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What Should We Pay for Drugs?

Critics say BC's new pharma panel, stacked with drug firm reps, may erode safety, raise costs.

By Andrew MacLeod 12 Dec 2007 | TheTyee.ca

Andrew MacLeod is The Tyee's legislative bureau chief in Victoria.

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Alan Cassels: Pharma watchdog.

Health Minister George Abbott's November appointment of a new pharmaceutical task force stacked with people connected to the industry is taking fire from critics.

Former MP and head of the Federation of Retired Union Members, Joy Langan, calls it "shocking and unbelievable." NDP health critic Adrian Dix says the panel's composition is "extraordinary and bizarre." Health researcher and writer Alan Cassels says, "People in my world are sort of bewildered by the whole task force."

Five of the nine people on the panel have clear connections to the pharmaceutical industry, including Russell Williams, the Ottawa-based head of the drug industry lobby group Canada's Research-Based Pharmaceutical Companies (Rx&D).

Before Abbott appointed Williams to the panel, he was already registered as an active lobbyist.

Williams' entry in the province's lobbyist registry fails to provide the details of when he was lobbying or with whom he's been talking, something an Information and Privacy Commissioner's office representative says they'll be contacting him about this week. The subjects, however, include national pharmaceutical policy, drug safety and effectiveness, and drug access and pricing. All are topics Abbott's new task force is supposed to address as well.

So, just what does Williams want to tell British Columbians about our drug policies? A media handler in his Ottawa office took the question and said he would try to set up an interview for Dec. 10, but in the end Williams wasn't available.

BC example watched nationally

Critics of Abbott's new panel say nobody is likely to represent the interests of patients or the public. NDP health care critic Adrian Dix was among those advocating having someone like Alan Cassels added to the panel.

Cassels, who is a drug policy researcher affiliated with the School of Health Information Sciences at the University of Victoria and is critical of the panel's pro-drug firm slant, considers Williams in particular an odd choice. "He represents the association that sued the government twice and lost over reference pricing," he says. "These are known foes of the government."

B.C. has been doing some things right to contain the amount the province spends on drugs, Cassels says. But every dollar the government saves is one the drug industry doesn't pocket. With talk of setting up a national drug plan growing, he says, industry players may want to quash the B.C. example.

The province's press release identified areas the panel would look at including the Common Drug Review, the Therapeutic Initiative and how it is decided which drugs PharmaCare covers. All are areas the industry doesn't like, Cassels says, and would not want to see replicated or strengthened in a national plan.

Since Cassels won't be on the panel, The Tyee asked him to walk us through those areas and give his perspective on why the industry might want to get rid of them.

Common Drug Review

The Common Drug Review is a federal group founded in recent years to provide advice to the provinces on which new drugs their public plans should cover. "They determine how does the drug fit among all the other drugs that are out there," says Cassels. "The Common Drug Review is probably enemy number one. It's questioning the value of their products."

If a new drug does the same thing as an older drug, but it's twice as expensive, the review would tell provinces paying for it that it is not a good use of public dollars. "That just drives the pharmaceutical companies fricking nuts. They just hate it."

Less than 10 per cent of new drugs represent medical breakthroughs, he says, so the vast majority of new products should not and do not gain endorsement during the review process. The beautiful thing about it, he says, is the decisions, based on "the rules of evidence," are made at a distance from the politicians and the lobbyists.

The review has given several drugs the thumbs down. "I would say they're one of the best things to ensure we're getting value out of our drug budgets."

As it happens, B.C. was a strong proponent for setting up the Common Drug Review. "Why are they bringing up a task force to question the very existence of it? It strikes me as bizarre," Cassels says.

Therapeutics Initiative

The Therapeutics Initiative, based at the University of British Columbia, has a similar mandate to the Common Drug Review. "The Therapeutics Initiative looks at the evidence," says Cassels who does not currently work for the initiative, but has in the past. "They do extensive reviews of the evidence on new drugs then make recommendations to the government and physicians. . . . They don't make policy decisions. They offer opinions about the quality of the evidence."

Those opinions carry weight with the people who make the decisions on what gets covered, he says. "The government does rely heavily on the Therapeutics Initiative because they are the body of expertise."

The agency has had a number of successes at raising early alarms, says Cassels.

The best example is Vioxx, an arthritis drug that Merck & Co. pulled from the market after it became apparent it increased the risk of heart attacks and strokes. While the drug was prescribed widely, it was used less often in B.C. than anywhere else in Canada.

"The warnings really came from the Therapeutics Initiative," says Cassels. The initiative warned there were many unknowns about the drug and there was a large potential for adverse affects. "Nobody else in the country was doing this. We prevented a lot of unnecessary deaths." He estimates at least 600 deaths were avoided in B.C. thanks to the initiative's caution on Vioxx.

The recommendation on Vioxx also saved the government about $500 million, says Cassels. That's good news if you are responsible for controlling public spending, but not so good if you are in the business of selling drugs. "Those are lost profits to companies. They will do whatever they can to stop that from happening."

No wonder, says Cassels, Abbott's new corporate-heavy PharmaCare panel wants to look at the Therapeutics Initiative. "They've always been hated by the drug companies," he says. "The reason the pharmaceutical industry hates them is they demand value from drugs. They encourage the government not to be spending on drugs with no additional value."

Reference Pricing

Another area where the panel will likely want changes is the government's policy of reference pricing, where PharmaCare pays for the cheapest drug that works.

The policy is used in just five classes of drugs, representing about 30 of the 5,000 medications on the market in the province. When a doctor sees a patient, says Cassels, "He's limited to prescribing the cheapest and oldest medicine first."

That older medicine in many cases will work just as well as the newest version of a drug, but at a fraction of the cost. If a patient tries the older drug and it doesn't work, the doctor can fill out a form asking for "special authority" to prescribe a newer one. Some 98 percent of those applications are approved, says Cassels.

Panel vice-chair George Morfitt led a 2002 review that found the program works well and saves the government about $12 million a year. Researchers at Harvard University and McMaster University have studied the policy and found it does not affect the health results for patients.

While reference pricing might be good for patients and the government that pays the bills, it does restrict drug companies' ability to charge top prices for new treatments that are no better than old drugs.

National program pushed

The threat to B.C.'s PharmaCare program comes at a time when pressure is mounting for a national drug plan. It is something the provinces and the federal government have been talking about in recent years and public meetings on the topic were held in Vancouver and Victoria earlier this week.

"It was always intended when medicare was set up in the '60s there'd be a national drug plan, but it's never seen the light of day," says Cassels. There's political support for the idea, but with Canadians spending some $21 billion a year on drugs, it's hard for politicians to commit to covering the bill. He says, "They get sticker shock big time."

That's where B.C. may have much to share with the rest of the country, Cassels says, and why the drug companies are keen to rewrite the province's policies. "A national PharmaCare program would only really be feasible with a strict approach to cost effectiveness. Otherwise it will never be affordable."

An interesting question for the panel to look at, he suggests, is how much money the Therapeutics Initiative, reference pricing and the Common Drug Review save the provincial government. "If that research got out to the rest of the country, every province in the country would be replicating the Therapeutics Initiative," he predicts.

But with Williams and others with drug industry connections dominating the panel, those questions, says Cassels, are unlikely to be on the agenda.

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