Standing Committee on Health Monday, March 21, 2016 Chair HESA

Standing Committee on Health Monday, March 21, 2016 Chair HESA
Standing Committee on Health
HESA
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NUMBER 004
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1st SESSION
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EVIDENCE
Monday, March 21, 2016
Chair
Mr. Bill Casey
42nd PARLIAMENT
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Standing Committee on Health
Monday, March 21, 2016
● (1530)
[English]
The Chair (Mr. Bill Casey (Cumberland—Colchester, Lib.)):
We'll call the meeting to order.
There are a couple of housekeeping issues that I want to go over
before we go very far. We asked the minister if we could have the
reports on e-cigarettes and safety code 6, and she replied that we
have to bring those reports back to this committee, discuss them, and
pass them, and then she will respond to them. However, as they are
now, they are expired.
I think the committee is interested in having responses to those
two studies. If we want to do that, we have to bring them back,
refresh them, and table them in the House of Commons in order for
them to respond. Does anybody want to make a motion to do that?
To start, I want put the Canada Health Act in context. I'll start by
making a few comments about the role of the federal government in
Canada's health care system.
As you likely all know, as a partner with many other players, most
notably the provinces and territories, the federal government has a
number of functions: we protect Canadians from environmental risks
associated with unsafe food, health, or consumer products; we
approve drugs for sale in the Canadian marketplace and monitor
their safety; we respond to infectious disease outbreaks and various
health emergencies; we support the delivery of health care to first
nations and the Inuit, federal inmates, members of the Canadian
Forces, and veterans; we promote and fund innovation and research
in health care; and we inform Canadians about various health risks
and beneficial practices that will help them make healthy choices.
Mr. Carrie.
Mr. Colin Carrie (Oshawa, CPC): Sure. I'll make a motion to
bring those reports back so that we can have the minister give us a
response.
The Chair: Could the analysts give each member a copy of those
two reports, the one on e-cigarettes and the one on safety code 6, so
that we will have them right away? We'll bring them back at a future
date.
Also, the issue of marijuana came up in the last meeting. Dr.
Leitch raised the marijuana issue in the last meeting, and we wrote to
the Minister of Justice to ask if we could expect a reference for any
legislation to come this way. We don't have an answer yet, but I just
wanted to let you know that we're working on that.
In the meantime, we should move ahead with those two reports,
and we'll get them under way.
We have two distinguished witnesses here today, and we're
looking forward to hearing from them. Ms. Abby Hoffman is the
assistant deputy minister, strategic policy, and Ms. Gigi Mandy is the
director of the Canada Health Act division, strategic policy.
We'd welcome opening statements, if you have them. You have
the floor.
Ms. Abby Hoffman (Assistant Deputy Minister, Strategic
Policy, Department of Health): Good afternoon to all of you.
Thanks for the invitation to talk to the committee about the
Canada Health Act generally, and the Canada Health Act annual
report for 2014-15, which was tabled in Parliament just about a
month ago, on February 25.
With respect to health care specifically, while responsibility for the
delivery of health care services rests primarily with provinces and
territories, historically and currently, the federal government has
exercised its spending power to support provinces and territories in
the discharge of their responsibilities, and in so doing, to set the
underlying principles and values for health care systems across the
country.
As you know, the main vehicle through which the federal
government transfers funds to provinces and territories is the Canada
health transfer. By way of reference, in 2015-16, the current fiscal
year, the federal government provided about $34 billion via the CHT,
which represents a little over 23% of the total spending by provinces
and territories. This transfer of funds to provinces and territories
under the CHT is not automatic. In fact, in order to receive its full
allocation, each province or territory must ensure that its publicly
funded health insurance plan meets the requirements of the Canada
Health Act.
The conditions and criteria of the act are, in effect, the national
principles that guide the Canadian health care system: universality,
comprehensiveness, accessibility of care, portability, and public
administration. These principles indicate who shall be covered, for
what, in general terms, and where within Canada and beyond our
borders, as well as the basic character of provincial health insurance
systems—that is, that those shall be publicly administered and
operate on a non-profit basis.
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March 21, 2016
Very importantly, the act also has provisions that discourage direct
charges to patients for publicly insured health care services. These
charges, defined variously as extra billing or user charges, are
articulated in the act. These provisions are a critical element, giving
meaning to the accessibility principle.
and user charges. In effect then, the goal of the Canada Health Act is
to ensure that medically necessary physician and hospital services, as
well as certain surgical dental services are available to Canadians on
uniform terms and conditions, and without financial or other barriers.
As the only federal legislation pertaining directly to the delivery of
health care services, the Canada Health Act is a good example of the
federal government using its spending power to set national
standards and promote the primary objective of Canadian health
care policy, which, as stated in section 3 of the act, is “to protect,
promote and restore the physical and mental well-being of residents
of Canada and to facilitate reasonable access to health services
without financial or other barriers”.
The federal government encourages provinces and territories to
experiment and design health care systems that meet their own
particular circumstances, so long as the principles of the CHA are
respected.
The CHA is an excellent example of how governments have
worked together over time to solve complex social policy challenges.
In the annual report, there is a description of the relevant history in
some detail. I just want to touch here on a couple of key milestones.
Canada's commitment to a largely publicly funded health care
system began in 1947 as an ambitious and visionary experiment in
public hospital insurance in Saskatchewan. Ultimately, to support
replication of the Saskatchewan arrangements, the federal government passed the Hospital Insurance and Diagnostic Services Act in
1957, which committed the federal government to share the cost of
these services with provinces. By 1961, all other provinces and
territories had adopted similar models.
A few years later, the same pattern was repeated when
Saskatchewan expanded its public health insurance regime into
coverage for physician services. The Parliament of Canada passed
the Medical Care Act in 1966, and again, other provinces and
territories followed suit by 1972. By that time, both hospital and
physician services were available to Canadians through a universal,
pooled risk health insurance scheme.
● (1535)
Although Saskatchewan's Tommy Douglas saw publicly insured
hospital and physician services as simply the initial stages of a
medicare system that would eventually include other elements of
care such as dental or access to drugs, the focus of Canadian
medicare has remained focused on hospital and physician services.
Moving ahead a little bit in historical terms, by 1979, it was
apparent that the objective of federal support for physician and
hospital services for Canadians was being undermined by additional
charges levied directly on patients.
In response to this growing threat to universal access to care, in
1979, at the request of the federal government, Justice Emmett Hall
undertook a review of the state of heath care services in Canada. His
report affirmed that health care services in Canada ranked among the
best in the world, but he warned that extra billing by doctors and user
charges levied by hospitals were creating a two-tier system that
threatened universal accessibility of care.
Justice Hall's report and the national debate it generated led to the
enactment of the Canada Health Act in 1984. The act retained the
basic principles contained in those two earlier pieces of legislation
and reaffirmed the country's commitment to a universal health
insurance program by adding specific prohibitions on extra billing
Since the act was passed, adherence by provinces and territories to
its principles has meant that the provincial and territorial health
insurance systems are much more alike than they are different. The
machinery of the administration of the act also contributes to the
consistency of a nationally publicly funded health care system. For
example, Health Canada chairs a federal-provincial-territorial
committee on reciprocal billing, which helps resolve issues
Canadians may face when moving to other provinces or when
travelling.
