THE STANDING SENATE COMMITTEE ON SOCIAL AFFAIRS, SCIENCE AND TECHNOLOGY
EVIDENCE
OTTAWA, Thursday, September 26, 2024
The Standing Senate Committee on Social Affairs, Science and Technology met with videoconference this day at 11:30 a.m. [ET] to study Bill C-64, An Act respecting pharmacare.
Senator Ratna Omidvar (Chair) in the chair.
The Chair: My name is Ratna Omidvar, and I am a senator from Ontario.
I am the Chair of the Standing Senate Committee on Social Affairs, Science and Technology.
Today, we are continuing our study of Bill C-64, An Act respecting pharmacare. Before we begin, I would like to ask my colleagues to introduce themselves to our witnesses and to the public, starting with the deputy chair of the committee.
Senator Cordy: Jane Cordy, Nova Scotia. Thank you and welcome to our committee this morning. Delighted to have you.
Senator Moodie: Rosemary Moodie, Ontario.
Senator Burey: Sharon Burey, Ontario.
Senator Osler: Flordeliz Gigi Osler, Manitoba.
[Translation]
Senator Cormier: René Cormier from New Brunswick.
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Senator Bernard: Senator Wanda Thomas Bernard, Nova Scotia.
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Senator Brazeau: Good morning, everyone. Patrick Brazeau from Quebec.
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Senator Seidman: Good morning, Judith Seidman, Quebec.
Senator Muggli: Tracy Muggli, Saskatchewan, Treaty 6 territory.
The Chair: Thank you colleagues. Joining us today for our first panel, we welcome the following witnesses in person — thank you for joining us in person — from the Canadian Medical Association, Dr. Joss Reimer, President; from the Society of Obstetricians and Gynaecologists of Canada, Dr. Diane Francœur, Chief Executive Officer; from the Canadian Pharmacists Association, Dr. Danielle Paes, Chief Pharmacist Officer, and Joelle Walker, Vice President, Professional and Public Affairs.
Thank you for joining us today. We will begin with opening remarks from Dr. Reimer followed by Dr. Francœur and Ms. Walker. You will have five minutes each for your statements followed by questions from my colleagues. Dr. Reimer, the floor is yours.
Joss Reimer, President, Canadian Medical Association: Thank you for the opportunity to speak today and contribute the clinician’s perspective on this initiative on pharmacare. It is vital that health care professionals have a voice in these discussions to ensure that future policies reflect the highest standards of patient care.
My name is Dr. Joss Reimer. I am President of the Canadian Medical Association, or the CMA. I’ve also had the privilege of serving as Chief Medical Officer and Vice-President of Medical Services for the Winnipeg Regional Health Authority and as the medical lead for Manitoba’s COVID-19 vaccine task force.
My focus has been on public health, health equity and harm reduction, while continuing to practise maternity care at Women’s Hospital in Winnipeg.
The CMA commends the federal government for introducing Bill C-64, An Act respecting pharmacare, and we fully support its swift passage. This bill, at its core, is about removing barriers to one of the most fundamental aspects of health care — access.
The CMA is committed to a robust, publicly funded health care system where access to vital care is determined by need, not by your bank account.
[Translation]
Canada’s medicare system ensures that hospital and physician services are covered, but many patients still face gaps in coverage for essential medications. When patients cannot afford prescriptions, the care we provide becomes incomplete. These gaps leave patients vulnerable and fracture what should be a seamless care system.
[English]
I represent physicians across Canada who deeply care about their patients’ access to medications. Over 70% of our members consider a patient’s ability to afford prescriptions before writing them.
Prescription medications are a cornerstone of a high-quality, patient-centred and cost-effective health care system.
Yet, Canadians face some of the highest drug prices in the world. Patients are handed a prescription as the key to better health, but the medicine cabinet they need to unlock comes with a price tag many can’t afford. Millions of Canadians either have inadequate drug coverage or none at all. More than 20% face financial hardship, leading to unfilled prescriptions, skipped doses or split pills. And these missed treatments have very real, costly impacts.
The average cost of receiving dialysis for someone whose diabetes has been poorly controlled, for example, is $70,000 per patient, per year.
Chair, as I mentioned, I work in women’s health. Recently, I had a patient who could not afford an intrauterine device, an IUD. She returned later with an unplanned pregnancy, facing emotional and further financial challenges.
I also regularly see patients who opt for invasive, expensive surgery, such as tubal ligation — or getting your tubes tied — because those costs are covered as it is a hospital service rather than a prescription birth control, which is not covered. These stories underscore the real-world impact of this issue.
A patchwork system of drug coverage leaves too many holes. The time has come to weave together a national plan that no Canadian can slip through.
For years, the CMA has called on governments to close the gaps in prescription drug coverage for patients. This is not a new issue. It’s one that has persisted for too long.
Bill C-64 addresses a critical need in our health care system — a system that remains in crisis with an increasing number of patients struggling to access timely, quality care despite the best efforts of health care workers.
With the inclusion of contraceptives and diabetes medications in its first phase, pharmacare will make a significant impact in the lives of so many Canadians, the patients we as doctors see every day.
Governments at all levels must collaborate to improve patient health by establishing a cost-shared prescription medication program. This is a step toward a continuum of affordable and accessible health care for everyone.
Bill C-64 is a commitment to dismantle financial barriers that prevent Canadians from accessing the care they need. It’s one stride toward comprehensive, universal coverage, but more work remains.
The CMA remains willing and able to provide the voices of health workers to ensure this legislation fulfills its promise.
The Chair: Thank you, Dr. Reimer. We will move on to Dr. Francœur.
[Translation]
Dr. Diane Francœur, Chief Executive Officer, The Society of Obstetricians and Gynaecologists of Canada: Good Morning, Madam Chair, members of the committee. My name is Diane Francœur. I am a practicing obstetrician and gynaecologist at CHU Sainte-Justine in Montreal, as well the Chief Executive Officer of the Society of Obstetricians and Gynaecologists of Canada, SOGC. I’m here today to discuss Bill C-64, which will provide for universal free coverage of a full suite of contraception options for Canadian women.
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Today, I want to highlight why this measure is important and long overdue, why it’s not just a “women’s issue” or a “luxury,” why it’s a smart economic policy that benefits all of society and why we urge you to ensure all forms of birth control are included in the final bill and to pass it without undue delay.
It’s fitting that we are talking about this today because today is World Contraception Day. We have a unique opportunity to mark this important awareness day by taking real action for women’s health and reproductive rights. Because today, somewhere in Canada, a woman will have to choose between buying groceries, paying her heating bill, filling up her gas tank or paying for her birth control.
We all know that Canadians are feeling the burden of the rising cost of living. But for 9 million women of child-bearing age, there’s an extra cost — the cost of preventing unintended pregnancy.
Birth control is a basic need, even though it’s not always openly talked about. Yet, for those 9 million women, it’s just as essential to their daily lives as any other personal or bodily need.
Contraception gives women autonomy to plan their lives and plan their families. Women with barrier-free access to birth control are more likely to finish school and participate in the workforce. They enjoy more economic stability, and when they do choose to have children, they have healthier pregnancies.
On average, Canadian women spend 30 years of their lives shouldering the costs of trying to avoid a pregnancy. But these costs can limit birth control options for women.
Canada currently has a patchwork of coverage for contraceptives, which varies depending on income, insurance and where you live. This forces some women to choose the cheapest method, not necessarily the best method for their bodies or their overall health. In some cases, they may not be able to afford any birth control at all, and this can result in unintended pregnancy. I see this every week in my obstetrics-gynaecology, or OB-GYN, practice. We can do better for Canadian women.
Until today, 40% of pregnancies in Canada are still unintended. This doesn’t just impact women and their families; it also affects the economy. The direct cost of unintended pregnancies in Canada is estimated at $320 million per year, and that doesn’t include the downstream costs to society or to parents.
[Translation]
As a national voice for women’s health, the SOGC welcomes this new bill that proposes universal free access to contraceptives. But we know that new programs, especially one as significant as this, can take time to implement. We know that big changes in health care can be challenging to implement.
That is why we urge you, honourable senators, to ensure that Bill C-64 is passed smoothly and without undue delay. To fully implement the commitments contained in this bill, Ottawa will have to negotiate agreements with the provinces and territories, which will take time. Any parliamentary delay will only force women to wait longer for the help they so desperately need. Our patients, our nurses, our daughters and our neighbours ask us every day when this bill will be passed, as they are waiting impatiently for this coverage. Every day that women take the risk of unplanned pregnancy is one too many.
We also urge you to make sure the final version of this bill covers all types of contraceptives: the pill, the patch, the ring, IUDs, the shot and the implant. Every option must be available so that women can choose the one that is best for them. This will ensure that 9 million women in Canada aren’t forced to make family planning decisions based on their income. Thank you.
