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

Prepared by Office of Audit and Evaluation
Health Canada and the Public Health Agency of Canada

October 2017

Table of Contents

List of Tables

List of Acronyms

AFN
Assembly of First Nations
APS
Aboriginal Peoples Survey
BC
British Columbia
CA
Contribution Agreement
CADTH
Canadian Agency for Drugs and Technologies in Health
CDEC
Canadian Drug Expert Committee
CDR
Common Drug Review
CHMS
Canadian Health Measures Survey
CIHI
Canadian Institute for Health Information
DBL
Drug Benefit List
DEC
Drug Exception Centre
DTAC
Drugs and Therapeutics Advisory Committee
EBP
Employee Benefit Plan
FNHA
First Nations Health Authority
FNIHB
First Nations and Inuit Health Branch
FNOHS
First Nations Oral Health Survey
F/P/T
Federal/provincial/territorial
HICPS
Health Information and Claims Processing Services
HQ
Headquarters
IT
Information Technology
ITK
Inuit Tapiriit Kanatami
MS&E
Medical Supplies and Equipment
MT
Medical Transportation
MTDS
Medical Transportation Data Store
MTRS
Medical Transportation Reporting System
NIHB
Non-Insured Health Benefits
NIO
National Indigenous Organizations
O&M
Operations and Maintenance
OAG
Office of the Auditor General
P/T
Provincial/territorial
PAA
Program Alignment Architecture
RHS
First Nations Regional Health Survey
STCIMHC
Short-Term Crisis Intervention Mental Health Counselling
SVS
Status Verification System
TRC
Truth and Reconciliation Commission of Canada
 
 

Executive Summary

The purpose of the evaluation was to assess the relevance and performance of Health Canada’s First Nations and Inuit Supplementary Health Benefits (Non-Insured Health Benefits) Program (NIHB Program) for the period of 2009-2010 to 2014-2015.

The evaluation was required in accordance with Section 42.1 of the Financial Administration Act, and the Treasury Board of Canada’s Policy on Evaluation (2009). The evaluation has been conducted to provide Health Canada’s senior management, central agencies, Ministers, Parliamentarians and Canadians with a credible and neutral assessment of the ongoing relevance and performance (defined in terms of effectiveness, efficiency and economy) of the NIHB Program. More specifically, the evaluation will provide the Deputy Minister of Health Canada, as well as senior management, with reliable information to support decision-making regarding the achievements made by the NIHB Program in providing supplementary health benefits to registered First Nations individuals and recognized Inuit living in Canada.

The NIHB Program is a long-established national health benefits program administered through the First Nations and Inuit Health Branch (FNIHB) at Health Canada. Under its 1997 Cabinet-approved mandate, which builds from the 1979 Indian Health Policy, the Program provides eligible First Nations people (both on- and off-reserve) and recognized Inuit residents of Canada with supplemental health benefits in a manner that contributes to their improved health status.

As of March 2015, the NIHB Program was available to approximately 825,000 eligible registered First Nations individuals and recognized Inuit, regardless of their place of residence in Canada. The Program provides access to a range of medically necessary, health-related goods and services when these benefits are not otherwise provided to eligible clients through private or provincial/territorial (P/T) programs. Program benefits include: pharmacy, medical supplies and equipment (MS&E), dental care, vision care, short-term crisis intervention mental health counselling (STCIMHC), and medical transportation (MT) to access medically required health services not available on-reserve or in the community of residence.

The NIHB Program is a large program which expended approximately $5.8 billion over the six-year period covered by this evaluation (2009-2010 to 2014-2015, inclusive), and processes a significant number of health benefit claims annually. For example, over 17 million paid claims in pharmacy products, MS&E and dental care benefits were processed in 2014-2015.

The objective of the NIHB Program is to provide non-insured health benefits to eligible First Nations people and Inuit in a manner that:

  • is appropriate to their unique health needs;
  • contributes to the achievement of an overall health status for First Nations people and Inuit that is comparable to that of the Canadian population as a whole;
  • is sustainable from a fiscal and benefit management perspective; and,
  • facilitates First Nations/Inuit control at a time and pace of their choosing.

Findings and Conclusions on Relevance

There is a strong and continued need for the NIHB Program, given the health disparities faced by First Nations and Inuit populations when compared to non-Indigenous Canadians. The Program responds to identified health needs by providing benefits and services that may not be available to clients in its absence.

In the absence of the Program, most members of the eligible population would be without key supports, benefits and services that they require to improve and/or maintain their health status. Given the high rates of chronic and acute disease among First Nations and Inuit populations, combined with the ongoing challenges of accessing culturally safe health care services and the socio-economic conditions for many communities, the services and benefits provided under the NIHB Program are an essential component of ongoing efforts to diminish substantial health disparities with the rest of Canadians that currently exist for First Nations individuals and Inuit.

The NIHB Program clearly aligns with key federal government priorities, as well as Health Canada’s strategic outcomes.

Health Canada, through FNIHB, provides health programs and services to First Nations individuals and Inuit based on departmental mission and Cabinet-approved mandate/policy statements. Improving the health of Indigenous people is a shared responsibility between federal, P/T governments and Indigenous partners. A key guiding principle in situations where benefits are covered under another plan is to have the NIHB Program act as a primary facilitator in coordinating payments, in order to ensure that the other plan meets its obligations and that clients are not denied service.

Findings and Conclusions on Performance

Clients are accessing the NIHB Program with utilization rates that have remained relatively constant throughout the period covered by the evaluation, for those benefit areas that could be assessed through administrative data (i.e., pharmacy, dental and MS&E benefit areas). The Program provided more than 825,000 eligible clients with access to benefits in 2014-2015. During this same year, approximately three-quarters (72%) of eligible clients had received at least one pharmacy, dental and/or MS&E benefit. The pharmacy benefit area had the highest annual utilization rate ranging from 63% to 66% of eligible clients, who had at least one paid pharmacy claim within a given year (between 441,000 and 499,000 individuals each year). This was followed by the dental benefit area at 35% to 38% of eligible clients (between 249,000 and 288,000 individuals each year), and the MS&E benefit area at 7% of eligible clients (between 51,000 and 56,000 individuals each year).

Some clients accessing NIHB Program benefits encountered various challenges and barriers. Of the challenges cited for each of the benefit areas, many were related to issues of awareness of coverage inclusions/exclusions, rather than accessibility of a benefit. Challenges related to coordination of benefits between the NIHB and provincial programs were noted as an example of an issue that is within the purview of Health Canada to adjust. The funding of NIHB Navigator positions, who assist clients in accessing Program benefits, has helped with coordination.

Decisions and policies related to pharmacy benefits are the most highly evidence-based, with dental and MS&E benefit decisions and policies actively using and integrating scientific evidence. The nature of the decisions required for each benefit area differs, with these three areas (pharmacy, dental, MS&E) being most closely reliant on current scientific evidence to effectively administer benefits. Administrative data, such as claims-level utilization data, were found to be incomplete in some benefit areas. Such challenges reduce the Program’s ability to analyze these data and use the results to inform planning, policy development, and Program adjustments. This is particularly the case in the MT benefit area, a significant portion of which is managed through contribution agreements.

Compliance is effectively monitored for three of the six benefit areas: pharmacy, dental and MS&E. The other three benefit areas, while not having a systematic and centralized audit program, have had internal and/or external audits during the period covered by the evaluation. The audits have resulted in recommendations for improvements in assuring client and provider compliance. The Program has taken steps to address the various recommendations (e.g., regional MT audits, national provider enrollment processes for vision care and STCIMHC).

Overall, the demonstration of expected outcomes is hampered by administrative data issues for some benefit areas (e.g., MT, STCIMHC, vision care), particularly related to data completeness and consistency. The delivery of two of the larger benefit areas (pharmacy, dental) is largely done from national headquarters, which contributes to a more systematic collection of administrative data supporting measurement and ongoing monitoring of outputs and outcomes. While MT benefits account for approximately one-third of Program expenditures, incomplete administrative data present a challenge to systematically measure and monitor outputs and outcomes.

The NIHB Program is large and complex, with multiple benefit areas, various delivery systems, and is subject to important cost drivers that can be volatile and are, for the most part, beyond the control of the Program. These cost drivers have the potential of placing significant pressures on expenditures and contribute to the challenges of managing such a large and complex Program. Despite this context, during the period covered by the evaluation, the Program managed to maintain overall expenditure growth to within the range of overall eligible population growth.

Specific indicators of efficiency, such as administrative costs per claim, demonstrate that the benefit areas with greater administrative consolidation (pharmacy, dental and, to some extent, MS&E) are maintaining efficiency. Some contributors to maintained efficiency include negotiated administration costs, established fee grids, an integrated transaction system, and the availability of administrative data that can be used to clearly monitor and assess the efficiency of claims management for these benefit areas. For those benefit areas with less administrative consolidation (MT, vision care, STCIMHC), it is challenging to determine levels of efficiency, given incomplete administrative data on outputs that can be linked to costs. As such, there may be opportunities to consider greater administrative consolidation in some of these areas.

Recommendation 1

Review and streamline NIHB Program coordination of benefits procedures and practices with other publicly and privately funded supplementary health benefit plans to ensure clarity, minimize delays and facilitate client access to benefits.

The evaluation found that clients and partners experienced challenges with NIHB Program processes used to coordinate benefits with other publicly and privately funded supplementary health benefit plans. Ambiguity in coordination of benefit procedures is, in part, attributable to the lack of clarity of the NIHB Program as a ‘payer of last resort' among benefit plans, which may result in unnecessary delays and confusion for clients in accessing health benefits. Additional efforts by the Program to clarify and streamline coordination of benefits processes and communications would lead to improved clarity and potentially improved benefit and service delivery for First Nations individuals and Inuit.

Recommendation 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 MT benefit expenditures where feasible.

MT benefits, unlike other benefit areas, cannot be linked directly to an individual's health status and treatment needs. The MT benefit area is more a function of where individuals reside than of their health status and treatment needs. Similarly, cost drivers, suppliers and the nature of the services provided under the MT benefit area are relatively unique when compared to the other NIHB Program benefit areas, and possibly more challenging to consolidate administratively. These differences, combined with some of the data integrity challenges encountered in monitoring and evaluating MT benefits, indicate that potential alternative management models for the MT benefit area could be further explored.

Recommendation 3

Consider greater standardization of administrative data collection for MT, vision care and STCIMHC benefits across regions to improve monitoring and demonstration of Program-level outcomes, such as access (e.g., utilization rates, approvals, denials, appeals).

