July 10, 2019 How to handle the high costs of diabetes

[00:00:10] Welcome everyone to Diabetes Canada's 2019 Type 1 webinar series. My name is Grace Leeder and I will be your host today. We are delighted that you're able to join us today for the webinar entitled "How to handle the high costs of type 1 diabetes". 

[00:00:24] Now I would like to welcome our speaker Kimberly Hansen, and thank her for joining us today. Before turning it over to Kim, I'd like to give you a brief introduction. Kimberly Hanson is the executive director of Federal Affairs at Diabetes Canada responsible for advocacy with the federal government and on national issues. Having lived with diabetes for more than 20 years, Kim is passionate about helping others live well with the disease, while also working towards a cure. Over the past 15 years Kim and her family have raised more than one million dollars for research into a cure for diabetes, and for supports for adults living with type 1 diabetes. So without further ado I present to you Kimberly Hansen. 

[00:00:59] Thanks so much Grace.  It's really nice to be here with you all- you some of the resources that might be available to help you or your loved one cope with the high costs of type 1 diabetes. As part of the Public Affairs and Advocacy team at Diabetes Canada, this is something that we're really focused on day in day out, advocating at the level of every province and territory, and at the federal level, to try to help lower these costs, so that everyone who has diabetes and take care of themselves the way that they need to without worrying about the financial burden. So today I'd like to talk to you about what that burden looks like, both at the sort of macro level, what is the treatment of diabetes costing our country and then also examples of financial support available, how that relate to Diabetes Canada's advocacy, and how you can get involved if you're as passionate about addressing some of the inequities in coverage that exist for people with diabetes, as I am. This slide shows the economic burden to Canada and this is a 10 year timeframe. And it really depicts- yeah a 10 year time frame. It really shows how diabetes is growing both in incidence and in prevalence, so that means that more people are getting diabetes, we're living longer with it, which is great, but the resulting cost burden to Canada is growing and enormous. It's growing at a rate of about 40 percent per decade, both the number of people with diabetes and the cost of the health care system. And the costs in 2019 of treating diabetes, of course that's both type 1 and Type 2, will be nearly 30 billion dollars. So it's a problem that needs to be addressed at a national level. Now we know that there's no way of preventing Type 1 diabetes, there can sometimes be ways of preventing or delaying Type 2 diabetes. Continuously improve the care that patients get to help reduce these costs over time and that's part of what our- perhaps more germane to the conversation we're having today is that living with type 1 diabetes poses an enormous burden to the individuals with it. It can be depending on your financial circumstances, where in Canada you live and what treatment protocol you're following, it can be as much as fifteen thousand dollars out of pocket. And those costs may actually be rising with the advent of new technologies such as insulin pumps integrated with continuous glucose monitoring features that really help to improve care and thereby minimize the risk of longterm complications, but come with a stiff price tag. Diabetes Canada's research shows that most Canadians with diabetes, both forms, pay more than three percent of their income or over fifteen hundred dollars per year, for a combination of the medications, devices, and supplies that we need to care for our diet. That 3 percent or 15 hundred dollars per year was defined by both the Kirby and Romanow commissions on health care as quote unquote catastrophic. So it really goes to prove the point that diabetes is not a disease that there's sufficient support or management of in Canada. I saw- I admire note on Twitter that in Canada we- we give free diagnoses of diabetes but not free- free care of diabetes. So and that means that 25 percent of Canadians with diabetes self report that- that the costs of treating the disease inhibit them from following their prescribed treatment regimen. And we know that that risks both their long term and their short term health. So we need to find ways to reduce that cost burden or the out-of-pocket cost burden for Canadians. Financial support for diabetes vary significantly, province to province, territory to territory, and depending on the age and life circumstances of the individual in question. And so I'm going to in a few moments to talk to you in a bit more detail about supports available in the province of Ontario. But I want to really recognize that before we get started that those vary widely province to province. And so if you're calling in from another part of Canada, what I'm sharing with you may not apply to your specific situation. What it should do is let you know what the categories of care that you should be able to find information from Diabetes Canada about, and I would invite you all to reach out to us at 1-800-Banting or visit our website, or certainly contact me personally and I'll be happy to give you information that's more specific to the province or territory where you may be living. The coverage varies for obviously the medications, whether those be insulin or in the case of some folks, you know medications that are blood glucose lowering, or that are supportive of cardiovascular health etc. Supplies can be as you know, a big cost of living with type 1 with test strips costing about a dollar each and you need to use many. Then there are devices such as insulin pumps, continuous or fla- flash glucose monitors etc. And then there's also a lot of variability in not only actually the copays or the deductibles that each of us have to pay, where we have supplemental insurance. But there's also big variability in the maximum of insurance that different plans will provide. So to look at the example of