Health Canada also hears from Canadians through correspondence
and telephone calls. In some cases, departmental officials are able to
assist Canadians as they navigate the health care system and we may
even intervene on their behalf.
For example, and this is a recurring situation, Canadians who
move from one area of the country to another do not always
understand that they are required to register with their new province's
health insurance scheme. This only comes to their attention when
they try to secure care using an expired or out-of-province card from
their old province of residence. Working with both implicated
provinces, we have on many occasions been able to assist Canadians
in maintaining their coverage.
Of course, when Canadians reach out to us to comment on the
delivery of specific services, we refer them to provincial and
territorial ministries who have jurisdiction in this area.
I want to stress on the issue of compliance by provinces and
territories that the health insurance plans of the provinces and
territories generally respect the criteria and conditions of the Canada
Health Act. In fact, the legislation in most provinces, governing their
health insurance schemes, often goes well beyond the requirements
of the Canada Health Act both in terms of the range of services
covered and mechanisms to ensure compliance with the values and
principles of universally accessible health care.
Many jurisdictions, as you likely know, cover to a certain degree
vision care, pharmaceuticals used outside of hospitals, ambulance
services, and so on. When provinces and territories provide care
outside the scope of the act, they are not bound by the requirements
of the act. They are free to arrange those services on their own terms
and conditions, and according to their own priorities. This allows
jurisdictions to target specific populations such as children, the
elderly, or specific regions, and to require some sharing in costs by
patients.
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We recognize that while the CHA may establish important
principles, provinces and territories are responsible for administering
their multi-faceted systems that are usually governed by considerably more complex legislation detailing every aspect of how their
health insurance scheme is administered, and how their health care
system is organized, financed, and governed.
● (1540)
While the core principles of the Canada Health Act have enduring
value, as health care evolves, the legislation has been subject to
periodic clarification and interpretation to ensure its application to
new circumstances.
Administration of the act, by way of example, has been informed
by three very important key interpretation letters over the past 30
years.
In 1985, Minister Jake Epp's letter elaborated in great detail on
the provisions of what was then still new legislation.
A decade later, in 1995, Minister Diane Marleau communicated
the federal policy on private clinics, which expanded the definition
of hospital to include facilities where patients, at that time, had to
pay facility fees to receive services covered under medicare. Her
letter was intended to put an end to those kinds of patient charges.
Finally, in 2002, Minister Anne McLellan wrote to the provinces
and territories to outline a Canada Health Act dispute avoidance and
resolution process. The objective of this initiative was to encourage
ongoing communication, in the interest of avoiding disputes in the
first place. In the event that such a dispute did occur and was not
resolvable through our normal informal processes, a formal process
to deal with these disputes was set out.
When instances of possible non-compliance with the Canada
Health Act arise, our approach to the administration of the act
emphasizes transparency, consultation, and dialogue with provincial
and territorial health ministries. We rely on the goodwill of provinces
and territories as we work through issues of concern, because under
the act we do not have any direct investigative powers.
The application of financial penalties, through deductions under
the Canada health transfer, is considered only as a last resort when
all other options to resolve an issue collaboratively have been
exhausted. These penalties are documented in the annual report,
which you may have seen.
As you may have seen in the annual report that was tabled in
February, from the time of the passage of the Canada Health Act
until March 2015, over $10 million has been deducted from
provincial or territorial transfer payments as a consequence of extra
billing and user charges. That may seem like a small amount. I'll just
note that the $10 million does not include close to $245 million that
was deducted from 1984 to 1987 and subsequently refunded to the
provinces and territories when they agreed to eliminate extra billing
and user charges. That refund mechanism, which is no longer in
effect, was intended at the time to act as an incentive for provinces
and territories to come into compliance with the act. That's why the
provision was time limited.
I want to be clear that our goal in administering the Canada Health
Act is not simply to levy penalties. In fact, it's not really to levy
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penalties at all, but rather, to achieve compliance and therefore
ensure access to insured services for Canadians, without barriers
associated with ability or willingness to pay.
Let me quickly make a couple of comments about the annual
report.
Tabling the report is a legislative requirement. It must be tabled in
the first 15 sitting days of each calendar year. Although it is tabled in
the federal Parliament, the content of it reflects the collaborative
effort of provincial, territorial, and federal governments to inform
Canadians about their publicly funded health insurance plans.
The federal section of the 2014-15 version of the report describes
the Canada Health Act, our approach to administering it, and
compliance issues that were on the table during the 2014-15
reporting period. As you may have seen, the bulk of the report is
actually taken up by overviews of provincial and territorial health
insurance plans. This information is provided to us at our request by
provinces and territories. This data shows how each of those plans
meets the conditions and criteria of the act, along with relevant
statistics on publicly insured hospital, physician, and surgical-dental
services in each jurisdiction.
However, it's important to note at the same time that while the
report contains a lot of information about medically necessary
physician and hospital services, which are subject to the criteria and
conditions of the act, the report's scope does not extend to reporting
on the status of the Canadian health care system as a whole. It is
simply a report on the extent to which provincial and territorial
health insurance plans comply with the conditions and the criteria of
the act.
● (1545)
As I come close to the end of my remarks here, let me comment
briefly on compliance issues. In terms of specific issues noted in this
year's report, you will see a commentary on a deduction to British
Columbia's CHT payment in the amount of a little over $241,000.
This deduction was taken in respect of extra billing and user charges
at private surgical clinics in B.C.
The report also notes a number of other recent and long-standing
compliance issues. These issues vary from following up on
stakeholder allegations of extra billing, to insisting that patients
cannot be billed directly when they elect, for example, to have
robotic-assisted surgery. Over the last year, we've approached
provinces where hospitals were charging patients directly for
preferred hospital accommodation when ward space was not
available. We've also raised concerns in some parts of the country
about membership fees at primary care clinics which, in our
judgment, had the potential to pose a barrier to access to insured
services.
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March 21, 2016
I'm happy to say that our compliance work is generally conducted
as a two-way street. From time to time provinces come forward and
ask for advanced assessments of initiatives they are considering, to
ensure that those conform to the requirements of the act, or at least
they know in advance what might ensue if there's an issue or a
proposal that might fall outside the act.
It sounds to me like you must make a lot of judgment calls in the
run of a day.
In the year in question we provided two such assessments. One
concerned a proposal by a charitable foundation to pay for a nurse
practitioner clinic dedicated to the clients of a community resource
centre. The province was concerned that providing preferred access
to clients would pose accessibility concerns under the act, but we
advised the questioner that since the services were not provided by
physicians nor in a hospital there were no concerns under the act.
Mr. Doug Eyolfson (Charleswood—St. James—Assiniboia—
Headingley, Lib.): Thank you for that very interesting and
informative presentation.
The second assessment concerned a proposal by a group of
ophthalmologists who wanted to charge patients for tests when they
were performed in a physician's office instead of in a hospital. In that
case there was a concern about the Canada Health Act, since the tests
form part of a physician service, and no direct fees may be charged
for such services when they are insured by a provincial or territorial
health insurance plan. That proposal was abandoned.
Lastly, before turning to questions I'd like to touch on a recurring
criticism that we certainly hear, and that is, that the Canada Health
Act is an outdated piece of legislation that impedes innovation and
modernization of health care systems. Not surprisingly, we have
another view.
