Evaluation of Health Canada's First Nations and Inuit Supplementary Health Benefits (Non-Insured Health Benefits) Program 2009-2010 to 2014-2015

Evaluation of the First Nations and Inuit Supplementary Health Benefits (Non-Insured Health Benefits) Program 2009-2010 to 2014-2015

Recommendations	Response	Action Plan	Deliverables	Expected Completion Date	Accountability	Resources
Recommendation as stated in the evaluation report	Identify whether program management agrees, agrees with conditions, or disagrees with the recommendation, and why	Identify what action(s) program management will take to address the recommendation	Identify key deliverables	Identify timeline for implementation of each deliverable	Identify Senior Management and Executive (DG and ADM level) accountable for the implementation of each deliverable	Describe the human and/or financial resources required to complete recommendation, including the source of resources (additional vs. existing budget)
1. Review and streamline NIHB Program Coordination of Benefits (COB) procedures and practices with other publicly and privately funded supplementary health benefit plans to ensure clarity, minimize delays and facilitate client access to benefits.	Management agrees to review and streamline COB procedures for coordination with a focus on privately funded supplementary health benefit plans. NIHB Program is not a party to the relationship between clients and their private insurers and, therefore, cannot compel private payers to meet their obligations to their own clients who pay premiums for their coverage (or those clients who have premiums paid on their behalf). Most public plans do not, as a matter of policy/legislation, extend benefit coverage to clients who are eligible for the NIHB Program (most do not have COB with other insurers as public plans are most often intended to provide coverage only where the client otherwise has none). Where a public plan does cover NIHB eligible clients, coordination of benefits generally works well. Where there is a potential for overlap with other public plans, the Program will work with provincial and territorial partners to explore arrangements.	Review COB procedures and practices	COB procedures and practices reviewed	Q2 (September) - 2017/18	Senior ADM, FNIHB DG, NIHB, FNIHB	N/A
		If needed, issue additional guidance to Program staff re: streamlined procedures	—Additional guidance issued (if needed) to Program staff re: streamlined procedures	Q3 (December) - 2017/18
		Issue communications products to clients to clarify COB practices and identify a point of contact to resolve COB issues	—Communications products issued to clients	Q2 (September) - 2017/18
		Work with the Ontario government to explore potential options for coordination related to OHIP+	— Discussion on potential collaboration	Q2 (September) - 2017/18
2. Consider conducting a strategic analysis, in specific geographic areas, to support the enhancement of local health services to improve access to care and to progressively reduce Medical Transportation (MT) benefit expenditures where feasible.	Management agrees to conduct analyses to identify opportunities for enhancement of local health services to improve access to care.	— Work with NIHB regions, as well as partners and other FNIHB Programs, to identify geographic areas where it would be feasible to either (a) bring providers into communities, or (b) bring services closer to the community in order to improve access to care. Begin with conducting assessments in Northern Ontario and Manitoba.	Work with NIHB regions, as well as partners and other FNIHB Programs, to: Inventory current arrangements to bring service providers into communities, identify best practices	Q4 (February) 2017/18	Senior ADM, FNIHB ADM, Regional Operations, FNIHB FNIHB Regional Executives DG, NIHB, FNIHB	TBC based on analyses to be conducted in FY2017/18
			Identify opportunities to bring services into/ closer to communities in Northern Ontario, and Northern Manitoba	Q2 (September) 2018/19
			Work with CIAD, legal services to develop standardized contribution agreement and/or contracting templates for ease of use by NIHB regions/other FNIHB Program areas (e.g. primary care) in bringing providers/ health services closer to communities	Q4 (February) 2017/18
			Report back to FNIHB-Senior Management Committee on findings/progress	Q2 (September) 2018/19
3. Consider greater standardization of administrative data collection for MT, vision and Mental Health Counselling benefits across regions to improve monitoring and demonstration of Program-level outcomes, such as access (e.g., utilization rates, approvals, appeals).	Management agrees with the recommendation and received funding through Budget 2017 to undertake procurement of new IT/claims processing systems in each of these benefit areas, which will (among other things) serve to increase standardization of NIHB administrative data collection nationally.	Re-procure the Health Information Claims Processing Services (HICPS) contract for the NIHB Program to include claims processing and associated services for both the vision care and mental health benefit areas.	Publish RFP for re-procurement of the HICPS contract (including vision and MHC)	Q1 (June) 2017/18	Senior ADM, FNIHB DG, NIHB, FNIHB	Project Team of 6 FTEs; Project funding of up to $23.9/5 years (total, for both projects) provided in Budget 2017
			Bid-evaluation for the HICPS contract (including vision and MHC)	Q2 (September) 2017/18
			HICPS contract awarded (including vision and MHC)	Q3 (December) 2017/18
			HICPS system build, testing, and implementation carried out	Q3 (November) 2020/21
		Procure a new Medical Transportation System solution (MTSS) that will (among other improved functionalities) serve to increase standardization of NIHB administrative data collection nationally.	Scope project;	Q2 (Sept) 2017/18	Senior ADM, FNIHB DG, NIHB, FNIHB	Project Team of 4 FTEs; Project funding of up to $23.9/5 years (total, for both projects) provided in Budget 2017
			Conduct Environmental Scans, including Aboriginal Business and Request for Information (RFI) Processes	Q4 (Mar) 2017/18
			Prepare business requirements and project documentation	Q3 (Oct) 2018/19
			Publish RFP; evaluate bids & award contract for MTSS	Q3 (Oct) 2019/20
			MTSS system build, testing, implementation	Q4 (March) 2020/21

Table 1: Program Resources ($M actual expenditures)^{Footnote a}

Year	NIHB Program Benefit Expenditures	CAs	Salaries	Capital Expenses	Operations and Maintenance	TotalFootnote b
2009-2010	$705.6	$152.6	$24.2	$0.0	$4.0	$886.4
2010-2011	$735.2	$154.2	$23.9	$0.1	$2.7	$916.1
2011-2012	$771.8	$161.1	$23.8	$0.1	$3.3	$960.1
2012-2013	$792.4	$169.3	$24.9	$0.0	$2.8	$989.4
2013-2014	$799.3	$183.0	$33.9	$0.0	$3.9	$1,020.1
2014-2015	$837.2	$191.4	$31.7	$0.0	$4.0	$1,064.3
Total+	$4,641.5	$1,011.6	$162.4	$0.2	$20.7	$5,836.4
Data Source: Chief Financial Officer Branch, Health Canada; information on FNHA expenditures provided by the NIHB Program.

Table 3: Program Resources ($M actual expenditures)

Benefit Area	Total Expenditures ($M)Footnote a	Percentage of Total Expenditures
Pharmacy	$2,157	39%
MT	$1,900	34%
Dental care	$1,134	20%
MS&E	$167	3%
Vision care	$164	3%
STCIMHC	$76	1%
Source: Chief Financial Officer Branch, Health Canada; information on FNHA expenditures provided by the NIHB Program. Table 3 - footnote a Expenditures exclude the BC region, FNHA, EBP and uncontrollable salaries. Return to Table 3 - footnote a

7.1 Pharmacy Benefit Area

According to the most recent NIHB Annual Report, "the NIHB Program provides eligible clients with coverage for pharmacy benefits not insured by private, public or P/T health care plans. The NIHB Program covers a range of prescription drugs and over-the-counter medications listed on the NIHB Drug Benefit List (DBL)" (Health Canada, 2015). A stated objective of the Program is to provide pharmacy benefits and services based on professional judgment, consistent with the current best practices of health services delivery and evidence-based standards of care. To achieve this objective, the addition and removal of pharmacy benefits covered by the NIHB Program follows an evidence-based standard of care approach, with an emphasis on client safety.

As noted in the NIHB Annual Report 2014-2015, claims for the pharmacy benefits provided to eligible First Nations and Inuit clients are processed via HICPS. HICPS includes administrative services and programs, technical support and automated information management systems, used to process and pay claims in accordance with NIHB Program client/benefit eligibility and pricing policies.

The NIHB Program is a member of the F/P/T Common Drug Review (CDR) process. As part of this process, and on behalf of participating F/P/T public drug plans, the Canadian Drug Expert Committee (CDEC) reviews new chemical entities, new combination drug products, or existing drug products with new indications on the Canadian market. Similar to other public drug plans, the NIHB Program makes listing decisions based on CDEC recommendations and other specific relevant factors, such as the particular circumstances of the Program's clients.

The evaluation found that the utilization rates for pharmacy benefits remained quite stable across the six-year period covered by the evaluation. As noted in Table 4, between 441,000 and 499,000 eligible NIHB Program clients had at least one paid claim resulting in a utilization rate ranging between 63% and 66% across this period. While the total number of individuals with paid claims in pharmacy grew by approximately 13%, the eligible population also grew somewhat proportionally (16%), resulting in similar utilization rates across six years.

Table 4 : Number of Clients Accessing Pharmacy Benefits and Utilization Rate

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015	Overall Growth
Number of Paid ClaimantsFootnote a
Overall	441,151	445,162	463,095	479,997	487,948	499,091	-
First Nations	423,132	427,303	444,481	460,925	468,486	478,809	-
Inuit	18,019	17,859	18,614	19,072	19,462	20,282	-
Growth Rate (Paid Claimants)
Overall		0.9%	3.9%	3.5%	1.6%	2.2%	13.1%
First Nations		1.0%	3.9%	3.6%	1.6%	2.2%	12.6%
Inuit		-0.9%	4.1%	2.4%	2.0%	4.0%	13.1%
Eligible Population Footnote b
Total	680,787	693,676	707,000	753,155	778,665	789,298	-
Growth rate		1.9%	1.9%	6.5%	3.4%	1.4%	15.9%
Share of Eligible Population (Utilization Rate)
Overall	64.8%	64.2%	65.5%	63.7%	62.7%	63.2%	-
First Nations	66.0%	65.4%	66.7%	64.8%	63.7%	64.2%	-
Inuit	45.7%	44.6%	45.7%	45.8%	45.4%	46.4%	-
Source: HICPS and the Status Verification System (SVS).

Population: Utilization rates of pharmacy benefits by First Nations clients have decreased during the evaluation period from 67% to 64%, which is likely explained by amendments to the Indian Act and other legal recognitions by Indigenous and Northern Affairs Canada, which have resulted in significant increases in the number of status First Nations people registered under the Indian Act and, consequently, eligible for the NIHB Program. Utilization rates of pharmacy benefits for Inuit clients have remained consistent from 2009-2010 to 2014-2015 at approximately 45% to 46%. While there is no completely comparable data on utilization rates for the general Canadian population, the Canadian Health Measures Survey (CHMS) found that between 2007-2011, 41% of Canadians (ages 6-79) had used a prescription drug in the previous two days.^{Footnote 7}

Gender: Throughout the evaluation period, utilization rates were generally higher for female clients when compared to male clients. Approximately 70% of eligible female clients had at least one paid pharmacy claim in 2014-2015, compared to approximately 56% of male clients. The gender distribution indicates a slightly greater proportion of females among the eligible population, representing approximately 51% in 2014-2015.

Age: The evaluation found that utilization rates increased steadily with age, from a low of 52% for clients 15 years old and younger in 2014-2015, to a maximum of 79% for clients aged 55 to 64 years old in that same year. Utilization rates for seniors (65 years old and older) were slightly lower (71% in 2014-2015).

General Trends Noted in the Utilization of Pharmacy Benefits

• In all regions, utilization rates were greater for prescription drugs, followed by over-the-counter medications.
• In most regions, the gap in utilization rates between genders was much smaller for clients aged under 15 years old or 65 years and older. The differences noticed in utilization rates by gender were more prevalent for clients in age groups between 15 and 44 years old.

Claims, Requests and Appeals for Pharmacy Benefits

As illustrated in Table 5 below, overall, most pharmacy benefits are paid as open benefits (97%), and the large majority of prior approval and exception drug requests are approved (90%). The number of denied requests for a medication by a client that are appealed is very low, at approximately 6%. Approval rates are calculated on the basis of the number of distinct medications claimed by distinct clients over a single fiscal year. These approval rates are not calculated on the basis of total pharmacy claims, as one client may submit a claim for the same medication several times in a single year.

Table 5 :  Pharmacy Benefit Claims, Requests and Appeals – 2014-2015

Claims	Claims Paid	Claims Rejected	Approval %
Open benefits Footnote a	3,630,148	128,982	96.6%

Requests	Requests Approved	Requests Denied	Approval %
Open benefits	20,920	329	98.4%
Limited-use benefits Footnote b	37,253	5,542	87.0%
Not listed	6,981	1,220	85.1%
Overall Requests	64,524	7,091	90.1%

Appeals	Appeals Approved	Appeals Denied	Approval %
Open benefits	1	3	25.0%
Limited-use benefits	5	0	100.0%
Not listed	241	204	54.2%
Overall Appeals	247	207	54.4%
Source: Analyses provided by the NIHB Program.

Open benefit medications are approved automatically by HICPS at point-of-service. This amounted to over 3.6 million paid claims in 2014-2015. For those medications that are categorized as "limited-use" by the NIHB Program, the approval rate for requests was approximately 87%, accounting for approximately 37,200 approvals. The approval rate among those medications that were requested, but categorized as "not listed", was approximately 85%, accounting for approximately 7,000 approvals.

Overall, there were 454 appeals recorded in 2014-2015 for the pharmacy benefit area, with nearly all (98%) occurring within the category of medications "not listed" for coverage by the Program. This represents an appeal rate of less than 0.01% of claims. Approval rates for appeals were approximately 54%.

