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

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Section 1: Introduction

During 2017/18, the Non-Insured Health Benefits (NIHB) program of the First Nations and Inuit Health Branch (FNIHB) at Indigenous Services Canada provided 867,749 eligible First Nations and Inuit clients with access to a range of medically necessary health-related goods and services not otherwise provided through private insurance plans, provincial/territorial health or social programs.

The NIHB program covers the following medically necessary benefits:

Through the coverage of these benefits, Indigenous Services Canada supports First Nations and Inuit in reaching an overall health status that is comparable with other Canadians.

The NIHB program operates according to the following guiding principles:

Now in its twenty-fourth edition, the 2017/18 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:

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. A key commitment made in the Framework Agreement is the transfer of Federal Health Programs, including Non-Insured Health Benefits (NIHB), from Canada to the First Nations Health Authority (FNHA).

Between July 2, 2013 and October 1, 2013, the FNHA assumed responsibility for the design, planning, management and delivery of the Non-Insured Health Benefits Program to First Nations clients residing in the British Columbia Region. Indigenous Services Canada has established and implemented measures so that Inuit clients, and First Nations who are in British Columbia temporarily, will continue to access benefits through the federal NIHB Program.

As a transitional measure, Indigenous Services Canada has continued to provide claims processing and certain adjudication services for the pharmacy, dental and MS&E benefits to First Nations clients in British Columbia on behalf of the FNHA. This arrangement will be in place for a term of up to four years. During 2017/18, the NIHB program and the FNHA continued working together in support of ongoing capacity building and to prepare for the full transfer of the NIHB Program in British Columbia following the conclusion of this transition period.

Section 2: Client population

As of March 31, 2018, there were 867,749 First Nations and Inuit clients eligible to receive benefits under the NIHB Program. The NIHB client population decreased significantly in 2013/14 as a result of the creation of the First Nations Health Authority (FNHA). In a phased approach, between July and October 2013, the FNHA assumed the programs, services, and responsibilities formerly delivered by Indigenous Services Canada's First Nations and Inuit Health Branch (FNIHB) to First Nation clients residing in British Columbia. Of the 867,749 total eligible clients at the end of the 2017/18 fiscal year, 819,977 (94.5%) were First Nations clients while 47,772 (5.5%) were Inuit clients.

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

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

First Nations and Inuit population data are drawn from the Status Verification System (SVS) which is operated by FNIHB. 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.

Historically, the First Nations and Inuit population has a higher growth rate than the Canadian population as a whole. This is primarily because First Nations and Inuit have a higher birth rate compared to the overall Canadian population. In addition, amendments to the Indian Acthave meant that a greater numbers of individuals are able to claim or restore their status as registered Indians. The passage of Bill C-3, the Gender Equity in Indian Registration Act, which came into force on January 31, 2011, has given eligible grandchildren of women who lost status as a result of marrying non-Indian men, entitlement to become 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. As of March 31, 2018, a total of 34,346 clients had become eligible to receive benefits through the NIHB Program as a result of this legislation.

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. As of March 31, 2018, a total of 24,878 Qalipu clients were registered in the SVS and were eligible to receive benefits through the NIHB program.

Figure 2.1: Eligible client population by region: March 2018

The total number of NIHB-eligible clients at the end of March 2018 was 867,749, an increase of 1.7% from March 2017.

The Ontario region had the largest proportion of the eligible population, representing 24.2% of the national total, followed by the Manitoba Region at 18.0% and the Saskatchewan region at 17.6%.

Note that 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).

Source: SVS adapted by Business Support, Audit and Negotiations Division
Description of Figure 2.1: Eligible client population by region
Region Population
Atlantic 65,573
Quebec 72,151
Ontario 210,295
Manitoba 155,850
Saskatchewan 152,324
Alberta 123,812
B.C. 18,184
Yukon 7,604
N.W.T 26,877
Nunavut 35,079
Total 867,749

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

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

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

Region First Nations Inuit Total % Change
March/17 March/18 March/17 March/18 March/17 March/18 2017 to 2018
Atlantic 64,362 65,194 371 379 64,733 65,573 1.3%
Quebec 69,494 70,632 1,436 1,519 70,930 72,151 1.7%
Ontario 206,501 209,496 765 799 207,266 210,295 1.5%
Manitoba 152,667 155,634 207 216 152,874 155,850 1.9%
Saskatchewan 148,879 152,243 74 81 148,953 152,324 2.3%
Alberta 120,466 123,162 629 650 121,095 123,812 2.2%
B.C. 18,258 17,821 349 363 18,607 18,184 -2.3%
Yukon 7,375 7,485 115 119 7,490 7,604 1.5%
Northwest Territories 18,115 18,310 8,501 8,567 26,616 26,877 1.0%
Nunavut 0 0 34,524 35,079 34,524 35,079 1.6%
National 806,117 819,977 46,971 47,772 853,088 867,749 1.7%
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 6.4%, from 815,800 in March 2009 to 867,749 in March 2018.

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

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

Source: SVS adapted by Business Support, Audit and Negotiations Division
Description of Figure 2.3.1: Eligible client population: March 2009 to March 2018
Year Population
2009 815,800
2010 831,090
2011 846,024
2012 896,624
2013 926,044
2014 808,686
2015 824,033
2016 839,129
2017 853,088
2018 867,749

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

Eligible client population by region, March 2014 to March 2018

Region March/14 March/15 March/16 March/17 March/18
Atlantic 62,015 62,756 63,712 64,733 65,573
Quebec 66,819 68,274 69,758 70,930 72,151
Ontario 197,092 200,518 204,232 207,266 210,295
Manitoba 144,416 147,932 150,475 152,874 155,850
Saskatchewan 140,164 143,228 145,968 148,953 152,324
Alberta 113,590 115,886 118,170 121,095 123,812
B.C. 19,628 19,283 19,277 18,607 18,184
Yukon 7,138 7,402 7,456 7,490 7,604
Northwest Territories 25,434 25,587 26,367 26,616 26,877
Nunavut 32,390 33,167 33,714 34,524 35,079
Total 808,686 824,033 839,129 853,088 867,749
Annual % Change -12.7% 1.9% 1.8% 1.7% 1.7%
Source: SVS adapted by Business Support, Audit and Negotiations Division

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

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

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

Source: SVS and Statistics Canada Catalogue No. 91-002-XWE, Quarterly Demographic Statistics, adapted by Business Support, Audit and Negotiations Division
Description of Figure 2.4: Annual population growth, Canadian population and eligible client population: 2009 to 2018
Year 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
NIHB client Population 815,800 831,090 846,024 896,624 926,044 808,686 824,033 839,129 853,088 867,749
Growth rate 2.1% 1.9% 1.8% 6.0% 3.3% -12.7% 1.9% 1.8% 1.7% 1.7%
Canadian population 33,592,686 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
Growth rate 1.1% 1.3% 1.0% 1.2% 1.2% 1.1% 0.9% 1.2% 1.2% 1.0%

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

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

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

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

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

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

Region Atlantic Quebec Ontario Manitoba
Age group Male Female Total Male Female Total Male Female Total Male Female Total
0–4 1,416 1,369 2,785 1,839 1,677 3,516 4,646 4,448 9,094 5,540 5,252 10,792
5–9 2,118 2,109 4,227 2,563 2,441 5,004 7,343 7,232 14,575 8,308 8,002 16,310
10–14 2,686 2,489 5,175 2,712 2,474 5,186 7,911 7,418 15,329 8,174 7,977 16,151
15–19 2,652 2,662 5,314 2,558 2,514 5,072 8,007 7,803 15,810 7,466 7,140 14,606
20–24 2,841 2,813 5,654 2,903 2,818 5,721 9,007 8,700 17,707 7,584 7,253 14,837
25–29 2,858 2,746 5,604 2,962 2,841 5,803 8,878 8,634 17,512 7,175 7,192 14,367
30–34 2,425 2,370 4,795 2,414 2,583 4,997 7,717 7,551 15,268 5,836 5,575 11,411
35–39 2,239 2,276 4,515 2,328 2,254 4,582 6,915 7,289 14,204 4,876 4,739 9,615
40–44 2,099 2,147 4,246 2,140 2,228 4,368 6,666 6,688 13,354 4,536 4,459 8,995
45–49 2,303 2,302 4,605 2,294 2,415 4,709 6,885 7,212 14,097 4,424 4,673 9,097
50–54 2,145 2,291 4,436 2,364 2,708 5,072 7,016 7,298 14,314 4,146 4,325 8,471
55–59 1,897 2,195 4,092 2,339 2,530 4,869 6,407 7,291 13,698 3,355 3,634 6,989
60–64 1,547 1,891 3,438 1,779 2,326 4,105 4,980 6,120 11,100 2,332 2,721 5,053
65+ 2,889 3,798 6,687 3,694 5,453 9,147 9,837 14,396 24,233 3,943 5,213 9,156
Total 32,115 33,458 65,573 34,889 37,262 72,151 102,215 108,080 210,295 77,695 78,155 155,850
Average age 35 37 36 36 39 37 36 38 37 30 31 30
Region Saskatchewan Alberta B.C. Yukon
Age group Male Female Total Male Female Total Male Female Total Male Female Total
0–4 4,995 4,910 9,905 4,402 4,289 8,691 585 578 1,163 148 135 283
5–9 8,008 7,777 15,785 6,781 6,457 13,238 599 609 1,208 240 223 463
10–14 8,060 7,946 16,006 6,483 6,449 12,932 603 582 1,185 257 223 480
15–19 7,496 7,301 14,797 6,030 5,664 11,694 653 611 1,264 283 255 538
20–24 7,372 7,373 14,745 6,166 5,765 11,931 717 599 1,316 318 309 627
25–29 7,435 7,243 14,678 5,814 5,650 11,464 719 651 1,370 318 311 629
30–34 6,114 6,049 12,163 4,842 4,713 9,555 731 705 1,436 310 274 584
35–39 5,044 4,923 9,967 3,957 4,114 8,071 704 690 1,394 278 264 542
40–44 4,412 4,460 8,872 3,495 3,558 7,053 589 604 1,193 238 227 465
45–49 4,283 4,522 8,805 3,313 3,429 6,742 601 636 1,237 293 237 530
50–54 3,785 4,112 7,897 2,960 3,304 6,264 572 724 1,296 339 316 655
55–59 3,060 3,411 6,471 2,442 2,846 5,288 499 661 1,160 288 312 600
60–64 2,035 2,410 4,445 1,690 2,129 3,819 333 508 841 184 215 399
65+ 3,277 4,511 7,788 2,880 4,190 7,070 765 1,356 2,121 308 501 809
Total 75,376 76,948 152,324 61,255 62,557 123,812 8,670 9,514 18,184 3,802 3,802 7,604
Average age 29 30 30 29 31 30 35 39 37 37 39 38
Region Northwest Territories Nunavut Total
Age group Male Female Total Male Female Total Male Female Total
0–4 646 642 1,288 1,928 1,847 3,775 26,145 25,147 51,292
5–9 1,002 943 1,945 2,099 2,024 4,123 39,061 37,817 76,878
10–14 1,031 993 2,024 1,960 1,875 3,835 39,877 38,426 78,303
15–19 964 1,021 1,985 1,788 1,644 3,432 37,897 36,615 74,512
20–24 1,290 1,220 2,511 1,626 1,638 3,264 39,824 38,489 78,313
25–29 1,390 1,390 2,780 1,611 1,522 3,133 39,160 38,180 77,340
30–34 1,158 1,110 2,268 1,269 1,292 2,561 32,816 32,222 65,038
35–39 959 929 1,888 1,050 1,029 2,079 28,350 28,507 56,857
40–44 781 849 1,630 893 902 1,795 25,849 26,122 51,971
45–49 964 963 1,927 914 924 1,838 26,274 27,313 53,587
50–54 846 914 1,760 831 863 1,694 25,004 26,855 51,859
55–59 688 837 1,525 562 599 1,161 21,537 24,316 45,853
60–64 440 602 1,042 385 407 792 15,705 19,329 35,034
65+ 1,029 1,276 2,305 763 834 1,597 29,385 41,528 70,913
Total 13,188 13,689 26,877 17,679 17,400 35,079 426,884 440,866 867,750
Average age 34 35 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% of the same age group in the Canadian population. The average age of First Nations and Inuit clients is 33 compared to 41 years of age for the Canadian population.