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The Chair: Thank you very much, Dr. Francœur. Ms. Walker.
[Translation]
Joelle Walker, Vice President, Canadian Pharmacists Association: Madam Chair and members of the committee, thank you very much for inviting us here today. I will make my remarks in English, but I will be happy to answer your questions in French or English.
[English]
I will make three points today. We are here today representing over 45,000 pharmacists, most of whom work in community pharmacies across every province and territory and in some of Canada’s most remote locations.
Pharmacists know drug plans. Anyone who’s walked into a pharmacy with their drug card knows that the pharmacist is the one managing their drug coverage. Every day, they submit millions of claims on behalf of their patients, they spend time on the phone with public and private insurance plans and they help patients identify alternative treatments when needed.
We often see patients who struggle with the costs of their medications, and changes are needed. However, it’s because of the pharmacists’ experience that we believe the best way forward is through a universal, mixed public-private model. It would limit disruption to the system and ensure the greatest benefits for Canadians.
This brings me to my second point. The potential for significant disruption can’t be overestimated. As members of this committee can likely attest from the recent Public Service Health Care Plan transition, changing drug plans can be extremely disruptive for plan members and for pharmacists. Switching from a private drug plan to a public drug plan can be equally disruptive, so changes must be implemented carefully to avoid confusion and reduce administrative burden.
Public drug plans across Canada are far less comprehensive than private plans. As the committee has heard, the diabetes and contraception lists are fairly limited. If the legislation shifts people from private to public, pharmacists and physicians will have to spend a considerable amount of time switching patients to new medications if those drugs are no longer covered, filling out paperwork to get special exemptions and communicating these changes to patients.
To provide a personal example, I’m on a birth control pill that is not listed on the proposed list of medications. It took me over three years to find something that worked for me that didn’t have some of the side effects that affected my day-to-day life. Knowing that contraceptives will be covered publicly, will my employer continue to cover contraceptives? Will my pharmacy still stock those drugs that aren’t covered? Will there be exemptions, and will my pharmacist have to apply for those exemptions for me? These are important questions that we believe need to be understood and answered before this legislation goes any further.
Finally, pharmacare should not just be about the cost of drugs. It should be about the care that people need to take those drugs. Every provincial pharmacare act recognizes this fact and incorporates pharmacy services in their legislation.
That’s why we’re proposing that this committee amend the definition of “pharmacare” to include pharmacy services, aligning Bill C-64 with provincial pharmacare programs.
In a recent poll conducted by Abacus Data, 83% Canadians agreed that the cost of pharmacy services should be included in the national pharmacare plan. That’s because Canadians understand and value the care that they get from pharmacists.
We also believe that pharmacists must be included in the committee of experts, which, again, would align with many provincial regulations. Pharmacists bring a unique, practical perspective, one grounded in daily interactions with patients. Their insights are critical to making sure this policy works in the real world.
In closing, we urge this committee to consider amendments that would clarify the role of private insurance in pharmacare and to ensure that pharmacy services are included in any national pharmacare plan.
I look forward to your questions.
The Chair: Thank you, Ms. Walker. We will go to questions. Colleagues, we will start with Senator Cordy.
Senator Cordy: Thank you all very much. You are all at the front line whether it’s as a doctor prescribing a medication or a pharmacist trying to fill medication prescriptions, so thank you all very much for being here.
Dr. Reimer and Dr. Francœur, you both spoke about the challenges of women in terms of contraceptives and how women have to make these decisions. You have said there are 9 million women dealing with unplanned pregnancies, which sort of blows me away. I guess we don’t hear about them all, but that’s a very high number that I think we should always consider.
What will this bill do for women of child-bearing age in terms of contraceptions and preventing pregnancies or for family planning because not everyone is trying to prevent a pregnancy?
Dr. Francœur: As you notice, I come from Quebec, so we have been allowing women to have free access to IUDs since 2006, and I still cannot believe that close to 20 years later, it is not available for the rest of the country. Canada is still a country, and every woman in this country should have the same access.
My background is also as a pediatric adolescent gynaecologist, so I used to run the teenage pregnancy clinic. When I started, our rates were like 28 per 1,000 adolescents being pregnant. Now it’s down to 4. Teenagers don’t get pregnant at the same rates because of these long, active contraceptive methods that are reversible, of course.
It is a matter of choice, and we know that when women have the best choice that fits them, they are going to stay on it, have fewer side effects and be happy. As my colleague pharmacist just said, sometimes they are not able to choose the best method for them because it is just too expensive. Even if you count it day by day, an IUD is sometimes a cheap choice, but you have to pay for it upfront and women don’t have this kind of money, and it is even worse now. I think the facts are there; we just need to make it available for the rest of the country.
Senator Cordy: Dr. Reimer, did you have anything to add?
Dr. Reimer: I completely agree with my colleague. The upfront costs are a huge barrier for many patients. I worked in a clinic in downtown Winnipeg that served northern Manitobans who go back and forth between Winnipeg and the North, and most of them cannot afford to pay for their medications. We would regularly have IUDs available in our clinic, but that was funded either by donation or by the physicians paying. We have had examples where we had to have difficult conversations about whether to use an expired IUD because there was no other option available. That’s the only one we have. They can’t afford anything.
These are conversations that are heartbreaking to have when an IUD is often the cheapest option in the long-run but still not available to that individual. So a bill like this will have a huge impact on Canadians and their ability to control their own family planning and make a major impact on their day-to-day lives, and it is for that reason that we encourage the swift passage of this bill without amendment to ensure that Canadians who have waited far too long for this coverage get the coverage that they need.
Senator Seidman: Thank you very much for your testimony here today, for taking the time to come and help us understand the importance of this piece of legislation. I would like to address my questions to you, Ms. Walker and Dr. Paes, if I might. As a Quebecer, I think we are very privileged and we understand only too well the importance of the pharmacist in health care as a front-line practitioner in many respects, and we know that we see our pharmacist more often than we see our general practitioners and very often pharmacists play an important role in diagnosis, in renewing prescriptions and in Quebec, most recently, even in prescribing. I feel very strongly that this is a very important aspect of the pharmacist’s role for Canadians right now when access to physicians is so challenging.
I find it interesting that pharmacy services are not included anywhere in this bill. “Pharmacist” isn’t included in the definitions and “pharmacy services” aren’t included. I don’t know if that’s my special perspective because of being a Quebecer and pharmacists have always played a large role in providing service. I ask you that, to start with.
I would also like to know — you talked a bit about the administrative and bureaucratic burdens that might be placed on pharmacists as they try to navigate the changes in the bill. I would also specifically like to ask you about drug shortages because I know that we heard yesterday about restrictions in Health Canada’s formulary, and you, Ms. Walker, spoke about a drug —
The Chair: A number of questions in a short time. Ms. Walker, they were all addressed to you.
Ms. Walker: In preparation for this, we reviewed all of the provincial legislation that relates to pharmacare. Every province has some form of pharmacare act, and it is very explicit in those bills that pharmacy services are part of that. When you get a prescription filled, there is the cost of the drug, the dispensing fee and often a number of other services that are provided to make sure that the medication is taken appropriately and that they all work together. That’s a critical component that we think is missing from the bill and should align with the provincial legislation, as we know it will have to be a bilateral discussion with the provinces.
The administrative burden is real, and I spoke about the Public Service Health Care Plan. We had a lot of pharmacies in Ottawa particularly who deal a lot with public service workers. Services, different types of drugs and packaging were not available in the transition, so pharmacists were spending time filling out forms, communicating with insurance plans about what was allowed and not allowed and especially for people who are maybe older, you can’t just send them to a website. You have to really help support them in getting that treatment. For us, those are really key elements, and any transition needs to be very carefully measured.
Lastly, on shortages, this is a real issue. Pharmacists spend about 20% of their time managing drug shortages. That’s time they are not spending doing other things, including direct patient care. The concept that if you bulk buy a lot of drugs, you save money is perhaps accurate in the pure sense, but it also has a lot of consequences. We’re most vulnerable in Canada when we only have one particular medication for something. If that medication, for whatever reason — if there is a plant malfunction in another country, we don’t have that supply. So we really do need to ensure that when we’re purchasing medications — which pharmacists essentially do the purchasing themselves — that we’re thoughtful about how such a program —
The Chair: Thank you, Ms. Walker. We may have to come back. There may be a second round.
Senator Osler: Thank you to all the witnesses who are here today. I have two questions. The first is to the Canadian Medical Association, or CMA, and the second to the Canadian Pharmacists Association, or CPA.
