Non-Insured Health Benefits Program: First Nations and Inuit Health Branch: Annual Report 2017-2018

Figure 2.2: Eligible client population by type and region: March 2017 and March 2018

Of the 867,749 total eligible clients at the end of the 2017/18 fiscal year, 819,977 (94.5%) were First Nations clients while 47,772 (5.5%) were Inuit clients. The number of First Nations clients increased by 1.7% and the number of Inuit clients increased by 1.7%

From March 2017 to March 2018, Saskatchewan had the highest percentage change in total eligible clients with a 2.3% increase, followed by Alberta and Manitoba with increases of 2.2% and 1.9% respectively.

Figure 2.3: Eligible client population

Over the past 10 years, the total number of eligible clients in the SVS has increased by 6.4%, from 815,800 in March 2009 to 867,749 in March 2018.

The NIHB Program client population was significantly impacted during this period by amendments to the Indian Act, such as the passage of Bill C-31, Bill C-3, and the creation of the new Qalipu Mi'kmaq Band, which increased the NIHB client population. In contrast, the creation of the First Nations Health Authority (FNHA) in British Columbia and the settlement of First Nations and Inuit self-government agreements, such as those with the Nisga'a Lisims government and the Nunatsiavut government, have decreased the total NIHB client population, as these individuals no longer receive benefits through Indigenous Services Canada's NIHB Program. The most notable such change occurred in 2013–14, when approximately 133,430 clients in B.C. were removed from the NIHB client population when they became eligible to receive non-insured health benefits through the FNHA.

Figure 2.3.1: Eligible client population: March 2009 to March 2018

Description of Figure 2.3.1: Eligible client population: March 2009 to March 2018

Year	Population
2009	815,800
2010	831,090
2011	846,024
2012	896,624
2013	926,044
2014	808,686
2015	824,033
2016	839,129
2017	853,088
2018	867,749

Over the past five years, the NIHB program's total number of eligible clients increased by 7.3% from 808,686 in March 2014 to 867,749 in March 2018. Alberta had the largest increase in eligible clients over this period, with a growth rate of 9.0%. The regions of Saskatchewan, Nunavut and Quebec followed with growth rates of 8.7%, 8.3% and 8.0% respectively.

Eligible client population by region, March 2014 to March 2018

Figure 2.4: Annual population growth, Canadian population and eligible client population: 2009 to 2018

From 2009 to 2018, the Canadian population increased by 10.3% while the NIHB eligible First Nations and Inuit client population increased by 6.4%. Prior to the removal of First Nations Health Authority (FNHA) clients, the NIHB ten year eligible population increase was 24.4%, with an average annual growth of 2.4%. Population growth is expected to return to historical rates in future fiscal years as the transition of residents of British Columbia to the FNHA is completed.

The higher than average NIHB Program client population growth rate of 6.0% in 2011/12 and 3.3% in 2012/13 can be attributed to the registration of new Bill C-3 clients as status Indians, and to new Qalipu Mi'kmaq First Nations clients in the Atlantic Region.

Figure 2.5: Eligible client population by age group, gender and region: March 2018

Of the 867,749 NIHB eligible clients on the SVS as of March 31, 2018, 49.2% were male (426,884) and 50.8% were female (440,865).

The average age of the eligible client population was 33 years of age. By region, this average ranged from a low of 27 years of age in Nunavut to a high of 38 years of age in the Yukon.

The average age of the male and female eligible client population was 32 years and 34 years respectively. The average age for males ranged from a low of 27 years in Nunavut to a high of 37 years in the Yukon Region. The average age for females varied from a low of 28 years in Nunavut to a high of 39 years in the Yukon and Quebec Region.

The NIHB eligible First Nations and Inuit client population is relatively young with nearly two-thirds (64.4%) under the age of 40. Of the total population, almost one-third (32.4%) are under the age of 20.

The senior population (clients 65 years of age and over) has been slowly increasing as a proportion of the total NIHB client population. In 2008/09, seniors represented 6.1% of the overall NIHB population. Most recently in 2017/18, seniors accounted for 8.2%. This demographic trend will contribute to cost pressures on the NIHB Program.

Figure 2.6: Population analysis by age group

The overall First Nations and Inuit client population is relatively young compared to the general Canadian population. The share of the NIHB client population under 20 years of age was 32.4% compared to 21.6% of the same age group in the Canadian population. The average age of First Nations and Inuit clients is 33 compared to 41 years of age for the Canadian population.

Figure 2.6.1: Proportion of Canadian population and of the First Nations and Inuit (FN&I) client population by age group

Description of Figure 2.6.1: Proportion of Canadian population and of the First Nations and Inuit (FN&I) client population by age group

Age group	Canadian population, July 2017	FN&I population, March 2018
0–9	10.8%	14.8%
10–19	10.8%	17.6%
20–29	13.8%	17.9%
30–39	13.8%	14.0%
40–49	13.0%	12.2%
50–59	14.5%	11.3%
60+	23.3%	12.2%
Total	100.0%	100.0%

A comparison of March 2014 to March 2018 eligible client population shows an aging population. The client population 40 and above, as a proportional share of the overall client population, increased from 33.9% in 2013 to 35.6% in 2018.

As the First Nations and Inuit client population ages, the costs associated with delivering Non-Insured Health Benefits, particularly pharmacy benefits, to this client population are expected to increase significantly.

Figure 2.6.2: Proportion of eligible First Nations and Inuit client population by age group

Description of Figure 2.6.2: Proportion of eligible First Nations and Inuit client population by age group

Age Group	March 2014	March 2018
0–9	16.3%	14.8%
10–19	18.4%	17.6%
20–29	17.8%	17.9%
30–39	13.6%	14.0%
40–49	13.0%	12.2%
50–59	10.5%	11.3%
60+	10.4%	12.2%
Total	100.0%	100.0%

Figure 3.1: NIHB program sustainability 2017/18

Cost and service pressures on the Canadian health system have been linked to factors such as an aging population and the increased demand for and utilization of health goods, particularly pharmaceuticals, and services. In addition to these factors, NIHB Program expenditures are driven by the number of eligible clients and their medical needs. The NIHB client population is growing at approximately two times the Canadian population growth rate. A significant proportion of NIHB clients live in small and remote communities, and require medical transportation to access health services that are not available locally.

