Health Committee on Oct. 2nd, 2018

[Kimberley Hanson]

Most of the provinces have some coverage for test strips under certain circumstances. If a person has type 1 diabetes they generally have much broader access to test strips than if they have type 2 diabetes. Different provinces have different limits. For example, Alberta's provisions for test strips are quite low. Ontario's are higher, and then there are programs that are available if a person is a senior or on social assistance. It really varies.

[Ben Lobb, Conservative, Huron—Bruce, ON]

In Ontario, for example, I've talked to many seniors about this, and they tell me that if it's a choice between buying the strips or having money to pay their heating bill, they're going with their heating bill. We're doing this study here, and it's as basic as that. The provinces have to step up to the plate here. We can have conference after conference on how to do this, but if a 70-year-old widow can't test her blood levels at regular intervals.... I asked her and she said, “Well, I just go by feel.”

I know there's a lot of brain power looking at this issue, but if the provinces don't want to do this, it's never going to work.

[Kimberley Hanson]

You're absolutely right.

First, it is critical that people have access to the test strips they need based on their experience of diabetes, and that really varies from individual to individual. That's why we stress that coverage for devices and supplies such as test strips must be part of a national pharmacare approach, because that is just as critical as the insulin or the metformin those people need to live.

You're also right that the provinces have a critical role to play in implementing this strategy. Really, the diabetes 360° recommendations are founded on the basis that we will collaborate with the provinces and the territories in order to implement them. We want to create greater alignment from one province to another, wherever possible, in the coverage available. We think this is possible based on the state of negotiations we've been having with the provinces to date.

[Ben Lobb, Conservative, Huron—Bruce, ON]

I just can't imagine the succession of health ministers and deputy ministers who are within each province and they don't know this. They have money for almost everything else when it comes close to an election, but for something like this which is so common sense, there is no money. It's probably political will and an old system at work.

There's a company in Hamilton which I toured in the spring. They are a software company specifically for chronic health disease issues, specifically around diabetes and other issues. It's a great Canadian story about a female CEO. Guess where they sell all their products? They sell in the United States of America. I asked her why. It's pretty easy because Medicaid and Medicare have framed it so that doctors and the clinics they practise under are forced to have a system where patients who have left the hospital don't go back because they aren't following their diet with respect to chronic diseases.

You asked a question around why not our provinces in this country. There's no system in place to allow to pay for these devices to be implemented and help. There's a high rate of uptake. There's a high rate of success. In the United States they're signing up thousands and thousands of patients every month, yet we have a system here where we can't do anything about it.

What do we do to break through here? It's almost like all the answers are there, but it's just that nobody has the will to get it done.

[Kimberley Hanson]

That's exactly why a strategy is so needed. Currently today, we have no overarching framework, no guidelines, no standards that we're working towards, no targets that we're working towards in any kind of coordinated way.

We think that strategy can really help achieve that. It can look at the health care system from a systems perspective to ask why we aren't incenting health care providers to ensure that their patients don't need to come back. There are actually countries where doctors are paid by their patients not coming. That has other issues associated with it.

I think that there are opportunities to find ways to make the system work much better if we could do it in a coordinated way and with an understanding of the outcome of our interventions.

[The Chair, Liberal, Bill Casey]

Sorry, but the time is up.

Mr. Ayoub, you have five minutes.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you, Mr. Chair.

Thanks to the witnesses for being here once again.

I will continue in the same vein as my colleague, Mr. Lobb.

We certainly have a lot of information, and we have talked about research before. We know there are action plans. According to research since 2009, there is a difference between treating people early and treating sick people who require immediate care. This is an urgent issue. I will not go into the details, but I don't think we will find a quick solution.

Before we talk about urgent matters, let us try to figure out what has been ineffective since the first action plans, the first observations, because nearly 10 years later, we are no further ahead. The studies have apparently not shown any concrete improvements or change of course.

So my question is fairly simple. What is not working—we have answered that in part—and what do we have to improve now? What best practices from elsewhere in the world can we draw on?

I invite anyone who wishes to answer to take the question.

[Lucie Tremblay]

First, I think we have to make what is invisible visible.

Until a person has been diagnosed with diabetes, has been identified as diabetic and has access to care, that in itself is a major problem. I have heard about a register to notify the persons affected and provide for early intervention. As a result, I think we need to invest more in prevention, in something that is invisible. As one of my friends often says, an ounce of prevention is worth a pound of cure.

Contrary to what Mr. Grewal said earlier, not all Canadians are aware of this. There is still a lot of work to be done in the areas of prevention and health promotion. That involves more than a mere visit to the doctor; a real continuum of measures is needed. Although diabetics need access to needles, injection supplies and test strips, they should also benefit from prevention and health promotion policies.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Who should do that?

