Non-Insured Health Benefits Program - Annual Report 2008/09

2010
Publication Number: 3192
Cat. No.: H33-1/2-2009E-PDF (PDF Version)
ISBN: 978-1-100-12754-5 (PDF Version)

Table of Contents

• Section 1 - Introduction and Background
• Section 2 - Client Population
• Section 3 - Program Expenditures
• Section 4 - NIHB Pharmacy Expenditure and Utilization Data
• Section 5 - NIHB Dental Expenditure and Utilization Data
• Section 6 - NIHB Medical Transportation Expenditure and Utilization Data
• Section 7 - NIHB Vision Benefits, Other Health Care Benefits and Premiums Expenditure Data
• Section 8 - Regional Expenditure Trends 1999/00 to 2008/09
• Section 9 - Initiatives and Activities
• Section 10 - Financial Resources
• Section 11 - Technical Notes

Section 1 - Introduction and Background

Introduction

This is the fifteenth annual report prepared by the First Nations and Inuit Health Branch (FNIHB) of Health Canada on the Non-Insured Health Benefits (NIHB) Program.

As part of performance management, the report provides national and regional NIHB data, including information on NIHB Program clients, expenditures, benefit types and benefit utilization, for the following target audiences:

• First Nations and Inuit organizations and governments at community, regional and national levels;
• Regional and Headquarters managers and staff of the First Nations and Inuit Health Branch; and
• Others in government and in non-government organizations with an interest in the provision of health care to First Nations and Inuit communities.

Background

The Non-Insured Health Benefits (NIHB) Program provides coverage for 815,800 (as of March 31, 2009) registered First Nations and recognized Inuit on a limited range of medically necessary health-related goods and services when they are not otherwise insured.

Provinces and territories are responsible for delivering health care services, guided by the provisions of the Canada Health Act. These services include insured hospital care and primary health care and the services of physicians and other health professionals. Like all Canadian residents, First Nations and Inuit access these insured services through provincial and territorial governments. There are, however, a number of health-related goods and services that are not insured by provinces and territories or private insurance plans.

To support First Nations and Inuit in reaching an overall health status that is comparable with other Canadians, the NIHB Program covers a specified range of medically necessary benefits. These include:

• Pharmacy benefits (including prescription and over-the-counter drugs as well as medical supplies and equipment);
• Dental services;
• Transportation to access medically necessary services;
• Eye and vision care services;
• Health care premiums in Alberta^* and British Columbia only; and
• Other health care services including short-term crisis intervention mental health counselling.

The NIHB Program operates according to a number of guiding principles:

• All registered First Nations and recognized Inuit normally resident of Canada, and not otherwise covered under a separate agreement with federal or provincial governments or through a separate self-government agreement, are eligible for non-insured health benefits, regardless of location in Canada or income level;
• Benefits will be provided based on professional, medical or dental judgment, consistent with the best practices of health services delivery and evidence-based standards of care;
• There will be national consistency with respect to mandatory benefits, equitable access and portability of benefits and services;
• The Program will be managed in a sustainable and cost-effective manner;
• Management processes will involve transparency and joint review structures, whenever jointly agreed to with First Nations and Inuit organizations; and
• When an NIHB-eligible client is also covered by another public or private health care plan, claims must be submitted to the client's other health care/benefits plan first. NIHB will then coordinate payment with the other payor on eligible benefits.

* In the February 4, 2008 Alberta Speech from the Throne, the provincial government committed to introduce legislation to phase out Alberta Health Care insurance premiums for all Albertans within four years. The Government of Alberta subsequently eliminated these premiums as of January 1, 2009.

Section 2 - Client Population

The NIHB client population has been growing steadily at an average rate of 2.0% over the last ten years. As of March 31, 2009, 815,800 First Nations and Inuit clients were registered in the Status Verification System (SVS) and were eligible to receive benefits under the NIHB Program.

The First Nations and Inuit population has a higher growth rate than the Canadian population as a whole. This is primarily because First Nations and Inuit have a higher birth rate compared to the overall Canadian population. In addition, amendments to the Indian Act, such as the passage of Bill C-31, have resulted in greater numbers of individuals being able to claim or restore their status as Registered Indians.

To become eligible under the Program, an individual must be a resident of Canada and have the following status:

• A registered Indian according to the Indian Act; or
• An Inuk recognized by one of the Inuit Land Claim organizations; or
• An infant less than one year of age, whose parent is an eligible client; and
• Currently registered or eligible for registration, under a provincial or territorial health insurance plan; and
• Is not otherwise covered under a separate agreement (e.g., a self-government agreement) with federal, provincial or territorial governments.

When clients are eligible for benefits under a private health care plan or a public health or social program, claims must be submitted to those plans and programs first before submitting them to the NIHB Program.

Figure 2.1 Eligible Client Population by Region March 2009

NIHB Program client eligibility information is provided by the Status Verification System (SVS). The total number of eligible clients on the SVS at the end of March 2009 was 815,800, an increase of 2.1% from March 2008.

The Ontario Region had the largest eligible population representing 21.6% of the national total, followed by the Manitoba Region at 16.1% and the Saskatchewan Region at 15.9%.

Source: SVS adapted by Program Analysis Division

Figure 2.2 Eligible Client Population by Type and Region March 2008 and March 2009

Of the 815,800 total eligible clients at the end of the 2008/09 fiscal year, 776,392 (95.2%) were First Nations clients while 39,408 (4.8%) were Inuit clients.

As of March 31, 2009 the SVS population statistics reflect a 2.1% growth rate. This is higher than the 0.8% growth rate recorded in the previous year; however, it is comparable to the growth rates recorded prior to 2007/08.* The number of First Nations and Inuit clients both increased by 2.1% in the past year.

From March 2008 to March 2009, Manitoba Region had the highest percentage change in total eligible clients with a 2.6% increase. The Alberta Region and Nunavut followed closely with a 2.4% change, while the Atlantic and Saskatchewan regions both recorded a 2.3% change.

Quick Fact

The share of NIHB client population under 20 years of age (36.9%) is high compared to the overall Canadian population (23.6%). There is a much higher percentage of seniors (65 and over) in the Canadian population (13.7%) than in the NIHB client population (6.1%). The average age of NIHB clients is 30, which is well below the Canadian average of 39.

	First Nations		Inuit		TOTAL		% Change
REGION	March/08	March/09	March/08	March/09	March/08	March/09	2008 to 2009
Atlantic	32,964	33,738	397	403	33,361	34,141	2.3%
Quebec	56,372	57,147	856	881	57,228	58,028	1.4%
Ontario	172,510	175,867	504	534	173,014	176,401	2.0%
Manitoba	127,876	131,222	134	141	128,010	131,363	2.6%
Saskatchewan	126,418	129,273	41	42	126,459	129,315	2.3%
Alberta	100,848	103,299	393	417	101,241	103,716	2.4%
B.C.	118,954	120,833	212	220	119,166	121,053	1.6%
Yukon	7,844	7,918	79	81	7,923	7,999	1.0%
N.W.T.	16,823	17,095	7,519	7,549	24,342	24,644	1.2%
Nunavut	0	0	28,469	29,140	28,469	29,140	2.4%
National	760,609	776,392	38,604	39,408	799,213	815,800	2.1%

Source: SVS adapted by Program Analysis Division

*The 0.8% growth rate recorded in 2007/08 is mainly attributed to the removal of the Labrador Inuit Association (LIA) population transferred under the Nunatsiavut self-government agreement. These individuals were no longer eligible for the NIHB Program and were therefore excluded from the NIHB Program client population.

Figure 2.3 Eligible Client Population March 2000 to March 2009

The total number of eligible clients on the SVS increased from 684,917 at the end of fiscal year 1999/00 to 815,800 in March 2009, an increase of 19.1% over this period.

The NIHB Program client population is characterized as a constantly changing population. Amendments to the Indian Act, such as the passage of Bill C-31, have resulted in significant increases in the NIHB population. In contrast, the conclusion of First Nations and Inuit self-government agreements has resulted in decreases in total client population. For example, under the terms of self-government agreements and associated funding arrangements with the Department of Indian and Northern Affairs Canada, the Nisga'a Lisims Government and Nunatsiavut Government have assumed responsibility for the delivery of non-insured health benefits. Clients covered under these agreements are no longer eligible to receive benefits through Health Canada's NIHB Program.

Source: SVS adapted by Program Analysis Division

Figure 2.4 Eligible Client Population by Region March 2005 to March 2009

The NIHB Program's total number of eligible clients increased by 7.5% from 759,084 in 2005, to 815,800 in 2009.

Nunavut had the largest increase in eligible clients over this period, with a growth rate of 11.4%, followed by the Manitoba Region at 10.3%, the Saskatchewan Region at 9.6% and the Alberta Region at 9.4%.

The 0.8% annual percentage change in March 2008 is primarily attributed to the decrease in eligible clients in the Atlantic Region resulting from the removal of Nunatsiavut clients who transitioned to self-government.

REGION	March/05	March/06	March/07	March/08	March/09
Atlantic	37,107	37,867	39,191	33,361	34,141
Quebec	54,587	55,436	56,518	57,228	58,028
Ontario	164,716	167,271	170,296	173,014	176,401
Manitoba	119,140	122,166	125,449	128,010	131,363
Saskatchewan	117,974	120,639	124,111	126,459	129,315
Alberta	94,801	97,001	99,553	101,241	103,716
B.C.	113,587	115,574	117,721	119,166	121,053
Yukon	7,711	7,788	7,877	7,923	7,999
N.W.T.	23,306	23,836	23,984	24,342	24,644
Nunavut	26,155	26,862	27,919	28,469	29,140
Total	759,084	774,440	792,619	799,213	815,800
Annual % Change	2.0%	2.0%	2.3%	0.8%	2.1%

Source: SVS adapted by Program Analysis Division

Figure 2.5 Eligible Client Population by Age Group, Gender and Region March 2009

Of the 815,800 eligible clients on the SVS as of March 31, 2009, 50.9% were female (415,398) and 49.1% were male (400,402).

The average age of the eligible client population was 30 years of age. By region, this average ranged from a high of 35 years of age in the Quebec Region to a low of 26 years of age in Nunavut.

The average age of the male and female eligible client population was 29 years and 32 years respectively. The average age for males ranged from 26 years in Nunavut and the Saskatchewan and Alberta regions to 33 years in the Yukon and the Quebec and Ontario regions. The average age for females varied from 26 years in Nunavut to 37 years in the Quebec Region.

The NIHB eligible First Nations and Inuit client population is relatively young with over two-thirds (67.9%) under the age of 40. Of the total population, over one-third or 36.9% are under the age of 20. Seniors (clients 65 years of age and over) represent 6.1% of the total population.

REGION	Atlantic			Quebec
Age Group	Male	Female	Total	Male	Female	Total
0-4	1,213	1,132	2,345	1,802	1,638	3,440
5-9	1,562	1,438	3,000	2,206	2,111	4,317
10-14	1,615	1,613	3,228	2,460	2,324	4,784
15-19	1,634	1,574	3,208	2,629	2,483	5,112
20-24	1,455	1,399	2,854	2,148	2,224	4,372
25-29	1,296	1,340	2,636	2,075	1,964	4,039
30-34	1,201	1,180	2,381	1,914	1,938	3,852
35-39	1,351	1,282	2,633	2,032	2,091	4,123
40-44	1,251	1,360	2,611	2,105	2,294	4,399
45-49	1,127	1,278	2,405	2,073	2,289	4,362
50-54	898	1,113	2,011	1,727	2,138	3,865
55-59	623	839	1,462	1,369	1,636	3,005
60-64	465	657	1,122	1,018	1,346	2,364
65+	889	1,356	2,245	2,304	3,690	5,994
Total	16,580	17,561	34,141	27,862	30,166	58,028
Average Age	30	33	32	33	37	35

 

REGION	Ontario			Manitoba
Age Group	Male	Female	Total	Male	Female	Total
0-4	4,373	4,262	8,635	6,601	6,415	13,016
5-9	6,677	6,377	13,054	7,282	6,989	14,271
10-14	7,708	7,295	15,003	7,301	7,034	14,335
15-19	8,045	7,748	15,793	7,295	7,195	14,490
20-24	7,335	6,920	14,255	6,023	5,747	11,770
25-29	6,608	6,758	13,366	5,089	4,797	9,886
30-34	6,400	6,368	12,768	4,589	4,545	9,134
35-39	6,664	6,692	13,356	4,583	4,792	9,375
40-44	6,809	6,985	13,794	4,393	4,485	8,878
45-49	6,514	7,140	13,654	3,707	3,971	7,678
50-54	5,391	6,273	11,664	2,700	3,009	5,709
55-59	3,939	4,889	8,828	1,877	2,248	4,125
60-64	2,973	3,922	6,895	1,427	1,664	3,091
65+	6,095	9,241	15,336	2,401	3,204	5,605
Total	85,531	90,870	176,401	65,268	66,095	131,363
Average Age	33	36	34	27	28	28

 

REGION	Saskatchewan			Alberta			B.C.
Age Group	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	6,174	6,072	12,246	4,712	4,699	9,411	4,036	3,831	7,867
5-9	7,233	7,076	14,309	5,878	5,542	11,420	4,887	4,751	9,638
10-14	7,188	7,150	14,338	6,010	5,628	11,638	5,236	4,944	10,180
15-19	7,620	7,274	14,894	5,987	5,623	11,610	5,898	5,422	11,320
20-24	6,456	6,300	12,756	5,028	4,922	9,950	5,452	5,180	10,632
25-29	5,209	5,144	10,353	4,183	4,363	8,546	4,889	4,684	9,573
30-34	4,607	4,679	9,286	3,712	3,690	7,402	4,413	4,414	8,827
35-39	4,479	4,634	9,113	3,438	3,650	7,088	4,508	4,555	9,063
40-44	4,146	4,428	8,574	3,283	3,422	6,705	4,534	4,797	9,331
45-49	3,424	3,760	7,184	2,790	3,170	5,960	4,525	5,087	9,612
50-54	2,431	2,819	5,250	1,966	2,398	4,364	3,459	4,047	7,506
55-59	1,633	1,977	3,610	1,363	1,774	3,137	2,573	3,013	5,586
60-64	1,152	1,475	2,627	963	1,301	2,264	1,814	2,236	4,050
65+	1,975	2,800	4,775	1,764	2,457	4,221	3,261	4,607	7,868
Total	63,727	65,588	129,315	51,077	52,639	103,716	59,485	61,568	121,053
Average Age	26	28	27	26	28	27	31	34	32

 

REGION	Yukon			N.W.T.
Age Group	Male	Female	Total	Male	Female	Total
0-4	201	176	377	888	812	1,700
5-9	282	257	539	948	992	1,940
10-14	332	309	641	1,194	1,147	2,341
15-19	361	332	693	1,439	1,406	2,845
20-24	328	322	650	1,201	1,138	2,339
25-29	329	312	641	1,017	990	2,007
30-34	297	265	562	839	868	1,707
35-39	354	302	656	969	948	1,917
40-44	381	343	724	916	972	1,888
45-49	372	375	747	721	881	1,602
50-54	215	273	488	544	693	1,237
55-59	149	230	379	428	496	924
60-64	126	173	299	316	381	697
65+	246	357	603	673	827	1,500
Total	3,973	4,026	7,999	12,093	12,551	24,644
Average Age	33	36	34	30	32	31

 

REGION	Nunavut			TOTAL
Age Group	Male	Female	Total	Male	Female	Total
0-4	1,698	1,614	3,312	31,698	30,651	62,349
5-9	1,843	1,715	3,558	38,798	37,248	76,046
10-14	1,703	1,599	3,302	40,747	39,043	79,790
15-19	1,698	1,580	3,278	42,606	40,637	83,243
20-24	1,454	1,416	2,870	36,880	35,568	72,448
25-29	1,129	1,148	2,277	31,824	31,500	63,324
30-34	975	966	1,941	28,947	28,913	57,860
35-39	960	922	1,882	29,338	29,868	59,206
40-44	903	934	1,837	28,721	30,020	58,741
45-49	708	703	1,411	25,961	28,654	54,615
50-54	431	451	882	19,762	23,214	42,976
55-59	381	362	743	14,335	17,464	31,799
60-64	326	301	627	10,580	13,456	24,036
65+	597	623	1,220	20,205	29,162	49,367
Total	14,806	14,334	29,140	400,402	415,398	815,800
Average Age	26	26	26	29	32	30

Source: SVS adapted by Program Analysis Division

Figure 2.6 Annual Population Growth, Canadian Population and Eligible Client Population 2000 to 2009

From 2000 to 2009, the Canadian population increased by 9.8% while the NIHB eligible First Nations and Inuit client population had an increase of 19.1%. Over the same period, the First Nations and Inuit client population grew at an average annual rate of 2.0% compared to 1.0% for the Canadian population. These trends in population growth are expected to continue, primarily as a result of the higher birth rate within First Nations and Inuit populations. As mentioned in Figure 2.2, the decrease in NIHB Program client population growth in 2007/08 was mainly attributed to the removal of the Labrador Inuit Association (LIA) population in the Atlantic Region who now receive non-insured health benefits through the Nunatsiavut Government.

Source: SVS and Statistics Canada Catalogue No. 91-002-XWE, Quarterly Demographic Statistics

Figure 2.7 Population Analysis by Age Group

The overall First Nations and Inuit population is relatively young compared to the general Canadian population. However, due to the aging of this population, it is anticipated that the costs associated with delivering non-insured health benefits, particularly pharmacy benefits, to this client population will increase significantly in the coming years.

A comparison of March 2005 to March 2009 eligible client population shows an aging population. The proportional share of the client population 40 and above increased by 8.2% from 226,483 in 2005 to 261,534 in 2009.

Proportion of Canadian Population and of the First Nations and Inuit (FN&I) Client Population by Age Group

Source: SVS adapted by Program Analysis Division and Statistics Canada CANSIM table 051-0001, Population by Age and Sex Group

Proportion of Eligible First Nations and Inuit Client Population by Age Group

Source: SVS adapted by Program Analysis Division

Section 3 - Program Expenditures

Figure 3.1 NIHB Expenditures by Benefit ($ Millions) 2008/09

Total Non-Insured Health Benefits expenditures in 2008/09 were $934.6 million. Of this total, NIHB Pharmacy costs (including medical supplies and equipment) represented the largest proportion at $419.0 million (44.8%), followed by NIHB Medical Transportation costs at $275.0 million (29.4%) and NIHB Dental costs at $176.4 million (18.9%).