You are familiar with the principles of the Canada Health Act, which is referred to in Bill C-64, in which the minister is to consider. Public administration, comprehensiveness, universality, portability and accessibility.
This committee has heard ambiguity on whether national pharmacare will be publicly administered, and that definition in the Canada Health Act is — requires that health insurance plans to be managed by a public agency on a not-for-profit basis.
CMA’s recent draft policy on managing public and private health care only calls on governments to ensure universal access to medically necessary prescription drugs regardless of a patient’s ability to pay.
Could you expand on that recommendation, and of those five principles, why speak only of universality and accessibility when evidence shows that the costs associated with administering public drug plans are a fraction of the costs of program administration incurred by private insurers? So why leave out public administration?
Dr. Reimer: Certainly, we value all of the principles of the Canada Health Act, and it is critical that all Canadians can trust in their health system to be available to them regardless of where they’re located, that it be comprehensive, accessible, portable and publicly administered as required.
With this bill, we recognize that there is still a lot of work that needs to occur with the bilateral negotiations between the provinces and the federal government, and it is a complex system with complex outcomes. But we also recognize that with an election coming, this bill is critical to bring Canadians the access that they need, that they have been waiting far too long to have.
While the details of how it is administered may still need to be worked out, we still encourage the Senate to pass the bill without amendments to ensure that Canadians do get access because access is what we’re hearing from Canadians as their primary concern right now in the health care system beyond any of the other principles in the Canada Health Act.
Senator Osler: Thank you. For CPA, you mentioned your recommendation of a universal, mixed public-private model. Similar to my last question: Have you given any consideration as to who would administer the public national pharmacare?
Ms. Walker: The way we sort of see this bill is — we have targeted two classes of medications, and they are extremely important. No one is debating that. Our view is that there are a lot of other disease groups — heart, cancer and there are patients there who are also looking for some relief — and the opportunity to provide a broader level of coverage for those people who don’t have coverage would be an amazing first step to really helping a broader number of Canadians have access rather than switching people who currently have a reasonable amount of coverage — who don’t maybe need it — in a first phase.
That’s sort of been our approach, and we know that it works well for a lot of provinces. Quebec has that model. Things can always get better, but we think that that’s a very appropriate way to move forward.
[Translation]
Senator Cormier: My question will be for Dr. Francœur. Welcome to all the witnesses.
On the one hand, you said that contraception wasn’t just a women’s issue. I agree with you. On that, I was thinking that the contraceptive pill for men is experimental, but condoms are available. Are they accessible? In fact, I’ve been asking myself a number of questions about the role men can play and the ways in which the medical system can help all citizens overcome the challenges related to contraception.
You said that the bill should be passed without amendment as quickly as possible, but you also said that all contraceptive methods should be included. Are all the methods included in the list of drugs, and if not, what should be done? That would undoubtedly require amendments or modifications on our part.
Dr. Francœur: That’s a very good question. Currently, all methods are included in the proposal: patches, pills, IUDs, implants and injections.
That said, in an ideal world, we’d like condoms to be there as well. We can’t have everything.
When it comes to women’s health, it always requires a day one. Let’s make it happen. Then we can always expand it. We see it in the field, and I think that Dr. Reimer has more or less the same experience as I do, that disadvantaged women are always negotiating. They don’t have any help to pay for contraceptives. Their spouses manipulate them. Not having access to free contraceptives is another step that increases inequities between men and women. In the proposal, we’d prefer that the bill be passed quickly and then it can always be improved. For now, all methods are included, so that women can have access to the method that will solve most of the problems they face every day and so that women don’t have to negotiate the cost of contraceptives with their spouses, because it doesn’t work. The situation is even worse for disadvantaged women.
Senator Cormier: Thank you, Dr. Francœur.
My second question is for Ms. Walker. I don’t know much about pharmacy services. You said that services should be included, and you named a few. Is there a list of priority services? Since the federal government will be signing agreements with the provinces and territories, would there be a way to take the needs of pharmacies into account in those agreements, as you’ve expressed them to us?
Ms. Walker: Pharmacists offer a variety of services in every province, and it’s the same in New Brunswick. Some of them are really very drug-specific, even just to write the prescription and educate the person on possible side effects, but they also offer a lot of immunization and prescription services for minor conditions. Our concern with the federal government’s bill was that it didn’t reflect exactly how the provinces saw the whole situation in the context of a public system. Every province has a public drug system. We think this should be reflected in the same bill.
Senator Cormier: Could this be negotiated in the agreements?
Ms. Walker: Absolutely. However, it would be nice to see it in the bill as well to make sure it’s clear.
[English]
The Chair: Thank you, Ms. Walker.
Senator Moodie: To the witnesses, thank you for being here today. I want to put it out there as a physician, I work with patients every day — with children with chronic diseases — to switch their drugs to new drugs. I write a prescription; it goes to the pharmacy; the pharmacist fills it. It’s as simple as that. I’m a little concerned about the way it is characterized as complicated and the time spent that would be required to transition patients perhaps towards pharmacare drugs that might come into play with this new plan. It has been characterized as a somewhat time-consuming and perhaps complicated process. I would like you to comment on why you see this as complicated and time-consuming.
Danielle Paes, Chief Pharmacist Officer, Canadian Pharmacists Association: I would be happy to provide my perspective as a pharmacist and as someone who was there on the front line when OHIP+ was rolled out. I was having conversations with parents, with children about what that coverage looked like. So when they would come to the pharmacy expecting their drug to be covered and it wasn’t, that’s a really hard conversation to have. So trying to understand what their insurance coverage currently is and how that aligns with the current formulary of the public plan, connecting with their doctor, with their nurse practitioner, trying to understand if there is going to be the need for a switch. Is there a timeline for this? Will there be any delays in therapy? Trying to make sure that transition is as smooth and as comfortable for our patients, especially sick children, is important.
Senator Moodie: I understand that, but understanding also that these are transitions that happen on a daily basis. There would be perhaps a period of expansion that has to be dealt be with. But your industry has dealt with periods of expansion before. So can you explain to me why this is seen as such a hurdle?
Ms. Paes: I think a lot of what pharmacists do is behind the scenes. We are on the phone with insurance plans. There is not a lot of visibility into what it takes to get access to medication. It is not just a list. It is a matter of making sure that everything aligns so that the actual drug gets into the hands of the patients. That’s just the first time. If there are side effects, if it is not tolerated, if the disease progression changes and we need to re-evaluate that, all that assessment, all of that follow-up that’s happening through that healthy relationship —
Senator Moodie: — the doctor as well. It is a system thing.
Ms. Paes: Absolutely.
Senator Moodie: I have another question if I have the time. We were talking about some of the services pharmacists provide. A lot of them are services that are reimbursed at the provincial level through negotiation at the provincial level. You talk about some of this, again, as another issue, but what do you see will be your role when and if there is a pharmacare bill in advocating for the appropriate reimbursements and time and whatever at the provincial level that you would be putting in place and needing to put in place to ensure that service is continued, as this is where these negotiations occur — not with the feds, not with the bills that we are doing. This is provincial. Provinces implement health care.
Ms. Walker: I’ll just use basic math because I’m terrible at math. The pharmacare bill specifically talks about the drug costs, but that’s not the only thing that a public plan pays for. It also includes the dispensing fee as a core expense. So it is important that the federal government make sure that when they are doing their funding, especially if the act says the drug costs, they may not be factoring in some of the additional costs they would need to transfer to provinces.
The Chair: Thank you. We may need to get back to that.
Senator Pate: Thank you. I would like to follow up with the Canadian Pharmacists Association. As you probably know, a peer-reviewed analysis in the Canadian Medical Association Journal found that a national mixed public-private system like the Quebec model would force Canadians to spend 20% — $5 billion — more per year for medicines while still having higher numbers of people unable to afford medicines versus comparable countries with single-payer systems. I’m curious as to how you would justify to Canadians, including your own patients, advocating for a system where employers and households would have to spend 20% more than they currently do for medicines with little to show for that increased cost. I want to underscore that it is my understanding, and it is fairly evident, that the negotiation of pharmacists’ fees is anticipated, as Senator Cormier indicated, in the negotiations between provinces and territories and it is part of the federal funding arrangement.
Ms. Walker: One of the distinguishing factors, in particular in Quebec, is they have a very robust formulary. That’s very important to provide the best level of care for patients. As I mentioned, my birth control pill is not on the list of proposed medications but it is covered by my private insurance. So I do pay a little bit out of pocket, and I think there are opportunities for the federal government to support those. But if you are focusing on a single small list of drugs, which is different from Quebec and significantly smaller than that of Quebec, it will affect the care that patients get on a day-to-day basis. And employers will have to make decisions about how they — this is something that was heard by the committee — will have to make decisions on how they decide to cover drug classes moving forward.
