SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
OTTAWA GENERAL HOSPITAL / HÔPITAL GÉNÉRAL D'OTTAWA
CANADIAN CANCER SOCIETY ONTARIO DIVISION
COMMUNITY HEALTH CENTRES: OTTAWA AND EASTERN ONTARIO
ROYAL OTTAWA HEALTH CARE GROUP
OTTAWA AND DISTRICT LABOUR COUNCIL
CANADIAN UNION OF PUBLIC EMPLOYEES LOCAL 870
CANADIAN DRUG MANUFACTURERS ASSOCIATION
CANADIAN MENTAL HEALTH ASSOCIATION, OTTAWA-CARLETON BRANCH
ONTARIO ASSOCIATION OF NEPHROLOGISTS OMA SECTION ON NEPHROLOGY
OTTAWA-CARLETON PHARMACISTS' ASSOCIATION
CONTENTS
Thursday 11 January 1996
Savings and Restructuring Act, 1995, Bill 26, Mr Eves / Loi de 1995 sur les économies et la restructuration, projet de loi 26, M. Eves
Ottawa General Hospital / Hôpital général d'Ottawa
Jacques Labelle, president / président
Pierre Richard, chairman of the board
Canadian Cancer Society, Ontario division
Dr Catherine Lochrin, vice-chair, medical affairs committee
Alex Bruce, cancer survivor
Ruth Lewkowicz, volunteer member, public affairs committee
Community health centres: Ottawa and eastern Ontario
Lois Crowe, board member
Paul Richard, board member
Cynthia Callard, board member
Dennise Albrecht, representative
Royal Ottawa Health Care Group
Dr John Atkinson, vice-chair
George Langill, president and CEO
Ottawa and District Labour Council
Naomi Gadbois, representative
Academy of Medicine, Ottawa
Dr Byron Lemmex, president
Dr Diamond Allidina, local director to the Ontario Medical Association board
Ontario Dental Association
Dr Roger Howard, president
John Gillies, executive director
Canadian Union of Public Employees, Local 870
Betty Sommers, president
Charles Shaver
Canadian Drug Manufacturers Association
Jack Kay, chair
Brenda Drinkwalter, president
Julie Tam, director, professional and scientific affairs
Canadian Mental Health Association, Ottawa-Carleton branch
Mark Parsons, board member
Joanne Lowe, executive director
Bill Carne, board member, Psychiatric Survivors of Ottawa
Ontario Association of Nephrologists; OMA Section on Nephrology
Dr Gerald Posen
Dr Peter Blake
Linda Kemp
Ottawa-Carleton Pharmacists' Association
Frank Tonon, president
Rosemary Killeen, past president; director, eastern Ontario district, Ontario Pharmacists' Association
Norman Ferkin, member
Barbara Ramsay, member; regional representative, Ontario College of Pharmacists
Seniors on Guard for Medicare
Romeo Maione, chair
June Cassey, vice-president
Mary Eady, executive secretary
Arthur Kube, president
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
Miclash, Frank (Kenora L) for Mr Sergio
Clement, Tony (Brampton South / -Sud PC) for Mr Kells
Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Chiarelli, Robert (Ottawa West / -Ouest L)
Grandmaître, Bernard (Ottawa East / -Est L)
Lalonde, Jean-Marc (Prescott and Russell / Prescott et Russell L)
McGuinty, Dalton (Ottawa South / -Sud L)
McLeod, Lyn (Fort William L)
Morin, Gilles E. (Carleton East / -Est L)
Patten, Richard (Ottawa Centre / -Centre L)
Rollins, E.J. Douglas (Quinte PC)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel: Campbell, Elaine, research officer, Legislative Research Service
The committee met at 0900 in the Delta Hotel, Ottawa.
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.
The Chair (Mr Jack Carroll): Good morning. Welcome to the hearings on Bill 26 by the standing committee on general government. We have to kind of check outside to see where we are these days. We've been travelling around a fair bit, but it is our day in Ottawa and we're delighted to be here.
I just want to remind the people in the audience that we are very happy you're here. We appreciate your interest in what's happening in our process, but I would like to remind you that the dialogue that takes place is between the presenters and the members at the table.
OTTAWA GENERAL HOSPITAL / HÔPITAL GÉNÉRAL D'OTTAWA
The Chair: Our first presenters this morning are from the Ottawa General Hospital, Jacques Labelle and Pierre Richard. Welcome, gentlemen. You have a half-hour to use as you see fit. Any time you leave for questions will begin with the Liberals. The floor is yours.
M. Jacques Labelle : Nous désirons débuter en vous exprimant l'appréciation d'avoir eu l'opportunité de vous laisser savoir notre point de vue ce matin. Tout particulièrement, nous apprécions le fait que nous avons été choisis pour être les premiers à vous adresser la parole.
En premier, j'aimerais dire quelques mots sur l'Hôpital général. L'Hôpital général est un des plus anciens hôpitaux au Canada. On fêtait l'an passé nos 150 années d'existence. En même temps, l'Hôpital général est un des plus modernes du Canada. Nous avons ouvert il y a environ 15 ans un hôpital tout nouveau, probablement ce qu'il y a de plus moderne en Ontario, sinon au Canada.
L'Hôpital général a été construit pour accommoder 1600 malades. Présentement, nous avons environ 400 lits à l'hôpital qui sont en opération ; 300 accumulent de la poussière.
J'aimerais aussi porter à votre attention le fait que l'Hôpital général est assez particulier, du fait que nous avons eu durant 15 ans des surplus annuels considérables. Au cours des 10 dernières années, la moyenne de notre surplus a été de huit millions de dollars par année, pour un total de quatre-vingt millions. Je vous dis ça simplement pour vous laisser savoir que je pense qu'on a une certaine crédibilité dans le monde hospitalier.
Our presentation will really address only two aspects of the bill, the amendments to the Ministry of Health Act as well as the Public Hospitals Act. We'd also like to say a few words at the end about the patient confidentiality and the concern that has been addressed about amendments that could affect this issue.
In recent years, because of new treatment modalities, thousands of acute care beds have been closed across Ontario hospitals. Just in Ottawa, over 500 beds were taken out of operation and a further 150, which were earmarked for future patient care, have remained mothballed. However, the saving potential of these reductions was never maximized, since the forces at hand did not allow for the concentration of these closures into specific plants, thereby allowing the remaining facilities to operate at full capacity.
Therefore, on the one hand we are not benefiting from the additional savings that would result from ceasing the operation of entire plants and shifting their patient activities to the remaining facilities. On the other hand, overhead costs are occupying an ever greater share of hospital budgets since they must operate much below capacity. Proportionately, we are spending more than ever on the maintenance of brick and mortar and less on patient care itself, and this ridiculous situation can only worsen with the very significant budget constraints recently announced.
The 17 teaching-tertiary care hospitals of Ontario receive approximately 40% of the total funding the Ministry of Health dedicates to all its hospitals. I believe there are about 230 hospitals in the province. This 40% is substantially higher than the percentage of patients they care for. This high funding level was historically justified by the fact that these hospitals were mandated to deliver tertiary care to the citizens of the province and provide training ground for medical students and residents. Both activities contribute to make teaching-tertiary care facilities 30% more expensive than other hospitals.
However, considering that only 20% to 25% of the clinical activities of these 17 hospitals is tertiary in nature, but the number of medical students and residents has been continuously declining over the decade, and that more training is to occur outside these facilities in future years, it is evident that their number can and must be diminished. Such a move would engender enormous savings without tangibly impacting patient care.
To be successful, to achieve the savings goals and to keep to an absolute minimum its effect on patient care, hospital restructuring in Ontario must rest on plant closures, the concentration of clinical and academic activities in as few facilities as possible and on mandate consolidation where unnecessary scattering of functions exists.
Experience has clearly demonstrated that though this type of fundamental restructuring represents the best way of protecting the superb health delivery system to which Ontarians have become accustomed, local interest groups and power structures will aggressively militate for the maintenance of a hospital system as close to the status quo as possible. They will tend to favour options that protect organizations, bricks and mortar and mandates as they exist, and this even at the expense of patient care. Unless a fundamental hospital restructuring is made to occur in a systematic, orderly and timely fashion, we will end up pauperizing the entire system, forcing all hospitals to provide less than optimal care, confronting large sections of patient populations with mounting waiting lists and eliminating more health care professionals than necessary.
The Ottawa General Hospital therefore considers that parts I and II of Bill 26, amending the Ministry of Health Act and the Public Hospitals Act, are essential under the present circumstances. However, we feel that the Health Services Restructuring Commission should cease its operation at the end of a four-year term, which I believe has now been accepted. At that time, based on the success of the commission, all of the proposed powers provided for in section 6 -- I'm not going to read them to you; you know them all -- should be reviewed with the object of returning as much as indicated to existing ministerial powers. Such an eventuality would represent the best incentive for the savings and restructuring commission to fulfil its mandate effectively and in a timely manner.
Again, we believe the purpose of this legislation is to rapidly and fundamentally restructure and reorient the system so as not to have to maintain a continued heavy hand over it in the future, while protecting our ability to deliver excellent quality care.
A few words about the confidentiality of patient information: The Ottawa General, as a teaching hospital, must open its medical charts to nursing students, physio students, occupational therapy students, psychology students, pharmacy students, as well as to its own pharmacists, OTs, physios, psychologists, social workers, nurses, as well as to its interns, its residents, its medical students, its medical staff and its management staff.
In my 15 years' experience at the Ottawa General, we've had no breach of confidentiality that I can remember that was brought to my attention. Inevitably there are minor breaches, but nothing substantial -- only to tell you that as the hospital system exists right now there are many people who have to look into patient charts, even more so in the last 15 years when there's been pressure for us to increase quality assurance as well as economic use of resources. This has meant we've had to form committees across the hospital involving management staff to continuously delve into the charts to see if there are ways of improving the care and ways of improving the economies of providing patient care.
At first there was a lot of suspicion that this would lead to all sorts of breaches. I can assure you that the process has not led to the breaches, but has led to substantial economies as well as to the improvement of patient care. We're only trying to tell you that it's absolutely necessary, for a well-managed system, for more than one person to look at the medical charts to see how we can better provide care and how we can create or achieve greater economies. That is our presentation. Thank you.
The Chair: We've got seven minutes per party for questions. For the sake of those who are new to the process, basically the Liberals have seven minutes. You can fight among yourselves how you're going to use them.
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Mrs Lyn McLeod (Leader of the Opposition): We've reached an understanding as to how we'll manage. We only wish we had voting rights for everyone around the table today.
I'll lead off. We find that there is simply not enough time in the question period to ask all the questions we'd like, and I understand that you really wanted to address essentially just one aspect of Bill 26, even in terms of health care provisions.
It would have been a welcome opportunity to be able to ask you about some of the other aspects of Bill 26 that affect even just hospitals and hospital operations, such as the fact that the Minister of Health has the power to appoint a supervisor without an inspector or an inspector's report to shut down voluntary boards of governors; that this act gives the minister the power not only to come in and facilitate hospital restructuring with a commission, but in fact to operate as a minister outside of the boundaries of the Public Hospitals Act. He's no longer governed by the regulations under the act.
We're concerned that that has some long-term consequences that are rather frightening. Also, there is absolutely no liability for any decisions the minister may make as he carries out the powers given to him under this act. All of those I think would probably be areas where you would have some concern.
I can come back, then, to your focus on hospital restructuring with a specific question. I think everybody would agree that at a time of limited financial resources, we have to look at the best utilization, including the whole question of how much goes into bricks and mortar and the distribution of resources. I guess the concern we have here with the way in which a hospital restructuring commission might work and the way in which the Minister of Health's powers would be exercised is the time of his intervention, the way in which it would be carried out, the community involvement in the planning process and whether the decisions are going to be made in a way that's conducive to the public interest in that community. We have to remember that this is a Finance bill. It came in on the day that $1.3 billion was taken our of hospital budgets.
I guess the question then following from that is, do you feel that you need a commitment that the dollars that would be achieved from any restructuring that goes on in Ottawa-Carleton -- and I know there's been a lot of anguish over it -- that any dollars that are saved need to stay in this community or this region to be used for the health care of people in this area? Have you any commitment that this would happen and do you need that commitment?
Mr Labelle: For one thing, I have to go back to your initial comments. We understand that the ministry will be given extraordinary powers, but we're saying for the next four years we're willing to live with this. At the end of the four years, based on the achievements, then we should consider whether or not these should be abolished. But we think that we have to go through extremely difficult, perilous years, and what above all is needed is decisiveness and the ability to get changes to occur rapidly.
Closing hospitals, transferring whole programs, transferring patients, transferring medical staff are extremely complex. If we don't put any urgency on that, I can see ourselves 10 years from now still looking at it and trying to find ways for it to occur. I think that this has to be a number one priority for the next four years, not only to plan it but to get it done, and I'm willing to pay whatever price is necessary to see it achieved.
On public consultation, I can only tell you that under previous governments we, the hospital, have had to do all sorts of public consultation. I'm not at all sure that the people who came to our institution to express their voices really represented the public. They represented particular interests of the public, but the public at large, I cannot say so.
Mr Richard Patten (Ottawa Centre): I'm interested in your qualification of absolute authority, but we want the authority to be for a terminal period of time. I would ask you if you feel that the authority, which by the way is unprecedented in Canada for any Health minister to have absolute authority to micromanage -- you just made the point that this was an extremely complex set of circumstances, and the minister, you will know, has talked about the importance of the district health councils throughout Ontario and the participating people who are involved in the whole health care area to get on with the job of looking at how they can best use the resources and find resources that are taken back.
How do you reconcile giving absolute power to one individual in an extremely complex area and the role of the community, in terms of working together and cooperating together in addressing health care concerns, let's say for example for the Ottawa-Carleton area? What role do you see the General playing in doing that?
Mr Labelle: First, I don't think it would be one individual. Obviously, when we talk about the Minister of Health, we're really talking about the Ministry of Health and all the expertise there, as well as the influence of the political process on it.
I can only give you an analogy. We in Ottawa have spent -- I don't know -- about $1 million in the last year and a half gathering information to determine how we should restructure, and we find ourselves today not really knowing where we should go. The process is not paying off. We've had tons of consultation, but we still haven't decided what we're going to do to absorb what we were told is going to be a $120-million cut, as well as the loss of revenue from Quebec of close to $35 million, for a total of about $150 million. We still are not any closer today than we were a year and a half ago when we started the consultation.
Mr Patten: By the way, who said there was a $120-million cut? Was this a directive from the Ministry of Health?
Mr Labelle: No. If we just take the 18% or whatever and factor in the budgets, we come to about that.
Mr Patten: What would be your position vis-à-vis incentives for the community to identify savings in light of emerging needs or new health care requirements? What should stay in the community and what kind of arrangement or agreement do you think would be important to provide for the real incentives for the health care participants in any particular area to deal with that?
Mr Labelle: I can only talk about my approach, which would be to first achieve the saving and then sit down and see how you reorient the saving. We mix up the process when we start talking about what we're going to do with it, when we haven't achieved it yet.
Ms Frances Lankin (Beaches-Woodbine): Thank you for your presentation. I am interested in the comments you made about the problems you've had in this region in coming to a consensus about what change is required. All the communities we've been to, and many other communities I'm aware of, that are going through the process of determining how their health care system should be restructured and what should happen to hospitals in that context are at different stages, no doubt about it. Some communities have very comprehensive reports and are in the process of implementing them, some have already gone ahead and merged and amalgamated or closed hospitals, and others are at a different place in the process.
You've indicated that you've done the consultation, you've been setting this and you don't know where to go. With this bill, what do you presume will happen? What do you think the minister will do, and based on what information or whose advice for the Ottawa area?
Mr Labelle: We at the General have made our advice known to the ministry. The ministry has its own staff it consulted, and they understand the system very well and they also have ideas.
Look, let's put it simply. We have closed 20% of the beds in this province, so most hospitals are operating at 80% capacity. The business approach would be to close 20% of the hospitals and have the others functioning at full capacity.
Second, there is a lot of duplication. For example, all the hospitals in Ottawa have long-term patients occupying acute-care beds at a great cost. If we were to concentrate all these long-term patients and move them to one facility and change the mandate of that one facility to a long-term-care facility, we could save probably two thirds or three quarters of its budget without any impact on patient care.
I think the ministry officials know that; it's just that it may not be politically appropriate to so recommend. But if we use all the wisdom there is in the ministry, as well as the wisdom there is in the community, and show a determination to accomplish what must be done, to me, it won't be difficult to accomplish.
Ms Lankin: It's interesting. I remember the debates I had with the Perley about becoming a long-term-care facility and the need for that, so I understand some of the politics of the hospitals in this region.
But I have to say to you, it's interesting: Your answer to my question is that the minister should listen to us, to our position. There are others out there in terms of the community --
Mr Labelle: No, I said its officials. They can listen to the hospital community, but above all, it's got to be its officials.
Ms Lankin: And the community at large, I would assume. The reason I'm raising this is because I'm concerned that the bill does need to have some terms of reference and mandate for the hospital restructuring commission and some linkages to the local health care planning process that's been led by district health councils.
I'll give you an example we've heard just this week. In another community the district health council and the community had gone through a long process, had come to a unanimous recommendation which they were in the process of implementing, and because of the lobbying of one particular hospital, the Minister of Health has changed the rules with respect to that restructuring report on one particular issue and has said, "No, I'm not going to accept your recommendation on that, even though there was a consensus."
I think the minister has the right to do that. I'm not arguing against it. But what I fear, given that early indication that it's so easy to go against the community process, is that it needs to be built into the legislation.
Mr Labelle: Except that you have to look at the other side, and let me tell you what's happening right now. Because we have not decided what was going to be in Ottawa, all of us have had to absorb a 5% cut. At the General, it's $6 million. What are we cutting? Nurses, OTs, physiotherapy. We don't care about the waiting list. We don't have the money. The more time we take to decide what the ultimate outcome will be, the more each facility has to trim and trim, and that's the problem.
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Ms Lankin: Every time I raise this, I feel like you're skirting my questions in defence of the bill. I support restructuring, and if you know my record when I was the Minister of Health, you would know I started many of the communities down this direction.
What I'm saying is that I think it would behoove us to have in the bill some terms of reference that relate what the restructuring commission is going to do to the local community planning process where that has occurred and where that has produced a report and a consensus. I'm really interested that you seem hesitant to support that kind of connection or linkage.
Mr Labelle: To the extent that it achieves the saving that must be achieved, obviously I could not oppose such an approach.
Ms Lankin: It took several questions to get to that point. That's interesting.
One other thing I wanted to talk about is that you mentioned you would like to see a sunset on the extraordinary powers under the bill. There are some things in there, like the ability of the minister to move in and to impose a physician human resource plan and some things that other hospitals have referred to as micromanaging. While they agree with the power to restructure and want to see that happen, they don't want to see the minister or the Ministry of Health step in and micromanage hospitals and make decisions about physician human resource plans, which is something that really should be done in the context of the knowledge of the mix and the requirements. Do you have any comments on that? Do you think those powers are appropriate or should be mitigated in some way?
Mr Labelle: In all honesty, we've been more concerned with the hospital globally than we have with individual elements such as what you're talking about, so we really haven't thought about it, but under --
Ms Lankin: That's a very important piece for hospitals.
Mr Labelle: Let me tell you that under abnormal circumstances, we all do micromanage. When I'm told that our budget's going to be cut by 6%, I begin to run, personally, housekeeping, nursing, as well as medical affairs, because it has to be done by tomorrow and I impose a lot of my will, which I would not do under normal circumstances. I'm saying that we are not under normal circumstances, and I can understand that a lot will be imposed upon us to get there quickly.
Mr Tony Clement (Brampton South): Thank you, gentlemen, for your very significant presentation. I have a few questions to flesh out some of your comments.
First of all, you acknowledge the need to restructure. You've said very forcefully that we have to get past a system where a lot of discussion occurs and a lot of input occurs but there is no way to get from the input and discussion to an actual decision which will reallocate the resources in the fairest and most efficient way.
In your mind, doesn't the decision-maker ultimately have to be the Minister of Health? Isn't it ultimately the minister who has to be responsible, as an elected official, for the system? Do you have any concerns or any apprehensions about that?
Mr Pierre Richard: At some point in time, somebody has to make the decision. We must recognize that the funding of hospitals is the taxpayers, and the source of that is from the province; therefore, the responsibility in funding for hospitals and the political responsibility lies at the ministerial, at the provincial government, level.
What we've seen here is that the hospital system has served us well, but it's all carried on through separate corporations, separate entities, what have you. What we're faced with now -- the $120-million figure was suggested a while ago. Just to stay afloat in this region, we need $120 million, so if we can save $120 million we'll stay afloat. There's no question that those savings have to be reinvested, they have to be generated to keep the health care system afloat.
When we look at these powers and when we look at this commission, we see that some of this corporate structure out there has served us very well and I suggest will continue to serve us very well, but there has to be a transitional period to put the building blocks back together and deal with plant closures and deal with reorganization.
The four-year period will allow us to do that, and allow us to do it quickly and efficiently and make decisions. There is going to be lobbying at whatever level, whether it's at the regional level or the ministerial level, but a decision has to be made, so ultimately the decision rests with the funding agency. That's why we have confidence that the restructuring commission will work fairly and in the good interests of the province.
Mr Clement: Let me turn to the issue of public consultation and its interaction with ministerial decision-making. Ms Lankin mentioned a situation that came to the fore in Sudbury. I might add parenthetically that I guess consensus is in the eye of the beholder. I don't think the minister would be saying anything about it if there was consensus in the community; in fact, we saw quite the opposite in the presentations to this committee.
The way the minister perceives this process working, and has said so on numerous occasions, is that there is an appropriate role for the providers to have their input. There is certainly an appropriate role for the district health councils to have their planning and advisory input, which has not been touched by this legislation. It's still sanctified in legislation, in the previous act, and that has not changed. But ultimately, all of that has to lead somewhere to a focal point which is a decision-making authority. Are you comfortable with that advisory, consultative process for the DHC and for the providers, ultimately leading to a decision?
Mr Labelle: I think what will happen is that as the commission is set up, as a few decisions are made affecting a certain community and as the rules of the game and as the process get known, the local communities will start to deliver much more than they have in the past. The point is that we've never known, as a local community, to what extent we could resist, to what extent we have to cooperate and to what extent we have to deliver. Once it's made clear what we have to do, it's amazing how people start to react positively to the reality.
Mr Clement: We've had in previous presentations and previous comments by my friends across the way a concern about the role of the minister and the ability of the minister to appoint supervisors in the hospital setting -- as a last resort, obviously. I might add parenthetically again that this power does exist under the existing legislation. We have removed the 30-day waiting period so the minister can act a bit more quickly if there's a paralytic situation in a particular hospital.
As administrators -- I'm asking you to speak against your own self-interest perhaps -- do you see a role for the minister in very exceptional circumstances to appoint supervisors in certain circumstances?
Mr Labelle: It's obvious that only a handful of hospitals will be affected. No Ministry of Health and no government could expect to maintain power if they were to exercise this thing in a foolish way on a weekly basis. It's just for us to know that if we don't get our act together, this can be invoked. It's just a form of motivation, as far as I see it.
Mr Clement: I want to turn to confidentiality and disclosure. As I've said at this committee on numerous occasions, the way I read the disclosure and the deemed to disclosure requirements, they are more specific, more constraining in the new legislation than they were under the old legislation. But there are some legitimate concerns out there, because it's something patients feel very strongly about. I was very impressed by the way you deal with it in your hospital to ensure that there's a balance between knowing what's going on in your hospital but at the same time ensuring that there is confidentiality.
If we were able to perhaps strengthen and clarify the confidentiality requirements, are you satisfied that the disclosure provisions are satisfactory in this bill?
Mr Labelle: We have no difficulty with it.
The Chair: Thank you, gentlemen. We appreciate your presentation this morning. Have a good day.
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CANADIAN CANCER SOCIETY ONTARIO DIVISION
The Chair: Our next group is the Canadian Cancer Society, Ontario division, represented by Dr Catherine Lochrin, vice-chair of the medical affairs committee; Alex Bruce, who's a student and a cancer survivor; and Ruth Lewkowicz, who's the vice-chair of the public issues committee. Good morning and welcome to our committee. You have a half-hour to use as you see fit. Questions, should you allow time for them, would begin with the New Democrats. The floor is yours.
Dr Catherine Lochrin: I'm a physician who specializes in cancer, primarily treating lung, breast and thyroid malignancies. I'm also vice-chair of medical affairs at the Ontario division of the Canadian Cancer Society, and in this capacity I am here today. I must say it was a privilege for me to have been asked to present to this committee on behalf of the Canadian Cancer Society. Next to me is Alex Bruce, a cancer survivor and a Canadian Cancer Society volunteer. Beside Alex is Ruth Lewkowicz, a volunteer member of our public issues committee.
Before I begin, I want to state that the views I express here today are those solely of the Canadian Cancer Society and in no way reflect the views of the Ottawa Regional Cancer Centre where I currently work.
Each of us will give a short presentation. I will put Bill 26 in context by providing information about Ontario's current cancer system. Alex will provide a patient's perspective on the proposed legislation. Ruth will speak to the specific issues in the bill which most concern the Canadian Cancer Society. We will then be happy to answer any questions that you have.
The Canadian Cancer Society is a national, community-based organization of volunteers whose mission is the eradication of cancer and the enhancement of the quality of life of people living with cancer. To this end, the Canadian Cancer Society is the single largest source of funds for cancer research.
Through offices in more than 70 communities across Ontario and through the efforts of more than 150,000 volunteers, we provide a range of services directly to cancer patients and their families. In Ontario, the Canadian Cancer Society subsidizes the government's northern health travel grant program for people who would not otherwise be able to benefit from the program. Donations to the cancer society augment the availability of provincial homemaking services.
Our volunteers transport patients to and from regional cancer centres and community hospitals, both for treatment and for follow-up visits. Lodges at the regional cancer centres were built entirely with donations from the Canadian Cancer Society and our volunteers are pleased to provide many hours of service to the residents of these lodges.
Our volunteers are also a major source of supportive care for people living with cancer. They offer people with cancer across Ontario the opportunity to speak with someone who has been there and who share ways to cope with the effects of illness.
Our cancer information service is the most complete source of factual information on cancer in this province and is fully accessible, by a toll-free number, for everyone throughout Ontario.
While the cancer society appreciates the challenges facing the government in its efforts to reduce the deficit, the Canadian Cancer Society has an obligation to make sure that the government does not put in place changes without regard for the human impact, especially on the sick and vulnerable. We strongly believe cancer patients must have timely access to a full range of high-quality care, from diagnosis to palliation, regardless of their ability to pay, no matter where in the province they live.
Our purpose here today is to bring to this committee's attention the potential impact of Bill 26 on cancer patients, particularly in light of the three features I will outline -- (1) the changing demographics of Canadian society, (2) the funding and delivery of cancer services, and (3) the advent of new technologies and treatment -- all of which are placing increasing pressures on the provision of cancer care.
First, I will address demography and cancer statistics. Who are the people living with cancer or at risk of developing cancer who will be affected by Bill 26? In 1995, an estimated 48,500 Ontarians were diagnosed with cancer and approximately half, 22,400 Ontarians, died of cancer. One in three individuals -- I look around this room -- is at risk of developing cancer in his life.
The fiscal restraint the government is seeking comes at a time when the health care system is in fact facing increasing demands for cancer services. This is because cancer is primarily a disease of an aging population, and the Canadian population is aging. In Canada as a whole between 1985 and 1995, there was a 37% increase in the number of people diagnosed with cancer; 72% of new cancer cases and 80% of cancer deaths occur among those who are least 60 years old. This is a vulnerable population.
This trend will continue with 1996 marking the 50th birthday of the first of the baby-boomers. As well as increasing demand for cancer services, older patients also have different needs that do not appear to be met under Bill 26. Ruth Lewkowicz will provide the specific details on these issues.
The second issue is the funding and delivery of cancer care. How will changes in the funding and delivery of what are currently hospital-based cancer services affect people living with cancer? Currently, Ontario spends $17 billion annually on health care. Cancer care accounts for $1 billion, which is about 6% of the total health care budget. Although the eight regional cancer centres and the Ontario Cancer Institute provide 100% of the radiation treatment in this province and 65% of the chemotherapy, overall this only accounts for 20% of the total cancer budget.
The remaining 80% of the money used to provide cancer services, that is, $800 million annually, is for surgical treatments, chemotherapy, hormonal therapy and in-hospital palliation funded by the tertiary and community hospitals. These very same hospitals have been told to absorb an 18% budget cut over the next three years, the very same hospitals that under Bill 26 could experience profound changes to both the volume and the nature of services that they currently provide.
By reducing the length of stay in hospital and by moving hospital-based cancer services like chemotherapy and palliative care into the community, the Canadian Cancer Society must be assured that patients will continue to receive these services regardless of their ability to pay. Can the government assure Ontarians that services moved into the community will have the same protection under the Canada Health Act as services currently provided in hospitals and practitioners' offices?
Bill 26 does not appear to provide such assurances. Opening the door to the possibility of a two-tier health care system in the name of deficit reduction is not acceptable to the Canadian Cancer Society, to people living with cancer or to the population at large.
The third issue I wish to address is new technology. How, in an environment with finite resources, do we determine which new technologies, techniques and drugs to cover? There are many new treatments becoming available. Most are very expensive. For example, in the area of new technology, we have techniques such as MRI scanning or PET scanning. Therapeutic treatments such as stem cell transplants are very expensive, and genetic screening, which is a huge can of worms, is around the corner.
Most new drugs are costly. Last week it was reported in the popular media that Taxol is effective in the treatment of ovarian cancer. Taxol costs $1,700 per injection, and drugs to alleviate the side-effects of treatment, like nausea, are also considerably expensive.
How do we decide what to fund? There are three important players in making such decisions: (1) the health care experts, (2) the patient, and (3) the government.
The role of the health care team is to evaluate the patient with a particular disease, to pursue the appropriate investigations and, based on this information, to recommend and explain an appropriate course of management for that particular individual.
The patient's role is to participate in the decision-making, but to do so, he must understand the nature of any proposed treatments, including the potential benefits, side-effects and alternative options of management.
The role of the government is to ensure that throughout the province patients are able to receive the same standard of care, regardless of location and, where possible, that this is the best available care for that individual.
However, amendments to the Health Insurance Act in Bill 26 appear to override the rights and responsibilities of both health care providers and patients in this treatment decision process. This is done by vesting unprecedented authority in the minister and general manager of OHIP to approve and reject insured services. It is alarming that Ministry of Health officials will be given the authority to decide whether a particular treatment was medically or therapeutically necessary. This will be decided retrospectively. Such action would completely nullify the expertise of health professionals specifically trained to make these decisions and ignore the desire of the patient to proceed with a particular course of treatment.
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The decision-making responsibilities of health care providers and patients are also undermined by the fact that a large number of fundamental components of the health care system have been left to be prescribed in regulation. One of the most disturbing instances is determining what specifically constitutes an insured medical service. In this regard, the Health Insurance Act states that services will be covered by OHIP if they are "prescribed services of hospitals and health facilities," "prescribed medically necessary services rendered by physicians," and "prescribed health care services rendered by prescribed practitioners," all subject to, I underline, "conditions and limitations as may be prescribed."
What are these conditions and limitations? Bill 26 provides only two: first, that services be performed in a designated facility; second, that insured services could be restricted based on a person's age. Is the age limitation an indication of the approach the government is going to take as it drafts regulations? What other arbitrary and discriminatory criteria is the government considering? And why is it that only the government is allowed a role in determining what services Ontarians will have access to?
The definition of an insured medical service will have an enormous impact on the treatment options available both to health care providers and patients, but under Bill 26 they will have no role in defining it.
In conclusion, it is apparent that Ontario's health care system is going to be fundamentally altered, and indeed this needs to happen. But the Cancer Society cannot support Bill 26 as currently drafted as the vehicle to bring about this change. The Canadian Cancer Society believes that Bill 26 exacerbates existing demographic and economic problems and in its current form senselessly creates additional problems that will lead to the unnecessary erosion of our health care system.
I challenge any member of this committee to spend a day with me, not as an MPP or as a dignitary but as a tacit observer, and to witness first hand the difficulties, decisions and obstacles that cancer patients in this province experience on a day-to-day basis in their daily lives.
I will now ask Alex Bruce to provide his personal experience and views about what needs to be protected in our health care system, and Ruth Lewkowicz will subsequently outline the changes the Canadian Cancer Society is requesting today.
Thank you for your time and attention.
Mr Alex Bruce: I am a third-year engineering student at Queen's University, I am a Canadian Cancer Society volunteer, and I am also a cancer survivor.
I would like to start by telling you how I started working with other people living with cancer. When I was a cancer patient I had a lot of questions myself, and I wanted to talk to someone about my experience with cancer. Social workers and doctors were always available, but because I had no specific problem, it seemed like a waste of their time to talk to me. Very little time is spent in hospital care, and patients tend to get lonely despite the best intentions of family and friends. So I began looking on the Internet for information, and I discovered, among other things, that the oncologist who pioneered my treatment is from Italy. I was able to get the information about my particular treatment from a database at the National Institutes of Health. Not only did I find a lot of information, I also found quite a few other people with similar stories.
Subsequently, I have become a volunteer with the Canadian Cancer Society. As a CanSurmount volunteer, I can share my experience of having "been there" and offer people peer support from the perspective of a cancer survivor. I also help people find information on the Internet about their particular condition.
As a recent cancer patient and as a volunteer with the Canadian Cancer Society, I have concerns with the proposed legislation outlined in Bill 26. In retrospect, given what I know about the health care system, and cancer treatment in particular, I believe I received the best care and the best medical advice available anywhere. However, I feel, based on my experience, that Bill 26 will undermine the kind of excellent care and medical advice that makes our health care system the envy of many.
My particular cancer story begins in May 1994, just a little over a year and a half ago, when I went to my family doctor with a bad cough. It had lasted for about two weeks. Before going to see him I had lost a lot of weight and energy, but with school exams I figured everyone was run-down. My family doctor gave me some antibiotics and told me to rest. Soon it became obvious there was something abnormal, and he ordered a chest X-ray, which showed the first signs of disease. I was quickly referred to a specialist and then to a surgeon, who performed two biopsies on me. I spent one night in hospital for the biopsies.
By the end of June, when I met the first oncologist, I had been diagnosed with full-blown Hodgkin's disease. From the time I first went to my family doctor until I met the oncologist who treated me, about six weeks passed. Apparently this is a normal amount of time for a diagnosis, but it seemed like an eternity to me.
My oncologist, in consultation with other specialists at the Toronto-Bayview Regional Cancer Centre, decided on an unusual hybrid of a standard treatment. At first there was a question of whether they would be able to offer me the treatment they wanted to, because one of the drugs was difficult to obtain. Eventually they were able to get the drug.
Once I began my treatment the question of cost started to arise -- and this was my first introduction to behind the scenes, so to speak -- but luckily, at no time was I ever responsible for the full cost of my treatment. I come from a middle-class family. I have a brother and a sister, who's also in university, and both my parents work. They're not rich. My mom, who does work for a large bank, has supplementary drug coverage. Unfortunately, we found out how limited that coverage can be, and we were never able to make use of it.
At first, I was only expected to pay for some standard side-effect drugs for nausea, and some of the basic treatment drugs. These are expensive but, relative to the entire treatment, they're fairly cheap. I also had to take another drug, Neupogen, which was covered by the Ontario drug benefit program. A week's treatment of Neupogen costs about $1,500; obviously, as a student, I can't afford this. While I was with the Scarborough clinic, which is where I was initially treated, I was covered on a monthly basis by the Ontario drug benefit program, but the Scarborough clinic had to continually justify my eligibility. Admittedly, I could have paid more of the costs of my drugs, but realistically it would have been at the expense of my university education.
My family and I were fortunate. I strongly believe the government must reconsider those elements in Bill 26 that shift the burden of drug costs to patients, whether through user fees or the deregulation of drug prices. I should point out that drugs like the Neupogen kept me out of the hospital and healthy enough to go to school, and during seven and a half months of treatment, I only spent one night in hospital, and that was for the biopsies at the very beginning.
So I ask, why can't the government continue to fund these kinds of drugs, which are obviously less expensive than having patients hospitalized?
As I've already told the committee, the care I received as a cancer patient was excellent. In fact, most of the health care providers I came in contact with often pointed out the costs to me for X-rays and blood tests, not to worry me but to make me aware of the entire decision they had to make.
My symptoms and the seriousness of side-effects were always weighed off against medically based factors. The amendments to the Health Insurance Act in Bill 26 redefining what is medically necessary are unnecessary and potentially dangerous, given that the people best equipped to decide, the medical experts, already make those decisions. For the government to restrict what is medically necessary discredits the experience and the judgement of our health care professionals.
As a patient, I enjoyed flexibility with both my treatment schedule and my treatment location. I had access to expertise from more than one oncologist and specialists at two different clinics. Because I'm a university student, this kind of flexibility is very important. For this reason I have concerns about the provisions in Bill 26 which allow Ministry of Health officials to determine where and by whom particular services are performed.
These same provisions are also troublesome from another perspective. While I trust and respect all my doctors, if I ever felt uncomfortable I would not want my right to find a new doctor, or for that matter a different treatment, limited by staff at the Ministry of Health.
Dr Lochrin has stated that cancer is primarily a disease of older people, and obviously I'm an exception. As someone who will likely live a long time after his experience with cancer, I find the provisions under Bill 26 that give the Minister of Health the power to review and share my medical history alarming. I am concerned that people would have access to my medical records and decisions might be made on my behalf without consultation. In short, I'm afraid of discrimination based on the fact that when I was 20 years old I was diagnosed with cancer.
Before I finish, I want to make the point that, as a patient, being well informed provided me with a lot of good healing power. Being empowered with information and with the ability to choose where I am treated, I felt I had responsibility for my own wellbeing, and I believe that contributed to the overall success of my treatment. I do not feel that I was simply at the whim of a monstrous, bureaucratic health system.
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Information, whether it's about the disease, treatment, side effects or nutrition, is critical to a person's treatment. The health care system needs to formalize the role that information sources and volunteer services like the Canadian Cancer Society play. Their largest resource -- people -- remains largely unrecognized.
As a cancer patient who was "cured" by our health care system, I know first hand the value of what is at stake as the system is restructured. Many of the components in Bill 26 jeopardize this care. The government should reconsider many of its decisions in regard to Bill 26 so that cancer patients, and all patients for that matter, continue to receive the same excellent care that I received.