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

Source: SVS and Statistics Canada CANSIM table 051-0001, Population by Age and Sex Group, adapted by Business Support, Audit and Negotiations Division
Description of Figure 2.6.1: Proportion of Canadian population and of the First Nations and Inuit (FN&I) client population by age group
Age group Canadian population, July 2017 FN&I population, March 2018
0–9 10.8% 14.8%
10–19 10.8% 17.6%
20–29 13.8% 17.9%
30–39 13.8% 14.0%
40–49 13.0% 12.2%
50–59 14.5% 11.3%
60+ 23.3% 12.2%
Total 100.0% 100.0%

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

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

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

Source: SVS adapted by Business Support, Audit and Negotiations Division
Description of Figure 2.6.2: Proportion of eligible First Nations and Inuit client population by age group
Age Group March 2014 March 2018
0–9 16.3% 14.8%
10–19 18.4% 17.6%
20–29 17.8% 17.9%
30–39 13.6% 14.0%
40–49 13.0% 12.2%
50–59 10.5% 11.3%
60+ 10.4% 12.2%
Total 100.0% 100.0%

Section 3: NIHB program benefit expenditures

Figure 3.1: NIHB program sustainability 2017/18

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

Factors influencing NIHB program expenditures
Client base Market forces Clinical evidence
  • 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

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

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

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

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 3.2: NIHB expenditures by benefit ($ millions) : 2017/18
Benefit Total expenditures 2017/18 Proportion of total exp. 2017/18
Medical transportation $459.5 35.1%
Pharmacy and MS&E $523.0 39.9%
Dental $249.0 19.0%
Vision care $33.6 2.6%
Mental health $33.1 2.5%
Other health care $11.1 0.9%
Total expenditures $1,309.2 100.0%

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

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

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

Benefit Total expenditures ($ 000's) 2016/17 Total ($ 000's) 2017/18 % Change from 2016/17
Medical transportation $417,035 $459,505 10.2%
Pharmacy and MS&E $494,520 $522,957 5.8%
Dental $235,831 $248,992 5.6%
Vision care $32,370 $33,578 3.7%
Mental health $21,728 $33,066 52.2%
Other $5,974 $11,143 86.5%
Total expenditures $1,207,458 $1,309,240 8.4%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

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

Region Medical transportation Pharmacy Dental Vision care Mental health Other health care Total
Atlantic $11,147 $33,021 $10,610 $3,632 $1,204 $427 $60,040
Quebec $23,918 $48,390 $17,961 $1,819 $1,861 $260 $94,210
Ontario $86,091 $99,550 $52,055 $6,848 $6,028 $375 $250,947
Manitoba $155,370 $98,046 $41,949 $4,479 $8,124 $240 $308,208
Saskatchewan $64,363 $119,326 $50,635 $6,905 $6,559 $210 $247,997
Alberta $51,187 $79,343 $47,637 $6,764 $7,761 $291 $192,983
North $67,413 $29,373 $25,141 $3,131 $1,528 $346 $126,933
Headquarters $16 $15,816 $2,770 $0 $0 $8,994 $27,595
Total $459,505 $522,957 $248,992 $33,578 $33,066 $11,143 $1,309,240
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

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

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

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

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

Region Medical Transportation Pharmacy Dental Vision care Mental health Other health care Proportion of NIHB expenditure Proportion of NIHB population
Atlantic 2.4% 6.3% 4.3% 10.8% 3.6% 3.8% 4.6% 7.6%
Quebec 5.2% 9.3% 7.2% 5.4% 5.6% 2.3% 7.2% 8.3%
Ontario 18.7% 19.0% 20.9% 20.4% 18.2% 3.4% 19.2% 24.2%
Manitoba 33.8% 18.7% 16.8% 13.3% 24.6% 2.2% 23.5% 18.0%
Saskatchewan 14.0% 22.8% 20.3% 20.6% 19.8% 1.9% 18.9% 17.6%
Alberta 11.1% 15.2% 19.1% 20.1% 23.5% 2.6% 14.7% 14.3%
North 14.7% 5.6% 10.1% 9.3% 4.6% 3.1% 9.7% 8.0%
Headquarters 0.0% 3.0% 1.1% 0.0% 0.0% 80.7% 2.1% 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: 2017/18

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

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

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

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

Region Medical transportation Pharmacy Dental Vision care Mental health Other health care Total
Atlantic 18.6% 55.0% 17.7% 6.0% 2.0% 0.7% 100%
Quebec 25.4% 51.4% 19.1% 1.9% 2.0% 0.3% 100%
Ontario 34.3% 39.7% 20.7% 2.7% 2.4% 0.1% 100%
Manitoba 50.4% 31.8% 13.6% 1.5% 2.6% 0.1% 100%
Saskatchewan 26.0% 48.1% 20.4% 2.8% 2.6% 0.1% 100%
Alberta 26.5% 41.1% 24.7% 3.5% 4.0% 0.2% 100%
North 53.1% 23.1% 19.8% 2.5% 1.2% 0.3% 100%
Headquarters 0.1% 57.3% 10.0% 0.0% 0.0% 32.6% 100%
National 35.1% 39.9% 19.0% 2.6% 2.5% 0.9% 100%
Source: FIRMS and SVS adapted by Business Support, Audit and Negotiations Division

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

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

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

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

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

NIHB annual expenditures ($ millions) and percentage change

Source: FIRMS and SVS adapted by Business Support, Audit and Negotiations Division
Description of Figure 3.7: NIHB annual expenditures ($ Millions) and percentage change 2008/09 to 2017/18
FY 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Annual Expenditures ($M) $940 $989 $1,028 $1,074 $1,105 $1,026 $1,031 $1,101 $1,207 $1,309
Annual % Change 4.7% 5.2% 3.9% 4.5% 2.8% -7.1% 0.5% 6.7% 9.7% 8.4%

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

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

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

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

Benefit 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Medical transportation $280,446 $301,673 $311,760 $333,304 $351,424 $352,036 $357,963 $375,904 $417,035 $459,505
Pharmacy $418,968 $435,097 $440,768 $459,359 $462,699 $416,165 $422,350 $456,430 $494,520 $522,957
Dental $176,382 $194,918 $215,796 $219,057 $222,706 $207,179 $201,886 $217,109 $235,831 $248,992
Vision care $26,577 $27,779 $29,219 $29,780 $32,167 $31,459 $29,704 $30,017 $32,370 $33,578
Mental health $11,380 $12,516 $12,083 $12,936 $14,337 $14,152 $15,581 $16,193 $21,728 $33,066
Other $26,430 $17,110 $18,428 $19,868 $21,257 $5,406 $4,005 $4,858 $5,974 $11,143
Total $940,182 $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
Annual % change 4.7% 5.2% 3.9% 4.5% 2.8% -7.1% 0.5% 6.7% 9.7% 8.4%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

Source: FIRMS and SVS adapted by Business Support, Audit and Negotiations Divisions
Description of Figure 3.9: Per capita NIHB expenditures by region: 2017/18
Atlantic Quebec Ontario Manitoba Saskatchewan Alberta North National
NIHB Per capita expenditures $916 $1,306 $1,193 $1,978 $1,628 $1,559 $1,825 $1,477

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). Coverage of pharmacy benefits and services are based on professional judgment, consistent with current best practices of health services delivery and evidence-based standards of care, with particular emphasis on client safety, intended to contribute to better health outcomes in a fair, equitable and cost-effective manner, while recognizing the unique health needs of First Nations and Inuit clients. Policies to achieve this objective have and will continue to be adopted by the NIHB program.

In addition, a limited but comprehensive 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. Clients must obtain a prescription from a prescriber that is recognized by the NIHB Program for MS&E items, and have the prescription filled at an approved provider. Items covered under the MS&E benefit 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 2017/18, the NIHB program paid for pharmacy and MS&E claims made by a total of 529,816 First Nations and Inuit clients. The total expenditure for these claims was $523.0 million or 39.9% 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): 2017/18

In 2017/18, NIHB pharmacy and MS&E benefits totalled $523.0 million or 39.9% of total NIHB expenditures.

