Thank you very much, Mr. Chair and committee, for inviting us to join you here today. We sincerely appreciate the invitation and the honour of being able to provide our perspectives to the committee.
My name is Dianne Balon, and I am the vice-president of government at Alberta Blue Cross. Accompanying me today is my colleague Margaret Wurzer. Margaret is a pharmacist by training.
As Alberta Blue Cross is a leading benefits carrier, we provide a full range of supplementary health benefits. Prescription drug coverage is one of the main benefits provided through the plans that we administer. Alberta Blue Cross is a not-for-profit organization, and we have a unique legislative mandate to serve the health and wellness of Albertans.
Our company administers and provides benefits coverage for both the private and the public sectors. Our plans include publicly funded, government-sponsored benefit plans for the Government of Alberta, as well as for the Government of the Northwest Territories; employer-sponsored benefit plans—we currently have over 5,700 employer group plans, some of these from publicly funded organizations and others entirely privately owned—and we also provide health benefits that individuals can purchase, for those who are self-employed or who have retired early.
Collectively, across these plans, Alberta Blue Cross provides prescription drug coverage to more than 1.6 million Albertans.
We are also part of the Canadian Association of Blue Cross Plans, which is collectively the largest not-for-profit benefit carrier in Canada, providing coverage to more than seven million Canadians.
Given the diversity of the customers we serve, along with many of our counterpart Blue Cross plans, we have a unique perspective on the provision of prescription drug benefits that is applicable to the discussion surrounding pharmacare. Our experience with these different plan sponsors highlights their varying objectives and philosophies, which form the basis for their decisions about the prescription drug coverage they offer.
As you know, publicly funded government-sponsored programs provide benefits essential for the societal good, typically with a focus on select populations, such as seniors, the vulnerable in social services programs, or those with specific disease conditions like cancer and organ transplant. Coverage decisions are guided by government policy, and as these programs are funded using taxpayer dollars, there is the ongoing challenge of sustainable funding. We typically see a traditionally smaller basket of drug products within their formularies.
Employers provide group benefits in the interest of keeping employees healthy and productive, and as part of an employee's overall compensation package. An employer's decisions regarding which drug to cover may be defined by union contracts or by the desire to maximize employee productivity—making sure they are at work and productive and not away sick—and to minimize disability claims, while ensuring they are providing a competitive compensation package. As a result, employer plans typically provide quite broad baskets of drugs on their plans. However, as employers are funding this coverage directly, they are well aware of benefit costs and the need to ensure plan sustainability.
Individual health plans—which are a rapidly growing segment of the benefit plan market in Canada, as more and more individuals are self-employed, working on contract or part time, or retirees—are self-funded by the individuals who pay for them. Individuals still want to have good coverage, with a focus on overall cost control, with formularies that are typically more narrowly defined or have more cost control mechanisms than a standard employer-sponsored plan.
All three of these market segments are faced with a common challenge—escalating drug costs and serious concerns about the viability of their drug plans.
We know there are a number of factors contributing to the increased drug benefit costs for plan sponsors. I'm sure you've heard them all. This includes an aging demographic and increasing prevalence of chronic disease, coupled with newer, more expensive therapies for currently treated diseases, as well as new drug therapies for diseases that had no drug treatments in the past.
As you know, more and more of the new drugs coming to the market are specialty drugs and typically cost in excess of $10,000 per patient per year, many treating common chronic medical conditions. Add to this the exorbitant costs of the orphan drugs to treat rare diseases.
While these drug cost pressures create significant challenges for benefit plans, we do recognize that many of these treatments can be life-changing, improving health outcomes and, in many cases, keeping patients out of the primary health care system. The challenge is how to fund these therapies in a sustainable manner on the benefit plan.
As our presentation comes in the context of the committee's already having heard from close to 80 witnesses, we have reviewed all prior presentations and concur with many of the comments that have already been made regarding the need for fundamental reforms.