Thank you very much for your attention.
Ms Ruth Lewkowicz: Good morning, Mr Chairman and members of the committee. I would like to preface my remarks about Bill 26 with a more general reference to the potential contribution of volunteer organizations to the overall efforts of this government.
In taking action to control the deficit, the government has on many occasions suggested that the volunteer sector can and should be utilized to fill the gaps left by its withdrawal from public services. This is misleading and unacceptable, especially in the area of health care.
The Canadian Cancer Society will continue our fund-raising efforts to provide $40 million worth of cancer research and patient services each year, but the Canadian Cancer Society cannot and will not be a substitute provider of medically necessary services.
The government must keep its commitment to maintaining our publicly funded health care system. However, in the unfortunate event that it does not fulfil this responsibility, the Canadian Cancer Society insists, and the public deserves, that the government be prepared to account for its decisions.
The health provisions of Bill 26 are numerous and complex. Like Alex, I will focus on those issues that directly affect the quality of care for people living with cancer and people at risk of developing cancer.
Amendments to the Public Hospitals Act, the Ministry of Health Act and the Private Hospitals Act give the minister exclusive power to fund, close and merge hospitals and to decide the type and volume of services that hospitals will provide. These amendments are excessive and give rise to problems in both the process and substance of hospital restructuring.
In terms of process, hospitals are public institutions, accountable through their volunteer boards of directors. Given this government's position on the importance of volunteers, it's difficult to understand why it's prepared to exclude volunteers from the important process of hospital restructuring. These provisions imply that hospital boards are not capable of responsible management or that they care little about the financial viability of their institutions.
Second, it removes indispensable local knowledge and expertise from the reform process. The creation of the Health Services Restructuring Commission poses similar problems by usurping the role of district health councils.
The government's restructuring model must include a formalized role for local participation to ensure that local patient needs are appropriately met within the network of existing and planned community services.
Bill 26 gives the government the authority to move quickly to rationalize hospital services, but this does not adequately address the corresponding need for care in the community. Such services must be in place before rationalization occurs. We already know that existing community services are inadequate. The requests for help that come to the Canadian Cancer Society tell us that the demand for us to top up the government's homemaking services will only increase.
We are especially concerned about hospital restructuring occurring in the absence of the support required for long-term care reform. As Dr Lochrin stated, cancer is a disease primarily of older people. To assume that seniors have relatives to rely on is faulty. To assume that community care is provided by friends and families is totally unrealistic. Both assumptions are out of date, both deny the current way of life in urban centres, and in rural centres for that matter. For government action to be progressive, it should be based on the realities of today as well as future expectations.
The Chair: May I interrupt you for just a minute? I just want to let you know you've got about six minutes left, just to make you aware of that. Whether you want to leave any time for questions or finish is your choice.
Ms Lewkowicz: I'll just make a few more points.
The Canadian Cancer Society has serious concerns about using the Independent Health Facilities Act as amended to build up community services. Because the amendments allow private, for-profit ownership, and because the minister and the general manager of OHIP would have the power under the act to list and delist medically necessary services, we are very concerned that the Independent Health Facilities Act will serve as a way to get around the Canada Health Act.
The result will surely be the creation of a two-tiered health care system in Ontario. The amendments to the Health Care Accessibility Act allowing the cabinet to set user fees for services currently covered by OHIP underscore this concern. Such changes are simply not acceptable.
Let's look at this in the context of providing chemotherapy because of its importance to so many cancer patients. Right now, chemotherapy provided in a hospital or regional cancer centre is covered through the institution's global budget. Because chemotherapy is essentially a drug, it's not an insured OHIP service. In many cases, chemotherapy is an outpatient treatment that can be provided in community facilities. Nowhere in the Independent Health Facilities Act does it explicitly guarantee that chemotherapy would continue to be covered by the public health care system outside of the hospital.
Even if the chemotherapy itself is covered, the fact that drugs are not insured services could allow for patients to be charged the cost of administering the treatment. Indeed, the wording of the act as it now stands appears to permit operators of these independent health facilities to charge patients a facility fee. Given the importance of pharmacological treatments, not only for cancer patients but really for all disease groups, the government must move immediately to address the problem.
First of all, the government must assure that the costs of drugs, as well as the costs associated with administering drugs in community facilities, are provided through the public health care system. Second, the government must guarantee that these services, regardless of whether they are listed on the OHIP schedule of benefits, are afforded the same protection under the Canada Health Act as insured services.
The Canadian Cancer Society is also very concerned about the imposition of a $2 fee for prescriptions for individuals with incomes under $16,000. We know that 20% of people over the age of 65 live at or below Statistics Canada's low-income level. When you have a diagnosis of cancer, it's unexpected, it produces dramatic change and limits the ability to shift resources. This is especially true for low-income seniors on a fixed income who are already spending at least 55% of their income on basic necessities. We strongly suggest that the government look at flexibility for paying the annual $100 fee by first of all considering increasing the income level requiring this payment or by spreading it out over the course of a year.
The government has a responsibility to communicate these changes to seniors well in advance so they can plan adequately. As well, the government has to evaluate the impact of these user fees to ensure that ODB recipients are not going without necessary treatment.
For cancer patients not covered by the drug benefit program, the Canadian Cancer Society is very concerned about the government's decision to deregulate the price of drugs. Cancer drugs are already in many cases prohibitively expensive. The premise that deregulation will lead to increased competition and a reduction in drug prices is a fallacy. Purchasing drugs is not like buying a new car or a new refrigerator, where you can shop around to find the best deal. The government is assuming that sick people have the time and the energy to shop around and therefore will drive down the prices of drugs. But what if the government is wrong? When you're dealing with health care, the stakes are very high and the cost of failure is horrific. We're asking that the government seriously consider dropping the amendments deregulating the pricing of prescription drugs.
Finally, I'd like to talk about the Health Insurance Act and the Health Care Accessibility Act and the unprecedented power given to the minister to view and disclose confidential medical records. These provisions seriously compromise the confidentiality of the practitioner-patient relationship. It could have a negative impact on the practitioner's ability to obtain accurate information from the patient, information that could be crucial in providing appropriate medical care.
The Ministry of Health already has the ability and the authority to review medical records, so with whom exactly does the government want to share confidential information? Is the government planning on privatizing OHIP payments? Is it the first step towards introducing a smart card?
The thought that employers or insurers could potentially have access to health information not authorized by the patient is extremely unsettling. Bill 26 does not offer appropriate safeguards to protect individual privacy.
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Bill 26 also does nothing to address the fact that the public at large has never had a meaningful role in decisions affecting the publicly financed health care system. How would the government propose to continuously gain the views of the public, and how would such views be factored into the policy decisions regarding what treatment is available and under what circumstances it will be administered?
We believe that Bill 26 in its current form is inadequate and unsuitable to deal with the problems confronting our health system. The process and the substance of change that it imposes on patients, providers and the health care system as a whole are far removed from the values held by the Canadian Cancer Society, by people living with cancer and indeed most Ontarians with regard to what we consider our most important social program.
We ask that the government take time and carefully consider all of the submissions to the committee. This is an opportunity for the government to restore respect for the democratic process by amending Bill 26 to include the input of the people that you were elected to serve.
The Chair: Thank you very much for your presentation. We appreciate your interest in the process. Unfortunately, there's no time left for questions.
Mr Robert Chiarelli (Ottawa West): Could I ask for unanimous consent to extend the morning sittings for eight or 10 minutes to enable some questioning of this delegation?
The Chair: Mr Chiarelli, we have been in this process now for about 150 presenters and we have stuck very firmly to the half-hour time line. I think it's fair to all participants that we continue in that process.
COMMUNITY HEALTH CENTRES: OTTAWA AND EASTERN ONTARIO
The Chair: Next is the Sandy Hill Community Health Centre. Good morning and welcome. You have a half-hour to use as you see fit. Should you allow time for questions, they would begin with the New Democrats. The floor is yours. Introduce yourselves so that Hansard can record it, please.
Ms Lois Crowe: My name is Lois Crowe and I'm the president of the Sandy Hill Community Health Centre. On my left is Paul Richard. He's from the Centretown Community Health Centre, and on his left is Cynthia Callard, who is with the Somerset West Community Health Centre. We're all board members. Also with us is Dennise Albrecht, who is the executive director of the Sandy Hill Community Health Centre.
We want to thank you for allowing us to present today. We're going to try and make our presentations brief so that we can get into some dialogue and some questions.
One of the things that community health centres are here for and one of the things that we do is we promote and we are committed to working in partnership with our communities, with our neighbourhoods, with our clients, with the ministry, with everyone. It's a team approach, it's a holistic approach to health.
We offer services, and not just direct health care services. We do have doctors and nurses, but also, depending on the centre, we have social workers, we have seniors' programs, we have community developers, health promoters, and that's part of the approach. It's a team approach to health care.
When we were looking at the presentation today, one of the things that we looked at is, when the Progressive Conservative government came out with documents, we weren't too concerned at first, because the words -- if I can just quote first from Jim Wilson, who is obviously the current Minister of Health. This was on May 31, 1995, and he said: "Health care is much more than a line item that eats up space and vast resources in a budget. The trademarks that have built and sustained our system -- compassion, caring and excellence -- are the same qualities that distinguish us as Canadians."
In the Mike Harris Forum on Bringing Common Sense to Health Care on December 2, 1994, the stated goals in health care of the soon-to-be government were its management and accountability, a health care bill of rights, individual responsibility and fostering community involvement.
Obviously, those are things, as far as community health centres are concerned, that we support 100% fundamentally, and that's where we're coming from as well. However, when you get down to the legislation that's been produced, we don't see those concerns reflected in the bill and that's what we want to speak about. We're going to focus on the health care portion, because that's obviously our area of expertise, and we're going to highlight a little bit.
The main areas of concern are the extensive powers given to the Ministry of Health and the government; defining the Health Services Restructuring Commission; the possible erosion of our non-profit health sector; decreased accessibility to health services; disclosure of personal information; and higher drug costs. These are the highlights of our concerns.
I want to start off with something simple, which is the Health Services Restructuring Commission. Bill 26 does not define the composition, the role or the responsibilities of this commission. The amendments allow specific members of the commission to act without the direction or the authority of the whole Health Services Restructuring Commission, and the government is insulated from legal liabilities arising from hospital restructuring. These are pretty serious concerns.
We have a number of recommendations and they are listed in our document, but we wanted to really talk about what our concerns are.
The next piece that I want to talk about is one of my own personal concerns: the extensive powers given to the Minister of Health and the government. In various documents, again, the government has said that it believes in individual control, individual participation, consumers' right to control their own health, and yet this bill actually does the opposite. It centralizes power. It doesn't put the power in our hands. It doesn't put the power in the hands of our consumers, our clients, the people we work with.
We represent, just at this table, the nine community health centres that put this presentation together. We have over 60,000 clients, just ourselves, in eastern Ontario, and there are more. We work with all the communities in eastern Ontario, and our whole goal and our whole purpose is to do exactly what the government has said in terms of working with individuals' rights to control their own health care. That's what we do; that's what we want. This bill doesn't allow that to happen. It centralizes the power. There aren't any checks and balances, and that is one of our main areas of concern.
I'm going to pass it over to Paul to continue.
Mr Paul Richard: Thank you, Lois. I will speak to the following two points: erosion of our non-profit health sector and decreased accessibility to health care services.
En termes d'érosion au secteur d'organismes à but non lucratif de santé, je voudrais commenter sur les effets possibles du processus d'appel de proposition pour les services indépendants de la santé tel que présenté dans le projet de loi.
On peut concevoir que de tels pouvoirs excessifs obtenus à travers ce projet de loi pourraient ronger au système de santé que l'on connaît aujourd'hui. Bien que l'approvisionnement de services de qualité ne soit pas une caractéristique exclusive aux organismes canadiens, ces derniers possèdent une orientation conforme aux valeurs canadiennes, tout en reflétant les principes de l'assurance-maladie de la Loi canadienne sur la santé, soit de l'anglais, medicare. On ignore l'impact de l'ouverture du secteur ontarien de la santé aux compagnies étrangères.
En plus de voir une perte possible d'emplois des mains des ontariens et des ontariennes, le résultat de cette ouverture peut aussi dépendre de la manière de laquelle les licences sont accordées aux organismes indépendants de la santé. Nous soutenons donc qu'un processus équitable en ce qui concerne l'allocation de licences à des organismes indépendants de la santé soit développé. De plus, nous recommandons que vous consultiez notre association provinciale, l'Association des centres de santé de l'Ontario, sur les ramifications potentielles qui découleraient d'une réallocation de ressources en provenance de la restructuration des hôpitaux.
La santé se compare mal à d'autres produits de commerce. Les mesures proposées dans de projet de loi auront des retombées d'envergure immense. Nous proposons donc de la prudence. Peut-être qu'il y aurait moyen de procéder par incrément dans l'allocation de licences en tenant compte de la diversité de la population ontarienne.
Un exemple d'un processus qui tient compte de la diversité de la population ontarienne serait l'aspect d'accessibilité en tant que déterminant de santé, ce qui m'emmène au deuxième sujet dont je voulais traiter : la réduction d'accessibilité aux services de la santé.
On soutient que le défi que présente l'accès est d'identifier tous les types possibles de barrières aux services et programmes de santé -- tels que l'espace, la langue, la culture, l'âge, l'orientation sexuelle, le statut socio-économique, un handicap -- et ainsi oeuvrer à éliminer ces barrières. Donc, l'exclusion de certains services de santé de l'assurance-maladie, le recours aux frais modérateurs en plus de la création continue de cliniques à but lucratif contribuent à la création d'un système de santé à plusieurs niveaux.
Grâce à notre rôle dans la communauté, nous connaissons l'effet dissuasif que de tels frais peuvent avoir lorsqu'un client ne possède pas les moyens financiers pour accéder à un service. Remettre un traitement peut mener à la nécessité d'une intervention plus coûteuse plus tard. Doit-on rappeler que l'introduction de frais modérateurs ne modifie pas l'abus du système ?
Voyons à sauvegarder et renforcer les cinq principes d'assurance-maladie sur lesquels repose notre système de santé : l'universalité, l'accessibilité, la transférabilité d'une province ou d'un territoire à l'autre, l'intégralité, et l'administration publique sans but lucratif. Sur ce point, je voudrais laisser la parole à Cynthia.
Ms Cynthia Callard: I want to comment on two aspects of this bill which are of significant concern to those who provide health services and to those who are in need of medical care.
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The first is the serious erosion this bill represents into the privileged and confidential relationship between doctor and patient. Under this law, for the first time, government employees will be able to remove confidential health care records from offices to photocopy them and use them as they wish. Ontario citizens were never asked, nor did we ever agree, to give the government the right to view and use information from our personal files, yet this bill assumes that power.
Our concerns are not only for the breach of privacy and the erosion of established civil liberties. This bill has serious implications for health. How can a doctor ask for or a patient divulge information in response to sensitive questions regarding illegal drug use or sexual orientation or sexual practice or even mental health when they know that the answers to those questions won't be safeguarded, when they know that this law permits the minister to make this information public, when they know that this law permits the information to be shared with any party the government contracts with, when they don't know if this information is going to become the source of gossip and anecdotes in government offices?
That's why we recommend that this committee delete those sections of the bill which erode any privacy.
There are alternatives available to the government. If they suspect fraud, there are policing provisions with established safeguards and established rules. If they suspect bad administrative practice, the Auditor General's office, which reports to the Legislature, not the government, is capable of investigating and reporting. If they suspect that medically unnecessary treatments are being prescribed, the licensing body for doctors has a mechanism that they can use to inspect. The government can always lay a complaint.
The second issue I wish to raise is that concerning the impact on drug prices. We have every reason to believe that the changes to the Ontario Drug Benefit Act will have a severe impact on people with low incomes, like seniors and welfare recipients, but also, deregulating drug prices will push those prices up. Prescription drugs are already unaffordable to many people; the changes will only worsen this.
Under this bill, the government, not the doctor, will be able to choose which drugs can be used for specific treatments under the Ontario drug benefit plan. If a doctor prescribes a different drug, ODB users will have to pay the difference, and there is a difference. Sometimes generics function differently in the body; there's a medical difference, a physiological difference. Sometimes they function differently on how patients follow a course of treatment.
I'll give you an example. Doxycycline, an antiobiotic, must be taken only twice a day. The generic equivalent, tetracycline, is taken four times a day. For a patient with a memory disorder, or for a caregiver of a patient with a memory disorder, this is a significant difference and it can impact on their health treatment. That's why we recommend that this committee retract the drug user fees provisions for members who are low-income seniors or welfare recipients, and we also recommend that this committee recommend that the provincial government maintain its role and responsibility in regulating drug prices.
Ms Crowe: In conclusion, talking about the areas of concern we talked about earlier, I want to highlight some of the recommendations for the committee.
First of all, I want to say again that we are representing nine community health centres, so there's a broad representation and broad input into this report. The three of us at the table were volunteer board members. Obviously, volunteer participation in health care is really important to us. It's something we believe in fundamentally. We want to make sure that in considering changes to this legislation, checks and balances are in place regarding the powers of the government.
We want to make sure that the composition, role and responsibilities of health services restructuring committees and commissions are defined and that accountability is assured.
We want to make sure that the Canadian-owned non-profit health sector is preserved.
We want to build strong partnerships with governments; we're here to work with the government. We do believe that health care reform is necessary. How we do that is where we can discuss things, but we're absolutely in favour of reforming the health care system.
We want to build strong partnerships between governments and local district health councils. They're in place and they're working. Health planning is certainly an area where the government can consult and use the district health councils.
Absolutely and fundamentally, one of the things we believe in is that there be no user fees at any part of the system.
The final point is around the erosion of privacy and confidentiality of personal health information. This is one of the fundamental beliefs of community health centres and around community health planners.
The Chair: We've got about four minutes per party left for questions, beginning with Ms Lankin.
Ms Lankin: When you say that you fundamentally believe in health care reform and restructuring, we know that to be true. The driving force for reallocation of resources from institution to community, from illness treatment to illness prevention and health promotion, has been led by many people in the reform movement but certainly community health centres have been in the forefront of that. I don't think anyone would at all question your commitment to that. In fact, I think you've played a role over the years in trying to get the hospitals to the point where they seem to be at now in acknowledging that the restructuring needs to take place and resources need to move from institution to community.
I am interested in you recommendations around definition of the restructuring commission and linkages to the local health planning process being led by DHCs and others at the community level. We had a representative present this morning from one of the hospitals, from the General, who said: "That community process really isn't working here in Ottawa. Consultation has gone on, but I'm not convinced it's really representatives of the public who've come forward, and we haven't reached a consensus." I think that was the bottom line. He was very supportive of the powers as they are in the bill, without spelling out any linkages to the local process.
I asked him: "If you want the minister then to settle this, because Ottawa can't get its act together and can't get to a consensus," which seemed to be what he was implying, "who is it the minister should listen to? What is it he should decide to impose on the community?" He said, "Well, us." That would be the view of the teaching, high-tech hospital in this area, which has a very important role to play overall, but one part. Do you have any comments on why you think this community consultation process needs to be built into the legislation, reflecting on what you've experienced in Ottawa?
Ms Dennise Albrecht: As the executive director of Sandy Hill and someone who has been involved in the restructuring here in Ottawa-Carleton, I would like to respond. The process of Ottawa-Carleton has really been based on its history. It's one of the areas in Ontario that has a very strong, community-based network of organizations that work together, including the hospitals. The process the district health council has used and has fought for is a very open consultation process, so we don't only hear from key stakeholders who may have a lot to gain or to lose in the process -- hospital executives, perhaps even board members from community health centres -- but an opportunity to hear from the consumers who benefit or lose from these different changes.
Part of the problem that Ottawa-Carleton has had is that the government has made three significant changes between September and December in its directions to this district health council. That has given an image of a great deal of confusion. In fact, the district health council and the volunteers who staff it and act on all of its committees, who number about 300, as well as the council, have rallied each time: when the time frame was reduced from nine months to three to get consultation to come up with a recommendation; when we fought for having an open consultation process rather than a closed-door, blue-ribbon panel who would just make the decision and impose it; and then in mid-December when finally the time deadline was extended and more money was provided. All those things have caused us to go back and change the work plan of the consultants and all the volunteers.
In a four-day period, we had 30,000 responses to the initial scenarios the council put forward, just on, "Are these the scenarios we should get more information about to cost?" I think that represents the kind of breadth that Ottawa-Carleton is known for, to get the voice of the people from a very diverse range.
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Mrs Janet Ecker (Durham West): Thank you very much for taking the time to come today and put forward some excellent suggestions. I have a question, but just quickly, there are some points I believe I can ease your mind on to a certain extent.
The first one is that it's not the government's intention to be forcing CHCs to become independent health facilities. The second point is that the whole restructuring process in this province has been and must continue to be based on the volunteer efforts of those involved on hospital boards and district health councils, because we think that is very important. Certainly, we are not planning on changing that.
The other point is that we are abiding by, and will be abiding by, the Canada Health Act. It is not our intent to get into a pointless and non-productive fight with the federal government over the Canada Health Act.
The other point is that there are now in the independent licensed health facilities, for-profit facilities. They are already there. The important thing about the Independent Health Facilities Act, which many individuals may not be aware of, is that the entire intent of that legislation is about quality, ensuring that regardless of who owns those facilities, regardless of what services they're providing, regardless of where they are, there is quality assurance being done in that facility by the health care team -- physicians, nurses and other professionals. That is the process that act brings in.
One of the problems is that in facilities not licensed under that act in Ontario, that are providing services now, there have actually been deaths. One of the things we want to do with this legislation is to make sure that those quality provisions can be extended to many other facilities.
Another point is that the confidentiality of patient records is a fundamental principle in the system. It was before this legislation, and it will continue to be after this legislation. There will not be patient records being strewn all over the streets, as some people would have you believe, with this legislation.
One of the things we have to deal with is the fact that there is misuse in the system. Seventy per cent of physicians told Maclean's magazine last year that they believe some of their colleagues were unnecessarily using the system and bringing people in, and that they shouldn't be. We also know, for example, if you look at OHIP information, that in one month alone 7,000 patients went to see more than five physicians in one month -- general physicians; we're not talking specialists here, people with special health needs. We're saying 7,000 individuals went to see five family doctors within one month. Physicians call that double-doctoring, and they tell us that's a problem.
The only way we're going to be able to get at that is to share information within the system, which is what's happening now for fraud and misuse. You mentioned the College of Physicians and Surgeons and the other regulatory bodies. The CPSO and the MRC looks at fraud and misuse by practitioners. They're telling us that system doesn't work and needs to be changed, because it's taking years and is not being able to get back the money that's been misused by some providers so we can make sure it gets to front-line health care, where it should be.
Would you feel more comfortable if the fraud and misuse provisions, if the college's MRC process, for example, were to be streamlined, were to be made more effective, so that it's the physicians and the public appointees within that process who are making those decisions? Would that make you feel more comfortable with the government trying to deal with misuse by either consumers and/or practitioners?
Ms Collard: I think there is a genuine need and desire of Ontarians to ensure that the health care system is sustainable because it's not misused. That's almost part of the rule of law. We have that in a variety of issues outside of health care as well: We want to make sure our income tax self-reporting system is maintained; we want to make sure crimes are prosecuted. But when the government has set up in the past ways of ensuring that income tax fraud is detected, they limit the powers of the Income Tax Act. For example, any material gained under an income tax investigation cannot be used in a criminal prosecution.
Those types of safeguards are not in this act. Those types of safeguards could be put into it. When they have extensive police powers, they put in a citizens' board which supervises the police, or with CSIS, they have a special review committee. The government is not giving that kind of safeguard, that we see in this bill, anyway. That is something you could add on to it.
Mr Bernard Grandmaître (Ottawa East): It seems that some members of the government have more information than the opposition, from comments from certain members of this committee. It seems there should be more consultation, because we need to know more, especially about the freedom of information.
Ma question s'adresse surtout à l'accessibilité des services. Vous avez mentionné tantôt vos inquiétudes concernant l'accessibilité de certains services offerts par les centres de santé communautaires. Alors, pourriez-vous m'expliquer d'avantage ou amplifier d'avantage sur vos inquiétudes concernant les services livrés, surtout en français, ou la prestation des services de vos centres communautaires ?
M. Richard : Le point principal, comme vous l'avez mentionné, c'est l'introduction de frais modérateurs pour accéder à un service. C'est donc sur ce point-là qu'on voulait mettre un peu plus d'emphase, parce que ça peut devenir un déterrent. Si quelqu'un veut accéder à un service et ne peut pas se permettre de défrayer les deux dollars ou quelque chose, il va se passer du service. Donc, c'est tout enchaîné avec le fait que s'il n'a pas son traitement ou qu'il n'est pas vu tout de suite, ça peut amener des coûts supplémentaires dans le futur. Donc, c'est sur ce point-là en particulier qu'on veut l'amener, pour l'accessibilité.
M. Grandmaître : Vous adressez surtout les frais d'utilisateur. Vous êtres absolument contre les frais d'utilisateur pour certains des services que vous offrez. Par contre, si on parle de Sandy Hill, le centre que je connais assez bien, comment est-ce que ce centre sera directement affecté avec les modifications ou les changements apportés par la loi 26 ?
Ms Crowe: You're asking how this bill is going to affect Sandy Hill?
Mr Grandmaître: Yes, directly.
Ms Crowe: One of the things Sandy Hill Community Health Centre does is service a lot of the hard-to-serve population. We're in the centre of town and deal with a lot of homeless people, a lot of people with different kinds of problems in terms of accessing health services. In fact, one of the reasons we set up our walk-in clinics is to deal with people who would never have access to a doctor otherwise, because they wouldn't feel comfortable. We have outreach workers who go and work with this population as well.
One effect of some of the changes we're already seeing is increased demand. We cannot take on any more health services clients; we're at our maximum. The provisions in this bill and provisions in some of the other legislation -- we're seeing an increase in the demands on the high end, the more intensive-need end of services. It's having a tremendous effect. Maybe Dennise can add to that.
Ms Albrecht: What Sandy Hill and the other community health centres are more interested in is the improving of the health status of the populations we serve, as opposed to just provision of service. Having that emphasis means we look at very broad issues: determinants of health, things that make people unwell. This bill taps on to a lot of those things. By taking away opportunities for people to be increasingly involved in decisions, not only in health care but all across their community -- which is a very basic democratic right, a factor that really builds strong and vibrant and healthy communities -- that impacts on us as well as some of the more direct service issues.
We talked about a qualitative care system that we have in Ontario, and we do. Many of us believe that is primarily because the base of that is Canadian-owned and non-profit. There is a very strong role for for-profit organizations but within a non-profit overall sector. For us, the erosion of that would affect the health status of the community.
The Chair: Thank you very much, folks. We appreciate your presentation and your interest in our process. Have a good day.
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Ms Lankin: Mr Chair, may I place a motion before the committee, please. My motion reads as follows:
Whereas there has been overwhelming public interest in Bill 26 and that 59 groups and individuals have requested to appear today here before the standing committee on general government in Ottawa, which far exceeds the 15 spaces available today for hearings;
I move that the committee recommends to the government House leader that when the House returns on January 29, 1996, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged for the community of Ottawa.
Further, that this committee recommends that the three House leaders meet as soon as possible to discuss this issue.
The Chair: Thank you, Ms Lankin. As we have done in other communities where a similar motion has been presented, I've asked for unanimous consent to discuss it at lunchtime rather than to impact on presenters who are here and have it impact on their time. Do I have unanimous consent for that?
Mrs McLeod: Mr Chairman, if I may just make a comment on that. We have agreed to that since I think we all recognize the importance of bringing forward this resolution every day with the government's resistance to voting on it. Unfortunately, when we do debate this at noon and vote on it at noon, it doesn't give people who are present the opportunity to see the very clear indication that the government is determined to pass this bill. Nevertheless, I recognize that in the interest of having the presenters make their presentations, we should follow the same format again.
But I do think it's important for those who are here to understand that --
The Chair: Are we or are we not going to defer this till lunchtime?
Mrs McLeod: I'm prepared to lend unanimous consent, but Mr Chairman, I want to add another point of information which is new to this committee, and that's the fact that when people see the number of opposition members at the table, they might wonder why we can't be successful in passing a resolution we support.
The Chair: Okay.
Mrs McLeod: It's because, as you know, only one member of the Liberal caucus present at the table actually has a voting right.
The Chair: Good point. Do we have unanimous consent to defer it till lunchtime? Agreed.
ROYAL OTTAWA HEALTH CARE GROUP
The Chair: Our next presenter is the Royal Ottawa Health Care Group, represented by Dr John Atkinson, the vice-chair, Mr Kevin Lamarque, the trustee, and Mr George Langill, executive director. I obviously missed one. Could I ask you all to identify yourselves for Hansard? Welcome to our committee. You have a half-hour. Questions, should you leave time for them, would begin with the government.
Dr John Atkinson: Thank you very much, Mr Chairman. I'm Dr John Atkinson, vice-chair of the Royal Ottawa Health Care Group. On my left is Mr George Langill, who is the president and CEO of the health care group. On my immediate right is Rick Bertrand, our chair, whom we never know quite where he's going to be at any point in time, but he's happily with us today, and finally on my far right is Kevin Lamarque, who is a member of our board.
We welcome the opportunity to meet with this panel today. We have a brief presentation and hopefully we'll leave time for questions because we're interested in that. I will start with an opening introduction as to the roles and activities of the Royal Ottawa Health Care Group. Mr Langill will speak to some specific recommendations and we have a small wrapup.
As representatives of the Royal Ottawa Health Care Group, we are pleased to appear before the general government committee as you undertake hearings on Bill 26, the Savings and Restructuring Act. We believe that Bill 26 has enormous implications for the health care system in Ontario and we are before you today to give our support to the recommendations put forward by the Ontario Hospital Association, support which I believe is generally accepted by the other health facilities in Ottawa.
We are also here speaking to you today not only as hospital representatives but more importantly as representatives and advocates for two very special population groups within the Ottawa-Carleton region: those with mental health illness problems and people with physical disabilities.
The Royal Ottawa Health Care Group operates two hospitals at different sites: the Royal Ottawa Hospital which offers health care services in mental health at its site on Carling Avenue, and the Rehabilitation Centre which provides specialized services in physical medicine and rehabilitation. Each is the major institution of its kind in eastern Ontario, providing comprehensive health care to individuals with physical disabilities and mental illnesses. Both are fully accredited teaching hospitals that provide bilingual services to the residents of the national capital region and beyond.
Through our main divisions and their satellite operations, the Royal Ottawa Health Care Group's services aim to help clients reach their highest level of physical, mental and vocational abilities. Our goal is to meet our clients' needs to the best of our ability. We have a highly professional group that is well-integrated, holistic and in fact has very good relationships with community agencies, some of which have presented here today. We provide counselling to help clients become as independent as possible. We meet those goals through our treatment programs, which are integrated with community agencies in many ways, research, education and advocacy on behalf of our patients and in partnership with the community.
The Royal Ottawa Health Care Group also operates several community-based and outreach services such as a transitional living centre for people with head injuries, a mobile rehabilitation clinic serving eastern and northeastern Ontario, a service designed for individuals exploring return to work after illness or injury, a drug and alcohol rehabilitation centre and a range of rehabilitation services aimed at the workplace. So you can see we extend far beyond the walls of our facilities. Many of our programs are recognized internationally and nationally as model programs for service delivery, education and research. We have a long-standing track record of responsible fiscal management.
For more than 85 years we have worked closely with community groups and individuals to represent and support the distinct needs of individuals with physical disabilities and mental illnesses. This long tradition as full partners and advocates brings us here today to comment on relevant aspects of Bill 26.
At the outset, we would like to reinforce that we are in full agreement with the recommendations on Bill 26 that have been put forward by the Ontario Hospital Association. Again, I believe there is general support for those recommendations within the Ottawa-Carleton region. We participated with the Ontario hospitals in mapping out the OHA position. Like the OHA, we believe that an unprecedented piece of legislation can be made to work only if the government is willing to make amendments in order to make the bill more palatable and feasible. There are aspects of Bill 26 that are most welcome, including those clauses covering new ways to enhance revenues, recognition of ability to pay in labour disputes and changes to speedy implementation of hospital bylaws, to name a few.
As advocates for the mentally ill and physically disabled, we would like to comment on four areas of the bill which affect or could affect our clients. I'll ask Mr Langill to speak to those.
Mr George Langill: Thank you, John, and thank you, Mr Chairman, for the opportunity.
We would like to present these four items to you as follows, and these are in no order of priority. Our first concern is access to medical records including their ownership, custody, use and disclosure. The current Mental Health Act of Ontario has special provisions relating to this subject. This recognizes the increased sensitivity of clinical information when treating persons with mental illness. Bill 26 proposes increased powers of access to clinical records. There are sections such as in schedule F, part II, of the amendments to the Public Hospitals Act, subsection 13(3), subclause 32(1)(t)(iv) of the act, as well as schedule H, part I of the amendments to the Health Insurance Act and Health Care Accessibility Act, sections 2 and 21, that allude to this in greater detail.
In our opinion, to further liberalize or even appear to liberalize access to such information generally, and particularly in regard to psychiatric patients, will not only impact the quality of clinical reporting but ultimately the quality of clinical care.
It is therefore our recommendation that the Mental Health Act must continue to take precedence over other legislation in respect to access to clinical information for psychiatric patients.
If I was to put this in more general terms, having heard the discussion this morning, first of all, I think we're encouraged by the comments that have been made around clinical information and confidentiality, but we believe again it's important to emphasize that the standards and practices established by the current Public Hospitals Act, and in particular the Mental Health Act, should be the minimum standard upon which the government builds in respect to any aspects of access to information, clinical information in particular.
The second point we would like to make is the issue of strong advocacy continuing for the vulnerable populations that our institution serves. Provisions under schedule F involving the restructuring of services, and particularly the restructuring commission, that could affect persons with mental illness or physical disabilities, must and should take into consideration the need for strong advocacy methods, particularly when these specialized services might be considered for restructuring, for example, with other larger, more acute medical services.
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History has shown that when larger, acute-oriented services are left to set priorities for the needs of these two populations, these populations are often marginalized. I stop at this point and say the reason our organization in fact exists is in some ways a reflection of that and the needs in that regard. The government has recognized this recently in our operating plans, where special provisions have had to be put in by the government to protect schedule 1 psychiatric beds from undue cuts by general hospitals, to name examples of this.
This could also apply to physician service action plans in the proposed legislative package, which for example propose powers to restrict the OHIP fee schedule. We would urge that any move to further restrict OHIP fee schedules must avoid the tendency to define essential services solely along lifesaving as opposed to quality-of-life considerations.
For example, physical rehabilitation medicine offers services which enhance the quality of life, including opportunities to return to work. Rehabilitation is a clear investment rather than an expenditure of health care dollars. It is known that over 80% of people receiving rehabilitation services for serious disability return to their homes, work, schools or active retirement. Furthermore, studies out of the US predominantly indicate that for every $1 spent on medical rehabilitation, $7 to $10 is saved in health care costs.
We therefore recommend that the unilateral and equitable treatment of all hospitals and health care services as proposed must recognize there are vulnerable populations whose needs may be marginalized through broader decisions involving hospital restructuring. We urge the government to ensure appropriate protection and mechanisms are established to prevent such occurrences.
Again, this may well be part of the more detailed discussion that will have to take place in terms of the restructuring commission itself as it begins its very difficult work.
Thirdly, we talk about interministerial coordination. The legislation does not address the serious question of coordination of health services falling outside the responsibility of the Ministry of Health. The most obvious example is mental health for children. In areas such as Ottawa-Carleton, responsibility for children's mental health is fragmented between the Ministry of Health and the Ministry of Community and Social Services, both of which have separate funding and planning responsibilities that are often not integrated around the delivery of services, and are often duplicated, in fact.
As a result of a 1977 decision by the government of Ontario, children's mental health services were placed under the jurisdiction of the Ministry of Community and Social Services. The major priorities of this ministry, as you know, are in social welfare and social services. This has led to gaps in planning, development and provision of health care services directed to the family, particularly as they relate to mental health services.
We allude in our presentation to some statistics that I will leave with you that show the very pressing need in this area that has been presented to the government in studies done by Dr Dan Offer and others in this province.
We feel the government of Ontario should use the opportunity of Bill 26 to address such serious concerns in the province which largely have their roots in a fragmented approach to ministerial responsibility. Using this example, the objective would be to have children accorded at least the same quality of mental health services as the adult population, where the treatment can be in the context of the whole family, not the child or adolescent in isolation.
As the legislation proposes to address fragmentation and coordination of service delivery, we recommend you give equal weight to reducing ministerial fragmentation on vital health delivery issues, such as the funding, planning and delivery of children' mental health care services and return responsibility of such health care services to the Ministry of Health.
Our last point relates to the health care continuum. Bill 26 deals largely with the restructuring of health services, but explicitly or mainly with the hospital component. In both psychiatry and physical rehabilitation there are many service components which fall outside the hospital sector, the community health centres that presented before us, many community mental health agencies, and home care, just to name a few. These are nevertheless integral parts of the system of service delivery. This legislation therefore deals with only part of the health care challenge by virtually ignoring the broader system of community services which remain largely fragmented into numerous small to medium-sized organizations with their own self-contained governments and administrative structures. It is our recommendation that restructuring of health care services should be broadened to include all components of the health care continuum, including community-based health care services. Perhaps, as a word of qualification, the emphasis has to be equally on all components on the continuum of service, not just the hospital component.
Dr Atkinson: In summary, we have these four recommendations placed before you, as well as our support for the recommendations to the Ontario Hospital Association:
-- That the Mental Health Act must continue to take precedence over other legislation in respect to access to clinical information for psychiatric patients;
-- That unilateral and equitable treatment of all hospital and health care services, as proposed, must recognize that there are vulnerable populations whose needs may be marginalized through broader decisions involving hospital restructuring. We urge the government to ensure appropriate protection and mechanisms are established to prevent such occurrences;
-- That, as the legislation proposes to address fragmentation and coordination of service delivery, we recommend that it give equal weight to reducing interministerial fragmentation on vital health delivery issues such as the funding, planning and delivery of children's mental health care services and return responsibility for such health care services to the Ministry of Health; and finally
-- That restructuring of health care services should be broadened to include all components of the health care continuum, including community-based health services.