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 $381.7 million or 73.0% of all NIHB pharmacy expenditures, followed by over-the-counter (OTC) drugs and controlled access drugs (CAD) which totalled $73.2 million or 14.0%. Medical supplies and equipment (MS&E) items paid through HICPS was the third largest component in the pharmacy benefit at $39.4 million or 7.5%.

Drugs and MS&E (regional), at $1.6 million or 0.3% 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 $11.3 million or 2.2% 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 $15.8 million or 3.0% in 2017/18. Included in this total are headquarters contract and claims processing expenditures related to the HICPS system.

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 4.1: Distribution of NIHB pharmacy and MS&E expenditures ($ Millions): 2017/18
Million $ Proportion
Prescription drugs (HICPS) $381.7 73.0%
OTC/CAD drugs (HICPS) $73.2 14.0%
Other costs $15.8 3.0%
Contribution agreements $11.3 2.2%
Drugs and MS&E (regional) $1.6 0.3%
MS&E (HICPS) $39.4 7.5%
Total $523.0 100.0%

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

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

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

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

Region Operating Total operating costs Total contribution costs Total costs
Prescription drugs OTC/CAD drugs Drugs/MS&E regional Medical supplies Medical equipment Other costs
Atlantic $23,980 $5,760 $18 $918 $2,345 $0 $33,021 $0 $33,021
Quebec $37,508 $8,680 $39 $751 $1,412 $0 $48,390 $0 $48,390
Ontario $74,131 $14,884 $1 $1,366 $4,043 $0 $94,425 $5,125 $99,550
Manitoba $74,740 $16,320 $0 $2,181 $4,804 $0 $98,046 $0 $98,046
Saskatchewan $94,283 $14,437 $1,137 $2,851 $6,575 $0 $119,284 $42 $119,326
Alberta $55,363 $9,740 $0 $2,286 $5,974 $0 $73,364 $5,979 $79,343
North $21,582 $3,378 $394 $1,086 $2,737 $0 $29,178 $195 $29,373
Headquarters $0 $0 $0 $35 $85 $15,696 $15,816 $0 $15,816
Total $381,664 $73,217 $1,589 $11,474 $27,976 $15,696 $511,615 $11,341 $522,957
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

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

Figure 4.3.1: Annual NIHB pharmacy expenditures and percentage change

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 4.3.1: Annual NIHB pharmacy expenditures and percentage change
Year Total pharmacy expenditures ($M) Annual percentage change
2013/14 $416.2 -10.1%
2014/15 $422.3 1.5%
2015/16 $456.4 8.1%
2016/17 $494.5 8.3%
2017/18 $523.0 5.8%

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

NIHB Pharmacy Expenditures ($ 000's)
Region 2013/14 2014/15 2015/16 2016/17 2017/18
Atlantic $27,517 $28,398 $30,064 $31,899 $33,021
Quebec $40,825 $42,581 $44,206 $47,444 $48,390
Ontario $78,510 $81,982 $88,872 $94,101 $99,550
Manitoba $77,034 $81,059 $87,997 $94,757 $98,046
Saskatchewan $78,546 $83,361 $91,170 $104,082 $119,326
Alberta $58,777 $64,087 $69,992 $77,265 $79,343
North $23,144 $23,941 $27,408 $28,488 $29,373
Headquarters $16,874 $16,678 $16,546 $16,302 $15,816
Total $416,165 $422,350 $456,430 $494,520 $522,957
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

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

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

Source: FIRMS and SVS adapted by Business Support, Audit and Negotiations Division
Description of Figure 4.4: Per capita NIHB pharmacy expenditures by region: 2017/18
Region Per capita
Atlantic $504
Quebec $671
Ontario $473
Manitoba $629
Saskatchewan $783
Alberta $641
North $422
National $584

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

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

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

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

Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division
Description of Figure 4.5: NIHB pharmacy operating expenditures per claimant by region: 2017/18
Region Per claimant expenditure (000's)
Atlantic $798
Quebec $1,098
Ontario $842
Manitoba $939
Sask $1,124
Alberta $907
North $781
National $933

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

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

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

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

Region Pharmacy utilization
2013/14 2014/15 2015/16 2016/17 2017/18
Atlantic 62% 62% 62% 63% 63%
Quebec 59% 60% 60% 60% 61%
Ontario 54% 54% 54% 54% 53%
Manitoba 66% 66% 67% 67% 67%
Saskatchewan 70% 70% 70% 70% 69%
Alberta 66% 66% 66% 66% 65%
Yukon 59% 60% 60% 60% 60%
Northwest Territories 53% 54% 54% 55% 55%
Nunavut 46% 47% 46% 47% 50%
National 61% 61% 61% 61% 61%
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

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

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

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

NIHB pharmacy claimants by age group, gender and region
Region Atlantic Quebec Ontario Manitoba
Age group Male Female Total Male Female Total Male Female Total Male Female Total
0–4 856 831 1,687 1,081 982 2,063 1,841 1,763 3,604 3,236 3,081 6,317
5–9 1,200 1,261 2,461 1,348 1,375 2,723 2,874 2,888 5,762 4,474 4,551 9,025
10–14 1,267 1,253 2,520 1,222 1,313 2,535 2,760 2,817 5,577 4,037 4,294 8,331
15–19 1,275 1,805 3,080 1,144 1,787 2,931 2,979 4,380 7,359 3,565 4,965 8,530
20–24 1,298 2,187 3,485 1,202 2,090 3,292 3,213 5,666 8,879 3,750 5,781 9,531
25–29 1,348 2,066 3,414 1,258 2,072 3,330 3,636 5,846 9,482 3,850 5,867 9,717
30–34 1,168 1,693 2,861 1,079 1,878 2,957 3,561 5,050 8,611 3,484 4,690 8,174
35–39 1,136 1,580 2,716 1,179 1,578 2,757 3,390 4,875 8,265 3,105 3,921 7,026
40–44 1,188 1,530 2,718 1,148 1,597 2,745 3,473 4,437 7,910 3,065 3,741 6,806
45–49 1,415 1,664 3,079 1,338 1,663 3,001 3,750 4,742 8,492 3,189 3,967 7,156
50–54 1,373 1,651 3,024 1,435 1,959 3,394 3,985 4,929 8,914 3,139 3,664 6,803
55–59 1,275 1,620 2,895 1,518 1,835 3,353 3,854 4,912 8,766 2,669 3,147 5,816
60–64 1,135 1,481 2,616 1,254 1,678 2,932 3,098 4,064 7,162 1,913 2,371 4,284
65+ 2,075 2,707 4,782 2,422 3,606 6,028 5,330 8,018 13,348 2,930 3,973 6,903
Total 18,009 23,329 41,338 18,628 25,413 44,041 47,744 64,387 112,131 46,406 58,013 104,419
Average age 38 38 38 39 40 39 39 40 40 32 33 33
Region Saskatchewan Alberta North Total
Age group Male Female Total Male Female Total Male Female Total Male Female Total
0–4 3,203 3,059 6,262 2,650 2,543 5,193 1,231 1,135 2,366 14,258 13,524 27,782
5–9 4,596 4,926 9,522 3,814 3,807 7,621 1,233 1,193 2,426 19,671 20,139 39,810
10–14 4,420 4,726 9,146 3,289 3,549 6,838 993 1,035 2,028 18,134 19,121 37,255
15–19 3,796 5,343 9,139 3,066 3,905 6,971 967 1,735 2,702 16,925 24,148 41,073
20–24 3,701 6,008 9,709 3,014 4,346 7,360 1,084 2,176 3,260 17,417 28,525 45,942
25–29 3,984 6,054 10,038 3,120 4,380 7,500 1,153 2,238 3,391 18,526 28,850 47,376
30–34 3,512 5,148 8,660 2,828 3,743 6,571 1,096 1,898 2,994 16,897 24,395 41,292
35–39 3,193 4,142 7,335 2,529 3,257 5,786 998 1,570 2,568 15,693 21,201 36,894
40–44 2,965 3,763 6,728 2,326 2,800 5,126 904 1,367 2,271 15,203 19,460 34,663
45–49 3,068 3,803 6,871 2,310 2,712 5,022 1,217 1,535 2,752 16,468 20,322 36,790
50–54 2,839 3,490 6,329 2,121 2,645 4,766 1,147 1,536 2,683 16,207 20,168 36,375
55–59 2,400 2,938 5,338 1,803 2,260 4,063 944 1,335 2,279 14,579 18,250 32,829
60–64 1,641 2,088 3,729 1,265 1,719 2,984 690 939 1,629 11,068 14,471 25,539
65+ 2,628 3,636 6,264 2,049 3,011 5,060 1,529 1,975 3,504 19,054 27,142 46,196
Total 45,946 59,124 105,070 36,184 44,677 80,861 15,186 21,667 36,853 230,100 299,716 529,816
Average age 31 32 32 31 33 32 35 36 36 34 36 35
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: 2017/18

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

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

Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division
Description of Figure 4.8: Distribution of eligible NIHB population, pharmacy expenditures and pharmacy incidence by age group: 2017/18
Age Eligible clients Incidence Expenditures
0–4 5.9% 0.9% 1.1%
5–9 8.9% 1.1% 1.7%
10–14 9.0% 1.3% 2.3%
15–19 8.6% 1.9% 2.6%
20–24 9.0% 3.5% 4.1%
25–29 8.9% 6.1% 6.1%
30–34 7.5% 7.2% 7.2%
35–39 6.6% 7.5% 7.7%
40–44 6.0% 7.9% 8.3%
45–49 6.2% 9.1% 9.6%
50–54 6.0% 10.1% 11.5%
55–59 5.3% 10.4% 11.0%
60–64 4.0% 9.5% 9.7%
65+ 8.2% 23.6% 17.0%
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 2017/18 the average cost per child aged 0 to 4 years was $196. The cost increased steadily for every age group, with claimants aged 35–39 having an average cost of $861, comparable to the total average claimant cost of $933. Claimants aged 60–64 years had the highest cost per claimant with an average of $1,878 for all pharmaceutical services received throughout the fiscal year.