We believe that, prior to the consideration of the value of a national pharmacare program, the following key policy changes should come first, as they advance the principles of pharmacare by promoting sustainable, more equitable access for Canadians.
First is a substantial decrease in Canadian prescription drug pricing. We believe that immediate action in this area will be foundational to ensuring that we have viable drug coverage in the future. We look forward to the work that the federal is already undertaking as part of her mandate to make sure drugs are affordable, accessible, and appropriately prescribed. The minister has stated that dramatic lowering of drug costs can be achieved with a few regulatory and guidance changes for the PMPRB, and we are fully supportive of her leadership in this regard.
We also see tremendous value in the partnership opportunities of the pan-Canadian pharmaceutical alliance and encourage this organization to work collaboratively to lower all drug prices for all Canadians.
Second is enhancing collaboration between the public and private sectors. With the current environment, we see many silos in public versus private, and we do believe there are many opportunities for streamlining administration and bringing efficiencies to the current processes.
For example, with our collaborative relationship with the Government of Alberta, we have been successful in establishing a process for securing consistent drug pricing across our public and private plans. In the Province of Alberta, we also operate under one pharmacy agreement that we have with the pharmacies, which provides for consistent dispensing fees and additional markups on drug costs for all our plan sponsors, both private and public. Albertans have benefited, as this has helped, to an extent, to control drug costs and increase plan sustainability for both sectors.
Now, moving to access, funding for high-cost orphan drugs is an area that poses substantial challenges to the sustainability of all drug plans, whether public or private. For these drugs, collaboration between public and private payers will be required to establish national coverage policies to ensure that the relatively small number of Canadians who need high-cost orphan drugs will have equitable access.
For other drugs, the topic of what is appropriate access is one that we struggle with, as how one defines medically necessary, appropriate, or equitable access may be determined by the objective for providing coverage. As an example, if your objective for providing benefits is to ensure that your employee is not on disability, you may think that a formulary with a small basket of drugs, one that does not include coverage for medication that will get your employee back to work faster, does not provide an appropriate level of access.
We recognize that the mandate of the committee is to consider national pharmacare, with a focus on drug benefits. However, as a provider of not only drug benefits but other extended health, dental, life, and disability benefits, and with our legislative mandate to serve the health and wellness of Albertans, we are cognizant of the implications of looking at the issue of drug benefits in isolation.
Any changes to the funding model for drug coverage should consider the potential implications it could have to the coverage level for other health benefits. These benefits include things like diabetic supplies, psychology services, physiotherapy benefits, wellness initiatives, and a host of other medical services that address individuals' health needs holistically.
In closing, Alberta Blue Cross congratulates the committee for undertaking a study into the value of national pharmacare. After reading all the information, we appreciate that this is a massive undertaking.
We sincerely thank you for the opportunity to bring forward and share our perspectives today. We welcome the opportunity to answer your questions and to be an integral part of the solution going forward.
Thank you. I'll try to be on time as well.
First, thank you very much for giving me this opportunity to appear in front of your committee.
By way of introduction, I am Commander Sylvain Grenier, as mentioned before, senior staff officer for pharmacy services in the Canadian Armed Forces, which I'll refer to as the CAF from now on. I am also a full-time military pharmacist.
I am the current president of the Military and Emergency Pharmacy Section of the International Pharmaceutical Federation. I am also an adjunct professor with the University of Ottawa and work one evening per week as a community pharmacist in Gatineau. I am here today in relation to my duties with the CAF. I have no conflict of interest to declare.
In the next 10 minutes, I'll provide you with a quick overview of the CAF's drug benefit program.
Last year, the CAF spent $26.6 million on medication, with 90% of these prescriptions being dispensed by our 23 military pharmacies. This is quite small when compared with the $30 billion spent annually on prescription drugs in Canada.
With a total of 71,000 eligible patients, this equates to an average cost per CAF member of approximately $375. The total expenditure has remained constant for the last five years.