We're pleased to answer questions and we note that you robbed us of three minutes of our time.
The Chair: We've got about five minutes per party for questions, beginning with the government.
Mrs Helen Johns (Huron): I'd like to thank you for your presentation today and the time you've obviously put into it. One of the issues I have been directly involved in is this issue of children's mental health and where it should be allocated. Children's Mental Health has made presentations both to me as a representative of the Minister of Health and I think to the Ministry of Community and Social Services. It's definitely an area that requires some thinking about, because I know that there's in some ways falling through the cracks. I appreciate you bringing us this again, and we will certainly be looking into that. Thank you very much.
The government recognizes that there has to be an ability to reallocate funds to such important areas as acquired brain injuries. The previous government started the process of trying to bring our people with acquired brain injuries back to Ontario and we have continued on that process. We believe it's a very high priority item: (a) It's financially cost all the taxpayers a lot of money; and (b) people want their family to be close to them. So it's a very important area.
I believe that part of this bill allows us to do that by giving us the ability to reallocate funds within the health care system so that we can put it to specific areas that the community requires or believes is important. I think that's a very good point for you to bring up today.
I was interested in your comments on community involvement. I don't know if you can answer this question for me, but we haven't changed the district health council's mandate or we haven't changed any of its power; is the district health council not meeting the needs of the persons with mental illness or physical disability? As far as we're concerned, the district health council should be taking into effect everyone's needs. Is that not the case in Ottawa-Carleton?
Dr Atkinson: I think the district health councils function very well in that role. They have had a committee on mental health services for a long period of time. What we've done, as an organization, is to broaden the community involvement. Because we are structured in a programmatic basis and one of our major programs is mental health services, we have a community advisory team consisting of volunteers and people who have had mental health problems that advise the hospital and are represented at the board on health issues. So we've gone beyond the DHC process, which we think is fine, to really bring the community to the health facility and be part of that decision-making process. This has been under way for two years and, from our standpoint, it has been very effective.
Mr Langill: Could I just add too that certainly the reconfiguration exercise that's been alluded to throughout the previous presentations has recognized mental health and rehabilitation as distinct areas that demand concern. I think the reconfiguration emphasis, though, has been more on the acute medical-surgical side to this point.
One thing that I would point out, that we're very pleased with the DHC's position on, is a recognition of a very real anomaly in this community that its major long-term provider of psychiatric services is 125 kilometres away in Brockville. The DHC has recognized that and has asked the government to look into this matter from the point of view of the divestment discussions that are now under way and the need to recognize that we must serve that client group in our communities in Ottawa-Carleton and we must do away with this historical anomaly that has not served them well by being 125 kilometres away from the community they live in.
So we're very pleased with the DHC stance, but I think that's an issue this government's going to have to come to grips with. The DHC has obviously limited powers in that regard.
Mrs Johns: I noticed that you used in your presentation, and not in the document, the quote of either does "liberalize or appear to liberalize" access to specific information when we're talking about access to medical records. Is Tony Clement's personal vendetta -- do you agree that it's an appearance as opposed to a reality in the legislation?
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Mr Langill: In the absence of being able to give you a definitive yes or no, I think we have to say that we're not sure. We've very encouraged by the comments that have been made this morning, but I think you've got to appreciate, from where we sit, that we're very concerned. In the absence of a statement of some minimum standard, and we see the minimum standard being the current practices that are in place -- Mr Labelle earlier on alluded to the fact that the Ottawa General had a good record in this regard. I would suggest they've minimized their risk because they follow the current legislation. So if the government is going to build from there, and we understand they have to, let's state the minimum standard of the current regulations in the Public Hospitals Act and the Mental Health Act, as it involves medical records.
Mr Dalton McGuinty (Ottawa South): Thank you, gentlemen, for your presentation. I wanted to raise with you the issue of this access to medical records and the potential disclosure of hitherto confidential information regarding a psychiatric patient. What gives me particular concern as well is the immunity provision which is found within Bill 26 which effectively provides that if the minister or an agent of the crown acts pursuant to the bill, he or she won't be subject to any liability.
It seems, if you stop to think about it for a minute, that there's something rather perverse here. Here you have a case of government, duly elected, exercising its authority within the framework of a parliamentary democracy -- government of the people, by the people, for the people -- saying, "By the way, if we do something you don't like, you can't sue us." I mean, talk about biting the hand that voted for you.
What I want you to tell us here today is something about the potential consequences of the release of confidential information regarding a psychiatric patient. There was a presenter here earlier today who talked about the continuing stigma connected with psychiatric illness in our society. Can you describe something of that potential consequence for us, please?
Dr Atkinson: There's no question that in our mental health program we deal with a unique population. It's imperative that these people have confidence that the system is going to protect their records and their need for services in the health system. I don't feel that it's quite as important on the rehabilitation side, which has more of a public acceptance of these problems. They don't have any kind of grey cover over them. So we're quite concerned, as we've reiterated, that the present Mental Health Act, which we feel has served well, continue to function.
In relationship to the lack of an appeal mechanism in any part of the bill as I understand it, I'll speak personally, not as a member of the board: I have grave concerns with that. I don't think that's appropriate. I feel there should some be some kind of appeal mechanism. But if we are going to provide the quality of care and if we're going to have the confidence of those patients with acute and chronic mental health problems, then we have to be able to reassure them that their discussions with our providers are confidential.
Mr Langill: May I just add to that, if I have a moment. The client-therapist interaction in mental health is an extremely important one to respect. It's based on trust being established, and that trust is often on the basis of the perception of the clients to the information that they're providing, which is highly sensitive. They're spilling their guts out to the therapist.
The effectiveness of our care there is largely dependent on our ability to ensure privacy. When anything appears to even threaten that, what you end up getting is therapists who will duplicate record systems, who will underreport, and then that becomes a real inherent risk to the patient, who may show up at our emergency and be treated on a medical record that in fact is deficient.
Those are things that we're concerned about. Again, we've been given some assurances, I think, that the government is also concerned about those sorts of things.
Mrs McLeod: That's exactly the point I wanted to make. The point that you've just raised is the one we've heard repeatedly at the hearings, and that's a tremendous concern about the violation of the trust relationship and the reluctance of patients to share information with their caregiver because of the danger of disclosure of information.
Like you, we had received some reassurances first of all from the Minister of Health saying that some amendments would be made to this. We've had that reassurance from time to time from members of the government, but we've also had, I must tell you, Mr Clement's repeated attempts -- I think Ms Johns referred to it as the vendetta -- to try and say there's nothing wrong with these provisions in the act, in spite of the privacy commissioner very clearly saying that this act, as presented, holds grave consequences for the privacy of any individual.
We want to see the amendments now that the government says it's going to bring in so that we don't have to keep raising this as an alarm if we can take reassurance from those amendments. I think, if we have time, Mr Chiarelli has a question.
The Chair: I'm sorry. Ms Lankin.
Ms Lankin: I'll just follow up with a comment on that. In fact, yesterday we provided the government with an opportunity. Mrs Johns, who is the parliamentary assistant to the Minister of Health, has on a number of occasions before this committee reassured presenters that in fact the government was going to amend the provisions with respect to health care information privacy. We afforded her with an opportunity to inform us whether those amendments would be in accordance with the recommendations of the privacy commissioner, who is the utmost expert on these issues and who has made a set of recommendations of what would satisfy the concerns. We failed to get that commitment from the government. We could go on and talk about a lot of other things if we could get that issue out of the way. We have yet to have any clarification.
That brings me to another point where you may want to get some kind of commitment from Mrs Johns while you're here today. You spoke about the desire to see some rationalization of services interministerially and bringing some of the children's mental health services from Comsoc over into the Ministry of Health. Let me share with you a rumour that is rampant in the two ministries, at this point in time, which is that the welfare income support portion of the Ministry of Community and Social Services will in fact be moved to the Ministry of Finance, and that the social service section and children's mental health service section of the Ministry of Community and Social Services will in fact be moved to the Ministry of Health, and that Comsoc as we know it now will be done away with. That's interesting.
The one assurance I would ask you to try and get for yourselves is that as the budgets are split up, the budget that goes over to the Ministry of Health is not what the government uses to meet its commitment of sealing the Health budget at $17.4 billion. As you know, they've just made $1.5 billion in cuts from that budget. They say that they will restore it to the $17.4 billion by the time they go back to the polls and face the electorate. The rumours inside the ministries are that this will be supplemented by money that is currently being expended on children's mental health services, bringing it over, which means cuts for everybody in that sense. So that's an area that I think it would behoove you to follow up with government as you're lobbying for these changes.
The specific question I wanted to ask you is with respect to the concerns you've raised around services for vulnerable populations as we go through the restructuring. You've recognized that at local levels there are committees and reports that are looking at how to protect those services locally. But you urged the government to ensure that appropriate protection in mechanisms is established to prevent such occurrences as when we saw general hospitals starting to cut back on schedule 1 psychiatric beds with the strain on their budget and the rationalization of services they had to go through. Have you thought through what protections or what mechanisms are necessary, how they would work, and are there any that we should try to see reflected in the bill through some amendments?
Dr Atkinson: I can answer this with some passion. I believe that the restructuring process that is going on in Ottawa-Carleton at this point is really designed around the adult, medical-surgical side of things, that this is where the savings should be identified and should be achieved. I'm not saying that as a protector of the ROH, because other studies, in fact the Toronto study, supported a network for mental health services and rehabilitation and said that resources should be put in there.
If you move into regional structure, where unsexy programs like rehabilitation and mental health compete with such things as children's programs or cardiac surgery, we get suckered every time. We don't want to see that happen. So we want to have some kind of protection to recognize that those two growing areas, worldwide, in health needs, mental health and rehabilitation, don't fall into a great juggernaut where they will be competing with attractive things like those things which save lives. We've commented that quality of life is every bit as important in the minds of many as saving lives, and indeed in some circumstances is more desirable. So that's our real concern. We don't want to be thrown into the hopper and have to compete that way. We feel that these services are recognized worldwide and there should be some kind of acknowledgement of that.
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The Chair: Thank you, gentlemen. We appreciate your being here and your involvement in our process.
Dr Atkinson: You didn't give me my three minutes.
The Chair: Came awful close.
Mr Chiarelli: On a point of information, Mr Chair: Mr Langill mentioned that he had provided some background material and statistics which I don't believe were distributed to the committee members. I wonder if you could ask the clerk to make that available.
The Chair: It's in the presentation, I believe.
Mr Chiarelli: Dr Offer's material?
Mr Langill: It's alluded to on pages 7 and 8.
Mr Chiarelli: Okay. I thought you said there was additional material which hadn't been presented.
Mr Langill: No, I just didn't read it.
The Chair: Thank you very much.
The hotel has kindly given us a little freebie here and provided us with some extra sitting room next door, so anybody who wants a seat, please avail yourself of that facility. Our thanks to the Delta Hotel for doing that.
Mrs McLeod: Mr Chairman, can I note this is the third day in a row when we've had to request extra seating. Perhaps as we look towards next week's hearings, we might plan for a larger public response than the committee had anticipated.
The Chair: We will pass that on to the clerk.
OTTAWA AND DISTRICT LABOUR COUNCIL
The Chair: The next group is the Ottawa and District Labour Council. Good morning and welcome to our committee. You have a half-hour to use as you see fit. Questions will begin with the Liberals, should you allow time for them, and the floor is yours.
Ms Naomi Gadbois: Thank you very much. My name is Naomi Gadbois. I'm proud to participate on behalf of the 34,000 members of the Ottawa and District Labour Council at these hearings on Bill 26, the Savings and Restructuring Act.
From the outset, the labour council and our affiliates would like to express our profound opposition to both the contents of this bill and the anti-democratic process with which the current government is forcing it upon the citizens of Ontario. The short notice of this hearing date and the exclusion of many groups from Ottawa who requested time with this committee violates all democratic sensibility. Had it not been for the civil disobedience tactics employed by both opposition parties on the floor of the Legislature to protect the normal and democratic process, we would not be before you today, as the Harris government was planning on ramming through another piece of highly regressive legislation without consultation or debate. We congratulate the opposition members both on this committee and in the House for taking such a stand.
This piece of legislation has the ability to create three completely new acts, totally repeal two acts and amend 44 other acts. To clearly understand the impact of this bill, one would have to review over 2,000 pages of text. I will suggest to you today that on the day this legislation was introduced, very few, if any, MPPs had taken the time or had the opportunity to do just that. I will also submit to you today that very few, if any, MPPs to date have taken the opportunity to closely examine all the changes to the 47 acts affected by this one piece of legislation.
At no other time in the history of this province have we seen a government so committed to the destruction of democracy. At no other time in its history have we seen a government so committed to undermining the health of its citizens. At no other time in this province's history have we seen a government so committed to robbing from the poor to give to the rich. At no other time in the history of this province have we seen a government so committed to lining the pockets of pharmaceutical companies and private American health care companies. At no other time in this province's history have we seen a government so committed to denying the rights of workers. At no other time in the province's history have we seen a government so committed to exposing private medical information while at the same time cutting off public access to public government information. And at no other time in this province's history have we seen a government so committed to destroying this province's history itself.
If this is a history lesson, then let me remind you that the bill you've put before us has only one historical context, and that's wartime. This one piece of legislation dramatically alters 47 acts of law. It seems inconceivable, but it's not unprecedented. The only time when this kind of sweeping change has ever taken place before has been in times of war.
What's the war here for this government? It's a war on the poor and working people in this province. What kind of price do people pay for the war? It would take days, weeks or months before any of us could really get a handle on the scope of this bill. We hardly have the time this morning to scratch the surface of the sweeping, fundamental and irreversible changes that the Harris government is trying to impose on Ontario, but as representatives of the citizens and working people of our community, we'll share with you our initial outrage at specific sections of this bill as it relates to health care.
Under the Canada Health Act, the people of our community have the right to universal, public, non-profit, portable health care. Under Mr Harris's plan it is the insurance companies, drug companies, private hospitals and his government who have all the rights: the right to cut us off when we're too sick or when we're too old; the right to refuse us treatment; the right to decide what medication we can or cannot have; the right to decide what doctor we see, whether or not we get to see a doctor at all etc. This bill is about a fundamental shift in the balance of power around health care.
Bill 26 clearly paves the way for the Americanization of our medical system, and yet our health care is what most Canadians say distinguishes us from Americans. Bill 26 encourages private American companies to open more private health clinics. This will lead directly to a two-tiered health care system, which Ontarians have said again and again they don't want.
Schedule Q of Bill 26 guts labour legislation that protects public sector workers. Because hospital workers are considered essential services, they don't have the right to free collective bargaining with the right to strike. Instead, if agreement isn't reached in collective bargaining, the matter goes to interest arbitration.
The Tories, however, apparently don't trust arbitrators to impose severe pay cuts on public sector workers, so they've changed the rules. Now, under Bill 26, arbitrators must consider the province's economic situation; they must consider the employer's ability to pay. This basically makes a mockery of the arbitration process. The government sets the budget, then says to the arbitrator, "This is all we can afford." The government wins their case, the worker loses, and the integrity of the arbitration process is thrown out the window. Furthermore, this provision places the onus of determining how much workers are paid on the arbitrator, who is supposed to consider how much services need to be reduced, and takes it off the shoulders of the government.
Arbitrators have responded to these kinds of tactics by concluding that ability to pay is no more than willingness to pay. Public sector workers in our community will be deprived of their right to a fair and impartial process for determining the terms and conditions of employment, rights that are enshrined by the United Nations, the International Labour Organization and our own Canadian Constitution.
Effective January 1, 1997, Bill 26 repeals the proxy provisions of the Pay Equity Act. An estimated 100,000 low-paid women who work in areas such as nursing homes, day cares and shelters, where there are no equivalent male-dominated job classifications, will have their right to fair pay abolished. Many of these women have struggled for years to finally win their 30%, 40%, or even 50% increases. Now they will be granted a measly 3%.
The omnibus bill takes away certain pension rights from Ontario public servants whose jobs are about to be eliminated by the Tories. Could it be that as the Harris government plans to lay off as many as 20,000 government employees, it plans to add insult to injury by cheating its employees out of $400 million to $500 million worth of pension money owed to them? That is a direct attack on the working men and women of this province. It is theft.
Bill 26 encourages privatization and contracting out of services. At the same time, it denies existing employees successor rights so that the decent paying jobs of qualified workers can be replaced by poorly paid, underqualified, non-union staff. Long-time unionized employees will lose their seniority, wages and jobs without successor rights protection. This will hurt workers in the Ottawa-Carleton region, it will hurt our economy as downward pressure is put on wages, and it will undoubtedly threaten the quality of patient care for citizens in Ottawa-Carleton as they are handed over to less qualified personnel.
If Bill 26 goes through, Ontario will be the only province that doesn't protect its citizens from soaring drug prices. Bill 26 so dramatically alters the listing and costing of drugs in this province that they've replaced its name, Prescription Drug Cost Regulation Act, with the Drug Interchangeability and Dispensing Fee Act, since it no longer regulates costs. Manufacturers are now free to determine the price for drugs, and under the patent protection of Bill C-91 the prices are sure to go up. As for citizens of our community who depend on the Ontario drug benefit plan, they will be forced to shop around for the best price for their prescriptions. The government now will only pay for generic drugs, even if the generic drug is not suitable for the individual.
The bill introduces "copayment," which is a slippery word for user fees, on prescriptions. It will hit Ontario drug benefit plan recipients very hard, mainly senior citizens and many mother-led families of disabled children, who have already had their social assistance benefits cut by almost 22%.
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If people in a city like ours can't afford prescription drugs -- and many already can't -- and if drug costs are no longer regulated, what then? Do we want a city in which sick and injured people can't get basic medication, people like schizophrenics who require medication to maintain their daily balance? Bill 26 practically promotes rising drug costs. We know enough to realize that this will result in people going without medication. Disease will spread, hospitalization and the demand for crisis intervention will increase, and our overall health costs will go up, not down.
It's laudable that the government wants to save money on drug costs, but why not go after the real issues? Take the federal drug patent legislation that extends drug patents for 20 years. Green Shield estimates that once that piece of legislation was introduced, the average price of new drugs increased 93% between 1987 and 1993. If the Harris government was really intent on saving health care dollars, it would go after the feds to repeal this legislation. Instead, they are making the situation even worse by repealing the only provincial legislation we have that effectively controls the cost of drugs. Or they would go after the overprescribing of drugs or tax the ridiculously high profits already being made by transnational drug companies.
The real deficit that people in Ontario should be worried about is the democracy deficit. When the government puts forward legislation that wipes out the ability of people to have a say in their local affairs, we have to wonder seriously whether this government has any commitment whatsoever to democratic principles.
Bill 26 is essentially about expanding the powers of the provincial government. Throughout, the bill gives cabinet or ministers exclusive power to make regulations or to issue directives that would override existing contractual arrangements, thus rendering binding agreements void, while putting in place provisions to ensure that they aren't liable for breaking these agreements.
The sweeping powers outlined in schedule M of Bill 26 amend the Municipal Act to give the government authority to amalgamate, restructure or dissolve all or part of a municipality if they receive a proposal to do so or if they deem it necessary as a result of their restructuring process, and they can do this with little or no provision for public input. They can also contract out or privatize municipal utilities and clear the way for a whole host of new municipal user fees, again with no public input.
Traditionally, changes of this nature require the municipality to hold a referendum, but Bill 26 eliminates this requirement. Why are they so afraid of the will of the people that they're cutting off communication? Apparently it's not important to this government what the people think about where they live or what services they depend on. If there's no requirement to hold municipal referenda, will the Tories just sell off our services to friends? Will it mean that services which don't make money are abandoned, services like hospitals and quality-care public nursing homes? The Harris government has promised to hold referenda, however, in any city that wants a casino. It's too bad we don't have the same options around hospitals.
Bill 26 will effectively muzzle the municipal politicians who may oppose restructuring in their community. Unlike the provincial government, they can be held personally liable if the municipality is deemed to be adversely affected financially by their refusal to comply with the government's regulations. Municipal councillors will be forced to either swim in the right-wing current or, along with their constituents, pay a heavy price for going against the tide.
Bill 26 gives the Minister of Health virtually unlimited power to dictate every detail of hospitals, including their funding, operation, closure and amalgamation. The minister can also appoint a supervisor to take over hospitals or tell individual hospitals what services they can or cannot provide. Should the hospital's community board of directors oppose any move by a supervisor, the board can be overruled, replaced or simply removed by the supervisor. The bill also gives the minister the power to make any other direction related to the hospital that he considers to be in the public interest. This makes full privatization of public services a great deal easier.
The citizens of Ottawa-Carleton are busy debating how hospitals might be amalgamated, how they can save hospitals etc, but this kind of public discussion is of no importance to the Harris government. By giving the Health minister the unilateral authority to close hospitals, local communities are robbed of the right to have their say in their own health care. It would appear that the health care needs of our citizens are not relevant to Mr Harris's plan.
Privatization doesn't mean the costs go away. It means that individual citizens pay for these services privately instead of through their tax bill. Privatization doesn't save money. When Britain privatized its water and sewer utilities, water bills increased by 74% in the first five years alone. Closer to home we have Alberta. Privatized liquor stores in that province have a smaller selection at higher prices. Privatization is about the loss of public accountability, and this bill is about ideology. It's about making money, not cost or care in our communities.
Section 32 of Bill 26 gives the minister the power to regulate the appointment of physicians and gives him potentially unlimited control over the fundamental decisions relating to where physicians work and whether patients have access to their services while in hospital. As for physicians' fees, they lose their contractual rights as bargained by the Ontario Medical Association. Under Bill 26 they will only be able to be paid for services deemed necessary by the government and will not be reimbursed for services the government considers extraneous. Since when does a high school diploma give Mr Harris the authority to determine what is medically necessary?
On that note, it is extremely frightening to see that the bill also makes reference to "prescribed age groups" to determine what services an individual is entitled to. Are we going to see no bypasses after 65? Further, physicians and patients have no right to appeal these decisions.
Bill 26 gives the government powers to determine what is or isn't medically necessary so it can determine what will or will not be paid for out of OHIP, without any public consultation. Whittling down the services insured under the Canada Health Act is simply another route to two-tiered health care. Those who can afford it will buy insurance to cover what the Canada Health Act or OHIP no longer cover. Transnational companies like Liberty Health are just waiting to move in.
Today in Ontario, the Independent Health Facilities Act requires the government to give preference to non-profit over profit-making facilities when a health clinic is being set up. It also gives preference to Canadian-owned operations over foreign-owned. But if Bill 26 goes through, this will be repealed. Why? To encourage American for-profit companies to take over more of Ontario's health care. That is what the government has in mind, yet it's not holding public hearings across the province to get the go-ahead from the people. Do the people want American-style health care? Every pollster in the country will tell you they don't, and so will almost every citizen.
In addition, Bill 26 allows the Minister of Health to contract with one or more specified persons who want to set up a new health facility. The current law requires a general request for proposals, to be fair to everyone. But Bill 26 takes this away, allowing the Minister of Health to handpick corporations or individuals who will be able to open businesses -- health care franchises -- that charge people money. Perhaps the Minister of Health has a few friends in mind or wants to make some new ones. In any case, the bill also denies those who lose bids the right to an appeal or hearing, and the government is not required to provide any reason for its decisions. It doesn't sound very much like the direct democracy we were hearing about in the election campaign.
Schedule K of Bill 26 seriously limits an individual's right to freedom of information by expanding powers to the head of an institution, the right to refuse access, which will undoubtedly result in major delays for access, coupled with lengthy and costly appeal proceedings. The bill puts in place user fees for requests for information -- this is public information -- as well as user fees to appeal decisions, fees that could differ from person to person. Bill 26 violates the very intent of legislation on freedom of information, which is for private citizens to be able to obtain information about the government's activities.
As for the disclosure of private medical information, Bill 26 effectively wipes out patient-doctor confidentiality. Now the Health minister would have the power to inspect your medical records and disclose the information. In fact, they don't even have to collect it themselves; they can hand the data over to private, for-profit firms to collect, use and disclose. Furthermore, the Minister of Health can choose to use your private medical information for a whole host of purposes, including providing it to private corporations like your insurance company, like your employer. The privacy commissioner has said he is very concerned about Mike Harris's plan. So are the members of this community.
User fees do not save money. Repeated studies have shown they generally cost more to administer than they bring in in revenue. Their only result, besides reinforcing the ideology, is to limit poor people's access to services, in this case health care and prescription drugs. User fees are a flat tax. Unlike income tax where you pay according to what you earn, user fees require everyone to pay the same amount. To one person this may be a drop in the bucket, to another it may mean their ability to make the rent. It's quite a choice: "Do I want a roof over my head or do I want medication for my sick kid?" We kid ourselves if we believe this won't be the choice faced by some people in our community. If it ever was, Ottawa's far from fat city these days.
Bill 26 also gives the government the power to charge hospital user fees, which would include accommodation and meals, necessary nursing services, lab tests, X-rays, drugs, the use of operating rooms, obstetrical delivery rooms and emergency room visits. The government has already announced that hospitals will be able to charge daily user fees to those patients in acute-care beds who are awaiting placement in chronic-care facilities or nursing homes. Patients will essentially be penalized because they have been placed on a waiting list for services that are already critically underfunded.
The bill authorizes an administrative fee of up to $150 which hospitals may charge to patients. This is completely unacceptable. People in this city who are poor, who cannot pay the rent and feed themselves, certainly do not have $150 if they are hospitalized, especially since living with a marginal income increases the risk of illness and emergency situations.
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Bill 26 brings in user fees for seniors and social assistance recipients under the Ontario Drug Benefit Act. In direct contradiction to Mike Harris's campaign promise, user fees will prevent many lower-income Ontarians from using services which are now universally available. The result will be a wider gulf between the haves and the have-nots.
Mr Harris is likely to say this is not a war on people, it's a war on debt. So why does schedule D of Bill 26 authorize the government to borrow up to $5.6 billion during this fiscal year from capital public markets, international loan markets and the Canada pension plan for the consolidated revenue fund. Could it be that this is how the Harris government intends to live up to its deficit-reduction targets? Or could it be this is how Mike Harris intends to finance his campaign promise of a 30% tax break? Even if the government is able to introduce its promised tax cut, the savings for most Ontarians will likely be outweighed by the new user fees, and we'll still be $5.6 billion further in debt.
What's contained in Bill 26 comes as a shock to all of us, and probably also to those who voted for Mr Harris's government. There was no mention of these changes in the so-called Common Sense Revolution, which clearly stated there would be no cuts to health care spending and that under this plan there would be no new user fees. Evidently he lied, big-time.
In the so-called Common Sense Revolution, Mike Harris talked about direct democracy, yet the omnibus bill removes requirements for citizen referenda. He talked of devolving power to the grass roots, yet in certain areas the bill centralizes power to a degree unsurpassed in the history of this province. Indeed, if the power is devolved at all in this bill it is to the corporate world, to drug companies, to for-profit nursing homes, to private clinics, to all those waiting in the wings to privatize public services and to those who profit from illness, disease and disability.
Mike Harris talked about responsible government, yet he had drafted a bill that gives the government vast new powers but also ensures it will not be held liable for any decisions it makes and carries out. Throughout the bill, especially in the health sections, the cabinet, the Minister of Health, hospital supervisors and boards of directors are protected by the legislation against any liability or court challenge. Yet the health care providers and citizens are not given any means to appeal decisions or to provide input in the decision-making process. All these democratic avenues have been removed from the system and Bill 26 deletes all references to district health councils. Mike Harris consistently badgers the poor to take responsibility for themselves and their situations, yet he seeks to shelter himself and his ministers from any responsibility for the situations they create in this province.
Bill 26 must be stopped. If it goes through, it will dramatically change the quality of care in this community and it will destroy this community's ability to determine for itself how we want to live here in Ottawa-Carleton. Bill 26 in a direct contravention of the principles of the Canada Health Act, as it effectively encourages the privatization and corporatization of health care. It's an attack on the elderly, the poor and all those who are most in need of compassion and high-quality care. It permits, and even encourages, extra-billing and entrenches two-tiered medicare. The only winners here are the American health care firms and the multinational drug companies.
But there are lots of losers. First and foremost, they are the citizens of our communities, who will be forced out of the health care system quicker and sicker, who will be denied appropriate types of care when needed, who will be bankrupted by soaring drug costs, user fees and private insurance. They'll be denied physician care by doctors whose contracts have been broken by the government, denied treatment on the basis of age or disability, exposed by lack of doctor-patient confidentiality, and the list goes on.
As for our health care providers who use their skills and care to nurture us back to health, keep us comfortable, fed and clean, help us die peacefully, these workers are being robbed of their pensions, are being denied their basic collective bargaining rights and are losing their jobs.
Nearly 30 years ago, Canadians decided that we wanted to share the burden of illness and injury together, that none of us should have to bear the cost alone, that we would spread our risk and pool our resources. That's what public health care is all about -- the citizens of this city and this province and this country all sharing the risk, pooling our resources and being involved in health care decisions.
Bill 26 signals the end of a public commitment to health care. It is a decisive move away from community and towards tight-fisted government control and individualism. It ushers in American-style, two-tiered, for-profit health care that will only serve to widen the growing gap between the haves and have-nots in our community and in this province.
The Ottawa and District Labour Council demands that the government take Bill 26 off the table and stop your war against the people and communities of Ontario. Thank you very much for your attention.
The Chair: We have one minute per party for questions, and only one minute, Mr Chiarelli.
Mr Chiarelli: I'll be very quick. This basically is an economic War Measures Act, as was the social contract. I think the NDP government recognized there was a serious and real deficit problem -- perhaps also a democracy deficit but also a real deficit problem.
You've indicated a lot of pain in Bill 26, but if it were to be taken off the table, how would your labour council address the deficit problem? As I mentioned, we know that the last government took very draconian action with the social contract, recognizing the problem. We now have Bill 26 -- a different government, a different philosophy -- dealing with the deficit problem. How do we deal with that problem and not impact on people and not cause people to have pain?
The Chair: Thank you, Mr Chiarelli. Ms Lankin.
Ms Lankin: In one minute is going to be difficult -- for me -- to put a question. You've said that in light of the criticisms and concerns you want the bill pulled right off the table. I would argue with you that there are some provisions in the bill that could go forward, that borrowing powers etc are necessary for the government to meet its fiscal obligations. We've suggested that those portions go forward on January 29 and that for the pieces of bigger policy with longer-term implications that don't have an impact on the immediate fiscal agenda we take a bit more time.
I know you're calling for the whole bill to be scrapped, but would you support an approach of that measure? Do you have any comments on that?
Ms Gadbois: Should I answer that question?
The Chair: When there's only a minute, if they don't make it a real short question, they don't give you any time to answer. You can have a short answer to Ms Lankin's question.
Ms Gadbois: I do. I have a short answer to both questions, actually.
The Chair: Only to Ms Lankin, because we're talking seconds here.
Ms Gadbois: Okay. We haven't had a chance to see what parts of the bill your party would consider to be worth keeping. That may be possible.
Our concern here, and I think we've made it clear in our brief, is that there hasn't been enough time. This government has been in place less than six months. Nobody's had a chance to read this thing, basically. In answer to Mr Chiarelli's question --
The Chair: For the government, please. Mr Clement.
Mr Clement: Thank you for your presentation. In the limited time, I just wanted to return to your brief where you said, "When Britain privatized its water and sewer utilities, water bills increased." I might note for the record that was because the British government, in its infinite wisdom, decided to set a floor price for water and utility bills, in effect dictating the price.
You see, that's the problem when government gets involved in micromanaging the marketplace: They tend to overcompensate and these things happen. Wouldn't it be better, where we can guarantee quality in a health-care sector, to have some market forces, such as in the deregulation of drug prices which might in fact drive prices down rather than up?
Ms Gadbois: Oh, no. Deregulation of drug prices is something the federal government has currently precluded, sir. So --
The Chair: Thank you very much. We appreciate your presentation. Too bad there wasn't any more time for questions, but unfortunately there isn't.
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ACADEMY OF MEDICINE, OTTAWA
The Chair: Our last presenter for the morning is the Academy of Medicine for the city of Ottawa, represented by Dr Bryan Lennox, the president, and Dr Diamond Allidina. Good morning and welcome to our committee. You have a half-hour.
Dr Byron Lemmex: Thank you very much. A slight correction there. My name is Byron Lemmex, and I'm a family physician here in Nepean. I'm president of the Ottawa Academy of Medicine, and beside me is Diamond Allidina, who's our local director on the board of the OMA. As I just finished telling you, I'm president of the Academy of Medicine of Ottawa, which has 579 members. I'm also a delegate to OMA council, which in our area represents over 1,700 physicians.
I also have the honour to represent over 1,650 patients in this region who have signed the local academy petition. This petition, in numbers, was obtained over two weeks from just 52 physician offices. This petition objects to Bill 26 because it cancels the partnership between government and physicians to manage health care on a joint basis. It gives unilateral power to the Minister of Health to reduce services and dictate medical care.
I don't wish to dwell on the subject of how unfair, dictatorial, draconian and unjust this bill is. It certainly is all of these. I wish to promote a partnership between physicians and the government and to offer some insight and propose some solutions to these complex problems.
As a family practitioner, I agree that some hospital services should move to the community. I personally make house calls and do a fair amount of palliative care. It requires a great deal of time and effort to allow a patient to die at home. The splendid work of the Victorian Order of Nurses often goes unrecognized, along with our own Ottawa-Carleton home care program, but repeatedly we are hampered by lack of funds.
Just this November, one of my patients was dying at home from bowel cancer. His bowels were blocked by his cancer and he was dying slowly of his cancer, heart failure and starvation. His final wish was to die at home, but he never really admitted he was dying. He lived five weeks at home, cared for by our nurses and his family. Unfortunately, home care funds ran out very quickly, as did his own personal insurance. For the last two weeks of his life, his wife had to call every morning to home care to see if services were going to be provided.
Please, if sick and elderly patients are removed from the hospital, fund the appropriate community agencies. Dying patients still need the care, whether in the community or in hospital, and your government should transfer those funds accordingly. I am ready, as other family physicians are, to care for patients at home, provided we have the other health professionals working with us.
The Ottawa-Carleton area is one of many areas undergoing reconfiguration. One concern with Bill 26 is the ability of a Health minister to close a hospital with a stroke of a pen. Our district health council has proposed the closure of two hospitals in its reconfiguration plan. By closing the Grace hospital and the Riverside hospital, over 300 beds will be lost to this area.
I wish to point out the number of beds closed is insignificant when compared to the loss of patient services each of these excellent hospitals provide. The Grace hospital provides over 9,000 patient services. The Riverside hospital provides over 10,000 patient services. These services include breast biopsies, cataract surgery, endoscopic procedures, minor surgery, and almost all, I might add, do not even require one night's stay in hospital. To lose 11 operating rooms and six ICU beds in this region would be a drastic reduction in health care services.
The University of Ottawa medical faculty provides many fine physicians to the people of Ontario each year: 32 family practice residents graduate each year from our university. Three local programs are here in Ottawa, with a satellite program in Sudbury, Ontario.
To force our young doctors to the north is not a solution. The retention rate of the Sudbury program is very high in keeping physicians in the north. It also has been shown that selecting medical students from these areas also promotes physicians to return to their home towns. The OMA has produced an incentive package to promote and retain physicians in these underserviced areas. Surely these few ideas are much better than forcing physicians to the north. As a physician who spent four years in Kapuskasing, I know your proposed legislation will drive physicians south, not north.
I have a graph here that shows the increase of physicians leaving Canada to the United States has increased 28% per year since 1988, and this graph ends in 1993. I would hate to imagine what this graph would look like in 1996.
Your proposed method of detecting fraud by physicians and patients is too harsh and unfair. The breach of patient confidentiality by giving the Minister of Health the power to demand a patient's file be on his desk is particularly sensitive in this region. I personally treat members of parliament's families and a few senators, and I don't mean the hockey Senators. If they know a political body can get access to information concerning themselves or their families, I'm afraid they may be reluctant to seek proper medical attention, especially for sensitive social issues. The medical review committee of the College of Physicians and Surgeons of Ontario is already directed by the general manager of OHIP to investigate frauds by patients and physicians. Surely by enhancing this program, which involves doctors investigating doctors, done in their offices and with a chance to appeal, would be more cost-effective and does not breach confidentiality, as your bill does, and is more effective.
Dr Diamond Allidina: Byron has talked to you about some concerns that we have as a physician body in this area. I'm going to talk about certain specifics of the bill that impact the practice of medicine for physicians and their patients.
I'm a psychiatrist in Ottawa. I'm a district director of over 1,700 physicians in this region.
I've heard concerns from family physicians, oncologists, psychiatrists, neurosurgeons and general surgeons. Like me, they're horrified at this bill and its broad-ranging implications for health care.
This is unprecedented in Canada. It will impact on how physicians diagnose, order tests and treat patients. Physicians have been wondering why this bill is intended to grab so much power for the ministry and its bureaucracy and sever a partnership link with the profession. Why does the ministry need such broad-ranging tools?
As we digest this complex bill, and as I talk to my colleagues, one glaring fact presents itself to us: The minister, and this government, with its relevant bureaucracy, needs this power to implement managed care.
Managed care, or, as it is dubbed by the physicians in this area, minimal care, is a concept popularized in the United States of America by their insurance companies, where the bottom line is profitability. It's now being imported to Canada by your government. It sets quotas for tests, services, treatments and referrals for a family physician. It sets limits on how long a patient stays in hospitals, the number of times a patient can see a specialist and the treatments that the specialist can render.
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Let me give you an example. I saw Tony Clement; he probably looks under 30. Supposing he were to go to one of our hospitals around here with chest pains. The GP would not be able to refer him for tests until and unless he surpasses a profile of a symptom complex. After the profile has been surpassed and after the GP has had a fill of his quota of referrals, then and then only can Tony Clement go and see a cardiologist. But the cardiologist is also limited. He can only see the patient after the approval from the insurance company. Having seen it and given the opinion, he can only treat after the approval. Who is the approving agent? A clerk.
As you can see, there is no room for patient-based care or treatment in this milieu. Medicine practised in this climate is not going to be patient-centred.
Let me just walk through some of the schedules that are going to help the government introduce minimal, or managed, care. Let's look at schedule H. This gives the ministry huge new powers to decide whether a particular service was medically necessary or is medically necessary or not. The consequences of this are going to make the doctor very anxious, since he does not know which test, procedure, prescription or referral could also be declared invalid after the fact. Therefore, the physician will demand prior authorization before he does anything or before he carries out any investigation or referral. This will lead to diminished care, longer waiting periods for the patient and, of course, increased bureaucracy for the government.
