I apologize. The date of my appearance was changed and I only had last night to deliver the information electronically.
I would like to present some evidence from a report I recently published that attempts to measure the number of reimbursement approvals by the provinces and compares that to the number of positive CDR recommendations issued. That same report attempted to measure the total wait times to access new medicines for those who are dependent on provincial drug plans. And I'd like to discuss some reasons that I belive the CDR process itself is really not necessary.
To begin, a recent report that I published compared the number of provincial reimbursement approvals versus CDR recommendations. What was found was that CDR recommended for reimbursement slightly less than half of the pharmaceuticals and only about 31% of the biological drugs that it reviewed during 2004 and 2005. This is based on data supplied by Brogan Inc., a database that summarizes much of what is available from Health Canada.
Even though the CDR approved a small number of drugs that it reviewed, the provinces themselves approved far fewer. In fact, on average, less than 20% of the new drugs that were reviewed by the CDR were accepted for reimbursement approval by the participating provinces. Interestingly, Quebec approved more new pharmaceuticals for reimbursement than the CDR itself. Quebec is not part of the CDR process, as you all know.
We also observed a large variation between the provinces in terms of reimbursement decisions. This suggested that cost factors, not scientific assessments of value, were driving reimbursement decisions. If science were the basis of this, it would be objective and they all would come to a similar standard. By separating the analysis for biological medicines versus pharmaceutical medicines, we also noted that far fewer biologicals were being approved for reimbursement relative to pharmaceuticals.
In terms of the wait time, including the delay for Health Canada approval on safety and effectiveness, and we also broke it down in terms of the CDR and provincial reimbursement time, we measured a total wait of 930 days, on average, across all drug submission types. This covered both biological and pharmaceutical medicines together. That was a total of two years and seven months, on average. Those people who are dependent on public drug programs wait up to two years and seven months to access a new drug.
We broke that down a little further into segments that measured the Health Canada delay for biologicals, with 633 days on average. The CDR added an additional 186 days, and provincial reimbursement across the provinces, on average, added an additional 187 days. That breakdown analysis did not include Quebec. Similarly for pharmaceuticals, Health Canada added 397 days to the wait; CDR added 257 days to the wait; and the provinces themselves, on average, added 201 days to the wait. For biologicals, we have two years and ten months that people were waiting for access to new biological medicines, and it was two years and five months on average for people to wait for access to new pharmaceuticals.
For a number of reasons, I believe the CDR is not necessary.
First, drug expenditures are not making public health insurance financially unsustainable. There is a misguided war against medicines going on in Canada. I publish research on an annual basis that measures the growth in public health expenditures in the provinces versus their total revenues from all sources, including federal transfers. That analysis shows that public health expenditures in every province are growing much faster than the ability of the provinces to pay for them. The blame for this, over time, has been shifted from doctors to hospitals, and now to drugs. The components of our health spending are being blamed for the unsustainable growth in public health expenditures. I believe this is misguided.
In the case of drugs, in particular patented medicines or new drugs receive most of the blame. But again, this is misguided. Patented medicines made up only 6.8% of public health expenditures in the most recent year, 2006, and even less in past years.It's simply impossible on a statistical level for patented medicines to make a major contribution to the unsustainable growth rate in public health expenditures overall. Therefore, cost containment measures of the nature that we see with the CDR are really unnecessary.
In fact, over 31 years, there is no statistical relationship between the rising percentage of public health expenditures going to drugs and changes in the overall growth rate of public health spending in Canada. The two are simply not linked. Drugs have increased as a percentage of overall public health spending, but it has not affected the growth rate.
Drug utilization is up, and this accounts for the rising share of expenditures going toward drugs. But as I mentioned, this has not had an impact on overall expenditure growth rates, because medicines are simply a cost-saving and cost-efficient substitute for other kinds of health technologies and treatments.
In fact, I decided to hypothetically eliminate spending on drugs in this analysis. Even if we spent zero on drugs, both patented and non-patented drugs, how would the other components of health spending grow? What would be the rates of growth? I found that all other components of health spending are growing at unsustainable rates, while accounting for more than 90% of public health spending. Therefore, the singular focus on drugs as a cost problem in health care is really misguided.
In fact, if public health insurance were designed differently for either our individual drug plans or public health insurance in general, there would be no need for a CDR.
Alternatively, we could introduce or should introduce deductibles, because insurance should only cover catastrophic expenses and not affordable expenses. Most drug expenditures are in fact affordable. According to Statistics Canada data, on average, most people spend less on pharmaceuticals every year than on things like alcohol, tobacco, and games of chance.
