Veterans Affairs Committee on Nov. 20th, 2018

[The Chair, Liberal, Neil Ellis]

Yes, if you could.

[Faith McIntyre]

Thank you. I would imagine you're referring to our VAC assistance line, which is our 24-7 line. I will need to follow up. If indeed that is happening, that should not be the case. We will certainly check into that and ensure that folks, particularly in an immediate crisis situation, aren't being pushed off, put on hold or left in other situations that might lead to their not wanting to continue to speak to an individual. I appreciate your flagging it.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you.

[The Chair, Liberal, Neil Ellis]

Mr. Bratina, I believe you are splitting time with Mr. Chen.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

Thank you very much.

I was reviewing one of those sites where people comment on having worked at a place. One place was VETS Canada. It seems like the overwhelming response is that people are very satisfied. They are happy to work for veterans and do the things that need to be done. There's job satisfaction that goes with it. One thing that was flagged was the shortage of team-building opportunities because your staff is under the gun. We're hearing comments, and there are newspaper articles and so on. Is there an interaction with the staff, in terms of morale and ensuring that they're working to their maximum capacity on behalf of the veterans?

Anyone can answer that.

[Faith McIntyre]

Thank you very much for the question. I can start, but I'd turn to Robert as well, who works in the field directly with staff.

It is unfortunate, I think, particularly when there are news articles that come out that paint a picture. We have staff here who are very passionate and who work their hardest to ensure that decisions are made in the best interests of veterans and their families. Taking time and building teams, we've developed a national orientation training program, which is something new. We are working through hiring all of the new staff and building that team, virtually as well as face to face. We're doing things such as holding off-site meetings and using various communications.

We actually just released a pulse survey as well. It's the second one with our employee council to really figure out the pulse of the staff. In response to that, then, what do we need to improve upon or what do we continue doing if things are going well?

Robert, I'll let you speak to some examples from your end.

[Robert Tomljenovic]

Yes, sure. Certainly, our staff work very hard. When you're case managing complex issues, certainly it can be challenging and whatnot. I will tell you, though; we talk about a workplace of choice. I've seen Veterans Affairs really try to move in that direction, by offering little things that provide some sort of self-care for our case managers, whether it's flex hours or work from home opportunities.

The other thing that we have now are wellness committees. They have popped up in virtually every one of our area offices. These committees really focus on well-being and helping to boost morale. We allow for some activities. We do some meditation over lunch. We've done chair yoga over lunch. I will tell you, staff have really appreciated that. I think they really benefit from it. It offers a nice balance during that challenging day. We've seen a huge difference from it.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mr. Chen.

[Shaun Chen, Scarborough North, Lib.]

Thank you, Mr. Chair.

I want to start off by thanking both of our guests for being with us today.

I want to echo the comments that they and my colleagues on the committee have made with respect to the work of VETS Canada and the Royal Canadian Legion. I'm very lucky to have the Centennial Branch 614 of the Legion just across the street from my constituency office. They do a fantastic job of getting veterans together. They've invited me a few times to their karaoke night, but it always seems to fall on a weekday when I'm in Ottawa. I do hope to join them one day. More importantly, they're really there to help veterans when the help is needed. The fact that the veterans are there to support each other is very, very important and tremendous.

My colleagues have mentioned the emergency fund. I know that this fund provides up to $1 million every fiscal year. This is a new fund, from my understanding. When was this fund first put in place?

[Robert Tomljenovic]

The fund first came into effect April 1, 2018.

[Shaun Chen]

It's 2018. Prior to that, if veterans needed access to emergency funding and support, and they called Veterans Affairs Canada, what would happen?

[Robert Tomljenovic]

I mentioned this before. We would look at a variety of third party funds out there, including assistance via the Legion or VETS Canada. We can tap into all sorts of benevolent funds, like the Royal Canadian Naval Benevolent Fund. There were always funds out there that we could tap into. The Soldiers' Aid Commission is another one that we use quite a bit.

There are third party funds out there and available, and those were the ones that we tapped into. The nice thing about the emergency fund is that when it came into effect, it gave.... The decision didn't rest with the staff within Veterans Affairs for those third party funds, but now it does, and that's why it can move more quickly. We're not waiting for a decision to come back.

[Shaun Chen]

The decision on whether to support a veteran is made by Veterans Canada. It's a new fund, and there's a tremendous need. This, to me, is in fact a great success because, as was pointed out earlier, 66% of the fund has already been spent for this fiscal year. Veterans are hearing about this, they're calling back and they're getting the supports they need.

What types of situations can you share with us regarding veterans who are getting funding through this emergency fund? What are they facing?

[Robert Tomljenovic]

Some of the ones that I've seen that have been approved have been looking at housing. That certainly is a big one, whether they need first and last months' rent or, for whatever reason or due to unforseen circumstances, they can't pay the rent for a month.

The fund is not there to look at long-term assistance, but sort of that short, unforeseen emergency. We've paid for food and anything that's a necessity. I believe, although I can't remember, that we had a veteran whose roof may have been leaking. In that instance, that's something we would look at repairing because of the damage that can happen if it isn't repaired. Those are some of the things that have come my way through the local area office.

