SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
AIDS COMMITTEE OF
TORONTO
TORONTO PEOPLE WITH AIDS FOUNDATION
INFORMATION AND PRIVACY COMMISSIONER OF ONTARIO
ONTARIO MEDICAL ASSOCIATION SECTION ON PSYCHIATRY
ONTARIO PSYCHIATRIC ASSOCIATION
PHARMACEUTICAL MANUFACTURERS ASSOCIATION OF CANADA
ONTARIO CHIROPRACTIC ASSOCIATION
WEST CENTRAL COMMUNITY HEALTH CENTRES
ONTARIO MEDICAL ASSOCIATION, DISTRICT 11
COMMUNITY RESOURCE CENTRE OF SCARBOROUGH
CONTENTS
Thursday 21 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
AIDS Committee of Toronto; Toronto People with AIDS Foundation
Joan Anderson, interim executive director, AIDS Committee of Toronto
Eric Dow, executive director, Toronto People with AIDS Foundation
Information and Privacy Commissioner of Ontario
Tom Wright, commissioner
Dr Ann Cavoukian, assistant commissioner of privacy
Ontario Advocacy Coalition
Orville Endicott, coordinator
Patricia Bregman, legal counsel
Ruth Lunel; Veronica Hering
Ontario Medical Association Section on Psychiatry
Dr Judy Hamilton, secretary
Dr Stephen Connell, member of the executive
Ontario Psychiatric Association
Dr Edward Rzadki, president
Dr Alan Eppel, chairman, public affairs working committee
Joseph Fox
Pharmaceutical Manufacturers Association of Canada
Paul Lucas, member, board of directors; co-chair, PMAC Ontario committee
Pam di Cenzo, co-chair, PMAC Ontario committee
Elizabeth Margles
Ontario Chiropractic Association
Dr Lloyd Taylor, Queen's Park representative
Peter Waite, executive director
Dr Bob Haig, director of government affairs
West Central Community Health Centres
Walter Weary, executive director
AIDS Action Now
Maggie Atkinson, co-chair
Tim McCaskell, past chair; member, steering committee
Ontario Medical Association, District 11
Dr James Seligman, chair
Community Resource Centre of Scarborough
Dr Bob Frankford, representative
Douglas Neath, former chair
Dr Evans Emyolu, member
Mike Boychyn, representative
Larry Edwards
Robert Kernerman
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
Klees, Frank (York-Mackenzie PC)
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Bartolucci, Rick (Sudbury L)
Colle, Mike (Oakwood L)
Curling, Alvin (Scarborough North / -Nord L)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel:
Campbell, Elaine, research officer, Legislative Research Service
Drummond, Alison, research officer, Legislative Research Service
The committee met at 0902 in committee room 1.
SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
Consideration of Bill 26, An Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring, Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda / Projet de loi 26, Loi visant à réaliser des économies budgétaires et à favoriser la prospérité économique par la restructuration, la rationalisation et l'efficience du secteur public et visant à mettre en oeuvre d'autres aspects du programme économique du gouvernement.
AIDS
COMMITTEE OF TORONTO
TORONTO PEOPLE WITH AIDS FOUNDATION
The Chair (Mr Jack Carroll): Our first presenters this morning are, from the AIDS Committee of Toronto, Joan Anderson, the interim executive director and, from the Toronto People with AIDS Foundation, Eric Dow, the executive director. Welcome to our committee. You have half an hour to use as you see fit. Any time that you allow for questions at the end will be shared evenly, beginning with the government. The floor is yours.
Ms Joan Anderson: Thank you very much. We want to make a few brief notes and then allow for questions and discussions. I want to focus in on a couple of issues, primarily the hospital restructuring and the issue of privatization. This afternoon you'll also have an opportunity to hear from AIDS Action Now, and they'll be dealing with a number of the issues related to the drug benefit plan and physician billing. What we've tried to do is to divide up issues so that you have an opportunity to hear from a number of organizations on a variety of concerns that we have about this bill.
To begin with, we want to be clear that we have concerns certainly about the entire process and the entire bill. We feel there are fundamental issues involved in this bill. The topics range over everything from mining through to health care. We feel that it would be a more appropriate tack for the government to take to divide up some of this bill and to allow for more meaningful consultation on specific issues and specific areas.
There is a tremendous amount of expertise, range of expertise, that you're being called upon to have and the government as a whole is being called upon to have, and we really feel that the kind of undue haste that is being taken and the combining of such a diverse number of issues is not the best way in which decisions are made.
We understand the intentions of the government in terms of the urgency you're feeling because of the economic situation. It's certainly something we are all experiencing and we all feel as well, but this kind of haste does not necessarily make the best decisions.
For our part, we're concerned because we certainly haven't had enough time to analyse the potential full impact and implication this bill has for people with HIV and the many communities at risk of HIV infection. What we see is that action could happen and in the coming years we're all going to experience the impact and outcomes that with some more thought and consultation we could have avoided. We understand you're trying to solve problems, but we're concerned about creating more problems.
With that as a beginning, I'd like to focus in on a couple of issues. I think the basic premise of this bill is stated very clearly up front, that the purpose of the bill has to do with achieving fiscal savings, it has to do with an economic agenda. From our point of view in terms of the issues in health care that this bill represents, we're very concerned that decisions need to be made in a combination of fiscal responsibility and achieving good health care and good quality health care and equitable health care in our society.
The language of this bill says to me that the priority for the decisions will be economic and not the health of the citizens of this province. That is a real concern when you're providing such unlimited powers to cabinet and ministers. I have no sense, when I read this legislation, of the appropriate structures, checks and balances being put into place, again to ensure that you get the best decisions that come from a combination of experiences and expertise and not just the experience and expertise that sits around any particular cabinet table by any particular government at any particular time.
The example I like to use is looking at the hospital restructuring issue. In previous governments a lot of consultation was done, for example, on the Public Hospitals Act. Many of us came and did briefs and did deputations on that issue. A lot of the deputations and a lot of the input talked about shifting care into the community, that we need a greater amount of care in the community and that hospitals need to become more accountable to their communities. This act says to me that hospitals will simply become more accountable to cabinet and that the distance between hospitals and communities will just continue to grow.
The real-life example that we're working with is the Wellesley Hospital in our community. It's a hospital that at one point used to be out of touch with its community. That's no longer true. It has put into place consultations with many segments of the community and has developed services that are meaningful and relevant. We know this is true for the working poor and the poor that live in that area. We know that is true for people living with HIV in our area.
The Wellesley has developed, with our help, with the help of the community, a model in terms of health care that involves a continuum of care from emergency, inpatient, outpatient and into the home. We're very concerned with the decisions being made quickly where we may see services completely eradicated in that community, such as emergency and inpatient, without the appropriate support in shifts into home care and community care. We're seeing home care also being downsized. So the continuum of care that has developed we see as going backwards in time to 10 years ago when services and care were fragmented.
Fragmented care ultimately is more costly care. If people receive the care they need when they need it, they're able to manage their illnesses and contribute and be part of their communities for a much longer period of time.
Community care also involves preventive care, not only of illnesses but of infections in the first place. We're very concerned about the kind of dislocation we know our communities will experience if decisions are taken that these services are eradicated without any appropriate substitutes and without due process.
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I'd just like to spend a moment in terms of our concern in changes that are proposed to the Health Care Accessibility Act, taking away the preference for non-profit Canadian operators. Again, we would like to see much more exploration and time and consultation on this issue before actions are taken. What we're concerned about is what we hear in the rhetoric and see in the potential in the bill for a two-tiered health care system.
The changes in the Health Care Accessibility Act look to us like an opening to hospital user fees. There is a lot of documentation, there are lots of studies, that indicate that user fees deter people from receiving the care when they need it. If they don't receive it when they need it, they will become more ill and the costs will be greater both to them as individuals and to society as a whole.
I have a sense from the language I hear and the language of this bill that there's a sense that economic agendas and the market will always produce the best results. We fundamentally disagree with that notion. The market does not always produce the best results when you're dealing with the health care of your citizens. It may work in terms of airplane competition or phone competition, but that's not what we're talking about. We're talking about quality of care for all citizens in Ontario.
We ask you to reconsider these issues. We ask you to give them the appropriate amount of time they deserve. What we're concerned about is the Minister of Health, that instead of being expected to be an advocate for health care around the cabinet table, he will have to become a financier and economist, and the health care of people in Ontario will suffer.
I'd like my colleague, Eric Dow, to speak to another aspect of the bill.
Mr Eric Dow: Good morning. I'm Eric Dow, the executive director of the Toronto People with AIDS Foundation. As Joan was saying, ACT, AIDS Action Now and PWA have gotten together and looked at different pieces of the bill because it's such a large bill. There's no way that one of our agencies is able to look at all of it. We haven't been given enough time.
I'm here representing over 4,000 men, women and children living in Metro Toronto with HIV and AIDS. I also understand about zero-balance budgets; that's how I operate the foundation. But one of my concerns with what's happening with this bill is that when I do a zero-balance budget at the foundation, the balance that I'm taking into account is not only dollars but also the needs of our clients. My concern is that this bill doesn't take into consideration the needs.
One of our biggest concerns is the issues around confidentiality. With the proposed changes the minister can collect, use or disclose personal information, the minister can enter into agreements to collect, use or disclose personal information and the licensee or other person can provide certain information, including personal medical information, to the director.
The bill also will provide the Minister of Health with a wide power to collect, use and disclose personal information, which may include information disclosing the type of medication prescribed for purposes related to the administration of the act or for any other purpose prescribed by regulation. The bill will significantly weaken the existing provisions under the act for protecting the confidentiality of medical records and for preventing their disclosure. Under the bill the minister would have the authority to enter into agreements to collect, use and disclose personal medical information concerning the provision of insured services.
In talking with the clients of the foundation and the volunteers and the staff, and 75% of our staff are HIV -- positive, the big question that kept coming back to me was "Why?" We don't understand why the minister feels he needs these powers and it hasn't been explained to us as to why. So there's a lot of fear. Why does a Minister of Health need to have access to all of this type of very confidential information? The discrimination and stigma that people with HIV and AIDS have faced in Ontario makes us extremely nervous that this information is going to be made available, especially for young people. One of our concerns is that fewer people will be willing to get tested. Right now they can get tested anonymously, non-nominally or nominally, but if this goes through, it doesn't matter how they're getting tested, the Minister of Health and others have access to this information.
The other concern is that many people may not be seeking the medical attention that they need. The concern for the Progressive Conservative government, to me, seems to be a lot around cost and the cost would increase if, for instance, I chose not to go and seek medical attention. Then, as I became more sick, I would need to be hospitalized. It costs a lot more to hospitalize me than it does to maintain my health, so costs to society as a whole increase.
One of the other major concerns for the foundation would be the implementation of user fees, but AIDS Action Now will be dealing with that later this afternoon.
Ms Anderson: Questions?
The Chair: We've got about five minutes per party, beginning with the government.
Mrs Janet Ecker (Durham West): Thank you very much for coming. I know all of us were a little late getting in here and you were here right on the dot of 9, so I apologize for that. It certainly does not mean any lack of interest in what you have to say and I think you've made some very cogent points.
One of the things you probably do know: I understand that the Minister of Health has met with organizations from the AIDS community and has talked about his desire to keep it a priority in terms of funding and to try and find savings in other areas to reinvest in the AIDS area, which would probably be very helpful because, from past work I have done, I certainly understand and appreciate the need for special care in this area.
You mentioned hospital restructuring. I just wanted to be clear. I thought what I heard you say was that there has been hospital downsizing already, loss of beds and whatever, but you hadn't seen the reinvestment in the front-line community care services that you wanted. Is that what I heard you say?
Ms Anderson: No. What we've been seeing is some downsizing already in terms of home care, and home care, for us, is where the real growth needs to occur. We understand there is not as much need for as many hospitals, so we're not against hospital downsizing overall. But again, we want real care taken in how that's done.
The decision that's before the government right now of the potential of closing the Wellesley model is causing us incredible concern because we don't see that as responding to the community needs. A certain model has developed there that combines the kind of inpatient and outpatient pieces and continuum of care that over the last decade we've said is the kind of model we wanted to work towards. And so now we see that potentially that's up for destruction. I think what we're asking for is that in terms of hospital restructuring, great attention be paid to the continuum of care, that people need support at all levels. Granted, there are more inpatient beds in Ontario than we need, but again, great care needs to be taken about which pieces of that get lost.
Mrs Ecker: Good point. The difficulty governments have in terms of wrestling with this is how to make that shift, and I think you've flagged an important area of discussion here in Toronto. A community-based planning process under the district health council here in Toronto that's been ongoing for quite some time has brought forward a plan that they believe is community-based and community-driven, and they're asking the Ministry of Health to implement that. You're expressing concerns that you believe the community-based process which the minister would like to accept the recommendations from has a hole, has a gap, has a problem with Wellesley. How would you recommend that the minister should be trying to get those recommendations from the community in order to implement them, in order to shift the resources to community care?
Ms Anderson: I think the process of the district health council was a really important one. What we were concerned about in the process, though, was that what that process has to do is highlight -- okay, you've done this planning, you've done some really good things, but where are the weaknesses? You need those checks and balances.
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To this point, for some reason, district health council for us hasn't paid enough attention to what the major weaknesses are in the plan. We believe in this process where you have the community consultations, you go through district health council. The minister himself can, through his own consultations and what he hears in district health council, weigh all of those things together and, we trust and hope, make the appropriate decision.
What we're concerned about with this bill is, it seems to kind of jump over all of that and say that economic considerations are the priority and, in a sense, the minister must make that the priority. Where is the structure in terms of the consultation process? I have a real sense of a lot of that being lost with this bill.
Mr Rick Bartolucci (Sudbury): It's very interesting that your concern is so great with regard to the privacy of information. Our next presenter is the commissioner and the assistant commissioner. I would suggest that if you have the time, you should stay around for his information and his presentation.
Could you give the committee and the government suggestions how they could improve that section of this bill so that the community you deal with feels confident in seeking the support and the help they need?
Ms Anderson: To be frank, the powers are too great. That part of the bill needs to be taken out. To allow that kind of power at the cabinet level is simply inappropriate and it flies in the face of the kind of sacrosanct place which we put on confidentiality and the privacy we put on people's individual medical information.
If it's undermined at the cabinet level, that means it can be undermined at many, many levels. It's just too dangerous. Whatever the intentions are, whatever good intentions there may be behind that, it's much too dangerous to allow it to stay.
Mr Dow: I think what you need to do is you need to guarantee the confidentiality of people living with HIV and AIDS. Jim Wilson, I'm sure, is a very nice person and he's not going to do anything evil with this information, but you haven't guaranteed us that he's going to be the only person who has it. He's not going to be the Minister of Health five years from now, probably. What you're asking us to do is to give up all of these guarantees of confidentiality to somebody right now we know but we're not going to know five years from now.
Mr Bartolucci: If you had your druthers, you would want that section of Bill 26 withdrawn completely.
Ms Anderson: Absolutely.
Mr Bartolucci: Secondly, you speak of home care. I too agree with you that that's where the focus should be. Again a suggestion to the government: How could they build that within Bill 26 so that, again, your community feels its needs are being addressed?
Ms Anderson: I think what we're looking for is the commitment, again, to continuum of care. What we'll be very concerned about is if we simply say the focus is home care, but we need the hospital backups. We need the labs, we need outpatient services as well. So what we're looking for is that continuum of care support. I'm very concerned that certain structures will disappear, and then you're left in the community, but you don't have the appropriate supports either at home or the kind of backup supports you need in a hospital.
Mr Bartolucci: This may be a redundant question, but I think it's an important question that I ask in light of what you said. Do you feel that Bill 26 provides for long-term protection for your community?
Ms Anderson: No. No, absolutely not. I think, again, it's situating so much power in a handful of people. We don't see in it a commitment to the kind of structures and consultation process that we know is important. We feel it is a step backwards. We've really struggled over the last number of years to try to move and help government move to a place where there's more community involvement in direction setting. This completely flies in the face of that. It sets all direction setting in one room with one small group of people. No matter how well intentioned those people are, they're not going to be able to make the best decisions without the appropriate structures in place and the checks and balances in place.
Ms Frances Lankin (Beaches-Woodbine): I appreciate your appearance here today and the thoughtful submission. I think your last comments were very important in terms of what this bill does in reversing the trend to giving people more access and more say in decision-making about the reform and restructuring of the health care system, and that's very worrisome.
I want to touch on the privacy of information issue as well, because I well recall, going through the process of trying to establish the anonymous, non-nominal and nominal testing programs with the community, our major concern inside government and within the community was to ensure that there were means of testing that were completely anonymous so as to encourage people to come forward. There was a very large fear that many people were choosing not to be tested because of their fear of disclosure of information.
So I guess I have two questions. One, as you read the act, can you tell me how you think it affects those categories of testing and particularly the anonymous testing, because I wasn't sure how in fact those records get married up so that you would have a risk of disclosure? Secondly, even if technically we don't know the answer to that yet, what's happening in the community in terms of people's response to this information about the concerns of the bill?
Mr Dow: I think I'll answer your second question first. Not only am I the executive director of PWA, but I also am a founding member of Positive Youth Outreach. So young people are a really large concern for me. I think one of the concerns that I have about the reaction that I'm seeing is a lot of young people who are at risk for HIV are very tentative to begin with and are actually very afraid of going to get tested at all with what they're hearing, because they're not hearing any answers from the government. They're not hearing exactly what does this mean, all they're hearing is that we want this power. So they're very afraid of what the government's going to be doing with this power.
We haven't had a lot of time to study what's going on with these changes, so in the brief discussions that we've had around testing -- and it was a lot of work to set up the anonymous and non-nominal and the nominal testing and to set up all of the anonymous testing sites -- we're not really sure what the point is any more with the proposed changes to anonymous testing. If you get tested anonymously, but the Minister of Health has access to your medical file, where's the anonymity? It's not there any more. That's our concern around the testing.
Ms Lankin: You mentioned that you haven't had a lot of time to look through the bill and to understand it. I think both of you referred to that. That has been a consistent theme. You may know that yesterday I tabled a motion with this committee to ask the committee to recommend extension of the hearings and splitting of the bill, and that was defeated here. I was very angered this morning when I read in the paper that the Premier is just saying people should send in written briefs, because I can tell you, the hundreds of people who are trying to get on the hearings, if they all sent in written briefs in the last two weeks of the hearings -- and I want people to know we come back here to Toronto and immediately go into clause-by-clause. I will take every waking minute to try to read every one of those briefs, but they won't all get read. So that's not real input.
I'm just thinking about organizations like yours with scarce resources. Here in Toronto you've got a bit more of a support network, perhaps the time to have been able to at least get a presentation together and come forward. What about some of the AIDS committees in some of the other communities? Are they going to have the resources and wherewithal to do the analysis and come forward and/or to do a written brief, as opposed, as you did today, to come and present an oral presentation?
Mr Dow: I don't know how they would be able to. Just looking at the resources I have available to me with one of the larger organizations, I don't have the resources to be able to do that, so I don't know how a smaller agency in the north or in Windsor or Thunder Bay is going to be able to do that.
Ms Anderson: I'm sure there will be at least a couple of groups out there that will manage to appear before the group, but it really is an issue. As we begin to analyse this bill and try to think through all the implications and all the ramifications, I cannot believe that you as a group or the government are going to have enough time in this process to be able to thoughtfully think through the potentials and the possibilities, so we'll end up kind of reaping the whirlwind at some point, and we're all very concerned about that.
We're also concerned about an undermining of the confidence in the government's systems in terms of things like confidentiality. You need to engage yourself in a kind of contract of trust with the citizens in Ontario. That's fundamental in terms of health care, and it's fundamental to have people access health care when they need it, in a timely way. The enormous powers and the disregard of the issue of confidentiality erodes that basic contract of trust with the community.
The Chair: Thank you very much. We appreciate your interest in our process and your presentation this morning. If you have any additional information to submit, we'd be pleased to accept that and consider it.
INFORMATION AND PRIVACY COMMISSIONER OF ONTARIO
The Chair: The next presenter is the Information and Privacy Commissioner of Ontario, Tom Wright, and with him, Ann Cavoukian and Sarah Jones. Good morning, and welcome. You have half an hour to use as you see fit. Questions would begin with the Liberals if you allow time for questions. The floor is yours, sir.
Mr Tom Wright: Good morning, members of the committee. My name is Tom Wright. I'm Information and Privacy Commissioner for the province of Ontario. Ann Cavoukian is the assistant commissioner of privacy in my office.
I appreciate having this opportunity to share with members of the committee my views on the privacy implications for health care information of schedules F, G and H of Bill 26. Before I begin, I have to tell members of the committee that I'm sort of experiencing a sense of déjà vu here. I was in this very room, before the other half of your committee on Monday, wearing my information commissioner hat, and here I am today, and I have my privacy commissioner hat firmly in place, I can assure you.
Before I begin, I thought it might be helpful if I explain to you what an information and privacy commissioner is -- and I will be brief -- and a little bit about what my office does.
As commissioner, I am an officer of the Legislative Assembly, independent of the government of the day, and I report to all members of the assembly through the Speaker. I was appointed in April 1991 for a five-year term by an all-party committee of the Legislature.
One of the roles my office has, and we've been given this by the Freedom of Information and Protection of Privacy Act, is to offer advice and comment on any proposed legislative schemes that the government puts forth. For the purposes of my remarks this morning, that's exactly what I'm going to be doing.
What we've tried to do to assist the committee is to provide you with a letter in which we briefly outline the concerns we have with schedules F, G and H. But I think more importantly, and I hope in a way that will help all members of the committee, attached to that letter is a series of charts that identify the specific amendments with which we have concerns and -- and I'd like to emphasize the "and" -- suggested alternative amendments which address those concerns.
At that point, with your indulgence, I'd really like to publicly thank staff in my office who have worked very, very hard over the past several weeks in looking at the schedules F, G and H and putting together the amendments that appear in the charts attached to the letter this morning.
It's important that I stress to the committee that I realize that reducing health care fraud is necessary, and I understand this is one of the major goals of these amendments. However, I also believe that in order to achieve this goal, it is not necessary to introduce measures which put the privacy of Ontarians at risk. What I hope to do through my remarks this morning is to demonstrate that privacy protection need not be viewed as a barrier to eliminating fraud and achieving efficiencies in the health care system.
I think there are two basic truths about privacy. One, privacy once lost cannot be regained. Two, having anyone -- and I emphasize "anyone" -- collect, use or disclose your personal information without your knowledge or consent is an invasion of privacy. Whether that invasion is justifiable or not, and if so, under what circumstances, I think is another question, and perhaps is the question that is in a sense hovering around some of the issues I'll be raising this morning.
I think we could all agree that the kinds of information covered by the Independent Health Facilities Act, the Ontario Drug Benefit Act and the Health Insurance Act are among the most sensitive of all personal information. This is information from patient diagnosis, hospital records and prescriptions, which contain details about a person's mental health, disease history, ancestry, possibly genetic makeup, and more. It's because of the very nature of the information that I express my concerns regarding these amendments.
Simply stated, in my view, the amendments have the potential to significantly increase the amount of personal health-related information that will be gathered. I'll stop there just for a moment, because it's the gathering in the first place where I think we have to look very carefully about, does this information need to be collected at all? It's all well and good to put controls in place, and we have a privacy act and you could have other legislation, but once your information is in the hands of someone else, it's out of your control and it creates the risk of inadvertent disclosure. I'm not suggesting in any way that disclosure would be deliberate. I'm suggesting that if you put it in the hands of someone else, it's out of your control, and this possibility exists.
In addition to the gathering issue, I feel the amendments will increase the number of uses that may be made of this information and raise the possibility of new disclosures of the information. My sense is that most individuals, and I know you've heard from a number of them already, expect that when their personal information moves beyond their direct control, specific limitations and controls will be in place to safeguard it. The words used in the privacy field are "fair information practices" such as those which appear in Ontario's access and privacy acts, and they exist to frame these kinds of safeguards that I'm referring to.
But they also exist to remind us that the personal information being collected, used or disclosed belongs to the person to whom it relates. It is not the government's information. The government is merely the custodian of the personal information that an individual has entrusted to it. The previous presenter, in response to one of the questions, used the word "trust," and I think she was absolutely accurate. There needs to be this comfort, this trust, in place.
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It's my respectful submission that with respect to the circumstances we're dealing with, with health-related information, there's an added twist. We provide information to government organizations very regularly. For example, we make an application for a driver's licence. We make that application and it's one to one. I provide it to whomever it is in the Ministry of Transportation. I know that the Ministry of Transportation has that information about me. In the scenarios we're talking about under F, G and H, as the person to whom that information relates, I don't know that those records may well leave the office of a doctor or a hospital and arrive at some way in the hands of a government department. I think what that does is that it enhances the obligation as it relates to the kinds of amendments being considered in schedules F, G and H.
In terms of the kinds of concerns we have, I think it's fair to say that we have an overriding concern about the greatly expanded authority the amendments give to the ministry and other bodies through agreements to collect directly or indirectly, use and disclose personal information, and in a number of cases to exercise those powers through regulation. Something that really caught my attention as I read through the amendments were how frequently the words "or for other prescribed purposes...by regulation" appear. That kind of provision may actually provide the authority which limits the ability of the Freedom of Information and Protection of Privacy Act to provide the safeguards it was designed to give.
There seems to be a bit of a misconception about what the freedom of information and privacy act can really do. It contains exceptions, for example, around disclosure of personal information. At last count -- in fact I counted this morning before I came -- there are 14 exceptions in the legislation itself right now, the privacy act, which permit disclosure of personal information. So the notion that in some way the privacy act is this protector out there -- it does provide the framework, but it does contain a long series of exceptions.
The amendments also give the Minister of Health the authority to disclose personal health-related information to any party who administers a law. Such parties are not defined, but would likely, I would suggest, include other ministries, other provinces, police forces and, presumably, private sector organizations.
Ontario, unlike the province of Quebec, does not have privacy protection legislation in the private sector. Quebec has had that since 1994 and is the first jurisdiction in North America to do so.
As well, there are circumstances where the organization in question is located outside the province, beyond the safeguards constructed through Ontario's laws. We are learning literally by the day just how much of our information resides elsewhere. I don't know how many people know, for example, that in Boston there's something called the Medical Information Bureau, which gathers medical information associated with insurance applications of people across Canada. It resides in Boston, and that particular state has no privacy protection. These are the kinds of concerns I want to bring to the attention of members of the committee.
More specifically, the amendments expand the already considerable powers of inspectors to gather identifiable information, particularly when it involves sensitive mental-health-related information. This has been a source of great discomfort for the individuals involved, and I believe you've heard from people who've made the same comment to you. To expand the inspection powers as proposed will heighten the anxieties of these individuals.
In terms of leaving the committee with some thoughts around directions in which we could go, we feel that the objective of detection and reduction of fraud can be equally satisfied through the use and disclosure of anonymous health-related information; in many cases, information where the name or other identifying information has been deleted. By doing so, individual patient privacy would be maintained and, as we have noted, detection of fraud and, for example, professional disciplinary proceedings could still be carried out.
By way of conclusion -- I don't want to intrude on the committee's time in terms of questions -- having looked at the amendments very carefully, I think the source of much of our concern arises from the vagueness of a number of the proposed amendments. At the outset of my remarks I said that individuals have an expectation that their personal information, particularly health-related information, should remain confidential once it leaves their control. Recent public opinion polls continue to press the point that Canadians have an increasingly high level of concern for privacy in their dealings with government organizations. There is also the more specific concern around the confidentiality of medical records.
Quite frankly, I'm not surprised by the reaction that has arisen as a result of schedules F, G and H. I think it confirms the general concern that people have in this era of computers and electronic records around their personal information.
In think the other thing that people anticipate or expect is that their health-related information is strongly protected already. My office regularly gets calls from members of the public about their health-related information, and they're surprised to learn, for example, that hospitals aren't covered by freedom of information and privacy legislation.
So in both 1992 and 1993, in my annual report which was tabled in the Legislature, as well as in other correspondence with the ministry, I urged the Ministry of Health to make the introduction of access and privacy legislation for health care records a top priority, and I have continued to do so on a continuing basis. I believe that, in the long run, specific legislation to protect health care records is the best way to ensure that legitimate treatment, planning and auditing needs associated with this extremely sensitive information are handled in a way that also respects the privacy of individuals involved.
We were advised over the past two weeks that the province of Manitoba has now prepared a discussion paper that's been released around this very issue of specific health care legislation. They are doing, I understand, a similar restructuring of the system and they've identified this kind of legislation as a priority to the success of their efforts.
I pick up once again on the point of the previous presenter. What I think we're all looking for is how to be successful in what it is we're trying to do. To be successful, I fully agree that there has to be this element of trust and confidence. Otherwise things simply will not work, not because they're not good, not because they're not well intentioned, but simply because people have a level of unease and discomfort. I think that is the kind of thing that we have tried to address in the amendments we have presented with that letter.
Just by way of closing -- I think it's always useful for me to do this -- people involved in privacy are not -- the classic description is Luddites. We are not anti-technology. In fact, over the past three years I have said, "Let's get out there and do what we can to make use of technology." We just completed a report with a similar organization in the Netherlands, the first international report of its kind, around privacy-enhancing technologies. They're out there.
I understand you had a presentation from George Tomko of Mytec Technologies Inc. Mr Tomko has also done a similar presentation for Ann and myself. There's a lot of potential for these kinds of technologies where you have anonymity. You still are able to meet the needs, for example, of positive identification or other things, but it can be done in a way that uses the technology.
I think that's how I'll close my remarks this morning. Thank you for your kind attention.
The Chair: Thank you. We've got about four minutes per party for questions, beginning with Mrs Caplan.
Mrs Elinor Caplan (Oriole): I'd like to thank you on behalf of the people of the province of Ontario. You've provided a great service to them, and I felt that the letter you sent to the minister was extremely timely. I had a personal conversation with you and so I want to thank you personally for the advice that you gave me. I want you to know that I was not only insulted by the minister but dismayed at, I guess, his dismissal of the concerns that were raised. It was only your letter that actually brought this issue and gave it the attention so that the minister now seems to have been willing to listen.
When members call you, you give them advice and guidance, and I know that even though you are the expert on these matters, you were not consulted prior to this legislation being tabled. I feel that's unfortunate.
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I also want to state that you were very eloquent in your support for and understanding of the need to deal with the issues of fraud, and I think that you equally are supportive of the need to deal with issues of research and so forth -- I see you nodding your head -- and also your support for the new technologies that would allow for that to be done in a way that protects individual privacy.
As I may not get another opportunity to say it, I want you to know that our members of the committee will be guided by your advice as far as amendments are concerned. We hope that the government will follow your direction and advice, and we'll be watching closely to see that it does.
But do you see any rush to have this done by January 29? Isn't this something where the government could table the legislation in the spring session, have it dealt with in the spring session with full public scrutiny? Isn't there time to have the comprehensive legislation, rather than the piecemeal approach that the government has chosen? Do you see any sense of the kind of urgency as suggested by this bill?
Mr Wright: That is, as you can appreciate, I think a very difficult question for me to answer. We have worked to the time frames that the government has set as far as its legislation is concerned. We have endeavoured to provide the amendments. I think the amendments we've offered are thoughtful.
As far as the timing on it, my preference at the end of the day would be that there be something that specifically addressed health care information, because I think it will allow us to take the full advantage of things like technology. In fact, the privacy act is a very awkward instrument when it comes to privacy protection and health care information. It's not specifically directed to that kind of information, and I think the advantage then, again, of the specific legislation is that it will allow us to deal with all the policy issues that arise in a comprehensive way and, I think, give the kind of guidance that we all could use, certainly my office included, as far as where we're going on this issue.
Mrs Caplan: What we're asking the government and the Minister of Health in particular to do is to extract all of those parts of this bill that deal with those issues, the ones that you've identified primarily, and remove them from this bill, look at those policy issues and bring in a comprehensive piece of legislation. We all want to deal with it expeditiously, and we think it can be dealt with in the spring session appropriately. I'm hoping that they choose to do that.
My fear, and I want to know if you share my fear, is that if you do this Band-Aid, if you just amend this legislation now, it will put off the urgency to deal with it comprehensively and the next time we have another piece of legislation, we'll have yet another Band-Aid.
Mr Wright: The further risk is that you simply don't get to take as full advantage of what might be available by way of restructuring etc of the health care system as if you gave people the clear guidelines in one place.
We, as I say, have gone through this and, as I'm sure all members of the committee have heard, it's not easy to piece it all together in terms of what it actually means. I hope the charts we provided have at least made a stab at doing that, but I think it would be far simpler for all concerned if we could look in one place.
Mrs Caplan: Do you ever feel pestered by members of the Legislature who ask for your advice?
The Chair: Thank you, Mrs Caplan. Ms Lankin.
Ms Lankin: I have three specific questions. I'm going to be short with them and I hope that you will allow me to get all three in.
Mr Wright, Ms Cavoukian, it's good to see you both again.
You may know that a certain portion of the act dealing with independent health facilities removes the current preference for not-for-profit Canadian organizations. This has raised the spectre of for-profit American organizations coming in and delivering health care services in the broader public sector in Ontario.
I am informed that, through the process of the Krever commission, the head of a US-based company that had Canadian operations refused to come into the jurisdiction to respond to violations of confidentiality by its Canadian employers. Have you given any thought to what this means, the possible spectre of private sector, for-profit, non-Canadian companies operating in the delivery of services that are currently covered under public sector pieces of legislation and confidentiality? Is there are any further risk that this perhaps engenders?
Mr Wright: I think one of the points I made in my remarks was along those lines, that once you move into a more private sector delivery of services, which again I fully understand as to why you might want to consider that, you do open up the potential for how that information is going to be held, the kinds of confidentiality provisions that are in place, and I think there is a risk. Once again, the Freedom of Information and Protection of Privacy Act only applies to government organizations. The example I gave was that it doesn't apply to hospitals.
How I would see more comprehensive legislation, it would apply to health care information wherever it is, in the hands of an insurance company, in the hands of the police. Wherever it might be, there would be this kind of overall direction around health care information, which I think would address the kinds of concerns around, does it matter where the organization resides?
The other thing that we have to remember is, we're not talking about pieces of paper any more. For all we know, we're talking about data banks. I gave the example of Boston; it could be anywhere in the world. It could be in Singapore, it could be in New Zealand. It no longer is a matter of a file, as you and I might think of it, going from a doctor's office to an individual who's standing there at the time. This is something that's going over a network.
I think the whole area of how you're even going to provide appropriate controls in that kind of environment -- you know, we hear about offshore banks. Well, you can see offshore data havens developing as well. We're looking at a totally new development as far as health care information is concerned, and the concerns, I think, similarly arise more greatly.
Ms Lankin: My second question is with respect to comments that you made which raise in my mind concerns about abuse of ministerial powers. That in fact was a question that was put to Premier Harris during the election campaign by the Ontario Medical Association, and he responded in the following manner: "The trend in legislation, both federally and provincially, has been to place excessive regulatory power in the hands of the minister and the cabinet." And he asked this question: "Who punishes the cabinet when the cabinet decides it's the law of the land."
You raise concerns about the vagueness of many of the amendments and the problems that will cause you as a privacy commissioner in doing your job in enforcing legislation. Could you elaborate on that, please?
Mr Wright: Sure. In fact, I have in front of me -- and it comes from the chart that I provided this morning -- Bill 26, dealing with the Independent Health Facilities Act. The particular section is on page 1 and it's section 37.1. It talks about the minister collecting, directly or indirectly -- it says "for purposes related to the administration of the Independent Health Facilities Act" and two other pieces of legislation, and then goes on to say "or for other prescribed purposes."
That appears, as I mentioned earlier, in a number of places throughout the amendments, and I guess, the way regulations work, we don't find out about it until after the regulation is in place. If you include the kinds of issues that we raised in the statute itself, it's there, it's clear, the public knows exactly what it is. I think there is a risk as far as regulation is concerned, particularly when you're dealing with this kind of information.
The Chair: Thank you, Ms Lankin. The third question, if you want to submit it to me, I'll see that it gets answered.
Ms Lankin: It's a very quick question and answer.
The Chair: So were the first two. I've allowed you much more time.
Ms Lankin: You don't have any flexibility with a witness as important as this?
Mrs Caplan: Can I move unanimous consent for that? Can we have unanimous consent so she can ask her question?
Mrs Ecker: Do we get equal time?
Mrs Caplan: Yes, sure.
The Chair: We're four days into the hearings. We've been very fair about the time allotment and we will continue to be. The time is up.
Mrs Caplan: I move unanimous consent to allow --
The Chair: Mrs Caplan, I've made a decision.
Mrs Caplan: Can I move unanimous consent? Frances, ask for unanimous consent.
The Chair: For four days, we have been using the same rules.
Ms Lankin: Is there unanimous consent?
Mrs Caplan: Will you give her unanimous consent to ask her question?
Mr Tony Clement (Brampton South): Just to ask the question.
Mrs Caplan: Yes, and he can answer it when he's answering you guys. Let her place the question.
Mr Clement: No, no. We have our own questions.
Mrs Caplan: You're not going to let her put --
The Chair: Who's speaking for the government? Mr Clement.
Mr Clement: Thank you very much for being here. In the spirit of freedom of information, I know that you have met with ministry officials on Friday, and I understand the officials found that a very fruitful meeting.
I thank you for your amendments as well. We certainly are looking for the qualitative amendments such as the ones that you proposed when we will consider amendments to this legislation.
First of all, I guess I've got two questions in the time allotted to me that I want to raise with you, both about schedule H, and firstly about the disclosure sections.
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I've read section 29 of the old Health Insurance Act and I've read section 21, which has the replacement for section 29. The way I read section 29 in the old act, it in fact is broader in terms of its scope and its powers than the new section 29 that's proposed because the new section 29 has four subclauses saying what the information is going to be used for.