Source: FIRMS adapted by Program Analysis Division

*Not reflected in the $934.6 million in NIHB expenditures is approximately $35.9 million in administration costs including Program staff and other headquarters and regional costs. More detail is provided in Figure 10.3.

Figure 3.2 NIHB Expenditures and Growth by Benefit 2007/08 and 2008/09

NIHB expenditures increased 4.0% or $36.4 million from 2007/08 to 2008/09. This increase (4.0%) was the lowest annual growth rate in the past eight years for the NIHB Program.

The highest net growth in expenditures over fiscal year 2007/08 was pharmacy benefits at $15.7 million followed by medical transportation benefits which increased by $12.7 million and dental benefits by $10.8 million.

Dental benefits had the highest growth rate in 2008/09, recording a 6.5% increase over the previous year.

The NIHB Premiums benefit category showed a decrease over the previous year at -9.5% ($2.8 million). This is mainly attributed to the elimination of Alberta premiums starting January 1, 2009.

The NIHB Other Health Care category, comprised mainly of short-term crisis mental health counselling, had a decrease over the last fiscal year of -7.5% ($923 thousand). This decrease can be partly attributed to funding arrangements allocated for crisis mental health counselling services through the Indian Residential Schools Resolution Health Support Program. The expenditures for the Indian Residential Schools Resolution Health Support Program have more than doubled from $12.1 million in 2007/08 to $28.1 million in 2008/09. The increased utilization of this Program has been a significant factor contributing to the decrease in NIHB mental health crisis counselling utilization rates and expenditures.

BENEFIT	Total Expenditures ($ 000's) 2007/08	Total Expenditures ($ 000's) 2008/09	% Change From 2007/08
Medical Transportation	$262,294*	$274,980	4.8%
Pharmacy	403,248*	418,968	3.9%
Dental	165,576	176,372	6.5%
Other Health Care	12,289	11,366	-7.5%
Premiums	29,211	26,430	-9.5%
Vision Care	25,621*	26,490	3.4%
Total Expenditures	$898,239	$934,607	4.0%

Source: FIRMS adapted by Program Analysis Division

*Number from 2007/08 NIHB Annual Report restated here and in subsequent sections. For further information see technical notes in Section 11.

Figure 3.3 NIHB Expenditures by Benefit and Region ($ 000's) 2008/09

The Manitoba Region accounted for the highest proportion of total expenditures with $183.5 million, or 19.6% of the national total, followed by the Ontario Region at $165.2 million (17.7%), and the Alberta and Saskatchewan regions with $133.6 million (14.3%) and $131.7 million (14.1%) respectively.

By contrast, the lowest expenditures were in the Yukon ($9.2 million) and Northwest Territories ($23.6 million). These totals represented 1.0% and 2.5% respectively of the national total.

Manitoba experienced the highest expenditure growth over the last fiscal year of 6.1% and represented the greatest proportion of total expenditures at 19.6%. In comparison, Ontario had relatively low expenditure growth of 0.8% and had a 17.7% proportional share of NIHB expenditures.

Headquarters expenditures in the table represent costs paid for health information and claims processing services.

Region	Medical Transportation	Pharmacy	Dental	Other Health Care	Premiums	Vision Care	TOTAL
Atlantic	$4,655	$20,119	$4,945	$251	$-	$1,596	$31,567
Quebec	20,502	36,069	12,895	375	-	1,220	71,060
Ontario	45,088	77,244	35,457	2,158	-	5,204	165,150
Manitoba	82,354	71,081	24,434	2,605	-	3,071	183,545
Saskatchewan	35,772	62,809	28,102	870	-	4,166	131,718
Alberta	35,357	54,189	25,016	3,940	9,920	5,225	133,646
British Columbia	22,711	56,104	24,718	1,165	16,510	3,251	124,458
Yukon	2,938	3,779	2,246	1	-	242	9,206
N.W.T.	7,952	8,210	6,279	-	-	1,130	23,571
Nunavut	17,653	7,084	8,349	-	-	1,387	34,473
Headquarters	-	22,281	3,932	-	-	-	26,213*
Total	$274,980	$418,968	$176,372	$11,366	$26,430	$26,490	$934,607

Source: FIRMS adapted by Program Analysis Division

*Note: A one time $3.0 million charge in contract reprocurement costs associated with the new claims processor ESI are included in the $26.2 million cost for processing claims.

Figure 3.4 Proportion of NIHB Expenditures by Region 2008/09

In 2008/09, the Manitoba Region had the highest proportion of total NIHB expenditures (19.6%) and accounted for almost one-third (29.9%) of the total NIHB Medical Transportation expenditures. This reflects the large number of First Nations clients living in remote or fly-in only northern communities in the Manitoba Region.

The Ontario Region, which accounted for 17.7% of total NIHB expenditures in 2008/09, recorded 20.1% of total NIHB Dental expenditures and 18.4% of total NIHB Pharmacy expenditures.

The proportion of NIHB Vision Care expenditures ranged from a high of 19.7% in the Alberta Region and 19.6% in the Ontario Region to a low of 0.9% in the Yukon.

The Alberta Region (34.7%) and the Manitoba Region (22.9%) combined accounted for over one half of the total NIHB Other Health Care expenditures in 2008/09.

In 2008/09, 62.5% of NIHB Premiums expenditures were paid in the British Columbia Region and 37.5% were paid in the Alberta Region. As of January 1, 2009, NIHB no longer pays for premiums in the Alberta Region as a result of the provincial decision to eliminate health care insurance premiums for all Albertans.

REGION	Medical Transportation	Pharmacy	Dental	Other Health Care
Atlantic	1.7%	4.8%	2.8%	2.2%
Quebec	7.5%	8.6%	7.3%	3.3%
Ontario	16.4%	18.4%	20.1%	19.0%
Manitoba	29.9%	17.0%	13.9%	22.9%
Saskatchewan	13.0%	15.0%	15.9%	7.7%
Alberta	12.9%	12.9%	14.2%	34.7%
British Columbia	8.3%	13.4%	14.0%	10.2%
Yukon	1.1%	0.9%	1.3%	0%
N.W.T.	2.9%	2.0%	3.6%	0%
Nunavut	6.4%	1.7%	4.7%	0%
Headquarters	0%	5.3%	2.2%	0%
Total	100%	100%	100%	100%

 

REGION	Premiums	Vision Care	Proportion of NIHB Expenditures	Proportion of NIHB Population
Atlantic	0%	6.0%	3.4%	4.2%
Quebec	0%	4.6%	7.6%	7.1%
Ontario	0%	19.6%	17.7%	21.6%
Manitoba	0%	11.6%	19.6%	16.1%
Saskatchewan	0%	15.7%	14.1%	15.9%
Alberta	37.5%	19.7%	14.3%	12.7%
British Columbia	62.5%	12.3%	13.3%	14.8%
Yukon	0%	0.9%	1.0%	1.0%
N.W.T.	0%	4.3%	2.5%	3.0%
Nunavut	0%	5.2%	3.7%	3.6%
Headquarters	0%	0%	2.8%	N/A
Total	100%	100%	100%	100%

Source: FIRMS and SVS adapted by Program Analysis Division

Figure 3.5 Proportion of NIHB Regional Expenditures by Benefit 2008/09

At the national level, almost three-quarters of total Program expenditures occurred in two benefit areas: pharmacy (44.8%) and medical transportation (29.4%). Dental expenditures accounted for almost one-fifth (18.9%) of total NIHB expenditures.

NIHB Medical Transportation expenditures accounted for 51.2% of total expenditures in Nunavut compared to 14.7% in the Atlantic Region. In the Atlantic Region, 63.7% of total expenditures were spent on pharmacy benefits compared to a low of 20.5% in Nunavut.

The proportion of dental expenditures ranged from 13.3% in the Manitoba Region to 26.6% in the Northwest Territories.

Pharmacy costs represented the highest percentage of total expenditures in all regions except Nunavut and the Manitoba Region, where transportation accounted for the largest share of costs.

REGION	Medical Transportation	Pharmacy	Dental	Other Health Care	Premiums	Vision Care	TOTAL
Atlantic	14.7%	63.7%	15.7%	0.8%	0%	5.1%	100%
Quebec	28.9%	50.8%	18.1%	0.5%	0%	1.7%	100%
Ontario	27.3%	46.8%	21.5%	1.3%	0%	3.2%	100%
Manitoba	44.9%	38.7%	13.3%	1.4%	0%	1.7%	100%
Saskatchewan	27.2%	47.7%	21.3%	0.7%	0%	3.2%	100%
Alberta	26.5%	40.5%	18.7%	2.9%	7.4%	3.9%	100%
British Columbia	18.2%	45.1%	19.9%	0.9%	13.3%	2.6%	100%
Yukon	31.9%	41.1%	24.4%	0%	0%	2.6%	100%
N.W.T.	33.7%	34.8%	26.6%	0%	0%	4.8%	100%
Nunavut	51.2%	20.5%	24.2%	0%	0%	4.0%	100%
Headquarters	0%	85.0%	15.0%	0%	0%	0%	100%
National	29.4%	44.8%	18.9%	1.2%	2.8%	2.8%	100%

Source: FIRMS adapted by Program Analysis Division

Figure 3.6 NIHB Annual Expenditures ($ Millions) 1999/00 to 2008/09

In 2008/09, NIHB Program expenditures were $934.6 million, up 4.0% from $898.2 million in 2007/08. Since 1999/00, total expenditures have grown by 71.5%. The average annualized growth over this period was 6.1%.

Source: FIRMS adapted by Program Analysis Division

Figure 3.7 Percentage Change in NIHB Annual Expenditures 1999/00 to 2008/09

The expenditures for the Non-Insured Health Benefits Program increased by 4.0% to $934.6 million in 2008/09. There has been wide variation in growth rates between 1999/00 and 2008/09, with a low of 4.0% in 2008/09 to a high of 9.6% in 2002/03. The average annualized growth over this period was 6.1%.

There are several factors that contribute to fluctuations in NIHB expenditure growth rates. These include policy changes designed to improve access to the Program and those intended to promote Program sustainability. Variations in the rates of growth have also resulted from self-government initiatives and changes in service delivery models within the Program and between the federal government and the provinces and territories.

Source: FIRMS adapted by Program Analysis Division

Figure 3.8 NIHB Annual Expenditures by Benefit ($ 000's) 1999/00 to 2008/09

The expenditures for NIHB Pharmacy benefits have grown more than other benefit areas in the period from 1999/00 to 2008/09. Pharmacy expenditures rose by 102.5% from $206.9 million in 1999/00 to $419.0 million in 2008/09. Over the same period, NIHB Medical Transportation expenditures grew by 55.3% and dental expenditures increased by 64.9%. Vision care and premiums expenditures had increases of 33.5% and 46.6% respectively over this period.

NIHB Other Health Care expenditures, comprised mainly of short-term crisis mental health counselling, decreased by 29.4% over this same time period. A negative 7.5% growth rate was recorded in fiscal year 2008/09. This benefit area continues to be impacted by funding arrangements allocated for crisis mental health counselling services through the Indian Residential Schools Resolution Health Support Program.

Benefit	1999/00		2000/01		2001/02		2002/03		2003/04
Medical Transportation	$177,078		$182,851		$195,719		$203,952		$205,793
Pharmacy	206,869		228,861		252,846		290,112		326,982
Dental	106,975		109,852		124,468		131,021		134,504
Other Health Care	16,108		16,775		14,135		16,894		16,557
Premiums	18,030		17,779		18,596		23,902		28,614
Vision Care	19,843		19,748		22,020		22,259		24,420
Total	$544,903		$575,866		$627,784		$688,140		$736,870
Annual % Change	5.7%		5.7%		9.0%		9.6%		7.1%

 

Benefit	2004/05		2005/06		2006/07		2007/08		2008/09
Medical Transportation	$211,527		$225,379		$241,602		$262,294		$274,980
Pharmacy	343,879		368,398		386,190		403,248		418,968
Dental	142,956		153,900		158,584		165,576		176,372
Other Health Care	16,904		17,115		16,271		12,289		11,366
Premiums	27,830		27,987		28,659		29,211		26,430
Vision Care	24,629		24,968		24,894		25,621		26,490
Total	$767,726		$817,748		$856,201		$898,239		$934,607
Annual % Change	4.2%		6.5%		4.7%		4.9%		4.0%

Source: FIRMS adapted by Program Analysis Division

Figure 3.9 Percentage Growth in NIHB Expenditures by Region 1999/00 to 2008/09

From 1999/00 to 2008/09, total NIHB expenditures in the Manitoba Region increased the most (99.4%) followed by the combined Northwest Territories and Nunavut and Saskatchewan Region, recording rates of growth of 96.3% and 88.1% respectively.

The Atlantic Region had the lowest increase at 43.7%. This low rate of growth can be attributed primarily to the movement towards self-government for Nunatsiavut Inuit that commenced in December of 2005. This transition process has resulted in a reallocation of funding previously identified for Atlantic Region clients to the Nunatsiavut Government.

Source: FIRMS adapted by Program Analysis Division

Figure 3.10 Per Capita NIHB Expenditures by Region (Excluding Premiums) 2008/09

The national per capita expenditure for all benefits in 2008/09 was $1,081. This is a slight increase from the 2007/08 national per capita expenditure of $1,061.

The Manitoba Region had the highest per capita cost at $1,397 in 2008/09. The Quebec Region ranks second in per capita expenditures at $1,225 followed by the Alberta Region at $1,193.

If premiums that were paid by the Program were included in these calculations, per capita costs in Alberta and British Columbia regions would be $1,289 and $1,028 respectively, with the national total adjusted to $1,114.

Source: FIRMS and SVS adapted by Program Analysis Division

Section 4 - NIHB Pharmacy Expenditure and Utilization Data

The NIHB Program covers claims for pharmacy benefits not covered by private or provincial/territorial health insurance plans. In fiscal year 2008/09, NIHB Pharmacy benefits totalled $419.0 million or 44.8% of total NIHB expenditures.

The objective of the drug benefit program is to provide eligible clients with access to pharmacy services that will:

• Contribute to optimal health outcomes in a fair, equitable and cost-effective manner, recognizing the unique health needs of First Nations and Inuit clients; and
• Provide drug benefits and services based on professional judgment, consistent with the current best practices of health services delivery and evidence-based standards of care.

The NIHB Program covers prescription drugs listed on the Non-Insured Health Benefits Drug Benefit List and approved over-the-counter medications. NIHB policy is to pay the 'lowest cost alternative drug', and to reimburse only the best price alternative or equivalent product in a group of interchangeable drug products.

In addition, the Program monitors professional fees closely to find the right balance between providing reasonable compensation to providers and maximizing the funding available for client benefits. In this regard, in 2008/09 the NIHB Program introduced the new Short-Term Dispensing Policy. This policy establishes compensation criteria for short-term refills of chronic use medications, and was implemented to address the significant increases in the frequency of the short-term dispensing of chronic medications that the Program has experienced in recent years.

Like prescription and over-the-counter medications, medical supplies and equipment benefits are covered in accordance with Program policies. Recipients must obtain a prescription from a physician or other licensed prescriber for medical supplies and/or equipment, and have the prescription filled at a pharmacy or approved medical supply and equipment provider. Items covered in this category of benefit include:

• Audiology items, such as hearing aids;
• Medical equipment including wheelchairs and walkers;
• Medical supplies, such as bandages and dressings;
• Orthotics and custom footwear;
• Pressure garments;
• Prosthetics;
• Oxygen supplies and equipment; and
• Respiratory supplies and equipment.

Figure 4.1 Distribution of NIHB Pharmacy Expenditures ($ Millions) 2008/09

In fiscal year 2008/09, NIHB Pharmacy benefits totalled $419.0 million. Figure 4.1 illustrates the components of pharmacy expenditures under the NIHB Program. The cost of prescription drugs paid through the Health Information and Claims Processing Services (HICPS) system was the largest component, accounting for $311.7 million or 74.4% of all NIHB Pharmacy expenditures, followed by over-the-counter (OTC) drugs (paid through HICPS) which totalled $50.5 million or 12.0%. Medical supplies and equipment (MS&E) paid through HICPS was the third largest component in the pharmacy benefit at $24.8 million or 5.9%. In total, the three components managed through automated claims processing accounted for 92.4% of all pharmacy costs.

Drugs and MS&E (Regional), at $1.4 million or 0.3%, refers to regionally managed prescription drugs and OTC medication. This category also includes medical supplies and equipment costs paid through regional offices.

Contributions, which accounted for $8.3 million or 2.0% of total pharmacy costs, are used to fund the provision of pharmacy benefits through agreements such as those with the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta.

Other costs totalled $22.3 million or 5.3% in 2008/09. Included in this total are Headquarters expenditures which represent costs related to automated claims payment.

Source: FIRMS adapted by Program Analysis Division

Figure 4.2 Total NIHB Pharmacy Expenditures by Type and Region ($ 000's) 2008/09

Prescription drug costs claimed electronically and paid through the Health Information and Claims Processing Services (HICPS) system represented the largest component of total costs accounting for $311.7 million or 74.4% of all NIHB Pharmacy costs. The Ontario Region (19.4%) and the Manitoba Region (18.1%) had the largest proportions of these costs in 2008/09.

The next highest component was over-the-counter drug costs at $50.5 million or 12.0%. The Ontario Region (21.6%), Manitoba Region (20.1%) and the Saskatchewan Region (17.9%) had the largest proportions of these costs in 2008/09.

The third highest component was the combined medical supplies and equipment (MS&E) category at $24.8 million (5.9%). The Alberta Region (18.8%) and the Manitoba Region (18.4%) had the highest proportions of MS&E costs in 2008/09.

