SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
UNITED FOOD AND COMMERCIAL WORKERS INTERNATIONAL UNION
TORONTO INJURED
WORKERS' ADVOCACY GROUP
UNION OF INJURED WORKERS
ONTARIO ASSOCIATION OF RADIOLOGISTS
FEMINIST ALLIANCE ON NEW REPRODUCTIVE AND GENETIC TECHNOLOGIES
INTERNATIONAL FREEDOM IN HEALTH
DRUG QUALITY AND THERAPEUTICS COMMITTEE
ONTARIO ASSOCIATION OF NON-PROFIT HOMES AND SERVICES FOR SENIORS
DAVENPORT-PERTH NEIGHBOURHOOD CENTRE
SCARBOROUGH PRESBYTERY UNITED CHURCH OF CANADA
PSYCHIATRY RESIDENTS'
ASSOCIATION OF TORONTO
RESIDENTS OF THE CLARKE INSTITUTE
CONTENTS
Wednesday 20 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
Mytec Technologies Inc
George Tomko, president and CEO, Mytec Technologies
Mark Inkster, director of marketing, Stentor Resource Centre
Mark Marshall, account director, health care solutions, Bell Canada
Keith Clemons, vice-president of marketing, Mytec Technologies
Halton Medical Society
Dr Garnet Maley, president
Dr Walter Koslowski, past president
United Food and Commercial Workers International Union
Bryan Neath, Ontario assistant to the Canadian director
Jay Nair, health, office, professional and education sector coordinator
Toronto Injured Workers' Advocacy Group; Union of Injured Workers
Orlando Buonastella, representative
Mark Bailey, representative
John McKinnon, representative
Carol McGregor, representative
Marion Endicott, representative
Eli Lilly Canada
Terry McCool, vice-president, corporate affairs
Dick Guest, director, business operations, Ontario
Canadian Grey Panthers
Dr Joe C. Moniz, executive director
Isobel Warren, director of communications
Rev Dr George McClintock, advocacy committee
Ontario Association of Radiologists
Dr Murray Miller, representative
Dr Isadore Czosniak, representative
Feminist Alliance on New Reproductive and Genetic Technologies
Melanie Rock, representative
Fiona Miller, representative
International Freedom in Health
Gord Coleman, executive director
Drug Quality and Therapeutics Committee
Dr Malcolm Moore, chair
Dr Allan Detsky, committee member
Income Maintenance Group
Scott Seiler, coordinator
Harry Beatty, staff lawyer, Advocacy Resource Centre for the Handicapped
Ontario Association of Non-Profit Homes and Services for Seniors
Michael Klejman, executive director
Davenport-Perth Neighbourhood Centre
Ruth Crammond, executive director
Scarborough Presbytery, United Church of Canada
Rev Dr Richard Magie, secretary
Rev Lorne Taylor-Walsh, representative
Psychiatry Residents' Association of Toronto; Residents of the Clarke Institute
Dr Joanne Sinai, co-president, Psychiatry Residents' Association of Toronto
Dr Aileen Brunet, co-president, Psychiatry Residents' Association of Toronto
Dr Cynthia Lazar, chief resident of pyschiatry, Clarke Institute
Pam McConnell
Kathy Bugeja
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:
Johns, Helen (Huron PC) for Mr Danford
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
Gilchrist, Steve (Scarborough East / -Est PC) for Mr Kells
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Castrilli, Annamarie (Downsview L)
Curling, Alvin (Scarborough North / -Nord L)
McLeod, Lyn (Fort William L)
Rae, Bob (York South /-Sud ND)
Stockwell, Chris (Etobicoke West / -Ouest PC)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel:
Campbell, Elaine, research officer, Legislative Research Service
Drummond, Alison, research officer, Legislative Research Service
The committee met at 0900 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 / 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.
The Chair (Mr Jack Carroll): Good morning. Welcome to our committee. As the first order of business, Mrs Caplan has a motion she'd like to introduce.
Mrs Elinor Caplan (Oriole): Thank you very much, Mr Chairman. This is a motion to extend public hearings on Bill 26.
I move that given the great numbers of groups and individuals who have expressed a desire to appear before the legislative committee to address their concerns relating to Bill 26, and given that all those who have or will still express a desire to appear before the committee cannot be accommodated over the time allocated to the committee to do its business;
That the committee request the House leaders to agree to extend the public hearings on Bill 26 to allow four weeks of hearings in the month of February; and
That in order to accommodate the government's desire to address their fiscal concerns, the government identify those portions of Bill 26 which must absolutely be dealt with on January 29 and allow the other portions of Bill 26 to continue to be subject to public hearings during the month of February and be dealt with when the Legislature reconvenes.
In light of the fact that we have people waiting to make presentation to the committee, and because I feel that is so important, Mr Chair, I would agree that we debate this at noonhour when the committee would normally adjourn for lunch. I request the cooperation of all members.
The Chair: Thank you very much, Mrs Caplan. Anybody have any problem with waiting?
Mr Steve Gilchrist (Scarborough East): Do you need a motion on the table?
The Chair: We'll debate it at lunchtime.
Mr Gilchrist: But you can't make a motion and then just leave it without tabling it.
Mrs Caplan: I'll make a motion that I'm willing to deal with it at noon, if that's agreeable to the committee.
The Chair: Anybody have any problem with that? Okay. Thank you very much.
MYTEC TECHNOLOGIES INC
The Chair: Our first presenters this morning are from Mytec. Welcome to our committee. You have half an hour to use as you see fit. Any time you allow for questions will be added up evenly, starting with the New Democratic Party. If I could please ask you to identify yourselves so that Hansard can record who's doing the speaking, the floor is yours.
Mr George Tomko: My name is George Tomko and I'm president and CEO of Mytec Technologies.
Mr Mark Inkster: I'm Mark Inkster, director of marketing at Stentor Resource Centre.
Mr Mark Marshall: Mark Marshall, account director, Bell Canada, health care solutions.
Mr Keith Clemons: Keith Clemons, vice-president of marketing with Mytec Technologies.
Mr Tomko: I'm going to be presenting concepts in security of health today and specifically detail some of the proposals that we are making to provide us with a secure health system.
Mytec was started here in Toronto for the purposes of developing an optical computer to protect the privacy of an individual's information. Protection of privacy, in my view, is one of the major issues in the coming decade, primarily because of our increasing reliance on informational databases and on an electronically networked society.
As a result, there are a lot of potential pressures on privacy. For example, for the first time in history lack of security will directly inhibit growth in commerce -- more specifically, the areas of electronic commerce, finance and administration -- and society just won't let that happen. They are going to take measures to stop fraud and that is part of the privacy problem. Should an individual's privacy be subordinated to the cause of reducing fraud?
Then there are other issues. There is a lot of useful patient data being collected or being generated by our health care system. With the exception of the attending physician, it is rarely looked at and it sits there. If we could share this information among the community of administrators, researchers, clinicians, then we could generate outcomes management, epidemiological and clinical studies, which we believe would definitely benefit all of society. So should an individual's privacy be subordinated to the general common good of sharing health-related information?
These are tough questions and, as a result, the issues have been relegated to policy decisions. What I will demonstrate today is that there is a technology available which precludes the necessity to infringe on an individual's privacy to eliminate fraud and to share health-related information.
What that will do is take part of the issue away from the policy level down to the technological level so that we, as society, don't have to make the decision to sacrifice one freedom at the expense of the other. With this technology in fact, elimination of fraud is a byproduct of protecting an individual's privacy. Let me now share with you the principles of this technology.
The patterns at the end of your fingers contain a wealth of two-dimensional, unique data. One can now use the ridges and grooves in the patterns of your fingers to code any information that you consider to be private and secure. Once that information is coded by your fingers, it is absolutely secure and private because your fingers have to be there to read it or decode it.
That process I've outlined here as enrolment. In this case the optical computer represented by the lens takes the pattern in the finger and codes a number. That number, which we call a bioscrypt, which is a compound of the term "biometrics encryption," can be stored on a card or a central database. It doesn't really matter because it's absolutely secure without your finger. It has no resemblance to a finger. It can't be converted back to a finger. It's just a number that's coded and no copy of the fingerprint is ever stored; what is stored is a coded number.
Now one of the important things is, that number can be a personal identification number. As a result, you don't have to remember your personal identification number, and if you don't have to remember it, it can be longer, which is more secure etc. Secondly, that number can be a pointer that points to a location in a computer database, and we'll talk about that. Thirdly, that number can be an encryption key used in cryptology to encrypt large volumes of data, such as health data. What it means is now you are in absolute control of the privacy of your information.
Now just to give how this actually works, let's say that you want to code the letter R. What the optical computer does is optically take that R and breaks it up into a myriad of pieces, each of these pieces represented by a dot. However, the location of each of these dots over a two-dimensional area is a function of the pattern in the finger, and since every finger is unique, that pattern is unique. Now if you want to code the letter E, you do the same thing and you superimpose it until you form this thing we call the bioscrypt.
Now let's say that you want to read or use your information. One now presents the live finger there to decode it. As we show here, the number or whatever the number is is released. Now the important point here is, the operation of successfully decoding your information confirms what or who you claim to be. I'll repeat that. The operation of successfully decoding your information confirms what or who you claim to be, and as the claimant you don't have to divulge your identity. Your claim can in fact be eligibility to receive services rendered by a card. Why is it necessary to give your name, address, social insurance number, just to authenticate eligibility? The point in any transaction is not to identify the user, but to authenticate eligibility.
That is what is so beautiful about currency. It authenticates eligibility for goods and services without divulging identity, and that is the goal that we who value privacy must seek. Wouldn't it be wonderful, for example, if the cards that we carried in our wallets or purses carried a minimal amount of sensitive or private information that could be read? In fact, with this type of technology all the information could be coded by your own God-given encryption keys, and eligibility is authenticated in an anonymous manner.
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This is a paradigm shift. We have up to 10 encryption keys at the ends of our fingers to in fact protect our privacy. God made it that way in anticipation of the electronic society. She probably knows that kind of stuff.
This technology is part of a proposal called SecurHealth, which we are proposing together with Bell Canada, Stentor, the Bank of Montreal and the Royal Bank of Canada. SecurHealth is an information delivery network which is built around the principles of privacy, legitimate access, sharing of information.
I won't get into the details because that's another presentation, but what I want to point out is an objective of SecurHealth, any database that allows you to do these kinds of things requires a patient record or a computerized patient record, which will not be centrally located. It'll be distributed among the health care provider community.
But without focusing on any of the details here, the important thing is there is a lot of information that is considered sensitive and private. On the other hand, there is a lot of information that, if we could share in a private way without infringing on privacy, would benefit our society enormously.
The objective is to structure a database such that it is an anonymous database that uses non-identifiable information with specific and tight controls because sometimes you want to access information. Again we focus on privacy; the byproduct is reduction of fraud. The way the system is set up, it reduces fraud, but that's not the goal.
Now let me define what we mean by anonymous database. What you want to be able to do is not to be able to link personal information, such as health care, to the name and address or to the identity of the individual. The link has to be done through some specific and tight controls and what we recommend is that that link be done through the individual's own finger pattern.
Let me describe the outcome. First of all, if I can kindly have your focus here, this is a computer database. It's not necessarily central; it can be a distributed database. But each of these rectangles represents a block of information and those blocks of information can be personal data, such as the name and address of the individual. They can be health data; they could be welfare data. However, the important thing is that when information is placed into this database, it is placed randomly so there is no link between a person's identity and his information.
Secondly, the actual information is encrypted, in the terms of cryptology, so that if someone -- for example, if I were to design that database, I would look at it and I could not extract any information. That is the criterion for success.
The other aspect is, the location of the data in this database is encrypted itself. So not only do we encrypt all the data; we encrypt where the data are, such that if we have in another location the location of these data, the keys to find out the location are held by the individual. So in this case, if the patient went into the physician's office, he would present his finger pattern; he would generate a number, as we described before; that number is a pointer which points to this location in a computer database. On his card could reside the keys to unlock the location of his data. That data would then be found, transmitted somehow to his physician, his physician has now the name, address, etc of the individual, and his health information, however the health information is encrypted. Going through a similar process, the physician slides his pattern, he unlocks his key; now his number is an encryption key, and he can decipher these data and read the information.
Although it looks complicated, with computers it's very fast. The beauty of optical technology is that this all occurs in a fraction of a second. That's how fast it is.
So what we have established here are tight and specific controls; it's non-identifiable data. For example, let's say the physician was treating a patient aged 60 with congestive heart failure and was thinking of giving him digoxin, for example. He might want to go into the database and say, "I'd like to know in this area, what have been the outcomes of other physicians giving digoxin?" Because he has the encryption key, he can do a query to the database, and it's just going to search the health information that is not related to personal ID. It can come back and say, "These are the results." So now we can benefit all of society and no one's privacy is being infringed upon.
I hope I have been able to demonstrate to you that there is innovative technology available which can protect the privacy of an individual, allow health data to be shared, with the byproduct of eliminating fraud. This technology is allowing us to do things that we couldn't even imagine a few years ago. You may be interested to know that Mytec was started here in Toronto; it's all-Ontario, all-Canadian; we have been listed on the Toronto Stock Exchange. In the early days, we teamed with the Ontario Laser and Lightwave Research Centre, which is one of Ontario's centres of excellence, to develop this breakthrough technology.
Optical computing, just for your information, uses as its basic unit of processing light waves or photons versus electrons and bits and bytes in digital computing. This technology will spawn a multibillion-dollar market, and our job, I believe, is to make the focus of that market here in Ontario, because we do have breakthrough technology. So I think another goal is that we make Ontario a model for privacy and we bring in a lot of high-tech, high-paying jobs as a result.
The Chair: Thank you very much for your presentation. We've got about four minutes per party left for questions, starting with Ms Lankin.
Ms Frances Lankin (Beaches-Woodbine): Thank you very much for your presentation. It's always important for us to know the developments that are occurring in Ontario industries, and it's particularly gratifying to see developments that come out of teamwork in work that has been done with centres of excellence and the research and development. Over the last few years we had a bit of a focus on health economic developments, and I think that there is a lot of good, in this area and other areas, product development that can be done that has tremendous export potential.
We have, over the last number of years -- I'm sure Elinor would have had the similar experience that I did -- looked at developing technologies for smart card technology and privacy protection and to allow us to have more access to unidentified but collective data which could be helpful. What I'm interested in -- because we're here on Bill 26 hearings -- is why you're here, and have you done a thorough analysis of the legislation? I'm projecting that perhaps you think the changes that are in the legislation are necessary as a support base to being able to implement this technology. I think that there are some changes that are required, but that we need a whole health privacy information structure, because there are lots of pieces of information within the ministry and other areas that aren't and wouldn't be directly controlled through this kind of technology.
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Basically, have you analysed the legislation; are there changes that are proposed that are necessary at this point to proceed with this kind of technology; is there anything else that would be required?
Mr Tomko: In terms of the legislation, what I wanted to demonstrate is the ability of technology to allow us to protect the privacy of an individual's information so that we can accomplish such things as sharing of information. There are many tunes that you can play with this technology. Some of the issues in the legislation, which ask for greater powers to share information, I think can be done with specific and tight controls. So I don't think that Ontario citizens have to worry that in fact their privacy is going to be infringed upon.
Ms Lankin: I think that if yours or other competing technologies that are being developed were put in place and were proven to be effective, those kinds of concerns could be addressed. Today, as we look at the passage of this legislation on January 29 that gives powers to non-medical inspectors hired by the Minister of Health and directed by the Minister of Health to go in and seize records and maybe even disclose that information, we're out of time sync here with what you might be able to provide in the future in order to be dealing with that.
Mr Tomko: Obviously, our goal is that anything done like that would be done under specific and tight controls using technology such as that. That's the issue, that if someone is going to look at health records, that there's a definite non-repudiation method to say: "I've looked at it, there's a audit procedure and I had a reason, or if I didn't have a reason, then I can be held accountable."
Ms Lankin: Those are the sorts of concerns that we have as well. I just say that I really do wish you tremendous success with this. It's an exciting development and I think it will be very important for the Ontario economy.
Mr Gilchrist: Mr Tomko, indeed very impressive and I guess doubly so that it's Ontario-based technology. I'm sure without prejudging the future of your firm's endeavours in this province, I think all Ontarians can be very proud of the fact that we have companies and consortiums such as yours that are applying themselves in these high-tech ways.
I think, to follow up on the questions from Ms Lankin, there's no doubt that fraud is one of the issues. Obviously, at the same time, access in a timely way to health information may very well be, in some cases, lifesaving in its potential: the ability to deal with people who are comatose or incapable of recounting their drug contraindications and sort of thing. I think there's fantastic potential in terms of serving a greater good there.
But let me just deal with the fraud issues, because studies undertaken by the previous government showed that the extent of health card fraud was somewhere between $65 and $700 million a year.
Ms Lankin: Between $65 million and --
Mr Gilchrist: Seven hundred million dollars. Fraudulent billings, obviously, impede the government's ability to deliver health care for those who are not being fraudulent. Obviously, every dollar we waste is a dollar we can't spend appropriately. It certainly eats into the incomes of responsible physicians and it reduces their ability to deliver quality services.
In a nutshell, is it safe to say that on the assumption that the privacy commissioner and such other tests as maybe this technology need to be submitted to are satisfied that it truly is a discreet data capture, that there is absolutely no way that the loss of your card compromises your personal database?
Do you believe it is possible to use the health care information for outcomes management and for planning and such good things without compromising an individual's privacy, and to what extent do you think that the government could deal with the issue of health card fraud by going to this sort of technology?
Mr Tomko: Absolutely, to your first question. You can in fact share information without infringing on privacy. The technology is here; we just need the will.
In terms of fraud, to say that one eliminates it completely is probably a little bit of an overstatement, because there are always going to be ways -- the human mind is quite ingenious, but it will reduce it to a fraction of what it is now. This technology is extremely secure. One always has to say, there's always a cost to getting around fraud. The cost of getting around this fraud is going to be very expensive and I don't think to access health services is worth the cost.
Mr Gilchrist: Have you had an opportunity to discuss this technology with the OMA or with physicians in general?
Mr Tomko: Yes, through our consortium we are talking with the various health care provider groups and discussing it, with good response.
Mr Gilchrist: So do you anticipate that within the health care delivery system, the pharmacists, the doctors themselves, there would be any antagonism, any resistance to implement this sort of technology?
Mr Tomko: One has to build a consensus. The most difficult thing that we find is explaining the technology, because it's very hard to divorce yourself from the historical stigma of fingerprinting, and this is not fingerprinting at all. I like to use the example that in the past we had poisons such as foxglove, and foxglove, married with good technology, became digoxin. That's the same thing we're doing. Yes, everything has a dark side, but we are in fact taking fingerprinting and marrying it with exciting technology now to protect your privacy. That's the thing that we have to communicate, and we're doing that through our discussions with them.
Ms Annamarie Castrilli (Downsview): Thank you very much for coming today. It's especially gratifying to see the partnership at work between business and centres of excellence. The goal certainly is a laudable one: the protection of privacy and the managing of information in a responsible manner.
I wonder if you could share with us whether this technology has been looked at by the privacy commissioner. Are there any concerns that he might have?
Mr Tomko: I made a presentation to all of the privacy commissioners across Canada at the last summit conference, including David Flaherty. I understand that Tom Wright is going to be here tomorrow, so I'll let him speak if you want to ask him that question, but we've gotten very good, positive feedback. They've been through the system, they have been enrolled, both Anne Cavoukian and Tom Wright, and I try to work very closely with them, because I've been a privacy advocate for many, many years.
Ms Castrilli: You gave us an example of how information might be shared about a patient with the attending physicians, whoever they might be. Could you elaborate on how it would work with respect to sharing information with entities, organizations, with respect to individual patients?
Mr Tomko: If you could elaborate on your question?
Ms Castrilli: In other words, for instance, if one of the objects, which you say is not the goal but it might be an object, is to eliminate fraud, how would you accomplish that? How would you in fact use the information to be able to do that?
Mr Tomko: You would store coded numbers in a database which we constructed -- the bioscripts -- and when someone enrolled, the optical computer would compare against the bioscripts. If there was a match, then a pointer would be released, as I had discussed, and that pointer would point to an encrypted location of the personal ID. To in fact decipher what that is, you would have to go through an administrator, who would use his finger pattern to unlock the key, the specific and tight controls. So as a result, in no way would information about the individual be divulged.
I have a slide here; if you have the time I can show you the schematic.
Ms Castrilli: I'd be curious in knowing how doctors would -- since one of the government's concerns is that the doctors may be in fact billing more than they should, how would this help in any way?
Mr Tomko: If that's the case, it would help because you would have non-reputable information that a patient did come and he did receive service and you would have non-reputable information that the physician did in fact attend to the patient. It depends on what the problem is. If we know what the problem is, we will come up with a solution. The technology is there.
Ms Castrilli: But a patient could in fact be there more than once and you wouldn't know whether it would be for separate things, would you?
Mr Tomko: If you want to build that into the system, you can build that into the system.
Ms Castrilli: Have you had any discussions with the government with respect to this? Is this the kind of system that they're envisioning for the future?
Mr Tomko: We started talking about this with the government two and a half years ago, when you were Minister of Health.
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Ms Castrilli: I was referring to the current government.
Mr Tomko: Yes, we still are doing missionary work.
Ms Castrilli: Are there any cost figures that you have?
Mr Tomko: Obviously the cost is a big issue. What we are proposing with our consortium is that the costs be taken out of savings, to make it a win-win situation. Obviously that's the best of both worlds, and we believe that this technology is so good that there will be definite savings.
Ms Castrilli: Thank you very much. Very impressive.
The Chair: Thank you, gentlemen. We appreciate your involvement in our process. Have a good day.
HALTON MEDICAL SOCIETY
The Chair: Our next presenters are from the Halton Medical Society: Garnet Maley, the president, and Dr Walter Koslowski, the past president.
Good morning, gentlemen, and welcome to our committee. You have a half-hour to use as you see fit. Questions will begin with the government party at the end of your presentation. The floor is yours.
Dr Garnet Maley: Thank you, Mr Chair. Initially, I'd like to apologize for two things. First of all, I've been up all night and I may not be quite as coherent as would be ideal.
Secondly, Dr. Koslowski and I would like to respond to a few of the issues that have been raised by Bill 26, and I apologize: For you this may seem awfully redundant, but this is our opportunity for foot soldiers like Dr Koslowski and I to really speak about what our concerns are.
I would like to divide our presentation into two sections. We're interested mostly in schedule H of Bill 26. We'd like to limit our discussion to our two major concerns. The first is questions about adverse effects on medical services if Bill 26 is able to pass unchanged, and the second is our very real concern, both as physicians and as patients, as to how Bill 26 will impinge upon patient confidentiality.
If I can give you a little travelogue to start, we're the Halton Medical Society. We represent 585 doctors in Halton county, and by and large we feel we offer excellent health care to the people in Halton. For those of you who need to brush up on your geography, Halton county lies between Toronto and Hamilton. It's in what used to be called the Golden Triangle and it stretches from the shores of Lake Ontario up to Highway 7.
In many ways Halton county is Ontario in microcosm. We have a densely populated urban area in the south, we have a middle range which is largely rural and agrarian, and in the north we have the rock climbers paradise of the Bruce Trail.
We do represent doctors, obviously, who work in large centres such as Oakville and Burlington, but there are also members of our organization who work in the metropolises of Milton, Campbellville, Limehouse and Speyside.
Many of our doctors are family practitioners and we provide comprehensive medical services. For example, if any one of you comes to our hospital, which is Milton District Hospital, Dr Koslowski and my family practitioner colleagues and I will suture your wounds, we'll set your fractures. If you have the misfortune to have a heart attack, we'll take care of you. If you're diabetic, we'll take care of that. We deliver babies. We intubate and ventilate people. We occasionally save lives and we counsel and comfort our dying patients.
We sound like a fairly competent group, but occasionally things do turn up that we can't handle, and we're here today to tell you what we feel is going to happen to our patients in this respect if Bill 26 is allowed to pass without amendment. Initially we'd like to talk about adverse effects on services. Our most concern at this point is with obstetrical services, and I'd like Dr Koslowski to give you an idea.
Dr Koslowski: I'm a general practitioner and have been in practice in the town of Milton for something like 27 or 28 years. I do provide comprehensive care that includes an office practice, where the major source of my income comes from, but I do admit patients to our local hospital, I discharge patients from there, I take care of them while they're there. I do some calls in our emergency department, and did so this last Sunday, and yes, I do obstetrics.
Well, 1995 is a bit of a different kettle of fish than 1965, and I would just like to point out some of the problems that someone like myself has encountered. When I graduated and first set up practice in Milton in 1968, my CMPA rates were $25. That was a uniform fee across the board for every physician, not only in Ontario but in Canada. It didn't matter whether I did brain surgery, orthopaedic surgery or general practice, $25 was the going rate.
My rate for this coming year -- and I'm classed as a code 78, and that is simply because I do obstetrics -- is going to be $4,432. If you want to look at the fee schedule for obstetrics, a vaginal delivery, that's a P0006, is $242. That means in order to pay this CMPA rate, I would have to do something like 20 deliveries. At this point in time, obstetrical practice is somewhat on the decline. I am an older practitioner. I still do 30 or 40 deliveries a year. Some of these patients I did deliver some 20 years ago. It's rather a pleasant thing for me, and I'd like to continue doing this. In fact, my patients appreciate me providing this service to them. But does it make economic sense to do this if I have to pay my own CMPA rates?
The previous government saw fit to partially reimburse me or totally reimburse me for these CMPA rates, recognizing the fact that really my income had been capped and I could not pass this increase in costs off to my patients.
While my plight seems rather sad perhaps, it pales by comparison when I talk to my obstetrical colleague. We do have one consulting obstetrician in the town of Milton. His rate in 1968 was $25. His CMPA rate for the coming year will be $23,340. For a caesarian section, my colleague gets about $290.60, $300. In other words, he'd have to perform about 70 sections just to cover his CMPA rates. In town, he does approximately 40, and he has simply stated that under those circumstances he no longer will provide that service. Can you really blame him?
Personally, I have practised in Milton long before an obstetrician came on the scene. The town, when I first started there, was about 6,000 people. It has now grown to a town of 35,000. While I might be willing to continue doing obstetrics without the use of an obstetrician, my younger colleagues have indicated to me that this is totally unacceptable to them. The net effect is that with the stroke of a pen the Minister of Health, if Bill 26 becomes legislation, has ended the practice of obstetrics at my hospital.
Dr Maley: I'd like to address another area in which we find ourselves lacking at times, and that is the question of orthopaedic coverage. As I outlined, our town is bordered on the north by Highway 401, on the south by the Queen Elizabeth Way and on the west by the Niagara Escarpment. You can imagine the sort of jams people get themselves into. Now, we can handle orthopaedic problems at our hospital. However, a year and a half ago our orthopaedic surgeon left for Virginia, and we've been scrambling ever since.
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It's fine to talk about things like integrated trauma programs, but in the past year I have had a couple of patients who've come in badly injured; one young man with two broken heels, a broken leg. I spent hours on the telephone, only to call a trauma centre finally and be told that this man wasn't sufficiently injured to be looked after by the trauma centre.
In summary, from our standpoint, orthopaedic coverage, not just obstetrical coverage, is also stretched to the limit in rural Ontario, and we feel again that by decreasing the Canadian Medical Protective Association rebate, orthopaedic surgeons will be even less likely to want to treat and transfer people from rural hospitals to larger centres.
To us it makes no sense to, on the one hand, try to improve physician coverage in rural Ontario while on the other hand to decrease their ability to perform the job, to make their overhead higher, to make their lifestyle more onerous. These people will, once they move to rural Ontario, get the hell out.
If I could just talk about "unnecessary services," this is a term that does crop up many times, and frankly it's quite insulting to physicians such as Dr Koslowski and I. We work in a small town. By and large, we all have more patients who make more demands on us than we're able to address. We're getting stretched hither and yon and we're not able to satisfy any of these people.
If the goal of Bill 26 is to rid the health care system of the minuscule amount of fraud that physicians perpetrate, it will certainly erect further layers of bureaucracy and that will certainly further hinder health care delivery.
Bill 26 threatens to require physicians to reimburse the health service plan for so-called "unnecessary services," but who decides what are unnecessary services. Is it going to be a civil servant at Queen's Park? Now, next week when I work in emergency, am I going to have to keep second-guessing myself that I'm going to run afoul of the whims of some Queen's Park mandarin?
When a doctor works in emergency, he or she is confronted with a variety of problems and the trick is to differentiate the trivial problems from the life-threatening ones. This is not always easy. Oftentimes you have to follow your intuition and you make a judgement based on experience, so-called, which is what one of my professors called an "educated guess."
Since I've been free to do this up until now, I've personally, in the last couple of years, detected brain haemorrhages in three very young people whom you didn't expect to have an intercranial problem, and I was able to send these people off for lifesaving treatment.
However, if the current propositions in Bill 26 were enforced at that time, none of those people would have been diagnosed. I would have said: Do I really have to send them for the CT scan? If it turns out that it's negative, am I going to be required to pay back the ambulance and the radiologist and the CT scan time?
If you take this a little further, abdominal pain is a particular bugaboo for physicians. This person who comes into emergency tonight complaining of abdominal pain: If it's a young woman, is she having a tubal pregnancy? Does she have the flu? Does she have a appendicitis? How do I find this out?
If I feel uncomfortable currently about my patient's symptoms, I can ask a surgeon to see him or her. But what then if the surgeon goes ahead, is sufficiently concerned to take the person to the operating room and then takes out a normal appendix? Will I have to pick up the tab? Will I have to pay for the surgeon, the hospital, the operating room, the nurse?
All of these things are going to become issues that doctors start to think about, and when this happens it's going to begin to affect our judgement.
We feel that Bill 26 will severely penalize the practising physician for merely doing what he or she feels is best for the patient. From a political standpoint or a financial standpoint this may be desirable, but I feel that physicians may become so preoccupied with dollars and cents that their judgements will be affected and certainly patients may suffer and may die.
I feel that it's preferable to focus our creative energies on relieving suffering and alleviating pain, rather than having to concentrate on potential financial penalties levied by Queen's Park.
I'll just move on to the last portion of our discussion, and that's about patient confidentiality. The far-reaching tentacles of Bill 26 will certainly endanger our patients' privacy. This bill allows the Health minister, as Ms Lankin pointed out, to appoint inspectors who will act under the direction of the general manager of OHIP. One of the principal flaws in this bill is that it concentrates far too much power in this person's hands. This person is a bureaucrat, has no political or legal accountability, since any decisions he or she makes we have no legal recourse to challenge. It seems to me, therefore, that at least within the Ontario health care system, the government intends to replace the rule of law with the rule of man, or more accurately, with the rule of two men, the Health minister and the general manager of OHIP.
Inspectors appointed by the general manager would have wide powers of entry without warrant, inspection -- really, powers that CSIS or the RCMP would salivate to have. Any judicial oversight would be eliminated. This really is an attack on our civil liberties that date back to the Magna Carta. Any physician who does not fully cooperate with such inspectors could face a stiff financial penalty regardless of whether this physician is found to be guilty or innocent. So much for the presumption of innocence.
Bill 26 would require physicians to surrender any confidential patient information that suited the whims of the general manager of OHIP. Such information would have to be submitted without warrant or without the necessity to show just cause. The breadth of Bill 26's attack on patient confidentiality extends even further. This bill would allow the government to collect, use and disclose a much wider range of personal information than is currently the case. In addition, and much more disturbing to me and my colleagues, is that the government would be allowed to "contract with a private organization to obtain and disseminate confidential patient information."
There's a lot of scope there. The implications are obvious. Organizations that are cash-strapped, such as the Workers' Compensation Board, could bring pressure to bear to gain access to confidential information in order to improve their cash flow. I can only hope that I'm able to retire or that hell freezes over before insurance companies and the Credit Bureau of Metropolitan Toronto are able to gain access to my own personal health file.
In summary, I feel that Bill 26 has awesome ramifications that legislators -- I hope -- are only beginning to realize. Enormous powers will be granted to the government which will allow it to unilaterally dictate where, when and how physicians will practise. It provides a tool for the assault on the civil rights of patients, physicians and other citizens of Ontario. It denies traditional legal recourse against arbitrary government actions, ignores long-cherished principles of presumption of innocence, permits arbitrary entry in search of private premises without warrants or judicial oversight.
It seems to me that the task of your committee is actually quite straightforward. You must decide if you believe in the rule of law and if you're willing to uphold that. Thank you.
The Chair: Thank you, doctors. We now have some time for questions, about three and a half minutes per party, beginning with Mrs Ecker.
Mrs Janet Ecker (Durham West): Thank you very much, doctors, for a very good presentation. I'm from Durham region, so I can appreciate and understand. We have very similar concerns. I think we've seen all the last three governments wrestle with the underserviced area problem and it still seems to be getting worse, and now Halton region has got underserviced areas. It's quite difficult, and we have to look at how we can best get some of those problems solved.
Just getting back to your concerns about confidentiality, I agree, confidentiality within the health care system is a fundamental principle. We all know there is misuse within the system, and when I use the term "misuse and abuse," I'm talking about everybody within the system, I'm not focusing on physicians. As you say, there is a small number, but we also know about and I've heard from many doctors about doubledoctoring from patients and whatever. How do we eliminate that to the extent it is possible to eliminate it, still protect confidentiality and make sure that the dollars being spent there are going for your patients?
Dr Koslowski: It's perhaps a difficult problem, but the impetus of this particular bill would be to create a further layer of bureaucracy, another investigating body that would have rights to go into doctors' offices and look at charts. I think the College of Physicians and Surgeons of Ontario, through its medical review committee, has ample mandate to do just that.
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Surely, if there are peculiar billing practices, your fancy OHIP computers must be able to pick that out. As far as I'm concerned, there is an existing setup to investigate questionable billing practices among physicians, and I don't know why this isn't being utilized. From my own personal experience -- I've been in practice for some 20-odd years, and let me tell you, for the first 20 years I never heard from the College of Physicians and Surgeons, and within the last five years I think I had three letters from them.
Mrs Ecker: It's the college that has expressed some concerns that the system does need to be improved. The question is how best to do it.
The other question I'd like to ask: The minister's been clear that he wants to work with the OMA to try and solve the insurance problems for obstetrics particularly, both GPs and obstetricians. Given that they're talking about increasing the rates of the Canadian Medical Protective Association 20% next year, has your society ever lobbied the CMPA to say, "Wait a minute"? As soon as the government started picking up the tab, the rates just went up like that. We question the need for that, and they haven't been able to demonstrate actuarially that that's justified. Have you ever lobbied them to say, "What's happening with the rates?"
Dr Koslowski: No. Actually, I think the CMPA is in my ball court, acts on my behalf. It was initially set up by physicians to protect us from rather large, litigious settlements. If you compare that with the American experience, the CMPA has done us a favour, because our rates are still far more reasonable than they are south of the border in terms of fees.
Mrs Ecker: Yet you're still having difficulties. There are difficulties for you being able to pay it, though, if you ended up --
Dr Koslowski: This is true, but that is not really the fault of the CMPA. It's the fault of the system. In Canada, much south-of-the-border consumerism has hit the market. Patients come in, they demand certain things, they demand good treatment. I suppose everybody should get good treatment, but then again, it's the consumer who demands a certain treatment. I think the expectations are enormous, that every procedure, every pregnancy, will end up in an uneventful event. Nothing could be further from the truth.
Obstetrics is sort of my pet peeve. Here you have a normal physiological event. This, in our society, suddenly has become a high-risk endeavour -- the highest premiums for the physician who does obstetrics. To me, this doesn't make any sense. Nature is never very kind. There will be a certain number of pregnancies that will end badly, and it doesn't matter whether it's a physician that's looking after that patient or whether it's a midwife. It's nature. But why are we, as physicians, being taken to task for the whims of nature?
Mrs Caplan: There are two issues I'd like to explore, and I'm really glad you raised the particular concern around the impact on family practice as well as obstetricians, on delivery.
I know for a fact, because we heard from the College of Physicians and Surgeons, that the minister was warned this would happen. I cannot believe he would have proceeded to do this without making the necessary arrangements to ensure that women would have access to the care they need. If family doctors don't deliver, if obstetricians switch their practices to gynaecology, they're not going to allow birthing centres and midwives to -- who's going to help women in need when they're ready to deliver their babies?
Dr Koslowski: I'm afraid I have no answer to that one for you.
Mrs Caplan: I'm tremendously upset that he didn't heed the warnings of the College of Physicians and Surgeons, who act in the public interest.
The second issue -- we only have a couple of minutes. I wish we had more time to pursue this. You raised the issue of inspectors. Contrary to what the parliamentary assistant said yesterday -- we're getting that Hansard and I'm going to demand an apology from her, because I believe it is wrong to give inaccurate information to presenters -- the inspectors that the minister appoints under the new powers of this legislation, section 40.1, could be anyone. There's no guarantee, as there is now, for the assessors and inspectors appointed by the MRC and the College of Physicians and Surgeons that any of those inspectors are required to be doctors. There's nothing in this legislation that would not allow any bureaucrat, any civil servant, without any training, to be appointed by the minister.
I have already said that I recognize the need to enhance the resources and the powers of the MRC and the College of Physicians and Surgeons. I don't understand why the minister, except at the urgings of some of the ministry people, who'd like a parallel process, is doing this. We know there has been no consultation with the Ontario Medical Association or the College of Physicians and Surgeons on this provision. I'm wondering if you have any views about why the minister would insist on having the powers to have his own inspectors, who would not be required to be doctors, to be able to walk in and look at all doctors' records and have access to patient information. Can you imagine why he would want to do that?
Dr Koslowski: No, I can't imagine why, and that's why I'm sitting here. This particular bill I find about as obnoxious as the comments attributed to the minister in Tuesday's Globe and Mail. To paint all physicians of the province as a bunch of crooks is beyond belief. We've heard things along these lines before, and I'm sure there are some fraudulent physicians out there, but as far as I'm concerned you've got the mechanism whereby you can nail some of these boys, and if there are a few rotten apples in the barrel, let's get them and get on with the job. But to say to me that I am literally screwing the system -- I don't believe so. I think I've given the system a good bang for its buck.
Ms Lankin: I truly appreciate your taking the time to come forward. I wish we had more time to explore some of the issues. I am very interested in the concerns you've raised about orthopaedics. We've heard the concerns about obstetrics before -- it's an area that has been explored in the media and in some of the hearings by the presenters -- but we haven't had an opportunity to talk about orthopaedic treatments and what it will mean for rural Ontario. That's one area I might ask you to pursue a little bit.
I just want to make a general comment. As I listen to you, it strikes me again that this bill, which takes such huge new powers on to the minister and the bureaucracy in the Ministry of Health, really allows civil servants to step in between you and your patients. While I personally support the need for a consensus management of the system overall, not micromanagement, not the medical decisions that need to be made between doctors and their patients in terms of patients' health. I really am very concerned about that. It is a bureaucratization of health.
It is also an undercutting of volunteerism in our communities, the fact that he can step in and take over the running of hospital boards without the controls and safeguards that were in the previous legislation. When I asked the minister directly why he would do that when there have only been a couple of occasions in the past where it was necessary to send the supervisor into a hospital, so why take on these greater powers, he had no answer. It seems to me that there are folks someplace in the bowels of Queen's Park who have put their wish list together and it's come out in this legislation, and we don't have time, the way the government is ramming this through, to dissect it piece by piece.
I also found abhorrent the way the minister scapegoated physicians. I think he was under attack in terms of this legislation, under a lot of pressure, and he lashed out. As the OMA yesterday said, he must have been having a bad day. Let me tell you, I don't want to give this guy any more powers if that's how he behaves when he has a bad day.
Would you please though go through the issue of what it means for orthopaedics? I didn't quite understand why you said orthopaedic surgeons would be more reluctant, given the CMPA rates, to refer from rural Ontario or accept referrals. Could you give us a bit more in-depth explanation?
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Dr Maley: I'll try, if my attention span is still with me. Our problem is that when a person has a major orthopaedic injury in rural Ontario, they must be transferred somewhere. In order to transfer a patient to another hospital for definitive treatment, one must find an orthopaedic surgeon who is willing to accept the patient.
A lot of this depends upon your personal rapport with the person on the other end of the phone; a lot of it depends upon the availability of facilities at a given time. But let's just say that the orthopaedic CMPA fees have increased almost as high or almost to the same degree as the obstetrical ones, I would think this is going to put orthopaedic surgeons into a fairly surly frame of mind, and I think they'll probably be a little less accommodating to us in the future if this is going to happen.
In addition to which, orthopaedic surgery is a very desirable specialty to be in with respect to job blandishments from south of the border, so I think we'll lose orthopaedic surgeons to the United States, and those that remain will be less accommodating.
The Chair: Thank you very much, Ms Lankin. Thank you, doctors, for your presentation. We appreciate your being involved in the process.
Ms Lankin: Mr Chair, I'd just like to put forward a request at this time. As I understand it, at noon today we will be debating a motion which will be calling on the government to extend public hearings and to split the bills. Yesterday, I informed this committee that there were already 316 applicants for the 274 available hearing spots across the province, as we travel.
I would appreciate it if we could receive an update on the number of applicants on the waiting list here in Toronto, the number of remaining spots, and the number of applicants updated today that have applied for out-of-town hearing spots so we would have that information available to the committee as we debate the motion.
The Chair: Okay, Ms Lankin, we can get that. We don't have to wait till lunchtime to deal with the motion. I've had a ruling that the motion is out of order because it is not in accordance with the December 12 order of the House under which the standing committee on general government is operating. Even if such a motion could be and then was passed by the committee, it could not override the abovementioned order of the House which has priority. That order of the House indicates that the standing committee on general government shall report the bill to the House on January 29, 1996, and that if it does not do so, the bill shall be deemed reported to and received by the House.
Mrs Caplan: Mr Chair, the motion is a request to the House leaders to reconsider that. That's all the motion is.
The Chair: The motion has been ruled out of order.
Ms Lankin: Could I ask a question, not with respect to this particular ruling that you've made. Could you be of assistance to us and advise us as to how we could put forward a motion that would be in order that would request reconsideration of this. As you know, when we report to the House on January 29, if there is all-party agreement that has been worked out between the House leaders, a motion could be passed through the House at that time which would supersede the orders of the House that you referred to. So if you could help us structure this in such a way as it would be in order, I think there is a very significant interest, at least on this side of the room, in debating this motion and in attempting to get more time for the people of Ontario to have input into this bill.
The Chair: I would think that kind of a discussion would have to begin with the House leaders. I would suggest that it be taken up at that level. Basically, the committee has to operate under the orders it was given. Any change in those orders would have to emanate from the House leaders, so I would suggest that you bring that up with your House leaders.
Ms Lankin: Just to follow up on that --
Interjection.
The Chair: I'll finish with Ms Lankin first.
Ms Lankin: I just wanted to finish that my request to you, though, was for assistance in structuring a motion for this committee. I recognize that should the House leaders choose to meet at any time, they are free to do that, but we on this side would like to have a request debated here from this committee to the House leaders to meet to discuss this. So if you could help us structure that motion so that it would be in order, that would be of great assistance to us.
The Chair: Okay, I will take that under advisement as to whether or not that's possible.
Mrs Ecker: I'll leave it with you to follow through, as Ms Lankin has suggested. But what I did wish to put forward to the committee is, depending on what happens with that motion, would it be of some assistance to have 20 minutes for presenters? We could get many more in. I recognize that's a short time frame, but we could perhaps get more in in advance of whatever decision the House leaders might well decide to make. That means all of us would have to be very short on questions, and I appreciate that, but that is one suggestion which might help take up some of the people.
Mrs Caplan: I raised the motion this morning on behalf of our caucus and of the opposition parties frankly because of the size of the growing waiting lists. This committee has not yet even advertised out of town, and all the slots are full. We are anticipating that over the course of the hearings we'll be able to see about 400 presentations to the committee. As I understand it, the expectation is the lists will be more than double that.
