:
Good morning, everyone. Happy new year.
Alice, happy new year.
This is the Standing Committee on Citizenship and Immigration, meeting number 40, on Tuesday, February 3, 2011. Pursuant to Standing Order 108(2), this is a study of the interim federal health program.
We're already late, so I'm going to suggest that the first group of witnesses go until 9:50, and the second group of witnesses will start at 9:50. Is there any problem? Silence. Okay.
Good morning, gentlemen. Our first set of guests for the first, I guess, roughly 45 minutes is the association québécoise des pharmaciens propriétaires. Monsieur Cadieux is the executive vice-president and director general. Good morning to you, sir. And we have Vincent Forcier, director of public affairs. Good morning to you.
You can make a brief presentation of roughly seven minutes, and then committee members will have some questions for you. We'll go in rounds.
You have the floor for up to seven minutes. You can start right now, sir.
I have a few words to present AQPP. If you don't mind, I'll do it in French. I'm sure you have translation.
[Translation]
The AQPP is a professional union representing the 1,800 owner pharmacists in Quebec.
Being a pharmacist is a prerequisite to owning a pharmacy in Quebec. In the case of large chains such as Shoppers Drug Mart/Pharmaprix and Jean Coutu, pharmacists are not owners, but rather franchisees.
The AQPP's mission is to consider and defend the economic, social and professional interests of its members. We carry out our mission primarily by negotiating agreements with various levels of government, such as the provincial government in the case of Quebec's public health care plan. The AQPP has also entered into a partnership agreement with the federal government that covers several programs.
At one time, the AQPP had an agreement with Citizenship and Immigration Canada. That was back in the 1990s. For reasons unbeknownst to me, that agreement was never renewed. In spite of that, refugees have continued to receive services. Pharmacists also never encountered any problems when it came to being reimbursed until about four years ago.
That is when problems first surfaced. Changes were introduced and rules were set, in our opinion, in a somewhat arbitrary manner, either by FAS or by CIC. Pharmacists no longer knew which medications were covered under the program, how much they would be reimbursed and the circumstances and terms under which their claims would be reimbursed.
All of which led to the problem we have today. Pharmacists decided that if they were not going to be reimbursed, they would either steer patients elsewhere or invite CIC to discuss a new agreement with the AQPP. For the past three years, we have repeatedly invited CIC to sit down and discuss an agreement, but unfortunately, our efforts have been unsuccessful.
Without an agreement, pharmacists who provide services to refugees have no way of knowing exactly which products are covered, what the level of coverage is, or the circumstances and terms under which their claims will be reimbursed. Each transaction carried out by the pharmacist therefore becomes problematic under the circumstances.
The AQPP is at a loss to explain the resistance it has encountered, despite the numerous invitations extended to CIC to negotiate a contract. The problem may be a lack of understanding. As I mentioned earlier, the AQPP already has agreements with the federal government covering first nations, with Health Canada, the RCMP, the Canadian Forces and Veterans Affairs Canada. The AQPP entered into this agreement with the federal government on the recommendation of Auditor General Sheila Fraser who had invited various federal agencies to come together to negotiate agreements.
So then, there is already an agreement in place. As we see it, CIC could take the exact same agreement and adjust the coverage to meet its needs. That would be a viable option. This approach has worked well with all of the other groups.
Since my time is almost up, I would like to wrap up by saying that we met early this week with CIC officials. We agreed on a temporary solution. We will restore service temporarily, even though it was never interrupted as such. We will ask our members to serve refugees, as per the program. That said, we still believe that the AQPP needs to negotiate an agreement with CIC quickly to resolve any outstanding issues and to set out all of the terms, conditions and coverage for refugees once and for all.
I hope that I have been able to give you an overview of the situation.
My colleagues and I will be happy to answer your questions.
Thank you for being here. I am very pleased that you accepted our invitation. I asked the committee to examine this matter because I felt it was urgent. I am delighted to hear that discussions are taking place with CIC and that progress is being made.
I take it—and you can clarify this for me—that this is a long-standing problem. The lack of progress on this issue forced you to resort to pressure tactics. That is probably not what you would call them, but I am referring to the directive sent out by the union to its pharmacists. I understood you to say that since the partners returned to the bargaining table and everyone seems to be acting in good faith, you intend to direct your pharmacists, at least as long as the process is ongoing, to continue delivering the same services that they have in the past.