[The Chair, Liberal, Neil Ellis]

Thank you.

Unfortunately, that ends our time today for this panel.

On behalf of the committee, I'd like to thank both of you for taking time out of your day and for all that you do for the men and women who have served.

We'll recess for a couple of minutes and get the next panel in.

Thank you.

[The Chair, Liberal, Neil Ellis]

I'd like to call the meeting back to order.

We have some in camera business which we're going to have to get to after this, so I'm going to have to hold you to your time. Try to take it easy on me.

In relation to our study of medical cannabis, we are pleased to welcome, from Veterans Affairs Canada, Dr. Cyd Courchesne, Director General, Health Professionals Division and Chief Medical Officer; and Dr. Alexandra Heber, Chief of Psychiatry, Health Professionals Division.

Dr. Courchesne, the floor is yours.

[Dr. Cyd Courchesne, Director General, Health Professionals Division, Chief Medical Officer, Department of Veterans Affairs]

Thank you, Mr. Chair.

Good afternoon, Mr. Chair, vice-chairs and members of the committee. I'm Dr. Cyd Courchesne, Director General of Health Professionals and Chief Medical Officer at Veterans Affairs Canada. I'm pleased to be here today with my colleague, Dr. Alexandra Heber, our chief psychiatrist.

We would like to thank you for the invitation to appear before the committee in regard to your study on the implications of veterans' mental health as it relates to medical cannabis through the medical cannabis program administered by Veterans Affairs Canada.

We will briefly touch on the reimbursement program for cannabis for medical purposes at Veterans Affairs Canada, the data on program uptake, the approvals process for reimbursement exceeding three grams per day and the most recent research data available to the department.

Veterans Affairs Canada's mandate is to provide exemplary, client-centred services and benefits that respond to the needs of veterans and their families, as well as its other clients, so as to recognize their service to Canada and keep the memory of their achievements and sacrifices alive for all Canadians.

Our goal is for veterans and their families to receive the care and support they need.

In 1999, legal access to possess dried marijuana for medical purposes was first approved. Since then, as a result of many court decisions, the way individuals access cannabis for medical purposes has changed significantly. Veterans Affairs Canada has provided coverage for the cost of cannabis for medical purposes since 2008.

Between 2008 and 2014, reimbursement was based on section 4 of the veterans health care regulations and in accordance with Health Canada's marijuana medical access regulations. The marijuana medical access regulations, implemented in 2001, provided limited access to marijuana for medical purposes for a number of conditions and circumstances as defined by Health Canada when authorized by specialists only.

In April 2014, Health Canada introduced the marijuana for medical purposes regulations, which removed limitations related to the authorization for specific conditions, and the requirement for authorization by a specialist was changed to a medical authorization.

It also provided individuals with a medical need to access quality-controlled dried marijuana produced under secure and sanitary conditions by licensed producers. In June 2015, licensed producers were permitted to produce and sell cannabis oil and fresh marijuana buds and leaves in addition to dried marijuana.

In August 2016, Health Canada's access to cannabis for medical purposes regulations were introduced, which set out provisions for individuals to grow a limited amount of cannabis for their own medical purposes, or to designate someone to produce it for them.

While cannabis for medical purposes is still not an approved therapeutic drug in Canada, the access to it continues to grow. With the advent of these new regulations, Veterans Affairs Canada subsequently experienced a significant increase in requests for cannabis for medical purposes reimbursement.

In its spring 2016 report, the Office of the Auditor General recommended that Veterans Affairs Canada improve the management of its drug benefits program to consider the health and well-being of veterans, as well as cost containment.

As a result, the department conducted an internal review, which involved consultation with medical professionals, subject matter experts, licensed providers and veteran beneficiaries. The result of this review led to the implementation of Veterans Affairs Canada's reimbursement policy for cannabis for medical purposes on November 22, 2016.

The 2016 policy allows eligible veterans to be reimbursed for a maximum of three grams per day of dried cannabis, or its equivalent in cannabis oil, and fresh cannabis at a fixed rate per gram.

The decision to reimburse for three grams per day is based on data obtained through consultations and research. Veterans Affairs Canada brought together a panel of Canadian medical experts, who recommended a very cautious approach to the use of cannabis for medical purposes, with some indicating one to two grams per day was a reasonable amount for the vast majority of cases.

Veterans Affairs Canada also reviewed current scientific evidence and consulted with veterans, stakeholders and licensed producers. The decision is also consistent with Health Canada data, which indicate that the average Canadian is authorized less than three grams per day.

The approval process to obtain a reimbursement from Veterans Affairs Canada for cannabis for medical purposes requires that veterans have an authorization from a medical practitioner, and that they be registered with a licensed producer from Health Canada's website. The documentation is received by Medavie Blue Cross, which sends it to Veterans Affairs Canada for a decision. Medavie Blue Cross sends the decision letter to the veteran on behalf of Veterans Affairs Canada.

