Non-Insured Health Benefits program: First Nations and Inuit Health Branch: Annual report 2018 to 2019

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Section 1: Overview
Section 2: Client population
Section 3: NIHB program benefit 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, mental health counselling benefits and other health care benefits data
Section 8: Regional expenditure trends
Section 9: NIHB program administration
Section 10: NIHB policy and program initiatives
Section 11: Technical notes

Section 1: Overview

Introduction

The Non-Insured Health Benefits (NIHB) program provides registered First Nations and recognized Inuit with coverage for a range of medically necessary health benefits including prescription drugs and over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment, mental health counselling and transportation to access medically required health services that are not available on reserve or in the community of residence. During fiscal year 2018 to 2019, NIHB provided access to benefit coverage to 873,312 eligible clients.

In line with Canada's commitments under the UN Declaration of the Rights of Indigenous Peoples and the Truth and Reconciliation Commission's Calls to Action, Indigenous Services Canada (ISC) works with Indigenous organizations including the Assembly of First Nations and the Inuit Tapiriit Kanatami, to advance shared priorities focused on improving and closing the gaps in health outcomes for Indigenous peoples.

Now in its 25th edition, the 2018 to 2019 NIHB Annual Report provides national and regional data on the NIHB program client population, expenditures, benefit types and benefit utilization. This report is published in accordance with the NIHB program's performance management responsibilities and is intended 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 Indigenous Services Canada
others in government and in non-government organizations with an interest in the provision of health services to First Nations and Inuit communities

British Columbia Tripartite Agreement

The British Columbia Tripartite Framework Agreement on First Nation Health Governance was signed by Canada, the First Nations Health Council (FNHC) and the British Columbia Ministry of Health on October 13, 2011. Consistent with the commitments set out in the Framework agreement, between July 2, 2013 and October 1, 2013 the First Nations Health Authority (FNHA) assumed responsibility for the design, management, delivery and the funding of the delivery of health services to First Nations residing in British Columbia. Since that time, BC First Nations have received their health benefits through the FNHA's Health Benefits Program, which replaced the NIHB Program in BC.

Section 2: Client population

To be an eligible client of the NIHB Program, an individual must be a resident of Canada and one of the following:

a First Nations person who is registered under the Indian Act
an Inuk recognized by an Inuit Land Claim organization
a child less than 18 months old whose parent is a registered First Nations person or a recognized Inuk

As of March 31, 2019, there were 873,312 First Nations and Inuit clients eligible to receive benefits under the NIHB Program, an increase of 0.6% from March 2018.

First Nations and Inuit population data are drawn from the Status Verification System (SVS) which is operated by the NIHB program. SVS data on First Nations clients are based on information provided by Crown-Indigenous Relations and Northern Affairs Canada (CIRNA). SVS data on Inuit clients are based on information provided by the Governments of the Northwest Territories and Nunavut, and Inuit organizations including the Inuvialuit Regional Corporation, Nunavut Tunngavik Incorporated and the Makivik Corporation.

Amendments to the Indian Act have meant that a greater numbers of individuals are able to claim or restore their status as registered Indians. Bill C-3, The Gender Equity in Indian Registration Act, which came into force on January 31, 2011, and Bill S-3, An Act to amend the Indian Act in response to the Superior Court of Quebec decision in Descheneaux c. Canada, which came into force December 12, 2017, aim to eliminate known sex-based inequities in registration. Because of this, many people became entitled to be registered as an Indian in accordance with the Indian Act. Once registered under the Indian Act, these individuals will be eligible to receive benefits through the NIHB program.

The creation of the new Qalipu Mi'kmaq First Nations band was announced on September 26, 2011 as a result of a settlement agreement that was negotiated between the Government of Canada and the Federation of Newfoundland Indians (FNI). Through the formation of this band, members of the Qalipu Mi'kmaq became recognized under the Indian Act and eligible for registration.

Figure 2.1: Eligible client population by region: March 2019

The Ontario region had the largest proportion of the eligible population, representing 24.3% of the national total, followed by the Manitoba region at 18.0% and the Saskatchewan region at 17.7%.

Figure 2.1 lists population values based on region of band registration, which is not necessarily the client's current region of residence. The majority of British Columbia clients previously covered by the NIHB Program are now covered by the B.C. First Nation Health Authority (FNHA) and are not represented in this chart. The remaining NIHB clients in B.C. are Inuit clients, or clients associated with B.C. bands, but residing in other provinces and territories of Canada (where they are covered under the federal NIHB Program).

Figure 2.2: Eligible client population by type and region: March 2018 and March 2019

Of the 873,312 total eligible clients at the end of the 2018 to 2019 fiscal year, 824,858 (94.5%) were First Nations clients while 48,454 (5.5%) were Inuit clients. The number of First Nations clients increased by 0.6% and the number of Inuit clients increased by 1.4%

From March 2018 to March 2019, the Northwest Territories had the highest percentage change in total eligible clients with a 3.3% increase, followed by Saskatchewan and Alberta with increases of 1.3% and 1.1% respectively.

Region	First Nations		Inuit		Total		% Change 2018 to 2019
Region	March 2018	March 2019	March 2018	March 2019	March 2018	March 2019	% Change 2018 to 2019
Atlantic	65,194	63,482	379	391	65,573	63,873	-2.6%
Quebec	70,632	71,298	1,519	1,584	72,151	72,882	1.0%
Ontario	209,496	211,353	799	823	210,295	212,176	0.9%
Manitoba	155,634	157,103	216	222	155,850	157,325	0.9%
Saskatchewan	152,243	154,240	81	83	152,324	154,323	1.3%
Alberta	123,162	124,517	650	692	123,812	125,209	1.1%
B.C.	17,821	17,044	363	373	18,184	17,417	-4.2%
Yukon	7,485	7,457	119	122	7,604	7,579	-0.3%
Northwest Territories	18,310	18,364	8,567	9,407	26,877	27,771	3.3%
Nunavut	0	0	35,079	34,757	35,079	34,757	-0.9%
National	819,977	824,858	47,772	48,454	867,749	873,312	0.6%
Source: SVS adapted by Business Support, Audit and Negotiations Division

Figure 2.3: Eligible client population

Over the past 10 years, the total number of eligible clients in the SVS has increased by 5.1%, from 831,090 in March 2010 to 873,312 in March 2019.

The NIHB program client population was significantly impacted during this period by amendments to the Indian Act affecting client eligibility and by the creation of the FNHA in British Columbia which resulted in approximately 133,430 clients in B.C. being removed from the NIHB client population when they became eligible to receive benefits through the FNHA.

Figure 2.3.1: Eligible client population, March 2010 to March 2019

Over the past 5 years, the NIHB program's total number of eligible clients increased by 6.0% from 824,033 in March 2015 to 873,312 in March 2019. The Northwest Territories had the largest increase in eligible clients over this period, with a growth rate of 8.5%. The regions of Alberta, Saskatchewan and Quebec followed with growth rates of 8.0%, 7.7% and 6.7% respectively.

Figure 2.3.2: Eligible client population by region, March 2015 to March 2019

Region	March 2015	March 2016	March 2017	March 2018	March 2019
Atlantic	62,756	63,712	64,733	65,573	63,873
Quebec	68,274	69,758	70,930	72,151	72,882
Ontario	200,518	204,232	207,266	210,295	212,176
Manitoba	147,932	150,475	152,874	155,850	157,325
Saskatchewan	143,228	145,968	148,953	152,324	154,323
Alberta	115,886	118,170	121,095	123,812	125,209
B.C.	19,283	19,277	18,607	18,184	17,417
Yukon	7,402	7,456	7,490	7,604	7,579
Northwest Territories	25,587	26,367	26,616	26,877	27,771
Nunavut	33,167	33,714	34,524	35,079	34,757
Total	824,033	839,129	853,088	867,749	873,312
Annual % change	1.9%	1.8%	1.7%	1.7%	0.6%
Source: SVS adapted by Business Support, Audit and Negotiations Division

Figure 2.4: Annual population growth, Canadian population and eligible client population: 2010 to 2019

From 2010 to 2019, the Canadian population increased by 10.3% while the NIHB eligible First Nations and Inuit client population increased by 5.1%. Factoring out the impact of the removal of FNHA clients, the NIHB 10 year eligible population increase was 24.4%, with an average annual growth of 2.2%.

The higher than average NIHB program client population growth rate of 6.0% in the 2011 to 2012 fiscal year and 3.3% in fiscal year 2012 to 2013 can be attributed to the registration of clients newly eligible under Bill C-3 as status Indians, and to new Qalipu Mi'kmaq First Nations clients in the Atlantic region.

Year	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019
NIHB client Population	831,090	846,024	896,624	926,044	808,686	824,033	839,129	853,088	867,749	873,312
Growth rate	1.9%	1.8%	6.0%	3.3%	-12.7%	1.9%	1.8%	1.7%	1.7%	0.6%
Canadian population	34,019,000	34,349,236	34,754,312	35,152,370	35,535,348	35,832,513	36,264,604	36,708,083	37,058,856	37,589,262
Growth rate	1.3%	1.0%	1.2%	1.2%	1.1%	0.8%	1.2%	1.2%	1.0%	1.4%

Figure 2.5: Eligible client population by age group, gender and region: March 2019

Of the 873,312 NIHB eligible clients on the SVS as of March 31, 2019, 49.2% were male (429,681) and 50.8% were female (443,631).

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 and British Columbia.

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 41 years in British Columbia.

The NIHB eligible First Nations and Inuit client population is relatively young with nearly two-thirds (63.7%) under the age of 40. Of the total population, almost one-third (31.6%) 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 fiscal year 2008 to 2009, seniors represented 6.1% of the overall NIHB population. Most recently in fiscal year 2018 to 2019, seniors accounted for 8.6%.

Region	Atlantic			Quebec			Ontario			Manitoba
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0–4	1,338	1,267	2,605	1,672	1,545	3,217	4,140	3,913	8,053	4,890	4,681	9,571
5–9	2,139	2,200	4,339	2,502	2,401	4,903	7,216	7,068	14,284	8,234	7,849	16,083
10–14	2,493	2,306	4,799	2,763	2,567	5,330	7,926	7,555	15,481	8,408	8,220	16,628
15–19	2,468	2,373	4,841	2,621	2,535	5,156	8,093	7,841	15,934	7,525	7,235	14,760
20–24	2,648	2,622	5,270	2,845	2,778	5,623	8,899	8,573	17,472	7,516	7,238	14,754
25–29	2,684	2,624	5,308	3,093	2,935	6,028	9,028	8,867	17,895	7,382	7,321	14,703
30–34	2,333	2,246	4,579	2,484	2,637	5,121	8,003	7,751	15,754	6,046	5,817	11,863
35–39	2,122	2,252	4,374	2,395	2,318	4,713	7,058	7,346	14,404	5,077	4,853	9,930
40–44	2,055	2,016	4,071	2,173	2,245	4,418	6,715	6,768	13,483	4,514	4,482	8,996
45–49	2,229	2,192	4,421	2,273	2,413	4,686	6,893	7,055	13,948	4,469	4,693	9,162
50–54	2,126	2,363	4,489	2,346	2,633	4,979	6,915	7,289	14,204	4,213	4,343	8,556
55–59	1,924	2,176	4,100	2,369	2,620	4,989	6,574	7,394	13,968	3,528	3,772	7,300
60–64	1,617	1,887	3,504	1,882	2,376	4,258	5,281	6,363	11,644	2,448	2,845	5,293
65+	3,114	4,059	7,173	3,829	5,632	9,461	10,437	15,215	25,652	4,177	5,549	9,726
Total	31,290	32,583	63,873	35,247	37,635	72,882	103,178	108,998	212,176	78,427	78,898	157,325
Average age	36	38	37	36	39	38	36	39	37	30	31	31
Source: SVS adapted by Business Support, Audit and Negotiations Division

Region	Saskatchewan			Alberta			B.C.			Yukon
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0–4	4,712	4,581	9,293	4,048	3,935	7,983	310	299	609	107	115	222
5–9	7,854	7,637	15,491	6,689	6,307	12,996	425	472	897	235	201	436
10–14	8,260	8,071	16,331	6,608	6,560	13,168	576	542	1,118	253	228	481
15–19	7,561	7,434	14,995	6,160	5,816	11,976	590	592	1,182	285	249	534
20–24	7,374	7,381	14,755	6,127	5,772	11,899	679	572	1,251	306	300	606
25–29	7,598	7,370	14,968	5,965	5,683	11,648	680	673	1,353	331	322	653
30–34	6,345	6,240	12,585	4,957	4,874	9,831	770	687	1,457	299	280	579
35–39	5,142	5,078	10,220	4,078	4,287	8,365	724	707	1,431	277	271	548
40–44	4,502	4,528	9,030	3,591	3,608	7,199	598	621	1,219	261	221	482
45–49	4,294	4,505	8,799	3,291	3,524	6,815	620	615	1,235	287	246	533
50–54	3,908	4,224	8,132	3,075	3,238	6,313	539	725	1,264	313	281	594
55–59	3,179	3,548	6,727	2,550	2,958	5,508	524	663	1,187	319	327	646
60–64	2,186	2,592	4,778	1,787	2,239	4,026	377	543	920	176	245	421
65+	3,479	4,740	8,219	3,050	4,432	7,482	834	1,460	2,294	334	510	844
Total	76,394	77,929	154,323	61,976	63,233	125,209	8,246	9,171	17,417	3,783	3,796	7,579
Average age	29	31	30	29	31	30	37	41	39	37	40	39
Source: SVS adapted by Business Support, Audit and Negotiations Division

Region	Northwest Territories			Nunavut			Total
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total
0–4	599	567	1,166	1,788	1,732	3,520	23,604	22,635	46,239
5–9	972	907	1,879	2,099	2,072	4,171	38,365	37,114	75,479
10–14	1,051	999	2,050	1,990	1,926	3,916	40,328	38,974	79,302
15–19	952	1,033	1,985	1,840	1,697	3,537	38,095	36,805	74,900
20–24	1,257	1,188	2,445	1,572	1,533	3,105	39,223	37,957	77,180
25–29	1,478	1,441	2,919	1,570	1,497	3,067	39,809	38,733	78,542
30–34	1,209	1,196	2,405	1,312	1,301	2,613	33,758	33,029	66,787
35–39	1,042	1,022	2,064	1,030	1,063	2,093	28,945	29,197	58,142
40–44	850	897	1,747	880	880	1,760	26,139	26,266	52,405
45–49	960	956	1,916	856	855	1,711	26,172	27,054	53,226
50–54	921	985	1,906	791	834	1,625	25,147	26,915	52,062
55–59	734	870	1,604	601	633	1,234	22,302	24,961	47,263
60–64	522	669	1,191	371	399	770	16,647	20,158	36,805
65+	1,112	1,381	2,493	781	855	1,636	31,147	43,833	74,980
Total	13,659	14,111	27,770	17,481	17,277	34,758	429,681	443,631	873,312
Average age	35	36	35	27	28	27	32	34	33
Source: SVS adapted by Business Support, Audit and Negotiations Division

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% for 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

A comparison of March 2015 to March 2019 eligible client population shows an aging population. The client population 40 and above, as a proportional share of the overall client population, increased from 34.3% in 2015 to 36.3% in 2019.