REGION	OPERATING
	Prescription Drugs	OTC Drugs	Drugs/MS&E Regional	Medical Supplies	Medical Equipment	Other Costs
Atlantic	$15,707	$2,764	$11	$455	$818	-
Quebec	30,142	4,968	3	366	580	-
Ontario	60,325	10,916	21	959	2,461	-
Manitoba	56,339	10,166	7	1,671	2,899	-
Saskatchewan	48,171	9,045	1,138	1,608	2,808	-
Alberta	39,191	5,462	63	1,591	3,059	-
British Columbia	46,602	5,274	58	1,054	2,676	-
Yukon	3,140	315	23	90	212	-
N.W.T.	6,318	805	15	386	636	-
Nunavut	5,785	738	110	233	219	-
Headquarters	-	-	-	-	-	22,281
Total	$311,720	$50,451	$1,447	$8,412	$16,368	$22,281

 

REGION	Total Operating Costs	Total Contribution Costs	Total Costs
Atlantic	$19,756	$363	$20,119
Quebec	36,059	10	36,069
Ontario	74,682	2,562	77,244
Manitoba	71,081	0	71,081
Saskatchewan	62,769	40	62,809
Alberta	49,366	4,823	54,189
British Columbia	55,663	441	56,104
Yukon	3,779	0	3,779
N.W.T.	8,159	51	8,210
Nunavut	7,084	0	7,084
Headquarters	22,281	-	22,281
Total	$410,679	$8,290	$418,968

Source: FIRMS adapted by Program Analysis Division

Figure 4.3 Annual NIHB Pharmacy Expenditures 2004/05 to 2008/09

NIHB Pharmacy expenditures increased by 3.9% during fiscal year 2008/09. This represents a 0.5 percentage point decrease over the previous year's growth rate. Over the past five years, growth in pharmacy expenditures has ranged from a high of 7.1% in 2005/06 to a low of 3.9% in 2008/09. The annualized growth rate over these five years is 5.1%.

Over the past five years there has been movement towards increased stability in NIHB Pharmacy expenditures. Reasons for this trend include the introduction of lower cost generic drugs as they become available on the market, optimizing drug utilization, and policy changes designed to promote NIHB Program sustainability.

The highest rate of growth in NIHB Pharmacy expenditures in 2008/09 took place in Nunavut, which increased by 7.7% over the previous fiscal year. The Atlantic Region had the second highest growth rate at 6.0%, followed by the Northwest Territories at 4.4%.

NIHB Pharmacy Expenditures and Annual Percentage Change

Source: FIRMS adapted by Program Analysis Division

NIHB Pharmacy Expenditures ($ 000's)

Region	2004/05	2005/06	2006/07	2007/08	2008/09
Atlantic	$17,533	$18,293	$18,938	$18,984	$20,119
Quebec	29,959	31,771	33,486	35,372	36,069
Ontario	67,508	73,223	77,788	77,191	77,244
Manitoba	53,998	59,409	64,966	69,317	71,081
Saskatchewan	52,636	55,687	58,083	60,749	62,809
Alberta	48,207	51,141	52,424	54,353	54,189
British Columbia	46,670	49,734	50,387	54,290	56,104
Yukon	3,476	3,655	3,641	3,802	3,779
N.W.T.	7,544	8,010	8,151	7,863	8,210
Nunavut	4,734	4,902	5,526	6,579	7,084
Headquarters	11,615	12,574	12,800	14,750	22,281
Total	$343,879	$368,398	$386,190	$403,248	$418,968

Source: FIRMS adapted by Program Analysis Division

Figure 4.4 Per Capita NIHB Pharmacy Expenditures by Region 2008/09

In 2008/09, the national per capita expenditure for NIHB Pharmacy benefits was $486, a marginal decrease from $487 recorded in 2007/08.

The Quebec Region had the highest per capita NIHB Pharmacy expenditure at $622, followed by the Atlantic Region at $589 and the Manitoba Region at $541.

The highest increases in per capita costs were in the Atlantic Region ($20) and Nunavut ($12). However, Nunavut continued to have the lowest per capita expenditure at $243.

A relatively low per capita expenditure in the Northwest Territories and Nunavut is partially attributed to lower than average utilization rates. (Refer to Figure 4.6)

Source: FIRMS and SVS adapted by Program Analysis Division

Figure 4.5 NIHB Pharmacy Operating Expenditures per Claimant by Region 2008/09

In 2008/09, the national average expenditure per eligible client receiving at least one pharmacy benefit was $745, a very slight increase over the recorded amount of $743 in 2007/08.

The Quebec Region had the highest average NIHB Pharmacy expenditure per claimant at $1,041, followed by the Atlantic Region at $883 and the Manitoba Region at $799. Nunavut had the lowest expenditure per claimant at $552, followed by the Northwest Territories at $621.

Quick Fact

An analysis of NIHB expenditures by claimant, based on age, indicates that costs increase with age. In early childhood, these expenditures are quite low but they increase with age and reach a peak in the older age groupings. In 2008/09, a claimant between the ages of 0 and 4 years of age incurred approximately $158 in expenditures on average, while claimants 65 years of age and older had the highest costs at approximately $2,119 per claimant.

Source: HICPS and FIRMS adapted by Program Analysis Division

Figure 4.6 NIHB Pharmacy Utilization Rates by Region 2004/05 to 2008/09

Utilization rates represent those clients who received at least one pharmacy benefit paid through the Health Information and Claims Processing Services (HICPS) system in the fiscal year as a proportion of the total number of clients eligible to receive benefits as registered on the Status Verification System (SVS) in that year.

In 2008/09, the national utilization rate was 64% for NIHB Pharmacy benefits paid through the HICPS system. This is identical to the utilization rates recorded since 2006/07. Regional rates ranged from 44% in Nunavut to 73% in the Saskatchewan Region.

The rates understate the actual level of service as the data do not include pharmacy services provided through contribution agreements and benefits provided through community health facilities. For example, if the Bigstone Cree Nation client population were excluded from the Alberta Region's population because the HICPS data do not capture any services used by this population, the utilization rate for pharmacy benefits in Alberta would have been 72% in 2008/09. The same scenario would apply for Ontario Region. If the Akwesasne client population were removed from the Ontario Region's population, the utilization rate for pharmacy benefits would have been 59%. If both the Bigstone and Akwesasne client population were removed from the overall NIHB population, the national utilization rate for pharmacy benefits would have been 65%.

The increased utilization rate recorded in the Atlantic Region (66%) in 2007/08 and 2008/09 compared to the previous years can be attributed to the removal of the Nunatsiavut clients who transitioned to self-government and were no longer eligible to receive coverage for pharmacy benefits under the NIHB Program.

Pharmacy Utilization

REGION	2004/05	2005/06	2006/07	2007/08	2008/09
Atlantic	60%	59%	58%	66%	66%
Quebec	61%	60%	60%	59%	60%
Ontario	56%	56%	56%	56%	55%
Manitoba	68%	69%	69%	68%	68%
Saskatchewan	76%	76%	74%	74%	73%
Alberta	70%	70%	68%	68%	67%
British Columbia	69%	70%	69%	68%	68%
Yukon	64%	65%	65%	64%	64%
N.W.T.	52%	52%	53%	53%	53%
Nunavut	42%	42%	43%	41%	44%
National	65%	65%	64%	64%	64%

Source: HICPS and SVS adapted by Program Analysis Division

Figure 4.7 NIHB Pharmacy Claimants by Age Group, Gender and Region 2008/09

Of the 815,800 clients eligible to receive benefits under the NIHB Program, 521,121 (64%) claimants received at least one pharmacy item paid through the Health Information and Claims Processing Services (HICPS) system in 2008/09.

Of this total, 292,550 were female (56%) and 228,571 were male (44%). This compares to the total eligible population where 51% were female and 49% were male.

The average age of pharmacy claimants was 32 years. The average age for male and female claimants was 31 and 33 years of age, respectively. The highest average age of pharmacy claimants was found in the Yukon (38 years of age), while the lowest was in the Saskatchewan Region (29 years of age).

Almost one-third (32%) of pharmacy claimants were under 20 years of age. Thirty-five percent of male claimants were in this age group while females accounted for 30%. Seniors (age 65 and over) represented approximately 7% of all pharmacy claimants in 2008/09.

REGION	Atlantic			Quebec
Age Group	Male	Female	Total	Male	Female	Total
0-4	813	765	1,578	1,069	948	2,017
5-9	958	928	1,886	1,063	1,023	2,086
10-14	889	939	1,828	1,059	1,033	2,092
15-19	873	1,144	2,017	1,047	1,714	2,761
20-24	721	1,073	1,794	873	1,663	2,536
25-29	719	1,077	1,796	895	1,487	2,382
30-34	691	930	1,621	914	1,455	2,369
35-39	818	945	1,763	1,082	1,490	2,572
40-44	761	984	1,745	1,166	1,638	2,804
45-49	722	901	1,623	1,218	1,615	2,833
50-54	630	833	1,463	1,077	1,545	2,622
55-59	465	660	1,125	873	1,181	2,054
60-64	335	469	804	724	1,014	1,738
65+	506	825	1,331	1,449	2,329	3,778
Total	9,901	12,473	22,374	14,509	20,135	34,644
Average Age	31	33	32	36	38	37

 

REGION	Ontario			Manitoba
Age Group	Male	Female	Total	Male	Female	Total
0-4	2,169	2,010	4,179	4,108	3,985	8,093
5-9	3,099	2,936	6,035	4,132	4,139	8,271
10-14	3,109	3,089	6,198	3,709	3,748	7,457
15-19	3,189	4,646	7,835	3,507	4,998	8,505
20-24	3,041	4,718	7,759	3,155	4,685	7,840
25-29	2,929	4,750	7,679	2,852	3,989	6,841
30-34	3,039	4,396	7,435	2,815	3,790	6,605
35-39	3,338	4,451	7,789	2,997	3,960	6,957
40-44	3,606	4,650	8,256	3,016	3,675	6,691
45-49	3,617	4,758	8,375	2,773	3,399	6,172
50-54	3,145	4,161	7,306	2,113	2,639	4,752
55-59	2,426	3,243	5,669	1,556	2,004	3,560
60-64	1,980	2,613	4,593	1,237	1,499	2,736
65+	3,344	5,243	8,587	1,867	2,616	4,483
Total	42,031	55,664	97,695	39,837	49,126	88,963
Average Age	35	37	36	29	31	30

 

REGION	Saskatchewan			Alberta
Age Group	Male	Female	Total	Male	Female	Total
0-4	4,386	4,236	8,622	3,032	2,940	5,972
5-9	4,726	4,896	9,622	3,363	3,293	6,656
10-14	4,108	4,502	8,610	3,050	3,142	6,192
15-19	4,137	5,552	9,689	3,070	3,866	6,936
20-24	3,621	5,468	9,089	2,722	3,872	6,594
25-29	3,178	4,499	7,677	2,476	3,542	6,018
30-34	3,016	4,036	7,052	2,325	2,957	5,282
35-39	3,086	3,986	7,072	2,233	2,918	5,151
40-44	2,981	3,773	6,754	2,257	2,674	4,931
45-49	2,564	3,273	5,837	2,016	2,561	4,577
50-54	1,894	2,513	4,407	1,481	2,010	3,491
55-59	1,365	1,770	3,135	1,062	1,473	2,535
60-64	1,016	1,326	2,342	776	1,082	1,858
65+	1,706	2,441	4,147	1,404	1,948	3,352
Total	41,784	52,271	94,055	31,267	38,278	69,545
Average Age	28	29	29	28	30	30

 

REGION	British Columbia			Yukon
Age Group	Male	Female	Total	Male	Female	Total
0-4	2,637	2,481	5,118	90	87	177
5-9	2,906	2,864	5,770	124	105	229
10-14	2,693	2,762	5,455	144	119	263
15-19	3,098	4,032	7,130	157	226	383
20-24	2,922	4,287	7,209	165	250	415
25-29	2,819	3,848	6,667	162	259	421
30-34	2,630	3,548	6,178	175	212	387
35-39	2,815	3,625	6,440	211	243	454
40-44	2,901	3,763	6,664	219	255	474
45-49	3,096	4,011	7,107	228	288	516
50-54	2,464	3,214	5,678	143	211	354
55-59	1,884	2,383	4,267	106	197	303
60-64	1,399	1,779	3,178	98	144	242
65+	2,411	3,483	5,894	197	300	497
Total	36,675	46,080	82,755	2,219	2,896	5,115
Average Age	33	35	34	36	39	38

 

REGION	N.W.T.			Nunavut			TOTAL
Age Group	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	363	331	694	635	571	1,206	19,302	18,354	37,656
5-9	332	391	723	461	432	893	21,164	21,007	42,171
10-14	366	385	751	377	392	769	19,504	20,111	39,615
15-19	460	744	1,204	423	825	1,248	19,961	27,747	47,708
20-24	429	816	1,245	399	994	1,393	18,048	27,826	45,874
25-29	362	749	1,111	357	835	1,192	16,749	25,035	41,784
30-34	353	659	1,012	314	661	975	16,272	22,644	38,916
35-39	439	681	1,120	400	581	981	17,419	22,880	40,299
40-44	449	668	1,117	370	631	1,001	17,726	22,711	40,437
45-49	377	638	1,015	319	469	788	16,930	21,913	38,843
50-54	341	501	842	209	349	558	13,497	17,976	31,473
55-59	265	368	633	227	280	507	10,229	13,559	23,788
60-64	226	302	528	222	241	463	8,013	10,469	18,482
65+	492	658	1,150	381	475	856	13,757	20,318	34,075
Total	5,254	7,891	13,145	5,094	7,736	12,830	228,571	292,550	521,121
Average Age	35	36	35	31	32	31	31	33	32

Source: HICPS adapted by Program Analysis Division

Figure 4.8 NIHB Pharmacy Claimants and Non-Claimants by Age Group and Gender 2008/09

Sixty-four percent of all eligible clients received at least one pharmacy benefit paid through the Health Information and Claims Processing Services (HICPS) system in 2008/09. Thirty-six percent of eligible clients did not access the Program through the HICPS system for any pharmacy benefits.

The use of pharmaceutical services and the associated costs varied according to age. Unchanged from 2007/08, more than 50% of eligible clients in each age group received pharmaceutical services or products in 2008/09. The highest utilization rate was observed among eligible clients aged 60 to 64 years, where 77% of eligible clients were claimants. The age group where pharmacy utilization was lowest in 2008/09 was the 10 to 14 age group, where 50% of clients received at least one pharmacy benefit.

Of the 294,679 non-claimants in 2008/09, 171,831 were male (58%) while 122,848 were female (42%). Forty-six percent of all non-claimants were under 20 years of age, while 75% were under 40 years of age.

Age Group	Claimants			Non-Claimants			TOTAL
	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	19,302	18,354	37,656	12,396	12,297	24,693	31,698	30,651	62,349
	61%	60%	60%	39%	40%	40%	100%	100%	100%
5-9	21,164	21,007	42,171	17,634	16,241	33,875	38,798	37,248	76,046
	55%	56%	55%	45%	44%	45%	100%	100%	100%
10-14	19,504	20,111	39,615	21,243	18,932	40,175	40,747	39,043	79,790
	48%	52%	50%	52%	48%	50%	100%	100%	100%
15-19	19,961	27,747	47,708	22,645	12,890	35,535	42,606	40,637	83,243
	47%	68%	57%	53%	32%	43%	100%	100%	100%
20-24	18,048	27,826	45,874	18,832	7,742	26,574	36,880	35,568	72,448
	49%	78%	63%	51%	22%	37%	100%	100%	100%
25-29	16,749	25,035	41,784	15,075	6,465	21,540	31,824	31,500	63,324
	53%	79%	66%	47%	21%	34%	100%	100%	100%
30-34	16,272	22,644	38,916	12,675	6,269	18,944	28,947	28,913	57,860
	56%	78%	67%	44%	22%	33%	100%	100%	100%
35-39	17,419	22,880	40,299	11,919	6,988	18,907	29,338	29,868	59,206
	59%	77%	68%	41%	23%	32%	100%	100%	100%
40-44	17,726	22,711	40,437	10,995	7,309	18,304	28,721	30,020	58,741
	62%	76%	69%	38%	24%	31%	100%	100%	100%
45-49	16,930	21,913	38,843	9,031	6,741	15,772	25,961	28,654	54,615
	65%	76%	71%	35%	24%	29%	100%	100%	100%
50-54	13,497	17,976	31,473	6,265	5,238	11,503	19,762	23,214	42,976
	68%	77%	73%	32%	23%	27%	100%	100%	100%
55-59	10,229	13,559	23,788	4,106	3,905	8,011	14,335	17,464	31,799
	71%	78%	75%	29%	22%	25%	100%	100%	100%
60-64	8,013	10,469	18,482	2,567	2,987	5,554	10,580	13,456	24,036
	76%	78%	77%	24%	22%	23%	100%	100%	100%
65+	13,757	20,318	34,075	6,448	8,844	15,292	20,205	29,162	49,367
	68%	70%	69%	32%	30%	31%	100%	100%	100%
Total	228,571	292,550	521,121	171,831	122,848	294,679	400,402	415,398	815,800
	57%	70%	64%	43%	30%	36%	100%	100%	100%

Source: HICPS and SVS adapted by Program Analysis Division

Figure 4.9 Distribution of Eligible NIHB Population, Pharmacy Expenditures and Pharmacy Incidence by Age Group 2008/09

The utilization rate of NIHB Pharmacy benefits within a given age group is not the primary determinant of expenditures. Rather, it is the frequency of claims^* submitted that acts as the principal driver of NIHB Pharmacy expenditures. In 2008/09, for example, 7.6% of all clients were in the 0 to 4 age group, but this group accounted for only 2.1% of all pharmacy claims made and only 1.5% of total pharmacy expenditures, a slight decrease over 2007/08. In contrast, the 65+ age group represented 6.1% of all eligible clients, but accounted for 23.0% of all pharmacy claims submitted and 18.6% of total pharmacy expenditures, a 1.8% increase over 2007/08.

During fiscal year 2008/09, the average claimant aged 65 or more submitted 84 claims versus 58 claims for their counterpart in the 60 to 64 age group and 7 claims for the average claimant in the 0 to 4 age group.

Quick Fact

An examination of pharmacy services utilization rates by NIHB claimants indicates that these rates vary according to age. For example, 60.4% of children aged 0 to 4 years received pharmaceutical services. A decrease occurs between the ages of 5 and 14 with the upward trend resuming around age 15.

Source: HICPS and SVS adapted by Program Analysis Division

*Claims are not equal to prescriptions as a prescription can comprise a number of claim lines. For further clarification see section 9.1.1.

Figure 4.10 NIHB Prescription Drug Utilization by Pharmacologic Therapeutic Class and Incidence 2008/09

Figure 4.10 demonstrates variation in utilization by therapeutic classification for prescription drugs.

Central Nervous System Agents, which include drug classes such as analgesics and sedatives, accounted for approximately one third (32.9%) of all prescription drug claims. This therapeutic class had a very slight variation from the 32.5% recorded in 2007/08.