I know you're going to say that one of them is for other purposes that are prescribed, but there is a rule of statutory interpretation that says the section has to be read in the context of the previous sections. So I put it to you, sir, that in fact the old section is broader than the new section in terms of its scope.
Mr Wright: I happen to have, courtesy of staff in my office, what I think is the existing legislation. I look at it and I see -- please correct me if I'm reading the wrong section -- that it talks about "with the particulars of his or her services and account that are required by this act" Is this the one that you're referring to?
Mr Clement: That's right, yes.
Mr Wright: Then I look at 37.1 in Bill 26 and what I read very clearly is -- I'm not sure I have the correct section.
Mr Clement: It's section 21 on page 101, which replaces section 29 of the old Health Insurance Act.
Dr Ann Cavoukian: Did you say 21 or 29?
Mr Clement: Section 21, which refers to section 29. It's confusing, but section 21 on page 101 of Bill 26 replaces section 29 of the old act with a new section 29.
While you're following that, can I ask my next question? Because I fear I won't have a chance.
Dr Cavoukian: I'd like to make a comment on that question, if I could. Generally speaking, and we don't, until we find the specific section --
Mr Clement: Maybe just take a look at it anyway.
Dr Cavoukian: What we should draw to your attention is that the previous legislation as well was very problematic from a privacy perspective. It is for that reason that the commissioner has met with the ministers of Health over time and recommended that specific privacy legislation for health care records be developed because of the problems with the existing legislation. So it's not that you begin from a place that is satisfactory for the protection of medical records.
Mr Clement: Fair point.
Dr Cavoukian: The changes you've recommended, in our view, don't diminish the existing problems to begin with. You must start from a position where you're dealing with a faulty piece of legislation that doesn't incorporate the necessary privacy protection, and then you're expanding on that.
The Chair: Mr Clement, your time is also up. Could I suggest that since --
Mrs Caplan: We'll give unanimous consent to continue.
Mr Clement: I'm willing to live by the rules, Elinor.
Mr Wright: I've found the section.
The Chair: Could I suggest that those specific technical questions be put in writing and we forward them to you and we'll get answers?
Mr Wright: We'll be happy to, certainly.
Ms Lankin: Mr Chair, I'm interested in asking if you would try to find a way to facilitate an opportunity for the privacy commissioner to brief this committee on the technical aspects of the amendments he has proposed. We will have to be dealing with the clause-by-clause. I've already pointed out earlier today that with the hundreds of people out there, if they do write in, as the Premier has suggested, this committee is not going to have the time to read those. We've got very specific and technical amendments that we want to go a good job on. I believe we need a technical briefing, and I think in this circumstance the half-hour presentation has been helpful to begin to pave the way, but we would require that kind of assistance. If that could be worked out, I think we would benefit and the legislation would benefit.
Mrs Ecker: Mr Chair, to respond to that, if I may. I note, by looking at the schedule for today and tomorrow, there are a number of vacancies that we don't seem to have people booked for. Perhaps there might well be time for an additional slot for Mr Wright, depending on what the schedule might be.
Ms Lankin: May I suggest if people can't be found for that, that's appropriate. I would remind you that we're culling through the list, the clerk is, and it's very difficult to schedule people on short notice, but if people do say yes on short notice, they need to be given that preference.
The Chair: We have people waiting to present. Could I suggest we discuss this at 12 o'clock?
Ms Lankin: Fine.
The Chair: Mr Wright, you would be available if we could --
Mr Wright: I'm more than happy to assist the committee in any way I can. At this time of year it's extremely awkward. There are one or two staff members who simply are not available. I think we would be more help to the committee, if we were to provide that kind of information, if they could join with us. Otherwise, as I say, I'd be concerned, as when Mr Clement raised his question, that I might be fumbling a little bit to find the appropriate section. They might have it more readily at hand and it might make things move more quickly as well for the committee.
The Chair: Could we discuss it at 12 and then get back to you and set up a date that would be appropriate for you and for us?
Mr Wright: Yes, certainly; that's fine.
ONTARIO ADVOCACY COALITION
The Chair: Our next presenters are from the Ontario Advocacy Coalition: Orville Endicott and Patricia Bregman. Welcome to our committee. You have a half an hour to use as you see fit. Any time you allot for questions, we'll begin with the New Democrats.
Mr Orville Endicott: Good morning. I'm Orville Endicott, the coordinator of the Ontario Advocacy Coalition. My colleague is Patricia Bregman, who is legal counsel of what used to be called, and in fact still is on the front cover of our submission, the Advocacy Resource Centre for the Handicapped. ARCH has now changed its name to ARCH, A Legal Resource Centre for Persons with Disabilities.
The Ontario Advocacy Coalition, now in its 10th year, consists of close to 50 voluntary associations, most of which have as a majority of their members persons who have firsthand experience of vulnerability because of disability, illness or advanced age.
The coalition's primary reason for being has always been to promote the creation of an independent, publicly funded social advocacy system for people who are at risk of abuse, neglect or exploitation because of their vulnerability.
Most of what we have to say about advocacy will of course be reserved for the committee dealing with Bill 19, which will hold hearings early in 1996.
We chose to appear before you today because we think we have developed over the past decade some valuable insights about the distribution of power in a democratic society, and because we see the omnibus bill as a very ominous threat to the balance between the government's dual obligations of governing on the one hand, and empowering citizens, especially those who are typically powerless, on the other.
The exercise of bringing in the Advocacy Act and our close involvement in the preparations for its full implementation was an example of how this balance can be struck. Admittedly, governments must maintain some control over the way things are done and especially over the amount of public money that is spent and over the value received as a result of that spending.
What we want to say to you today has already been said very recently by the Ombudsman for the province of British Columbia. These are her words: "People are no longer prepared to let government act unilaterally or dominate their lives. People need to participate in decisions that affect their interests. They will strongly resist others making decisions on issues they feel are important. To be successful, social policies and programs can no longer simply be designed by a government official or department."
We think this movement towards citizen participation in public policy development is a recovery of the fundamental principle of democracy. It is a fragile movement, but we believe it is so crucial to the future of our free society that we urge you not to take any legislative or executive action to crush it.
Speaking of participation in the development of policy, I have to tell you our coalition has been particularly frustrated in its attempts to communicate with the ministry responsible for the advocacy legislation and related matters. Even with the assistance of the parliamentary assistant to the minister, we have been unable even to get an acknowledgement of letters we have written as early as July requesting a meeting.
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We had an occasion to meet the parliamentary assistant at a meeting on disability issues where he was a speaker, and he started off by saying, "It's very important that we hear from groups such as yours." The theme of his address was -- again, these are his exact words -- "Let's find our common ground and get to work on it."
We certainly appreciate that theme. Finding our common ground and getting to work on it is exactly what we want to do. We believe we can find common ground, not only with respect to the needs of vulnerable and impoverished people in our society, but also with respect to the need to trim the financial sails of the ship of state. We are the people with the greatest amount of experience in the art of doing more and more with less and less. The tools with which we do our work are very limited. The government has said it needs this legislation to give it the tools with which to restructure health and other social programs in order to eliminate the deficit. These, in this legislation, are quite clearly power tools.
Ms Bregman is going to focus on some of the specific provisions in Bill 26 which we believe will create too much government power over citizens and the services they require. She won't be able to touch on everything that is in our brief. She is responsible for the portions that she will be talking about. I urge you to take the opportunity to read it.
Ms Patricia Bregman: I appreciate being here and I will say that I was here last night watching some of it and I've been following them on television. I do, in the written submission, address some of the questions Mr Clement raised last night about the Health Insurance Act and the Canada Health Act. I'll talk about them briefly but they are more fully addressed within the text of this.
I want to start with an overview and talk about general problems we see. One is leaving power to regulation. Despite the government saying they have a red tape commission in place, this legislation adds enormous new powers. There's very little opportunity in terms of regulation for public oversight and there's nobody in this room who doesn't know what we've already experienced, the mistakes in regulations and the impact they have on the lives of people; in this case, people with disabilities in the social assistance system. We think that's particularly dangerous.
We are not suggesting that somebody is hard-hearted, but when you have a process that does not allow scrutiny -- and I should add that not only was there no scrutiny of this legislation after the fact but the normal process of consulting before the act was not there at all. I think you can attribute some of the outcry about lack of post-consultation to that.
I think you need to really think through the extent to which you give regulatory power in a process in which there is no public access and in which the doors, despite what we hear from the various ministers, are continually shut. Many of our member organizations have had the same experience as the Ontario Advocacy Coalition. They can't even get answers to letters and that's particularly disturbing. These are groups that said, when the government was elected, "We will work with you, we would like to try and work with you," and to have the doors slammed in the face is really disheartening to a lot of people.
Our second concern is the complexity of the regime you're setting up. Taken in pieces, some of it looks very good, some doesn't. But I don't see any sense of comprehensiveness of where things are going, how things will impact. You talk about tools. Really, what you're doing is giving yourself powers to restructure, but without an overall restructuring plan in place.
For example, look at the copayments which are going to negatively impact on people. You've introduced, I can't even count the number of copayments and user fees. You've given yourself the power, where they seem to impose on a particular group, to pull back, but what do you do when you have a municipality and you have a hospital and you have a doctor and you have an independent health facility and a drug plan all putting these user fees on an individual? How are you going to decide which one of those groups doesn't get to charge their user fee?
That's going to have enormous impact and I don't see anything in this legislation that says how you're going to set your priorities if people become overtaxed. There's a real danger within this without having that kind of framework. I can't get anybody who can explain to me how it will work because clearly those with the loudest voices are going to succeed and everybody will convince you that they need their user fee in place.
Having said that, I'm going to move on to specifics in terms of health care. We see the change in the definitions and in some of the changes in the powers of the general manager as significantly undermining the universality of the health care system. I'm not going to read it but I have excerpted relevant sections from the Canada Health Act to remind people what it talks about in terms of accessibility, which says accessible on the same terms and conditions for every user.
What you have done in redefining "insured services" -- moving away from "medically necessary" into saying "insured services are what the minister defines" -- is setting up a patchwork in which different people are going to have different services insured for them. It may be age, it may be facility, it may be hospital.
I've outlined, and I won't read, two scenarios that we would see as commonly arising. They may look very complex and confusing to you, but let me assure you these are real scenarios that come up of somebody who needs a service covered in health facility A and a service covered by a different eligible physician. Where are they going to go and how are they going to get there?
You're really creating a system that is looking at defining services no longer as universal, no longer on the basis of being medically necessary but on the basis of arbitrary categories, on the basis of finance, and that is not a way to set health policy that's going to work in the long run.
Regardless of the need to cut -- and we accept the need to change the way physicians are compensated -- but by doing it in a way that puts in categories that are going to allow enormous differential, I don't think anybody has thought through clearly what is going to happen when patient A needs a particular service, particularly where he or she has complex care needs. I'd urge you to read the two scenarios with care and really think through, what would you tell this person when they come?
I have to say at this point that we're particularly concerned about the age discrimination aspect. I know it was raised that it was in the Health Insurance Act previously, but I think, as the privacy commissioner said, number one, because something is in previous legislation does not mean it's acceptable and, number two, the Health Insurance Act was passed prior to the charter, so there wasn't any way in which that could be introduced. We clearly think it's discriminatory.
The Canadian Bar Association has done a very good analysis of the charter implications, which I can't give to you but perhaps they will give to you, that really raise the issue. I'm not trying to give a legal opinion at this point -- I don't have time -- but look at it very carefully. We think it will not stand up. I have brought with me and I'll circulate copies of an article about the Roberts decision, which was referred to yesterday and may give you a better insight into that case and what the Court of Appeal said in that. I've got it with me and I can pass it around.
The other part we're concerned about is this change in the general manager's ability to refuse to pay for services that are not only medically not necessary but therapeutically not necessary. It was raised that this is not very different, but we think there's a fundamental difference in this change. Medically necessary, you can have clinical guidelines and standards. Therapeutic is new. You only add new words to legislation if you intend to change what it's doing and the only logical reason, unless it's redundant, that you would add "therapeutic" is to narrow it.
Our concern is that where we're dealing with people with disabilities, whose lives are often undervalued -- and all you have to do is look at the coverage of Robert Latimer to know about how people undervalue the lives of people with severe disabilities -- "therapeutic" will become "Do I think that person's quality of life is worth living?"
I've referred to Oregon in here because in Oregon that's exactly what happened. In the Americans with Disabilities Act they could not go forward with a system that said you can look at quality of life and the "therapeutic" value of something. It's discriminatory and it may lead to people not being treated.
We have already been getting phone calls from people in Ontario: a paraplegic, for example, who is not terminally ill, who went to a hospital with pneumonia and the hospital said to his wife, "He's probably too much trouble for you and we don't think we're going to treat his pneumonia." That to me is something that is going to happen with increasing regularity if we allow this change and allow them to determine what's therapeutic.
I point out in the brief that part of the problem is we have no access to the whole process of decision-making as to what's medically necessary. Is the general manager, for example, going to tell patients that the care they received was not medically necessary, was not living up to the standard of care? Is the patient going to be able to make submissions to the general manager and say, "My quality of life is not what you might think it is, but it's important to me"?
You may have seen recently the profile of Judge Sam Filer, who has got ALS. He's lived for nine years and watched his son get married last month and watched his daughter grow up. He was told to die. They wanted nine years ago to disconnect the respirators.
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We need to really think this through, what the impact is going to be. It doesn't mean you can't make changes. Our concern is that you're racing ahead and making changes that are really going to have significant impacts on people, that nobody's thought about, nobody can deal with.
One of the big gaps in the act that we point out is that, as we go through all these user fees and changes of rules, you have not given the minister any authority to make exceptions. When you move into a categorizing system, which is what you're doing, what happens to the people outside the category? They're not going to get care or, alternatively, they're going to have to pay for their care.
I'm trying to give you the highlights from here, because I think it's really important that you understand that this is not something that is simply a matter of changing the rules and suddenly we're going to save all this money. In the long run, it is going to cost you money, because people will not get treatment.
In the US now, for example, in the managed-care kind of system you're introducing, I have a friend who couldn't call 911 without first calling for permission, because the doctor said it may not be medically necessary. "I won't be reimbursed so I'm not going to let you do it without calling first." I think we have to be wary of moving into a system that tries to micro-manage to that level. There are ways to deal with misuse and overuse of the system, and I think there are different ways. We would certainly be happy to work with you on ways that can do it without being discriminatory and without jeopardizing the lives of people with disabilities.
I'm going to skip ahead now and talk about one other piece, and that has to do with the Advocacy Act. One of our concerns is that we are now going to have a system with all kinds of new rules. They're going to be greeted at the door of a hospital and be told, "You have to pay this," and the doctor is going to say, "I can't do this for you." There's nobody there that's going to be able to speak for them. We are getting enormous numbers of calls from families and from other people.
At the same time that you repeal the Advocacy Act, saying it's interfering with the decisions between families and doctors and the health care system, the government has moved to go in and interfere and step into those decisions with blunt edges, and we're beginning to wonder if maybe the repeal of the Advocacy Act was not coincidental with this. This is far more intrusive. If you really want to get out of the lives and the decision-making, I think you really have to think through what you're doing here.
Finally, on the freedom of information act, I worked for the Krever commission many years ago and have followed this for a long time. You need to think through, in particular, the personal information charges. You're going to be collecting information about people, making decisions about their benefits, deciding what they can do, and not giving people access to the information even to be able to make corrections about what you're making decisions on. It makes no sense. The people who are most going to be affected again are not going to be able to have access.
I urge you to read the rest of it. I've tried to go through it to leave some time for questions. I think everybody knows we're available for further discussion or suggestions or comments on amendments. We think this is fundamentally important and we really would like to contribute in a positive way, and not see our constituencies hurt in the way that we fear they're going to be hurt right now.
The Chair: Thank you. We have about four minutes per party for questions, beginning with Ms Lankin.
Ms Lankin: Thank you. I would appreciate it, if you do give some thought to specific amendments, if you would share that with the committee, as we'll be working and developing amendments. I will take the time to read through your brief, and I'm sorry that there's not enough time for you to present that thoroughly.
I want to start with a question to the minister's parliamentary assistant, just a clarification if I can. You raised their concern of section 12 of schedule H, which amends section 18 of the Health Insurance Act. The old provision allowed the general manager to deny payment for services if they had reasonable grounds to believe that all or part of the service was not medically necessary. The amendment adds the words "or therapeutically." Could you tell me why the government is adding the words "or therapeutically?"
The Chair: Mrs Lankin, Mrs Johns is here as a regular member of the committee, not as the PA for the Minister of Health.
Ms Lankin: Who's here then carrying the bill that we could ask for that clarification?
The Chair: So far we've been submitting questions to the Chair and we've been getting answers from the ministry.
Ms Lankin: Normally the PA carries the legislation.
The Chair: In this particular instance, there isn't --
Mr Bartolucci: As a point of information, Mr Chair, clearly the member on the other side has offered her viewpoint as the PA in past presentations, so would it not be most fitting that she be given that opportunity to answer the question?
Ms Lankin: It's a clarification.
Mr Bartolucci: It's just clarification.
Mrs Caplan: That's right, and I have to tell you, in the 10 years I've been here I've never seen a bill go through without someone carrying it on behalf of the government. It's a point I made the other day. The parliamentary assistant is here, and it's her obligation to speak on behalf of the minister if there's a question on this bill.
The Chair: In this particular situation we are here to hear deputations from the public. You have been presenting questions to the ministry through the Chair, and we've been getting back answers quite rapidly.
Ms Lankin: This is a very quick question. The parliamentary assistant is here. She said the other day when she came back and took exception to the member for Oriole's comments that when she wasn't here she'd ensured that Mr Baird had come in to take her place to carry the bill, and she's back now. She indicated that. It's a very simple, quick question. I just wanted clarification before I go on to ask a question of the people participating.
The Chair: Do you want to take a five-minute recess?
Ms Lankin: For what reason? Why?
Mr Bartolucci: Can we discuss it during the recess?
Mrs Caplan: Mr Chairman, you don't take instructions from the government. You're the independent Chair of this committee. The standard of this committee is that if the parliamentary assistant is here --
The Chair: But I can make a decision to take a five-minute recess, which I have decided to do.
Ms Lankin: Mr Chair, before you do that, please, I withdraw my question to the parliamentary assistant. I don't want to take this group's time up any more with a recess while you get direction on how to rule with respect to whether they answer a question or not. I'll go on with other questions.
The Chair: The committee is recessed for five minutes.
The committee recessed from 1026 to 1030.
The Chair: Just for your information on that final exchange, there is no requirement in the standing orders, despite the fact that there might be some --
Mrs Caplan: Precedent and tradition? Practice?
The Chair: I have the floor, Mrs Caplan. There is no requirement in the standing orders that anybody be here to carry the bill.
Mrs Caplan: I have never, ever seen that.
Mr Alvin Curling (Scarborough North): Never seen that.
The Chair: So based on that, Ms Lankin, you were in the middle of your questioning, and you have a couple of minutes left.
Ms Lankin: A couple of minutes left.
Mr Curling: You might as well just go away, then.
Ms Lankin: Ms Bregman, let me ask you, with respect to the Health Care Accessibility Act: You raise questions -- and it's hard to get answers to questions, as you can see --
Mrs Caplan: Gross incompetence.
Ms Lankin: -- with respect to the bill's stated intent to allow user fees to be charged on insured services provided in hospitals, and yet we know under the Canada Health Act that where there are user fees on insured services, there is in fact a provision for those to be clawed back and/or the dispute like we saw in Alberta. I have been unable to understand from the legislation what manner of user fees or charges could be put on insured services in hospitals that wouldn't violate the Canada Health Act.
Ms Bregman: Basically, I took a look at the Canada Health Act -- and I thought I brought it and I didn't. The Canada Health Act will allow user fees on insured services in hospitals, but what they do is they claw it back. I'm having a great deal of difficulty understanding, then, why we are going to make people pay out of pocket, because the hospital, which is out the $1.3 billion or whatever -- you're going to lose the money in any case. In other words, it's not going to go against the deficit because the Canada Health Act, the federal government, is going to claw you back on whatever I pay.
That's my interpretation. You can get a legal opinion of the Canada Health Act. I'm not trying to give you a full legal opinion, but that is the provision within the Canada Health Act. It applies to both extra billing and user charges. Somebody has to look at that, because I have trouble with the fact that they don't limit what copayments can be in this legislation. It's clear it could be emergency services, drugs, whatever, because there isn't a restriction on what you can put user charges on.
The Chair: Thank you. Thanks, Ms Lankin.
Ms Lankin: Could I just place on the record a question to the ministry to clarify --
The Chair: After your time for this particular section is up, if you want to submit the question, we'll take it. To the government.
Mrs Helen Johns (Huron): Thank you very much, Ms Bregman, for being here. I would like to thank you for your presentation. As with the long-term care, you always make me think, and I appreciate that. I too worry about disabled people and have learned a lot about sickness versus just not being able to do things that the rest of us have. So I'm interested in your talk, and I'll read your document very fully as we move forward.
This is obviously a complex problem, and the government is really struggling to try and deal with a complex issue. I think some of the things that have happened are that the people have called for powers for us to be able to do some of the things we need to do, ie, restructuring. The Metropolitan Toronto District Health Council has asked for kind of exceptional powers for us to be able to get this done. We've tried for 11 years to get hospitals to deal with it, and we've been really unsuccessful. We've tried to deal with the doctor issues, and we've been pretty unsuccessful in that, having four years of unresolved resolution. So I guess from my standpoint, knowing how bright you are, I'm wondering, do you think that those powers are excessive, and can you see why we need those?
Ms Bregman: Yes, I do think they're excessive. I think there are things you need. Part of the problem with this legislation is that it's not enough time for people to really think through and come up with alternatives, and it's just too convoluted.
But I think what you've done has gone beyond that. You're really making fundamental changes. You're not simply giving yourself the power to deal with the doctors. I've worked in the health care sector for a long time, including health professions. I know the issues and I know the difficulties. But what you're doing is then going one step farther and now creating all of these new categories as to what insured services is going to be and who can do them. Nobody has thought through how this is going to work.
I was in the ministry for a year and a half on patients' rights issues. I can tell you that it's not going to work. You're going to end up with more of a patchwork system and overlapping and people not having services, and your minister is going to be swamped with people who say, "What can we do?" You try to exclude yourself from liability. I think you have to have some concern, and I raised it, that the kinds of decisions you're making are actually the kinds insurance companies make. I think you may have some problems with liability that you don't need to have.
I think there are ways of structuring what you want in a far more focused and targeted way and a time-limited way without having to fundamentally redesign what insured services are and how the various pieces are going to work together. I just don't see any justification for this whole package to go forth like that. You do need some power; that's fine. But I think you're going to in the end find you're hurting yourself to some extent.
I also have to say I think you're relying to some extent on the assumption -- I don't know if you've seen the Liberty insurance ads, but I certainly have, in the paper, saying, "We'll pick up your extra."
The other thing you need to keep in mind with this is that people with disabilities often can't get insurance.
Mr Bartolucci: I guess my problem here as I sit and listen to all the presentations is, do you feel as if you're a part of this at all? Do you feel you have ownership in this at all?
Ms Bregman: I don't, and I think that's going to be a problem for people because people really don't understand. I can read and I'm articulate. My concern is it's extraordinarily hard to get information, basic information, right now, and I'm not sure why.
I think this will change as the government gets used to being a government, but people right now can't even find out what the new rules are, and I think people are going to say, "What happened?" They're going to walk into their doctor's office in a hospital and their doctor's going to tell them something and it may or may not be accurate, but unless you do this type of change with education and input and a buy-in from people, it just isn't going to work. People are going to call up the minister and they're going to listen to every single person who tells them what's wrong. They're not going to have the facts, and we know that you can misrepresent things quite easily. That's what's going to happen.
Mr Bartolucci: I guess my biggest concern is, as I listen to the government members, that I don't think the people putting the legislation together understand the powers that they've given themselves. Clearly with the people that you advocate for, would you share that opinion?
Ms Bregman: I think they haven't thought through the consequences and the interrelationship. That's been something that's haunted health care reform, and both ministers previously have tried to deal with it. We always work on bits of the system, and even though this is all-encompassing, that's what's still happening.
I don't know if they understand the powers or not. I don't think, given the time it took to develop it and the time now, that anybody's really thought through, on the ground, how this is going to work. How am I going to take Mr X through the system? I think you have to test this kind of change on real people, on real situations, and with the people who are working at the grass-roots level with these people, to say, "Okay, if that's going to happen, what do we do to change it so it doesn't happen that way?" to avoid the unintended consequences which can be absolutely devastating.
People are really having a hard time now getting health care. More and more we're hearing: "We're not going to treat people with AIDS for pneumonia. We're not going to treat this." There's this all-encompassing, "The bottom line is everything." I think we have to send a message that, yes, the bottom line is important, but there are also other fundamental principles in terms of health care.
Mr Bartolucci: One final question. Do you not think it's critical that we split this bill?
Ms Bregman: Yes, I already said that.
The Chair: Thank you very much for your attendance. I apologize for using up more of your time than you had allotted to us, but those things do happen. We appreciate your attendance here this morning.
Ms Lankin: Is this an appropriate time for me to table my questions?
The Chair: Yes.
Ms Lankin: I would like the ministry to respond to three questions for me.
First, with respect to the Ontario Advocacy Coalition's submission, page 11, scenario A and scenario B that they set out, individual patients with multiple health problems and the effect of the redefinition of "insured services" and restrictions on what constitutes "eligible physicians," if they could look at those scenarios and indicate whether or not the perceived concerns are correct.
Secondly, section 12 of schedule H, which amends section 18 of the Health Insurance Act, which changes the restrictions on which the general manager can deny payment from reasonable grounds that services were not "medically necessary" to "medically or therapeutically necessary," adding the words "or therapeutically." I'd like to know what the intent of that is. If that could be clarified for us, it would be helpful.
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And with respect to the Health Care Accessibility Act, the question that's raised about user fees being placed on insured services in hospitals and the relationship of those actions to the Canada Health Act which Ms Bregman suggests, while allowing some user fees, would reduce the amount of payment the province receives. Could we find out if in fact that would be a potential outcome of any hospital introducing user fees on insured services as provided for in the amendments under Bill 26?
The Chair: Ministry staff have those questions. Okay.
Mrs Caplan: I'd like to add one further small question. It'll take just 30 seconds.
The Chair: Could we hold on that? We have some people that have given us their time. I think we'll hold the questions.
Mrs Caplan: I appreciate it. It just follows on Mrs Lankin's question and it will take me 30 seconds. I'd appreciate the opportunity to place it now.
The Chair: Carry on.
Mrs Caplan: What I'd like in a follow-up to the questions that Ms Lankin asked is not just what the intention of the government is regarding the scenarios that have been suggested by ARCH, but would this legislation permit -- is it possible that this could occur, not just the intention but the possibility that those scenarios could occur? Thank you.
RUTH LUNEL
The Chair: Our next presenter is Ruth Lunel, seniors consultant and advocate. Okay. You have half an hour to use as you see fit. Any time you allow for questions will begin with the government. The floor is yours. Welcome.
Mrs Ruth Lunel: Members of the committee, in fact I feel very lucky to be here today. I asked for a copy of Bill 26 of my local MPP so I could go through it page by page, and I was refused unless I paid for it. I went to an opposition MPP and received it free of charge on Tuesday evening. So I haven't had too much time to go through this bill. However, I am going to make a deputation on behalf of over 1,800 seniors that I service within Metro Toronto.
My name is Mrs Ruth Lunel. In the past 12 years I have been working freelance as a seniors consultant and advocate registered with consumer relations of the government of Ontario. My range in this field is everything from pre-retirement seminars to the demise of seniors or handicapped.
This so-called omnibus bill is and has been very upsetting to many persons in nursing homes as well as housing. Privatizing of these facilities will very definitely increase costs to the consumer and many will not be able to absorb these costs. Health care and housing, as well as food and freedom of speech, is a human right, but one which you are, as a governing body, muzzling the general public from participating in.
Mrs Caplan: Absolutely.
Mrs Lunel: Numerous seniors and handicapped are upset because of the fees you have decided to charge for medication, even though you promised not to touch health care. Many will not be able to afford especially the dispensing fee for dumping pills from one bottle to another and putting a label on it, or in many instances just placing a label on an already existing bottle. The price for just doing this is $6.11 per prescription. In regard to that, I am on nine different prescriptions, and for me to get those prescriptions filled, it costs me approximately $73 before I even receive one of my doctor's prescriptions.
Meals on Wheels for seniors have already been increased from $2.50 to $4 plus packaging, and seniors are being asked to order a week at a time and also pay for these in advance. If they don't show up, the senior is out of pocket.
Numerous seniors have no family members in close proximity and never worked, so the only income they have is old age security and guaranteed income supplement. Many have to rely on help from home care in order to live in a clean environment because of their disabilities.
Your government is actually causing real devastation in not only our senior population, but has cut off numerous necessary services which are there in order for these people to survive.
Would you do this to your own families? I do not think so. However, it behooves me to know who of a decent family would even recognize you who are now our elected representatives.
Waste of funds for district health councils and committees, as well as the Golden report, could have been put to much better use, and I happen to make deputations on a weekly basis to the district health councils.
Many of us who volunteer our services to help our fellow man will be placed into withdrawing our services as additional costs to us will make it impossible to continue. I can quote -- we have lost 80 volunteers within the area of Scarborough to date because of this.
Mr Harris, volunteers will not take up the slack which you are causing in our society. Volunteers usually give freely of their services and costs of gas, as well as wear and tear on vehicles, are consumed by the owners. I know I spend as much as 60 hours a week and sometimes more without compensation.
The fact that you intend to give the Minister of Health the right to access personal medical records is a direct violation of privacy and of one's human rights and your position does not exempt you from possible court charges because of this.
It is not your right to tell persons where you can work or to designate areas, especially in the medical profession.
You may also believe that housing should not be included in the health aspect of this Bill 26, but it is in many instances very pertinent. Why? Because numerous seniors still live in the government housing and with your idea of selling off these facilities, many are really scared of losing their homes.
The lifting of rent controls is also a very upsetting factor and is already causing numerous health problems. As a matter of fact, a little over a week ago I got a call from a senior. I ended up taking her to the hospital because she had had a series of mini-strokes. They advised me to take her back home. I told her I was not taking her back home. Within two hours, that woman was dead.
The freedom of information act is a very necessary acquisition for the public as so much is hidden from the taxpayers by politicians and much is not above board. There are no other means of access to numerous records to which the taxpayer has a right.
Mr Harris, your very dictatorial attitude toward the taxpayer who, in fact, is your employer, should have been more thought out and not been implemented so fast and furious. Dictatorship is not needed in Canada, especially in Ontario. However, before long our Canada will be worse than any Third World country. There will be more crime, street people and demonstrations.
Whatever has happened to government of the people, for the people and especially by the people?
In Ontario, one is better off in the criminal element as they are at least not threatened by loss of their home, no food nor a warm place to sleep and clothes on their backs. Also, they maintain their privacy as to their records, as many taxpayers are being subjected to cutbacks in welfare which takes all of the above away from children and the handicapped.
The Harris government must be very naïve because are you not aware that housing is and was subsidized by the taxpayers, as well as federal funds? How can you think that you can sell it out from under people?
Even I who have been independent all of my 76 years may not be able to maintain my home because of these added fees to my health care.
And remember, head tax defeated Margaret Thatcher. Defeat came to Brian Mulroney because of his trying to index seniors' pensions. Also, David Horrox, head of Scarborough school board, was defeated because of his domineering attitude. All these people were Conservatives. The electorate will not forget, as Mr Horrox found out.
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I would also like to read you an item that we presented to Mr Horrox and it says:
"What is a taxpayer?
"A taxpayer is the most important person in a politician's life.
"A taxpayer is not dependent on us, we are dependent on him.
"A taxpayer is not an interruption of our work, he is the purpose of it.
"A taxpayer does us a favour when he comes to us, we aren't doing him a favour by listening to him.
"A taxpayer is an essential part of this office, not an outsider.
"A taxpayer is not just money in our pockets, he is a human being with feelings and deserves to be treated with respect.
"A taxpayer is a person who comes to us with his needs and concerns. It is our job to look after them.
"A taxpayer deserves the most courteous attention we can give him.
"He is the lifeblood of this and every government.
"He pays our salary and provides us with added luxuries that we could never obtain anywhere in the private business sector, like one third tax-free salary; free travel all over the world; severance pay when not re-elected; early pensions before the age of 65 etc.
"Without him we would be out of our job, just plain nobodies," and don't you people ever forget it.
The Chair: Thank you very much. We've got about four minutes per party left for questions, beginning with the government.
Mr Frank Klees (York-Mackenzie): Mr Chair, perhaps I could lead off. Thank you very much for your presentation and I would just like to say at the outset that we certainly are very aware of the personal service that you've given to the community in Ontario and we want to commend you for that and, on behalf of the government, I certainly thank you for that.
I'd like to address a couple of issues that you've raised. I want to, for clarification, also point out to you that one of the great disappointments to us over the last month or so has been the degree of misinformation that has been circulating around the government's intent and around this act. One of the things that we're hopeful of is that through this process we can clarify some of those things.
We also want to assure you that it's certainly not the government's intent in any way to negatively affect seniors in this province. In fact, we're convinced that the steps we're taking to ensure the financial stability of the province will in fact ensure that the seniors of our province are looked after and that the needs they have will in fact be secure.
With regard to your concern about the cost-sharing on drugs, are you aware that we are the only province in the country now that doesn't have some form of cost-sharing on the drug plan?
Mrs Lunel: I travel right across Canada with seniors' housing and developing and one thing and another, and you can't tell me anything about my country of Canada, because I make it a point to find out exactly what's going on, where and when.
Mr Klees: I'm sure you are. The point that I wanted to make is that every other province in Canada has some form of cost-sharing and one of the things we're looking to do is to ensure that the seniors of our province in fact have the kind of safety net they deserve by ensuring that we bring some reasonableness into the cost-sharing around drugs.
I also just wanted to assure you that many of the -- I would call it perhaps propaganda around the issue of the information of security -- it's not the minister's intent to look at personal information regarding patients. The only thing we're doing in regard to that is extending the freedom of information access to those medical service facilities that aren't now covered under the existing act. The minister is not taking any additional powers on to himself now that don't already exist in the act.
Mrs Lunel: Can I just bring a point up here, the fact is that I cannot have my doctor release my records to another doctor of my choosing without my handwritten consent. Now, why does the Minister of Health figure he has the right to break that trust?
Mr Klees: He doesn't either, and it's only with regard to investigations regarding the possibility of fraudulent billings. Again, I think the important thing we have to understand here is that this is not about the government trying to access personal information, it's about the government ensuring the financial viability of the health system in our province. I think it's important for you to understand that.
Mrs Lunel: This leaves it open. Do they believe the billings from a doctor for patients? Because this puts the onus on the Minister of Health to definitely have trust in a doctor's decisions. If I don't have trust in a doctor, why do you people figure we should have trust in you?
Mr Curling: Mrs Lunel, I want to thank you for your presentation, your directness. One of the things that came out so blatantly is the fact that as you try to participate -- because we know how difficult it was to have people participating in this process -- as an activist, an advocate for seniors, you were told that you would be charged $18 for that.
Mrs Lunel: That's right.
Mr Curling: What member -- who told you that?
Mrs Lunel: Our new MPP in Scarborough, Mr Dan Newman.
Mr Curling: That is very unfortunate, because, you see, that is another part of shutting people out of the process.
Mrs Lunel: It definitely is.
Mr Curling: As a matter of fact, there are people who had gotten this bill who need two or three weeks to understand it, and you couldn't even get it. Do you feel in any way, with all this that's happening in the last couple of weeks, betrayed by this government?
Mrs Lunel: Definitely we've been betrayed, because nobody has had a sense of what has been going on. We got hit with this type of a bill. I got it a day before I came here from you, Mr Curling, thank you very much. I'm telling you right now, I still haven't had time to go through it the way I would like to. I guarantee you that when I get a chance to go through it, there will be another letter sent to Mr Harris. I am going to have a petition signed by every senior I can contact. I don't pull any punches.
Mr Curling: The minister made a statement here in his opening statement, an overview of what he intends to do. He selected individuals he said he has consulted with and whom he refused to consult with. One of the groups he said he refused to consult with is what they call "special-interest groups." To me, I try to put a face on those. Has he consulted you?
Mrs Lunel: Not at all.
Mr Curling: And you represented quite a few seniors from time to time over the years?
Mrs Lunel: As you know, I travel all over Ontario because I am called numerous times because of lack of information that I seem to have access to, not only from various areas where I visit but also even from the federal government, that is not forthcoming from our own local politicians or especially the Ontario government.
Mr Curling: As a senior, and the questions that you get from the government side, do you feel that you seniors are the cause of this deficit? I understand that this health strategy here that they're doing is to tell you that the seniors were the cause, so we've got to put a tax on all the things that they do. Do you get that impression?
Mrs Lunel: Alvin, the seniors are not responsible for the deficit; it's very poor management by the government itself.
Mr Klees: That's an insult.
The Chair: Mr Klees, Mr Curling was nice and quiet while you were speaking, I expect you to extend him the same courtesy.
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Mr Curling: Do you feel that if we break this bill up, this huge omnibus bill, this power-grabbing bill, this very dictatorial approach to it -- do you feel if the government would even try to break this bill up in many parts that it would assist us to understand it and to give better recommendation and advice to the government?
Mrs Lunel: If they put it in layman's language, as I tell many of the doctors to tell patients, it would be far more appreciated and more people would understand what the government was trying to do to them, and I think this is what is necessary.
Ms Lankin: Thank you very much, Ruth. It is terrific to see you again. It's probably been 10 or 11 years since I've seen you.
Mrs Lunel: Over 10 years, Frances.
Ms Lankin: And you're still fighting away. It's terrific.