Senator Pate: Dr. Francœur, when you testified at committee in the House of Commons, you talked about the situation is becoming embarrassing; you have worked with Organisation for Economic Co-operation and Development, or OECD, countries around free access to medication. I understand that you have experience and know about the situation in England and Australia, both of which have well-established, effective and cost-effective universal public single-payer systems. Bill C-64 is a first step toward Canada being able to build a similar system. I’m curious as to whether you would agree that the successful experiences of Australia, England and other countries should encourage Canada forward?
Dr. Francœur: Absolutely. The Quebec model is not perfect. There is always room for improvement. Nevertheless, I sat on the RAMQ board for seven years so I know pretty much how the program is robust and well managed. Contraception is the first step but, as I said, day one is always welcome; then there are many days following. B.C. and I hear that Manitoba is looking at covering menopause drugs as well. It is time in this country that we care about women. Canadian women are half of the population. They deserve that we make sure their rights are not forgotten.
Senator Pate: Thank you.
Senator Bernard: Thank you all for being here, for the evidence you are providing and your responses to my colleagues’ questions. I have been thinking — one of you mentioned teen pregnancy, and I was taken back about 40 years. Early in my career, I was doing a lot of community-based work around teen pregnancy. We were particularly concerned about teenage pregnancy in African-Nova Scotian communities and low-income communities. We established community-based health centres, community-based clinics. But still in a lot of those communities — because of stigma, some forms of resistance — the uptake was not what we thought it would be. I don’t know if any of you have any experience in terms of the work that has been done in the last 20 years or so to reduce the stigma, to address some of those gaps around addressing teen pregnancy issues.
Dr. Francœur: I can take this one easily. I think it’s all about building trust. They have to trust — no matter where they come from because there are teens being pregnant in high-income families as well. So they have to feel respected. They have to feel that we care about them. We are so privileged in Canada that teen pregnancy went down, but we can always do better because we want to keep them in school. You know, the youngest girl I delivered was 11. So these things happen in our country. So it’s pretty bad.
When I was doing that clinic, we used to lobby everyone who had a wallet around to get money and buy big jars of condoms. They were empty all the time. When they were free, they would use them all the time to prevent pregnancy and sexually transmitted infections. So it worked.
I’ll finish quickly on that. We had so much joy around this bill that we are going to host our first public summit for women in November. We want to educate them. We want to let them know what the methods are — so in provinces where pharmacists can work with us hand in hand, women will come and they will already know what they need and what they want because we are going to share as much information. And this is the best way to respect people, to get that knowledge so they can make the best choice for them.
Senator Bernard: You are saying the numbers have come down. Do you have research that looks at if the numbers are coming down, are they coming down across the board or are there still some communities, some population groups where the numbers may not be moving in the direction we would hope?
Dr. Francœur: It’s all about access, and access to primary care in our country is, unfortunately, very difficult. So the more people that are going to be around the table — of course, I’m in favour of pharmacists prescribing the pill like school nurses. Many years ago, in Quebec, we saw the first decrease with allowing the nurses in schools to be able to prescribe the pill. That made a big change because it was easy to see someone. This was probably the biggest step that we have taken in decreasing teenage pregnancy. But we need nurses, we need physicians and we need people in every community. My day two would be put that on the shelf in the pharmacy. You don’t need a prescription if you don’t have any —
The Chair: Thank you, Dr. Francœur.
Senator Burey: Thank you so much for being here and giving us your expert testimony. I’m also a physician and I do write prescriptions. I have been in Ontario as well. There are two questions and I’ll get them right off the bat. Dr. Francœur and Dr. Reimer, you spoke about the vital importance of passing this bill. I would like you to put a point on this in particular reference to the — you spoke about the access issue — most vulnerable patients. That’s the question to you.
Then to Ms. Walker and Dr. Paes: Regarding this bill and pharmacy services, is there anything in this bill that would preclude working out the details in the bilateral agreements?
Dr. Francœur: I would say with low-income women, everything is difficult. Whenever you have to talk about money, you just increase the distance between you and the patient. There is no way out. And like Dr. Reimer said, for years, we have been asking drug companies, give us some samples, give us some IUDs, give us some implants. But nowadays, they don’t anymore. Our shelves are all empty. We used to have a lot of free drugs but we don’t anymore.
These women are so vulnerable. No matter what age they are — teenagers I would say probably less than the older women. When you talk about money, you make them feel even more vulnerable because you are talking about a dream they will never have. To be sure, they are not going to have children when they already have too many or when they don’t want to have one now. So talking about money just makes them feel worse, and the conversation is difficult and it is not respectful.
The Chair: Ms. Walker, the second question was to you.
Ms. Walker: I would say there is nothing in the bill that precludes it. However, it is constantly surprising to us that when we think about pharmacare that we are not talking about those professionals who deliver the programs. So kind of alluding to say on eye care you are just providing glasses but not the actual service that the person who is helping you figure out whether you have the right glasses. For us, they are very closely tied together. If we are having a conversation about just drug costs, we are missing an entire portion of the care that goes along with those drugs.
Senator Brazeau: Thank you all for being with us today. We have heard many witnesses talk about the need to pass this as quickly as possible and without amendment. I guess we understand that the door is kind of unlocked now and it is slightly open. I guess what stakeholders are wanting is for that door to kick wide open and to have future negotiations to include more medications.
My question is: Given the fact you have not proposed any amendments — and, again, we understand that governments are not as open to amendments as one might think because they try to keep it simple — if you were to suggest an amendment or two to strengthen this piece of legislation and to avoid any miscommunication with respect to it, what would that be?
Dr. Reimer: Following Senator Osler’s question, as well as Senator Pate’s, having a single-payer universal system is certainly a goal that we would like to move towards. That’s more than an amendment I would say at this point. From the CMA’s perspective, we see this as a critical first step towards universal pharmacare for all Canadians. The two topics that are chosen affect a very large proportion of Canadians. We support this as a way to open that door, as you said, recognizing that we very much want to see it moving towards universality and moving towards a publicly administered system in the future.
For today, we very much value what it offers to Canadians who have been waiting decades to have this covered. In particular, as we talked about, the vulnerability of some of these individuals and the stigma, having coverage for contraceptives will do a lot to change the stigma as well and change the public discourse around what it means to be able to control your own family planning.
Senator Brazeau: Anyone else?
Ms. Walker: We have proposed some amendments to broaden the definition of pharmacare, and I hope the committee will consider that. There is another area in the bill that I would also flag, and that is the area of bulk purchasing.
There is a misconception that governments buy drugs. Pharmacies buy drugs, and then they are reimbursed by governments for those drugs. Bulk purchasing is also predicated on a concept, which is that you have to buy one particular drug in bulk, and that’s what makes us vulnerable to drug shortages. We would recommend the committee think about removing that language in the bill.
The Chair: If I may, I need to ask Ms. Walker a question of clarification since you are suggesting the bill be amended to include pharmacy services. Are pharmacy services, in your view, adequately accommodated for in provincial agreements?
Ms. Paes: I think there is always room for improvement.
The Chair: But they are provided for in provincial agreements?
Ms. Paes: There are services that are available through provincial plans, yes.
The Chair: Thank you.
Senator Seidman: Thank you for allowing me to return to the issue of drug shortages. You mentioned, Ms. Walker, that there is this risk. If you look at the list of medications that the government has proposed — we heard a lot about this yesterday in witness testimony — the list is a lot smaller than a lot of provincial formularies and certainly than that of private providers. Looking specifically at the diabetes medications, I have a chart here that shows the total cost covered by health benefit plans by medication, class and province. If you look down, by province, at the diabetes medications, they give you the total cost of the medication class by province and the percent that is not on the federal list. More than 80% of all the diabetes medications that are covered by each province are not on the current list of coverage for diabetes.
So the current list seems to cover a single version of each of the products selected, which means it is reliant on a single manufacturer, which then increases supply chain problems. I’m putting it out there for you because I think plus 80% of the medications not being covered that are currently covered by the provinces and private providers is alarming.
Ms. Walker: I think the concept of trying to move diabetes patients primarily to this list — same for contraception — is challenging because, as you mentioned, pharmacists will stock what is covered and what people take. When they are making those decisions — and I can’t speak for manufacturers — they’ll make decisions on whether they want to bring product to Canada. If it is not something they feel they will be selling a lot of, then they are not going to be providing that. There are a lot of case examples of drugs for cancer, for example, where there used to be seven or eight manufacturers, now there are two or three. But when one of them goes short, the others can’t keep up and that’s when we cause ourselves a shortage. I think we have to be thoughtful about the kinds of lists we put forward and be mindful that we need a large number of options for patients, and also make sure that manufacturers bring their product to the Canadian market.
