This week: prostatectomy, prescription drug costs, exome sequencing for rare mutations
Learning objectives – Amol, Nathan, and Travis discuss:
1. Understand that radical prostatectomy improved overall and disease free survival and decreased metastasis compared with watchful waiting in men with localized prostate cancer of intermediate grade.
2. Understand how the cost of prescription drugs is regulated in Canada and how this impacts patients
3. Understand the application of exome sequencing to genetic discovery in rare clinical syndromes
Continuing medical education
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Anna Bill-Axelson et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med. 2014; 370:932-942. (PubMed)
Karen Tang et al. Addressing cost-related barriers to prescription drug use in Canada. CMAJ. 2014 Mar 4;186(4):276-80. (PubMed)
Paulina Navon Alkon et al. Mutant Adenosine Deaminase 2 in a Polyarteritis Nodosa Vasculopathy. N Engl J Med. 2014; 370:921-931. (PubMed)
Nathan – In New York, a Heart Surgery Factory With ‘Obscene Levels’ of Pay, David Armstrong et al, Bloomberg, Mar 6, 2014.
Travis – Long-Acting Integrase Inhibitor Protects Macaques from Intrarectal Simian/Human Immunodeficiency Virus, Chastity D. Andrews et al, Science, Mar 7, 2014.
Amol – Thirty-thousand-year-old distant relative of giant icosahedral DNA viruses with a pandoravirus morphology, Matthieu Legendre et al, PNAS, Jan 30, 2014.
The Rounds Table is a free-flowing conversation and we may mis-speak (or just plain be wrong) from time to time. We will do our best to catch mistakes and where possible, we will edit the episode to correct the error. We will indicate here if any change has been made. If you notice anything, please let us know!
In the original recording, Amol made reference to spending on drugs being 70% public and 30% private. This was an error – 70/30 is the public/private split for overall health care spending in Canada. The correct distribution of drug spending in Canada is 46.5% public, 36% private insurance, and 17.5% out-of-pocket. Reference: CIHI, Drug Expenditures in Canada 1985-2010, table 1, page 10.). The podcast has been edited to reflect the accurate numbers.
Question of the week
Should Canada have a national drug plan?
Chris, thanks for listening, thank you for your insightful comment, and thanks for pointing out the error on drug expenditure. Our very own Jeremy Petch picked up on this as well and we’ve included it in our weekly “corrections” section.
Thanks for the suggestion for the article from the Canadian Life and Health Insurance Agency. Is this the report you’re speaking of?
I absolutely agree that drug policy, management, and cost is a larger issue than simply thinking about who pays for what (and how much). Your call for a meaningful conversation with all players at the table is spot on. But where would this conversation happen? Do you think a venue exists at present?
Regarding Q2 – Drug Pricing:
Some comments on this part of the discussion. First, the split in drugs is about 56% private (mostly private insurance) and 44% public (mostly provincial). The provinces are now collaborating on price negotiations with brand pharma, though the net prices are not public information and QC is not part of that exercise. The provinces tend to simply set generic drug prices without any apparent negotiation. This is rendering the PMPRB less effective as a price setter, other than to determine a ceiling price which (ironically since this is a government board) is relevant now only for private purchases. The effects of purchasing power need to be explored: New Zealand is a commonly used comparator but is not very similar to Canada. You mentioned one major reason – one federal buyer in NZ and literally millions here – the provinces, and every patient. We could certainly be more aggressive price setters in this country, but we should not focus so narrowly. We should also consider the overall value the drug brings which could be improved by investments in patient education, adherence and preventing the chronic disease that drives most health system costs.
The Canadian Life and Health Insurance Association published a policy paper last year describing its positions and recommendations on drug regulation; it is an interesting read from what was until recently an unlikely source.
This brings me to my last point. We cannot have a useful conversation about drug policy, pricing and management in this country if we continue to exclude the 35% of all Rx costs paid by employers through private insurance. Prices, adherence, prevention and disease management are bigger issues that need provincial, professional, patient, academic and private sector voices at the table.