While the NIHB Program currently collects a large amount of data, there are some challenges with data integrity in three of the benefit areas, namely MT, vision care and STCIMHC benefits. There is a need to improve data collection across regions for these three benefit areas, so that the Program can monitor and demonstrate Program-level outcomes, related specifically to accessibility of benefits. Improving data collection for the MT benefit area is a priority, given its substantial growth combined with its significant proportion of total Program expenditures during the evaluation period.

Management Response and Action Plan
Evaluation of the 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

1.0 Evaluation Purpose

The purpose of the evaluation was to assess the relevance and performance of Health Canada's First Nations and Inuit Supplementary Health Benefits (Non-Insured Health Benefits) Program (NIHB Program) for the period of 2009-2010 to 2014-2015.

The evaluation was carried out in accordance with Section 42.1 of the Financial Administration Act, which requires that every department conduct, every five years, a review of the relevance and effectiveness of each ongoing program of grants and contributions. The Treasury Board of Canada's Policy on Evaluation (2009) defines such a review as a form of evaluation. The evaluation has been conducted to provide Health Canada's senior management, central agencies, Ministers, Parliamentarians and Canadians with a credible and neutral assessment of the ongoing relevance and performance (defined in terms of effectiveness, efficiency and economy) of the NIHB Program. More specifically, the evaluation will provide the Deputy Minister of Health Canada, as well as senior management, with reliable information to support decision-making regarding the achievements made by the Program in providing supplementary health benefits to registered First Nations individuals and recognized Inuit living in Canada.

2.0 Program Description

2.1 Program Context

Improving the health of Indigenous people is a shared responsibility among federal, provincial and territorial (F/P/T) governments, and First Nations and Inuit partners. Provinces and territories are responsible for the provision of insured health services to all eligible provincial and territorial (P/T) residents, including Indigenous people under the Canada Health Act. Health Canada supplements P/T health programs for First Nations individuals and Inuit based on policy, rather than legislation.

The NIHB Program is a long established national health benefits program administered through the First Nations and Inuit Health Branch (FNIHB) at Health Canada. Under its 1997 Cabinet-approved mandate, which builds from the 1979 Indian Health Policy, the NIHB Program provides eligible registered First Nations people (both on- and off-reserve) and recognized Inuit residents of Canada with supplemental health benefits in a manner that contributes to their improved health status.

A 2010 evaluation of the NIHB Program included the activities carried out during fiscal years 2005-2006 to 2008-2009. The 2010 evaluation found the Program to be relevant and responsive to the needs of its client population, to be aligned with federal government priorities and departmental strategic objectives, and to be consistent with federal government roles and responsibilities. The evaluation also determined that the Program had been effective in meeting its immediate and intermediate outcomes, had provided evidence-based benefits and responded to medically necessary interventions, and had addressed budgetary constraints while maintaining services.

2.2 Program Profile

As of March 2015, the NIHB Program is available to approximately 825,000 eligible registered First Nations individuals and recognized Inuit, regardless of their place of residence in Canada. The Program provides access to a range of medically necessary, health-related goods and services when these benefits are not otherwise provided to eligible clients through private or P/T programs. Program benefits include: pharmacy, medical supplies and equipment (MS&E); dental care; vision care; short-term crisis intervention mental health counselling (STCIMHC); and, medical transportation (MT) to access medically required health services not available on-reserve or in the community of residence.

The NIHB Program is a large program, which expended approximately $5.8 billion over the six-year period covered by this evaluation, and processes a significant number of health benefit claims annually. For example, over 17 million paid claims in pharmacy products, MS&E, and dental care benefits were processed in 2014-2015. In 2014-2015, the Program's human resources consisted of 449 full-time equivalents.

The objective of the NIHB Program is to provide non-insured health benefits to eligible First Nations people and Inuit in a manner that:

  • is appropriate to their unique health needs;
  • contributes to the achievement of an overall health status for First Nations people and Inuit that is comparable to that of the Canadian population as a whole;
  • is sustainable from a fiscal and benefit management perspective; and,
  • facilitates First Nations/Inuit control at a time and pace of their choosing.

Roles and Responsibilities

NIHB National Headquarters
NIHB national headquarters (HQ) is responsible for the development of national NIHB policies and procedures, ongoing expenditure analysis to support Program management, national Program communications aimed at clients and providers, National Indigenous Organizations (NIOs) partner engagement, support for the Health Information and Claims Processing Services (HICPS) system, development and maintenance of the national Medical Transportation Reporting System (MTRS) and the Medical Transportation Data Store (MTDS), and adjudication of claims for drugs with restrictions, as well as adjudication of all claims for dental services requiring predetermination and orthodontic benefit claims.

NIHB Regional Offices
NIHB representatives in Health Canada regional offices are responsible for operationalizing and managing claim payments, mostly for MT, vision care and STCIMHC benefits. These regional offices have established call centres to manage these benefits. Delivery of benefits is also facilitated through contribution agreements (CAs) between Health Canada regional offices and First Nations and Inuit organizations/communities that administer certain NIHB Program benefit areas to their community members.

First Nations and Inuit Communities
Health Canada has hundreds of CAs with First Nations and Inuit communities to deliver NIHB Program components (primarily MT benefits or 486 CAs in 2013-2014) directly to community members. In the case of the Mohawk Council of Akwesasne in Ontario and Québec and the Bigstone Cree Nation in Alberta, the CAs provide for the delivery of all NIHB Program components directly to their community members.

In addition, there are two Indigenous governments, the Nisga'a Lisims Government in British Columbia (BC) and the Nunatsiavut Government in Newfoundland and Labrador, that have assumed full responsibility for NIHB as part of their Self-Government Agreements.

Territories
Health Canada delivers the NIHB Program directly to clients in the Yukon. In Nunavut and the Northwest Territories, portions of the Program are administered via CAs with the territorial governments.

British Columbia
In 2013, the BC First Nations Health Authority (FNHA) assumed responsibility for the programs and services formerly delivered by Health Canada's FNIHB to First Nations clients residing in BC, in accordance with the British Columbia Tripartite Framework Agreement on First Nation Health Governance and related sub-agreements. For Inuit clients residing in BC, the NIHB Program continues to deliver supplemental health benefits.

Benefit Delivery

Benefits under the NIHB Program are delivered based on national policy frameworks, with delivery models that may be adapted to unique considerations in each region and community, including alignment with P/T practices. The delivery of the Program is complex, involving service arrangements with health care providers, territorial governments, the private sector and First Nations and Inuit organizations.

Approximately 60% of benefit expenditures are provided through service agreements with enrolled providers (e.g., dentists, pharmacists), most of which are administered via HICPS. Through this system, providers bill the NIHB Program directly for the payment of pharmacy, MS&E and dental claims. Most of the remaining benefits (i.e., MT, vision care, and STCIMHC), as well as portions of pharmacy and dental benefits, are delivered through Health Canada regional offices working with First Nations and Inuit organizations that administer the Program at the regional and community level, often through CAs.

The NIHB Program does not provide direct services to clients, rather it relies on pharmacists, dentists and other health service providers to deliver services to clients. Through HICPS, contracts and other mechanisms, the Program reimburses providers for the cost of eligible services. Most benefits are limited to medical necessity, while some services require prior approval for coverage, have set fees, and are subject to frequency limitations.

NIHB Program clients are not required to contribute financially to their benefits (as there are no co-payments or deductibles).

Program Delivery Models

In the Yukon, Alberta, Manitoba, Saskatchewan, Ontario, Québec and Atlantic regions, the following delivery models are used:

  • delivery directly from NIHB Program national HQ (pharmacy benefits, fee for service dental benefits and orthodontic benefits); and,
  • delivery primarily through the regions (MT, MS&E, vision care, and STCIMHC).

In Nunavut and the Northwest Territories, the NIHB Program is administered via a CA with the two territorial governments.

Integration with Other Programs

Apart from MT, all provinces and territories administer some form of supplementaryFootnote 1 benefit programs. These programs are generally targeted to seniors, or individuals in need of financial assistance, or those with specific health needs. In addition, employer-sponsored health benefit packages, as well as benefits purchased by individuals, are available through various private sector companies.

Health Canada documentation consistently positions the NIHB Program as a ‘payer of last resort', in accordance with the Program's Cabinet-approved mandate statement that indicates “in cases where a benefit is covered under another plan, NIHB will act as the primary facilitator in coordinating payment to ensure the other plan meets its obligations and that clients are not denied service”. For example, the NIHB Program Annual Report 2014/2015 indicates: “When clients are eligible for benefits under a private health care plan or a public health or social program, claims must be submitted to those plans and programs first before submitting them to the NIHB Program” (Health Canada, 2015, p. 9). Frameworks and guides for NIHB Program benefits state that Program clients are required to access any public or private health or P/T programs for which they are eligible, prior to accessing the NIHB Program.

2.3 Program Logic Model and Narrative

The longer-term expected outcome for the Program is that NIHB will be provided in a manner that contributes to the improved health status of First Nations individuals and Inuit. There are numerous outputs, as well as immediate and intermediate outcomes, needed to achieve this final goal. The outputs in the NIHB Program logic model are divided across five areas:

  • service provision (benefit delivery);
  • capacity building;
  • stakeholder engagement and collaboration;
  • data collection, analysis and surveillance; and,
  • policy development and knowledge sharing.

These outputs are expected to contribute to the following outcomes:

Immediate Outcomes

  • Access by eligible clients to nationally consistent, portable NIHB (appropriate to their unique health needs).
  • Evidence-based benefit policy and Program development (consistent with best practices of health service delivery).
  • Claims for NIHB processed efficiently (for both regional and centralized delivery).
  • Client and provider compliance with Program requirements.
  • Collaborative relations with partners and stakeholders to facilitate service delivery. 

Intermediate Outcome

  • NIHB Program managed in a cost-effective and sustainable manner.

The intended reach for the Program is the approximately 825,000Footnote 2 eligible First Nations individuals and Inuit in Canada who can receive benefits through the Program. An eligible recipient is identified as a resident of Canada and one of the following:

  • a registered Indian per the Indian Act;
  • an Inuk recognized by one of the Inuit Land Claim organizations; or,
  • an infant less than age one (1) year, whose parent is an eligible recipient.

The connection between these outputs and the expected outcomes is depicted in a logic model (see Appendix 2). The evaluation assessed the degree to which the defined outputs were being produced and outcomes were being achieved over the evaluation time frame.

2.4. Program Alignment Architecture and Resources

The NIHB Program is Program 3.2 under Health Canada's Program Alignment Architecture (PAA): Supplementary Health Benefits for First Nations and Inuit. The NIHB Program supports Health Canada's Strategic Outcome 3: First Nations and Inuit communities and individuals receive health services and benefits that are responsive to their needs so as to improve their health status.