Senator Seidman: Thank you.
Senator Moodie: I’m thinking about global security for drug access — supply chains, in other words. I thought we heard from Canada’s Drug Agency, or CDA, in testimony, but I have certainly had conversations with them and I have heard that as part of drug purchasing, the expectation that they would create a stable protected drug supply will be part of their responsibility.
I also think I have heard somewhere along the line on these travels that as well as creating agreements with pharmaceutical companies to provide drugs, there are ways that other jurisdictions have placed financial responsibility on these companies and as part of these deals, for lack of availability of their drugs — a serious disincentive for them, therefore, to interrupt supply — it very much transfers the responsibility on to them if there is an interrupted supply.
I’m wondering how in a new world, perhaps, where this might be the way we, as a country, and as other countries have gone might consider the development of this kind of agency moving in this direction. What are your thoughts about this? It would certainly take the responsibility away from the pharmacy that feels the responsibility to protect access to drugs.
Ms. Walker: We are incredibly supportive of any action that will help protect Canada’s drug supply. There are many issues, and I know we don’t have a lot of time to talk about that. I’m happy to come back on this issue.
Each drug shortage in Canada has a different cause. Some are caused by high demand, some because there is an issue in a plant that had to close down for a period and it doesn’t provide it. But Canada is also 2% of the global market, which presents its own challenges.
If I think back to some of the COVID vaccines that we were able to get at sort of the front of the line, we paid for that access. It is important when thinking about this that it is not just one lever that we need to pull but to think about where we want to be as a country in terms of access. Are we trying to provide broad access or fairly limited access for Canadians? I think what we have heard from Canadians is they want to know they have broad access to medications that will work for them, and we want to be financially responsible for that, but they are sometimes trade-offs on how you think about access.
Senator Osler: May I read my question into the record? It’s for CPA to request a written response, and then cede the rest of my time to the sponsor of the bill, Senator Pate.
The Chair: Sure.
Senator Osler: You suggested an amendment to broaden the definition of pharmacare to include pharmacy services. Could that change in definition be a step towards harmonizing national pharmacare across provinces and territories? If the definition is not changed, what could be a possible consequence? Could I have a written response, please?
Senator Pate: Thank you very much, Senator Osler. Mine is a follow-up to Senator Moodie’s question. In New Zealand, where bulk purchasing is an issue, one of the things they have been able to negotiate contracts where the manufacturers are responsible for security of supply, including by requiring manufacturers to pay costs associated with sourcing alternative suppliers if they run out of stock. Why wouldn’t that be an option that’s available in Canada? If we don’t have time, could you provide a written response?
The Chair: We don’t have time. Colleagues, I remind you that the next panel has pharmacy experts on it, so you can put some of those questions to them again.
To our witnesses, thank you very much. You have really helped us a great deal in understanding your perspectives. Thank you.
For our next panel, we welcome the following witnesses joining us in person: from the Neighbourhood Pharmacy Association of Canada, Dr. Shelita Dattani, Senior Vice President, Pharmacy Affairs and Stakeholder Relations, and Marie-Claude Vézina, Board Chair; from Association québécoise des pharmaciens propriétaires, Benoit Morin, President, and Jean Bourcier, Vice President and Chief Executive Officer. Joining us by video conference from the Canadian Association for Pharmacy Distribution Management, Angelique Berg, President and Chief Executive Officer. Thank you for joining us today. We will begin with opening remarks from Dr. Dattani followed by Mr. Morin and Ms. Berg. You will each have five minutes for your opening statements. Dr. Dattani, let’s start with you.
Shelita Dattani, Senior Vice President, Pharmacy Affairs and Stakeholder Relations, Neighbourhood Pharmacy Association of Canada: Thank you very much. Good afternoon, senators. My name is Shelita Dattani. I am a practising pharmacist here in Ottawa, and I am very passionate about the role that pharmacy teams play across the country. I am also the Senior Vice President of Pharmacy Affairs and Strategic Engagement at the Neighbourhood Pharmacy Association of Canada.
We represent Canada’s pharmacies, from the independent community pharmacy like the one my dad owned here in Ottawa for 31 years to all the diverse models of pharmacies. We care for Canadians through over 12,000 pharmacies in urban, suburban, rural, remote and First Nations communities. Thank you for having me here today to speak on behalf of our members across the country.
Neighbourhood Pharmacy strongly believes that all Canadians must have access to the medications that they need when they need them. As someone who has worked behind the pharmacy counter, I have seen first-hand the struggles of my patients without drug coverage, as we talked about previously, whether patients who don’t know if their child’s insulin is fully covered by their plan or the young woman who doesn’t have any coverage for her contraception, as we discussed during the last session.
Helping patients access and navigate their drug coverage every day gives us the insights on what works, what doesn’t work and where the gaps are. It also means we can help support you as policy-makers to achieve what we believe is our common goal.
The vast majority of Canadians already have some access to some form of medication coverage through their provincial drug programs, employee benefit programs or other private programs, and most of them are happy with it.
The government’s top priority should be extending medications to the small percentage of Canadians who don’t have it while also ensuring that we don’t disrupt the coverage that a majority of Canadians already enjoy today.
As pharmacy owners and operators, we have seen the disruption that can be caused to patient access when government programs are set up to replace coverage that already exists.
For example, in 2018, the OHIP+ program in Ontario sought to provide comprehensive medication coverage to Ontarians under the age of 25 whether they had existing coverage or not based on the Ontario provincial drug formulary. This was well-intentioned to ensure no youth was left behind, but in reality, the government paid millions more than needed for medications Ontarians were already accessing. Many of these young adults faced a disruption when their coverage changed or the medication — maybe the antidepressant they were stabilized on was not now covered by the provincial formulary. So many of us, again, as we have discussed, spend a lot of time trying to help these patients navigate the system and deal with the emotional and mental frustration over examples like this.
I think about one of my colleague’s patients, a child with cancer who was receiving chemotherapy that was covered by their parents’ plan. When the switch happened in Ontario, the chemotherapy drugs were not automatically covered by OHIP+ under the formulary, and their private plan withdrew coverage as soon as OHIP+ came into effect. The child did end up qualifying for OHIP coverage through an Exceptional Access Program in Ontario, but the doctor had to fill out an application and paperwork. This process took eight weeks during which time the child was unable to receive their drugs. Imagine the emotional toll this took on the family.
As this committee considers Bill C-64, it is essential that patients like this are not placed at risk of having to change programs or medications because of a national policy.
As pharmacists, business owners and Canadians, we also understand our responsibility to be fiscally pragmatic. A program that replaces all existing coverage for contraceptives and diabetes medications could cost, by our analyses, nearly $900 million per year, yet providing coverage for only those uninsured would achieve the same objective at a third of that cost. Working collaboratively with each province and territory to equitably build up their existing programs, public and private, and fill gaps in coverage would allow taxpayer dollars to be targeted where they are so desperately needed across health care right now.
While our patients’ access to care will always be our top priority, we can’t overlook the impact these types of programs can have on pharmacies and the services that we provide. Pharmacies pay for their rent, their staff and their inventory, primarily through dispensing fees and markups. These fees, which is how we are funded, are reduced in publicly funded programs and will be in single-payer pharmacare. As pharmacy operating funds decrease, so does our ability to stay open to serve the communities that we need to, and an unintended consequence of single-payer pharmacare could very well be a reduction in pharmacy services and medication access.
As we have heard from other colleagues, Canadians are relying on pharmacies more than ever now to access medication, to access vaccination-related needs and services. So we need to ensure that we’re building a pharmacare program that increases access to health care, not reduces it. We’re calling on the Senate and all parliamentarians to ensure that through this legislation, it is made clear that any national pharmacare program must prioritize Canadians who do not have coverage and those with insufficient coverage. No existing plan should be displaced or disrupted as part of national pharmacare.
Work hand in hand with provincial and territorial governments to build on their existing plans. In our own engagement with provincial governments, we know that governments know their residents and their needs. Their input is essential for a national program to be a success.
And, finally, partner with medication experts and pharmacy operators like us. Bring us into the implementable solutions that can ensure that all Canadians have access to the medications they need when they need them.
We do commend the federal government for their work thus far, but we feel we must get this program right. Canadians are counting on us. Thank you very much for the invitation.
The Chair: Thank you very much. Mr. Morin.
Benoit Morin, President, Association québécoise des pharmaciens propriétaires: Thank you, Madam Chair.
[Translation]
Honourable senators, thank you for inviting me to appear before you, as President of the Association québécoise des pharmaciens propriétaires, as well as my colleague Jean Bourcier, Vice President and Chief Executive Officer. We represent the 2,092 pharmacist-owners of the 1,891 community pharmacies in Quebec, regardless of chain or company.
