FOR FURTHER DEBATE
Many witnesses made thoughtful comments on matters strictly outside the Committee mandate. In this section, the Committee records some of these themes in the hope that others will find these ideas and opinions useful.
A. On A National Pharmacare Program
The pharmaceutical industry has shown spectacular growth and scientific achievement over the past half-century. It continues to play an important role in health and health care. Technological progress, changing disease patterns, and the evolution of health care systems have all contributed to increasing the importance of pharmaceuticals in the delivery of health care in developed and developing countries world-wide. Drugs are used to control the onset and progress of disease, to relieve pain and the symptoms of illness, to facilitate surgical procedures and recovery, and to eradicate illnesses. At the same time, advances in such other areas as surgical procedures have changed the patterns of health care, particularly in hospitals, resulting in shorter lengths of stay and in the substitution of ambulatory or same-day treatment, for in-patient care.It is within this context of the growing role and importance of pharmaceuticals that the Committee heard from numerous witnesses on the future course of pharmaceutical reform. The Committee heard that the way to control the growth of drug expenditures, and to improve appropriate access to and utilization of drugs is to ensure that medically necessary prescription drugs are made available to all Canadians without any form of user fee, deductible or co-payment. Numerous witnesses supported the recommendation from the National Forum on Health that our health insurance system move toward the integration of prescription drugs as a fully funded component of publicly funded health care. The Committee heard witness after witness testify that prescription drugs have as good a claim to "medical necessity" as do medical and hospital services. Access to drugs should be accorded equal importance. It was argued that to treat drugs as a commodity like any other is both irrational and inconsistent with the important role that drugs play in the continuum of health care. Public policy must safeguard what is in the best interests of the public and to view pharmaceutical products as essential public goods. To many witnesses, the proposal for a national Pharmacare program embodies the core values that Canadians hold on health and health care.
You can dismiss our group as a bunch of cranky middle class Seniors bitching, but you can't dismiss the report of the National Forum on Health. It is reflective of present conditions, the thinking and the values of the vast majority of Canadians regardless of their politics. Its section dealing with Pharmacare should be the roadmap for your recommendations in terms of changes to Bill C-91.
Prescription drugs must be recognized as an essential component of universal health care and funded appropriately. . . . A nation that holds sacrosanct the concepts of universality and accessibility in health care can no longer tolerate the absence of prescription drugs as a critical component of that care.
Canada is the only rich nation except for the US which doesn't have a national drug plan. It is time to sew the patches on the quilt together and mend all the holes in the safety net where drug coverage is concerned.
A universal drug insurance program is long overdue in Canada. It makes little sense (in this day when common sense is so highly prized) to cover the visit to the doctor, and the consequent diagnosis, but withhold payment for the treatment. While the majority of Canadians have some coverage for drug costs either through Provincial programs, or through private insurance, there are still 3.6 million Canadians who have no drug insurance at all. Provincial Governments are protecting the public purse by future shifting drug costs to the individual consumer. They do this in several ways: by removing drugs from the Formulary which specifies drugs that qualify for public coverage; by increasing the co-payment for recipients; and by encouraging early release from hospital. All of these are false economies.
Establish a national, universal drug insurance plan. Replace current patchwork of plans and implement a program of rational drug use.
The reason that we, on the one hand, state with considerable confidence that we think a publicly funded universal system would be less expensive than the mix-funded alternative that we have now is that historical experience, but on the other hand the single payer - which would be provincial governments in this case if we adopted the medicare model - must have access to a range of options. It must be possible for the payer to choose drugs from different sources. And that's where we overlap with Bill C-91 because to the extent that increasing the patent protection available to suppliers of drugs makes it more difficult to find alternatives to a particular drug, it makes it harder for a prudent purchaser to exercise and to exploit the power that comes with being a collective purchaser, to being a big buyer.
What we would see is the necessity of insuring that whatever regulatory framework you structure you provide provincial governments as the ultimate payers for a universal system, you provide them with the freedom of action, the options that they need to be able to act as prudent purchasers. And if we can do that then we believe that we can actually get better care for Canadians at lower cost by giving the purchasers options to choose the most appropriate drugs.
In 1964, the then Royal Commission on Health Services outlined a new bold direction for health care: "That as a nation, we now take all necessary legislative, organizational and financial decisions to make all the fruits of the health sciences available to all our residents without hinderance of any kind". We have the opportunity with this review of Bill C-91 to take a dramatic step forward toward this vision by establishing a national drug program, by stopping the needless and very costly patent protection afforded by this legislation, and by re-asserting proper public control and accountability over the pharmaceutical industry.
A national drug plan provides universal access to needed therapies by all Canadians irrespective of their financial circumstances, or in which province they reside. A national drug plan also provides the opportunity to address the principle of the use of appropriate technology. . . . Canada's health care system is going through enormous change, and pharmaceutical policy must be in step with the positive goals of health reform. It has an important role to play. As all health administrations attempt to move from institutional to community-based care, prescription medicines will be a crucial resource in enabling patients to achieve a good quality of life outside of acute care facilities. But this can only be accomplished if they are accessible, affordable and used appropriately.
