8. Care using select treatments
Cristina A. Mattison and John N. Lavis
Prescription and over-the-counter drugs 318
Complementary and alternative therapies 331
Dental services 333
Conclusion 342
Copyright © 2016 McMaster University.All rights reserved.
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Any corrections, updates, feedback and suggestions provided do not certify authorship. Please send your comments to mhf@mcmaster.ca.
e appropriate citation for this book chapter is: Mattison CA, Lavis JN. Care using select treatments. In Lavis JN (editor), Ontario’s health
system: Key insights for engaged citizens, professionals and policymakers. Hamilton: McMaster Health Forum; 2016, p. 315-47.
ISBN 978-1-927565-12-4 (Online)
ISBN 978-1-927565-11-7 (Print)
316 Ontario’s health system
Key messages for citizens
• e majority of prescription and over-the-counter drugs, complemen-
tary and alternative therapies, and dental services are paid for by private
insurers or out-of-pocket, with government funding concentrated in
two areas:
•
drugs provided in hospital or covered through programs funded
by the provincial government (Ontario Drug Benet Program and
selected drug and/or disease-specic programs); and
•
dental surgery performed in hospital and dental services covered
through programs funded by provincial and municipal governments.
• Chiropractors, homeopaths, massage therapists, naturopaths and tradi-
tional Chinese medicine practitioners are regulated health professionals
who provide complementary and alternative therapies.
Key messages for health professionals
• In the past decade, the scope of practice of pharmacists has been
expanded to include: 1) prescription renewal and some alterations;
2) certain smoking-cessation prescriptions; 3) administration of u
vaccines to those aged ve years and older; 4) using medication to
demonstrate its use to newly diagnosed patients (e.g., asthma inhalers);
5) select below-the-dermis procedures (e.g., blood glucose testing); and
6) provision of the naloxone kit (for opioid overdoses).
• Complementary and alternative therapies are delivered by practitioners
who work in private practice and do not receive funding from the
government.
• Aside from the dental services oered in hospitals and through select
programs, dental services are also delivered in private practice and with-
out funding from government.
Care using select treatments 317
Key messages for policymakers
• From 2000-01 to 2013-14, public prescription drug costs have steadily
increased, with prescription drug costs to the government and to recip-
ients increasing, in both cases, by 93%, drug costs at formulary prices
increasing by 81%, drug mark-up increasing by 47%, and dispensing
and compounding fees increasing by 170%.
• From 2000-01 to 2013-14, Ontario Drug Benet Program bene-
ciaries and costs have also increased, with the number of beneciaries
increasing by 39% and claims increasing by 200%.
• While the use of complementary and alternative therapies is growing,
they are almost exclusively paid for privately, either out-of-pocket or
through private insurance plans.
• Only 1% of dental service expenditures were publicly nanced in 2010,
and while most dental services are paid for privately, there are a number
of dental programs that support children, people with disabilities, and
those in need of signicant jaw reconstruction (oered in hospitals).
. . .
In this chapter we prole care that involves three broad categories of
treatments: prescription and over-the-counter drugs, complementary and
alternative therapies, and dental services. To begin, we focus on prescrip-
tion and over-the-counter drugs. As covered in Chapter 1, when public
and private spending are combined, drugs are the second largest category of
health-system expenditure, which places them behind hospitals but before
physicians. Complementary and alternative therapies are discussed as they
are increasingly being used by many Ontarians either alongside or instead
of the types of treatments covered in Chapters 6 and 7, even though their
delivery operates entirely outside of the publicly funded health system.
Dental services are also discussed, as they are an often taken-for-granted
category of treatments that are also delivered largely outside the publicly
funded health system.
318 Ontario’s health system
Prescription and over-the-counter drugs
Understanding the role of drugs in health systems is important for three
reasons: 1) prescription and over-the-counter drugs are the most commonly
used therapeutic intervention; 2) such drugs can have major benets, but
they can also cause harm; and 3) drugs are the second most costly comp-
onent of healthcare in Ontario (see Figure 1.2). For example, the Canadian
Health Measures Survey identied that between 2007 and 2011, 41% of
the household population (aged six to 79 years) reported using prescription
drugs, and use increased with age – from 12% among six-to-14-year-olds
to 83% among those aged 65 to 79 years.(1)
ree key features of how prescription and over-the-counter drugs are
governed, nanced and delivered warrant singling out, and we return to
these features in more detail below. First, the provincial government funds
a number of programs to subsidize the cost of drugs for eligible Ontarians
(Table 8.1), however, private sources of funds – both private insurance
and out-of-pocket payments – are relied on by many Ontarians (Table
8.2). Second, pharmacists play a central role in the delivery of prescription
and over-the-counter drugs, and their scope of practice has increased sig-
nicantly over the past decade. ird, the federal government plays a key
role in the approval and regulation of drugs and a national body informs
provincial government decisions about which drugs to fund through its
programs. Where relevant in the sub-sections below, we begin by describ-
ing the context in Ontario and then provide any key relevant federal or
national details.
Program Benet
Ontario Drug Benet
(ODB) Program
Covers most of the cost of prescription drugs, some nutrition products and some
diabetic testing agents as listed in the ODB Program formulary (which includes
approximately 4,400 products), with set fees for patients2
Exceptional Access
Program
Covers most of the cost of prescription drugs not on the approved ODB formulary
and requested by a physician (e.g., when the drugs on the ODB formulary have been
tried but have not worked or an alternative drug is not available on the formulary)
Each request is reviewed according to Exceptional Access Program criteria, which
have been developed by the Committee to Evaluate Drugs (i.e., the Ministry of
Health and Long-Term Care’s expert advisory committee on drug-related issues)
Trillium Drug
Program
Covers most of the cost of prescription drugs for those who have high prescription
drug costs relative to their household income3
Table 8.1: Publicly funded drug programs
1
Continued on next page
Care using select treatments 319
Program Benet
New Drug Funding
Program
Full coverage of approved new and expensive intravenous cancer drugs administered
in regional cancer centres and hospitals
e majority of intravenous cancer drugs are funded through this program, with the
exception of older and less expensive drugs, which are covered under the Systemic
Treatment Quality-Based Program
Special Drugs Program Full coverage of disease-specic drugs when prescribed to outpatients by a designated
centre/physician (e.g., drugs for cystic brosis, Gaucher's disease, schizophrenia,
thalassemia, and children with growth failure)
Inherited Metabolic
Diseases Program
Full coverage of certain outpatient metabolic disorder treatment-related drugs,
supplements, and specialty foods (e.g., infant feeds, low protein foods, and modied
l-amino acid mixtures)
Respiratory Syncytial
Virus Prophylaxis
Program
Full coverage of palivizumab, which is used to prevent serious lower respiratory tract
infections caused by respiratory syncytial virus in infants less than two years of age
(at the start of respiratory syncytial virus season)
Visudyne (Verteporn)
Program
Full coverage of verteporn, which is used to slow the progression of age-related
macular degeneration (an eye-related condition leading to blindness)
Sources: 16; 17; 78-81
Notes:
1 Called the Ontario Public Drug Programs
2 A fee (called a co-payment) of up to $6.11 applies to all prescriptions. Higher income seniors also pay a $100 deductible before the
cost of prescription drugs is covered. Lower income seniors can apply for the Seniors Co-Payment Program, which caps the co-pay-
ment at up to $2 per prescription (the same co-payment paid by social assistance recipients).