Quebec has an important distinction: you have to be a pharmacist to own a pharmacy. This ensures that professional independence and ethics take precedence over business decisions, and that patient well-being is at the heart of our priorities.
I would like to begin by saying that our association supports the Government of Canada’s commitment to improving the accessibility and affordability of prescription drugs for all Canadians.
I would also like to remind you that all Quebeckers have had access to universal drug coverage since 1997. At present, out-of-pocket expenses are established on an equitable basis among insured individuals, even at $0 for some, regardless of their health condition.
Implementing a no-cost approach for the two targeted conditions would only create inequity between patients based on their medical condition. We believe that ensuring that deductible and co-insurance levels are set objectively, taking into account the needs of all patients, is a better way to intervene.
Even so, this won’t solve the real problem of drug coverage for patients outside the current Quebec system. A small portion of the population doesn’t take advantage of their insurance plan, even though it is mandatory. The real problem of access is one of public health. Mental health issues, lack of understanding or education, or fears about taking medication are real barriers to access for this small segment of the population. A single-payer public plan will not solve the problem.
The best solution would therefore be to address the barriers related to social factors and intervene with targeted public health programs. For example, when it comes to contraceptives, a woman may not want this type of medication to appear on a spouse’s or parent’s insurance record and may choose not to use it, even though her situation requires it. In this context, a targeted, no-cost program may be beneficial. In the case of diabetes, we need to address other factors that explain a patient’s failure to take their medication, such as mental health issues.
It’s also important to ensure that the system, as proposed, does not itself hinder accessibility. Community pharmacies in Quebec are distinguished by their accessibility and front-line care. Pharmacy teams offer a multitude of services that go far beyond dispensing and monitoring medications. The Quebec network of community pharmacies is accessible and well distributed across the province, giving many Quebeckers access to their services. However, the successful deployment of these services is closely linked to the financial health of the pharmacies and, as a result, to their funding. Designing a national single-payer plan in Quebec would jeopardize the pharmacy model at the expense of patients.
Currently, Quebec pharmacies are funded mainly by professional fees for dispensing and monitoring medications. Variations in these fees can influence the ability of pharmacies to develop services for patients. The mixed public-private system allows pharmacies to provide their services in a predictable and stable manner for the plan administrator, the Régie de l’assurance maladie du Québec.
It is precisely this flexibility that allows Quebec pharmacies to grow, to be present in all regions and to offer a multitude of services to patients. Without this flexibility, the financial health of the pharmacy network would be undermined, with even greater repercussions in remote areas.
I’d also like to point out that the Quebec model meets the objectives set by the proposed national plan by promoting accessibility, affordability and optimal use of pharmaceutical products, and by providing universal coverage for all residents.
In conclusion, designing a national single-payer plan in Quebec would be counterproductive. What’s more, it would weaken Quebec’s community pharmacy model, a network firmly rooted in communities and envied by every Canadian province. If we really want to improve access drugs in Quebec, it’s important to look at the real reasons why patients don’t get their drugs.
Thank you, Madam Chair.
[English]
The Chair: Thank you very much, Mr. Morin.
Ms. Berg, please.
Angelique Berg, President and Chief Executive Officer, Canadian Association for Pharmacy Distribution Management: Thank you, Madam Chair and members of the committee. It is a pleasure to participate today.
I am Angelique Berg, President and CEO at CAPDM, the Canadian Association for Pharmacy Distribution Management. CAPDM is the trade association for distributors that handle over 90% of the medicines our country consumes. With their trading partners, distributors form our safe, timely and reliable supply chain that ensures physical access to medications.
So, naturally, we support the aim of Bill C-64. We support both affordability and access to medications for all Canadians, in balance, and not at the expense of one or the other.
We seek and encourage greater clarity with regard to Bill C-64. Many aspects have yet to be articulated and are to be determined after Royal Assent, which presents concerns about the potential risks and the impact to supply chain stakeholders.
I have no doubt many of you are meeting CAPDM for the first time today, so I’ll provide some basics about the supply chain because, similar to how electricity reaches our homes, we rarely think about how our medicines get to us, so long as they do.
The supply chain begins with manufacturers, who sell to distributors, who then sell to pharmacies and hospitals. It is a pull model where prescriber and patient demand drive purchases by pharmacies and hospitals, which drives purchases by distributors for manufacturers. The majority of our supply chain companies are CAPDM members and form the critical infrastructure that equips the health care system and its professionals with medicines for the patients they treat.
Distributors are important pharmacare stakeholders, streamlining orders and deliveries for 15,000 products between hundreds of manufacturers and over 12,000 points of dispensing. This consolidation is estimated to deliver savings to the country of over $1 billion annually. Their safety stock also provides a short-term shortage buffer against drug shortages.
Distributors employ over 46,000 people, and our industry’s over 30 distribution centres must comply with at least three overarching acts, up to seven different Health Canada licences and use advanced technology to meet these requirements.
Pharmaceuticals themselves are sensitive products. They cannot be kept in just any warehouse or put on any truck like an Amazon package. The handling of medicines is extremely complex, highly regulated — as it should be — requiring temperature-controlled storage and packaging for the safety of Canadians. These do not store or move cheaply.
Drug distribution is an expensive undertaking in our vast country. Our market is not only physically challenging due to our geography, temperature swings and climate events and lack of paved roads in rural areas, but it is also a controlled market, where funding is limited, yet operating and regulatory costs are uncontrolled and move with the market.
Distribution is largely funded — rather than on the cost of the service provided or the distance travelled — as a factor of the listed drug prices, which are regulated and out of our control. As an example, in 2007, the first generic pricing agreement reduced funding to the distribution sector by $50 million. The lower the price, the less available to get medications to Canadians, especially to rural regions.
On the cost side, in the last five to ten years, costs have increased at least 2.5 times faster than volumes, with market forces such as rising fuel and labour costs.
Increased regulation also drives costs. Health Canada’s regulations on temperature control alone cost the sector over $20 million annually.
The result is a very low margin business to the tune of a funding gap of $100 million annually. Distributors have been able to absorb the reduced costs with only minimal impact to Canadians, to date. As written, the potential consequences could erode the supply chain’s infrastructure, which is already precarious, resulting in contracted physical access and exacerbated drug shortages.
Distributors have run so leanly and efficiently that they have driven all of the additional areas out of their services, and the unenviable choices, should costs continue to fall, are as follows: to stop carrying the growing number of money-losing products, including many long-standing medicines for chronic conditions, such as lipid-lowering drugs and cardiovascular protection agents; further reduce the expense of safety stock, significantly reducing the ability to prevent or mitigate drug shortages; or reduce overall service frequency and speed to remote and rural regions, which are the highest cost to serve.
Secondly, a restrictive national formulary and bulk purchasing agreement could disrupt Canada’s drug supply, as we heard from my colleagues. This can already be seen with the proposed national pharmacare list of diabetes drugs, which only includes half of the drugs on the market today. Affected Canadians would be forced to switch from their current therapy to something on the list, which has a domino effect on the supply chain. As distributors’ buffer stock is depleted and manufacturers of drugs not listed on the list leave the market, over time, the drug supply will be more vulnerable to shortages.
The same applies to how bulk purchasing, whatever that will mean, will be pursued, particularly if it results in restrictive formularies in Canada relying on fewer suppliers.
The Chair: We have to stop there. I am sure you will get lots of questions put to you. Colleagues, we go to questions, four minutes each.
Senator Seidman: Thank you very much for being with us today and giving us your testimony, helping us understand what is obviously an important piece of legislation.
All of you have expressed certain cautionary tales about what the unintended consequences could be from this piece of legislation. I am particularly interested in rural and remote areas because neighbourhood pharmacies — smaller pharmacies as opposed to large chain pharmacies, and you both very much focused on small community pharmacies — what are the particular risks, and how could we mitigate them, given we’re sitting here with a piece of legislation and a lot of pressure to get it passed, especially without amendments? So let’s hear what you have to say.
Ms. Dattani: Thank you very much for the question.
I want to emphasize again that we represent pharmacies of all delivery models, as I alluded to in my remarks. I often think of the small pharmacy my dad had in a rural community, and I often think of my colleagues in Nova Scotia or northern Ontario where their pharmacy may be their key access point and function almost as an emergency department.
Drawing the connection, as I expressed before, between how pharmacy is generally funded in this country through dispensing fees and markups to operate and how public plans could impact that if we go to a single-payer model makes it more difficult, especially for those small pharmacies in those rural communities to stay open. If you need somebody — your child is sick and you need to go on a Friday night or Sunday morning — and that pharmacy just can’t afford to stay open, they can’t keep their lights on and can’t pay their wages, that is the real impact. We have to draw that connection between health policy and rural pharmacy.