The other aspect of the schedule gives the ministry unilateral powers to define an insured service and to set a fee for that service, which could mean setting a fee that is nil. The consequence of this is that treatments can be directed to be given not on medical need, based on any scientific criteria, but on political agenda, social agenda, hearsay, quackery, ideology, at the whim of politicians and bureaucrats. You may be surprised to hear that and think that this cannot happen in Canada. It can and it does.
Let me give you an example. In psychiatry, mentally ill patients are a very vulnerable population and they're extremely vulnerable to any new treatments or any new quack ideas that come out. Well, any politician can make use of it for his or her gain.
I can further illustrate the example by saying one of the treatments that we use in rehabilitation of our patients is called intensive psychoanalytic treatment. Scientific basis shows that this is the only treatment and the most comprehensive treatment in the United States that's employed in looking after functionally ill or some dysfunctionally ill mentally ill patients. It can not only cure patients' symptoms but make them productive as employees or as partners.
In Alberta, two years ago the ministry decided to delist this treatment. What was the reasoning? Patients talk about sexual matters to their psychiatrist -- no scientific criteria; that was the reason.
Because the minister and his bureaucracy have the power, they can utilize any reason for any patient, whether it be an AIDS patient, a cancer patient or a heart patient, to decide what could be given to the patient. This is managed care, and it is wrong care.
Since the government is getting into the business of setting fees without the knowledge, expertise and organizational structure to carry out this complex process, it would mean that the government would have to increase its bureaucracy to micromanage this system. This was against the Common Sense Revolution.
As you can see, to deliver managed care à la bureaucracy, it will be necessary to silence the doctors and alienate the profession. This bill does this wonderfully. Schedule I can make all our agreements null and void, destabilize the profession, make us anxious so we keep quiet. There's time to come yet; we have about 10 more days before we are really silenced.
Schedule F ensures that the doctors' silence and their compliance is maintained. This schedule systematically removes fairness and due process for the physician. Physician rights are rescinded, there is no right of appeal and the government insulates itself from any legal action. Further, any medical practice, any office practice can be expropriated and its licence withdrawn. In fact, the physician practice in this province is totally unprotected, with no right of appeal.
Also, the general manager of OHIP may personally determine whether or not an individual physician will be deemed eligible to receive a billing number. Hospital privileges will be solely at the discretion of the administration. The tremendous fallout from this for a specialist or a GP is that if he or she acts too often as a spokesperson for the patient or points out too often the deficiencies in the health care system, his or her fate will be sealed. Of course, this issue often opens up the issue of abuse by the CEOs. You will hear a little bit about that this afternoon. We, the physicians, would have to agree to be directed just to keep on practising medicine.
The concern that we physicians have is that managed care, à la bureaucracy, would provide inadequate care for the acutely ill, longer waiting time for the appropriate treatment and many patients, especially the borderline patients between illness and health, will just fall through the cracks in the system if they are not assertive enough. The outlook for the elderly and the chronically ill is even more dismal.
This bill destroys the traditional partnership between the physicians and the government in the delivery of health care, provides disincentives for good medical care and restructures how health care is delivered in this province. The impact you have heard from Byron is that it will be hard to keep or attract physicians in this region. A recent survey of departing physicians does not necessarily point to an economic factor; it points to relevant factors like stability, predictability and autonomy in the field of practice.
Let me assure you, especially Mr Clement since he has raised the issue, that the government has had the mandate since it got elected to get the tools to restructure health care service. I attended the health care forum in Ottawa that was chaired by Jim Wilson and Mike Harris, Health Policy Discussions on Health Care in the Conservative Arena, and also looked through the manifesto. There was nothing in your platform when you were being elected that suggested that you were going to bring in Bill 26, to implement it, to restructure the health care system in the province. On the contrary, you talked the opposite. You have had a 180-degree turnaround since you got elected.
I'm urging you, since you do not have the mandate to restructure health care services, you do not have the mandate to close hospital beds, to reduce physician services and ration care, that you go back to the people of Ontario and gain that mandate. You gained the mandate in other areas; you did not gain the mandate in health care services.
Thank you very much indeed. Byron and I will entertain any questions from you.
The Chair: We've got about four minutes per party for questions, beginning with the New Democrats.
Ms Lankin: Thank you for your presentation, doctors. It was very powerful. I want to share with you that we have heard similar concerns from physicians as we have travelled, this week, northern Ontario and before Christmas in Toronto. I sense that the state of morale and the lack of stability in the profession right now is at a crisis point, and I fear for what that means for patient care as we're going through this period as well.
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I have a couple of specific questions; let me start with one that we heard in northeastern and northwestern Ontario. We've been in Timmins, Sudbury and Thunder Bay this week, and this is our first opportunity to come into southeastern Ontario. We've heard that the cancellation of the rebate for malpractice insurance will mean in the north that the practice of obstetrics and certain orthopaedic treatments, surgeries, will virtually evaporate up there, that those services won't be available. I'm interested if you have any views about what that change is going to mean for services in the Ottawa-Carleton region.
Dr Lemmex: Just this Monday the executive of the academy met and four out of the five hospitals that do obstetrics in the Ottawa-Carleton region had representatives there. They have told me that between these four hospitals there are six obstetricians who are going to stop doing deliveries as a result of the loss of the CMPA rebate. We also know of one orthopaedic surgeon who is going to be leaving as a result of just the turmoil that is going on in the province of Ontario. The neurosurgeons are starting to think very seriously about taking on very difficult cases that are high-risk because the obstetricians, neurosurgeons and orthopaedic surgeons are the highest-paying dues payers for the CMPA. So the effect in this community will be quite drastic.
Ms Lankin: Are those services that are currently at appropriate service levels, or are any of these areas already jeopardized in terms of the number of physicians that we have?
Dr Lemmex: Certainly in the Ottawa-Carleton area we have a fair number of obstetricians. The problem is that these people work so hard they limit the number of deliveries they do because they have a life to lead too. Now what's going to happen, with six of their colleagues who are going to stop doing it, the ones who are left are going to be working harder and harder. Their fatigue factor is going to take over and you may find that they're going to start to leave because they can't stand the work pace. It's a cascade.
Mrs Ecker: Thank you, doctors, for coming today and taking the time to share your thoughts and your concerns and make your suggestions. While I certainly respect very much your opinion, Dr Allidina, you will forgive me if I do not share all of what you have said. I would like to point out that the minister will be addressing if the CMPA decision is going to be restricting access, especially in the area of obstetricians. He's going to address that, and I refer you to a recent article in the Medical Post where he explained about doing that, because it is not the intent to do that.
In outlining some of the concerns that you have about Bill 26, I think you've also made a very eloquent case for the problems that are in the system now: that physicians have been leaving since 1988; the fact that you've had difficulty and your patient had difficulty getting home care now. I think one of the reasons why we talked a lot about restructuring during the election -- I certainly did in my riding -- one of the reasons we talked about the need for it was because individuals like physicians and other health care providers in hospitals told us that it was desperately needed. We've closed 9,000 beds in this province over the last several years, and unfortunately the bricks and mortar haven't followed, which is what one of the hospital administrators mentioned earlier.
The other point: You talked about misuse, abuse and whatever in the system, and I think it's interesting to note that almost two thirds of your colleagues believe that some of their colleagues are encouraging use in the system that's not appropriate; that 64% of the public believes that is the case; that OHIP records would indicate that, for example, there were 7,000 patients who actually went to five or more GPs in one month, which I think most of us would agree seems to be a tad excessive. I think most people agree that there is a need to get in and address what's happening with the misuse of the system by practitioners and consumers.
You mentioned that the MRC may be a cost-effective way to do that. The college has lobbied very strongly over the last several years that it is not a cost-effective way to do it and wants to change it and streamline and get more authority to do it to make it a more cost-effective way to do it. Given the experience that the academy has had with the complaints mediation process between CPSO and yourself that you've put up, is there a way for the ministry to work with the college further to set up mediation processes, complaints mediation, give them more effectiveness, more powers -- streamlining of the MRC process, for example -- to try and address misuse in the system in a better, more effective way?
Dr Lemmex: First of all, fraud and the physicians: You're dealing with 0.5% of the profession. You just mentioned there are 7,000 patients who were abusing the system. Nowhere in the legislation do I see where you're going to attack the consumer and say, "You're defrauding the system."
Mrs Ecker: First of all, I'm not attacking anybody in the legislation, but in order --
Dr Lemmex: Other than physicians.
Mrs Ecker: No, no. In order to have information. In order to go after that misuse of the system by anybody, you need the information to do it.
Dr Lemmex: Well, let me answer your question. The academy was involved in a pilot project with the College of Physicians and Surgeons to deal with complaints, and we still and always have done with complaints to physicians from the public. Nothing goes on to the CPSO unless it's a drastic things, such as sexual abuse or so on. We did the pilot project at my telling the members of the academy I felt this was important. We did it, we produced the data, we sent it back to the college. What was happening is the college said: "Hey, this is great. We want to put in a layperson, we want to put in a member of the college. We want to have a branch office." The bureaucracy started to build.
What we do right now is we have mediators who are past presidents of the academy. They go to the patient's home. They sit down, they talk to the patient. They say, "What was the problem you had with this physician?" They go to the physician, they sit down with the physician and say, "This is what the patient says; what's your story?" Then they get together and they say: "All right, how are we going to sort this out? Do you just want an apology? Do you just want it recognized that what you did was wrong, or tell the patient that that was wrong?" Simple, clean, very neat. The college wanted all the bureaucrats involved; we said, "No, thank you."
Mrs McLeod: I appreciate and share your concerns in a number of areas, your concern about the loss not only of hospital beds but of hospital services and whether or not those services are going to be provided in the community. I appreciate your concern about whether government-managed care indeed becomes minimal care, and I truly believe that those concerns become even greater when the ability to make these kinds of cuts is brought forward, the power to make those cut is given to a government that is driven by a totally unrealistic fiscal agenda.
I think we have to keep recognizing, as you've said, that there was no campaign plan for this fundamental restructuring of health care beyond just hospitals, and this bill is not a bill about restructuring health care. It is a Finance bill and it makes the Minister of Health subservient, as somebody said yesterday, to the Minister of Finance. That's really what we're talking about here, is how to take dollars out of health care.
I also note the point was made repeatedly over the last few days as we travelled in northern Ontario that this bill will make the retention of physicians more difficult, not better. Incidentally, just to put on the record, one of the figures we were given yesterday was that in northern Ontario the family medicine program that trains physicians in the north has a retention rate of 67%. So there are better ways.
The concern that we heard, and you've touched on it again today, is that the billing numbers, the coercive powers of Bill 26, and the ways in which Bill 26 allows the Minister of Health essentially to practise medicine without a licence and get in the way of the practice of medicine by professionals will have a very negative effect on physicians practising in Ontario. I'm wondering if you can touch on a number of ways in which you fear it could get in the way. Is it already having an effect on the day-to-day operations in physicians' offices?
Dr Lemmex: One of the services we offer at the academy is physician availability, where if a new patient moves to Ottawa-Carleton and is looking for a physician, they can call our office and we will give them a list of family physicians in their area and so on. That list is dwindling. There are fewer and fewer family practitioners who are taking new patients.
Also, as I just explained, the complaints department -- just in the last two weeks we've had numerous patients calling saying they went to see their doctor to ask for a test and the doctor looked at them and said, "I'm not going to order that test because the government may claw back all the funds that come for providing that test, and I refuse to do that." These patients are calling and they are irate. They want to know why they can't have this test done. The physicians are spending time -- there are patients in the waiting room -- explaining to them that if they order this test and it's proved unnecessary, that physician will have to fund the cost of that test. The number of calls that we're getting is increasing day by day, and this legislation isn't even enacted yet.
Mr Chiarelli: I just had a point of information. I was just wondering if the Chair, over the noon hour, might put out a couple of phone calls to see whether we can get the local Tories, John Baird and Garry Guzzo, in here to listen to some of these presentations.
The Chair: Thank you very much, doctors. We appreciate you being here today and your interest in our process. Have a good day.
We'll now deal with Ms Lankin's motion. In view of the fact that we've dealt with this before, can we shrink the time a little bit, Ms Lankin? No. Okay, you have the floor. We agreed, unanimous consent, for five minutes.
Ms Lankin: May we have copies of it circulated, please, before we start, Mr Chair?
The Chair: Do we have unanimous consent for a maximum of one presenter and a maximum of five minutes, with Ms Lankin having the ability to split her time at the beginning and the end? Mr Clement?
Mr Clement: Yes, absolutely.
The Chair: Okay, Ms Lankin, the floor is yours.
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Ms Lankin: Thank you very much, Mr Chair. As you will well know and the members of the committee who have been travelling to all of the centres this week, this is the third successive day that we have had to implore the hotel to make either more space available or more chairs available. We have had crowds come out to listen, to understand what is going on with this legislation beyond anything that this committee expected or that we've ever experienced with other pieces of legislation travelling the province.
The number of groups or individuals who have applied to be heard by the committee, to make a presentation, is unprecedented in its volume. These two weeks alone -- forget about what happened before Christmas -- when we're travelling outside of Toronto, the two subcommittees that are travelling, there have been over 1,000 groups or individuals who have applied for the fewer than 300 hearing spaces that are available.
I think that one of the things I have heard, as members of the government have argued against this motion, is that somehow we are getting a full range of views presented and that that is sufficient for the committee to be able to get on with the legislators' job which will be, at some point in time, to consider amendments and then to report to the Legislature for consideration of the bill.
I would like to point out to you that this is about our ninth day of hearings -- when you think of the Toronto hearings and hearings in Timmins, Sudbury, Thunder Bay and here today in Ottawa -- and virtually every day there have been new considerations or new aspects brought up that have been brought to our attention. Yesterday, I was stunned by some of the considerations that the bioethicist who presented before us drew to our attention and there's work to be done to understand that and an opportunity -- we need the transcripts before we can start to question other people about those considerations.
Every day there have been new areas and new concerns that have been raised, things that even as familiar as I am now with all of these pages of the health sections at least of this bill, areas that I am still understanding new implications for, and we still have debates about interpretations where Mr Clement, for example, has a particular interpretation that differs very much from the privacy commissioner's, and we will be hearing again from the privacy commissioner trying to sort through some of that.
Today in Ottawa, there were 59, say 60 groups, that applied to appear here. There were only 15 spaces available. We're only hearing a quarter of the groups that wanted to make a presentation. There are all sorts of professions that are not being heard from and individuals in the public whose views we won't get a chance to hear.
I believe it is very important that, given the extent of this bill, given the breadth of this bill and the depth of the changes, that we provide the time for public input. I've said on a number of occasions that our party is willing to pass on the 29th those pieces that the government absolutely needs for its fiscal agenda. What we would like to have is the opportunity on the bigger policy areas to have more public input and a bit more time to understand the direction that you're going and what it is that you're trying to accomplish.
So I would urge the government members to consider support of this motion today. The numbers just keep getting bigger, community after community, and I hope that you will take a different position.
Mr Clement: I would like to speak against this motion, as I have done so in the previous centres that we have debated this particular issue. I am quite heartened actually by the quality of presentations, by the diversity and multiplicity of views that we have heard. Ottawa-Carleton has been no exception to that.
We have heard from patients and providers and doctors and health officials and labour officials. We are hearing from the Ontario Dental Association, for gosh sakes, after lunch, so from my perspective, this process -- and again, I disagree with the premise of Ms Lankin's motion -- is a process that is allowing legislators, parliamentarians, acting on behalf of the Legislature, to hear a diversity of viewpoints, to consider those viewpoints in our subsequent deliberations for potential amendments. The minister has already stated on the record that this process is important for the Minister of Health and that we are listening very closely, at least from our side, and I'm sure from the other side, to the potential amendments that will come forward.
Ultimately, this process is a legislative process. I would note once more for the record that both sides of this committee will have heard, by my calculation, over 750 presenters from a variety of backgrounds and that this process allows more time for more public input than any bill in the previous two parliaments.
From my perspective, though, ultimately we as legislators have a duty, have a responsibility, have an obligation to act, to legislate, to consider the viewpoints that we have heard and that are available in written form as well -- and last night I did a bit of extra reading from the written briefs -- to consider all of those viewpoints and to consider the viewpoints of our constituents and to act.
Quite frankly, this morning yet again we heard from presenters who were quite anxious for the government to proceed with restructuring. They know that the system isn't working in health care, they know that the status quo is not working in health care and that patients are at risk. They are expecting us as legislators to act, to use our talents to act for the benefit of the people of Ontario. I, for one, would like to see us act sooner rather than later, because every month, every day that we delay action costs us, costs the taxpayers, costs patients resources that go to interest on the debt -- $1 million an hour. We spend more than we earn as a government. That means less funds, less resources to hospitals, to palliative care, to long-term care, to HIV sufferers, to cancer sufferers.
I, for one, cannot condone spending one more minute after January 29 on this piece of legislation. I intend to vote against the motion.
Mr Frank Miclash (Kenora): I'll try to remain calm, cool and collected, only if I'm not provoked.
As Ms Lankin has indicated, we have had a great number of requests, and I must say these are official requests, come to the clerk's office. We're not talking about the hundreds of phone calls that we get to the constituency offices from people wanting to know how they can become a part of this process, a part of the process I might suggest that Mr Harris promised them. I'll quote from what he called his Northern Focus Tour, back in January 1995, which he waved in the faces of many of my constituents in June 1995. It indicates, "Recognizing the special needs of people in the north, we will give northerners a direct say in changing the Ministry of Health's planning and resource allocation so that it concludes more consideration for northern priorities and conditions."
I must say, had it not been for the opposition tactic to get this show out on the road, the people in Timmins and Sudbury and Thunder Bay, and here in Ottawa, would not have been heard in their local communities. As I suggested to the presenter that day in Sudbury, there was no way that she would have been heard in the hearings that the government had suggested, up until that turning point.
As Ms Lankin has already indicated as well, we've had an overflowing crowd in every community that we have been to. These are people who have come in the hope that there may be a spot for them, people who have shown a great interest -- more interest than I've ever seen in a committee in my eight years as a legislator. I have to say that we have to take another look at what we're doing here. Ms Lankin has indicated that she would like this to go back to the House leaders for their discussion. I see nothing wrong with that. We have three House leaders sitting in Toronto, and I think they should have the opportunity, and I think this committee should give them that opportunity through this motion, to take another look at the number of people who want to make presentations to this committee as we move throughout the rest of the province and throughout Ontario and give them those opportunities.
We will certainly be supporting this motion.
The Chair: One minute left, Ms Lankin.
Ms Lankin: Let me just start by saying very briefly that I would dispute claims that Mr Clement continues to make about this bill having more public input than any other bill in the previous two legislatures. That is just patently false. I can show you the kinds of discussion papers and consultations that went into drafting of legislation, the kinds of public processes that were involved, which are all part of good governing and good legislation which is completely missing in this bill, which is unprecedented in its scope and unprecedented in the speed with which it is being rammed through.
You've said to people that you're listening. How can the people in this room have any faith that that is true when the vast majority of people who have come forward have asked for this bill to be split up and certain portions of it to be slowed down so there can be greater public input? If you're listening, then support this resolution, which does not determine the matter but simply says what this committee has heard and passes on that concern of the public to the House leaders for the House leaders to determine.
It is not our job to set the House agenda; it is the House leaders' job. It is our job to pass on recommendations from what we hear from people, and if you are truly listening, Mr Clement, you will finally support this motion, because this is what we have heard over and over again from the people of Ontario.
The Chair: We will now call for the vote. Ms Lankin has asked for a recorded vote.
Those in favour of Ms Lankin's motion?
Ayes
Lankin, Miclash.
The Chair: Those opposed?
Nays
Clement, Ecker, Johns.
The Chair: The motion is defeated, three to two. We'll recess until 1 o'clock.
The committee recessed from 1211 to 1301.
ONTARIO DENTAL ASSOCIATION
The Chair: Good afternoon. Dr Roger Howard is here representing the Ontario Dental Association. Welcome to our committee. We'll ask you to introduce all the presenters. You have a half-hour of our time. Questions, should you allow time for them, would begin with the government. The floor is yours.
Dr Roger Howard: Good afternoon, Mr Chairman. Thank you for this opportunity to meet with the committee about the Savings and Restructuring Act. I'm Roger Howard. I'm a general dentist practising here in Ottawa, and I'm also president of the Ontario Dental Association. With me today is the ODA's executive director, Mr John Gillies, and our director of professional affairs, Linda Samek.
The Ontario Dental Association is the voluntary professional organization which represents the dentists of Ontario, supports our members in the provision of exemplary oral health services and promotes the attainment of optimal health for the people of Ontario. As independent health providers, our members understand the challenges of delivering care within today's dynamic and changing environment. The changing economy is just one of many factors that must be considered in the management of our own offices as well as within Ontario's health care delivery system.
As responsible health care professionals, our members recognize that it may be necessary to implement some system-wide changes if we are to balance the delivery of quality health care services while managing related public costs. We believe we can and must accomplish the dual goals of delivering quality care and controlling costs without dismantling the existing legislative framework.
Let me assure you this is not a plea to retain the status quo. We are not resistant to change, but we are concerned that the omnibus legislation has created an atmosphere of fear, mistrust and confusion for health care professionals and the public alike.
There is a perception that the government is attempting to tear down current structures and have the minister take control of the day-to-day management of the health care system, especially our hospitals. While we do not subscribe to this theory, we recognize the need to find avenues that will enable all parties to enter into meaningful partnerships with the government. The ODA wishes to assure members of the committee that it's our intent to work with the government and other interested parties to develop responsible solutions to identified problems within the current system.
Our goal is to ensure that the legislative framework supports a health care delivery system that recognizes the needs of the public, the responsibility and accountability of individual practitioners, and leadership from the community, from health care workers and the government. As we revise the existing legislative framework, we must work to preserve key Canadian values such as providing access to care as close to home as possible, delivering quality care, maintaining individual dignity and contributing to the quality of life of individuals.
As we stated earlier, we believe that the balanced evolution of our health care system depends on a cooperative partnership with government -- a partnership of providers, voluntary and regulatory organizations, our public institutions, the ministry and the public that we all serve.
As a voluntary professional organization, we are here today to discuss some of our thoughts about this bill and how it may affect Ontario dentists, other practitioners and individual Ontarians. We believe it is possible to find practical solutions to some of our concerns about the bill, solutions that will work for the government, for providers and for the public.
With this as background, we trust that you will find the following comments helpful.
The first of the three or four areas we will address relates to the areas of confidentiality and recordkeeping. Under part II of schedule F, amendments to the Public Hospitals Act, there is a provision to draw regulations regarding the ownership, custody, use, disclosure, retention and disposal of medical records.
Similarly, part IV of schedule F, amendments to the Independent Health Facilities Act, permits the minister to collect, directly or indirectly, use or disclose personal information in the administration of the Independent Health Facilities Act, the Health Insurance Act or the Health Care Accessibility Act, or for other purposes that may be prescribed.
Schedule H, the amendments to the Health Insurance Act, outlines amendments to the Health Insurance Act and also permits the minister to enter into agreements to collect, use and disclose personal information concerning insured services provided by physicians, practitioners or health facilities.
In Ontario, our health care system protects the privacy of the patient-practitioner relationship. There are specific legislative requirements that seek to protect the welfare of children, and other limited circumstances of public protection that provide for the release of information. Our patients rely on their health care providers and our public institutions and structures to safeguard their personal privacy, yet the broad powers of information collection and disclosure scattered throughout Bill 26 provide no limitations for government respecting either the patient-practitioner relationship or the release of the personal and private information contained in the patient record.
The powers of collection and disclosure granted to both the Minister of Health and, under the Health Insurance Act, to the general manager of OHIP are too broad and vague. If they were adopted, these new sweeping policies would violate patient privacy. It is particularly disturbing to find that the powers do not appear to be limited to the delivery of insured services. Rather, there is a blanket provision which deems insured persons to have authorized the disclosure of information related to services provided by a physician, practitioner, hospital, health facility and any other prescribed person or organization.
We believe that the vague language related to data collection and disclosure may lead to the release of confidential information which could be harmful to individual patients or groups of patients. With a better understanding of the goal of such clauses, we would be able to build in needed public safeguards. The unrestricted powers appear to be both unnecessary and unreasonable. The public we serve, health care providers and our public institutions need to understand what information will be released and how the information may be used.
We are pleased to learn that the minister is working closely with the privacy commissioner and reconsidering all sections of the legislation related to the collection, use and disclosure of information to ensure that the necessary information controls are built into the legislative framework. Because of the potential for the inadvertent release of patient information, it is not practical to leave the development of protective safeguards to the regulation-making process. Meeting the concerns outlined by the privacy commissioner and others, including limitations on the collection, uses and disclosure of information in the act, would result in a significant improvement in this legislation. We certainly look forward to an opportunity to review amendments in this area.
Turning to another recordkeeping matter, we suggest that consistent recordkeeping requirements be introduced for practitioners. Recordkeeping regulations are drawn under the Regulated Health Professions Act and the related profession-specific acts; therefore, we do not believe it is necessary to draw additional recordkeeping requirements under this legislation for regulated providers. While we believe it may be redundant to set out recordkeeping requirements in the Health Insurance Act, we suggest that any parallel requirements for regulated health care providers be consistent with the profession-specific clinical and financial recordkeeping requirements. This approach will avoid confusion for practitioners and permit practitioners to take a streamlined approach to recordkeeping.
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The second matter we want to touch on is the change in definition under the Independent Health Facilities Act. Under the existing legislation, an independent health facility means "a health facility in which one or more members of the public receive services that are insured services and for which facility fees are charged, but does not include a health facility mentioned in section 2."
We do not understand why the phrase "insured services" has been dropped from the meaning. Without any understanding of the intent of this change, we're concerned that some of our members may inadvertently be captured under this new definition. As the majority of our members do not provide OHIP-covered services, you can understand our apprehension about this wording change. We're flagging this as a potential problem and suggest that the phrase "insured services" remain in the definition of an independent health facility.
The next matter on our list is the setting of fees for insured services at nil, at zero. The ministry has established both a fee-for-service payment system and an alternative delivery payment mechanism related to the delivery of insured health services. Under this legislation, the ministry retains the right to establish covered services and also to establish services that will not be considered to be covered for the purposes of the Health Insurance Act. We expect that the ODA will continue to be included in the consultation which leads to the establishment of either an insured or a non-insured service. But, with the consultation completed, we would not support the establishment of zero-rated insured services.
Under the OHIP fee-for-delivery system, our members continue to subsidize the delivery of insured services to the public. We accept that the OHIP schedule of benefits does not reflect the true cost of providing services. We cannot, however, accept that government would mandate practitioners to provide services for free.
Our members believe in charity, and through our component societies many dentists participate in local programs such as Dentistry With a Heart where individual dentist offer their services free of charge. But this is a voluntary charitable program. In our view, charity should continue to be an individual choice.
These decisions are taken voluntarily by individual dentists out of their sense of professional responsibility. As with all those who provide public services, these are private acts of charity that are part of any civilized society. In the past, legislators decided that society should not have to rely solely on such private acts of charity to meet basic needs such as health care. We should not consider returning to such an era.
If the ministry is intent on not paying for specified services, those services can be delisted. Therefore, we ask that subsection 17.1(4) of the Health Insurance Act be deleted to ensure that practitioners are not required to reduce fees for OHIP-covered services to nil.
A prime concern for the ODA relates to the role and powers granted to the general manager of OHIP. With the increased role and powers granted to the general manager, protective checks and balances are lost. Under Bill 26, the physician or practitioner review committees need not receive referrals from the general manager for investigation. Instead, the physician or practitioner must request that the appropriate committee review the decision of the general manager. Further, for the practitioner to have the decision reviewed by the committee, an application fee must be paid. This fee merely serves as a roadblock in the process of achieving a full investigation and a hearing related to the matter.
It's particularly disturbing to learn that the findings of the appeal to the review committee would not be supported with the review committee's reasons for the decision. The written reasons for the decision will only be made available to the persons affected upon request. Finally, the physician or practitioner who is required to reimburse the plan will be required to pay an additional amount for the cost of the review.
We are concerned that the general manager is granted excessive powers that would be better placed in the hands of a review committee charged to investigate the matter and make appropriate findings. We recognize that an OHIP profile of a practitioner or a patient inquiry may cause the general manager to believe that there are billing irregularities. However, there is no mechanism outlining the manner in which the general manager should make a final decision about these matters. In fact, we are concerned that the general manager would be asked to make decisions about whether services were medically or therapeutically necessary and provided in accordance with accepted professional standards. It is one matter for the general manager to suspect that there may be a problem, based on information such as the volume of services provided; it's another to expect that a judgement could be made on superficial information. Is the general manager expected to make a patient diagnosis to determine medical necessity?
A clearly defined process, including a formal review by an appropriate committee, is required to make decisions which will have an impact upon the reputation and livelihood of individual practitioners. Unfortunately, the cost of achieving this due process under Bill 26 serves as a deterrent to the practitioner who wishes to simply resolve the matter. In our society there is a generally accepted custom to prove that there is a finding of guilt. We create a slippery slope for justice when a single bureaucrat is granted the authority to identify a potential billing problem and simultaneously is granted the power and responsibility to make decisions based on that assumption of guilt.
Despite our concerns about the role and authority outlined for the general manager with respect to the management of the system, we agree that the review process must be seen to be more efficient. The establishment of multiple review panels may assist in streamlining the decision-making process, but we believe more can be done to fix today's problems by involving the professions in the solution.
Therefore, we propose that an ad hoc committee of professions that receive payment from OHIP be formed to develop solutions that will balance the need for an efficient and effective decision-making mechanism intended to eliminate abuse and, as necessary, seek reimbursement from practitioners while ensuring a fair process is available to those suspected of utilizing the system inappropriately. The ODA would volunteer to lead such a process if the minister would delay proclamation of this section for a six-month period within which the parties would be required to arrive at an alternate solution to this matter. We think this is a workable solution that leaves the onus of designing an acceptable review process in the hands of those who must live with the result. In the end, the government retains the authority to implement an alternate process, but we believe that providers have the incentive to develop a fair review mechanism: fair for providers, fair for patients and fair for government.
Before closing, we want to turn briefly to the importance of strategic planning. Because we believe that tough times require the best in strategic planning, we want to touch on our concerns about the planning disincentives built into this legislation.
The authorities granted to the minister to alter funding terms, to set fees at nil and to revise agreed-upon human resource plans are just a few of the examples of system-wide planning disincentives. Now more than ever we need to explore options that will reward sound fiscal and professional planning to make the most of our resources. We need to develop systems that encourage all parties to honour commitments that were made in good faith. We need to develop a framework that ensures the public they can rely on the agreements carved out by regulated professional providers and the government in the interests of society. We cannot manage this complex health care delivery system in a reactionary mode.
There is much more that must be said about Bill 26, and our association will be providing the committee with a detailed brief in the next few days. We believe these hearings have provided an opportunity to explore areas that can be improved upon without detracting from necessary government controls. We are pleased that there was an agreement to engage in this important consultative process.
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As we conclude our remarks, I will quickly summarize some areas of the bill that we have asked the committee to consider: first, the need to build in appropriate protections for the collection, use and disclosure of confidential patient information; second, the need to include the phrase "insured services" in the definition of "independent health facility"; third, the inappropriateness of establishing zero-rated fees for covered health services; fourth, the opportunity to establish a multidisciplinary committee to consider alternatives to the proposed sections of the bill related to the powers of the general manager of OHIP and the role of the physician or practitioner review committees.
I don't need to tell all the members of the committee that this is a very complex bill. You have a great deal of work ahead of you. We trust that our comments will be helpful in your deliberations. If there is still time, we would certainly be pleased to answer any questions.
The Chair: Okay, thank you. We've got about three minutes per party, beginning with the government.
Mrs Ecker: Thank you very much, Dr Howard and Mr Gillies and Ms Samek, for taking the time to come to Ottawa and provide some excellent suggestions on the legislation.
Just a quick point on removing the words "insured services" out of the Independent Health Facilities Act. I can appreciate the point you're making about the impact on the dental profession of that, but my understanding of the purpose of that is that the difficulty when the legislation was originally put together was that it limited itself to insured services, and the quality assurance provisions within that legislation were therefore limited to just those kinds of clinics and facilities, which at the time was a legitimate judgement, I understand, because that's where most of the services were.
We now have a whole bunch of clinics and facilities that are offering a lot of kinds of services, from cosmetics to other things. There have actually been deaths, at least one death that I'm aware of. The intent was to try to take those quality provisions and extend them to some of these other kinds of clinics where they need this. So that was one thing, as I understand. You may wish to elaborate on that.
The other quick question I wanted to ask was that the College of Physicians and Surgeons, I understand, has brought forward suggestions for streamlining the medical review process to go after some of the misuse in the system. You're suggesting here a review process from the professions. Are you suggesting that would be in addition to, or are you familiar with what's perhaps happening there? It's certainly a unique suggestion that may well be worth looking at.
Dr Howard: I'm not familiar with what the physicians are proposing. We would be pleased to help lead any process that would find a solution that would meet the needs of the government as well as meeting the needs of the profession and the public.
Mr John Gillies: I think our concern principally, on the first part of Mrs Ecker's question, is that certainly the government has a responsibility to deal effectively with the services for which they are responsible as the payors. The way that we read the bill, that could be extended significantly to virtually replace the public licensing authorities or the regulatory bodies that are in the field. After going through this whole concept of the health professions legislation review that was initiated in 1982 that we've all been working on over this long period of time, it seems silly for the government now to turn around and just displace that whole exercise that's taken place over that period.
Mr Miclash: Mr Chair, you'll remember that at noon I read into the record a quote during the debate on a resolution that we had put forward to us, and that's to extend the hearings because we're hearing from such groups as this. I referred the document that Mike Harris put out at that time saying that he was going to consult with the people across the province of Ontario in terms of any changes to the health care system.
You represent a good number of health care professionals in this province. The question I would ask is, as I've asked many times to a number of deputants before the committee, were you consulted on any part of the drafting of Bill 26 before it was presented?
Dr Howard: We were not consulted before the legislation was drafted. We certainly welcome any opportunity that we have to meet with government and discuss our concerns. Any opportunity for dialogue between the professions and the government we think is useful and helpful. We believe the ODA has a track record of working with government to find solutions that meet the needs of government, the professions and the public.
Mr Miclash: Do you know of any other groups that were consulted in the drafting of this bill?
Dr Howard: I wouldn't be able to comment on other groups.
Mr Patten: I likewise would like to congratulate you on your paper: very thoughtful and a very nice demur by which you present this. But there are some very serious points that you've identified, two of which in particular I'd like to know, if not changed in the proposed legislation -- the inclusion, for example, of "insured services" and the establishment of zero-rated fees where you're obliged to provide those services without any compensation. If those are not done, what's the impact on your profession?
Dr Howard: I'm sorry. Could you repeat the last part?
Mr Patten: The impact on your profession potentially, if you could do a best-case/worst-case scenario. If no amendments are made to the legislation as it is now, if it does not acknowledge the insured services definition, for example, what could potentially happen?
Dr Howard: I think as you have identified, practitioners would be required to provide services at no fee, and we don't feel that's appropriate. If the government does not wish to pay for a particular service, that service should be delisted. If they wish to pay for that service, it should be part of the covered services.
Ms Lankin: I too appreciate the constructive tone of your presentation. I think there are some very good suggestions there.
A comment before I ask my question. Throughout the brief you've made some references to the concern you have about the need to develop protective safeguards in the legislation and not leave it to simply the regulation-making process, which is much more behind closed doors and not open necessarily to the kind of public input and scrutiny these public hearings are providing for the legislation itself. You've said that with respect to the privacy commissioner's concerns, with respect to the general manager of OHIP's concerns, but you have suggested perhaps an alternative that allows for a six-month process before this piece of the legislation is proclaimed.
I just caution you that what you end up with at the end of the day then is perhaps a voluntary agreement, but with a piece of legislation that still provides all the powers to the general manager of OHIP to make those determinations about medically and therapeutically necessary services. The problem you have is that while you might have a very good relationship with the current Minister of Health, at any point in time that voluntary agreement can be abandoned and you rely on what is in the legislation. So I think our opportunity to get it right is now, by building these things into the legislation. That's just a comment.
I want to come back to the independent health facilities question, because Ms Ecker has today and on other occasions said the intent is to extend the quality control provisions to a whole range of other health care settings, and that could well include your profession, chiropractors and many more. It also would extend the right to revoke licences on 24 hours' notice, to hand out licences without tender, to open up for-profit, American-owned as opposed to the system that's there now.
You're regulated by a college. What are the quality controls there? Should we be concerned that you don't have any quality assurance, and do we need this legislation, as Ms Ecker said, to extend that?
Dr Howard: A comment to your comment. I think, as you know, we strive to maintain good relationships with any Minister of Health.
Ms Lankin: That you do.
Dr Howard: On the second aspect of that, the concern on the regulatory authority, we do have a mandated quality assurance program. Every regulated profession in Ontario does so as part of the new disciplines under which we operate. So we're having some difficulty in understanding the transfer that appears to be taking place here, and quite frankly we haven't captured the rationale for it, although we certainly recognize that the concerns are great and the impact could be very ominous.
We have some degree of confidence, I think, that people will be aware of the concern and the fact that there may be other methods of dealing with this, and I think the consultative process that is taking place at these hearings hopefully will result in the necessary changes.
Ms Lankin: We hope so too.
The Chair: We appreciate your presentation with us today and thank you very much. Have a good day.
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CANADIAN UNION OF PUBLIC EMPLOYEES LOCAL 870
The Chair: The next group is the Canadian Union of Public Employees, Local 870, represented by Betty Sommers. Good afternoon and welcome to our committee.
Ms Betty Sommers: My name is Betty Sommers and I am the president of the Canadian Union of Public Employees, Local 870, representing approximately 450 workers at the Perley Rideau Veterans' Health Centre here in Ottawa. But I am here today also representing more than 20,000 health care workers, including nursing and support staff here in Ottawa-Carleton.