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

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

Therapeutic classification Claimants % Change from 2016/17 Examples of product in the therapeutic class
Non-Steroidal Anti-Inflammatory Drugs (NSAID) 201,511 0.5% Voltaren (Diclofenac)
Penicillins 160,477 -0.9% Amoxil (Amoxicillin)
Miscellaneous Analgesics and Antipyretics 122,558 4.0% Tylenol (Acetaminophen)
Opioid Agonists 114,450 -5.3% Statex (Morphine Sulphate)
Antidepressants 95,168 5.3% Effexor (Venlafaxine)
Proton Pump Inhibitors 90,031 1.0% Losec (Omeprazole)
Beta-Adrenergic Agonists 87,279 0.5% Ventolin (Salbutamol)
SMMA — Anti-inflammatory Agents 78,355 -1.8% Cortate Cream (Hydrocortisone)
Cephalosporins 74,956 -0.8% Keflex (Cephalexin)
Adrenals 68,927 -1.6% Flovent (Fluticasone Propionate)
Source: HICPS adapted by Business Support, Audit and Negotiations Division

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

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

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

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

Source: HICPS adapted by Business Support, Audit and Negotiations Division
Description of Figure 4.10: NIHB prescription drug claims incidence by pharmacologic therapeutic class : 2017/18
Sub-benefit % of Claims
Central nervous system agents 34.2%
Cardiovascular drugs 20.5%
Hormones and synthetic substitutes 13.6%
Anti-infective agents 7.5%
Gastrointestinal drugs 7.3%
Autonomic drugs 2.7%
Electrolytic / caloric / water balance 2.1%
Skin and mucous membrane agents 1.8%
All others 10.2%
Total 100.0%

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

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

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

Source: HICPS adapted by Business Support, Audit and Negotiations Division
Description of Figure 4.11: NIHB over-the-counter drugs (including controlled access drugs — CAD) claims incidence by pharmacologic therapeutic class: 2017/18
Pharmacologic Therapeutic Class % of Claims
Vitamins 28.1%
Central nervous system agents 25.8%
Gastrointestinal drugs 7.9%
Diabetic devices 7.3%
Blood formation and coagulation 6.8%
Hormones and synthetic substitutes 6.0%
Skin and mucous membrane agents 4.2%
Diagnostic agents 4.1%
All others 9.8%
total 100.0%

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

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

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

Source: HICPS adapted by Business Support, Audit and Negotiations Division
Description of Figure 4.12: NIHB medical supplies by category and claims incidence: 2017/18
Sub-benefit % of claims
Incontinence supplies 25.4%
Hearing aid supplies 22.9%
Wound care supplies 22.8%
Ostomy supplies 6.7%
Oxygen supplies 4.9%
Bandages 4.4%
Catheter supplies 2.8%
Enteral nutrition supplies 2.0%
All others 8.1%

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

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

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

Source: HICPS adapted by Business Support, Audit and Negotiations Division
Description of Figure 4.13: NIHB medical equipment by category and claims incidence: 2017/18
Sub-Benefit % of Claims
Oxygen Equipment 24.5%
Hearing Aids 22.6%
Limb Orthoses 8.7%
Walking Aids 7.4%
Custom Made Footwear 6.9%
Wheelchairs and Accessories 9.2%
Toileting Aids 4.6%
Compression Garments 2.9%
Bathing Aids 2.7%
All Others 10.6%

Section 5: NIHB dental expenditure and utilization data

The NIHB Program recognizes the importance of good oral health in contributing to the overall health of First Nations and Inuit clients, and covers a broad range of dental services in an effort to address the unique oral health needs of this client population.

In 2017/18, a total of 310,247 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 $249.0 million or 19.0% of total NIHB expenditures. The dental benefit accounts for the third largest Program expenditure.

Coverage for NIHB Dental benefits is based on scientific evidence and current standards of care, and takes into consideration the client's current oral health status and treatment history and accumulated scientific research. Dental services must be provided by a licensed dental professional, such as a dentist, dental specialist, or denturist. 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 policies and criteria, as described in the NIHB Dental Benefits Guide.

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

  • 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 to correct significant irregularities in teeth and jaws
  • adjunctive services such as general anaesthesia and sedation.

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

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

The next highest component was contribution agreements, which accounted for $12.3 million or 4.9% of total dental expenditures. Contribution allocations were used to fund the provision of dental benefits through agreements such as those with the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta.

Expenditures for contract dentists providing services to clients in remote communities totalled $8.2 million or 3.3% of total costs.

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

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 5.1: Distribution of NIHB dental expenditures ($ millions): 2017/18
Million $ Proportion
Fee-for-service (HICPS) $225.7 90.6%
Contract dentists $8.2 3.3%
Other costs $2.8 1.1%
Contribution agreements $12.3 4.9%
Fee-for-service (HICPS) $249.0 100.0%

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

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

Region Operating Total operating costs Total contribution costs Total costs
Fee-for-service Contract dentists Other costs
Atlantic $10,610 $0 $0 $10,610 - $10,610
Quebec $17,843 $0 $0 $17,843 $119 $17,961
Ontario $43,275 $2,431 $46 $45,751 $6,350 $52,101
Manitoba $36,572 $5,377 $0 $41,949 $0 $41,949
Saskatchewan $47,397 $0 $0 $47,397 $3,238 $50,635
Alberta $45,207 $27 $0 $45,234 $2,402 $47,637
North $24,605 $354 $0 $24,959 $183 $25,141
Headquarters - - $2,770 $2,770 - $2,770
Total $225,742 $8,188 $2,816 $236,746 $12,291 $249,038
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

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

Figure 5.3.1: NIHB Dental expenditures and annual percentage change

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 5.3.1: NIHB Dental expenditures and annual percentage change
Year Expenditures (000s) Percentage change
2013/14 $207.2 -7%
2014/15 $201.9 -2.6%
2015/16 $217.1 7.5%
2016/17 $235.8 8.6%
2017/18 $249.0 5.6%

Figure 5.3.2: NIHB dental expenditures by region

NIHB dental expenditures ($ 000's)
Region 2013/14 2014/15 2015/16 2016/17 2017/18
Atlantic $8,609 $8,238 $8,846 $9,593 $10,610
Quebec $15,216 $15,799 $16,641 $17,569 $17,961
Ontario $43,972 $46,759 $49,903 $52,105 $52,101
Manitoba $33,649 $33,527 $36,764 $39,986 $41,949
Saskatchewan $36,399 $37,679 $41,028 $47,321 $50,635
Alberta $34,928 $35,974 $39,753 $44,315 $47,637
North $20,415 $20,413 $20,936 $20,936 $25,141
Headquarters $2,978 $2,943 $2,920 $2,877 $2,770
Total $207,179 $201,886 $217,109 $235,831 $249,038
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

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

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

Source: SVS and FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 5.4: Per capita NIHB dental expenditures by region: 2017/18
Region Per capita
Atlantic $162
Quebec $249
Ontario $248
Manitoba $269
Saskatchewan $332
Alberta $385
North $361
National $255

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

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

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

Source: FIRMS and HICPS adapted by Business Support, Audit and Negotiations Division
Description of Figure 5.5: NIHB dental fee-for-service expenditures per claimant by region: 2017/18
Region Per claimant
Atlantic $469
Quebec $563
Ontario $647
Manitoba $720
Saskatchewan $819
Alberta $903
North $904
National $728

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

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

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

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

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

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

Region Dental utilization NIHB dental
utilization
last two years 2016/18
2013/14 2014/15 2015/16 2016/17 2017/18
Atlantic 34% 33% 34% 34% 34% 45%
Quebec 45% 45% 45% 44% 44% 55%
Ontario 32% 32% 32% 32% 32% 42%
Manitoba 32% 32% 32% 33% 33% 46%
Saskatchewan 36% 36% 36% 38% 38% 53%
Alberta 41% 39% 40% 41% 40% 55%
Yukon 39% 37% 36% 36% 36% 50%
Northwest Territories 43% 41% 40% 41% 41% 56%
Nunavut 43% 42% 40% 38% 38% 54%
National 36% 35% 35% 36% 36% 48%
Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

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

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

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

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

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

Region Atlantic Quebec Ontario Manitoba
Age group Male Female Total Male Female Total Male Female Total Male Female Total
0–4 155 159 314 392 397 789 969 968 1,937 1,398 1,341 2,739
5–9 621 681 1,302 1,607 1,592 3,199 3,200 3,309 6,509 3,119 3,053 6,172
10–14 855 870 1,725 1,676 1,639 3,315 3,353 3,355 6,708 2,949 3,340 6,289
15–19 1,011 1,191 2,202 1,172 1,399 2,571 2,783 3,106 5,889 2,381 2,991 5,372
20–24 860 1,168 2,028 1,036 1,429 2,465 2,292 3,059 5,351 1,859 2,719 4,578
25–29 859 1,165 2,024 1,058 1,393 2,451 2,192 3,085 5,277 1,833 2,675 4,508
30–34 734 978 1,712 845 1,217 2,062 1,908 2,665 4,573 1,461 2,137 3,598
35–39 682 905 1,587 845 1,121 1,966 1,716 2,541 4,257 1,305 1,722 3,027
40–44 635 868 1,503 856 1,133 1,989 1,689 2,287 3,976 1,253 1,648 2,901
45–49 749 922 1,671 937 1,157 2,094 1,776 2,410 4,186 1,211 1,703 2,914
50–54 691 928 1,619 998 1,298 2,296 1,873 2,568 4,441 1,200 1,568 2,768
55–59 622 918 1,540 929 1,172 2,101 1,752 2,529 4,281 961 1,344 2,305
60–64 539 811 1,350 679 991 1,670 1,395 2,164 3,559 656 917 1,573
65+ 860 1,170 2,030 1,126 1,607 2,733 2,226 3,696 5,922 809 1,209 2,018
Total 9,873 12,734 22,607 14,156 17,545 31,701 29,124 37,742 66,866 22,395 28,367 50,762
Average age 36 38 37 34 36 35 33 36 35 28 30 29
Region Saskatchewan Alberta North Total
Age group Male Female Total Male Female Total Male Female Total Male Female Total
0–4 1,384 1,425 2,809 1,351 1,347 2,698 823 842 1,665 6,540 6,567 13,107
5–9 3,695 3,924 7,619 3,632 3,611 7,243 1,324 1,382 2,706 17,349 17,714 35,063
10–14 3,591 3,901 7,492 3,290 3,564 6,854 1,278 1,540 2,818 17,143 18,369 35,512
15–19 2,559 3,265 5,824 2,475 2,916 5,391 1,098 1,575 2,673 13,615 16,603 30,218
20–24 1,941 3,204 5,145 1,790 2,429 4,219 1,143 1,635 2,778 11,036 15,789 26,825
25–29 2,130 3,224 5,354 1,701 2,445 4,146 1,130 1,663 2,793 11,021 15,818 26,839
30–34 1,818 2,628 4,446 1,482 2,106 3,588 901 1,347 2,248 9,253 13,252 22,505
35–39 1,567 2,112 3,679 1,251 1,802 3,053 724 1,015 1,739 8,184 11,367 19,551
40–44 1,390 1,901 3,291 1,116 1,636 2,752 632 873 1,505 7,653 10,468 18,121
45–49 1,474 1,997 3,471 1,101 1,497 2,598 722 899 1,621 8,063 10,709 18,772
50–54 1,304 1,723 3,027 1,052 1,462 2,514 638 826 1,464 7,837 10,528 18,365
55–59 1,018 1,307 2,325 813 1,174 1,987 481 708 1,189 6,637 9,240 15,877
60–64 635 880 1,515 557 836 1,393 294 464 758 4,798 7,131 11,929
65+ 749 1,113 1,862 624 989 1,613 530 725 1,255 6,966 10,597 17,563
Total 25,255 32,604 57,859 22,235 27,814 50,049 11,718 15,494 27,212 136,095 174,152 310,247
Average age 27 29 28 26 29 27 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: 2017/18

