SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
CATHOLIC HEALTH
ASSOCIATION OF ONTARIO
SALVATION ARMY AND JEWISH HOSPITALS
BOEHRINGER INGELHEIM (CANADA) LTD
HAMILTON-WENTWORTH DISTRICT HEALTH COUNCIL
ASSOCIATION OF ONTARIO PHYSICIANS AND DENTISTS IN PUBLIC SERVICE
HALTON REGION COALITION FOR SOCIAL JUSTICE
MEDICAL REFORM GROUP OF ONTARIO
HALTON REGION COALITION FOR SOCIAL JUSTICE
HAMILTON ACADEMY OF
MEDICINE
EVA GEDE
OAKVILLE-TRAFALGAR MEMORIAL HOSPITAL
UNITED SENIOR CITIZENS
OF ONTARIO
STEELWORKERS ORGANIZATION OF ACTIVE RETIREES
UNITED STEELWORKERS OF AMERICA, DISTRICT 6
ST JOSEPH'S HOSPITAL,
HAMILTON
ST JOSEPH'S HEALTH CARE SYSTEM
ONTARIO ASSOCIATION OF SPEECH-LANGUAGE PATHOLOGISTS AND AUDIOLOGISTS
CONTENTS
Friday 19 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
Catholic Health Association of Ontario; Salvation Army and Jewish hospitals
Ronald Marr, president, CHAO
Bishop Anthony Tonnos, chair, CHAO
Lieutenant-Colonel Irene Stickland, president and CEO, Salvation Army Grace Hospital, Scarborough
Joseph Mapa, chief operating officer, Mount Sinai Hospital
Ontario Medical Association
Dr Lorne Finkelstein, board member
Dr William Orovan, member, executive committee, negotiating committee
Boehringer Ingelheim (Canada) Ltd
Dr Karen Gilberg, vice-president, external affairs and health economics
Alan Fukuda, head of external affairs
Hamilton-Wentworth District Health Council
Dr Susan Watt, chair
Association of Ontario Physicians and Dentists in Public Service
Dr John Deadman, past president
Halton Region Coalition for Social Justice
Terry Kelly, representative
Medical Reform Group of Ontario
Dr Gordon Guyatt, representative
Halton Region Coalition for Social Justice
Terry Kelly, representative
David Michor, chair, Hamilton-Wentworth Health Care Workers Joint Action Committee
Robert Heaton, councillor, town of Halton Hills
Hamilton Academy of Medicine; Eva Gede
Dr Kari Smedstad, president
Oakville-Trafalgar Memorial Hospital
John Oliver, president and CEO
Dr Lorne Martin, chief of staff
United Senior Citizens of Ontario; Steelworkers Organization of Active Retirees
Gwen Lee, representative
Bill Fuller, representative
Orville Kerr, representative
United Steelworkers of America, District 6
Harry Hynd, director
St Joseph's Hospital, Hamilton; St Joseph's Health Care System
Sister Joan O'Sullivan, vice-president, St Joseph's Health Care System
Allan Greve, president and CEO, St Joseph's Hospital, Hamilton
Brian Guest, executive director, St Joseph's Health Care System
Ontario Association of Speech-language Pathologists and Audiologists
William Hogle, executive director
Fiona Ryner, past president
David Barr, president
Randy Zettle
Barbara Sullivan
STANDING COMMITTEE ON GENERAL GOVERNMENT
Chair / Président: Carroll, Jack (Chatham-Kent PC)
*Carroll, Jack (Chatham-Kent PC)
Danford, Harry (Hastings-Peterborough PC)
Kells, Morley (Etobicoke-Lakeshore PC)
Marchese, Rosario (Fort York ND)
Sergio, Mario (Yorkview L)
Stewart, R. Gary (Peterborough PC)
*In attendance / présents
Substitutions present / Membres remplaçants présents:
Caplan, Elinor (Oriole L) for Mr Sergio
Clement, Tony (Brampton South / -Sud PC) for Mr Kells
Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart
Johns, Helen (Huron PC) for Mr Danford
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Agostino, Dominic (Hamilton East / -Est L)
Christopherson, David (Hamilton Centre / -Centre ND)
Curling, Alvin (Scarborough North / -Nord L)
Doyle, Ed (Wentworth East / -Est PC)
McLeod, Lyn (Fort William L)
Pupatello, Sandra (Windsor-Sandwich L)
Skarica, Toni (Wentworth North / -Nord PC)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel: Drummond, Alison, research officer, Legislative Research Service
The committee met at 0900 in the Hamilton Convention Centre, Hamilton.
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, everyone. Welcome to the standing committee on general government's hearings on Bill 26. We're in Hamilton this morning, I think. We've been to so many different places we have to look at the road sign when we get up in the morning to know where we are. We are in Hamilton and we're delighted to be here. This is our last stop on our cross-province tour. We are here to listen to the concerns of the people of Hamilton and we're happy to be here.
Before we get on to our first presenter, there are a couple of housekeeping things to be attended to, so the first person I'll call on is Mr Clement.
Mr Tony Clement (Brampton South): For the benefit of the record and for the public present, I would like to declare for the record that the government side has tabled further amendments that we wish to propose on Monday to schedules F, G, H and I of Bill 26 for the benefit of the committee.
The Chair: Ms Lankin, you had a motion.
Ms Frances Lankin (Beaches-Woodbine): Yes. I've tabled two motions with the clerk. The first motion reads as follows:
Whereas there has been overwhelming public interest in Bill 26 and 84 groups and individuals have requested to appear before the standing committee on general government in Hamilton which far exceed the 15 spaces available today for hearings;
I move that this committee recommends to the government House leader that, when the House returns on January 29, 1996, 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 Hamilton;
Further, this committee recommends that the three House leaders meet as soon as possible to discuss this issue.
The Chair: In other areas where we've been we've limited the discussion on this to a minute per party in order to accommodate our guests who are here to make presentations. Do we have the same agreement this morning? Okay.
Ms Lankin: This is the last day of public hearings on this bill and, as you can see, here in Hamilton we have over 80 groups that have applied for 15 spaces. The public interest is overwhelming, and it has been in every community we have visited. In the last two weeks, while the two committees have been travelling the province, there have been over 1,000 individuals and groups that have applied to be heard before this committee and there have been less than 300 spaces -- about 275, roughly speaking. Hundreds and hundreds of voices are not being heard. Hundreds and hundreds of opinions are not being registered upon the mind of this committee as it goes into debating, in the final stages, the amendments to this bill and passage or defeat of the bill overall.
I must say that every day we have heard new implications of issues in the bill that we hadn't understood or didn't realize what the implications would be for a particular region or for a particular group of people. I think it is a shame that the people have been denied the opportunity to have full input.
The government will say that a broad range of people have come forward, and that's true and that's good. The government will say that it has listened and it is making amendments, and thank God, because if we'd gone through before Christmas there would be no amendments to this bill. But I still believe that this bill is fundamentally flawed and that there are areas of this bill that require extensive consultation and extensive rewriting.
I'll just close by saying we have offered on January 29 to pass those parts of the bill that the government feels it needs for its fiscal agenda. Let me say to Mr Clement, before he says his mantra out here about all the money they're going to save on January 30, the day after the bill's passed, many sections of this bill dealing with fundamental reform of how health services are delivered in this province are not going to save you money on January 30. Many of them change forever the face of medicare as it is delivered in this province.
It deserves to have appropriate public debate and you are denying that by the process that you insist on. In light of all of the presentations you've heard asking for this bill to be split up, to be slowed down and to be dealt with appropriately, I urge you today to support this motion.
Mr Clement: I cannot support the motion. I believe, quite frankly, that we have had a very good process that has allowed the public an opportunity to express a diversity of views over the past three weeks of hearings. By the end of today, both sides of the committee will have heard at least 750 presenters, representing a multiplicity of views. Certainly it's no exaggeration to say that not all of them were terribly pleased with the government's position, and that's what an open process is all about.
I repeat that this piece of legislation will have had more committee time, more public time for an opportunity to discuss its merits and demerits than any bill in the previous two Parliaments and that the quality of discussion that we have heard over the last three weeks has been of a very high nature. People have been able to give us some excellent recommendations, many of which are encompassed in the government's amendments which we have tabled today.
To Ms Lankin's last point, let me just say this: There is not only a fiscal cost in not proceeding with alacrity, there is a cost in terms of our ability to manage the health care system, to manage a better health care system. Every day that we wait, every month that we wait means that we have one month less to make the investments into palliative care, long-term care, HIV sufferers, cancer sufferers, whatever, to reinvest those savings that this bill will allow us to do in the health care system, and I, for one, do not want to wait another day.
Mr Dominic Agostino (Hamilton East): I speak in support of the motion today. We have, from day one, made the same request. The overwhelming response should give the government some clear indication and some reason for concern as to what they're doing and the speed at which they're proceeding with this bill.
What we see here today is an example of what has happened across Ontario. There are shadow hearings occurring in Hamilton, and I urge other people that are here, members of the committee, particularly government members, to take the opportunity to walk down one floor to the Albion Room and listen to many of the groups that you have shut out and not allowed to be here today. They have taken it on their own to be there.
This bill is the most massive power grab by any government in the history of this province. If you're going to proceed in such a manner, in a manner that I believe is going to destroy the health care system across Ontario, the damage you're going to inflict on health care across Ontario cannot be and may not be undone by any future government because of the magnitude.
You ran an election on open government; you ran an election on listening to people. That was Mike's big thing: "We're going to listen to the average person. We're going to listen to people across this province." Well, what do you say to the thousands and thousands and thousands of individuals across Ontario you have denied access to? This is not a democratic process. The way this government is handling this bill and the way this government is handling this public process is the exact same brutal way and the same undemocratic way that they have tried to ram this bill through the Legislature.
I believe very much that a fair opportunity would be to pass the key elements that you want, that are necessary for your budget, but allow the people of Ontario that opportunity. Maybe the reason is that you're afraid to listen even more to what people have to say because you have taken a beating, frankly, in the last two weeks from people across the province, and if you allowed more hearings, this beating would continue.
The Chair: We'll now have the vote on the motion.
Ms Lankin: Mr Chair.
The Chair: Oh, I'm sorry, Ms Lankin.
Ms Lankin: Thank you. Just a very quick wrapup. Let me say to Mr Clement that the ability for the government to work with communities in the reform of health care is already in place, has been in place for years and has been starting to take place community by community, led by community folks, community interests, bringing forward their points of view on restructuring and facilitated by the ministry, not a power grab where the minister comes in and dictates to communities.
Let me also say to you that the fundamental rewriting of the rules of health care that is contained within this bill will inevitably lead us to an Americanized system, a two-tier health care system, the undermining of the Canada Health Act and medicare as we know it. I, for one, go on record as saying that that will be on the heads of the Conservative Party, on the head of Mike Harris, on the heads of those of you who would disallow appropriate community debate to bring about community consensus on the direction of reform.
I think it is a shame. I think the way in which you've proceeded is arrogant. I think it denies public input. I think it is simply anti-democratic, and I will have no part of it. I believe that your government will suffer in the long run and so will the people of Ontario and our health care system, and that's the biggest shame of all.
The Chair: Thank you, Ms Lankin.
Ms Lankin: Recorded vote.
The Chair: Ms Lankin has asked for a recorded vote. Just for you folks in the audience, there are only five people at the table who have the right to vote. They will be the five that vote.
Ayes
Caplan, Lankin.
Nays
Clement, Ecker, Johns.
The Chair: The motion is defeated.
Mr Agostino: On a point of order, Mr Chair: We have a number of people standing at the back. Can we accommodate them?
The Chair: Mr Agostino, we've already asked for the wall to be taken down, and there will be a little noise associated with that. Okay. Mrs Caplan.
Ms Lankin: I have a second motion.
The Chair: Oh, I'm sorry, Ms Lankin.
Ms Lankin: It's been a long week, Mr Chair. You're forgiven.
The Chair: It has been a long week.
Ms Lankin: I just want to indicate that I tabled a second motion. That second motion dealt with a theme that I have been following every day, which is a demand for the government to table its amendments. While I am sorely disappointed that the Minister of Health did not live up to his commitment to me to table the amendments in a timely fashion -- he promised he wouldn't wait until the last minute, and here we are at the last day; we start clause-by-clause on Monday -- I appreciate the fact that I do finally have them, so I will withdraw that motion.
0910
Mrs Elinor Caplan (Oriole): We've had this motion every single day. If this one is defeated, and I suspect that it will be, we have a specific motion for Hamilton that I'd like to deal with after this one. We've been tremendously frustrated because of the numbers of people that have been turned away. Given the implications of Bill 26 and the implications that people are just beginning to understand, and we're just beginning to understand when these hearings began and we realized how many groups wanted to come forward, we have been trying to make sure they would have the opportunity to be heard.
All we have requested, day after day, is that the government members of this committee vote to alert the House leaders. Yesterday in Niagara --
The Chair: Is this the motion you're introducing?
Mrs Caplan: I'm going to introduce the motion.
The Chair: Could you introduce the motion first and then we'll go on to the discussion.
Mrs Caplan: Yes.
Whereas Bill 26 impacts in a major way on every individual in Ontario; and
Whereas Bill 26 requires broad public input before being passed into law; and
Whereas there are 84 groups in Hamilton that want to provide input into the bill but only 15 will be heard;
I move that when the House returns on January 29, 1996, the order with respect to Bill 26 be amended such that the portions of the bill that do not require urgent passage for fiscal reasons be returned to the standing committee on general government so that further hearings can be arranged for the community of Hamilton.
The Chair: Can we limit our discussion on this one, since it's substantially the same as the first one, to a minute so we can allow our presenters to come to the fore, please.
Mrs Caplan: The reason we tabled this motion today -- as you know, Mr Chairman, I tabled a motion on the very first day of the hearings because of the concern -- is that in each centre of the province we have been attempting to alert the government and requesting. Since the members today, I expect, are going to defeat a motion that simply says "recommend" -- or I think the first motion just says "request" -- I think there should be a motion on the floor that actually directs. I think they're going to defeat it and I'm very concerned that, with that defeat, they send out such a negative message to the people of this province, not only those who have been heard but those who have not been heard.
I'm imploring the members of the government caucus who have the opportunity to send that message that you now have a chance to choose. You can choose a very reasonable, "Let's just alert them, ask them to consider before the 29th, give a little additional time," or you can take a more extreme motion that actually tells them to amend.
I think those are the only two choices, because if you proceed with this bill without doing one of the two things that have been proposed today, either alerting the House leaders or actually suggesting to them that they amend that closure bill, then you are risking the wrath of the people of this province, and they will not stand for this railroading of democracy.
Mr David Christopherson (Hamilton Centre): I appreciate the opportunity to be with the committee here today. This is my first chance to be with the health portion committee. I've been with the other group through a number of communities, and I can tell you exactly the same thing is happening on the other side of Bill 26.
Every community I've been in -- I was in Thunder Bay two days ago, Ottawa yesterday -- it's the same. In fact, I would say to the government members, it's not only people who are opposed to Bill 26 who want more time. A good portion of the people who are supporting what you're doing acknowledge in their briefs that there was not enough time to adequately deal with this bill.
If you want to have any moral authority -- you'll have the legal authority -- to implement the powers you're giving yourself in Bill 26, then you'd bloody well better give the people of Ontario an opportunity to be heard at least once before you seize all these powers and run with them for the next four years.
You've got one opportunity now, one opportunity left, to give the people of Ontario their say. This is a reasonable motion put forward by the Liberals, and my voting colleague, Ms Lankin, will be supporting this. We urge you, please, at the 11th hour, listen to what the people of Ontario are saying to you and give them their say, give them at least a voice in this process.
Mr Clement: As I said earlier, this bill requires urgent passage not only for fiscal reasons but for health care reasons. We have heard many deputations over the past three weeks of hearings -- not all deputations but many deputations -- say: "We need the government to act. There is a health care crisis in this province." These are significant players who said this, hospital boards and chambers of commerce and other agents in our community, who said, "We need the government to act." It's not only a question of the fiscal exigencies; it's also a question of ensuring that our health care has the proper resources to do its job for the people of Ontario. It's for health care reasons that we have to pass Bill 26 on January 29.
Mrs Caplan: That's not what they said. Even the chamber of commerce said, "Slow down." Even the big insurance companies said, "Delay." Even the people who came supporting this bill said, "We have very serious considerations and we're asking you to slow down and we're saying take more time." They're as worried as everyone here. They are as worried as everyone who has said to you that trying to pass this bill before Christmas was an abuse of democracy and an abuse of process. What they're saying to you now is that you're going to produce bad law if you continue on this railroad to ram this through. Everyone is telling you to take a little more time. Even those who came in support of the bill said, "If you take a little more time you'll get better law."
I've very briefly looked at the amendments you put forward today, and even the amendments to the privacy have not addressed people's concerns. These privacy concerns are not scoped to fraud. People will not have an opportunity to have anything to say about that, because today is the last day of public hearings. I can tell you, if they don't have a chance to have their say, you are not going to have the moral authority and the consent of the public necessary to move forward in the name of restructuring. You haven't told them what restructuring will mean and you haven't given the protection for Canadian medicare and you haven't given the protections for health care, and that's the betrayal of a trust.
The Chair: All those in favour of the motion? Those opposed? The motion is defeated.
Just for the sake of the audience, politicians sometimes have a little trouble deciding what a minute is. The minutes you just saw are not the kind of minutes we normally have here, so anybody coming forward with a presentation, don't multiply these minutes by 30.
CATHOLIC HEALTH ASSOCIATION OF ONTARIO
SALVATION ARMY AND JEWISH HOSPITALS
The Chair: Our first presenters this morning are the Most Reverend Anthony Tonnos, chair of the Catholic Health Association of Ontario; Mr Ron Marr, president of the Catholic Health Association of Ontario; Lieutenant-Colonel Irene Stickland, president and CEO of the Salvation Army Grace Hospital, Scarborough; and Mr Joseph Mapa, executive vice-president of Mount Sinai Hospital in Toronto. Good morning and welcome to our committee.
Interjection.
The Chair: Did I not say Bishop Tonnos? I'm sorry, Bishop. You have a half-hour to use as you see fit. Questions, should you allow the opportunity for them, would begin with the government. The floor is yours.
Mr Ron Marr: Thank you, Mr Chairman, for the opportunity of the Catholic Health Association, the Salvation Army and Jewish hospitals to appear before your committee for these public hearings on this most important piece of legislation. In our opinion, Bill 26, the Savings and Restructuring Act, is perhaps one of the most important pieces of legislation to be introduced into the Ontario Legislature in recent memory. It is only fitting that the public and stakeholders be given the opportunity to comment on this bill. We trust that this committee and the government will make significant amendments to the bill which will move restructuring forward in the spirit of collaboration and with the public interest in mind.
0920
I'd like to introduce the members of our delegation to you. My name is Ron Marr and I am the president of the Catholic Health Association of Ontario. Bishop Anthony Tonnos is the bishop of the diocese of Hamilton and is here today in his capacity as chair of the Catholic Health Association of Ontario. Joining us today in presenting this brief are representatives of the Salvation Army and Jewish hospitals in Ontario. Lieutenant-Colonel Irene Stickland is the president and CEO of the Salvation Army Grace Hospital in Scarborough, and Mr Joseph Mapa is the executive vice-president and chief operating officer of Mount Sinai Hospital in Toronto.
Bishop Tonnos, Lieutenant-Colonel Stickland and Mr Mapa will each give you a brief overview of denominational health care in Ontario, and I will, at the end of their presentations, summarize our concerns about Bill 26 for you. I'd like to call on Bishop Tonnos to begin our presentations.
Bishop Anthony Tonnos: The Catholic Health Association of Ontario is a partnership of Catholic hospitals, homes for the aged and community-based services located in large urban areas and smaller communities across the province. The association also has as its members the Ontario Conference of Catholic Bishops and the 10 sponsors -- religious congregations and lay groups -- of the Catholic health institutions.
The Catholic health ministry is a major participant in Ontario's health care system and has been so for 150 years. Catholic hospitals across Ontario were initially staffed with religious sisters, a few lay nurses and student nurses. A great deal has changed since then. In 1960, with the advent of universal health insurance, the government began a partnership with the religious communities of sisters. Ontario's health care system was designed to provide health care services to the public and was not intended to compromise the rights of religious congregations and the church to witness Catholic values in health care. The partnership between government and denominational providers has meant that the Catholic health ministry has become an important contributor to Ontario's health care system. Over 30,000 people are employed in the Catholic health ministry in Ontario, and the hospital sector alone accounts for $1.3 billion of the $7.5 billion to $8 billion spent on hospital care in Ontario.
However, the Catholic health ministry is not really about numbers of employees or billions of dollars. It is about health care that is rooted in the ministry of healing that is a fundamental aspect of the Catholic Church and began with its founder, the Lord Jesus Christ. It is a ministry for all persons, regardless of creed, which focuses on respect for life and the wholeness of the person.
The Salvation Army and Jewish health services in Ontario share in a special way many of the characteristics of the Catholic health ministry and are present with us today to demonstrate the solidarity of the denominational health sector in reference to our shared concerns with Bill 26.
The governance structures of Catholic and other denominational hospitals allow us to achieve the goals of our respective ministries while working with local communities and government to plan and deliver needed health services. Through representative and voluntary local boards of directors, Catholic and other denominational health institutions and community-based services are good stewards of scarce financial resources. We are anxious to find ways to eliminate unnecessary duplication and to bring about progress and change to Ontario's health care system.
Lieutenant-Colonel Irene Stickland: The Salvation Army is a branch of the Christian church and is actively involved in health care and social services as a significant component of its Christian mission and ministry.
For over 114 years, the Salvation Army has served in areas of addiction rehabilitation, corrections and justice services, children and family services, and health care. You will know that the motivation behind the Salvation Army's involvement in these services is Christian compassion that reaches out to meet human need.
The Salvation Army has operated facilities in Canada since 1905, and in each of these hospitals, the mission of caring encompasses the physical, emotional and spiritual wellbeing of patients and their families. We endeavour to minister to the whole person, giving individualized care appropriate to personal needs. In fulfilling the mission, the Salvation Army is committed to a standard of professional and technical excellence, seeking to complement modern medicine with a spiritual dimension which will provide holistic care and enhance the healing process. I think it's fair to say and demonstrated that the Salvation Army hospitals, along with denominational hospitals, have been very focused also on utilizing resources effectively and have done that in history till this date.
In Ontario, the Salvation Army operates three hospitals, four long-term-care facilities, as well as community-based mental health programs. The hospitals are listed in your written document. I won't review those but will just say that the quality and efficiency of these hospitals is recognized in the community and within the health care system and has been validated by the designation of the Salvation Army Scarborough Grace Hospital with a four-year accreditation status by the Canadian Council on Health Facilities Accreditation. I believe it is noteworthy to say that at least two of the Jewish hospitals have also been designated. So denominational health care is up there, achieving the quality and demonstrating this to our communities. It's well known in the communities that these services are provided in that fashion.
With respect to the Scarborough Grace Hospital and the other Salvation Army hospitals, and I believe our colleagues as well in the other two systems, while retaining our own governance and administration each of these hospitals is actively involved in planning programs and services with other hospitals and agencies in their region in order to best utilize the available resources and to improve the coordination of patient care. In Windsor, for instance, the Salvation Army is a partner in the governance and management of the Hôtel-Dieu Grace Hospital, a merger of the Religious Hospitallers of St Joseph Hôtel-Dieu Hospital and the Salvation Army hospital. This merger of the two facilities demonstrates the commitment of both denominations to the health care ministry of the church in going beyond the individual institutions in providing quality care and sharing common values.
The Salvation Army has endeavoured to respond always to changing needs. Health care reform is essential as our society grapples with the economic realities of this age. The Salvation Army, along with our colleagues in the Catholic Health Association of Ontario and the Jewish health care services, is committed to working with local communities and agencies and with the government in finding ways to meet community need. Together, we believe we can find solutions, and we appreciate the opportunity to be part of this process. We look forward to having a meaningful role as health services unfold in these difficult days.
Mr Joseph Mapa: My name is Joseph Mapa and I'm chief operating officer of Mount Sinai Hospital in Toronto. We're also pleased to be part of these vital and critical public hearings, because it's our view that the success of our hospitals in Ontario has always been based and must continue to be based on the volunteer governance system. Today's hearing is a very significant forum, because it reflects the give-and-take consultative process which must remain the framework in which Bill 26 comes into existence.
The key message we would like to convey this morning is that every caution should be taken to avoid any deterioration or dismantling of our voluntary, community-based governance system. Put another way, we would advocate that we do everything we can to promote and support our governance system. It is our belief that the strengths and achievements of our current system emanate from the efforts, values and aspirations of our communities throughout the province, including the vital denominational communities.
The genesis of the Jewish community's support for health care is rooted in the traditional Jewish values of Tsdakah: giving, sharing and caring for the sick. When the institution of hospitals became an integral part of the community service, Jewish communities throughout North America began to direct their efforts towards the building and the development of services caring for the sick.
Even though the Jewish community-supported hospitals have provided and continue to provide for the distinctive religious and cultural needs of the Jewish community, such as observance of dietary laws or religious services, the fundamental tenet of these institutions is to serve the total community with the highest quality of compassionate care. This reflects the traditional Jewish social values of contributing to the welfare of the total community.
Mount Sinai Hospital and Baycrest Centre for Geriatric Care exemplify the history, tradition and implementation of these values, as well as the success of the cultural pluralism which continues to be one of our province's major attributes. Our province is indeed fortunate and visionary to be able to tap into this wonderful pool of human resource and denominational support. There are many reasons for this and they relate to community tradition, sensitivity, diversity of need, advice and fund-raising from which so many Ontarians benefit.
0930
I cannot speak on behalf of each and every denominational hospital, but I can speak for Mount Sinai Hospital which I believe is a good example of so many other institutions in Ontario which are rooted in, and have benefited from, unique community traditions and values.
Mount Sinai Hospital, as most of you are aware, was conceived and developed within the Jewish community in service to the general community. As a downtown hospital situated in a multicultural setting and as a hospital which has its roots in the Jewish community, we have extensive links with community-based service organizations and various ethnic organizations such as the Chinese-Canadian constituency. Not unlike other urban hospitals, we have profound appreciation for the multicultural needs of our patients. To this end, for example, we have instituted a variety of programs including our multilanguage interpreter service with access to over 48 languages by 270 interpreters. Of particular note is our special outreach program to our adjacent Chinese community. This relationship manifests itself in a variety of programs as well as representation on our board and key committees.