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

Section 3: NIHB program benefit expenditures

Figure 3.1: NIHB program sustainability: 2018 to 2019

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 twice 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.

Factors influencing NIHB program expenditures
Client base	Market forces	Evidence/Input
Changing demographics, including high population growth, an aging population, and uncertainty about the registration of new or existing clients Health status, including high prevalence of chronic and infectious diseases Geographic distribution of client population and accessibility of health services	Introduction and price of new therapies and procedures Provincial/Territorial decisions and insurance industry dynamics Shift from hospital treatments (insured) to non-insured coverage Economic factors, including inflation, volatility in the price of gas and oil, and employment status Geographic accessibility of health benefits and services Changes in scope of practice Relationships with health professional associations	Prescribing and treatment decisions of regulated health professionals Evolving evidence on treatment options Preventive intervention versus restorative oral treatment Input from First Nations and Inuit partner organizations

Figure 3.2: NIHB expenditures by benefit ($ millions): 2018 to 2019

In 2018 to 2019, total NIHB program benefit expenditures were $1,390.6 million. This represents an increase of 6.2% over NIHB expenditures of $1,309.2 million in 2017 to 2018. Of the 2018 to 2019 total, Pharmacy costs (including medical supplies and equipment) represented the largest proportion at $535.9 million (38.5%), followed by Medical Transportation costs at $495.0 million (35.6%) and Dental costs at $269.0 million (19.3%).

NIHB Pharmacy and MS&E, Dental and Medical Transportation benefit expenditures accounted for 93.5% of NIHB expenditures in 2018 to 2019.

Not reflected in the $1,390.6 million in NIHB expenditures is approximately $42.0 million in administration costs. More detail is provided in Figure 9.1.

Figure 3.3: NIHB expenditures and growth by benefit: 2018 to 2019

NIHB program benefit expenditures increased by 6.2%, or $81.0 million from fiscal year 2017 to 2018. All NIHB benefit areas had an increase in expenditures over the previous fiscal year. The highest net increase in expenditures over fiscal year 2017 to 2018 was in the NIHB Medical Transportation benefit at $35.5 million, followed by the NIHB dental benefit with an increase of $20.0 million and the NIHB Pharmacy and MS&E benefit which increased by $13.0 million. Factors affecting benefit expenditure growth are discussed in subsequent sections of this report.

Benefit	Total expenditures ($ 000's) 2017 to 2018	Total expenditures ($ 000's) 2018 to 2019	% Change from 2017 to 2018
Medical transportation	$459,505	$495,034	7.7%
Pharmacy and MS&E	$522,957	$535,949	2.5%
Dental	$248,992	$269,008	8.0%
Vision care	$33,578	$36,467	8.6%
Mental health	$33,066	$42,656	29.0%
Other*	$11,143	$11,450	2.8%
Total expenditures	$1,309,240	$1,390,563	6.2%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Other expenditures are related to contribution agreements including funding arrangements with the FNHA for clients eligible under Bills C-3, S-3, and Qalipu clients, and for payment of health premiums for Inuit clients in British Columbia.

Figure 3.4: NIHB expenditures by benefit and region ($ 000's): 2018 to 2019

The Manitoba region accounted for the highest proportion of total expenditures at $321.0 million, or 23.1% of the national total, followed by the Ontario region at $269.1 million (19.4%), and the Saskatchewan region at $265.2 million (19.1%). In comparison, the lowest expenditure was in the Atlantic region at $63.3 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 clients eligible under Bills C-3 and S-3, and Qalipu clients and for payment of health premiums for Inuit clients in British Columbia, as well as with national client stakeholder organizations (Assembly of First Nations and Inuit Tapiriit Kanatami), and regional Indigenous organizations. These expenditures account for 2.3% ($31.8 million) of NIHB expenditures, and do not include the $42.0 million in headquarters administrative costs outlined in Figure 9.1.

Region	Medical transportation	Pharmacy	Dental	Vision care	Mental health	Other health care	Total
Atlantic	$11,820	$34,348	$10,841	$3,885	$1,932	$514	$63,340
Quebec	$24,642	$48,967	$17,882	$1,908	$2,382	$336	$96,117
Ontario	$98,605	$100,558	$53,667	$6,744	$9,053	$504	$269,131
Manitoba	$156,961	$101,250	$48,099	$4,699	$9,705	$240	$320,953
Saskatchewan	$75,330	$118,250	$55,603	$7,822	$7,867	$210	$265,082
Alberta	$56,870	$83,103	$51,617	$7,696	$9,545	$292	$209,124
North	$70,806	$31,571	$26,211	$3,713	$2,172	$346	$134,819
Headquarters	$0	$17,827	$4,993	$0	$0	$9,007	$31,827
Total	$495,034	$535,949	$269,008	$36,467	$42,656	$11,450	$1,390,563
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 3.5: Proportion of NIHB expenditures by region: 2018 to 2019

In fiscal year 2018 to 2019, the Manitoba region had the highest proportion of total NIHB expenditures (23.1%) and accounted for 31.7% 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 22.1%, followed by Manitoba and Ontario at 18.9% and 18.8% respectively.

The Saskatchewan region, which accounted for 19.1% of total NIHB expenditures in fiscal year 2018 to 2019, recorded the highest proportion of total NIHB Dental expenditures at 20.7%, followed by Ontario and Alberta at 19.9% and 19.2% respectively.

The proportion of NIHB Vision Care expenditures ranged from highs of 21.5% in the Saskatchewan region, 18.5% in the Ontario region and 21.1% in the Alberta region to a low of 5.2 % in Quebec.

Region	Medical transportation	Pharmacy	Dental	Vision care	Mental health	Other health care	Proportion of NIHB expenditure	Proportion of NIHB population
Atlantic	2.4%	6.4%	4.0%	10.7%	4.5%	4.5%	4.6%	7.3%
Quebec	5.0%	9.1%	6.6%	5.2%	5.6%	2.9%	6.9%	8.3%
Ontario	19.9%	18.8%	19.9%	18.5%	21.2%	4.4%	19.4%	24.3%
Manitoba	31.7%	18.9%	17.9%	12.9%	22.8%	2.1%	23.1%	18.0%
Saskatchewan	15.2%	22.1%	20.7%	21.5%	18.4%	1.8%	19.1%	17.7%
Alberta	11.5%	15.5%	19.2%	21.1%	22.4%	2.6%	15.0%	14.3%
North	14.3%	5.9%	9.7%	10.2%	5.1%	3.0%	9.7%	8.0%
Headquarters	0.0%	3.3%	1.9%	0.0%	0.0%	78.7%	2.3%	0.0%
Total	100%	100%	100%	100%	100%	100%	100%	100%
Source: FIRMS and SVS adapted by Business Support, Audit and Negotiations Division

Figure 3.6: Proportion of NIHB regional expenditures by benefit: 2018 to 2019

At the national level, 74.1% of total program expenditures occurred in two benefit areas: pharmacy (38.5%) and medical transportation (35.6%). Dental expenditures accounted for almost one-fifth (19.3%) of total NIHB expenditures.

Medical transportation expenditures accounted for half of benefit expenditures in the Northern and Manitoba regions (52.5% and 48.9%, respectively). Conversely, in the Atlantic region only 18.7% of benefit expenditures were spent on medical transportation.

The proportion of dental expenditures ranged from 15.0% in the Manitoba region to 24.7% in Alberta region.

In the Atlantic region, 54.2% 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.

Region	Medical transportation	Pharmacy	Dental	Vision care	Mental health	Other health care	Total
Atlantic	18.7%	54.2%	17.1%	6.1%	3.0%	0.8%	100%
Quebec	25.6%	50.9%	18.6%	2.0%	2.5%	0.3%	100%
Ontario	36.6%	37.4%	19.9%	2.5%	3.4%	0.2%	100%
Manitoba	48.9%	31.5%	15.0%	1.5%	3.0%	0.1%	100%
Saskatchewan	28.4%	44.6%	21.0%	3.0%	3.0%	0.1%	100%
Alberta	27.2%	39.7%	24.7%	3.7%	4.6%	0.1%	100%
North	52.5%	23.4%	19.4%	2.8%	1.6%	0.3%	100%
Headquarters	0.0%	56.0%	15.7%	0.0%	0.0%	28.3%	100%
National	35.6%	38.5%	19.3%	2.6%	3.1%	0.8%	100%
Source: FIRMS and SVS adapted by Business Support, Audit and Negotiations Division

Figure 3.7: NIHB annual expenditures ($ Millions) and percentage change: 2009 to 2010 to 2018 to 2019

In 2018 to 2019, NIHB program expenditures totalled $1,390.6 million, an increase of 6.2% from $1,309.2 million in fiscal 2017 to 2018. Since fiscal year 2009 to 2010, total expenditures have grown by 40.6%. The annualized rate of growth over this period was 3.5%. There has been wide variation in growth rates between 2009 to 2010 and 2018 to 2019, from a low of -7.1% in 2013 to 2014* to a high of 9.7 % in 2016 to 2017.

Fluctuations in NIHB expenditure growth rates are impacted by a number of factors as set out in figure 3.1. 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 to 2014, the creation of the Qalipu Mi'kmaq band in 2011, and an increase in eligible clients as a result of amendments to the Indian Act.

If expenditures for FNHA eligible clients are excluded from 2012 to 2013 and 2013 to 2014 total NIHB expenditures, then the growth rate for 2013 to 2014 would have been 2.8%.

NIHB annual expenditures ($ millions) and percentage change

Figure 3.8: NIHB annual expenditures by benefit ($ 000's): 2009 to 2010 to 2018 to 2019

In the period from fiscal year 2009 to 2010 to fiscal year 2018 to 2019, expenditures for NIHB mental health services and medical transportation benefits have grown more than other benefit areas. NIHB mental health expenditures grew by 240.8% from $12.5 million in fiscal 2009 to 2010 to $42.7 million in fiscal 2018 to 2019. NIHB medical transportation expenditures rose by 64.1% from $301.7 million in fiscal 2009 to 2010 to $495.0 million in fiscal 2018 to 2019.

Over the same period, NIHB dental expenditures increased by 37.2% and NIHB pharmacy expenditures increased by 23.2%.

Decreases in 'other' expenditures in fiscal year 2013 to 2014 can be attributed 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 clients eligible under Bills C-3 and S-3, Qalipu clients, and for payment of premiums for Inuit clients in British Columbia, as well as with regional First Nations and Inuit organizations that employ NIHB Navigators to act as a resource for communities, organizations or individuals who need assistance or information on the NIHB program.

Benefit	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Medical transportation	$301,673	$311,760	$333,304	$351,424	$352,036	$357,963	$375,904	$417,035	$459,505	$495,034
Pharmacy	$435,097	$440,768	$459,359	$462,699	$416,165	$422,350	$456,430	$494,520	$522,957	$535,949
Dental	$194,918	$215,796	$219,057	$222,706	$207,179	$201,886	$217,109	$235,831	$248,992	$269,008
Vision care	$27,779	$29,219	$29,780	$32,167	$31,459	$29,704	$30,017	$32,370	$33,578	$36,467
Mental health	$12,516	$12,083	$12,936	$14,337	$14,152	$15,581	$16,193	$21,728	$33,066	$42,656
Other	$17,110	$18,428	$19,868	$21,257	$5,406	$4,005	$4,858	$5,974	$11,143	$11,450
Total	$989,094	$1,028,053	$1,074,304	$1,104,591	$1,026,397	$1,031,488	$1,100,512	$1,207,458	$1,309,240	$1,390,563
Annual % change	5.2%	3.9%	4.5%	2.8%	-7.1%	0.5%	6.7%	9.7%	8.4%	6.2%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 3.9: Per capita NIHB expenditures by region: 2018 to 2019

The national per capita expenditure for all benefits in 2018 to 2019 was $1,556. Manitoba had the highest per capita cost in 2018 to 2019 at $2,040. The Northern region followed with a per capita cost of $1,923. 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 $992, due to the comparatively low medical transportation expenditures in the region.

