été annoncé par le ministre et va bon train, l'AAIM exhorte le Comité de la santé à recommander l'adoption, par le truchement du processus de renouveau législatif de Santé Canada, de nouveaux règlements qui permettront de produire une PDC sur les médicaments d'ordonnance qui soit pondérée, exacte, réglementée et examinée à l'avance. En fait, la PDC en provenance des États-Unis est déjà ici, et le statu quo n'est pas une solution. Les Canadiens veulent un meilleur accès à l'information, pour pouvoir participer vraiment aux décisions concernant leurs propres soins. La solution canadienne fera en sorte que la PDC soit pondérée, réglementée, exacte et, surtout, canadienne.

Merci beaucoup de votre attention.

The Chair: Thank you, Ms. Kothawala.

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

Mr. Rob Merrifield: I'm going to keep my question really short, because I want to leave you an opportunity. We've heard two views. This end of the table is saying no to advertising. Is that not what you said?

Mr. Jean Joubert: I'm sorry. To the contrary, I said we need to inform Canadians better.

Mr. Rob Merrifield: That was my question, how--

Mr. Jean Joubert: I think it was in the previous session--

Mr. Rob Merrifield: Actually, you said no ads, but information.

Mr. Jean Joubert: Well, I didn't say “no ads”. I said we have ads and we have Internet, that's a fact. And I'm saying that because of that we need to provide more information, we need to educate more our insured population. So in a way I support more information, as opposed to restricting information.

Mr. Rob Merrifield: I couldn't agree with you more.

The Chair: We don't understand what you're saying. Ads and information are two different things to us.

Mr. Jean Joubert: I agree, but it's part of the information. I'm not opposed to ads, that's my point. But I think with ads that are there--as the other party mentioned, it's a fact, it's there and we get it from the U.S.--we need to provide more education. The plan sponsors and the insurers that manage these private plans will need to do a better job.

Further, we think we can influence the selection of drugs through the design of these plans to give incentive to people to make the right choices.

Mr. Rob Merrifield: So what you're saying is more information. If it comes in the way of ads, you're okay with that. It's one way of doing it, right?

Mr. Jean Joubert: That's right.

Dr. Steven Semelman (Vice-President, Health Management Operations, ESI Canada): I don't know if it's a catch line, but to me as a researcher, unbiased information is not advertising. They're oxymorons. If you're going to call it advertising, call it advertising. If you're going to call it information, call it information.

What Anne mentioned is that--

Mr. Rob Merrifield: Okay, but the Canadian solution we have here, a made-in-Canada solution--that's what I'm looking for--that's advertising with information, is that right?

Dr. Steven Semelman: As is the U.S.--

Mrs. Anne Kothawala: Yes.

Dr. Steven Semelman: As was the U.S. when it first started. When the U.S. first started--

Mrs. Anne Kothawala: No, that's entirely incorrect, Dr. Semelman.

Dr. Steven Semelman: When the U.S. first started, when they quoted one of the laws for DTCA in the U.S., it was that you had to have an advertisement in a magazine. When it first came out, they were quoting The New England Journal of Medicine, they were quoting The American Journal of Cardiology. Now you see People magazine. So they're using the law to their own benefit, so it truly is advertising.

But you're right, if a made-in-Canada solution can be advertising with information and unbiased information, I wouldn't really even call it advertising. I'd just say “providing the information to consumers in an unbiased fashion”.

Mr. Rob Merrifield: Well, okay.

You have a comment, Mrs. Graham.

Mrs Sandra Graham (Senior Vice-President for Public Affairs of the Canadian Association of Broadcasters, Alliance for Access to Medical Information): Advertising is what you make it; it's the regulations you put around it to say what can and cannot be done. What we're trying to develop in order to make our conditions in our country better is to be able to have that balanced, branded information--advertising--that will allow Canadians to have better information so they can make up their own minds as to how they want to address their issues.

Obviously, with prescription drugs there is a doctor involved who has to prescribe the particular medication, and a pharmacist involved who has to dispense the medication. That obviously provides additional checks and balances. But what we're looking for is to give Canadians what they want, which is information, and let them do their homework when they go in to see the doctor, having an advertisement, which is a very, very powerful tool.

You'll see from the information on magazines alone--I represent television and radio broadcasters--it is an extremely powerful tool that has the ability to reach hundreds and thousands of Canadians across the country.

Why don't we design a system that will actually meet the needs of our consumers?

Mr. Rob Merrifield: Okay, Mr. Chiles, just talk. Thank you.

Mr. Vernon Chiles: The therapeutics products directorate had a number of sessions, and the latest one, in 1999, developed six principles for information for the consumer. I won't read the details, but they are: ensuring safety, assisting consumers to make informed choices, respecting the health care practitioner, addressing health care costs, ensuring accountability, and acknowledging the Canadian environment. I suspect Anne would probably say that her approach addresses all of those principles.

But the people who developed that--I was part of that consultation--were thinking in terms of information, and part of that information would be based on the product monographs that are approved by Health Canada--not just the ones that are there now, but the product monograph as it is rewritten in lay language. I understand there is an initiative to have that done within Health Canada. I don't know at what stage it is at the moment.

