SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
EMPLOYER COMMITTEE ON HEALTH CARE IN ONTARIO
ASSOCIATION OF ONTARIO HEALTH CENTRES
CANADIAN UNION OF PUBLIC EMPLOYEES
TORONTO PSYCHOANALYTIC SOCIETY
SUNNYBROOK HEALTH SCIENCE CENTRE
ONTARIO PHARMACISTS' ASSOCIATION
SOUTH RIVERDALE COMMUNITY HEALTH CENTRE
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
CANADIAN PENSIONERS CONCERNED, ONTARIO DIVISION
MEDICAL IMAGING CLINICS OF ONTARIO INC
CONTENTS
Monday 18 December 1995
Savings and Restructuring Act, 1995, Bill 26, Mr Eves / Loi de 1995 sur les économies
et la restructuration, projet de loi 26, M. Eves
Ministry of Health
Hon Jim Wilson, Minister of Health
Gail Czukar, counsel
Carole McKeogh, counsel
Employer Committee on Health Care in Ontario
Carmine Domanico, representative
Association of Ontario Health Centres
Sonny Arrojado, executive director
Canadian Union of Public Employees
Sid Ryan, president, Ontario division
Michael Hurley, first vice-president, Ontario division
Toronto Psychoanalytic Society
David Iseman, president
Douglas Weir, acting chair, public affairs committee
Sunnybrook Health Science Centre
Tom Closson, president and CEO
Ontario Pharmacists' Association
David Windross, chair, public affairs committee
Wayne Marigold, president and chairman of the board
South Riverdale Community Health Centre
Liz Feltes, executive director
Hospital for Sick Children
Michael Strofolino, president and CEO
Alan Goldbloom, vice-president
College of Physicians and Surgeons of Ontario
Michael Dixon, registrar
Helen Gordon, president
David Walker, immediate past president
Older Women's Network
Frances Chapkin, co-chair
Ethel Meade, co-chair
Grace Buller, co-chair
Survivors of Medical Abuse
Sharon Danley, co-facilitator
Velma Demerson, representative
Humber Memorial Hospital
Mark Rochon, president and CEO
Ontario Hospital Association
David Martin, president
Ron Sapsford, chief operating officer
Canadian Pensioners Concerned, Ontario Division
Mae Harman, president
Medical Imaging Clinics of Ontario Inc
Nabil Bechai, director
STANDING COMMITTEE ON GENERAL GOVERNMENT
Chair / Président: Carroll, Jack (Chatham-Kent PC)
*Carroll, Jack (Chatham-Kent PC)
Danford, Harry (Hastings-Peterborough PC)
Kells, Morley (Etobicoke-Lakeshore PC)
Marchese, Rosario (Fort York ND)
Sergio, Mario (Yorkview L)
Stewart, R. Gary (Peterborough PC)
*In attendance / présents
Substitutions present / Membres remplaçants présents:
Caplan, Elinore (Oriole L) for Mr Sergio
Clement, Tony (Brampton South / -Sud PC) for Mr Kells
Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart
Johns, Helen (Huron PC) for Mr Danford
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Bartolucci, Rick (Sudbury L)
Churley, Marilyn (Riverdale ND)
Curling, Alvin (Scarborough North / -Nord L)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel:
Campbell, Elaine, research officer, Legislative Research Service
Drummond, Alison, research officer, Legislative Research Service
The committee met at 0905 in room 151.
SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
Consideration of Bill 26, An Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring, Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda / Projet de loi 26, Loi visant à réaliser des économies budgétaires et à favoriser la prospérité économique par la restructuration, la rationalisation et l'efficience du secteur public et visant à mettre en oeuvre d'autres aspects du programme économique du gouvernement.
MINISTRY OF HEALTH
The Chair (Mr Jack Carroll): Good morning. Welcome to our first committee hearing on Bill 26. For those of you who are not aware, we have split the committee on general government into two sections. In committee room 1, a subcommittee of this committee is sitting. Ministers Johnson, Leach, Hodgson and Witmer will be appearing in that room. This section is strictly for the health-related issues, so the first item on the agenda is the Minister of Health, Minister Wilson. Welcome. You have one hour of our time, sir. The floor is yours.
Hon Jim Wilson (Minister of Health): Mr Chairman, committee members, thank you very much for the invitation. I should say at the outset that 25 copies of my remarks should be here momentarily. They were going through the photocopier as we left the office across the road.
Mr Chairman and committee members, I appear before you today with one single, all-encompassing request, and that is, let's not play politics with the health of the people of Ontario in terms of the delivery of health care services.
We will be spending a great deal of time over the next few weeks of committee hearings discussing the means of reforming and restructuring Ontario's health care system. There will be honest disagreements about tools and mechanisms.
There should be no disagreement, however, about our goal. We have to focus on the best interests of patients. The one thing about which there can be no argument is that the health care system is in serious financial trouble, serious enough to threaten its stability and, in the long run, its very existence.
Anyone who knows anything about Ontario's health care system recognizes the need to stop tinkering with it and to move ahead with comprehensive reform of the system itself. Nor do we have the luxury of time. Tough decisions have been deferred so long that we are in a downward spiral requiring urgent remedial action. Ontario's debt as a whole is escalating at the frightening rate of $1 million an hour. With the exception of our debt, health care is the largest single component of costs.
We do not, of course, plan to cut the overall health care budget, but we will have to do a great deal of fundamental restructuring to keep the total costs at present levels while better targeting care and cutting waste and duplication.
If we can agree at the outset on these two simple things -- the need for comprehensive reform and the extreme urgency of the issue -- this committee has an historic opportunity. Working together, we can achieve something over the coming weeks that will have a positive effect on the lives of all the people of Ontario for generations to come.
Bill 26 as a whole is large and covers a wide spectrum of issues and legislation. But for all its size, there is little or nothing in the bill that is new or radical.
Omnibus bills are common practice in Canada. Sometimes when they introduce entirely new issues of principle which have never been publicly debated before, they cause concern. This is not the case with Bill 26. Much of the bill merely clarifies, and frequently puts stricter limits on, what has already been done and proposed by previous governments. Much of it merely does what previous governments had put explicitly on their legislative programs, after extensive consultation, but failed to implement.
There was a range of reasons for non-implementation: lack of time, lack of vision and lack of intestinal fortitude. Whatever the reason, it remains true that the vast majority of the measures of Bill 26 have been supported in the past by all the political parties and the public. Today, if anything, the public feels more strongly than ever that we have serious and urgent financial problems which must be dealt with immediately and in an integrated way.
From this consensus, this committee should move forward and refocus on why we are all here -- not to fight for the sectoral agendas of special interests; we are here to protect the best interests of Ontarians as a whole.
Bill 26 was introduced by the Minister of Finance to provide the tools to help various sectors of the Ontario economy to meet the minister's new financial targets: municipalities, colleges, universities and schools.
It is the essential backing for the Finance minister's economic statement, which is geared to creating an Ontario which pays its own way and where opportunity outweighs unemployment, and making government a partner in change rather than a burden.
I will of course be dealing with the parts of Bill 26 pertaining to health care: hospitals, physicians, service providers, patients.
The major health care sections of Bill 26 are: the Health Services Restructuring Act, the Ontario Drug Benefit Act, the Health Insurance Act, the Physician Services Delivery Act, and the Independent Health Facilities Act.
But I would caution that the bill has to be read as a whole. The sum is greater than its parts. That's why we presented it as an omnibus, comprehensive bill. Bill 26 amendments and new acts will give the government the tools for a restructuring of the hospital sector, but they go further in providing a blueprint to restructure and integrate the overall health care system.
The government is committed to holding health care spending at $17.4 billion. Whatever cuts we make will be dedicated to holding spending levels. We will not be successful unless there are fundamental changes in how the Ministry of Health does business and how the hospitals are managed and how the physicians and care providers do business and in the level of understanding of patients throughout Ontario about their health care system.
We don't need to spend more money on health care in this province. I think we have consensus on that. But we do need to spend it better; like the White Queen in Alice Through the Looking Glass, we have to run to stay in the same place. People have to have access to the health care system, and to ensure continued access today, tomorrow and for the next generation, we have to be able to pay for it.
At the same time, the population is aging and becoming more diverse. Needs are changing. Investment must shift to take this into account. Investment must increase in priority areas. This means reinvesting in long-term care, in public health programs, in home care, in dialysis and cardiovascular care, in cancer and other high-level priorities.
This means significant restructuring. Piecemeal changes just won't cut it. It means greater efficiency. It means cost-cutting, particularly in areas where financial responsibility is conspicuous by its absence.
But, and I want to emphasize this, it also means redistribution. Many people who accept that we are making the system more efficient do not know that we are also making it more humane.
Take the example of people who work but earn less than $20,000 a year. In some cases it would pay such people, particularly those with high drug expenses, to quit their jobs and go on welfare to qualify them to receive free drugs.
No one wants to push the working poor on to welfare rolls, but governments previously did this by setting a $500 drug deductible on the first $20,000 of net family income. So we are lowering the deductible for this group, and my ministry expects that an additional 140,000 people will become eligible for benefits as a result.
Doing this costs money, which has to be found in savings or diverted from elsewhere in the health care system. One of the ways we will generate the resources will be to get people already benefiting from the Ontario drug benefit program to kick in small amounts for each prescription.
Seniors earning less than $16,000, senior couples earning less than $24,000 and social assistance recipients will be asked to pay $2 for each prescription filled. Seniors earning over these amounts, and this group includes some of the most affluent people in Ontario, of which 20% have annual incomes greater than $50,000, will pay the first $100 in prescription costs per person each year, and then a dispensing fee of up to $6.11 per prescription.
We estimate that half of all low-income seniors will pay $32 or less each year. Half of those on social assistance will pay a maximum of $8 for a single person or $24 for a family per year. The revised programs will save an estimated $225 million each year and cover about 20% of all Ontarians.
I have gone into some great detail about drugs and deductibles partly because they have generated a great deal of ill-informed publicity. Everyone else, that is, all other provinces, already require that people share the costs of their drug programs. Ontario is the last province to introduce cost-sharing, and has done so in a humane and efficient manner.
We have minimized the pain for the poor. We have transferred money from the more affluent, who really do not need society to pay for all of their drug needs, and we have rewarded the working poor for working. This systems approach to the issue of drug costs is typical of the systems approach underlying the entire Bill 26.
The health care system will not be reformed by publishing invitations to special interests for their input, adding up their requests and greasing their wheels, with the squeakiest getting the most grease. Our responsibility as a government is to represent all Ontarians, and Bill 26 demonstrates our determination to do so.
I would now like to turn to discuss the contents and implications of the bill in more detail. As I've already made clear, the interrelationships within the system are crucial, and I'll try to address these as I go along. Nevertheless, for convenience, I will divide my discussion into broad subject groups, and if you want more detail on how the component parts fit together, my staff and I will be happy to answer any questions you may have later.
Let me first turn to hospitals, what we hope can be achieved in that area and how Bill 26 will help us achieve our goals.
Many people fear change. True change does not happen easily and it's never comfortable. Most governments are no different.
The Public Hospitals Act was proclaimed in 1931. A lot of things have changed since 1931, so the previous NDP government initiated a review of the Public Hospitals Act in 1989. They raised expectations for major reform of the act but unfortunately, for a number of reasons, did not implement those recommendations.
Its review, as indicated by the report's title, was Into the 21st Century, but unfortunately we didn't get into the 21st century. What they did do in terms of legislation to prepare and recognize the changing shape of hospitals and the hospital sector is what's now contained in Bill 26, because nothing really got done. The report was shelved, as I said.
This is not to say, though, in all fairness to all parties and politicians and people in the system, that nothing at all didn't get done. Reality intrudes, whatever government does.
We should not forget that Ontario's hospitals and those who work in them have been living through change for a number of years now. Fewer hospital beds, more patients and less money have become part of their lives. In many ways, it seems that Bill 26 is simply catching up to the daily reality that people in the system now work with.
Communities became actively involved in planning for restructuring under the previous government, through district health councils. Thirty communities involving 134 hospitals across Ontario are today involved in local hospital restructuring projects. This is happening as we speak.
The previous government should be given credit for starting the process. But, as Churchill might have put it, they forgot to provide the tools to finish the job. I've often said that they didn't leave a blueprint of what I was supposed to do with 30 restructuring projects actively coming into the ministry and the 60-some projects going on across the province.
Previous governments cut hospital beds -- 6,700 to be exact. But by leaving the existing infrastructure in place largely unchanged, they have negated a good start and compounded problems. Much of the staff is still there. The bricks and mortar are still there. The only difference is, they no longer serve patients.
Duplication, overlap, overcapacity in major service areas have remained untouched. Service inefficiencies continue to be rife, and this has to be changed.
The Minister of Finance told the House that the 6,700 acute-care beds closed over the last five years were the equivalent to 30 midsized hospitals.
But the previous government left the system and the taxpayers to cope with the overhead costs of all these redundant bricks and mortar. They never took the needed steps to help hospitals restructure and become more efficient. If we don't become more efficient, we're going to continue to waste taxpayers' money.
There are restructuring studies and initiatives completed or under way, as I said, in about 60 communities across the province.
Our district health council volunteers have been working long and hard and making tough decisions, planning for hospitals and how best to meet their communities' future health needs. They have been sending me their recommendations. Some of these community-driven restructuring studies have recommended that hospitals merge or close. The volunteers are rightly proud of their work.
The previous government initiated these studies. Let me ask, did they intend them to gather dust on some shelf when they were finished? Are they telling us and these communities that their recommendations were never intended to be taken seriously? Surely they knew that to respond to these community-driven plans, changes would have to be made to the legislation.
Communities knew this. They have told us that there are roadblocks and that we need a process and a structure for implementation that is "results-oriented and action-oriented" and we will see restructuring completed as soon as possible. I will return to our hospital restructuring agenda in just a minute.
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The tools to do the job: Let me summarize some of the things we're proposing to do by finally revising the outdated Ontario hospitals act. Major revisions include:
Payments to hospitals: The government has always controlled hospital funding, and this simply clarifies what has been in practice under all governments. Our objective is to make the changes necessary to sustain our health care system into the future and for future generations. This change to the legislation is necessary to allow us to keep our promises to focus resources on direct patient care and to better match resources to patient care needs.
A simple kind of "terms and conditions" for funding that might be applied is, for example, how many transplants the hospital is expected to perform or how many cardiac surgeries, for example at the Ottawa Heart Institute, a subject that's been raised in the House on many occasions. I shouldn't have to personally visit the hospital to ensure that it matches available resources to services the hospital itself considers a priority, as was the case with the Ottawa Heart Institute. There is no intention in Bill 26 that this authority be used to micro-manage hospitals.
Under the NDP, the steering committee reviewing the Public Hospitals Act recommended that, "The Minister of Health should be authorized to contract with individual hospitals and intermediate agencies to obtain specific outputs." So in Bill 26, we're responding to those recommendations.
This government, as you know, Mr Chairman, has no list of hospitals to be closed. With government spending dollars at $1 million an hour more than it takes in, it's clear that the status quo is not an option.
Hospitals have recognized the need for restructuring the health care system. Much planning has been done, as I said, but the Ontario Hospital Association and the district health councils have asked for help with implementation. A Health Services Restructuring Commission, to which I'll return in a minute, will have the power to implement restructuring plans, including closing, merging or amalgamating hospitals if this is what the local planning bodies determine is the best way to eliminate costly duplication. This will also speed the 60-plus restructuring studies across the province, ensuring that restructuring takes place in a planned and orderly fashion.
Where a facility is closed, the act will ensure that a physician or health care worker cannot proceed to costly and unnecessary litigation against the former corporation or the government for privileges attached to a facility that no longer exists.
Restructuring the system will drive scarce health care dollars to front-line services where they are needed.
We have set out very clearly our objectives in restructuring our hospital sector: to ensure that quality care continues to be available to Ontarians; to focus resources on front-line patient care; to ensure that we eliminate waste and duplication; to improve the use of existing resources; and to ensure that people's needs are met in the most efficient and effective way possible by integrating delivery of local services.
Hospitals and professional health care managers are asking the government for the tools to do the job. In particular they want two things to carry them through this restructuring period and to meet the objectives I've just set out.
Bill 26 responds to both of the requests.
First, with respect to financial planning, the Ontario Hospital Association and health care professionals have asked that hospital budget reductions be lower in year one and higher in subsequent years so that financial targets could be achieved through restructuring. We have done this by setting reduction targets at 4% in the first year, followed by 5% and 7% in subsequent years -- sorry, it's 4%, 5% and 6% of total revenues; it's 5%, 6% and 7% of transfers.
The three-year funding plan for hospitals provided in the economic statement provides certainty in each hospital's resource allocation. Overall, the plan will constrain transfers to hospitals, as I said, by about 4% of their total $8.5-billion revenues in the 1995-96 fiscal year.
Let's put this in context. Overall government spending is being reduced by 28% over the next two years, internal government spending will be cut by an average of 33%, and the Legislature itself is having its budget cut by 20%.
This is not to argue that hospitals should applaud these actions. Nobody expects that. It's a difficult process for everyone.
But let's keep things in perspective. This government is not going to give special treatment to people who shout the loudest. The Ontario Hospital Association has asked that funding not be reduced across the board, but that reductions contain a differential that recognizes small hospitals and hospitals in high-growth areas. We will do this.
In addition to requesting certainty for financial planning, the OHA asked our government for a set of tools to assist hospitals in carrying out restructuring. Bill 26 provides those tools.
For example, we will allow hospitals to establish crown foundations, thereby making it easier for them to solicit charitable donations. We will develop guidelines for arbitrators that will instruct them to consider employers' ability to pay salary and wage increases, a vitally important point, since labour costs represent about 70% of operating expenses. We will allow hospitals additional means to raise revenues within the parameters of the Canada Health Act.
Provincial Health Services Restructuring Commission: One final tool we were asked for and have provided is the Provincial Health Services Restructuring Commission, which will start work in January. Fairly extensive powers will be devolved to the commission, and clearly we are looking at some sort of completion of the commission's task within a four-year period. At that time, we expect the powers to cease with the task.
I will be issuing a release today indicating that this government will sunset those powers in four years' time and there will be reviews available to the minister and to Parliament during that period to ensure that the commission is carrying out its mandate.
The task of the commission will be to facilitate and accelerate the implementation of hospital restructuring by developing and directing specific restructuring plans. We expect the commission to start with the Metropolitan Toronto District Health Council's recommendations.
The commission will play an invaluable role in assisting with the changes that we all know have to happen to move the health care system from where we are now to where we want it to be in the future. It will be free of the politics of Queen's Park but it will not work in a vacuum. This is key, because, as you well know, restructuring has always been community-driven, and it will continue to be so when the commission is up and running. The community has to be involved in these decisions.
Communities have asked for our help to restructure and the commission will work with local hospital systems and district health councils to identify ways to correct inefficiencies, cut waste and eliminate duplication.
As restructuring proceeds, we will continue to listen to what hospitals have to say on how we can, together, manage through this period of change. Let me make this very clear: The restructuring commission will continue to work with the DHCs to facilitate and accelerate the implementation of the restructuring plans developed in communities across the province. The Ontario Hospital Association itself said in its news release after the economic statement, "the establishment of a health services restructuring commission must make it possible to accelerate implementation of many restructuring projects across Ontario."
The Ontario Hospital Association says that hospitals have long advocated that restructuring is the key to long-term savings, specifically through rationalization of programs and services. These would include mergers, alliances and amalgamations of institutions.
Other statements from third parties supporting urgent action on hospital restructuring include Mr Tom Closson, chief executive officer of Sunnybrook Health Sciences Centre, who said, "We should get on with it and do what we should have done years ago." Mr Mark Rochon, CEO of Humber Memorial Hospital, said, "While hospital restructuring will occur `fast,' it can be done without hurting patient care."
The Ontario Hospital Association's news release reads as follows: "Hospitals are appreciative of the multi-year nature of today's funding announcement."
Remember always that Bill 26's objective is to make the changes necessary to sustain our health care system into the future. These changes to the legislation are necessary to allow us to keep our promises to focus resources on direct patient care and to better match resources to patient care needs, as I've said.
Why spend on unnecessary overheard and administration costs? Lawyers tell us that drafting of this legislation requires that the Minister of Health obtain these authorities in order that they can be delegated. We will delegate that authority to the Health Services Restructuring Commission.
The people who wrote Metropolitan Toronto restructuring study, well respected in their field, recommended such a body to take the politics out of implementing restructuring studies. The Minister of Health will not be exercising these powers unilaterally.
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Voluntary agreements work best and fastest, and that's ultimately what we'd like to see.
Under the previous government, the steering committee reviewing the Public Hospitals Act recommended that "the Public Hospitals Act should authorize the minister, under specified conditions, to require formation of a joint venture or partnership, a federation with a new board of directors or a merger of hospitals."
The previous government heard this advice that said there were circumstances where such an authority may be required to prepare hospitals for the future. However, nothing was done.
The test will always be "the public interest." This terminology was not unknown to previous administrations. For example, one of the recommendations the previous government received was that the Public Hospitals Act should allow "for the regulation of hospitals by the minister through review of performance and intervention when necessary to protect the public interest."
Let me conclude my discussion of hospitals and Bill 26 in this section by assuring this committee that the authority will always be test against the public interest, as clearly outlined in the bill.
Let me turn to the pivotal role of physicians in the health care system and some of the ways Bill 26 will impact on this role. Let's keep in mind what I said at the start: the focus here should be the patient.
We want to continue to work with the medical profession in a relationship based on recognition and respect. Cooperation, fairness and equity do not come from a legal document; they come from the will to work together. Bill 26 provides many of the tools that I am sure will improve partnership and trust between physicians and the government, and I hope this becomes clear.
The province pays almost $4 billion per year for physician services, approximately 9% of the total provincial budget. This has been increasing at an average of 13% per year during the past decade.
In 1991 a new agreement was negotiated with the OMA. This created a joint management process and gave the OMA representation rights for both fee-for-service and alternative payment physicians.
The agreement also mandated compulsory dues, provided for arbitration on global funding amounts, instituted individual payment thresholds, and prescribed a utilization cost-sharing formula.
In 1993 the social contract agreement placed a maximum on the global funding amount, with the financial target to be achieved primarily through utilization reductions and in-year overpayment recoveries.
However, utilization continued to rise, overpayment accumulated because of a lack of OMA agreement to sufficient levels of in-year recoveries, and none of the necessary schedule of benefit changes were made because of the lack of agreement to reallocate funds.
Several matters of dispute did not get resolved but rather were placed in front of umpires in the alternative dispute resolute mechanism.
So let's be very clear here. Jointly managing a system under tremendous pressure requires all parties to make difficult policy and economic decisions. During the past few years, as a result of the constraints posed by the agreement, the government was not able to proceed with key policy changes such as enhancing payments to rural and northern physicians in order to ensure equitable access to medical services in those areas.
An example in point: Despite a fact-finder's report to the contrary, the government has been forced to reallocate additional money from savings and other sectors to fund the recently announced sessional fee for small-hospital emergency services, because the OMA had refused to agree to reallocation from the physician services budget.
The expiry of the 1993 social contract agreement will see the reinstatement of the 1991 agreement provisions, which will mean a significant automatic increase in funding which is not affordable in the current fiscal environment, and a return to an open-ended system with few controls and incentives for responsible management within our financial means.
The agreements have served neither physician nor public well. We continue to see an exacerbation of physician resource maldistribution. Over an eight-year period of time, only one out of every eight physicians graduating have located in underserviced areas. Why, even the small community of Alliston, the community I represent, just 55 minutes north of Toronto, is today underserviced. Ontarians face a lack of access to basic medical services in an increasing number of communities across the province. There is continued physician disengagement from the rest of the health care system, and uncontrolled utilization increases, with an average of 3% yearly increases over the past few years.
There is a serious lack of appropriate incentives to influence utilization and encourage appropriate care, and there are difficulties proceeding with alternative payment programs because the OMA will not agree on conversion of dollars to fund physicians who wish to be paid on a non-fee-for-service basis.
Our policy priorities are: managing physician supply and distribution; protecting essential and necessary medical services; implementing utilization management measures; strengthening accountability; improving efficiency; using alternative payment mechanisms to support system changes where we can get agreement; making physician payments more current and managing expenditures within the budgetary limits. This is quite an agenda. A lot needs to be done, and it needs to be done quickly.
It is essential that government has the necessary tools and authorities to manage and make changes in a responsive and timely fashion. As I've said, we are totally committed to working with the medical profession to make the changes needed to the system. Our joint goal must be to resolve issues and make sure the health system responds to the needs of the people and providers.
A comprehensive action plan has been prepared and we have had preliminary discussions with the Ontario Medical Association. Some of the changes necessitate support from legislation. These are primarily in the areas of limiting billing privileges in certain areas of the province so as to address the distribution of physician resources, and monitoring and investigating inappropriate billings to improve public accountability of the money spent.
Utilization of physicians services has increased beyond the rate of growth in the population for over 20 years. Payments to physicians constitute 22% of provincial health spending and, as I said, 9% of the total provincial budget.
During the decade from 1984 to 1994, the number of physicians billing OHIP increased 40% while the population grew by only 10.5%. As the number of patients per physician declined, the number of services per patient increased. This has resulted in increased financial pressure on government and the Ontario economy.
As studies have repeatedly shown for years, the current fee-for-service system is unmanaged, unplanned and inefficient. It is imperative to find ways of making health care delivery more efficient and effective. The legislative changes proposed will support the government in putting into place policies and practices which will manage expenditures.
The legislative proposals will permit changes in physician compensation in ways that will help to manage overall health costs, address issues of supply and distribution, and promote greater accountability from this crucial group of providers.
My ministry's objectives with respect to utilization management are:
-- To provide the necessary tools to manage expenditures within a fixed budget.
-- To work in partnership with physicians and other health care providers to improve the quality and appropriateness of medical services provided.
-- To ensure more progressive payment management mechanisms.
The new mechanisms for utilization management under consideration include:
-- Implementing a global hard cap for total physician payments and recovering the majority of overruns from the pool, which will be recovered in the year in which the overrun occurred.
-- Working with the OMA to ensure that new medical services are funded from within the existing pool, changing some of the rules and the schedule of benefits to ensure that opportunities exist for fair payment while eliminating opportunities for abuse, and introducing incentives and disincentives into the schedule to foster appropriate practice patterns and the availability of specialists.
-- Adjusting threshold levels to discourage overutilization.
-- Providing patients and providers with information on costs of health care services, something that's long overdue.
Generally, with respect to provider payment control measures, we're moving in order to ensure financial accountability and controlling billing abuse by health care providers. These are essential program elements. I'm not here to say in any way that provider fraud is a large problem, but we do need tools where we think it's occurring to check out to see whether it is occurring and to refer inappropriate billings and practices to the proper authorities.
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Essential parts of this program in terms of management are that we have to be more effective about detecting abuse, we need the authority to properly investigate suspected abuse, and we need effective sanctions to discourage such abuse. The Provincial Auditor, the College of Physicians and Surgeons of Ontario and various internal government reviews have all cited significant weaknesses in the control of billing abuse. As a result, they have recommended strengthening the legislative authority to deal with these problems.
Under the existing act, the general manager of OHIP can only recover inappropriate billings by requiring that cases be referred to the medical review committee or practitioner review committee, as the case may be. The proposed amendments permit the general manager to make direct recoveries without using the review committees. If the provider objects to a recovery of money by the general manager, the provider has a right of appeal to the medical review committee or the practitioner review committee. The request for a review filed by the provider must be accompanied by an application fee, and this fee is refundable if the MRC or the PRC finds in favour of the provider.
This authority will complement that which already exists through the peer review process by providing a means to recover smaller amounts than can be justified being reviewed through the detailed peer review process. This may be of some help to physicians who may wish in the future to deal with billing disputes directly with the general manager and not have them referred to the peer review process through the medical review committee. Smaller amounts should be settled out of those quasi-judicial processes.
Recovery of inappropriate physician billings may take up to six years because of the backlog in the MRC and procedural delaying tactics of physicians and their lawyers. There are lots of cases on the books right now where these things are very prolonged processes. The amendments to clarify and strengthen the authority of the review committees and their inspectors will rectify this problem and ensure timely consideration of problems.
Under the existing act there are no penalties to discourage billing abuse. The provider has only to pay back the money, and is given a year or more to do so. The media has referred to this as an interest-free loan. Amendments to the legislation give the authority to deter billing abuse by providers by charging back-dated interest on inappropriate billings, publicly disclosing the identity of the provider after due process, and charging for the cost of a review committee investigation, which is costing us on average $22,000 per case.
Excessive referrals: Physicians act as the gatekeeper to the health care system. The role brings with it serious responsibilities not just to the individual patient, but to the strength and viability of the health care system itself. Doctors must therefore be accountable for the expenditure of resources resulting from their decisions.
Currently, there is no means to take action against a physician who makes excessive referrals for lab tests or imaging tests such as X-ray or ultrasound, and for consultation to other physicians. Amendments to the act permit the medical review committee to investigate matters of excessive referrals and to direct the physician to reimburse the ministry for the cost of the referrals based upon its determination of medical necessity. Again, that's the MRC.
Every year an average of 5% of the recoveries recommended by the review committees is lost because of bankruptcy, departure from the province, retirement and various other reasons. Under the proposed amendments, if the general manager or the MRC or PRC determines that amounts are owing to the Ontario health insurance plan, then in the case of an appeal the appeal board can order a security for payment. The general manager will still have the authority to recover overpayments through deductions from monthly remittances to the provider even if an appeal has been filed.
Opting out is no longer a method to avoid recoveries of the plan. If the provider does not voluntarily repay money owing to OHIP, the general manager can require the provider temporarily to opt in.
The provisions of Bill 26 concerning the collection and disclosure of information have caused a great deal of discussion. Let me make very clear that we have to come up with a way to protect patient confidentiality and privacy, and at the same time guard against abuses and the threat of double payments. My government wants to ensure that the privacy issue does not become a red herring which distracts everyone from the enormous sums of taxpayers' money at stake here. At the same time, we take the issue of confidentiality very seriously, so much so that I want to make emphasis today that we recognize the concerns that the public might have in this area of collection of information. I also want to emphasize that we expect these committee hearings to clarify the provisions in the act around the collection and disclosure of information.
Since the passing of the Health Insurance Act in 1972, patients have been deemed to have consented to the release of their information. For the past 23 years, the general manager of OHIP has routinely received medical information to verify the payment of claims. The amendments to the Health Insurance Act that we're making in Bill 26 narrow the use of the information to the purpose of making payments and the monitoring and controlling of payments, and to other uses that are prescribed by regulation and are consistent with the purpose of the plan, which is OHIP. Use of this information is critical to ensure that the government can responsibly manage the $3.8 billion in expenditures in the OHIP pool.
There is a trend away from fee-for-service and towards alternative payment programs. For fiscal accountability and planning and to be able to detect double-billing, the amendments contained in Bill 26 introduce the authority to collect patient service information in the same way it is done for services paid on a fee-for-service basis. We are simply modernizing this section of the act.
When a physician is paid by more organizations than just OHIP for his or her services, there is no way or mechanism to find out if the physician is billing twice for the same services. By entering into agreements to exchange information with other organizations such as the Workers' Compensation Board, Correctional Services or private insurance companies, these amendments would permit the ministry to detect such billing abuses.
As well, disclosure of information is allowed for the purpose of providing for more effective management of the health care system. For example, the amendments will permit the ministry to disclose information to the Institute for Clinical Evaluative Sciences for research purposes: Dr David Naylor and his group of expert researchers at Sunnybrook. Research of this nature is essential to provide information to physicians to help them with decision-making and to provide a basis upon which the ministry can plan for the future need for services.
The National Population Health Survey released in October this year asked for the permission of respondents right across Canada to link information in provincial health files. No less than 95% of respondents consented to this provision.
The existing act provides immunity for the general manager of OHIP and ministry staff against any disclosure of information in accordance with the act, and "in accordance with the act" is all-important. The proposed amendments merely extend this provision to the minister and also afford protection to members of the public and health care professionals who provide the ministry with information concerning billing abuse. This is a crucial part of the act, and I want to ensure that during the examination, particularly clause-by-clause, all members fully understand what we're doing here. It is not new and it is not far-reaching.
To recap some of the issues I have discussed so far:
With regard to the collection and use of information, Bill 26 amends critical pieces of the Public Hospitals Act, the Independent Health Facilities Act and the Health Insurance Act to allow the collection of information to prevent fraud, misuse and abuse of the system. The power to collect this information already exists in the Independent Health Facilities Act and is now being extended to other health care facilities. This will ensure that duplicate billings do not occur; for example, from a physician who gets a salary but bills fee-for-service for the same service. It has been estimated that fraud -- and it's provider and consumer fraud -- to the health care system is in the range of about $65 million each year.
The information collected will also be used for planning for future services to eliminate waste and duplication.
The information is protected under the Freedom of Information and Protection of Privacy Act and the confidentiality sections of the Health Insurance Act. Names, addresses and personal details and records are of no use in preventing fraud or eliminating waste and duplication.
Meetings are planned with the privacy commissioner, and we've already begun those meetings, to ensure that any concerns he might have are addressed. Amendments can be made to the act if serious concerns arise. The commissioner has already sent over some amendments that he would like us to consider, and we are considering those.
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With regard to ministry inspectors, once claims have been paid, the ministry can only investigate inappropriate OHIP billing by referring physicians to the Medical Review Committee. As I said before, the Medical Review Committee process is lengthy and expensive, with an average of $22,000 being spent per case, limiting it to a certain number of budgeted cases. Therefore, because of the cost, it's limited to a certain number of budgeted cases. We have hundreds of cases in backlog now.
The amendments provide for ministry inspectors to act under the direction of the general manager of OHIP. This is intended to complement the review committee inspections and deal with the cases that are not referred to the committees.
The powers and duties of the inspectors relate only to the provision of insured services.
The powers of the inspectors have been increased so that effective and timely inspections can be carried out by the review committees. Unnecessary delays caused by a lack of authority to compel providers to cooperate with the committees will be eliminated.
Entry and removal of information from a physician's office will only take place if it is necessary to enable the general manager of OHIP to administer the plan and the Health Insurance Act, or if it is permitted under the Freedom of Information and Protection of Privacy Act.
The health care envelope has been sealed at $17.4 billion for this term of the government. However, I want to remind you that the government pays out, as I said, $1 million more every hour than it takes in. It's therefore necessary to restructure the system.
As part of that restructuring and reform, the government has developed a cost-sharing plan for those receiving drugs through the Ontario drug benefit plan. As I said, the revisions to the act and the revisions to the ODB will allow us to bring about 140,000 working poor people on to the program.
The deregulation of the non-ODB drug market will ultimately increase competition. With competition, prices traditionally go down, not up.
Generic drug companies and brand name drug companies both agree that prices will go down, especially as third party insurers will be able to buy in bulk and affect pricing.
The federal government monitors patent drug prices and the Patented Medicine Prices Review Board, an independent quasi-judicial body, prevents successive price increases to patented drugs sold in Canada.
Since the board's creation in 1987, patented drug prices have increased on average 2.1% compared to inflation increases of 3.3%.
As I've said before, the health care system needs to be restructured to ensure that every Ontarian has access to necessary health services.
More than 70 communities in rural and northern Ontario have experienced a crisis in health care. Their ready access to emergency and other health care services has been severely curtailed.
We have enough doctors in this province, but there are several urban areas that have an oversupply of physicians.
Controlling billing privileges is an option designed to address needs of the rural and northern communities for physician services. There is a very generous incentive package offered to physicians, interns and residents which the government hopes will be effective in recruiting and retaining physicians where they are needed.
For every physician over the last eight years who has gone into an area of need or underserviced area, seven have gone into an overserviced area.
I've met and talked with both the Professional Association of Internes and Residents of Ontario and the Ontario Medical Association and I've agreed with them and made it very clear that I'm willing to give our new incentive package, which is the most generous incentive package in the history of the province, a period of time to see if it will work. In other words, we won't move on limiting billing numbers if we see significant progress being made in response to our incentive package.
There's nothing new in the control of billing privileges. BC, Alberta, New Brunswick, Nova Scotia and Newfoundland each have some form of restriction to ensure that new physicians go to areas where they are needed.
BC, Manitoba, Quebec, Nova Scotia and PEI have discounts on billings for new physicians entering practice and Nova Scotia no longer allows physicians to relocate from their current practices.
I want to tell you a little bit about the Independent Health Facilities Act before I wind up.
Significant components of the Independent Health Facilities Act are its quality assurance provisions, safeguards for the health care system from patient charges and the ability for the government to manage the number and location of facilities.
The Independent Health Facilities Act was passed in 1989 and has served the province extremely well in preventing the entry of two-tiered medicine which has plagued other provincial jurisdictions. Amendments that we are making make it possible to enhance quality of care in a broader variety of facilities.
The minister, with the approval of cabinet, may designate as independent health facilities those facilities providing non-OHIP coverage services; for example, liposuction and other cosmetic services and most fertility services.
This responds to the recommendation of a 1990 coroner's inquest into a death related to a liposuction procedure. It was recommended that the ministry ensure that the quality of services in private hospitals and facilities providing non-OHIP insured services be regulated under IHFA-type legislation.
The act can be extended to OHIP services that are similar to those already covered by it, such as echocardiography and a variety of other diagnostic tests.
This also extends the ability to use the Independent Health Facilities Act to manage the number and location of new health facilities and ensure coordination with local restructuring plans.
We must do this in order to prevent duplication and to eliminate waste within the system.
New grandfather provisions ensure that anyone providing a service that is newly brought under the act can immediately apply for a licence; for example, facilities providing the kinds of OHIP and non-OHIP services mentioned above including private hospitals.
Amendments also provide flexibility in responding to community needs and hospital restructuring. The amendments would allow the minister to permit one or more specific persons to submit a proposal rather than having a general RFP process. This would allow one or more specific organizations recommended by the Health Services Restructuring Commission to provide a service needed as the result of a hospital closing.
The amendments would also allow an existing hospital to become a non-hospital ambulatory care facility without having to go through an RFP process.
They would allow licensed operators of facilities that are to be closed in overserviced areas and who are willing to establish a new facility in an underserviced area to be exempt from all of the old licensing requirements.
The amendments will streamline the request for proposal process.
By eliminating preferences that impose unnecessary obstacles to identifying the most qualified person to operate a facility: It will allow the government to consider individuals or corporations that can provided the best service at the least cost, and with a high commitment to community care as well as the highest ability to integrate the service within the existing system or planned reforms.
By eliminating costly and time-consuming appeals that contribute nothing to improved access to and quality of care, but rather waste taxpayers' dollars and increase the delay in getting the needed services up and running.
Amendments to the IHFA will make it possible to add new services to licences instead of having to licence a new facility for each new service, which is rather bizarre when you think about it.
It will confirm the government's ability to address routine relocation issues.
It will allow the director to remove a single service from a licence where there is a quality problem with that service, without having to revoke the entire licence and therefore stopping the facility from providing any other services.
Further, amendments will give the government increased control over expenditures by providing explicit authority to recover inappropriate fee-for-service billings, and they will give the government explicit authority to collect, use and disclose personal information to administer the act; for example, claims payment and utilization data to prevent fraud and abuse of the system, as I've mentioned in other amendments to other acts.
As well, they will allow the government to share relevant information with the College of Physicians and Surgeons of Ontario for quality assurance and with district health councils to assist with integrated planning for service across the province.
Amendments will also grant regulation-making power to charge additional fees to cover administration costs for all licence changes and for quality assessments. They will grant regulation-making power to prescribe conditions for physician affiliation in support of new billing number limitations for specialists, allowing the government to ensure that communities in need of specialists will be able to acquire them in an appropriate and fair manner.
Amendments will give the minister the ability to revoke licences or to remove services from licences in overserviced areas, as I've said, and to offer new licences in underserviced areas to the affected operators, thereby ensuring equitable access to care across the province.
Let me address another issue that has arisen from the tabling of Bill 26, and that's the privatization or Americanization of health services.
The government, in Bill 26, has taken the bias out of health care. We want the highest quality service at the best price. This means levelling the playing field and allowing all service providers to bid to offer those services.
The request for proposal criteria can and will define the manner in which services must be delivered.
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This government wants to develop the Ontario economy by encouraging Ontario companies and service providers. These measures will encourage Ontario health care industries to expand and develop.
Amendments removing bias in the act are planned to take the politics out of health care. Remember, we had a not-for-profit bias in the act which didn't make a lot of sense when many organizations were willing to provide highest quality at best price and a fair tendering process, and we've done that. Later this afternoon, we'll be announcing the successful tenders across the province in the dialysis tender we put out just a few months ago. You will see there a combination of public sector not-for-profit and independent health facilities for-profit, like some of the clinics we already have up and running in the province.
This government is not Americanizing hospital services. Ontario hospitals will continue to provide insured services to Ontario residents on a priority basis.
Ontario hospitals now provide services to residents of other provinces based on the interprovincial reciprocal agreements.
On an exception basis, hospitals now provide services to out-of-country residents for emergency or compassionate reasons.
While a policy is being developed for the use of excess hospital capacity, any such policy will safeguard the priority of Ontario residents to health care services.
Under the current act it simply says you have to be Canadian to apply. What you do is you get a few of your buddies together, you apply for an incorporation under the Ontario Corporations Act and you set up a shop on Main Street, Toronto, or Main Street, Ontario, and apply through the RFP process. It's ridiculous.
Through the regulatory authority that will be permitted under Bill 26, we can ensure greater restrictions, if that's the wish of Parliament and the people of Ontario, rather than simply having "Canadian," and by the way our lawyers are unable to define what's "Canadian," given that we're not sure whose backing many of the services now being provided through independent health facilities. There could very well be hundreds of independent health facilities out there now that have the backing of American companies. We don't know that because they incorporated and applied through the current process.
We can strengthen that if that's the wish. We could also bring in new services and technology from other countries, if that's the wish, and again, in all of these insured services, it is a single-payor system and OHIP covers the cost for patients. We're not talking about user fees.
Another issue that has arisen is patient education about the cost of their health care. People must understand that the cost of medical services continues to increase with growing rates of utilization. We need to educate patients about the cost of these services and examine the major factors contributing to this growth.
The Ontario Medical Association has expressed interest in reviewing patient utilization factors and implementing some controls, and my ministry is willing to explore options with them.
We need a thorough analysis of utilization patterns in this province.
We are looking at providing cost statements to patients to inform them of the cost of services they receive. This has been tried in a few locations, such as Sunnybrook hospital and a BC pilot project, albeit with mixed results.
We are reviewing the development or setup of a medical review committee to explore alternative options to deliver service for certain patients with a high level of medical need.
We also need to educate physicians about the best use of scarce medical resources.
Let me add right here that there is not a bottomless well of money with which this government can continue to supply services endlessly. We need to carefully examine and monitor health care priorities, both individually and at the government and physician or other provider levels. Knowing costs, and determining need will help all of us to do our part to sustain the health care system.
Other items I want to comment on, but I'll be very brief.
With respect to investigators and supervisors, the current legislation provides for both investigators and supervisors. These are not new concepts.
There are a couple of sections that deal with no proceeding against the crown. I remind members that these provisions merely ensure that taxpayers' money does not get tied up in court cases but gets directed to front-line services that people need and deserve.
There are regulations re hospital bylaws contemplated in Bill 26. This change eliminates the red tape facing hospitals in obtaining approval of hospital bylaws. There is no longer a requirement that they obtain Ministry of Health approval. Bureaucrats will no longer be micro-managing the wording of hospital bylaws.
There are regulations, as I've said, with respect to physician privileges. You know, what sense is there in providing a process for contesting whether a physician has privileges in a situation where the hospital may be closing? Again, this provision merely ensures that taxpayers are not paying for time and energy wasted in the courts.
The changes ensure that hospitals must prepare and submit physician human resource plans.
Regulations for subsidiaries of hospitals: Planning and implementing plans for the future hospital sector should be made in an environment in which the public has full disclosure of the hospitals' financial resources.
Again under the NDP, the steering committee reviewing the Public Hospitals Act recommended that "the conditions within which hospitals' foundations, or other separate corporations of the hospitals, can carry out their activities" should be defined in legislation and include, "The foundations' transactions with the hospital should be disclosed in the annual audited financial statements and all hospital foundation should be required to disclose their audited financial statements to the public."
The opposition may not dwell on all of these aspects of this legislation and the economic statement, but these changes are welcomed by the hospital sector.
Just to remind you of some of the examples of the tools that were requested and that we're delivering on, these were requested by the hospital sector: multi-year funding commitment -- we're delivering on that; commitment to work with the sector on a fair and equitable process to implement funding reductions; guidelines for arbitrators, as I've said; disbanding the Workplace Health and Safety Agency; halting planning for multiservice agencies; introducing the Health Care Consent Act to streamline and simplify consent-to-treatment legislation; ability to establish crown foundations to make it easier for hospitals to solicit charitable donations; streamlined processes in dealing with the ministry on operating plans and capital projects; and a commitment to increased flexibility to generate revenue.
This will all have to be done within the context of the Canada Health Act, of which I and this government are strong supporters.
In conclusion, I wish to say again to the committee that I am grateful for the opportunity to present you with details included in Bill 26. This government has committed to the people of Ontario that we will deliver a sustainable health care system within a declared funding envelope that is protected. We have committed to eliminating waste, duplication and fraud within our system.
The health care components of Bill 26 will give the government and our service providers the tools we all need to restructure the system, not only to make it financially responsible, but to maintain its high quality and reputation as the best health care system in the world.
Thank you, Mr Chair. I look forward to the comments from the critics and any questions you may have.
The Chair: Thank you, Mr Minister. We now have a half-hour each for the two opposition parties. I presume that you want the minister to stay.