Challenges and Barriers to Accessing Pharmacy Benefits

The evaluation did not find any major challenges or barriers to accessing pharmacy benefits. In interviews with partners, some challenges in other benefit areas were noted, but the pharmacy benefit area was generally perceived as accessible. Program accessibility would normally be defined as eligible clients being able to access the benefits and services that are covered by the NIHB Program. The evaluation found that coverage concerns are often raised as 'accessibility issues' when NIHB Program clients cannot access specific services or benefits they request because said services or benefits are outside the scope of what is covered by the NIHB Program. Similarly, a client may request a product that is not covered by the Program and receive coverage for an alternate product or item that is covered. These issues may be linked to the level of client awareness and more detailed knowledge of the specific coverage (inclusion and exclusions) of the Program. From interviews with partner organizations and Program representatives, various examples were provided that illustrate that clients' perceptions of NIHB Program 'accessibility problems' may be more accurately characterized as a lack of awareness regarding specific coverage.

Client Awareness of Pharmacy Benefits 

According to interviews and documentary evidence, the general level of awareness of the NIHB Program, and in particular the pharmacy benefits, is relatively high among First Nations clients, with most clients having heard of the NIHB Program. First Nations partners noted that awareness levels among First Nations clients have improved, which may be helped in part by the role that NIHB Navigators are playing for First Nations clients. As previously noted, the evaluation had challenges collecting data on Inuit perspectives (i.e., limited response to the survey and interviews), which included issues of client awareness.

The evaluation found that the pharmacy benefit area's policies were evidence-based. One key demonstration of evidence-based decision-making is the NIHB Program's active membership in the Canadian Agency for Drugs and Technologies in Health (CADTH) F/P/T CDR process. Through the CDR process, CADTH conducts thorough and objective evaluations of the clinical, economic, and patient evidence on drugs, and uses this evaluation to provide reimbursement recommendations and advice to Canada's F/P/T public drug plans, including the NIHB Program. As noted on the CADTH website:

"In formulating its drug reimbursement recommendations, CADTH analyzes studies that report on the clinical effectiveness, safety, and cost-effectiveness of the drugs under review. Drugs are compared with current accepted therapy to determine the therapeutic advantages and disadvantages of the new drugs, as well as the cost-effectiveness of the drugs in comparison to current therapeutic options. In addition to the clinical and economic evidence, the CDR process considers input by patients, drug manufacturers, and clinicians." (CADTH, 2016)

Reviews are undertaken for new drugs, as well as existing drugs approved for new indications. The CDR was set up by F/P/T public drug plans to reduce duplication of efforts in reviewing drug submissions, to maximize the use of limited resources and expertise, and to enhance the consistency and quality of drug reviews, thereby contributing to the quality and sustainability of Canadian public drug plans. The NIHB Program and other drug plans make listing decisions based on the recommendations from the CDEC (a component of the CDR Process) and other specific relevant factors, such as the circumstances of NIHB Program clients.

In addition to its participation in the CDR process, the NIHB Program, as of 2012, has developed an advisory body, the NIHB DTAC. Line extensions of existing drug products on the DBL, drug class reviews and reviews of existing listing criteria are referred to the DTAC. The DTAC is composed of highly qualified health professionals, who bring impartial and practical expert medical and pharmaceutical advice to the NIHB Program in order to promote improvement in health outcomes for First Nations and Inuit clients through the effective use of pharmaceuticals. DTAC membership includes practicing physicians and pharmacists from community and hospital settings, including First Nations physicians. Their approach is evidence-based and the advice reflects medical and scientific knowledge, current utilization trends, current clinical practices, health care delivery, and specific departmental client health care needs.

The third area of pharmacy benefit programming that demonstrates the use of an evidence-based approach in decision-making is the continued support and use of the NIHB DEC. The NIHB DEC was established in December 1997 to process and expedite pharmacists' requests for drug benefits that require prior approval, to help ensure consistent application of the NIHB Program drug benefit coverage policy across the country, and to ensure an evidence-based approach to providing drug benefit coverage.

The pharmacy benefit area demonstrated client and provider compliance through ongoing pre- and post-payment verification processes that included extensive provider audit programs.
According to the NIHB Annual Report 2014/2015, the objectives of the audit program for the pharmacy benefit area are to detect billing irregularities, to validate active licensure of providers, to ensure that services paid for were received by eligible NIHB Program clients, and to ensure that providers retained appropriate documentation to support each claim. The components of the Provider Audit Program for the pharmacy benefit area include: a next-day claims verification program, a client confirmation program, a provider profiling program, an on-site audit program, and a desk audit program. Claims not meeting the billing requirements of the NIHB Program are subject to audit recovery. According to the NIHB Annual Report 2014/2015, 81 audits were completed in 2014-2015 resulting in approximately $2.1 million being recovered by the Program.

7.2 Medical Supplies and Equipment Benefit Area

The NIHB Program covers the costs of various types of MS&E when the costs are not covered by another plan or program for which the client is eligible. Most MS&E benefits require prior approval from the appropriate Health Canada regional office and a prescription from an eligible prescriber. Like pharmacy and dental claims, the MS&E benefits provided to eligible First Nations and Inuit clients are processed via the HICPS system.

Eligible benefits are those available through enrolled pharmacies and MS&E providers for personal use in a home setting or other ambulatory setting. Guidelines outlining recommended quantities or replacements are based on the average medical needs of clients. Requests exceeding these guidelines may be considered on a case-by-case basis if a medical need is demonstrated (Health Canada, 2012c).

The MS&E categories covered under this benefit area include:

• audiology (hearing aids and supplies);
• general MS&E benefits (wound dressing supplies, wheelchairs, etc.);
• orthotics and custom footwear;
• ostomy supplies and devices;
• oxygen equipment and supplies;
• pressure garments and pressure orthotics (compression device and scar management);
• prosthetic benefits (breast, eye, limbs); and,
• respiratory equipment and supplies.

Similar to some of the other benefit areas, the utilization rates for MS&E benefits remained quite stable across the six-year period covered by the evaluation. As noted in Table 6, while the total number of individuals with paid claims in the MS&E benefit area grew by approximately 11%, the population grew somewhat proportionally (16%) resulting in similar utilization rates across six years.

Table 6 :  Number of Clients Accessing MS&E Benefits and Utilization Rate

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015	Overall Growth
Number of Paid ClaimantsFootnote a
Overall	50,614	51,449	52,473	53,340	54,930	56,034	-
First Nations	48,556	49,459	50,356	51,132	52,448	53,382	-
Inuit	2,058	1,990	2,117	2,208	2,482	2,652	-
Growth Rate (Paid Claimants)
Overall		1.6%	2.0%	1.6%	2.9%	2.0%	10.7%
First Nations		1.8%	1.8%	1.5%	2.5%	1.7%	9.9%
Inuit		-3.4%	6.0%	4.1%	11.0%	6.4%	28.9%
Eligible PopulationFootnote b
Total	680,787	693,676	707,000	753,155	778,665	789,298	-
Growth rate		1.9%	1.9%	6.5%	3.4%	1.4%	15.9%
Share of Eligible Population (Utilization Rate)
Overall	7.4%	7.4%	7.4%	7.1%	7.1%	7.1%	-
First Nations	7.6%	7.6%	7.6%	7.2%	7.1%	7.2%	-
Inuit	5.2%	5.0%	5.2%	5.3%	5.8%	6.1%	-
Source: HICPS and SVS.

Population: Over the evaluation period, utilization rates by First Nations clients for MS&E have remained relatively constant, ranging between 7% and 8%. Utilization rates among Inuit clients have also remained relatively constant, ranging between 5% and 6%. The evaluation was not able to find any comparable utilization rates for the general Canadian population.

Gender: There were relatively more females who accessed MS&E benefits (57% of clients in 2014-2015) than males (43% of clients in 2014-2015). The gap in utilization rates between males and females was much narrower than that observed in other benefit areas, with only a two percentage point difference in 2014-2015 (i.e., utilization rate of 8% for females and 6% for males).

Age: Utilization rates remained relatively low (under 10%) for clients 44 years old and younger and increased steadily for older clients (10% utilization rate for clients 45 to 54 years old, 16% for clients 55 to 64 years old and 28% for clients 65 years old and greater in 2014-2015).

General Trends Noted in the Utilization of MS&E Benefits

• Utilization rates for supplies are higher than utilization rates for equipment.
• Utilization rates for MS&E tend to increase with age, which is consistent with the type of products covered under this benefit area (e.g., wheelchairs, mobility assistance devices, hearing aids). 

Appeals for MS&E Benefits

In order to understand the extent to which there were access issues for the benefit area, the evaluation reviewed higher-level appeals data (Level 3)^{Footnote 8} for a five-year period covered by the evaluation. Responsibility for the management and delivery of MS&E benefits is shared between the NIHB Program's national HQ and regional offices. The requests and appeals processes (Levels 1 and 2) for MS&E benefits operate at the regional level, and data are not systematically compiled at a national level.

According to data supplied by the Program, there were a total of seven Level 3 appeals for MS&E benefits in the period of 2010-2011 to 2014-2015. Of these seven appeals, one was approved and six were denied.

Challenges and Barriers to Accessing MS&E Benefits

The evaluation identified few challenges or barriers to accessing MS&E benefits. The main areas identified during interviews with partners were not related directly to accessing NIHB Program benefits per se, but more related to having access to health service providers who could diagnose conditions, and then prescribe and provide MS&E to meet clients' needs. According to interviews with partners, this is of particular concern among Program clients in more remote and isolated communities, and was highlighted as a concern for Inuit clients in particular. One area for improvement raised in interviews with partners was the need to increase the number of MS&E-enrolled providers, particularly those attached to provincial health care settings, such as MS&E stores in hospitals.

The purpose of the Pharmacy and Medical Supplies and Equipment Benefit - Policy Framework (2010) is to explain the overarching policies that guide the administration of the pharmacy and MS&E benefits under the NIHB Program. The Provider Guide for Medical Supplies and Equipment (MS&E) Benefits (2009) offers information on specific NIHB Program policies relevant to MS&E providers. It explains the parameters of the Program's MS&E benefits by describing the important elements of each associated coverage policy.

According to the Policy Framework, the objective of the MS&E benefit area is to provide clients with access to MS&E goods and services in a fair, equitable and cost-effective manner that will contribute to (Health Canada, 2010a):

• improving the overall health status of First Nations and Inuit clients, recognizing their individual health needs and the context of health service delivery; and,
• providing coverage for a range of MS&E benefits and services based on professional judgment, as is consistent with the current best practices of health services delivery and evidence-based standards of care.

Listed MS&E benefits fall into four categories: open benefits, prior approval items, exceptions, and exclusions. Prior approval items and exceptions require a prescription from a recognized MS&E prescriber, as well as supporting documentation from the appropriate MS&E professional (e.g., a report from an occupational therapist to ensure a client's wheelchair will meet the client's individual needs). The Policy Framework clearly outlines that MS&E benefits be delivered in consideration of current best practices, evidence-based standards of care, professional judgement, and medical justification.

The evaluation found that the Provider Guide for the MS&E benefit area and the Policy Framework had been updated during the evaluation period. A review of various records of decision and memoranda to Assistant Deputy Ministers developed during the evaluation period covered demonstrated how best practices, standards and evidence-based decision making were integrated into the ongoing development and implementation of coverage policy for the MS&E benefit area.

Similar to the pharmacy benefit area, the MS&E benefit area demonstrated client and provider compliance through ongoing pre- and post-payment verification processes that included extensive provider audit programs. The Provider Audit Program for MS&E benefits is designed in the same manner as that for pharmacy benefits and has the same components (see Pharmacy Benefit Area). Claims not meeting the billing requirements of the NIHB Program are subject to audit recovery. According to the NIHB Annual Report 2014/2015, 13 audits were completed in 2014-2015 resulting in over $738,000 being recovered by the Program.

7.3 Dental Benefit Area

The NIHB Program covers a broad range of dental services to address the unique oral health needs of the client population. Dental services must be provided by a licensed dental professional, such as a dentist, dental specialist, or denturist. Some of the dental services covered under the Program's dental benefits require predetermination prior to initiating treatment. During the predetermination process, the Program reviews the dental services submitted against its established Dental Policy Framework and the NIHB Dental Benefits Guide, and takes into consideration the client's oral health status and needs (Health Canada, 2016).

Most dental services covered by the Program's dental benefits result in fee-for-service charges paid through the HICPS system (88% of costs in 2014-2015). Other services are managed through CAs with specific communities (6% of costs in 2014-2015), and in a small proportion of cases, through direct contracts with dental professionals to provide services to remote communities (4% of costs in 2014-2015).

The range of dental services covered by the NIHB Program includes:

• diagnostic services, such as examinations and radiographs;
• preventive services, such as scaling, polishing, fluorides and sealants;
• restorative services, such as fillings and crowns;
• endodontic services, such as root canal treatments;
• periodontal services, such as deep scaling;
• removable prosthodontic services, such as dentures;
• oral surgery services, such as extractions;
• orthodontic services to correct significant irregularities in teeth and jaws; and,
• adjunctive services, such as general anaesthesia and sedation.

As with the pharmacy and MS&E benefits, the utilization rates for dental benefits remained quite stable across the six-year period covered by the evaluation. As noted in Table 7, while the growth in the total number of individuals with paid dental claims was approximately 16%, this mirrored the overall population growth (16%), resulting in similar utilization rates across six years.