Our bond with the Jewish community, of course, is very special, as indeed is the bond that Baycrest Centre for Geriatric Care has with the Jewish community. Mount Sinai Hospital provides a number of services to this community including kosher food, Sabbath elevators, and synagogue and rabbinical services. Our Jewish community support has been outstanding, reflecting traditional Jewish values towards the health and welfare of the community at large. The fund-raising support provided by the Jewish community for our research institute is an excellent example of how the support of such a committed community is indispensable and contributes to everyone's benefit. Mount Sinai Hospital's research institute has gained an international reputation in a short time and brings credit to the entire health care system in Ontario. It is not funded in any way by the ministry and is dependent for its capital and operating requirements on the efforts of our volunteers who raise funds as well as provide leadership in governance.
The point I would like to make is that the success of our hospital in serving the community, as in the case of so many other communities and denominational hospitals in Ontario, is intertwined with the intimate involvement and dedication of our volunteer trustees. It is a personal, genuine concern and responsibility to our patients and the communities we serve. And this should be coveted. Our hospital's board plays a unique role in our institutions, especially in those associated with particular sectors of the community. Our board, as I have indicated, serves as a representative of the Jewish and other communities and in many ways reflects their needs and priorities.
I would like to conclude my remarks by reinforcing our support and committed participation in the vital change process currently under way to ensure the long-term prosperity of our health care system and its principles, and to re-emphasize that an integral part of that long-term prosperity must include a continued involvement of our dedicated communities and the trustees that represent them.
Mr Marr: This rather lengthy background to denominational health care was intentional, to give you an idea of some of the background and basis for our concerns and comments on Bill 26, which I'm going to share with you at this time.
I do want to talk to you for a few minutes about one other very vital piece of information before we go on. That pertains to the commitment of all three Ontario political parties to the Catholic and denominational health ministry in this province.
Last spring representatives of our association and the sisters, who are the sponsors of Catholic health care, met individually with the leaders of Ontario's three main political parties. Mr Rae, Mrs McLeod and Mr Harris each confirmed the commitment of their respective party to the vital role of Catholic and denominational hospitals and to the maintenance of our governance structures. Since that time, in public statements and meetings with Mr Harris, Mr Wilson and the Deputy Minister of Health, we have stated clearly the intent of the partners in Catholic health care to remain active participants in all sectors of Ontario's health care system for the long-term future. Concurrently we have stated that we wish to be active participants in bringing about much-needed change and progress to our health care system. At the same time, however, we require respect for our traditional roles and governance structures.
As the new government began the task of bringing about such change and progress, our association offered advice on how to improve the system without compromising quality of care and the cultural and religious diversity of this province.
I'm going to skip the next section of the brief, which gives you some details on that advice. I realize we're running short on time, and I want to get directly to our comments on Bill 26, so I'll skip directly to page 13.
The Catholic Health Association, our members and the denominational health sector in general recognize that change must and will happen and that we are prepared to work with the government and local communities to see that real change takes place. We also recognize that legislative changes may also be required to provide the provincial government and the Ministry of Health with the tools necessary to facilitate change in the way hospital services are delivered in Ontario. We question, however, some of the unrestricted powers conferred upon the minister through Bill 26. Other groups, including the Ontario Hospital Association, have articulated many of the specifics of this bill which cause our members concern. We will focus today on those sections of the bill which we believe have direct impact on denominational hospitals.
We recognize that in some situations and in some communities the Minister of Health may need additional tools to facilitate the implementation of hospital restructuring studies. In principle, the creation of the Health Services Restructuring Commission may be such a vehicle needed to facilitate this change. There are, however, components of the proposed commission which prohibit us from fully endorsing this concept at this time. Specifically, we believe that clarification is needed concerning who will serve on the commission and how will the members be selected, and secondly, what will be the specific mandate in terms of reference of the commission. We were pleased to hear that the Minister of Health has agreed to limit the tenure of the commission to four years, and we support this initiative.
Bill 26 proposes that the powers of closure and amalgamations of hospitals and other matters related to a hospital may be delegated to the Health Services Restructuring Commission or to any other entity. We believe that this approach removes the accountability for such major initiatives from the elected representative, the Minister of Health, and places decision-making on such important matters in the hands of unelected and unaccountable persons.
The Chair: Mr Marr, excuse me just for a minute.
Sir, I'll have to tell you that we're not allowed to have any signs in the room, please. Could I ask you to remove the signs, please.
Interruption.
The Chair: Could I ask you to remove the signs, please.
Mr Agostino: On a point of order, Mr Chairman: Last week at the public hearings they were allowed to have the signs. They were not disruptive. They had them there at the back. They were allowed to. There was no problem, no disruption, and I don't see a problem, why you would ask these gentlemen now to do it. They were allowed to do it last week, and they did it in a very quiet way and a very peaceful way, as they are doing it today.
The Chair: We have had a consistent policy on this committee that we do not allow any signs. Would you please remove the signs.
Interruption.
The Chair: I'm going to call a short recess.
The committee recessed from 0938 to 0952.
The Chair: Okay, we're ready to resume please. I'll just explain a couple of things. The situation with the signs: The reason I stopped the meeting was because there was a disagreement going on at the back of the room about whether the signs should be up or down. They were going up and somebody else was taking them down. I was concerned about what was going on there, so I thought it prudent to stop the proceedings at that point. The members of the committee and the local MPPs have agreed that the signs that are there will be allowed to stay there. I don't have a problem with that. The second thing is that we were having trouble with our sound system, so we took the opportunity to fix that while we had a break. The third was the press asked to get moved up a little closer so they could hear.
Having taken care of all of those things, we now will try to get back to wherever you were. Mr Marr, you can pick it up, and I apologize for the interruption.
Mr Marr: It's quite okay, Mr Chairman.
We were talking about our concerns around Bill 26 in terms of the proposed restructuring commission and mentioned very briefly that the beginning concerns had to do with who was going to serve on the commission and the specific mandate and terms of reference.
Bill 26 proposes that the powers of closure and amalgamation of hospitals and other matters related to hospitals may be delegated to this health system restructuring commission or to some other entity. We believe that this approach removes the accountability for such major initiatives from the elected representative, the Minister of Health, and places decision-making on such important matters in the hands of unelected and unaccountable persons. We are also concerned about the likelihood of the creation of a large bureaucracy to support such a commission and the consequent increase in influence and control by the civil service in these important matters. Decisions like closing hospitals, forcing mergers or other collaborative ventures among hospitals, and the other proposed powers are so significant that it is imperative that the minister retain the ultimate decision-making authority and consequent accountability. The work of the commission must be directly accountable, not only to the people and the communities of Ontario, but also to the provincial cabinet. Only the minister can be accountable in such a manner and only the minister has the full appreciation of the policy directions of the provincial cabinet.
Consequently, we make the following three recommendations in reference to the proposed Health Services Restructuring Commission:
(1) That the commission be an advisory body to the Minister of Health and that the minister retain the final authority to act on any recommendations of the commission.
(2) That the terms of reference for the commission clearly state that it is government policy for local communities to define the details of hospital restructuring and that the commission will only deal with restructuring studies and communities where local solutions to hospital restructuring have not been achieved within a specific time frame. Clearly, our opinion is that the job of the commission is to implement studies that have local consensus.
(3) That specific criteria be developed to guide the minister in making his decisions concerning which restructuring studies and communities he will ask the commission to address.
I'd like to focus at this point on proposed amendments to the existing Public Hospitals Act. Catholic and other denominational hospitals have historically provided quality care to all residents of the province of Ontario without regard to creed. Catholic and other denominational hospitals have thrived in an atmosphere of pluralism and tolerance which have been the hallmarks of this province for generations.
The corporate integrity of Catholic and other denominational hospitals actualize the missions of these hospitals. The missions of our hospitals, as we have said repeatedly this morning, focus on holistic and compassionate care which stresses the physical, emotional and spiritual components of healing.
Our association, our members and the members of other denominations have stated repeatedly that we support the principle of hospital and health system reform and that we will collaborate at both the provincial and local levels to ensure that change happens and that the goals of hospital restructuring are achieved.
We are, however, very concerned with section 6 of the proposed amendments to the Public Hospitals Act, which may impact on the corporate integrity of denominational hospitals. We are particularly concerned with the proposed amendments to the act which relate to the closing of hospitals, the amalgamation of hospitals, the determination of what services will be provided by a hospital, the appointment and the powers of the supervisor, the authority of the minister to unilaterally set or eliminate the budget of a hospital, and the proposed power to have the government write hospital bylaws.
We believe that the granting permanently of these sweeping powers to the Minister of Health goes far beyond the authority needed by the minister to ensure that hospital restructuring takes place. We recognize that the Minister of Health may need some extraordinary powers to ensure that restructuring studies which have been duly undertaken, supported by local communities and approved by the minister are implemented. We believe these extraordinary powers should not be enshrined permanently in the legislation. We support the minister's amendments submitted to this committee on January 17 which "repeal the powers of the minister to close and amalgamate hospitals, to transfer hospital programs, and to issue other directions to hospitals at the end of four years."
There is an issue, however, which is more important to us than the time limitations of these powers. We believe that the granting of these powers to the Minister of Health or the proposed commission encroaches upon the corporate integrity of Catholic and other denominational hospitals and has the potential to force Catholic and other denominational hospitals to merge with hospitals that do not share their mission and values, provide services which are in contradiction to their missions or cease to provide services which are central to their missions.
In addition, these sweeping changes to the Public Hospitals Act are potentially contrary to the commitment of Premier Harris and the leaders of the Liberal and New Democratic parties, which I mentioned earlier. This commitment was to preserve the corporate structures of Catholic and other denominational hospitals. We consider the proposed powers for the minister or commission to force mergers between denominational and non-denominational hospitals as being contrary to this commitment.
The corporate integrity of the Catholic and other denominational hospitals, as I mentioned earlier, actualizes our mission. The forced merger or amalgamation of denominational and non-denominational hospitals will, in effect, nullify the mission of the denominational hospital. Consequently, we cannot support any provisions of Bill 26 which will give the government, the Minister of Health or a restructuring commission the power to force a merger of a denominational hospital with a non-denominational hospital. As we have stated repeatedly this morning and over the last number of years, we believe strongly that alternative, collaborative arrangements are available which can achieve the objectives of hospital restructuring while respecting the corporate integrity, structure and mission of the denominational hospitals.
There are many examples across this province of such collaborative ventures where the denominational hospital has been able to continue to exist, to continue with its corporate structure, and yet the goals of hospital restructuring and collaboration between hospitals have been achieved and are being achieved. A good example of that kind of collaborative venture is right here in the city of Hamilton, where a collaborative venture between St Joseph's Hospital and the Hamilton Civic Hospitals was the first major initiative in the last number of years to try and bring about major change in the way hospital services are delivered in this city in a collaborative way but yet maintain the corporate structures and missions of both institutions.
1000
Other communities such as London, Sarnia and a number of other communities also are in the midst of developing these kinds of collaborative ventures, which will allow the denominational hospital to continue but which will in the long run achieve the objectives of health and hospital reform.
In reference to these issues, we would like to make two additional recommendations to the committee:
(4) That the proposed Health Services Restructuring Commission be informed of the commitment of the leaders of Ontario's three major political parties to the maintenance of the mission and corporate structures of Catholic and other denominational hospitals and that the proposed commission be directed to respect these commitments during its deliberations and in formulating its recommendations to the Minister of Health.
(5) That when acting upon those sections of Bill 26 related to hospital mergers or amalgamations the Minister of Health and the civil service be cognizant of the need to maintain the corporate integrity of denominational hospitals in order to ensure the maintenance of the missions of these corporations and that alternative methods of collaboration be found to achieve the goals of hospital restructuring.
The Catholic Health Association of Ontario, the Salvation Army and the Jewish health services request that the standing committee seriously consider our comments and recommendations.
We recognize that hospital restructuring must and will continue in Ontario and in some instances must be accelerated. We are very concerned, however, that the rights and responsibilities of local communities and providers must be balanced with the powers and authority of the Minister of Health and with the economic imperative which is confronting all of Ontario today.
We want to reiterate that Catholic and other denominational hospitals are prepared to work with the government and local communities to move restructuring ahead. We are very concerned, however, that parts of Bill 26 threaten the continuation of denominational health care in Ontario and urge that those sections be amended to allow us to continue to provide quality and value-based health care to the residents of Ontario.
Mr Clement: Thank you very much, gentlemen, and Mrs Stickland for your presentation. You brought up some excellent points. This issue of the role of the denominational and non-denominational restructuring came up in Ottawa earlier in our presentations. Upon some further research and some further statements, because it was an issue in the Ottawa region, I believe, and the restructuring that's going on there, the Minister of Health has made it pretty clear that he favours solutions that maintain the integrity of denominational representation but that he is looking to both the denominational and non-denominational hospitals to get on with the job of restructuring. The debate over denominational versus non-denominational governance should not be an impediment to the restructuring. But he's prepared to work with the various hospitals to further that initiative.
I wanted to just ask you a couple of quick questions, then. We have proposed as the government an amendment to Bill 26 which would remove the power of the minister to write or rewrite bylaws. So I'm presuming that you agree with that and that's a further confirmation of independent governance.
Mr Marr: Yes, we support that amendment.
Mr Clement: I've made also the point in earlier presentations that our changes to the Ministry of Health Act do not change the role of district health councils; they are still in the act, they still have a role to analyse, plan and make recommendations to either the restructuring commission or to the minister. Does that assurance and the presence of that language in the act go some way to assuage you that there is a possibility for local input?
Mr Marr: I think, Mr Clement, that our concern is more about ensuring that local solutions are found to local problems. We've historically stated that there is not a cookie-cutter approach to this issue of hospital restructuring across this province. Our concern with the bill, and especially the restructuring commission, is the lack of clarity at this point about the terms of reference and composition of that group.
We recognize that in some communities, where consensus has not been achieved in terms of implementation, the minister or the government may need additional tools to see that studies which have been duly conducted by district health councils with all the participation of the local community and approved by local communities and approved by the minister, get implemented. Our concern is, will the commission go beyond that kind of a mandate and actually get into the part of redoing district health council studies or making decisions on their own without any kind of local input?
Mr Agostino: I thank the presenters and I first of all feel very strongly for the role that denominational hospitals have played and should continue to play in the health care system. It's a very historic and very important and very significant contribution to health care across this province, and I appreciate very much that role and thank the people here for the role that they've played in that.
I guess the concern I have, when I hear my friends across the floor talk about the health care system and the answers you've been given this morning along the lines of, "Trust me; we will take care of that; we will look after your concerns" -- I think that is part of the problem with this bill, that the regulations, which are going to be the real beef and the real meat of this matter, are not here. We will not deal with those regulations, and frankly I don't trust this government when it comes to health care. This government said that not one cent would be cut from health care; that commitment has been broken. This government is now telling every group that's coming forward, "We'll look after the concerns that you have; we'll look after the things that you're talking about." Frankly, I don't trust them; I don't think people across this province trust them.
We saw a piece of literature come out earlier in the week that talked about consultation. Government propaganda had said that they consulted with stakeholders when Bill 26 was introduced. We have not come across any stakeholders yet who have been consulted. I use the word carefully with my bishop sitting here in front of me, but I really believe that we've seen nothing but lies in regard to health care from this government. This is a continuation of that process, and I certainly would not put any faith in the government saying that they're going to address your concerns. I think that the meat and the heart of this is the regulations that will come later.
The Chair: Mr Agostino, you've used up your two minutes.
Mr Agostino: Just a question, if I can?
The Chair: Sorry; two minutes.
Mr Christopherson: Before my colleague Ms Lankin asks a question, I just wanted to thank the delegation for coming forward and raising these concerns. I would also underscore the importance of being sure that you've got in writing, in regulation and in the law, exactly what you need, because without that, the government's intention, as we see it and I see it, is to take the powers in Bill 26, retreat back into the cabinet room and then just govern by edict, as they did in the summer shortly after they were elected. I'm very concerned that the promises they're making, and I heard them in other communities on other issues, aren't really worth much if they're not in writing. So I urge you so very, very much to make sure that you're having written dialogue. If you hear commitments here today that you want in writing, we can give you the Hansard; forward that to the minister as quickly as possible and ask for confirmation that that's what they're intending to do and you'd like to see it in regulation.
Ms Lankin: I have a couple of specific questions, but I'd like to preface them by saying we have heard from many, the concerns you've raised about the relationship between the work of the commission and the district health councils, and we will be moving an amendment to that effect. We've also heard concerns about the makeup of the commission, and we will be moving an amendment that tries to deal with that and should specifically reference denominational institutions.
On the issue of accountability in ministerial decision-making in this area, I need to inform you that the amendments the government has tabled actually go further the other way; they give the right to have powers given to the restructuring commission, delegated from the minister. So I think that's not what you want.
My question, though, is on supervisors. I will be moving an amendment which actually says that the existing due process rules that are in place should remain in place for all circumstances other than the direct decision to close, and even then there should be --
The Chair: Thank you very much. We appreciate your presentation here this morning and your interest in our process, and again I apologize for the delay. Thank you.
1010
ONTARIO MEDICAL ASSOCIATION
The Chair: Our next presenters are Dr Lorne Finkelstein and Dr Bill Orovan on behalf of the OMA. Good morning, doctors. Welcome to our committee.
Dr Lorne Finkelstein: Thank you, Mr Chair and committee members, for the opportunity to speak with you this morning. My name is Dr Lorne Finkelstein. I'm a cardiologist in Hamilton and an OMA board member representing district 4, which stretches from Oakville to Hamilton and around the lake to Fort Erie. With me is Dr William Orovan, a member of the OMA's executive committee and of the OMA's negotiating committee.
This morning I plan to review for you what I believe are the very constructive proposals that the Ontario Medical Association submitted to government last week for amending and improving Bill 26.
First, I'd like to say that it's important for you in the government to understand that the province's doctors and the OMA are fully aware of the issues that need to be addressed, issues that we must address together if we are to maintain, manage and deliver accessible and quality health care for the people of Ontario.
I mention this because my colleagues and I were extremely concerned and frustrated by the minister's presentation to this committee made when you first launched your hearings on December 18, and by the remarks he was quoted to have made to members of the news media following his presentation. It was ludicrous for the minister to suggest that the OMA has not been providing him or his ministry with ideas or proposals to address health care issues.
The minister invited the OMA to discuss a number of important issues back in October. We met frequently that month and we made numerous proposals to improve the health care system, some of which the minister has since adopted as his own.
The minister clearly left this committee with the wrong impression on December 18. We can only conclude that there is little, if any, accurate communication between the bureaucrats, to whom our alternatives and proposals were delivered, and the minister.
Ontario's physicians in the OMA have been offering constructive solutions in these matters for years. This morning I will review with you some of the many proposed amendments to Bill 26, a full and detailed package which our association submitted to the government one week ago today. I'll share with you some of the highlights of our proposed amendments and recommendations.
First, I'd like to address schedule I, which deals with a fundamental issue: the nature of the relationship between Ontario's 23,000 physicians and the provincial government.
Unfortunately, Bill 26 in its current form would allow the government to eliminate any formal partnership between the government and the medical profession by eliminating any agreements with the Ontario Medical Association. This is one of our main concerns with the entire omnibus bill. The government could decide it won't recognize the OMA as a representative of physicians. It won't enter into agreements and the government could decide it will terminate any existing agreements between it and the OMA.
We recommend that the government must continue to recognize the OMA as representing Ontario's 23,000 physicians.
The government must also recognize that the OMA represents the medical needs of the people of Ontario and that physicians are advocates for their patients.
The government must also continue to negotiate and respect agreements with the OMA. To do otherwise would leave Ontario as the only province in Canada where there's no agreement and no formal partnership between government and physicians.
We recommend that the government delete this section of Bill 26 and replace it with wording that would allow termination of existing agreements only upon the negotiation and execution of a new agreement between the OMA and the government of Ontario that replaces existing agreements.
Referring to schedule H, which involves who is to determine what is medically necessary, serious threats to patient privacy, a duplicate system of government inspectors and restrictions on where doctors may practise: What's extremely troubling for physicians and potentially very harmful to the accessibility and quality of Ontario's medical care is that Bill 26 gives bureaucrats in the Ministry of Health the power to determine what is and is not medically necessary for our patients.
What this means is that someone at Queen's Park, who's not a physician, could determine after the fact that a service rendered by a physician was not medically necessary. In addition, Bill 26 enables the medical review committee of the College of Physicians and Surgeons of Ontario to order a physician to repay all costs of service requested for a patient by that physician if the MRC later determines those services were not medically necessary.
What's very troubling for physicians is that absolutely no guidelines exist as to how a ministry bureaucrat or the MRC will exercise their new authority in determining what is or is not medically necessary. For example, suppose I am asked to see any one of you to assess chest pain you might be experiencing. As part of that assessment I order an ECG, an electrocardiogram, at a laboratory. The ECG results prove to be normal, and I'm able to reassure you that you haven't had a heart attack.
Now, under Bill 26, a few months later the government could deem that this normal ECG was not medically necessary. I would be charged back out of my own income the cost of that ECG. The result would be that the next time a patient would come to see me for assessment I would be very hesitant to order that test or in fact any test. As a result, the quality of care I'm able to give my patients and the quality of care my patients expect will be diminished because of the government's second-guessing of my diagnostic abilities.
These new powers under Bill 26 are unnecessarily broad and will have a chilling effect on physicians, whose first concern is and must continue to be the medical needs of our patients. Constant and intimidating threats hanging over the heads of physicians will have a damaging effect on the quality of medical care patients receive in Ontario.
I'll now focus on the confidentiality and privacy of patient medical records, which become a thing of the past under Bill 26. The OMA supports the amendments that were put forward by Ontario's Information and Privacy Commissioner. These amendments would ensure that only in the case of a fraud investigation would access be given to personal and private medical files. The OMA recommends that there ought to be reasonable grounds to suspect fraud before an investigation is launched. Information that's required by government to manage the system on a daily basis must be of an anonymous nature in order to protect the privacy of patients.
Although we've heard that the ministry may amend this part of Bill 26, the omnibus bill would create a whole new stream of inspectors whose aim would be to recover moneys paid to doctors as a result of supposed inappropriate billings. This would duplicate what the government already has in the medical review committee. The OMA recommends that if the government is concerned about the efficiency of the medical review committee, then it should adopt the expedited medical review process which has been proposed to government by the College of Physicians and Surgeons. This would eliminate the need for a duplicate stream of inspectors and would accomplish the government's objective using a proven system that is completely confidential.
As for government's proposed billing number restrictions to address doctor distribution, we believe the scheme won't work and could very likely drive many more physicians, including much-needed specialists, out of Ontario. The OMA has proposed a plan to the minister which would include the government's existing northern and rural funding along with funding from the current OHIP pool to encourage more physicians to work in northern and rural areas of the province. We've been talking with government about incentives and other proposals designed to improve physician distribution for years. Unfortunately, however, we've been unable to convince government to fund any of the significant proposals that we have made. We continue to be ready and willing to address physician distribution issues with government, but in a cooperative manner.
Schedule F of Bill 26 gives the minister powers to close and amalgamate hospitals or adjust their services. The OMA recognizes the need for significant restructuring within hospitals and it supports the general thrust of this aspect of Bill 26. However, the OMA believes these powers should be viewed as extraordinary and must be time limited. Recently proposed amendments to Bill 26 from the government indicate that the government is following the OMA's advice in this matter.
On the Health Services Restructuring Commission to be established under Bill 26, the OMA recommends that the HSRC's role should be confined to implementing initiatives that are approved by the minister. Decisions involving the significant restructuring of hospitals are for the minister alone to make, and they should not be delegated to others.
Another very important aspect of Bill 26 is that it eliminates many protections of due process for physicians in the case of hospital closure or program closure. For the majority of those physicians who are not hospital employees, other common avenues of redress are not available to them. For that reason, we recommend that doctors be given reasonable notice of hospital closure or program change and that best efforts be made to provide those physicians with privileges at other hospitals or facilities. If a reasonable notice period is not provided, financial compensation should be offered. These protections are extremely important, given that Bill 26 requires that specialists be affiliated with a hospital in order to maintain the OHIP billing number that allows physicians to provide services to patients.
1020
Another aspect of health care the government apparently intends to micromanage through Bill 26 is physician human resource plans, PHRPs, which are currently prepared by hospitals. We believe that hospitals, and not the government, are in the best position to determine their requirements for medical staff. The OMA proposes that the government create a standardized reporting method for PHRPs which would be provided as part of a hospital's annual operating plan submissions to government.
Bill 26 makes a number of changes to the Independent Health Facilities Act that we believe could have a very negative effect on health care. For instance, Bill 26 could extend the application of the IHFA to all services provided by physicians, making those services subject to a licence under the act. For example, the minister could designate services such as an annual health exam or sutures to be covered by the IHFA, and without a licence a physician could not provide those services. This would subject physicians to a dual licensing scheme, one under the Medicine Act, administered by the College of Physicians and Surgeons, and another under the IHFA. A CPSO licence to practise medicine can be revoked for professional misconduct, incompetence, incapacity or for failing to follow recommendations of the college, but an IHFA licence may simply be revoked or not renewed without cause and services could be eliminated from a licence at any time. This could have a major impact on the practice of medicine and would lead to a tremendous uncertainly as to the viability of a licence. This would empower the Minister of Health to remove any doctor's licence at any time with no need for the minister to show cause, and no appeal by a physician would be allowed.
The OMA recommends that this proposed change to the IHFA be withdrawn and that the government exercise, should need be, its current regulatory power under the IHFA.
Another way Bill 26 could significantly increase the uncertainty for operators of IHFs, or independent health facilities, is the new powers the government would have to refuse to grant a licence to existing facilities, revoke licences mid-term or refuse to renew a licence. None of these new powers is linked to quality of care.
The OMA feels the government should provide the operators of the IHF with as much certainty as possible. We recommend it do this by grandparenting facilities that are already providing services that the minister may choose to designate under the act, and that government revoke a licence, eliminate services or refuse to renew a licence only in cases involving public safety. We also recommend that compensation be provided upon revocation of a licence, elimination of services or non-renewal of a licence. Failure of government to take these actions would likely result in a level of uncertainty that could limit the number of physicians willing to invest in IHFs, which could potentially decrease the quality of care and result in longer waiting lists in hospitals for services such as X-rays, ultrasounds and cataract surgery.
Bill 26 would lead to even more uncertainty for the operators of IHFs because it introduces differential fees for the same services and does not factor into account operating costs and overhead costs related to services.
