PACC Committee Meeting

37th PARLIAMENT, 2nd SESSION

Standing Committee on Public Accounts

EVIDENCE

CONTENTS

Wednesday, February 5, 2003

¹

1530

The Vice-Chair (Ms. Beth Phinney (Hamilton Mountain, Lib.))

Mr. Ian Potter (Assistant Deputy Minister, First Nations and Inuit Health Branch, Department of Health)

The Vice-Chair (Ms. Beth Phinney)

Mr. Ian Potter

The Vice-Chair (Ms. Beth Phinney)

Mr. Ian Potter

¹

1535

The Vice-Chair (Ms. Beth Phinney)

Mr. Ian Potter

¹

1540

The Vice-Chair (Ms. Beth Phinney)

Mr. Ian Potter

The Vice-Chair (Ms. Beth Phinney)

¹

1545

Mr. Philip Mayfield (Cariboo—Chilcotin, Canadian Alliance)

Mr. Ian Potter

Mr. Philip Mayfield

Mr. Ian Potter

Mr. Philip Mayfield

Mr. Ian Potter

Mr. Philip Mayfield

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1550

Mr. Ian Potter

Mr. Philip Mayfield

Mr. Ian Potter

The Vice-Chair (Ms. Beth Phinney)

Mr. John Bryden (Ancaster—Dundas—Flamborough—Aldershot, Lib.)

¹

1555

Mr. Ian Potter

Mr. John Bryden

Mr. Ian Potter

Mr. John Bryden

º

1600

Mr. Ian Potter

Mr. John Bryden

Mr. Ian Potter

The Vice-Chair (Ms. Beth Phinney)

Mr. Roger Gaudet (Berthier—Montcalm, BQ)

Mr. Ian Potter

º

1605

The Vice-Chair (Ms. Beth Phinney)

Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP)

The Vice-Chair (Ms. Beth Phinney)

Ms. Judy Wasylycia-Leis

Mr. Ian Potter

º

1610

º

1615

The Vice-Chair (Ms. Beth Phinney)

Mr. Ian Potter

The Vice-Chair (Ms. Beth Phinney)

Mr. Steve Mahoney (Mississauga West, Lib.)

Mr. Ian Potter

Mr. Steve Mahoney

Mr. Ian Potter

Mr. Steve Mahoney

Mr. Ian Potter

Mr. Steve Mahoney

Mr. Ian Potter

º

1620

Mr. Steve Mahoney

Mr. Ian Potter

The Vice-Chair (Ms. Beth Phinney)

Mr. Philip Mayfield

Mr. Ian Potter

Mr. Philip Mayfield

Mr. Ian Potter

Mr. Peter Cooney (Acting Director General, Non-Insured Health Benefits, First Nations and Inuit Health Branch, Department of Health)

º

1625

The Vice-Chair (Ms. Beth Phinney)

Mr. Tony Tirabassi (Niagara Centre, Lib.)

Mr. Ian Potter

Mr. Tony Tirabassi

Mr. Ian Potter

Mr. Tony Tirabassi

The Vice-Chair (Ms. Beth Phinney)

Ms. Judy Wasylycia-Leis

The Vice-Chair (Ms. Beth Phinney)

The Clerk of the Committee

The Vice-Chair (Ms. Beth Phinney)

Ms. Judy Wasylycia-Leis

The Vice-Chair (Ms. Beth Phinney)

Ms. Judy Wasylycia-Leis

Mr. John Bryden

º

1630

The Vice-Chair (Ms. Beth Phinney)

Ms. Judy Wasylycia-Leis

Mr. Ian Potter

The Vice-Chair (Ms. Beth Phinney)

Mr. John Bryden

The Vice-Chair (Ms. Beth Phinney)

Mr. Philip Mayfield

The Vice-Chair (Ms. Beth Phinney)

Ms. Val Meredith (South Surrey—White Rock—Langley, Canadian Alliance)

º

1635

Mr. Ian Potter

Ms. Val Meredith

Mr. Ian Potter

Ms. Val Meredith

Mr. Ian Potter

Ms. Val Meredith

Mr. Ian Potter

Ms. Val Meredith

Mr. Ian Potter

Mr. Peter Cooney

º

1640

The Vice-Chair (Ms. Beth Phinney)

Mr. Philip Mayfield

Mr. Ian Potter

Mr. Philip Mayfield

Mr. Ian Potter

Mr. Philip Mayfield

Mr. Ian Potter

The Vice-Chair (Ms. Beth Phinney)

Ms. Val Meredith

Mr. Ian Potter

Mr. Philip Mayfield

Mr. Ian Potter

The Vice-Chair (Ms. Beth Phinney)

Mr. Philip Mayfield

º

1645

Mr. Ian Potter

Mr. Peter Cooney

Mr. Philip Mayfield

Mr. Peter Cooney

Mr. Philip Mayfield

The Vice-Chair (Ms. Beth Phinney)

Mr. Roger Gaudet

Mr. Ian Potter

Mr. Roger Gaudet

Mr. Ian Potter

º

1650

The Vice-Chair (Ms. Beth Phinney)

Ms. Val Meredith

Mr. Ian Potter

Ms. Val Meredith

Mr. Ian Potter

Ms. Val Meredith

The Vice-Chair (Ms. Beth Phinney)

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CANADA

Standing Committee on Public Accounts

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NUMBER 011

l

2nd SESSION

l

37th PARLIAMENT

---

EVIDENCE

Wednesday, February 5, 2003

[Recorded by Electronic Apparatus]

¹  (1530)  

[English]

    The Vice-Chair (Ms. Beth Phinney (Hamilton Mountain, Lib.)): Pursuant to Standing Order 108(3)(e), this is an update of the non-insured health benefits program of chapter 15 (Health Canada—First Nations Health) of the October 2000 report of the Auditor General of Canada.

    We have four people with us today as witnesses. Ian Potter is Assistant Deputy Minister, First Nations and Inuit Health Branch. Would you like to introduce the other three with you?

    Mr. Ian Potter (Assistant Deputy Minister, First Nations and Inuit Health Branch, Department of Health): Yes, I will. Thank you very much, Madam Chairman.

    I'm joined today by Dr. Peter Cooney, who is the director general of the non-insured health benefits program, Mr. Sony Perron, who is the manager of quality, audit, and assurance, and Christine Dufour, who is a policy analyst.