The Program's financial expenditures for the years 2009-2010 through 2014-2015 are presented below (Table 1). Overall, the Program expended approximately $5.8 billion over six years. Most expenditures were for benefits (i.e., expenditures directly attributable to health service providers who provided health products and services to eligible clients) funded either directly through NIHB Program national HQ, regional offices or through CAs with communities.

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.

3.0 Evaluation Description

3.1 Evaluation Scope, Approach and Design

The scope of the evaluation covered the period from April 1, 2009 to March 31, 2015 and included all NIHB Program benefit areas. The one main area of exclusion was the assessment of any services transferred to the FNHA on July 2013 in accordance with the British Columbia Tripartite Framework Agreement on First Nation Health Governance and sub-agreements, which will be evaluated separately.

The evaluation issues were aligned with the Treasury Board of Canada's Policy on Evaluation (2009) and considered the five core evaluation issues under the two themes of relevance and performance (see Appendix 4)Footnote 3.  Corresponding to each of the core evaluation issues, specific questions were developed based on Program considerations and these guided the evaluation process.

An outcome-based evaluation approach was implemented to assess the Program's progress towards the achievement of its expected outcomes and whether there were any unintended consequences.

The analysis and reporting of findings occurred at a Program level for the core issues related to relevance. For the core issues related to Program performance, progress made towards the achievement of most of the expected immediate outcomes was analyzed according to each of the six specific benefit areas of the NIHB Program. Progress towards the longer-term expected outcome was assessed overall for the Program. In addition, it should be noted that some expected immediate and intermediate outcomes identified for the Program (e.g., efficiency, cost-effectiveness) are typically addressed under the core evaluation issue of Program efficiency and economy. For the current evaluation, the reporting of findings for these outcomes was placed under the performance core issue addressing efficiency and economy.

The Treasury Board's Policy on Evaluation (2009) also guided the identification of the evaluation design and data collection methods, so that the evaluation would meet the objectives and requirements of the policy. A non-experimental design was used, based on the evaluation matrix document, which detailed the evaluation strategy for this Program and provided consistency in the collection of data to support the evaluation. The evaluation followed the Agreement for FNIHB Departmental Evaluations developed between the Assembly of First Nations (AFN), Inuit Tapiriit Kanatami (ITK), FNIHB and the Evaluation Directorate Health Canada and Public Health Agency of Canada (now the Office of Audit and Evaluation), regarding the evaluation of FNIHB programming. This included consultation with AFN and ITK during the development of the evaluation methodology, during the development of the instruments used in First Nations and Inuit communities, at the presentation of  preliminary findings and, finally, during the crafting of the evaluation report.

Data for the evaluation was collected using various methods, which included a literature review, a document review, an administrative data review, key informant interviews, a survey of Inuit NIHB Program clientsFootnote 4, and a benchmarking study. Data were analyzed by triangulating information gathered from the different methods listed above. Multiple lines of evidence and triangulation were used to increase the reliability and credibility of the evaluation findings and conclusions.

For the purposes of the evaluation, the terms ‘partners' and ‘stakeholders' are used as follows:  partners are organizations that assist in the implementation of the Program or that have parallel programs that deal with health benefit provision for the client population or related issues (e.g., health care providers, territorial governments, NIOs such as AFN and ITK), while stakeholders receive the benefits or the effects of the Program (i.e., client population).

3.2 Limitations and Mitigation Strategies

Most evaluations face constraints that may have implications for the validity and reliability of evaluation findings and conclusions.

Table 2 outlines the limitations encountered during the implementation of the methods selected for this evaluation. Also noted are the mitigation strategies put in place to ensure that the evaluation findings can be used with confidence to guide Program planning and decision making.

Table 2:  Limitations, Impacts and Mitigation Strategies
Limitation Impact Mitigation Strategy

The online survey with Inuit clients distributed through Inuit organizations received very few responses (n=19 completed). Additionally, some of the administrative data analyzed for the evaluation was not able to disaggregate Inuit clients from all NIHB Program clients.

The Inuit client and community perspective was not obtained for the evaluation.

Where relevant, the report indicates when the findings do not include the perspectives of Inuit clients directly. In some cases, it was possible to consider information from additional sources, such as interviews with Inuit organizations and document reviews when available.

The evaluation team was unable to interview the number of First Nations community representatives initially planned, and the evaluation did not directly collect the perspective of First Nations clients on evaluation issues.

The perspectives of First Nations clients and community representatives may not be fully represented in the evaluation findings.

Interviews with NIHB Navigators were included to gain a proxy indication of First Nations clients and community members. Where possible, the report indicates when the findings do not include the perspectives of groups that are underrepresented in key informant interview findings.

The evaluation team was not able to complete the planned number of interviews with representatives from the three territories, as these representatives were unavailable for an interview.

There is limited information outlining the perspectives and opinions of territorial representatives and, in some cases, limited details on delivery and impacts of NIHB.

Where possible, the evaluation team collected information from documents and key informants from HQ and Health Canada’s Northern Region to gain a limited understanding of the main issues with respect to the NIHB Program in the territories.

Administrative data from transactional systems, which track operational expenditures, often exclude CAs and other contracts managed by the regions or have incomplete information.

Incomplete findings on operational expenditures in some benefit areas. Challenging to draw conclusions on areas such as efficiency and economy, for MT, vision care and STCIMHC benefit areas.

The analysis focused on the benefit areas that have more integrated systems and processes, namely pharmacy, dental and MS&E. Additionally, the calculation of utilization rates for the eligible population was adjusted to subtract two major population groups: the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta. This was done to account for limited information, available for the evaluation, on population groups served via CAs for dental and pharmacy benefits. Only these two groups were excluded, given that the characteristics of the CAs in other populations (i.e., only some portion of benefits covered) or the size of the population served via the CAs (i.e., small population groups) do not justify their exclusion from the population base for the analysis, as the expected impact is negligible.

Current FNHA beneficiaries in BC cannot be identified in the NIHB Program data prior to 2014. This is the result of FNHA having adopted a different model of client eligibility (based on residency in BC) in contrast with NIHB Program eligibility, which is based on registration (i.e., region of registration may differ from region of residency). The scope of the evaluation excluded all those activities, outputs and outcomes that are currently covered by the FNHA.

Data analysis may not accurately exclude all those individuals currently associated with the FNHA.

The number of clients associated with the FNHA was estimated by examining the number of FNHA clients as of March 31, 2015, including the distribution by age and gender, and then removing a similar proportion from the appropriate age and gender population brackets for years 2009 to 2013. FNHA-related expenditures and activities were also removed where possible.

Overall complexity of evaluating a large and intricate program such as the NIHB Program.

There are some evaluation questions and areas of scope that are not covered as in-depth as may have been warranted.

The evaluation team focused on addressing the evaluation questions based on available resources, strategically focusing efforts on understanding the limitations and challenges with the administrative data available for larger benefit expenditure areas (e.g., MT), using proxy or partial information where available, and investigating possible alternative data sources to evaluate the NIHB Program.

4.0 Relevance: Issue #1 – Continued Need for Program

Does the Program continue to address a demonstrable need?

The evaluation found that there continues to be a strong need for the supplementary health benefits delivered under the NIHB Program among First Nations individuals and Inuit. First Nations and Inuit populations' health needs associated with NIHB Program benefit areas remain numerous, diverse and complex. Rates of chronic and infectious disease continue to be significantly higher among First Nations individuals living on-reserve and Inuit populations when compared with the general Canadian population. Many First Nations individuals and Inuit continue to experience inequality in accessing health care due to social determinants of health, geographic and economic barriers, and concerns regarding cultural safety.

The NIHB Program is operating within the context of considerable and continuing health disparities between its eligible clients and the non-Indigenous population of Canada. The academic and grey literature available on the health status of First Nations and Inuit populations (see Appendix 1) outlines findings of significantly poorer overall health for these groups when considering various aspects, ranging from specific acute disease prevalence rates to broader measures of social determinants of health at the community level, such as housing conditions, access to health care and employment rates. The health-related needs of First Nations people living on-reserve are relatively well-studied and documented, due in large part to the multiple iterations of the First Nations Regional Health Survey (RHS), a self-reported survey within First Nations communities. The Aboriginal Peoples Survey (APS) in 2012 provides some health information for Inuit and First Nations people living off-reserve.

Some of the key findings from the evaluation that demonstrate the continued need for the supplementary benefits provided under the NIHB Program include:

  • Self-rated health status – According to the RHS 2008/10, 44% of First Nations adults living on-reserve rated their health as ‘excellent' or ‘very good' compared with 60% of the general Canadian population (First Nations Information Governance Centre, 2012). Per the 2012 APS, 45% of Inuit reported excellent or very good health, while the comparable figure for the total population of Canada was 63% (Wallace, 2014). The comparisons to the overall Canadian population should be qualified with the understanding that important health determinants, such as geographic location and socio-economic conditions, may not be comparable between these groups.

  • Chronic diseases – Rates of chronic disease experienced by First Nations and Inuit populations are greater than that of the general Canadian population. For example, age-standardized rates show the prevalence of diabetes was 17% among First Nations individuals living on-reserve, and 10% among First Nations individuals living off-reserve, compared to 5% in the non-Indigenous population. The age-standardized prevalence rate of diabetes in Inuit populations was comparable to the one seen in the general Canadian population (Public Health Agency of Canada, 2011). There is also evidence to suggest that the rates of Type 2 diabetes and related cardiovascular disease risk factors are increasing among Inuit (Château-Degat et al., 2010). Other chronic diseases where there continue to be noted disparities are: circulatory diseases (Health Canada, 2013), some cancers (Maar et al., 2013), respiratory conditions (Banerji et al, 2013; Crighton, Wilson, and Senécal, 2010), and musculo-skeletal disorders such as arthritis (Health Canada, 2013).

  • Infectious diseases – There continues to be a disproportionate burden of tuberculosis and other infectious diseases among First Nations people living on-reserve and Inuit populations. For example, tuberculosis rates among First Nations people living on-reserve were found to be 25 times higher than Canadian-born, non-Indigenous people, while rates among Inuit were 154 times higher (Health Canada, 2012a). Other infectious diseases that exhibit differential rates of infection include: giardiasis (1.6 times higher than the Canadian rate), hepatitis A (5.3 times higher), shigellosis (19.3 times higher) (Quiñonez and Lavoie, 2009), and sexually transmitted infections, such as chlamydia among youth (approximately 7 times higher) (Ning and Wilson, 2012), and HIV (new infection rate among Indigenous persons is about 3.6 times higher than among non-Indigenous persons) (Health Canada, 2012a).