Frankly and honestly, I don't think any change in the 30 minutes would accomplish -- you can see how little time there is now to talk to the people who are coming forward, and I wouldn't want to frustrate them any further by the fact that there is no time for any real dialogue. But second to that, even if there was a small amendment to the amount of time, we still could not possibly accommodate the overwhelming majority of people who have requested so far to come before the committee and those who we anticipate will respond to the knowledge that the committee is going to be in their communities around this province.
The motion I placed this morning was a very reasonable one. We understand that the government may have some requirements for January 29, but as we've looked at this bill, there are major portions of this bill that we believe would not impede the government's fiscal requirements and could be dealt with when the House resumes on March 18.
The intention of the motion was to accommodate those people who want to be heard, to accommodate the government's desire and right to bring forward its agenda, but also to request the House leaders to consider this expeditiously in light of the growing frustration that people are going to feel if they are denied access to this committee in a timely way. We want to anticipate what could likely occur across this province if they are denied.
The Chair: Excuse me, Mrs Caplan.
Mrs Caplan: That's the reason I place that motion --
The Chair: Excuse me, Mrs Caplan.
Mrs Caplan: -- and I would request assistance on drafting one that would be in order.
The Chair: Excuse me, I have ruled on that motion. We won't talk about that any more. I have already told Ms Lankin that I would take an additional request under advisement and report back, and I will do that.
Is this about this same motion?
Mr Alvin Curling (Scarborough North): There's a suggestion made by Mrs Ecker about the time. When you're going to rule on this motion, or you're suggesting that you're going to be coming back on this motion, I would then say to you, please do not consider cutting it down to 20 minutes because, I'm telling you, the frustration is very high out there. As a matter of fact, as we see how complex this bill is, people are saying even 30 minutes is not adequate for them to present their case. I think what we are looking at is an extended time for more people to participate in this.
The Chair: I will report back on that possibility.
UNITED FOOD AND COMMERCIAL WORKERS INTERNATIONAL UNION
The Chair: We had a cancellation at 10 o'clock; it's interesting. Our next presenters are the group scheduled for 10:30 who are here early, United Food and Commercial Workers, represented by Bryan Neath and Jay Nair. Welcome, gentlemen.
Mrs Caplan: Mr Chair, before we begin, in light of the fact that we had a cancellation, I did make a request that the parliamentary assistant who's here representing the ministry correct the record and apologize. Could she please do that at this time?
The Chair: Mrs Caplan, that request is out of order.
Mrs Caplan: When will it be in order?
The Chair: It will not be in order. There are differences of opinion that have been expressed on both sides here. We will not be in a position to apologize for all of them.
Okay, gentlemen, welcome to the committee. You have half an hour to use as you see fit. Any time you leave for questions at the end will be shared equally by the parties, beginning with the Liberal Party. The floor is yours.
Mr Bryan Neath: Thank you very much. Let me first introduce ourselves. My name is Bryan Neath, I'm the Ontario assistant to the Canadian director for UFCW. With me is Jay Nair, who is the director for the health care education sector of Local 175 of UFCW.
Perhaps we need, for some people around this table, to have a small introduction of the UFCW in total so you can have an understanding of why we are here.
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Our union, the United Food and Commercial Workers Union, is the largest private sector union in North America, with 1.4 million members. We have over 185,000 members in Canada and over 80,000 in the province of Ontario alone. We represent more than 20 sectors. We're in the industry sector of the food side, we're in the service sector on the food side. On the service sector side, we represent education workers, municipal workers, health care workers; we have health care workers in the non-profit nursing homes and in the for-profit nursing homes. We have hospital workers under collective agreement in UFCW. We have a statement in UFCW that we literally represent workers from the cradle to the grave, because we also have funeral workers who are represented by United Food and Commercial Workers.
Let me tell you that we also have across Canada, in all other provinces except for the province of Ontario now, agricultural workers. Most people around this table will know why we don't have any agriculture workers left any more: it's because by the stroke of a pen by the Tory government -- this government -- suddenly those workers who were represented by us are no longer represented by us. I think that's clearly an indication of this government, which clearly is an indication on this bill of this government, that they do not care about working people and that they're more concerned about the question of economics and business.
I guess for me to start, I would like to say I thank the opposition parties, both the Liberals and the NDP, for being here, because I believe without them we would not be here to be able to make our presentation to this committee, because I'm sure that the hope of the government of the day is to have this rammed through legislation so that people like us cannot come here to make these presentations. Let me echo some of the comments that were made in the debate that happened before our presentation.
Thirty minutes is not even close enough for us to make this presentation. Because we represent so many members and because the bill is so extensive, it's impossible for us to deal with all of the issues. We're here in the health care sector today to deal with the questions in the bill dealing with health care, but most of the sections of the bill are so intertwined that they're going to have such an adverse effect on working people, not just working people in the health care sector, but also working people in all sectors of this province and certainly in all of the sectors that we represent.
I would like to make one other final introductory point, that UFCW takes great pride in making presentations to standing committees. When we do this, we usually do this under the aspect of doing it bilingually. We always have had bilingual presentations. Unfortunately, this government has rammed this through so fast, so quickly, and it's such a deep, in-depth bill, it was impossible for us to have a bilingual presentation for this presentation and we're actually quite annoyed about that aspect of it.
Again, as I indicated, this bill is extremely extensive, and although we have touched on almost all aspects of the bill in our presentations, we certainly are not going to go through it. In some of the sections we didn't put in the information we really wanted to and, again, that had to do with time. But we have touched on those sections.
I'm going to pass off to Jay and Jay's going to go through the document for you in a point-by-point area. We aren't going to deal with the schedules B, C, D, E, H, I, K, L, N and O, but, hopefully, we'll be able to have time to touch on some of those other sections. Jay?
Mr Jay Nair: Thank you, Bryan, and thank you for allowing me to do the presentation on behalf of the health sector. It makes me share with you the discussion I had with my wife this morning, the architect of my destiny in partnership. The first question she asked me was, "Where are you going today?" I said, "I'm going down to Queen's Park." She said, "What for?" I said, "I'm going to do a presentation on Bill 26." She says, "What's Bill 26?" "Well, it's something that's going to gut this province from what we have and what we are going to have." She says, "Are they going to listen to you?" I said, "At least one out of the 20 or 30 people who are around may listen, and somebody has to do it."
That's why I'm here today. Thank you for that, and I thank the parties that brought this about -- the opposition parties to this Tory government which is trying to recarve or reshape Ontario, not to the Ontario that I enjoyed for 20 years, but to the Ontario that my children and grandchildren are not going to enjoy. So that's how bitter I am here today, trying to present a document to you and trying to enlighten those who are trying to reshape the province not to be a province of haves but a province of have-nots.
Having said that, I would like to bring to the fore the very act to achieve fiscal savings and to promote economic prosperity through public sector restructuring. The target is the public sector. And economic prosperity to whom? For whom? For the buddies who put you in government or for the population, the Ontarians that we have in the province, for all partners in this province? I am one for partnership and I've dealt with partnerships; I've worked with the previous government with partnerships.
I don't want to go into much detail of what UFCW is all about.
Why are we sitting here? The adverse impact of the small sector, the health sector, that we have, that we represent, will impact on the retail, the service, the industrial sector that we represent. It's a snowball effect. Whatever happens to the public sector will inevitably end up in the retail food store when the employees will be asked by the private sector operator or private sector owner to give concessions, give cuts, because there's no money flowing into the revenue of the retail stores or the manufacturing or the poultry plants. That is why we are sitting here and trying to present a picture.
In brief, I want to just bring to the fore what this bill is all about, and page 3 of our document gives you a highlight of all the things. Let me just highlight two or three things.
It rewrites the rules for bargaining with police officers, firefighters, hospital workers and other workers in the broader public sector, and we have them -- nursing homes for profit, non-profit, homes for the aged, psychiatric hospitals and day care and municipal workers -- forcing arbitrators to consider the possibility of service cuts.
The arbitrators were sitting and ruling on briefs that both parties presented, and asked: "What is feasible? What is workable within the ambit of public sector workers?" They would transfer payments from the government, my tax and your tax, to go and pay for these services, for the nursing home residents, for the long-term-care residents, personal care providers and all that. The arbitrators ruled in a sort of unbiased way for and against, or for the working people of the respective homes.
This bill is going to give the arbitrator the tool or the avenue to go and decide the possibility of service cuts. Let's take that in a scenario, a service cut in the public sector: hospitals, nursing homes, police services and so on. Less money coming into the coffers, less money going into the retail sector, less money coming back to the revenue department in the government, and what are you going to get paid on? Fresh air? Those are the things that are realistic. Those are the things that we talk about when you talk about reality.
Take the other one, the existing law giving preference to Canadian-owned non-profit health care providers. Is Ontario for sale? Yes, it is. This government said it's for sale, for sale to the high profit makers, the maximizing of profits on the backs of working people, backs of the sick, backs of the elderly, backs of the children. Those are the things that this province is heading into. We are going to get the Americans coming in here. We might get people from Europe coming in here. It's free. It's a free-market economy. Come in and do what they want to do and gut what we have earned over the years.
I'm only at 20 years. What I've seen in 20 years and the growth that my family has seen -- am I going to find my children and grandchildren probably don't see what I saw? I've been struggling all my life and have come through systems that are worse than this, and we've replaced them.
Just to highlight on the health care, we've found partnerships working before. We had discussions before with the health sector, the tripartite system, where the business community, the labour movement and the government sat around tables and discussed the future of health care under the long-term-care bill. The minister knows. She saw me before at the presentation of the MSA hearings. But they didn't listen to us. "This is what is going to be done and this is what we're going to do. You come in. That's fine. By all means present your views and so on and so forth, but we have an agenda." And that is the agenda that we are scared about, that my children are scared about, our children are scared about, and the future of Ontario is scared. They don't have the time to come here and pound at the doors and say, "Don't do this, don't do this," because we have it a little too good. They don't know what true suffering is.
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I'm just going to rush through and find -- the document is self-explanatory and if at the time you ask the questions, that's fine. I'm looking at page 9. This bill, the Independent Health Facilities Act, eliminates the requirement of the present act that preference to operate independent health facilities be given to non-profit Canadian operators. That again is forcing or allowing for-profit agencies to come into the system, and I've seen it happen in many places; Liberty is one.
User fees and drug benefits: Are Ontarians with health problems expected to haggle over prices with pharmacists as they do with grocers for their tuna, and then get arrested on top of that? Are we going to go and defend them? No, Mr Chairperson and the panelists, we are not going to see that happen; we don't wish to see that happen.
I'm going to touch on two things quickly.
Equality for women: The proxy method was put in place purposely to bring women's value up to what the male worker in the province was earning for years and years and years, to bring about the balance, to bring about equality. By a stroke of the pen the proxy method is gone out the window. Why? Is this government portraying the anti-women agenda? Is this government trying to say that the women are not essential partners in the workforce of the day? What is it? This bill is giving powers to the ministers to change whenever and if ever they want to. So that is something that this union, UFCW, is strongly against. We represent quite a number of women in the workforce and most of them are part-time to begin with. Therefore, we find that this is deplorable.
Municipalities: We heard from mayors that they're going to increase user fees. Even if you have a fire in North York, the mayor is trying to say you're going to pay a fee when the fire department comes to you. Are we going to allow that? So your money that you're giving back and you promised to give back in taxes to Ontarians, they're going to start paying somewhere else.
Last but not least on my presentation is the board of arbitration, which is crucial to our sector, the health sector, and the homes for the aged and nursing homes that go through the Hospital Labour Disputes Arbitration Act. We have arbitrators who over the years have been using the criterion "ability to pay," but they haven't given much credence to that, the reason being we don't have such a thing as full disclosure.
Full disclosure means even a dollar that comes from the government, what do you do with that dollar to provide the care and the personal needs of the residents? This government is always saying the residents come first, but the money that's flowing from the ministry to the operator, we don't have the full and final disclosure of every cent, the profit. Is it allowing them to maximize the profits on the elderly? Is it this government's agenda to allow the for-profit operators to make as much as they can and let the haves and the have-nots and so on in a class structure that is going to be vastly different? So those are some of the things the UFCW is not going to be a party to and I don't want this government going that direction. Ability to pay has been used before.
In conclusion, Bill 26 represents the most authoritarian power grab in Ontario's modern history. It is an affront to democracy and a disgrace to Ontario that this Harris government has such little regard for the principles of democracy. Just as in the 1960s and early 1970s, when the United Nations declared apartheid as a crime against humanity, so is this Harris government of Ontario declaring crime against the population of Ontario, all Ontarians, not the affluent, not the rich, by passing legislation since being elected attacking the poor, less fortunate, elderly, disabled and children. Those are the people you're attacking, the future of Ontario.
We feel strongly that the United Nations should declare the Tory government of Mike Harris as a government that is guilty of crimes against humanity. I know there's some cynicism around the table, but this is something that I've gone through; I've seen this.
Once again we in the UFCW are demanding that you govern for all the people of Ontario rather than those you assiduously promote economic prosperity to. It has been already demonstrated that employment is not highest where real wages are lowest, and that low wages and high unemployment go hand in hand. So by lowering wages, this government will decrease tax revenue and increase social costs, and the unemployment rate will increase also. This results in people not having enough money to spend in the communities and on services.
We, the UFCW, again have to believe that this is not adequate consultation. A detailed analysis and full democratic discussion is necessary by all the citizens of Ontario in order to fully understand the ramifications of Bill 26.
Just for information, I brought in a document from South Africa, that we overthrew a government. That is what we call consultation. They had consultations by people presenting this way, but every citizen of the country -- 41 million of them -- has access to the draft Constitution of the country so that they have input.
And how did they use it? They got in paper companies, private sector operators, to provide the free paper. So they printed the whole document, every article, the Bill of Rights right through to the end. And what has been done? It's given the opportunity for the people of South Africa to decide their own destiny.
But what have we done? We have become a Grinch at Christmas to come out with a document saying: "Listen, ram it through. Go right through the spectrum of the Ontario population. Limit the time frame" -- I'm limited; I can see my time is running -- and left it to the bureaucrats, left it to the ministers, who arbitrarily one day may get up and say: "Jay Nair has to be arrested. Jay Nair is earning so many dollars; he has to pay a tax." That goes for the population of Ontario.
So this is what this bill is sending out: a bad message, a message that's empowering a few ministers who can determine the destiny of the population of Ontario.
Thank you, Mr Chairperson.
Mr Neath: We purposely left time. Being in standing committees many times in the past, we realize that when you simply read through your documents -- you already in most cases have preconceived ideas of the questions you want to ask, and so we've left time for the questions. Hopefully, we'll get some good questions.
The Chair: We've got about three minutes per party, beginning with the Liberals.
Ms Castrilli: Thank you very much for appearing today and for a very passionate presentation. It is very difficult in the time allotted to you to do any more than you've already done, and we thank you for that.
We on this side of the table share your concerns. We share your concerns about the content and we share your concerns about the process. Dealing with the former, in particular -- you are the largest public sector union in Ontario, as I understand it?
Mr Neath: Not in Ontario.
Ms Castrilli: I'm sorry, private sector union in Ontario.
Mr Neath: No, not in Ontario either. We are the largest private sector union in North America.
Ms Castrilli: In North America. All right, even better.
Mr Neath: We're the second-largest private sector union in Canada.
Ms Castrilli: Second in Canada. Okay. May I ask, have you had any input on the legislation? Have you been consulted? Has the minister met with you?
Mr Neath: Very simply, the answer is no. We have not been consulted at all. We have not been consulted on any of the pieces of legislation that have gone through this government, and certainly not on Bill 7, which is another piece of legislation that has been and will be devastating to the workers of Ontario.
Ms Castrilli: From your brief, which we've not had an opportunity to read yet, it appears that you have a great many concerns, some of them detailed quite a bit. Do you feel that the bill in its present form could go forth? Do you feel that it should be withdrawn? Do you feel that there are some parts that should be split out of it? Do you have any views on that?
Mr Nair: My gut feeling? I'll give you two feelings. One, my personal, it shouldn't be there, because there isn't any evidence that says that something is broken. If you give me evidence -- we don't want guesstimates. We don't want, you know, certain arias of people who say, "No, this is happening." Give us facts, give us figures. There's nothing there.
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The second thing as far the union is concerned is that it's going to impact on our workforce, it's going to snowball. It's not only the public sector, health care workers or the education workers or the municipal workers; it's going to adversely impact on even the gravediggers down in the municipality. It's them plus the retail sector we represent.
The whole economy is not going to go forward; it's going to go in reverse. Are we going to have a First World democracy and live in Third World standards? Is that the agenda? It's an assumption; I don't know. But this bill is going to empower some ministers to do things that -- it's scary. It should be repealed. It shouldn't have anything short of full consultation. Go right to the depths of every part of the legislation and prove to us, prove to the working person in Ontario, that these are the problems and we want to rectify them. Fine, but not just ram it through -- 30 days, and then January 29 we get it passed, and on February 1 somebody gets up and says, "This is what's going to happen." I don't buy that.
Ms Lankin: Thank you, Mr Nair and Mr Neath. I appreciate your organization's efforts in putting a presentation together and coming down here. I was particularly struck by the newspaper document you showed us about how, in another jurisdiction, governments tried to communicate with the people about what it was they were attempting to do.
We have heard from people who wanted to participate in these hearings that in trying to get a copy of the bill and the compendium information -- which is, by the way, well over 2,000 pages -- calling the legislative library, they were told they would have to photocopy it themselves. At 30 cents a page, that's over $600, and many groups and organizations could not afford that nor have the time, upon getting the 2,000-some-odd pages, to go through it and make a presentation and be here this week.
It is absolutely wrong on the part of any government to put together so much in one bill that people cannot have access in an affordable way to the information to be able to respond. That's one of the problems we have here.
In terms of that, together with the short time, you've been able to put together an analysis of some of your concerns in the bill. I wonder, have you really had the time to go out and consult with your members and educate them about what's in the bill and hear what they say from the front line? That's part of what we would all like to have the time to do. I know, as I sit here, that I have very little time to go back into my constituency and talk to my constituents. I read their letters that come in, but I'm not having that dialogue because the government hasn't left us time. What have you been able to accomplish in your organization?
Mr Neath: All we have been able to accomplish is to get our researchers and a few people who are knowledgeable on particular issues, such as Jay and myself, to put the document together. We haven't had time to talk to one member about what's in the bill, because it's impossible in a short time frame. We got a copy of the bill at a very late stage just to put the document together, and there hasn't been enough people who can sit down, certainly in our organization, in time enough to deal with these pieces of legislation.
I had a conversation just last week with the people who deal with our pension plans, because there is a section here that deals with pension plans. We are quite concerned, even though this pension legislation you're dealing with may not affect us today, but it may affect us in the future in some other types of legislation, and we wanted to spend some time to deal with this issue on pension. Our experts who administer the UFCW pension plan are telling us it takes hours of work to deal with one page of changes to pension legislation, never mind to deal with what you have here. So we didn't even have time to consult on the pension side.
What needs to happen here, to respond to one of the questions before, is that you have to break this bill into many different sections, pension being one of them. We'd like to spend time and hours to deal with the pension question alone so we can make sure that what you're doing to the public service will not have an effect on the pension act in the private sector. We do have people in the public service too who will be affected.
We need time to have that debate. We're here in the health care sector. We're trying to get on on the other side so we can perhaps have in-depth debates on the other issues. We can't get in, because the lineup is huge.
Mrs Helen Johns (Huron): I'd like to thank you for presenting to us today. We'll make sure we read your submission. We haven't had time yet, but we will read it.
Of course, there are some fundamental disagreements I have with your presentation, especially Jay, and I just want to say a couple of things about that. You suggested Ontario should maintain its status quo. I suggest that Ontario can't maintain its status quo. From 1900 through to 1970, real growth in North America grew by 3.6%. Since that time, it's grown by 2.2%, and government since 1970 has not really changed the way it has spent. As a result of that we have gone into debt of $100 billion, which allows us to have huge interest payments every year. If we maintain the status quo, that interest will grow at such a rate that we will have no health care and we will have no education and we will have none of the things that you and I hold dear and that I think are absolutely mandatory for my children and grandchildren. So the status quo is not acceptable. We need real change and we believe we need it right now.
One of the things you talked about in your submission was the restructuring of hospitals. I think you're saying that hospitals are not broken and that there doesn't need to be restructuring change. The district health council has told us that there needs to be change, there needs to be this commission or some body to move the system forward, because hospitals, left to their own, could not restructure. Could I have your comments on that?
Mr Neath: First of all, one of the things you should do if you're going to have some changes -- and there needs to be change. We sit here as a union and we make this pitch to anybody. We don't think profits are bad. Profits are actually good, in cases; they keep some of our members working. We're not afraid to say that. Some people in the trade union movement may be afraid to say that, but we're not afraid to say that. There are some problems and there need to be some changes; there's no doubt about that. But what you do when you have problems and changes is sit down as a group of people in partnerships and try to find out, "What are the problems and how do we fix the problems?" What your government has said to us, through this bill, is: "You couldn't be a partner in this. You might not understand it enough. We have the legislation, we have all the answers, and we are going to ram that legislation through and we are going to give the power to the other people and not the power and/or the discussion and partnerships."
I sit on -- I think I still do; I'm not sure any more -- the retail sector strategy committee that was put up by the previous government. I sat with Wilf Posluns from Dylex; he was the chair of the committee and I was one of the co-chairs. We talked about ways we can work together to improve the retail sector in the province, and we came up with some very good ideas in order to have those changes made. But here in this particular bill, in this restructuring you're talking about, there's no partnership, no discussion. Unless you have those things and unless you hear about how we could help in the input, you're just going to go -- I believe your philosophy is --
The Chair: Thank you very much, sir. We appreciate your attendance here this morning.
Mr Neath: I thought you would cut me off. I'm used to being cut off when I have --
The Chair: I figured you were going to go on there for a while. I was fairly generous with you.
Mr Nair: We need more time.
Mr Neath: We'd like to go on for a long time, by the way.
The Chair: Thank you very much. We appreciate your interest in the process and your presentation this morning. Have a good day.
At the risk of making sure that everybody comes back in five minutes, we're going to have a five-minute recess.
The committee recessed from 1039 to 1046.
The Chair: Our five minutes is up. Amazingly enough, almost everyone is still here.
TORONTO INJURED WORKERS' ADVOCACY GROUP
UNION OF INJURED WORKERS
The Chair: Our next presenters are from the Toronto Injured Workers' Advocacy Group and the Union of Injured Workers, represented by Orlando Buonastella, Mark Bailey, John McKinnon, Carl McGregor and Marion Endicott. We may have to put one more seat up there.
Welcome to our committee. We appreciate your attendance here this morning. You have one half-hour to use as you see fit. Any time you leave for questions will be shared among the three parties, beginning with the New Democratic Party. The floor's yours, and if you could maybe identify yourselves so Hansard could record who's speaking, please.
Mr Orlando Buonastella: My name is Orlando Buonastella, and I have with me John McKinnon, Marion Endicott, Carol McGregor and Mark Bailey. We represent two organizations: the Union of Injured Workers and the Toronto Injured Workers' Advocacy Group. Our groups represent injured workers. We have been representing injured workers for over 20 years and we represent mostly injured workers who are on a permanent disability, so the most vulnerable group of injured workers and by implication one of the most vulnerable groups in our society.
In our experience, we have made presentations to many governments over the years: the Conservative governments under Mr Davis, the Liberals, the NDP government and of course today's government. I'd like to begin by stating that we have never seen a government that is afraid of public debate and afraid of public scrutiny like today's government, and we don't say this with a lot of pleasure.
We believe that it was a scandal that public hearings on Bill 26 had to be fought for. It's a sad day for this province when there has to be a province inside the Legislature -- and we're used to being outside of the Legislature to advance our points -- to get something that we were used to, and that is something so basic as public hearings on a very important and fundamental bill.
As I said before, we have had experience in dealing with another Conservative government, the government of Bill Davis. We were opposed to many of their policies on workers' compensation, which is our area of expertise, but they always welcomed our criticism and they always welcomed public debate. Often they weren't just doing it as an exercise. They listened and they actually changed legislation after public debate.
In 1983, for example, there was a government plan to change the pension system. They invited everyone to make submissions. They had hearings on the steps of the Legislature, unprecedented in our history, in order to hear everyone who came to speak, and they withdrew the part of the bill, in those days, that was objectionable and carried on with the part of the bill that had consensus.
They never called us a special-interest group; they never did. They never told us, "We don't need to consult because we have consulted before the election," because they knew the difference between necessarily being partisan before an election and the need to govern on behalf of all of the people when you're in government. That's when you need consensus and you're no longer carrying on strict and necessary partisanship, before the election.
They also know that you need to hear from people with expertise. This was a government that had expertise itself, having been in government for some 40 years. It wasn't a new government. They knew you had to welcome expertise. It's because of this experience that we are particularly strong and that we make an emphatic point about the need for democracy.
We will make specific comments, of course, on Bill 26, but let me start by saying that injured workers will be particularly hit by Bill 26 because injured workers tend to be, as you can very easily appreciate, on very low incomes, so user fees will affect them in a particular way, not proportionately, in other words; they will be particularly hit. And injured workers are not on a fixed income. Most injured workers don't have the full protection of cost of living, so they're already declining; their incomes are already declining from year to year.
We know also that after Bill 26 is implemented, more hits are going to come, very painful hits for injured workers, and they're included in the government proposals to reduce benefits by 5% weekly, to review the lifetime pension awards -- a lot of our injured workers are very scared about this -- introduce a three-day waiting period and reduce future economic loss awards by 15% to 40%.
When injured workers look at Bill 26, they know that it's not going to be only Bill 26, that there are other cuts to come. They're very much aware of this. Injured workers are also very much distraught about the rationale of why their benefits should be cut. I'm just going to talk a little bit about this and then my colleagues will talk about Bill 26 specifically.
Injured workers hear that there need to be cuts to benefits because expenses are going out of control. Injured workers then go to the statistics and they see these are official board statistics: Benefits to injured workers, and they're represented by this graph, have been going down year after year, and in 1994 they're at the lowest point in 10 years. They were at the highest point in 1985, when there was a Conservative government, and injured workers come to us and they say: "Go figure. We need to cut our benefits because we're getting too much? But it's statistically wrong."
Then injured workers hear: "We need to cut your benefits because the unfunded liability is going up too much. It's out of control." And they say: "You go figure this. Our benefits are going down year after year and this graph of the unfunded liability is going up? It doesn't make sense to me. Can you figure it out for me?" They're thinking.
Then we go and look at the assumptions for the unfunded liability, this monstrous graph, this God that justifies injured workers' benefits being sacrificed. "We must sacrifice benefits because this graph is going up." We're looking at the assumptions. It assumes that inflation will be 4% until the year 2014, so the graph goes up. Benefits will go up according to inflation, a little bit less than inflation, so there's no real increase but the graph goes up because inflation goes up; that's the assumption year after year.
The assessment rates are frozen at $3 for eternity. No wonder this graph is going up. So injured workers are in disbelief and they know that more cuts are coming.
Now we're going to make a few comments about Bill 26 to see how it interrelates with the cuts to compensation. We're going to start off with Mark Bailey.
Mr Mark Bailey: I want to address specifically an issue which we think is fundamental to workers' rights to access to information from the WCB which is raised by the amendments to the Freedom of Information and Protection of Privacy Act, which are contained in Bill 26.
Currently under the Workers' Compensation Act, workers are entitled to their file only if there is an issue in dispute. Often workers, and we as workers' advocates, make requests under the Freedom of Information and Protection of Privacy Act rather than under the Workers' Compensation Act because either we don't know if there's an issue in dispute or we don't know particularly what that issue is. So the Freedom of Information and Protection of Privacy Act is an important mechanism for workers to get hold of their files so that they can proceed with their claims.
As a result, the amendments to this act in Bill 26 raise some real concerns. Specifically, the provision in the bill for the institution of a specific fee which is determined by the Lieutenant Governor in Council raises the obvious spectre that impoverished injured workers will not even be able to get their objections off the ground because they are unable to financially afford access to their files.
The second amendment to the Freedom of Information and Protection of Privacy Act included in Bill 26 that gives us concern is the powers of the head of the institution to refuse a request if that request is frivolous or vexatious. Obviously, this raises the spectre that the board can refuse an access request, and that would necessitate an expensive and lengthy appeal to the Information and Privacy Commissioner simply to get the workers' compensation objection even off the ground.
Those two aspects of the changes to the Freedom of Information and Protection of Privacy Act give us great concern. I think it's rather obvious that access to information from government institutions is fundamental to an open and democratic society, and we think it's somewhat ironic that changes to this act are contained in a bill in which the government has been accused, in terms of the procedure for its enactment, of also acting undemocratically.
That's it for my comments. If there are no questions, then I will turn it over to Mr John McKinnon.
Mr John McKinnon: I wanted to speak to you regarding one of the portions of the bill dealing with changes to the Health Insurance Act and the Health Care Accessibility Act. I too wish that we had more time to study this and analyse this, but I'm just going to touch on one of the issues now that is going to, in our view, have a chilling effect on the treatment and diagnosis of injured workers with permanent disabilities, and it's going to restrict their access to necessary health care.
The particular section that I'm dealing with is in schedule H, section 12 of this part of the bill, dealing with section 18 of the Health Care Accessibility Act. In a nutshell, it's talking about paying for services and saying that the general manager can refuse to pay a physician or can pay a reduced amount, "If he or she has reasonable grounds to believe that all or part of the services were not medically or therapeutically necessary." Then in subsection 18(5) it goes on to say that the general manager can require a physician to reimburse the plan if it later discovers circumstances which cause the general manager to believe that the services or the treatment were not medically or therapeutically necessary.
This, I think, has repercussions which are going to significantly affect injured workers in a number of ways, and I can only just touch on them now. First of all I can say, and probably all of you who have injured workers coming to your constituency offices can vouch for this, that the Workers' Compensation Board itself is responsible for a tremendous amount of referral to specialists and diagnostic procedures that are not medically necessary and they're not therapeutically beneficial, and it's the Workers' Compensation Board itself which often forces injured workers to go shopping from doctor to doctor.
There are a couple of essential reasons for this. One is that the Workers' Compensation Board has a profound bias against the opinion of the family doctor. Quite often the injured worker will suffer an injury or a disease from work, will see the family doctor, the family doctor will have a good grip on the situation and have an idea of what the appropriate treatment is, when the return to work and so forth should be, but that's never good enough for the WCB. Anyone who's made a phone call to the compensation board has heard an adjudicator say: "That's just the opinion of the family doctor. Why should I take the opinion of the family doctor? Our doctor, who reviewed the paper, says this person should be better. Maybe this person shouldn't be injured at all."
This bias against the family doctor results in the injured worker going back to the family doctor and saying: "I'm sorry, this isn't good enough. I need to go see a specialist." The family doctor then begins this parade of referrals to the various specialists and the consultation reports, which are quite expensive to the health insurance plan, and then those reports come into the WCB only, in most cases, to back up what the initial gut feeling of the family physician was.
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The second reason, in addition to the bias against the family doctor, is the bias against the treating specialist, because often, even though the injured worker has gone back to the family doctor, been referred to some specialists, come back with some new reports, diagnostic procedures, X-rays and CAT scans and so on, the WCB still says, "We had our special consultant look at it and we don't agree." Once again, the injured worker is forced to go back to the family doctor and say, "This is not good enough."
The family doctor in many cases would agree that this is not medically or therapeutically necessary. However, these are their patients, and they have an obligation, if you check under the code of ethics of the Canadian Medical Association and, I believe, the College of Physicians and Surgeons, to provide whatever health care and referrals are necessary to assist their patients in making applications for any forms of disability-related benefits that the patients may be entitled to.
As a physician, the doctor has an obligation to continue this referral until there's enough paper built up at the WCB for them to see that the family doctor was right all along. The thing is, the WCB is not setting up these appointments; it's not taking responsibility for it. They are just saying: "I'm sorry, your benefits are cut. If you don't get more clear and convincing medical evidence, we're not going to pay you." The onus then is on the injured worker and the family physician to go from doctor to doctor to doctor at tremendous cost to the plan, not necessarily medically helpful or therapeutically necessary, but simply to deal with the bias at the WCB. So this is one reason.
What injured workers are going to be finding is that the compensation board is going to be saying, "Your benefits are cut because we don't think this evidence is clear and convincing enough." The family doctor is going to be saying, "Wait a minute. I can't send you to see these specialists. I'm not going to do any more X-rays or tests because it may come out of my pocket. I'll tell you right now, I know what's wrong with you and I know what you need to do, and that should be the end of it." But the injured worker is going to be caught between a rock and a hard place. The board won't pay the benefits; the doctor won't make the referrals. They're stuck.
There's another reason too why this provision of the bill creates special problems for people with permanent disabilities and for injured workers, and that's because basically getting better, getting rid of the disability is the only hope that injured workers have for any continuing participation in the workforce.
The WCB statistics for returning people to work are absolutely appalling. The board's most recent statistics of the re-employment rate among people with permanent disabilities three years after the injury show that of that group, the people with permanent disabilities, 80% -- the exact figure is 78.4% -- of those injured workers have not returned to work three years after their injury. Another amazing statistic published by the WCB is that of the people who were fortunate enough to get back to work within a year after their injury, at this three-year point 37% are unemployed again; 37% lost the jobs that they got originally after their injury.
What this tells us is that the re-employment provisions in the Workers' Compensation Act aren't working. They aren't getting injured workers back to work. Carol is going to speak about the implications of the repeal of pay equity, but I just want to say that injured workers, like all people with disabilities, want to work, and injured workers can see the writing on the wall. The only way they're going to work again is if they get better and the only way they're going to get better is if they keep going from doctor to doctor to doctor till they find a doctor who knows what's wrong with them and who says he can fix it.
This bill is going to have a chilling effect on those doctors who would otherwise help an injured worker to find the appropriate specialist, to find the appropriate treatment, to do something, anything, to help him get better, because, once again, the doctors are worried, "This may come out of my pocket." The doctor may be saying: "I really don't know what's wrong with you. I can't say for certain that there's anything physically wrong with you. I believe you, but I don't know." If the doctors are worried about having to pay out of their own pocket for whatever further specialist investigations or treatment, they're not going to make the referrals.
Some people might say maybe we shouldn't be paying for people who go from doctor to doctor to doctor if there's no hope for them, but it's not the case that there's no hope for them. The Workers' Compensation Appeals Tribunal is a specialized tribunal that has been involved in a number of cases and has done an in-depth investigation of this issue. I just want to refer to you a couple of their findings on this point from the major decision, decision 915, which looked into permanent disabilities.
They say, "A significant proportion of enigmatic chronic pain cases are, however, in fact attributable to unfound or unfindable organic or physical causes." They go through all the situations where injured workers are thought to have nothing wrong with them and it's not the case. They talk about failed or mistaken diagnoses. They say, "About 10% of patients (who have had thorough work-ups) referred to pain clinics" -- because there's nothing else that the doctors can do -- "eventually are found to have a neoplasm or other occult [obscure] medical condition that slowly became manifest."
They say there are also a great number of cases where the organic or physical problem is simply beyond the current capacity of medical science to find; for example, "In the order of 10% to 15% of rheumatologists' patients suffer from intractable musculoskeletal pain of a previously undiagnosed origin." They also refer to a doctor saying that, with back injuries, "5% of vertebrae fractures are not picked up by X-ray examination."
Their conclusion on this point was "that some significant proportion of all enigmatic chronic pain cases will be cases in which, if it were possible to really know, the fundamental reason for the pain is organic not psychological." It's not in their heads. It's not a psychological problem.
This bill is going to have a chilling effect on the treatment and diagnosis of those injured workers. It's essentially a sentence to permanent disability for a lot of injured workers, people who would otherwise have some hope for treatment, for diagnosis, for a cure, if their doctors weren't constrained by the payment provisions of the bill.
I'll turn it over now to Carol McGregor, who is going to speak about another aspect of the problem of returning to work.
Ms Carol McGregor: Mr Chairman and members of the committee, one of the major documents that has come out through the federal government across the country in the last few years has been on the improved health status of people with disabilities after they have returned to work.
It's well known that health care costs have been reduced, Canada pension costs have been reduced, welfare costs have been reduced, because once people with disabilities are in the labour force, their general health care has improved. But we know from what John was saying and we know statistically from Stats Canada that the unemployment rate for people with disabilities is in the area of 60% to 80% in unemployment and underemployment. It is probably higher as we are seeing certainly cutbacks in both the federal and provincial services. I know personally that within the provincial government disabled people are being cut at a drastic rate, and we have been launching some appeals outside of my job here with the clinic.
There has been some perception, I guess the government's perception, that injured workers want to stay home and just collect their pensions. I assure you this is furthest from the truth. Injured workers have always lobbied for employment equity. You have killed employment equity. Employers have not rehired; they've not brought injured workers back into their workforce. Why is that? Can they not accommodate them? Under workers' compensation Bill 160, it says they have to accommodate them under the point of "undue hardship."
I am currently working for this legal clinic and I don't have any equipment. This legal clinic is at the point of undue hardship. If I can't get the equipment, I can't do this job and I have to quit and go back on pension. I am now currently trying to fight with your government just to get equipment.
Injured workers face the same situation within their own workforce. They face that situation of trying to get their positions accommodated, but employers do not accommodate. I can't stress to you the obligation of employers in terms of re-employing injured workers back into the workforce to improve their health.
The new government program that was recently announced that's going to provide accommodation equipment, my understanding is that's coming out of excess funds out of the access fund, which is a source for me, and it's only going to probably assist 30 disabled people out of 1.6 million disabled Ontarians. I find this appalling.
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Ms Marion Endicott: I have the final point to make, and that is on the board's financial improvements package. This is a big, fat document with which the board proposes to make major savings. Really, there are probably a number of points in this package that overlap with Bill 26. But one in particular that concerns us is the fact that the board has identified that the Ontario government, they believe, should be paying for the drug costs of injured workers with permanent disabilities over the age of 65; in other words, paying for the compensation-related drug costs. The government is already paying for the other drug costs.
The compensation board is looking forward to shifting $900,000 worth of revenue costs per year from their responsibility to the responsibility of this government. We of course vigorously oppose that as taxpayers. We can think of many other better things to do with $900,000 per year, lots of other services that need attention, when in fact it is the employers of Ontario who have the responsibility to pay for any cost that is related to any injury that workers sustain in the course of their work.
Bill 26 worsens the situation. It makes the shift even further and more regressive. Bill 26 introduces the concept of user fees and proposes to have individuals pay a user fee on any prescription. As long as it's under the Workers' Compensation Act the compensation board would pay for the entire cost because that is what is required by the legislation; however, if part of this cost shifts to the government, then under Bill 26 injured workers will suddenly be required to pay some portion of the costs arising out of their injury.
We simply cannot accept that. In the first place, as you may well know, I'm sure all of you, injured workers are not well off. They can ill afford this extra cost. In addition to that, it's just illegal. The Workers' Compensation Act requires that the injured worker not make any payments towards the cost of their claim; that's quite clear and quite correct because, as I will remind you, injured workers gave up the right to sue in order to receive this other kind of compensation.
Should injured workers have the right to sue, you can be sure that the employers of this province would be paying a lot more money on a yearly basis to injured workers than they are presently paying in assessments to the WCB. Workers have given up that richer benefit that they could be receiving, if they had the right to sue, for the security of workers' compensation benefits. It doesn't require that they go out and get lawyers and wait to find out what they're going to get, but rather it's paid up front on a no-fault basis.
The introduction of user fees, the shift to the Ontario government, simply does not fit within the concept of the Workers' Compensation Act. We have to put this into the context of the general problem of user fees. User fees, user fees, user fees. That's what Bill 26 is all about, right? And what are user fees?
Does this government think that the people of Ontario are so stupid that they can't recognize that user fees are simply a tax by another name? It is the most regressive form of a tax that is possible -- there can be no more regressive a form -- and simply continues the trend that this government has initiated of disassembling society into fragments of individuals who are simply supposed to make do the best they can in the world.
The people of Ontario are going to become increasingly angry as every single little ritual in life has a user fee attached to it, from putting out the garbage to going to the library to take a book out. I mean, this is just unconscionable, frustrating and simply, for injured workers, too much to bear. They don't have that money.
You may know that injured workers already have a very high rate of taking their life. I don't know what the statistics are, but you will read every year of a number of injured workers in this province who have killed themselves in some form or other and the note that they have left indicates that the reason this has happened is due to their frustrations with the WCB, the way they have been treated, the problems of living in pain without adequate income.
I can unfortunately predict that if injured workers are forced to bear the burden of all these different user fees, including the ones on their prescriptions, which they shouldn't even have to be paying under law, but all those others too, if they try to take their kids to the swimming pool or to the library, life will become ever more unbearable for them and you will see increasing tragedy going on in this society, which is simply not correct from a human point of view, and if you want to look at the financial aspects of it, as this government is wont to do, it's going to end up costing the society more, in money as well as spirit and humanity. That's the point that I want to make on Bill 26.
I guess, sort of in summary, I'd just like to come back to the point that Orlando was making at the beginning about the unfunded liability. You may have wondered why he was talking about that, and how is that related to Bill 26?
One of the reasons it's related is that what we're finding is that this government is going forward with drastic, major changes to all sorts of bills without understanding what it's doing.
The unfunded liability at the WCB is something that is quite complex in some ways, quite simple in other ways, and it is not a debt. That's very clear. There are many things to be said about the unfunded liability, but the critical thing to understand is that it does not represent a financial problem for the compensation system, and yet it is being used as a reason for drastically reducing the benefits and services that injured workers require.
Mr Buonastella: The new god.
Ms Endicott: It's the new god, right, that we sacrifice injured workers to. So this is why we think it's important to make the point about the unfunded liability, for example, and of course Bill 26 is also fraught with these kinds of drastic, drastic changes, major powers put into the hands of a government which has shown itself over and over again to not really understand the basis on which it's making its decisions.
I thank you for having us here today.
The Chair: Thank you very much for your presentation. You've used up all of your half hour plus a little bit, so there isn't any time for questions but we do appreciate your attendance here this morning and your interest in the process.
Our last presenters for the morning are the Eli Lilly corporation, and I believe they're out in the hall. The clerk has just gone to bring them in, so don't run away.
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ELI LILLY CANADA
The Chair: Gentlemen, welcome to our committee. We appreciate your attendance here this morning and you have a half-hour to use as you see fit. Any time that you leave for questions, we'll begin with the New Democrats at the end. The floor is yours, gentlemen.
Mr Terry McCool: Thank you. We have to wait to catch our breath here.
My name is Terry McCool. I'm the vice-president of corporate affairs with Eli Lilly. With me today is Dick Guest, who's the director of our Ontario operations, and Craig Martin, who's the director of government and professional affairs. We certainly appreciate the opportunity to appear before you today to offer our views on Bill 26.
We'd like to begin by stating that we support the government in its efforts to reduce the deficit and bring spending under control. In doing so, we believe that it's equally critical that the goal of quality, efficiency and effectiveness of health care not be compromised. Although many of our comments today will focus specifically on the proposed legislative changes, we'd like to offer some comments on the broader context of health care provision in Ontario.
First, I'd like to give you a little bit of background about Eli Lilly and company. We are an integrated health care company which provides innovative pharmaceutical products and health services within the Canadian health care environment. We are an Ontario-based company with our head office and fully integrated manufacturing and research facility located in Scarborough. We employ over 550 people in Canada, and 430 are employed within the province of Ontario.
Our company's global mission is to create and deliver superior health care solutions by combining pharmaceutical innovation, disease prevention and management and information technologies in order to provide our customers worldwide with optimal clinical and economic outcomes. To this end, we have begun our transition from a traditional pharmaceutical company to an integrated health care company through the purchase of Sudbury-based Rx Plus, a health benefits management company, and the establishment of a health management service company focusing on disease management.
At Lilly, we will also continue to work to discover breakthrough compounds that focus on unmet clinical needs. Our research focuses on five key areas: endocrinology, specifically diabetes and osteoporosis; infectious disease; cancer; the central nervous system; and cardiovascular disease.