Ontario. Ontario has I would say it's one of the better provinces in terms of the coverage that it provides. It's Monitoring for Health Program provides coverage for test strips, lancets and blood glucose monitors for people who use insulin or have gestational diabetes provided that they have no supplemental health insurance. The Ontario Drug Benefit provides coverage for prescription drugs and blood glucose strips for seniors, those on social assistance or children and youth 24 and under and through the OHIP plus program, again provided that there isn't any supplemental insurance otherwise in place, for example through your employer. The Trillium Drug Program provides help for Ontarians who have high prescription drug costs relative to their income. And there's an annual deductible that's determined based on the size of the household and its income. I spoke with one woman who lives with diabetes and she was saying that the combination of medications that she's on cost her a thousand dollars a month, and she sort of slips through the cracks, of the programs available, so that's a really enormous burden for somebody with a lower income, that the Trillium is meant to fill but doesn't always. The Ontario Disability Support Program or ODSP, provides coverage for insulin and test strips for those that qualify and if- if people qualify for the Mandatory Special Necessities benefit, which often relates to that candidate being- taking social assistance, or a certain age or income level, then they can provide coverage for syringes, and alcohol swabs, and lancets, those kinds of things which often interestingly, are not covered at all. Then there's finally there is some limited coverage for CGM, again available available through the Mandatory Special Necessities benefit. But I should say that it is- it's a relatively restrictive program available only to a small cohort of those with type 1, who are or perhaps not insured otherwise, who are- who are earning a lower income. Then finally there's the Assistive Devices Program and this was a real game changer when it was introduced about 15 years ago, providing support for insulin pumps and the supplies needed to use them. It provides coverage of the cost of an insulin pump every five years and twenty four hundred dollars per year towards pump supplies, which is not the entirety of the cost, which is estimated at about three thousand dollars a year depending on the pump you use etc.. But it certainly goes a long way towards it. And then there's also under the ADP there is the syringes for seniors program. For those 65 and older who use insulin. So if you were to look at this on a grid and you could you could make or have a grid like this for each province and territory.  See where there are- where there's strong coverage. Those are the blocks that are indicated in green. Where there is no coverage, those are the blocks indicated in red. So for example, unless you are on social assistance there is no support available for you for ketones strips or continuous glucose monitors through any public plan. And so there are limitations and you'll see that most of the squares some availability for cat- individuals in that category but, it's limited or there are parameters that you have to qualify for. There are also some federal programs that Canadians can access regardless of where in Canada your-. Most notable one is perhaps the Disability Tax Credit. So it's a non refundable tax credit for those who qualify, and it's intended to offset the costs- the extra costs that come with living with a- a quote unquote severe and prolonged disability or impairment. And I want to just recognize here that the word disability is a word that many folks that I know with type one don't like to use when referring to themselves, and I totally understand that and so I just want to sort of explain that where I'm using the word disability in this presentation I'm only using it because in the terms of the definition used in the Income Tax Act, not in any way to imply that this is something that we can't all live- live well and full lives with. So the Disability Tax Credit basically gives allows those who qualify for it to reduce their income and therefore it's worth an average of about fifteen hundred dollars extra when it's tax return time, varies based on the individual's income. The disability tax credit is also a gateway program for other important programs such as the Child Disability Benefits. So if you are a parent of a child living with type 1 diabetes and- and they qualify for the disability tax credit or DTC, that will allow you also to receive the child disability benefit of up to two hundred and thirty dollars per month on an income adjusted basis, until that child reaches age 18. The DTC also allows those who are eligible to create Registered Disability Savings programs, and these are basically protected savings vehicles, a lot like registered education savings programs, where if your child qualifies or you qualify for the DTC and you create a RDSP for yourself. If you make a contribution, of say a thousand dollars per year to that fund, it will attract up to three times your contribution in government grants and bonds. And again how much it attracts varies based on your income level etc. But it can be a really great way to an income tax protected basis save for potential future medical costs, once the person who is eligible reaches age 60. And then finally there is a medical expense tax credit. Many of you will be familiar with whereby you can have refunded up to 15 percent of eligible medical expenses up to a certain maximum to help defray any costs that you don't have insurance coverage for, so that's a federal program as well. A lot of people have reached out to us in the past couple of years wanting to understand the eligibility criteria for the disability tax credit and that's for a few reasons. One is I would say that it's a program that's a bit confusing and the eligibility- eligibility criteria are- a lot of us getting denied, whereas previously we had not been. And Diabetes Canada advocated and got that changed, but it created a lot of confusion around what the eligibility criteria were. 

