Health — Issue No. 4 — Friday, December 13, 2013 (HTML)

Present: Norm Letnick, MLA (Chair); Judy Darcy, MLA (Deputy Chair); Donna Barnett, MLA; Dr. Doug Bing, MLA; Katrine Conroy, MLA; Sue Hammell, MLA; Linda Larson, MLA; Richard T. Lee, MLA; Jane Jae Kyung Shin, MLA

2. The following witnesses appeared before the Committee and made a presentation titled Health System Overview and answered questions:

• Heather Davidson, Assistant Deputy Minister, Health Services Planning and Innovation Division

4. The following witnesses appeared before the Committee and made a presentation titled BC Drug Review Process - Overview and answered questions:

• Barbara Walman, Assistant Deputy Minister, Medical Beneficiary and Pharmaceutical Services Division

The following electronic version is for informational purposes only.
The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH


CONTENTS
Page
Ministry of Health: Health System Overview	85
H. Davidson
Ministry of Health: B.C. Drug Review Process Overview	98
B. Walman
M. Moneo

N. Letnick (Chair): Good Friday morning, everyone. Welcome to Friday the 13th, December 13, 2013. That's double 13. I don't know. This is not a good start. The Select Standing Committee on Health.

It's a pleasure to have all of you here and those of you who are on the phone. I understand Richard and Jane are on the phone, and I'm sure we'll get a few more at some point as the flights become clearer. For those that are trying to get here via Helijet, apparently it's fogged in, but they are making their way to YVR.

The Select Standing Committee on Health today is going to be looking at an overview of the health care system provided to us by Ministry of Health staff Heather Davidson, assistant deputy minister of health services planning and innovation division, and Nick Grant, executive director of operational and strategic planning, both of whom are experts in their fields.

I understand the deputy minister is feeling ill, so he could not make it today. Please pass on the committee's best wishes for him. Hopefully, when we do see him in the new year, he's 100 percent. That would be great.

Following the first item, the health system overview, from eight till 10:30, we'll be looking at the B.C. drug review process. This will be from 10:30 till noon. At that point I'll introduce Barbara, who will be talking to us on that issue.

Without any further ado, I don't see there's a need for a motion to approve the agenda, Susan, so we'll just go right into it.

H. Davidson: Thank you very much for inviting us here today. I do bring regrets from our deputy minister. He has one of those conditions that the health care system, unfortunately, can't help him with — a virus — and we're probably all glad that he's at home recuperating and not here sharing his joy. He did very much want to be here and just sent his regrets.

As Norm mentioned, this is very much an overview of the health care system and getting in at a fairly high level to some of the challenges and work we're doing at the ministry, with our health partners, to address some of the issues.

As you know, the health system is large and complex. There is very much activity going on. We won't go into a lot of depth on issues, but if there are some issues you would like to go into in deeper detail, we would be happy to come back and present on any particular topic that is of interest to you beyond what we can cover in today's session.

N. Letnick (Chair): With that, what I would ask is that members on the telephone and here in the committee room withhold their questions until you've finished your first presentation, and then we'll do some Q and A at that point. It will also make it easier to manage, instead of people on the phone trying to jump in through the conversation. So grab your pens, and write down your questions.

If we have time today in the allotted slot and they have a question on something that's not covered by you, then we'll offer that opportunity, as well, to them and get into that discussion. You might have to wing it a little bit at that point, but I'm sure you can do it.

H. Davidson: I'm happy…. There are a lot of things we can answer questions on, but I know that within an hour and a half the complexities of the health care system and people's particular interests will not be complete — cover every issue.

In terms of looking at what we do want to cover, it's how the health care system is structured in B.C., how well we perform in B.C. relative to other Canadian provinces and other international comparisons, understanding the challenges we're facing in our health care system right now and a progress update in terms of work we have been doing over the last many years to address these challenges.

If you go to the next one, this is to cover the basic sort of health care structure. As I said, the health care system is big, complex. It's a big, complex system, but we have tried in the ministry to explain it or understand it in a way that breaks down that complexity so that it's not just: "It's so big and complex that we can't understand it."

At its basic level, what we have is populations and patients, or beneficiaries, because we have a public insurance system in B.C., like all Canadian provinces. We have services we deliver to those populations. We have providers, who are the actual people that deliver the services — physicians, nurses, etc. And we have organizations that hire the providers and/or provide the facilities and infrastructure within which providers work.

Going through those, in terms of the population of B.C., as you know, we have a population of 4.6 million. We're almost equally males and females, but we're not equally divided across the age span.

A third of our population now is over the age of 50. We expect that that will continue to grow over the next 15 or 20 years as the baby boomers age. The baby boomers — the oldest are 67 and beginning to move through
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to their older years.

Over the next 15 years as the baby boomers age, there will be fewer school-age children in B.C. than people over the age of 65, and more people will begin to retire than are entering the workforce. That will produce all kinds of social change, we anticipate, not least of which will be increasing demands on the health care system. By the year 2022 one in five British Columbians, 20 percent, will be over the age of 65.

In terms of the health care needs, at its most simple level the goal of the health care system is to meet the population and patient health care needs. You can look at the needs in terms of staying healthy, getting better, living with illness or disability and coping with end of life.

One of the things that we have done in B.C. to try, again, to be able to get our arms around the complexities of people's health care needs and the system is to divide our population into these 13 population segments, with the idea that not everybody's needs are the same, obviously, and you need to understand what particular population groups need.

This is based on some work that was originated at Johns Hopkins Hospital in the U.S. What it does is it takes the administrative data that we collect at the ministry — so hospital encounters, PharmaCare data, physician billings, disease registries and all of the other kinds of administrative data we have. It looks at people in terms of their health care use over a single year and, based on their use of the system as a proxy for their needs, segments people into a particular category based on their highest health care need in that particular year.

As you can imagine, you could be in more than one category, but you're put into the highest category of need for a particular year. Everybody in B.C. can be divided, identified in one of those categories, from a healthy non-user to somebody in end-of-life care. So the healthy user and down to disability in the community — it goes in order of highest health care need.

That's one of the things that we've done in B.C. to try to understand our population, and it's actually proven to be quite a useful tool. I'll be talking more about how we use this population segmentation. As you can also imagine, over the years you can move from one category to another as your conditions change.

In terms of beneficiaries, the basic eligibility for most health care services is based on your Medical Services Plan eligibility, which operates under the Medicare Protection Act and is overseen by the Medical Services Commission. Registration in MSP is mandatory for all eligible B.C. residents and their dependents since 1998. In the act it defines who is a resident of B.C. and therefore eligible for publicly funded health services.

Then there are also categories of people that are deemed residents. These are people that may not meet the eligibility criteria but are deemed residents. These might be children or a spouse of somebody who is an eligible resident that are still in the process of applying for full citizenship, or students or workers on temporary work permits into the province. Those are the deemed residents.

If you're eligible for MSP, that also provides eligibility for hospital services and a number of other publicly funded services. The Medical Services Plan covers medically required treatment from a doctor or a physician; maternity care provided by midwives as well as physicians; diagnostic services, if they're ordered by a registered medical practitioner; dental and oral surgery, if done in hospital. For some of the supplementary benefits such as acupuncture, massage therapy, physical therapy and so forth, those are covered for people on premium assistance only — so ten visits a year, $23 per visit.

That's sort of the population and the beneficiary side of things. Again, on the health services side, trying to be able to understand the system in a way that's meaningful and just like we've tried to divide the population into segments based on the need, we've also looked at the health services we provide and divided them into a defined number of service lines that are included here in population and public health, community-based services, specialty population health and care services, diagnostic and pharmacy services, and hospital services.

If you look at the levels of service, we often talk about things like health promotion, primary care, secondary care, and so on. This just really tries to provide a definition of what these things mean and how we use common definitions of them. I'm just going to speak briefly to primary care, because I'll be talking more about that, and that's really one of the focuses of our strategy.

Primary care is the principal point of contact for patients and the most frequent place of contact for patients. In B.C. it's primarily provided by general practitioners — so family physicians and also, to a more limited extent, nurse practitioners.

This is where the primary care physicians are meant to be the ongoing continuity that a patient would have with the system and also to help coordinate access to other more specialized forms of care. As you know, you go to your general physician and get a referral to a specialist. The role of these is really to help support health maintenance and minor illnesses as well as the referral to the more specialty care and then the ongoing oversight of chronic diseases.

The secondary care is really the specialists, the specialty care. Then tertiary care is really the very highly specialized complex care that's provided in a few of the larger hospitals in the province, a lot of which are located in the Lower Mainland, but we also have tertiary centres in Victoria and the other large centres in the province.

In terms of our providers, this just shows the numbers and major categories of providers. You can see that the biggest category of providers is health support workers,
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who work both in our facilities — acute care and continuing care facilities — as well as in the community. The allied health professionals include some of the professionals like psychologists — people that are professionals but not doctors or nurses. That would be psychologists, physiotherapists, etc. — those kinds of people.

We have 5,800 GPs, 3,700 specialist physicians, 1,300 surgical physicians and then almost 50,000 nurses, if you include across…. You can see the various categories of nursing professionals.

Organizationally, in terms of the roles and responsibilities, the Ministry of Health, for the most part, does not deliver services directly. Our role is really one of — we use the term — stewardship, which is providing leadership and direction to the health care system, setting the strategic direction for the system and establishing the standards and expectations for the organizations that actually provide service, which are, in large part, health authorities in B.C.

We have a number of tools that we're able to use, or levers, to actually effect change in the system — perhaps not as powerful as people think, but these are the levers here in the second bullet, which are legislation and professional regulation. We have ability to fund and, by our funding decisions, establish priorities. We negotiate and bargain on behalf of the province with the professional groups, and we establish an accountability framework for health authorities, in which we're able to provide them direction and hold them accountable for the services that they deliver.

We do have some provincial programs that we manage, and this includes, as I've already talked about, the Medical Services Plan, which is our health insurance for, primarily, physician service; PharmaCare, which you'll hear more about when Barb speaks, which is prescription drug insurance for B.C.; and then also the Vital Statistics Agency, which is our registry of births, deaths and marriages.

The health authorities. Primarily in B.C. we've moved to a regionalized system where health authorities — we have five, as you know — deliver the full continuum of health services to meet the needs of the population within a particular geographic region. They have the entire budget for hospitals and community services. The things they don't include are the ones I just mentioned: the physician services and PharmaCare — drugs.

We have one Provincial Health Services Authority, which looks at provincewide and specialized health care services like renal services, cardiac services, the Cancer Agency — some of these provincewide specialized programs.

Then we in B.C. have the first, First Nations Health Authority, which is responsible for the services that were previously delivered through Health Canada to First Nations. They are very newly formed, in the last few months, and they are working on that and also working in close collaboration with our health authorities around services delivered to First Nations and aboriginal people that don't live on reserve and the broader range of services that First Nations and aboriginal people require that are beyond the Health Canada services.

A large part of the complexity and challenge of the health care system is that there is a lot of people. Decision-making and authority in the system are really quite dispersed among a lot of players in the health care system. The ministry, as I said, has a particular leadership and stewardship role. And we have some tools at hand, but the key decisions about health care are made by health professionals, as they should be, working with patients at the front line and in those interactions.

We have very highly educated and really powerful groups of stakeholders and physicians, nurses and other professionals, the unions, the regulatory colleges. We have to work with all of these groups, and all of these groups play a role in the effective and successful delivery of health care in B.C. So really, a lot of the work that we do in the ministry is around collaboration and partnerships with these groups, which also have a very key role to play in the health care system in delivering health care to the population.

I'll just run quickly through legislation. You'll be relieved to know that I'm not going to cover all 35 legislative acts and regulations that we have but just some of the major ones. The major one federally, as I'm sure you're well aware, is the Canada Health Act, and then there are four key pieces of legislation regarding how our system is organized and managed, which are the Medicare Protection Act, the Health Professions Act, the Health Authorities Act and the Hospital Act.

The Canada Health Act is really the most significant piece of federal legislation. It establishes the conditions which the provinces have to meet in order to receive federal funding contributions. The enforcement mechanism for the federal government is through their spending authority, the federal funding, so when there are violations of the Canada Health Act, their authority is a financial penalty to our transfer payments.