Our Ontario research commitment includes the Lilly analytical research laboratory at the Reichmann research centre at Sunnybrook Hospital, and we are currently constructing a $25-million bioanalytical laboratory at our Scarborough site. From 1990 to 1994, we invested greater than $52 million in research in this province and in the past year close to $13 million.
Through our integrated approach to health care, we will ensure better utilization of existing health technologies to provide more optimal outcomes. We will also explore opportunities to provide information that will help prevent diseases and utilize information and information technology to better manage diseases and improve health outcomes.
I'd like to comment briefly about health care in general and health care in Ontario.
Over the past decade, we have seen a growing increase in health care costs in Canada. Currently, the nation, based on 1993 figures, spends approximately $72 billion on health care. That includes about 47% on hospitals, 15% on physician services, 16% on pharmaceutical costs and the rest on a variety of other health professionals, capital and some other expenditures. Ontario and a number of other provinces in Canada have used a variety of very blunt measures to try and control expenditures, and in fact much of the effort has been focused on drug expenditures, hospitals and physician services.
What is often left unacknowledged is that despite these measures, the demand for health care continues to escalate. Our population is aging. Demographically, seniors are the fastest-growing portion of our population and will continue to be for the next several years. Not only are the numbers of seniors increasing, they are living longer and healthier lives, thanks to many advances in lifestyle and in technology. The net effect is that it is not uncommon for individuals to suffer from several chronic diseases as they age. Treatment costs increase exponentially as people age. In view of these realities, without major gains in efficiencies and effectiveness, capping Ontario's health care expenditures at $17 billion may be very difficult.
We believe that the health care environment is changing globally, allowing for and demanding a more integrated approach to managing health care. In the past, a significant amount of time and energy has been spent managing the component pieces of health care. Yet controlling individual components has not led to control of overall costs. Health care costs are very much linked to patients, their diseases and optimal treatment of those diseases. Integrating systems and information allows for better decisions and better allocation of resources.
Traditionally, we have viewed the management of a disease as a series of separate activities: diagnosis, treatment, either with pharmaceuticals or hospitalization with medical or surgical intervention, follow-up, observation and sometimes resolution. Each of these activities has been managed individually and separately. It was assumed that if health professionals and providers did the best job with each component in isolation, they would achieve the best possible outcome for patients.
Today, medicine has become too complex and health care costs too much of a societal burden. As a result, health care systems around the world are becoming more organized and integrated. People are beginning to recognize that components of health care are best managed together, with an optimal therapeutic and economic outcome as the goal.
That is why disease management is a patient-focused approach and provides a more realistic perspective of health care. Disease management is viewed as a connected set of activities that must be managed together rather than separately. Each component of treatment and patient care is planned throughout the disease cycle. Importantly, disease management stresses appropriate treatment along with prevention and early diagnosis.
We believe both Lilly and other pharmaceutical companies can play a role in disease management. It will require integrating systems to generate information that enables better decisions about the management of patients and their diseases. Disease management will enable physicians to make better use of pharmaceuticals and other interventions and as a result provide more value for the health care dollar.
As other costs are contained, we believe pharmaceuticals administered as elements of a comprehensive disease management program will often be both clinically and economically superior to other forms of treatment. As a result, therapy costs may appropriately rise as a percentage of total health care spending. Currently, 16% of national health care expenditures are on pharmaceutical costs. However, only 6% are on prescription drugs. The remainder of the costs are for over-the-counter medications and pharmacists' professional fees.
Despite the small portion of health care dollars spent on prescription drugs, this area continues to be the focus of cost-control measures. We are concerned that this cost management approach compromises the overall goal of integrated health care management and urge the government to change the focus from component management to disease management.
As health care continues to evolve and become more integrated, we believe that not only governments but also consumers need to be more knowledgeable about their diseases and how they are being managed. We also believe consumers should bear some personal responsibility for maintaining healthy lifestyles and should assume some of the costs associated with their treatment. As such, we support the government in its intention to add a component of cost-sharing to the drug benefit program. However, we believe that the copayment should not fall only on the drug component. As well, this copayment should not disadvantage those on social assistance or seniors on guaranteed annual income supplements. With this increased responsibility and cost-sharing, there should come increased choice and involvement in health care options.
Turning now to the proposed legislative changes contained in schedule G of the bill, we'd like to offer some more specific comments.
First, it is important to note that the wording of the accompanying regulations to Bill 26, which are not available yet, will be critical to ensuring the success of the proposed legislative changes. The Minister of Health is given increased powers, through regulation, to establish the reimbursement price for listed products and outline the prescribing criteria for products or therapeutic classes. Lilly Canada would like to review and comment on these regulations before they are passed next year.
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Lilly Canada supports the proposed changes to the Prescription Drug Cost Regulation Act to deregulate the price of pharmaceutical products in the private market. The artificial environment created by the best available price did not promote competition in this marketplace.
Contrary to media reports, we do not believe that this deregulation will result in significant price increases for patented products. I can commit on behalf of Lilly that we will provide all our products at reasonable prices throughout the Ontario market. We would further like to assure the public that any potential price increases on our patented products would be within the Patented Medicine Prices Review Board guidelines, the federal body that regulates patented drug prices. As you may be aware, the PMPRB regulates the entry level prices for new products and allows no more than the CPI increase on existing patented products.
To ensure transparency throughout the system, we recommend that the drug price, the markup and the professional fee be separately itemized in the information provided to consumers. This will enable consumers and private payers to monitor each component of their reimbursement cost.
We are supportive of eliminating BAP. We feel that actual acquisition costs whereby pharmacy is reimbursed for the actual cost of the product plus an appropriate upcharge and professional fee is a fair method of reimbursement.
While we continue to have some questions regarding the implementation of the price negotiation between the government and manufacturers, it is our interpretation that the PMPRB sets prices for new compounds and this process will be respected by the Ontario drug benefit program. As a component of this process, we understand that the cost effectiveness information will be reviewed by the government to determine how products will be reimbursed. As a result, we would expect to see a reduced role for the drug quality and therapeutics committee and a more open and transparent process.
For companies which distribute their products directly to pharmacy, their final price includes all distribution costs. For companies that use wholesalers as their method of distribution, their final price is the factory gate price to the wholesaler and does not recognize the cost for distribution. We recommend that the new regulations allow for different upcharges for products required through various distribution channels. We believe the wholesalers have a valuable role to play in the distribution of pharmaceutical products and would like to see that role recognized by an appropriate upcharge.
Bill 26 proposes to eliminate payments for no-substitution prescriptions. We understand the need to control expenditures in the ODB budget and recognize the ministry can achieve savings by eliminating no subprescriptions. However, we are concerned that it will be difficult to gain access to brand products when a physician deems it medically necessary. Furthermore, in all cases where substitution is occurring, it is our view that the patient must be fully informed before the generic product is substituted for the brand-name medication.
Consistent with disease management approach, Lilly strongly supports enhanced participation of the consumer in all aspects of health care. As consumers take more and more responsibility for payment of their therapies, they must be allowed more control over their choices and be given the option of paying the difference in price between brand and generic products.
Consistent with the recommendations of the Pharmaceutical Inquiry of Ontario or the Lowy commission, Lilly Canada supports a legislative amendment that requires pharmacists to inform patients when substitution occurs and allows them the opportunity to pay the price difference.
Bill 26 also proposes to restrict payment for certain drugs under the ODB Act to situations where specific clinical criteria are met. This process is known as linking reimbursement to guidelines.
Lilly believes that several key considerations must be made prior to implementing the legislative change. First, we must stress that all clinical guidelines be evidence based to ensure their validity and their usefulness in clinical practice. Second, we believe that guidelines must not restrict the ability of physicians to tailor therapy to meet the needs of individual patients and we are concerned that linking guidelines to reimbursement may hamper the physicians' ability to address very specific clinical situations. In additional, communication and administrative issues could prove to be very costly and time-consuming if prescribing criteria are too rigidly enforced.
The current Ontario anti-infective guidelines were developed based on clinical judgement and experience. They serve as a useful educational tool and have been fully supported by Lilly. Based on this experience, we believe the industry needs to play a stronger role in the development and communication of appropriate guidelines and we would like to work with the government to develop, disseminate and implement these prescribing criteria.
In conclusion, Lilly Canada recognizes the need of the provincial government to achieve fiscal savings and supports the general direction being charted by the government with this legislation. We believe that the proposed legislative changes are critical to the future of the pharmaceutical industry and the overall economy of the province. Eli Lilly Canada has been in Ontario for over 55 years and is committed to working with the government to ensure that the people of Ontario benefit from the optimal utilization of prescription drugs, which is believed by many to be the most cost-effective component of health care. Thank you. I look forward to your questions.
The Chair: Thank you very much, sir. We've got about five minutes per party left for questions, beginning with Ms Lankin.
Ms Lankin: Thank you for your presentation. The committee appreciates you taking the time to be here with us. I have a few questions based on different parts of your submission, so I'll just run through them one at a time perhaps.
On page 3 in the section dealing with consumer involvement, you talk about a general support for the intention to add a component of cost sharing to the drug benefit program, but you indicate that you believe the copayment should not fall on the drug component alone. Could you explain what you think should happen instead?
Mr McCool: Drugs currently fall outside of the Canada Health Act, but we think that issues around deductibles or copayments fall within the drug area. We think that that probably isn't fair if consumers are going to take more responsibility for their health care. Specifically, we do not have any specific recommendations as to what things should be listed as copayment, but a lot of services fall outside of what is currently being covered by the government.
Ms Lankin: Are you suggesting that the government should be looking at user fees in areas covered by the Canada Health Act, for example?
Mr McCool: I wouldn't go so far as to suggest that the government should be looking at user fees. I would suggest that the government should look at maybe what's covered under the Canada Health Act. I think that's where the first description needs to take place. The sense of universality and comprehensiveness is getting very, very difficult to afford within the context of the Canadian health care system, and I think the government needs to decide what it means by comprehensiveness.
Ms Lankin: I think the Finance minister agrees with you. He made similar comments in Ottawa at the federal-provincial finance ministers' meetings, where he suggested that the province required more flexibility and there should be changes to the Canada Health Act.
Mr McCool: We're just suggesting that it should be looked at, rather than only looking at making deductibles and copays associated with prescription drugs, because we think that penalizes the most appropriate utilization of those drugs.
Ms Lankin: You indicated that you thought the copayment should not disadvantage those on social assistance or seniors with guaranteed annual supplement. Are you suggesting that there should be an amendment to the structure of the copayment as is set out in Bill 26?
Mr McCool: Whether it's an amendment or not, we think it should be looked at. We think that for some individuals there is a financial penalty based on the number of prescription drugs.
Ms Lankin: Currently, the bill would provide that everybody, irrespective of income, would pay at least the $2 user fee per prescription, and you think that might be problematic for some people.
Mr McCool: Yes, I do.
Ms Lankin: I'm interested in your view, and there have been some other representatives of the pharmaceutical industry who have echoed this, that the deregulation of non-ODB drug prices is something that, contrary to what we've read in the media, won't necessitate or won't bring about increased costs.
The pharmacists who have come here think that it might because they think they'll have a harder time negotiating, particularly independent pharmacists as opposed to the chains, or that it might drive everything into the large chain bulk-buying. The pharmaceutical industry that comes suggests that if there is anything it might be in the markup of pharmacists, and we know in rural areas where perhaps there is a monopoly situation that's a possibility. As members of the public, we're left sort of wondering when we see different parts of the industry pointing at each other as to where the villain might be if in fact there are increases.
I'm wondering whether you think the amendment -- and I suspect you're asking for an amendment with respect to the transparency. Do you believe that that would correct any of those problems, and how would that assist in small-town Ontario or rural Ontario, where you have an independent who has to pay whatever they can individually negotiate with a drug manufacturer and is the only game in town and has no controls on the markup that they're putting in place?
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Mr Dick Guest: Yes. What you're really asking then is will the small-town rural pharmacist be disadvantaged as opposed to a big city or a chain pharmacy.
Ms Lankin: The individuals purchasing the product from that, yes.
Mr Guest: Or the individual who's purchasing it. Our goal is certainly not to disadvantage, from a pricing point of view, anybody whether you're in rural Ontario or whether you're in urban Ontario. The point about the breakdown of the costs would make that transparent to show that the cost would be very similar for the drug component, and then the other components would be costed appropriately.
Ms Lankin: So at least it would be transparent.
The Chair: Thank you very much, Ms Lankin.
Ms Lankin: That's five minutes already? I have so many more questions.
The Chair: That's five minutes. It was a wonderful long question.
Mr Tony Clement (Brampton South): Thank you very much for your comprehensive presentation and your suggestions. May I say, as I said last night to one of the presenters, that we are very much interested in particular amendments that are brought forward by deputants because, the way we see this process, it's an open process. There are possibilities of amendment. The bill is not written in stone. In fact, as we hear presentations, the wheels are working in our minds to actively consider amendments. So your presentation was very useful in that respect.
Just to springboard off something that Ms Lankin said, are you subject to federal competition laws?
Mr Guest: Yes, we are.
Mr Clement: So there are laws prescribing against saying to one buyer that your price is this, and to another buyer, your price is that. You can't really do that. You have to have a price.
Mr McCool: We have to treat all buyers the same in terms of their scope and size, but you can't have different prices to different payers.
Mr Clement: For different products? Or reflecting your costs, transportation costs, that sort of thing.
Mr McCool: Yes.
Mr Clement: But you can't just arbitrarily say, "Because you're Mr So-and-so from This Rural Area, even though our transportation costs are the same, we're going to charge you at a higher price because we don't like you."
Mr McCool: No.
Mr Clement: Let me just talk a bit more about that, because we also heard yesterday from I guess one of your competitors that in fact the way they saw the structure of the pharmaceutical market is, you've got generics where the pressure is down in terms of prices, and you've got the brand names where we've got federal regulations which are in effect so that they saw, and I'm not trying to put you on the record in terms of your pricing strategies, that the pharmaceutical prices would either be flat-lined or in some cases competitive pressure would drive them down through the change in the government policies proposed. Are you able to comment on that at all?
Mr McCool: We would see it the same way. The patented products are controlled by the prices review board, so that's pretty much established. There has been very little growth in the consumer price index in Canada, so the prices have been pretty much flat. In the multi-source market, which is the generic market, far more competition could take place if it wasn't for the fact that, at least in Ontario, there has been a fixed price, and so our suspicion is, prices will probably come down, given the increased competition.
Mr Clement: Let me jump in and ask my final question probably in the limited amount of time we have, but I'm in full agreement with you that we need a more integrated approach to health care delivery. But the question is, how do we get there from here? Who is the actor that can promote an integrated approach, because you have so many different actors in so many different communities. Would it be fair to say that the only actor possible, in order to help shape that in conjunction with the various actors in the community, would be the Minister of Health? That's the leadership you're looking for.
Mr McCool: Under the Canadian system, it's the Minister of Health or the deputy minister.
Mr Clement: He needs those tools to do that, doesn't he?
Mr McCool: That's right.
Mrs Caplan: I have a question. The first one follows up on an erroneous perception that was left and that was that you have the same price for every purchaser no matter what their volume or anything. I just want you to clarify, you do offer different prices to different purchasers of your drugs, depending upon the volume of their purchase and other factors.
Mr McCool: That's correct.
Mrs Caplan: That's correct.
Mr McCool: That's right.
Mrs Caplan: Right, of course. I'm wondering, will you be negotiating a price for the ODB drugs with the minister?
Mr McCool: We don't anticipate that; we think that the minister will respect the price that the Patented Medicine Prices Review Board approves in Canada. We don't see the necessity to negotiate that price based on good cost-effectiveness criteria. We will price our products based on their value in the marketplace, and the body that scrutinizes that will be the PMPRB. We would expect all provinces in Canada to respect that federal legislative act.
Mrs Caplan: Have you had any indication from the minister that this is in fact the case, that he has no intention of negotiating on behalf of the ODB, given the fact that it's such a significant part of the Ontario market?
Mr McCool: We have not talked to the minister about this. All we can do is read what is in the act, just like probably you can.
Mrs Caplan: The other thing I'd like to clarify -- and the parliamentary assistant is here today -- is that it is the practice, Mr Chair, at the committee for the parliamentary assistant, who speaks on behalf of the ministry, to clarify what is in the bill.
Yesterday, the parliamentary assistant suggested, on the concerns you have around no substitution, there would be a procedure in place for the ministry to in fact pay for drugs where doctors have said that the brand-name product is the only appropriate product, and that is why I believe you probably said today that it would be difficult to gain access. My question really is for clarification from the parliamentary assistant. Do you still stand by those comments?
Interjection.
The Chair: Yes, it is acceptable practice that you answer a question on behalf of the ministry.
Mrs Johns: I have to hear what she says I said again.
Mrs Caplan: What you said to Glaxo Wellcome yesterday was that there would be a procedure, a mechanism in place for anyone who required an alternative in a non-substitution segment, that they would be able to apply. If a doctor prescribed a drug that was considered a non-substitution drug, they could receive payment for the alternative drug through some mechanism in the ministry. Do you understand that?
Mrs Johns: No, but I don't think I said that. I'd have to see it in writing. If you could forward it to me, I'd be happy to comment on that.
The Chair: Okay. Do you want to get back on to the answer?
Mrs Johns: I'd like to see where she's quoting me from, the context.
The Chair: More important is, is the question --
Mrs Caplan: The question is, do you foresee a mechanism that will allow any relaxation to your no-substitution rule that is written in the legislation?
Mrs Johns: No.
Mrs Caplan: Well, I would suggest that in fact that's not what you said yesterday to Glaxo Wellcome.
Mrs Johns: I said yesterday that-
The Chair: Okay, we don't have an argument --
Mrs Caplan: No, no, I'm not arguing. I just want to clarify it, because not only will it be difficult, as you have said; it will be impossible. Because the answer that we have from the ministry, and I'll quote from what will be on the record -- it says here that there will be no mechanism for the ministry to pay for the additional cost of a no-substitution prescription. That's what this legislation says. That is contrary to what the parliamentary assistant said yesterday in response to Glaxo Wellcome.
I know that you monitor the hearings and that you'd want to know accurately what the legislation says. So that if you believe that there should be a mechanism, then you could propose an amendment to the minister to achieve what the parliamentary assistant said would be possible. Did you want to comment on that? Because I think that was probably your understanding from the presentation from Glaxo Wellcome.
Mr Chris Stockwell (Etobicoke West): Mr Chair, is it in order now for the member to start suggesting what --
The Chair: Let's --
Mr Stockwell: The question is contrary to what she said yesterday.
The Chair: The question has been asked to the presenters. We're here to get public input, not to argue among ourselves. The question will be answered by the people from Eli Lilly, please.
Mr McCool: We just think that under the present scheme, for a physician to get a certain product for a patient to go through the regulatory hurdles of calling to get approval, at the end of the day they get discouraged by that process and ultimately don't do it.
Mrs Caplan: Well, there's no --
The Chair: Thank you very much, Mrs Caplan. Your time has expired.
We appreciate your attendance at our meeting this morning.
Mr McCool: Could I just have one clarification?
The Chair: We've allotted everyone so much time.
Mr Curling: He wants a clarification.
Mrs Caplan: Let him ask his question, Mr Chair.
Mr McCool: I just wanted to clarify one point. I might have left the impression that we had multiple prices in Canada. Currently, we have one price to all customers in Canada, just to clarify that.
The Chair: Thank you very much. We appreciate your attendance this morning and your interest in our process.
Ms Lankin: Mr Chair, if I may, I would like to move a motion. I have copies of it here if the clerk would like to circulate this. The motion reads as follows:
Whereas there has been overwhelming public interest in Bill 26 and that requests to appear before the standing committee on general government far exceed the number of spaces available;
I move that this committee recommends to the government House leader that when the House returns on January 29, 1996, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged; and further, that this committee recommends to the government House leader, based on the submissions to the committee to date, that Bill 26 be separated into several bills to allow the public an opportunity to adequately analyse the bill.
Further, that this committee recommends that the three House leaders meet as soon as possible to discuss this issue.
The Chair: Thank you very much for the motion. I will reserve my decision on the admissibility of that motion until this afternoon.
Ms Lankin: I recognize that, given that we have had a question about the admissibility, you would have to rule on that. If the motion is in order, could you indicate when we would have an opportunity to debate this?
The Chair: I will advise on that this afternoon too.
Mrs Caplan: Mr Chairman, could I speak to that?
The Chair: Are you going to speak to the motion?
Mrs Caplan: No, not to the motion, but to the admissibility of the motion. I would suggest that the clerks have been working to --
The Chair: I would rather make the decision on the admissibility of it first; then we can talk about it.
Mrs Caplan: Because we believe this is an extremely important issue.
The Chair: I know you do and I said I would rule on it this afternoon. We're recessed until this afternoon.
The committee recessed from 1152 to 1302.
The Chair: Good afternoon, folks. Welcome to our committee. Prior to our break at lunchtime, Ms Lankin put forward a motion which I won't re-read at this point in time, but I will say my decision is that the motion is in order and I would ask for unanimous consent, out of respect for the presenters who are here, so that we don't infringe on their time, that we discuss this during our dinner break at 5 o'clock. Does everybody feel comfortable with that?
Ms Lankin: Absolutely, Mr Chair.
The Chair: Okay, thank you.
CANADIAN GREY PANTHERS
The Chair: Our first group of presenters represents the Canadian Grey Panthers: Joe Moniz, Isobel Warren, Penny Gray and the Reverend Dr George McClintock. Welcome to our committee. You have a half-hour to use as you see fit. When we get around to questions, they will begin with the government. The floor is yours.
Dr Joe C. Moniz: First of all, I'd like to thank you all for inviting us here today. It's a pleasure and an honour to be here to address some very important issues.
I'd like to start off by saying that In the brief you have before you, we've summarized the recommendations briefly up front, prior to reading the body of the brief.
Firstly, we'd like to immediately implement a pharmacy smart card program;
-- Re-examine income levels for the proposed $100 deductible;
-- Undertake a province-wide medication education program for both the medical community and the public;
-- Utilize electronic communications such as bulletin boards and the Internet;
-- Re-examine costs, both financial and social, of hospital closures;
-- Examine the role of nurse practitioners and regional health centres to deal with home care requirements;
-- In general, adopt a proactive stance in promoting preventive rather than medicative health care, and this includes re-examining the funding of alternative therapy which has a proven track record;
-- Initiate and maintain an ongoing consultation with seniors through focus groups and through Canadian Grey Panther member surveys.
On the following page we briefly summarize the association. The Canadian Grey Panthers advocacy group is an organization that seeks to combine the wisdom of elders with the energies of youth to create a more humane and caring climate for seniors of today, tomorrow and of the future.
The uniqueness of the Grey Panthers, again, is the intergenerational approach. We're concerned about seniors today because we'll all be seniors tomorrow. It's of great concern to many of our members who are of the younger age category. They are concerned and they don't want seniors to be affected in any way.
The Canadian Grey Panthers are deeply concerned about the apparent erosion of health care for seniors and for all citizens of Ontario. As our population ages, we foresee the need for changes in health care delivery, for expansion of home care and home services and for increased nursing home care for frail seniors. We fear that current and upcoming cutbacks will create terrible hardships for seniors, depriving them of essential medicare and support, exposing them to suffering and deprivation that are not in keeping with a civilized society.
We urge the ministry to review any decision to reduce services to seniors and to act with caution in exposing our senior population, many of whom already live below the poverty line, to increased expense and risk.
We further urge the ministry to implement measures to promote a preventive approach to senior health care rather than the present medicative one.
Our members feel a sense of betrayal. Many of our members see the current cutbacks as a breach of trust, an abrogation of the commitment made by our government to the welfare of seniors and the specific election promise that health care funding would not be touched.
Our members feel betrayed. Over decades they have contributed, through multiple tax layers and their own careful planning, to the financial stability of the province, believing that they were building for their own and their families' futures. Instead, they see the disintegration of social welfare programs to which they have contributed.
Seniors are concerned, indeed fearful, not only for their own present and future welfare but for that of their children and grandchildren. While acknowledging the urgent need to reduce government costs, the Canadian Grey Panthers suggest that this be achieved by controlling waste and duplication of services by increasing taxes for banks, large businesses and corporations and by stimulating the economy to create more jobs rather than by forcing more and more people into poverty.
Seniors and health care: Today's older seniors have been conditioned lifelong to accept, without question or challenge, their doctors' decisions on health matters. Unfortunately, most of today's doctors are inadequately trained in geriatric medicine, nor does their caseload permit them to assess adequately the patients' real problems and perhaps to recommend alternative therapies.
Sleeping pills are just an example. Research has proven that seniors require less sleep than their younger counterparts and that seniors' nervous systems retain hypnotic drugs longer than younger bodies, yet doctors continue to prescribe sleeping pills which may cause serious accidents and falls requiring costly medical attention. A very high percentage of senior hospital admissions is the result of drug overdoses.
Agism likewise takes its toll. Many health care professionals perceive seniors as irrelevant either in society or in their practice and resort to the quick-fix tranquilizer or sleeping pill.
Dissatisfied with the assembly-line approach of many health care providers, seniors may go from doctor to doctor, seeking answers but receiving yet another prescription. The result is that our older population is seriously overmedicated, some taking a dozen or more drugs of questionable value, and in some cases taking duplicate, generic and brand name, drugs.
Next, user fees: The prescription user fee system puts special hardship upon the senior population, many of whom are already in dire financial straits. Canadian Grey Panthers urge the ministry to re-examine the $16,000 and $24,000 income levels for the $100 deductible amount and to readjust these levels to an amount that is a more realistic reflection of the poverty levels of this province's seniors, especially those living in large urban centres.
The Canadian Grey Panthers recommend that doctors and pharmacists be empowered to dispense long-term drug prescriptions required for chronic conditions to help seniors avoid user and dispensary fees.
We turn now to the smart card alternative. The $100 deductible would be more palatable if the resulting funds were put to effective use. The Canadian Grey Panthers recommend the immediate implementation of a pharmacy smart card, an electronic monitor of individual prescription drug use.
The universal use of this already developed system would eliminate double or triple prescriptions and thus much of the high cost associated with seniors overmedication: the cost of the drugs themselves, as well as overuse of hospital and medical facilities due to drug-related illnesses, accidents or falls.
As well, the smart card would encourage users to patronize a single pharmacy, where the pharmacist can not only monitor medications but also provide advice on drug use.
Although there are costs involved in setting up the pharmacy smart card, it should result in both monetary savings and enhancement of the health of Ontario citizens of all ages.
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Educational programs: Canadian Grey Panthers recommend a province-wide educational program on senior health care and medications aimed at both seniors and the medical community to combat overmedication and the creeping agism that contributes to it.
Electronic communication: The Canadian Grey Panthers note the widespread availability of electronic communication systems, bulletin boards and the Internet, and urges the ministry to utilize these systems to communicate with seniors and/or health care providers. We acknowledge that the extreme elderly of our present society are not acquainted with today's technology, but the implementation of this recommendation now will ensure that future elders, already computer literate, will utilize the cost-effective means of communication.
Hospital closures: The Canadian Grey Panthers are deeply concerned about the possible closures of hospitals and other health care facilities. Again, we urge the ministry to re-examine these proposals which could well result in greater wastage and increased costs as well as depriving our communities of some accessible, specialized and highly prized facilities.
Reducing costs: What we want to promote here is a win-win situation where we can help you to save money and to reduce costs. We'd like to offer you some ideas on where costs can be reduced.
The Canadian Grey Panthers urge that in lieu of penalizing seniors with user fees and reduced services, methods be developed to minimize the need for senior hospitalization and medication, while enhancing the quality of care. These include the following:
-- Expanded home care and home care service programs, and renewed emphasis on the role of the nurse-practitioner discipline, relieving pressure on hospitals and institutions and providing seniors with more security and personalized care.
-- Development of regional health centres, which at present are stretched far beyond their limits. In rural areas especially, public health nurses carry huge caseloads that often require hours of travel daily and leave little time for patient assessment and emotional support.
-- Enhancement of volunteer programs and education.
-- Development of communications technology that allows seniors to communicate with their health care providers, including doctors, from their own homes. This would include a hotline for emergency response.
-- Emphasis on home security devices that summon assistance in the event of an emergency.
-- Continued inducements to encourage doctors to relocate to rural and small urban centres.
-- Implementation of educational programs for both seniors and health care providers to overcome the assembly-line approach to health care and combat agism.
-- Development of a preventive approach to medical care rather than a drug-based one.
-- In particular, the Canadian Grey Panthers urge the ministry to consult with seniors through focus groups and surveys before implementing these dangerous and indeed destructive cuts.
Canadian Grey Panthers are willing to cooperate with the ministry in communicating with seniors through surveys of our entire membership as well as conducting focus groups to assess realistically both attitudes of seniors and the impact of proposed changes upon their lives.
And now a look to the future: The Canadian population is aging. Today's healthier elders are living longer, and as they enter their later years they will require more services, care and medical attention. While demand for subsidized retirement homes may decrease, the need for specialized nursing homes for frail elderly people is likely to increase.
Canadian Grey Panthers strongly urge the ministry to look to the future and to take a proactive stance in expanding services to seniors, especially those outside of institutions ie, home care and other home-based services, in order to be prepared for the age wave of the future.
The Chair: Thank you very much. We've got about 15 minutes left in total for questions, beginning with five minutes for the government; Mrs Ecker.
Mrs Ecker: I thank you very much for coming today and thank you for an excellent presentation. You've made some points that I think are quite good.
The government would certainly support your recommendations on the need for a smart card in the health care system. I think we'd also support your concerns over the problem of overmedication of seniors. It's one of the reasons why we have a pharmacy computer system which tracks the prescriptions on ODB to try and address that. We recognize that we need to continue to do more along those lines, and welcome your suggestions on this.
What I would like to do is ask you a little bit about the Ontario drug benefit program. You made the point that the $100 deductible, you'd like to see that put to good use. I think probably as you're very familiar with, the costs of the drug program have tripled over the last several years and a couple of previous governments have tried to wrestle with how to address that.
One of the tacks that's been taken in Ontario and other provinces is to delist drugs. Other provinces have chosen to introduce minimum copayments. Ontario felt that we wanted to take the copayment route, that that was better than completely delisting drugs which might be very, very badly needed by some seniors, and it also gave us an opportunity to extend drug benefits to 140,000 low-income individuals.
So I just wondered if you could have some comments about what might be the best way to address those costs, given that some provinces have wandered down the delisting route, some have taken copayment, and we had sort of thought copayment might be the best way to do it because we didn't like the concept of delisting. So I wonder if there are any comments on that.
Dr Moniz: Actually, that point was raised. We had a collecting of members, about 120 I believe it was, and we asked them that same question. Again, no particular amount was raised, but it was funny how they all said it was more of a question of the $16,000 issue versus the $24,000 issue. No amount was actually stressed, $100; it was the fact that, why $16,000? That was more in response to your question, because we asked them similarly what they thought. You're talking about the copayment amount, or the deductible of $100?
Mrs Ecker: Well, there are two things. I guess, first of all, I was talking about sort of the concept, because there's kind of two ways to go at it. One is to delist drugs off the formulary, which we thought was not appropriate; and the other one is to try and implement some form of copayment system, which has also been tried and is also happening in other provinces and seems to be working, as I gather, in some of the other province.
Dr Moniz: It was funny that the point raised was that -- there was no negative feeling about the payment itself, but again: "Why is it that last year I received so many drugs, this particular drug, for free? Now I have to pay for this particular drug." So there is a negative feeling among the membership about that.
Mrs Ecker: Perhaps if we were able to communicate better, that this is a way to preserve the drugs on the system they have access to?
Dr Moniz: That's right.
Mrs Ecker: Okay. Thank you, a good point. You'd mentioned about wanting to shift more of the resources from the health system into some of -- I think it was community based and geriatric care --
Dr Moniz: Right.
Mrs Ecker: -- and the minister has certainly acknowledged that we need to do more on geriatric care.
I guess the concern is that again the last three governments had talked about shifting from out of the acute care hospital-based, get out of that and take the resource and put it in other areas; and none of us have been actually do that because we haven't had the authority. I guess, how do we take that resource from hospitals now and acute care and shift it without some change in the legislation and authority that gives the ministry the ability to do that?
Dr Moniz: I'm a gerontologist. I graduated from McMaster University, and that was one of the key questions: How do we do it? But the question is, it's needed. It is very much necessary, because seniors will want to stay within their own homes. They don't want to go into institutions. They don't want to go into chronic care units. They just do not want it.
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In response to your question, it's a question we've been asking ourselves: How do we do it? Really, it's difficult. It has to be done. That's the key thing here. And how we do it? We have our research department that we can provide you on how we do it. But the point is it's needed.
Mrs Lyn McLeod (Leader of the Opposition): I'll lead off the questions, then. You've very clearly pointed out concerns with overmedication and sometimes inappropriate medication of seniors. I wonder though, do you think that charging seniors for their drugs is a deterrent to that and a way of coping with that, or would it be more effective to look at better pharmaceutical management of seniors, both through geriatric training of physicians and also working with pharmacists? I just wonder quite frankly why the government would be suggesting that the way that you deal with the real concern about appropriate medication is to charge seniors, as if somehow seniors were going to have to pay the cost of their illness.
Ms Isobel Warren: If I could comment on that. I think that in fact many seniors will cease to take needed drugs as a result of that user fee, especially those in the lower income levels. We firmly believe that the proper route to follow is to provide a different kind of delivery and to provide monitoring of the drugs that are being taken and to reduce the costs of both hospitals and drug plans by eliminating unnecessary drug use. So our feeling is that it will certainly reduce the amount of drugs that seniors are taking but it may not be the right kind of reduction and in the right area at all.
Mrs McLeod: It sometimes surprises me that I think we sometimes forget why seniors are having their drugs paid for by government, and it's in large part because seniors are on fixed incomes and because for the realities of aging they are likely to experience more medical difficulties and therefore the cost of their drugs can become prohibitive for people on fixed incomes. Even though you're trying to deal with something which would be more fair by looking at the $100 deductible being at a higher level of income, could you make a case that seniors in fact should not have to pay for their drugs?
Ms Warren: Certainly seniors in the lower-income groups should not have to pay for their drugs; $16,000 is the low-income cutoff in urban areas; $24,000 is the low-income cutoff for couples. That's a serious hardship for people in that income range to afford their drugs. Now, as to whether it is time to reassess the free access to drugs for people in higher-income ranges is another matter, but our primary concern right here and right now is that we see especially low-income seniors being subjected to real hardship right away.
Ms Castrilli: I want to thank you for this. It's a very thoughtful presentation, given the very stringent time limits which you must have had. I wondered, because of that, if you might expound on something that's not in your paper, and I expect you haven't dealt with it because you haven't had the time, and that's the whole notion of confidentiality of records. Seniors do have a number of health concerns. Those have been documented. Bill 26 provides for very far-sweeping provisions which would allow that information to be disseminated quite freely and with very little liability. Is that something that's of concern to you?
Rev Dr George McClintock: Yes, this is one of the aspects that is of concern to all who are seniors and all who work with seniors, I believe, that the patient-doctor relationship and all other confidential relationships should somehow be protected in whatever electronic support systems may be used. It all goes with the importance of doing what we can to maintain the dignity of the individual and to protect their individual rights.
There was one point I wanted to make also in response to Mrs Ecker's question and that goes to the matter of reducing drug costs. One of the possibilities would be to re-examine the scope of what's allowed under OHIP and the drug benefit plan and see where alternative therapies may well prove much more economical and beneficial to the seniors. As it is, I think one of the reasons there tends to be an overuse of drugs is that it's an attempt by the medical profession to provide some comfort or relief to pain that might be better handled by a good chiropractitioner or some of the other alternative therapies. So we would suggest that this could well be an area that would reduce drug costs considerably.
Ms Lankin: I'm glad that you made that last point, because I was a bit disturbed when Ms Ecker said, "There's one of two ways to go about it: you either delist or you put the copayment in." I had an opportunity to examine that and felt it would be important to proceed along drug education and prescribing guidelines. In fact, we were able to get the first clinical guidelines on anti-infectives in place and work is going on for more which will be available for this government to implement. I think that is an appropriate way to proceed before you look at something like copayments.
You've spoken about the financial hardship with respect to the level of low-income cutoff for deductibles and the problem that will cause people with respect to having to make perhaps inappropriate choices about medications that they take. I'm wondering if you've looked at the actual $2-per-prescription user fee for those below $16,000, particularly if someone has multiple medication needs. Have you had an opportunity to examine any particular cases of any of your members or what that might mean for some seniors? Is it similar to your arguments about the deductible?
Dr Moniz: Yes, very much so. They're living on tight enough incomes now. They just cannot, because some are taking -- I know of one case -- 22 different drugs, and they just can't cope. They just cannot afford it. That was raised continuously through that focus group that we held.
Ms Lankin: And those prescriptions might be on a monthly or a three-monthly basis for example.
Dr Moniz: On a monthly basis.
Ms Lankin: My goodness.
Just to let you know, there were two or three representations yesterday from people who work in the mental health field who indicated that for people who are required to take medications for significant mental health problems -- and a number of those people would be now living in the community but unable to work; they would be in very low-income situations, perhaps on social assistance and recipients of ODB assistance -- compliance with their medication program was really put at risk by this user fee. That just opens the door for people re-entering the hospital system.
Dr Moniz: Absolutely.
Ms Lankin: One of the other reasons, to add to Mrs McLeod's comments, that the drug program has been established as it has for seniors is that using these medications can help seniors live healthily outside of institutional settings as well, and there's a cost inherent in both health and, for this government's concern, the fiscal bottom line if they don't take those medications.
Dr Moniz: That's right.
Ms Lankin: I just wanted to also comment on your concern around hospital closures and the need to ensure that there's a reinvestment in the community. I don't know if you've looked through that section of the bill, but the powers are entirely left to the minister to decide. There's no spelling out what the role of the commission is, no relationship to the district health councils or local planning. There's nothing that has proved the government's statement that they need these powers. They refer to the Doctors Hospital case, but that was one hospital for fiscal reasons, not Metro DHC health restructuring.
I would point out to you that in Windsor, where there has been a restructuring process, where there had been a government commitment for the dollars saved in the hospital to go into the community, this government has withdrawn that commitment for the dollars to be reinvested in the community. So I think your concerns are warranted.
Would you like to see amendments to the legislation in this area around the minister's powers and do you have any recommendations for the committee?
Dr Moniz: In answer to your first question, yes, amendments. We'd like to be given the opportunity to generate some amendments and present to you, but because of the shortness of putting this together -- yes, we do agree and yes, we would like to recommend. That's why we're here, to help you in terms of developing the right recommendations.
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The Chair: I'm sorry, the time allotted is up. If you do have some further ideas that you would like to share with the committee, we'd be only too happy to have you submit those to the clerk's office or to the ministry and we'd be happy to look at those. Thank you very much for your interest in our process and for your presentation.
Are the people from the Shared Health Services Network here? No. We will recess for a few minutes until they appear, say, 15 minutes.
The committee recessed from 1331 to 1427.
ONTARIO ASSOCIATION OF RADIOLOGISTS
The Chair: Our next presenters are here from the Ontario Association of Radiologists, Dr Murray Miller and Dr Isadore Czosniak. Welcome, gentlemen. We appreciate you being here this afternoon. You have half an hour to use as you see fit. Any time you allow for questions will be shared evenly and would begin with the Liberal Party. So the floor is yours, gentlemen.
Dr Murray Miller: I'm Dr Murray Miller. Beside me is Dr Isadore Czosniak. We're here today as representatives of the Ontario Association of Radiologists. At the outset, I'd like to say that we're grateful to have this opportunity to address you today on Bill 26. We have many comments, some positive, some negative, but all of which we trust you will find constructive.
Just as a way of background, the Ontario Association of Radiologists is a voluntary professional organization. We represent approximately 700 diagnostic imaging specialists in Ontario. We are here in the capacity of the executive of the Ontario Association of Radiologists. In addition, both Dr Czosniak and I sit on the College of Physicians and Surgeons' quality management task force, the OMA breast cancer committee, the Ministry of Health's advisory committee on the Healing Arts Radiation Protection Commission, the so-called HARP commission, the ICES committee on breast cancer screening guidelines and the committee advising the Ministry of Health and the Ontario Hospital Association on the implementation of magnetic resonance imaging in Ontario.
Over the past 30 years, 90% of the progress in medicine has been the result of improvements in diagnostic imaging. The evolution of outpatient care and decreased length of stay in hospitals are largely due to advances in diagnostic imaging and interventional radiology. For example, CAT scanning has completely eliminated the need for exploratory surgery, mammography has resulted in decreased mortality from breast cancer and radiologists can now treat abscesses and perform biopsies on an outpatient basis, obviating the need for more expensive and riskier surgical procedures, which tend to be associated with prolonged lengths of stay in hospitals.
At the outset, we would like to state that the breakdown of relations between the government and the Ontario Medical Association is a dangerous and unwelcome development to seasoned observers of health care in Ontario. It is unacceptable and unhelpful for a provincial government to unilaterally use its legislative powers to sideline a legitimate organization which not only represents 23,000 physicians but is one of the province's key players in shaping policy and delivery of medical services to the patients of this province. Our experience has clearly demonstrated that change will not occur if the major players are prevented from participating in the process. We would ask the government to reconsider its approach and take a fresh approach in building a constructive relationship with the Ontario Medical Association.
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We have followed with great interest the issues leading up to the tabling of the legislation and would like to address some of the issues raised by the Minister of Health in a November 22 letter to the OMA and in his opening remarks to this committee. The minister identified the following concerns and policy priorities:
(1) Improved supply and distribution of physicians.
(2) Better management of utilization.
(3) Sustaining the present level of care.
(4) Meeting changing health care needs.
(5) Improving efficiency and accountability.
We would like to address each of these issues and explain how the radiologists of Ontario have met and will continue to meet the challenges that face us today.
First of all, with regard to improved supply and distribution of physicians, we appreciate the concern of the minister regarding the supply of physicians in Ontario. However, we must point out that there is an appropriate supply of radiologists in the province. Every area of Ontario is currently served by radiologists.
The Ontario Association of Radiologists is active all across Ontario. When we are made aware of a demand for radiology services, we have accommodated the location by acting as a clearing house and assisting in arrangements. For example, there are formal arrangements between southern and northern Ontario groups of radiologists which provide cross-coverage expertise which would otherwise be unavailable locally. As a consequence of our program, some of the radiologists have decided to relocate permanently to northern communities.
The OAR is well into completing a comprehensive human resources plan in association with the university teaching programs to ensure that the future supply meets the needs into the next century.
In terms of better management of utilization, we sat before a similar committee in 1989, the social development committee. At that point in our deputation we proposed an eight-point plan. We feel that it is as relevant today as it was when it was first proposed. It should be noted that many of the points that were brought forward were to specifically address the issue of appropriate utilization. Since October 1989, we have actively pursued elements of our eight-point plan by undertaking some of the following initiatives:
We have supported the development of the Health Arts Radiation Protection Act and its evolution.
We've been involved in initiatives in quality management and continuous quality improvement. As a matter of fact, the majority of the authors of the national Quality Management Manual for Diagnostic Imaging are Ontario radiologists.
Initiatives to provide evidence-based information and criteria for the use of radio-opaque contrast media have been published and accepted by the Ontario Hospital Association and the Ministry of Health.
We have had initiatives for the development of a provincial MRI program with which we've had great cooperation from the Ministry of Health.
We have been active in standards development, both on a national and international basis, and the standards are now formally part of the Clinical Practice Parameters and Facility Standards of the College of Physicians and Surgeons of Ontario.
Ontario radiologists have been actively involved and continue to be actively involved in the assessment program for independent health facilities in cooperation with both the Ministry of Health and the College of Physicians and Surgeons.
There are current developments in evidence-based appropriateness guidelines for diagnostic imaging which are being undertaken by Ontario radiologists in conjunction with the college.