In the documents tabled, you will find a graph comparing the average cost of prescriptions processed at CAF pharmacies versus those processed at private sector community pharmacies.
On average, the CAF saves $25—or 38%—per prescription filled by a CAF pharmacy. This figure takes into account the infrastructure costs and the salary and benefits of the military, public servants, and contractors who work in military pharmacies. This works out to savings of almost $14 million annually.
The principles upon which the CAF drug benefit program is based come from the CAF spectrum of care, under the authority of the commander of military personnel command. The spectrum of care delineates which health benefits will be covered for CAF patients. Since CAF members are excluded from receiving care from the provinces under the Canada Health Act, the spectrum of care includes many medical conditions covered by the various provinces.
I'd like to touch briefly on the process whereby medications are included on or excluded from the CAF drug benefit list, which we call the DBL.
Our process is evidence-based and relies heavily on the review conducted by the common drug review, the CDR, of CADTH. After the drug has been reviewed by the CDR, the CAF pharmacy and therapeutics committee, which we call the P and T committee, will review the recommendations and determine the drug's applicability to the military context.
The P and T committee comprises clinicians: physicians—both general practitioners and specialists—as well as pharmacists, nurse practitioners, physician assistants, and other health care providers.
After being evaluated, a drug will be placed into one of the three classifications. The first is inclusion into our DBL as a regular benefit, meaning that there are no criteria or specific requirements governing its prescription. The second is as a special authorization drug, meaning that the patient needs to meet criteria established by the P and T committee in order to receive that medication, which is often the case for second-line therapy agents. Third is exclusion of the drug from the DBL, which we often refer to as a non-formulary drug, which means that it could be dispensed with the approval of our drug exception centre.
For drugs that are not reviewed by the CDR, which include many over-the-counter medications and older medications, the P and T committee will conduct its own analysis. Similar to civilian hospitals, the CAF benefit program also covers select non-prescription drugs that are not normally covered under other public plans. These include smoking-cessation agents, antihistamines, topical antibiotics, and over-the-counter pain medications, just to name a few. Although they are classified as over-the-counter medications, in our organization, they require a prescription by an authorized prescriber.
The CAF benefit list currently includes 1,065 different drugs out of the over 13,000 drugs available on the market in Canada, with 78% of these drugs covered under regular benefits.
As mentioned earlier, CAF patients can have their prescriptions filled by military of civilian pharmacies.
However, our policy states that the prescriptions must be filled by a military pharmacy, except for after-hours emergency prescriptions, or if the patient does not have access to a military pharmacy, since not all bases have military pharmacies.
Our program does not require deductibles, premiums, copayments, or user fees. There are no annual limits for medically necessary coverage. And this is true for both military and civilian pharmacies.
When a patient presents at the pharmacy, if the drug is a regular benefit or a special authorization drug, and the patient meets the criteria for that drug, it can then be dispensed.
If the patient does not meet the criteria, or if the drug is non-formulary, the Drug Exception Centre, located here in Ottawa, will review the request. The pharmacists working at the DEC will look at the request on a case-by-case basis and will provide a decision.
In the end, there will always be coverage, either because the request is supported, or because there is an acceptable alternative available. Our patients are never left to pay for their medication, unless the condition falls outside the spectrum of care.
As part of our drug benefit program, we have a drug use evaluation cell, which is responsible for reporting on drug usage. It produces reports related to costs and statistics, like the ones I mentioned earlier, as well as clinical reports focused on helping the health care team make optimal treatment decisions.
For example, the cell generates reports on specific classes of medications and subsequently verifies that patients prescribed these medications have the appropriate military employment limitations.
Currently, we are working on a series of reports on opioid use, in order to identify potential risk to our patients.
Finally, we employ several cost-saving strategies in addition to our rigorous formulary management.