    The Vice-Chair (Ms. Beth Phinney): She looks very young to be a senior policy analyst. She must have some secrets we don't have to stay so young.

    Mr. Potter, would you like to start with your opening statement?

    Mr. Ian Potter: Yes, I would, Madam Chairman.

    The Vice-Chair (Ms. Beth Phinney): Do we have copies of your opening statement?

    Mr. Ian Potter: I didn't bring copies, sorry. I can make them available afterwards. My apologies to the committee.

¹  (1535)  

    The Vice-Chair (Ms. Beth Phinney): Okay.

    Go ahead, Mr. Potter.

    Mr. Ian Potter: Thank you very much for this opportunity to bring you up to date on the actions we have taken in the Department of Health subsequent to our tabling of the report with you on non-insured health benefits in May 2002.

    In our report in May we indicated that to address the recommendations by the committee, we were moving on a number of fronts, with a focus on control and prevention measures. Our activities have concentrated on three main things, improving accountability by enhancing our processing and audit systems, implementing measures to better protect our clients, and improving communications and administration of our program.

    Improving accountability continues to be an important focus. The non-insured health benefits management framework has been put in place and has set out a work plan for evaluation of the processes and audit systems we're dealing with. Quarterly reports are now completed and provide regional information on the use of override codes. Reports are generated for every provider billing the program on their use of overrides, and these reports allow us to further profile code utilization and to better target our audit and follow-up activities with providers. This activity has resulted in a 28% decrease in the number of drug utilization messages being overridden by pharmacists, in spite of a 25% increase in the number of claims being processed between 1999 and 2002. In over 80% of the claims that were rejected or overridden, pharmacists have indicated that they're using professional judgment, consulting with the prescribing physician, or interviewing the client to determine that there is a particular need to proceed with that prescription.

    On the audit side, the program has reduced the threshold that triggers next-day audits. This has resulted in an increase in the number of claims being reviewed, and while that has taken place, we have actually been able to increase our audit activity so that the on-site audit backlog has been addressed. The program has exceeded its target number of audits, which was 570 for the 1999-2002 period, and we have conducted a total of 616 on-site audits. That's where we actually send auditors into the office of a provider to look at their records. With the 616 audits performed, we've identified $8.6 million targeted for recovery. Generally, it's because the service is outside the terms and conditions of the program. Some of these funds have been recovered, others are in litigation. There will be 140 audits conducted in the year 2003-2004 on the non-insured health benefit program. Of these 60 will be on-site audits with pharmacists and 20 medical supply and equipment audits.

    I'm pleased to inform you that the collection of client consent for the use of personal information was launched in September 2002 and is continuing with a target date of September 1, 2003. As you can imagine, this has been a significant undertaking, but one that will allow the program to meet requirements of federal, provincial, and territorial privacy legislation.

    First nation and Inuit organizations have been involved in the development of the client consent initiative. We've had consultations with the Canadian Pharmacists Association and the Canadian Dental Association, together with their provincial and territorial counterparts. In order to fully address the first nations and Inuit concerns and to be able to reach the 720,000 beneficiaries of the program, we've established a target date of September 2003 for implementation of the process.

[Translation]

    A phased approach to the widespread distribution of consent material started in the summer of 2002, with consent materials now available nationally. An enhanced media campaign is to be implemented March 1 involving television and radio ads.

    We are taking steps to re-establish our comprehensive Drug Utilization Review protocol, with the target for full operation in September of this year.

    The Branch continues to provide addictions prevention services focusing on treatment, community outreach and education, and research and development. Culturally sensitive treatment services include individual, group and in some centers, family counseling. Aftercare programs are available to the client and their family to provide them with the necessary support during their recovery process.

[English]

    Treatment centres also provide awareness and education to community members on addiction issues and information on the treatment services available. Recognizing that prescription misuse is inextricably linked to social and emotional wellness, First Nations and Inuit Heath Branch, through it's building healthy communities program, is training community members to better deal with traumatic situations and crises, which in turn could help to curb the utilization of prescription drugs.

    We are using the opportunity of obtaining client consent to raise awareness of drug misuse and abuse among first nations and Inuit, as well as pharmacists and physicians. We have asked first nations and Inuit groups to consider what further action should be taken to deal with prescription drug abuse. The head of the Assembly of First Nations, National Chief Matthew Coon Come, has indicated to our minister that he is in the process of looking at other programs or initiatives we could take to address the problem of prescription drug misuse.

    The committee raised with us the question of the automatic systems used by pharmacists that alert them to whether this drug has been prescribed before and made some recommendations on improving that system. The system, managed by the Canadian Pharmacists Association, is now being adapted by the Canadian Institute for Health Information and is called the National eClaims Standard. They're working on an update. They haven't established a date for the release, but once it is released, we will switch to that system, which will facilitate efficient coordination of benefits, improved access to patient medication history, and provide interactive communication with other health professionals. These were issues the committee raised with us before.

    As an update on another issue the committee raised with us, the relationship with the College of Physicians and Surgeons in Saskatchewan, we have taken steps to provide them with encrypted pharmacy utilization information for the year 2001 to support the systems development for the Saskatchewan triplicate prescription program. This is a program where they were getting prescription triplicates from all pharmacists, so for every prescription that was issued in Saskatchewan, a triplicate was sent to the provincial government, which would allow them to deal with the College of Physicians and Surgeons. Their problem was that the system relied on paper, and they have now been trying to link it with our system, so that it can be an automated electronic system. We're in the process of working with them. This is a first step, and once we have consent on client utilization, we will be able to provide detailed information about the clients, which will facilitate the work they were trying to do dealing with potential prescription misuse.

    That's the conclusion of my comments. I would like to thank the committee for its interest in our program, and I am available to answer any questions.

¹  (1540)  

    The Vice-Chair (Ms. Beth Phinney): Thank you, Mr. Potter.

    How quickly could we have a copy of your notes?

    Mr. Ian Potter: You can have them right now.

    The Vice-Chair (Ms. Beth Phinney): Okay, good. Thank you.

    I just want to mention that this is a update of a report we had. John Bryden asked that we do this update, so we're going to give him the lead question when we come to the government side.

    Mr. Mayfield.