We could also introduce flat percentage co-payments. There should be a price at the point of consumption for health care goods and services, not only for drugs but for other health services.
We should have comprehensive coverage, including drugs, so there is an equal application of deductibles and co-payments to all types of medical treatments to encourage efficient substitution among competing health care options. Because drug plans only cover about one-third of the population and private plans or cash out-of-pocket payments cover the rest, the effective price at the point of service for drugs is much higher than for those things drugs might substitute for that are under the medicare package.
It does not mean I'm an advocate of expanding the medicare umbrella to include drugs. I think there are international examples of systems that introduced private insurance that is comprehensively inclusive of drugs that are more sustainable, better able to provide value for money, and preserve consumer choice.
Last, I would like to point out that even advocates and representatives of the CDR have stated that the real rationale for the CDR is to remove the element of inter-jurisdictional policy competition among provinces in terms of what they list for coverage under their drug plans. I believe this reduces accountability for rational decisions. It's part of the strength of our democracy and federalism in Canada to have policy competition among jurisdictions.
Unfortunately, the people impacted on by policies such as the CDR do not represent a lot of votes. About 4% or less of the population face catastrophic expenditures for health care in any given year. These people simply represent too few votes to have a voice in the absence of groups like the Diabetes Association, for instance, who are here today.
That is the sum of the details of my presentation. I'd be happy to accept your questions.
Thank you, Mr. Chairman.
First of all, thank you for inviting us here today. We appreciate it. I would also like to take the opportunity to introduce Karen Philp, our vice-president of public policy.
The Canadian Diabetes Association asks for your assistance. Today, the common drug review isn't working for Canadians with diabetes. We believe that with your support, we can make it work better or all Canadians, and we offer you our recommendations for your consideration during your critical study of prescription drugs.
Why is getting the CDR right important to Canadians with diabetes? First of all, there are more than two million people living with diabetes who need a mix of anywhere from five to eight prescription drugs in order to manage their diabetes effectively and to avoid heart attacks, stroke, kidney failure, and blindness. Being able to get the drugs prescribed by their doctors is the single biggest challenge identified by Canadians with diabetes in our survey undertaken for our Diabetes Report 2005, which I believe you all have.
Diabetes, as you know, is a progressive disease, and the longer you live with it, the harder it is for you to manage it. Canadians with type 1 diabetes need insulin daily or they die. Canadians with type 2 diabetes are often initially prescribed lifestyle changes before their doctors recommend oral medications and/or insulin as well as drugs for the prevention of complications, such as medications for lowering blood pressure and cholesterol and kidney-protecting drugs. After a few years, most Canadians with diabetes learn to self-manage their disease with a cocktail of between five and eight prescription drugs each day. In consultation with their health teams, they evaluate the effectiveness of their disease management on a regular basis.
Diabetes is responsible for 10% of all admissions to acute care hospitals. Yet research shows that if Canadians are able to manage their diabetes effectively with medications prescribed by their doctors, they may avoid the serious complications. This, Mr. Chairman, would free up more than 280,000 hospital beds each year for other Canadians waiting for surgery or acute care. By helping Canadians manage their diabetes effectively, all Canadians will benefit. By reducing the rates of serious complications related to diabetes, health care resources can be invested in better health care for all of us.
Recent research illustrated that for every dollar invested up front in managing diabetes, the B.C. government saved four dollars a year by not having to have complications treated in other parts of their health care system.
Over 70% of Canadians believe that the long-term savings from helping Canadians manage their diabetes effectively justifies government paying the cost of diabetes medications, devices, and supplies.
We all know that Canada has a unique heritage as a world leader in diabetes research that began with the discovery of insulin by Dr. Banting and Dr. Best. Canada continues to lead the world in diabetes research and innovation, whether it's through the islet cell transplants in Edmonton or the $25 million DREAM international clinical trial for the prevention of type 2 diabetes, led by McMaster University researchers. The Canadian Diabetes Association believes that Canada's leading role in diabetes research may be undermined if the CDR continues working as it currently does.
Finally, the common drug review is the foundation for a national pharmaceutical strategy as well as for a national catastrophic drug plan. Therefore, we believe the common drug review must have clear processes in place, be accountable, and be more transparent in order to give all Canadians greater confidence in its role in pharmaceutical policy-making.