Figure 3.2: NIHB expenditures by benefit ($ millions) : 2017/18

In 2017/18, total NIHB Program benefit expenditures were $1,309.2 million. This represents an increase of 8.4% over NIHB expenditures of $1,207.5 million in 2016/17. Of the 2017/18 total, Pharmacy costs (including medical supplies and equipment) represented the largest proportion at $523.0 million (39.9%), followed by Medical Transportation costs at $459.5 million (35.1%) and Dental costs at $249.0 million (19.0%).

NIHB Pharmacy and MS&E, Dental and Medical Transportation benefit expenditures accounted for 94.1% of NIHB expenditures in 2017/18.

* Not reflected in the $1,309.2 million in NIHB expenditures is approximately $41.7 million in administration costs including program staff and other headquarters and regional costs. More detail is provided in Figure 9.1.

Figure 3.3: NIHB expenditures and growth by benefit: 2017/18

NIHB program benefit expenditures increased by 8.4%, or $101.8 million from 2016/17. All NIHB benefit areas had an increase in expenditures over the previous fiscal year. The highest net increase in expenditures over fiscal year 2016/17 was in the NIHB Medical Transportation benefit at $42.5 million, followed by NIHB Pharmacy and MS&E benefits with an increase of $28.4 million and the NIHB Dental benefit which increased by $13.2 million. Factors affecting benefit expenditure growth are discussed in subsequent sections of this report.

Figure 3.4: NIHB expenditures by benefit and region ($ 000's): 2017/18

The Manitoba region accounted for the highest proportion of total expenditures at $308.2 million, or 23.5% of the national total, followed by the Ontario region at $250.9 million (19.2%), and the Saskatchewan region at $248.0 million (18.9%). In comparison, the lowest expenditure was in the Atlantic region at $60.0 million (4.6%).

Headquarters expenditures by benefit type represent costs paid for claims processing services. Headquarters expenditures in the ‘other health care' category include funding arrangements with the FNHA for Bill C-3 and Qalipu clients and for payment of Inuit premiums in British Columbia, as well as with national client partner organizations (Assembly of First Nations and Inuit Tapiriit Kanatami), and regional Indigenous organizations. These expenditures account for 2.1% ($27.6 million) of NIHB expenditures, and do not include the $18.5 million in headquarters administrative costs outlined in Figure 9.1.

Figure 3.5: Proportion of NIHB expenditures by region: 2017/18

In 2017/18, the Manitoba region had the highest proportion of total NIHB expenditures (23.5%) and accounted for 33.8% of total NIHB Medical Transportation expenditures. This can be attributed to the large number of First Nations clients living in remote or fly-in only northern communities in the Manitoba region.

The Saskatchewan region accounted for the highest proportion of NIHB Pharmacy expenditures at 22.8%, followed by Ontario and Manitoba at 19.2% and 18.7% respectively.

The Ontario region, which accounted for 19.2% of total NIHB expenditures in 2017/18, recorded the highest proportion of total NIHB Dental expenditures at 20.9%. This region also accounted for the highest proportion of the total NIHB population at 24.2%.

The proportion of NIHB Vision Care expenditures ranged from highs of 20.6% in the Saskatchewan region, 20.4% in the Ontario region and 20.1% in the Alberta region to a low of 5.4 % in Quebec.

The Manitoba region (24.6%) and the Alberta region (23.5%) combined accounted for nearly one-half of total NIHB Mental Health expenditures in 2017/18.

Figure 3.6: Proportion of NIHB regional expenditures by benefit: 2017/18

At the national level, three-quarters (75.0%) of total program expenditures occurred in two benefit areas: pharmacy (39.9%) and medical transportation (35.1%). Dental expenditures accounted for almost one-fifth (19.0%) of total NIHB expenditures.

Medical transportation expenditures accounted for half of benefit expenditures in the Manitoba and Northern regions (50.4% and 53.1%, respectively). Conversely, in the Atlantic region only 18.6% of benefit expenditures were spent on medical transportation.

The proportion of dental expenditures ranged from 13.6% in the Manitoba region to 24.7% in Alberta region.

In the Atlantic region, 55.0% of total expenditures were spent on pharmacy benefits. Pharmacy costs represented the highest percentage of total expenditures in all regions except in the Northern region and in Manitoba, where transportation accounted for the largest share of costs.

Figure 3.7: NIHB annual expenditures ($ Millions) and percentage change: 2008/09 to 2017/18

In 2017/18, NIHB program expenditures totalled $1,309.2 million, an increase of 8.4% from $1,207.5 million in 2016/17. Since 2008/09, total expenditures have grown by 39.3%. The annualized rate of growth over this period was 3.4%. There has been wide variation in growth rates between 2008/09 and 2017/18, from a low of -7.1% in 2013/14* to a high of 9.7 % in 2016/17.

Fluctuations in NIHB expenditure growth rates are impacted by a number of factors. Changes in the eligible client population have a direct impact on growth. Notable examples include the transfer of responsibility for First Nations clients residing in B.C. to the FNHA in 2013/14, the creation of the Qalipu Mi'kmaq band in 2011, and court decisions such as Bill C-3 that have resulted in newly eligible clients.

NIHB expenditure growth rates are also impacted by the introduction of new therapies and generic drugs to the market, changes to provincial pricing policies, and economic inflationary pressures. In addition, rates of expenditure growth are impacted by new self-government initiatives, policy changes to improve access to benefits or promote sustainability, and changes in service delivery models within the Program, within the federal government, and between the provinces and territories.

*If expenditures for FNHA eligible clients are excluded from 2012/13 and 2013/14 total NIHB expenditures, then the growth rate for 2013/14 would have been 2.8%.

NIHB annual expenditures ($ millions) and percentage change

Figure 3.8: NIHB annual expenditures by benefit ($ 000's): 2008/09 to 2017/18

In the period from 2008/09 to 2017/18, expenditures for NIHB mental health services and medical transportation benefits have grown more than other benefit areas. NIHB mental health expenditures grew by 190.6% from $11.4 million in 2008/09 to $33.1 million in 2017/18. NIHB medical transportation expenditures rose by 63.8% from $280.4 million in 2008/09 to $459.5 million in 2017/18.

Over the same period, NIHB dental expenditures increased by 41.2% and NIHB pharmacy expenditures increased by 24.8%.

Decreases in ‘other' expenditures in 2009/10 and 2013/14 can be attributed to the Government of Alberta eliminating Alberta health care insurance premiums for all Alberta residents in 2009 and to the transfer of responsibility for health care insurance premiums for First Nations clients residing in British Columbia to the First Nations Health Authority in 2013. This expenditure category also includes funding arrangements with the FNHA for Bill C-3 and Qalipu clients and for payment of premiums for Inuit clients in British Columbia, as well as with regional Indigenous organizations that employ NIHB Navigators to act as a resource for communities, organizations or individuals who need assistance or information on the NIHB program.