[00:15:22] So people with type 1 diabetes generally qualify for the disability tax credit under the category of life sustaining therapy. There are a number of categories such as mobility impairment, or vision or what have you, but usually we qualify under life sustaining therapy and in order to qualify under the category of life sustaining therapy, you need to be able to demonstrate that you require an average of 14 hours per week to administer therapy related to your diabetes. For certain eligible activities and I'll cover those in a second and an important note is that when- when an adult has a child with Type 1 diabetes whom they are supporting and caring for their diabetes, the time that both the adult and that child spend on eligible activities can be counted towards that 14 hour per week requirement. So that usually means that for children it's usually not a problem, to qualify for the disability tax credit. It tends to be a little bit more challenging in some cases for adults.

[00:16:37] So the eligible activities are checking your blood sugars, logging them, making adjustments to dosing, preparing, and administering insulin.

[00:16:50] And I should say there that that would not include the time that it takes for your insulin pump to deliver a bolus, for example it would just be the time that it takes for you to program it in. The time that it takes to calibrate any equipment, so what about I don't know if anybody does this anymore but it used to be you'd have to administer a controlled substance on your glucometer every now and again. So any kind of calibration, calibrating obviously continuous glucose monitor that counts. Testing for ketones, and then logging as I mentioned your blood sugar levels. What you cannot count, and it is carbohydrate counting for the time that it takes you to calculate how much carbohydrate is in the food you're about to consume and what that therefore means in terms of the dose of insulin that you need to take. You can't count the time that you spend recovering from any therapy. So for example even though it takes us 15 minutes or more to recover from a low blood sugar you can't count that time. You can't count the time you spent exercising or visiting the doctor or buying supplies. Obviously Diabetes Canada disagrees with some of these activities being ineligible, in particular carbohydrate counting. How on earth is somebody supposed to calculate the dose of insulin without calculating how much carbohydrate they're eating. And I'll talk to you in a few minutes about what we're doing to try to change that, but for the moment, those are the eligible and ineligible activities and so anybody applying for the disability tax credit should ensure that they say- do not say carbohydrate counting anywhere in your application or it will be rejected. So this is an example of how people with type 1 diabetes might meet the DTC eligibility criteria. This is a sample or a specimen it's not meant to necessarily be prescriptive for you. But each of these activities is eligible for counting against the 14 hour per week requirement. And these estimates of how much time they can take I think are relatively normal for most of us. And so these activities total to one hundred and thirty eight minutes per day which adds to a little over 14 hours per week. So this could be a bit of a reference for anybody wishing to apply in filling out their form. This slide is a reference for all of you. It provides links to instructions on how to fill out a T2201, which is the form that you need to complete and have your health care provider also fill in and and then sign before you mail it in. There is also a link to a document that we've created that might answer some questions that your health care provider might have about your eligibility and how to fill out these forms. We've heard lots of questions and hesitation from health care providers, particularly since the kerfuffle in 2017, so do have a look for that document and consider bringing it into your appointment when you want to go ask for your care provider to sign your form. I should note that the form can be signed not only by your doctor but also by a nurse practitioner. And that's often how many clinics will have these completed. Some of the clinics will ask that you keep a log and return that log to them. Some just ask you to fill out a form on the spot that indicates the kind of time that you're spending. It varies clinic to clinic. Once you send that form in the CRA will review your application and they may send follow up questions to your health care provider., looking for more information. If you are deemed eligible your tax returns for your period of eligibility will be reassessed, and a refund will be remitted. So what that means is that if you apply now and are accepted and you've been living with diabetes for the last seven years and the CRA says yes you're eligible retroactive 2012, then once they've completed your assessments and reassessment, they'll- they'll give you a refund that goes back all the way to 2012. It does take, I should say several months to get through this process. It's not a quick one. 