In the CAF, we have a policy on the use of generic drugs, which directs the use of generic equivalents over the use of brand name drugs. Since 90% of our prescriptions are filled at our military pharmacies, we also procure medications. We therefore have several contracts with manufacturers that are negotiated by Public Works as part of the federal, provincial, and territorial contracts. We are also considering looking into joining the pCPA.
I'd like to thank you again for inviting me here today.
I look forward to answering your questions.
Of course, I have a bias as a federal organization. We have to sometimes deal with the complexity of the coverage between the different provinces. Our spectrum of care as set out in our P and T committee is that when we look at different drugs we also have to look at what's being covered by other provinces to provide some kind of equity to our members. Some areas—not all, and I can't really put a number on it—are more challenging than others.
For example, fertility drugs, are we covering them or not? Some provinces are and some are not. With the more common diseases such as hypertension and diabetes, it's not a problem. For the more common diseases, there's going to be a wide floor that is going to be there. The CDR, which is being followed by all the provinces and the departments, is going to be there.
I think it will be a huge advantage to have one national pharmacare or formulary. Currently, the hospitals are trying to align their formularies with the provincial benefits. If you're hospitalized, they start medication in the hospital, then you're released into the population, so your coverage needs to extend there.
If each province has a different formulary, then the hospitals also have to adapt to it. The hospital may benefit and they have already benefited from doing bulk purchasing through contracting. If we had a national formulary, there could be opportunities for all the hospitals across Canada to negotiate as one entity rather than doing it by province. Similar to what we are doing in the military, we could have a procurement power as well as the agreements we get with pCPA.
If we had one national formulary, there would be many more benefits to be had. There might be more political challenges to get there, but I think the end result would be better.
When we look at prescription drug costs, I can probably speak to two key buckets. One would be related to the cost of the actual dispensing of the prescription, so that's your drug cost along with your dispensing fees and your markups.
With that, there's a number of plan management things that we offer to our plan sponsors to try to keep the number of dispensing activities at a reasonable level. For example, if you're on a chronic disease medication and you're stabilized on it, we have programs to try to encourage use of less dispensing, such as dispensing a three-month supply as opposed to monthly dispensing. Those are some of the cost drivers in terms of the dispensing.
We also, as Dianne alluded to, have a pharmacy agreement with our Alberta pharmacies whereby we have caps on the dispensing fees and the markups that they can charge. Through those mechanisms, we're able to control the cost.
The challenge, though, with the drugs that are now being dispensed is the very high cost drugs, the orphan drugs, the specialty drugs. More and more, we're seeing these biologics being used for very chronic common diseases. We have drugs now for treating cholesterol that used to be hundreds of dollars per patient per month. Now we're at between $7,200 to $22,000 per patient per month.
Another cost consideration and the second bucket of costs is really the mix of drugs. As I'm sure many of you have heard, if we look at drugs for treating diabetes, there are some that are in the cost range of 18¢ a day versus some that are $3 per day. At Alberta Blue Cross we put in processes similar to what was talked about with the Canadian Forces, things like step therapy and special authorization. Those are processes that we use to try to manage the cost and, at least hopefully, influence prescribing maybe some of the more cost-effective therapies.
Ladies and gentlemen, colleagues, it gives me great pleasure to be here today. This is the first time that, as senior advisor on these issues, I have had the honour of addressing a House of Commons standing committee.
Thank you for this great opportunity. I think I will remember this moment for quite some time. Thank you all very much.
I want to give an overview of what happened at the Canadian Blood Services and Héma-Québec conference held in Toronto regarding the blood ban for men who have sex with men. I was honoured to bring opening greetings to that conference on behalf of the . The reason is that Health Canada provided the funding for researchers to actually look at closing the gaps in this population of men who have sex with men. This conference was an opportunity to bring together leading researchers from Canada and around the world in terms of the leading best science.