I'm going to be very gentle with the member who's just joined our committee across the way and just indicate to you that Mr Klees provided you with some information with respect to the freedom of information and protection of privacy provisions of the act that was incorrect. But you took him on pretty good on your own, so we don't need to go in and correct the record on his comments.
I'm interested in a couple of things that you said that I didn't understand fully but that disturbed me. One, you talked about the obvious importance of volunteers and the reliance that government has always had on volunteers, and this government sees an increasing role for volunteers, but you talked about the various charges and fees that volunteers are facing in different areas which are becoming a barrier to them giving of their time, particularly seniors. Could you elaborate?
Mrs Lunel: I pay for my own gas. I take seniors to and from hospital, pay parking fees. I also go and visit seniors, and Veronica here can tell you the trunk of my car has a cooler in it, and I am never without milk, bread, vegetables and staples, because I find many of the seniors do not have sufficient to live on, and they can't get out to go to the food banks or anything like that, so I fill in. I have my bills at home, and up to date, out of my own picket, excluding gas and wear and tear on my car, I have spent over $12,000 on other people. And because of these new changes, I am going to have to stop all that, and when it comes right down to it, God knows how these seniors are going to get what I have been providing for them. I don't know. I never knew what was going on in my own community until after my husband passed away and I took this work on. As you know, I was a union steward.
Ms Lankin: I remember. Ruth, you talked about the copayment, the user fee, on drugs and the problem that would cause for some seniors, and I think we all recognize it's more of a problem for low-income seniors than it would be for some others.
Mrs Lunel: It is.
Ms Lankin: The group that presented just prior to you raised the concern of this bill, in other sections of it that we're not even dealing with in this committee, giving more powers to municipalities to impose all sorts of user fees. The cumulative effect of all of that, and also the challenge -- if one or two or three of these new user fees are income-tested and you're at that cutoff at $16,000, what do you get charged for and what don't you get charged for? If you have new user fees for drugs and for libraries and for your Wheel-Trans etc, the accumulation of this is a real problem. Can you relate that to the seniors you work with?
Mrs Lunel: They tried that in England, and you know what happened to Margaret Thatcher. If they try it here in Ontario, I can assure you, there will be more demonstrations by the elderly than we ever had when we went to Ottawa with Brian Mulroney's act of wanting to index seniors' pensions.
Ms Lankin: De-index, yes.
Mrs Lunel: There will be more of us out here on the park here than you ever saw in Ottawa.
Ms Veronica Hering: And they'll be supported by the people who live in housing, because we feel just as upset as seniors.
I just want to take this time to say that I'd appreciate if the government side would even listen to anything that's being said, because they've been talking the whole time and it's nothing but plain out rude.
The Chair: Thank you, Mrs Lunel. We appreciate your attendance here this morning and your involvement in the process.
ONTARIO MEDICAL ASSOCIATION SECTION ON PSYCHIATRY
The Chair: Our next presenters are from the Ontario Medical Association section on psychiatry, Dr Judy Hamilton and Dr Stephen Connell. Good morning and welcome to our committee. You have a half-hour to use as you see fit. Any questions would start with the Liberals at the end of your presentation. The floor is yours.
Dr Judy Hamilton: Mr Chairman and members of the standing committee on general government, my name is Judy Hamilton and I am the secretary of the section on psychiatry of the Ontario Medical Association. I am appearing today with Dr Stephen Connell, who is also a member of the executive of the section on psychiatry. I will make some introductory remarks about our work and then three general points about Bill 26 and psychiatric patients and practice. Dr Connell will then make several more specific points.
We represent the 1,400 psychiatrists of Ontario, all of whom are members of the section on psychiatry of the OMA. As well as our organization, these psychiatrists are also members of organizations representing their areas of work, for example, the Ontario Psychiatric Association, the Association of General Hospital Psychiatrists, the Association of Mental Hospital Psychiatrists and the Toronto Psychoanalytic Society. All of these associations are represented on the section on psychiatry and all have active memberships and executives who are constantly trying to assess and improve the quality of care of psychiatric patients under their purview.
Psychiatrists are first trained as medical doctors, mostly in the universities of Ontario, and then take four years of specialty training in psychiatry in general hospitals, mental hospitals, research hospitals like the Clarke Institute and community settings. They train in the treatment of adults and children with psychotic illnesses, severe personality disorders, symptom disorders like obsessive compulsive disorder, and people who have experienced traumas like the death of a parent or sexual abuse.
Psychiatrists work under what we call a bio-psycho-social model, meaning that we understand the person from the comprehensive view of their biology, psychology and social influences, how these all affect each other and how the treatments interrelate.
For example, a not atypical patient these days is the depressed, to the point of suicidal, 60-year-old man who has apparently fainted while in a preoccupied state of anxiety over the possibility that he will lose his job. A psychiatrist is in a position to assess whether this man is experiencing only a psychiatric, depressive illness; whether he might also be experiencing transient ischemic attacks -- that is, blood blockages to the brain -- which caused him to faint; which medications he could safely use if he has this or other physical problems; and whether his symptoms themselves may be the result of medicines he's taking.
To introduce the social part of the assessment, the psychiatrist may have to assess the 17-year-old son of this man, the son who is failing and avoiding school, using regular amounts of marijuana, having severe verbal fights with the father and has started having unusually prolonged headaches. The psychiatrist must decide how many of this family he should treat, whether individually or in a couple or a group, with what medicines or psychotherapy, whether or not anyone needs further physical investigations or hospitalization.
From the period of training on, psychiatrists tend to work mainly in the community, mainly in general hospitals or in mental hospital settings. Many of those working in cities with universities do various amounts of direct teaching or supervision of residents, interns, medical students and other non-medical professionals. Many of especially child and adolescent psychiatrists consult to community agencies, such as group homes, while geriatric psychiatrists consult to nursing homes and homes for senior citizens. Because of the complex nature of this work, much of it involves a great deal of consultation: consultation with other psychiatrists, other physicians, other professionals and agencies. One could say that psychiatrists are specialists in consultation, and at several levels, with individuals, families, groups, in assessing, planning and evaluating outcomes of interventions.
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Similar to many groups who have presented to you this week, we are very sympathetic to this government's attempts to reorganize the delivery of essential health and social services in such a way as to cut costs and reduce the deficit. We understand and agree with the concept that the security of such programs in the future depends on the reduction of not only the deficit but the resource-eating debt.
One of our major concerns about Bill 26, however, is the impression given that it was constructed without consultation with the involved service providers. We are concerned that this might be setting a precedent of non-consultation for the implementation of many features of the bill. Therefore, we would like to use our presentation to outline some reasons and areas within psychiatry which we think require and will benefit from consultation with psychiatrists.
For example, psychiatry has traditionally based its findings and methods on scientific principles and caring for people conceived of as sick and disabled. Our natural, scientific and attitudinal home is in the practice of medicine, and we have felt that this association was important, not only for maintaining the high standards of professionalism associated with medicine but also because this has served psychiatric patients well, much better than historically earlier conceptions of psychiatric patients as morally or religiously depraved or socially deviant or even gifted in clairvoyance.
Politically speaking, in Ontario and all other provinces, psychiatry has been part of the medical association, and as such has always had a relationship with the government and the public that has been negotiated. Bill 26 is planning to abrogate all agreements between the government and the Ontario Medical Association and manage the health care system more directly by regulations, cabinet decisions, adjudications by the manager of OHIP and so on.
Our concern about this aspect of Bill 26 is that by removing all the negotiating rights from us psychiatrists, this will expose our patients and their treatments entirely to the effects of the political process. This process would be the expression of both the government of the day, which at least has the authority and accountability of having been elected, and a relatively inaccessible, unnamed bureaucracy that also embraces ideologies and biases when it comes to health care in general and psychiatric illness and care in particular.
Now, this particular group of patients is especially prone to suffer from social and political prejudice, from lack of knowledge by other groups in society and from the promotion of false cures and misleading influences. Because a lot of the assessment and treatment in psychiatry occurs using everyday language and attending to people's thoughts and feelings, psychiatric patients are particularly subject to other people's thinking they know what's best for them, prescribing what is fashionable in the lay understanding and lay press without an understanding of the person's whole condition. Even members of the Legislature and the Ministry of Health might think that they could recommend and regulate certain treatments they themselves have found useful.
Therefore, in the context of the changes proposed in Bill 26, we urge the government to think about how to protect this population of people, vulnerable in an illness sense, from the dangers that might ensue from direct exposure to the political process, both at the level of the government and the bureaucracy, and we urge you to think about how to promote and ensure accountability in decisions that are taken with respect to psychiatric treatments.
Now, we don't think that the government, through Bill 26, is intending to get into the business of practising medicine, including psychiatry, but it does seem to be intending in a general sense to regulate the structures supplying medical care, including psychiatric care. There is currently an extensive program under way in the Ministry of Health directed towards mental health reform out of which changes in the structures delivering mental health care are being contemplated and, some hope, planned for. This planning process has consulted with very few psychiatrists, and this lack of consultation with psychiatrists in the area of mental health reform seems to us to be a harbinger, an indicator, of things to come under Bill 26. This is a particular problem in psychiatry.
For one thing, in psychiatric treatment the structure of the treatment is part of the treatment. For example, in physical medicine if a person has severe angina they require an ECG and perhaps an intensive care unit. But it does not much matter whether this takes place in downtown Toronto, in a suburb or even in a mall. However, for a person with a mental illness, certain structures or environments are not only not useful, they are harmful. This is documented in the psychiatric literature and is not obvious to the untrained. Hence, if there is not adequate consultation with psychiatrists, the ministry may find that it has phased out structures, certain kinds of groups and settings necessary for cost-effective treatments and made generally available settings useful only to a small subgroup of psychiatric patients.
Another problem with the lack of consultation with psychiatrists is that current and former psychiatric patients, especially that large majority who have been successfully treated, are often unable or unwilling to identify themselves in public. That is, the consumers of psychiatric services are not generally available to the government for consultation and feedback. This unwillingness of these patients to identify themselves may be because of prejudice against psychiatric illness in families and in the workplace, or it may be because these patients often want to leave that distressing part of their lives behind and do not want to speak up and participate in activities predicated on their future possible need for psychiatric treatment.
Politically, this means that these patients cannot defend their needs and wishes for scientifically based treatments or fight for their share of health care resources. Therefore, we urge the government, in the context of the changes proposed by Bill 26, to consult with psychiatrists in matters of psychiatric structures and treatments.
Now I would like to turn over to Dr Connell, who will speak on some specific proposals in Bill 26 as they apply to psychiatry.
Dr Stephen Connell: It's very ironic that the Minister of Health said the following to the Legislature on July 26, 1993, and I quote from Hansard:
"They're going to go ahead and just ignore all the good things the OMA and other people in the health care system have helped to bring about in the last couple of years. The government admits that the medical profession in this province over the last couple of years has probably saved the government upwards of $2 billion. They've done that through a system of negotiations, through the joint management committee, through this memorandum of understanding, through lengthy and legalistic processes that are set out therein."
We want Mr Wilson, as Minister of Health, to consult with us. We have a lot to offer in a constructive partnership. We cannot understand why this government that talks about stakeholders and partners in other areas of funding would jettison so completely the consultation and negotiation process in the biggest area of government expenditure in the province.
I now want to address four specific areas of concern in Bill 26: hospital restructuring, confidentiality and the protection of privacy of psychiatric records, affiliation with a facility and manpower distribution. Those are the four areas.
Let's begin with hospital restructuring. Psychiatric patients are hospitalized to either a provincially run facility, such as the Queen Street Mental Health Centre, or to a psychiatric ward of a general hospital, such as the Wellesley or Toronto General or Peel Memorial.
As many of you know, there has been an emptying out of psychiatric hospitals of patients into the community over the past 20 years. Psychiatry has met this challenge by focusing more on community based care, consultation and networking with families and front-line staff of agencies who support and treat these patients. Mental illness is often insidiously chronic, however, with patients rapidly decompensating at times and suddenly they urgently need hospital beds.
In Metro Toronto, we're already short of these beds, and doctors have to spend hours sometimes hunting down a bed for a sick patient in need of admission or certified as having to stay in hospital because they're at risk of harming themselves or others.
If hospitals are closed or downsized or merged, we are concerned that our patients won't have the psychiatric beds that they need. You can't put an acutely psychotic or suicidal or homicidal or terrified trauma victim on a waiting list like you can for elective surgery.
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We urgently need to meet with the Minister of Health to ensure that the needs of our psychiatric population are not abandoned when hospitals restructure or close or when he determines the type and volume of services to be delivered in a hospital. The issue is not one that the government or mental health reformers or the district health councils have consulted us on. We want to help and be consulted to avert a crisis. Don't leave us in the lurch with our patients roaming the streets in danger. We want to be part of the solution.
Confidentiality: Trust and confidentiality are crucial for successful psychiatric care. The deepest secrets and sources of shame lie in our patient records. Presidential candidacies -- for example, you might remember George McGovern -- have been ruined by the invasion of the privacy of a psychiatric record. Up to now that could be guaranteed not to happen in Ontario.
Defrauding OHIP is wrong and we unequivocally support the government in eliminating it. Our patients have received audit letters from OHIP. They're asked to confirm that a service of a certain value has occurred on a certain date, and I believe they cooperate with OHIP. Some of them tell us they received their notice; I suspect others don't.
It's our view that this system should be sufficient to audit service delivery when carried out in conjunction with the tracking of billing profiles for individual doctors and medical practice audits. All of this occurs at the moment without any invasion of confidentiality or privacy.
This Bill 26 empowers the manager of OHIP, as you know, through ministry-appointed inspectors, to seize and examine medical files, determine the medical necessity of services and interview medical office staff without the knowledge of patients. People suffer as a result of violations into their psychiatric records. They've often suffered from intrusions and abuse of power. Some suffer from disorders of trust. The building and preserving of trust would be prevented by the threat of unknown others having access to their files. Psychiatric patients feel very, very strongly about this.
We must urgently consult with the minister to help him find a way to prevent further damage while eliminating the fraud. We urge him not to just listen to his staff but also the patients and psychiatrists who only want to optimize the process of treatment and recovery in a cost-effective and responsible way that also eliminates fraud.
Affiliation with a facility: The bill requires new psychiatrists to be affiliated with a facility in order to obtain a billing number. This makes no sense to psychiatric practice. We work in the community in a network that involves primary care practitioners, agencies, families, schools, workplace and patient. Often we see families or couples or treat people in groups. We try terribly hard to keep patients out of hospital and away from institutions, and we're often successful in that.
The costs of hospital-based treatment, whether inpatient or outpatient, are more expensive than that which we can provide in our offices. We get paid the same whether we treat a patient as an outpatient in a hospital or in our office or in a clinic. Most psychiatric patient care is delivered in private offices. This is the successful model of health care delivery in Ontario. Why change it?
Someone seems to advise the government to have psychiatrists migrate to hospital settings. We see no rational basis for this. It's wrongheaded. It will mean a huge shortage of psychiatrists and waiting lists for appointments, because there are no way near enough hospitals to absorb all the psychiatrists. There are 1,400 of us. Figure out how many hospitals you need to attach everyone to.
The move in psychiatry is away from institutional care and towards helping patients remain in communities. We just don't understand why the government is promoting a reversal of this, and we ask to meet urgently with the minister in order to preserve and enhance the mental health care system, not send it backwards.
I'm originally from New Zealand. As many of you know, some of the reforms proposed in the Common Sense Revolution have been tested out in New Zealand with success in terms of economic indicators. The health reforms there, however, have not been handled well and it's been disastrous for psychiatric patients. I'm sad to remind you that the Globe and Mail reported several months back that New Zealand now has the highest suicide rate in the western world and that the homicide rate has skyrocketed to be third after the United States and Scotland.
We urgently ask the government to consult us to ensure that health care reforms that promote efficiency and economic reform don't result in a psychiatric disaster. We need to work together with you to learn from societies such as New Zealand so that we can preserve the Ontario tradition of quality mental health care and excellence in psychiatric care and training. It's all too easy for ill-informed bureaucrats to push agendas that might sound trendy or adversarial. We're very worried about the future of mental health care in Ontario and feel it can only benefit from proper process and scientific rigour in examining all the alternatives in a framework of partnership.
Manpower distribution: We're acutely aware of the manpower shortages in psychiatry in areas of Ontario. Our colleagues, beleaguered in these communities, have been working with us, with teaching hospitals and with other professional bodies to come up with solutions. Why is the government unilaterally coming up with measures in Bill 26 without us, the providers, being consulted? We want a partnership in solving the problems so that the most intelligent, workable solution to equitable distribution of psychiatric care to all Ontarians occurs. We need to meet urgently with the Minister of Health to share our ideas and projects and invite him to work with us.
Some of the ideas that we've had about this: There needs to be a good fit between the psychiatrist and the community. Just as trust is pivotal to individual care, the psychiatrist who is accepted by his community and the agencies in his network will build, usually by word of mouth, a confidence that allows psychiatric patients to come forward for treatment. Psychiatrists who resent being sent to communities in which they work will not be as effective in being accepted by the community.
For this reason, we view secondment and forced distribution of psychiatrists to be the least desirable approach to solving the manpower problem. We're disappointed that the government has jumped to this option while ignoring a cooperative, integrated and coordinated partnership to achieve the same goal.
The locum program has been helpful for GPs. This could be extended to psychiatrists to bring immediate relief to underserviced communities or to relieve beleaguered psychiatrists.
The provincial coordinating committee, PCCAR, a group of academics and members of government, has been working on a comprehensive manpower plan. We support this initiative, which will provide for a critical mass of integrated specialists/subspecialists for each region in Ontario.
Academic centres are moving towards developing rural psychiatrists and help them move to rural communities.
Alternate payment plans may be helpful in attracting psychiatrists to underserviced areas. There should be flexibility about where that money comes from to ensure that we have psychiatrists who want to go to a community, who can be on a direct contract, for example, to that community.
We are currently proposing to the OMA changes in the fee schedule to encourage psychiatrists to staff psychiatric inpatient units and to provide consultations to the community.
Psychiatric treatment is time-limited and often long-term as conditions are chronic. A psychiatrist can only treat a limited number of patients properly in any day. Psychiatric utilization is a function of the incidence of mental illness and the demands that competent treatment places on the psychiatrist's time. Moving psychiatrists from one community to another or from the community to a hospital will not address the treatment needs for Ontario's psychiatric patients. Each psychiatrist will earn the same amount of money whether he works in an office in London or a hospital in Sudbury, for there are only so many hours in a day. Manpower distribution is best addressed by partnership and consultation, not manipulation or Big Brotherism.
We're prepared to work with the government to solve the problem. Under Bill 26, it would appear that the government is not prepared to work with us. This places the psychiatric care of Ontarians in jeopardy.
Already we have a mental health reform process, started under the previous government and nurtured by the bureaucracy within the MOH, which is attempting to design a health care system without consulting psychiatrists at large. This is a huge waste of time and money and only promotes bias and division.
We offer the government and the Minister of Health sincere consultation and partnership and we hope that reason and common sense will prevail and we can participate with you in planning for mental health care in Ontario.
The Chair: Thank you. We have time for one quick question from each party, beginning with the Liberals.
Mr Bartolucci: Let me get back to the privacy of information. I think the bond that you have between patient and doctor is that of trust. Do you feel that the foundation of this trust is destroyed with this legislation?
Dr Connell: I do. I'll give you an example. I have a patient whose insurance company wanted to get all of the files. I filled out a form explaining what the conditions were and what I thought the prognosis was, and they wanted a copy of her entire file. She refused to go ahead and get life insurance on that basis, because she did not want any other party to examine her psychiatric file.
They feel very strongly about this. They don't want any invasion. It's hard to appreciate if you haven't known someone who's been in psychiatric care or if you've been in it yourself, but there's a tremendous amount of time it takes to build the trust that allows this material to come out in session after session, and it's all in the file. We don't see any reason that financial or fiscal concerns to eliminate fraud should have any access to that information. They're just not linked in our minds.
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Ms Lankin: Dr Connell, I wanted to ask you about the elements of your presentation dealing with young doctors, and I guess the billing number restrictions and those sorts of things that you raised. We heard from a group of psychiatric residents last night who raised concerns about underserviced specialties in a sense here within the city itself, where there's perhaps a larger population of chronically mentally ill and I guess an underserved need for various types of communities there.
I have a series of statements by a number of doctors, and these numbers are growing, and I hope over the course of the next couple of days to get them all on the record, one of them from Dr Walter Rosser, chair of family practice, University of Toronto. He says: "All of our residents are being inundated with requests to go south of the border. Three weeks ago, when Bill 26 was introduced, residents in Toronto surveyed all of the members that will be graduating from our program in June; 80% of them said that if these changes come through, they'll leave the province and go south of the border."
Are you worried about what will happen with the psychiatric residents and the supply of psychiatrists, not just in terms of those who unhappily go to other areas of the province but the service needs here in a large metropolitan area as well?
Dr Connell: I don't know if you've had any experience of trying to get a psychiatrist in Toronto at the moment, but it's very difficult.
Ms Lankin: I would just call you. You live in my riding.
Dr Connell: This can't be allowed to happen. We can't allow this to happen. We have to address and consult and develop a plan not just to maintain the service delivery that we've got at the moment, but to rationalize the delivery for the whole province. We can't allow it to decline any further in Toronto, let alone the rest of Ontario. We have colleagues in Sudbury. They're very short of psychiatrists up there, for example. There's one guy left and another three have gone. We try to help these guys out, but we've also got huge demands on our time here in Toronto. It just can't be allowed to happen.
Mr Klees: Dr Connell, how many psychiatrists currently are practising in the province of Ontario?
Dr Connell: Of the 1,400, I'm not sure how many are actively in practice.
Mr Klees: But we have 1,400 psychiatrists in the province of Ontario. I'm very interested in hearing from you on an issue that I'm personally very close to. I represent York-Mackenzie, which is Aurora, Newmarket, King, the northern part of York region. This past year, within the last three months, we have had to make special arrangements to bring a psychiatrist from South America because we could not find a psychiatrist to come to York region from anywhere in the province. How do we deal with this?
Dr Connell: I'll give you my experience. I got my immigration on the basis of serving an underserviced community, which was Brampton. I worked at Peel Memorial Hospital for three years, served that community as a psychiatrist, and that helped them out and it helped me out.
Mr Klees: Are you suggesting that for all of our underserviced areas in the province of Ontario we have to recruit from outside the country?
Dr Connell: No, but I'm giving you one example from my own personal experience of how --
Mr Klees: But that was your experience; it's now ours.
The Chair: Thank you, doctors. We appreciate your involvement in our process and we appreciate your being here.
Ms Lankin: On a point of order: A member should allow a presenter to answer the question, if you're asking a question.
Mr Clement: That's news to your side.
Interjections.
The Chair: We have one issue left outstanding from earlier that we said we would deal with, and that was the question of whether or not we would allow some time for the privacy commissioner to talk to the members of the committee. Can we have this discussion, please, folks? We have several openings available to us in the schedule: one this afternoon at 3 o'clock, three this evening and some tomorrow. I guess the first question is, do we have general approval or unanimous consent to be addressed again by the privacy commissioner?
Mr Bartolucci: Yes.
Ms Lankin: Yes.
The Chair: Okay. We have two yeses.
Mrs Johns: Did he not say he didn't have people available to address us today?
The Chair: I don't know about today, but the issue is, do we want him to address us? That's the first issue.
Mrs Johns: I see. Okay.
Mr Clement: If it's available and if no other person wishes to take that spot, based on the agreement of the three persons on the subcommittee --
The Chair: So we have unanimous consent that we would like the privacy commissioner. How much time do we need? Does anybody have any thoughts about how much time we need?
Mr Bartolucci: Why don't we slot it for tomorrow and why don't we slot it for an hour, and if we don't use the whole time, then we can do lots of the housekeeping stuff in the morning and get it out of the way. I believe tomorrow would be very appropriate because we will be in a different room and there will be more people who will have the opportunity to hear his comments.
Mr Clement: We don't have any time in the morning, Rick, tomorrow.
Mr Bartolucci: We don't have time?
The Chair: The only time we have tomorrow is that we have half an hour at 1:30 and then we have the afternoon from 2:30 on. We have to stop at 6, but we have no appointments for tomorrow afternoon. By the way, there is no waiting list to appear before this committee. There are a few names out, that we have invited people and we haven't answers back yet, but there's no outstanding waiting list.
Mr Bartolucci: Let's firm this one up first then, all right, Mr Chair? How about tomorrow afternoon then and we'll slot an hour?
Mrs Johns: I think he said his people weren't here this week.
The Chair: We'll deal with that with him.
Mr Bartolucci: Excuse me. I believe he said he would be happy to meet with us again, but that he was short-staffed.
Ms Lankin: I understand what you're attempting to accomplish, Mr Bartolucci, but I would prefer, given that I made the request in the first place, to have the privacy commissioner come forward when he has a full team of staff available with him so that we can actually have an in-depth briefing on the proposed amendments. I suspect that means it will be sometime in January when we would be able to do that with him.
If you could contact him and if he is available, with staff, to come tomorrow, that would be fine. I would appreciate tomorrow rather than today, because I'd like to have some time to read the amendments so that I'm actually a step ahead and can have an informed discussion with them and have some questions ready. That would be fine, but I suspect it would be more appropriate for his schedule and staff to try and do it some time in January. I would urge us not to do it without his staff backing that he suggested he would need to have a full briefing.
Mr Clement: I tend to agree with Ms Lankin. There's no point in wasting his time and our time if he does not have the staff necessary to put his position accurately on record. If we have questions, and I did not mean to embarrass the privacy commissioner with my line of questioning, but it would be helpful obviously if we have some time to go over his amendments and he has some time to go over our concerns. That process in January makes a lot more sense to me.
The Chair: Okay. We've got a bit of a problem with January of course, in that we're not going to be in town until clause-by-clause. That presents a bit of a problem in January. There may be a solution around that.
Mr Clement: Are we oversubscribed for Hamilton, for instance? That's pretty close to Toronto.
Ms Lankin: That's the last day so that's not that helpful.
Mr Clement: That's the last day. It's right before clause-by-clause, so it's almost appropriate.
Ms Lankin: I don't know whether this is possible, and members may well have made plans and I would understand it if it couldn't be possible: I was thinking even of a voluntary briefing session being established for the Friday before we start to go out of town. I think that's the 5th or something like that. The only thing I would request is that I would like it to be on the Hansard record.
The Chair: I throw this out as a possibility.
Mrs Johns: We come in very late at night on a Friday. We'll all obviously be here Saturday morning. How about the Saturday morning? We come in very late. We leave Kingston at 9:30 at night and come in, and then we go out at 2:30 on the Sunday, so we'll all be in town, probably, because we from out of town won't have any opportunity to go home that weekend.
The Chair: Could I make a suggestion? When we start clause-by-clause, the time allotted is 10 am to 6 pm. Could we take the first hour, take 9 o'clock on the first Monday of clause-by-clause, from 9 to 10, for the privacy commissioner? Then it's fresh in our minds. It's after we've had all our consultation and it's before we do clause-by-clause.
Clerk of the Committee (Ms Tonia Grannum): Could I just say something on the record? The order of the House says on the week of January 22, 10 am to 6 pm to complete clause-by-clause. We're not authorized to sit January 5 either. Was there a suggestion on another date that I heard?
Mrs Johns: I just wanted the Saturday, so we wouldn't be authorized for that either.
Clerk of the Committee: Saturday we're not authorized to sit either.
Mr Clement: I think we should see what his availability is, and our availability. I don't want to crowd out anyone from Hamilton, but maybe that's a possibility.
Mr Bartolucci: It may resolve itself if he can get his staff tomorrow.
The Chair: We've got unanimous consent for the privacy commissioner for an hour with his staff at the best available time for all of us. Can you leave it up to the Chair and the clerk to try to schedule a time and report back?
Mr Clement: My only caveat is if we are taking it during regularly scheduled time, I would like to shave it back to half an hour if there's demand. I don't want to knock anybody off because we've agreed to the privacy commissioner.
The Chair: I don't even think we'd knock half an hour off if in fact there was a member of the public who wanted to present.
Interjections.
The Chair: Okay. We're recessed until 1 o'clock.
The committee recessed from 1140 to 1306.
ONTARIO PSYCHIATRIC ASSOCIATION
The Chair: I think we will begin as close to on time as possible, and we understand the Liberal member is on her way.
From the Ontario Psychiatric Association, Dr Edward Rzadki and Dr Alan Eppel. Welcome, gentlemen. We appreciate your being here. You have a half an hour to use as you see fit. Any time you allow for questions will begin with Ms Lankin from the New Democrats. The floor is yours.
Dr Edward Rzadki: Thank you for giving us the opportunity to appear before your committee. I'm president of the Ontario Psychiatric Association and I'm Edward Rzadki. Next to me is Dr Alan Eppel and he's chairman of our public affairs working committee.
Bill 26 is an unwieldy, multifaceted kind of bill, and we've had a short time to really deal with all the issues. However, first let me be complimentary. The Metropolitan Toronto District Health Council has recently gone through a couple of years of planning where they involved many stakeholders. There was a lot of consultation. There was much consensus-building, a lot of data, a lot of evidence, and they came up with some recommendations.
I can understand that the present government, in order to implement the recommendations, will need to make some changes in the legislation to allow those things to take place. The concern I have of course is that the powers may be too lengthy, and perhaps these powers, powers of the implementation commission, should be time-limited until the implementation is completed.
I'm going to turn it over now to Dr Alan Eppel to discuss more about the process issues.
Dr Alan Eppel: Firstly, I think that the issues the bill attempts to address are real. There are significant problems that we are faced with in the health care system and certainly within the psychiatric system -- problems of maldistribution, underserviced areas, shortage of specialists in various capacities and the difficulties with access for many of the patients and those in the community who need care. There are real problems and there have been difficulties attempting to resolve those problems.
There are times when we're all called upon to maybe give something up or make sacrifices for our province or our country, and this is one of those times that all of us in Ontario now face. However, the powers in Bill 26, as you know, are very sweeping and potentially arbitrary. So one of the main issues is the need to build in some fair process. The power of the bill allows the minister to make hospital closures, designate areas where physicians may practice, as you're all familiar with; I won't repeat them all.
All those powers are very dramatic, very sweeping, and there are no checks and balances in terms of a fair process to use objective criteria -- medical evidence, health care evidence -- to make those decisions, and there are no processes of appeal. So I think the major, general, global factor about this bill is that the powers in it lack fair process and due process of appeal.
Dr Rzadki: I'd just like to tell you a little bit more about the Ontario Psychiatric Association. We are a voluntary group. We represent organized psychiatry in Ontario. Our aims are to develop professional education and excellence in the clinical practice of psychiatry. We also advocate for the mentally ill and we advocate for an improved mental health system for Ontario. These are part of our objectives in our constitution.
Back to some of the specific issues about the bill: The issue of confidentiality is key to building trust with our patients. It's difficult enough to build trust these days, and anything which interferes with that will seriously impair the therapeutic alliance that's very necessary for psychiatrists and all physicians to produce the kind of results that we want. We're very concerned about that part of the bill.
The government also wishes to introduce tremendous coercive, punitive powers in terms of obtaining information from doctors' offices. My understanding is that that's already available through the Medical Review Committee. So I'm puzzled why more powers are required.
The $2 user fee for prescriptions is a very serious concern for those of us psychiatrists who practice in areas that deal primarily with the seriously mentally ill. Many of our patients who are seriously mentally ill are on welfare, and if they need to add money from their pockets to buy medication, that's going to be extremely difficult. Many of them are functioning in the community at limited levels of function and only because we've been able to convince them that medication is necessary. So anything that would interfere with their ability to continue to maintain the treatment that keeps them well and keeps them out of hospital is a very serious concern to us. We believe that if it interferes with patients' ability to continue treatment, the costs will be even greater because they'll have to be admitted, perhaps, to hospital where we know the costs are higher.
The Ontario Psychiatric Association doesn't negotiate fees, but we're very concerned about those areas that Dr Eppel mentioned. There are underserviced areas in Ontario. It's not just geographic. In the north certainly there are problems. However, there are programs that have been introduced, with the cooperation of psychiatrists and the government and the mental health branch of the government, as in Thunder Bay and Kenora, that allow cooperation, consultation, consensus-building, commitment to provide a program -- and those things work. One doesn't have to be coercive in order to get programs to work.
First of all, one needs to decide what kind of program you want. That requires a lot of consultation. Once you decide on the goals and objectives of the program, you need to provide the resources to make it work. I think in Ontario we can do that, and there are examples where that's already been done.
You've heard this before, but psychiatrists are different. We're physicians, but we're a little bit different. We do a lot of indirect service, consultation with non-patients, allied to health workers who provide more direct care to our patients. We call that indirect service.
In the past, indirect service was funded separately. Recently, since the social contract, 25% reductions in these indirect sessional fees have resulted in more difficulty obtaining psychiatrists to work in those areas where you really require a lot of indirect care. There just aren't enough psychiatrists to do one-to-one care. Even in Toronto it's difficult to get a psychiatrist, where we think we have a lot of psychiatrists. But has anybody here tried to get one? It's not that easy. That's one area we're concerned about.
I've already mentioned the Metropolitan Toronto District Health Council report, and I just want to emphasize, even though not everyone's happy with the results of the recommendations, that process did attempt to involve many players and attempted to get the appropriate information. I think that this government, in its effort to improve health care, to improve the system of health care, should be using those kind of methods to improve health care, the methods of continuous quality improvement, where you need the appropriate people involved, where you look at processes and not just bad apples, not just bad people. If you improve processes, I'm convinced that you can improve programs.
In summary, the Ontario Psychiatric Association supports mental health reform with its emphasis on the coordinative, comprehensive system. We also believe we need better information systems to measure outcomes and effective treatment methods. We will be submitting a written brief before January 19, which will be a bit more fleshy than our verbal presentation. I thank you, Mr Chairman, for your attention.
The Chair: Thank you, and we look forward to getting your written brief. We've got about six minutes or so left per party, beginning with Ms Lankin.
Ms Lankin: Thank you very much. I have questions in two or three areas that I'd like to raise with you. If I could start, first of all, on the issue of the powers given to the restructuring commission and the minister with respect to closure and merger of hospitals etc, we've heard a number of concerns about these. Other people have suggested this should be time-limited -- not just the commission, by the way; the extraordinary powers in section 6 given to the minister to do just about anything he wants as well. Those people were saying if it is necessary to accomplish the restructuring, make it time-limited; let's not leave this in there forever. Would you agree with that approach?
Dr Rzadki: We would.
Ms Lankin: The one thing I wanted to ask you about is, you said when you started off, in wanting to be complimentary, that you believe, for example, an important piece of work like the district health council restructuring report for Metro Toronto, if the minister needs powers to implement that, they should be there. I'm wondering whether you have had any advice or if you've formed an opinion based on the legislation that he actually requires these new powers to do it. I know that's the reason the government's given, but I have some reason to question that, based on my own experience in the ministry and some legal work that's been done. Have you just accepted that or do you have reason to believe that?
Dr Rzadki: I'm not familiar or very knowledgeable about what powers the minister has at the present time, but I'm told that the minister cannot at the present time close hospitals.
Ms Lankin: I think that stems probably from the Doctors' Hospital decision. At that point in time there was a decision that a hospital couldn't be closed solely for fiscal reasons without looking at issues of patient care etc. I would argue that's a far cry from what the DHC's gone through in terms of the community consultation in the report. But that's an issue for us to work through.
You talked about coercive power and restricting billing numbers in dealing with the problem of underserviced areas. We know that there have been a couple of processes put in place. The Scott report was commissioned by the previous government and came out just before the election, and the previous government was committed to it and this government says it is. PCCCAR, the Provincial Coordinating Committee on Community and Academic Health Science Centre Relations -- have you been involved in that?
Dr Rzadki: As a matter of fact, the Ontario Psychiatric Association is always involved, when invited, in any kind of mental health planning, and we currently are involved in a subcommittee on psychiatric human resources, a subcommittee of PCCCAR.
Ms Lankin: I guess my problem is, we haven't got Scott implemented yet. It just came out a few months ago and there was an election and the government's now said they're going to implement it. PCCCAR is coming up with recommendations and those have to be put in place and we have to see how that affects the service, and yet they're saying if we don't have these problems fixed out there by June, when the next group of graduates is just going to be graduating anyway and won't know where they end up practising, it seems to me to be precipitate. What is your expected time line for PCCCAR and how that could influence the distribution into underserviced areas?
Dr Rzadki: The committee the OPA sits on is just one subcommittee of probably many that PCCCAR has dealing with the supply of physicians across the province. Our time line is to have a recommendation some time by February or March. My understanding is that if the recommendations are accepted, they may be enacted some time in the spring.
I like the process. It's a consultative process. It involves the stakeholders that need to be involved in looking at human resource issues, especially when it comes to underserviced areas. I'm supportive of that process. It worries me that without looking at the objective data, looking at evidence, looking at what the opinions of experts and consumers are, decisions may be made which may not be appropriate.
Ms Lankin: Just one last comment that I'll leave with you: The minister has been overheard to say that if you can sort through these issues and solve these things, then he may not use the powers in the legislation.
I have a wonderful quote from Hansard of him attacking the former Minister of Health, Ruth Grier, saying: "Oh right, you're going to put a gun to doctors' heads. You're going to tell them that you're not going to use this power in the legislation; it's only there if they don't negotiate. You don't know what you're going to come up with in negotiations, but you know what draconian powers you need to use behind closed cabinet doors." That's almost verbatim, I've read it so often. So I don't buy that as an answer from him on this. I too trust in the PCCCAR process and I hope you'll have an opportunity to implement those recommendations.
Dr Rzadki: Here's another one for you: If you want to catch barracudas, you don't need a minnow net.
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Mr Klees: Thank you for your presentation. In the past, the ministry has requested hospitals to protect mental health services in the province, and generally our sense is that this hasn't always happened. Bill 26 provides the ministry with some additional clout, if you will, to ensure that essential services are indeed protected. Do you agree with that measure and could you comment on that?