Table 7 :  Number of Clients Accessing Dental Benefits and Utilization Rate

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015	Overall Growth
Number of Paid ClaimantsFootnote a
Overall	248,888	261,276	264,955	282,761	275,722	288,229	-
First Nations	232,820	244,024	247,888	258,805	265,032	270,550	-
Inuit	16,068	17,252	17,067	16,917	17,729	17,679	-
Growth Rate (Paid Claimants)
Overall		4.7%	1.4%	6.3%	-2.6%	4.3%	15.8%
First Nations		4.6%	1.6%	4.2%	2.3%	2.0%	16.2%
Inuit		6.9%	-1.1%	-0.9%	4.6%	-0.3%	10.0%
Eligible PopulationFootnote b
Total	680,787	693,676	707,000	753,155	778,665	789,298	-
Growth rate		1.9%	1.9%	6.5%	3.4%	1.4%	15.9%
Share of Eligible Population (Utilization Rate)
Overall	36.6%	37.7%	37.5%	37.5%	35.4%	36.5%	-
First Nations	36.3%	37.3%	37.2%	36.4%	36.0%	36.3%	-
Inuit	40.8%	43.1%	41.9%	40.7%	41.3%	40.5%	-
Source: HICPS and SVS.

Population: Utilization rates of dental benefits by First Nations clients remained relatively constant over the evaluation period ranging from 36% to 37%. Utilization rates of dental benefits for Inuit clients ranged from 41% to 43% over the same period. Utilization of the Program's dental benefits is not the same as overall utilization or access to dental care by the client population, which may be covered or accessed through other means that are not part of the NIHB Program. In the RHS 2008/10, 57% of First Nations adults living in First Nations communities reported receiving dental care in the 12 months prior to the survey, and three-quarters (76%) of First Nations youth reported receiving dental care in the year prior to RHS 2008/10. Some potential reasons for the lower utilization rates observed in NIHB Program data are: clients accessing the services provided under CAs, or by contract dentists working in communities, participants in child oral health initiatives, individuals who have private insurance, availability of dental services in the community, and the client's perception of no need for dental care (as per the FNOHS, 2009-2010). According to the CHMS, 74% of Canadians have seen a dental professional in the last year between 2007 and 2009.

Gender: During the evaluation period, 56% of clients who accessed dental benefits were female and 44% were male, even though the distribution of the eligible population was 51% females and 49% males. The utilization rate among the female client population (40%) was greater than the utilization rate among the male client population (33%) throughout the evaluation period.

Age: Utilization rates ranged between 35% and 39% for most age groups, except for clients aged 65 and older, who had a lower utilization rate. Nonetheless, utilization rates for older clients (65 years old and older age group) increased during the evaluation period, from 22% in 2009-2010 to 25% in 2014-2015.

General Trends Noted in the Utilization of Dental Benefits

• Contrary to what was noted regarding pharmacy and MS&E benefits, utilization rates tend to decrease with age for dental benefits across all regions.
• In all regions, there are three types of dental services where the largest utilization rates are attained: diagnostic services, which include examinations, preventative services, which include scaling, polishing and fluorides, and restorative services, such as fillings and crowns. 

Claims, Requests and Appeals for Dental Benefits

To understand the extent to which there were access issues for the dental benefit area, the evaluation reviewed claim approval rates, in combination with requests and appeals data, for one year (2014-2015). As illustrated in Table 8 below, most claims processed by HICPS for "Schedule A" dental procedures are approved (90%). This amounted to approximately 1.8 million paid claims in 2014-2015. The overall approval rate for those procedures where requests are made is approximately 61%. Within this overall rate, the rates for different types of requests vary, such as dental procedures/benefits/services that are Schedule B (requiring predetermination) with an approval rate of approximately 59%, or 46,000 approvals, and procedures that were requested but categorized as Schedule C/D (beyond the normal scope of the NIHB Program) with an approval rate of approximately 20%, or 3,600 approvals.

An analysis of appeals data (see Table 8) indicates that over one-third (35%) of Level 1 dental appeals are approved, while a much smaller proportion of orthodontic Level 1 appeals  are approved (5%). According to Program representatives, the rates of approval for orthodontic appeals reflect the fact that: 1) initial orthodontic coverage decisions are based on the clinical information that must be included with the initial request for coverage; and, 2) the coverage criteria used are clear and objective. All requests for orthodontic treatment are pre-approved and, as part of this process, orthodontists submit treatment plans and supporting clinical information (e.g., panoramic x-rays, diagnostic models) before cases are reviewed, so that the initial adjudication decision can be based on complete clinical information that allows for detailed measurements. For other Program benefit areas where complete clinical information is not required for initial adjudication, approval rates for appeals are significantly higher as the appeals process provides clients and their physicians with the opportunity to submit clinical and contextual information to justify the claim (e.g., diagnostic tests).

Table 8:  Dental Benefit Claims and Requests – 2014-2015

Claims	Claims Paid	Claims Rejected	Paid as Submitted %
Schedule AFootnote a	1,792,048	190,382	90.4%

Requests	Requests Approved	Requests Denied	Approval %
Schedule A	61,113	26,044	70.1%
Schedule B Footnote b	46,007	31,411	59.4%
Schedule C/DFootnote c	3,639	14,484	20.1%
Overall Requests	110,759	71,939	60.6%

	Level 1		Level 2		Level 3
Appeals**	Total Appeals	% Approved	Total Appeals	% Approved	Total Appeals	% Approved
Dental	633	34.6%	71	16.9%	59	13.6%
Orthodontic	535	4.5%	130	1.5%	34	0.0%
Overall Appeals	1168	20.8%	201	7.0%	93	8.6%
Source: Analyses provided by the NIHB Program.

Challenges and Barriers to Accessing Dental Benefits 

Interviews with partners noted that one of the more frequently cited challenges in clients accessing dental benefits was the availability of dental services. This is of particular concern among NIHB Program clients in more remote and isolated communities, and was highlighted as a concern for Inuit clients in particular. The Program is aware of this challenge and is addressing it in part through the provision of dental services via dentists contracted directly through the NIHB Program to provide services to clients within remote communities (approximately 4% of expenditures in 2014-2015). Similarly, MT benefits can be accessed through the Program by individuals requiring dental services that are not available in their communities.

Another issue raised was a lack of interest by some dentists in enrolling with the NIHB Program, as their preference is to ask the client to pay for services rather than seek reimbursement from the NIHB Program. This approach does not include any interaction between the private practice dental practitioner and the Program.

The 2014 Dental Benefit Policy Framework indicates that the objective of the NIHB Program dental benefits is to provide eligible clients with access to oral health services in a fair, equitable and cost-effective manner that will: 1) address oral health needs and contribute to improving the oral health status of eligible First Nations and Inuit clients; and, 2) provide coverage for a range of dental services based on professional judgment and the client's oral health status/condition, consistent with current best practices of health services delivery and evidence-based services and standards of care (Health Canada, 2014c).

As outlined in the 2014 Policy Framework, the dental services covered under the NIHB Program dental benefit are reviewed on an ongoing basis through consultation with dental provider associations and First Nations and Inuit organizations. The Program uses the services of CADTH to provide literature reviews of clinical evidence that inform dental benefit coverage policy decisions. The Program has also developed and implemented trial projects during the evaluation period to inform dental benefit coverage policy decisions in areas such as endodontics. As adjustments are made to the Program, dental providers and clients are notified through NIHB dental newsletters, communications to dental associations, and updates to the NIHB Dental Benefits Guide and the NIHB Regional Dental Benefit Grids.

The evaluation found that the dental benefit area demonstrates client and provider compliance through the NIHB Provider Audit Program. The audit program is administered through HICPS and is designed in the same manner as that for pharmacy benefits (see Pharmacy Benefit area).

According to the 2014 NIHB Dental Benefits Guide, audit activities are administrative in nature and based on accepted industry practices. All claims that do not meet the billing requirements of the NIHB Program are subject to audit recovery. According to the NIHB Annual Report 2014/2015, 49 audits were completed in 2014-2015 resulting in over $799,000 being recovered by the Program.

7.4 Medical Transportation Benefit Area

The NIHB Program's MT benefits aid with the payment of transportation to the nearest appropriate health professional or health facility for clients to access eligible, medically necessary health services that cannot be obtained on the reserve or in the community of residence.

The Program's MT benefits include:

• ground travel (private vehicle, commercial taxi, fee-for-service driver and vehicle, band vehicle, bus, train, snowmobile taxi, and ground ambulance);
• air travel (scheduled flights, chartered flights, helicopter, and air ambulance);
• water travel (motorized boat, boat taxi, and ferry);
• living expenses (meals and accommodations); and,
• transportation costs for health professionals to provide services to isolated communities.

The Program's MT benefits may be provided for clients to access the following types of medically required health services:

• medical services defined as insured services by P/T health plans (e.g., appointments with physicians, hospital care);
• diagnostic tests and medical treatments covered by P/T health plans;
• alcohol, solvent, drug abuse and detox treatments;
• traditional healers; and,
• NIHB (vision care, dental, mental health).

The Program's MT benefits may also be provided for approved medical and non-medical escorts to accompany clients who are travelling to access medically necessary health services. In addition to facilitating client travel to appointments for these medical services, significant efforts have been made over the past few years to bring health care professionals into otherwise under-serviced and/or remote and isolated communities.

The Program's MT benefits are operationally managed by regional offices. These benefits are also managed by First Nations or Inuit Health Authorities, organizations or territorial governments who, under a CA, have assumed responsibility for the administration and coverage of MT benefits to eligible clients. According to the NIHB Annual Report 2013/2014, there were 486 MT CAs in place representing approximately 46% of MT benefit expenses for that year.

The evaluators devoted considerable effort to compiling, analyzing, and reporting on the administrative data used to monitor and deliver the MT benefits under the NIHB Program. Upon completion of the various analyses, and in consultation with Program representatives, it was determined that the challenges encountered with gaps in the nationally compiled data precluded its use to accurately assess many of the expected immediate outcomes for the MT benefit area on a national level (e.g., utilization rates indicating access). The approach used to deliver MT benefits (operationally managed by regions, combined with numerous CAs) contributes to the challenges experienced in compiling an accurate, national profile of the NIHB Program clients accessing this benefit.

The two sources of transactional data on MT are the MTRS and the MTDS. The MTRS is used to track transactional data at the regional level; however, Ontario and Alberta used their own systems during the timeframe of the evaluation and data from these regions were thus excluded from any extractions using MTRS.^{Footnote 9}  In addition, information on MT covered via CAs is collected in various ways across regions and is not consistently entered into the MTRS.^{Footnote 10} According to Program representatives, CA data are often not reported with intact client-level identifiers that can be used to analyze client access. This is a historical legacy issue linked to the level of detail that CA recipients are asked to report. This has resulted in a very limited representation of MT activity in the system, as there were 486 MT CAs in place, representing approximately 46% of MT benefit expenses (Health Canada, 2014a). Program representatives have indicated that funding provided via CAs is expected to increase in the future, consistent with the NIHB Program mandate to support First Nations and Inuit control at a time and pace of their choosing. Finally, expenditure amounts entered in MTRS contain a mixture of actuals and planned.^{Footnote 11}

Since 2005, the Program has been working on the development of MTDS with the intent to centralize and standardize all regional MT data. MTDS 1.0 contains data going back to 2007-2008; however, it is a system that does not separate operational from CA MT benefits, and that does not allow for the production of complex reports. MTDS 2.0 was launched in 2013-2014 and contains information for different years, depending on the region, as illustrated in Table 9. After exploring whether it would be of interest to use MTDS as a data source for this analysis, Program representatives confirmed that similar challenges would be faced as with MTRS, as the data stored primarily contains information on MT operational expenditures, which represents approximately half of all Program activities. Furthermore, the period of analysis would be reduced to 2013-2014, as this was the only year for which data were available for all regions. Also, the emphasis on the utilization of the data extraction was originally placed on the calculation of average costs, which is a complex kind of reporting that cannot be produced using MTDS.

Table 9 : MT Operational Data Availability by Region

Region	Source	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015
Atlantic	MTRS	x	x	x	x	x	x
	MTDS 2.0	-	-	-	-	x	Apr-Feb
Québec	MTRS	x	x	x	x	x	x
	MTDS 2.0	-	-	-	-	x	Apr-Feb
Ontario	MTRS	-	-	-	-	-
	MTDS 2.0	-	-	x	x	x	x
Manitoba	MTRS	x	x	x	x	x	x
	MTDS 2.0	-	-	-	-	x	Apr-Feb
Manitoba (emergency)	MTRS	-	-	-	-	-	Nov-Mar
	MTDS 2.0	-	-	x	x	x	Apr-Feb
Saskatchewan	MTRS	x	x	x	x	x	x
	MTDS 2.0	-	-	-	-	x	Apr-Feb
Alberta	MTRS	-	-	-	-	-
	MTDS 2.0	x	x	x	x	x	Apr-Dec
Alberta (emergency)	MTRS	-	-	-	-	-	Aug-Mar
	MTDS 2.0	-	-	x	x	x	Apr-Feb
North	MTRS	x	x	x	x	x	x
	MTDS 2.0	-	-	-	-	x	Apr-Feb
Source: Analysis provided by the NIHB Program (June 2015).

Upon consultation with Program representatives, the evaluation team decided to focus the analysis of number of claims and claimants in MT on data available for two regions: Manitoba and Saskatchewan. This is due to the fact that information for Ontario and Alberta was unavailable in MTRS, as well as the impact on data representativeness due to the large share of MT expenses allocated via CAs. According to the NIHB Annual Report 2013/2014, in this year Manitoba and Saskatchewan represented approximately 32% and 12% of the Program's MT annual expenditures respectively, and the share of operating expenditures as a percentage of total regional MT expenditures (i.e., operating and CA expenditures) was 77% in each.