[00:21:34] I mentioned earlier the child's disability benefit. So it's a tax free benefit for families with kids under 18 who are eligible for the DTC. You have to file a tax return in order to be eligible for this benefit, otherwise the system doesn't know that you qualify for it, and the amount that you get is indexed to income. So I just indicated on this slide 3 reference levelS just as an indication. But obviously it would be individual. I talked a few minutes ago about Registered Disability Savings Plans and these are we've had some great news recently about RDSPs that- that mean that I would really encourage anybody that qualifies for the DTC to open and save in an RDSP, if that is at all possible for you because as I mentioned it can attract up to three times your contributions in government grants and bonds. And so that can- it can become a really sizable nest egg for your- your loved one or for you to use for your medical costs in a fairly short period of time.

[00:22:48] So the reason why I say we've had good news recently is that in budget 2019 the government committed that they will, going forward make RDSPs secure against any changes in eligibility criteria. So it used to be, that if the CRA changed eligibility criteria and a person who used to qualify for the DTC stopped qualifying then the government could take back all of its contributions made throughout the life of that savings vehicle. And that's really not fair because if a person legitimately qualified for a period of time and then the eligibility criteria changed, they shouldn't lose contributions that were made while they legitimately qualified, and so the government has recognized that and committed to changing that. So if you get the DTC then do consider opening an RDSP. You open it at a bank or a financial institution and they'll help you do all the necessary paperwork and make a contribution to it. And then that will just automatically attract government contributions at an amount that will vary based on your income.

[00:24:03] So in 2017 the CRA made a change to their- their processes really the way that they interpreted applications whereby they determined that adults living with type 1 diabetes generally do not need more than 14 hours a week to manage their- their care. And that's really not true across the board. So we were able effectively to argue that over a period of time. And that resulted in a whole bunch of folks who had been wrongfully denied in May- in mid 2017 getting reassessed and being given the disability tax credit after the fact. So a little over half of us got approved on review. That's really good but not good enough. And it is still the case that nearly all children are being approved. I know virtually none who have ever been denied. And most adults, still get approved. Do be very very careful not to count ineligible activities because like I said before that will result in you immediately getting rejected.

[00:25:15] And so that's basically where we are.