Section 4: NIHB pharmacy expenditure and utilization data

The NIHB program covers a comprehensive range of prescription drugs and over-the-counter medications listed on the NIHB Drug Benefit List (DBL). In addition, a range of medical supplies and equipment (MS&E) items are covered by the program. Like prescription and over-the-counter medications, MS&E benefits are evidence-based and covered in accordance with program policies. Items covered through the MS&E benefit are intended to address NIHB clients' medical needs in relation to basic activities of daily living (ADL) such as eating, bathing, dressing, toileting and transferring, and include:

audiology benefits, such as hearing aids and repairs
medical equipment, such as 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

In fiscal year 2018 to 2019, the NIHB program paid for pharmacy and MS&E claims made by a total of 541,253 First Nations and Inuit clients. The total expenditure for these claims was $535.9 million or 38.5% of total NIHB expenditures. Of all the NIHB program benefits, the pharmacy benefit accounts for the largest share of expenditures and is the benefit most utilized by clients.

Figure 4.1: Distribution of NIHB pharmacy and MS&E expenditures ($ Millions): 2018 to 2019

Figure 4.1 illustrates the components of pharmacy and MS&E 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 $378.4 million or 70.6% of all NIHB pharmacy expenditures, followed by over-the-counter (OTC) drugs and controlled access drugs (CAD) which totalled $77.4 million or 14.4%. Medical supplies and equipment (MS&E) items paid through HICPS was the third largest component in the pharmacy benefit at $45.4 million or 8.5%.

Drugs and MS&E (regional), at $2.0 million or 0.4% of pharmacy and MS&E benefit costs, refers to regionally managed prescription drugs and OTC medications. This category also includes MS&E items paid through Indigenous Services Canada regional offices.

Contribution agreements, which accounted for $14.9 million or 2.8% of total pharmacy and MS&E benefit 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 $17.8 million or 3.3% in 2018 to 2019. Included in this total are headquarters contract and claims processing expenditures related to the HICPS system.

Figure 4.2: Total NIHB pharmacy and MS&E expenditures by type and region ($ 000's): 2018 to 2019

Prescription drug costs paid through the HICPS system represented the largest component of total costs accounting for $378.4 million or 70.0% of all NIHB Pharmacy costs. The Saskatchewan region had the largest proportion of these costs at 24.0%, followed by Manitoba at 19.6% and Ontario at 18.9%.

The next highest component was over-the-counter (OTC) and controlled access drug (CAD) costs at $77.4 million or 14.4%. The regions of Manitoba (23.0%), Saskatchewan (20.0%) and Ontario (19.0%) had the largest proportions of these costs in 2018 to 2019.

The third highest component was the combined medical supplies and equipment (MS&E) category at $45.4 million (8.4%). Saskatchewan (23.1%) had the highest proportion of MS&E costs in 2018 to 2019. This was followed by Manitoba (20.2%) and Alberta (20.1%).

Region	Operating						Total operating costs	Total contribution costs	Total costs
Region	Prescription drugs	OTC/CAD drugs	Drugs/MS&E regional	Medical supplies	Medical equipment	Other costs	Total operating costs	Total contribution costs	Total costs
Atlantic	$24,455	$5,992	$18	$1,029	$2,853	$0	$34,348	$0	$34,348
Quebec	$37,655	$8,954	$14	$803	$1,542	$0	$48,967	$0	$48,967
Ontario	$71,701	$14,700	$39	$1,562	$4,532	$0	$92,534	$8,025	$100,558
Manitoba	$74,310	$17,774	$0	$2,560	$6,605	$0	$101,250	$0	$101,250
Saskatchewan	$90,757	$15,438	$1,534	$3,075	$7,403	$0	$118,207	$42	$118,250
Alberta	$56,547	$10,780	$14	$2,629	$6,484	$0	$76,454	$6,649	$83,103
North	$22,921	$3,718	$403	$1,296	$3,021	$0	$31,359	$212	$31,571
Headquarters	$0	$0	$0	$0	-$10	$17,827	$17,817	$0	$17,817
Total	$378,426	$77,361	$2,022	$12,955	$32,430	$17,827	$521,021	$14,928	$535,949
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 4.3: Annual NIHB pharmacy expenditures: 2014 to 2015 to 2018 to 2019

NIHB pharmacy expenditures increased by 2.8% during fiscal year 2018 to 2019. Over the past 5 years, growth in pharmacy expenditures has ranged from a high of 8.3% in 2016 to 2017 to a low of 1.5% in 2014 to 2015.

The 5 year annualized growth rate for NIHB pharmacy expenditures is 4.9%. The introduction of lower cost generic drugs as they become available on the market, optimized drug utilization, and changes in generic pricing policies in key provinces have kept pharmacy benefit growth moderate. As well, NIHB has negotiated Product Listing Agreements (PLA) with drug manufacturers to allow for the coverage of certain medications at a reduced price through the use of rebates, medications which would otherwise not be considered cost-effective or affordable. NIHB currently has more than 150 PLA in effect.

Figure 4.3.1: Annual NIHB pharmacy expenditures and percentage change

Figure 4.3.2: NIHB pharmacy expenditures ($ 000's) by region

NIHB Pharmacy Expenditures ($ 000's)
Region	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Atlantic	$28,398	$30,064	$31,899	$33,021	$34,348
Quebec	$42,581	$44,206	$47,444	$48,390	$48,967
Ontario	$81,982	$88,872	$94,101	$99,550	$100,558
Manitoba	$81,059	$87,997	$94,757	$98,046	$101,250
Saskatchewan	$83,361	$91,170	$104,082	$119,326	$118,250
Alberta	$64,087	$69,992	$77,265	$79,343	$83,103
North	$23,941	$27,408	$28,488	$29,373	$31,571
Headquarters	$16,678	$16,546	$16,302	$15,816	$17,817
Total	$422,350	$456,430	$494,520	$522,957	$535,949
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 4.4: Per capita NIHB pharmacy expenditures by region: 2018 to 2019

In 2018 to 2019, the national per capita expenditure for NIHB Pharmacy benefits was $593. This was an increase of 1.5% from the $584 recorded in 2017 to 2018.

The Saskatchewan region had the highest per capita NIHB Pharmacy expenditure at $766, followed by the Quebec region at $672.

The Northern region had the lowest per capita expenditure at $450 followed by the Ontario region at $474. 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: 2018 to 2019

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 2018 to 2019, the national average per claimant expenditure was $926, a decrease of 0.7% over 2017 to 2018.

The Quebec Region had the highest average NIHB Pharmacy operating expenditure per claimant at $1,070, followed by Saskatchewan at $1,051.

Figure 4.6: NIHB pharmacy utilization rates by region: 2014 to 2015 to 2018 to 2019

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 2018 to 2019, the national utilization rate was 62% 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 71.5% in 2018 to 2019. 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 52.6%. 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 63.5%.

Region	Pharmacy utilization
Region	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Atlantic	62%	62%	63%	63%	68%
Quebec	60%	60%	60%	61%	63%
Ontario	54%	54%	54%	53%	49%
Manitoba	66%	67%	67%	67%	69%
Saskatchewan	70%	70%	70%	69%	72%
Alberta	66%	66%	66%	65%	67%
Yukon	60%	60%	60%	60%	60%
N.W.T.	54%	54%	55%	55%	57%
Nunavut	47%	46%	47%	50%	52%
National	61%	61%	61%	61%	62%
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

Figure 4.7: NIHB pharmacy claimants by age group, gender and region: 2018 to 2019

Of the 873,312 clients eligible to receive benefits under the NIHB program, a total of 529,180 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 2018 to 2019. Of this total, 299,698 were female (57%) and 229,482 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 36 years. The average age for female and male claimants was 36 and 35 years of age, respectively.

Region	Atlantic			Quebec			Ontario			Manitoba
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0–4	811	806	1,617	987	937	1,924	1,182	1,034	2,216	3,066	2,983	6,049
5–9	1,113	1,245	2,358	1,305	1,328	2,633	1,881	1,886	3,767	4,402	4,416	8,818
10–14	1,283	1,243	2,526	1,297	1,333	2,630	1,978	2,000	3,978	4,091	4,391	8,482
15–19	1,223	1,799	3,022	1,143	1,763	2,906	2,083	3,506	5,589	3,565	4,967	8,532
20–24	1,272	2,169	3,441	1,129	2,019	3,148	2,276	4,437	6,713	3,697	5,663	9,360
25–29	1,383	2,152	3,535	1,289	2,153	3,442	3,664	5,868	9,532	4,006	5,967	9,973
30–34	1,228	1,757	2,985	1,125	1,919	3,044	3,623	5,185	8,808	3,617	4,827	8,444
35–39	1,189	1,702	2,891	1,187	1,640	2,827	3,359	4,817	8,176	3,184	4,080	7,264
40–44	1,206	1,570	2,776	1,185	1,582	2,767	3,409	4,417	7,826	3,097	3,742	6,839
45–49	1,424	1,715	3,139	1,337	1,681	3,018	3,722	4,656	8,378	3,133	3,965	7,098
50–54	1,473	1,814	3,287	1,455	1,908	3,363	3,957	4,913	8,870	3,167	3,663	6,830
55–59	1,395	1,748	3,143	1,563	1,918	3,481	3,960	4,983	8,943	2,795	3,262	6,057
60–64	1,274	1,608	2,882	1,333	1,775	3,108	3,309	4,243	7,552	2,009	2,474	4,483
65+	2,454	3,231	5,685	2,592	3,801	6,393	5,585	8,346	13,931	3,067	4,233	7,300
Total	18,728	24,559	43,287	18,927	25,757	44,684	43,988	60,291	104,279	46,896	58,633	105,529
Average age	39	39	39	39	40	40	42	42	42	33	34	33
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

Region	Saskatchewan			Alberta			North			Total
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0–4	3,161	3,085	6,246	2,571	2,456	5,027	1,193	1,052	2,245	13,021	12,395	25,416
5–9	4,607	4,839	9,446	3,771	3,757	7,528	1,273	1,238	2,511	18,443	18,801	37,244
10–14	4,393	4,802	9,195	3,315	3,533	6,848	1,025	1,048	2,073	17,506	18,476	35,982
15–19	3,863	5,418	9,281	3,041	3,944	6,985	981	1,759	2,740	16,014	23,360	39,374
20–24	3,630	6,019	9,649	3,075	4,386	7,461	1,066	2,088	3,154	16,284	27,017	43,301
25–29	4,172	6,172	10,344	3,163	4,387	7,550	1,200	2,224	3,424	19,049	29,239	48,288
30–34	3,791	5,307	9,098	2,879	3,809	6,688	1,122	1,961	3,083	17,571	25,059	42,630
35–39	3,239	4,280	7,519	2,618	3,412	6,030	1,002	1,651	2,653	15,951	21,838	37,789
40–44	3,050	3,818	6,868	2,356	2,832	5,188	937	1,390	2,327	15,377	19,592	34,969
45–49	3,085	3,790	6,875	2,265	2,825	5,090	1,163	1,483	2,646	16,314	20,353	36,667
50–54	2,906	3,589	6,495	2,153	2,575	4,728	1,158	1,543	2,701	16,433	20,284	36,717
55–59	2,472	3,060	5,532	1,857	2,369	4,226	1,034	1,399	2,433	15,215	18,956	34,171
60–64	1,816	2,276	4,092	1,370	1,820	3,190	741	1,031	1,772	11,923	15,367	27,290
65+	2,795	3,818	6,613	2,185	3,225	5,410	1,600	2,075	3,675	20,381	28,961	49,342
Total	46,980	60,273	107,253	36,619	45,330	81,949	15,495	21,942	37,437	229,482	299,698	529,180
Average age	32	33	32	31	33	32	36	36	36	35	36	36
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

Figure 4.8: Distribution of eligible NIHB population, pharmacy expenditures and pharmacy incidence by age group: 2018 to 2019

The main drivers of NIHB pharmacy expenditures are the cost of medications, the volume of claims submitted and the professional fees associated with filling these claims. Claims are not equal to prescriptions as a prescription can comprise a number of claim lines. For further clarification see Section 9.3.2.

In 2018 to 2019, 5.3% of all clients were in the 0 to 4 age group, but this group accounted for only 0.8% of all pharmacy claims made and only 1.1% of total pharmacy expenditures. In contrast, 8.6% of all eligible clients were in the 65+ age group, but accounted for 23.7 % of all pharmacy claims submitted and 17.5% of total pharmacy expenditures.

During 2018 to 2019, the average claimant aged 65 or more submitted 92 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.