Although the Committee heard from a majority of witnesses in favour of a national drug plan, a number of witnesses also sounded the caution that any such initiative must be well thought out, carefully planned and be sustainable over the long term. A number of questions also have to be answered before implementation:
Would this national drug plan fall under the parameters of the Canada Health Act? If it did, would co-payments and deductibles be banned? Is there adequate funding to allow such a program to meet the expectations of Canadians? Given the volatility of the pricing issue, would the program be sustainable over the long term without effective cost controls?... Such a program would require centralized administration, purchasing and utilization management to achieve effective management and cost control.
We concur with the Forum that pharmaceuticals would, ideally, be part of a comprehensive rmedicare program. The question is - How do we get there from here? It is clear that a national pharmacare program can become a reality only if the federal government provides leadership by ensuring that prescription drugs are affordable. Further, such a program would only be sustainable if the cost of prescription drugs remained tightly controlled. The recommendations of your committee will have a significant impact on the future viability of such a program.
B. Drug Approval Process
The Committee also heard from a number of witnesses that efforts should be made towards improving the current functioning of our drug approval process. Several participants noted that while not specifically addressed in Bill C-91, improving the review process for drugs will go a long way to ensuring that people who need these medicines can have quicker access to them.
Canadians need timely access to new drug therapies and cannot afford unnecessary delays caused by duplicative review processes at both the federal and provincial level. Once a drug is approved federally, it should be available immediately in the provinces thereby eliminating years of accessibility and unnecessary additional costs. The elimination of duplicative provincial regulatory review and harmonization of federal reviews with other countries will assist in bringing medicines more quickly to people who need them.
The Industry Committee should recommend an audit inquiry, that is, an inquiry to determine reasonable performance standards for health hazard management in the drug approval process in Health Canada, and to assess whether these performance standards have been met in the public interest. . . . Canada needs a means for independent investigation of key drug safety decisions, made by qualified medical and scientific staff, who are acting in the public interest, acting openly without constraint of confidentiality, and who are paid solely by the public and do not take or require investment from the pharmaceutical industry whose profits are threatened.
Regulatory approval delays in Canada are a significant problem, as they are in the United States. Effort must be made by the government to expedite the review and approval times. This will protect as much of the effective patent life as possible, while at the same time assuring consumer safety and faster access to improved medicines. . . . that the federal government work arduously to improve procedural and approval processes, and to reduce the time for all new drug approval to the average time for approval in other G-7 countries by making use of Canadian university expertise.
[R]equire disclosure from physicians and scientist who advise Health Canada on drug approval of past and on-going financial relationship with companies seeking drug approval. . . .
[P]rohibit physicians and scientists from advising government on drug approval if those individuals have an on-going financial relationship with a drug company who is seeking approval of its drug.
On the other hand, the Committee also heard evidence from the Drugs Directorate of Health Canada that the processing times for the approval of new drugs is competitive with other countries.
You have a chart in there on the Canadian review times, which I think we're particularly proud of. It shows that while our workload has almost doubled in the area of new drug submissions, we have halved the processing time in the last three years.... I believe we are competitive with our peers, if you like, in drug regulation around the world, despite being somewhat at a disadvantage in resources available.
C. Restrictions on Advertising and Promotion
The Committee also heard testimony on the issue of restricting the advertisement and promotion of pharmaceutical products. Various witnesses before the Committee noted that pharmaceutical industry activities to promote their products and increase sales are not always in the best interest of the patient. In light of this conflict of interests between the patient and drug manufacturer, many witnesses urged the Committee to examine reasonable restrictions on pharmaceutical marketing practices. In particular, professional licensing authorities and educational institutions should take a stronger stand to shield students in the health professions from drug company representatives, and to limit the use of sponsorships and subsidies to professionals. Similarly, other witnesses emphasized that direct-to-consumer advertising for prescription drugs should not be allowed and that current legislative loopholes should be closed.
A considerable amount of money is spent by patented drug manufacturers on advertising and public relations. We are informed, for example, that physicians are often given promotional samples to encourage them to prescribe them and so generate sales. They may even be given other goods and services. These practices should be discouraged, for the same reason that tobacco advertising is restricted.
Committee members are reminded of recommendations provided to the Committee by Dr. Philip Berger in his presentation. . . . [The National Federation of Nurses Unions] recommends that the Standing Committee on Health undertake an examination of the promotional activities of pharmaceutical companies to ensure that commercial objectives do not violate the ethical and scientific goals of promoting and weaken the manner in which the current self-regulatory codes are enforced. The Committee should examine the establishment of an independent body with legislative authority to control advertising and promotion, and improve prescribing.
That current prohibitions against marketing prescription drugs directly to consumers be maintained, and that such marketing continue to be restricted to health professionals, but that in addition, schools that educate health professionals follow the lead of McMaster Medical School, in prohibiting drug marketers from having direct access to students, other than through the director of their program.