Health Committee on Nov. 28th, 2017

[Casey Thomas]

In terms of the types, I can't give you a list, but something like a root canal, orthodontics, or a crown—anything that is more extensive or more complex—would require a pre-approval. Something such as a filling or a scaling, for example, would be the type of service that wouldn't require a pre-approval.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Okay. Do you know if the decision on whether or not it was pre-approved was determined on level of complexity, or was there another decision in terms of requiring what would need pre-approval and what would not?

[Casey Thomas]

The department has developed a schedule of services that it will provide overall. When you look at the schedule's extensive list, you see that about 40% of the services require pre-approval. The department has predetermined that if a dentist prescribes or requires to give a patient a particular service, then 40% of those services would require pre-approval.

What the department has demonstrated is that in the claims they pay for, only 4% of the claims have actually come back, having received or required a pre-approval.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

All right. In those requiring pre-approval, does the pre-approval process itself appear to present any difficulties or any barriers?

[Casey Thomas]

In the course of our audit, we didn't look at individual cases. The dentists themselves have the patient files, so we wouldn't have had access to those files.

What we did look at is the process that the department went through to determine what should be on the list. I don't think I completely answered your question earlier, in that there are criteria that the department has developed, which I think you alluded to but I didn't speak about. We didn't look at the individual decisions themselves, but we did look at the process the department uses to determine the list and the criteria.

[Michael Ferguson]

The other thing in terms of the pre-approval was that they had set a standard of 10 days. If you look at the way they've described the standard, you as an individual would think that you would get an answer back within 10 days on your particular situation, but they weren't measuring it and monitoring it on an individual basis. They were sort of aggregating a whole bunch of decisions and coming up to see whether they were, on average, actually meeting that 10 days.

From the point of view of an individual, if you went to their website, for example, you would expect that you would get a decision within 10 days. You may not actually get the decision within 10 days, even though the department would be saying that they met their service standard because they would be averaging your decision in with other decisions. That could cause some concern and perhaps complaining on the part of people receiving services, who expect that they would be managing that service standard on an individual basis for making a decision within 10 days, when in fact they're measuring it on an averaging basis.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you.

There was a document done by the Assembly of First Nations. It's called the “First Nations Health Transformation Agenda”. They talked about the national utilization rate for dental benefits. It was 34% of eligible individuals. This compared to 61% for those who were eligible for pharmacy benefits. The report noted that part of the reason for the low rate of utilization—I'll read this verbatim—was “poor overall communication about the...benefits and, particularly in the case of dental, a hesitation or unwillingness of First Nations clients to try to navigate the onerous NIHB approvals process.”

Would you say that your review supports this conclusion that some of these low utilization rates are in part due to how onerous this approval process was in discouraging people from navigating it?

[Michael Ferguson]

Again, that wasn't where we were looking in terms of the audit. There are a number of services they provide that people have access to and, certainly, we did find that in the course of the year about 300,000 people, I think it was, had accessed these services. The population that would be eligible for the services would be significantly higher than that 300,000. That indicates there's work for the department to do to understand who is getting access to the services.

Again, we did find that they made some changes from time to time on the services that were available, and there were some communication issues that we identified. For example, if the department made a decision to change the services they pay for, they didn't communicate that right away. Their reason for this was that when they made this type of change they had to program it into their system, their payment system, and that took a while to do.

In our report, we identified an example where they made a change in 2014. I think it was about the number of X-rays, for example, that they would pay for. They increased it from six to 10, but it took them two years to actually tell people that they had increased it from six to 10. In the meantime, somebody may have heard from their dental service provider that they had already had their six X-rays and couldn't have any more, so then they might have put something off, whereas another dental provider might have said, “Okay, I think you need another X-ray, so I'll ask for approval.” They then would get approval because the department had already increased from six to 10 but hadn't actually communicated it.

