Sustaining our momentum on pan-Canadian drug pricing

Dr. Michael Law is an assistant professor at the Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia.

I can’t help but be struck by the relative progress on two important pharmaceutical policy files that were commitments in the original 2003 Health Accord.

First, consider the progress toward harmonizing the assessment of drugs. Since 2003, the Common Drug Review (CDR) has produced 236 recommendations on new drugs, and the reviews are widely used by provincial drug plans. Moves toward jointly assessing the evidence on new drugs have become well entrenched in Canada.

In contrast, consider the baby steps we’ve made toward the Accord commitment to collaborate on drug pricing. On the brand side, it has become increasingly common for countries to negotiate confidential deals with pharmaceutical companies through so-called product listing agreements (PLAs). These agreements provide confidential discounts to drug plans in exchange for coverage, particularly as our current system allows one province to be played off against another.

On the generic drug side, while other countries get companies to aggressively compete with one another to obtain lower prices, we’ve stuck to our old formula of pricing generics as an arbitrary percentage of the brand name price. So, in short, I think there’s a need for more pan-Canadian work on drug pricing.

After many years of being stalled, we’ve recently started to see some changes. These initiatives have been launched by individual provinces, and then brought to the national level through the Council of the Federation. First, in 2010 the premiers agreed to band together to secure better deals on brand name medicines, and subsequently in 2012 they agreed to pursue generic drugs through collective bulk purchasing.

Given the commitment to pan-Canadian movement made back in 2003, progress to date has been modest: collective purchasing strategies have been completed for seven brand name products and six generic drugs. When you consider that millions of Canadians use thousands of different prescription drugs, it’s abundantly clear that there is a slew of further opportunities for collaborative initiatives.

I think an important question at this point will be how to build on these initiatives and maintain this new momentum. As the Council pointed out in their report on the National Pharmaceuticals Strategy, as governments change, priorities shift, often leaving valuable policy initiatives unfinished.  We have already started seeing this to some degree when Quebec recently decided not to continue participating in these new initiatives.

Making sure we maintain this momentum is important, as there are still significant barriers to negotiating brand prices together, and Canadians continue to pay for generic drugs using an outdated pricing model. Following the lead of the Common Drug Review, perhaps it’s time we institutionalized these joint-purchasing initiatives through a formal body or governance structure that can build on and expand these recent successes. A more permanent body would help address these serious issues, and solidify our current momentum on pan-Canadian prescription drug pricing initiatives.

Still Waiting After All These Years

Dr. Chris Simpson is chair of the Wait Time Alliance and
President elect nominee of the Canadian Medical Association.

Yesterday afternoon, in my capacity as Cardiac Program Medical Director at my hospital, I met with Mr. B, a 72 year old man whose wife died in hospital.

I was expecting that he would want to talk about her hospital care; perhaps he wanted to explore why she died and if anything could have been done differently. I reviewed her chart thoroughly in advance so I could be sure I had all the facts I would need to discuss her case with him in a meaningful and productive way.

As it turned out, he didn’t want to talk about that at all. Instead, he wanted to talk to me about his wife’s experience leading up to her surgery. He told me her story chronologically. She’d had a series of encounters, each characterized by a wait. She had waited in the ER. She waited for diagnostic tests. She waited for consultations, she waited for decisions and she waited for her surgery.

“All of the doctors and staff were great”, he repeatedly told me, almost as if he were trying to protect those of us who work on the front line from critique, “but the system let her down.”

He went on to explain how all of these constituent waits in her health care journey left this very thoughtful, seemingly-empowered and articulate man and his wife feeling afraid, vulnerable, disconnected, anxious, demoralized and uncertain.

************************************

Canadians understand that when they require non-urgent health care, they will usually have to wait. When waits are appropriately brief and when patients feel connected and in control, they feel confident and satisfied. When waits are too long, however, and when people are left “in limbo” between encounters, patients and their families experience anxiety, economic hardship, needless pain and suffering, and perhaps even more serious adverse events, including death. Also important is the societal cost of excess waiting. The Canadian Medical Association has estimated that waits exceeding medically acceptable benchmarks for just four key procedures cost the Canadian economy $14.8 billion dollars in a single year (http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf).

As I reflect on the nearly ten years that have passed since the 2004 health accord was signed by the federal government and the provinces and territories, I find little reason to cheer. Despite all the goodwill, hard work and cooperation; despite the money committed to reducing wait times and the intense pressure from the public to improve, we have seen only modest progress. Over the past year or two, most discouragingly, we are now seeing the reversal of that modest progress. CIHI (http://www.cihi.ca/cihi-ext-portal/pdf/internet/HCIC2012_SUMMARY_EN), the Health Council of Canada, and the Wait Time Alliance (www.waittimealliance.ca) all agree that wait times have worsened again. Essentially, we’re regressing right back to where we started.

How is it that all this work and all these resources have not led to sustained improvements in wait times?

The reasons are many but they essentially boil down to one indisputable truth: the money that was invested didn’t buy change. All we did was to make the numbers look a little better for a short time. Our “success” was fleeting. The Senate Committee on Social Affairs, Science and Technology, in its review of the progress made since the 2004 Accord (http://www.parl.gc.ca/Content/SEN/Committee/411/soci/rep/rep07mar12-e.pdf) echoed this sentiment, recommending that investments must be used to buy change, not to maintain the status quo.