Age	Eligible clients	Incidence	Expenditures
0–4	5.3%	0.8%	1.1%
5–9	8.6%	1.0%	1.7%
10–14	9.1%	1.2%	2.1%
15–19	8.6%	1.7%	2.7%
20–24	8.8%	3.0%	3.6%
25–29	9.0%	6.0%	6.3%
30–34	7.6%	7.4%	7.3%
35–39	6.7%	7.8%	7.9%
40–44	6.0%	7.7%	8.3%
45–49	6.1%	9.1%	9.6%
50–54	6.0%	10.1%	10.7%
55–59	5.4%	10.6%	11.2%
60–64	4.2%	9.8%	9.8%
65+	8.6%	23.7%	17.5%
Total	100.0%	100.0%	100.0%

An examination of pharmacy benefit cost per NIHB claimant indicates that these expenditures vary according to age. For example, in 2018 to 2019 the average cost per child aged 0 to 4 years was $218. The cost increased steadily for every age group, with claimants aged 30–34 having an average cost of $863, comparable to the total average claimant cost of $947. Claimants aged 60–64 years had the highest cost per claimant with an average of $1,799 for all pharmaceutical services received throughout the fiscal year.

Figure 4.9: NIHB top 10 therapeutic classes by number of claimants: 2018 to 2019

Figure 4.9 ranks the top 10 therapeutic classes according to number of claimants. In 2018 to 2019, Non-Steroidal Anti-Inflammatory Drugs (NSAID) had the highest number of distinct claimants at 202,281, an increase of 0.4% over 2017 to 2018. Penicillins such as Amoxil (Amoxicillin) ranked second in number of claimants with 151,954 followed by Miscellaneous Analgesics and Antipyretics with 128,606 claimants.

Therapeutic classification	Claimants	% Change from 2017 to 2018	Examples of product in the therapeutic class
Non-Steroidal Anti-Inflammatory Drugs (NSAID)	202,281	0.4%	Voltaren (Diclofenac)
Penicillins	151,954	-5.3%	Amoxil (Amoxicillin)
Miscellaneous Analgesics and Antipyretics	128,606	4.9%	Tylenol (Acetaminophen)
Opioid Agonists	108,118	-5.5%	Statex (Morphine Sulphate)
Antidepressants	98,613	3.6%	Effexor (Venlafaxine)
Proton Pump Inhibitors	92,250	2.5%	Losec (Omeprazole)
Beta-Adrenergic Agonists	84,562	-3.1%	Ventolin (Salbutamol)
SMMA — Anti-inflammatory Agents	75,634	-3.5%	Cortate Cream (Hydrocortisone)
Cephalosporins	72,489	-3.3%	Keflex (Cephalexin)
HMG-COA Reductase Inhibitors (Statins)	69,876	4.4%	Lipitor (Atorvastatin)
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Figure 4.10: NIHB prescription drug claims incidence by therapeutic class: 2018 to 2019

Figure 4.10 looks at 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 2018 to 2019. 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 20.7% followed by hormones and synthetic substitutes, which consist primarily of oral contraceptives and insulin, at 13.8%. 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 therapeutic class: 2018 to 2019

Figure 4.11 shows the 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 with the authority to prescribe in their province or territory of practice.

Vitamins were the highest category of OTC medications in 2018 to 2019 accounting for 28.5% of all OTC drug claims. OTC central nervous system agents (such as acetaminophen), which are drugs used to manage pain such as headaches, followed at 24.3% of all OTC drug claims, and gastrointestinal products such as antacids and laxatives, which are used to treat heartburn and constipation, at 7.7%.

Figure 4.12: NIHB medical supplies by category and claims incidence: 2018 to 2019

Figure 4.12 shows the variation in medical supply claims incidence by category.

In 2018 to 2019, incontinence supplies such as liners and pads accounted for 27.1% of all medical supply claims. Hearing aid supplies, such as batteries, represented 21.6% of all medical supply claims, followed by wound care supplies at 21.3%.

Figure 4.13: NIHB medical equipment by category and claims incidence: 2018 to 2019

Figure 4.13 shows the variation in medical equipment claims incidence by category.

Claims for oxygen equipment accounted for 22.9% of all medical equipment claims in 2018 to 2019. Hearing aids was the next highest category at 21.9%, followed by limb orthoses at 10.0% and walking aids at 8.3%.

Section 5: NIHB dental expenditure and utilization data

The NIHB program covers a broad range of dental services including:

diagnostic services such as examinations and radiographs
preventive services such as scaling, polishing, fluorides and sealants
restorative services such as fillings and crowns
endodontic services such as root canal treatments
periodontal services such as deep scaling
removable prosthodontic services such as dentures
oral surgery services such as extractions
orthodontic services such as braces
adjunctive services such as general anaesthesia and sedation

In 2018 to 2019, a total of 326,699 First Nations and Inuit clients accessed dental benefits through the NIHB program, based on claims paid through the HICPS system. The total expenditure for dental benefit claims was $269 million or 19.3% of total NIHB expenditures. The dental benefit accounts for the third largest program expenditure.

Some dental services require predetermination prior to the initiation of treatment. Predetermination is a review that determines if the proposed dental service is covered under the program's guidelines and criteria, as described in the NIHB Dental Benefits Guide. This review is undertaken by the Dental Predetermination Centre (DPC).

Figure 5.1: Distribution of NIHB dental expenditures ($ millions): 2018 to 2019

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 $241.1 million or 89.6% of all NIHB Dental costs.

The next highest component was contribution agreements, which accounted for $14.4 million or 5.3% of total dental expenditures. Contribution agreements are 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 $8.6 million or 3.2% of total costs.

Other costs totalled $5 million or 1.9% in 2018 to 2019. 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): 2018 to 2019

Of the $269.0 million in NIHB dental expenditures in 2018 to 2019, the regions of Saskatchewan (20.7%), Ontario (19.9%), Alberta (19.2%) and Manitoba (17.9%) had the largest overall proportion. The Saskatchewan region had the highest total dental expenditure at $55.6 million and the Atlantic region had the lowest total dental expenditure at $10.8 million.

Region	Operating			Total operating costs	Total contribution costs	Total costs
Region	Fee-for-service	Contract dentists	Other costs	Total operating costs	Total contribution costs	Total costs
Atlantic	$10,841	$0	$0	$10,841	-	$10,841
Quebec	$17,842	$0	$0	$17,842	$40	$17,882
Ontario	$44,396	$2,582	$0	$46,978	$6,689	$53,667
Manitoba	$41,509	$5,587	$0	$47,096	$1,003	$48,099
Saskatchewan	$51,742	$0	$0	$51,742	$3,861	$55,603
Alberta	$49,066	$31	$0	$49,097	$2,521	$51,617
North	$25,613	$360	$0	$25,972	$239	$26,211
Headquarters	-	-	$4,993	$4,993	-	$4,993
Total	$241,104	$8,560	$3,423	$253,086	$14,352	$269,008
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 5.3: Annual NIHB dental expenditures: 2014 to 2015 to 2018 to 2019

NIHB dental expenditures increased by 8.0% during fiscal year 2018 to 2019. The decrease in overall NIHB dental expenditures recorded in fiscal year 2014 to 2015 can be attributed to the transfer of responsibility for the delivery of dental benefits for eligible First Nation clients residing in British Columbia to the FNHA during the 2013 to 2014 fiscal year.

Over the last 5 years, annual growth rates for NIHB Dental expenditures have ranged from a high of 8.6% in 2016 to 2017 to a low of -2.6% in 2014 to 2015.

Figure 5.3.1: NIHB Dental expenditures and annual percentage change

Figure 5.3.2: NIHB dental expenditures by region

NIHB dental expenditures ($ 000's)
Region	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Atlantic	$8,238	$8,846	$9,593	$10,610	$10,841
Quebec	$15,799	$16,641	$17,569	$17,961	$17,882
Ontario	$46,759	$49,903	$52,105	$52,101	$53,667
Manitoba	$33,527	$36,764	$39,986	$41,949	$48,099
Saskatchewan	$37,679	$41,028	$47,321	$50,635	$55,603
Alberta	$35,974	$39,753	$44,315	$47,637	$51,617
North	$20,413	$20,936	$20,936	$25,141	$26,211
Headquarters	$2,943	$2,920	$2,877	$2,770	$3,423
Total	$201,886	$217,109	$235,831	$249,038	$269,008
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 5.4: Per capita NIHB dental expenditures by region: 2018 to 2019

In 2018 to 2019, the national per capita NIHB dental expenditure was $302, an increase of 6.3% from $284 in 2017 to 2018.

The Alberta region had the highest per capita dental expenditure at $412, followed by the Northern region at $374 and Saskatchewan region at $360. The Atlantic region had the lowest per capita dental expenditure at $170 per eligible client.

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: 2018 to 2019

In 2018 to 2019, the national NIHB dental expenditure per claimant (i.e. eligible clients who received at least one dental benefit) was $738, an increase of 1.4% over the $728 in 2017 to 2018.

The Alberta region had the highest dental expenditure per claimant at $936 followed by the Northern region at $913, an increase of 3.6% and 0.9% respectively from $903 and $904 in the previous year.

Figure 5.6: NIHB dental utilization rates by region: 2014 to 2015 to 2018 to 2019

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 2018 to 2019, the national utilization rate for dental benefits paid through the HICPS system was 37%, a slight increase over the previous 4 fiscal years. National NIHB dental utilization rates have remained fairly stable over the past 5 years.

Dental utilization rates vary across the regions with the highest dental utilization rate found in the Quebec region (43%). 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:

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 45% in 2018 to 2019. 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 38%.

Over the 2 year period between 2017 to 2018 and 2018 to 2019, 434,110 distinct clients received NIHB Dental services through HICPS, resulting in an overall 50% utilization rate over this period.

Region	Dental utilization					NIHB dental utilization last 2 years 2017 to 2019
Region	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	NIHB dental utilization last 2 years 2017 to 2019
Atlantic	33%	34%	34%	34%	37%	48%
Quebec	45%	45%	44%	44%	43%	55%
Ontario	32%	32%	32%	32%	32%	41%
Manitoba	32%	32%	33%	33%	39%	51%
Saskatchewan	36%	36%	38%	38%	39%	54%
Alberta	39%	40%	41%	40%	42%	56%
Yukon	37%	36%	36%	36%	37%	51%
Northwest Territories	41%	40%	41%	41%	41%	56%
Nunavut	42%	40%	38%	38%	40%	56%
National	35%	35%	36%	36%	37%	50%
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

Figure 5.7: NIHB dental claimants by age group, gender and region: 2018 to 2019

Of the 873,312 clients eligible to receive dental benefits through the NIHB program, 326,699 claimants (37%) received at least one dental procedure paid through the HICPS system in 2018 to 2019.

Of this total, 183,019 were female (56%) and 143,680 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 (36 years of age). The average age for female and male claimants was 32 and 30 years of age respectively.

Approximately 36% 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 2018 to 2019.

Region	Atlantic			Quebec			Ontario			Manitoba
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0–4	161	164	325	375	371	746	927	915	1,842	1,547	1,581	3,128
5–9	621	633	1,254	1,443	1,468	2,911	3,116	3,244	6,360	3,534	3,545	7,079
10–14	851	889	1,740	1,669	1,691	3,360	3,302	3,363	6,665	3,693	4,154	7,847
15–19	1,026	1,164	2,190	1,158	1,366	2,524	2,847	3,133	5,980	2,801	3,431	6,232
20–24	896	1,181	2,077	966	1,339	2,305	2,270	3,054	5,324	2,216	3,111	5,327
25–29	869	1,190	2,059	1,062	1,421	2,483	2,263	3,150	5,413	2,378	3,329	5,707
30–34	762	964	1,726	858	1,280	2,138	1,905	2,676	4,581	1,843	2,609	4,452
35–39	708	952	1,660	825	1,120	1,945	1,664	2,515	4,179	1,601	2,139	3,740
40–44	650	864	1,514	847	1,110	1,957	1,699	2,248	3,947	1,559	1,948	3,507
45–49	733	978	1,711	856	1,157	2,013	1,758	2,316	4,074	1,511	1,962	3,473
50–54	742	1,006	1,748	942	1,253	2,195	1,817	2,596	4,413	1,458	1,799	3,257
55–59	674	919	1,593	897	1,169	2,066	1,800	2,643	4,443	1,215	1,562	2,777
60–64	580	877	1,457	722	1,040	1,762	1,487	2,226	3,713	822	1,082	1,904
65+	1,002	1,364	2,366	1,204	1,740	2,944	2,364	3,883	6,247	1,009	1,454	2,463
Total	10,275	13,145	23,420	13,824	17,525	31,349	29,219	37,962	67,181	27,187	33,706	60,893
Average age	37	39	38	34	36	35	33	36	35	28	30	29
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Region	Saskatchewan			Alberta			North			Total
Age group	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
0–4	1,376	1,353	2,729	1,380	1,363	2,743	854	805	1,659	6,661	6,580	13,241
5–9	3,691	3,758	7,449	3,704	3,590	7,294	1,379	1,437	2,816	17,620	17,829	35,449
10–14	3,756	4,194	7,950	3,395	3,739	7,134	1,361	1,667	3,028	18,190	19,866	38,056
15–19	2,643	3,424	6,067	2,668	3,100	5,768	1,220	1,654	2,874	14,503	17,414	31,917
20–24	2,052	3,310	5,362	1,860	2,495	4,355	1,121	1,578	2,699	11,500	16,212	27,712
25–29	2,233	3,338	5,571	1,789	2,500	4,289	1,151	1,684	2,835	11,865	16,795	28,660
30–34	2,020	2,789	4,809	1,571	2,217	3,788	917	1,402	2,319	9,996	14,096	24,092
35–39	1,607	2,148	3,755	1,362	1,963	3,325	744	1,124	1,868	8,622	12,117	20,739
40–44	1,479	1,984	3,463	1,256	1,688	2,944	646	895	1,541	8,213	10,866	19,079
45–49	1,463	1,985	3,448	1,087	1,617	2,704	680	867	1,547	8,195	11,033	19,228
50–54	1,381	1,820	3,201	1,085	1,452	2,537	638	834	1,472	8,141	10,928	19,069
55–59	1,057	1,448	2,505	850	1,277	2,127	513	715	1,228	7,083	9,847	16,930
60–64	726	1,020	1,746	637	942	1,579	337	480	817	5,350	7,739	13,089
65+	853	1,218	2,071	717	1,131	1,848	547	814	1,361	7,741	11,697	19,438
Total	26,337	33,789	60,126	23,361	29,074	52,435	12,108	15,956	28,064	143,680	183,019	326,699
Average age	28	29	29	26	29	28	29	30	30	30	32	31
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Figure 5.8: NIHB fee-for-service dental expenditures by sub-benefit: 2018 to 2019

In 2018 to 2019, expenditures for restorative services (as an example: crowns and fillings) were the highest of all dental sub-benefit categories at $109.2 million. Diagnostic services (as an example: examinations and x-rays) at $31.3 million and prevenative services (as an example: scaling, sealants) at $29.4 million were the next highest sub-benefit categories. Rounding out the top 5 was oral surgery (as an example: extractions) at $26.9 million and endodontic services (as an example: root canal treatments) at $17.1 million.

