2000 October Report of the Auditor General of Canada

Community Health Programs Delivered Through Separate Contribution Agreements and Transfer of Health Programs to Community Control

13.36

Health Canada should review its program structure and ensure that it reflects the manner in which the programs are actually delivered.

Satisfactory progress. The Department has initiated a project that will identify specific objectives for each program, and it believes this will alleviate overlap of program objectives. At the time of our audit this had not been completed; we found that there is still some overlap between program objectives.

13.40

The Department should ensure that the contribution agreements are clear about specific objectives and activities that the First Nations will undertake. It should encourage First Nations to define measures of success.

Unsatisfactory progress. In many cases, programs still do not include clear objectives and activities for the specific community.

13.44

The Department should ensure that it receives the activity reports required under contribution agreements. It should work with First Nations to improve these activity reports so that they provide information on results achieved.

Satisfactory progress. Some improvement, but not all required activity reports are completed for all programs. Reports remain mostly lists of activities undertaken.

PAC No. 2

That Health Canada monitor those aspects of the community health programs that are not affected by transfer agreements. This monitoring function must be done in accordance with departmental policies, be supported by thorough evaluation of risks, and targeted accordingly.

Unsatisfactory progress. Monitoring of reporting requirements remains weak. The proposed automated contribution system to track reports is not yet operational in all regions.

13.58

The Department should ensure that updated community health plans that meet the basic requirements are prepared, and that they form the basis of both initial and renewed transfer agreements.

Unsatisfactory progress. Many renewed agreements were signed without an updated community health plan.

13.65

The Department should work with First Nations to improve measurement of the services provided and of expected changes to health. These measures should be included in the annual reports. In addition, the Department should ensure that First Nations conduct the required evaluations of the achievement of program objectives.

Unsatisfactory progress. Under two thirds of transfer agreement files reviewed had an annual report for 1998-99. Those provided tended not to include performance information.

Some transfer agreements were renewed without evaluations having been completed. Some completed evaluations had quality problems.

13.70

The Department should clarify the nature and scope of audit requirements under transfer agreements and ensure that the required audit opinions are provided.

Satisfactory progress. The Department has revised its audit guidelines to clarify the nature and scope of comprehensive audit requirements. Not all transfer agreements had audits completed as required. Audit reports provided did not meet all requirements.

13.74

The Department should ensure that future evaluations will determine the extent to which the transfer initiative contributes to improving the health of First Nations.

Unsatisfactory progress. The Department believed that more emphasis on community-based evaluations would lead to better health information to deal with the issue of improved health status. As noted above, community-based evaluations were either not done or inadequate.

PAC No. 1

That Health Canada monitor the transfer of the delivery of community health programs to First Nations and work with the communities to ensure that the conditions set forth in the accountability framework are met. In particular, the Department must ensure that the audit (both financial and comprehensive) and evaluation requirements of all transfer agreements are satisfied.

Unsatisfactory progress. The accountability framework is still under development. As described above, audit and evaluation requirements have not been met satisfactorily.

PAC No. 3

That Health Canada provide information on the status of community health programs in its annual Performance Reports. Information on the status of the transfer process, the Department's monitoring activities, audits and reports completed, and health outcomes achieved under the programs should be included.

Unsatisfactory progress. Recent departmental annual performance reports have provided limited information on the status of community health programs, including outcomes achieved.

Non-Insured Health Benefits

13.114

In cases where it identifies a significant pattern of inappropriate use of prescription drugs, the Department should perform a more rigorous follow-up with Non-Insured Health Benefits clients, physicians, pharmacists and professional bodies.

Satisfactory progress. A protocol was implemented to follow up on cases of suspected drug misuse, with some success. However, officials stopped following the protocol in May 1999 as management was unsure of the appropriateness of the approach in the absence of either client consent or statutory authority. The Department is currently considering options to deal with this situation.

13.120

In implementing the point-of-service system for prescription drugs, the Department should ensure the system will facilitate timely intervention where potentially inappropriate prescription drug use is identified. The Department should provide a clear protocol to guide intervention and should closely monitor pharmacists' overrides of warning messages.

Unsatisfactory progress. The point-of-service system provides limited information in the form of warning messages to assist pharmacists in making decisions on dispensing prescriptions. This resulted in rejection of a number of claims. But Health Canada has not adequately monitored the warning messages that were overriden by pharmacists. Nor has it undertaken sufficient analysis of the effectiveness of warning messages. The Department has agreed with three provincial pharmacy bodies on compensating pharmacists for professional services in cases where they have not filled a prescription for valid reasons, but few pharmacists have taken advantage of the provision.

PAC No. 4

That Health Canada explore the possibility, with various jurisdictions, of having access to information and privacy legislation amended in order to allow its point-of-sale system to provide more information on recent prescriptions.

PAC No. 5

That Health Canada monitor the use of overrides by pharmacists and step up its efforts to devise an incentive scheme for those pharmacists who do not fill prescriptions when warning messages are issued.

13.123

The Department should build on its existing strategies to address the combined problem of prescription drug and solvent and alcohol abuse, and increase efforts in community health programs relating to prevention, community education, and treatment of prescription drug addiction.

Satisfactory progress. Multiple addiction is a systemic, long-term and complex problem. Departmental efforts are ongoing.

13.140

Health Canada should clarify, and enforce, the contract requirement for audit of pharmacy and dental care providers by the contractor. The Department should take appropriate steps to improve claims-processing system controls and edits and strengthen verification of claims and audits of providers.

Unsatisfactory progress. The Department was slow to develop and incorporate an audit strategy based on appropriate assessment of risks in its new claims-processing contract. It failed to ensure that the contractor would perform the required on-site audits of pharmacy and dental providers. Problem with system edit to identify duplicate claims has been resolved.

13.149

Health Canada should establish clear program criteria and minimum standards for medical transportation benefits. It should also undertake audits of medical transportation expenditures based on an assessment of risks.

Unsatisfactory progress. Work on updating national transportation directives has not yet been completed. No evidence of any audits of transportation expenditures paid directly to providers.

PAC No. 6

That Health Canada fix systemic problems with the Non-Insured Health Benefits program before the program becomes available for transfer to First Nations communities.

Unsatisfactory progress. As described above, many problems have not yet been fixed.

PAC No. 7

That Health Canada adopt and apply the framework for transferring community health programs when it conducts the transfer of the Non-Insured Health Benefits program to the First Nations.

Unsatisfactory progress. Most Non-Insured Health Benefits transfer pilots have not been evaluated. A new accountability framework is still under development.

PAC No. 8

That Health Canada submit a copy of the new contract for processing pharmacy and dental claims under the Non-Insured Health Benefits program to the Committee by 1 June 1998.

Fully addressed. A copy of new contract was provided to the Committee.

PAC No. 9

That Health Canada work with First Nations communities to establish optimal therapy as the central goal of the Non-Insured Health Benefits program and include references to this effort in its annual Performance Report.

Unsatisfactory progress. Predetermination process for dental benefits implemented. As described above, officials stopped following the drug utilization review follow-up protocol, which forms a part of a strategy to improve drug therapy. Limited information contained in the Department's recent annual performance report referencing this effort.

PAC No. 10

That Health Canada provide the Committee with a copy of its action plan for carrying out the recommendations made by the Auditor General by 30 April 1998. This plan should include target implementation dates, and a discussion of how the Department proposes to monitor and report the changes and the results that are achieved.

Fully addressed. An action plan was forwarded to the Committee in February 1998. The Department advised the Committee that it intended to update this plan on a semi-annual basis until full implementation is achieved.