Figure 3.9: Per capita NIHB expenditures by region: 2017/18

The national per capita expenditure for all benefits in 2017/18 was $1,477. Manitoba had the highest per capita cost in 2017/18 at $1,978. The Northern region followed with a per capita cost of $1,825. The higher than average per capita cost for these regions is partly attributable to high medical transportation costs due to the large number of First Nations and Inuit clients living in remote or fly-in only northern communities. In contrast, the Atlantic region had the lowest per capita cost of $916, due to the comparatively low medical transportation expenditures in the region.

Figure 4.2: Total NIHB pharmacy and MS&E expenditures by type and region ($ 000's): 2017/18

Prescription drug costs paid through the HICPS system represented the largest component of total costs accounting for $381.7 million or 73.0% of all NIHB Pharmacy costs. The Saskatchewan region had the largest proportion of these costs at 24.7%, followed by Manitoba at 19.6% and the Ontario region at 19.4%.

The next highest component was over-the-counter (OTC) and controlled access drug (CAD) costs at $73.2 million or 14.0%. The regions of Manitoba (22.3%), Ontario (20.3%) and Saskatchewan (19.7%) had the largest proportions of these costs in 2017/18.

The third highest component was the combined medical supplies and equipment (MS&E) category at $39.4 million (7.5%). Saskatchewan region (23.9%) had the highest proportion of MS&E costs in 2017/18. This was followed by the Alberta Region (20.9%) and the Manitoba region (17.7%).

Figure 4.3: Annual NIHB pharmacy expenditures: 2013/14 to 2017/18

NIHB pharmacy expenditures increased by 5.8% during fiscal year 2017/18. Over the past five years, growth in pharmacy expenditures has ranged from a high of 8.3% in 2016/17 to a low of -10.1% in 2013/14. If expenditures for FNHA eligible clients are excluded from 2012/13 and 2013/14 total NIHB expenditures, then the growth rate for 2013/14 would have been 1.5%.

The five year annualized growth rate for NIHB pharmacy expenditures is 4.7%. Growth has been moderate and steady over the past five years. Reasons for this stability include the introduction of lower cost generic drugs as they become available on the market, optimizing drug utilization, policy changes designed to promote NIHB program sustainability, such as the implementation of the NIHB Short-Term Dispensing Policy in 2008/09, and changes in generic pricing policies in key provinces (Quebec, Ontario, Saskatchewan and British Columbia).

Figure 4.3.1: Annual NIHB pharmacy expenditures and percentage change

Description of Figure 4.3.1: Annual NIHB pharmacy expenditures and percentage change

Year	Total pharmacy expenditures ($M)	Annual percentage change
2013/14	$416.2	-10.1%
2014/15	$422.3	1.5%
2015/16	$456.4	8.1%
2016/17	$494.5	8.3%
2017/18	$523.0	5.8%

Figure 4.4: Per capita NIHB pharmacy expenditures by region: 2017/18

In 2017/18, the national per capita expenditure for NIHB Pharmacy benefits was $584. This was an increase of 4.3% from the $560 recorded in 2016/17.

The Saskatchewan region had the highest per capita NIHB Pharmacy expenditure at $783, followed by the Quebec Region at $671.

The Northern region had the lowest per capita expenditure at $422 followed by the Ontario region at $473. A relatively low per capita expenditure in the North is attributed to lower than average utilization rates and also a younger population utilizing lower cost medications. (Refer to Figure 4.6)

Figure 4.5: NIHB pharmacy operating expenditures per claimant by region: 2017/18

Expenditures per claimant are based on the total cost of pharmacy claims processed through the HICPS system, divided by the number of clients who submitted at least one pharmacy claim.

In 2017/18, the national average per claimant expenditure was $933, an increase of 4.6% over 2016/17.

The Saskatchewan Region had the highest average NIHB Pharmacy operating expenditure per claimant at $1,124, followed by Quebec at $1,098.

Figure 4.6: NIHB pharmacy utilization rates by region: 2013/14 to 2017/18

Utilization rates represent the number of clients who received at least one pharmacy benefit paid through the HICPS system in the fiscal year, as a proportion of the total number of eligible clients.

In 2017/18, the national utilization rate was 61% for NIHB Pharmacy benefits paid through the HICPS system.

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 or provided completely via alternate health coverage. For example, if the Bigstone Cree Nation client population were removed from the Alberta region's population because the HICPS system does not capture any data on services used by this population, the utilization rate for pharmacy benefits in Alberta would have been 70% in 2017/18. Similarly for the Ontario region, if the Akwesasne client population were removed from the Ontario Region's population, the utilization rate for pharmacy benefits would have been 57%. If both the Bigstone and Akwesasne client populations were removed from the overall NIHB population, the national utilization rate for pharmacy benefits would have been 63%.

Figure 4.7: NIHB pharmacy claimants by age group, gender and region: 2017/18

Of the 867,749 clients eligible to receive benefits under the NIHB Program, a total of 529,816 claimants, representing 61% of the NIHB client population, received at least one pharmacy item paid through the Health Information and Claims Processing Services (HICPS) system in 2017/18. Of this total, 299,716 were female (57%) and 230,100 were male (43%). This compares to the total eligible population where 51% were female and 49% were male.

The average age of pharmacy claimants was 35 years. The average age for female and male claimants was 36 and 34 years of age, respectively.

Figure 4.8: Distribution of eligible NIHB population, pharmacy expenditures and pharmacy incidence by age group: 2017/18

The main drivers of NIHB pharmacy expenditures are the cost of medications, the volume of claims^{Footnote 1} submitted and the professional fees associated with filling these claims. In 2017/18, 5.9% of all clients were in the 0 to 4 age group, but this group accounted for only 0.9% of all pharmacy claims made and only 1.1% of total pharmacy expenditures. In contrast, 8.2% of all eligible clients were in the 65+ age group, but accounted for 23.6 % of all pharmacy claims submitted and 17.0% of total pharmacy expenditures.

During 2017/18, the average claimant aged 65 or more submitted 94 claims compared to 68 claims for their counterpart in the 60 to 64 age group and 6 claims for the average claimant in the 0 to 4 age group.

An examination of pharmacy benefit cost per NIHB claimant indicates that these expenditures vary according to age. For example, in 2017/18 the average cost per child aged 0 to 4 years was $196. The cost increased steadily for every age group, with claimants aged 35–39 having an average cost of $861, comparable to the total average claimant cost of $933. Claimants aged 60–64 years had the highest cost per claimant with an average of $1,878 for all pharmaceutical services received throughout the fiscal year.