To ensure greater rigour in the department's approach, a process for approving exceptional requests was put in place in November 2016, when the policy was introduced.

While reimbursement requests for up to three grams per day require a medical authorization document from a general practitioner, or a nurse practitioner in some provinces, requests for more than three grams per day may be approved only when supported by additional documentation from a medical specialist with expertise in the veteran's diagnosed condition. For example, if the veteran is eligible for treatment benefits associated with a mental health condition, the specialist's document would be provided by a psychiatrist. For pain due to cancer, an oncologist could provide the supporting document.

Each exceptional claim is reviewed on a case-by-case basis. The medical specialist's supporting document must include a rationale for the use of more than three grams per day, confirmation that there are no contraindications when using cannabis for medical purposes, and an indication that alternative treatments have been ineffective or contraindicated.

Similar to other treatment benefits reimbursed by Veterans Affairs Canada, the exceptional approvals process is a mechanism to help ensure the health and well-being of the veteran remains at the forefront of any decision.

Veterans Affairs Canada reimburses only for medical treatments authorized by the veteran's physician or health care practitioner. The department does not prescribe medical treatment.

VAC considers the veteran's own physician to be in the best position to identify and authorize the most appropriate treatment to address the patient's health condition.

In 2017-18, a total of 7,298 veterans were reimbursed for medical cannabis, at a cost of approximately $51 million. While the number of veterans seeking reimbursement continues to rise, the cost per veteran has decreased.

An analysis of expenditure data for the nine-month period between April 1 and December 31, 2017 revealed expenditures of $39 million. Had the 2016 reimbursement policy for cannabis for medical purposes not been in place, it is estimated that costs would have been $91 million for the same period, indicative of a potential cost savings of $52 million. This meets the Auditor General's recommendation to contain costs, while ensuring the health and well-being of veterans.

A comparison between December 2016 and December 2017 provides further evidence of the policy's impact. In December 2016, Veterans Affairs Canada reimbursed an average of 155 grams per eligible veteran, at an average cost of $11.28 per gram. In contrast, in December 2017, reimbursements declined to an average of 89 grams, at an average cost of $8.38 per gram.

On December 31, 2017, approximately one year after the reimbursement policy was implemented, of the 6,119 veterans with active medical authorizations from their health care professionals, only 734 veterans, or 12%, had exceptional approvals in place. This is in sharp contrast to the previous year.

On December 31, 2016, a total of 2,771 veterans, or 66% of all recipients, were authorized for more than three grams per day. This decline in the number of veterans requesting reimbursement for over three grams per day is also in line with Veterans Affairs Canada's focus on supporting the health and well-being of veterans and their families.

On August 31, 2018, a total of 8,175 veterans were being reimbursed for medical cannabis, for a total expenditure of $29.7 million.

On October 17, 2018, the Government of Canada’s new Cannabis Act and cannabis regulations came into effect, providing legal access to cannabis for Canadians. The act and regulations also control and regulate the production, distribution and sale of recreational cannabis and cannabis for medical purposes.

To coincide with the coming into force of the new act and regulations, Veterans Affairs Canada has updated its reimbursement policy, which simply reflects adjustments to the language under the new legal recreational cannabis regime. Veterans will experience no change in the current reimbursement process for cannabis for medical purposes. Under the revised policy, Veterans Affairs Canada will continue to reimburse for a maximum of three grams per day of dried cannabis, or its equivalent in fresh cannabis or cannabis oil. Veterans Affairs Canada will only reimburse eligible veterans for cannabis for medical purposes.

That concludes our opening statement, Mr. Chair.

We would be pleased to answer any questions you have.

[The Chair, Liberal, Neil Ellis]

Thank you.

We'll start with Mr. Kitchen.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you, Mr. Chair.

Thank you both for coming today.

Dr. Courchesne, thank you very much for your presentation. You indicated that in December 2016 there were 4,719 veterans receiving medical marijuana; December 31, 2017, 6,119; and August 31, 2018, 8,175.

Do you have any suggestion as to why the number keeps going up?

[Dr. Cyd Courchesne]

You would have to ask the doctors who prescribe it to their patients. We have no control over that.

We saw a rise with the change in regulations over the years from Health Canada. At the beginning, the criteria were very restrictive and they kept being challenged in court. Every time the courts would come back and say that the rules are too restrictive, so Health Canada would revise them. It was when they removed the requirement to go to a specialist and for anyone with a prescribing licence.... That's when we saw a sharp increase.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you.

Do you have a breakdown as to years of service, age and sex, etc., for those 8,175 veterans? If not, can you get that for us? Also, do you have a breakdown by rank?

[Dr. Cyd Courchesne]

I have a breakdown of how many grams the 8,175 are using, but I don't have that other type of breakdown because we don't collect that information.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Do you know what percentage would be under the age of 25?

[Dr. Cyd Courchesne]

I would have to correlate that with our findings. I can give you how many of our veterans are under 25, which is not the majority. The majority of our veterans are above 25 years old, because many of them have 10 years or more of service.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Okay, thank you.