Dr Rzadki: Absolutely I agree with that measure. I'm happy to say that the Metropolitan district health council in its final report to the minister has, in bold face, suggested that acute-care general hospitals with psychiatric beds should have some protection, given the tremendous restructuring that will take place and changes in the fiscal realities. I applaud that and the OPA certainly supports anything that will maintain beds as they're needed until the community services are in place which might obviate the need for beds.
Mr Klees: You're aware that the minister has clearly stated that with regard to the power relating to control of billing numbers, he does not intend to use that, that he would prefer to see some initiative coming forward from the medical profession to solve that problem, but that if it doesn't get solved, he needs to know that there's something there he can rely on.
With regard to psychiatric services -- my home riding is York-Mackenzie, the northern part of York region. At York County Hospital specifically, we had a situation this past year, in June, where all the psychiatric staff walked out of the hospital, resigned. We have been scrambling to get some service in place. We've had to recruit a psychiatrist from South America to provide services in that hospital. This is an ongoing problem. Do you have anything in mind, beyond the minister having to resort to billing number allocation, to solve that problem?
Dr Rzadki: You mentioned a very specific area and location. It's Newmarket. The problems the psychiatrists there were having were very specific. They were not provided with sufficient non-medical support. You might be aware that in Newmarket there are many homes for special care or homes that deal with patients who have been discharged from psychiatric hospitals. This hospital was getting a lot of patients suddenly living in their community without appropriate resources to deal with them. I'm familiar with that situation and I understand why they resigned.
But the important thing is that if the government wants to support those areas where there are problems, we need to look at incentives that will keep psychiatrists working in those situations. Incentives are not just financial; the incentives are all those tools we need as psychiatrists to help deal with our patients. That's not just money; it's having the social workers and other people who can help us deal with that, especially in the community.
Mr Curling: Your presentation is quite thought-provoking. You have echoed many of the things that a majority of the presenters have come forward here with.
To follow up on the question the government has just put to you, it reminds me of the reforms in the 1970s, when some of the psychiatric patients were in Parkdale.
Dr Rzadki: They're still there.
Mr Curling: Exactly. That's my point.
While reform is necessary in this process and we welcome any reform that improves things, do you feel this is a bit too rushed, not thought through properly? The repercussions sometimes cost us lots more in the long run. It's like the old saying, "Pay me now or pay me later." We're paying for that now. What are your thoughts on that?
Dr Eppel: One small example of that might be the $2 fee on prescriptions, which could lead to much higher costs in terms of rehospitalization and other interventions in a population that may not be able to cope with what to us may seem a small cost but, over time and with other cuts in social service funding and so forth, is quite significant. That may be an example of what you're saying, that it is difficult to foresee all the implications in such a short period of time without studying the bill in more detail and getting some consultation from stakeholders, both providers and consumers.
Dr Rzadki: On the other hand, we do know that mental health reform is under way -- it has been for many years -- and there have been many reports with wonderful recommendations. The problem is that they continue sometimes unimplemented. We do need to look at, if there is a consensus to move towards reform, what resources, what incentives do we need to make those programs work? If you need any legislation to do that, please do it, but it should be in keeping with certain principles of respect and dignity for the people involved, including the ones who provide health care as well as the ones who receive it.
Mr Curling: I want to touch on the confidentiality of patients' files. The privacy commissioner earlier on, before the hearings even started, released a precaution about what could happen if these files and information are in the wrong hands. With the sweeping powers we see here, what kind of impact do you feel it would have on your patients or on your profession, as professionals, having this information in the hands of -- I don't want to belittle politicians, but people other than professionals who can deal with this situation?
Dr Rzadki: I'm very concerned about those sweeping powers. Confidentiality, as I said earlier, is a very important part of building a relationship with patients, and it's not always easy, with some of the patients we're dealing with. Often, we see patients who don't particularly want to see us, so anything that interferes with building the trust we need will hamper appropriate management. I'm very concerned about that.
Mr Bartolucci: Maybe a follow-up to Mr Klees's question with regard to the minister's power to direct or dictate services, the volumes of services etc: Do you not see as a possible consequence the lessening of psychiatric services available to the public because of this legislation, if he so deems it?
Dr Rzadki: I'm very heartened to have heard the minister say that he is concerned about the lack of mental health services, so I hope he lives up to those words. We're very encouraged by that. But the powers you need to live up to those words -- well, that's the problem, I guess.
Mr Bartolucci: Here we're not talking about the minister's words; we're talking about the powers within those words. Today he may be saying yes, but tomorrow he may change his mind. The legislation is flawed, because it allows him to redirect those energies so that in fact your services could suffer. Is that not true?
Dr Rzadki: I don't believe the intention of the government is to make mental health services suffer. I hope not. That's why the OPA would support time-limited powers to enact or implement the kinds of recommendations that have come after consensus-building, consultation -- the commitment to make the program work.
Mr Bartolucci: I guess you don't agree, then, with your fellow professionals who have appeared before us and said they're very concerned that it seriously limits your clinical integrity as well as your powers to deliver your services.
Dr Rzadki: I'd like to be very clear. Once there are programs that make sense to everyone involved and that we think would improve health care, then, with the legislation we have, from my limited understanding of it, I understand that we don't have enough legislative power to make those programs work. If we don't, then we should have.
But where there is not proper consultation, where there is not proper involvement of the stakeholders, where there is not consensus-building, where there is not commitment to some agreed- upon goals for a program, I am very much concerned about powers which are arbitrary, seem to be very coercive and punitive.
The Chair: Thank you very much, Mr Bartolucci, and thank you, doctors. We appreciate your coming here this afternoon and being involved in our process.
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JOSEPH FOX
The Chair: Our next presenter is Joseph Fox. Good afternoon, and welcome. You have a half-hour to use as you see fit. Any time you leave for questions will begin with the government. The floor is yours, sir.
Mr Joseph Fox: I understand that I'm given 15 minutes to a half-hour, and then I get the hook.
The Chair: Well, it's kind of like that.
Mr Fox: First of all, I think it's wise that I give you a personal background, which will confirm what I'm going to say. I've been a practising pharmacist for 42 years, enjoying the ownership of three drugstores. I retired and was accepted at the school of medicine to audit courses, which I've done for years. I've lectured to the public and lectured to the school of nursing. I also have done a lot of research at the science and medicine library on campus and am involved in research throughout the States as well, Johns Hopkins, Duke University. I think I have a background which confirms what I'm going to say.
To begin with, this may be a surprise, but this will be praise of what Mike Harris's government is doing relative to health care, and that's the area I'm talking about. As you probably know, there's been prolonged bleeding, haemorrhaging of health care costs over the years. I'm going back to when I served on the standing committee and worked with Peterson's Murray Elston. We worked on defeating the extra billing, which served a purpose. But since then, and I am not referring to you as a former Premier -- Minister of Health, rather --
Ms Lankin: That's quite a promotion I got there for a moment.
Mr Fox: Nothing has happened since then to stop the prolonged bleeding, from the days of Murray Elston in Peterson's cabinet. I've watched this. I've been on standing committees. We were successful, as I said, in saving costs to the public with the extra billing. It was a long-fought battle, but it worked. But I've seen a lack of preventing an ongoing bleeding, increasing the deficit year by year. Even this year is going to show a 13% increase in the deficit.
What I'm saying is that I strongly praise the present Minister of Health for doing what he's doing in cutting back on unnecessary utilization of medical services. I'm talking about health disciplines, pharmacists, physiotherapists and doctors. I'm not only picking on doctors.
I have suggestions, which I've done before, for means and methods to put an end to this. Down in Kingston you have a great group of people to whom, as you know, the billings by health disciplines are sent. They have been highlighting the billing by doctors and health disciplines who are repeatedly seeing patients long before it's necessary or even -- as you know, hypertension doesn't require a patient to be seen and his blood pressure checked every two weeks. Usually it's two to three months when medication is controlling the problem.
There are other abuses -- I don't mind using the word "abuse" -- where the staff there have flagged the excessive utilization of services. Nothing was done about it.
May I call you Frances Lankin? You probably were aware of it as well. This is at 49 Place Darnes in Kingston. They're a great group. I've spent time with them. They're a great group of people and they get frustrated. There's no pickup of what's happening to these people who should not be allowed to keep on billing and billing for no reason at all. As a matter of fact, one point was made that they're going to ensure there's no excessive use of ordering tests by doctors which are unnecessary and more often repeated than necessary. That's another area of the problem.
I understand that the present minister, that's one of the factors they're going to apply, which is very good, which has been ignored. Again, I'm not criticizing because I know you've done a good job in your time. But it's a little irritating to someone who is a taxpayer and someone who's done so much research. I've seen areas in small towns, pharmacies, and in large cities, where they too, the pharmacists, are not allowed to -- there was a time years ago, long before your grandfather was born, when a pharmacist could not even discuss or talk to the patient about what happened in the doctor's office. He couldn't even put the name of the drug, which of course is done today, on the label. There's been quite a change.
Let me go on to the methods that I think should be applied to help this. I've also spoken to the Provincial Auditor, Douglas Archer, who retired three years ago. He also agreed that there has been a terrible haemorrhaging in this area of the costs in health care. We had quite a nice meeting.
What I want to say about the methods that come into being is that we have a problem which has been cut back. We have walk-in clinics, and quite a few here, which are so prolific and unnecessary. We're having problems which come up all the time in my research and with doctors who are also working together.
A patient, Mrs Smith, goes to see her doctor, can't see her doctor because he's not available, goes to a walk-in clinic which has no record of her past, and is told what her problem is and what should be done. Then she decides, "I better get back to my doctor when he's back in town on Monday," and he of course has a different diagnosis and prognosis. Now she's got two different ones. It's interesting too what is happening in not all of them but enough of them, in the walk-in clinics, where they'll encourage the patient, "Come back to me," instead of saying: "Go back to see your doctor. This is only temporary."
Now she's got two opinions. She says: "I have to have three. I must go to the third because these are conflicting." She goes to the third doctor. This is not uncommon. The government is paying not for just one visit; they're paying for three visits. It's called triple doctoring, which was brought up in the days with the Peterson government, Murray Elston. So this can be checked into. Triple doctoring has got to be stopped.
I made a point here. Here are my other points.
In the excessive utilization of medical health services, we mentioned about doctors ordering tests unnecessarily. This takes place, as you probably recognize, mostly in clinics where the doctors own the lab. There was a time where they couldn't own a pharmacy. I think that's also been softened. But that must be stopped.
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I usually have a written report or brief, but I didn't have the time. I just was phoned yesterday about coming in at 1:30 today.
Now, what you've got is a very strong board called the Health Services Appeal Board. Once they find out that the doctor or the health discipline has been refused his billing, he can appeal it. Are you all aware of the Health Services Appeal Board? Good. He can come and protest the cancellation of his billing. Now, this is a good group; they should be strengthened too. The doctors find: "We can't do this. We can't do excessive utilization. We can't get away with it." That's another method which should be emphasized and should be used by the Ministry of Health.
Pharmacies now. I've spoken to the college yesterday. I had time spent with them to see what they're doing, where a pharmacy can, as you all probably have learned, give you advice on things without running to a doctor. They have now a program in being called Quality Assurance, where the pharmacist will be given the time to show what can be had, over-the-counter medication, to prevent this person rushing to Emergency or rushing in to her doctor, which can be handled very well, and that's quite a thing the Ontario College of Pharmacists is doing because they know the need to stop this flow into doctors' offices unnecessarily.
This has come into effect in the training of the pharmacists and the time spent. The inspectors will be checking not only about how many books you must have in your library and other aspects; they'll be trained to have the pharmacist spend time taking care of you and advising what can be done at the pharmacy. This is going to be quite an accent on a future in pharmacy. So there is another saving.
I mentioned the walk-in clinics and I mentioned the -- if I could just take a moment. Oh, yes, Emergency. As you all probably know -- and I've spent time at Sunnybrook and Ottawa Civic; I've been down to Hopkins. I've spent time talking to Duke University. These are well-recognized areas. And that is the problem that comes to being of doctors not being up-to-date in what they're doing, which is a separate subject. That's something I'm involved in over at the university. The triage -- when you go into Emerg, you have a triage which now represents a nurse who's qualified in whether it warrants going further to see the doctor in Emerg. What they're doing now is, suggested by myself and a few of the retired doctors, the triage nurse should have a backup of a volunteer doctor, usually retired, and a pharmacist, to back up what the triage nurse is saying so there's no money spent, no time spent, where Emergency, particularly in Sunnybrook, the Toronto Hospital, has to spend more time seeing people who are not necessary to be seen.
So the overall picture is that money can be saved. Money has to be saved, and the deficit can be reduced if only these different aspects will be exercised. Now, if there are any questions, I'm willing.
The Chair: Thank you very much, sir. We've got about five minutes per party for questions, beginning with the government.
Mr Clement: Thank you very much for your presentation and for your thoughtful elaboration of the tangled history of health care reform in Ontario, something of which I don't think any of us who are in political life should be proud. It really has been a litany of lost opportunities, and it's not just a lost opportunity; it is a lost opportunity that has cost the taxpayers of Ontario money. The result of that is that we have, if we are further into debt and deficit as a result of some of this, then we have less money now to apply into the system because we're paying interest on the debt. So it really is a vicious circle that we are trying very hard to get out of.
I was very cognizant of your examination of the history of things, and then you went into a bit on some of what you saw as some abuses in the system, some overmedication, excessive use of procedures. That's on the physician's side, but there's also the patient's side, triple doctoring.
Mr Fox: True.
Mr Clement: I'm not trying to blame this all on the physician at all. There are in fact persons who are abusing the system from the patient end of things as well, which I suppose is our justification, if one is needed, to allow for greater investigatory powers in the act. I just want you to elaborate a bit on what you see as the use and abuse of the system and whether you think that justifies governmental action.
Mr Fox: We use the word "exploitation" -- we use this in our own meetings -- by the public. It is true, because something free, instead of going to a show they'll go to a doctor's office. They're liable to walk down the street. As I was saying, triple doctoring is very bad.
Once Dr A sees a patient and recognizes the problem, be it dermatological, whatever, it is sufficient for the patient to leave. But what is happening is that the patient now decides, "This is great. I can go to whoever I want," as I told you: triple doctoring. That's exploitation.
What is happening now, once Dr A punches in and bills in, by his computer preferably -- pharmacists all have computers, and that will happen. He'll punch in, "Dr So-and-so saw Mrs B on such and such a day with a problem, dermatological." She decides she wants to go to another doctor. She's not too sure. She doesn't like relating to the doctor: very short in his manner. And she goes, and Dr So-and-so is putting through his card, his billing, and suddenly up comes the flag: "Mrs B has been seen by Dr A. We're not paying. You'll just have to ask the patient." So the circumstance is that she'll have to pay. Do you know that 71% it happens that the patient goes out, doesn't want to pay?
The same thing applies where you get medication with the delisting of a lot of the ODB. The pharmacist says, "I'm sorry, this is not on the free list." This is the case 62%. They say: "That's fine, then. We will leave." So there is a case where good things are happening.
Mr Clement: If I am permitted, Mr Chair, let's just talk about some of the overmedication that occurs and that does affect seniors, as we know, and we've heard examples in this committee. Somebody has suggested that the cost-sharing $2 copayment might in fact inhibit overmedication both from the patient end, the patients who seem to want to have overmedication although they don't realize the side-effects, but on the other hand it might also inhibit some physicians who are just in the habit of writing prescriptions for everything under the sun. From your knowledge and your background, is that a possibility at least?
Mr Fox: Could you just break it down to one point? You're saying -- what are you asking me?
Mr Clement: We're trying to figure out whether the copayment will inhibit even physicians a bit so that they'll think twice about overmedicating, overprescribing.
Mr Fox: Oh, I see. I'm a strong believer in user fees. It's been very successful in Quebec and out in Saskatchewan. I'm very strong in it. It shouldn't apply to those people who have an income under $16,000 or whatever, but the rest of the public can.
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Mr Bartolucci: Thanks so much for what I think are words of wisdom, and I respect that. I'd like you to just carry on and clarify for me a little bit how you feel this whole process should have taken place in the first place. Do you believe, for example -- and let's carry on with the example of Mr Clement, the example you used with regard to abuse or fraud with regard to doctors. Do you feel that the OMA, which is concerned about that, should be excluded from the process of remediation?
Mr Fox: I'm sorry, the last few words were which?
Mr Bartolucci: Do you think that the doctors, the Ontario Medical Association, should be excluded from the process of remediation to remove the problem or to alleviate the problem of fraud or abuse?
Mr Fox: First of all, I'm not attacking the medical profession.
Mr Bartolucci: I understand that.
Mr Fox: In all professions there is a problem. It's just that we've got to hold up and stop this haemorrhaging. For instance, the Law Society of Upper Canada is doing a terrific job holding back the problems or correcting the problems. This involves money to the government as well. The Ontario College of Pharmacists has strict rules and they also -- the disciplinary committee and the infringement committee are very strong.
I have a little thought. I have a lot of respect for what is happening up on College Street where the College of Physicians and Surgeons is. I don't feel that they're as strong. The Law Society of Upper Canada really hits the lawyers. Lawyers know they can't take their chances failing in trust of their clients. Pharmacists know that they will much more rapidly lose their licence or their time of practising if they fail. There's a little bit of weakness. I mentioned this before. I've been involved with retired doctors who have also said now that they're free, there is quite a change. As you probably read in the papers, such-and-such a doctor has been cleared, and I think there should be a little more strength applied. After all, the umbrella of the Ministry of Health -- they're responsible; the medical profession, pharmacists, all health systems are responsible. I think there should be a little more monitoring by the Ministry of Health.
Mr Bartolucci: Because of your experience and because of your age, could you please tell me, though, do you ever strengthen something or someone by removing them from the opportunities to be a part of the solution?
Mr Fox: When I used to lecture, one of my questions to the students or whatever was, "I'm failing to get the solid point." I'm sorry.
Mr Bartolucci: Well, what's happening here is that with this legislation, the government effectively destroys the OMA.
Mr Fox: Oh, I see, Bill 26.
Mr Bartolucci: Do you think that's right?
Mr Fox: I think the government should have within its power to stop this, but do it within reason. Not every case is going to be hit with a baseball bat.
Mr Bartolucci: In consultation with the association?
The Chair: Thank you, Mr Bartolucci.
Mr Bartolucci: Yes? Thank you.
Ms Lankin: Mr Fox, thank you very much for your reflections on the health care system and the changes that you've seen or haven't seen. Some of the things that you've raised as issues of concern are in fact things other people have identified as cost drivers in the health care system. If I may, I just want to take a couple of moments and share with you some things I'm aware of, though, that have happened in those areas, and hopefully that will make you feel a little bit better about what's gone on.
Just in response to Mr Clement, let me say that while you say no one should be proud, let me tell you, personally I'm quite proud of some of the things that we accomplished when I was in the portfolio of Minister of Health, and I'm going to tell you a couple of things.
The costs of the health budget were increasing by 10%, 11%, 12% every year for over a decade.
Mr Fox: And 13% this year.
Ms Lankin: While I was there, we brought down the growth of cost of the health budget to 1% the first year and to flat line the second year. Some of the things that you addressed, lab tests, for example, there are very simple solutions in some of these areas that are contributing to helping save costs. The sheets used to be long lists with all the lab tests on and it was easy to check them all off -- simply reformulating those sheets, reformatting them; a very simple thing, something that the doctors told us to do and that we listened to and followed through on.
Doctors doing too many things to people in certain areas -- well, it's not all fraud. Sometimes it's patterns of practice. Why is it in certain parts of the province that women are more likely to have a caesarean section than a vaginal birth? What's the reason for that? If it's not anything to do with the health, it's to do with the patterns of practice. Government can't step in as a bureaucrat in between the doctor and the patient and make that decision. That's one of the problems I have with this legislation.
Mr Fox: That's true.
Ms Lankin: What we did was establish the Institute for Clinical Evaluative Sciences to do the epidemiological research, to develop the clinical guidelines to help influence, peer influence, doctors' patterns of practice. That'll pay off a whole lot more in the long run for the wellbeing and the health of our population than bureaucratic or political intervention between the doctor and the patient.
With respect to drugs, I agree with some of the concerns you've raised. We established a drug utilization review; there are clinical guidelines being developed at this point in time; the computer network that's being put in. Much of what this government says we have to do they wouldn't be able to do if the groundwork hadn't been set. I hear much from them about the DHC reports. Quite frankly, as Minister of Health, in many of the communities that we're talking about, together with those communities and the DHCs, I started that process. So I have a real hard time listening to them now coming and saying, "Well, we need these extraordinary powers to be able to move ahead."
Walk-in clinics negotiated differential rates. It used to be that there was a higher rate for evening or weekends which applied to normal doctors' offices. These walk-in clinics set up as a commercial situation, they open those hours and they get the higher billing rates but on a volume basis. Well, that was costing money and it wasn't necessarily good service. We negotiated differential rates that would try to slow that down.
In terms of triaging in emergency, seniors often would come in and would be admitted into hospital. We know that often there would end up being a disorientation that would take place and/or many times seniors wouldn't be successfully reintegrated back into their home and would end up going into institutions or long-term care settings.
We have early intervention programs there that help through coordinated home care nursing, VON nursing and others, to stop the admission, to get the right care in the home and to help that senior back into their home quickly for more successful opportunity to stay in the home.
These are all things that have allowed us to do the beginning of the restructuring and reform. The job isn't done, and this is where I agree with the government and with what you've said. There is much remaining to do and I hope this government will continue along that line. I think it's a shame that they can never bring it within themselves to acknowledge that it's work that's been done by others: the Liberals and the New Democrats, and Tories before that. It's an evolutionary process.
Revolutionary change will be very damaging to our health care system. That's what I fear. I think some of the powers and some of the provisions of this legislation go beyond what is required. There are other elements of it that I actually support and if I had the chance, if this bill was broken up, I'd be voting in favour of some parts of it. But some parts of this go way too far to give bureaucrats and politicians power over what should be an issue between patients and doctors and other health care providers. That's my concern.
The Chair: Thank you very much, Ms Lankin. I didn't hear a question there. Thank you very much, sir. We appreciate your involvement in our process this afternoon and your presentation. Have a good day, sir.
Mr Fox: Thank you very much. May I just say that I would just want -- I said I respected your term. I knew your term very well. I never worked with your office. But what I'm saying in effect is that we need -- just stronger control is necessary and attention has got to be paid to these people down there in Kingston who are saying: "Please pay attention to these doctors. Get after them. Get the College of Physicians and Surgeons to come in." I'm just asking for a little more strength and control.
The Chair: We appreciate that.
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PHARMACEUTICAL MANUFACTURERS ASSOCIATION OF CANADA
The Chair: Our next group is representing the Pharmaceutical Manufacturers Association of Canada: Gerry Jeffcott, Pam di Cenzo and Paul Lucas. Welcome to our committee. We appreciate your being here this afternoon. You have a half-hour to use as you see fit. Questions, if you leave time for them, will start with the Liberals. The floor is yours.
Mr Paul Lucas: On behalf of the Ontario committee of the Pharmaceutical Manufacturers Association of Canada, I'd like to thank you for the opportunity to appear today before the committee to offer the association's views regarding Bill 26.
I'm Paul Lucas, president of Glaxo Wellcome and a member of the PMAC board of directors. With me is Pam di Cenzo, associate director, national accounts and managed care for Smithkline Beecham; and Gerry Jeffcott, director, provincial government relations for PMAC. Pam and I are the co-chairs of the PMAC Ontario committee. Our comments on Bill 26 will focus on the proposed legislative changes to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act.
As a starting point, we thought it might be helpful to provide you with some background information on the brand name pharmaceutical industry in Ontario. Currently, 40 of the PMAC's 65 member companies maintain their head offices in Ontario. Many of the other 25 have a sizable presence in the province as well. In 1994, these companies contributed a significant $1.2 billion to the province's economy.
The brand name pharmaceutical industry has met and surpassed its research and development commitments which were made in response to recent changes to the federal patent protection legislation outlined in Bill C-91. The practical result of those commitments is the industry's contribution of $236.2 million in 1994 to research and development and at least $1.1 billion in R&D since 1987 in Ontario alone.
Almost one quarter of the industry's research and development investments are spent externally. As a result, the brand name pharmaceutical industry is a major contributor to basic and clinical research conducted at universities and hospitals throughout the province. In 1993-94, the brand name industry contributed $43 million to the five faculties of medicine in Ontario which represent 13.2% of the total amount spent in these faculties on biomedical research. This investment in research has resulted in the creation of and support for numerous jobs in Ontario and has recently led to Canadian discoveries of treatments for hepatitis B and AIDS.
Brand name companies located in Ontario have a tremendous export capability and many companies have been awarded North American and global research and product mandates. With more than half of the pharmaceutical companies located in this province, it is vital that the provincial government demonstrate that Ontario has a welcome business environment. This is important to maintain current investment and employment and to attract future investment. A welcome business environment, which this government is working to address for the pharmaceutical industry, includes such issues as market access for new products, fair taxation policies, and the elimination of regulatory duplication and unnecessary regulations.
Market access in Ontario is critical. Based on a 1994 survey conducted by the PMAC, of the 77 original new medicines approved for sale by the federal health protection branch between 1990 and 1993, only 23 had been approved for full listing on the Ontario drug benefit program plan list.
We are hopeful that the government's efforts to control expenditures will result in greater opportunities for the Ontario drug benefit program to reimburse new and cost-effective medications for the benefit of Ontario residents.
The PMAC recognizes that some of the proposed legislative changes to the ODB Act and the PDCR Act contained in Bill 26 have been advocated by the PMAC and its member companies over the years. The industry appreciates the government's efforts to address these issues and the Ministry of Health's commitment to reforming the drug benefit program.
The joint liaison committee was established to provide a forum for discussion between the industry and the government on issues of mutual interest and concern. The PMAC encourages the Ministry of Health to refer the regulations accompanying this legislation to the joint liaison committee for a review prior to the implementation of these changes.
Our comments today will focus on three specific changes proposed in Bill 26: the elimination of full payment for "no substitution" on prescriptions; linking prescribing criteria to reimbursement; and deregulation in the private marketplace.
Elimination of full payment for "no substitution" on prescriptions: Currently the ODB Act and the PDCR Act provide the Ministry of Health the authority to designate any number of pharmaceutical products with the same active ingredients as interchangeable. This permits the pharmacist to substitute a generic version of a product for a brand-name medicine. Presently a physician can avoid this substitution by writing "no substitution" on the prescription and the ministry will pay the difference in price between the generic and the brand-name medicine.
Bill 26 contains an amendment to the ODB Act under which the ministry will no longer recognize the use of "no substitution" by physicians. The Ministry of Health would only reimburse the cost of the lowest-priced interchangeable product and would not reimburse the pharmacy the difference in cost when a physician writes "no substitution" on a prescription.
The rationale for permitting a physician to restrict the pharmacist from substituting is to allow for the patient to receive medication and treatment appropriate to their particular condition. In addition, in the interest of optimal drug therapy, physicians should still have the option to specify a brand of medication when it is in the interest of the patient to do so.
The PMAC believes that physicians and patients should be informed before substitution occurs. Patients should be informed in advance that they have the option to refuse the dispensing of an interchangeable product and pay the difference in cost for the brand-name product. Under the current mandatory substitution provisions of the legislation, neither the patient nor the physician is informed when a product is switched to a cheaper alternative brand.
The PMAC recommends that the PDCR Act be amended to require that the patient and physician are informed before substitution occurs. This amendment should also ensure that patients are told directly about their option to pay the difference in cost for the brand name. In addition, an expedited special authorization process must be available to allow physicians to prescribe a particular brand when, in their professional judgement, they believe it is appropriate for their patient to receive this particular brand.
Linking prescribing criteria to reimbursement: Bill 26 proposes that the Minister of Health be given the power through regulations accompanying the ODB Act to define prescribing criteria which must be met in order to ensure that a given drug product or class of drug products will be reimbursed. This provision would allow the ministry to link prescribing criteria or guidelines to reimbursement.
The PMAC has been assured by ministry officials that this change is intended simply as enabling legislation and that the ministry does not intend to link prescribing criteria to reimbursement immediately. While the industry appreciates that assurance, it does not alleviate our concerns.
The PMAC believes that optimal patient care should be the goal of any therapeutic guideline. Therefore, such guidelines must be flexible enough for physicians to exercise their professional judgement in order to meet the individual medical needs of each patient. We are concerned about a process which creates a financial disincentive for the physician to provide what he or she feels is in the best interest of the patient.
We understand that the specified "clinical criteria," as defined in the legislation, will be outlined by regulation on a case-by-case basis. Given the industry's recognized expertise regarding its products and related therapeutic categories, we believe that the industry and individual manufacturers affected by the prescribing criteria should have an opportunity to participate in the development of these criteria and to offer input regarding the implications of their implementation.
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Deregulation of price in the private marketplace: The PMAC commends the ministry's initiative in deregulating the private marketplace for pharmaceuticals through the proposed legislative changes to the PDCR Act. This provision will reduce the government's role in regulating a market in which it has no direct financial interest. It will also create a more competitive environment in which purchasers of pharmaceuticals will not be constrained any longer by government-imposed pricing structures.
However, in light of recent articles in the press and presentations to this committee, the PMAC would like to take this opportunity to clarify the impact of these changes with respect to pharmaceutical prices in the private market. It is critical to note that the prices of all new and existing patented medicines, which represent the majority of the market for brand-name companies, continue to be regulated federally by the Patented Medicine Prices Review Board.
These federal regulations impose strict restrictions on the introductory prices of new medicines and ensure that the prices on existing products do not rise more than the consumer price index. The most recent report of the PMPRB indicates that the industry's prices have increased at rates significantly less than inflation since 1988. In contrast, non-patented products, which include all generic products, are not subject to PMPRB regulations.
Where problems could arise is in the final cost of the medication. While the factory prices of products should remain stable, the manufacturer will have no way of controlling what the pharmacist will charge the patient. This places even greater importance on the consumer being informed about the components that make up the eventual price of their prescriptions.
The PMAC proposes that an amendment be added to the Drug Interchangeability and Dispensing Fee Act requiring the pharmacist to detail the cost components, including dispensing fee, additional markup and the actual cost of the medication itself on a prescription. Given the fact that dispensing fees and the associated markups will no longer be regulated, it is important to provide a detailed breakdown of these cost components in order to enable patients to make more accurate comparisons among pharmacies.
Recognizing that the regulations accompanying this legislation are not yet available and given the increase in authority granted to the minister through the associated regulations, including the power to establish the reimbursement price for listed products and to outline specified prescribing criteria for products or therapeutic classes, the PMAC would appreciate an opportunity to review, assess and comment on the draft regulations before they are passed.
Finally, the PMAC commends the Ministry of Health regarding its recent announcement that it will eliminate offsets. This was a process in which brand-name manufacturers were required to offset the cost of adding any new medicines to the ODB list by removing a previously listed medicine from the formulary or by lowering the prices of existing products. The new product submission process associated with the ODB formulary, which requires a pharmacoeconomic analysis comparing a new product to other treatments, will measure the cost-effectiveness and deliver cost savings to the health care system.
In conclusion, the PMAC Ontario committee appreciates the efforts of the government to address some of the issues advocated by the industry through the proposed changes to the ODB Act and the PDCR Act.
In addition, we support the consumer's right to know when product substitution is contemplated as well as the involvement of the industry in the development of specified prescribing criteria and the need for flexibility for physicians when applying these criteria. Finally, the PMAC feels strongly about the patient's need to receive a complete breakdown of the cost components of the price of prescriptions.
The PMAC thanks you for the opportunity to present before the committee and we'd be pleased to entertain any questions that you might have.
The Chair: Thank you very much. We've got about four minutes per party left, beginning with the Liberals.
Mrs Caplan: I appreciate the very excellent brief. I have a concern about something that you've raised on page 5. You seem to assume that there will be a special authorization section 8 possibility for anyone who requires a brand-name drug, which is no longer possible under the no-substitution rule. Is that your understanding?
Mr Lucas: I think what we're recommending is that there be some sort of opportunity for the physicians if they feel in their professional judgement that the patient needs that brand-name product, or in fact it could be a generic product which may be substituted for another generic product. But we feel there needs to be some sort of approval process which is an expedited process that allows that to happen when medically necessary.
Mrs Caplan: At the present time the special authorization is available for drugs that are not listed on the formulary, and I've been informed in writing by the ministry that it does not intend any mechanism to allow for the payment of a brand-name or a generic drug in a no-substitution prescription that has been written.
I'm hoping they will consider an amendment, because I think that, while there are few cases, there are some where for a whole lot of reasons the patient cannot tolerate the interchangeable product. I'm very concerned about the impact of that because, as you know, people who need their medicine, if it's not going to be the right one, their health is going to be threatened.
I agree with you, by the way, that all changes and reforms to the drug benefit program should lead to optimal therapy. I think that shouldn't just be the goal of the therapeutic guideline but should be the goal of the whole program. I think you'd agree with that.
Mr Lucas: Absolutely, yes.
Mrs Caplan: Did you have a question, Alvin?
Mr Curling: I was getting the understanding, as you read, that you'd much rather the power is in the hands of the doctor and the patient, which is much more effective. I got that point. Correct me if I'm wrong. The other part about it too is a mixture about the costs of health care and the concern about the deficit of the government. You are much more concerned about the health of the patient. When those two things are coming together with this kind of reform, it seems to me it's the patient who suffers most, not the deficit.
Mr Lucas: We support the initiatives of the government to deal with the economic and financial issues that we're all facing today in this province. In the current health care system itself the patient may actually not be well served. We referred to a situation with drugs, for example, where the patient is actually not informed when a drug is substituted that they might be on. They might be on their heart medication for three years and, all of a sudden, they come into the pharmacy one day and there's a generic available and the pharmacist substitutes. The patient doesn't know, their physician doesn't know.
I think there's a real opportunity to deal with some of these issues around patient care, and at the same time there's a sense that there is a significant amount of money in the health care system today, and if it's used perhaps more efficiently and more effectively, we can not only save costs but improve patient care.
Ms Lankin: Paul, thank you for the presentation. It's a complicated relationship that government has with the industry. I remember switching hats from Health to Economic Development, and you were still there.
On one hand, we want to see more investment in primary research, not just secondary research -- and I really do appreciate the numbers you've given us about the industry's involvement with academic research in the universities -- moving away from not just simply clinical trials but to more of the original research; all of that, and of course the manufacturing capacity. On the other hand, industry wants a hospitable climate for the introduction of its drugs, particularly into the non-ODB markets. I understand the competing forces, and at the same time government has got to control costs.
The main question I want to ask you -- the thing that is the newest and most different about all of this is the deregulation of the non-ODB market, and that's what has raised the spectre of concern. Yesterday we had a presentation from one of your member organizations, a competitor of your company, who indicated complete support, obviously, for the deregulation but who indicated that they believed that the government, with respect to those negotiations, would be guided by the PMPRB and that therefore it would be a simplified process, more transparent, and a diminishing role for the DQTC. I'll be honest with you that that set off some alarms in my mind, and I think you can understand why.
The Patented Medicine Prices Review Board price is a maximum price. If we're not talking about getting better value through the process of negotiating on the volume of ODB from the government, this worries me in terms of costs to the government, let alone what happens out there.
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There are two parts to it: One is the negotiations with the government and if in fact it is PMAC's position that there will need to be a lessened role for the DQTC and just more of an acceptance of the PMPRB price; secondly, on the outside, the prices. I can't see how they won't vary by volume, insurance companies and large chains versus independent pharmacists buying, and necessarily by distance and for shipping, and rural, small-town areas; and not just for the price of the drug but the other component you mentioned, which is the pharmacist's markup where they have a monopoly in town.
Can you answer that concern? I think that is a genuine concern that people have as they look at this proposal.
Mr Lucas: Well, there were a few issues in there. I will try to address those.
First of all, on the PMPRB regulations and what they allow, they allow pricing up to the increase in the CPI. I think the industry's record stands, that even though those price increases were allowed, the recent record of the industry is actually to price products below that increase in the CPI.
Ms Lankin: Could I just ask for one clarification? Do you expect that the ministry, for the ODB drugs, will pay that price?
Mr Lucas: I don't know where that came from. I have had no indication from anyone anywhere that that would be the case. In fact, the government's approach for 1996 is to offer another reimbursement freeze for all products listed on the ODB formulary, and that is certainly the message that we've had. So there's no indication whatsoever that we're going to be able to price at those levels, even though PMPRB regulations allows them.
Ms Lankin: That's what Eli Lilly said yesterday, just so you know.
Mr Lucas: Yes, I read some things in the paper. I was surprised to hear that, because we haven't heard any indication that would be the case.
Ms Pam di Cenzo: I think another point is that the federal PMPRB is actually a regulatory body that is already looking at costs and ensuring that the consumer is protected and that the user is protected by the price that the product is allowed to enter into the country. So I think the perception from the Toronto Star article, where it said the "maximum price available," is a bit of a misperception. The price that is available when it comes into Canada has got to be less than a medium price in a basket of seven countries, and it has to be lower than at least one other country.
Ms Lankin: Yes, but the point here was that if the Ontario government just used that as its guideline in what it negotiates on the price, that would probably cost us more than we're currently paying on ODB drugs. That's the concern.
The idea of these negotiations, from what I heard the minister say, was a big volume user, a big negotiator at the table with a lot of clout. We're going to negotiate hard with you guys and we're going to get rock-bottom price, which then leads us to wonder whether or not the price in the deregulated market, even though there'd be competition -- I understand that argument -- might not have to go up to compensate for that in order for you to be able to preserve your profit margin. I just don't understand how it couldn't.
Mr Lucas: We're still wrestling with how it can, because the ability for companies to have two prices in a marketplace is virtually impossible in the Canadian marketplace and in Ontario. There's a lot of speculation around what may happen with prices, but the reality is that in Ontario there is a reimbursement freeze for ODB. The government is our largest customer, for all of our companies, and it would continue to get the best price, I suspect.