Cardiovascular Drugs had the next highest share of prescription drug claims at 19.2% followed by Hormones, which consist primarily of oral contraceptives and insulin, at 13.2%.

Variation in the utilization of these therapeutic classes was minimal compared to 2007/08.

Source: HICPS adapted by Program Analysis Division

Figure 4.11 NIHB Over-the-Counter Drugs (Including Controlled Access Drugs - CAD) by Pharmacologic Therapeutic Class and Claims Incidence 2008/09

Figure 4.11 demonstrates variation in utilization by therapeutic classification for over-the-counter (OTC) drugs.

Central Nervous System Agents, which include drugs such as acetaminophen, was the highest ranking therapeutic class, accounting for 31.0% of all OTC drug claims.

Gastrointestinal products such as antacids and laxatives are the next highest category of OTC medication at 10.9%, followed by Vitamins at 8.3% and the Electrolytic/Caloric/Water Balance class such as calcium at 8.1%.

The most significant shift from the last fiscal year in utilization of OTCs by therapeutic class was among Vitamins, which increased by 0.9 percentage points. The most significant decreases were in the Skin and Mucous Membrane class, such as fucidin, and the Central Nervous System class which decreased by 0.6 and 0.5 percentage points respectively.

Source: HICPS adapted by Program Analysis Division

Figure 4.12 NIHB Top Ten Therapeutic Classes by Claims Incidence 2008/09

Figure 4.12 ranks the top ten therapeutic classes according to claims incidence. In 2008/09, Non-Steroidal Anti-Inflammatory Agents (NSAIDs) had the highest claims incidence total at 851,973. Voltaren (Diclofenac) is an example of a drug product in this therapeutic class.

Opiate Agonists such as Tylenol no.3 (Acetaminophen w/codeine) ranked second in claims incidence with 793,182 followed by the Pharmaceutical Aids class^* with 644,740 claims. There was a significant increase in the number of Pharmaceutical Aids claims in 2008/09 compared to the 461,477 claims recorded for this class the previous fiscal year. This increase can be attributed in part to the introduction of a new policy for the daily dispense of Methadone in June 2008. Previously, Methadone was dispensed in some regions on a weekly basis.

Within the top ten therapeutic classes, the Pharmaceutical Aids class had the largest percentage increase (44.0%) over the last fiscal year. The HMG-CoA Reductase Inhibitors (Statins) and Proton Pump Inhibitor (PPIs) classes had a 7.4% and 7.1% change in incidence over the fiscal year 2007/08 respectively.

The class with the largest decrease in incidence over the last fiscal year was the Miscellaneous Analgesics and Antipyretics class with a decrease of 5.3%. The Anxiolytics, Sedatives and Hypnotics-Benzodiazepines class decreased 1.2%.

Therapeutic Classification	Claims Incidence	% Change from 2007/08	Examples of Drug Product in the Therapeutic Class
Non-Steroidal Anti-Inflammatory Agents (NSAID)	851,973	2.3%	Voltaren (Diclofenac)
Opiate Agonists	793,182	2.8%	Tylenol no.3 (Acetaminophen w/codeine)
Pharmaceutical Aids	664,740	44.0%	Methadone
Antidepressants	599,661	1.7%	Effexor (Venlafaxine)
Angiotensin-Converting Enzyme Inhibitors	500,195	1.5%	Altace (Ramipril)
Anxiolytics, Sedatives and Hypnotics - Benzodiazepines	434,016	-1.2%	Ativan (Lorazepam)
HMG-CoA Reductase Inhibitors (Statins)	408,864	7.4%	Lipitor (Atorvastatin)
Proton-Pump Inhibitors	388,573	7.1%	Losec (Omeprazole)
Biguanides	342,932	3.5%	Glucophage (Metformin)
Miscellaneous Analgesics and Antipyretics	309,026	-5.3%	Tylenol (Acetaminophen)

Source: HICPS adapted by Program Analysis Division

*The Pharmaceutical Aids class is a broad category which contains a wide variety of drug and medical products that do not belong to any other class. The largest component of this class is Methadone. Diabetic test strips are also another example of this class.

Figure 4.13 NIHB Top Ten Therapeutic Classes by Expenditure 2008/09

Figure 4.13 ranks the top ten therapeutic classes according to expenditure. Cholesterol reducers in the HMG-CoA Reductase Inhibitors (Statins) class such as Lipitor (Atorvastatin) had expenditures of $24.1 million in 2008/09. This is an increase of 9.5% over fiscal year 2007/08 but less than the increase observed in the previous year, 11.8% from 2006/07 to 2007/08. While ranking first in terms of expenditures, HMG-CoA Reductase Inhibitors (Statins) ranked seventh in terms of claims incidence.

Opiate Agonists, which ranked second in terms of claims incidence, was the second largest therapeutic class by expenditure at $18.1 million. Tylenol no.3 (Acetaminophen w/codeine) is an example of a drug product listed in this therapeutic classification.

The third largest expenditure classes were Antidepressants and Proton Pump Inhibitors, both at $17.1 million.

Within the top ten therapeutic classes, the therapeutic class with the highest percentage increase in expenditure over fiscal year 2007/08 was the HMG-CoA Reductase Inhibitors (Statins) class (9.5%), followed by the Dihydropyridines class (9.0%). The third highest percentage change was in the Biguanides class (5.9%).

Angiotensin-Converting Enzyme Inhibitors decreased by 8.0% in expenditures over fiscal year 2007/08. Proton Pump Inhibitors and Antidepressants decreased by 6.1% and 1.2% respectively in expenditures over the previous fiscal year.

Therapeutic Classification	Expenditure ($ 000's)	% Change from 2007/08	Examples of Drug Product in the Therapeutic Class
HMG-CoA Reductase Inhibitors (Statins)	$24,066	9.5%	Lipitor (Atorvastatin)
Opiate Agonists	18,108	5.1%	Tylenol no.3 (Acetaminophen w/codeine)
Antidepressants	17,140	-1.2%	Effexor (Venlafaxine)
Proton Pump Inhibitors	17,060	-6.1%	Losec (Omeprazole)
Antipsychotic Agents	14,947	0.7%	Risperdal (Risperidone)
Angiotensin-Converting Enzyme Inhibitors	14,781	-8.0%	Altace (Ramipril)
Non-Steroidal Anti-Inflammatory Agents (NSAIDs)	13,103	1.3%	Voltaren (Diclofenac)
Biguanides	11,813	5.9%	Glucophage (Metformin)
Dihydropyridines	8,821	9.0%	Norvasc (Amlodipine)
Beta Adrenergic Agonist	$8,775	5.3%	Ventolin (Salbutamol)

Source: HICPS adapted by Program Analysis Division

Figure 4.14 NIHB Medical Supplies by Category and Claims Incidence 2008/09

Figure 4.14 demonstrates variation in medical supply claims by specific category.

Dressing supplies accounted for 34.1% of all medical supply claims in 2008/09. Incontinence supplies represented the second highest category of medical supplies at 22.6% followed by hearing aid services at 12.6% and bandages at 9.7%.

The most significant change in claims for medical supplies over fiscal year 2007/08 was in bandages which declined 0.8 percentage points, and dressing supplies which decreased by 0.7 percentage points. Hearing aid services increased by 0.6 percentage points over the previous fiscal year.

Source: HICPS adapted by Program Analysis Division

Figure 4.15 NIHB Medical Equipment by Category and Claims Incidence 2008/09

Figure 4.15 demonstrates variation in medical equipment claims by category.

Claims for oxygen equipment accounted for 19.3% of all medical equipment claims in 2008/09. Limb orthoses was the next highest at 18.7% followed by hearing aids at 13.4% and walking aids at 12.1%.

The most significant shift in the proportion of total medical equipment claims over the fiscal year 2007/08 was in oxygen equipment which increased by 3.0 percentage points.

Custom made footwear declined 0.8 percentage points as a share of total claims for medical equipment over the previous fiscal year, followed by limb orthoses and hearing aids which each declined 0.7 percentage points.

Source: HICPS adapted by Program Analysis Division

Section 5 - NIHB Dental Expenditure and Utilization Data

In 2008/09, NIHB Dental expenditures amounted to $176.4 million, accounting for 18.9% of total NIHB expenditures.

Coverage for NIHB Dental services is determined on an individual basis, taking into consideration current oral health status, recipient history, accumulated scientific research, and availability of treatment alternatives. Dental services must be provided by a licensed dental professional, such as a dentist, dental specialist, or denturist, who has agreed to provide services to First Nations and Inuit clients through the NIHB Program.

NIHB dental services are determined on an individual basis and are based on current Program policies. Some dental services require predetermination prior to the initiation of treatment. Predetermination is a review to determine if the proposed dental services are covered under the Program's criteria, guidelines and policies. During the predetermination process, the NIHB Program reviews the dental services submitted against its established Dental Policy Framework which outlines clear definitions of the types of benefits available to clients.

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

• Diagnostic services such as examinations or radiographs;
• Preventive services such as cleaning, polishing, fluorides and sealants;
• Restorative services such as fillings^*;
• Endodontics such as root canal treatments^*;
• Periodontal services such as scaling^*;
• Prosthodontics including removable dentures^*;
• Oral surgery such as simple extractions of teeth^*;
• Orthodontics to correct significant irregularities in teeth and jaws (predetermination applies); and
• Adjunctive services such as sedation (predetermination applies).

* Predetermination applies for some dental services within these categories.

Figure 5.1 Distribution of NIHB Dental Expenditures ($ Millions) 2008/09

NIHB Dental expenditures totalled $176.4 million in 2008/09. Fee-for-service dental costs paid through the Health Information and Claims Processing Services (HICPS) system represented the largest expenditure component, accounting for $150.7 million or 85.4% of all NIHB Dental costs.

Contributions, which accounted for $13.4 million or 7.6% of total dental expenditures, were the next highest component. Contribution costs were used to fund the provision of dental benefits through agreements such as those with the Governments of the Northwest Territories and Nunavut, the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta.

Expenditures for contract dentists providing services to clients in remote communities totalled $8.2 million or 4.6% of total costs.

Other costs totalled $4.1 million or 2.3% in 2008/09. The majority of these costs are related to claims processing and payment services.

Source: FIRMS adapted by Program Analysis Division

Figure 5.2 Total NIHB Dental Expenditures by Type and Region ($ 000's) 2008/09

Dental expenditures totalled $176.4 million in 2008/09. The Ontario (20.1%), Saskatchewan (15.9%) and Alberta (14.2%) regions had the largest proportion of overall dental costs.

Of the $176.4 million, $162.9 million (92.4%) were operating expenditures while $13.4 million (7.6%) were contribution expenditures.

REGION	OPERATING			Total Operating Costs	Total Contribution Costs	TOTAL COSTS
	Fee-For-Service	Contract Dentists	Other Costs
Atlantic	$4,690	$0	$1	$4,691	$255	$4,945
Quebec	12,895	0	0	12,895	0	12,895
Ontario	28,472	2,189	149	30,810	4,647	35,457
Manitoba	19,846	4,588	0	24,434	0	24,434
Saskatchewan	24,967	35	3	25,004	3,097	28,102
Alberta	22,569	351	7	22,926	2,090	25,016
British Columbia	23,507	608	0	24,114	603	24,718
Yukon	2,246	0	0	2,246	0	2,246
N.W.T.	5,781	0	0	5,781	498	6,279
Nunavut	5,702	412	0	6,115	2,235	8,349
Headquarters	-	-	3,932	3,932	-	3,932
Total	$150,674	$8,183	$4,092	$162,949	$13,424	$176,372

Source: FIRMS adapted by Program Analysis Division

Figure 5.3 Annual NIHB Dental Expenditures 2004/05 to 2008/09

NIHB Dental expenditures increased by 6.5% in fiscal year 2008/09, which was the highest rate of growth of all benefits. This is an increase of 2.1 percentage points over the previous fiscal year's growth.

In the last five years, annual growth rates for NIHB Dental expenditures have ranged from a high of 7.7% in 2005/06 to a low of 3.0% in 2006/07, with the average annualized growth rate being 5.6%.

In 2008/09, the highest rate of growth in NIHB Dental expenditures was in the Saskatchewan Region, which increased by 14.1% compared to the previous year. The largest net increases in expenditures took place in the regions of Saskatchewan and Manitoba where total dental costs grew by $3.5 million and $2.7 million respectively.

The Ontario Region had the highest total dental expenditure at $35.5 million and the Yukon had the lowest total dental expenditure at $2.2 million.

NIHB Dental Expenditures and Annual Percentage Change

Source: FIRMS adapted by Program Analysis Division

NIHB Dental Expenditures ($000's)

Region	2004/05	2005/06	2006/07	2007/08	2008/09
Atlantic	$4,934	$4,831	$5,128	$5,204	$4,945
Quebec	10,525	10,970	11,603	12,141	12,895
Ontario	29,655	32,064	32,777	33,467	35,457
Manitoba	18,705	20,326	20,756	21,696	24,434
Saskatchewan	19,530	22,038	23,219	24,636	28,102
Alberta	19,306	20,594	21,006	22,391	25,016
British Columbia	20,357	22,439	22,588	22,968	24,718
Yukon	1,229	1,863	2,033	1,998	2,246
N.W.T.	5,173	5,249	5,249	5,752	6,279
Nunavut	8,566	8,137	8,740	9,002	8,349
Headquarters	4,978	5,389	5,486	6,321	3,932
Total	$142,956	$153,900	$158,584	$165,576	$176,372

Source: FIRMS adapted by Program Analysis Division

Figure 5.4 Per Capita NIHB Dental Expenditures by Region 2008/09

In 2008/09, the national per capita NIHB Dental expenditure was $211, an increase of 6.2% from the previous year's figure of $199.

Nunavut had the highest per capita dental expenditure at $287, a decrease from $316 in the previous year; followed by the Yukon at $281, an increase from $252; and the Northwest Territories at $255, an increase from $236.

The Atlantic Region had the lowest per capita dental cost at $145 per eligible client, a decrease from the $156 registered in 2007/08.

Per capita values reflect total NIHB expenditures as divided by total eligible NIHB client population. These values do not include additional financial resources provided to First Nations and Inuit populations through other Health Canada programs or through transfer and other arrangements.

Source: SVS and FIRMS adapted by Program Analysis Division

Figure 5.5 NIHB Dental Fee-For-Service Expenditures per Claimant by Region 2008/09

In 2008/09, the national NIHB Dental expenditure per eligible client receiving at least one dental benefit was $512. This is an increase of 6.3% over the $481 recorded in 2007/08.

Yukon had the highest dental expenditure per claimant at $714, a significant increase (29.7%) from the $550 in the previous year. This can be attributed in part to a greater uptake of oral surgery procedures and higher costs for restorative procedures. The Alberta Region followed at $575 and the Northwest Territories at $563. The Atlantic Region registered the lowest dental expenditure per claimant at $392.

Source: HICPS adapted by Program Analysis Division,

Figure 5.6 NIHB Dental Utilization Rates by Region 2004/05 to 2008/09

Utilization rates reflect those clients who received at least one dental service paid through the Health Information and Claims Processing Services (HICPS) system during the fiscal year as a proportion of the total number of clients eligible to receive benefits as registered on the Status Verification System (SVS) in that year.

The national utilization rate in 2008/09 for dental benefits paid through the HICPS system was 36%, unchanged from the previous two years. The highest dental utilization rate (44%) was found in the Quebec Region. The lowest rate was recorded in the Manitoba Region (30%). It should also be noted, however, that the Manitoba Region had the largest expenditure in 2008/09 for contract dental services.

The rates will somewhat understate the actual level of service as the data do not include:

• Health Canada dental clinics (except in the Yukon);
• Contract dental services provided in some regions;
• Services provided by Health Canada Dental Therapists or other FNIHB dental programs such as Children's Oral Health Initiative (COHI); and
• Dental services provided through contribution agreements.

For example, if the Bigstone Cree Nation client population were excluded from the Alberta Region's population, because the HICPS data do not capture any services utilized by this population, the utilization rate for dental benefits for Alberta would have been 41% in 2008/09. The same scenario would apply for the Ontario Region. If the Akwesasne client population in Ontario were to be removed, the utilization rate for dental benefits in Ontario would have been 35%. If both the Bigstone and Akwesasne client population were removed from the overall NIHB population, the national utilization rate for dental benefits would have been 37%.

Over the two year period between 2007/08 and 2008/09, 407,410 distinct clients received NIHB Dental services resulting in an overall 50% utilization rate over this period.

Dental Utilization

REGION	2004/05	2005/06	2006/07	2007/08	2008/09	NIHB Dental Utilization Last Two Years 2007/09
Atlantic	36%	36%	34%	36%	35%	49%
Quebec	46%	46%	44%	44%	44%	50%
Ontario	33%	34%	33%	33%	33%	43%
Manitoba	23%	30%	29%	30%	30%	44%
Saskatchewan	38%	38%	36%	36%	37%	45%
Alberta	39%	39%	37%	37%	38%	66%
British Columbia	39%	40%	39%	39%	39%	57%
Yukon	31%	34%	36%	38%	39%	49%
N.W.T.	44%	44%	41%	42%	42%	51%
Nunavut	48%	45%	40%	43%	41%	56%
National	36%	37%	36%	36%	36%	50%

Source: HICPS and SVS adapted by Program Analysis Division

Figure 5.7 NIHB Dental Claimants by Age Group, Gender and Region 2008/09

Of the 815,800 clients eligible to receive dental benefits through the NIHB Program, 294,557 (36%) claimants received at least one dental procedure paid through the Health Information and Claims Processing Services (HICPS) system in 2008/09.

Of this total, 164,588 were female (56%) while 129,969 were male (44%). This compares to the total eligible population where 51% are female and 49% are male.

The average age of dental claimants was 29 years, indicating clients tend to access dental services at a younger age compared to pharmacy services (32 years of age). The highest average age of dental claimants was found in the Yukon (35 years of age) while the lowest was in Nunavut at 25 years of age.

Approximately forty percent of all dental claimants were under 20 years of age. Forty-four percent of male claimants were in this age group while females accounted for 37%. Approximately 3% of all claimants were seniors (age 65 and over) in 2008/09.