In that case, the access to those types of services might have been uneven because either some dental service providers knew about it or some asked for pre-approval, whereas others didn't know about it or didn't ask for the pre-approval.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you.

[The Chair, Liberal, Bill Casey]

Your time is up.

Now we're going to our five-minute rounds, starting with Mr. Webber.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, Mr. Chair, and thank you to our witnesses for being here today.

I'm thinking back to my days back in Alberta in provincial politics when I served as the aboriginal relations minister and dealt a lot with Alberta's dental hygienists association in trying to expand their scope of practice. Initially, for any type of work they did, they required a dentist to be on site, either supervising their work or being on the same site somewhere in case something occurred where a dentist was required. We were able to change that through a lot of work within government to expand their scope of practice so they could provide preventative services, such as scaling, fluoride treatment, or sealants, without the assistance of a dentist or a dentist on site. This enabled them to be mobile and to go out to the communities and do their preventative maintenance work without having a dentist with them.

With regard to Health Canada and their policy, where are they with implementing these health services? Do they require a dentist to be on site? What's their scope for the hygienists out there?

[Casey Thomas]

First of all, we didn't look at each of the provincial or territorial requirements, but essentially that's what Health Canada relies on. They are able to use the practitioners in each of the provinces and territories as the provincial jurisdictions regulate them. If a hygienist has the ability to do more in a province, then Health Canada would be able to rely on that service in that province. When you look at it, you see that each of the regions or each of the provinces and territories has a different service delivery mechanism, depending on the provincial or territorial regulations.

[Len Webber, Conservative, Calgary Confederation, AB]

I see. It is a provincial jurisdiction. They decide who has what scope of practice there. Okay. Perhaps Health Canada can put pressure on these jurisdictions that don't have that wide acceptance of dental hygienists and their skills.

Also, in your report, you state, “According to Health Canada's Non-Insured Health Benefits Program 2015-16 annual report, in that fiscal year, fee-for-service expenditures were approximately $87 million for restorative services” and “$24 million each for preventive services and diagnostic services”.

That was back in 2015-16. How is that comparable to the years after that? Has it increased significantly? Is it relatively the same? Is there a comparison from previous years? Do you have those numbers, by chance?

[Casey Thomas]

We didn't look back to determine any sort of comparison over the years, but what I can say is that.... There was a question earlier about the weighting between preventive and restorative, and while the department can definitely do work to encourage more preventive services, for example, some of it is reliant on the dentist who is determining what service a client requires. The services themselves seem to remain about the same overall.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you.

I'm going to pass my last one on to my colleague.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Thank you.

I noted that there was sometimes a gap in the human resources needed to execute the services. Can you give us some detail about what resources were missing? Was it hygienists? Dentists? Was it consistent across the country?

[Casey Thomas]

Basically what we saw was a lack of service providers that had been identified by the department or the regions themselves. For example, two regions identified the need for contract dentists and had looked to find out if they could get more.

Similarly, as we report, the dental therapist community is declining, and the regional plans that we spoke about earlier have identified the need to fill those spots and to determine how they're going to do that, but as we report as well, they haven't necessarily acted quickly enough on this. They've known since 2009 that the dental therapists' numbers were declining, but they haven't taken enough action yet to fill those spots.

[The Chair, Liberal, Bill Casey]

Now we'll go to Mr. McKinnon.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you, Chair.

Mr. Ferguson, your report indicates that first nations and Inuit populations have almost twice as much dental disease and more oral health needs than the general population and cites reasons such as fewer dental visits, lack of affordable and nutritious food, and so forth. Among these on this list, though, are things such as geographic barriers. We know that some of our indigenous communities, particularly in the Far North, are very remote. I would think that this is a very dominant factor in those areas. It would answer for fewer dental visits and all these other things.

I wonder if you were able to correlate your data in relating need with geographic remoteness in any way.

[Michael Ferguson]

Again, that's the type of analysis that we would like to see the department do.