Certainly we are very much in favour of lots and lots of consumer information. Where I disagree with my colleague is that we feel that advertising, because of its inherent bias, is not going to give that balanced information that we support. We support the balance. In our brief we acknowledge that parliamentarians may not be able to resist the pressure from interest groups like manufacturers and the media and that they may have to do something. So we have some suggestions.

If you really want to do it, we'll make a few suggestions, but we're really not in favour of it.

Mrs. Anne Kothawala: In response to that, are there any specific elements of the made-in-Canada solution that you don't think respond to your issue?

Mr. Svend Robinson: I think we're here to ask the questions.

Mr. Rob Merrifield: No, that's good. That was my next question anyway, so go ahead and ask that one.

The Chair: You can answer that, because Mr. Merrifield wanted that one.

Mr. Rob Merrifield: Yes, go ahead and answer that one. It's a fair question. What is it about the proposal you don't like?

Mr. Vernon Chiles: I won't say I don't like it, but I'm very skeptical about whether that pre-screening can be done adequately. The committee has heard a lot of testimony in the last few days--and I'm sure before that--about the difficulty with pre-screening and getting balanced advertising directly to health professionals. I think doing that for the public is going to create just as much if not more of a challenge, so I'm skeptical about whether it can be adequately achieved.

Mr. Rob Merrifield: Okay, let me ask a question the other way. Who is the independent pre-screener?

Mrs Sandra Graham: That could be an organization that already exists, for example the advertising standards council, or it could be one that is created. But it should be independent from any kind of influence to ensure that it is fair, accurate, and balanced.

Mr. Rob Merrifield: That's a tough one. We have a lot of accusations that Health Canada is not unbiased.

Mrs Sandra Graham: Yes. I think this issue is screaming out for regulation. Put the regulations in place.

Mr. Rob Merrifield: Who's the unbiased third party?

Mrs Sandra Graham: For example, if it happens to be a medication specifically for arthritis, then the Arthritis Society should be involved, so that there are other kinds of information. It's not just a pill for every ill, as I heard earlier this morning, but there are other ways, other treatments and alternative therapies that can help in a particular condition or disease, and Canadians should know about these. Websites and 1-800 numbers are good tools, as well.

In the discussions we've had with patient groups, with the doctors, with the nurses, when we went around and asked, “What problem do we all have with this?”, we had a lot of informal dialogue with regard to their not liking this or liking that, and what the main objective was. What everyone was certainly saying was they wanted information to be able to make up their minds on how to approach their particular situation. You have to have that dialogue with yourself, with your family, and with your physician, but you have to have the information at hand.

Mr. Rob Merrifield: I'm a free enterpriser; I like freedom of choice. That's what Canada was founded on. But you have to really ask yourself, is it choice when the information may not be accurate?

We heard from Health Canada officials who have come to this committee that a lot of these drugs are inappropriately approved and 20% of them are withdrawn. We really have to start questioning how effective advertising can be if we think it's right information when it's not. We even have doctors sitting here saying they weren't aware of all the details of the studies that went into the approvals. So they'd have a very difficult time knowing whether it's accurate or not or whether the side effects are as acute as what's said, or they may not even be aware of the side effects.

Dr. Steven Semelman: Can I pick up on that?

Mr. Vernon Chiles: Sorry, Steve, go ahead.

Dr. Steven Semelman: I just wanted to make two points in addressing that.

First of all, if you have advertising, there has to be a sponsor of that advertising, and the sponsor is the pharmaceutical company. If you make regulations that are too strict, you're not going to have the advertising, so it's a self-fulfilling prophecy. If you make it third party, very strict, they're going to want to have their message out in their terms.

A second one is a statistic. And I'm sorry, I don't have the paper with me, but I've been quoting this in a number of sessions that I've had. It's a U.S. statistic, and it goes to Anne's, I guess, polling, where 16% of the population say they only ask the physician. That's in Canada, I'm assuming. In the U.S., the statistic was closer to 50% of the patients. After reading an article, they asked their physicians for that prescription, and 89% of those doctors who were asked wrote the prescription for that name.

Mr. Vernon Chiles: The details of that study, Steve, are referenced in Dr. Lexchin's presentation that was presented earlier.

Dr. Steven Semelman: I wasn't here. Thank you, Vern.

So it is a little bit different, because we do have direct-to-consumer advertising in a different way in Canada; it's more muted. In the U.S. it's more out there, so you are going to see more information.

Mr. Rob Merrifield: Yes, there could also be a study on all kinds of patients who go into general practitioners' offices who know more about the disease or problems they have than their physicians do.

The Chair: Thank you, Mr. Merrifield. We'll have to move on now.

Mr. Rob Merrifield: May I just pick up on that one?

The Chair: No, excuse me, Mr. Merrifield, your time is up.

We'll move to Dr. Bennett.

Ms. Carolyn Bennett: Carry on. What were you going to say?

Mr. Vernon Chiles: Mr. Merrifield was mentioning some of the difficulties with the proposal and the fact that many physicians are concerned that we don't have enough information from the initial clinical trials and so on. In our brief we say if you really have to have advertising, because we don't know for sure when drugs are first marketed where they're going to fit, it's really not possible to design a balanced ad at that stage. So what we're saying is if you really have to have it, it shouldn't be allowed for five years, until there's a better feeling for where that product fits in the market.