Ms Lankin: I think they suspect that too.
Mr Lucas: Yes.
Mrs Johns: I just want to restate that again. I know that it's probably clear for everybody; I just want to make sure. Do you agree that this bill actually provides the government with greater flexibility to negotiate reasonable prices?
Mr Lucas: On the ODB specifically? I don't understand what the process of negotiation will be, but when I hear "negotiation," I understand that as our largest customer, they're going to want the best price, and I suspect there will be an approach to achieving that. From a business point of view, it would be clear to us that, again, being our largest customer, they're going to get the best price.
Mrs Johns: Regulations already in place would allow us to give you what you wanted when you were asking for a detailed breakdown of drug costs, including the drug itself, markup and the fees. We are looking into that as a government and as the Ministry of Health, so I just wanted to let you know that.
I met with one of the people from your association and had a heart-wrenching story about a drug that they truly believed would help a number of people in the community, and they couldn't get it on to the formulary. From my standpoint, being new to the ministry, it was quite a heart-wrenching story because it relates to breast cancer, and it was really important to me to be concerned about that.
The ODB program needs to be more sustainable, obviously, in order to allow the government to add new products to the program. Do you think these new changes to Bill 26 will allow that to happen?
Mr Lucas: We very much would hope that would happen. All governments have been faced with trying to manage the cost of a program like this, and unfortunately part of the response has been to not list new chemical entities. Ontario actually has, as I outlined in the brief, one of the worst records of introducing new medicines to the formulary.
We would hope and recommend that perhaps some of the reallocation of dollars that might be able to occur in the system through better management of the system could be applied to adding, not necessarily all new drugs, but those that are deemed to be medically important and cost-effective for the system overall.
Ms di Cenzo: I think on that point as well, the emphasis that will be placed on pharmacoeconomics, first of all, allows us to move away from silo budgeting which, as the industry, we commend. We recognize that, from a treasury point of view, it's very difficult when you're trying to manage and get bottom lines and achieve the cost savings and efficiencies in government. But looking at it from the health management point of view, we need to be able to move away from those plots and recognize that costs in one area might actually offset medical costs, physician costs, diagnostic costs in another area.
By looking at the changes in Bill 26, it's going to put a greater emphasis on a holistic approach, you might say, to looking at the management of health care, and a pharmacoeconomic emphasis. Actually, Frances, getting back to your comment, the DQTC could play a greater role in being able to assess the value, the cost-effective as well as the therapeutic value, of the product and not be so duplicative perhaps of what is already a federal activity, looking at the safety and efficacy of a product.
The Chair: Thank you very much for your presentation. We appreciate your interest in our process.
ELIZABETH MARGLES
The Chair: Our next presenter is Elizabeth Margles.
You have half an hour to use as you see fit. Questions will begin with the New Democratic Party, any time you allow. The floor is yours.
Ms Elizabeth Margles: I'd like to start by thanking you for allowing me the opportunity to appear before you today. As other participants have done, I would especially like to thank the opposition members who forced these hearings, for if not for them, the concerns of some Ontario citizens like me would not be heard.
I probably represent the silent majority of Ontarians. I agree with some of the policies of the Liberals, some of the NDP and even some of the Conservatives, though with regard to Bill 26, I'm not convinced that you're at all progressive.
I'm here today to demonstrate to you how an all-encompassing bill like Bill 26 has much wider-reaching implications than the government has considered, how it is vacuous in some parts, how the government definitions are faulty and how, in the government's efforts for a short-sighted power and control grab, Bill 26 can lead to the disintegration of societal contribution and professional demoralization.
When I told some friends and colleagues that I had the opportunity to come here today, after finding out at 5 o'clock yesterday afternoon, I was urged by them to stick to economic and financial messages and to get away from the social messages, because finance is what the government is most concerned about. I'll give you a little bit of that, but what I'm most concerned about are the social issues involved in Bill 26.
To give you some background, I'm from Montreal originally. I moved to Toronto for school and because I believed I would have more career opportunities here. I put myself through graduate school, earning a master's degree in environmental studies, working part-time and full-time jobs the entire time. I'm now one of the youngest senior consultants in the country's largest public relations and public affairs firms, specializing in environmental communications and crisis management. Our clients are Toronto-based, Ontario-based, including the PMAC, national and international.
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I love my job. I love the company that I work for. I look forward to work every day, and I look forward to continuing to build my career at the same company for many years. I work about 50 to 60 hours a week, but I enjoy myself and get so much out of it that I don't really care, including the satisfaction of helping communicate difficult and technical issues to everyday people.
The other important part of my life is my husband. I am married to a resident in orthopaedic surgery. He also put himself through school with jobs and scholarships, first through a degree in mechanical engineering and then medical school. He's no slouch. Let's just get that off the table. Talking about hours, he works 110 hours a week. He's on call overnight in hospital three nights per week for a seven-year residency. The University of Toronto has mandatory research for at least one year of orthopaedic surgery, and he's elected to do two to earn a master's degree in clinical epidemiology. With the research comes a 30% pay cut. All this for about $9.58 an hour.
While we certainly appreciate that his education was subsidized, as was everybody else's that benefited from our educational system, we also would like the government to appreciate that, as a young couple, we would like to plan our lives rather than be at the mercy of a punitive and coercive system that would have us move to rural Ontario.
As I mentioned, I was born in Montreal. Though my parents and extended family are still there, all my friends have also moved to Toronto. My husband was born and raised here. All his friends and family are here, including his 90-year-old grandmother, his parents who -- and my mother-in-law will probably kill me for this -- will soon be getting on in years, his two brothers and his twin sister. I'm so grateful that his family is here, because they have become my family. No one who has not lived hours away from all that is familiar, including family, can know the effects, the hardships and the loneliness that this can induce.
While we are not orthodox or even as observant as our families would like, the fact is that we are a Jewish family. It is intrinsically a part of who we are. We both benefited from parochial and public school growing up, and though we may go infrequently, we enjoy going to synagogue and we enjoy Sabbath dinners with his family every Friday night.
By now I've probably painted a pretty favourable picture of what my life is like, and I am the first person to recognize how fortunate we are and how fortunate I am. As an aside, I'm particularly ashamed that it took me so long to speak up against this bill. For the first few months of this government I sat by and watched all the decisions being made, and since they didn't affect my life, I didn't say anything. Now here I am because it has finally affected me. But this won't be the last time I say something.
Though I am fortunate, all this would be lost if Bill 26 is passed in its current state. We would have absolutely no representation of our religious community in a northern rural town. Our children would be the only ones of their faith, and while I fully believe in multiculturalism, it is very important to us that our children not feel singled out, different and ostracized. And make no mistake: This argument may be made for any other ethnic or religious minority in a similar position.
By passing Bill 26 in its present state, I would also be lost. My contribution to society, both socially and financially, would be greatly diminished. I would be completely unemployable in a small, rural town and would go from being a contributing taxpayer who looks forward to earning more money -- therefore paying more taxes -- and buying a house -- more taxes again -- and sending my kids to school -- more taxes -- to collecting unemployment insurance for the first time in my life. This would also apply to spouses who are partners in law firms, small business owners, teachers with seniority at their school boards and to physician couples who've already established medical practices here in Toronto.
Before I get to the other faults in Bill 26, I would just like to make a personal commentary on Minister Jim Wilson's remarks on the opening day of these hearings.
I don't know what sort of personal vendetta Mr Wilson has against physicians. I am sure that there is some abuse by some physicians some of the time, just as there are some MPPs who have made some erroneous decisions, some unethical decisions, some immoral decisions. That doesn't necessarily mean, does it, that all MPPs are unethical, immoral and irresponsible? What it means is that you deal with those people as individuals and you put in place an infrastructure that prevents that from happening again.
But the minister would have us believe two erroneous and misguided premises: (1) that the way to solve the health care delivery problems, the way to solve one iniquitous situation is to create another; and (2) that all doctors all of the time are nothing but abusive, thieving, unethical snake oil salespeople, including my husband.
Just to serve as an eye-opener for Mr Wilson and his staff, I can't speak for other specialties, but let me give you a snapshot of what it's really like to be an orthopaedic surgical resident in Ontario.
As I mentioned, my husband works 110 hours a week. He starts work at 6:30 in the morning and usually makes it home between 7:30 and 8:00 pm. He gobbles down dinner and studies for a couple of hours before he falls asleep in his books. In clinic he sees about 80 patients a day. On OR days, he doesn't see daylight. He sees a lot of people he can help, whom he enjoys helping. He chose orthopaedics because -- it sounds silly coming from a doctor -- he doesn't like sick people. He sees an almost immediate and positive result of his efforts: people walking again. They are long and arduous surgeries, yet he enjoys it.
But he also sees abuse by patients, abuse by parents. At this time of year he sees the elderly abandoned in the ER. He sees trauma and death from drunk driving accidents. He sees people who don't take any responsibility for their home care, even if they've known about an elective joint replacement for months. It's all part of the job. And during all this political upheaval, he continues to love his job and continues to contribute to society.
It is I who am constantly amazed at his faith in the system and in people. But Minister Wilson's remarks go too far, as does Bill 26. Minister Wilson's remarks are an insult as Bill 26 is unconstitutional. I challenge the minister and his bureaucratic soldiers to one day in my husband's shoes. He wouldn't have the strength, ability or mental capacity to last one day, let alone qualify him for all the powers he deems himself in this bill, from judging what is a necessary procedure to deciding where people are entitled to build their careers. We try to believe in the system and the process, but it is increasingly difficult when people like us, educated, taxpaying citizens, who give to their community either by volunteering like I do or by career choice like my husband does, are constantly and thoroughly demoralized, battered and made to think that we are expendable entities rather than contributors to the province.
As far as the vacuous and faulty nature of the bill goes, there are far more people qualified to comment on specifics, but as a layperson I see glaring examples of both. This bill allows hospital administrators to fire doctors on any basis with no appeal process. Administrators are money and resource managers, not physicians. I am no more qualified to run a hospital than an administrator is to counsel my clients. Just because an arbitrary act deems it so does not make it so, and just because someone is handed a portfolio does not qualify Jim Wilson to determine which procedures are medically necessary.
Medicine is an art as much as a science. While protocol has its place, any doctor will tell you that what medication, therapy or procedure works for one patient may not work for another. Are these subtleties covered in the bill?
I'm not sure how the ministry defines "underserviced." If Bill 26 defines it purely geographically and purely supply-side economics, then it is as shortsighted as it will be ineffective. There are underserviced areas in the GTA. My husband has been on call in one GTA hospital only to be woken up at 4 o'clock in the morning to admit a transfer patient from another GTA hospital where there's been no orthopaedic surgeon on call. I read last year that a hospital in Scarborough was looking for two or three orthopaedic surgeons for over 10 months.
As far as the north is concerned -- and I know you're from there -- my husband spent a couple of days in New Liskeard with a staff surgeon from the Toronto Hospital who goes up north every couple of months. They undertook routine surgeries and ran a clinic. Elective surgery patients are flown down to Toronto to have their operations. Simply, there is not enough volume to warrant a full-time orthopaedic surgeon there. It is more cost-effective to fly them down here rather than invest in the equipment and staff resources to supply an orthopaedic practice up there. Would the government forcibly relocate an orthopaedic surgeon just to sit around setting bones, which a good general practitioner or general surgeon can do, all for the sake of an occasional hip replacement that could be managed better here?
As for the government's representatives and remarks on this bill, I've been watching these hearings for two days -- this is what I'm spending my vacation time doing -- and I'm shocked at the inability of the government representatives to get their story straight. Yesterday when the psychiatry residents were here, the government said that there may be a window, a short-term relocation, when in the bill there is no mention of any time period. The relocation is unlimited and forced. And even if it was a two-year relocation, does the government understand that fellowships follow residency, so that someone like my husband will be in his mid- to late thirties when he starts practising? The government wants to keep someone hostage until they are 40 years old before they can practise their career where they want.
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The minister was quoted as saying that he couldn't believe people would go to medical school only to practise in overserviced areas, and I agree. But I would say to the minister that if the demand is there, and it is, there are very few overserviced areas in the province. I would also say that the demand, given our demographics, is only going to grow in metropolitan areas. I would say that the minister should take a good, hard look at what he is proposing and to whom he is proposing to do it. What Bill 26 and Minister Wilson propose will take away good doctors not only from urban, high-demand centres, but away entirely from the province. It will destroy families, reduce incentive, reduce tax revenue, replace one gap in service with another and slowly but surely demoralize the profession to the point of non-existence. And when that day comes, no language in any bill will qualify the minister to cure the ills of this province.
The Chair: Thank you. We've got five minutes per party left for questions, beginning with Ms Lankin.
Ms Lankin: One of the things that I do often is try to convince women to seek political careers. I'm encouraging you, no matter what party you choose to run for, please consider it.
Ms Margles: That's why I got it out of the way first that I agreed with a bit of everything that was going on. So I'm more of a diplomat than a politician.
Ms Lankin: If you're spending your holidays watching these hearings, get a life.
Ms Margles: I don't have one. My husband doesn't have vacation.
Ms Lankin: I actually appreciate that you've been watching these hearings. I think, as witnessed yesterday and in some of the letters that I got around the motion that was moved, there are people who are watching and are very concerned.
You have said it all, and I don't have a specific question. With your permission, I'd like to use this time to read comments of other doctors into the record.
Ms Margles: Sure.
Ms Lankin: Dr David Mendelssohn, who's a nephrologist at the Toronto Hospital, says:
"Physicians have patient advocacy as their main concern. We bring that perspective to the table. We want our patients to be able to access the system when they need it and get appropriate and high-quality care when they need it. I think the public had better understand that they would be best served if both the ministry, which is concerned about cost, and the physicians, who are concerned about access and quality, sit down at the same table in a non-confrontational manner and figure out what needs to be done.
"Clearly things need to be done. Physicians understand that change is needed. We understand there is a huge debt and we're not against change. We want to be at the table so that we can protect the interests of our patients."
Dr Tom Todd, who's the head of the division of thoracic surgery at the Toronto Hospital, says:
"There are efforts being made to place remedies before us all -- the professions, the population and our patients -- that could be sweeping in their scope, and if I understand the legislation correctly, it allows the power to implement those changes to be in the hands of a very few who perhaps don't understand the situation."
Dr Wendy Graham, who is a family physician at St Joe's centre --
Ms Margles: Can I just say, that was one of the points I didn't have a chance to make.
Ms Lankin: Please take the time. Go ahead.
Ms Margles: The government was elected in part on the premise that it would go for smaller government. This is not smaller government; this is more power in fewer hands. That doesn't mean it's smaller government; it just means it's a different kind of government, and not the kind of government that we're used to and not the kind of government that we elected.
Ms Lankin: Dr Michael Gordon, who's the head of geriatrics at Baycrest geriatric centre, says:
"I'm concerned that what is happening now is potentially going to fracture the medical and health care system of Ontario. It impugns the reputation and professionalism of physicians, and many components of the bill are quite authoritarian. The citizens of Ontario deserve better as do the patients and the physicians, all of whom are citizens."
I think some of those comments echo the comments that you've made. I just want to say thank you for coming and for presenting. It was most eloquent, it was most moving and I hope that the government listens. There are alternatives in terms of the Scott report and the PCCAR process and other processes. I agree with them that there's a problem that needs to continue to be resolved, but there are alternatives.
Ms Margles: I don't think you're going to find any new doctor -- and that's really who this bill is directed at -- any new doctor who doesn't recognize that there are problems in the system, but you can't punish one part of the profession just for the sake of other problems and other things that have been going on.
Ms Lankin: Thank you very much.
The Chair: Thank you, Ms Lankin. The government, Mr Clement.
Mr Clement: Thank you very much for your presentation. You've given us a lot to think about and I want to assure you that we were listening intently to what you had to say.
I just wanted to clear up a couple of things though with respect to Minister Wilson and his comments, because they have been widely reported and from my perspective misunderstood. He also said in his remarks, which if you were watching I hope you had the opportunity to hear: "We want to continue to work with the medical profession in a relationship based on mutual recognition and respect. Cooperation, fairness and equity does not come from a legal document; it comes from the will to work together."
Further, he said: "We are totally committed to working with the medical profession to make changes in the system. Our joint goal must be to resolve issues and make sure that the health system responds to the needs of the people and providers."
So I would like to balance some of the reported --
Ms Margles: I'm not sure how he can rationalize working with the profession when he's trying to disintegrate the OMA and has refused to deal with the OMA, which is the profession's representative body.
Mr Clement: Oh, I think we want to deal with the OMA. Perhaps reasonable people can differ on this, but I think it's important that the minister has made it clear that we want to be involved with the OMA. We want to have discussions with them to get to the mutually satisfactory solutions. So I can assure you that's part of the minister's agenda and I wanted to get it on the table.
Could I just ask you, though, more generally, do you think that the status quo is working in Ontario generally, but also in the health care system? Do you think it's working well for patients and for doctors the way things have been going?
Ms Margles: As far as which problem?
Mr Clement: I know we've got lots of problems. You're absolutely right.
Ms Margles: This is the problem with the government and this was the problem with a question that you directed at an earlier participant. You said last evening to a woman, and I don't know her name, "If you had five minutes, what would you do as Health minister?" What this bill appears to have done is that someone said to every office and every department: "You have five minutes. Go and run. Go and solve the problems." I said clearly, I am not an expert; I am a layperson. I can't tell you about the status quo. I can't tell you what specific problems need to be solved.
Mr Clement: You're a voter and a taxpayer. I'd ask you whether you like the status quo in this province.
Ms Margles: Regarding what?
Mr Clement: Regarding the way this province is run; regarding the way we have health care; regarding --
Interjection: Be specific.
Ms Lankin: How long does she have to answer that question?
Mr Clement: Let me be more specific then.
Ms Margles: I think you have four years to answer that. I don't think that in the five minutes I have remaining I can answer that.
Mr Clement: I was looking for a yes or no.
Interruption.
Ms Margles: If the status quo is the current government, then my answer would be no.
The Chair: The people who are in here as guests are not allowed to participate.
Mr Clement: I think you're upset by the question. I'm sorry about that, but I was asking you the question because I asked a lot of people in my riding that question during the election, whether the status quo was working for them, whether doubling the debt, doubling taxes meant that things were getting better or in fact were they getting worse, do we need more hospital beds or --
Ms Margles: You know, I have to say that I resent where you're going to, okay? Just because I'm all for deficit reduction and debt fighting does not necessarily make me believe in the status quo. You're not going to get me to say that we have to fight the debt and we have to fight the deficit by whatever means necessary if that means what I demonstrated here this morning is going to occur, if what it means is putting disabled people -- cancelling their welfare, if it means all these sorts of things that have been presented to the people of Ontario in the last six months.
Mr Clement: I thank you for your views.
Mrs Caplan: I want to leave a minute; one of my colleagues also has something they want to say.
An excellent presentation. Very articulate. Very passionate. You've said it all and I know your family and your friends, who asked you to come and speak on their behalf, will be very proud of you. You talk about the environment. There are a couple of other doctors I think should be quoted and be on the record, people whom I know and whom Mike Harris should know also.
Dr Wendy Graham, who's from North Bay, said, "What I deeply regret is the present tone and attitude being expressed most recently by the government, and it will preclude an opportunity for all of us to work together to bring about the reforms necessary for the survival...."
Hugh Scully, whom I had the opportunity to work with when I was Minister of Health, said, "The kind of dialogue that's going on today is very unhelpful to patients and counterproductive to any kind of a constructive partnership."
I think you've made the case. I hope that you will continue to advocate and I'm sorry that there will not be more individuals who will have the opportunity to come before this committee because the government has refused to allow more time.
Alvin, go ahead.
Mr Curling: Ms Margles, I want to congratulate you. You have put a face to legislation and, as you say, the social aspect of it. The fact is that at times, and we remind the government that they are doing it to the people, not for the people. You're doing it to them. You have put it very well. As a matter of fact, coming here, even fighting to come here, is a situation that really appalled us all in a democratic process. You're an example of what we all are fighting for in this country and we'll make no government, regardless of what party it is, stop that process. We want to thank you very, very much for that.
Mr Bartolucci: Just one question: Is this government moving too quickly?
Ms Margles: Absolutely --
Mr Bartolucci: Terrific.
Ms Margles: -- and in the wrong direction.
Mr Bartolucci: Great.
Ms Margles: And without a driver.
Mrs Caplan: And by the way, you are absolutely right when you say that there's a certain critical mass necessary to ensure high-quality care. I believe that's the reason they're going to back off their stupid billing number proposal, as it doesn't work, it's not right, it's unfair and there are much better solutions that will make sure that young doctors like your husband and others will know there's an important place for them. We've invested a lot in them and we can't afford to lose them.
Ms Margles: Absolutely.
The Chair: Thank you very much for attending this afternoon and making a presentation to us.
We have an opening at 3 o'clock and the next group will not be ready until 3:15. We'll recess till 3:15.
The committee recessed from 1451 to 1517.
ONTARIO CHIROPRACTIC ASSOCIATION
The Chair: My apologies for being late; we'll put that on the record.
Our next presenters are the Ontario Chiropractic Association, represented by Dr Bob Haig, Dr Lloyd Taylor and Mr Peter Waite. Welcome, gentlemen. We appreciate your attendance at our committee. You have a half-hour to use as you see fit. Questioning will begin with the government, if you allow time for questions.
Dr Lloyd Taylor: Thank you very much. We appreciate the opportunity of being here this afternoon. I'm Dr Lloyd Taylor, in general practice in Welland as a chiropractor. I do Queen's Park for the Ontario chiropractors and have done for a number of years. Accompanying me is Dr Bob Haig, who is director of government affairs to the Ontario Chiropractic Association, and Mr Peter Waite, who is executive director of the association.
You know, you're supposed to be out having Christmas holidays and relaxing and enjoying the good life, and we find ourselves here this afternoon. We appreciate the stalwartness of all these MPPs sitting here.
Peter Waite will read the executive summary.
Mr Peter Waite: Thank you very much, Lloyd. The Ontario Chiropractic Association is a voluntary professional association which represents over 1,550, which is about 86%, of the 1,800 doctors of chiropractic who are registered with the College of Chiropractors of Ontario. There are about 4,000 doctors of chiropractic in Canada and about 50,000 in North America. The profession has grown tremendously in stature and size during the last 20 years. A major reason has been its now scientifically proven effectiveness in the management of patients with back pain and other neuromusculoskeletal disorders.
The OCA has reviewed Bill 26, which proposes a Savings and Restructuring Act, with particular references to the provisions relating to health services which are found in schedules F to I. Generically, these provide the minister with legal authority to exert much greater control over, first of all, supply and distribution of health practitioners, and, secondly, payments to those who provide health services and products.
Although the proposed legislation changes contain new regulatory powers that might have a significant impact on its members, the OCA supports the need for the legislative changes and the broad framework in which they are cast.
The OCA agrees with the findings of a number of studies indicating that there is unacceptable growth and inefficiency in the health care system in Ontario and that it is reasonable that health practitioners should be subject to significantly increased accountability.
Specifically, the proposed amendments to the Health Insurance Act, which is schedule H in Bill 26, contain much greater powers to manage payments through the enhanced stature of review committees and give the ministry the necessary authority to share and give limited disclosure of health care information.
On a balance of interests, the OCA endorses these changes as necessary and appropriate.
Dr Haig will now cover our submission in more detail.
Dr Bob Haig: The Ontario Chiropractic Association has reviewed Bill 26, which proposes the Savings and Restructuring Act, with particular reference to the provisions relating to health services. These appear in the following schedules to the bill: schedule F, health services restructuring; schedule G, amendments to the Ontario Drug Benefit Act, Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991; schedule H, amendments to the Health Insurance Act and the Health Care Accessibility Act; and schedule I, Physician Services Delivery Management Act, 1995.
Generically, these provide the minister with legal authority to exert much greater control over the supply and distribution of health providers and over payments to those who provide health care services and products.
The OCA agrees with the findings of a number of studies indicating that there is unacceptable growth and inefficiency in the health care system. The proposed general restructuring is necessary, and at a time when the people of Ontario are providing funding of $4 billion in fee-for-service payments, it is unreasonable for providers to argue against the need for greater accountability. When I say "providers," I am of course including chiropractors in there. It is appropriate that the government is moving from the role of a passive payor to active analysis of whether services provided are evidence-based, safe, effective, cost-effective and provided within the context of formally developed clinical guidelines.
All this is simply to say that normal market principles -- that the payor should be able to purchase quality -- should govern the provision of publicly funded health care services.
An example, something that is apparent to the OCA because it falls within the scope of practice of chiropractic, is the management of common mechanical back pain. I want to make a few points just with respect to this. Experts generally acknowledge that "low-back pain clearly represents the single greatest and most inefficient expenditure of health care resources in our society today."
Levels of disability from simple low-back pain, which are growing in North America at 14 times the rate of the population, are described by leading experts, including the World Health Organization, as an epidemic.
New, evidence-based, multidisciplinary guidelines sponsored by government and published in the United States and in the United Kingdom in December 1994 make very clear recommendations against many standard treatments that are paid for by the government of Ontario today. These recommendations are on the grounds of ineffectiveness -- for example, with TENS -- on the grounds of potential harm -- for example, with some prescription drugs and steroid injections -- and on the grounds that they promote chronic problems and disability, and examples of that are prolonged bed rest and the use of many passive modalities.
The guidelines that I've referred to above endorse efforts to keep patients moving with the use of exercise and early return to the activities of daily living. Within both of those guidelines, there are only two treatments which are recommended for the treatment of acute adult low-back pain. Those are spinal manipulation and simple, over-the-counter, pain-relieving medication -- two treatments for which the Ontario health insurance plan pays very little funding at all.
In 1993 the Manga report, which was commissioned by the Ontario Ministry of Health and was prepared by health economists at the University of Ottawa -- it's titled The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain -- recommends major restructuring of services for the management of back pain in Ontario. The guidelines that I've mentioned above are in fact supported by the Manga recommendations.
We cite this as an example where there is a clear need for restructuring within the health care system and for the government to take a more active role in the management of health care services. To put it in perspective, I can recall hearing the comment from the researchers that if in fact low-back pain was handled more effectively, the potential cost savings would be in the hundreds of millions of dollars, a very significant amount of money.
Many of the specific powers relevant to the accountability of health professionals whose services are funded through OHIP are found in the proposed amendments to the Health Insurance Act, or appendix H. These amendments increase authority to manage payments in various respects, such as:
Providing more control to define what services are insured and under what conditions and limitations the services are insured;
Providing clear authority for OHIP to refuse to pay a claim at the time it is submitted and to recover any amount previously paid where OHIP believe it should not have been paid in the first place;
Permitting OHIP, upon the direction of review committees, to recover amounts paid by the plan or under the Independent Health Facilities Act when a practitioner requests an insured services, like a diagnostic or a laboratory test, which is not therapeutically necessary;
Requiring insured service providers to maintain records necessary to establish with some certainty that services were rendered, and that the services were therapeutically necessary, and clarifying that in the absence of adequate records no payment will be made;
Permitting the minister to appoint inspectors for the purpose of inspecting the practices of practitioners, including chiropractors -- I'll throw that in -- and health facilities, and setting out clearly that inspection authority.
These amendments also give the ministry the necessary authority to share and disclose information by, for
Providing clear authority for the minister to enter into agreements to use, collect and disclose information;
Extending the minister's and OHIP's authority to disclose information obtained under the Health Insurance Act if the disclosure is necessary for the effective management of health care in Ontario;
Requiring practitioners and others to give OHIP such information as may be required for the purposes of the act or prescribed by regulation;
Permitting the practitioner review committees to provide to the governing college of the practitioner certain information relating to services rendered.
These are very clearly broad powers, but there is also a clear need, in our view, for better management of the health care system and the resources in it.
On a balance of interest, the Ontario Chiropractic Association supports these new powers. Having regard to the general legislation on confidentiality of patient records and current realities, we do not see reasonable grounds for suggesting the likely inappropriate use or abuse of these powers. On the other hand, the powers are necessary to achieve accountability at a time of demonstrated unacceptable growth and inefficiency in various provider services.
Let me just say that we have, unfortunately, prepared this brief on fairly short notice. I'll go even further, to say that our general counsel, who attended the briefings on our behalf and prepared the brief, is unable to be with us. He's with his family in New Zealand at this time. I appreciate that there may be specific questions that we won't be able to answer at this time, but we'll be happy to provide anything that you wish at a later date.
The Chair: Thank you very much. We have about six minutes left per party, beginning with the government.
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Mr Klees: Thank you very much for a very thoughtful and I believe a very responsible presentation. I found your reference to "passive payor" very interesting. I think it concisely describes the passive role of government in the health care system over the last number of years and also very adequately describes why we have the problems that you refer to today.
I find it very interesting that you welcome, or you don't have a great deal of objection to, the issue of permitting the ministry to appoint inspectors, and yet we have heard from groups over the last couple of days that they take great exception to the issue of inspectors. Could you comment on that?
Dr Haig: The answer is the same: It's the balance between the two. It's fair to say that there will be some members of the Ontario Chiropractic Association who might not appreciate the association taking that stance. Clearly there will be individuals of all provider groups who are not going to be happy with that and clearly it sets up the situation where there is less control by the practitioner, chiropractors included, of how things happen. But balance that off against what we see as the need for better management and we find that to be acceptable.
Mr Klees: Thank you. One other question from me. The fact is that there are a number of problems, from what we've heard from the profession and what we see objectively, within the system of how we pay for health care services that are provided. Do you have any recommendations on how we can improve or better manage that system?
Dr Haig: I'll just take a minute here, if I might. I made reference to the Manga report, the report on the chiropractic management of low-back pain. That was referred to a chiropractic service review committee, which was a joint committee of the Ministry of Health and the Ontario Chiropractic Association that looked at many issues relating to the delivery of chiropractic services within the province. They met for about 18 months, I think, and looked extensively at things and dealt with many issues, one of which was not funding. Because of the time period it was in -- it was within the period of the social contract -- funding was not one of the issues that was in there. But there were a number of things in there that dealt with how chiropractic services are delivered, and I have a copy of this that I can leave with you.
Two of those recommendations I'll just read to you now. One is, "That medical specialists be allowed to bill OHIP for a referred consultation with respect to patients referred directly by a chiropractor." The issue there is that a specialist can bill a consultation fee only if the referral is received from a general practitioner or other physician, not from a chiropractor. There are many, many circumstances where patients enter a chiropractor's office, the chiropractor determines they should be seen by a medical specialist but frequently -- not in all cases but frequently -- cannot make that referral, the result being that the patient has to go through the loop, has to go back to the GP before he gets to the medical specialist. That obviously is an inefficient way to do things.
If you accept, as the RHPA does, as the public does, that the chiropractor is completely qualified to do what he's doing, the government is unable to do that, because they don't have the authority to make those kinds of decisions, they don't have the authority to make the decision to allow chiropractors to refer directly or to alter the fee that the specialist gets. There are other issues involved there, but that's one example.
Essentially the same situation exists with respect to referral by chiropractors of patients to independent health facilities for X-rays. More than half of chiropractors have X-ray facilities within their offices. Those who don't frequently have to refer patients out for X-rays. The current legislation prevents an independent health facility from taking films at the request of a chiropractor, so again that patient has to be referred to a physician and generate an extra visit before he gets to the independent health facility.
These are small examples, I understand, in the whole scheme of things, and I'm not even able to give you an idea of the volume of services that we're talking about, but clearly those are examples where things could be done better. The way things exist right now, the government doesn't have the ability to do them that way.
Mrs Caplan: Thank you very much for your presentation. It's always nice to see you. The question I have is, have you had your legal counsel review this to determine whether or not chiropractic services will be or could be, at this time or in the future, determined to be part of an IHF? As I read the legislation, the government could decide to do that with the powers they have, and I'm wondering how your membership would feel about being wrapped in under the IHF designation.
Dr Haig: Mrs Caplan, as I read it now, I read it the same way. We have not had an opportunity to discuss that with our counsel so I'm not really qualified to answer that for you, but I understand exactly what you're saying. As I said, we're in a difficult position. We felt that we wanted to make some comment on this when the opportunity arose. We're not as thoroughly prepared as we would like to be. That is something I will get back to you on, if you wish.
Mrs Caplan: I think it's important because there are implications in this legislation that I think many have not yet fully understood, which is one of the concerns we have about having this all proclaimed by January 29. Certainly we have said that we believe that there are some parts of this legislation that the government could have and must have, such as the fiscal powers and so forth, but other parts that have broad policy implications such as this, since we've had not indication from the government what their intention is around the broad powers -- pretty much what they said is, "Give us the tools," as in absolute power and control, "and stay tuned." So we're very concerned because we don't think that anybody fully understands the implications. Further, Bob, it's fine for them to say, "No, no; we have no intention of wrapping in chiropractic," but Ministers of Health don't last very long, and the next guy or gal -- I speak from --
Mrs Johns: From experience.
Mrs Caplan: -- experience, the longevity is not such -- I mean, look at all the pictures on the wall.
Dr Haig: I know.
Mrs Caplan: I'm wondering if you would be concerned about that, and the fact that once this bill passes, should a future minister decide that chiropractic services should be delivered in an independent health facility, that could be done without any consultation with your members, without any process opportunity by your members, and you're coming forward today in support of a bill that could affect them. I express caution to you because I read this bill and see things in there that you may not have contemplated.
Dr Haig: I understand where you're coming from. I very clearly acknowledge that the provisions in this bill that will apply to everyone else can apply to us just as well. That's clear and I acknowledge that.
You know the situation that chiropractors have been in in Ontario. You know it is not mandated by the Canada Health Act. You understand that there are rights that exist for other professions within the system that don't exist for us. We view our service as one, and there's all kinds of documented evidence now, which the public is wanting more and more of, that is proving to be effective and cost-effective and has been recommended many times should be thoroughly integrated into the health care system.
Mrs Caplan: Right. The only point I'm making --
Dr Haig: I'm sorry; I do apologize for cutting you off, but I'm saying that in the context of having viewed the health care system from this side of things for a while, and everything I say is in the context that we recognize things have to change.
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Mrs Caplan: I'm not disagreeing with the need for change; I've talked about it since 1987. What I am saying is that in this legislation, all services, both insured and uninsured, can be included in an independent health facility. We don't know what that's going to mean for chiropractic services. I guess my question of you is, would you support a delay on this bill so that we could explore those implications and your members could have a chance to come forward and let us know how they would feel about that, before this bill is passed and in law? That's all I'm saying to you: Is your support unequivocal regardless of what the future implications might be for chiropractic services?
Dr Haig: Specifically with respect to the IHFs, I can commit now to get back to you before the out-of-town public hearings are done.
Mrs Caplan: Great. No, I'm just interested in that because what we're doing here is exploring the potential uses of the powers of this bill, the fact that so much can be done by regulation. I just want to know how chiropractors feel about that. I'd appreciate hearing back from you.
Ms Lankin: I found your presentation interesting. I know you're always a good bunch of guys to get along with, but boy, that was pretty soft and pretty open in terms of its endorsement. I'm going to add my voice to Elinor's to suggest to you to be a bit cautious.
What I do take from your message, which I think is very positive and I think the government will appreciate very much, is the profession's understanding for the need for restructuring and change. That has been a constant, consistent position of the OCA. I think we need to appreciate that and to understand how willing the profession has been to work through, over a very long period of time, trying to convince people that you're willing partners in that change and that you have a role to play as health care providers beyond what has been allowed for in the system under the current structure. I understand all that, as you well know.
I would just suggest to you that, in my opinion, looking at this bill, there are dangers and pitfalls in the way in which it has been constructed and in the open powers and powers to be described in regulation that we should care about and we should explore: the ability to designate eligible providers in classes, groups, by specialty, on and on, without any sense in the legislation of what the goal is or what we're trying to achieve there; the ability, by again prescribing in regulation, to determine what services are delivered where and what they're going to be paid for, unilaterally, in what volumes and to what kinds of providers and geographically different; the powers around the restructuring commission which set out no obligations, goals. Nothing is there; it just establishes it; it doesn't link it to the DHCs, to community consultation.
As to the inspection powers of the Medical Review Committee that you talked about being enhanced, I also support that, but the inspectors appointed by the minister in the general OHIP division: non-medical, non-chiropractic, non-professional, having access to those documents, being able to go into your office as a provider and take your patient records, not just to confirm in terms of fraud, and substitute decision-making around what's therapeutically necessary.
I think the greater management of the system as opposed to, someone said earlier, a passive payor in an insurance system is right. We've talked about that. But some of these things go far beyond what is necessary, I believe, and there are dangers in there.
I don't attribute bad intentions to Jim Wilson, but let me just put to you, how many years have you tried, through the Ministry of Health, to get some movement and recognition of chiropractic? How many years did it take before you got support for the Manga report to get done? You know the inherent blockages inside the bureaucracy. This power on to the bureaucracy, to me, is not necessarily in the best interests of the public overall with respect to the changes that have to happen. I would rather see the combination of providers and consumers and communities have more power with respect to these changes than the way this is going.
That's a bit of a speech, I'm sorry, but I really urge you to go through this and to be cautious, because I think there are some problems. I appreciate your overall support for what the government has to accomplish, however.
Dr Haig: This is difficult for everyone, let's face it. It is not a partisan issue. It's not a partisan issue at all. It's not a doctor-chiropractor-government issue either. While it would be nice if everything was very clear at the start, it isn't that way, and things have to work through. We're glad to be part of the process. I'm hearing what you're saying, and Elinor as well. That specific item, we'll get back to you on. I can tell you that before the out-of-town committee hearings are finished, if we have anything else to bring forward, we'll do that, okay?
Ms Lankin: I appreciate that. Thank you.
The Chair: Thank you, gentlemen. We appreciate your interest in our process in being with us today. Have a good day.
Dr Taylor: To have two former Ministers of Health asking questions in the same room at the same time is very appropriate; at the same time in the same room is very unusual. To all of you, the very best of the season.