3 An income-based deductible of approximately 4% of total household net income, and subsequent co-payment of up to $2 may apply.
Source: 82
Notes:
1 ese data are forecasts from the Canadian Institute for Health Information. We have made an exception to our ‘no forecasts’ rule
(which we explain in Chapter 1) because actual data from earlier years are not publicly available.
2Other public programs include the Non-Insured Health Benets program and other federal government programs.
2013
1
Percentage of
population
Population covered by public and private insurance (thousands)
Private insurers 7,631 54%
Ontario Public Drug Programs 3,831 27%
Uninsured (entirely out-of-pocket) 2,461 17%
Other public programs2 235 2%
Costs by public and private sources ($ millions)
Ontario Public Drug Programs 4,400 39%
Private insurers 4,000 36%
Out-of-pocket 2,600 23%
Other public programs2 200 2%
Total costs 11,200
Table 8.2: Drug coverage and costs by source (public and private), 2013
320 Ontario’s health system
Policies that govern prescription and over-the-counter drugs
e main policies that govern prescription and over-the-counter drugs at
the provincial level are listed in Figure 8.1 and include the:
1) Ontario Drug Benet Act, 1990, which established the current
administration of public drug programs in Ontario and the require-
ments for the formulary;
2) Drug and Pharmacies Regulation Act, 1990, which established the
regulations governing pharmacies;
3) Pharmacy Act, 1991, which established the scope of practice of
pharmacists;
4) Drug Interchangeability and Dispensing Fee Act, 1993, which established
rules for interchanging one prescribed drug with another (containing
the same active ingredients and dosage);
5) Transparent Drug System for Patients Act, 2006, which formalized
the Ontario Public Drug Programs and includes commitments to
consumer/patient engagement, transparency, and using clinical and
economic evidence in drug-funding decisions;
6) Regulated Health Professions Statute Law Amendment Act, 2009, which
expanded the scope of practice for pharmacists, among a number of
other health professions; and
7) Narcotics Safety and Awareness Act, 2010, which established a
monitoring system for the prescribing and dispensing of narcotics and
other monitored drugs, in order to reduce the misuse and abuse of
these types of drugs.
At the federal level, two key policies govern prescription and over-the-
counter drugs:
1) the Food and Drugs Act, 1985, which requires drug manufacturers to
provide scientic evidence on the safety, ecacy and quality of the
product under review in order to obtain authorization to market a
drug in Canada and which, through amendments made by Bill C-17,
requires a robust drug-surveillance system, procedures to recall unsafe
therapeutic products, and clearer labelling for children 12 and under;(2;
3) and
2) the Patent Act, 1985, which established the Patented Medicine Prices
Review Board and which, through amendments made by regulation
SOR/93-133, established the conditions under which generic drugs
can be marketed.(4; 5)
Care using select treatments 321
Under the terms of the Food and Drugs Act, 1985, the erapeutic Products
Directorate of Health Canada’s Health Products and Food Branch regulates
which prescription and over-the-counter drugs, as well as medical devices,
can be oered for sale in Canada.(6) Expedited reviews can be conducted
under special circumstances. For example, the Priority Review Process pro-
vides faster review of promising drugs for life-threatening conditions, and
the Special Access Program allows physicians to prescribe drugs that are
not currently oered in Canada, albeit under very restricted circumstances
(e.g., when standard treatments have failed or are not appropriate in spe-
cic circumstances).(2) On the other hand, some drugs undergo a very
lengthy review process. e issue of approving medications for abortion in
Canada, for example, was prolonged, and the review of Mifegymiso – the
combination of mifepristone and misoprostil that can be used to terminate
pregnancies – began in November of 2012, but was not approved until July
2015, and its use is restricted to patients who can access an ultrasound and
a physician who is registered and trained to prescribe the drug.(7; 8)
Health Canada sets specic guidelines for the marketing of prescription
and over-the-counter drugs. Most notably, direct-to-consumer advertising
of pharmaceutical products (whether using print, broadcast or internet
media) is prohibited in Canada, with the exception of: 1) public health
vaccination campaigns that do not promote a specic product; 2) reminder
advertisements (which include only the brand name and not the drug’s
indications); and 3) disease-oriented or help-seeking advertisements (which
describe the disease or condition but do not include a brand name).(9; 10)
at said, Ontarians are exposed to a signicant amount of pharmaceu-
tical advertising through media from the U.S. Further complicating the
issue is that while direct-to-consumer advertising is not allowed, direct-to-
consumer information campaigns are allowed, and properly distinguishing
between the two requires resources.(11) To ensure compliance with Health
Canada’s guidelines, the Pharmaceutical Advertising Advisory Board
reviews materials for health products directed at health professionals, and
it works with Advertising Standards Canada to review (voluntarily submit-
ted) prescription drug and educational materials on medical conditions
and diseases aimed at consumers.(12)
Under the terms of the Patent Act, 1985, the Patented Medicine Prices
Review Board regulates the ‘factory gate’ ceiling price of patented drugs
(not the wholesale price or the retail price charged by pharmacies) and
322 Ontario’s health system
Figure 8.1: Prescription and over-the-counter drugs
Provincial
PlacesPeople
‘Technology’
provision
1
Home and
community care
Primary care Specialty care
PoliciesPrograms
Regulated Health Professions Statute Law Amendment Act, 2009
Narcotics Safety and
Awareness Act, 2010
Transparent Drug System
for Patients Act, 2006
Drug Interchangeability and
Dispensing Fee Act, 1993
Pharmacy Act, 1991
Ontario Drug Benet
Act, 1990
Drug and Pharmacies
Regulation Act, 1990
Narcotics Monitoring
System
Universal Inuenza
Immunization Program
MedsCheck Program
Pharmacy Smoking
Cessation Program
Pharmaceutical Opinion
Program
Ontario Naloxone
Pharmacy Program
Ontario Public Drug
Programs
Ontario Drug
Benet Program
3
Selected drug and/or
disease-specic
programs
4
Pharmacists who dispense, physicians and others who prescribe, drug research and
development professionals, and other regulated health professionals
Health professional associations (e.g., Ontario Pharmacists Association)
Citizens and patients
Committee to Evaluate Drugs, Ontario Pharmacy Council,
Ontario Citizen’s Council, and Citizen’s Reference Panel on Health Services
Professional servicesProfessionals Drug coverageCitizens
Community pharmacies, hospitals, long-term care homes, and in primary care as a part of Family Health Teams
Care using select treatments 323
Sources: 2; 13; 15; 17; 26;
28-31; 33-37; 44;
79-81; 83; 84
Notes:
1
In this case, ‘technology’
includes prescription and
over-the-counter drugs
and vaccines (not devices,
diagnostics and surgeries
as are sometimes included
in this column).