Ms. Carolyn Bennett: Mr. Chiles, are you a pharmacist?

Mr. Vernon Chiles: Yes.

Ms. Carolyn Bennett: You're legendary, right?

Mr. Vernon Chiles: Pardon? Do I look that old?

Mr. Jeannot Castonguay: It's because you're smart.

Ms. Carolyn Bennett: You were the pioneer in what was truly pharmacare, in terms of pharmacist counselling, isn't that right?

Mr. Vernon Chiles: We did some, yes.

Ms. Carolyn Bennett: Yes, I remember being on that drug reform secretariat, and yours was the model that everybody wanted and everybody had to copy what you were doing in your store. Isn't that right?

Mr. Vernon Chiles: I don't know.

Ms. Carolyn Bennett: But it was only today when I saw you that the name came back from a decade or something ago. Anyway, we do thank you.

My colleague says that drugs are inappropriately approved. I don't think it's inappropriate because the study is only done on so many people. We're saying the post-market surveillance needs to continue, and I think today they were saying it should be like a temporary approval until you can get the post-market evidence tracked and the surveillance done. Is that...?

Mr. Vernon Chiles: There's some talk of Health Canada giving drugs conditional approvals, and there's also some talk in the provincial formularies of giving conditional listings. That is somewhat problematic, because once you get people stabilized on drugs and you say, okay, we're going to take it back, we're not going to list it any more, it's tough to do. So they've been loath to go that route, even though intuitively it makes some sense.

Ms. Carolyn Bennett: What experience does either Mr. Joubert's organization or Green Shield have in data mining information you already have in terms of what groups of drugs...? I know--

Mr. Vernon Chiles: I think we've done that sort of thing.

Ms. Carolyn Bennett: Assure Health Management, Inc. was, what, 6 million Canadians or something? You can see the people who are on uppers and downers at the same time. You can see that old-fashioned.... Can you find that tetracycline has been inappropriately prescribed to kids? Are there things we should be doing in this quality piece that Michael Rachlis was talking about by just getting the resources around data mining the information that already exists?

Mr. Vernon Chiles: When we're adjudicating claims, we can't tell exactly what the indications are and so on, but if there's an adverse drug interaction, the pharmacist automatically gets a flag, and if the person is already on the same kind of drug, there's a notice. So those kinds of things, hopefully, are going to be prevented.

Mr. Joubert and myself also recommended that those kinds of electronic communications can be used to a much greater extent than they are currently used, and that's going to be important, we feel, in terms of improving health care.

Ms. Carolyn Bennett: Today we use a big word called pharmacoepidemiologic evidence. Can you produce that for us if you were asked to, if CIHI asked you?

Mr. Vernon Chiles: I don't think we can from our database.

Dr. Steven Semelman: You can set up a methodology on anything to get pharmacoepidemiologic data because all you're doing is looking at age and sex, etc. What you can't get, what we don't have, and neither does any pharmacist, including myself as a pharmacist, is the diagnosis.

So you can get drug patterns by age, as Mr. Joubert has mentioned, the four versus fourteen in the different age groups. You can get what interactions happen because there's a drug interaction profile and a similar drug profile that is standard throughout the industry. Every pharmacist gets that because we know the different types of drugs, because some people go multi-pharmacy. Individual pharmacies can only have that information. So we have the information for the entire patient, and we can message the pharmacy if they've gone to another pharmacy and if there is an interaction, or if it's double-doctoring or double-pharmacying.

Can we get that information? Yes. We can build methodology around it, but we can't equate drugs to diagnosis. So we can't tell you pediatrician number one is prescribing this drug for this indication. We can only tell you that this drug is being prescribed in this age group with other drugs.

Ms. Carolyn Bennett: In some countries the diagnosis does go on the prescription. There's a place for the diagnosis and then there's a place for the prescription. Would you, in electronic prescribing, want the diagnosis there?

Mr. Vernon Chiles: Yes.

I think this committee should be aware of the work that is being done in Montreal by Robin Tamblyn. She is doing a project with claims adjudication, but also electronic prescribing, where the indication is there. There can be feedback about interactions and so on. Her project is called MOXXI, the Medical Office of the Twenty-First Century. It's really interesting stuff, and this committee should be aware of that.

Ms. Carolyn Bennett: I think we've asked her to come.

Dr. Steven Semelman: In fact, pharmacists have been lobbying, without even electronic prescribing, just to have the diagnosis on the prescription the physician is writing now, so they can put it into their database to know and give additional information to counsel patients in a more intelligent manner. They can only counsel on the drugs; this way they can counsel them as well on the disease state. So whether it's electronic or not, it behooves the pharmacist to have that diagnosis.

Ms. Carolyn Bennett: From the broadcasters'/newspapers' point of view, we have what's happening here already, not just from the American side but what the companies are already doing, and it's somewhat questionable, I think, in terms of the feeling that Health Canada may not be enforcing what's already out there.

Today on the subway there was a Marvellon ad in the subway thing. It's quite clear it's a birth control pill, but we have these funny rules that say you can name the drug if you don't name the disease and you can name the disease if you don't name the drug, yet no one is really enforcing this. Is there any responsibility for the broadcasters to not be putting something up if you think it's not in keeping with the law or the intent of the law?