¹  (1545)  

    Mr. Philip Mayfield (Cariboo—Chilcotin, Canadian Alliance): Thank you very much, Madam Chair.

    I want to say how pleased I am that Mr. Bryden can be here today, because this is a subject of particular interest, and he has been forthright in carrying it back to the committee at least once, perhaps on more occasions than that.

    I also want to thank Mr. Potter. I wish I did have the report, because trying to make notes and keep it in my mind did keep me busy, and I still don't have it all, but we'll do the best we can.

    What I want to talk about primarily is the consent form in this non-insured health benefits program. It's my understanding that no one can receive benefits under the NIHB program unless they have a band number. Is that correct?

    Mr. Ian Potter: They need to be a status Indian under the Indian Act or a recognized Inuit or Innu. There are different numbering systems that are used. Some are treaty numbers, some are band numbers, but the principle of law is that you have to be a status Indian or registered Indian recognized by the Indian Act.

    Mr. Philip Mayfield: But there is a defined population these benefits are limited to. If I'm not mistaken, the benefits are already available to these people before the consent form. Is that correct?

    Mr. Ian Potter: The program goes back 50 years or more in some form, and it's become more and more standardized over the last few years. Through the last ten years we don't have a general consent form for all aspects of the program.

    Mr. Philip Mayfield: But my point is that these benefits were available to that population without a consent form. I guess we're saying now they have to sign a consent form, as of September 1 this year, to get those benefits. Is that correct?

    Mr. Ian Potter: Except for dental. We introduced a consent form for dental services in 1998.

    Mr. Philip Mayfield: Okay.

    The problem, as I understand it--and this has to be the third or fourth time we've discussed this issue at the committee--is the issue of privacy. We've gone through a couple of cuts at getting a computer program going that would keep track of, particularly, prescriptions. The difficulty is that we can't ask people to put it on the provincial computer program, as in British Columbia, because of privacy concerns. I have to admit, this is a problem I have not really understood. Most people go to the doctor, get a prescription, go the pharmacist, and the pharmacist fills it out. In British Columbia, when I get a prescription in my home town of Williams Lake, if the previous prescription was received in Vancouver, it's not uncommon for the pharmacist to say, I see you got this in Vancouver the last time you had it filled. So it's pretty common that people who are not under the NIHB program have their prescriptions recorded, so the pharmacist knows what you're taking and often gives advice.

    I do have some questions about this form itself. Informed consent usually has a technical or a legal meaning, and I'm wondering what informed consent in signing this form means. Does it mean they need to have a lawyer or a doctor or a professional describe something to them? What does informed consent mean?

¹  (1550)  

    Mr. Ian Potter: As I understand it, it is the understanding of an individual as to why they're being asked for the use of their personal information, that we can transmit their personal information to other parties, for what purposes we're going to use that information, and in what context we're going to use it. The advice I've received is that in order for consent to be valid, people must be reasonably informed of those things. Why do you need it? What purpose are you going to use it for? How is it going to be stored and protected? The documents you're referring to--and I have copies, should other members not have this material--were developed in consultation with our legal counsel, the Privacy Commissioner, and other organizations who know much more about this than I, to assure ourselves that this process met the test, so that when people filled out these forms and signed them, we would have the ability to manage the program and use their personal health information. Our belief is that this process and this document fulfil the obligations of informed consent.

    Mr. Philip Mayfield: I presume this is going to be distributed among the population of those who need these forms. One of the concerns I have about the form itself is that the attitude of many rural people--and I'm not limiting this to native Indian people--is not to take it very seriously. I'm wondering also about people who may not have the ability to understand what this form is, or if they do, to go through the steps of completing it with the correct information, because illiteracy is a common problem in many rural areas. It occurred to me that if we need informed consent, these forms perhaps could be handled most easily by the prescribing physician or the pharmacist, who is closer to the situation, would understand the type of information a person would need to have informed consent, and would also confront the person with the need to give that consent, without which they're not going to get their medication or whatever they need in a timely manner. I am concerned about running into a big problem about September 1, when everybody must have a consent form to get the medicine or the prescription filled. I'm wondering if there are alternatives to this form here that you have considered.

    Mr. Ian Potter: Yes, there are. We have been in discussion with a number of aboriginal organizations, regional first nation organizations, Inuit organizations. We've taken steps to translate this into a number of aboriginal languages. We've also indicated that the form could be adapted, as long as it meets the legal requirements. I understand there have been some adaptations of this. Our minister has indicated to the AFN that if they have suggestions on how to make this form better, they should make them known. You're right, this is a form that has been driven by lawyers and their needs. If we can find people who can adapt it so it's more easily understood, as long as it meets the legal requirements, we're prepared to use a different form.

    The Vice-Chair (Ms. Beth Phinney): Thank you.

    We'll let John Bryden go now, because he's the one who's most familiar with it.

    Mr. John Bryden (Ancaster—Dundas—Flamborough—Aldershot, Lib.): For newcomers to the committee, aboriginals, particularly in the urban centres, were using the non-insured health benefits program and the free drugs it provided and were overdosing, and I think we can safely say that many hundreds in the program died as a result. We had a witness here in 2001, Lorraine Stonechild, who described how she lost a brother and a son to overdoses; they would go around to various doctors and various pharmacists. It became a privacy issue. Attempts by Health Canada, as we understood from Mr. Potter's previous testimony, to collate data on people who might abuse the program were frustrated by a Privacy Commissioner ruling. He said, with respect to the sharing of health information, trying to improve health care was a goal that should not come at the expense of privacy. Consequently, there was a pulling back on the sharing of data.

    Mr. Potter, I'm very pleased to hear what you've said, because obviously, there is a serious effort, as the committee recommended, to collect and share data. I understand that you are still pursuing the consent problem. I saw the consent form, and I thought it was a very good document, but I wonder if you could explain to me how that consent form can capture those who may be unwilling to give their consent because they like to doctor-hop and go to various pharmacies, the very people who are at risk of overdosing by securing multiple prescriptions. How does this consent form address that problem?

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    Mr. Ian Potter: Mr. Bryden, you've asked an important question. I think there are limitations to what we can do, but we have taken steps to work with the directors of health clinics, health authorities, groups that are providing health services to first nation and Inuit people, and they are prepared to work with us to help get people to fill out forms and understand the importance of that. Some of the AFN organizations are concerned about the impact on treaty rights, and so we've been trying to move step by step, so as not to offend that sensibility. Also, people's friends and relatives are well motivated often. They often know about the situation, so we're hoping that with their help, we will get consent from all of the users. There may be some who won't give it.