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

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

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

Fee-for-service top 5 dental sub-benefits ($ Millions) and percentage change
Dental sub-benefit 2016/17 2017/18 % change from 2016/17
Restorative services $94.9 $99.0 4.3%
Diagnostic services $27.9 $29.1 4.2%
Preventative services $26.3 $28.0 6.8%
Oral surgery $24.3 $24.6 1.2%
Endodontic services $13.3 $15.3 15.0%
Fee-for-service top 5 dental procedures ($ Millions) and percentage change
Dental procedure 2016/17 2017/18 % change from 2016/17
Composite restorations $80.1 $84.3 5.3%
Scaling $20.2 $21.7 7.3%
Extractions $17.0 $17.4 2.3%
Root canal therapy $11.3 $13.4 18.4%
Intraoral radiographs $9.6 $10.1 5.9%
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: 2017/18

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

The ratio of incidence to expenditures is relatively consistent across most age groupings; however, there are notable exceptions. For children aged 0 to 9, a larger number of low-cost procedures (e.g., low-cost restorative procedures such as fillings) are provided, so this group accounts for 25.2% of claims, but only 17.7% of expenditures.

Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division
Description of Figure 5.9: Distribution of eligible NIHB population, dental expenditures and incidence by age group: 2017/18
Age Eligible clients Incidence Expenditures
0–4 51,292 5.9% 276,069 12.4% $19,007,938.19 8.5%
5–9 76,878 8.9% 283,398 12.8% $20,593,673.68 9.2%
10–14 78,303 9.0% 111,415 5.0% $11,046,306.18 4.9%
15–19 74,511 8.6% 233,663 10.5% $24,749,879.24 11.1%
20–24 78,313 9.0% 194,361 8.8% $22,891,153.31 10.2%
25–29 77,340 8.9% 191,461 8.6% $21,993,672.85 9.8%
30–34 65,038 7.5% 155,871 7.0% $17,410,668.20 7.8%
35–39 56,857 6.6% 130,448 5.9% $14,270,088 6.4%
40–44 51,971 6.0% 120,828 5.4% $13,046,910 5.8%
45–49 53,587 6.2% 124,698 5.6% $13,682,377 6.1%
50–54 51,859 6.0% 121,277 5.5% $13,414,124 6.0%
55–59 45,853 5.3% 101,199 4.6% $11,244,625 5.0%
60–64 35,034 4.0% 72,666 3.3% $8,138,982 3.6%
65+ 70,913 8.2% 101,259 4.6% $11,922,001 5.3%
Total 867,749 100.0% 2,218,613 100.0% $223,412,402 100.0%

Section 6: NIHB Medical transportation expenditure and utilization data

In 2017/18, Non-Insured Health Benefits Medical Transportation expenditures amounted to $459.5 million or 35.1% of total NIHB expenditures. The medical transportation benefit is the second largest program expenditure.

NIHB medical transportation benefits are needs driven and funded in accordance with the policies set out in the NIHB Medical Transportation Policy Framework to assist eligible clients to access medically necessary health services that cannot be obtained on reserve or in 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 (e.g., 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) to travel with a client, or so that a family member or caregiver can accompany a client who needs assistance.

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 enhance 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): 2017/18

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

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

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

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

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 6.1: Distribution of NIHB medical transportation expenditures ($ Millions): 2017/18
Expenditure type Expenditure ($M) %
Scheduled flights $85.1 18.5%
Living expenses $59.7 13.0%
Land ambulance $49.7 10.8%
Air ambulance $44.4 9.7%
Land & water $21.2 4.6%
Chartered flights $8.3 1.8%
Contribution agreements $191.1 41.6%
Total $459.5 100.0%

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

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

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

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

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

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

Figure 6.2.1: NIHB Medical transportation expenditures and annual percentage change

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 6.2.1: NIHB Medical transportation expenditures and annual percentage change
Year Expenditure ($M) Annual percentage change
2013/14 $352.0 0.2%
2014/15 $358.0 1.7%
2015/16 $375.9 5.0%
2016/17 $417.0 10.9%
2017/18 $459.5 10.2%

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

NIHB medical transportation expenditures ($ 000's)
Region 2013/14 2014/15 2015/16 2016/17 2017/18
Atlantic $6,916 $7,419 $8,380 $9,277 $11,147
Quebec $21,945 $23,506 $23,687 $23,501 $23,918
Ontario $62,865 $65,781 $67,772 $74,890 $86,091
Manitoba $111,016 $115,705 $125,308 $147,167 $155,370
Saskatchewan $47,180 $51,543 $53,566 $58,902 $64,363
Alberta $41,451 $45,756 $46,252 $48,157 $51,187
North $44,703 $48,246 $50,940 $55,125 $67,413
Total $352,036 $357,963 $375,904 $417,019 $459,489
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

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

In 2017/18, the Manitoba region had the highest overall NIHB medical transportation expenditure at $155.4 million, primarily as a result of air transportation which totalled $81.4 million. High medical transportation costs in the region reflect in part the large number of First Nations clients living in remote or fly-in only northern communities.

The Ontario region represented the second highest medical transportation expenditure total in 2017/18 at $86.1 million. The Northern region and Saskatchewan followed at $67.4 million and $64.4 million, respectively.

Type Atlantic Quebec Ontario Manitoba Saskatchewan Alberta North Total
Scheduled flights $1,767 $210 $30,127 $41,873 $8,136 $1,650 $1,291 $85,054
Air ambulance $30 $114 $176 $35,151 $5,015 $1,635 $2,261 $44,382
Chartered flights $0 $0 $748 $4,395 $996 $2,148 $1 $8,287
Land ambulance $558 $191 $867 $15,598 $18,918 $13,550 $2 $49,684
Land & water $1,163 $88 $3,742 $4,881 $8,256 $2,265 $839 $21,234
Living expenses $791 $22 $23,536 $22,584 $6,507 $4,609 $1,651 $59,700
Total operating $4,309 $625 $59,196 $124,481 $47,828 $25,858 $6,044 $268,341
Total contributions $6,838 $23,293 $26,895 $30,889 $16,534 $25,329 $61,369 $191,148
Total $11,147 $23,918 $86,091 $155,370 $64,363 $51,187 $67,413 $459,489
% Change from 2016/17 20.2% 1.8% 15.0% 5.6% 9.3% 6.3% 22.3% 10.2%
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

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

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

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 6.4: NIHB medical transportation contribution and operating expenditures by region ($ Millions): 2017/18
($ 000 of dollars)
Type Atlantic Quebec Ontario Manitoba Saskatchewan Alberta North Total
Total contribution expenditures $6.8 $23.3 $26.9 $30.9 $16.5 $25.3 $61.4 $191.1
Total operating expenditures $4.3 $0.6 $59.2 $124.5 $47.8 $25.9 $6.0 $268.3

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

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

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

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 6.5: NIHB medical transportation operating expenditure by type ($ Millions): 2017/18
MT category Expenditure ($M)
Scheduled air $85.1
Living expenses $49.7
Land ambulance $59.7
Air ambulance $44.4
Land taxi $11.2
Chartered flights $8.3
Other land/water $5.4
Private vehicle $4.6

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

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

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

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

Source: SVS and FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 6.6: Per capita NIHB medical transportation expenditures by region: 2017/18
Population Transportation Per Capita
Atlantic 65,573 $11,147,080 $170
Quebec 72,151 $23,918,400 $332
Ontario 210,295 $86,090,571 $409
Manitoba 155,850 $155,370,278 $997
Sask 152,324 $64,362,631 $423
Alberta 123,812 $51,186,522 $413
North 69,560 $67,413,395 $969
National 867,749 $459,488,877 $530

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

In 2017/18, the total combined expenditure for NIHB vision benefits ($33.6 million), mental health counselling benefits ($33.1 million) and other health care benefits ($11.1 million) was $77.8 million, or 5.9% of total NIHB expenditures for the fiscal year.

The NIHB program provides coverage for

  • eye examinations
  • corrective eyewear. Eligible benefits are described in the Vision Care Benefit List.
  • eyeglass repairs
  • Other vision care benefits depending on the specific medical needs of the client.

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

Vision care benefits are eligible when provided by an NIHB recognized provider (optician, optometrist or ophthalmologist), in accordance with the policies set out in the NIHB Vision Care Policy Framework and the Vision Care Benefit List. Many provincial or territorial health plans provide public coverage for eye examinations based on the client's age or medical condition, and NIHB provides coverage for other clients where needed.

NIHB mental health counselling benefits are intended to provide coverage to support individuals in significant distress in order to stabilize their condition and transition them to other mental health supports, if needed. Mental health counselling is eligible for coverage when it is provided by an NIHB recognized mental health professional such as a registered psychologist. The program also works with communities to provide services to help respond to community-level crisis events.