We continue to be actively involved in health research with regard to utilization and outcome.
We feel that Ontario radiologists have accepted the challenge to promote the rational cost-effective use of diagnostic imaging, and we can assure you that we will continue to do so.
With regard to sustaining the present level of care, it's quite clear that we've been living under constraints for the past number of years, but despite these constraints the radiologists have managed to introduce new techniques and skills, some of which we've mentioned previously. These have translated into cost savings to the health care system, specifically by reducing length of stay and other accomplishments.
We are in agreement with the minister's statement that investment in technology is a very cost-effective way of extracting greater value from today's health care system.
With regard to meeting changing health care needs, the diagnostic demands of an aging population are clearly more intensive. Radiologists are the key physicians in deciding the appropriate use of medical technology for an elderly population. Other examples include both cancer and cardiovascular treatments which were raised by the minister as areas of concern. It must be stressed that these treatments are always preceded by appropriate diagnostic testing. In the absence of availability of the diagnostic testing, treatment is ultimately delayed.
In terms of improving efficiency and accountability: In order to ensure optimal and appropriate utilization of imaging technology, it is our assertion, supported by the accompanying brief which you have from the US General Accounting Office, that imaging is best done by imaging physicians. The US government study confirmed that imaging physicians are by far the most cost-effective managers of imaging equipment.
Now I'd like to make a few comments about the proposed amendments to the Independent Health Facilities Act.
Radiologists are uniquely affected by Bill 26 because our members are intimately involved with independent health facilities and with hospitals.
As members of this committee are aware, radiologists have been instrumental in assisting in the development of regulations in the existing Independent Health Facilities Act. Many of the changes proposed in Bill 26 currently exist as ministry policies and now will be brought into the act in a more formal way. Radiologists have worked closely with ministry officials in the development of these policies over the past six years.
Specifically with regard to some of the proposed amendments, I'd like to make the following comments.
We have some specific concerns about revocation of an IHF licence. Under the existing Independent Health Facilities Act, the minister has the right to refuse an IHF licence only at the time of renewal. The position of the government and ministry officials has always been that renewal will only be denied on quality assurance issues. We urge that this be retained and defined as such in the proposed legislation. Radiologists have no objection whatsoever to the revocation of an IHF licence when there are patients' care and quality concerns. We strongly support the College of Physicians and Surgeons in their ground-breaking activities in the field of quality management.
Therefore, we urge that the committee put forth amendments that IHF licence revocation be restricted on the grounds of quality issues, whether it be at the time of renewal or any other time during the term of licence.
Similarly, for removal of services in an IHF, we feel that the same standards should apply when specific services are removed and the terms of a licence are altered. They should only be done for quality issues.
With regard to the clause on specific requests for proposals, the proposed amendment provides the Minister of Health with the power to issue a specific request for proposals, which would allow the minister to select a party to provide services and to provide that party with one or more licences. It is our concern that this provision is open-ended and creates the potential for significant mischief. A situation could arise where a well established IHF clinic which has been serving a community of patients for many years is suddenly faced with the fact that the ministry has now awarded another licence which affects the viability of the existing clinic. This would in fact run counter to the minister's concern about appropriate availability of services.
We propose an amendment that such provisions should be tightly defined and provide preference to existing IHF holders, particularly those that are recognized as high quality facilities owned and operated by the radiologists who are currently in practice in the area.
With regard to due process, the proposed amendments remove the due process rights that are currently contained in the Independent Health Facilities Act and in all other health care statutes. This 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 Independent Health Facilities Act. To maintain high quality imaging equipment, independent health facilities require a stable licensing environment. Investment in such equipment is extremely difficult in the face of the threat of expropriation without compensation. The average cost of equipment in an independent health facility runs in the neighbourhood of $500,000 to $1.5 million. It is difficult to imagine how one could make such a financial commitment with the possibility of losing a licence with virtually no notice. The removal of due process incorrectly suggests that the quality assurance program, which is run by the College of Physicians and Surgeons, has not worked even though it is the most stringent in all of North America. The government has greatly amplified the legislative authority and discretion extended to both 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 six-year experience with radiologists that the Independent Health Facilities Act can be made to work successfully, and the inclusion of due process rights is a necessary and reasonable component to maintain balance.
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We therefore propose that the committee consider an amendment which will provide the necessary stability and encourage investment in high-quality care. We further urge an appeals process consistent with the present legislation, along with a longer notice period, be provided.
With regard to removal of Canadian preference, the government's proposal to remove the preference for Canadian applicants seeking a new independent health facility licence opens the way for large American entities to apply to replace existing local Ontario expertise. It is questionable as to how a government would be able to enforce the same level of quality assurance provisions on a foreign-owned and non-physician body. It is our experience, both Dr Czosniak and I, with the College of Physicians and Surgeons, that it cannot enforce quality provisions on non-physicians.
The lack of the college's ability to discipline non-physicians has been a problem in the past. It is not unique to expect that the ownership of professional practices is limited to Canadian professionals. In virtually every other profession, whether it is legal, accounting, architectural or many others, the practice must be owned by a Canadian-based practitioner. This kind of limitation is seen even in non-professional areas such as publishing and broadcasting. In an area as important as the public health, coupled with the demand for increased fiscal restraint, it is essential that ownership and accountability remain in the hands of physicians licensed to practise in Ontario. Therefore, we recommend that the ownership of independent health facilities be restricted to Ontario licensed physicians.
Now I'd like to turn to the proposed amendments to the Public Hospitals Act. We preface our comments about the Public Hospitals Act by advising the committee of the close working relationship between the Ontario Association of Radiologists and the Ontario Hospital Association. We have worked closely with the OHA on matters of mutual concern and have even acted in the past as mediators between the OMA and the OHA. We look forward to this continued cooperative relationship.
The Public Hospitals Act amendments allow a hospital board to (a) refuse applications for reappointments, new appointments and change in hospital privileges; (b) to revoke appointments; and (c) to cancel or substantially alter privileges. No hearing is required, and the existing statutory safeguards contained in section 37, paragraphs (3) to (7), and sections 38 to 43, do not apply. The legislation makes a dangerous break with the past by providing immunity to the hospital and the board. This has been widely misinterpreted as applying only in the event of a hospital closure. In fact, we have received an opinion that this applies to all public hospitals.
The Ontario Association of Radiologists is deeply concerned that the delicate balance between hospitals and physicians who work in those hospitals would be strongly weighted on the side of hospital administrators and the boards. While this will not result in a discontinuation of the mutual respect between hospital and management and physicians in all cases, there is enough evidence at the moment that the cooperative agreements of the past have broken down due to increasing fiscal pressures on hospital managers. There have been several cases where hospital administrators have attempted to breach the Canada Health Act and the College of Physicians and Surgeons' code of ethics by having physicians split their fees with the hospital. Therefore, the association urges the committee to consider that these extraordinary powers should only be available in a situation where a hospital closes.
In conclusion, Dr Czosniak and I would like to take the opportunity to thank you, on behalf of the association, for permitting us to address the committee on these important issues. Over the past six years, the radiologists of Ontario have dealt with these types of issues, which the minister is now proposing for the broader medical community. It is important to be cognizant of some of the lessons learned over that period.
First of all, the effective implementation of any statute dealing with medical care requires close cooperation and a strong working relationship between physicians and the Ministry of Health. I am proud to say that our association has developed such relationships over the past six years. We would urge that the government develop similar relationships with the OMA based on a shared vision of medical care in Ontario.
With regard to quality, we feel very strongly that maintenance of quality care must be paramount. The provision of quality care can be accomplished even in the face of fiscal restraint as demonstrated by the quality management program of the College of Physicians and Surgeons with regard to independent health facilities.
Once again, I must remind the committee that we have been leaders in the field in North America and this has occurred because of active participation and cooperation with Ontario radiologists.
The final point I'd like to make is that the present Independent Health Facilities Act and Public Hospitals Act have served the patients of Ontario well. The impact of the proposed changes on quality and accessibility must be closely assessed prior to enactment.
We look forward to continuing our input on Bill 26 and are willing and able to assist in drafting amendments and regulations. We believe that our cooperative relationship and ongoing communication between ourselves and the Ministry of Health should be a model for others. Thank you very much.
The Chair: Thank you, doctor. My apologies for mispronouncing Dr Czosniak's name. I had the wrong spelling up here. We've got about 12 minutes left for questioning, four minutes per party, beginning with Mrs McLeod, the Liberal Party.
Mrs McLeod: On page 5, you deal with your concerns around the independent health facilities and I'm appreciative of the concerns you raise. I guess I'd like to ask you to just maybe speculate, if you will, for a moment on what underlies your concerns. Why do you think the government would want such an open-ended power to make decisions about revoking a licence for other than quality reasons? When might the minister use that kind of a power? What is it that as radiologists you might be afraid of happening in the future?
Dr Miller: I think our primary concern is not how things might be applied, but the fact that they can be applied. Once again, when we look at an independent health facility where we're being called upon to make a significant dollar investment, it's always a concern that unless there is some stability -- I mean I'm quite confident that I can say I can provide high-quality imaging but, on the other hand, if there's a risk that for no stated reason a licence can be revoked, then the concern is why would anyone want to put that investment in to maintain the quality because you can guarantee maintenance of quality, but unless there's a corresponding guarantee that the licence and the ability to practise will be there, then people are going to be loath to make the investment to start with.
Mrs McLeod: On another issue, because you've raised a number of issues of concern in your paper, do you know what the retention rate is for Ontario graduates in radiology now? Do a large percentage of them stay and practise in Ontario?
Dr Miller: It's a somewhat difficult question to answer because the way a radiology residency is structured, it's a four-year residency. Historically, many people have gone on to do fellowships and I believe our numbers indicate this year virtually everyone is doing a fellowship, so that's additional training. What happens after the fourth year is some people do stay here to do the additional training, but there is a limited number of slots so people tend to go all over North America. We do have a widely known reputation, the Ontario radiologists. After people have left the province to do additional training, it's hard to track where they end up, but by and large there has been significant retention of radiologists within Ontario.
Mrs McLeod: Because I was struck by the statement you make that we do have an adequate supply and the distribution is not a problem in terms of radiology because of the work that's been done. I guess I'm wondering what effect you think it might have if there is the coercive use of billing numbers in order to deal with the distribution problem, whether that will affect the retention rate of radiologists in the province.
Dr Miller: I think it's clear that people are concerned and certainly there is availability of positions across the border and in other provinces and ultimately it's up to everyone to make a decision as to where they want to practise.
Ms Castrilli: I have two quick questions. The first is, the Ontario Medical Association appeared before us yesterday and stated quite clearly that they were not consulted by the government prior to the legislation being introduced. I wondered if that is also the case with your association.
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Dr Miller: In general, we wouldn't expect to be consulted before legislation is introduced, but it's really been our trademark in the last six years, since the introduction of the Independent Health Facilities Act, that we provide our input whether we're consulted or not. I don't anticipate it's going to be any different with this.
Ms Castrilli: All right. The second question is, are you troubled by the fact that this legislation deals with so many things? You've dealt with your particular area very clearly and very cogently, and I thank you for the presentation, but this legislation also deals with the Mining Act, with municipalities, with changing the definition of milk in some instances. Would you be in favour of splitting the legislation in order to give a more in-depth look at your particular concerns?
Dr Miller: I think we can address our concerns, can bring them forth to the ministry. I'm not sure in what mechanism it has to be addressed, but clearly, as long as our concerns are addressed, I think we'll be happy. We don't have a position on milk.
Ms Lankin: I think most people in the province don't even know that milk is referred to in this omnibus bill or what's happening with that.
The bottom line is that you're looking for amendments and you think there are amendments that will be necessary in order for this act to treat your profession fairly.
Dr Miller: Yes.
Ms Lankin: Just to let you know, in terms of the time available as it's currently scheduled, the week of January 22 is available for the committee that is the other half, which is sitting over in another room dealing with all of the other bills -- Municipal Act, Mining Act, Milk Act etc -- and this committee, which has been dealing with all the Health bills, to come together and to do a clause-by-clause, one clause at a time, through this thick act and to deal with government-proposed amendments and amendments proposed by the two opposition parties. So number one will be to convince the government to support your amendments and number two is to hope that we get that far as we go through it in that week in order for them to be dealt with.
I think that you raise some very important concerns. I want to speak first of all to the issue you raised on the Public Hospitals Act. The parliamentary assistant to the Minister of Health yesterday told the OMA that it shouldn't worry about the fact that doctors having their privileges revoked would have no appeals because it was only in the situation of closures and wasn't that appropriate? In fact, that's an incorrect interpretation of the legislation. I think yours is correct.
If you look at clause 32(1)(u), it gives the same powers that the board has to revoke privileges when there's closure. It says that there can be regulations set out "providing that a board may exercise the powers set out in subsection 44(1) under conditions other than ceasing to operate as a public hospital" and providing that all of the appeal sections don't apply.
For your profession, when the alternative to hospital privileges and practising has been structured, by and large in this province, to be through an independent health facility and with the restrictions on public tender, for example, for new licences in independent health facilities, what does this mean for a physician who could lose their hospital privileges, have no right to appeal and no ability to bid on an open public tender for a licence for an independent health facility?
Dr Miller: I think that there are a number of issues there. Clearly, when a hospital closes people are going to have problems going forward, because they're no longer going to have positions there. My anticipation is that no matter what happens in terms of hospital closures or changes in independent health facilities, the patients of Ontario are going to need imaging, and given that we're adequately served today, I don't anticipate that there's going to be a large workload reduction.
On the other hand, we are concerned about the balance of power between hospitals and physicians who work in hospitals, and we do feel very strongly that the present structure has served hospitals, patients and physicians well. Again, we'd urge that the committee recommend that the present structure be maintained.
The Chair: Mrs Johns, you have a point of order?
Mrs Johns: Yes. I didn't speak to the OMA yesterday, so the parliamentary assistant couldn't have said that.
Ms Lankin: Perhaps it wasn't the OMA. It was one of the physician groups that was here.
Mrs Johns: I think we should make sure that we get the correct person and the correct comment before we say it out loud at this --
Ms Lankin: The comment's correct; it may have been the wrong group. My apologies.
The Chair: The government, Mrs Johns.
Mrs Johns: I'd like to thank you for being here. We've heard from a number of radiologists over the last three days and we appreciate all the input we're getting from you. Thank you very much.
One of the things I wanted to comment on when you're talking about your improved supply and distribution of physicians is that I was pleasantly surprised that the radiologists are handling all of Ontario. As you may or may not know about me, I come from rural Ontario, and we are an area underserviced by doctors. In effect, there are 70 communities like mine in Ontario that lack basic physician services, and it's an area of very high importance to this government. We've had this problem for 26 years and politicians of all stripes have been unable to solve that, so it's interesting that the radiologists have solved it by themselves. I want to look into that after, and I appreciate that comment.
I have a couple of questions about IHF, if I might. One of your proposals is, "Therefore, we recommend that ownership of IHF be restricted to Ontario licensed physicians." There's some controversy about that recommendation. I think the college of physicians has looked at it long and hard as a result of conflict of interest and self-referrals of doctors to other services. Can you comment on that a little?
Dr Miller: I'll let Dr Czosniak comment on the self-referral, but I would like to make one comment and I'm glad you raised the issue. One of the problems the college has had, and I'm aware of it because I sit on the committee, is that the college fundamentally can't discipline someone who's not a physician.
I'll a relate a circumstance in Texas last year. Some places opened to do entertainment ultrasound; in other words, pregnant women would come, they'd take a video of the ultrasound and send it home with the mother for a fee of $50 or whatever it was. The FDA moved in and shut those places down, on the basis that they were not legally allowed to operate imaging equipment because they weren't certified as licensed practitioners by any body in the United States. They were simply there for entertainment purposes.
If the same thing happens in Ontario today, no one has the power to go in and say, "Cease operation." There's no power provided by the health protection branch federally and the College of Physicians and Surgeons has absolutely no jurisdiction unless myself or Dr Czosniak or another physician does it. But if some non-physician goes ahead and purchases equipment which is readily available, there is no body in this province which has the jurisdiction to go in and say, "You cannot operate this."
To me, that's astounding. It's beyond comprehension that a tightly regulated group that trained for 15 years of postgraduate training can't operate the equipment, but someone with no training whatsoever can operate it, unfettered by any regulation or law.
I don't know whether that will necessarily be encompassed in this, but that would be something you people could consider encompassing in it, saying that imaging equipment has to be operated by imaging physicians. I think it would be a relatively simple amendment that would allow us to give the same protection that people in the United States have.
I'll let Dr Czosniak address the self-referral issue.
The Chair: Doctors, we're out of time. Is the self-referral thing a quick answer?
Dr Isadore Czosniak: I'll try to give a quick answer. The brief we gave you from the General Accounting Office in the United States outlines the problem in the US, where there is a major problem with self-referral, and several states have enacted legislation, in fact 14 of them ranging all the way from Maine to California.
The problem is that in Canada there is not a lot of information. I've seen information coming from ICES -- that's the Institute for Clinical Evaluative Sciences, at Sunnybrook -- on this point. I think we're only seeing the tip of the iceberg and I think there is a problem, as some of the studies from ICES have shown. I do think it's a problem, and in the financial circumstances we're in now, it's a problem we should be addressing.
The Chair: If you have any input you want to share with us about how that might be addressed, it would be helpful and we would appreciate receiving that. Thank you very much, doctors, for your time and your interest in our process.
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FEMINIST ALLIANCE ON NEW REPRODUCTIVE AND GENETIC TECHNOLOGIES
The Chair: The next group is the Feminist Alliance on New Reproductive and Genetic Technologies, represented by Fiona Miller and Melanie Rock. Good afternoon, ladies, and welcome to our committee. We appreciate your attendance here this afternoon. You have 30 minutes to use as you see fit.
Ms Melanie Rock: Thank you very much. We're very pleased to be here today. It's very important, we feel, for members of the government, as well as for representatives of other political parties and the broader public, really, to have an opportunity to discuss these very important issues, and not exclusively with professional bodies, but with representatives from the community of women who stand to be very profoundly affected by some of the issues and some of the changes that are being proposed through this legislation.
To put the broader implications of Bill 26 is really our purpose here today, and to discuss the implications for the determinants of health and wellbeing for women, including poverty, including isolation, including access to appropriate health and related social services. This is an important issue, and our attendance here today is important to us, because it represents an opportunity to participate in a democratized decision-making process about health and wellbeing issues that are not just economic issues really social issues. So the two are very closely tied together.
Our group has been working for a number of years in the feminist community, both as individuals and as a collective, so we're very grateful to have this opportunity to speak with you today.
Fiona will basically walk through the brief that we've prepared, and we're very much looking forward to a dialogue at the end of the discussion period.
Ms Fiona Miller: Hi. First of all, let me just say what I'm going to do in the 15 minutes of presentation. We want to raise issues related to this brief in two ways. First is an issue of democracy, which I think is something that many groups have been raising, particularly unions. The second issue that we want to frame is the issue of women's health, and we really need to broaden our understanding of what we're talking about there.
First of all, who are we? We're the Feminist Alliance. It's a women's collective based in Toronto.
We're a member group of NAC, the National Action Committee on the Status of Women, and we work in coalition with many other organizations concerned with the environment, social justice, animal rights, food policy, women's rights and women's health.
We engage in many activities, many educationals, arranging workshops, lectures, but also we seek to contribute to policy developments, to meet with governments and to contribute to democratizing the policymaking process.
We're women concerned with women's health in general, but specifically we have very particular concerns about the new reproductive, genetic and bio-technologies. We do think that Bill 26 has ramifications for all of these things.
Part one: Let's talk about the issue of democracy. As many briefs have already put out or outlined, Bill 26 does gather extensive powers into the hands of government ministers and the Ontario cabinet to make decisions affecting the delivery of public services and the operation of public institutions.
In many instances such decisions would be made without parliamentary debate, meaningful public scrutiny or any process of public decision-making. Many of these changes would be made without due process and without right of appeal. Many would also grant legal immunity to those involved and insulate the government from future liability.
The anti-democratic centralization of ultimate decision-making power that the bill will permit is accompanied at the same time by a certain devolution of some powers to municipalities and to commercial interests. We see also a granting to municipalities of more powers to impose what really are regressive forms of taxation, ie, user fees, but they are regressive forms of taxation; also, granting certain employers more power to force down public sector wages through contravening contractual obligations and granting drug manufacturers more power to set drug prices. So there's also a devolution.
Bill 26 is really an act to restructure Ontario in many ways, and we believe that it's a major step in the creation of a two-tiered medical system in this province.
We want to draw your attention to the fact that these changes have particular implications for women and for other groups already marginalized from decision-making power in this society. It advances the principle that Vandana Shiva, a well-known Third World activist, has termed "protecting the strong from the weak." This is a complete inversion of the function of government. It will further marginalize the marginalized, with long-term implications for the nature and health of our society. We really want to stress the issue of long-term over short-term and point out to a government that's apparently very concerned about financial issues the enormous costs of problems that could and should have been prevented.
First, let's talk about the issue of informed decision-making. This is an essential principle that physicians and other health care providers have sought to advance, and Bill 26 contravenes this principle in particular by assuming that every insured patient is deemed to have consented to the disclosure of confidential medical information. That's just one example of a quite graphic contravention of informed decision-making rights.
On a collective level, however, we also believe the principle of informed decision-making provides a very important model for public decision-making. We feel that Bill 26, in its content, and not just in its content but, very importantly, in its process, in the process of its development and in the process of its introduction, contravenes this principle. The public has not been able to receive full and clear information and the public has not had sufficient time for consideration.
The public interest and the public process: I want to point out that upon reading through sections of the bill and commentaries on the bill, it's clear that Bill 26 misrepresents the public interest. It suggests that cabinet and ministers are competent to assess the public interest without due process. In fact, the service of the public interest requires informed decision-making by members of the public and public involvement in decision-making. This cannot be appropriated by cabinet alone. It is not something they can do independently. It's crucial that stakeholders -- consumers and service providers -- be part of these decision-making processes. It's also crucial that citizens in general, not just as consumers, have a right, have a role to contribute their community sensibilities and their expertise as members of communities to the process of decision-making.
We really do feel that it's important to put on record our objection to the process that's been put in place. There has been inadequate time. There is no intervenor funding. It's a very difficult process to actually contribute meaningfully to this debate. So we really claim our right to speak about general issues and we want to give the obligation to the government proposing this bill to actually look into the specifics and research the specifics of the implications we're raising.
Let's look at part 2, which is the issue in general of women's health. First of all, let's define women's health. Women's health is not just a medical state indicating the absence of pathology; it includes women's emotional, social, cultural, mental and physical wellbeing over both the short and the long terms.
We think it's important to take a determinants approach to women's health. Women's health is determined not just by access to health care, but also by the physical environment, by the social, political and economic context of women's lives.
The determinants approach to health assessment and health betterment suggests the impossibility of examining health policy and social policy in isolation. I think it's important to stress that it's increasingly recognized by many levels of government, particularly the federal government, that a determinants approach to health is an important adjunct to a medical approach to health. And it's a long-term rather than a shortsighted, I might say, approach.
Bill 26, it's important to recognize, although it has many, many profound implications on health care, does not seem to have an understanding of health. Not only does it not have a determinants understanding of health; it even fails to consider medical necessity. So in effect it's not only reducing our understanding of health from a broad understanding of health which includes social implications; it's minimalizing it below the standard definition of health, which is a medical interpretation of health, by removing reference to medically necessary services in the Health Insurance Act. I think that's fairly profound in terms of a misunderstanding of health, and it permits economic dogma, if I may put it so boldly, to override health concerns.
We'd like to assess some of what we consider to be the general health threats from Bill 26. We feel that women's health in Ontario is threatened in numerous ways. Let me just add, as an aside, that we of course consider that everybody's health is threatened by this bill. We are not in the slightest bit less concerned about men's health; it's just that we do think it's important to raise issues of women's health in particular because they are so often and so frequently ignored. So that's why we're making this emphasis, but let me stress that we are of course concerned about the health of all Ontarians.
It's necessary to stress that the health effects of these changes are long-term. We're talking about long-term implications. As determinants of general population health, we can expect to see many of the effects of Bill 26 arising in years to come with, again, concomitant increases in costs to address problems that were better addressed through prevention. We wish to point out five particular determinants affected by Bill 26, but this list is not complete. Bill 26 will have many effects that will only become apparent over time.
First, the environmental determinants and threats to the environment which harm our health: For women, an issue of profound concern is breast cancer and the environmental toxins that have a role in its causation. Environmental degradation, however, is going to be fostered by this bill, we believe, through gutting the laws governing cleanups with mines, threatening the viability of conservation authorities and changes to laws governing forest fire prevention and lakes and river improvement, which are the only ones that we've noticed, but we're sure there are probably more.
Second, threats to women's aspirations for economic equality: We think it's extremely important to indicate that amendments to the Pay Equity Act are going to have an implication, obviously, on at least 100,000 low-paid women in terms of their economic status. But this is a health determinant. This is a threat to women's health.
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Third, threats to economic justice: Workers will be negatively affected by various aspects of the bill. We wish to point out that, as was recently revealed, the income gap between women and men is now growing in this country. Changes that adversely affect workers will doubly affect women workers and other marginalized workers. I won't go through the details there. We also want to point out in terms of an issue of economic justice that the increase in user fees for both social and health services envisioned by Bill 26, including municipal services, prescription drugs and medical and hospital user fees, is a form of regressive taxation that disproportionately hurts the poorest and the most marginalized members of our society. It's important to constantly reiterate that user fees are a form of taxation; they're a form of regressive taxation.
Fourth, threats to social justice: Of course, threats to social justice affect all Ontarians, but they affect women and members of marginalized groups in particular. Health effects, including mental health effects, may not be immediately visible but do accrue through increased stress and anxiety brought about by general changes, and specifically by some limitations that have been imposed upon the public's right to access information and the public's right to privacy. We'll get into some of those implications in a bit more detail later.
Fifth, there are obviously threats in this bill to accessible and good health care. Bill 26 threatens accessible and decent health care in a number of ways: (1) by fostering the further erosion of the principle of universality, (2) by fostering commercialization, privatization and deregulation. I won't go through all the details, but it is important to point out that things like removing limitations on for-profit operators are going to encourage American for-profit companies to take over an increasing part of Ontario's health care system. We've got a deregulation of drug prices, making it more difficult for people to get access to drugs at reasonable prices and conceivably creating regional disparities in terms of drug prices that are going to affect people. And we are inviting new user fees, funding reductions and delisting.
In terms of a threat to social justice, we think there's also an issue here in the bill of fostering conflicts of interest. We're particularly concerned about places in the bill such as the changes to procedures for establishing an independent health facility that would allow the minister to limit a request for proposals to specified persons rather than a public call for tenders. We think something like that is a problem in terms of raising issues of conflict of interest. We also think there's a lot of flexibility in terms of discretionary powers in the bill that do raise, do intensify, concerns that already exist about conflicts of interest between ministers or the cabinet in terms of their personal or their private interests versus their public responsibilities. The only way to ensure that there are public responsibilities is through due process; not through particularity and not through discretion, but through due process.
All right, the next section. We want to look at some particular issues related to women's health that have some particular implications for the reproductive, genetic and biotechnologies that are our specific concern.
We believe there are several specific changes introduced by Bill 26 which will have a negative effect on women's health. In particular, the provisions which threaten the right to privacy for medical records are very, very worrying. But Bill 26 is more than the sum of its parts. Taken together, the bill advances the existing trends towards a more inaccessible and ineffective health care system for women and a more unjust society which will affect women and other marginalized groups disproportionately. We believe this bill has particular implications for NRGTs.
The Ontario government has already been involved in an attempt to further the interests of the biotechnology industry. The previous government, through the Ministry of Economic Development and Trade, did fund the Biotechnology Council of Ontario to develop a wish list for the advancement of their interests in the province, but fortunately the previous government was responsive to the concerns of public interest groups when we raised our voices and the proposals of the BCO did not proceed. We raise this point because we believe that Bill 26 frames an approach to health and health care that will advance the interests of industry over the interests of citizens. When it comes to biotechnology, some of the concerns that existed around the BCO, this raises particular concerns for women.
Our health care and our social systems are already advancing down a path of increasing intolerance towards difference and diversity. The use of diagnostics to screen for genetic and other congenital "defects" in the embryo or foetus is increasing. It is important to remember that these tests are not very informative. They provide information about a genetic, chromosomal or other congenital issue, but they cannot assess health status, they cannot assess the degree to which the condition will be disabling, because disability is not just about biology. It's about the social conditions that improve or retard the rights and opportunities for persons with disabilities.
These technologies are promoted as advancing women's rights, but we question this. We have serious concerns that these technologies threaten the rights of persons with disabilities by promoting eugenic attitudes which equate the value of an individual with certain arbitrary standards such as their DNA, their "intelligence" or their physical "ability."
They also threaten women's reproductive autonomy by imposing quality control standards on women. The imperative to produce a quality child has already led to much scapegoating and the legal infringement of women's rights. We've seen a lot of hype about things like coke babies and the dangers of foetal alcoholism, with very, very poor research, I must add. The kind of hype that we've seen really does illustrate the way that non-definitive research is made to serve the agenda of blaming poor women for their poverty and subjecting all pregnant women to sanctimonious injunctions which completely exaggerate the level of control that women actually have over their lives, the environmental conditions of their lives, the social and economic conditions of their lives.
We think the increasingly high-tech approach to pregnancy, the tendency to set up a conflictual relationship between a woman and her foetus and the increasing obligation to produce quality children grossly exaggerate women's power. It's important to add this to the issue of industry. We do think the increasing commercialization of health care in this province is going to promote higher-tech approaches that really don't look at broader issues in terms of health assessment and health determination.
I should also say as an aside that we are a pro-choice organization. Our concern about prenatal diagnosis is in no way reflective of a concern about abortion. It's a concern about selectivity. It's a concern about eugenics, which is completely different from a concern about a woman's rights to make decisions about her reproductive life.
I also want to raise concerns about pre-symptomatic genetic diagnostics, which are a very big growth industry in biotechnology. They haven't really grown that much in this province but we can certainly anticipate their further growth with greater commercialization of the health care industry.
This information, when carefully and respectfully gathered, may be of interest to certain affected individuals, but there are many problems attached. The privacy commissioner of Canada has clearly identified genetic testing as an issue of concern for privacy.
Bill 26, however, will further restrict an individual's right to privacy, with serious implications for their ability to access health and life insurance or even health care in the new two-tiered health care system being advanced by this bill. This is an extremely important point in terms of genetic information. There needs to be stronger protection for privacy rights. There needs to be absolute insurance that this kind of information cannot go to insurance companies, cannot go to employers, cannot get outside the hands of those who are protecting the interests of the individuals.
These infringements on privacy will make it harder for women to make decisions about their reproductive lives. Aware that medical information can be made available to others, women will be pressured even more strongly to avoid genetic taints in their offspring. Furthermore, we are concerned that women's reproductive histories, including women's use of therapeutic abortion procedures, will no longer be private, with serious implications for some women.
These are just some of the specific things that we think relate to NRGTs.
In closing, we wish to communicate to the government our strong concerns about Bill 26. We hope the government will withdraw this bill and develop systems of public participation which permit changes to proceed in a manner that genuinely serves the public interest. Thank you.
The Chair: Thank you. We've got about nine minutes left for questions, beginning with Ms Lankin.
Ms Lankin: It's a very thoughtful and thought-provoking presentation. I might just add as an aside that if you couldn't speak as quickly as you did, we wouldn't have got through it all in the half-hour that we'd allotted you, but I'm glad you have and that there are couple of minutes left.
My first question is with respect to your comments on the centralization of power. You've spoken about the process that we're going through with this bill as being fundamentally anti-democratic, but you also speak to the centralization of power as being a danger to democratic processes in our communities, and you made reference to a principle that Vandana Shiva terms protecting the strong from the weak. Could you elaborate on that, talking about marginalization? And you go on with long-term implications for the nature and health of our communities.
Ms Miller: I don't know if I can elaborate. I mean, it's one of those striking phrases that Vandana Shiva uses which I think points out quite clearly in a very, very succinct way what the concern is of so many people when it comes to this bill in particular, but also, I must add, to the way this government is proceeding.
There is a strong sense that what we are seeing is a government that's not protecting our interests, and in fact not only is it not protecting our interests but it's taking rights away from us and we are feeling less and less able to influence this government and to influence it in a democratic way. It's transferring our rights.
We're being termed as individual special interests. We're not special interests; we are citizens. We're not paid to sit here, unlike yourselves. In fact not only are we not paid to sit here, this costs us money, but this is a duty that we take on and we take very seriously as citizens of this province who have very serious concerns about this province. We feel that the concerns of people like ourselves are not being considered.
Ms Rock: I would like to just pull in a point that I heard Ms Johns raise with respect to being from a rural part of the province. Being from a rural area of Canada originally and not being someone who grew up in Toronto, I think very often the temptation is to phrase things in terms of equality of opportunity. We're looking at issues around equality of outcome. People want to have jobs in this province; they want to make a decent wage. But ultimately what people require is a decent income. This is one of the fundamental determinants of health and wellbeing.
With respect to genetic and reproductive technologies in particular, there may be a temptation to say, "What we really need to do is make sure that all available technologies, all available procedures, are equally available to all people in different parts of Ontario." This is not necessarily the approach you advocate. We need to have a process that very democratically and very appropriately looks at priorities for public spending.
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In terms of looking at the determinants of health and wellbeing, income is of fundamental importance. That is a key component, having access to health services, appropriate triaging, so that if you need to come into a city like Toronto to get certain services those are available, but there are mechanisms to permit that to happen.
With respect to issues such as therapeutic abortion, if somebody is in need of that type of a service and that service is available to them as a right to a woman who lives in any part of Ontario, this is an appropriate way of prioritizing, triaging, health services. This is, I think, of fundamental importance in thinking about how to proceed on a health and wellbeing agenda.
The Chair: Okay, we need to get on to the next question. The government.
Mr Clement: Thank you very much for your presentation. I wanted to turn first to your concerns about confidentiality and privacy. It's the government's position that under this bill there are still protections for confidential information under the Freedom of Information and Protection of Privacy Act. That's not good enough for you, though?
Ms Rock: I'd like to speak to this with respect to the issue of confidentiality of medical records and the way in which women who come in are dealt with by the social service and the health care system. Recently, for example, there was an important decision made with respect to access to counselling files. We're looking at the issue of health and wellbeing in a broader sense and simply saying: "This is a hospital. This is about health care." We're talking about the different ways in which the systems and the social environment are set up that in the long run have negative impacts on the health and wellbeing of women.
The freedom of information act is a very useful avenue and a very important avenue. However, there are concerns about privacy with respect to, for example, genetic testing and the ways in which this bill fails to protect in the long term some of these important agendas such as reproductive and genetic results, the intersection between the public and the private health systems, so that if I am prediagnosed at age 5 as having early-onset Alzheimer's and that information is made available to employers, this obviously affects my employability.
Mr Clement: I agree with you there, but I don't think we're suggesting that.
Ms Rock: The decisions that are made at this point about how to structure access to resources in Ontario have very long-term implications. That's the issue.
Mr Clement: Can I just turn to another issue? I think you dealt very cogently on the determinants to women's health. It's a broader picture than simply health care, and I agree with you 100% on that. We on our side believe that the deficits that have been racked up by previous governments, the lack of control of spending, have endangered our social assistance system, endangered our health care, endangered the ability for Ontario to create jobs and that will have an impact on women's health if we continue with the status quo, which is deteriorating.
Ms Rock: I respectfully request that this government look at the revenue side of the equation.
Mr Clement: We are looking at the revenue side. There is no revenue if there's no economic opportunity.
Ms Rock: That's my answer. The deficit -- can I just make a point?
The Chair: Thank you, Mr Clement. We have to go on to the next question.
Ms Rock: I think the point needs to be made that there are alternatives. There are always alternatives and dogma is never an answer.
Ms Castrilli: Let me just pick up where Mr Clement left off and read you a letter from the privacy commissioner of December 6 in which he states that the bill has "the potential to significantly increase the amount of personal, health-related information that will be gathered, significantly increase the number of uses that may be made of this information and raise the possibility of new and troubling disclosures of the information." That's repeated again in an article that the privacy commissioner wrote in the Toronto Star earlier this month. So your concerns about privacy and the use of confidential information have been looked at by individuals who are experienced in this area and found wanting.
You have recommended that the bill be withdrawn. If that is not possible, would you recommend that the bill be divided into appropriate sections in order to be able to be discussed at greater length and have a period of public consultation? You yourself said that you were rather rushed in trying to get this together, and I commend you, because you've covered a lot of territory in your presentation.
Ms Rock: I think it's absolutely essential that there be sufficient time for a meaningful process of public information-gathering and public contributions to the decision-making process. I don't particularly mind how that's done. If it's broken up into sections, then that may or may not work. I don't want to insist upon a particular approach, but what's crucial is that there be an extended process.
The existing set of hearings are absolutely inadequate. There are many, many groups that we are in contact with that have not been able to and will not be able to pull together their time to do this. I'm a PhD student, so I actually have the time and I actually have some of the facilities. I also consider it to be my job, as what good old Harold Innis called the "public intellectual," to do this kind of work, but there are not many organizations that have those resources, limited as they are. This is a completely inadequate process and it needs to be extended.
There needs to be, I will add, intervenor funding. It is not possible for groups like ourselves that have no resources to pull together a really critically detailed analysis of the sections of this bill without some support. If we're going to be asked questions such as the honourable Mr Clement asked -- do we really think that this act, in terms of freedom of information and privacy, is as bad as we think? -- then I want to hire a lawyer. I will be happy to do that and I'll get back to you. It's important that if we're making these kinds of contributions and we're doing the kind of research that needs to be done, we need to have the support in order to do that fully.
The Chair: Thank you. We appreciate your attendance here and your involvement in our process.
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INTERNATIONAL FREEDOM IN HEALTH
The Chair: Our next presenter is from International Freedom in Health, Mr J.G. Coleman. Good afternoon, sir, and welcome to our committee. You have a half-hour to use as you see fit. Any time that you leave for questions will be divided up, beginning with the government. The floor is yours.
Mr Gord Coleman: Good afternoon. My name is Gord Coleman and I am the executive director of International Freedom in Health, a non-profit umbrella organization representing Canada, the United States and Mexico, which seeks to establish just and inclusionary global health delivery systems under the banner of freedom of choice.
The good doctors DeMarco, Culbert and Rodriguez were not able to attend today representing their respective countries, having only been given 48 hours' notice to present. I convey their regrets. I will be reading today from my prepared text from the left-hand side of the folder which has been distributed to you.
We'd like to thank you for your invitation to present today on Bill 26, which we now refer to as the Ontario ominous bill. Our half-hour time restriction will not permit us to delve as deeply into the potential human rights infringements of this bill as we might like, so we have prepared a package for each of the committee members as a fast and easy reference guide.
In order that you do not label us as simply lobbyists, as the chief medical officer of this province has, we invite you to read our charter mission statements and our Ontario health reform proposal, labelled exhibit 1, at your convenience. Please note that this proposal has sat with the past two provincial administrations here without so much as an acknowledgement of its receipt.
To add further insight as to who we are and what we're all about, I would like to take the liberty of reading three of our seven mandates.
"Article II: To link the many disparate health groups, agencies and associations, by way of communications in the areas of world health movement, questionable legislation, potentially unfair business practices, unilateral treaties and trade pacts, health research and discoveries and threatening litigation.
"Article VI: To foster a legacy of trust and camaraderie through diligent negotiations within the existing medical models, towards the `shared vision' of universal health freedom for all.
"Article VII: To vigilantly guard against any and all medical human rights infringements, whether they be economically, politically, legally or sociologically motivated."
The areas on which we would like to focus our attention today for expediency's sake evolve around the issues of privacy, access to information, conflict of interest, informed consent, freedom of choice and leadership.
We believe the best way to do this is through taking a microscopic look at the root problem which now has the potential of blossoming into an unmanageable killer weed under this proposed legislation if not seriously addressed now.
The original Hippocratic oath, as taken by doctors, and its subsequent modified oath, as signed in Geneva in 1948, with the name the International Physicians' Code of Ethics, both state in article IV, "Protect the patient's secrets." Today we intend to prove that this oath has been violated, along with alleging that 12 of the 49 other articles which are endorsed by the Canadian Medical Association are in serious jeopardy of being breached as well. I refer you to exhibits 2 and 3.
How can medical practitioners be expected to work to the best of their ability, let alone place the wellbeing needs of the patient first, under the kinds of moral dilemmas this type of legislation promotes? You will note that in virtually every one of these statements it is the patient who has all the rights and determines all of their choices, not the physician nor the government, this in relationship to the verdicts passed down for the atrocities committed against the Holocaust victims during the Second World War.
On December 13, 1993, Bill 100, an act pertaining to doctor-patient sexual abuse, was passed in this building under closure. Within this very-needed bill, a last-minute section, number 27, was put in which gave your province's College of Physicians and Surgeons unprecedented search-and-seizure powers. This was one of the first unconstitutional medical power grabs in this province, which has set up this present greedy bid for more power.
On the floor of the House that day, 13 faxes were cited by Jim Wilson, the then Health opposition critic, and Barb Sullivan, his counterpart from the Liberal side. These letters were signed by the presidents of the various regulated health profession associations that were vehemently opposed to this section being added to the bill. I draw your attention and refer you to exhibit 4.
I would caution you, in these hearings, to avoid this kind of naysayer trap which most presenters coming before you are setting. I find it very ironic that all 13 of these letters are virtually identical and were written by the same lobbyist firm in Ottawa and simply distributed for signature that day; don't you? In fact, when Mr Harris's office was contacted about it, one of his top personal assistants was quoted as saying, "That's how the game is played here."
As we do not consider it a game at all, we met with Mr Harris and Jim Wilson on April 28, 1994, to discuss this kind of abuse of power. As opposition leader then, Mr Harris was more than sympathetic, issuing two letters stating his concerns about this issue of circumvention of law and due process. Please refer to exhibits 5 and 6.
In letter 5, he stated that these quality assurance provisions impose "significant restrictions on both the providers of health care and the citizens of Ontario."
In letter 6, to Ruth Grier, the then Minister of Health, he stated that this last-minute move to amend section 95 of schedule 2 of the Regulated Health Professions Act could well be a human rights violation and implored the minister to exercise her section 12 authority to refer the matter to the regulated health professions advisory council level as "[t]his issue is not in my opinion frivolous of vexatious."
As brief asides, Mr Wilson made two comments to us at the meeting of April 28 which did not sit well. First he said: "Wait until the regulation changes are published. Then submit your own changes. We change regulations around here at a rate of 300 a day on average." Then he said, in a reference directed at Janet Ecker, one of your committee members today, former Tory, then CPSO director of policy, research and analysis and now Tory backbencher: "I'm not very happy with her. She used to be one of us. I don't know what she's trying to accomplish by this."
I now refer you to exhibit 7, paragraph 7, page 2. Our organization and many others find it hard to fathom why all this power to circumvent due process of law was required for the "six to 12 physicians in the province who are found each year to have significant deficiencies in clinical skills."
As for the February 16, 1994, three-page letter from the CPSO registrar, Michael Dixon, to Michael Harris -- as a case in point, the present case of the CPSO v Dr Krop has nothing to do with sexual abuse, yet it was these powers of private medical record confiscation which see him being prosecuted in a non-judicial setting in addition to confidential patient records being bantered about.
In conclusion, despite Mr Harris and Jim Wilson labelling these aforementioned issues as "somewhat of a red herring," we believe the question needs to be raised. What caused Mr Harris to change his mind? As early as December 1993, and up to the election of June 8, 1995, both Michael Harris and Jim Wilson were supportive of the case that potential abuses in the area of privacy and confidentiality might occur. However, from June 9, 1995, onwards there appears to be a need for even greater and broader unconstrained powers being bestowed upon bureaucrats and newly elected officials for reasons known only to them.
