Pharmacare is gradually gaining attention as an election issue. There is, however, little clarity regarding what, precisely, is meant by "pharmacare"
Would it be administered directly by Ottawa? Funded by the federal government but administered by the provinces? Would there be premiums? Would the premiums be the same in all provinces? Even the Conservative party, usually gun-shy over any mention of health care, is willing to commit to a “pharmacare” plan if it simply means a federal presence at the table when governments are collectively negotiating the cost of pharmaceuticals.
Promising more affordable drugs to Canadians is a useful electoral stratagem for any political party. Yet if the collaborative bulk purchasing of pharmaceuticals is all any of the parties has in mind, they are either discouragingly obtuse or willfully disingenuous regarding what Ottawa could and should take responsibility for when it comes to pharmaceuticals. The current administration has been notably successful in expounding the position (echoed by the provinces themselves for quite some time) that “health care belongs to the provinces, after all.” And, while there is much room for debate on that point, it is inescapably clear that Ottawa has full jurisdiction over the regulation of pharmaceuticals. Given that drugs are such a huge component of modern health care, it is undeniable that Ottawa has a key role to play. It is remarkable that there is no mention of a national pharmaceutical strategy in this election campaign. While certain elements of the National Pharmaceutical Strategy introduced in the 2004 10-Year Plan to Strengthen Health Care are somewhat outdated, the idea of having a national pharmaceutical strategy that goes beyond bulk purchasing is certainly more relevant now than ever.
There are three aspects to a contemporary pharmaceutical strategy that go beyond bulk purchasing, and they are all firmly within Ottawa’s bailiwick.
The first is the determination of drug prices. Canada, like most countries, regulates the price of pharmaceuticals. This is why they cost less in Canada than in the US. But the system we use to regulate prices is hoary and inadequate, and that is why we have higher drug prices than almost every other country except for the US. Currently, the Patented Medicines Prices Review Board bases its pricing of drugs upon a basket of seven comparator countries (including many high-price states such as the Switzerland and the US). This is a simple and inexpensive way of determining prices, which is why it is used in many developing states. Canada can and ought to do better.
A much more sophisticated and effective method of evaluating drugs is to link the price you pay with the real-life effectiveness of the drug. For many reasons, the treatment effect claimed by drug makers is overstated in RCT results; it is not uncommon for the effectiveness of drugs to be quite disappointing in practice. So, rather than paying per unit for unproven services, a more rigorous payment system would reward outcomes including not only treatment effectiveness, but also patient experience and safety. This is known as cost-effectiveness pricing (CEP), which puts the onus for producing outcomes on the drug makers. One can also build a pricing system on the principle of value-based design, which in addition to the outcomes noted above also incorporates less clinical variables such as socioeconomic impact. There is good evidence that such pricing systems are much more efficient in getting good value for money. But such approaches also require a solid evidence base from which to make these decisions, and Canada simply does not have the technical capacity to do so.
But it could. And the development of a strong Health Technology Assessment (HTA) capacity could be the second component of a modern pharmaceutical strategy. Despite the notable presence of small but impressive units such as CNODES or UBC’s Therapeutics Initiative, there is no permanent and well-funded HTA agency (like the UK’s NICE, Germany’s IQWiG, France’s HAS, or Sweden’s TLV) that could provide the data necessary to make effective costing decisions on pharmaceuticals. Even the little federal state of Belgium has the KCE, its own HTA agency. But Canada does not. And, while some provinces have small HTA units, there is no coordination between those that do, which means expensive research can be unwittingly duplicated.
The third element of a national pharmaceutical strategy would involve the issue of safety. It is curious that access to drugs plays such a focal role in this election campaign, but the safety of the drugs to which people have access does not. In November 2014, Bill C-17, also known as Vanessa’s Law, was given royal assent. This legislation was a major step forward. But Vanessa’s Law still requires a armature of regulation that will permit the intent of the law to be effectively executed. This regulatory framework should promote greater transparency both from drug manufacturers, who can withhold clinical trial data from public scrutiny, and from Health Canada, which should be required to publish the reasons it did not approve particular drugs for certain indications (so that such drugs will not be used off-label for these indications). The new regulatory framework should also ensure that drugs already on the market are subject to appropriate surveillance regarding the development of any adverse events.
Given the utter lack of any coordinated pharmaceutical policy in this country, collaborative bulk buying is indeed a step forward. But we could do much better. Rather than applauding political parties for taking such timid baby steps, we should be demanding to know why they’re not doing more.