NIHB other health care includes expenditures related to funding arrangements with the FNHA for Bill C-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.

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

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

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

Region Operating Contributions Total
Atlantic $3,632 $0 $3,632
Quebec $1,819 $0 $1,819
Ontario $6,295 $552 $6,848
Manitoba $4,153 $326 $4,479
Saskatchewan $6,905 $0 $6,905
Alberta $5,763 $1,001 $6,764
North $366 $2,766 $3,131
Total $28,933 $4,645 $33,578
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

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

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

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

Figure 7.2.1: Annual NIHB vision expenditures and percentage change

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 7.2.1: Annual NIHB vision expenditures and percentage change
Year Total vision expenditures ($M) Annual percentage change (%)
2013/14 $31.5 -2.2%
2014/15 $29.7 -5.6%
2015/16 $30.0 1.0%
2016/17 $32.4 7.8%
2017/18 $33.6 3.7%

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

NIHB vision expenditures ($ 000's)
Region 2013/14 2014/15 2015/16 2016/17 2017/18
Atlantic $2,757 $2,666 $3,021 $3,502 $3,632
Quebec $1,619 $1,622 $1,749 $1,762 $1,819
Ontario $5,721 $5,717 $6,160 $6,223 $6,848
Manitoba $4,348 $4,800 $4,212 $4,204 $4,479
Saskatchewan $5,611 $6,066 $6,104 $6,533 $6,905
Alberta $5,936 $7,084 $6,207 $6,928 $6,764
North $3,763 $1,743 $2,564 $3,217 $3,131
Total $29,755 $29,704 $30,017 $32,370 $33,578
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 7.3: Per capita NIHB vision expenditures by region: 2017/18

In 2017/18, the national per capita expenditure in NIHB vision benefits was $39.

Alberta and the Atlantic region had the highest per capita expenditure at $55, followed by the Northern region and Saskatchewan at $45. The lowest per capita NIHB Vision benefit expenditure was in the Quebec region at $25.

Source: SVS and FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 7.3: Per capita NIHB vision expenditures by region: 2017/18
Region Per Capita
Atlantic $55
Quebec $25
Ontario $33
Manitoba $29
Sask $45
Alberta $55
North $45
National $39

Figure 7.4: NIHB mental health counselling expenditures by region ($ 000's): 2017/18

Prior to 2014/15, NIHB mental health counselling expenditures we67B Annual Report, and going forward, expenditures associated with the provision of mental health counselling services to NIHB clients will be reported separately.

In 2017/18, NIHB mental health counselling expenditures amounted to $33.1 million. Regional operating expenditures accounted for $18.0 million (54.5%) of total expenditures while contribution costs accounted for $15.1 million (45.5%).

In 2017/18, the Manitoba region had the highest percentage share of NIHB mental health counselling expenditures at 24.5% followed by the Alberta and Saskatchewan regions at 23.5% and 19.8% respectively.

Region Operating Contributions Total
Atlantic $481 $724 $1,204
Quebec $1,159 $702 $1,861
Ontario $5,015 $1,013 $6,028
Manitoba $4,259 $3,865 $8,124
Saskatchewan $3,307 $3,251 $6,559
Alberta $3,785 $3,977 $7,761
North $0 $1,528 $1,528
Total $18,006 $15,060 $33,066
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 7.5: Per capita NIHB mental health counselling expenditures by region ($ 000's): 2017/18

In 2017/18, the national per capita expenditure for NIHB Mental Health Counselling was $38.

The Alberta region had the highest per capita expenditure at $63, followed by the Manitoba region at $52 per eligible client.

Source: SVS and FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 7.5: Per capita NIHB mental health counselling expenditures by region ($ 000's): 2017/18
Region Per Capita
Atlantic $18
Quebec $26
Ontario $29
Manitoba $52
Saskatchewan $43
Alberta $63
North $22
National $38

Figure 7.6: NIHB other health care expenditures by region ($ 000's): 2017/18

In 2017/18, NIHB other health care expenditures totalled $6.0 million. The majority of these expenditures are related to contribution agreements including funding arrangements with the FNHA for Bill C-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 Indigenous organizations that employ NIHB Navigators to act as a resource for communities, organizations or individuals who need assistance or information on the NIHB program.

Region Operating Contributions Total
Atlantic $5 $422 $427
Quebec $3 $256 $260
Ontario $0 $375 $375
Manitoba $0 $240 $240
Saskatchewan $0 $210 $210
Alberta $11 $280 $291
North $1 $345 $346
Headquarters $66 $8,927 $8,994
Total $88 $11,055 $11,143
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Section 8: Regional expenditure trends: 2008/09 to 2017/18

Figure 8.1: Atlantic region: 2008/09 to 2017/18

Over the ten year period from 2008/09 to 2017/18, 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, 2018, a total of 24,878 Qalipu clients were eligible to receive benefits through the NIHB Program. The decrease in expenditures in 2013/14 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.

Annual expenditures in the Atlantic Region for 2017/18 totalled $60.0 million, an increase of 9.0% over the $55.1 million spent in 2016/17. Pharmacy expenditures in 2017/18 increased by 3.5% to $33.0 million, medical transportation costs increased by 20.2% to $11.1 million and dental expenditures increased by 10.6% to $10.6 million. Mental health expenditures increased by 100.5% and vision care expenditures increased by 3.7%.

Pharmacy expenditures accounted for more than half of the Atlantic Region's total expenditures at 55.0%. Medical transportation expenditures ranked second at 18.6%, followed by dental at 17.7%. Vision care and mental health expenditures accounted for 6.0% and 2.0% of total expenditures respectively.

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

Description of Figure 8.1.1: Percentage change in Atlantic region NIHB expenditures ($ 000's)
Atlantic region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Total benefits annual % change 3.4% 6.6% 11.4% 14.3% 16.7% -7.9% 1.9% 8.2% 8.5% 9.0%

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

Atlantic region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Transportation $4,655 $5,048 $5,314 $5,841 $6,875 $6,916 $7,419 $8,380 $9,277 $11,147
Pharmacy $20,119 $21,357 $23,689 $27,571 $29,979 $27,517 $28,398 $30,064 $31,899 $33,021
Dental $4,945 $5,426 $6,481 $7,164 $9,660 $8,609 $8,238 $8,846 $9,593 $10,610
Mental health $251 $213 $241 $254 $512 $235 $169 $419 $601 $1,204
Vision care $1,596 $1,612 $1,758 $2,021 $2,969 $2,757 $2,666 $3,021 $3,502 $3,632
Other health care $0 $0 $0 $0 $0 $0 $21 $44 $207 $427
Total $31,567 $33,656 $37,482 $42,850 $49,995 $46,033 $46,912 $50,773 $55,079 $60,040
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.2: Quebec region: 2008/09 to 2017/18

Annual expenditures in the Quebec region for 2017/18 totalled $94.2 million, an increase of 2.6% from the $91.8 million spent in 2016/17.

Pharmacy expenditures increased by 2.0% to $48.4 million and dental expenditures increased by 2.2% to $18.0 million, while medical transportation costs in 2017/18 increased by 1.8% to $23.9 million. Mental health expenditures increased by 44.1% and vision care expenditures increased by 3.2%.

Pharmacy expenditures accounted for half of the Quebec region's total expenditures in 2017/18 at 51.4%. Medical transportation expenditures ranked second at 25.4%, followed by dental at 19.1%. Vision care and mental health expenditures accounted for 1.9% and 2.0% of total expenditures respectively.

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

Description of Figure 8.2.1: Percentage change in Quebec region NIHB expenditures ($ 000's)
Quebec region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Total benefits annual % change 2.4% 3.0% 1.6% 4.8% 3.8% -0.4% 5.0% 3.6% 4.7% 2.6%

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

Quebec region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Transportation $20,502 $19,918 $18,943 $21,708 $22,578 $21,945 $23,506 $23,687 $23,501 $23,918
Pharmacy $36,069 $37,358 $38,234 $38,827 $40,393 $40,825 $42,581 $44,206 $47,444 $48,390
Dental $12,895 $14,159 $15,245 $15,138 $15,239 $15,216 $15,799 $16,641 $17,569 $17,961
Mental health $375 $459 $597 $875 $1,135 $1,003 $1,148 $1,148 $1,292 $1,861
Vision care $1,220 $1,280 $1,336 $1,404 $1,570 $1,619 $1,622 $1,749 $1,762 $1,819
Other health care $0 $0 $0 $0 $0 $0 $10 $258 $263 $260
Total $71,060 $73,174 $74,355 $77,951 $80,915 $80,608 $84,666 $87,690 $91,831 $94,210
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.3: Ontario region: 2008/09 to 2017/18

Annual expenditures in the Ontario region for 2017/18 totalled $250.9 million, an increase of 8.3% from the $231.7 million spent in 2016/17.

In 2017/18, Ontario had the highest expenditures in dental care of all of the regions, at $52.1 million, a slight decrease of -0.1% over 2016/17. Pharmacy expenditures in 2017/18 increased by 5.8% to $99.6 million, while medical transportation costs increased by 15.0% to $86.1 million. Vision care and mental health expenditures increased by 10.0% and 47.4% respectively.

Pharmacy expenditures accounted for 39.7% of the Ontario region's total expenditures. Medical transportation costs ranked second at 34.3%, followed by dental at 20.7%. Vision care and mental health expenditures accounted for 2.7% and 2.4% of total expenditures respectively.

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

Description of Figure 8.3.1: Percentage change in Ontario region NIHB expenditures ($ 000's)
Ontario region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Total benefits annual % change 1.9% 5.1% -0.5% 3.5% 3.2% 4.0% 4.7% 6.3% 7.4% 8.3%

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

Ontario region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Transportation $46,848 $51,889 $52,358 $54,725 $59,251 $62,865 $65,781 $67,772 $74,890 $86,091
Pharmacy $77,244 $77,564 $73,887 $76,430 $77,131 $78,510 $81,982 $88,872 $94,101 $99,550
Dental $35,457 $38,047 $40,594 $41,848 $42,259 $43,972 $46,759 $49,903 $52,105 $52,055
Mental health $2,158 $2,603 $2,632 $2,349 $2,490 $2,862 $2,803 $3,021 $4,091 $6,028
Vision care $5,204 $5,343 $5,183 $5,425 $5,412 $5,721 $5,717 $6,160 $6,223 $6,848
Other health care $0 $0 $0 $0 $0 $0 $2 $11 $254 $375
Total $166,910 $175,447 $174,653 $180,778 $186,544 $193,929 $203,043 $215,738 $231,663 $250,947
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.4: Manitoba region: 2008/09 to 2017/18

Annual expenditures in the Manitoba region for 2017/18 totalled $308.2 million, an increase of 5.6% from the $292.0 million spent in 2016/17. Pharmacy expenditures in 2017/18 increased by 3.5% to $98.0 million, while medical transportation costs increased by 5.6% to $155.4 million. Dental expenditures increased by 4.9% to $41.9 million. Mental health expenditures increased by 44.2% while vision increased by 6.5%.