2
Bans direct-to-consumer
advertising for prescrip-
tion drugs under two
provisions of the Food
and Drugs Act, 1985
(Schedule A and Schedule
F)
3
Includes Trillium Drug
Program, Exceptional
Access Program and
Compassionate Review
Policy
4
Includes the last ve pro-
grams listed in Table 8.1
Provincial Federal
Places People
Long-term care Public health
Food and Drugs Act, 1985
2
Patent Act, 1985
First Nations and Inuit
Health Branch
Non-Insured Health
Benets
Veterans Affairs Canada
Health Care Benets
Program
Health Canada - Health
Products and Food Branch
Therapeutic Products
Directorate
Royal Canadian Mounted
Police
Public Service Health
Care Plan
Canadian Agency for
Drugs and Technology
in Health
Status First Nations peoples
and eligible Inuit, Canadian
Armed Forces, veterans,
Royal Canadian Mounted
Police, and federal offenders
Correctional Services
Canada
Health Services Program
Policies Programs
Department of National
Defence
Spectrum of Care
Patented Medicines Prices
Review Board
Patented Medicines
Regulations, 1994
Canadian Expert Drug
Advisory Committee,
Common Drug Review,
pan-Canadian Oncology
Drug Review, and
pan-Canadian
Pharmaceutical Alliance
324 Ontario’s health system
reports on prescription drug-price trends and on research and development
spending by pharmaceutical companies.(13) e board began operation in
1987 and is part of the federal government’s ‘Health Portfolio,’ although
it operates at arm's-length from the minister of health and independ-
ently from Health Canada, which is the federal government’s health depart-
ment.(13) e Patented Medicine Prices Review Board has jurisdiction
over ‘factory-gate’ prices (i.e., product price at the factory) for patented
prescription and over-the-counter drugs, and does not extend to whole-
saler or retailer pricing.(14)
While also formally part of governance arrangements, we address below
– in the sub-section on ‘places and people’ – the scope of practice of phar-
macists and the few health professions who can prescribe drugs.
Drug programs
Publicly funded drug programs (Figure 8.1) are administered as part of the
Ontario Public Drug Programs, which were re-designed to their current
form in 2007 through the Transparent Drug System for Patients Act,
2006.(15) e majority of the drugs oered through the Ontario Public
Drug Programs are listed on the Ontario Drug Benet (ODB) Program
formulary, with the exception of those covered through the Exceptional
Access Program and its associated Compassionate Review Policy. ere are
around 4,400 drug products listed on the ODB Program formulary.(16)
e Exceptional Access Program provides access to over 850 drugs that are
not covered by the formulary, but are approved for sale in Canada.(15) In
2013-14, approximately 64,200 Exceptional Access Program requests were
made and 52,000 were approved (81%).(17)
e Ontario Public Drug Programs (Table 8.1) include the:
1) ODB Program for those aged 65 and older, recipients of home care,
residents of Homes for Special Care and long-term care homes, and
recipients of social assistance through either Ontario Works or the
Ontario Disability Support Program;
2) Exceptional Access Program for those meeting the eligibility criteria
for the ODB Program and, as noted above, needing drugs that are not
covered on the formulary but were requested by a physician (and that
are usually expensive drugs and only cost-eective in a small group of
patients);
Care using select treatments 325
3) Trillium Drug Program for those with very high drug costs relative to
household income (those who do not qualify for the ODB Program
can apply for the Trillium Drug Program);
4) New Drug Funding Program for select intravenous cancer drugs, which
are often very expensive (see Chapter 7);
5) Special Drugs Program for a range of serious conditions (e.g., full
outpatient drug coverage for cystic brosis and thalassemia, among
others, and including clozapine for schizophrenia);
6) Inherited Metabolic Diseases Program for those with metabolic disorders
(full outpatient drug coverage, as well as coverage of supplements and
specialty foods);
7) Respiratory Syncytial Virus Prophylaxis Program for high-risk infants
(full coverage of palivizumab, which is used to prevent serious lower
respiratory tract infections); and
8) Visudyne (Verteporn) for those with age-related macular degen-
eration.(18; 19)
e Ministry of Health and Long-Term Care’s Drugs for Rare Disease
framework was created in 2007 by a panel of clinical and health technol-
ogy assessment experts as a response to the lack of a national strategy.(20)
A draft of the framework is used to assess funding requests for drugs for
rare diseases. Five drugs have been evaluated using the framework, three of
which are available through the Exceptional Access Program.(20; 21)
e Ontario Public Drug Programs are responsible for: 1) determining
which products should be eligible for public reimbursement, which is done
based on recommendations from the Committee to Evaluate Drugs; 2)
making funding decisions; and; 3) negotiating agreements with drug man-
ufacturers as appropriate.(15)
In making its recommendations, the Committee to Evaluate Drugs, which
is comprised of 16 members (physicians with additional expertise in drugs
or critical appraisal, pharmacists, health economists, and two patient rep-
resentatives), considers recommendations about patented drugs from the
Canadian Drug Expert Committee (or, in the case of cancer drugs, from
the pan-Canadian Oncology Drug Review’s Expert Review Committee)
and extensive drug reviews provided through the broader Common Drug
Review.(22) Up until 2003, provinces and territories conducted drug
reviews independently. e Common Drug Review is the result of a
2002 intergovernmental agreement to ensure that publicly funded drugs
326 Ontario’s health system
are cost-eective, while eliminating duplication of eorts across jurisdic-
tions.(23; 24) e Common Drug Review is coordinated by the Canadian
Agency for Drugs and Technologies in Health, an independent, not-for-
prot organization that was created in 1989 by federal, provincial and
territorial governments in an eort to centralize the review of health tech-
nologies and drugs, and the provision of recommendations.(25)
e Ontario Public Drug Programs’ executive ocer has the nal decision
as to whether a drug should be listed on the formulary or made available
through the Exceptional Access Program.(15) rough the Compassionate
Review Policy, the executive ocer, with the assistance of expert clinical
reviewers, can consider funding requests on a case-by-case basis in instances
where a quick decision is needed (e.g., due to life-, limb- or organ-threat-
ening conditions).(15)
e federal government manages public drug plans for select populations:
1) status First Nations peoples and eligible Inuit through the First Nations
and Inuit Health Branch’s Non-Insured Health Benets program,