    We're not sharing it with just anyone, we're only doing it with very careful, clear-cut guidelines, so that the information is used to improve care for the individual. It's a test of health care requirement that we're using. Our plan is to put in limits, so that should you not have that form filled out, you can get a prescription in an emergency, but if it's not an emergency, you will be limited, in that you'll have to pay for it yourself and claim it back from us.

    Mr. John Bryden: Mr. Potter, that sounds, under the circumstances, like an excellent plan, but if a person doesn't sign a consent form and then secures the drugs independently, will there still be a means to track those drug requests? Because these are the people who are the problem.

    Mr. Ian Potter: If they don't claim from us?

    Mr. John Bryden: If they don't sign the consent form and get the drugs by either paying themselves or being issued them on an individual claim basis, will these be trackable, or will it be necessary to track them?

º  (1600)  

    Mr. Ian Potter: If there is a claim to us and non-insured health benefits is reimbursing the pharmacist, we will be able to track it. As to how we intervene, we'll work on that, because we may not be in a position to share the information with a health professional. However, a number of provinces have passed legislation that has introduced this triplicate idea. B.C., I think, is a good example, where all prescriptions, whether we pay for them or Great West or any of the other insurance companies pays for them, are registered with the province, and the province does that review, and they raise issues with the College of Physicians and Surgeons if they feel there's a problem there, or they look at the situation, and they can intervene with health authorities.

    Mr. John Bryden: In previous testimony you indicated that there was no adequate method of tracking those who had actually died, the people who had become victims of the system. The Auditor General in 1997, for example, indicated that in Alberta 42 people died between 1986 and1988, and when you were last here, I think I asked you whether you knew how many had died overall as a result of multiple prescriptions. You were unable to supply the information. Does Health Canada have or is it going to have some means of determining whether this is correcting the problem, whether fewer people are going to be dying as a result of drug overdose in this program?

    Mr. Ian Potter: There are limitations with the current record system when it comes to knowing what the attribution is for someone dying. If someone dies in an automobile accident, the cause of death may be registered as trauma or something, while that person may have overdosed on a certain prescription drug, we don't know. So there are some limitations, depending on the circumstances of the death. We are interested in your question. We're trying to pursue a way whereby we can find out that information, maybe not on a total system, but on more of a research survey basis, where we'd actually have to go in and look at samples of the records and see what the differences are. Improvements in the death records are an issue we're also pursuing on a longer-term basis with registrars of vital statistics, but I think that will take us a while, so in the interim we're trying to look at whether we can put in place some kind of research framework.

    The Vice-Chair (Ms. Beth Phinney): Thank you very much, Mr. Potter.

[Translation]

    Mr. Gaudet.

    Mr. Roger Gaudet (Berthier—Montcalm, BQ): Thank you, Madam Chair. This is the first time that I've attended a meeting of this committee.

    Earlier, you stated that the number of overrides by pharmacists has decreased by 28 per cent. Are you talking strictly about pharmaceutical products? All people seem to be talking about are pharmacies. Pharmaceuticals represent a $1.155 billion industry. Do prescriptions account for most of the claims submitted? Are pharmacists the only ones dealing with this issue? My brother is a pharmacist. I think I'll put him on to this. It seems like a great deal of money to me, an industry worth $1.155 billion.

[English]

    Mr. Ian Potter: The overall budget of non-insured health benefits is not $1.3 billion or $1.4 billion.

[Translation]

    In reality, we're looking at approximately $200,000 per year for pharmacies. However, we do receive a large number of claims from pharmacists for reimbursement of their services. We receive some 8.3 million claims from pharmacists in Canada.

[English]

    In all those claims there is a formula we apply as to whether they are within or outside the normal. If they're outside a normal situation, which could be a repeat prescription or a contraindication, one drug versus another, there are these indicators that go to the pharmacists. The pharmacists get them and are told, don't proceed with this prescription unless you can confirm that there are no problems. Those allow the pharmacist to override the system: the system says, stop, the pharmacist can use his professional judgment to override. Since we have been working with the pharmacists and implementing this program, we've seen a significant decrease in the number of overrides. So pharmacists are more sensitive to the data or to the fact that they shouldn't proceed. While the number of actual prescriptions we're receiving has gone up 25%, the number of overrides by pharmacists has gone down by 28%. This is an indication that our system is starting to work, that it's picking up people who may be doctor shopping, visiting two, three or four doctors, getting a central nervous system prescription. Our system will then tell the pharmacist, the next time the person appears, this is a multiple prescription within a certain period of time, you may not want to proceed. We think our system is working.

º  (1605)  

    The Vice-Chair (Ms. Beth Phinney): Thank you.

    Ms. Wasylycia-Leis.

    Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP): Thank you, Madam Chair.

    The Vice-Chair (Ms. Beth Phinney): Welcome to the committee.

    Ms. Judy Wasylycia-Leis: Thank you. Different critic, but same issue, same witnesses from when I started out six years ago.

    I'm glad to have the chance to talk about this issue. It seems to me the client consent initiative is well along the path of implementation, from what you indicated today, to be fully operational by September 1 of this year. My understanding is that there are outstanding concerns in the Assembly of First Nations. I didn't hear you talk about those specifically today. I think it would be useful to hear your understanding of what those concerns are and how you respond to the resolution that was passed by the assembly this past summer.

    Mr. Ian Potter: I'm pleased to respond to that question.

    We have had discussions on this issue for about three years with the Assembly of First Nations. We had a working group together with them that was addressing this issue. I know there are some concerns; there always have been, and probably still will be, in some first nations communities. I was a bit surprised by the resolution last summer, because of the amount of work we had done with the groups, and we are continuing our dialogue to try to resolve that. We met as recently as last Friday with the national chief and discussed this issue. We agreed that we would be meeting with their organization, hopefully this month, to try to resolve outstanding issues.

    One of those is whether this infringes on a right first nations have, a treaty right or an aboriginal right. The advice I received from our lawyers is that it does not, that this is an issue about privacy and whether or not there is a right to health service. This has no impact on that.