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As these new powers have the potential of being abused further still with regard to personal medical files being abused and doctors placed in a conflict-of-interest position, torn between honouring their oath or the government of the day, we contend that articles 3, 6, 25, 28, 40 and 42 of the International Physician's Code of Ethics have been breached and continue to be breached as we sit here deciding on whether or not to increase these alleged illegal powers.
Notwithstanding the fact that we may never know the reasonings for Mr Harris's 180-degree turn on these issues, we call upon this committee to strike all human rights infringement sections from the bill, in addition to putting forth a motion in the House to abrogate section 27 of Bill 100 prior to any international court action being taken. Thank you very much for your time.
The Chair: Thank you, sir. We have about five minutes per party left for questions, beginning with the government.
Mrs Ecker: Thank you very much for your presentation and for taking the time to bring forward your concerns. I'd certainly enjoy debating the merits of Bill 100 again with you. I think the previous government actually took some very important steps -- I know Ms Lankin may hold this against me later -- on the quality assurance things in that respect. But we're here to discuss Bill 26, not Bill 100.
I'd like to talk a little bit about better outcomes, more effective care, because your organization has frequently argued that alternative medicine can provide more effective, more cost-effective, better care for many patients, that it would help in preventive measures etc. You've also argued that it might help prevent some of the misuse and abuse within the system that has occurred.
I guess one of the questions is, we recognize and acknowledge that better outcome measurements are really important in terms of the effectiveness of treatments -- what works, what doesn't -- not only for the patient but on a cost-effective basis. How is it possible to collect that information from the health care system unless we can devise a system where we can share that information: the treatment information, the data on what's happening in the system, what's happening with the treatments, albeit with confidentiality protections which we acknowledge are very important and are certainly interested in making sure that that is maintained. What's the best way to collect that information while protecting confidentiality?
Mr Coleman: That's a very good question. Far be it from me to suggest what the best method is. I should correct you that you're confusing me with freedom of choice in health care as opposed to International Freedom in Health. But let me quote Jim Wilson --
Mrs Ecker: The arguments are very similar.
Mr Coleman: It's not the same organization. Let me quote Mr Jim Wilson on CBC Newsworld two mornings ago: "As you know, we do not have armies of inspectors out there regarding this question and this issue." So I would return by asking the question: If all 24 regulated health professions were to have had their own quality assurance/management committees in place by the end of this year, there would have been in fact an army of inspectors. However, this government seems to negate the inspectors' aspect of it by wanting everything computerized. I can tell you in no uncertain terms, beware of computers. They literally work for you.
Mrs Ecker: So you're suggesting that we should not be computerizing health information within Ontario in terms of better, effective management of the system?
Mr Coleman: Not unless your security codes are fail-safe, and there is not a fail-safe system out there in the world today.
Mrs Ecker: So you don't have any further suggestions on how we can collect that information so we can take a look at the outcomes of either alternative treatments or more traditional treatments? Obviously, that's something I gather everybody has difficulty deciding on.
Mr Coleman: No. I can say in no uncertain terms again, certainly not by breaching the trust between a physician and a patient.
Mrs Ecker: Okay. Are there ways the government can work to better ensure that patients do have a wider range of choices for health care available to them?
Mr Coleman: Most certainly. They're in the health proposal which is in front of you.
Mrs Ecker: Would you care to elaborate at all on them?
Mr Coleman: How much time do I have?
The Chair: You've got about 30 seconds.
Mr Coleman: Well, we should pause for a commercial break then.
The Chair: Okay. Mrs Caplan.
Mrs Caplan: I appreciate a very thoughtful presentation. We haven't always agreed on all the issues, but I share your concerns when it comes to the powers of the minister, particularly the concerns regarding patient confidentiality, because this bill, as you've pointed out, gives the minister unrestricted powers to collect, to share. Even if there is inadvertent disclosure, or deliberate disclosure, public disclosure, there are no sanctions or penalties that can be brought against the minister.
I want you to know that where I disagree with you is that I do think it's in the patients' interests to have their providers have the information that they need to provide good care, and I think there's got to be provision for the sharing of that information. I think that's good quality care and that's continuance of care.
Mr Coleman: My response to that is simply, let every citizen of Ontario have access to their own medical files, on a smart card or whatever basis, so that they can convey that information upon feeling as though they've been taken advantage of, on that basis.
Mrs Caplan: I hear what you're saying and I think that there are ways to ensure that the patient has the opportunity to give that consent; for example, seniors who sometimes forget, when they go from doctor to doctor, which drugs they have been prescribed and the way that they are supposed to take them -- it's important that they know so that they can make sure that person is getting the best-quality care.
My concerns are not for the information shared among providers, who are all covered by this freedom of information legislation. What I've said and what we ask is that the government remove all the sections and do what the protection of privacy commissioner has recommended, and that is: Bring in a piece of legislation that will allow for appropriate access to ensure high-quality patient care, to make sure their confidentiality is protected, to allow for appropriate research and to deal with the issues of fraud in a way which also protects personal privacy, so that that bill can be debated and we can all be assured that whether it is through smart card technology or whatever method the government chooses, people can be assured that nobody can snoop into their medical records for purposes other than high-quality care and appropriate research to which they have consented.
That's the basis of my concerns, and I share those concerns with you because those protections are not in this legislation, and the privacy commissioner has been very clear that they're not in this legislation. I wanted to make sure that was clear as to how I was feeling about this, and also that I've heard your concerns and I don't think that our two positions are irreconcilable on this point.
Mr Coleman: Not at all. In fact, we'd be happy to support you on the latter.
Mrs Caplan: Support for the removal of all those sections and a new piece of legislation to be able to deal with those important issues of quality care, access to records for research and fraud and do it in one piece of legislation that will also ensure privacy?
Mr Coleman: That's correct.
Mrs Caplan: Thank you very much.
Ms Lankin: Thank you, Mr Coleman, for spending the time here with us today to make your views known. I think that the content of your presentation has been covered by the questions of my colleagues. I'm pleased to hear your support for the suggestion that these sections be pulled out of the bill and that we deal with a comprehensive approach on protection of health information, the privacy of health information.
You may be interested to know, in the last couple of days a whole myriad of groups has been calling for this government to stop this hearing process, to split the bills and to allow us the appropriate time to do the analysis and to debate these bills separately; groups like the Toronto Psychoanalytic Society, the College of Physicians and Surgeons -- at one point you may agree with them on there -- the South Riverdale Community Health Centre, the Lakeshore Area Multi-Service Project, the Ontario Coalition of Senior Citizens' Organizations, Survivors of Medical Abuse, the Older Women's Network, the OMA, and the Feminist Alliance on New Reproductive and Genetic Technologies just finished presenting us with the same thing, and many other groups.
I would like to inform you that at 5 o'clock today we will be debating a motion I tabled in this committee this morning which calls on this committee to recommend to the government House leader that on January 29, when this bill is to be reported back, the House actually amend the order of business to refer the bill out to further committees, that the bill be split and that we have an opportunity to adequately analyse and debate this bill.
I'm very hopeful that this committee will pass that. I take your words as support for that motion, and I would encourage you to stay and watch that particular debate.
Mr Coleman: I thank you for the invitation, and I will. Might I add that, hopefully, some of this Mike Harris evidence I've entered today will be a major poker chip in your achieving that end.
Ms Lankin: Thank you.
The Chair: Thank you, sir, for your presentation this afternoon. We appreciate your involvement in our process.
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DRUG QUALITY AND THERAPEUTICS COMMITTEE
The Chair: Our next presentation is from the Drug Quality and Therapeutics Committee, Dr Malcolm Moore.
Mrs Ecker: Mr Chair, as they're taking their seats, I'd like the record to show that last time I checked, I don't think I'd describe myself as a former Tory.
The Chair: Duly noted.
Good afternoon, gentlemen. We welcome you to our committee. You have a half-hour to use as you see fit. If you leave time for questions at the end, questions will begin with the official opposition, the Liberals.
Dr Malcolm Moore: Good afternoon. I'm Dr Malcolm Moore. I'm a medical oncologist and clinical pharmacologist at the Ontario Cancer Institute/Princess Margaret Hospital, and I'm also the chair of the Drug Quality and Therapeutics Committee, the province of Ontario.
Dr Allan Detsky: I'm Dr Allan Detsky. I'm a faculty member in the division of community health at the University of Toronto, and I've been a member of the Drug Quality and Therapeutics Committee since 1991.
Dr Moore: What I'd like to do is first of all give you a brief summary, a couple of minutes of education about what our committee does and how we fit into the drug program area. Then Dr Detsky will make a few comments and we'll take some questions. There are some points regarding what I'm going to present that are just being handed out.
The DQTC is an expert advisory committee to the Ministry of Health. We don't work for the Ministry of Health; we all have regular jobs somewhere else. We provide advice regarding drug-related issues. At the present time there are 12 of us. We're physicians, clinical pharmacologists, pharmacists, health economists and clinical epidemiologists from around the province. Our terms of reference are fairly extensive, but basically the primary function we serve is to give decisions or advice to the minister regarding what status drugs should have on the Ontario Drug Benefit Formulary.
The Ontario Drug Benefit Formulary, just to remind you, is basically a listing of products, and if the drug is listed in the formulary it will be paid for for people who are beneficiaries for the program, which is seniors, people in home care and long-term-care facilities, and people on family benefits or general welfare assistance.
In the context of the bill, I think it's important to recognize that there are really three ways we can classify drugs under the current program.
The first is that if we add a drug to the formulary, it is available to all beneficiaries without restrictions.
We also have another category which is called "limited use," and when we have a limited use product, we provide what we think are reasonable indications for the use of that product. However, the current legislation does not allow the ministry the authority to restrict payment for those indications, so in fact, even though we list indications, if anyone prescribes it for any use, it has to be paid for.
The third category is that we will not add a drug to the formulary. Under those situations, it is still available under section 8, which basically means that the physician has to write a letter to the minister outlining why this patient requires this drug. I should let you know that for certain drugs where we're concerned about inappropriate usage, this is actually the mechanism we use to control the usage.
You could spend the entire hearings on the whole problem of the cost of the drug program, but basically, even though it's a free drug program, drugs are not free. In fact, as time goes on, we're looking at more and more expensive drugs for inclusion, drugs that cost hundreds or thousands of dollars a month. The problem of the cost of the drug program is not an Ontario-specific problem. This is something that has been seen in all jurisdictions around the world.
In general there are two reasons. One is that as the population gets older you have more people qualifying for the program, and more importantly, the new drugs we're considering are in general much more expensive than the older ones. They may offer some advantages and they may be in areas where previously we did not use drugs. As new drugs come out there's an expectation they'll be added to the formulary, so we're expanding the whole therapeutic armamentarium all the time.
Our committee feels that in these fiscal times, it's very important that we try to get good value for our money, and there are two ways we would look at that.
The first is that if we're going to add a new product to the formulary, we want to be sure that for the money we're spending we're getting good value. I'm proud to say that in Ontario we're recognized as one of the world leaders in requiring pharmacoeconomic assessments before drugs go into the formulary. Dr Detsky, who's beside me, has been the leader in that.
The second area is ensuring that the drugs that are available on the formulary are used appropriately, and I think this is an area where we have not done so well. Many of the expensive new drugs that we've added are of value, but our feeling is that often they're used inappropriately, what I would call economically inappropriately. There are cheaper drugs available that could be used. In order to deal with this issue, we do need some guidelines for the use of certain drugs and, in addition, some way of ensuring that the guidelines are followed.
With those caveats, I'd like to go through the four areas within schedule G of the bill, if I've got this right, that relate to the kind of work the committee does and just provide you some comments.
The first is the whole issue of cost-sharing. What I'd like to say here is that cost-sharing is not an extraordinary measure. We're the only provincial jurisdiction that doesn't have it, in fact I think one of the only ones in the world that does not have it, so that by itself is not unique. And there's pretty good evidence that many seniors are on too many medications, and perhaps something that makes the patient and the physician look twice about what they're on and why they're on it could be a good thing.
As I understand this bill, this bill does not mandate any particular cost-sharing model. It just allows the process to occur. The committee feels it's a reasonable process. However, there's still some debate that could occur about what the best model of cost-sharing should be.
The second item, which is a relatively minor one, is the payment of "no substitution" prescriptions. Basically, at present, if a doctor writes a prescription for what we'll call an originator product and there's a generic in the formulary, the generic is provided, and that's cheaper, unless the doctor writes "no substitution," in which case the government has to provide the originator.
Our committee spends a lot of time making sure that the generic products are as good as the original products, and therefore we feel that spending extra money on using the originator when a generic exists is not good value for the money. We would be strongly supportive of that measure in the bill.
The third issue is the whole issue of conditions of payment. This, to my mind, is the most important aspect of the bill regarding what our committee does. As I've said, at the present time if a drug is listed as a benefit, the government must pay for it regardless in which circumstances it's prescribed. We feel very strongly as a committee that for certain drugs reimbursement should be limited to be consistent with some generally accepted guidelines for drug use. This is not totally inclusive, but that might include only certain patients, only certain diseases or certain severity of disease, or only when other things have been tried and don't work. We might also want to limit a prescription size or duration of therapy, or we might only want to pay when certain prescribers who are acknowledged as being knowledgeable might use it.
The fact that we could not do that in the past has frustrated our committee, because we've been aware for some time that in certain areas prescribing could be better than it currently is, so the power to do that has the potential to provide some significant benefit. There are still issues around confidentiality that need to be addressed in terms of collecting information about payment. However, in general we're supportive of changes regarding linking payment to indications.
The last, which is quite a minor item, is the whole area of limiting of billing access to pharmacies that are on the network. Again, it's very important, when we're spending the kind of money we are on the drug program, that we can monitor and audit the system, and as such, all the pharmacies should be on the network. We would support that provision of the bill.
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Dr Detsky: As I mentioned before, I'm Allan Detsky, from the University of Toronto. I've been on the committee for about five years now and took the lead in developing the pharmacoeconomic guidelines for ensuring that manufacturers provide us with information on which we could base decisions about value for money.
There are 12 members of the committee and at any given time there are probably 28 opinions, so I'm going to give you my opinion, which may or may not reflect the majority opinion of the members of the committee.
I'm particularly disturbed by this bill and certainly would not support the nature of the bill, because it is overencompassing and too far-reaching. While we on the DQTC have given many ministers several ideas about how to control drug costs and achieve more appropriate utilization on the part of physicians acting as agents for their patients, I think a broad, sweeping bill giving this much unspecified power to government is a very unwise decision. If the government passes this bill, I think it's going to find itself in hot water very quickly in a number of areas.
We certainly do need help in terms of allowing the DQTC to make recommendations to government that actually could be enacted in terms of appropriate utilization, but in my opinion, the portions of the bill ought to be significantly broken up so that the specific proposals could be debated one by one, in order to get a broad-based view, to not fall into a trap.
Let me give you the example of the cost-sharing proposal that the government has proposed. Cost-sharing per se is something I am very much in support of, unlike most of my health economist colleagues cross Canada. I think it's a very good idea, but the blunt type of cost-sharing that has been proposed, which is a $2 fee for everyone, plus paying the dispensing fee by seniors who have income sufficient above the cut-point level, is not the right way to achieve appropriate utilization, because it doesn't teach the consumer anything about the extra cost for the extra value they're getting out of specific drugs.
Simply allowing the government to say it can impose cost-sharing without specifically debating the appropriate form of cost-sharing, in my opinion is an unwise idea. This entire bill, even as it reflects specifically the drug plan, is too much, too quick, too much power in one set of hands, without appropriately thinking through what's going to happen and will allow the government to make some very unwise decisions.
I've been a faculty member at the University of Toronto for 15 years. I've seen, I believe, 10 ministers of Health; there are two of them sitting here. Some of them held office so shortly, that for all I know, some of you guys were ministers of Health too. It's a complicated field. Even Mrs Caplan, who was in office about the longest -- with all due respect to Mrs Caplan, I don't think she fully understood health care even at the end of her term. She was still mispronouncing the words, as I recall. It's a complicated issue.
We health care providers were here before you guys took power; we're going to be here after you lose power. You have the potential to do good, you have the potential to do harm, and you need to go very slowly. In my opinion you ought to break this entire bill up, even the drug part of it, so that the specific proposals can be done in an equitable and efficient way.
The Chair: Thank you. We have about six minutes per party left for questions. Mrs Caplan, you start.
Mrs Caplan: I believe that everything Dr Detsky has said should be heard and listened to by the government. You're quite correct, ministers of Health are not doctors. The terminology and pronunciation of the words are complicated, and the policies are very complicated. That's one of the reasons that, as you know, or I hope you know, I stood in the House and said I never wanted these powers and I don't think any Minister of Health should have all of these powers. I said that when I was Minister of Health, I say it now, and I would hope the government will listen, not only to the deputations coming here but from someone who actually sat in that chair and said, for all the reasons you have mentioned, that no minister should have all of those absolute powers. I want to thank you very much for coming forward. I know it is a dissenting view on the DQTC.
Dr Detsky: It might not be. I don't know.
Mrs Caplan: It might not -- well, I understood it was a dissenting view from DQTC, or not?
Dr Detsky: I'm not sure that it is.
Mrs Caplan: You're not sure. Okay. The Drug Quality and Therapeutics Committee does excellent work. I always have had and continue to have great respect for their advice when it comes to drugs and drug therapies and so forth.
I'm concerned about the support for cost share because it has nothing whatever to do with achieving optimal therapy and appropriate drug use no matter what the model is. I think there are some serious issues here not only with the model that this government has chosen, which not only places an onerous burden on those who can least afford it, but it does not achieve the goal of appropriate drug use or good decision-making around the use of drugs. So I share your concern on that.
By the way, I support your request and suggestion that just the drug portion of this bill be a separate bill so that it can receive the full scrutiny and understanding of all the implications of the bill. I said in the House that I felt that all the components of just health should not be considered eligible for one omnibus bill because of the complexities, and the fact that whether it's deregulation of drug prices, the policy on no substitution, it's so complex that, frankly, even the members of the government caucus are not certain about it.
I want to take this opportunity to apologize to the parliamentary assistant --
Mrs Johns: Thank you.
Mrs Caplan: -- because she did not make the comment. However, her colleague did. It was Mr Clement who said, and I want to put this on the record: "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?"
He said that to Mrs Feltes from the South Riverdale Community Health Centre, and while I listened to your presentation I wasn't certain whether you believed that this bill would allow that substitution to be paid for if in fact there was a special authorization on behalf of the patient. I thought I heard you suggest that it might be, and I wanted you to know that I did receive from the ministry the following comment on the no-substitution prescriptions.
They say, and this is from the ministry and I'll table this: "Under the proposed amendments in Bill 26 there will be no mechanism for the ministry to pay for the additional cost of no-substitution prescriptions. The ministry will no longer pay for a more expensive brand when there is a less expensive interchangeable product."
Mr Clement: "Interchangeable." That's the test?
Mrs Caplan: Of course, and that's what you were referring to when you said, "in terms of the interchangeability issue of drugs." That's what Hansard says.
Just to clarify, because it is a very complex issue: What the ministry pays for today is that if a doctor says his patient cannot tolerate the cheaper generic version for medical reasons, then the ministry, without the doctor having to go through a special authorization form, will pay the difference. That's the policy today. Under the policy today as well there can be application for special-authorization drugs which are not on the formulary.
Under the new policy we don't know if there's going to be any change on the special authorization. That's not contained in the bill but, given the broad powers of the minister, I believe that those decisions could be made arbitrarily and without public scrutiny, those broad powers --
The Chair: Thank you, Mrs Caplan.
Mrs Caplan: Just allow me, if I could just finish my sentence, and I will be very brief. However, on the interchangeability issue there is no mechanism for someone who has an adverse reaction or a medical problem with a generic drug. If you get an opportunity to comment on that, I'd appreciate it.
I'm sorry for taking all of the time. As I say, I agree with everything that Dr Detsky had to say.
The Chair: Thank you, Mrs Caplan. Ms Lankin.
Ms Lankin: I'm going to ask you not to take any of my time with you to answer Elinor's question that she didn't get around to.
Dr Detsky: She both asked and answered at the same time.
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Ms Lankin: Actually, just to follow up on the issue of no substitutions, Dr Rachlis was presenting here yesterday and he was speaking to us about the BC government's policy of not simply enforcing a substitution of the generic brand, ie, the same chemical compound, but giving the province the ability to substitute for the cheapest --
Dr Detsky: Therapeutic.
Ms Lankin: -- therapeutic. Thank you. Have you taken a look at what's happening in BC? Does DQTC have any comments or thoughts about that?
Dr Moore: I must say, personally, I think that's not a bad model for costs, for cost sharing and reasonable cost savings. The status at the DQTC at the moment is that the ministry is compiling information for us about that, and it's sort of a business arising from the minutes and as more information comes available they're going to report back. So there are certain attractions to that system, but it's not something we've considered in any detail.
Dr Detsky: I'm going to give you something very specific. People who have sat on the DQTC know that there are five areas of drugs where you could save about $200 million.
Ms Lankin: Yes, I've seen the list.
Dr Detsky: Non-steroidal anti-inflammatories, anti-depressants, choice of anti-hypertensives, choice of anti-ulcer and anti-heartburn drugs and some antibiotics.
You have four mechanisms: cost-sharing reference pricing in these specific areas, which is exactly what BC is doing, going very slowly, three drug classes at a time, which I think could be a wise thing to do. I'm not in favour of widespread reference pricing, but limited.
You could provide incentives for providers, for the prescribers to actually behave better, via mechanisms through physician reimbursement. That's the second mechanism. Those two things are decentralized. It puts it in the hands of the patient to make the decision of, "Do I want the cheaper drug or the more expensive drug?" in consultation with the physician.
The third way, which seems to be what this bill is talking about, is administrative micro-management -- very expensive, exceedingly difficult to do. Mrs Caplan as minister, Mr Wilson as minister or you as minister would not have wanted to be making these decisions in a micro-management way. That seems to be the direction here. I think that could work, but it would be expensive and would make lots of mistakes.
The fourth, which I think doesn't work at all, is education, pure education without incentives.
You take those five drugs, you debate these four mechanisms, you come up with a single bill to address appropriate utilization and you can save $200 million. That's very different than what I see in this bill.
Ms Lankin: I've got one more question, but I appreciate your comments. I want to tell you that we have heard the terminology of micro-management and bureaucratizing health care over and over again and this is only partway through day three of these hearings.
I also wanted just to ask you to talk about the process of the elimination of best available price from this context. The government will be going into negotiations with pharmaceutical manufacturers with respect to the price of purchase for drugs listed under the ODB.
We've heard from a number of pharmaceutical manufacturers. Today, we heard from one of them that their interpretation of what the minister is going to do is that they will be following the Patented Medicine Prices Review Board guidelines and they expect that the prices will be set in that context, including looking at the cost-effectiveness information from that context. This sort of slipped through because --
Dr Detsky: Of which they have none.
Ms Lankin: -- I don't think a lot of people understood it and they went on to say -- and this is dramatic, I thought -- "As a result, we would expect to see a reduced role for the Drug Quality and Therapeutics Committee and a more open and transparent process."
I know the debate that has gone on within the industry and the ministry and the DQTC, particularly around the cost-effectiveness guidelines, pharmaco-economic guidelines that we've been trying to put in place. Could you comment on those representations from the industry this morning?
Dr Detsky: The last thing you want to do is replace your regulated price with the Patented Medicine Prices Review Board's regulated price. Here's the one part of what I've seen in the bill that I actually do like.
For a complex set of economic reasons, which I don't have time to explain here -- it would take an hour's lecture -- I do believe that deregulation of prices in the pharmaceutical area will actually lead to lower prices in Ontario for everyone, and it's specifically because the patient's physician doesn't have anything to do with the demand side, because the price is free to them and it will give the ministry and the private insurers greater power to negotiate much harder with manufacturers to come up with a reduced price.
But for God's sake don't replace that with the Patented Medicine Prices Review Board. That just gives them a different target to set their price at.
Ms Lankin: They seem to assume, from their knowledge of what's happening, that's the process that's going to take place and that DQTC is going to be cut out.
Dr Detsky: Then they don't understand markets; they don't understand this market at all. Mrs Caplan will identify with this comment: In my family, the worst thing you could do is buy retail. The province of Ontario is the largest single purchaser of drugs, and we pay retail. There is tremendous room for getting a better price, but not by replacing the BAP with the Patented Medicine Prices Review.
Ms Lankin: And certainly not by cutting out the DQTC in terms of pharmaco-economic analysis.
The Chair: For the government, we have Mrs Johns.
Mrs Johns: I'd like to thank you both for coming here. It was an interesting presentation in the fact that we saw two varying opinions in the same organization.
I think it shows that one of the continual thought processes is that we need change. Change isn't necessarily bad. We can't maintain the status quo in health care; we have to look for alternatives, and I think that's important, in our search, in looking for alternatives to how health care is being provided now. So I thank you for that.
I'm going to ask you each specific questions because you have such varying opinions, first of all to Dr Moore: The opposition seems concerned about the government no longer paying the full cost of a no-substitute claim. Can you tell me what you feel about that?
Dr Moore: First of all, as is obvious, we have a fairly spirited committee --
Mrs Johns: I would say so.
Dr Moore: -- and a lot of interesting dialogue. We discussed certain areas of this bill at the committee meeting we had just over a week ago and this is what we came up with that we could agree on. We did not, at that committee, get into the whole context of, should this bill be split up and how is this bill for doctors and hospitals?
Dr Detsky: I wasn't there.
Dr Moore: And he wasn't there. We just wanted to focus on certain drug issues that we thought were relevant to us, and the others; there are other concerns.
With regard to the no-substitutions, our feeling is that again -- and this is something we agree with the federal government on, which is unique -- there's agreement about certain criteria that have to be met to declare a drug interchangeable. We think that only under exceptional circumstances should that be broken. So the practice of just routinely writing "no substitution" on a prescription does, to my mind, not meet that.
If there's an exceptional circumstance where someone goes from one to the other, has an adverse reaction with the generic and you don't know its cause, there should be some sort of exceptional mechanism to get coverage, which would be the section 8. But the fact of the matter is, the money we're spending on no-substitutions right now, as I understand it, is basically people routinely writing "no subs" for the original prescription, not the situation where someone runs into trouble. To be honest, if you look at it, I think it's three drugs and it's done by promotion. I don't know if the manufacturers are here, but there are certain manufacturers who promote this --
Ms Lankin: There are big posters that say "No Subs."
Dr Moore: Yes. So I think you want to get rid of that because you'll save a lot of money. In those unique circumstances they may occur. We believe they're identical products, essentially, but there may be a situation where it might be reasonable that you could go through the section 8 mechanism.
Mrs Johns: Dr Detsky, one of the things that I think you disagreed with your cohort on was cost-sharing method; you definitely disagreed with the bill on the cost-sharing method. What would you recommend as an alternative to what we have, which is $2 for under a certain income and $100 plus dispensing fees over a certain income?
Dr Detsky: I don't think we disagree on this. What that mechanism does is address, "Should I buy the drug or not?" which is an important issue. But the more important issue is, once I choose to use an anti-hypertensive, should I pick a diuretic that's genericized at two cents a day or should I pick Vasotec, an ACE inhibitor, not genericized, at, and I'm making the price up, a buck a day? It's that level of price sensitivity that the patient and the clinician ought to have some opinion about.
A blunt across-the-board fee at $2 a prescription doesn't in any way allow them to discuss, "Once I've spent my $2 per prescription, should I pick the cheaper one or should I pick the less expensive one?" The reference pricing system around targeted specific drugs does get at that because it says: "We'll give you 10 cents for any anti-hypertensive you want per day. If the patient chooses to pay a buck, that's his or her business," and that's the kind of cost sharing I would be in favour of.
The second aspect of your cost-sharing bill -- I assume it's your government's cost-sharing bill -- is that doing this for patients on social assistance -- and Malcolm knows I'm certainly no bleeding-heart Liberal or NDP member -- is very counterproductive, because that will certainly lead to individuals without the means to pay for prescriptions not buying prescriptions that they truly need, which means coming back to the emergency ward sicker. For both efficiency grounds -- it doesn't give the right price signal -- and equity grounds -- it penalizes the wrong people -- I think that specific cost-sharing, if debated by itself, is a bad idea.
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The Chair: Thank you very much, Ms Johns; your time flies, doesn't it? Doctors, we appreciate your attendance this afternoon, your involvement in our process. Have a good day.
Mrs Caplan: Do I have time to put a question to the ministry on record while the next presentation's coming?
The Chair: Sure.
Mrs Caplan: On the issues that were raised by the last presentation, the question that I have is, in the case of a prescription that would have been written for no substitution, which the ministry no longer will pay for and there's no mechanism for under section 8 for a special authorization, is there an opportunity for the patient to pay the difference between the generic and the brand name, as requested by the manufacturers, or is it an all-or-nothing, either they get the generic or they have to pay the full price of the brand name? I'd like to have some clarification.
The Chair: I think we have the answer to that, don't we? Did you hear that question?
Mrs Johns: I wasn't listening.
The Chair: Do we have the answer to that quickly or do we need to get back with a written answer?
Mrs Caplan: The question is, is there any way that a patient for whom the generic is prescribed but who would prefer the brand name can pay the difference, or is it an all-or-nothing, they either get the generic under the ODB or they have to pay the full price, not just the difference? If so, could you reference a section here so we can see where that opportunity is?
Mrs Johns: They can pay the difference is the answer.
The Chair: The ministry people will get us a section.
Mrs Johns: They'll get you the section.
Mrs Caplan: I appreciate that.
The Chair: Our next presenters are on their way, but they're not here yet, so why don't we have a five-minute coffee break? Recessed.
The committee recessed from 1623 to 1630.
INCOME MAINTENANCE GROUP
The Chair: We have our last group for this afternoon, the Income Maintenance Group, represented by Scott Seiler. Obviously someone's with you, Mr Seiler, whom I'll allow you to introduce. Welcome to our committee. You have one half-hour to use as you see fit. Questioning will start with the New Democrats at the end of your presentation. The floor is yours, sir.
Mr Scott Seiler: My name is Scott Seiler and I'm the coordinator of the Income Maintenance group. This is Harry Beatty and he is a staff lawyer with the Advocacy Resource Centre for the Handicapped here in Toronto.
We represent the Income Maintenance Group, which has been in existence since 1978 and has been dealing with social assistance, social services and health-related issues since then. Basically, what I'm here to talk about are some of the issues that we feel are very important around Bill 26. I guess I'll start right away so we can have as much time for questions as possible.
I would like to first talk about the drug benefit plan and the copayment issue around the drug benefit plan. I think it's very important for all of you to realize that any copayment for persons with disabilities on social assistance will probably end up making people make a choice between, "Do I buy food, pay my rent or get the medications?" That's how slim the budgets are for people with disabilities on assistance. For the most part, people have high rents and it's not exactly easy to put out any other money.
We've also got some issues around the copayment as well. We're going to be faced with multiple copayments. We're going to be faced with copayments for other services as well, both on the provincial and municipal levels. The copayments are going to rise for people who are on these very limited incomes.
So it's very important that we do not have copayments. The Income Maintenance Group has fought for no copayments for any kind of health-related services, including the drug benefit plan, for a long, long time. I think it's very important that we do not see any copayments in any future plans; they will be prohibitive, they will be costly to the government in many ways.
For instance, one of the ways that they will be costly is that if people aren't taking psychiatric medications, you're going to end up with people being hospitalized -- the same with many other medications -- and the hospitalization will definitely be more expensive than the $2 or $3 or however much the copayment would be. Also, we're afraid that copayments will increase as time goes on and we'll end up with a system where the majority of the payment for the medication will not be from the formulary itself but from the consumer using the drug itself.
The next issue I want to talk about is the narrowing of the definition of "disability" and the issue of health records being secured in this province, and the confidentiality issue for freedom of information as well.
One of the things that we are concerned about in the Income Maintenance Group is the narrowing of the definition of "disability," which would mean that less people who are on disability pensions would end up being eligible for such pensions. Using the files that doctors hold in their possession, the Health minister would be able to get access through Bill 26 and the provisions for the ministry to be able to have people's personal health records. I'm afraid that we're going to see here a situation where the people's personal files will be compared with the files that are on record by programs such as the FBA program and the family benefits people to be able to cross-reference to see if people are truly disabled or not. We think this is basically a wrong idea, and it's not the way to save any money as well.
The narrowing of the definition of "disability" has some costs as well. Some of the costs of narrowing the definition of "disability" will be homelessness, increased suicides, increased illnesses, increased hospitalizations and institutionalizations. You're not going to solve a problem by narrowing the definition of "disability" or lessening the number of people on disability pension, because they're just going to have to go somewhere else to be fed and housed if they're not getting the proper things they're getting now, and those places could be institutions, the prison system and many other things too.
Mr Harry Beatty: One of the things the Income Maintenance Group has discussed over the years, and that of course our members have discussed with many individuals with disabilities and family members, is the range of disability-related costs which individuals with disabilities and their families face. If you set it in the context of the proposed $2 copayment for social assistance recipients, it doesn't seem like that much money, but we believe that because of cutbacks on all levels, both governmental cutbacks and cutbacks in the non-profit sector and also increased cost constraints on for-profit services too, people are going to be faced with more and more costs, and the cumulative effect really gives us a problem.
Of course the disability-related costs are the greatest, usually, for those in most need. The same individual may require several medications each month, but may also require a wheelchair or other large-sized assistive device, where of course there's a basic 25% copayment under the assistive devices program, and it's often larger because of caps that have been placed on some of the devices. There is personal care, transportation, if there isn't equal access to accessible transit, and so on. With charges like the copayments, if you look at them one at a time, you may get the sense that this isn't too much, but if you look at the cumulative effect, it may be quite a bit more.
I want to talk a bit about the section of our brief called "Equal Access to Health Care for Persons With Disabilities," beginning on page 7. Of course, many disability organizations and individuals with disabilities have argued against the medical model of disability services, which means basically that they don't believe that all services for people with disability have to be within a health care system or delivered by health professionals. At the same time, it's an obvious fact that health services are of particular importance to many people within the disability community who may require medications, as we discussed, or surgery, or may be more likely to go into the hospital.
In our legislation, there has always been a strong, at least theoretical, guarantee of equal access for persons with disabilities, particularly under the charter, the Human Rights Code and the Canada Health Act. We believe that as well, besides being enshrined in legislation, there is and will continue to be widespread public support for the principle of equal access to the health care system for all.
We believe, however, that there are major concerns raised for this principle by Bill 26. I believe many seniors' groups have addressed the proposed subsections 11(4) and 11(5) of the amended Health Insurance Act which, would authorize age to be used as a criterion in definition of "insured services." This would be under the regulation. The group believes this is discriminatory, that regulations which will exclude people from essential health services on a blanket basis on the basis of age are discriminatory both as a matter of policy and also in law. In the Roberts case, which was litigated by our office, the Ontario Court of Appeal ruled that an arbitrary age restriction on health care services, in that case the assistive devices program, violated the charter and the Human Rights Code.
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To the extent that the new legislation creates a two-tier system, obviously when something is excluded from insured services it's available only to those who can pay privately. We're concerned that people with the lowest incomes and the highest needs will not be able to pay and won't get the services.
We are particularly concerned, as mentioned in paragraph 16, about the very broad discretion given to the general manager of the health insurance plan under section 18. There's an authority to refuse to pay for services that are "not medically or therapeutically necessary." Unless I'm mistaken, that phrase is not defined, but that is the phrase that is commonly referred to in very difficult decisions about whether treatment should be given to those with serious disabilities or major illnesses.
We are concerned that if payment is not guaranteed, the ultimate effect may be to deny services to newborns with multiple disabilities, to those who can only be assisted by new or emerging treatments, and to those who may require only palliative care. Certainly we hope this would not be a direction to go in. But we see there may be a concern, say, if you could envisage a family at the hospital with a loved one where one of these very, very difficult decisions has to be made. Now there'll be a new element: There'll be a concern on the part of the physicians that perhaps these services are not going to be funded, that perhaps they have to be in touch with the general manager.
I certainly hope we are not going in that direction, but the use of this language certainly suggests that now the health insurance plan will be involved in these cases through administrative guidelines. It won't just be the family and the physician and others like ethics committees and so on who will be involved; it'll be into a funding decision. Of course, in any area where the physician and hospital or other health service provider cannot be guaranteed payment, the alternative is either to delay the treatment or service until clarification or approval is received from the plan or, alternatively, to require the family or the individual to make some kind of indemnification or post security.
Basically, our group would like to see a much larger role for consumers in the restructuring envisaged by Bill 26. Important decisions are going to be made about the restructuring of the health care system, involving people who need specialized medical help such as: Where is there going to be kidney treatment? Where will the treatments be for sight and hearing loss, for AIDS and HIV, for MS, for cystic fibrosis and on and on?
We believe there should be a formalized role for those groups in determining what will be an insured service, in decisions about physician allocations, so there will be some input around expertise of physicians who can address these problems and of course in decisions about the information needs of government, which Scott has already addressed.
Finally, we'll just touch very generally on the so-called MUSH sector, which is facing significant cutbacks, only to relate our issues to some which have been raised, I'm sure, and will be raised by municipalities, hospitals, school boards, colleges and universities.
The concern is basically that the accommodations made within these essential services for persons with disabilities may be seen as optional and may be discontinued. We believe we are already seeing this and may see more in future. We've touched on the hospitals and their ability to charge. I believe it's even envisaged by the regulation that they may charge for insured services if the regulations permit it.
In the municipal sector, some municipalities have already restricted or increased the payment for parallel transit or accessible transit. We have seen a pattern over several years of the special-needs programs, supplementary aid and special assistance being reduced or eliminated in municipalities because they're not legally required to provide it. That's the program people go to if they have, say, special dental needs that are not covered by the family benefits program, if they're on social assistance, or if they're not on social assistance but are otherwise in need. Municipalities are getting out of this area.
Within the educational sector we have seen examples where school boards are downsizing by eliminating "special education" services. We think they're just education services, such as educational assistants, speech language experts and psychologists. We know there are concerns among disabled students about the future of the disabled students' centres at colleges and universities, which have made so much difference.
Just to return to the point Scott made, is there really a cost saving if you go backwards on the accessibility of the education system? Many persons with disabilities have been assisted to be gainfully employed by these accommodations. If we move in the wrong direction, does that mean in the long term that more people will be on public support? We think that's the case.
The point we always try to make is that we are not saying that government should just spend without regard to the cost, but that expending what is necessary to keep moving in the mainstreaming direction, to keep moving towards employment for people and to support families whose disabled family member is at home, in the long run makes economic sense as well as human sense. We're hoping, obviously, that some of the provisions we have questioned in Bill 26 will be reconsidered.
Thank you. Do you have anything to add, Scott?
Mr Seiler: No. Maybe we can get some questions.
The Chair: We have about four minutes each for questions, beginning with Ms Lankin.
Ms Lankin: Thank you so much for your presentation. I have to tell you, as I was listening to you and as I was going through your presentation, you raise issues that I know this committee has not heard before and that we haven't dealt with. That's happened a couple of times today. I am personally feeling as a member of this committee, as we just keep rolling on, one submission after another, I don't know how to be able to process this and to have the time to work with groups like yours to determine what the appropriate amendments are.
Basically, the powers provided to the minister are so broad and so unrestricted that all the nature of the concerns you raise are very real concerns, yet there is no way in the legislation to address that, unless we start from scratch and start working through putting the appropriate language of restrictions in place. That's not going to happen unless the government members of this committee support our request to try and get this bill broken up so we can deal with it in manageable pieces.
Bad laws get passed when you ram them through like this, and your presentation, along with many other very good ones -- but yours speaks most eloquently to the shortcomings in this legislation and the dangers and pitfalls that are there.
For example, I was flipping through trying to look and understand the point you were raising about age discrimination, and that was raised by a group yesterday. It was pointed out to me by a member of the media, actually, which is helpful as we're all scurrying through looking at this, that there was a provision in the old legislation that allowed them, by regulation, to prescribe certain services by age. But it's now been rewritten and put into the middle of a section and I can't tell, even cross-referencing it to the old legislation, which I have here, without some legal assistance, whether this confers new powers or different powers or how those powers were used before.
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This one little section has, in my mind, immediately 10 questions, not the least of which is, how does it relate to the court decision dealing with assistive devices and was the section, as it was written, struck down? Does this mean it has now been rewritten so that it is going to stand the test of court or, in fact, should we be taking it out all together because it was dealt with by a court in other circumstances, under assistive devices, perhaps different language -- I don't know -- than insured services?
Your presentation has raised a whole range of questions. I don't have a specific question for you. I just want to say that I think you have, as much as many other groups, or perhaps more, made the case for the debate we are going to have at 5 o'clock about the motion to extend these hearings and to break these bills up.
If you have any comments on that that you want to give to the government members on this committee, because they will carry the balance of votes here, then I would appreciate your doing that.
The Chair: Unfortunately, Ms Lankin, you didn't leave them any time for any comments.
Ms Lankin: Oh, sorry.
The Chair: For the government, Mr Clement.
Mr Clement: I enjoyed your presentation. You got me thinking that I had misread the legislation the first time around when it came to services deemed by the general manager to be not medically or therapeutically necessary, so I was scrambling around a bit and I apologize. But I reread the previous legislation as well as the new legislation and the only change -- under the old legislation the general manager had the authority to refer to the Medical Review Committee anything that he deemed or she deemed to be services that were not medically necessary, based on reasonable grounds. We've added, "medically or therapeutically necessary." That's one change. I don't think much turns on that except to -- perhaps even if it does -- to expand it, that's fine by me, if there are cases of fraud and abuse. The only changes -- he doesn't have to, or she doesn't have to, refer it to the Medical Review Committee, which takes five years, to get through anywhere.
Mrs McLeod: A small change.
Mr Clement: Excuse me, I have the floor. He or she has the opportunity to deal with it forthwith, which I think, in terms of physicians, gives them the comfort to know that it's going to be dealt with rather than hanging like a sword of Damocles over them for four or five years.
I just wanted you to know that it was under the previous legislation this power existed to review. What we've done is allowed it to be dealt with more simply, more equitably and faster than the previous legislation, but the power was there. So your concern that there are new, undemocratic powers, I think is misplaced. Would you like to respond to that?
Mr Beatty: Well, we didn't have time obviously to compare it in detail with the existing legislation, but it still essentially gives a broad discretion to the general manager with no guidelines at all as to how that is going to be addressed.
Mr Clement: I don't mean to put you on the spot. I'm sorry.
Mr Beatty: I have to say honestly we didn't have a chance to review the previous legislation, but it still seems to be unacceptable discretion notwithstanding that it may have been there before.
Mr Clement: That's fair and you're entitled to your opinion. Can I just ask a brief question about the Ontario drug benefit payments, which you raised at the outset of your presentation? What we have done through the copayment is also announced the extension through Trillium of drug benefit plans to 140,000 more people. Now, obviously, that's a quid pro quo. Governments have tried to be all things to all people for so long that we've got into this financial mess, so we wanted to be fiscally prudent about it. But how do you feel about extending the benefits to 140,000 more people under Trillium? Isn't that a good public policy move?
Mr Seiler: Yes, it is a very good public policy move, but at the same time, it's a very poor public policy move to end up with a restrictive program. It will end up with nobody using it because people will have to make choices between the medication or eating.
Mr Clement: Well, I disagree with that interpretation.
Mr Seiler: And that is the case even now, before, because there are lots of things that are not covered by the Ontario drug benefit plan that people are needing to buy on a constant basis and because these things aren't covered, they're paying out of their pocket, where at one time they were covered. So the extra costs are mounting for people on disability pensions and eventually they will hit the wall. They will not be able to afford it and it will mean a choice between medication and/or rent or food.
This has been shown in other jurisdictions where these payments have been put into place. Alberta, Saskatchewan, British Columbia have all had similar experiences to what I'm talking about. People are asked to make those choices and people are making those choices. They're ending up in the hospitals and more money is being spent providing care in hospitals.