We'd like to remind members of the committee that the act allows
provinces and territories the flexibility to experiment with various
governance, organizational, delivery, and financing arrangements,
provided those experiments meet the Canada Health Act test of no
direct patient charges for insured services.
For example, many provinces are experimenting with family
health teams, where physicians and other health care professionals
work together to manage various aspects of patient care.
Other provinces have made care for those suffering from chronic
conditions in remote areas less burdensome through tele-monitoring
of patients' conditions.
Since no direct charges are made to patients in either of these
cases there is no concern under these alternative delivery models. We
think they are examples of the way in which the act is sufficiently
flexible to accommodate delivery models that, frankly, were not
envisaged in 1984 when the act was passed.
Let's just make this our concluding comment in these initial
remarks. Our general view is that we think the values that underpin
the act—those of equality, fairness, and solidarity—are just as
relevant today as they were in 1984, and they will remain relevant as
we continue to improve our health care system to meet the evolving
needs of Canadians.
Mr. Chairman, I'll stop there, and both Gigi Mandy and I will be
happy to take the members' questions.
Thank you.
● (1550)
The Chair: Thank you very much.
We'll start our questioning with Dr. Eyolfson.
One of the things you spoke of was how the Canada Health Act
does exclude some services, in particular out-of-hospital pharmaceuticals and ambulance services. Would you see the exclusion of
these services as a problem for the long-term viability of the Canada
Health Act?
● (1555)
Ms. Abby Hoffman: I'll start, and Gigi may want to comment.
They don't impact the viability of the act in that it's still the case
that a very large portion of health care spending in Canada goes to
hospital and physician services. They are, obviously, governed by
the conditions and criteria of the act.
I think it is the case that the result of the Canada Health Act's
focus on physician and hospital services does mean that across the
country other services, such as the ones you've mentioned and many
others, are either not covered at all, or if covered, are covered in
different ways in different parts of the country. The good news is that
in many provinces they've evolved to pretty much the same level of
development, so a lot of these services are covered in some manner
or another. Drug coverage is clearly an issue, as well as access to
other services in the community, for example, home care.
The fact that there are differences across the country is an issue of
concern, even if provincial and territorial funding in these areas is
quite robust. At this point, that is simply the state of play across the
country.
Mr. Doug Eyolfson: Could Health Canada measure the potential
benefit of universal coverage for pharmacare in cost savings to the
health care system, versus the outlay of cash initially to establish
such a system?
Ms. Abby Hoffman: Are you speaking specifically about drugs,
or are you talking more—
Mr. Doug Eyolfson: I'm talking more about drugs. Is there any
analysis that might look at the cost of funding out-of-hospital
pharmaceuticals versus the costs saved to the health care system by
improving outcomes in those who can't afford them? Has any
analysis like that been done?
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HESA-04
Ms. Abby Hoffman: There's no algorithm that makes a precise
calculation of the consequences of forgone access to drugs among
those Canadians who cannot afford to fill prescriptions. We do know
from various surveys that it's not a huge portion, but there is a critical
mass of Canadians who actually say they do not fill or renew
prescriptions because they simply cannot afford to. We do know that
there are downstream costs to the health care system, incremental
costs associated with that. We would note from any of these studies
that have been done that they are likely larger than the costs
associated with providing drug coverage for those individuals.
Yes, there are downstream costs in terms of deteriorating health,
possible admission to hospital, and utilization of other health care
services. I think it's actually the reason that now, as you know, under
the discussions about a shared health agenda and the potential of a
new health accord, access to pharmaceuticals is one of the key
components of that effort. There is a lot of concern about both the
cost implications and the toll that it's taken on the health of those
individuals who simply cannot afford drugs.
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Mr. Colin Carrie: I want to thank Dr. Hoffman for being here.
Whenever we have such a famous and inspirational Canadian in
front of us, I think we're honoured by that.
My first question to you is basically an update. I think you're
aware of Quebec's Bill 20. I was wondering where that legislation is
at, and what the department's viewpoint is on it.
Ms. Abby Hoffman: You're talking about the intent to develop a
schedule of fees that patients would be charged, or I would say the
owners of clinics would be allowed to impose on patients for certain
services delivered in clinics.
At the moment our understanding is the legislation has been
passed. A schedule of permissible fees is being developed. Up to this
point, that fee schedule has not been published. An effective date, in
our understanding, is possibly in late spring. In the May to June
period, that schedule would be published, and the regulations would
be in effect that would allow providers to levy these fees for services
in a particular facility; that is, in clinics.
The people we're talking about are individuals who do not qualify
for provincial/territorial public drug plans, which are mainly focused
on older Canadians or people on social assistance. We are talking
about people whose employment status is such that they don't have
access to private insurance. There's that still quite sizable portion of
the population who pay out of pocket for their own drugs. And a
portion of those people—about a quarter of the total, some smaller
portion, but nonetheless a significant portion—simply cut back on
drugs that they should otherwise be using.
Of course it hasn't happened yet, so nobody has been charged
anything. We certainly would say that is a fairly direct challenge to
the Canada Health Act.. Interestingly, as we understand the
arrangements, some of those same services if provided in a hospital
would be provided to patients without any fee being imposed. This
would be a fee that would be charged in particular settings where
these services would be delivered.
Mr. Doug Eyolfson: Based on your experience, if there were to
be some level of expanded coverage for out-of-hospital pharmaceuticals, can you see what kinds of high-level administration
challenges there would be, other than the initial outlay of funds?
For my second question, you mentioned in your presentation that
the Canada health transfers are up to $34 billion, or somewhere
around there.
● (1600)
Ms. Abby Hoffman: The design of any kind of program that
would try to bring in some sort of coherent coverage regime would
have to deal first of all with who's eligible, under what conditions,
how are they being reimbursed for drugs, on what kind of formulary,
and with what kind of copays or patient contributions.
One thing initially one would want to guard against is people
finding a new initiative so attractive they remove themselves from
either their existing employment-based supplementary benefits
coverage, or they remove themselves from some other public plan.
The complexities around the design of drug plans are quite
significant. The provincial programs, the federal government's
program for first nations and Inuit, and the non-insured health
benefits programs are complex things to design. I think ultimately
most people would argue whether somebody has access to an
employment-based program, or they have access to a publicly
financed plan, the parameters should be the same.
A lot of people talk about having for example a common
formulary for access to drugs for all Canadians regardless of how
they have their coverage financed.
The Chair: Mr. Carrie.
Mr. Colin Carrie: Thank you for that.
Out of curiosity, in about the last 10 years has the federal
government ever lowered or cut these transfers, or have they always
gone up every year?
Ms. Abby Hoffman: The transfers are subject to arrangements
between the federal government and the provinces. Currently the
year-over-year increase of the total pot of the Canada health transfer
is 6%. There is a complex formula. It's less complex than it used to
be because it's now on an equal per capita basis for determining how
much each province gets. The only reason I'm suggesting that it's
complicated is because when there was a move from an old formula
to equal per capita then adjustments had to be made to move forward
into that new regime.
No jurisdiction has received less in any year through the CHT than
they received in a prior year. In cases where there had been
deductions associated with issues of compliance under the Canada
Health Act, the amounts are as much symbolic as they are material.
In recent years none of the deductions to CHT for non-compliance
have significantly eroded what any jurisdiction has received as CHT.