[00:25:20] There are two main ongoing issues with respect to the disability tax credit and the related programs that Diabetes Canada is advocating in respect of. One is that we maintain that the eligibility criteria in the Income Tax Act should be clarified to remove the current ambiguity around calculating carbohydrates. And so I say their ambiguity. But I told you a minute ago that it's ineligible. Don't say it. And the reason for that is that the Income Tax Act is not clear that carbohydrate counting is ineligible. But the way that the analysts at the CRA are interpreting it is such that they're basically making it ineligible. So we want the government to recognize that carbohydrate counting is part and parcel of calculating insulin dosages and to do it well, it can be quite time consuming and to remove any restrictions in their processes from allowing us to calculate it, or to count the time spent calculating it. The second thing is that we don't agree with the way that the eligibility criteria and the way that the application form is is worded and is set up because it effectively requires your doctor to certify that you're spending 14 hours a week performing activities that you're performing at home, not in a clinical setting. And that's not really fair to the doctor. How are they supposed to know how long it takes you to change your infusion set, or do a blood sugar test. So we want them to change the- revisit the way that the whole thing is worded, revisit the 14 hour requirement, and make it less bureaucratic and less arbitrary. And so there are changes that we are hoping will come in the near future that will make that possible. So one thing that's important that happened in the last year is the- the Senate, after the problems that people with diabetes incurred accessing the disability tax credit in 2017, the Senate committed to study the problem and make recommendations on some solutions. So they released this report, "Breaking down barriers" In June of 2018 and they really did a very comprehensive study and came up with 16 recommendations for the improvement of the administration of the disability tax credit. Diabetes Canada wholly supports the recommendations that they made. They are not only specific to people with diabetes but to people with many many many disabilities that might qualify for the DTC.

[00:28:09] And we really encourage the government promptly to implement their- their recommended solutions. We expect to be hearing back shortly on any plans to do so from the government. The other thing that- that did- that happened in the last years that the Disability Advisory Committee, which is a group of advocates and individuals living with disabilities- this group advises the Canada Revenue Agency about problems with the disability tax credit and related programs. And they'll be releasing a report on their findings sometime in the next month or so. And I think that that's going to be you know it's going to be very welcome recommendations for people with many different diseases. And it will be additional impetus for the government to consider making amendments to the CRA's administrative rules and regulations. So we're going to keep a close eye on that and keep pushing for that. I mentioned at the outset of this presentation that a lot of Diabetes Canada's advocacy relates to addressing or trying to help mitigate the high costs of living with this disease. And- and there are a number of things that we're doing here that we're actively advocating for that relate to that. Some of you may have heard that we are pushing for a nationwide strategy to address the diabetes epidemic. We're calling it Diabetes 360 and we have lots of support from people all over Canada as well as from many parliamentarians. The Standing Committee on Health and the Standing Committee on Finance both recommended its implementation. Unfortunately it wasn't funded in budget 2019, but we're going to be working hard to make this an election issue, in order to ensure that it's funded not later than budget 2020. So please stay tuned, watch our social media channels, and stay in touch with me because we're going to be launching a petition next week that you can sign and invite your community to sign, calling on all elected officials to stand behind this, and we really hope that you'll take a minute to add your name to that list. We're also continuing as I mentioned, to advocate for fair access to the disability tax credit.

[00:30:31] We are working with many provinces to push for supports for kids with type 1 diabetes in schools and we were really pleased recently when Alberta agreed to create a policy becoming the last of the provinces and territories to create a policy to protect the needs of kids with type 1 in school and the ability to be supported with their- their- their care of their diabetes while at school. We're pushing in every province and territory for enhanced coverage for not just medications but also devices and supplies. At a federal level, we've been working closely with the government to implement aspects of the healthy eating strategy, which we believe will help to reduce the risk of some folks developing Type 2 diabetes. I think it's germane to those of us with type 1 because we can all benefit from eating healthily, from having regular physical activity, those types of things that- that helps all of us with well with this disease. And then we're also advocating very very actively for the right approach to a national pharmacare plan.

[00:31:47] We absolutely want to see that everyone have access to the medications and devices and supplies that they need, and so we've been very clear with the Pharmacare Commission that it's not enough just to cover drugs, it has to also be supplies. But we also have to make sure that we do this in a way that ensures that people with diabetes are still going to have access to new and innovative medications, as innovations are made in things like insulin.

[00:32:16] We wouldn't want to all have to only have access to the same old kinds of insulin that maybe aren't as effective for us anymore.