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 half of the Manitoba region's total expenditures at 50.4%. Pharmacy costs ranked second at 31.8%, followed by dental at 13.6%. Mental health and vision expenditures accounted for 2.6% and 1.5% of total expenditures respectively.

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

Description of Figure 8.4.1: Percentage change in Manitoba region NIHB expenditures ($ 000's)
Manitoba region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Total benefits annual % change 6.6% 5.9% 6.1% 5.6% 4.2% 0.6% 4.1% 7.9% 13.1% 5.6%

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

Manitoba region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Transportation $83,193 $89,078 $94,940 $101,609 $109,409 $111,016 $115,705 $125,308 $147,167 $155,370
Pharmacy $71,081 $72,789 $76,496 $80,639 $80,676 $77,034 $81,059 $87,997 $94,757 $98,046
Dental $24,444 $26,954 $29,399 $29,861 $30,734 $33,649 $33,527 $36,764 $39,986 $41,949
Mental health $2,619 $3,143 $2,930 $3,109 $3,429 $3,622 $4,099 $3,780 $5,635 $8,124
Vision care $3,157 $3,407 $3,612 $3,813 $4,048 $4,348 $4,800 $4,212 $4,204 $4,479
Other health care $0 $0 $0 $0 $0 $0 $0 $17 $240 $240
Total $184,494 $195,371 $207,377 $219,031 $228,295 $229,670 $239,190 $258,077 $291,989 $308,208
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.5: Saskatchewan region: 2008/09 to 2017/18

Annual expenditures in the Saskatchewan region for 2017/18 totalled $248.0 million, an increase of 12.5% from the $220.5 million spent in 2016/17.

Saskatchewan had the highest expenditures in pharmacy, followed closely by Ontario and Manitoba. In Saskatchewan, pharmacy expenditures in 2017/18 increased by 14.6% to $119.3 million, while medical transportation costs increased by 9.3% to $64.4 million and dental expenditures increased by 7.0% to $50.6 million. Vision care and mental health expenditures increased by 5.7% and 98.5% respectively.

Pharmacy expenditures comprised the largest portion of the Saskatchewan region's total expenditures at 48.1%, medical transportation costs ranked second at 26.0%, followed by dental at 20.4%. Vision care and mental health expenditures accounted for 2.8% and 2.6% of total expenditures respectively.

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

Description of Figure 8.5.1: Percentage change in Saskatchewan region NIHB expenditures ($ 000's)
Saskatchewan region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Total benefits annual % change 4.4% 7.0% 8.5% 5.1% 1.3% 3.3% 6.7% 7.5% 13.9% 12.5%

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

Saskatchewan region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Transportation $36,239 $38,971 $41,896 $45,084 $45,793 $47,180 $51,543 $53,566 $58,902 $64,363
Pharmacy $62,809 $66,639 $70,625 $73,293 $74,646 $78,546 $83,361 $91,170 $104,082 $119,326
Dental $28,102 $30,777 $35,317 $36,941 $36,219 $36,399 $37,679 $41,028 $47,321 $50,635
Mental health $870 $812 $896 $1,499 $1,038 $1,017 $1,351 $1,631 $3,304 $6,559
Vision care $4,166 $4,222 $4,658 $4,449 $5,676 $5,611 $6,066 $6,104 $6,533 $6,905
Other health care $0 $0 $0 $0 $0 $0 $0 $4 $210 $210
Total $132,185 $141,420 $153,393 $161,265 $163,372 $168,752 $180,000 $193,502 $220,352 $247,997
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.6: Alberta region: 2008/09 to 2017/18

The decreased growth rate recorded in 2009/10 is primarily the result of the NIHB Program no longer covering provincial health premiums in the Alberta region because the Government of Alberta eliminated Alberta Health Care insurance premiums for all Albertans as of January 1, 2009.

Annual expenditures in the Alberta region for 2017/18 totalled $193.0 million, an increase of 5.4% from the $183.1 million spent in 2016/17. Pharmacy expenditures in 2017/18 increased by 2.7% to $79.3 million, while medical transportation costs increased by 6.3% to $51.2 million and dental expenditures increased by 7.5% to $47.6 million. Mental health expenditures increased by 20.5% and vision care expenditures decreased by -2.4%.

Pharmacy expenditures accounted for 41.1% of the Alberta region's total expenditures. Medical transportation costs ranked second at 26.5 %, followed closely by dental at 24.7%. Mental health and vision care expenditures accounted for 4.0% and 3.5% of total expenditures respectively.

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

Description of Figure 8.6.1: Percentage change in Alberta region NIHB expenditures ($ 000's)
Alberta Region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Total benefits annual % change 1.9% -2.2% 6.2% 3.3% 1.1% 0.8% 8.8% 5.8% 8.9% 5.4%
Total benefits annual % change (Excluding premiums) 4.7% 5.6% 6.2% 3.3% 1.1% 0.8% 8.8% 5.8% 8.9% 5.4%

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

Alberta region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Transportation $35,357 $36,601 $35,877 $37,371 $39,216 $41,451 $45,756 $46,252 $48,157 $51,187
Pharmacy $54,189 $56,570 $59,738 $61,621 $60,584 $58,777 $64,087 $69,992 $77,265 $79,343
Dental $25,016 $27,756 $33,421 $34,543 $34,501 $34,928 $35,974 $39,753 $44,315 $47,637
Mental health $3,940 $4,363 $3,903 $3,957 $4,791 $4,959 $6,010 $6,003 $6,444 $7,761
Vision care $5,225 $5,377 $5,778 $5,822 $5,836 $5,936 $7,084 $6,207 $6,928 $6,764
Other health care $9,920 $0 $0 $0 $0 $0 $0 $3 $0 $291
Subtotal (excluding premiums) $123,726 $130,666 $138,717 $143,313 $144,928 $146,051 $158,911 $168,211 $183,108 $192,983
Total $133,646 $130,666 $138,717 $143,313 $144,928 $146,051 $158,911 $168,211 $183,108 $192,983
Source: FIRMS adapted by Business Support, Audit and Negotiations Division

Figure 8.7: Northern region: 2008/09 to 2017/18

Annual expenditures in the Northern region for 2017/18 totalled $126.9 million, an increase of 16.3% from the $109.2 million spent in 2016/17.

Medical transportation expenditures in 2017/18 increased by 22.3% to $67.4 million while pharmacy costs increased by 3.1% to $29.4 million. Dental expenditures increased by 14.5% to $25.1 million. Vision care expenditures decreased by -2.7% and mental health expenditures increased by 322.7%.

Similar to Manitoba, medical transportation expenditures comprised the largest portion of the Northern region's total expenditures at 53.1%. Pharmacy costs ranked second at 23.1 %, followed by dental at 19.8%. Vision care and mental health expenditures accounted for 2.5% and 1.2% of total expenditures respectively.

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

Description of Figure 8.7.1: Percentage change in Northern region NIHB expenditures ($ 000's)
Northern region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Total benefits annual % change 9.8% 12.1% 9.8% 2.4% 0.9% 3.9% 2.5% 8.2% 7.0% 16.3%

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

Northern region 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Transportation $30,942 $34,622 $36,464 $40,455 $41,727 $44,703 $48,246 $50,940 $55,125 $67,413
Pharmacy $19,073 $20,555 $23,190 $23,863 $23,682 $23,144 $23,941 $27,408 $28,488 $29,373
Dental $16,874 $19,627 $22,537 $20,079 $19,773 $20,415 $20,413 $20,936 $21,966 $25,141
Mental health $1 $1 $2 $4 $4 $2 $0 $191 $362 $1,528
Vision care $2,759 $3,284 $3,550 $3,387 $3,370 $3,763 $1,743 $2,564 $3,217 $3,131
Other health care $0 $0 $0 $0 $0 $0 $1 $1 $0 $346
Total $69,649 $78,089 $85,744 $87,787 $88,557 $92,027 $94,343 $102,040 $109,157 $126,933
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): 2017/18

Figure 9.1 provides the Program administration funds expended by each region as well as NIHB headquarters (HQ) in Ottawa. In 2017/18, total NIHB administration costs were $60.1 million representing an increase of 6.7% 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)
  • audits and provider negotiations
  • adjudicating benefit requests through the NIHB Drug Exception Centre and the Dental Predetermination Centre and
  • maintaining productive relationships with partner organizations at the national level as well as with other federal departments and agencies.

The roles of the NIHB regions include:

  • adjudicating benefit requests for medical transportation, medical supplies and equipment, dental, vision benefits, and mental health counselling benefits
  • working with NIHB headquarters on policy development, provider negotiations and audits and
  • maintaining productive 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.
Categories Atlantic Quebec Ontario Manitoba Saskatchewan Alberta Northern region HQ Total
Salaries $1,449 $1,803 $3,942 $3,032 $3,288 $3,668 $1,435 $13,903 $32,520
EBP $290 $361 $788 $606 $658 $727 $287 $2,774 $6,490
Operating $81 $79 $261 $63 $123 $133 $80 $1,829 $2,650
Subtotal $1,819 $2,243 $4,992 $3,701 $4,069 $4,528 $1,802 $18,506 $41,660
Claims processing contract costs $18,466
Total administration costs $60,126
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): 2013/14 to 2017/18

The NIHB program is responsible for developing, maintaining and managing key business processes, systems and services required to deliver eligible non-insured health benefits. Figure 9.2 provides the percentage of NIHB Program administrative costs as a proportion of overall NIHB benefit expenditures. In 2017/18, total NIHB benefit expenditures were $1,309.2 million, of which direct benefit expenditures totaled $1,290.8 million and expenditures for claims processing administration amounted to $18.5 million. An additional $41.7 million was spent on salaries and operating costs associated with Program administration.

