3.1 Veteran Profile
As of March 31, 2016, there were 1,762 CAF and war service Veterans in receipt of MMP. The majority of these Veterans (1,545) range in age from 30 to 59. 969 Veterans were assigned a case manager. Many Veterans were in receipt of a number of VAC programs and details can be found in Appendix A.
Health Canada’s Consumer Information – Cannabis (Marihuana, marijuana) document of December 2015 notes cannabis may be authorized for the relief of symptoms associated with a variety of disorders which have not responded to conventional medical treatments. These symptoms (or conditions) may include: severe refractory nausea and vomiting associated with cancer chemotherapy; loss of appetite and body weight in cancer patients and patients with HIV/AIDS; pain and muscle spasms associated with multiple sclerosis; chronic non-cancer pain (mainly neuropathic); severe refractory cancer-associated pain; insomnia and depressed mood associated with chronic diseases (HIV/AIDS, chronic non-cancer pain); and symptoms encountered in the palliative/end-of-life care setting. It is noted that this list is not exhaustive.
VAC provides for the cost of health care for Veterans for the condition(s) for which the Veteran has received a VAC disability pension or disability award. The Department may also provide for the cost of care for some Veterans, such as low-income or seriously disabled war service Veterans, for non-pensioned/awarded conditions to the extent the care is not available from the province/territory in which they reside.
The majority of Veterans (71%) receive MMP as a result of their disability benefit condition. A review of these conditions notes post-traumatic stress disorder, chronic pain, musculoskeletal conditions (i.e., lumbar disc disease, osteoarthritis), and other mental health conditions (i.e., major depressive disorder, generalized anxiety disorder) as the most common disability benefit conditions with an authorization for MMP.
The review team conducted a gender-based analysis and noted no significant differences between the genders. A review of all disability benefit conditions also noted essentially no differences based on gender.
3.2 Internal Governance and Compliance
MMP Approval Process
VAC may provide coverage for MMP for eligible recipients upon receipt of a request accompanied by:
- A copy of the completed medical document (or similar document) as required under the MMPR; and
- A copy of the completed and confirmed registration with a Licensed Producer (Licensed Producers must possess a valid license with Health Canada and bill VAC directly via Medavie Blue Cross).
Requests that are in excess of 10 grams are approved at 10 grams and the remaining amount in excess of 10 grams are further considered for approval. Veterans who purchased MMP prior to being approved by VAC may submit receipts for consideration for reimbursement as long as applicable approval documentation is provided. Recipients who request coverage from multiple producers or who request to switch their coverage from one producer to another must provide a copy of a new medical document and confirmation of registration with the new licensed producer. Recipients are notified by letter of the approval of the authorization, including the effective dates.
File Review Results
The review team sampled 50 recipient authorizations to test for compliance with regulations, guidance, and VAC business processes. There was general compliance with the guidelines and business processes. All authorizations had a copy of the completed medical document as required under the MMPRs included a copy of the completed and confirmed registration with a licensed producer. Effective dates for 5 authorizations in the approval system did not match the dates noted in the letters sent to the recipients. There were also administrative errors including noting the incorrect pension/award condition versus MMP diagnosis (i.e. left knee vs right knee) and notation of the applicable licensed producer.
3.3 Veteran Health, Safety and Well-Being
Authorization Amounts
There is no scientifically defined amount of MMP for any medical condition. Amounts are highly individualized and require finding the right amount that maximizes the desired effect, while causing minimal cognitive impairment. VAC currently reimburses Veterans up to 10 grams/day of MMP. Table 3 below shows 26% of the authorizations are for 3 grams/day or less of marijuana; 23% are for 5 grams/day and 37% are for 8 to 10 grams/day of MMP.
| Grams/Day | Recipients | Percentage |
|---|---|---|
| 1 gram | 81 | 4.58% |
| 2 grams | 169 | 9.55% |
| 3 grams | 210 | 11.86% |
| 4 grams | 121 | 6.84% |
| 5 grams | 413 | 23.33% |
| 6 grams | 64 | 3.62% |
| 7 grams | 59 | 3.33% |
| 8 grams | 110 | 6.21% |
| 9 grams | 7 | 0.40% |
| 10 grams | 529 | 29.89% |
| 10+ grams | 7 | 0.40% |
| Total | 1,770* | 100% |
Source: AED Data Analysis.
*The total recipients in Table 3 do not equal the population of 1,762 as the information was acquired from separate sources. One source was based on the adjudication date of the MMP reimbursement and the other source used the effective date of the MMP authorization causing a difference of 8 recipients.