REGION	Atlantic			Quebec
Age Group	Male	Female	Total	Male	Female	Total
0-4	114	109	223	383	363	746
5-9	463	473	936	1,418	1,366	2,784
10-14	739	807	1,546	1,604	1,630	3,234
15-19	665	727	1,392	1,276	1,408	2,684
20-24	452	579	1,031	725	1,127	1,852
25-29	408	591	999	764	1,018	1,782
30-34	387	561	948	770	1,034	1,804
35-39	452	543	995	839	1,132	1,971
40-44	386	589	975	887	1,154	2,041
45-49	362	497	859	837	1,099	1,936
50-54	315	454	769	697	958	1,655
55-59	194	310	504	504	619	1,123
60-64	143	211	354	344	488	832
65+	173	267	440	526	817	1,343
Total	5,253	6,718	11,971	11,574	14,213	25,787
Average Age	30	32	31	30	33	31

 

REGION	Ontario			Manitoba
Age Group	Male	Female	Total	Male	Female	Total
0-4	870	809	1,679	1,502	1,465	2,967
5-9	3,061	2,999	6,060	2,500	2,533	5,033
10-14	3,460	3,542	7,002	2,368	2,643	5,011
15-19	2,858	3,210	6,068	1,952	2,593	4,545
20-24	1,839	2,576	4,415	1,289	2,045	3,334
25-29	1,695	2,621	4,316	1,249	1,761	3,010
30-34	1,658	2,385	4,043	1,125	1,647	2,772
35-39	1,766	2,436	4,202	1,174	1,721	2,895
40-44	1,865	2,557	4,422	1,213	1,547	2,760
45-49	1,820	2,560	4,380	1,074	1,384	2,458
50-54	1,549	2,211	3,760	752	1,041	1,793
55-59	1,084	1,622	2,706	500	709	1,209
60-64	791	1,233	2,024	331	473	804
65+	1,147	1,915	3,062	353	582	935
Total	25,463	32,676	58,139	17,382	22,144	39,526
Average Age	30	33	32	26	28	27

 

REGION	Saskatchewan			Alberta
Age Group	Male	Female	Total	Male	Female	Total
0-4	1,225	1,262	2,487	1,234	1,228	2,462
5-9	3,252	3,325	6,577	2,752	2,727	5,479
10-14	2,984	3,376	6,360	2,661	2,865	5,526
15-19	2,270	3,011	5,281	2,044	2,521	4,565
20-24	1,726	2,605	4,331	1,356	2,012	3,368
25-29	1,562	2,322	3,884	1,267	1,854	3,121
30-34	1,409	2,105	3,514	1,171	1,642	2,813
35-39	1,510	2,148	3,658	1,101	1,636	2,737
40-44	1,541	1,948	3,489	1,083	1,489	2,572
45-49	1,221	1,683	2,904	969	1,374	2,343
50-54	860	1,207	2,067	681	963	1,644
55-59	541	725	1,266	421	637	1,058
60-64	346	456	802	258	419	677
65+	405	579	984	378	509	887
Total	20,852	26,752	47,604	17,376	21,876	39,252
Average Age	26	27	27	25	27	26

 

REGION	British Columbia			Yukon
Age Group	Male	Female	Total	Male	Female	Total
0-4	1,235	1,169	2,404	37	57	94
5-9	2,652	2,639	5,291	126	107	233
10-14	2,758	2,742	5,500	111	112	223
15-19	2,361	2,738	5,099	100	153	253
20-24	1,567	2,260	3,827	120	160	280
25-29	1,496	2,116	3,612	109	172	281
30-34	1,402	1,972	3,374	106	137	243
35-39	1,433	1,894	3,327	109	161	270
40-44	1,467	2,015	3,482	145	171	316
45-49	1,526	2,061	3,587	136	161	297
50-54	1,151	1,578	2,729	79	110	189
55-59	763	1,031	1,794	55	116	171
60-64	497	669	1,166	46	64	110
65+	719	973	1,692	76	111	187
Total	21,027	25,857	46,884	1,355	1,792	3,147
Average Age	28	30	29	34	35	35

 

REGION	N.W.T.			Nunavut			TOTAL
Age Group	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	220	202	422	523	505	1,028	7,343	7,169	14,512
5-9	425	509	934	664	665	1,329	17,313	17,343	34,656
10-14	502	552	1,054	663	825	1,488	17,850	19,094	36,944
15-19	555	689	1,244	662	948	1,610	14,743	17,998	32,741
20-24	432	595	1,027	598	894	1,492	10,104	14,853	24,957
25-29	367	537	904	455	660	1,115	9,372	13,652	23,024
30-34	298	476	774	357	530	887	8,683	12,489	21,172
35-39	351	487	838	336	473	809	9,071	12,631	21,702
40-44	340	462	802	313	403	716	9,240	12,335	21,575
45-49	277	440	717	240	279	519	8,462	11,538	20,000
50-54	227	303	530	120	185	305	6,431	9,010	15,441
55-59	155	213	368	117	141	258	4,334	6,123	10,457
60-64	122	144	266	90	99	189	2,968	4,256	7,224
65+	177	209	386	101	135	236	4,055	6,097	10,152
Total	4,448	5,818	10,266	5,239	6,742	11,981	129,969	164,588	294,557
Average Age	29	31	30	24	25	25	28	30	29

Source: HICPS adapted by Program Analysis Division

Figure 5.8 NIHB Dental Claimants and Non-Claimants by Age Group and Gender 2008/09

Thirty-six percent of all eligible clients received at least one dental procedure paid through the Health Information and Claims Processing Services (HICPS) system in 2008/09. Sixty-four percent of eligible clients did not access the Program through HICPS for any dental benefits.

Of the 521,243 non-claimants in 2008/09, 270,433 were male (52%), while 250,810 were female (48%). Thirty-five percent of all non-claimants were under 20 years of age, while approximately two-thirds (66%) were under 40 years of age.

Claimants under the age of 20 accounted for 40% of all NIHB eligible clients who received dental benefits through the HICPS system, while the claimants 65 years and older accounted for approximately 3%.

Age Group	Claimants			Non-Claimants			TOTAL
	Male	Female	Total	Male	Female	Total	Male	Female	Total
0-4	7,343	7,169	14,512	24,355	23,482	47,837	31,698	30,651	62,349
	23%	23%	23%	77%	77%	77%	100%	100%	100%
5-9	17,313	17,343	34,656	21,485	19,905	41,390	38,798	37,248	76,046
	45%	47%	46%	55%	53%	54%	100%	100%	100%
10-14	17,850	19,094	36,944	22,897	19,949	42,846	40,747	39,043	79,790
	44%	49%	46%	56%	51%	54%	100%	100%	100%
15-19	14,743	17,998	32,741	27,863	22,639	50,502	42,606	40,637	83,243
	35%	44%	39%	65%	56%	61%	100%	100%	100%
20-24	10,104	14,853	24,957	26,776	20,715	47,491	36,880	35,568	72,448
	27%	42%	34%	73%	58%	66%	100%	100%	100%
25-29	9,372	13,652	23,024	22,452	17,848	40,300	31,824	31,500	63,324
	29%	43%	36%	71%	57%	64%	100%	100%	100%
30-34	8,683	12,489	21,172	20,264	16,424	36,688	28,947	28,913	57,860
	30%	43%	37%	70%	57%	63%	100%	100%	100%
35-39	9,071	12,631	21,702	20,267	17,237	37,504	29,338	29,868	59,206
	31%	42%	37%	69%	58%	63%	100%	100%	100%
40-44	9,240	12,335	21,575	19,481	17,685	37,166	28,721	30,020	58,741
	32%	41%	37%	68%	59%	63%	100%	100%	100%
45-49	8,462	11,538	20,000	17,499	17,116	34,615	25,961	28,654	54,615
	33%	40%	37%	67%	60%	63%	100%	100%	100%
50-54	6,431	9,010	15,441	13,331	14,204	27,535	19,762	23,214	42,976
	33%	39%	36%	67%	61%	64%	100%	100%	100%
55-59	4,334	6,123	10,457	10,001	11,341	21,342	14,335	17,464	31,799
	30%	35%	33%	70%	65%	67%	100%	100%	100%
60-64	2,968	4,256	7,224	7,612	9,200	16,812	10,580	13,456	24,036
	28%	32%	30%	72%	68%	70%	100%	100%	100%
65+	4,055	6,097	10,152	16,150	23,065	39,215	20,205	29,162	49,367
	20%	21%	21%	80%	79%	79%	100%	100%	100%
Total	129,969	164,588	294,557	270,433	250,810	521,243	400,402	415,398	815,800
	32%	40%	36%	68%	60%	64%	100%	100%	100%

Source: HICPS and SVS adapted by Program Analysis Division

Figure 5.9 NIHB Fee-for-Service Dental Expenditures by Sub-Benefit 2008/09

Expenditures for Restorative Services (crowns, fillings, etc.) were the highest of all dental sub-benefit categories at $68.7 million in 2008/09. This is a 12.6% increase over the previous fiscal year.

Diagnostic Services (examinations, x-rays, etc.) at $18.4 million and Preventive Services (scaling, sealants, etc.) at $17.2 million were the next highest sub-benefit categories, followed by Oral Surgery (extractions) at $14.6 million and Removable Prosthodontics (dentures) at $9.5 million.

In 2008/09, the three largest dental procedures by expenditure were Composite Restorations ($49.5 million), Scaling ($11.7 million) and Extractions ($10.2 million).

Fee-For-Service Top 5 Dental Sub-Benefits ($ Millions) and Percentage Change

Dental Sub-Benefit	2008/09	% Change from 2007/08
Restorative Services	$68.7	12.6%
Diagnostic Services	$18.4	8.4%
Preventive Services	$17.2	7.7%
Oral Surgery	$14.6	12.5%
Removable Prosthodontics	$9.5	4.8%

Fee-For-Service Top 5 Dental Procedures ($Millions) and Percentage Change

Dental Procedure	2008/09	% Change from 2007/08
Composite Restorations	$49.5	15.5%
Scaling	$11.7	8.4%
Extractions	$10.2	12.0%
Amalgam Restorations	$6.8	0.3%
Root Canal Therapy	$6.5	9.6%

Source: HICPS adapted by Program Analysis Division

Figure 5.10 Distribution of Eligible NIHB Population, Dental Expenditures and Incidence by Age Group 2008/09

The main drivers of NIHB Dental expenditures are increases in utilization rates and increases in the fees charged for services by dental professionals. The type of dental services provided also has an impact on expenditures.

The ratio of expenditures to incidence is relatively consistent across most age groupings; however, there are notable exceptions. For children aged 0 to 9, a larger number of low-cost procedures (e.g., low-cost restorative procedures such as fillings and stainless steel crowns) are provided. The result was a ratio of incidence to expenditures of 26.8% to 19.0%.

With respect to the ratio of eligible clients to expenditures, a relatively stable relationship exists across most age groups. The notable exceptions to this pattern are youth aged 10 to 14 and clients who are 65 years of age and older. The ratios of eligible clients to expenditures for these two groups are 9.8% to 5.8% and 6.1% to 4.0% respectively.

Section 6 - NIHB Medical Transportation Expenditure and Utilization Data

In 2008/09, Non-Insured Health Benefits Medical Transportation (MT) expenditures amounted to $275.0 million or 29.4% of total NIHB expenditures.

NIHB Medical Transportation benefits are funded in accordance with the policies set out in the NIHB Medical Transportation Policy Framework to assist eligible clients to access medically necessary health services that cannot be obtained on reserve or in the community of residence.

NIHB Medical Transportation benefits are operationally managed by regional offices. These benefits are also managed by First Nations or Inuit Health Authorities, organizations or territorial governments who, under a contribution agreement, have assumed responsibility for the administration and funding of medical transportation benefits to eligible clients.

Medical Transportation benefits include:

• Ground Travel (private vehicle; commercial taxi; fee-for-service driver and vehicle; band vehicle; bus; train; snowmobile taxi; and ground ambulance);
• Air Travel (scheduled flights; chartered flights; helicopter; air ambulance);
• Water Travel (motorized boat; boat taxi; and ferry);
• Living Expenses (accommodations and meals); and
• Transportation costs for health professionals to provide services to isolated communities.

Medical transportation data for past NIHB Annual Reports were provided through the Framework for Integrated Resource Management System (FIRMS) only. However, medical transportation data are also collected regionally through other electronic systems. Operational data at the regional level are tracked through the Medical Transportation Reporting System (MTRS) for most regions, while the Alberta and Ontario regions use their own systems. Contribution agreement data are also collected, but in a limited manner. Some communities report on spreadsheet templates, others by paper reports. In some regions, other information such as ambulance data is collected separately.

In 2005, an initiative was launched to collect medical transportation data on a national basis. The Medical Transportation Data Store (MTDS) has been created to act as a centralized system for cross regional data. The MTDS will serve as a repository for selected operational data, as well as the data collected from medical transportation contribution agreements, and ambulance data systems. The objective of the MTDS is to enable aggregate reporting on medical transportation at a national level in order to further strengthen Program management, provide enhanced data analysis and reporting and aid in decision making.

The MTDS has been maintaining data since 2006/07 and significant improvements in data collection and populating MTDS have been made in the subsequent two fiscal years. Most regions have successfully submitted operating data, although some issues still remain to be resolved before all operating expenditures will be available through MTDS. In addition, steps are underway to improve data collection related to contribution agreements.

Figure 6.1 Distribution of NIHB Medical Transportation Expenditures ($ Millions) 2008/09

NIHB Medical Transportation expenditures totalled $275.0 million in 2008/09. Contribution agreements represented $130.3 million, or 47.4% of the total benefit.

Land and water transportation at $52.0 million (18.9%) and scheduled flights at $41.5 million (15.1%) were the largest medical transportation operating expenditures, accounting for over one-third of the total benefit.

Travel associated with professional services (e.g., physician, dentist, mental health professional) totalled $5.7 million (2.1%). This category was previously captured as part of other medical transportation categories or under other health care depending on the region; it can now be reported on separately as a result of a new accounting methodology implemented in 2008/09.

Source: FIRMS adapted by Program Analysis Division

Figure 6.2 Annual NIHB Medical Transportation Expenditures 2004/05 to 2008/09

NIHB Medical Transportation expenditures increased by 4.8% in 2008/09. Over the last five years, growth in this benefit area has ranged from a high of 8.6% in 2007/08 to a low of 2.8% in 2004/05, with a five year annualized growth rate of 6.0%, the highest for all benefit areas over this period.

In 2007/08, there was a one time investment in medical transportation of $4.8 million to purchase new vans and computers in certain communities. Without this one time investment, the growth rate in 2008/09 would have been 6.8% rather than 4.8%.

Over the past five years, overall medical transportation costs have grown by 30.0% from $211.5 million in 2004/05 to $275.0 million in 2008/09. On a regional basis, the highest growth rates over this period were in the Manitoba Region where expenditures grew by 47.3% from $55.9 million in 2004/05 to $82.4 million in 2008/09 and in the Saskatchewan Region where costs increased by 33.7% from $26.8 million to $35.8 million.
In the Atlantic Region, costs declined by 24.0% over the past five years due to the transfer of resources to the Nunatsiavut Government under a self-government agreement.

NIHB Medical Transportation Expenditures and Annual Percentage Change

Source: FIRMS adapted by Program Analysis Division

NIHB Medical Transportation Expenditures ($ 000's)

Region	2004/05	2005/06	2006/07	2007/08	2008/09
Atlantic	$6,124	$5,590	$4,401	$4,585	$4,655
Quebec	17,291	17,886	18,473	20,133	20,502
Ontario	35,258	38,553	40,572	45,618	45,088
Manitoba	55,895	63,322	69,047	76,082	82,354
Saskatchewan	26,758	28,786	31,816	36,108	35,772
Alberta	29,686	30,712	32,204	32,107	35,357
British Columbia	17,340	16,944	20,284	21,613	22,711
Yukon	1,774	2,100	2,421	2,935	2,938
N.W.T.	7,428	6,710	7,116	6,943	7,952
Nunavut	13,972	14,776	15,268	16,171	17,653
Total	$211,527	$225,379	$241,602	$262,294	$274,980

Source: FIRMS adapted by Program Analysis Division

Figure 6.3 NIHB Expenditures on Medical Transportation by Type and Region ($ 000's) 2008/09

NIHB Medical Transportation expenditures increased by 4.8% to $275.0 million in 2008/09. In 2007/08, there was a one time investment in medical transportation of $4.8 million to purchase new vans and computers in certain communities. The majority of these resources were allocated to the Manitoba and Ontario regions. Without this one time investment, the growth rate of medical transportation in 2008/09 would have been 6.8% rather than 4.8%.

In 2008/09, the Ontario Region registered a decrease in total transportation expenditures at -1.2%, while Manitoba had an 8.2% rate of growth. However, it should be noted that in 2007/08 these two regions received one time investments in medical transportation of $2.7 million and $1.6 million respectively. Without these one time investments, the growth rates in 2008/09 would have been 5.1% in Ontario and 10.6% in Manitoba.

The Northwest Territories had the largest percentage increase in medical transportation expenditures in 2008/09 at 14.5%. The Alberta Region followed with a 10.1% increase and Nunavut with a 9.2% increase in expenditures.

The Manitoba Region had the highest overall NIHB Medical Transportation expenditure at $82.4 million, primarily as a result of air transportation which totalled $41.7 million. High medical transportation costs in the region reflect in part the large number of First Nations clients living in remote or fly-in only northern communities.

The Ontario Region registered $45.1 million and represented the second highest medical transportation expenditure totals in 2008/09. The Saskatchewan and Alberta regions followed at $35.8 million and $35.4 million respectively in medical transportation expenditures.