    Other concerns are with the process by which we have developed this. As you're very well aware, there are very different first nation groups across the country, and many of them have different expectations and traditions. It's very hard for us to involve them all in this process, although we've tried and we've tried to adapt it to their interests and translate into their language. I think there is still work to be done to resolve those issues.

    There was also a concern as to whether first nations should provide governments with their information. Often I hear from first nations a slogan, “ownership, control, and access”; they would like to own the data about themselves, control it, and control access to it. They're very concerned because of the history of their relationships, where groups have abused information about them. They're quite concerned that this not happen again. I'm trying to assure them that's not the case, that we are using the information to improve the health service and the health of first nations, and that we will put in place all the provisions of security and control we can.

    Our concern to move this ahead is the health of first nations and access to service. We're concerned that there are people at risk, our system knows it, and we can't act without their consent. I feel strongly that we should try to protect them. We also know there are providers, because of provincial laws or federal law, doctors and pharmacists, whose associations are saying to them, you should be careful about providing information to a government agency or a paying agency unless you have the consent of the person; their reading of the law says they need that in order to pass it on. We are encountering situations where pharmacists may stop billing us directly, may refuse to provide the information directly to us. If that happens, we can't pay for the prescription, and it means the person at the counter will not get it in many cases, because they won't be able to pay for it. So I'm quite concerned that providers will stop dealing with us because they are fearful of passing on the personal information that you had a prescription for this particular substance, which is personal information. They will not be able to send it to us so we can pay them, and so they will stop providing the service.

º  (1610)  

    We actually have physicians now who we are calling up. We have a number of drugs on the exception list. These are drugs that are very expensive or whose use is restricted for certain circumstances. When a prescription is filled for that drug, the pharmacist cannot get us to reimburse them for it unless they fill in a special form that shows why that patient needs it. When we contact the physician and say they have to explain that, they say they can't, this is personal health information, and without consent, they're not telling. If that's the case, we can't pay and the patient is denied that prescription.

    So that's why we're doing it, and hopefully, we can address the concerns of the AFN.

º  (1615)  

    The Vice-Chair (Ms. Beth Phinney): Thank you, Mr. Potter.

    Now we're on the four-minute rounds, and, Mr. Potter, that includes the answer. We're asking you to keep your answers a bit shorter.

    Mr. Ian Potter: Sorry.

    The Vice-Chair (Ms. Beth Phinney): Okay.

    Mr. Mahoney.

    Mr. Steve Mahoney (Mississauga West, Lib.): Thank you.

    Mr. Potter, I'm interested in the issue of the Privacy Commissioner. What you were seeking was consent on utilization of information on the client. Why would the Privacy Commissioner have any concerns if there were consent and if the people consenting knew exactly what it was you were getting the information for?

    Mr. Ian Potter: Our dealing with the Privacy Commissioner was to explain to him the process we were taking to seek consent. We wanted his advice as to whether he felt that met his requirements.

    Mr. Steve Mahoney: And did it?

    Mr. Ian Potter: Yes, it does.

    Mr. Steve Mahoney: So he has no concerns.

    Mr. Ian Potter: He has no concerns with the process we are following now. He had concerns about what we were doing previously, when we were using individuals' information without their consent.

    Mr. Steve Mahoney: Okay. So as long as consent is there, he's satisfied with that.

    Mr. Ian Potter: That's right.

º  (1620)  

    Mr. Steve Mahoney: I'm curious about some of the information here. I'm new to this issue, although I'm a recycled member of this committee, so some of my questions you may have answered before. I note somewhere in here that the total expenditure is $1.3 billion out of the department's $2.5 billion.

    You talk about abuse, saying the levels of abuse have been consistent with those under similar private and provincial programs. Can you tell me what you mean by that? Are you talking percentage? Is it a per capita issue? How do you determine the levels of abuse? Further, when you're looking at abuse, are you working with other agencies, such as the RCMP, in trying to quantify the abuse, and then somehow to provide education programs or whatever to counter it?

    Mr. Ian Potter: There are two types of abuse. One is abuse by people who are covered by the programs, the clients or the patients, where they may be fabricating a prescription form and seeking a benefit, getting drugs they don't use and selling them to someone else. Those we look at through the records to see who's receiving and how many prescriptions, and we try to deal with them, usually, through health providers, the physicians and the pharmacists.

    Then there is provider abuse, where from time to time, as in any other program, you find people who claim services that weren't delivered, add to some of the services they did deliver, or duplicate things. Some of these are done without any ill intent; they maybe batch up a thing and send them in twice. With others there is malfeasance. Where we believe there is malfeasance, we call in the police. Where we believe there is a professional issue, we go to the professional licensing body, which is usually the college of physicians and surgeons or the college of pharmacists, whoever looks at their professional ethics and standards. So if we believe there is abuse by a provider, we usually inform them and ask for an explanation. If we don't think it's a reasonable explanation, we usually inform their licensing body. If we believe it's a question of criminal malfeasance, we inform the RCMP.

    The Vice-Chair (Ms. Beth Phinney): Mr. Mayfield.

    Mr. Philip Mayfield: I think what we have been talking about is how we can protect people from themselves in abusing drugs. I am having some difficulty understanding how a consent form is really going to stop that. If there is a doctor who is giving too many prescriptions to an individual, you can report the doctor to the professional association, but that's about all you can do, and it's going to take a while for that to happen, I would think, and the same with the pharmacist. What about the person who says, no, I'm not going to sign this, I'm not going to be a part of that program, I'm just going to pay for it myself? And what about those people who are a part of the insurance program the rest of us are involved with? How are they covered in this?

    Mr. Ian Potter: Those are broader questions we are trying, as one part of this issue, to deal with, and we work with provincial governments and professional associations to try to address those questions. What we are trying to do with consent is have information about individuals' prescription habits. Where there is suspicion that the person is abusing a prescription drug, we can inform their health providers. Because sometimes they are seeing three or four doctors, and the doctors don't know they're seeing someone else. This would allow us to say, you are seeing patient X; patient X is also visiting doctors Y and so on, so you may want to talk to that patient before you provide any more care. If the person doesn't send us a bill, we don't know about it.