which will likely be extended to non-status First Nations and Métis
in light of the 2016 Supreme Court decision (see Chapter 9 for more
details on Indigenous health);(26)
2) members of the Canadian Forces (and their dependents) through the
Department of National Defence’s Spectrum of Care program, which
includes the Canadian Armed Forces Drug Benet List;(27; 28)
3) qualied veterans through Veterans Aairs Canada’s Programs of
Choice, which includes the Health Care Benets Program;(29)
4) Royal Canadian Mounted Police through the Public Service Health
Care Plan;(30) and
5) federal oenders through Correctional Service Canada’s Health Services
Program.(31 )
Places and people involved in prescription and over-the-counter drugs
Prescription and over-the-counter drugs are available through pharma-
cies, with private for-prot community pharmacies located in abundance
in most non-remote communities. In 2015 there were 4,012 community
pharmacies in Ontario, of which:
• 49% (1,967) are independently owned;
• 26% (1,051) are franchises (e.g., Shoppers Drug Mart) or banner
Care using select treatments 327
retailers (e.g., Guardian);
• 22% (872) are large chains (greater than 15 stores) (e.g., Rexall); and
• 3% (122) are small chains (from three to 15 stores).(32)
Pharmacy departments are important components of hospitals, providing
prescription and clinical pharmacy assistance to patients and prescribers.
Most pharmacists work in pharmacies, but some can be found in home and
community care organizations, as members of Family Health Teams, and
in long-term care homes.(33) As part of the Regulated Health Professions
Statute Law Amendment Act, 2009, the government expanded the role of
pharmacists.(34) Pharmacists’ scope of practice and/or publicly funded
practice has grown to include:
1) one 30-minute annual review of prescriptions for those taking a
minimum of three medications for a chronic condition, which was
expanded in 2010 to include residents of long-term care homes,
people living with diabetes, and people who are home-bound (through
MedsCheck);
2) inuenza vaccine administration in those aged ve and up, through the
Universal Inuenza Immunization Program;
3) prescription of certain smoking-cessation drugs, through the Pharmacy
Smoking Cessation Program
4) renewal and adaptation (e.g., dosage amounts) of some prescription
medications, through the Pharmaceutical Opinion Program;
5) injections or inhalations to patients for education or demonstration
purposes;
6) procedures on tissue below the dermis for the limited purposes of
patient self-care education and chronic-disease monitoring (e.g., blood
glucose monitoring); and
7) naloxone kit provision without a prescription and at no cost, which
involves training from the pharmacist on how to properly administer
the drug to treat opioid overdose (intramuscular injection), through
the Ontario Naloxone Pharmacy Program.(20; 34-37)
Under the terms of the Narcotics Safety and Awareness Act, 2010, phar-
macists also contribute data about the dispensing of narcotics and other
controlled substances to the Narcotics Monitoring System, and receive
warning messages about potential misuse.(17) Pharmacists are represented
by the Ontario Pharmacists Association.
Only physicians, dentists, nurse practitioners, midwives and (as noted, in
328 Ontario’s health system
limited ways) pharmacists are allowed to prescribe drugs to humans (and
veterinarians can prescribe drugs to animals). In its 2014 election plat-
form, the Liberal Party signalled the Government of Ontario’s intent to
further expand nurses’ and pharmacists’ ability to prescribe.(38; 39) e
Health Professions Regulatory Advisory Council recently reviewed three
models for registered nurse prescribing (independent prescribing, supple-
mentary prescribing, and use of protocols) and made recommendations to
the Minister of Health and Long-Term Care on prescribing by registered
nurses in Ontario.(40)
National-level associations represent the brand-name pharmaceuti-
cal industry (Innovative Medicines Canada, which was formerly called
Rx&D), generic-drug industry (Canadian Generic Pharmaceutical
Association), and homeopathic product manufacturers and distributors
(Canadian Homeopathic Pharmaceutical Association).(41-43) A national
initiative (the pan-Canadian Pharmaceutical Alliance) has been created
to achieve greater value for brand-name and generic drugs for publicly
funded drug programs, with Ontario leading the brand-name-drugs
initiative and Nova Scotia and Saskatchewan co-leading the generic-drug
initiative.(44) Other national (non-governmental) initiatives, such as the
Canadian Deprescribing Network and Choosing Wisely Canada, have
been created to reduce the use of potentially inappropriate prescription
and over-the-counter drugs.(45)
Governance, financial and delivery arrangements for prescription and
over-the-counter drugs
e governance arrangements for prescription and over-the-counter drugs
have been established through the provincial and federal government pol-
icies described above. In terms of nancial arrangements, just over half
(54%) of Ontarians are covered by private insurers, 27% are covered by
Ontario Public Drug Programs, 17% are uninsured (i.e., requiring out-
of-pocket payments for all drugs), and the remaining 2% are covered by
federal government programs (Table 8.2, noting that in this table we have
made an exception to our ‘no forecasts’ rule because actual data from ear-
lier years are not publicly available). e number of ODB Program claims
have increased signicantly over time, increasing by 200% between 2000-
01 and 2013-14 in 2002 dollars (Table 8.3). Most notably, among ODB
Program beneciaries, those covered through the Trillium Drug Program
Care using select treatments 329
Indicators
Beneciaries and costs
1,2
2000-01 2010-11 2013-14
13-year
percentage
change2
All beneciaries and claims (thousands)
Beneciaries 2,080 2,600 2,900 39%
Claims 49,000 124,000 147,000 200%
Beneciaries by ministry (thousands)
Health and long-term care — 1,970 2,180 —
Community and social services — 670 700 —
Beneciaries by type (thousands)
Core senior3 884 1,383 1,609 82%
Ontario Disability Support
Program4
250 351 392 57%
Ontario Works4 368 344 332 -10%
Lower income senior5 411 300 283 -31%
Trillium Drug Program 52 189 190 265%
Long-term care6 41 102 103 82%
Home care7 68 85 92 57%
Beneciaries by age or program (thousands)
≥65 1,405 1,746 1,961 40%
<65 593 690 716 21%
Trillium Drug Program 61 179 190 211%
Cost per beneciary
Long-term care
$1,469 $3,227 $3,134
113%
Home care
$1,927 $2,018 $2,267
18%
Ontario Disability Support
Program $1,402 $2,087 $2,230 59%
Trillium Drug Program
$1,654 $1,652 $2,001
21%
Lower income senior
$1,339 $1,969 $1,920
43%
Core senior
$1,104 $1,997 $1,223
11%
Ontario Works
$230 $429 $499
117%
Table 8.3: Ontario Drug Benefit Program beneficiaries and costs
, 2000-01 to 2013-14
Sources: 82; 85-88.