In Table 10, the number of clients for Manitoba is presented by access to emergency and non-emergency services. With regard to the marked change in emergency travel utilization rates in 2014-2015, it must be noted that this is the result of a 2014 change in the Manitoba region's data entry practices (to improve data integrity). More specifically, prior to 2014, Manitoba entered MT emergency information in the MTRS system only when meals and accommodations were involved. Since 2014, all emergency MT data from Manitoba are entered in MTRS, which explains the change observed in the number of paid claimants: a sharp increase from approximately 3,400 in 2013-2014 to over 10,000 in 2014-2015 or 474%. This also impacted the overall growth in the number of paid claimants in the region, rising from approximately 13,500 in 2009-2010 to 26,700 in 2014-2015 or 98%.

Table 10 : Number of Clients Accessing MT Benefits and Utilization Rate – MANITOBA

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015	Overall Growth
Number of Paid ClaimantsFootnote a
Overall	13,519	14,735	16,136	16,422	19,628	26,750	-
EmergencyFootnote b	1,779	2,570	3,195	2,391	3,433	10,217	-
Non-emergency	11,740	12,165	12,941	14,031	16,195	16,533	-
Growth Rate (Paid Claimants)
Overall		8.3%	8.7%	1.7%	16.3%	26.6%	97.9%
EmergencyFootnote b		44.5%	24.3%	-25.2%	43.6%	197.6%	474.3%
Non-emergency		3.6%	6.4%	8.4%	15.4%	2.1%	40.8%
Share of Eligible Population (Utilization Rate)Footnote c
Overall	10.3%	11.0%	11.8%	11.6%	13.6%	18.5%	-
EmergencyFootnote b	1.4%	1.9%	2.3%	1.7%	2.4%	7.1%	-
Non-emergency	8.9%	9.1%	9.4%	10.0%	11.2%	11.4%	-
Source: MTRS.

 

In the case of Saskatchewan, as presented in Table 11, the rate of growth observed in the number of clients over the period of evaluation is 13%, although there is some unexplained variation observed in the number of paid claimants accessing non-emergency services. In 2014-2015, a year when data entry practices in both regions were similar, it is noted that overall utilization rates are comparable for both regions, at approximately 19%.

Table 11 :  Number of Clients Accessing MT Benefits and Utilization Rate – SASKATCHEWAN

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015	Overall Growth
Number of Paid ClaimantsFootnote a
Overall	22,869	20,808	19,386	19,797	25,361	25,733	-
Emergency	11,867	12,476	12,525	12,718	12,995	13,327	-
Non-emergency	11,002	8,332	6,861	7,079	12,366	12,406	-
Growth Rate (Paid Claimants)
Overall		-9.9%	-7.3%	2.1%	21.9%	1.4%	12.5%
Emergency		5.1%	0.4%	1.5%	2.2%	2.6%	12.3%
Non-emergency		-24.3%	-17.7%	3.2%	74.7%	0.3%	12.8%
Share of Eligible Population (Utilization Rate)Footnote b
Overall	18.3%	16.3%	14.9%	14.8%	18.5%	18.4%	-
Emergency	9.5%	9.8%	9.6%	9.5%	9.5%	9.5%	-
Non-emergency	8.8%	6.5%	5.3%	5.3%	9.0%	8.9%	-
Source: HICPS and SVS.

Claims, Requests and Appeals for MT Benefits

The NIHB Program does not systematically compile approval rates or information on appeals at a national level.

Challenges and Barriers to Accessing MT Benefits

The MT benefit area was a central topic of discussion in many of the key informant interviews conducted with partners and with NIHB Program representatives. Three key themes were noted across the key informant groups:

• The high level of importance of the MT benefit area, given the extreme challenges often involved in accessing health services for many remote or isolated communities.
• The facilitative nature of MT benefits with respect to other health services. It was noted that MT does not provide a direct medical benefit in and of itself, but it is key to facilitating access to other benefit areas and various insured health services.
• The numerous challenges or barriers and significant expenditures associated with delivering MT benefits. 

First Nations individuals and Inuit in many communities experience challenges in accessing health services for various reasons. These can include geographic challenges (e.g., remote, isolated communities with limited services), changes in health system delivery models (e.g., centralization of P/T health services in major urban centres), challenges inherent in navigating complex health systems, as well as economic and cultural barriers, and racism.

The needs associated with MT range considerably including, but not limited to, emergency health care, maternal health care, dental visits, medical consultations, testing/diagnoses, dialysis, chemotherapy, and transporting health professionals for locums in communities. To access various health services, many First Nations individuals and Inuit in remote or rural locations are required to travel from their home communities, sometimes for extended periods of time, depending on treatments. 

Based on these many factors, NIHB Program regional offices (and in some cases CA recipients) face a complex task in arranging the various aspects of MT benefit coverage for clients. In particular, those travelling from remote and isolated areas to access health services have greater distances to travel to access P/T-insured and other health services, and the available modes of travel may also be limited and likely impacted by factors such as inclement weather. The complex nature of arranging travel for clients in geographically remote or isolated areas has led some Program regional offices to develop specialized call centres to plan and coordinate various aspects of MT, taking into account specific local circumstances in a multitude of communities. Some of the challenges encountered with northern travel in particular have led the Program to implement transportation units in some areas.

Other factors beyond the control of the Program are related to the location of the nearest appropriate health professional or health facility (e.g., the location of provincially-insured physician or specialist services, the offices of private practice/fee-for-service health professionals, such as dentists or mental health professionals). In addition to facilitating client travel to appointments for these medical services, the Program has made efforts to bring health care professionals into under-serviced and/or remote and isolated communities.

During interviews, various partners and NIHB Program representatives reported specific challenges with respect to accessing MT benefits, including:

•  Approval of escorts is perceived as variable and inconsistent. As a Program based on medical need, coverage of escorts is only provided when clients have a documented medical or legal need to be accompanied while travelling. Nonetheless, some potential issues were noted with respect to coverage of escorts in specific situations, such as:
  • Seniors - clients over 65 are not automatically covered for an escort, unless specific medical or legal needs are documented.
  • Language/interpreter requirements - escorts are currently covered by the Program when a language barrier exists to access a medically required health service; however, partners report that escorts for language purposes may be sent home if there are interpretation services available in the hospital or location of the health service.
  • Teenage parents - in most cases, where a prenatal client is also a minor, there is a legal requirement for this client to be accompanied by a parent or guardian in the event the latter is required to consent to medical procedures needed by the former. Nonetheless, if the father of the child is also a minor, for example, he would not be able to provide such legal consent, nor would he be of legal age to sign for accommodations (e.g., a hotel room). Various partners expressed the view that two escorts should be covered for travel in these circumstances to allow a baby's father to be present at the birth.
  • Length of stay – the NIHB Medical Transportation Policy Framework indicates that "Unless there is a medical or legal requirement for an escort to stay longer, or it is more practical financially …, the escort shall return to the community by the earliest and most economical reasonable means."  Partners report that, in some cases, there is a need for escort coverage to be extended to allow the escort to remain with the client for an extended period.
• Delays and long timelines for approvals and reimbursements.

Notwithstanding reports of long timelines for travel approval, MTRS data indicate that from 2009-2010 to 2014-2015, the average number of days (calculated annually) for regional staff to approve and book medical travel arrangements for NIHB Program clients in Manitoba and Saskatchewan ranged from two to five days. It should be noted that timelines for coverage approval do not apply to emergency situations (emergency services are contacted directly in these situations, with arrangements for coverage approval and payment made after the fact).

The 2005 NIHB Medical Transportation Policy Framework defines the policies and benefits under which the NIHB Program provides coverage for MT for eligible clients to access medically required health services not provided on reserve or in the community of residence. The 2012 Medical Transportation Operations Manual provides a common framework to guide adjudication in applying the policies of the Framework to the specific circumstances of individual cases. The Operations Manual was developed by regional NIHB Program managers in collaboration with HQ staff and is updated as necessary through similar joint regional-HQ processes. Updates to policies are documented in various records of decisions.

Unlike the coverage policy frameworks for the other NIHB areas, there is no specific mention of evidence-based, best practices, or professional standards in either the 2005 Framework or 2012 Operations Manual for the MT benefit area. This is likely due to the nature of this benefit being substantially different from other medically-based NIHB areas. The MT benefits could be conceptualized more as a facilitative service for clients, rather than a medically-based procedure, service or device that is characteristic of other benefit areas.

Interviews with partners and regional NIHB Program representatives noted that decision-making within the MT benefit area could be facilitated with improved operational and administrative data. Such data could support business cases and proposals for alternative delivery approaches for MT at the community and regional level (e.g., purchase of lodges, recruitment of health service providers for communities, group transportation), potentially contributing to increased efficiency.

In 2015, the OAG noted in an audit of MT that "Health Canada maintained insufficient documentation to demonstrate that MT benefits were administered according to selected principles of the 2005 Medical Transportation Policy Framework." (OAG, 2015)  Health Canada agreed with the recommendation and committed to modify its guidelines to better align with current operating practices related to the assertion of medical needs and confirmation of attendance. In addition, Health Canada committed to disseminate to its staff clear instructions on the processing and retaining of transitional records necessary for the adjudication of benefits.

The 2010 internal audit conducted by Health Canada's Audit and Accountability Bureau for the MT benefit area noted that, among the operationally managed benefits, there was one of two regions examined in which the procedure for conducting the claim verification process needed clarification with regard to roles and responsibilities and documentation of verification steps to be carried out by staff. The follow-up audit conducted in 2012 indicated that the recommendation had been fully addressed.

With respect to MT benefits delivered through CAs, the 2010 internal audit found that CA recipients were required to report their total actual annual expenditures for MT. The audit indicated that this level of reporting did not provide sufficient information for NIHB Program managers to assess if funding was spent on appropriate expenses for MT, nor to identify root causes for deficits. This led to additional recommendations in a 2012 follow-up audit aimed at revising the CA templates to require detailed annual financial reporting on MT expenditures by cost category, and ensuring that NIHB Program officers formalize monitoring practices related to MT benefits and use templates developed by Program HQ, including for site visit reporting. Since 2014, the Program has put in place a contract to perform regional audits for the operationally managed MT benefits, and to date has completed 13 MT audits.

7.5 Vision Care Benefit Area

Vision care benefits are covered in accordance with the policies set out in the NIHB Vision Care Policy Framework. The following categories of vision care benefits are covered:

• eye examinations, when they are not insured by the provinces/territories (e.g., eye exams for children, elderly and diabetic clients are insured services in some provinces/territories);
• eyeglasses that are prescribed by a vision-care provider;
• eyeglass repairs; and,
• other vision care benefits, depending on specific medical needs.

The vision care benefit area is managed jointly by the NIHB Program's national HQ and regional offices. Program regional staff are responsible for most aspects of vision care benefit administration and operations. HQ responsibilities include the development of national benefit coverage policy and communications material, coordination of national working groups and stakeholder/provider relations, benefit audits, and the management of Level 3 appeals. The national office supports the regions in negotiating agreements with providers, where these agreements are in place.

The majority of vision care benefits are delivered through a fee-for-service model where independent (i.e., private practice) vision care professionals provide services to Program clients at their normal place of business. Vision care benefits are provided by an NIHB Program-recognized provider. A vision care provider (i.e., an optometrist, optician or ophthalmologist) must be licensed/certified, authorized, and in good standing with the P/T regulatory body where they practice. Providers may enrol with the Program in order to bill it directly for eligible items and services provided to eligible clients. Some clients pay up-front for vision care services (primarily for those services received from non-enrolled providers) and seek reimbursement from the NIHB Program.

Based on data compiled by the NIHB Program for the ongoing AFN-NIHB Joint Review process, approximately 127,000 and 132,000 NIHB Program clients accessed vision care benefits in 2012-2013 and 2014-2015, respectively. These numbers do not include benefits provided through CAs (approximately 12% of expenditures in 2014-2015).

For the AFN-NIHB Joint Review process, the Program calculated a blended two-year (2013-2014 to 2014-2015) utilization rate for the two most common services (eye exams and eyewear) by age group for those NIHB Program clients who received vision care services (not including services provided through CAs). The utilization rate for eye exams ranged from 1% to 3% among children (0-19 years), and from 16% to 34% among adults. Eyewear utilization rates ranged from 7% to 30% among children (0-19 years), and from 28% to 41% among adults. The Program noted that the proportion of clients accessing vision care benefits is influenced by the availability of other public vision care programs that provide access to similar services, particularly eye exams. Most provinces cover eye exams for children and seniors, resulting in lower utilization rates for eye exams among these age groups.

Challenges and Barriers to Accessing Vision Care Benefits

In interviews with partners, it was noted that NIHB Program clients are relatively aware of the vision care benefits overall, although some of the coverage specifics are less well-known unless the client engages with an enrolled service provider or directly with the Program to get approval or make a specific claim. Partners indicated that clients do not generally have many challenges accessing NIHB Program vision care benefits. While not directly an issue of accessibility, during interviews, a few partners noted some challenges with respect to coverage including the types of lenses that are covered, the amount covered for frames, and some of the requirements for obtaining contact lenses. According to Program representatives, subsequent to the evaluation period, the NIHB Program's vision case coverage has been updated to include coverage of progressive lenses.

According to the 2012 NIHB Vision Care Policy Framework, the objective of the NIHB Program vision care benefit area is to provide eligible clients with access to vision care benefits and services in a fair, equitable, and cost-effective manner that will:

• contribute to improving the overall health status of First Nations and Inuit clients, recognizing their individual health needs and the context of health service delivery; and,
• provide coverage for a range of vision care benefits and services based on professional judgment, consistent with the current best practices of health services delivery and evidence-based standards of care.

Interpretation of specific policies and processes are outlined in the 2013 Vision Care Benefit Guide.