Mrs Caplan: You should be very worried because we agreed.
The Chair: I'm not sure whether the West Central Communiity Heath Centres, Walter Weary, is here. Maggie Atkinson from AIDS Action Now? We are about 15 minutes ahead of time so we will take a 15-minute recess.
The committee recessed from 1545 to 1600.
WEST CENTRAL COMMUNITY HEALTH CENTRES
The Chair: With us now from the West Central Community Health Centres is Walter Weary, executive director. Welcome to our committee. You have a half-hour to use as you see fit. Any time you allow for questions will start with the Liberals. The floor is yours.
Mr Walter Weary: I'm very pleased that you have given me the opportunity to speak here today. I have prepared a brief that I believe that has been handed out. I would like to read it.
I would first like to give you a little bit of background about West Central Community Health Centres. We're comprised of three centres in the inner core of Toronto. Two of our centres are located in the Queen and Bathurst area and the third is on Jarvis Street near Wellesley. As you can imagine, the communities have a mixture of residents, from middle and upper middle class to some of the poorest in the city. About 40% speak English as a first language. Portuguese, Chinese and Italian are other languages spoken in the area.
West Central has been providing community health services since 1969. In recent years we have been very successful at removing some of the barriers that prevent many of the most isolated people in the area from accessing health services. I hope we would continue to work in that area.
We see our mission at West Central to be a resource to improve the health and quality of life of people in the community we serve. We achieve this mission by providing medical and dental services, counselling, education, community development and health promotion. We are very proud of West Central's ability to work in partnership with the community to identify needs and implement programs and services on behalf of all individuals, groups and agencies in the community. West Central has health promotion and prevention programs that are designed to enhance the health and wellbeing of all community members, as well as to help eliminate the personal, social, political and environmental factors that encourage illness.
We also work to reduce inequities that contribute to poor health and to direct our efforts towards communities and individuals with the greatest needs. As mentioned above, we work very hard to make the health care system accessible to isolated community members. We also encourage and support the right of all people to make informed choices about their health and wellbeing. West Central is committed both to providing personal, effective and efficient programs and clinical services, and to continuous improvement as we recognize the inevitability of the community's changing needs. All these goals enable us to provide effective and efficient health services.
We at West Central have some understanding of the government's position regarding the deficit. There are enormous pressures on our economy at present and it seems that drastic measures are required, but it is also important that we must do more than simply reduce services as rapidly as possible. We need a vision for the future of health care and for the future of our society.
When we reviewed the many decisions proposed by Bill 26, it become apparent that whereas Bill 26 gives the government tools to make sweeping changes in many sectors of our society, what the document needs is a clear overall vision for the future of health care that would direct those changes, and that vision is one of the topics I would like to discuss here today. With a future vision it is likely that many will assume the worst about the changes that will occur to areas that Bill 26 touches. Now I'd like to talk further about the vision.
A very important part of the democratic process requires that the citizenry of the country be informed and supportive of the government's policy formulation process. The new government has taken steps to provide leadership in the implementation of change in our society, yet in a successful democracy a government can be measured both by its ability to lead and the extent to which its policies are in concert with those supported by the majority of the electorate.
Bill 26 includes sweeping changes to over 40 pieces of legislation. It was brought to our attention approximately two weeks ago and it was only last Friday that we were able to obtain a copy. In this short time all we could hope to do is bring forth our key concerns surrounding the proposed changes in health policy. For this reason, we can't emphasize strongly enough how critical it is that the changes not be legislated or implemented until they meet with greater public understanding and debate. A large part of the decision-making process is communications, and without effective discussion and deliberation of dramatic changes, a great deal of confusion can be created.
When we began to examine this bill, the goals and objectives for the overall process were not apparent to us. We acknowledge a need for deficit management, but what is expected is that other goals and values would be considered in concert with financial goals in order to direct and create a society that will meet the needs of all Ontarians.
Our review of the bill led us to the principles in the Canada Health Act. As you know, these principles are widely accepted and are agreed to by a broad range of Canadians. You're probably familiar with them; they are comprehensiveness, universality, accessibility, portability and public administration. These basic principles provide an enormous measure of support and solace to Canadians. They form the basis of the Canadian medicare program, which was designed primarily to lessen the devastating financial hardship that many families faced when a family member became ill for a period of time prior to medicare. They ensure that comprehensive health care is available to all Canadians on like terms.
The goal of medicare was and still remains an issue of equity in the use and financing of health services. It's at this point that I must ask the question: Is the government committed to the principles of the Canada Health Act? If the answer is no, what principles or values other than the need to reduce the deficit are behind the many legislative changes in Bill 26? Does this bill strengthen or erode the principles in the Canada Health Act, and is the government committed to the equity expressed therein?
We're very concerned that the government may have as one of its objectives in the proposed omnibus bill the removal or reduction of the principles expressed in the Canada Health Act. Only last Thursday there was a quote in the Toronto Star attributed to your Finance minister, Ernie Eves, who was at that time talking about the Canada Health Act. It stated, "Maybe what we should be talking about is having a set of national principles and objectives as opposed to federal standards imposed by the federal government." It's therefore important that the government clearly delineate whether or not it will support the principles in the Canada Health Act. If it will not, it should spell out the principles that it does hold in high regard so that we are able to ascertain exactly why the concentration of powers as indicated in Bill 26 is necessary, and what they are going to be used for.
I would like to say at this moment that I recognize that it might be possible to trust the current government with the kinds of concentration of powers that are expressed in this bill and it may be possible to trust the participants who are here today, but there's no guarantee that those people will continue to be in charge in the future, and I am concerned about making legislation that could be used for other purposes than what was intended.
Inequity is another issue that we were concerned about. The recent reduction in social assistance has had a major impact on many of West Central's clients. Already people are unable to cover the costs of the basic prerequisites of health, such as food and clothing and shelter. The omnibus bill heightens this inequity. The imposition of copayments will have a great impact on social assistance recipients and low-income seniors.
I would like to just mention that copayments, although they could seem like a small barrier to receiving health care, could for someone who was elderly and perhaps receiving a large number of medications, which is quite common with the elderly, have a large impact. It's common for elderly people to have 10 or 12 different medications, and if for each they pay $2, that comes to $20 a month or maybe more. That will have a big impact on the ability of those people to acquire the medications.
I would also like to say that it in a way is forcing physicians to try to prescribe in a different manner so that the seniors could avoid paying the fee. That might mean that physicians end up prescribing for three or four months of medications, and that could easily cause confusion both by the senior and by other people who are involved in giving the medication. Having a lot of pills around the house is not wise either, because I think children often mistake them for candies or eat them, and that could cause other health problems.
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The deregulation of drug prices and the imposition of a wider range of facility fees are all going to increase the hardship on our low-income populations. These sectors already bear an enormous burden due to the battle against the deficit. The imposition of user fees in the past has never been successful in lowering costs and reducing the utilization of the health care system. What it has been successful at is reducing its accessibility to low-income groups.
Our health centre does in fact deal with a lot of low-income groups. One of the three centres works primarily with street youth, who have very few resources -- many don't even have social assistance -- and any kind of user fees are going to be an effective barrier against them receiving health care in the future.
For example, treatment postponed to a later date could result in more expensive interventions. Before coming today I talked to our physicians. They could have gone on forever about this issue, but even with acute problems such as a chest infection, if someone avoids taking antibiotics early on in the infection at a cost of $10 or $12 because of user fees or whatever, the infection could spread, perhaps resulting in something like pneumonia, and that in turn could lead to emergency care at a hospital or even longer term care after admission in the hospital. The cost would then escalate not simply by a factor of two or three, but maybe by a factor of 10, or even 100-fold. Chronic conditions affecting the elderly -- and I guess I've seen this already in our health centre where people are unable to get medication that they require for things like hypertension and asthma and diabetes -- can lead to much more serious issues such as stroke or heart attack, kidney disease, and in the case of diabetes, I guess blindness even.
For these reasons, we regret the implementation of user fees into a health system that is based on the principle of universal access.
The next item is confidentiality. The relationship between patients and their health care providers is an extremely sensitive one. Without a patient's full confidence and full disclosure, the health care provider is at a serious disadvantage during the process of assessment, diagnosis and provision of appropriate treatment. Disclosure is also an integral part of health care prevention in order that appropriate education and support can be provided to patients.
Bill 26 gives expanded authority to the Minister of Health to inspect, copy and disclose confidential medical records. This disclosure by government includes the release of information to third parties such as law enforcement agencies, as well as other ministries, provinces, police forces and perhaps even private sector organizations.
If patients cannot be guaranteed confidentiality while interacting with health care professionals, they will not disclose important information. This is particularly important I guess in the area of drug use or alcohol use, alcohol being a primary one, or sexual preference, where disease prevention can be very effective.
Ultimately, higher costs would be encountered by the system as diseases will be revealed in more advanced stages and with greater frequency. The bill must be amended to provide assurance that medical information will be as strictly protected as it is at present. For example, health insurance staff and inspectors reviewing cases of suspected fraud or medical misconduct are sworn to confidentiality. West Central agrees with the Ontario privacy commissioner's conclusion last week that the privacy of Ontarians is at risk. It's a very big part of the service provided at West Central that we are able to gain the trust of people and that they are assured that the information that's disclosed in the privacy of the physician's or nurse's office stays at that point. If we aren't able to provide that assurance, it's very clear to us that we will not be given the information upon which to act, and that ultimately will be very expensive to the government.
"Canada first" is another issue that was raised. According to the Globe and Mail of Monday, December 18, 1995, there are over 900 independent health facilities licensed under the Independent Health Facilities Act. These facilities provide a wide variety of services such as ultrasound, nuclear medicine and X-rays.
According to the article, "Amendments to the Independent Health Facilities Act would drop the existing requirements that the province in its funding decisions encourage Canadian-owned non-profit health care clinics." This explicitly encourages foreign ownership of many of Ontario's health care agencies when at present we have an effective and competent non-profit system providing the same services. Is this an attack on the values expressed in the Canada Health Act that established public administration and universal health care? Is it the intention of the government to make our health care system similar to the American approach, which has already been proven to be less efficient and more costly than the Canadian health care system? Neither the omnibus bill nor the government has been clear on this point, and we hope that you clarify your direction before proceeding further.
As you are no doubt aware, the Canadian single-payer system is much less costly to administer than the American health care system. In the area of administration alone, the Canadian system costs approximately a fifth of the American system. In addition, the costs associated with health care in Canada have been increasing at a lower rate than those in the United States. It's in this area that we'd ask the government to exercise deliberation before proceeding, for in the haste to cut the deficit, we might end up creating a system that is more costly than the current health care system. We might end up with a system that does not have the financial restraints built into it that the Canadian system has. Some of these constraints are the negotiations between physicians and hospitals around fees and payments and the ability to ban extra billing.
Again we have to ask the question, what are the values, other than deficit reduction, that are propelling Bill 26, and what is the future of health care that the Progressive Conservative Party is promoting in Ontario? Any planning process must answer questions like these prior to setting out its strategic direction. We would hope the government will be able to provide the people of Ontario with these answers before proceeding with the centralization of powers that Bill 26 is proposing.
Public participation: Like many countries, Canada has a long and time-honoured tradition of public participation in the management of its programs. For many public institutions, the board of directors is an integral part of the feedback process that ensures that the community is both informed, knowledgeable and able to influence decisions that are made within the organization. Under the proposed Bill 26, the Minister of Health is assuming responsibility for almost unlimited authority to close public and private hospitals with no prior public consultation or local input.
In the past, it has emphasized a strong commitment to the enhancement of the voluntary sector and local responsibility, but this unprecedented centralizing of power at the ministerial level strips the voluntary sector of the opportunity to give valuable input. This will discourage responsible community-based decision-making. In Canada, participatory decision-making is a hallmark of both public administration and accessibility, and the changes proposed by Bill 26 greatly reduce the role of community volunteers in this area.
In addition, it is highly unlikely that the government will have an in-depth knowledge of the thousands and thousands of issues important to the many communities of Ontario. I know you're well informed, perhaps much more well informed than the average citizen, but it's not possible for a centralized government to understand the details of each and every community. Speaking from personal experience as the executive director of a community health centre which serves maybe 15,000 or 20,000 people in a community of a couple of hundred thousand -- and we only have 30 staff -- it's impossible for me to know the details of everything that goes on in our health centre and of all the services provided by the health centre. It's only through consultation with the community and with people at the health centre that I'm able to understand the changing dynamics in the community, and I think the same applies to the government.
When you're going to make a decision, or as many decisions as this bill entails, you really do have to spend time testing the waters first so that you get a sense of the real impact of that decision or those decisions on the community, and I would encourage you to follow a course of action that allowed that.
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It might be appropriate to close a hospital here or a health facility there, but actions of that nature should not be taken without full consultation of the community affected. It's only after this consultation that the government, with full knowledge of the issues at hand, should act.
I'm not saying here that the government should always do everything the community says. It's not a practical solution necessarily, but you certainly should know the variables that you're dealing with before you make the decision.
In summary, I'd like to return to our original question: Does this bill strengthen or erode the fundamental principles underlying our existing health care system, and does it reflect a commitment to equity as expressed in the Canada Health Act?
We would have to say that it all depends on the emphasis given to those values other than deficit reduction. The changes in Bill 26 could only be fully understood by all Ontarians after an open and public debate in the light of the principles stated earlier. This debate can hardly occur when over 40 pieces of legislation are being altered hastily in a bill of this sort.
On the one hand, we commend the government for its efforts to try to manage the affairs of the day effectively but, on the other hand, we caution them in proceeding at this pace without the support of a fully informed public. It would be unwise, and perhaps reckless.
I'd like to stop there and thank you very much for the opportunity you have given us to give our comments on Bill 26. I very much hope you will benefit from the time and effort that you have invested in these hearings, and that you will seriously consider the issues raised in the many deputations you have heard and will hear regarding Bill 26 in the coming weeks.
The Chair: You've left us with one of our greatest challenges in this committee, time for three quick questions, starting with Mrs Caplan.
Mr Bartolucci: Thank you, Mr Chair.
The Chair: Oh, Mr Bartolucci.
Mr Bartolucci: We've assumed different roles now. Thank you very much for an excellent presentation. What you've done here is you've taken, I think, the concerns of everyone who has presented and very, very succinctly posed problems and fears that not only you but every other group who are wary of this legislation feel.
Let me ask you one simple question. Are you fearful that the ministry isn't fully aware of the powers it has given itself with regard to the long-term health care issues?
Mr Weary: I can't answer whether the ministry is fully aware or not, because they haven't consulted me. I can say that I, and I think many other people at West Central are concerned that the centralization of power could lead to decisions that might be harmful in the long run. I certainly think the ministry is in many ways well informed, but some of the changes I have seen I think are going to end up costing society a great deal.
Ms Lankin: I'd like to ask you a question about the macro picture in a question that you posed around the vision. The previous government adopted a sort of strategic direction which included a framework of decision-making based on determinants of health for the whole government.
So far, we've seen this government cut income assistance to people, cap pay equity payouts, eliminate the proxy pay equity, which is in this bill, for the lowest-paid women, and eliminate social housing programs. Just this week they removed a ban on municipal incineration without putting in place the strict guidelines they promised they would do. This legislation allows for user fees on community and social recreational services. There's a reduction in access to early childhood education.
The first part of my question is, are these things consistent with a determinants-of-health framework? Secondly, on the issue of universality, in terms of medicare as part of the vision, under the Health Care Accessibility Act in this bill, it allows for user fees to be put on insured services in hospitals. We know under the Canada Health Act that while that might be permitted, there is a clawback through transfer payments to the province from the federal government. No government in their right mind would introduce that if they thought the money was just going to be clawed back. Put that together with the Finance minister's statements looking for flexibility in the Canada Health Act, and it strikes me that there is a worry about the government division with respect to universality and the potential of a two-tier health care system. Can you comment on those two areas?
Mr Weary: You're right, it is macro. I would say that the handling of the deficit is definitely in many ways inconsistent with, or can be seen as inconsistent with, providing good services in society and that many of the cutbacks that have occurred have had a major impact on the determinants of health.
I personally am glad I'm not the government at the present time, because I think the decisions it's got to make are very hard, very tough ones. But I do think some of them -- the removal of shelter, the reduction of food costs in the budgets of low-income people -- may not be as wise as they could have been. The result will likely be added costs to the system in the future, and I think already at our health centre we're beginning to see that as people come in.
The Chair: Thank you, Ms Lankin. You weren't quite as good at a quick question as Mr Bartolucci was.
Ms Lankin: Thanks for your comments, Mr Chairman, your opinion is important to me.
The Chair: I just had to throw that in.
Mrs Caplan: Keep the cards and letters coming.
The Chair: I know that you will dwell on that.
Mr Weary: I wish I could chair our staff meetings with the same strong hand.
Mrs Ecker: Just very quickly, you raise a couple of questions. Just ease your mind that Bill 26 is not going to undermine the Canada Health Act because we believe in the Canada Health Act. Secondly, the independent health facilities legislation extension: The reason we want to extend that is because of the excellent quality assurance provisions that are under that legislation which the Liberal government brought in.
The other thing I think it's important to note is that when the Independent Health Facilities Act was brought in, there were many for-profit centres that were grandfathered under that legislation, so there certainly is no concern, I don't believe, about profit or for-profit. I think what is important is, are the regulations going under that legislation leading to quality assurance? We think they are, and so that's one of the reasons we want to extend that.
What I did want to just quickly ask is, as someone in a community health centre where you're seeing the need for reallocation and restructuring within the health care system to take some of the resources out of the hospital sector -- the acute care -- and putting it into community-based, has that happened enough in the past and do you see it happening now and is it happening fast enough?
Mr Weary: I think in the past that the government has been very slow to respond when it takes money away from one section to put it into another section. Indeed, I guess if I were forced to generalize, I would say it doesn't always happen the way you would like it to.
I think it's very important that as the changes, especially to the hospital sector, happen, money be put into the community to pick up a lot of the loose ends. Otherwise, the costs will come back at the government later on. I'm not sure if I answered it directly.
The Chair: Thank you, sir, for your presentation this afternoon. We appreciate your interest in our process.
AIDS ACTION NOW
The Chair: Our next presenters are from the AIDS Action Now committee, Maggie Atkinson and Tim McCaskell. Good afternoon and welcome to our committee. You have a half-hour to use as you see fit. Any time you allow for questions, we'll begin with the Liberals. The floor is yours.
Ms Maggie Atkinson: Thank you. I'll just introduce ourselves. I'm Maggie Atkinson, obviously, and this is Tim McCaskell. We're from AIDS Action Now. I'm the co-chair and Tim is a past chair of AIDS Action Now and is currently a member of the steering committee.
AIDS Action Now, as some of you may know, is a volunteer organization. It's Toronto-based in Ontario and it is a completely volunteer organization; we accept no funding from government or from pharmaceutical companies. The majority of our steering committee are people living with HIV or AIDS.
Tim will begin our presentation. I'm sorry that we don't have a brief, but we'll follow up with a written submission.
Mr Tim McCaskell: In terms of an introductory remark, I wanted to say something about our concern with the scope of this bill, and to try to impress upon you the fact that decisions made at this level which may appear to be purely administrative or financial have real ramifications on the lives of people living with AIDS and HIV and on questions of public health in this province, and that decisions made precipitously, without consultation, will not serve the interests of people in this province.
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As an example, I wanted to speak about the part of this bill that would allow the minister access to personal medical information for purposes prescribed by cabinet. This, we're assured, is in order to prevent fraud from taking place, and it would seem on that level to be a perfectly reasonable kind of request. However, in terms of the lives of people with AIDS and HIV, serious ramifications would come from that kind of legislation. When we're talking about AIDS and HIV, we're talking about a stigmatized disease that's affecting particularly vulnerable communities.
Often, the only person with whom a person at high risk for contracting HIV might be willing to discuss, or to whom they would disclose their situation, would be their family physician. Fear, however, that those personal records of their family physician might end up in the hands of a bureaucrat or a politician would mean that people simply won't disclose, and with less disclosure there'll be less counselling, with less counselling there'll be less testing, and with less testing there'll be less treatment, less early diagnosis and less early intervention, and therefore we'd be maximizing the spread of this virus because people will not be equipped to deal with it.
That isn't the intention of the bill, but it certainly would be the effect of it, which is why we feel that bills that centralize power in this way are precisely so dangerous for people living with AIDS and HIV and for the public health of people in this province.
I understand that this morning people from the AIDS Committee of Toronto and the Toronto People with AIDS Foundation spoke to you, and we certainly want to reiterate many of the concerns they brought up. Our presentation will focus more on questions of drug cost and availability, and access to physicians.
The first thing I wanted to bring up was the question of user fees. The bill allows the government to impose a minimum $2 charge per prescription for people obtaining benefits under the Ontario Drug Benefit Act, and it would give cabinet powers to enact other user fees and other copayments without consultation.
People with AIDS and HIV often find themselves dependent on the Ontario drug benefit plan to pay for prescriptions. Unable to work, we often find ourselves on or below the poverty line. A $2 prescription fee may not seem like a great deal, but where we're talking about people who routinely may have to submit 10 or more prescriptions per month, 12 months a year, we're talking about whittling down an already meagre existence to levels where such basics as nutrition will be seriously put into jeopardy, and where nutrition is undermined, health is undermined. That has the potential of starting patients on a vicious downward spiral which ultimately will cost the health system a whole lot more because people will find themselves in hospital and much sicker.
Furthermore, on the level of principle, I think what we're looking at here is a kind of regressive form of taxation where the poorer and the sicker one is, the greater percentage of your income you will end up paying.
In terms of AIDS and HIV, any changes which discourage people from filling prescriptions or which lower already marginal standards of living will be a false saving and will ultimately cost the health system a great deal more.
The second area I want to look at is the deregulation of drug prices. Presently, drug prices are standardized across the province by the Prescription Drug Cost Regulation Act. Repealing the power to regulate, which Bill 26 envisages, will at the very least undermine the uniformity of drug pricing. The idea is, of course, that freed from this regulation, the market will determine the lowest feasible cost for drugs, but that kind of classical economic model presupposes mobile consumers who can shop around for the best possible price and competition between pharmacies.
People who are sick, however, are not mobile consumers. They're not going to be able to spend all day trekking around from pharmacy to pharmacy depending on the price of different drugs. People living in remote areas will have even less choice if there's only one pharmacy in town. What that means is that people will be paying widely different costs for similar drugs across the province.
What people with AIDS and HIV need to know is that the most convenient pharmacy will offer standard prices and that one pharmacist will oversee all our pharmaceutical needs. If I have to go to one pharmacy to get one drug and another pharmacy for another drug because it's cheaper there, then I lose any kind of continuity and, quite frankly, I count on the pharmacist to oversee the silly mistakes that my doctor might occasionally make, because those mistakes in my case could very well be fatal. We feel that deregulation as is proposed in this bill can only be detrimental to people living with AIDS and HIV.
Finally, the alteration to the way that drugs are listed on the formulary: The present procedure is that the DQTC recommends drugs to be entered on the formulary and the minister approves them. We already have serious problems getting new AIDS drugs on the formulary in an expeditious manner. It may take up to a year. The minimum time it takes to get a drug, once it's approved in Canada, on the formulary is approximately three months.
We feel that any changes that place more responsibility on an already overburdened cabinet, which has little expertise in this area, can only slow down this process and further delay access to life-saving medications. If this were one or two drugs, maybe there would be room for manoeuvre, but I think people have to recognize that, in terms of AIDS and HIV, new treatments are coming down the tubes all the time. This is a serious, continuing problem we have. Anything that delays those drugs getting on the formulary delays those drugs getting into people's bodies, and that can be a life-and-death situation.
The bill also gives cabinet the power to establish clinical criteria for use of drugs under the ODB. I think that people in Ontario go to doctors to find out which medications they need, not to politicians. We sincerely doubt that cabinet has the expertise to second-guess the medical treatment that doctors are prescribing. That kind of second-guessing will really interfere with the doctor-patient relationship, which is essential to our medical system. Once again, these changes, no matter what their intention, we feel can only be to the detriment of people living with AIDS and HIV in the province. Maggie wanted to talk about access to doctors.
Ms Atkinson: There's currently a shortage of physicians in this province who will treat people with HIV and AIDS. This is a problem which was rated as a priority by the Ontario Advisory Committee on HIV/AIDS in Ontario's HIV and AIDS Plan to the Year 2000. The restriction of new physician billing numbers in Toronto would have a potentially disastrous effect on HIV primary care in this province.
What we would like to see is, if there is going to be any restriction on new billing numbers for physicians in Toronto or in any major centres, that there be provision made so that any restrictions on new billing numbers would not apply to physicians who indicate an intention to specialize in HIV primary care.
Approximately 16,000 people in Ontario have tested HIV-positive. There are probably a lot more who haven't already tested. Seventy per cent of those who have tested positive live in Metro Toronto. Approximately half of those who have tested positive and who are undergoing treatment from physicians are seen by a small group of doctors here in Toronto, the Toronto HIV Primary Care Physicians Group, and there are only 50 of them.
Fifty doctors here in Toronto are seeing half of the 16,000 HIV-positive people in Ontario. They are severely overworked and stressed. Some of the physicians who have been involved in HIV care since the beginning of the epidemic are fatigued and they are pulling back from their practices. Their practices are actually closed to any new HIV-positive patients. There's a crying need for new physicians in this area.
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We have found that there's a real reluctance among GPs to practise in this area. First of all, part of the problem seems to be the stigma that surrounds this disease. Part of it's probably due to homophobia, but there are also disincentives in the current medical remuneration system that prevent doctors from going into this area or continuing in this area.
For example, if you look at the Toronto HIV Primary Care Physicians Group, they make a substantially lower amount per year than other GPs because the fee-for-service remuneration model does not adequately compensate them for the amount of time they have to spend with individual patients, nor does it compensate them for the paperwork they have to do.
There's not only the paperwork for insurance forms, disability forms, which people on disability can't afford to pay for, but also the paperwork involved in enrolling patients in clinical trials, in access to drugs under emergency drug release programs and through open arms of trials. All this is paperwork they have to take on in order to provide adequate care for their patients.
We would like to see some of the recommendations of the report, Ontario's HIV/AIDS Plan to the Year 2000, implemented, but in particular we're concerned that new doctors need to be encouraged to enter this area and therefore that there not be any restrictions on billing numbers on doctors who will specialize in this area.
We believe that HIV care has been recognized and should continue to be recognized as an underserviced area of practice and that underserviced areas shouldn't be looked at just as a geographic problem. It's clear that, even in Toronto where there are approximately 4,000 GPs I believe, HIV is an underserviced area. In recognition of that problem, there shouldn't be a restriction on billing numbers for doctors who are interested in entering this area.
We are aware that there are some interns who have expressed an interest in this area, who have done some specialized training in this area, but they are discouraged and concerned, as are we, that they won't be able to practise in Toronto if there's this kind of restriction. We'd like to see at least some kind of provision made for this.
Those are our main points. We'd be happy to answer any questions that you have.
The Chair: Thank you very much. We have about four minutes per party, beginning with the Liberals.
Ms Lankin: Mr Chair, I don't want to tell you how to do your job, but you're out of rotation.
Mr Clement: Yes, she's right.
Mrs Johns: Tell him how to do his job.
Ms Lankin: I'll just begin while you're looking at your list.
The Chair: Is it your turn? My apologies.
Ms Lankin: Not a problem. Thank you very much for your presentation. I want you to know that we've heard from other groups who have talked about underserviced areas of practice as opposed to underserviced geographic areas. Psychiatric interns were before us who talked about certain psychiatric specialties in terms of people who have suffered, for example, from childhood abuse or certain ethnocultural -- I think that you make the case very well and I think it is well known within the ministry the problems with the underservicing and certainly the problems facing those physicians and how stretched they are as a group.
I believe that the government has got that message and I hope that if they do continue with this billing restriction -- and I think there are some problems with that whole approach -- that that message at least has already gotten through.
The other thing I want to just comment on quickly that you raised was on the deregulation of drug prices. You're the first group to present this issue of what it would mean for those who are not ODB to be going from pharmacy to pharmacy to shop for the lowest price, particularly if they are multiple drugs that a person needs as a person living with HIV or with AIDS -- that's obvious -- the loss of the pharmacological counselling and control of the drug program that a patient is on. That's an issue we haven't heard and it's an issue I think we need to raise and to perhaps get some response on from the ministry.
I'd like to ask you a question around privacy. We know that the government intends these new powers given to ministry- appointed inspectors in OHIP to be used for the purposes of rooting out fraud. We know that and we understand that. But the privacy commissioner and others have raised concerns about what inadvertently happens with those powers, and you've raised the concerns about the fear that people have.
I remember when we put in place the anonymous, non-nominal testing, there was a medical officer of health in one jurisdiction who wanted reporting built in and the fear that that struck in the community and how resistant people were. I was convinced at the time that really would threaten the success of the testing program. I'm wondering if you would just elaborate on that because I think it would be helpful for members of the committee who are going to deal with this to understand how pervasive that is and what it means for the community.
Mr McCaskell: I think there are two levels to do with privacy. There's a level of principle, that people have the right to their privacy, and I think everybody understands that. But I think that the level we're dealing with here is something which I wouldn't say is more serious but is serious in a different way, because what we're talking about is what lengths people will go to to preserve their privacy and how that can affect public health.
I know of people who were working, had an insurance program, and when they were diagnosed with AIDS and HIV bought their own drugs rather than put those drugs through their insurance program because they didn't want people in their office or even in the insurance company to know what they were suffering from since the drugs they had would be AIDS-specific.
That may or may not be paranoia, but it is a real fact. If the people who are at high risk of contracting HIV and AIDS feel that their medical records are not completely and utterly private, they will go to enormous lengths to maintain that privacy, and that would mean not seeking out physicians and it would mean never testing. We know that once people test, their behaviour in terms of responsible activity changes dramatically. But people who think they may be infected but don't really know for sure can always talk themselves into not following safer sex guidelines.
Mrs Johns: I appreciate your coming here today. I think the minister has clearly indicated that AIDS is a priority of the government. We have met with some of the AIDS organizations, so we are trying to understand a number of the issues that you've presented.
Can I just say that the proposed restriction of billing numbers would have exemptions in it for physicians providing care to people living with HIV, being HIV-positive, and other specialty areas that we have to hammer out, but that's I think very important. Also, the minister has said at this particular point that we're going to wait for the OMA to give us recommendations on how to deal with our rural and northern problems without using billing restrictions.
We would certainly like to do that as a government and so we await the results of PACA, the provincial advisory committee on AIDS, and we await the results of the OMA to be able to tell us how we should proceed with that. This is in here in case recommendations don't come along and we need to use that.
Regarding the listing of drugs, there's no changes to the role of the DQTC. Our reforms, we believe, will allow us to ensure sustainability of the program and increase maybe the ability to add drugs to it. In the past there's been this great pressure on the drug plan because it has tripled in 10 years, and we've had to delist drugs in previous governments just because of those kinds of pressures. We would like to be able to add new drugs to it, especially in the area of HIV and AIDS. We have to make it more sustainable and affordable for that to happen.
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Any suggestions, if we don't implement this system, how you would like it to be done? Obviously, we can't just keep letting it grow, tripling in 10 years. Anything that you can give me as recommendations?
Mr McCaskell: I think we have to recognize that in terms of AIDS and HIV, we have therapies now which really do slow the rate of disease and that although you may end up paying more for drugs at the ODB level, you're saving enormous amounts from people who otherwise would find themselves hospitalized.
When studies have been done, it's been shown that pharmaceuticals are the cheapest kind of medical care, much cheaper than having somebody in a hospital bed with an IV in their arm or whatever. So certainly in terms of AIDS drugs, we have 3TC, which has just been given its notice of compliance and we have three new protease inhibitors. There's going to be more demand for those new drugs and they're going to be expensive. However, I think we're going to see on the other end a lot fewer people very sick in hospitals absorbing huge amounts from the medical system. So I think we have to look at an overall cost analysis, and not simply focus on the ODB section of it, because that in fact may be the most cost-effective way to deal with this disease.
Ms Lankin: Mr Chair, I have a point of order, please: If you recall, at one point in time I placed a question of clarification to the parliamentary assistant to the minister and requested that she clarify something in the act. I was told by you that she was not acting as a parliamentary assistant to the minister, not representing the ministry, was not responsible for carrying the bill. We've got no one here responsible for carrying the bill to clarify things. Yet I just heard the parliamentary assistant provide information that the billing number restrictions will not apply to the underserviced area of specialty dealing with HIV-AIDS patients. I'm glad to hear that. It's the first time I've heard that. We've had other groups come forward.
Either you are representing the ministry and speaking for the ministry and interpreting this bill or you're not. I would really like as a matter of order to request that the ministry have somebody here who has carriage of the bill who can clarify questions for us and that we don't get piecemeal information that pops out in response to groups' legitimate concerns.
Mrs Johns: That piece of information is in the public document in the backgrounder that all of us have, I believe.
The Chair: That's really not a point of order. This morning I clarified the issue that there is nothing in the standing orders that requires --
Ms Lankin: No, I agree. It is only precedent and history and tradition.
The Chair: -- and those are what we are operating under.
Ms Lankin: I know we're not operating under precedent, history and tradition.
Mrs Caplan: I want to take a few minutes to make some comments about your very excellent presentation and I think the very legitimate concerns that you have raised. You have presented some important new information for the committee, things that we haven't heard before.
I will be spending a few minutes at the end of my time to put some things on the record, Mr Chairman, so I give you notice of that.
While there are fine words from the parliamentary assistant to the minister, this legislation does not contain an exemption. The powers are so broad that they may or may not do that by regulation, but the reality is that there is nothing in this legislation that should give you comfort that this will happen, nor comfort that it could be changed at any time in the future -- without consultation, without discussion -- because it is part of the broad regulatory authority.
My question is, do you believe that if there is going to be an exemption, it should be contained in the legislation, or are you satisfied to have issues like that dealt with behind closed doors at the cabinet table, without consultation and without scrutiny?
Ms Atkinson: Obviously, we would prefer to see that there be provision in the legislation for exemptions for underserviced areas in general. I don't think there's probably a necessity to define which are underserviced areas. In fact, that may change from time to time.
Mrs Caplan: You could define a broad underserviced area with some criteria for what that would mean and then allow by regulation as they need the flexibility to identify programs or disease-specific needs. To me, that would be appropriate. But to have legislation that is this unclear, I think your concerns are justified.
Ms Atkinson: I agree. I think probably most of the groups that are coming before you are concerned about the sweeping nature of the legislation and how broad it is and that it's very hard to know exactly what the implications of it will be. So of course we would like to see some protection within the legislation providing an exemption for underserviced areas.
Mrs Caplan: That's one of the reasons why we have requested that those components of the health legislation that are not urgent -- and I don't believe that this is one that has to be dealt with by January 29. These kinds of issues certainly could receive greater scrutiny. If they would sever those portions of the bill, would you support some additional time at committee to explore possible amendments and deal with it in perhaps the spring session of the Legislature?
Ms Atkinson: I think, especially with the issue of new billing numbers, that when you consider that new graduates won't be coming out until probably in the fall, it would make sense to put this issue off for further consultation until the spring.
Mrs Caplan: Especially since the minister --
The Chair: Thank you very much, Mrs Caplan.
Mrs Caplan: I wanted to put a couple of things on the record.
The Chair: I'll excuse our guests first and then you can do that.
Thank you very much for coming this afternoon and being part of our process. We appreciate your interest. I hope you have a good day.
Mrs Caplan: The last point, just to finish my sentence, and I appreciate that, is that I think that part of the argument --
The Chair: Mrs Caplan --
Mrs Caplan: I will be putting something on the record.
The Chair: -- are these questions for the ministry?
Mrs Caplan: Yes, I guess I could -- let me put it in the form of a question.
The Chair: Wait a minute now. You've had your fair share of time here. I'm going to allow these people to excuse themselves.
Mrs Caplan: Yes, okay. Thank you.
The Chair: Thank you very much for coming.
Now if you have some questions to address to the ministry, then we'll --
Mrs Caplan: Right. Given the fact that the minister has said very clearly he has no intention whatever of implementing these restrictions in the legislation before summer, why would he object to severing this and allowing for more scrutiny, more time for public hearings on this component of the bill to be dealt with in the spring session of the legislature? There would still be time for that to be implemented, since he is not planning on having this till the summer anyway. That's question number one for the ministry.
I do have three points. Then I will --
The Chair: In the form of a question, or is this a statement?
Mrs Caplan: These are no longer questions, although there is one that is a question of the minister.
The Chair: Basically, we made an agreement that we would allot time fairly between witnesses. I guess if you're going to have five or 10 minutes here to make a statement, then I have to be fair. I would need to do that for everybody.
Mrs Caplan: That's fine.
The Chair: So is the situation that we're going to skip our lunch and allow statements to be made now through the dinner period?
Mrs Caplan: It's not going to take long, Mr Chairman.
The Chair: Is that what you would like to do, Ms Lankin?
Ms Lankin: I am willing to hear what Elinor has to say. She has short comments. Let her put it on the record. This is crazy.
Mr Clement: That's fine.
Mrs Caplan: The first thing that I would request of the minister is the tabling of the amendments that we are hearing about so that they can be before the committee and people will know what they are intending to do. Those groups that are coming before us will want to know what is contemplated. We've heard already that they have amendments. I'd ask that they be tabled tomorrow morning, please. That's number one.
Number two, I would ask the minister to designate someone to have carriage of this legislation. There is time for some short questions, and in fact there is a tradition in this Legislature, and I'd like to name the precedents. While there's no requirement in the standing orders, Mr Chairman, there are precedents, and I think the precedent that I would name is the Independent Health Facilities Act legislation, which I carried personally as minister and attended the committee hearings. When I could not be there personally, my parliamentary assistant sat in.