Ms Castrilli: I have to tell you, yours is a wonderful presentation. I can't remember when I've agreed more with something that has been said in a presentation. When you say you believe in a society that promotes an approach that can be cost-effective and fair and compassionate, which I think is the thrust of your presentation, it's exactly the kind of thing we've been talking about.
I have to take issue with Mr Clement yet again today. I apologize. I hope he doesn't take this personally, but he seems to misinterpret things and unfortunately he's done it as well this time.
The new proposed section 18 of the Health Insurance Act, as you rightly pointed out, gives in fact the general manager incredible powers. That's a far cry from what was under the previous legislation, which gave some powers to a Medical Review Committee which is made up of professionals who understand the subject matter and not a bureaucrat. What we're talking about is bureaucratic intrusion in a sector which is very delicate, which is an enormous change -- an absolutely enormous change. It isn't just a little change, nor is it a little change to say that services can be refused because they're not medically or therapeutically necessary. That is again a very large change and I take issue with that.
Let me ask you a question, since I'm delighted to have a lawyer before us. We don't often get lawyers in this committee.
Mr Clement: For free.
Ms Castrilli: Well, you know what they say about free legal advice.
You made a point in your presentation that there are provisions of the bill which may in fact infringe the Charter of Rights, the Ontario Human Rights Code and the Canada Health Act. I wonder if you might elaborate on that just a little bit.
Mr Beatty: Essentially, what there is in the bill is the provision about making the regulations with an age restriction on certain services. I guess whether it would actually violate the charter or the Human Rights Code would depend on how it was drafted and what it said.
I think in the Roberts case, which incidentally was not specific -- the assistive devices program isn't under the Health Insurance Act, so it didn't specifically deal with this legislation, but essentially what was objected to was using prohibited ground of discrimination as a criterion.
I know there is some concern among seniors, because many in the health care field have put forward that over a certain age you don't get a bypass and that kind of thing. I think there certainly would be a concern if rules of that type were enforced. Again, Mr Clement has pointed out that there was a provision like that before. I didn't have a chance to research that, but I'm not aware of any regulation being passed pursuant to that before, or any rules being implemented to say over a certain age you don't get such and such service.
The Chair: Thank you, Mr Seiler and Mr Beatty. We appreciate your attendance and your interest in our process and your presentation. Have a good evening.
When we first got together this afternoon, we deferred a motion that had been put forward by Ms Lankin until this evening, until the public presentations were over. I will read the motion.
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"Whereas there has been overwhelming public interest in Bill 26 and that requests to appear before the standing committee on general government far exceed the number of spaces available;
"Moved by Frances Lankin:
"I move that this committee recommends to the government House leader that when the House returns on January 29, 1996, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged; and further, that this committee recommends to the government House leader, based on the submissions to the committee to date, that Bill 26 be separated into several bills to allow the public an opportunity to adequately analyse the bill. Further, that this committee recommends that the three House leaders meet as soon as possible to discuss this issue."
If I could just make a couple of comments before inviting Ms Lankin to speak, our next presenters are here at 6 o'clock, so I would like to have some agreement that we would allow each person who would choose to speak one opportunity to speak, other than Ms Lankin, who will be allowed to wrap up at the end. Do I have approval for that from everybody? Okay. Ms Lankin.
Ms Lankin: Mr Chair, may I just make one technical correction of the record, that the motion should read "I move that this subcommittee," and all references to "committee" should be "subcommittee." I believe that we're a subcommittee, aren't we, or no, they are?
The Chair: We are the committee.
Ms Lankin: So we're okay on that?
The Chair: Right.
Ms Lankin: Okay, good. We're all divided.
Thank you very much. I moved this motion for a number of reasons. I believe profoundly, and have since the day this bill was introduced, in the manner in which it was introduced, and since having a chance to look at it, that this is a bill that is unmanageable for appropriate democratic analysis, input, debate and passage. I believe that this bill has strung together very, very important public policy areas which the public has a right to have knowledge of, to have understanding of and to have input into. That, of course, led to the opposition parties' actions to demand of the government public hearings, and of course that is history. Negotiations took place, and a package was put together; not one that we were happy with but one that we were prepared to live with and to try and make work.
As we entered into the hearings this week -- and I remind people this is only day three -- we have heard from virtually every group in this subcommittee, and many groups in the other subcommittee that have come forward, a plea for the government to break this bill up into manageable pieces and to allow the appropriate time for groups and individuals to analyse, to understand, to have input into and to have a legislative debate and process that serves the public interest. There's a lot of language in the health bills here about "in the public interest." Let me tell you that I don't believe the way in which this bill is being proceeded with is in the public interest.
I was reviewing the Hansards of the last couple of days, of groups like the Toronto Psychoanalytic Society, the College of Physicians and Surgeons of Ontario, South Riverdale Community Health Centre, Survivors of Medical Abuse, Older Women's Network, Ontario Coalition of Senior Citizens' Organizations, the OMA, LAMP, on and on, and many groups you've heard today. I don't need to highlight all of those groups, because you heard them, this committee, the members of this committee heard them make a plea for this bill to be broken up and this bill to be dealt with in a time and fashion that allows for appropriate debate.
I had what I think was an incredible speech, in my mind, prepared to give on this motion, which quoted extensively from Hansard, quotes from Mr Wilson when he was Health critic in reference to a 13-page bill called Bill 50, as opposed to the 211 pages in Bill 26, in which he talked about it being rammed through and undemocratic. You would have loved it. It would have been great theatre. I'm not going to do that, because I personally am quite overwhelmed with what's happened this afternoon, and I want to share that with you.
Since I moved this motion at noon, letters have started to come in. Don't believe for a moment that people aren't watching what is going on here. I heard some government members saying when a group didn't show: "I guess they're not interested. I guess there isn't really that much interest." One of the groups that cancelled today cancelled because the notice was so short they couldn't get their brief together and they couldn't get their people together to get here at the time slot that was available.
We only passed this bill, second reading, last week. We haven't given people the time to prepare. Many groups have done yeoman service in getting their stuff together and getting here. But groups and individuals have different levels of resources in being able to do that, and we are cutting out many voices of Ontarians by proceeding in this manner.
But people are watching, and I want to share this with you, a note that the OMA supports breaking up Bill 126 and the extension of the hearings.
There's a letter to the Chair which I have a copy of:
"On behalf of the Chinese Canadian National Council, I am writing in support of the motion put forward by Frances Lankin, MPP, Beaches-Woodbine, concerning Bill 26.
"Given the extensive scope of Bill 26, it is critical that the Ontario public be allowed ample opportunities to understand the proposed legislation and to provide input."
It continues on. I won't read all of these into the record because that would take the whole hour.
From Daniel Kushner, a fax: "I strongly support your motion to subdivide Bill 26 into manageable and coherent pieces in order to allow debate and discussion of this sweeping and complex legislative proposal."
From the National Action Committee on the Status of Women: "On behalf of NAC" -- this is to the committee -- "I would like to express our support for the motion being put forward...regarding public hearings on Bill 26." They go on to offer some comments on the bill.
"Dear Ms Lankin:
"It has come to the attention of the AIDS Committee of Toronto that you have proposed an alternative approach to managing the many important components of Bill 26.
"In my deputation December 21 on behalf of ACT I am prepared to state our concerns about the approach that is being taken with Bill 26.
"We are definitely in support of a process that allows sufficient time."
This is from a number of councillors at city council, and addressed to me:
"This is to support your motion to have the standing committee on general government conduct further public hearings in the city of Toronto on Bill 26 as well as to separate Bill 26 into several bills to allow for better public understanding and debate.
"Toronto city council passed both of these resolutions on 18 December...as stated in the city of Toronto submission."
That's signed by a number of councillors and the mayor of the city of Toronto.
From the Ontario Professional Fire Fighters Association: "Due to the sweeping powers of Bill 26 and its impact on the level of services that the citizens in the province of Ontario have come to expect, the Ontario Professional Fire Fighters Association urge you to support the motion that has been tabled by Frances Lankin."
Another letter from UFCW, who were here today indicating that they had made that pitch to the committee and that they support the motion and they also support the motion that the three House leaders meet as soon as possible to discuss this important issue.
A fax from Carol Kushner, who is a health policy analyst: "I fully support your motion to break up Bill 25 into smaller acts to allow for proper debate and discussion. Given such sweeping proposals for change, it is particularly essential for government to demonstrate respect for democracy in this respect."
From the Ontario Teachers' Federation, signed by the president and addressed to me:
"I have heard about your efforts in the standing committee on general government urging the committee to request that Bill 26 be separated....
"I hope that the members of the committee exercise their democratic responsibilities appropriately and support your motion."
From the Ontario Coalition of Senior Citizens' Organizations, again addressed to me, a letter of support. They applaud the move to request more time for public hearings and changes to Bill 26.
This is a letter addressed to the committee from the president of the Ontario Psychiatric Association:
"The OPA is looking forward to appearing before you tomorrow. We understand, however, that many interested parties have not been so fortunate" as to be able to have more hearings. "We believe that the government should extend the hearing schedule.... We also believe Bill 26 is very unwieldy as presented and we agree with those who have recommended that the bill be subdivided."
They keep coming, as we're speaking.
The Ontario Nurses' Association agrees that more time is necessary before Bill 26 can be properly analysed, and "fully support your motion that the bill be separated...and there be further opportunity."
Parkdale Community Legal Services, addressed to the clerks of the committee and indicating a lot of reasons that "We wholeheartedly support Ms Lankin's motion and urge the government to respect the concerns which the motion represents."
The Alliance of Seniors to Protect Canada's Social Programs "strongly supports Frances Lankin's motion that Bill 26 be broken into separate bills, each duly debated and with public consultation prior to enactment."
The Association of General Hospital Psychiatric Services, signed by the president, an open letter to this standing committee. They've been here and they've presented. They would request, however, that there be more time allowed to schedule extended hearings and to allow for more thought and feedback on a large number of issues. They also support the bill being divided.
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The Amalgamated Transit Union, Canadian council, signed by the Canadian director: In here, they're expressing their strong concern about the speed with this legislation is being pushed through and asking: "I appeal to all members of the standing committee on general government to separate the bills and give the public more time to understand and digest the changes that are being considered."
From the Equal Pay Coalition, a spokesperson from that coalition. This is interesting because this highlights what happens when you put a whole bunch of bills together:
"The Equal Pay Coalition, a coalition of 39 organizations in Ontario that seeks to ensure equal pay for work of equal value, supports Frances Lankin's motion that Bill 26 be separated into separate bills to allow the public to adequately analyse the bill.
"The Equal Pay Coalition is deeply concerned about the government's plan to repeal part of the Pay Equity Act that allowed thousands of women in all-female workplaces to achieve pay equity.
"While the health-related sections of Bill 26 have been highly publicized, other sections of the bill dealing with issues such as pay equity have been virtually ignored.
"We urge this government, as a matter of fairness, to separate the bill and allow more time for public input."
This is from the chairperson of the Church in Society Committee, Toronto Conference, United Church of Canada, and is to support the motion to split the bill. It says, "This bill as it stands touches on such a variety of subjects that it is virtually impossible to deal with it in any intelligent or consistent manner in either the Legislature or by the public." Please split the bill.
From the Older Women's Network: They recommend that the bill be split and that there be amendments and that there be proper public consultation.
The Canadian Environmental Law Association: This is a very long letter dealing with various sections of the bill, but the bottom line is that they support the motion that will be brought today requesting Bill 26 be separated and allowing public debate.
Metro Toronto Chinese and Southeast Asian Legal Clinic: Support for the motion being put forward.
Debby Copes, who's a well-known family doctor: "I strongly support your motion to have Bill 26 broken up into smaller acts which would each be given the proper debate and discussion."
Michael Rachlis, who was here, who indicated that, has also sent a letter in on this.
This is to the standing committee. This is one you might find interesting. I read the one from city councillors signed by the mayor of Toronto. This is from Metro, signed by Jack Layton, but it refers to debate today. It says:
"Whereas there has been overwhelming public interest in Bill 26 and that requests to appear before the standing committee on general government far exceed the number of spaces available, please be advised that today the council of the municipality of Metropolitan Toronto passed the following motion:
"`Metropolitan council, in its brief to the Legislature, recommend that the present omnibus bill be divided and the various sections be submitted as separate bills, with adequate time for public hearings.'"
They continue to come.
Dr Weisbred, a Conservative voter, urged "further time to adequately consider the ramifications of Bill 26."
Mr Chair, I'm sure there will be more that will be arriving as we talk on this. I don't know if I'll have a chance to read those names in. But it was only noon I moved that motion and people are responding and asking this committee to take seriously the requests of the many, many groups that have come forward here. I just want for the record to let people know what has happened in terms of requests to present before the committee.
There are currently, as of this morning -- not currently; more calls have come in today. But as of this morning, there were 232 requests for the 188 spots here in Toronto. Yesterday morning, you might remember, for out-of-town there were 316 requests for the 274 places. This morning, there were 396 requests, so another 80 came in yesterday afternoon for the 274 places. That's 628 requests for the 462 places. We haven't even placed the advertisements yet for the out-of-town hearings. Please listen to the fact that people want an opportunity to understand this bill, to speak to this bill and to deal with it in manageable pieces. I urge the government members of the committee to support the motion that I have put forward and to speak to their caucus and to speak to their government House leader to do what is the right thing in the public interest.
The Chair: Keeping up with the rotation that we've been following, we'll go over to the government.
Mr Clement: I'm told by the House leader that the government and the Legislative Assembly through which this committee works have given this legislation more committee time than any other legislation in the previous two parliaments. I might recall for the honourable member, Mrs Lankin, that the omnibus Bill 175, as proposed by the NDP when they were in power, amended 139 statutes, 14 different ministries, and there was absolutely no committee time -- none.
To date, for this committee, we have been the recipients of at least 60 -- well, at least 50 -- oral submissions to date, and more will be forthcoming in Toronto. We are travelling across the province from Windsor to Timmins in the scope of two weeks in January. This bill, Bill 26, has been given a total of 220 hours at committee. If we were operating on normal committee time, that would be 43 weeks of committee time to review this piece of legislation.
Mr Chairman, we have said from the beginning, from the government side, that we welcome all submissions to this committee. I've been on the record at this committee welcoming amendments, welcoming input either of the verbal variety or of the written variety. We are listening to all suggestions. We are open to changes. We want to approve this legislation as well. And written submissions will be ongoing and received by this committee on an ongoing basis.
If I can quote the leader of the official opposition, Mrs McLeod, on December 8 in the Thunder Bay Times News, she said: "We now have a substantial amount of time to look at this bill," and for once I agree with her.
I might add, Mr Chairman, for the record, as you know and as Mrs Lankin knows, the committee time for Bill 26 was negotiated with the two opposition parties and the government. On the government side, we are standing by the agreement that was reached by the three parties. We are not going to go back on our word.
And, Mr Chair, if I can wrap up, from our perspective we are giving every opportunity for the public to have their say. That's what the committee process is all about. That was something we were always committed to, and I'm looking forward to moving on so that we can actually hear from the public rather than participating in what I see, quite frankly, as an opportunity for the opposition to gain some points, when we know we have reached an agreement that they felt comfortable with a week ago and we are in fact hearing from people and allowing the people from all over Ontario to have their say on this most important bill.
Mrs Caplan: I'm going to support the motion that is on the floor because I think it is reasonable. As you know, I attempted to table a very similar motion that was ruled out of order, and we worked with the Clerk's office to develop an alternative one. I believe that we have heard in the last two days far more concern. We have heard concern about the fact that people feel there is inadequate time to even develop proposals and recommendations and amendments.
I had a phone call today from presenters who were here yesterday who are saying they are all of a sudden starting to identify issues in this bill as they listen to other presentations, things that they had not contemplated. Mr Chairman, many of the presenters who have presented focused on their own area of expertise in the bill and, as we heard this afternoon from the Drug Quality and Therapeutics Committee, for example, they have not considered any of the other implications outside of that very narrow range.
The thing I have found most frankly disturbing, and that's the word I'm going to use, very disturbing, is that we have had such an overwhelming response from people who want to be heard that cannot be accommodated. I don't think that could have been contemplated even a week ago when an agreement was reached that would allow the bill to proceed. The purpose of public hearings is to listen, and if there are concerns raised and if people are saying, "I haven't had or don't feel I will have an opportunity to come before committee and I want that opportunity," then I think the committee that is hearing all of this -- and we're hearing it in the form of representations that are being made to the committee, in people who are contacting the clerk to say, "We want to come and are being told there's no space for us to make representation," people who are writing and faxing members to say: "Please help us get time to come before this committee. We are just now aware of what this bill contains. We are very concerned about this and we are feeling that democracy is not being well served if we don't have the opportunity to come before committee."
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The motion that is before this committee is one that asks the House leaders to consider additional time for this committee. That is not an unusual request. House leaders in their best judgment make decisions about how much time they think is necessary, and I'll give you an example. Bill 19, which contains three distinct sections, one dealing with consent to treatment, one dealing with repeal of the Advocacy Act and one dealing with substitute decision laws -- that package of bills, very important -- is receiving three weeks of public hearings, one week in Toronto and two weeks across the province, and a full week of clause-by-clause. That's four weeks of committee time on that one bill.
The member from the government benches, Mr Clement, raises how other omnibus legislation has been dealt with, and I think that's important, though not particularly relevant, because we've never seen an omnibus bill of this size and scope. But the bill that he points out, Bill 175, I was here and I rose to object, frankly, to having contentious issues contained in an omnibus bill which traditionally has been used for housekeeping.
Let me tell you what happened with that piece of legislation, Mr Clement. That legislation was tabled in the spring session of the Legislature and it did amend 139 statutes in 14 different ministries. Concerns were raised about some of the aspects of that bill, and the NDP government -- and I was very critical at the time; you can read the Hansard -- agreed to remove everything from that bill that was contentious, everything in that bill that anyone had a concern about.
They did that. They severed those parts of the bill that were deemed contentious, and the bill became a housekeeping bill, as omnibus bills traditionally have been. That's the reason that Bill 175 was passed without any committee time. It was passed because everybody in the House said: "This is housekeeping. It doesn't require public hearings because there is nothing contentious in this bill."
To use Bill 175 as an example of why this bill doesn't need further scrutiny is unfair. I'm not going to question the motivations; the member was not here. But Mr Eves was here and Mr Harris was here and Mr Wilson was here, and they spoke in support of having appropriate scrutiny for issues that were contentious.
What we have heard from every group that has come before us, whether they support the bill or not, is evidence that Bill 26 contains many, many issues which are considered controversial and contentious. Certainly we have not heard a broad consensus. We have not heard anyone that I can recall who came forward who didn't question some aspect of the bill. We also have not heard from any group that said, "I wouldn't like more time to look at some of the other areas, because I haven't a chance to look at it."
All that set aside, regardless of the support that's out there for splitting the bill and reviewing it individually, let's set that aside for a minute. I hope the House leaders will consider that and the government will agree to do that, because that's the right and proper thing. But what this committee is saying is that we believe that democracy should not be denied and that when you have -- and I'm going to repeat the numbers again because they are growing every moment that we sit here. There are 232 people who have applied to be heard before this committee here in Toronto alone.
There was no advertisement of these hearings. People were asked to prepare extensive briefs on a moment's notice. Many of them have had difficulty in doing that and we have had requests from those who have been unable to have their briefs prepared if they could have some additional time to come before the committee and to do that.
All of the slots are presently filled for committee time here in Toronto and we have had 232 groups who have requested it and, as I've said, there are more coming in to request additional time in Toronto. We have 274 slots available in the 11 cities across the province that this committee will be travelling to. We have already had 396 requests and not one newspaper ad has been put in the papers alerting people to the fact that this bill is being debated at committee.
Surely the government members, and particularly the backbenchers, who came to this Legislature to see thorough and adequate debate given to issues of concern to their constituents, would want to allow their constituents -- not just mine, their constituents -- across this province -- and I remind them that they have over 80 seats in this Legislature and they can do as they please, but it's their constituents as well as mine, organizations who are situated across this province that are making the request for an opportunity to be heard by this committee. I don't think that's an unreasonable request. To deny them that is a denial of democracy, and I believe it's a denial of their right to participate in the democratic process.
We've heard representations of the feelings of frustration and the sense of powerlessness that people feel when they are denied that opportunity to be heard. In fact, Mr Chairman, I was very careful this morning when I placed my motion to say that we recognize that there may be some portions of this bill that the government must have by January 29 and we are prepared to live up to the commitment that House meet on that day.
But the House leaders could accomplish the request of people who want to speak to this massive bill, which has numerous controversial issues that people are just beginning to realize the consequences of and the implications of, people who want to come forward and give their advice and suggestions, people who would like to see this bill split, I'll grant you that, but people who want to be heard.
All this amendment does is say, "Don't compare this to a Bill 175-that's not fair -- but look at this bill in its complexity and listen to the hundreds of people, hundreds of organizations, hundreds of individuals, who are being denied the opportunity to be heard because of your desire for unnecessary speed." And I say "unnecessary." We're prepared to deal with those things that must be dealt with on an urgent basis, but many, many of the features of this bill do not require that speed.
Give people the opportunity to assert their democratic rights by participating in democracy. If you deny that, then you diminish the work that we all do here. I would ask the members of the government bench to seriously consider why they were elected to this place and what they feel their role is, if it is not to listen to the people of this province who simply want to come forward and be heard. You are the members of this committee and you know of the backlog and the inability of this committee to accommodate the public who want to be heard. I ask you not to vote against this motion that is on the floor.
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Ms Lankin: I believe Mr Rae has a few comments before I wrap up.
The Chair: Mr Rae, welcome to our committee.
Mr Bob Rae (York South): It's nice to be here once again. The main thing I want to say to committee members is that the trouble with this bill is that it tries to do such an extraordinary amount and it was drafted in such haste. There are lots of signs of this and lots of signs that the real implications of this legislation have not been adequately analysed. I would just say that, from my experience as Premier sitting around a cabinet table, there are many instances where you're working under a timetable that's not entirely realistic and where, in this case, you've got an extraordinary number of things that the government is trying to do.
The things we can do that need to be done quickly, could be quite easily and readily severed. The sections dealing with revenue, the sections dealing, for example, with the borrowing authority, the sections that deal with the needs of the government of an administrative kind can be very quickly severed by agreement and could then be dealt with quickly by the House. But I think if people don't believe that there's a problem with some of the things we're being asked to do, then I just don't think they've considered the bill.
The public is inadequately informed still. The bill is referred to as an omnibus bill. They don't know what that means. Various professions are only just now becoming aware of its implications. I find it ironic, when Mr Clement was such an ardent opponent of quotas, that this actually is a quota bill; the other one wasn't. Employment equity was not a quota bill; this actually is a quota bill. This is the first time in the history of the province that the government of Ontario has given the Minister of Health and the Ministry of Health the power to impose a quota on doctors, where they will practise and how they will practise. This has never been done before.
We're going to see an exodus of doctors from this province on an accelerated basis, starting with our youngest doctors. Just by way of parenthesis, there are more women now graduating from university and medical school than ever before in the history of the province. Those women are going to be leaving us for jurisdictions where they can practise, and the implications of this have not be adequately understood.
I really do believe that the committee members on the opposite side have an opportunity to think this through very carefully and to really go back to the government. All we're asking for is an opportunity to speak to the House leaders and say, "You've got to understand what this does and where you're going to get into trouble and where we are all going to get into trouble as a result of the steps that are being taken here."
My view would be that this proposal, which is saying, "Let's take a deep breath here, let's recognize the problem, let's understand the depth of emotion that underlies the opposition to this," doesn't come from political partisans of one stripe or another. It doesn't come from one particular group in our society. It comes from an astonishing array of people who suddenly realize that they're being caught up in a change of their way of life that they had not anticipated on the basis of the political promises that were part of the last election.
I would hope very much that the government members would think through very carefully about the importance of accepting the proposal that my colleague Frances Lankin has made. I think it's a very sensible proposal. It's one that relates to the practical problem which the committee now has.
The government is creating a huge problem for itself, I would argue, even potentially legally, by denying some people the right to be heard and then turning around and passing legislation which affects the rights of those people. I think the government is going to find itself in a problem with respect to the passage of this legislation because one of the arguments that will immediately be used -- and this legislation, if passed in its current form, will cause more litigation and more lawsuits and more legal battles than any legislation that has ever been passed in recent memory by the Legislature.
One of the things the committee had better consider is, given the fact that's going to happen, whether it might not be a good idea to hear the other side. You've now got yourself in a jackpot where you can't possibly hear the other side, because the number of people who want to be heard, those views are not going to be able to be considered, and you haven't even started the advertising process. As soon as you start the advertising process, you're going to find the numbers of people who want to appear compared to the number of people who can will be completely out of control. That's the problem that you've got.
I think that what Frances's motion tries to do is to say, let's recognize the severity of this problem, and I think it's a very sound motion.
The Chair: Thank you, Mr Rae. Any further comment from the government side? No? Ms Lankin, you get a chance to wrap it up.
Ms Lankin: I will not take very long of the committee's time. I want to indicate that while we have been having this debate, two more letters of support have arrived. One is a letter addressed to Premier Harris and it's from the Association of Ontario Health Centres, which made a submission to this committee and is speaking on behalf of many member centres which have raised concerns regarding the limited time for the hearings, and they are supporting the motion. The other is from Elizabeth Greaves, who's the executive director of Dixon Hall, and she most eloquently says that she was notified this morning at 9:30 of an opportunity to present this afternoon to the subcommittee meeting in the other room.
"While appreciative of the opportunity, we regret having inadequate time to examine the legislation and its implications.
"We are aware of many who felt silenced by the weight of the proposed legislation and the time frame for response.
"I fully support your motion to have bill 26 broken into sections, with time for true input from the many Ontarians who would respond."
May I say to members of the committee to look carefully at the wording of my motion. It is simply that this committee make a recommendation to the government House leader to look at splitting the bill and giving us more committee time to hear from people. You know you have heard from the individual groups and organizations that have been here. You've heard me read this into the record. You know the numbers before we've even placed the ads for out of town. It's overwhelming.
This is not the same, with all due respect, as the other pieces of legislation you cited, and neither is the overwhelming public response to participate, the overwhelming public concern. Don't run roughshod over that, and particularly don't do it at this committee level. Join with us on the committee at least in making a recommendation to the government House leader and let him meet with the other House leaders and see if they can work through a more appropriate way to deal with this bill, as I said earlier, one that is in the public interest.
The Chair: We've had the debate that we agreed to on all sides, so I will put the question. All those in favour of Ms Lankin's motion? All those opposed? The motion is defeated.
Ms Lankin: Shame.
The Chair: We stand recessed until 6 o'clock.
The committee recessed from 1739 to 1810.
The Chair: Welcome back. We apologize for being a little bit late, but we ran a little long in the afternoon session and we had to get something to eat.
ONTARIO ASSOCIATION OF NON-PROFIT HOMES AND SERVICES FOR SENIORS
The Chair: Our first presenters this evening are the Ontario Association of Non-Profit Homes and Services for Seniors, Michael Klejman. Welcome, sir, to our committee. We appreciate you being here. You have a half-hour to use as you see fit. Questions will start with the government at the end of your presentation.
Mr Michael Klejman: Thank you very much, Mr Chairman, and a good afternoon, or early good evening, ladies and gentleman. My name is Michael Klejman. I'm the executive director of the Ontario Association of Non-Profit Homes and Services for Seniors, OANHSS. I'm pleased to have this opportunity to address the committee. At the outset, let me just say a few words about the association, although I think a number of you are probably familiar with us.
The Ontario Association of Non-Profit Homes and Services for Seniors represents municipal and charitable homes for the aged, non-profit nursing homes, seniors' apartments, seniors' supportive housing settings and agencies that provide outreach services to seniors who are living independently. In all, our 300 members serve about 10% of Ontario's seniors and employ over 22,000 people.
At the outset, let me say that we continue to accept the government's commitment that the current level of support for health services in Ontario will be maintained. The period of change that Bill 26 triggers is unavoidable. It is indeed tragic that the tackling of fiscal crisis is intertwined with the health restructuring initiative. It is difficult sometimes, if not impossible, to distinguish between what is purely cost-cutting and what is a part of a painful but probably necessary process of change in the health sector.
Bill 26 is generally accepted and supported by our members. We see in it much that puts forward the premise of accelerating the process of change. It is in this vein, therefore, that I will offer suggestions for amendments to certain sections of the bill that relate to health services.
Before doing so, I would like to put forward to the committee several points that are rooted in our experience and knowledge of the long-term-care system. It was only a little over two years ago that long-term care was integrated under the Ministry of Health. We became a part of the health system and see long-term care today as one of the key elements in an effort to maintain quality health services without allowing its costs to go through the roof.
I will speak for a few minutes about long-term care.
Canada, as many industrialized countries, is and will continue to experience a rapid increase in its elderly population over the next several decades. This elderly population is a significant user of health care dollars, certainly well above the relative percentage it represents in the population as a whole. The most dramatic increase in population is expected in the oldest subgroup, those 85 years and older. This segment of the population places the most significant demands on the health system.
The historical evolution of health service utilization was driven by the availability of services and perceived sense of which services are the best. Whether we consider the demands on hospitals, physician services or prescription drugs, the pattern has been the same. We have heard many proponents advocating for a reduction in the number of so-called bed blockers in acute care beds, and just two years ago the chronic care role study reported that 50% of patients in chronic care beds need not be there. We have also heard many references to overutilization of drugs and physician services by the elderly.
Over the past decade, successive Ontario governments have promised and planned to reform the long-term-care system, seeing in it probably their only answer to the escalating costs. Since 1985, several initiatives have been launched, and all have pretty well fizzled before coming to full fruition. We are now in the midst of a major economic crisis, and our fears are growing that once again reform of long-term care may be delayed.
I would like to put forward a strong argument that this is precisely the time to accelerate the reform of long-term care. Before making this point, I want to offer an illustration why it is important to move with reforms. To make my point, I will make several assumptions, and I have to make these assumptions because our multibillion-dollar health system cannot generate specific data, so I'm relying on my own knowledge of the system.
I made an earlier reference to acute care beds being inappropriately occupied. I've seen estimates that about 5,000 hospital beds per year are inappropriately occupied. The 50% of chronic care beds suggested in the chronic care role study equates to about another 5,000 patients. If we assume that an average per diem in an acute care hospital is about $300 and in a chronic care hospital $200, and I believe both figures to be in the low end of their respective ranges, then over one year the province spends over $900 million on these 10,000 beds. If the care for these individuals were to be provided in long-term care facilities, homes for the aged and nursing homes, the province would reduce the spending by $547 million a year. Assuming that some of these 10,000 individuals can be supported in the community through enhanced homemaking and other visitation services, the potential for reduction in expenditures would be even greater.
I must caution again that the above calculation is intended more as an illustration of the issue rather than a fully verified calculation, although I'd be prepared to explain how I arrived at these figures.
Recommendations: OANHSS urges the government to make a strong commitment to reallocate resources to long-term care and to begin that process now so the impacts of changes in hospital and physician services are minimized. The current thrust to restructure the health care system needs to incorporate a clear indication of the alternative health services that we have to establish to enable the closing and reconfiguration of hospitals to take place. To follow the theme of best services for the best price, I believe that the following services must be strengthened now and the following specific measures need to be implemented:
(1) Strengthen and coordinate support services for the elderly living independently. This includes in-home services like homemaking, nursing and supportive housing.
(2) Enhance the funding per diem levels in homes for the aged and nursing homes while moving to a full level-of-care-based funding system.
(3) Develop specialized geriatric and psychogeriatric services that will be accessible to front-line services, both facility and community-based.
(4) Proceed speedily with implementation of a coordinated and integrated community long-term care system.
(5) Amend the user-pay system so that it's based on the ability to pay and takes into consideration both assets and income.
At this point, I'd like to speak to some sections of Bill 26 and put forward suggestions on amendments to the bill.
Looking at part I of schedule F, amendments to the Ministry of Health Act, section 8 calls for the establishment of the Health Services Restructuring Commission. We believe that critical to the success of this commission, and particularly its local and geographical entities, will be the commission's actual makeup. It will be important that the commission is comprised of a wide range of individuals who can bring both expertise and impartiality to the process.
We recommend therefore that a subsection be inserted that sets forth the expected makeup of the commission.
The hospital restructuring process appears to be a time-limited undertaking. The existence of the commission with powers as proposed in this bill is acceptable within the framework of the restructuring initiative but would be overly intrusive if it were to remain permanently in the act.
Therefore, we recommend that a subsection be added to set time limits on these expanded powers and to tie the existence of the commission to a fixed time frame.
Looking at the amendments to the Public Hospitals Act that are proposed in Bill 26, this provision proffers on the minister extraordinary powers. I, as a representative of corporations that operate as independent entities that are governed and have legal obligations, feel a bit threatened by such broad ministerial powers. As stated above, when there is a clear focus for these powers, we can accept them. In the long run, they may undermine the very foundation of the voluntary system.
We recommend therefore that a sunset clause for the expiry of section 6 and subsections 9(3), (5) and (6) be incorporated into the bill.
We also note that references are made to the "in the public interest" provision, and it appears in several parts of the bill. While the intent is probably understood on a hypothetical basis, in practical terms it's most vague.
We recommend therefore that a set of definitions or appropriate indicators of what would constitute the public interest be added.
Moving to the Independent Health Facilities Act, provisions of the amendments contained in this part raise some questions about the possible impact of opening up the health system to foreign-owned companies. This concern is partially based on two competing priorities that such companies are struggling with: One is maximization of net income; the other is the provision of best possible care. There may be merit in recognizing the prevailing interests of the public, and to maintain a high service standard in the independent health setting, some additional provisions to this section of the bill should be added.
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We recommend that section 21 of the bill, subsection 5(2) of the act, include specific references to indicators of quality services that have to be considered by the minister when deciding whether to authorize requests for proposals. Such indicators should include staff qualifications and professional certification. Similar provisions should be added to section 23.
Moving on to schedule G, part I, amendments to the Ontario Drug Benefit Act, provisions of this section of the bill introduce a prescription copayment system. We wish to raise a serious concern identified within our facility long-term-care sector.
About half of the 56,000 residents in homes for the aged and nursing homes have little or no income outside of the federal OAS and GIS pensions and Ontario Gains supplement. These individuals are left each month with, at most, $112. From this amount, they have to meet all of their personal needs in a facility. The impact of having to pay $2 per prescription will be tremendous on these individuals, particularly if they require several prescriptions, and I should note that these prescriptions cannot be extended for long periods of time. They have to be frequently renewed.
We recommend, therefore, that either there be an exemption for residents in long-term-care facilities who have no income or assets beyond the $112 a month from mandatory copayment or to allow appropriate funding to flow to facilities that provide care to these individuals.
In conclusion, the above recommendations for amending Bill 26 are offered within the framework of support to the initiative to restructure the health system.
This submission also drew your attention to the need to move quickly on the urgently needed changes in the long-term-care system that must go hand in hand with the restructuring effort to ensure that the health system in our province continues to be responsive to our needs and sets a standard envied by others.
The Chair: Thank you very much. We appreciate your presentation. We have about five minutes each for questions per party, starting with the government.
Mrs Johns: Thank you for your presentation. We appreciate your information. I'm interested in a few items you raised. With respect to long-term care and your statement basically that there needs to be a shifting of funds to long-term care, I would assume from that statement and from your comment about the restructuring of hospitals that you feel that restructuring of hospitals is necessary. Can you talk about that?
Mr Klejman: Yes. We see that as an integrated process. The discussion about the need to restructure, downsize hospitals, look at alternative methods of providing health services, has been in this province for a number of years. We agree with it. Some of our members operate hospitals in addition to operating long-term-care services, and they themselves have sought provisions to shift some of their own resources from the hospital operations to the long-term-care facilities. Unfortunately, current legislated and regulatory provisions prohibit them from doing that.
So we see the need to shift resources. We see the need to shift utilization from hospital services to services provided by other sectors within the health care system.
Mrs Johns: I'm also interested in your comments about the drug benefit plan. As I follow through in your numbers, I can see that there may be some hardship for people to be able to afford that. Have you run through a number of alternatives and kind of come up with it? I mean, obviously the status quo we have in drug benefits we can't stay with. We have to look for alternatives to move the health care on. Can you tell me what other alternatives there might be?
Mr Klejman: We actually are working with some Ministry of Health staff. We've had conference calls on this issue, looking at options, such as extended periods for prescriptions rather than limiting them to 30 days or 60 days, opening up so a prescription may last as long as the attending physician or a medical director of a facility feels that's an appropriate medication. We also have talked in the past about recycling methodology where medication that isn't used can be recycled through some sort of a properly supervised process. We've looked too at some concepts about broadening the concept of pharmacies that may be affiliated with local hospitals taking under their umbrellas a number of long-term-care facilities so we find some sort of a way of cutting some costs in providing pharmacists' services.
We haven't come up with specific recommendations. There's been a period of maybe five to 10 days we've had to discuss it, but we certainly would be very eager to look at some alternatives. The impact right now is a concern to us.
Mrs Johns: Thank you for your time. Do you want to ask him something?
Mr Clement: I'd like to ask Mr Klejman, from your perspective, is there a crisis in the health care system?
Mr Klejman: There is. There are two ways of looking at the crisis: One way of looking at the crisis is, if we leave the system as it is today, we don't have enough money to support it. If we try to change it, we have to then be consistent and comprehensive changing it. It doesn't solve the crisis to just deal with one side of the health system, dealing with utilization of physicians' services or hospital services. We have to, at the same time, offer alternative services, put in place alternative services.
We would very much like to see a three-year plan that talks about where the money that will be released from hospital restructuring or any other restructuring will go to plug the holes to pick up the demand that will be generated by maybe lost opportunities for people to use emergency rooms. They need to have alternatives to going to emergency wards in hospitals.
Mrs Caplan: Thank you very much. I appreciate it. It's nice to see you again, Michael. You've made some, I think, very important recommendations for amendments to the bill and I guess my first question is, did you have an opportunity to review this legislation with either the minister or someone from the ministry prior to their tabling it?
Mr Klejman: No, we have not.
Mrs Caplan: There was no consultation with you?
Mr Klejman: No. I can tell you I've been involved in this very enjoyable and challenging business for about eight years now and I have been -- maybe not as strong as I should be -- an advocate for pre-legislative tabling consultations with all the provincial governments that I've had the pleasure of working with. This is maybe a weakness I see now -- our parliamentary process in this province, that we are faced with something that's legislatively at the last run.
Mrs Caplan: Have you received any assurance from the minister that the $1.3 billion they are cutting from the transfer to hospitals is going to be reallocated to your sector? Have they given you an assurance, a time line, a plan as to how that's going to be accomplished?
Mr Klejman: I do recall a meeting with the minister that our association had in mid-October and we did walk away from that meeting with an impression that the funding will not disappear from our sector. That's why in our presentation today I said that we are going on faith, believing the minister and the Premier that they'll live up to that commitment.
Mrs Caplan: So your expectation is that the $1.3 billion that has been cut from hospitals will be reallocated in this coming budget for the health sector? That's your expectation?
Mr Klejman: Yes, we're looking basically at the plan. I don't know whether it's one year or two years, but look for a plan that talks about what will happen in the health system as an alternative to now our reliance on, let's say, hospital services.
Mrs Caplan: Just to point out to you, because I think you should be cautious and aware, the economic statement that was tabled by the Minister of Finance, the whole $1.3 billion was in the statement to do two things: one, to reduce the bottom line, which is this year's deficit expectation; and second, we believe that, given the tax cut implication which is going to cost them $5 billion in revenue, in order for them to find that $5 billion, they're going to have to take that from existing programs and while they promise to cut not one cent from the health sector, that $1.3 billion from hospital transfers and from health, plus the $225 million from the drug plan, plus the half a billion dollars, the reduction from $7.8 billion to $7.4 billion, is going to pay for that tax cut and their deficit reduction because they promised they would cut the income tax rate by 30% and balance the budget by the year 2001.
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We're going to be watching very carefully to see where they're going to come up with the money to allocate to long-term care and to other parts of health. The rumour is out there, and from very good sources, that the intention is to break up the Ministry of Community and Social Services and move those programs like children's mental health and others into the Ministry of Health -- I see you nod. Have you heard those same rumours, Michael?
Mr Klejman: Yes, over coffee.
Mrs Caplan: Does that give you concern?
Mr Klejman: We have concerns. We certainly are concerned because we don't see now clear paths as to how the money will be retained. We like to have both a mix of some serious scepticism and blind faith in our approach to our role as an association. We also have the need to believe that we will not be dismantled as a health system, because I think the repercussions to that in this province are just horrendous. Anyone in their right mind I don't think can conceive of that kind of a revolution taking place.
Mrs Caplan: My last question --
The Chair: Thanks, Mrs Caplan.
Mrs Caplan: No more time?
The Chair: No; too bad. Ms Lankin.
Mrs Caplan: That sounded like real sincerity, Jack.
Ms Lankin: Mr Chair, I wasn't even looking at you and I could hear that sincerity dripping as you said that.
Michael, it's good to see you again, and thank you for your presentation. I appreciate your cautious and constructive criticism and approach. It's in fact I think the way your association has always conducted itself in relationship to government and the ministry.
I think you have set forward some very specific amendments that I both understand and generally support. I want to talk about a couple of areas that perhaps you haven't touched on in amendments and see if you would be supportive if we were to put forward amendments of that nature.
You spoke about the need for the hospital restructuring to take place, and in fact it's more than that, it's health systems restructuring, but one particular focus is hospitals. I absolutely agree with that, and I absolutely agree that money needs to be reinvested into the community. I've said that more times than enough when I was minister and before and since.
Let me give you an example. Windsor: health systems restructuring, community process, DHC-led, lots of consensus, long process, agreement to go from four hospitals to two, a sense of what they needed to build up the other parts of the health system in the community, a commitment that the dollars saved, operating dollars from the hospital restructuring, downsizing, would go into that community and there would be the capital dollars available to physically change the hospital layout if it's needed.
This government has withdrawn its commitment to the community dollars being invested and the capital dollars. The Metropolitan Toronto District Health Council restructuring report -- all of its recommendations are predicated on the reinvestment of those dollars in the community. There's been a suggestion that the legislation should be much clearer in terms of the roles and objectives of the restructuring commission, its relationship to DHCs and community consensus reports, and a formula for reinvestment of dollars saved through hospital restructuring. When you give the minister all of these powers that that in fact be reinvested in the health system to ensure that we don't create kind of gaps that Ms Caplan and I fear are going to happen -- as that money, as it appears in the economic statement, is applied to the bottom line of the deficit and to pay for the tax cuts.
Would you be supportive of some kinds of recommendations that set out the powers of the commission, tie it to DHC reports, community consultation and see a formula for reinvestment of the dollars?
Mr Klejman: Without having a sense or seeing what the government is envisioning as the regulatory aspect of this legislation its --
Ms Lankin: You don't know either.
Mr Klejman: I think what I'd like to leave is an offer and certainly a willingness on our part to participate in the process that begins to set out the hows of implementing the restructuring. Certainly I have no reason to suspect from our contacts with both senior civil servants and the minister and parliamentary assistant that they are unwilling to talk with us about how to proceed through this process. I hope it starts soon, and if this legislation is a trigger for such planning and laying out groundwork, I think that --
Ms Lankin: Michael, does it not concern you that the commitment in Windsor for that reinvestment of the hospital dollars into the community has been withdrawn?
Mr Klejman: I wasn't aware of that. Yes, it does.
Ms Lankin: I hope your faith is well placed.
Mr Klejman: Any time we see money for alternatives to hospital services not being there, that, I think, is going to compound both the hospital situation and the services environment for those who are not in hospital.
The Chair: Thank you very much. We appreciate your interest in our process and your presentation tonight.
Mr Klejman: Thank you, and I admire your perseverance.
DAVENPORT-PERTH NEIGHBOURHOOD CENTRE
The Chair: Our next presenter is from the Davenport-Perth community health centre, Ruth Crammond. I hope I pronounced that right. Welcome to our committee. You have half an hour to use as you see fit and any time you allow for questions, we'll start with the Liberals. The floor is yours.