  • Oral health – The RHS 2008/10 found that, among First Nations adults living on-reserve or in northern First Nations communities aged 20 years and over who had at least one natural tooth, more than half (57%) reported having at least one tooth with untreated decay (which is higher than the 19% in the total Canadian population) (First Nations Information Governance Centre, 2012). Similarly, data from clinical examinations carried out for the First Nations Oral Health Survey (FNOHS) provide evidence of unmet need for dental care among First Nations adults living in First Nations on-reserve communities. For example, eight in ten adults (83%) reported having some type of dental treatment need (First Nations Information Governance Centre, 2012). A high prevalence of reported caries was found among Inuit preschool-aged children in Nunavut (Pacey et al., 2010).

  • Mental health and addictions – According to the literature review, as a result of a history of colonization, isolation, poverty and language barriers, abuse of substances tends to be more common in northern and remote communities compared to southern and non-isolated communities. These northern communities are also more vulnerable to suicide and violence (Canadian Centre on Substance Abuse, 2014). Similarly, social, economic and historical determinants, such as residential school experiences and other forms of colonization, have led to socio-economic marginalization and intergenerational trauma, resulting in depression and other psychiatric disorders, and engagement in self-destructive behaviours (Halseth, 2013). Findings from the Truth and Reconciliation Commission of Canada (TRC) noted the importance of understanding and addressing issues of high rates of suicide and mental health afflicting Indigenous people in Canada (TRC, 2015).

  • Challenges with accessing health services – In addition to the disparities that exist for various health conditions between First Nations and Inuit populations compared with the general Canadian population, another major area of need for many First Nations individuals and Inuit is access to health services. First Nations individuals and Inuit in many communities experience challenges with access to health services for various reasons, which 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 navigating complex health systems, economic barriers, cultural barriers, and racism.

    The needs associated with MT range considerably from 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 living in remote/rural locations are required to travel away from their home communities, sometimes for extended periods of time, depending on treatments. According to FNIHBFootnote 5, most Inuit communities (over 90%) can be classified as remote-isolated or isolated, while approximately one-third of First Nations communities can be classified as semi-isolated, isolated or remote-isolated (Muttitt, Vigneault, and Loewen, 2004). In addition, in many jurisdictions, there has been an increased centralization of health services and closures of rural hospitals, contributing to an increased need to transport clients to services.

  • Defining and receiving health services in a culturally safe manner – According to the literature, there is a continuing need for First Nations individuals and Inuit to be able to define and receive health services in a culturally safe manner. This goes beyond the need for cultural sensitivity and cultural competence (which are also necessary) by directly addressing the power relations between service users and service providers (Allan and Smylie, 2015). This need was echoed in the various Calls to Action from the TRC (TRC, 2015) by indicating a need for increased funding of Indigenous health centres, recognizing the value of Indigenous healing practices and their use in the treatment of Indigenous patients, in collaboration with Indigenous healers and Elders, to increase the number of Indigenous professionals working in health care, and to provide cultural competency training for all health care professionals. Defining and receiving health services in a culturally safe manner also refers to recognizing the differences between Indigenous communities and groups, and actively working to eliminate the assumption that all Indigenous people have similar needs, preferences or approaches to understanding, maintaining and improving their health.

Is the Program responsive to the needs of its client population?

The NIHB Program responds to the need for health status parity for First Nations individuals and Inuit in relation to non-Indigenous Canadians by providing coverage for health benefits and services that may not be available to its clients in the absence of the Program. The Program-supplied benefits and services supplement those that are currently supplied to Canadians under the public P/T health insurance systems. Moreover, the Program responds to the need for equitable access to health services for First Nations individuals and Inuit by addressing some of the challenges and barriers through MT benefits.

In response to the need for First Nations individuals and Inuit to define and receive health services in a culturally safe manner, the NIHB Program provides opportunities for communities to directly deliver some benefits through CAs, funds First Nations NIHB Navigator positions, and works collaboratively at the national and regional levels with First Nations and Inuit communities and organizations.

Nonetheless, with regards to NIHB Program responsiveness to the needs of its client population, issues were raised by key informants with respect to coverage, particularly with respect to various allied health services/therapy services and benefits (such as massage therapy, physiotherapy, etc.).

Responding to the Need for Health Status Parity

The NIHB Program responds to the needs of First Nations individuals and Inuit by attempting to address the various health disparities that exist between the client population and non-Indigenous Canadians. This response is within the context of complex health needs, multiple contributing factors, and an array of partners involved in a variety of First Nations and Inuit health programming. The NIHB Program response is characterized as providing all eligible clients with coverage for supplemental health services and benefits that they would not necessarily be assured of receiving in the absence of the Program.

These services and benefits are considered supplemental to those Canadians would receive under the current public P/T health insurance plans. While key to achieving and maintaining health (e.g., medication, dental care), these are services and benefits that Canadians would generally obtain either by paying for them out of pocket, through a private insurance plan paid by the individual, or through a supplemental health insurance plan provided by some employers. For some specific populations of Canadians (e.g., seniors or those with low incomes), most provinces and territories have additional programs to provide a limited number of these benefits/services; however, NIHB Program clients are often excluded from these plans. Under the NIHB Program, all eligible clients are provided with supplemental benefits and access to services that are generally equivalent or surpass the benefits and services provided by the additional P/T programs for special populations, and are comparable in some benefit areas to a few of the supplemental health insurance plans provided by employers. For example, in terms of differences, plans for special populations and employer plans generally do not include MT benefits, and often require some level of co-payment.

Specifically, the NIHB Program responds to the areas of greatest health disparity in the following manner:

  • Self-rated health status – The NIHB Program can be considered one contributor to the continuum of services available to improve the health status and well-being of First Nations individuals and Inuit by providing benefits and access to services in various areas such as pharmacy, dental care, vision care, MS&E and STCIMHC. While the benefit coverage in these areas is somewhat comparable to, or surpasses, other supplemental benefit plans for special populations, partner organizations and NIHB Program representatives who were consulted for the evaluation believed that the Program would be more responsive to actual client needs related to health status if coverage was expanded to include allied therapies. It was suggested that coverage of some allied therapies viewed as preventative in nature, such as physiotherapy or massage therapy, could potentially contribute to a decreased use of other NIHB, reducing the need for pharmaceuticals to address pain. Examining the medical evidence on this subject was beyond the scope of the evaluation.
  • Chronic diseases – The NIHB Program responds to increased rates of various chronic diseases among First Nations individuals and Inuit through pharmacy, vision care and MS&E benefits, and by providing access to emergency treatment, physician diagnostic, and primary care treatment services via MT. Treatment of diseases, such as diabetes, circulatory diseases, cancer, respiratory conditions, and musculo-skeletal disorders, such as arthritis, usually require the extensive use of supplementary benefits, particularly in the areas of pharmacy and MS&E.
  • Infectious diseases – The NIHB Program's provision of pharmaceuticals and MT to receive medical treatment for infectious diseases can be considered a response to the increased rates of several of these diseases among First Nations individuals and Inuit. While the contributing factors to many of these diseases are well outside the scope of the Program, the Program is able to respond by providing access to treatment, and in some cases prevention, through pharmaceutical services.
  • Oral health –The NIHB Program responds to the need for improved oral health primarily by providing coverage for dental care services to its clients. While the services provided by the Program exceed or are comparable with programs for other special populations (these other programs often focus on emergency dental care only), partner organizations and NIHB Program representatives noted that better awareness and uptake of preventative oral health care is needed.
  • Mental health and addictions – The NIHB Program responds to the complex mental health- and addictions-related needs of First Nations individuals and Inuit through the provision of STCIMHC, pharmacy and MT benefits. As noted in the review of the STCIMHC benefit area under the AFN-NIHB Joint Review, this benefit is a component that addresses limited aspects of an extensive, complex First Nations mental wellness continuum that has been developed with culture as the foundation.

Responding to the Need for Equitable Access to Health Services

The MT benefit area is designed to address certain geographic challenges and changes in health systems, by facilitating transportation for Program clients to access suitable health services, and in some cases, transporting health professionals into communities to provide services to Program clients. As well, economic barriers are considered in the design of the MT benefit area by ensuring that, in addition to transportation costs being covered, lodging and meal allowances are provided. The Program contributes to addressing cultural concerns through the MT benefit area by including escorts for various circumstances, including language interpretation. Cultural concerns have also been considered in the design of the NIHB Program through the recent implementation of the First Nations NIHB Navigators to assist clients in understanding and accessing Program benefits.Footnote 6

Responding to the Need to Define and Receive Health Services in a Culturally Safe Manner

The NIHB Program responds in part to the need to define and receive health services in a culturally safe manner by working with First Nations and Inuit communities to have the communities directly deliver some NIHB Program benefits through CAs. In addition, there are efforts by Program representatives at the national and regional levels to work jointly with communities, Tribal Councils and NIOs to gather considerations and feedback on issues of Program design, coverage, etc.

Indigenous partners indicate that the collaborative nature of this work has recently been improving, as evidenced by amelioration in the responsiveness of the NIHB Program to understand and directly address the power relations that Indigenous organizations view as inherent to the relationship. Another important component of the NIHB Program that supports efforts in this area is the implementation of First Nations NIHB Navigators who assist clients in understanding Program policies and facilitate access to services. This has not yet been implemented for Inuit clients, but was in development (in collaboration with Inuit partner organizations) at the time this report was being prepared.

5.0 Relevance: Issue #2 – Alignment with Government Priorities

Is the Program aligned with federal government priorities?

The NIHB Program's objectives align with the federal government's stated priorities as outlined in Speeches from the Throne during the evaluation period, in particular the 2015 commitment to close gaps in health outcomes between Indigenous and non-Indigenous communities.

The 2015 Speech from the Throne, Making Real Change Happen, noted that “the Government will work co-operatively to implement recommendations of the Truth and Reconciliation Commission of Canada.”  Under the TRC, there are a number of relevant Calls to Action related to Indigenous health, five of which are directly addressed to the federal government. Specifically, Call to Action [19] states “we call upon the federal government, in consultation with Aboriginal peoples, to establish measurable goals to identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities…” (TRC, 2015, p. 322). In the 2013 Speech from the Throne, Seizing Canada's Moment: Prosperity and Opportunity in an Uncertain World, it was noted that “our Government will continue to work in partnership with Aboriginal peoples to create healthy, prosperous, self-sufficient communities" (p. 22). Key investments outlined in budget speeches during the period covered by the evaluation include 2011 and 2013 investments in First Nations and Inuit health designed to improve the quality of health services in First Nations communities and continued funding for the NIHB Program.

Is the Program aligned with departmental strategic outcomes?