The Savings and Restructuring Act represents an enormous fraud and breach of promise perpetrated against the people of Ontario by the Harris government. It is the prelude to a revolution, not a Common Sense Revolution, but one that achieves its goals at the expense of the elderly, the poor, the disabled and all the vulnerable members of our society who seem to be heartily despised by those currently in power. Bill 26 is not about reform or even saving money; it is about slashing programs, privatizing our social support system and, on a more fundamental level, dismantling the democratic structures that give the citizens of Ontario control over the future of their province.
In regard to health care, Bill 26 gives the Minister of Health unlimited authority to enact the onerous cutbacks announced in the government's economic statement. The elimination of funding to the hospital sector alone could result in the layoff of up to 26,000 workers -- up to 2,000 in Ottawa-Carleton -- and will severely restrict access to health care services. Bill 26 will profoundly damage publicly funded medicare and encourage the privatization and corporatization of health care, similar to the American style of health care. If this legislation is enacted, we will see rapid encroachment by the private sector, whose goal is to see profit from illness, disability and death.
This government, if it chose to do so, could promote genuine reform that would improve quality and access to care in an equitable and cost-effective manner. Key to this type of reform is the creation of a supportive environment for good health, which includes a strong social safety net and other public policies that ensure shelter, education, food and a safe work environment. Governing bodies of the health care system need to be democratic, accountable and representative. In addition, specific action must be taken to stop the true waste in the provision of health care, namely, the elimination of fee-for-service payments which encourage overbooking, overprescribing and overtreating by physicians. In addition, we need to enact genuine patent law reform that promotes lower drug prices. Controlling drug costs would free up millions of dollars for health care. Streamlining administration would save millions of health care dollars by eliminating unnecessary site-by-site duplication of services.
Finally, we must preserve and strengthen the Canada Health Act. Unfortunately, recent statements by the Minister of Finance indicate that this government sees the Canada Health Act as an impediment to their ability to privatize health services.
Cuts to the drug benefit plan: The Ontario drug benefit plan provides payment for prescription drugs to seniors and those on welfare. Should schedule G be enacted, the legislation will have dramatic impact on low-income persons and seniors. Bill 26 would put a two-tier health system in place, since a user fee for prescription drugs will be introduced. This, along with the proposed $100 deductible for the poor, will mean large numbers of the sick will be unable to afford treatment. This is another breach of promise by the proponents of the Common Sense Revolution, who clearly stated in their election campaign that new user fees would not be introduced and that services to seniors and the disabled would remain untouched. As with other sections of Bill 26, the minister and cabinet will have power to establish and set, behind closed doors, the levels of user fees under the Ontario drug benefit plan. Cabinet will essentially act as pharmacists, making decisions over which drugs are eligible to receive reimbursement under the plan.
The interference in the medical process by the government is astounding. Medical necessity or other health criteria do not have to be considered; cost will be the criterion.
Deregulation of drug prices: Bill 26 will repeal the power of the minister to regulate the prices of drugs charged to anyone not covered under the Ontario drug benefit plan. Drug companies will be free to determine the prices for products other than those provided under the drug benefit plan. Without regulation we can expect that the cost of drugs will increase substantially.
The government is also putting itself above the law. Not only does the legislation remove any public process for setting prices of drugs and determining issues under the Ontario drug benefit plan, but it is reversing court rulings that went against past government decisions.
Power to impose user fees: Bill 26 would provide explicit authority for cabinet to make regulations which could permit hospitals to charge user fees for any hospital-based insured services, including those already covered under OHIP. As an example of this, the government has already announced that hospitals will be able to charge daily user fees to those patients in acute care beds who are awaiting placement in chronic care facilities or nursing homes. Patients will essentially be penalized because they are forced to wait for services that are already critically underfunded and are going to be cut even further by the Harris government.
With this new legislation, the Tories are encouraging hospitals to offset their budget reductions by charging user fees, allowing them to bring in additional revenues at the expense of the patient. This is yet another example of the broken promises by the Tory government, which promised the citizens of Ontario that no new user fees would be introduced during its term of office.
Delisting of medically necessary services: To date, the Health Insurance Act has required that OHIP cover all medically necessary services. Under Bill 26, the cabinet will decide which services are insured and under what limitations and conditions. These provisions will most likely be used to limit access to services which are now provided under the Health Insurance Act. The government can decide at will which types of care are medically necessary and which are not. The potential for abuse is enormous, and certain services which are currently covered under OHIP could be delisted simply because the government decides they are too expensive.
Loss of confidentiality of medical information: Confidentiality of personal medical information becomes a thing of the past under this legislation. Bottom-line economic considerations will override the right of citizens to have their personal medical histories held in confidence. Bill 26 will allow the minister to collect, use or disclose personal medical information for various administrative purposes.
One of the key rationales for this disclosure is that it is necessary for the "effective management of the health care system." Those who are most vulnerable in our society could find themselves the victims of a campaign to deprive them of adequate and necessary levels of care, because the government deems them to be abusers of the system.
Impact of Bill 26 on hospitals: Bill 26 will give the minister virtually unlimited powers with respect to the funding and operation of public hospitals. It will allow the minister to ignore the needs and desires of the local communities, such as Ottawa-Carleton, that access hospital services and give him unlimited control over all hospital matters.
Ottawa-Carleton is facing a 38% increase in demand for health care services, which will exist as a result of estimated growth and aging of the population by the year 2006.
We in Ottawa-Carleton should not be cutting any more acute care beds. Ottawa-Carleton has decreased its inpatient hospital utilization rate by a staggering 43% between 1989-90 and 1993-94, with a further 104 acute care beds that have been cut since that time. Ottawa-Carleton already has a significantly lower acute inpatient day rate per 1,000, at 647, than the provincial average at 694, or Klein's Alberta rate at 927, where protests over hospital cuts have resulted in a moratorium on further cuts.
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Our calculations indicate that if we adjusted the acute care bed complement of 1,874 beds in 1993-94 to reflect the estimated demographic growth to the year 2006, approximately 2,586 acute care beds would be required, which is 816 more than currently exist.
As for chronic care and long-term care, at this time there are 169 persons awaiting placement into chronic care and an astounding 1,111 persons are waiting for a bed in a long-term care facility.
Currently in the Public Hospitals Act, funding is allocated by specific criteria and regulation. The minister cannot terminate funding simply for budgetary reasons. His decisions must take into account their effect on patient care. Under Bill 26, however, the minister can decide that the availability of financial resources is the only relevant criterion when making funding decisions.
The minister also has the unlimited authority to close hospitals, force mergers between institutions or order hospitals to change or eliminate the types of services that they deliver. Since the government has made it clear that it thinks that too much money is spent on inpatient services already, it can also use this bill to compel hospitals to reduce the volume of acute care that they provide. This will result in patients being forced out of the system much too quickly, or even denied appropriate levels of care. As a result of these changes to health care, we believe that people will die unnecessarily.
Since the government has also stated that up to 38 hospitals in Ontario must be closed, the bill will provide it with the necessary mechanism to achieve this goal quickly and aggressively. No public consultation will be necessary on even a superficial basis.
Finally, Bill 26 provides tremendous levels of liability protection to the government during the restructuring processes. They cannot be sued or held accountable for virtually any actions that they take under the authority of the new legislation. The Ministry of Health will become a dictatorship and the citizens of Ontario will have no recourse or protection from the damage that will be inflicted on them by the Harris regime.
Privatization through independent health facilities: Changes to the Independent Health Facilities Act essentially eliminate tendering processes by giving the minister the authority to request proposals from specific individuals for the establishment of a private health facility. The new legislation will also eliminate the requirement that preference be given to non-profit Canadian operators.
These changes will allow the Minister of Health to handpick corporations or individuals to open up shop, even open up franchises of health care clinics that charge patients money. In tandem with the massive cuts being proposed to health services, it seems clear that this new legislation will allow health care gaps to be filled by more private companies intent on making profit from sickness.
Interest arbitration: We strongly object to the proposal which would force arbitrators to consider ability to pay in determining their awards. Funding in the public sector is determined by financial decisions. Thus, if ability to pay were a criterion in interest arbitration, the Harris government could determine wages and benefits simply by allocating fixed or reduced amounts for employee compensation. The introduction of this kind of restriction would make the interest arbitration process a complete sham.
We believe that the most appropriate way to settle collective agreements is by allowing the parties to test their strength with the option of resorting to strike-lockout mechanisms. Legislation which forces compulsory arbitration on certain groups of employees should be repealed and these employees should be granted the right to strike. They have already been denied these rights because previous governments have deemed their work to be part of an essential service. It is, however, ludicrous for the current government to hold the same position. If the Tories can eliminate the jobs of up to 26,000 hospital workers, then surely they cannot deem their work to be essential.
Conclusion: This government's attempt to ram through Bill 26 with virtually no public consultation is a foreshadowing of the way the business of the province will be conducted in the future. If the Tories have their way, all government will be a business, one committed to transferring as much of the public purse as they can into the hands of their friends in the private sector, regardless of the impacts on the citizens of Ontario. These impacts will be severe, and none more so than on the delivery of care, which will no longer be based on access or quality of services but on the financial considerations and the desire to privatize Ontario's medical system.
The proposes changes to hospital and health services will damage beyond repair publicly funded medicare, a system which tries to protect all Ontarians in an equitable and compassionate manner. If this legislation is enacted, there is no doubt in our minds that the people of this province will experience a rapid and tragic decline in the quality of care they currently receive.
Taken as a whole, Bill 26 represents a vicious assault on basic principles of democracy and accountability. It is a perversion of the trust placed in the government by the electorate. It illuminates the multiple deceptions and contradictions and shows the Common Sense Revolution to be nothing more than a dictatorship.
On behalf of the thousands of health care workers here in Ottawa-Carleton, we demand that the Harris regime withdraw Bill 26 in its entirety or face the democratic consequences of a betrayed electorate.
The Chair: Thank you. We've got about four minutes left for questions, beginning with the Liberals.
Mr Patten: Thank you, Ms Sommers. A number of the issues you raise have been identified by others as well, particularly the concern about the overwhelming power grab in this bill. Given your position with CUPE, when you discuss among yourselves, what fears do you have related to jobs? How many jobs do you see this affecting in terms of lost jobs, in terms of perhaps part-time jobs or this sort of thing?
Ms Sommers: In analysing the figures, we figure at least 2,000 jobs lost or reduced from full-time to part-time; at least 2,000 jobs here in Ottawa-Carleton.
Mr Patten: That's a lot of jobs.
The provision you identified of ability to pay is a crucial element, in your view and in many others' as well. We have to adjust arrangements for a perceived expensive system, and if not contain costs, find costs. This government's committed to that. What contribution can the union make to the frugalization or the efficiencies of a system that are not continuing to rise in cost?
Ms Sommers: That's a difficult question to answer, but I feel there are many ways that could be addressed. There is wastage in the system. In our workplaces we see it. There's duplication of administration services, there's waste of food, there's waste of everything, and that all costs money. Our members feel very strongly that if issues even as small as that were looked at, thousands and maybe even millions of dollars would be saved in the systems.
Ms Lankin: Thank you very much. I appreciate your presentation. I have questions in two areas. I'm going to start off with the issues you raise around interest arbitration. I'm glad you've raised them. I believe the government genuinely doesn't understand, because it has said it thinks it's reasonable that ability to pay should be considered, that it's a limited purse. They don't understand that what arbitrators have come to say very strongly in the past is that ability to pay is simply willingness to pay in terms of the decisions made about budgets, about revenues, and workers have no control over that. I've urged them to read the Johnston commission report coming out of the CUPE hospital strike so many years ago that set out a lot of this.
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But I want to deal with one particular group of employees that will be affected. This affects police and fire, and under the Hospital Labour Disputes Arbitration Act nursing home employees are covered and for-profit nursing home situations will be covered. Here we'll have a situation where for-profit employers, businesses, will get to determine what on their bottom line goes to the profit, what's left over, go over and make a pitch to an arbitrator that that's what they have the ability to pay and those workers' wages will be affected by that decision. Am I correct in my understanding of the application?
Ms Sommers: Yes.
Ms Lankin: Your union represents some of those. Can you talk about where they're at now on the wage scale and what you think this means for that group of employees?
Ms Sommers: Especially for workers in the nursing home sector, they are already grossly underpaid, and the majority of those workers are women. If wages and benefits were to be reduced even further, they would not be able to work in those jobs because it wouldn't even be feasible to be there. Then where would they be? On the welfare lines and wherever. That would be an added burden to the province.
Also, the concerns I hear from these nursing home workers is that they're grossly underpaid and the quality of care we're delivering is already at risk because there is reduced staff as it is. These owners are running a business for profit and if they can get three people to do the work of six people, they'll try. Who's at risk more than the patients in these nursing homes?
Ms Lankin: My second question is around some of the concerns you raised about services being unilaterally delisted. The possibility is there for that in the legislation. I read into the record the other day a letter from a doctor to a senior cabinet minister in this government in which he reiterated a discussion they had that set out an intention on the part of the government to develop a list of core services. We've heard this elsewhere.
Yesterday we heard from a bioethicist who said this necessarily means that those things that are not covered will be paid for in the private market. There are some people in this province who believe that's the appropriate way to go, that we can't continue to pay for everything. We've heard that, but that's not a debate we've ever had. It fundamentally changes the values of our health care system, and as Canadians in Canadian society, the values in our society are very intricately connected to the values of our health care system.
Have you been part of any debate? Do you think the government's campaign set out their intention in this direction? Is that a debate we need to have before this government proceeds with these kinds of powers?
Ms Sommers: Very clearly, there needs to be a good long debate on that. And no, to my knowledge, no one from the labour movement has had an opportunity for that kind of debate.
Mr E.J. Douglas Rollins (Quinte): Betty, thanks for coming to this forum of debate with the government, to the hearing. I think it does give the opportunity for dialogue. I don't always agree with the things you have, and of course we don't always have to agree, but there is an end result we need to look at.
One thing you've expressed was that deregulating drug prices would definitely cause prices to go up. Most people, particularly most people in the free world, agree that competition has a tendency to put prices down, and as soon as you deregulate that and allow these big companies to compete for the market, they're not going to sell drugs if they're priced too high. I think most people do have the ability to find out who's selling the cheaper drugs.
You also seem to think our health budget is being cut. I think it's been restated on many occasions by our minister that the dollars earmarked in that envelope for our entire health budget are going to stay the same. It may be adjusted from time to time, because we do know there have been some deficiencies and inefficiencies in the system.
We have closed some 6,500 beds in the province of Ontario in the last two or three years, but we have not closed one administration. Common sense tells you that when you remove that number of beds from the system, somewhere along the line some of those piles of bricks should have closed doors on them; otherwise we're heating floor upon floor of hospitals that have not got anybody in them. They're just there; they're not running at capacity. It's more efficient, more commonsense to close one or two or three of those hospitals, put those facilities together and make them more efficient. That's one of the things this government has been trying to do.
You stated that we said we were closing 38 hospitals.
Ms Sommers: I said up to 38.
Mr Rollins: That's a little misleading: up to 38 hospitals. We will probably look at closing any hospital where there can be some amalgamation and some dollar saving to keep allowing the public to have the good service they have. You've stated here that you've got 169 people waiting on a list, you've got 1,011. Is it working now? I would say it isn't. Is the system working now?
Ms Sommers: The system isn't working properly, but the answer is not to close hospitals. The answer is to look at who is in those beds. As you said, X beds have been removed from the system. Why have those beds been removed from the system? Because there has been no funding dollars for those beds. It's not as if there are not people waiting to go into these beds.
Mr Rollins: In all fairness, we've changed the system around and we have to give the hospitals some credit. These hospitals have put a lot more patients through in a lot shorter time and have done a lot of day surgery that's put people back out into the system, to still allow us to continually support other payments.
There's a perception that this government's in the position that we're going to null and void all health care. That is not the intent. We want a better bang for our buck, and we're darned well going to try to push every department and every facility of it to try to get it.
You also mentioned the arbitration. Over the last four or five years, as anybody who reads the paper well knows, arbitration has never taken into consideration the ability to support of the people paying the bill. All they're looking at is one thing and one thing only, entirely on the one side of it. Those arbitrators are going to be asked by this government to take a good, firm stand in looking at the ability to pay of the people who provide the tax dollars. You and I and all the rest of us are the taxpayers. That's who we have to look after. We can't afford to raise more taxes. It just doesn't work that way any more.
The Chair: Thank you for your presentation. We appreciate your involvement in our process.
CHARLES SHAVER
The Chair: The next presenter is Dr Charles Shaver. Good afternoon, and welcome.
Dr Charles Shaver: Thank you. First of all, I'd like to give everybody in this room a bit of background, because if you know where I'm coming from, you'll understand why I'm here.
I was born in Montreal. My father was a neurosurgeon, trained under Dr Penfield, was forced to go to the United States for further training and could never return to Canada -- lack of jobs. I grew up in the Midwest, went to Princeton on a full scholarship, graduated in biochemistry in 1966, to Johns Hopkins in 1970, and returned to Canada that year. Probably because of the 24 years I spent in the United States, I've been very attuned to issues such as freedom and justice and equality, and that's why I'm here today.
I spoke before the Peterson government about 10 years ago in Toronto when Bill 94 was being discussed, and at that time I was looking for something that would make the public concerned about progressive erosion of freedom of physicians. At that time I predicted that there might well be a loss of confidentiality of patient records. I summarized it as: An employer is always entitled to see his employee's work, and our charts are our work, so the more we become employees of the state and the less autonomy we have, the greater the risk is that the government can at its will look at private patient records.
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I'd like to just quickly go over my presentation here, which many of you have. I might let you know that this was published today in the Hamilton Spectator and it went on the wire services of Southam, so it may appear in some of the other regional newspapers.
As you know, this bill is scheduled to pass final reading on January 29, and in it the Ministry of Health will assume unprecedented powers and will be able to dictate when, how and if physicians can practise. Existing agreements with the Ontario Medical Association will be cancelled and the subsidy of malpractice insurance will cease. These issues have been covered elsewhere, and I will not deal with them here.
The minister alone will determine which areas are overserviced and will not issue new billing numbers to family physicians contemplating setting up practice in any of these areas. I understand there are about 12 different counties that have been designated. Seemingly ignored are situations in which a spouse can only obtain employment in a large city or perhaps in which children require special schooling.
In the Ottawa Citizen last Saturday, there was a large letter from an older physician who had practised in rural areas who is now teaching at the University of Ottawa, and he was extolling the virtues of rural practice. As I read the letter, it occurred to me that he could never duplicate this today, that he would be banned from returning to a large city to impart his knowledge to the new residents. I think this has been overlooked. A billing number is a one-way ticket to an outlying area.
The legislation also states that a specialist affiliated with a hospital has to have privileges in order to retain his billing number. Already many dermatologists, psychiatrists and radiologists practise entirely outside of hospitals. Would they then lose their billing numbers? What would happen to a specialist now at a hospital targeted for closure? Would that specialist be able to continue his office practice while looking for a new hospital appointment? If he were not able to find a hospital in this city, would he be able to locate to another city in Ontario? He probably would not be able to locate to another Canadian province, with the possible exceptions of Saskatchewan and Newfoundland, because of restrictions on billing numbers and licences, and it would probably be easier for him to simply go to the United States.
An older internist such as myself might eventually want to give up some of his active hospital privileges so as not to be required to work nights and weekends in the emergency department. It's unclear to me from the legislation whether he'll be allowed to maintain a pure office practice during his last few years before full retirement. So it's not clear to me whether "hospital affiliation" means active or simply consulting staff.
Also, the minister would possess the authority to determine retroactively which consultations and other services in his opinion were medically and therapeutically unnecessary, but these might be based more on fiscal than on medical considerations. Moreover, the indications for many surgical procedures, medications and diagnostic tests change rapidly, and a consensus at a given point in time is difficult to achieve even among experienced clinicians. Let me give you a few examples, just in my brief professional career.
Not too many years ago, people with diverticulosis were placed on low-fibre diets. Now they're placed on high-fibre diets.
When I was training in cardiology in Toronto, Dr Donald Beanlands, who is now head of cardiology at the Heart Institute, told me and all of the other residents that a clot had nothing to do with a heart attack initially, that the clot was a secondary event. It was only a few years later that people went back to the old thinking and discovered that the clot was important, and they developed thrombolytic therapy, the use of blood thinners to treat acute heart attacks.
As far as people who were on the dialysis list awaiting a kidney transplant, in the early 1970s we were told not to transfuse these people because we would expose them to foreign antigens. Later on the concept of blocking antibodies developed and we were encouraged to transfuse patients. I understand in the past five years, after reanalysis of the statistics, these people actually did not do better with transfusion and of course they were exposed to HIV and hepatitis C. So now we've gone one and a half cycles around the clock.
If you were a bureaucrat in Toronto or in Kingston, determining whether a transfusion was necessary in a dialysis patient, what criteria would you use? The point of my examples is to show that it is absurd, that no person can indicate exactly what is or is not medically indicated.
According to the new legislation, physicians would be required to the Ministry of Health for services which were deemed "medically unnecessary." Some physicians might respond by seeking prior approval, which would of course result in a delay in obtaining services. Others would perceive that their income was now tied directly to curtailing services and would refer only patients with what appeared to be serious illnesses. Utilization would fall, but at the expense of unmet patient needs.
Throughout all of this the provincial government is sending, both to doctors and patients, a very mixed message. It advises patients to practise preventive medicine, and yet, how can patients practise preventive medicine and how can they arrange to have a stress ECG, a mammogram, a Pap smear, a colonoscopy or even a serum cholesterol determination at an earlier age or more frequently than the government deems to be "medically necessary"? Most they travel to a private clinic in the United States?
Don't forget also that at the same time that the government is eliminating the reimbursement of malpractice insurance, they're also putting patients and physicians at greater risk by closing hospitals, closing emergency departments, so that many patients who a few years ago would have been admitted for observation with suspicious chest pains are now being sent home.
A very interesting thing which I hit upon -- and I don't think anyone has discussed this before your committee -- is the whole issue of the Canada Health Act as it relates to this. Some of you may realize that for the past 10 years I tried to persuade the Quebec government to comply with the Canada Health Act. It appeared to me that they were violating the Canada Health Act by not providing the full rate of reimbursement to patients when they were treated outside of Quebec.
A number of Quebec patients have been for years coming to Ottawa and seeking out consultations and tests which they perceive to be speedier or of a superior quality. They would pay out of their own pocket, knowing that they would be partially reimbursed. A whole succession of federal Health ministers, including the Honourable Perrin Beatty, has not intervened. I mention in my brief Perrin Beatty for one reason: that Mr Wilson used to work for Mr Beatty; so at that time, in an earlier lifetime, he could have had the power to intervene and tell Quebec that it was violating the Canada Health Act, and for obvious reasons he chose to keep a low profile.
I felt that maybe we should just turn the whole thing around and say that a precedent now appears to have been set, and to be consistent, the federal government should now permit Ontario patients to pay for services when they are deemed "medically unnecessary." I can appreciate that the government might not have the money to pay for a serum cholesterol every two or three months, but certain patients may wish to have this done. Why not allow the Minister of Health to pay for one annual cholesterol and, if the patient wants to have it done more often, he pays out of his own pocket?
They may not be able to afford to do a stress ECG on younger patients. If they want to set an arbitrary cutoff -- and in the act they do indicate they will have that power -- then fine, we will only do a stress ECG at public expense in somebody age 45 or older. But if you're 35 with a bad family history, why should you not have the right to pay out of your own pocket to have a stress ECG?
In the present system, the only way to do this is to find an insurance company, apply for insurance, and they may then require you to have a stress ECG and then it becomes a third-party payment, which is acceptable. This is ridiculous. A patient should be able to pay directly for some service that he himself wants to have.
If the federal and provincial governments do not agree with me and still feel that either the test is fully covered by OHIP or the doctor will have to pay for it or the test isn't done, then this raises the whole issue of accountability. What responsibility do federal and provincial Health ministers now bear for a diagnosis which is missed at an earlier, possibly more treatable stage?
Now we will get into the issue of inspectors. Bill 26 does provide for the appointment of a new class of inspectors with expanded powers. Physicians must provide all information on private patient medical records and the inspectors may remove, copy and disclose any information at their discretion. What hasn't been emphasized here, I believe, is that patients also have to cooperate, and I quote: "Every person who receives insured services shall cooperate fully with an inspector who is carrying out an inspection under the act." I'm not sure if in your earlier meetings it's been mentioned that the fine for noncompliance is $5,000.
Who will be these inspectors? I've talked to several doctors in Ottawa who used to work in Quebec, where they've had this process for a number of years, and in Quebec these tend to be retired Quebec provincial police officers, hardly the most tactful of inspectors. How will these inspectors be trained? What investment is the government prepared to make in their ongoing education and in others making the decisions of what is "medically necessary"?
Moreover, what possible psychological trauma might occur if an inspector, having no formal psychiatric training or possibly not even an MD degree, were to interview a patient who had received psychiatric services or who had undergone a therapeutic abortion or even a number of D and Cs for recurrent miscarriages? I could foresee that an interview done over the telephone in a few minutes could cause damage that would take months to repair by a professional.
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Traditionally, the doctor-patient relationship has been based on free and open communication. In future, patients with sexually transmitted diseases, alcohol or drug problems might well forgo care for fear that their records would be scrutinized by one of the government inspectors. To what possible misuse might this information be put if it concerned a political opponent of the government in power?
Many charts contain documents requested and paid for by third parties such as insurance companies, employers and other government departments. It's unclear to me from the legislation whether these are also to be examined by the inspectors. Also, what rights do patients have over notes in older charts, written at a time when the new powers of the Minister of Health were not anticipated? Can you say that the inspector is only entitled to look at the last three pages of the chart, or can he look at the entire chart? That's unclear to me.
Amendments to the legislation which merely delete reference to the expanded powers of the new inspectors do not totally solve the problem of maintaining patient chart confidentiality. This is a very key point, very important. Don't forget it. I am not happy if you simply do window dressing and simply eliminate reference to the inspectors or indicate, "We will collect the information, but be very careful it doesn't get into the wrong hands."
Don't forget, physicians spend 10 to 12 years in training. They train for more years than almost anyone else in society, probably. At the end of the process, they have only one paymaster. Unlike a teacher, they cannot apply to work at another school board or tutor in their own home. If they are to work in Ontario and pay their mortgage and feed their families, they have only one paymaster. They will be very reluctant to jeopardize their cash flow.
Private practice has been outlawed by the Canada Health Act and Bill 94, the Health Care Accessibility Act. Under the new legislation, Bill 26, the Minister of Health will have the power to expropriate a medical practice without any of the protections normally accorded to a small business. A specialist can have his hospital privileges and billing number revoked without any due process of appeal.
As state employees, physicians, like all other civil servants, will be reluctant to criticize their one and only paymaster, and they will lose what residual freedom they once had to act as independent advocates of their patients. Thus, without even specifying the power of the inspectors, the ability of the government to obtain access to these medical records will be absolute and unchecked as long as physicians can be intimidated by total loss of their billing number and hence their livelihood.
I'd like to raise a point at this juncture which has not been raised to your committee. We've been concerned about the power of the government over physicians. No one has discussed the power of chief executive officers of hospitals. This is a very important point. If I am reading electrocardiograms at my hospital, in order to lose the right to read electrocardiograms, someone has to prove that I am negligent; if somebody is reading X-rays, someone has to prove that he is negligent or incompetent to remove his privileges. Under the new legislation, there will be no such safety check whatsoever. If the chief executive officer of the hospital says, "I don't like the colour of tie you're wearing; you're out," there's no appeal.
I know for a fact that certain hospitals already are using this power to intimidate physicians to ask for so-called voluntary contributions to help balance their budgets. Some also may be asked to charge reduced amounts for providing care to inpatients so as to reduce the amount coming out of the global budget that normally would be paid to physicians. I could foresee a time when physicians who read electrocardiograms, let's say, will be told that if they did not accept an even lower rate, there are a number of unemployed physicians from newly closed hospitals who are prepared to undercut them and read the electrocardiograms at a cheaper price. This is much what happens in the United States now at the HMOs, and I don't think we want this in Canada.
The other thing is that up until now physicians have been the only group within hospitals who have had the knowledge of what goes on in the hospitals, and the ability to act as independent advocates for the public as to the efficient running of hospitals and to act as advocates for the nurses and other hospital employees. Under this legislation, if a physician can lose his hospital privileges with no appeal, then physicians will be muzzled, like all other hospital employees, and there will be no one to speak out on behalf of the public or on behalf of the other hospital employees. This is a very key concept and I think it should be stressed.
In summary, I was struck by this legislation. I'm not stupid, but I had great difficulty reading this in either official language. I did not have access to all of the other documents necessary to interpret it. I doubt if a tenth of 1% of doctors would have taken the time to obtain the documents, which I did, and go through them a number of times. There were a number of things that just struck me as very unfair, and very malicious, in fact. For example, let me just quote a few things.
If you have a copy of the bill, this is from schedule H on page 100, section 27.1. Let me read this:
"Every physician, practitioner and health facility who provides insured services shall make such contribution to the plan" -- we don't call it "clawback now," we call it "contribution"; we're already at the moment tithing to Mr Harris, but this is called a contribution -- "as may be prescribed relating to the amount of fees payable to him, her or it under the plan during such prior period as may be prescribed."
What does that mean? As an internist I normally receive, before clawback, about $105 for a consultation. If the government were short of cash, could it say, "Well, we think a consultation is worth $70 and we think you've been overpaid all these years so we're going to go back to fiscal year 1990-91, 1991-92 etc, and ask you to pay back $35 for every consultation you saw during the past four or five years"? Under this legislation, they would have that power. I would ask anyone in this room whether he thinks this is fair treatment of physicians. Are we going to be treated as second-class citizens? You may wonder why so many physicians are thinking of leaving the country now.
Another one. I know of a number of doctors who don't always get their exams the first time around. It's very difficult now to start off in family practice and then decide to specialize in anaesthesia or internal medicine. A number of barriers have been erected. It's very difficult to get into a residency training program. But this legislation adds yet another hurdle. Listen to this. This is on page 104, subsection 29.4(4):
"An eligible physician ceases to be an eligible physician" -- "eligible" means he can have a billing number -- "if he or she changes the nature of his or her practice from that of a family practitioner to that of a specialist."
Why do we have to have yet another barrier? Does everybody have to know at age 18 exactly what he's going to do with his life? Is no one allowed to change his mind and go a different direction? This is totally unacceptable.
Now here's one that particularly bothered me, probably because of the 24 years I lived in the United States. This is on page 112, schedule H, subsection (1.2):
"A regulation may create different classes of persons, facilities, accounts or payments and may establish different entitlements," etc.
Listen again: "A regulation may create different classes of persons...." Does that mean based on race, religion, sexual orientation, HIV positivity? What? Age? It's not spelled out. I was taught that if something is not spelled out, I'm not content to hear that they will never abuse their power.
I find it very scary to think that this can go through as written, and I would remind everybody in this room, this whole omnibus bill, lengthy as it is, is only a skeleton, only a framework. The true flesh will be applied to the skeleton in the form of regulations, which do not have to go before Parliament. They can go only before the caucus. We are told, "Never sign a blank Visa slip, never give your Visa number out over the phone." Are we prepared, as citizens of Ontario, to hand over our charter freedoms to this government? The government did not get a mandate to do that.
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I brought with me here just a few pages of the Charter of Rights which I thought might be relevant, such things as mobility rights, every citizen of Canada, every person has the right "to move and take up residence in any province; and...to pursue the gaining of a livelihood in any province." It seems to me that's being violated.
"Everyone has the right to life, liberty...principles of fundamental justice." Are principles of fundamental justice adhered to by this legislation?
Number 11: "Any person charged with an offence" is "to be presumed innocent until proven guilty." In this legislation, nothing has to be indicated. An inspector can enter your office, not because of aberrant billing patterns but for reasons of his own; the government does not have to specify these reasons. It doesn't seem to me as if you're presumed innocent till proven guilty. Also he's "not to be found guilty on account of any act or omission."
Equality rights, number 15: "Every individual is equal before and under the law." I've heard some people say to me: "Well, after all, you doctors are making so much money. It doesn't matter." I'm afraid it really bothers me when someone says, "Well, we're not going to discriminate against you because of your race or religion, but we are because of your occupation or your perceived income."
Does the government now have the right to tell a doctor that because his income is a certain amount, it can tell him where he can live, that it can come into his office and seize his records, that it can go back in time and tell him that his services were worth much less than he's already been paid for? It seems to me that we have a two-tiered systems of rights for physicians and one system for everybody else.
I'd be happy to entertain any questions.
The Chair: There isn't a practical time left for questions. The last time we did this one-minute-per-party thing, we didn't get any answers. So you've got about three minutes left, doctor, if you want to continue on with some more comments of yours.
Ms Lankin: Oh, Chair.
The Chair: The practical one-minute-per-party thing does not work.
Dr Shaver: One thing I would like to tell you is that I have been surprised in this debate by how the press has come on side. I have talked to a number of people. I have faxed articles to people like Bob Sheppard from the Globe and Mail, Thomas Walkom from the Toronto Star, and people who have traditionally been our enemies seem to perceive the injustice in this legislation.
But that didn't seem to be enough to derail the legislation, so early last week I took it upon myself to write some of the people on the other side of the border. Actually, two days ago I did a 15-minute interview for the New York Times. They're very interested in this and they're going to have an article out in the next few days you might be interested in seeing. This is a letter I sent to Peter Jennings at ABC in New York:
"Personal freedom, fairness and choice, always valued by Americans, are now being denied to residents of Ontario. Americans may be shocked to discover that physicians and other individuals in the democratic country of Canada have been denied their right to appeal arbitrary decisions by ministers of the Ontario provincial government.
"The Canadian medicare system, with a single paymaster, has been viewed by many Americans as a desirable model. They might now be surprised to discover that its natural evolution results in rationing of services and an elimination of freedoms and rights of both patients and physicians. Many Canadian physicians and nurses will likely emigrate to the United States in the next few years. Americans may wish to know what factors motivated their moves."
This has also been sent to CNN and to WBBM in Chicago and a few other people. I think it might provide a more objective viewpoint of what's going on in our country.
Really, I could never understand when I was growing up and going to school in the United States how a dictatorship could come to power. I'm not going to be perceived as a scaremonger here, but when I see what is happening here, it really bothers me. Again, I don't want to appear to be inflammatory, but if you think about what I've said over the past half-hour, a murderer or a rapist, such as Paul Bernardo, has greater rights of appeal than do the physicians of Ontario. That's a deplorable situation.
The Chair: Thank you, doctor.
Ms Lankin: Mr Chair, I'd like to raise a point of order with me, if I may. Let me preface it by saying that I appreciate that you have done a very, very good job in chairing as we've gone through these hearings, but both my colleague and I, in looking at the time, believe that in fact there were six minutes left at the point at which you said that there were only three, and that's a problem. I didn't object at the time because I wanted to continue to hear Dr Shaver. He had more to add and that was fine.
But secondly, may I indicate to you that the purpose of the time left over for the parties is to be used as the three parties see fit, which may include questions, often does, but sometimes it's comment on the presenter's presentation, and that you as Chair do not have a right to unilaterally change that process and to deny us that opportunity. You haven't done it before. You've been terrific in the way you've chaired. I just would ask you to take that under consideration and please not to repeat what I think was an error in the procedures.
Mr Miclash: If I may just make a comment on that as well, Mr Chair. According to my watch it was 24 minutes after the hour, and I believe the next presenters weren't on my schedule until 2:30. At the present time it's about 27 minutes after, and I too felt that we had about two minutes per party. I fully agree with Ms Lankin that even if we didn't want to ask a question but make a comment, I think that time was ours to be split three ways, as you've done in the past.
The Chair: Not that I have to explain, I don't think, what I did, but I think you do have to allow me some latitude to manage the time. We got into an argument this morning with one-minute questions with Mr Chiarelli. I chose not to do that this afternoon. One minute is not a practical time for questions. So I think the doctor used the time more effectively.
Ms Lankin: Mr Chair --
The Chair: I don't want to get into an argument about this.
Ms Lankin: I don't want to get into an argument either. I would just suggest to you that if there are three minutes left and you think it's not practicable for questions, I could understand that, but I should have the right as a member to indicate whether or not I wish to use that one minute for a comment on the presentation that comes before us. That is entirely acceptable and is tradition under the rules. I do give you a lot of flexibility and I think you've done a good job. I've said that. I would just ask you to think about the decision that you have just made in this last presentation and please to attempt not to repeat that.
CANADIAN DRUG MANUFACTURERS ASSOCIATION
The Chair: The next presenters are the Canadian Drug Manufacturers Association, Julia Tam, Brenda Drinkwalter and Jack Kay. Welcome to our committee.
Mr Jack Kay: Thank you for the opportunity to appear before this committee. My name is Jack Kay. I'm chair of the Canadian Drug Manufacturers Association. With me is Brenda Drinkwalter, the president of CDMA, and Julie Tam, a pharmacist and our director of professional and scientific affairs.
The CDMA represents the Canadian-owned pharmaceutical manufacturers that specialize in the production of high-quality, affordable generic prescription drugs as well as the research and development of innovative pharmaceuticals. CDMA member companies employ close to 4,000 men and women in communities across Canada and spend over 13% of their sales on research and development in this country.
Canadians and Ontarians value the high-quality, affordable medicine that has been a cornerstone of our public health care system for over a quarter of a century. Through our research, development and manufacturing activities, CDMA member companies are making a strong contribution to the advancement of our health care system.
The Ontario-based CDMA member companies are a strong and emerging force in the domestic and international pharmaceutical industries. CDMA companies employ nearly 3,000 Ontarians in a variety of sophisticated, high-tech positions. By comparison, only five years ago there were less than 1,300 employees in the Ontario generic sector. Spending on R&D is expected to reach $350 million in Ontario over the coming three years.
The level of usage of generic drugs in Ontario has traditionally been higher than elsewhere in Canada because of the favourable provincial drug substitution laws. However, recent changes in the government drug programs of other provinces to favour the use of generic drugs and their increased use by third-party payors has increased the overall generic presence in Canada.
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Currently, 41% of all prescriptions filled in Ontario are with generic drugs. Because of lower prices, generics represent only 13.4% of actual dollars spent on prescription drugs in Ontario.
Generic products are of the same quality as brand-name drugs manufactured by the foreign-owned multinational drug companies and must meet the same stringent standards established by the health protection branch of the federal Department of Health.