Further, the bill would allow a nil payment for services rendered. The prospect of having fees reduced dramatically, even to a nil amount, would lead to uncertainty among operators, which may have the same impact on patient care as a potential revocation or elimination of services from a licence that I mentioned earlier.
Bill 26 should be amended to require that fees prescribed by regulation should factor into account operating and overhead costs related to provision of services.
Bill 26 would eliminate the current preference to independent health facility licence applicants who are Canadian citizens, permanent residents or Canadian-controlled corporations. This means that future licences could be granted to non-Canadian, and in particular US-owned, corporations. The OMA is concerned that independent health facilities that are owned by non-physicians may not meet the same standards for quality of care. This change could also have a negative impact on the Ontario economy, since it is domestically based corporations that spawn job creation and provide a stimulus to the provincial and national economies.
Therefore, the OMA recommends preference for new licences be given to Ontario applicants, especially Ontario physicians.
Finally, looking at schedule G dealing with the Ontario Drug Benefit Act, we see that Bill 26 would strip the Ontario Pharmacists' Association of its ability to negotiate dispensing fees and/or have representation rights on behalf of pharmacists. This one has a very familiar ring to it.
As you might expect, the OMA recommends that pharmacists should have the right to be represented by their association and to have agreements with government.
On drug substitution, Bill 26 proposes the government pay only for the lowest-priced product within a class of "interchangeable" drug products for persons covered under the Ontario drug benefit plan. Government would no longer pay the difference between the generic cost and the brand-name cost when the prescriber writes "no substitution" on a prescription and a pharmacy charges the patient the additional cost. While the OMA supports in principle the government's program to provide patients with quality drug products at reasonable prices, we believe it must continue to provide exemptions to its drug substitution rules when interchanging drug products may result in adverse or allergic reactions in some patients. Furthermore, Bill 26 allows the minister to determine clinical criteria for prescribing drugs which will be used as standards for payment of Ontario drug benefit claims.
The OMA recommends that the introduction and use of clinical criteria should be part of a comprehensive and professionally sanctioned drug utilization review system which includes consideration of clinical criteria, quality and cost. It would make use of an expert review panel and would provide feedback to health care professionals.
The multiple issues of providing medical care to the citizens of Ontario are complex. Bill 26, as it stands now, would allow the government to manage all aspects of our health care. We believe that such decisions should be based on collaboration and partnership between government, which must decide what it can afford and is willing to provide, the public, which must decide what medical services it wants from government, and the medical profession, whose members have tremendous expertise as medical care providers.
Mr Chair and committee members, that's a review of some of the Ontario Medical Association's proposed amendments to Bill 26. Dr Orovan and I would be pleased to answer any of your questions, after which we will provide you with a copy of the OMA's formal amendments package. Thank you.
Mrs Lyn McLeod (Leader of the Opposition): Thank you both for your presentation and for the very thorough work that you've done in presenting constructive amendments to Bill 26. I'm sure you're aware that there have been some amendments tabled by the government today, and we are all going to look to see how fully that package of amendments addresses the concerns that have been raised virtually every day that these hearings have been held. Thank God this did not become law on December 14 or there would have been no amendments to reflect the kinds of concerns that you and others have raised every day that these hearings have been held. I want to congratulate you and your colleagues because you've been able to bring the concerns forward so clearly as to what this bill in its original form would do to patient care and the access to health care in this province.
Having said that, we are going to be looking at those amendments very critically because there are a lot of issues that have been raised. The privacy one you note in your brief. There are some amendments on privacy. Nothing less than the recommendations of the privacy commissioner will be satisfactory, and I think we're going to find that still the government is looking at finding wholesale fraud in using the ability to investigate doctors' records.
I want to ask you about the "medically necessary," which seems to be addressed in part by amendments. We'll look at how well that's done. But the capacity to set fees at zero, which to me sounds like delisting by any other name, even though the government says that they're not delisting services: Is setting fees at zero a way of delisting services and, in your view, should that be done only through a process of looking at what is and is not medically necessary in a very open way?
Dr William Orovan: Setting fees at zero is even worse than delisting, because what it does is say that the physician cannot be paid for delivering the service and the patient who wants that service could not buy it. At least if it was delisted, the patient would still have the opportunity. So setting fees for medical service at zero ensures that that service will not be available.
Mrs McLeod: You've indicated a concern that billing numbers, coercive methods, would in fact make our recruitment and retention of physician problem even worse by driving physicians out of the province. There are a number of parts of Bill 26 that give the government control over who practises, how many practise and where physicians practise, including the ability to decide who's an eligible physician, the ability to set quorums, and even the ability to put in place regulations that would determine who gets chosen to go to specific areas if there are too many people. Can I assume that you would want to see all the parts of Bill 26 that give the government direct coercive control over physicians' practising withdrawn from this bill?
Dr Orovan: The amendments that we'll table with you suggest in schedule H that sections 22 through 27 should be withdrawn, and those are the sections that you allude to.
1030
Ms Lankin: We all know that we just got the amendments. I don't profess to have a full understanding of them, but I have been going through them and, by and large, I think they address very few of your concerns. The OMA is still nowhere after this bill passes; the micromanagement of physician resource plans in hospitals: still there; billing numbers, eligibility issues, all of the sections in schedule H that you just raised are still a problem; still no appeal of the revocation of hospital privileges; if the hospital ceases to provide a service which is moved to another hospital, you don't necessarily get to follow your patients -- all due process areas that are gone.
Let me address medical necessity, because we've been saying that the old system that had the general manager of OHIP refer a concern to the medical review committee should stay. If they want to streamline the medical review committee, then fine. But the general manager now still makes this decision, if they are of the opinion, after consulting with a physician, that it wasn't medically necessary. But let me tell you, they've separated out therapeutically necessary for other practitioners but they still only have consulting with a physician. I don't think the chiropractors are going to be too happy about the fact that the general manager's going to consult with a physician about whether what they did was therapeutically necessary. Really bad drafting problems here.
They've got a process that you still have to decide to appeal to the medical review committee. You can choose expedited arbitration, if I can use the labour term, but if you do that, you don't get to appeal the results of it at the end. Due process denied again. If you do appeal through the review committee and it's found to be that you were only partially right and you get partial payments, less than half of what you billed for, you've got to pay for the review process. There are whole sections in here about time frames and everything else which we've not seen until today which really totally change the process of doctors' decision-making and, I would now argue, other health care practitioners who haven't had a chance to address it. Can you comment on this section, if you know anything about it yet in the amendments?
Dr Orovan: I have had an opportunity to review the amendments very briefly, and I would agree with most of your concerns. The amendments do remove the minister's ability to appoint a second stream of inspectors, and we support that.
Ms Lankin: That's good, yes.
Dr Orovan: But they do change the standard by which the general manager may initiate an investigation. He used to require reasonable grounds. In the amended form, he only needs to be "of the opinion." He does need to consult a physician, but who that physician might be is not defined in any way. If you select the fast-track process, and you may end up with a single-physician review, you do not have an opportunity to appeal. So it's removed one set of problems and introduced a whole series of others.
Ms Lankin: A whole new set, yes.
Mrs Janet Ecker (Durham West): Thank you, doctors, for taking the time out of what I know would be a very busy schedule to come forward and table some very detailed, very comprehensive amendments. I look forward to being able to go over them further.
One of the things that I think we've certainly heard and I've certainly heard in the past from physicians is about misuse in the system by, yes, physicians and consumers. We acknowledge that that's out there. It's interesting to note that the entire MRC process is about misuse of the system. That's why there are powers there to talk about overbilling that is perhaps not medically necessary. I think it's interesting that in a recent poll that Maclean's did, 70% of physicians agreed that some of their colleagues -- a minority, but some -- were encouraging people to come for visits that were not medically necessary and that there were problems with it. So I think this is something we're interested in trying to pursue.
Under the previous process, the general manager who had questions about billing practices, questions about whether they were medically necessary, referred them to the MRC. The college that administered the MRC has said that process has not been working, for many reasons I won't get into, so the government had attempted to make some changes. I understand that the college and the OMA have been working together to come up with recommendations as to how we can streamline that process and maintain that role for that MRC so that if there is misuse, it's being addressed with physicians: peer judgements and that kind of thing.
If the government were to adopt those recommendations, to look at those recommendations and put them forward, would that ease some of the concerns you have? Because I think that answers "medically necessary," confidentiality, judgement by peers; that is in that process.
Dr Orovan: I think we addressed a little of that in Ms Lankin's question earlier. I think they have gone some distance towards that. We were appalled by the thought that the minister might appoint his own personal police force independent of the college, so that issue has been addressed, but it's introduced a whole series of other issues. There is no due process. As I said a moment ago, in order to initiate an investigation, the general manager of OHIP at least needed to have reasonable grounds to believe. Now he just has to be "of the opinion." It provides the opportunity for fishing expeditions on the part of the general manager of OHIP.
We all want to get rid of any fraudulent billing practices. The minister himself acknowledged that fraudulent billing practices are an exceedingly small part of the total fraud issue.
The Chair: Thank you, doctors. We appreciate you being here this morning and making a presentation to us. Have a good day.
Mr Agostino: Mr Chair, before we go to the next one, a request and a letter from Dr McCutcheon, president and CEO of Hamilton Civic Hospitals, along with a letter which basically outlines that he's been denied access and would like to have read into the record this brief and that it be circulated to the committee. On behalf of Dr McCutcheon and the Hamilton Civic Hospitals, I would like to table this with the committee.
BOEHRINGER INGELHEIM (CANADA) LTD
The Chair: Our next presenters are from Boehringer Ingelheim (Canada) Ltd: Dr Karen Gilberg, Mr Alan Fukuda and Mr Barry Wilson. Good morning and welcome to our committee.
Dr Karen Gilberg: My name is Karen Gilberg. I am a physician and vice-president of external affairs and health economics for Boehringer Ingelheim (Canada) Ltd, an Ontario-based, research-intensive pharmaceutical company. With me are Alan Fukuda, head of external affairs, and Barry Wilson, a member of our external affairs group. On behalf of our company, we want to thank you for the opportunity of presenting our perspectives regarding the health care portion of Bill 26.
As I just mentioned, BICL is an Ontario-based, research-intensive pharmaceutical company and is a member of the privately owned Boehringer Ingelheim group of companies, with headquarters based in Ingelheim, Germany. Canadian operations commenced in 1972 at Montreal and now are headquartered in Burlington, Ontario, with approximately 500 employees in Canada involved in five health businesses coast to coast.
Our five Canadian business areas consist of human prescription pharmaceuticals, human self-medication products, animal health products, and fine chemicals, all located in Ontario. In addition, we have a basic research institute located in Laval, Quebec, involved in basic research and drug discovery. This centre is the research centre worldwide for drug discovery in the area of virology for Boehringer Ingelheim. In addition to these businesses, we export pharmaceutical products to the Caribbean from our Ontario-based plant.
In 1994 the annual federal Patented Medicine Prices Review Board report listed BICL's research and development expenditures to be 33.4% of sales, versus an industry average of 11.3%. These figures are consistent with our expenditures in the preceding years and into the foreseeable future. In addition to our own in-house basic and clinical research, we promote and support significant basic and clinical research projects in Ontario hospitals, universities and research institutions. Most recently, BICL and our parent company, in conjunction with the Samuel Lunenfeld Research Institute of Mount Sinai Hospital in Toronto and Sequana Therapeutics in California, announced a joint international research alliance to attempt to isolate, clone and sequence genes associated with asthma, with the potential for development of new treatments for this very common and costly disorder.
1040
During 1994, BICL invested approximately $8 million to fund an extensive range of medical and scientific research projects in Ontario, and in 1995 we were designated as the centre of excellence for health economic research for all the Boehringer Ingelheim companies in North America.
This decision has resulted in the creation of additional new scientific and medical full-time positions in addition to the approximately 125 full-time scientists we currently employ. Such positions are pivotal to a thriving and competitive research-based pharmaceutical industry and to supporting scientific and medical research in Canada, as well as to the support of the scientific and medical research community within Ontario.
At BICL, our research activities are directed towards fundamental discoveries and development of new therapeutic agents that provide added value, measured both in the short and the long term, to patients, physicians and the health care system overall.
Let me proceed by stating that our representations to the committee today reflect our strong commitment to improved health care via the development of innovative and cost-effective medicines to ultimately improve overall health care outcomes.
Secondly, we are proponents of the principles of disease management. We believe that pharmaceuticals, coupled with clinical practice guidelines and care maps, will enable better decisions about the management of patients and their diseases, while placing more information and control in the patient's hands.
We also believe that comprehensive disease management will enable physicians to utilize pharmaceuticals and other interventions more effectively, resulting in the provision of more value for every dollar committed to health care.
Despite the small portion of health care dollars spent currently on prescription medicine -- that is, 5.5% of national health care expenditures are on pharmaceutical costs and 2.4% on patented prescription medicines -- prescription drugs are typically the continual focus of cost-control measures.
In fact, "pharmaceuticals are the most widely used of all technologies and are one of the most cost-effective when used properly," the Science Council of Canada reported in a 1991 study of medication and health policy. "Making optimal use of medication technologies has never been more crucial."
This is an area in which I'd like to make some personal notes. I believe that it's imperative that I give you some examples of the types of pharmaceutical advances that the Science Council refers to, examples that have revolutionized and improved health care just in the 23 years since I graduated from medical school.
The first example is of cimetidine, which is a drug that's used for ulcer disease and the treatment of gastrointestinal bleeding. At the time that I finished medical school and entered into training, the majority of beds on gastroenterology services in the hospitals were filled with patients with GI bleeds and ulcers. In addition to that, the most common procedure done in hospitals was vagotomy pyloroplasty, a surgical procedure for the treatment of ulcer disease and bleeding.
Since the introduction of cimetidine, the number of hospital days for inpatient treatment of GI bleeding and ulcers has dropped dramatically. The frequency of this surgery is almost non-existent now and the number of days which patients have to lose from work has decreased to being negligible. This is a significant improvement in health care.
Later on, during my training in my own specialty, I was involved in research with a compound called bromocriptine. This was a product that was being developed for use in pituitary tumours which secrete a product called prolactin. At that time, the only treatment available was radiation and invasive surgery. Patients who are unable to have the pituitary tumour shrink adequately develop blind spots because of the location of the tumour, near the optic nerves. Since the time that prolactin has been approved and used for this, the number of surgeries and radiation has decreased and the incidence of blindness due to pituitary tumours has significantly decreased. This drug has gone on to be developed in a second indication of Parkinson's disease, another very critical illness.
When I first joined the industry, the company that I worked for was just beginning development of ultrashort-acting general anaesthetic agents. We recently heard, in the restructuring of the hospitals, that the potential of having hospitals dedicated to outpatient surgery, day beds, would occur. This has been made possible because of products like the ultrashort-acting anaesthetic agents; that is, hospital days have been cut, patients are able to go home to their own families and not stay in hospital. This is a huge saving to the health care system overall.
The last example is that of inhaled corticosteroids, which are used for the treatment of patients with asthma. Prior to the availability of these compounds, patients received oral corticosteroids, which created significant side-effects in them. The ease of use of the inhaled steroids has led to decreased exacerbations of asthma, and this itself has led to decreased emergency room and hospital room visits. Both of these have also led to an improved quality of life for patients and their families, with decreased school absences and decreased work absences.
We cannot emphasize enough that we and our research-based colleagues in the industry are very concerned that Ontario's history of silo budget cost management severely undermines the more important goal of integrated health care management and improved health care outcomes. We therefore commend this government's willingness and early efforts to reform aspects of the ODB to reduce expenditures while maintaining quality. We sincerely hope that their efforts to control expenditures will in future result in the ODB being able to quickly assess and reimburse new and innovative, cost-effective medicines for the benefit of Ontario residents. As such, we urge you all to assist in changing Ontario's past course of component cost management to one of integrated disease management which includes outcomes assessment and continuous quality improvement.
Our representations will also reflect BICL's support for the principle of optimal therapy or optimal patient care; that is, the practice whereby a patient receives the treatment most appropriate to his or her specific condition.
This morning, we wish to focus on several proposed legislative changes to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act as they relate to our business interests as well as their effects on the present health care system in Ontario. Specifically, we will comment on copays and deductibles, deregulation of the private marketplace and transparency in the system. With these principles in mind, we wish to proceed with comments pertaining to the issue of copays and deductibles.
Cost-sharing is quickly becoming a fiscal necessity in the economic reality in which we all work and live. As you are all aware, Ontario is presently the sole province in Canada which does not require a patient contribution from those who receive publicly funded prescription products. As such, we fully understand and support the need for the government's proposed model in which contributions are linked to the patient's ability to pay.
Health care in Canada is evolving and becoming more integrated. Governments and consumers need to be more knowledgeable about disease states and how they are being managed. Patients, in turn, must be more responsible and active in their own health care. The health care market is changing rapidly from a provider-driven one to one driven by the needs and wants of the consumer and of society.
Consequently, due to the present fiscal realities the Ontario health care system faces, we believe that consumers must assume more responsibility, both for maintaining healthy lifestyles and, to some degree, for assuming a portion of the cost associated with their treatment.
1050
However, it is important to emphasize that the proposed copay model of ability to pay should not unduly disadvantage those on social assistance or those seniors on guaranteed annual income supplements. We believe that the government's proposed legislation has the least financial impact on the consumer when compared to other provinces in Canada.
BICL also supports the government's proposal to deregulate prices in the private marketplace for pharmaceuticals. We support this proposal and its intent to create a more competitive environment where government-imposed pricing structures will not constrain purchasers of pharmaceuticals.
Contrary to recent media articles, we contend that the price of pharmaceuticals will not automatically increase in the private sector. We are referring, when we talk about price, to the price which we sell our products at to the wholesaler and retailer. We cannot control what will happen to the pharmacy markup, but we suspect that competition can force the markups to be kept at a low level.
However, for this to occur, the consumer must assume the final responsibility to shop for the best price. To do this in an equitable manner, the consumer must be informed. The only way to ensure that the consumer is informed is to inject transparency into the system whereby the pharmacist must post the dispensing fee, markup and acquisition costs of medications. We strongly recommend that the ministry pursue this initiative.
You are all familiar with the strict federal Patented Medicines Prices Review Board pricing guidelines which regulate prices of new products and restrict price increases of existing innovative pharmaceutical products to the consumer price index. It is important to note that generic products are not subject to these PMPRB guidelines. Despite the fact that PMPRB has allowed these marginal price increases for patented medicines over the last several years, the provincial formularies have disallowed or frozen any increase. In fact, BICL has not implemented a price increase in several years, and we do not anticipate this to change due to Bill 26.
BICL has a one-price policy to all retailers and wholesalers in the province, and we do not envision this policy changing as a result of the deregulation of private sector pricing. At this time, price negotiation between the government and the manufacturers on the reimbursed drug benefit price is not an area where we foresee difficulties. However, we would welcome and require further clarification of the negotiation process.
In closing, BICL recognizes the need for this government to restore the fiscal health of this province and we are supportive of the government's general direction regarding the ODB and PDCRA components of Bill 26 to achieve this objective.
Specifically, we recognize the need for a system of copay and deductible. We encourage the minister to put in place the necessity for pharmacists to post dispensing fees, acquisition costs and markups to allow the consumer to make an informed decision on where to buy their medications. We are supportive of the deregulation of the private sector pricing, especially if pharmacists are required to post all these costs. We believe that the proposed legislative changes are important to the future of the pharmaceutical industry, to research and development, and to the overall economy of this province.
More importantly, however, we believe that this government is attempting to make change at a time when change is most needed in order to guarantee that Ontario's health care system remains viable and responsive to the people of this province. We are pleased to learn that the present time-consuming system of offsets will be eliminated. We commend this action on the part of the government.
Finally, we encourage the elimination of the silo mentality by budgeting for total health care and by the evaluation of total health care outcomes.
On behalf of BICL, we thank you for the opportunity of making a presentation before the committee and would be pleased to answer questions that you may have.
Ms Lankin: I appreciate your participation in the hearings. I think that your presentation follows very much like the other brand-name pharmaceutical industrial representatives who have come forward, and there's a great consistency again in the brand-name pharmaceutical industry. I say that specifically because the generic companies have had a different perception of some aspects of it. In fact, that's almost predictable, in my experience with those parts of the industry. I would have to say on some of the aspects of your presentation, from other health care professionals, whether it be pharmacists or whether it be particular physicians like psychiatrists in dealing with medications for persons with mental illnesses and/or psychiatric disabilities around issues of co-pay, there's been a very different position put forward. So those things are all up there and debatable.
There's also some very contrary evidence that's been provided to the committee on the effect of deregulation and whether prices will go up or down in the general market. I don't think anyone actually knows. I'll be fair on that. I appreciate your opinion, but what we've heard has been very divided.
One thing I wanted to ask you about is the prices of your products, the patent protection drugs, to the ministry under the ODB, because it's going to be subject to a process of negotiation. The minister has indicated he believes that, being just about the largest purchaser out there, he's going to get a better price from you. Yet we've heard from other representatives of the industry that, given the federal regulation and the PMPRB process, you've got a one-price policy; you're not about the change that, and there isn't really much room for the minister to gain there. We've heard from the generic companies on their side of the issue, and that's another thing, but I'd like you to address that because you are federally regulated. Are the taxpayers going to get a saving under this new scheme of negotiations with you for your drugs?
Mr Alan Fukuda: Well, I think we envision that the Ontario government, as you said, will continue to be the largest customer, so there may be savings for them to incur. But going back to what Dr Gilberg said, we always have had a one-price policy. So presently and into the future the government will continue to get the best price and that price is also shared by the private sector.
Mr Clement: Thank you very much for your presentation and I'm very pleased to hear that you feel our changes to the ODB to allow for some accountability and for it to exist in a fiscally responsible manner -- that we're on the right track in that regard. I thank you for your comments on that.
I thank you also for your view that the way we are proposing the copayment will have the least financial impact on our consumers compared to the other provinces and how they attribute copayments to individuals.
I want to come back to Ms Lankin's point, because we have to be fair to her point of view. We have her different evidence with respect to how prices will go for drugs once we deregulate, and the opposition has been quite good at repeating the point of view that the prices will go through the roof; they'll escalate to a great extent. So I want to thank you for bringing to the committee's attention once more that there is a federal body called the Patent Medicine Prices Review Board which does have a cap and has very strict criteria for pricing for patent medicines, which are in effect a monopoly because that's why you have a patent, and that will have a very large impact to either stabilize or reduce prices in the patent medicine field.
We also have the generic aspect of our industry, and I know you're not experts on that, but is it your understanding that there's enough competition between both patent medicines and generics and within the generic field that that will have a stabilizing or reducing effect on drugs?
Mr Fukuda: Yes, I think there is sufficient competition. First of all, you mention that brand-name products, single-source products, are a monopoly. That is true in terms of the chemical; it's a monopoly. But, like in all marketplaces, there is more than one asthmatic drug, there is more than one GI drug, so there is obviously competition among these brand-name products that will inject some price control as well. But overall I think things will not change greatly after Bill 26 in terms of prices going up. I just cannot see prices going up.
Mrs Caplan: Thank you very much for your presentation. It's very similar to some of the other ones that we've heard from the drug companies. I share your goal for optimal therapy and I'm pleased that it was included in the presentation, because we haven't heard that from everyone and that's something I feel very strongly about. What that means is that people get drugs that will help them and that the whole process of using drugs is to have a good result, for anyone who doesn't know what "optimal therapy" means.
I don't see how Bill 26 is going to achieve optimal therapy when you're going to tell people they have to barter -- that's competition -- or shop around. A mother with a child with a 104_ fever isn't interested in getting the best price for the drug; she's interested in getting optimal therapy and getting her child well as quickly as possible. I see you nodding your head.
We've heard from the mental health associations that ex-psychiatric patients and people who are still on drugs for mental health reasons get a very small prescription frequently because there are serious compliance problems -- they don't take their drugs properly. Also for seniors, frequently huge compliance problems. So this bill will exacerbate that by making people choose between food and drugs, especially, we've heard, those on the comfort allowance -- 20% to 25% of their comfort allowance is going to be taken up with drugs -- and people on disability pensions and so forth, with limited incomes.
You tell me how you see Bill 26 achieving optimal therapy.
Dr Gilberg: Let me give you an example with regard to your first comment about the mother with the child with a fever of 104_ shopping around. One of my daughters requires medication on a recurrent basis. I have three pharmacies in the area. I have shopped around in order to ensure that I know what the various pharmacies already charge for that medication, what their up-charge is, and so the next time I have a prescription for another product, on an urgent basis or not, I am going to know which pharmacy is the best one. I think it is critical that the consumer start to look around before the urgent situation occurs.
Mrs Caplan: I think you've raised a really good point. What about people in small communities where they don't have the ability to shop around; there's only one drugstore?
The Chair: Thank you very much, Mrs Caplan.
We appreciate your being here this morning and your interest in our process.
HAMILTON-WENTWORTH DISTRICT HEALTH COUNCIL
The Chair: Our next presenters are from the Hamilton-Wentworth District Health Council, Ms Susan Goodman and Dr Susan Watt. Good morning. Welcome to our committee.
Dr Susan Watt: It's a privilege to be here.
Interruption.
The Chair: We'll have a short recess.
The committee recessed from 1103 to 1110.
The Chair: Welcome to our committee. Questions, should you allow the opportunity for them, will begin with the government at the end of your presentation.
Dr Watt: Thank you for having us here.
Interruption.
The Chair: Obviously the people don't want your voice to be heard. I can't control that, so we'll recess. The committee stands recessed until such time as we can conduct our hearings.
The committee recessed from 1111 to 1114.
The Chair: I'd just like to explain that we do have a couple of options here. We basically are here to listen to the people of Hamilton. We are here until 5 o'clock this evening. We are prepared to listen. Now, we can't listen in this kind of an environment, so if you want us to listen, we would expect that you respect us.
Interruption.
The Chair: If you don't want us to listen, we'll just go home.
Interruption.
The committee recessed from 1115 to 1120.
The Chair: Okay. Let's try it once more and see if we can get on with our proceedings. Unfortunately, we are going to have to cut into the length of all of the presentations a little bit. The floor is yours.
Dr Watt: We come to present to you this morning as the Hamilton-Wentworth District Health Council. Although two previous ministers are around the table, I would like to briefly tell you there are 33 district health councils in Ontario covering now 100% of the Ontario population. This service advises the Minister of Health on coordinated planning from a local perspective and provides a link between the government and the community.