The five conditions. Public administration, where you have to run the system as a publicly administered insurance system. Comprehensiveness: covering a full range of services although limited only to medically necessary physician services and hospital services. Universality: everybody is entitled to be covered by health insurance. Reasonable accessibility: no barriers, financial or otherwise, to receiving access. Portability: your benefits and your eligibility for benefits, if you move, exists within Canada as a whole, so if you move from province to province, your benefits are portable.

The provincial legislation, as I've mentioned already, the Medicare Protection Act, defines the eligibility for beneficiaries but also establishes the fee-for-service pay-
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ment system, primarily for physicians but also some of the other groups — like dental surgeons, podiatrists and nurse practitioners, who are considered registered practitioners — and the conditions around those practitioners enrolling and getting payment from the system.

Essentially, once you're licensed by your professional body — in the case of physicians, the College of Physicians and Surgeons — you can apply for eligibility to the Medical Services Plan, and if approved, then you're eligible for payment. Then the Medical Services Commission oversees the payment and the quality of physician services.

The Health Professions Act is what oversees…. We have one act that oversees all of the self-regulating professions. We have 25 in B.C. Basically, the self-regulating professions have the authority to license and set the conditions under which a practitioner could be licensed as a physician or a nurse or whatever, and then they're also responsible for the quality and standards of care and discipline of members.

We have one profession, the emergency medical assistants, who have a government-appointed licensing board under a separate statute. Primarily, professionals are regulated through the Health Professions Act.

The Health Authorities Act is what allowed the creation of the health authorities, and this really only oversees the regional health authorities, so it doesn't cover the Provincial Health Services Authority or the First Nations Health Authority. It gives the minister the ability to create provincial standards, set the strategic direction for the system. It requires the minister to satisfy the criteria in the Canada Health Act.

I should also mention that the Medicare Protection Act requires the Medical Services Commission to act in accordance with the Canada Health Act requirements, and it sets out the purposes of the regional health boards, which are really to develop regional health plans, to manage the budgets that are allocated by the province, to deliver the regional services and to monitor and comply with provincial standards and establish regional operational policies and standards for operations in their regions.

The Hospital Act is the act that regulates our public hospitals and also allows regulation and licensing of private hospitals. Private hospitals in B.C. right now are really extended care facilities — the nursing homes and convalescent homes. They are what used to be called extended care facilities, but they are licensed under the private hospitals section of the Hospital Act.

Now I'll turn to how our health system is performing. That covered sort of the structure and how we're organized. This benchmarked performance is how B.C. compares to other provinces in Canada — provinces and territories, I'm sure.

Health care outcomes, which are measured through the Canadian Institute for Health Information…. The proxy for it here is premature mortality from treatable causes. If you die of a disease that could have been treated, and your life extended, that's considered premature mortality. I can't add sort of how they measure that, but they're the institute that does all of the health information and metrics for our health care system.

B.C. is number one on that measure. Our life expectancy at birth is also number one, and cancer mortality is also number one. In a couple of areas, heart disease mortality and infant mortality, we're number two. Then on self-reported health status — this is how people say they are — we're number four.

The next slide shows spending per capita. As you can see, we're getting relatively good outcomes in health care — in health and health care outcomes — and we're not one of the high spenders in health care. We're the third lowest, but very close in spending. Ontario and Quebec and B.C. are the three lowest in per-capita spending on health care.

This just shows where B.C. is relative to international comparisons in both life expectancy and spending per capita. B.C. is in green, and Canada is in red. Again, you can see that B.C., compared to other Canadian provinces, is a higher performer, and very high internationally as well.

The other point that you can note from this graph is that spending on health care is not necessarily correlated with life expectancy or health outcomes. You can see the big outlier internationally is the U.S., which spends the most by far and has some of the lowest life expectancy among international OECD countries.

This slide shows international comparisons on quality and access, and this was developed by the OECD. The data that this is based on is primarily survey data. So it's public surveys as well as surveys of physicians.

This is really just to show…. We don't have a lot of benchmark data, and this is the data that has recently been available. It shows that Canada, overall, in terms of quality and outcomes — in the view of the public and providers, which is important — is not a very strong performer, except in health outcomes.

It's number two for long, healthy, productive lives internationally. But on some of the ratings of quality and access, we're not as high a performer.

So we do have some challenges in Canada that we need to address. I would say that where B.C. falls on this…. We don't have specific benchmarks, but as we talk about the challenges in our system, some of them relate to access and quality.

Now getting to some of the challenges we're facing. The challenges that B.C. faces and Canada faces are similar across all developed countries right now.

We all have aging populations. We are all constrained by fiscal and economics right now — very tight budgets.
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The incidence of chronic disease is increasing, in part related to an aging population, but in part because of lifestyle and other kinds of issues. We have a health care system that was established and developed to deal with a population, at the time, which mainly faced acute care, episodic health care needs, whereas we now have a population that has chronic health care needs that require long-term care, not episodic. Our system was not designed for those purposes.

So like other countries and like other provinces, B.C. is working to change the system to address these new challenges that are being faced. The strategies that we're using — and I'll go into more detail — to address these challenges are similar. There's a defined range of strategies that B.C. and Canada and other international jurisdictions are using to try to address and transform the system to meet the needs of an aging population with chronic disease. I'll speak more to that.

We've made progress, I would say, in B.C. But we have not been able…. We are certainly not where we want to be in terms of systemwide change. There has been a comment frequently made that Canada is a nation of pilot projects. Wide-scale transformation, system-level transformation has been very challenging in Canada, and I would say that we have not successfully achieved it yet, nor has any other Canadian jurisdiction or, for that matter, very many international jurisdictions. There are places, but systemwide, wide-scale change is very challenging. We are working on that, and I'll speak to the kinds of progress.

This next slide shows the kinds of strategies that are common across the developed world in terms of trying to address the challenges I just referred to.

Strengthening primary care. Primary care is the care from family physicians or other health care practitioners in the community which provides your ongoing continuity of care as well as access to other, more highly specialized forms of care, so really trying to strengthen that level of care so that people don't need to move to the more expensive, specialized areas of care. The majority of their needs can be met through primary care.

Chronic disease management. As I said, the incidence and prevalence of chronic diseases is increasing in our population, partly as a result of…. The system has been very effective in dealing with acute care problems in terms of heart disease, cancer — those kinds of things. Now people live longer and have the opportunity to develop chronic diseases. So a success and a challenge of the health care system for us.

Wait times are a challenge across the whole system. Every province in Canada has issues with emergency room congestion — and also other jurisdictions. I was just reading a report from the NHS about their emergency room congestion problems, which sounded very familiar to what we experience here in B.C. Strategies to address that are common and being developed.

Moving from global funding, which is how we fund our health authorities and hospitals, to activity-based funding or to funding based on quality and outcomes and trying to use financial incentives to both maximize efficiency and quality, is also a very prominent approach being used throughout the world and also in B.C.

Seniors services. Recognizing that, you know, we have a growing population of seniors as our baby boomer generation ages and gets into the older categories, we really need to think about the approach that we use to deliver care to seniors and also how we are going to fund those services into the future.

Technology. As you know, technology is changing constantly. Trying to create electronic health records, moving the health care system from a paper-based system with files in individual physician offices and paper files in hospitals to a more electronic system that actually can follow the patient around and utilize all of the benefits of technology, has been a challenge in Canada in general. Again, while we're making progress, we are not as far along as we could be or should be.

Managing growth and public funding. Health care costs have been increasing faster than the rate of GDP growth or inflation in most parts of the world. Recognizing that as health care expenditures increase, it's pushing out other areas of potential public spending for things like education and other things that are part of a civil society. Managing that growth in health care funding is something that's high on the radar for most countries.

Those are the common challenges. I'm going to go into little bit more detail of the specifics for British Columbia now with these. This is a hard slide to see, and the details of it are not as important as some of the key points, which I will walk you through.

You will recall earlier I spoke about the work that B.C. does to divide our population into segments to understand what their health care needs are, from healthy non-users to people in end-of-life care. Then we have a matrix that looks at the population. On the left y-axis are the population segments. Across the x-axis at the top are the various types of health care service lines, from population health services to residential care. What you can do is look at how the different population segments use health care services in any given year.

I should point out, just in terms of the numbers here that because this is based on our administrative data, it represents not the full health care spend but the spend that we can actually attribute to individual use of services. You know, a physician visit — we have fee-for-service payments that tell us which patient saw which doctor and received what services.

For some public health services, for some kinds of services, we don't have individual point-of-care data, so that's not included in there. We are working to get some estimates of that across the different population segments
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so we'll have a more complete…. But this represents — let me just get the exact numbers — $9.2 million out of our $16 million health care spend…

…so it's not complete data. This is also based on data from 2009-10. Again, we are updating the data, and we will, in the next couple of weeks, have more updated data.

I think the point I wanted to just highlight for you is you can see that the population…. As you would hope, healthy non-users and people with minor episodic health needs…. That might be, you know, going to the doctor for a bladder infection. You know, you're mostly healthy, but you have a few…. Those two groups represent 50 percent of the population and use, in total, 6 percent of health care expenditure. You can go down and you can see that there are also some groups like the frail population living in residential care. They represent 1 percent of the population and utilize 19 percent of health care resources.

There are other populations. People with highly complex chronic conditions — 4 percent of the population, 18 percent of health care dollars. There's another population, mental health and substance-use needs — 2 percent of the population. Their expenditure is not so high — 7 percent — but that's in a particular given year.

We know that the burden of disease is very high for people with mental health and addictions issues because it tends, particularly mental health disease, to emerge early in life and be a chronic condition that needs to be managed over the life course. There's a very high burden of disease as well as other associated social costs related to mental health and addictions if not treated appropriately through the health care system. It's another population that's important to look at.

As noted, there are three populations in particular that we have, through this analysis, really tried to focus on: frail populations living in residential care, people with medium complex chronic conditions — and that might be COPD — and then people with highly complex chronic conditions. These three population segments are primarily seniors, but not entirely. They use — together, those three groups — 47 percent of all health care services in any given year.

The other thing that we've looked at through this form of analysis is which populations are growing the quickest over the next short term, medium term and long term. As you can see, the populations that are of highest concern in terms of high health care needs and utilizations are also the populations that are growing the quickest. The frail in residential care are the highest-growing population.

These numbers are based on, and these estimates of growth are…. If we don't make any changes to the way that we deliver health care services or meet the needs of these populations, these would be the growth rates. This is based on a status quo assumption that everything stays as it is. You can see that, as I said, the populations that are growing the most quickly are the ones that are the highest users of health care services and have the highest health care needs.

When you look at why…. I mentioned that health care costs have been growing more quickly than GDP and inflation. This slide tries to explain why that is. Overall, inflation accounts for 2 percent; population growth and aging of the population, 1.2 percent and 0.7 percent. Aging on its own is not a significant driver of health care costs — in contrast to a lot of the popular mythology about the grey tsunami.

What is a bigger…. It's some of the other ones — utilization of services. Across all population groups we all are using more services than we used to in the past. Then there are rapidly changing technology, genetic testing, personalized medicine, surgical procedural advances, drug advances, etc. All the things that are helping us live longer are also driving up health care costs. Then a real challenge is our infrastructure. Hospitals, residential care facilities and so forth are aging, and replacement costs continue to escalate. These are the things that drive health care costs.

One of the good pieces of news is we actually have been able to constrain the growth of health care spending in B.C. In '11-12 we were averaging 6.3 percent; in '12-13, 2.8 percent; and in '13-14, 2.3 percent. We're anticipating that this level will stabilize over time. As you can see — as government revenues have been a challenge through the recession — the proportion of provincial government expenditures is still quite high in B.C. — 47 percent, but it would be even higher if we hadn't been able to constrain the overall growth of health care expenditures.

In terms of progress update, in terms of how we're doing in dealing with these population needs and particular challenges, over the last four years we have been working with our health sector partners on what we have called the innovation and change agenda. The innovation and change agenda had four main components. There were three aspects that were really about transforming service delivery, and then a fourth which was sort of an underlying foundational piece, which I will cover.