Mrs Elinor Caplan (Oriole): Yes, I would appreciate and expect that he would stay.
The Chair: Okay. Beginning with the official opposition, Mrs Caplan.
Mrs Caplan: Thank you very much. I appreciate the fact that the minister has taken the time, even though we received his written remarks a little bit later. I'm hoping that he will agree that any questions that we place on the record, either during these 30 minutes or in writing during the committee process, will be answered in writing by the minister before the end of public hearings. Can we have that agreement?
Hon Mr Wilson: Agreed; I'll do the best I can.
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Mrs Caplan: Thank you very much. I appreciate that.
There are a number of things that I wanted to address. I think, if I can, Mr Chair, with some liberty, I'd like to start out by quoting the CSR document when it comes to health care. This is at the back, "The Next Step -- Public Involvement." It says:
"Health care" -- plus others -- "won't be touched....
"We are ready to listen, to learn and to work with anyone who wants to join us and who can show us more creative, more effective ways to end waste and duplication....
"But how we get there will be discussed in partnership with all Ontarians."
My first question to the minister is, does he stand by that comment?
Hon Mr Wilson: Yes.
Mrs Caplan: Thank you, because that's one question that I'm going to be asking presenters who come before this committee: Were they consulted? Did they offer suggestions? Was there advice taken? Do they feel that the process, as well as the substantial issues in Bill 26, addresses their concerns in a way which allows for transparency and scrutiny and lives up to that commitment that was made in the CSR? While the minister says yes, I would predict that the presenters who come before this committee would strongly disagree with what the minister has just said.
I'm going to attempt to outline some of the concerns that we have, but I also want to address, if I can, some of the minister's comments. While he used a lot of very nice words, I have to tell you I know what many of those words mean, and I would say to this minister that your partisanship and your arrogance will be your downfall. When it comes to this legislation, to begin by saying, "We don't want health care to be partisan," and then to go on and suggest that nobody had attempted anything, I would say to him that, with two former ministers sitting here at this table, the minister should read his own words.
I pulled out some of his own words and I thought, as we began Bill 26, and after the minister in his own prepared remarks suggested that previous governments had in fact suggested many of the things he was saying, it might be interesting to remind him about some of the things that he said when he was the Health critic sitting on this side of the table, and ask him, either today if there's time or, if there's not, formally in writing, how he could sit in his place today and not blush when he said the things that he did, given what he said to former governments, and particularly the previous government on Bill 50.
I'm going to quote some of what he said, just to remind him. He said, "If I were the Tory Minister of Health, if we had won the last election and I were the Conservative Minister of Health for this province, if I or any of my colleagues in the Ontario PC Party or in fact the Liberal Party tried to bring in legislation that's this draconian, the NDP would be hanging from those chandeliers." He was referring to the NDP legislation --
Mr Alvin Curling (Scarborough North): He's blushing.
Mrs Caplan: He's finally blushing. It's appropriate, Minister, for you to blush, because in fact many of the provisions that you have put in here, and not only those but an accumulation of powers that I would say to you were never contemplated by the NDP under Bill 50, are included in this legislation as well. Bill 26 has an accumulation of powers for the Minister of Health which he acknowledged in his opening statement today, powers without appeal, without hearing, without access to the courts.
I know he says in here, "Court challenges are messy." Well, Mr Minister, I want to remind you that democracy is also sometimes not as neat as everyone would like, but it is worth the fight to preserve democratic opportunity for people to have hearings, for people to have appeals, and yes, Minister, to have court challenges. For you to sit there and say it's messy, I have to tell you, my blood pressure rose considerably.
You went on to say, "They" -- and he's referring now to the NDP -- "would absolutely want all of our heads on a serving plate." He's referring now to the fact if he brought in a bill like Bill 50, and what I say to you is that Bill 26 goes far beyond anything that was ever contemplated in Bill 50.
One of the comments that he made that frankly I just find so fascinating is he's now referring to Ruth Grier, and he refers to her as "Dr Ruth" in his comments. I remember the day that he said this. He said, "She, along with Bob Rae and all the NDP caucus, who sit there like a bunch of bumpkins, are going to tell physicians and health care professionals in this province how to do their jobs." This is the minister who in Bill 26, which is before us here today, is not only going to tell them how to do their jobs, because he is defining for the very first time insured services and removing the "medical necessity" component, allowing him and his cabinet to make those kinds of decisions -- never before in the history of this province -- he's not only going to tell them how to do their jobs; this legislation allows him, Minister of Health Jim Wilson, to say where they will practise, when they can practise, how they can practise and for how much they can practise.
Again, this legislation goes far beyond anything that was contemplated, and he goes on to say of this bunch of bumpkins that he refers to, "They're going to tell every physician exactly what services can be rendered, what services will be paid for and how often those services will be available to the people of this province."
The fundamental question that Jim Wilson asked when he was Health critic, and he put this on the record, he said to the people of Ontario, "Do you trust Bob Rae, do you trust Dr Ruth Grier, to run your health care system?" I would suggest that if he were to just substitute a few of those words and if he today were to stand before the people of the province and say, "Do you trust Mike Harris, do you trust" -- and I'm going to leave the word "doctor" out because he was saying that in a very patronizing way towards Ruth Grier, because in fact she's not a doctor, but if he were to say, "Do you trust Jim Wilson to run your health care system?" I think that he would find, and he will find if he listens to what people say as they come before this committee, that the people of this province, those people who deliver the services, those professionals who deliver the services and those non-professionals who deliver the services, and the people who receive their services, the patients and the consumers of health services, would answer his own question by saying, "No, I don't trust Mike Harris and I don't trust Jim Wilson to have absolute control and dictatorial authority over every aspect of the delivery of health services." They would answer that question, "No."
When we look at Bill 26, we find that exactly the same concerns Jim Wilson expressed when he was Health critic he has included in the provisions of this bill. He complained because the previous Health minister said, "Well, we may not use all the powers." We've heard Minister Wilson saying exactly the same thing -- "We may not use all of these powers." He said to them what I also found ironic in the minister's own remarks this afternoon, was her saying, "Well, we may not ever use these wide-sweeping powers we're taking unto ourselves, the ability to make the decisions behind closed cabinet doors, the ability to bypass any negotiations with the union, the Ontario Medical Association." He went on to say that they, the NDP, brought Bill 50 in -- that was the expenditure control plan -- in such a draconian way that it was unbelievable to him and to his colleagues that they were getting away with it.
I want to say to you that Jim Wilson and Mike Harris are not going to get away with Bill 26. The people of this province are starting to realize that if the government had had its way, this bill would be law today. That was their intention. They wanted this bill by the time that the House adjourned for the Christmas break. Bill 26 would be law today if Mike Harris and Jim Wilson had had their way. What we are beginning to hear and to discover are the many provisions of this bill.
So I have a question for the minister. You referred to the Information and Privacy Commissioner's concerns. You've said that you're meeting with him. I have a copy of his letter -- I'm sure you have read it -- and in his letter he asks if you will bring in legislation to protect health information. The question I have for you is, will you make the commitment today to withdraw all of the sections of this bill as they relate to access and disclosure of patient information, those provisions that would say to the Minister of Health that you are no longer accountable and you are no longer accountable publicly because you can disclose that without penalty? Would you remove all of those sections from this bill and make the commitment to do as the freedom of information and protection of personal privacy commissioner has requested, and bring in separate legislation to deal with all of those provisions which are in Bill 26?
Hon Mr Wilson: The short answer is no. If I may be permitted, it boils down to that our provisions are very similar to the provisions contained in Ms Caplan's government's 1989 Independent Health Facilities Act with respect to privacy. Suddenly the privacy commissioner -- and this committee will have an opportunity to ask him why -- after six years with no problems with respect to disclosure of information under that act, wants a separate health privacy protection act. Now, over the term of the government we're not ruling out maybe having to do something on that, but it's very clear to the ministry lawyers -- and we're sawing off between lawyers here now -- that Bill 26 and amendments to the Health Insurance Act and to the powers of the general manager and OHIP are fully overridden by the Freedom of Information and Protection of Privacy Act.
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The commissioner has asked in that letter, Ms Caplan, for some amendments, which we're looking at, that would tighten up provisions in Bill 26, and I've already said publicly we'd be willing to do that.
With respect to extending immunity to the Minister, Ms Caplan, I would say, if somebody wrote me a letter about fraud in the system, should I pass that on to the CPSO or OHIP investigators with immunity, as if anyone else? This is not disclosure of the patients' names and records for out on the street. This is the same security of information that was good enough for your government and good enough for the NDP. It would be a rare case that the minister would need immunity.
You know this is a standard clause in every piece of health legislation that we have and in many, many other pieces of legislation, because I've sat on these committees with you. So to take it out of context and blow it up for the public is a little unfair, given that we think -- and by the end of the committee hearings we'll know for sure -- that the intent is to strengthen and safeguard records.
You also know that the people who have access to these records, like OHIP inspectors, which, in the cases of patients' records, will be health professionals themselves, so they're bound by oath, they're bound by their colleges and the conduct with respect to confidentiality that must occur as doctors, as health professionals, are also bound by this act and the Freedom of Information and Protection of Privacy Act. There also are extreme penalties in this act if any of those officers of the crown or acting on behalf of the crown or the minister disclose information. So the buck stops with the inspectors themselves. These names and patient records don't go to the Minister of Health and they won't go to the Minister of Health. In this act, there's no way they can.
Mrs Caplan: If the minister were right, I would agree with him. But he's wrong and the commissioner of privacy says he's wrong. He hasn't read his legislation or he doesn't understand his legislation, but this legislation very clearly gives the minister access to information, and the ability to disclose that information, without accountability. You are saved harmless from any effect of that disclosure. That's what the legislation says. Any person who reads that understands that. Those provisions are new. They were not contained before. The minister is clearly and absolutely wrong.
Hon Mr Wilson: No, Mr Chairman --
Mrs Caplan: All we're asking him to do is follow the advice of the commissioner of privacy and bring in his proposals in a separate piece of legislation so that we can have full scrutiny and so we can fully understand that people's records are protected, that their privacy is protected in a way which the commissioner of privacy says is acceptable.
I am very upset to hear the minister today say that he refuses to do that. That's a simple request and he's said no and I don't like that. I also believe that the people of this province will find that an unacceptable response from this minister. He's couching the language in terminology which I think the people will find tremendously unacceptable.
I do want to put on the record some of the other concerns that we have, things that are in this bill that I think we'll be hearing about from presenters and things that the minister did not, I think, accurately reflect in -- I don't want to question is motivation, but he did not present in a way that I think people really clearly will understand.
What he's saying is that he is going to set up a commission, an unelected, unaccountable commission, to have the powers that he is taking unto himself. He's saying: "First of all, I'm going to have the power in Bill 26 to close, to merge, to amalgamate. I'm going to have the power," he says, "to set levels of service in every hospital and every facility across this province." Then he's going to give that power to a commission -- unelected, unaccountable commission -- to do as it wishes.
I would suggest to you, Mr Chairman, that the minister who sits here and says, "I don't think that this should be partisan" -- I would say to him, I think this should be accountable. You're setting up a commission with no accountability and you're trying to wash your hands of it and suggest that no, no, no, this isn't going to be your decision. Well, I would ask that you rethink that.
There is the ability in the Ministry of Health Act to set up as many advisory committees as you wish. You do not need to have this restructuring commission set up with the powers and authorities. Those must remain with you. If, as you said, the buck stops with you, then have the courage to stand up in this place today and admit the fact that you have those powers.
I would agree that there are some provisions in this legislation -- some, and I mentioned some of them when I spoke in the House -- and changes that are needed. I admitted that and I said that particularly when it comes to transparency of hospital records and foundations -- I referred to that. But the minister today talks about Into the 21st Century and one of the questions I would like to ask is whether or not the recommendations of Into the 21st Century are included in Bill 26, because as I read it, they are not. What the minister has attempted to do is to suggest that Bill 26 reflects the recommendations of the Into the 21st Century report on how to change the Public Hospitals Act.
I'm not going to use the word "misleading" because it is unparliamentary, but I would say to the minister that your characterization of your changes to the Public Hospitals Act does not conform with the recommendations of Into the 21st Century, and so I'd ask for an analysis to be tabled with his committee to show what was recommended by Into the 21st Century and what is in Bill 26 and what is left out of Bill 26 that was recommended, and perhaps a rationale of why the minister did not take the recommendations that were made to him, since he was the one who brought up the report of Into the 21st Century. I think that is a fair question and I know that's going to take a little bit of work.
Not only does this minister take unto himself the power to close arbitrarily, without consultation, without appeal, to eliminate volunteer boards -- he says in his comments that the power of investigators and inspectors are already in legislation, and he's right. But with this minister it's not only what he says, it's what he doesn't say. The existing powers of inspectors and supervisors are very clear as far as the process that must be followed upon the appointment of an investigator and then the appointment of a supervisor is concerned. The appointment of a supervisor wipes out voluntary boards. It allows the minister not only to micro-manage but to take over any hospital, and now with this it will be any health facility in this province. I would point out to the minister that his new provisions allow that with no process and no appeal. That is brand-new and it goes far beyond what was included in any previous legislation.
We've already addressed the ability of the minister for the very first time to snoop into medical records. I won't dwell on that again.
The bill -- and I believe this should be separate legislation. If you want to make changes to the drug plan, bring it in in separate legislation. To suggest that your proposals for -- and you've used all kinds of words. I'm going to use the word "user fee" because I believe that when you said and when your Premier, Mike Harris, said, "No new user fees," people thought that meant no new user fees for drugs and I think they see that as a major betrayal. He referred to it as a question of fairness, and so the question that I'd put on the record is -- first of all, it's a broken promise; there's no getting away from that -- do you think it's fair that a single senior with an income of $16,001 is treated exactly the same as a single senior with an income of $100,000? Is that fair?
Do you think it's fair that a family on welfare with a bunch of kids who have chronic illness and disease, disabled persons, families with incomes of $24,001, are treated exactly the same as families, seniors, with incomes of in excess of $100,000? Is that fair to you, Jim Wilson? Is that fair, to Mike Harris? I don't think that's fair to the people of this province.
We prepared our briefing book, and I want to compliment our staff on the exceptional work they've done, and we've put the cover very clearly. It says, "Not One Cent." We heard the minister today refer to the fact that we have a debt here in this province. I want to point out to him that not one cent of the debt is going to be reduced during the mandate of the Harris government. This government said not one cent of health care is going to be touched, not one penny is going to be cut, and we have seen to date $1.3 billion taken out of the health budget, taken from the hospitals. The minister shakes his head no, but that was the economic statement that was presented. As they presented their deficit number for this year, it included a reduction of $1.3 billion from the expenditure on hospitals. That's the fact, that's the reality, and he can shake his head as much as he wants, but that's the truth -- $1.3 billion.
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He talks about $225 million from the drugs as savings. It's not savings. That's additional revenue, revenue from those people whom they promised not to hurt: seniors, disabled, children. Those are the people who are going to be hurt with this $225 million of user fees, additional revenues that are being collected.
Not only do I decry the way this bill was presented, but I've listened very carefully to the minister's statement. I can go through it in detail. He says on one hand, "We are not going to micro-manage," and on the other hand he is requiring hospitals to present human resource and manpower plans that are so fluid it would require such massive bureaucracy to study and address and then, because of his ability to interfere with those plans, I would suggest, that is in fact micro-management. So while he says on one hand that's not what he's doing, on the other hand it's exactly what he is doing. This bill gives him the ability to micro-manage the system. He's already talked about possible amendments and one of my last questions to the minister will be: Will you table those amendments today? Will you give us the opportunity to see what you are considering as these hearings go forward? Because my fear is that those amendments will be tabled on the last day and we know that there'll be no opportunity for presenters who come forward to see what you are proposing in the way of amendments. So I would ask if those amendments would be tabled.
As I sum up -- did you want to have any time?
Mr Curling: If I've got a minute.
Mrs Caplan: I'm going to leave just a minute for my colleagues. There's much here that the minister has said, but he has talked a lot about partnership and trust. He also talked about no bottomless well. Well, Minister, given the way you have treated your partners, I don't believe they will ever trust you, and I believe that Bill 26 not only poisons your relationship with them, it poisons the very well that you refer to. I would say to you that the only way you can reinstate partnership and reinstate trust is to withdraw Bill 26. Bring back sections of it if you wish in parts that can be scrutinized and digested and debated and discussed, with sufficient time and with that partnership where people will come forward and offer you their advice and their assistance and their participation. But if you insist on ramming this bill through by the end of January, as is your plan, then any hope of partnership, trust, will be gone, and that well will be poisoned for a long time to come.
The Chair: Thank you, Mrs Caplan. We've got a couple of minutes left. So, Mr Curling.
Mr Curling: Thank you, Mr Chairman. You know how anxious I am to participate in this democratic process, not only myself but my colleagues who were shut out and also the people of the province who were shut out in participating in this most important bill.
One of the things I want to put on record basically is for the minister to list to me -- as he said first, his statement started as non-partisan, almost saying non-political, but he mentioned quite often about special interest groups. I keep wondering as your government keeps saying, "We will not respond to special interest groups." Could you list for me in the process who are special interest groups, who these people are, and tell me why you would not respond to special interest groups? Also, define to me if a doctor is not a special interest group or their organization is not a special interest group. Because one of the main and most important things about our process, this very democratic process, is to get all the people who are interested in democracy and their health to participate, the communication that we want, the consultation that we want in this kind of process. Tell us who are these special interest groups that you and your government so adamantly refuse to address and refuse to recognize.
My other comment, Mr Minister, through the Chair, is that although we do have public hearings now in this rather rushed period of time, at this time many, many people are calling my office and many of my colleagues' offices, hoping that if the opportunity does not allow them to make some presentation, that you and your government will make some recommendation to the committee that we have extended time in which to hear these people who are very, very anxious to participate in the omnibus bill that is going to have a very, very adverse effect on their lives, and hopefully that you'll go back to some of the comments that my colleagues have mentioned and some of your own soul-searching speeches that you gave at that time, that you realized that we must be sensitive to all those people in our society.
The Chair: Minister, you've got a minute for a quick answer.
Hon Mr Wilson: The member for Oriole, Mrs Caplan, asked about amendments. We have no interest in holding amendments back. I found that frustrating when I was in opposition actually. I couldn't understand why the government, when a good point was made and agreed upon, would wait till the last day to put in amendments and continue to get hammered day after day, witness after witness, when they were already intending on doing it.
The Ontario Hospital Association has asked us to sunset the Health Services Restructuring Commission powers. They're not intended to be ongoing powers; they're intended to get the job done. So we're signalling that today, and as soon as the legal wording is available for review by committee members, I will ask members of our caucus to table those. With respect to the privacy commissioner, meetings are ongoing and we will table those amendments.
The health care envelope has been sealed at $17.4 billion. Not one cent's been taken out. The fact of the matter is Mr Eves's cuts in transfer payments to hospitals begin on April 1, 1996, so nothing's happened now.
I've already spent a large portion of those savings within the health care envelope when I announced paramedic services, when I announced dialysis services, when I announced symptom relief medication for ambulances; $19 million for cardiac care surgery, which will dramatically reduce the waiting list in this province over the next two years -- 1,435 people will get more services; acquired brain injury, bringing patients back from the United States, something that we're very proud of. I've already spent a lot of that money.
Secondly, there are members in this room who are asking me for tens of millions of dollars, particularly the Windsor one I think about, in order to prime the pump to get the restructuring going on the capital side in Windsor. When you're going from four hospital buildings to two, tens of millions of dollars are needed on capital renovations to move into those buildings. Where do members think the money's coming from? It's coming out of the operating side and it's going to be fully reinvested in the system within a $17.4-billion budget. That's our commitment and the commitment's firm.
The Chair: Thank you, Mr Minister. Okay, we now have a half hour for the third party. Ms Lankin.
Ms Frances Lankin (Beaches-Woodbine): Beware the minister who uses the word "I." I counted about 20 or 25 of them in that last little diatribe from the minister: "I have announced," "I have spent," "I have done this," "my ministry." From your opening statement, where you went from imploring us to treat this as a non-political issue to very, very quickly talking about previous governments with lack of vision and lack of intestinal fortitude, I've got to tell you I found that to be one of the most arrogant and basically dishonest portrayals of the past that I have heard from a minister of the crown. I was both surprised and disappointed. It doesn't set a good tone to begin this process of review of this legislation.
I, however, want to use my time I think to build on the comments that have been made by my colleague from the Liberal Party, another former Minister of Health -- this is sort of an interesting scenario here -- and spend most of my time asking questions, because I believe in a general sense her overview of the legislation and her read of the legislation is one with which I would agree.
I also, just in passing, must say I agree with her comments about the dramatic change that has happened in the minister's attitude since he was a critic to the point in time that he became the minister. I'm not sure what it is about sitting in that ministerial seat that does this to people, but I remember very well him, as critic, assuring us that he knew there was $700 million worth of fraud in the health card system. Today he refers to studies quoting a number of $65 million. I've heard that number somewhere before, but it's one that the minister, when critic, didn't believe.
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I remember him standing in his spot accusing our government of actions which were causing doctors to flee Ontario in large, dramatic numbers, and yet the background materials his ministry provides and that he has sent over to us with his signature on talks about relative stability over the past decade in terms of the number of doctors leaving and/or entering the province and entering practice.
This is a government that abhors quotas and yet within the legislation sets numerical quotas for doctors and where they can practise. This is a minister who in opposition, I remember, attacked me personally when we took one particular drug and moved it on to a special approvals process because of recommendations from the Drug Quality and Therapeutics Committee.
I remember him specifically raising the instance of one of his constituents and a doctor being very opposed to anything that would not allow doctors to require that no substitutions be made, even in this case where there was an approvals process. Yet now he suggests that individuals could pay. I would like to go back and speak with the minister's constituent and understand whether or not that particular person is in a position to pay for the drug. It's a very different position than you took before, and in many ways you are now singing a different tune.
I would like, as I go through my questions, to ask you if you could give us some detail about the changes that you are proposing, with the previous provisions of the act that's in place that you are repealing provided, and why the specific changes are being made. I am quite sure, given the length and complexity of the proposed amendments to various pieces of legislation contained in schedule F and beyond, that I won't get through all of my questions, but I will take them in sequential order and see how far we get.
You spoke about the Health Services Restructuring Commission and have indicated today that you will be tabling an amendment which will put a sunset clause into the legislation with respect to that commission. I'm wondering why you've not set out any terms and conditions with respect to that commission in the legislation, why it will all be done by regulatory power. Why are there no goals, no responsibilities, no objectives set out in the legislation?
Hon Mr Wilson: I think the policy intent of the government has been made very clear. We didn't think up this idea. It's come from district health councils. There's a very specific reference to an authority or a commission in the Metropolitan Toronto District Health Council's recommendation to government. It is, I think, clear to a number of people that it's very difficult for the volunteers who write the district health council reports to then turn around and have to implement their own reports. We're bogged down in some areas of the province where communities --
Ms Lankin: My question was: Why have you not set out any goals or objectives or terms or conditions with respect to the Health Services Restructuring Commission in the legislation?
Hon Mr Wilson: We've done the very best we can to try to put some flesh on the bones with respect to the commission. The powers of the commission are clear as delegated and held accountable through the Minister of Health to Parliament, which was the best way in terms of legal advice that we could do this.
This is brand new. This will be the largest restructuring in North America. The Metropolitan Toronto District Health Council hospital restructuring report is the largest of its kind in North America, and I agree, we've learned some things from other provinces --
Ms Lankin: Okay --
Hon Mr Wilson: A human resources plan is required --
Ms Lankin: Mr Minister, I have a lot of questions and I don't want speeches on all of these, please.
Hon Mr Wilson: I recall you used to give me some pretty lengthy answers.
Ms Lankin: If we could try to get to the answers.
Specifically, the duties set out in subsection 8(7) say: "The commission shall perform any duties assigned to it by or under this or any other act," and you're telling us that in fact you think the duties and the powers are clear.
Let me ask you another question with respect to the section you're repealing. What is contained in there that will no longer be available to the public or through legislation in the new act?
Hon Mr Wilson: Sorry, Ms Lankin, I missed the first part. Somebody was interfering with me.
Ms Lankin: You're repealing section 8 of the Ministry of Health Act. What sections of that will no longer be in force? What are you doing away with through repealing that section?
Hon Mr Wilson: The specifics of the section --
Ms Lankin: Let me suggest to you that it is the provisions with respect to the district health councils. Does that jog your memory?
Hon Mr Wilson: In terms of district health councils, when Bill 173 was brought forward, we did argue that to codify something that's been in existence for 20 years, we didn't feel, was necessary, and therefore we've said to district health councils they have to be the ears, eyes and conscience of --
Ms Lankin: Will district health councils still have any legislative reference in section 8 of the Ministry of Health Act?
Hon Mr Wilson: Mr Chairman, in fairness, I'll need my section-by-section binder, and just ask that that be done.
In section 8, my recollection would be that we're repealing the Ontario Council of Health, which is being replaced, unlike Mrs Caplan said. She said, "You have the authority to set up all kinds of advisory committees." You're right, but we're repealing the Ontario Council of Health and putting in a hospital restructuring commission.
Ms Lankin: Okay. Subsection 8(8) of the existing act sets out district health councils' powers -- sorry, I go back before that, under subsection 8(4), functions of district health council. Subsection 8(5) talks about capital and members of district health councils.
Hon Mr Wilson: I'm sorry, just repeat the first part.
Ms Lankin: What I'm trying to understand is, if you have repealed that section and you replaced references to the Ontario Health Council and district health councils with the Health Services Restructuring Commission, which you are now indicating you're going to sunset in four years, will there be any references left to district health councils or the roles and obligations of district health councils, and where will those be found?
Hon Mr Wilson: Yes, there will. Bill 173 still stands, and its provisions and changes. Secondly, I don't think the Ontario health council has met in a long time. It's a redundant council and we want to replace it with --
Ms Lankin: I'm talking about district health councils, which I specifically referred to.
Hon Mr Wilson: Yes, there are still references in terms of amendments that your government made. The bill still stands. We're not repealing Bill 173 or some of the changes you made, and the regulations have not been developed -- I don't think they were developed when you left office -- with respect to putting flesh on the bones of district health councils. I've said in the general policy statement, though, we'd like to roll their mandates back to being the ears, eyes and conscience of the local communities.
Ms Lankin: I think that it would be helpful if we could get a written response on that with respect to that section because on first reading it would indicate section 8 being repealed and nothing being referred to in the new section 8. All references to district health councils in this Ministry of Health Act in that section are gone.
If I may continue on, under Public Hospitals Act amendments, in terms of funding you've referred to the language "in the public interest" as being fairly standard language and something that shouldn't concern us at all. Currently in the legislation, the requirements of the minister to fund are in accordance with regulations, and those regulations have been set out and they cover a number of different criteria. That has been completely removed. There is no longer reference to regulations in the section. It simply has three very, very broad and sweeping criteria allowing you to either make grants or loans, impose conditions on funding, or reduce, suspend or terminate funding. Why would you want to be in a position to make these kinds of decisions without any set of criteria that are available for public scrutiny, ie, set out in regulations under the act?
Hon Mr Wilson: There will be criteria in terms of policy and in terms of regulations, but the fact of the matter is, if you go back a few years --
Ms Lankin: I'm sorry, would you repeat that? You said there will be regulations under this section? There's no provision in the legislation.
Hon Mr Wilson: I'll have to ask legal counsel to clarify, but let me tell you the intent of the section. As you know, it's been very difficult to do any hospital restructuring. As I said in my remarks, 6,700 beds are closed but the bricks and mortar, empty hallways in some cases, still exist, and the only option the Minister of Health has under current legislation is to starve a hospital to death. I don't think that's a good way to go about restructuring the system. So we've developed these tools in consultation with our partners --
Ms Lankin: Mr Minister, again, you've gone off the question. I'm sorry, but I did hear your speech. I listened to you for an hour, and I would like to get at some of the specifics. This is the only chance I have to get at the specifics.
Hon Mr Wilson: Gail Czukar from the Ministry of Health legal branch will provide the specifics with respect to the regulatory authority that the member asks for.
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Ms Gail Czukar: You're speaking with respect to section 5 of the Public Hospitals Act, the funding section?
Ms Lankin: Yes.
Ms Czukar: In clause 32(1)(s), it speaks to regulations that can be made "governing the manner of determining the amounts of grants, loans and financial assistance...made to hospitals under section 5 or the amounts themselves...prescribing the time, manner, terms and conditions of payment," and so on. So there is provision for regulations to be made with respect to payments to hospitals.
Ms Lankin: The changes that are being made here in this section, Mr Minister, appear to provide you very broad grounds on which to make decisions with respect to funding of hospitals. As I understand it, in the past there has been a court ruling that indicated that the minister could not act for fiscal or budgetary reasons alone without regard to the effect on patient care in deciding to change funding levels, in this case to proceed to close and/or amalgamate hospitals.
The changes that you are proposing to the Legislature and to the legislation allow you to determine whether closure or amalgamation should occur, again in this broad phrase, if it is in the public interest, which would seem to allow you to take into account anything you deem to be relevant, including availability of financial resource. This is quite different than the court decision that has previously been in place.
Could I ask you why you're making those specific changes?
Hon Mr Wilson: "In the public interest" is a good question, because it's a test and limitation on the authority and how it may be exercised. I'll certainly ask Carole in a moment to explain because it is important that members note that.
With respect to the court case, you're right. I think in the past when ministers of Health tried to influence the behaviour of a particular hospital or indeed tried to convert that hospital to something other than a public hospital, the funding route was taken, and I don't think it was a very good way to go about things. Clearly the court said that because they provide medically necessary services onsite that starving a hospital to death is not the way to go.
I think the process that's contained in the bill with a commission is a fairer process, and again --
Ms Lankin: I'm sorry, Minister, that's not what the court decision said. Could I clarify my question?
Hon Mr Wilson: It's clear, though, that nothing will done unilaterally, in that the district health councils make these recommendations. Again, I would ask you, Ms Lankin, you had 30 studies coming in in the next few weeks. What am I supposed to do with them? Just sit on them? Five million dollars alone for the Metro Toronto study, no process in place, you didn't move on the legislation at all to lay some groundwork on what to do with these hospitals.
Did you intend that hospitals would simply go back to the old game of just fighting with the government back and forth for a number of years until one side blinks? That's just not the way it's going to be. We've been told by the OHA that restructuring has to occur and we're trying to facilitate it.
Ms Lankin: I think when on shaky ground politicians, particularly ministers, move to the offence. Quite frankly, you haven't answered any of the specific technical questions, and that worries me.
I'm going to come back to some of the comments that Ms Caplan made with respect to your understanding of the legislation and the powers that you're taking on to yourself.
There have been provisions in place in legislation and processes in place with respect to how decisions about funding were made. There have been protections, in both the legislation of the past and in court interpretations of that, that those decisions about funding and about closures and about amalgamations, while the right in the minister to make, must be made keeping issues such as patient care in the forefront, and not made solely on the basis of fiscal decisions.
You have changed the language and given yourself complete protection on liability issues in a way that has not existed in legislation before. You said in your presentation in a number of areas that you're merely extending these protections of liability to the minister.
I can point, as I go through my questions, to points in the legislation where before the crown was liable. For example, under some of these decisions with respect to inspectors and supervisors coming in under the Public Hospitals Act, you have taken additional protection to insulate the minister and cabinet from legal liability. Prior to that, crown was liable for certain of those actions. The inspectors weren't but the crown was.
Why have you taken that next step? What is it that you're afraid of in terms of liability? What are you trying to protect yourself against?
Hon Mr Wilson: With respect to the latter point, crown liability is maintained in sub (2), there, but you've taken a very narrow definition of it. It's only fair, I think, to have legal counsel respond, because some of the comments that the honourable member has put on the record simply wouldn't withstand the legal scrutiny. I'd like, in fairness, to ask Carole McKeogh, from the legal branch of the ministry, to respond specifically to your former comments, where you say we're taking out quality provisions and that. Nothing could be further from the truth.
Ms Lankin: Taking out what? Sorry?
Hon Mr Wilson: You mentioned "maintenance of quality and quality assurance."
Ms Lankin: No, I never used those words.
Hon Mr Wilson: I thought you said "quality" there.
Ms Lankin: No.
Hon Mr Wilson: I'm sorry. Do you want to respond, Carole?
Ms Carole McKeogh: Sure. I think that the reference to the former case was the Doctors Hospital case in 1976, and that was a court decision where the government had moved to revoke the approval of Doctors Hospital under section 4 of the Public Hospitals Act for fiscal reasons.
They wanted to revoke its approval as a hospital for fiscal reasons, and the court held that in regard to the revocation of an approval of a public hospital under the current act as it now stands, there was no action that could be taken for fiscal reasons. The act was purely regulatory in nature. I don't have the case in front of me at this exact moment but, as I recall, the words were "regulatory in nature," and that fiscal issues did not arise under the Public Hospitals Act.
The amendments to the act are intended to broaden the grounds upon which action can be taken, with the public interest being defined in subsection 9.1(1) to include a number of issues, including fiscal issues. But the patient care issues are also maintained in the 9.1 text.
Ms Lankin: Mr Minister, the provisions in the Public Hospitals Act expand the powers given to inspectors and to supervisors, and there are a couple of points of this that are disturbing to me, one in general, but again it's not spelled out in the legislation and it is very much of a discussion of the minister and the direction of the minister. Particularly, though, when appointing a supervisor, in the previous legislation there was a requirement for the tabling of an investigator's report and there were criteria in terms of under what conditions etc. Why is that being done away with?
Hon Mr Wilson: Much of that is preserved in this legislation.
Ms Lankin: Not the specific points that I've just raised.
Hon Mr Wilson: I'll ask Carole to respond to that.
Ms McKeogh: Section 8 of the current legislation deals with investigators and section 9 deals with supervisors. The section 8 provisions remain in so far as investigators do table a report. However, the section 9 provision, the link between the report and the supervisors, is removed. It's no longer a necessary precondition.
Ms Lankin: My question was that exactly, and it was why? Your answer in its first part was wrong. Perhaps you could answer the why.
Ms Marilyn Churley (Riverdale): The minister doesn't know his own bill.
Hon Mr Wilson: It would depend on your interpretation. We admit up front -- I said in my remarks that we're expediting some of these processes. There isn't the precondition for the report to be submitted prior so that a supervisor can go in and do what might have to be done again. This is very, very rarely used. A supervisor hasn't been used -- I think maybe twice in the last 10 years -- but we're modernizing the act.
The reason I asked legal counsel is I get the suspicion that the honourable member, no matter what I say, just doesn't believe me. If I say certain provisions are --
Ms Lankin: Well, you've got a point there.
Hon Mr Wilson: -- preserved in the act, she says I'm wrong.
Ms Churley: You don't know it.
Hon Mr Wilson: I can't win.
Ms Lankin: With respect to the appointment of the supervisors and the responsibility of supervisors, it is my understanding that, before, the act provided that supervisors could play an advisory role essentially to the board of the hospital. Now it appears that they can go further than they could before and can actually take over the administration or running of the hospital in a more direct hands-on way.
Given that this section has been so rarely used, as you said, there have only been a couple of supervisors appointed, why did you feel it was necessary to provide supervisors with that kind of power, which essentially would undermine the role of the voluntary boards?
Hon Mr Wilson: Again, those broad powers were contained in the old section of the act in terms of supervisors could direct the board and could do things in joint discussion with the board, and that's maintained in this act.
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Ms Lankin: Are you suggesting that the act doesn't take it further in terms of the powers of the supervisor to actually assume the duties and responsibilities of the board?
Hon Mr Wilson: Yes, it does take it slightly further.
Ms Lankin: Why?
Hon Mr Wilson: Again, in cases where it may be required. You know we would like to be able to do things as expeditiously as possible. It's a very rare provision, and the need would only arise under extreme circumstances. We're not contemplating having supervisors running around to every hospital to upset their voluntary governance if this is the case. There are safeguards in there which would trigger a supervisor being called onto the scene.
Ms Lankin: Here's my problem with that --
Hon Mr Wilson: For example, if a hospital --
Ms Lankin: Mr Minister, I've only got a couple of minutes left. I've heard your answer.
Hon Mr Wilson: Could I answer? If a hospital refused to provide certain services because of financial constraints or otherwise, then a supervisor would come in and have to direct. The rare case would be hospitals simply handing you over the keys, saying, "We can't live within this fiscal environment," or something, and a supervisor would go in. But we don't expect that. That power's been there in the past. It has been used very, very rarely, and this doesn't alter it --
Ms Lankin: Mr Chair --
The Chair: Thank you, Mr Minister.
Hon Mr Wilson: -- in my opinion significantly.
Ms Lankin: Here's my problem with what you've just told us. You've agreed that powers of investigators and supervisors have been expanded. You have told us that the use of supervisors is so rare, there have only been two examples in the last 10 years, in your words. You think and contemplate that it would be so extremely rare that a supervisor would ever do this, yet you've contemplated the exact circumstance in which you're going to have a supervisor take over the duties and the responsibilities of the board as opposed to the former role which was simply advisory.
If you go on, you can give absolute direction, as the minister, to that supervisor with respect to the running of the hospital. In fact you can insist that the board carry out any of the directions of the supervisor, which could be directions of yours, which would include overriding provisions of other legislation, overriding the letters patent and the bylaws of the hospital and overriding other contractual obligations.
For example, I don't know, but we'll ask some of the health care employee organizations that come forward here whether or not they see this as the possibility in the future of you directing a hospital board, under supervision or through direction, to override provisions of contracts and collective agreements.
These are very broad powers. It is not at all easy to understand why you would provide those powers to yourself, as minister, being able to direct a supervisor, when you said it is such a rare circumstance that you would ever get there.
Continuing, in the Public Hospitals Act there are powers you give yourself to insist that when physician resource plans are submitted by hospitals, you can impose amendments to the plan yourself unilaterally.
You've extended the provision of immunity from liability in all sorts of situations. You've taken away rights of appeal. Even in circumstances other than closure, when doctors and physicians are revoked privileges, you've taken away rights to appeal to the hospital and courts, and you give cabinet the authority to set out in regulation if you will allow them any other form of appeal, but not necessarily will you allow them appeal.
There are many changes that go on in areas of the Independent Health Facilities Act that you've set out in terms of drug listing, and I've already raised some of the concerns I have about your obvious change in position from when you were critic to when you were minister.
Let me ask you, with respect to the process for adding lists to what is covered under the plan, you now have the ability to decide whether or not you think it is advisable, in the public interest, to add a drug. What would you be considering? Would that include the cost of the drug?
Hon Mr Wilson: We'll be still taking the advice of the DQTC with respect to additions to the ODB.
Mrs Caplan: But you still have that power to decide unilaterally.
The Chair: Mrs Caplan, this is a --
Mrs Caplan: And he didn't answer the question.
Hon Mr Wilson: Mrs Caplan, you have that power now, I suppose. When the DQTC's recommendations go to cabinet, they can say nay or yea.
Ms Lankin: Then why are you making these amendments?
Hon Mr Wilson: The amendments clarify the statutory right to do that, because we've had court cases, as you know.
Ms Lankin: And lost a court case. I remember very well that court case.
Hon Mr Wilson: We lost a court case. We don't intend to lose any more.
Ms Lankin: It's very interesting that you would even include within the legislation a reversal of court cases that the crown had lost. I find it extraordinary in terms of the broad, sweeping approach you would take.
The Chair: You're down to your last two minutes.
Ms Lankin: Thank you. I also understand that you would now be in a position to impose clinical criteria. In your review of whether or not particular pharmacists and/or drugs would be reimbursed for, it gives you the power to overrule the decision of a doctor or pharmacist as to what is appropriate medication by refusing to pay and requiring the patient to bear the full difference in cost. Why do you think that you, as Minister of Health, should be in a position to override professional medical decision-making in dispensing?
Hon Mr Wilson: The member knows very well that the Minister of Health, as a layperson, doesn't make these decisions or recommendations; that the Drug Quality and Therapeutics Committee, which consists of microbiologists and pharmacists and other experts, makes recommendations to the medical community about what's appropriate.
I agree, Ms Lankin, that clearly, if somebody, as in your previous example, insists on getting the name brand of a particular drug when there is already a generic listed on the ODB --
Ms Lankin: That's not the specifics I was referring to.
Hon Mr Wilson: But I want to go back to your earlier accusation.
Ms Lankin: Mr Chair, I have one more question I want to get in.
Hon Mr Wilson: Go ahead, Ms Lankin.
Ms Lankin: As you can see, there are many parts of the bill that I have not been able to get to in terms of asking questions at this point in time and getting the specifics. I will be tabling questions in a number of these areas and hope to receive written response on them.
The last area I want to ask you about is hospital user fees and their relationship to the Health Care Accessibility Act. There have been questions asked of you and asked of the Premier, and we have had different answers with respect to what it is you are trying to achieve by allowing hospitals to charge user fees for any hospital-based insured services. I would be interested in having a complete explanation of this in writing, but now just verbally, particularly when you put this in conjunction with the Minister of Finance's statements with respect to needing flexibility under the Canada Health Act.
There are provisions in your legislation which take away the requirement in certain facilities for you to fund medically necessary services and allow cabinet to determine what medical services will be funded, taking away that language of "medically necessary."
The Chair: Ms Lankin, it's a good thing you asked for it in writing, because you've run out of time for a verbal response. The time is up for this particular part of the exchange.
Hon Mr Wilson: Can I take one minute to respond to that latter one?
Mrs Caplan: Can we have unanimous consent to allow the minister to answer?
The Chair: Thanks very much, Mr Minister.
Hon Mr Wilson: Can I take one minute --
The Chair: No, we've got an awful lot of work to do today and we're going to have to stick very tightly to our agenda. Thank you very much, Mr Minister, for your attendance here this morning.
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EMPLOYER COMMITTEE ON HEALTH CARE IN ONTARIO
The Chair: The first presenter is from the Employer Committee on Health Care in Ontario, Carmine Domanico. You have a half-hour to use as you see fit. Any time you leave for questions at the end will be divided evenly among the three parties, beginning with the Liberal Party.
Mr Carmine Domanico: Thank you, Mr Chair. I have some prepared statements that we, as an employer committee, have put together, and I'll read from the notes. At this time we don't have time to provide you with a copy of the statement, but we will provide a copy to you later in the week.
The Employer Committee on Health Care is a group of more than 30 of Ontario's largest employers, who are concerned about the effectiveness of our health care system. We believe that as employers, we can and are making an important contribution to maintaining a healthy and productive workforce. We are here to comment on the issues raised in the omnibus bill recently introduced by your government, on November 29, both from an employer and employee perspective.
First, we would like to express our support to the government for its willingness to address some of the difficult issues facing the delivery and funding of health care in this province, as outlined in the 1995 fiscal and economic statement delivered earlier this year.
We appreciate the consultative process the ministry has taken in drafting the amendments and understand that the information provided by ECHCO concerning the impact on employer-sponsored programs influenced the development of the final plan design.
We support many of the issues documented in the ECHCO paper distributed in July 1995, which was called "A Perspective on Health Care," of which we will also provide a copy along with our submission. We provided the minister with a copy of the paper earlier on when it was released.
Some of the areas we support are as follows:
Support to the Health Professions Regulatory Advisory Council in the role of nurse practitioners as part of the mainstream of health care delivery. ECHCO believes that nurse practitioners will complement, not replace, the services provided by the family physician and other primary health care practitioners, especially in the rural and northern areas of Ontario, by adding value and improving upon the overall quality and cost-effectiveness of the system by providing increased accessibility, promoting speedier rehabilitation and increased consumer health education.
The use of smart cards and the collection of data containing health care information about individual patients will result, we believe, in less duplication of diagnostic services, speedier and safer treatment and information-sharing to individuals regarding treatments and outcomes at a higher level. We believe that enhanced technology could help promote the sharing of best practices, coordination of benefits, as well as coordination of health education, to increase the effectiveness and efficiencies of the health care system.
We support previous proposals made related to regionalizing and restructuring of hospitals so that services offered by hospitals are streamlined, resulting in regional specialization, closing unproductive capacity, sharing patient information, combining purchasing power and sharing information technology.
While we support the proposed restructuring within hospitals, we understand that the reduction in transfer payments beginning in 1996 will have a significant impact on the way hospitals will generate revenue.
You have stated in the bill that there is potential to achieve further efficiencies by using hospital resources more efficiently. ECHCO acknowledges the need for other sources of revenue, and it is our goal to work with hospitals who have the ability and desire to lead their organization to work with the private sector to help generate those necessary revenues.
ECHCO initiated and is pursuing such opportunities with various hospitals and hospital groups. ECHCO is currently meeting with various hospitals and their groups to create a hospital- employer model to develop a way to achieve additional revenues for hospitals; in exchange, employers can use the non-physician resources available within the hospital structure, such as rehabilitation, physiotherapy, health education and blood pressure clinics.
The issues in the bill in respect of physician services raised the potential for suppliers, such as physicians in hospitals, to try to make up the revenue shortfall from the public marketplace, such as government-provided services in the private marketplace, such as employers and individuals. This brings up two points.
There needs to be a framework for determining what is medically necessary and therefore, by definition, what isn't medically necessary, so that what is determined as necessary for the health and wellbeing of individuals will continue to be covered by government plans.
The government, in recognizing that it is doing this, and physicians in particular, will almost certainly allow physicians to bill third parties for non-medically necessary services, such as pre-employment physicals and other work-related issues. Usually, when employers receive these bills they are far higher than what the government would pay for these services. In fact, when physicians bill employers for medicals, they charge far more than they would charge OHIP in general. A very clear example of this is in the drug benefits costs.