The NIHB Program retains a vision care professional on contract (either an optometrist or an ophthalmologist), whose primary operational function is to review benefit exception cases to ensure that adjudication decisions are in line with established clinical practices and guidelines (these are generally claims for highly specialized eyewear for less common vision conditions). The Program also calls on this professional to provide advice to support the development of vision care coverage policy. For example, the Program's vision care professional was consulted to support the development of the 2012 Vision Care Benefit List, to ensure that the items covered and the listed criteria for common exceptions were based on established clinical practice and guidelines.

The 2014 internal audit conducted by Health Canada's Audit and Accountability Bureau for the vision care benefit area noted that, despite a well-documented audit framework for the benefit, there was no evidence of a structured provider audit plan from HQ or the regions. While the framework called for sample size calculation and random sample selection, the audit found that the Program performed at most one or two audits per year based on referrals from the regions. This finding resulted in a recommendation to fully implement the provider audit framework for vision care.

To respond to the recommendation, in 2014 the Program implemented a rolling two-year schedule of audits to be undertaken nationally. Also, a new nationally standardized vision care provider enrolment process was implemented in early 2015 to increase providers' understanding and compliance with NIHB Program requirements.

7.6 Short-Term Crisis Intervention Mental Health Counselling Benefit Area

The NIHB Program's STCIMHC benefit area^{Footnote 12} is intended to provide coverage for mental health counselling to address crisis situations when no other mental health services are available or being provided. This benefit is intended to support the provision of immediate psychological and emotional care to individuals in significant distress in order to stabilize their condition, minimize potential trauma from acute life events and, as appropriate, transition them to other mental health supports.

The STCIMHC benefit area provides up to a maximum of 15 hours of counselling (plus five additional hours, if needed, to transition the client to other services) per mental health crisis over a 20-week period. Eligible billable services under the STCIMHC benefit area may include:

• initial assessment (maximum of two hours, in addition to the 15 hours of counselling) performed by an enrolled provider; and,
• counselling sessions (e.g., individual, family, or group counselling).

STCIMHC benefits are accessed in three ways:

• Fee for service and contracts: Nationally, fee-for-service arrangements and contracts account for most STCIMHC benefit expenditures (approximately 70%). Enrolled providers are independent mental health professionals who deliver services at their usual place of business, or travel to First Nations communities, and bill the Program for individual clients on a fee-for-service basis. In Ontario, Atlantic Canada, Québec and the Yukon, this model accounts for the majority of services provided. While most clients contact a provider directly, clients or community health staff may also contact the NIHB Program regional office for a list of enrolled providers in their area. Two hours for an initial assessment do not require prior approval. Following the initial assessment, mental health counselling providers must obtain prior approval from the Program's regional office to confirm cost coverage. The Program's regional staff processes all fee-for-service prior approvals and claims. In the Alberta region, Health Canada contracts with enrolled providers who have expressed a willingness to travel to communities to provide STCIMHC services. Health Directors aid in the selection of suitable mental health counsellors, and serve as their community's point of contact with providers. Providers are reimbursed on a per diem basis and travel costs are provided. Contracts stipulate a minimum number of days (per week or month) that the provider will deliver services in the communities, and additional time beyond contract parameters can be granted with prior approval. Clients typically work with their local health centre to schedule appointments.
• CAs:  Nationally, approximately 30% of STCIMHC expenditures are done through CAs for benefit delivery managed by First Nations communities, or organizations that contract or employ mental health professionals, and enable communities to tailor mental health services to address their specific needs. CAs may be ongoing, or short-term in response to a specific community situation that increases the need for STCIMHC.

To bill the NIHB Program, mental health providers must be enrolled with the Program. To qualify as a NIHB Program STCIMHC provider, mental health providers must be registered with a legislated professional regulatory body and eligible for independent practice in the province or territory where the service is being provided. Eligible legislated mental health providers include psychologists and social workers with clinical counselling orientation. In exceptional circumstances, other mental health counselling providers who do not meet these requirements may be utilized.

Actual utilization rates for STCIMHC benefits could not be calculated for the evaluation because a significant proportion of the benefit is delivered to clients through CAs. Based on data compiled by the NIHB Program for the ongoing AFN-NIHB Joint Review process, approximately 10,000 NIHB Program clients accessed STCIMHC benefits through the fee-for-service delivery model in 2014-2015. These numbers do not include benefits provided through CAs (approximately 30% of expenditures). Given that the denominator of eligible population cannot be determined for these figures, utilization rates could not be calculated for the evaluation.

Challenges and Barriers to Accessing STCIMHC Benefits

• According to interviews with partners, the level of awareness of STCIMHC benefits is relatively low among clients. Nonetheless, partners did not indicate any major challenges in accessing the benefit.  

The STCIMHC Policy Framework was updated in 2013, along with the STCIMHC Benefit Guide. According to the 2013 STCIMHC Benefit Guide, benefits will be provided based on the judgment of recognized medical professionals, consistent with the best practices of health services delivery and evidence-based standards of care. During the period covered by the evaluation, Health Canada collected treatment plans as part of the prior approval process. As of 2015, prior approval is now based on the provider's assertion that the services being provided to the client are for the purpose outlined in the Guide, serving as a short-term bridge to longer-term treatment as required.

The 2014 internal audit conducted by Health Canada's Audit and Accountability Bureau for the STCIMHC benefit area noted that, despite a well-documented audit framework for the benefit area, there was no evidence of a structured provider audit plan from HQ or the regions for STCIMHC. While the framework called for sample size calculation and random sample selection, auditors were not provided with the results from any STCIMHC audits conducted during the requested timeframe. This finding resulted in a recommendation to fully implement the STCIMHC provider audit framework. To respond to the recommendation, a rolling two-year schedule of audits was undertaken starting in 2014. In addition, a new nationally standardized mental health counselling provider enrolment process was implemented in early 2015. The purpose of the enrolment process is to increase providers' understanding and compliance with NIHB Program requirements.

7.7 Collaboration

Provinces

The evaluation found that the main challenge regarding collaboration between the NIHB Program and the provinces concerns coordination of supplemental health benefits. Partners and NIHB Program representatives indicated in interviews that the lack of coordination of public supplemental benefit programs presents a challenge for the Program. They noted that the NIHB Program is, according to policy, the 'payer of last resort'; however, most provinces do not provide coverage for NIHB Program clients under their supplemental benefit plans for special populations.

According to key informants, including service providers, regional NIHB Program representatives, as well as First Nations communities and organizations, the challenges with coordination between the NIHB Program and various provincial supplementary benefit programs can contribute to stress, frustration and, ultimately, lack of access to benefits for some clients, as they are unable to successfully navigate the system.

According to Program representatives, under the Program's mandate, when a client confirms that their coverage status - whether under public or private insurance - has changed, the NIHB Program works to facilitate access to eligible benefits. Program representatives indicated that, while there had been some issues identified with publicly funded P/T plans over time, these had not been a generalized problem affecting daily Program operations and had been related to variances in P/T programs and their coverage for specialized populations, such as clients living in personal care homes and individuals living with HIV / AIDS or cancer. NIHB Program representatives reported that these issues, once identified, had been resolved, with either the Program providing coverage, or P/T programs continuing to provide coverage for First Nations individuals and Inuit as residents of the relevant province or territory.

Payment coordination with third-party payers by the NIHB Program increased over the evaluation period. According to analyses provided by the Program, the proportion of dental claims that were coordinated with third-party payers rose from approximately 9% in 2012 to 11% in 2015. The proportion of pharmacy claims that were coordinated with third-party payers increased from approximately 10% in 2012 to 13% in 2015. This results in approximately 13% to 15% of all dental clients and approximately 9% to 12% of all pharmacy clients having coordinated claims between 2012 and 2015.^{Footnote 13}  The majority of these claims are coordinated automatically through HICPS, without the need for clients or providers to take additional steps beyond submitting claims.

Service Providers

From interviews with identified service provider groups, some respondents noted that they had experienced challenges with respect to various issues, such as:

• coordination of benefits;
• administrative burden associated with prior approvals/predetermination and appeals;
• low rates of reimbursement for specific services within pharmacy, dental and MS&E benefits; and,
• inconsistencies in the approval of some benefits, both across and within regions.

While some respondents perceived that negotiations and consultations had been challenging, they also noted improvements in this area over recent years. Some service provider associations noted that NIHB Program representatives have been more receptive to listening to their challenges with the Program, and, in some instances, making adjustments or piloting new processes (e.g., no longer requiring mental health treatment plans, removing the predetermination requirement from some dental procedures).

The evaluation did find a potential gap in NIHB Program communications with relevant health service providers. During interviews with partners, it was noted that, since physicians are not service providers under the NIHB Program, there is limited engagement, either nationally or regionally, with physician associations. This was noted as somewhat counterintuitive, given the key role physicians play in Program clients accessing many of the benefit areas (e.g., determining medical necessity, prescribing medications).

National Indigenous Organizations and Communities

While there were a few issues noted, key informants remarked that there has been considerable improvement in collaboration efforts between the NIHB Program and AFN and ITK over the past few years. The key contributions to improvements included a more collaborative approach being exhibited by the NIHB Program team at the national office (HQ), with ongoing communication and discussion being promoted, and the implementation of joint review processes with both AFN and ITK.

For First Nations communities, the development and implementation of those services provided by NIHB Navigators was viewed very positively overall. Interviews with partners and NIHB Program representatives indicated that there was a perceived need for more NIHB Navigators in some regions. Some NIHB Navigators noted that the cultural sensitivity and cultural competency among Program staff could be improved. Partners also noted that there is an ongoing need for NIHB Navigator training support and engagement. There are currently no Inuit NIHB Navigators, although the creation of such positions was in development at the time of drafting of this report.

Finally, First Nations partners noted that, in their view, there was a long-standing, ongoing need to address the mistrust from clients towards the NIHB Program that has built up over time.

9.0 Performance: Issue #5 – Demonstration of Efficiency and Economy

The Treasury Board of Canada's Policy on Evaluation (2009) and guidance document, Assessing Program Resource Utilization When Evaluating Federal Programs (2013), define the demonstration of efficiency and economy as an assessment of resource utilization in relation to the production of outputs, and progress toward expected outcomes. As part of this assessment, programs are expected to have standardized performance measurement systems in place, and that the programs' expenditure data, drawn from financial systems, can be linked to specific inputs, activities, outputs and expected results.

The evaluation provides observations on efficiency and economy based on findings from the literature review, administrative data review (including available financial data), benchmarking exercise and key informant interviews.

Usually, evaluations conducted under the Treasury Board of Canada's Policy on Evaluation (2009) analyze the extent to which program budgets reflect expenditures across various categories and components. The current evaluation was unable to make a direct comparison, given the differences in how budgets and expenditures are captured for the NIHB Program. The Program's total budget over the evaluation period was approximately $6.0 billion. Annual budgets throughout the evaluation period are summarized in Table 12. The Program's budget increased annually from approximately $864.2 million in 2009-2010 to approximately $1.1 billion in 2014-2015.

Table 12 :  NIHB Program Annual Budget ($M)^{Footnote a}

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015	Total
Base budget	$864.2	$911.2	$993.5	$1,044.7	$1,068.4	$1,104.0	$5,986.0
Growth rate	--	5.4%	9.0%	5.2%	2.3%	3.3%	--
Source: Chief Financial Officer Branch, Health Canada.

The primary source of NIHB Program financial information used for the evaluation was data provided by the Chief Financial Officer Branch of Health Canada. NIHB Program representatives noted that these data do not necessarily always reflect the information presented in the Program's annual reports, given adjustments made at year-end and the clarification of potential coding errors from regions.

Program expenditures were reported in Section 2.4. Due to the structure of the financial system, it was not possible to exclude FNHA-associated expenditures before the transfer of responsibility in 2013-2014. NIHB Program expenditures, excluding FNHA clients, were thus estimated by excluding all expenses associated with the BC region.

9.1 Efficiency of Claims Processing

As illustrated in Table 13, expenditures for all benefit areas have increased since 2009-2010. STCIMHC benefits experienced the largest growth rate over the period, increasing from $11.5 million in 2009-2010 to $15.2 million in 2014-2015, for a growth rate of 32%.^{Footnote 14} MT experienced the second largest increase, with an overall growth rate of 27% over the evaluation period. Nonetheless, in dollar terms, MT benefit expenditures accounted for the largest increase, with expenditures increasing from $281.2 million in 2009-2010 to $357.3 million in 2014-2015.