Did I understand you correctly?
:
I really could not give you a figure in terms of sales percentages, because I'm not familiar with each pharmacy's sales figures. Also, since we do not have an agreement, I do not know the percentage of medications covered by CIC. However, substantial sums of money are involved. You understand that the money is advanced by individuals, by pharmacists. The worst case we saw was that of a pharmacist who had to advance thousands of dollars and who had been fighting with CIC for three years.
Let me give you some examples of products delivered to patients and what they cost. For instance, the monthly cost of triple therapy to treat HIV-AIDS is $1,500. This is each and every month and if the pharmacist is not reimbursed for the cost of treating a few patients, it doesn't take long for the cost to add up, after two, three or fourth months, to several thousand dollars.
It is the same for serious pulmonary infections treated with vancomycin. One seven-day course of treatment costs $500. The costs also add up quickly in this case. These are costs that that individuals, the owner pharmacists, must cover up front. It's not large corporations, but rather individuals, who are paying up front.
:
The go-between is RAMQ, the same as the ODB in Ontario.
[Translation]
In Ontario, pharmacists do not negotiate an agreement because they do not have a union. They fall under corporations and corporations are not allowed to negotiate with anyone because that would contravene the Competition Act. So the Ontario government sets up its own program and submits it to the ODB to manage.
The same thing goes for Quebec. They negotiate with the government, with the department of health and social services, and the department lets the Régie de l'assurance maladie du Québec manage the program.
We can draw a parallel. In this case, the Régie de l'assurance maladie du Québec would be Medavie Blue Cross. However, the agreement has to be with CIC because CIC is responsible for the program.
:
We are not asking for exactly the same thing. I believe the structure is similar. In my view, what we are asking for is more similar to our agreement with the federal government for the other four groups, meaning first nations, the RCMP, the Department of Veterans Affairs, and so on.
There already is an agreement. There is an agreement with the federal government that was signed by four different groups. All that is left to do is for the Department of Citizenship and Immigration to take the agreement and adjust the coverage of services and products it wants to pay for. It does not have to pay for the same products and services as the others. It has its own plan. If the department works with Medavie Blue Cross, it will be able to change the coverage at any time. It won’t even have to let the pharmacists know, since everything will be done electronically. So, when the pharmacist sends a claim, Medavie Blue Cross will say whether it is covered or not through the electronic system.
There already are agreements in place and they leave plenty of leeway. There was a lack of understanding on CIC's part, but they have complete freedom to adjust the coverage. CIC is in charge of that, not us. We just want to set the terms and conditions that govern our relationship with the government in order to make sure that we provide the right services and the right products, which are reimbursed under the plan, and that pharmacists will be paid within a reasonable timeframe.
:
That's not an issue because pharmacists have never refused to serve anyone or to dispense a prescription. They would never do that because, as you clearly pointed out, they are subjected to ethical rules and a code of conduct. No pharmacist refuses to serve a patient.
If our members are not able to be reimbursed by CIC because they are not included in an agreement, we recommend that they ask the refugees to pay for their medication if they have the means. Otherwise, pharmacists have the obligation to assist them and direct them to a service, a hospital or a clinic, where they can get the products they need.
The third option we are suggesting to our members is to serve the patient and then send a claim to CIC. We cannot guarantee that they will be reimbursed. Under no circumstances have pharmacists in Quebec refused, nor will they ever refuse, to assist a patient without at least directing them to another service so that they can get what they need from somewhere else.
:
Some drugs may not be covered by the Quebec public system and be covered for refugees. Each program has its own particularities and each program covers certain products.
For example, for the Canadian Forces, certain programs are put in place to cover over-the-counter drugs that are not covered by the Government of Quebec for Quebeckers. So, the Canadian Forces pay for certain over-the-counter drugs and the troops can get them on their military base.
In Quebec, there's an agreement for troops who aren't stationed on a base. They can get over-the-counter drugs at a pharmacy and be reimbursed. There are distinctions to be made in each program.
It's possible that some products are covered for refugees, as well as other products that are covered for the Quebec population. That's quite possible, but I couldn't list those products or say exactly what they are.
:
Thank you, Mr. Chairman.