Notes:
1
Ination adjusted to 2002, according to Statistics Canada's Consumer Price Index (healthcare), CANSIM 326-0020: value x (CPI
2002/CPIi) = value (2002) where i = year
2 Data not available for the specic reference period are denoted by —.
3 Refers to the majority of seniors eligible for the Ontario Drug Benet (ODB) Program, for whom the regular ODB Program deduct-
ible (the rst $100 of the prescription cost) and co-payment ($6.11 for each approved prescription lled) apply
4 Oered through the Ministry of Community and Social Services and includes health benets for those requiring nancial assistance
5 Refers to ODB Program-eligible seniors who meet one of the seniors co-payment income thresholds (e.g., pay up to $2 per prescrip-
tion if they are a single senior with a yearly net income of less than $19,300 or a senior couple with a combined yearly income of less
than $32,300)
6
Long-term care included Homes for Special Care in 2000-01
7
Home care included Homes for Special Care in 2010-11 and 2013-14
330 Ontario’s health system
Indicator
Costs1,2 ($ millions)
3-year
percentage
change
13-year
percentage
change
2000-012 2010-11 2013-14
Prescription cost breakdown
Drug cost3
$1,727 $2,916 $3,129
7% 81%
Mark-up4
$163 $222 $239
8% 47%
Dispensing and
compounding fees $328 $695 $887 28% 170%
Cost to payer
Government cost
$1,956 $3,404 $3,768
11% 93%
Ministry of Health and
Long-Term Care — $2,666 $2,891 8% —
Ministry of Community
and Social Services — $738 $877 19% —
Recipient cost5
$262 $435 $505
16% 93%
Cost by type of drug
Brand name —
$2,523 $2,696
7% —
Generic —
$1,317 $1,597
21% —
Exceptional Access Program
— $263 $419 59% —
Cancer drugs costs
Ontario Drug Benet
Program — $183 $230 26% —
New Drugs Funding
Program6 — $186 $223 20% —
Special Drugs Program
—
$112 $91
-19% —
Table 8.4: Publicly funded prescription-drug costs
, 2000-01 to 2013-14
Sources: adapted from 85-89
Notes:
1 Ination adjusted to 2002, according to Statistics Canada's Consumer Price Index (healthcare), CANSIM 326-0020: value x (CPI
2002/CPIi) = value (2002) where i = year
2 Data not available for the specic reference period are denoted by —.
3 Cost of a drug at formulary prices
4 Total mark-up paid per eligible claim (maximum 8%)
5 Co-payment and deductible
6 Administered by Cancer Care Ontario
have increased by 265% over the same time period. Similarly, publicly
funded prescription-drug costs have increased signicantly between 2000-
01 and 2013-14: measured in 2002 dollars, drug costs have increased by
81%, mark-up by 47%, and dispensing and compounding fees by 170%
(Table 8.4). Delivery arrangements for prescription and over-the-counter
drugs in Ontario include: 4,012 pharmacies as of 2015, mostly in com-
munity settings; 12,630 pharmacists as of 2013; and 93 pharmacists per
100,000 population as of 2013 (see Tables 5.2 and 5.3).
Care using select treatments 331
Complementary and alternative therapies
Regulated complementary and alternative therapies include:
1) chiropractic, which involves the diagnosis and treatment of health
issues of the muscular, nervous and skeletal system, with a particular
focus on the spine;
2) homeopathy, which involves giving very small doses of natural sub-
stances that are purported to cause the body to produce an immun-
ological and therapeutic benet (where large doses could cause
symptoms of the disease itself);
3) massage therapy, which involves working and acting on the body with
pressure;
4) naturopathy, which involves the use of acupuncture, herbal medicine
and homeopathy, as well as diet and lifestyle counselling; and
5) traditional Chinese medicine, which involves the use of acupuncture,
cupping, herbal medicine and massage, among other approaches.
e health professionals providing such therapies have only become for-
mally regulated in the last one to two-and-a-half decades. ere are many
other unregulated health workers providing complementary and alternative
therapies, such as herbalists, osteopaths and Reiki practitioners. And while
such therapies are increasingly being used by Ontarians, they are almost
exclusively paid for privately, either out-of-pocket or through private-in-
surance plans (which tend to have relatively limited coverage). Moreover,
there is relatively little integration of such therapies in the care provided
in any of the sectors described in Chapter 6, or for any of the conditions
described in Chapter 7.
Policies that govern complementary and alternative therapies
e major policies that govern complementary and alternative therapies
are the Regulated Health Professions Act, 1991, and the acts specic to com-
plementary and alternative therapy-providing professions:
1) Chiropractic Act, 1991;
2) Massage erapy Act, 1991;
3) Traditional Chinese Medicine Act, 2006;
4) Homeopathy Act, 2007; and
5) Naturopathy Act, 2007.
ese acts establish what these professions can do, and provide for the
332 Ontario’s health system
establishment of the regulatory colleges that govern them (College of
Chiropractors of Ontario, College of Massage erapists of Ontario,
College of Traditional Chinese Medicine Practitioners and Acupuncturists
of Ontario, College of Homeopaths of Ontario, and College of Naturopaths
of Ontario). More detail about such regulatory colleges is provided in
Chapter 5.
At the federal government level, the Natural Health Products Regulations
(SOR/2003-196) accompanying the Food and Drugs Act, 1985, stipulates
that natural health products that are classied as a drug must follow the
drug-review process, which includes clinical trials to prove safety and e-
cacy, and must have a Drug Identication Number to be sold.(46) Also,
the amendments made by Bill C-17 to the Food and Drugs Act (which were
mentioned earlier in this chapter), mean that Health Canada will no longer
approve any health claims for homeopathic cough, cold and u products
for children 12 and under unless they are backed by scientic evidence.