● (1605)
Mr. Colin Carrie: Thanks for clarifying that, because I've heard
that some people out there are stating that the federal government has
cut transfers.
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How effective have previous increases in the federal health care
funding been in promoting health care system reform efforts? Also,
what kind of accountability is there with the transfers? I know the
federal government has been giving 6% per year. For example, in
Ontario I think for a few years their increases in spending have only
been 2%, so they're getting 6% and spending 2%. Just out of
curiosity, do you think the accountability measures that are there are
good enough, or is it something that needs to be looked at?
Ms. Abby Hoffman: There's one accountability measure, as I
mentioned, related to the CHT, and that's the requirement to comply
with the Canada Health Act. I think it's fair to say that the transfers
for health are, obviously, in respect of health, but they're also part of
the fiscal arrangements of the country. Ultimately, as far as the CHT
is concerned, it's up to each province or territory to decide how they
spend that money.
I should just note one thing from a pure mathematical standpoint.
You may be right that the Canada health transfer has gone up in
percentage rates that exceed the growth in health care spending in
particular recipient provinces. But it's worth remembering that the
federal government's contribution is somewhere in that 20% to 24%
range. I'm not belittling the value of 6% on 23%, but obviously the
bulk of the burden of spending on health care is still borne by
provincial treasuries.
Also, I'll just say that under the 2004 accord there were reporting
obligations, which provinces and territories accomplished. They do
not, however, constitute iron-clad guarantees about either reporting
or what the recipient province or territory will do with the money. I
think this is simply a matter of respecting the jurisdictional
responsibilities the provinces, territories, and federal government
respectively have.
Mr. Colin Carrie: I know we've made major investments in stuff
like the Canadian partnership organizations, such as the Canadian
Partnership Against Cancer, the Mental Health Commission of
Canada, and other national associations working to address
Canadians' biggest health challenges. I was wondering if you could
let us know the biggest successes achieved in these areas and how
you think the organizations should be adapting to new challenges as
we go forward.
Ms. Abby Hoffman: Mr. Carrie, are you talking specifically
about organizations like the Canadian Partnership Against Cancer?
● (1610)
Mr. Colin Carrie: Yes.
Ms. Abby Hoffman: I'll just say—and this may or may not be
known to members of the committee—that there are eight
organizations that Health Canada funds, which play various roles
in the health system. There's the cancer partnership, the Canadian
Institute for Health Information, the Mental Health Commission, the
Canadian Centre on Substance Abuse, the Patient Safety Institute,
the Canada Health Infoway, and so on.
These organizations, which we describe as “shared governance
organizations”, are managed.... In fact, most of them were created by
the federal government, but they have federal, provincial, and
territorial representation on them. They are intended to be highly
responsive to needs identified across the country.
March 21, 2016
Unlike the CHT, which, as I mentioned, is a lot of money with an
important accountability but really only in the area of the Canada
Health Act, these other organizations have a specific responsibility in
their particular area of interest. The Canada Health Infoway is
specifically in the business of advancing electronic health records,
and that sort of thing. The cancer partnership is dedicated to getting
everybody in the cancer community working to the same objectives
with the most important advances in cancer control and prevention.
I don't know if I would characterize it as saying that we have
more control over those organizations. That's not really the main
point I want to make. What I simply want to say is that they are
clearly focused on their main business. There are not issues around
whether or not, for example, the Canadian Partnership Against
Cancer is spending money on something other than cancer. They
can't, they don't, and they won't. They are really focused on their
task.
The total cost to the federal government of these organizations I've
just mentioned, in terms of budgetary allocation, is less than $400
million a year, which is not a large amount in the grand scheme of
health care spending in Canada, which is in the hundreds of billions
of dollars. They really do very important work with, as I say,
relatively small resources, because of the very focused mandates
they have and the governance that helps direct the work they do.
The Chair: Mr. Davies.
Mr. Don Davies (Vancouver Kingsway, NDP): Thank you, Ms.
Hoffman and Ms. Mandy, for being with us today.
Ms. Hoffman, you've already covered the general scheme of the
act. You mentioned in this report that over the last 20 years the
federal government reductions in health transfers to provinces and
territories based on Health Act violations totalled $10 million. I think
your words were that it was fairly small. That's the first reaction I
had. I was surprised that in 20 years it's only been $10 million when
the act calls for dollar-for-dollar reduction for violations of the
Canada Health Act. My first question is: does that figure accurately
reflect dollar for dollar the exact amount charged for health services
delivered to Canadians across this country in the 20-year period?
Ms. Abby Hoffman: There's one example, and it's actually one
of the examples that's cited in the report this year. I'll just connect my
comment here to something that I touched on in my remarks which
is that the objective here is not to impose penalties. The objective is
to try to bring the respective provincial health insurance programs
into alignment with the Canada Health Act.
March 21, 2016
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We know in British Columbia, because it's the subject of an
ongoing dialogue with that province, that one could make an
estimate of charges that are being levied on patients that exceed the
amount of our deduction, which I think I identified is something in
the range of a quarter of a million dollars. The deduction we made is
based on the actual documented extra billing and user charges that
we know have been levied in British Columbia. Could we, via
process of extrapolation based on other evidence, audit reports, and
so on, come to the conclusion that in fact the amount is higher than
that? Yes, we probably could, and we may in fact come to that
decision at some point. Right now we are working with the province
and officials in the medical services plan in B.C. to see if we can't
find some other solution.
I'll just say that this gets complicated because a number of the
people in British Columbia, as patients who accept patient charges,
willingly do so because they think it's a benefit to them to jump the
queue and get what they believe will be faster access to care.
Mr. Don Davies: There are two options, and I hear stories of user
fees as the health critic for the New Democrats. There's a
proliferation of extra charges for diagnostic services across the
country. I mean, there's a new MRI clinic that's opening in
Saskatchewan. I hear stories of constant up-selling for people, let's
say in cataract surgery, where for a little extra money you can get a
superior lens. Quantum-wise, would you agree with me that this
figure has to represent... I mean, the amount of extra billing or user
fees in this country clearly exceeds the amount that the federal
government is actually recovering. I don't quarrel with the general
approach of trying to be collaborative, but I just want to get an idea
of the quantum.
Ms. Abby Hoffman: I think what you've asserted is fair. I will
just note, though, when you're talking about up-charge, whether it's
for a lighter weight cast, or some kind of—I don't want to call them
bells and whistles because there may be some therapeutic benefits—
norm in that jurisdiction, the standard of care up to here is publicly
insured. If somebody wants to pay for an embellishment then they're
free do to that, but I think where we want to draw the line is that
what would be defined as medically necessary care is covered.
The issue of private clinics is a long-standing issue, and we're very
concerned about it. I'll just say, just so members of the committee are
aware, that there is a charter challenge in British Columbia. An
owner of one of the more lucrative private clinics is basically
asserting that his charter of rights as a provider and the charter of
rights of patients are being infringed by virtue of his not being able
to sell care and the patients not being able to buy it. I think frankly
the result of that case will have a very important impact.
● (1615)
Mr. Don Davies: The other thing that came to me when I looked
at the chart in your report is that British Columbia has been
penalized—if I can use that word—13 years in row. That doesn't
speak to me to the effectiveness of trying to discipline provinces to
respect the Canada Health Act. Now, I know a part of that must be
the Day clinic over and over again.