The major activities that the district health councils have been involved with around the province recently have had to do with restructuring. In Hamilton-Wentworth this has been an attempt to look at system-wide restructuring in the delivery of health services. This initiative preceded the present government and, indeed, two previous governments. The health council has taken a serious look at how it can have a plan against which it can make judgements about the advisability of service mixes, proportions of hospital beds to population, the kinds of services that this community needs to get excellent health care, to ensure excellent teaching and to continue the tradition of excellent research in Hamilton-Wentworth.
We are only going to comment on limited sections of Bill 26 that particularly address the issue of planning, since that's the domain of district health councils. However, I do not wish it to be thought that our absence of comments on other sections of the legislation necessarily means that we condone those other pieces of legislation. We are, however, going to comment on those areas that we know best and feel we can provide some sound advice to this committee on.
If we can look first at the proposal of a restructuring commission, we believe that there needs to be a direct connection between such a commission and the local district health councils to ensure that community health needs are addressed through an approach to developing integrated health care delivery systems.
The commission should be there and established to serve local restructuring implementation committees, not the other way around, and implementation should be led and managed locally. The commission may serve a reasonable purpose as a roadblock-buster where problems emerge in getting a well-entrenched system to consider other options that local communities have developed. We believe in locally grown and locally developed solutions to our health care system, recognizing that for some of us that locality stretches far beyond our immediate geographic boundaries, as in Hamilton-Wentworth where we provide tertiary services to a significant section of central-west Ontario.
We believe that the appointments to the commission should include individuals who understand local health planning and that the commission should have the capacity to interface directly with district health councils.
We believe that the ministry needs to provide effective principles for reinvestment in the community of any cost savings achieved through restructuring. We need funding models for effective, flexible and responsive delivery. We need aggressive planning benchmarks for health service restructuring. We need to know that the success of the restructuring is going to be measured by health outcomes, not just by dollar outcomes.
It is our opinion that, in some instances, the appointment of personnel to make the implementation of health services restructuring happen may be necessary. We are concerned that this not be a sweeping power but targeted specifically for the purposes of unsticking the system and getting new systems in place when the minister has decided that this is the direction in which it should go. Our job is to advise the minister. However, we believe in voluntary governance. We believe that it provides the mechanism for critical community input into decisions which affect local health care. This local voluntary governance needs to be respected in the decision-making process in health care restructuring.
We are concerned, from a planning perspective, about the amendments in the Independent Health Facilities Act. We believe that licensing, funding and quality assurance must be within a context for developing an integrated health delivery system which is based on community needs. It needs to be more than simply a demonstration of utilization, so that independent health facilities fit within this broader health planning context.
We believe that provincial standards on numbers and types should be established within the context of ensuring universal access to high-quality care. We are concerned that independent health facilities may begin to drive the system rather than responding to a need in the system, particularly if for example hospital corporations were to pick up the operation of independent health facilities, or if there were services that we have come to expect reasonably to be provided within our communities in the public sector that get carved off into independent health facilities. So we are very concerned about whether or not this will lead to independent health facilities driving the health care system in this community rather than being some kind of adjunct to that system.
Following after the presentation from a pharmaceutical company, I dare to be quite conservative in my recommendation to this committee about pharmaceuticals. What I am very concerned about as a planner is that deregulation will add costs to care both in hospitals and in the community and that what we're doing is not a cost reduction but rather a cost transfer. It may cost the minister less money but it won't cost the public less money, particularly if more and more care is going into the community and those transfers of costs are already notable in our community. Certainly, in last week's consultation with the community, and I spent nine hours a day, four days last week talking to people and listening to people in the community, their concerns were about these kinds of transfers of costs which don't represent a real cost reduction at all, but simply a question of who the paymaster will be.
We share the much expressed concern about the potential for breach of patient privacy in terms of health records. We wish to make it quite clear that from a planning perspective there is no need to have access to clinical records individually, but rather to the aggregate data on utilization and need.
We believe that the processes in amendments to the Health Insurance Act and the Health Care Accessibility Act have the potential to undermine professional judgement of clinicians without appeal mechanisms. In our community that would not be an acceptable move.
We also believe that these amendments will again promote the transfer of costs to patients as uninsured services. We are very concerned about that because, although we might like to think of health care as a market, all the evidence is that it doesn't operate as a free market. This is a place in which one must, as a patient, accede to some of the expertise for which we pay quite dearly.
Finally, we are concerned about the amendments to the Pay Equity Act. We are concerned about the elimination of pay equity to low-paid workers who provide care to our most vulnerable persons, and we certainly know, in our analysis of personnel in our system, these would be the people who are providing hands-on care to our elderly, to our chronically psychiatrically disabled and to people living in protected settings in the community. We are very concerned that is the group that is going to be hit by the proposed amendments to the Pay Equity Act.
These are already, at best, precarious situations in our community. We know about them. We have advised this and previous governments of our concerns about this part of the system. To remove the pay equity would further jeopardize these groups that we are being told about by our community on a regular basis.
In summary, generally we support government's role in facilitating the implementation of health care restructuring based on comprehensive community plans. As a health council, we are both willing and able to provide input and support to help maximize the value of the Health Services Restructuring Commission. We believe that there must be a critical link between local planning and implementation that must be maintained with the commission and indeed with the ministry.
We would be pleased to answer questions and have provided you with a full submission.
1130
Mrs Ecker: Thank you for coming and putting forward a very detailed brief with some very comprehensive and excellent suggestions. I'm sorry we have been a little delayed today in terms of getting to you, but I was very pleased to hear what you've put forward.
I think one of the points that you make very clearly is about the value of the district health council, the value of the local planning process. I've been a volunteer in a restructuring exercise put on by my local DHC and was extremely impressed by how well it was done. I think we are moving ahead with some very good suggestions in that area which will improve the health care in that particular region.
I guess the minister, as I understand it, has been very clear that that link must be maintained. If we were to make that more explicit in some fashion, that there is clearly an intent and that clearly the objective is to continue to work on implementing what the district health council process which was under way when we came in last year continue, would that assist in the district health councils and give some comfort to the fact that the work you are doing should be continuing?
Dr Watt: It would be a necessary but insufficient move to satisfy us at this point. We need to know about mechanisms. One of the problems of restructuring in periods of tremendous change is that you are not quite sure what you are restructuring towards or what support you are going to get at the end of the road. We are talking about thousands of hours of community time in restructuring by professionals and citizens alike --
Mrs Ecker: That's right.
Dr Watt: -- and that in the effort to give the minister good advice. We fully recognize that the minister may or may not take that advice, but we certainly would like to know that if the advice is taken we have something to do with how it is implemented. The planning is only half of it. How you get it together and how you get your community to work together will be the success or failure of whether those recommendations work in the end.
Mrs Ecker: Because the minister, and again I can speak with some experience in my local region, has asked the district health council to continue with the overseeing of the implementation process because, again, he wants that work to be done so the ministry can make appropriate restructuring.
I think the other point that I would like to make is that one of the messages we've heard loud and clear from people is the need to reinvest savings, the need to reinvest in front-line services or in community services as we move money out of the hospital structure. I think that we have also heard from areas that feel they need more reinvestment for various reasons: The north has unique needs; growth regions have unique needs, so some people in effect are asking for more money than we might be able to give to other people. I guess what the minister has made clear is that there will be reinvestment in local communities; there will be reinvestment in programs. Of course the challenge will be, "How much?" If some people are going to get less rather than more, and depending on the recommendations that come forward, that is going to be difficult.
Mrs Sandra Pupatello (Windsor-Sandwich): Today is the first day a member of the government's side has indicated that there may be an amendment concerning the DHCs. I am pleased to hear that today.
As you mentioned, it doesn't go far enough. The story that we've heard to date over the last couple of weeks has simply been: "We're not changing anything to do with the district health councils. They're okay. We're not touching that." Well, the reality is that when you touch every other aspect of these acts, the role they had absolutely changes because now, with such dictatorial powers placed with the minister, the function of the DHCs change automatically. Your point is well taken. However, we are still looking forward, Mrs Ecker, to what you will introduce as an amendment that relates to the DHC, now that you are on record as indicating that.
Mrs Ecker: I didn't say we were going to do that.
Mrs Pupatello: I'd also like to mention the point about reinvesting of savings, which has been critical to every DHC in Ontario. Again, we are hearing the general comment that gives some kind of comfort to communities that the money saved in their communities is coming back to them. This again is a misrepresentation by committee members in every town this hearing has been moved to, and they must be on record for this. It is a complete misrepresentation.
The minister in fact is on record in the House as denying that savings found within communities will go back to their communities. Instead, he said it will go back into the provincial pot. "Maybe, maybe, maybe something might come around somewhere else in Ontario." That is the minister's line. For committee members to suggest anything else is absolutely inappropriate. That is a fact, we have that on record and we've been very explicit with the minister.
Where I come from as well we've done massive restructuring. If what happened in Windsor would happen in Toronto you'd shut down 22 hospitals, and that's what's happened in Windsor. We've lost literally 50%. So we have a natural concern about this.
Have you addressed that in your restructuring processes so far: the reinvestment into local communities and the move into local community services outside hospitals?
Dr Watt: The restructuring process that we're involved with is not just for hospitals; it is for the whole community. Our council convinced the ministry that it was really important not to carve off and just look at hospitals but to look at the whole system. So we're keenly aware of that and we certainly will be looking at total packages when we bring our recommendations to the minister.
Mr Christopherson: I'd like to comment on the public demonstration we just witnessed before I comment on the presentation. Regardless of how people feel about that kind of disruption, in terms of the process of legislative work, the fact is the government shouldn't be surprised when people react that way. When you take a bill like Bill 26 and try to take so much power in one fell swoop and exclude literally thousands of individuals and groups, you're going to get that kind of reaction. This is still a democracy, whether you want to accept it or not, and you're going to continue to see that kind of reaction over Bill 26 long after you've passed it and rammed it through the House. So get ready. There's a lot more to come.
With regard to the presentation, I sat on a DHC some years ago, in another life, and recall what it was like trying to function in those changing times, and things were really just beginning to show the early signs of change. I also want to focus on the dollars being reinvested and to ask whether you have any comfort at all that the work you're doing now and the work that's been done in the past, and Hamilton is quite a bit ahead of a lot of other communities in terms of comprehensive health care -- what is your comfort level with regard to your ability to keep those savings in this community at this point?
Dr Watt: I would have no comfort level at the moment. The fact is that the district health council will make a report to the minister, and one would hope that the minister will attend to that report, but that's the level of comfort I have about that.
Mr Christopherson: That speaks volumes, and I expected that answer. The reason I asked it is that there's an inherent contradiction in the result of what's happening in this community and other communities in health care and what the government talks about in terms of devolving responsibility. The whole part of Bill 26 is supposed to be to empower communities to take control over their own destiny. The reality is that in one of the most critical areas of concern, health care, you're leaving the impression that you're taking away -- and I say this to government members -- the right of local communities to determine for themselves, and if they are successful, you look as if you're ready to pounce and scoop all that money out of this community and every other community that tries to come to grips with escalating costs and more and more pressure on health care.
I would only say to the DHC and everyone else in health care in this community that at the end of the day this government intends to do whatever it is it intends to do. As I said to the other groups, if you don't see it in writing, then you ought to expect that you've lost your argument.
The Chair: Thank you, ladies. We appreciate your attendance here today and your interest in our process.
1140
Mr Agostino: Mr Chairman, before the next group, can I put into the record -- I'll be doing this all day, so it'll be no surprise to the committee -- present to the committee a brief presented at the shadow hearings by the Canadian Union of Public Employees, Local 768 of St Joseph's Hospital, and the Canadian Union of Public Employees, Hamilton-Wentworth health care workers joint action committee, both presented at the shadow hearings. I'd like to submit this to the committee for their consideration.
ASSOCIATION OF ONTARIO PHYSICIANS AND DENTISTS IN PUBLIC SERVICE
The Chair: The next presenters are the Association of Ontario Physicians and Dentists in Public Service. Welcome to our committee. Unfortunately, our times are being cut back a little because of some problems we've had today. We're down to 20 minutes, so if you could shorten your presentation a little to allow some time for questions, they would begin with the Liberals.
Dr John Deadman: I am John Deadman. I am a psychiatrist at Hamilton Psychiatric Hospital. I am also representing the Association of Physicians and Dentists in Public Service, which is a professional group that represents all the doctors who work in the 10 provincial psychiatric hospitals, plus other physicians who work in departments of government throughout the provincial civil service.
In view of the time, I won't read the brief, which has just been passed around. I'll make a few brief points and then leave some time for questions. Before I do that, let me introduce my colleagues to the committee. With me are Debra Eklove, the executive director of the association that represents the physicians in psych hospitals; Dr Murray Kronis, a dentist at the Mental Health Centre, Penetanguishene; and Dr Ed Rotstein, a psychiatrist at Hamilton Psychiatric Hospital.
As I mentioned, I don't intend to read the brief. Most of the points in there have been made by other groups, and in most cases, several times, so you should be familiar with most of the stuff in there. I've got four points that I'll go through very quickly and then we can respond to any questions.
The first is the question of confidentiality. The positions taken by a number of other groups we can subscribe to very well. Our big concern is the special concern about people who have psychiatric problems; they are particularly sensitive to confidentiality problems. Even though I heard through the news media recently that there is a plan to put a sunset clause on that -- and I don't understand exactly what that means -- I really don't think that's quite sufficient. Even having that, what I will call the bill's provision for people to get information without going through the usual route is unacceptable.
The second point I would like to make is that we have some problems with the $2 dispensing fee for our patients. I should point out that the medications we use with these patients are not that pleasant to take. Our folks definitely do not like taking these drugs, and even the very small disincentive of $2 for people on a welfare level of income is a barrier and I think will lead to non-compliance on the part of our patients, which means rehospitalization in many cases. This is one of the unintended adverse consequences of what seems like a good move to control costs. I think it'll have exactly the opposite effect, and that's true for a lot of the ways of controlling costs that have been proposed in the bill.
Another point I would like to make is that there are provisions in the bill which allow a minister to exercise certain powers, which he does not have now, to require where physicians may practise. For example, the clear intention is to encourage people, require them perhaps, in order to have hospital privileges, to require them to work in underserviced areas and, particularly in the case of psychiatry, to require them to work with the severely mentally ill.
I should point out that for our group at least, we're already doing that. That's where we are. This is not something that affects us in that sense. If we have any problem with these provisions, it is not that we say they shouldn't happen, but the way in which it is being done.
We really think we need some process whereby we can get people into these areas, because at times we feel really quite beleaguered in trying to deal with these huge problems for the severely mentally ill or trying to get people to provide service in more remote parts of the province, and we've just not been able to deal with this effectively. We're saying that we don't think putting billing number restrictions, requiring people to work in hospitals in order to have a billing number, is going to work. We may be in favour of the principle, but we don't think the way that the bill goes at it is likely to work.
We would encourage the government to look at that one again. In particular, we'd like you to look at incentives that really might work, and we'd like them to look also at the question of whether the training of psychiatrists is adequate to do the job psychiatry is expected to do in a modern environment. That's really where you ought to be looking.
I'll stop and leave a few minutes for questions.
Mr Agostino: I've had a chance to review the brief. You've made some excellent points, particularly as it affects the individuals you deal with, that is, the mentally ill in this community and across this province.
You talk about the sunset clauses that may or may not come for certain parts of the bill. The simplest way of explaining that is that suspension of democracy, Tory-style, will only be for the time they choose to suspend democracy, whether it's in hospital closings or any other provision. The sunset clause is something they have thrown out a number of times for provisions in parts of this bill, but it very clearly says that the dictatorial powers they have will be given to them for the period they choose to be dictators. After that time, hopefully we'll go back to a democratic system of doing things in this province.
On the issue of how it affects the mentally ill, you talk about user fees as they affect an individual. Last night, you were on a cable program with Elinor Caplan and a representative of one of the hospital unions, and a young woman called who is on medication for a mental illness that she's experienced for a number of years. She's very concerned about the fact that she's going to have to make some choices. Because of the nature of the medication, she cannot do it once a month or every two months; it has to happen more often. She really is at a point where she's going to have to make some choices whether she can afford to continue taking the medication. To many people it might not seem like a lot of money, but for this individual on a very fixed and very limited income, it's going to come down to a choice between choosing whether she can afford to eat or whether she can afford to pay for her medication.
We're concerned that we're going to see much more of that, along with the various types of cuts in services for the mentally ill. What do you believe will be the result of these user fees that are now in place, and how can that impact not only the people who are in institutions, but many people who aren't in institutions now but who are in homes and may end up on the street as a result of some of these changes?
Dr Deadman: The big thing we're concerned about is that some of the folks who have been on these medications aren't even going to think it through to the point the person you referred to did. They're simply going to say, "Who needs this stuff?" The consequence of that for a large number will be that they may well have a relapse and be back in hospital. That's going to cost the system a heck of a lot more than a reduced number of prescriptions or whatever this $2 fee may be intended to produce.
1150
Mr Agostino: In regard to the issue of confidentiality, particularly in this area, because often an unfair stigma is attached to mental illness and the effects and so on, how would your facilities or you as doctors deal with the possibility of government having access to your patients' files, to having an agent of the minister have access to a file of any doctor if they feel there's cause?
Dr Deadman: In the present laws there are quite a few provisions whereby people can get access to files. We think they're more than sufficient in the present legislation without concern for Bill 26.
Mr Christopherson: Again it's an area I've had some experience in when I was on city council. I want to pick up on the confidentiality issue Dominic just touched on and then move into some other areas. It's worth stating again that this is not the first time this government has encroached into areas of privacy and that other people have raised the alarm. In fact, in Bill 7 -- where there were no public hearings, I would remind everyone, and that whole bill was rammed through the House with no public input -- the privacy commissioner actually issued a letter to all legislators saying, "I've got some real concerns in Bill 7, the labour relations law, with regard to information that is now going to be denied people" -- information working the other way.
For a government that ran on a platform of being transparent and accountable, it shows the inherent contradiction between what they say and what they do. And now buried in Bill 26 is another one of these ticking time bombs, and because of the lack of time there's just not enough focus. But you could spend a number of weeks examining that part alone in terms of what the thoughts are this government with regard to privacy of information, access to information, the transparency of government -- all of which, I say again, is in contradiction to what they said they would do when they were on the campaign trail.
When you talk about the impact of the changes to Ontario drug benefit plan on the psychiatrically disabled, it speaks to the fact that this government is forcing the most vulnerable in our society to carry the biggest burden. We know that the 22% cut in social assistance rates is going to affect the psychiatric hospitals and the whole area of psychiatric services. Phyl Turner -- if she's not still here, she was here earlier -- can talk at great length about this.
I want to ask you if you see any hope at all on the horizon. I give the government this one opportunity. Is there anything at all the government is doing so far that gives you some kind of hope that the most vulnerable in our society are actually going to somehow be better off as a result of the actions this government's taken to date?
Dr Deadman: The problem is, I don't know how this stuff is going to work out -- I don't think anybody does -- and that makes it a very difficult question to answer. My feeling is that we certainly do need changes in the system, but it isn't as if this just came up this year. We've known about this for 30 years and we've been working on it for 30 years. I simply don't know how to answer your question because I can't predict how this is all going to work out. My big concern is that it's kind of loosey-goosey: "the minister may, at his discretion," "the public interest." I see all these phrases in here, but I simply don't know how to interpret them.
Mr Christopherson: That's fair. Given the track record so far, I don't have any comfort, as a representative of the Hamilton area, that the actions the government's taking are going to help people. In fact, I think they're going to hurt a whole lot of people.
Someone else, the pharmacists' association, talked about the whole idea of meds, that not taking the meds for the psychiatrically disabled is either going to put them back in the psychiatric hospital or, given the fact that there's not going to be much of a psychiatric hospital system, probably on the street as street people, or back in jail, which is the last place in the world someone who has a medical problem as opposed to a criminal problem should be. All of this is just going to exacerbate that whole cycle we know. Any thoughts on that?
Dr Deadman: Very much. I was talking to some people who work at the Hamilton-Wentworth Detention Centre and their joking comment about the fact that some of our patients had wound up in that facility was, "Oh, yes, some days we just call this place Hamilton Psychiatric Hospital, north unit."
Mr Toni Skarica (Wentworth North): I would like to comment on what Mr Christopherson said earlier about the demonstration that took place. Basically, he indicated that because of Bill 26 and the way the government is proceeding, somehow we deserve this kind of demonstration and we are to expect it in the future. I'd like to make a couple of things clear: One is that this government has always been willing to grant public hearings; the only dispute was when and how. Secondly --
Mrs Pupatello: Toni, that's not true.
Mr Skarica: Let me finish. No one has a right to interfere with these proceedings. We talked about democracy. This is not democracy.
Mr Christopherson: How would you know?
Mr Skarica: Mr Christopherson asked how I would know. I personally like Mr Christopherson, but I hated his government. You want to talk about democracy? Nobody in this party had heard of me a year ago. I didn't like what was happening, and I used the democratic process in a legitimate way and ran in the election and won. I represent the people as much and more than anybody here.
Second, what they did is technically a criminal offence. I refer you to section 175 of the Criminal Code. I'm not going to read it, but what they did is a criminal offence. All of history has shown that the end never justifies the means. When you're prepared to break laws to achieve your end, you're a society in deep trouble.
Mrs McLeod: Mr Chair, who is he charging?
Mr Skarica: I'm talking about those people that interfered with these proceedings.
Third, it's completely inconsiderate to the people who have done a lot of work and wanted to have their presentations and have now been cut short. Gentlemen, I ask you, how much work, how many hours, did you put into your presentation?
Ms Lankin: That's not fair. Let's focus on Bill 26.
Mr Skarica: No. How many hours did you put into your presentations? I'm asking the questions.
Dr Deadman: We had several people working on it. I personally put in several hours myself, and I have thought about this considerably over several months now. I wouldn't know how many hours I've put in on it if you include that sort of thing.
Mr Skarica: Many, many hours, correct?
Dr Deadman: Correct.
Mr Skarica: That demonstration has caused your presentation to be cut short, correct?
Dr Deadman: I bow to the ruling of the Chair. Yes, it is a little shorter than we had intended.
Mr Skarica: Those are my questions.
The Chair: Thank you very much, doctors. We appreciate your presence and your interest in our process.
Mrs McLeod: Mr Chair, if there is a government member who is concerned that there is not adequate time for public presentations to this committee, we would welcome a motion from the government side to extend the hearings not only today but beyond today. We have been waiting for this for weeks.
Interjections.
The Chair: We have one more group to hear from. We can either hear from them quietly, or we can go to lunch. I presume we'd like to hear from them.
Mr Agostino: Mr Chair, can I again take the opportunity to introduce a number of other briefs into the record from the shadow hearings downstairs: a brief submitted by the Hamilton-Wentworth Coalition for Social Justice, a brief submitted by the Crown Point Assembly and a brief presented by the Mental Health Rights Coalition of the Region of Hamilton-Wentworth. I would ask that those be included and circulated to the committee from the shadow hearings downstairs.
1200
Mrs McLeod: Mr Chairman, I understand that a motion to extend the hearings was placed earlier today and was defeated by a vote of the committee. However, I would ask for your ruling, given the interest of a member of the Conservatives to extend the hearings and that he's expressed concern about the shortening of the hearings. It would be my understanding that a member who voted against that motion could move a motion of reconsideration, so the vote could be placed again today to extend the hearings beyond today.
Mr Clement: He did not vote against the motion.
Mrs McLeod: Mr Chairman, I'm asking for your ruling, although I always love to get Mr Clement's personal opinions of what's happening around this table. I ask, Mr Chairman, given an apparent concern on the part of the government members that these hearings are being shortened, whether we could have some indication for reconsideration by the government itself.
The Chair: The member who made the comments did not vote this morning. The member's comments were directed to the fact that the presentations today had to be shortened because of our time frame. I don't think it had anything to do with extending the hearings.
Mrs McLeod: Just for clarity, it would be my understanding that all the government members who voted against the motion this morning and constitute a majority continue to believe that these hearings should end today and would not reconsider that motion?
The Chair: I would assume that was indicated by their vote this morning.
HALTON REGION COALITION FOR SOCIAL JUSTICE
The Chair: The next group is the Halton Region Coalition for Social Justice, represented by Terry Kelly, David Michor, Miriam Lockhart and Robert Heaton.
Mr Terry Kelly: Thank you. I'm representing the Halton Region Coalition for Social Justice. I'm also a spokesman for the Halton Health Coalition, which was formed in conjunction with our social justice coalition.
I want to introduce the three other panelists: the town of Halton Hills councillor, alderman for ward 2, Robert Heaton, who's a former Georgetown hospital board member and a former Halton Hills volunteer ambulance service member. Miriam Lockhart is the president of CUPE Local 778, St Peter's Hospital. That's the hospital where last night 330 workers were given their layoff notice. David Michor is the chairperson of the Hamilton-Wentworth Health Care Workers Joint Action Committee.
After the failed attempt at sneaking Bill 26 in without any public input, let alone any collective debate, it has become obvious why this undemocratic procedure was undertaken. Bill 26 is an odious and repugnant piece of legislation that has as its objective the obliteration of public services in this province.
Throughout this century the producers of wealth, the working men and women of Ontario, have struggled long and hard to build a social infrastructure that would service the needs of all the people in this province. This is the real commonsense revolution and not the pathetic machinations of the present government.
The direction this government is going in with this ominous Bill 26 is clear: streamlining the decision-making process to the exclusion of public participation and accountability, disguising tax increases as user fees, or whatever terminology is in vogue at the present. Those who can afford the services will receive them and those who cannot will once again be deceived by the Tory government that routinely says one thing and does another. One thing is certain: Using a metaphor from two decades ago, the present-day corporate bums will continue to not pay their fair share while the rest of us will be burdened with ever-increasing taxes and service fee payments.
Schedule A of this nefarious piece of legislation, the Public Sector Salary Disclosure Act, 1995, is another example of government waste. All public sector employees who earn $100,000 a year salary and benefits for non-profit enterprises, which receive either $1 million or 10% of their gross revenue from provincial funds -- they will be put on some kind of public wanted poster. This is as long as it is for a non-profit entity, one exception being employees who work at for-profit enterprises, such as many nursing homes. That's cool and that's the Tory way. For they are like the $600,000-plus salaried private sector CEOs who will definitely not be exposed to public scrutiny.
Schedule F amends four acts directly related to health care: the Ministry of Health Act, the Public Hospitals Act, the Private Hospitals Act and the Independent Health Facilities Act. Schedule F is an outright assault on the Canada Health Act: (1) It gives arbitrary authority to close public hospitals, (2) it arbitrarily allows private corporations to open licensed, profit-from-pain facilities in this province, and (3) it tolerates an array of user fees, extra billing procedures and installs a two-tier health care system.