The first piece was really focusing on health and prevention of chronic diseases. As I've mentioned, chronic disease is a growing concern and issue in B.C. and elsewhere. We know that many of these chronic conditions could be prevented or slowed in progression through lifestyle and behavioural changes. We have a number of initiatives — healthy families B.C., healthy start, etc. — which are really trying to promote better health and healthier lifestyles across the whole age continuum from kids in school to healthy aging.
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We also focused on trying to provide the majority of care for people in community-based settings. This is the strengthening primary care work that I spoke of, which most jurisdictions are working on right now, really, for everybody — the majority of care in the community but particularly focusing on the needs of the frail elderly, people with dementia, end-of-life care, people with these moderate and severe complex chronic conditions and people with moderate to severe mental illness and substance use.

In the hospital sector, trying to ensure high quality and efficiency — standardizing care protocols based on evidence. We've had a number of…. Just as one example of a care protocol, one of the ones that we've worked on is 48/6, which is the six things you should do for a senior within the first 48 hours of entering hospital.

We know that once seniors enter hospitals, because of the environment in hospitals, they can decompensate. And if you don't address…. They're really basic things, like hydration, mobility, cognition. There's a protocol for nursing and other staff within the hospital around these six care standards that need to be done in the first 48 hours. We have a number of those where there's evidence that this is the best practice, so we're implementing them provincewide.

Diagnostic imaging services. We know that wait times for diagnostic imaging services like MRIs or CT scans can actually delay further treatment because you need to get the MRI to get the surgery or to understand the proper diagnosis. When there are delays for these, it can delay other treatment. So we've been doing work to improve access and have increased the number and volume of these services provided in B.C.

Increasing surgical capacity and reducing wait times. A lot of work has been done on that. These are around elective surgeries, particularly in the area of joint replacement surgery. There has been a lot of work on that.

The flow through emergency departments and basic hospital patient flow. As I mentioned earlier, emergency room congestion is a problem that's quite widespread both in B.C. and elsewhere. Trying to address that through a number of strategies has been part of the focus in the hospital sector.

As I said, there's sort of a foundational strategy. This is a series of things around efficiency, productivity and sustainability of the system. This was really how we were trying to manage to reduce budget growth from 7 percent to less than 3 percent over five years. We've been able to do that.

One of the things is Lean process improvements, which is a quality improvement technique to reduce waste. Active management of pharmaceutical and laboratory costs — Barbara will talk about the pharmaceutical side of that.

There has been consolidation of what we call back-office functions across health authorities — payroll and things like that.

Shared purchasing. Using the leverage of the whole province to purchase equipment and supplies in hospitals has reduced the costs.

We've also done some…. It says "experimentation" there because it's very small scale yet in terms of the overall budget. It's a very, very small portion, but we're looking at how changing financial incentives can help get the outcomes and quality that we're looking for in the system.

We've done a lot of work on information management, information technology — implementing e-health, making the information systems that developed over a number of years as separate systems more accessible, and then always trying to ensure that people's privacy and the security of that information are protected. A year or so ago we launched the B.C. Services Card.

This is just goes into…. I won't speak of this in great detail, but you can certainly read it. In each of the major initiatives — the three service transformations about health promotion, improved strength in community care and quality hospital care — there's a lot of activity that has happened.

As I said, the healthy families B.C. program, which is the most comprehensive health promotion program in Canada, is really helping. It's designed to help people manage their own health and reduce chronic disease, with a high focus on nutrition and healthy lifestyles. You can read some of the initiatives there.

Overall, in B.C. we do have the lowest rate in Canada of exposure to second-hand smoke at home and the lowest portion of people that are overweight or obese, both for young people and for adults.

We've banned commercial tanning bed use for people under 18 because we know that it's a risk factor for skin cancer.

And we have some special programs that are targeted at low-income families to allow them access to low-cost produce — healthy vegetables and fruit.

In the primary and community care area, one of the big pieces of work that we've done over the last four years is to put in place some of the structural elements that will enable us to improve the community care.

As you are probably aware, for the most part, up until the last four years, family physicians were really quite isolated in the community. They might work in a solo practice or with a couple of other practitioners, but they didn't really have a lot of contact necessarily with the rest of the system or with their colleagues. There was no easy way for them to do that. Increasingly, as family physicians have stopped providing privileges in hospitals, they became quite isolated and didn't really have a strong way to have their voice heard in the system.

What we did was we created these divisions of family practice, which were voluntary associations of practi-
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tioners within a community — family physicians in a community — to establish a division and to get access to small amounts of funding from the government. They had to have 80 percent of the physicians in a community. Over the last four or five years we now have in place 129 divisions of family practice, including a couple here in Victoria and on the peninsula.

As those divisions of family practice…. They now can work together with their colleagues. They're provided with practice support and special educational and training opportunities.

We also created what we called collaborative services committees, CSCs, which are joint committees of the divisions and the health authorities. Now the family practitioners in a community have a mechanism with which to work with the health authority to improve services for patients in their communities — again, with a particular focus on those targeted populations.

A huge amount of work has gone into establishing these groups, and we're beginning to see progress on the kind of service transformation we need to actually improve services for those target groups that I spoke of — at the local level, which is where change always happens.

We've also established the Patient Voices Network, which has received a lot of international attention. It is to provide a place for patients to have a voice in the system, to be part of policy and program decisions and provide feedback to the system.

We've provided funding for 135 new nurse practitioner positions through the province over the next three years — again, trying to improve access to primary care through nurse practitioners.

We have what are called shared care plans — trying to get to that integrated record where all of the practitioners working with the patient, including the patient and the family, actually understand what the care plan is for that patient, based on their own needs and particular…. About 220,000 of these plans have now been developed, and more will be developed.

In terms of outcome, another measure that we use to measure the effectiveness of community care is what's called the ambulatory care sensitive condition rate, which is conditions for which you could be successfully treated in the community. These are people that end up going to emergency rooms or hospitals with these ambulatory care sensitive conditions. An indicator of poor community care is essentially what the importance of it is.

COPD is one example — chronic obstructive pulmonary disease. It's treatable in the community. It's an ambulatory care sensitive condition.

We have in B.C. the lowest rate in Canada of hospital admissions related to things that could have been treated more effectively in the community. Not to say that we could not do a lot better in providing community care, but we are doing reasonably well within Canada.

On the mental health side, we have the mental health strategy, the ten-year plan, which is sort of an overall framework for how we look at mental health across the whole continuum and across the lifespan.

Some of the specific achievements are listed here in terms of the increased capacity of the system, particularly around beds for people with mental health problems or addiction issues, both for adults and for young people.

We are making strides in expanding services for addictions and for children with mental health and behavioral challenges, and also trying to do research. We've recently launched some new activities around people with severe addiction and mental health issues, which have been recently announced.

In terms of care for seniors, there's the B.C. action plan, which I know some of you here in the room will be very familiar with. Some of the things that are part of that are the Better at Home program with United Way, which is really trying to look at some of the non-medical support that seniors need to be able to live in their own homes — things like shopping, housecleaning, transportation and so forth. There are also, supportive municipalities and communities through the age-friendly grants for them to improve accessibility to services and create what we call age-friendly communities.

We have recently launched an elder abuse prevention strategy looking at how we can both increase awareness of elder abuse as an issue, as well as provide resources in the community for people to report and respond to elder abuse when it occurs.

We have increased the kinds of options that are available for people when they need residential care — supported housing and assisted-living opportunities.

And we have established the seniors advocate position and are currently in the process of recruitment for one. In fact, I think today is the final day of the posting, so we'll be able to look at how many applicants we've had and start the process of culling through that list and, hopefully, have an advocate in place by the spring.

In terms of rural health, it's another big issue in B.C. just because of our large geography and the challenges of that environment and many remote and rural communities. We have done a lot of work in the telehealth area in terms of making…. There are a variety of things that are included under telehealth. One of the things is allowing people to have access to specialists who may not be located in their region, but they can talk to them through these telehealth networks that we have in place. We have 100 communities now that have access to telehealth, including within our First Nations, which are often some of the very remote communities.

You can see in the next slide just some examples of tele-oncology, tele–home care, tele–wound care, etc. There's a lot of work in this area because it is an opportunity to reduce people's need to travel and move around. We hope to continue to expand these areas both within our
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regional health authorities and the First Nations Health Authority.

We have a large number of physician programs. I was just speaking this week to a physician from B.C. who had just been at an international conference on rural physicians and said that Canada has the most comprehensive program internationally compared to other countries like Australia. I can't remember the other ones, but the conference was in Australia, which is why that sticks in my mind.

Among Canadian provinces, B.C. has the most comprehensive rural physician recruitment program. We have a number of incentives to attract physicians to rural communities and to help retain them there and support them in their practice when they are in these rural and remote areas — including the medical school in Prince George, which is helping recruit people to medical school that come from a more rural or northern background.

We have just over 1,600 physicians in our rural areas, and it is increasing slowly. But we know full well that there are still many communities that don't have doctors or are trying to get more physicians, and it remains an ongoing challenge.

In terms of medical education, as I mentioned — I got a bit ahead of myself — we are trying to move towards physician supply in rural areas through our medical schools and distributed medical school that we have in B.C. It is again, I think, quite a unique…. It's all part of UBC, but there are satellites in Prince George, Kelowna, Victoria and, I think, Surrey. There's one in the Fraser Valley, I know, as well.

The goal is really to get people that have that background and have lived in rural areas, or not, to train in those areas so they have the experience and competence and confidence to go out and work in those areas.

Actually, it's right here. It doesn't say the Fraser, so I could be wrong about that.

We also have travel support programs — again, knowing that people have to travel, and that's an expense for people that live in some of the more remote areas. There are a number of programs that are delivered by both the health authorities as well as the travel assistance program, which is run through the province and largely through B.C. Ferries. We provide accommodation for people when they have to travel in the Lower Mainland. We also work with some of the non-profit charities to help coordinate transportation for people that need to travel.

In terms of physicians, as I said, we're aware that despite all of the incentives and the comprehensive range, it still is a challenge in remote areas as well as other areas of the province for people.

Not everybody who wants a physician is able to access one right now. So we've got this physician — GP for Me — program to ensure that…. It includes supports to physicians, including funding and other kinds of training and support through specialists so that physicians, GPs, feel more confident taking some of the more complex patient groups onto their caseload. We will be continuing to monitor the effectiveness of those initiatives.

We have got what we call the collaborative services committees — I mentioned that earlier — to bring together the physicians and the health authorities and community partners in communities to look at local services, what their local needs are and how they might respond to those local needs.

We have Rural Physicians for B.C. to help support physicians in some of the more remote communities. And we've doubled the number of spaces for medical education in B.C. over the past number of years. We are effective in recruiting physicians from across Canada and internationally through these various incentive programs that we've established.

In terms of the efficiency and sustainability of the system, some of the successes we've had are…. We have reduced the price of generic drugs — I know you'll hear more about that through Barb — through the Lean process improvements, which have really occurred across the continuum of services within the health authorities, showing quite an improvement in access and efficiency in a number of program areas.

We have the consolidated administrative services and purchasing across health authorities. We've got the financial incentives, the activity- and patient-focused funding initiatives. And we're making progress on the e-health approach — overall, I think, shown in the reduction in the growth of health care funding from 7 percent to under 3 percent.

That's currently where we're at. We have to, in response to the minister's mandate letter, come back to cabinet with options to continue to improve health care value for patients and for the public. We have been doing a refresh of our innovation and change agenda and looking at our data, looking at what other countries are doing, talking to our many stakeholders.

We'd anticipate that we will, as requested, go back to cabinet in the next short period of time with some recommendations for how we want to continue to improve our health care system to meet the challenges that I've laid out in this presentation.

N. Letnick (Chair): Thank you, Heather. I think you're even six minutes ahead of schedule.

N. Letnick (Chair): To support you. Very good. All
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right. Thank you very much.

For those of you who are on the phone, what we'll do is go around the table here in the small House first, and then I'll get to you on the telephone. So if you want to start writing out your questions, we'll be with you in just a minute.

N. Letnick (Chair): Yeah, why don't you do one or two? We do have half an hour for this, and I'm sure everyone else has ten as well. What we'll do is afterwards we'll put together a list and maybe take up Heather's offer for a follow-up in February.