My name is Albert Deschamps. I'm regional director for Citizenship and Immigration Canada for the Quebec region. As you mentioned, I'm accompanied today by Dr. Danielle Grondin, the director general of CIC's health branch.
I would like to thank the committee for inviting us here today and for taking notice of this important issue. CIC strives to provide refugees with the best health care possible. The interim federal health program provides emergency and essential health services to refugees, refugee claimants, and others who have not yet received provincial or territorial health coverage.
[Translation]
The IFHP has a transitional role only and is not designed to replace provincial or territorial health insurance programs, but provides coverage to eligible individuals prior to qualifying for provincial or territorial coverage.
[English]
The IFHP does not pay the beneficiaries but reimburses the providers of health care services the cost of such care. Participating providers, physicians, dentists, hospitals, clinics, pharmacists, etc., are reimbursed directly for services rendered to eligible beneficiaries by submitting invoices to the IFH claims administrator.
The IFHP serves approximately 128,000 recipients in Canada and about 25,000 in Quebec through a network of over 18,000 registered health care providers across Canada. In 2009-10 overall costs under the IFH program were $80 million--$20 million for Quebec. The IFHP medication costs for Canada were $14 million, of which $5.5 million were in Quebec.
On January 17, 2011, as a result of a competitive process, Medavie Blue Cross assumed responsibility for the administration of the interim federal health program.
[Translation]
As the committee is aware, on this date, the Association québécoise des pharmaciens propriétaires had also encouraged its members to not participate to the new electronic system put in place by Medavie Blue Cross. This was an important concern for CIC, since refugees do not have the means to pay for their prescriptions without the assurance of this program.
[English]
Today, I am pleased to report to the committee that much progress has since been achieved on this issue. On January 31, officials from CIC and the AQPP met in Montreal for an initial discussion regarding pharmacy services in Quebec and the IFHP. A temporary arrangement has been established in order to ensure that the IFHP beneficiaries who are prescribed medication can access that medication.
As of yesterday, February 2, the AQPP advised its members to resume offering regular services to IFHP beneficiaries while discussions between the parties continue.
Let me give you some background on how we got here. On January 17, 2011, Medavie Blue Cross assumed responsibility for the administration of the program, providing electronic claims adjudication services, including service standards. This modernized service will allow providers to determine eligibility of clients, services, and costs eligible for reimbursement. It would also allow for rapid reimbursement to health providers.
[Translation]
However, as pharmacists were being asked to register with the new administrator, the AQPP gave instructions to the software developer to not program the pharmacist's system, thus depriving them of the tool that would inform them of client eligibility, services covered and costs. It informed its members accordingly.
[English]
We acknowledge that in the past concerns were periodically raised with regard to delays in their reimbursement system, which was paper-based. However, when such claims were brought to our attention, they were fully reviewed and adjudicated. In some cases, the IFHP did reimburse the claim, but in the majority of them the claim was not eligible or only partly eligible for reimbursement. This was primarily because the product or service provided was not covered by the IFHP.
The AQPP hasn't submitted to CIC any other claims to consider in recent months, and I'm pleased to report that, as of today, all outstanding claims that we have been made aware of have been reviewed and adjudicated.
[Translation]
We have also reached out to pharmacists in Quebec to contact CIC if they have any claims that were submitted more than a month ago that have not yet been reimbursed.
[English]
As of January 17, as part of service standards, claims submitted electronically will now be processed in two weeks. Claims submitted by mail directly to Medavie Blue Cross will be processed within three weeks. In good faith we will continue our discussions with the AQPP, and we're hopeful that we will arrive at a solution that will satisfy both parties in order to continue to deliver health services to refugees under the IFHP.
:
In fact, I have some statistics here.
Basically, as was mentioned, there are refugee claimants, who are either waiting for their claims or whose claims have been rejected and are awaiting their removal from Canada. So these are covered.
There are resettled convention refugees, but there are also victims of trafficking. There are also border agency detainees. And there is a unique population, as in Quebec right now with the Haitian population, which is also covered by those programs.
As to the types of conditions, not all of the eligible clients will use the pharmaceutical services. For example, it varies from 78% for those who are refugee claimants to 48% of the resettled.