According to The College of Family Physicians, physicians involved with authorizing dried cannabis should “start low and go slowFootnote 4” however for 464 Veterans, their first MMP authorization was between 8 and 10 grams/day. Current information/research suggests authorization amount guidelines between 0.68 and 3 grams per day. See Appendix B for additional information. Interviews with VAC front line staff anecdotally noted that Veterans taking 1-2 grams/day, at appropriate times are managing well.
Cannabis Oil and Fresh Marijuana
The June 11, 2015 Supreme Court of Canada decision R. v. Smith provided authority for individuals authorized to possess marijuana under the MMPR and those falling under a court injunction to possess marijuana derivatives for their own use. This led to Health Canada issuing an exemption under the Controlled Drugs and Substances Act allowing licensed producers to produce and sell cannabis oil and fresh marijuana buds and leaves in addition to dried marijuana Footnote 5.
Interviews with front line VAC staff indicate both Veterans and VAC staff are concerned about the potential harmful side effects of smoked and vapourized dried marijuana. As Health Canada now approves cannabis oil and fresh marijuana buds, there is confusion as to VAC’s refusal to reimburse for these substances.
The effects from oils are known to be slow and erratic and the effects last longer compared to smoked or vapourized products. Health Canada notes that authorized amounts for orally administered products are even less well established than those for smoking or vapourization.Footnote 6 Licensed producers must determine the quantity of fresh marijuana or oil that is equivalent to one gram of dried marijuana.
Recommendation:
It is recommended that the Assistant Deputy Minister, Strategic Policy and Commemoration and the Assistant Deputy Minister, Service Delivery develop and implement a policy concerning marijuana for medical purposes. The policy to include:
- Lower gram limits for new authorizations;
- Review of current authorized amounts for existing beneficiaries; and
- Cannabis oil and fresh marijuana.
Management Action Plan
Veterans Affairs Canada will develop a policy on marijuana for medical purposes, putting the health, well-being and safety of our Veterans at the forefront. Processes will be developed in support of the Department’s policy approach.
MMP and other Medication Usage
High doses of drugs such as opioids/narcotics, benzodiazepines, anti-depressants, anti-psychoticsFootnote 7 should be authorized with caution in those individuals who are taking MMP. In fiscal year 2015-16, 1,051 Veterans were receiving reimbursement from VAC for one or more of these types of medication while receiving reimbursement for MMP. When under the care of a physician, the risks associated with taking a number of drugs are mitigated.
Data analysis identified that approximately 255 Veterans received an authorization for MMP from a licensed physician or nurse practitioner outside the Veterans province of residence. This could be interpreted several ways:
- Veteran was working outside their province of residence;
- Veteran’s treating physician would not authorize MMP;
- Veteran did not want to request MMP from his treating physician; or
- Veteran may not have a treating physician.
Follow-ups
A number of interviewees indicated concern regarding Veterans who obtain a MMP authorization from an individual other than their treating physician, particularly for Veterans who received authorizations for a higher number of grams. Current Health Canada regulations require an authorization for MMP from a licensed physician or a licensed nurse practitioner but there is no requirement for ongoing follow-up. The College of Family Physicians of Canada in their “Authorizing Dried Cannabis for Chronic Pain or Anxiety, Preliminary Guidance” recommends the authorizing physician regularly monitor the patient’s response to treatmentFootnote 8. However, physicians comply with the guidelines provided by their provincial regulatory body and these guidelines vary from province to province.
Additional Resources for Staff
Reimbursements for MMP have increased over the past year resulting in more staff involvement. During VAC field staff interviews, there were indications that case managers, in particular, are in need of help and support. Staff mentioned that the following would be beneficial; tools to help case managers work with Veterans, education on the effects of MMP (e.g. when is MMP utilized and for what conditions, pain management etc.), and addictions training. Sharing of best practices would also be beneficial.
Recommendation:
It is recommended that the Assistant Deputy Minister, Service Delivery determine training gaps and deliver training to VAC staff in relation to marijuana for medical purposes.
Management Action Plan
VAC is committed to the health, safety and well-being of all Veterans. VAC will provide all appropriate information and training materials to front line staff to ensure they are equipped with the latest information and best practices in relation to marijuana for medical purposes. The need for continuing education, sharing of best practices and development of case studies will be important going forward to ensure that front line staff have the most current information regarding marijuana for medical purposes. The creation of a multidisciplinary team will allow the completion of a needs assessment, content development and delivery of training in relation to marijuana for medical purposes. VAC proposes the following:
- A multidisciplinary team will be established to conduct a needs assessment and develop training content in relation to marijuana for medical purposes. The team will consist of health professionals, front line service delivery staff, and head office service delivery staff as well other appropriate personnel.
