Waiting has come to be the hallmark of Canada's health system.
We wait in the ER; we wait for appointments with a family doctor and even longer for a specialist; we wait for surgery; we wait for a place in a nursing home.
But what about new drugs?
We wait for those too – among the longest waits in the world.
On average, it takes 493 days between the time a new drug is approved and the time it is included on a provincial formulary and eligible for reimbursement by public drug plans. That's a whopping 217 days longer than the average in comparable Western countries.
That tidbit comes from a new report "Access to New Medicines in Public Drug Plans," published by Rx & D – Canada's Research-Based Pharmaceutical Companies.
Now, it has to be said upfront that, in most cases, it's not clear that waits matter to outcomes, whether it's waiting for stitches in the ER or the latest cancer drug. But waiting is inconvenient and, when it comes to medication, it can be costly, because some patients will opt to pay out-of-pocket rather than wait months to see if they will be reimbursed for the new drug they were prescribed.
Still, comparing Canada's performance to that of 17 similar OECD countries is informative.
In fact, the most striking aspect of the report – one barely mentioned by Rx & D – is that Canada is the only country (aside from the U.S.) that doesn't have a universal drug plan. In Canada, the rules for reimbursement are byzantine and vary considerably between jurisdictions. (That fact even made comparisons complicated; in most countries, funding decisions are made centrally; in Canada, it is province-by-province so the researchers used access by 80 per cent of relevant patients as a surrogate for "full" coverage.)
Between 2009 and 2013, a total of 141 new medicines were approved in Canada and 130 were launched. (Another caution: Just because a drug is "new" doesn't mean it works better than the "old" drugs on the market; it's a new molecular entity or combination.)
Only 23 per cent of those new drugs were eligible for reimbursement for the bulk of Canadian patients. That ranks Canada 16 out of 18 countries studied.
By comparison, 154 new medicines were launched in Japan and 100 per cent were eligible for reimbursement; at the other end of the spectrum, there were only 40 launches in New Zealand, and 16 were covered by public insurance.
In addition, Canada places a lot of restrictions on reimbursement, with income-based deductibles, co-payments and it also mitigates costs with caps on how much patients pay out-of-pocket. About 90 per cent of drugs come with reimbursement conditions, ranking Canada 14 out of 18 countries. Again, Japan is the most generous – drugs come with no added cost; and in New Zealand, virtually all prescriptions come with conditions.
In fact, while the Rx & D report gives us some comparative numbers on specific criteria, what it is lacking is that larger context.
Japan is essentially a pharmaceutical company paradise because it quickly approves and pays for all new drugs. But do patients actually have better outcomes? Or does it just mean the state pays a lot more to placate patients? We don't really know.
Similarly, what is the downside of New Zealand's highly restrictive approach? We know that patients there have access to a lot fewer drugs; many companies don't bother launching products there because the market is small and the state-run drug agency vigorously restricts prices. Are New Zealanders suffering horribly because of this approach? Again, we don't really know.
It should be remembered, too, that this analysis examines only Canada's public drug plans. In this country, the majority of people depend on private drug plans for coverage, and about 40 per cent of overall drug costs are covered by private drug plans, whose reimbursement rules can be different from public plans, especially when it comes to new drugs.
The other quirk of the report is that it says nothing about cost.
You can't really discuss drugs, or the importance (or lack) of access, without considering the overall drug budget.
In Canada, we spent $33.9-billion on drugs last year, and more than $30-billion of that total is on prescription drugs.
Almost three-quarters of the drugs we use are generics, but they account for less than 40 per cent of spending. This is another way of saying that brand-name drugs are more expensive – and that's logical because of the costs of research and development. Generic companies essentially "copy" existing drugs once patents expire. (Though, to be fair, that is a bit of an oversimplification.)
This report looked at the very top of the pyramid – new brand-name drugs. These are among the most bedevilling because they tend to be the most expensive. As technologies change, and we have products sicj as biologics and drugs targeted at patients with specific genetic traits (personalized medicine), those costs can be astronomical; there are now $1-million drugs.
Whether they are worth the price is not cut-and-dried. It usually depends on a lot of factors. But rushing decisions is foolhardy and funding everything willy-nilly is foolhardy.
Access to essential medicines is a key component of a quality health system. But speed of approval is not the most important factor.
In the long run, equitable access and affordability matter much more and, on those areas, this report is a reminder that Canada fails miserably on those two counts.
We fail not only when it comes to new drugs, but to overall drug access, which is even more troubling.
André Picard is The Globe's public health columnist.
André Picard