Figure 4.9: NIHB top ten therapeutic classes by number of claimants: 2017/18

Figure 4.9 ranks the top ten therapeutic classes according to number of claimants. In 2017/18, Non-Steroidal Anti-Inflammatory Drugs (NSAID) had the highest number of distinct claimants at 202 thousand, an increase of 0.5% over 2016/17. Penicillins such as Amoxil (Amoxicillin) ranked second in number of claimants with 160 thousand followed by Miscellaneous Analgesics and Antipyretics with 123 thousand claimants.

Figure 4.10: NIHB prescription drug claims incidence by pharmacologic therapeutic class: 2017/18

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

Central nervous system agents, which include drug classes such as analgesics and sedatives, accounted for 34.2% of all prescription drug claims in 2017/18. Central nervous systems agents are used in the treatment of diverse health conditions such as arthritis, depression or epilepsy.

Cardiovascular drugs had the next highest share of prescription drug claims at 20.5% followed by hormones and synthetic substitutes, which consist primarily of oral contraceptives and insulin, at 13.6%. Cardiovascular drugs are used to treat clients with arrhythmias, hypercholesterolemia or ischemic heart disease. Hormones and synthetic substitutes are given to clients to treat conditions such as diabetes or hypothyroidism.

Figure 4.11: NIHB over-the-counter drugs (including controlled access drugs — CAD) claims incidence by pharmacologic therapeutic class: 2017/18

Figure 4.11 demonstrates variation in claims incidence by therapeutic classification for over-the-counter (OTC) drugs. The NIHB program covers the cost of some OTC drugs. To be reimbursed by the NIHB program, all OTC drugs require a prescription from a recognized health professional who has the authority to prescribe in their province or territory of practice.

Vitamins were the highest category of OTC medications in 2017/18 accounting for 28.1% of all OTC drug claims. OTC central nervous system agents, which are drugs used to manage pain such as headaches (e.g. acetaminophen), followed at 25.8% of all OTC drug claims, and gastrointestinal products such as antacids and laxatives, which are used to treat heartburn and constipation, at 7.9%.

Figure 4.12: NIHB medical supplies by category and claims incidence: 2017/18

Figure 4.12 demonstrates variation in medical supply claims incidence by category.

In 2017/18, incontinence supplies such as liners and pads accounted for 25.4% of all medical supply claims. Hearing aid supplies, such as batteries, represented 22.9% of all medical supply claims, followed by wound care supplies at 22.8%.

Figure 4.13: NIHB medical equipment by category and claims incidence: 2017/18

Figure 4.13 demonstrates variation in medical equipment claims incidence by category.

Claims for oxygen equipment accounted for 24.5% of all medical equipment claims in 2017/18. Hearing aids was the next highest category at 22.6%, followed by limb orthoses at 9.2% and walking aids at 8.7%.

Figure 5.1: Distribution of NIHB dental expenditures ($ millions): 2017/18

NIHB Dental expenditures totalled $249.0 million in 2017/18. Figure 5.1 illustrates the distinct components of dental expenditures under the NIHB program. Fee-for-service dental costs paid through the Health Information and Claims Processing Services (HICPS) system represented the largest expenditure component, accounting for $225.7 million or 90.6% of all NIHB Dental costs.

The next highest component was contribution agreements, which accounted for $12.3 million or 4.9% of total dental expenditures. Contribution allocations were used to fund the provision of dental benefits through agreements such as those with 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 3.3% of total costs.

Other costs totalled $2.8 million or 1.1% in 2017/18. The majority of these costs are related to benefit claims processing through the HICPS system.

Figure 5.2: Total NIHB dental expenditures by type and region ($ 000's): 2017/18

NIHB dental expenditures totalled $249.0 million in 2017/18. The regions of Ontario (20.9%), Saskatchewan (20.3%), Alberta (19.1%) and Manitoba (16.8%) had the largest proportion of overall dental costs. The Ontario region had the highest total dental expenditure at $52.1 million and the Atlantic region had the lowest total dental expenditure at $10.6 million.

Figure 5.3: Annual NIHB dental expenditures: 2013/14 to 2017/18

NIHB dental expenditures increased by 5.6% during fiscal year 2017/18. The decrease in overall NIHB dental expenditures recorded in fiscal years 2013/14 and 2014/15 can be attributed to the transfer of eligible First Nation clients residing in British Columbia to the First Nations Health Authority (FNHA). If expenditures for FNHA eligible clients are excluded from 2012/13 and 2013/14 total NIHB expenditures, then the dental expenditure growth rate for 2013/14 would have been 3.8%.

Over the last five years, annual growth rates for NIHB Dental expenditures have ranged from a high of 8.6% in 2016/17 to a low of -7.0% in 2013/14.

Figure 5.3.1: NIHB Dental expenditures and annual percentage change

Description of Figure 5.3.1: NIHB Dental expenditures and annual percentage change

Year	Expenditures (000s)	Percentage change
2013/14	$207.2	-7%
2014/15	$201.9	-2.6%
2015/16	$217.1	7.5%
2016/17	$235.8	8.6%
2017/18	$249.0	5.6%

Figure 5.4: Per capita NIHB dental expenditures by region: 2017/18

In 2017/18, the national per capita NIHB Dental expenditure was $255, a decrease of -6.6% from $273 recorded in 2016/17.

The Alberta region had the highest per capita dental expenditure at $385, followed closely by the Northern Region at $361 and Saskatchewan region at $332. The Atlantic region had the lowest per capita dental cost at $162 per eligible client. The lower per capita cost in the Atlantic region can be partly attributed to an increase in the eligible client population in this region as a result of the registration of 24,745 Qalipu Mi'kmaq First Nations clients. A large number of these clients have alternative dental coverage, so the lower level of dental benefit utilization for these new clients has impacted the dental per capita cost for the Atlantic region as a whole.

Per capita values reflect NIHB dental expenditures only, and do not include additional dental services that may be provided to First Nations and Inuit populations through other Indigenous Services Canada programs or through transfers and other arrangements.

Figure 5.5: NIHB dental fee-for-service expenditures per claimant by region: 2017/18

In 2017/18, the national NIHB dental expenditure per claimant (i.e. eligible clients who received at least one dental benefit) was $728. This represents an increase of 5.2% over the $692 recorded in 2016/17.

The Northern region had the highest dental expenditure per claimant at $904 followed by the Alberta region at $903, an increase of 12.7% and 5.9% respectively from $802 and $853 in the previous year.