H. Davidson: We can also provide written responses to questions that you don't get answered here.

J. Darcy (Deputy Chair): Okay, good. Thank you for a wonderful presentation. That was very helpful.

I have a question about divisions of family practice, which are certainly an excellent innovation. One of the challenges, I understand, in the divisions of family practice — this is based on conversations with family docs, who are part of them — is that there is limited funding for nurse practitioners or other health care professionals, which would really enable us to move to more of a multidisciplinary team approach in family practice and using physicians when we need physicians, seeing other health care professionals.

I understand that there is some limited funding available for nurse practitioners, which is what you've referred to. Is the ministry looking at — maybe this isn't a fair question to you; you'll tell me — expanding the number of nurse practitioners that are funded for divisions of family practice, and are you looking at possible funding of other health care professionals like dietitians, for instance, when you have chronic conditions and so on?

H. Davidson: One of the goals that we…. I can't answer the question about nurse practitioners, because I simply don't know about increased funding for that.

I would say, though, that overall, the intended strategy that we're trying to use through the collaborative services committees is for the family practitioners to work with the community services that are provided through the health authorities. That's what is beginning to happen. We have given the health authorities $50 million a year additional funding — I think that we're in year 2 of that — to increase their community services, and then working with the physicians. That's what we're calling integrated primary and community care.

I can give you a couple of examples of things that have happened through that additional funding. This is where the Home is Best program has received that funding. This is where the health authorities are providing, through this funding, additional enhanced and expanded home support services for people that are eligible to go into a residential care facility either still living at home or in hospital waiting for residential care placement — so to get people home and support them at home.

It has been proven highly effective. People actually end up not going into residential care when a bed comes available because they see that they're actually able to manage at home, so that's been quite effective.

Also, programs for people with mental illness. Again, to give you one example and to show how it works with the physicians, this is a program, I believe, in Kamloops where people with severe mental health issues often don't have primary care because physicians consider them challenging and don't want to have them.

What they did, through their division there, was to say: "If you provide the primary care and take these patients on, we will provide the mental health supports that they need. If they have an exacerbation or an issue comes up, you will be able to get the supports for these people. So you don't have to worry that you're going to be challenged with trying to deal with very complex mental health and social issues. We will do that for you."

As a result — again, I'm not good with specific numbers — they have been able to provide access to primary care to a large group of people with severe mental health and addictions issues who otherwise would not be getting basic primary care and who would end up in the hospital. That just shows the collaboration.

In many places the home care workers and the health care community support teams are much more linked with the family physicians in a community, and some of them actually go work in a GP's office to go over common cases. It's trying to create that team so that rather than giving funding to the divisions, the idea is to link them better with the community health services that are already being provided in the community. Also, we know we need to increase the capacity of community supports that are available, and that's what the $50 million is beginning to do.

J. Darcy (Deputy Chair): I'll do the other questions in writing, except for one. That's rural health and, in particular, emergency services in rural health, and ambulance services. It's certainly an issue that I hear about and our critic for northern and rural health hears about all the time. There's a model of the use of ambulance paramedics in rural communities that means that we lose ambulance paramedics continually because they're on call for $2 an hour and don't have the training that's necessary, in many cases.
[ Page 95 ]

I wonder if there are any initiatives or if there is any sort of project in place within the ministry to address that issue of emergency services in rural communities.

H. Davidson: As I'm sure you're aware, we have recently, in the last couple of years, moved the emergency health services under the Provincial Health Services Authority, with the intention that this would ultimately help enable better integration of our emergency services with the health authority services. There is an interest in looking at and some active work underway around trying to better utilize paramedics in some of these rural and remote communities in other areas so that it would be to achieve what you're speaking of in terms of retention of the emergency services.

I think, again, I would agree that it remains an area of challenge where we need to continue to work, but I think the first step was trying to get the foundational piece in place, which was to establish the new emergency health services commission under the provincial health services.

There is very active planning to look at how we might better utilize and actually provide…. When you're in one of these more rural and remote communities and they don't have the specialized acute care services, what you need to do is be able to get people out quickly and efficiently when something happens. I think it's an area of very active work in planning, but I don't have specific details about it.

N. Letnick (Chair): Thank you. I'm sure we're going to have way more questions than time. Why don't we forward the questions through Susan, and that way, we can all get the answers together to all these great questions that we're going to have.

K. Conroy: Just for information, the rural medicine program is actually starting in Selkirk College in Castlegar this fall also, as a satellite program with UBC. We're really excited about it, as is the community. That's another one that's happening.

You talked about modernization of services for seniors, and you're looking at different models and funding models across jurisdictions. What other jurisdictions are you looking at?

H. Davidson: The ones that we typically look at are other Commonwealth countries, so the U.K., Australia and New Zealand. As well, there's a lot of really good work that's happened in some of the European countries, the Scandinavian countries.

I mean, even in the U.S., there are places that have really excellent care. I do understand that Diane Finegood from the Michael Smith Foundation came and spoke to you and has invited you to a session with the international experts that we're bringing together to advise us in January, so you will have the opportunity.

I'm actually excited about that session. I don't think we're on the same day, but some of the leading experts in the world and people that have really done some innovative and progressive programs for seniors…. So really looking at those countries that we know have done…. Japan is another country that has done a lot. Some of the European countries and Japan — their population is older than ours. They've already experienced and had to deal with some of these issues of an aging population, so we can learn from their experience.

K. Conroy: I'm looking forward to that session in January also. I noticed in some of the other charts that they are mostly Commonwealth countries and the United States, and there aren't any Scandinavian countries. Germany, I think, is the only European country in the charts of the other presentation.

H. Davidson: Yeah, because that's the OECD. They did it, not us. We got that chart from the OECD. It was them that chose those countries, not us.

Just a quick clarification. When you were talking about dollars, you said $9.2 billion, and on the chart is says $9.2 million.

H. Davidson: Okay, that's probably why I read it. It's a mistake. Thank you for catching that. That's really sad in the Ministry of Health — millions, billions. We get confused.

K. Conroy: You talked about aging infrastructure and replacement cost escalation. Has the ministry done any kind of cost projection on what it's going to cost the ministry and how this is going to fall into place? It's a huge issue in rural B.C., especially because it's a cost-sharing factor with regional districts and municipalities as well as the health authorities and the ministries.

H. Davidson: I would believe that our capital…. We'd have to ask our people that work on the capital areas, and that might be something you'd want to have them come back or submit a question. But it's not my area of expertise, unfortunately.

L. Larson: Just one quick question. I've got lots, but I'll just hit on one. The 48/6 — where is that being implemented now? Or how far along has that gone?
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H. Davidson: I can't say specifically. Our goal is to have it implemented fully across B.C. in all of the facilities, but I don't know the progress that's been made on that yet. I could certainly find that out.

L. Larson: Yeah. I'd like to know what health authorities are sort of on board and embracing it and passing that information on to their front-line people.

H. Davidson: Yes, we can find that out. The intent is that all of the health authorities will be doing it. We are monitoring that, so I can let you know.

S. Hammell: I would just like to ask a supplementary question around the mental health area. You said, if I heard you correctly — and I've come in late — that you have a pilot or a project in Kamloops where physicians are encouraged to take on those people with severe mental illness and they get additional support or get access to support. Is that correct?

H. Davidson: The patients…. I think what the goal of the integration projects is…. There had been, previously, GPs providing primary care services. There were health authorities providing mental health supports.

The problem was that they didn't connect. If a physician had a patient that was suffering an exacerbation of a mental health issue, which does happen for people, they didn't necessarily know what community resources were available for them.

The idea of this program was to say to the physicians — this was the health authorities saying it to the physicians: "If you are willing to take on these patients and provide their primary medical care, we will work with you to ensure that they get the mental health supports that they need through the programs that we offer as part of our community services as a health authority."

S. Hammell: Would we assume, then, that many mental health patients outside of that integrated service that's in Kamloops don't have primary physicians and therefore are unable, through that method anyway, to access the community health supports?

H. Davidson: I don't think that those two necessarily follow. What I can say is that patients with severe mental health and addictions issues are often underserved by family practitioners, either because of their mental health condition and its challenge or because family physicians may be reluctant to take on some of these more complex patients.

I would say that we also have community health services…. I think the idea is, really, that we believe that we will have more effective services and better-quality services for patients if we integrate the services, as opposed to, in the past, them operating as two silos.

Family physicians were often not integrated with the community services, not aware of them. They might be serving the same population, the same group of patients in a community, or they might not be. There was no way of knowing.

The idea is to bring together the two service partners and make sure that they're working together collaboratively to support each other, because the mental health services will be better, as well, if people are getting proper basic medical care.

I would also say, which I have acknowledged, that we do know that we need to improve our capacity to provide community care for people with severe mental health and addictions issues. We are doing that.

D. Bing: I'm quite intrigued by the idea of telehealth that you have there and the way you're able to service remote communities, especially First Nations communities. How long has this program been in effect, and how successful has it been so far?

H. Davidson: You know, I just heard a presentation on this on Wednesday, and I don't remember either of those details. It's very widespread, though.

I will have to get back to you on that, because I honestly can't remember the specific details. It has been in place for quite a number of years now, and it has continually expanded year over year.

D. Bing: Do the patients actually talk to a physician on the other end? Is it like a teleconference?

H. Davidson: Yes, it's like a video conference. The way that it has been set up is that it uses the network, the electronic network or whatever, that has been established within health authorities, which is secure and private.

The physician would go to a health authority facility and the patient would go to a health authority facility. That's what those sites are that I referenced — the number. And then they would see each other on a video conferencing system. It enables that security and privacy in ensuring that it's not going out over Skype — personal. The patient would actually talk to a psychiatrist or thoracic….

It's used a lot for post-surgical treatment follow-up so that patients don't have to come back to see the physician that they've already had a treatment with for oncology. For those kinds of follow-ups, it's one of the various…. That's really where they started, and it's continued to expand and prove very useful in that.
[ Page 97 ]

D. Bing: This would all be part of the public system, and it wouldn't be private at all. Is that right?

H. Davidson: The way that this was set up, as I said, was to use the secure network that the health authorities have so that it would be based in…. The place where the person would come and the physician would come would be public, would be one of these sites that can log on to the secure health authority network.

N. Letnick (Chair): Yes, I've actually seen a thoracic surgeon in Kelowna using it quite a bit.

N. Letnick (Chair): No, not yet. Well, there is robotic surgery. But no, this was for follow-up.

N. Letnick (Chair): On the phone, I believe, we still have Richard and Jane. Anybody else on the telephone?

Okay, Richard and Jane, let's start with ladies first. Jane, did you have a question?

J. Shin: Some of the questions were already asked by the previous speakers. The only thing that I think I have on my list is, given the series of recommendations that have been forwarded to the ministry, including the dental association…. I've been actually following up with that particular group.

I'm just curious to find out what some of the recommendations are that the ministry has been prioritizing to work on. For example, with the B.C. Dental Association, it's some quick policy changes that can be done without any funding requirements. I'm just curious to find out what some of the things are that the ministry has been working on.

H. Davidson: Sorry, just to clarify. The dental association forwarded these through this committee or through some other way?

H. Davidson: Okay, I'm not familiar with that. I can follow up, but I don't know specifically, and I'm not sure what we can find out.

J. Shin: Yeah, I was just curious to see if these recommendations were looked at on a case-by-case basis or if there was a consolidated way that the ministry was reviewing them together and going ahead with a certain one. If there is a summary that we can have a look at….

H. Davidson: These are just recommendations that different groups make to the ministry?

H. Davidson: Okay. On the health professional regulation piece, we do have…. I mean part of the benefit of a consolidated statutory system is that we do have a common approach and a group in the ministry that's responsible for the professional regulation and the whole health human resource area. We can follow up with them.

R. Lee: I have a couple of questions. One is on the cost pressures on the health system. If you add up all this, the increases, that would be about 5.5 percent over a number of years. And then the government spending is about 0.5 percent average a year.

What kind of age sectors are you foreseeing to have the best efficiency, savings, that kind of thing, to bring those two numbers closer together? I understand, for example, mental health would be an increase of spending. Some other area would be a reduction by innovation or efficiency.

Which area, which age-group checklist…? Probably it's in here. I just want to see the overall view from the ministry's planning that you must be….

Also, in terms of age factors, you can allocate those savings or the services. For example, is it primary care or tertiary care — that kind of thing?

H. Davidson: Just so I that can repeat what I understand the first question to be, it is: given what we said are the pressures on the health care expenditure, how have we been able to reduce it to 2.7 or whatever the exact number is right now? That's the first question.