Whenever there has been significant legislation with policy implications, not only through the previous government, where they always had a parliamentary assistant -- I remember both Mr Wessenger and Mr O'Connor, I believe, having carriage of those bills -- but when I was there, either myself or my parliamentary assistant, and frankly, through the years prior to that when there was a Conservative government, traditionally whenever there was a major policy concern, we always had someone having official carriage of that legislation representing the minister, or in fact the minister himself or herself, at the committee to answer questions that could be answered at that moment.
There was also traditionally in this House the opportunity for members to put questions on the record. So I am requesting that the minister either come personally to have carriage of this bill -- I understand it is complicated and I understand that he may not have confidence in anyone else answering questions at committee, and that's okay. I'm not taking a shot at the parliamentary assistant. If he feels that only he can do it, that's fine. If there is someone else whom he feels can be properly briefed to have carriage of the legislation, that's the request that I would make. I think certainly the members of the opposition would feel that is most appropriate and in the traditions of this Parliament. That's the second thing.
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The third request I would have is of the clerk, and that is that I'd like an update on the waiting list for the committee. I'd like that for tomorrow morning if we could have that, please.
My last request: There was a discussion about having the Information and Privacy Commissioner reappear before the committee and, given the time of year and given the events that are going on with the committee and the number of presentations that are wanted to be made, I'd like to make a suggestion. If that is acceptable to the committee and to the minister, perhaps it would be helpful, Mr Chairman.
I would like to suggest that on the first day of clause-by-clause, which is January 22, the first half-hour, from 9 till 9:30, be available to the freedom of information commissioner to discuss his proposed amendments. Should the committee feel that's appropriate, I think that would be the appropriate time for him to come and answer questions and discuss his amendments. That's perfectly in order and I would so move that, if it requires a motion. If not, I'm happy to just have some consensus from the committee that we request the freedom of information and protection of personal privacy commissioner to appear before the committee on the first day of clause-by-clause deliberations.
Thank you very much, Mr Chairman, for your patience.
The Chair: As far as the motion goes, the motion is out of order because under the standing orders of the committee we're not allowed to sit before 10 o'clock, and then only to consider clause-by-clause.
Mr Clement: Amend it to say 10 to 10:30. I think that's what you meant.
Mrs Caplan: What I'm --
Ms Lankin: Let him finish. There is a suggestion.
Mrs Caplan: Okay.
The Chair: Excuse me. We're not allowed to sit before 10 o'clock as a committee, and when we do sit at 10, we do have to consider clause-by-clause. My suggestion to Ms Lankin, who originally brought the idea up -- we're going to discuss it at a subcommittee meeting at 5 o'clock -- was that we meet unofficially as a committee, with no Hansard, no support staff, at 9 o'clock that morning and allow the privacy commissioner an hour or two to brief us on issues of the bill.
Mrs Caplan: I think that would be very helpful. I have no difficulty with that whatever, as long as --
The Chair: So we'll ask --
Mrs Caplan: Well, there is no Hansard. I would assume the committee will be open for anyone who wishes to attend. This is not a closed session.
Mr Clement: No, it's not a closed session.
Mrs Caplan: That's fine.
The Chair: Because it really is basically not a committee meeting.
Mrs Caplan: That's fine. As long as it's an open meeting I have no problem with that.
The Chair: Is the waiting list you're looking for just for Toronto?
Mrs Caplan: Not only from Toronto, but requests from around the province as well. But if you have the Toronto number, I'd appreciate that.
The Chair: The clerk has advised me that by noon would be the earliest that would be available.
Mrs Caplan: Tomorrow by noon. That would be great.
The Chair: Anything further?
Mr Clement: Can I speak to Mrs Caplan's first two comments, please? With respect to the tabling of amendments, I think what we have made clear is that, just as the opposition parties are actively considering amendments, hearing the deputations, and perhaps you're getting some views as to what amendments you wish to propose, so too the government members of the committee are actively considering amendments that we would like to support based on the deputations, based on the presentations of those members of the public who wish to present before this committee.
I'm not aware of any amendments that are waiting to be presented. The time to present amendments is at the clause-by-clause portion of this committee, so I don't think there's anything to accommodate Mrs Caplan with respect to that.
With respect to the role of Helen Johns at this committee, my understanding is that this is the committee on general government. This committee had referred to it Bill 26, which is commonly known as an omnibus bill. My understanding is that for omnibus bills there is usually no parliamentary assistant assigned unless it deals almost exclusively with one piece of the government.
Bill 26 deals with 14 different ministries, so there is no parliamentary assistant designated for either this committee or the subcommittee meeting in the other room. That's a bit of a technicality, but having said all that, I think we can accommodate Mrs Caplan or any member of this committee. If they have any requests of the ministry or minister, it or he can respond with alacrity, and I think we've shown that. The legislative assistant is in the room, as he has been for the past week, and we had a turnaround time of less than 48 hours for the original questions Mrs Caplan asked. I think that shows a willingness to work with the committee to answer any issues that come up.
Ms Lankin: I wasn't going to speak, but I have been provoked. Very simply, if the legislative assistant is responding with the kind of alacrity with which I've seen him responding to notes to Mrs Johns, perhaps he could take carriage of the bill and answer some of our questions.
Mr Clement: I think that was a snarky comment.
Ms Lankin: That was sarcastic. I apologize. It is 5 o'clock.
On the first issue with respect to amendments, I just want to indicate that I don't think that is a satisfactory answer. When the minister was here on Monday, I did request of him that amendments he had contemplated and that were prepared be tabled, and he agreed to table them early. The reason for that, Mr Clement, is very simple. It's not a question of ongoing consideration and tabling according to the time lines. There is a responsibility on the part of the government to see an informed process of consideration of the bill, and if there are to be amendments in certain areas that the government is aware of, they should be tabled so that all participants and committee members don't waste time going over and over again issues that are going to be amended.
I point to the issue of what the minister committed to in terms of an amendment for the sunset review of the restructuring commission. If that comes in in that language, we'll still keep talking about it. If, however, as a result of what we've heard, it comes in in language that sunsets the commission and the special powers, as everyone understands his announcement, we could stop talking about that issue.
I really think your answer was not helpful to the process, and I would request again that the minister, as he indicated he would but has not yet done, would table amendments that are prepared and ready.
The Chair: Just for clarification, the only reference to amendments in the motion under which we are operating is that "all proposed amendments shall be filed with the clerk by 4 o'clock on January 25, 1996." That's the motion under which we are operating.
Mrs Caplan: Well, that's the last date on which amendments can be tabled, but there's no restriction that they can't be tabled before then.
The Chair: But that's the only reference to amendments.
Mrs Caplan: That's right. Can I speak, Mr Chairman, very briefly? It is tradition that you have a date which is the last point at which amendments can be filed, but we did make the request of the minister, especially as policy statements were being made, that we have those amendments. Frankly, it clarifies the government's intent for the people coming. The other thing is that the government always has the right to change its mind and bring in further amendments, so it's not risking anything by tabling what it's thinking about now. Given the speed at which this legislation is going through, I think it would be helpful to the process. It's in that spirit that I am requesting proposed amendments as early as possible, and I would point out that the minister did commit to that.
Mr Clement: You said tomorrow, though.
Mrs Caplan: Well, I'd like them as soon as possible, tomorrow if you have them. He did the press release last week, for heaven's sake, and he should have that ready. But if it's not, Monday is fine. I would like it so people could have it and review it as quickly as possible. It would be nice if they could be here before these hearings end so that those who are appearing next week could have access to that via fax machines and so forth. That's the reason I'm requesting it.
The Chair: Thank you very much, Mrs Caplan. We stand recessed until 6 o'clock.
The committee recessed from 1710 to 1800.
ONTARIO MEDICAL ASSOCIATION, DISTRICT 11
The Chair: Good evening and welcome to our committee. Our first presenter this evening is --
Ms Kathy Bugeja: It's supposed to be Dr James Seligman, but he's not here. If you would like, I could read his text on his behalf.
The Chair: Do you expect him to be here?
Ms Bugeja: Yes, I do, but since he's an orthopaedic surgeon, sometimes he has emergencies that will delay him.
The Chair: Okay, he was going to read his text; no problem. If you want to come forward and read it, then if he comes in, you can --
Mrs Johns: Can you deepen your voice a little?
Ms Bugeja: I guess. I think I can handle this.
The Chair: You see, you get to do it twice in two nights, right?
Ms Bugeja: No, this isn't the same text. Honestly, last night was really my text from my heart, from my experience. It really was my chance at 15 minutes of fame. But tonight, as I had mentioned to you --
The Chair: Is that him before you there?
Ms Bugeja: That's him, thank God.
Dr James Seligman: I can't control the traffic. Sorry for my tardiness; I had a couple of weak patients.
The Chair: We're just very prompt here, that's all.
Dr Seligman: I know; it's a nice change.
The Chair: Welcome to our committee. We appreciate your attendance. You have a half-hour to use as you see fit. Questions, if you leave time for them, will begin with the government. So the floor is yours, sir.
Dr Seligman: Good evening. My name is Dr James Seligman. I'm an orthopaedic surgeon. I practise at Northwestern General Hospital in Toronto. I'm also the chairman of District 11 of the Ontario Medical Association, which represents approximately 7,000 physicians in Metropolitan Toronto.
I know you've had presentation from other representatives of the OMA and I don't intend to give you the same presentation, because the Toronto district concentrates its time and energy on pursuing issues unique to Metropolitan Toronto physicians. It is their interests and their concerns that I am bringing to you today.
The OMA District 11 prides itself on being very involved in those health care initiatives that either affect or have an effect on health care of the citizens of Metropolitan Toronto. For example, over the last several years, OMA District 11 has actively participated in a number of projects undertaken by district health council, the annual hospital operating plan process, the maternal, newborn and child review, and most recently, the hospital restructuring project.
Our rationale for participating in these initiatives has always been very consistent: We are committed to improving access to and quality of health care in Metropolitan Toronto. We steadfastly pursue this commitment, because our concern and moral obligation as a profession is doing what is right for the patient. As providers working throughout all levels of the Metropolitan Toronto health care system, we're in an ideal position to assume this advocacy role.
It is from this commitment to our patients and to a quality health care system for Metropolitan Toronto that we come to you today to present our comments on the health-related section of Bill 26, the Savings and Restructuring Act. In particular, I'd like to focus on three specific areas.
One is the minister's comments on hospital restructuring, which is an area in which we have secured some hard-won patient care gains at the MTDHC table and would like to retain in the provincial plan. Number two is the impact of Bill 26 on the average physician in practice. Number three is some alternative suggestions for meeting government's fiscal needs. We'll start off with the hospital restructuring.
In his comments to the standing committee on Monday, Mr Wilson indicated that the Provincial Health Services Restructuring Commission will start with the Metropolitan Toronto District Health Council recommendations. Without going through an entire analysis of the report -- it will be included as a supplementary to this presentation -- I would like to highlight some of the things about this report and some of our concerns, because these issues are universal to any restructuring contemplated for Ontario.
To the MTDHC's credit, specific concerns raised by us during the two-year process have been acknowledged and incorporated in the restructuring report. These concerns focus on the need to ensure continuity of programs and services in a reconfigured acute-care sector through transfer of operating budgets and personnel providing that care between institutions.
From a physician standpoint, OMA District 11 is pleased the MTDHC report recognizes that (1) the total demand for physicians' services in hospitals is not expected to decrease, given the expected increase in acute-care demand; (2) physicians currently practising in Metro Toronto hospitals must be able to move with their work and must have preferential access to positions within the restructured hospital system; (3) as physicians move between facilities, mechanisms to ensure equitable access to hospital resources by all physicians, new and continuing, must be developed; (4) as physician movement will occur across the city, consideration should be given to developing open and standardized credentialling and appointment procedures for both the teaching and community hospital systems; and, lastly, labour adjustments and support concepts applicable to unionized labour, such as retraining, posting and early retirement, could apply to physicians as well.
Recognizing that physicians are not hospital employees, however, the MTDHC recommendations only call for the restructuring authority to establish a process which provides for the involvement of local hospital boards, physicians and the University of Toronto in developing equitable mechanisms to address cross-hospital issues such as the movement, credentialling, selection and appointment of physicians. Given that the responsibility of the restructuring authority stops short of ensuring these cross-hospital issues will be implemented, however, there is no guarantee that this will actually happen. Critical medical care may not be available, therefore, to individuals affected by restructuring. Moreover, it is unclear whether the fundamental principle of individuals being able to retain the provider and mode of treatment of their choice will still prevail.
In the interest of ensuring continuity of care in a reconfigured acute-care sector, the MTDHC or government must guarantee the ability of physicians to provide care to their patients. Consequently, District 11 recommends a strengthening of the MTDHC recommendations as they pertain to physician movement, credentialling, selection and appointments across the system. To that end, OMA District 11 is prepared to work with the relevant stakeholders to ensure these concepts will be realized.
How are these points relevant to our discussion on Bill 26? If you take these points related to physician movement across the system as a package, the issue of physician billing numbers goes beyond a geographically defined quota system. The issue goes back to its fundamental base. Each number is a physician providing patient care. Patient care cannot be compromised for financial expediency, nor can it be tied to a specific hospital, for this risks losing the ability to service the need altogether.
If I happen to be the best orthopaedic surgeon in Toronto and my hospital closes, under Bill 26 my services may not be available, period, unless some other hospital grants me privileges. Currently, hospital privileges are not easy to come by. Consequently, under Bill 26, I and the patients I serve could be totally locked out of the system. This is why we at District 11 have emphasized the necessity of providers being able to move across a reconfigured health care system. Patient care cannot be compromised.
While the MTDHC report reinforces continuity of care within the institutional sector, neither it nor Bill 26 addresses how the community-based sector will be adequately prepared to handle the vast increase in responsibility that will be offloaded from the hospital sector. As they currently stand, the MTDHC restructuring recommendations either transfer individuals sooner or reroute them altogether from the hospital system into the community without knowing how their care will be handled. The MTDHC report has assumed the primary care sector, which is far less structured than the hospital sector, will pick up that burden of care, but the provision of 24-hour, seven-day-a-week access goes beyond a simple extension of office hours. All the elements readily on hand within hospitals -- for example, diagnostic capabilities, shared information networks, and timely specialist backup support -- must be available to primary care providers in the community if this sector is expected to provide this level of care without compromising patient and informal caregiver health.
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If the MTDHC or the provincial government arbitrarily and unilaterally decides to offload a significant amount of hospital-based care into a community sector that is currently unprepared and ill-equipped to handle that care, then the MTDHC or government must assume responsibility for preparing, monitoring and modifying this sector. Developing, funding and reinforcing an entire sector is not the responsibility of the providers delivering the care. Primary care providers are instrumental, however, in identifying the prerequisites necessary to deliver a greater mix and number of services in the community. To that end, OMA District 11 is prepared to participate with government and other key stakeholders to address this major gap in the MTDHC's or government's restructuring plans.
I want to emphasize our desire to stay in the process. We want to be at the table of the hospital restructuring commission. We feel we've earned that right; we've secured the principles that facilitate provider movement. It's time to turn the principles into reality, and we want to be there to make it happen.
I raise these points today because the physicians of Metropolitan Toronto are strongly committed to preserving and enhancing health care for Toronto. It's not just an issue of jobs or vested interests, as Mr Wilson's comments seem to suggest. It's about patients and ensuring the ability of all providers to provide that care across the system. Some of the providers are hospital-based and some of them are not. This reflects the reality of health care today. The continuum of care goes beyond hospital walls. These are principles that have been advanced by government. How could Bill 26 be so inconsistent, then, as to restrict physician care according to geography or hospital privileges? The inconsistency and illogic of some of the aspects of Bill 26 gets into the whole realm of what it's going to be like for the average doctor to provide care.
My comments on this issue are not unique to me. In talking to my members, they cannot believe the depth and breadth of the total control proposed by this bill. Earlier today I was speaking to a large group, and they're shocked by what's in front of them.
In its quest to address the financial crisis of this province, Bill 26 is seeking to create a viable society by strict regimentation of national and individual lives. Conflicting interests would be adjusted by total subordination to service of the state. If that sounds like a textbook definition of totalitarian dictatorship to you, guess what? It is. I got it from the dictionary. The scary thing is, it's bang on for what is facing the profession with this bill.
As a practising physician who has spent years training for what I do in providing care to my patients that is both thorough and responsible, with this bill I don't know what it's going to be like to practise any more; what it's going to be like when I can't order a test. If I order a test, I'm not sure if the government's going to charge me for the test. If I don't order the test, I have to protect myself from the patient who decides to sue me because they felt I should have ordered the test. Thus I end up in a catch-22 situation. How does the government propose to protect me from this situation, given the current medical-legal environment that places no limitations on the ability of patients to sue the medical profession? I have a compelling duty to provide lifesaving service, but now government is either second-guessing me or telling me it's not going to pay for the services at all.
So what are my options? I'm not sure. Many of my colleagues don't know. Some of us are not going to do or order any tests. This isn't job action; it's simply paralysis resulting from massive fear of reprisal. Others will do the test, do their job to the best of their ability, maybe even work for free, but how fair is this in western society?
To put it into dollars and cents, as an orthopaedic surgeon I get about 50 bucks to do a consult. I'm not going to order a CT scan on a patient when I'm going to possibly be billed $500 later by a government bureaucrat who knows nothing about the situation because they feel the test wasn't needed. Is that going to be based upon the fact that the test was reported as normal and therefore not needed?
I have some backup of this in the DHC report. They've decided that over 50% of the patients who show up to emergency departments don't have to be there. Why don't they have to be there? Because they've done their analysis on the walk-out diagnosis. They haven't done the analysis on the walk-in diagnosis. If a 40-year-old male walks into an emergency department with chest pain, he's supposed to be in an emergency department. After the fact, after the ECG, the blood tests etc, they decide: "You know what? It's only chest wall pain. It's not significant. You can go home." Well, the diagnosis that's put down is chest wall pain, and from the DHC report, that's an unnecessary emergency department visit. So if I want to extrapolate that, a government bureaucrat is going to say: "Well, the test is reported as normal. That test didn't have to be done." It puts us in a very difficult position and, to tell you the truth, I won't order tests like that. I want to get government approval first, and that's what you're going to be doing to the health care system.
It's totally unfair that the public retains its legal and individual rights and the profession is totally stripped of theirs. For government to exercise unilateral control over what I do, how I do it, when, how, and then determine whether I'm going to get paid or, worse yet, pay back the system beyond the service that I delivered is totally absurd. You can do all this and I have no legal recourse to protest or appeal. What did I and all my colleagues do to deserve this treatment? This is not democracy; this is a dictatorship.
You can't play the game without knowing the rules. If you're not going to offer guidance to physicians, most of them will play it safe to the extreme: no tests. Patient care will be compromised. As I emphasized before, this isn't a threat and it isn't a job action. It's simply paralysis resulting from massive government intrusion on our ability to provide care for our patients.
I appreciate the very difficult financial situation this government is trying to correct, but you can't correct the woes of the health care system by solely attacking the providers. As an orthopaedic surgeon, I can see anywhere from 60 to 100 patients in my fracture clinic on Mondays. And you know what? I don't ask any of them to come in. They're all sent in from the emergency department and everywhere else, and I can tell them not to come back and they keep coming back. So don't tell me that the physicians are generating business. It comes on its own. We're providing services that are needed.
Use of the health care system is comprised of two parts: the user and the provider. Yes, we provide care to the individual, but we don't know how many times the patient has sought the same type of care from someone else. There are no limitations on access to care, nor is there any ability to track a patient's movement. If you want to control health care utilization, you have to be able to track the patient. Patient rostering is an idea that has been put forth: not capitation, but strictly rostering that says to the individual, "There's a primary care doctor you have chosen to provide your care directly, or through whom you will access other services within the system." That's the only way for the government to get some type of control on how frequently the system is accessed by individuals.
This assumes, of course, that the information system's capability exists to be able to detect those individuals who stray from this arrangement. Very simply, you're rostered, you pick your family doctor, and that's who you go to. If you want to go to a walk-in clinic or another doctor, you have to pay for it. The system can't afford for people to go to as many doctors as they want.
As well, when you go to all these different doctors, all these different doctors end up ordering multiple tests and repeating things because nobody knows what anybody else has done. Half the time we don't even know that they've seen a dozen other doctors, and if they do that, that's fine as long as they're willing to pay for it. We are now at the point where we realize OHIP cannot provide everything to everyone, and it certainly cannot provide the identical service, such as double-doctoring, to individuals who don't like the initial or second or third opinion they've heard.
Doesn't it make sense to start defining what is available and essential to all individuals under OHIP and at the same time develop a mechanism that will allow individuals to access care beyond that which is provided under OHIP should they so choose? The precedent already exists in the government's long-term-care reforms and in what we see with respect to home care services. These precedents exist because they take the strain off the public system while still providing people the service they need. Why not extrapolate this experience to the larger health care system?
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And while we're on the subject, it's time third parties paid their fair share of health care utilization, similar to what we see with the Workers' Compensation Board. There's no reason why people involved in motor vehicle accidents, people involved with suing third parties, do not have a similar type of numbers situation where the government directly collects and these people are not drawing more and more on the health care system.
Finally, I appreciate the government's desire to staff underserviced areas in the province, but I don't believe you can force anyone to go where they either don't want to go or are ill prepared to provide that service. I believe in taking an incentive approach to addressing the physician distribution issue. Right now we have financial incentives for new doctors to practise up north, but maybe we should start earlier in the process. Maybe there's something we can learn from other bodies in the province that fund their potential candidates' education. Why can't we sponsor physicians in medical school who will go up to the north and practise? These are the types of physicians who will be committed to staying up north. I know this isn't an immediate solution but I still think it's one to consider. You will not force new doctors to go up into northern Ontario if they don't want to. What they will do is go south of the border. Legislation like this is absurd.
I've spent the last 15 minutes or so going through some of the issues that are important to Toronto physicians. These aren't all our points but they mean a lot to us. We intend to submit a further commentary before your final submission. If there are any questions, I'd be happy to answer them.
The Chair: Thank you, doctor. We look forward to your final submission. We've left about two and a half minutes per party, beginning with Mr Clement.
Mr Clement: Thank you very much for your submission. Certainly it was well thought out and you've given us a lot to think about, so I thank you for that.
The bulk of your remarks was about what was medically necessary and the oversight and review that you feel is in the new bill. I'll be honest with you. I'm having trouble following this argument by physicians, because I read the new bill, the new sections, and I read the old sections, and the new section talks about a general manager refusing to pay if there's "reasonable grounds." There's a test in there, reasonable grounds. Even if you think they are acting unreasonably in a situation, you can request, under section 18.1, that the decision of the general manager be reviewed by the Medical Eligibility Committee or the Medical Review Committee. That's what we're proposing.
Then I read the old legislation, which seems to be as, shall I say, draconian as the new legislation. If you're talking about balance of draconian laws, the old legislation was perhaps even broader: "all or part of such services were not medically necessary," as decided by the general manager. Now, the only difference, and I acknowledge that, is that he has to go through the MRC, so there's that one step, but you have under the new legislation an appeal to the MRC. Could you just explain to me if I'm missing something here?
Dr Seligman: A lot of it seems to be the way things are being presented.
Mr Clement: The way things --
Dr Seligman: Are being presented. This legislation comes through as a sledgehammer. Throughout the legislation, consistently, I have no right of appeal, I have no right to sue for any potential losses. I don't have the exact legislation in front of me right now, but very consistent in this is that we have no rights; we cannot appeal anything. As a physician, then, I start saying you're allowed to, under your thing, take away my hospital privileges; I can't appeal. You're allowed to come into my office, go through my hospital charts for no reason that I have to know about. You're allowed to, by calling my office an independent health facility, then close it; I have no right of appeal.
This whole thing with respect to the tests becomes very simple. If you want to set up guidelines or rules for the way tests are ordered, that's a different story. If you want to say, for example, "We will limit these tests to this level of specialists and they're the only ones who can order them. We don't want all the family doctors ordering them," that's different. You're now setting up exact rules so that as a doctor I don't have to worry, "Should I order a test?" No, I'm not allowed to. So if I feel a test is needed, I will have to refer the patient on because they have a more significant problem.
But I won't be in the situation -- for example, let's say you're a neurologist right now. If you come into a neurologist's office with a headache, that neurologist has to order a CT scan of your head for no other reason than medical-legal, because anywhere down the road he could be sued. Now the manager of OHIP says: "Look, he ordered all these normal CT scans of heads. This is ridiculous. We're going to charge him for all of those." You can't have it both ways.
Mr Clement: I guess I'm saying that was under the old act too.
The Chair: Sorry, Mr Clement. We have to go on to Mr Colle.
Mr Colle: I guess the most striking thing you're saying to us in all your concerns is that there's a very strong, heavy-handed approach, an authoritarian approach, a dictatorial approach. I don't know: How can you explain yourself, explain the frustration of doctors in terms of getting that message across to the government that this is what the message is, this is what Bill 26 is saying, and how can you explain in very few words that this is what you're objecting to, is just the sledgehammer approach to medicine?
Dr Seligman: I would expect to be treated like any other citizen in this country, and that is to have rights. When I see legislation come in place that does not allow me any right of appeal, I'm sorry, that is not democracy under any definition; that is a dictatorship. Because you've got a general manager of OHIP who now controls me. A matter worse: Now you're going to put me into a hospital that I have to be tied to, so that CEO controls me. He can fire me at any time; I can't appeal.
Where else in society is anything like that? Nowhere. Yes, the government has said, "We're not going to do all these things." I'm sorry. If it's written down in law, it's been put there for a reason. Yes, it may not be used now, but it's there. As far as I'm concerned, we are in a democracy and I would expect democratic rules. We also have a Constitution. I'd like to know where it is constitutional for the government to force people to be moved from here to here, where it is constitutional to not have a right of appeal. This is ridiculous.
What do I think? I can tell you in a short sentence. I have never in my life ever dreamed -- and this is not a threat, okay? -- of moving down to the States. But you know what? I'm actively looking into it now, and I'm probably one of the last people anybody would expect, but I'm actively looking into it. It's because of this government.
It goes a step further, unfortunately. I don't want to slam every government, but we've gone through the Liberal government and the NDP government, where we felt things weren't great. I am a Conservative: hard, big-C, okay? I can guarantee you that with what is going on, I would never in my life ever vote for a Conservative government in this province. I have never voted anything but Conservative. This is fascism. It's another F word. It's a little longer than the four letters. But this is ridiculous. There's a point to which you push things. This has gone too far.
Ms Lankin: Just so you know what that's about, I have my name here because at this time of night the Chair seems to forget it, so I point it out on the other side.
In response to what Mr Clement said, I want to put my views on the record on this. He seemed to suggest to you that the old section 18 in the Health Insurance Act was broader than the new one. Quite frankly, under the old one, the general manager could decide that he had reasonable grounds to doubt something and could refer it to the Medical Review Committee, which is a peer review. Now he takes a decision and you have to appeal it.
But what's insidious about this in terms of what's in the language: Before, if they thought the services weren't rendered -- that's still there. If they thought they weren't medically necessary -- they've added the words "or therapeutically" necessary. You don't add words unless they have some import. So what does it mean? Are the bureaucrats going to decide whether it was therapeutically necessary? Then if they thought they weren't provided in accordance with professional standards, which was in the old one, or if they were misrepresented -- that was in the old one, except now it adds the words "intentionally or inadvertently" -- it could be taken away, and then "under any other circumstance as prescribed in regulation."
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So this is very different and it is much larger, and it is problematic in the way in which the legislation is framed. I continue to say I don't disagree with what the government's attempting to achieve in certain areas. The way this is structured is a bureaucratic nightmare. Lord knows, we did certain things as a government that the physicians didn't like as well. But this is the very thing that Jim Wilson would have stood and railed against us on as critic.
You've said that you're going to provide us with a more in-depth analysis in January. The things you've raised either require deletion from the act or huge amendments to make them satisfactory. Do you have time to prepare the in-detail recommendations of amendments for us?
Dr Seligman: We can try.
Ms Lankin: I'm asking it because I'm presuming it's going to be difficult to do. I'm feeling the sense of frustration of groups that want to do an analysis and give us amendments and don't have time. I'm afraid we're not going to have the best information from the public in front us when we come to the final days of this.
Dr Seligman: I can tell you we will be doing our best to. This whole thing has been unbelievably upsetting as a profession, because-it's funny, and I can't believe I'm saying this -- we look back to the NDP and we wish those days were back.
Ms Lankin: And the Chair cuts you off at that point. Did you notice? Now, is this an unbiased Chair or what?
Dr Seligman: I never thought in my life I would ever say something like that.
The Chair: On that note, thank you very much for taking the time to be with us tonight. We appreciate your submission and we look forward to the additional information you're going to forward to us.
COMMUNITY RESOURCE CENTRE OF SCARBOROUGH
The Chair: Our next group is the Community Resource Centre of Scarborough, represented by Bob Frankford, who's a former member of this august organization, Douglas Heath, Mike Boychyn and Evans Emyolu. Good evening, gentlemen. If you would just introduce yourselves for Hansard, so they know who each one of you is. We appreciate your attendance here tonight. You have half an hour to use as you see fit. Any time you allow for questions will begin with the Liberals. The floor is yours.
Dr Bob Frankford: I'm Dr Bob Frankford.
Mr Douglas Heath: I'm Douglas Heath. I'm a former chair of the Community Resource Centre of Scarborough.
Dr Evans Emyolu: I'm Dr Evans Emyolu. I'm also a member of the Community Resource Centre of Scarborough.
Mr Mike Boychyn: I'm Mike Boychyn.
Mr Heath: I apologize. We're reading from our brief, but we've had little enough time to prepare it, let alone practise a proper presentation. So here goes.
Mr Chair, honourable members, members of the public, the Community Resource Centre of Scarborough is a voluntary, non-profit organization that has served citizens' groups since 1991 by providing workspace, information and resources to encourage citizen participation, particularly in the areas of social justice and the environment.
We are concerned with many aspects of this bill, not just the health aspects, but we've been scheduled here. Due to the time limits we will only be focusing on a few, such as the fashion in which this bill was introduced and will be discussed, and how it affects our municipality and our health care system.
Bill 26 was badly flawed from the start. It was introduced quietly, behind the backs of Ontarians, under cover of the November 29 economic statement, while opposition members and the media were in the lockup for that statement and unable to attend the House. It is a very extensive bill which alters 44 provincial statutes and creates three others, covering virtually every ministry. We, like other groups and individuals, have found it almost impossible to come to terms with everything that is in this bill in the time which the government has given, an amount of time which is, by far, more than this government originally intended to give Ontarians to comment on this bill.
Had the government had its way, this bill would already be passed by now, without so much as a moment of open public debate. We suspect this has been purposeful, an attempt by the government to implement wide-reaching changes behind the public's back while we focused on other things, like the Christmas holiday. This bill may not be against the letter of the rules of order of the Legislative Assembly, as the Speaker has determined, but it is certainly against their democratic spirit and intent.
The Community Resource Centre of Scarborough believes that it is impossible to fully debate the merits of Bill 26 in the way it has been presented. There are too many changes in too many different areas to discuss in the time we've been given, changes that will affect everyone in the area we serve, the city of Scarborough, and everyone in the province.
To deal with this, we recommend that Bill 26 be broken up into several bills, one concerning changes to medicare and the Ontario drug benefit plan; one concerning changes to public sector collective bargaining, arbitration and pay equity; one dealing with changes to the Municipal Act, conservation authorities and matters concerning transportation; one implementing previous NDP government budgets and giving the Ontario government borrowing authority; and finally, a bill containing the other provisions which don't fit anywhere else. All of these bills should receive a full debate in the House and full public hearings, as bills with the potential to drastically affect people's lives really deserve.
The city of Scarborough isn't in an unusual situation among municipalities in Ontario. It has a fragile economy, an eroding tax base and an aging population. We already have been hurt by government policies, having had tens of millions of dollars taken away from our schools and hospitals and from the very poorest of our citizens. We deal in the centre with these people every day, and we know that Bill 26 adds insult to injury for all residents of our city.
The effects of this bill on the city of Scarborough are many. The government in this bill has given municipalities like our own the authority to charge citizens twice, once through their taxes and again through user fees, for everything the government does. Parents may have to pay an annual fee so that their children are free to read in public libraries, and enjoying the beauty and recreational possibilities in our extensive system of public parks could be subject to an admission fee, and even essential services like police and fire services could be subject to a fee, a cruel indignity to victims of crime or of fire.
We pay now for these services through our municipal and provincial taxes, which at least have some connection with our ability as taxpayers to pay for them. User fees don't have that connection. Rich or poor, we will all pay the same for the services we use regardless of our need for the service or our ability to pay for it. This bill also gives authority for municipalities to impose a poll tax, with the same but much greater effect -- and, incidentally, responsible for the political end of another Conservative, in Britain, with similar policies to this government.
We agree with the need to impose user fees on garbage collection and the use of water, sewers and electricity in order to encourage waste reduction and conservation. The possibility that this bill may allow municipalities to impose a fuel tax is welcome to us. However, the government has cut the Green Communities initiative which encouraged these kinds of efforts to help people finance the transition to efficiency and lessen their exposure to such taxes and charges. Poor people, without the money to buy new, efficient lighting, insulate pipes, fix leaks and use low-flow fixtures, will pay these user fees but not be able to become efficient and avoid paying them.
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The powers this bill gives to the provincial cabinet and to our own municipal government in relation to things with can be done without public input of any kind are quite astounding. Privatization of the utilities the people of Scarborough own together could be done without our permission, as could privatization of garbage collection or even as critical a service as public transit or fire protection. Road and transit grants would be up to the discretion of the minister to give out. We hope the minister will use this new power to fund transit improvements, but quite frankly, given the government's record on transportation so far, we aren't very confident in this. Provincial arbitrators will be given the power under this bill to virtually be able to dictate what services our municipality will offer and what services it won't.
On health care, we're very concerned with the power given the Minister of Health to close or restructure hospitals arbitrarily, without reference to the medical needs of the community. It is very suspicious to us that the minister and cabinet are also protected from legal liability due to cuts in funding or restructuring the health care system when the government is also pulling out of funding malpractice insurance for doctors. We're afraid that doctors could be left on the line, being sued for decisions the government forced them to make.
We're horrified with the possibility that our medical records would no longer belong to us and our physician and could be examined at any moment by the minister or his chosen agents. This is an unsupportable invasion of privacy. The minister could also say, without reference to medical expertise, whether or not medical procedures now paid for under the Ontario health insurance plan are necessary and if they can be funded. We concur with the government that changes to serve underserviced areas and communities are needed, but are uneasy about the approach that is being used.
Introducing copayments and eliminating the regulation of drugs is an insane prescription for making drugs inaccessible to those who need them, primarily seniors, as well as endangering the future financial viability of the plan. Where there is no competition for necessary drugs, as there is in cases where there is patent protection, drug costs need to be regulated to protect consumers and to protect the drug plan from being bankrupted. If we have no control over what drug companies charge the province or individual consumers for their drugs, the drug plan could easily have costs that spiral out of control. Welfare recipients who have had their cheques cut by 20% are in no position to be paying these drug costs. It may well eventually come down to a parent or someone else having to choose between buying the drugs they or their children need and paying the rent or buying food. This is completely unacceptable.
I will now hand things over to Dr Bob Frankford, who will speak a bit more about the health effects of this plan.
Dr Frankford: I've been working as a physician at Seaton House. I'm becoming very familiar with the needs of the most needy population of people, who would be homeless if an institution like Seaton House didn't exist.
I'm totally bewildered about the implications of any sort of a user fee on my clients there. Every day I see high health needs. I write frequent prescriptions. I stand by my medical judgement on what is needed. I try to write short prescriptions, partly because of the real risk of diversion of drugs, so I just have no idea what I would be doing if there was a user fee, however minimal, because I have no doubt this would add up to an impossible amount to many of the clients I see there.
I suppose one might say that, like so many other things, they would be supported as a last resort by the municipality of Metropolitan Toronto. That would be yet another downloading of an essential cost to the municipality. I fail to see how that benefits, particularly in the face of what I regard as the universal right established by the Canada Health Act to medical care, which to me has to include necessary prescription drugs.
That's all I'd like to say at this point, but we'd like to welcome questions from the members of the committee.
The Chair: Thank you. We have about five minutes per party left, beginning with the Liberals. Mr Colle.
Mr Mike Colle (Oakwood): Thank you very much for the presentation. One of the themes in your presentation is the unfairness of user fees, and I'm just wondering, for instance, in Seaton House which is a hostel for, as you said, people who are most vulnerable, especially at this time of the year, what would happen if all of a sudden -- as you know, this government is proposing to enact a $2 user fee, which is part of Bill 26. What's going to happen to those men in Seaton House when they have to pay $2 for prescribed drugs?
Dr Frankford: They just don't have it. You would be chasing an uncollectible bill. I suppose you could go after the pharmacist and essentially cut his fee if he was willing to go along with it, or one would have to go to Metro Toronto and say that this is something you have to add to your budget, although I don't think they're advised to do that.
To me, we have a medicare system, a Canada Health Act, and I'm just totally perplexed by any suggestion that necessary drugs or the treatment that I prescribe is not free. If I see someone in a diabetic coma, do I check their financial resources first? Maybe it's acceptable south of the border, but this is not what I want in this country.
Mr Colle: I guess the government has said, "It's only two bucks." I know the Minister of Health said, "I talked to a lot of seniors and they thought it was a great idea for this $2 user fee." Is it quite common that these men, for instance, would not have $2 in their pocket?
Dr Frankford: These men don't have anything. They're living there as a substitute for welfare. They get a personal needs allowance of three dollars and something per day. That's it. There is no cash.
Mr Colle: I think this other gentleman would like to comment.
Dr Emyolu: What I wanted to add is that it might be important for the government to tell the public the distribution and redistribution impact of this bill on the ethnic community, those of them that are on welfare. Everybody knows what they are getting, if you put it as single. So we want, in my own community, the Nigerian Canadian Association wants to know the distributional and redistributional aspects of this bill.
