Health Committee on March 21st, 2016

[Don Davies, NDP, Vancouver Kingsway, BC]

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?

[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.

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.

[Don Davies, NDP, Vancouver Kingsway, BC]

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.

[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.

[Don Davies, NDP, Vancouver Kingsway, BC]

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 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.

[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—

[Don Davies, NDP, Vancouver Kingsway, BC]

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?

[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, Liberal, Bill Casey]

Mr. Ayoub.

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

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.

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.

[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?

[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.

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

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?

[Abby Hoffman]

That's correct. The act does not prescribe with any degree of specificity what services shall be provided and what specific quality standards shall prevail. That is up to the jurisdiction in question to determine.

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

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?

[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.

[The Chair, Liberal, Bill Casey]

Dr. Leitch.

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

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.

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?

[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.

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.

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

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?

[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.

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.

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

To disagree just slightly, I think having determined outcomes is actually valuable. Working toward those as goals is important.

[Abby Hoffman]

Yes.

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

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, Liberal, Bill Casey]

You're over your time. Sorry. That was very interesting, though.

Ms. Sidhu.