All Canadians may need to access prescription drugs at some point in their lives, but Canadians living with chronic diseases like diabetes need them daily to live healthy and productive lives.
Our association welcomed the introduction of the common drug review in 2002. However, in our view, the common drug review has not, and is not, meeting its promise in 2007. To put it bluntly, the CDR is not working for Canadians living with diabetes.
Our association reviewed all CDR recommendations relating to four diabetes medications. All four medications the CDR recommended as not to list, yet all four of these drugs have been listed by at least one participating drug plan in Canada and are being provided on an open listing in at least four other countries.
After review, we concluded that there are serious flaws in the CDR drug review process. These flaws include unnecessary duplication and delays. All participating drug plans continue to review or even enhance their drug review process. Another flaw is too much of a focus on costs and not enough on helping drug plans establish a place in therapy for medication. It's irresponsible for the CDR just to say no.
Finally, CDR lacks transparency and accountability. We outline in detail in our written submission our concern about this, but in particular, the lack of independent appeal process is simply unacceptable.
Having said all this, we also propose a way forward for you to consider. Our association proposes that the health standing committee recommend that the Minister of Health appoint an independent panel to review the original mandate of the common drug review in relation to the roles of Health Canada, the Patented Medicine Prices Review Board, and provincial and territorial drug review processes.
Our association also asks you to recommend that the health minister create a new conditional listing for drugs approved by Health Canada as safe and effective. This new listing could be for anywhere between three to five years, while government and industry—and we believe industry must be involved in the design if we are asking them to pay the cost of the research—as well as health organizations undertake a research program that identifies the real-world economic costs and health benefits of a new drug. Governments would then make a final decision once the research results were known and published.
Finally, we ask you to recommend the immediate implementation of a number of steps while the independent panel undertakes its review and makes its recommendations. First, introduce greater transparency while maintaining a rigorous, objective drug review process by requiring CDR to cite all publicly available clinical studies and research used in their listing recommendation; release the criteria used to evaluate the cost-effectiveness of a medication; enter in discussions with CIHR on investing in research in Canadian universities to generate the much-needed economic and cost-effectiveness data; invite all interested parties to provide CDR with recommendations of qualified reviewers for their consideration in the selection of their reviewers of the scientific and clinical evidence for each drug; publish an annual list of these individuals contracted to review the scientific literature after a listing recommendation has been made public; and finally, introduce an independent appeal process that does not include individuals who have the initial recommendation for listing.
Mr. Chairman, we get the opportunity of travelling this country from coast to coast several times a year, and I won't give you all of the sayings or the requests by many of our stakeholders, but Mr. Ron Whipple, who lives in Fredericton, New Brunswick, made a comment that I thought is relevant to this committee. He stated very clearly that he would like to die with his diabetes and not because of it.
Thank you very much.
Thank you very much. That was perfect.
I am Durhane Wong-Rieger. I am actually the volunteer president of the Canadian Organization for Rare Disorders.
CORD is a national network of patient organizations and groups representing Canadians who have rare disorders. There are about 5,000 to maybe 7,000 rare disorders in Canada, which affect, we believe, up to 10% of the Canadian population. Most of these disorders do have a genetic base. Most of them affect infants, children. CORD's mission, then, is to provide a common voice for those affected by rare disorders, and we do education, support, and advocacy.
I optimistically entitled my presentation to you—which I apologize for not having in front of you—“How Canada's Common Drug Review is Failing Patients With Rare Disorders and How to Fix It”.
In the decade before 1984, there were about 34 new drugs for rare disorders, in that entire decade. In the two decades since 1983, when the United States passed the Orphan Drug Act, there have been more than 300 new therapies introduced, approved for patient access. Similarly, since the European Union passed their orphan drug act in 2000, there have been more than 30 new therapies approved for market access in Europe.
The reaction from our patients and from health care providers has been one of hope. We hear oftentimes, “Thank goodness we finally have a chance for life. Hopefully, there will soon be a therapy for our condition.” We contrast that with the reaction from our drug plan gatekeepers, who tend to say, “Oh my gosh, how can we afford this? And how many other therapies are there in the pipeline?”
Therein lies our conundrum. Patients anxiously await each new therapy because it offers them a chance for life, and what we get are drug plan managers who view each new approved drug as a cost centre threatening to overrun their already oversubscribed drug budgets.
What we would like to maybe move to is to talk about what would be the desired outcomes of an effective drug review process for rare disorders. I think what we would want to see is that in fact Canadians with rare disorders would have the same access to new therapies as those with more common ones.