Mrs. Sandra Graham: The birth control one brings a very interesting comment. I have two daughters, and at the time I think they were 11 and 15. I was in my kitchen doing something and I heard the youngest one say, “I don't get it”, and the older one said, “It's birth control, stupid.” I went in and I said, “What are you talking about?” It was an ad. It was the Alesse Canadian ad, where you have some teenager jumping around at a disco to some catchy little tune, and it demonstrated to me that neither of them were getting the information they needed as young women. I felt irresponsible, but it is a law that we have right now and there's the need of Canadians, who are looking for information.

The laws that were written in 1953 under the Canadian Food and Drugs Act are not appropriate. They were very appropriate in 1953, when there was a real concern with regard to selling snake oil.

I had the pleasure to be on the Health Canada working group on schedule A, which is looking at that right now, after your committee recommended it, after they looked into natural health food products, I believe. And they were appropriate then, but they're not appropriate now.

What we're seeing with all the people we spoke to--and we've actually met with over 70 members of Parliament on this issue--is that whenever someone and their family, or themselves, have some kind of condition or an ailment, the first thing they want to do is find out as much information as they possibly can, no matter where that information comes from, whether it's from the Internet, whether it's from television, whether it's from books, whether it's discussing it with colleagues and friends. They want to have information so they can start to make the decision about what they do next.

This is just another tool, but because we feel it's already here--there are 75 television services that come in from the United States--if the programming is not identical to when Canadian services have it, you're going to be exposed to American advertising. So the issue is, how do we make sure it's a Canadian model, that it's branded Canadian so that it shows that a Canadian regulator has approved this?

The people we've spoken to, the majority of the members of Parliament, did not know that the ads they saw on television were not regulated by a Canadian authority. I think they are a fair representation of the constituents they represent.

This is irresponsible and it's confusing, and I think in this day and age it's time we looked at how to make it better. I am not a proponent for American ads. I think they're terrible. How do we make them better?

The Chair: Thank you, Ms. Graham.

Thank you, Dr. Bennett.

We'll move to Mr. Robinson.

Mr. Svend Robinson: Thank you very much.

This frankly, to me, has almost an Alice in Wonderland quality to it. Let's be very real here about what's happening. Ms. Kothawala is representing an industry that stands to make a lot of money from ads appearing in Canadian newspapers. That's all well and good, and I have to say you do a very eloquent and passionate and effective job in presenting the interests of newspapers that want to make more money from ads. Ms. Graham is the representative of another industry that wants to make a lot of money from ads. That's what this is all about.

This bizarre suggestion that what this is about is providing more information to Canadians so they can make informed decisions about their health, I frankly find just ludicrous. The biggest newspaper in Canada, the Toronto Star—I assume they're a member of your association—strongly recommended against direct-to-consumer advertising. And they're right; I think they're absolutely right. In fact, I think the existing regulation should be repealed, and I'll be doing everything in my power to try to convince my colleagues that this is the decision we should be making.

Pharmaceutical companies are not benevolent societies. They're not in the business of providing information. They're in the business of making lots and lots of money. They're the most profitable companies in the world. If they don't make money from advertising, they won't advertise, because they'd be breaching their fiduciary duty to their shareholders.

Frankly, it's absurd to come in with this so-called made-in-Canada solution. It's very poorly thought out, and it's irresponsible from a health perspective. You talk, for example, about DTC on new medications not appearing for six months. Well, give me a break. Six months is not even a beginning of a long enough time to determine. We're talking about new medications here. In six months, do you think you can have any realistic assessment of the impact of that new medication? This is about money. It's about your industry making money; it's about big pharma making lots and lots of money. You're certainly entitled to bring that perspective forward, but....

You're an alliance. Are there two members of the alliance, or are there more?

Mrs. Anne Kothawala: Magazines Canada is a member. The Institute of Communications and Advertisingis a member as well.

Mr. Svend Robinson: Do you receive any money directly or indirectly from pharma?

Mrs. Anne Kothawala: We do not.

Mr. Svend Robinson: Why would a pharmaceutical company advertise if the information they provided in their ad resulted in fewer of their drugs being sold?

Mrs. Anne Kothawala: I think the point you're raising is a suggestion that because we have a self-interest in this, there is somehow no rational public policy basis to change the current situation.

Mr. Svend Robinson: No, I'm asking a specific question. If the results of the independent information they would generously provide to the public as a public duty meant that fewer Canadians would buy their medications, why would they advertise?

Mrs. Sandra Graham: I would propose that they wouldn't. I think if there are regulations put in place and they are enforced, either they follow the rules or they don't advertise.

Mr. Svend Robinson: Exactly. They're not going to advertise unless they think the results of their ads are going to mean that more of their drugs are sold. Isn't that right?

Mrs. Sandra Graham: Yes.

Mr. Svend Robinson: We're a health committee here. We're not in the business of helping to sell more drugs. We're here to make sure that Canadians' health is as good as possible.

What you're saying is.... You just admitted that—

Mrs. Anne Kothawala: Hang on a second, though—

Mr. Svend Robinson: Hold on. That's what Ms. Graham said. There's one reason they would advertise: to sell more drugs. You've admitted that, and it's true.