Figure 5.6: NIHB dental utilization rates by region: 2013/14 to 2017/18

Utilization rates reflect the number of clients who, during the fiscal year, received at least one dental service paid through the HICPS system as a proportion of the total number of eligible clients.

In 2017/18, the national utilization rate for dental benefits paid through the HICPS system was 36%, consistent with the previous four fiscal years. National NIHB dental utilization rates have remained stable over the past five years.

Dental utilization rates vary across the regions with the highest dental utilization rate found in the Quebec region (44%). The lowest dental utilization rate was in the Ontario region (32%). It should be noted that the dental utilization rates understate the actual level of service, as this data does not include:

• Indigenous Services Canada dental clinics (except in the Yukon)
• contract dental services provided in some regions
• services provided by Indigenous Services Canada dental therapists or other FNIHB dental programs such as the Children's Oral Health Initiative (COHI)
• dental services provided through contribution agreements. For example, HICPS data does not capture any services utilized by the Bigstone Cree Nation. If this client population was removed from the Alberta Region's population, the utilization rate for dental benefits for Alberta would have been 43% in 2017/18. 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 34%. If both the Bigstone and Akwesasne client populations were removed from the overall NIHB population, the national utilization rate for dental benefits would have been 37%.

Over the two year period between 2016/17 and 2017/18, 420,215 distinct clients received NIHB Dental services resulting in an overall 48% utilization rate over this period.

Figure 5.7: NIHB dental claimants by age group, gender and region: 2017/18

Of the 867,749 clients eligible to receive dental benefits through the NIHB program, 310,247 (36%) claimants received at least one dental procedure paid through the HICPS system in 2017/18.

Of this total, 174,152 were female (56%) and 136,095 were male (44%), compared to the total eligible NIHB population where 51% were female and 49% were male.

The average age of dental claimants was 31 years, indicating clients tend to access dental services at a slightly younger age compared to pharmacy services (35 years of age). The average age for female and male claimants was 32 and 30 years of age respectively.

Approximately 37% of all dental claimants were under 20 years of age. Forty percent of male claimants were in this age group compared to 34% of female claimants. Approximately 6% of all claimants were seniors (ages 65 and over) in 2017/18.

Figure 5.8: NIHB fee-for-service dental expenditures by sub-benefit: 2017/18

First Nations and Inuit experience a higher rate of dental disease such as periodontal disease and caries compared to other Canadians. Poor oral health can contribute to a greater incidence and severity of other medical conditions such as diabetes, respiratory illnesses and cardiovascular diseases. The broad range of dental services covered by the NIHB Program provides the opportunity to ensure that proper oral care required for overall good health is available to First Nations and Inuit clients. In 2017/18, through the NIHB Program's Dental Benefit, the oral health needs of approximately 204,000 clients who required intraoral radiograph services, 193,000 clients who received scaling procedures, and 144,000 clients who required restoration treatments were addressed.

In 2017/18, expenditures for restorative services (crowns, fillings, etc.) were the highest of all dental sub-benefit categories at $99.0 million. Diagnostic services (examinations, x-rays, etc.) at $29.1 million and preventative services (scaling, sealants, etc.) at $28.0 million were the next highest sub-benefit categories. Rounding out the top 5 was oral surgery (extractions, etc.) at $24.6 million and endodontic services (root canal treatments, etc.) at $15.3 million.

In 2017/18, the three largest dental procedures by expenditure were composite restorations ($84.3 million), scaling ($21.7 million) and extractions ($17.4 million).

Figure 5.9: Distribution of eligible NIHB population, dental expenditures and incidence by age group: 2017/18

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

The ratio of incidence to expenditures 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) are provided, so this group accounts for 25.2% of claims, but only 17.7% of expenditures.

Figure 6.1: Distribution of NIHB medical transportation expenditures ($ Millions): 2017/18

In 2017/18, NIHB medical transportation expenditures totalled $459.5 million. Figure 6.1 illustrates the components of medical transportation expenditures under the NIHB program.

Contribution agreements for the management of medical transportation benefits by First Nations or Inuit Health Authorities, organizations or territorial governments represented the largest component, accounting for $191.1 million, or 41.6% of total benefit expenditures.

Of benefits managed by the NIHB program, scheduled flights at $85.1 million (18.5%), living expenses at $59.7 million (13.0%) and land ambulance at $49.7 million (10.8%) were the largest expenditures, accounting for a combined total of over 40%.

Rounding out medical transportation expenditures are costs for air ambulance at $44.4 million (9.7%), land and water at $21.2 million (4.6%) and chartered flights at $8.3 million (1.8%).

Figure 6.2: Annual NIHB medical transportation expenditures: 2013/14 to 2017/18

NIHB medical transportation expenditures increased by 10.2% in 2017/18 compared to the previous year.

Over the past five years, overall medical transportation costs have grown by 30.5% from $352.0 million in 2013/14 to $459.5 million in 2017/18. As with other benefits, expenditure growth during this period was significantly impacted by the transfer of B.C. clients to the FNHA in 2013.

On a regional basis, the highest growth rates over this period were in the Atlantic region where expenditures grew by 61.2% from $6.9 million in 2013/14 to $11.1 million in 2017/18. This was followed by the Manitoba region with an increase of 40.0% from $111.0 million in 2013/14 to $155.4 million in 2017/18.

The Manitoba region had the highest total medical transportation expenditure at $155.4 million and had the largest net increase in expenditures over the past five years as medical transportation costs grew by $44.4 million over this period. The Ontario region had the second largest net increase in expenditures over the past five years at $23.2 million followed by the Northern region at $22.7 million.

*If expenditures for FNHA eligible clients are excluded from 2012/13 and 2013/14 total NIHB expenditures, then the growth rate for 2013/14 would have been 3.6%.

Figure 6.2.1: NIHB Medical transportation expenditures and annual percentage change

Description of Figure 6.2.1: NIHB Medical transportation expenditures and annual percentage change

Year	Expenditure ($M)	Annual percentage change
2013/14	$352.0	0.2%
2014/15	$358.0	1.7%
2015/16	$375.9	5.0%
2016/17	$417.0	10.9%
2017/18	$459.5	10.2%

Figure 6.3: NIHB medical transportation expenditures by type and region ($ 000's): 2017/18

National NIHB medical transportation expenditures increased by 10.2% to $459.5 million in 2017/18.

The Northern region had the largest percentage increase in medical transportation expenditures in 2017/18, with an increase of 22.3% from the previous fiscal year. The Atlantic region followed with a 20.2% increase in expenditures.