TYPE	Atlantic	Quebec	Ontario	Manitoba	Saskatchewan
Scheduled Flights	$697	$170	$13,518	$21,682	$3,563
Air Ambulance/Chartered Flights	21	7	773	20,030	2,312
Living Expenses	352	9	5,845	8,900	2,187
Land & Water	1,314	287	3,944	11,711	17,612
Outside Canada	0	0	44	1	0
Professional Travel	8	12	709	2,070	1,688
Total Operating	$2,392	$485	$24,832	$64,393	$27,363
Total Contributions	$2,264	$20,016	$20,255	$17,961	$8,409
Total	$4,655	$20,502	$45,088	$82,354	$35,772
% Change from 2007/08	1.5%	1.8%	-1.2%	8.2%	-0.9%

 

TYPE	Alberta	B.C.	Yukon	N.W.T.	Nunavut	Total
Scheduled Flights	$723	$404	$694	$0	$0	$41,452
Air Ambulance/Chartered Flights	1,134	28	749	0	0	25,053
Living Expenses	1,786	622	750	0	0	20,450
Land & Water	14,658	1,761	744	0	0	52,031
Outside Canada	0	0	0	0	0	44
Professional Travel	503	696	1	0	0	5,687
Total Operating	$18,805	$3,510	$2,938	$0	$0	$144,717
Total Contributions	$16,552	$19,201	$0	$7,952	$17,653	$130,263
Total	$35,357	$22,711	$2,938	$7,952	$17,653	$274,980
% Change from 2007/08	10.1%	5.1%	0.1%	14.5%	9.2%	4.8%

Source: FIRMS adapted by Program Analysis Division

Figure 6.4 NIHB Medical Transportation Contribution and Operating Expenditures by Region ($ Millions) 2008/09

Figure 6.4 compares contribution funding to direct operating costs in NIHB Medical Transportation. Contribution funds are provided to First Nations bands and other organizations to manage elements of the medical transportation benefit (e.g., coordinating accommodations, managing ground transportation, etc.).

The Manitoba Region had the largest operating expenditure for NIHB Medical Transportation in 2008/09 at $64.4 million. The Saskatchewan Region was the next largest at $27.4 million, followed by the Ontario Region at $24.8 million. Together these three regions accounted for 80.6% of all operating expenditures on medical transportation.

The largest contribution expenditures for NIHB Medical Transportation were registered as follows: the Ontario Region ($20.3 million), Quebec Region ($20.0 million), British Columbia Region ($19.2 million), Manitoba Region ($18.0 million), and Nunavut ($17.7 million). Almost all NIHB Medical Transportation services were delivered via contribution agreements in Quebec, British Columbia, the Northwest Territories and Nunavut.

Source: FIRMS adapted by Program Analysis Division

Figure 6.5 NIHB Medical Transportation Operating Expenditure by Type ($ Millions) 2008/09

The largest portion of NIHB Medical Transportation operating expenditures fell under scheduled flights ($41.5 million) representing 28.6%. Ambulance costs follow closely with land ambulance ($33.2 million) representing 23.0%, and air ambulance ($21.8 million) at 15.0%. Living expenses ($20.4 million), which include accommodations and meals, comprised 14.1% of all operating medical transportation costs.

Private vehicle expenditures (1.6%) consist of the costs reimbursed through a per-kilometre allowance for private vehicle use by a client to access medically necessary eligible health services. In 2008, the NIHB base private mileage rates were directly linked to the National Joint Council (NJC) Government Commuting Rates. The NIHB rates are updated on April 1st of each year according to the NJC rates in effect as of January 1st of that year.

Professional travel expenditures ($5.7 million) consists of the costs related to bringing health professionals to under serviced or remote/isolated communities in order to enhance access to clients and contribute to better health outcomes.

Source: FIRMS adapted by Program Analysis Division

Figure 6.6 Per Capita NIHB Medical Transportation Expenditures by Region 2008/09

In 2008/09, the national per capita expenditure in NIHB Medical Transportation was $337. This is a 3.1% increase over the 2007/08 per capita expenditure of $327.

The Manitoba Region recorded the highest per capita expenditure in transportation at $627, followed by Nunavut at $606. These expenditures reflect the large number of First Nations and Inuit clients living in remote or fly-in only northern communities that need to be sent south for medical and dental services.

In contrast, the Atlantic Region recorded the lowest per capita expenditure at $136.

Source: SVS and FIRMS adapted by Program Analysis Division

Figure 6.7 NIHB Medical Transportation Emergency (Ambulance) Operating Expenditures by Region 2008/09

In 2008/09, regionally managed NIHB Medical Transportation operating costs totalled $144.7 million. Of this total, $54.7 million or 37.8% were emergency operating expenditures. Emergency operating costs (defined as "ambulance") include all ambulance costs for both land and air ambulance service.

Emergency costs varied considerably from region to region, largely as a result of different provincial/territorial government coverage for emergency transportation. In regions such as Manitoba, Saskatchewan and Yukon, NIHB pays for the entire cost of land and air ambulances for NIHB clients. In the remaining regions, NIHB covers certain user fees or flat rates depending on the coverage provided by the provincial/territorial governments.

In 2008/09, Manitoba Region ambulance expenditures were $25.8 million dollars, comprising nearly half of the total ambulance expenditures for this year. The high cost was primarily due to the size of the client population in the Manitoba Region living in remote or fly-in only communities.

The majority of the medical transportation operating expenditures within the Alberta Region consisted of emergency costs (74.1%). These costs included land and air ambulance. Alberta Region's high proportion of emergency costs is due to the provincial system not paying for any share of these costs on a universal basis (except for seniors and social assistance recipients). Nearly half (45.1%) of transportation operating expenditures in the British Columbia Region were for emergency transportation; the proportion was similar for both the Saskatchewan and Manitoba regions, at 44.7% and 40.0% respectively.

The Ontario Region had the lowest percentage spent on emergency transportation, accounting for only 1.6% of the Region's total operating expenditures.

In terms of absolute expenditures, the Manitoba Region recorded the highest emergency operating expenditures in 2008/09 at $25.8 million, followed by the Alberta Region at $13.9 million and the Saskatchewan Region at $12.2 million.

Source: FIRMS adapted by Program Analysis Division

Emergency (Ambulance) Expenditures by Type and Region ($ 000's), 2008/09

TYPE		Atlantic	Quebec	Ontario	Manitoba
Ambulance Operating Costs	Air Ambulance	$2.1	$0.0	$0.3	$17,939.9
	Land Ambulance	228.3	122.7	391.2	7,831.6
	Total	230.4	122.7	391.5	25,771.6
Share of Ambulance Costs	Air Ambulance	0.9%	0.0%	0.1%	69.6%
	Land Ambulance	99.1%	100.0%	99.9%	30.4%
Total Operating Costs		$2,391.5	$485.2	$24,832.3	$64,392.5
Emergency Operating Costs as % of Total Operating		9.6%	25.3%	1.6%	40.0%

Emergency (Ambulance) Expenditures by Type and Region ($ 000's), 2008/09

TYPE		Saskatchewan	Alberta	British Columbia	Yukon	National
Ambulance Operating Costs	Air Ambulance	$1,929.5	$1,130.7	$27.7	$409.8	$21,440.1
	Land Ambulance	10,301.7	12,805.9	1,556.1	0.0	33,237.4
	Total	12,231.2	13,936.6	1,583.8	409.8	54,677.5
Share of Ambulance Costs	Air Ambulance	15.8%	8.1%	1.8%	100.0%	39.2%
	Land Ambulance	84.2%	91.9%	98.2%	0.0%	60.8%
Total Operating Costs		$27,362.5	$18,804.8	$3,510.2	$2,938.1	$144,717.1
Emergency Operating Costs as % of Total Operating		44.7%	74.1%	45.1%	13.9%	37.8%

Source: FIRMS adapted by Program Analysis Division

Figure 6.8
Distribution of Client Appointments by Health Specialty 2008/09

According to the Medical Transportation Data Store (MTDS), in 2008/09 just over one-quarter of all appointments were with Emergentologists (emergency room specialists). Approximately 16% of appointments requiring some form of medical transportation were with General Practitioners and 6.0% were with Dentists.

Figure 6.8 shows the top ten most visited health care practitioners. The remaining 35.2% of all appointments include other practitioners such as Pediatricians and Neurosurgeons. There are over 80 types of health care practitioners identified in the MTDS.

Source: Medical Transportation Data Store (MTDS) adapted by Program Analysis Division

Section 7 - NIHB Vision Benefits, Other Health Care Benefits and Premiums Expenditure Data

In 2008/09, total expenditures for NIHB Vision benefits ($26.5 million), Other Health Care benefits ($11.4 million) and Premiums ($26.4 million) amounted to $64.3 million, or 6.9% of total NIHB expenditures for the fiscal year.

Vision care benefits are covered in accordance with the policies set out in the Non-Insured Health Benefits Vision Care Framework. The NIHB Program covers:

• Eye examinations, when they are not insured by the province/territory;
• Eyeglasses that are prescribed by a vision care professional;
• Eyeglass repairs;
• Eye prosthesis (an artificial eye); and
• Other vision care benefits depending on the specific medical needs of the recipient.

Other Health Care comprises primarily short-term crisis intervention mental health counselling. This service is provided by a recognized professional mental health therapist when no other service is available to the client. The NIHB Program covers:

• The initial assessment;
• Development of a treatment plan; and
• Fees and associated travel costs for the professional mental health therapist when it is deemed cost-effective to provide such services in a community.

In 2008/09, the NIHB Program funded provincial health premiums for eligible clients in the British Columbia and Alberta regions. The Government of Alberta eliminated Alberta Health Care insurance premiums for all Albertans as of January 1, 2009. Consequently, the NIHB Program no longer pays for health premiums in the Alberta Region.

Figure 7.1 NIHB Vision Expenditures by Region ($ 000's) 2008/09

In 2008/09, NIHB Vision expenditures amounted to $26.5 million. Regional operating expenditures accounted for 82.7% of total expenditures with contribution costs accounting for the remaining 17.3%.

The Alberta and Ontario regions had the highest percentage shares in NIHB Vision benefit costs at 19.7% and 19.6% respectively, followed by the Saskatchewan Region at 15.7%.

Region	Operating	Contributions	Total
Atlantic	$1,572	$24	$1,596
Quebec	1,170	50	1,220
Ontario	4,760	444	5,204
Manitoba	2,853	217	3,071
Saskatchewan	4,149	17	4,166
Alberta	4,428	797	5,225
British Columbia	2,740	510	3,251
Yukon	242	0	242
N.W.T.	0	1,130	1,130
Nunavut	0	1,387	1,387
Total	$ 21,914	$4,577	$26,490

Source: FIRMS adapted by Program Analysis Division

Figure 7.2 Annual NIHB Vision Expenditures 2004/05 to 2008/09

In 2008/09, NIHB Vision expenditures increased by 3.4%, compared to the 2.9% increase recorded in 2007/08. Over the previous five fiscal years the highest growth rate was recorded in 2008/09 at 3.4% and the lowest was in 2006/07 at -0.3%, with the annualized growth rate in this benefit area over the last five years being 1.6%.

In 2008/09, the highest percentage change in NIHB Vision expenditures was in Nunavut which increased by 21.7%, followed by the Northwest Territories which increased by 11.7%. This reflects increases in compensation paid to vision care professionals in the North.

The Alberta and Ontario regions had the highest expenditures in vision care with each region at approximately $5.2 million in 2008/09. The Ontario and Quebec regions both had negative growth rates at -3.0%.

NIHB Vision Expenditures and Annual Percentage Change

Source: FIRMS adapted by Program Analysis Division

NIHB Vision Expenditures ($ 000's)

Region	2004/05	2005/06	2006/07	2007/08	2008/09
Atlantic	$1,619	$1,614	$1,408	$1,495	$1,596
Quebec	1,349	1,135	1,270	1,257	1,220
Ontario	5,428	5,458	5,485	5,366	5,204
Manitoba	2,684	2,864	2,841	2,936	3,071
Saskatchewan	3,431	4,072	3,835	4,126	4,166
Alberta	4,720	4,762	4,690	4,942	5,225
British Columbia	3,249	3,049	3,232	3,120	3,251
Yukon	480	228	274	230	242
N.W.T.	718	743	819	1,011	1,130
Nunavut	951	1,044	1,040	1,139	1,387
Total	$24,629	$24,968	$24,894	$25,621	$26,490

Source: FIRMS adapted by Program Analysis Division

Figure 7.3 Per Capita NIHB Vision Expenditures by Region 2008/09

In 2008/09, the national per capita expenditure in NIHB Vision Care was $32. This remains unchanged since fiscal year 2004/05.

The Alberta Region had the highest per capita expenditure at $50, followed by Nunavut at $48, the Atlantic Region at $47 and the Northwest Territories at $46. The Quebec Region registered the lowest per capita expenditure at $21.

Source: SVS and FIRMS adapted by Program Analysis Division

Figure 7.4 NIHB Other Health Care Expenditures by Region ($ 000's) 2008/09

In 2008/09, NIHB Other Health Care expenditures, which includes short-term crisis mental health counselling, amounted to $11.4 million. Regional operating expenditures accounted for 69.5% of total expenditures with contribution costs accounting for the remaining 30.5%.

The Alberta Region had the highest percentage share of other health care costs at 34.7% followed by the Manitoba and Ontario regions at 22.9% and 19.0% respectively.

In the Northwest Territories and Nunavut, the NIHB Program does not provide crisis intervention mental health counselling services, the largest component of other health care costs, as this is the responsibility of the territorial governments.

Region	Operating	Contributions	Total
Atlantic	$129	$122	$251
Quebec	375	0	375
Ontario	2,158	0	2,158
Manitoba	1,945	660	2,605
Saskatchewan	465	405	870
Alberta	2,552	1,387	3,940
British Columbia	274	891	1,165
Yukon	1	0	1
N.W.T.	0	0	0
Nunavut	0	0	0
Total	$7,900	$3,466	$11,366

Source: FIRMS adapted by Program Analysis Division

Figure 7.5 Annual NIHB Other Health Care Expenditures 2004/05 to 2008/09

In 2008/09, NIHB Other Health Care expenditures decreased by 7.5%, a smaller change compared to the decrease of 24.5% in 2007/08. Over the previous five fiscal years the annualized growth rate in this benefit area was -7.2%.

The highest expenditures for NIHB Other Health Care benefits were recorded in the Alberta Region at $3.9 million followed by the Manitoba Region at $2.6 million.

Expenditures under other health care comprise primarily short-term crisis mental health counselling. Like other NIHB benefits, these services are demand-driven. The decline in expenditures experienced over the past several years is a result of clients accessing services through other service points such as counselling and mental health services through the Indian Residential Schools Resolution Health Support Program.

The decreased growth rate in 2007/08 is attributed primarily to an accounting methodology change which affected the other health care and medical transportation benefit categories. In previous fiscal years, physician travel to communities was reported under other health care in approximately half of the regions. This change in methodology for reporting medical transportation and other health care resulted in a decrease of 24.5% in other health care expenditures in 2007/08.

NIHB Other Health Care Expenditures and Annual Percentage Change

Source: FIRMS adapted by Program Analysis Division

NIHB Other Health Care Expenditures ($ 000's)

Region	2004/05	2005/06	2006/07	2007/08	2008/09
Atlantic	$161	$201	$192	$272	$251
Quebec	697	750	583	471	375
Ontario	2,404	2,213	2,530	2,172	2,158
Manitoba	5,685	5,690	4,786	2,964	2,605
Saskatchewan	2,295	2,237	2,244	942	870
Alberta	4,078	4,537	4,736	4,343	3,940
British Columbia	1,581	1,486	1,177	1,120	1,165
Yukon	4	1	22	4	1
N.W.T.	0	0	0	0	0
Nunavut	0	0	0	0	0
Total	$16,904	$17,115	$16,271	$12,289	$11,366

Source: FIRMS adapted by Program Analysis Division

Figure 7.6 Per Capita NIHB Other Health Care Expenditures by Region 2008/09

In 2008/09, the national per capita expenditure for NIHB Other Health Care was $14, a marginal decrease from $15 in 2007/08. This decrease can be attributed to funding arrangements allocated for crisis mental health counselling services through the Indian Residential Schools Resolution Health Support Program. Short-term mental health crisis counselling was the largest component of the other health care benefit.

The Alberta Region had the highest per capita expenditures at $38, a decrease from $43 in the previous year; followed by the Manitoba Region with a total of $20 per eligible client, a decrease from $23 in the previous year.

Source: SVS and FIRMS adapted by Program Analysis Division

Figure 7.7 Annual NIHB Premiums Expenditures 2004/05 to 2008/09

In 2008/09, NIHB Premiums expenditures totalled $26.4 million. NIHB Premiums expenditures decreased by 9.5% ($2.8 million), a significant change compared to the 1.9% increase recorded in 2007/08. Over the previous five fiscal years the highest growth rate was recorded in 2006/07 at 2.4%, with the annualized growth rate for this benefit area being -1.6%.

The decreased growth rate in 2008/09 is mainly attributed to the NIHB Program no longer funding provincial health premiums in the Alberta Region as of January 1, 2009. The Government of Alberta eliminated Alberta Health Care insurance premiums for all Albertans as of January 1, 2009. Consequently, the NIHB Program no longer pays for health premiums in the Alberta Region.

NIHB Premiums Expenditures and Annual Percentage Change

Source: FIRMS adapted by Program Analysis Division

NIHB Premiums Expenditures ($ 000's)

Region	2004/05	2005/06	2006/07	2007/08	2008/09
Alberta	$12,377	$12,381	$12,709	$12,961	$9,920
British Columbia	15,453	15,606	15,951	16,250	16,510
Total	$27,830	$27,987	$28,659	$29,211	$26,430

Source: FIRMS adapted by Program Analysis Division

Section 8 - Regional Expenditure Trends 1999/00 to 2008/09

Figure 8.1 Atlantic Region 1999/00 to 2008/09

Annual expenditures in the Atlantic Region for 2008/09 totalled $31.6 million, an increase of 3.4% from the $30.5 million spent in 2007/08. Pharmacy expenditures in 2008/09 increased by 6.0% to $20.1 million, medical transportation costs increased by 1.5% to $4.7 million and dental expenditures decreased by 5.0% to $4.9 million. Vision care expenditures increased by 6.8% and other health care costs decreased by 7.6%.
Pharmacy expenditures accounted for more than half of the Atlantic Region's total expenditures at 63.7%, dental expenditures ranked second at 15.7%, followed by medical transportation at 14.7%. Vision care and other health care accounted for 5.1% and 0.8% of total expenditures respectively.