In amending the Ministry of Health Act, Bill 26 establishes the Hospital Services Restructuring Commission, whose mandate is to implement the government's agenda on hospital restructuring. There are no restrictions on the duties of this commission. The Health minister can delegate authority to the commission, which will then have the power to restructure in whatever fashion fits the minister's fancy. Judging from the actions of this government, closing a hospital or eliminating services will be based on fiscal consideration and not on the medical and health care requirements of the community.
The Hospital Services Restructuring Commission will be the hatchet the Tory government uses to chop to pieces our publicly owned health care system. These barbaric actions will be protected from any liability or damages as long as they act in good faith. With the present provincial regime's slash-and-burn record, the people of Ontario would be better off placing their faith in the devil.
This invidious Bill 26 repeals section 8 of the Ministry of Health Act. This section establishes district health councils and details their functions. The section also gives direction to the councils in regard to the first nations communities. The new section 8 makes no reference to district health councils. This leaves the restructuring commission free to cut at the dictates of the autocratic Minister of Health.
In amending the Public Hospitals Act, Bill 26 gives the Minister of Health practically dictatorial authority over every aspect of funding, operation, closure and amalgamation of our public hospitals. The bill primarily transforms democratic structures and direction of the community hospital boards. The minister has the power to overrule all hospital board decisions without any consultation. Decisions to close or amalgamate hospitals will not be made with consideration to the quality of care but will be based on financial and budgetary concerns.
The amendments to the Public Hospitals Act can regulate hospital supervisors to implement the Health minister's orders to take control of the local hospital board of directors. This ominous Bill 26 protects the entire clique -- the minister, investigator, the hospital supervisors and the boards of directors -- from any liability as a result of hospital restructuring. Beyond the pale, it is outrageous that this elected élite has not thought of protecting the men, women and children of this province who will suffer as a result of the restructuring. This is a ripoff.
Sections 5 and 6 of the Public Hospitals Act gives power to the minister to fund public hospitals as defined by the regulations. These have been repealed and the new sections give the minister the freedom to decide when, how much and under what conditions the ministry will give grants, loans and/or financial assistance. The minister will have the capacity to require repayment and to reduce or terminate grants and loans. The minister will have the authority under the new section 6 to close hospitals, order hospitals amalgamated and define the services to be delivered by a hospital. The effect of these sections will be to allow the minister to amass far greater control and to be able to decide all funding matters of the hospital with no consideration to the fundamental needs of the employees, patients and the community.
The only consideration the minister has to take into account is if the action is in the public interest. In defining "public interest," section 9.1, the minister and his cabinet are not limited to but can consider matters they regard as relevant. One has to ask, why are they not limited to the quality of management and the administration of our hospitals, the quality of care and treatment of patients in the hospitals and the proper management of health care in general? The minister and the cabinet should be held accountable specifically to these principles of health care in their consultation and determination. The availability of resources, the focus of this government, claiming the lack of being the major reason for a reduction in services: They need to get their priorities straight. Make those with the wealth pay their fair share. It's not a new idea, but if implemented, it would certainly be a new and unique experience for that class.
1210
The lack of accountability is rife in this bill. The bill gives the minister the ability to make regulations concerning hospital subsidies, hospital foundations and the disposal and/or purchase of hospital assets. Millions of dollars are involved in these funds and assets, and when the hospitals close or merge, no accountability, no liability. Only in Tory Ontario, it seems.
In schedule F, the Private Hospitals Act is amended to give the Health minister the authority to rescind a private hospital's licence at any time and reduce or withdraw any grant, loan or other financial assistance without notice. The bill repeals the right to a hearing and appeal. The minister is protected from any liability.
The objectionable Bill 26 will no longer give preference to non-profit Canadian health care providers or to solicit proposals for new facilities from the general public. The minister can now request proposals be limited to only one or to more than one specific person. This leaves the door open for the profit-from-pain US health care corporations.
The combination of the Tory health care cuts of more than $1.3 billion over the next three years and the minister's power to allow these primarily foreign-owned corporate giants to set up for-profit clinics will leave our children's, the sick's and seniors' health and wellbeing at the mercy of the corporate balance sheet. This certainly will be the treacherous Tory regime's legacy.
The scurrilous Bill 26 gives the minister the authority to collect and disclose confidential medical information for the purpose of the administration of the Independent Health Facilities Act, the Health Insurance Act and the Health Care Accessibility Act. This is more in tune to Pinochet's Chile than the present day Ontario.
The obnoxious Bill 26 proposes to change the Independent Health Facilities Act to do away with our universal, accessible, non-profit, publicly administered health care system. The bill redefines terms such as "facility fees" and "independent health facility" to allow a charge or fee for any service designated by the minister. That includes any facility the minister defines through regulations. Independent health facilities will be able to serve a large proportion of health care facilities and will be allowed to charge fees to insured persons. We have extra-billing. A flash in the recent past: No to extra-billing. I'm talking about the Tories' election promises. No to extra-billing. No to user fees. No to cuts to the health care system. That's a lie, lie and more lies.
The government has put economic considerations ahead of the confidentiality of people's medical records. As noted in today's Star, some of the medical records, by the way, of people in Ontario are right now in Boston. When people's medical information has been disclosed, they are left with no redress.
Bill 26 amends the Drug Benefit Act and includes copayments and user fees as well as deductibility of $100 per year. The minister can determine what drugs are listed or not and overrule the decision of the doctors or pharmacists as to what is appropriate medication for the patient. The patient can be required to pay the difference between the approved and prescribed drug. The user fees for prescription drugs will not reduce the need for medication. In the long term it will increase the need for more serious medical intervention.
User fees are being promoted as a form of cost cutting but are just another new revenue grab, taking away from the people who can least afford it, the irony being that those who feel the pain are single mothers on social assistance, disabled and seniors, while those who gain are the large pharmaceutical corporations free to continue to reap massive profits.
Bill 26 removes reference to "medically necessary" services, opening the door to delisting of services. The cabinet will also be free to determine what medical services are insured or not. They will have the power to determine what services are medically or therapeutically necessary without any public debate. This is just another way of introducing a two-tiered health care system. The large transnational insurance corporations are gleeful in their expectation of massive profits.
Bill 26, in amending the Health Care Accessibility Act, will open the door to hospitals charging user fees on everything from accommodation, meals, nursing services, labs and drug tests and drugs, to use of operating rooms and use of emergency room facilities. The bill allows for administration fees of up to $150 per patient. The question has to be asked: When in need of medical services, what happens to the masses of people in this province who cannot afford these vile user fees?
Bill 26 amends the Pay Equity Act. It repeals the proxy provisions affecting the right of fair pay to an estimated 100,000 women working in low-paid jobs in nursing homes and day care facilities. This is another example of the intent of the Tory government to rip off the poor to the benefit of the wealthy private corporations.
Bill 26 amends the Freedom of Information and Protection of Privacy Act and will make it difficult for people to gain access to documents. It will also limit the access of what information is available. This bill also introduces user fees under the guise of application and appeal fees.
The next schedule is to do -- I'm not going to mention it all. It's the teachers' collective negotiations act being amended, the fire act, the labour disputes etc, the Public Service Act. The bill amends these various pieces of legislation, essentially introducing compulsory arbitration and effectively removing the right to strike. Bill 26 requires arbitrators to make decisions based on the employer's ability to pay, taking into account their fiscal situation. This creates an environment where there is no incentive for the employer to negotiate in good faith. It handcuffs the arbitrator into becoming an arbitrary decision-making process that can only produce wage freezes and reductions, loss of benefits and working conditions for public service workers. This will also lead to a loss of services and revenues to the community at large.
The omnibus Bill 26 in its sheer size and the breadth of its intent has to be compared with the free trade act. As that piece of odious legislation, the free trade pact, has devastated the country in terms of job losses and sovereignty, so will the omnibus bill. Nor is it a coincidence that both pieces of legislation were and are promoted by tyrannical Tory regimes.
Bill 26 will change dramatically the intent of dozens of pieces of legislation from their present intent. It is not possible for the public to fully participate with the bill in its present form and in the short time allocated for public hearings.
This omnibus bill is not needed to achieve fiscal savings or to promote economic prosperity. What is needed is the implementation of a program of full employment and strengthening of public non-profit social services, health care, and massive increases, not cuts, to our education system.
The Chair: Thank you very much. That uses up all your time. We appreciate your interest and your presence here today and your presentation.
We are now recessed until 1 o'clock.
Ms Lankin: Could I place a question on the record before we recess? This is to the ministry and it's with respect to amendments that were tabled this morning.
I would like a fairly quick turnaround on this, if it's at all possible, because I believe I have found the amendment of all amendments which means that the government will never have to return to the Legislature of Ontario to do anything it ever wants in the future in the health care system.
In the Health Care Accessibility Act, which I think will be confirmed is a very small act which was essentially some revisions that government at one point in history wanted to make without opening up other pieces of legislation, I have found an amendment which gives the Lieutenant Governor in Council regulation powers, I quote, "prescribing anything that must or may be prescribed under the act," which means that the Lieutenant Governor -- ie, cabinet; ie, the minister -- can make a regulation now to set out areas under which it can make regulations. This is incredible, unheard of.
Under the Health Care Accessibility Act, I would like the ministry to answer to me: Does the minister ever have to go back to the Legislature of Ontario to prescribe an area or a regulation under an area, any area they want, or can it all be done behind closed doors in the cabinet room with the stroke of a pen?
I believe that we've just seen the end of democracy in the health care system in Ontario.
The Chair: Thank you, Ms Lankin. We stand --
Mrs Caplan: Before you adjourn, may I comment --
The Chair: On that question?
Mrs Caplan: Yes.
The Chair: No. We're going to recess until 1 o'clock.
The committee recessed from 1221 to 1311.
The Chair: Could we just talk a little bit about the situation here, folks? First of all, is the gentleman from CUPE in the audience, the gentleman who was at the table just before lunch? The committee has asked me to allow him, some time this afternoon, to make a 10-minute presentation if he chooses to. I don't know where he is, but we'd accommodate him at any time.
The other thing, obviously it's difficult to continue with the signs up. I'd like to invite you to put the signs down, sit in the audience and listen to the presentations. We're here to listen to the people of Hamilton. We have some more to listen to and we'd like to do that. It's not a very nice environment to try to do it in with the signs. I'd like to invite you to put the signs down, have a seat and participate in the process with us.
So whenever he comes in, we'll squeeze him in between. I'd like to get started now and get him after the next one. Is that fair?
Mr Terry Kelly: Are you going to allow the other participants who are with us?
The Chair: The gentleman from CUPE who asked for 10 minutes, we'll put him in between a couple of presentations.
Mr Kelly: There were four of us here. There are three other people. They can share that time.
The Chair: They can share the 10 minutes. Do we have a deal here, folks?
Interruption.
The Chair: Okay, thank you.
MEDICAL REFORM GROUP OF ONTARIO
The Chair: The first presenter this afternoon is the Medical Reform Group of Ontario, represented by Gordon Guyatt, Murray Enkin and Ian Scott. Welcome to our committee, gentlemen. You have a half-hour of our time to use as you see fit. Questions, should you allow the opportunity for them, would begin with the New Democrats. The floor is yours.
Dr Gordon Guyatt: We appreciate the opportunity to present here. We're going to talk about four aspects of the bill: the changes proposed to the Independent Health Facilities Act, Ontario Drug Benefit Act, Prescription Drug Cost Regulation Act and the Health Insurance Act.
For those who don't know about us, briefly, the Medical Reform Group of Ontario is a group of approximately 200 physicians and medical students who have been formed around three founding principles. One is that health care is a right and that universal access to health care should not be impeded by financial barriers. Secondly, we believe that health and ill health and the determinants of ill health are not only medical but social, political and economic in nature. Finally, we think that as currently structured, the health care system is excessively hierarchical. It is as a consequence of those principles that our criticisms of the act come from.
To start with the changes proposed to the Independent Health Facilities Act, the act currently regulates facilities that provide medical care such as cataract operations, freestanding abortion clinics, endoscopy and day surgical procedures as well as some diagnostic procedures. The three important changes to the act that we see include the definition of independent health facilities broadened to whatever the minister defines; second, the less restriction on what facility fees the minister can designate be charged by independent health facilities; and third, the removal of the current recommendation that the minister gives preference to Canadian-owned, not-for-profit independent health facilities.
Clearly any charges, any facility fees are potentially an impediment to access to health care and violate the principle of universal access. We are also extremely concerned that the changes in the legislation will result in the ability of the minister to request or facilitate or to permit American health care corporations to move in and run independent health facilities.
We have seen for quite some time now the dramatic differences and consequences of the differences between Canadian and American approaches to health care delivery. In the United States we see massive barriers to access on the ability to pay and we see the suffering that results from lack of access to health care.
In the last five years there have been dramatic changes to American health care with the advent of managed care and the move for large, for-profit corporations into the administration of health care in the United States. The results of that have been twofold. From the point of view of physicians, physicians have lost an enormous amount of autonomy and there is extensive regulation of physician activities by the for-profit owners and health care managers of the managed-care corporations. More important than that, there's been a deterioration now in the quality of care in the United States not only for the individuals who previously had relatively little access to care -- the poor and uninsured -- but for a very large proportion of lower-middle and middle-class Americans.
The reasons are pretty obvious. If you have for-profit corporations running health care, their interests are to deliver the minimal amount of care consistent with simply getting people to pay up, and the result has been that all sorts of people are being denied aspects of care by health care managers of these managed-care corporations. This is clearly not the direction for Canadian health care to go.
These American corporations are waiting in the wings. They see Ontario and Canada as a potential market that they would love to get into. If in fact the intent of the government was to allow these people in, it could not do a better job than to amend the legislation in the way that is proposed. This is not the direction that Canadian citizens want, and certainly the people of Ontario do not want their tax dollars going to enhance the profits of American corporations. For those reasons, the provision that preference be given to Canadian-owned, not-for-profit independent facilities should surely be left in place.
The second aspect of the bill that we would like to address is changes to the Ontario Drug Benefit Act. Bill 26 institutes a copayment or user fee for people who use the Ontario drug benefit plan. Seniors and low-income families will be required to pay a $2 user fee, and for every individual whose income exceeds $16,000 and families whose income exceeds $24,000 there will be a deductible of $100 per year. For those people, $16,000 and $24,000 cuts, there will be in addition the payment of the full cost of the dispensing fee, $6.11.
1320
The first question we would like you to consider is, what will be the impact of these changes in terms of access to drugs and use of prescription drugs by the poor? When you consider that many of the people affected by this will be the very individuals who've had their welfare benefits cut by over 20%; when you consider that many individuals whom this affects are already in a position where their basic necessities of life are compromised -- for instance, many of these people are getting their food from food banks; when you consider those facts, it is inevitable that even small user fees of this sort will lead people to not visit physicians because they will know that they will have difficulty paying for their prescriptions or not filling prescriptions that they get.
If there was any doubt about the logic of that, we can actually refer to prior evidence about these sorts of changes. In 1971, the Saskatchewan government introduced a user fee for physicians' services which were previously fully covered, the equivalent in today's dollars of $6. The result of that was an 18% decrease in the use of physicians' services by low-income people. Small user fees lead poor people to not get the care they need.
In a more recent example, on June 1, 1990, Nova Scotia imposed a $3 copayment on all seniors except for those in nursing homes and homes for the aged. We are already seeing since that a decline in the number of people using the pharmacare plan, particularly those who have to pay the user fees.
You have to accept, I think, that the poor, the beneficiaries of the Ontario drug benefit plan, will on occasion, because of these user fees, not get the drugs that are prescribed. What is going to be the impact of that? The pharmaceutical services are not discretionary items. The people for whom the drugs are prescribed are not asking for the drugs; they come from medical problems, and physicians prescribe those drugs. If they do not get the medication that is prescribed, it is going to have obvious adverse effects on their health status.
Once again, common sense would tell us that, but there are also empirical data to substantiate it. There have been a number of American studies that have looked at the potential adverse effects on health status by the institution of limitations on drug prescribing. For instance, in one study that followed legislation in the 1980s in New Hampshire, where medicaid recipients were restricted and there was a cap of three drugs -- they could not receive any more and get reimbursed for them -- the result was an increase in the rates of admission to nursing homes and a sharp increase in the use of emergency mental health services and hospitalization in people affected by the cap.
This government is very appropriately interested in efficient health care and limitations of expenditures on health, while maintaining full services. A government with that interest should note that in this study the increased health utilization of mental health services amounted to 17 times the cost of whatever was saved in the drug expenditures.
The Ontario decision to require the copayments for every prescription was accompanied by a statement from the Finance minister: "We are expecting everybody in the province to pay their share and they are.... We are trying to be as fair and equitable as we can." From what we have said already, it is not fair to request people who are already on marginal incomes to pay for drugs. It is going to have adverse effects on their health status. In an appendix to our brief you will see an analysis that we have done suggesting that poor households already pay a greater proportion of their household incomes on drugs than the affluent, even before this legislation. So there is nothing, we would argue, fair about this legislation whatsoever.
Another important issue is that this opens the door for further copayments. Once you start, there is a much greater risk of gradual increases. If you are really going to want to hold it to incomes of $16,000 and $24,000, you will need to index that. We wonder whether consideration has been given to that, or in effect the income at which these charges will be instituted, the real income, will become lower and lower each year. But the real concern is that there is going to be further erosion in access to drug services by the poor beneficiaries of the drug benefit plan.
In summary, the people who are now going to be paying these copayments, the poor, already have worst health status. They are already people who are extremely marginal. They are people relying on food banks for their food. It is clear that there is going to be decreased utilization of needed drugs prescribed by physicians for conditions, and when these people are not able to get that, their health status is going to deteriorate further. Anything that you propose that you are going to save, the evidence suggests that even if you discount the fact of the suffering associated with worst health status, there's going to be increased use of health services that is going to offset any possible savings.
The third issue we would like to address is the changes to the prescription drug act. Drug prices for Ontarians not covered by the Ontario drug benefit plan will, according to the legislation, be deregulated. Until now, drug prices in the Ontario Drug Benefit Formulary have been applied to everyone. With the proposed changes, Ontario will be the only province in Canada not regulating drug prices, and indeed, 60% of all prescription products will be affected by this legislation.
The Health minister has indicated, and again I quote, that consumers are going to have to "put pressure directly on manufacturers.... That's how markets work." "People don't buy certain cars when they get too expensive -- they go and buy another car. For the vast majority of drugs, there is some choice on the market."
I'm afraid that even as a not very sophisticated student of health economics, that kind of perspective really is quite naïve. It is a fundamental and basic tenet of health economics that the health system does not operate on a market the way other markets operate. That would be the first sentence of any health economics text that you picked up.
When patients come to a physician and receive a medication, and most of us can attest to this in our roles as patients, we do not have the education to know what the alternatives are, and the questions are not asked: "Doctor, is there any cheaper medication that you can give me?" rather than the one you have been prescribed. It simply does not happen. Not only that, but as a medical educator, for better or worse, we can attest to the fact that the culture of physician training is not to put a high value on the cost of the medications, and cost is not the basis on which drugs are prescribed. The market economics that the minister suggests might apply here simply do not play out that way in the health care system.
The pharmaceutical industry is lobbying in favour of these changes. Let us assume that the truth was that drug prices would get lower as a result of this legislation and pharmaceutical company profits would as a result go down. Do you honestly believe that under those circumstances the industry would be lobbying for this legislation? They are smart people, as you well know. They are lobbying for this legislation because they know perfectly well, as other witnesses for this committee have told you, that drug prices are going to go up and pharmaceutical industry profits are going to increase. That is why they are lobbying for this legislation. The beneficiaries of these changes are going to be the profits to the pharmaceutical industry; the people who are going to suffer and be penalized are the people of Ontario.
1330
The next issue we would like to address is changes to the Health Insurance Act. We are not going to focus on all changes to the Health Insurance Act, but rather would just like to focus on a single aspect of those changes, which is the restriction of billing numbers to new physicians and the stipulation that specialist physicians will get billing numbers only if they can obtain hospital privileges. The result of this is that primary care physicians will be restricted in the areas that they can set up practice and similar restrictions are liable to be in place for consultants as well.
We understand that the government, in offering these changes, is attempting to address a very real problem in health care utilization and service in Ontario, which is that there are underserviced areas in particularly small communities and rural communities, and people do not have the physicians they need in the same way as urban communities. However, the proposed solution targets a particularly vulnerable group, and we see this unfortunate tendency of the government trying to solve fiscal problems by raising policies that seem repeatedly to be targeting the most vulnerable and the people least able to defend themselves. This seems to be another example.
While this is unfair to newly graduated physicians, it is not the consequences to physicians that we would like to point out and emphasize, but rather the consequences of these changes for the public. To consider those changes, you have to look at what are the differences between these newly graduated physicians and people who have been in practice for many years.
One of the differences, aside from the fact that they're obviously younger, is in the demographic background of medical school graduates in comparison to people who have been in practice for many years. There are many more women graduating from medical schools. There are many more people of colour graduating from medical schools. In other words, the new graduates of medical schools have a demographic makeup much closer to the population they serve than do doctors who have been in practice for many years. The result is likely to be an increased sensitivity to the needs of those populations and a greater ability to meet their special needs.
As a medical educator, I can also speak to the differences in medical training that newly graduated physicians underwent in their medical training in comparison to the traditional approaches of years past.
The first point is that unfortunately, to an extent, medical practice physicians tend to get stuck in the practice that they were trained in during their medical school and residency training. Clearly, more up-to-date practice is going to be a part of the way newly graduated physicians manage their patients.
Second, there is a much greater stress in trying to deal with this particular problem of getting stuck in your practice on evaluating new evidence. Newly graduated physicians are taught to a much greater extent than their older colleagues to make a critical assessment of the evidence and particularly a focus on assessing new evidence.
Another change in medical training has been one that I'm sure would appeal to the government in that we are beginning to stress aspects of the efficiency of health care in terms of our medical care decisions, which tends not to have been done in the past.
Finally, we put a greater stress on ethical issues and on patient autonomy than has been the case in the past.
These clearly are positive changes, and what the proposed legislation will do is restrict the citizens of a large portion of Ontario from the benefits of having these newly graduated physicians who have all these positive and to an extent innovative aspects of practice that will be part of how they deliver care. So to that extent it is the people of Ontario who will suffer from these restrictions. There is also a considerable risk that in the areas to which you're not going to allow the new physicians to come, you're going to see closed practices, with potential increases in inefficient use of health care due to use of emergency rooms and walk-in clinics.
We could sympathize to some extent with the government were this the only solution to the problem of maldistribution of physicians. The problem is that it is not the only solution. There are a variety of solutions, better solutions, available. The one that we would like to emphasize is the change in the method of funding physicians in the health care system.
There are many problems with the current fee-for-service system, and indeed one of the major problems is that it allows the concentration of physicians in urban areas, because even though you have a relatively low ratio of patients to physicians, physicians can simply deliver more intense care, deliver more services, and as a result maintain their incomes because of the fee-for-service system by this increased delivery of services.
A capitation system, in which physicians are paid on a per capita basis for their patients irrespective of the volume of service they deliver to those patients, would change the dynamic completely. It would end the incentive to deliver excessive and unnecessary care and instead substitute an incentive to deliver care most efficiently. It would mean that physicians in urban areas could not simply increase their rate of services and billing and as a result make up for a low patient-to-physician ratio by that mechanism. It would thus force physicians who wanted to maintain their incomes into the areas where they are underserviced. We recognize that it would not, in and of itself, solve the problem completely and that appropriate incentives and supports would still be necessary in addition, but it would go a long way to solving that problem.
We would suggest then that the government would be much better off making some fundamental changes in the structure of physician reimbursement, which would have a number of positive effects, including a fair way of addressing the maldistribution of physicians rather than once again targeting a particularly vulnerable group to the detriment both of newly graduated physicians and the people of Ontario.
I'd like to conclude by saying that the four aspects of the bill that we have highlighted as particular problems are not the only ones that the Medical Reform Group is troubled by. You have heard criticisms from a wide variety of other groups around various aspects of the bill where the Medical Reform Group has concerns, but we have identified and highlighted four areas that we think are particularly problematic.
Given that these very fundamental problems which threaten both universal, equally accessible care for Ontario citizens and target the poor and disadvantaged will lead to a group with already poor health status having their health status deteriorate further, all the aspects of the bill that we have identified should be seriously reconsidered, restructured, or simply eliminated.
The Chair: Thank you. We just have time for a one-minute statement by each party.
1340
Ms Lankin: I'll give my one minute to you just on user fees. The government says that every other province has them in drug programs, so it shouldn't be a problem here. Are you aware of any studies of the effect of it in other provinces?
Dr Guyatt: It's very difficult to do these before-after studies. To do a study properly, you would at the very least require before and after. However, I did mention the Nova Scotia experience, which is the one we know of where we do have such before-after data. It was only instituted in 1990, but the preliminary evidence already suggests a decrease in utilization of needed pharmaceutical services by people in Nova Scotia who are subject to those user fees.
Mrs Helen Johns (Huron): Thank you very much for your presentation. There was some excellent information in there that I intend to look at again. I wanted to talk about the structure of physician reimbursement. That's one of my pet peeves because I come from rural Ontario and we've toured the north. You spoke out against fee for service, you spoke about capitation; you didn't speak about differentiated fees. Can you comment on the OMA and its vision about how the structure of the physician reimbursement should be or are you speaking for yourself in this area?
Dr Guyatt: Well, clearly there have been efforts for about 20 years to address the maldistribution of physicians which have been far from completely successful. We believe that neither Band-Aid solutions nor solutions that unfairly target newly graduated physicians are appropriate. We believe that if you really want to address some of the fundamental problems, you need wide-ranging solutions that address the whole structure of reimbursement, and capitation would be a very positive way to do that.
Mrs Caplan: Thank you for an excellent presentation. I agree with everything that is here. I hope the government will listen to you. I think I've worked with all of you over the course of the years that I was Minister of Health. Your advice was always excellent. You've proposed solutions. You've identified the problems. I believe that Bill 26 is not only going to be bad for health care but for the health of the province. Do you want to say anything further about that?
Dr Guyatt: I don't know. Ian, Murray, anything?
Mrs Caplan: You've always provided such good advice. Thank you for coming. This is the end of the hearings. They intend to pass this bill on January 29. I'm hoping that they will delay this bill so that it can be withdrawn and have sections brought in that reflect the kinds of alternatives that you have proposed.