I want to move to another issue of the five principles. We've had
in the news in the last 30 days a handful of first nations communities
in this country declaring public health emergencies, and that is not a
new story, unfortunately, in this country. In terms of the principles of
7
universality and accessibility to make sure that Canadians have
reasonable access to reasonably comparable levels of service, how
we square that with the fact that we have first nations across this
country who clearly do not have universal or equivalent access to
health services. I'm wondering if the department has a view on that.
Ms. Abby Hoffman: I think it's our understanding the committee
may be doing some work specifically on the issue of health care and
the health status of first nations and Inuit. If I may, I think I would
rather defer to my colleagues in the first nations and Inuit health
branch, who can better speak to these issues.
However, I would say just as a general point at this stage that the
circumstances in those environments—and maybe as you've
expressed it—are not issues related to the Canada Health Act.
These are issues related to the fairness and the appropriateness with
which first nations individuals, particularly those on reserve, who are
living in very, very difficult conditions—
Mr. Don Davies: May I interrupt you to ask a quick question? I'm
sorry, I don't mean to, but I want to clarify this. Don't first nations
fall under the direct responsibility of the federal government?
Ms. Abby Hoffman: First nations and Inuit would be regarded as
insured persons for the purpose of the Canada Health Act. They
receive services from the federal government. They are also entitled
to services from provincial and territorial governments.
A lot of the issues, as I think you know, have to do with the kind
of interface of what the federal government provides, what first
nations health authorities provide, and what the provinces and
territories may provide.
The Chair: Mr. Ayoub.
[Translation]
Mr. Ramez Ayoub (Thérèse-De Blainville, Lib.): Thank you,
Mr. Chair.
Ms. Hoffman, we're very fortunate to have the opportunity to ask
you questions today.
I was looking at the principles of the Canada Health Act:
universality, comprehensiveness, accessibility of care, portability,
and public administration. Quebec has what is known as a two-tier
system, with private clinics and such offering services. It's an issue
that's come up before. In Canada, some $34 billion in funding is
allocated across the health care sector.
8
HESA-04
What are the standards of care, in terms of the service quality the
public can expect? Statistically, where do things stand, and what is
the level of care provided? We talk a lot about public funding in the
health care sector, but what we don't hear much about are important
measures like response or wait times. I'm talking about how long
members of the public and patients have to wait to receive services.
As a result, those who can afford it have the option of accessing
services through private clinics and the private sector, thus
perpetuating the two-tier system.
I'd like to hear your thoughts on that.
[English]
Ms. Abby Hoffman: Well, first of all, I can say that with respect
to the Canada Health Act specifically it does not impose on
provinces and territories any particular standard of care. The Canada
Health Act is all about the conditions under which the public health
insurance scheme in a particular jurisdiction operates.
I think we would share with you the concern both about variability
in access to services and, whether it's variable or not, about waiting
times that are of such a duration for critical services that they
actually imperil the health status of members of the population.
With respect to the système à deux vitesses, obviously we are very
concerned about that. We have been discussing this issue with
officials in Quebec specifically for some time.
Similarly, elsewhere in the country where we know there are
charges for services at clinics, we have conversations with those
jurisdictions. This is particularly the case in diagnostic clinics. If an
individual is able to pay and get more rapid access, let's say, for an
MRI or some other diagnostic test, not only do they get that initial
diagnostic test more quickly, but they get access, then, to the care
they might need based on the result of that test as well. This remains
a concern for us. We've tried many different ways over the years to....
We have a private clinics policy that's aimed at addressing some of
these concerns, but I can tell you that it's not an easy thing to do.
Gigi, do you want to make any further comment on clinics?
● (1620)
Ms. Gigi Mandy (Director, Canada Health Act Division,
Strategic Policy, Department of Health): I think you pretty well
covered it. We do have a lot of concerns. There are provinces that
have strong regulatory frameworks, and the services in their private
clinics are well integrated into the public system. They're provided
under contract and patients have a way to pay. Other provinces don't
have strong regulatory frameworks, and that's where you see the
patients being charged directly at the clinic and issues of concern to
us arising.
[Translation]
Mr. Ramez Ayoub: I'd like to make sure I understand the
situation.
The Canada Health Act ensures the provision of services but does
not address service quality or delivery. That dimension is the
responsibility of the province, is that correct?
[English]
Ms. Abby Hoffman: That's correct. The act does not prescribe
with any degree of specificity what services shall be provided and
March 21, 2016
what specific quality standards shall prevail. That is up to the
jurisdiction in question to determine.
[Translation]
Mr. Ramez Ayoub: There were other issues I wanted to ask you
about, but I can't seem to get past this one.
Handing the responsibility over to the provinces is one thing, but
ensuring universal access to care is another. The money is paid out,
but no follow-up or information is available when it comes to the
quality of care. And no such statistics are available, either. What's
gone on over the past 10 or 20 years in terms of the level of health
care provided nationwide? I don't mean in each province, but from
coast to coast to coast. The goal is to make sure that Canadians all
over the country have access to the same level of service and health
care. How can we possibly achieve that without any statistics or data
on service quality?
[English]
Ms. Abby Hoffman: I'll make a distinction between whether or
not there are data available and whether or not there's a requirement
based on the results of those data to make adjustments where
necessary, that is, where the performance of a particular health care
system is not comparable with what it might be elsewhere in the
country.
There's a lot of information available. The Canadian Institute for
Health Information is a national health data organization, financed
mainly by the federal government, but with contributions from the
provinces and territories. It collects and produces a lot of health
information. You can go on that site and look under “health system
performance”, put in your postal code, put in the name of a local
hospital or health authority, and get a huge amount of information
about the performance of that particular institution or health region.
Then you can compare these data with those of other health
authorities or institutions across the country. The information is
there.
There's also a lot of information comparing Canada's performance
with that of other countries in the OECD and elsewhere. But to your
specific point, nobody is calling for immediate measures to be taken
here. This is the reality of the country. The information is there, but
the decisions on where to make adjustments fall principally on
individual provinces and territories and their governance structures
to determine where remediation occurs.
● (1625)
The Chair: Dr. Leitch.
Hon. K. Kellie Leitch (Simcoe—Grey, CPC): Thank you for
your time today. We really appreciate it.
I know all of us want to end up on the same page as we try to
contemplate some of these things over the next year or two. Since I
live in this system, I would hope I understand somewhat how it
works.
March 21, 2016
HESA-04
Could you tell us what you view as the current challenges for
access to care? Those of us who are standing on the front lines can
sometimes see things a bit differently. It can sometimes become
frustrating because of the situation you're standing in at that specific
moment. It's also important to look at the broader issues of access to
care and how we should be addressing them. It would be useful to
understand these issues and how you identify them, because they
may be different from the ones we're identifying here. Dr. Eyolfson
and I may experience other things first-hand.
What are your criteria for addressing access to care? How do we
get the right outcomes, and what are the criteria that Health Canada
is looking at to try to get us to that right place?
Ms. Abby Hoffman: Well, maybe I'll identify a few areas in
response to your question, which gets at the imponderables of health
care policy in the country.