Percentage Change in Atlantic Region NIHB Expenditures

Annual Expenditures by Benefit ($ 000's)

Atlantic Region	1999/00	2000/01	2001/02	2002/03	2003/04
Medical Transportation	$6,425	$6,098	$6,235	$6,314	$6,498
Pharmacy	10,126	11,371	12,667	14,322	16,265
Dental	3,819	4,511	5,196	4,691	4,857
Other Health Care	123	138	173	198	141
Vision Care	1,479	1,583	1,433	1,604	1,631
Total	$21,972	$23,701	$25,704	$27,128	$29,391

Annual Expenditures by Benefit ($ 000's)

Atlantic Region	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$6,124	$5,590	$4,401	$4,585	$4,655
Pharmacy	17,533	18,293	18,938	18,984	20,119
Dental	4,934	4,831	5,128	5,204	4,945
Other Health Care	161	201	192	272	251
Vision Care	1,619	1,614	1,408	1,495	1,596
Total	$30,371	$30,529	$30,067	$30,539	$31,567

Source: FIRMS adapted by Program Analysis Division

Figure 8.2 Quebec Region 1999/00 to 2008/09

Annual expenditures in the Quebec Region for 2008/09 totalled $71.1 million, an increase of 2.4% from the $69.4 million spent in 2007/08. Pharmacy expenditures in 2008/09 increased by 2.0% to $36.1 million, medical transportation costs increased by 1.8% to $20.5 million and dental expenditures increased by 6.2% to $12.9 million. Vision care and other health care expenditures decreased by 3.0% and 20.4% respectively.
Pharmacy costs accounted for half of the Quebec Region's total expenditures at 50.8%, medical transportation expenditures ranked second at 28.9%, followed by dental at 18.1%. Vision care and other health care accounted for 1.7% and 0.5% of total expenditures respectively.

Percentage Change in Quebec Region NIHB Expenditures

Annual Expenditures by Benefit ($ 000's)

Quebec Region	1999/00	2000/01	2001/02	2002/03	2003/04
Medical Transportation	$15,761	$15,475	$16,589	$16,877	$16,985
Pharmacy	17,388	19,680	22,209	25,005	27,436
Dental	9,015	9,574	10,505	10,292	10,277
Other Health Care	1,278	1,355	544	695	726
Vision Care	910	984	1,119	1,173	1,097
Total	$44,352	$47,068	$50,966	$54,042	$56,521

Annual Expenditures by Benefit ($ 000's)

Quebec Region	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$17,291	$17,886	$18,473	$20,133	$20,502
Pharmacy	29,959	31,771	33,486	35,372	36,069
Dental	10,525	10,970	11,603	12,141	12,895
Other Health Care	697	750	583	471	375
Vision Care	1,349	1,135	1,270	1,257	1,220
Total	$59,820	$62,512	$65,414	$69,374	$71,060

Source: FIRMS adapted by Program Analysis Division

Figure 8.3 Ontario Region 1999/00 to 2008/09

Annual expenditures in the Ontario Region for 2008/09 totalled $165.2 million, an increase of 0.8% from the $163.8 million spent in 2007/08. Pharmacy expenditures in 2008/09 remained unchanged from 2007/08 at $77.2 million, medical transportation costs decreased by 1.2% to $45.1 million. However, in 2007/08 the Ontario Region had a one time investment in medical transportation of $2.7 million. Without this one time investment, the growth rate of medical transportation expenditures in 2008/09 would have been 5.1% rather than -1.2%. Dental expenditures increased by 5.9% to $35.5 million while vision care and other health care expenditures decreased by 3.0% and 0.6% respectively.

Pharmacy expenditures accounted for 46.8% of the Ontario Region's total expenditures, medical transportation costs ranked second at 27.3%, followed by dental at 21.5%. Vision care and other health care accounted for 3.2% and 1.3% of total expenditures respectively.

Percentage Change in Ontario Region NIHB Expenditures

Annual Expenditures by Benefit ($ 000's)

Ontario Region	1999/00	2000/01	2001/02	2002/03	2003/04
Medical Transportation	$32,713	$35,072	$40,264	$37,493	$36,620
Pharmacy	40,346	45,244	51,167	57,929	62,953
Dental	23,558	23,255	27,568	29,042	27,760
Other Health Care	3,431	3,899	2,183	2,548	2,250
Vision Care	4,672	4,792	4,886	5,085	5,196
Total	$104,720	$112,262	$126,068	$132,097	$134,779

Annual Expenditures by Benefit ($ 000's)

Ontario Region	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$35,258	$38,553	$40,572	$45,618	$45,088
Pharmacy	67,508	73,223	77,788	77,191	77,244
Dental	29,655	32,064	32,777	33,467	35,457
Other Health Care	2,404	2,213	2,530	2,172	2,158
Vision Care	5,428	5,458	5,485	5,366	5,204
Total	$140,253	$151,510	$159,152	$163,814	$165,150

Source: FIRMS adapted by Program Analysis Division

Figure 8.4 Manitoba Region 1999/00 to 2008/09

Annual expenditures in the Manitoba Region for 2008/09 totalled $183.5 million, an increase of 6.1% from the $173.0 million spent in 2007/08. Pharmacy expenditures in 2008/09 increased by 2.5% to $71.1 million, medical transportation costs increased by 8.2% to $82.4 million. However, in 2007/08 the Manitoba Region had a one time investment in medical transportation of $1.6 million. Without this one time investment, the growth rate of medical transportation expenditures in 2008/09 would have been 10.6% rather than 8.2%. Dental expenditures increased by 12.6% to $24.4 million and vision care costs increased by 4.6% while other health care decreased by 12.1%.

Medical transportation expenditures comprised the largest portion of Manitoba Region's total expenditures at 44.9%, pharmacy costs ranked second at 38.7%, followed by dental at 13.3%. Vision care and other health care accounted for 1.7% and 1.4% of total expenditures respectively.

Percentage Change in Manitoba Region NIHB Expenditures

Annual Expenditures by Benefit ($ 000's)

Manitoba Region	1999/00	2000/01	2001/02	2002/03	2003/04
Medical Transportation	$44,413	$46,089	$48,320	$51,199	$53,533
Pharmacy	31,132	35,533	36,078	42,525	48,519
Dental	10,189	11,832	16,319	16,600	17,313
Other Health Care	4,399	3,218	4,023	4,675	5,621
Vision Care	1,899	1,748	2,860	2,640	2,888
Total	$92,032	$98,420	$107,600	$117,638	$127,874

Annual Expenditures by Benefit ($ 000's)

Manitoba Region	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$55,895	$63,322	$69,047	$76,082	$82,354
Pharmacy	53,998	59,409	64,966	69,317	71,081
Dental	18,705	20,326	20,756	21,696	24,434
Other Health Care	5,685	5,690	4,786	2,964	2,605
Vision Care	2,684	2,864	2,841	2,936	3,071
Total	$136,967	$151,610	$162,396	$172,994	$183,545

Source: FIRMS adapted by Program Analysis Division

Figure 8.5 Saskatchewan Region 1999/00 to 2008/09

Annual expenditures in the Saskatchewan Region for 2008/09 totalled $131.7 million, an increase of 4.1% from the $126.6 million spent in 2007/08. Pharmacy expenditures in 2008/09 increased by 3.4% to $62.8 million, medical transportation costs decreased by 0.9% to $35.8 million and dental expenditures increased by 14.1% to $28.1 million. Vision care costs increased by 1.0% while other health care expenditures decreased by 7.6%.

Pharmacy expenditures accounted for almost half of the Saskatchewan Region's total expenditures at 47.7%, medical transportation costs ranked second at 27.2%, followed by dental at 21.3%. Vision care and other health care accounted for 3.2% and 0.7% of total expenditures respectively.

Percentage Change in Saskatchewan Region NIHB Expenditures

Annual Expenditures by Benefit ($ 000's)

Saskatchewan Region	1999/00	2000/01	2001/02	2002/03	2003/04
Medical Transportation	$22,038	$24,438	$23,862	$25,853	$25,854
Pharmacy	30,983	34,926	38,240	44,394	48,952
Dental	12,307	12,731	15,708	17,649	18,297
Other Health Care	1,948	2,032	2,663	2,671	2,370
Vision Care	2,755	2,890	3,113	3,360	3,375
Total	$70,031	$77,017	$83,586	$93,927	$98,847

Annual Expenditures by Benefit ($ 000's)

Saskatchewan Region	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$26,758	$28,786	$31,816	$36,108	$35,772
Pharmacy	52,636	55,687	58,083	60,749	62,809
Dental	19,530	22,038	23,219	24,636	28,102
Other Health Care	2,295	2,237	2,244	942	870
Vision Care	3,431	4,072	3,835	4,126	4,166
Total	$104,651	$112,820	$119,197	$126,561	$131,718

Source: FIRMS adapted by Program Analysis Division

Figure 8.6 Alberta Region 1999/00 to 2008/09

Annual expenditures in the Alberta Region for 2008/09 totalled $133.6 million, an increase of 1.9% from the $131.1 million spent in 2007/08. Pharmacy expenditures in 2008/09 decreased by 0.3% to $54.2 million, medical transportation costs increased by 10.1% to $35.4 million and dental expenditures increased by 11.7% to $25.0 million. The cost of premiums and other health care decreased by 23.5% and 9.3% respectively, while vision care costs increased by 5.7%.

The decreased growth rate of premiums is mainly attributed to the NIHB Program no longer funding provincial health premiums in the Alberta Region as of January 1, 2009. The Government of Alberta eliminated Alberta Health Care insurance premiums for all Albertans as of January 1, 2009. Consequently, in 2008/09 the NIHB Program paid for health premiums in the Alberta Region for only three-quarters of the year.

Pharmacy expenditures accounted for 40.5% of the Alberta Region's total expenditures, medical transportation costs ranked second at 26.5%, followed by dental at 18.7%. Premiums, vision care and other health care accounted for 7.4%, 3.9% and 2.9% of total expenditures respectively.

Percentage Change in Alberta Region NIHB Expenditures

Annual Expenditures by Benefit ($ 000's)

Alberta Region	1999/00	2000/01	2001/02	2002/03	2003/04
Medical Transportation	$27,774	$28,116	$29,796	$28,856	$29,030
Pharmacy	28,843	33,365	36,781	41,590	45,588
Dental	16,455	15,527	16,680	18,375	19,237
Other Health Care	2,944	4,285	3,371	3,856	3,794
Vision Care	3,894	3,696	4,397	4,239	4,576
Sub-Total	79,910	84,989	91,025	96,916	102,224
Premiums	8,480	8,689	8,914	11,790	12,202
Total	$88,390	$93,678	$99,939	$108,706	$114,426

Annual Expenditures by Benefit ($ 000's)

Alberta Region	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$29,686	$30,712	$32,204	$32,107	$35,357
Pharmacy	48,207	51,141	52,424	54,353	54,189
Dental	19,306	20,594	21,006	22,391	25,016
Other Health Care	4,078	4,537	4,736	4,343	3,940
Vision Care	4,720	4,762	4,690	4,942	5,225
Sub-Total	105,996	111,746	115,060	118,135	123,726
Premiums	12,377	12,381	12,709	12,961	9,920
Total	$118,373	$124,127	$127,769	$131,096	$133,646

Source: FIRMS adapted by Program Analysis Division

Figure 8.7 British Columbia Region 1999/00 to 2008/09

Annual expenditures in the British Columbia Region for 2008/09 totalled $124.5 million, an increase of 4.3% from the $119.4 million spent in 2007/08. Pharmacy expenditures in 2008/09 increased by 3.3% to $56.1 million, medical transportation costs increased by 5.1% to $22.7 million and dental expenditures increased by 7.6% to $24.7 million. The cost of premiums, vision care and other health care increased by 1.6%, 4.2% and 4.0% respectively.

Pharmacy expenditures accounted for 45.1% of the British Columbia Region's total expenditures, dental costs ranked second at 19.9%, followed by medical transportation at 18.2%. Premiums, vision care and other health care accounted for 13.3%, 2.6% and 0.9 % of total expenditures respectively.

Percentage Change in British Columbia Region NIHB Expenditures

Annual Expenditures by Benefit ($ 000's)

British Columbia Region	1999/00	2000/01	2001/02	2002/03	2003/04
Medical Transportation	$12,954	$12,718	$14,039	$16,410	$16,408
Pharmacy	28,748	30,185	33,592	38,922	44,141
Dental	17,490	18,078	18,230	19,224	18,338
Other Health Care	1,903	1,831	1,165	1,240	1,653
Vision Care	2,656	2,518	2,622	2,601	3,259
Sub-Total	63,751	65,330	69,648	78,397	83,800
Premiums	9,551	9,091	9,682	12,113	16,411
Total	$73,302	$74,421	$79,330	$90,510	$100,212

Annual Expenditures by Benefit ($ 000's)

British Columbia Region	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$17,340	$16,944	$20,284	$21,613	$22,711
Pharmacy	46,670	49,734	50,387	54,290	56,104
Dental	20,357	22,439	22,588	22,968	24,718
Other Health Care	1,581	1,486	1,177	1,120	1,165
Vision Care	3,249	3,049	3,232	3,120	3,251
Sub-Total	89,197	93,652	97,669	103,111	107,948
Premiums	15,453	15,606	15,951	16,250	16,510
Total	$104,650	$109,259	$113,620	$119,361	$124,458

Source: FIRMS adapted by Program Analysis Division

Figure 8.8 Yukon 1999/00 to 2008/09

Annual expenditures in the Yukon for 2008/09 totalled $9.2 million, an increase of 2.6% from the $9.0 million spent in 2007/08. Pharmacy expenditures in 2008/09 decreased slightly by 0.6% while medical transportation costs increased slightly by 0.1%. Dental expenditures increased by 12.4% to $2.2 million and vision care costs increased by 5.2%.

Pharmacy expenditures accounted for 41.1% of Yukon's total expenditures, medical transportation expenditures ranked second at 31.9%, followed by dental and vision care at 24.4% and 2.6% respectively.

Percentage Change in Yukon NIHB Expenditures

Annual Expenditures by Benefit ($ 000's)

Yukon	1999/00	2000/01	2001/02	2002/03	2003/04
Medical Transportation	$1,865	$1,852	$2,020	$1,957	$1,600
Pharmacy	1,953	2,393	2,649	3,048	3,214
Dental	1,184	994	1,284	1,236	1,365
Other Health Care	82	16	13	11	2
Vision Care	229	208	199	218	223
Total	$5,313	$5,463	$6,165	$6,470	$6,405

Annual Expenditures by Benefit ($ 000's)

Yukon	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$1,774	$2,100	$2,421	$2,935	$2,938
Pharmacy	3,476	3,655	3,641	3,802	3,779
Dental	1,229	1,863	2,033	1,998	2,246
Other Health Care	4	1	22	4	1
Vision Care	480	228	274	230	242
Total	$6,963	$7,847	$8,392	$8,970	$9,206

Source: FIRMS adapted by Program Analysis Division

Figure 8.9 Northwest Territories and Nunavut 1999/00 to 2008/09

Annual expenditures in the Northwest Territories and Nunavut for 2008/09 totalled $58.0 million, an increase of 6.6% from the $54.5 million spent in 2007/08. Pharmacy expenditures in 2008/09 increased by 5.9% to $15.3 million, medical transportation costs increased by 10.8% to $25.6 million and dental expenditures decreased by 0.9% to $14.6 million. Vision care costs increased by 17.0% to $2.5 million. There were no other health care costs to be reported as this benefit category is primarily comprised of short-term crisis mental health services, which is covered by the territorial governments.

Medical transportation costs accounted for 44.1% of total expenditures, pharmacy expenditures ranked second at 26.3%, followed by dental at 25.2%. Vision care made up 4.3% of total expenditures.

Percentage Change in Northwest Territories and Nunavut NIHB Expenditures

Source: FIRMS adapted by Program Analysis Division

Annual Expenditures by Benefit ($ 000's)

Northwest Territories and Nunavut	1999/00	2000/01	2001/02	2002/03	2003/04
Medical Transportation	$13,136	$12,993	$14,594	$18,995	$19,265
Pharmacy	6,697	7,605	8,382	10,157	11,310
Dental	8,393	8,013	8,228	9,468	11,657
Other Health Care	0	0	0	1,000	0
Vision Care	1,349	1,329	1,391	1,341	2,175
Total	$29,575	$29,940	$32,595	$40,961	$44,407

Annual Expenditures by Benefit ($ 000's)

Northwest Territories and Nunavut	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$21,401	$21,486	$22,384	$23,114	$25,604
Pharmacy	12,278	12,912	13,677	14,441	15,294
Dental	13,738	13,386	13,989	14,754	14,628
Other Health Care	0	0	0	0	0
Vision Care	1,669	1,787	1,859	2,150	2,517
Total	$49,086	$49,571	$51,909	$54,460	$58,043

Figure 8.9.1 Northwest Territories and Nunavut 2003/04 to 2008/09

The following two tables provide separate regional information on the NIHB benefit expenditures for the Northwest Territories and Nunavut since 2003/04. Separate data for these two regions cannot be reported on for the period prior to 2003/04.

Annual Expenditures by Benefit ($ 000's)

Northwest Territories	2003/04	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$6,856	$7,428	$6,710	$7,116	$6,943	$7,952
Pharmacy	7,161	7,544	8,010	8,151	7,863	8,210
Dental	4,726	5,173	5,249	5,249	5,752	6,279
Other Health Care	0	0	0	0	0	0
Vision Care	700	718	743	819	1,011	1,130
Total	$19,443	$20,863	$20,712	$21,335	$21,570	$23,571

Source: FIRMS adapted by Program Analysis Division

Annual Expenditures by Benefit ($ 000's)

Nunavut	2003/04	2004/05	2005/06	2006/07	2007/08	2008/09
Medical Transportation	$12,409	$13,972	$14,776	$15,268	$16,171	$17,653
Pharmacy	4,150	4,734	4,902	5,526	6,579	7,084
Dental	6,932	8,566	8,137	8,740	9,002	8,349
Other Health Care	0	0	0	0	0	0
Vision Care	1,475	951	1,044	1,040	1,139	1,387
Total	$24,965	$28,223	$28,860	$30,574	$32,890	$34,473

Source: FIRMS adapted by Program Analysis Division

Section 9 - Initiatives and Activities

Section 9.1 Health Information and Claims Processing Services (HICPS) 2008/09

Claims for the Non-Insured Health Benefits (NIHB) Program pharmacy, dental and medical supplies and equipment (MS&E) benefits provided to eligible First Nations and Inuit clients are processed via the Health Information and Claims Processing Services (HICPS) system. HICPS includes administrative services and programs, technical support and automated information management systems used to process and pay claims in accordance with NIHB Program client/benefit eligibility and pricing policies.

The NIHB Program is responsible for developing, maintaining and managing key business processes, systems and services required to deliver HICPS. Since 1990, the NIHB Program has retained the services of a private sector contractor to administer the following core claims processing services on its behalf:

• Provider registration and communications;
• Claim adjudication and reporting systems development and maintenance;
• Systems in support of benefit prior approval and predetermination operations;
• Claim processing and payment operations;
• Provider audit programs and audit recoveries; and
• Standard and ad hoc reporting.