Natural health products that are classied as food are limited in the claims
they can make and do not have to provide as much safety information in
their labelling.(46)
Programs that involve complementary and alternative therapies
ere are no publicly funded programs available to Ontarians, however,
the Workplace Safety and Insurance Board (which, as described in Chapter
7, is funded by employer premiums) pays for some chiropractic care and
massage therapy for workers who require treatment for musculoskeletal
injuries.(47) Also, the Ontario Disability Support Program oered through
the Ministry of Community and Social Services provides nancial support
to help with travel costs for therapies or treatments provided by any of the
28 health professions regulated under the Regulated Health Professions Act,
1991, which includes the ve professions being discussed here.(48)
Places and people involved in complementary and alternative
therapies
Complementary and alternative therapies are primarily provided in private
clinics and oces, although they can be provided in a client’s home (e.g.,
massage therapy), in some primary-care oces and clinics (e.g., chiro-
practic), and in some hospitals, rehabilitation centres, and long-term care
Care using select treatments 333
homes (e.g., massage therapy). With the exception of traditional Chinese
medicine practitioners, the regulated health professions providing com-
plementary and alternative therapy are represented by their respective
associations, namely the Ontario Association of Naturopathic Doctors,
Ontario Chiropractic Association, Ontario Homeopathic Association, and
Registered Massage erapists’ Association of Ontario.
Governance, financial and delivery arrangements for complementary
and alternative therapies
e governance arrangements that are the most relevant to complemen-
tary and alternative therapies have been covered in the ‘policies’ section
above and pertain to the regulation of the ve health professions. e
key nancial arrangement for this type of care is the complete reliance on
out-of-pocket payment or coverage through private insurers. In terms of
delivery arrangements, there are 12,660 registered massage therapists as
of 2014, 4,515 chiropractors as of 2013 (see Table 5.2), 2,952 registered
traditional Chinese medicine practitioners as of 2015, 1,425 registered
naturopaths as of 2015, and 396 registered homeopaths as of 2016.(49-52)
Naturopaths can be trained in only one school in Canada (Canadian
College of Naturopathic Medicine), and chiropractors can be trained in
only one school in Ontario (Canadian Memorial Chiropractor College)
and one in the rest of Canada (which operates in French in Quebec),
whereas registered massage therapists, traditional Chinese medicine prac-
titioners and registered homeopaths can obtain their training through a
number of colleges.
Dental services
Dental services include:
1) preventive services (e.g., regular check-ups that may include teeth
cleaning, uoride applications, ssure sealants, and X-rays);
2) curative services, which range from restorative treatments (e.g., dental
llings) to endodontics (e.g., root canals), orthodontics (e.g., braces),
periodontics (e.g., gum therapies) and prosthodontics (e.g., dentures),
as well as oral surgery (e.g., tooth extractions and dental implants); and
3) cosmetic procedures (e.g., veneers and braces), increases in which reect
a change in focus from oral function to appearance.
334 Ontario’s health system
Dental visits in Ontario are primarily preventive and curative in nature,
although one in ve visits are related to dental emergencies.(53)
e health professionals involved in providing dental services include:
1) dental hygienists, who focus primarily on oral disease prevention (e.g.,
scaling teeth and administering topical uoride) and who can also work
independently or alongside dentists;
2) dentists, who diagnose, prevent, and treat diseases and conditions of
the oral cavity and who can be involved in primary care (most dentists)
or specialty care (those with a certication in anesthesiology, endodon-
tics, oral and maxillofacial surgery, orthodontics, pediatric dentistry,
periodontics, prosthodontics, dental public health, oral pathology and
oral radiology);
3) denturists, who design, construct, repair and alter dentures (i.e., remov-
able oral prostheses) and who can work independently or alongside
dentists;
4) dental technologists, who design, construct, repair and alter dentures,
implants and orthodontic devices and who work alongside dentists and
denturists; and
5) dental assistants, who provide clinical and administrative assistance to
dentists and dental hygienists but who cannot work independently of
such health professionals.
Similar to complementary and alternative therapies, dental services are
largely paid for privately, either out-of-pocket or through private insur-
ance plans (which often require signicant cost-sharing by patients). In
Ontario in 2010, only about 1% of dental-service expenditures were paid
for by government,(54; 55) which would place Ontario (if it were a coun-
try) very low in a ranking of Organisation for Economic Cooperation
and Development (OECD) countries by extent of public nancing. Two
thirds (68%) of Ontarians reported in 2005 that they have private dental
insurance, with the percentage dropping for older adults (36%) and for
those with lower income (40%) and education (41%).(53) Even those with
private dental insurance can face limits on service units or frequency, signif-
icant cost-sharing, and yearly and lifetime maximums on reimbursement.
Care using select treatments 335
Policies that govern dental services
e key policies governing the provision of dental services by health pro-
fessionals (Figure 8.2) include the:
1) Regulated Health Professionals Act, 1991, which rearmed dentistry
and denturism and established dental hygiene and dental technology
as regulated health professions that are overseen by the Royal College
of Dental Surgeons of Ontario, the College of Dental Hygienists of
Ontario, the College of Denturists of Ontario, and the College of
Dental Technologists of Ontario, respectively (as well as the Regulated
Health Professions Statute Law Amendment Act, 2009, which makes
changes to scopes of practice for dentists, dental hygienists, and dental
technologists);
2) Dentistry Act, 1991, which established the self-regulation regime for
dentists;
3) Dental Hygiene Act, 1991, which established the self-regulation regime
for dental hygienists;
4) Denturism Act, 1991, which established the self-regulation regime for
denturists; and
5) Dental Technology Act, 1991, which established the self-regulation
regime for dental technologists.
As noted earlier in this chapter, dentists are like physicians, nurse practi-
tioners, midwives, and (in limited ways) pharmacists in being allowed to
prescribe drugs to humans, which means that dentists are also governed by
policies such as the Narcotics Safety and Awareness Act, 2010, which estab-
lished a monitoring system for the prescribing and dispensing of narcotics
and other monitored drugs. Dental assistants are not a regulated health
profession and the Ontario Dental Assistants Association acts as the certi-
fying body (and membership association) for them.