The NIHB Program is aligned with Health Canada's Strategic Outcome #3: First Nations and Inuit communities and individuals receive health services and benefits that are responsive to their needs so as to improve their health status.

The NIHB Program aligns with Health Canada's Strategic Outcome #3: First Nations and Inuit communities and individuals receive health services and benefits that are responsive to their needs so as to improve their health status. The NIHB Program is Program 3.2: Supplementary Health Benefits for First Nations and Inuit within Health Canada's PAA. This strategic outcome is being implemented throughout FNIHB in accordance with the 2012 First Nations and Inuit Health Branch Strategic Plan: A Shared Path to Improved Health. The Plan outlines how Health Canada supports First Nations individuals and Inuit in achieving their health and wellness goals by working with First Nations, Inuit and P/T representatives to advance collaborative models of health and health care that support individuals, families and communities from a holistic perspective, while respecting jurisdictional roles and responsibilities. In fulfilling this strategic outcome, and in pursuit of the strategic goals outlined above, FNIHB provides a range of programs and services, including the NIHB Program, which is delivered in accordance with the Program's 1997 Cabinet-approved mandate.

6.0 Relevance: Issue #3 – Alignment with Federal Roles and Responsibilities

Is the Program aligned with federal roles and responsibilities?

There is no specific statutory authority for the provision of health care programs and services to First Nations individuals and Inuit by the Minister of Health. Health Canada, through FNIHB, provides health programs and services to First Nations individuals and Inuit based on departmental mission and Cabinet-approved mandate/policy statements. The Indian Health Policy (1979) outlines the goals of the federal government with respect to Indigenous health.

Improving the health of Indigenous people is a shared responsibility between F/P/T governments and Indigenous partners and reflects the legacy of historical program and funding decisions by successive governments intended to improve the health of First Nations and Inuit populations.

Most insured, primary care services to First Nations and Inuit populations are provided and funded by the P/T system, and are delivered in off-reserve hospitals and clinics. The health services funded by the federal government and provided through FNIHB are delivered primarily on-reserve, and are in the areas of health promotion and health education services, with some public health and environmental health services. The federal government also funds primary health care in remote and isolated First Nations communities, as well as home and community care, health promotion, and disease prevention programs to First Nations individuals and Inuit in the territories.

In the case of the NIHB Program, the federal government provides supplementary health benefits to all recognized Inuit and registered First Nations (both on- and off-reserve) residents in Canada, except where supplementary health benefits are delivered by an alternative model, as noted earlier in this report. In the Yukon, FNIHB delivers the full NIHB Program to eligible First Nations individuals, whereas in the Northwest Territories and Nunavut, the Program is delivered in partnership with the territorial governments.

There is no specific statutory authority for the provision of health care programs and services to First Nations individuals and Inuit by the Minister of Health. The Constitution Act, 1867 does not explicitly include ‘health' as a legislative power assigned either to Parliament (in Section 91) or to the provincial legislatures (in Section 92). Nonetheless, the Courts have confirmed that most aspects of the regulation of health care are within provincial jurisdiction. For example, provinces have extensive authority over public health as a local or private matter under s. 92(16) of the Constitution Act, 1867, over the regulation of medical professions as matters of property and civil rights under s. 92(13), and over hospitals under s. 92(7).

The federal government has the power to enact legislation in relation to certain health-related matters, which are ancillary to other federal powers, including federal spending powers (e.g., Canada Health Act) and criminal law powers (e.g., drugs, tobacco and hazardous product laws). In addition, the federal government has power to enact health legislation based on its “peace, order and good government” powers under s. 91 of the Constitution Act, 1867 (e.g., laws pertaining to quarantine and national emergencies). These laws would apply to First Nations individuals on- or off-reserve and Inuit. Additionally, the federal government may legislate in relation to First Nations individuals and Inuit because of its jurisdiction over “Indians, and Lands reserved for the Indians” in s. 91(24) of the Constitution Act, 1867.

In absence of specific statutory authority, legal authority for the provision of health care programs and services by the Minister of Health to First Nations individuals and Inuit is found in the following: Section 4 of the Department of Health Act, 1996 that provides for the general powers, duties and functions of the Minister, which extend to, and include, all matters relating to the promotion and preservation of the health of the people of Canada over which Parliament has jurisdiction. The specific health care programs and services provided by FNIHB are approved annually by means of the Appropriations Act, through which Parliament grants approval to the Minister for the budgets and objectives of specific programs (such as the NIHB Program). The Treasury Board provides authority for specific program activities.

The 1979 Indian Health Policy aims to improve the health status in First Nations and Inuit communities, yet also recognizes the interrelated nature of the Canadian health system. The goal of the Policy is to achieve an increasing level of health in Indigenous communities, generated and maintained by the communities themselves. This increasing level of health for Indigenous communities is considered to be built on three pillars: 1) community development, both socio-economic development and cultural and spiritual development, to remove the conditions which prevent the members of the community from achieving a state of physical, mental and social well-being; 2) the traditional relationship of the Indigenous people to the federal government, in which the federal government serves as advocate for the interests of communities to the larger Canadian society and its institutions, and promotes the capacity of Indigenous communities to achieve their aspirations; and, 3) the Canadian health system, composed of specialized and interrelated elements, which may be the responsibility of federal, provincial or municipal governments, Bands, or the private sector.

While the federal representatives who were interviewed for the evaluation presented the responsibility for First Nations and Inuit health services as shared, others tended to view responsibility as largely resting with the federal government. Specifically, interviews with First Nations communities and organizations, along with documentation from these organizations, reflect the views of First Nations partners and key informants that the benefits delivered under the NIHB Program are one component of what they view as First Nations people's Treaty Right to Health. As outlined in a NIHB Bulletin from the AFN (Summer 2015), the claim is made that these services are part of Treaty Right to Health, an inherent right to health based on Supreme Court rulings, and covered under the United Nations Declaration on the Rights of Indigenous Peoples.

Do the Program and its services duplicate or overlap with other programs?

The evaluation did not find any evidence of duplication with other programming at the federal level. Nonetheless, at the P/T level, the NIHB Program is viewed by provinces most often as a replacement rather than complementary to what is included in supplemental provincial health benefit coverage.

The evaluation examined other federal programming focused on the same clientele, and did not find any evidence of duplication. While there are complimentary services and initiatives being offered (e.g., the Children's Oral Health Initiative, the National Native Alcohol and Drug Abuse Program), there does not appear to be overlap in benefits or services.

According to interviews with regional NIHB Program representatives and partners, provinces generally consider First Nations and Inuit clients as ineligible for supplemental health benefit coverage under their various programs, given the coverage of these specific populations under the NIHB Program. As a result, the NIHB Program may act as a first payer for some of the supplemental benefits provided by provinces to other residents. The evaluation found that while some NIHB Program clients would likely be eligible for provincial supplemental health benefit programs (e.g., social assistance recipients), they are often deemed ineligible for these supplemental programs because they are eligible for NIHB Program coverage. In various jurisdictions, this practice has the effect of making the NIHB Program a ‘payer of first resort' among public plans, rather than of last resort.

There are a few exceptions where a province will cover some benefits, mostly when they are part of larger screening or public health initiatives (e.g., screening vision/hearing tests for young children, flu vaccinations) or through programming that targets specific segments of the population in certain provinces. In these cases, the province acts as a ‘payer of first resort'.

7.0 Performance: Issue #4 – Achievement of Expected Outcomes (Effectiveness) – Immediate Outcomes

The five expected immediate outcomes for the NIHB Program were identified as:

  • access by eligible clients to nationally consistent, portable non-insured health benefits (appropriate to their unique health needs);
  • evidence-based benefit policy and Program development (consistent with best practices of health service delivery);
  • client and provider compliance with Program requirements;
  • collaborative relations with partners and stakeholders to facilitate service delivery; and,
  • claims for NIHB processed efficiently (for both regional and centralized delivery).

The findings for the first three outcomes (i.e., Program access, evidence-based policy/Program development, and compliance with Program requirements) were analyzed according to each of the NIHB Program's six main benefit areas. The fourth immediate outcome (i.e., collaborative relations with partners/stakeholders) was analyzed at the Program level, given that many of the relations with partners and stakeholders cross multiple benefit areas. The findings for the fifth immediate outcome (i.e., efficiency of claims processing) were analyzed by benefit area and are presented under the core issue of performance related to demonstration of efficiency and economy. Similarly, the findings for the expected intermediate outcome of the Program being managed in a cost-effective and sustainable manner are also presented under demonstration of efficiency and economy.

The six benefit areas vary considerably by size according to expenditures. As illustrated in Table 3, for the six-year period covered by the evaluation, the pharmacy benefit area accounted for the greatest proportion of expenditures at 39%, or approximately $2.2 billion. The second largest area by expenditures was MT benefits at 34%, or approximately $1.9 billion, followed by the dental care benefit at 20%, or approximately $1.1 billion. The remaining three benefit areas are relatively small by comparison, together accounting for 7% of expenditures over the period of evaluation, or approximately $407 million combined.

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.

Do clients access pharmacy benefits?

The annual utilization rates across the period covered by the evaluation remained relatively constant, ranging from 63% to 66% of eligible clients who had at least one paid pharmacy claim within a given year, which equates to between 441,000 and 499,000 individuals each year.

The annual utilization rates among First Nations clients ranged between 64% and 67%. The utilization rate among Inuit clients was relatively stable between 45% and 46% during the same period.

Overall, there were very few denials in 2014-2015, with most pharmacy benefit claims paid (97%) and additional requests approved, including some open benefit requests, limited use benefit requests, and requests for benefits not listed (90%). The overall appeal rate was very low, with less than 0.01% of claims being appealed.

According to partners, the general awareness of pharmacy benefits among First Nations clients is relatively high, but detailed knowledge of specific coverage is lower, which could be expected among clients of most drug plans, whether in the private or public sectors. According to interviews with partners, overall awareness and accessibility to pharmacy benefits among First Nations clients improved during this period, perhaps in part as a result of the implementation of NIHB Navigators. The evaluation had limited data on issues and concerns with accessibility and awareness among Inuit clients, given challenges with some of the evaluation methods implemented (i.e., survey of clients, interviews with territorial representatives).

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.

Is Program and policy development for the pharmacy benefit area evidence-based?

The evaluation found that the pharmacy benefit area's policies and decision-making is evidence-based. The NIHB Program's participation in the F/P/T CDR Process, along with the establishment of the NIHB Drug and Therapeutics Advisory Committee (DTAC) and the NIHB Drug Exception Centre (DEC), contribute to the strong evidence-based approach regarding listing decisions, coverage policy development, and Program decision-making for pharmacy benefits.