    We recognize that the pharmacists' associations are concerned with this, physicians are concerned with this, and health program people are concerned with this. So we have supported programs in the communities to try to deal with drug abuse. As I said in my comments, we are providing support to aboriginal and first nation communities for them to put on programs of aid for addictions--and people are addicted not only to narcotics that are illegal, but also to prescription drugs. We're trying to provide health education and support to those groups that would work with them to try to avoid the problem.

    Mr. Philip Mayfield: This program depends upon the compliance of the patient, the doctor, the pharmacist, and all the rest of it. Do you have any indication yet of the status of this compliance? Is it too early for that?

    Mr. Ian Potter: From the number of overrides, where we're seeing it fall, I think we're getting greater compliance.

    I'll ask Dr. Cooney to respond to that in respect of dealing with professional organizations.

    Mr. Peter Cooney (Acting Director General, Non-Insured Health Benefits, First Nations and Inuit Health Branch, Department of Health): Thank you, Mr. Potter.

    If you remember, in the past we've discussed the numbers of on-site audits we've been doing, and the numbers were low. We have done a considerable number of on-site audits in the last 12 months. We have specifically audited on the override code. In other words, if a pharmacist continually overrides and keeps dispensing the same drug, that will trigger our system. We audit specifically now to that code. So we're finding far greater compliance with pharmacists and professional bodies because of the wish to comply and the fact that they are being audited to the specific code. We're finding the same thing with physicians. As we're working with physicians' organizations across the country in relation to triplicate prescription programs, the physicians are also dealing with us on a more regular basis. So overall, we're finding that professional groups are complying more. Our feeling is that when the consent initiative is completed, there will be a comfortable flow of confidential information between us and the specific physicians involved and the licensing bodies of those physicians and pharmacists. If there are any loose ends, they will be tied up at that point.

º  (1625)  

    The Vice-Chair (Ms. Beth Phinney): Thank you, Mr. Cooney.

    Mr. Tirabassi.

    Mr. Tony Tirabassi (Niagara Centre, Lib.): Thank you, Madam Chair.

    I'd like to welcome our witnesses as well.

    I am new to this committee, and it is an issue that really doesn't hit back home in my riding. Nonetheless, I am interested in an overview of the parameters of your department. I see here the area that you address and how that fits into the overall health department. Could you begin with that, please?

    Mr. Ian Potter: We're discussing here the non-insured health benefits program, which fits into a broader program of first nation and Inuit health, which Health Canada runs, and that's one branch of the department. The department has a variety of different roles, most of them national, regulation, drug approvals, environmental issues, population and public health. First Nations and Inuit Health Branch takes the responsibility the federal government has to provide health services to Indians and Inuit. This is a responsibility the Government of Canada accepted over a hundred years ago. We run two types of programs, a community health service program, where we provide primary care and public health services on reserves, and this program, non-insured health benefits, which provides pharmaceutical benefits, vision, dental, and transportation services for all registered Indians, status Indians, and Inuit in Canada, about 720,000. Our program insures the things that aren't part of the basic insurance program provinces provide.

    Mr. Tony Tirabassi: Does this not also cover off-reserve?

    Mr. Ian Potter: The community program is just on reserve. We actually have nurse practitioners on reserve, but we don't have any off reserve, that's a provincial responsibility. This program, which covers drugs, dental, pharmaceutical, and vision, applies on and off reserve. So if you're a status Indian or Inuit in Canada, you're covered by this program.

    Mr. Tony Tirabassi: Thanks.

    The Vice-Chair (Ms. Beth Phinney): Ms. Wasylycia-Leis.

    Ms. Judy Wasylycia-Leis: Thank you, Madam Chair.

    Excuse me for not knowing the background to the way the committee operates, but it would seem to me to make sense to have representatives of the AFN invited to appear before the committee on this issue of the client consent initiative. It's just for information.

    The Vice-Chair (Ms. Beth Phinney): I'm not sure who I should ask. I wasn't here either when they did this before. Were they in earlier?

    The Clerk of the Committee: I don't believe they were, Madam Chair.

    The Vice-Chair (Ms. Beth Phinney): Could you repeat your comment, because Mr. Bryden is the expert here?

    Ms. Judy Wasylycia-Leis: I'm just wondering if the committee has invited or received a request from the Assembly of First Nations to appear before public accounts on this issue of the client consent initiative.

    The Vice-Chair (Ms. Beth Phinney): We're just trying to get an update now, because we've really finished the report.

    Ms. Judy Wasylycia-Leis: It just makes sense, given that there's obviously still a gap.

    Mr. John Bryden: I don't know that there is a gap. Basically, it has to do with aboriginals in urban settings, the urban poor who are aboriginal. The problem cropped up mainly in Regina, Edmonton, various places. It's not an on-reserve problem, because there are controls there. The Assembly of First Nations has never made any application to this committee, because the committee's approach is in reaction to an Auditor General's report, so it was seen as a government administration problem. The last time we had Mr. Potter was also an update. The Auditor General visited this problem in 1997, again in the year 2000, there was an update in the year 2001, and now we are where we are.

º  (1630)  

    The Vice-Chair (Ms. Beth Phinney): The researchers say there was no request. We can look into it and find out.

    Ms. Judy Wasylycia-Leis: The issue, as far as I can tell, seems to be protection of information. I know you've tried to answer that today, but I still have questions as to what assurances the assembly has received that information will be protected and will be used for the intended purpose and that there's no chance that Health Canada would use the information for other purposes or without the consent of the individual. I think we need some clarity on those questions. Probably, there's some history here in the matter of trust and information perhaps not being used in the way it was supposed to be used. That's my question. If you can offer more clarification on that, it would be useful.

    Mr. Ian Potter: I think you're right, it's to do with the long history and concerns. We're trying to address that in a respectful way, and I think the comfort level is different in different parts of the country and with different first nations. Some are quite comfortable with the process, others aren't.

    The Vice-Chair (Ms. Beth Phinney): Thank you, Mr. Potter.

    Mr. Bryden.

    Mr. John Bryden: Mr. Potter, I've been with this problem for a very long time, and this is probably my last appearance on this public accounts committee. I want to tell you I'm convinced by your testimony that you and your officials have approached this problem in a creative and determined way, and as a consequence, lives will be saved. We know lives will be saved. We who have been close to this problem for a long time know people have been dying, and I really congratulate you on the effort you've put forward. I'm satisfied that you're going in the right direction. It's also a great credit to the committee process that a standing committee of Parliament can work with officials and do great good.