Fee-for-service top 5 dental sub-benefits ($ millions) and percentage change
Dental sub-benefit	2017 to 2018	2018 to 2019	% Change from 2017 to 2018
Restorative services	$99.0	$109.2	10.3%
Diagnostic services	$29.1	$31.3	7.7%
Preventive services	$28.0	$29.4	4.8%
Oral surgery	$24.6	$26.9	9.6%
Endodontic services	$15.3	$17.1	12.1%
Source: HICPS adapted by Business Support, Audit and Negotiations Division

In 2018 to 2019, the 3 largest dental procedures by expenditure were composite restorations ($92.7 million), scaling ($22.3 million) and extractions ($18.9 million).

Fee-for-service top 5 dental procedures ($ millions) and percentage change
Dental procedure	2017 to 2018	2018 to 2019	% Change from 2017 to 2018
Composite restorations	$84.3	$92.7	10.0%
Scaling	$21.7	$22.3	3.0%
Extractions	$17.4	$18.9	8.8%
Root canal therapy	$13.4	$15.2	13.3%
Intraoral radiographs	$10.1	$11.1	9.6%
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Figure 5.9: Distribution of eligible NIHB population, dental expenditures and incidence by age group: 2018 to 2019

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 (as an example: low-cost restorative procedures such as fillings) are provided, so this group accounts for 24.6% of claims, but only 17.4% of expenditures.

Age	Eligible Clients	Expenditures	Incidence
0–4	5.3%	8.0%	11.8%
5–9	8.6%	9.5%	12.8%
10–14	9.1%	4.7%	4.8%
15–19	8.6%	11.2%	10.7%
20–24	8.8%	10.0%	8.7%
25–29	9.0%	9.8%	8.8%
30–34	7.6%	7.8%	7.2%
35–39	6.7%	6.5%	6.0%
40–44	6.0%	5.9%	5.5%
45–49	6.1%	6.0%	5.5%
50–54	6.0%	5.9%	5.4%
55–59	5.4%	5.1%	4.6%
60–64	4.2%	3.9%	3.5%
65+	8.6%	5.7%	4.8%
Total	100.0%	100.0%	100.0%

Section 6: NIHB medical transportation expenditures and utilization data

In 2018 to 2019, NIHB medical transportation expenditures amounted to $459.0 million or 35.1% of total NIHB expenditures. The medical transportation benefit is the second largest program expenditure.

NIHB medical transportation benefits are intended to assist eligible clients to access medically necessary health services that cannot be obtained on reserve or in their community of residence.

NIHB medical transportation benefits are managed by Indigenous Services Canada regional offices, or by First Nations or Inuit Health Authorities, organizations or territorial governments who manage the benefit through contribution agreements.

NIHB 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 and air ambulance)
water travel (motorized boat, boat taxi and ferry)
living expenses (meals and accommodations)
transportation costs for health professionals to provide services to isolated communities

NIHB medical transportation benefits may be provided for clients to access the following types of medically required health services:

medical services insured by provincial/territorial health plans (as an example, appointments with physician, diagnostic tests, hospital care)
alcohol, solvent, drug abuse and detox treatments
traditional healers
eligible benefits and services covered by the NIHB program

NIHB medical transportation benefits may also be provided for a medical escort (such as a nurse) or a non-medical escort (such as family member or caregiver) to travel with a client who needs assistance. As of July, 2017, NIHB provides coverage for a non-medical escort for all pregnant women who require transportation outside their community to deliver their babies.

In addition to facilitating client travel to appointments for these medical services, significant efforts have been made over the past few years to bring health care professionals to under-serviced and/or remote and isolated communities. These efforts facilitate access to medically necessary services in communities and can be more cost effective than bringing individual clients to the service provider.

Figure 6.1: Distribution of NIHB medical transportation expenditures ($ Millions): 2018 to 2019

In 2018 to 2019, NIHB medical transportation expenditures totalled $495.0 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 $215.7 million, or 43.6% of total benefit expenditures.

Of benefits managed by the NIHB program, scheduled flights at $89.7 million (18.1%), living expenses at $64.8 million (13.1%) and air ambulance at $46.0 million (9.3%) were the largest expenditures, accounting for a combined total of over 40%.

Rounding out medical transportation expenditures are costs for land ambulance at $45.3 million (9.1%), land and water transportation at $21.4 million (4.3%) and chartered flights at $12.2 million (2.5%).

Figure 6.2: Annual NIHB medical transportation expenditures: 2014 to 2015 to 2018 to 2019

NIHB medical transportation expenditures increased by 7.7% in 2018 to 2019 compared to the previous year. Over the past 5 years, overall medical transportation costs have grown by 38.3% from $358.0 million in 2014 to 2015 to $495.0 million in 2018 to 2019.

On a regional basis, the highest growth rates over this period were in the Atlantic region where expenditures grew by 59.3% from $7.4 million in 2014 to 2015 to $11.8 million in 2018 to 2019. This was followed by the Ontario region with an increase of 49.0% from $65.8 million in 2014 to 2015 to $98.6 million in 2018 to 2019.

The Manitoba region had the highest total medical transportation expenditure at $157.0 million and had the largest net increase in expenditures over the past 5 years as medical transportation costs grew by $41.2 million over this period. The Ontario region had the second largest net increase in expenditures over the past 5 years at $32.8 million followed by Saskatchewan at $23.8 million.

Figure 6.2.1: NIHB medical transportation expenditures and annual percentage change

Figure 6.2.2: NIHB medical transportation expenditures by region ($ 000's)

NIHB medical transportation expenditures ($ 000's)
Region	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Atlantic	$7,419	$8,380	$9,277	$11,147	$11,820
Quebec	$23,506	$23,687	$23,501	$23,918	$24,642
Ontario	$65,781	$67,772	$74,890	$86,091	$98,605
Manitoba	$115,705	$125,308	$147,167	$155,370	$156,961
Saskatchewan	$51,543	$53,566	$58,902	$64,363	$75,330
Alberta	$45,756	$46,252	$48,157	$51,187	$56,870
North	$48,246	$50,940	$55,125	$67,413	$70,806
Total	$357,963	$375,904	$417,019	$459,489	$495,034
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 6.3: NIHB medical transportation expenditures by type and region ($ 000's): 2018 to 2019

Saskatchewan had the largest percentage increase in medical transportation expenditures in 2018 to 2019, with an increase of 17.0% from the previous fiscal year. Ontario followed with a 14.5% increase in expenditures.

In 2018 to 2019, the Manitoba region had the highest overall NIHB medical transportation expenditure at $157.0 million, primarily as a result of air transportation which totalled $85.4 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 2018 to 2019 at $98.6 million. Saskatchewan and the Northern region followed at $75.3 million and $70.8 million, respectively.

Type	Atlantic	Quebec	Ontario	Manitoba	Saskatchewan	Alberta	North	Total
Scheduled flights	$2,059	$282	$34,167	$42,273	$8,152	$1,231	$1,524	$89,689
Air ambulance	$14	$36	$103	$34,740	$6,766	$1,978	$2,354	$45,991
Chartered flights	$1	$0	$384	$8,420	$1,428	$2,007	$0	$12,240
Land ambulance	$562	$249	$859	$10,622	$19,704	$13,290	$3	$45,289
Land & water	$1,085	$87	$3,618	$4,341	$9,740	$1,605	$875	$21,351
Living expenses	$932	$24	$24,870	$23,952	$7,890	$5,469	$1,622	$64,758
Total operating	$4,651	$678	$63,999	$124,350	$53,681	$25,580	$6,377	$279,317
Total contributions	$7,169	$23,964	$34,605	$32,612	$21,648	$31,289	$64,429	$215,716
Total	$11,820	$24,642	$98,605	$156,961	$75,330	$56,870	$70,806	$495,034
% Change from 2017 to 2018	6.0%	3.0%	14.5%	1.0%	17.0%	11.1%	5.0%	7.7%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 6.4: NIHB medical transportation contribution and operating expenditures by region ($ Millions): 2018 to 2019

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 (such as, coordinating accommodations and managing ground transportation), 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 2018 to 2019 at $124.4 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 $64.0 million, followed by the Saskatchewan region at $53.7 million. Together these 3 regions accounted for 86.7% of all operating expenditures for medical transportation.

In 2018 to 2019, the Northern region had the largest contribution expenditures for NIHB medical transportation at $64.4 million, followed by the regions of Ontario and Manitoba at $34.6 million and $32.6 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): 2018 to 2019

In 2018 to 2019, scheduled flights represented the largest portion of NIHB's medical transportation operating expenditures at $89.7 million or 32.1% of the total national operating expenditures. Living expenses, which include accommodations and meals, was the second highest at $64.8 million, or 23.2% of operating expenditures. Air ambulance followed at $46.0 million or 16.2%, and land ambulance costs comprised $45.3 million or 16.5% of medical transportation operating costs.

Private vehicle expenditures ($4.3 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: 2018 to 2019

In 2018 to 2019, the national per capita expenditure for NIHB medical transportation benefits was $567.

The Northern region recorded the highest per capita expenditure in medical transportation at $1,010, followed by Manitoba at $998. 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 $185, a slight increase from $170 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.

Section 7: NIHB vision benefits, mental health counselling benefits and other health care benefits data

The NIHB program provides coverage for vision care benefits as set out in the NIHB Guide to Vision Benefits, including:

eye examinations when they are not insured by the province or territory
corrective eyewear (glasses, contact lenses) when prescribed by a vision care professional
eyeglass repairs
other vision care benefits depending on the specific medical needs of the

Some items such as ocular prosthesis and low vision aids are covered by NIHB as medical supplies and equipment benefits.

The NIHB program provides coverage for mental health benefits as set out in the NIHB Guide to Mental Health Counselling Services. The NIHB mental health counselling benefit is intended to provide coverage for mental health counselling to complement other mental wellness services that may be available. Mental health counselling is eligible for coverage when it is provided by an NIHB recognized mental health professional such as a registered psychologist. The provision of this benefit is part of FNIHB's commitment to work towards the development of a coordinated and comprehensive approach to mental health and addictions programming. The mental health counselling benefit is offered in a way that:

recognizes the NIHB mental health counselling benefit as a component of a mental wellness continuum that includes other FNIHB, community-based and provincial or territorial mental health programming and services
supports culturally competent mental health counselling

NIHB other health care includes expenditures related to funding arrangements with the FNHA for clients eligible under Bills C-3 and S-3 and Qalipu clients, and for payment of health premiums for Inuit clients in British Columbia. Other expenditures also include funding for program oversight and partner contribution agreements.

In 2018 to 2019, the total combined expenditure for NIHB vision benefits ($36.5 million), mental health counselling benefits ($42.7 million) and other health care benefits ($11.4 million) was $90.6 million, or 6.5% of total NIHB expenditures for the fiscal year.

Figure 7.1: NIHB vision expenditures and growth by region ($ 000's): 2018 to 2019

NIHB vision expenditures totalled $36.5 million in 2018 to 2019. Regional operating expenditures accounted for $31.0 million ( 85.1%) of total expenditures while contribution costs accounted for $5.4 million (14.9%).

In 2018 to 2019, the Saskatchewan region had the highest expenditures in NIHB vision benefits at $7.8 million, a percentage share of 21.5%, followed by the Alberta region at $7.8 million (21.1%) and the Ontario region at $6.7 million (18.5%).

Region	Operating	Contributions	Total
Atlantic	$3,885	$0	$3,885
Quebec	$1,908	$0	$1,908
Ontario	$6,162	$582	$6,744
Manitoba	$4,373	$326	$4,699
Saskatchewan	$7,822	$0	$7,822
Alberta	$6,495	$1,201	$7,696
North	$376	$3,338	$3,713
Total	$31,021	$5,446	$36,467
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 7.2: Annual NIHB vision expenditures: 2014 to 2015 to 2018 to 2019

In 2018 to 2019, NIHB vision expenditures increased by 8.6% from the previous year. As with other benefits, vision care expenditures declined in 2014 to 2015 due to the transfer of First Nations clients residing in B.C. to the FNHA in fiscal year 2013 to 2014, and increased in subsequent years.