On the conditions, we have done a survey of the 200 most used pharmaceuticals. Roughly 14% to 17% are for anti-infectious medication and heart conditions. These are the most frequently prescribed medications. Then you have those for neurological disorders, to treat mental illness, depression, schizophrenia, and those types of things. Those are in the second group, and so on, concluding with gastrointestinal and others.
:
I can answer that, if I may, since our office has dealt with it. In fact, yes, we were aware there were delays, so we have reviewed all the claims that we received. Either they have been paid—those that were delayed, and it was a real payment—or they were adjudicated and the pharmacist was informed that either it was not eligible or...and so on. So this is one category.
Last year as well we reassessed some claims that the AQPP sent to us for reconsideration. All of these have also been reviewed and decisions were made. Of those, most of them were ineligible; that is, it was not covered or the client was not eligible, and so on.
We have heard about the allegation that there was a three-month delay; however, we have no evidence that there was a three-month delay. We have no documents, and documents have not been submitted, either by the pharmacist in question or the AQPP, that prove or demonstrate that there were such payment delays for $10,000 or $30,000, as we have heard.
We have invited the pharmacists, certainly, over the course of the last few weeks, especially those registered, to please submit. We have given an address, fax number, and everything to submit those claims. But so far, at this date, it's all adjudicated.
First, these are refugees asking for protection and, under the law, Canadian society has the obligation to give them that protection. There is also the category of Convention refugees, and, with the commission, we have already agreed to bring them to Canada. Those international obligations also have to be honoured on Canadian soil.
The health status of those refugees, mainly the Convention refugees—though there are different characteristics—is a function of their country of origin and the conditions in which they were living. In some countries, they had no access to medical services and, because of epidemiological conditions and infectious diseases, their health status has deteriorated. It is very important for Convention refugees to receive treatment. In any event, they are eligible for those services under our provincial and territorial health plans. We cover them for the waiting period, which is normally three months, but as soon as they are eligible, our program no longer covers them.
It is also important to cover those groups for what we call supplementary coverage, for medication and all those things that may not be covered by health plans; though the plans cover them for people on social assistance, for example. We take all the provincial social assistance programs already in place and we adapt them. That allows us to reach some degree of parity in what is offered to those groups in the provinces and territories.
That is important for three reasons. First, it is important for the refugees themselves, whatever category they are in, that we are concerned about their state of health and provide the necessary care. Second, it is important for public health, especially if they show signs of infectious diseases that can be spread to those close to them and to the community. We have to provide treatment for that. Third, by assuming the costs, we ease the strain on the resources of the provincial and territorial health systems, at least with regard to the costs. That all must be seen as positive.
It is important for Canadians to realize that this coverage for refugees seeking asylum actually does not last very long. The coverage provided to asylum-seekers by the program ceases when their cases are dismissed; in other words, they are covered until they leave Canada, and then that's it. If asylum-seekers withdraw or give up their claims for protection, the coverage ceases as well. Of course, if it comes to light at any time that a person is living in Canada illegally, the coverage also ceases. It really is temporary, just until the commission has rendered its verdict. If the commission gives a person refugee status, that person becomes eligible for provincial programs automatically.
:
We are not necessarily negotiating with each person. We rely on a system, a formulary—the Quebec formulary—that has already been negotiated, that already exists. We make it the same for everyone. It is a federal program. The pharmacists are already licensed; the Ordre des pharmaciens takes care of that. They are licensed. We use the Quebec formulary, the RAMQ's, but using the lowest cost. Then the pharmacists sign up.
The coverage is already set and all the RAMQ's medications are covered. We also have the possibility of getting preapproval for medications that may not be covered. The RAMQ, for example, does not cover some anti-malaria drugs, some antiparasitic drugs for intestinal parasites. Nor does it cover vitamins and products like that. Since we are dealing with vulnerable people who are often malnourished, it is better for them to be covered. So we cover them, and they are already in the system. Everything is there. This is not like a union agreement with each pharmacy. Far from it. The pharmacists are licensed and the RAMQ already has a negotiated system for people on social assistance. We just make use of it.
The Chair: Thank you.
Dr. Danielle Grondin: We have even done price comparisons, to go back to the example that came up in connection with HIV. Everything is carefully compared.
The Chair: Thank you.
Dr. Danielle Grondin: If the prescription specifies no substitute medications, that will be paid for. There is really no reason for litigation, but we are continuing the discussions in order to understand what AQPP wants.