Frankly, that's not the sole objective of a health committee. We want to make sure Canadians' health is as good as possible. In some cases, that means fewer dosages of a particular drug will be sold, particularly fewer of a new drug that may have questionable, if any, therapeutic advantages.

Yes, I understand completely. You want to make more money. You couched it very nobly; I think it was so that you can distribute more news to Canadians, or something like that. It helps your shareholders—that's what you're here about. But from the perspective of a member of Parliament representing the Canadian people, that's not where I'm going.

Mrs. Anne Kothawala: With all due respect, I think it should be part of the mandate, because you're ignoring the number of people who do actually.... You're suggesting there are no drugs out there that can actually help Canadians with conditions they suffer from. Tell that to the person who's suffering from breast cancer. Tell that to the person who's suffering from heart disease. There are drugs out there that help them with their conditions.

Mr. Svend Robinson: Nobody is suggesting there aren't drugs that help people, obviously. If there weren't—

Mrs. Anne Kothawala: But you're saying that as a health committee you're just interested in the health of Canadians; therefore, you're not interested in drugs.

Mr. Svend Robinson: No, I'm not saying that at all. I'm saying we're not in the business of changing a policy whose sole objective would be to sell more drugs. That's the only reason—

Mrs. Anne Kothawala: The sole objective would be to inform Canadians, because there would be a third-party link—third-party, unbiased information—that would say, “Are you suffering from diabetes? Go visit the Canadian Diabetes Association website and see what the alternatives are for you. This drug may not be for you.” No, it won't say that blatantly in the ad, but it will say it on the website.

Mr. Svend Robinson: If fewer drugs are going to be sold as a result of that information, they're not going to advertise.

Mrs. Sandra Graham: Then they don't.

Mr. Jean Joubert: One point around this is that better health for Canadians does not necessarily come with fewer drugs; sometimes it's more drugs. Here's my point: how many people who should be on maintenance drugs for life stop taking their drugs after one year? I think in a study in the U.S., about 50% of the people who should be taking a drug for their cholesterol level dropped their medication after one year. The money spent was a serious waste.

Mr. Svend Robinson: Advertising is not the response to that kind of circumstance.

Mr. Jean Joubert: My point is, sometimes more drugs may be necessary. That's where I could see an ad reminding people, “You should take your drugs.”

Mr. Svend Robinson: That's an information ad....

Mr. Jean Joubert: It's part of the information, but that's where both the interest of the pharma company and the interest of the patient could be the same.

I hear you when you say that all the other areas—and it's mostly for lifestyle drugs that there is more advertisement.... We would say here that in the plan design, maybe there are things individuals should pay more for, if they want them. That becomes their choice, but that's the free market.

Dr. Steven Semelman: I just have two points. Made in Canada is made in Canada, but when you're looking at parallels with the U.S, the U.S direct-to-consumer advertising does not advertise obscure diseases—there are hardly any—and even some mainstream diseases.

There are a number of drugs they advertise that they know will be good sellers. I have not seen one ad about breast cancer, I'm sorry. I see some about hypertension and a lot about Viagra. It's because of these drugs that they're on sale. From 1997, when the law was passed, they've doubled their advertising budget—in five years—for drugs, and there are only 15 drugs that they actually doubled.

If we're looking at providing information, we have a great system to do it, and it's not advertising. It's using your most unbiased professionals to get that information: you have your nurse practitioners, you have your pharmacists, and you have your physicians. If they don't only get information from the pharmaceutical company, those are unbiased. So you would be giving information. You don't need radio ads and you don't need television to do those.

Mr. Svend Robinson: I want to come back very briefly to one final question about your suggestion that as part of the made-in-Canada solution there wouldn't be any ads for six months after a new medication comes on the market. How did you come up with that six-month figure? If the concern is health, did you consult with health experts and health professionals? And do you really think that six months is the time that's needed to determine the real therapeutic effects of a drug?

Mrs. Sandra Graham: As I believe Anne said in her oral presentation, we consulted with doctors—and this is with the Medical Association, Pharmacists Association, the Nurses Association, and the Hospital Association. We asked them, and they said six months was a timeframe that would be reasonable.

Mr. Svend Robinson: I'm sorry, which medical group recommended six months?

Mrs. Sandra Graham: It was a number of them. These are the consultations we've had over the last two years.

Mr. Svend Robinson: Because of the time constraints, maybe you could provide to the committee information on specifically which groups recommended six months on new medications. Can you do that?

Mrs. Sandra Graham: Yes.

Mr. Svend Robinson: Good. Thank you.

The Chair: Dr. Joubert.

Mr. Vernon Chiles: I said five years, and I'll admit that my figure was one that I drew out of a hat. But it's an intuitive thing.

The committee has this, The Medical Letter, which talks in its most recent issue about this new drug that has the big advantage of lowering cholesterol at lower costs. The Medical Letter likes it, but its bottom line is just one sentence: “Until more data become available, rosuvastatin should be reserved for non-Asian patients who have not responded adequately to statins with a longer safety record.” You need to have more evidence there; even though it looks great, they still say you have to wait.

So that's why six months is definitely too short, and maybe even five years is too short—though I have no scientific basis for saying five years.

The Chair: Thank you very much, Mr. Robinson.

Dr. Castonguay.

Mr. Jeannot Castonguay: Merci, madame la présidente.