Dr Guyatt: I guess the final thing, then, is to say that there really are terribly serious problems with this. The adverse effects on health are going to be real. The dangers to universal care are real. Please reconsider these proposals.
The Chair: Thank you, doctors. Ms Lankin.
Ms Lankin: I'd like to table a request to legislative research. On page 7 of the presenters' documentation there is a list of references to research papers and reports dealing with the effect of user fees and copayments on drug use in seniors' populations and others under drug user programs. I would appreciate it if legislative research could provide us with an overview of the content and findings of this list of studies if possible.
HALTON REGION COALITION FOR SOCIAL JUSTICE
The Chair: There were four people sitting at the presenters' table at lunch when I recessed the meeting. The committee has agreed to let three of those them share a final 10 minutes. Would they come forward now.
Mr Agostino: Mr Chair, could I just continue to submit to the committee copies of briefs that have been submitted to the shadow hearings this morning? I have one here from the CUPE, Ontario division, women's committee, Local 167; the Hamilton District CUPE Council; and one from Allan Boudreau, executive director of Poverty Watch. I'd like to present these to the committee on behalf of the shadow hearings that are happening one floor below us.
The Chair: Okay, thank you. Just briefly, before you start, this morning was long. My apologies. You can share 10 minutes however you see fit.
Mr Terry Kelly: I just want to say to the Chairman that one of the presenters, Miriam Lockhart, who was from the St Peter's Hospital workers -- that's the local where they laid off 230 workers last night -- is back at the hospital, having to take care of some issues concerning that. In her place will be Joan Webb of CUPE 778, which is also from the St Peter's Hospital workers, and she'll participate in the presentation. I'll let David Michor, from the Hamilton-Wentworth Health Care Workers Joint Action Committee, take over.
Mr David Michor: I'm the acting chair for CUPE Hamilton-Wentworth health care workers. We represent approximately 3,700 health care workers in Hamilton-Wentworth. Only by the graces of the coalition for social justice have we been provided an opportunity to make presentation here.
I have to apologize for the anger that I expressed prior to this, but this is just an accumulation of a number of events that through the action of the government of the province we are constantly being ignored and that our positions are not being heard. We had applied for standing to this board, and upon review of those who have been provided standing, it becomes extremely obvious that there is not one group representing workers within the health care sector of Hamilton-Wentworth. This is the issue that we are addressing today. I find it absolutely appalling that we were not provided proper standing.
Obviously I'm not going to have time to properly review our documents. Two of them have been submitted and I understand both have been circulated. The reason why I have brought forth one of the sisters from St Peter's Hospital is to show and make a demonstration in front of this board some of the examples of what we are going to be experiencing right across the province in reductions within health care service.
St Peter's Hospital has committed itself to a reduction of 65 full-time-equivalence positions within that facility, and every single position reflects those people who provide direct patient care. The only reason that this is being done is because of the reductions of the provincial government, and their actions clearly reflect those of Bill 26. They are taking actions prior to this legislation provided. They are violating the terms of the collective agreement and they are exercising what they believe are going to be their rights, beginning at the end of the month, February 1.
This is quite obscene. The contents of this bill are definitely going to be undermining the labour relationship we have had on an ongoing basis with health care within this system. The district health council was here earlier. They spoke of their plan for the future of health care in Hamilton-Wentworth. That clearly also reflects the impacts of Bill 26. They have and they are proposing a vision of one superboard to monitor all health care in Hamilton-Wentworth. It appears to us that these people are intent on monitoring and controlling every aspect of health care, not only those within the hospitals, but those within every other sector within the health care facilities.
Again, this group has claimed that they have addressed their concerns and brought forth their recommendations to the stakeholders of health care in Hamilton-Wentworth. It is only through our forcing our way into these positions and into these meetings that we have been provided any representation at all. We have been absolutely denied a voice in any of these hearings. We have sent letters to the boards of directors at the hospitals of Hamilton -- Wentworth. They are refusing our standing in front of the boards to discuss issues such as mergers, collaborations. They are summarily dismissing us as being an equal partner and a reasonable stakeholder in this process.
It is our belief that these people are operating on the premise of what they believe Bill 26 is going to provide them. This is absolutely obscene and is a gross injustice to the people of Ontario. Not only do I request that you people overturn this bill, but I strongly support the opportunity to extend these hearings and further investigation into these so that people such as ourselves who represent these workers have an opportunity to make proper representation in front of your group.
I pretty much ate up most of our time, so I guess I can pass it back, and if you want to close up with some further comments; I see we have another individual here and I don't want to hog the entire 10 minutes.
Mr Kelly: I would just like to add, especially just with what we've heard today in relation to the fact of the closures at St Peter's Hospital in Burlington, where 230 workers have lost their job, that issue concerns us. Presently, right now, there's a waiting list of 457 on the chronic care waiting list in Halton region. There have been announcements last month that St Joseph's Hospital in Burlington will close 50 beds, and there are another 35 beds to be closed. That's to add on to the 456.
1350
We have Martindale House, which is part of Allendale in Milton, where 100 beds are closing. There is talk of privatizing it, but there's been nothing confirmed with that. But those beds are gone. They're history. That's added on to the 456. Now across the road here in Hamilton, we've got 230 workers going, and I'm assuming that's primarily a chronic care facility. I'm assuming that is going to be adding on to the list quite a considerable number.
So what is happening? What we would like to know is, and in this bill, what are you going to do with all of these people? These people need facilities. People within the community, the families, are not capable of providing that home care, proper home care. They don't have that expertise.
On top of that, in Sheridan, so that they can take some grant money from Disney, they're closing down 10 programs, including the nursing hospital in Sheridan. We don't have to wait until after the omnibus bill. This government is already trampling on the elderly here in this province. This is a very serious situation. We have to start dealing with this, and this bill here does nothing to do that. It just exacerbates the situation.
Mr Robert Heaton: I'll finish up. I'm from north Halton. In our area of Milton and Georgetown, the hospitals are there as a result of the residents 35 years ago through local initiatives. It was for economic development, to move employers there. If we lose the hospitals, we're going to be scared that we won't get any economic development in the future.
We're supposed to be part of the GTA. I'll give you a comparison. Bolton, which is in Peel region in Caledon, they don't have a hospital. They have to go to Orangeville, half an hour to an hour -- in this weather, who knows, when the roads are icy -- and/or Etobicoke. They made a big mistake years ago. Our people were smart. They have a hospital. We're really nervous that this legislation might take it away from us. That's just going to shut us down. If we're going to take the GTA growth, we have to have a hospital. This legislation's making us really nervous.
Our mental health patients come here to Hamilton, to St Joe's. I used to be an ambulance attendant at night. I know; I've done it. I've also gone to 999 Queen Street, now 1001 Queen Street in Toronto. I've also had to deliver those patients. When those ambulances are out of our area, delivering those patients to the out-of-service areas, they're not at home picking up people; they're not available. They have to come from Brampton, from Guelph, to pick up our residents to take them to Peel or Toronto or Hamilton or wherever else.
So we're really worried about our accessible health services and we're really worried about the legislation in Bill 26. Our seniors are worried too because of these beds that are at risk. These seniors right now, with no nursing beds available and the GTA growth coming -- it's causing them a lot of concern. That's why I came down to support some of these other groups today. Thank you.
The Chair: Thank you very much. We appreciate your comments, and again, apologies for this morning.
Mr Heaton: Are there any questions?
The Chair: Ten minutes is what the committee agreed and which was left over from this morning. We've used up the 10 minutes.
Mr Heaton: Great. Thank you.
Mr Agostino: Mr Chairman, can I read, while we have the time here to get set up, other briefs that have been presented to the shadow hearings, one from Hamilton and one from the Niagara francophone community health centre; and one from John Asling, communications officer of the United Church of Canada, Hamilton Conference. I'd like to add these into the record, given to this committee from the shadow hearings downstairs.
HAMILTON ACADEMY OF MEDICINE
EVA GEDE
The Chair: The next presenter is the Hamilton Academy of Medicine, represented by Kari Smedstad. Welcome to our committee.
Dr Kari Smedstad: Thank you very much for allowing us to come and speak at these hearings. It's very clear, I think, that it is necessary to have public hearings, seeing how many people have been interested, and we're grateful we got on the list. With me is Dr Walter Owsianik, the vice-president of the academy. I'm an associate professor of anaesthesia at McMaster University and this year I'm president of the Academy of Medicine.
I represent today 825 doctors in this city. These are doctors who are specialists, general practitioners, academic, in hospital and out of hospital; all kinds of doctors are members of the academy of medicine. We are essentially small business people, and as such we understand the need for fiscal restraint in Ontario. We have been very concerned about the deficit, in Canada and in Ontario, and we want to work with the government to help solve some of these problems.
We also believe, I think, that there is enough money in the health care system. We spend a third of our budget on health care. That is more than many other countries do that have similar or equal type of equal-access health care, and I'm not talking about the United States; I'm talking about other countries. They do exist, whether it's universality, and there's less money being spent. We really think the answer to the current crisis in health care is better management of the existing structures and funds, not throwing more money at it.
You're in Hamilton today, and I'd like to point out some of the unique features of the health care system in Hamilton, because Hamilton, as I'm sure you do know, is well known not only in Canada but around the world for its health care delivery. In this city the health care workers of all kinds, all health care professionals, have worked together for over 25 years trying to devise a regionalized approach to health care that recognizes the strengths of the different institutions, agencies and providers.
You should be aware that there is little duplication of services in Hamilton, but we are aware we can still do better. Some of the recent moves to merge the two hospital boards and to continue collaboration between all the hospitals will, I think, make it easier to provide excellent care for less money. Two of the boards that merged have two sites, so there are four hospitals turned into one, and then the other big hospital, of the acute care variety, is part of the collaboration. We also collaborated with the two other hospitals that are not acute care, but chronic care. So there is a lot of cooperation here.
Through McMaster University and through the clinical services here we have centres of excellence in clinical programs, and these recognize that in-hospital care of the patient is only really a small part of what the patient needs. There are strong links between the hospitals and the community health care agencies, and we believe this will continue to improve now that we have a health action task force, which is a division of the district health council, working together with all the health care providers in Hamilton to try and improve the system.
You should also be aware that the doctors here continue to serve a large population outside the city of 1.8 million people. We're delivering tertiary care specialist services here to central west Ontario because we are part of the faculty of health sciences at McMaster University and of the medical school. Hamilton hospitals are world-renowned teaching hospitals. As a result of that, the citizens in this community receive world-class health care. There are services available here that are not available anywhere else, and I believe we, the health care workers, manage that system with care, compassion and fiscal responsibility, and with the will and the knowledge to improve it further without increasing costs. At least we did that until the spectre of Bill 26 came along.
It has had a profound effect on us. We're frightened as physicians, and we're profoundly disappointed in this bill. We really do wonder why any government could introduce such legislation in the name of savings and restructuring without realizing -- or maybe they did realize -- but at least without acknowledging that it also will dismantle and destroy many of the safeguards built into our health care system.
I'd like to emphasize again that the doctors in Hamilton are frightened, and there are those who have lived in other regimes under totalitarianism who use that word to describe what they see in this bill. Many of us regard the implications of this bill as being undemocratic. And why is that? It's because the bill contains clauses that remove basic constitutional rights such as the right to confidentiality of private medical information. I know you've heard this many times, but we'd like to emphasize that this is something that cannot be allowed to go through.
1400
This bill also denies doctors the right to any legal action or any due process if their livelihood is taken away.
Doctors have what's called privileges in hospitals. Most of us are not employed by the hospital. I am employed by a university, but most doctors work in the hospitals with a kind of licence to do their craft there, which is called privilege. This is granted not because we'd like to have everybody working here, but because there is a need. Our hospitals have a resource plan. People are granted licences, granted privileges, because they are needed. We don't have a hundred surgeons working at Chedoke-McMaster, we have seven or eight, because that's all we need, and so on. So there is a process put in place for doctors' privileges to be granted, and if they're taken away now, you can at least object. You can say, "Well, how come? I haven't been found incompetent," which is a ground for taking your privileges away. You have legal grounds to at least question. Under this bill, that right, due process, is taken away. This is one of the reasons we think it's undemocratic.
This bill allows government officials the right to enter offices to seize records and to make judgements on the necessity of tests and treatments that patients receive. Again, we find that incomprehensible. Specifically, we are very worried because the bill gives the ministry complete immunity from any legal challenges to actions they may take, no matter how arbitrary or destructive these actions might be. That is undemocratic and that is totalitarian.
We think that this ministry does not need the powers it vests in itself by this bill because it would be impossible for the ministry to practise medicine.
We recognize that the ministry must save money and that health care is costly. But the need for health care does not go away when hospitals close, and we've heard that here this morning from other people. The need for health care does not go away if doctors are denied licences. By removing the providers, the patients will be denied care or the system will be overburdened and stretched somewhere else. So we think as doctors in this city that the answer lies in joint management, and we want to and are willing to work with the ministry in managing the system. I'll tell you that Hamilton is living proof that health care workers can do that successfully.
There are other problems to us working with the government, because the bill's schedule I voids any of the existing agreements with the Ontario Medical Association. The OMA has worked with government for decades developing health care policies in this province. Frances Lankin, who's here, and Elinor Caplan, who just left, know this because they worked with the OMA on health care policies in their terms as Health minister. The OMA is not just a doctors' union. In fact, the OMA never functioned as a union until perhaps a little bit in the last three or four years. But it has never really been a union.
There are many instances I'd like to bring to your attention, but I think one of the better ones is that of the antenatal record. Now, many of you have probably carried this thing around in your purses, because this is the document that all doctors in this province use to record the progress of pregnancy. It gives information to the hospitals on the health status of all the mothers-to-be in Ontario. It was developed by the OMA, by the expertise that exists there. The printing and distribution of the form was financed by the ministry. This particular document is recognized across Canada as a model in documentation for safe birth. There are other examples, such as maternal transport guidelines for high-risk pregnancy, again developed by the OMA, working with the ministry to finance transportation.
So without cooperation between the body that has the expertise to set standards and guide practice and the government that administers and finances the health care, the recipient of that health care, which is the patient, will ultimately lose out. You've heard that from others.
The OMA, I believe, also negotiated a reasonable economic solution to the fiscal crisis in the spirit of fairness both to the budget and to the doctors. You should be aware, and I'm sure you know, that the doctors of this province agreed to cap their incomes. They saw their pay reduced by a 12% to 15% clawback annually for the last three years for those who are on fee-for-service. Those of us who earn salaries for services have had our salaries frozen for the last four years. The OMA has proposed several mechanisms for sustaining that restraint, but the government has vested in itself powers to break all these agreements, and this frightens us. It scares us even more, though, that the bill proposes powers to allow the government inspectors to manage the individual patient's care.
I work in an academic environment, and we are very aware of the difficulties in setting appropriate standards for cost-effective medical care which improve outcome. These are some of the things Dr Guyatt spoke about, and he works with this as well.
The universities, the specialist colleges and the clinical departments struggle with this on a daily basis and we all know that in any individual case you may not be able to fit a particular patient into a guideline because individuals differ. Sir William Osler, who spent some of his school days in Dundas, Ontario, and then became probably the father of scientific clinical medicine in the western world, said that it is as important to know which patient has the disease as to know which disease the patient has. Gordon Guyatt spoke about that when he talked about the determinants of health being social as well as pathological.
You should know that there are 10,000 new medical articles being published every single week, and some of the guidelines that come out are out of date before they are published. Now, that doesn't mean that we shouldn't use guidelines. We definitely should develop guidelines and we should work within them, knowing that they will fit groups but not necessarily individuals. So how can the ministry then hope to decide what is medically necessary treatment in a given case?
The purpose of schedule H, sections 30 to 33, is to try to catch those very few physicians who do inappropriate things, who bill for things they haven't done, who are the bad apples in the barrel. There are some, but they are few and far between, and there are already very real powers in place to deal with this through the review mechanism of our regulating body, the College of Physicians and Surgeons of Ontario. All the doctors in this province respect this body, and our practices can be and are inspected at random. We think the government should allow the CPSO to continue this work. I can tell you that most of us would rather be up in a court of law than be hauled up before the college for a disciplinary hearing, where you actually are guilty until proven innocent rather than the other way around. What is more, we actually then pay for the disciplinary hearing, not the taxpayer, if it's done by the college. We all pay into having ourselves disciplined.
You've heard about the restrictions on licensing. This bill allows the ministry to restrict all the licences of all the new doctors and specialists who start working in Ontario in order to try to fill some 200 positions in the north. Well, let me tell you, we do not need conscripts to the army of northern doctors. What we do need and what we have proposed was an incentive plan to not only send the doctors to the north, but keep them there.
I tell you, it is not money that is at issue here; it is lack of support for northern doctors. Particularly the young doctor in the north feels isolated. There are no colleagues you can call upon down the corridor to come and help you with a case: "Come and see this patient. I'm not quite sure what's going on." There's no one to discuss things with, no one to share the responsibility with, there's no relief for nights and weekends and holidays. Doctors who move to these areas burn out, which is the modern term for it. I know about this. I didn't know about the term "burnout"; they hadn't invented it when I was there. But I worked in the Arctic for two years. I worked in northern Ontario for another two years. I know what I'm talking about.
In those communities we don't need one or two doctors that we can send up there. We need community-based group health care with many different kinds of health care professional workers, and there should be access to relief, to information systems, to support systems. It will be easier now with modern technologies to get information systems, but you still need someone to take over for you when you're too tired. You still need on-call systems. You need group practices.
It's not just in the north. I have a friend who is a general practitioner in Caledonia who's been trying to get a colleague to join her for the last five or six years. This bill, which does not designate Caledonia as an underserviced area, is going to prevent that altogether. So patients there will not get doctors, and doctors there will not get relief either. You're going to have more and more of these burned-out doctors all over the province.
1410
I've been a doctor for an awful long time now. I have worked in England, Australia and North America. I've practised in isolated northern communities, islands in the North Sea, Moose Factory, I've worked with the Flying Doctors service in Australia, and I've worked in world-class university centres, both here and in Europe.
With this experience and background, let me tell you that I firmly believe that Ontario's and Canada's doctors are the best in the world. Here, I will say without a shadow of a doubt, there is a uniformly high ethical standard in the medical profession. Gordon Guyatt told you a little while ago about the new curriculum in the medical schools and how all these things are now built into it. But I would also like to stress that the doctors who are already here, who are not necessarily new, also have this standard.
Ontarians have doctors with the best training anywhere, and that's the reason the Ontario family doctors get one or two job offers every single week from the USA. They don't want dumb doctors down there, they want the best, so they ask Ontarians to come. Your doctors here are compassionate and caring. We believe we practise responsible medicine. But it's hard to practise responsible medicine and be compassionate and caring when you're scared, demoralized, depressed and fearful of the future, and that's what's happening to the doctors in Hamilton as a result of Bill 26.
We lost 19 of our members to the United States in the last year, and this week I learned of two more Hamilton family doctors who are leaving. Please reconsider the draconian powers the ministry vests in itself by Bill 26 before you destroy the morale of those of us who are choosing to stay here, because we cannot practise responsible medicine under the provisions of Bill 26.
We really do want to work with the ministry. We want to help improve the system and we want to try to contain costs. We are looking for a spirit of cooperation between us and the government, one that restores the confidentiality of patients and the confidence we have in the system and the confidence the ministry has in us, and one that protects the public and the practitioners alike. Bill 26, I'm afraid to say, prevents us from doing that, and it will be the public that bears the consequences. I thank you for your time.
Mrs Ecker: Thank you very much, both of you, for coming here. I'm very familiar with many of the representatives of medicine from Hamilton and am familiar with the excellent work done in this community and this area. I also grew up listening to many quotes about Sir William Osler, who was one of our great family physicians before they even coined the term. Thank you very much for coming.
I think you make an excellent point that the answer lies in joint management of the system. One of the things that has certainly distressed me over the years is that every government seems to have its period of non-cooperation with the medical profession. We had extra billing and the strike under the Liberals. We had the social contract and consent and block fees with the NDP. It would appear that we now have Bill 26.
One of the interesting things was that the previous government and the OMA attempted to do a joint management agreement to try to solve many problems in the system that were not unique to any administration and still plague us, from lack of distribution of physicians to many other problems.
Would you care to comment a little on what hasn't worked in the past with agreements like that and what further advice you would have for in the future, as we all try to head to a goal that I would say we do support?
Dr Smedstad: I speak on behalf of the Academy of Medicine, not necessarily on behalf of the OMA, but the two are interlinked in that we are a branch society of the Ontario Medical Association.
One of the things that has not worked in the past is coercion, on any side. You cannot force people to do one thing or another. You need to have choice, and the Ontario Medical Association has championed for choice and also for alternative ways of dealing with things; that is not something that only the government says. If we are to work together, these things have to be taken into account.
The College of Family Physicians is talking about primary care reform; so is the Ontario Medical Association now. Those of us who work for universities are in favour of alternative forms of payment. So are many the physicians, both in primary care and specialists. If you're going to discuss anything at all, all these things have to be available for discussion and there has to be respect on both sides. Sometimes things haven't worked so well because there has been a lack of respect from one side or the other, and I'd like to see that go.
Mrs Caplan: Our leader, Mrs McLeod, is going to ask the questions. I would just like to compliment you on an excellent brief and say what an enjoyable evening I had the other night. I enjoy that kind of healthy debate.
Mrs McLeod: I want to begin with a compliment too. It may seem unusual for a group of physicians in Hamilton to be acknowledging the problem of recruitment of physicians in northern Ontario, but I think one of the reasons it's appropriate is because McMaster was the originator of the northern Ontario medical program which has become such a very positive, proven model for enhancing recruitment as well as retention in northern Ontario. I wanted to begin with that, because I've been frustrated over the course of hearings by the government's insistence that we need coercive models because nobody's been able to find any constructive ways of resolving the issues. I think there are constructive models, and the challenge is to build on those in a more comprehensive way.
Dr Smedstad: One of the ways to try is to give incentives to students from the north to come down to the big centres, get educated, and then go back. People want to live in the north if they're familiar with the north, but you can't just move someone up who's never been there. I went to the Arctic totally naïve and I was scared out of my wits many a time. It is a very difficult situation.
Mrs McLeod: You comment on the outflux of physicians already, and just in the last little while we are seeing more people leaving northern Ontario as well. The problem with Bill 26 is that it's already creating a kind of environment which is encouraging people to leave, not stay. What has to change besides the coercive aspects of this bill?
Dr Smedstad: There was an article published this week in the Canadian Medical Association Journal on the determinants that made doctors leave, and money wasn't really the one. It was the "push factors," as they called it, of government control and regulation, knowing full well that there are lots of regulations in the United States as well. But it's a question of uncertainty here now, and the things that make you stay are things like family being close, the living conditions, the climate you're in.
Incentives -- not necessarily monetary incentives, but others. Coercion is not going to work. It's going to send a few people up there for a year or two and then off they go again. Having been in the Arctic for four years, it's the sort of thing you're glad you've done but you never want to do again, unless there's some real reason to stay there, you come from there or you're familiar with the situation and like it. You've got to have incentives.
Ms Lankin: Thank you very much. I truly appreciate your presentation. I want to concur with some of the remarks you made right at the beginning when you said: "We believe there is enough money in the health care system. The answer to the current crisis is better management of existing structures and funds." You will remember that when I was Minister of Health, those are words I said as well. One of the frustrations I've had about the government's legislation and comments of the government members on the committee is the suggestion that nothing has happened. A great deal has happened over the last number of years and people are engaged in restructuring of the health care system, and there's a much better acceptance of that basic principle you set out than there was in the past.
You indicated a number of concerns specifically with the bill, and said that doctors in Hamilton are frightened because the bill contains clauses that remove basic constitutional rights around confidentiality of private medical information. Amendments tabled today go some way to address that -- and I'll be honest and say I haven't been able to understand them all yet -- but I think they fall short. That's an issue that's still going to be there. The bill denies doctors the right to legal action if their livelihood is taken away. They didn't fix that; that's still in the bill. The bill allows government officials the right to enter offices, seize records -- they've done away with the ministry inspectors and it's back to the college, so that's good -- and make judgements on the necessity of tests and treatment patients receive. The ministry can still do that; they didn't fix that. The bill gives the ministry complete immunity from legal challenges, no matter how arbitrary or destructive the actions. The bill still does that.
1420
A whole lot of what you said you have a problem with has not been fixed. The government has tabled its package of amendments to the bill now. We're voting on clause-by-clause next week. What are you going to say to them? There they are. They're not answering your concerns.
Dr Smedstad: It is very frightening. I have a colleague here, Dr Eva Gede, who does not represent the academy; she represents herself. As a physician in Hamilton, I wonder, Eva, if you would like to make an answer to Frances Lankin's question.
Dr Eva Gede: I make these comments on my own behalf. I would like to say that the haste in which this government is trying to pass the bill, the broken promises so it gives the appearance of lies and deceit, the apparent grab for dictatorial powers, the abrogation of democratic rights, the invasion of privacy, the accusation of fraud and being held guilty and not given the chance to prove innocence, and decisions made by bureaucrats who don't know what they are making decisions about -- these are reminiscent of the Stalinist terror regime under which I had the misfortune to grow up. You know what happens economically to a regime like that, that's run by ignorant bureaucrats: It fails.
As regards health care, the top bureaucrats and the rich and the wealthy get the best that anybody has to offer, and for the rest of us, like here in Ontario, what kind of health care will we get with intimidated, overcontrolled and demoralized doctors? It'll be health care Soviet Russia style. It'll be health care à la Romania.
The Chair: Thank you, doctors. We appreciate your presentation here today.
Mrs McLeod: Mr Chairman, you'll recall that yesterday I undertook to transcribe and therefore be able to table a presentation on behalf of a Dr Alison MacTavish, a family doctor in Niagara Falls who had made two efforts to be present to present to the committee and did want to have her concerns about the outflux of family physicians from the region known. I therefore table that brief with you today.
Mr Agostino: Mr Chair, I want to table with the committee a form that is now being used by physicians in our community asking for preauthorization from the ministry whenever they have to carry out a procedure, and that includes X-rays, blood tests, cardiograms, surgery, hospital admissions and health services. These forms are being sent to the ministry on a daily basis on behalf of patients. Dr Levy here, who has submitted this, does this every single time he has a patient he has to deal with, in order to comply with the intent of Bill 26, and that's preauthorization by the ministry. I want to table it for the committee. The forms you see here will probably become standard forms across Ontario for all doctors if this bill goes through, and they are very much like the American style of forms that are used.