On a regional basis, the highest expenditure growth rate over this 5 year period was in the Northern region where expenditures grew by 113.1% from $1.7 million in 2014 to 2015 to $3.7 million in 2018 to 2019. The largest net increases in expenditures over the past 5 years took place in the Northern region where total vision benefit costs grew by $1.9 million over this period, followed by the Saskatchewan region where costs grew by $1.8 million. The significant drop in Northern region vision expenditures in fiscal year 2014 to 2015 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

Figure 7.2.2: Annual NIHB vision expenditures by region ($ 000's)

NIHB vision expenditures ($ 000's)
Region	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Atlantic	$2,666	$3,021	$3,502	$3,632	$3,885
Quebec	$1,622	$1,749	$1,762	$1,819	$1,908
Ontario	$5,717	$6,160	$6,223	$6,848	$6,744
Manitoba	$4,800	$4,212	$4,204	$4,479	$4,699
Saskatchewan	$6,066	$6,104	$6,533	$6,905	$7,822
Alberta	$7,084	$6,207	$6,928	$6,764	$7,696
North	$1,743	$2,564	$3,217	$3,131	$3,713
Total	$29,704	$30,017	$32,370	$33,578	$36,467
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 7.3: Per capita NIHB vision expenditures by region: 2018 to 2019

In 2018 to 2019, the national per capita expenditure in NIHB vision benefits was $42.

Alberta and the Atlantic region had the highest per capita expenditure at $61 each, followed by the Northern region and Saskatchewan at $53 and $51 respectively. The lowest per capita NIHB Vision benefit expenditure was in the Quebec region at $26.

Figure 7.4: NIHB mental health counselling expenditures by region ($ 000's): 2018 to 2019

In 2018 to 2019, NIHB mental health counselling expenditures amounted to $42.7 million. Regional operating expenditures accounted for $24.3 million (57.0%) of total expenditures while contribution costs accounted for $18.4 million (43.0%).

In 2018 to 2019, the Manitoba region had the highest percentage share of NIHB mental health counselling expenditures at 22.8% followed by the Alberta and Ontario regions at 22.4% and 21.2% respectively.

Region	Operating	Contributions	Total
Atlantic	$977	$954	$1,932
Quebec	$1,597	$785	$2,382
Ontario	$7,937	$1,116	$9,053
Manitoba	$5,984	$3,721	$9,705
Saskatchewan	$2,614	$5,253	$7,867
Alberta	$5,173	$4,372	$9,545
North	$21	$2,151	$2,172
Total	$24,302	$18,353	$42,656
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 7.5: NIHB mental health counselling expenditures and annual percentage change

2014 to 2015 to 2018 to 2019

NIHB mental health counselling expenditures increased by 29.0% during fiscal year 2018 to 2019. Over the past 5 years, overall mental health counselling costs have grown by 173.8% from $15.6 million in 2014 to 2015 to $42.7 million in 2018 to 2019. Budget 2017 provided funding to expand the benefit by removing the requirement that counselling be provided in response to a crisis.

On a regional basis, the highest growth rates over this period were in the Atlantic region where expenditures grew by 1040.1% from $169 thousand in 2014 to 2015 to $1.9 million in 2018 to 2019. This was followed by Saskatchewan with an increase of 482.2% from $1.4 million in 2014 to 2015 to $7.9 million in 2018 to 2019.

The Alberta region had the highest total mental health counselling expenditure at $9.5 million.

Figure 7.5.1: NIHB mental health counselling expenditures and annual percentage change

Prior to 2014 to 2015, NIHB mental health counselling expenditures were reported under other health care. In this edition of the NIHB Annual Report, and going forward, expenditures associated with the provision of mental health counselling services to NIHB clients will be reported separately.

Figure 7.5.2: NIHB mental health counselling expenditures by region ($ 000's)

Region	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Atlantic	$169	$419	$601	$1,204	$1,932
Quebec	$1,148	$1,148	$1,292	$1,861	$2,382
Ontario	$2,803	$3,021	$4,091	$6,028	$9,053
Manitoba	$4,099	$3,780	$5,635	$8,124	$9,705
Saskatchewan	$1,351	$1,631	$3,304	$6,559	$7,867
Alberta	$6,010	$6,003	$6,444	$7,761	$9,545
North	$0	$191	$362	$1,528	$2,172
Total	$15,581	$16,193	$21,728	$33,066	$42,656
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 7.6: Per capita NIHB mental health counselling expenditures by region ($ 000's): 2018 to 2019

In 2018 to 2019, the national per capita expenditure for NIHB Mental Health Counselling was $49 per NIHB-eligible client.

The Alberta region had the highest per capita expenditure at $76, followed by the Manitoba region at $62 per NIHB-eligible client.

Figure 7.7: NIHB other health care expenditures by region ($ 000's): 2018 to 2019

In 2018 to 2019, NIHB other health care expenditures totalled $11.4 million. The majority of these expenditures are related to contribution agreements including funding arrangements with the FNHA for clients eligible under Bill C-3 and S-3, and Qalipu clients, and for payment of health premiums for Inuit clients in British Columbia.

Other expenditures in this category include contribution agreements with national client partner organizations (Assembly of First Nations and Inuit Tapiriit Kanatami), as well as with regional First Nations and Inuit organizations that employ NIHB Navigators to act as a resource for communities, organizations or individuals who need assistance or information on the NIHB program.

Region	Operating	Contributions	Total
Atlantic	$3	$511	$514
Quebec	$0	$336	$336
Ontario	$4	$500	$504
Manitoba	$0	$240	$240
Saskatchewan	$0	$210	$210
Alberta	$12	$280	$292
North	$1	$345	$346
Headquarters	$70	$8,937	$9,007
Total	$91	$11,359	$11,450
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Section 8: Regional expenditure trends

2009 to 2010 to 2018 to 2019

Figure 8.1: Atlantic region: 2009 to 2010 to 2018 to 2019

Annual expenditures in the Atlantic Region for 2018 to 2019 totalled $63.3 million, an increase of 5.5% over the $60.0 million spent in 2017 to 2018. Pharmacy expenditures in 2018 to 2019 increased by 4.0% to $34.3 million, medical transportation costs increased by 6.0% to $11.8 million and dental expenditures increased by 2.2% to $10.8 million. Mental health expenditures increased by 60.4% and vision care expenditures increased by 7.0%.

Pharmacy expenditures accounted for more than half of the Atlantic Region's total expenditures at 54.2%. Medical transportation expenditures ranked second at 18.7%, followed by dental at 17.1%. Vision care and mental health expenditures accounted for 6.1% and 3.0% of total expenditures respectively.

Over the 10 year period from 2009 to 2010 to 2018 to 2019, NIHB expenditures in the Atlantic Region were impacted by changes to the NIHB eligible client population. The creation of the Qalipu Mi'kmaq First Nation band in 2011 resulted in a 2 year surge in Atlantic Regional expenditures. As of March 31, 2019, a total of 22,418 Qalipu clients were eligible to receive benefits through the NIHB Program. The decrease in expenditures in 2013 to 2014 can be attributed to the transfer of authority to the First Nations Health Authority for clients registered to Atlantic First Nations, but residing in British Columbia.

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

Atlantic region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Total expenditure ($M)	$33,656	$37,482	$42,850	$49,995	$46,033	$46,912	$50,773	$55,079	$60,040	$63,342
Total benefits annual % change	6.6%	11.4%	14.3%	16.7%	-7.9%	1.9%	8.2%	8.5%	9.0%	5.5%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

Atlantic region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Transportation	$5,048	$5,314	$5,841	$6,875	$6,916	$7,419	$8,380	$9,277	$11,147	$11,820
Pharmacy	$21,357	$23,689	$27,571	$29,979	$27,517	$28,398	$30,064	$31,899	$33,021	$34,348
Dental	$5,426	$6,481	$7,164	$9,660	$8,609	$8,238	$8,846	$9,593	$10,610	$10,841
Mental health	$213	$241	$254	$512	$235	$169	$419	$601	$1,204	$1,932
Vision care	$1,612	$1,758	$2,021	$2,969	$2,757	$2,666	$3,021	$3,502	$3,632	$3,885
Other health care	$0	$0	$0	$0	$0	$21	$44	$207	$427	$516
Total	$33,656	$37,482	$42,850	$49,995	$46,033	$46,912	$50,773	$55,079	$60,040	$63,342
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.2: Quebec region: 2009 to 2010 to 2018 to 2019

Annual expenditures in the Quebec region for 2018 to 2019 totalled $96.1 million, an increase of 2.0% from the $94.2 million spent in 2017 to 2018.

Pharmacy expenditures increased by 1.2% to $49.0 million and dental expenditures decreased by -0.4% to $17.9 million, while medical transportation costs in 2018 to 2019 increased by 3.0% to $24.6 million. Mental health expenditures increased by 28.0% and vision care expenditures increased by 4.9%.

Pharmacy expenditures accounted for half of the Quebec region's total expenditures in 2018 to 2019 at 50.9%. Medical transportation expenditures ranked second at 25.6%, followed by dental at 18.6%. Mental health counselling and vision care expenditures accounted for 2.5% and 2.0% of total expenditures respectively.

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

Quebec region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Total expenditure ($M)	$73,174	$74,355	$77,951	$80,915	$80,608	$84,666	$87,690	$91,831	$94,210	$96,120
Total benefits annual % change	3.0%	1.6%	4.8%	3.8%	-0.4%	5.0%	3.6%	4.7%	2.6%	2.0%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

Quebec region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Transportation	$19,918	$18,943	$21,708	$22,578	$21,945	$23,506	$23,687	$23,501	$23,918	$24,642
Pharmacy	$37,358	$38,234	$38,827	$40,393	$40,825	$42,581	$44,206	$47,444	$48,390	$48,967
Dental	$14,159	$15,245	$15,138	$15,239	$15,216	$15,799	$16,641	$17,569	$17,961	$17,882
Mental health	$459	$597	$875	$1,135	$1,003	$1,148	$1,148	$1,292	$1,861	$2,382
Vision care	$1,280	$1,336	$1,404	$1,570	$1,619	$1,622	$1,749	$1,762	$1,819	$1,908
Other health care	$0	$0	$0	$0	$0	$10	$258	$263	$260	$339
Total	$73,174	$74,355	$77,951	$80,915	$80,608	$84,666	$87,690	$91,831	$94,210	$96,120
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.3: Ontario region: 2009 to 2010 to 2018 to 2019

Annual expenditures in the Ontario region for 2018 to 2019 totalled $269.1 million, an increase of 8.3% from the $250.9 million spent in 2017 to 2018.

In 2018 to 2019, Ontario pharmacy expenditures increased by 1.0% to $100.6 million, while medical transportation costs increased by 14.5% to $98.6 million. Mental health counselling expenditures increased by 50.2%, while vision care expenditures decreased slightly by -1.5%.

Pharmacy expenditures accounted for 37.4% of the Ontario region's total expenditures. Medical transportation costs ranked second at 36.6%, followed by dental at 19.9%. Mental health and vision care expenditures accounted for 3.4% and 2.5% of total expenditures respectively.

Figure 8.3.1: Percentage change in Ontario region NIHB expenditures ($ 000's)

Ontario region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Total expenditure ($M)	$175,447	$174,653	$180,778	$186,544	$193,929	$203,043	$215,738	$231,663	$250,947	$269,127
Total benefits annual % change	5.1%	-0.5%	3.5%	3.2%	4.0%	4.7%	6.3%	7.4%	8.3%	7.2%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.3.2: Annual expenditures by benefit ($ 000's)

Ontario region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Transportation	$51,889	$52,358	$54,725	$59,251	$62,865	$65,781	$67,772	$74,890	$86,091	$98,605
Pharmacy	$77,564	$73,887	$76,430	$77,131	$78,510	$81,982	$88,872	$94,101	$99,550	$100,558
Dental	$38,047	$40,594	$41,848	$42,259	$43,972	$46,759	$49,903	$52,105	$52,055	$53,667
Mental health	$2,603	$2,632	$2,349	$2,490	$2,862	$2,803	$3,021	$4,091	$6,028	$9,053
Vision care	$5,343	$5,183	$5,425	$5,412	$5,721	$5,717	$6,160	$6,223	$6,848	$6,744
Other health care	$0	$0	$0	$0	$0	$2	$11	$254	$375	$500
Total	$175,447	$174,653	$180,778	$186,544	$193,929	$203,043	$215,738	$231,663	$250,947	$269,127
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.4: Manitoba region: 2009 to 2010 to 2018 to 2019

Annual expenditures in the Manitoba region for 2018 to 2019 totalled $321.0 million, an increase of 4.1% from the $308.2 million spent in 2017 to 2018. Pharmacy expenditures in 2018 to 2019 increased by 3.3% to $101.3 million, while medical transportation costs increased by 1.0% to $157.0 million. Dental expenditures increased by 14.7% to $48.1 million. Mental health expenditures increased by 19.5% while vision increased by 4.9%.

Unlike most other regions, pharmacy expenditures in Manitoba do not represent the largest proportion of total expenditures. Due to the higher proportion of clients living in northern or remote communities in Manitoba, medical transportation expenditures comprised almost half of the Manitoba region's total expenditures at 48.9%. Pharmacy costs ranked second at 31.5%, followed by dental at 15.0%. Mental health and vision expenditures accounted for 3.0% and 1.5% of total expenditures respectively.