We talk about a Canadian DTCA, and someone mentioned at one point that it has to be fair and balanced information. I'm trying to understand what is fair. Fair to whom? That's my first question. Is fair and balanced information the same thing as unbiased information?

Am I to understand that the CMA, the Canadian Pharmacists Association, and the Canadian Nurses Association are in favour of a Canadian DTCA? I had discussions with some members of the CMA and that was not the impression I was left with. So I would like to know exactly if you had discussions with them and where they stand—if you can provide us with that information.

Mrs. Anne Kothawala: I think they recognize—and based on our consultations with them—that the status quo is untenable. They realize as well that the American DTCA is here, and that it's time that we, as Canadians, took control of this issue and decided what we're going to do about it. We continue to bury our heads in the sand and say, “Oh, well, let's just prevent it from coming in”. Well, we can't; we can't prevent it from coming in. The American DTCA is here, and Canadians are being exposed to it.

So doctors have a responsibility, which they recognize, to figure out what.... If six months isn't the right time, maybe it's longer. We have to work through this process and continue to consult with them, but I think they have recognized very clearly that the status quo is not an option. They are prepared to work with us to try to find a workable solution.

Mr. Jeannot Castonguay: That would be a different position than they had a year ago, because I know that a year ago they were not supporting—

Mrs. Sandra Graham: They still don't, and I want to make that very clear—they still do not.

Several years ago, and over the last two years when this was just beginning to be new—after the Americans passed their legislation—we had a consultation process where we went around and informally spoke with these various associations and said to them, “What don't we like about it?” We had those kinds of ongoing discussions on what we don't like about the American situation and how we can fix it.

With all of those consultations and ongoing discussions, and working and talking with the CMA, we still don't agree. I'll be very honest on that. They have come a long way and we have come a long way, absolutely.

We have direct-to-consumer information in this country right now, but what we don't have is Canadian direct-to-consumer advertising. What we're trying to say is that there's got to be a way to develop some kind of an advertising scheme that blends the best of both worlds.

Mrs. Anne Kothawala: Frankly, I don't think it's inconsistent to say that if drug companies buy advertising and stand to sell more of their particular drugs, it could potentially be beneficial to the health of Canadians. I think those are not inconsistent at all.

Mr. Jeannot Castonguay: Steven, I believe you want to add something.

Dr. Steven Semelman: I guess I'm like an emotional researcher, if that's possible. We have done studies over the last five years to show.... When we presented it to the private payer world in May, it was very, very cognizant in showing that in one year, of the new drugs admitted into the book for private payers who pay for the patients, less than 1% of those new drugs were the bottom line for all drugs in our database. So it was very, very small.

The physicians are not comfortable prescribing a drug when the drug just gets admitted by Health Canada. It takes a year or more for the comfort levels to go up to prescribe the drug, just because the physicians are reading some of this unbiased information.

So if you're looking at a six-month moratorium before you advertise, you could actually increase the amount of drug use that may not be appropriate, because the correct studies have not been out. A case in point is that when drugs like Celebrex and Vioxx came out, the studies have shown that they were good in a number of patients because they reduced the amount of side effects when used for inflammation and arthritis; they reduced the number of bleeds people get.

Further studies, which happened to be three years down the road, have shown that the older drugs, like Ibuprofen, Motrin, and Naproxen, are equally effective in many of the patients. If they are not effective, then you can go to the higher-cost drugs.

So when you're talking about six months, there just isn't enough evidence to show you that you should be advertising, because the physicians have not felt comfortable with some of these new drugs.

Mrs. Sandra Graham: This is exactly what the physicians and nurses said to us. They don't want it to be as it is in the United States, where a drug comes to market quite quickly and there is no pre-screening of advertising.

They wanted to have a lag time in order to be able to learn about the drug—not to learn about the long-term effects of it, but to learn about its properties. They didn't want to be blindsided, that all of a sudden there's a drug on the market whose advertising hadn't been pre-screened. They wanted to have their opportunity to learn about it, so that when there were any questions about it, they'd be able to answer them.

They wanted to have none of that.

Mr. Jeannot Castonguay: Another topic, maybe for Vernon. We were told by some witnesses here that we should seriously consider a Canadian pharmacare system that would save quite a few dollars on the cost of medications. Is there a danger that the opposite could happen because of the perception that it would be a free system?

The reason I'm directing the question to you is that you mentioned that when they're responsible for a small percentage of the cost of their medication, there could be some overuse of medication. Is that what I understood? Do you see any danger in a pharmacare system that would be perceived as free, that could increase the costs because people would use more drugs?

Mr. Vernon Chiles: Well, people will use more drugs. And Dr. Lexchin, in the previous presentation, acknowledged that in his projections. He included that.

Before the Romanow inquiry and the Kirby Senate inquiry, there was an inquiry in Saskatchewan by a man by the name of Ken Fyke. He looked at that and said, “In principle, I'm in favour of pharmacare because it's part of the health system. Drugs are so important, why shouldn't we do that?” I guess I'm sort of on his side on that, but he also said governments have a terrible history of being able to control the cost increases. He didn't think governments would be able to proceed along those lines. Then when we had Mr. Romanow and Senator Kirby come along, even though, especially in the case of Romanow, philosophically he would be in favour of pharmacare, he had to put that more as a longer-range goal in his report and deal with the catastrophic issues first.