Total NIHB program administration costs ($60.1 million, including claims processing and other program administration) as a proportion of direct benefit expenditures ($1.3 billion), was 4.7% in 2017/18. Over the past five 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 2014/15 to a low of 4.7% in 2016/17 and 2017/18.

Source: FIRMS adapted by Business Support, Audit and Negotiations Division
Description of Figure 9.2: Non-Insured Health Benefits administration costs as a proportion of benefit expenditures ($ Millions): 2013/14 to 2017/18
Fiscal year NIHB benefit expenditures ($M) % Administrative costs
2013/14 $1,026.4 5.3%
2014/15 $1,031.5 5.4%
2015/16 $1,100.5 5.0%
2016/17 $1,207.5 4.7%
2017/18 $1,309.2 4.7%

Section 9.3: Health Information and Claims Processing Services (HICPS): 2017/18

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

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 (formally ESI 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, 2018, there were 27,045 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, 2018.

Figure 9.3.1: Number of NIHB providers by region and benefit: April 2016 to March 2018

Region Pharmacy MS&E Dental
Atlantic 818 235 1,052
Quebec 1,992 218 2,908
Ontario 4,087 793 6,049
Manitoba 444 78 771
Saskatchewan 424 92 543
Alberta 1,462 292 2,540
British Columbia 1,031 67 912
Yukon 11 10 53
Northwest Territories 12 7 48
Nunavut 8 2 86
Total 10,289 1,794 14,962
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: 2017/18

Figure 9.3.2 sets out the total number of pharmacy, dental and MS&E claims settled through the HICPS system in fiscal year 2017/18. During this period, a total of 25,923,875 claim lines were processed through HICPS, an increase of 4.9% over the previous fiscal year. Ontario had the highest volume of total claims processed at 7.1 million, followed by Manitoba at 4.7 million and Saskatchewan at 4.2 million.

Claim Lines vs. 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 (e.g., Methadone) are dispensed daily and will increase the per capita number of claim lines.

Region Pharmacy Dental MS&E Total
Atlantic 1,480,510 169,347 43,490 1,693,347
Quebec 2,981,584 225,973 34,272 3,241,829
Ontario 6,454,140 602,191 48,790 7,105,121
Manitoba 4,143,277 465,875 87,392 4,696,544
Saskatchewan 3,605,778 552,120 89,509 4,247,407
Alberta 3,059,988 526,162 62,038 3,648,188
British Columbia 155,126 30,581 1,825 187,532
Yukon 117,282 24,767 3,287 145,336
Northwest Territories 355,719 99,967 10,520 466,206
Nunavut 327,813 150,075 14,477 492,365
Total claim lines 22,681,217 2,847,058 395,600 25,923,875
Source: HICPS adapted by Business Support, Audit and Negotiations Division

Section 9.4: Benefits management

The NIHB Program is responsible for developing, maintaining and managing key business processes, systems and services required to deliver eligible non-insured health benefits. 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 NIHB Drug Exception Centre (DEC) was established in December 1997 to process and expedite pharmacists' requests for drug benefits that require prior approval, to help ensure consistent application of the NIHB drug benefit policy across the country, and to ensure an evidence-based approach to funding drug benefits. The DEC handles requests for prior approval from pharmacy providers across Canada.

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

The DEC is a single call centre that provides efficient responses to all requests for drugs that are not on the NIHB Drug Benefit List or require prior approval, for extemporaneous mixtures containing exception or Limited Use (LU) drugs, for prescriptions on which prescribers have indicated "no substitution," and for claims that exceed $1,999.99. Figure 9.4 shows the volume of requests made to the DEC in 2017/18.

Status Open benefit
(unrestricted)
Open benefit (restricted) Exceptions Limited use Total
Total requested 23,236 12,783 20,916 66,382 123,317
Total approved 19,926 9,670 14,918 52,990 97,504

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

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

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

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

Drug Exception Centre special authorization process

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

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

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

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

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

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

Dental Predetermination Centre

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

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

Medical Supplies and Equipment Review Centre

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

Section 9.5: Claims verification activities: 2017/18

The NIHB program is a publicly-funded program that must account for the expenditure of those public funds. Claims verification activities contribute to the fulfillment of this overall requirement. As part of the 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 2017/18, 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 NIHB Provider Guide, Claims Submission Kit, Provider Agreement and other relevant documents. The objectives of the claims verification activities are to detect billing irregularities, to validate active licensure of providers, to ensure that services paid for were received by eligible NIHB clients and to ensure that providers retained appropriate documentation in support of each claim. Claims not meeting the billing requirements of the NIHB Program are subject to recovery.

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

  1. Next Day Claims Verification (NDCV) program, which consists of a review of a defined sample of claims submitted by providers the day following receipt by the claims processor
  2. Client Confirmation Program (CCP), which consists of a monthly mail-out to a randomly selected sample of NIHB clients to confirm the receipt of the benefit that has been billed on their behalf
  3. 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
  4. 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. Generally, a smaller number of claims are reviewed during a desk audit.

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.

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

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

Dental
Region Audits completed Recoveries NDCV/CCP savings Total recoveries/ savings
Atlantic 1 $10,336 $39,694 $50,030
Quebec 5 $10,591 $47,173 $57,764
Ontario 3 $12,179 $165,808 $177,987
Manitoba 4 $66,443 $78,107 $144,550
Saskatchewan 8 $30,689 $97,641 $128,330
Alberta 11 $72,975 $164,384 $237,359
British Columbia 7 $0 $29,115 $29,115
Yukon 1 $19,136 $3,109 $22,245
Northwest Territories 3 $0 $17,006 $17,006
Nunavut 8 $33,007 $10,494 $43,501
Total 51 $255,356 $652,530 $907,886

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

Region Audits completed Recoveries NDCV/CCP savings Total recoveries/ savings
Atlantic 3 $12,245 $75,424 $87,668
Quebec 6 $26,306 $135,016 $161,322
Ontario 8 $167,569 $426,621 $594,191
Manitoba 11 $242,125 $129,346 $371,471
Saskatchewan 1 $73,303 $76,254 $149,557
Alberta 19 $506,434 $129,371 $635,805
British Columbia 13 $0 $8,448 $8,448
Yukon 0 $4,278 $13,848 $18,126
Northwest Territories 0 $3,107 $11,114 $14,220
Nunavut 1 $488 $33,312 $33,799
Total 62 $1,035,855 $1,038,753 $2,074,607

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

Region Audits completed Recoveries NDCV/CCP savings Total recoveries/savings
Atlantic 0 $0 $6,226 $6,226
Quebec 0 $0 $4,424 $4,424
Ontario 2 $538 $5,037 $5,574
Manitoba 3 $17,599 $8,011 $25,610
Saskatchewan 0 $0 $10,791 $10,791
Alberta 2 $0 -$509 -$509
British Columbia 0 $0 $36 $36
Yukon 0 $0 $0 $0
Northwest Territories 0 $0 $0 $0
Nunavut 0 $0 -$625 -$625
Total 7 $18,137 $33,391 $51,527

* 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.

Section 10: NIHB policy and program initiatives

Section 10.1: Evidence-based policy development

NIHB Drug benefit listing and review

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

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

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

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

NIHB Drugs and Therapeutics Advisory Committee (DTAC)

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

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

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

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

NIHB Oral Health Advisory Committee (NOHAC)

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

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

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

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

Additional members may include other types of oral health professionals such as dental anesthesiologist, denturist, oral surgeon, endodontist, and orthodontist. More information on the NOHAC and its members can be found on the Government of Canada's website

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 the Non-Insured Health Benefits (NIHB) program, bear a responsibility to those they serve. The NIHB program places a high priority on client safety, and has a number of strategies in place to encourage the safe use of prescription medications.

Point of sale (POS) warning and rejection messages

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

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

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

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

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

Trend analysis of prescription drug use

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

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

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

Reduction in the opioid dose limit

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

Coverage of naloxone

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

Dental benefit client safety

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

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

Section 10.3: Client and provider communications

NIHB is continually seeking ways to improve communications with clients, providers and partner organizations 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 (ESC), Indigenous Services Canada's claims processing contractor, and are available via the ESC website.

The NIHB website is a key venue for disseminating Program information. NIHB program updatesare produced quarterly to provide information for clients regarding changes to benefit coverage. They can be found on the Canada.ca website, and are promoted through social media on Health 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 Indigenous 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. 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 FNIHB representatives. An implementation plan for changes and improvements to the NIHB mental health counselling benefit was finalized in 2015. In 2016/17 NIHB implemented numerous changes as a result, including improvements to provider enrolment and claim forms, and updating the benefit policy guide to clarify eligibility of group and family counselling.

Reviews of other benefits are underway, and NIHB prepared administrative profiles of the dental, pharmacy and vision care benefits to support the work of the Joint Review. AFN conducted a robust program of client, provider and partner organizations 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 2017/18 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 in-year transfer of responsibility for First Nations individuals residing in British Columbia to the First Nations Health Authority (FNHA) in 2013/14, select financial and utilization data relating to the British Columbia Region have been suppressed. National totals, however, include these values.

Fiscal year 2014/15 expenditures totals for Alberta Medical Transportation, Vision and MSE benefits have been restated and differ from the expenditures totals that appeared in the 2014/15 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 FNIHB. 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.

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 the Framework for Integrated Resource Management System (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.

In 2005, an initiative was launched to collect medical transportation data on a national basis. The Medical Transportation Data Store (MTDS) was created to act as a centralized system for cross regional data. The 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.

In 2013/14, a new version of the MTDS was released to enhance the data collection method and improve the reporting capability of the data store. These enhancements ensure that the MTDS responds reliably to NIHB's analytical needs, and allows accurate analysis of medical transportation (MT) cost drivers in order to manage the efficiency and effectiveness of the MT benefit. In addition, steps are currently underway to improve data collection related to contribution agreements.

Vision care, emergency mental health care, other health care and premiums data

Financial data on the NIHB vision care, other health care and premiums benefits are provided through the Framework for Integrated Resource Management System (FIRMS).

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