    With that, Madam Chairman, I put closure to at least this term of office, if you can call it an office, on the public accounts committee. I thank my colleagues, because I've enjoyed sitting on this committee very much.

    The Vice-Chair (Ms. Beth Phinney): Thank you, Mr. Bryden.

    Mr. Mayfield.

    Mr. Philip Mayfield: Madam Chair, if I may speak for a moment, on behalf of the committee, as this is likely the last time you're going to be here, at least for a time, Mr. Bryden, I'd like to thank you for your dedication to our concerns. This issue today is a good example of how you have brought your concerns and your intelligence to bear. It's been my pleasure, and I'm sure it has been for other members of the committee, to share in that with you. I want to thank you very much.

    The Vice-Chair (Ms. Beth Phinney): Thank you very much, Mr. Mayfield.

    Ms. Meredith.

    Ms. Val Meredith (South Surrey—White Rock—Langley, Canadian Alliance): I am new and I missed the initial hearings, the reviews, and all the rest of it, but having lived in an area that was 50% aboriginal, with on-reserve and off-reserve native people, I'm curious as to how you determine what your program is going to cover. In British Columbia and Alberta there are health care insurance premiums. Does this program pay for the individual's premium, so that they're covered under the provincial health care?

º  (1635)  

    Mr. Ian Potter: Yes, it does.

    Ms. Val Meredith: So this is an insurance program above and beyond that to deal with those areas that are not insured.

    Through this computerized program on prescription drugs and what not, you identify where there's abuse, whether it's the doctors giving out more than one prescription, whether it's the pharmacist giving out more prescriptions. Who does the follow-up? When you identify that there is an abuse or that there is a duplication of services, who actually does what? Does somebody in your department contact the pharmacist? Does somebody in your department contact the doctor? What is the follow-up once it's been identified that there is a duplication of prescriptions?

    Mr. Ian Potter: The follow-up would depend on the assessment of the issue. If we believe there is a pattern, that an individual is getting a number of prescriptions that could be dangerous to their health, they're visiting a number of doctors, receiving similar prescriptions for the same ailment, going to a number of pharmacies and getting them filled, so that none of the health providers knows the full story of this person, in that case we would provide that information to the health providers. So if you're visiting a few doctors, we would be explaining to them that the patient is not only seeing you, but seeing a number of others.

    Ms. Val Meredith: Would you do it by a letter, would you do it by a personal visit? How would you inform the medical practitioners of what's going on?

    Mr. Ian Potter: It's by letter.

    Ms. Val Meredith: So you would give out the names of the other doctors they're seeing, so they would know the medical practitioners who need to be talking to each other?

    Mr. Ian Potter: That is the area where we're seeking consent. It requires judgment, and the judgment is done by health professionals, who would look at the situation and say, this is a case where this person could be at risk. We're very careful. You may have some reason for visiting two doctors and not telling each of them, and it might be quite legitimate for you to do that. But if we see a pattern we believe would put you at risk, it is our obligation to inform those health professionals that they don't know the whole story about this patient, so their treatment might actually be putting that person in peril.

    Ms. Val Meredith: My understanding is that in the province of British Columbia--and I could be way off the wall on this--they do have a program where pharmacies are aware of what prescriptions have been given out to individuals, where one prescription may have a very dangerous effect taken with a different prescription. So if you're getting this information from the pharmacies, if they understand that someone gets a prescription from one doctor and another from another doctor and there's a dangerous situation, and you've sent them a letter, what's the follow-up to make sure they've actually done something about it?

    Mr. Ian Potter: Perhaps I could ask Dr. Cooney to respond to that.

    Mr. Peter Cooney: With the physicians, there is a letter to advise them. Generally, the physicians then determine, if there are, say, three of them, that two won't see this patient, and the third physician continues to see them. With the pharmacists, there are three basic messages--and you've alluded to them in your comments--drug-to-drug interaction, if there's a problem with the drugs, the same drug within a limited timeframe, a repeat prescription, or the same category of drug within a limited timeframe. Those messages go to the pharmacist, and the pharmacist then makes a professional decision whether they're going to override the message or not. In other words, if there's an ulcer medication and the patient didn't respond to the first medication, the physician may genuinely give them a second medication within the timeframe, and the pharmacist would then override. So that's a genuine override. There are cases, however, where it may be a barbiturate or some type of mood-altering drug, in which case the pharmacist is alerted to the fact that there may be a problem with this patient, and they would then question the patient. They are the overrides we referred to earlier.

    In 1999, when we started appearing before this committee, about 1.7% of all claims were overridden. It's a small number, but it was high in relation to the number of overrides that were seen. What has happened in the last three years is that the number has come down to 0.9%, and that's with the 28% decrease in overall claim numbers we've seen. Then, as I mentioned earlier, we audited those overrides. So if you find a pharmacist who is continually overriding, you do an on-site audit with that pharmacist to determine why. With the automated system, we have managed to reduce these overrides. You're always going to get some, because there will always be genuine cases, but what we want to do is distinguish the genuine from the not-so-genuine, and the automated process does that.

    What consent is going to do for us is allow us to go back to the pharmacist's licensing body or to the physician's licensing body and advise them that doctor X or pharmacist Y is overprescribing in this area and we're very concerned. That's the part we couldn't share in the past, because of the privacy of the patient issue, and that is what the patient is consenting to now. And this is what we're doing in our meetings with the first nations groups, explaining this so that they feel comfortable that this is the right thing to do and it's a positive thing.

º  (1640)  

    The Vice-Chair (Ms. Beth Phinney): Thank you very much.

    Mr. Mayfield.

    Mr. Philip Mayfield: Thank you very much.

    Very briefly, do you have any idea of what the cost of this consent form program has been?

    Mr. Ian Potter: It will be about $3.2 million this year, and next year about $1.9 million.

    Mr. Philip Mayfield: So there will be an ongoing cost each year, I guess.

    Mr. Ian Potter: Yes, but it will drop quite considerably.

    Mr. Philip Mayfield: I presume these are in all doctors' offices and pharmacies.

    Mr. Ian Potter: Yes.

    The Vice-Chair (Ms. Beth Phinney): Ms. Meredith.