It means that those with rare and oftentimes severe and life-threatening disorders would receive therapies that are equivalent to the standard of care and best practices of other countries; that therapy would be approved and available for patients similarly through the public and the private drug plans, and they would be based on evidence of safety, effectiveness, and tolerance.
Importantly, we would expect that therapy be made available to appropriate patients based on some reasonable extrapolations from the available evidence, and we would want to see timely feedback on real-world safety and effectiveness for each patient, as well as a collection of aggregate information that would advise all stakeholders, including patients and health care providers, as well as the regulators and manufacturers, in terms of their longer-term effectiveness and safety.
Sadly, what is the current status? It is a sad but true fact that Canadian patients with rare disorders have probably the worst access among all patients in the developed world to new therapies—and I don't say that lightly. These are often treatments for severe, debilitating, and life-threatening disorders, sometimes the only treatment.
What are some of these new therapies? There are therapies such as the treatments for metabolic disorders, for Gaucher disease, and what we've heard recently a lot about, Fabry disease, MPS, and now recently Pompe disease, all severely debilitating, life-threatening disorders that now have a treatment available.
There are treatments for rare blood pressure and blood disorders. For pulmonary arterial hypertension, the first new therapy, the first therapy ever, was introduced in 1995; now we have three therapies available. Hemophilia, thrombocytopenia—these are all newer therapies that can improve clotting with less risk.
There are treatments for pituitary, thyroid, and parathyroid-related diseases. One of the ones that we've recently had introduced in Canada, which in fact was rejected, is a treatment for acromegaly, which untreated would cause gigantism.
Many of the disorders that are rare are childhood disorders, and we're now seeing, for instance, for the first time, new treatments for childhood leukemias.
About one third of these orphan drugs are for some rare forms of cancer.
Unfortunately, in our experience, the common drug review process is inherently biased against what we call “orphan drugs”, these drugs for rare disorders. The pharmaco-economic process that is used by the CDR relies often, and almost exclusively, on large-scale randomized clinical trials, and clinical trials that have long-term evidence in terms of benefit. That is patently impossible when you're talking about a rare disorder, which has very small patient groups available for clinical trials.
Also, we do not have the long-term evidence. Often we don't know a whole lot about the natural state of the disease, and we certainly have not had the drugs long enough to collect the long-term evidence.
As evidence of the fact, of the 11 drugs submitted for rare conditions since the CDR has been in business, all of which are for debilitating or life-threatening disorders, almost every single one has been rejected. These are all drugs, interestingly enough, that are available to patients through public drug funding in most other developed countries, and even in developing countries.
These drugs include Somavert, for gigantism; Replagal, for Fabry disease; Fabrazyme, for Fabry disease; Amevive, for chronic pIaque psoriasis; Aldurazyme, for MPS I; Zavesca, for Gaucher disease; Forteo, for a rare form of osteoporosis; three drugs—Sensipar, Nexavar, and Sutent—for rare forms of kidney cancer. The last one, Exjade, is for transfusion-related iron overload, which actually just this past week, we were notified, had a recommendation for very limited use.
The result is that we end up with this two-tier process. All of these drugs, interestingly enough, are available if you have a private drug plan, the kind of private drug plan most politicians and bureaucrats who are actually managing this process have access to, but that anybody on a public drug plan does not have access to.
Sadly, to the best of my knowledge, there is no drug for a rare disorder being paid for currently by a Canadian public drug plan that has not been put on the plan without some strident patient advocacy. Despite what most people believe, patients do not like to go through this process.
We end up also with some very bizarre kinds of things happening. I think of Naglazyme, a treatment for MPS VI that the manufacturers chose not even to submit. Through advocacy, it is being paid for by the Ontario government, though now only available through a special access program. It means there's no safety monitoring, no ongoing monitoring of the drug.
The same thing happened with a recent case in MPS II. Elaprase is a drug still going through Health Canada. There was advocacy on the part of the parents. B.C. said yes. Interestingly enough, in two cases in Ontario, the Ontario government said no, let's wait.
We've seen this happen with regard to AIDS drugs and cancer drugs, where strident advocacy was required. We would submit that if the CDR had been in place when the first AIDS drugs came into use, they would have also been rejected by the CDR, and in fact all of those patients would have been experiencing the same fate as many of our patients with rare disorders: they would have just died.
There are some other very bizarre things that I want to point out to you in terms of how this CDR process actually doesn't work.