In 2017/18, the Manitoba region had the highest overall NIHB medical transportation expenditure at $155.4 million, primarily as a result of air transportation which totalled $81.4 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 represented the second highest medical transportation expenditure total in 2017/18 at $86.1 million. The Northern region and Saskatchewan followed at $67.4 million and $64.4 million, respectively.

Figure 6.4: NIHB medical transportation contribution and operating expenditures by region ($ Millions): 2017/18

Figure 6.4 compares contribution funding to operating costs in NIHB medical transportation. Contribution funding is provided to First Nations bands, territorial governments and other organizations to manage elements of the medical transportation benefit (e.g., coordinating accommodations, managing ground transportation, etc.), whereas operating costs are medical transportation benefits that are managed directly by Indigenous Services Canada regional offices.

Manitoba region had the largest operating expenditure for NIHB medical transportation in 2017/18 at $124.5 million. This higher cost in the Manitoba region is due largely to the high number of clients living in remote or fly-in only communities in the northern areas of the province who require air travel to access health services in Winnipeg. The Ontario region had the next largest operating expenditure at $59.2 million, followed by the Saskatchewan region at $47.8 million. Together these three regions accounted for 86.3% of all operating expenditures for medical transportation.

In 2017/18, the Northern region had the largest contribution expenditures for NIHB medical transportation at $61.4 million, followed by the regions of Manitoba and Ontario at $30.9 million and $26.9 million, respectively. Almost all NIHB medical transportation services were delivered via contribution agreements in Quebec.

Figure 6.5: NIHB medical transportation operating expenditure by type ($ Millions): 2017/18

In 2017/18, scheduled flights represented the largest portion of NIHB's medical transportation operating expenditures at $85.1 million or 31.7% of the total national operating expenditures. Living expenses, which include accommodations and meals, was the second highest at $59.7 million, or 22.2% of operating expenditures. Land ambulance followed at $49.7 million or 18.5%, and air ambulance costs comprised $44.4 million or 16.5% of medical transportation operating costs.

Private vehicle expenditures ($4.6 million) are the costs reimbursed through a per-kilometre allowance for private vehicle used by a client to access eligible health services. The NIHB private vehicle kilometric allowance rates are directly linked to the National Joint Council's (NJC) Government Commuting Assistance Directive Lower Kilometric Rates.

Figure 6.6: Per capita NIHB medical transportation expenditures by region: 2017/18

In 2017/18, the national per capita expenditure for NIHB medical transportation benefits was $530.

Manitoba recorded the highest per capita expenditure in medical transportation at $997, followed by the Northern region at $969. These expenditures reflect the large number of First Nations and Inuit clients living in remote or fly-in communities that need to fly south for health services.

In contrast, the Atlantic region had the lowest per capita expenditure at $170, a slight increase from $143 in the previous year. Compared to other regions, this lower per capita cost is reflective of the geography of the region, which allows easier access to health services with less need for air travel.

Figure 7.1: NIHB vision expenditures and growth by region ($ 000's): 2017/18

NIHB vision expenditures totalled $33.6 million in 2017/18. Regional operating expenditures accounted for $28.9 million ( 86.2%) of total expenditures while contribution costs accounted for $4.6 million (13.8%).

In 2017/18, the Saskatchewan region had the highest expenditures in NIHB vision benefits at $6.9 million, a percentage share of 20.6%, followed by the Ontario region at $6.8 million (20.4%) and the Alberta region at $6.8 million (20.1%).

Figure 7.2: Annual NIHB vision expenditures: 2013/14 to 2017/18

In 2017/18, NIHB vision expenditures increased by 3.7% from the previous year. Over the past five years, as with other benefits, vision care expenditures declined sharply in 2013/14 and 2014/15 due to the transfer of B.C. clients to the FNHA, and increased in subsequent years.

On a regional basis, the highest expenditure growth rate over this five year period was in the Atlantic region where expenditures grew by 31.7% from $2.8 million in 2013/14 to $3.6 million in 2017/18. The largest net increases in expenditures over the past five years took place in the Saskatchewan region where total vision benefit costs grew by $1.3 million over this period, followed by the Ontario region where costs grew by $1.1 million. The significant drop in Northern region vision expenditures in fiscal year 2014/15 is due to a change in financial coding for specific vision benefit contribution agreements in Nunavut and the Northwest Territories.

Figure 7.2.1: Annual NIHB vision expenditures and percentage change

Description of Figure 7.2.1: Annual NIHB vision expenditures and percentage change

Year	Total vision expenditures ($M)	Annual percentage change (%)
2013/14	$31.5	-2.2%
2014/15	$29.7	-5.6%
2015/16	$30.0	1.0%
2016/17	$32.4	7.8%
2017/18	$33.6	3.7%

Figure 8.1.1: Percentage change in Atlantic region NIHB expenditures ($ 000's)

Figure 8.1.2: Annual expenditures by benefit ($ 000's)

Figure 8.2.1: Percentage change in Quebec region NIHB expenditures ($ 000's)

Figure 8.2.2: Annual Expenditures by Benefit ($ 000's)

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.

The DEC supports the implementation of the Prescription Drug Abuse Strategy to address and prevent potential misuse of prescription drugs. The Program has set limits on medications of concern, and developed a structured approach towards client safety which includes the implementation of the Prescription Monitoring Program across the country.

The DEC is a single call centre that provides 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 (LU) drugs, for prescriptions on which prescribers have indicated "no substitution," and for claims that exceed $1,999.99. Figure 9.4 shows the volume of requests made to the DEC in 2017/18.

Open benefit (unrestricted): Drugs included on the NIHB Drug Benefit List for which the total dollar value exceeds point of sale limit, the pre-determined frequency limit has been reached or for which more than a three-month supply is requested.

Open benefit (restricted): Drugs included on the NIHB Drug Benefit List which have been restricted due to safety concerns. These drugs are part of the Prescription Drug Abuse Strategy, such as opioids, benzodiazepines, stimulants and gabapentin.

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.

Drug Exception Centre special authorization process

The Special Authorization Process for pharmacy providers has been in effect since November 2009. This program has accelerated the internal DEC process to extend medication approvals to approximately 60 additional drugs for chronic conditions.These drugs have been granted extended authorization periods beyond one year, and some will now have an indefinite authorization period, thereby facilitating access for NIHB clients and eliminating unnecessary calls by pharmacists to the DEC.