Senator Seidman: Thank you.
[Translation]
Mr. Morin: Thank you. In Quebec, we represent small village pharmacies. We represent all pharmacies. I’m a pharmacist-owner in the Montreal area. I have a number of colleagues in the regions and they often have the main front-line access.
In Quebec, a parliamentary committee was held two days ago on Bill 67, which plans to expand the role of front-line pharmacies. This role will be a major one, meaning that pharmacists will be able to prescribe medication for several common conditions. Village pharmacies will become extremely important to their communities — they will probably become one of the only access points to medical care. The financial health of these pharmacies is important. We have to invest in pharmacies, not the other way around, if we want them to play an increasingly important role, because they are resources. There’s a shortage of pharmacy workers, too, so resources are more expensive.
The adverse effect of the bill would be to destabilize the financial health of pharmacies. That’s one of the issues that’s been raised; you need stability and you need to be able to forecast revenue to be able to invest, organize and recreate a way of working. We’re not just going to be asked to distribute drugs and monitor them, but also to be front-line workers.
[English]
Senator Seidman: Ms. Berg, I will go back to you about the drug shortage issue. You have talked about the supply chain. I would like to know something, to continue a long line of questioning that some of my colleagues had earlier today. Say we pass this legislation. What particular guardrails or aspects should we guard against in looking at provincial-federal negotiations to try to maximize and not run into supply chain problems?
The Chair: Hold on to the answer to that question. Hopefully, we can get back to it in the second round.
Senator Osler: Thank you, witnesses, for being here today. I’m going to direct my question first to the Neighbourhood Pharmacy Association of Canada and then perhaps l’Association québécoise des pharmaciens propriétaires and the CAPDM, if there is time.
For the Neighbourhood Pharmacy Association of Canada, if you were in the room, you heard my questions to the last panel. They were on program administration. I see in your written brief that one question for consideration that you have suggested to this committee is: How will the program outlined in Bill C-64 be administered? You mentioned that various federal programs have different practices in place. For example, the federal dental benefit is administered by a third-party provider and childcare agreements are administered differently. Your association has offered support and advice.
My question for all the organizations is this: What advice would you provide regarding a national pharmacare program as outlined in Bill C-64?
Ms. Dattani: Thank you for the question.
First and foremost, there is a lot to learn, as we said in the brief as well, from a lot of discussion with the provinces to understand what their own challenges are, to help and support and build up their programs. I think how to implement and adjudicate is something that pharmacists themselves — and pharmacy owners and operators — very much understand; they understand the challenges and gaps.
There are a number of different options, as we outlined. Going through them, understanding what the provincial challenges are and how the federal government can best work with each province to help customize and enter into discussion to help build up those programs and fill some of those gaps are parts of that implementation. Including organizations like ours and individuals like our pharmacists, pharmacy owners and operators on the committee of experts to start diving into implementation and solutions is very worthwhile and an important dialogue that will continue after Royal Assent. We would very much like to be part of that.
Senator Osler: Perhaps I should clarify my question a little bit: Do you imagine a national pharmacare program administered through each existing province’s public pharmacare program, administered by the federal government or a third-party provider?
Ms. Dattani: The provinces know how to administer their programs. Again, they know their patients and their needs. So building on what already works well — other colleagues spoke about thinking about where we are with formularies and ensuring they are robust enough to be able to meet the needs of people in their jurisdictions and not create challenges in resilience and drug supply. Those are some of the things that I would think about.
[Translation]
Mr. Morin: Thank you for the question. I think the program should be as simple as possible, and yes, through RAMQ, the provincial program would be a good solution. The solution must be computerized, simple to administer online with real-time payments. I think the Régie de l’assurance maladie du Québec is an excellent model. If we could go through that, it would be a plus.
Senator Osler: Thank you.
Jean Bourcier, Vice President and Chief Executive Officer, Association québécoise des pharmaciens propriétaires: What we also have to avoid is a model that imposes an administrative burden on pharmacists, on people on the ground. This will allow them to take care of clinical tasks and prevent them from spending too much time administering the program, because it’s a complex one. We have to bear in mind that there’s a shortage of health care professionals. We need to optimize the use of health care professionals in tasks that are clinical, with tasks related to patients and not related to a program.
The Association québécoise des pharmaciens propriétaires and Quebec has 27 years of experience with a universal program, and we can help manage these programs.
[English]
The Chair: Thank you. We won’t get back to Ms. Berg for an answer to your question. Hopefully, we will get to it at some point.
Senator Pate: Thank you for appearing. My question is for the Association québécoise des pharmaciens propriétaires as well.
In June, you published a news release discussing legal action you have launched to address practices of patient steering occurring in Quebec, which you described as akin to patients being held hostage. There are three things. Could you please describe what “patient steering” is and how it prevents patients from accessing medicines? Also, please clarify how the steering of patients happens and who orchestrates the steering.
Those targeted by your legal action include three patient support providers financed by drug companies, according to the news release — so more information about that — and what role they play would be helpful.
Also, do you see preferred patient network agreements between some pharmacies and private insurance companies about where patients can access medicines as raising similar concerns?
[Translation]
Mr. Morin: Thank you for the question. It’s difficult to answer in a short space of time.
Patients are directed to a system where they are subject to being controlled. A third party forces them to go to a particular pharmacy, which isn’t their pharmacy, with a pharmacist they don’t know. The file is being split, because a third party will intervene based on the doctor’s prescription for a product sold by a manufacturer who participates in a patient support program. They determine which pharmacy the patient will go to. This is illegal in Quebec.
All over the world, this is an unfair way of doing things. It should be the patient’s health care professional who decides. A third party should never intervene with the patient’s choice. Unfortunately, this happens. There’s an attempt to implement this Canadian way of doing things in Quebec. For us, this is a major issue and unthinkable. It is not a viable long-term system. It can’t be assumed that we’ll play the role you want us to play on the front line of chronic diseases and treatment, and expect patients to deal with three or four different pharmacies. I could tell a patient to stop treatment temporarily because he has an infection, but the patient support program or the other pharmacist will call him and insist that he take his product, because he’s managing only the product. This makes no sense in patient management.
[English]
Senator Moodie: This question is for the pharmacy representatives here today. We have been hearing testimony in the last few days about the very tragic and difficult reality of patients, women who cannot afford their medicines or their reproductive devices; of the best outcomes being driven by upstream delivery and access to critical medicines that sometimes prevent critical and life-threatening complications such as blindness, renal failure, loss of limb, unwanted pregnancies and all that that carries, not to mention the economic burden, the burden of illness on the health care system in our country, on all of us; of the failure to support patients to have adequate access to medicines. We have been hearing about that, including about the complicated private plans that individuals are forced to navigate and may get a yay or nay for their particular drug.
Putting aside the need for protecting the financial well-being of pharmacies, would a national pharmacare plan in fact provide the drugs for individuals who currently are not covered, who present themselves — free of costs — get their drug, with no co-pays — would this not improve the burden on patients, improve access and improve outcomes?
Ms. Dattani: I’m happy to take that on first. I 100% agree with you, Senator Moodie. As a woman, as a health care provider, I think women have the right to good reproductive health. This is a public health issue, 100% agree. Where I am is the road to get there. So we know, as we described in our testimony, that the vast majority of Canadians do have some sort of coverage for — drug coverage in general. There are many other patient groups and populations as was alluded to also in the last session that have challenges and are part of that uninsured group. So we think that focusing time, money and energy on leaving no one behind because of financial barriers and getting everyone covered who doesn’t have insurance is an excellent use of government dollars and health care resources.
[Translation]
Senator Cormier: Welcome to the witnesses.
My question is for all of you. When the minister appeared before us, he said that people would have the choice of using the public plan or the private plan. If the bill passes and someone goes to a pharmacy to get diabetes medication, will they be able to use their private insurance for it? If so, will private insurance be required to cover the cost from the first dollar? If private insurance doesn’t cover the medication, will the patient be able to use their provincial plan? Do you have any answers to these questions? Is there any flexibility? Does private insurance have to cover costs from the first dollar?
Mr. Morin: My understanding of the bill is that as long as a product is covered by the federal public plan, it’s covered by the federal public plan from the first dollar. It isn’t submitted to the private insurer. If the patient’s product isn’t included in the list of drugs covered by this plan, then it’s covered by the provincial plan, either public or private. For the same file, we will manage two different programs, one with no cost and the other with a co-payment or co-insurance deductible, which may also be zero in the case of the Quebec government for Quebec patients. So we’ll be managing two programs. That’s my understanding of things.