What I thought I might do, Mr. Chair and colleagues, is to give you a couple of highlights from the remarks, and then also share some of the feedback that I received from stakeholders and people who attended that conference.
The whole theme of the speech was on pursuing research to make sure we have the safest blood system possible, and also making sure that our donor supply can be as inclusive as possible. We care about this as Canadians because blood safety is paramount. Our interest as a government—we ran on this—is that we want to know the best research to close the knowledge gaps on donor screening of men who have sex with men. We're going to talk about that term later, because I've had some pushback from the community on the actual term itself.
The call to action is that everyone has a role to play in the blood screening process and in making sure we have enough blood for people who need it. However, there are some perverse effects that have stemmed from the fact that we have the blood ban in place. We need to reconcile the need to protect the safety of Canada's blood supply with the need to make sure that the donor system is as inclusive as possible.
Where the blood ban came from, as you all know as members of this committee and as Canadians who lived through this, was in the response to the Krever inquiry. In the early days of the blood ban, it was a lifetime ban. If you were a gay man who was involved in any sexual activity with another man after 1977, it was a lifetime ban. More recently, that lifetime ban was reduced to a five-year ban. Then, as a party, we ran on getting that five-year ban down to zero. We now have the blood suppliers, Héma-Québec and CBS, who have declared a one-year deferral period.
Now, it's clear to members of the community, although the distinction is not always there, that it's not the government saying that the deferral period is in place. It is CBS and Héma-Québec who have put those restrictions in place.
What I wanted to convey, and what I did convey at the conference, is that we have to talk about the central role that evidence needs to play in protecting the blood supply, but also making the blood supply as inclusive as possible. If you look at the microbiology, at the science, what is the reason for having blood in the supply for two months after nucleic acid tests, knowing what's in the blood supply, and then not allowing people to use that blood or give that blood for a year, five years, or 20 years? The microbiology doesn't support it.
One of the analogies I used—it wasn't in my remarks but I used it because I hear this all the time as a member of the community—is how it is possible that a young college student, of any gender, with multiple partners can give blood as a heterosexual, and all of that student's partners can give blood unrestricted, but two monogamous gay men living in partnership cannot, unless they declare that they have not had sex together for a year. Show me the science that shows that makes sense, because I don't have many explanations for the community to explain how that makes sense.
We have two choices as a community, and this was hotly debated by researchers and members of the community. We get to a behaviour-based analysis where we look at the population of men who have sex with men and at populations within that large basket of people—takings labels aside—and the risk factors, or we take a look at increasing our screening so that regardless of who you are or the risk factors that come to bear, the screening technologies provide the safest blood system possible. Those are the two largest areas that the researchers were debating. Do we have a world-class screening system that doesn't exclude anybody, or do we look at a behaviour-based process?
I just did my first western tour as special adviser, and we were in Winnipeg, Toronto, Vancouver, Saskatoon, and Edmonton. I can tell you that in talking with members of the community, we had several men in the community who objected to the very term “men who have sex with men”.
They said, “I'm just a person, and like other people, I have sex. Why am I a part of the subgroup? Why can't we just talk about risk factors for all populations regardless of sexual orientation or gender?”
When we take a look at the restrictions that CBS and Héma-Québec have put on the trans community, it is even more onerous. We are actually forcing people to go back to their birth gender to determine if they can give blood or not. I had one trans activist in Vancouver who said she is now 14 months after surgery, and as of two days ago her blood is fine, but if she was another gender, her blood wouldn't be fine. We have gotten ourselves into this kind of perverse way of defining populations and sub-populations when it's clear to the community and it's clear to me as a parliamentarian that I want a safe blood supply, but I also want an inclusive blood supply. I can't give blood, as a gay man, unless I say that I haven't had sex for a year. I lived in the United Kingdom from 1994 to 1996, so I may never be able to give blood because that was the time of the tainted blood scandal.