I think when you do projections, they're based on the assumption that nothing changes. So if you don't change the system, that's what the increases will be. What we have been trying to do through the innovation and change agenda is kind of move the care towards the… First of all, focus on keeping people as healthy as possible so they don't need health care. Then, when they do, try to provide it in the community, which is a much less expensive way of providing care.

Some of the ways that we've reduced — it's not a spending reduction; it's a reduction in the rate of increase — have been through both the additional efficiencies, through the shared services and some of those kind of things, as well as trying to move care to less expensive settings. As well, I think control of…. You know, the biggest expenditure in health care is humans — pay-
[ Page 98 ]
ing salaries and fees. Control over pay increases through the cooperative gains programs and those kinds of things has helped maintain health care expenditures to the level that they are currently at.

R. Lee: In terms of the age, in which age sector do you foresee the most savings in terms of efficiencies?

H. Davidson: Which age do we see the most savings? I haven't ever thought about it that way, but where I would see potential for savings is potentially in that group in residential care, who are a very small proportion of the population but using a lot of expenditures.

What we know from some of the analyses that we've done on that data is that a large part of that high expenditure is actually before they get into the residential care because they come in through the hospital. So a lot of it is hospital use.

I think if you were able to better support people and provide the necessary home and community supports, you wouldn't necessarily be going into hospital and having that very difficult transition year that people often have from having a health crisis — something happening to them like a broken hip, which ends up in hospital and decompensation and then into a residential care facility. I think we could, and we're looking at…. That would encompass the whole thing from falls prevention to how you support people in different ways so they don't go through that care path.

It's not about savings per se, although that is the outcome. It's about how you actually prevent or support people in the community so they don't have to use some of the more expensive forms of care — which really is people's preference anyway, to stay in the community for as long as possible, living independently as possible.

Is there anybody else on the telephone? Hearing none, then I'll wrap it up with one final question, if I may.

At some point you said that Canada is a nation of pilot projects. You also said there are some roadblocks to systemwide changes. Any idea that you can share today of what some of those roadblocks are?

H. Davidson: I would say that a large part of it, in my understanding and thinking about it, is that health care is a complex system, and there is no single authority that has the ability to change the system. If we could change it by legislation or just giving more money, we would have done that already. In fact, we did put a lot more money into the health care system, and it didn't solve all of the problems.

In my opinion, it's because of the diffuse power and the influence that different groups have. We have physicians who are critical to actually providing the care. They have to buy into whatever change we want. We have front-line nurses who are providing care.

To actually do the change, which is what we want to do, to change the interaction between a patient and the system…. It's those people, the people that are providing front-line care in those front-line interactions, that have to change. Getting everybody to buy in and be on side with that and change the status quo, which is uncomfortable for a lot of people, requires different kinds of efforts than a simple diktat from Victoria. We know that.

I would say that on the positive side there is a lot more research and science and evidence about how you do effect large-scale change in a system as complex as health. We are trying to learn from that in B.C. I think some of the success of our efforts in the innovation and change agenda, in moving forward to the extent we have, has been because we've been trying to learn from the evidence that has begun to emerge on how you do effect system change in complex systems like health care.

N. Letnick (Chair): Thank you, Heather, for a great presentation, and Nick, for being there in a supportive role. You've done Stephen proud, and I really appreciate it.

The standing committee will recess for a couple of minutes so that people can charge their coffee glasses and do whatever else comes with coffee. Thank you very much.

N. Letnick (Chair): I'd like to invite Barbara Walman to take over the speaker's microphone. Barbara is assistant deputy minister, medical beneficiary and pharmaceutical division for Ministry of Health. Barbara is here with Mitch. I'm not wearing my glasses, so I can't see your last name.

B. Walman: Well, thank you very much. Mitch and I are both delighted to be here to talk about the drug review process today. I think there is lots of interest in actually how drugs are listed in British Columbia on the provincial formulary. Then we'll move, I think, to some
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slides that we've prepared for you on the PharmaCare program.

I guess to start with, Mitch is here with me. He's the acting executive director for our policy, outcomes evaluation and research branch. We are, I would say, a relatively small organization, division, in the Ministry of Health. The pharmaceutical services area right now probably has less than about 100 people to manage what is over a $1 billion program for the most part — so lean and mean we sometimes could be described as.

Like I say, I'm very happy to be here to talk about the process — you know, how all of this actually comes to fruition — and then the actual programs that we deliver on behalf of British Columbians.

To get started, I guess, to begin with, just to talk a little bit about a drug formulary and the management of that formulary. A formulary, as you know, is really an updated list of medications, for the most part, that are covered by the provincial publicly funded drug plan. We have ongoing processes to update the formulary, including processes to identify drug products that are medically appropriate and cost-effective. We also have tools, again, to evaluate and improve the formulary to ensure that it's current, optimally used — I'll talk a little bit more about that later — and again, there's the bullet around there about being cost-effective.

Just to point out that the PharmaCare formulary and the plans that we talk about are for drugs that are used in a community care setting. These numbers — the $1 billion and other numbers that you will see — are not cancer drugs. The B.C. Cancer Agency has their own funding envelope for cancer drugs. It's not for the anti-retroviral medication. We provide funding directly to the Centre for Excellence in HIV/AIDS. They actually purchase and look after that specialty formulary themselves. Transplant medications, again, are available and funded through the B.C. Transplant Society, kidney dialysis medication through the B.C. Renal Agency and drugs and hospitals. Health authorities are block funded for their pharmaceutical costs — directly to the health authorities.

You'll see in our presentation today that there are quite a few graphs. This one is hard to read. I actually had to have it blown up again even bigger.

The drug review process that we use in British Columbia starts…. Basically, we call them drug sponsors, but they're drug manufacturers, for the most part, who send a submission through to Health Canada. The federal government is responsible for reviewing those submissions and ensuring that they meet the safety, effectiveness and quality control standards that are set by Health Canada. They decide, basically, approved or not approved for sale in Canada.

Once that happens, the drug sponsor again is responsible for taking that yes to the common drug review. The common drug review is housed or supported in CADTH, which is the Canadian Agency for Drugs and Technologies in Health. That's a stand-alone organization that's funded both by the federal government and by provinces. Just for the drug-listing process, we support that to the tune of almost $650,000 a year. So CADTH is supported. They receive funding from the federal government and from each of the provinces except Quebec.

The common drug review is a national review. They compare the drugs with existing drugs. They do clinical evidence reviews. They ensure that there's value for money, and they make recommendations. Again, they recommend to list, or not, to the provinces. I will tell you that different provinces have different processes after that common drug review is done at that level.

In British Columbia the drug sponsor again says: "We have a decision from this national body." They come to British Columbia, and we put it through our Drug Benefit Council, which I will talk more about. Again, the Drug Benefit Council looks at it from a PharmaCare — from a British Columbia — perspective, a lens. They make a recommendation to the Ministry of Health on whether to list or not list.

On the next slide, you'll see that this is a bit of a repeat, just talking about that common drug review process. That just gives you a bit more detail on exactly what the CDR — the common drug review — process looks at when it reviews a drug on behalf of the provinces and territories. It is around new drugs. New chemicals, new combination products or new indications for old drugs is what their mandate is. They do a very systemic review of available clinical evidence, and they conduct reviews of pharmacoeconomic evidence.

Again, the pharmacoeconomic really looks at comparing the value of one pharmaceutical drug or drug therapy to another. There are lots of really interesting words and combinations of words when you get into this portfolio.

Before I get into any more detail, I think one of the interesting things to point out is that back in 2007-2008 there was a Pharmaceutical Task Force — I think many of you would remember that — that provided recommendations aimed at improving the ministry's drug review process. Minister Abbott was the minister then, and he basically accepted the recommendations of that task force. It was done, really, to ensure and facilitate more transparency, faster listing of drugs and to ensure that the Drug Benefit Council actually had public members on it, I think, for the first time.

Since 2009-10 we have undertaken a number of activities and process improvements, including adding three public members to the Drug Benefit Council. We've added and increased the stakeholder input opportunities. We have physicians, patients and the drug companies that provide us with information. We have a roster of available drug review teams that were done. We put that through an RFP, so people had the opportunity to apply to be on those rosters.
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We established target drug review completion times. In the past I think it was just done as it could be done, and now we've set up some very clear timelines that we want to meet to ensure that we're actually getting those important drugs to market in British Columbia faster. They eliminated the drug review backlog, obviously.

We've integrated our processes just very recently with the new pan-Canadian purchasing alliance that the Council of the Federation and the Premiers have endorsed very heavily across Canada. Our timelines…. We're moving our processes to ensure that we are part of that important alliance.

We've also, as I noted, increased transparency of processes and decisions, We've done that, basically, through an enhanced website, for example, where we absolutely show what the drug review process is. We have listed the Drug Benefit Council terms and memberships. We have new conflict-of-interest guidelines. We want to ensure that people that are making decisions are unbiased from that perspective.

We've met quite often with different patient groups. Often, you know, decisions are made, and sometimes they're a disappointing decision for some patient groups. They want to know why: "Why was that decision made? What was the rationale? Why would you not cover that drug in British Columbia?" So we've worked very hard to have the decisions and rationale posted and available to, obviously, very interested people and patients in British Columbia.

We've got a new and very effective, I think, electronic formulary. It's really a search engine. If you are being prescribed something and you are eligible for PharmaCare benefits, you can go on line, look it up and see if it is a full benefit or a partial benefit and what that impact might be for you personally.

Again, Heather mentioned the Your Voice patient input mechanism. We rely very heavily on that as well. I can tell you that it's very well used.

Just a quick overview of the Drug Benefit Council. The terms of reference require it to have 12 members. Nine are professional, and three are public members. It meets once a month. Their output and their mandate is to provide recommendations to the ministry with reasons. The recommendations — just so you know, it's not a yes or no. It can be to list, so that's yes; to list with some criteria, which is common; not to list; and a fourth one is not to list at the submitted price.

They have a lot of information that they look at, at each of these meetings around each of these drugs and have some discretion on what they recommend to the province.

Another chart for you to look at around the current drug review process. What I wanted to show you here is there is the CDR, the common drug review process that provides us with similar kinds of recommendations around listing with criteria: do not list at the submitted price, do not list, or list.

The Drug Benefit Council, for the most part, looks at the work that the common drug review has already looked at. That includes the clinical practice reviews, the clinical evidence reviews, the pharmacoeconomic evidence reviews, patient input, manufacturers' comments, the budget impact — and, really, how that drug or indication would fit into our formulary in British Columbia. Then it comes to the ministry, obviously. We've talked about that.

The underlying new process or new opportunity really is the pan-Canadian pricing alliance. That is relatively new this past year, where the Council of the Federation has gotten together and looked at things that are happening across the country around pricing, around availability, and have directed, basically, provinces to work together on what's called a pricing alliance.

At first, I think you might have seen it was a purchasing alliance, but we actually don't purchase drugs. We're a payer of drugs, so much like an insurance company, we pay after you're found to be eligible. We don't actually buy drugs.

We're very involved in the pan-Canadian alliance. What happens is that when a drug has gone through that common drug review, British Columbia agrees that yes, that's a drug that we're interested in. There's a lead province at this point that negotiates directly with the manufacturer on behalf of all jurisdictions except Quebec on price. It's kind of a one-stop shop, if you like, for the manufacturers and for the provinces.

It's relatively new. It's a relatively new process, so we're refining it as we go. But again, the idea, certainly from the council, was that we're a large nation, that we spend a lot of money on prescription drugs and that there should be some ability to get a better deal, quite frankly, as a pan-Canadian instead of kind of one-off deals with each of these manufacturers.

Just to go back to our Drug Benefit Council, the common drug review does the first round of work where they look at the trials, they look at the clinical evidence, they look at cost. But then when it comes to B.C., we really do have a good second look.

Up until recently we have kind of doubled…. Everything that they've done, we've done again. We're starting to look at whether that's sustainable or not.

There is a very small number of drugs or indications that we review that doesn't go through the common drug review. That would be like new line extensions. So if a drug is now going from intravenous to subcutaneous, that wouldn't go all the way through that whole process. They could just come to the Drug Benefit Council and ask that that new line extension be approved in British Columbia.
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We also, through the Drug Benefit Council, have the opportunity to do therapeutic reviews. Those are classes of drugs. The most recent one they did was to look at all of the drugs that are in the formulary and are being asked to be put on the formulary around overactive bladder, for example. They've also done some work on diabetes and the biologics.

