Citizenship and Immigration Committee on Feb. 3rd, 2011

[The Chair, Conservative, David Tilson]

Good morning, everyone. Happy new year.

Alice, happy new year.

This is the Standing Committee on Citizenship and Immigration, meeting number 40, on Tuesday, February 3, 2011. Pursuant to Standing Order 108(2), this is a study of the interim federal health program.

We're already late, so I'm going to suggest that the first group of witnesses go until 9:50, and the second group of witnesses will start at 9:50. Is there any problem? Silence. Okay.

Good morning, gentlemen. Our first set of guests for the first, I guess, roughly 45 minutes is the association québécoise des pharmaciens propriétaires. Monsieur Cadieux is the executive vice-president and director general. Good morning to you, sir. And we have Vincent Forcier, director of public affairs. Good morning to you.

You can make a brief presentation of roughly seven minutes, and then committee members will have some questions for you. We'll go in rounds.

You have the floor for up to seven minutes. You can start right now, sir.

[Normand Cadieux, Executive Vice-President and Director General, Association québécoise des pharmaciens propriétaires]

Thank you, Mr. Chair.

I have a few words to present AQPP. If you don't mind, I'll do it in French. I'm sure you have translation.

The AQPP is a professional union representing the 1,800 owner pharmacists in Quebec.

Being a pharmacist is a prerequisite to owning a pharmacy in Quebec. In the case of large chains such as Shoppers Drug Mart/Pharmaprix and Jean Coutu, pharmacists are not owners, but rather franchisees.

The AQPP's mission is to consider and defend the economic, social and professional interests of its members. We carry out our mission primarily by negotiating agreements with various levels of government, such as the provincial government in the case of Quebec's public health care plan. The AQPP has also entered into a partnership agreement with the federal government that covers several programs.

At one time, the AQPP had an agreement with Citizenship and Immigration Canada. That was back in the 1990s. For reasons unbeknownst to me, that agreement was never renewed. In spite of that, refugees have continued to receive services. Pharmacists also never encountered any problems when it came to being reimbursed until about four years ago.

That is when problems first surfaced. Changes were introduced and rules were set, in our opinion, in a somewhat arbitrary manner, either by FAS or by CIC. Pharmacists no longer knew which medications were covered under the program, how much they would be reimbursed and the circumstances and terms under which their claims would be reimbursed.

All of which led to the problem we have today. Pharmacists decided that if they were not going to be reimbursed, they would either steer patients elsewhere or invite CIC to discuss a new agreement with the AQPP. For the past three years, we have repeatedly invited CIC to sit down and discuss an agreement, but unfortunately, our efforts have been unsuccessful.

Without an agreement, pharmacists who provide services to refugees have no way of knowing exactly which products are covered, what the level of coverage is, or the circumstances and terms under which their claims will be reimbursed. Each transaction carried out by the pharmacist therefore becomes problematic under the circumstances.

The AQPP is at a loss to explain the resistance it has encountered, despite the numerous invitations extended to CIC to negotiate a contract. The problem may be a lack of understanding. As I mentioned earlier, the AQPP already has agreements with the federal government covering first nations, with Health Canada, the RCMP, the Canadian Forces and Veterans Affairs Canada. The AQPP entered into this agreement with the federal government on the recommendation of Auditor General Sheila Fraser who had invited various federal agencies to come together to negotiate agreements.

So then, there is already an agreement in place. As we see it, CIC could take the exact same agreement and adjust the coverage to meet its needs. That would be a viable option. This approach has worked well with all of the other groups.

Since my time is almost up, I would like to wrap up by saying that we met early this week with CIC officials. We agreed on a temporary solution. We will restore service temporarily, even though it was never interrupted as such. We will ask our members to serve refugees, as per the program. That said, we still believe that the AQPP needs to negotiate an agreement with CIC quickly to resolve any outstanding issues and to set out all of the terms, conditions and coverage for refugees once and for all.

I hope that I have been able to give you an overview of the situation.

My colleagues and I will be happy to answer your questions.

[The Chair, Conservative, David Tilson]

Mr. Trudeau.

[Justin Trudeau, Liberal, Papineau, QC]

Thank you, Mr. Chair.

Was the agreement that the AQPP had with the federal government in the 1990s a detailed, formal agreement like the one currently in place with first nations and the RCMP?