We have to take the blood supply seriously, but we also need to make it the most inclusive blood supply possible. With that in mind, $3 million was put on the table for researchers to move forward and take a look at this issue. I have to give a shout-out to the Canadian Blood Services—congratulations—and to Héma-Québec for the work they did in bringing several organizations, stakeholder organizations, from across the country to the conference.
Héma-Québec and Canadian Blood Services have done a great job of reaching out to members of the community, leaders of the community, including Egale Canada, including various organizations across the country. That partnership, if you will, that advisory role that members of the community play, is a very important role for us to know as parliamentarians. What the community wants, and what we would like to see, and what I urge you as parliamentarians to push us to get, is the data that will help us get to a behavioural approach so that we can de-stigmatize gay men who are in committed relationships, because I think it's important that we de-stigmatize the population.
I mentioned this in my opening remarks. We know that there are allies who are long-time friends with members of the gay community who do not give blood because of the blood ban. That is perverse. When Canadians who are allies to our LGBTQ community aren't giving blood because they disagree with the science and the fundamentals around the blood ban, and those units are not in the system, we are losing out as a country.
I think there's a way forward. The and I have talked about this. As an evidence-based government, it's important for us to have the data, but it's also important for us to make sure that we are not acting in the absence of data. That's why this $3 million and this conference room was important.
The other thing that came up, and I would encourage members of this committee to consider in the future, is to invite Héma-Québec to present to this committee. They indicated to me that they had not presented in some time and that CBS had, so that may be something you would like to explore.
With regard to this whole issue, I think that, with the help of science, it is possible to have a very inclusive Canadian blood system, while maintaining the security of this system. It is very important that Canadians be more involved in their blood system and that this system be very inclusive.
I think what I would say, having heard from stakeholders after the conference, is that this is emotional. We heard from members who lived with tainted blood before the Krever inquiry. We absolutely have to get this right. We have to balance the needs of patients who are receiving blood, Canadians who are receiving blood, with the overwhelming desire of members of the LGBTQ community to contribute to the blood supply.
Mr. Chair, members of the committee, this was a good first start. There is much research that needs to be done. I urge you to pay close and constant attention to this issue. I think that when we are able to work with researchers and scientists to demonstrate the true risk factors of gay men living in committed relationships and we can get this one-year restriction reduced, you will see an increase to the blood supply and one of the safest blood supply systems in the world.
Thank you for your attention.
What is important to know about this conference is that the $3 million was used to bring the officials around the table and also to literally set the scientific agenda for the research that has yet to be conducted. We have yet to see the research. We have yet to see the results of the research.
What's important for Canadians to know is that there is a separation between the blood regulator and the government. What happened during the campaign—this came from our youth wing, and you would have seen it at the doors—is that the youth wing and many coalitions from around the country pushed very hard and we ran as a party to get the blood ban down to zero. When you look at the science in other jurisdictions in the rest of the world, this position is supported.
We are moving as fast and as well as we can as a government. We cannot tell CBS and Héma-Québec to reduce this to zero. That's not how this works. The blood regulators, with the best science they have at their disposal, make a recommendation to Health Canada. Then Health Canada approves that reduction in the deferral period.
The conference is an important first step in getting the data. At best, LGBTQ2 Canadians are invisible in the data. When you talk sub-populations of the LGBTQ2 population, the data isn't any more forthcoming. We need to understand the behavioural risks of populations. We also need to empower scientists who believe they can have a blood-screening system that can unequivocally tell us what is in the blood supply.
As to participation, I wasn't informed about the inability of Conservative MPs or other MPs to be involved. My role as special adviser is non-partisan. I'm here to advance the causes of LGBTQ2 Canadians regardless of political stripe. I want Canadians regardless of political stripe to give blood and be able to get blood.
If we can get more blood in the supply and it's more inclusive, that's what I'm here for. I can tell you the is moving fast on this. As an evidence-based government, we need to see the data and that's why this was an important first step. I appreciate your work on the file.