Mr Colle: In other words, you're not aware of any impact study the government has done as a result of all these changes that this bill is going to bring about and the effect it's going to have on vulnerable groups and groups that certainly need support in Scarborough.
Dr Emyolu: Exactly.
Mr Heath: A quick comment. I don't quite see the economic logic about charging a copayment or user fee on drugs. The idea behind it, I assume, is to lower the use of unnecessary drugs by charging a fee. Well, guess what? Consumers do not choose the drugs they use. They are chosen for them by their doctors. We can't go out and choose which elements of a prescription we choose to give ourselves or ignore because we don't want to pay the user fee.
Mr Bartolucci: I'd like you to react to this quote from the Minister of Health. "The health care system will not be reformed by publishing invitations to special interests for their input, adding up their requests and greasing their wheels with the squeakiest getting the most grease." What was your gut reaction to that?
Mr Heath: Well, it certainly won't be reformed by autocratic fiat from the minister either. No, we have to consult people in the health community who know the health care system and know what they're dealing with before going ahead with these changes.
Mr Bartolucci: Do you not see that the only alternative is to extend these hearings?
The Chair: Thank you, Mr Bartolucci. Ms Lankin.
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Ms Lankin: In your presentation I think that you did a very good job of talking about this bill in terms of its effect on the determinants of health in the broadest sense, and you touched on some of the other areas. I want to take it on from there and talk about another sort of vision set of values or whatever and that's with respect to medicare, the Canada Health Act and universality. I'm not sure if you're aware of this provision, but let me put this to you and see how you respond.
Under the Health Care Accessibility Act there is an amendment proposed which would allow the Lieutenant Governor, by regulation, to deem that certain insured services performed in a hospital could be charged for in addition to the insured services recovered from OHIP. When I raised this earlier, I was told by one of the government members, Ms Ecker, when she responded to the panellists: "Don't worry. We support the Canada Health Act and there isn't a problem here."
I've been unable to determine what the goal of this is, because currently my understanding is, from the research we've done under the Canada Health Act, that if a hospital did charge a user fee for an insured service prescribed under regulation under this legislation, the federal government would reduce transfers to the province by a corresponding amount. They have a clawback provision. Now what provincial government would do that? It wouldn't make sense.
But then last week we heard the Finance minister musing about the need to have flexibility under the Canada Health Act. As we look at this and several other sections, we're starting to wonder whether there are amendments in this legislation that are there in the event of a loosening of the Canada Health Act in the future, if they are successful along with the Alberta government etc.
The background paper that the government gives us says, "This is to clarify that you can't charge user fees for insured services in a hospital." It wasn't even in the act before. There was nothing to clarify on that. Why would it be set out that it is to allow, by regulation, for it to be charged and a separate clause that says, "You can charge different amounts in different classes of hospitals by regulation"?
I don't believe the background note on this. Have you looked at that or do you have any general comments on the issue of accessibility, universality and the Canada Health Act vis-à-vis Bill 26?
Dr Frankford: It would require a lot of time to work through all the things you've said, but I'm a very strong believer in universality. I think my main regret really is that the Canada Health Act is not universal enough. I think it gives too much discretion. I think it would be quite possible to set much broader national goals at the same time as maintaining the provincial role in the running of health care.
I think the idea of insured services which are medically necessary and so on is not in fact as big a problem as is made out. I think that the federal Reform Party's proposal that we should confer on which things are medically necessary as a sort of Oregon approach is a nightmare. I think even from their political self-interest, it's a very unwise move because it sounds attractive but it's an absolute swamp as --
Ms Lankin: As we found out.
Dr Frankford: You know, the idea, "Let's eliminate annual health exams." It sounds easy, but no government can easily do that, although they keep on trying.
If I can go back to Mr Bartolucci's question about the extent of public hearings, I would very much support the idea of having separate health hearings because it is such an involved complex field and I don't think that it's special interest. I think it's just the many, many stakeholders who deserve to have a chance to bring their positions forward. I think that we can have some sort of comprehensive model, but we cannot do it under the time pressure that this bill holds us to.
Mrs Johns: Thank you for coming. It's an interesting presentation and I appreciate your comments. I want to go back to the topics of drugs that they were talking about earlier. I have a quote from Thomas Walkom in November 1993 which says, "Rae and NDP backbenchers such as Dr Bob Frankford of Scarborough East defended the idea of targeting money towards those most in need."
At that point I want to draw to your attention that under this bill and our further discussions from the minister, we have been able to target 140,000 people who have never had health care benefits as a result of this money and being able to decrease the limits on the Trillium drug plan. I'm sure from that standpoint those 140,000 individuals are a very important part to you.
You said something in your statement about drug regulation, and I just want to say that the cash market is deregulated, but we believe that government will have greater flexibility in negotiating the best prices for the ODB and therefore once again will help the poor and the taxpayers of Ontario.
My question goes on to that. During your time in government, you delisted drugs from the formulary twice. You delisted 130 different drugs to achieve $20 million in savings, while in September 1993 you delisted another 110 drugs, for about $37 million in savings. Delisting is a 100% user fee, as you well know, making seniors pay the full cost of the medication. Do you agree that cost-sharing is better than delisting?
Dr Frankford: I would like to take a very illness-centred approach and think in terms of medical necessity. We should have an essential drug list, and you could be looking at the WHO and bodies like that which do have an essential drug list, which I think should be free.
As I said before, it doesn't make sense to have free medicare as some wonderful national achievement if what I'm prescribing as treatment is not free. I'm perfectly willing to accept limits on that. One can look at other countries -- I forget, is it Italy? -- there are some countries where thousands of drugs are available and it's a real mess in every way, both fiscally and clinically. So I'm very prepared to go for a quite limited list, and I'm also quite prepared not to expect change of that scale overnight, but I think it should be an objective to make a more comprehensive free health care system.
We have not even got into the other things which are not covered. I am perplexed by the things I would like to prescribe which are not there. Is dentistry covered? Well, a little bit here and there. Physiotherapy? Some is, some isn't. I don't think this makes sense, to have multiple-tier systems by default.
I hope I was at least pushing the government of which I was a part in the direction to say, "Let's move towards more universality, because it's actually cheaper." Gee whiz, isn't that what we're all about? It would actually reduce the deficit if you look at models from other countries.
I've written to our friend Marcel Massé, the federal Minister of Intergovernmental Affairs, who in the early days spoke out of turn, but I think he spoke correctly, and I'm on the record as having complimented this, saying, "Let's look at European models because they're cheaper, and we would reduce costs." He's absolutely right, or he was right. but he's not supposed to be right and he's being told to be quiet about that. I'm very willing to go for a system of greater universality.
Mrs Johns: You'd prefer to have drugs delisted then.
The Chair: Thank you, gentlemen. We appreciate your attending our committee this evening and we appreciate your presentation.
It would appear that our next presenter, Women's Health in Women's Hands, isn't here. I guess we'll have a short recess, but don't go too far away.
Ms Lankin: Could we get an update on what's happening for the evening? My schedule stops at 7.
Clerk of the Committee: I handed out another agenda. It's somewhere on your desk.
The committee recessed from 1900 to 1913.
LARRY EDWARDS
The Chair: Our 7 o'clock group is not going to make it. Fortunately, Dr Larry Edwards has come a few minutes early, so we're going to get him in and out a little quicker than he thought. Dr Edwards, welcome to our committee. You have half an hour to use as you see fit. Any time you leave for questions would begin with Ms Lankin from the New Democratic Party.
Dr Larry Edwards: I am a specialist in internal medicine and gastroenterology practising in the northwest part of the city. I graduated from the University of Toronto in 1961.
About five years ago I was in Central America doing medical clinics. I had my eldest daughter with me and she was very impressed with the medical care we were doing there and she told me she wanted to become a doctor. I advised her not to. I said: "Lara, practising medicine in Ontario is not the same as practising medicine here. There's a lot of government interference in the practise of medicine in Ontario."
Well, nothing has changed. There has been ongoing government interference, in the perception of the doctors and the patients, and there continues to be. In this proposed Bill 26, the implications for the medical profession are horrendous, absolutely horrendous. Any seriously thinking doctor is totally aghast at what is being proposed here.
We are to be at the entire mercy of our CEO or hospital administrator. If he decides we're off staff, that's it; we have no recourse. If the Minister of Health or the director of OHIP decides we're not to have a billing number, we have no recourse. We are apparently to be told where and when to practise. Furthermore, we are to be told that if we order some tests and a subsequent review of our records shows that these were not "medically necessary," we are to reimburse the system for the cost of these tests.
I was asked 10 days ago by one of my longest-standing and best friends, with whom I went through high school and medical school, who came to one of my fund-raisers when I was a PC candidate in this election, "Larry, when you ran in the election, did you have any idea that any of this was being proposed?" I said no, that what was being proposed and what I knew was that the government was going to protect the health care envelope at the present level of spending and not cut any services. In the six months since the election, things have apparently changed. I have no idea how or why, or why the minister is seeking such powers, like Draco in the seventh century BC, and everybody calls them draconian because they are. I have no idea.
I have a friend, Dr David Huggins, the chief OMA negotiator, who says that the proposal vis-à-vis insisting that doctors go to underserviced areas -- well, they want trained doctors for these underserviced areas. They have a program in Sudbury and at Lakehead -- I guess it's called Thunder Bay now -- where they have turned out about 25 GPs a year in each of these places in the last two or three years, and they have a 70% rate for these people staying in underserviced areas. David Huggins feels this is the way to go, and through incentives it should be done, but not through restricted billing numbers.
Getting back to Central America, in Honduras and I believe in Ecuador also, where I've been, the government insists that you serve one or two years in an underserviced area before you can come to one of the big city areas. We've met some of these doctors, and some of them are not the least bit interested in treating the people in this area, and we could face the same thing here.
I put my name in last week when I saw the second of the two all-night telecasts. I've talked to some people in the government, those who will return my calls, and I'm told it's entirely a financial matter, that there was $2.4 billion this government didn't know about when it took over and this entire omnibus bill is to make up this $2.4-billion deficit. Everybody in their right mind, and certainly the majority of the doctors in the province, are in agreement with curtailing government spending. Government's been overspending for many years. But we're not in agreement with giving up our liberties to the point that we don't have what the average person has in terms of rights and freedoms. That's why I'm here.
The Chair: Thank you, Doctor. You've left lots of time for questions, about six or seven minutes each, starting with Ms Lankin.
Ms Lankin: Dr Edwards, thank you for coming. I imagine it might have been a difficult choice for you to come and talk to the committee.
My own feeling about this bill, to set aside its size and all the various pieces to talk just about what the health care pieces attempt to do, is that I support the government's effort at restructuring and fiscal responsibility. We can certainly have a disagreement about the nature of the problem and why the problem's there and/or the way to go about it. That's a partisan difference and that's for another arena.
What I'm concerned about is that this bill takes powers on to the minister and to bureaucrats in the ministry beyond what is necessary to effect the restructuring, that it denies rights beyond what is necessary to achieve the goals the government has, and that it is ill-thought-out in the speed in which it was put together in the various departments that must have worked on it, and the compilation of all the parts spells a very dangerous story for the future. In fact, it's very contrary in intent to the government's proclamations about wanting less government, not wanting to bureaucratize health care and not wanting to undermine volunteers. I see all those elements in the bill.
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Let me ask you a couple of questions. I know that at other times under other governments there have been measures the governments have taken -- or have tried to take and then sat down and negotiated alternatives -- that the medical profession has been very angry about. There have in the past been suggestions that the nature of government actions would cause large numbers of physicians to flee the jurisdiction.
The Minister of Health himself, when he came and presented to us at the beginning of this week, indicated that this wasn't a concern, that if you look over the last 10 years, it had been pretty stable at 1% to 2% of physicians leaving and a certain percentage coming back, that it was pretty stable -- besides the fact that that's different from what he used to say when he attacked me as minister.
I've heard from a lot of physicians here that the level of interference with decision-making and billing numbers and lack of rights of appeal are going to cause people this time to seriously consider leaving. Do you believe that is a real, likely result -- I don't at all intend to sound demeaning -- or is it an easy point to make when one is upset with what government is doing? How real is it, would you say?
Dr Edwards: I think it's very real. I've heard even more this time than ever before that doctors are planning to leave. Right now I've got a young lad from Honduras who's been up on the Herbie fund four times. I first saw him five or six years ago, and he had a serious congenital malformation. Dr Churchill at the Hospital for Sick Children was the world's expert in this operation. He did the initial two operations, but he's now in California, so this time up, there's somebody else in his place.
We're losing very skilled people and we're going to lose -- if this thing goes through unchanged, it's going to be a serious problem, in my opinion. It's going to be a serious problem not only for those who leave but for those who stay. It's going to be very difficult to practise medicine under this type of unheard-of interference, and, "Look behind you before you make a move." That's not the way to practise medicine.
Ms Lankin: Let me ask you about that part of it. In the old bill, if the general manager of OHIP had reasonable grounds to think something was wrong with the billing, they would refer it to the Medical Review Committee and there's a peer review process. Now the general manager would make a decision and it would be up to the doctor to appeal that to the Medical Review Committee. But the grounds have changed slightly and there's a couple of new words that have been added.
It used to be if there were reasonable grounds to suspect that the service wasn't "medically necessary." Now they've added the words "medically or therapeutically necessary." As a layperson, I have a certain sense of what that difference might be and what that means, "therapeutic," but how do you relate to that as a professional, to know that the general manager of OHIP and the bureaucratic structure would be trying to make a decision up front about whether something was therapeutically necessary? How would they do it?
Dr Edwards: They can't. That's the short answer. "Medically necessary" is totally different from "medically advisable." The people using the statistics for closing some of the emergency departments are using exit data. If somebody goes to the emergency department thinking he's had a heart attack and it turns out his cardiogram is normal -- the doctor takes his story, checks a few things, says, "Fine, you're under a lot of stress; you're okay" -- they use that exit diagnosis to determine that his visit was not medically necessary. Well, that's absolute rubbish, and that's one of the things that has been used to determine that a lot of these emergency department visits are not necessary. That's after the fact. You can't do that. They're trying to do the same thing here.
What if every MPP and every civil servant were liable financially, somewhere down the line, for every mistake he made? "Oh, by the way, you know that mistake you made two years ago? That's going to cost you $2 million." Get real.
Ms Lankin: You mentioned also the powers of hospitals with respect to revocation of privileges. It's clear in one section of the act that where a hospital closes or merges or whatever and it's restructuring and downsizing, there is the right to revoke without appeal. A point's been made, that where is there ensuring that the physician follows the patients as you restructure? That's not in the act.
The piece that is in the act is that, irrespective of closure or merger, in any other circumstances it can be thrown into the regulations. A hospital could revoke the privileges and there's no right of appeal. If privileges are revoked and you're in an overserviced area, you have a patient base you've worked with. Again, I believe the government needs to deal with the issues of underserviced areas and overserviced areas and hospital closures. But where's the physician left in this, in terms of your practice and your patients?
Dr Edwards: You're up the creek without a paddle. The problem with hospital mergers is also -- for example, my hospital, Humber Memorial Hospital, and an adjacent hospital, Northwestern, have apparently been ordered to merge, and I guess this is going to come through. One of the hospitals has an oversupply of one particular subspecialty, and when the hospitals merge, are all these people going to be accommodated even though it could be an oversupply? Or is the purpose of the bill to be there so they can say to one or more people like this: "You drew the short straw. You're going to have to go somewhere else"?
A lot of this stuff is open to interpretation. If a person like the minister or the director of OHIP or the CEO of the hospital has wide powers, without any ability to appeal a decision, you have to really hope they've got your best interests at heart, and those who come after them.
Mrs Ecker: Thank you very much, Dr Edwards, for coming tonight. I certainly know of your record of service. You have set a very high standard in this province for much of the care and the things you have been involved in.
Before I ask a question, I would like to point out that the phrase "not therapeutically necessary" is indeed in the old Health Insurance Act, as is "reasonable grounds," as is "not medically necessary," so the fact that those phrases are included in the new legislation -- they were also in the old legislation.
Anyway, you talked about underserviced areas a little. As you know, for many years the government and the OMA have been talking about what to do about underserviced areas. There have been incentive programs, there have been mentor programs, there have been special programs with the college and the OMA, bringing in physicians from other countries, there have been the educational programs in the north. A number of things have happened to try to get physicians into underserviced areas, and the problem has been getting worse.
The Minister of Health has gone to the OMA again this year to say, "How can we resolve this problem?" and the problem remains unresolved. So the minister has felt it was necessary to bring in restrictions for new physicians -- not existing physicians; for new physicians -- on billing numbers. He is also implementing the recommendations from the Scott report, which talk about incentives for physicians in new areas. You're quite right to point out that some of the educational programs in colleges like Lakehead are going to be very helpful and very useful.
Given that we've had literally years, and at least three governments previously have wrestled with the underserviced area program, trying to solve that problem, what is a government, any government left with in terms of trying to get physicians in those areas? The problem is getting worse. There are more and more communities that are in desperate need of physicians.
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Dr Edwards: I don't know personally, but Dr Huggins says that he's made these suggestions before, and I'll pass them on again, that departments of psychiatry and general surgery especially, but also probably obstetrics, paediatrics and internal medicine, intern training should have a rotation through a northern area. It seems to me, not being at all on the inside, that there has been probably relatively poor communication, because I think you should bring a third party into the equation, and that's the medical schools and the training programs.
Mrs Ecker: Mr Wilson has tried to do that. He does try to do that.
Dr Edwards: That's admirable, because I think you need to have a good coordination between the three. I remember when a friend of mine, Dr Martin Barkin, was the Deputy Minister of Health. He made the comment at one time that somebody said we're getting too many doctors and we need to cut back on medical school enrolment, and his comment was, "Which medical school enrolment would you choose to cut back on?" The answer I would say would be everybody by the same amount so as to be fair.
Obviously it's a problem, but I don't really see what that has to do with some of these other measures which include total invasion of privacy of doctors' patients' records. Somebody has told me that was present in previous legislation. Perhaps it was, but the clear feeling seems to be that this is intensified so that the government can take any records they want to prove whatever point they want, including, I suppose, whether somebody had ordered a service that wasn't medically necessary.
Mrs Ecker: We think there hasn't been an extension, or a breaking of confidentiality, and if it takes an amendment to prove that is not the case, we're certainly prepared to consider that, because we do believe that confidentiality is very important, but patient information, without identifiers, must be accessible for quality control purposes, for example, which it is under independent health facilities, under quality assurance provisions, and we want to maintain that kind of quality assurance.
The other thing I would ask is that I know that in my own area where we have gone through a restructuring exercise, and I know that in the Metropolitan Toronto District Health Council restructuring exercise, a human resource plan has been very much part of that plan, because they quite recognize that all health care professionals -- doctors, nurses -- are going to be displaced by the restructuring exercise and they have put a lot of time into trying to make sure that they can be accommodated to the extent that it is at all possible. The government has said very clearly that it is those restructuring plans with those human resource recommendations in them that are what the government wants to follow, those community recommendations. I just wondered if you had some comments on that.
Dr Edwards: I think that's good and essential, and I've seen some manpower studies available province-wide and Canada-wide. I would hope there would be some dealing with that problem. That, I think, is essential. But the perception remains that all my medical colleagues and I are very concerned that we are being put as responsible for any overspending. Any clear-thinking person realizes this is not the case. The patient is driving the system; it's not the doctors. Where the doctors are driving the system in unnecessary tests or consultations, it's because of this threat of being sued and/or reprimanded by the College of Physicians and Surgeons, which seems to pander endlessly to frivolous complaints.
Mr Colle: One thing that seems to come through in your presentation is that you feel there's been a dramatic shift of principle or an abandonment of principle. You offered your services as a candidate in the last provincial election because, I'm sure, you believed in the basic principles of the Conservative Party. I guess that was the ultimate political involvement and you felt strongly enough to do that. I would assume you did that because you felt you could contribute as part of this new governance that you thought was needed. I commend you for doing that.
I know you have also spent, not to be patronizing, a good number of months and years away from your family helping people in the Third World because you really believe in your profession and the ability to help people. I know you're a man of conviction and I think that was why you were a candidate in the last election against Bob Rae. What I'm trying to get to is, why has the party that stood for certain principles abandoned its principles?
The thing that intrigued me was your comment when you phoned someone inside the offices of the party's inner sanctum, or the government's inner sanctum, and they said, "It's a financial matter." Did they ever try to explain that this might be a way of protecting, saving, enriching, offering better medical care to people who need these important services or was it just a financial decision by someone outside of Jim Wilson or whatever?
Dr Edwards: My feeling is that these proposed solutions had been floating around first ministers' conferences, of health, for five to ten years, and the prior government and the government before it rejected some of these measures as being too harsh. They've been there for a long time and they've all been put up by the civil service. Why they're being embraced at the present time by the present government and the present Minister of Health is a deep mystery to me. I think it's unfortunate and misguided; perhaps a convenience, an easy way, to seek a plan that's already been there, laid out before you and all you have to do is plug it in: Here it is, all set up for you.
I object to it very strenuously. I only got involved in this election because I felt that the last two governments didn't address the problem correctly. Never would I have imagined that this government could possibly be looking to make matters worse in the opinion of the doctors of this province, and I speak for 90% of the doctors of the province. I have talked to a lot of doctors, from all over the province, and I am not aligned with the OMA, except as a member, but we all are, and I do it for the health insurance premiums.
Mr Colle: To follow up on that, I want to read a quote from the now Minister of Health when he was in opposition: "They're going to tell every physician exactly what services can be rendered, what services will be paid for and how often those services will be available to the people of this province. The fundamental question here is, do you trust Bob Rae, do you trust Dr Ruth Grier to run your health care system?"
With the articles in this Bill 26 and the intrusion it is essentially establishing into a doctor's ability to provide that essential service, one on one with their patients, do you trust the Minister of Health in essence to be the guardian of our medical services in Ontario?
Dr Edwards: I wouldn't trust any one person to have so much power. That's the whole problem, whether it be Jim Wilson or whether it be someone else. It's just a terrible mistake. If he says, as he is reported to have said, that he'll never use some of these powers. if they're there, the person succeeding him can. Besides, when a certain person took away the rights of an entire people in 1933, proclaiming a general measures act, it was saying, "I'm taking away all your rights, but trust me." It's not on, believe me. Nobody can accept it.
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The Chair: Thank you, doctor. We appreciate your interest in our process and your coming to talk to us tonight.
Ms Lankin: Mr Chair, may I take a moment to correct something I said, on the record?
The Chair: Yes.
Ms Lankin: Ms Ecker had pointed out that there was a reference in the old Health Insurance Act to "therapeutically necessary," and in fact she's right. It is under a section that doesn't deal with doctors, it deals with practitioners, and as I read it, I've come to understand a little bit better the provision in Bill 26 with respect to that. Perhaps for our legislative drafting convenience, it seems to have drawn together physicians and practitioners under one clause and so the reference to "medically necessary" and "therapeutically necessary" appear in the one clause referencing.
You're nodding your head. I suspect you just found that out as you've been flipping here looking.
Mrs Johns: That's what I was running back there for.
Ms Lankin: The point that we made about the decision of the general manager taking effect and the doctor having to appeal to the medical review as opposed to before, the decision of the general manager being referred to the medical review or practitioner review, we were correct on that point.
I just make one point as I say this, which is that I've been looking at this legislation in the old acts and the descriptions in the backgrounders for two weeks now and I've been sitting through these hearings and I've been raising points and I've been trying to understand it and have just put these two pieces together, and this is the reason why you can't do law like this and why you can't have these kinds of proceedings going on without somebody carrying the bill who can answer these things. We have been struggling on that point now for two days and it could have been explained.
The Chair: Thank you, Ms Lankin. I appreciate your comments.
ROBERT KERNERMAN
The Chair: Our next presenter is Robert Kernerman. Good evening, sir. Welcome to our committee. You have a half-hour to use as you see fit. Questions, if there's time for them, will start with the government. The floor is yours, sir.
Mr Robert Kernerman: I have some experience in this area. I was a hospital board member for eight years in the city of Windsor. I was the chairman of a hospital there for two years. I sat on the Essex district health council for 10 years and, as well, I was on the Red Cross there for eight years. I'm going back to the 1970s, which is history, but I've kept kind of current on some of these matters.
In my opinion, Bill 26 is long overdue. If we have over our heads here a $100-billion debt in the province, as I understand it, that equates to about $12,000 a person, so on the $100 billion we have to pay roughly $8 billion or $9 billion a year in interest, and my understanding is that's the reason we're getting involved in this particular bill: to try and downsize the debt so we don't have this hanging over our kids and our grandchildren.
Going back to the late 1970s, when I was involved as a chairman of the hospital board in Windsor, we were actually starting off with the rationalization of services and the hospitals really didn't cooperate much with each other, and I would suggest that hospitals don't. Much like municipalities, you have to have some sort of stick over their head or else they'll just procrastinate, keep talking, having committee reviews and hearings and papers. I don't really think this is a bad thing, for the government to stimulate and move along and try and streamline the bureaucracy, much like a lot of corporations have had to do over the last 10 years.
As you all know, there's been a terrific amount of downsizing in a lot of industries. I used to be associated with the automobile industry when I lived in Windsor. At that time, Chrysler Canada, when I was there, had about 14,000 employees; today they have 8,000. There have been terrific advances in technology, and much of this has to happen here. This is an area in which it probably hasn't happened. I'm only going into this because I think it's important to get into the background and probably some of the reasons why this bill has been brought in.
I would suggest that perhaps the entire medicare system, which was initiated by Mr Justice Hall under I think then Prime Minister Diefenbaker, may be somewhat outdated and perhaps we have to get into some sort of modified user fee, something so that the doctors would continue to be motivated and people who need medical care or medical assistance, if they can afford to pay for it, have to pay for it.
To get into the reason Bill 26 has come in, so I can make some suggestions, the overspending which our province has unfortunately incurred over the last 15 years and the loss of the manufacturing job base to the Third World is something I think this government can correct by offering some accelerated tax credits for high-tech manufacturing equipment which would increase the job base and bring back jobs which have been lost basically to the Pacific Rim.
The Premier, as was pointed out in the media yesterday, was somewhat disappointed that we only increased our job base in Ontario by 12,000 jobs instead of 70,000. I think we have to make a very strong, concerted effort to be very competitive with some of the states in the United States, such as the Carolinas. It may require changes in some provincial legislation to offer certain types of incentives, but all this will really increase the job base, will bring in more revenue, will make bills like Bill 26 not as necessary as it is today.
I don't want to get into all the details on Bill 26 because obviously you've heard from other people on that, but I think you have to look at the whole picture. Quite frankly, sometimes that's lost sight of.
The other point I want to make is that the minister's discretion I feel should be exercised in a reasonable manner and in a compassionate manner, because as you know, when you get into the healing business, basically you're dealing with lives, and the minister should deal with all this in a reasonable and a compassionate way. My suggestion is that we should increase our charitable tax credits so that basically the individuals and the private sector become more responsible for the real poor, for the disabled, rather than have to go to the government every time something comes up.
Basically, that's my presentation.
The Chair: We've got a fair bit of time left for questions, beginning with the government.
Mr Clement: Thank you very much for your presentation. I very much appreciate the time and effort you took to be here in front of the committee at this late hour.
From your perspective, you've had a lot of time assisting in the health care sector, particularly in Windsor and Essex. Is the status quo in health care working right now, as you see it?
Mr Kernerman: Down there?
Mr Clement: Down there or anywhere.
Mr Kernerman: The status quo? From what the previous speaker said, the doctors have been under quite a bit of pressure over the last number of years. I don't think this is something that's come up because of this particular bill. No, I don't think the status quo is working. I don't think the doctors have been motivated to really practise medicine. We've got a great group of doctors in Ontario and they want to be business people. They're getting into the swing of the new government. They really want to be business people, and maybe the system has to be changed so that they are business people.
Mr Clement: To allow for more entrepreneurial aspects in the health care system.
Mr Kernerman: That's right, yes.
Mr Clement: That requires changes, and I guess what we're grappling with as a government, just so you know, is that we want to see some changes. We want to see value for money for the taxpayer, and we want to see value for the patient, obviously -- that's got to be a primary concern of any health care system -- but there's got to be, at the end of the day, and I hope Ms Lankin will agree with me on this, an actor who actually gets things done. We can talk and talk till the cows come home, but unless you have an actor, then we're creating more of a problem for ourselves, not less of a problem. Would it be fair to say that the only actor who can deal with all these aspects of the health care system is the Minister of Health? Is there anybody else out there who can deal with it?
Mr Kernerman: The minister has to, because it's a socialistic system. It's not a free enterprise system; the government's involved in it, and perhaps it's about time they start phasing out of it. I know you have restrictions from the federal government, and this has come up, but I really think times have changed. We're going to be in a worse and worse position against the Third World. Mike Harris is doing a great job. You have to go in that direction, and the public wants him to.
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Mr Clement: We've heard a lot of criticism from the opposition in this committee, and, to be fair, some of the presenters have said this as well, that we're going too far too fast. What's your point of view on this?
Mr Kernerman: Too far too fast? No, because we have a $100-billion debt hanging over heads. We're never going to get rid of it. That's the whole motivating factor here. If we didn't, we could sit around for years and talk about this and talk about that and have studies and commissions come back, reports. We haven't got time. I think that's what the Premier is concerned about. The public is telling him that we don't have time. That's the message from the last election, unless I'm wrong, and he's following what the people have told him.
Mr Colle: I infer from the questions and your answers that you think we should be following the American model of medicare: pay as you go, free enterprise.
Mr Kernerman: They have problems, but if all the doctors suddenly over the years have been -- particularly in Windsor, over the last 10 or 15 years a lot of the specialists have gone over to the States because it's easy to lure them over to Detroit for conferences and then they somehow disappear into the American system.
The doctors are the key to the whole deal here because they're the ones providing it, and the minister is over it because he's paying the bill. Yes, I think you have to get into the free enterprise system more.
Mr Colle: So the American system would maybe be the way to go.
Mr Kernerman: Well, if I can correct that, the American system doesn't help the real poor sometimes. I don't know if they can all afford it.
Mr Colle: So there is a problem with the American system. That 40 million people in the States have no coverage at all is a bit of a concern to you.
Mr Kernerman: This is why we're ahead of them in that part. But the other people who can pay -- I mean, I can pay. I don't have to be on this system. If I go to a doctor and it's $150, I'll pay him.
Mr Colle: You mentioned that the rationale behind all this is the debt. If this is all motivated by the debt, why is the Harris government so committed to throwing away $3 million to $4 million a day on this tax cut for the rich? If you were really concerned about the debt, maybe you would use that money to lower the debt rather than give a tax cut to the people who do pretty well by themselves.
Mr Kernerman: I think the philosophy there is that the money going back to people will go back into the system and purchase more goods, which would create more jobs. Unfortunately, those jobs are in the Third World. That's why we have to increase our job base here.
But with what happened yesterday or the day before with the increased expansion at the Honda plant, to me, that's a perfect opportunity for tool and die incentives and for moulding incentives for the car industry. You're asking, what has this got to do with health care? It has, because it's all one picture. This is an opportunity where the government should be offering certain incentives so that the sourcing is done here. Again, we create more jobs here and we have more money here, so Bill 26 does not become as critical.
Mr Bartolucci: Do you agree with the Information and Privacy Commissioner that there should be about 37 amendments to the existing legislation with regard to privacy of information?
Mr Kernerman: I'm sorry, I haven't gone over all those points. Could you give me one or two of the more salient ones?
Mr Bartolucci: Do you think the Health minister should have access to information --
Mr Kernerman: I can answer that. I personally don't have anything to hide. If I were going around every day to a different doctor for a different opinion about some matter, maybe I would.
Mr Bartolucci: So you're saying he should have the right to that information and to do with it what he wishes.
Mr Kernerman: He's paying the bill.
Mr Bartolucci: No, he's not paying the bill. We're paying the bill. The taxpayer is paying the bill.
Mr Kernerman: That's fine. He's administering the funds. I think he should, yes.
Mr Bartolucci: What's your reaction to the government's desire not to pay CMPA premiums any more? What effect will that have on services to the public at large?
Mr Kernerman: What is CMPA?
Mr Bartolucci: The Canadian medical protective --
Ms Lankin: Malpractice insurance.
Mr Bartolucci: Yes, malpractice insurance, simply put. Have you read that section?
Mr Kernerman: No. What is the existing policy now, can I ask?
Mr Bartolucci: Do you believe doctors in the province have rights to protection?
Mr Kernerman: Yes, of course.
Mr Bartolucci: Who should be paying for this?
Mr Kernerman: In terms of their malpractice insurance? Who's paying for it now?
Mr Clement: The taxpayers.
Mr Bartolucci: Partially.
Mr Kernerman: I guess he's trying to reduce the costs. Is that what you're saying?
Mr Bartolucci: I don't know what his rationale is.
Mr Kernerman: I'm not that familiar with the motivation for the change there.
Mr Bartolucci: An earlier group of physicians and surgeons proposed that a commission on the provision of medical services be established to advise the minister. Do you think that that's a good idea?
Mr Kernerman: What would be the scope of their responsibilities? What would they do?
Mr Bartolucci: It would be readily accessible information about how services should be provided throughout Ontario. Do you think that's a good idea or a bad idea?
Mr Kernerman: It depends. Who would be on the commission?
Mr Bartolucci: I would suggest that it would be made up of doctors.
Mr Kernerman: I don't see anything wrong with that. This is part of the dialogue. You always have to have a dialogue with your doctors.
Mr Bartolucci: Do you think the dialogue should continue?
The Chair: Thank you very much, Mr Colle.
Mr Colle: Bartolucci's his name.
The Chair: I'm sorry, Mr Bartolucci. Ms Lankin.
Ms Lankin: Mr Kernerman, I appreciate you coming tonight. Did you travel from Windsor to be here?
Mr Kernerman: No, I live here.
Ms Lankin: Oh, you live here now. But I appreciate you taking the time.
You can well imagine that there would be some parts of the views you've put forward that I would hold a different opinion on. That's fine. Those things are always open to debate and discussion.
Having listened to Mr Bartolucci, I don't want to ask you questions on specific parts of the bill if you're not familiar with the actual bill. It was more the intent of the bill overall that you wanted to address tonight. Is that fair?
Mr Kernerman: That's right, the reasons and the philosophy behind it.
Ms Lankin: Let me just share with you that I think there has grown in this province, among the public and among the political parties, a consensus around the need to deal with fiscal challenges facing the government. There are some very different points of view about how they should be addressed.
Putting that aside for a moment, just so you know why my party will oppose this bill, it's not because we don't think the government should try and deal with the fiscal matters it's set out and that it should not try and proceed with the mandate it was elected on. We believe that this bill as it is put together -- and now let me just talk about the health sections this committee is dealing with -- takes draconian powers on to the minister and the bureaucracy far beyond what is necessary to deal with the fiscal elements, and that it is poorly drafted and poorly thought through in that sense.
While I appreciate your comments in general, that you support the government's mandate and its direction and if this bill's necessary to do it, therefore you support the bill, it's difficult to have the discussion with you because I would want to go into the parts and show you where some of the parts go far beyond what's necessary to meet the government's goal. So that, in the nature of the dialogue, would be difficult.
I am intrigued by some of the other things you have suggested the government could or should be doing around economic development. As we strive to have a competitive economy, I think we have to look to other jurisdictions. I tend to look more to the more industrialized northern states than South Carolina and others in terms of the package of incentives.
But you mentioned tool and die makers around auto plants. I had the occasion, when I was Minister of Economic Development and Trade, to spend a lot of time looking at the fact that the Big Three in particular had dramatically cut back on their financing to tool and die makers for the production of new tools and moulds for products, and that there is a huge gap in terms of credit from the banks in Canada, as there is not in the States, where there are regional or state banks in Michigan and in the auto-producing sectors that understand how this goes.
We looked at the development of a tooling fund which had some government dollars as a guarantee -- not actual dollars but as a guarantee -- backing and leveraging the participation of banks to get them into the field, because they're not used to dealing with it. There was a great deal of consensus in the industry and in the financial institutions that this would be helpful. It's something that I felt we should start to proceed on. This was just before the election.
The current government has decided not to proceed on any elements of working with industry in any way that involves financial backing. Do you think this could be something that would be worth looking at, that perhaps I should be a bit more aggressive in trying to persuade the Minister of Economic Development, Trade and Tourism to take a second look?
Mr Kernerman: I hope the present government considers getting involved in that. As you know, some of the hearings in Ottawa with regard to the monopoly the five banks have -- that really shouldn't happen in this country, but unfortunately it has, and obtaining funds for industry today is very difficult. The banks are actually very arrogant if you're a small or medium-sized business and you want to get a loan. Yes, I agree. This is something the government probably should start to get involved in if it has the opportunity.
The Chair: Thank you, sir. We appreciate your attendance at our committee tonight and your interest in our process.
Mrs Johns: Could I add something, Mr Chair? I know I'm not here as the PA, but I want to say, just to clear the record, that I believe in Ms Lankin's first opinion of this, that "physician" and "practitioner" aren't defined in the same direction. So it isn't like I've let you go for two days believing that.
"Practitioner" is defined as someone other than a physician who practises, and a physician is a medical doctor. In the initial documents, it was only the non-medical who was therapeutic; in this one, the physician and the practitioner --
Ms Lankin: I know that. That's what I said too.
Mrs Johns: Okay.
The Chair: Before we get to go home early tonight, the subcommittee met and we have made a decision that I want to refer to you. A request was put in and we have forwarded it on to the ministries, that the ministers be available during clause-by-clause if in fact they are presenting any substantive amendments to the bill.
We are passing that request along to the House leaders so we can get some assistance in that area. I just wanted to make you aware of that.
Thanks very much. The committee is adjourned until 9 o'clock in the morning.
The committee adjourned at 2004.