Table 13 : NIHB Program Expenditures^{Footnote a}, Annual Growth Rate and Distribution by Benefit Area

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015	Total
Expenditures ($M)
Pharmacy	$368.3	$370.3	$388.4	$392.3	$391.9	$413.0	$2,324.2
Dental	$165.9	$185.3	$190.0	$193.0	$198.4	$201.4	$1,134.0
MT	$281.2	$288.5	$308.2	$325.5	$338.8	$357.3	$1,899.5
Vision care	$24.5	$25.9	$26.3	$28.9	$29.0	$29.0	$163.6
STCIMHC	$11.5	$11.1	$11.5	$12.9	$13.2	$15.2	$75.4
PremiumsFootnote b	$0.1	$0.1	$0.1	$0.3	$0.1	$0.1	$0.8
Audit servicesFootnote c	$10.2	$10.4	$11.4	$10.3	$9.3	$9.6	$61.2
OversightFootnote d	$24.7	$24.5	$24.2	$26.2	$39.4	$38.7	$177.7
Total	$886.4	$916.1	$960.1	$989.4	$1,020.1	$1,064.3	$5,836.4
Annual Growth Rate							Overall
Pharmacy	--	0.5%	4.9%	1.0%	-0.1%	5.4%	12.1%
Dental	--	11.7%	2.5%	1.6%	2.8%	1.5%	21.4%
MT	--	2.6%	6.8%	5.6%	4.1%	5.5%	27.1%
Vision care	--	5.7%	1.5%	9.9%	0.3%	0.0%	18.4%
STCIMHC	--	-3.5%	3.6%	12.2%	2.3%	15.2%	32.2%
Premiums	--	0.0%	0.0%	200.0%	-66.7%	0.0%	0.0%
Audit services	--	2.0%	9.6%	-9.6%	-9.7%	3.2%	-5.9%
Oversight	--	-0.8%	-1.2%	8.3%	50.4%	-1.8%	56.7%
Total	--	3.4%	4.8%	3.1%	3.1%	4.3%	20.1%
Distribution							-
Pharmacy	41.6%	40.4%	40.5%	39.7%	38.4%	38.8%	-
Dental	18.7%	20.2%	19.8%	19.5%	19.4%	18.9%	-
MT	31.7%	31.5%	32.1%	32.9%	33.2%	33.6%	-
Vision care	2.8%	2.8%	2.7%	2.9%	2.8%	2.7%	-
STCIMHC	1.3%	1.2%	1.2%	1.3%	1.3%	1.4%	-
Premiums	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	-
Audit services	1.2%	1.1%	1.2%	1.0%	0.9%	0.9%	-
Oversight	2.8%	2.7%	2.5%	2.6%	3.9%	3.6%	-
Source: Chief Financial Officer Branch, Health Canada.

9.1.1 Number of Claims

Changes in claim volume relate to changes in client utilization patterns (e.g., changes in total eligible client population and uptake/awareness of Program benefits) and reflect demand for health benefits. In addition, claim volume can be used to help assess claim processing efficiency, if changes result from efficiency-oriented policies and/or new business processes. Claim volume may also vary because of changes in administrative processes, in coverage policy or in population characteristics (e.g., the health condition of the client population, the proportion with access to private/alternate benefit coverage). Moreover, increases in claim volume have an impact on claim processing costs, may have an impact on workload (depending on level of automation) and, therefore, on administrative costs. More specifically, in the case of the NIHB Program, the number of claims processed in a year is affected by the following factors:

• Operational procedures used to determine how a claim is entered into the system, given that a claim line is not equivalent to a prescription: Repeated prescriptions are logged in the system as another claim line every time the prescription is refilled: “Therefore, it is possible for an individual who has a prescription that repeats multiple times in a year to have numerous related claim lines associated with the single prescription. Some prescriptions (e.g., methadone) are dispensed daily and will increase the per capita number of claim lines” (Health Canada, 2014a, p. 85).
• Policies that specify how claims should be managed: Policies have been put in place to specify the amount of provider compensation for specific medications (e.g., pharmacist dispensing fees when dispensing quantities for less than 28- and seven-day supplies).^{Footnote 15}  These policies contribute to reducing professional fees billed in a short duration, as well as claim volumes.

With these considerations in mind, the number of claims per benefit area and annual growth rates are summarized in Table 14. In 2009-2010, there were more than 11 million pharmacy claims processed and paid, which increased to 15 million in 2014-2015, for an overall growth rate of 36%. The number of processed and paid dental claims increased from 1.7 million in 2009-2010 to nearly 2 million in 2014-2015, for an overall growth rate of 16%. Finally, the number of processed and paid MS&E claims increased by 20% during the evaluation period, from approximately 185,500 in 2009-2010 to slightly over 223,200 in 2014-2015.

Table 14 : Number of Paid Claims and Annual Percentage Growth by Benefit Area

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015	Overall Growth
Number of Paid ClaimsFootnote a
Pharmacy	11,000,590	11,824,274	12,710,434	13,454,232	14,050,395	15,001,770	--
Dental	1,696,677	1,820,768	1,801,448	1,847,483	1,899,500	1,959,388	--
MS&E	185,535	189,179	198,149	202,349	215,496	223,231	--
Annual Growth Rate
Pharmacy	--	7.0%	7.0%	5.5%	4.2%	6.3%	36.4%
Dental	--	6.8%	-1.1%	5.2%	-2.8%	5.7%	15.5%
MS&E	--	1.9%	4.5%	2.1%	6.1%	3.5%	20.3%
Source: HICPS.

9.1.2 Cost per Claim Line Processed

Claim administration costs for pharmacy and dental benefits were reviewed for 2010-2011 through to 2014-2015. Using the number of claim lines reported, the average cost per claim line was calculated. Claim lines include claims paid, reversed and rejected.^{Footnote 16} Throughout the evaluation period, the average cost per claim line for pharmacy was very close to that of claims processed electronically. For dental claims, the average cost per claim line throughout the evaluation period suggested that a greater number of dental claims were paper-based. This reliance on paper records may be a function of provider choice and/or infrastructure available to providers in some remote areas. Data for MS&E, while showing a considerable increase, were deemed unreliable.

9.1.3 Ratio of Administrative Costs to Total Expenditures

As noted in Table 15, the largest expense category was benefits provided by the NIHB Program ($837.2 million in 2014-2015). These were payments made directly or indirectly (via third-party contractor) to service providers for benefits provided to First Nations and Inuit clients. The second largest expense was benefits provided via CAs ($191.4 million in 2014-2015). These consisted of conditional transfers to recipients for the delivery of the Program, which may have included one or more benefits.

Table 15 : NIHB Expenditures^{Footnote a}, Annual Growth Rate and Distribution by Type of Expense

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015
Expenditures ($M)
Salaries and other remuneration	$24.2	$23.9	$23.8	$24.9	$33.9	$31.7
O&M	$4	$2.7	$3.3	$2.8	$3.9	$4.0
Benefits (NIHB)	$705.6	$735.2	$771.8	$792.4	$799.3	$837.2
Benefits (CA)	$152.6	$154.2	$161.1	$169.3	$183	$191.4
Capital expenses	$0	$0.1	$0.1	$0	$0	$0.0
Total	$886.4	$916.1	$960.1	$989.4	$1,020.1	$1,064.3
Annual Growth Rate
Salaries and other remuneration	--	-1.2%	-0.4%	4.6%	36.1%	-6.5%
O&M	--	-32.5%	22.2%	-15.2%	39.3%	2.6%
Benefits (NIHB)	--	4.2%	5.0%	2.7%	0.9%	4.7%
Benefits (CA)	--	1.0%	4.5%	5.1%	8.1%	4.6%
Capital expensesFootnote b	--	--	--	--	--	--
Distribution
Salaries and other remuneration	2.7%	2.6%	2.5%	2.5%	3.3%	3.0%
O&M	0.5%	0.3%	0.3%	0.3%	0.4%	0.4%
Benefits (NIHB)	79.6%	80.3%	80.4%	80.1%	78.4%	78.7%
Benefits (CA)	17.2%	16.8%	16.8%	17.1%	17.9%	18.0%
Capital expenses	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Source: Chief Financial Officer Branch, Health Canada; information on FNHA expenditures received from the NIHB Program.

Using the information provided in Table 15, it was possible to estimate the share of administrative costs over total expenditures. Administrative costs considered in this calculation included salaries and other remuneration (e.g., regular salaries, overtime, bonuses), as well as operations and maintenance (O&M) expenditures that support the delivery of the Program and include travel, supplies, certain equipment and contracts, among others. The results from this calculation are summarized in Table 16, and show that the share of administrative costs ranged between 3% and 4% during the evaluation period. It should be noted that the estimates of administrative costs may exclude some or all of the costs associated with claims processing (i.e., costs associated with HICPS), since these costs were not presented separately in the expenditure data provided. In addition, O&M expenditures, which generally include contracts, seemed low compared to total claim administration costs. The administrative data provided no further details to reconcile these figures.

Table 16 : NIHB Program Administrative Costs ($M)

	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015
Administrative costs	$28.2	$26.6	$27.1	$27.7	$37.8	$35.7
Total expendituresFootnote a	$886.4	$916.1	$960.1	$989.4	$1,020.1	$1,064.3
Share of administrative costs	3.2%	2.9%	2.8%	2.8%	3.7%	3.4%
Source:Estimations based on data provided by the Chief Financial Officer Branch, Health Canada; information on FNHA expenditures received from the NIHB Program. 2 Changes in accounting treatment, starting in 2013-2014, resulted in an increase in expenditures, due to the inclusion of indirect cost.

It was not possible to obtain information on the share of administrative costs for public plans through the benchmarking exercise, as the differences in delivery approaches, coverage and definitions used to track information did not allow for a comparison. Nonetheless, during interviews, private and non-profit insurance plan representatives reported that administrative costs would vary with the size, complexity and delivery of a program, and may range from as low as 3.5% to as high as 12%.

9.2  Managed in a Sustainable Manner

In-Year Monitoring

As one indication of the extent to which the NIHB Program can evaluate benefit management and respond to new and changing cost pressures in the short term, the evaluation examined in-year monitoring for Program expenditures. During the six-year period covered by the evaluation, the NIHB Program had numerous policies and procedures in place to monitor ongoing expenditures for the various benefit areas, namely:

• Monthly forecasting fee-for-service pharmacy and dental claims through claims processor: NIHB Program HQ is responsible for preparing a monthly forecast for these funds, which represent approximately 55% of the entire Program benefits funding envelope. Two separate methodologies are utilized to forecast these funds, depending on which period of the fiscal year is being considered. In early fiscal year periods^{Footnote 17} (months three through five), the monthly fee-for-service forecast is calculated using year-to-date actuals divided by the proportion of the previous fiscal year's spending for that period. This proportional method serves to adjust for historical period fluctuations, such as a consistent annual spending lag in summer months. From period six onwards, the monthly fee-for-service forecast is calculated using year-to-date actuals multiplied by the weighted days remaining in the fiscal year. Weighted day calculations account for weekday business days versus weekend days and holidays in the calendar year, by region.

• Regional forecasts: Regions submit their monthly forecasts for regionally managed benefits for periods three through 11. Regionally managed benefits represent approximately 45% of the NIHB Program benefits funding envelope. Once regions have submitted their forecasts, Program HQ reviews regional values, making adjustments to the forecasts as required. Capacity and accuracy in preparing monthly forecasts varies by region, in that some regions forecast what they believe they will spend, while others simply forecast to their allocation.

Another indication of the in-year monitoring of the NIHB Program includes the extent to which the Program can manage expenditures within budgets established at the beginning of each year. For the final two years of the evaluation period (2013-2014 to 2014-2015), the evaluation found that NIHB Program expenditures followed relatively closely the annual budget for each of those two years. As noted in Table 17, for these two years combined, the expenditures were approximately 3% lower than budget.

Table 17 : NIHB Program Annual Budget ($M), Expenditures ($M) and Variance

	2013-2014	2014-2015	Total
Total budget	$1,068.40	$1,103.95	$2,172.35
Total expenditures	$1,026.90	$1,070.70	$2,097.60
Variance between budget and expenditures	$41.50	$33.25	$74.75
Percentage variance	4%	3%	3%
Source: Chief Financial Officer Branch, Health Canada. Budgets and expenditures exclude the BC region and FNHA but include EBP.

The NIHB Program provided the evaluation team with information on in-house variance analysis regarding the accuracy of a series of in-year forecasting exercises. While the values used did not align with expenditures and budgets provided to the evaluation team by Health Canada's Chief Financial Officer Branch, likely due to different sets of inclusions/exclusions used with each of the two sources, the results of the Program's analyses indicated that, for the period covered by the evaluation, the in-year expenditures were very close to the amount forecasted at the start of the year. As illustrated in Table 18, the overall expenditures, according to the Program's own analyses, was $6.25 billion, which was quite close to the $6.35 billion forecasted through an annual prediction, or approximately 2% positive variance for the entire period covered by the evaluation. Overall, the benefit area that demonstrated the highest level of variance was MT, showing a positive variance of approximately 6%.

Table 18 : NIHB Program Annual Expenditures ($000s), Forecasted ($000s), and Variance

Benefit Area	2009-2010	2010-2011	2011-2012	2012-2013	2013-2014	2014-2015	Total
Expenditures by Benefit ($000s)Footnote a
MT	$301,673	$311,760	$333,304	$351,424	$352,036	$356,610	$2,006,807
Pharmacy	$435,097	$440,768	$459,359	$462,699	$416,165	$421,895	$2,635,983
Dental	$194,918	$215,796	$219,057	$222,706	$207,179	$201,886	$1,261,542
Vision care	$27,779	$29,219	$29,780	$32,167	$31,459	$29,151	$179,555
Premiums	$17,110	$18,428	$19,868	$21,257	$5,406	$0	$82,069
Other health care	$12,516	$12,083	$12,936	$14,337	$14,152	$19,483	$85,507
Total	$989,094	$1,028,053	$1,074,304	$1,104,591	$1,026,397	$1,029,025	$6,251,464
Forecasted Expenditures by Benefit ($000s)Footnote b
MT	$292,191	$320,599	$465,912	$361,417	$346,723	$355,123	$2,141,965
Pharmacy	$431,487	$448,799	$338,506	$499,581	$432,056	$416,952	$2,567,381
Dental	$190,216	$205,853	$238,324	$239,064	$212,100	$205,823	$1,291,380
Vision care	$26,925	$28,685	$30,682	$31,987	$31,412	$31,044	$180,735
Premiums	$16,774	$18,247	$19,127	$21,443	$5,722	$0	$81,313
Other health care	$11,593	$13,645	$12,541	$13,742	$15,107	$18,249	$84,877
Total	$969,185	$1,035,827	$1,105,092	$1,167,234	$1,043,120	$1,027,191	$6,347,649
Percentage Difference between Forecast and Expenditures
MT	-3.1%	2.8%	39.8%	2.8%	-1.5%	-0.4%	6.3%
Pharmacy	-0.8%	1.8%	-26.3%	8.0%	3.8%	-1.2%	-2.7%
Dental	-2.4%	-4.6%	8.8%	7.3%	2.4%	2.0%	2.3%
Vision care	-3.1%	-1.8%	3.0%	-0.6%	-0.2%	6.5%	0.7%
Premiums	-2.0%	-1.0%	-3.7%	0.9%	5.8%	---	-0.9%
Other health care	-7.4%	12.9%	-3.1%	-4.2%	6.8%	-6.3%	-0.7%
Total	-2.0%	0.8%	2.9%	5.7%	1.6%	-0.2%	1.5%
Source: NIHB Program.