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.

Are clients and providers in the pharmacy benefit area in compliance with Program requirements?

The pharmacy benefit area demonstrates client/provider compliance through various levels of audit.

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.

Do clients access MS&E benefits?

The annual utilization rates across the period covered by the evaluation remained constant, at approximately 7% of eligible clients who had at least one paid MS&E benefit claim within a given year, which equates to between 51,000 and 56,000 individuals each year.

The annual utilization rate among First Nations clients ranged from 7 % to 8%. The utilization rate among Inuit clients ranged from 5% to 6% during this period. The utilization rate is substantially higher among older clients (e.g., 28% for those 65-years and older in 2014-2015).

MS&E benefits are managed at the regional level, and data on approval rates and lower level appeals are not compiled at a national level for the benefit area. There are a small number of Level 3 appeals (on average, less than two per year).

Challenges and barriers to accessing MS&E benefits, as identified through interviews with partners and NIHB Program representatives, were related more to accessibility to health services and enrolled MS&E providers, rather than to accessing MS&E benefits through the Program.

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.

Is Program and policy development for the MS&E benefit area evidence-based?

The 2009 Provider Guide for Medical Supplies and Equipment (MS&E) Benefits and the 2010 Pharmacy and Medical Supplies and Equipment Benefit - Policy Framework outline the core objectives and processes for the MS&E benefit area. The evaluation found that the Provider Guide and the Policy Framework were updated on an ongoing basis throughout the evaluation period, with records of decisions and memoranda outlining updates and changes based on best practices, standards and evidence-based decision-making.

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.

Are clients and providers in the MS&E benefit area in compliance with Program requirements?

The MS&E benefit area demonstrates client/provider compliance through various levels of audit.

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.

Do clients access dental benefits?

The annual utilization rates for dental benefits remained relatively constant across the evaluation period, ranging from 35% to 38% of eligible clients who had at least one paid dental claim within a given year, which equates to between 249,000 and 288,000 individuals each year. The utilization rates for the NIHB Program's dental benefits are likely lower than overall dental care rates among the eligible population, given that some clients are accessing dental services through other programs (other FNIHB programming, provincial programs), services provided under CAs, contracted dentists serving remote communities, or via private insurance plans.

The annual utilization rate among First Nations clients ranged from 36% to 37% during the period covered by the evaluation. The utilization rate among Inuit clients ranged from 41% to 43%.

In 2014-2015, the approval rate for dental claims that did not require predetermination was approximately 90%. For those procedures where requests were made (e.g., Schedule B predetermination, additional consideration for Schedule A procedures), there was an overall approval rate of approximately 61%.

One challenge noted by partners for clients accessing the Program's dental benefits is the availability of dental care. This is being addressed in part through the Program by engaging contract dentists to provide services in remote and isolated communities (approximately 4% of expenditures in 2014-2015), and through the provision of MT benefits for those clients needing to travel to obtain dental care. Another issue raised was a lack of interest by some dentists in enrolling with the Program, as their preference is to ask the client to pay for services rather than seek reimbursement from the Program. This approach does not include any interaction between the private practice dental practitioner and the NIHB Program.

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.

Is Program and policy development for dental benefits evidence-based?

The evaluation found that the various policies guiding dental benefits are evidence-based. The Dental Benefit Policy Framework was updated during the evaluation period, and the dental services covered under the benefit area are reviewed on an ongoing basis using various sources of evidence, including consultations with dental associations and client organizations, results from trial projects and CADTH literature reviews. Updated policies are communicated through various channels.

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.

Are clients and providers of the dental benefit area in compliance with Program requirements?

The dental benefit area demonstrates client/provider compliance through various levels of audit.

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.

Do clients access MT benefits?

The evaluation focused on analyzing MT utilization rates in two regions, Manitoba and Saskatchewan, as a result of data limitations at the national level. There was considerable variability in the calculated utilization rates in Manitoba during the period covered by the evaluation, but this is likely more reflective of data entry practices rather than actual utilization rates. In 2014-2015, the year for which data entry was comparable, the utilization rate was approximately 19% in each of the two regions.

Interviews with partners highlighted the importance of the MT benefit area for clients, along with some reported challenges in accessing the benefit related to the timeliness of approvals and reimbursements, and issues related to variability in interpretation of the MT escort coverage policy in some regions.

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).

Is Program and policy development for the MT benefit area evidence-based?

The MT benefits facilitate access to health services that cannot be obtained in clients' communities. As a result, the evidence base required to develop coverage policy for this benefit area is substantially different from other medically-based Program benefit areas that use scientific evidence to guide activities towards specific desired health outcomes.

Interviews with regions and partners noted that improved administrative and operational data for the MT benefit area would assist in developing more detailed and accurate business cases and proposals for alternative MT delivery approaches at the community and regional levels, potentially contributing to increased efficiency.

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.

Are clients and providers for MT benefits in compliance with Program requirements?

Progress in ensuring client and provider compliance with NIHB Program requirements has been made over the six-year period covered by the evaluation. During most of this period, there was not a systematic, integrated audit program for the MT benefit area; however, there were both external and internal audits conducted on this benefit area.

The Office of the Auditor General (OAG) in 2015 noted that there were issues with documentation sufficiently demonstrating MT benefit administration according to selected principles from the MT Framework regarding the assertion of medical needs and confirmation of attendance. Health Canada responded to the recommendation by agreeing to modify its guidelines accordingly. From internal audits, there were recommendations calling for additional financial reporting from CA holders for MT benefits, and clarification of the claim verification process staff roles and responsibilities to ensure client and provider compliance. A follow-up internal audit in 2012 found that these recommendations had been addressed. Since 2014, the Program has had in place a contract to perform regional audits for the operationally managed MT benefits, and to date has completed 13 audits.

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.

Do clients access vision care benefits?

Annual utilization rates for vision care benefits are challenging to calculate given that the benefit is managed at the regional level, with regions using various vision care data systems for administrative data collection during the period covered by the evaluation. Based on data recently compiled by the NIHB Program, approximately 127,000 (2012-2013) to 132,000 (2014-2015) clients accessed vision care benefits (not including those receiving benefits under CAs). Blended two-year utilization rates for eyewear benefits for adults in this subgroup over a two-year period (2013-2014 to 2014-2015) ranged from 28% to 41%.

According to interviews with partners, the awareness of the NIHB Program vision care benefit among First Nations clients is relatively high. The evaluation did not find any large challenges noted with respect to clients accessing these benefits, although some coverage issues were noted in the areas of types of lenses covered (e.g., bifocals vs. progressives), frame costs covered, and requirements for contact lenses. It should also be noted that, according to Program representatives and subsequent to the evaluation period, the NIHB Program's vision care coverage has been updated to include coverage of progressive lenses.

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.

 Is Program and policy development for the vision care benefit area evidence-based?

The NIHB Vision Care Policy Framework was updated in 2012, along with a Vision Care Benefit Guide in 2013. The Framework indicated that the benefits and services are based on professional judgement, consistent with the current best practices of health services delivery and evidence-based standards of care.

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.

Are clients and providers of the vision care benefit area in compliance with Program requirements?

Progress in ensuring client and provider compliance with Program requirements has been made over the six-year period covered by the evaluation. Unlike the more centrally delivered NIHB Program benefits (i.e., pharmacy, dental and MS&E benefits), the vision care benefit area did not have a systematic, centralized audit program for most of the period covered by the evaluation (2009-2010 to 2014-2015). During this period, there was one internal audit conducted of the vision care benefit area. With respect to client and provider compliance, the audit found that the provider audit framework for vision care had not been fully implemented. As a result, in 2014, the Program implemented a rolling two-year schedule of audits for this benefit to be undertaken nationally. A new, nationally standardized vision care provider enrolment process was implemented in early 2015 to increase providers' understanding and compliance with Program requirements.

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 areaFootnote 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.

Do clients access STCIMHC benefits?

Utilization rates for STCIMHC benefits are challenging to calculate given the way the benefit is delivered (regionally and through CAs). Based on data recently compiled by the NIHB Program, approximately 10,000 clients accessed services through fee-for-service arrangements in 2014-2015, which accounted for approximately 70% of STCIMHC benefit expenditures.

Partners indicated that client awareness of STCIMHC benefits is low, but did not indicate any large challenges in accessing the benefit.

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.  

Is Program and policy development for the STCIMHC benefit area evidence-based?

The STCIMHC Policy Framework and Benefit Guide were updated in 2013. The Guide references that evidence-based standards and best practices are used in coverage policy development related to the STCIMHC benefit area. Prior approval is not required for the initial assessment, but must be obtained for coverage of ongoing treatment. The services of provincially-regulated mental health professionals covered under this benefit are implemented as a short-term bridge to longer-term treatment, as required.

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.

Are clients and providers for the STCIMHC benefit area in compliance with Program requirements?

Progress in ensuring client and provider compliance with Program requirements has been made over the six-year period covered by the evaluation. Unlike the more centrally delivered NIHB Program benefits (i.e., pharmacy, dental, and MS&E benefits), the STCIMHC benefit area did not have a systematic, centralized audit program for most of the period covered by the evaluation (2009-2010 to 2014-2015). During this period, there was one internal audit of the STCIMHC benefit area in 2014. With respect to client and provider compliance, the audit found that the provider audit framework for STCIMHC had not been fully implemented. As a result, in 2014, the Program implemented a rolling two-year schedule of audits for this benefit, to be undertaken nationally. A new, nationally standardized STCIMHC provider enrolment process was implemented in early 2015 to increase providers' understanding and compliance with Program requirements.

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

How has collaboration impacted service delivery?

While NIHB Program representatives' collaborations with various partners are seen to be improving, there are some challenges with respect to coordination and collaboration that are impacting Program service delivery. These challenges are likely contributing to other identified issues, such as client awareness of specific coverage and access concerns reported by some stakeholders for some benefit areas. Despite these challenges, significant proportions of dental and pharmacy claims were coordinated with third-party payers (ranging from 9% to 13%, depending on the year and benefit area).

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.

8.0 Performance: Issue #4 – Achievement of Expected Outcomes (Effectiveness) – Longer-term Outcomes

Does the NIHB Program contribute to the improved health status of its clients?

As noted in the FNIHB Strategic Plan, the overall health status of First Nations and Inuit populations remains below that of the general Canadian population, as measured by most major indicators of health. Given that these discrepancies “…are rooted in a range of historical, political, cultural, geographical and jurisdictional factors” (Health Canada, 2012d) and the multitude of factors affecting the health status of these populations, it remains challenging to specifically isolate the impact of the NIHB Program. Nonetheless, the evaluation found evidence of logical links between the evidence-based benefits covered by the NIHB Program and their contributions to improved health among First Nations and Inuit clients in the longer term.