[00:32:25] I mentioned our Diabetes 360 strategy and I just wanted to take one minute to give you a high level sense of it. It contains four targets that are aimed at ensuring that 90 percent of Canadians live in an environment that preserves their health and prevents them developing diabetes. In a case of type 1, our specific recommendation in this area is that research into the underlying causes and techniques for preventing the disease be funded and supported. The second target area is screening. We want to ensure that 90 percent of Canadians are aware of their diabetes status, so whether they're living with diabetes or pre diabetes or not, and usually Type 1 is a little bit more dramatic in its onset, so most people with Type 1 figure out that they've got it fairly quickly, but it's not uncommon for people with Type 1 to go- who develop it in adulthood, to go misdiagnosed for sometimes years, and that's that's a real damage to the health and wellness of the individual. So we need to help ensure that screening is done better and more consistently across the board. Then we want to make sure that that 90 percent of Canadians that have diabetes are engaged in appropriate interventions to prevent its complications. And so that might be you know accessing formal health care such as seeing an endocrinologist or a specialist. But it's also accessing community support for living well with the disease, whether that's a support group or a yoga program or a cooking class that's given in- in another language or that's specific to foods that are cultural for a specific group.

[00:34:17] All of those things are forms of treatment and it's under this category that we're pushing for increased fairer access to all medications as well as care. And then finally all three of those targets will drive towards the fourth, which is that 90 percent of Canadians engaged in those interventions should be achieving improved health outcomes. 

[00:34:40] So that means that maybe we'll have lower A1C's or maybe will have better lipid profiles, but more importantly perhaps we'll have a greater sense of well-being living with diabetes, that's critically important for chronic disease. So our strategy includes a number of recommendations to drive towards, achieving those four target outcomes. 

[00:35:06] And as I mentioned we- we developed recommendations that are specific to those with Type 1. So I talked about what those are under the first and second categories. Under the third category, it would really be kind of pushing even more deeply for additional access to drugs devices and technologies. And then we recognize that there's a need for better transitional care for young adults who are maybe aging out of pediatric care settings and into adult care settings that are less focused specifically on Type 1, and a lot of these young adults are kind of getting lost to the system during a critical period of their life where they don't maybe have insurance through work or the financial means to care for themselves as well as they need to. And so they're- they're having more emergency incidences related to their diabetes and we can do a lot better to support people through that transition. And then finally where- it where people with Type 1 are concerned we recognize that it's not really about just sort of achieving a lower A1C at all costs. I would say that it's not about that for any individual but- but for us it might be more- more possible to quantify how much time people are spending and range especially with the the the degree to which more and more folks are using continuous glucose monitors and can kind of have data about that. We believe is- this is- this strategy is implemented at all cost one hundred and fifty million dollars over seven years and that will be for a kind of center of expertise to work with the provinces and territories to help them to improve their patient care pathways,, to help give them the data that they need to know how well they're doing and reducing the burden of diabetes in that province or territory.

[00:37:02] And and to help improve outcomes for the people living in those provinces. We- we believe that based on on research that's been done that it will it will result in 9 billion dollars in savings to the health care system alone in those seven years, plus another nine billion dollars in savings for employers in benefits costs and added productivity. Perhaps more importantly it would prevent about seven hundred and seventy thousand people in Canada from receiving a diagnosis of Type 2 during that seven year period. Two hundred and forty five thousand fewer hospitalizations and 35000 fewer lower leg amputations. So we think that the economics of Diabetes 360 makes huge sense. More importantly, it's just the more humane thing to do for everyone living with the disease. So if you want to push for increased access to medications, devices, supplies, care, if you believe that a strategy could help improve care for people with diabetes in Canada, please consider adding your voice to our advocacy. You can visit our website to get involved. You can call 1-80- Banting or email us and they'll put you in touch with me and my colleagues on our Public Affairs and Advocacy team. You can consider writing to or meeting with your local elected officials. You can talk to your local candidates when they come doorknocking. If you're having a provincial election or this fall for the federal election. Log or tweet your story and hashtag Diabetes 360. And as I mentioned our petition will launch hopefully next week so please do consider signing that. And we thought I would be really really pleased to take any questions or comments that you may have.