In Canada, according to the latest IMS Canadian drugstore and hospital audit, generics represented 37% of all prescriptions filled in Canada. In terms of pharmaceutical sales value, the generics are much smaller because of the low prices we charge for the products. For the first half of 1995, generics accounted for 12% of prescription dollar sales. A comparison of brand and generic prices for the top 25 genericized products in 1995 shows that, on average, generic products are priced 42% less than their brand-name counterparts in Ontario.
A recent study by CDMA, called Generic Drugs: Savings to Canada's Health Care System, showed that generic drugs save Canadian purchasers $750 million annually. This represents a savings of more than 13% of the total annual drug bill in Canada. Given that Ontario represents approximately 40% of the Canadian total market, savings in Ontario due to generic drugs could be up to $300 million.
The importance of this saving is highlighted by the fact that drug expenditures are now the second-largest category of health expenditures in Canada. Expenditures on drugs continued a decade-long trend of having the highest level of growth of all categories of health expenditures. Expenditures for both prescription and non-prescription drugs increased from 8% of total health care expenditures in 1977 to 15% in 1993. The Green Shield Report on Drug Costs concluded that the main reason for this increase was the shift to new, higher-cost drugs from older, lower-cost drugs which have been genericized.
Once a generic product is on the market, it is very rare that its price ever increases. Typically, prices decrease over time as more competitors enter the market. The 1995 IMS study Generics Canada shows clearly that more competition brings the price of generic products down. When a product is available from one generic manufacturer, the generic price is equal to 79% of the brand. This falls to approximately 54% of the brand when four companies are marketing the same drug.
The message then is clear: Generics are an important part of the solution to rising drug costs. The more efficient and effective the process of bringing generic drugs to market, the greater the savings. The potential for generic drugs to bring even greater cost savings depends, in a large measure, on government policy and practice.
Ms Brenda Drinkwalter: Now we would like to comment on the proposed changes to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act under Bill 26.
The CDMA recognizes the importance of this government's efforts to limit the cost of the Ontario drug benefit program. At the same time, we would emphasize to government the need to safeguard the interests of all Ontario consumers, not just those where the government pays the bill.
Pharmaceuticals are essential goods. A diabetic, for example, cannot simply decide that he or she will not purchase their insulin if the price is too high, or a diabetic cannot decide to purchase a high-priced insulin and stretch its use over a longer period by reducing the dose. These are choices a consumer can make if purchasing other commodities, for example household appliances, gasoline, food or cars. That is why governments in most industrialized countries intervene in the pharmaceutical marketplace with measures to protect their citizens.
Our comments today will focus on areas of the bill that we support, together with improvements to the bill that we feel are necessary to maintain the appropriate balance between the interests of consumers, employers and governments, who pay for drugs, and the pharmaceutical industry, that makes an important contribution to the economy of this province. Specifically, we are going to address the areas of no-substitution prescriptions; mandatory substitution provisions; interchangeability off formulary; accelerating the approval of cost-saving generics; copays and deductibles; the minister's power to set prices; and price deregulation in the cash marketplace.
With respect to no-substitution prescriptions, the CDMA commends the government for eliminating the previous rule that enabled a doctor, simply by writing "no substitution" on a prescription for an ODB patient, to force the taxpayers to pay for a brand-name product even though a low-cost and effective generic product was available. Brand drug companies' promotional efforts are often targeted at thwarting substitution of low-cost drugs in the interests of protecting market share at the consumers' expense. The proposed legislation does not restrict a physician's right to prescribe a drug; it only limits the amount the government will pay.
With respect to mandatory substitution, the CDMA also commends the government for maintaining mandatory price substitution, that is, a statutory rule requiring that, absent certain exceptions, the pharmacist must dispense the lowest-cost product in his or her inventory if the drug is a multisource product. This keeps the cost of drugs reasonable for Ontario's citizens, who are often not knowledgeable enough to make meaningful price comparisons.
We will now turn to areas where the CDMA believes that the bill can be improved by way of amendment to the benefit of all consumers in the province.
The previously mentioned principle of mandatory substitution as structured in the bill does not extend to all drugs for which an equivalent generic is available. The regulations to the bill must be structured to ensure that consumer savings are maximized.
Regulations under the Prescription Drug Cost Regulation Act currently specify that a generic drug cannot be designated as interchangeable and substituted unless the brand product is an ODB benefit, that is, that government pays for that product on the formulary. Many brand products are not listed today in the formulary because the government thinks they are too expensive or in some cases because the brand company has decided not to list the product, effectively blocking competition from the lower-priced generic. This means that for an increasing number of products, Ontario consumers have no effective access to lower-cost drugs, even though they are available and consumers in other provinces enjoy savings from those same products.
Let me highlight this for you with an example which you have in your briefs. A patient may be diagnosed with a chlamydia infection. The doctor then prescribes Vibramycin, a brand name; doxycycline is the generic equivalent. Even though there is a generic doxycycline available, the pharmacist cannot interchange it and will dispense the brand-name Vibramycin, which costs 168% more. Why is the generic not interchangeable? Simply because the government doesn't list the brand as a benefit in the ODB program. With a regulatory addition to Bill 26, this can be changed and the patient will only have to pay 63 cents a tablet instead of $1.69.
The report of the Pharmaceutical Inquiry of Ontario, the Lowy commission, recommended in 1990 that Ontario address this regulatory problem with urgency. Regulatory changes were drafted, finally, in the spring of 1995 to effect this long-overdue change. While employers, insurers, pharmacists and this sector of the industry gave strong support to this regulatory change, it was opposed by the brand-name industry, which would lose market share if competition from generics was not prohibited by this unintended regulatory problem.
We submit that the regulatory change to permit interchangeability of drugs not in the drug benefit formulary be embodied in the regulations to the Drug Interchangeability and Dispensing Fee Act without further delay. This would provide savings of $26 million to Ontario consumers at no incremental cost to government. The government has a duty to ensure that its regulations do not inhibit but encourage access to low-cost drugs for all Ontario consumers.
The Ontario government could achieve major savings to the ODB plan simply by eliminating pointless regulatory delays in getting new generic products on the formulary. New generic products should be designated as interchangeable automatically and immediately after receiving approval from the federal government. This has been the case in other provinces for many years.
CDMA conducted a study of the provincial formulary approval times for those products that were recently added to the ODB formulary as of September 1, 1995. The time taken to gain entry to formularies in various provinces was compared for identical submissions. Median times for formulary acceptance are set out in your brief, but they ranged from 16 months in the province of Ontario to as low as one month in the province of British Columbia. We calculated that Ontario consumers overpaid $6.2 million for brand products solely as a result of these delays, even though a generic existed and was available in other provinces.
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In the spirit of assisting the government with streamlining the regulatory process, CDMA prepared a thorough legal analysis in September 1995 of the changes required to simplify the Ontario process so it would be as efficient as the process in other provinces. This would maximize savings not only to the drug program but for all consumers. We have copies of this report available if it would be useful to members of the committee. In this time of fiscal restraint, the bill and its regulations should be structured to incorporate these changes without delay.
The CDMA is also concerned about the proposed copayment and deductible schedule. It may prove to be a financial hardship for seniors and those receiving social assistance. It focuses unfairly on pharmacists' dispensing fees. CDMA believes that the government should seriously investigate the alternative copayment schedules proposed by these various organizations.
With respect to the ministerial power to set prices, the changes significantly increase the government's power to set the price of prescription drugs on the formulary, contrary to the briefing documents which suggest that the market is being deregulated. Proposed changes in the bill are intended not only to give the government sweeping powers to set prices but also to give no effect to the previous decisions of the courts that pricing policies have been unlawful.
The CDMA believes it is unfair for the government to attempt to retroactively undo proper legal decisions. We also question whether the government has the legal authority to completely shield itself from judicial interpretation, as this bill attempts to do.
The CDMA believes that giving the government the power to set prices is somewhat counterproductive. It appears that the change is intended to give the government the power to compel new generic manufacturers to give prices below those of previously listed brands as a condition of being listed as interchangeable.
Setting introductory formulary prices for generics is unnecessary and arbitrary for products which are, by definition, competitive commodity goods. Arbitrary processes also give rise to costly litigation, which CDMA views as a waste of both corporate and taxpayer resources.
We do not feel it is logical, and feel it is a complete waste of taxpayer money, for the government to refuse to list a generic because it is not offered at an arbitrary 75% of the brand-product price. If the government is already paying $1 a tablet for the brand-name product, it doesn't make sense to deny listing to the generic and to continue to pay for the high-priced brand product simply because the savings are not as large as the government would like. The generic should be listed if it comes in at 90 cents, 75 cents or 50 cents. The ODB program needs to realize savings wherever it can.
Generic prices will often be priced considerably less than 25% below the brand product due to competitive pressures in the marketplace. The CDMA recently did a study of the prices in Ontario of all 57 non-formulary generics where the prices were not regulated but, rather, set by the marketplace. It found that prices were on average 33% lower, even though competition was very limited; in most cases there was only one generic.
Unilateral government action to set prices ignores the generic manufacturers' costs and risks, which will vary from product to product; it ignores the marketplace situation. Setting prices could make it uneconomic to produce new generics or reduce the incentive to bring them out quickly. Price freezes, for example, have already created situations where generic manufacturers are forced to sell below cost. Their exit from the market would leave the government only the high-priced brand, often priced at many times the generic, and it would be forced to incur costs well above what it is presently incurring.
The way to achieve lower prices is to list generic equivalents of as many products as possible on the formulary as soon as possible and to encourage competition and investment in new generic products. Generic manufacturers compete vigorously with each other and studies show that the more generic manufacturers competing for market share, the lower the price. New powers to set price will more likely lead to arbitrary interference in the market, costly litigation and paralysis of the competitive forces that have worked well to bring prices down.
With respect to price deregulation in the cash marketplace, the wording of subsection 7(2) of the Drug Interchangeability and Dispensing Fee Act appears to deregulate the price of non-ODB sales of monopoly brand-name products only, products that are the most expensive and where the consumer exposure is the greatest. This section says that if the dispenser supplies an interchangeable drug, that is, where there is generic competition, then he or she:
"shall not charge, in addition to the dispensing fee, more than the lowest amount the dispenser would charge for the product dispensed or the products that are interchangeable with it in the dispenser's inventory."
We interpret this to mean that the pharmacists cannot charge a consumer more than the lowest amount he or she would charge any patient, which includes an ODB customer, for a particular multisource drug. While "amount" remains undefined, it would appear to refer to the drug cost component plus markup. The proposed wording is difficult to interpret and should be clearly specified as in the previous PDCRA section. The wording should clarify that the pharmacist is obliged to charge, in addition to the dispensing fee and markup, an amount no more than his lowest acquisition cost for an interchangeable product in his inventory.
CDMA supports the limited consumer protection offered by section 7, as we believe that all Ontarians deserve full cost savings available from generics. In the absence of price competition from generics, consumers must have access to fair and reasonable prices for drug products and markup percentages.
In conclusion, we would suggest that Bill 26 fails to address the significant opportunities for realizing savings in drug costs for Ontario consumers. It appears to take aim at the domestic industry, unnecessarily increasing the government's power to regulate the small generic sector, which represents only 13% of the market, where competitive market forces are adequate and even superior to regulation in controlling costs. It is noteworthy that the foreign-owned multinational sector responsible for the lion's share, 87%, of the drug bill lauds the government for the bill. They must expect somehow to be a beneficiary of these changes. We ask, at what cost to Ontarians?
The bill, in the structure of the copay system, unfairly targets pharmacy, who have an important contribution to make in controlling drug costs through patient counselling and in particular controlling inappropriate drug utilization.
The total lack of consultation in crafting Bill 26 and the absence of interpretive regulations has resulted in legislation that puts at risk the delicate balance that must be maintained between the interests of the province's consumers, governments and employers who pay for drugs and the province's pharmaceutical industry that makes an important contribution to the economy of this province. These changes should be suspended pending a thorough regulatory impact analysis and a comprehensive consultation process on the effect of this bill on all parties.
Thank you very much, and we would be happy to answer your questions.
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Ms Lankin: Mr Chair, we're over halfway through the hearings, and I have to tell you, with respect to this section of the act, I am totally confused. I don't know what it says and what it means, and I think you know that I have been attempting, through asking questions, to figure it out.
I have to tell you, I appreciate your presentation, but boy, you've got me overwhelmed at this point. I asked questions of every brand-name company that came forward and of the Ontario division of PMAC and spent some time off the record trying to talk with someone who knew more about this than me to explain it to me, and got the sense that what would happen is -- well, the government thinks it's going to negotiate a big deal as a big purchaser. In terms of brand-name drugs, that price is already regulated through the Patented Medicine Prices Review Board and that price wouldn't change, so there wouldn't be a saving there, but the real big savings would come on the generic drugs for government, and what you charge us for generic drugs here in Ontario is substantially higher as a proportion of patent medicine prices than you do in the deregulated free market in the United States. This is what I was led to understand. You might want to respond to that.
But now you're telling me that the way you read this act, if the government gets a really good price with you because it's a big purchaser, for an interchangeable product, the pharmacist will have to charge that same low price to everyone else. I don't know what you're going to charge the pharmacist, yet there isn't a control on the patent -- if everyone else is confused, you're with me on this. I'd like to have representatives of both parts of the industry in front of us and hear them debate this so maybe we can figure out, before we get into trying to deal with amendments, what this is all about. But if you can help me understand it, I would appreciate that.
Mr Kay: The reality is that prices in Canada, whether it be from the multisource industry, the CDMA, or from the brand industry, are really set across the country. There are no price differentials that the government or consumers in Ontario pay from what consumers will pay in the province of British Columbia. So as far as the changes go, there will not be savings to the Ontario government by saying they are going to negotiate generic prices, because generic prices are set at a national level.
The other important thing to remember is, at this point in time, generic prices are frozen. We cannot increase our prices. Hence, we are very hesitant -- and in fact as a business person we cannot afford -- to give the Ontario government lower prices on certain products, because we cannot increase prices on other products.
As an example, there are several products within the Ontario drug benefit formulary that the generic industry has listed and we are losing money on those products. I will give you the example of a drug called sulfinpyrazone where the generic is listed as $6.61 a hundred. We lose money on every bottle that we sell in the province of Ontario. The brand-name is listed at $31.55 per hundred. If we delist our product from the formulary, which we are considering doing, then the Ontario government will be paying $31.55 per hundred tablets. We have asked the ministry to at least allow us increase our price to cover our increased raw material prices to $15 per hundred, which is still half of what the brand is charging the government. Hence, we'll remove the product from the formulary, the government will pay $31.55 and at this time it's paying $6.61. It is illogical.
Mr Clement: Just parenthetically, it really isn't unusual for different players in any particular industry to read legislation, or proposed legislation, from a different perspective, and people can I think legitimately disagree over what hundreds of current bills say, let alone what proposed bills say. So it doesn't surprise me nor alarm me that there are differences of interpretation between what we're hearing today and what we heard before Christmas.
I did want to try to shed some light through our discussion about this, though. First of all, on the no subs rule, we've heard a lot of commentary in the past about how a no subs rule will inevitably mean that patient care will suffer, because even if generics and brand names are chemically identical, they can affect patients in dissimilar fashions, which quite frankly did alarm me when I heard that kind of evidence before this committee. I'm just a lay person on this, so I don't have any background, but is that a valid argument or is that an invalid argument?
Mr Kay: It's an invalid argument. It's a spurious argument. In fact, if you look at the sales of generic drugs in Canada, many of the generic products available in Canada are in fact manufactured by the brand industry itself and sold under a different label.
If you look at the history of the generic industry since 1969, when it really evolved into the industry it is today, the only complaints about generic substitution have been anecdotal complaints. There is no scientific validity to say that because of the non-medicinal ingredients we use in the manufacturing of our products, there is going to be an untoward effect on the consumers in Canada. There are just no scientific data.
Mr Clement: That's comforting to know. Can I just refer you to your conclusion, where you ask rhetorically -- I don't mean that pejoratively when I say that, but it was a question in your presentation -- why the foreign-owned multinational sector would be happy with deregulation. Can I probe this way and say you represent a number of generic companies and other companies. If I asked you, are you ready to compete in the marketplace, your answer would probably be: "Absolutely yes. We're here to compete. My company can compete with the best of my competitors and is a darn sight better than the rest of my competitors." Wouldn't the drug manufacturers have the same sort of analysis, the brand names?
Mr Kay: The brand-name industry with monopoly products does not compete with other brand-name companies. They have exclusive products. They might all have products in the NSAIF area, which is non-steroidal anti-inflammatory. When they are monopoly priced, they are high-priced. The only time competition comes into a chemical entity is when it is genericized and where it --
Mr Clement: That's why we have the patent medicine review board federally, though, isn't it?
The Chair: Thank you, Mr Clement. Ms McLeod.
Mrs McLeod: I begin by saying that Mr Clement may not be alarmed, but I am extremely alarmed that no one, least of all the government, has any idea what deregulation of drug prices is going to mean either to the government's cost of providing the ODB or to the individual consumer of drug products. I wholeheartedly support the final lines of this presentation that say all these changes "should be suspended pending a thorough regulatory impact analysis and a comprehensive consultation process."
Having said that, I will therefore ask you, because I share Ms Lankin's sense of we just cannot get a clear picture of the cost impact at this point, the only thing that's clear in my mind is the Minister of Health suggesting that the way in which consumers will respond is to go from pharmacy to pharmacy bartering for the best price in drugs. That stays very clear in my memory.
I'd like to ask you about the copayment implication. You cited the Green Shield study on utilization, and there was another figure that was presented to us this week that 15.1% of the increase in utilization was due to an increased quantity being prescribed per claim. We've seen other data from other provinces that say if there's a large quantity on any given claim, there is a lot of wastage and therefore the total utilization will go up. There's a concern then that seems to follow that if the copayment scheme is brought in and physicians and pharmacists, in wanting to minimize the effect of the copayment for people on limited incomes, prescribe larger quantities per claim, that could lead to greater utilization and therefore, ironically, to a greater cost for government of the ODB plan. Is there a logic to that?
Ms Julie Tam: There is a logic to that. In British Columbia, where the same copay system is used -- in British Columbia, the senior has to pay 75% of the dispensing fee -- they have three times the size of the average number of days on a prescription that they do in Ontario. British Columbia has identified that people getting large numbers of prescriptions lead to inappropriate taking of the prescription or out and out usage. You get a new prescription from the doctor and the doctor writes "for 100 days," you take it for 15 days and you don't like the side effects, so you don't take it any more and then you waste the rest of the prescription. So this copayment schedule, where in Ontario they're saying you have to pay either the pharmacist's fee or $2, will probably lead to people choosing to get larger amounts in every one prescription in an effort to save $2, but meanwhile the government or whoever has to pay much more in the cost of a drug just so the person doesn't have to pay the extra $2. It doesn't make sense.
The Chair: Thank you for your presentation. We appreciate your interest in our committee process.
Ms Lankin: Mr Chair, may I table a question, please? I'm wondering if the ministry would attempt to provide members of the committee with a detailed briefing note with respect to the Drug Interchangeability and Dispensing Fee Act, and I think in particular price deregulation and the cash market, as well as some of the issues that have been raised with respect to the differential purchasing power of the government with respect to patented drugs and generic drugs, to explain that in greater detail from the ministry's perspective for members of the committee. I've looked in the book and the briefing notes that have been provided and they are not sufficient to help me to understand the intent and the potential impact of this section. I think all committee members might benefit from receiving that.
Mr Clement: On that same point, Mr Chairman, with due deference to Ms Lankin, I think the procedure is if she has specific questions, the ministry is quite happy to accede to her request. That's pretty broad.
Ms Lankin: If Mr Chair would like to give me the time to put all the specific questions out, when he chastised me yesterday for taking too long to do that, I think people know the kinds of questions I've been asking. I'm just asking for the ministry's advice to us with respect to that, and I think you would want to facilitate that, not block members from getting access to ministry information.
Mr Clement: No, no. I'm not blocking anybody. I'm just asking for specifics.
The Chair: Mr Clement, the question is in order.
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CANADIAN MENTAL HEALTH ASSOCIATION, OTTAWA-CARLETON BRANCH
The Chair: The next presenters are the Canadian Mental Health Association, the Ottawa-Carleton branch. Good afternoon and welcome to our committee. You have half an hour of our time.
Mr Mark Parsons: Thank you for inviting us today. I hope we will have time for questions. We'll try to keep this to 15 minutes so we'll have some time. My name is Mark Parsons. I'm a board member of the Canadian Mental Health Association of Ottawa-Carleton. On my right is Joanne Lowe, the executive director of that same Canadian Mental Health Association, and on my left is Bill Carne, a board member of the Psychiatric Survivors of Ottawa.
We, Joanne and I at least, are here today representing the Canadian Mental Health Association of the Ottawa-Carleton branch. CMHA is a non-profit organization involved in planning for the delivery of services for people who have a serious mental illness. Directed by a community board, CMHA is partnered with members of the community, including consumer-survivors and family members, other community agencies and government representatives.
Our focus today is on the impacts that the provincial budget and Bill 26 will have upon the lives of people who experience a serious mental illness. To understand the impacts of these proposed changes, and the changes that this government has already introduced in Ontario, have upon individuals with a psychiatric disability, it is important to first understand the nature of psychiatric illness.
Mental illness can be defined as a medically identifiable disability that includes a group of symptoms that can affect a person's thinking, feeling or relational abilities. Illnesses include schizophrenia, depression and manic depression. The symptoms of these mental or psychiatric disabilities are often invisible, not visibly apparent in the same way many physical disabilities are. They are persistent or chronic and they are episodic, in that many symptoms may be alleviated for a period of time, only to recur in times of stress or hardship -- like today I guess, for me anyway.
The effects of mental illness -- I'll try to keep sane through the whole thing --
The Chair: Do you want to change places with me maybe?
Mr Parsons: No, I do not, though I wouldn't mind the salary, I think.
Interjection: You might be surprised.
Mr Parsons: No, you'd be surprised at what I earn, I think.
The effects of mental illness also include a cluster of other potentially debilitating factors, such as fatigue and exhaustion, and the stress brought on by the stigma and hardships associated with having a psychiatric disability. One of the most pressing hardships is the economic reality of living in poverty that many people with a psychiatric disability face. The episodic nature of psychiatric disability makes it very difficult for many people who have a mental illness to secure and maintain consistent employment, especially in the competitive job market.
The symptoms of mental illness can be managed in various ways, including therapy, medication and support. Physicians and psychiatrists provide medical treatment and community services such as case managers, outreach workers and peer support also provide the necessary support for a person in order to prevent recurrence of symptoms. A range of service from informal support such as family and friends to more formal community support such as supportive housing and crisis intervention to formal treatment such as hospital care is often required for people with a mental illness.
Our focus at CHMA is on community supports. We believe that a full range of services available in the community are necessary to maintain mental health and prevent recurrence of illness and costly hospitalization.
People with psychiatric illness require more than the formal mental health services of hospitals, community agencies and private practice. A new framework for support prepared by CMHA national outlines the integrated community resource base required to live a health and fulfilling life. Jobs or other productive activities, shelter, food and adequate income are all basic necessities to both physical and mental health.
The recent cuts have had serious negative impacts on the lives of many people with a psychiatric disability. This government, prior to and since its spring election, has stated clearly that any economic cuts brought in by the government in its attempt to reduce the deficit would not affect people who are disabled, that people with disabilities would not be penalized.
We are here today to tell you, like many others in Ontario have already told you, that the changes you have already introduced, and those you introduced in your budget statement and through Bill 26, do in fact penalize people who are disabled. Most individuals who have a psychiatric disability are on some form of social assistance. Individuals who have been formally diagnosed by a doctor may be receiving family benefits allowance. There are many people who have a psychiatric illness who are only receiving general welfare assistance because they do not want the label of being permanently disabled, for example, and their application for FBA has not been processed, or for other individual reasons. There are many reasons not to end up on FBA and live on general welfare.
Today we will give you some background information specific to Ottawa-Carleton and speak to you on the implications of hospital restructuring, the proposed changes to the Ontario Drug Benefit Act and access to personal information. I'll ask Joanne to do that for us.
Ms Joanne Lowe: Although we acknowledge that the health services of Ontario can be delivered in a coordinated fashion with less financial cost, service change or reduction in one part of the health sector system will impact many other areas of the community and must be planned for and managed in a manner that will prevent long-term, greater economic costs. It is critical that any restructuring or reviewing of both hospital-based and community-based mental health services be done in partnership with consumers, family members and providers in the local communities affected.
While there are common issues that affect most people with a mental health problem, each community is unique in many ways. In Ottawa-Carleton, consumer-survivors and family members are a critical component in the mental health planning process. We have a planning and decision-making structure in place, and although, like all decision-making structures, it can be improved, we feel strongly that this government needs to respect the individual integrity and uniqueness of each community it represents. The proposed Health Services Restructuring Commission and any other process or structure for government decision-making must have input from stakeholders and be partnered with local communities.
The pressure on family members and community support services will be more than they are able to cope with in the current level of resources and funding in our community. The cutbacks to hospitals and the focus on core hospital services will put pressure on hospitals to be closing psychiatric services. If hospitals are unilaterally closed, there will be an extra burden for family members to care for individuals whom they might not have had the resources or ability to care for. Family members can attest that it is extremely difficult to manage when a son or daughter or spouse is experiencing severe symptoms of mental illness. Hospital care and treatment are currently the only resort in Ottawa-Carleton when someone is in crisis.
At CMHA we recognize the need for hospital restructuring and support efforts to do so. In the area of mental health services, the restructuring process has already begun. All that is necessary at this stage is for the government to move strongly toward mental health reform. The demand for and pressure on community-based mental health services has never been so great in Ottawa-Carleton as it is at present. Currently in Ottawa-Carleton, $120.8 million is spent on mental health care each year. Only 4% of this amount is spent on community mental health services, such as case management and outreach services. The remaining 96% is spent on hospital services, salary and professional fees and OHIP billing.
There is a current imbalance in the range of community and hospital services in Ottawa-Carleton. This current imbalance will not be rectified by providing the Minister of Health with the power to unilaterally close hospitals. The reallocation of resources to the community is not likely to occur in this event, and our expectation is that any saving from hospital restructuring be allocated directly into our own community. Appropriate and necessary services in the community close to where a person lives can prevent costly emergency crises and rehospitalizations. Some of these community supports would include case management, emergency services, psychiatric rehab services, and the list goes on and on.
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One of our main areas of concern regarding the recent budget announcements and the proposed Bill 26 are the proposed changes to the Ontario drug benefit and Trillium drug plans. Our concerns are not just philosophical, but very practical. People with a psychiatric illness often require multiple, ongoing prescriptions. While it may not seem a lot to someone who has an adequate income and does not require ongoing medication, the $2 copayment for prescriptions is more than people with a psychiatric disability are able to bear.
Many people with a psychiatric illness require ongoing medication to manage their symptoms, and for many individuals with a psychiatric illness, taking medications daily is part of a necessary lifelong routine that enables them to stay well. Without medication, many would become sick again and would need to be rehospitalized. Further, it is not uncommon for one person to need more than one different medication to combat either the illness itself or to counteract side-effects of the other medications. One person we spoke to yesterday has four prescriptions she will have filled out each month; another has seven prescriptions monthly. This number is not uncommon.
During times of crises, individuals will see their doctors more often, perhaps weekly or even twice a week. Doctors will often only provide enough medication and prescription to last until the next appointment, in order to monitor the effects of the medication and the symptoms of the illness. Weekly amounts of medication will similarly be prescribed when a medication is being introduced to a patient so that the impacts of the side-effects of the medication can be closely monitored and the dosage adjusted accordingly.
These are important reasons for discouraging the provision of more than a month's prescription at a time. A person who is experiencing a recurrence of the illness or being introduced to a new medication therefore may easily have between 10 to 20 prescriptions in a month. This is not to say that even an ongoing cost of two or three medications is a cost that can be accommodated for someone who experiences a mental health problem on a fixed income. For individuals with a psychiatric illness who are living in a supervised boarding home, for example, this fee needs to come out of their $112 "comfort" allowance, the only direct income they have each month. For everyone on social assistance, the additional cost of prescriptions will be difficult to bear.
The changes to the drug plans and legislation will deny and restrict people's access to necessary medication. They will restrict people's access through introduction of user fees. Staff at CMHA have just in the last week talked to two people who had no money for the bus to get to the drugstore to get their prescriptions filled. One person had two prescriptions, the other one had three. Both individuals spoke about their concerns about the $2 copayment, stating that they would not be able to afford it and stating that they just wouldn't bother to get their prescriptions filled.
This change to the Ontario drug benefit plan unjustly targets people who have chronic illness requiring medication. These are individuals who are most in need of financial assistance. They certainly do not have disposable income that can accommodate this burden.
The impact of introducing this $2 copayment to people with a psychiatric illness will be that some people will not get their prescriptions filled; they will get more sick and quite possibly require hospitalization. The changes to the drug plan will also restrict access to necessary medication. We also have strong concerns regarding the province no longer cost-sharing, through municipalities, the discretionary provision of drugs and drug-related products through supplementary aid or special assistance.
In Ottawa-Carleton, the region will not be able to pick up this difference. The working poor will not be covered, and for those who have a mental illness who do not work for pay, many of them will have part-time or episodic work and will be living on very low income. This will impact upon them, as their costs of medication will no longer be covered through supplementary aid and special assistance.
The proposed changes regarding no-substitution claims are also of strong concern to us. The government needs to recognize that when a prescription is labelled "no substitute," it is because that particular medication is what is required, not an interchangeable one of a lesser price. Medications for people with a psychiatric illness are very precise. When no substitution is indicated, it is because generic products or brand-name products are not suitable. People do not do as well on a generic drug. A change to what seems to be similar medication can result in serious side-effects. The individual should not have to pay the difference, and the difference needs to be covered under this drug plan.
When a new medication is brought to the market, it takes time, often years, before a generic or a substitute drug is developed. Not covering the medication under the drug plan will restrict people's access to treatment that they may need quite significantly.
The changes in the conditions of payment proposed by this government could restrict payment for specific drugs to situations where clinical criteria have been satisfied -- a specific illness or that other treatments are ineffective, for example. We have questions and concerns regarding what the clinical criteria will be.
Who will determine the criteria that must be satisfied and how criteria will be determined as being satisfied? CMHA Ottawa-Carleton strongly believes that the most effective treatment is determined best by the mental health consumer with their doctor and other health supports. Client/patient self-determination of their own treatment is paramount.
CMHA Ottawa-Carleton supports the recommendation of the Ontario division that drugs prescribed for psychiatric illness be exempt from the deductible and the $2 copayment. There needs to be inclusion in the drug plan of medication which counters the side-effects of other medications and prescriptions.
While it may appear in the short term that there will be cost savings through the proposed changes in Bill 26, it would be irresponsible not to take into consideration the long-term expenses associated with increasing numbers of rehospitalizations and the use of other services as a result of these cuts at the front end.
The provincial cuts to social assistance and the reductions to municipal transfers have already impacted people with a psychiatric disability. While many individuals with a mental illness receive the family benefits allowance, there are those individuals who are on general welfare assistance and have been cut by the 21.6% in their income.
As well, some individuals with a psychiatric disability are able to work part-time or periodically. They are among the working poor. Community supports such as non-profit and subsidized housing, outreach and case management services, counselling, special assistance and supplementary aid, transportation, supportive employment services, emergency shelters and emergency food are basic supports in many of these individuals' lives. All of these community supports have been reduced or are in severe jeopardy due to the provincial government cutbacks.
Cuts to non-profit housing mean less adequate and affordable housing and cuts to social services mean less supports for people to maintain this housing. For people with a mental health problem this can mean the difference between having shelter and living on the street. Cuts to municipalities have also meant that local government is less able to provide grants to emergency shelters, drop-in centres, food banks and other critical services with people with mental illness.
Currently, the emergency shelters in Ottawa-Carleton are full to capacity. Food banks are having to turn people away because of the tremendous demand. The stress associated with living in poverty and being vulnerable to homelessness and hunger has increased severely among consumer-survivors of Ottawa-Carleton. This stress exacerbates symptoms of a person's illness.
Mr Parsons: We actually get to the closing remarks now. Isn't that fabulous? Although Joanne did a wonderful job.
To summarize, we would like to leave you with a set of illustrations on how the changes already introduced and proposed changes impact upon people with a psychiatric disability.
We have a really nice diagram. This is Joe -- he's up in the top left-hand corner -- and he lives in a boarding home, so his housing and food are provided for him. He's given meals and he's given a room to live in and he gets $112 as a personal needs allowance, often called a comfort allowance.
But poor Joe, although he gets his food and a nice room somewhere, he has to pay for his transportation, and in Ottawa-Carleton that's $57. He has to pay for his copayment on medication as well, and that's an extra $14 for a stable person receiving medication. For all his clothing and personal care, his haircuts, his cold medicine, any coffee he wants to buy, doing his laundry, things like that, he would then have an extra $41 in a month to achieve all this. That's poor Joe's life experiences and what some of these changes would do for him.
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Ms Lowe: This is an illustration of what life would mean to Jane currently, and on top of that, the proposed changes that would come out of Bill 26 and the provincial cuts that have already taken place. Jane is on FBA. She receives $920 a month. She lives in a bachelor apartment for which she pays $522 a month, which is a fairly conservative figure for an apartment in Ottawa-Carleton. She pays $170 for food on a monthly basis. Her transportation has just gone up by $3 a month this year, up to $57, and for her telephone, her hydro and her cable, it's about $38 a month. For her medication, there's the new charge of the copayment if she gets four prescriptions a month, which is a fairly conservative figure for Jane, times $2. For other expenses she's left with $125 to buy clothing, to meet personal care needs that would include soap, toothpaste, shampoo, cold medicine, laundry and entertainment. That's what life looks like for Jane under the circumstances.
Mr Parsons: To conclude, we strongly urge that in review of Bill 26, this government recognize the critical needs of people with a psychiatric disability; that it support the process and principles of mental health reform, which will strengthen the community's ability to respond to people's mental health needs; that it consult and plan with community stakeholders, especially consumer-survivors and family members, in developing and restructuring the mental health care system; that it not proceed with the amendments to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act until a more comprehensive review and consultation is completed; that it provide for access to the treatment and medication necessary to alleviate the symptoms of mental illness.
I'd like to thank you for the opportunity to provide comment on Bill 26 and the impacts the proposed changes in this bill will have within the lives of people with a psychiatric illness. We hope this government seeks out the input of many community members, especially client groups, whenever it intends to introduce changes in Ontario.
I understand that many other groups wished to speak to this committee while you were in Ottawa but have not been able to do so. We hope that everyone will have the opportunity to have their views heard by you before you have finished this hearing process.
Now I'd like to introduce you to Bill Carne. He's a board member of the Psychiatric Survivors of Ottawa, who have asked him to speak on behalf of confidentiality.
Mr Bill Carne: Thank you for hearing concerns on mental health issues. I also would like to thank the Canadian Mental Health Association, Ottawa-Carleton branch, for giving me some time to speak. CMHA Ottawa is very supportive of psychiatric consumer-survivors in Ottawa.
My organization is the Psychiatric Survivors of Ottawa. We receive Ministry of Health funding to provide supports to consumer-survivors. As many of our members offer a lot of volunteer time, we provide great benefits for little cost, and our funding is coming up shortly.
Our main issue is that of confidentiality of patient records. I would like to open by making you aware that the issue of confidentiality of patient records affects you personally. It is the clinical records of you and your family members that are also affected by the proposed changes. If these records were to include issues such as mental illness, AIDS, abortion etc, and this information were made public, it could possibly be very damaging to your chances for re-election. You thus see on a very personal basis the importance of having strong safeguard procedures and policies in place to prevent abuse and accidental release of this information.
Confidentiality is a major issue for people with a psychiatric history. For example, the return address of all correspondence sent by our organization does not include our name. If someone were to call our office asking for a member, we would advise the caller that we will contact that person, if they are a member, and that person can, if they so choose, return the call.
We have very deep concerns about the possible impact of people being fearful of full disclosure of whatever they say to their doctor. Already we have been advised by some of our members that they're not raising key issues with their doctors for fear that information will become public, yet unless they give full disclosure to the doctor, they cannot receive the treatment they need. As well, you're aware that the confidentiality of information by battered women is already an issue.
A Ministry of Health spokesperson on a local radio show said the changes were to be done to update an old act, that many new payment methods have come into place other than fee-for-service and to be accountable for the money the ministry is spending, a means to prevent fraud and misuse of the system is necessary. While we agree with this in principle, we are not sure this method is the best process to achieve this.
You're aware that the Information and Privacy Commissioner has already expressed very serious concerns about the wording and possible effects of this act as it stands. We ask you to consider his concerns when redrafting this part of the act.
We suggest that what you propose as regulations for safeguards be actually put into the act, making it harder to make changes to these protocols. We suggest that a penalty for disclosure, even accidentally, be put into this act. If possible, we would like it to be illegal for the press to release any information obtained by disclosure of this information.
I emphasize very strongly that if you have a psychiatric history, the stigma is extremely great. There are many working people, with real jobs, who, if it were found out they had a psychiatric history, might lose those jobs. Myself, I acted as an advocate for about a year and a half before I was willing to go public to my friends and things like that.
Finally, we are not too sure how you would decide what files are to be chosen for examination. At present, it just seems to be on a hit-or-miss basis. As a suggestion, perhaps there's a means to, say, compare OHIP and WCB files by patient number and date to find possible causes of abuse.
Thank you very much for your time.
Mrs Ecker: Thank you very much for coming and for an excellent presentation. I agree with you that confidentiality is an extremely important principle, especially in the mental health field. It is my understanding that section 8 of the Mental Health Act, which does have specific provisions for what can and cannot happen, makes the Mental Health Act supersede any other legislation. If there were anything in 26 that would compromise confidentiality -- we don't think there is, but if there were -- section 8 of the Mental Health Act I believe would supersede that. I would in the seconds I have provide you with at least that assurance.
Mr Patten: Thank you for your presentation. In the interests of time, we heard just prior to you from the Canadian Drug Manufacturers Association extolling the virtues of generic drugs. One of the comments you made was that many patients do not do as well with the generic drugs as they do with brand names. Is that based on research evidence, empirical observation or --
Ms Lowe: It's based on experiences of the clients we hear from, as well as the experiences we've heard from the other branches across Ontario through the Canadian Mental Health Association. The best comment I could make to that would be that we believe our clients when they tell us they're just not as good all the time.