OAKVILLE-TRAFALGAR MEMORIAL HOSPITAL
The Chair: Our next presenter is the Oakville-Trafalgar Memorial Hospital, represented by John Oliver, the president and chief executive officer, and Dr Lorne Martin, the chief of staff.
Mr John Oliver: Thank you very much. On behalf of the board of governors, doctors and staff of Oakville-Trafalgar Memorial Hospital, I would like to extend our appreciation to you, Mr Chairman, and the members of the committee for allowing us the opportunity to appear today to present our views on Bill 26. As you indicated, my name is John Oliver. I'm the president and chief executive officer of Oakville-Trafalgar Memorial Hospital, and with me today is Dr Lorne Martin, chief of staff.
We were notified of our presentation late yesterday, so we apologize for not having material to circulate. That will be available Monday morning. If I could characterize the thrust of our presentation, it's to give you a feel for some of the positive and some of the negative aspects of Bill 26 within a local context -- in this case, that's Oakville and the region of Halton -- to give you a feel for how it impacts on us and also how it can benefit us.
Oakville-Trafalgar hospital is a 275-bed, acute-care community general hospital. We provide primary and secondary care services. We have approximately 265 medical staff and employ 1,200 people at our hospital. We serve a referral population of about 150,000.
At the outset, we'd like to indicate our support for the presentation that the Ontario Hospital Association made to your committee on December 18, 1995. We are also members of the OHA regional council 4, whom you heard from in Kitchener earlier this week, and we endorse the views contained in that presentation.
The following remarks focus on health service restructuring and, while representing the views of Oakville-Trafalgar hospital, are fully endorsed and supported by the other three hospitals in Halton. That includes Joseph Brant Memorial Hospital in Burlington, Milton District Hospital in Milton, and Georgetown and District Memorial Hospital in Halton Hills, and further is endorsed by the Halton District Health Council.
With respect to schedule F, health services restructuring, we fully support the concept of a provincial restructuring commission. This is an innovation which in the present funding circumstances is absolutely essential in order to ensure the restructuring of the hospital system on a priority basis and to preserve equitable access to services in all parts of Ontario.
To provide a local example, in October 1993 OTMH and Joseph Brant hospital in Burlington, under the leadership of our district health council, conducted a hospital utilization study. They had a specific mandate to develop restructuring opportunities within the Halton hospital system. The conclusion of the study, fully endorsed by the Ministry of Health, was that, given the sizes of the communities of Burlington and Oakville, both of which are serving referral populations of 150,000, and the distance between these hospitals, each centre needed to maintain a range of acute-care inpatient and ambulatory clinical services to meet the community's needs close to home and to maintain the viability of the hospitals and the critical mass of each health professional group.
During the review, the hospitals formed a consortium that's maximized many joint venture opportunities and business alliances in administrative and in the hotel service areas of our hospitals. In short, the study concluded that the hospitals in the region of Halton are already restructured. Further, we are experiencing significant growth rates. Through 1991-96, the region of Halton experienced a population growth rate of almost 18%. In the next five years we're anticipating a growth rate of 15%.
At the same time, the regions of Halton, Durham, Peel and York, which we commonly refer to as the GTA 905 regions, have the lowest per capita funding allocations in the province. The GTA 905 hospital funding is approximately $317 per capita, compared to an average of almost $700 across Ontario.
The capacity of the Halton hospital system to reduce spending in the order of 19% to 20%, as is required in the most recent provincial economic statement, is much less than the capacity of other parts of Ontario. It is our hope that through mechanisms such as the Health Services Restructuring Commission the targeted reductions to hospital expenditures can be met by addressing overcapacity and/or service delivery duplication that is occurring in our current provincial system.
Again, we fully endorse and encourage hospital restructuring to ensure an equitable allocation of resources and an equitable provision of essential hospital-based services for all Ontario residents. There is a need, however, for government to clarify the mandate for the commission and to ensure that those on the commission are knowledgeable, objective and decisive. We understand the government is prepared to sunset the powers of intervention which Bill 26 confers upon the Minister of Health. We believe this is an appropriate step to preserve the principles of voluntary trustee governance and local community decision-making.
Further amendments we would ask for are as follows, and these points are consistent with the Ontario Hospital Association's position paper: Only the Minister of Health should be able to have the power to close or merge hospitals unilaterally; certain circumstances relating to when the minister can appoint a supervisor, particularly related to the availability of financial resources in the health care system in general, should be sunsetted in conjunction with the restructuring commission; and finally, the role of the district health councils in relation to the work of the restructuring commission needs to be clearly addressed, if not in legislation, then certainly through regulation.
We also support those areas of the bill that are aimed at assisting hospitals and health providers to cope with the budgetary situations that we are all facing. Elements such as guidelines for arbitrators, multi-year funding commitments, revisions to operating and capital plan processes and the ability to access other sources of revenue like crown foundations and copayments are welcome tools. We would, however, encourage you again to revisit the submission from December 18 prepared by the Ontario Hospital Association, particularly around arbitration rulings with respect to ability to pay and maintenance of pay equity issues.
From a personal perspective as a professional working in the system, I believe that after the restructuring and downsizing of hospitals it is essential that we move forward to develop a fully integrated health care system. We should now be envisioning a client focus system that integrates all providers, including facility- and community-based health services, physician and social service agencies. The integrated system should transform our now fractured current health care delivery model into a true system for the prevention and treatment of illness and disability for current and future Ontarians. We need responsible government leadership in order for these kinds of changes to happen to our system.
1430
Like our other colleagues across the province, we recognize the very serious financial circumstances facing the province in our health care system. We recognize that Bill 26 is in part a response to those circumstances. My medical colleague Dr Lorne Martin, chief of staff, will now speak to other sections of Bill 26 that deal specifically with medical manpower ramifications in the Oakville-Halton Memorial Hospital service provision.
Dr Lorne Martin: Thank you very much, members of the panel, for this opportunity to appear before you. I really want to take you right into our hospital and right into one particular service in our hospital which we are having some very significant difficulties with and try to explain to you the scope of those difficulties and how this bill is going to make things even harder for us, and that is the obstetrical care that we provide in our hospital and in our community.
My main point is that there is an immediate crisis in the delivery of obstetrical care, particularly in our community and in some respects province-wide, and that this bill will exacerbate that problem. When I say "immediate" I'm really talking about February 1996, and if this government doesn't take some steps to address that crisis, we will have difficulty providing obstetrical service to the women of this province.
I want to talk a little bit about prior to the omnibus bill. We have, in our community, practising right now five obstetricians. It's a community that would normally require seven. In fact, we did have seven 10 years ago. We did have seven five years ago, but we lost two to the United States and because of the general manpower situation across the province, we've had difficulty with recruitment and we have really been struggling over the last couple of years to maintain our service.
Of those five obstetricians, two of them no longer provide primary obstetrical care, so the lion's share of work falls to three individuals. Of those three individuals, one's had a heart attack, one is pregnant at this time, so we really have one other individual who's quarterbacking the entire obstetrical care for our community. For the last year, we've been almost a day-to-day service. On Monday we've been wondering whether on Friday we were going to be able to maintain the service.
The family physicians, as you're probably also aware, have been abandoning the practice of obstetrics province-wide and we've also experienced this in our community. So there is a crisis. We have worked very, very hard to try to find some long-term solutions to this crisis. We believe, through recruitment, we can manage this and then unfortunately, along comes the omnibus bill and now we really don't know how on Earth we're going to get by.
I'm speaking now specifically to the cancellation of the Canadian Medical Protective Association reimbursement and I'm sure you're aware of this, but the obstetricians' malpractice payment has gone from $5,000 annually to $24,000 annually, and when delivering a baby remunerates a physician $220, you can see how difficult it is to make up that amount of money and that amount of increase in malpractice insurance.
As a result of the omnibus bill, we've been informed by two of our obstetricians that they will no longer provide call, so we now, in terms of our call schedule, are down to three doctors and it just can't be done. This is a province-wide problem. I know you had a presentation from the Ontario Society of Obstetricians and Gynaecologists. I know that they informed you that they're talking about a complete withdrawal of obstetrical services come the middle of this year some time, a date yet to be established.
So I hope that you will hear this message, that there is an immediate crisis in relation to this particular medical service, and that it has to be addressed and it has to be addressed immediately. There are no solutions; there are no obstetricians out there whom we can find to work for us, and that is a problem that many, many communities are facing.
We have two specific recommendations for you and the first one and the most important one is that you defer the implementation of any change to the CMPA reimbursement program until these issues are negotiated and settled. I'm sure that if the implementation is deferred, our doctors will work with us in our hospital, but that would require a commitment that there would be no retroactivity to any decisions that are made.
You should also be very aware that if you, for example, just allow the obstetricians to have their reimbursement and you apply the law to all the other physicians in the province, you will have, in my opinion, immediate job action from a number of other medical groups that are going to be affected in the same financial way. So I don't think a specific solution to the obstetricians is going to work here either.
The second recommendation I have for you is that you recognize that the obstetrical fees themselves are grossly deficient and support measures to increase those fees. Two hundred and twenty dollars is just not enough to sustain economically this medical practice for either family physicians or specialists.
My second point, and I'll be very brief about it, is around the physician human resource planning and the requirement to submit this document to the Ministry of Health for approval. I don't think they understand this requirement in the bill. I don't see what advantage it's going to give the minister. It's not going to address the fiscal issues. You already have complete control over hospital budgets. You have complete control over the overall OHIP payments. When we add a doctor to our hospital, we have to pay for it. It doesn't in any way increase the expenses to the ministry.
I gather the only advantage to the minister approving manpower plans is that it would allow the ministry to manage physician resources across the province. I don't think you can do it. Managing physician resources is a very complex issue. There are a whole bunch of local factors that will affect the requirements of a physician. When a respirologist retires and goes off the call schedule, the community might need a nephrologist to replace them. I'm not going to go into all the details. But I just think it's an information issue. I don't see how the ministry can centrally manage over 200 hospitals' physician manpower. I don't see how they could possibly have adequate information, possibly respond in a timely enough fashion, and I think you'll position yourself as being responsible for every time a patient needs to see a doctor who isn't there because you haven't approved it. You're going to end up taking that responsibility yourselves.
So my recommendation around the aspects of the omnibus bill that speak to physician human resource planning are that you either delete these altogether and maintain the status quo, or if there are requirements around restructuring, as John has said, we would support that, but those requirements should be tied to restructuring and should also have a sunset clause built into them so that they expire at the end of the restructuring portions of the bill. Thank you very much. That concludes my presentation.
Mrs McLeod: My colleague has a number of questions. We likely won't have time to get them all in. I just wanted to underscore the immediacy of the crisis in obstetrics and the need for urgent action on the part of the minister to fix the damage that's been done, and to comment that that is perhaps the most immediate example we have of the horrendous impact of one unilateral, thoughtless and very political action. God save us from some of these other impacts that other portions of this bill might have if they use these powers.
Mrs Pupatello: Thank you. When you mentioned earlier that they really should sit down and negotiate something regarding the obstetricians and the crisis there, I thought, who are they going to negotiate with? They've already stopped negotiating with the OMA, and I have this vision of the ministry calling 23,000 doctors across Ontario and chatting about what kind of a contract they're going to have with that individual doctor, which in essence is what this government's proposing to do. It's just ludicrous.
I wanted to mention, in speaking about your hospital, you were talking about the allocation of funding. Would you say overall that you're well-funded, well-serviced in your community in general in health?
Mr Oliver: The research that we've been doing suggests that within the GTA 905 group, which are the 905 area codes, Halton, Peel, Durham and York have been experiencing very significant growth. In fact, every five years we add approximately the city of the size of Hamilton to the GTA 905 area. We are also behind somewhat in the per capita hospital funding. So the short answer is no, but that we all need to be part of the solution to the financial problem that we're facing and there need to be adjustments to our area, but we also need to be part of the overall solutions.
Mr Christopherson: Thank you for the presentation. You started earlier in your presentation talking about the fact that you really didn't know how you were going to find the 19% to 20% that you now have to find on top of all the other constraints that you've been under. Could you give me a sense of what sort of things are on the table if there's no relief from that 19% to 20% and you indeed have to follow through, notwithstanding the other things that are happening in Bill 26?
Mr Oliver: I have to be honest. We strongly are endorsing restructuring and encouraging it to be happening. I've been working with a restructuring committee that's looking at the issue provincially. We are looking now to find ways to absorb the 5% to 6% reduction that we're facing next year. The following two years we will have to be into service reductions in order to meet that kind of change in hospital funding within Halton.
1440
I do believe, and I believe others in our field feel, that through restructuring that kind of financial expenditure can be withdrawn from hospital funding, that there is enough duplication and excess capacity in our current system that the remaining amount can be found but it's going to require strong provincial leadership to make that kind of change happen in some of the health systems that we have around the province.
Mr Christopherson: And if that doesn't happen?
Mr Oliver: If the answer to that is across-the-board cuts that are applied equally to areas such as Halton, Durham, Peel and York as to other areas that have not yet restructured, then there will be inequitable service distribution.
Mr Clement: Just a brief comment on the funding formula arrangements. As a member from Peel region I'm quite sympathetic to your point of view. I think we've won the intellectual argument with the minister, and it's a question of doing the restructuring that has to be done in the hospital sector so that we can do the reallocation of funding formulae without having a deleterious impact in other areas.
But you've got me going a bit on the obstetricians, I must say, because I think the minister's made it pretty clear that he wants to try to find a solution for that. Then you come out and say, "But if we try to find a particular solution to the obstetricians and help them out, then it's going to be a job action." You can sense a bit of frustration in my voice, perhaps.
Dr Martin: Sure.
Mr Clement: I think the minister very much wants to deal with the OMA and find a solution to this, but now you've just threatened job action. How should the minister respond to that?
Dr Martin: I sure don't want to be perceived as threatening job action and I don't think I was suggesting no particular solution is possible. But with respect to the CMPA reimbursement, if you just say the obstetricians will be exempt from those requirements, the other physicians are going to perceive themselves in a very equal situation. It's going to precipitate a reaction from those groups, and I'm not threatening at all.
I don't think that's going to be the answer. There are other potential answers. There are answers, for example, in adjusting the fee schedule so that the obstetricians' remuneration is more reasonable, and in making a cogent argument that there's a problem there which pre-existed the omnibus bill and had to be addressed. So a lot of it is perception.
Mr Clement: I thank you for your last comment.
The Chair: Thank you, doctor; thank you gentlemen.
Mrs McLeod: You can't do a Caesarian section without an anaesthetist.
The Chair: We appreciate your presentation here this afternoon and your interest in our process.
Mr Agostino: Mr Chairman, as the groups are getting ready I take the opportunity to read other groups into the record that have made presentations to the shadow hearing. I present these to the committee: the Conserver Society of Hamilton and District, Josephine D'Amico and the Inter-Faith Social Assistance Reform Coalition, as well as other groups which I'll read later which have made and will continue to make presentations to the committee today. I'd like these in the record and for distribution to committee members.
Mr Clement: Mr Chairman, I also have a presentation to the committee. It's a letter to the minister from the Provincial Adult Cardiac Care Network in response to some comments that Ms Lankin made earlier in the proceedings, to share with the committee.
UNITED SENIOR CITIZENS OF ONTARIO
STEELWORKERS ORGANIZATION OF ACTIVE RETIREES
The Chair: The next group is the seniors tenants of Hamilton, represented by Gwen Lee. Obviously, Gwen brought some help with her. Welcome to our committee.
Mrs Gwen Lee: Thank you for the opportunity to make a presentation addressing our concerns about some of the content of Bill 26. I am representing seniors in the Hamilton-Wentworth area, namely, Hamilton-Wentworth Housing Authority senior tenants; United Senior Citizens of Ontario, known as the USCO, zone 14; and the Steelworkers Organization of Active Retirees. I belong to all of these groups.
For the moment I must digress in order to establish the reasons for my concerns. In the Common Sense Revolution, on page 13, it is written that Ontario Realty Corp would be directed "to sell...more than 84,000 units owned by Ontario Housing Corp."
Now I will come to the health issue: supportive housing. When deregulation of the psychiatric hospitals took place, the Hamilton-Wentworth Housing Authority made several units available to former patients who are now out in the community with little or no support. There are now three supportive housing projects in this area involved with psychiatric patients. The one that I am familiar with, known as the Annex, is at 500 MacNab Street North in Hamilton.
The residents in the Annex are tenants with Hamilton-Wentworth Housing Authority, with all the rights, privileges and responsibilities of all Hamilton-Wentworth Housing Authority tenants. They have listed the various agencies that are involved in this program; it's quite lengthy. In order to be accepted as a tenant, he/she must agree to participate in the program and will rent the unit under the Landlord and Tenant Act. This building, at 500 MacNab Street North, is one of the buildings that this government is proposing to sell.
Another project now taking place is Aging in Place, which is at 801 Upper Gage Avenue, Sanford Avenue, and Macassa Apartments. Expansion is proposed to other seniors' buildings. These buildings are also part of the HWHA portfolio and are part of the 84,000 units that are to be privatized.
A third project is located at another HWHA building at 191 Main Street West in the city of Hamilton. This is a supportive housing project. There was grave concern that homes for the aged would only accept frail, elderly patients and there are not enough spaces for many seniors at risk. Many of them are not able to care for themselves in a normal setting. Supportive housing is the answer to this problem. Bachelor apartments at 191 Main Street West were renovated to meet the needs of people who would slip through the cracks in the system. Twenty units are already in place and another 20 units have been approved. I should say at this time that the district health council, out of their money, gave the money for this.
The residents in these units are rent-geared-to-income tenants of Hamilton-Wentworth Housing. There is 24-hour-a-day onsite care, and VON and St Elizabeth nurses provide care. There is an emergency response system and congregate dining at midday. I can answer any questions you have about what else exists there.
The 191 Main Street West project is a new initiative and is presently accepting applications. Seven tenants have already been approved and many, many more applications have been made. There will be no difficulty in filling the units with tenants who meet the eligibility standards.
All of these projects are at risk if the apartment buildings are sold. The safety net that is now in place will be gone, and vulnerable people will lose the security they now have. If these buildings are sold, the landlord is not going to allow these programs to continue. These tenants will then be out in the community, scattered all over the area, with little or no support, at much greater cost than at present. I urge you to show compassion for the tenants concerned and to realize the damage you will be doing to supportive housing if these buildings are privatized.
The government says that it will consult with families, volunteers, members of the disabilities and seniors communities, the medical profession and caregivers. These hearings taking place now are too little and too late. There is not enough time to hear all who have genuine concerns.
When I came to Canada in 1946, there was no health care system. You only got help if you could pay for it. Please don't return to the old ways. Many of us fought long and hard for what is now recognized as the best health care system in North America. I urge you, do not pass legislation that will make the poor, the disabled and some seniors unable to get the care and medication they need.
On page 4 of the Common Sense Revolution is a statement that "policy is designed to meet the needs of the less fortunate and the disadvantaged." I urge you to keep this commitment and to show compassion to them and really give a hand up.
Thank you for listening and hopefully acting on some of the concerns I have addressed, including rethinking on privatization of OHC properties.
1450
Mr Bill Fuller: My name is Bill Fuller. I represent the Steelworkers Organization of Active Retirees in the province. The presentation I make will be on behalf of both SOAR, the Steelworkers organization, and the United Senior Citizens of Ontario, of which I am also an officer.
I guess I regret somewhat the way the opportunity came about to address the committee here. Our organization, through Orville here, made representation or a request very early to be considered for representation at this hearing. We're still patiently waiting for a response as I guess are the rest of the retirees of this community. It kind of ticks me off, so I'll be quite honest about it.
Let me begin by thanking Gwen Lee and the Ontario Legislature for the opportunity to put forward a few of our organization's views on a far-reaching, mean-spirited Bill 26 and the effect it has on our health care, not only in our community but in the province as we see it and understand it. The bill at best should have been put forward in three or four sections so that proper attention and scrutiny as well as understanding could have been more comprehensive, not only to the recipients but to the providers of the existing health care services.
The government's original position on the bill was to put the legislation into effect with little debate or disclosure of the impact Bill 26 will have on the communities, the existing health care system and the many different segments of people in our province. Bill 26 will place an undue burden on the poor, the marginalized, the young, the seniors and the challenged in our communities throughout the province. It is our belief that a health care system cannot be operated on the basis of straight economics, which Bill 26 accommodates. The human aspect, tempered by understanding, compassion and yes, even common sense, is necessary.
The bill introduces user fees, unrestricted costs and the loss and security and protection of services established in the current health care system. Giving bureaucrats executive authority to close hospitals with one stroke of the political pen, with little or no justification, is ludicrous at best.
The government's termination of the long-term care program is another example of operating in a vacuum without the benefit of adequate study or even consultation with the local health councils that have served our community so well.
Seniors have been promoting the savings and benefits of long-term care in excess of 10 years. That's a long time. It seems the program was scuttled to satisfy the interests of a few profit-making providers in health care services at the expense of the elderly and their families, who will be the losers.
The provisions of the Public Sector Salary Disclosure Act in Bill 26 of the hospital executive officers' salaries in excess of $100,000 per year did in fact put sufficient pressure on some of our local hospitals to disclose the salaries or salary ranges of some of the hospital executive officers. Some of our hospitals did not think this was necessary even though those funds came directly from the taxpayers.
Following the tabling of Bill 26, the hospitals, namely the General and the Henderson, as well as the Chedoke-McMaster Hospitals, agreed to pursue a merger of these hospitals with the blending of services. The announcement by the hospital spokesperson indicated a huge saving in health care costs over the not-too-distant future, and that may well be possible.
The other side of that issue is the fact that the hospitals made these decisions and announcement in isolation. There was no discussion with the government, the employees of the hospitals, their unions or even the Hamilton and District Health Council. One can only come to the conclusion that the decisions were made in the best interests of the hospitals.
What will the impact on this decision have on other hospitals in our community, such as St Peter's -- and this was written before the announced cutback at St Peter's -- or the community health centre at St Joseph's in our east end? I was an integral part of watching that community health centre emanate from the fruit farm that it was prior to being what it is today.
The decisions may impact on the other surrounding communities and hospitals as well, and I'm sure they will. It'll have more far-reaching effects than just on the community of Hamilton here.
The health care system in Ontario, although not perfect, is a system that makes our province and our country unique. People from many countries visit Ontario to view first hand the health care system now in effect. I think the St Joseph's Community Health Centre in the east end is one of those facilities where people do come, on a very regular basis, to look at that type of a facility.
It's taken many years to reach the level of service that our health care provides, and it has served us well. To have any one group, be it a government that seems only interested in the economic aspect of our health care system or a hospital board that is only self-serving in its decisions, is unsatisfactory and will destroy the system as we know and we understand it.
Only understanding, cooperation and full consultation with all parties in an open and clear atmosphere where all participants are heard is acceptable. Anything less will lead us back to the system in the days -- and it's not too many years ago -- when the health care system served only those who could afford it.
Bill 26 will put that undue burden on those groups I mentioned earlier. The simple fact is that health care is a societal issue. It's not a partisan one; it's not something you can run on sheer economics. It just doesn't work.
I watched with interest in the United States the effect of grey power on the election down there where the Democratic government was elected. The issue there was health care as well. The senior citizens in Hamilton, although we may not count a great deal, over the next few years there's going to be a dramatic increase in that, and I'm certain you people know about that. These people just don't need the aggravation.
I can picture the residents of St Peter's Hospital. I'm a diabetic; I use their chiropody clinic there. I don't know how many patients they have who go through that small segment on an outpatient basis; probably 1,000, maybe 1,500. Most of them are diabetics. Under all probability that's one of the outpatient services that will be dropped. If it is, I don't know who's going to keep track of the number of limbs that are going to be lost from diabetes. I daresay that there will be many. They're all elderly that go there, let me assure you of that, and a lot of them are the frail elderly that are residents there. It just disturbs me to no end that seniors were not given the consideration that I think they should have been entitled to.
That, basically, is the presentation from the United Senior Citizens of Ontario and the Steelworkers' Organization of Active Retirees.
Mr Christopherson: To Gwen Lee, Bill Fuller and Orville Kerr, thank you very much. For those members who aren't from the Hamilton area, these are three of our leading lights in the fight to represent the needs of seniors in our community. If you spend any time at all in Hamilton, especially in Hamilton politics and Hamilton issues on the activist side of things, you'll find these three popping up constantly, out in front, making sure that the needs of seniors are being represented. Again, whenever I have a chance I like to do this. I want to thank each of you, Bill and Gwen and Orville, for the work that you do and the contribution you make to our community, and you're doing it again today. I thank you very much for that.
I want to say to you that the position of the New Democrats in the Ontario Legislature with regard to Bill 26 and the other actions of the government has led us to believe that in many ways the needs of seniors, particularly those who are low income and more vulnerable -- because, like everyone else, if you've got money you don't have as big a problem with some of these things as if you don't -- as we see it, all the measures of the government to date, in particular Bill 26, lead us to a whole series of issues that could lead to a serious decline in the quality of life of seniors in Hamilton and other communities across the province.
It is, of course, health care, which is arguably the most single important issue, but there's changes to the Ontario drug benefit plan.
1500
The housing that you mentioned, again can have an enormous impact if there isn't proper housing and the supportive services that Gwen spoke of.
When we talk about use fees, let's remember that it's seniors who use the libraries and recreation services disproportionately, if you will, to other parts of the community, and for very good and obvious reasons.
Bus fare increases are likely as a result of transfer payment cutbacks this government has made.
Seniors are very concerned about their vulnerability with regard to fire protection and police protection, and we've heard firefighters and police officers coming forward expressing concern about the ability to maintain the level of service that they have. I can't say directly to these government members, but I can on the other committees I've been on, that positions like that have them saying, "You're just fearmongering," and so I would put to the three of you who are here, do you think that that is fearmongering and rhetoric, or is there a legitimate concern in the areas I've mentioned in the ranks of the seniors in our community?
Mrs Lee: That's the way it is out there. I should long ago have given up what I'm doing, because I'm 81 and I'll soon be 82 and it's about time to wind down a bit, but I've been involved with the Hamilton-Wentworth Housing Authority, I was vice-chairman of the seniors council and all these other things that come along with it, and everywhere I go I hear, "What is going to happen to us with this Bill 26?" People are scared without even having seen it, just by what they're hearing from other people. So I'm sure if they had the document they'd have a fit, thinking what might happen to them.
Mr Fuller: Can I respond to that one very briefly? Very briefly, just imagine what's going through the minds of the residents of St Peter's at this particular time. Can you imagine what's going through their mind? They're in the latter stages of their life. What kind of a message is that to them? You know, they don't need that.