Zavesca, for Gaucher disease, is a second-line therapy, a first oral therapy. The first-line therapy Cerazyme was introduced about ten years ago as the first breakthrough therapy for this type of lysosomal storage disorder. Zavesca was turned down by the CDR. They said it didn't have enough evidence and it cost too much.
The irony of it is that in fact it came to the CDR with better clinical evidence and cost less than Cerazyme, and yet it was still turned down. So we know that if Cerazyme had been introduced today, none of those patients would have gotten access, and the ten-year data we now have for Cerazyme, which demonstrates definitively that it's effective—All of those patients would have never been on the treatment. Many of them would have died.
We know that too because, as I mentioned, three other enzyme replacement therapies similar to Cerazyme have been systematically turned down by the CDR as having not enough long-term data and not enough evidence of statistical significance, objecting to the use of surrogate markers in terms of long-term clinical outcomes.
I'll give you one final example, which we think is very bizarre. That's Nexavar. This is one of the kidney drugs that were turned down. I think it's really bizarre, because in my opinion it was turned down because the evidence was too good.
What happened with Nexavar? In phase three clinical trials, interim data was coming through showing very clearly that the drug was effective. The U.S. FDA suggested that patients who were on the control arm for ethical reasons be given an opportunity to cross over to the treatment arm. Many of them chose to do that.
Well, lo and behold, by the time the clinical trials were concluded, we did not have enough patients in the control arm to actually achieve statistical significance to say that the drug was more effective than the placebo.
The U.S. FDA got it; the European Union got it; even Health Canada got it. They all approved the drug. The CDR said no, thank you, that they didn't have sufficient evidence of long-term clinical benefits, and they could not seem to understand that there was no way that evidence was going to be forthcoming.
The CDR has said repeatedly that they know these longer-term trials could be done, because they've seen evidence from the Cerazyme example. We now have longer-term evidence from the Fabry disease for drugs that have been approved and are available elsewhere. They're saying, fine, do the long-term studies. We're saying it is unethical to expect that patients in Canada will wait 4 to 10 years while these trials are being done, while patients have access elsewhere in the country. And quite frankly, once the drug has been approved through the clinical trials and is available elsewhere, what motivation is there for any company to do this kind of clinical trial for our very few rare-disorders patients? It means that our patients end up being the control group, quite frankly. I think we are very concerned about what's happening in terms of the trend here.
It is our opinion, though, that we could in fact have a much more effective process. Interestingly, we do not disagree that publicly funded health care programs should assess drugs and other technologies for safety, efficacy, and even cost-effectiveness. Moreover, we agree there should in fact be randomized control trials where possible. However, we think these trials have to be appropriate to the patient population, and the standards that are used have to be appropriate.
Internationally, there have now been agreed-upon standards by which you would actually do clinical trials with small patient populations. There's international agreement around what surrogate markets are available and how they should be evaluated. Why is it that everybody except for the Canadian common drug review can get on board with this?
As I say, our real quarrel is not with Health Canada. We think Health Canada gets it. And we think the progressive licensing framework provides a vehicle by which some of this can actually be done. Unfortunately, when we get to the common drug review, they oftentimes re-review what Health Canada has done; they oftentimes come out with different conclusions. They claim it's because it's real world versus what would happen in a laboratory. We contend that if you don't in fact make the drug available to people in the real world, how will you ever collect real-world evidence? It is being collected elsewhere. We need to be a part of these international collections.
I think there is a little disagreement that the Canadian common drug review is failing Canadian patients. I'll give you an example. Other than rare disorders, 14 innovative therapies were reviewed by the common drug review over the last two and a half years. Of those 14, 12 were turned down. It's the same problem: a lack of long-term sufficient evidence, or it costs too much. Of the two that were actually approved, by their own admission, one was approved with the same lack of evidence, but it cost less than the standard of care, and somebody said, hello, it's okay for you to approve a drug that has not your standard of quality evidence just because it's cheaper.
I think what we want to move towards in this country is a process that's appropriate. We can look at other countries, and I've given you some examples that you can look at when you get the written submission.
There are two things that we want to suggest in terms of fixing the common drug review for rare disorders, and maybe for any innovation therapy.
First of all, there needs to be a separate process. We look at what the Dutch have done; we look at what the U.K. has done. We need to have a separate process that is run by experts who understand rare disorders and will use appropriate processes of evaluation. We do not object to health technology assessments. We don't even object to pharmaco-economic assessment. But it has to be done with the right tools, and it has to be done within the right framework of what we're talking about here. So it has to be a separate process.