Policies governing the provision of dental services in three of the six sectors
described in Chapter 6, namely specialty (hospital) care, long-term care
and public health, include the:
1) Health Insurance Act, 1990, which established the dental services
(most notably hospital-based surgical procedures provided by a dental
surgeon) covered under the Ontario Health Insurance Plan (OHIP)
Schedule of Benets;
2) Nursing Homes Act, 1990, which established that dental services will be
arranged for long-term care home residents, albeit at their own expense;
336 Ontario’s health system
Figure 8.2: Dental services
Provincial
PlacesPeople
‘Technology’
provision
Dental hygienists, general practitioner dentists, certied dental specialists, denturists,
dental technologists, registered nurses, registered practical nurses, and other
regulated health professionals, as well as dental assistants, personal support workers
and other unregulated health workers
Citizens, parents and caregivers
Dental health professional associations (e.g., Ontario Dental Association and
Ontario Association for Public Health Dentistry)
Ontario Clean Water Agency
Home and
community care
Primary care Specialty care
ProfessionalsCitizens
Regulated Health Professions Act, 1991, Regulated Health Professions Statute Law
Amendment Act, 2009
Oral and Maxillofacial
Rehabilitation
Hospitals
Health Insurance Act, 1990
Narcotics Safety Awareness Act, 2010
Dentistry Act, Dental Hygiene Act,
Denturism Act, Dental Technology Act, 1991
Oral hygiene care in the
community (for those
needing help with activities
of daily living)
Private ofces and clinics
Pharmacies
PoliciesPrograms
Care using select treatments 337
Sources: 54; 90-95
Provincial Federal
Places People
Long-term care Public health
Public Health Agency of
Canada Act, 2006
Programs available to select
groups (status First Nations
and eligible Inuit through
Non-Insured Health
Benets, Canadian Armed
Forces through Spectrum
of Care, Royal Canadian
Mounted Police through
Public Service Health Care
Plan, and federal offenders
through Health Services
Program)
Status First Nations
peoples and eligible Inuit,
Canadian Armed Forces,
veterans, Royal Canadian
Mounted Police, and
federal offenders
Local public health
agency clinics
Elementary schools
(for dental screenings)
Municipal waterworks
Policies Programs
Long-Term Care
Homes Act, 2007
Nursing Homes Act, 1990
Health Protection and
Promotion Act, 1990
Healthy Smiles Ontario
Municipal water
uoridation
Fluoridation Act, 1990
Safe Drinking Water
Act, 2002
Dentistry Act, 1991
Oral hygiene care in
long-term care homes (for
those needing help with
activities of daily living)
338 Ontario’s health system
3) Long-Term Care Homes Act, 2007, which established the nature of the
oral care provided for residents (e.g., daily mouth care and physical
assistance, and an oer of an annual dental assessment, which is subject
to payment authorization); and
4) Health Protection and Promotion Act, 1990, which established the
mandatory health programs and services (which include some dental
services) to be provided by boards of health and which we return to
below.
Several other policies established specic eligibility criteria for the dental
services provided as part of social service and public health programs,
including the:
1) Children and Family Services Act, 1990, which established the right for
‘children in care’ to receive dental services;(56)
2) Ontario Works Act, 1997, which established the health benets, includ-
ing dental services, for Ontarians receiving social assistance payments
and their dependents;(57) and
3) Ontario Disability Support Act, 1997, which established the health ben-
ets for Ontarians living with a disability and needing help with living
expenses.(58)
ese policies are not shown in Figure 8.2 because they are outside the
formal health system per se. While not acts and regulations (i.e., legal
instruments), the Ontario Public Health Standards set the parameters for
many of these services (as described in more detail in Chapter 6). Points of
intersection with care for select conditions (Chapter 7) include the role of
dental professionals in the diagnosis and treatment of some work-related
oral injuries, and in screening for oral cancers through routine check-ups.
Policies governing the provision of population-based dental services include
the:
1) Fluoridation Act, 1990, which established a provision for municipal
governments to create, maintain and operate a water-uoridation
system in connection with a municipal waterworks system;(59) and
2) Safe Drinking Water Act, 2002, which established the regulation of
drinking water systems and drinking water testing, and the subsequent
Ontario Drinking Water System Regulation (O.Reg. 170/03), which
requires yearly publication of drinking water quality reports by munic-
ipalities.(60; 61)
e Public Health Program Standards contain a protocol that outlines
Care using select treatments 339
the actions needed when uoride levels fall below the therapeutic
range (0.6 - 0.8 ppm) or above the maximum acceptable concentration
(1.5 ppm).(62) As of 2007, 76% of Ontarians (9,229,015) have access to
uoridated water.(63) Including uoride in health products can also be
considered a population-based dental service. When such products con-
tain a large concentration of uoride (e.g., toothpaste and dental rinse)
and carry a therapeutic claim, they are considered under the Food and
Drugs Act, 1985 and regulated under the Natural Health Products Reg-
ulations.(64)
As may be inferred from the description of these policies, the public stew-
ardship role set for government is relatively limited for dental services
compared to many other healthcare services. Moreover, in Ontario there is
no chief dental ocer, although there is one at the federal level, within the
Public Health Agency of Canada. And with the exception of the limited
data collection mandated by the Public Health Program Standards, there
are no province-level data collected on dental services and dental health
(54) and hence no public reporting about access to dental services (e.g.,
how many people do not seek care or return for recommended treatments
because of cost), costs of dental services (e.g., how much do people pay,
including out-of-pocket) or outcomes of dental services (e.g., Community
Periodontal Index or number of missing teeth).
Programs that involve dental services
Publicly funded dental programs in Ontario are primarily aimed at chil-
dren through the Healthy Smiles Ontario program, with a small subset
focusing on people with disabilities and those in need of signicant surgi-
cal dental services delivered in hospital (Table 8.5). Covered dental services
focus mainly on prevention (e.g., uoride application) and basic treatment
(e.g., llings, root canals, dentures and extractions), not cosmetics (e.g.,
whitening, veneers and orthodontics).