Figure 8.4.1: Percentage change in Manitoba region NIHB expenditures ($ 000's)

Manitoba region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Total expenditure ($M)	$195,371	$207,377	$219,031	$228,295	$229,670	$239,190	$258,077	$291,989	$308,208	$320,953
Total benefits annual % change	5.9%	6.1%	5.6%	4.2%	0.6%	4.1%	7.9%	13.1%	5.6%	4.1%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.4.2: Annual expenditures by benefit ($ 000's)

Manitoba region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Transportation	$89,078	$94,940	$101,609	$109,409	$111,016	$115,705	$125,308	$147,167	$155,370	$156,961
Pharmacy	$72,789	$76,496	$80,639	$80,676	$77,034	$81,059	$87,997	$94,757	$98,046	$101,250
Dental	$26,954	$29,399	$29,861	$30,734	$33,649	$33,527	$36,764	$39,986	$41,949	$48,099
Mental health	$3,143	$2,930	$3,109	$3,429	$3,622	$4,099	$3,780	$5,635	$8,124	$9,705
Vision care	$3,407	$3,612	$3,813	$4,048	$4,348	$4,800	$4,212	$4,204	$4,479	$4,699
Other health care	$0	$0	$0	$0	$0	$0	$17	$240	$240	$240
Total	$195,371	$207,377	$219,031	$228,295	$229,670	$239,190	$258,077	$291,989	$308,208	$320,953
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.5: Saskatchewan region: 2009 to 2010 to 2018 to 2019

Annual expenditures in the Saskatchewan region for 2018 to 2019 totalled $265.1 million, an increase of 6.9% from the $248.0 million spent in 2017 to 2018.

Saskatchewan is the region with the highest expenditures in pharmacy, followed closely by Manitoba and Ontario. In Saskatchewan, pharmacy expenditures in 2018 to 2019 decreased by 0.9% to $118.3 million, while medical transportation costs increased by 17.0% to $75.3 million and dental expenditures increased by 9.8% to $55.6 million. Mental health and vision care expenditures increased by 19.9% and 13.3% respectively.

Pharmacy expenditures comprised the largest portion of the Saskatchewan region's total expenditures at 44.6%, medical transportation costs ranked second at 28.4%, followed by dental at 21.0%. Vision care and mental health expenditures accounted for 3.0% and 3.0% of total expenditures respectively.

Figure 8.5.1: Percentage change in Saskatchewan region NIHB expenditures ($ 000's)

Saskatchewan region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Total expenditure ($M)	$141,420	$153,393	$161,265	$163,372	$168,752	$180,000	$193,502	$220,352	$247,997	$265,082
Total benefits annual % change	7.0%	8.5%	5.1%	1.3%	3.3%	6.7%	7.5%	13.9%	12.5%	6.9%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.5.2: Annual expenditures by benefit ($ 000's)

Saskatchewan region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Transportation	$38,971	$41,896	$45,084	$45,793	$47,180	$51,543	$53,566	$58,902	$64,363	$75,330
Pharmacy	$66,639	$70,625	$73,293	$74,646	$78,546	$83,361	$91,170	$104,082	$119,326	$118,250
Dental	$30,777	$35,317	$36,941	$36,219	$36,399	$37,679	$41,028	$47,321	$50,635	$55,603
Mental health	$812	$896	$1,499	$1,038	$1,017	$1,351	$1,631	$3,304	$6,559	$7,867
Vision care	$4,222	$4,658	$4,449	$5,676	$5,611	$6,066	$6,104	$6,533	$6,905	$7,822
Other health care	$0	$0	$0	$0	$0	$0	$4	$210	$210	$210
Total	$141,420	$153,393	$161,265	$163,372	$168,752	$180,000	$193,502	$220,352	$247,997	$265,082
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.6: Alberta region: 2009 to 2010 to 2018 to 2019

Annual expenditures in the Alberta region for 2018 to 2019 totalled $209.1 million, an increase of 8.4% from the $193.0 million spent in 2017 to 2018. Pharmacy expenditures increased by 4.7% to $83.1 million, while medical transportation costs increased by 11.1% to $56.8 million and dental expenditures increased by 8.4% to $51.6 million. Mental health expenditures increased by 23.0% and vision care expenditures increased by 13.8%.

Pharmacy expenditures accounted for 39.7% of the Alberta region's total expenditures. Medical transportation costs ranked second at 27.2%, followed closely by dental at 24.7%. Mental health and vision care expenditures accounted for 4.6% and 3.7% of total expenditures respectively.

The negative growth rate recorded in 2009 to 2010 was the result of the Government of Alberta eliminating Alberta Health Care insurance premiums for all Albertans as of January 1, 2009.

Figure 8.6.1: Percentage change in Alberta region NIHB expenditures ($ 000's)

Alberta region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Total expenditure ($M)	$130,666	$138,717	$143,313	$144,928	$146,051	$158,911	$168,211	$183,108	$192,983	$209,122
Total benefits annual % change	-2.2%	6.2%	3.3%	1.1%	0.8%	8.8%	5.8%	8.9%	5.4%	8.4%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.6.2: Annual expenditures by benefit ($ 000's)

Alberta region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Transportation	$36,601	$35,877	$37,371	$39,216	$41,451	$45,756	$46,252	$48,157	$51,187	$56,870
Pharmacy	$56,570	$59,738	$61,621	$60,584	$58,777	$64,087	$69,992	$77,265	$79,343	$83,103
Dental	$27,756	$33,421	$34,543	$34,501	$34,928	$35,974	$39,753	$44,315	$47,637	$51,617
Mental health	$4,363	$3,903	$3,957	$4,791	$4,959	$6,010	$6,003	$6,444	$7,761	$9,545
Vision care	$5,377	$5,778	$5,822	$5,836	$5,936	$7,084	$6,207	$6,928	$6,764	$7,696
Other health care	$0	$0	$0	$0	$0	$0	$3	$0	$291	$291
Subtotal (excluding premiums)	$130,666	$138,717	$143,313	$144,928	$146,051	$158,911	$168,211	$183,108	$192,983	$209,122
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.7: Northern region: 2009 to 2010 to 2018 to 2019

Annual expenditures in the Northern region for 2018 to 2019 totalled $134.5 million, an increase of 5.9% from the $126.9 million spent in 2017 to 2018.

Medical transportation expenditures in 2018 to 2019 increased by 5.0% to $70.8 million while pharmacy costs increased by 7.5% to $31.6 million. Dental expenditures increased by 4.3% to $26.2 million. Vision care expenditures increased by 18.6% and mental health expenditures increased by 42.2%.

Similar to Manitoba, medical transportation expenditures comprised the largest portion of the Northern region's total expenditures at 52.7%. Pharmacy costs ranked second at 23.5 %, followed by dental at 19.5%. Vision care and mental health expenditures accounted for 2.8% and 1.6% of total expenditures respectively.

Figure 8.7.1: Percentage change in Northern region NIHB expenditures ($ 000's)

Northern region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Total expenditure ($M)	$78,089	$85,744	$87,787	$88,557	$92,027	$94,343	$102,040	$109,157	$126,933	$134,474
Total benefits annual % change	12.1%	9.8%	2.4%	0.9%	3.9%	2.5%	8.2%	7.0%	16.3%	5.9%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.7.2: Annual expenditures by benefit ($ 000's)

Northern region	2009 to 2010	2010 to 2011	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019
Transportation	$34,622	$36,464	$40,455	$41,727	$44,703	$48,246	$50,940	$55,125	$67,413	$70,806
Pharmacy	$20,555	$23,190	$23,863	$23,682	$23,144	$23,941	$27,408	$28,488	$29,373	$31,571
Dental	$19,627	$22,537	$20,079	$19,773	$20,415	$20,413	$20,936	$21,966	$25,141	$26,211
Mental health	$1	$2	$4	$4	$2	$0	$191	$362	$1,528	$2,172
Vision care	$3,284	$3,550	$3,387	$3,370	$3,763	$1,743	$2,564	$3,217	$3,131	$3,713
Other health care	$0	$0	$0	$0	$0	$1	$1	$0	$346	$1
Total	$78,089	$85,744	$87,787	$88,557	$92,027	$94,343	$102,040	$109,157	$126,933	$134,474
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Section 9: NIHB program administration

Figure 9.1: Non-insured health benefits administration costs ($ 000's): 2018 to 2019

Figure 9.1 provides the program administration expenditure by region as well as NIHB headquarters (HQ) in Ottawa. In 2018 to 2019, total NIHB administration costs were $64.8 million representing an increase of 7.8% over the previous fiscal year.

The roles of NIHB headquarters include:

program policy development and determination of eligible benefits
development and maintenance of the HICPS system and other national systems such as the Medical Transportation Reporting System (MTRS)
claims verification and provider negotiations
adjudicating benefit requests through the NIHB Drug Exception Centre and the Dental Predetermination Centre
providing expert advice through the MS&E Review Centre and
maintaining relationships with partner organizations at the national level as well as with other federal departments and agencies

The roles of the NIHB regional offices include:

adjudicating benefit requests for medical transportation, medical supplies and equipment, vision, and mental health counselling benefits
maintaining relationships with partner organizations at the provincial/territorial level as well as with provincial/territorial officials

Claims processing contract costs are related to the administration of pharmacy, medical supplies and equipment and dental benefits through the Health Information and Claims Processing Services (HICPS) system, and include:

claim processing and payment operations
claim adjudication and reporting systems development and maintenance
provider registration and communications
systems in support of pharmacy and MS&E benefits prior approval and dental predetermination processes
provider audit programs and audit recoveries and
standard and ad hoc reporting

Figure 9.1: NIHB Program administration expenditures by region ($ 000's)
Categories	Atlantic	Quebec	Ontario	Manitoba	Saskatchewan	Alberta	Northern region	HQ	Total
Salaries	$1,449	$1,784	$3,995	$2,979	$3,296	$3,599	$1,367	$14,451	$32,919
EBP	$290	$355	$799	$596	$659	$719	$273	$2,880	$6,571
Operating	$228	$82	$311	$59	$150	$79	$87	$1,517	$2,513
Subtotal	$1,967	$2,221	$5,105	$3,634	$4,104	$4,396	$1,727	$18,848	$42,003
Claims processing contract costs									$22,820
Total administration costs									$64,823
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 9.2: Non-Insured Health Benefits administration costs as a proportion of benefit expenditures ($ Millions): 2014 to 2015 to 2018 to 2019

Figure 9.2 provides the percentage of NIHB program administrative costs as a proportion of overall NIHB benefit expenditures. In 2018 to 2019, total NIHB benefit expenditures were $1,390.2 million, of which direct benefit expenditures totaled $1,367.4 million and expenditures for claims processing administration amounted to $22.8 million. An additional $42.0 million was spent on salaries and operating costs associated with program administration.

Total NIHB program administration costs ($64.8 million, including claims processing and other program administration) as a proportion of direct benefit expenditures ($1.4 billion), was 4.7% in 2018 to 2019. Over the past 5 fiscal years, the percentage of NIHB program administrative costs as a proportion of total benefit expenditures has ranged from a high of 5.4% in 2014 to 2015 to a low of 4.7% the past 3 fiscal years.

Section 9.3: Health Information and Claims Processing Services (HICPS): 2018 to 2019

Claims for the 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.

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:

claim processing and payment operations
claim adjudication and reporting systems development and maintenance
provider registration and communications
systems in support of pharmacy and MS&E benefits prior approval and dental predetermination processes
provider audit programs and audit recoveries and
standard and ad hoc reporting

The current HICPS contract is with Express Scripts Canada. This contract came into force on December 6, 2009, following a competitive contracting process led by Public Works and Government Services Canada (PWGSC). The NIHB program manages the HICPS contract as the project authority in conjunction with PWGSC, the contract authority.

As of March 31, 2019, there were 28,098 active providers registered with the HICPS claims processor to deliver NIHB pharmacy, MS&E and dental benefits. The number of active providers by region and by benefit is outlined in the table below. The number of claims settled through the HICPS system is highlighted in Figure 9.3.2.

An active provider refers to a provider who has submitted at least one claim in the 24 months prior to March 31, 2019.

Figure 9.3.1: Number of NIHB providers by region and benefit: April 2017 to March 2019

Region	Pharmacy	MS&E	Dental
Atlantic	837	250	1,061
Quebec	1,950	217	2,953
Ontario	4,160	842	6,263
Manitoba	464	88	793
Saskatchewan	436	104	577
Alberta	1,558	326	2,589
British Columbia	1,111	82	1193
Yukon	11	9	56
Northwest Territories	12	7	53
Nunavut	10	2	84
Total	10,549	1,927	15,622
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Figure 9.3.2: Number of claim lines settled through the Health Information and Claims Processing Services (HICPS) system: 2018 to 2019

Figure 9.3.2 sets out the total number of pharmacy, dental and MS&E claims settled through the HICPS system in fiscal year 2018 to 2019. During this period, a total of 27,295,656 claim lines were processed through HICPS, an increase of 5.3% over the previous fiscal year. Ontario had the highest volume of total claims processed at 7.4 million, followed by Manitoba at 5.0 million and Saskatchewan at 4.5 million.

Claim lines and prescriptions

It is important to note that the program reports annually on claim lines. This is an administrative unit of measure as opposed to a health care unit of measure. A claim line represents a transaction in 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 (such as methadone) are dispensed daily and will increase the number of claim lines.