[00:39:01] Yes so we do have a few questions that I open I'll open up the fort for people to type in the chat box. If they have any other questions as well. So the first question is is is Diabetes Canada advocating for pen needles to be covered. It's quite frustrating that insulin is covered but not the pen needles or syringes.

[00:39:20] Absolutely we are. I often say insulin doesn't do a person an awful lot of good if they can't afford the syringes or the pen needles to be able to inject it. So that's why when we've been meeting with the National Pharmacare Commission we've been saying, it's not enough just to cover drugs, you have to also cover the supplies that people need in order to be able to take them. Needles, syringes, lancets, as well as test strips and other devices are absolutely in that category and so we're pushing as I mentioned at the provincial level, but we're also pushing for a nationwide strategy that would make the inequities and the gaps in coverage, province to province, a lot more visible to governments at all levels, and a lot harder to maintain.

[00:40:09] That's great. So I have a couple of questions that are related to the disability tax credit. So one is if I had previous- if I previously had the disability tax credit but then were denied, will I lose the grants and bonds that are in my RDSP.

[00:40:23] In the past, that would have been the case, yes, but in budget 2019 the federal government committed that going forward that will no longer be the case. I should say that the exact mechanism via which they will ensure that it's not the case going forward isn't fully clear yet. We're having meetings to better understand that kind of as we speak, but they have committed in writing in budget 2019 that moving forward any contributions that were made by the government as well as you during the period that you qualified are protected even if you are later deemed no longer to be eligible for whatever reason.

[00:41:08] Thank you. What should I do if my doctor is not willing to sign off on the disability tax credit.

[00:41:15] That's a really tough one and I would say that we've heard a number of- we've heard from a number of people whose doctors are in that position. So my advice is always as follows. Please do refer to the documents linked in this slide deck because it was written intended to be for health care providers use and so it may answer some of the questions or concerns that they have in a way that would help make them willing to sign it. Please also consider inviting them to contact me or ask if they would be willing to receive a call from me I would be happy to speak to them on your behalf and to clarify any questions that they may have. And if that fails, some clinicians are really just unwilling to sign these forms, they need- some people don't believe that we that that it's it's right. And so if that's the case, you may need to consider getting another health care provider to complete the form for you. So for example if your endocrinologist is unwilling, perhaps your general practitioner might be willing or if your- that you know maybe it a nurse practitioner that you have access to who would be willing to complete it. And I would just also say that, yeah, you know we can't we cannot unfortunately force any doctors to complete these forms but we we are trying at Diabetes Canada to get the word to the health care provider community to let them know that that many people with Type 1 diabetes do meet these eligibility criteria and that the purpose of the program is to recognize that diabetes is a disease that imposes extra costs on you and sometimes when I've reminded health care practitioners of the purpose of the disability tax credit, that's helped them get around some of the objections that they may have had to the idea of us qualifying for a disability tax credit, which sometimes have related more to the idea of whether they consider diabetes a disability. As I mentioned earlier in my remarks, I'm not here to say that diabetes is a disability in the broadest sense of the word. I think that, that's a word that carries a lot of different meanings and connotations for each individual. And that's really not the point here. The point is, do we meet the definition under the Income Tax Act. And I would submit that in many cases people with Type 1 diabetes do meet that definition. And so there are programs eligible or available rather, so sometimes clarifying that can be of help.

[00:44:09] That's great. I really appreciate the clarification. So that is all the time we have for questions that just note that if we didn't get to your question and we are unable to answer today please send us an email at webinars at diabetes dot ca and we'll get back to you as soon as possible. And as Kimberly mentioned for those of you looking for more support and resources for living well with diabetes, feel free to call our toll free line at 1-800-Banting that's 1-800-226-8464. Thank you for joining us today and we hope you've had- you've enjoyed learning with Diabetes Canada. We look forward to your participation in the future.