I've mentioned patient input. It was really just launched in October of 2010. This is where patients, caregivers and patient groups provide input through Your Voice, a website, for the drugs under review. We also ask that a conflict of interest be declared there so that we actually know who is making the comments.

In a nutshell, really, when we are making drug decisions for listings on the private, taxpayer-funded program, we consider, obviously, the recommendations from the Drug Benefit Council, the clinical evidence that's available, the cost-effectiveness of the medication. We look at our PharmaCare policy for this type of drug and other drugs in that program area.

We need to look at the number of PharmaCare plans that we already have and which ones would actually cover that drug — which plan that would come into and which rules, I guess, would go with that. Then we look at the cost always. You know, do we have the resources to cover that particular drug?

Our timelines. You'll see on this one that it used to be six months, nine months and 12 months, but I would say that with the new pan-Canadian, we have moved up our drug decision-making way faster. Once it comes out of a common drug review, we're looking at a month or two, probably closer to two months, for a provincial decision. We are anxious to be part of that alliance, so we need to make those decisions quite a bit quicker.

After a full decision is made, there's still quite a bit of work that is done in the program. Once a decision is made, then there's implementation, obviously. We engage with health authorities so that they know what drugs we are listing. We finalize the drug listing criteria. There might be some special authority required. We need to change PharmaNet. The actual system needs to be changed to accept that drug.

We communicate with Health Insurance B.C., which runs the program for us. We have a big PharmaCare newsletter that goes out to pharmacies so that they know which drugs are actually being covered. We have letters that go to physicians. And we, of course, try to keep our website as up to date as possible.

Our experience. I thought I'd put in a slide that just kind of shows you our review experience to date. We've completed, I think, 34 listings this past year. Like I said before, we also had a really good look at what the common drug review says and what we came up with in British Columbia — and a very high congruency with all of the recommendations coming out of that review process. That just gives you some idea of what the decisions are.

These are the actual drugs. I'm not going to read them to you, because I have to declare that I am not a pharmacist. Those are the drugs — the ones that were accepted as benefits and the ones that we declined to list in 2013, up till December 1, 2013. So 32 drugs were reviewed, and that's our listing.

I think what I would say is that with the ability to list drugs also comes a duty to actually look at programs to support optimal drug use. What that means is that for every drug that's out there, as most of you know, there are side effects. There are drugs that interact with each other. There are drugs that have adverse reactions. What we're trying to do, along with the listing of drugs, is to support prescribers, mostly — and pharmacists — around the optimal use of those drugs.

We do therapeutic reviews. We work very closely with some outside researchers around therapeutic reviews looking at the evidence of multiple drugs in those related therapeutic areas. We support information on good, appropriate drug use to inform and educate prescribers, health professionals, patients and the public.

One of the ways we do that is through a program called PAD, which is provincial academic detailing. That was established late in 2008. We have approximately 12 academic detailers, we call them, out in the province that we fund and that are in the health authority setting. But they visit. They're highly trained pharmacists who actually visit physicians in their workplaces to talk about optimal drug use.

What we do with that program is that we select topics. We look at what's happening in the formulary. We look at the usage. We look at the plans and select topics that are timely, we think, and ripe for an education topic.

In the past we've done the human papillomavirus vaccine. We did that back in 2009. The anti-coagulants for atrial fibrillation. Antibiotics in the community was a big one. COPD. Osteoporosis. A huge uptake in those.

Right now we are presenting on statins and cardiovascular disease, acute otitis media, and we just launched our opioids and chronic non-cancer pain session.

In the future we're starting to put our package together around oral anti-coagulants in atrial fibrillation, so that's under development right now.

We've been doing these for a quite a while. Thousands of presentations have been made. We've also started to track what a difference even…. You can imagine. We have nine or 12 people out in a province as big as British Columbia, trying to make a difference in actually changing the patterns, perhaps, of prescribing. We're starting to see if we can track some of that behaviour and ensure that we are getting the best information possible out to those prescribers.

That's really, in a nutshell, the drug review process in British Columbia.
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I thought we'd take the next little while to talk about the actual PharmaCare program. Once drugs are accepted, then this is really how the PharmaCare program works. Is that okay with you?

B. Walman: The B.C. PharmaCare program provides coverage for drugs and certain medical supplies and devices basically for all eligible B.C. residents. We help — again, remembering that this is the publicly funded insurance drug program for British Columbia. I will tell you that it's approximately a billion dollars. Last year, I think, just under 800,000 people were beneficiaries of that program.

Many, many people in British Columbia also have private insurance. Then there are, of course, people that are cash payers in British Columbia.

The program, writ large, covers eligible prescription medications. There are certain non-prescription medications that are covered. We have a small program for medical supplies. We pay pharmacists for dispensing fees, and we also pay pharmacists for specific clinical professional pharmacy services, on behalf of British Columbians.

PharmaCare consists of one universal plan, which is the Fair PharmaCare plan, and then nine smaller plans that are designed to meet the needs of very specific patient populations.

The specifics page talks to you about the lists of drugs and medical supplies that are generally covered in British Columbia — again, many prescription drugs, most insulins, the needles, blood glucose test strips, syringes, insulin pump supplies for people with diabetes. We have an insulin pump for the children-under-18 program. There are certain ostomy supplies that are included in PharmaCare, designated or prosthetic appliances and children's orthotic devices.

We have a smoking cessation program that supports nicotine replacement therapy. I mentioned the pharmacist-delivered medication review services, prescription adaptations by a pharmacist and publicly funded vaccines that are provided by a trained pharmacist.

This is the expenditure graph, which looks at the total PharmaCare expenditure over this past eight fiscal years. It's interesting. For this year our budget is $1.179 billion. Last year PharmaCare accounted for approximately 7 percent of ministry expenditures. So the drug costs are a huge cost in the British Columbia system. We had an average cost per capita of approximately $239 and provided benefits, like I said before, for just under 800,000 British Columbians.

One of the things that we were asked to talk about was the cost drivers. One of the cost drivers for the PharmaCare program is the increasing use of drug treatments outside of hospital. As I noted before, when you're in the hospital, the health authority is responsible for the cost of your drugs. When you're released back into the community, more than likely PharmaCare would become responsible for that.

There's the introduction of newer, more expensive drug therapies and, again, the demand increase due to an aging population and an increase in the number of people living with chronic and severe conditions.

One of the areas that we're always interested in, of course, in British Columbia is seniors. We did a chart up for you that basically shows you the seniors and non-seniors benefits. In '12-13, 48 percent of seniors in British Columbia received some form of PharmaCare coverage compared to 11 percent of non-seniors in the province, and 39 percent of total drug expenditures claimed through retail pharmacies in B.C. was paid by PharmaCare.

So 42 percent of total drug expenditures for seniors and 36 percent for non — again, recognizing that many of us have private insurance such as Blue Cross, etc., and then there is a small portion of British Columbians who do pay cash.

I thought this was an interesting slide for you: the PharmaCare beneficiaries, which basically compares the number of beneficiaries to B.C.'s total population in five-year age groups. You can see when we kind of use the most resources or the most medications.

Last year we had the opportunity to actually proclaim the new Pharmaceutical Services Act. Heather didn't mention the Pharmaceutical Services Act in her slides, but this act basically shifts the PharmaCare program from one which relied, basically, on policy to one that is protected by legislation. We were absolutely delighted to have that piece of legislation go forward.

There are transition provisions in the act that allow and actually require us to develop, now, the regulations that describe the program that is basically in place. We have about a three-year window to do that.

The first regulation that was deposited was the drug price regulation. That happened for the April 1, 2013, reduction in generic drugs.

We're working right now on regulations that will describe providers, information management — which is a big topic for us — drug plans and beneficiaries. That work is being done basically as we speak. We have a couple of other outstanding regulations around administration and enforcement that will be done later. It doesn't have to be done in that two-year plan.

I'm going to give you a lot of numbers, coming up. I'm not going to read all of these to you, but we want to talk about the actual plans themselves.

I know, having been in other ministries and worked very closely with MLAs in communities, that people do have a lot of questions. I'm sure that a lot of people come to your offices asking questions about their benefits and
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about: "How does this work?" and "I thought I was covered; now I'm not covered," "My doctor has to do this. He wants to charge me for that." The PharmaCare plan is, from my perspective, a very good plan, but it does have a lot of rules and can be seen to be somewhat complex.

Before I start going into the complexity, maybe, of some of the plans, what I would say is that we would be delighted at any time to go into more depth around some of these plans and how they work and what the rules are. Like I say, I know that a lot of you and your CAs get many questions. We answer lots of bullets on your behalf. So I just wanted to put that on record — that we'd be delighted to provide a more technical briefing, should you require one.

Fair PharmaCare began May 1, 2003. It's the largest of our drug coverage plans in B.C. This is assistance for individuals. It's based on their annual net income. For families, assistance is based on their combined annual net income of both spouses. At the end of March this year over 1.2 million families were registered for Fair PharmaCare.

B.C. residents who are actively enrolled in MSP, our Medical Services Plan, are eligible to register for Fair PharmaCare, but you do have to register. You do have to go on line or call HIBC and actually register for the program.

As noted, PharmaCare uses the family's net income from income tax returns to calculate the family's level of coverage. We use income tax data from two years ago to calculate the….

N. Letnick (Chair): If the folks on the telephone could put their phones on mute, that'd be great. When it's time for questions, we can ask you to take it off mute.

B. Walman: I just wanted to ensure that you understood that we work with the Canada Revenue Agency to collect that data. But we also know that families have changes in income. What you were making two years ago might not be what you're making today. So if there is at least a 10 percent reduction in your income, you can actually request an adjustment to your deductible or to your family maximum. That's done through Health Insurance B.C., who is our administrator.

One of the things that you will probably have questions about and be interested in is the deductibles and co-payment part of our program.

Individuals and families that are registered for Fair PharmaCare basically pay their full drug costs and dispensing fees until they reach their deductible. Individuals who do not…. Just so you know, if you haven't registered for Fair PharmaCare, you're automatically assigned a deductible of $10,000. It's just an assignment for those that haven't formally registered.

Once your deductible is met, PharmaCare pays 70 percent of the eligible costs until they reach their annual family maximum. Once the maximum is met, that's when PharmaCare kicks in to 100 percent.

Eligible costs are the maximum amounts PharmaCare pays for a prescription drug, medical supply or pharmacy dispensing fees. And we need to very clear that only eligible costs count towards your deductible and family maximums. The deductible is the amount of money that a family needs to spend each year on a prescription drug or a medical supply before PharmaCare begins paying the 70 percent of the eligible costs.

M. Moneo: Sure. The way that the Fair PharmaCare program is structured is that people will pay…. A percentage of their net family income will be their deductible. But we set it up so it's for people that were born after 1940. I'll get into a little bit about the enhanced PharmaCare assistance after I explain the more universal one.

If your net family income is $15,000 or below, you're assigned a zero deductible. In other words, you won't have to pay any deductible up front. PharmaCare will start covering you up to 70 percent of your drug costs, and you'll pay the remaining 30 percent. Once you've paid 2 percent of your net income, 2 percent of the $15,000, we'll start paying for 100 percent of your eligible drug costs.

If you earn between $15,000 and $30,000 — that, again, is net family income — the deductible level is set at 2 percent. And if you earn greater than $30,000 net family income, your deductible is set at 3 percent.

The family maximum amounts shift as well. For the lower-income families in British Columbia, the family maximum level is set at 2 percent of their net income. For the people that earn higher incomes, it's set at 4 percent, and there's a 3 percent for the middle group.

When Fair PharmaCare was introduced in May of 2003, there was a transition period for people who were…. If you recall, before Fair PharmaCare there were fixed deductible levels. I think lower-income seniors paid a deductible of about $200, and lower-income non-seniors paid a deductible of $800. I think there was an $800, a $1,000, a $200, $400 — something like that.