Ms Lankin: My question's about Jane and Joe. Jane's learned some new skills at the urging of the Minister of Community and Social Services -- how to barter with her grocer for the cost of a tin of tuna -- and now the Minister of Health wants both Jane and Joe to go out and barter with their pharmacists and find the best price; particularly Joe, who perhaps doesn't have the experience of bartering because his food's provided for. How he's going to deal with going from pharmacy to pharmacy to pharmacy to get the best price on those seven different prescriptions that you talked about?
Mr Parsons: Poor Joe has everything delivered to him. He would get it through the boarding home itself. There would be additional drugs that he might get that wouldn't be psychiatric, but most drugs would be dealt with by the boarding homes. So he quite often doesn't get out. That's the issue; he doesn't leave at all.
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Ms Lankin: He doesn't have to bargain for them.
Mr Parsons: No, he would --
The Chair: Thank you for your presentation. We appreciate your interest in our committee process.
Mr Carne: If I could just add one thing to respond to your question. In the Mental Health Act, when information is released to non-doctors, the name is blanked out of all information, so when you're doing this maybe that could be blanked out and some sort of code number used for confidentiality.
Mr Clement: That's right, and that's how it's going to be.
Mrs Ecker: It supersedes Bill 26.
Mr Clement: That trumps anything that we're doing. The Mental Health Act says it.
ONTARIO ASSOCIATION OF NEPHROLOGISTS OMA SECTION ON NEPHROLOGY
The Chair: The next group are the Ontario Association of Nephrologists, Dr Gerald Posen and Dr Peter Blake. Good afternoon, gentlemen. Welcome to our committee.
Dr Gerald Posen: Thank you very much. We welcome this opportunity to appear before the committee to address certain issues relating to the bill and to the provision of health care in Ontario.
First of all, I'd better tell you what nephrologists are. It will help all of us as we approach this. We are the physicians who look after the patients on haemodialysis, peritoneal dialysis and kidney transplant in the province. A major portion of our work involves just that. Both dialysis and transplant -- and this is really important to understand -- are life-sustaining therapies; prior to the 1960s patients with end-stage renal failure all died.
Our members work in hospitals where most of the dialysis services are currently provided. Due to the special nature of our work, 80% of the nephrologists in the province hold privileges with the various teaching hospitals throughout Ontario.
We would like to state that we acknowledge and support the government's efforts to contain costs and to control the provincial deficit. We are sympathetic to a government that is fiscally responsible and is willing to take active measures to balance the provincial budget. We also appreciate the government's need to make cuts affecting all Ontario residents and industries, including health care.
We would like to make a few comments on aspects of the bill which affect, firstly, all physicians in general and, secondly, raise concerns about nephrologists.
It is not our intention to comment on all the statutory amendments contained in the bill. Our purpose is to sensitize the committee to the needs. Our long-term objective -- and this is something we have talked about and we are trying to relate with the government -- is to foster a working relationship with the government and the Ministry of Health to preserve and enhance the delivery of quality health care to the people of Ontario. We ask you to consider our comments in that light.
As members of the Ontario Medical Association Section on Nephrology, we support -- in fact, we enthusiastically support -- the idea of a partnership. We have been active in the very early days of this when the Ontario government was unbelievably supportive in starting dialysis facilities and home dialysis in the province. Probably none of you here realize it, but Ontario was probably the first government in the world to start a home dialysis program fully funded by the ministry, and that was in 1968, and that was through meetings with our early association and the Minister of Health. So we have a long history to build on.
We feel it is terribly important that the ministry continue working with physicians through the Ontario Medical Association to help each other. It is our recommendation that the ministry resume negotiations with the OMA in an atmosphere of mutual cooperation.
The amendments to the Public Hospitals Act give the hospital board the power to refuse applications for appointments, reappointments or to make changes in hospital privileges, revoke appointments and cancel or substantially alter hospital privileges if the hospital board or the ministry decides the hospital should cease to operate. Amendments leave it open that such changes will also apply to situations other than hospital closures, and this is one of our great fears. It appears that no hearing would be required and that the statutory safeguards that would otherwise protect the physician's rights would not apply. The hospital and the ministry would be immune from liability. This is very frightening if hospitals merge. Where do we have to turn to? As mentioned before, most of us nephrologists work in hospitals.
Given that all our members require their hospital privileges to carry on their practices, we are deeply concerned with these amendments. The existing balance of power in Ontario's hospitals, between the administrators who by their nature are focused on issues of cost containment and physicians who are the patients' advocates, has served the interests of Ontario's patients very well. It is the permanence of the physician's appointment that allows him to challenge the hospital administration in order to ensure the highest quality of care.
The bill opens the door to allow financial and other improper pressures to be brought to bear on physicians to influence their clinical judgement. Only the best interests of the patients should in fact influence a physician's judgement.
The bill, we would state, we'd like to be amended to provide that the only time physician privileges may be revoked, outside the already well established situations contemplated by the Publics Hospital Act and case law, is when a hospital is closing, such revocation to take place upon the date of closure. The right to revoke privileges should not apply when hospitals merge or in any other situation. We cannot overemphasize the importance of this to the interests of our patients.
We agree in principle to the privacy act and we support all that has been said about this. This is terribly important for all of us.
Now I'd like to turn to issues affecting nephrologists and turn it over to the chair of our association, Dr Peter Blake.
Dr Peter Blake: Thank you, Gerry. I'd like to talk a little bit here about the issues that affect nephrologists and nephrology patients and are related to this bill.
Let me, first of all, give you a little bit of background. In Ontario, over the last decade, there has been a steady increase in the need for dialysis. If you could perhaps turn to the first exhibit, you'll see a graph which I think shows this fairly clearly. Over the last decade, from about 1,500 patients on chronic dialysis therapy, we have gone to a stage where we have now almost 4,000. That's a very, very emphatic increase that's going on, and this is the background against which I'd like you to see these comments.
The increase is occurring. Why? Well, primarily, there are two factors here. Firstly, medicine has just gotten a bit better at doing dialysis and keeping people alive who would not have been able to even receive dialysis 20 or 30 years ago. For example, an elderly diabetic, or not even an elderly one, say a 65-year-old diabetic, would not have been accepted for dialysis in Ontario or in most countries 20 years ago. Now that's almost routine, and those people are living fruitful lives. So the number of people we're able to dialyse has increased at quite a rate.
A second phenomenon that you're all aware of is the aging of the population. Like many diseases, this disease mainly affects older people.
So these two processes working together have led to this enormous increase in the number of patients whom we're having to deal with, and it looks like it's going to go on for some time yet. There's no sign of a plateau being reached, either in this or in other western countries.
It's important to emphasize that this increase is a real and legitimate increase. This is not something that physicians have drummed up to make more money for themselves or something. This is a patient-driven or a disease-driven increase in demand, and not a physician-driven -- we're hearing a lot lately about physicians driving increased demand. This is certainly not a situation like that. It's a life-sustaining treatment and it's quite a straightforward matter; either the treatment is given to the patient or the patient dies. It's as stark as that.
As an example of the seriousness of this issue, in the United States where most things are done by paying for it, in health care this condition is treated differently to everything else. Since 1973 all US citizens, regardless of age or income, have the right to receive dialysis and renal transplant free of charge. That's a very unique thing in the United States, and it strengthens the point that I'm making here today.
For these reasons, I think it's inappropriate for the government to try and resolve the present utilization problem, or perceived utilization problem, by imposing restrictions on the medical profession as a whole, regardless of specialty, in the manner that's being proposed in this Bill 26. It's a little bit oversimplified to assume that utilization can be controlled by restricting the ability of physicians to bill OHIP and by second-guessing their professional judgement. As this example of dialysis demonstrates, there are legitimate areas where utilization is increasing in a manner that's quite outside the control of physicians, and it's very important that this be recognized and facilitated, as it has been in the past.
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The second point I would like to make is, the government has recently announced -- and the government is aware of this dialysis issue; both this and the previous government -- its commitment to provide additional funding for dialysis in the province. We very much welcome these initiatives, for the reasons I've shown you; there's a proven need for this service.
Having said that, we're concerned that there hasn't been a corresponding increase in funding for the doctors who are going to ultimately be responsible for providing these services. In other words, the government has provided additional funding for dialysis, all of which will be given to hospitals and health care facilities; it hasn't worked out clearly who's going to deliver those. We have, as I'll show you in a moment, a limited number of nephrologists in the province. Unless funding is made available, there won't be enough nephrologists to deliver the sort of quality of care we think we're delivering now.
We agree that it's appropriate for the government to commit additional resources, of course, and to issue new licences for dialysis services. But if we don't fund appropriate numbers of physicians at the same time, and if all the money to pay for this comes from the present fixed OHIP billing globe, we're going to find that not just the nephrologists are unhappy about that but the rest of the physicians. We've become very unpopular, you might understand, with our fellow physicians because we can't decrease our utilization. We're being asked by the OMA to claw back, to decrease utilization; we find we can't do it, not because we're nasty but because it's disease-driven. You can appreciate that we're finding that we're having to take on an ever-increasing workload without additional funding, and this is a quality-of-care issue ultimately. You can only look after so many patients and do it well.
Let me move a little bit into the area of manpower for my third point. With respect to the government's powers in this bill to direct where physicians may work, what services they may provide and how much they may bill, it should be recognized that in many specialties -- and I'm going to talk about nephrology. There's currently a marked shortage in many areas of the province of nephrologists.
If I could take you to the second exhibit, it's not the most easily readable, but it compares all the provinces. If you look opposite Ontario and halfway down, you'll see we've expressed this as the number of dialysis patients per nephrologist in Ontario. In 1986, a mere 10 years ago, there were almost 25 dialysis patients for each nephrologist. That number has gone up now to almost 38 in 1993. That's a 50% increase in the workload per nephrologist. That's resulting from the fact that the number of patients is increasing much faster than the number of nephrologists.
Why are the nephrologists not increasing? Well, it's not been, up to now, an attractive specialty for medical graduates to do. It's perceived as having a high workload that keeps increasing. It's an on-call specialty; it's one of those ones where you get called at weekends and at night-time. The patients are ill, and they're chronically ill, which some people don't like to deal with. Also, it tends to be tied in to university centres because of the nature of where this therapy is delivered, and that limits people's mobility somewhat. So it hasn't been the most attractive one, and up to recently a significant proportion of Ontario's nephrologists have been foreign medical graduates. That is becoming less feasible now, so we're going to have to generate our own nephrologists. But it is not something that has been terribly attractive up to now.
The third exhibit makes an interesting point about this. We have an age distribution problem. If you look at exhibit C, it tells you which five years of their career each nephrologist in Ontario is in. You'll notice a big peak in the 55-60 age group. This reflects the fact that nephrology is about 30 years old. The first generation of nephrologists is reaching retirement age. This is going to further accentuate the manpower problem unless we get better at getting people to do this particular specialty.
Despite all these difficulties, we feel that we've worked hard as a group to try to address problems in the province with nephrology. We had an issue a few years ago, and we still do, with the northern areas, that it's difficult to get nephrologists to go and work, just like other doctors, in parts of northern Ontario. That's improved a bit; we still need to do better. We believe we can address this without having to force people to do things. We have a number of ideas that we'd be happy to share with the Ministry of Health. Obviously, some include incentives, but there are other methods that could be used as well. Certainly, forcing people to do it would not be something that would be very attractive to us, and you've heard that from many other speakers.
I think also, to the extent that Bill 26 is viewed as detrimental to physicians in general and the practice of nephrology in particular, it will make our shortage problems worse and further compromise patient care. We believe we can avoid these things. We would like to talk to the ministry and help solve the problem. We have a tradition of doing that and we think we can continue to do it effectively.
Moving on to the next point, Bill 26 gives the Ministry of Health the authority to increase or decrease the fees payable to physicians according to a lot of different factors, including specialization, experience, frequency of providing the service, the place and the setting. It even gives the authority for paying nil for some services. We feel these are very extreme powers.
If this bill is passed, the minister will have the authority to determine who is an eligible physician, who will be allowed to bill OHIP. He will have the exclusive authority to define what services are insured and under what conditions and limitations they're insured. These issues will no longer require prior consultation with and approval from the OMA. We regret this.
Based on our experience with proposed fee code adjustments to the OHIP schedule, we feel it's important for the government to recognize the sorts of factors that I've been talking about when decreasing or eliminating fees for various services. A decision to decrease the fee for certain prescribed services may have an effect on the availability of those services, and in something like dialysis that's obviously very important because it's life-sustaining.
We would urge the minister therefore to amend Bill 26 to leave the fee codes under the purview of the OMA. If he won't do that, we would invite him to consult with the nephrologists on issues pertaining to our fee codes so that changes that are made are made in a way that will not compromise patient care.
The fifth point is one I briefly want to deal with: the Independent Health Facilities Act. This present ministry has introduced a new initiative in dialysis which we welcome. They have opened the field up to independent health facilities. Previously, dialysis has been overwhelmingly delivered by hospitals. Therefore, the Independent Health Facilities Act suddenly becomes an issue of some concern to us.
We would very strongly favour that this process that has gone on just in the last six months for dialysis, which is a tendering process, the so-called RFP or request-for-proposal process -- it's an open tendering or bidding process -- continue if this is the way we're going to go. We don't like the idea that the minister would have the ability to request proposals from one group only, as he saw fit. We feel that's an arbitrary power. We like the idea of this process being as public and transparent as is possible.
With respect to the minister's powers to revoke a licence from an IHF, an independent health facility, for cost-containment reasons, we'd also like, in the interests of fairness, that there be some appeal involved in these cases, that this relatively arbitrary power be subject to appeal. And I think fairness dictates that individuals who are operating dialysis facilities in the future in Ontario should be compensated for their investments if they are rendered useless as a result of a minister's action.
In the spirit of co-operation, our organization would be willing to work with ministry officials and the College of Physicians and Surgeons of Ontario to expand quality assurance guidelines. This is now an important issue as well. If for the first time we're going to have private companies delivering dialysis in Ontario as a new initiative, we think it becomes increasingly important to ensure that quality is maintained. We pride ourselves in Canada generally that we have a very high standard in our dialysis units. We sometimes compare very favourably with the US and we like to be quite proud about that. We're concerned that with the independent health facilities coming in, the standards could be allowed to drop if we don't monitor them very carefully. We would like the minister to get involved in ensuring that standards are maintained when this goes ahead.
I'm going to finish up by saying we would like to acknowledge again the initiative of the Ministry of Health in this recent request for tendering. I think it indicates that they are aware of the dialysis problem, that it's a sincere attempt to solve it. We think some of the aspects of Bill 26 threaten this process and make it less likely to be successful.
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We'd like to go on cooperating with the ministry. Some of the statements made lately about doctors haven't been that nice. We think, by and large, we're a reasonably dedicated group of professionals. Most of my nephrology colleagues work hard. Most of them work, I think, 50 hours or more a week. Maybe politicians find that relatively little. Over the course of each day, we deal with high-pressure medicine. We feel we're pretty dedicated and we feel we'd like to be involved in decision-making about our patients. We feel we know best, I suppose, about a lot of the issues pertaining to those patients, and we worry about a minister or a ministry having arbitrary powers to overrule us.
If I could sum up, we have ever-increasing numbers of patients. We don't have enough nephrologists. This is a concern. It's a simple supply-demand problem. We're worried this imbalance will get worse and we feel we have something to contribute to prevent it getting worse. It's a basic quality-of-care issue for our patients and we'd like your support on this.
The Chair: We've got about three minutes per party left for questions, beginning with the Liberals.
Mr McGuinty: Thank you very much, gentlemen, for your presentation. I think one of the questions we have to ask ourselves any time we have a piece of legislation is: What is the policy that informs it, what is the government trying to do, and in particular, I guess, with respect to the health care aspects of this, what role does the government see doctors playing in the province?
I'm reminded of what a professor told me once, somewhat in jest, about universities. He said, "They'd be great places but for the students." It seems to me the government is saying, "The delivery of health care in the province would be great but for doctors."
I'm very concerned in particular about new blood, introducing new blood, getting new doctors on line. I think it's tragic if we can't create a climate which encourages young people both to get into medicine in this province and, furthermore, to stay here and practise. What has to be done in order to ensure that happens?
Dr Posen: It's very difficult to answer that. What I see in medical students today is the same dedication that I've always seen in students.
I think people are afraid of an autocracy. What we have done in the past with governments way back -- again, I was part of the original group with Matthew Dymond, when he was Minister of Health, that got this home dialysis program, the first in the world, the best in the world, here in Ontario. It was meetings with him, meetings with the ministry, and this is what we're asking for. Let us continue to meet and discuss together, and I think people will stay in the province. We all understand times are tough fiscally. We're not asking you anything financially. We're asking to be able to talk to you.
Dr Blake: I would add one thing to that. I see the problem not just as people not wanting to do medicine; people still want to do medicine. I would like to see them wanting to do specialties like nephrology. Obviously, I've got a bias here. I think we've got to make it attractive to do things like that. Encumbering us with the sort of autocratic things Dr Posen has talked about might make that more difficult. There's a perception that: "I don't want to work in a specialty. You spend all your time fighting for this and fighting for that. I'd rather be out on my own, working somewhere else." I wouldn't like to encourage that attitude further.
Ms Lankin: I want to particularly ask you about your concerns around revocation of hospital privileges. It's pretty clear in the act, under a closure situation, what the powers are of the hospital CEO and the fact that there's no appeal from it. I would think the argument that the government would put forward is, "But we've allowed for other regulations to control situations other than closures, so therefore you should trust us that we're going to do something different." It doesn't say that the existing process, with all of the due process and appeals, will prevail, but something that's going to be written in regulation.
As Dr Shaver said earlier, you've got to wonder what those regulations are going to be. There won't be public scrutiny of them, there won't be legislative debate; they're done by cabinet. Whether it's with respect to that, whether it's with respect to the assurances we get that they're not going to violate the Canada Health Act although they're moving things out from under the protection of the Canada Health Act clauses and pieces of the legislation, or the assurances that the hospital restructuring committee is going to listen to DHCs although it doesn't say that in the legislation, everything's going to be done by regulation. Someone said to us yesterday, "It's like the government's asking us for a blank cheque, but we don't know what the number is they're going to write in.
Could you tell us what you would like to see with respect to issues of revocation of hospital privileges? Do you want it spelled out in the legislation? Do you want an assurance that it's the same as it is now except for closures? What changes are you asking for?
Dr Blake: Yes, I think exactly what you say. We're reluctant as a group to take this sort of thing on trust.
Let me give you an example of what it's like for a nephrologist. We're sometimes troublemakers in a hospital. As I've said before, we can't control our own utilization. We annoy the administration. We fight with them at times, in a healthy way. Most of the time we get on okay but we do fight with them because they've got a shrinking pie and we want more of it. We're not always that popular. The fact that they can't arbitrarily sack me or my colleagues makes it easier for us to do that.
I would worry about a situation where my job could be unilaterally revoked because I might be a little bit of a troublemaker. You might say that's not going to happen and it's unrealistic, but I don't know; maybe it will. I don't like taking that sort of thing on trust. I want to be able to be a patient advocate, and that really does happen; it's not a theoretical thing. Every week in every hospital, I think, and Gerry will agree with me, I'm sure, we're in a healthy sort of battle with the administration to make sure our dialysis patients get what we think they need.
Dr Posen: If I can just add to that to say that now there is merging talk. Dr Blake comes from London, Ontario, and they're merging in London. We're talking merging in Ottawa. We want to go ahead with it. I cannot emphasize to you more how much we all are aware of the financial problems. We're not trying to hide from them. But if hospitals merge, we don't want an administration that I fought with last week to turn around to me and say, "Okay, Posen, sorry, you made too many bad points." This has to be carefully spelled out, and it can be in your legislation.
Mr Rollins: Thanks for you two gentlemen being here. It's much appreciated to get up to speed on some of your thinking on some of this.
I think this government has at no time ever thought that the quality and the care and the utmost of the whole health system -- it has got to be in cooperation with the doctors. I know that for some of the moneys we have taken from different parts of the health budget and put back in, it's certainly been one of the areas where we put it back in, dialysis, and we've certainly put some of it back into areas that aren't connected with hospitals, in the assumption that probably down the road some of those areas are going to be without hospital services.
We can provide to the communities of Ontario, whether it's in northern Ontario or 60 miles away -- I come from Belleville, and just recently, in the last few years, we finally got a dialysis system in Belleville. All those patients were driving from Belleville to Kingston and/or to Oshawa or to Peterborough. I think that's the kind of thing that this government has backed up with spending money out in the community to allow our patients to a little bit closer facilitate those services.
There's no question about it: Under the act at the present time, even though there is an independent opening up of some biddings of natures, those conditions will have to be held at the utmost of quality and care, because under the regulations we've got to obtain that, and we'll have to rely once again back on the doctors to make sure this quality of care is continued. I think we need to cooperate with you people, to talk to more of your people who are going in to be doctors to take up your segment of the doctor profession, because we need, as you tell us, more of those people as our aging population goes up.
Dr Posen: I agree with you and I think all governments -- the Liberal, the NDP and the present Conservative government -- have worked very closely with us.
This bill scares us, basically. We need some assurance that the cooperation will go back to what it was in the past, and if what you say is true and this does come out, if the bill is changed so that the cooperation is part, that it's not a fight between the OMA or it's not a fight between the doctors and the government -- let us go back to what it was before. We're a partnership. We need each other.
The Chair: Thank you, doctors. We appreciate your interest in our process and your presentation.
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LINDA KEMP
The Chair: The next group -- it's not a group; it's one lady, Linda Kemp, a registered nurse. Good afternoon and welcome to our committee.
Mrs Linda Kemp: Honourable Chairman, distinguished members of the committee, I would like to thank you for your consideration in providing the opportunity to voice my concerns on a number of the health care issues which would arise from Bill 26.
I am a neonatal ICU nurse with a considerable background of experience in medical research. I'm a member of the reproductive panel. However, the concerns that I present today may not be representative of the reproductive panel or of the Ottawa-Carleton district health council. I am present as a nurse and as a concerned citizen.
The following Bill 26 concerns will be addressed:
The power given to the Health minister to close or merge hospitals or to take over their operation and to dictate type and volume of service without proper consultation.
The deep cuts in care leave gaps allowing for a loss of accountability. Moreover, in protecting itself from legal liability resulting from the restructuring process, the government eliminates any recourse currently available to the patient. In other words, responsibility or culpability for patient outcome on the part of the physician, the institution or the government falls into a void.
The impact that these cuts and changes already have and will have on the quality of care with specific examples of risks and complications to patients, gaps in service and insurance coverage, the rapid incorporation of unproven technology into medical use, the hidden costs, and the effect on mother and infant safety with early maternity discharge.
The ludicrous and incomprehensible assumption that the government, without the benefit of medical training, patient examination or history, can decide for doctors regarding medically necessary procedures, consultations and treatment; in short, patient management. Why have doctors?
The introduction of United States-style, cost-driven managed care into our system (1) with the ability of the Health minister to decide which companies can provide care without submitting to a tendering process and (2) in the deletion of the requirement to encourage Canadian-owned, non-profit health care clinics.
Finally, the removal of price controls on many drugs, freeing the drug manufacturers to charge whatever the market will bear, especially in light of large insurance carriers screening and excluding patients.
Hospitals have reduced inpatient services in many areas due to financial pressures. New technology and methods of treatment such as laparoscopic surgery have been incorporated rapidly into practice in response to the crisis. However, laparoscopy does have the potential of causing a multitude of complications, as there are risks inherent in the procedure itself such as possible perforation of internal organs or blood vessels through the insertion of the Veress needle or trocars, haemorrhage, ureter and bile duct injuries, metal allergy, gas embolism and possible spread of cancer. These complications, which can range from minor to major to even fatal, can or will create additional demands on the system.
Dr Marco Pelosi, in a recent issue of Obstetrics and Gynecology, noted "that it is unfortunate that the type of technique, as complicated or risky as it might be, is not considered a crucial issue as long as the current criteria of acceptance of laparoscopic surgery over laparotomy -- shorter hospital stay and faster recovery -- are fulfilled."
Complications can result from the inadequacy of the limited, two-dimensional view, equipment malfunction and failure, surgical inexperience, and especially from an incomplete evaluation of outcome.
Dr Ronald Schwartz, with the department of gynaecology, Medical College of Georgia, notes that "the true incidence of complication is unknown due to a lack of case studies and the fact that investigators are reluctant to report complications because of fear of injury to personal reputation or medico-legal complications."
Dr Victor Gomel, author and professor of obstetrics and gynaecology at the University of British Columbia, makes a very important distinction about laparoscopic surgery in noting that "operative laparoscopy has been termed `minimally invasive surgery'" and states that surgery "is equally invasive regardless of the approach. A more realistic term is `minimal access surgery,' as only the route is minimized." He further cautions that the term "`minimally invasive' also creates the impression that the operation is minor."
The 1995 Auditor General's report has identified a significant gap in pre-market assessment and risk-rating of medical devices. Devices not listed on the regulation as being high risk do not require pre-market approval. Unfortunately, few changes have been made to this list since 1985, with the result that many new devices viewed by the bureau as being high risk are not subject to pre-market approval, due to delays encountered in passing the amendments to the regulations proposed by the health protection branch. As it stands now, action regarding a device can only be taken after it is marketed. The Hearn report noted in 1992 that approximately 5% of medical devices undergo in-depth, pre-market review and that the safety of medical devices was the biggest problem area being reported by 44% of institutions.
The true incidence of complications is not yet known in many instances due to under-reporting. It is difficult to report complications if there is insufficient data on outcome. This determination of outcome is only possible with the establishment of an accurate complication rate based on long-term follow-up of possibly two to five years. Telephone contact at regular intervals could provide valuable information and early identification of patient problems. Outcome could be further determined by an evaluation of efficacy and cost-effectiveness based on the rate of complications and factoring in the hidden costs of additional treatment and readmission, costs of the expensive equipment and increased OR time, as well as a comparison with other methods of treatment and identification of the appropriate indications and risk-benefit ratio to the patient.
The present situation is that new technology and treatment are being very heavily relied upon and promoted in response to the current cost constraints in medical care. A restructuring of the system is evolving while a need for critical evaluation still exists in terms of safety, outcome, efficacy and cost-effectiveness. If the evaluation process of this in itself is incomplete, how can we evaluate the impact of these changes on our health care?
The Ottawa Citizen cited a recent example with the contamination of laparoscopic insufflator pumps with patient fluids, thereby creating a hazard of cross-infection. This is a shocking, potentially life-threatening and totally unacceptable situation. What is also inexcusable is that the public was never properly notified. With all of the concerns about the blood supply, blood products and awareness of HIV and hepatitis, the seriousness of this cannot be minimized in any way. As hospitals actively promote laparoscopic surgery to the public, and as the method is rapidly incorporated into use, I think some explanations are in order.
The problem regarding medical devices could be addressed by increasing the mandate of the medical devices evaluation division in monitoring advances in technology and their safe application in health care as a priority.
The need for an independent health auditor similar to the US Surgeon General with the ability to override the system when necessary and provide warnings in special instances was recently proposed by Dr Richard Mathias, the federal government's director of field epidemiology, to the Krever inquiry.
Research-based health care is necessary to ensure safety and maintenance and improvement in the quality of service.
The end result? Patients are being discharged home rapidly, often in a much earlier stage of recovery, with increased needs for care and without the benefit of time in hospital to allow for greater recovery, identification of problems and complications, counselling and treatment. Many serious post-operative complications can occur after 48 hours, and for many patients this may be long after discharge. Coupled with the present inadequacies in community and home care, where and how can we expect all of this to take place? In a sense, are we not discharging patients out the front door only to return through the back door?
What do you do if you experience complications after hospitalization? Do you seek out your family doctor, who has probably not yet received your discharge summary from the hospital? Do you go, if you are able, to a community health centre or urgent care centre, where they may not have any of your records unless you are already their patient?
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Do you use the emergency services at the hospital you were discharged from, creating an additional burden on that service?
Will you have access to the outpatient clinics? The Ottawa-Carleton Regional District Health Council report projects that there will be no increased demand on this service due to a further shift of care to community and home care.
If you do not meet the specific criteria for home care and VON services at the time of discharge, will it be possible to seek their assistance?
Are there hidden costs to the patient as the transition to community and home care takes place?
No matter which of these routes you choose, there is a chance that vital information about your health will not be properly reported to your surgeon or other specialist. How will they make accurate judgements about the effectiveness of this treatment if this information is lost to them? The danger is that this determination will be made on the patient's condition at the time of discharge or shortly thereafter, not on the fact that they may have required further treatment, hospitalization or surgery. Even worse, patients may try to deal with problems or complications without seeking assistance.
One of the most underrated benefits of a longer hospital stay in any situation of illness, surgery or childbirth is that a period of rest and recovery was imposed upon us for our own good. In the past the temptation to do too much too soon was eliminated. Now it will be encouraged.
As the care shifts from hospital to community, closer links must be established. CLSCs in Quebec offering combined social and medical services can serve as a model.
Significant gaps in care are already evident:
Premature discharge can leave the patient very much at risk in the home situation.
Ambulance service is inadequate in many outlying areas, areas that may also be seeing hospitals closing. In addition, requirements for ambulance to take the patient to the closest facility may not always be in the best interests of the patient.
There is a catch to VON and home care and there are hidden costs. Patients are required to have a medically necessary procedure in order to qualify for VON care. In order to be eligible for home care, you must first be eligible for VON care. If you don't qualify for VON care but definitely require home care, you may be required to pay for some services.
There are hidden costs to the patient.
I'd like to bring to your attention a major concern with private insurance carriers.
At the time of my recent discharge from hospital, my husband was in transition in employment. As a result, we were faced with a three-month waiting period for eligibility into the new employer's plan. In order to bridge the gap, we applied to Blue Cross, now Liberty Mutual. As a result of their review of my current health history, I was denied preferred hospital benefit and prescription drug benefit.
In addition, our three children, who all have asthma and allergies, not an uncommon problem, were all denied coverage for all asthma and allergy medications.
The appalling fact is that if I had not been so fortunate in having a new employer-based medical insurance plan, I would now be without extended medical coverage and therefore also without medication coverage. Our children would be without coverage for all asthma and allergy medication and we would be financially devastated.
So as you are delisting services and slashing your way through the health care system and allowing drug manufacturers to charge whatever the market will bear, keep in mind that the private insurance carriers will be carefully screening and excluding people and will not be there to cover the consequences for the patient.
Who will pay for what the government might classify as inappropriate use of resources? The patient? The doctor? OHIP? Not likely. Private insurance carriers? Not a chance. So much for universal health care.
Proposed changes to local health care raise other troubling questions:
Waits for surgery may be decreased for some, but will this result in longer waits for others requiring hospitalization as fewer beds are available?
We have already experienced cutbacks in beds. Has there been a corresponding decrease in management since there are fewer beds to manage?
Are expectations about the coping abilities of patients and families too high? Feelings of isolation and helplessness and insecurity can result from the rapid transition in care. This will certainly add to the stress of dealing with illness and incapacity. Basic support of the patient is in itself therapeutic.
Will you be separated from your newborn if either one of you requires rehospitalization? The maternity and early discharge program is already suffering the effects of cutbacks. The incidence of newborns readmitted for problems such as jaundice and dehydration has doubled between 1987 and 1994 as the hospital stay has been reduced to 2.7 days. Noting that engorgement and dehydration are occurring sooner, Dr Jack Newman of the breast feeding clinic at Toronto's Sick Children's Hospital commented: "In my opinion, early discharge is a disaster, although the government would never admit it. There's probably not a lot of money being saved because it costs $1,000 a day to later readmit a baby to ICU."
Not only are the insurance companies controlling health care in the United States, they are driving the system into unsafe practices here in Canada.
In a recent Medical Post article, Dr. Mennuti of the American College of Obstetricians and Gynecologists stated: "The motive is cost-containment and obstetrics is, not surprisingly, a target because obstetrical delivery is the most frequent cause of hospitalization in the United States. However, the safety of early discharge has not yet been studied adequately or established.... Not all serious maternal or newborn problems are evident in the first 12-24 hours."
I recently contacted the American Nurses' Association and obtained this information. A tremendous backlash is developing in the United States against managed, cost-driven care. Many providers are now in the position where they no longer have any say. They must discharge patients in less than 48 hours whether or not it is appropriate. If they fail to comply, the provider risks exclusion from the system.
The states are reacting quickly to ensure 48-hour care. In total now, 20 states, almost half, have introduced or passed 48-hour maternity care legislation, with 96 hours for C-sections, as well as individual hospitals and cities taking action to ensure the same. This is being fought with legislation on a federal level as well with the Newborn and Mother's Protection Act of 1995.
With proposals here to further reduce the stay to 24 hours when possible, we can expect the situation to worsen and place even greater demands on an already compromised community and home care situation.
At this point, I would also like to comment on another obstetrical issue which has a number of safety concerns. Independent birthing centres were recently raised as a possibility for Ottawa-Carleton. The reproductive panel has stated clearly its concerns, which included a lack of anaesthesia services and a lack of emergency medical and surgical backup services leading to a potential lack of safety. It was stated that the birthing centre concept should be physically attached to an acute care facility. I would like to confirm the ministry's decision not to proceed with funding to free-standing birthing centres and to focus resources on existing facilities.
The health council reports have acknowledged these complications:
The number of beds cannot be reduced without putting in place alternative services.
A serious inadequacy in home care services must be addressed. There is a need for reallocation for the expansion of the home care support program to support shorter stays.
Many of the agencies offering long-term and in-home care receive all or most of their funding from the Ministry of Health.
In the last year alone, referrals to home care have increased 10%.
Remember, the home care program in Ottawa-Carleton is $800,000 over budget this year without the province yet making up the loss. The immediate consequence is that home care is now in the process of reducing services, and VON services have been decreased by 15% recently.
As the Ministry of Health provides all or most of the funding for long-term and in-home care, we can look to your management of this as a microcosm of what we can expect if you were to manage our health care. You have removed $33 million in long-term community care funding, and while encouraging shorter hospital stays for maternity care, medical treatment and promotion of unproven technology, further inadequately fund the transfer of care to the community and home care situation, and then conveniently eliminate culpability for outcome or backlash through dictatorial legislation. This is unconscionable.
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There are serious gaps in service which, without relief, will only continue to widen. Action is needed now to ensure that this situation is remedied. Reallocation of funding is the priority. A coordinated continuum of care must be in place and available to the patient before further cuts and shifts in care occur, and it is imperative that the new technologies, the changes in medical and surgical treatments and in service delivery are monitored and evaluated closely as these are the basis for the foundation of change that is occurring.
I would like to close with the following two quotes:
Dr Shindul-Rothschild, assistant professor, Boston College, school of nursing: "When the health care system itself becomes the primary threat to quality care, advocacy by necessity must move from the bedside into the public sector. No one knew this better than the founder of modern nursing, Florence Nightingale."
And from Florence Nightingale: "The ultimate goal is to manage quality. But you cannot manage it until you have a way to measure it, and you cannot measure it until you are able to monitor it."
In closing, I would like to express my sincere appreciation for the opportunity to be present today. It is at once a challenge and an honour to participate in formulating change in this manner. I am hoping that many of your questions will be answered with the rather considerable amount of documentation I have provided. I have tremendous faith in the system and believe that the task can be accomplished while maintaining the priorities considered universal.
Ms Lankin: Thank you very much, Ms Kemp. I appreciate your presentation. It was very thorough and I think provided a very interesting perspective on some of the challenges we all face in engaging in health care reform and restructuring. I thank you for the documentation which we'll have a chance to go through.
As a former Health minister, all of the pitfalls that you were describing -- I remember trying to grapple with understanding the complexity of the restructuring challenge before us and wanting to avoid those pitfalls and wanting to ensure that the process was community-driven, with an open opportunity for a consensus to be developed, because I'm worried, quite frankly, that as you narrow the number of people you listen to and/or who make the decision, the greater chance for error. You've talked about that a lot in your presentation and you underscore it by also talking about the fact that reallocation is a priority.
On a number of occasions in these hearings, I have urged the government to make very clear that the minister's powers around hospital restructuring and the hospital restructuring commission are linked very clearly in the legislation, with terms of reference, mandates, limits on powers and linkages to district health council led processes. We've been assured by the government that's what it intends, but it's not what the legislation says.
Here's one of the reasons I believe that's really critical. I'll give you Windsor as an example, where they did not just a hospital restructuring, but as we know, you need to do a health system restructuring. They've identified moving from four hospitals to two and they've identified the service gaps in the community, and the need to take the operational savings from moving from four hospitals to two and how to reinvest it in the community for a seamless health system in that community. The commitment had been there from the previous government, in working through this process, for that to happen. This Minister of Health has said: "Yes, close your hospitals, but I'm taking the money. It's not going into the community."
Metro Toronto has just done an extensive report on hospital restructuring -- not full health systems, but they did identify some community gaps. They have a phased process of where you have to invest up front before you close a service and where you can reinvest after. They've timed it all out; no commitment that this would in fact happen.
You may not have time to answer, but perhaps in response to someone else. That reallocation is, I think, in jeopardy.
Mrs Johns: I'd like to thank you for your presentation. What your presentation reinforced for me was that we have to maintain quality assurances. They are mandatory. We have to know that our health care is high quality, the best in the world, as we all believe it is. I think all of the people around this table sit through these hearings because that's what they want to have happen. We want to have best quality care, so we are working towards that, if that's any consolation. Sometimes I think that gets lost in the system.
What we are trying to do here is make sure that the community has an ability to say what they believe is good-quality health care, because we believe that the people in the community are the only people who can tell us what they best need. Obviously, I am not telling you anything when I am saying to you that long-term care and home care, VON, has been increasing at a substantial rate, 13% per year throughout Ontario for the last two years and probably before that also. These are the two stats I know.
How can we manage long-term care without doing some of the hard things we are talking about doing in this bill, ie, restructuring the hospitals? How can we allow long-term care to grow? Can you give me some ideas about things that we may have overlooked in our ability to try and manage health care and have a continuum of health care in Ottawa?
Mrs Kemp: I think there needs to be a better sharing of knowledge. Certainly the communication in the transition from the hospital to the community sector can be improved in many ways. I think we have to do it gradually, we have to use a lot of the existing resources and we have to be able to use the people who are already trained and perhaps change them in position rather than letting people go. Another of my concerns is that a lot of highly trained people will be lost in the transition.
I'm most of all concerned about the information transfer that occurs from hospital to community. From personal experience I know that does take place, and that can have grave consequences for the patient. I think that has to be a real priority as well.