For 2008/09 the HICPS contract continued with First Canadian Health Management Corporation (FCH). The NIHB Program manages the HICPS contract as the project authority in conjunction with Public Works and Government Services Canada (PWGSC), the contract authority. The FCH contract expired on November 30, 2009. Operation under the new HICPS contract which was awarded to Express Script Inc (ESI) Canada in 2007 commenced on December 1, 2009. During fiscal year 2008/09, pre-implementation phases for the new contract and a transition process between contractors were implemented.

In fiscal year 2008/09, 25,105 active providers^* were registered with the HICPS claims processor to deliver NIHB pharmacy, MS&E and dental benefits. The number of claims settled through the HICPS system is highlighted in Figure 9.1.1.

* An active provider has participated in the NIHB Program at least once over the past 24 months.

Figure 9.1.1 Number of Claim Lines Settled Through the Health Information and Claims Processing Services System in 2008/09

Figure 9.1.1 sets out the total number of pharmacy, dental and MS&E claims settled through the HICPS system in fiscal year 2008/09. During this time, 18,121,554 claim lines were processed through HICPS, an increase of 3.9% over the previous fiscal year.

Claim Lines vs. Prescriptions

It is important to note that the Program reports annually on claim lines. This is an administrative as opposed to a health care unit of measure. A claim line represents a transaction on the claims processing system and is not equivalent to a prescription. Prescriptions can contain a number of different drugs with each one represented by a separate claim line. Prescriptions for a number of drugs may be repeated and refilled many times throughout the year. In the case of repeating prescriptions, each time a prescription is refilled, the system will log another transaction (claim line). Therefore, it is possible for an individual who has a prescription that repeats multiple times in a year to have numerous related claim lines associated with the single prescription. Some prescriptions (e.g., methadone) are dispensed daily and will augment the per capita number of claim lines.

Region	Pharmacy	Dental	MS&E	Total
Atlantic	685,867	88,516	20,866	795,249
Quebec	1,647,854	165,913	14,833	1,828,600
Ontario	3,597,924	509,759	31,888	4,139,571
Manitoba	2,389,974	336,134	71,573	2,797,681
Saskatchewan	2,005,236	327,070	59,439	2,391,745
Alberta	2,148,398	454,083	55,447	2,657,928
British Columbia	2,419,115	464,903	37,407	2,921,425
Yukon	85,829	23,330	3,193	112,352
Northwest Territories	162,799	73,442	6,794	243,035
Nunavut	142,957	86,057	4,954	233,968
Total	15,285,953	2,529,207	306,394	18,121,554

Source: HICPS adapted by Program Analysis Division

Section 9.2 Provider Audit Activities 2008/09

The NIHB Program is a publicly-funded program that must account for the expenditure of those public funds. The Provider Audit Program contributes to the fulfillment of this overall requirement. As part of the Health Information and Claims Processing Services (HICPS) system financial controls, Health Canada has mandated the claims processor to maintain a set of pre-payment as well as post-payment verification processes including a provider audit program. During 2008/09, FCH carried out audit activities as directed by the NIHB Program. The audit activities address the need of the NIHB Program both to comply with accountability requirements for the use of public funds and to ensure provider compliance with the terms and conditions of the Program as outlined in the NIHB Provider Information Kits and other relevant documents. The objectives of the audit program are to detect billing irregularities, to validate active licensure of providers, to ensure that any required signatures on claim submissions are valid, to ensure that services paid for were received by eligible NIHB clients and to ensure that providers retained appropriate documentation in support of each claim. Claims not meeting the billing requirements of the NIHB Program are subject to audit recovery.

There are five components of the Provider Audit Program for the pharmacy, medical supplies and equipment and dental benefit areas. These are:

1. Next Day Claims Verification (NDCV) Program which consists of a review of a defined sample of claims submitted by providers the day following receipt by FCH;
2. Client Confirmation Program (CCP) which consists of a monthly mail-out to a randomly selected sample of NIHB clients to confirm the receipt of the benefit that has been billed on their behalf;
3. Provider Profiling Program which consists of a review of the billings of all providers against selected criteria and the determination of the most appropriate follow-up activity if concerns are identified;
4. On-Site Audit Program which consists of the selection of a sample of claims for administrative validation with a provider's records through an on-site visit; and
5. Desk Audit Program which consists of the selection of a sample of claims for administrative validation with a provider's records. Unlike on-site audits, a desk audit serves to validate records through the use of fax or mail. Generally, a smaller number of claims are reviewed during a desk audit.

During 2008/09, the primary issues identified in on-site audits were as follows:

• Documentation to support paid claims was either not available for audit review or did not meet the NIHB Program requirements;
• Paid claims did not match the item/service provided to the client;
• Items/services were claimed prior to client(s) receiving the services/items;
• Professional fee submitted was higher than the NIHB approved rate; and
• Overcharging of drugs/items and/or associated fees/markup.

Completion of the audit process often spans more than one fiscal year. Although the complete audit recovery for any audit may overlap into another fiscal year, recoveries from on-site audits are recorded in the fiscal year in which they are received.

Annual Provider Review

Since the summer of 2007, NIHB has conducted an annual review of providers to identify anomalous billing patterns. Providers with unexplained anomalies can be put under a restricted billing regime or de-listed as a provider because of financial risk to the NIHB Program. In 2008/09, ten pharmacy and two dental providers were de-listed as a result of profiling.

Benefit Audit Frameworks

As part of meeting its management accountability responsibilities, NIHB has developed additional audit frameworks for NIHB Medical Transportation, Vision Care and Mental Health Care benefits. These frameworks provide effective mechanisms to conduct reviews on the utilization of these benefits and their associated expenditures, and will provide the foundation for future enhanced audit activities.

Figure 9.2.1 Audit Recoveries by Benefit and Region 2008/09

Figure 9.2.1 identifies audit recoveries, Next Day Claims Verification (NDCV) and Client Confirmation Program (CCP) savings from all components of the FCH Provider Audit Program during the 2008/09 fiscal year.

Pharmacy

Region	Audits Completed	Recoveries	NDCV/CCP Savings	Total Recoveries/Savings
Atlantic	1	$ 51,812	$ 16,312	$ 68,124
Quebec	2	17,832	46,494	64,326
Ontario	33	195,687	130,517	326,204
Manitoba	7	364,951	139,372	504,323
Saskatchewan	16	204,989	62,082	267,070
Alberta	24	153,032	78,452	231,484
British Columbia	20	78,618	42,032	120,650
Yukon	0	0	3,425	3,425
N.W.T.	0	0	20,338	20,338
Nunavut	0	0	17,846	17,846
Total	103	$ 1,066,922	$ 556,869	$ 1,623,791

Dental

Region	Audits Completed	Recoveries	NDCV/CCP Savings	Total Recoveries/Savings
Atlantic	1	$ 23,868	$ 13,187	$ 37,055
Quebec	6	8,787	15,956	24,743
Ontario	2	21,299	94,434	115,733
Manitoba	4	16,536	37,298	53,833
Saskatchewan	10	78,550	36,802	115,351
Alberta	12	14,035	80,095	94,131
British Columbia	9	35,961	75,919	111,880
Yukon	2	0	2,296	2,296
N.W.T.	0	0	8,020	8,020
Nunavut	0	7,769	11,425	19,194
Total	46	$ 206,805	$ 375,432	$ 582,236

MS&E

Region	Audits Completed	Recoveries	NDCV/CCP Savings	Total Recoveries/Savings
Atlantic	0	$ 0	$ 34,601	$ 34,601
Quebec	0	0	8,593	8,593
Ontario	4	0	16,635	16,635
Manitoba	5	1,916	18,620	20,536
Saskatchewan	1	0	6,834	6,834
Alberta	2	0	30,791	30,791
British Columbia	0	13,359	19,842	33,201
Yukon	0	0	1,778	1,778
N.W.T.	0	0	5,152	5,152
Nunavut	0	0	5,079	5,079
Total	12	$ 15,275	$ 147,925	$ 163,200

 

Section 9.3 Federal Dental Care Advisory Committee (FDCAC)

The Federal Dental Care Advisory Committee (FDCAC) is an advisory body of oral health professionals established to provide advice on dental matters as requested by federal departments.

Participating federal departments include: Health Canada, Veterans Affairs Canada, Royal Canadian Mounted Police, Correctional Services Canada, Citizenship and Immigration Canada and National Defence. Observers are included at FDCAC meetings at the discretion of the Chair in consultation with the federal departments. The total number of observers shall not exceed three. The suggested composition is two observers from the Assembly of First Nations (AFN) and one from the Inuit Tapiriit Kanatami (ITK).

The mandate of the FDCAC is to advise the Chief Dental Officer at Health Canada and each of the federal departments on oral health policy, on best practices and evidence based oral health as well as on specific clinical issues, including current issues, new technologies, procedures as well as complementary issues that will impact on the oral and dental health and needs of their clients.

The approach is evidence-based. The professional advice reflects dental and scientific knowledge, current best practice in all aspects of clinical practice as well as health and health care delivery appropriate to specific client health needs. The expert dental health professional advice assures federal clients of a dental program which considers their health and oral health needs, facilitates decision-making within resource allocation and fosters communication with dental health professionals providing services on behalf of federal programs.

The Committee may have up to four scheduled meetings each year, and may be required to meet for an additional meeting depending upon the needs of the federal departments. The appointment of members is carried out by the Chair in consultation with the federal departments and the FDCAC Secretariat to determine the expertise required. A normal term of appointment for members is three years renewable. Rotation of members is gradual to ensure continuity of membership on the FDCAC.

The responsibility for the FDCAC Secretariat was assumed by the Office of the Chief Dental Officer as of April 1, 2006. The NIHB Program remains an active participant on the FDCAC.

Section 9.4 The Drug Review Process

The review process for drug products that are considered for inclusion as a benefit under the NIHB Program depends on the type of drug. The process is different depending on whether the product represents a new chemical entity or new combination drug product, as set out below.

The NIHB Program is a member of the Federal/Provincial/Territorial (F/P/T) Common Drug Review (CDR) process, whereby drugs that are new chemical entities, new combination drug products, or existing drug products with new indications on the Canadian market are reviewed on behalf of all participating F/P/T public drug programs. For these drug products, the CDR, through the Canadian Expert Drug Advisory Committee (CEDAC), helps support and inform public drug plan listing decisions about new drugs by providing rigorous reviews of the clinical evidence, cost effectiveness of drugs, and detailed listing recommendations. The CDR was set up by F/P/T public drug programs to reduce duplication of effort in reviewing drug submissions, to maximize the use of limited resources and expertise, and to enhance the consistency and quality of drug reviews, thereby contributing to the quality and sustainability of Canadian public drug plans. The NIHB Program and other drug plans make listing decisions based on CEDAC recommendations and other specific relevant factors, such as the particular circumstances of NIHB clients.

The Canadian Agency for Drugs and Technologies in Health provides a list of requirements for manufacturers' submissions and a summary of procedures for the Common Drug Review Process. Inquiries about the CDR process should be directed to:

Common Drug Review (CDR)
Canadian Agency for Drugs and
Technologies in Health
865 Carling Avenue, Suite 600
Ottawa, Ontario K1S 5S8
Telephone: (613) 226-2553
Website: www.cadth.ca

Existing drug products on the Drug Benefit List with new formulations, drug class reviews and/or line extension drug products are the subject of a different process. Such products are referred to the Federal Pharmacy and Therapeutics (FP&T) Committee for recommendations on formulary listing for the NIHB Program and other participating federal drug plans. The FP&T Committee is an advisory body of health professionals established by federal drug programs to provide evidence-based pharmacy and medical advice to participating federal departments, which include: Health Canada, Veterans Affairs Canada, the Royal Canadian Mounted Police, Correctional Services Canada, Citizenship and Immigration Canada and National Defence.

The FP&T Committee generally meets three times a year and members serve for two to three years. Individual members are selected based on their specific areas of expertise and experience, with consideration being given to providing a balance between scientific knowledge and practical community experience. As a result, the membership of this Committee includes practicing physicians and pharmacists from community and hospital settings and includes First Nations physicians. In its review of drugs, the Committee follows an evidence-based approach and considers current medical and scientific knowledge, current clinical practice, health care delivery and specific client health needs. The NIHB Program and other federal drug plans make their formulary listing decisions based on the recommendations of the FP&T Committee and other specific relevant factors, such as the particular circumstances of their clients. It is the goal of the NIHB Program to maintain a comprehensive list of cost-effective drugs which will allow practitioners to prescribe an appropriate course of therapy for NIHB clients.

Other drug products, such as generic drug products, are reviewed internally. Generic drug products are considered for inclusion on the NIHB formulary based on provincial interchangeability lists and other relevant factors.

Section 9.5 Drug Use Evaluation (DUE)

The use of prescription drugs in ways that are not supported by clinical evidence affects the health of many Canadians. In order to effectively address the issue for NIHB clients, the problem of sub-optimal prescription drug use must be understood in the context of health status and health program issues impacting First Nations and Inuit.

Optimal drug use means providing the right drug to the right client in the right dose at the right time. The First Nations and Inuit Health Branch (FNIHB) of Health Canada recognizes that, in order to address medication issues and improve health outcomes, the Branch must work with First Nations and Inuit communities, organizations and stakeholders to develop and implement strategies around awareness, promotion, prevention and treatment. This includes:

• Reviewing aggregate FNIHB information to identify trends and issues;
• Engaging First Nations and Inuit communities, organizations and stakeholders in working together on approaches and materials; and
• Working with prescribers, pharmacists and clients to address specific instances of at-risk clients.

In the context of FNIHB community-based mental health and substance abuse programs, the Non-Insured Health Benefits Program recognizes the value of drug use evaluation as a tool to support these activities. Programs and strategies based on DUE can work to improve the quality of client care, enhance therapeutic outcomes, and optimize pharmaceutical expenditures and thereby improve health outcomes.

To assist the NIHB Program, a Drug Use Evaluation Advisory Committee (DUEAC) has been established. The DUEAC is an advisory body of licensed health care professionals - experts in drug use evaluation, Aboriginal health issues and drug utilization. The membership of the Committee includes a number of First Nations and Inuit health care professionals.

The DUE Advisory Committee provides advice and recommendations to support a comprehensive DUE Program to promote safe, therapeutically effective and efficient use of drug therapy and contribute to positive health outcomes for eligible First Nations and Inuit clients of the NIHB Program.

The objectives of the Committee include:

• Providing recommendations that lead to improved prescribing, dispensing and use of drugs among First Nations and Inuit clients;
• Where appropriate, facilitating partnerships with First Nations and Inuit communities and FNIHB regional offices in order to recommend culturally appropriate educational interventions and strategies as well as tools for their implementation; and
• Evaluating the effectiveness of the intervention strategies, as required.

NIHB has undertaken many DUE activities since the inception of the Committee in December of 2003. All DUE activities conducted by NIHB are done in a manner respecting existing privacy legislation and guidelines. For further information please see Drug Use Evaluation Bulletins at: http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/index-eng.php#drug-med

FNIHB has also established the Drug Utilization and Prevention and Promotion Working Group (DUPPWG). The purpose of the DUPPWG is to ensure a coordinated and consistent approach to the implementation of all DUE client and population level initiatives across the Program to promote improvement in health outcomes of First Nations and Inuit clients through effective use of pharmaceuticals.

Drug Utilization Reviews

A drug utilization review, which is part of the point-of-service or online adjudication system, provides an analysis of both previous and current pharmacy claims data to identify potential drug-related problems.

Messages are sent electronically in real time to pharmacists to alert them of potential problems. These messages are intended to enhance pharmacy practice with additional information. For a listing of these messages, please refer to: http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/provide-fournir/pharma-prod/pay-paie-eng.php#drug_review

NIHB Prescription Monitoring Program (NIHB PMP)

The NIHB PMP was established in early 2007 by the NIHB Program consistent with the continuing focus on protecting client safety and improving health outcomes. The NIHB PMP allows the NIHB Program to make effective interventions with individual clients and prescribers/providers of potential misuse/abuse of benzodiazepine and opioid drug products at the point-of-sale in pharmacies. The pharmacy provider must call the Drug Exception Centre (DEC) for a client in the NIHB PMP when a point-of-sale message indicates to do so. Both the prescribers' and providers' collaboration are a critical aspect of the PMP process. The NIHB PMP was implemented initially in the Alberta Region. The NIHB PMP will expand to Nova Scotia in 2009/10 and to other regions in the future.

More information on these initiatives, is provided in the Report on Client Safety on the Health Canada web site: http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/2009_secur_rpt/index-eng.php

Section 9.6 Drug Exception Centre (DEC)

The NIHB Drug Exception Centre (DEC) was established in December 1997 to process and expedite pharmacists' requests for drug benefits that require prior approval, to help ensure consistent application of the NIHB drug benefit policy across the country, and to ensure an evidence-based approach to funding drug benefits. The DEC handles requests for prior approval from pharmacy providers across Canada.

In April 2008, the DEC implemented an Automatic Call Distribution (ACD) system. This system enhances the Centre's capacity to keep pace with industry trends and delivers notable service enhancements such as improved call management practices, provides the scalability and flexibility to respond rapidly to evolving business needs, and offers resilient business continuity solutions to help ensure critical services can be delivered during a disruption.

Figure 9.6.1 Total NIHB Drug Exception Centre Requests/Approvals 2008/09

The DEC is a single call centre to provide efficient responses to all requests for drugs that are not on the NIHB Drug Benefit List or require prior approval, for extemporaneous mixtures containing exception or limited use drugs, for prescriptions on which prescribers have indicated "No Substitution", and for claims that exceed $999.99.

Status	Benefit	Exceptions	Limited Use	Total
Total Requested	3,664	37,584	148,639	189,887
Total Approved	2,967	26,149	131,665	160,781

Benefit: Drugs included on the NIHB Drug Benefit List for which the total dollar value exceeds Point of Sale limit or for which more than a three-month supply is requested.

Exceptions: Drugs not included on the NIHB Drug Benefit List, as well as requests for drugs for which the physician has indicated "No Substitution".

Limited Use: Drugs covered only if they are prescribed for conditions which meet specific criteria for Program coverage.

Section 9.7 Federal Healthcare