- The team will conduct a Needs Assessment to ensure that the training content will meet the needs of front line staff based on the information currently available on this topic.
- The team will develop the training content necessary for front line staff. This includes best practices and other communication pieces as appropriate.
- Health Professionals will determine if and what material can be provided to front line staff before implementation of training.
- The full training package will be rolled out to front line staff. Realizing that the information available on this topic continues to evolve, materials will need to be updated on an ongoing basis.
3.4 Review of VAC Benefits and Services
Based on anecdotal evidence, the review team expected to find that usage of other medication decreased when Veterans began using MMP. The review team compared Veterans receiving MMP 6 months prior to their first reimbursement of MMP with the immediate 6 months following when MMP was used.
Table 4 is a summary of drugs, excluding MMP, approved under VAC’s Program of Choice (POC) 10, Prescription Drugs. The data is issued by transaction, where transaction data equates to the filling of a prescription. The table shows that during the 6 months after a Veteran's first MMP reimbursement, the number of prescriptions being filled for Anti-Depressants, Opioids/Narcotics, and Benzodiazepines decreased slightly. Refills for the other drugs category and anti-psychotics increased slightly.
When the comparison of drug reimbursements is expanded to one year before and one year after a Veteran's first MMP reimbursement, the review team noted a slight increase in the number of prescription refilled. Slight increases were noted in all drug categories with the exception of opioids/narcotics. However, the review team was not able to determine if there was a decrease in the dosage of prescribed drugs. The data does not show a statistically significant variance in use of prescription drugs after the utilization of MMP.
| Category | *# prescription drug transactions 6 mo. before first MMP reimbursement | *# prescription drug transactions 6 mo. after first MMP reimbursement | % change (vs. total trans.) | **# prescription drug transactions 1 year before first MMP reimbursement | **# prescription drug transactions 1 year after first MMP reimbursement | % change (vs. total trans.) |
|---|---|---|---|---|---|---|
| Other Drugs | 8,544 | 8,697 | 1.48% | 10,653 | 11,455 | 1.32% |
| Anti-Depressants | 3,337 | 3,313 | 0.05% | 3,866 | 4,002 | -0.30% |
| Opioids/Narcotics | 2,417 | 2,179 | -1.36% | 2,588 | 2,499 | -1.11% |
| Benzodiazepines | 1,249 | 1,188 | -0.32% | 1,363 | 1,424 | -0.04% |
| Anti-Psychotics | 413 | 432 | 0.14% | 466 | 515 | 0.13% |
| Total | 15,960 | 15,809 | 18,936 | 19,895 |
Source: AED Data Analysis.
Note: For 6 months, first marijuana reimbursement adjudication date was on or before September 30, 2015. For 1 year, first marijuana reimbursement adjudication date was on or before March 31, 2015.
* All POC 10 Drug transactions (excluding marijuana) for 887 Recipients within the parameters noted above
** All POC 10 Drug transactions (excluding marijuana) for 562 Recipients within the parameters noted above
The costs for drugs (excluding MMP) also increased during the periods reviewed. See Table 5. This increase can be attributed to the rising costs of prescription drugs and the increase in prescriptions filled in the one year period.
| Category | *# prescription drug costs 6 mo. before first MMP reimbursement | *# prescription drug costs 6 mo. after first MMP reimbursement | % change (vs. total exp.) | **# prescription drug costs 1 year before first MMP reimbursement | **# prescription drug costs 1 year after first MMP reimbursement | % change (vs. total exp.) |
|---|---|---|---|---|---|---|
| Other Drugs | $ 513,441.91 | $ 651,170.78 | 4.88% | $ 686,528.83 | $ 818,185.85 | 2.86% |
| Anti-Depressants | $ 162,718.45 | $ 174,935.64 | -1.57% | $ 189,068.84 | $ 208,959.74 | -0.54% |
| Opioids/Narcotics | $ 128,368.75 | $ 126,987.87 | -2.33% | $ 154,833.02 | $ 148,757.67 | -2.24% |
| Benzodiazepines | $ 18,052.66 | $ 17,967.71 | -0.32% | $ 16,541.04 | $ 17,532.69 | -0.01% |
| Anti-Psychotics | $ 37,896.77 | $ 37,670.57 | -0.67% | $ 37,779.25 | $ 43,463.90 | 0.03% |
| Total Expenditures | $ 860,478.54 | $ 1,008,732.57 | $ 1,084,750.98 | $ 1,236,899.85 |
Source: AED Data Analysis.