Mr Patten: Thank you for that very comprehensive set of statements. I'd like to ask you a process question, though, because I see you are on the panel of the district health council. I am asking this question because at the moment, without the authority that the minister himself or herself would have to intervene at points at which it is perceived that the public interest is not being served, we get such interventions from the Ministry of Health to the point of embarrassing the people in this particular community who have worked through, very hard and very diligently -- I won't comment on the quality of work, but they have worked hard -- and continue to be undercut time and time again.
When you look at this particular bill, does this give you faith that this is a solution to rectify in making decisions that will be in the best interest of health care and of the health care for our particular community?
Mrs Kemp: I'm answering as a nurse and a citizen, not as a member of the district health council, but no, it doesn't give me faith. The thing that concerns me most is the tremendous amount of input that has gone into all the recommendations that have been made. It has drawn on the expertise of a huge number of people in the community with an enormous amount of background, and I think that is to be highly valued in forming any change. I think we can do it but I think we have to make the most of all the resources we have.
Mrs McLeod: Would you also feel that in any final decisions about restructuring, the dollars saved, or at least a significant portion of the dollars saved, should remain in this region to be used for community care or other health care needs?
Mrs Kemp: I have to answer for myself, not for the district health council, but that has been the priority and it continues to be the priority. Community funding has to be in place and the continuum of care uninterrupted. Let's put the structures, the steps, into place and make the money available before we make any further cuts.
The Chair: Thank you very much. We appreciate your involvement in our process this afternoon.
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OTTAWA-CARLETON PHARMACISTS' ASSOCIATION
The Chair: The next presenter is the Ottawa-Carleton Pharmacists' Association, represented by Frank Tonon, the president; Rosemary Killeen, the past president; Barbara Ramsay, a member; and Norman Ferkin, a member. Good afternoon and welcome to our committee.
Mr Frank Tonon: Mr Chairman, committee members, honoured guests, ladies and gentlemen, a special thank you for allowing us to address you this afternoon. I guess someone always has to be last on the docket each day.
My name is Frank Tonon. I am a community pharmacist and president of the Ottawa-Carleton pharmacists. My colleagues are Rosemary Killeen, who is past president and also director of the eastern Ontario district of the Ontario Pharmacists' Association; Barbara Ramsay is our Ontario College of Pharmacists' representative for this area; and Norman Firkin is a community pharmacy owner, our parliamentarian and member of our local association.
Our Ottawa-Carleton association is a voluntary association of pharmacists and pharmacy students from many different walks of the profession. We intend to provide leadership to all our pharmacists at the local level by providing ongoing continuing education units and seminars for them, assuring quality control in the general practice of pharmacy in Ottawa and disseminating information and education to the public, ultimately working to improve the quality of care we can give our patients.
This role is becoming more important in the current environment of rapid and significant change in health care. Community pharmacists play a very vital and integral role in delivering health care services to the people of Ontario every day. As drug therapy becomes more complex and health care services are moved into the community, we need a strong community pharmacy in every community.
We recognize the need for Ontario to get its financial house in order. Obviously, we support this as owners and taxpayers. We believe that today's complex public policy problems are best addressed, though, by inviting all players to offer their ideas, which you have very admirably done, and by having all the players work together in a effort to share experience and to share knowledge.
We want to offer you a few viable solutions, as our colleagues have from the Ontario Pharmacists' Association and other local associations, and as obviously many groups and individuals have and will do in the next few days. We believe our view may be a little bit unique because it comes from the street level, an everyday level. This gives us a valuable insight into the problems, day to day, that government's trying to address, and hopefully we'll be able to give you good advice and sound direction.
As I mentioned, my colleagues and I are street-level pharmacists. We represent over 300 pharmacists in Ottawa-Carleton and a couple of hundred pharmacies, actually. Every week we deal with thousands of prescriptions and countless requests for consultations on non-prescription medications. We help people to decide on how to treat their minor ailments and sometimes we even help them to decide whether they should go to the doctor or to emergency. That does happen every day, so we do play a vital and important health promotion and illness prevention role every day. We are truly on the front line, doing our best to make sure our patients get the drug therapy and health care they need to get well and to keep them in good health.
Health care is obviously one of the complex sectors in the economy. It's been studied and analysed from every angle but still remains very difficult to manage, especially manage effectively. It doesn't lend itself to simple solutions.
Past experience has shown that changes must be introduced with great care to avoid unacceptable and unforeseen consequences. This user fee concept is a good example. This will not reduce the so-called abuse of the system. User fees are profoundly inequitable in terms of access to essential health care on a day-to-day basis. However, debate about this concept serves many, many stakeholders very well by drawing attention away from very important and very real issues.
The emphasis on dollars, on money, on getting the fiscal house of Ontario in order could well turn out to be one of the best things that's ever happened in health care if government policymakers do the right things and all the players work together to achieve appropriate changes.
We are at the retail level every day and we know from our experiences that if you want to solve a problem, whether it's a financial problem, a staffing problem, regardless, you must understand the underlying causes and focus on the right thing. We are very concerned that many of the changes proposed in Bill 26 will have unintentional and negative effects and will not solve the cost problems that they're intended to solve.
We are very concerned that there is too little focus on making sure medications are properly used. When properly managed, drug therapy is highly cost-effective. Drugs are used every day to replace surgery, to prevent debilitating illnesses, to restore people with serious chronic diseases to fully productive lives, to get people back to work the next day.
However, there's lots of evidence that therapeutic drugs are not used properly. We have information from Ontario, from other provinces, from the States, substantial information that shows widespread non-compliance and drug wastage and very costly adverse effects when medication misuse does arise.
There's no hiding that in the past 25 years drug expenditures have been one of the fastest-growing categories of health expenditures: 15% of total health expenditures, that's a big number. Billions of dollars are spent on drugs each year; in 1993, $11 billion in Canada, $300 a person. But billions of dollars are also spent on correcting the results of inappropriate drug use and non-compliance, people not taking their medication properly, resulting in more than $3 billion in direct costs to health care nationally. So spending $300 on medication is one thing, but correcting it with another $100 in expenditures is another thing when people do not take their medication properly.
Various studies show that at least 10% of hospital admissions can be attributed to medication misuse and adverse drug reactions, many of which can be prevented. Overusing drugs in Ontario costs more than $50 million a year. Not using your drugs properly happens about four out of 10 times. A Quebec study shows, for one example, that more than 30% of the elderly take sedatives. Is this necessary? Is this cost-effective?
Prescription drug expenditures, obviously, for the elderly in Ontario have been increasing rapidly also. From 1985-90, drug ingredient costs increased 130%; per capita drug expenditures increased 93%. Just in British Columbia, one study finds that 30% of the elderly are exposed to six or more medications at any one time. We see this every day in our practices. Whether the patients are at home, living with family or institutionalized, too many people are taking too many drugs.
Unfortunately, in addition, inappropriate drug use is not only confined to the elderly. In the population at large there's widespread misuse of certain drugs on a regular basis: antibiotics, sedatives, painkillers, anti-depressants. Some are necessary, but I'm talking about misuse.
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What about wastage? Medicine cabinet cleanup campaigns or brown bag drug return campaigns always find tons of drugs accumulated, millions of doses accumulated, and that's just what's turned in. You can imagine what's at home. The British Columbia royal commission heard that up to 50% of dispensed drugs may only partially be used. I wonder if they're used effectively. Credible, cost-effective quality care is the right thing to focus on. Ineffective services and inappropriate drug use and wastage must cease. So let's try to do the right thing.
Lots and lots of attention is given to "drug use review" and "drug use management" at the broad level of public or private drug plans. This aspect of appropriate drug use is important, but it's only a part of the picture. The critically important idea of counselling individual patients and monitoring their drug use is not only neglected but it is harmed by the increasing pressure on the so-called professional fee and the increasingly competitive retail environment. Yet, a relatively small investment in this area on drug use management for the individual patient would yield savings.
I'd like to stress that this situation just didn't happen. It's been brewing for many decades. No one group is to blame for it. Many players, many people, many governments, many associations have unintentionally contributed to the problems. No one group or association can solve it alone, obviously. It'll take a combined effort and a combined contribution of all stakeholders to improve the situation. A one-sided effort will not be successful.
The overall challenge is, how do we begin improving drug therapy, releasing some of these savings and improving treatment outcomes for all the people in Ontario taking medications? As we said earlier, no one party acting alone can solve this problem, but your community pharmacist, the community pharmacist in Ontario, is the key player. This is due to our training, knowledge, expertise and to our uniquely accessible physical location on the main streets of Ontario and our unique day-to-day personal exposure to our patients.
No one else can provide the services that patients need in order to get the most out of their drug therapy. No one else has the trust and the confidence of patients to reinforce proper drug therapy every day. If every community pharmacy does not remain a viable and active part of our health care system, the quality of drug therapy is going to degenerate. We can't afford that, short-term or long-term.
Our value has been shown in lots of studies and includes direct cost saving, and even avoiding harm to the patient, which ultimately is more cost savings. Take a number -- $74, say, for each outpatient pharmacist intervention; $111 saved for each pharmacist nursing home or institutional intervention; in the States, more than $37 billion saved in five years by pharmacists just being involved in reviewing drug use for patients. How can we avoid harm? Well, one big number: more than 90% reduction in emergency and physician visits over a six-month period when high-risk asthmatics were followed and educated by pharmacists.
We know that the community pharmacist can make drug therapy most cost-effective and at the same time improve treatment outcomes. For years the profession has been encouraged to improve services to patients, most recently by introducing the total pharmaceutical care concept. However, this is one concept, and patient care has just started to improve. This is because the key players, pharmacists, have not had the ongoing framework and practical tools they need in day-to-day life in the real world.
Many pharmacists have actively gone at it alone and created their own tricks -- I shouldn't say "tricks"; their own niche maybe -- created their own ways to help counsel their patients, but the level of patient care must be upgraded on a wider and consistent scale if we're going to make a real dent in the problem of drug misuse and patient noncompliance.
We support the introduction of mandatory patient counselling by our licensing body, the Ontario College of Pharmacists. This at least establishes minimum patient contact every day. However, our experience at the street level indicates this is only one component of the process necessary to achieve rational, cost-effective drug therapy. The bottom line is this: If we are going to be successful, government and pharmacy must be partners, with other stakeholders, in devising the components of the process. We have to believe we can save money, but we have to do it together.
Some street-level pharmacists have developed, as I said, their own tricks or tools, like one simple patient consultation checkoff list that can be used in the real world of pharmacies. It warns of food interactions, it warns of possible side-effects, it offers lots of other information if necessary. Many pharmacists are using patient information leaflets throughout the province now. This is long overdue. We are starting to move well beyond talking about doing things and we are doing something about it, at added cost to us, at added time to us.
We shouldn't be sidetracked from what we strongly believe is the right thing to do, but we do need the government's support in doing this. We need you to understand the real cost drivers in drug therapy. We want you to join us in focusing on the right thing. Let's make cost-effective drug therapy a reality across Ontario and set an example for the other provinces. But we want you to give us a chance.
We suggest four easy steps initially: Let's define the services and interventions required to achieve credible, cost-effective quality care. Let's define what kind of dialogue between the patient and the pharmacist is required to achieve at least more cost-effective drug therapy. Let's determine the time commitment required by the pharmacist to do this function. And obviously, let's pay the pharmacist fairly to provide these services.
In Ottawa-Carleton this checklist has been used by some pharmacists already. It has been used for some time. We are trying to gain more wide acceptance for this. We're redesigning our pharmacies with private counselling areas, but we cannot expect counselling to be effective if the patient is not offered privacy or offered the opportunity for contact.
Street-level pharmacists are doing their part. We're making our investments to help achieve rational, cost-effective drug therapy with our patients. We would like to see it evolve right across Ontario if it's a possibility. There is a role for government in this evolution and we are seeking a strong partnership to help promote the process and generate some of the benefits we have outlined.
What's the immediate role we see for government? One pressing need is for government to address the appropriate reimbursement of pharmacy services. A single fee, the dispensing fee, that posted fee, the so-called professional fee that focuses on the drug product, does not reflect the different types of service that the community pharmacist gives today. It's outdated.
We would like the reimbursement to be tied to the provision of appropriate services, with payment based on the type of pharmacy service provided and the amount of cognitive effort required. The joint pharmacy-government task force on alternative forms of reimbursement, cosponsored by the Ontario Pharmacists' Association, must continue to work on this vitally important issue.
We would also venture to say that the government has an obligation, like health professionals, to do no harm. We can appreciate the difficulty in turning around the ship of state, but it's important to discuss possible courses of action with those who can help shed light on the probable real impact of policy changes. We in Ottawa-Carleton will always make ourselves available to assist government in this regard.
We believe that if the public were better informed, the question of Bill 26 and its impact on drug therapy would be a major public policy issue. The public has a keen interest, as it always has had, in the debate about medicare and its funding. But there is no way that the public is aware of the cost to patients and payors of medication misuse and non-compliance.
We see a major inconsistency in the policy process underlying this particular bill. The copayment is a user fee for necessary drug treatment. We question the legitimacy and fairness of making many of the lowest-income members of our society contribute to the cost of their own necessary drug therapy while vast amounts of money could be saved by reducing the inappropriate use of drugs and non-compliance in the way we have only partially outlined today.
It is not acceptable to make changes that in any way deprive people of essential care before every effort has been made to achieve rational, cost-effective drug therapy. Just give us a chance.
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We are recommending that the Health minister start at once to build on the work we have done at the street level. Through your committee's hearings, we are inviting him to join us on a project with the single focus of achieving rational, cost-effective drug therapy for all Ontario residents. We know this can be done if the key stakeholders work together, giving priority to total patient care.
We would like to suggest four collaborative steps.
Establish a joint task force to implement a simple counselling checklist throughout the province so we can start immediately to get the benefits province-wide that we are already seeing in Ottawa-Carleton with very simple tools such as this.
Maintain the existing joint task force on alternative forms of reimbursement so that a system based on the type of pharmacy service which links payment to treatments and processes that are effective can be put in place.
Work with us to review, refine and implement the best ideas on the improvement of pharmacy services, which we will gather from the street level in all pharmacy associations and pharmacies in Ontario.
Maintain the legislative consultation process with the Ontario Pharmacists' Association. This is imperative.
Thank you very much, Mr Chairman and your committee, for listening to me. I invite your discussion and questions to me or my colleagues. I'd like to wrap up by saying that while we've been in this room, thousands of community pharmacists like ourselves are on the front lines in Ontario every day. They're helping their patients get the most benefit from their drug therapy. They're helping people avoid unnecessary doctors' visits by discussing treatment of their minor ailments. They're providing health promotion advice and illness prevention. In short, they are making major contributions towards cost-effective health care as both drug experts and the most accessible health professionals in Ontario. We hope a stronger partnership can develop between ourselves and yourselves, so that community pharmacists will be able to make a greater and a more valuable contribution to cost-effective health care. Just give us the chance.
Mr Clement: I very much enjoyed your presentation. It gave us a lot to think about, so I thank you for the time you put into that. I want to reiterate for the record a very poignant comment you made, which is that too many people are taking too many drugs. Certainly it is not the intention or the effect, I don't think, of government policy to restrict what is necessary, but we've got to do our part to ensure that the drugs are allocated to the right people at the right time in the right quantity.
You're an interesting group. If I can put it this way, of all the groups we've heard from, aside from the drug manufacturers themselves, you as a provider are probably the most private sector part of this whole edifice. You're primarily a retailer, with some government involvement because of the drug programs.
Mr Tonon: It is very unique, yes.
Mr Clement: I find that very interesting. You've got a lot of worthwhile initiatives in here. Why do we need government involvement with those initiatives? You've got a College of Pharmacists. They've got a quality assurance program they're involved with. Why don't you just go out and do it? Why do you need our approval?
Ms Rosemary Killeen: There is a joint task force on alternative forms of reimbursement in place, with the government and the Ontario Pharmacists' Association studying various ways to implement some of the cost-effective care mechanisms we've talked about. But with the Ontario Drug Benefit Act as it is structured now -- and approximately 40% of patients in Ontario who get prescriptions filled are recipients of benefits under that plan -- those mechanisms we talked about are not yet in place, and what we're asking for is the opportunity to work with the government to put them in place. I'm talking about linking payments for pharmacists to services provided rather than products provided, making sure that the mechanisms for cost-effective review of patient medications is there as part of the system. Those things are not yet in place. We ask for the opportunity to work with the government to put them in place.
Mrs McLeod: I appreciate the presentation. I'm concerned that despite your valid pleas for consultation, a number of changes, particularly under the Ontario Drug Benefit Act amendments, will affect your practice as pharmacists. I'd like to ask you about all of them, but with the limited time, I'm going to focus on the drug use management, which you have identified as a concern and as something that needs a positive focus from front-line pharmacists.
I'm concerned when Mr Clement says the government needs to do its part to make sure that people get the right drugs in the right doses. I want to draw your attention to section 23 of the bill, which is the government's view, apparently, of how to have good drug use management, and that's for the government to be able to prescribe the criteria for prescribing drugs. I'd like your comments about whether you see this getting in the way of the professional judgement of both the physician and the front-line pharmacist and therefore of effective patient drug management.
Mr Norman Ferkin: I'll try to answer that. As regards the physician aspect of it, I don't think we can address that. That is purely within the purview of the competency of the physician, and we have never pretended to try to tell the physicians what to prescribe and when. It's purely based on their diagnosis.
As far as controlling the quantity and number of drugs prescribed for an individual are concerned, we have the opportunity when receiving the prescriptions for an individual from a multitude of prescribers, which does happen, to review the totality of their drug profile and predict, by doing so, which drugs may cause problems and which may conceivably be avoided or changed to other drugs, thereby either reducing the cost of the medication itself or preventing possible interactions which will cause further medical costs -- not necessarily drug costs, but medical costs overall.
That would be the area where we could input the most.
Ms Lankin: I might have a slightly different focus on this from Mrs McLeod's, because I actually believe that prescribing guidelines are a good thing for the multiple professions to work together to develop. Too many people are having inappropriate drugs prescribed. But I am concerned when I hear Mr Clement say the bill is intended to make sure that the right person gets the right drug at the right time, when the only policy tool they're using is the user fee. I don't understand how that accomplishes that.
Comment on that, but my question is, in addition to prescribing guidelines and drug utilization review, you make the very important point about using your pharmacological expertise and pharmaceutical counselling. What in the bill mitigates against the possibility of moving in the direction you've identified to set out appropriate compensation for those services rendered?
Ms Killeen: At an easy glance, number one, there will no longer be a legislative process existing between the Ontario Pharmacists' Association and the government for any kind of financial discussion with regard to the Ontario drug benefits system. That may limit our ability to discuss or consult on any kind of issue, financial or non-financial. All the kinds of consultative processes necessary to get these valuable programs started are perhaps being completely eliminated by the fact that we will no longer have the ability to speak on behalf of pharmacists in Ontario. We've only had that right by the legislation as it was enshrined, and that's a tremendous loss to patients in general of Ontario, as well as those on the Ontario drug benefit program.
Ms Barbara Ramsay: If I might also make a comment, with regard to the copay aspect of this legislation, I represent pharmacists to the college, which is the regulatory body as opposed to the negotiating body the ministry deals with on an ongoing basis. The concern here is that the college heretofore has been challenged to control maximum drug pricing; it has no mandate at the present time to control minimum drug pricing. Ergo, when the government puts a policy forth that contains a suggested $2 copay, it may have rationalized that it feels this is a suitable stipend for the consumer to cover off; the reality is that the pharmacist on the front line, who realizes the importance of the medication to the treatment of the condition as it was so prescribed by the physician, has a real challenge when the financially indigent but very needy patient is in front of them.
What do they do and who is accountable for that? And from a college perspective, as we try to ensure the quality of health care and ensure public health care in Ontario, where is the accountability to the individual pharmacist? In other words, if the person can't pay the $2 copay, as a pharmacist what do you do? As a college, when do we challenge that pharmacist for poor performance, perhaps negligent performance?
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But from a financial perspective, when does that pharmacist draw the line and say, "This is my professional fee." By the way we would challenge the reworking of this policy to remove the term "dispensing fee." You don't challenge physicians with suturing fees or lawyers with suing fees. They are professional fees, and we deem that the services we provide are in fact professional as well.
So some of these challenges are there, Ms Lankin, absolutely.
The Chair: Thank you. We appreciate your presentation and your involvement in our committee process.
SENIORS ON GUARD FOR MEDICARE
The Chair: The last presenter for the afternoon is Seniors on Guard for Medicare, represented by Art Kube, president; Romeo Maione, chair; June Cassey, vice-president; and Mary Eady, executive secretary. I hope I got those names close.
Interjection: Close but no cigar.
The Chair: Close but no cigar. Oh, well, it's late. Good afternoon and welcome to our committee.
Mr Romeo Maione: We're happy to have been chosen to speak. We're the last, so I guess the last wine is not the best, but there may be a miracle. We're a spontaneous group. We've been conceived just rather lately. Our conception came about with Bill C-91 of the federal government.
The Chair: Excuse me, sir. Could you introduce yourselves so that Hansard knows who's speaking?
Mr Maione: Okay. I'm Romeo Maione and I'm the chair of the group. On my right here is June Cassey, the vice-president. On my immediate left is Mary Eady, our executive secretary, and to my far left, where he belongs, is Arthur Kube, who is our president.
Seniors on Guard for Medicare is a group of senior citizens coming from varying backgrounds who got together spontaneously to enhance medicare. Generally, it was Bill C-91 that brought it all about. When we saw the incredible increase in prices of drugs, we knew that medicare was in trouble. That's what started us going together.
First of all, I'd like to excuse ourselves for some of the mistakes you'll find grammatically in the thing, as senior citizens are not exactly up to date when it comes to computers. That shows you how spontaneous we are. We're not a very professional group.
Most of our members before you were born before 1930. We represent a part of Canadian history when there was sickness and no medicare. We went through the Depression, and many of our members fought in the Second World War against fascism and for the preservation of democracy. It is because of this history that our generation built this country and this province into a more caring and democratic society, and of that we are proud. We hasten to add also that most of these things came about when Conservative provincial governments were installed in Ontario.
At the outset, we want to state that we are extremely upset that the Ontario government would introduce such a wide-reaching omnibus bill, which is a 211-page document with 17 schedules that amend 43 laws, that create three new laws and repeal two others -- and which was expected to pass for Christmas -- a wonderful Christmas present; I wonder who would have thought about this bill during Christmas -- and which, if passed, will have very negative implications for the health care of the people of the province. What makes it completely unpalatable is that the Premier of Ontario has neither asked nor received a mandate for these largely arbitrary changes dealing with health care.
During the election campaign, Mr Harris promised (1) not to cut the health care budget, (2) not to introduce user fees, (3) not to hit seniors and disabled welfare recipients. Bill 26 makes a complete falsehood of these commitments and also flies in the face of Canadian legislative convention, which, if a government is forced because of changing circumstances to make a complete shift in policy, calls for the presentation of a white paper and allows for broad public discussion on that policy change, and not by tabling an omnibus bill, which is very undemocratic to start off with and should only be used as a housekeeping tool once a major piece of legislation is passed. Broad public discussion is exactly what we need, especially in the area of health care provision.
It was a federal Conservative government which appointed the royal commission that brought medicare to this country. It would only be appropriate that Ontario appoint a commission to look at all aspects of medicare and make appropriate recommendations.
Committee members, to be perfectly straightforward, we just don't trust some bureaucrats in Queen's Park with monkeying around with our health care delivery. We didn't get medicare overnight, it took a lot of time, and we demand that you make haste slowly when it comes to changing our health care. The only precedent for such haste and legislative onslaught came in 1983 by the then Social Credit government of British Columbia, and we don't have to tell you where Social Credit is today. Could it be, just by chance, that Norm Spector is back from Israel and now giving the same bad advice to the Ontario government as he did to the BC government in 1983?
Mrs June Cassey: We want to deal now with some of the specific aspects of Bill 26. Naturally, the first thing that jumps into our face is schedule G, amendments to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act. While we recognize that there has been a massive increase in the drug costs to an otherwise fairly cost-stable medicare system, we believe firmly that the prescription offered in schedule G is the wrong kind of medicine.
First, user fees are not very cost-effective. The administrative costs would most likely double. Second, these user fees would be a real hardship on the less-well-off and would discourage their seeking treatment they need, leading in the long run to more expensive hospitalization. Third, seniors have planned for their retirement, and that's something that governments have encouraged seniors to do, but now you are saddling us with expenditures which seniors have not planned for. Some of our members were covered by drug plans as part of the retirement package at a former place of employment prior to the Ontario drug benefit plan coming into effect. We doubt that those former employers will be prepared to reinstate that lapsed coverage.
If the government is really serious about reducing the cost of drugs, then it should demand that Ottawa rescind Bill C-91. In addition, Ontario should encourage the promotion of generic drugs and engage in bulk purchases of some of the more expensive licensed drugs, like other jurisdictions have done.
If anyone in the government thinks that deregulating drug prices will bring down the cost of drugs, then we've got a bridge we'd like to sell them. As long as you have five or six monopolies holding all the licences and governments protecting these licences, drug costs will continue to escalate. Doing away with C-91 and making sure that medical discoveries made in our universities stay in the public domain can bring about the stabilization and eventual decrease in the cost of drugs. If the government wants to follow the lead of a famous Tory, it could introduce the Enoch Powell plan, which has prescription drug costs in the UK at least half of ours.
In addition, we have strong concerns about proposed changes to present legislation as proposed in Bill 26, which is projecting four very disturbing trends:
(1) The destruction of confidentiality between patient and doctor by the loss of confidentiality of medical information. These proposed changes are open to abuse and we think are contrary to both the Ontario Freedom of Information and Protection of Privacy Act and definitely in contravention of the Canadian Bill of Rights. Should Bill 26 become law, this issue will certainly end up in the courts.
(2) The centralization of decision-making by bureaucrats in Toronto on what services will be covered, what referrals a general practitioner may make, what medical procedures a patient can receive and what hospital facilities stay open or are closed. If you fine a GP for making what might be in the opinion of some bureaucrat an unnecessary referral, you have the same situation as you have in the US, where doctors refuse to give first aid on the street in fear of being sued. Common sense tells us that medical decisions should be left to the doctors, in conjunction with their patients, and the issue of hospital facilities should be largely a community-based decision, taking into consideration provincial funding arrangements.
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Mrs Mary Eady: (3) The move towards user fees. While hospitals are presently permitted to charge patients for a limited range of insured services, Bill 26 provides explicit authority for cabinet, which probably means the senior bureaucrats in the ministries of Health or Finance, to make regulations which could permit hospitals to charge patient user fees for any hospital-based insured services, including those already covered under OHIP. For instance, the government has already announced that hospitals will be able to charge daily user fees to those patients in acute care beds who are waiting for a place in a chronic care facility or a nursing home. This might not break the letter of the Canada Health Act but certainly prostitutes its intent.
(4) The move towards privatization through independent health facilities. For instance, the proposed changes in Bill 26 to the Independent Health Facilities Act basically eliminate the tendering procedure by giving the ministry the authority to request proposals from specific individuals for the setting up of a private health care facility. To add insult to injury, as a criterion for selecting a provider, the minister can examine the availability of public funding to pay for the establishment and operation of such a facility. For instance, the proposed changes will eliminate the requirement that preference in the tendering procedure be given to non-profit Canadian operators. This will allow the Minister of Health -- if we were cynics, we would say his patronage agent -- to handpick corporations or individuals to open up shop, even open up franchises of health care clinics that charge people money. We say this is nothing short of bringing American health care through the back door into Ontario.
Although we are an organization of seniors, we nevertheless have to speak out against the adverse effect of Bill 26 on health care and other public employees. Should the bill in its present form become law and the minister use his or her prerogative, indications are that over 20,000 health care workers would lose their jobs. Members of this committee, we have been around and we saw what happened when the government deinstitutionalized mentally challenged adult institutions. Today they are part of our street people, living a miserable life. The health care workers who lost their jobs then didn't get jobs in community-based support facilities because such facilities just were not set up. It is these present health care workers who provide the quality health care to us envied by the vast majority of our neighbours to the south. If you do away with the workers, surely it's understood that you also lessen the quality of health care. We have a moral obligation not to undermine the job security of these workers. Now we'll hear from Art Kube.
Mr Arthur Kube: One more pont we'd like to raise, which does not necessarily fall into the confines of Bill 26 but which reflects a penny-wise but dollar-foolish attitude by government: It is the present cutbacks to home care for the elderly, be it for home nursing or homemaking services. Some of our members have experienced as much as a 60% cutback in services, creating real hardship for themselves and their caregivers. Because of provincial funding cuts, it is coming to the point where more and more elderly will have to go into institutional care, at much greater cost to the province.
In conclusion, we want, through this committee, to say to our provincial government that Bill 26 is a blueprint for confrontation and division. It's at best a very crude attempt to impose the will of a Queen's Park majority on the majority of Ontarians. The people of Ontario are opposed to the proposed changes to our health care system as contained in Bill 26. The government might get away, in the short run, with the intergeneration game of playing the young against the old, by changing the drug benefit plan and reduced-quality health care. But we advise the Premier and his caucus that this is a dangerous game to play. If you force the pendulum to swing too far one way, it will swing just as far the other way.
If our government thinks that creating insecurity among seniors, among hundreds of thousands of public employees and their families, does not affect the spending pattern, then I would suggest he is either a knave or a fool. Most Ontarians don't even know the real negatives -- also, watching television, I'm not so sure that even cabinet ministers do -- and the uncertainty already about Bill 26, and also you have to add the federal government cutbacks are extracting already a very heavy toll on the merchant-class support of the government. Ontario's recovery is stalled, and the adoption of Bill 26 will lead us into a massive recession and a further revenue crisis. We ask the government to use some common sense in governing this province. Withdraw Bill 26 and forget about that simplistic tax cut, which ultimately will benefit the very rich. If the government wants to review medicare and health care delivery -- because we agree that it's far from perfect as far as prevention, governance and cost-efficiency are concerned, but let's do it properly by the establishment of a commission with the widest possible public input.
With thanks to the members of the legislative committee, all this is submitted as sage advice by the Seniors on Guard for Medicare.
Mr Patten: Thank you for the presentation; it was very good. I see some old friends, meaning length of time I've known you, not any reference to your age, Romeo and Mary.
Mr Maione: Call me a senior friend.
Mr Patten: All right, a senior friend.
Your point relating to destruction of confidentiality between the patient and the doctor, which has come up in more presentations than not, today: Have you had any legal opinion related to the constitutionality of it in terms of the Human Rights Code?
Mr Kube: We didn't get any direct legal opinion, but some of our people in the group have worked in the area of human rights legislation and confidentiality. What they're telling us is, their reading of the legislation is that there's no protection in the proposed legislation against certain things, be it in terms of communicable disease, be it in terms of drug use and other matters. They are just saying, "Look, there's nothing in there." But they're also telling us -- and there again, we listened to news reports, for instance. You have the person who is administering the province's act expressing publicly some real reservations. That sends a signal to us that there might be something wrong.
Mr Patten: All right. We have the same concerns that you do on that one; we're just curious if you had had other legal opinion, because we would love to speak to such legal counsellors if they were available.
A second point that you made in terms of what I'd like to ask you is on the independent health facilities and the two questions you brought up in terms of the authority to request proposals for specific individuals: that the normal procedure of requests for proposals has been taken away and that the right for the minister to even request individuals without tender seems to be an anomaly in normal procedures of public institutions doing business and even in the case of some big businesses, for sure. Have you received any information on the explanation for that from the government, as to what the rationale is behind that?
Mr Kube: No.
Mr Patten: All right. Maybe our friends can answer that at some point.
The last question I'd have is in terms of the apparent increased liability of doctors, with the authority of the minister being able, by way of the general manager of OHIP or whoever, to judge without appeal whether certain procedures or certain tests were done too frequently or if in the public interest or in the interest of a particular individual there was some sort of general malpractice, but it seems to be expanded broadly at this point. Does that worry you in terms of how you think your medical practitioners would be feeling at this particular time in terms of being supercautious and perhaps being slowed down in their ability to respond to treatment for their patients?
Mr Kube: I think it's only logical. The point we made, for instance, in terms of doctors in the United States not even giving first aid on the highway because they're scared they're going to be sued -- you're really moving into that sort of system in Canada if you move in that particular direction, and then if a general practitioner thinks he should refer you but isn't 100% sure. Medicine isn't a perfect science; far from it. Surely we should err towards the benefit of the patients. If it would be major abuse -- we came in here and we heard that approximately 7,000 people are supposed to have abused it; 7,000 out of seven million? That is not what we might call major abuse.
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Ms Lankin: I truly appreciate your presentation. You wrapped up saying it was sage advice, and it's sage indeed. I believe that as elders you carry a moral authority and I hope that is something which has an impact on the government and that it listens. I know the careers some of you have had. I don't know all of you but I know the contributions you have made to building the system we have in place today and to the creation of medicare.
I would like you to reflect on something this committee was told in another town this week in another presentation by a bioethicist. He told us that this legislation and the way in which it's constructed necessarily will lead to decisions about core lists of services, which means certain things will no longer be insured medical services under medicare, and that those things will then be offered and paid for in the private market. He pointed out that there is a constituency of thought in this country that supports a move in that direction, but that that represents a dramatic value change for our health care system, the values that underpin our health care system, and that there has not been a public debate to reach a consensus that it's the appropriate direction to go.
He also said that the value of our health care system is integral to the values of our country and in some ways the self-definition as Canadians, and that this kind of change in this area will affect many other ares of our social interaction and values of our life. I wonder if from your experience you could reflect on that. Mary, I might start with you.
Mrs Eady: It's one of the things that really concerns us. You're right, we did, I believe, do things to help bring about medicare. I think we're keepers of the memory of the community of what it was like without it. I think a lot of people don't understand what it was like to not have the kind of system that we have now. We remember when it wasn't there.
The question of how we decided to establish it wasn't to say, "Okay, we're going to have one system for people who can afford to pay and one for those who can't." We decided we were going to have a system in which we would share in a cooperative way the health costs of the people in the country. What disturbs me as a senior is seeing that concept and that I think principle that made Canada a different country from the path taken by the United States and other countries in the world.
It seems to me that is the thing that's at risk. It's the thing that I think Canadians want to preserve: that question of cooperative caring for each other. I think this kind of push and opening the door, if you like, for further privatization of the health care system really puts those principles at risk and basically changes the face of the country. I don't think it's a small thing at all and it's something that we have to very carefully consider.
I really hope the government does reconsider some of the sections that we've touched upon. To me they're fundamental changes which the Canadian public has not had the time or the opportunity to really debate and to decide what it is they wish to have happen.
Mrs Ecker: Thank you very much for taking the time to come before us and provide your views and comments and suggestions, very much appreciated. As you probably know, there have been some excellent suggestions made through these committee hearings. The government's certainly prepared to consider many of them in terms of enhancing and strengthening this legislation to get on with the important job of restructuring.
Just a couple of quick points. You've expressed some concerns on some items.
One of the things that I said earlier today I'll say again: We are not going to be violating the Canada Health Act. We're not interested in getting into a pointless or non-productive fight with Ottawa against the Canada Health Act. In fact, this government moved to extend or reimburse or reinstate full coverage for seniors' out-of-country coverage to be in compliance with the Canada Health Act. So we're certainly not intending on doing that and Bill 26 will not be doing that.
Confidentiality: We believe that is protected. There are provisions. But that is also an area that if we need to strengthen and enhance that to ensure that, we certainly will do so.
The other point is the decision of what is medically necessary. The general manager of OHIP in the previous Health Insurance Act had the power to make decisions about what was medically necessary in terms of payments and inappropriate billings. That was made on the advice of physicians. That will continue to be the case in the new legislation so that physicians will be making those decisions. I think that is important.
The Independent Health Facilities Act is legislation that talks about licensing facilities to promote quality assurance in those facilities. The difficulty is that there are many facilities providing health care services that are not regulated under that legislation. There are quality problems, and the intent is to try and bring more of them under that legislation so that we can do the quality assurance activities that have worked so well under the independent health facilities legislation which previous governments had brought in and supported and our government supports. So I think that's important.
It's also important to remember that those regulations for quality assurance apply regardless of who owns the facility, and there are for-profit centres now on licence under the Independent Health Facilities Act. I think those things are important to bring forward.
The quick question which I would like to ask is about one of the things that we've heard: the inappropriate prescribing for many seniors that unfortunately is still occurring for various reasons. A number of people have highlighted it. What advice would you give to the government about how we can work with the stakeholders to try and stop or minimize the inappropriate prescribing for seniors?
Mr Kube: I think what has to happen is that we have to take -- for instance, we came together on C-91. I don't know if you people know that for every three medical doctors you have one drug salesman.
Mr Maione: Drug pushers.
Mr Kube: I mean, they're legal drug pushers. I think you always blame the patient, and to a certain extent --
Mrs Ecker: I'm not blaming the patient.
Mr Kube: But sometimes if you go into a drugstore you don't like to pay the filling fee twice, and you know you're on that medicine for a six-month period, so why pay twice? I'm telling you that the push, very largely, for consumption of drugs comes from the industry itself. I think that's where the problem really lies. We know drug costs to the medicare system have increased by 128%.
Mrs Ecker: How would we deal with that with the drug companies?
Mr Maione: License the drug pushers.
Mr Kube: In the first place, you're now going to have a 10-year period where no single generic drug will come on the market because you have more than extended the time limit of licensed drugs. So for 10 years you're not going to have any generic drugs coming on the market. At one time a new drug came on and a licensed drug came off and became a generic drug, and therefore the drug costs balanced each other. But right now, for 10 years you're going to see increase after increase unless you deal with that particular problem. You're going to be in trouble with medicare. We know that.
If you look at the rest of the medicare system, the costs, they haven't skyrocketed. We understand, for instance, that we have some demographic problems which will be coming up. We understand there has to be discussion about health care in this country. The only discussion we have had in terms of health care in this country is because the President of the United States a couple of years ago started a discussion about health care in the United States, and then all at once Canadians of their own health care system. They went over and became very convinced that what they saw there they didn't like. We don't like to see any wedge coming into our system which moves us towards theirs.
Mrs Ecker: We are not bringing the American health care system to Ontario.
Ms Lankin: That's what the bill's all about.
Mrs Ecker: No, it's not.
The Chair: Thank you. We appreciate your being here this afternoon and your input.
The meeting is adjourned.
The committee adjourned at 1731.