Further, anything that prohibits competition, such as advertising fees, for the ability of organizing the setup of preferred provider networks etc to ensure that the private marketplace can deal competitively for delisted services -- in other words, the private marketplace can go out and purchase these services at the quality and price they want rather than knowing what they are going to pay, because the physicians, for example, cannot advertise their fees.
I'm going to go into changes in regard to the ODB program in more detail and ECHCO's view of the changes.
The implementation of the $100-per-person annual deductible plus a prescription deductible and the amount of the dispensing fee, a fee which cannot exceed $6.11, are effective cost-containment features. They cut costs for the government for the obvious reasons of cost-sharing, but they also cut costs by reducing overuse and abuse, both of which need to be removed from the system. This reduction in utilization should not negatively affect health, as the per-prescription, out-of-pocket expenses are affordable by most, and for those who cannot afford it there is a safety net for the deductible being reduced to a $2 copayment per prescription filled.
Mechanisms are needed to ensure that there is no waiving of these deductibles, otherwise the impact on the utilization will be lost. The pharmacist's operating licence would be dependent on adhering to these additional mechanisms.
Other non-ODB drug requirements of senior citizens are paid by the senior. In this area, many have employer drug plans to rely on. In the past few years, many plans have implemented cost-containment measures that accomplish objectives similar to those of the Ministry of Health, that is, bringing the senior into the decision process by participation financially in each drug purchase, therefore cost-sharing. Many plans include coinsurance such as a 75-25 wherein the retiree pays 25% of each prescription filled, ingredient and dispensing fees combined.
Trillium program: The new $2 copyament within the Trillium drug program is a positive measure for the same reasons I've stated previously; likewise for the use of deductibles and copayments for those newly eligible, those with net incomes under $20,000.
BAP, best available price, at 10% markup limited for drugs listed on the ODB formulary for anyone: The system, if it did not exist today, likely would not be implemented. However, its presence brings stability and fairness to the thousands of plan sponsors, most of whom are small and so not able to afford negotiating in pricing, and even to those with a vested interest in removing BAP structures; that is, the brand-name drug manufacturers, the generic drug manufacturers, the pharmacists and the online adjudication service companies. There would be no incremental gain to plan sponsors nor consumers. In fact, they would be losers.
The bill would include the following changes for drugs listed on the ODB formulary:
Remove the current manufacturers' pricing mechanisms on brand-name patented drugs, mostly prescription-required drugs, wherein all buyers pay the same price set between the manufacturer's federal board or the ODB;
Remove the current pricing mechanisms -- best available price -- on generic drugs where they are often multiple versions of the same drug;
Remove the limit on the markup allowed for the pharmacists, currently 10%. This is in addition to the dispensing fee. There's already exposure on drugs not listed on the ODB formulary, but the vast majority of drug expenditures are on drugs on the ODB formulary.
The changes will leave plan sponsors with no choice but to implement online adjudication with all its upfront and ongoing costs, and consumers will be confused and feel helpless as a result of a complex set of rules. The solution is apparent.
Do not change the ODB, in so far as it already has an acceptable mechanism to set the price for the ODB-listed drug products.
Do not change the Prescription Drug Cost Regulation Act so it no longer restricts what the pharmacist can charge non-ODB consumers for the drugs. What has existed works well. What has existed will still be in place for ODB anyway. Also, to require pharmacists to post their dispensing fees while allowing full discretion on the markup would be inconsistent and misleading.
Finally, to close, the reason the employers' committee was formed, we had three themes that came out of our paper in July. They were: information and education; streamlining and coordinating services; illness prevention and promotion of good health. We feel that in the bill a lot of these areas were touched upon, and we thank the ministry for taking these points into consideration.
What we mean by that is meaningful reform will depend upon reliable information about costs from related health outcomes. We believe that incentives in the system can improve dramatically when payers, patients, providers and referring doctors can base decisions on a comparison of relevant outcome measures and their prices.
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There's streamlining and coordinating of services. Studies indicate significant savings can potentially be achieved through the streamlining and coordinating of hospital services and ensuring more cost-effective modes of delivery without adversely affecting the health of the population.
Finally, under illness prevention and promotion of good health, employers and their employer groups offer opportunities to test and measure health care options, reforms or models before rolling them out on a province-wide basis. There are many employer best practices such as interim work centres and retraining of disabled employees which can also serve as public health care models.
That ends my remarks.
The Chair: Thank you, Mr Domanico. We have about five or six minutes per party, and we'll start with the official opposition. Mr Bartolucci.
Mr Rick Bartolucci (Sudbury): Mr Domanico, good morning. Were you consulted prior to the legislation being introduced?
Mr Domanico: In regard to the ODB?
Mr Bartolucci: Yes.
Mr Domanico: Yes, we had surveyed our members at the request of the ministry to see what the impact of the changes would be. So we had provided some input to the ministry as to the effect of what would happen as regard to the ODB.
Mr Bartolucci: You offered some suggestions of what is good and you offered some suggestions as to what is not so good. When you gave your suggestions with regard to what your concerns were, how were they addressed?
Mr Domanico: In what form were they addressed?
Mr Bartolucci: Yes.
Mr Domanico: We had face-to-face meetings mostly. What we had tried to bring forth from our perspective was, "Here are the changes that you're proposing to implement and here's what the impact would be on a cost perspective to us and, as a result, any cost shift to the employee as well." So the recommendations that we made we felt were taken into consideration and we feel good about that exchange of information and being consulted upon, because traditionally we have not been consulted upon; we've been sort of neglected in the process and therefore have had to absorb a lot of the cost shifts and react to changes versus proactively getting ready for a change.
Mr Bartolucci: What are you still really concerned about?
Mr Domanico: We see, from the point of view of the whole budgetary process, that there's going to be less and less funds available to the health care system in Ontario. Therefore, as a result of that, we don't know what actions the government may be taking and our biggest concern is that we want to be a player up front when those changes are being considered, to be able to give our input into those changes. We want to be available as a consultative group, as an employer committee, to be able to advise versus not being able to advise and then having to react to those changes. That's our biggest concern.
Mr Bartolucci: So am I to understand then you're satisfied with everything in Bill 26?
Mr Domanico: We're satisfied with the direction that Bill 26 is taking. I can't speak to any more than that on specific details. I'm not an expert in each area and I don't profess to be.
Mr Bartolucci: With regard to health care though, are you satisfied with every aspect of Bill 26?
Mr Domanico: Well, we're not totally happy with regard to the ODB, with the dispensing fee transfer and the deductible, because we will end up absorbing a lot of that cost. So, no, we're not satisfied with that. But we understand that at a consideration of making us first payer in the system, it's the better of two evils.
Mr Bartolucci: What you're telling us then is that the government wasn't fully receptive to any recommendations that you might have made.
Mr Domanico: The recommendations they were originally pursuing would have been a lot more detrimental to us, so they were receptive to that. Fully receptive is to not pass on any costs, and that did not occur.
Mr Bartolucci: Yes, all right. Thank you.
The Chair: The official opposition has another minute-and-a-half or so, if you want to use it up.
Mrs Caplan: Yes, I do. Have you looked at the bill, at the extensive powers that the minister takes unto himself, not only in the area of drugs but when it refers to hospitals and all providers and so forth? Have you had a chance to review those powers?
Mr Domanico: Not to any great detail. We understand the scope of some of those powers and understand that the government is trying to gain some control over how revenues will be spent as a result, to have more control over the system. As an employer I really don't have any concern with respect to that.
Mrs Caplan: I guess the last question that I would have for you is there's a lot of information contained in access to information around drug use and so on and so forth. The freedom of information commissioner has expressed real concerns over the powers of the minister to disclose information, which go far beyond anything in the past. Do you share those concerns, one, and would you like to see those provisions taken out of this legislation and put into a separate act, as suggested by the privacy commissioner, so that included in that additional act could also be additional safeguards to privacy?
Mr Domanico: With regard to the whole issue of privacy and confidentiality, we see that as a major concern. What we as employers want to focus on is that we believe that shared information could be effectively done in a confidential manner. We do it today with all our banking and somehow that seems okay, but when it comes to a doctor treating a patient, we believe that that doctor should have available to them the most information about that patient's care, whether it's electronically -- electronically would be the preferred manner so that you get it on time and they can prescribe the required treatment to get the best outcome.
The Chair: Thank you very much, Mr Domanico. Thank you, Mrs Caplan. The third party.
Ms Lankin: Mr Domanico, you've set out in the opening comments a number of key things that you were concerned about. I think you suggested that there had been a paper produced. I'm not sure --
Mr Domanico: Yes, we had a paper that was published in July of this year.
Ms Lankin: I haven't seen that. So that's something that perhaps, along with your statement --
Mr Domanico: Yes, we'll send that along.
Ms Lankin: That would be helpful; thank you.
You indicated that many of your ideas from that paper had affected the final design and you listed some of them. You referred to nurse practitioners, smart cards, a framework for what is medically necessary as examples. I fail to see where those issues are directly addressed in the legislation that is before us today.
Mr Domanico: On the medically necessary one, we feel there's still some more work to be done in that area of defining what is medically necessary. We encourage the government to continue to work in that area. We don't believe it's fully done in this bill, no.
Ms Lankin: It's not addressed at all.
Mr Domanico: It's not addressed in the bill at all. It needs to be pursued because we believe it's a key in determining what the assistance will pay for and what the patients will pay for.
Ms Lankin: And smart cards, how is that accomplished by this bill?
Mr Domanico: Back to the point that I made to Ms Caplan, we believe that eventually you as a patient will carry all the information about yourself with you so that no matter which physician you go to see will have access to that data. That's the use of smart cards --
Ms Lankin: That's something that in fact government has been looking at and has been evaluating in a pilot project already. I again don't see this legislation providing smart card technology in Ontario. Is there something in particular that you like about this legislation for that project?
Mr Domanico: We believe that the bill encourages the use of new technologies. In our discussions with the ministry, one of the reasons for not pursuing with the OHIP card that was working under your government was that this card did not contain as much of the information or wasn't integrated as it should have been with other systems. So we're still encouraging that this be pursued.
Ms Lankin: And nurse practitioners?
Mr Domanico: Yes.
Ms Lankin: Again, this is something that many people support. I remember, when I was minister, it was an area that we looked at, the re-establishment of the nurse practitioners education program which had been cancelled and there was the question of fiscal planning to be able to bring that back. What is it in this legislation you like with respect to nurse practitioners?
Mr Domanico: Specific to nurse practitioners? I have to tell you a little about our structure. We are structured in our committee based on about five subcommittees, and I've just received all the information from the various subcommittees. I could not particularly answer such --
Ms Lankin: I think, Mr Domanico, that a number of these areas that you've listed as key goals for your organization are very important in terms of health care reform, and they're ones that I would agree with. I do suggest to you, however, if you take a look at Bill 26 that they're not contained within this bill and that's not what this bill is about.
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The one area that you did address, though, that you favour and that is contained in Bill 26 was the issue of copayments on the Ontario drug benefit plan, which I understand would affect many of the employers with respect to the benefit plans. I guess that was one of the issues that you were interested in.
I was interested in your comments that this would stop abuse in overmedication. I find that interesting, given that all of the studies that have been done over the years and ones that I have reviewed personally and the ministry has reviewed indicate in fact that the problem with the costs in the drug plan is not as a result of people abusing the system; it's a result of doctors overprescribing and that in fact over the last number of years there hasn't been an increase in the per-patient utilization and the majority of the cost increase in the system has come from the increase in drug prices itself.
So I'm wondering where you got this perception from that copayments are going to stop overmedication. Wouldn't prescribing guidelines be a more effective way of doing that?
Mr Domanico: We agree that prescribing guidelines should be pursued as well. I understand the studies that you're speaking of with respect to the co-sharing of costs. However, we see in our plans as well that when employers have introduced drug cards where there is no co-sharing, actually there have been utilization increases in the plans. We believe that having some co-share mechanism within the system assists the individual in their decision-making process, that there is a cost for them as well as for the employer, versus that it is a no-cost benefit.
Mr Tony Clement (Brampton South): Thank you, Mr Domanico, for being here today to be our inaugural speaker from the public. There's a couple of things that I wanted you to elaborate on from your remarks. Speaking first about something that occurred just a few minutes ago, Mr Bartolucci was pressing you on what aspects of Bill 26 you were less enamoured with, rather than more enamoured with. You said right at the end of that series of questions that the one thing that you felt could be a problem for employers was that in fact with the copayments being instituted, it would be the employers who would be absorbing the cost of the deductible or the dispensary fee, rather than the employees who would incurring that cost. You saw that obviously, as an employer or an association representing employers, as problematic. Could you just elaborate on that and how you see that as a problem?
Mr Domanico: Most of our plan designs for our pensioners are written in such a manner -- and, again, we're reviewing these as a result of, over recent years, changes in transfer of costs to the employers -- that in some cases whatever the government plans don't pick up, we'll pick up. This was said at an era or time when we didn't have a lot of these transfers of costs occurring. Therefore, we had an obligation to our pensioners, to our soon-to-be pensioners and employees who are working with us, who understand that that is what the benefit will be when they retire. Therefore, we have a dilemma. We can't just unilaterally say, "Okay, we're not going to cover that any more because of what has happened over here." Therefore, we will end up, in a lot of cases, picking up some of those costs that are transferred to us. We're reviewing our plans, but those will all be more on a prospective basis than what we can do about current retirees and soon-to-be retirees. We have an obligation with them and we'll continue to maintain that obligation.
Mr Clement: I see. I wanted to turn for my second question just to the issue of the confidentiality provisions, which have certainly generated a lot of heat and not a lot of light yet, but hopefully that'll change in the next few weeks. For you, that intersected with the smart card technology which you discussed with Ms Lankin just a bit. But could you just elaborate a bit? I know in your original brief in July you talked a bit about how smart card technology could both be a confidentiality tool but could also be a tool to root out some of the inefficiencies in the system, some fraud in the system and so on. Could you just elaborate a bit on that?
Mr Domanico: In one method, if you had a system that was well integrated across the province or across the country for that matter, where an individual may be going for double doctoring, which may include double prescription, the whole gamut out there, there is no way for a doctor or physician or any health care provider today to be able to check that what they're providing or recommending for the individual has not already been recommended or is detrimental to some other care that the individual is getting. They may go somewhere for care for an asthma problem and somewhere else for care for a heart problem, and the recommendations, unless those doctors and the patient shares that information willingly, they may be giving treatment that may be detrimental to the individual's health.
We believe that use of smart cards and information sharing will provide the physician or the professional the required information to be able to treat the individual properly.
You see that we have that in some of our systems today where pharmacists are online now adjudicating claims, and they can see that if a certain prescription is being given and they know that the individual's currently under a different prescription, that can in fact be detrimental to the individual. So that's an example of where we believe smart card technology would be helpful, and that's confidential.
The Chair: No further questions, thank you very much. We appreciate your attendance here this morning and being part of our process.
Mr Domanico: Thank you very much and we'll forward it to you by the end of the week, our paper and copies of our position paper as well.
ASSOCIATION OF ONTARIO HEALTH CENTRES
The Chair: The next presenter is the Association of Ontario Health Centres, Sonny Arrojado. Did I come close on that? Whatever time you allow for questions -- you can have 30 minutes -- will be split evenly among the parties. The questioning will begin with the New Democratic Party. The floor is yours.
Ms Sonny Arrojado: Good morning, ladies and gentlemen. We thank the government and this committee for providing us with the opportunity to present our comments and recommendations in respect of Bill 26, the Savings and Restructuring Act.
The Association of Ontario Health Centres is the provincial organization of community health centres and some health service organizations in Ontario. Our mission is to represent member centres in the promotion of healthy public policy, healthy individuals and communities through the creation and continuing development of health centres which embody the principles of accessible quality primary care, health promotion and active community ownership and participation.
Given this mission, we support the reform of Ontario's health care system. Although we primarily view fiscal constraint as an inappropriate reason for reforming the health care system, we acknowledge that it has a practical role in pushing the health care reform agenda.
We also acknowledge that Ontario's Progressive Conservative government was elected with a mandate, among others, of fiscal restraint and management. Our concern for the inevitable effects of funding cuts to the health budget was lessened by the Progressive Conservative Party goals and commitment for the health care system as identified in the document, the Mike Harris Forum on Bringing Common Sense to Health Care, December 2, 1994.
We generally supported all of the goals identified in the document. In particular, we believed that the PC goals specific to management and accountability, health care bill of rights, individual responsibility and fostering community involvement, combined with the party's political will, could provide a functional framework for a truly reformed health care system.
As noted, these goals are: On management and accountability, improving management and accountability at all levels of the health care system to make it more responsive and accountable to the people who provide care and the people who receive it; on the health care bill of rights, to empower the consumers of the health care system with the rights to proper care and to participation in decisions regarding that care; on individual responsibility, to promote individual responsibility allowing Ontarians to make informed choices about healthier lifestyle options and informed decisions about their health; on fostering community involvement, to give communities more say in establishing their local health care priorities as well as how and where they want health care services to be provided.
Because of these goals, we have committed to working with this government in achieving these goals as strategies to achieving health care reform in Ontario.
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Given our understanding of the government's stated intent, we are alarmed at the common themes throughout the proposed legislative amendments contained in Bill 26. We acknowledge that Bill 26 is intended to achieve fiscal savings. We also recognize the pressures on this government to undertake measures which result in this outcome.
As noted in the title of Bill 26, the overall thrust of the proposed amendments is to grant government with the legislative powers and tools to meet its fiscal objectives. However, certain provisions in Bill 26 cause us to be greatly concerned that in the pursuit of fiscal savings, government would end up enacting legislation that will effectively nullify the Progressive Conservative Party's goals on achieving health care reform. We would like to raise those concerns with the committee this morning.
The volume of Bill 26, combined with the extremely short notice we had, makes it virtually impossible for us to review Bill 26 in its entirety. Therefore, we have limited our review, our commentary and recommendations to those sections in the bill pertaining to health services.
In this respect, we found several portions of Bill 26 in direct conflict with most of the PC Party health care goals noted in the previously noted document. We must note, however, our opinion that certain provisions of Bill 26 would provide the necessary levers, legislatively, to move the health reform agenda. We support the government's proposed amendments specific to these particular provisions. Unfortunately, logistical limitations hinder us from commenting on these areas in this presentation. We would be pleased to discuss those areas directly with the Minister of Health at his convenience.
Provisions in part IV of Bill 26, schedule F, open up the potential for a range of facilities, such as community health centres, to be deemed independent health facilities within the meaning of the act. We hope the Health minister will provide us with the opportunity to be consulted if such a possibility is being contemplated.
Specific provisions in Bill 26 cause us great concern. We have attached to our presentation an appendix which is a more detailed commentary on areas that are of immediate concern to us.
We are generally concerned with the provisions of Bill 26 which grant unqualified sweeping powers to the Minister of Health. Specifically, we believe existing legislation already provides broad powers. There's a wide range of these authorities and powers contained in the Ministry of Health Act, in particular the extensive provisions of section 6 of the act. Without the clear rationale for the additional extraordinary legislative powers, we are gravely concerned with the potentially dangerous consequences of having one individual, albeit the Health minister, having unrestricted extraordinary powers over health matters affecting all Ontarians.
We acknowledge that the current Health minister has already publicly indicated that he will not likely use all the powers that are referred to in Bill 26. With due respect to the Health minister, we are gravely concerned that these sweeping powers be enshrined in law without a corresponding set of checks and balances as part of these amendments.
We further acknowledge that in certain instances the Health minister may need specific extraordinary powers to effect the changes necessary to reform the system. However, it is imperative that the rationale for these extraordinary powers are widely communicated and clearly understood. In addition, it is essential that some form of sunset clause to these powers be included to ensure that such powers are not used beyond the original intent of the legislation.
We are concerned with the extensive use of the phrase "public interest" without a clear understanding of how this determination will be arrived at. The only apparent qualification for most of these extraordinary powers is the proviso that the Health minister or the Lieutenant Governor in Council consider "public interest."
We conducted a brief literature review and have found that it is difficult to define public interest and that there is no firm criteria that will hold for every single situation. There appears to be no definitive legal precedent that can be broadly applied. Macaulay, in his Practice and Procedure Before Administrative Tribunals, notes that one of the problems in assessing the public interest is the fact that a benefit to one group is often a detriment to another.
We accept that the concept of public interest is dynamic and can change from situation to situation depending on the values of those who are in a position to make the determination. We are nevertheless perplexed that the concept of public interest is not reflected in the provisions of Bill 26 referring to the Private Hospitals Act. Albeit owned privately, private hospitals still use public funds to provide services to members of the public. As such, we are particularly concerned with unqualified legislation that relates to how public interest is determined. In the relevant sections of Bill 26, this power is vested in the Health minister or Lieutenant Governor in Council. AOHC believes that these powers need to be filtered through a process which includes that public input and consultation be incorporated into the legislation as a criterion for the Health minister's or Lieutenant Governor in Council's consideration of what is in the public interest. The relevant authority must give regard to the diversity of Ontario's population as it relates to the varying levels of health status as influenced by gender, age, disability, socioeconomic status, geography, culture, ethnicity and language.
We are concerned that the legislation process will be held subordinate to the regulations process. Amendments proposed in schedule F, part I, of Bill 26 do not define the function of the Health Services Restructuring Commission being created. Notwithstanding this lack of definition, the amendment proposed in subsection 2(1) grants the Health minister the power to make regulations for "assigning duties to the Health Services Restructuring Commission and respecting any conditions with respect to the assigning of those duties." We are greatly concerned that the proposed amendments will allow for the subsequent granting of extensive powers possible through the regulations process.
For example, subsection 8(8) of schedule F of the bill states: "Where a regulation is made assigning a duty to the commission, the Lieutenant Governor in Council may provide that only specified members of the commission are to carry out that duty or that only specified members of the commission are to carry out that duty within a specified geographic area, and where the regulation so provides, any action or decision of those members shall be deemed to be an action or decision of the commission."
This amendment is clearly dangerous, not only in the sense that specified individuals can act without the need for their authority and direction to be sanctioned by the commission as a whole, it is also alarming in that it confers to individuals extensive powers that have not previously been given scope by legislation.
The regulations process as such is not subject to credible public scrutiny nor is it open to debate as required by the legislation process. In this case, there is great potential for the subsequent granting of extensive powers to be hidden from public scrutiny. We believe that regulations must only be used to define in greater detail powers that are already broadly referred to in the legislation, and strongly caution the government against this approach.
We are concerned with the potential for Bill 26 amendments to be in conflict with existing legislation. Once proclaimed, the provisions of Bill 26 will be disconnected from their original purpose, which is fiscal savings and restructuring. These provisions then become consolidated into specific existing statutes such as the Ministry of Health Act, the Public Hospitals Act and others.
Once integrated into other pieces of legislation, the provisions of the bill become subordinate to other purposes not envisioned by the drafters of Bill 26, which opens the door to potential abuse of power and disregard for the democratic process. In addition, even some of the seemingly more modest proposals for achieving savings contained in this bill may be subject to substantial abuse of power over time.
We believe the intent of amendments must be incorporated in Bill 26 provisions. Bill 26 provisions respecting the Health Services Restructuring Commission create only the shell that would subsequently allow for the granting of potentially extensive powers through the regulations process. In its November 29 fiscal and economic statement, the government has clearly stated its intent in creating the commission as being to "facilitate the restructuring of the hospital system." Subsection 8.1(4) of the existing Ministry of Health Act defines in great detail the functions of district health councils.
Restructuring of the health care system requires significant and massive shifting and readjustment of funding, governance structures, services, provider roles, among others. It is, and will continue to be for some time, a painful and frustrating process for most Ontarians. Nevertheless, we believe that some mechanisms open to government could alleviate some of the frustration through a clarity of direction and transparency of process. It is imperative that the functions of the Health Services Restructuring Commission be defined to ensure a clear delineation of the role of the commission as it relates to the existing role of district health councils.
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There is a lack of built in appeal mechanisms in Bill 26. While Bill 26 provisions are unprecedented in the scope of powers given to the Minister of Health and the Lieutenant Governor in Council or their respective designates, there is no corresponding set of appeal mechanisms. The government's previously noted health care goals will only be given life if tested against a system that allows concerns arising from government decisions to be heard. As noted in the previously noted Progressive Conservative Party document, "The public should be a key player in determining local community health care priorities." We urge the government to incorporate appeal mechanisms into Bill 26 that will allow the public at the local level a key role in determining their health priorities.
We are concerned with the erosion and nullification of authority and autonomy of duly incorporated local boards of directors. We believe that provisions in Bill 26 supersede existing accountability and authority granted already to local boards through the Corporations Act.
In Ontario, as most of you are aware, local public hospital boards are incorporated under the Corporations Act and specific corporate powers are also provided for under existing sections of the Public Hospitals Act. This approach, we believe, provided an assurance that the local facility is subject to appropriate lawful checks and balances contained in the legislation. At the same time, this also allows community input and local autonomy and authority in decision-making.
The provisions of Bill 26 specific to amending various portions of the Public Hospitals Act have the direct effect of undermining and nullifying a local board of director's authority and autonomy. For instance, the ministerial powers detailed in subsections 6(1) to (8) of part II, schedule F, are tantamount to the displacement by default of the corporate status of the local board. In effect, the proposed amendments render the local board of directors merely an instrument of the Health minister to do as he wishes, with little or no qualification. In concert with the other provisions of Bill 26, this approach eliminates the capacity of local boards to ensure that the community has more say in establishing its health priorities.
We are concerned that the bill by default creates a parallel system of authority and accountability. We strongly believe that government's role is to set general policy on health, define broad parameters for the system and ensure appropriate monitoring systems that will provide accountability to both the public and the government. The process and structures for health services delivery must satisfy broad parameters set by government, but these parameters should be flexible enough to adapt to the local situation and preserve those community structures that allow for effective management.
In fact, we were encouraged by the PC Party's commitment on management and accountability, articulated in the document, which stated:
"We believe that Ontario's health care system would benefit from a team approach to management at all levels. Under our approach, professionals would be encouraged to bring innovative ideas forward and assist in system management, creating more of a team environment. This would lower barriers between professional and management and focus everyone on improving health care for the people of Ontario."
Bill 26 provisions effectively grant the Health minister or his designate the authority to manage at the local level. Notwithstanding the retention of the existing section 7 of the Public Hospitals Act, which provides for the powers of public hospitals under specified acts they are created under, sections 5, 6, 7, 8 and 9 of part II of schedule F of the bill essentially allow the Health minister to establish a parallel system of management and authority accountable only to the Health minister.
The bill must be amended to clearly delineate power and authority that can be exercised at the local level, at the regional level and at the provincial level. Without qualification, certain provisions in the bill will create a parallel system of authority without the corresponding accountability.
This situation, we believe, could lead to disorder, parallel systems competing for control, regulatory powers being applied inequitably throughout the province and other chaotic situations which would categorically undermine any possibility of achieving a "coordinated system of management, with health care professionals leading the way, working with government and incorporating community and consumer concerns," as noted in the previously noted BCSTHC document.
We are concerned that Bill 26 provisions will have the effect of undermining community capacity building and ownership. As it currently stands, existing administrative structures have been inadequate in maximizing public input into health care decisions. This situation was recognized by the PC Party in its document, which stated:
"For too long, the public has been a silent partner in important health care decisions, and has had to defer to politicians and administrators to manage Ontario's health care system.... In too many cases, there has been no real consultation with the public before services which people value highly are reduced.... True consultation only occurs when government not only listens to the people, but hears what they have to say and responds to their concerns with action."
Ironically, Bill 26 provisions exclude existing legislation that allows opportunities for public input and consultation in critical decisions regarding health services at the local level. For instance, subsection 13(1) of part II, schedule F, of Bill 26 amends existing clause 32(1)(d) of the act, which allows the minister, in making regulations respecting hospitals, to prescribe matters upon which bylaws are to be passed by hospitals. The Bill 26 amendment proposes to add to the previously noted section the following, "prescribing provisions of bylaws to be passed by hospitals and providing for the filing of bylaws with the ministry."
The current act contains numerous provisions that already allow the Health minister broad powers which include, among others, the monitoring and supervision of hospitals, the care of patients, appointments to hospital boards and approval of hospital bylaws. For example, subsection 12(1) of the existing Public Hospitals Act already allows the Health minister veto power on bylaws passed by hospitals. The Bill 26 amendment would provide the Health minister with the additional power to also prescribe what those bylaw provisions should be.
In effect, there is no substantive decision-making power left in public hospitals, and unless amended, Bill 26 will result in a total lack of legislative requirement to involve the community in the determination of health care priorities at the local level. Unchecked, the situation will inevitably lead to the breaking down of volunteerism, community self-reliance and community ownership as we know it in Ontario.
I'm not going to comment further on the public interest because we have referred to that previously, but it does refer to this as well.
In addition, we are concerned with Bill 26 creating the potential for unfair treatment. Provisions of part IV, schedule F, of Bill 26 open the potential for a range of facilities to be deemed independent health facilities within the meaning of the act. Subsection 5(1) of part IV provides for a director authorized by the Health minister to request one or more proposals for the establishment and operation of one or more independent health facilities by:
"(a) sending a request for a proposal to one or more specified persons; or
"(b) publishing a notice in a newspaper of general circulation in Ontario...."
We believe the proposed amendment gives the government legislative authority to be selective in who can send in requests for proposals and how these are to be processed and awarded. There is no built in assurance that fair opportunity to the public must occur.
Furthermore, provisions of subsection 7(1), schedule G, part I delete from the existing legislation reference to the fee negotiating committee which has joint representation from the Ministry of Health and the Ontario Pharmacists' Association and excludes the OPA in the determination of dispensing fees. While this could be a mechanism for keeping prices down to allow for the softening of copayment provisions, eliminating OPA's involvement results in the government dealing directly with the manufacturers without some kind of public or quasi-public disclosure review included in the act. We are concerned that the potential for selected manufacturers to drive up the prices is real.
There are other areas that we are concerned with, and we are definitely concerned with the unprecedented disclosure of personal information, but you have that in the submission.
In the interests of time, I would like to conclude that we have, within logistical constraints, taken a close and temperate review of the provisions of Bill 26 relating to health services. We found the provisions that we believe are necessary to effect the reform of the health care system in Ontario and support those specific provisions.
We are, however, deeply concerned with specific provisions that grant unqualified extraordinary powers to government, erode and nullify the authority and autonomy of local incorporated boards of directors, undermine community capacities and ownership and open up the potential for unfair treatment as well as granting unprecedented access and use of personal health records. On balance, we believe that these provisions would put in great jeopardy the goals and commitment articulated by the PC Party as contained in its document, Mike Harris Forum on Bringing Common Sense to Health Care, December 2, 1994.
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We urge this committee to seriously consider our recommendation. We strongly believe that the legislative structure and framework for health care reform must be one that provides for a prudent balance between the rights and responsibilities of consumers and health providers with the powers and authority of the Health minister and those to whom these powers are delegated.
Finally, we have a set of recommendations which I will now quote.
We strongly recommend that the provisions of Bill 26 respecting health care services be amended to ensure that the health care goals articulated in the document Mike Harris Forum on Bringing Common Sense to Health Care, December 2, 1994, are not nullified.
We strongly recommend that public input and consultation be incorporated into Bill 26 as criteria for the Health minister's consideration of what is "in the public interest." Furthermore, we urge that in considering what is in the public interest, the Health minister give regard to the diversity of Ontario's population as it relates to the varying levels of health status influenced by gender, age, disability, socioeconomic level, geography, culture, ethnicity and language.
We also strongly recommend that a sunset clause on the extraordinary powers of the Health minister or his designate be incorporated into the bill.
We recommend that the government's stated intent to "facilitate the restructuring of the hospital system" in establishing the Health Services Restructuring Commission be incorporated into the provisions of the bill.
We recommend that the government use regulations only in defining in greater detail powers that are already broadly referred to in the legislation. In this respect, we strongly urge the government to delete subsection 8(8) of part I of schedule F of the bill.
We recommend government incorporate appeal mechanisms into Bill 26 to ensure that the public is a key player in determining local community health care priorities.
We also recommend that some form of public or quasi-public disclosure and review be incorporated in the bill specific to the Ontario Drug Benefit Act to ensure transparency in the negotiations with the Health minister and drug manufacturers.
Finally, we strongly recommend the deletion of paragraph 42(1)31 of schedule F, part IV, which allows the minister to pass regulations "prescribing conditions under which the minister may collect, use or disclose personal information under subsection 37.1(1) and conditions under which the minister may enter into agreements under subsection 37.1(2)."
That is our submission, ladies and gentlemen. Thank you.
The Chair: Thank you very much. We only have less than a minute per party, not really any practical time, unless, Ms Lankin, you have a very quick question.
Ms Lankin: I guess, out of the list of questions I had -- let me say it was an excellent presentation. I appreciate it. The relationship between the restructuring commission role and the DHC role is currently set out in the Ministry of Health Act. Could you comment for us on what clarifications you believe are required and what amendments would be helpful in the legislation?
Ms Arrojado: I think our concern is that there is no clarity right in the bill as to what the commission will be doing, certainly not that is obvious to us, and we have spent a great many hours looking through it. It's possible that we have missed it, but there's certainly nothing in there that we think defines what this commission is, which could have broad and extensive powers on health matters.
The Chair: Mrs Ecker, one minute.
Mrs Janet Ecker (Durham West): Okay. You support the district health council public consultation process? Did I hear you say you thought that was a good thing that that should be happening, should continue to happen?
Ms Arrojado: I think what we generally support is a process by which the public can be involved in the consultation process. I don't know what specifically you were referring to as part of the process of the district health council.
Mrs Ecker: I was just going to clarify that my understanding, not being a lawyer but reading the legislation, is that Bill 26 specifically leaves the district health councils in the legislation and that they do do public consultation as part of the restructuring exercises that are currently under way around the province, that public consultation is part of that. I just thought that was a point worth making.
Ms Arrojado: It's not clear for us. We're familiar with the process the district health councils undertake, and they vary also from district health council to district health council. What is not clear to us, and what is of concern, is that we don't know whether it means anything at all what the district health councils will do, how that feeds into the commission, what in fact is the process that will be taken to deal with that process. I think what we are seeking is some clarity as to exactly where is the input, how the input is going to be incorporated and how that is laid out so that we clearly know in fact where we should give our input to.
The Chair: Thank you very much. Mr Bartolucci, one minute.
Mr Bartolucci: It was an excellent presentation. Given what you said earlier about the document Bringing Common Sense to Health Care, having read that and having listened to it, understanding what's happened in the formulation of this bill, do you feel betrayed?
Ms Arrojado: We cannot say that we feel betrayed as an organization, because the commitment was not made to AOHC specifically, it was made in a general statement to Ontarians. However, we have taken that as a commitment to Ontarians as a whole and feel extremely disappointed that we have not been able to assist prior to this time in that process, and we're really concerned over that.
Mr Bartolucci: Do you feel that you were consulted?
The Chair: On that note, we'll break for lunch. We appreciate your attendance here this morning and your interest in our process. The committee stands in recess until 1 o'clock.
The committee recessed from 1206 to 1302.
CANADIAN UNION OF PUBLIC EMPLOYEES
The Chair: Our afternoon session is about to begin. Our first presenter is Mr Ryan from the Canadian Union of Public Employees. Mr Ryan, welcome to the committee. You have half an hour to use as you see fit. Any time for questioning will be divided among the parties evenly at the end and would start with the government. The floor is yours, sir.
Mr Sid Ryan: Thank you for the opportunity to present this afternoon. Let me introduce the people I've got with me here today. On my left I've got May Peron. May is the chairperson of our health care workers' committee. To my immediate right is Michael Hurley. Michael is the first vice-president of CUPE Ontario. To Michael's right is Vanessa Kelly, who is the CUPE researcher. We apologize for not having a brief to present to you here today, but we will mail it in. I think you'll appreciate that we got very, very short notice of this meeting. As a matter of fact, it was late Friday evening by the time we finally got our spot today at 1:30. So we will get the brief and put it together.
Let me begin by saying that the Savings and Restructuring Act represents an enormous fraud and breach of promise perpetrated against the people of Ontario by the Harris government. It is the prelude to a revolution, not a Common Sense Revolution but one that achieves its goals at the expense of the elderly, the poor, the disabled and all the vulnerable members of our society who are so heartily despised by this government currently in power. Bill 26 is not about reform or even saving money; it is about slashing programs, privatizing our social support system and, at a more fundamental level, dismantling the democratic structures that give the citizens of Ontario control over the future of their province.
In regard to health care, the bill gives the Minister of Health unlimited authority to enact the onerous cutbacks announced in the government's economic statement. The elimination of funding to the hospital sector alone could result in the layoff of up to 26,000 workers and will severely restrict access to health care services. Bill 26 will profoundly damage publicly funded medicare and encourage the privatization and corporatization of health care. If this legislation is enacted, we will see rapid encroachment by the private sector, whose goal is to profit from illness, disability and death.
This government, if it chooses to do so, could promote genuine reform that would improve quality and access to care in an equitable and cost-effective manner. Key to this type of reform is the creation of a supportive environment for good health, which includes a strong social safety net and other public policies that ensure shelter, education, food and a safe work environment. Governing bodies of the health care system need to be democratic, accountable and representative.
In addition, specific actions must be taken to stop the true waste in the provision of health care, namely the elimination of fee-for-service payments, which encourage overbookings, overprescribing and overtreating by physicians.
In addition, we need to enact genuine patent law reform that promotes lower drug prices. Controlling drug costs would free up millions of dollars for health care.
Finally, we must preserve and strengthen the Canada Health Act. Unfortunately, recent statements by the Minister of Finance indicate that this government sees the Canada Health Act as an impediment to its ability to privatize health services.
Cuts to the drug benefit plan: The Ontario drug benefit plan provides payment for prescription drugs to seniors and those on welfare. Should schedule G be enacted, the legislation will have dramatic impacts on low-income persons and seniors. The bill would put a two-tier health care system in place, since a user fee for prescription drugs will be introduced. This, along with the proposed $100 deductible for the poor, will mean large numbers of the sick will be unable to afford treatment. This is another breach of promise by the proponents of the Common Sense Revolution, who clearly stated in their election campaign that new user fees would not be introduced and that services to seniors and the disabled would remain untouched.
As with other sections of the bill, the minister and cabinet will have full power to establish and set, behind closed doors, the levels of user fees under the drug benefit plan. Cabinet will essentially act as pharmacists, making decisions over which drugs are eligible to receive reimbursement under the plan. The interference in the medical process by the government is astounding. Medical necessity or other health criteria do not have to be considered. Costs will be the criterion.
Deregulation of drug prices: The bill will repeal the power of the minister to regulate the price of drugs charged to anyone not covered under the Ontario drug benefit plan. Drug companies will be free to determine the prices for their products other than those provided under the drug benefit plan. Without regulation, we can expect that the cost of drugs will increase substantially. The government is also putting itself above the law. Not only does the legislation remove any public process for setting prices of drugs and determining issues under the Ontario drug benefit plan, but it is also reversing court rulings that went against past government decisions.
Power to impose user fees: Bill 26 would provide explicit authority for the cabinet to make regulations which could permit hospitals to charge user fees for any hospital-based insured services, including those already covered under OHIP. As an example of this, the government has already announced that hospitals will be able to charge daily user fees to those patients in acute-care beds who are awaiting placement in chronic-care facilities or nursing homes. Patients will essentially be penalized because they have been placed on a waiting list for services that are already critically underfunded.
With this new legislation, the Tories are encouraging hospitals to offset their budget reductions by charging user fees, allowing them to bring in additional revenues at the expense of the patients. This is yet another example of the broken promises by the Tory government, who promised the citizens of Ontario that no new user fees would be introduced during their term in office.
Delisting of medically necessary services: To date, the Health Insurance Act has required that OHIP cover all medically necessary services provided by physicians. The bill removes any reference to medically necessary services and instead authorizes the cabinet to decide which services will be insured, and under what limitations and conditions. These provisions will most likely be used to limit access to services which are now provided under the Health Insurance Act. The government can decide at will what types of care are medically necessary and what are not. The potential for abuse is enormous and certain services which are currently covered under OHIP could be delisted simply because the government decides they are too expensive.
Loss of confidentiality of medical information: Confidentiality of personal medical information becomes a thing of the past under this legislation. Bottom-line economic considerations will override the right of citizens to have their personal medical histories held in confidence. The bill will allow the minister to collect, use or disclose personal medical information for various administrative purposes. One of the key rationales for this disclosure is that it is necessary for the effective management of the health care system. Those who are most vulnerable in our society could find themselves the victims of a campaign to deprive them of adequate and necessary levels of care because the government deems them to be abusers of the system.
At this point I'd like to pass you over to Michael Hurley, our first vice-president, who will continue with the presentation.
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Mr Michael Hurley: Today's Star has a photo story from Edmonton of a woman who was refused admittance and gave birth in her hotel. Alberta has more institutional beds available to its population than Ontario does at this point, and the Progressive Conservative government is proposing to dramatically reduce the number of institutional beds available. We're already seeing people being turned away for services. We're already seeing people dying as a result of that. There are inquests under way in the regional municipality of Durham, for example. So these are no small matters that we're talking about here today.
The hospital closures that are under way target specific communities, and we should talk about that before we go to the powers the government is proposing to accrue to itself. Here in Metropolitan Toronto and across the province, the specific targets of the government's closure programs are services for seniors citizens, and particularly chronic care services. Seniors are very much threatened by the hospital closures here in Metropolitan Toronto and around the province. It's to close hospitals for seniors -- the majority of the hospitals being looked at, I think, for closure provide those kinds of services -- that the government is accruing its new powers.
In addition, other constituencies are threatened here: the poor. The closure of downtown emergency wards -- which are used by low-income people because they don't have family physicians, reports tell us -- is being proposed. They target a specific constituency. Here in Metro you can also see people with HIV, AIDS and women's health programs being very much threatened by the government's program.
Those are the constituencies being threatened. We already have people being turned away, we already have a dramatic access problem, and the government's expenditure reduction, which was announced contemporaneously with the Savings and Restructuring Act, is going to mean the closure of many more beds; it's going to mean many more people turned away; it's going to be mean people die in Ontario.
But the government has accrued to itself in this legislation some new powers. It's a dramatic shift for the Ministry of Health. Under the previous government we had a commitment, although it was difficult to enforce at the local level, to an open and collaborative planning process. There was an understanding that decisions around health care services should be ones into which constituencies like senior citizens had some meaningful input, and that local health authorities like district health councils should be the bodies that made recommendations to the minister. But it appears as though these bodies have not been responding fast enough, and this bill now will give the Minister of Health virtually unlimited powers with respect to the funding and operation of public hospitals. It will allow the minister to ignore the needs and desires of the local communities who access hospital services and give him unlimited control over all hospital matters.
Currently in the Public Hospitals Act, as you know, funding is allocated by specific criteria and regulation. The minister cannot terminate funding simply for budgetary reasons; his decisions must take into account their effect on patient care. Under Bill 26, however, the minister can decide that the availability of financial resources is the only relevant criterion when making funding decisions.
The minister also has the unlimited authority to close hospitals, force mergers between institutions, or order hospitals to change or eliminate the types of services they deliver. Since the government has made it clear that they think that too much money is spent on inpatient services already, it can also use this bill to compel hospitals to contract the volume of acute care that they provide. This will result in patients being forced out of the system much too quickly or even denied appropriate levels of care. As a result of these changes to health care, CUPE believes that people in Ontario will die unnecessarily.
Since the government has also stated that up to 38 hospitals in Ontario must be closed, the bill will provide it with the necessary mechanism to achieve this goal quickly and aggressively. No public consultation will be necessary even on a superficial basis. Rural Ontarians will be particularly hard hit by closures as small hospitals are shut down and sick people are forced to travel greater distances to access even the most basic hospital services like giving birth.
Finally, the bill provides tremendous levels of liability protection to the government during restructuring processes, and isn't that a wise move, since basically the government is proposing changes that will result in citizens wanting to lay lawsuits against the government and against hospitals and against district health councils because their relatives have received inferior care or, worse, no care at all. The Ministry of Health will become in effect a dictatorship, and the citizens of Ontario will have no recourse or protection from the damage that will be inflicted on them by this government.
Linked to the hospital closures, the fact that there's no new money in the health budget and that the Independent Health Facilities Act has been amended to allow for the establishment of independent health facilities of a for-profit character means that services will be driven out of the hospital sector where citizens can now receive them, paid for by OHIP; that is to say, without personal cost, no matter what your income level, you can be expecting that you will be receiving treatment and physiotherapy and other services in a hospital. Those services are closing down. The expenditure reductions the government has announced are going to make that a reality and the door has been opened to for-profit private clinics and, more specifically, American, corporations which will move into this province to deliver services. Since there's no money for it to be found in the budget, they can only be provided on a fee-for-service basis and they can only be provided on a for-profit basis.
The government is also amending the Hospital Labour Disputes Arbitration Act, under I think, schedule Q, and that will have an impact on bargaining. We'd like to record that we strongly object to the proposal which would force arbitrators to consider ability to pay in determining awards. Funding in the public sector is determined by government financial decisions. Thus, if ability to pay were a criterion in interest arbitration, the Harris government could determine wages and benefits simply by allocating fixed or reduced amounts for employee compensation.
I'd like to point out to you that we believe the most appropriate way to settle collective agreements is by allowing the parties to test their strength, with the option of resorting to strike lockout mechanisms. Legislation which forces compulsory arbitration on certain groups of employees should be repealed and these groups should be granted the right to strike. Doctors, for example, have talked publicly about strike action. If there is a group of workers that should be considered most essential to the delivery of health care, would it not be doctors? Doctors have the unfettered right to strike here in Ontario.
We have been denied these rights, those of us who work in the health care system, because previous governments have deemed our work to be part of an essential service. We have, however, been laid off by the thousands over the last five years and your proposals as a government are to lay off a further 26,000 of us. So we find it hard to continue to believe that we are as essential as you once held us to be in the past, and we would suggest to you strongly that rather than gerrymander with the legislation that affects bargaining in our sector, you institute the right to strike for health care workers.
Mr Ryan: Okay, we would be prepared to take some questions.
The Chair: Thank you very much. We have about three or four minutes per party, starting with the government.
Mrs Helen Johns (Huron): I'd like to thank CUPE for coming in to speak to us today. You represent a number of Ontarians and we're pleased to hear your view always.
I'd like to clarify a few things that I heard both of you say that I think the CUPE employees would like to hear too, so I'd like to put them into the record. The previous government closed, as did, I think, the last two governments, hospital beds throughout Ontario to the effect of closing approximately 33 mid-sized hospitals without ever closing a hospital. So there have been approximately 6,800 beds closed in Ontario at this particular time. Our process at this point is looking at restructuring the whole system on a global aspect so that we provide good health care to Ontario.
The second thing is that we have moved very quickly to solve some of the problems that were in the previous government's policies with emergency rooms. Coming from rural Ontario, I can tell you that emergency rooms -- you were lucky to have them open under the previous government and the one before that as a result of having them not taking the actions that are necessary for that to happen.
In rural Ontario, we've made some substantial moves to ensure that emergency rooms are done by putting $70 per hour to the doctors. So we're the first government that's had the strength to be able to make those kinds of statements.
The government does have no list of closures. You're suggesting to us that we have this plan somewhere to close hospitals that evolved with seniors -- that act with seniors. I'm saying there is no process to talk about specific hospitals at this point. We're waiting for the communities to decide which hospitals are open. I think we'll all agree at this table that ascertaining where hospitals are and what should be open and what shouldn't be for the need of the community is the most important aspect that you, as representing people who work in businesses, and us as representing the people of Ontario, have available to them.
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Rural doctors -- we've made some substantial moves to get doctors to rural Ontario. I know you represent a lot of people from rural Ontario and we're making every effort to get these doctors here. That's why we're saying, "If you can't come up with an alternative, doctors, we'll make sure there is an alternative for rural Ontario." So your rural members shouldn't be worried about health care in rural Ontario.
Relevant criteria, talking about the lack of dollars in the system, that's where my question's coming today, I think we all know, everybody in Ontario apparently is agreeing that $17.4 billion is enough money in the health care system. I think we all agree that there needs to be some changes to the way the health care system is evolving because we need to move it towards the next millennium. I heard you say --
The Chair: Thank you, Mrs Johns. It was an interesting statement, but I didn't hear a question there. So your time is up.
Mrs Johns: All right.
The Chair: Mrs Caplan.
Mrs Caplan: Thank you.
Mr Ryan: Could I respond to that perhaps?
Mrs Caplan: Sure. Take my time.
The Chair: I'm sorry --
Mrs Caplan: Yes. I'm allowing him as part of my time to respond, Mr Chairman.
Mr Ryan: First off, I know you said you were pleased to be hearing from us. It's interesting that it's taken six months and the brave actions of the member across, Alvin Curling, to force your government into public consultation. We've sent at least 20 letters to your minister, Jim Wilson, requesting that we have an opportunity to sit down and discuss some of these changes.
Mrs Johns: I mentioned you --
Mr Ryan: You've never met with me in your life.
Mr Curling: Don't respond.
The Chair: Excuse me.
Interjection.
The Chair: Mr Ryan has the floor. He did not interrupt you. I'd just as soon you not interrupt him.
Mr Ryan: We've never had the opportunity to sit down and discuss health care reform with your government. You've never once consulted with any union that I'm aware of; nor with the Ontario Federation of Labour, which we sit on, have you ever consulted.
Secondly, in terms of restructuring of the health care system it's interesting that Jim Flaherty from the Durham region promised us faithfully that the hospital in Whitby would be kept open as a full-service hospital and said he would resign if that promise was not kept, and we find out just a couple of weeks ago that in fact the emergency ward in that hospital is being closed down and it's going to continue to be closed down.
In the city of Windsor where we sat down with the previous government and we negotiated an agreement between the unions and the hospital administrators about how we would close some hospitals, but keep the money in the community so we could put it into community-based care. There was $70 million we found in savings. Your government has come in just two weeks ago and scrapped that agreement between the employees and the hospital administration to the point now where the agreement in Windsor is in jeopardy.
So don't talk to me, please, here today about how your government is looking after reinvesting health care dollars in the community-based care because it is not. It's an absolute lie.
The Chair: Thank you, Mr Ryan, and thank you, Mrs Caplan, for donating your time.
Mrs Caplan: In fact, my question was going to be, have you been consulted? Would you be willing to be a partner and do you trust these guys, but you've answered that.
The Chair: Okay. Ms Lankin.
Ms Lankin: Thank you very much. I appreciate all of the elements of your presentation and there are a number of questions I would like to pursue with you, but time is short.
In one area in particular, as I read some of the amendments to the Public Hospitals Act, I'm concerned about the powers given to the minister in the appointment of investigators and supervisors and sort of the unfettered powers of what they can investigate now as compared to the previous legislation and, in addition to that, the ability of the minister to give directions to the supervisor and/or to boards, as a matter of fact, even when a supervisor isn't there. In particular, there is a provision that says that when the minister gives direction to a board of a hospital, despite any other act, despite any letters patent, despite any bylaws or any contracts, if you look into the section on regulations, the board is deemed to have the power to implement the minister's directions.
I raised this question with the minister and I didn't get a clear answer, and perhaps it is complicated, but I'm wondering whether you have any opinion as to whether or not that could lead to the overriding of collective agreements and/or other forms of service contracts that exist within hospital employment.
Mr Hurley: It's clear to us that the bill gives the government dramatically new powers, the power to, in effect, take over the operations of any hospital it wants to, and it makes a mockery of any notion that the health services should be run on the basis of public input and consultation democratically by volunteers etc; all of which seem to be things that most people agreed upon in the past, and certainly contradicts the direction of the government.
With respect to our collective agreements, we will not allow our collective agreements to be overridden by this government. If there's an attempt to do that in the health care sector, then I think you'll see some form of illegal strike action. People will not allow that to happen. We will not pay for the deficit, these workers who are making $12 and $14 an hour.
In terms of the new powers the government is accruing to itself and in response also to the previous question, I think that it's important the government is going to be driven to close hospitals by the economics of the situation, not at all by care criteria. And they will be closing hospitals, they have encouraged hospitals to close beds and to move to outpatient and ambulatory services and clinical services to deliver those to people. Hospitals have done that.
They now have closed beds, and now they will close hospitals by pretending that all of the care is oriented around the beds, when in fact we have two previous Ministers of Health sitting on this side of the table, both of whom will say probably they invested a good deal of their efforts trying to ensure that in fact the health care system moved away from beds and on to services. What they're really doing here is cutting the money for services, and with the introduction of the other change it will mean for-profit services will sprout in their place and people will not get care.
I think they need these powers, Ms Lankin, in order to close the hospitals, and they're going to do that -- I think they're going to start to do that, and there's going to be tremendous opposition to doing that.
The Chair: Okay. Thank you very much. We appreciate your participation in our process and your presentation here today.
TORONTO PSYCHOANALYTIC SOCIETY
The Chair: The next group are the Toronto Psychoanalytic Society, represented by Dr Douglas Weir and Dr David Iseman.
Welcome to our committee, gentlemen. You have a half-hour to use as you see fit. Any time that you leave for questions will be divided evenly, and the Liberals will start the questioning when the time arises.
Dr David Iseman: My name is David Iseman and I'm the president of the Toronto Psychoanalytic Society. I'm appearing today with Dr Doug Weir, who is the acting chair of the public affairs committee of the Toronto Psychoanalytic Society.
We represent the members of the Toronto Psychoanalytic Society, as well as the three other Ontario branches of the Canadian Psychoanalytic Society. Currently there are over 200 psychoanalysts in practice in Ontario. About 90% of these people are psychiatrists who, after completing their medical degrees and subsequent psychiatric qualifications, have undertaken an additional five years of intensive psychoanalytic training prior to qualifying to practice as psychoanalysts.
Most psychoanalysts pursue their psychoanalytic training after completing a psychiatric residency. Psychoanalytic training takes a minimum of five years under extensive supervision. Few other psychotherapies require or provide as much training. In fact, most psychoanalysts regularly supervise GPs, psychiatrists and non-medical practitioners who have practices in which they, in turn, provide short-term and long-term psychotherapy.
Among the members of the Ontario psychoanalytic societies are to be found many of the leading psychiatric educators within our province, men and women of outstanding qualification, expertise and commitment. There are also among our membership a few non-psychiatrist physicians and psychoanalysts with PhDs in psychology or other related fields. As you know, only physicians are permitted to charge their psychotherapy services to OHIP.
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Psychoanalysis is one of the most studied forms of treatment, and its efficacy and results are well documented. Psychoanalysis is a proven, effective treatment for serious mental illness that forestalls psychiatric hospitalization, reduces other forms of medical utilization and provides savings to the health care system in direct and indirect cost offsets. Eighty-two per cent of patients currently in psychoanalysis have already tried briefer forms of treatment without success.
Many patients consider themselves to be in analysis regardless of the treatment they are receiving. Although some may be in a type of psychotherapy, only a very small number are actually in psychoanalysis; that is, a treatment for serious mental illness requiring four to five sessions per week for an extended period of time, typically three to seven years. Psychoanalysis is long, but it is not interminable. The average analysis lasts about five years.
Psychoanalysis is only one kind of psychotherapy derived from psychoanalytic concepts and technique. There are other types of psychotherapy, some of which are unrelated to psychoanalytic theory. In fact, there are more than 250 distinct psychotherapies. The results of some of these methods have never been systematically studied. Psychoanalysis and psychoanalytically oriented psychotherapy have the distinction of being documented in all general psychiatric textbooks. Similarly, the principles of psychoanalytically oriented psychotherapy are a required part of the curriculum of all Canadian psychiatric training programs, whereas many of the other psychotherapies are not covered at all or are optional.
Every leading psychiatric association across Ontario and Canada has unequivocally supported the retention of psychoanalysis as an insured medical procedure. Dr Fred Lowy, former chair of the department of psychiatry at the University of Toronto and formerly dean of the faculty of medicine at U of T stated: "Psychoanalysis is an effective form of intensive psychotherapy for the limited number of patients for whom it is indicated. Indeed for persons with certain crippling personality disorders it is the treatment of choice." The five current chairs of the departments of psychiatry at Ontario universities agree.
Our presentation today concerns the impact of recent proposals by the government of Ontario under Bill 26 to permit the government to unilaterally define an insured service and to set fees for the provision of those services. The consequences of these measures could include a reduction in the accessibility to psychoanalytic psychotherapy services through arbitrary funding cuts, restrictions on where it could be practised and other serious obstacles. Patients will suffer.
Bill 26 could further reduce accessibility to psychoanalytic psychotherapy by determining that new psychiatrists wishing a community-based psychoanalytic practice which does not require a hospital appointment would not be eligible to obtain an OHIP billing number. This would likely limit the number of new psychiatrists who decide to pursue psychoanalytic training. Any disincentive to undertaking psychoanalytic training will have extensive consequences because the supervision of GPs, psychiatrists and non-medical psychotherapists, which is a part of any analytic practice and which incidentally does not result in a direct charge to OHIP, will be lost.
The legislation will also have grave consequences for the practice of psychoanalysis. The government could, without a warrant, seize patient records, review and disclose patient information by public officials for any purpose. There would then be no safeguards on the privacy of the records and the confidentiality between patients and their doctors. Confidentiality is essential in the establishment of trust in the analytic setting, and trust and openness are crucial to change in the individual. Patients with profound difficulty, such as traumatic disorders, severe depressions, personality disorders and other serious mental illnesses do respond. Psychoanalysis is one of the most intense, intimate and yet misunderstood treatments in medical practice.
I'd like to call on Dr Doug Weir to elaborate on these issues.
Dr Douglas Weir: In November 1993, I was privileged to appear before the standing committee on social development to speak about the impact that delisting effective and medically necessary treatments like psychoanalysis would have on patients in need, and to voice the concerns of our profession on how arbitrary and unilateral decision-making would seriously limit our ability to maintain clinical integrity.
In the spring of 1993, the former government had introduced Bill 50, which in its original text included severe measures restricting access to psychotherapy services. These measures would have destroyed our ability to provide patients with necessary psychoanalytic treatment under OHIP. Under this proposal, people seeking treatment for serious mental illness would have been unfairly discriminated against and denied access to intensive psychotherapy and psychoanalysis when that was the care they needed.
Our patients are among the most vulnerable in society, and allowing them to be neglected would not only be unconscionable but it would also have ended up costing our health care system more, both in direct and indirect costs. Thankfully, the amendments introduced to Bill 50 avoided these outcomes, partly as a result of the work of several prominent members of this Legislature from all parties.
For those of you who may not be aware of the details, the controversy surrounding the fight against the NDP proposal to restrict access to intensive psychotherapy took more than three years to resolve. In February 1992, psychiatrists in Ontario had learned, without warning or consultation, that psychoanalysis was included on a list of so-called borderline cosmetic surgeries. This list was being considered for removal from the schedule of OHIP benefits.
A vigorous defence of psychotherapy and psychoanalysis was launched. The Ontario branches of the Canadian Psychoanalytic Society, the Ontario Psychiatric Association, the chairs of psychiatry of the five medical schools in Ontario and a dedicated, tenacious group of patients raised their serious concerns. Despite their warnings, the government continued to give consideration to this proposal, and in March 1992 referred it to the joint management committee of the OMA and the Ontario government for their recommendation.
The JMC reviewed the scientific evidence supporting the efficacy and medical necessity of psychoanalysis. On October 14, 1992, the JMC made a clear recommendation to the ministry to maintain psychoanalysis as an insured service. The Minister of Health wrote to anxious patients reassuring them that the JMC subcommittee recommendation was "for psychoanalysis to be maintained within the fee schedule and that no further action would be taken without consultation with the OMA and others."
You can imagine their distress when they discovered their ongoing treatments were once again under attack with the introduction of Bill 50. After further representation, Bill 50 was amended in a way that retracted the measures restricting access to psychotherapy and psychoanalysis.
The Honourable Jim Wilson, currently Minister of Health, was the then Conservative Health critic. He said in the Legislative Assembly of Ontario on July 26, 1993, of Bill 50: "The government is using its current fiscal situation as an opportunity to pass this very dangerous legislation. There are no limits on what services can be restricted by the government under Bill 50. It's not just psychotherapy.... The power to ration insured and medically necessary services applies to everyone and everything. The number of medical services deemed appropriate can just be decided unilaterally by some bureaucrat saving money, some unaccountable bureaucrat who has no agenda but the government's agenda."
Having heard the Honourable Jim Wilson make these remarks in 1993, I was shocked when I heard that the Conservative government's omnibus legislation, Bill 26, contained health-related provisions providing the government with almost unlimited control over the delivery of medical services and giving them unilateral decision-making authority. This time, psychoanalysis and psychotherapy are not specifically mentioned in the bill. However, this legislation proposes to give the ministry even more authority to make unilateral decisions than Bill 50 did, with all its potentially negative outcomes, a proposal which Mr Wilson had so effectively criticized and had helped to defeat only two years ago.
Schedule H of Bill 26 contains amendments to the Health Insurance Act and the Health Care Accessibility Act. These amendments permit government to unilaterally define an insured service, allowing them to refuse to pay for services if the general manager of OHIP "believed that all or part of the services were not medically or therapeutically necessary," and permitting the general manager of OHIP to have a physician repay "unnecessary services."
Despite these references to "insured services," "uninsured services" and "medically necessary" services, there are no guidelines that define "medical necessity." One reason may be that no universally recognized guidelines exist about what is and what is not a medically necessary service.
Schedule H of Bill 26 permits the government to unilaterally determine the fees payable for an insured service and allows for the basic fee for an insured service to be nil. The bill also allows for an adjustment of the fee payable for an insured service by decreasing or increasing the fee on the basis of specialization, frequency with which the physician or practitioner provides the insured service, the geographic area in which the insured service is provided, the setting in which the insured service is provided and other unspecified factors. These regulations would effectively delist services by making the fee so low that it would be impossible for physicians to offer these otherwise insured services.
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We are greatly concerned that these proposed regulations could be used to arbitrarily cut psychoanalysis on the basis of unilateral decisions by the government. Our members, like other service providers in the health care field, understand the challenges we all face in the responsible management of health care costs in Ontario. However, our experience has shown that ill-conceived proposals combined with a lack of consultation can result in seriously flawed health care policy.
Our purpose in coming here today is to warn you against the dangers of delisting effective and medically necessary treatments and to point out the negative impact of arbitrary and unilateral decision-making on our ability to maintain clinical integrity.
Ironically, I am here to repeat the Honourable Jim Wilson's 1993 words: "The government is using its current fiscal situation as an opportunity to pass this very dangerous legislation. There are no limits on what services can be restricted by the government under Bill 26."
Even more alarming is that such unilateral decisions by the Ministry of Health could have the effect of making clinical decisions on behalf of patients and undermining the principles of medicare, affecting both comprehensiveness and universal access to needed treatment.
In 1993, the ministry neglected to consult widely on this issue. Instead of having to consult more, Bill 26 would allow the ministry a free hand to introduce proposals such as a limitation on psychotherapy without having to consult with anyone.
Psychiatrists and psychoanalysts are aware of the need for changes in the delivery of health care in Ontario. We hope you will take the initiative to correct this legislation and ensure that health care policy is not given over to the flawed process which yielded similar proposals in the past.
Before I finish my presentation and answer your questions, I want to address two additional problems with Bill 26.
Bill 26 permits the government to unilaterally determine what constitutes an eligible physician for purposes of obtaining a billing number. After this section of the bill comes into force, new physicians, if they are a specialist, and 90% of psychoanalysts are specialists in the area of psychiatry, in order to acquire a billing number, will be forced to have a hospital appointment. Psychotherapy and psychoanalysis are traditionally community-based therapies and normally do not require a hospital appointment to be effectively carried out.
This does not mean that we do not treat patients with serious medical problems. In 1993, Dr Norman Doidge, head of the assessment clinic at the Clarke Institute of Psychiatry, conducted a survey of Ontario psychoanalytic practise and found that the major users of psychoanalysis in Ontario are women of average income, not the worried well or the rich neurotics that are pictured in the media. Frequently, these patients have histories of childhood trauma such as sexual abuse, physical abuse and death of a sibling. Eighty-two per cent had attempted other forms of treatment, including briefer forms of psychotherapy and medication, prior to psychoanalysis. Most patients had multiple psychiatric disorders.
Long-term psychotherapies lead to decreased physical morbidity in patients, and numerous studies have shown that medical utilization by emotionally disturbed people decreases following outpatient psychotherapy. There is also evidence that psychoanalysis and long-term psychoanalytic psychotherapy forestall psychiatric hospitalization. Even considered solely in terms of health care costs, outpatient psychotherapy and psychoanalysis is not an undue burden on the health care budget.
The ability of psychoanalysts to work in the communities in which their patients live has proven to be effective from both a service delivery and cost-savings point of view. Bill 26 would seriously limit the ability of future psychiatrists from practising in the community. Currently, psychiatrists in the so-called oversupplied areas often have long waiting lists and the Ministry of Health has never adequately documented that there are too many practitioners in those areas.
Our members would urge you to reconsider those aspects of Bill 26 that limit new psychiatrists from opening practices in the community without a hospital appointment.
The final issue I want to address today is the impact Bill 26 will have on patient confidentiality. The Ministry of Health has identified as a priority the need to prevent inappropriate and fraudulent billing and to increase recovery of overpayment for inappropriate and fraudulent billing. To achieve these objectives, schedule H of Bill 26 includes amendments that provide the Ministry of Health with new investigative powers by which inspectors can enter and inspect a physician's office without a warrant and collect patients' records. With its new power, persons receiving an insured service will be deemed to have authorized government to use at its discretion personal information regarding those insured services.
Our members are mindful of the need to monitor fraud in our health insurance plan. Unfortunately, there are no safeguards in schedule H of Bill 26 to protect the confidentiality of patient records.
The first principle of psychoanalysis and psychoanalytic psychotherapy is the confidentiality of the treatment. It is the foundation of trust between the practitioner and the patient. Although this is recognized by everyone, infringements of confidentiality are often too easily accepted in the pursuit of other goals. Many people in psychotherapy or psychoanalysis have been abused by people in positions of authority and would be very wary of giving authorization to Ministry of Health inspectors to look at their psychotherapy records at the discretion of an inspector who they do not know or have any reason to trust. The consequences of the measures in Bill 26 will be to discourage vulnerable individuals from seeking the medical treatment they need because they are afraid that the privacy of their medical records and the confidentiality between them and their doctors will be open to arbitrary violation.
We ask that Bill 26 be changed to provide safeguards for patient confidentiality. The general manager of OHIP knows who the patients are who receive insured services from any physician. It would simply be a matter of requiring that inspectors request permission from patients whose records they wish to look at. By doing this, patients would know when their records are being looked at, and if they felt the material contained in their record was too personal, the inspectors could obtain the information necessary to meet the ministry objectives by interviewing the patient. Such an interview would establish whether the insured services were rendered, whether the insured services were misrepresented, and this process would preserve the patient's ability to protect the privacy of their medical records.
The College of Physicians and Surgeons already has the power in its peer review program to investigate if services are being provided according to accepted medical standards. The ministry has not provided sufficient explanation as to why inspectors who are not necessarily medical practitioners are also needed to carry out this task. We fail to see the need to rush this part of the legislation through without proper consultation with the College of Physicians and Surgeons, psychiatrists, patient groups and our own members. Again I repeat the Honourable Jim Wilson's 1993 words, "The government is using its current fiscal situation as an opportunity to pass this very dangerous legislation." There are no limits on what inspectors can do under Bill 26.
Health care providers and patient groups are too often ignored by the ministry as it follows its own misguided course. We hope you will take the initiative to remove those aspects of this bill that are harmful because they compromise the delivery of care, individual freedoms, the privacy of records and the confidentiality between patients and their doctors.
We would ask that you not use the current fiscal situation as a reason to pass legislation that will provide the government with almost unlimited control over the delivery of medical services. We hope you will take the initiative to remove those parts of schedule H of Bill 26 that we address today and allow adequate consultation with all stakeholders so that health care policy is not given over to this flawed process.
We will be pleased to answer any questions of the committee or provide clarifications on any of the points we've raised.
The Chair: Thank you very much, gentlemen. We have a short time left for questions, beginning with the official opposition. You have two minutes, Mrs Caplan.
Mrs Caplan: Yes, I'll keep it very short. I am assuming that you were not consulted. Is that true?
Dr Iseman: That's correct.
Mrs Caplan: Now, this is not the first time that this issue has been before a legislative committee. At the time of the introduction of the Independent Health Facilities Act, your organization was here with identical concerns, I know, because that was the bill I brought forward, and it was amended to put in place the protections that responded to your concerns. You were here again in Bill 50, and at that time it was Jim Wilson and Ernie Eves both who were advocates. Why do you think you weren't consulted on this, since they obviously were aware of your concerns?
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Dr Iseman: Well, I did write the minister when he first took office and reiterated the offer to consult and offer whatever help I could and I got a very polite response thanking me and he said he would be in touch. That was the last thing.
Mrs Caplan: But they promised that they would consult in their CSR document.
One last point: The concerns that you raise around arbitrary violation of confidentiality is something of course I've been very concerned about, but it's more than just arbitrary, it's even inadvertent violation. This law, for the very first time, says to the minister, anybody who works for the minister, the general manager of OHIP, anyone who even inadvertently releases confidential information, that they are protected from any lawsuit or recourse. Were you aware of that provision, and did you want to speak to that in the last couple of seconds that you have?
Dr Weir: I guess I wasn't aware of it, but that just underlines the importance of looking at this, and I guess part of that must have to do with my sense that this is being rushed through and that there hasn't been enough time for the various people involved to look at it and to build into it safeguards for patient privacy.
Mrs Caplan: In fact, if Jim Wilson had had his way, this would be law today.
The Chair: Thank you very much, Mrs Caplan.
Ms Lankin: Thank you for your presentation. You referred at one point to the powers of the general manager of OHIP, and there are some changes being proposed under the Health Insurance Act that would give the general manager, and the minister -- cabinet -- more powers, many of them able to be exercised unilaterally and without any right of appeal. I think when you put it all together, it's quite concerning.
There is a section in which the general manager can refuse payment if the general manager believes a particular service is not therapeutically necessary. It seems to me that this would involve the general manager in second-guessing the appropriateness of particular treatments, and I'm really concerned about that in a lot of ways. Currently, there is a whole process that people can undertake with the College of Physicians and Surgeons with respect to the appropriateness of treatment decisions by physicians, but this gives a bureaucrat in the Ministry of Health the right to second-guess, and very little options around appeal. Have you looked at that section, and what does that mean for your particular profession and your patients?
Dr Weir: Yes, I've looked at that, and that concerns me also, especially because I don't know what information they would make that decision on, first of all, so it would be very arbitrary, and there would be no mechanism for the patient to appeal, and that in the end they would not get any treatment. It would be after the fact, in a way, after the treatment had maybe been started, and there would be no mechanism for the patient to maybe get that reinstated.
Ms Lankin: Would that require the general manager to review the patient's files in order to make a decision about the appropriateness of treatment?
Dr Weir: That would be one way, and then at least they would have some information. My fear would be that they in fact would go on the kind of information that one submits to OHIP, which is very limited, in terms of age, sex and diagnosis. That's really the only information that they have.
The Chair: Okay, thank you, doctor. Anybody from the government?
Mr Clement: Thank you for your presentations. Under the current system, in terms of confidentiality of records, the general manager, as you quite rightly put it, has the ability to acquire information as to who is receiving insured services. And you make a worthwhile point in terms of the type of information that you feel comfortable could be conveyed to an investigator. Really, we're not talking about, as far as I understand it, the actual records of the type of sessions that the patient is having. Are we really not talking about whether that person has received the service and whether there has been an accurate reflection?
Dr Weir: If I can answer that, okay, if that's what they want to do, they already have the power of doing that. Whether somebody comes to my office, I submit to OHIP. OHIP already has the power and regularly does this. They randomly select my patients to check whether I in fact actually saw them.
It seems to me that other than whether I've seen the patient, if they want to make the kinds of decisions that this bill is addressing, they have to look at the whole record. It's not like it's just a list of appointments that I saw people. It has all the intimate details of their life in it, and they're going to be looking at that to make the decisions as to whether or not it was therapeutically appropriate, and it's going to be somebody who has maybe no training but is some low-level clerk at OHIP who on some random basis is going to decide whether or not a decision was made appropriately.
Mr Clement: You're making a few assumptions there, but you do acknowledge in your paper that fraud is a potential problem and that there has to be a balancing of the needs of society -- the taxpayers -- to root out fraud, with the rights of the individual, that there has to be a balancing there.
Dr Weir: Yes, there has to be a balance, but I think that they have enough powers now to do that. I don't know if they need to be able to charge into my office and look into patients' records, and I don't think the people of Ontario want these inspectors to be doing that.
Mr Clement: I don't think anybody is suggesting that we're going to do that.
The Chair: Thank you very much, Doctor, and thank you, Mr Clement. We appreciate your involvement in our process.
Mrs Caplan: It's what you're doing.
Mr Clement: That's the way a democratic society works.
Mrs Caplan: On a point of order, Mr Chair: I would suggest that Mr Clement read the act --
Mr Clement: If the honourable member wishes to pass the time, her time, to do that --
Mrs Caplan: -- because he's trying to put on the record information that is not accurate.
The Chair: Excuse me.
Mr Curling: On a point of order, Mr Chairman: Why don't you go and listen to her?
Mr Clement: I've listened to her ad nauseam.
Mrs Caplan: Read the bill. At least find out what's in it.
The Chair: Excuse me.
Mrs Caplan: Thank you.
Mr Clement: No, thank you.
The Chair: I would appreciate it if we would show some respect to one another, and when somebody has the floor, we'll allow them to talk. You have your turn.
Thank you very much, doctors.
SUNNYBROOK HEALTH SCIENCE CENTRE
The Chair: Is Tom Closson from Sunnybrook Health Science Centre here? Welcome, Mr Closson. You have half an hour to use as you see fit. Questions at the end will be divided. The time will be divided evenly, beginning with the New Democrats. The floor is yours, sir.
Mr Tom Closson: Thank you very much. I want to talk to Bill 26 and the impact it has on hospitals, and I want to talk specifically about changes to the Public Hospitals Act and also changes to the Hospital Labour Disputes Arbitration Act.
Just to summarize very quickly, I'm going to discuss the need for having Bill 26, given our critical financial situation. I want to identify some changes that I think should be made to Bill 26 where I think it goes a little bit too far, and I also want to identify some changes that should be made to Bill 26 where I don't think it goes far enough.
Let me first of all talk to the need for the bill itself. This province is in a serious financial situation due to overspending by governments in the 1980s and the early 1990s. In health care alone, as I'm sure you all know, the amount of money that went into hospitals and physicians' services, which makes up about 70% of health care, increased through the 1980s and the early 1990s at the rate of 10% per annum, which is much faster than the gross domestic product, much faster than inflation and population and any measure you can think of. We got a little carried away during those years, to a large extent due to health overexpenditure, I would suggest, and now we've ended up with an accumulated debt of close to $100 billion.
I like to think about this: that if we didn't have this accumulated debt, meaning we didn't have interest payments to pay, we wouldn't have a deficit right now. So the situation we have today is because of overspending. We wouldn't have to be cutting anything today if we hadn't overspent over the last 15 years. It's something for all of us, and I'm not just blaming it on the politicians; I think the public had a big part in pushing the politicians to overspend.
Now, in Ontario at the moment we don't have a health care system. I'll say that again: We don't have a health care system. We have over 200 hospitals, we have over 200 laboratories, we have thousands of physicians practising alone in single-office practices and we have thousands of health and social service agencies. The big word among most of them is "autonomy," and I think autonomy is what's getting us into major difficulty in this province and again one of the main reasons we're overspending and clearly the reason we don't have a health system.
In fact, I'd go so far as to say that I see an enormous amount of self-serving behaviour going on among the various providers and among the agencies that are being funded by the government. Rather than focusing on working together or merging or integrating to be able to ensure access for patients, the major concern of these organizations seems to be autonomy, independence, at a time when we can't afford to spend the amount of money that we're currently spending.
This level of autonomy I think is putting patient care at major risk if we're going to cut the amount of money out of the system that has to be cut out of it so that we can balance the budget. The bottom-up consensus building that was attempted over the last five years clearly hasn't worked. The amount of energy all of us as providers have spent trying to get together in consensus-building activities has really produced very little. Certainly as individual organizations we've been trying to improve our own efficiency, but the health care system's efficiency can't be improved by individual organizations operating alone. There has to be a much greater level of integration among hospitals and between physicians and hospitals.
This 18% that's being cut out of hospitals over the next three years is a huge number. I don't want to minimize the size of that number. In fact, it'll be taking us back to what hospitals were funded at in 1989-90 by the time we get to 1999-2000. But having said that, I think it's something that is necessary. Given it's such a huge amount of money, the only way you're going to get the money out is by taking drastic measures, things like closing and merging hospitals, which in my opinion is long overdue. We have many hospitals operating in this province at far below their built capacity. Health care has changed enormously. You don't need all these beds; you don't need all these buildings. You need to provide services close to people in their homes; you need to have organizations working together. Closures and mergers need to happen. Not too many hospitals are coming up to volunteer to close or merge.
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Changing roles: Hospitals have been providing whatever service they think is appropriate, not necessarily what their local community requires.
Integration of doctors and hospitals to create a health system: This bill doesn't really deal with that in any big way, but I've got to tell you, once we get through the next two to three years, there are much more substantive changes that need to be made in the health care system to bring together hospitals and physicians into integrated health systems. The days of doctors and hospitals being autonomous from each other really have to end. If you want to have an efficient system, as you can see in other jurisdictions, that's the direction everyone is heading.
So I believe overall, then, the government has to intervene to force the changes that need to be made in health care. These changes are not going to occur on their own, and if we cut 18% out of the system without closures and mergers and changes of roles, we're going to see very much reduced access to health care.
Where the bill goes a little bit too far -- and I'm not going to be very comprehensive here because the Ontario Hospital Association's speaking later today and I generally agree with what they're going to be saying to you, so what I'm going to do is just focus on a couple of points that I think are very important.
The first one is voluntary governance. In the end, several years down the road, I don't think this government or any government will want to be involved in micromanaging the system. My understanding is, the civil service is going to actually decline in its size, and it's a very complicated system. So you have to ultimately put the responsibility for day-to-day management back in the hands of voluntary governance structures. Therefore, I think it's very important that the major powers that the government is taking on to itself in the short term, which I think are essential to make the changes that need to be made, be time-limited. I heard through the rumour mill this morning that the minister said at the beginning of this session that he already plans to do that, but the specific things that need to be time-limited are directing boards to cease operating hospitals, directing boards to cease to provide specific services and directing boards to amalgamate. I think that we don't, as taxpayers, want to see a government that has a sufficient number of civil servants to be able to provide information that would allow that to happen in any sort of planned-out way. So I think we're much better off getting on with the major changes and then trying to remove some of those significant powers that have been centralized through the legislation.
The second thing, and it's a more minor issue but I just want to put it on the table because I don't know who else is going to put it on the table, is that in the act it talks about "hospitals may appoint physicians only in accordance with approved human resource plans." This may sound like a very innocuous little statement, but in my opinion it's unworkable. You've got to understand that a doctor is not a doctor. In a teaching centre like ourselves, doctors are involved in clinical practice, in research, in teaching -- I couldn't tell you exactly the number of physicians by specialty that I will need in a year or two from now. Things change very quickly. If a doctor spends more time on education, they have less time for clinical practice. If they spend more time on research, they have less time for clinical practice. Having to go back to the government to get these medical manpower plans or staffing plans approved would just be a waste of everybody's time.
I understand that the reason for putting this into the legislation was to try and control the OHIP pool and trying to make sure that specialist physicians are tied into hospitals. I believe strongly that specialist physicians should be tied into hospitals, but I think they should be tied in a lot more strongly than just in a medical staffing plan. We need to integrate the funding for hospitals and physicians, particularly specialist physicians, and also with economic linkages to primary care physicians so that you can actually develop integrated systems of hospitals and physicians. That's the way you're going to get savings in the system. That's the way you're going to get continuity of care so that the physicians and hospitals together can focus on providing care and service to a community, to a population, as opposed to just doing their little piece of the action which is what it is now with all of the discontinuities of the provision of service.
I haven't seen any government over the last 10 years really make very significant strides in this area and I think it's essential that we start thinking about having a health system rather than just having a bunch of providers.
The final thing I want to talk about is where the bill doesn't go far enough. This bill is intended to remove barriers to restructuring, and that I applaud, as I think you've already gathered, but it doesn't address weaknesses in the Hospital Labour Disputes Arbitration Act regarding contracting out. Hospitals need the flexibility to look at options for sharing services, to take advantage of technology.
I'll give two examples: food services and laboratories. In Ontario we spend $1 billion a year on lab services. There are over 200 labs. If you had four to six regional labs in this province I predict you could save $300 million a year. Why? Because of the benefits of using technology. We have a lab system that was designed for the 1960s, not one that's designed for the 1990s. Food services: Every hospital has its own dietary department where we produce this food. Very inefficient way to go: 70% of the cost is labour; only 30% of the cost is food. You could produce food of higher quality at a much lower cost by grouping hospitals together in terms of the production of food and then sending it to hospitals for reheating. This is done in a lot of other jurisdictions and we're way behind the times. The fact is that the labour disputes arbitration act is actually a barrier to trying to make these changes. We've got no unions in some hospitals; we have CUPE in some hospitals; we have SEIU in others; we have OPSEU or we don't have OPSEU. We have all these different situations. We need to have greater flexibility to go after the efficiency that's potentially out there.
My prediction is you could probably save 5% to 10% in the system just by amalgamating these kinds of services, and that's a good chunk of the way towards 18%. I think we have to remember what the system's here for. It isn't here to produce food; it isn't here to do lab tests; it's here to care for patients. So if you can produce food and you can do lab testing at the cheapest cost while maintaining quality, you can have more nurses and physios and social workers and psychologists to actually provide care to patients.
Hospitals need to be relieved of the restrictions imposed on contracting out work of the bargaining unit and the interest arbitrators should be barred from awarding such provisions in the future. All of our collective agreements have these clauses in them. How did they get there? We didn't negotiate them. The Ontario Hospital Association didn't negotiate them. They were put in there by interest arbitrators, the first one going back to 1979. I've got to tell you, the 1990s are not the 1970s, and we need to have more flexibility to look at different ways of providing these support services.
I'm not suggesting we throw people out on the street; I'm suggesting we treat people fairly. We need to look at early retirement, voluntary severance and the potential for moving people into these new, combined support service entities, but we certainly need an awful lot more flexibility than we have right now. We need to use the resources for patient care, not for inefficient, fragmented support services. They're not inefficient due to any reason for the staff who work in them; the staff who work in them work very hard. The reason for the inefficiency is we're not making maximum use of the technology that is available today.
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So in conclusion, in health care language I want to say that given the enormous debt that this province has, this is a critical emergency. This isn't an elective procedure we're talking about here. I believe that it should be addressed quickly, very quickly, and it needs to be addressed with radical measures. I think this legislation is radical, but I think it's necessary if we're going to protect the public and ensure that they have good access to health care in Ontario.
The Chair: Thank you very much. We've got about five minutes per party for questions, starting with Ms Lankin.
Ms Lankin: Thank you, Mr Closson, for your presentation. I have to say, the first 10 minutes or so of your presentation I agree with your analysis of what's happening out there in the health care system. In fact, it sounded very much almost verbatim like a speech that I gave on a number of occasions when I was Minister of Health, talking about the 1980s and the budget increasing by 10% as compared to any other measure that you might look and, talking about the fact that we didn't have a system, talking about the autonomy of various parts of the system and their jealous guarding of autonomy. In fact when we introduced legislation on long-term care to create multiservice agencies, we ran right smack dab into that protection of autonomy of agencies, and as I recall it the now Minister of Health was a fierce opponent of that and defended individual groups' autonomy.
It's interesting, though, to hear your next steps in terms of the things you said. Particularly, as I recall it, when I made some of those comments the Ontario Hospital Association was very vociferous in its concerns that the kind of changes we were proposing, the funding restrictions, which at that point in time were sort of flat-lining with some onetime monies, would cause 14,000 layoffs in the system, and there was a lot of bemoaning of the action.
So your position today is refreshing in a sense and I think that the system has moved in terms of its understanding of the need for change and I think that many of the restructuring reports that are coming forward and many of the actions hospitals have taken on their own indicate a willingness to proceed in that direction. Therefore, I'm concerned about some of the powers in here; not the goals of what we're trying to accomplish, but some of the powers that are here.
May I just inform you that the minister's comments this morning about sunsetting provisions had to do with the hospital restructuring commission, not with the powers set out in the act that he accrues to himself. Particularly around voluntary governance -- you raised this -- the provisions you refer to in terms of directions to close, amalgamate, merge and that sort of thing, but I'm wondering if you're aware that there is a general provision, irrespective of all of those, that stands on its own that says the minister may make any other direction related to a hospital that the minister considers is in the public interest and that the board of the hospital shall ensure that that direction is carried out and implemented, irrespective of any other act, of letters patent, of bylaws, of contracts.
To me, this is incredibly sweeping and undermining of the voluntary governance structure of the public hospitals, with no limitations, no fettering and no provision for sunsetting in the future. I'm wondering if you could comment on that particular aspect.
Mr Closson: I'll repeat, I guess, to some extent what I already said. I think it is important that there be sunsetting on some of the powers in the legislation and my reason for saying that is very much because I think that government can't get involved in the detailed day-to-day running of health systems. It's just too complicated, and the decisions are hard enough to make when you're working at the local level; they're certainly not going to be made well from Queen's Park.
I gave you some examples of the kinds of things that I think need to be included as provisions that need to be sunsetted. I think you'll be hearing more from the OHA later today in a more comprehensive sense, so I think I'll just leave it at that.
Ms Lankin: With respect to your query for greater powers in the Hospital Labour Disputes Arbitration Act -- that section isn't directly before us; it's with the other subcommittee that's meeting -- in addressing that, I'm interested in the fact that you feel you need legislative change to be able to accomplish amalgamation, for example, of laboratory services or of food services. I am aware of hospitals that have done that. I am aware of the hospital industry labour-management committee a number of years ago, in the late 1980s, having developed guidelines for mergers. It happens all the time. There are provisions for how you merge various local unions. In fact, what I think you're talking about is getting around not amalgamating and merging those services, because that's done every day in this province, but contracting out to private operators outside of the hospital circumstance. Is that the legislative protection and/or freedom that you're looking for?
Mr Closson: I think some of the things that have been done in terms of merging support services have been done on a pretty small scale. It used to be a lot easier. For example, at Sunnybrook we contracted out our laundry service several years ago and, following the collective agreement, we were able to guarantee all employees' positions by using attrition, but there are fewer and fewer support services or support-service positions within our organizations and there's less and less attrition, so it's very difficult to use that mechanism any more.
I think you need to look at every situation differently. I think in the lab arena, there is some advantage to having private sector partnering around labs, because I think the private sector organizations have more experience than the public sector organizations do at moving lab specimens around efficiently.
In the dietary field we've been talking in the Metro area about a 20-hospital group, and we have a private sector partner we've been working with to look at how we could provide food services for 20 hospitals in total. We're talking about major investment capital over time. We're talking about expertise in providing thousands and thousands of meals per day. These are things that none of us has particular expertise in. Our expertise is in health care.
The Chair: Thanks very much. For the government?
Mrs Ecker: Mr Closson, thank you very much for coming, and I think you put the need for restructuring very well in your argument. I think if there's something the last three governments have tried to wrestle with, it's reforming and changing the health care system. Hopefully, this time we might over the next couple of years be able to actually get some of the things done that everybody's been trying to do for many years on this system.
One thing I wanted to ask you to clarify a little bit, I believe you said you had some concerns about the bill's wanting positions to be appointed as part of a human resource plan, which was a recommendation, as I recall, something that had been talked about in the report, Into the 21st Century: Ontario Public Hospitals, which I think many people thought was an excellent way to go. I just wonder if you could clarify a little bit what your concern was and what you might recommend to replace it. I thought, if I heard you correctly, that you had some concerns about it.
Mr Closson: My understanding as to why it's being put into this legislation is to try and come to grips with the maldistribution of specialist physicians in the province, requiring them to be aligned with a hospital in each case, and therefore, if the government had control over how many specialist physicians could be aligned with each hospital, they'd have control over where the specialists were able to practice.
Whether that's a good idea or not, I don't know, but the mechanism that's being used to make this happen would be very difficult to follow through within the hospital community. At Sunnybrook, where we have about 250 full-time physicians, let's say we have at the moment about eight cardiologists. If three of those cardiologists decided to spend more of their time doing research, that would mean we'd need additional cardiologists. The way I read the legislation, we would have to go back and get approval from the government to be able to change the numbers associated with the plan, and that would be very difficult.
Every time people change their practice at all, you'd have to go back and get approval. People age. We're a trauma program. They reach a certain stage where they don't want to be up all night, so they change their style of practice. Then we have to bring in additional surgeons, orthopaedic surgeons, general surgeons, to take the calls. Going back to the government every time one of these little things changes I think would just be a waste of the government's time and certainly would waste our time.
I think it's better if you look for other mechanisms to deal with the distribution of specialist physicians. I think tying it in to the manpower plans or staffing plans of the hospitals isn't the best way to do it. Instead the government should be looking at contracting with hospitals for serving certain populations and meeting the needs of those populations and giving them the flexibility to actually switch from physicians to possibly alternatives to physicians, and not get so caught up on counting MDs. I think counting MDs is a path that's going to just waste everybody's time.
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Mrs Ecker: Would you be supportive of the direction and the intent of the powers that say that the minister or the ministry can actually contract with a hospital or facility for certain services and outcomes for what they should be providing for the money in a global sense?
Mr Closson: Very much so, and I'd like to see it tied into populations that the hospital is supposed to serve, like taking total responsibility, along with physicians in an integrated group, to serve the full needs of populations for a certain sum of money.
Mrs Caplan: If you added to your concept of the hospital and the doctors in a coordinated, comprehensive plan the community groups as well, you'd have a comprehensive health organization which was funded on the basis of that population and the needs of that population. Not only would you have my support, but I've told the minister that that's what I think is appropriate reform.
The other thing that would happen would be that you would have an incentive for hospitals and doctors and community organizations to come together to serve that population. I also had a little déjà vu as I listened to the beginning of your remarks, because it's something that we have been advocating, although I believe that most of the powers are there in existing legislation. There need to be a few small changes in order to implement it.
But my sense is that this bill is a bureaucrat's dream. It gives the minister, and thereby the ministry, all the powers to centralize control, as opposed to the kind of partnership model that you've been advocating. While it may allow for a contract-type situation -- and I raised in my opening remarks with the minister this morning the view that the manpower plan requirement leads to micro-management, because it allows the minister to impose a plan on a hospital -- it removes any of the level of trust and it also creates huge paperwork, because as you've said, the plans are fluid and they're ever-changing.
The concern I have is the powers in this bill permit micro-management. In fact, as I read the accumulated powers that are there, I am quite fearful that it would block the development of exactly what you want, which is the partnership between the hospitals, the doctors, the community organizations and the development of a CHO, which ultimately might need legislation but, in my view and from my experience, could be accomplished simply by arranging with the ministry alternative funding formulas, and they already have that power right now.
The question I have for you is -- and I've heard your comments and taken your advice regarding expenditures in the province over the past few years -- what impact do you think the $5-billion tax cut is having on the expenditure plan of this government? The fact that they are attempting to balance the budget, but not till the year 2001, not reduce the debt, and cutting $1.3 billion out of hospitals at this time? If they didn't have that $5-billion tax cut, what do you think could be accomplished?
Mr Closson: I think Ontario has one of the highest tax rates in Canada, if I'm not mistaken, and I think the high tax rates are actually acting as a disincentive for industry to want to invest in this province. So I'm a firm believer that our tax rates do need to be lowered and we need to stimulate the economy and create new jobs.
A lot the jobs in health care are jobs of the past; they're not jobs of the future. We need to stimulate new industries in this province to be able to develop jobs of the future so that we can get people employed. I think all the literature suggests that the best way to achieve health status is by having people employed.
We're going to have go through a bit of rocky phase here, where there'll likely be higher unemployment, but hopefully we're going to be able to stimulate the economy at the same time and create new jobs for people. Personally, I think it needs to be a balanced strategy. I'm not going to debate with you the numbers, because that's not really what I'm here for, but conceptually that's the way I feel.
I'd like to just comment, if I can, on your other comment about CHOs, comprehensive health organizations. Clearly what I'm talking about is something that looks an awful lot like a comprehensive health organization. But we've made basically no progress on comprehensive health organizations in Ontario since 1988, when the first ideas came forward from the Premier's council, and part of the reason for that gets back to everybody wanting to be autonomous. I do believe we need some legislation to break down some of this autonomy and force some major structural changes in the system.
I also, though, agree with you that the funding system is really at the heart of all this, and if we could really focus on changing the funding system for doctors and hospitals and community agencies, we could make progress really quickly.
The Chair: Thank you very much, Mr Closson. We appreciate your attendance here and your involvement in our process.
ONTARIO PHARMACISTS' ASSOCIATION
The Chair: The next group is the Ontario Pharmacists' Association, represented by Gary Sands, Wayne Marigold, David Windross and Barb Stuart.
Good afternoon and welcome to our committee. You have a half-hour of our time to use as you see fit. The questions will begin at the end with the government, so the floor is yours. Obviously I introduced one person who's not here, did I?
Mr David Windross: No, he's here.
Mr Wayne Marigold: My name is Wayne Marigold. I'm the president and chairman of the board of the Ontario Pharmacists' Association. With me are the chair of our public affairs committee, David Windross, to my immediate left; our chief executive officer, Barbara Stuart, to my right; and Gary Sands, our manager of government and public affairs, to my far left.
Today my colleagues and I speak to you on behalf of over 4,500 pharmacists across Ontario who are members of our professional association. Our association, in addition to providing services to our members, strives to enhance the standards of practice in our profession in the interest of pharmacy and the public. We are, at least for the time being, also mandated to negotiate the dispensing fees paid to pharmacists by the Ministry of Health under the Ontario drug benefit plan.
Over the years we have worked cooperatively and diligently with governments, led by all parties, to enhance the quality and cost-effectiveness of pharmaceutical care. We were, therefore, shocked and dismayed, like others who have built close working relationships with the government, particularly the Ministry of Health, by the total lack of consultation on the significant changes proposed to the health care system.
But on a positive note, we are pleased that the government is holding these hearings. We appreciate this opportunity to put forward both our concerns and our suggestions.
At the outset, let me say that we agree wholeheartedly with the need to bring Ontario's spending under control. Governments at all levels simply cannot continue to spend more than they receive in revenues. Governments can no longer live beyond their means.
But as the government moves forward with its agenda to reduce and control spending, it must ensure that those who truly need assistance continue to have access to the support they require to maintain their health. Essential services must be protected, and quality drug therapy is one of these essential services.
Today the association wishes to address three topics: copayments, deregulation and negotiation of professional fees.
We wish to address these topics with certain principles in mind. Some of these are OPA policies, some are Ministry of Health statements and some come from Premier Mike Harris.
"Quality drug therapy is an essential component of the health care system and the quality of life in Ontario." Ontario Pharmacists' Association.
"Prescription drugs are powerful agents for improving and maintaining health." Ministry of Health, Drug Programs Framework for Reform.
"All Ontarians should have equitable access to drug coverage." Ministry of Health, Drug Programs Framework for Reform.
"Ontarians have told us keeping their health care is their number one priority." Mike Harris.
"We have explicitly ruled out new user fees. However, we recognize that long-term funding stability will require different sources of funding. Our plan includes a new fair share health care levy." In a letter to me from Mike Harris in May 1995.
With these principles in mind, let us examine copayments. The Ontario drug benefit plan and the Trillium drug plan cover about 2.5 million people or 21% of all Ontarians. It is proposed that, effective June 1, 1996, people receiving benefits under the ODB plan will be asked to share in the costs.
Seniors earning less than $16,000 -- and couples less than $24,000 -- and social assistance recipients will pay a $2 copayment for each prescription filled. Seniors earning over those amounts will pay the first $100 in prescription costs each year per person and then the Ontario drug benefit dispensing fee of up to $6.11 per prescription.
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The Trillium drug program, which was established in April 1995 to help people who have high drug expenses in relation to their incomes, will also change. It is proposed that effective April 1, 1996, the program's coverage will be extended by lowering the annual deductible for those earning less than $20,000 per year. Further, starting June 1, 1996, the Trillium drug program will require a $2 copayment for each prescription filled.
These proposed revisions will save an estimated $225 million to protect the program's future, allow government to add new drugs to the formulary and expand the Trillium drug program eligibility.
The OPA does not question the need to control ODB program expenditures and supports the government's desire to protect the program's future. However, we do question whether or not copayments are the most appropriate method to accomplish these goals. We believe there are better alternatives.
The OPA was not consulted on the changes to the program and therefore has little information on the assumptions and analysis used by the government to reach its decision to institute copayments. However, it is generally acknowledged that copayments are introduced by governments to transfer a part of the cost of prescription drugs to the patient and to reduce overall consumption.
But do copayments work? What are their side effects and long-term implications on patient care?
Many studies have been conducted on the impacts of copayments. These studies have examined claims that copayments reduce drug program expenditures by decreasing utilization, shifting costs to patients, encouraging more appropriate drug utilization and creating more cost-conscious patients who seek lower cost sources or substitutes for their prescription drugs.
While knowledge and research regarding the effects of copayments is improving, much remains to be known. Only a small number of copayment types and beneficiary groups have been evaluated, and few under controlled situations. Therefore, much of the analysis is open to interpretation.
Bearing this in mind, while studies in the US and UK suggest that utilization does decrease when copayments are introduced, recent experience in the province of Quebec suggests that reductions in utilization are temporary and that consumption returns to pre-copayment levels within one year of implementation.
But even if copayments reduce utilization, is this a good thing?
Where utilization decreases, the analysis cannot determine the degree to which appropriate and inappropriate utilization are reduced. However, it is clear that a substantial proportion of decreased utilization occurs among needed medications.
In one US study, the copayments had little effect on the utilization of the discretionary drugs such as sedatives and analgesics, whose withdrawal immediately affects the patient's sense of wellbeing. The largest effect was on drugs such as diuretics used in the treatment of serious but asymptomatic diseases. In addition, while there are no published studies of the effect of copayments on general health quality, they have been associated with some specific adverse health outcomes, particularly among low-income patients.
With respect to the final claim that copayments make patients more cost-conscious, there is no doubt that patients will be more aware of drug therapy costs. However, unless patients are able to make informed decisions based on quality and appropriateness of alternatives, the impact of non-compliance decisions based on cost factors alone may have detrimental impacts on their health.
There is simply not enough hard data and empirical evidence to truly evaluate the effects of copayments except to say in the short term copayments will save governments money by shifting some of the cost to low-income and seniors patients. But these costs may create a financial barrier significant enough for some people to reduce the use of much-needed medications. Alternatively, the copayments may reduce what they can spend on food or rent. As an example, a senior who may be admitted to the hospital with pneumonia may get an expensive medication while in hospital, get a prescription for it when they leave hospital, and if they have to make a decision based on the costs that they have to pay, may not take the medication, will be readmitted to hospital and further cost the health care system more money.
We cannot afford to experiment on a matter so vital to Ontarians until we know the facts.
Copayments force patients to make decisions on drug therapy and the quality of their health based on their ability to pay rather than the necessity of the prescribed drug therapy. A reduction in patient compliance resulting in further complications may ultimately increase expenditures on physician and hospital services.
There is a great possibility that savings achieved in the drug programs will be more than offset by increases in other areas of health care.
Copayments are at odds with the concept of a drug benefit program designed to ensure that drug therapy is available to all those in need on an equitable basis. While we support the government's desire to protect the future of the drug benefit program, it should not be done at the expense of the health of those who genuinely need assistance. The proposed copayments will create undue burdens and hardships for low-income seniors and social assistance patients.
Copayments are a quick fix which may in the long run do more harm than good.
Copayments will also present significant administrative challenges for pharmacy in the community as well as in hospitals, nursing homes and homes for the aged. Copayments will be difficult to collect and may impact on patients' rights to protection of privacy.
There are other options and solutions. We propose to eliminate the need for copayments by reducing program costs and by asking all Ontarians and ODB and Trillium beneficiaries to pay a fair share.
We are still working on the details of our proposal. However, a general outline is as follows:
First, we would generate funds through a fair share health care levy, as outlined in the Common Sense Revolution.
The Common Sense Revolution states, "In the last decade, user fees and copayments have been rising," and "We looked at these kinds of options, but decided the most effective and fair method was to give the public and health professionals alike a true and full accounting of the costs of health care and ask individuals to pay a fair share of those costs based on income."
The fair share health care levy proposed in the Common Sense Revolution would generate $400 million for the health care system. A minimal increase in the levy could generate a significant portion of the funds required for the drug benefit programs.
Second, we would impose a fair share drug tax on medications purchased by ODB and Trillium program beneficiaries whose incomes are in excess of $16,000 per person. This fair share drug tax to be levied on the total prescription cost, and collected at the point of purchase, would replace the $100 annual deductible and $6.11 prescription fee payments proposed to be collected from seniors earning more than $16,000.
Third, we would vigorously pursue cost savings through more efficient and effective management of the programs and quality improvements to address issues of inappropriate prescribing and utilization.
In the report entitled Drug Programs: Framework for Reform, the Ministry of Health in 1994 set out a number of statistics, principles and plans that point the way for reform and major cost savings. Studies report rates of inappropriate prescribing in Ontario of 25% to 40%. Each year, 17,000 people are treated for prescription drug problems, and it is estimated that 20% of all hospital admissions for seniors are related to medication misuse. That's one out of every five seniors.
These concerns are especially important to seniors who, because of age and because they are the largest consumers of pharmaceuticals, have the highest potential for adverse reactions and interactions.
A concerted effort is required to improve appropriate prescribing and utilization. This, combined with the implementation of medication management strategies and pharmaceutical care models that make better use of the professional training, expertise and advice of pharmacists, can have significant short- and long-term cost savings.
We agree with the Ministry of Health that responsible use of prescribed medication involves a partnership between patient, pharmacist and physician. The appropriate use of prescription drugs depends on patients, pharmacists and physicians having the knowledge and information they need. We see a system where better informed patients will use medications wisely and make it easier for physicians and pharmacists to serve them well.
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This can be accomplished through a number of initiatives, some of which include:
Prescribing guidelines, training and information for physicians to ensure that the drugs prescribed are therapeutically appropriate.
Patient education and counselling by pharmacists and physicians to encourage responsible use of prescribed medications.
Use of the professional services of pharmacists to help patients and physicians.
Drug utilization reviews to encourage best drug therapy.
Medication passports to help patients, physicians and pharmacists keep track of all medication dispensed.
Drug information services or hotlines to provide support and information to all parties.
Trial prescriptions to reduce drug wastage.
These are just some of the cost-saving measures that would be introduced quickly and have long-term benefits. While estimates of cost savings are being developed, the potential benefit is enormous. Trial prescriptions alone that have been successfully implemented in a number of jurisdictions may save tens of millions of dollars in reduced drug wastage.
In conclusion, while copayments might be attractive to government as a short-term way of reducing drug program expenditures by $225 million, we believe the hardship and adverse impact on the health of the program beneficiaries to be excessive and unnecessary.
Our plan, which is based in principle on the Common Sense Revolution fair share health care plan, presents a fair and reasonable alternative under which everyone will pay their fair share, with no new user fees as promised. Top quality drug therapy and top quality health care will continue to be available to all Ontarians.
It is our position that a new fair share health care levy and drug tax combined with a determined cooperative effort by government and the health professions to reduce costs can generate cost savings equal to or greater than the $225 million in savings projected through copayments and eliminate the need to implement them.
Now I would like to address the proposed changes to the Prescription Drug Cost Regulation Act. These will remove all restrictions on the price manufacturers can charge pharmacists for drugs to be dispensed to Ontario residents except ODB and Trillium beneficiaries. They will also remove restrictions on the markup charged by pharmacists on those drugs.
Currently, the maximum charge for drugs in the cash-paying, non-ODB market is the sum of the best available price set by the government, a markup set by the government and the pharmacy's usual and customary professional fee.
Under the proposed changes, the government will continue to set the price for a drug product by agreement with the manufacturers for drugs dispensed to ODB and Trillium beneficiaries, but it will eliminate any restrictions on the price the drug manufacturers can charge pharmacists and hospitals for products to be dispensed to non-ODB consumers.
This change will mean that independent pharmacies, chains and hospitals will have to bargain individually with drug manufacturers, and some will get better prices than others.
Similarly, the government will continue to set the markup on the drug costs it pays pharmacies dispensing drugs to ODB and Trillium program beneficiaries. But the proposed changes will remove any restrictions on the markup pharmacies can charge non-ODB consumers.
This sets the stage for wide variations in the amounts paid by individual patients, pharmacies, hospitals and consumers for the same product in different geographic locations. This goes against the principle that all Ontario residents should have equitable access to drug therapy.
While ODB covers about 25% of the population and private insurers cover another 55%, almost 20% of Ontario's citizens, or about 2.5 million people, have no prescription drug plan. The proposed changes will leave these people extremely vulnerable to unmanageable drug cost increases.
Ontario residents in small urban, rural and remote areas of the province, who have access to a limited number of community pharmacists, may face higher markup costs due to the pharmacists' inability to negotiate a reasonable drug product cost.
The proposed deregulation of drug prices and markups will create an uneven playing field for pharmacy and for cash-paying or privately insured non-ODB patients, with little or no overall public benefit. We also worry about the impact on employers and employee benefit programs.
Quality drug therapy is an essential ingredient of the health care system and the quality of life in Ontario. Quality drug therapy can delay or prevent the need for more expensive health services. It is too much a public good to be left totally unregulated.
All Ontarians, and particularly Ontario's most vulnerable residents, must be protected against unmanageable drug expenditures in the same fashion as ODB and Trillium beneficiaries.
It is common sense that all Ontarians should have access to, and receive the benefits of, the drug benefit price that the government will set by agreement with the manufacturer.
Similarly, like ODB and Trillium program beneficiaries, all Ontarians should have the right and obligation to pay only the markup percentages on drug costs set by the government in consultation with pharmacy.
It is our position that government should continue to negotiate and set fair and reasonable prices for drug products and markup percentages on drug costs for all Ontarians.
Now, turning to our third and final point, I would like to talk about the process by which the government proposes to set the professional fee for ODB prescriptions.
The maximum professional fee for prescriptions provided through the Ontario drug benefit program is currently subject to negotiation with the Ontario Pharmacists' Association. The proposed changes will eliminate the negotiation process with the OPA. The government will unilaterally set the maximum professional fee for ODB prescriptions by regulation.
But the present government has never negotiated with the OPA under the present legislation. We are therefore disappointed that the government proposes to eliminate the process instead of making it work better for both parties.
The pharmacy profession must have a voice in determining a fair and reasonable professional fee. The negotiation process with the OPA should be streamlined and made more effective, not eliminated.
Pharmacists are an integral part of the health care delivery system in Ontario. The professional fee of pharmacists should reflect their level of professional training and the professional services they are expected to provide. The professional fee should also reflect their role as front-line gatekeepers in the health care system. Their counselling, monitoring and communicating activities required by the pharmaceutical care model being developed by the profession can have a significant impact on the health of Ontarians and maximize the effectiveness of drug therapy programs.
There are fresh approaches to determining a fair and reasonable fee that can be equitable to the government and the profession, and be in the public interest. It's our position that government must work with the OPA to create an effective and open process to set pharmacists' professional fees in order that the profession may continue to provide quality, cost-effective drug therapy.
This brings us to the end of our presentation. We believe we have put forward reasonable proposals to enable the government to (1) eliminate the proposed copayments through innovative cost reductions and a program where everyone will pay their fair share; (2) continue to protect all Ontario residents from unmanageable increases in their drug therapy costs; and (3) create an effective process for the profession to have a voice in its future and the future of the drug therapy program, through the OPA.
These proposals will not only save money and protect the program's future, but will also improve the quality of health in this province and reduce expenditures on hospital and physician visits and in other areas of health care.
Simply put, these proposals will help to ensure that all Ontarians who need drug therapy will have equitable access to, and receive, the right drug, in the right dosage, at the right price and will understand how, why and when to use it.
In the coming days and weeks we will continue to develop the details of our proposals. We invite and encourage the government, our colleagues in the health care field, seniors, employers and others to work with us to build a quality drug therapy program that is sustainable for the future.
The Chair: Thank you very much. We have time for a quick question, a couple of minutes, starting with the government.
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Mrs Johns: Just for the record, the minister met with OPA on September 6; the College of Physicians and Surgeons of Ontario, CPSO, on September 12; the Pharmaceutical Manufacturers Association of Canada, PMAC, on October 2; the Canadian Drug Manufacturers Association, CDMA, on October 12; and the Canadian Association of Chain Drug Stores, CACDS, on November 21.
With your admitted concern about balancing the budget and stretching the health care dollars, can you tell me why you believe, as you stated in the third part of the presentation, that the government should be involved in setting and determining what the pharmaceutical industry is worth, where you talk about working with you to decide on the potential rate, in the last section, section III? That question wasn't very well worded.
Mr Marigold: I'm not sure what you mean by the rate.
Mrs Johns: "But the present government has never negotiated with the OPA under the present legislation. We are, therefore, disappointed that the government proposes to eliminate the process instead of making it work...for both parties." That's what I'm interested in. Why should the government be involved in that in the first place? Why does the government need to be a liaison to be able to ascertain what you should be charging the public?
Mr Marigold: In the past the negotiation process has been a bit of a problem. We recognize that, but prior to about five or six years ago it seemed to work fairly effectively. We believe that we have a number of issues, excluding the fee, that we can talk to the government about, non-fee issues that will save the program money.
The Chair: Thank you. Mrs Caplan.
Mrs Caplan: Obviously you had a meeting with the minister. Did he or anyone in the ministry share with you the proposals that they have in this legislation? I know that you wrote them offering to consult with them. That's one. Second, the issue that the parliamentary assistant raises is, why should you be involved? The alternative to negotiation is arbitrarily setting the dispensing fee and also the opportunity for pharmacy to give the government advice and suggestions on modification to the plan, and within that context -- I mean, there are always tensions around negotiations, but is it fair to say that you have had a reasonably decent relationship in other areas? The third question is that you missed one alternative -- I'm putting it all at once because I'm just going to get a chance for one question -- and that is, rather than an increase in the fair share health levy, did you consider recommending a reduction in the tax cut of $5 billion to find the additional resources that are necessary to fund the plan without copayments or user fees?
Mr Marigold: I'll attempt to answer the last question first. We are still reviewing all of the information. Obviously the omnibus bill was rather large. We haven't had a lot of time to review it. In fact, we just found out Friday afternoon that we were presenting today. I guess that answers that part of the question.
The first part of the question, if I can remember it, was whether we've been consulted. We met with Mr Wilson, but it was basically an introductory meeting. There was no reference whatsoever to any of these potential changes. When we left that particular meeting, we wrote to the minister volunteering to be involved in any kind of process to consult, talk about a variety of issues that affected health care -- not specifically even the ODB program; health care in general. We felt we had a lot to contribute. We should be involved in these discussions. The response was, "Well, we'll see," type of thing, and we did not, obviously, get any consultation.
The Chair: Thank you very much. Ms Lankin.
Ms Lankin: I too was confused by Mrs Johns's question. She seemed to be asking why did you think the government should be involved in these discussions around the dispensing fee. In fact, what the government is proposing is to cut you out of the discussions and to do it unilaterally. So that was very bizarre or perhaps a lack of understanding of what's actually in the bill.
You touched on a couple of things, and I am particularly concerned about regional pricing, which you mentioned. I think you indicated that, as individual and independent pharmacies would have to purchase and negotiate their own prices from drug manufacturers, there could be differential pricing. I would suggest also, with all due respect to your members in small urban or rural centres where there perhaps may be more of a monopoly situation of independent pharmacies, that the markup might vary regionally as well. From looking at this, is it likely or is it just a possibility that there are going to be higher drug costs for non-ODB drug patients in rural and small-town areas?
Mr Marigold: I don't think we can answer that completely because, again, that would be speculation on our part as to what may happen, but certainly the distribution costs to pharmacies in smaller areas might be more. There are a number of factors that could affect the local community and what the pharmacist might charge. So certainly it's possible, but it's very hard to speculate on any of the details at this point.
The Chair: Thank you very much. We appreciate your attendance this afternoon and your interest in our process.
Mrs Caplan: Mr Chairman, I mentioned that from time to time I'd like to put a question on the record. Perhaps, while the changeover is coming, I could pose a question that could be answered by the ministry?
The Chair: We're going to have a few minutes after this presentation, because the next presenter cancelled. So did you want to hold it till then?
Mrs Caplan: Sure. Although it did relate to this, I will do that. That's fine.
SOUTH RIVERDALE COMMUNITY HEALTH CENTRE
The Chair: The next group is the South Riverdale Community Health Centre, represented by the executive director, Liz Feltes. Welcome to our committee. You have a half-hour to do with as you see fit. Questions, should you leave some time, will begin with the Liberals. The floor is yours.
Ms Liz Feltes: I doubt if I will need half an hour. I come from a small organization which nevertheless thinks that this is an important piece of legislation that we ought to comment on. South Riverdale Community Health Centre is a community-controlled organization funded by the Ministry of Health. Its role is to provide good primary care and to engage in clinical and other initiatives that promote health.
Bill 26 touches on health care directly, and we will make some comments about that, but its vast scope touches the life and health of Ontario and civic society in very fundamental ways, and we feel we must comment on that too.
The purpose of Bill 26 is clearly stated; it has to do with the government's economic agenda. We agree that reform is needed in various aspects of this public sector and that this government has been given a parliamentary majority which encourages it to make reforms. But we differ on how in a democracy reforms should be made. In our submission, we'll address democratic principles and then go on to some of the specifics of the bill.
The process of the public getting to these hearings was profoundly undemocratic, and that process is symptomatic of Bill 26 itself. Two essential principles of democracy are openness and public debate of issues that affect its citizens.
But it's clear here that the bill gives sweeping powers to the Minister of Health, the Minister of Municipal Affairs, their designates or appointees, or the Lieutenant Governor in Council, and through regulations that require no debate. Public consultation, consultation and negotiation with affected parties, with hospitals, with hospital boards, with doctors, with the Ontario Medical Association, with pharmacists, with municipalities -- and that's to name only some of the parties touched on in Bill 26 -- all are to be set aside, and in most instances the bill makes it clear that there is to be no appeal from the exercise of these powers.
One of the reasons that we as a community health centre want to comment on this is because the principles that we espouse are very much based on community people having a say in the affairs of their community, just as we feel that the people of Ontario should have a say in what is being done in their province.
It appears that the only groups which the minister will commit to discussions with are drug manufacturers and the people invited to submit proposals for establishing independent health facilities. I've had people checking through these documents several times. This government has said it is committed to maintaining health spending and the Canadian health care system. The fact that the drug manufacturers and independent health facilities get preferred treatment in Bill 26 causes us to question that commitment.
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In the case of hospital and health matters, the Minister of Health alone is deemed capable of knowing what is "in the public interest" to do. Much of the health system restructuring could be achieved without this recourse to absolute power. Of course, that echoes in the mind with that phrase about absolute power corrupting absolutely. We believe that the government should be as committed to democracy and its necessary safeguards as it is to a fiscal agenda.
Our recommendation here is that any powers given to any of the ministers to bring about restructuring be limited to a carefully specified time frame.
Turning to hospitals and doctors, as the explanatory note to schedule F, part II states: "The minister is given the power to reduce, suspend, withhold or terminate funding to a hospital if the minister considers it in the public interest to do so." This alone should be sufficient to bring about the hospital restructuring that is needed, yet Bill 26 goes on to set up a system where the minister could seize control of hospitals and manage them through a "hospital supervisor" accountable only to him.
This approach undermines the role of volunteer boards of directors and sweeps away the notion of community responsibility and involvement in the public sector.
Further reforms turn all physicians into government workers with no recourse to ministerial decisions. There are provisions that allow the minister to set quotas on the types of doctors practising and on their ability to move to "oversupplied" areas. The bill allows doctors no recourse through the courts to challenge their loss of right to practice. While we do believe that the number of doctors entering into fee-for-service -- that is to say, OHIP -- billing practice should be controlled, the methods used in Bill 26 are shocking in their sweeping nature.
What is lacking is public debate, a polling of ideas and selection of the most appropriate approach. What has become of the questions raised in the Common Sense Revolution paper of bringing common sense to health care? For instance: "How do we get health care institutions, caregivers and the communities and people they serve all involved in funding decisions? How do we provide opportunities for health care professionals to share their innovative ideas for better management and accountability?"
The involvement of health care providers and consumers seems to have disappeared from the government's agenda with Bill 26.
Turning to the independent health facilities, others have already remarked on the removal of the clause giving preferential treatment to Canadian and non-profit independent health facilities. This, together with the new subsection 5(1), which permits the Minister of Health to request proposals from one or more persons of his choosing rather than issuing a general request for proposal, makes us very uneasy. It opens up potential conflict-of-interest problems. Why should the government want this particular control?
For those of us interested in protecting the Canada Health Act and the Canadian health care system, this looks like an attempt to bring in more privatization, and quite possibly US-style privatization. The door that is at present ajar would be opened wide to a two-tier health system, in our view. This was not the promise of the Common Sense Revolution.
We therefore recommend that clause 5(1)(a) amending the Independent Health Facilities Act be removed from Bill 26.
On drug benefits, announcements have already been made requiring copayments for medications under the Ontario drug benefit plan, no matter what a person's income. Like many community health centres, we have a very high proportion of poor people among our patients. They are poor because they are ill, and they are ill because they are poor. They've already suffered an enormous drop in income with a 21.6% cut in welfare. They're having difficulty getting enough food, let alone paying for drugs.
Poor people have multiple illnesses and complex problems associated with poverty. Some may have several medications they must renew each month; there could be five or six. They will have to give up food in order to pay the announced ODB fees. This is not a policy designed to get people out of poverty and into jobs; it appears to be designed to mire them further in poverty and ill health.
The proposed subsection 4(4) of the Ontario Drug Benefit Act insists on the interchangeability of prescribed drugs. While we agree with the principle of interchangeability in general, in practice one brand of medication may be effective for some individuals where another is not. This is referred to as the bioavailability of a drug, and has to do with individual body chemistry.
If you are poor and the only medication effective for you is more expensive than its interchangeable cousin, you're going to be caught in a catch-22 situation. You either cannot afford to pay the difference, or you have the problem that the interchangeable drug is going to be ineffective, which means you remain ill and unable to earn a living.
Further in that act that's being discussed, subsection 8(1.2) does allow a physician to appeal directly to the minister in this type of case. But this seems to us to be introducing red tape, and it will be time-consuming and very expensive, given the cost of answering letters to ministers.
We recommend here that as long as a prescription is signed by a doctor with direction for no substitutions, that prescription should be filled without cost to ODB recipients. If particular doctors sign abnormally high numbers of such prescriptions, their practice can be investigated.
The proposed section 22 of the same act does away with the existing power of the minister to regulate drug prices. We believe this contradicts the stated purpose of this bill. We are convinced that this will indirectly cost the province dearly and hinder any economic recovery. We expect that the pharmaceutical manufacturers will benefit, as they have from the provisions of NAFTA, without giving us reduced prices or more jobs. Our expectation is that health benefit plans of all employers will rise as a result. As a result the cost of running the public sector will also increase.
We recommend that the minister continue to control drug prices.
Speaking now of insured services and medically necessary services, the bill makes it possible to prescribe insured services by regulation, not, as previously, in negotiation with the Ontario Medical Association. In effect, this power is given unilaterally to the Minister of Health. He will also be able to establish the conditions and limitations for the insured services and the OHIP fee payable.
We understand from subsection 17.1(5) of the Health Insurance Act that there are to be some incentives in the fee schedule to practise in remote parts of the province. This could be useful, but the same subsection includes so many other variables that we must conclude that the resulting red tape would tie the system up in costly knots for long periods of time.
There should be consultation with physicians and other health care professionals, as well as the general public, about what is insured by OHIP and under what conditions.
The proposed subsection 2(3) and section 9 of the Health Care Accessibility Act introduces the possibility of using regulations to permit a hospital to charge for insured services. It also allows insured services to be regulated in such a way as to permit hospitals to charge for hospital operating costs such as meals, hotel costs, toilet trays and so on.
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Our recommendation is that subsection 2(3) and section 9 in its entirety be deleted from Bill 26.
Finally, turning to the issue of confidentiality, a great many sections of the bill impose prescribed ways in which the health care sector is to collect information about providers and patients and to make that information available to the Minister of Health. So far as we could determine, the only place where safeguards were imposed was in the amendment to the Health Insurance Act, where the general manager of OHIP is told that he or she "must not identify, or enable a person to identify, a patient."
Why is this phrase not inserted at each point where the bill talks of the Minister of Health gathering and publishing information? We would recommend that the confidentiality of patient records be protected by including that phrase in every place where information is being collected by the minister.
If I might just summarize verbally, as I didn't have time to do it before getting over here, we feel that Bill 26 is just too big; it is not so much an omnibus as a juggernaut. In sweeping up so many issues within itself, it overlooks some very basic issues of fairness and of support to medicare which are very important to the people of Ontario. We feel that the bill ought to be divided up; that health care should be treated separately and dealt with separately, with its own hearings and consultations; that municipal restructuring should be treated similarly; and that possibly the civil service and pension changes could be collected in another section. The rest might then in fact be an omnibus bill on its own.
I thank you for the opportunity to speak.
The Chair: Thank you. We have about four minutes per party for questions, starting with Mr Bartolucci.
Mr Bartolucci: Liz, thank you very much for your excellent presentation. You spoke about many issues that are of concern to the opposition, but in a nutshell and in a very real way, if and when this bill passes, how will life at the South Riverdale Community Health Centre change? Could you just outline that for the committee, please.
Ms Feltes: Obviously, our physicians are going to have difficulty with prescriptions, first and foremost, in knowing just how to work with people who are poor, who are possibly going to have to pay for drugs and who may not be allowed to have the phrase "no substitutions honoured" on their prescription forms. We'll have to be discussing matters with the minister quite frequently, I imagine.
I worry too about quite another sort of issue in terms of running the centre in the current situation. I can't quite tell, from what is being done to physicians, whether, if we were ever to need to lay off a doctor, that person would have billing rights anywhere within Toronto or anywhere at all.
That rebounds on how we work within the community health centre, as regards our doctors in particular.
We have real worries about what are considered "medically necessary" services. There are so many definitions that could change, and when you deal with a population that is generally poor, as we do, these things are of direct importance to us in the way we are able to give good service and good primary care to our clients, and it's just a very big worry sitting there on the horizon. We would like much more clarity and much more consultation before it's put into law.
Mr Bartolucci: You spoke to process, at the beginning. Process is of very great importance to any democracy. If you had the opportunity, as you will right now, to give the government some advice and some direction, how would you tell them to improve the process before passage of this bill?
Ms Feltes: I would go back and ask them to split it up, to give much more time for consultation with some of the interest groups: doctors, the OMA, people like myself. I heard, like the people before me, on Friday afternoon that I was to be here today, and that's a massive piece of legislation to go through. Just open up the process; listen to what you hear. There will still be time to get things done and to have some of the fiscal agenda get going, but you will get much more help with getting that agenda going if you open up the process and get people working with you and not in opposition.
Mr Bartolucci: Your comments are much appreciated.
The Chair: Thank you very much; we appreciate your comments.
I almost forgot you there, Ms Lankin.
Ms Lankin: Never.
The Chair: You wouldn't let me do that, would you?
Ms Lankin: Thank you very much. Additionally, I appreciate your presentation. Your comments on process and the desire to see the bill split -- if there's one message that I hope gets through to the government members on this committee as we go through this process, it is that even with the public hearings that we're having, we are still rushing this consideration of a huge piece of new public policy touching on a number of different areas, and it would be appropriate to split the bill and to slow down a bit.
The fiscal arguments that you raised in your last comments are ones the government puts forward as to why they need to move so quickly, but I think we could point out that they do have flexibility with respect to the time of the implementation of any kind of tax cut, or whether they even do that, and that would give them the fiscal room to make sure there was appropriate consideration of this.
There's one area you touched on with respect to independent health facilities and the removal of the provision that was a preference for Canadian-owned, not-for-profit organizations. You talked about the Americanization of the system. I'm wondering if you could expand a little bit on what you fear might happen in that area.
Secondly, when we heard from the Association of Ontario Health Centres this morning, Sonny Arrojado made reference to the possibility that community health centres might in fact become independent health facilities, with this statement about all services being delivered through facilities that are licensed. In there there's a huge range of powers for revocation of licences and suspension of licences by the minister without processes of appeal. Could you comment on what that means potentially for primary care being provided through the community health centres?
Ms Feltes: Well, I must say you take me by surprise. I hadn't expected community health centres to be possibly named as independent health facilities. I haven't had a chance to really consider that with the rest of my staff and with my board.
Ms Lankin: This is a suggestion that Sonny made this morning.
Ms Feltes: It's an avenue, but again I would need to go back to the legislation that has been written here, because again, so much of it is hedged about with things the minister can do on his own without actually consulting the parties involved. I think it's a fearful step to just walk into becoming an independent health care facility without knowing really what the parameters are and without somehow thinking, Jeez, they might be revoked or changed without your having much say-so.
Can I return to the business about Americanization or American-style privatization? There are a number of us who have come together in the province and across Canada. I'm thinking of the Canadian Health Coalition in particular here, and recently Ralph Nader came to talk to that coalition. He has made it very clear that there are forces, insurance companies and other forces, in the US who would very much like to have the health care system in Canada changed. They don't particularly like having a model health care system that can be pointed to. I think there are forces like that ready to look at any opportunity they can to undermine the Canadian health care system and to step in and change it.
The Chair: Thank you very much. The government: Mr Clement.
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Mr Clement: I sincerely hope we don't have the beginnings of the next Oliver Stone movie in terms of the next conspiracy, but I appreciate your remarks.
I just wanted to go back to some of the text of your document that you've presented to us. Firstly, on the first page you very rightly talked about some of the powers that are quite extraordinary in terms of realigning our hospital system, and I just wanted to make you aware today that the Minister of Health has made it clear that these would sunset after a four-year period, so they would not be on the books for ever and ever, amen.
In terms of your comments regarding the new powers in the act to make subservient the volunteer boards of directors of hospitals, were you aware that under the previous legislation, specifically subsection 9(7), if the Minister of Health, under that legislation, appointed a supervisor, no act of the board or of the hospital would be valid unless it was approved in writing by the supervisor? That was under the previous legislation. Wouldn't that be considered extraordinary under your definition?
Ms Feltes: I agree that that is similar to what I'd said, but I do think this goes much further with the hospital supervisor who can step in and simply run the hospital.
Mr Clement: I'm sorry. In --
Ms Feltes: Who seems to be able to step right in and run the hospital without reference.
Mr Clement: Yes, I think you're right, they would be stepping in and running the hospital, but that's what they would be doing if they could veto anything that a board would do.
Turning then to this whole issue of the independent health facilities, can you envisage any circumstances based on your experience where it might be a plus for patients, for taxpayers, for Ontarians to have some health facilities that are not necessarily Canadian? Maybe there's some new technology in France or in Thailand that could be very quickly imported to Canada that would be of great use to patients. Is that possible, based on your experience?
Ms Feltes: I'm sure that is a possibility, but my feeling was that it should be imported by Canadian institutions and made use of in that way.
Mr Clement: Sometimes these things have patents and things like that, so it may not be possible.
Finally, in terms of the interchangeability issue of drugs, which I agree with you is of great concern, my understanding is that the government's position is that if the person cannot use the cheaper drug because of medical reasons, the government will pay the difference. If that is in fact the proper interpretation of the bill, would you be happy with that?
Ms Feltes: I would be happy with that. I'm not happy with the process. The process is that the physician has to write to the minister and request specifically that this person not have to use the interchangeable drug, and in my experience of writing to ministers, that takes a long time and it's very costly in terms of the civil service at Queen's Park.
Mr Clement: Thank you very much for your input. I appreciate it.
The Chair: Thanks for your presentation today. We appreciate your involvement in the process.
The next group is not here, so we'll take your question, Mrs Caplan, and then we'll break for a few minutes until the next group.
Mrs Caplan: I appreciate it. There are two questions. One perhaps research could do, because I think it's more research than the ministry.
Last week in the Legislature, Premier Harris made a statement, and I think he said that the vast majority of Ontarians are not covered by drug plans. He wasn't speaking just about the ODB; he was talking about all drug plans.
The information that we have today that was presented by the Ontario Pharmacists' Association says that, "While ODB covers about 25% of the population and private insurers cover another 55%" -- they say "almost" and I'm going to substitute the word "only" -- "only 20% of Ontario citizens, who are about 2.5 million people, have no prescription drug plan."
I'd appreciate it if you could look up that reference and see who is correct, and also the context of his response in that I think it was to suggest that because such a large proportion had no plan, therefore market forces would work. Could you just clarify that for me?
Secondly, I guess the question that I would ask, as it relates to the last presenter, of the ministry: Is there anything in this legislation that would preclude a community health centre, or in fact any doctor's office or clinic of any sort, from being declared an independent health facility? The suggestion that a community health centre could be covered caught this woman by surprise. I think we should have clarification from the ministry: Is there anything in here that would preclude that?
Last, I didn't see in the legislation, and I'd like you to point it out to me, where it would permit payment on a no-substitution prescription. Would that be by regulation that you have to get advance approval from the ministry? Perhaps the ministry could provide advice to us on the experience they have had where physicians now have to get advance approval for limited formulary drugs, as to the volume and perhaps the number of people who have to be employed to deal with the idea of getting advance approval from the ministry.
Those are the three questions that I have.
The Chair: Do those two questions of the ministry need some research, and report back tomorrow, or if we reconvened in 20 minutes would you be able to deal with those? No? Tomorrow?
Mr Brett James: Tomorrow.
Mrs Caplan: Tomorrow? Thank you.
The Chair: We will leave it up to you to come back to us. So the questions have been noted.
Mrs Caplan: I appreciate that. And by the way, I understand that these may be difficult questions to gather all the research on. I'd like them as soon as possible, but I would like them before we leave the hearings in Toronto so that they can be addressed to the people who are here. I wouldn't like to see them at 5 o'clock on Friday; Friday morning at the latest, if that's okay. I want to be reasonable. Thanks.
The Chair: All right, we'll take a 15-minute break and reconvene. Hopefully, Mr Strofolino will be here by then. So we'll come back in 15 minutes.
The committee recessed from 1526 to 1551.
The Chair: I think we will proceed.
Ms Lankin: I just wondered if I could raise a procedural question before we continue. I certainly understand how much work the clerk's office must be going through, trying to schedule these participations in the hearings by the public, and I appreciate that. I wanted to raise a concern, however.
We just had a half-hour break which was occasioned by the group that was going to be here this afternoon having combined its presentation with a group this morning. I know, for example, there's a woman here in the audience who just introduced herself to me who called last week to try and get on the list. She was informed that all the spaces were taken, that there wouldn't be much chance of it and that she should just send in something written down the road. She's been sitting here all day, listening.
I'm just wondering what process we have undertaken to try and contact groups that might have been able to come forward and fill that space, or even individuals who had oral presentations and not written presentations who might have been able to come forward and fill that space, rather than having the committee take a break and denying that half-hour to someone to participate.
The Chair: Basically, as it relates to that space, we weren't aware that it was going to be open until 1:30, which was just a couple of hours before it did open up because the man who was supposed to be there presented with Mr Ryan at 1:30. We have tried, as we agreed to in the subcommittee, to fill in blank spaces off the appropriate list. As an example, the space at 6:30 has now been filled in with somebody. It's not an exact science, but we are doing the best we can, if we have an empty space, to go to the list and try to get somebody else to come in even on very short notice.
But we haven't made any provision to ask anybody who's here whether or not they want to make a presentation and we never talked about that in the subcommittee. Maybe it's something we should talk about.
Ms Lankin: Perhaps we could arrange to have that discussion.
The Chair: Yes.
HOSPITAL FOR SICK CHILDREN
The Chair: Our next presenters are from the Hospital for Sick Children, with Mike Strofolino, president and CEO. Good afternoon, folks. Welcome to our committee. You have half an hour to use as you see fit. Any time you leave for questions at the end will be divided evenly among the parties, and the questioning would start with the New Democratic Party. The floor is yours.
Mr Michael Strofolino: First of all, let me introduce those who are with me: Mary Federau, vice-president of the hospital; Alan Goldbloom, vice-president of the hospital; Claudia Anderson, chief of public affairs.
Although you've generously given me 30 minutes for my presentation, I will take far less than that. My comments are brief and should be completed in about 10 minutes or less, and hopefully there will be questions that we can address.
I approach the hearing today as the president of the Hospital for Sick Children, this province's largest and most advanced provider of medical services for children; second, as an advocate for the wellbeing for children, a role Sick Kids has undertaken for the past 120 years; and third, as a world leader of an academic health sciences centre devoted exclusively to the care of children, research and the education of paediatricians who go on to work in this province in more than 40 countries worldwide.
Because of the funding crisis in which this province finds itself, we support what Bill 26 sets out to do: to achieve fiscal savings through public sector restructuring, streamlining and efficiency. Many of my hospital colleagues are finding it difficult to be as bold as we have been in saying this publicly. After all, it means that some hospitals that have served the public well and in good faith will be merged or closed. Hospitals have been efficient as individual institutions but a system-wide consolidation needs to take place. We must find a new way to provide health care services. We must restructure.
Equal, across-the-board funding cuts to all hospitals do not work. Worse than that, such cuts are bringing a valued institution such as Sick Kids, a hospital that provides unique services not available elsewhere in the province, to its knees. If the Hospital for Sick Children must cut or cap services because there isn't enough money to provide them, both children and taxpayers will pay a heavy price. Children will be placed on waiting lists that could imperil their health or they'll be sent to the United States for treatment that would cost Ontario taxpayers more than if it were provided locally.
As we squeeze, the best and brightest physicians and scientists will be wooed away to health care and research centres where the goal remains to be the best and at the leading edge. A hospital like Sick Kids, known internationally as a pre-eminent centre of excellence in the care of children, will lose its position. The results? Our children will be obliged to wait for centres in other countries to export new techniques and technologies to us. They will not receive the state-of-the-art care that is now available.
But here in Metro we have a restructuring plan for children's health services that we believe will provide a wider range of health care services than are available now, closer to where they live at less cost than we're now spending. Success, however, is dependent on three things: (1) restructuring the present system to remove overheard and inefficiencies, consolidating the gains already made by individual hospitals; (2) a reallocation of funding to maintain excellent health care services for children; and (3) developing a health care system for children predicated on health; that is, illness and accident prevention and health promotion.
So we at Sick Kids support restructuring and the provisions -- I believe the jargon is to call them "tools" -- within Bill 26 that will allow this to occur. At the same time, we have concerns about schedule F, health services restructuring, which allows the government to close and merge any and all hospitals into any configuration without further statutory or regulatory change and without the requirement of public discussion. Hospitals would have no right of hearing or appeal.
Therefore, we recommend:
(1) That a time limit be incorporated into this proposal. Although restructuring will be ongoing and not limited, we believe, to the next year or two, there must be some process for these powers by the minister, and by the ministers of Health in the future, to be assessed or reviewed before renewal or extension.
(2) There should be some mechanism by which any given hospital and its constituents could respond before actions are taken that will forever change the nature of the hospital. This process has recently occurred in Metro Toronto through the work of the DHC restructuring committee, where we believe significant consultation was accepted.
(3) If the government intends to appoint a supervisor, a hospital should have fair notice and be given an opportunity to respond in writing to meet with the minister prior to the appointment.
(4) Finally, we ask that the bill be more specific concerning the role of the Health Services Restructuring Commission: how it will be constituted, how it will function and how long it will be in existence. My understanding is, the minister did introduce a sunset clause this morning and we certainly support that. I believe it's a four-year sunset clause and we are in support of that.
The tools in Bill 26 should be considered as loose-tight controls for short-term improvement, not government micro-management of hospitals. Restructuring is just the beginning of a system-wide approach to health care, where continuous quality improvement and positive change should be the norm and not the exception. A reformed health care system should incorporate incentives that reward excellence, while promoting innovation and creativity. Long-term controls will not succeed in improved performance.
In closing, we strongly commend the government for the courage to make difficult decisions and implement needed changes. We further commend the government recommendation to establish hospital crown foundations. The children in this province who require health care services have benefited in the past century from a partnership of government support, private philanthropy, voluntary governance and dedicated men and women. Restructuring would allow what we've built, which is the envy of the world, to continue on their behalf.
We're open for questions.
The Chair: Thank you. We have about six minutes or so and we start with Ms Lankin.
Ms Lankin: I'm not sure exactly which parts of the health bills it is that you support. I understand in general your support for the restructuring that needs to be done and I agree with you on that.
The concerns that you've raised about limits on powers and the role of the commission to be spelled out in the legislation, those are all the same sorts of concerns that the opposition members have raised, and by and large, with the exception of a couple of I think warranted and necessary amendments in this package, the kind of restructuring that we believe needs to be undertaken -- for example, the Metro restructuring report -- can be done without such extraordinary powers being given to the minister.
I'm wondering if you have perhaps a more specific answer to which provisions in the bill it is that you support and believe are necessary in order to undertake the restructuring.
Mr Strofolino: I think that becomes a difficult question. Certainly I'm not an expert in all of the bill, but I would say that in restructuring, in the history of hospitals and the ability of hospitals to restructure themselves, without sufficient power it would be difficult for the government to implement restructuring. We don't believe necessarily that restructuring will take place unless it's moved and motivated by the government in some way.
Ms Lankin: So the powers to merge, amalgamate etc: I'm extrapolating from your answer, but I would think those are the ones that you support, but you're saying there need to be time limits put on those.
Mr Strofolino: That is correct.
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Ms Lankin: The minister didn't table amendments this morning, but he did indicate that he would be providing us with an amendment that would sunset the restructuring commission. But it's clear from his press release, which we were given a copy of -- well, the media provided me with a copy of it -- that it is only the commission that will be sunsetted, not the powers contained in the act. I think that's an area of an amendment that we would need to pursue through this committee process.
In addition to the powers to merge and amalgamate, or direct merging and amalgamating, there is a provision in here that gives the minister the power to make any other direction to the board of a hospital with respect to any matter in that hospital that the minister believes to be in the public interest -- it's very broad and sweeping powers -- and it indicates that the hospital board must implement that direction and it must implement it irrespective of any letters of patent of the hospital, the bylaws of the hospital or any other act.
That goes far beyond the simple merging and amalgamation or closure, and it's not clear what all could be caught under that. Have you reviewed that provision? Does that provision give you any cause for concern?
Mr Strofolino: It does give me some concern in the context of micro-managing a hospital. It doesn't give me a concern when it comes to moving the system forward and bringing about change.
Ms Lankin: So perhaps there should be some controls put on that kind of power and what it's used for.
Mr Strofolino: I think they should be defined. I'm not so sure of controls; I don't like "controls" as a word.
Ms Lankin: Definition or criteria or --
Mr Strofolino: Yes.
Ms Lankin: Okay. When you talk about micro-management of the hospital, there's another area where it talks about hospitals having to have physician resource plans, which I think is a reasonable thing. In that, it suggests that the minister can impose amendments to the plan, any amendments the minister would want. I found that to be a bit startling and perhaps going too far.
I can understand a process of negotiations and approval, but simply the ability to unilaterally impose amendments-have you looked at that and what it might mean for a hospital, particularly like Sick Kids, that has an important academic research role as well?
Mr Strofolino: Again, controls are not what I envision, but clearly the Hospital for Sick Children would indulge in a human resource plan for physicians which would be contingent on our needs, whether it incorporates research, teaching, and patient care. So we would be the ones, I believe, together with our community, in deciding what the needs of the hospital would be and therefore with the human resource requirements of the physicians. I'm not so sure that overriding that particular type of plan makes a lot of sense.
Ms Lankin: You mentioned the need to set out the powers of the restructuring commission in the act, and I agree with you on that. I asked the minister this morning why he didn't do that, and essentially it was to maintain as much flexibility as possible. I'm not sure; I might not have given his answer correctly. It's a long way to remember back.
I'm wondering what you would anticipate being spelled out. What would be helpful? Its relationship to hospitals, to district health council processes, to the other various restructuring initiatives that are under way? What would you be looking for?
Mr Strofolino: Again, as we've stated in our presentation, I believe restructuring is just the beginning; I don't believe it's the end. I think the commission's powers may have to be broader at the initial stages and to ensure that we move forward both on restructuring and continued health reform.
I don't look at this as one point in time. In other words, others may look at this as, once we're done with this, we're back to business as usual. This is the beginning. So therefore, in trying to identify the powers, I don't know what particular powers; I know at the end of the day whatever is going to be needed to be flexible enough to get the job done should be incorporated in those powers.
Ms Lankin: But you did suggest that you believe it should be set out in the act.
Mr Strofolino: I would have more comfort if it was set out in the act.
The Chair: Thank you, Ms Lankin. For the government, Mrs Ecker.
Mrs Ecker: Thank you very much, Mr Strofolino and your group, for coming forward. The Sick Kids hospital has certainly got a reputation which we all are very, very familiar with, whether or not we've been involved in the health care field at all.
One of the things I wanted to ask about was: You have been through, and you've seen many governments go through, trying to get the health care system where we all want it to be, and you've certainly indicated that you support some of the powers, as long as there's appropriate sunset, and we certainly look forward to suggestions that you might have to offer on that.
Just as a quick aside, I do find it slightly interesting that there's concern about the minister's power to order things with hospitals when under the Regulated Health Professions Act, which was supported by all three parties and the last two governments, the minister has the power to order regulatory colleges to do anything that the minister requires. So it's certainly not a new idea.
But just how quickly do you think restructuring needs to happen? We've all seen how frustrating -- I think everybody has wrestled with trying to get it done, and there's a view, from our government anyway, that we believe we need stronger powers to get it done. How fast do you think it should be done or it can be done?
Mr Strofolino: Yesterday. I think it's fair to say that we're beyond the time when it should've been done. We're sort of working from behind the eight ball at this point in time.
Mrs Ecker: The last point: Your hospital has moved into the forefront by establishing an alternative payment plan for your physicians. I wondered how well that was working. I have heard anecdotally from some of the local physicians in my area that they think it has meant -- this is their perception -- that the doctors at Sick Kids aren't working as hard now because they're having more trouble getting people in because they're not on a fee-for-service basis. I was just interested in how well you thought the new plan was working.
Mr Strofolino: I think it's the only alternative for an academic health science centre, number one, because it certainly values patient care as well as research and academic activities. Without it, this institution can't move forward. It will not be what it has been. Two, our ambulatory activity is significantly up over the five-year period in which it was implemented and our paediatricians are working as hard, if not harder, than in the past.
The misconception within the community, I think, has to do with downloading of other hospitals on to Sick Children through our emergency area. Seventy per cent of our admissions now are emergent versus 30% elective. Two years ago it was 50-50. So you can see that more and more emergent are being shipped down to Sick Kids. So the perception's out there. I think that's a little bit of perhaps I might use the word "jealousy," but certainly I wouldn't say that the plan has caused our physicians to slack off.
If you know the basis of an academic health science centre, they're not there for the money. They could be in other places for the money. Some people may not like that, but the fact is that they could make a lot more money being technicians in other hospitals. They are at an academic health science centre because they wish to conduct research and to provide teaching to students from all over the world. That's not really necessarily the drive, but they do need protected time for those two activities.
Mrs Ecker: How do you see the approach that physician specialists have to have admitting privileges or privileges with hospitals in order to be allowed to continue? Do you think that's a good thing?
Dr Alan Goldbloom: I think that certainly is easier to answer with respect to hospitals like our own, which is a highly specialized hospital. I think the future of teaching hospitals is that virtually all of their staff will be full-time staff associated there. In fact that's been in the spirit of the alternate funding plan, and other such arrangements.
Even the physician human resource plans that have been talked about very much coincide with our own direction. We've been working on developing a physician human resource plan so that the physician complement of the hospital is part of that hospital's overall strategic plan in achieving whatever goals the hospital has.
It's a little bit more difficult in particularly some of the primary care specialties which, in some situations, may be able to exist out of hospitals. I suspect that there will be a need to deal with some of those on an individual specialty basis.
Mrs Caplan: I just have a couple of very short questions. Excellent presentation, and I think you would not be surprised to know that I agree with much of what you've had to say around the need to restructure. I've been saying that for a number of years, and the importance of alternate funding plans before you can do that. I believe that unless you can secure income, people will not participate in restructuring.
But I do have some concerns, and I share your concerns, around the powers of the minister. My concern is that while he has said that the restructuring commission will be sunset after four years, do you think that any minister will give up all of those powers that he is amassing in this legislation, considering the fact that it does allow the ministry total and complete and absolute control -- and I'm using the word deliberately -- control over every aspect and facet of the delivery of services? Do you think once a minister has those powers he -- or she in the future, whichever -- will ever give them up, sunset or not?
Mr Strofolino: Without being facetious, I'm not a prophet so I wouldn't dare look into the future. I think, though, at the end of the day clearly if we don't restructure the system regardless of who has the powers, we will all pay. Frankly, the use of the powers, as they are scoped now, without getting into all of them, may be better served as something in the background than actually to be utilized. In other words, utilizing those powers I think will create more problems than just having those powers.
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Mrs Caplan: I think you're optimistic. For example, when it comes to Sick Children's Hospital, I could foresee the day come when the minister would dictate the volumes that you could have -- that is the power that is given in this bill -- where if your board were to threaten to put kids on the front lawn if he didn't give them more money, he would say to the board, "Thank you for your service," and send in a supervisor. Think about it; this is possible. Not only that, but the supervisor would take over responsibilities and duties of the administration and direct that which the minister ordered.
The requirement for human resource plans, not only does he require you under this legislation to submit them, even though we know how fluid they are, but he can override them either by reducing your medical staff complement or by requiring an increase in that complement without providing the necessary funding to go along with it or by ordering it to be reduced as a result of a reduction in funding that is arbitrary and that is possible in the legislation.
I am wondering if you have understood the implications of the powers that he has and how it may affect your hospital and the voluntary governance of your hospital.
Mr Strofolino: I'll go back to my statement again. I believe good management will persevere; I might be optimistic. But, secondly, there's never been a supervisor who has been able to understand and fully manage an institution when he or she walks in. The powers that are conveyed with the minister happen to be one thing. Whether they're capable of managing institutions hands-on remains to be seen.
I said before, we support the powers with the limitation that micro-management is not to take place. Professionals who are close to the patient, who have a sense of the patient, and decentralized decision-making are the key to the future. Hands-on control, as I said, long-term controls are not in my view the solution; short-term, they are. We have to stop the bleeding, and I think there has to be some way of getting the restructuring moving. I look at it within that context.
Mrs Caplan: I agree with what you're saying about the ministry's inability to micro-manage. I think you're absolutely right. The fear that I have is that the accumulation of all of these powers is not only a slippery slope, it poses a very definite danger of arbitrary measures, and in the name of short-term expediency, my own view is that all of those powers are not necessary even in the short term to give you the effected result.
I'm not saying that there aren't some changes that are needed. But I'm wondering if you've looked at it to say, what is really required and what could we say is not necessary in order to achieve those objectives?
Mr Strofolino: I'm not so sure I can say that at this point, because I'm not so sure what set of circumstances are going to arise during restructuring. Right now we're looking at mergers and consolidations as what I see to be the simple part of restructuring. That's merely consolidating the gains made and combining facilities. The longer-term view on changing health care delivery systems will require a lot more complex thinking and a lot more analysis before we move forward. This is just the initial step.
I don't think I want to venture as to what powers should or should not be, and it becomes a problem for me to say to limit this or limit that. I understand the long-term implications, but at the end of the day the public has a right to accountability, and if this is the way the public is going to hold us accountable, then I'm prepared to go ahead with it.
I don't think we should be afraid of being controlled. I'm not afraid of being controlled. I think if we're managing effectively and rationally, I'm willing to sit with anybody who wants to come in take a look at our practices. I'm putting that in front of the public. I see that as one way of being accountable, not one thing to be afraid of or fearful of.
The Chair: Thank you very much. We appreciate your presentation and your involvement in our process.
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
The Chair: The next presenter is the College of Physicians and Surgeons of Ontario, Dr Michael Dixon, the registrar, Dr Helen Gordon, the president, and Dr David Walker, the immediate past president. Good afternoon and welcome to our committee. You have one half-hour to use as you see fit. Any time that you leave for questions will be divided equally among the parties, and the questioning would begin with the government. The floor is yours.
Dr Michael Dixon: Thank you, Mr Chair. Good afternoon. With me today is Dr Helen Gordon, the president of the college, and to her left Dr David Walker, the immediate past president. I'm Michael Dixon, the registrar.
First, let me say we appreciate the opportunity to appear before this committee to address some of the issues in Bill 26 that directly affect the mandate of the College of Physicians and Surgeons of Ontario. The mandate of the college, simply put, is to protect the public and to guard the medical profession. In other words, our concern is for the accessibility, availability and quality of medical services.
It has already been noted by many commentators, interest groups and partners in health care that Bill 26 is vast and complex. We share that view and note that we cannot possibly address, in the short time available, all the ramifications of the sections of the legislation that relate to the mandate of the college specifically or, for that matter, to health care generally.
It is the view of the college that the wording of many of the provisions in the bill is unusually broad and vague. The problem with these provisions is that they are written more broadly than we believe they need to be. As a result, future abuses of these new powers are difficult to predict but are certainly entirely possible.
That being said, what we will do in our presentation today is outline briefly what we see as some of the pros and cons of a limited but important number of aspects of the bill.
First and foremost, we believe that the minister must establish an ongoing public process to deal with what we see as the paramount concern of many Ontarians, namely, the accessibility and availability of medical services, particularly in underserviced areas.
We believe the most appropriate way to deal with this long-recognized issue is for the minister to quickly establish a commission on the provision of medical services. This commission should not be an unwieldy, expensive bureaucracy but rather an unpaid, quick-response advisory body with members drawn from those groups who should be partners in health care.
First on that list should be members of the public from the underserviced communities. The commission should also include representatives from this college, and organizations such as the College of Family Physicians, the Ontario Medical Association, the Centre for Health Economics and Policy Analysis, the Institute for Clinical Evaluative Sciences and the Council of Ontario Faculties of Medicine.
This commission should be tasked to define the needs of underserviced areas, to select the individuals to serve in those areas and, recognizing the urgency of the situation, to submit its best advice to the minister on an ongoing and timely basis.
We don't believe any Minister of Health should act alone to determine either medical necessity or the specific medical needs of various communities, but we do understand the political realities that have resulted in these powers being written into Bill 26.
We believe the minister should make the effort to provide the means, through a commission on the provision of medical services, for various partners with a direct interest in physician distribution to come to the table and be seized with the duty of providing their best advice.
We believe that such a commission can and should find various mechanisms, short of billing numbers, to encourage doctors to locate and stay in underserviced areas. We believe that physicians, like other groups in society, respond better to carrots than to sticks.
Dr Gordon is going to continue with discussion on physician distribution.
Dr Helen Gordon: The recognition of physician distribution as a problem is not, as the committee knows, a new one, nor are some of the possible solutions to it unknown. They include such things as differential fees and various alternatives to the fee-for-service practice.
There are a number of possible incentives that could and should be offered to physicians before the punitive approach of billing numbers, which could be used as a last resort. We're confident that the aforementioned public commission on medical services would be able to produce a broad range of incentives and means of implementing them, and we would be pleased to answer questions in that area after our presentation.
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Attempts to force physicians into underserviced areas with billing numbers will not, we fear, result in the best quality of medicine. No one works well under duress.
Having outlined to you our main recommendation, we'd like to touch briefly now on some other aspects of the legislation and we would like to acknowledge that the college was consulted on some aspects of this bill and some of the recommendations and requests we made in the public interest have been taken into account.
First of all, we've long sought greater access to OHIP information and easier disclosure by the Medical Review Committee to the college itself. As you may know, while the MRC is technically a committee of the college, the majority of its members are appointed by the minister to review cases of allegedly inappropriate billing that is submitted to it by OHIP. The college has been pressing for some time for expanded powers for its inspectors, who are already under a duty of confidentiality, and that too has been addressed. However, we note that the government has also made provision at the same time for its own review process, including appointment of its own inspectors. We wonder about the necessity for, and the advisability of, this parallel authority.
When the Medical Review Committee uses its powers of inspection, it does so for a specific, clearly defined referral from the general manager of OHIP that has arisen from a documented concern. However, under this bill the government could use its powers of inspection without evidence of a prior concern and with no defined scope to the inquiry.
To carry on with some of our other aspects, I'd turn it over to Dr David Walker.
Dr David Walker: Thank you, Helen. Turning now to some of the ramifications for the independent health facilities program of this bill, the committee is no doubt aware that the college has the legislated mandate under the current IHFA to perform quality assessments and independent health facilities. While Bill 26 makes amendments which broaden the definition of an independent health facility and the services that such facilities might provide, it does not at the same time make provision for the college to carry out what we believe are the necessary quality assessments in those newly designated facilities.
For some time, the college has been recommending changes to the current IHFA and we're pleased to note that some of these have been included in the proposed legislation. These are including uninsured services as part of an expanded IHF program, causing IHFs to cease operations if they've been deemed to be operating unsafely, even if the IHF has launched an appeal; not requiring assessors to give written notice of an impending assessment; and the ability to charge IHFs directly for subsequent reassessments if they continue to fail to comply.
So, to the extent that some elements of Bill 26 are attempts by the government to improve the quality of health care, we welcome them.
We believe that the manner in which Bill 26 eradicates government support for payments to the Canadian Medical Protective Association could reduce the availability and accessibility of important medical services. We are not here to justify or defend the CMPA, nor its alleged $1-billion surplus. But surely, if the government is going to go to war with the CMPA over the fee issue, the government should at the same time deal with the much more important consideration of the effects on patients that this dispute will have.
We believe that patient care need not have been compromised had the appropriate steps been taken at the time the government announced its intentions regarding CMPA dues. The fallout from the government's withdrawal from CMPA support was predictable, foreseeable and therefore preventable. The fact that nothing has yet been done to alleviate the impact on medical services to the public is, to say the least, unfortunate.
With the removal of the CMPA subsidy, many physicians will simply opt to stop delivering babies. A family practitioner who delivers babies will find his or her CMPA cost has more than doubled to over $4,000 per annum. The cost to an obstetrician who delivers babies leaps to more than $23,000 per year. Obstetrical services that were once available in some communities will simply not be there when people need them. The same could be said of vital orthopaedic and neurosurgical services. Michael?
Dr Dixon: Let us summarize by saying that we welcome some aspects of Bill 26 as they relate to powers of inspection of the college under the auspices of the Medical Review Committee and the independent health facilities program.
We believe, however, that some of the provisions of the legislation are unnecessarily intrusive and we urge the minister to establish a public process to deal with the access to and availability of medical services in all areas of the province. We believe that the process should include an unpaid commission on the provision of medical services and that the commission must provide the minister with its best advice and specific recommendations on solving the medical needs issues of underserviced areas.
Ultimately, the extensive authority granted the Minister of Health by Bill 26 may well not resolve the deep-seated, multifaceted and widespread problems that the proposed legislation attempts to address. It will only put further stresses on an already destabilized health care system.
Therefore, we believe that what is needed in advance of the imposition of such sweeping powers is a concerted effort to find consensus on the solutions. By consensus we do not mean necessarily unanimity. We also believe there should be a clear understanding that if solutions are not forthcoming as a result of consultation the minister will have to resolve the problems by intrusive means.
In closing, we want to thank you for your attention and urge committee members to do what is in the best interests of the public.
The Chair: Thank you. We've left some considerable time for questions, beginning with the government. We have about six minutes each.
Mrs Johns: I'd like to thank you all for coming here today. We appreciate your time and your insightful comments. I just wanted to talk about a couple of issues that you've raised, the first being the commission. It's my understanding that the college has been part of discussions in committees for several years that have wrestled with the issue of underserviced areas. Some of those discussions have come up with reports and others have provided us with no real solutions.
The last government prepared the Scott report, and I'm sure you're familiar with it, which our government is prepared to implement, and we have started to do that as we've proceeded through. Why do you believe we need another group or another study which will be able to solve the problem any better than the documents we have already in our hands?
Dr Dixon: We're not proposing that this be another study. We propose this be an operational committee to achieve the objectives that the government has set. I think what is different now than in the past is that there is a clear determination on the part of this government, and I might say quite appropriately, to deal with this problem. Secondly, there are the means to do it in this legislation. However, I think there are opportunities to do this in a more effective manner and that the college would like to be a party to that, recognizing that if at the end of the day -- and a time should be set -- that solutions are not forthcoming, then the minister will have to take whatever action he deems fit in the circumstance. But there is the opportunity for collaboration with the partners in health care now that there's a clear determination and a clear threat of action.
Dr Walker: If I might add to that, the solutions I believe are already there. We now see the will to do something about this. I'm in communication directly where I work with younger physicians, the physicians of tomorrow. They tell me that if they're made to go north they'll go south, but that there are clear incentives which are already recognized that would make them go to places that they're needed to go to. So there are intermediate steps which would require the will of a number of different players in order to achieve what are very worthy objectives, which I certainly applaud and I think most physicians would applaud.
The answers are actually easily available. They're a step short of indenturing physicians which will achieve them.
Mrs Johns: The minister has this power of course in the act but has said that he will not use this power for a period of time to allow doctors, physicians, a number of different people, to come together and give us a different approach than to just freeze billing numbers. Will that not solve the same kind of issue that you're talking about here? Is that time frame not what you're looking for and has the minister not already said he will do that?
Dr Gordon: Perhaps if I could just comment on that. I'd like to comment on two aspects of your question. I think it's important to remember that the solution to physician resource management in a province like Ontario is a very long-term program. Starting with undergraduates to having someone serve a community is more like a 10- to 15-year period, so any solutions that are going to come up are going to need to be consultative at a number of levels. This is not something you can do as a quick fix. Therefore, the advice needs to be formalized in a way that the exchange can happen, that it can go on. There needs to be some way of having that consultation.
If I could just comment on the powers to the minister, one is quite prepared to believe that the current minister might not use these except under the most extreme circumstances, but when one establishes very broad powers in legislation, one has to remember that one doesn't always control that use of power, and once it's established, it's available.
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Mrs Johns: I was just interested in your comments on the CMPA. Coming from an accounting business background and a husband in the insurance business, I am always concerned about actuarial requirements and how funds are set up. It's been drawn to my attention that our fund has grown at a faster rate than in America, that we have $1 billion in reserves. I'd just like you to comment on the actuarial validity of the CMPA and how it came into existence, why it's there.
Dr Walker: I'm sure just as you and your husband probably wouldn't comment on the diagnosis of one of my patients, I'd hesitate to comment on the actuarial validity of the studies of the actuaries that the CMPA hires, except to say that my understanding is that they hire the best and that the best actuaries say that's the amount of money they need to pay to the people of Canada who are successful in liabilities against physicians. I don't know whether that's true or not, but it's the best estimate that I have.
I would like to say, however, that if the government, rightly or wrongly, chooses to get out of those subsidies -- and I, as a physician, have no objection to that. In fact, I think it's a good thing to get out of. Giving me 24 hours' notice between hearing about it and having to write my cheque for next year was probably not the best planning vehicle. It led me to make decisions rather abruptly that might have been made over a course of time that was a little more productive for the people of Ontario. So I think the time frame is as troubling as anything. I can't comment on the actuarial validity.
Mrs Caplan: Thank you very much for an excellent presentation. There's nothing here that I disagree with, but there are a couple of areas I would like to explore.
On the consultation, you make a point of saying that you were consulted on some of the aspects and areas. Did the minister share with you what in total he was proposing to present, and did you have the opportunity, as a partner, particularly a partner who has the public interest mandate, for the kind of consultation you felt was adequate?
Dr Dixon: No, we did not.
Mrs Caplan: On the issue of CMPA, did you warn the minister? Were you aware? It was out in the press that he was considering it. Did you let him know -- I was going to use the word "alert" as opposed to "warn," but I think "warn" is the right word -- what might happen if those doctors practising in areas where they were going to see massive fee increases, regardless of the validity of the actuarial studies and all of that, what would happen to patient care? Was he aware of that before the decision was made?
Dr Dixon: I personally communicated with the minister's office. I did not communicate with the minister directly; I could not reach him. But I did make very clear to an official what the college's view was of the implications of this move, not disagreeing with the policy but the way it was being implemented, as Dr Walker says, on very short notice.
The issue is not whether the CMPA is right or wrong; the issue is that obstetricians are faced as to whether they're going to continue having to deliver 100 babies for nothing to make up the incremental cost. That's the issue. That has to be addressed in a variety of different ways.
Mrs Caplan: I agree, and the issue is are patients going to get the care that they need.
I agree, by the way, with the enhanced powers for the Medical Review Committee and the inspectors on behalf of the college. Were you consulted about the minister's intention to be able to appoint his own inspectors and have a parallel process?
Dr Dixon: Yes. We were aware that that was the proposal they had been contemplating for some years. We have spoken against it. We don't think it's necessary or particularly helpful to have non-medical inspectors seizing medical records and then trying to make some sense out of them and determine whether they should refer them to the Medical Review Committee. If they feel that there's some concern about the physician's billings, they should refer it to the Medical Review Committee. They have expanded under the last government the role of the Medical Review Committee and the support for it. We anticipate that it will be far more effective, particularly with this new legislation, than it has been in the past, so why not use it? Why complicate the matter with another set of inspectors who are going to try to second-guess the qualified medical inspectors?
Mrs Caplan: My last question is for the very excellent proposal that you make of an ongoing administrative body, and the name that you've chosen is fine. As I understand it, there are existing bodies under the acronym of PCCCAR and others where most of the partners are at the table already with the exception perhaps of some public representation. Could that not easily be transformed into the type of body you're suggesting so that there would be the opportunity for the public process rather than the arbitrary nature of the powers the minister is taking unto himself? Is that what you had in mind?
Dr Dixon: The point I would make about PCCCAR and its various subcommittees is that their term of reference is for a longer perspective on the planning for health and human resources over time. What I think we need now is action. We have a government that clearly is determined to deal with the problem. It is seizing unto itself significant powers to achieve that. I think there's a clear will on the part of the various partners to recognize that and to deal with it. What we need is not more long-range planning; it is more short-term implementation and get on with it. We've been talking about health and human resources for as long as I can remember in this province.
Mr Bartolucci: Doctors, any one, the minister this morning spoke of the tools he wanted to develop to manage doctors. You've said that you've had limited discussions with him. What tools did you suggest to him to manage doctors that you do not find in Bill 26?
Dr Walker: I don't believe we suggested any to manage doctors, to be honest. Our mandate is to protect the public, and so we've been advising, when asked, on various issues to do with particularly the Independent Health Facilities Act and other parameters, ways in which the public interest would be served. I think it's really between the OMA and the Minister of Health and the Ministry of Health to manage doctors. We do have concerns, having been asked now and having the opportunity to be here today to express our views about the implications of some of the more extreme powers that have been proposed in this, in that we would firmly believe that some modest powers and some incentives for change could be achieved quite simply. I believe that's the appropriate answer to make.
Mr Bartolucci: Just one other: I'm still bothered that the minister and the ministry would want to appoint its own inspectors. What do you think the underlying reason is for this appointment of its own inspectors?
Dr Dixon: I can only speculate. I think in the past the minister, and certainly it's been shared by the college, has been frustrated by the slowness of the MRC process, and that was directly related to the inadequacies of the Health Insurance Act, and finally we now see some opportunity for amending that act and giving the necessary authority for the college inspectors and the Medical Review Committee, which are appointed by the minister on the recommendation of the college, to deal with the issues and to deal with them far more expeditiously than in the past. We were frustrated by the delays that were possible under the existing legislation.
At that time, I think the ministry felt that by having its own inspectors, it could do some preliminary reviews and shake out really the ones they wanted to refer to the Medical Review Committee. I personally don't think they can accomplish that, and as I said earlier, if they have concerns, they should simply refer the matters. We now have the capacity to do at least 100 reviews a year and we'll probably be able to increase that as we have the effectiveness of this new legislation.
Ms Lankin: Let me pick up on that point. You had indicated that you knew the ministry was looking at this type of proposal for appointment of their own inspectors over the last number of years, and in fact you're quite right. This is a proposal that's been kicking around on the shelves. It's one which certain people within the bureaucracy, the Ministry of Health, find very attractive, and it has been put forward to a number of ministers, who after extensive consultation with a number of groups, yourself in particular, have rejected that and have understood, or at least have accepted, the argument that the Medical Review Committee, beefing up the role of the Medical Review Committee, and as we see some good aspects of this bill, some of the powers of the inspectors, is the more appropriate way to go.
A lot of concerns are raised around the access to information, the privacy and disclosure of information, the appropriate decision-making of a non-medical review officer and someone within the ministry, and in general the administration of OHIP and some of the decision-making that may go on outside of the Medical Review Committee.
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You also raised concern about duplication and parallel effort. Could you tell me from any of your discussions or consultations with the minister, what reasons he has given you for deciding this time to take this long-standing ministry bureaucratic desire and to put it into the legislation? What reasons has he given you for rejecting your very strong cautions against that?
Dr Dixon: I'm not aware of any discussions that have taken place with this minister or preceding ministers in respect to this particular issue. We've been talking about these issues entirely with staff in the ministry and in the OHIP administration.
Ms Lankin: I can certainly inform you that discussions that were taking place made it to my desk, for example, in terms of a previous review of provisions, and in fact those changes didn't make it into the changes that my successor brought forward as a result of policy decisions that were taken.
But you're indicating that there has been no discussion with you then at the ministerial level with respect to these new inspectors and what their role and relationship would be vis-à-vis the Medical Review Committee.
Dr Dixon: I can say that very confidently in the recent past; I can't say that over the course of 10 years because I simply can't recall.
Ms Lankin: No, I'm talking about this minister.
Dr Dixon: Certainly not with the last couple of ministers.
Ms Lankin: You've also talked about the establishment of a commission on the provision of medical services, and I'm interested, you describe this as a job that needs to get done. We need to have the partnership process there, something where the minister would be exercising these new and very extensive powers he takes on to himself in conjunction with partners that would be out in the field.
It sounds to me a little bit like the rationale the minister gave us with respect to the establishment of the Health Services Restructuring Commisssion, a commission which he sees being time limited, four years, and there'll be a sunset review clause so it might be sunsetted. Would you approve the addition of a provision for a commission of the provision of medical services within the legislation, to be a vehicle for both provider and public input into the decision-making or the implementation of the powers the minister has taken?
Dr Walker: It's a simple question with many ramifications. I'm not sure I'd say yes or no to that, but certainly the ability of all the parties involved, with some enhanced powers of government to effect the distribution, the retention of physicians and dealing with many other issues for that matter, would be helpful.
At the moment, there are many organizations with long- and short-term goals. There has been no legislative power to make changes. There are, we believe, four or five fairly simple approaches to redistribution of physicians which would solve the problem, particularly along the lines of preferential entry or re-entry to subsequent training, which certainly appeals to those younger colleagues who would be interested in that sort of thing.
That sort of discussion, though, requires the input and the agreement of those who train physicians, those who represent physicians, those communities that need physicians and those who have some expertise in the requirements of communities for physicians. Therefore, we believe if those groupings could be gotten together, we would see some fairly rapid outputs in terms of substantial and meaningful plans to redistribute physicians appropriately.
Ms Lankin: This is more a technical question and I'm actually trying to understand some of the changes in the act in terms of what it means for the working of OHIP, the general manager and his decision-making powers, and the Medical Review Committee and the college. I genuinely don't know the answer to this.
The manager appears to have newer, broader powers to determine on his own whether or not he will make payment for services rendered, and a number of criteria for which he can reject a payment, one of them being, in his opinion, that it was not medically or therapeutically necessary. While that's subject to review by the Medical Review Committee, I'm not sure how that fits into the scheme we have today. It makes me nervous that the general manager would be making a determination up front about whether something is medically or therapeutically necessary. That seems to me to be something that's more in the purview of the college, with respect to the practice of individual physicians.
Dr Dixon: I agree with your interpretation. That would appear to be the intent of the legislation, to give the general manager that authority. We too are concerned and somewhat puzzled about how he or she might exercise that authority. Presumably, they would rely on their inspectors to provide information which they would then review with medical experts to see whether the services were indicated or not.
That has really been, since 1972, the role of the Medical Review Committee: to determine medical necessity and whether the services were appropriately billed etc. I think the general manager is really trying to prejudge the Medical Review Committee because if he makes a substantial recovery -- he would make the recovery -- the physician has the right under the legislation to request a referral to the Medical Review Committee to have the matter in essence reviewed by that committee.
I'm not sure what is achieved, because I'm sure any physician who was subjected to a significant recovery would exercise that option. There would be nothing for him or her to lose. The practice has been over the years for the general manager and the medical officers in OHIP to recommend to physicians that they don't think they'll pay for a given service, and if the physician doesn't object then they don't pay for it if it's a matter of some judgement. But certainly the rule has been and the legislation provides currently that if there is no agreement, it has to go to the Medical Review Committee.
I think what is proposed is that there be more involvement of the general manager earlier in the process and I don't see how that's going to work, quite frankly.
The Chair: Thank you very much. We appreciate your attendance here today and being involved in our process.
The committee stands recessed now until 6 o'clock.
The committee recessed from 1647 to 1801.
OLDER WOMEN'S NETWORK
The Chair: It's 6 o'clock. Our first presenters this evening are from the Older Women's Network. Frances Chapkin is the chair. You ladies can have a seat. Oh, and Ethel Meade and Grace Buller. Welcome to our committee. You have half an hour to use as you see fit. Any time you leave at the end for questions will be divided evenly among the three parties, and we would be starting with the Liberal Party. That would be the order of questions. So the floor is yours. Carry on, please.
Ms Frances Chapkin: I'm sorry everybody isn't here, because what we have to say is very important. Hopefully the presentation will be read by the others who aren't present.
The Older Women's Network of the greater Toronto area works to achieve a caring society in which older women have the opportunity to live in security, with dignity and to realize their potential. OWN is a voice for older women in our changing, diverse Canadian society which challenges agism, sexism and racism. It is an advocacy organization of 400 women which seeks to overcome injustices and inequities in the home, in the workplace and in the larger society. This voluntary group of senior women advocates on issues of concern to seniors and to all generations.
Grace Buller, Ethel Meade and Frances Chapkin, co-chairs of this organization, are here today to strongly express our views regarding schedules F, G and H of Bill 26, a bill that significantly alters more than 40 Ontario laws. We are concerned about the extraordinary powers it gives to cabinet, as well as the undemocratic way in which the government has attempted to pass this legislation -- without public input or adequate parliamentary debate.
I could add that we only obtained a copy of the bill a few days ago and were informed Friday of today's date for our presentation. We would have preferred not to have prepared this in haste and not just the week before Christmas. But speed and little or no public consultation seem to be the style of the present government. We hope these hearings are not just window dressing and that what we submit to you will be seriously considered.
We shall now present our case as to why the proposed health amendments are harmful to the lives of older women and must be withdrawn. Amendments regarding health should be presented in an independent bill, with due debate and public consultation prior to enactment.
Ethel Meade will address our concerns regarding schedules F and H, Health Services Restructuring; Amendments to the Health Insurance Act and the Health Care Accessibility Act. Then Grace Buller will address our concerns regarding schedule G, dealing with the drug benefit act and prescription drug cost regulation.
Ms Ethel Meade: Without lessening our objection to the manner in which Bill 26 has been introduced and the nature of its sweeping powers, I want to comment particularly on schedule F, entitled Health Services Restructuring, and schedule H, Amendments to the Health Insurance Act and the Health Care Accessibility Act.
Health services restructuring: Older Women's Network has followed with interest and actively participated in consultations with the Metropolitan Toronto District Health Council's hospital restructuring committee. We are aware of the plan produced by that committee after many months of deliberations and consultations with both professionals in the health care delivery system and with interested citizens. The restructuring plan, approved by the district health council and presented to the Minister of Health, includes strong recommendations for the substantial enhancement of community-based care and the increase of long-term-care facilities as a precondition for the closing and merging of hospitals.
We know that the committee has also recommended a hospital restructuring authority with the power to implement their plan and override, if necessary, the objections of any hospital unwilling to close or merge with another hospital as prescribed. These implementation proposals sounded quite draconian, but they had some justification in the evident need to close some hospitals and fill up others, rather than to continue the expensive operation of all existing hospitals with their hundreds of closed-down beds.
The provisions of Bill 26, schedule F, appear to have been inspired by the DHC's hospital restructuring authority. But Bill 26 is a far cry from that recommendation, which was for a time-limited authority, working at arm's length from the ministry to carry out a specific and long-deliberated plan. Schedule F, on the other hand, proposes giving to the Minister of Health unprecedented, unlimited and wholly arbitrary power over every hospital in the province.
Until now, the Minister of Health has had the power to give financial aid to hospitals under publicly proclaimed regulations. Under the new section 5, any "grant, loan or financial assistance" to hospitals is at the minister's discretion, according to what he deems to be "the public interest." He may pay or not pay, or impose conditions on payments or reduce the rate of payment as he sees fit.
Under the new section 6, the minister may instruct a hospital to cease operating, or two hospitals to merge or any hospital to terminate a specific service or to provide a specific service or to increase or decrease the volume of any specific service. To make sure that the minister's power is adequate to his needs, we have subsection (5) which allows him to make "any other direction related to a hospital" that he considers in the public interest.
The power to appoint one or more persons to investigate and report on the "quality of management and administration of a hospital" and/or the "quality of care and treatment of patients in a hospital" has now been broadened to include "any other matter relating to a hospital" that is deemed to be "in the public interest."
With no indication of any connection between the report of an investigator and the appointment of a supervisor, the new section 9 greatly expands the role of a supervisor appointed by the Lieutenant Governor in Council. Reporting to and carrying out every direction of the minister, the supervisor may now exercise all the powers of a hospital's board or, if it is a corporation, of the corporation, its officers and its members. Ontario hospitals are, under this bill, to exist at the grace and pleasure of the Minister of Health.
Finally, subsection 9.1(1) states that in defining the public interest the minister and the Lieutenant Governor in Council may consider "any matter they regard as relevant." In other words, cabinet will determine what the public interest is in regard to each and every hospital in the province.
Among the examples of what the minister may consider in defining the public interest -- though he may consider anything -- is the availability of financial resources for the management of the health care system and for the delivery of health care services. We understand clearly that the availability of resources is entirely a matter of priorities. The Minister of Health may well find less resources available for health care because more are needed in order to cut the income taxes of the well-to-do. Of course he may have, for the moment, more common sense than to do that, but there is no safeguard in Bill 26 against such political decisions.
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It is hard to believe that in what we thought was a democratic society a government could propose to arrogate to itself what even the government's friend the Globe and Mail calls "unconstrained power." What have been cited so far are by no means all the powers that are to be vested in the Minister of Health alone, as we will see in looking at schedule H.
With all these powers there is no suggestion that the minister must, in exercising them, seek relevant advice. He might, though the bill does not suggest it, seek advice from such bodies as district health councils, with their call on the volunteer expertise of a variety of health care providers and interested consumers of health care services. He may feel, of course, that he needs no advice -- he knows what is good for us. Or he may, in his wisdom, seek what advice he chooses. Plenty of advice will no doubt be available to him from American insurance companies, for example, and other American corporations now profiting from the providing of health care south of the border.
That he may already have heard advice from such sources is suggested by part IV of schedule F, amendments to the Independent Health Facilities Act. These lengthy amendments seem to contemplate considerable expansion of independent facilities licensed to charge a facility fee over and above what they will receive from the government for insured services. A facility fee is defined in the new subsection 1(1) of the act. It means:
"(a) a charge, fee or payment for...a service or operating cost that,
"(i) supports, assists and is a necessary adjunct...to an insured service, and
"(ii) is not part of the insured service, or
"(b) a charge, fee or payment for...a service or class of services designated by the minister...."
We used to call this extra-billing. Is this not exactly the kind of arrangement that the federal government has recently declared out of bounds in Alberta?
Disregarding the Canada Health Act, the government clearly intends to license, as it sees fit -- in the public interest, of course -- independent facilities charging extra fees. The conditions for such licensing are spelled out, including the authority for the minister to request proposals for the establishment of independent facilities. He is not even required to ask for tenders, but may simply send "a request for a proposal to one or more specified persons." This is quoted from amended subsection 5(1). In the amending of subsection 6(3), what has been eliminated is the requirement, in considering proposals, that preference be given to non-profit Canadian persons and organizations.
What we have in schedule F is a greatly enhanced power to close hospitals and a greatly enhanced power to license independent fee-charging facilities. In some circles this is known as two-tier medicine, though common sense probably forbids the use of this term. All promises by the government to preserve the Canada Health Act ring hollow when one reads what is proposed in Bill 26.
And this direct attack on the principles of the Canada Health Act has been slipped into an omnibus bill that creates three new acts, repeals two acts and amends 44 other acts. We are opposed to both aspects of this attempt to undermine the Canada Health Act: both the arbitrary power to close public hospitals and the equally arbitrary power to invite private American or any other profit-making corporations to open licensed fee-charging facilities in Ontario.
Amendments to the Health Insurance Act and the Health Care Accessibility Act: Under these amendments, the definition of insured services has been modified in significant ways. Subsection 11.2(1) defines them as "prescribed services of hospitals and health facilities" and "prescribed medically necessary services," but with a new condition: The services have to be rendered under such conditions and limitations as may be prescribed. In other words, the government will be free to determine whether medically necessary services are actually insured services or not.
Even more ominously, subsection (4) states that such services as may be prescribed are insured only if they are provided to insured persons in prescribed age groups. What conditions and limitations the Minister of Health may choose to prescribe no one can guess, but we are bound to wonder if "prescribed age groups" means something like no bypasses after the age of 70, or if you have Alzheimer's, why bother to treat your pneumonia? The possibilities are limitless, and what they suggest is the slippery slope to a final solution of the problem of what is sometimes called the burden of an aging population.
I am not saying that the government had such ideas specifically in mind in drawing up these amendments, but there is nothing in Bill 26 to prohibit such prescriptions. Nor is there any way to know how the very knowledge that such power has been included in the bill will affect the actions of health care providers. Under ever-increasing pressure to cut costs and get patients out of hospitals, will they informally begin to make such value judgements themselves? Will they ask themselves, "Is this old geezer worth saving?" "Should we bother doing anything for that old bag?" We ask, is this provision not a violation of the charter as well as of basic human rights?
The new section 18 of the Health Insurance Act sets forth the conditions under which the general manager may refuse to pay an account submitted by a physician, practitioner or health facility. One of the conditions is that "he or she has reasonable grounds to believe that all or part of the services were not medically or therapeutically necessary."
This provision has more than one implication. A family physician may refer a patient to a specialist because he or she believes the patient may have a serious condition. If the specialist finds that the suspected condition does not exist, is the family physician liable for the specialist's fee?
More threatening, from our point of view, is how this can affect palliative care -- for HIV/AIDS patients, and in fact for all who are dying. Are medical interventions for their comfort therapeutically necessary? Or are they just a frill for which the minister deems there are not enough resources?
We are all the more disturbed by this new stipulation because it appears to be an attempt to modify the concept of medically necessary services. Since this has become one of the theme songs of those who think we can no longer afford the Canada Health Act, we are opposed to it on principle. Whittling down the services that are insured under the Health Act is another route to two-tier medicine. Those who can afford it will begin to buy insurance to cover whatever the Health Act no longer covers. Nothing could please Liberty Mutual more. And nothing could be more harmful to the five principles which have made our health care system the envy of the world.
Two other matters are all we have had time to consider in preparing this section of our presentation. The first is the proposed annulling of the long-established right to privacy of medical records. This is completely unacceptable. The second is the authorizing of an administrative fee of up to $150 which hospitals may charge to patients. This violates the Health Act, as well as any sense of social justice. Does this government really believe that everybody can raise $150 if necessary, just like everybody can have a cellular phone in his or her car? There are people in this province who are poor, who may not be able to pay the rent and feed themselves. And there are more such people as a result of actions the government has already taken in the months since it came to power. Now, if they are hospitalized, are they to face an additional burden?
Mr Chairman, while we appreciate the opportunity to appear at this hearing and present our views, we do not find these scanty last-minute hearings adequate for the consideration of such drastic proposals as those contained in schedules F and H. The omnibus bill should be withdrawn and the proposals regarding health presented in an independent bill, subject to full debate in the House and full opportunity for interested citizens and organizations to prepare their views at extended public hearings.
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Ms Grace Buller: I'd like to deal with the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act.
Under the proposed amendments, senior citizens and social assistance recipients will be required, as of June 1, 1996, to pay user fees. High-income seniors, defined by the government as those earning over $16,000 per year, $24,000 for couples, will pay the first $100 in prescription costs and, after that, the dispensing fee of $6.11 for every prescription they have filled during the year. Low-income seniors -- those with less than $16,000 -- and social assistance recipients, residents of nursing homes and homes for the aged, will pay a $2 copayment for each prescription.
The Common Sense Revolution states that "aid for seniors and the disabled will not be cut," and "there will be no new user fees." Bill 26 has broken this promise in its attack on the present Ontario drug benefit program.
User fees restrict accessibility and create a two-tiered health system -- one for those who can afford it and one for those who cannot. The most serious problem with user fees is that they will penalize the least healthy and often the poorest in society, for they often discourage people from seeking the help they need. This can only lead to greater costs in the long run, with an increase in hospitalization cases.
Under the proposed amendments, the Minister of Health is given the authority to take price into account in determining whether a drug product is listed as a benefit. In other words, if the medication your doctor thinks you need is too expensive, it can be delisted, and you will have to pay the whole cost as well as the dispensing fee. At the same time, it is provided that there will be no restriction on the markup that the minister pays on drug prices. Drug companies can raise their prices as they choose and the minister can delist as he chooses. It's the patient who pays.
The thrust of these amendments is underscored by the changes to the Prescription Drug Cost Regulation Act and the Drug Interchangeability and Dispensing Fee Act. The amount to be charged for a drug will no longer be regulated. Costs will rise for non-senior consumers and may well increase for the listed drugs for which the government pays, thus diminishing total health care resources. And Ontario will become the only province in Canada that does not regulate drug prices. Further, the government will no longer pay the difference between a brand name and a generic drug, even if the physician has clearly defined reasons for specifying the drug he chooses.
With the reduction of welfare by 21.6%, the possible loss of rent control and the inability of welfare recipients to feed themselves now on their present income, this further erosion in their benefits may be the direct cause of deaths in this province. We call on this government to stop its cruel and inhumane policies of harming the old, the sick, the poor, as well as women and children.
Ms Chapkin: In conclusion, we believe that if the amendments in schedules F, G and H are enacted, they would lead to a user-fee, two-tier health system, one for the rich and one for the poor. Until now, we believed that under the Canada Health Act that would be impossible. We do believe that a number of the proposed amendments are in outright violation of the Canada Health Act.
Other schedules in Bill 26 give permission to municipalities to introduce new taxes and user fees which will add additional financial burdens for older women, particularly those living on fixed incomes. Some 60% of older women living alone are living on guaranteed income supplements: $11,000 a year.
Maintaining a healthy lifestyle and being able to afford additional medical expenses will be next to impossible for them. Where will these older women end up? Either requiring costly hospitalization, being warehoused in institutions or dying prematurely. We hope the fate of older women now and in the future will not be the one this bill would create.
Bill 26 is an ominous, draconian bill. Its schedules F, G and H would signal the end of a legitimate health care system. It must not be enacted.
Thank you for hearing us. If you have any questions, we're available.
The Chair: Thank you. We have a very short period of time for questions, a minute each.
Mrs Caplan: I'll be very brief. An excellent brief. I'm aware of the important work that you've done and that you continue to do. I'd ask, were you consulted by the minister on any of the implications of this bill as an important consumers' group that represents older women?
Ms Chapkin: No.
Mrs Caplan: There was no consultation at all. Are you aware that the government wanted this bill by now, by the time the House rose, before Christmas?
Ms Chapkin: Yes.
Mrs Caplan: Thank you for coming today. Anybody else?
Mr Curling: I just want to comment that this would be law without any participation. It's an excellent presentation, and the opportunity for you to present this, I hope, is an eye-opener and some common sense will come to them.
Mrs Caplan: Thanks for coming.
Ms Lankin: Let me add my compliments to those of my colleagues for your presentation. It is very thorough. I am impressed with how much you have been able to cover in the short time that was available to you to do the analysis. I found myself again yesterday going through the act finding additional provisions and trying to relate back to the original bills and understand what it was all about.
You've answered Ms Caplan's question that you weren't consulted at all. I guess the next question would be, in the short time we have, what would you like to see happen? You've said that these schedules should not be enacted. I'm asking, I guess, are you looking for amendments or are you suggesting these bills should just not be enacted?
Ms Meade: We're suggesting that the health sections of this bill be presented independently, together, as a health amendment bill of whatever kind and be treated like a normal bill, with debate in the House and with public hearings and so on.
Ms Lankin: And with some time, of course, to understand all the elements of it.
Ms Meade: And of course with some time, right.
Ms Chapkin: That's what the second-last paragraph of the introduction states.
The Chair: A quick question from the government.
Mr Clement: I thank you for the amount of time you've put into your presentation, although I must say for the record that I disagree with almost all of it. But that's what the committee process is all about.
Let me just focus in on the drug benefit plan, because you've said some strong things about that. Every other province in the Dominion of Canada has introduced cost-sharing for their drug programs. Is there anything special about elderly women or older women in Ontario that should militate against them being under the same regime?
Mrs Caplan: Harris's promise.
Mr Clement: Mrs Caplan, please.
The Chair: Let the ladies to answer the question.
Ms Buller: Every other province in Canada does regulate drug prices. If this bill were implemented, then presumably drug prices would rise dramatically. Therefore it would be very harmful if drug prices rise dramatically.
Mr Clement: Do I have time for a supplementary?
The Chair: No, that uses up all the time. Thank you very much. We appreciate you being involved in our process. Good evening.
SURVIVORS OF MEDICAL ABUSE
The Chair: The next presenter is Sharon Danley, representing Survivors of Medical Abuse. With Sharon is Velma Demerson. Good evening, ladies, and welcome to our committee. You have a half hour to use as you see fit. Any time you allow for questions would start with the New Democratic Party. So the floor is yours.
Ms Sharon Danley: Thank you for the opportunity that was presented by the alternate people to help us come here and speak today. Having just received part of this bill on Saturday and due to the inadequate time constraints, one needs to review this ominous bill properly. We hope you will appreciate any lack of bureaucratic expertise or anything like that in this presentation.
We would also like to state for the record that we are downright appalled over many aspects of the bill that we've been able to scan and are genuinely afraid for the future of Ontario and its peoples.
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The proposed measures in this bill encourage cause for massive alarm. Too many wars have been fought, lives given and tears shed to have all that's been achieved offhandedly tossed out in order to support this present government's political state that is just plain hurting people. But to attempt to ram this bill through undermines the democratic process and we condemn it as fodder for more legal abuse of a democracy.
Because our unfunded group hasn't the wherewithal to acquire legal expertise nor the time to even sift and absorb this proposed legislation, I will only respond in layperson fashion, so please bear with me.
One major area of concern for many, many women is the proposal that the Minister of Health would be given the power to "collect, use and disclose personal information for specified purposes and to enter into agreements for the exchange of personal information for specified purposes."
It is obvious to us that much is lost in bureaucracy, financial decision-making, legalizing bills and so on. We need to incorporate a view through other windows when addressing this bill. There are millions of women, girls, grandmothers and many who are disabled, marginalized and elderly who have experienced all kinds of violations just for being women and who also seek therapies of choice to heal themselves.
It is painful, but I will repeat something I presented to this Legislature in November 1993 to the standing committee on social development regarding Bill 100.
Personally, I have experienced a sexual assault by my son's paediatrician and sought redress before the College of Physicians and Surgeons. I was brutalized and revictimized in countless ways and developed several post-traumatic problems as a result. All of this was caused because my personal medical records were disclosed to my perpetrating physician in an attempt to defend himself on insidious, private, unrelated points. I can't calculate the cost to me and my family for this intrusion and betrayal of trust.
There are many women who have experienced this kind of legal and immoral abuse by having their records opened for view under the guise of legal rights. This proposed legislation openly condones continued violence against us. It sends a loud, clear message that women will not only continue to suffer violence, but the Ontario government will put its stamp of approval on it, allowing medical records to be opened by the Minister of Health, who, with much respect, is a bureaucrat not trained in psychiatry or medicine. And once again with respect, I question his office's knowledge on women's issues.
Ladies and gentlemen, you must know how much information is out there to support what I am saying. Anyone with the simplest mind can calculate that violence increases health costs. You are sending double and triple messages in this bill. There is no common sense about it.
We see this tactic as yet another attempt to flame the fires of witchhunts and other forms of fem brutality that have historically been thrust upon us. The fact that a government would even consider such a vile intrusion into the rights of women, and all people for that matter, to have trusted, confidential therapeutic relationships is not only unconscionable, it is terrorism at its worst and against all that democracy and human rights stand for.
On the other side of the coin, this same government proposes to gut the Freedom of Information and Protection of Privacy Act and structure things in such a way that allows it to operate in secrecy, without accountability. This government shows its true colours and its collective misogyny when it considers such wretched legislation. Not only is this blatant dictatorship, it is shameful.
In several sections of this bill we find the theme statement, "if the minister is of the opinion that it is in the public interest to do so." This is dangerous, as he then has the right to do whatever he wants. Where does the minister get such expertise to make enormous decisions without public input, especially when it affects us all on a mass scale? What does "public interest" really mean, in plain language?
Many in our group believe there is far too much drugging of women, and people in general. Let's face it: The multibillion-dollar drug industry has a vested interest, supported by allopathic medicine, to keep Ontarians drugged, and what better way than to define violence against women, inequity, sexual assault, emotional battering and a whole host of other abuses as psychiatric problems that need drugging in order to medicate pain? God forbid holistic, indigenous spiritual ways, women's right to birth as they wish, and alternate therapies of choice be relied upon for healing and would speak loudly to cutting costs. This would threaten their obscene profits and power over our lives. This is just another way to get rich on the backs of the marginalized, as we see it. Further, we demand to know why these alternative forms of health care aren't recognized under the OHIP system. It certainly makes common sense to millions of us that they should be.
However, we do recognize the need for drugs in other instances. My own son wouldn't be alive today had it not been for specialized medicine and drugs and health care people with a work ethic that today I bow to. My daughter's severe epilepsy relies heavily on drugs and new technologies, but to bill the marginalized under the highly marketed need to bring down the deficit is again an unconscionable act. We need far more time and public hearings and a separate bill on this issue.
This government and the public are concerned with abuse of OHIP. Our group knows of numbers of doctors who while sexually assaulting their patients were collecting from OHIP for services rendered and in many cases were invoicing for services they never rendered. This is clearly doctor fraud. A simple solution, as we see it: Have the patient sign a receipt with the specific health services rendered, and the attending physician, patient and OHIP would all get a copy. This puts power in everyone's pockets.
This government's activities are threatening our health and wellbeing through its policymaking. Surely you can find creative, effective ways to deal with our financial constraints which are much more equitable and humane, rather than rob from the poor to give to the rich. Where is Robin Hood?
Thank you for the opportunity to speak, and we welcome any questions.
The Chair: Thank you. We have about six minutes per party, starting with Ms Lankin.
Ms Lankin: Thank you, Ms Danley, for your presentation. I did follow the hearings on Bill 100 and I remember the contribution that you made on behalf of your organization and admired the bravery it took to share your own personal experiences with the committee.
I understand from listening to your presentation that there is a great deal of concern with respect to the privacy provisions. We've asked this question of the minister a number of times, and you know the Information and Privacy Commissioner has raised concerns.
The minister has said that the provisions he has introduced in at least one section of the act are no more than what occur already with respect to the right of inspectors to look at records in independent health facilities, and yet there are others who argue that there are two or three different sections of the legislation that actually deal with disclosure of information that collectively, put together, represent a real threat and that it's more than the minister would say.
I understand the point you made that as a non-funded volunteer group you haven't had a chance to understand the intricacies of that. I would imagine there are many members of the public who likewise won't have had access to the bill, won't have understood, and would have considerable concerns based on at least what they have read in the papers to date. How has this affected members of your organization that you're aware of? Their response to this bill: What has it meant for them?
Ms Danley: It's created a fear, a very real fear. And a fear that we have, for those of us who have had -- thank you -- the courage to stand is that women will now go back. They won't say anything; they'll keep closeted again. We know what closeted, secret information does in the wrong hands. If a woman, or anyone, has the ability to deal with her healing in the most gut-level ways, to know that anybody would even look at the record, let alone bring it out or share it with someone else, and how would it be used, sends everyone underground, and that's not good because that supports violence against women.
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Ms Lankin: I genuinely believe the minister's intent with respect to these sorts of changes is twofold: one, to provide an opportunity for appropriate investigation of potentially fraudulent situations, which I think we would all support, and secondly, to provide a networked information system which might be able to be contained on the smart card technology and to allow that to be transferred out to an independent agency they contract with to provide the health card, as opposed to doing it inside government. I think that's what it's all about, and I think there are ways in which that could be accommodated, and most people would feel there could be some merit to that kind of approach of consolidated information.
What's missing is all the protection. I know that the commissioner has raised significant concerns -- we'll be pursuing that -- and I'm hopeful that your presentation will help other members of the committee understand the importance which that issue is to a number of people and how insecure they feel right now.
I'm also interested in your comments about essentially the fiscal situation and the government using the fiscal challenge that faces the government, and I would be the first to agree with them on that point, but using that as the reason for this. I think we on this side see an alternative, which is to ask them not to proceed with their tax cut at this point in time, because we think the size and the depth and the speed of the cuts are being fuelled more by the need to pay for that tax cut than balancing the budget, given that we see in this term of government they won't even balance the budget.
Do you have any thoughts on that as an alternative? And if that was the case, what would you like to see slowed down in terms of the cuts with respect to the sections of the bill in front of us today?
Ms Danley: There certainly have to be more creative ways, and one of the things, as I've said, while we're trying to gather money, is there's an awful lot of fraud going on with OHIP that we know about. Why hasn't anything been made accountable in all of this? We don't understand that. We know that to support these kinds of violence things increases health costs. It will increase things.
If we could have another week or so to talk among ourselves and brainstorm, I'm sure we could come up with more, and we'd be more than happy to make ourselves available at any time, but other than pretty much what we've said in here, I can't think of anything.
Ms Lankin: Were you consulted at all?
Ms Danley: Not at all. No, not at all.
I have written to the minister's office two or three times and asked for information about the health professions board. We have some very large, grave concerns about that board and a number of other issues, and what is this government's stand on these whole issues regarding our protection, our health and our wellbeing, especially with our group and the abuses that many of us have incurred through the medical system? How is that going to be remedied? The cost for insurance to doctors for malpractice has risen greatly. Victims don't get any money for any of this, but everybody else seems to be taken care of.
The Chair: We're going to have to go on to the next question. Where are we at? The government.
Mrs Johns: Thank you for coming today, Mrs Danley. I can understand in your presentation the dichotomy you feel between keeping your public records to yourself and the ability to go after doctors for fraud, and those two things come out very strongly in the presentation. We as a government are very concerned about that; hence some of the reasons why we've implemented some of the things we have done in the bill.
I would suspect from listening to you, and not knowing your story -- I don't have the past history to be able to go back as Ms Lankin does, but I would suspect that you probably dealt in the past with some kind of a Medical Review Committee to try and ascertain the problems that went on with your case. Did you do that at that particular point?
Ms Danley: Yes.
Mrs Johns: I understand from things I've read that it's a very costly review and it doesn't help very many people, only 100 people at $22,000 a year. Did you find that with the Medical Review Committee?
Ms Danley: I don't know about that particular information, but when you say "medical review," we've dealt mostly with the College of Physicians and Surgeons, their tribunals, their form of court, and it is really ineffective.
Mrs Johns: Okay. What we have tried very hard to do in this bill, just to bring in the government's perspective, when you're talking about fraud, is to be able to tie physicians who we feel are defrauding the public by having the records opened up -- I know there's a problem with those two issues that's a very difficult problem, but sometimes we have to confirm procedures. We've been unable to do that at the level -- there's a backup, right now, of three years with the whole process of going through this and trying to get back at doctors, so we're very concerned about that. I appreciate your bringing that up.
You also talked about drugs. I just wanted to see if you felt there was some change in the way we were going to be allowing people to have drugs, if there was something in the act that you saw that I'm unaware of, by what you're saying in this section.
Ms Danley: I guess again, such a short review, the idea that the marginalized are going to have to put money out -- most people who have severe health problems, or a lot of them are on disability pensions, they're impossible pensions to live on for most people, and then to add a fee for the drugs that they're already on, to me that's another unconscionable act. It's so negligible. Why not deal with the drug companies? Again, this is where we have a very strong feeling about alternative forms of therapy and healing and care that aren't being addressed at all. We feel very strongly that many women are drugged far beyond what is necessary.
Mrs Johns: From my standpoint, I believe that copayment will allow us to put 140,000 working-class poor on the Trillium plan; I think that's an advantage and that some people would be happy to help sponsor that to happen.
Can you just talk about receipts and signing them for services -- that's a concept we're interested in in the government-and how you would envision that would work.
Ms Danley: I think what bothers me is that when I buy service for anything else, I usually sign some form of receipt stating that I've received what I've paid for. Because OHIP is the middle person or middle management here, it doesn't mean to say the money doesn't come out of my pocket. Well, why isn't there a form where if a doctor's attending to me and gives me X number of treatments or deals with certain things, it is written or somehow on the form and I can say, "Yes, I have received this"?
We know there are many cases where doctors, once they have your health card -- and this is not true of all doctors; this is just the ones who are fraudulent -- have put people's names in as having attended them when in fact they did not. If you're asked a question about, "Well, you've quite smoking, how's it going?" that can be put in as a counselling cost etc. There's abuse of that within the system because nobody gets to see it.
Why is it that I automatically give my card over when I go in, the nurse in attendance puts it through to OHIP and, as far as I know, nothing else is done? My doctor sees me and that's it; end of day. There isn't any other thing that I deal with in life where I don't sign for something saying I've either received the goods or, yes, this is in good order or whatever. It just astounds me that when we know there's fraud going on, why this kind of activity isn't looked into.
That way the patients know too exactly what they're getting, and I think that's really important. There's no power in any of the patients' hands. You're made to feel like cattle, and the bureaucracies will take care of everything. Well, that adds to the powerlessness that most of us are feeling out there already. It just adds more.
If I were dealing directly with a doctor and there were no OHIP system, he would give me a bill, I would pay for it and the bill would be itemized. So maybe we need to take a bigger look.
Mrs Caplan: I just wanted to make a couple of points. I'm really pleased that you're here and that you've had the opportunity to come to committee. I understand the point that you make about the rights of patients or consumers who feel that they have not been well treated, that you have to have access to an impartial body that can help you do that. There's nothing in this bill that would change the existing procedures.
The Medical Review Committee does not deal with individuals; it has to do with concerns about doctors, and the powers of the Medical Review Committee are significantly enhanced, as are the powers of inspectors of the College of Physicians and Surgeons, to deal with potential fraud. The concern we have is that notwithstanding the fact that the minister says there are new powers, there is a new inspector created who reports directly to the general manager of OHIP, who does not have to be a doctor, who can have direct access to patient files and information.
Just for your information, when we asked the Minister of Health today to take those sections out of the bill and put them into a new and separate bill which would also have protection-of-privacy information for patients, as he was requested to do by the personal privacy commissioner, he said that no, he wouldn't do that.
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That's what's happening with this bill. You talk about power; it's all being accumulated in the hands of the Minister of Health and the government. They wanted this bill before Christmas, without having this kind of opportunity across the province for people to come and learn more about the bill.
I know you've had a difficult and frustrating time, and really I don't have any questions for you other than saying how much I appreciate your coming and having the opportunity to tell the committee about your fears. I think that your fears are reflected in a lot of people who don't understand what is in this bill, and I agree with you that there's a lot to be afraid of.
If I had just one question, it's: Do you think it would be easier for people to understand if this bill were subdivided into different components, so you had one that dealt with drugs and one that dealt with hospitals and that kind of thing?
Ms Danley: I do think subdivision is absolutely mandatory. As well, we need for the public to understand better. When it's pushed through like it is, to those of us for whom this isn't our training it's difficult enough, and for those who are still in a survival mode it's all they can do to survive sometimes, let alone try to understand the bureaucracy that's going to affect their lives in a mammoth way.
Mrs Caplan: I've always believed it's important that the public have information and that they feel empowered to be able to come and speak their minds, but when you have a process like this which is so complex, I think it inhibits the opportunity for individuals to come. So I congratulate you for really coming and talking to this important bill.
Ms Danley: Thank you. Can I just have Ms Demerson speak on that last comment?
Ms Velma Demerson: The matter of anyone having access to doctors' records -- you say it's going to be private but it seems to me that these days everything goes on the computer and he has a secretary and so forth and it's not going to be private. I don't think it should be done.
Mrs Caplan: The privacy commissioner shares your concern; we share your concern. The only person who doesn't seem to hear it is Minister Wilson.
The Chair: Mr Curling, Mrs Caplan was kind enough to leave you a couple of minutes.
Mr Curling: I think you should know that was an excellent presentation for the short time which you were given. You shouldn't make any apologies at all about your presentation, how it was typed, because even the minister was not even ready when he came. He was three quarters of the way through his presentation before we got any written documentation at all of his speech.
You said you were not consulted. The minister had a presumptuous point, saying that you may be regarded as a special-interest group, because the minister's statement said that the health care system will not be reformed by publishing invitations to special interests for their input, adding their requests and greasing the wheels, with the squeakiest getting the most grease.
It is that kind of arrogance we're talking about, that the participation in the process is being denied and undermined.
Ms Danley: It is very arrogant, especially when it takes a lot of courage for the women I've dealt with to come forward, to even say anything to anyone, let alone speak to government, and we do -- our special interest is not just in ourselves but in our daughters, our mothers, our female friends, our co-workers. "Special interest" is special interest in our government, in our province. If that's a special interest, well --
Mr Curling: It's democracy.
Mr Bartolucci: Do you then feel, Ms Danley, that you were cheated in this whole process?
Ms Danley: Yes, I do, and I believe I speak for my colleagues: Cheated in that we're not consulted, and even sometimes if we are I'm not sure we're heard. The problem with that is, then you have to step up and you have to say, "Wait a minute, listen," and what this creates is a basis for violence. It gets people scared, and when people are scared they act out, and when they act out we have real problems.
What is it costing our government with the step-up in security? What's it costing in the lives of children? What's it costing in the emotional health of a lot of women in these situations who are going to have to keep pulling from the health care system year after year because we're continuing to be violated through our legislation?
The Chair: Thank you very much. We appreciate your interest in coming to present to us tonight.
HUMBER MEMORIAL HOSPITAL
The Chair: The next presenter is Mark Rochon from Humber Memorial Hospital. Good evening, Mr Rochon. Welcome to our committee. You have half an hour to use as you see fit. Questions, should you allow time for them, will begin with the government. The floor is yours, sir.
Mr Mark Rochon: Good evening, Mr Chairman and members of the committee. Thank you for providing me with this opportunity to comment on Bill 26, the Savings and Restructuring Act. As you've said, I'm president and CEO of Humber Memorial Hospital and I've worked in health care management for over 15 years. I've also had the privilege of serving this province on a secondment to the Ministry of Health as assistant deputy minister, institutional health, from January 1994 to March 1995.
Let me begin by stating at the outset that I support the need to correct the province's financial position. In my view, the amount that the province spends on debt service costs is the most significant threat to health care that we face. Given the combination of declining transfer payments from the federal government and a best-case scenario of relatively total government revenues, ever-increasing spending on debt servicing will be devastating to all human services. The need to deal with this challenge now is, in my view, self-evident.
With the need to deal with fiscal pressures as a backdrop, let me turn to Bill 26, the Savings and Restructuring Act, introduced on November 29. I will limit my comments this evening to the proposed amendments relating to the Public Hospitals Act, the Ministry of Health Act and legislation concerning labour relations.
First the Public Hospitals Act: My read of the policy objectives behind the proposed amendments to the Public Hospitals Act is to create the legislative and policy levers that the Minister of Health and the Ministry of Health need to restructure the health care system.
Most individual hospitals have responded quite well to the challenges of the last several years. Improved medical technology and practice patterns have reduced the need for inpatient hospitalization. Further, the growth in ambulatory services and more community alternatives to hospitalization have allowed the system to improve efficiency at the micro- or individual-hospital level.
More patients are being treated in fewer beds. By reducing the inpatient capacity and transferring resources to ambulatory or community settings, the hospital sector now provides more services, with approximately 11,000 fewer full-time equivalent positions and 9,000 fewer beds, than four years ago. In my view, this is a good-news story. Doing more with less and doing it better is an objective that the hospital community strives for.
I don't want to leave the impression that the system is perfect, that there are no challenges. On the contrary, we must continue to address important issues such as access to high-priority services, including cardiac surgery, cancer treatment and dialysis. However, we must also recognize that if we're going to be able to address such pressures, the system will have to be open to reallocation of resources.
The pocket of the payer is only so deep, and the system as it stands allocates funds on the basis of history of use rather than need. We can no longer afford to operate a system based upon patterns of previous service delivery. The needs of Ontarians and the limit to resources will require that the payer, the government, after appropriate consultation, must be able to decide in a timely fashion how to meet the objectives of providing exemplary care to the citizens of Ontario in an affordable fashion.
In my view, the system can be made more efficient and likely more effective if we restructure. Restructuring to date has, as I mentioned earlier, been largely a matter of individual hospitals doing better with the resources they receive. There is, however, a limit to what individual hospitals can continue to do on their own by way of improving efficiencies.
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In addition to the limited opportunities for increased efficiencies that remain within individual hospitals, the hospital system as a whole must adapt to an environment characterized by increasing demand for services, limited resources and overcapacity in terms of plant infrastructure.
Restructuring in the larger context means redesigning the way in which all hospital resources are configured to meet the needs of Ontario as a whole. It means taking advantage of excess capacity to consolidate hospitals. It means consolidating programs so that a minimum critical mass is present to achieve both quality and efficiency goals. It means getting the hospital sector to behave more like an integrated system. It means that the payor, the government, must be more explicit in what it expects from hospitals for the money it transfers.
Hospitals, for the most part, find it extremely difficult to merge, close or transfer services on their own. This is not to say that there are no examples of voluntary consolidations in Ontario; there are, and the individuals involved are to be congratulated for their courage. But hospitals will not normally volunteer to seek out arrangements that compromise their organizational identity. I'm a strong advocate of voluntary governance of hospitals. It has and will serve this province well. However, there are limits to the utility of voluntary governance, particularly when it stands in the way of the best interests of the community.
In my view, the Minister of Health must have the power to, at the end of the day, force system restructuring when voluntary efforts fail. Why? Because we must make the system more affordable and better able to respond to the needs of our growing and aging population. To accomplish this, we must take money from overhead expenses and apply it to aspects of hospital operation that provide direct patient services. All of this must be accomplished in the pursuit of doing more with less and doing it better.
The question at hand is, how should those legislative and policy levers be designed to give the minister the opportunity to do what is necessary to improve accessibility of services and the affordability of the system? I agree with the need for the minister to have the power to make changes to improve the system. However, I believe that some aspects of Bill 26 relating to the Public Hospitals Act warrant reconsideration.
Specifically, subsection 5(2) provides the minister with the power to "impose terms and conditions on grants, loans and financial assistance." As the payor, the minister ought to have the right to impose terms and conditions on grants to hospitals. However, these terms and conditions ought to be tied directly to the ministry's expectations regarding the delivery of services by hospitals. There must be an opportunity for hospitals to negotiate with the ministry over these matters. The right to impose conditions ought to be tied to service expectations on the one hand and payment expectations on the other.
Section 6 provides the minister with the power to issue directions to hospitals to close, amalgamate or alter services. The minister must have the power to issue directions to reconfigure the hospital system, but not to operate the system. The payor must have the clear authority to make decisions relating to the future role of specific providers within the health care system. Given the significance of these powers, it is my view that they should be time-limited; perhaps three years.
This will provide an opportunity for a re-evaluation. It is also my view that the statute should provide the parties -- hospitals -- a time-limited opportunity to work things out voluntarily. By this I mean that hospitals should be given the opportunity to voluntarily implement restructuring recommendations such as mergers and program transfers within specified time frames. In the absence of evidence that a voluntary arrangement can be attained, the minister would issue a direction.
In section 9, it is proposed that the Lieutenant Governor in Council appoint hospital supervisors. The power to appoint a hospital supervisor has been in place for more than 10 years, and it has been used sparingly. However, the existing legislation provides the hospital board the opportunity to review a report of a hospital investigator that could lead to the appointment of a supervisor and provide its side of the story prior to the appointment. I believe it is important for hospitals to be heard before the minister decides whether a supervisor is required. It provides the minister with an opportunity to make a more informed decision. Perhaps the existing 30-day time frame can be reduced.
Section 10, eliminating the need for the minister's approval of hospital bylaws, is welcome. However 10(1) gives the minister the right to determine the content of the hospitals bylaw. In my view, there may be certain minimum requirements that the minister may, in the public interest, require a hospital bylaw to provide. However, they should be specified and clearly at a minimum.
Let's turn to the Ministry of Health Act for a moment. I support the creation of the Health Services Restructuring Commission. The commission will, in my view, help expedite restructuring in Ontario by providing a group with a mandate to redevelop health services. However, the decisions to merge or close hospitals should not be delegated by the minister to this group, as contemplated by subsection 32(1) of the amendments to the Public Hospitals Act. The commission should be the group that deals with issues of implementation once the direction from the payor, the government, has been set.
I understand that earlier today the minister stated that the commission will be subject to a four-year sunset provision. This is a welcome improvement to allow for re-evaluation. However, as stated earlier, the powers outlined in section 6 should also be subject to similar sunset provisions.
Labour relations: The social contract is scheduled to expire on March 31, 1996. With its expiration, there will be expectations of salary increases. Salary increases will only serve to exacerbate our problems of providing services to Ontarians. Setting out guidelines for contract disputes to be settled at arbitration is welcome. However, I am concerned about its application. Ability to pay may vary from provider to provider. How will this be taken into account? I'm not aware of jurisdictions where guidelines have had the desired effect.
I'm not sure what the answer to the problem is. However, it is significant and must be addressed. Perhaps the government may wish to consider specifying the envelope within which settlements can be awarded.
In summary, in many respects hospitals are public utilities. They provide services that are crucial to a community's growth and development. Decisions about the future of hospitals must be made with the opportunity for the community affected to make its position known to the minister before a decision is taken.
The minister must specify at the onset of restructuring activities how he will ascertain the public interest in given communities. He must specify the process by which his decisions will be informed by the views of patients, families, employees and physicians. Communities must be given an opportunity to participate in matters affecting health services. However, there must be a limit to the debate. At some point, deliberations must come to an end. The combination of the increasing health needs of our citizens, combined with mounting government debt, requires solutions that can be implemented in a timely manner.
Mrs Ecker: Thank you very much, Mr Rochon, for coming and for some very good suggestions. We certainly welcome your comments on the sunset provisions. As you had mentioned, the minister had indicated some willingness to entertain suggestions along those lines, for the commission at least, and you're making some suggestions for further areas as well.
Did I hear you correctly when you said you didn't think the restructuring commission should have the authority to handle closures and mergers of hospitals? Can you elaborate on that? You think the minister should make that decision, as opposed to the arm's-length structure that he tried to put forward?
Mr Rochon: I think the commission should be in the implementation game. In my view, the minister should be making the decision about what hospitals are to merge and close. There will usually be a community process involving the district health council that would come up with a series of recommendations. At that point, the minister should review those recommendations, determine which ones are the significant ones this government can buy, make decisions and then turn it over to the commission to implement.
Given Ontario's history of closing hospitals and merging hospitals, in my view these issues are quite significant and require firm direction from the minister.
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Mrs Ecker: You also said that you thought the payor should be putting expectations on hospitals. How do you think that would be best arrived at in terms of how we should structure something like that?
Mr Rochon: We have some examples of that today. When the payor -- the government -- decides to provide cardiac services in Ontario, it contracts with hospitals to provide those services. It also does the same thing with dialysis and trauma. As money gets tighter, the need to be clearer about expectations increases. I could see a system whereby hospitals, as providers, and the Ministry of Health or some other body determine the scope of what services should be provided by that hospital and at what price, so that both sides are clear how much money is coming in and what's expected for that money.
Mrs Ecker: Is that something that should be done through the district health council process, much like the Toronto restructuring has been done, or is there some other option?
Mr Rochon: I think that process has to be tied directly with the body that holds the purse-strings.
Mrs Caplan: I appreciate your representations before the committee. It's well-thought-out, and obviously the experience you had within the ministry was helpful in the preparation. A lot of people are having some difficulty in understanding the intricacies and complexities of this legislation, and it's helpful to have someone with your experience come forward.
You've been very clear on a couple of things. I just wanted to point out to you that in the news release today, the minister was very clear when talking about the restructuring commission that's going to be established under this legislation. He says: "The commission needs the tools to be able to do its work. I want to be very clear that the powers will be given to the commission, not to me."
As I understand that, what the minister is attempting to do is distance himself from the decision-making, actually not make the decisions, and that this commission will be far more than implementation. If my interpretation of that is correct, can I understand that you don't support that? You believe the minister should make the decision and that the commission should be strictly implementation?
Mr Rochon: Correct.
Mrs Caplan: The second point, and I thought you raised the point very well, was the size of the debt and the debt service costs as a result. Since this legislation is referring to fiscal savings, one would think it was the goal of the government to reduce the debt, stabilize the debt. Are you aware, Mark, that under this government's plan, the debt will not be reduced over the next five years? In fact, they do not get to a stable situation on the debt -- what I'm saying and what that means is that the debt continues to rise, and that's primarily because of the $5-billion tax cut promise. Debt servicing costs will also continue to rise because they're borrowing more and more. All this pain we're going through isn't having the desired effect of stabilizing the debt. Are you aware of that?
Mr Rochon: My understanding is that there are two sides to the argument; that one side is aimed at reducing the tax burden on Ontarians and the second side is aimed at reducing the size of the operating deficit and debt. Reducing debt takes a long time, but my view is that these measures are aimed, at least in the first instance, at reducing the operating deficit from year to year, and that's where I see it paying off.
Mrs Caplan: The actual total deficit isn't reduced until the year 2001. It is reduced, but it doesn't get to zero until March 2001. It's at that point that the debt would be stabilized, and that's after the next election. People who say, "We have to do this because we have to deal with the debt, quickly deal with out deficit," are being fooled, is the word I would use.
I do have one other question. You were very clear and used the words "after consultation"; in other words, you believe the minister should have some powers to take action after consultation. Have you found anything in this legislation that requires the minister to have any kind of consultation process before decision-making?
Mr Rochon: No, I have not. But I --
Mrs Caplan: Would you recommend that it might be included?
Mr Rochon: Yes. My view is that consultation adds to the decision-making, makes it better. I also understand that legislation is drafted in a way to make it clear and make it less subject to interpretation, so you make decisions in terms of what you put into legislation.
Mr Bartolucci: I'd like to get back to your restructuring committee model. Could you just expand on what type of a relationship your model would have with regard to the DHCs? What type of a relationship?
Mr Rochon: I think it would have to have some sort of an opportunity to communicate and to debate with the district health council, but in my view, the restructuring commission would report directly to the minister. That would be the relationship. So the relationship with the district health council would be one of perhaps seeking advice or obtaining some understanding from the district health council about its recommendations and so forth. But the accountability relationship would be between the commission and the minister.
Mr Bartolucci: And that it would have no power at all in closing or merging hospitals?
Mr Rochon: Those decisions would be made by the minister. It would then be up to the restructuring commission to implement those decisions.
Ms Lankin: Mr Rochon, thank you for your presentation. I should tell you that you're the third hospital CEO who's been here today and your presentations are remarkably similar in terms of the concerns that have been raised and in terms of parts of the act that you are supporting. You have a couple of additional points that you've raised that I'm quite interested in and Mrs Caplan just spoke to one of them, that being a requirement for some form of consultation prior to decision-making.
I think that many of us understand the need for health system restructuring, not just hospital restructuring that you were referring to, but broader health system restructuring, and that, at some point in time, decisions have to be taken. It's arguable in my mind whether or not those powers exist already but, having said that, if you are to take more powers on to yourself as a minister they should be with respect to decisions at the end of the process, and I think that's the point you were making.
Could you envision amendments, or would you be supportive of us working at least, perhaps with a group of you and through the OHA, on amendments that would set out some process for requirement of consultation prior to the minister exercising the decision-making powers around closures and mergers of hospitals, for example?
Mr Rochon: I think that's a good idea. I don't know if it's required to be in the statute, for example, but certainly there ought to be a clear process, sort of a minimum requirement for consultation before decisions as significant as closing a hospital are taken. But on the other hand, we have to make sure that these processes don't take forever. They have to be time-limited and they have to come to an end.
Ms Lankin: The other thing that's interesting is, you talked about government, the minister having the ability to impose conditions on grants and you're saying essentially there's a flip side to that and a responsibility for the ministry to be clear with hospitals about what the expectations are.
That kind of partnership and contractor negotiations about how things get done is an important part of how the system works today in the way in which we've seen these issues unfold over the last few years. Again, you're the third hospital CEO who's come forward and said: "This is necessary. We have to restructure. We have to close. We have to merge." But all of you think that none of the rest of your colleagues believe that nor would they be cooperative in helping to achieve that.
Windsor, for example, did go through a process, did arrive at a decision, had a commitment of money to be reinvested into the community because it was a health system restructuring, not just hospital, and a requirement for some capital investment to facilitate that. That plan's there and it's viable, but the commitment for the capital investment and the reinvestment in the community has gone and therefore the willingness of the hospitals and the community that were involved is a bit shaky at this point in time to proceed along that line.
How would this act help in that situation? Because what I see would happen is the minister would certainly have the right to go in and say: "Two of your hospitals must close. Two must merge." This is what we end up with, but your health system hasn't been restructured because the government's part of that contract, that partnership, has just been pulled out from underneath the community.
Mr Rochon: You ask a very complicated question because, in part, what we're doing is talking about a scenario that occurred under one process and trying to superimpose a contemplated process on to it. I guess how I would see it unfolding under what's contemplated is that the minister, if we were starting from square one, would ask for a report, some form of recommendation, and then, having heard what the recommendations are, having given the community an opportunity to debate, would be put in the position of having to decide that certain things have to happen in that community: mergers and closures.
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Ms Lankin: Let me ask you something perhaps more relevant about Metro, because you would, both from your time in the ministry and from your position, have a sense of the Metro restructuring report.
The recommendations of the community, after considerable consultation and study and a review of the report and now further amendments, are predicated on an understanding of an ability to invest in community where there will be gaps created by the restructuring of hospitals. If there isn't any relationship between the planning process, the consultation process and the end decision-making process of the minister set out, how can we be assured with the Metro report, for example, where recommendations are contingent upon other things happening and timing and phasing so that patient care is kept paramount, that that is even taken into account if the powers here are so stark and so direct, to simply merge and close hospitals based on, from what I hear from the minister, excess capacity of physical space only, not taking into account all these other issues?
Mr Rochon: My view is that those issues would be taken into account. It's not just a one-dimensional problem, it's not just a matter of closing hospitals, and the recommendations in Metropolitan Toronto deal with the need to reinvest in the community. If you don't reinvest in the community, your health system falls apart. The minister has accountability for the health system, so in my view he would have to consider what's needed by way of community and other investments to make hospital restructuring work, hopefully paying off by way of improved services and lower cost.
The Chair: Thank you very much, Mr Rochon. We appreciate your attendance here tonight and your involvement in our process. Have a good evening.
ONTARIO HOSPITAL ASSOCIATION
The Chair: The next presentation is from the Ontario Hospital Association. Representing them are David Martin, the president; Ron Sapsford, the chief operating officer; and Carolyn Shushelski, senior legal counsel. The floor is yours.
Mr David Martin: Thank you very much, Mr Chairman. As you said, we're here representing the Ontario Hospital Association. Much of what we are about to say has been discussed with the hospitals in the province and I think it's generally supported. We are very grateful that we have the opportunity to present our comments to this multi-faceted group, and I hope we can be of some help to you in your deliberations.
As I'm sure is everyone who's presenting to your committee, we are concerned about the magnitude of the changes being made in the legislation. This is unprecedented and needs a great deal of thought. Just to give you a little of my background, I've been in hospital management now for about 35 years. I was happily retired as the president of the Hospital for Sick Children. Because of some of the problems that the OHA has encountered, I was enticed back for --
Ms Lankin: Pressed into duty.
Mr Martin: Yes, that's probably the good way to put it. We are, I think, making some progress.
There are certainly some sections of this act that concern the Ontario Hospital Association and the hospitals it represents. At the same time, we recognize the need for legislation to help with the restructuring of our health system. There is no question that as the legislation sits today it would be impossible to restructure our health system, as was encountered in the Doctors' Hospital situation many years ago. At the present time, and as the minister has said, he does not have the power to close a hospital. There is no question that if we are going to maintain a balanced, healthy health system in the province, it has to come about by a number of changes, which include restructuring our health system. So legislation is necessary.
We have had some interesting discussions with the minister and presented some of our views. I would say, from what we heard this morning, some of these have not been addressed, and that's what we would like to talk to you about tonight. I'm sure some of this will be duplication of what you've already heard -- you've been sitting here since 9 o'clock this morning -- and so all of this is not going to be new news.
One of the problems we see is that the legislation, as it's drafted at the present time, in the long term would not support the voluntary hospital system that we presently have. I think there's need for immediate powers for the government, but in the long term that could be very detrimental and could be misused in terms of maintaining a balance in our system between the voluntary hospital system that we have been so successful with over the years, and that power has to be balanced between government and our hospital boards in our communities. That's, I think, the major issue.
What we're mainly concerned about is that there be a sunset, and I know from listening to the previous comments that this has already been brought to you. From the OHA standpoint, there has to be a sunset to this legislation, and the announcement this morning did not cover that. Sunsetting the powers of the commission does not sunset the legislation, and that's the important issue: that after this restructuring is done -- and we all concede that there's a need for this kind of legislation in the short term -- in the long term, this legislation must go off the books. Then, as we address the situation maybe four or five years down the road and we've accomplished what we set out to do, the need for legislation at that time must be reconsidered. The opposition at that time should make a decision as to what's necessary for the circumstances as they exist. That, to us, is the most important part of this whole thing. So that's one thing.
The second thing is around delegation of authority. The bill proposes that the powers of closure and amalgamation "and any other matters related to a hospital" may be delegated by the minister "to any person or body," and we think that's very dangerous, because you can't conclude what might happen around that kind of power and it removes the accountability from the minister for major, major changes that are going to take place. So we feel that the powers must not be delegated and that the minister must make the decisions and refer approved plans to the commission for implementation.
The reason for that is, if we're not careful we'll set up a new commission, the government will delegate all the powers, and then we'll have the same lobbying and the same problems that you're facing as opposition and government -- the new implementation group will be facing exactly those same things and trying to make new decisions and revising what, in the Toronto scene, is a two-year program to try to come up with recommendations. So I think that what the commission should be doing is implementing the decisions made by the minister, and that that power should not be delegated to start to play with the plans that have been carefully thought out by the district health councils throughout the province. That's the second issue.
The other issue is around due process, and we have agreed that the district health council process is the proper way to go about restructuring. So it's important at the same time that the hospitals and the communities have an opportunity to say what they think and to try to come to a decision around the district health council process. It's at that point that hospitals must be assured that they would have input, and the community must have input, into that process. Once it gets passed and approved by the district health council, then it's into the minister's hands, and the minister must then make the decisions around those issues and then delegate it back to the restructuring committee. So we want to make sure that hospitals have their say but at the appropriate time in the process, which is at the DHC level.
The next issue we're concerned about is the role of the supervisor. Elinor, you may remember, I was the first CEO appointed to go into Toronto East General when the Conservative government at that time passed legislation to give them the power to appoint a supervisor over the board. That was met with tremendous resistance at that time by the hospital community, and yet I think it worked very well. It has been used very judiciously by all parties; it has not been abused. It was very helpful in sorting out the problems of Toronto East General and has been used a couple of times since.
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What we're concerned about now is that the supervisor can be appointed without any reference to cabinet or to anyone, and for purposes very much broadened as compared to before. It was originally set up to deal with the problems of an individual hospital, and the government could make a decision: "This hospital is out of control. We must do something." Now a supervisor can be appointed because of problems in funding, or whatever, in the health system. So it may not relate to a problem with the individual hospital at all, and the hospital has no right under the legislation to discuss the issue prior to the supervisor being appointed. Under the present legislation, the hospital has a month in which to negotiate and discuss with the minister the reasons for appointing the supervisor, to see whether there can be changes made that would maybe obviate the need for a supervisor. That doesn't exist in the new legislation. We think that's a problem.
I think those are the major issues that I had to discuss with you. Ron Sapsford is now going to continue with a few other issues and then we can get into question period.
Mr Ron Sapsford: Our next set of comments is on the Health Services Restructuring Commission itself. The OHA is concerned about the current lack of information about the specific mandate of the commission as it's currently defined in the statute. Given that much of the mandate will be defined by regulation, the OHA is quite anxious to have some ability to advise the government and to have some input into the formulation of those regulations.
In general, however, as we noted earlier, we believe that the commission's role should be to implement the plans developed by DHCs or voluntarily by hospitals, as the case may be, and approved by the minister. The commission must have some flexibility, but the minister, not the commission, should make decisions relating to closures and amalgamations specifically.
Hospitals in the province agree that the commission needs sufficient flexibility in its mandate to vary the plans proposed by DHCs. There will often be changes required as a result of issues that arise during the implementation process. This could include program realignment among hospitals or perhaps issues related to the physical plant of hospitals. These are substantial powers that the hospital system is willing to accept in order to facilitate restructuring, given the unprecedented fiscal challenges over the next several years.
Under the existing act there is a requirement of hospitals, where they pass bylaws, to submit those bylaws for the approval of the minister. We're pleased with the change in the bill that would remove that approval process so that hospital bylaws could be implemented on the approval of the board.
However, in Bill 26 the proposed amendments would also enable the Lieutenant Governor, through regulation, to write in detail any or all hospital bylaws. This provision, in our view, is in direct conflict with the responsibilities of the board of a hospital and its powers under the Corporations Act of Ontario. OHA believes that the cabinet and the Lieutenant Governor should not have the power to write hospital bylaws on behalf of hospitals.
The proposed amendments to Bill 26 give the minister unrestricted powers on terms and conditions on hospital funding. We believe the unrestricted nature of these proposals would lead to micro-management of hospitals and impose a degree of inflexibility on day-to-day operations.
We would also like to flag the issue of the Minister approving medical manpower plans, which again, in our view, would be operationally difficult to manage. We will have more to add on this particular issue in our supplementary brief to the committee.
With the end of the social contract in March 1996 hospitals must return to the bargaining table with hospital unions. Given the fiscal reductions that have been imposed on hospitals for the next three fiscal years, any further increase in costs increases the pressure on hospital services and access to hospital services.