First is the whole issue of those services that are, at this point,
provided in the health care systems across the country on a
discretionary basis. Whether we're talking about home care or access
to drugs or mental health services or palliative care or whatever, I
think many people would say these are elements one would expect to
be generally available in contemporary health care systems. They are
provided to a degree in most provinces and territories, but to a highly
variable extent and certainly not at the level one would expect to
serve the whole population well. That's one huge area of challenge.
Second, even though we all like to think our health care systems
are evolving and adapting, either to demographic change or to
technology or whatever, the fact of the matter is that systems don't
adapt as readily and as efficiently as they should. Very often there are
very good ideas, but it takes a long time for those ideas to roll out
across the country. I'll give you an example. In mainstream media in
the last few days, you may have seen something about the
astonishing overuse of prescription drugs, particularly psychoactive
drugs, among elderly Canadians, particularly, but not only, by those
individuals who are in nursing homes or other institutional settings.
A lot of work has been done to try to make sure that only patients
who have been properly diagnosed are actually being administered
these drugs.
This is a great initiative and it's going on in some parts of the
country. New Brunswick has just announced, for example, that it's
going to roll this process out across its entire nursing home system.
One could easily ask, if this is a problem everywhere in Canada,
which we're led to believe it is, how long will it take to roll out the
same protocol across the country. I'm simply saying there are a lot of
things we know how to fix, but it takes a long time to roll those fixes
out across the country.
Third, partly because of the Canada Health Act, but just for
reasons of historical legacy, there's a real focus on hospitals, even
though hospitals are consuming a slightly smaller portion of the total
health care spending across the country than was the case maybe 20
to 40 years ago. I think we still do not have as much of a focus as we
should on delivering care, particularly for people with chronic
conditions, to people living in their own homes or in community
settings. I think some people would argue that we're still not making
investments in the optimal locations.
9
Fourth is with respect to digital and electronic health records and
so on. We've made a lot of progress in the country in terms of
digitizing test results and making sure that physicians' offices have
access to electronic medical records, but these records often are not
interoperable. Somebody can go to a hospital, and certain test results
are recorded, and anyone with privileges at that hospital can get
access to that information. The same patient goes to their family
doctor who has a different system, and someone in that family
doctor's office actually receives by mail or fax the results of a test
done in a hospital, scans it, and puts it into a record in the physician's
office. I think one could say this is a really suboptimal way of
operating in 2016.
I could go on with a longer list, but those are four things I would
say many people would say we need to tackle.
● (1630)
Hon. K. Kellie Leitch: I would agree with you, whether it be with
regard to adaptability, consistency, or issues around shared services
or challenges within the system.
In your opinion, with respect to how we move the bar on those
key criteria in the plan going forward, what two or three mechanisms
would you recommend to create that accountability in our relationship federally with our provincial partners?
To your point about rollout, it's fine that every time there's a new
opportunity for better access to care for patients that we see it at the
Hospital for Sick Children in Toronto, but, obviously, we want to see
that in every children's hospital in the country and quickly, not two to
five years hence. What are your thoughts from a public policy or
program perspective with regard to addressing that accountability
issue so that we close the gap in rollout consistency or otherwise?
Ms. Abby Hoffman: I would start by saying that I'm not too sure
the federal government can really hold provinces and territories or
health care institutions or regional health authorities to account for
what they do or do not do. What we can do is try to provide support.
I'll go back to the example of the use of psychoactive drugs among
seniors in institutions. We support an organization called the
Canadian Foundation for Healthcare Improvement. It has done a
lot of the preliminary work looking at this issue of the overuse of
medications among seniors in institutions. I think the best thing we
can do, and it doesn't cost a whole lot of money, is to support that
organization so that, with the model they may develop in a couple of
jurisdictions, they get support to be able to roll that out and talk to
people elsewhere in the country, and the spread effect takes place as
quickly as possible. That's more what we can do.
10
HESA-04
On a larger scale, just to go back to the issue of drugs and access,
for example, and universal access or not, one of the most important
things we can do in our own backyard, and with provinces and
territories, is to focus on the issue of drug prices and drug costs.
Drug coverage, and expanding that coverage, will be limited if
Canadian drug prices and total costs remain as high as they are
today. That's a different approach. It's not an accountability
approach, it's working with provinces, building on some of the
things they're already doing, and using some of the levers we have to
try to get drug prices to the point where there's actually money freed
up to expand coverage, while still operating within the same total
drug bill.
The best way for us to operate depends on what it is.
Hon. K. Kellie Leitch: To disagree just slightly, I think having
determined outcomes is actually valuable. Working toward those as
goals is important.
Ms. Abby Hoffman: Yes.
Hon. K. Kellie Leitch: I don't think anyone who has been
involved intimately with patient care or with research for patient care
doesn't have a mindset of what their outcome will be or how many
patients they want to involve in their study, etc. I think we do have to
have a bit of granularity, which I associate with accountability in
order to get to the right spot.
I have a different question—
The Chair: You're over your time. Sorry. That was very
interesting, though.
Ms. Sidhu.
Ms. Sonia Sidhu (Brampton South, Lib.): Thank you to Ms.
Hoffman and Ms. Mandy for their valuable presentation.
Mental health has been highlighted as a priority under the Canada
Health Act. Are there major differences between the provinces
regarding the delivery of mental health services across the country,
and does there need to be improvement across the board?
● (1635)
Ms. Abby Hoffman: There are only general references to mental
health in the Canada Health Act. Regardless of that, I think everyone
acknowledges that mental health services are very important,
particularly for young people. If we think about children, teenagers,
and young adults, mental health issues certainly are.... I don't want to
say they're pervasive, but they are significant. I think we recognize
that across the country.
Again, it's not just an issue of variability in services. I think almost
everybody would say that the service offerings in mental health are
not what they should be. It's partly an issue of money. It's partly an
issue of trying to figure out how to provide mental health services in
a way that is affordable. It doesn't necessarily mean that psychiatrists
and psychologists are the only health professionals who actually can
do something in the mental health area.
The government has made it clear as part of the discussions with
provincial and territorial governments under a new health accord that
mental health services is a focus of that activity. We're not at the
place yet where I can say that we're doing this or we're doing that.
March 21, 2016
That's an ongoing discussion with the provinces. I'll just say that it's
a really important focus that will be pursued over the next several
years.
Ms. Sonia Sidhu: Would you agree that access to mental health
care is more difficult outside major urban centres? As well, how does
our approach need to be different in rural areas?
Ms. Abby Hoffman: I think your point is well taken. There are
challenges for individuals and families accessing mental health
services in big cities, but the situation is compounded in less
populous areas. We know, for example, there has been some good
work done on delivering mental health services and counselling
through telehealth applications. I think there are some things that can
be looked at that will certainly help deal with mental health concerns
of people living in smaller communities. Clearly, if you have a town
of 5,000, 10,000, or even fewer people, it's unlikely there will be a
full battery of mental health services available in the community on
an ongoing basis. Other ways of delivering services to people in
those kinds of settings will be required.
Ms. Sonia Sidhu: We live in an era in which technology plays a
primary role in every sector, whether it's by increasing effectiveness,
facilitating tasks, or offering better services.
In the health sector, the technologies that we currently use are in
constant evolution. Those advancements are absolutely necessary in
order to save lives.
What is Health Canada's commitment to facilitating innovation for
health care services?
Ms. Abby Hoffman:
mention.