The other thing we're suggesting is that there be a separate fund—again, as the Dutch have done, as the U.K. has done in many cases--allocated just for rare disorders. That would help even the playing field, because under the current circumstances, rare disorders can never get access in the same way as more common drugs. We're recommending, based on some of our international experiences and on what's available currently, that 2% of the public drug fund should be allocated separately for rare disorders. It should be handled by a separate committee, by a separate process, and this fund, then, should be established nationally and shared by all the provinces. We would actually like to call upon the federal government to kickstart this by putting together that fund and making it available, and then helping to set the terms of reference and guidelines by which those drugs would be reviewed and accessed.
We don't object to safety and assessment. In fact, patients don't want drugs that are not safe and don't have long-term effectiveness. I think the U.K. has a very innovative program, which we think is very valuable, and that is, when a drug is deemed safe and has sufficient evidence of efficacy, it's made available to patients where there's a high risk in terms of debilitation or death. And the patient then signs an agreement that says, after x amount of time, if you don't get the effectiveness, then you're taken off the drug.
I will just finish by saying that the question was asked to our U.K. visitor, what happens when you take patients off the drug? He says it has never happened. He says the patients take themselves off. Nobody wants to take a drug that isn't working and isn't considered to be safe. We've never had that problem. We would contend to you there's enough good international evidence about how an effective process could be done. We certainly believe, as an aside to it, is that the more appropriate use of HTA should be applied not only to the rare disorders, but also to some of the more common disorders and certainly to innovative therapies.
Quite frankly, I don't think we object as much in terms of what the common drug review does, and it isn't as if there's a complete duplication.
What's happened is that the common drug review has taken over a pharmaco-economic assessment that the provinces used to have to do anyway. Only a few provinces were able to do it. So what they said was, okay, let's bring it all together. As Karen said, it was a good idea in spirit; we don't need to have 17 jurisdictions doing this.
The provinces were then supposed to take up the information and make some decisions around the budgetary impact. That didn't happened, and that's a concern.
Now, regarding JODR, instead of the recommendation coming out of the CDR.... They're still going to do the assessment and go to each cancer agency to say, okay, do you want to list it, or not? The cancer groups got together and said, let's have one common process that in theory will pick up the recommendations from the CDR and take them to the next step, which is to look at what in fact our ability to do it is, based on the number of patients, etc. They would then make a common decision as to whether to list it, going towards a bit of what Karen was talking about, in terms of—hopefully—a national standard.
I think the problem is twofold. First, as you've heard over and over, the CDR uses a very narrow process, so very few drugs actually get recommended. This is a problem for cancer patients, and certainly for some of us who are looking at the rare cancers.
This goes back to Steven Fletcher's question. You used to get very advanced and very good expertise from places like B.C. They said, we are going to disregard that; obviously this is not a good recommendation that the CDR is giving us. We're going to go ahead and list it.
Where you have some good expertise provincially, you get some uptake. You also get some of the ability to leverage and play one off the other, etc., except that this is not the way you really want to run a drug plan. But that has happened.
In theory, is JODR a good idea, a bad idea, or a total duplication? Not really. On the other hand, in practice, you get bad recommendations coming out of the CDR.
With JODR, it's the same as with some of the provinces. You still have to go back and do some other kind of reassessment.
For instance, in Ontario, we know that the Committee to Evaluate Drugs does kind of a first level of what the CDR does. They don't just take it and say, thank you very much, good job, and we'll sort of move with it. They do their own bit of pharmaco-economic assessment.
So there has been duplication. In theory, if they had more confidence in the CDR, they would be able to pick it up.
Alberta has announced that they're not going to do that anymore. Alberta said, we will take the recommendations that the CDR gives us and implement them. I think patients are really frightened about that, because the recommendations coming out of the CDR are so lousy.
In some respects, the hope was...you get to Ontario, and sometimes you can have some hope that they will make a more enlightened decision, or that JODR will make a more enlightened decision. We've seen that happen, even with rare drugs. Some were turned down by the CDR, and the province said it would pick them up.
The problem is twofold. One is a lousy process coming out of the CDR, and there is a lack of confidence among the provinces in terms of what to do about it.
So there are still two steps of the process that would need to be done, but the problem is that there's a huge amount of overlap in the middle. Would one seamless process be better? Probably.