PACC Committee Report

In particular, the Committee recommends:

RECOMMENDATION 14

That Health Canada, in consultation with First Nations and Inuit communities, develop and implement formal evaluation plans for the community health programs, including the transfer initiative, and the Non‑Insured Health Insurance Benefits program.

RECOMMENDATION 15

That Health Canada include the evaluation plans for community health programs and the Non-Insured Health Benefits program in its report onplans and priorities, beginning with the report for fiscal year 2002-2003.

RECOMMENDATION 16

That Health Canada list all completed evaluation reports for community health programs and the Non-Insured Health Benefits program in its annual performance reports commencing with the Report for the period ending 31 March 2002.

NON-INSURED HEALTH BENEFITS

In 1997, the Auditor General warned that prescription drugs provided under the NIHB program were subject to misuse or abuse. A review of Health Canada’s own data had shown that some NIHB clients could receive an alarmingly large amount of prescription drugs. The Auditor General reported that the Department had been aware of the problem for almost ten years, but that he had found “no evidence that the ease of access to prescription drugs [had] changed in any significant way.” 

Although the Department asserts that abuse of prescription drugs under the NIHB program is no worse than under other comparable programs, it says that it is concerned about the problem and is addressing it. In 1997 and 2000, the Auditor General reported that although prescription drug misuse is not unique to First Nations, it has “serious implications for First Nations health, particularly when the program [is] intended to improve it.” For his part, Dr. Kendall told the Committee that although prescription drug abuse is a society-wide problem, “it is more pervasive among First Nations people.”

The Department has taken some measures to strengthen controls following the 1997 audit. The focal point of these efforts is a point-of-service system ― a key tool for administering pharmacy benefits and controlling prescription drug abuse ― which is now mandatory for all pharmacies serving NIHB clients. Using data generated by the system, the Department had begun to intervene in cases of suspected misuse. There are, however, limitations in the information generated by point-of-service system, and in the use and analysis of that information, which lead to a reduction in the system effectiveness in controlling prescription drug use.

The follow-up audit found that “as implemented, the point-of-service system … is not designed to provide detailed information on previous prescriptions obtained or doctors visited.” Furthermore, although the system being tested in 1997 provided the dates of the client’s last three prescriptions, the one currently in place does not. Mr. Joubert testified that the reasons for this were technical, not legal and Dr. Cooney confirmed this. Mr. Joubert further testified: “limited amount of information does create a barrier for the pharmacist to be very effective in his communication with the prescriber.” The Committee believes that information generated by the point-of-service system should be strengthened and accordingly recommends:

RECOMMENDATION 17

That Health Canada immediately upgrade the point-of-service system for pharmacies under the Non-Insured Health Benefits program so that the system provides the dates, quantities, and drugs prescribed of at least a client’s last three prescriptions and information on doctors visited.

The point-of-service system generates three warnings to pharmacists: drug‑to‑drug interaction potential; duplicate drug; and duplicate drug ― other pharmacy. The pharmacist can override these warnings, but must enter a code signalling the reasons why. The Auditor General found that Health Canada was not monitoring overrides adequately and that its analysis of the data, begun only in March 2000, was limited.

Mr. Potter testified that Health Canada is now monitoring overrides more closely as part of an enhancement of its drug utilization review. Although this is appropriate, the Committee believes that more rigorous analysis of overrides is also required and therefore recommends:

RECOMMENDATION 18

That Health Canada regularly analyze overrides of warnings generated by the point-of-service system to determine whether warning messages are effective, whether prescriptions rejected by some pharmacists have been filled by others, and how and why clients with very large numbers of prescriptions are getting through the system.

RECOMMENDATION 19

That Health Canada include a discussion of its analysis of pharmacists’ overrides along with subsequent action taken in response to that analysis in its performance reports beginning with the report for the period ending 31 March 2002.

In 1997, the Auditor General found that Health Canada was slow to intervene in cases of suspected prescription drug misuse. He recommended “in cases where it identifies a significant pattern of inappropriate use of prescription drugs, the Department should perform a more rigorous follow-up with NIHB clients, physicians, pharmacists and professional bodies.” Health Canada agreed. The Department updated and implemented its drug utilization review protocol to better identify and follow up on cases that suggested prescription drug misuse. This intervention consisted of following up with clients, physicians, pharmacists and professional bodies. In Mr. Potter’s words, the Department “was taking information about an individual’s use of certain prescription drugs and sharing them with other professional health providers.” There were signs that this intervention was working: evidence from Alberta and Saskatchewan up to early 1999 showed a decline in the number of cases involving access to large amounts of central nervous system drugs.

Dr. Kendall, of the College of Physicians and Surgeons of Saskatchewan, spoke favourably about Health Canada’s interventions, telling the Committee that the College was “beginning to make some inroads in terms of dealing with physicians who have highly inappropriate prescribing practices” as a result. He indicated the College “would actually get referred [to it] a printout showing a prescribing pattern which Health Canada officials would say ‘We think there’s a reason for concern and then we would investigate.”

However, Health Canada stopped its interventions in May 1999 because it was advised that its approach was inappropriate in the absence of either client consent or specific statutory authority for the program. The Department issued a revised protocol stating that misuse of benefits will be identified primarily through the point-of-service system (and the drug utilization warning messages that the system generates).

The Auditor General reported that evidence from some regions showed that the number of cases of access to large amounts of central nervous system drugs had started to increase after the Department ceased its intervention. Dr. Kendall testified that with the intervention at an end, his College now feels that local Health Canada officials “have their hands tied behind their backs because they can’t give us any information.”

Mrs. Stonechild reminded the Committee of the terrible personal consequences that can result when information on overprescribing is not shared. She testified that she is having a “hard time understanding why 300 prescriptions were written out to [her] brother and no one monitored it, no one told anyone, … if this information was shared, maybe he’d still be alive today.”

After ceasing its interventions and issuing a revised drug utilization review protocol, the Department began to review ways of resuming interventions. The first option would have been to recommend legislation and regulations that would authorize the Department to use client information in the administration and management of the program. For example some provinces centralize the recording of central nervous system drugs in order to identify misuse and multiple use by individual patients. The other would be to have clients voluntarily consent to the use of their personal health information by the program. According to Mr. Potter, the Department has chosen the latter option and is negotiating arrangements with the Assembly of First Nations and the Inuit Tapirisat of Canada. The Department believes that consent will be more forthcoming if these two organizations provide their endorsement. Once this endorsement has been received, Dr. Cooney testified that Health Canada intends to “target band offices and First Nations offices for people on reserve, and will also use the pharmacy chains as the point of enrolment in the program.” He added that the Department’s goal is to have the enrolment process operational in the fall of 2001. In the meantime, the Committee believes that there is merit in the approach used by some provinces and recommends: