1996 ANNUAL REPORT,
PROVINCIAL AUDITOR
MINISTRY OF HEALTH
CONTENTS
Thursday 20 February 1997
1996 annual report, Provincial Auditor
Ministry of Health
Mr Charlie Bigenwald, acting assistant deputy minister, health strategies
Ms Hania Kralka, manager, alternate payment program
Ms Mary Catherine Lindberg, assistant deputy minister, health insurance and related programs
Ms Marsha Barnes, director, provider services branch
STANDING COMMITTEE ON PUBLIC ACCOUNTS
Chair / Président: Mr Bernard Grandmaître (Ottawa East /-Est L)
Vice-Chair / Vice-Président: Mr Richard Patten (Ottawa Centre /-Centre L)
*Mr Marcel Beaubien (Lambton PC)
*Mr Dave Boushy (Sarnia PC)
Mr Gary Carr (Oakville South / -Sud PC)
Mrs Brenda Elliott (Guelph PC)
*Mr Gary Fox (Prince Edward-Lennox-South Hastings / Prince Edward-Lennox-Hastings-Sud PC)
*Mr Bernard Grandmaître (Ottawa East /-Est L)
Mr John Hastings (Etobicoke-Rexdale PC)
*Mr Jean-Marc Lalonde (Prescott and Russell / Prescott et Russell L)
*Ms Shelley Martel (Sudbury East / -Est ND)
Mr Richard Patten (Ottawa Centre /-Centre L)
Mr Gilles Pouliot (Lake Nipigon / Lac-Nipigon ND)
*Mrs Sandra Pupatello (Windsor-Sandwich L)
*Mr Derwyn Shea (High Park-Swansea PC)
*Mr Toni Skarica (Wentworth North / -Nord PC)
*In attendance /présents
Substitutions present /Membres remplaçants présents:
Mr John R. O'Toole (Durham East / Est PC) for Mrs Elliott
Also taking part /Autre participant:
Mr Erik Peters, Provincial Auditor
Clerk / Greffière: Ms Donna Bryce
Staff / Personnel: Ms Elaine Campbell, research officer, Legislative Research Service
The committee met at 1042 in room 228, following a closed session.
1996 ANNUAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH
The Chair (Mr Bernard Grandmaître): The floor is yours, Mr ADM.
Mr Charlie Bigenwald: I'd like to just say a few words about the overall direction of the Ministry of Health that's contained in our business plan. We just finished up actually going through our second year of preparing a business plan.
I think it's safe to say that over the last couple of years there have been major changes in health care in Ontario and right across Canada. Those changes have required looking for new ways of providing service but always keeping in our vision of health care the patient first.
We welcome the work that our internal audit function provides the ministry as well as the insights we receive from the Provincial Auditor, because often in times of change it's important that we have an outside view of some of our changes to make sure that the management controls and accountability evolve with the system.
With the alternative payment program specifically, the auditor's recommendations have identified, I think, three or four areas, primarily weaknesses in reporting and monitoring, documentation and accountability. We agree with the directions of the recommendations and it has encouraged us really to take another look at setting measurable standards, developing better data collection systems and performing timely reconciliations. We'll go into a little more detail on each one of the recommendations of the auditor in a minute, but there are three major things that have been instituted.
The first is moving to automated reporting systems where just up until recently we had a combination of some automation and some paper systems. We're now requiring that automation and we're going back to many of our earlier agreements to make the changes.
Second, we have in place in the ministry a senior management committee that reviews all of the mandates of all of the agreements and essentially provides direction on which agreements will be changed, which new ones will be negotiated.
Third, we have been requesting annual financial statements from all of the alternative payment program sponsors as well as the reporting and monitoring that we're putting in place.
I'd like to say a little bit about the history. I think it's important you understand where these alternative payment plans came from.
Early in the 1970s and pretty much through until the late 1980s, the alternative payment plans were a mechanism for small groups of physicians to provide services that were not necessarily well provided by the fee-for-service system. For things like pain clinics, rehabilitation centres and a variety of other agencies, the fee-for-service code system was not good enough for individuals to be able to provide the kind of services they needed to provide. So they would come into the ministry and ask for an alternative payment system, and we would negotiate a system with them to more or less give them block funding or program funding to carry out the functions they needed to carry out.
By definition, one of the things that happened early on was that the fee-for-service system, and subsequently the billing system, did not fit the provision of service. There was a mismatch. We did not get detailed service reports on many of those agreements because, by definition, they were providing other kinds of service than what the codes allowed us to track. Frankly, early on we were quite pleased in many cases to even find physicians to provide some of the services that we needed provided that weren't being covered.
During the late 1980s, or throughout the 1980s but culminating towards the end of it, we found a massive growth in payments to physicians. Between 1980 and 1990, the growth of the OHIP or the insurance budget was 232%. It grew from $1 billion to about $3.5 billion. During the same time period, the ministry grew by about 200% and the payments to hospitals grew by 170%. The point is that the physician payments were growing faster than the other major components of the ministry.
As a result of that, the ministry began to be a bit more aggressive in attempting to negotiate larger alternative payment plans with larger numbers of physicians or larger parts of hospitals in a variety of other settings. What the ministry received or got out of these agreements with larger institutions was some cost containment. We were able to get some funding predictability and it wasn't open-ended like the fee-for-service system was.
Physicians, on the other hand, or the sponsoring agencies in these agreements, got predictability, which often was helpful in their ability to plan what they were going to do over a period greater than one year, and it also allowed them some flexibility to be able to make changes in the way they deliver services such that it was more efficient.
To encourage physicians -- again I'm talking about in the late 1980s -- to join some of these plans, often some extra funding was put into the plan, extra than just the amount of money they used to bill for fee-for-service, moving it over to the alternative payment plan. That extra money was an incentive in some cases to provide different services, more services, and often it was the money that was available to cover other reporting mechanisms and some of the things that they may not have had to do if they were on a fee-for-service basis.
We move then to the early 1990s, and we were still quite active in negotiating new agreements and dealing with some of our older agreements. After the 1991 physician agreement, however, the contract with the Ontario Medical Association, the dynamics of those agreements changed a bit. If you recall, under that agreement the OMA was formally the bargaining agent, negotiating agent, for physicians at all of these tables. That made some of the changes that we wanted to introduce a bit more difficult.
For example, obviously the Ontario Medical Association was very concerned and very narrowly focused on the preservation of the fee-for-service pool of money. They were not interested in converting any more money than was absolutely necessary, the absolute minimum amount that the physicians previously had been billing into the new system. That made it difficult. Either the reporting wasn't done, or in some cases the ministry had to come up with new sources of funding over and above what was converted from the fee-for-service pool to allow for that extra reporting to be undertaken.
Second, by definition, many of these agreements were being negotiated within existing agencies, primarily large teaching hospitals that were under a series of bylaws, were under legislation, and had a fairly tight management and professional control due to the contracts they had with universities or the contracts they had with professionals. The combination of that with the change in the way the services were delivered in some cases did not lead to increased specific reporting of individual services.
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We have some good examples of alternative payment plans in terms of what they've accomplished for us over time. One notable one, for example, is a walk-in clinic at the Sick Kids Hospital where previously individuals would go directly into the emergency room. They now have the ability to triage individuals who don't actually need the emergency service and send them to the clinic for less serious services.
As we come up to the current date, I think the Provincial Auditor's report does point out many of the difficulties we had. Since the recent legislation which allowed the ministry to go back and open up some of these agreements without the OMA present or without the negotiation right of the Ontario Medical Association, we've been able to begin to retrofit and require many of the sponsors of these agreements to do some of the reporting I think that the Provincial Auditor has pointed out.
Inside the ministry, because of the massive growth of the alternative payment plans between 1985 and 1997, the overall budget for these plans grew from $14 million to about $120 million. That has required us to automate, it has required us to hire new staff. We have a new focus within the ministry negotiations secretariat responsible for the negotiation side of those agreements and we now have a larger staff in place to help us manage the existing agreements.
I'd like now to introduce Hania Kralka, the manager of the program, who will address the individual recommendations of the Provincial Auditor's report.
Ms Hania Kralka: Thank you, Charlie. Good morning, ladies and gentlemen. It has been a very busy and challenging few months since the audit report came out. I have certainly had my share of, I would consider, woes in trying to address that since then and I have been delighted to do so actually. We have been implementing changes and improvements. Many started even before the audit and we've made sure that they've continued and improved.
The ministry focus in this past year, 1996-97, has been to negotiate agreements in underserviced areas and in underserviced services. We have not been able to renegotiate or negotiate new agreements in my program so we have taken this opportunity to initiate changes in policy, and the policy has been to standardize and automate all the reporting data. We report now primarily through shadow billing. We have an implementation plan which indicates that by the end of 1997-98 all contracts will be reporting on shadow billing.
Just so you all know what shadow billing is, it is reporting service data paid at nil so that we now have all the service data but there are no dollars attached to the service data because the dollars are paid through my program.
The implementation schedule I've mentioned that plans to have everything done by the end of 1997-98 has added eight clinics since the summer. We now have 19 clinics on shadow billing, which is an improvement of 70%. We also have just recently sent out an additional nine registration letters and they should be shadow billing hopefully by April 1.
We've also required programs to review fee-for-service activity both in and outside of an APP. When you have an alternate payment plan, which I always refer to as an APP, physicians can continue in certain instances to bill fee-for-service for services outside the scope of the agreement. We need to monitor this to make sure we don't have a duplication, so we have developed additional requirements documents. This is where we identify all the work that is going on inside the agreement. We list physicians. We have put in plans to make sure that physician lists are updated, and we monitor this very carefully. This is progressing, as well as the shadow billing, so we are trying to do this hand in hand.
It certainly has not been easy and there have been a lot of problems and a lot of objections on the part of the physicians. Many of these groups of physicians have had alternate payment arrangements for a long time and have done no billing for the services provided. They do have a fear that if they shadow bill, not all their services will be captured simply because they have been doing things differently. That was the reason why they had an APP to begin with.
We have approval now, and this really did just happen within the past few weeks, to begin what we now call enhanced shadow billing, where we have developed new codes. We will do this in partnership with individual contracts, where we will develop codes to identify some of the different and new services that these physicians are doing under APPs. We will then have a better picture of what is going on. We'll have more integrated data but we will not have dollar values, so that we won't mess with the accounts, so to speak. Certainly this will make all data more meaningful both to the ministry and to the contractors. They'll get a better picture of what they're doing.
We are also asking for audited financial statements now. We do have contracts which say these statements will be provided as required. Since we have not been able to renegotiate or even negotiate new agreements, we've been asking for these financial statements now probably a little earlier than we might normally, because we would only ask for these financial statements before a renegotiation so we could see where they were at.
We are trying wherever we can to also make these financial statements an annual event so that we then can have an update. We did go back in many of the agreements where we thought we could find some money. We went back to a five-year period and we have now recovered over $1 million. However, I have to be honest that we've also uncovered many shortfalls where we have not been able to fund, and now these agreements, when we do come to renegotiate, may be coming back and asking for additional money. So we've uncovered two things.
We're also participating in what we call GAPP, which is a generic APP data collection system. This system is using one of the largest contracts that we have as a model, and we hope this will be a model that can be used across many more APPs eventually, when it is complete. So far, the data that have been received have shown significant advantages over OHIP. We hope to expand the project and we now are getting a lot of diagnosis and a lot of procedure data we did not get before.
We certainly think that all this improved reporting will support more effective evaluations. We think that evaluation is a key component of all APPs and it's certainly something that we're doing more now. We are seeking additional evaluation expertise, both inside and outside the ministry, and certainly two of the staff that I've hired since the summer -- prior to that we had surplus staff in those positions -- have evaluation expertise. We made sure they had this before they came on with the program.
If I could just take a few minutes now to go through each recommendation and indicate what we have done, since this is something that is not in the audit report, how we have updated the response.
The first recommendation dealt with the need for formal agreements. As I have mentioned, we have not been able to negotiate this past year. However, we are prioritizing our renegotiations for 1997-98 and we have standardized and automated a lot of our reporting, so we hope this has gone a big step forward.
The second recommendation dealt with value for funds. They recommended that we submit service data and audited financial statements and that these be reconciled on a timely basis. We thought this recommendation dealt primarily with what we call funding letters that did not have all the information specified as far as reporting. We are implementing shadow billing on the funding letters first off, before we do contracts, and we are asking for audited financial statements. We are recovering the money, as I indicated, over $1 million, but we have found and uncovered a lot of shortfalls.
The third recommendation: Requests for increases should be documented and assessed. We certainly are trying to do this better than we have done before, and as Charlie mentioned, there is a senior-level ministry mandate committee that now reviews all changes.
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To avoid duplication, OHIP data should be compared and physician roster changes documented. As I mentioned, we are registering with shadow billing. The registration process has made physician numbers and physician changes more accurate and more available to us, and we have also updated all the procedures, including the requirements documents.
The auditors next recommended that we link clinical research and education to measurable performance targets. This is in academic health science centres. As Charlie mentioned, they do have a lot of protocol and rules and regulations there already in the institutions and in the university. However, we will continue to participate in evaluations, and it is in these evaluations that we hope to develop more performance measurement targets.
The next recommendation dealt with evaluating committed funds for research and the specific level of detail and enforced reporting requirements for all clinical research and education activities. We have reviewed academic health science centres' submissions so far in their reporting. We have assessed them for updates and we have asked for financial statements whenever we can.
The next one is that we develop a data collection system that is timely, and in the meantime physicians should provide info to OHIP. We felt that this dealt with the GAPP project in the large academic health science centre. There was some data missing in 1994 and 1995. We now know that the new data that is coming in is even better than before, so we hope to somehow be able to go back and pick up some of that old data, but in the meantime we feel we are getting better data.
The second-last recommendation tells us to verify funds incorporated into future agreements and evaluate their use. In developing globally funded agreements, we had to use estimates, and we feel these estimates can be adjusted either in midterm or at the time of renegotiations. We will probably be adjusting both upwards and downwards in these agreements.
The last recommendation dealt with the effective provision of medical services, that we should develop guidelines for evaluation and for reporting. I think we've made a lot of progress in this. We have developed committees and teams in the ministry that will be dealing with evaluation both externally and internally.
In summary, I'd just like to say that we've recruited staff with specialized skills and expertise to support and stabilize reporting and evaluation. We have sought to standardize and automate all reporting. We have supported monitoring evaluation and value-for-money audits whenever we can. We have made significant recoveries. We have participated in the continuing evaluation of new reporting systems that will hopefully provide more meaningful and integrated information for the ministry.
We certainly are supportive of the program. We would like to keep on addressing and meeting the challenges that lie ahead, and we certainly are grateful for the Provincial Auditor to point out where we needed more improvement. I do think we've achieved a lot of significant results. Thank you.
The Chair: We've extended our time by five minutes, so we'll split 10 minutes between the caucuses.
Mr John O'Toole (Durham East): Thank you very much for your presentation. I'm a substitute on this committee, so forgive my lack of information, but something you mentioned caught my interest and so I'll ask a specific question. Walk-in clinics: They are an APP, I guess?
Ms Kralka: No.
Mr O'Toole: Are they not? You mentioned it, though, in your remarks. How do they get paid? They seem to be growing like wildfire.
Mr Bigenwald: Normal -- I perhaps misuse the term -- walk-in clinics are paid like normal fee-for-service doctors, so the doctors just bill for that service. The specific walk-in clinic I mentioned was an add-on in the Hospital for Sick Children which was a substantial improvement, and the only way they could do that was with an alternative payment plan.
Ms Kralka: They use the same money and split the --
Mr O'Toole: But it all comes out of the fee-for-service, the whole pool, right?
Ms Kralka: Originally, yes, the money came out of it.
Mr O'Toole: All of the money kind of comes out of the one big envelope, and some of it's APP, some of it's fee-for-service --
Mr Bigenwald: Correct.
Mr O'Toole: Is there any other method of -- I guess some doctors are paid on salary or something like that. Does that come out of the same pool?
Mr Bigenwald: Physicians who practise in community health centres are on a salary. That does not come out of the same pool.
Mr O'Toole: I'm told at Sick Kids they're all on salary. Do they have a physicians' agreement, or how does that work?
Mr Bigenwald: We have a contract with all of the physicians at Sick Kids.
Mr O'Toole: I'd ask the same question as the auditor: How do we know what we're getting? I think it's wonderful. I'd like a rostering system, technically, of some sort, and say if you have a lot of people with high needs you should probably make more. How do we account for having a lot of specialists making a couple of hundred thousand or whatever -- I have no idea what they make and I don't need to know.
Mr Bigenwald: The agreement with Sick Kids is a fairly extensive one, and that is one of the places where we do have a fairly rigorous reporting system. To generally answer your question, we negotiate up front the kind of thing they're going to do. In essence it was the kind of thing they were doing in the past. They are controlled quite rigorously professionally by the college but they're also controlled under the laws and the management of Sick Kids hospital. We think we have a pretty good handle on the Sick Kids agreement in particular and what they've done. How long has the agreement been --
Ms Kralka: The first one was in 1990, and there was a second one in 1994.
Mr O'Toole: Just one last question if I may. Very interesting. Thank you for your candid response.
The other thing I wanted to know -- there are two sides to the shadow billing as well. I would hope we were doing it so that we were getting value for money. You need to do it; otherwise you have no idea what you're doing. But that is the case too that would prove their case. We've now given them the very weapon to beat us over the head with and say, "Look, for $3 million you're getting $4 million worth of fee-for-service." Is that the way it really works? Do they get the data that you're collecting under the shadow billing? They know what they're worth?
Ms Kralka: Yes, they do.
Mr O'Toole: That's interesting. There's an advantage in having the security of funding, though. That argument should be made as well, that you say, "You can go and buy the building and all the good stuff that gives you this great income."
Thank you for your time.
Mr Jean-Marc Lalonde (Prescott and Russell): Thank you, both of you, for coming down and telling us what your ministry is doing to improve the health system.
I don't want to question the research that is going on or what you have done up to now, but I feel at the present time that your ministry has a $17.7-billion budget and the mistake that I think is going on at the present time is we're trying to implement some of the changes that you are doing some research on a little too soon, before the mechanism is in place. We've seen many times, and especially this morning we had discussion of some additional expenses that are going on and reducing the services instead of improving the services. I think it's your duty and your task to make sure the patient gets the better service at the lower dollar.
I was just listening to Madam's comment a little while ago and also Mr O'Toole had just brought it to our attention. I really feel the walk-in clinic is the future to save money and to improve services. The previous government had started to create some community health centres in different municipalities or in different areas, similar to the CLSCs in Quebec. I know hospitals are really against this system and doctors are against it because in those community health centres the doctors are paid on a salary basis instead of a per patient basis. But the cost between having a patient go to a community health centre and a patient go to the hospital emergency is a big, big difference. It is a saving, and you don't get better service going to a hospital many times for a little cut at the end of your finger.
But my worry at the present time is that, yes, we are all looking forward to some new changes, but the problem is we're trying to implement them too early. We are negotiating contracts like we do with hockey players, baseball players at the present time, before the contracts have expired and very often at lesser service and at higher costs. I think this is the part that you people will have to look at very closely to continue getting the best services or the best health care for the people of this province.
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I wonder if you people, before you implement some changes, are reviewing every case for what the impact is going to be. Are we going to be able to give better service? At the present time we know we have gone through this mega-week, we call it, but we came down with so many changes that the people in this province did not know where to turn their heads, so everything is going through without analysing anything. So I wonder if you people sit down with your chef de service or the head of a different section before you implement any new services within the health department. Do you sit down before you implement a new service?
Mr Bigenwald: I would make two points, I guess. One is there's no doubt that the changes within health care have been increasing in velocity and that has put a great strain and a responsibility on us to do as well as we can to ensure that the impacts are either mitigated or that we know what the impacts are.
I think if you look at, for example, some of the recommendations of the Health Services Restructuring Commission, they have been particularly sensitive in their recommendations to the fact that you can't just do something with a hospital and not something in the community out here. So the recommendations to the hospitals from the commission deal specifically with hospital issues, but the recommendations that have come in to the minister deal with all of that other activity. I think you'll find, particularly in the case of a couple of the early reports that have come in, we've already initiated or are getting under way some of those community-based things that need to be done to support the changes on the hospital side.
Ms Shelley Martel (Sudbury East): Sorry if you've mentioned this and I didn't catch it. Can you give me what the province pays right now for the alternate payment plan?
Mr Bigenwald: The current budget for all of the alternative payment plans is about $120 million.
Ms Martel: Just so I'm clear, is that all outside the OHIP pool now? Under the OMA agreement with the government in 1991, was a portion of that shared between the OHIP pool -- no, it wouldn't have been, except for some physicians you've identified who are doing both. Everything else is outside of that pool now?
Ms Kralka: In 1991, with the agreement with the OMA, the alternate payment program was smaller. From that point, every time we negotiated an agreement we converted money from the pool into the program. If we terminated a contract, the money went back into the pool.
Ms Martel: In terms of the change that this government has made, what is the policy now around funding new agreements, and if agreements are terminated, where does the money flow back to?
Ms Kralka: Right now the money continues to flow back into the fee-for-service pool if it's terminated. As far as the change is concerned, there are negotiations going on right now and conversion, I understand, continues to be an issue with the OMA.
Ms Martel: I think you mentioned a couple of times in your remarks that you've not been able to undertake any new agreements in the last year. Am I correct?
Ms Kralka: This was the ministry's own decision where it was going to focus its time and efforts in APP negotiations, and where it decided was the north, the community-sponsored contracts, the globally funded agreements that are now hopefully going to be in place soon. That's where the focus has been: to develop policy and to put efforts into placing physicians there first. Now I understand this is the year when we're going back and opening up again other agreements on a broader base.
Ms Martel: But the issue of where the money is going to come for new agreements has not been resolved yet.
Ms Kralka: It's still under negotiation with the OMA, I understand.
Ms Martel: You mentioned something about some work in underserviced areas which I was curious about. Can you just expand on that, because good portions of the riding I represent have already been declared underserviced and remain without physicians.
Mr Bigenwald: If you recall the announcement of the community-sponsored contracts a few months ago, we've put a lot of effort into all of those communities -- I think there were 21 communities involving 39 physicians -- but each one of those communities was a separate negotiation between the physician, the community and the ministry. We've put a lot of effort into trying to nail all of those down as fast as we can because those are the areas in Ontario, largely in the north, that historically and chronically have been unable to attract physicians.
Ms Martel: How close are you to having completed all those, or do the numbers that you gave me represent completed negotiations with communities?
Mr Bigenwald: No, they're not all completed. I believe we're close. Out of the 21 communities that were identified, I believe we have somewhere on the order of eight or 10 completed; I think we have another eight or 10 under negotiation; and I believe there were a couple of communities that have declined the opportunity at this point. I could get you an update on those numbers.
Ms Martel: If you wouldn't mind, that would be helpful. Then over and above the 21, I'd be interested in knowing what the current status is of how many other communities remain on the list, because I take it the 21 do not represent negotiations -- probably about half -- of the communities that are probably on. There are usually about 40 that are --
Mr Bigenwald: Yes.
Ms Martel: I would appreciate having that information.
Tell me the nature of the recovery. You talked about $1 million that had been recovered. Can I ask in general terms what was the nature of the moneys that were recovered? Was it just people not reporting accurately, or was there some common thread that you saw all the way through? Conversely, because you've been doing the shadow billing, what is the nature of the -- I don't want to say new services -- but perhaps services that weren't covered that you may well have to look at then because they have been discovered through this review?
Ms Kralka: Some of the money that we recovered, and we went back five years to find this money, we recovered through, I'm going to use the word "misunderstanding," where physicians billed for services within the agreement. These were not large amounts, but we did find some money where physicians billed. In other cases where we had assigned money for, say, a number of physicians -- in one case we actually had a physician die at the beginning of a fiscal year very suddenly, certainly was not expected to, and they couldn't find anybody to replace that physician. That caused a deficit in the program. They kept hoping they would find one. So we recovered that money because they were not able to find one within a fiscal year.
In other areas their projections had been wrong; in other areas bed numbers went down, patient numbers went down, and we were able to address this. As I said, we have a problem where we have discovered a lot of what they would consider to be legitimate shortfalls that we have not paid for. We still have not addressed this and we expect they will be coming back.
In shadow billing, because these programs are trying to get away from volume-driven, fee-for-service practice, we find that the shadow billing usually comes out to be less than, in dollar value anyway, what they provided under OHIP, which is why we're trying to put in enhanced shadow billing, where we will try to identify some of the things they're doing over and beyond, to see that we are getting value for our dollar and there is something being done.
The Chair: Thank you. We must go on. Thank you for being our guests this morning.
We'll go on to section 3.14. Again, the ADM is our guest this morning, if I can call her our guest, Mary Catherine Lindberg, health insurance and related programs, and Marsha Barnes, director of provider services branch. Good morning.
Ms Mary Catherine Lindberg: Thank you very much for the opportunity. This morning I'm speaking about the independent health facilities and not drug programs.
The independent health facilities represent a unique response to the challenge of dealing with the development of facilities in which complex procedures are performed outside hospitals. Ontario was the first province to enact such legislation in 1990. About 1,000 facilities are licensed and funded under the Independent Health Facilities Act; 22 are ambulatory care facilities in which a variety of surgical or other invasive procedures are performed, and the remainder are diagnostic facilities.
Much of our effort in the early years of the independent health facilities involved dealing with the major implementation requirements such as revising the OHIP schedule of benefits for physician services to show which services have facility fees -- for example, a service when performed out a hospital would have costs for equipment, staffing and supplies -- identifying the owners of existing facilities who were entitled to apply for a licence, such as those who owned or operated a facility providing covered services at the time the legislation was implemented; setting licensing conditions and terms of funding, as well as establishing a method of payment of facility fees to the licensed facilities.
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There are two other significant components of this act. One is the planning provisions and the other is the quality assurance provision.
The planning provisions give us the ability to manage the number and location of non-hospital facilities that fall under the act. To appreciate the need for this, we have to look at the history of the act.
In the late 1980s, the government had three choices for dealing with the large variety of physician services that had historically been performed in hospital. If we use surgery, it's a good example. The OHIP fee for many surgical procedures assumes they would be performed in hospitals. In other words, the OHIP fee covered only the surgeon's remuneration. The hospital's global budget covered the cost of actually carrying out the procedure.
As these services moved outside the hospital, the OHIP fee still paid the physicians, but there were no funding costs. That had always been paid through the hospital's global budget. Patients were being charged facility fees, even though the service was an insured medical service.
Faced with this situation, there were three choices. The first was to put new fees into the schedule to cover facility costs, fees that could be billed by a physician anywhere in Ontario. The result would have been a host of unregulated private facilities competing with our hospitals.
The second choice was to allow patients to pay for the costs of these insured services outside the hospital. The result would have been a two-tiered system, in violation of the Canada Health Act.
The third choice was to fund the cost of these services only in licensed facilities, and this is the result, the development of the Independent Health Facilities Act. In other words, we have legislation under which we can fund the cost of providing insured services outside the hospital. However, the act allows the ministry to fund only the costs in licensed facilities and makes it illegal to charge patients. The Independent Health Facilities Act safeguards the health care system from patient charges for insured services. Any new licence would require that the ministry issue a request for a proposal and this includes an informal evaluation process which is an important planning device. This process has resulted in some new ambulatory independent health facilities, such as a laser dermatology facility in Ottawa, and three new dialysis clinics in Peterborough, Ajax and Stoney Creek.
The total number of ambulatory independent health care facilities is 22. These facilities are funded by the ministry for the insured services they provide. They are funded on the basis of an approved budget of $13 million. The quality of care provided in the ambulatory care independent health facilities have been assessed more than once and the results indicate that the professional standards have been met or exceeded.
The independent health facilities legislation also covers a number of diagnostic services that are funded under the OHIP schedule of benefits for physician services. Only licensed independent health facilities can bill facility fees that are really technical fees that are listed in the independent health facilities schedule. The professional fees are listed in the OHIP schedule of benefits. The fees billed by diagnostic independent health facilities are included in the OHIP fee-for-service pool.
At the time of the introduction of the independent health facilities, all existing IHFs were grandfathered under the act and there have been no requests for proposals for any new diagnostic independent health facilities. There are currently 950 licensed diagnostic independent health facilities. They provide the following services: diagnostic radiology, diagnostic ultrasound, pulmonary function tests and nuclear medicine studies. The total annual funding for diagnostic independent health facilities is $160 million.
The auditor recommended the ministry develop criteria for determining when an independent health facility should be extended to diagnostic services currently not caught under the act. He cites quality assurance reasons for extending the independent health facilities in this way, as well as being able to do more planning and system management.
In 1996, amendments to the Independent Health Facilities Act were proclaimed which made it possible to extend the act to include additional medical services. The College of Physicians and Surgeons and the Ministry of Health are developing criteria to expand the services licensed under the act. The criteria being developed seek to provide a way to distinguish between services whose quality can be regulated adequately under the quality assurance provisions of the Regulated Health Professions Act and on the other hand services that would be more appropriately brought under the Independent Health Facilities Act for planning system utilization or quality assurance programs.
These criteria address quality assurance as well as the growth in service delivery. Amendments also facilitate using the act to help hospital restructuring. We recognize that we must proceed in expanding the number of independent health facilities with care. We don't want to undo the efficiencies achieved by hospital restructuring by prematurely creating a large number of new independent health facilities.
The Independent Health Facilities Act quality assurance program mandates a major role for the College of Physicians and Surgeons in implementing and assuring all IHFs in which physicians provide insured services. The College of Physicians and Surgeons has developed practice parameters and facility standards for all licensed services. These are drafted by a special task force, usually appointed by the college. They are then reviewed by external professional groups and revised before being adopted.
The CPSO also appoints and trains medical and technical assessors to carry out onsite visits and to report to the registrar of the college, but these visits must be requested by the director of the independent health facilities. The CPSO registrar provides the director with a detailed report which lists positive and negative findings and proposes remedial action. In the case of adverse assessments, the director orders the operator to correct the deficiencies and may impose sanctions, such as suspending, revoking or refusing to renew a licence or part of a licence. Any order to correct deficiencies is accompanied by a demand that the operator submit a plan to the CPSO and meet with the CPSO to ensure that this plan is adequate. A reassessment ensures that the plan has been implemented.
In the case of positive assessments, the ministry also provides feedback to the operators to facilitate continuous quality improvement. The average ministry turnaround time from the time we receive a CPSO report is just under one month. Where an assessment is unfavourable, the ministry seeks to expedite the case so it is as much as a one-week turnaround. Please let me note where an immediate threat to life, health or safety is observed, the ministry's four-day target turnaround can be and has been met.
Experience with the independent health facilities has shown that there are major achievements in reducing the utilization of services captured under the Independent Health Facilities Act over those currently being provided by the fee for service through the schedule of benefits. As well, we have a respected quality assurance program that ensures there's a high quality of services for the Ontario residents.
The ministry values the auditor's report, as it helps us make this program achieve even better results and is a unique and very important program to the ministry. I have Marsha Barnes with me, who's actually designated as the director of the independent health facilities. We're prepared to entertain any questions you have on this program.
The Chair: We've got lots of time, so we'll start with the third party.
Ms Martel: I just want to clarify: I understood you to say there have been no new requests for new diagnostic independent health facilities since --
Ms Marsha Barnes: There have never been any.
Ms Martel: There have never been any new requests since the grandfathering and since the act went into effect.
Ms Barnes: That's right.
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Ms Martel: What I was unclear about -- explain if you could again to me, please, as a consequence of the changes in the act made under Bill 26, what exactly the ministry and the OMA are negotiating now. Is it the new services which may be added to independent health facilities that can be then billed through the OHIP pool?
Ms Lindberg: There are no negotiations. What currently is happening is that we could extend the services to other ambulatory care kinds of services if we wished. We're working with the College of Physicians and Surgeons, who are actually our quality assessors, to decide whether there should be additional types of independent health facilities set up. An example would be whether sleep studies that are currently being done in physicians' offices or in physicians' clinics could be put under an independent health facility instead of being done on a fee-for-service basis. That's just an example of some of the things that are going on at this time.
We're working with the college to identify those kinds of services. Then they have to establish a whole quality assurance program so that we can assess them. If we were going to call for a proposal for sleep studies, then we'd need whole criteria to assess them against and to determine how we should pay for them. That has nothing to do with the OMA negotiations. The OMA negotiations are all on fee-for-service. If we were going to move, say, some fee-for-service over to the OMA, then we'd have to negotiate that with them, but currently we're just deciding which services we could, if we wanted to, move over into an independent health facility.
Ms Martel: Can you give me some other examples -- I think you've called those things ambulatory types of care. I don't really understand clearly what that means.
Ms Lindberg: We have two types. We have what we call ambulatory, but diagnostics are X-rays, those things. The ambulatory care ones are things such as dialysis, plastic surgery, ophthalmology surgery, those kinds of things. We could expand that role if and when we wish to, but we don't depend on our assessment of whether we should or shouldn't; we're waiting for the college to give that assessment to us.
Ms Martel: You also mentioned that -- I think this is correct -- part of the amendments would address a need that would come through hospital restructuring. My question is, which services do you see would be likely to shift then? Are you referring back to dialysis and ophthalmology?
Ms Lindberg: It could be dialysis or it could be other -- it's becoming more and more convenient to do some of these services in doctor-type offices. You don't need the infrastructure of a hospital to do things, such as chronic dialysis. You can use a clinic-type setting as long as you have the quality assurance there, the right kind of assurances that the quality is going to be delivered.
You could move those outside, and that's what we're saying: If some hospitals or physicians would like to move something out of the hospital, even their X-rays, we could move it out and set up an independent health facility. Another example is if a community health centre decided that they wanted to expand their services to do X-rays, then they would have to be licensed under the Independent Health Facilities Act to do that.
Those are the kinds of things we're talking about. This will help us in the restructuring of the delivery of health care.
Ms Martel: Clearly you haven't really entered into any of those negotiations yet, because you're at the very beginning.
Ms Lindberg: No.
Ms Martel: One of the changes in Bill 26 -- which, no surprise, I disagreed with -- with respect to health facilities was to allow requests for proposals outside of Canada: outside, not-for-profit agencies. I guess I have a different philosophical view. Tell me, is that going to be part of the negotiations? If I understand correctly, you've not negotiated any new contracts, so while that provision exists, it has not been implemented in any way, shape or form.
Ms Lindberg: When we call for a new independent health facility we put out a request for proposals, usually through an assessment, if the DHC has said there is a need for it. Currently when we've put those out, we've actually said we still want Canadian preference clauses in our request for proposals. We have some not-for-profit, but physicians consider themselves in that same category, so it's really difficult. We really are working for the best quality and the best price when we're looking at the independent health facilities, mainly because we feel very confident on the quality assurance side with the college and the work we were doing on that side.
The Chair: Can I move on to members of the government? Then I'm sure, Ms Martel, you'll have a second chance to ask more questions. Mr Shea, please.
Mr Derwyn Shea (High Park-Swansea): Let me just get a handle on what is happening to put this in another term and make sure I'm moving down the right path. I have the one argument of the concentration of services, and I see with this system a deconcentration of services, a flow out from very cost-intensive centres we know as hospitals into less cost-intensive areas, clinics and so forth. You've rightly put your finger on things like dialysis and eye laser and so forth. Am I correct so far when I say this is what we're seeing? We're almost seeing a spinoff of services from the hospital, specializations that are moving out, the sort of thing that ultimately destroyed the Canadian National Exhibition, using another parallel example, as we spin off on a trade show, so you move out and away you go. I want to come back to that because it's a question I'd like your thoughts on.
As that occurs, and on the one hand you're getting some benefits for the community, are you convinced that you're getting cost benefits in terms of the service that is provided to the patient? On the other hand, is there a corresponding benefit by insisting that the hospital, when that is spun off, does not stay in competitive service but is now reducing its budget accordingly and is ensuring that the budget savings are directed towards those that provide the service in that area and are not spread across into service provisions elsewhere in the hospital? A simple question.
Ms Lindberg: Yes, very simple. The answer to the cost benefits to patients: Currently the only comparison we have is the same service being offered on a fee-for-service basis versus the independent health facilities. We've actually seen the independent health facility services remain lower or not increasing -- in fact, I think they decrease in utilization -- where on same types of services on the fee-for-service we've seen huge increases.
We know for sure we're giving a better-quality service because they are assessed and they are under an assessment. If you're a private doctor's office and you're offering a certain test, there is no quality assurance available to that doctor's office. He can't call somebody up and say, "Come in and see if I'm giving good service," where we insist that happens in an independent health facility.
What we're trying to do on the hospital side, if a hospital decides it wants to move out a service that is able to be done in the community and does not have to have that infrastructure of a big hospital around it, is that the money moves with that clinic. That's what we did with dialysis. We actually haven't ever closed down any dialysis units because there's a 10% increase of dialysis patients every year. But when we expanded the services, where we expanded both in hospitals and in independent health facilities, we used the same money from the hospital pool that was given to growth for both of those services.
Mr Shea: I heard the code phrase "if the hospital wants." Are you telling me that in all instances the new external facilities are a manifestation of a desire of a hospital to find lower costs and move out?
Ms Lindberg: No, not necessarily.
Mr Shea: Right, and that's where I want to start from. What I'm really doing is engendering competition in the system, and when one says there is a reduced increase of use in the independent system versus in the hospital system, that's almost comparing two different systems at play as well as two different costs and that becomes an awfully difficult thing to begin to evaluate, doesn't it?
Ms Lindberg: Do you want to answer that?
Ms Barnes: Yes. Using dialysis as an example, what we're trying to do there is have hospitals treat the patients with higher acuity, the sicker patients, the patients who can't be treated in a self-care unit outside of the hospital. Therefore their costs could be expected to be higher on a per patient basis. We haven't done the analysis yet because it's very hard, as you know, to get hospital per patient types of costs where the less acute patients, the chronic patients who only need supervision by a physician and not a physician onsite during their dialysis, can be treated in the independent health facility closer to the patient's home, where they don't have to travel as far, and at a reduced cost.
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Mr Shea: I understand the theory. I guess what I'm trying to now plumb is if the ministry is in fact doing the kinds of patient care cost-effective studies that I would think you would want to be out. In some instances, this is almost like a triage issue. It's a matter of hospitals will deal with a certain level of service, and in other cases you will now go to other centres for that service. I can live with that as long as I am convinced that indeed the costs are commensurate with the requirements in each instance, and I need to have from you some assurance that you've done studies to be able to show this committee that is the case.
Ms Lindberg: We haven't actually done any studies, but we've done some cost comparisons between services in hospitals and services in the independent health facilities. They are less expensive, but when you say that, the hospitals obviously say, "We're treating more acute patients, so of course."
Mr Shea: Of course, and their overhead is significantly different. All of that stuff is altogether different, so that's --
Ms Lindberg: We haven't done cost-effectiveness studies. We've done cost-comparison studies, and they are less.
Mr Shea: I don't want to prolong that one. It's one I will probably come back to a little bit. I'd like to go to the issue of -- I don't know what to call it -- enforcement or monitoring of regulations, I suppose, just to click into something that's of interest to me, and that is the question of how you indeed ensure that the independent facilities are meeting the standards you expect of them. I presume that you don't have your own inspectors. From what you've written here, I assume that you've made a deal with the college to do the inspections for you.
Ms Lindberg: That's right.
Mr Shea: Can you just clarify for the record why you have done that? Why have you gone to the college to do that?
Ms Lindberg: The reason is that the college has a responsibility under the Regulated Health Professions Act to ensure that physicians are giving quality services, and they license physicians. Physicians offer these services. It made more sense to have them, who are involved in quality assurance, looking after the services that physicians give, putting out guidelines of how physicians should work to whatever procedure they're working through, and they have the guidelines. They do the re-evaluation. So it make more sense for them to develop it. They have the expertise, and they also have the ability as a peer group with another physician to do it, rather than the ministry hiring a group of physicians to come in and do that. We used the college because they have that expertise there.
Mr Shea: It's a philosophical --
The Chair: Thank you, Mr Shea. I must move on.
Mr Shea: I was getting into some great philosophy here for a moment, Chairman, but I'll defer now to the opposition.
The Chair: I'm sure you'll get a second opportunity.
Mr Shea: I'm sure I will, sir.
Mrs Sandra Pupatello (Windsor-Sandwich): Can you tell me how many independent health facilities you've gone into without prior warning since the passage of Bill 26, for investigation?
Ms Barnes: We haven't done any. You mean without notice? No, we haven't done any.
Mrs Pupatello: How many have you done with notice?
Ms Barnes: Since the passage of Bill 26?
Mrs Pupatello: Yes.
Ms Barnes: I don't know that offhand.
Mrs Pupatello: Do you think there have been many or none or --
Ms Barnes: The target for this fiscal year is 150 assessments this year.
Mrs Pupatello: So those assessments would be done with warning?
Ms Barnes: Yes. The college will notify the facility that they want to come and do an assessment and make an arrangement with the facility operator for the day that they'll be there. Part of the reason for doing that is that it's very important that the facility quality adviser is onsite at that time. That's the physician who has legal responsibility for quality in the location, and it's important that person be there.
Mrs Pupatello: I understand. Why do you think there was a clause in Bill 26 then to allow for visits onsite without prior warning? What was the purpose if a year to date it's never been utilized?
Ms Barnes: There were some rare circumstances in the past where the college found that the facility operator wasn't being cooperative, or if they had reason to believe that the facility operator might be tampering with and trying to put on the best show that they could when they came into the site. To date, that hasn't been an issue since the passage of the legislation, so it's a clause that is to be used in exceptional circumstances only.
Mrs Pupatello: Of the ones who likely have been, even though you don't know the number, how far into the 150-or-so target per year, have you had some very terrible circumstances you've discovered when you've gone to these centres?
Ms Barnes: We've had a requirement since Bill 126, I believe, or at least since the auditor's report, where there has been a finding, where the assessors, when they were in the facility, faxed to the college a letter -- this is the process we've put in place -- to indicate that they found a significant concern. The college immediately let us know and we instituted the suspension order within a day.
Mrs Pupatello: So you've had one.
Ms Barnes: There's been one emergency suspension of that nature. There certainly have been other suspensions this year.
Mrs Pupatello: For the assistant deputy: In this discussion regarding the independent health facilities where they relate to kidney dialysis, do you know offhand whether the offsites, out-of-hospital dialysis, are haemodialysis or peritoneal?
Ms Lindberg: It's only haemo, and it's chronic haemo. It's those people who are chronic and stable, not acute haemodialysis.
Mrs Pupatello: So hospitals would have a legitimate concern, if you initiated a cost analysis, that you have to compare apples to apples. For example, patients who are significantly -- the reality is that while you have an increase of 10% per year, you also have an aging kidney dialysis population. As people are living longer, they are staying on dialysis longer, and you're getting patients who years ago likely would have been deceased and now they may be 80 and on dialysis, or 70 or 60, whatever.
You have an aging population and significant multiple problems along with dialysis, so your population has changed, I think, in terms of whom you're serving even compared to 10 years ago. Those who would be offsite would tend to be your younger, mobile patients who won't need doctor supervision individually and/or wouldn't need a nurse per patient. Even in the hospital setting I don't think they're getting that today, but they certainly wouldn't get that in the independent health facility.
Ms Lindberg: No, I think they would get that but the independent health facility doesn't necessarily have younger or mobile patients. One of the advantages of the independent health facilities is that the elderly don't have to travel as far. We're trying to make it closer. Usually they have to be driven, obviously, and it's closer to where they are so that they don't have to drive all the way to the hospital.
Mrs Pupatello: It would be the status of their health as opposed to age.
Ms Lindberg: It's acuity of care that is the determinant, not age or anything else. If you're chronic and you're stable -- a lot of elderly patients who are being dialysed are actually fairly stable. They just have to go there routinely three or four times a week.
Mrs Pupatello: You would say offhand that the ratio of patient to staff is significantly less in an independent health facility than you'd find in a hospital?
Ms Lindberg: I don't know the ratios of patient to staff. I don't think it is. I think what's different in a hospital is that they have onsite physicians usually supervising, where in an independent health facility we don't have the nephrologist supervising onsite. But in independent health facilities we have the same number of nurses per patient they would in a dialysis unit in a hospital. In fact, sometimes their ratios are exactly the same. That's not the difference. Usually the difference is in the nephrologist's attendance.
Mrs Pupatello: Okay. My colleague has some questions.
Mr Lalonde: I'd just like to know how many CHCs we have in the province.
Ms Lindberg: Independent health facilities?
Mr Lalonde: No, community health centres.
Ms Lindberg: I don't know. I'm sorry.
Mr Lalonde: Do you know, though, if the college of physicians is supporting community health centres?
Ms Lindberg: I would assume they are because they're fairly supportive of anybody who gives good quality service and the most appropriate service. The College of Physicians and Surgeons of Ontario is very much into delivering quality assurance and making sure that physicians deliver the most appropriate service, and CHCs are usually doing that.
Mr Lalonde: Is it your ministry's intention to increase the number of CHCs in the province?
Ms Lindberg: I honestly cannot answer that. The CHC program does not report to me and I honestly don't know.
Ms Martel: I want to go back to how the ministry undertakes a cost comparison between hospitals and independent health facilities in the provision of particular diagnostic services.
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Ms Lindberg: In fairness, it's a straight cost comparison. It's just this many patients, these kinds of dollars going into the independent health facilities versus into the dialysis unit in the hospital. That's why I said that if you take cost comparisons, they're not cost-effectiveness comparisons. A hospital is supporting a lab, a pharmacy, overhead and much more administration, those kinds of things that are essential to run the hospital; where in an independent health facility they don't have a lab, they send the tests out and bill OHIP, they don't have a pharmacy, they don't have the kind of superstructure or the administration that would be in a hospital. So as I say, they're cost comparisons and you really can't compare them.
Ms Martel: Let me ask how the ministry is going to come to grips with the following problem that I see with restructuring. There's been a restructuring report in my community that's very public. One of the issues that has been looked at by a working group, made up of all the hospitals and the Ministry of Health, was the issue of, should we have a centralized lab service? There is a large lab, paid for by the taxpayers already, at the hospital which will remain and which will be expanded under the restructuring plan. Yet on the table is also a request from MDS to build a new lab in the community at a price of $4 million, their argument being that because they are an independent health facility, they will be able to deliver this at a lower cost to taxpayers overall.
Needless to say, my colleagues and I have some significant concerns about whether the ministry is going to approve an independent lab being built by MDS while we have a lab sitting underutilized right now at the hospital that will remain. How is the ministry going to start to figure out what the cost benefits are here and what the cost comparisons are so we make a decision that at the end of the day that ensures we've got an effective, efficient and lower-cost system?
Ms Lindberg: Independent health facility laboratories are not under the independent health facilities. They are actually under a lab licensing scheme which is paid through OHIP or through the hospital budget. We have a lab services restructuring group looking at how we should be paying for lab services and how we should be looking at restructuring lab services. We don't need to lose the viability of a hospital lab, because we need viable hospital labs that give good stat work, do excellent work and are very proficient. You still have your community work that has to be done. You need work done in the primary care setting where a physician should be able to do some sort of onsite lab tests and not have to send them out.
The whole lab restructuring process is looking at all that and looking at an alternate way of paying for it other than fee-for-service or in a global budget or however we decide to do that.
Mr Shea: I share the question of Ms Martel in a way. She knows from the questions I've been raising that I have the same kinds of interests. I think we're both trying to ensure that patients in this province are getting the very best for the very least, and that's what we're trying to work towards.
I get the chance to raise the question, because I know that you're as troubled as I am by the classic phrase in Plato's Republic, "Who will guard the guardians?" Let me get to the philosophical question first of all: Why should the consumer pay practitioners to monitor and evaluate the performance standards of practitioners?
Ms Lindberg: Physicians are a self-regulating profession, as are pharmacists, nurses --
Mr Shea: I understand.
Ms Lindberg: Because of the way the legislation is set up, physicians regulate themselves. But we have a fair amount of ability within a number of the acts we have at the College of Physicians and Surgeons that would come back on the College of Physicians and Surgeons if they weren't performing the things they should be doing, but they have the expertise.
Mr Shea: I acknowledge that. The question I pose is, why should the taxpayer, the consumer, pay for them to do what they should be doing? That is, their own quality assurance studies.
Ms Lindberg: I think it goes beyond just physicians. Physicians pay their licences and that's how the college looks after what they do for physicians. They have the expertise. We can either hire staff to do it ourselves or we can pay them to help us do it. We felt it was better to pay them to help us do it than us to hire seven or eight docs at $100,000 each to do it.
Mr Shea: I understand that answer.
The final one then is in terms of the question I raised earlier that other members have also addressed: Are there studies under way or about to start or recently have been completed that give us some kind of cost analysis of the shift from the cost-intensive focus of the hospital to the less cost-intensive centres, the IHFs?
Ms Lindberg: One of the studies that we've been asking the Institute for Clinical Evaluative Sciences to look at is assuring that we're not losing quality or effectiveness or appropriateness -- because that's the other problem -- by moving certain things out. We've asked that they help us determine that.
Mr Shea: Are they also addressing the question that as the shift occurs, either the hospitals are finding other kinds of services to provide in other parts of their mandate or are in fact severing the costs there and not continuing to bleed us, killing us by a thousand cuts, in other words?
Ms Lindberg: What we're trying to do and what we're looking at very closely is making sure the money follows the patient; the money doesn't stay here. If you're the patient and you're moving through the system, that will give us more effectiveness.
Mr Shea: I applaud that and I agree with you. The difficulty I've got is on the other hand I have a large infrastructure that is in place and has to be in place particularly for the more intensive care. How do we ensure that is not excessive, is not inordinate?
Ms Lindberg: That's a question we need to answer, but I think one of the things we want to make sure is we do studies. In a hospital they have what they call a quality assurance program. It's not just physicians, but it's a member of each one of the professions on this quality assurance. They actually look once a month at what services they're doing, where they're doing them, why they're doing them and doing what they call quality assurance and quality improvement -- total quality management, however they all manage it; each one has a different way of doing it.
Mr Shea: Last question, Chair: The dollar following the patient I understand. The difficulty I have in the concept, and you may be able to respond to it, is it assumes that the patient has choices of where to go for services and the choice ought to be exercised where it's the most cost-effective. But it also assumes that at certain points the patient may have to enter into a setting where there is a significant infrastructure required to meet their needs. There's a cost to maintain that infrastructure at all times. That's why I'm saying, have we got studies that indicate how you can find at least some kind of an appropriate-sized infrastructure that is not wasteful, that has been downsized sufficiently but also has the capacity to meet the changing needs?
Ms Lindberg: The joint policy and planning committee of the ministry and the OHA are actually looking at that right now in their funding --
Mr Shea: When will we see some written documentation?
Ms Lindberg: Probably in the spring. It's spring now, isn't it? It's supposed to be by June or so.
Mr Shea: Could I at least ask that I see something when it's available, Chairman?
The Chair: Yes.
Maybe the Chair can have the last question. You people have been under tremendous pressure, if I can use the word "pressure," in the last 12 or 14 months, because you're continually implementing not only new programs, but you're trying to improve the quality of these programs. How difficult has it been to assess your progress or your failures? How difficult has it been, for the last 12 or 14 months?
Ms Lindberg: In some cases, it has not been that difficult. The use of dialysis is probably one of the better ones, because we have actually been able to give services closer to home for a number of people and that kind of thing. If I can go back to a previous time, we're looking at the prescribing of drugs. We keep trying to get more appropriate use of drugs and I'm not sure we're achieving that. So it just depends on individuals and how we're approaching the programs. Sometimes physicians' services move very quickly to meet some of the demands and then other times we don't seem to achieve it.
The Chair: Maybe my last question is, how much time is spent on assessing a new program or a new service? Are you too busy implementing the wishes of the government that you don't have any time to assess?
Ms Lindberg: In any new program, we build in some evaluation and monitoring. The previous speaker talked about why we put in shadow billing on an APP. We have no other way of measuring it, so we ask them to shadow-bill. We always have a monitoring and we always spend some time going back and reviewing it, just to be sure that we aren't really causing -- one of our things is we don't want to cause damage, and the other thing is we really want to make sure that when we do something, we're doing it well.
The Chair: So we can assure the auditor that he doesn't have to audit your books next year.
Ms Lindberg: That's right; he doesn't have to come back again.
Mr Shea: I just wanted to pick up one final point to make the member for Windsor-Sandwich, at least, happy as well in terms of your response. The ADM was right, in my experience, that the seniors are finding some of these centres far less threatening and far more convenient to get to. I personally have a 96-year-old mother going for eye surgery next week who finds it much more convenient to get to a centre of that sort than to truck all the way up to Sunnybrook hospital. So I think there are some advantages, but it doesn't take away from my basic question of, I want to see the effectiveness of places like Sunnybrook hospital that continue to expand forever. I want to see what that means, compared to other things.
The Chair: Ms Lindberg and Ms Barnes, thank you for being with us this morning.
Just one announcement. I feel like a minister. February 27 we'll be dealing with section 3.15. That's the Whitby Mental Health Centre. Thank you for your assistance this morning and your presence.
The committee adjourned at 1201.