There are a couple of things I could
First of all, we support an organization called the Canadian
Agency for Drugs and Technologies in Health. One of the things that
it does is assesses the potential benefits of new technologies as they
come on stream and provides advice to provinces and territories and
health care institutions and providers, and so on, so that good
decisions can be made about when to adopt a new technology, for
what kinds of patients, when to decommission or take out of
circulation technologies that are no longer optimal.
In the area of e-health we certainly have provided a lot of support
historically to the Canada Health Infoway to pursue all kinds of
health information technology advances, including in telehealth,
electronic health records, that sort of thing.
The Chair: Mr. Webber.
Mr. Len Webber (Calgary Confederation, CPC): Thank you,
Dr. Hoffman, for your information.
I have a question. I'm hearing more and more about Canadians
seeking surgical procedures or dental procedures outside the country,
whether because they want to fast-track treatment or because it's less
expensive for things like dentures and teeth implants and such. Then
they come back to Canada and they develop complications and so
they seek treatment within Canada, often costing taxpayers more
with the treatment and the healing than it would be to actually do the
procedure to begin with.
March 21, 2016
HESA-04
I just want to know what your thoughts are with respect to what is
occurring. Are these incidents increasing? Are you hearing more and
more of these types of stories? I certainly am, with some of my
constituents.
What policies are in place with respect to people like this who
come back and seek these treatments?
11
What do you view as the main challenges at that table? Where will
the resistance by the provinces and territories be to a health accord?
Ms. Abby Hoffman: I don't know that I would necessarily say
resistance. There is always a delicate balance in a discussion about
what priorities should be and within those priorities what actions
should be taken.
● (1640)
Ms. Abby Hoffman: Well, we're hearing about this as well,
maybe through the same sources, which are significantly through the
media.
I think I can tell you that most provincial and territorial
jurisdictions do have systems for advance approval of procedures
that are done out of the country. However, clearly a lot of the cases
you're referring to are instances where someone just simply
chooses...either the procedure is not available in Canada and they
think it will be better for them, or as you say, they may not wish to
wait, or who knows precisely the circumstances.
The government was quite clear in its platform commitments that
it wanted to pursue an accord. It wanted to have an accord that would
be focused on mental health, home care, innovation, and
pharmaceuticals.
When Minister Philpott met with her provincial and territorial
colleagues in January in Vancouver, there was an agreement among
that collection of ministers that aspiring to an accord with those
priority areas was something that they were prepared to pursue.
That's step one. We've got a general agreement that those are areas
that require attention.
Of course, one of the benefits of our system is that regardless of
how somebody becomes ill, if individuals go to another country and
have botched procedures or the procedures they've undergone don't
produce the result that they expected, and they actually are more ill
than they were, those individuals are entitled to receive care in
Canada. It's partly an issue of public information. We know over
time people have gone to the United States, Mexico, or other
countries seeking care, thinking that it's a silver bullet for whatever
condition they're suffering from, and the consequences unfortunately
have been dire.
When it comes to the specifics of what will be done in each area,
this will be the subject of discussion. At the end of the day, the
communiqué that ministers released in January talked about bilateral
agreements. These are bilateral agreements between the federal
government and each individual province or territory. The discussion
that's going on now is in regard to the kinds of initiatives in these
areas that will be on the table for discussion and potentially for
support.
I think a lot of this is about public education and people needing to
be cautioned to be very careful about a decision to get care in another
country without consulting anyone, either their own doctor or their
own insurance scheme, whether it's public or private insurance. It's a
risky business, and we are hearing about more of these cases.
The art of achieving an accord is to get to an array of proposals
and ideas which would allow every jurisdiction to say, “Here are
things that really are important for our particular jurisdiction,” which
means it could be quite a different arrangement within a broad
umbrella approach across the country.
Ms. Gigi Mandy: I was just going to add that we've heard
recently about people who have gone out of country seeking bariatric
surgery, people who are overweight but may not meet the criteria for
the surgery here. There was one case in the news about a woman
who was only 35 pounds overweight. That's what she wanted to lose.
She went out of the country and had surgery, and had disastrous
effects.
In some cases it will be easier to arrive at a conclusion. For
example, to take the area of drugs, everybody agrees that drug prices
are too high and, generally, it's agreed that there are two ways of
trying to deal with drug prices. You can regulate or you can use
market power; that is, collective purchasing power to negotiate better
with manufacturers, or some combination of the two.
One of the problems is when people come back, they often may
have incomplete medical records. It really poses challenges for the
doctors here who are trying to correct the problems because they
don't know exactly what has been done or what the complications
were.
That's an example where at this point, and not getting into all the
detail, it's reasonable to presuppose that governments generally will
be on the same page.
Mr. Len Webber: That's very interesting. Again, thank you for
that. I hear more and more of it daily and it is a concern. Of course,
public awareness is key to that.
The Chair: Mr. Oliver.
Mr. John Oliver (Oakville, Lib.): Thank you very much.
Some of my earlier questions have been asked already. I'm going
to go into a different area. The Minister of Health has a requirement
to develop a new health accord by the end of 2017 or 2018.
In other areas, take home care, for example, everybody recognizes
that we don't have sufficient home care in the country, but the
specific aspects of home care that maybe need improvement—
● (1645)
Mr. John Oliver: I want to ask about home care because I am
curious about it. It doesn't follow as clearly as hospital and physician
care under the CHA. Would you view home care as part of the CHA
mandate?
12
HESA-04
Ms. Abby Hoffman: I would not view it technically as part of the
Canada Health Act. The general feeling about home care is that,
particularly but not only for older Canadians who may have one or
maybe multiple chronic conditions, those individuals may from time
to time have acute episodes and need to be hospitalized. For the most
part their care should be provided through the sort of primary care
system and through care that's mainly delivered in home and
community settings.
Everybody kind of agrees with that sort of general philosophy.
Exactly how that's achieved depends. Ontario, for example, is
basically pulling back from a system of delivering home care that it
had in place for quite a long time. Other provinces are taking
different approaches.
Mr. John Oliver: I am also curious about compliance. The
penalty model or the clawback model doesn't appear to have a lot of
compliance problems, other than what we saw in British Columbia
and Newfoundland. The last five or six years have been very quiet
on the compliance front.
Is that because you're not able to detect it or don't hear about it?
When you do hear about it, are the tools you have sufficient or do
you think there should be stronger tools built in?
Ms. Abby Hoffman: We're not going to say that we know about
every single issue that may crop up across the country. We think
we've got a pretty good idea of what's going on. We don't, however,
have any authority to investigate. We cannot go out to a clinic and
conduct an audit or demand to see the books of a health care
institution. The federal government does not have that authority.
Having said that, I'm not too sure that we necessarily want it or
need it. I think, generally speaking, we feel that we are aware of
issues out there and we then enter into the dialogue with the province
or territory in question. As I indicated in my remarks, it's a bit
variable across the country. The largest province right now, Ontario,
has the fewest compliance issues. Ontario is, to our knowledge—I
can always be proven wrong—absolutely assiduous about following
up on any allegation that a patient has been charged. They have very
effective legislation, which has many more powers than the Canada
Health Act, to actually go out, investigate, and penalize a physician
or a clinic owner. They reimburse any patient who it's believed has
been charged unfairly under their legislation, and ours.