The 2012 FNIHB Strategic Plan outlines how the overall health status of First Nations individuals and Inuit remains lower than that of other Canadians, and how many of the discrepancies “…are rooted in a range of historical, political, cultural, geographical and jurisdictional factors” (Health Canada, 2012d). Combined with an understanding that health status is multi-dimensional, with various determinants, it is challenging to identify specific impacts from a single program. Within this context, the evaluation drew logical links between the NIHB Program and its likely contributions to health status.

The evaluation undertook a brief scan of clinical practice guidelines and directives from various organizations that govern health professionals involved in the benefit areas under the NIHB Program. The purpose of this scan was to document a potential link between NIHB and improved health status of First Nations and Inuit clients. The assumption was that if clinical practice guidelines and directives are based on evidence, with scientific links to improved health outcomes for populations, then NIHB following these guidelines could be considered to contribute to the improved health status of First Nations individuals and Inuit, assuming clients utilize the benefits as required. The main findings from this scan were that almost all guidelines and standards reviewed indicated the importance of scientific evidence-based directives. This indicates that professionals providing services under the NIHB Program are following evidence-based guidelines and are thus contributing to improvements in health status. It was noted that there are not always ‘national’ level standards or guidelines for many of the medical professions, given that the regulatory process for many of these is at the P/T level.

Overall, respondents during key informant interviews noted that there was a link between the NIHB Program and the health status of its client population. Although many of the health status markers (e.g., chronic disease rates) had not improved over the period covered by the evaluation, interviewees noted that without the NIHB Program, many clients would not have been able to access supplementary benefits, and their health conditions would have deteriorated further. Key informants also indicated that while the Program was contributing to improved health status, this contribution varied according to levels of awareness and accessibility, and the diverse needs of the client population.

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

Are claims processed efficiently?

While not a direct measure of efficiency, Program expenditure increases during the period covered by the evaluation were in line with the proportional increases in eligible population and number of claims paid. Overall, the annual expenditure growth rate for the NIHB Program was 3% to 5%, resulting in an overall growth rate of approximately 20% across the six-year period covered by the evaluation (2009-2010 to 2014-2015). In comparison, the eligible population for the NIHB Program experienced a 16% overall growth during the same period. Similarly, the number of paid claims processed in the two centrally managed benefit areas of pharmacy and dental (together accounting for approximately 60% of expenditures), increased by approximately 36% and 16% respectively.

The evaluation found that administrative cost per claim for pharmacy and dental benefits remained constant across the evaluation period, pointing to maintained efficiency. This is primarily driven by fixed costs per processed claim, which are negotiated at different rates for electronic versus paper-based claims. The average dental claim processing cost suggests some continued reliance on paper records, which may be impacting efficiency. This reliance on paper records may be a function of provider choice and/or infrastructure available to providers in some remote areas. It was also found that the ratio of administrative costs to total expenditures for the NIHB Program was low when compared to other plans, and certainly within the range of 4% to 12% identified in the benchmarking exercise. Various policies and agreements had been implemented during the period covered by the evaluation to reduce costs, such as short term dispensing.

With respect to benefit expenditures, STCIMHC experienced the largest growth (32%) followed by MT (27%), dental (21%), vision care (18%) and pharmacy (12%, including MS&E) benefits. Cost per claim and per capita cost can be readily determined for pharmacy, dental and MS&E benefits using available HICPS data. Nonetheless, the data for the MT, vision care and STCIMHC benefit areas are incomplete and are drawn from different information technology (IT) systems in a form that is challenging to analyze in the same manner. As such, it was not possible to determine if the cost per client or cost per claim had increased in these benefit areas across the period of the evaluation.

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 ExpendituresFootnote 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

The number of claims per major benefit area increased over the evaluation period (36%, 20% and 16% for pharmacy, MS&E and dental claims, respectively).

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

Administrative cost per claim for pharmacy and dental benefits remained constant across the evaluation period pointing to maintained efficiency. This is primarily driven by fixed costs per processed claim, which are negotiated at different rates for electronic versus paper-based claims. The average dental benefit claim processing cost would indicate that a significant proportion of claims are handled in hard copy, which is less efficient than electronic processing. Data for MS&E, while showing a considerable increase, were deemed unreliable.

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

The ratio of administrative costs to total expenditures ranged from 3% to 4% during the period of evaluation. Overall, compared with other plans, the ratio of administrative costs to total expenditures for the NIHB Program appeared to be low.

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 ExpendituresFootnote 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

Is the Program better able to evaluate benefit management and predict/respond to new/changing cost pressures?

The NIHB Program has implemented detailed processes and systems to monitor expenditures on a monthly and quarterly basis for most benefit areas. This contributes to the Program having the capacity to track and quickly update within-year budgets and make adjustments as required. The Program has tended to operate within a -2% to 6% variance from budgeted or forecasted expenditures over the period covered by the evaluation. The evaluation found that accurate forecasting beyond a one-year time frame was 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 that considers cost drivers and combines this information with historical expenditure patterns across the specific benefit areas.

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 periodsFootnote 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.

Is the Program managed in a cost-effective and sustainable manner?

The NIHB Program experienced an average annual expenditure growth rate of approximately 4% across the period of the evaluation, which is comparable to the growth rates of health public expenditures, according to Canadian Institute for Health Information (CIHI). The ratio of administration costs to benefit expenditures for the NIHB Program was assessed at approximately 3% in 2014-2015. This ratio is in the low end of the range, when compared with various private sector plans that reported variability in administrative costs according to plan size, complexity and delivery.

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 

How does the Program compare with similar publicly/privately funded plans?

In comparison with other plans examined for the evaluation, the NIHB Program is unique in not requiring co-payment. The NIHB Program's coverage of pharmacy, MS&E and vision care benefits is comparable to that provided by other publicly funded plans. Nonetheless, these plans are often restricted to specific groups considered to be vulnerable populations (e.g., social assistance recipients, people with disabilities, seniors, children), and are not available to the general Canadian population. The NIHB Program's dental benefits coverage is generally superior to that found among other publicly funded plans. The Program's approach to processing claims is similar to that of many other plans, with increasing use of electronic claim submission and built-in audit and approval algorithms. It is challenging to compare NIHB Program coverage with private plans, given the large variation among the latter.

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.

10.0 ConclusionsFootnote 19

10.1 Relevance Conclusions

Continued Need

There is a strong and continued need for the NIHB Program, given the health disparities faced by First Nations and Inuit populations when compared to non-Indigenous Canadians. The Program responds to identified health needs by providing benefits and services that may not be available to clients in its absence.

In the absence of the Program, most members of the eligible population would be without key supports, benefits and services that they require to improve and/or maintain their health status. Given the high rates of chronic and acute diseases among First Nations and Inuit populations, combined with the ongoing challenges of accessing culturally safe health care services and the socio-economic conditions for many communities, the services and benefits provided under the NIHB Program are an essential component of ongoing efforts to diminish substantial health disparities with the rest of Canadians that currently exist for First Nations individuals and Inuit.

Alignment with Government Priorities

The NIHB Program clearly aligns with key federal government priorities, as well as Health Canada's strategic outcomes.

Alignment with Federal Roles and Responsibilities

Health Canada, through FNIHB, provides health programs and services to First Nations individuals and Inuit based on departmental mission and Cabinet-approved mandate/policy statements. Improving the health of Indigenous people is a shared responsibility between F/P/T governments and Indigenous partners. A key guiding principle in situations where benefits are covered under another plan is to have the NIHB Program act as a primary facilitator in coordinating payments, in order to ensure that the other plan meets its obligations and that clients are not denied service.

10.2 Performance Conclusions

Achievement of Expected Outcomes (Effectiveness)

Clients are accessing the NIHB Program with utilization rates that have remained relatively constant throughout the period covered by the evaluation, for those benefit areas that could be assessed through administrative data (i.e., pharmacy, dental and MS&E benefit areas). The Program provided more than 825,000 eligible clients with access to benefits in 2014-2015. During this same year, approximately three-quarters (72%) of eligible clients had received at least one pharmacy, dental and/or MS&E benefit. The pharmacy benefit area had the highest annual utilization rate ranging from 63% to 66% of eligible clients, who had at least one paid pharmacy claim within a given year (between 441,000 and 499,000 individuals each year). This was followed by the dental benefit area at 35% to 38% of eligible clients (between 249,000 and 288,000 individuals each year), and the MS&E benefit area at 7% of eligible clients (between 51,000 and 56,000 individuals each year).

Some clients accessing NIHB Program benefits encountered various challenges and barriers. Of the challenges cited for each of the benefit areas, many were related to issues of awareness of coverage inclusions/exclusions, rather than accessibility of a benefit. Challenges related to coordination of benefits between the NIHB and provincial programs were noted as an example of an issue that is within the purview of Health Canada to adjust. The funding of NIHB Navigator positions, who assist clients in accessing NIHB Program benefits, has helped with coordination.

Decisions and policies related to pharmacy benefits are the most highly evidence-based, with dental and MS&E benefit decisions and policies actively using and integrating scientific evidence. The nature of the decisions required for each benefit area differ, with these three areas (pharmacy, dental, MS&E) being most closely reliant on current scientific evidence to effectively administer benefits. Administrative data, such as claims-level utilization data, were found to be incomplete in some benefit areas. Such challenges reduce the Program's ability to analyze these data and use the results to inform planning, policy development, and Program adjustments. This is particularly the case in the MT benefit area, a significant portion of which is managed through CAs.

Compliance is effectively monitored for three of the six benefit areas: pharmacy, dental and MS&E. The other three benefit areas, while not having a systematic and centralized audit program, have had internal and/or external audits during the period covered by the evaluation. The audits have resulted in recommendations for improvements in assuring client and provider compliance. The Program has taken steps to address the various recommendations (e.g., regional MT audits, national provider enrollment processes for vision care and STCIMHC).

Overall, the demonstration of expected outcomes is hampered by administrative data issues for some benefit areas (e.g., MT, STCIMHC, vision care), particularly related to data completeness and consistency. The delivery of two of the larger benefit areas (pharmacy, dental) is largely done from national HQ, which contributes to a more systematic collection of administrative data supporting measurement and ongoing monitoring of outputs and outcomes. While MT benefits account for approximately one-third of Program expenditures, incomplete administrative data present a challenge to systematically measure and monitor outputs and outcomes.

Demonstration of Efficiency and Economy

The NIHB Program is large and complex, with multiple benefit areas, various delivery systems, and is subject to important cost drivers that can be volatile and are, for the most part, beyond the control of the Program. These cost drivers have the potential of placing significant pressures on expenditures and contribute to the challenges in managing such a large and complex Program. Despite this context, during the period covered by the evaluation, the Program managed to maintain overall expenditure growth to within the range of overall eligible population growth.