Figure 9.3.2: Number of claim lines processed through HICPS by region and benefit
Region	Pharmacy	Dental	MS&E	Total
Atlantic	1,589,794	173,849	47,526	1,811,169
Quebec	3,111,557	226,345	36,785	3,374,687
Ontario	6,672,123	624,666	54,483	7,351,272
Manitoba	4,383,307	523,036	100,218	5,006,561
Saskatchewan	3,823,088	604,800	103,504	4,531,392
Alberta	3,205,515	585,097	69,739	3,860,351
British Columbia	160,881	32,756	2,118	195,755
Yukon	133,323	24,163	2,983	160,469
Northwest Territories	376,716	102,968	12,080	491,764
Nunavut	343,844	149,811	18,581	512,236
Total claim lines	23,800,148	3,047,491	448,017	27,295,656
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Section 9.4: Benefits management

Many items or services covered by the NIHB program are open benefits. This means that prior approval is not required, and an enrolled provider can provide the service right away. Some items or services require prior approval from NIHB to ensure that they meet criteria for coverage.

Drug Exception Centre (DEC)

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 2018 to 2019.

Figure 9.4: Volume of requests and approvals made to the DEC by benefit listing type*
Status	Open benefit (unrestricted)	Open benefit (restricted)	Exceptions	Limited use	Total
Total requested	26,228	11,373	21,963	49,492	109,056
Total approved	22,335	8,354	14,700	39,806	85,195
Source: HICPS adapted by Business Support, Audit and Negotiations Division

*Benefit listing type refers to a drug product's status on the NIHB Drug Benefit List (DBL), and are defined as follows:

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 3 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.

The DEC also supports the implementation of the Problematic Substance Use 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 Client Safety Program across the country.

Dental Predetermination Centre

The Dental Predetermination Centre (DPC) is a call centre that provides efficient adjudication of all dental and orthodontic predetermination, post-determination, client reimbursements and adjudication of appeals. In addition, the DPC is responsible for addressing client and provider inquiries and to assist clients and providers with the submission of the predetermination, post-determination, client reimbursement and appeal requests.

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 health professionals, including 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.

Section 9.5: Claims verification activities: 2018 to 2019

As part of the NIHB program's risk management activities, Indigenous Services Canada has mandated its claims processor to maintain a set of pre-payment and post-payment processes, including claims verification activities.

During 2018 to 2019, the claims processor carried out claims verifications as directed by the NIHB program. The verifications address the need of the NIHB program 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 appropriate NIHB Provider Guide, Claims Submission Kit, Provider Agreement and other relevant documents.

There are 4 components within claims verification activities for the pharmacy, medical supplies and equipment and dental benefit areas. These are:

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 the claims processor
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
On-Site claim verification program, which consists of the selection of a sample of claims for administrative validation with a provider's records through an on-site visit
Desk claim verification program, which consists of the selection of a sample of claims for administrative validation with a provider's records. Unlike on-site verifications, a desk claim verification serves to validate records through the use of fax or mail

Completion of the claim verification process often spans more than one fiscal year. Although the complete recovery for any verification may overlap into another fiscal year, recoveries from claims verification activities are recorded in the fiscal year in which they are received.

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 2018 to 2019 fiscal year.

Figure 9.5.1: Dental audit recoveries by region: 2018 to 2019

Dental
Region	Audits completed	Recoveries	NDCV/CCP savings	Total recoveries/ savings
Atlantic	0	$14,070	$34,473	$48,543
Quebec	2	$15,082	$27,323	$42,405
Ontario	5	$12,970	$111,495	$124,465
Manitoba	4	$197,122	$82,046	$279,168
Saskatchewan	3	$171,909	$84,601	$256,509
Alberta	7	$55,840	$182,858	$238,698
Yukon	1	$0	$3,499	$3,499
N.W.T.	2	$15,940	$15,940	$26,560
Nunavut	9	$83,450	$20,508	$103,958
Total	33	$561,063	$562,743	$1,123,806
Source: Electronic Scripts Canada adapted by Business Support, Audit and Negotiations Division

Figure 9.5.2: Pharmacy audit recoveries by region: 2018 to 2019

Pharmacy
Region	Audits completed	Recoveries	NDCV/CCP savings	Total recoveries/ savings
Atlantic	0	$0	$104,559	$104,559
Quebec	4	$6,999	$167,489	$174,488
Ontario	4	$162,516	$704,634	$867,150
Manitoba	6	$179,864	$190,521	$370,385
Saskatchewan	4	$0	$93,919	$93,919
Alberta	7	$178,976	$172,660	$351,636
Yukon	0	$0	$40,897	$40,897
N.W.T.	0	$0	$23,515	$23,515
Nunavut	1	$1,360	$31,205	$32,565
Total	26	$529,715	$1,529,399	$2,059,114
Source: Electronic Scripts Canada adapted by Business Support, Audit and Negotiations Division

Figure 9.5.2: Medical supplies and equipment audit recoveries by region: 2018 to 2019

MS&E
Region	Audits completed	Recoveries	NDCV/CCP savings	Total recoveries/savings
Atlantic	0	$0	$13,233	$13,233
Quebec	1	$0	$7,991	$7,991
Ontario	0	$0	$31,117	$31,117
Manitoba	0	$0	$3,691	$3,691
Saskatchewan	0	$0	$6,887	$6,887
Alberta	2	$0	$20,344	$20,344
Yukon	0	$0	$100	$100
N.W.T.	0	$0	$1,342	$1,342
Nunavut	0	$0	$0	$0
Total	3	$0	$84,706	$84,706
Source: Electronic Scripts Canada adapted by Business Support, Audit and Negotiations Division

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. Recoveries and savings for claims for non-FNHA clients processed in British Columbia are recorded under Alberta regional totals.

Section 10: NIHB policy and program initiatives

Section 10.1: Evidence-based policy development

NIHB Drug benefit listing and review

The NIHB Drug Benefits List (DBL) is a listing of all of the drugs provided as benefits by the NIHB program. Drugs considered for, or currently listed on, the 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 the Canadian Agency for Drugs and Technologies in Health (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.

NIHB Oral Health Advisory Committee (NOHAC)

The NIHB Oral Health Advisory Committee (NOHAC) supports Inigenous Services Canada's NIHB Program by providing impartial expert advice on oral health matters as they pertain to Canada's First Nations and Inuit population. Through NOHAC, the NIHB Program is able to access external professional expertise to inform and improve the criteria, guidelines and policies under which the Program covers dental services provided to eligible First Nations and Inuit clients.

Section 10.2: Client safety

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 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. 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 including serious liver damage can result from prolonged use, 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 use disorder 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 Client Safety Program (NIHB-CSP, formerly known as the Prescription Monitoring Program) which focuses on reducing client safety risks associated with problematic use of restricted medications such as benzodiazepines, opioids, gabapentin, and stimulant drugs. Clients are enrolled in the NIHB-CSP based on their patterns of prescription drug use. Additionally, clients treated for opioid use disorder with methadone, buprenorphine/naloxone (Suboxone and generics), long acting morphine (Kadian) or others are enrolled. Enrolment in the NIHB-CSP may restrict clients to a specific prescriber or group practice or require clients to have future claims verified and authorized by a pharmacist at NIHB's Drug Exception Centre.

The NIHB-CSP 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-CSP operates in all regions of Canada, with the exception of Quebec, and monitored the safety of nearly 22,600 clients in 2018 to 2019.

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."

Benzodiazepine dose limit policy

For client safety, the NIHB program limits the maximum dose of benzodiazepines that may be reimbursed per month for a client. Since March 2013, the program has gradually been lowering the dose limit, which is currently at 40 mg of diazepam equivalents (DEQ) per day. This dose limit is being further reduced to 30 mg DEQ per day, implemented region-by-region. Additionally, the NIHB Program has a 30-day maximum dispense policy for all benzodiazepines.

Gabapentin and Pregabalin dose limit policy

For client safety, the NIHB program limits the maximum dose of gabapentin that may be reimbursed per month for a client. Since March 2013, the program has gradually been lowering the dose limit, which is currently at 4000 mg of gabapentin per day. This dose limit is being further reduced to 3600 mg per day, implemented region-by-region. Additionally, the NIHB program has a 30-day maximum dispense policy for gabapentin and pregabalin.

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 (such as, 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.

Section 10.3: Client and provider communications

NIHB is continually seeking ways to improve communications with clients, providers and partners regarding benefit coverage and administration.

The NIHB program regularly produces newsletters and updates to inform clients and providers about any changes to NIHB policy and benefit coverage information. For example, NIHB enrolled providers for dental, pharmacy and MS&E receive policy updates and relevant information regarding benefits through both quarterly provider newsletters and fax broadcasts.

The provider newsletters are distributed to enrolled providers by Express Scripts Canada, Indigenous Services Canada's claims processing contractor.

The NIHB website is a key venue for disseminating program information. NIHB program updates are produced quarterly to provide information for clients regarding changes to benefit coverage. They are also promoted through social media on the Government of Canada's Healthy First Nations and Inuit Facebook Page. NIHB develops additional posts for the Healthy First Nations and Inuit Facebook page that promote client awareness of their benefit coverage. Often these posts are planned in conjunction with broader public health promotion campaigns (such as, a post on diabetes awareness will include a reminder about NIHB coverage of diabetes medications and supplies, and a post on vision health that will include a reminder about NIHB coverage of eye exams).

NIHB strives to be accessible and responsive to clients. Clients can contact NIHB directly by calling Indigenous Services Canada regional offices, or the NIHB Dental Predetermination Centre. In 2016, NIHB implemented new ways for clients to contact the program on-line: the Contact us web page for the NIHB program now provides an email address for direct inquiries to the NIHB program and the NIHB Feedback form enables clients to inquire or send feedback directly to the program.

Section 10.4 NIHB navigators

NIHB navigators help eligible clients to navigate and access the NIHB program. They are a resource for communities, organizations or individuals who need support or information on NIHB-related issues. Navigators are employed by regional First Nations and Inuit organizations. Their roles and activities are adapted to meet regional needs, and generally include the following:

increase understanding of the NIHB Program and share information on eligible benefits
help clients and communities to resolve NIHB-related issues
link with health departments and agencies to help improve client access to NIHB benefits and related health services

Section 10.5: Collaboration with First Nations and Inuit partners

In 2014, the Government of Canada agreed to undertake a multi-year Joint Review of the NIHB program in partnership with the Assembly of First Nations (AFN). The overall objective of the review is to identify and implement actions that enhance client access to benefits, identify gaps in benefits, streamline service delivery to be more responsive to client needs, and increase program efficiencies. The Joint Review is guided by a Steering Committee comprised of First Nations and Indigenous Services Canada's representatives.

As part of this process, the AFN conducted a robust program of client, provider and stakeholder engagement activities to gather broad input and perspectives that will inform recommendations for program improvements.

Indigenous Services Canada continues to work with Inuit representatives through the Inuit NIHB Senior Bilateral Committee (INSBC) to identify and address areas of concern and recommendations to improve the quality, access, and delivery of NIHB benefits to Inuit clients. NIHB updates Inuit partners regularly on progress made to advance INSBC priority issues, including working towards the implementation of NIHB navigator positions for Inuit clients in Nunavut and the Inuvialuit Settlement Region.

Section 11: Technical notes

Information contained in the 2018 to 2019 NIHB Annual Report has been extracted from several databases. All tables and charts are footnoted with the appropriate data sources. These data sources are considered to be of very high quality but, as in any administrative data set, some data may be subject to coding errors or other anomalies. For this reason, users of the data should always refer to the most current edition of the NIHB annual report. Please note that some table totals may not add due to rounding procedures.

To address reporting challenges related to NIHB clients registered to British Columbia bands but living elsewhere, and Inuit clients living in BC, select financial and utilization data relating to the British Columbia Region have been suppressed. National totals, however, include these values.

Fiscal year 2014 to 2015 expenditures totals for Alberta medical transportation, vision and MSE benefits have been restated and differ from the expenditures totals that appeared in the 2014 to 2015 edition of the NIHB annual report.

Population data

First Nations and Inuit population data are drawn from the Status Verification System (SVS) which is operated by NIHB. SVS data on First Nations clients are based on information provided by Crown-Indigenous Relations and Northern Affairs Canada. SVS data on Inuit clients are based on information provided by the Governments of the Northwest Territories and Nunavut, and Inuit organizations including the Inuvialuit Regional Corporation, Nunavut Tunngavik Incorporated and the Makivik Corporation.

Pharmacy and dental data

Two Indigenous Services Canada data systems provide information on the expenditures and utilization of the NIHB pharmacy and dental benefits. The Framework for Integrated Resource Management System (FIRMS) is the source of most of the expenditure data, while the Health Information and Claims Processing Services (HICPS) system provides detailed information on the utilization of the pharmacy (including MS&E) and dental benefit areas.

Medical transportation data

Medical transportation financial data are provided through FIRMS. 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 region uses its own system. Contribution agreement data are also collected, but in a limited manner. In some communities, MTRS is used to collect contribution agreement data, while other communities report data using spreadsheet templates, in-house data management systems or through paper reports.

The Medical Transportation Data Store (MTDS) serves 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.

Vision care, mental health counselling and other health care data

Financial data on the NIHB vision care, mental health counselling and other health care benefits are provided through FIRMS.

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Date modified:: 2020-05-20