[Normand Cadieux]

Yes, absolutely. Conditions and coverage were set out in the agreement. CIC was not very well equipped at the time and it asked us to draw up a list of medications. We managed that list along with the department. Our members were familiar with the list because we had supplied it to them. So the short answer is yes, there was a formal agreement in place and when a problem arose, it was settled quickly.

[Justin Trudeau, Liberal, Papineau, QC]

Did you encounter any delays when it came to being reimbursed? In your reports, you refer to some major problems at this time in this area.

[Normand Cadieux]

No, we did not have any problems on that score. Today, however, we are encountering major delays. Some of our members have been waiting one, two or even three years in some cases to be reimbursed, because there is no agreement that spells out whether the medications dispensed to refugees are covered.

[Justin Trudeau, Liberal, Papineau, QC]

There is no problem getting a claim reimbursed when the money is owed directly and CIC agrees that the claim must be paid. The problem is more that there is no agreement spelling out which products or services are covered. However, claims are reimbursed quickly when it is clear that a product is covered. Correct me if I'm wrong, but delays are encountered only when there is a disagreement over coverage.

[Normand Cadieux]

When a product is designated as being covered, generally reimbursement is relatively straightforward. However, I can give you a few examples of cases that have posed a problem. The federal government is trying to follow the provincial program model, but there are many differences where coverage is concerned. The federal government reimburses the quantity of the product that results in the cheaper price per unit. It is different under Quebec's provincial program. Pharmacists tend to supply the smallest prescription quantity or the quantity best suited to the length of the treatment program. These smaller quantities are not subject to reimbursement under the federal program. This has led to disputes as reimbursement of the cost of these products is not necessarily automatic.

It isn't always logical. For instance, the blood glucose testing strips that patients use come in packages of 50 or 100 units. Obviously, the unit cost for the 100-strip package is lower and that is the quantity covered by the federal government. However, in Quebec, the cost of the 50-unit package is reimbursed. Fifty test strips represents a one-year supply, while 100 strips is enough for two years of testing. But after one year, the strips are no longer good and must be discarded. Clearly this decision makes no sense. Pharmacists tend to go with the quantity that does makes sense, but then they are not reimbursed.

[Justin Trudeau, Liberal, Papineau, QC]

A new agreement was entered into this year with Medavie Blue Cross. In your opinion, will the situation improve as a result of this agreement?

[Normand Cadieux]

Absolutely. You have to understand that the agreement is between CIC and Medavie Blue Cross, not between CIC and pharmacists. Pharmacists have not reached an agreement with Medavie Blue Cross. They do not know the terms of the agreement between the two parties. However, the fact that such an agreement has been signed between CIC and Medavie Blue Cross will facilitate matters. Medavie will be linked electronically and in real time with pharmacists. Every time the pharmacist provides a service, he will know whether or not that service is covered. This will certainly make things better, but an agreement is still needed to provide a proper framework.

[Justin Trudeau, Liberal, Papineau, QC]

I understand, but is an agreement really necessary, given that your link to Medavie Blue Cross will resolve your dilemma somewhat and provide you with information as to which services are covered and which ones are not?

[Normand Cadieux]

An agreement is necessary because the pharmacist does not have any contractual ties with Medavie Blue Cross. If the company refuses to reimburse a claim for a product or decides to make a withdrawal from the pharmacist's account—because the system operates by direct deposit—because an error has been made or because it wants to be compensated, then there are no safeguards in place. It is commonplace in the industry to have intermediaries step in and impose their own rules. Obviously, we do not want pharmacists put in these kinds of situations. We want them to be familiar with the conditions they must abide by when they agree to honour the Medavie Blue Cross card.

[Justin Trudeau, Liberal, Papineau, QC]

Why is the problem more pronounced in Quebec than elsewhere in Canada?

[Normand Cadieux]

I do not think other provinces are facing a very different situation. However, we are the only pharmacists in Canada and North America to belong to a professional union. There is no other union like ours anywhere. In other provinces, Medavie Blue Cross and CIC send out a contract to pharmacists or to companies like Shoppers Drug Mart and they decide whether or not to sign on. In Quebec, pharmacists are represented by our union and we manage the agreements on behalf of each pharmacist. In other provinces, if 10 pharmacists sign the contract, then these 10 are bound by it. In Quebec, the union signs the agreement on behalf of the 1,800 pharmacists who are then all bound to honour it.