Note: For 6 months, first marijuana reimbursement adjudication date was on or before September 30, 2015. For 1 year, first marijuana reimbursement adjudication date was on or before March 31, 2015.
* All POC 10 Drug transactions (excluding marijuana) for 887 Recipients within the parameters noted above
** All POC 10 Drug transactions (excluding marijuana) for 562 Recipients within the parameters noted above
POC 12 – Related Health Services
VAC Related Health Services, otherwise known as POC 12, are services provided by health care professionals other than physicians, dentists and nurses. Commonly used services are massage therapy, chiropractic, and physiotherapy, as noted in Table 6 below. The review team conducted a similar analysis for POC 12 services as was noted above for the Other Drugs (before and after 6 months and one year). The goal of the analysis was to determine any trends that may be occurring before and after the Veteran receives an MMP authorization.
Although there was an expectation that there would be decreases in all POC 12 services, Table 6 demonstrates an increase in all POC 12 services with the exception of Rehabilitation - Psychology Visit or Operational Stress Injury (OSI) Clinic psychiatrist visit. Definition of the Rehabilitation Program and OSI Clinics can be found in Appendix A. The decrease in Rehabilitation - Psychology Visit or OSI Psychiatrist Visit could be attributed to coding for payment. Many Veterans would be in the Rehabilitation Program or referred to OSI Clinics related to their disability condition. POC 12 services in these cases would be coded to their disability benefit rather than the Rehabilitation Program.
| Treatment Description | *# Related Health Services transactions 6 mo. before first MMP reimbursement | *# Related Health Services transactions 6 mo. after first MMP reimbursement | % change (vs. total trans.) | **# Related Health Services transactions 1 year before first MMP reimbursement | **# Related Health Services transactions 1 year after first MMP reimbursement | % change (vs. total trans.) |
|---|---|---|---|---|---|---|
| Psychologist Visit | 807 | 1,440 | 6.39% | 694 | 1,257 | 3.40% |
| Massage Therapist | 827 | 1,149 | 0.44% | 667 | 1,256 | 4.13% |
| Rehabilitation - Psychology Visit or OSI Psychiatrist Visit | 633 | 547 | -5.88% | 659 | 650 | -6.57% |
| Chiropractor Visit | 406 | 511 | -0.78% | 342 | 572 | 0.83% |
| Physiotherapy Visit | 323 | 495 | 1.03% | 298 | 531 | 1.31% |
| All Other Treatments | 935 | 1,208 | -1.21% | 946 | 1,283 | -3.11% |
| Total Transactions | 3,931 | 5,350 | 3,606 | 5,549 |
Source: AED Data Analysis.
Note: For 6 months, first marijuana reimbursement adjudication date was on or before September 30, 2015. For 1 year, first marijuana reimbursement adjudication date was on or before March 31, 2015.
* All POC 12 transactions for the 805 Recipients within the parameters noted above
** All POC 12 transactions for the 525 Recipients within the parameters noted above
Benefit Costs
Recipient numbers and corresponding costs of MMP have been increasing exponentially since 2009. For example, there has been an increase of 64% in the number of recipients with a corresponding 75% increase in costs between 2014 and 2015. Actual fiscal year 2015-16 costs for related MMP include $20,538,153 for dry product, $203,574 for shipping, and $154,725 for vaporizers, for a total of $20,896,452.
In fiscal year 2015-16, VAC reimbursed 1,745,644 grams at an average price of $11.77 per gram. As noted earlier, the OAG has recommended for VAC to explore ways that costs associated with MMP could be contained. VAC fully agreed with this recommendation.
3.5 Review Observations
The review team observed the following areas in regards to Veteran’s health, safety and well-being and authorizations for MMP:
- Based on current medical research, VAC authorization limit of 10 gram per day is too high;
- Veterans and VAC staff have concerns regarding VAC’s non approval of oils and fresh marijuana particularly from a health point of view (smoking and cancer);
- Staff require additional information and understanding of MMP and its use/purpose and,
- No change was noted in Veterans access to POC 10 benefits (excluding MMP) although an increase was noted in the use of Related Health Services – POC 12.