The government's proposed amendments to the Hospital Labour Disputes Arbitration Act are an effort to ensure that arbitrators apply appropriate criteria when making awards. Hospitals support that objective but do not believe that the "ability to pay" criteria as written in Bill 26 will be effective. In order to strengthen the intention to effect "ability to pay" criteria, OHA is proposing a series of amendments, which we have attached to the submission.
May of our hospital members believe that given the change in technology affecting laboratories, food services and other support services, it is important that hospitals have the ability to change and restructure their operations. Many collective agreement provisions currently restrict the hospitals' ability to contract out services or to otherwise determine which members of the staff will do which specific work. Many hospitals believe that these provisions enshrine an unnecessary level of inflexibility.
Our final recommendation is that the Pay Equity Act be amended to clarify that once pay has been achieved for a specific group of employees, there be no maintenance requirement and the Pay Equity Act no longer apply to that group.
In conclusion, we would like to reiterate that while there are considerable areas of mutual agreement between the OHA hospitals and the government on many aspects of Bill 26, we would have significant concerns if the bill were passed in its present form. We believe that the amendments we have put forward will allow the government the needed power to effect the necessary changes in the hospital system while at the same time respecting the traditional role of voluntary hospitals boards and the community's right to influence the direction of health care restructuring in the province. We believe that our amendments are reasonable and constructive and hope that they will be viewed as such by representatives of all parties on this committee.
The Chair: Thank you. We've got about five minutes per party left for questions, beginning with Mrs Caplan.
Mrs Caplan: Thank you very much. As always, a very excellent brief. I guess my first question really goes to the point of consultation. When this bill was first tabled, the minister stood in the House and said that he was just doing what you asked him to do. What you've identified today are some very serious concerns that you have, and frankly that we raised and that we share, about the danger of delegatory authority, about the fact that there is no due process and about the ability of -- and I'm going to use the word "minister," but really it's not the minister, it's the ministry, to micro-manage any hospital that they wish, should they be able to convince the minister that it would be in the public interest. I see you nodding your head.
I want to ask you, did the minister share with you his proposals, as they are in Bill 26, before they were tabled? Did you know what he was planning to do?
Mr Martin: No, we did not. When the minister said that he shared information, we did meet with him and give him a list of 20-odd items that we felt were necessary if we were going to be successful in the implementation. We discussed those and he has implemented many of those. But not around the legislation.
Mrs Caplan: He didn't share the legislation with you. I feel that's not an adequate consultation process, from my perspective. I guess I would ask you if your view of consultation is that you would have that kind of sharing in advance so that you could offer advice on what was being proposed.
Mr Martin: If we had had an opportunity to read it, we could have maybe countered some of these problems and had them resolved before we got to this kind of a process. But I'm not sure what was envisaged at that time.
Mrs Caplan: What was envisioned at that time was that this bill would be passed before Christmas. The fact that we're here today I think is very important, and the issues that you've raised are extremely important. Frankly, I'm surprised that you're not here today saying that the minister has accepted your amendments and will be tabling them as government amendments, because I think that they all address very important issues. I am concerned, because after hearing the concerns about sunsetting, the news release that came out today from the minister does not do what you asked him to do.
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Mr Martin: Not at all. It does not address the basic issue. As I'll repeat again, there's no point in withdrawing the power from the commission after four years and leaving the legislation as it sits.
Mrs Caplan: The other thing, David -- you've been around for a long time and so has Ron -- how many times have you ever seen something sunset, even when there was a sunset provision in the legislation? Can you ever think of anything that has really successfully been sunset once a minister has had that power?
Mr Martin: I can't at the present time think of anything.
Mrs Caplan: Neither can I. That's why I would argue that while there are some minor changes in the powers that are required to allow hospital restructuring, it is very dangerous even to give a minister these powers and we should be looking at what exactly is really needed. I would ask the OHA to go back and look at what you think really has to happen, because he can tell you he's going to sunset the commission and he can tell you, "Oh, I'm not going to use all those powers," but I would urge you to look at what you think is the bare minimum requirement, given the authorities that you know already exist and the processes that already exist, and you articulated them extremely well, because I think this bill is extremely dangerous just in the powers that it accumulates in the hands of one person.
The other thing you didn't identify that I'd ask you to consider -- not only in my view is "make any other direction" too broad, but I'd ask if you believe that it's too broad to have that "in the public interest" test without any criteria. Does that give you any pause?
Mr Martin: Sure it does because, in whose opinion?
Mrs Caplan: Right. So I'd ask you to look at that and perhaps propose amendments along those lines as well.
Ms Lankin: I too appreciate the work that has gone into this. They're very concise and clear recommendations, and I find myself supportive of a number of them. I have a bit of trouble, as I'm sure you can imagine, with some of the provisions that you've proposed with respect to the Hospital Labour Disputes Arbitration Act, but I understand the issues that you're raising. You're getting boxed in, in a sense, by the conditions that you face.
Mr Martin: We are.
Ms Lankin: So I understand what you're asking for. I think that there is the potential of an unfairness in the result of that, but that's for another committee meeting down the hall. We don't have to deal with that immediately.
On the issue of public interest, just to pick up where Ms Caplan left off, in the act it appears to give a completely wide-open definition. It does suggest some of the things that could be included but without limiting the generality of the foregoing, and it goes through and it sets out some of the things that we've seen in old pieces of legislation, like "the quality of the management and administration of a hospital; and the quality of the care and treatment of patients in the hospital," and then it adds clauses (c) and (d), which you refer to in your brief, "the proper management of the health care system in general; and the availability of financial resources for the management of the health care system and for the delivery of health care services."
Mr Martin: It's that (c) and (d) that really concern us in terms of appointing a supervisor where there's no right of appeal and no right to discuss prior to the appointment.
Ms Lankin: It actually appears to me, and I might be wrong in my reading of this, that that's in a separate section -- it's 9.1 -- and I think it is applicable to the interpretation of "public interest" as it is used in the act in general, not just with respect to supervisors.
Mr Martin: Yes.
Ms Lankin: I think it's even broader than your concern. So I flag that for you, that it might be even more serious than you had thought.
You also indicated that you felt that the power of the minister, with respect to volunteer boards and directions to boards, to "make any other direction" -- which I find extraordinary -- perhaps needs to be clarified. I'd like to know how necessary you think that is. I understand that when we want to effect restructuring we want to make sure we have the powers to merge and amalgamate and close if necessary. I would argue that we don't need to go this far. I think that some of the things -- you mentioned the Doctors' Hospital decision -- had to do with the sole motivation and reason in one hospital situation as opposed to all of the work, for example, that's been done in the Metro restructuring study that would argue a better health care delivery at the end.
Do you believe we need for the minister to be able to step in and give directions to volunteer boards, make volunteer boards follow those directions? In fact, irrespective of your letters patent, your bylaws or any other piece of legislation, it's very wide and very sweeping.
Mr Martin: It is, and this is what we're talking about: maintaining a balance in the system. Our system works. Obviously it has its problems now, with the funding issue, but our system has worked because we had a balance. The Minister of Health -- and two of you have been ministers, so you know the pressures, but there was always a balance. It had to be finally acceptable to the minister and the community, and we had our battles and we sorted them out.
You can't get it too one-sided or then you destroy the volunteer board, because, for instance, if that hospital is so frightened that it can't stand up and say, "This is not acceptable to our community," because of the fear of having a supervisor come in with a very broad mandate with no right of appeal, then you destroy the balance in the system and that's what our concern is.
Ms Lankin: We tried to understand this morning from the minister why he felt he needed the powers with respect to appointments of supervisors. We pointed out that in the old act there was a requirement for the supervisor to take into account the report of an investigator, which assumes that the report of an investigator has to be written and therefore an investigator's been appointed. Those steps lead up to appointment of a supervisor. That's gone. It can be appointed at any time by the minister directly. That supervisor can assume the management decisions of the board, exercise all powers of the board.
In asking the minister, his defence was, "Well, it's been so rarely used in the past; I mean, this is a very unusual provision," and that begs the question, if it's rarely been used, "What are you anticipating and why do you think you're going to have to use it and why do you need more powers if in fact this isn't a provision that has been used frequently"?
Has the minister given you any explanation for why he has increased his own powers to appoint a supervisor and the powers of a supervisor to take over the management and decision-making and day-to-day operation of a hospital, thereby usurping the role of the voluntary board?
Mr Martin: No, there has been no discussion around that issue, and I'm right back to exactly what you're saying. The legislation is already on the books, but it does at least give the hospital and its board the protection that it has an opportunity to discuss the issue of appointment of a supervisor for a month prior to that point. There could be situations where the issues could be resolved without the appointment of a supervisor, which means the supervisor has total power over the board. Now the board has no power once that supervisor's appointed. It's a very major step.
Mr Clement: Mr Martin, I thank you for your report and certainly the substance is very thought-provoking. I just wanted to get to process for a second, though. I think there was an allegation here that prior to the introduction of the legislation, you didn't have an opportunity to see the legislation at all. Did you see the legislation prior to its introduction?
Mr Martin: Not at all, no.
Mr Clement: Not at a meeting on November 17?
Mr Sapsford: The draft of the bill was shared at a meeting; I'm not sure of the exact date. We had a one-hour opportunity to read the sections dealing with the health portion of it and make a few comments, but it was not left with us. The copy was returned and we had no further information until --
Mr Clement: Kind of like a lockup, which is usual.
Mr Sapsford: Yes.
Mr Clement: Thank you for correcting the record, though. I do appreciate that.
Mr Sapsford: We did not have any formal consultation on the point.
Mr Clement: Right, but I think you did get to see the legislation. I guess we're under the definition of what "consultation" is at this point. But the fact is that you did have meetings with the minister to discuss public policy in the health care sphere and you have had so in the past.
Mr Martin: Yes. We had a meeting with the Minister of Finance and the Minister of Health together and then I've had one meeting since with the minister.
Mr Clement: Let me ask you this: Where in the current legislation does it say that the minister has to meet with you? Would it be safe to say nowhere in the current legislation?
Mr Martin: I don't think it's in the legislation but it's rather understood that the president of the Ontario Hospital Association would meet with the minister if there were things of this magnitude being implemented.
Mr Clement: I couldn't agree with you more. I guess my point is, would you not expect that in public policy formulation in Ontario, pre-Bill 26 and post-Bill 26, the minister de facto, regardless of what it says in legislation, is going to meet with the head of the OHA. Is that fair to say?
Mr Martin: Well, I would hope so.
Mr Clement: I would hope so too.
I would like to just ask you one more question, about the OHA call to action, which made a number of specific recommendations, I think, about how to get the tools ready for the minister and for the ministry to get hospitals restructured. I've heard our minister say that from his perspective 23 out of the 25 recommendations in that report found their way into the legislation. Is that your understanding as well?
Mr Martin: All those points weren't legislative issues; they were around multi-year funding, not loading at the front end, those kinds of issues. They've done that -- some of it around the labour legislation he's implemented. So it's a balance of both.
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I'm not sitting here saying that we haven't talked to the minister. What I'm saying is that the question was asked, did we have an opportunity to review the legislation and discuss it with anyone at the ministry or with the minister himself. We did not.
Mr Clement: But you saw the legislation beforehand.
Mr Martin: Only at a meeting. They briefly saw it and it was taken away. We did not have it at the OHA where we could sit down and say, "Here are the issues." That's all I'm saying.
Mr Clement: In fairness, though, it's difficult to present a fiscal plan on the one hand and on the other hand have it all over heck's half acre. So I understand. There has to be a balance, surely. Surely the OHA board knows about the balance that has to be struck between things that are matters that have to be held internal and things that are matters for public debate. That's all I'm saying.
Mr Martin: The only thing I could say is this is so complex that it takes a very high-level lawyer in our organization to sit down and start to work out what are the implications of it and what would be a more appropriate way to word this or to direct it. You can't do that by someone glancing over a huge document in half an hour at a meeting somewhere. That's not the way consultation takes place.
The Chair: Thank you very much. We appreciate your attendance with us tonight and your interest in our process. Have a good evening.
CANADIAN PENSIONERS CONCERNED, ONTARIO DIVISION
The Chair: The next presenter is Canadian Pensioners Concerned, Ontario Division; Mae Harman, president. Good evening and welcome to our committee. You have a half-hour to use as you see fit. If you leave time for questions, they would begin with the New Democrats. The floor is yours.
Ms Mae Harman: My name is Mae Harman. I'm president of Canadian Pensioners Concerned, which is a voluntary group of seniors who advocate on issues of concern to seniors and to all generations.
We've approximately 700 members throughout the province and a number of affiliate groups. We network with a number of other seniors' and advocacy groups. We send letters and position statements to government officials at both federal and provincial levels and meet with members of Parliament from time to time. We hold forums and issue a newsletter four times a year. We participate in consultations and serve on advisory committees as requested.
While in the past we have been active participants in consultations and served on advisory committees on long-term care, chronic care, advocacy, substitute decision-making, drug benefits, and have sat in on budget lockups, we have, under this government, been invited to only one consultation and that was on long-term care.
Letters to present government officials are seldom acknowledged and requests for meetings declined or unanswered. We believe that our concerns should be listened to and that our knowledge and life experience could continue to be a useful resource to those who govern.
As citizens who have lived for three-score plus years under a democratic form of government, we are most alarmed by the attempt to ram Bill 26 through in a hurry and without adequate discussion, and with the tremendous power the bill would give the government to pry into our personal lives, restrict our choices and control our daily living. This process of decision-making and control frightens us and outranks our concerns about the various 40-some bills lumped under one act.
It would be superfluous to dwell on how the bill was presented to the Legislature, the attempt to restrict debate on the part of both members of Parliament and the public, and the intention to push so many pieces of legislation through before Christmas without adequate presentation of the real meaning of each separate bill and separate and full debate of each piece.
The ludicrous high cost of the weighty various tomes involved has made them quite inaccessible to organizations like ours and impossible to analyse what is really intended. Some ministers have obviously found analysis difficult too. MPPs will have found it extremely difficult to consult their constituents on their views of the legislation.
The government claims to be giving back control to families and individuals, but has wiped out the Advocacy Act which would have empowered the old and the disabled to make their own decisions with the help of advocates and rights advisers. It has cancelled the multiservice agencies which were being planned as community responsive programs combining health and social services and utilizing the services of local community agencies. Those of us who have worked for years developing plans for these services are devastated by the waste of our time and energy and the trashing of carefully thought out planning to meet the needs of consumers.
Seniors have a great deal of anxiety about the kind of health and social work services which will be available to them when they need them. We had anticipated that community long-term care would bring services to us in our homes and allow us to stay in familiar settings as long as it was safe and feasible. We talked about the right service at the right time and place by the right caregivers. Money from hospital restructuring was to be transferred to the community for this purpose. It appears from Bill 26 that money from hospital restructuring will go to pay the debt.
There are numerous horror stories about deteriorating services in some nursing homes. There are waiting periods in any case. There are some closed emergency wards, waiting periods for some kinds of surgery, patients sent home without adequate arrangements for recovery. We hear about cost-cutting, but little about an organized plan to coordinate all of the different aspects of health care. We've been talking about restructuring in chronic care, in hospitals, in communities, in nursing homes, but there seems no effort to bring it all together. At the same time, we hear about the possibility of various user fees for patients at every level of care.
Many of our community agencies which add so much to the quality of life for all age groups are experiencing cuts in grants. This is happening at the very same time as demands for help have increased because of the cuts in welfare and other services to the most vulnerable members of our society: the old, the poor, the disabled, the children. Community agencies are the lifeline for so many people, especially in the lower income areas of a big city where people encounter poverty, loneliness and alienation. The loss of funds and staffing will cause many organizations to close their doors and others to cut back on the very services that are most needed. User fees seem inevitable if some agencies are to survive, but these will prohibit those most in need of services from participating.
We wrote to the Minister of Health on November 9 in regard to user fees for drugs for seniors and welfare recipients. We said in part: "The imposition of user fees sets up a two-tier system whereby those who can afford to pay for drugs will be able to purchase them and those who cannot afford them will be deprived. A $2 fee may sound like a small amount but to a welfare recipient whose income has already been cut back or to a senior totally dependent on old age security and the supplement, it can become an insurmountable difficulty. He or she must choose whether to buy bread, or tokens to take him to the food bank, or used winter clothing, or snow boots at Goodwill or the prescription. It is likely that the prescription will be passed over in favour of the other essentials. Lack of any of the above purchases will in many cases lead to more intense health problems and a greater cost to the province in health care, so where is the saving?
2000
Many of us living on modest incomes just above the poverty level will find the $100 deductible plus a fee for each prescription a real hardship if we require frequent prescriptions and expensive drugs. The prescription fee in most cases seems very high for counting out a few pills. Taking the cap off the price of drugs will no doubt cause the price of over-the-counter drugs, which most of us use -- aspirin, laxatives, calcium, antacids, sunscreen and others not covered by the drug benefit program -- to rise, adding to our expenses.
It is the high cost of drugs that makes the drug benefit plan expensive. Government should make the protected patents of the international cartels its focus of attention, rather than seniors and welfare recipients. The provincial government should lobby the federal government in this regard.
It is claimed that the use of drugs is abused, but it is doctors who prescribe, not patients. Duplication of prescription and overprescribing was supposed to be identified by the new computer system. If it isn't working, it should be fixed.
The spectre of user fees at the municipal level, as provincial grants to municipalities are cut, weighs heavily on seniors' minds. Our fixed incomes in most cases will not adjust to fees for garbage collection, entrance to parks and libraries, bus fare and property tax increases, poll taxes etc. As it is, seniors are dependent on hiring many services which younger people can provide for themselves -- housecleaning, snow shovelling, lawn cutting, tax services.
Implicit in Bill 26 is the intent to terminate the employment of thousands of people as services and programs are cut. Many more jobs will be lost as businesses are no longer able to sell goods and services to those who are unemployed. How this will help to generate the economy is hard to understand. At the same time, training programs are being cut and increased tuition fees will make it necessary for some students to drop out of universities and colleges and join the unemployed. Where there is no hope, the people perish. What we need is jobs, jobs, jobs.
Except for the rich, a decrease in income tax, which is tainted money taken from the poor, will be more than eaten up by increased user fees and taxes. We strongly support a fair and progressive system of taxation, with higher taxes for higher levels of income. There are too many loopholes and too many people investing and banking their money out-of-country.
Seniors groups, unlike business, are often referred to as special-interest groups concerned only with their own comfort. Our concerns go far beyond ourselves. We are parents, grandparents, aunts and uncles who care about all generations. We want for all children the opportunity to develop their full potential. We want for them adequate income security, safe and stimulating child care, training and education for useful and productive lives, good health care, and a social safety net when needed.
As much as we worry about how Bill 26 will affect our own health care, our housing, our transportation and our incomes, seniors want a caring, compassionate society and a good quality of community life for all. We will continue to fight for the fruition of these ideals.
Ms Lankin: We truly appreciate your taking the time to come down here with your presentation. I was struck by our last remarks when you said, "Seniors groups, unlike business, are often referred to as special-interest." You're not the first group that's presented here or at the day-long hearings the New Democratic Party held who has raised this concern about their views being written off by the government simply by this language of "special interests." Anyone who raises a concern or an issue and puts an argument forward can be dismissed with the back of a hand by being called a special interest, yet there are certain groups within our society that aren't treated that way.
You've indicated that you've written to the minister, and other than long-term care, you haven't participated in any consultation. Is that correct?
Ms Harman: Only on long-term care, and not with the minister; with the parliamentary assistant and staff.
Ms Lankin: Specifically with respect to the changes to the Ontario drug benefit program and the introduction of user fees in that program, which obviously has a primary effect on seniors as one of the main groups of ODB recipients, there was no consultation with your group?
Ms Harman: I might say that when your government was in power, we did have consultation. Your government brought forward some ideas for user fees and thought better of it after consultation. Our organization has had no consultation on this with the present government.
Ms Lankin: Perhaps the present government would argue that that was a reason not to consult, that it might be forced to change its mind if it actually met up with you folks.
In your presentation, you did talk about the difficulty of groups to participate in these hearings, with the complexity of the bill and, I think you said, the tomes of documents. Did you have problems getting the materials or having access to the materials to review these legislative proposals and the various acts they affect?
Ms Harman: We understood that there was a high charge for them, so we didn't pursue that.
Ms Lankin: This is extremely problematic, that an organization such as yours, that doesn't have financial resources but is trying to provide an organized voice for pensioners' concerns, is left in the position of both lack of time and an inability to actually get the documents to examine what's going on. Essentially, you're having to rely on whatever is portrayed in the media to get your information.
I guess we could argue that if the government had had its way, there would be nothing left in the media, because this would have been done and passed a week ago. We hope that by travelling the province, we will be able to get more information out to people and be able to get their response.
I understand that this is sort of an umbrella question because you haven't looked at the specifics of the bill, but do you have the sense that this bill is fixable by amendments, or do have a preferred route that you would recommend the government go at this time? Some groups have suggested that we should still go back to the original request that the bills be split up into separate segments that are understandable and can be worked with. Have you given any thought to that?
Ms Harman: The previous group that presented, that has many resources we don't, expressed their difficulty in analysing the bill. It's much more difficult for our group, which doesn't have lawyers and other people who are capable of in-depth analysis, to understand what this bill is about. The timing certainly is a big problem, because there just hasn't been time to seek resources and get information.
Ms Lankin: In light of that, we truly do appreciate your taking the time to come down here to present your views on this. Thank you.
Mrs Johns: I'd like to thank you again for coming, Mae. I have a couple of questions about specific issues I'd like to deal with. I'll deal with the biggest issue first.
You talked about the drug benefit plan and the imposition of the user fee and how hard it would be for some people to handle even the $2 fee. This issue is controversial within your own organization and with seniors and people who use the Ontario drug benefit plan. Many people who are being asked to make a copayment, even if it's as small as $2, feel that to get 140,000 working-class poor on to the Trillium drug benefit, it's worth it for them to help the community. In fact, Murray Squires, who's the president of the Sarnia chapter of Pensioners Concerned, said, quoting the London Free Press, "He believes seniors are more than willing to help pay the drug cost. `We had agreed to pay what seemed fair.'" What do you think about that?
Ms Harman: What does "fair" mean? It's very difficult for many seniors, and the excuse that seniors should give up something so that some other group can be covered doesn't make any sense to me. I think everybody should be covering the costs, not just so-called wealthy seniors.
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Mrs Johns: I just wanted to check on a couple of things you said in here. You talked about long-term care. As you know from being in consultation with us on that long-term care process, long-term care is increasing by 13% per year, and we need to get money from somewhere. You go on to say that money from hospital restructuring should be used for this purpose, so in effect you don't have problems with the hospital restructuring we're talking about within the act? The pensioners believe that's the right way to go?
Ms Harman: There's probably a need for hospital restructuring, but I certainly don't agree with all the details of which hospital has to go and so on. I don't think this is an organized plan.
Mrs Johns: You don't think it should be community-driven? You don't think the communities should decide on how it's done?
Ms Harman: I certainly think communities should. That's what we were doing with long-term care, planning community-organized and community-administered long-term care, and that seems to have slipped entirely out of our hands.
Mrs Johns: I just wanted to comment. You have a paragraph that says there are numerous horror stories about deteriorating services in some nursing homes, waiting periods in any case, some closed emergency wards, waiting periods for some kinds of surgery. Many of the savings we're making this government is allocating back to specific areas such as reducing the waiting lists and bringing more dialysis, which is an important issue for seniors. We're also in rural Ontario working very hard to keep emergency wards open. I'm sure that's something you would want to know with respect to --
Ms Harman: I didn't hear that.
Mrs Johns: I figured. I don't have any other questions.
Mr Clement: Is it Miss Harman or Mrs Harman?
Ms Harman: Ms.
Mr Clement: Ms Harman, I just wanted to refer back to your comment about your organization's view about the long term, that you represent pensioners but you also are grandmothers, you've got granddaughters and grandsons and so on. It's a difference of perspective.
Maybe you and I will never agree on this, but we honestly believe that the changes that have to go on, that we were elected to do, actually will enable government to fulfil its mandate in terms of services and enable children and grandchildren to have a better opportunity and more jobs in our economy. Do you want to comment on my world view as opposed to your world view?
Ms Harman: I can't see where it's helping children to cut welfare allowances, to cut grants to children's aid societies, to be cutting back on child care. I really can't see where that's helping children.
Mr Clement: What I was talking about was the fact that we seem to be more and more in debt as a society and as a government, and that takes away money because the interest on the debt means you can't spend that dollar on child services, on education, on welfare. That's what I was referring to.
Ms Harman: This is a very rich province. We pay our CEOs tremendous salaries. There is money in this province, and it doesn't have to come from the most disadvantaged people.
Mr Clement: So higher taxes is the solution, you're saying.
Ms Harman: We're saying fair taxation, progressive taxation, yes.
Mr Bartolucci: Mae, thank you very much for your presentation. It was excellent. You don't have to be a lawyer to speak from the heart and speak simple facts that make a whole lot of common sense. With that in mind, do you feel this bill is unduly harsh on seniors, and if so, how? Do you think you're being treated fairly, Mae, through this bill?
Ms Harman: I think that we're not being treated fairly in terms of drug benefits and some of the things that will be happening through municipal cuts. I've been involved in a press conference in Toronto on the question of what we're going to do with old-age homes, whether we're going to sell some of them off or close them or what we're going to do. I don't think we're being dealt with fairly in terms of long-term care. I can't foresee, of course. I don't know what the plan is for long-term care. That has not been revealed to me, except that I know what we worked on in our communities for several years now, in terms of planning, has been wiped out with doing away with the multiservice agency.
Mr Bartolucci: The minister, Mae, has said that a copayment is not a user fee. What is your definition of a "copayment"? Would you say a copayment is a user fee?
Ms Harman: I think in terms of drug benefits, it certainly is. You're paying in terms of what you're using, so that's a user fee. In the past, it was granted to us as seniors as a benefit.
Mr Bartolucci: Do you think the minister is given too much power with Bill 26 -- the Minister of Health in particular?
Ms Harman: I think there are a lot of ramifications that I haven't been able to analyse. The business of information about individuals' health and how the minister can have access to that and can give it out to others -- whether that is going to be changed or not is something I don't know.
Mr Bartolucci: Mae, if you look at this bill and its complexity, as you've alluded to earlier on in your presentation, would you like to see this bill split into many different sections and be dealt with --
Ms Harman: I think it's the only feasible way to handle these various pieces. They are just too much all wound up into one ball of wax.
Mr Bartolucci: Great. Do you think as well that these hearings should be extended so that everyone who wanted to would have an opportunity to take part in this process?
Ms Harman: Well, of course. This is a democracy. Citizens have the right to discuss legislation and debate it and make representation on it; at least I thought they had.
The Chair: Mr Bartolucci, did you want give Ms Lankin a chance here or do you want to keep going?
Mrs Caplan: I have one question actually.
The Chair: Not Mrs Lankin, I'm sorry, Mrs Caplan.
Mr Bartolucci: Go ahead.
Mrs Caplan: Is it all right? The government caucus have made the point that some seniors, particularly better off seniors, have said that they'd be willing to pay or help out if they thought it was reducing the debt and helping with the fiscal situation. Given the fact that there's a $5-billion tax cut that seniors, sick seniors and disabled persons are being asked to contribute towards, do you think that's what they thought they would be helping with when they said they would be willing to help? How do you think seniors, particularly the low-income and sick seniors, are feeling about paying a new user fee in order to see the rich get a tax cut?
Ms Harman: I think there's an illusion that there are a lot of rich seniors out there, and that is an illusion. There are very few rich seniors in the first place. In the second place, I think when people talk about "Well, a $2 fee for your prescription doesn't sound like very much," but if you're on very expensive drugs, as many seniors are and they get more expensive as you get older and sicker, then it can add up to a great deal of money. It's one thing to think of $2 now, but how many $2 and how often?
Mrs Caplan: Just to help with the definition, according to this government, you're a well-off senior if your income is $16,001.
Ms Harman: I know. That's really rich.
Mrs Caplan: Then you're rich and then you can contribute a deductible and pay the dispensing fee to contribute towards the tax cut. Do you think that's what seniors thought Mike Harris meant when he said no new user fees and we won't hurt the disabled or seniors?
Ms Harman: No, I don't think they thought about it.
The Chair: Thank you, Ms Harman. We appreciate your interest in coming to make a presentation to us.
2020
MEDICAL IMAGING CLINICS OF ONTARIO INC
The Chair: The next group, Medical Imaging Clinics of Ontario, represented by Dr. Nabil Bechai. Welcome, sir. You have half an hour to use as you see fit. Any time you allow for questions would begin with the government members. So the floor is yours.
Dr Nabil Bechai: Thank you very much. Members of the committee, I'm Dr Nabil Bechai, a radiologist and the director of MICO, Medical Imaging Clinics of Ontario. I would like to address the committee on the proposed changes to the Independent Health Facilities Act.
I would like to thank you for the opportunity to appear before the committee for two reasons: first, to inform you about what radiologists have done since their inclusion in the IHFA legislation in 1989; and second, to make some remarks about the proposed changes to the Independent Health Facilities Act.
First, I was among the many radiologists who appeared before the social development committee in 1989 when the government made a last-minute decision to include diagnostic imaging clinics into the Independent Health Facilities Act legislation without any consultation with the affected parties. At that time it was only through the strong objection of the province's 700 radiologists and the Ontario Association of Radiologists that we had the legislation referred back to the committee. As you know, radiologists are the only group of physicians who practise as a specialty under the Independent Health Facilities Act. As a consequence, we are uniquely qualified to provide advice on the legislation to date and to offer some constructive advice about how it could be improved.
As a result of the enactment of the IHFA legislation in 1989, radiologists have been (1), required to obtain a licence in order to provide community-based imaging care; (2), restricted from providing new services; (3), prevented from opening new offices; (4), not allowed to move to a new location without receiving ministry approval; and (5), subjected to higher administrative operating costs.
Since the passage of the 1989 legislation, radiologists under the umbrella of the Ontario Association of Radiologists have galvanized into action and continue to be active in many areas. Radiologists heard the wake-up call and organized to become the most proactive group of physicians in Ontario. Our relationship with the College of Physicians and Surgeons is held out as an example of how working in consultation rather than confrontation benefits the patients of Ontario. We have become extensively involved with officials from the Ministry of Health from the junior officer level to the minister on a wide range of matters. I'm pleased to say that most of these interactions have been positive and constructive for both sides.
The dominant theme of the 1989 social development committee hearings dealt with the government's concern about quality assurance in diagnostic imaging clinics even though no evidence of transgressions was offered. Following the hearings and our inclusion in the IHFA, we undertook to redouble our efforts to ensure that no such accusation about poor quality could be made. We immediately moved into action on several fronts. Radiologists became integrally involved in the Ministry of Health's internal IHFA committee charged with the development of the regulations. The Ontario Association of Radiologists developed a comprehensive quality assurance manual for radiologist IHF clinic owners. There are hundreds of QA manuals in circulation and in fact they have been ordered by many hospital diagnostic imaging departments.
Radiologists felt that it was necessary to develop an organization outside of the Ontario Association of Radiologists that could singlemindedly deal with all of the new demands placed on community-based independent health facilities. It is important to know that about half of outpatient diagnostic imaging exams are performed in independent health facilities. Of course, the other half is in hospitals. This represents approximately five million X-ray, mammography, ultrasound and nuclear medicine examinations done annually. It is a clear fact that the independent health facility clinics are a major component of the province's delivery of health care services which go beyond the capability of hospitals. MICO Medical Imaging Clinics of Ontario, which I'm representing, a corporation owned and operated by radiologists, was established in 1991 with a key objective of promoting high quality imaging standards in radiologist-owned clinics.
Unlike all other physician practices, radiology clinics are really akin to being a small business. Radiologists must invest a significant amount of their own money to purchase the expensive equipment necessary to operate a diagnostic imaging clinic. The average investment is well in excess of $500,000, with many clinics having equipment costs in the range of $1.25 million to $1.5 million. For example, an ultrasound machine could cost up to $250,000, an X-ray machine could cost $150,000, a fluoroscopy unit can cost anywhere between $250,000 to $600,000, a nuclear medicine camera can cost about $400,000, and so forth. In addition, imaging clinics require an extensive list of ancillary equipment and facilities, ongoing maintenance of equipment and are labour-intensive operations requiring a team of highly trained technologists. In short, these are expensive operations to run. Overhead in an imaging clinic is in the order of 75% to 80%.
The social contract has made it extremely difficult to operate clinics because the clawback has been applied to the overhead as well. A Deloitte and Touche management study which studied about 117 of the IHF clinics, commissioned by the Ontario Association of Radiologists in 1992, revealed that almost all of the clinics are operating at a loss. That's in 1992. I may add with the clawbacks that we have been facing, this has been significantly worse. MICO fears that further cuts to imaging technical fees, the fees which are intended to cover the overhead expenses, will force many diagnostic imaging clinics to close. I'm afraid that these clinics might close in the areas where they are needed most.
The goals and objectives of Medical Imaging Clinics of Ontario are as follows:
To assure quality of service to the public and the referring physicians;
To create an ongoing education program for radiologists and staff working in IHFs;
To establish an ongoing quality assurance program for diagnostic imaging clinics;
To focus the voice of radiologists when dealing with government and other institutions when dealing with matters relating to the IHFA, such as today;
To establish a source of expertise on regulatory requirements pertaining to the IHFA; and
To obtain the most commonly required items on a collective purchasing basis.
Each year, MICO's membership has grown to the point where it is now representing the majority of the IHF clinics owned by radiologists. In the past, MICO has organized many quality assurance and education seminars that have been attended by radiologists and technologists from all corners of the province. These all-day or half-day seminars have included courses on mammography, how to manage a clinic using quality management techniques, compliance with the IHFA requirements, addressing the College of Physicians and Surgeons' quality assurance process, and so forth. Officials from the Ministry of Health's alternate funding unit and senior representatives of the College of Physicians and Surgeons have made several presentations over the past four years at these educational seminars
Radiologists have also responded to the ministry's decision to nominate the College of Physicians and Surgeons as the body responsible for quality assurance in the IHF clinics. There are several radiologists who are active members of the college's radiology task force committee. Included in the membership of this committee are leading Canadian radiologists from teaching centres, as well as others who have extensive experience in both hospitals and imaging clinics. Furthermore, there are a large number of radiologists and imaging technologists who have volunteered to be college IHF assessors. MICO applauds the work of these two groups and can assure members of the legislative committee that this has been a very successful dimension of the IHFA legislation.
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An enormous effort has been made by Ontario radiologists to address all of the quality assurance requirements stipulated in the IHFA legislation and regulations along with their active participation in the ongoing implementation of the College of Physicians and Surgeons of Ontario's thorough quality assessment process. The ministry, in conjunction with the College of Physicians and Surgeons, has implemented the most stringent quality assurance requirements anywhere in North America. It is clear from our many conversations with senior ministry officials that the IHFA is seen as a model for the provision of quality assurance in medical practices. The expertise of the IHFA legislation has proved that radiologist-owned clinics have a superior record of quality to those that are non-physician-owned.
I would like to now turn to the proposed amendments to the Independent Health Facilities Act as currently proposed in Bill 26. There are a number of new elements in the legislation that cause us concern from the perspective of diagnostic imaging physicians.
Revocation of an IHFA licence: Under the existing terms of the IHFA legislation, radiologists had their clinics licensed for a five-year period with a reasonable expectation that the licence would be renewed as long as the clinic was providing quality patient care.
The legislation would now allow the Minister of Health to revoke an IHF licence before the end of the normal five-year term. In addition, the amendments make it easier for the minister to revoke a licence at the time of renewal in the name of cost-effectiveness without any right of appeal to the Health Facilities Appeal Board or to the courts and without the right to compensation. This is expropriation without compensation. This would have a catastrophic impact on individual radiologists who have investments ranging from hundreds of thousands of dollars to millions of dollars in high-quality imaging clinics. A revocation would force those physician owners into bankruptcy, cause staff unemployment and, most importantly, reduce the overall level of access for Ontario patients. I remind you once again that 50% of the outpatient imaging in Ontario is done in IHF facilities.
Any changes which the government wants to make in this area should be made in consultation and cooperation with radiologists. Radiologists can provide the lowest-cost diagnostic imaging services but such cost must recognize the enormous investment in capital which radiologists have made in and to the health care system. In this regard, radiologist-owned clinics are different. These clinics are different because the College of Physicians and Surgeons cannot discipline a non-physician owner, unlike the college's ability to remove a physician's medical licence. This remains an area of weakness in the legislation which has not been addressed. It is essential that the act not allow the government to arbitrarily close a clinic that is providing needed high-quality imaging services.
Changes to the due process: The proposed amendments remove the due process rights that are currently contained in the IHFA and in all existing statutes. The departure seems to be the trademark of Bill 26. The serious erosion of due process rights, a cornerstone of our legal system, will not be available to physicians operating under the IHFA. The removal of due process incorrectly suggests that the quality assurance program and the involvement of the College of Physicians and Surgeons have not worked, even though it is the most stringent in North America.
The government has greatly amplified the legislative authority and discretion extended to elected and unelected officials. We fear that the open-ended nature of this expansion of powers leaves the door open to abuse in the future with little or no appeal provisions for the affected parties. The government must recognize from their five-year experience with radiologists that the IHFA can be made to work successfully and that the inclusion of due process rights is a necessary and reasonable component to maintain balance.
Maximum allowable consideration: As mentioned previously, there is a sizeable investment in diagnostic imaging clinics. Radiologists were successful in getting the government to recognize goodwill value, known as the maximum allowable consideration, or MAC. The goodwill was grandparented into the legislation, although the value was frozen relative to the legislation's 1990 proclamation date. In Bill 26 there is an unclear reference to the creation of different MACs for different classes of facilities. It is unreasonable for the draft legislation to suggest the other medical practices that may be drawn into the legislation have no value. The committee should recommend that there be some clarity on this point.
Specific request for proposals: The proposed amendment provides the Minister of Health with the power to issue a specific request for proposals, RFP, which would allow the minister to select a party to provide services and to provide that party with one or more licences. MICO's concern is that this provision is open-ended and creates the potential for significant mischief. A situation could arise where a well-established IHF clinic has been serving patients in a community for many years and is suddenly faced with the fact that the ministry has awarded another licence which affects the viability of the existing clinic. It is the advice of MICO that such provisions should be tightly defined and provide preference to the existing IHF licence holders who are recognized as highly qualified clinical owners by radiologists who are currently operating in that area.
Removal of Canadian preference: The government's proposal to remove the preference for Canadian applicants seeking a new IHF licence opens the way to allow large American entities to apply to replace local Ontario expertise. It is questionable as to how the government would be able to enforce the same level of quality assurance provisions on foreign-owned and non-physician bodies.
Collection and use of information: The power to collect and use information is without any parameters and has been properly criticized by several critics, including the media. In some ways it amounts to treating physicians and patients with less respect and fewer rights than we afford persons charged with criminal offences. Secondly, it raises the issue of whether or not ministry officials are competent to be reviewing and second-guessing clinical decisions. Will all Ministry of Health's reviewers be physicians? Even so, how will they deal with areas of objective judgement? This is an area of tremendous potential abuse.
In summary, a strong and constructive rapport with the Ministry of Health's officials has developed by means of an ongoing two-way dialogue. Legislators and members of the general government committee should note that the IHFA has been a watershed in educating both radiologists and Ministry of Health officials that this legislation cannot become a workable statute unless there is a solid working relationship between diagnostic imaging physicians and ministry officials.
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Radiologists, through MICO, have worked closely with officials to modify draft regulations to make them workable. The collaborative relationship that exists between Ministry of Health officials, the College of Physicians and Surgeons and radiologists has proven to be a more meaningful way of delivering high-quality health care. Legislators should note that any of the new directions as proposed in Bill 26 will create ill-feeling and an unstable environment. For radiology IHF clinics, it is essential that a stable environment exist, particularly in view of the large investments that must be made so that we can maintain continued quality improvements.
In closing, I would like to summarize with the following points:
-- Quality assurance and high-quality management in IHF clinics is best delivered by radiologists and licences should be restricted to radiologists in the future.
-- The IHFA should not be expanded to allow American or Canadian businesses to provide for-profit imaging services. They should be delivered by radiologist-owned clinics on a local basis which have direct access to patients, their referring physicians and the local community.
-- Specific requests for proposals have the potential to be very damaging and should have more specific parameters developed with preference being given to the existing high-quality local providers.
-- Lastly, recognize the high cost of diagnostic imaging and the need to maintain a stable environment to provide patients with access to high-quality health care services.
The Chair: We have about two and a half minutes left per party, beginning with the government.
Mrs Ecker: Dr Bechai, thank you very much for coming and bringing forward your suggestions for amendments to Bill 26. I just wanted to clarify one of your recommendations. You say, "The IHFA should not be expanded to allow American and Canadian businesses to provide for-profit imaging services."
I guess what I'm curious about is, if you have an IHFA licence, regardless of who owns the facility, you would still have the same quality assurance and rules and regulations if you were going to be set up as an IHFA here, and if a physician were to work in such a centre, that physician would be subject to the same QA and regulatory powers of the College of Physicians and Surgeons.
I'm curious why you believe that -- profit or non-profit or American or Canadian -- the ownership has something to do with the quality. As I understand it, the regulatory requirements would be similar so that the quality assurance provisions which, as you quite rightly point out, have been very helpful in terms of making sure that the quality is maintained, would be the same regardless of the ownership.
Dr Bechai: I think you may have asked two questions in your question. There are two things here.
The first one, which is easier -- I'll deal with it first -- is the for-profit. I'm not sure that with the tight supply of money we have today in Ontario, we want to give the entrepreneurs the health care dollars which should be used for actual health care. I'm not sure that that is the foremost, best way of spending money, health care dollars, which are very scarce. We are closing hospitals now, and I'm not sure that the government is really interested in putting the money in the pockets of people who want to do it for profit.
The second thing is that when it is done by a physician who owns the clinic, that physician is totally under the control of the college as opposed to if the physician is working for someone else who wants to cut corners simply because he wants to make a profit. That person might cut corners and the physician is really caught in between a rock and a hard place because he has to keep his job, but on the other hand has to live within the constraints that the owner gives. The owner does not have the College of Physicians and Surgeons to deal with. The worst thing that can happen to that owner is that they might suspend his licence for a period of time until it will be reinstated, and the quality here is in question.
Mrs Caplan: First of all, let me say it's very nice to see you again, and I'm glad the IHFA has worked out as well as you report. I remember the last time you came before the committee some years ago. Were you consulted by the government as to what it was planning to do as far as changes to the IHFA?
Dr Bechai: No.
Mrs Caplan: No consultation?
Dr Bechai: No. We hope there will be further consultation.
Mrs Caplan: After the bill's passed?
Dr Bechai: Hopefully before, and in developing the regulations.
Mrs Caplan: You're aware that they wanted this bill passed before Christmas?
Dr Bechai: Unfortunately, but it's not the case any more.
Mrs Caplan: If they invite you for consultations now, you would propose amendments to this legislation?
Dr Bechai: Definitely, as we have suggested here.
Mrs Caplan: I hope they listen to you and I hope we'll see some amendments forthcoming, because the IHFA has worked well, and you're here today, I think, with some very important messages for this government.
Is there anything further on the consultation side? You said you've had a very good relationship with the ministry. Were you surprised that they didn't consult with you about this?
Dr Bechai: I think yes, but we can understand how it happened. With Bill 26, there are so many amendments to all kinds of different statues that we can understand what happened. But having seen what happened, I think it is very important that from now on there will be consultation, and if there are amendments to be made to the bill, I hope that the government will be open to consultation and amendments as required.
The Chair: Thank you.
Mrs Caplan: Would you recommend that they deal with the bills individually as opposed to one big package? Would that have been easier, do you think? Was that the last question?
The Chair: That was the last question, yes. Ms Lankin.
Ms Lankin: I only have a couple of quick questions. You indicated you're hopeful that between now and January 29, which is the government's stated date for passing this legislation, you'll have an opportunity to participate in consultation and to submit some amendments.
I'm wondering, from looking at the comments you've made and trying to look at the provisions under the Independent Health Facilities Act, whether it's amendments that you're looking for or whether you wish the government not to proceed with the amendments that are proposed in Bill 26. Are there portions here that you have looked at and do support? Could we perhaps distinguish?
Dr Bechai: I think we looked at the act or the amendments. Some of our recommendations are, for example, not to allow for-profit, non-Canadian interests, and this would in fact be removing some of the amendments proposed. In other areas we would like to just change or alter the recommendation a little bit, and in some other areas it's okay as it is. So I think we are not totally negative, but certainly there should be some changes.
Ms Lankin: I think one of the problems that we're all going to have as we deal with this -- I should tell you, the members of the other committee down the hall have all decided to take a poll among themselves, or a pool actually, with respect to how many amendments are going to be tabled by the government on those bills that are down there. We might do the same with respect to the health sections here.
I think the problem we're going to have is one week to deal with a large variety of amendments. I personally hold the point of view that it would still make sense for us to break this down into some chunks. I don't think we will do the public process justice by January 29.
Having said that, as you go through, and if you are in a position to have some further consultation with the government and you actually provide it with recommended amendments flowing from your comments, I hope you will share those with all members of the committee, because it will be here in the committee, in clause-by-clause, that we have an opportunity to pursue those amendments, and we would appreciate it if you would table those with us very soon.
The Chair: On that note, Dr Bechai, thank you very much for your time tonight. We appreciate your being involved in our process.
That is our last presenter for tonight. Just a couple of housekeeping things. We will not be in this room tomorrow, we'll be down in committee room 1, so take everything with you that you own.
The committee stands adjourned until 9 in the morning.
The committee adjourned at 2050.