[English]
Ms. Dattani: I would agree with my colleague from Quebec. I think there are deeper risks beyond that, potentially, as we understand and unravel some of the potential ambiguity. There is risk that plan sponsors, such as employers, may end up dropping some of that coverage, dropping the plan. This was alluded to in the earlier session as well. The next layer of that onion is that there may be less product generally available in Canada or fewer therapeutic choices. We know that drug therapy is complex, that we need to meet the needs of Canadians with robust drug choices out there. The real risk of having less resilience in our drug supply would be there as well.
The Chair: Can I ask you if your industry was consulted on this legislation?
Ms. Dattani: If our sector was consulted on the legislation?
The Chair: Yes.
Ms. Dattani: Yes, absolutely.
The Chair: And you put forward your concerns and recommendations? Okay. Thank you.
Senator Burey: Thank you so much for your expert testimony. I wanted to speak with Ms. Berg. Thank you for explaining the manufacturing distribution, pharmacy, hospital and the work that you do. In one of our other sessions, we heard that there is bulk buying for public plans across Canada. Just to make sure that that is correct — so what did you learn from that that would help in this situation? You obviously have experience from the bulk buying part of the question, which is now existing in Canada for public plans.
Then to Dr. Dattani regarding the agreements made. I’m from Ontario, so I know about OHIP+, but I understand that in the agreements made in the Ontario pharmacare plan, there was a way — with the savings made from the bulk buying and from the coverage — that supported pharmacies. Could you comment on whether or not that is a system that could probably, if I’m right about this, be something that would go forward? That is the way I understand conceptualizing how you are going to support both the distribution and the work of the pharmacies, that is, with the savings you are going to support a secure system in Canada.
Ms. Dattani: I will maybe ask for more clarity on a way to support the pharmacists. I’m not entirely sure —
The Chair: Senator Burey, is the question not to Ms. Berg?
Senator Burey: Yes, the first question is to Ms. Berg. Go ahead about the bulk buying and whether or not we already don’t have infrastructure and whether what you learned from that could assist in what we are doing now.
Ms. Berg: We do. And we appreciate the focus on pharmacy and the nuances of therapeutic implications at a clinical level as well. Bulk purchasing is done by the supply chain actors, so the people who actually touch the product. That is from the pharmacies as was mentioned, from distributors to manufacturers. It also happens on a hospital level by group purchasing organizations. The unintended consequences of bulk buying is that it puts the concentration of drugs into one area, and the contracts naturally give more control and robustness to the —
Senator Burey: With the time, I wanted to know if there was anything you learned from that system that exists now that could inform the work going forward.
Ms. Berg: Yes, absolutely. Bulk purchasing has the risk to reduce the number of manufacturers operating in Canada and to reduce the supply available to Canadians.
Senator Burey: Back to my question about OHIP+ and some form of agreement being made with the government and pharmacists to offset some of the losses from the pharmacy. Can you comment on that?
Ms. Dattani: If there was any sort of delay, would any of the savings be funnelled back to support the pharmacy? Is that what you are asking?
Senator Burey: I’m asking if this does exist and if this wouldn’t be the way to support pharmacists in this universal system?
Ms. Dattani: Absolutely. I think it would.
The Chair: Wonders do not cease. We have time for a second round.
Senator Seidman: Ms. Berg, if I might go back to you with my question that I tried to ask at the end of my four minutes. In fact, you just said that bulk purchasing has some unintended consequence of ultimately reducing supply to Canadians. You also spoke about supply chains and the fact that this formulary list or this list of medications that Health Canada has provided with the legislation, specifically say for diabetic medications, reduces down to pretty much single manufacturers. I would like you to help us understand the risks here and if there is some way to mitigate them.
Ms. Berg: Competition is good, so the more competition we have, the better the choice for patients and the more drugs on the market.
What I’m very concerned about is that we are not talking about the infrastructure that supports it and the way that distribution is funded. Distributors get the drugs to the health care professionals who treat the patients in Canada. We don’t think about that infrastructure, but I can’t emphasize enough how critical it is. These are the people who equip the health care system and the people within it with the drugs that are needed.
What we would like to call on is for this committee to carefully consider Bill C-64 and introduce an amendment to the legislation that includes the principle that clearly addresses physical access of pharmaceutical products to Canadians.
Right now, the distribution is funded based on the price of the drug and controlled by provincial markups. A drug for funding for distribution is the same whether it is being delivered to downtown Ottawa or to Fort St. John, B.C., or to Nunavut. It doesn’t matter. It’s the same cost, and that’s unsustainable. That is how precariously the supply chain is operating now. Inasmuch as we would like to be able to say we can do anything, we are at a precipice. There is nothing more to give.
Senator Seidman: Thank you.
Senator Osler: I have been asking questions on how and who will administer national pharmacare. This question was asked at the last panel and prompted in part by the brief from the Neighbourhood Pharmacy Association of Canada. Based on your organization’s experience, can you provide this committee with any advice on how and who should administer a national pharmacare program?
Ms. Berg: Thank you for the question. In terms of coordination nationally, it would be terrific to have an overarching coordinating body. Right now, all the negotiations and regulations on distributors are at the provincial level, and that model has remained the same for the last 15 years without any increases. Likewise, generic medicines were reduced in 2007, and there’s no increase there. The distribution right now is hurting. It is precarious. We would suggest that we look at a model whereby the cost of the service delivered is considered and protected so that the supply chain can remain robust and continue to support the health care system.
Senator Pate: My question is, again, for the Association québécoise des pharmaciens propriétaires.
Nine Quebec civil society and labour groups representing over 1 million Québécois — so more than one in four households in Quebec — have vocally opposed the idea of Quebec opting out of national pharmacare while keeping federal funding, pointing to concerns about its current public-private plan. The concerns include that one, in Quebec and across Canada, girls and women with access to drug plans belonging to parents or abusive partners cannot access medicine, particularly contraceptive medications; two, in the absence of drug price controls associated with a single-payer system, drug prices are climbing and pushing employer plans to the brink — none of our systems are ready to respond to the pricing challenges posed by new ultra-high-cost medicines. Working toward a single-payer system could though — and three, drug prices are currently higher in Quebec than the Canadian average as a result of the mixed public-private system. They have the second-highest prices in the world after the U.S., and too many cannot afford medication.
Given these shared challenges we face, do you agree there is merit to work together to address these issues rather than just reject them out of hand?
[Translation]
Mr. Morin: Absolutely. In the brief, we talk about the situation of young women and women who must have access to contraceptives in complete privacy and without leaving a record — safely, let’s put it that way.
As for the higher prices in Quebec or elsewhere, it’s also important to take into account rebates paid to the government or third parties to establish the real price of drugs. There’s a mechanism where prices are negotiated, and this negotiation increases the base price, but in fact third parties pay less. So there’s a whole part that we don’t see, that we don’t know about, which is interesting to look at.
Our claim is that the public-private plan improves access to medication. Private coverage often has a broader form under certain conditions and compared to the choice of the group that wants to invest in its insurance and where there will be broader coverage.
There’s no doubt that we need to address the evolution of drug costs, whether there’s a single payer or several payers. Pricing is important, and it puts the plan at risk. Putting too much pressure on prices puts another part of the plan at risk, because providers are disappearing, and we have to spend a lot of time, as health care professionals, changing the patient’s treatment rather than dealing with their real problems. We’re prepared to discuss these issues because they’re important.
[English]
Senator Pate: If anybody else would like to comment, I’m happy to have their comments.
Ms. Dattani: I think I agree with our colleagues in Quebec and also the colleagues in the previous session. Investing in the opportunities where pharmacies and pharmacy teams can ensure that the outcomes of those medications are toward cost avoidance and other areas of the health care system. The care regarding optimal outcomes and medication use is just as important as access to the medications and should be factored into the dialogue.
Ms. Berg: We believe that collaboration is absolutely essential. We do support Bill C-64 with an amendment to protect the infrastructure. The collaboration is especially important in the servicing of rural areas. It is the most costly area to service in Canada. It is the most vulnerable because these are businesses and they are going to have to make some unsavoury decisions. Collaboration with the supply chain actors, those people who touch the product, is essential, and we would be most pleased to work with government on this.
The Chair: Thank you, colleagues. I believe our time has come to an end.
Colleagues, please remember that next week is a marathon. We will meet and continue our study of Bill C-64 next Wednesday. We will have two committee meetings, one from 12:00 to 1:30 p.m. in room W110, and then at our usual time slot at 4:15 p.m. in this room.
Thank you to all our witnesses here and online for answering our questions. Your testimony is extremely valuable to us.
Colleagues, there being no further business, this meeting is adjourned.
(The committee adjourned.)