Forecasting

The evaluation found that the factors contributing to fluctuations in NIHB Program expenditures and their growth rate are numerous, and can be difficult to forecast accurately due to their volatility and/or limited information available. This creates a challenge in being able to forecast Program costs beyond a one-year time frame. From the document review, interviews with industry representatives and discussions with Program representatives, the evaluation team developed a list of potential cost drivers that could substantially impact Program expenditures within the various benefit areas. As illustrated in Table 19 below, most of the potential cost drivers could have either a positive or negative impact on NIHB Program costs. The magnitude of the impact of most cost drivers could also vary considerably depending on many factors that fall far outside of the NIHB Program's realm of control. Except for a few of the more steadily growing drivers (e.g., demographic changes), there are considerable challenges involved in accurately predicting the direction and exact magnitude of the impact on NIHB Program costs when forecasting out five or 10 years.

Table 19 : Cost Drivers and Impacts on NIHB Program Costs

Potential Cost Drivers	Impact on Cost
Legislation or court decisions that impact access and the NIHB Program's eligible client population	↑
NIHB Program policy changes that impact access	↑ or ↓
NIHB Program policy changes that impact coverage	↑ or ↓
NIHB Program policy changes that impact implementationFootnote 18	↑ or ↓
Policy changes within other benefit programs (e.g., access/coverage provided by provincial plans, private plans)	↑ or ↓
Changes in other federal government programming (e.g., Indian Residential Schools, Oral Health initiatives)	↑ or ↓
Demographics – population growth, aging	↑
Changes in various disease rates (e.g., chronic, communicable)	↑ or ↓
Change in utilization rates among eligible population	↑ or ↓
New therapies/treatments approved (e.g., Hepatitis C, cholesterol)	↑
New medical devices/equipment available	↑
Introduction of generic drugs	↓
Product Listing Agreements	↓
Use of info-technology for plan management (efficiencies, cost)	↑ or ↓
Changes in service provider fees	↑
Travel costs (travel, location of P/T insured services, lodging, meals)	↑ or ↓
Telemedicine	↑ or ↓
Health professionals in communities	↑ or ↓
Economic conditions	↑ or ↓

The NIHB Program is currently developing a five-year forecasting model for all benefit areas. According to documentation provided by the Program, the approach involves focusing on both recent expenditure growth and eligible population growth (the NIHB Program's client base grows at a rate nearly double that of the general Canadian population). The methodology has been designed to incorporate historical factors that drove expenditure growth over the preceding two years, while also controlling for variability in expenditures caused by changes in P/T drug pricing policies, backlogs in claims processing, or the use of accounting practices that can affect year-end results.

The extent to which the Program is managed in a cost-effective and sustainable manner is related to measuring efficiency while achieving outcomes and containing costs. The evaluation attempted to assess this area with two main indicators: growth in expenditures compared to other plans and Canadian trends, and the ratio of administration costs to benefit expenditures compared to industry benchmarks. Comparators of growth rates and industry benchmarks were not readily available from industry sources consulted for the evaluation (e.g., document review, interviews with industry representatives).

As noted previously in Section 9.1, the average annual growth rate was approximately 4% for NIHB Program expenditures, ranging from 3% to 5%. While not an exact comparison, based on CIHI estimates, average annual growth in health public expenditures was 7% between 2000 and 2010, decreased to 2.9% between 2010 and 2013, and reached 3.1% in 2014 (CIHI, 2015). This would indicate that the expenditure growth exhibited by the NIHB Program is within the range of other health public expenditures.

The ratio of administration costs to benefit expenditures for the NIHB Program was assessed as approximately 3% in 2014-2015. Information on the share of administrative costs for public plans was unavailable for the evaluation, as the differences in delivery approaches, coverage and definitions used to track information between the various plans did not allow for a comparison. Private and non-profit plans reported that administrative costs would vary with size, complexity and delivery of a program, and the share of total costs quoted ranged from as low 3.5% to as high as 12%.

During discussions and interviews with NIHB Program representatives, several areas and processes were highlighted as contributing to cost management and the overall cost-effectiveness of the Program during the period covered by the evaluation. Examples included systematic integration of operations for some of the benefit areas, increased automation of claims, negotiation of pharmacy fees, establishment of regional fee grids for dental service providers, and reduction in prior approval/predetermination requirements for those procedures with very high approval rates. Policies and agreements were also highlighted as contributing to cost management, such as the Short-Term Dispensing Policies implemented during the period covered by the evaluation, and various Product Listing Agreements dating from 2010, which allow the NIHB Program to provide clients with more open access to newer and higher-cost medications.

It was noted that a unique feature of the NIHB Program, when compared to other plans, is its emphasis on various aspects of client safety. The processes implemented to advocate client safety may contribute initially to costs, but may improve overall effectiveness with respect to outcomes, such as improved health and wellbeing. Various procedures have been implemented in areas such as opiate prescribing and frequency of prescriptions.

9.3  Comparisons with Other Programs and Plans 

It is challenging to compare the NIHB Program directly with other plans, as there is considerable variety and options both within and between different types of plans. There were no adequate comparisons found for MT, as this is not normally covered as an individually-based benefit in either the private or public plans examined. Similarly, the STCIMHC benefit area is difficult to compare due to limited coverage for these types of services under other public plans, and variation in counselling and psychotherapy benefits available through private plans. Therefore, the evaluation selected a few comparative dimensions for four NIHB Program benefit areas, namely pharmacy, dental, MS&E and vision care.

Pharmacy Benefits

As noted in Table 20, key differences between the NIHB Program's pharmacy benefits and other benefit plans were the following:

• The NIHB Program does not require clients to co-pay any proportion of the benefits. Most other plans examined have some level of co-payment.
• NIHB Program coverage includes some non-prescription drugs. The other plans examined did not provide coverage for non-prescription drugs.

The NIHB Program's pharmacy benefits do not differ substantially from the other plans examined with respect to claims processing or requirements for prior approval.

Table 20 : Comparison of Types of Drug and Pharmacy Benefit Plans

Dimension	NIHB Program	Employee Plans and Private Insurance Plans	Publicly-funded Plans for Targeted Populations
Eligibility	First Nation person registered under the Indian Act, Inuit recognized by Inuit land claim organization, or infant less than one year old whose parent is eligible.	Enrollment in plan.	Usually a member of a potentially vulnerable group (e.g., seniors, retirees, person with disability, social assistance recipient).
Coverage	Formulary-based, includes both prescription and some non-prescription drugs; based on CADTH.	Varies: includes both non-formulary and formulary-based. Interviewees indicated a trend towards moving away from open formularies.	Provincial formularies, usually based on CADTH. In some cases, maximum allowable cost and low-cost alternative policies apply.
Co-payment	No co-payment.	Most have some level of co-payment.	Most have some level of co-payment.
Claims processing	Standard is electronic processing, often including rule-based processes with policies/audits built into the system.	Standard is electronic processing, often including rule-based processes with policies/audits built into the system.	Standard is electronic processing, often including rule-based processes with policies/audits built into the system.
Prior approval	Prior approval for limited use benefits and exceptions. Extensions require re-approval.	Clients may pay up front and seek reimbursement up to an annual maximum dollar amount. Usually, co-payment or deductible required. Prior approval for a few drugs based on high cost and/or alternative to be tried first.	Varies: usually require prior approval for limited use drugs and drugs not on formulary.

Dental Benefits

As noted in Table 21, key differences between the NIHB Program's dental benefits and other benefit plans were the following:

• The NIHB Program does not require clients to co-pay any proportion of the benefits. NIHB Program benefits are not set with deductibles or maximum annual allowances. Most other plans examined have some level of co-payment, deductible, annual maximum or both.
• NIHB Program coverage is considerably more extensive than the publicly funded plans examined.
• NIHB Program predetermination is primarily paper-based, while the other plans tend to use electronic processing for predetermination.

The NIHB Program's dental benefit coverages did not differ substantially from the other plans examined with respect to the use of predetermination and regional fee grids/schedules to guide amounts claimed.

Table 21 : Comparison of Types of Dental Benefit Plans

Dimension	NIHB Program	Employee Plans and Private Insurance Plans	Publicly-funded Plans for Targeted Populations
Eligibility	First Nation person registered under the Indian Act, Inuit recognized by Inuit land claim organization, or infant less than one year old whose parent is eligible.	Enrollment in plan.	Usually a member of a potentially vulnerable group (e.g., children, retirees, person with disability, social assistance recipient).
Coverage	Includes preventative, restorative, diagnostic, prosthodontic removable, oral surgery, periodontal, endodontic, orthodontic, and adjunctive services (orthodontics are based on medical necessity). No annual maximums on total expenditures.	Varies considerably: depends on plan sponsor. Often has maximum annual allowances.	Adult coverage is mostly centered on emergency procedures. Child programs include preventative and restorative services. No public coverage of orthodontics (aside from cleft lip/palate).
Co-payment	No co-payment.	Most have some level of co-payment.	Most have some level of co-payment.
Claims processing	Standard is electronic processing, often including rule-based processes with policies/audits built into the system. Predetermination processing is paper-based and policy ruled.	Standard is electronic processing, often including rule-based processes with policies/audits built into the system. Predetermination processingis electronic (occasionally by fax).	Standard is electronic processing, often including rule-based processes with policies/audits built into the system. Predetermination processing is electronic (occasionally by fax).
Predetermination	Predetermination required for various treatments (mostly high-end procedures).	Predetermination often required for procedures with a cost over a certain amount (e.g., $500), or a series of procedures.	Information not available from sources consulted.
Fee grids	Regional fee grids.	Often have a fee schedule in place; regional differences.	Information not available from sources consulted.

MS&E Benefits

As noted in Table 22, key differences between the NIHB Program's MS&E benefits and other benefit plans were the following:

• The NIHB Program does not require clients to co-pay any proportion of the benefits. Most other plans examined do have at least some level of co-payment.
• NIHB Program coverage is all under the one program, while many of the public programs appear to be very specific to certain needs (e.g., aids to independent living).
• NIHB Program claims processing is primarily electronic, while the public-funded plans appear to have more paper-based processing in comparison.

The NIHB Program's MS&E benefits did not differ substantially from the other plans examined with respect to the requirement of prior approval for many items, more specifically equipment.

Table 22 : Comparison of Types of MS&E Benefit Plans

Dimension	NIHB Program	Employee Plans and Private Insurance Plans	Publicly-funded Plans for Targeted Populations
Eligibility	First Nation person registered under the Indian Act, Inuit recognized by Inuit land claim organization, or infant less than one year old whose parent is eligible.	Enrollment in plan.	Usually a member of a potentially vulnerable group (e.g., children, retirees, person with disability, social assistance recipient).
Coverage	Broad coverage in several areas; MS&E deemed a medical necessity; restrictions on suppliers, frequency, models.	Varies considerably: depends on plan sponsor. Often have maximum allowed amounts by area.	Coverage in several areas. Coverage for certain areas tends to be aligned with a specific program, rather than one overall plan (e.g., aids to independent living).
Co-payment	No co-payment.	Most have some level of co-payment.	Most have some level of co-payment.
Claims processing	Standard is electronic processing, often including rule-based processes with policies/audits built into the system.	Standard is electronic processing, often including rule-based processes with policies/audits built into the system.	Varies: seems to be a mix of paper-based and some electronic processing.
Prior approval	Prescription from a recognized prescriber is required. Most items must be prior approved by the Program's regional office.	Variable: interviewees noted a trend towards increasingly prior approval needed for larger or higher-priced equipment.	Most items need prior approval, particularly equipment.

 

Vision Care Benefits

As noted in Table 23, key differences between the NIHB Program's vision care benefits and other benefit plans were the following:

• The NIHB Program does not require clients to co-pay any proportion of the benefits. Most other plans examined do have at least some level of co-payment.
• NIHB Program claims processing is primarily paper-based, while the private insurance plans appear to have more electronic-based processing.
• The NIHB Program requires prior approval, while private insurance plans tend to work with maximum coverage amounts.

The NIHB Program's vision care benefits did not differ substantially from the other public plans examined with respect to restrictions on frequency of examinations and on models of eyewear.

Table 23 :  Comparison of Types of Vision Care Benefit Plans

Dimension	NIHB Program	Employee Plans and Private Insurance Plans	Publicly-funded Plans for Targeted Populations
Eligibility	First Nation person registered under the Indian Act, Inuit recognized by Inuit land claim organization, or infant less than one year old whose parent is eligible.	Enrollment in plan.	Usually a member of a potentially vulnerable group (e.g., children, retirees, person with disability, social assistance recipient).
Coverage	Prescribed eyeglasses, repairs, eye examinations when not covered, other depending on medically necessary needs. Restrictions on frequency and models.	Varies: depends on plan sponsor. Usually maximum coverage outlined.	Varies: often restrictions on frequency, models and costs.
Co-payment	No co-payment.	Most have some level of co-payment.	Information not available from sources consulted.
Claims processing	Paper-based.	Varies depending on plan.	Varies: seems to be a mix of paper-based and some electronic processing.
Prior approval	Prescription is required. Most items must be approved by the Program's regional office.	Usually not required: coverage up to a maximum per year.	Most items need prior approval.