One concern I have is that if we had a national pharmacare system, there would be significant deductibles and co-payments and so on in order to help fund it, and employer groups that are currently in place would then still be on the hook for some of these co-payments and deductibles. Also, the public system would have to have a reasonably restrictive formulary in order to be able to afford to fund the plan. There would be a fair number of drugs that wouldn't be covered, so you'd still have a private sector drug plan operating parallel...smaller, much reduced, but it would still be there. So then the employers would say, “Hey, we're having to pay taxes for a public system and we're still running a fairly significant parallel side system”, so there would still be those inefficiencies. That's part of my concern.

Mr. Jeannot Castonguay: Should we go that route? What would you suggest we do about that?

Mr. Vernon Chiles: I guess I lean on the side of adequate provision for catastrophic coverage, something like we have with the Trillium Plan and so on. They can always be tweaked, but it's very important that everybody has that as a drug treatment. That's important. I agree with that.

Mr. Jeannot Castonguay: Yes.

Dr. Steven Semelman: We certainly have a provincial pharmacare system in our country. We have B.C., Saskatchewan, Manitoba, my favourite, Quebec. Quebec's seems like it's the fairest system for insurers as well as for the public plan. Again, when the Quebec government felt they could not insure the public plan, they raised premiums, raised deductible, so that's going to happen. But in the Quebec system they do have the majority of drugs on the formulary. But again, when you're talking about catastrophic coverage, people only have to pay $833 a year, whereas in B.C. you have a below and above 65 threshold, income-based, as well as Saskatchewan.

It would be very, very interesting--and I can't say I'm for or against it. I'm with Vern. It would be very interesting to see what the national system would do in order to make it affordable for themselves, for the private payers who are still going to be on the hook for the drugs that are not covered, and for the patients themselves, to make sure they can afford the coverage they would be enjoying in a provincial system. They certainly don't want it to be less than the provincial system is giving them now.

Mr. Vernon Chiles: One other point. There's a lot to be gained from cooperation among the public and private plans in terms of describing guidelines and policies so that physicians and pharmacists aren't having to deal with 50 different sets of policies. I think a lot can be achieved in that direction.

The Chair: Thank you, Mr. Castonguay. Perhaps I could have a few minutes here; we have a few minutes left before it's time to adjourn.

Anne, you said “we” took the time, “we” met with MPs, nurses associations, and “we” took two years, apparently, to assemble all these ideas. Who is “we”? Was it your members, the members who belong to these two associations? Was it a lobbying firm you hired, or was it you and Sandra specifically?

Mrs. Anne Kothawala: It was us, basically, and magazines and the Institute of Communications and Advertising.

The Chair: Okay.

Mrs. Anne Kothawala: The trade associations that represent the members of the alliance for our--

The Chair: So you personally met with these groups and asked them these questions, the questions you're going to submit to us, at least the polling questions.

Mrs. Anne Kothawala: The polling questions.

Mrs. Sandra Graham: The polling questions we didn't ask.... The 2003 poll we--

The Chair: No, no, I understand that. There are two activities.

Mrs. Sandra Graham: We do apologize for the poll. We actually should have brought it. It was actually just done yesterday, so I apologize.

Mrs. Anne Kothawala: We wanted to time it in time for....

The Chair: Good PR.

You said “we” took the time. I assume it's you and Sandra who did it. I understand why you feel so passionately about it. You were sent on a mission, you've done it for two years, and now you want to sell it; you want to release your PR thing. You're very forthright about it. I like that.

But who paid for your time? Is it just part of the regular salary your association pays you? Was there nothing else?

I've met with the Canadian Association of Broadcasters, for example--

Mrs. Sandra Graham: Me. I met with you.

The Chair: Yes. When I was on heritage, we met a lot. They seem to have a lot of irons in the fire. I can't imagine them releasing you and Sandra to just do this for two years.

Mrs. Sandra Graham: I don't do just this. I do copyright, I do broadcasting policy, I do CRTC, I do part II licence fees.

The Chair: So this was one project.

Mrs. Sandra Graham: One project. We have a—

Mrs. Anne Kothawala: Sandra and I don't sleep.

Mrs. Sandra Graham: No, we don't.

I can speak for my own association. We have identified a number of priorities that we have to do on an ongoing basis, since we are a national organization representing our members, and this is one of them.

The Chair: Yes. I think I understand where you're coming from. I'm glad your association was sufficiently interested. I assume the lucrative rewards that would come if you're successful at pushing direct-to-consumer advertising in the Canadian version would be sufficient to justify the time you spent on it.

Mrs. Sandra Graham: If I could just address that slightly, our members brought this to our attention, the Canadian Association of Broadcasters, about three years ago, because they saw a very uneven playing field with regard to advertising revenues.

It is pervasive in the United States, and from a purely business perspective, they said, “Look into this”. They also said, “While you're looking into it, make sure it makes sense”. So that's been our mantra for the last couple of years—to make sure it makes sense.