[The Chair, Conservative, David Tilson]

Monsieur St-Cyr.

[Thierry St-Cyr, Bloc, Jeanne-Le Ber, QC]

Thank you, Mr. Chair.

Thank you for being here. I am very pleased that you accepted our invitation. I asked the committee to examine this matter because I felt it was urgent. I am delighted to hear that discussions are taking place with CIC and that progress is being made.

I take it—and you can clarify this for me—that this is a long-standing problem. The lack of progress on this issue forced you to resort to pressure tactics. That is probably not what you would call them, but I am referring to the directive sent out by the union to its pharmacists. I understood you to say that since the partners returned to the bargaining table and everyone seems to be acting in good faith, you intend to direct your pharmacists, at least as long as the process is ongoing, to continue delivering the same services that they have in the past.

Did I understand you correctly?

[Normand Cadieux]

Absolutely. We agreed with CIC representatives to continue delivering services, providing of course that certain criteria are defined. This is only a temporary solution, because again, things will happen in a haphazard way and pharmacists will not know for certain how things are going to be. The situation will continue to be a problem as long as there is no formal agreement or electronic links with Medavie Blue Cross in place.

We are prepared to tolerate this situation provided action is taken quickly. If an agreement can be reached with CIC quickly, we will arrange to put everything in place, such as the programming. Pharmacies use computer systems and we will need to have our software developers program the system for the agreement. There will be a short delay, but by coming to an agreement as quickly as possible, the problem should be resolved. But first, we need an agreement, and we are not there yet.

[Thierry St-Cyr, Bloc, Jeanne-Le Ber, QC]

So then, in the short term, that is this afternoon or tomorrow, as long as things are moving forward, we can reassure refugees who are worried that they might get their medications free of charge. For now, full service has been restored.

[Normand Cadieux]

Absolutely. We are working with our members and also with CIC, to ensure that everything is running smoothly, at least for now.

[Thierry St-Cyr, Bloc, Jeanne-Le Ber, QC]

Okay. Thank you very much. That is reassuring. I think all members are happy to hear you say that. The committee has scheduled two meetings to examine this issue, but if things do not progress quickly enough, I will ask my colleagues to come back to this again later. We will not abandon Quebec's pharmacists or refugees.

Mr. Trudeau alluded to the difference between pharmacists in Quebec and elsewhere in Canada. You explained about unions and you also quickly mentioned that pharmacies in Quebec are owned by pharmacists. Is that required by law?

[Normand Cadieux]

Yes, it is. Pursuant to the Pharmacy Act, only a pharmacist may be the owner of a pharmacy.

[Thierry St-Cyr, Bloc, Jeanne-Le Ber, QC]

For owner pharmacists, what are the financial implications of the problems they are having with CIC in terms of having medication costs reimbursed? What percentage of overall sales does this represent? I'm assuming it varies by region. Are we talking about everyday medications or about costly ones as well? What are the financial implications for pharmacists?

[Normand Cadieux]

I really could not give you a figure in terms of sales percentages, because I'm not familiar with each pharmacy's sales figures. Also, since we do not have an agreement, I do not know the percentage of medications covered by CIC. However, substantial sums of money are involved. You understand that the money is advanced by individuals, by pharmacists. The worst case we saw was that of a pharmacist who had to advance thousands of dollars and who had been fighting with CIC for three years.

Let me give you some examples of products delivered to patients and what they cost. For instance, the monthly cost of triple therapy to treat HIV-AIDS is $1,500. This is each and every month and if the pharmacist is not reimbursed for the cost of treating a few patients, it doesn't take long for the cost to add up, after two, three or fourth months, to several thousand dollars.

It is the same for serious pulmonary infections treated with vancomycin. One seven-day course of treatment costs $500. The costs also add up quickly in this case. These are costs that that individuals, the owner pharmacists, must cover up front. It's not large corporations, but rather individuals, who are paying up front.

[Thierry St-Cyr, Bloc, Jeanne-Le Ber, QC]

You mentioned computer systems. You also spoke of signing an agreement and expressed the hope that it would closely resemble other agreements that you have signed with other federal government agencies. I assume that when it comes to computer systems, programming, design and so forth, and to the knowledge of participating pharmacists, it is easier to go with a system that is already in place and works well, rather than put in place an entirely new one.