To transition those people when we introduced Fair PharmaCare, we created an enhanced assistance plan. That plan provides…. As you see in the table, it gives those people a little bit more relief financially, but it was intended just for people who were about to turn 65 back in May 2003. That's why it isn't really a seniors plan anymore, because now it's ten years later. It's only really effective for people who are 75 years or older now. That gets confusing for some beneficiaries, because they say:
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"Oh, I'm a senior. I've turned 65. Why am I not getting the same level of coverage that people that were born in 1940 were?" But that was just a transitional measure that was done.

B. Walman: Okay. The other nine PharmaCare plans. The majority of these…. Just so you know, you can be on more than one plan. Some people, some patients, access more than one of our drug plans.

Plan B is another very popular plan. This is the permanent residents of licensed residential care. Plan B — PharmaCare provides 100 percent coverage of eligible prescription drugs and designated medical supplies for permanent residents of licensed residential care in B.C.

We have a plan C, which is for individuals receiving income assistance. This plan provides 100 percent coverage as well, for eligible prescription costs and medical benefits for people that are receiving income assistance through the Ministry of Social Development and Social Innovation.

We have a plan F — I don't know what happened to E — and this is for children receiving medical or full financial assistance through the Ministry of Children and Family Development's At Home program. They qualify for full coverage of eligible prescription drugs and designated supplies.

Moving on to plan D, this is for individuals with cystic fibrosis who are registered with a provincial cystic fibrosis clinic. They receive 100 percent coverage of the digestive enzymes and other products listed in the cystic fibrosis formulary. Coverage for other products in the formulary is subject to the rules of the patient's primary plan. So 100 percent of the enzymes, but for some of the other products, they would have to meet the same deductibles.

Plan G is our no-charge, 100 percent funded psychiatric medication plan. This is available to individuals basically of any age who are registered with a mental health service centre and who demonstrate clinical and financial need. The plan provides coverage for certain psychiatric medications. Who is eligible is decided at those health service centres.

Plan P is for our patients who wish to receive palliative care benefits at home. This is for people who have reached the end stage of a life-threatening disease or illness and who want to receive their care at home. Beneficiaries receive 100 percent coverage of eligible drugs through this plan and 100 percent coverage of medical supplies and equipment through the local health authorities.

Plan M is one of our newer plans. This covers individuals for, basically, medication management services that are provided by pharmacies in community pharmacy. This includes prescription renewals and adaptations.

Plan S is another relatively new program. This is our smoking cessation program which covers nicotine replacement therapies. It also covers prescription medications. Again, those medications are in accordance with the rules of your primary plan.

Plan X is basically the funding that we provide to the B.C. Centre for Excellence in HIV/AIDS that operates from St. Paul's Hospital. HIV-positive people living in British Columbia receive their drugs free of charge when they're enrolled with the centre.

What we thought I'd do is just give you a snapshot of the total claims expenditure for all of the plans. This includes both dispensing fees and residential care pharmacy fees. You'll see that the number of claims…. It goes back to…. It gives you, we thought, a really good kind of glimpse at what's happening in the PharmaCare world.

Looking at the number of claims — almost 22 million claims in 2006-07. Last year we were at almost 31 million claims. The number of beneficiaries remains relatively stable. The ingredient cost — what it is that PharmaCare pays for, for the drugs — goes from $673 million to $748 million. Professional fees and capitation fees paid for long-term care went from, basically, $157 million to almost $223 million.

So this gives you a sense of where that $1 billion is spent. It looks at the average number of claims per beneficiary, the total cost paid per beneficiary, the average professional fees paid per claim, the ingredient cost paid per claim.

You'll see that, for example, in 2006-07 the average ingredient cost was almost $31, and it's now closer to $24. A lot of that has to do with our negotiations and the changes to our regulation around the costs for generic drugs.

We have a low-cost alternative program. We have maximum-payable programs. We have a number of ways that we control the cost of those drugs that Mitch is going to tell you about later.

The average total paid per claim, again, dropping. The average day's supply per claim also dropping, which is interesting.

The next slide shows you what the pie looks like. As I said, Fair PharmaCare, plan I, is our biggest plan at almost $570 million. Plan C is our next-biggest plan. Those are people receiving income assistance. Then I guess it goes down from there. Maybe it's not in any chronological order from a cost perspective.

What we did is provided you the Fair PharmaCare claims and expenditures. I don't think we'll go through each of these in detail for you, but I think it's a really good background to see how the dollars are actually split out, how it is that those funds are paid.

Basically, the good news, we think, for Fair PharmaCare is the total registration has grown each year since 2003. As noted earlier, over 1.2 million families are currently registered.

Looking at plan B expenditures. As noted, we provide
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prescription medication, 100 percent coverage, in plan B. We have approximately 29,000 British Columbians who are benefiting from that coverage.

One of the things that you'll note here is that we talk about a capitation fee. Instead of a dispensing fee, pharmacists that provide service to these residential care facilities are paid on a per-bed basis instead of on a per-drug-dispensed basis. That's what that capitation is about.

Plan C, again, is our income assistance. Approximately 174,000 or 175,000 residents receive coverage from plan C.

Cystic fibrosis plan. Basically, since 1995 individuals with cystic fibrosis who are registered with the clinic have received coverage for the digestive enzymes. About 300 individuals with cystic fibrosis receive coverage under that plan. Only four other provinces have actual designated plans for cystic fibrosis at this time.

The at-home program — another very valuable program, we think — provides community-based…. Obviously, the home program provides family care for children with disabilities age 18 or under who would otherwise become reliant or institutionalized. This plan F provides benefits at no charge for that program.

Plan G, as I noted, is our no-charge psychiatric medication. Approximately 31,000 patients were registered — again, 100 percent, ensuring that there's no barrier to people with mental health issues accessing these important pharmaceuticals.

Because I only have ten minutes, we're going to flip through this. I'm getting the hook. We'll go real quickly, I think, through the PharmaCare coverage rules.

M. Moneo: Barbara gave a pretty good overview of the different plans and the plan rules and eligibility for the patients who receive benefits under those plans. In addition to that — this is where a little bit of complexity comes in — we have another layer, and that deals with the drugs. When we list a drug, we list it either as a regular benefit, which means that it's eligible for 100 percent full reimbursement of the drug cost, but the beneficiary still has to meet their deductible and their family maximum and all the other eligibility rules.

We also list drugs as partial benefits, which means that we will pay a portion of that drug cost for the beneficiary. And then we have limited-coverage drugs. Limited-coverage drugs are usually drugs where there are a number of different lines of therapy. We will cover it if a patient doesn't respond to the first line of therapy and the doctor writes a special authority and says: "My patient took this for a certain duration, and it wasn't effective for them." Then we move them on to a second line, so we pay for it then.

But we only pay for it when we have an indication that the first line or the second line wasn't effective. In that way, we contain the costs, because usually the second and third and fourth lines of therapy are more expensive than the first line. We want people to try the course of the regular therapy first and then move on to the more advanced ones.

There's a low-cost alternative program in B.C., and B.C. is very proud of it. In fact, it was the first jurisdiction that introduced a low-cost alternative program. What that is: when there are multiple sources of the same drugs…. This usually pertains if there's a brand-name drug, it loses its patent, and then generic drug manufacturers market their drugs. Often a number of generic manufacturers bring their drug to market at the same time, so there's competition.

What the low-cost alternative program does is ensure that B.C. is paying for the generic drug price. A patient may request to have a brand-name drug or more expensive drug dispensed to them, but if they're covered by the program, the program will only cover the cost of the generic drug and they'll have to pay out of pocket or whatever for the brand-name drug — unless, of course, it's a limited-coverage drug, where a patient may have an adverse reaction to the filler in a generic or something like that. In that case, PharmaCare will pay for the full cost of the alternate drug.

The alternate drug isn't always the brand-name drug. It could be another generic drug. They have to try a number of drugs, and they get the most suitable drug for them. But it is paid. The low-cost alternative program has been very effective in containing costs in that manner.

Barbara spoke about the Pharmaceutical Services Act and the drug price regulation earlier. In that regulation we also started to regulate the price of the generic drug. Before, generic drugs used to be about 65 percent of the brand-name drug. The manufacturer would just submit the cost that they wanted, sort of what they thought the market would demand. A lot of it was driven by prices in Ontario and other, larger jurisdictions.

Now in B.C. with the drug price regulation, we indicate that we're only going to pay a benchmark price for the generic product. Currently it's at 25 percent of the brand-name product, and in April of this coming year, April 2014, it will drop to 20 percent. That's another great way of containing costs for the province, and it's relatively new.

In addition to the low-cost alternative program, we have a reference drug program. The reference drug program was implemented in the 1990s. As you may recall at that time, there were a lot of drugs being introduced onto the market that had what they call me-too drugs joining them. An innovative therapy would be marketed, and then other manufacturers would introduce drugs that were similar, that had a similar effect. What happened was that there were a number of drugs available that would fit into a therapeutic class that would be used by doctors to treat a certain condition. They'd have options.

What we did at that time was we looked at the thera-
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peutic classes where there were a lot of these me-too drugs, and we decided, based on clinical evidence and cost, what the underlying reference drug price should be. That's a daily…. It's a calculation, but essentially, the most cost-effective and effective drug in that therapeutic class is the reference product.

The PharmaCare program will cover up to the cost of that reference product, and if a patient wants a different drug within that class, they'd have to pay the remaining amount out of pocket. Again, it's based on first-line, second-line, third-line therapy, and the limited drug coverage rules apply to that too. So if a drug isn't effective based on a physician's recommendation, the patient could get another drug within the RDP as well.

Now, with a lot drugs becoming generic, the RDP is a little bit different. There aren't as many brand-name drugs in those therapeutic classes — those five categories that we cover them in.

Just so you know, two of the classes deal with antihypertensive drugs to treat high blood pressure. One is for gastrointestinal conditions. That's another class. One is for heart conditions, and the last one is NSAIDS for things like arthritis and that — rheumatoid and osteoarthritis. Those are the five target areas.

M. Moneo: One is ACE inhibitors, which are used to treat high blood pressure. Antihypertensives, they're called. The other one is calcium channel blockers, which, again, are used to treat high blood pressure.

The third one is histamine 2 receptor blockers, commonly known as H2 blockers. Those are for gastrointestinal, acid stomach, those types of things.

The fourth one is oral nitrates, which are heart medications. And the last ones are non-steroidal anti-inflammatory drugs, better known as NSAIDS. They're anti-inflammatories. They're often used to treat various forms of arthritis.

The other thing we wanted to bring up was the special authority. All of that being said — all of the plans, all of the costing rules and requirements — we also have a special authority process. This really grants full benefit status to a medication that would otherwise be a partial benefit or a limited coverage, but it is an application process.

This is where the doctor needs to fill out a form, and it goes into our special authority area for approval. It's very much criteria-led, criteria-driven, as Mitch alluded to. There are first lines of therapy that we cover. If that therapy doesn't necessarily work for their patient, they have the opportunity to ask for a drug that perhaps isn't covered at that point to be paid for on behalf of that patient.

There is a process for getting that done. The doctors are very familiar with that and often patients are as well. We have a group of people — pharmacists and technicians — that work in that program, and they receive hundreds of requests a day through that program.

We've also just given you the top ten prescription drugs and, basically, what we spend on them a year. Just as an FYI, we're often asked what the top drugs are. One of the other top drivers right now for us is blood glucose test strips. We spend almost $26 million on test strips, so we're looking at opportunities in that area.

I'm not going to talk to you…. I've put in some slides there about PharmaNet. PharmaNet is our system, a fabulous system. Almost all prescriptions are required to be entered by a pharmacist into PharmaNet. It's a wonderful health system. It shows what drugs you're on. It adjudicates it in real time against all of these plans and makes it quite easy, I think, in British Columbia both to understand what's paid for and what's not. It's a great database that we use for a lot of our research.

The last slide was really around opportunities and challenges. This 25 years…. I mean, I think we kind of laughed out loud when we saw 25 years, especially in the drug world, where it's just non-stop, really, I would say. One of the things that we're really thinking about and trying to wrap our heads around is the patient-centric health care. It's personalized medicine. It's personalized benefits.

As we move further into genomics and testing and the new biologics and subsequent entry biologics, one of the big things that's certainly on our radar going forward are expensive drugs for rare diseases. When I first started this job, I can tell you that the benchmark for an expensive drug was around $50,000 a year for a patient. Now we're seeing requests for $750,000 a year.