For Limited Use (LU) medications with an indefinite authorization, it is only necessary for the pharmacy provider to confirm that the client meets the clinical criteria once by obtaining a prior approval and then the client will be set up on indefinite approval.

For other drugs that continue to have a defined authorization period (i.e., 2, 3 or 5 years), a new approval must be completed according to the authorization period.

Implementing extended authorization periods for drugs used in certain chronic conditions has significantly reduced the administrative burden on pharmacy providers and enabled the DEC to deal with more complicated reviews, such as supporting the implementation of Prescription Drug Abuse Strategy.

Increased efficiency of HICPS system to facilitate prior approvals for specific drugs

The Health Information and Claims Processing System (HICPS) has the capacity to automatically adjudicate a number of medications to facilitate access for clients and pharmacists and to reduce calls to the DEC. For these specific drugs, the system provides a prompt to pharmacists to continue with the prior approval process automatically and if the pharmacists select this prompt, the request is automatically sent to the DEC for review without necessitating a call to the DEC. In this way, the DEC can immediately send a Benefit Evaluation Questionnaire (BEQ) to the physician and thereby reduce the workload of pharmacists.

Dental Predetermination Centre

The creation of a national Dental Predetermination Centre (DPC) in September 2012 has streamlined Program resources dedicated to dental benefit management, including predetermination, post-determination, client reimbursements and adjudication of appeals. Measures have been taken to simplify processes, ensure consistency in adjudication, and stabilize the workforce in the DPC. All of these measures have helped to improve processing time so that, since summer of 2014, the DPC has met the Program standard turnaround time for 10 business days to process predetermination requests. Since the creation of the DPC, NIHB has been able to remove predetermination requirements for certain dental services including:

• replacement of complete standard dentures
• orthodontic examinations and diagnostic records
• most surgical services delivered by oral maxillofacial surgeons and,
• complicated tooth extractions.

Medical Supplies and Equipment Review Centre

NIHB staff at the regional level manage prior approval of medical supplies and equipment benefit requests, with support from the MS&E Review Centre (MSERC) at the NIHB national office. The Medical Supplies and Equipment Review Centre (MSERC) is staffed in-house by various administrative and health professionals, such as Registered Nurses. In cases where advice is required by a particular specialist, such as an audiologist or an orthotist, information is forwarded to the appropriate specialist consultant for review. Consultants make their recommendations based upon the current standards of practice, best practices, current scientific evidence, program policy and recommended guidelines within their field of specialty.

Figure 9.5.1: Dental audit recoveries by region: 2017/18

The following figures identify audit recoveries, Next Day Claims Verification (NDCV) and Client Confirmation Program (CCP) savings* from all components of the Provider Audit Program during the 2017/18 fiscal year.

Figure 9.5.2: Pharmacy audit recoveries by region: 2017/18

Figure 9.5.3: Medical supplies and equipment audit recoveries by region: 2017/18

* All claims that are reversed prior to being paid to providers are deemed savings to the program. Subsequent appeals to these reversals may lead to claims being paid in full to providers' once appropriate billing and supporting documentation has been provided for review. NDCV savings listed in the recovery charts above, per benefit, take into account the provider appeals process.

NIHB Drug benefit listing and review

NIHB program drug benefits are based on the judgement of health professionals, consistent with the best practices of health services delivery and evidence-based standards of care. They are based on recommendations from pan-Canadian expert committees through the Canadian Agency for Drugs and Technologies in Health (CADTH) and the NIHB Drugs and Therapeutics Advisory Committee (DTAC).

As with other public drug plans in Canada, drugs considered for, or currently listed on, the Drug Benefit List (DBL) must meet minimum criteria. For example, they must be legally available for sale in Canada with a Notice of Compliance (NOC) and Drug Identification Number (DIN) or Natural Product Number (NPN), and be dispensed in a pharmacy. The drugs must also demonstrate evidence of therapeutic efficacy, safety, and incremental benefit in proportion to incremental cost.

The review process for drug products that are considered for inclusion as a benefit under the NIHB Program varies depending on the type of drug submitted. Submissions for new chemical entities, new combination drug products and existing chemical entities with new indications, must be sent to CADTH, an independent organization that provides research and information about the effectiveness of drugs and other medical treatments.

Through the Common Drug Review (CDR) and pan-Canadian Oncology Drug Review (pCODR) processes, CADTH conducts objective evaluations of the clinical, economic, and patient evidence on drugs and medical technologies. Based on this information, the CADTH expert committees provide coverage recommendations and advice to Canada's public drug plans, including the NIHB Program. The CDR and pCODR were established by federal, provincial and territorial public drug plans to reduce duplication of effort in reviewing drug submissions, to maximize the use of resources and expertise, and to enhance the consistency and quality of drug reviews.

NIHB Drugs and Therapeutics Advisory Committee (DTAC)

The NIHB DTAC is an advisory body of highly qualified health professionals who bring impartial and practical expert medical and pharmaceutical advice to the NIHB program to promote improvement in the health outcomes of First Nations and Inuit clients through effective use of pharmaceuticals. The approach is evidence-based and the advice reflects medical and scientific knowledge, current utilization trends, current clinical practice, health care delivery and client healthcare needs.

DTAC members must hold a qualification and license in Canada as recognized health professionals with expertise in one or more areas including, but not limited to:

• drug use evaluation/utilization
• clinical epidemiology
• medical or pharmacy quality assurance
• Indigenous health issues
• health systems research
• pharmacoeconomics
• general practice
• geriatrics
• pediatrics
• drug addiction treatment or prevention

The DTAC is comprised of 8–12 core members, including First Nations or Inuit health professionals. At least three DTAC members must be physicians and at least three members must be pharmacists. The NIHB DTAC provides drug formulary listing and client safety initiative recommendations to the NIHB Program. The NIHB Program, in turn, makes listing decisions based on DTAC recommendations and other factors. More information on DTAC and its members can be found on the Government of Canada's website

NIHB Oral Health Advisory Committee (NOHAC)

Established in 2016, the NIHB Oral Health Advisory Committee (NOHAC) is an independent advisory body of highly qualified oral health professionals and academic specialists who bring impartial and practical expert views, advice, and recommendations to the NIHB program to support the improvement of oral health outcomes for First Nations and Inuit clients. The advice and recommendations provided by the Committee will follow an evidence-based approach and will reflect scientific knowledge, as well as current clinical and oral health care delivery and disease prevention best practices.

NOHAC provides professional advice on a variety of topics identified by NIHB, including NIHB dental benefit policies and criteria, best practices and evidence-based oral health disease prevention and treatment, specific clinical issues, and existing and emerging dental technologies, their use within the context of a public health program and their impact on oral health outcomes for the NIHB Program client population.