What would real, transformational change look like?

Well, it would start with the assembly of clear and timely information on outcomes and performance, the tools to measure these, and the establishment of a national body that is resourced and empowered to collect, analyze and present these data. We can’t change what we don’t measure.

Transformational change would also see more accountability to deliver the change that is purchased by the investment. We won’t change if the payers don’t hold us all accountable to deliver the change that the resources provided are intended to buy.

Transformational change means far less “siloism” in the system. It’s often said that we are a nation of health care pilot projects. Our jurisdictional and cultural silos impede the sharing of successes and best practices. We are forever “re-inventing the wheel” because we have diminishing national focus, standards, and goals.

And finally, transformational change means that all stakeholders in the system have to step up to do their part. Physician groups and other health care professional organizations must continue to advocate for individual patients but we also must embrace our civic professionalism – to help our system find better value for money and to help lead our collective responsibility to find a path to sustainability.

****************************************************************************

Putting my doctor hat back on, though, I see this as being about how to fundamentally change our approach to the provision of care from one that is provider-centric to one that is patient-centered. Mr. and Mrs. B wanted us to accompany them on their journey. Instead, we invited them to join us on ours.
 
Mr. and Mrs. B recognized the excellence embedded in the silos, but felt abandoned at the transition points in her care pathway. The transition points between each component are the wait times; it is at these bottlenecks where negative perceptions, inequities, and suboptimal outcomes are born. It is also where inefficiency and waste are generated.

They deserved better. All Canadians deserve better. And we can do better. Together, we can build a health care system that is truly worthy of Canadians’ confidence and trust. 

Health Human Resources (HHR) in Canada Part 2: Where to next?

John G. Abbott, CEO, Health Council of Canada

In my previous blog post I outlined some of the pressing challenges our health care systems face when addressing the management of our health human resources and underlined the need for a strategic approach.

So, what steps should Canada take to get to the high-performing health care system all Canadians want? From the Health Council’s perspective, there are several basic elements we need to work on.

1. Set a vision and measurable goals 

 

We need to set specific targets nationally and provincially that are aligned for each of our professions. These have to be based on our population health needs, the interprofessional collaboration model of care and the capacity of our education and training system to meet them. For example, we should aim to be self-sufficient and set a timeframe to reduce our reliance on international recruitment across all professions. In addition, we could set explicit targets for training the workforce we know we’re going to need to care for the growing number of complex patients living in the community and at home.

2. Address our human resources challenges in workforce planning 

 

Canada has shown that, given time, it can implement innovative ways of delivering better quality care more efficiently at the “micro level”. But, when it comes to achieving a high-performing health care system, time is not on our side. We need governments and professional bodies to better collaborate to create supportive “macro level” policies that accelerate the implementation and spread of innovative practices. This includes regulatory frameworks that support professionals to work in teams and a post-secondary education system that is more responsive to training professionals that meet projected population health needs.

3. Central body of evidence 

 

Traditionally, knowledge translation on health human resources has been a one-way street where researchers produce evidence which they communicate to decision-makers. It is, therefore, not surprising that we don’t yet have a shared information base.

Seeing this, a number of Canadian health care stakeholders are calling for the establishment of a health human resources observatory. An observatory would be a forum where researchers, governments, employers, health professionals and unions can come together to share their views and gradually develop an evidence base that has “buy-in” from all sectors.

An observatory could also be a forum for coordinating research on health workforce issues, strengthening data collection and sharing approaches across provinces and territories. In this role it would build on the current trend towards increased interprovincial collaboration.

In 2010, the House of Commons Standing Committee on Health recommended the creation of a national observatory. The Health Council has endorsed this recommendation. Among peer nations, Australia has established an observatory whose work is highly regarded by experts in the field. Known as Health Workforce Australia, the observatory states as its goal: to build a sustainable health workforce for Australia.

In fact, the building blocks of an observatory are already up and running in the form of the Canadian HHR Network. The Pan-Canadian Health Human Resources Network (CHHRN) was established with federal funds and is made up of renowned researchers and policy makers. The Network has over 75 users from across Canada, and their Advisory Committee includes health ministry representatives.

The Network is already a valued source of best practice information on issues like health human resource retention and productivity.

To conclude, I believe that Canada is in a strong position to enact policy changes that would improve the productivity of our health workforce and improve the performance of our health care systems. Today’s governments and health care managers are well-versed in the language of quality improvement in health care. They also realize that there are cost-savings to be made by reorganizing our health systems to produce more effective care that is responsive to the needs and wishes of patients.

Just as Canada is proud of having one of the world’s strongest financial systems, shouldn’t we also want to have one of the best health care systems in the world? Canada has the knowledge and resources required to plan for our future health care needs, and this is more than true for our health workforce.

In the end, we want not only to be self-sufficient nationally, but to have the highly-skilled people to meet our health care demand needs in each region of the country. That will require a strategic approach built on continued collaboration amongst governments, professional bodies, their regulators and the education and training community.