I'll start with this. I may ask Mr. Martire to provide some details on other work we've done in terms of access to health services in remote first nations as well, but that's the type of information we would expect the department to be able to do, again, to try to understand.... It's one thing to know that there is a gap, with the rate of dental disease being twice that of other populations in Canada, but then there are all of these different factors that can contribute to that, such as the remoteness and the availability of nutritious food and those types of things. We would like to see the department being able to do some sort of correlation on that.

Certainly, you're right; the remoteness of first nations is a factor. The other audit that I mentioned we did was on access to health services in remote first nations. I'll ask Mr. Martire to perhaps give you a bit of information on that issue.

[Joe Martire, Principal, Office of the Auditor General]

Thank you.

The report we're referring to was tabled in the spring of 2015. It focused basically on remote first nation communities. We focused in on Manitoba and northern Ontario, which account for about 65% of all the remote first nations in Canada that are on reserve.

The issue there is that if you think about it, what we were trying to get to was what kind of access they have to clinical and client services. That would include medical transportation. The focal point in these remote communities, as you may be aware, is basically the nursing station. That's their first point of contact. Let's say a dentist comes in. There's an issue around where you put them when they arrive. We found barriers in terms of the accommodation and the state of facilities that were there.

Then there's the actual transportation policy with regard to any health issue, including dental. I think dental covered about 5% of their.... We looked to see how they were actually applying their medical transportation policy. In there we found some significant weaknesses. For example, the first thing that has to happen is that you have to be registered. If your child is not registered, then you may be denied access. We took a sample of about 50 people in the two communities. Half of them were not registered in Manitoba. In Ontario they didn't keep the data, but some of the communities we visited told us us that in one particular community at least 50 individuals weren't registered. Right away that causes complications.

The good news is that if there are medical emergencies, people do get transported to get their needs assessed. The problem is when you're trying to get them back. If you call Health Canada and they're not in the system, then you might have some issues. On the dental specifically, the population.... As I said, it's about 5% of all the transportation benefits, and there are issues with that.

We talked a lot about documentation. That was another area where we found some significant deficiencies. If you look at the medical transportation policy, certain principles guide what that policy is supposed to do. We took a sample of those principles. We tried to look at the compliance rate. In Manitoba we looked at five. For example, we looked at whether the transportation was medically required, 0%. We looked at the attendance confirmation, written confirmation by a health professional that the person actually attended the appointment, 0%. In Ontario it was a little bit better, but they had significant problems with documentation.

There was some discussion earlier about the quality of documentation. In this particular area, it was pretty bad. In Manitoba particularly, they didn't keep documents as they were required to do with the federal government's policy on record-keeping. That's the issue not only for dental but for all health services. For remote locations, the nursing stations are the first point of contact. If people can't be treated there, then the medical transportation policy is designed to bring them to the nearest location to get that service.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you.

[The Chair, Liberal, Bill Casey]

Your time is up.

Mr. Van Kesteren.

[Dave Van Kesteren, Conservative, Chatham-Kent—Leamington, ON]

Thank you, Chair.

Thank you for being here.

I know the question has been asked before, but I want to ask it again, because I want to get your on-the-ground reaction. It was noted that these procedures were supposed to have taken place, and Health Canada had acknowledged that this was the plan.

Mr. Ferguson, when you confronted Health Canada with those facts, what was their reaction? Did they just shrug their shoulders? They must have had some kind of response. I'm a little baffled about that.

[Michael Ferguson]

If I understand the question, it's about the fact that they hadn't put the strategy in place. In 2010 they identified they needed a strategy, and again later on. I'll perhaps ask Ms. Thomas to characterize the conversations we had, but what I would say is that unfortunately we come across this not infrequently in departments. They identify the need for a strategy, they start work on the strategy, but then they never totally complete it. It's not unique to this department.

In terms of the conversations we had with them, I'll ask Ms. Thomas to comment.