Specific indicators of efficiency, such as administrative costs per claim, demonstrate that the benefit areas with greater administrative consolidation (pharmacy, dental and, to some extent, MS&E) are maintaining efficiency. Some contributors to maintained efficiency include negotiated administration costs, established fee grids, an integrated transaction system, and the availability of administrative data that can be used to clearly monitor and assess the efficiency of claims management for these benefit areas. For those benefit areas with less administrative consolidation (MT, vision care, STCIMHC), it is challenging to determine levels of efficiency, given incomplete administrative data on outputs that can be linked to costs. As such, there may be opportunities to consider greater administrative consolidation in some of these areas.

11.0 Recommendations

Recommendation 1

Review and streamline NIHB Program coordination of benefits procedures and practices with other publicly and privately funded supplementary health benefit plans to ensure clarity, minimize delays and facilitate client access to benefits.

The evaluation found that clients and partners experienced challenges with NIHB Program processes used to coordinate benefits with other publicly and privately funded supplementary health benefit plans. Ambiguity in coordination of benefit procedures is, in part, attributable to the lack of clarity of the NIHB Program as a ‘payer of last resort’ among benefit plans, which may result in unnecessary delays and confusion for clients in accessing health benefits. Additional efforts by the Program to clarify and streamline coordination of benefits processes and communications would lead to improved clarity and potentially improved benefit and service delivery for First Nations individuals and Inuit.

Recommendation 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 MT benefit expenditures where feasible.

MT benefits, unlike other benefit areas, cannot be linked directly to an individual’s health status and treatment needs. The MT benefit area is more a function of where individuals reside than of their health status and treatment needs. Similarly, cost drivers, suppliers and the nature of the services provided under the MT benefit area are relatively unique when compared to the other NIHB Program benefit areas, and possibly more challenging to consolidate administratively. These differences, combined with some of the data integrity challenges encountered in monitoring and evaluating MT benefits, indicate that potential alternative management models for the MT benefit area could be further explored.

Recommendation 3

Consider greater standardization of administrative data collection for MT, vision care and STCIMHC benefits across regions to improve monitoring and demonstration of Program-level outcomes, such as access (e.g., utilization rates, approvals, denials, appeals).

While the NIHB Program currently collects a large amount of data, there are some challenges with data integrity in three of the benefit areas, namely MT, vision care and STCIMHC benefits. There is a need to improve data collection across regions for these three benefit areas, so that the Program can monitor and demonstrate Program-level outcomes, related specifically to accessibility of benefits. Improving data collection for the MT benefit area is a priority, given its substantial growth combined with its significant proportion of total Program expenditures during the evaluation period.

Appendix 1 – Logic Model

Target Group

Registered First Nations individuals and recognized Inuit living in Canada

Themes

Service Provision (benefit delivery)

Capacity Building

Stakeholder Engagement and Collaboration

Data Collection, Analysis and Surveillance

Policy Development and Knowledge Sharing

Outputs
  • Clients receive needed health benefits (pharmacy, MS&E, dental care, MT, vision care, STCIMHC)
  • Benefits provided/delivered according to NIHB Program policy
  • Benefit claims processed
  • CAs
  • Co-management arrangements
  • Support for community health planning/priority setting
  • Client communications; stakeholder awareness and input regarding Program policy
  • Information sessions, workshops and community visits
  • Joint projects (e.g., consolidated CAs, work plan, working groups, etc.)
  • Data capture and systems (HICPS, SVS, MTRS/MTDS)
  • Trend and cost analysis/expenditure forecasts
  • Surveillance/client safety analysis and measures
  • Provider Audit Program
  • Reviews/evaluation
  • Program policies/eligibility criteria
  • Cost-effective and evidence-based benefit policies/frameworks
Immediate Outcomes

Access by eligible clients to nationally consistent, portable NIHB (appropriate to their unique health needs)

Evidence-based benefit policy and Program development (consistent with best practices of health service delivery)

Claims for NIHB processed efficiently (for both regional and centralized delivery)

Client and provider compliance with Program requirements

Collaborative relations with partners and stakeholders to facilitate service delivery

Intermediate Outcome

NIHB Program managed in a cost-effective and sustainable manner

Longer-term Outcome

NIHB provided in a manner that contributes to improved health status of First Nations individuals and Inuit

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.

Appendix 3 – Evaluation Description

Evaluation Scope

The scope of the evaluation included all the activities of Health Canada's First Nations and Inuit NIHB Program. NIHB Program benefits include: pharmacy, MS&E, dental care, vision care, STCIMHC, and MT to access medically required health services not available on-reserve or in the community of residence. The scope of the evaluation did not include any of the services provided by BC's FNHA in accordance with the British Columbia Tripartite Framework Agreement on First Nation Health Governance and sub-agreements, which will be evaluated separately. The period covered by the evaluation included activities from April 2011 to March 2016. Data collection, analysis and reporting activities spanned the period from March 2015 to June 2017.

Evaluation Issues

The specific questions used in this evaluation were based on five core issues. These are noted in Table 1 below. Corresponding to each of the core issues, evaluation questions were tailored to the program and guided the evaluation process.

Appendix 3 – Table 1:  Core Evaluation Issues and Questions
Core Issues Evaluation Questions
Relevance

Issue #1: Continued need for Program

Assessment of the extent to which the Program continues to address a demonstrable need and is responsive to the needs of Canadians.

  • Does the Program continue to address a demonstrable need?
  • Is the Program responsive to the needs of its client population?

Issue #2: Alignment with government priorities

Assessment of the linkages between program objectives and (i) federal government priorities and (ii) departmental strategic outcomes.

  • Is the Program aligned with federal government priorities?
  • Is the Program aligned with departmental strategic outcomes?

Issue #3: Alignment with federal roles and responsibilities

Assessment of the role and responsibilities for the federal government in delivering the program.

  • Is the Program aligned with federal roles and responsibilities?
  • Do the Program and its services duplicate or overlap with other programs?
Performance (effectiveness, efficiency and economy)

Issue #4: Achievement of expected outcomes (effectiveness)

Assessment of progress toward expected outcomes (including immediate, intermediate and ultimate outcomes) with reference to performance targets and program reach, program design, including the linkage and contribution of outputs to outcomes.

  • Do clients access the Program?
  • Is Program and policy development evidence-based?
  • Are clients and providers in compliance with Program requirements?
  • How has collaboration impacted service delivery?
  • Does the Program contribute to the improved health status of its clients?
  • Have there been any unintended consequences or challenges experienced in the delivery of the Program?

Issue #5: Demonstration of efficiency and economy

Assessment of resource utilization in relation to the production of outputs and progress toward expected outcomes.

  • Is the Program using its existing resources optimally?
  • Has the Program produced its outputs and achieved its outcomes in the most economical manner?
  • How and in what ways can economy and/or sustainability be improved?
  • Is performance data collected and used for decision-making?

Data Collection and Analysis Methods

The evaluation methodology was based on multiple lines of evidence. It included a literature, document, and administrative data review, a survey, key informant interviews, and a benchmarking study. Data were analyzed by triangulating information gathered through each of these methods. This included:

  • a systematic compilation, review and summarization of data to illustrate key findings;
  • a compilation and analysis of quantitative data obtained from the Program's databases, followed by validation from Program representatives; and,
  • a thematic analysis of qualitative data.

A summary of the data collection methodology and its intended contribution to the evaluation process is provided in the following sub-sections.

Literature, Document and Administrative Data Review

Method details:

  • Environmental scan of relevant sources linked to the Program area, together with a review of documents/files and databases provided by the Program and identified during the evaluation through other methods (e.g., key informant interviews).

Sources:

  • Scientific journals, grey literature, Treasury Board submissions, Memoranda to Cabinet, public opinion research reports, previous performance, evaluation and audit reports, policy documents, budget and expenditure information, performance measurement data reports, annual progress reports, grants and contributions files, financial and non-financial databases, and administrative records specific to the evaluation questions.

Intended use:

  • Provide background information on the history and objectives of the Program, as well as progress towards the achievement of intended outcomes.
  • Use as key source of qualitative and quantitative information.
  • Provide insights into any important shifts/changes that have occurred during the life of the Program.

Survey

Method details:

  • Self-administered, bilingual, web-based survey piloted prior to dissemination.
  • Survey guides tailored to Program clients.
  • Total responses: 27.

Target:

  • Program stakeholders (i.e., registered First Nations individuals and recognized Inuit residents in Canada receiving services from the NIHB Program).
  • Based on interest from regional Inuit organizations, the survey targeted Inuit residing in Nunavut, and Inuvialuit.
  • Responses: 19 surveys completed; 8 partials.

Intended use:

  • Assess client population perspectives on Program delivery.
  • Assist in further understanding the information gathered from other lines of evidence and provide additional context.

Key Informant Interviews

Method details:

  • Guided interviews conducted in-person and/or via telephone.
  • Interview guides tailored to the different target audiences.
  • Total responses: 42.

Target:

  • Program representatives: 7 at headquarters, 7 regional.
  • Partners: 3 National Indigenous Organizations, 2 representatives from territorial governments involved in CAs, 4 First Nations and Inuit organizations that administer the NIHB Program directly at the community level, and 10 health care service providers.
  • Stakeholders: 9 NIHB Navigators (proxy for First Nations clients).

Intended use:

  • Assist in further understanding the information gathered from other lines of evidence and provide additional context.

Benchmarking

Method details:

  • Environmental scan, data reviews and guided interviews conducted in-person or via telephone.
  • Several private and public plans analyzed to have access to richer data for qualitative analysis.
  • Benefit areas for comparison included pharmacy, dental, MS&E, MT and vision care.
  • Emphasis on a qualitative, comparative analysis of cost drivers.
  • Focus on a qualitative assessment of business practices, service standards and performance measurement approaches in the industry.

Sources:

  • Documentation published by private, non-profit, and public sector providers on their plans, benefits, and business practices.
  • Documentation from previous benchmarking exercises conducted for the NIHB Program.
  • Academic and grey literature.
  • Publicly available information on large public sector plans to complement information obtained via interviews.
  • Information from professional associations.
  • Nine interviews with twelve individuals from private sector/non-profit providers, public sector providers, industry experts/representatives from health insurance associations, and experts in eHealth.

Intended use:

Contribute to the identification of best practices, lessons learned, as well as alternatives that could be applied to the NIHB Program.

  • Identify similarities and differences with other publicly/privately funded plans, and reasons for the differences.

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