    Ms. Val Meredith: Is it a consent form that will last for a long period of time, not a renewal every year?

    Mr. Ian Potter: It lasts for a lifetime, or for a long period of time.

    Mr. Philip Mayfield: Thank you very much.

    We do have a little help from our researchers. There is a matter that has been raised by them in putting this together. The NIHB program is intended to be an insurance program of last resort. Someone who has another insurance policy should not be drawing on the NIHB, and clients are required to declare voluntarily if they are covered by another policy. How many clients have indicated that they have third-party coverage? How much has been saved as a result? Has the department been conducting regular audits to determine if there is a gap between those who are declaring and those who have not? If so, what results have been obtained and what actions has the department taken?

    Mr. Ian Potter: I'm afraid I can't answer that for you at the moment, but I'll take it under advisement and see if I can get you the information.

    The Vice-Chair (Ms. Beth Phinney): Please get it to us as soon as you can. Thank you very much.

    Mr. Philip Mayfield: We've talked about the need to have this consent form signed before you can get things. There's an override. Are there other circumstances in which a person who may not have signed a consent form can perhaps receive prescription drugs from the pharmacist after September?

º  (1645)  

    Mr. Ian Potter: I'll ask Dr. Cooney to explain.

    Mr. Peter Cooney: After September, there's a first forgiveness, as Mr. Potter identified. In other words, if the patient goes in and doesn't know that a consent was necessary, if it's their first visit, we clear the first prescription for them, and they then take the consent kit, which you have seen, and go home and consider signing the consent. Hopefully, they'll sign it and submit it. If they still opt not to sign the consent, we are putting a form in place called a consent for reimbursement. So they pay for the drugs or the service, or they have a third party, their band or a relative or whatever, pay for the service, and then they submit the claim for reimbursement. That gets loaded on the system, and the cheque is paid directly to the patient. So if you get a service under the non-Insured health benefits program, that service gets loaded on the automated system.

    Mr. Philip Mayfield: And that's the only exception, correct?

    Mr. Peter Cooney: The first forgiveness and consent for reimbursement.

    Mr. Philip Mayfield: It is going through the back door, isn't it?

    The Vice-Chair (Ms. Beth Phinney): Thank you, Dr. Cooney.

    Mr. Gaudet.

[Translation]

    Mr. Roger Gaudet: Thank you, Madam Chair.

    Perhaps my question is too simplistic, but why not designate certain pharmacies to fill prescriptions? That way, you could verify everything at the same time. Specific pharmacies could be designated for this purpose. That would be the easiest approach to take. You could gather all of the information at the same time. As things now stand, people get their prescriptions filled anywhere. However, if they went to designated pharmacies for their prescription needs, just as consumers do when...For example, people go to specific locations to purchase alcohol. It cannot be purchased just anywhere. Perhaps it would be a good idea to have specially designated pharmacies for prescriptions. This arrangement would mean your having to do fewer checks. Thank you.

[English]

    Mr. Ian Potter: The main reason we have this process is the geographic distribution of first nations and Inuit people. We are serving over 600 communities, reserve communities or aboriginal communities. Then there are aboriginal people living in many cities and towns in Canada. In order to allow them to have access to health services that are readily available, we've chosen to say we will deal with all of the pharmacies that are there and offer those pharmacies the ability to register with us, so they can deal with the first nation or Inuit client. We've looked at the question of whether we would want to centralize and use our own pharmacy system. We're still in discussions about that. We do that for certain first nation communities where we're providing a clinic, but for ease of availability, we find it's a better system to allow people to go to their local pharmacy and get reimbursed there.

[Translation]

    Mr. Roger Gaudet: That doesn't mean there would only be one pharmacy for everything else. If there's more than one pharmacy in a town, it would be a matter of designating a main one for prescription needs, or of designating a pharmacy for this purpose on a reserve. Specially selected pharmacies would fill prescriptions. Instead of going to one of four pharmacies in a town, customers would head to one for their prescription needs. That's my suggestion.

[English]

    Mr. Ian Potter: It's something we'll consider. There are lots of pros and cons, and there's how you would choose and what process we would go through. Our objective is to provide a health service that's easily available to people who are in need and not make it too difficult.

º  (1650)  

    The Vice-Chair (Ms. Beth Phinney): Ms. Meredith.

    Ms. Val Meredith: I just wanted to clarify what I heard. What I heard is that if somebody doesn't sign the consent form, for the first time they will get their prescription, and after that, if they get their prescription paid for, but then send in a reimbursement form to Indian Affairs, to your insurance program, the information they have not given consent for will still go into the system.

    Mr. Ian Potter: No. Once the system becomes operational in September, there will be some people who, in spite of our best efforts, don't know they have to sign these forms, and if they show up at a pharmacist, we're prepared to allow them to get one prescription, and we will pay for it directly to the pharmacist. The pharmacist can bill us automatically through the Internet system, and we will reimburse them. Once that's past, the person, hopefully, is informed. If they then say they will not provide consent, we're not taking the position that we won't pay for their drugs, but we cannot use the automated system, because the pharmacist will not have the consent of someone to load that information in the system. What we are saying to them is, here is a form; you pay the pharmacist; you can send us your health information directly, and therefore you don't have to consent to a third party, but in that form you have to give consent for us to process that form. In order for us to process it, we have to send your information to a company that processes the bills.

    Ms. Val Meredith: So the only difference is that the consent form allows the pharmacist to get the information from them and to give it to you. Without that, you still require the information, but you'll get it directly from them and not through a third party. But what if they don't want to give you the information?

    Mr. Ian Potter: If they refuse to give us any information, we can't process their claim, because we will have no idea whether it was a real claim. We won't be able to talk to the pharmacist to see whether they actually filled it. We won't be able to approach the person's physician to see whether they actually gave it. So without consent for us to at least fulfil our obligations, we would not be in a position to pay that claim.

    Ms. Val Meredith: Okay. Thank you.

    The Vice-Chair (Ms. Beth Phinney): Mr. Potter, we'd like to thank you very much for coming, and the people who came with you. We may write a report on this meeting. Thank you for the progress that's been made.

    Could I speak to the committee members for just a moment? We were intending to go on with something else and to do a consideration of a report. Because there isn't much time left in the meeting, we'll do that on Monday.

    The meeting is adjourned to the call of the chair.