Ms Ruth Crammond: Thank you. I appreciate the opportunity to talk to you tonight. I'm sure this is a lengthy and somewhat drawn-out process for you, but we think the consultation process is really important.
Davenport-Perth Neighbourhood Centre is a multipurpose community organization that provides primary health care and social services in Toronto, so we're a community health centre and a neighbourhood centre. We provide programs for seniors, youth, children and adults in a low-income area of the city and we use a population health approach to provide services and programs that address not only the health problems of people as they present them, but also work to ameliorate conditions that cause bad health.
The area served by the centre is home to many immigrants and newcomers to Canada and many families with young children. The area has been very badly affected by the poor economy and the rate of unemployment is high. So this is not an unfamiliar situation to many of you, I'm sure.
The centre is run by a 21-member volunteer board of directors who are elected by neighbourhood residents. We work very hard to maintain community and local accountability at the centre and we think this is an important part of why our health services are effective. The structure ensures that the services remain accountable to residents. Voting members, for example, that elect the board of directors must be neighbourhood residents themselves and two thirds of the board of directors must live in the area that we serve.
Volunteers also play a very important role in the management of the centre, as well as the delivery of programs, and last year we clocked over 6,000 volunteer hours that are donated to centre programs and activities.
As a community health centre, we do support the need for reforms in our health system to improve the quality of care for the community within the context of limited resources. We are concerned, however, that the changes in the system shouldn't compromise the quality of health care or the principles of the Canada Health Act and, in particular, we're concerned about universality and accessibility with the kind of people we service in our area.
Although the bill affects our community in many ways, because of its magnitude and its complexity and the length of time that I've had to review it, I'm only going to comment on some of the aspects of the bill that relate to the provision of health care services and some areas where we may be able to bring some of our experiences as a community health centre to reflect on the possible impacts of the bill.
I first must also strongly support the message of the previous speaker that, as I said, we do support some of the hospital restructuring initiatives and recognize that there are other ways that health care can be delivered and more effective ways, and that we've been exploring those ways and continuing, through our association of health centres, to explore those ways with this government and with previous governments that have been looking at this problem and with the district health council in Metro Toronto.
The first section I wanted to talk about was schedule F, part I, section 8, and to state, as I'm sure many others have, that we believe the power granted to the Minister of Health and the Health Services Restructuring Commission by this section of the bill is extraordinary and we perceive that it exceeds the power required to effect reform to the health care system.
The amendments erode accountability and some of the checks and balances that are built into the system to ensure that a careful and well-planned approach to change and restructuring takes place. We know that the change needs to happen, but we're also afraid to lose the things that do work well in our health care system and we want the change to happen gradually and thoughtfully.
So if special powers must be granted, we recommend some of the following changes: That the Health Services Restructuring Commission should be given a specific purpose described in schedule F in order to ensure that this extraordinary allocation of power should be limited in scope and used only for the purpose of hospital restructuring.
We recommend also that the Health Services Restructuring Commission and the extraordinary powers granted to the Minister of Health should have a limited time frame imposed on them.
Subsection 8(8), which allows the Lieutenant Governor in Council to provide that only specified members could be able to carry out a duty or act on behalf of the commission, should be eliminated. We have concerns about one person being able to make significant decisions without having to consult at least with a group of others or to have some check and balance against important decisions that could be made.
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Schedule F, part II, the amendments to the Public Hospitals Act, is actually the section I'd like to talk about a bit more. The powers granted to the Minister of Health in this section we are concerned would undermine the function and structure of hospital boards of directors. The reason I'm speaking to this is that it creates concern for community organizations like ours as well in the voluntary sector. It creates some confusion about the role of voluntary sector organizations in the delivery of services and programs. Through the new legislation, the government will be creating two parallel systems of management of health services, which will lead to a lack of clarity about the channels of accountability and authority.
We realize the legislation addresses hospitals only in this case, but we are concerned that it does set a precedent for other organizations. As I explained before, we're managed by a voluntary board of directors, and these volunteers donate countless hours to the organization. In return, they understand that they have both the responsibility and the authority to manage the organization. As I said, they come from the neighbourhood and they then have ownership over the organization and feel they are accountable for the public dollars they've been entrusted to manage.
These boards act as a check and balance, both to us as the staff in the organization and also between the organization and the government. They provide a mechanism for residents to monitor the spending of public funds, and they promote community responsibility and involvement. This structure places decision-making at the local level and avoids the danger of inappropriate decisions being made by a large and distant bureaucracy. The government has influence in the organization through the conditions of its grants and its funding, which we must fulfil, and the board is entrusted to manage and fulfil these conditions.
In addition, the board can determine what contracts to accept or refuse and can also seek funds from the private sector, which we in fact do in our organization. If the government steps in to manage the organization directly, the boards won't be able to carry out their functions and volunteers may not continue to serve on boards like ours. I think it will take away some of the incentive and initiatives that the community members feel in acting on boards of directors if they feel the government can come in and mandate and change the mission or the constitution of the organization.
I think the government needs to decide whether it wishes to be involved in the day-to-day management and direct delivery of health care or whether it wishes to maintain a system that empowers voluntary board structures to manage and maintain and deliver the health care services.
We recommend that the government review section 6 of the bill to ensure that the current system of voluntary management will not be jeopardized through the introduction of this bill. In particular, we have special concerns about subsections 6(5), 6(6) and 6(7), which we suggest should be eliminated from the bill.
The next section I want to talk about, very briefly, is the Independent Health Facilities Act. We think this may have many more implications for us, but we're unclear yet about what these are, even the definition of what an "independent health facility" is. That may include community health centres. It may not. We're not clear on that and haven't had time to have some dialogue with the government to understand what that might mean.
But we are particularly concerned that the government could, under this legislation, select individuals and organizations to submit proposals for the operation of independent health facilities without necessarily putting that open to public tender. This, we believe, doesn't allow for fair and open competition. We recommend that all requests for proposals should be published to the general public.
We recommend that subsection 5(1) be changed to read that requests for proposals must be published in a newspaper of general circulation in Ontario. As I said, we're not sure about the rest of that section.
Schedule F, part IV, which I'm sure you've heard about from other people as well, the disclosure of personal information, is also another area of grave concern to us. In the newspapers, I read that the minister stated that this amendment would allow him to collect and use personal information for "purposes related to the administration of the Independent Health Facilities Act, the Health Insurance Act" and so on, and that it's necessary to address issues of physician fraud.
Community health centres do support the idea that an important part of health care reform is the reform of physician services and primary health care. We very much support that. However, we also think there are many ways in which the system of physician care can be reformed without infringing on the rights of individual patients.
Community health centre physicians, for example, are on salary, and work as part of a multidisciplinary team. The physicians are supervised by the director of the centre and accountable to the director and the team. We do peer review, where the charts are audited and reviewed by members of the team. All of these are conditions of working at the centre.
We also know there are many alternative methods of payment for physicians being considered at this point. We think models such as this could be put in place to ensure quality of care and the best use of health care dollars, rather than granting the minister power to go into somebody's chart and perhaps break some important issues of confidentiality.
So we recommend that paragraph 31 of subsection 42(1), which allows the Minister of Health to pass regulations prescribing conditions under which the minister may collect, use or disclose personal information, should be deleted. We also encourage the government to review alternative methods of physician payment as ways of improving physician services.
In summary, as I mentioned earlier, the complexity and scope of the bill and the short time frame for review doesn't allow me to comment further on the other sections. The most pressing concerns we have are with the provisions that grant extraordinary powers to the government and interfere with the abilities of local boards to effect their mandates. In addition, we're concerned about the amendments that jeopardize the privacy of patient records, which threatens the promise of confidentiality that has always been a really important part of our health centre's commitment to our clients.
I very much appreciate some time you've given me to speak. I also want to say that this process of consultation allows people with real experience in the field to bring these experiences forward to you so the implications of such far-reaching legislation can be better understood. I hope the government will consider the consultation in this spirit and understand that this process will likely create better and stronger legislation.
The Chair: Thank you. You've left about three and a half minutes per party, beginning with Mrs Caplan.
Mrs Caplan: Thank you very much. I agree with all the areas you've raised; I share your concerns. Of course, I also have concerns in a large number of areas you haven't raised. I appreciate that you haven't had a lot of time to go in-depth, but you've made an excellent presentation.
I'm going to focus on your last comments regarding consultation. Do you think more people should be heard on this bill, that it would help with the community's understanding, and also that the bill should be split into individual bills so people with expertise from different areas could come before the committee to focus on their area of interest and expertise without having to say, "I don't know anything about that other field," and rely on someone else to speak for them?
Ms Crammond: I can't comment on the numbers of people, because I'm not sure how many people will actually be presenting. I do find, though, that there is so much in the bill that having it in separate pieces would have helped a lot. I also think having a bit more time, and time not only for presentation but for dialogue. I do think that the intention of some sections of the bill are appropriate, but there may be implications to the bill that neither we nor perhaps the government have understood entirely. By being able to talk back and forth, we can have a better understanding of what that really means and perhaps improve the legislation before it's passed.
Mrs Caplan: You've said it very eloquently. There are hundreds of people who have applied to the committee who we will not be able to hear because there's not enough committee time to do that.
I did want to answer one of the questions you have. I asked the question about the implication for community health centres, because the legislation is not clear. The question I asked is, "Is there anything in this legislation that would preclude a community health centre, in fact a doctor's office or clinic of any sort, from being declared an independent health facility?"
I'm happy to share all of this with you, because I know it would take more time than we have, but it does say not only that CHCs, community health centres, can now be required to be licensed as an independent health facility if they are providing a service for which a facility fee is attached, and that there are some community health centres now that have independent health facility licences, but this legislation allows for new technologies to be included, so that CHCs could well be required to license, and the kinds of services they're talking about could include additional diagnostic services such as echocardiography, whole-term monitoring and EEGS.
So if you're doing any of that now or if you contemplate doing or wanting to do any of that, you would have to have an IHF licence, as required by the new amendments. Similarly, should any of that change in the future arbitrarily, simply because the minister believes it would be in the public interest, without any process, you could then be included in the bill. There are a lot of implications here that we all should be very concerned about, to know what the process is going to be.
I think you've made a very good point regarding the commission and the opportunity for micromanagement. One of the major concerns is that there is no process requirements in this legislation for dealing with those enormous powers of the minister, which he can then delegate.
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I just want to say thank you very much, and if you do have any other thoughts -- I hope you'll have the opportunity to come before the committee again in the future, but if you don't, please feel free to let us know other concerns you have, because people are just beginning to realize the implications of this bill.
Ms Lankin: We really appreciate your presentation. As you know if you heard the comments I made to the last presenter, I agree with your first recommendation that the restructuring commission should be given a specific purpose, that that should be set out so the extraordinary allocation of power is limited to the purposes we are able to debate and agree upon.
I also agree completely with the restructuring of the health care system and the movement of resources from illness treatment to health promotion and illness prevention, and from institutional care to community-based care where appropriate. What I worry about is the cuts happening on the institutional side and the reinvestment not taking place, and that's always been the struggle we have had, whether it be years ago with what happened in psychiatric hospitals and/or whether it be the most recent experience of what we've seen in Windsor where, after a concerted community effort to restructure their health system, the commitments were not there for those dollars that were saved to be reinvested.
You've raised a point which I have been very concerned about and have raised a number of times in the last couple of days, but there's so much in this bill that I think it's getting swamped by other issues, and that's the impact of this legislation on volunteerism and voluntary governance and the voluntary boards.
There are two sections of the Public Hospitals Act that are of concern. One is the new powers given to the minister to appoint a supervisor and the lack of process requirements around that appointment, and then the powers given to that supervisor, not just to advise the board, but to actually step in and take on the board's day-to-day operational requirements. There was always, with respect to certain things, if a hospital is under supervision, a requirement that the board get the supervisor's approval on certain things, but now it's the whole ball of wax.
More important than that, and you've hit it right on the head, in 6(5), (6) and (7) the minister can give his own direction directly to the board and the board must implement that. Irrespective of any other act, letters patent, bylaw of the board etc etc, it has to be done. Where is the support for volunteerism? I worry about that. You deal, in another part of the health sector, with community boards. Could you please just elaborate on why we have community boards and the role and the importance of it? I know the answer to this, but I think others need to hear this.
Ms Crammond: As I tried to outline in the presentation, for us in the health and community sector, our board acts to direct, to do our strategic planning, to identify our priorities, to tell us what's important, to set up the kinds of mechanisms for decision-making in the organization that they believe are important to maintain accountability. They're also accountable to make sure that the public funds they receive are appropriately spent, so it's also a check-and-balance kind of function.
What I think is also important in the health restructuring is that our community tells us what kind of health services they want provided. For example, we do a lot of obstetrical; we have a physician that does obstetrics. We focus a lot on pre- and postnatal care because our community has told us there are a lot of families with young children and that's the kind of program they want in our community health centre. Each community health centre looks different because they have voluntary boards of directors and those boards know what that community wants better than some of, perhaps, even the staff coming in or than the government would from a distance.
Ms Lankin: Do I still have time, Mr Chair?
The Chair: Would you like a little more time?
Ms Lankin: If I could have a little more time, of course I would like a little more time.
I will underscore the importance of that, because I actually believe that this is a minister who, at least as I have heard him speak over the years, has spoken in favour of volunteer boards and not undermining the role of volunteers, and in fact accused the previous government of doing that as we tried to create multiservice agencies, a group which would still be controlled by a community board, nothing like what we see in this legislation.
The other question I would have with respect to amendments that you don't touch on -- while you say we should set out the restructuring commission's specific purpose, I have also been working on and have felt that it's important to have an amendment that ties the role and the purpose of that commission to the kind of work that district health councils have been doing in local health care planning with the community consultation, so that these actions aren't taken just by the minister in absence of that community consultation-DHC health planning process. Would you support amendments of that type and can you comment on that?
Ms Crammond: Yes, I would. There has been some controversy, of course, with the district health council reports, but I think they have gone through a long process of consultation and made recommendations on that basis.
The Chair: Thank you very much, Ms Lankin. For the government, Mrs Ecker.
Mrs Ecker: Thank you very much for doing a very excellent presentation with I think some very good recommendations. I would just like to quickly touch on two points, that it's not the intent of this legislation, that the community health centre is not changing the role of what it's doing, not getting into high-tech diagnostic or whatever, that there's no requirement to be included under the Independent Health Facilities Act legislation.
The other thing I think it's important to note, and Ms Lankin referred to it a little bit, is that the minister and government very much understand the contribution that the voluntary sector makes to the health care system. We couldn't be carrying through on the implementation of all the restructuring plans that are out there, for example, in my region in Toronto and other areas, if it hadn't been for the work of the voluntary sector and the community health centres. It just quite simply wouldn't be there without the volunteer boards. So we quite recognize that and that's certainly not the intent of the bill, to replace that. If there are suggestions or recommendations on how we can ensure that is clear to communities out there, I'm sure the committee would be prepared to consider those.
What I would like to ask a little bit about is because you have, as you say, experience on the front line. One of the things that we've talked a little bit about is restructuring the system and trying to get some of the resources from the hospital-based area into the community care area. Has that happened at all yet out there? If it has, is it happening fast enough? Does it need to happen fast enough? Just some thoughts on how you see that happening.
Ms Crammond: That's a big question. We haven't seen it significantly. The number of community health centres, for example, was increased under the previous government, but not as many as we would have liked still. We don't yet see any real plans or any commitment yet to what's really going to happen in the primary care sector. There has been some review of it, but until that sector is really looked at, then we've only looked at the hospital restructuring, as the previous speaker talked about, without looking at what's going to follow it.
So there hasn't been a significant shift from the institutional sector into the community sector and we have great fears, as the beds close in the hospital, about what's going to happen, who we're going to see and how we're going to be able to manage that care as we talked about, as we're trying to move people away from emergency departments. We would need to be able to extend our hours, extend our facilities and that sort of thing and we don't have the resources. We've been flat-lined this year certainly.
We need to also talk and plan that together. We have been working with our local hospital, but we would need something bigger than that to be able to look at how those resources are going to be reallocated.
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Mrs Ecker: Excellent point. You've got physicians on salary at the centre. Is that working well and do you think that adopting that kind of mechanism on a broader basis within the system might help us in the underserviced areas, getting physicians out into some of the areas where everybody's been having difficulties getting that to occur?
Ms Crammond: Absolutely. I think if you wanted to talk also to more physicians who are on salary -- because I know that physicians as a group, you'd have to also talk to them, but I think you'd find that the physicians who are on salary are very happy with that arrangement. There are advantages both for the physicians and for the health clinics. I talked about some of the advantages for the patients and the clinics in that there's accountability, there's a team structure, so there's peer review. It's not such a closed sort of shop as it is when people are working in a fee-for-service. It's also a capped budget so you know every year what your expenditures are going to be.
As well, we think that in our neighbourhood, because we work with people who have many issues relating to poverty and health, often multiple health problems, people get the time that they need with the physician. They're not in and out in five minutes; they get a proper appointment. We also have a social worker on staff. We use nurse practitioners also, which I think is a really effective use of health care dollars. So a multi-disciplinary team approach.
The other thing is we find that many health problems are related to anxiety or other issues altogether, so we offer community programs in groups instead of having people go to the physicians. Our concern right now is with the Ministry of Community and Social Services cutting back on its programming. We think that more people are going to go see their doctor instead of going to the community club or the group that they used to go to, because they're going to need to go talk to somebody because they have anxiety and they're lonely and all of these other issues. So instead of going to a community service for that support, and perhaps a youth worker, they'll have to make an appointment with a physician who, we all know, is much more expensive and doesn't necessarily provide what people really need, which is community support.
The Chair: Thank you very much, Mrs Ecker, and thank you for your presentation. We appreciate your involvement in our process.
SCARBOROUGH PRESBYTERY UNITED CHURCH OF CANADA
The Chair: Our next group is from the Scarborough Presbytery of the United Church of Canada, Rev Dr Richard Magie and Rev Lorne Taylor-Walsh. Welcome, gentlemen. You have half an hour to use as you see fit. When we get around to questions they will begin with the government. So the floor is yours.
Rev Dr Richard Magie: I would like to thank you for the opportunity to be here this evening, and based on the conversation, the debate that was taking place in the committee when I arrived, I'm not sure whether I should be grateful to be among the chosen few or to be frustrated by the government's limitations on its ability to listen. However, I will choose the grateful route tonight because it has been a long journey just arriving. I don't mean that by way of miles. I think it's worthwhile reviewing some of the process that we went through prior to coming here.
When I was first given the half hour before the committee, that was before the finance committee, because it appeared that this was a bill that was intended to attack the budget deficit, and I believe I heard Mr Clement on the news last night giving that response to this bill. Then I was phoned to tell me that it was no longer a finance bill but it was a bill in general government and would I be pleased to take my half hour before this committee. Then I got another call saying, "Were you concerned about health issues or general issues, or what were you concerned about?" And I said, "Right now I'm concerned about a lot of things."
So, Mr Chairman, my comments this evening are not going to be restricted entirely to health issues, but will relate in some way to what I would perceive to be general government, which I believe is what this committee is about.
It is the business of the church to be concerned about the religious and spiritual needs of people. From the Christian tradition's point of view, moral behaviour is an expected response to the grace of God encountered in Jesus Christ. The entire study of Christian moral theology reflects the struggle to come to terms with our response to God in the way we live and organize ourselves as community and as family.
Dr Joseph Fletcher, professor of christian ethics from the States defines moral theology and moral behaviour this way:
"The essence of morality lies in the quality of interrelationships which can be established among people. Moral conduct is that kind of behaviour which enables people in their relationships with each other to experience a greater sense of trust and appreciation for others, which increases the capacity of people to work together, and which reduces social distance and continually furthers one's outreach to other persons and groups, which increases one's sense of self respect and produces a greater measure of personal harmony.
"Immoral behaviour is just the converse. Behaviour which creates distrust destroys appreciation for others, decreases the capacity for cooperation, lessens concern for others, causes persons or groups to shut themselves off or be shut off from others, and which decreases an individual's sense of self respect is immoral behaviour."
It is against this standard of moral decency that I am looking at Bill 26.
We have some concerns about this bill. Obviously, it is such a large bill, there are a number of issues that I do have to say that I would be able to support and be in favour of: arbitration, the borrowing provisions, and issues of that nature I find very little difficulty with. However, being as how it is all lumped into one barrel, we have to raise the issues within that legislation as we perceive them.
The first concern that I would like to raise before the committee is that it is our belief that through the process of democracy, the voices of all people can be heard and the common or collective mind can be discerned. When many of our people heard of the Common Sense Revolution, we somehow got the idea that it was this common mind that was being solicited. We believe that anytime the democratic process is diminished or interfered with, the common mind is obscured. The reluctance of the government to allow these hearings would be but one example of democracy interfered with.
More specifically, in schedule M, part 1, section 1, it provides that the minister may, by regulation alone, frustrate the democratic process of a municipality even to the extent of dissolving a municipality. This does not vary very much as I understand the legislation in the health side of the legislation.
The government is quick to claim that in the last election it consulted with the public and received its mandate. While in the same tone, I, as a municipal councillor, and school board members also received a mandate and that mandate was not to destroy, redefine or divide the community.
This bill, before it is even passed, has already created all-out turf wars among municipal civil servants who are now hatching up schemes to protect their own jobs using the Conservative catchwords of economy and efficiency. I believe in Huron county, Ms Johns, in your constituency, there are six different schemes currently being considered by municipalities where the townships and municipalities are looking at trying to structure themselves into one community while the county is monitoring these and discerning some way how they can survive as a second-tier government.
Concern 2: Under schedule M, 25.2(12) is the wording which places an order in council above "any act or regulation which with it conflicts." In fairness, the inclination to govern through regulation instead of legislation did not begin with this government, but what Bill 26 does is to push it to new and dangerous extremes. This practice cannot measure up to the standards of moral conduct required by those who give their consent to be governed.
Concern 3: In Bill 26, the Minister of Health is given the power to unilaterally remove unspecified health care services from OHIP coverage. This provision has two possible outcomes. Either the procedure will no longer be in the repertoire of treatment modalities or we are back to an extra billing process in a way which I believe has just recently had some negative press in the province of Alberta.
These measures may have an immediate result in saving money, but at what cost? When people with minimal life skills -- the sick, the emotionally fragile and the vulnerable -- find that their safety net is torn, they simply do not have the resources to object or to find alternatives. This action has the potential to put lives and health at risk, and consequently is not acceptable moral conduct.
Concern 4: The restriction to access on freedom of information. Mark 4:22 says, "Whatever is hidden away will be brought into the open and whatever is covered up will be uncovered." In this legislation, requests that are regarded as frivolous or vexatious can be denied. If a minister or agency does not wish to reveal some document or information, of course they're going to be vexed about a request to reveal it.
Government in secret, behind closed doors, where information is withheld, will always breed suspicion and distrust. When the people you were elected to govern withhold their consent to be governed, the result is usually some form of anarchy. Such a situation does not have to exist in a very large segment of society before democracy begin to crumble. One example would be the underground economy. You simply cannot govern if you are not trusted. When suspicion and distrust prevail, communication and understanding are diminished and social distance is expanded, and as a consequence, the measure fails the test of morality.
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Finally, we make four general recommendations to improve Bill 26, which are in your handout.
I would suggest, in addition, that since this bill is provided as a means by which the government intends to reduce its deficit, I would draw but one example of how absurd that can be when it is not well thought out.
If in fact the government were to act on the powers that are contained in this bill to restructure and realign municipalities, given the town of Goderich, with which I have some familiarity, and the townships were incorporated within the town of Goderich, you could save a considerable amount of money in duplication of services and you could save in terms of councillors, fewer representations on council, and there would be those immediate economies to the government. But don't think it's going to stop there.
We would then have to build a new pollution treatment centre, we would then have to build a new water treatment facility, and we would then have to begin to think about what it's going to cost to extend municipal services to a sparsely populated area in which there are enclaves of urbanization. So in the long run the costs of this kind of restructuring can overwhelm you without having any kind of vision contained in the bill of what shape that restructuring might take.
I would hope that at the very least, if you cannot act on the specific recommendations, this bill could be reduced into its component parts so that each of the parts could be negotiated on its own merit. That way, those parts of the bill which are commendable and which speak to the issues at hand can be acted upon quickly, as the Premier seems to want, and can be put into place, while the other areas which cause much grief, much difficulty and much division in community can receive the kind of debate that the democratic process would ask for.
The Chair: Thank you. We have about 15 minutes left for questions, beginning with Ms Lankin.
Ms Lankin: Thank you very much.
I'm just sitting here reflecting on your --
The Chair: Five minutes each.
Ms Lankin: I understood that was implicit in your directions.
I was just sitting here reflecting on the last comments that you made, again a plea to break the bill up and for appropriate time for analysis and public debate. Mr Chair, I'm just terribly frustrated with the results of today and the fact that government members on this committee defeated a motion which would have made such a recommendation to the government House leader. I suppose we will continue to try to convince them, and I am gratified and pleased that you put forward that point of view, and I'll leave that.
The actual recommendations you make, you know, it's very interesting. This speaks to the need for some time for people to understand what's going on. You talk about the change to structures and boundaries and services permitted by a municipality being done just by word of the minister. In fact, I understand that yesterday or earlier today -- the days are all running together -- there was a presentation by the Toronto board of trade at the other committee which supported the bill for that very reason that that was there, because they really believe we need to have GTA restructuring and they want to see it done. The bill doesn't deal with regional governments; it only deals with local and municipal governments. So the very reason they were coming forward to argue support for it in fact wasn't contained in the bill. People haven't had time to really understand it.
Your comments on how this sets a new standard in terms of governing by regulation instead of legislation -- I want to read to you from the Medical Times. This is an interview with Mike Harris, I guess just before or during the election. The question was that both the Liberals and Tories had pledged not to abuse ministerial powers, and this is what Harris said about it: "The trend in legislation, both federally and provincially, has been to place excessive regulatory power in the hands of ministers and the cabinet." And he asks this question: Who will punish the cabinet when the cabinet decides it's the law of the land? Yet he turns around and does this.
I think you've put together a cogent presentation with recommendations. I'm interested in your experience as a municipal councillor, as a member of the police services board and as a minister and part of the faith community. You must hear from a lot of people.
Dr Magie: Indeed.
Ms Lankin: Are you starting to hear from people questions about what's going on in this bill? I don't think people understand it.
Dr Magie: Most people, Ms Lankin, that I've talked to have not had the opportunity to review the bill itself, but it vexes me terribly to hear veterans say to me as recently as today, "I went to war 50 years ago to stop a man like this." That's the impression that is out there, and I think that kind of impression frankly is sad. I think there's a hurt, there's an angst, there's a sense of betrayal. And these are people who are not on the welfare system. These are people who are working and paying taxes and in some cases pensioners who are saying this. These are supporters, if you'll excuse me, of the Conservative Party who are saying these kinds of things, and there is a real sense of dismay.
I think the issue that I would highlight and that I try to portray when I'm approached in this manner is that there's no right-thinking person who would not acknowledge the fact that the deficit is a problem. That's a given.
Ms Lankin: I agree with you.
Dr Magie: But the ends do not justify any means of achieving them. In other words, a moral end, a proper end, does not justify immoral behaviour in arriving there. That is the difficulty that people are having to wrestle with. They want the government to bring down the deficit, no doubt about it, but they don't want them to do it at the expense of the values that they hold to be good and true. They do not want the province dismantled in the process.
Mr Clement: I had a whole line of questioning, but I'm going to throw that out the window to discuss with you your definitions, I suppose. You say in your paper that immoral behaviour is the converse -- your definition -- and that "Behaviour which creates distrust destroys appreciation for others," and so on. Then you tie that in to Bill 26.
Dr Magie: Correct.
Mr Clement: I guess reasonable people can differ on what constitutes moral and immoral behaviour, just as reasonable people can differ on the true definition of "dictatorship." One could make the argument, surely, that another form of dictatorship is a dictatorship, an enslavement, that is caused by such excessive government regulation and spending, trying to be all things to all people -- in short, the status quo -- which creates misery, creates over the past 10 years a doubling of spending and a doubling of taxes, and yet more people using the food banks, and yet more people on welfare, and yet more unemployed.
From our perspective, we think we are doing the moral thing by seeking to address the very wrongs which you seem to attribute to us. Would you like to comment on that, please?
Dr Magie: Yes. I attribute those wrongs to you, sir, because it's your government that drafted this bill. I did not in any way attempt to justify any other kinds of activities which would not meet the criteria for moral behaviour that I set before you.
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Mr Clement: Well, again we're on to definitions. But can you see at all the need to deal with the crisis that we now have in our province?
Dr Magie: I'm getting a tap on the arm, if I may.
Rev Lorne Taylor-Walsh: Am I permitted to make a comment as well?
The Chair: Sure.
Mr Taylor-Walsh: A lot of my training has been done by aboriginal people in this country, and one of the things is they said that the United Church of Canada was doing immoral things and things that were hurting people in communities, because they say we must take time to listen to everybody. So we could have made decisions within five days -- every meeting with native people, as you know, lasts for five days, which is great for a bureaucrat like me -- but we said, "We need to take time."
We took the time to visit every native community in this nation. Out of that time of one year came the apology from the United Church, came a whole renewal of the eldership, which in the province of Ontario was almost extinguished, and it has now risen to enormous spiritual power because we took time to listen and talk to one another.
The morality is, will we take the time to listen and discern the common mind for the common good? The whole meaning of that common sense is the common mind for the common good. We can't come to that unless we take time to listen. That's what we were pleading for in our presentation.
Mr Clement: I acknowledge your point. That's why, as a party, we took four years to listen prior to June 8.
Ms Lankin: Oh, please. Don't insult --
Mr Clement: I believe I have the floor, Mr Chairman. I'm not saying that I corner the market on this, but I certainly can speak for my riding of Brampton South, where I knocked on 20,000 doors and listened to my constituents.
Ms Lankin: Are you talking about Bill 26?
Mr Clement: From my perspective, what I heard from the people who got me here was that the status quo wasn't working; the status quo in fact was creating more misery than it was alleviating. They wanted a government that was going to institute real change so we could get on the virtuous circle, the circle of jobs, opportunity, wealth creation, growth, the social justice that comes from an economy that works. Would you like to comment on that, sir?
Dr Magie: Yes. I think there's an appropriate response to that, Mr Clement. I had a little boy in my Sunday school when I went up to the children's time about two weeks ago, and I said, "Guess what?" He said, "Jesus Christ." It took me by surprise so I looked at him and I said, "Excuse me?" and he said, "I'm sorry. I didn't hear the question, but I knew he was the answer to every question."
I seem to sense here that there is an answer in the government to every question, and that is that the status quo isn't very good and we need to reduce the deficit. I take that as a given.
Mrs Caplan: What I underlined in your presentation was a quote that you've just repeated, and I think it's worth repeating again: "We believe that through the process of democracy the voices of all people can be heard and the common and collective mind can be discerned."
I'm going to ask you once again to state your support for all of those people, and so far there are 232 people who have applied for 188 slots here in Toronto, and there are 396 people -- and organizations, I should say -- that have applied for 274 slots in the 11 cities across this province. We have not yet advertised. What do you think should be said to those voices that are being turned away and not being given the opportunity to be heard in this democracy?
Dr Magie: There are two levels of concern that I bring to this bill. One has to do with specific content, which is addressed in the brief. The other level of concern has to do with process. When the process of democracy is frustrated, that doesn't mean that it doesn't exist, but what it does mean is that it is being interfered with, and being interfered with because of the lack of presentation ability by people who wish to do what I'm doing here this evening, and that is to voice our concerns.
When that process is interfered with, the legitimacy of government is also interfered with. In other words, the consent of the people to be governed will be withheld, and there are many, many ways by which people do that, as this government and the two governments that preceded it have found out: the withholding of services, the withholding of taxes, the tax reduction and tax avoidance extremes that people went to, the citizens' coalitions and what not by which the processes of government were diverted.
When I went on a municipal council, one of the first things that was told to me was: "You've got to be careful with the laws you pass. You can pass legislation that says that people can only park on the sides of buildings. The problem is, who's going to adhere to it?" That's basically the problem we see here.
Mr Taylor-Walsh: Within the area of ministry, my specialty is conflict resolution and organization of renewal. Everything I have read says that whenever we tend to centralize control, the level of anxiety increases exponentially -- in everything. When we have an anxious public, the first thing we've got to do is to reduce the level of control so that people feel they have an input to the process, they can talk about how controls should be exercised. Then the level of anxiety goes down enormously and you can get creativity, you can get common mind, you can get hope again -- not struggle, not challenging people. So if my profession says anything, that's what it says to Bill 26: Reduce control, not increase it.
Mrs Caplan: In fact, this consultation document that Mr Clement refers to, where he personally knocked on 20,000 doors and discussed in detail, does exactly and talks about exactly the opposite of what Bill 26 is about. It says, "Less government regulation." This bill, as you know, contains not only broad, sweeping powers for ministers without scrutiny and accountability, but the most enormous regulatory authority that has ever been seen in one piece of legislation. This is centralization of government authority, not decentralization. So if that's the consultation they had and that's what they told people they were going to do, don't you think they should open the doors and let people come in and hear what it is they are planning to do?
Dr Magie: Yes, this is the season of peace on earth and goodwill towards one another. Please.
Ms Lankin: Mr Chair, may I suggest we might want to engage this gentleman's services in terms of conflict resolution and anxiety lowering. It might be helpful if we revisit this question among ourselves as committee members.
The Chair: We could probably use him in the Legislature. Thank you very much, gentlemen. We appreciate your words of wisdom and your appearance with us tonight and your interest in our process. Have a good evening.
Dr Magie: Thank you for listening.
PSYCHIATRY RESIDENTS' ASSOCIATION OF TORONTO
RESIDENTS OF THE CLARKE INSTITUTE
The Chair: Our next presenters are here on behalf of the Residents of the Clarke Institute, Dr Cynthia Lazar and Dr Joanne Sinai. Welcome to our committee, ladies. You have half an hour to use as you see fit. Any time you allow for questions we'll begin with the government. The floor is yours.
Dr Joanne Sinai: We are expecting another member, but we'll start and ask her to join us when she comes, if that's okay.
The Chair: Yes.
Dr Sinai: Good evening, honourable members. I am Joanne Sinai and I represent PRAT, which is the Psychiatry Residents' Association of Toronto. This is Cynthia Lazar and she is chief resident of psychiatry at the Clarke Institute.
What I am going to do is read out a letter that the PRAT executive has written to our Health minister, the Honourable Jim Wilson. What we would like to do is convey our deep concerns regarding Bill 26, schedule H, amendments to the Health Insurance Act, sections 29.1 to 29.7.
Our resident group includes over 125 young doctors in training in our five-year program at the University of Toronto. We represent a multitude of backgrounds and life experiences and we chose to train in psychiatry because we all feel very strongly about dedicating our careers to working with the mentally ill.
As you are aware, the mentally ill are extremely disadvantaged in our society. Many of them require long-term care as illnesses such as schizophrenia and bipolar disorder, which you may know better as manic depression, are lifelong. We are concerned that changes to the bill will disadvantage these people with psychiatric illnesses even further than they are already.
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It's our position in fact that limiting billing numbers in the "overserviced" areas and forcing doctors to relocate to the north would be very shortsighted. Contrary to what is implied by Bill 26, there are very many underserviced areas in southern Ontario. These include child psychiatry, geriatric psychiatry, forensic psychiatry, HIV and medical psychiatry, chronic care psychiatry, women's mental health and cross-cultural psychiatry. In addition, persons with major mental illnesses tend to cluster in larger centres in Ontario. Not allowing new graduates to work in the areas wherever there is a need, regardless of geography, will further disservice these populations.
The department of psychiatry at the University of Toronto is dedicated to serving Ontario's northern communities. We have a provincial psychiatric outreach program that has introduced many psychiatric residents to northern communities such as Kenora, Sault Ste Marie and Baffin Island. There are also University of Toronto psychiatrists who provide services to other northern communities, such as Timmins, Manitoulin Island and Peterborough. Residents will also be able to serve these additional communities in the near future.
Involving residents in this process allows us to become aware of practice opportunities in the north as well as matching us with excellent role models who already have an interest with working in that area. We believe that psychiatrists who choose to work and are suited to work in the geographically underserviced communities or domains are more likely to stay and provide a greater quality of care than doctors who are forced to do so.
We would ask that you would consider implementing the recommendations of the Scott and the PCCCAR -- the Provincial Coordinating Committee on Community and Academic Health Science Centre Relations -- reports rather than implementing coercive measures, such as billing number restrictions, to address physician resource issues. For example, developing re-entry programs for physicians practising in underserviced areas and promoting the use of telecommunication technology to link isolated health care providers with secondary or tertiary care centres have been suggested as solutions by the PCCCAR reports.
The omnibus bill also puts forth that physicians must have institutional appointments. In psychiatry, in particular, the focus is shifting from institutional to community care models, which can be much more cost-effective. The bill therefore would also limit the ability of psychiatrists to operate within a community setting.
I'd like to introduce Aileen Brunet. She's co-president of PRAT and she is now going to go over some of the points that I mentioned in further detail.
Dr Aileen Brunet: I would like to expand upon a few of the points mentioned by my colleague Dr Joanne Sinai. The subcommittee on underserviced area needs of the Provincial Coordinating Committee on Community and Academic Health Science Centre Relations, also known as PCCCAR, has acknowledged that people with psychiatric problems have difficulty getting the care they need in both rural and urban areas. It is our position that the implementation of Bill 26, particularly schedules F through I, will result in further difficulties for this vulnerable population.
Hospital restructuring, hospital closures and bed eliminations will significantly impact the provision of care to the severely mentally ill. For many of these patients intermittent, and occasionally prolonged, hospitalizations are necessary. There are no community services yet in place to deal with potentially dangerous and very ill individuals. To close beds without these provisions in place could have disastrous consequences.
Many of our patients are unable to live in the community, and options for them are shrinking. Conventional nursing homes and long-term-care facilities will often refuse psychiatric patients, and the proposed closure of long-term facilities such as Runnymede will limit their options even further. In a personal example, one of my patients where I'm working right now, the Queen Street Mental Health Centre, has been on the waiting list for the Runnymede chronic care facility for several months. He is not requiring the type of care that we have at Queen Street Mental Health Centre, but there is not room for him at Runnymede. If Runnymede closes, where will the patients currently there go? And then where will my patient go?
Proposed changes to the Ontario drug benefit program will also negatively impact on psychiatric patients. Many people with psychiatric problems are on social assistance and will have difficulty affording so-called copayments or dispensing fees. Our patients are often on a number of medications and may require frequent changes in order to achieve symptom resolution and to regain functioning and rejoin society. To place such an undue financial burden on an already disadvantaged population is essentially punishing them for their illness.
The proposals contained in schedule H of Bill 26 will also have significant repercussions on psychiatric patients and those who provide their care. Current psychiatrists in training have dedicated five years of post-graduate study to the acquisition of up-to-date skills that will enable them to appropriately the mentally ill. Many current psychiatrists in training have strong interests in working in areas and domains of practice that are underserviced.
I personally am hoping to have a career in forensic psychiatry, which is an area of psychiatry that is vastly underserviced in all aspects of the province. I also have been on several trips to underserviced areas that have been provided by visiting specialty clinics that our clinic has, to Kenora and to Baffin Island, and it's through this experience that I'm gaining exposure to more rural underserviced communities and acquiring an appreciation for what they need and how I can best serve that.
We believe that coercive recruitment and retention measures will not work. Both the subcommittee of underserviced area needs of PCCCAR and the Scott report on the issue of small or rural hospital emergency department physician services recommend comprehensive strategies to address the limitations of coercive approaches to underserviced areas health human resources planning.
Their suggestions include direct contracts, creating residency re-entry training positions for physicians from underserviced areas, providing increased visiting specialty clinics and promoting telecommunication links to secondary or tertiary centres to provide support to physicians in underserviced areas. Physicians will go to underserviced areas if reasonable recruitment and retention measures are in place to avoid the burnout which is the vicious cycle that has been occurring up to this point.
I think there are several other reasons why this bill could negatively impact on the care of patients, but at this point I'll stop and introduce Dr Cynthia Lazar, a chief resident in psychiatry.
Dr Cynthia Lazar: Good evening, honourable members. As you heard from my colleagues, as residents we have very major concerns about this proposed legislation. I'd like to personalize some of these concerns by telling my story.
I entered medical school almost 15 years ago at the age of 19. I'd wanted to be a doctor since I was three. Once I completed my medical school training, I did two years of a residency in internal medicine and then went into general practice in Toronto. I stayed there for five years. I have a strong sense of social responsibility, and this was satisfied by becoming an HIV primary care physician; it was quite gratifying. In 1991, when I entered the residency program in psychiatry, it was to improve my skills in counselling, to reconnect with academic practice and with the intention of returning to service that community, to alleviate suffering among people with HIV and AIDS. I've excelled in the program and certainly found my niche in medicine.
In these times it's impossible to be a resident and not have one's career choices be influenced by community needs. There still exist pockets of great need within this city. I've become interested in women's mental health and would like to return to serve those suffering with HIV and AIDS, and women as well. I've sought out training in two modalities of short-term psychotherapy to alleviate anxiety and depression. These are not widely taught yet in our program and I would like to be able to teach these short-term therapies to other residents.
Under the proposed legislation, I'd not be eligible to be remunerated for my work unless I have a hospital appointment. There's certainly no guarantee of this when under the proposed legislation there may be hospital closures. I'm interested in providing consultations to the north, but I don't think I would find a large HIV population in the north. I would really be at the mercy of the Minister of Health, who may decide that Toronto is overserviced and overlook these pockets of need.
Along the way over my 15 years of training, I've very happily married and had a child, and as a result I may not work full-time once I get out of my residency while I'm raising a young family. But I indeed would like to work. My husband has worked for 12 years in the same field, and his job could not be transported to the north. Unfortunately, we've made a very painful decision that between the choices of breaking up our young family to pursue both careers or giving up one career, mine would have to be sacrificed.
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Four years ago when I gave up my general practice in order to enter the residency, I did expect to practise in the city in which I was born and raised and have worked for all my adult life, the city in which my son and husband live. I think this was a reasonable expectation four years ago, let alone 15 years ago when I entered medical school. I don't expect people to feel sorry for me, and it's not a harangue for pity. I don't pity myself. I feel extremely privileged, even if I'm anxious about my future. I'm not in a position to be pitied when there are people in this province who are suffering greatly under financial burdens and living with debt.
However, I think it's a great waste to see my 15 years of training go unused. I'm a very expensive resource that's been dearly paid for by the people of Ontario, and I do think that I would like to offer my services. I don't see myself as such an exception among the residents. Most residents have trained for many, many years and entered medical school in a very different climate, with different expectations.
The psychiatrists and residents that I work with are, for the most part, an altruistic group. Somehow our governmental and societal view of doctors has changed greatly. Personal physicians seem to be preserved as exceptions, while the profession as a whole is painted as malevolent mercenaries and fraud artists.
I hope my story will serve to change some of this view. My concern is that with this wide and sweeping legislation, the Minister of Health has a very blunt instrument that may waste our precious resources without solving the problem of servicing the needs of the north.
Our profession will suffer greatly by sacrificing its young. Health care will suffer by not using its newest doctors. Psychiatrists and psychiatry residents understand the need for reducing health care costs. However, young doctors should not be sacrificed. We've waited many years to practise, and we're eager to alleviate suffering in the community that has supported us in our training.
The Chair: Thank you. We have about four minutes per party for questions, beginning with the government.
Mrs Johns: Thank you very much for your presentation. It was indeed insightful and I can't help but feel sorry for you, to be honest. I have young kids too and I know it's a difficult time when you have to look at different alternatives to things that you've planned before.