NOHAC members must hold a qualification and license in Canada as recognized oral health professionals (with the exception of the health economist and epidemiologist), and includes both First Nations and Inuit oral health professionals. The Committee has a minimum of 8 members from the following fields of oral health care and related academic disciplines.

• public health dentist
• dental general practitioner
• pedodontist
• prosthodontist
• periodontist
• dental hygienist
• health economist
• epidemiologist / biostatistician

Additional members may include other types of oral health professionals such as dental anesthesiologist, denturist, oral surgeon, endodontist, and orthodontist. More information on the NOHAC and its members can be found on the Non-Insured Health Benefits Oral Health Advisory Committee.

Pharmacy benefit client safety initiatives

Prescription drugs have the capacity to heal but also the capacity to do harm if not used correctly. Public drug plans, like the Non-Insured Health Benefits (NIHB) program, bear a responsibility to those they serve. The NIHB program places a high priority on client safety, and has a number of strategies in place to encourage the safe use of prescription medications.

Point of sale (POS) warning and rejection messages

The NIHB Program sends messages electronically in real-time at the POS to warn pharmacy providers about potential client safety issues including drug interactions and repeat prescriptions. Certain warning messages also require the pharmacy providers to report back with specific codes that give the Program information about the actions they have taken related to the warning code received.

The NIHB Program also sends rejection messages to pharmacists when a client's claims history indicates potential misuse or overuse of a range of prescription medications. When a rejection message is received, a pharmacy provider must contact NIHB's Drug Exception Centre (DEC), a national toll-free call centre. The DEC will provide more information to the pharmacy provider regarding the reason for coverage rejection and follow up with the prescribing physician before the Program will authorize coverage for the pharmacy benefit in question. The NIHB program may refuse coverage for pharmacy benefits when there is evidence that suggests client safety may be at risk.

An example of a rejection message is when a client exceeds the maximum allowable quantities for acetaminophen and acetaminophen-based opioids. Clients are often unaware of the long-term consequences of commonly available acetaminophen-based products. Negative health effects can result from prolonged use, including serious liver damage if recommended dosages are exceeded.

Another example of a rejection message is a code that was created to address the health risks associated with the misuse of specific drugs of concern. These drugs include opioids (such as morphine, codeine, and oxycodone which are used to relieve pain), benzodiazepines (so-called "minor" tranquilizers, sleep aids and anti-anxiety medications) and methadone (a long-acting synthetic opioid used to treat opioid addiction or pain). In designing this warning message, it was important to recognize that all of these drugs have clinically valid applications. Therefore, the warning message was designed to focus attention on cases where there were concerns about potential misuse. This intervention addresses situations where clients access:

• 3 or more active prescriptions for benzodiazepines
• 3 or more opioids
• 3 or more benzodiazepines and 3 or more opioids
• a prescription for methadone in association with opioid-based drugs.

Trend analysis of prescription drug use

The NIHB program analyzes broad patterns of utilization, prescribing, and dispensing on an on-going basis. This work is conducted by a team of licensed pharmacists, pharmacy technicians and experts in data analysis. Once patterns are identified, the program intervenes to prevent the recurrence of inappropriate prescription drug use. NIHB's Prescription Drug Surveillance Strategy tracks how drugs like opioids, benzodiazepines and stimulants are prescribed and dispensed. NIHB has an electronic system that monitors claims for these drugs and lets health providers know if there is a concern. The goal of these measures is to protect client safety.

In January of 2007, NIHB launched the Prescription Monitoring Program (PMP) which focuses on potential drug use disorders related to benzodiazepines, opioids, gabapentin, and stimulant drugs. The NIHB PMP process starts by identifying clients at highest potential risk for drug use disorder for these drugs by reviewing the number of prescribing physicians (which may be an indication of "doctor shopping"), the number of pharmacy providers and the number or dose of opioids, benzodiazepines, gabapentin or stimulants claimed. Enrolment may restrict clients to a specific prescriber or prescribers in a group practice or require clients to have future claims verified and authorized by a pharmacist at NIHB's Drug Exception Centre. If the client or their health care provider cannot provide evidence to support the continuation of the drug therapy in question, the Program reserves the right to refuse coverage for the pharmacy benefit requested.

The NIHB PMP complements existing activities and promotes the optimal use of medications by allowing the program to enhance interventions when there are concerns about how a client is using their medications. The NIHB PMP operates in all regions of Canada, with the exception of Quebec, and monitored nearly 15,000 clients in 2017/18.

Reduction in the opioid dose limit

To ensure appropriate opioid use amongst NIHB clients, beginning in September 2013, the NIHB Program implemented an opioid dose limit for clients with chronic non-cancer/non-palliative pain. This limit is calculated based on the total daily dose of all opioids a client is receiving covered through the program. This limit was reduced to 200 mg of morphine equivalence per day at the end of 2017 as per the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain published in 2010, which states, "chronic non-cancer pain can be managed effectively in most patients with dosages at or below 200 mg/day of morphine or equivalent. Consideration of a higher dosage requires careful reassessment of the pain and of risk for opioid use disorder, and frequent monitoring with evidence of improved patient outcomes."

Coverage of naloxone

In addition to methadone, Suboxone, and Kadian to treat opioid use disorder, the NIHB program covers injectable and nasal naloxone, a medication that can temporarily reverse the toxic effects of opioid drugs (e.g. heroin, morphine, fentanyl). Medical help is still required after administration of naloxone. To improve access to this life saving medication, the Program added injectable and nasal naloxone and injectable and nasal naloxone with administration supply (kit) as an open benefit on the Drug Benefit List. Individuals at risk of opioid toxicity and people close to them are encouraged to have a naloxone kit on hand, and the training to use it.

Dental benefit client safety

One of the objectives of the NIHB Program dental benefit is to provide dental services based on evidence-based standards of care and professional judgment, consistent with current best practices of health services delivery.

The NIHB Sedation and General Anaesthesia Policy is one example of the Program's commitment to client safety. Sedation and general anaesthesia services must be provided in conjunction with eligible dental services and require predetermination under the NIHB Program, in other words, approval prior to commencement of treatment. Coverage for sedation and general anaesthesia services is provided with a frequency of once in any twelve month period. In extenuating circumstances, additional sessions would be considered for coverage. This policy, while respecting the professional expertise of dental providers, encourages the minimal risk approach to the use of sedation and general anaesthesia in conjunction with associated dental services.