Health Committee on March 21st, 2016

[Sonia Sidhu, Liberal, Brampton South, ON]

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?

[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. 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.

[Sonia Sidhu, Liberal, Brampton South, ON]

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?

[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.

[Sonia Sidhu, Liberal, Brampton South, ON]

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?

[Abby Hoffman]

There are a couple of things I could mention.

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, Liberal, Bill Casey]

Mr. Webber.

[Len Webber, Conservative, Calgary Confederation, AB]

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.

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?

[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.

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.

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.

[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.

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.

[Len Webber, Conservative, Calgary Confederation, AB]

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, Liberal, Bill Casey]

Mr. Oliver.

[John Oliver, Liberal, Oakville, ON]

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.

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?

[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.

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.

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.

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.

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.

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.

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—

[John Oliver, Liberal, Oakville, ON]

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?

[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.

[John Oliver, Liberal, Oakville, ON]

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?

[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.

[John Oliver, Liberal, Oakville, ON]

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?

[Abby Hoffman]

Maybe the fact that it exists is helping.

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 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, Liberal, Bill Casey]

Mr. Davies, welcome back.

[Don Davies, NDP, Vancouver Kingsway, BC]

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.

[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.

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—

[Don Davies, NDP, Vancouver Kingsway, BC]

Sorry for interrupting. Do they actually get the money back from the clinic that charged them?

[Gigi Mandy]

They do. They reimburse the patient first, and then they recover the money from the physician.