We are not in the business of promoting snake oil. I'm sorry, Mr. Robinson, you feel we're a cynical organization and industry, but we do want to make sure that we have responsibilities for the viewers and listeners we serve. And speaking on behalf of the readers of magazines and newspapers, the only thing we have with our audiences is trust. If that gets broken down, then we are not a credible industry. As for our members, yes, as we said straight out, this is revenue for us, and as a mature industry in this country, we do have to look at where we have additional streams of revenue, so we can achieve what we need to do. But at the same time, our members have instructed us to do it right, to invest the time. And it is legwork. I am in Ottawa.

The Chair: We understand all that, and we congratulate you for a good job, but we also recognize the self-interest that is part of it. There obviously is money to be made for magazines, for television, for radio, and for the advertising industry as a whole. It will greatly expand their realm of opportunity to develop ads.

I understand where you're coming from. Mr. Chiles has been very clear where he stands. The only person who really puzzles me here is Mr. Joubert, because Mr. Semelman and Mr. Chiles, both of whom represent the insurance industry in this field, seem to be of a mind. I haven't heard them disagree on anything.

Mr. Joubert, you already pay out $1.5 billion and take care of six million Canadians. All the testimony we have had in the six or seven weeks we've been listening to witnesses has led us to believe, I would say 99% of it, that if we have direct-to-consumer advertising—not information, advertising—the cost of drugs will go up. There will be more prescribing and it will raise the demand. It sells the idea that there's a pill for every ill, simply because people are exposed to it. All you have to do is look at some of these magazines.

I wasn't worried about my health until I started to look at this magazine. Then all of a sudden I want to take my pulse and my temperature and rush off to the doctor, because they're trying to make you feel that you're sick and you're not well, in much the same way as the cosmetic industry has tried to make every woman feel she needs 50,000 products all the time.

So do you really want to pay out more money from your insurance company? And how would your stockholders feel about that?

I'm checking with my broker later to see if I'm invested, because I'm very worried about ESI Canada.

Mr. Jean Joubert: My position is that advertisements or information coming from the manufacturer are inevitable. It will come one way or the other. Right now it's coming through U.S. publications, and a lot of this comes from the Internet.

The Chair: But should we encourage it? Should we encourage it or discourage it, if it's biased? That's what I don't understand about your position.

Mr. Jean Joubert: I'm not here to encourage it. I didn't say I would encourage it; I'm just saying it's inevitable.

My point is, on the solutions for this, more and more it's the patient. I think that has been recognized by several speakers, that the patients have a role in the selection of the drugs.

The doctors are overworked--they sign and move on--and the pharmacists are very busy. There's a shortage of pharmacists, and they fill whatever comes in. So more and more the patient has a role to play here too in selecting the therapies and the choices--and there are choices.

We're saying we need to improve the education of people. That's not advertising. I think we need to educate and we need to give them incentives to make the right decisions for themselves.

When we say we don't need to make choices, should the lifestyle drugs be reimbursed at the same rate as the life-sustaining drugs? Should we put the budget where it's more required and less where it's not required? That's what we propose, and we're looking at ways to manage plans with what we call the three-tier co-pays, where the individual will pay more to go to a very expensive therapy that has a less costly alternative.

So we're more a proponent of an open free market but where we help people make the right decisions for themselves. That's what we're saying.

The Chair: I don't understand what you're--

Mr. Jean Joubert: I didn't come here with the idea of pushing for ads or not. I'm just saying it's quite inevitable that information will hit the consumers, and my point is that we need to balance this with much more education and strategies to help them make the right decisions.

Dr. Steven Semelman: I think I need another translation device.

The Chair: I was just going to say I need another translation device.

The other thing I don't understand is how you and Mr. Semelman can work for the same company and have such disparate views.

I will finish with this question. Do you--

Dr. Steven Semelman: Please don't get me in trouble.

The Chair: Mr. Semelman is coming across as an insurance executive, but I just can't help but ask Mr. Joubert if he has his membership in the new party that's emerging, because I think he needs to get one.

Mr. Rob Merrifield: Actually, you should all consider that, including the chair.

The Chair: Mr. Merrifield could accommodate you, Mr. Joubert, if you need one.

Mr. Rob Merrifield: We're a big tent.

Mr. Svend Robinson: Not that big.

The Chair: Not as big as we are.

Mr. Rob Merrifield: No. There are some limits.

Mr. Jean Joubert: I didn't come here to support advertising. I'm just saying it's a fact; it's there. I'm proposing more education, more information. So don't take my position as supporting advertising.

The Chair: Good. That's what I was hoping you would say.

Mrs. Anne Kothawala: If I could just make one last point....

The Chair: I'll refute it if you do.

Mrs. Anne Kothawala: I can't let this go unchallenged. You say, should we encourage it or discourage it? Our view is that you can't discourage DTCA, because it is here. We have American DTCA, and you can't discourage that.

The Chair: You don't have enough faith in Canadians, because Canadians were also exposed to 18 months' worth of propaganda, George Bush's propaganda, about all the reasons we needed to go to war in Iraq. They saw that on American television every single day for hours, and on every newscast, and they rejected it. It's the same with the tobacco thing and it's the same with split-run magazines.

Mrs. Anne Kothawala: You don't have faith in Canadians if you don't think they can take this information that they say they want and deserve. Let's listen to what Canadians think about this.

The Chair: I think you've spent too much time on this one project, Anne. Your newspaper association better get you out doing something else, a variety of projects.

I'd better adjourn before someone hits me over the head with this.