Similar to the federal government-funded drug plans for select groups out-
lined in the prescription and over-the-counter drugs section, the federal
government funds dental services for the following groups:
1) status First Nations peoples and eligible Inuit through the First Nations
and Inuit Health Branch’s Non-Insured Health Benets program,
which will likely be extended to non-status First Nations and Métis
340 Ontario’s health system
Program
1
Services Who delivers/funds Who is covered
Children
Elementary school
dental screenings
Visual screening lasting
30-60 seconds
Local public health agen-
cies with funding from
the Ministry of Health
and Long-Term Care and
municipal governments
Children in junior and senior
kindergarten and grade 2, and
for children in grades 4, 6 and
8 in high-need schools
Healthy Smiles
Ontario
Preventive care and basic
and urgent treatments
(e.g., check-ups, cleaning,
scaling, X-rays and llings)
for children in low-income
households without access
to any form of dental
coverage
Ministry of Health and
Long-Term Care
Children 17 years and
younger who do not have
access to any form of dental
coverage and whose house-
hold income falls below a
certain threshold (which varies
depending on the number of
children in the home)
Children and adults
Ontario Disability
Support Program
Basic dental services as
well as additional services
if the disability, prescribed
medications or treatment
aect oral health (available
through the Dental Special
Care Plan)
Ministry of Community
and Social Services
Adults registered in the
program as well as spouse
(children 17 years and
younger are automatically
enrolled in the Healthy Smiles
Ontario program)
Assistance for
Children with
Severe Disabilities
Dental services, among
other healthcare-related
costs, that can be paid for
using the $25 to $440 per
month provided (with
the amount received
depending on income and
disability severity)
Ministry of Children and
Youth Services
Parent(s) or legal guardian
whose child is under 18 years,
living at home, and has a
severe disability (children 17
years and younger are part of
the Healthy Smiles Ontario
program)
Adults
Ontario Works Basic dental services Ministry of Community
and Social Services
Adults registered in the
program as well as spouse
(children 17 years and
younger are automatically
enrolled in the Healthy Smiles
Ontario program)
Oral and
Maxillofacial
Rehabilitation
Program
Surgical placement of
dental implants to attach a
prosthetic device
Ministry of Health and
Long-Term Care
Adults (18 years and older)
who hold a valid health card,
and are assessed as a suitable
candidate for dental implant
surgery
Table 8.5: Dental programs
Sources: 54; 90-97
Notes:
1
With the exception of the programs listed in the table and dental surgery performed in hospital, regular dental services are not publicly
covered under the Ontario Health Insurance Plan and residents of Ontario must pay the cost of these services out-of-pocket or through
their private insurance plans. Also, in January 2016, six publicly funded dental programs were combined into the new Healthy Smiles
Ontario program (dental benets for children under Ontario Works, Ontario Disability Support Program, Assistance for Children
with Severe Disabilities, Children In Need Of Treatment, Healthy Smiles Ontario, and preventive oral health services provided by
local public health agencies).(97)
Care using select treatments 341
in light of the 2016 Supreme Court decision (see Chapter 9 for more
details on Indigenous health);(65)
2) members of the Canadian Forces (and their dependents) through the
Department of National Defence;(66)
3) qualied veterans through Veterans Aairs Canada;(67)
4) Royal Canadian Mounted Police through the Public Service Health
Care Plan;(30) and
5) federal oenders through Correctional Service Canada.(31)
Places and people involved in dental services
Most primary and specialty dental services are provided in private oces
and clinics, and typically not alongside family physicians or other prim-
ary-care team members or alongside medical specialists or other specialty
team members (Figure 8.2). In select cases, dental services are provided in
local public health agency clinics and Community Health Centres, and
sometimes alongside other public health practitioners. e maintenance
of good oral hygiene is handled by most Ontarians themselves (or in the
case of younger children, by their parents), however, those needing help
with activities of daily living may receive oral hygiene care in their home or
in a school, hospital or long-term care home. Ontarians buy many dental
products (e.g., toothpaste, toothbrushes, and interdental cleaning products
like dental oss) in pharmacies. Water uoridation takes place in munici-
pal waterworks.
e people involved in providing dental services include citizens and care-
givers as noted above, as well as dental hygienists, dentists, denturists, dental
technologists and dental assistants, who are in turn represented by their
respective professional associations (e.g., Ontario Dental Association). e
Royal College of Dental Surgeons of Ontario (the regulatory college for
dentists) oers an online ‘nd a dentist’ service on its website. Registered
nurses and registered practical nurses provide assessments of oral health
and hygiene practices, and develop care plans for adults requiring help with
their activities of daily living (in the home and community sector, hospitals
and long-term care homes).(68) Similarly, personal support workers, under
the direction of a registered nurse or a registered practical nurse, provide
oral hygiene for adults requiring help with their activities of daily living.
(69) e Ontario Clean Water Agency provides water services to munici-
palities, including water uoridation.
342 Ontario’s health system
Governance, financial and delivery arrangements for dental services
e key governance arrangements for dental services have been covered in
the ‘polices’ section above, but both nancial and delivery arrangements
warrant additional comments.
With the exception of the publicly funded dental programs that cover a
relatively small proportion of the population and the dental surgery per-
formed in hospital, most dental services are paid for privately (as described
in the introduction to this section). ese payments are almost always made
on a fee-for-service basis, with suggested (usually lower bounds for) fees for
dental services set annually by the Ontario Dental Association, (70) and with
xed fees for the small subset of dental services provided in hospitals set in
the OHIP Schedule of Benets.(71) In collaboration with the Canadian
Dental Association and other provinces, the Ontario Dental Association
developed a national electronic data-interchange network, which allows
for dental oces to electronically submit claims to insurance companies.(72)
Dental services, excluding cosmetic procedures, are considered eligible
medical expenses that can be claimed on tax returns.(73)
ere were 13,271 dental hygienists, 9,050 dentists, and 522 dental tech-
nologists as of 2013, and 8,500 dental assistants as of 2012.(74; 75) As
examples of the limited volume of publicly funded dental services, in
2011-12 local public health agencies provided 27,425 units of scaling,
30,465 topical uoride applications, and 8,303 ssure sealants.(54) e
interval between dental check-ups is typically set by the publicly funded
programs and private insurers (and not according to a guideline, as is done
in the U.K.).(76) Also, there is typically no risk assessment for the tailored
provision of prevention services.
Conclusion
All three of the select treatments proled in this chapter rely to a signi-
cant degree on out-of-pocket payment or private insurance. For conditions
without strong evidence of their eectiveness and cost-eectiveness, this
may be entirely appropriate. However, for eective and cost-eective treat-
ments, there is a high likelihood of underuse by those with low incomes.
Prescription and over-the-counter drugs are a particular source of concern
given their high and rising costs. Pharmacare2020 has been launched by
Care using select treatments 343
pharmaceutical policy advocates and researchers to encourage the creation
of a universal pharmacare program that would complement Ontario’s exist-
ing insurance programs for hospital-based and physician-provided care,
and this eort has been supported by the Ontario Liberal government.(38;
77) However, there are no such initiatives for dental services, no talk of
alternative remuneration methods for dental professionals that could give
greater attention to prevention, and no mention of dental professionals in
the Patients First Act, 2016 despite its focus on interprofessional prima-
ry-care teams being accountable for dened populations.
344 Ontario’s health system
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