[Lucie Tremblay]

I think the message has to be clear.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Where should the leadership come from?

[Lucie Tremblay]

Dr. Whiteside said earlier that certain countries have managed to stand out. At some point, we in Canada have to send a strong message.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

What is preventing us from doing that right now? What is in the way of showing leadership? Why is there no leadership?

[Lucie Tremblay]

I will let others answer your question. They probably know more about it than I do.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Dr. Whiteside, let me turn to you.

Do you want to answer that question? Where is the lack of leadership?

[Dr. Catharine Whiteside]

I think the lack of leadership is actually sitting with the provinces and the provincial ministries of health. As Mr. Lobb has said, this kind of issue needs to be prioritized politically.

If we look around the world.... I take Sweden as an excellent model. Sweden is the size of Ontario. Ninety per cent of individuals with diabetes are registered. They're followed carefully and the outcomes are tracked. They have the best outcomes for diabetes and complications in the world because they use information and tracking of performance as the gold standard for improving care.

It's the lack of tracking individuals with chronic disease—like diabetes and its complications—province by province, that really hides this issue of lack of care.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

How do we compare with Sweden, for example, on the prevention side and the identification?

[Dr. Catharine Whiteside]

We compare relatively poorly. I draw to your attention a very important assessment of value-based outcome measures that was published by the Economist Intelligence Unit in 2016. This indicates that one of the very important shortcomings of Canada, across the provinces, is the lack of registries of individuals with certain types of diseases. This is in contrast to a country like Sweden, where most of the chronic diseases—heart disease, diabetes, kidney failure—are all tracked, measured and managed in community sites that enable the individual with a disease to co-design their prevention strategies with health care professionals.

That is the model I think Canada should adopt. I think it could be a fundamental outcome of a national diabetes strategy, if the provinces are willing to work on that strategy.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you.

[The Chair, Liberal, Bill Casey]

Thanks very much, but the time is up.

We are moving to Mr. Webber.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you.

I have a couple of questions on the actual products that are out there. For example, insulin pumps haven't been brought up.

A few years back, during a provincial election in Alberta, there was a lot of talk about the coverage of insulin pumps and who would provide it if they were elected and who would not. Of course, I just assumed at the time that test strips and syringes and all that were covered in Alberta, but Kimberley, you mentioned that's not the case in Alberta or in Canada.

Could you elaborate on that? Are any of the provinces doing this right?

[Kimberley Hanson]

Currently, there are critical gaps in what is covered in terms of diabetic supplies and devices in every province and territory in Canada.

I'm remiss in not having mentioned an insulin pump because I have been wearing one for 23 years and literally couldn't live without it.

In this day and age, it's actually kind of shocking to me that we're still at the point where, in many provinces, there is no coverage for insulin pumps or that coverage is limited by age. In some places, they are only covered for children until age 25. Type 1 diabetes is not a disease we have any cure for; it certainly doesn't disappear when you're 25. In fact, the longer you have it, typically, the more complications you're at risk for, etc.

Currently, no province is getting this right. Further to Dr. Whiteside's comments in response to Mr. Ayoub's question, I think there is currently a lack of leadership, and that leadership can't come from one body. It has to be a collaboration among all of the actors that are affecting the health care system: provincial and federal governments and civil society organizations like ours that advocate for the patients. The private sector also has a role to play in making these really valuable interventions available to everyone. The companies that manufacture insulin pumps, test strips and syringes have a role to play in making them more ubiquitously available in a manner that's sustainable for our economy.

[Len Webber, Conservative, Calgary Confederation, AB]

In the long run, are insulin pumps perhaps a way of saving costs, keeping people from having to go the syringe route for the rest of their lives?

[Kimberley Hanson]

We are seeing data suggesting that for people who are good candidates for insulin pumps the pumps do prevent long-term complications, thereby saving costs to the health care system. Insulin pump technology is still relatively new and data are emerging as more and more people are coming to wear them. As we come to better understand the longer-term experience of living with a pump, we will know more, but it certainly stands to reason that there are long-term complications to be avoided.

The other really important thing I should say is that, as Mr. Prowten and Mr. Tohill mentioned earlier, the risk of diabetic ketoacidosis, DKA, which is really high blood sugar, a crisis the body gets into that's potentially fatal, is particularly high for people with type 1 diabetes. These people are also particularly at risk of severe hypoglycemia, which can put them into seizures and comas.

Insulin pumps can be critical in helping to avoid conditions that cause hospitalizations and expensive emergency interventions in the short term.

[Len Webber, Conservative, Calgary Confederation, AB]

How much is an insulin pump?