I have to tell you that the demand on the system is unrelenting. Everybody wants the new drug. There are, obviously, some new, innovative therapies that are being developed by pharmaceutical companies that are fabulous, but they come at a price. If you go back into some of the slides that I showed you, you'll see the number of prescriptions rising. The number of prescriptions per person is rising.

We're trying to drive the costs down through some of the really good programs that we've got. We negotiate directly on a number of drugs. We have a small team that ne-
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gotiates price directly with them. We're as hard as we can be in getting the best price for British Columbians, but as those numbers climb up, as the number of prescriptions that are being prescribed climbs, as the demand for these expensive drugs continues…. It is a finite resource, and $1 billion a year for 700,000 or 800,000 people is a lot of money. I would say we're absolutely doing our best to control and support people to the best of our ability.

We're going to do a round robin of questions. Just to remind committee members, if we can limit our questions to one or maybe two at the outside to give everyone a chance. If there are any other questions we'll submit them to Susan in writing, and then we'll determine if we need to bring Barb and/or Mitch back for answers or if we can do it via writing.

D. Barnett: Norm, I'm going to hang up. The noise on this phone is incredible. So I will put my questions in writing.

J. Shin: I do have several questions. I think I might need to put this in writing.

R. Lee: It's about pharmacists and physicians working together. I think there was some…. I met a pharmacist yesterday, actually, about some programs — for example, the trial prescription program, the self-monitoring of blood glucose and also the smoking cessation services, that kind of thing. If they can work together and keep the pharmacists a larger scope of practice, the system could save some money. What's the thought about that?

B. Walman: Thank you, Richard, for that. The pharmacy association put forward some white papers — many of you will have seen that or may have met with them — talking about their proposals for basically an expanded scope of service or scope of practice for pharmacists in the community. So we've received those.

We're doing quite a bit of work in British Columbia right now. Pharmacists, as you know, do vaccinations — hundreds of thousands of publicly funded vaccinations. They can do adaptations already. We are paying for med reviews. So we pay $60 or $70, depending on the review that's done, on behalf of British Columbians.

But I agree with you that when you look at the system writ large, there are ways that other health professionals can do some of the work that would certainly support patients in the community. We've received the white papers. I think there were six or seven proposals in those papers that we are looking at.

N. Letnick (Chair): Okay, Richard. If you can send your question by e-mail, that would be great.

D. Bing: Thank you for your presentation. As you were saying, the demand on the system is unrelenting, and there's always demand for new drugs and new approvals, when it's a very finite resource.

When you were talking about the Drug Benefit Council, I was wondering: are all drugs approved as a benefit publicly funded? I noticed, on page 14, approval was given to Botox, Clostridium botulinum toxin. I was thinking that that is more of a cosmetic drug in most cases, and I wonder if we should be publicly funding that drug.

M. Moneo: Botox does have another indication. It's only funded…. It isn't funded for cosmetic purposes or whatever. I'm sorry. I'm not a pharmacist. But that's where the special authority process comes into play that Barbara had mentioned. There's an indication for Botox.

B. Walman: It's medical. I was always pretty excited when I saw Botox on here, to tell you the truth, but apparently, it's not cosmetic. It is just for a medical indication, absolutely.

M. Moneo: Yeah, it's a very limited indication. Some drugs can be used for many different purposes, and with the special authority process that Barbara had mentioned, we can ensure that we're only paying for that drug when it's used for, let's say, pain or whatever, not for cosmetic purposes.

S. Hammell: I just have a couple of questions. In your
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drug review process, in the overview, you have the three pieces. One is Health Canada, then we go to the common drug review, and then we go to Ministry of Health.

Your final piece of your flow chart says that the Ministry of Health makes a decision. Who in the Ministry of Health makes that decision? The common drug review you've made very transparent, very clear. You mention that. So are these the same kinds of standards?

B. Walman: We have a formulary manager, so it comes to the ministry. It's basically me.

It comes to Eric. Eric Lun is our executive director of drug intelligence. They run the formulary. So it comes to them. They make a recommendation.

It comes, basically — the delegated authority — from the minister to list drugs. So it comes to my office.

S. Hammell: In 2012 nine did not get recommended through the common drug review, and then nine were non-beneficial — so 18, in fact, that came into B.C. Are these the same nine?

S. Hammell: Okay. Then there's one other question, if you'll indulge me. It's around the prescription and fraud. In that last page you were talking about fraud.

What I've had happen a couple of times, which has come through my constituency, is people taking on the identity of someone, of a CareCard, and then going and shopping around and getting a lot of medication through fraudulent means.

Part of the problem appears to me to be the fact that CareCards or whatever cards are not demanded at the doctor's office. If they're not demanded at the doctor's office, is there any ability to enforce that or to require that? The police could not follow up. They have no authority to go in and demand that doctors….

This I see as a problem. I'm just wondering if there's any action being taken around that part of the drug abuse in terms of fraudulent behaviour by people. I think it's quite significant.

A couple of things are happening. One is the B.C. Services Card. As you know, we've been working very diligently, because at one point there were more CareCards than people. And it doesn't have a photo ID on it. So one of the mandates, certainly, for the B.C. Services Card is that it would have a mandate and an expiration date.

Right now you're born in British Columbia, you get a card, and that's your PIN number, your PHN number, forever. There's no need to ever re-enrol or to prove your identity.

A couple of other things. There are requirements from a pharmacy standards, a practice perspective. When you go into a pharmacy, a pharmacist is supposed to ensure that it's you. They're supposed to check your drug history on PharmaNet, and they're supposed to give you counselling on that drug. So there are practice standards, for sure.

One of the things that happens, I think, in doctors' offices is that people come to the office, they need to be seen, and they show a card or don't, or they say: "Oh, you remember me from last time." So there are ways that people do get around. But the services card, I think, is our best attempt to certainly cut down on the cases that you're talking about, Sue.

S. Hammell: But can I just ask again about the doctors' offices being required to have people actually show a medical card rather than just tell them? Is there a requirement to do that?

B. Walman: Let me double-check on that for you. I thought that there was, but I think there might be some room to say if you know the person or if you're reasonably confident that…. So let me check on what the wording is around that and get back to you on it.

J. Darcy (Deputy Chair): My question. I could have asked it in the last segment, but I think it makes sense here too. It has to do with doctors now being able to do prescriptions over the telephone. I expect that in the discussions about rolling that out, your division would also have been involved in that.

Can you tell me: what are the limits on what physicians can do as far as…? Is it prescribing or just renewals over the telephone? Also, is it something that doctors are obliged to do?

B. Walman: Yeah, I'm going to get the real details on that. I've got pieces of information that probably wouldn't be that helpful to you.

I know there's a fee schedule that's associated with it. We know that we have requirements from a pharmacy perspective for getting things renewed and what that costs. But let me just see what the actual criteria is and/or was. Those are good questions. I'll get that back to you.

J. Darcy (Deputy Chair): Can I ask something about chemo drugs? Are all chemo drugs covered?

B. Walman: Well, the Cancer Agency makes that decision. I would say that there's a whole listing kind of process that is done on chemo drugs, much the same
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as it's done on community drugs, I'd call them. They go through a drug review process much the same.

I would say not all are covered, necessarily. There are drugs that are chosen by the Cancer Agency for coverage from their perspective.

J. Darcy (Deputy Chair): Okay. Let me just ask it differently. I didn't mean more specialized ones. If someone is being treated for breast cancer at the Cancer Agency and they are told they need X or Y type of chemo, would that, then, be covered?

N. Letnick (Chair): I get a question as well. You almost ended the discussion talking about expensive drugs, technology that's coming down — half a million dollars a year, those kinds of prices and more. How do you decide the value…? I don't want to say the value of the human life, but how do you decide whether or not the public payer is going to pay those kinds of prices to give someone the drugs that they require?

B. Walman: Well, you know, that is probably one of the most difficult questions. Part of it is around a willingness to pay, right? If this is — and it is — a publicly funded, taxpayer-funded, program, we could pay, you know, $1 million, but what is it that we would not be able to pay if it is a finite resource?

The common drug review does do, at a certain level, a cost-benefit analysis. They use quality of life. Is it something that will save your life? Will it give you two more months? I mean, there's a whole list of criteria that they look at — they're called QoLs — and put it against the price of that drug. Then they come up with these recommendations. But candidly, there are drugs that are brought forward that are just too expensive. They're just not financially viable.

The common drug review will come back and say: "Do not list at that price." Like, that price does not make sense from the pharmacoeconomic work that they've done. That's where we get into the negotiation part. Sometimes the companies will agree to lower their price, and other times they choose not to. I have to say those are very difficult.

When you're talking about some of the generics or even some of the older brands that are, you know, $1 or $5 a day, it's not as difficult a decision from an economic perspective. But like I say, $300,000 or $750,000 — and it's for life, so it's not a one-time cost. You need to extrapolate that over the life of your patient.

N. Letnick (Chair): I understand the quality of life here and how that's used, but at some point, as you said, some drugs are just too expensive, and you don't look at them, and some drugs are okay, and they go through the system easier. Then you have the ones in that fringe category that require a lot of analysis. Are those discussions available for the public to see how exactly a decision has been arrived at?

The reason why I ask is — I know you chuckled when you saw 25 years — that's our mandate: to look at the system as the boomers age through. Obviously, there are going to be a lot more drugs available. There are going to be a lot more people wanting them. Perhaps one of the questions we have to ask British Columbians is: at what point is a drug too expensive?

Is that background information available so that we can share with British Columbians now and then ask them: do we have it right as a government?

B. Walman: I would say that we are absolutely thinking about that. I think there is some research being done at the University of British Columbia. There are a couple of researchers that are very interested in kind of the societal willingness to pay and the opportunity costs. "If we do pay $1 million a year, then are you okay having more kids in your kindergarten class?" You know: what's the balance, given that it is, again, taxpayer dollars? Where do you find that kind of sweet spot around what you pay for and what you give up to pay for that?

I think there is some research. I would have to say that we are not alone. We are having those discussions around expensive drugs and how we're going to deal with those in the future.

We're starting to have that even through this pan-Canadian alliance, if you like, so it is something that we're…. For example, the federal government is just starting to…. They've done some consultation. We haven't seen the final product yet. They're talking about orphan drugs — which, again, are drugs, basically, for rare diseases.

They're looking at even some legislation around that, like how that would be dealt with from a federal perspective. We're anxious to see that.

The conversation is starting to be more public, I would say. At this point we don't have anything, I don't think, to share with you, but in the future we will.

N. Letnick (Chair): Okay. I'll put some questions on e-mail as well and send it to Sue, and we'll see what happens with that.

Barbara and Mitch, thank you very much for your presentation — much appreciated. I hope you have the best of the Christmas season.

N. Letnick (Chair): To all the members of the committee, I wish you the same: the best of health during the Christmas break. Remember, if you drink, don't drive. But I'm sure I don't have to remind you of that.

To staff: thank you very much for your work. It's much appreciated, including Hansard back there, who I see has a fireplace going on their monitor. That's on the record now, Hansard, so how do you like that?

Hansard Services publishes transcripts both in print and on the Internet.
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Chair:	* Norm Letnick (Kelowna–Lake Country BC Liberal)
Deputy Chair:	* Judy Darcy (New Westminster NDP)
Members:	* Donna Barnett (Cariboo-Chilcotin BC Liberal)
	* Dr. Doug Bing (Maple Ridge–Pitt Meadows BC Liberal)
	* Katrine Conroy (Kootenay West NDP)
	* Sue Hammell (Surrey–Green Timbers NDP)
	* Linda Larson (Boundary-Similkameen BC Liberal)
	* Richard T. Lee (Burnaby North BC Liberal)
	* Jane Jae Kyung Shin (Burnaby-Lougheed NDP)
	Michelle Stilwell (Parksville-Qualicum BC Liberal)
	* denotes member present
Clerk:	Susan Sourial
Committee Staff:	Josie Schofield (Manager, Committee Research Services)
	Gordon Robinson (Committee Researcher)

Witnesses:	Heather Davidson (Ministry of Health)
	Nick Grant (Ministry of Health)
	Mitch Moneo (Ministry of Health)
	Barbara Walman (Ministry of Health)

REPORT OF PROCEEDINGS (Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH