Submission by Manulife

Competition Bureau of Canada
October 21, 2020

Sent by email to: cbmarketstudies-etudesdemarchebc@ised-isde.gc.ca

Re. Consultation on Innovation and Choice in Canada’s Health Care Sector

We are pleased to provide comments to the Competition Bureau of Canada in response to its consultation on digital transformation of the health care sector.

Manulife plays an important role in helping Canadians access health services. We work with over 23,000 employers and organizations to provide health benefit solutions, including dental, paramedical, health, vision and drug benefits, to 5 million Canadians. In 2019, we paid over $4.7 billion in benefits, and helped 2.8 million Canadians by covering $1.8 billion of their prescription drugs costs.

As a benefits provider, we leverage online tools and apps to provide health services and supports to millions of Canadians. For example, we work to provide plan members with critical pieces of information or alerts on helpful programs to manage chronic health issues, often by app or telephone. We offer our customers several virtual health programs including Akira, a service that connects plan members with doctors online; Phzio, a virtual physiotherapy service; and Beacon, which provides internet-based Cognitive Behavioural Therapy (iCBT) services.

1. Are there ways that policies can better support innovation, choice and access to digital health care solutions? For example, do specific rules unnecessarily impact the ability to offer virtual products and services to Canadians? Please explain.

Limitations on data flows, as well as lack of coordination across provinces regarding rules on what types of services can be delivered virtually, can negatively impact our ability to offer digital health solutions to Canadians.

Policies that either intentionally or unintentionally lead to restrictions on data flows pose a risk to the availability of digital health solutions
Most virtual health solutions and applications are created by international, often American, firms. Bringing these solutions to Canada can be difficult because of provincial rules or practices that restrict the sharing information across borders, including those currently in place in Nova Scotia and British Columbia and potential new legislation in Quebec.

It is not clear that large, global providers can or will adapt their products and services to comply with the data localization rules on a province-by-province basis, which may leave many Canadians unable to access many best-in-class health solutions. It can also lead to complexity and additional cost for companies like Manulife who want to provide these solutions that can improve the physical and mental health of our customers. We strongly believe that well informed customers should have the right to choose to access digital health and wellness services and applications provided by or developed by parties outside Canada.

To avoid access issues while still maintaining an appropriate level of protection, it would make sense for provinces to apply rules to the use of residents’ data that are based on the data itself regardless of where the data is stored or processed. This would allow an individual’s data to be treated with the same level of protection whether it is stored in Canada or abroad. Similarly, data localization rules in other jurisdictions can hamper the ability of Canadian digital health and wellness companies to deliver solutions outside of Canada.

Variation in rules create barriers to adoption
Another barrier to the adoption of digital health solutions is the variation in rules across provinces covering what types of services can be delivered online, and by whom. Additionally, some health providers often must be registered in the same jurisdiction as the client receiving the service. This can create barriers to providing uniform digital health services to all Canadians. Virtual health consultations or physiotherapy, for example, may be less accessible to residents of Nunavut or PEI than Ontario if there is a limited number of providers registered locally.

The varying criteria and cost of join provincial health accreditation bodies in many fields, as well as varying licensing standards and residency requirements, may make it difficult for online solutions to be provided across Canada.

2. What other barriers are impeding Canadians' access to virtual care and restricting innovation and choice in the health care sector? Can these barriers be reduced—and, if so, how—in order to facilitate the entry and expansion of digital solutions?

There are several non-regulatory barriers that could restrict access to services. Varying levels of broadband service, particularly in rural, remote and northern communities, could reduce access. The willingness of health providers to adopt and invest in technology could also provide a barrier to virtual care.

Governments should also ensure that payment structures enable the growth of virtual care; payment schedules are often detailed and outdated, with some providers currently only compensated for in person services.

A lack of consistency in the digitization of health records may also inhibit the growth of virtual care technology. Governments should consider requiring publicly funded health care providers to adopt standardized, digital recordkeeping to permit information to be shared across providers. By ensuring health records are in a consistent and accessible format, patients can import this information into apps and online services to provide Canadians with an overall picture of their health. This is currently unavailable with inconsistency in the record keeping of health service providers and incompatible formats across service providers. This limits patient access to their records and results in poorer health outcomes for Canadians.

Finally, there is still ambiguity around what is required to provide consent to medical records, as well as what is required for data access, storage and security requirements. Clarifying requirements to electronic consent may enable records becoming widely accepted.

3. What measures have other jurisdictions taken to improve access to virtual care? How have barriers to innovation and choice been eliminated, while balancing legal and regulatory requirements in the delivery of digital health care solutions? Can similar measures be adopted in Canada? Why or why not?

Create a centralized review and approval process
To implement use of digital health tools and apps, organizations like Manulife are required to undertake substantial levels of due diligence to ensure the tool or app is appropriate and meet our standards. This can often take many months for each tool or app.

We believe there may be a role for the federal government to play by taking on this review and approval role. The National Health Service in the UK has created a centralized approval process for health applications to ensure they meet a broad array of standards, including privacy, cybersecurity and national security standards. Once approved by the NHS, the application may be made available for use within the country.

Create a national digital health record approach
Canada could also look to other jurisdictions for success in the use of digital health records, many of which start with the creation of a national agency with responsibility for coordination and consistency.

For example, in 2016 Australia created the Australian Digital Health Agency, which has responsibility for the country’s digital health strategy. Since then, the Agency has created a national system that allows all Australians to have a My Health Record which supports prescription information, medical notes, referrals and diagnostic imaging reports. Patients can access their own medical information and control access, as well as add in personal information around information such allergies or their health care wishes should they become incapacitated.

Other countries are undertaking similar efforts, including Norway and Singapore. Denmark has a national agency that creates standards to ensure compatibility across regions, and to ensure both patients and health professionals have access to information such as medication use and prescriptions. National patient identifier numbers have also been a common factor among countries that have been successful in creating a national strategy.

4. What impact has the COVID-19 pandemic had on innovation and choice in Canada's health care sector, and on Canadians' ability to access health care virtually? Have any barriers hindered the adoption of digital solutions in response to the COVID-19 pandemic? Please explain.

Consumers, Healthcare Practitioners and Employers willingness to embrace online health solutions has grown significantly in the last six months. To ensure continued momentum, governments should work to build familiarity and trust with digital options across the various stakeholders.

Thank you for undertaking this study and I would be happy to meet to discuss if that would be helpful. Manulife is committed to improving the health of our customers and all Canadians. We strongly believe that virtual health care can help Canadians live longer and better lives.

Donna Carbell
Head of Group Benefits
Manulife Canada