The private and non-profit sectors are moving towards greater customization in health benefit insurance coverage (e.g., health spending account, wellness, prevention and allied/paramedical health services).

Through the benchmarking exercise, the evaluation found that private and non-profit sector health insurance plans favour customization in coverage (i.e., plan sponsors choose the most appropriate plan for members). Furthermore, plan sponsors (e.g., employers) may choose to offer plan members (e.g., employees) a fixed plan or a flexible/modular plan with options. There appears to be some customization, depending on the public sector programs (e.g., decentralized delivery models, types of coverage); however, fixed plans seem more common in public sector organizations. In comparison, the NIHB Program establishes national policy frameworks to support the Program’s mandate to provide nationally consistent and portable benefits. In the case of regionally managed benefit areas, the Program’s regional offices work within these frameworks to implement coverage in a manner that reflects differences across and within regions (e.g., available P/T coverage and location of P/T health services, delivery of benefits through CA and/or contract provider as needed).

It was also found that providing the option to plan members of having a health spending account is an increasingly common practice among private and non-profit health insurance plans. In an analysis of health benefits by the Conference Board of Canada, it was found that 65% of public organizations offer a health spending account to their plan members.

In keeping with the customization and tailoring of coverage, the evaluation found that private and non-profit insurers are increasingly developing coverage based on a holistic approach to health care that includes wellness, prevention, and allied/paramedical health services; however, offering paramedical services is a cost driver for many plans. Some coverage for allied/paramedical services is observed in government-sponsored programs. In comparison, the NIHB Program provides no coverage for allied services, or for mental health services other than those addressing a crisis.

Use of IT is common practice among private and non-profit plans (e.g., electronic processing, increased used of mobile applications to disseminate information and manage benefits, and websites with information organized by client type and coverage).

Electronic processing is a common practice among private and non-profit insurance companies and government supplemental health insurance programs, particularly for drug and dental benefits, and is being implemented for other benefits. Alternatively, fax and phone are used with very little reliance on paper records. In comparison, although the NIHB Program uses electronic processing for drug and dental benefits, processing of predetermination and prior approvals relies heavily on paper submissions, which may impact efficiency. According to Program representatives, this requirement is based on government policy related to privacy requirements for transmitting personal health information.

Private and non-profit insurance companies are increasingly using mobile applications to disseminate information and manage benefits. These applications are not in use by the NIHB Program and could potentially contribute to clarifying service eligibility for clients.

Private and non-profit insurance companies have well-developed websites with information organized by client type and coverage. Information on the NIHB Program’s website is generally difficult to find or unclear. Most partners interviewed were critical of the web-based information and client bulletins available from the NIHB Program. While this evaluation was underway, key NIHB information on the Health Canada website was being revised and migrated to the new Government of Canada site, with the intention of improving clarity and access to web-based Program information.

Predetermination and prior approval are becoming more common in private and non-profit insurance plans in order to contain costs and, while timeliness is a performance measure, coordination with other benefits is a priority.

Predetermination and prior approvals are becoming more common in the private and non-profit sectors in order to contain costs. In comparison, the challenges observed with the NIHB Program are linked to the complexity of the approval process, the greater number of benefits that must be submitted for predetermination or prior approval when compared to some other plans, and the limited automation or availability of electronic processing in some benefit areas.

Timeliness is considered a performance measure in private and non-profit plans. In comparison, the NIHB Program publishes service standards for dental benefits and STCIMHC benefits, while, for the other benefits, there are internal Program metrics available.

Ensuring that other sources of insurance coverage are taken into consideration before paying for benefits is a priority for private and non-profit plans. Although the NIHB Program is presented as a ‘payer of last resort’, it is treated as a first payer by most supplemental health benefit provincial programs and some private plans. During interviews with partners and NIHB Program representatives, it was noted that Program clients may be reluctant to declare private plan insurance coverage for various reasons (e.g., view Program benefits as an inherent right, challenges to reinstate Program benefits once a private plan is declared). It is challenging to determine how, and to what extent, there are actual coordination issues with private insurance plans, versus a perception of these issues being at play.

In general, increased oversight of service providers by all plans is a direct result of cost containment efforts. Private and non-profit insurance plans emphasize retention, satisfaction, and market share. Public programs focus on utilization rates and financial measures. Health outcomes are becoming of interest to some non-profit plans.

The different objectives of private, non-profit, and public plans are reflected in the performance measures of interest. Private and non-profit health insurance plans emphasize retention, satisfaction and market share in their measures. Some plan representatives also mentioned financial measures and timeliness of service. Health outcomes are becoming of interest to some non-profit plans. Public programs focus on utilization rates and financial measures. In comparison, the NIHB Program tends to focus on various categories of benefit utilization expenditures (financial measures) and client safety.

Appendix 2 – Summary of Findings

Rating of Findings

Ratings have been provided to indicate the degree to which each evaluation issue and question has been addressed.

Relevance rating symbols and significance

A summary of relevance ratings is presented in Table 1 below, together with a description of the ratings in the footnote to the table.

Appendix 2 – Table 1:  Relevance Ratings

Evaluation Issues	Indicators	Overall Rating	Summary
Continued need for Program
Does the Program continue to address a demonstrable need? Is the Program responsive to the needs of its client population?	Incidence and prevalence of identified health needs among the client population and alignment with NIHB Partners' perspectives on the usefulness and accessibility/reach of the Program Client population perspectives on the usefulness and accessibility/reach of the Program	High	The Program continues to address a demonstrable need. The Program is responsive to the needs of its client population.
Alignment with government priorities
Is the Program aligned with federal government priorities? Is the Program aligned with departmental strategic outcomes?	Evidence of Program alignment with federal government priorities Evidence of Program alignment with HC's strategic outcomes	High	The Program is aligned with federal government priorities and departmental strategic outcomes.
Alignment with federal roles and responsibilities
Is the Program aligned with federal roles and responsibilities?	Evidence of Program alignment with federal roles and responsibilities as these relate to First Nations and Inuit NIHB Evidence of Program differentiation/complementarity from/with publicly/privately funded plans	Low	The Program is aligned with federal roles and responsibilities. The NIHB Program is most often viewed by provinces as a replacement rather than complementary to what is included in supplemental provincial health benefit coverage. This can contribute to difficulties for some NIHB Program clients as they are unable to successfully navigate the system.
Overall rating: High There is a demonstrable need for program activities; there is a demonstrated link between program objectives and (i) federal government priorities and (ii) departmental strategic outcomes; role and responsibilities for the federal government in delivering the program are clear. Partial There is a partial need for program activities; there is some direct or indirect link between program objectives and (i) federal government priorities and (ii) departmental strategic outcomes; role and responsibilities for the federal government in delivering the program are partially clear. Low There is no demonstrable need for program activities; there is no clear link between program objectives and (i) federal government priorities and (ii) departmental strategic outcomes; role and responsibilities for the federal government in delivering the program have not clearly been articulated.

Performance rating symbols and significance

A summary of performance ratings is presented in Table 2 below, together with a description of the ratings in the footnote to the table.

Appendix 2 – Table 2:  Performance Ratings

Evaluation Issues	Indicators	Overall Rating	Summary
Achievement of expected outcomes (effectiveness)
To what extent have the immediate outcomes been achieved?
Access by eligible clients to nationally consistent, portable NIHB Evidence-based benefit policy and Program development (consistent with best practices of health service delivery) Client and provider compliance with program requirements	# and % of clients that access each benefit area annually % of MT expenditures directed to remote communities # and % of policies updated annually as a result of new evidence or best practices Results of provider and client profiling activities; on-site audits per year	Achieved	Pharmacy benefit area: Access: annual utilization rates remained relatively constant. Awareness of benefits among First Nations clients is relatively high but detailed knowledge of specific coverage is lower; NIHB Navigators are playing an important role. Evidence-based development: strong evidence-based approach regarding listing decisions, coverage policy development and Program decision-making supported by consultation and internal processes. Compliance: consistently demonstrated through various levels of audit.
		Achieved	MS&E benefit area: Access: annual utilization rates remained relatively stable. Data on approval rates and appeals (except for higher level 3 appeals) are not systematically compiled at a national level. Evidence-based development: supported by documentation outlining updates and changes based on best practices, standards and evidence-based decision-making. Compliance: consistently demonstrated through various levels of audit.
		Achieved	Dental benefit area: Access: annual utilization rates remained relatively constant. Access concerns are more related to the availability of dental care, which is being addressed through contract dentists and MT. Evidence-based development: supported by consultation, trial projects and external reviews of clinical evidence. Compliance: consistently demonstrated through various levels of audit.
		Little progress; priority for attention	MT benefit area: Access: challenges with data gaps at the national level. Access concerns were identified related to the timeliness of approvals and reimbursements, as well as variability in the interpretation of the MT escort policy in some regions. Evidence-based development: policy framework in place and operations manual updated as necessary through joint regional-HQ processes. Updates to policies are documented in various records of decisions. Enhanced administrative and operational data may assist in developing alternative delivery approaches. Compliance: there is no systematic, integrated audit program. The Program committed to modify its guidelines to better align with operating practices related to the assertion of medical needs and confirmation of attendance. The Program also implemented a regional audit initiative in 2014.
		Progress made; further work warranted	Vision care benefit area: Access: transactional data, including number of claims and paid claimants, are tracked regionally through the use of various data systems; calculating annual utilization rates is challenging. Clients are relatively aware of the benefit, although some coverage specifics are less well-known. There are generally no access concerns. Evidence-based development: benefits and services are based on professional judgement, consistent with the current best practices of health services delivery and evidence-based standards of care. The Program relies on health professional advice to support the development of coverage policy. Compliance: there is no systematic, centralized audit program. The Program implemented (2014) a rolling two-year national audit schedule, as well as a nationally standardized provider enrollment process (2015).
		Progress made; further work warranted	STCIMHC benefit area: Access: transactional data, including number of claims and paid claimants, are tracked regionally; calculating annual utilization rates is challenging. Awareness of the benefit is relatively low among clients. No major challenges in accessing the benefit were identified. Evidence-based development: benefits are provided based on professional judgement, consistent with the best practices of health services delivery and evidence-based standards of care. Compliance: there is no systematic, centralized audit program. The Program implemented (2014) a rolling two-year national audit schedule as well as a nationally standardized provider enrollment process (2015).
Claims for NIHB processed efficiently (regional and centralized)	Claims processing service cost per annual % change by benefit area # of claims annually and % change by benefit area	See Demonstration of Efficiency and Economy.
Collaborative relations with partners and stakeholders to facilitate service delivery	Evidence/results from meetings, communications with NIOs, other stakeholder and provider organizations	Little progress; priority for attention	Engagement with various partners has improved but there are challenges related to coordination and collaboration (e.g., supplemental health benefit coordination, administrative burden associated with prior approvals/predetermination and appeals, regional inconsistencies in some benefit approvals).
To what extent have the intermediate outcomes been achieved?
NIHB Program managed in a cost-effective and sustainable manner	Annual benefit expenditures and annual % change compared to other plans/Canadian trends Ratio of administration costs to benefit expenditures compared to industry benchmarks	See Demonstration of Efficiency and Economy.
To what extent have the longer-term outcomes been achieved?
NIHB provided in a manner that contributes to improved health status of First Nations individuals and Inuit	# of eligible clients/annual % change # and % of client population that accessed at least one benefit annually (by benefit and blended) Evidence that the provision of benefits contributes to improved health	Achieved	The evaluation found evidence of logical links between NIHB and their contribution to improved health among First Nations and Inuit clients, although it is challenging to determine the extent of this contribution given the multitude of factors that contribute to or detract from this goal.
Demonstration of Efficiency and Economy
Are claims processed efficiently? Is the Program better able to evaluate benefit management and predict/respond to new/changing cost pressures? Is the Program managed in a cost-effective and sustainable manner? How does the Program compare with similar publicly/privately funded plans?	Claims processing service cost per annual % change by benefit area # of claims annually and % change by benefit area Annual benefit expenditures and annual % change compared to other plans/Canadian trends Ratio of administration costs to benefit expenditures compared to industry benchmarks Assessment of Program in comparison with similar publicly/privately funded plans Enhancement to the Program's ability to evaluate benefit management and to predict and respond to new or changing cost pressures	Progress made; further work warranted	Program expenditure increases during the period of evaluation were in line with proportional increases in the eligible population and number of claims paid. Cost per claim for pharmacy and dental benefits remained constant across the evaluation period, due primarily to negotiated (contract) costs per processed claim. The average dental benefit claim processing cost appeared to indicate a reliance on paper processing. Data for MS&E, while showing a considerable increase, were deemed unreliable. Data for MT, vision care and STCIMHC benefits are incomplete and drawn from different IT systems in a form that precluded their analysis. The Program's ratio of administrative costs to total expenditures ranged from 3% to 4% during the period of evaluation, which appeared low when compared to other plans. The Program has implemented processes and systems to monitor expenditures on a monthly and quarterly basis for most benefit areas. Accurate forecasting beyond a one-year time frame is challenging for the Program given the large number of potential cost drivers and their volatility. The Program is currently developing and implementing a five-year forecasting model.
Overall rating: Achieved The intended outcomes or goals have been achieved or met. Progress made; further work warranted Considerable progress has been made to meet the intended outcomes or goals, but attention is still needed. Little progress; priority for attention Little progress has been made to meet the intended outcomes or goals and attention is needed on a priority basis.