I just want to talk in general about doctors for a few minutes, because you've raised that issue about doctors, and I want to tell you the dilemma that we have as a government. I come from rural Ontario, and it's grouped with northern Ontario, and basically I believe there's a two-tiered health system in Ontario. The two tiers come from some people having doctors and some people not being able to have doctors.
We've had a problem in Ontario for 26 years that some parts of Ontario do not have doctors, and governments of all political stripes have not been able to solve the problem. It's a big issue. I feel strongly about it. I ran, as part of my campaign, on the fact that there had to be an ability for all people to have available to them health care services, doctors, emergency rooms, which we do not have in my community because it's underserviced.
Out of eight doctors that come out of medical school, one doctor goes to rural or northern Ontario, seven go to overserviced areas. We can't continue to follow on in that process. So what we have said as a government is that we need a window of opportunity to ask people to change the system, maybe have rural and northern practices in the first two or three years of your residency so that you have time to see what goes on in northern Ontario or rural Ontario, and it allows you an opportunity to see us. We're asking for that window to allow all people in Ontario to have health care.
We talked about 6,800 beds being eliminated, but no hospitals have closed. I just want to talk about the need -- in the document it says "specialists." We would like specialists to be tied to a hospital. Why do you not see yourself as having a need to be tied to a hospital, or do you see that? Any one of you is fine.
Dr Lazar: Okay, and then Aileen Brunet will get a chance to comment.
For me personally, I would like to be tied to a hospital, but I see that in psychiatry overall it's a problem. As there's been a push to reach the needs of the community and move out into the community, tying every psychiatrist to a hospital would be a regressive move against this push. Outreach programs do better when they're not tied to a hospital, when they're actually tied to community resources such as the outreach program at Seaton House.
So for me personally, I would be very happy to be tied to a hospital, but there's no guarantee. The most obvious hospital for me to be tied to with women's mental health would be Women's College, which is slated for closure. With the number of hospital closures that have been suggested, those hospital appointments will be few and far between and anxiously sought after, and certainly not every specialist will be able to get one.
Dr Brunet: My comment is just that although, on the face of it, it may appear reasonable, I don't think the purpose of it has been clearly explained to us, other than controlling the number of billing numbers of physicians. If it's made mandatory that we have to have a hospital privilege, and then the government legislates the number of people who get hospital privileges, that restricts the number of people who can work.
I would just like to qualify that some of the areas that are referred to as overserviced, I think we've tried to make the point, are not. Anyone who tries to find a psychiatrist in Toronto must wait a long time. I agree the north is underserviced, I agree we need to do something about that, but I think to create a north-south dichotomy is an error. There are a lot of people who do not get services in the south, and particularly with psychiatry, which is what we want to talk about today, people with mental illness tend to gravitate to these areas, particularly severe, chronic mental illness. This is where they are; it won't do them any good to make us go north.
Mrs Caplan: I think you've put your case extremely well for the unmet needs in areas that may be overserviced in some respects. Certainly there are within that bigger picture areas of special needs. That's why, frankly, I think the whole billing number scheme is wrong. It's unnecessary to solve the problems. I do think that affiliation, whether with a hospital or a facility or a program -- and I would hope this legislation would be amended to include programs so that you could have the affiliation with a community.
The notion of being affiliated I think is important in the development of a system, but I don't think you have to say you must have hospital privileges or that you must be with an independent health facility. I do believe that if there are mental health programs that you could be affiliated with in an area where perhaps there is a surplus of family doctors, we could accommodate the needs of the community, whether it was the needs of severely mentally ill or HIV patients, or whatever the identified program requirement was, to open up opportunities for the new and the young.
God knows, we need the expertise and the skills that you and your colleagues bring. I believe, and I'm a former Minister of Health, that billing numbers not only are wrong and unfair, but they're the wrong solution to the problem and there are better solutions that have been proposed. One of those, frankly, is starting to look at the practices of retirement planning and that sort of thing that will open up new opportunities for the new graduates that we've got such a large investment in.
So I share your concerns. Frankly, I predict that he will remove the billing numbers from this legislation, because nowhere did they ever say that was what they were going to do. I think if they are convinced of nothing else, I'm hopeful that they will be convinced that there are far better solutions. Nobody wants to be treated by a doctor who is forced to work in the community; nobody wants to be looked after by someone who doesn't want to look after them. That's not good, quality care.
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I did want you to also comment, if you would, on the effect of copayment, the user fee, for drugs. We've heard from other psychiatrists that your patients will be disadvantaged, particularly the ones who have compliance problems or potential for suicide, where drugs are given out on a very limited and restricted basis, perhaps some who also have very small comfort allowances available to them. What will be the impact of the user fee that is being imposed by this government?
Dr Sinai: I can respond. Many of our patients, if they do have housing, are in situations where the person who runs the boarding home or the group home has full control of all the funds that come in. They provide them with housing and three meals a day and they often get as little as, say, $10 a week as a comfort allowance. The points brought up about our patients often being non-compliant, having to be given repeat prescriptions at times and also those who are suicidal only being given a limited amount of medication at a time are very real.
In addition, because often they become drug-resistant or often it takes trials of several types of medications before you can treat someone adequately, this is a population where we do expect that we will be changing prescriptions rather often at times, and also that there will be a need to use a pharmacy more often than with other types of patients. Our patients just don't have that extra cash to be able to go to a drugstore and pay $2 every time they need to get a prescription.
Ms Lankin: I think you put your case forward very well and it's very understandable. I'm going to use this time just to tell you a little bit about what I've been hearing as these committee hearings have gone on, and what disturbs me. It's primarily things that I hear the members opposite saying and, with all due respect, Ms Johns, I don't mean to pick on you tonight --
Mrs Johns: You've been doing it all day. Go ahead.
Ms Lankin: -- here I am again. I find myself really frustrated by the things you say, because it sounds to me like either you're saying them quickly and not thinking or you don't understand what is actually happening currently in the Ministry of Health.
You just told these three young doctors that all you were asking is for them maybe to go and do a little bit of time of their residency in northern or rural Ontario. That's not what this bill proposes. Let's be direct with people in terms of what powers we are giving the minister to restrict access to billing numbers and to indenture people to different parts of the province. Be clear. We already have a program in this province to encourage residency placements in northern Ontario. That's been in place already and it is something that needs to be built on; it hasn't done enough. So don't suggest that's what this bill's doing.
Mrs Johns: I'm not.
Ms Lankin: Those are the words I just heard you say. Yesterday, I read from Hansard that you said that previous governments' policies in terms of underserviced areas meant that there were problems with emergency rooms. It was the governments' policies; you were lucky to have emergency rooms open. Then with another group, you told them that the minister said he's not going to use this power for a period of time, he's going to get people together and work through this and see if we can find alternatives. But you're still passing draconian powers in legislation.
Let me tell you what Jim Wilson, then Health critic, now Minister of Health, said to the previous Minister of Health on Bill 50, which had minor things in it compared to what's in this bill with respect to doctors. He says, "The minister says in her remarks this afternoon, `Oh, it's a fail-safe bill. We won't use it. It's simply a gun to the head of the physicians and other health care practitioners out there who bill OHIP. It's a gun to their head to negotiate with us at the table. They're the powers we think we need to bring health care expenditures under control.'"
He says: "I find it ironic, because you're at the table with the physicians. You don't know what agreement you're going to come up with," as you work through these issues and you all sit down, as you referred to, "but you seem to know what draconian, closed-door cabinet powers you need. You're ramming this bill through the Legislature."
That's what I would suggest your government is doing. I would say your minister's words should be thrown right back at him. I'm sorry to have used the time this way, but I have heard what I think is an incorrect interpretation of the legislation with respect to these powers several times now and I think it needs to be clarified.
I have one quick question for you. I understand that there have been other representations made to the Ministry of Health over the past period of time, trying to get it to understand the issues you raised of underserviced specialties like women's mental health or ethnocultural mental health. Do you believe there has been any progress made on that? Have any of those areas been added to what this government intends to define as underserviced areas or underserviced specialties?
Dr Lazar: I think you realize, because the wording is quite vague within the bill, there is no guarantee that that message has been received loud and clear by the government or any true acknowledgement that those are pockets of underserviced need in our community.
The Chair: Thank you, ladies. We appreciate your interest in our process and your presentation tonight.
Our next presenter is Pam McConnell. Not here? We'll have a five-minute recess.
The committee recessed from 1956 to 2007.
PAM MCCONNELL
The Chair: Pam McConnell is a Toronto city councillor. Welcome to our committee. You have half hour to use as you see fit. Any time that you leave for questions will begin with the Liberals. The floor is yours.
Ms Pam McConnell: Thank you very much, Mr Chair. I want to say, first of all, I'm sorry I was a few minutes late. I was at a community event today before I came. I was at an event at St Paul's Church, and the children at St Paul's Church were doing the Nativity story as they're a Christian church. As part of that, they were doing the birth of a child in Regent Park. They're calling their play Sleep in Heavenly Peace.
I would say that part of what their message was today, and certainly in terms of some of the highlights of the things that they thought was of concern in the year, I was a bit surprised to hear that, along with the assassination of Rabin and the explosion of nuclear devices in the South Pacific, one of their disasters of the year that they read out from the newspapers was the cuts of your government. In that vein, I felt it was a good opportunity for me to reflect on the needs of my community, and that's why I'm here today.
I will be speaking primarily on the health-related matters of the bill, but I wish to add a few more comments on the more serious implications of the other aspects of the rest of the bill.
I believe this bill should be broken down into some logical components, perhaps four or five sections, so many of us can begin to address some of those questions as well as have some of our community understand what is before them. There should be sufficient time for the public to interpret what is really meant by each section so that the meaningful responses and the proposals for amendments could be made through hearings throughout the province.
This process preferred by the current provincial government I find quite disgraceful, and I find it very contemptuous of the public, and particularly of my community.
I am tonight representing my community and I also wish to echo the recommendations made the day before yesterday by my city council through the presentation made at the other subcommittee by my colleague Councillor Kyle Rae. This week, Toronto city council, I'm sure you know, approved a motion opposing your bill, asking for the bill to be broken into parts, asking for further public hearings in January for the Toronto area and asking that the health-related schedules to this bill be deleted.
I represent ward 7, as I have explained to you. It is the east downtown area of the city of Toronto, in St George-St David riding. This area includes my Cabbagetown, my Regent Park, our Moss Park and our St James Town areas, which I'm sure most of you know, among others. The communities in my ward are being very seriously affected by the actions of this government. Recently, it was calculated that in St George-St David riding alone $13 million annually was clawed back from the social assistance recipients living south of Bloor Street, and not so coincidentally, approximately $13 million annually in tax rebates is expected to flow north of Bloor Street to the better-off residents of Rosedale and Moore Park.
My ward has many working poor, and they live in private rental housing, non-profit housing, cooperative housing, as well as public housing. In recent weeks, we have learned that all three forms of this affordable housing are being threatened by the Progressive Conservative government. Tenants are worried sick, as I heard tonight, about losing their rent control. The residents of non-profits and cooperatives have been told to expect cuts in their subsidies and possibly a loss of some of their rent-geared-to-income units, and large meetings of public housing tenants have been held to discuss rumours of selling off their buildings.
Believe me, it is no exaggeration to say that my community is sick with anxiety, a feeling of helplessness and real effects, some of which are the experiencing of cold, of hunger and now of dispossession.
This week, I was very proud of the actions my city council took to set up the multimillion-dollar "survival fund" which will attempt to compensate for some of the devastating impacts of your provincial cutbacks to the most poor, to the most vulnerable of my city. We will concentrate on hunger and, in particular, on children and shelter and support programs for our homeless. My ward has the highest concentration in Metro of inner-city schools, of public housing, of school food programs and, of course, of shelters and drop-ins for the homeless.
It is against this backdrop, and my concern for the health of my community, that I wish to assess some of the impacts of the omnibus bill. I am not an expert in health services or legislation, and due to the serious lack of time or coherent explanation of the bill from the government, I can only react to what these provisions seem to imply. I am, however, an expert on the needs and the health of my community, and I have represented this community as a school trustee and a councillor for 13 consecutive years.
I do not have the luxury of thinking of this solely as a bill to provide "the tools for restructuring," as though it's not real flesh and real blood and that it won't really hurt people. Neither can you, as committee members, afford to think of some of these measures in isolation from the cumulative impact on the poor and the vulnerable of all the economic pressures and the other provincial actions and all the cutbacks.
With regards to schedule F, the Independent Health Facilities Act and the Public Hospitals Act, subsection 6(3) of the section of this act, which currently requires that government preference would be given to Canadian-owned and non-profit operators of health clinics and facilities, should not be repealed.
This goes against everything that we, as Canadians, have come to expect in our health care system and is not at all what is promised in the Common Sense Revolution. The bill would remove the requirement for tendering, which ought to be an integral part of the so-called competitive profit sector. But my reading of the other clauses amending this act increases my horror at the trend that is emerging: the insight into the direction this provincial government is heading and the power it's giving itself to get there quickly, without any public scrutiny, without any public debate.
As I understand it, the minister will be able to define almost unlimited types of health services as being subject to a facility fee. User fees of any and all descriptions could be charged to certain types of persons, to certain types of health services, at the whim of the minister.
Taken with the other changes to the health facilities, the only conclusion one can draw is that we will be well on our way to a very serious two-tier health system. Questions must be asked about the Americanization of our system and about the preference the government may give to the profit-making health facilities, about the extra user fees, and perhaps even the competition that would be set up against the community health centres.
In my community, as you know, Regent Park Community Health Centre has been serving the community for nearly 25 years. It takes a preventive approach to health care. It provides a more holistic approach to health services and is sensitive to the community -- our community -- it serves. And yes, it is less expensive to provide health services with doctors on salaries. Will it be forced now to charge user fees for some of its services, or will the private health clinics, without being tendered, be encouraged to compete with our health centre, providing fewer integrated preventive services? Will future funding of our centre be curtailed so that it is not unfairly subsidized as a competitor? What will the user fees be and what will they be for?
In relation to the powers of the minister under these amendments to close, merge, direct the services to be provided by the hospitals, without public review, I find this very scary. We all know that from time to time our health service needs a bit of review and that institutions and approaches need changing. However, Canadians feel ownership and pride in their health centres and their health system. They expect to be consulted, and they have participated in local health councils, in hospital communities and in local health centres.
Recent discussions about the Wellesley Hospital and the Central Hospital have created strong reaction in our community. I should tell you that when I was holding a petition on Parliament Street -- and I know many of you have done that yourselves, tried to solicit people to sign things, and many walk by and others of the faithful come up and put their name on it. When I held this petition on Parliament Street, people lined up. There wasn't anybody who walked by who didn't sign for the Wellesley Hospital and the merger with the Central Hospital. That's how important hospitals are within our communities.
It is not that one can say nothing should change. Of course things should change. But our health care system is too important to be regulated solely by bureaucratically driven decisions made behind closed doors.
With regard to schedule G, the Drug Benefit Act and the Prescription Drug Cost Regulation Act, the deregulation of the drug prices will affect every member of my community, yet the majority are not in a position, in any way, as I have explained to you, to pay higher drug costs. No one believes that prices will generally go down, and if they weren't likely to go up it wouldn't be welcomed by the drug industry.
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Seniors and social assistance recipients will have to pay more for their prescriptions. Maybe if there was more time to do this carefully, there could be some agreement reached on the well-off seniors paying deductions for their drugs, but the automatic user charge per prescription penalizes those who cannot afford it. The poor cannot afford to pay user fees for their drugs this year. Next year, with the loss of income, possible housing pressures, the cumulative effect of other cutbacks and the general user fee increase, where will the sick be getting the extra funds for the drug user fees?
With regard to schedule H, the Health Insurance Act and the Health Care Accessibility Act, "medically necessary services" was an important part of the definition of insured services. It is very disturbing that Bill 26 removes that reference to the medically necessary services and gives the minister power to unilaterally define what is insured and under what conditions. The minister will be able to differentiate based on the type of health care provider or the type of health care recipient.
The amendments to the Health Care Accessibility Act provide that hospitals can charge fees for services to people who are insured and the government can allow charges for services that are currently insured. Combined with the concerns I expressed under section F, I fear that residents of my community could have to pay more for certain sorts of health services at the very time they cannot pay their rent, cannot feed their children.
The other matters in Bill 26 that concern me with regard to health are in schedule M. The general trend towards the privatization of public utilities without adequate public debate, in my opinion is not acceptable. Decisions of such import as this should not be made in a hurry, and the quality of the decision-making will deteriorate in direct proportion to the extent to which the public are considered extraneous to the process. The omnibus portion of this schedule which amends subsection 220.1(2) of the Municipal Act to allow for unfettered user fees and permit direct taxes such as poll taxes needs no further comment from me other than to say that this has simply got to be deleted from the bill.
User fees that are limited and appropriate have their place in municipal financial matters, but this bill makes an ideology of user fees, and most of my community cannot afford any of those user fees. Library, community services and other services are essential to the health and to the civility of our communities. We need a more thoughtful approach. It is not acceptable for a provincial government, with a bill bent on downloading as much of its costs and its responsibilities as it can, to play innocent and then to say it's up to local municipalities to decide on user fees. The fiscal pressures have a way of taking away our freedom of choice.
In closing, let me thank you for the opportunity of speaking to you and to tell you the general views I have with regard to Bill 26. However, the thing I would most like to leave with you is that this may play out differently in different communities, but in my community, which has already been hit and where children are singing in their Christmas pageants about the cuts in their parents' cheques and the soreness in their bellies, this is not a time to be adding additional costs to these families. These additional costs will not permit many members of my community to survive. Thank you, Mr Chair.
The Chair: Thank you. We have about 10 minutes left in total, so it will be about three minutes each, beginning with Mrs Caplan.
Mrs Caplan: As you were speaking I was thinking about some of the phone calls I've had from people in my community. Oriole riding has the same broad socioeconomic communities that we see in this province, everything from luxury condos to expensive and middle-class family homes, and we have the highest percentage of high-rise and high-density, multiple-family buildings. In those buildings are people who are suffering.
I told the story a couple of nights ago about a call that I had received from a constituent who had been looking for work for 15 months, had three children and he was paying $900 a month in rent, not an exorbitant amount for a family of five in Toronto, but it constituted almost 70% of the money that was available to him. He told me that he and his wife were surviving on sugared water for one meal a day so that their children could eat better, but they were out of food and they were too proud to go to a food bank.
I don't think the people of this province are aware of the suffering that is out there. These are people who will be required to pay for prescriptions when their children are sick, and if this bill goes through and the municipality brings in user fees for recreational services, their children will not be able to participate.
I don't think that people understand the broad implications of this bill, and that's why one of the requests we're making is to have the bill divided and allow for greater scrutiny. One of the concerns I have is the level of frustration that is out there when people can't be heard, when they can't come to a city council, when they can't come to a legislative committee.
For everyone who comes, like yourself, there are hundreds who are afraid to come, because many of the people who live in Oriole come from countries where they were fearful of government. So they phone me and they don't even want to tell me their names; they want to tell me their story. I try to assure them that they have nothing to be fearful about, and then they read about the implications of this bill.
I just want to ask you, what do you tell them when they call your offices with these stories, Pam? What advice do you give them?
Ms McConnell: It's very hard, Elinor.
Mrs Caplan: It's very hard.
Ms McConnell: It's very hard, and I don't think people understand that we are going from meeting to meeting, from place to place, and people are crying. I've represented this community for many years. It's always been a poverty community.
I recently had a meeting down in Moss Park and someone was explaining something with regard to something totally different and suddenly burst into tears. I knew her. She was 65 years old. Afterwards, I hugged her and I said: "Are you all right? What's the matter?" and she said, "Pam, I'm $300 behind in my rent and I have no way of catching up." This is a member of my community who has lived in my community, who has brought up three generations of kids in my community, all good kids. But when people get behind, they are unable to do this.
What concerns me is not just the individual little pieces of all of this. Some of it is housekeeping, sure, but the massive implications of what happens when you do this to people who are already up against the wall is that you cause serious mental health concerns. I have much more concern within my community. I worry about the children and their bellies. I think, okay, it's hard. We'll focus our money and we'll do that; somehow we will manage to do that.
But what we cannot stop from happening is the worry that the mothers and the grandmothers and the grandfathers are having in our community, and it's killing them. So that's what concerns me about the mental health concerns.
The Chair: Mrs Caplan.
Ms Lankin: You did it again. I don't even have to look at you and I know you did it again.
Mrs Caplan: You do not wish to give me your time?
Ms Lankin: No, you can't have it, Elinor.
The Chair: My apologies. Officially, on the record, my apologies. Ms Lankin.
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Ms Lankin: Pam, thank you very much for taking the time to be here for your presentation. Too often when we debate these sorts of things through the Legislature or through the political forum -- it almost doesn't matter what level of government it's at -- it is too easy for all of us to engage in a forum for just partisan batting things back and forth across the badminton net.
I fear that something has happened over the course of the last few months here. I believe, in an attempt to have an honest assessment of it, that there is a government that has a very strong sense of where it wants to go in their agenda and that it has moved very quickly to put a lot of, as they call it, tools together in an omnibus bill. I think that through this, the left hand didn't know what the right hand was doing. Various departments of various ministries were putting together things at breakneck speed.
Overlaid on top of that was an agenda from the centre of government and the result is a patchwork, a mishmash, not necessarily compatible from one section to the other. There are errors and there are omissions and there are problems and there are things that I believe the government even intended to do that I would argue are wrong in content.
I think this is what happens when you move very, very quickly, and not just this bill, but the economic statement that was the backdrop for this bill, the decision around the welfare cuts when there's been no training put in place. There is no hand up that the government talked about. I believe that they wanted to do that, but they didn't do that. It's all moved too quickly.
I guess I'm taking the opportunity of your presentation, because I think you speak very eloquently on behalf of a community that is affected in a very profound way by the cumulative effect of all these things. I take this opportunity to say to people, make your government slow down and think about it. Talk to your cabinet ministers. Have cabinet rediscuss this. Have another discussion at caucus about this.
Pam, earlier tonight we tried to move a motion to extend things.
The Chair: Ms Lankin, I'm going to have to interrupt you because you've used up your time.
Ms Lankin: I'm sorry. I just want to thank you very much, because I'm profoundly moved by your presentation on behalf of the people of your community and I appreciate you being here tonight.
Ms McConnell: Thank you very much.
The Chair: Okay. For the government, Mrs Ecker.
Mrs Ecker: Thank you very much, Ms McConnell, for your very sincere and heartfelt comments. I don't know whether this is going to turn into a question or whether this is going to be a bit of a response to Ms Lankin's comments.
I don't think anybody has a monopoly on caring for what's happening out there in our province right now, but at $1 million more an hour that we're spending on interest, on the debt, than we take in, that's a serious problem. That's a million bucks that you could do an awful lot with in a health centre in your community. That's a million bucks that we could do an awful lot more with for welfare recipients. But we haven't got it because it's disappearing off to the money lenders.
Mrs Caplan: In the tax cut.
Mrs Ecker: It's disappearing off to the money lenders. That's something we believe we have to stop, and the only way we're going to stop it is by starting to look at government spending that we are doing here, and that means there are going to have to be changes. They are changes, and that means they're going to be difficult changes, and there are human consequences to those changes. I think we all recognize that.
But if we don't do that now, when? When are we going to do it? You're saying we're moving too fast. All you have to do is take a look at the growth in the expenditure of the debt. How much more time do we want to waste in terms of trying to make some of these moves to try and preserve the funding? It's not a question of the status quo versus a reduced welfare cheque; it's a question of a reduced welfare cheque or no welfare cheque, because that's what we're facing here.
Ms Lankin: Why are you doing the tax cut then?
Mrs Ecker: Because a tax break for the working poor and the middle class is going to be the only break they've had in the last 10 years, Ms Lankin.
Interjections.
Mrs Ecker: It's the only break they're going to have.
The Chair: Ms Lankin and Mrs Caplan, I believe that people in the government allowed you to have your say with no interruption. I think it's only fair that you do the same for them.
Mrs Ecker: Ms McConnell, one of the things that you've talked about is the importance of volunteer involvement, community involvement in health care, for example. I don't think you meant to, but you seemed to pass over a little bit the need for restructuring within the hospital sector, and you said hospitals were important.
One of the things that every Minister of Health for the past many, many years has talked about is the need to take some of those resources out of the hospitals and reinvest them back into the community, where you can do the community-based care that we all know that we need.
First of all, do you agree with that direction? Secondly, do you believe it's happened enough? Thirdly, if it isn't happening enough, how do we do it? How do we get those resources out there and restructure the system?
Ms McConnell: I'll start with your final question. I think that the problem with "What is the restructuring plan?" is that so far we are not seeing the additional money that comes out of the cuts to health care at the hospital, at the institutional level, in any way flowing into the community. If I could balance that with another analogy, with a real-life analogy, when you said that you were going to cut welfare costs and welfare cheques, you said that there would be a hand up; that we would have a system in place in Regent Park, in St James Town, in Cabbagetown, in Corktown, in my community, that would help people make up the difference or get a job. The answer to you is, we don't have that. So we didn't get the safety net; we just got the axe.
So now what you're asking is, is it possible to restructure hospitals? Of course it's possible for us to restructure them, and there are some very good ways to do it. But one of the ways that you don't do it is to take a hospital like the Wellesley Hospital -- which five years ago we would have all argued, "Take it and throw it out the window." It did nothing for our community. Nobody used it, and suddenly that hospital, of all hospitals, took a whole different approach to things. It now has a birthing clinic that saves you money. It now has one of the major AIDS hospitalizations that is attached to and close to Casey House. So you've got some private money; you've got some public money.
In addition to that, when you put that together, the outreach of the Wellesley, with the multilingual services and the day surgery that can be done at the central hospital -- bingo -- you've got a great circumstance where you could save $11 million. But the question is, will the $11 million end up in our community? Will we have the additional neonatal care that we need for the children in poverty? Will we have the extra dialysis, the extra ambulatory devices that people of the poor need?
You see, one of the things that's true is that health and poverty are related. So I hope that answers your question.
The Chair: Ms McConnell, I've been really quite generous on the time with you.
Ms McConnell: Yes, thank you. I appreciate it.
The Chair: We appreciate your coming to our committee and presenting to us and your interest in the process. Thank you very much.
Ms McConnell: Just before I go, I had to present this to you from the children. They did ask me to pass this on to you. They have done their work and they have said they hoped that you would help them sleep in heavenly peace. I'm sure that in all our multilingual communities and all our religious communities this is a message that is universal.
KATHY BUGEJA
The Chair: Our last presenter for the evening is Kathy Bugeja. I'm hope I'm right on the pronunciation.
Ms Kathy Bugeja: Close enough.
The Chair: Welcome to our committee. You went from being on early to being on late. It's amazing how things change. You have a half-hour to use as you see fit. Questions will begin with the New Democratic Party if you allow such time for questions. So the floor is yours.
Ms Bugeja: That's fine. Good evening. My name is Kathy Bugeja. I feel very honoured to be able to present my views, as a consumer, on the health sector portion of Bill 26. Briefly, I'm married -- my husband, Leo, is in the audience here to give me some moral support -- and I am a mother of two young sons.
Both my husband and I earned an MBA degree at the University of Toronto, and we have lived and worked in Ontario all our lives. My work background includes many years in the private sector as a mergers and acquisitions specialist and I currently run a successful business in the health care sector.
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So I feel I can offer a unique perspective here tonight, both as a grateful -- and I do emphasize "grateful" -- user of the health care system and as someone who works extensively with providers in the system.
It's within this context that I would like to offer comments on some elements of Bill 26. Let me be clear: I am not here to slam this bill. I appreciate the very difficult task we all face in trying to put a lid on escalating health care costs. I am here to offer constructive input and suggestions that I feel would balance the focus of this bill and ensure that patient care is not compromised.
Specifically, I would like to address three areas: individual consumer responsibility for health care utilization; hospital restructuring and the need to ensure continuity of care within the rest of the health care system; and physician services.
Let's begin with individual consumer responsibility. I applaud Bill 26's proposals regarding the Ontario drug benefit plan -- not because I want to inflict undue hardship on some of the current participants in the plan; I feel that aspect can addressed in other ways. But I do feel this bill and this section will force participants in the plan to go back to their doctor and ask, "Do I really need these drugs?" and that's not a bad thing.
It is proven scientifically that seniors have a much slower metabolism rate to absorb medications. Fewer seniors on fewer compound medications will result in fewer adverse drug reactions and fewer admissions to emergency. Everyone benefits from this.
My question is: How can we extend this concept to other segments of the health care system? How can we make individuals more responsible for their use of the health care system?
In my opinion, putting controls on the user end of health care, the demand side of the health care equation, will render far greater savings than attacking providers on the supply side of the equation.
Everyone knows at least half a dozen people who either run to the doctor for every little ailment or who shop around until they find a specialist opinion they want to hear. Worse yet are the horror stories of health card numbers being used by five different people at the same time. Only these people, not the providers, know how they are using or misusing the system, because we have an OHIP information system that is out of date and totally inadequate to track even basic patient care usage.
What happened to those consortiums we heard about that were going to launch the OHIP system into the 21st century? Why do I see nothing in this legislation to address this major weakness in our current health care system? If you can't bring the OHIP system up to spec, then tender the job out to someone else who can. Failing that, your only solution is to restrict the range and mix of services offered under OHIP, and that gets into a whole new spectrum of issues, including patient choice and the right and ability to access care inside and outside the publicly funded system.
While I'm happy to elaborate upon this point during questions and answers, I would like to switch the focus of my remarks now to hospital restructuring.
I am somewhat encouraged that Mr Wilson, in his remarks to this committee on Monday, intends to use the hospital restructuring report of the Metropolitan Toronto District Health Council as a template for restructuring across the province, for that report incorporates a very important principle that took a lot of energy and commitment to secure.
That principle is: Regardless of what form restructuring takes -- mergers, closures, downsizing, reconfiguration, no matter what you call it -- it is recognized that the true or total demand for service, both inpatient and outpatient, still exists in the system and that this demand must be accommodated in the system to ensure patient care and the ability of providers to provide that care is not compromised.
Consequently, the MTDHC report recommends that any transfer of operating programs and services between institutions must include the operating budgets and personnel providing that care. This is critical to ensure continuity of care is not adversely affected by government's restructuring plans.
While the MTDHC report is fairly strong in ensuring continuity of care in the acute care sector, it is not as strong in ensuring continuity of care from the acute to the community or primary care sector. Right now, Home Care in Metropolitan Toronto is handling a 20% increase in caseload in fiscal 1995-96 over 1994-95. Many of these cases reflect post-op patients who are discharged sooner from hospital, ie, who demonstrate an increased level of acuity, as well as an increasing number of complex, chronic care patients receiving care at home. This jump in volume is before any restructuring has happened in Metro.
How will Home Care and the rest of the primary care sector handle the massive surge in caseload when 12 hospitals are reconfigured and hospital services are offloaded into the community? While the MTDHC report acknowledges the need to enhance community-based supports within a reconfigured hospital system, it sets limitations on what it recommends be provided. Moreover, it provides no mechanism to illustrate how this might be done. Bill 26 doesn't really address this either. It talks about taking a systems approach, but it's only focusing on one component of the continuum of care -- downsizing the hospital sector.
Mr Wilson, in his remarks this past Monday, talks about developing the tools he needs to get the job done. Well, I need tools too. I love my parents and I love my in-laws, but I can't look after them and my family and my business, which contributes valuable tax dollars, without the proper tools at hand to assume an increased burden of care in the community.
I need a primary care sector that's developed to handle the job. I need family physicians who have the incentive and the commitment to provide community-based care. I need nursing and other provider options that give me flexibility and peace of mind.
I don't care if I have to pay for it, but I want to be able to make the choice. I don't want a political ideologue telling me I can't pay for alternative arrangements. Having lived with a grandmother who was chronically ill for close to 15 years, I know what we needed but couldn't get. This experience has led me to volunteer my time and energy as a member of the board of the Home Care program for Metropolitan Toronto.
If I'm to do the job of informal caregiver as envisioned by government, I need the tools to do the job. Government's job is to either provide those tools or create the market environment to develop them.
Finally, I would like to address Bill 26's treatment of physicians.
Let me begin by drawing from my experience as a mother. If I continually belittle my boys, tell them they're no good, tell them I mistrust what they do or hit them for no reason, with no advance warning and with no ability to defend their actions, what do you think happens? How are they going to turn out?
I believe in positive reinforcement -- setting guidelines and clear expectations, providing some latitude that allows for growth and working through difficult times together. I believe we should employ the same approach with physicians, but Bill 26 doesn't do this.
In its quest to deal with utilization control from a supply-side economics perspective, Bill 26 assumes total and absolute control over providers will control health care utilization. This is wrong, not only because it fails to address the demand side of the health care equation, but also because it's immoral.
Bill 26 grants extraordinary powers in extraordinary times, but I do not believe those powers extend to treating individuals like suspected criminals. As a society, we have spent incredible sums of money to train and support physicians in the health care system, and they, along with all the other health care providers, have built and developed a system that we are all proud of.
While we acknowledge that this success could only be done as a team of health care professionals working together, Bill 26 isolates one member of that team, physicians, and states: "You are no longer valuable and we don't trust you to be a reliable player on the team. To that end, we will control what you do, where you do it, how you do it, to whom, and how, or if, you will get paid." This isn't fair. You're dealing too many blows at once.
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While accountability to the payor is just as important as accountability to the patient, Bill 26's approach to ensuring this is highly questionable, because the people who will feel the ripple effect of these blows to the profession will be you and I. Patient care will be compromised. You cannot do a good job if you are demoralized, abused, fearful of your job or your ability to perform your work. There are innumerable examples in industry that demonstrate this fact.
The medical profession is already showing signs of the siege mentality engendered by this bill. Talk to the average physician in practice. They're running scared. They're being hammered from every side and they don't even know why. Now, maybe this doesn't speak well of their ability to read the winds of change, but that doesn't justify this treatment.
This kind of treatment doesn't encourage physicians to be willing partners in comanaging the health care system. This approach does the exact opposite. I know because my business niche in this industry is working with physicians and other providers to effect change, helping them downsize or close programs, develop new programs, merge existing programs and services, or reposition their hospital, department, division or unit for change.
I know what works and what doesn't. The right approach neither coddles nor deifies the profession, but it does treat the profession with respect, the same respect accorded to all the other providers, administrators and planners in the system who are trying to do the best job they can in difficult times.
If you think bashing the medical profession will accomplish your objectives, then I think you're getting the wrong advice. Maybe you should be talking to people whose experience illustrates the direction you and I want our health care to go.
We all have a stake in our health care system, and I passionately believe that we can all work together to make it through these difficult times. I know it can happen; I've seen it happen; I've made it happen. But it's not going to happen if we begin by clubbing each other over the head to enforce our points of view.
Talking to you tonight has been like a dream come true for me; to have an opportunity to offer some insight that might improve our health care system is really a once-in-a-lifetime opportunity. If there's a chance to lend my expertise as you implement some of this legislation in the months to come, I would jump at that opportunity.
Whatever you do to the health care system, do it right. Assemble the right team, take a systems approach to ensure you follow through the logic of your decisions and treat others as you would want them to treat you. I see this treatment demonstrated every day among the health care providers and administrators with whom I work.
On behalf of the silent majority in Ontario, I'd like to take this opportunity to thank them for a job well done. I wish you, the members of the standing committee, the greatest success as you tackle a most difficult task.
I believe in this system and the people who work in it. I see living proof every day that this system works when I look at my families, but change is constant and present in every industry. I will do everything I can to make our health care system better.
Thank you for listening.
The Chair: Thank you for your presentation. We have left about four minutes per party for questions, starting with Ms Lankin.
Ms Lankin: It's a very thoughtful presentation to wrap up this evening. I can tell, just from the words but also the way in which you delivered your presentation, how passionately you feel about our health care system, and that's something I share with you completely.
Part of what we as a committee need to grapple with, if in fact we continue to deal with the bills all together like this, is how we priorize amendments that we are going to move, because quite frankly there will only be one week to do clause-by-clause for the whole, not just the health section. The committee's to come together and do the whole of Bill 26. As we go through the hearings, I'm listening to try and get a sense of where the majority consensus in the public is for where amendments are needed.
I want to ask you particularly about the hospital restructuring section and the need for ensuring continued care within the rest of the health care system. The Public Hospitals Act amendments that are there set up the hospital restructuring commission. There are no powers or objectives set out. There's no tied-in relationship to the DHC and those reports in Metro or anywhere else. The powers aren't time-limited just to deal with restructuring.
We have heard recommendations for amendments in all three of those areas: sunset, not just of the commission but the powers, the extraordinary powers for restructuring, in three or four years' time; have the special purpose of the commission set out in the legislation clearly; and link it to the community consultation, consensus-building process led by health planners and DHC. Would you agree with those kinds of recommendations, or do you have alternative or additional suggestions for amendments in that area?
Ms Bugeja: In the hospital restructuring and the setting up of a commission specifically?
Ms Lankin: And the follow-through, what you've addressed as a concern.
Ms Bugeja: I do have some concerns that the commission would be represented, or the health restructuring authority, as the MTDHC report referred to it, would have the right representation of groups to ensure that the continuity of care is not compromised. Right now it's only in principle that the ability of providers to provide care across the system is not compromised. I would like to see that principle a reality, because if it's not a reality, patients are going to suffer extraordinary amounts of difficulty. It will just complicate what patients feel now when they're discharged from hospital.
I would also like that restructuring authority to examine some of the underlying rationale behind the MTDHC report. It's too bad you don't have anything to draw on because I'm a very visual person, but having been involved with the DHC process for at least four or five years -- its predecessor was called the health services realignment committee -- a major flaw in how the restructuring report was set up was that it took some assumptions about how you can spin people through the system faster; then it arrived at a total number of inpatient cases for the system.
Then there's a massive break in logic that says, "From that total demand, this shakes out to 12 fewer hospitals." What's missing in the analysis and the sharing of information with the people who volunteered their time in the process are the critical mass targets and requirements used by the DHC consultants to arrive at their recommendations.
We don't know why only four sites, or three sites, in Toronto got paediatric care. We can only assume they're working that a viable critical mass for delivery of obstetrics is 3,500. Where did they get that from? Where did they get that critical mass requirement from? Who says that 90% of the patients who are currently billed as alternate level of care can be handled in the community? Presumably they're institutionalized because that is the place of last resort; there are no other people in their families or in the community who can look after them.
This rationale has to be reviewed. Just as you have an auditor to review the financial statements of the government, I think you need an auditor to review some of these DHC reports to ensure that some of the stuff is logical and rational.
Ms Lankin: You think that would be a role for the commission?
Ms Bugeja: Yes, the commission should do that.
Mr Clement: Thank you for your presentation. Just as you said it was a pleasure to be here, it was a pleasure to listen to you as well. I thank you for that. I'm going to congratulate you right now because I'm going to use all the power and authority vested in me, which is none, to appoint you for the next three minutes the Minister of Health.
Ms Bugeja: Okay.
Mr Clement: You're now the Minister of Health. How would you approach the health care system? What would be your top five priorities? How would you get us through to the health care system we all want in Ontario?
Ms Bugeja: I think part of the problem you're using in addressing the health care system is you're putting all your issues in one big basket, one big melting pot. I told you I work with physicians. They commonly do that too. They take all their crises and they put them all in the same basket and they don't rank them and they don't put them along a time line. So when you're faced with all these issues at once, you panic or you get paralysed into inertia where nothing happens.
If I were Minister of Health, what I would do is take all of the issues that I found were burning issues -- provider issues, consumer utilization issues, ODB issues, all of this stuff -- and I would actually start ranking them in terms of urgency and ability to address the issue, and I would put time lines, almost develop a critical path of how we should address this stuff. The health card is a classic example. I said we should develop OHIP into a viable system. Now, that's not going to happen overnight, so that would be one of those issues I would start working on now and aim for a year or two to have a viable proposal on the table of government saying, "This is what we're going to do." These consortiums would be working on this stuff; that's possible.
I would then kind of rank other issues that government needed to address immediately. But even on the provider side, even the physician side, they're not all immediate issues that you really need to deal with. As to the billing numbers issue and the relocation and maldistribution of physician resources, you know there's a time line that relates to when these people graduate and when they finish their residency, so you already have a defined time line to work with in the system. You could easily look at the attrition rate of physicians right now and probably do a matching, and I bet you dollars to doughnuts your maldistribution problem would not be as great as what you're thinking.
The short answer to your question is, I would take all the issues in that melting pot, I would sort through them and I would pick out the ones that are the critical ones to deal with now, and then I would temper some of the amendments you're doing, such as charging user fees for the ODB and I would look at it, as Pam had said, in context with what these other people are facing.
If our ambition is to reduce usage of ODB and get these people to go back to their docs to reduce the medications they're on, if that's really our principal, underlying rationale for that, is there a better way we can do it without penalizing them financially? That's what I would do.
The Chair: Thank you very much. Mrs Caplan, you get the final kick at the cat tonight.
Mrs Caplan: Thank you very much. I also share your passion. While I don't agree with all your solutions, I think that the opportunity to have this discussion and this debate is extremely important.
What I was most moved with was your excitement at being able to come before a committee, and one of the things I feel very strongly about is that that is an essential part of our democracy. There are hundreds of people who want to come before this committee who cannot be accommodated. We haven't even advertised and there are hundreds of people across the province who have applied to speak to the committee in the 11 cities we're going to and we can't accommodate them.
One of the things we are trying to do is ask the government to reconsider. We recognize there may be some things that they must have by January 29, but I think, as you look at this bill, as you've said on your critical path time line, there are many things for a little bit of extra time for people like yourself to have the opportunity to express your views before this committee and to have the thrill of participating that you had tonight.
As you sum up, I'm going to give you the opportunity to make the pitch and try and convince the government members. They voted against a motion that would have asked for consideration for more public hearing time. By letting them know how important this was to you and to the hundreds of people who don't have this opportunity, but who want to come, would you try and convince them to allow us more time.
Ms Bugeja: I would have to agree. This legislation is so massive. In one way it's political genius to wrap it all up in one so that it's all or nothing, but I do believe there are various sections within the legislation that need to be addressed.
Frankly, in legislation that's so all-encompassing, that affects everybody in every walk of life, I don't think you can give this the bum's rush, and this is what's happening: You're giving it the bum's rush. You're not giving people enough time.
On the one hand, I appreciate that if you give people too much time, the event kind of trickles and nothing gets done. Okay, Jim Wilson's remarks to your committee on Monday highlighted that we've allowed so much time for process, that nothing ever get done. But I think there are some elements we should be able to extract that you want to address now and there are some elements that we need more careful study of, or at least opportunity for people to provide input.
I knew of these committee hearings because of working in the sector, I kind of heard it through inside information, but not everybody is so lucky and by the time they signed up for Toronto, there were like 2,000 people on the list. It's absurd. When I heard that it was on, I couldn't believe it. I really, really was excited because I get excited working with providers in the system. I get excited seeing them change. It can be done.
The other thing I'd like to caution you about is that what you observe in the medical profession at one level, please don't assume is the same in the medical profession at the other level. I see change happening every day with the docs I work with. I all them my guys; it's a generic term, but they're my guys and they're my guys in the north and they're my guys in Windsor and they're my guys in Toronto.
I see that change and I see them working in change and it's difficult for them to change because their training does not allow them to change that easily. Their training makes them very introspective and quick-fix mentality, and macroenvironmental changes are difficult for them but they are capable of doing it.
Please do not think that what you're dealing with at one level is indicative of how the whole profession is. Don't bash them over the head. Give people an opportunity to comment on this bill. I think people appreciate the financial urgency of the budget, but from a personal standpoint, I really don't care about a tax rebate. If somebody else is suffering and somebody else's children are going hungry, I really don't care for 150 bucks or whatever it is. To me, it's like pieces of silver. I can't in any good conscience even absorb it.
Mrs Caplan: Thank you. Very eloquent. I appreciate it.
The Chair: We appreciate your interest in the committee process and have a good evening.
The committee stands adjourned until tomorrow morning at 9 o'clock.
The committee adjourned at 2100.