The following by Dr Joel Lexchin offered in response to a National Newswatch opinion piece "Severely reducing drug prices by federal regulation will harm not help patients" by Nigel Rawson, John Adams and Beth Vanstone.Both John Adams and Beth Vanstone have been and are severely affected by our current pharmaceutical policy environment. For many diseases we need better therapies and even when those therapies are available their prices make them unaffordable. These problems make people passionate about reforming our system. My work in the emergency department makes me passionate also. I see people coming into hospital who wouldn't have been there if they were able to afford the medications that they need. After people have been seen in the emergency department, we are often reaching into the hospital's drug supply because our patients don't have drug insurance. We all want to reform the system and make things better for patients.However, passion can sometimes get in the way of objectively evaluating the evidence and that's what's happened in the case of the op ed by Nigel Rawson, John Adams and Beth Vanstone.The authors accuse me of partly relying on opinion poll results for some of my arguments and instead claim that they are using “verifiable research” to show that lower Canadian prices will lead to fewer introductions of new drugs. One such piece of “research” is found in Canadian Health Policy, the journal published by the Canadian Health Policy Institute where Dr. Rawson is an affiliate scholar. The journal article in question was authored by Yanick Labrie.Here is what Justice Steeves had to say about the quality of Mr. Labrie's research when he testified in the Cambie trial in British Columbia about whether patients should be allowed to purchase private insurance to jump the queue for medical procedures and whether doctors should be allowed to extra bill : “I have concluded that Mr. Labrie's evidence is to be afforded little or no weight due to his lack of independence and lack of reliable methodology in his report.”They also accuse me of smearing the actions of patient groups. Many patient groups struggle for the resources that they need to help their membership, but taking donations also puts patient groups in a conflict of interest situation just as when doctors take money from drug companies. A recent systematic review found four studies that looked at the question of how some patient groups resolve this conflict of interest. “These studies addressed a range of highly controversial issues: overdiagnosis, pharmaceutical advertising, harm from opioid use, and high drug costs. All four studies represent situations in which a conflict existed between the interests of commercial sponsors and the interests of patients or the public…The data available from the four studies point to positions reflective of sponsors' interests” although for a variety of reasons this conclusion should be viewed with caution.Here in Canada, drug companies said that they donated to 114 patient groups, but over 30% of those groups did not acknowledge receiving funding from companies. Among those groups that did acknowledge donations, only 20 out of the 79 gave the date of the donations, 4 gave information about the purpose of the donations and none gave either the exact amount of the donations or what proportion of their income came from donations.It does cost a lot of money to bring new drugs to market, but a good deal of that investment comes from public sources and the drugs that benefit from public investment are the most therapeutically innovative ones. In the case of the COVID vaccines that Rawson and colleagues reference, the United States Congressional Budget Office estimates that the Biomedical Research and Development Authority alone spent $19.3 billion. Unlike the COVID vaccines, and contrary to what Rawson would have us believe, most new drugs are not therapeutically any better than drugs already on the market. Less than a third of new drugs approved by the US Food and Drug Administration and the European Medicines Agency in the decade from 2007 to 2017 were rated as having high therapeutic value by at least one of five independent organizations.We should also remember that the largest pharmaceutical companies invest more money in dividends and share buybacks than they do in research and development. Share buybacks up the value of shares which are the major source of income for senior drug company executives. In recent years, the total compensation of the 6 most highly paid drug company executives ranged from a low of $38.6 million to a high of $98.4 million.What about the question of patient groups and donations from drug companies? Many patient groups struggle for the resources that they need to help their membership, but what happens when they take donations from drug companies? A recent systematic review found four studies that looked at this question. “These studies addressed a range of highly controversial issues: overdiagnosis, pharmaceutical advertising, harm from opioid use, and high drug costs.All four studies represent situations in which a conflict existed between the interests of commercial sponsors and the interests of patients or the public…The data available from the four studies point to positions reflective of sponsors' interests” although for a variety of reasons this conclusion should be viewed with caution.Is the Quebec model the way to ensure that all Canadians have coverage for the drugs that they need, as asserted by Rawson, Adams and Vanstone? On some measures, such as whether patients don't fill prescriptions or skip doses, Quebec does relatively better than the Canadian average. But given the poor drug coverage in other provinces that is not the right comparison. For example, Quebec lags behind Australia, Germany, the Netherlands and the United Kingdom – all offer universal drug coverage – on nonadherence. Similarly, a greater percentage of people in Quebec report spending more than $1,000 out-of-pocket on drugs, and total per capita spending on drugs in Quebec ($1,087) is higher than the average in the rest of Canada ($912) and in countries with universal coverage ($826). Adopting a Quebec model in the rest of Canada would actually drive drug spending up.One thing Rawson and colleagues are right about is that the PMPRB is no longer fit for purpose. Right now Canada pays the third highest amount in the world per person for drugs and only the United States, Switzerland and Germany have higher prices.  That's why the federal government needs to go ahead and implement reforms to the PMPRB regulations. Those changes will help lower drug costs and pave the way for a national pharmacare plan.Pharmacare was supposed to follow medicare back in the 1960s and we've been hearing promises about it ever since. Back in 2018 the Liberal government appointed former Ontario Health Minister Eric Hoskins to tell Canadians how to implement pharmacare and Hoskins final report laid out a timetable for how to get there by January 1, 2027. Canada is the only country that has universal insurance for hospital and doctor care that doesn't cover drugs. Reforms to the PMPRB regulations will help change that situation.