Two of the biggest challenges that are out there right at the
moment—they've come up earlier in this conversation today—are in
Saskatchewan and Quebec where there are legislative initiatives
proposing to basically codify and allow patient charges. These are
not a secret. It's not a question of us not knowing about them, it's a
question of how best to enter into a conversation with the
jurisdictions concerned to turn those situations around.
● (1650)
March 21, 2016
very heated. It was a very charged environment. There have been
offers on a couple of occasions by the federal minister to proceed
with the dispute avoidance and resolution process. I think in one, if
not both cases, a change in government ensued and the new
government was not predisposed to pursue the cases so aggressively,
so they were abandoned. I'm not making this as a prediction, but it is
there and it's possible that if there are situations that are important
and they're not able to be resolved, that proposal and process could
be put back on the table.
The Chair: Mr. Davies, welcome back.
Mr. Don Davies: Thank you.
Just to pick up on that, I noticed Ontario hasn't paid a dollar in 20
years in violation of the Canada Health Act. I'm looking at a report
done two years ago by the Ontario Health Coalition. They say six
researchers, working with the Ontario Health Coalition, phoned 135
private clinics and hospitals to find out whether they charged patients
user fees and extra billing for services. The researchers found that the
majority of the private clinics they talked to charged patients user
fees ranging from $50 to $3500 or more. We found that a significant
number of the clinics are violating the Canada Health Act and
Ontario legislation prohibition on user fees, extra billing, and the sale
of queue-jumping. There's example after example, particularly in the
eye field. There are $50 administration fees, snack fees for
colonoscopies. I'm having a hard time squaring this, that by your
report Ontario has a pristine record, and yet other people are finding
that half the private clinics in Ontario are charging obviously
hundreds of thousands, if not millions, of dollars in user fees a year.
I'm wondering if you could square that for me.
Ms. Gigi Mandy: There are two things. We did take the report to
the Province of Ontario and asked them to investigate and get back
to us. We were also aware of most of the instances that were
documented in the report and had already approached Ontario about
them.
As Abby mentioned, Ontario has a very strong framework. There
are things that go on, and often they are mistakes, like an
administrator at a clinic doesn't know that they can't charge a
patient for that, or something happens that shouldn't happen. But
Ontario is very good about investigating complaints, and unlike
other provinces, it doesn't have to be the patient who brings a
complaint to them directly. It can be a stakeholder group, it can be
the media; they will investigate anything.
Ms. Abby Hoffman: Maybe the fact that it exists is helping.
If they investigate a clinic and they find a charge for a
colonoscopy or cataract surgery, they not only ensure that patient
is reimbursed, they look at the records of all the patients who
received the same service at that clinic and ensure they're reimbursed
as well. In fact, Ontario very openly—
The reality is, that formal process has actually never been used. It
was put in place at a time when the debate between the federal
government and provinces about the status of private clinics was
Mr. Don Davies: Sorry for interrupting. Do they actually get the
money back from the clinic that charged them?
Mr. John Oliver: Has the dispute avoidance and resolution
process that's been recently added in been helping a lot where you do
hear and where you're working through them?
March 21, 2016
HESA-04
Ms. Gigi Mandy: They do. They reimburse the patient first, and
then they recover the money from the physician.
Mr. Don Davies: So in your view it's working. Okay.
Ms. Gigi Mandy: That's right.
Mr. Don Davies: I have only a brief time. I want to get one more
question, if I could, on a different subject. It's on the issue of access.
I'm going to take the example of abortion services. We know that in
Prince Edward Island—an entire province—and in vast rural areas in
Canada, women do not have access to abortion services, and that's a
medically necessary procedure as defined by the Supreme Court of
Canada.
Why has P.E.I. not been penalized or addressed in some manner
for failing to provide access to such an essential reproductive health
service? Maybe give us the department's view on that.
● (1655)
Ms. Abby Hoffman: I'll start, and Gigi may want to add.
First of all I'll say that the issue of access to abortion services has
been a long-standing concern. Over the last decade New Brunswick
and P.E.I. have drawn the most attention and concern from us. There
has been considerable evolution in New Brunswick, and some in P.E.
I. It used to be, and is still the case today, that a woman in P.E.I.
needed to go off the island. I think we would say it's hard to square
that standard of care with real accessibility as we understand it under
the Canada Health Act. There has been some flexibility in the criteria
and conditions that apply to women who have to go off the island.
We know that there are some discussions going on about dealing
with the current situation of no access on the actual territory of
Prince Edward Island. It continues to be a topic of discussion with
respect to that part of the country.
In general we are concerned and we are having some discussions
about it, about the fact that it is still the case not just in rural areas but
elsewhere that often abortion services are available only in hospitals;
they're insured only in hospitals. There may be a private clinic, but in
some parts of the country, historically, if a woman went to a private
clinic instead of a hospital she was charged and not necessarily
reimbursed by the province, which is a clear Canada Health Act
violation, because you cannot be charged for what is otherwise an
insured service performed in a different institutional setting. It's an
issue we continue to pay a lot of attention to.
It is a bit tricky under the Canada Health Act to say to a province,
for example, that may have several hospitals that are performing
abortions that they have to meet a threshold of availability—which
might often mean either more hospitals or clinics—where abortion
services could be provided. I think we would not be disinterested in
this issue, but.... Finding a province in breach of the Canada Health
Act on extra billing and user charges is, relatively speaking,
13
straightforward: either an individual was charged or he or she wasn't.
When it comes to determining whether the extent to which a service
is available in a jurisdiction violates the accessibility principle is a lot
different. We're having a conversation amongst ourselves right at the
moment about New Brunswick, which has made considerable
improvement over the last several years in this regard. But some
people might look at the New Brunswick situation and say, “Well,
that's great, but there are not enough locations”. We haven't made
that determination yet.
I'll just simply say it's something we're concerned about, we pay a
lot of attention to it, but it is very tricky to actually have us sitting
here in Ottawa saying that this service is not available in a
sufficiently geographically dispersed manner to meet an accessibility
test. That's a tough one for us.
The Chair: You're done. You can come back, though.
Mr. Don Davies: Thank you.
The Chair: Well, thank you very much. That completes our round
of questions. I had one myself.
You mentioned that the transfer payments are now determined on
a per capita basis. What were they before, and what do you think
they might be in the future, or what should they be?
Ms. Abby Hoffman: I think you might have to invite my
colleagues from the Department of Finance to talk about that. It was
a very complicated formula that has evolved over the years, but it
took into consideration various issues related to taxation and fiscal
capacity. People often said there was only a handful of people in
Canada who could actually even understand what the basis was for
the federal health transfer. There was a decision taken some time ago
now, but brought into effect more recently, that the formula should
be on an equal per capita basis.
I'll just simply say that the prior formula, which you really would
have to talk to Department of Finance officials about, was much
more complicated and had much more to do with the overall
arrangements for fiscal federalism than it did for financing health
care per se.
● (1700)
The Chair: Thank you for taking the time to do this. You
certainly enlightened us on a lot of aspects of the Health Act.
I'm going to propose that we suspend the meeting for a few
minutes and we go in camera. I know you don't like that. We're going
to talk about people and people's names.
We'll suspend for a couple of minutes. Everybody will have to
leave, except the members.
[Proceedings continue in camera]
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