Mr Ed Doyle (Wentworth East): Thank you very much for appearing. I really appreciated your comments, both of you. You mentioned you had come here in 1946, and at that time there was no health care --
Mrs Lee: No, there was nothing. That is one of the badges that we used to use in those days when we were trying to get it.
Mr Doyle: Yes. And I think it was Mr Fuller who mentioned that we're concerned that this is an issue which should not be partisan. I think I agree with both those comments, that we're certainly not in any position where we want to see our health care system deteriorate and we certainly don't want to be in a position that you had expressed as a possible fear of losing it altogether.
We truly believe that the actions we're trying to implement are simply so that we can ensure we don't have a deteriorating health care system. We're trying to ensure that it is protected, not just today and tomorrow but five years down the road, because of our extreme concern over a debt that continues to mount -- $100 billion, $1 million an hour that we're spending, and so on. These are some of the reasons that we're taking measures that in some cases certainly may appear to be unpopular, but they're measures we're attempting to take to ensure that we protect our society, to protect the elderly, to protect all members of society, the young and the old as well.
Having said that, I would like to ask you, are you aware that under the changes to the drug benefit plan 140,000 new people will be added to those rolls? These are people who do not make very much money, less than $20,000 a year, but they will now be added to the rolls. I simply want to know if a $2 fee, in order to help finance that a little bit, will help put the 140,000 people on to the rolls to ensure they have a little bit more assistance as well. Do you agree with that?
Mr Fuller: Could I respond to that? I'm vice-president of the St Vincent de Paul in the east end of the city with Holy Family parish, and they bring aid and assistance to the poor. I don't have a book full, but I have a number of pages of families in that east end. Most of them are single-parent families with two or three children who have had their welfare cheques cut, and let me assure you, those people are not going to pay $2 for a prescription. They don't have it. They don't have enough money for food, for goodness' sake. We take food to them. It's the poorest of the poor. I don't know how you can convince the people in St Peter's hospital. You maybe even go down there this evening and ask them first hand if they're convinced that there are no cuts in the hospital budget. Your revolution speaks of that: "We will not cut health care spending." You convince them. I wouldn't want that. You just can't do it. Talk to the seniors.
Mr Agostino: First of all, I want to add to what my colleague David Christopherson said on the great work that Gwen, Bill and Orville have done in the community. Certainly from the time I spent on council I've seen them a number of times make presentations and fight very hard on behalf of seniors across this community at city council and often quite successfully. I appreciate the work and the commitment they have to our community.
Your brief says it all. I think the betrayal of seniors started the day after the election. It started the morning of June 9 and it has continued. They were not going to cut aid to seniors. This government was not going to cut programs for seniors. We saw the programs of social service agencies that dealt with seniors being gutted. We saw the imposition of user fees: a total betrayal of the commitment the Premier had made during the election that user fees would not be implemented, and particularly on the people who are least able to afford it, and senior citizens on fixed incomes and obviously with high medication costs affected by user fees. Now we have seen the health care component in St Peter's, as Bill mentioned, a perfect example of cuts to health care that are hurting senior citizens across Ontario. It's that simple. There's no other way.
St Peter's is not doing this because all of a sudden they woke up and realized they had too many staff people. St Peter's is doing this because this government has made it clear that they're not going to get the money to run the programs they're running and to give the kind of care that seniors need in this community. That is why the layoffs were announced this morning and that is why more layoffs are going to happen in the health care system and the hospital system across this city and this province as a result of your government funding cut to these hospitals who need the money to carry the programs they're carrying.
The DARTS locally, the same way. Transportation cuts have occurred. DARTS -- for people who are not from Hamilton, it is the disabled and aged transit system, parallel to the Toronto Wheel-Trans system. Major cuts have occurred there, cutbacks, as a result of transfer payments that have been cut.
These are some of the early effects that the Common Sense Revolution is having on senior citizens across this community. I think there was a gentleman who made the reference to grey power and the impact it has. I certainly realize how important it is. All of us around this table had better understand very clearly that, this betrayal continuing, there will be one hell of a political price to pay four years from now at the polls for this government. The senior citizens of this province are going to lead that charge. With that statement I'll turn to Alvin Curling, who may make a statement for the rest of my time.
The Chair: The gentleman here, did you have a comment on that, sir?
Mr Orville Kerr: I'm representing a group that is mostly senior citizens. There's a group of about 30 patients in Jarvis, Caledonia and Hagersville. This nurse, who is a friend of mine -- this is just an example -- two weeks ago she was given notice. Talk about deterioration of the health system. There's one case here where those 30 patients were relying on this nurse to look after them. They're rheumatoid arthritis patients who are unable to get out of their homes. She was given notice that her service wasn't required any more. I said, "Well, who's going to look after them?" She said: "I have no idea. They never told me." So that's one example. This has already started.
I put in an application to register for this hearing and there was so much to be said about Bill 26. After reading that bill, I never saw anything so dictatorial in all my life. When I watched those members at Queen's Park, and I was as close to them as I am now, sitting at my television and looking at those people, their attitude for the criticism the opposition members have imparted to this bill, and they wanted to put that through before Christmas -- that's a disgrace. That bill should have been split up into different sections and discussed properly. They're supposed to be representing the people of Ontario.
1510
The Chair: Thank you very much. We appreciate your being here this afternoon and your presentation.
Mrs McLeod: Mr Chairman, I would like to place two questions on the record for the committee.
The first is to the Ministry of Health. Because I feel after two weeks of hearings that answers to these questions are urgent, and because I think the information should be readily available, I ask that the response to this question be tabled with the committee before the amendment process begins on Monday morning.
The question arises from a news release that the Minister of Health has put out today in which the statements attributed to the Minister of Health are in direct contradiction to the information in the backgrounder, as to the nature of one of the specific amendments that's been put forward, and in fact appears to be totally contradictory to the amendment itself.
I point out to the Ministry of Health, so that they can follow the question, that in the news release of the Minister of Health it says, "The general manager of the Ontario health insurance plan will only be able to recover or withhold payments for non-medically necessary services on the advice of a physician." It furthermore says in a direct quote attributed to the Minister of Health, "From the outset, it was never expected that medical necessity would be determined by anyone else but a physician." Mr Chairman, I that that is a deliberately misleading statement on the part of the Minister of Health.
Furthermore, it is contradicted in the background document that is attached to the press release, in which it says, "Amendments to this section of Bill 26 make explicit that the general manager's actions to recover moneys or deny payment on the basis of `medical necessity' are guided by the advice of a physician." I think you will agree that those are not synonymous statements, that "guided by the advice of" is not the same as "withholding payments on the advice of."
Furthermore, there is a lack of consistency with the wording of the amendment itself, which states very clearly that if after consulting with a physician he or she, ie, the general manager, is "of the opinion" that all or part of the services were not "medically necessary," payment can be denied.
I will not read the whole amendment into the record, but I would like a very clear, uncategorical answer from the Ministry of Health as to exactly who will determine "medically necessary" and determine who will be able to deny payment in the first instance, on the determination of it not being a medically necessary service.
Mr Chairman, I think that is a legitimate request before the amendment process begins. As the last presenter has just said, this is an incredibly difficult bill for people to understand. The amendment process is going to be even more difficult as we attempt to go through clause-by-clause and relate this bill to previous bills to amend it.
When the Minister of Health puts out press releases which are in my view a deliberate attempt to distort the nature of the amendment, I think we have a very serious concern about the public understanding of the process we're engaged in.
The Chair: Thank you, Mrs McLeod.
Mrs McLeod: I have two questions.
Mrs Caplan: Go ahead.
Mrs McLeod: Did you want me to do the second? You may have a third.
Mrs Caplan: Yes.
Mrs McLeod: My second question is to the Minister of Health.
The Chair: Are we going to allow these people just to sit and wait to read their presentations?
Mrs McLeod: I will be very brief, Mr Chairman.
The Chair: But everybody's got their hand up for a question.
Mr Clement: It sounds like we're debating the amendments already, Mr Chairman.
Mrs McLeod: Mr Chairman, we have been two weeks, a very short two weeks, hearing from hundreds of people who are concerned about this bill, and every presenter has said it has bene difficult to understand the nature of the bill and every presenter has said, "We hope the Minister of Health will listen and will respond." I think, to take a few minutes now towards the end of these presentations to express a very real concern that there is still not clarity being provided by either the Ministry of Health or particularly the Minister of Health, is a legitimate use of the committee's time for a few moments. In that regard I will just place very briefly a second question. This one is to the Minister of Health.
The Chair: My comment was out of respect for the people who are waiting to present. That was all.
Mrs McLeod: I understand that, Mr Chairman, but I think that the people are here because they are concerned about this bill. I want to place a question to the Minister of Health, again in relationship to the news release which was put out today in which the minister says -- and it is in quotes; I realize it is not his voice speaking but it is in quotes -- "Bill 26 has always protected patient confidentiality." I would like to ask how the Minister of Health can possibly make that statement, particularly when he is bringing forward amendments to the confidentiality provision and particularly when he has not been present to hear every presentation which has raised the concern about lack of protection of confidentiality.
Mrs Caplan: I want to place one very short and quick question. There's a quote from Mr Wilson in his press release that says, "From the outset, it was never expected that medical necessity would be determined by anyone else but a physician." I see no amendment here, Mr Chairman, and I would ask the minister specifically to say where the amendment is that will delete cabinet's ability to determine what is medically necessary if this statement that the minister made in this press release today is true.
Ms Lankin: Dealing with the same specific amendment, a very quick question as it's in the press release which is reflective of the amendment, "The general manager of the Ontario health insurance plan will only be able to recover or withhold payments for non-medically necessary services on the advice of a physician." I would ask for a clarification.
It is my understanding that the general manager of the Ontario health insurance plan will also only be able to recover or withhold payments for non-therapeutically necessary services on the advice of a physician, which I believe means the general manager would consult with a medical physician with respect to therapeutic necessity of services by such health care professionals as chiropractors, physiotherapists and chiropodists.
Mr Clement: That's right.
UNITED STEELWORKERS OF AMERICA, DISTRICT 6
The Chair: Our next presenter is the United Steelworkers of America, represented by Harry Hynd, director of District 6, and Sheila Block. Welcome.
Mr Harry Hynd: The Steelworkers represent more than 80,000 women and men in a wide range of different industries in Ontario, from miners in northern Ontario to steelworkers in Hamilton to department store, supermarket and manufacturing workers throughout the province, to taxi drivers in Ottawa, to hospitals, to nursing home workers in eastern Ontario. Our members have an interest in the health aspects of Bill 26, both as consumers and as providers of health care.
The Steelworkers is a member group of the Canadian Health Coalition. The coalition works towards maintaining a universal, accessible health care system for Canadians. A useful guide to evaluating the impact of Bill 26 is the coalitions's 10 goals for improving health care for Canadians. In considering the changes to the health care system that will result from Bill 26, I found it useful to ask myself whether these changes will make progress towards meeting these goals or whether they will take us further away from them.
The goals include:
(1) Create good health;
(2) Preserve and strengthen the Canada Health Act, the foundation of medicare;
(3) Make the health care system democratic, accountable and representative.
(4) Provide a continuum of care from large institutions to the home.
(5) Protect our investment in the skills and abilities of our health care workers.
(6) Ensure fair wages for all health care providers.
(7) Eliminate profit-making from illness.
(8) Reduce overprescribing and make drugs affordable.
(9) Stop fee-for-service payments.
(10) Expand methods of health care and the role of non-physician health providers.
Make the health care system democratic, accountable and representative: If Bill 26 is passed, it will provide cabinet and the Minister of Health with unprecedented new powers over the delivery of health care and the operations of hospitals and other health care facilities. Decisions about health care will be made without parliamentary debate or public scrutiny and without input from the community, from health care consumers or from health care providers.
Until now, the Health Insurance Act has required that OHIP cover all medically necessary services provided by doctors. Bill 26 removes any reference to "medically necessary services," substituting a broad power in cabinet to decide which medical services will be insured. It will also give cabinet the power to set any limitations or conditions that it wishes.
The Public Hospitals Act is amended to give the Minister of Health virtually unlimited powers with respect to funding, operation, closure and amalgamation of hospitals. Bill 26 will take away the independence of hospitals and the communities they serve to make health care decisions and will provide overriding control to the Minister of Health and cabinet. Court decisions have ruled that under the existing Public Hospitals Act, the minister cannot ignore patient care and use only budgetary considerations in deciding whether to close down a hospital. The bill will allow the minister to close and amalgamate a public hospital whenever the minister decides it is in the public interest to do so. It then allows the minister to decide what constitutes public interest.
1520
The minister's power over the provision of funding to hospitals will no longer be limited by the regulations under the act. As a result, the minister can decide all hospital funding matters without taking into account the criteria that are now in the regulations. Funding can also be made conditional on meeting the minister's criteria. The only limitation on the minister is whatever he deems it possible in the public interest. Once again, the minister can decide what is in the public interest.
The bill also gives the minister the power to tell a hospital what services to provide, in what amounts to provide services or whether or not to stop providing certain services.
However, it seems that the total control over funding, the continued existence of hospitals and the services provided were not sufficient draconian powers for the minister. The bill will also provide the minister with the power to force a hospital to do anything else he wants to do which is in the public interest. Once again the minister decides what the public interest is.
The Private Hospitals Act was amended in a similar way. The minister will have the power to revoke a private hospital licence at any time and to reduce or terminate any grant, loan or other financial assistance without notice. The hearings and rights of appeal that are currently provided for under the act will no longer be available.
The amendments to the Independent Health Facilities Act similarly expand the powers of the minister. It gives the minister more control over the services that are currently provided under the act. It also expands the power of the minister to bring services under the act. Once they are brought under the act, the minister can control who provides the services and how they are provided.
The concentration of this kind of decision-making power in the hands of any minister would be draconian. The lack of any regulation or a definition of the criteria on which decisions are to be made reduces accountability. This is a huge step backward from the NDP government's moves to provide communities, consumers of health care and providers of health care with input into the decisions about the provision of health care.
Health care workers provide services so important to the community that life or health would be threatened if they were withdrawn. Because of this, they are denied the right to strike in support of their collective bargaining demands. As an alternative to the right to strike, these workers have access to a process of interest arbitration. A neutral third party determines their contract when the parties come to an impasse in bargaining.
Bill 26 contains amendments which will circumscribe that alternative to such an extent that it may become ineffective. The bill introduces additional criteria into the arbitration process which arbitrators have consistently found to be political in nature and impossible to apply in practice. These additional criteria are the employer's ability to pay in the light of its fiscal situation; the extent to which services may have to be reduced if the current funding levels are not increased; the economic situation in Ontario and in the municipality or municipalities concerned; a comparison of the terms and conditions of employment and nature of the work performed with other employees in the broader public sector; and the employer's need for qualified employees.
Arbitrators will have to take ability to pay into account in their arbitration decisions. At first glance, this may sound reasonable. However, arbitrators have been unable to define "ability to pay" in the public sector. They have argued that "ability to pay" in the public sector really means "willingness to pay," which is unilaterally determined by the employer.
The criterion could allow governments and employers to unilaterally determine wages and benefits by simply allocating a fixed or reduced amount for employee compensation in their transfer payments or budgets. It compromises the independence of arbitrators and the integrity of the arbitration process by leading them to a predetermined result and biases their decisions in favour of employers. The International Labour Organization, in 1985, acknowledged that the imposition of an ability-to-pay criterion deprives employees of a fair and impartial mechanism for determining their terms and conditions of employment.
It will also undermine the collective bargaining process. It is the uncertainty of the outcome of the interest arbitration process that provides an incentive for reaching a negotiated settlement in the health care sector. The amendments in Bill 26 eliminate that uncertainty. Employers will be able to fix or reduce the budget for employee compensation and then turn around and argue that arbitrators are bound by the employer's own budgetary decisions. There would be little, if any, incentive for employers to reach an agreement when arbitrators, in their awards, will have to impose the employer's position.
The amendments in Bill 26 will also require arbitrators to take into account potential public service cuts in their awards. This puts arbitrators in the position of making decisions about the levels of public services that will be provided. These are decisions that should be made by politicians who are accountable to the public.
The bill continues on to introduce two other new criteria: the economic situation in the municipality, and the employer's need for qualified employees. These criteria add further complexity to the arbitration process. Wages in the health care sector have been moving towards an industry norm over the last 20 years. Arbitrators will now be required to evaluate the relative economic performance of municipalities in the province. They will then be required to determine what the impact of these differences in economic performance should be on wage rates. Putting aside the difficulty of this task, what is the point of it? If the steel industry is in a slump, why should that have any impact on the wages of health care workers?
The Steelworkers represent workers in nursing homes, retirement homes and hospitals across Ontario. These workers provide care for the sick, the elderly and the infirm in our society. They provide the support services that allow the rest of us to continue to go to work and to school and to care for our children. They let us do these things with the assurance that members of our families who are in need are cared for. These women -- for the vast majority of the workers are women -- do work that is literally backbreaking. The injury rate in this industry is notoriously high. These workers do not receive public acknowledgement or recognition for the essential services they provide. However, the least we can provide them with, as a province and as a society, are fair wages and working conditions. The proposed criteria in Bill 26 will prevent these workers from keeping fair wages and working conditions when they have achieved them, or from ever attaining them if they have not.
The bill will eliminate the requirement in the Independent Health Facilities Act that preference be given to non-profit Canadian operators. This opens the door to for-profit US health care providers to be licensed and provide health care services under the act. Shame, shame, shame.
Bill 26 will amend the Ontario Drug Benefit Act so that the government can introduce a system of user fees. There are also changes to the pricing of drugs under the act. The bill replaces the existing best-available-price requirement with a price agreed to by the manufacturer of the drug. The bill will deregulate the price of drugs charged to everyone who is not covered by the Ontario drug benefit plan. Manufacturers will be able to charge whatever they like. This deregulation, in combination with the monopoly power that the federal Tories gave to multinational drug companies, will result in increased prices for prescription drugs. It will also result in more variation in the prices of drugs across the province. In remote areas like the mining communities in which many of our members live, there will likely be large increases in drug prices.
1530
The concentration of power in the hands of any government to the extent contemplated by this bill would be wrong. This bill punishes health care workers. It further removes decisions about the provisions of health care services from consumers and producers of those services and denies the democratic process. All of this is aimed at reducing health care expenditures by at least $1.4 billion. The huge reduction will be implemented by a government that promised not one cent of spending would be cut from health care.
Bill 26, unamended, will reduce the quality of health care in the province. The government should proceed with those portions of the bill that are essential for the functioning of government. It should give much more extensive study to the rest of the bill and allow for much more public input. Thank you.
Mrs Ecker: Thank you very much for coming today and bringing forward some very detailed and comprehensive comments about your concerns about Bill 26. There are just a couple of quick points I'd like to make.
With Bill 26, there's certainly a lot of disagreement about who decides what a medically necessary service is, but I do believe, from my reading of the legislation, that medically necessary services as a concept are certainly included and maintained in Bill 26, so I think that's a piece of information that may be of assistance to your consideration of the legislation.
Secondly, the other point that I would like to make as well is that this government -- and I've said it many times during these hearings -- is not prepared to get into a non-productive fight with the federal government over the Canada Health Act, and there are many references in Bill 26 to abiding by the Canada Health Act. There's another one here that talks about, "A regulation...shall not include a provision that would disqualify the province of Ontario, under the Canada Health Act, for contribution by the government of Canada...." So I think there's certainly not only an intent and an objective but wording that would also support that, because we believe that is also something that is very, very important.
One of the things that we did talk about in the election -- and again, I can only speak for what I said in my riding, but I was very, very clear that what we were talking about was maintaining the health care envelope at $17.4 billion and restructuring within that envelope and finding savings from one area in one kind of care to reinvest into another area or another kind of care. And we've heard very much from many people here about the unique needs in various communities and various regions for different kinds of reinvestment. We've also heard we need some mechanism -- there's disagreement about how, but we certainly have heard the message that we need to get on with reforming and changing the system.
You've made some criticisms about the current restructuring powers the government has. We have put forward some amendments which may or may not address your concerns. Do you have any further comments about how you believe the restructuring exercise should be continuing within communities so that we can get on with an objective that I believe we all share?
Mr Hynd: Well, you've asked lots of questions. I'll try to answer the ones I can remember.
I derive no satisfaction from what you may have said to your constituents. I can only derive my information from what I read in the Common Sense Revolution, what I've heard from the government in the media, what I saw on the television and what I've read in the legislation.
I don't believe anyone could expect that the health care system would continue to provide the same kind of care that it does if you say there's a spending envelope that's going to stay closed. That's like saying to anyone in Ontario that we're going to improve and maintain your standard of living, but your wages will remain constant.
I can also tell you that I know that health care in Ontario will deteriorate. I can tell you that I know that the health care providers will be demoralized by the results of this legislation. I can tell you the standards of living by the health care providers will deteriorate. I can tell you that the provisions and the services that they provide will not be maintained. That's just a fact of life. If you think about your envelope and you think about 10 years down the road and you tell me that that envelope will provide the same services, I doubt it.
Mr Alvin Curling (Scarborough North): This is a government that took 22% from the poor and told them that they can live better. This is the government also, as you said, sir, that took $1.4 billion from health care, which told us that they would not take one cent out, and tried to look us straight in the face and say they haven't touched it. We saw it. We saw it in the statement they did, and still coming to us and telling us they didn't touch it. This is the government too that tells you, as you sit here and give your presentation: "Tell us more. You haven't told us a thing." That's what the Tories have said: "Could you tell us more." I would say to this government that giving you, sir, and the people of Ontario the limited time to comprehend this huge bill, which they don't understand, and asking you, "Give us more," you've given us a lot to look at.
My question to you is, having given us all of that to examine, do you think they have listened? Do you think they heard it? Do you think they'll change?
Mr Hynd: I don't have any sense the government will change. The government was forced into these hearings. It's unfortunate that these hearings didn't last much longer. I think that given an opportunity, the populace of Ontario would want to speak about the negative impact this bill will have on the people of this province in a myriad of ways, including our rights. We would be talking about this for an eternity. This is a draconian bill.
Mr Curling: As you can see, our leader and all the members of the opposition asked for extended time with this bill. Not partisan stuff, but to understand the impact that this is going to have on the lives of our people.
The senior citizens were here a while ago and mentioned about selling off the houses on the senior citizens, which the minister has indicated he will do, and the appeal to them, "Don't do this, because things that you have done before are hurting us." And the minister continues to say he will sell off all the Ontario Housing to the private sector without any concern.
Tell me, do you see any face at all, any soul or so, any human feel of this bill, or just the bottom line, talking about $1 million is being spent on paying off the debt? Do you see any concern for people in this bill?
Mr Hynd: If there was a care for human souls in the provision of health care in this bill, the bill would look a lot different than it does. It would be trying to improve health care. It would be offering health care providers an opportunity to tell the government how in their view health care could be improved. We do have a good system, but it's not perfect. I think this will make the health care system much worse in Ontario.
I know that I derive no satisfaction from all levels of government that affect us here in Ontario with respect to the health care of Canadians. In the federal government there seems to be an indication of the same problem, that they are looking at health care with an economic viewpoint rather than the economics not being dictated in reducing the provision of health care. If in fact the government, both levels of government, were really interested in saving money from health care, they would look at the huge salaries they have paid to a whole bunch of hangers-on. They would look at the massive profits that have been made through the deals that were made on the drugs and that will be extended by this legislation. So I think health care is going to be a lot worse than it is.
Mr Christopherson: I want to thank you, Harry, for coming in and making this presentation. In Hamilton, of course, steelworkers are a significant and important part of our community and have shaped in large part a lot of the values that our community has. I think it's great that you came in here today and spoke not only on behalf of Hamilton steelworkers but all 80,000 of your members across the province.
You will know that this government from the outset, even before the election, has done everything it can to take unions and slap a label on them of special-interest. In making that label stick they can then disregard and dismiss you by trying to convince people that the only thing you care about is you and yours, and everybody else be damned. Unfortunately, they've been able to do that with an awful lot of people like environmentalists, feminists and people who fight for those in poverty etc. Eventually there's nothing left but their own special interests, which of course are the very well-to-do in this province.
I say that because I think it's worth noting that fully half of this presentation had nothing to do with wages, had nothing to do with working conditions of the members of the Steelworkers' union in Ontario but rather spoke to health care, quality of life, public services, all the things that make Ontario the great place to live in that it is and all the things that this government seems to be going after. That needs to be said time and time again.
I want to draw attention to page 5, Harry, where you talked about the fact that their changes to the Independent Health Facilities Act may open the door to non-profit, US-type health care. At the end of that you threw in, "Shame, shame." Why should your members and other workers in this province care so much about the introduction of for-profit, US-type health care services in Ontario? Why does that matter to working people?
Mr Hynd: It matters to working people and should matter to Canadians. If one really looks at the health care system in the United States, the people I spoke about making ludicrous salaries in the health system have expanded 100-fold in the United States. It's a big-money business. Anyone who wants to look at the operations that have been performed with frequency, for money -- when you're in business, you're selling a product. If you're selling the removal of appendices, then that's what you'll do. I think it's criminal that we would open the doors to profiteers, because the health care system was introduced because people couldn't afford to pay for health care on the basis of when they needed it.
I don't have to go back to 1946. I didn't come here in 1946; I came here in 1957. I can remember in the 1960s when a young child three months old was injured in Hamilton, brain-damaged, no ability to fix that in Canada. The cost of that operation to that child was $10,000 in the 1960s. I made $2,000 a year in 1960. The parent of this child was an electrician. We had a collection in the plant and collected about $5,000. But that Steelworker today -- or I should say yesterday -- would have no fear about his ability to have his child looked after in a humane, professional and decent way. But tomorrow that Steelworker is going to be concerned.
The Chair: Thank you, folks. We appreciate your presentation and your interest in our process.
We're going to take a short three-minute recess.
The committee recessed from 1544 to 1547.
ST JOSEPH'S HOSPITAL, HAMILTON
ST JOSEPH'S HEALTH CARE SYSTEM
The Chair: The next group of presenters represent St Joseph's Hospital: Sister Joan O'Sullivan, Mr Paul Wendling, Mr Allan Greve and Mr Brian Guest. Welcome.
Sister Joan O'Sullivan: Thank you, Mr Chairman, for the opportunity to respond to Bill 26, the Savings and Restructuring Act. My name is Sister Joan O'Sullivan. I am the vice-president of St Joseph's Health Care System and am here on behalf of Sister Teresita McInally, who is president and chair of St Joseph's Health Care System. My past experiences include time spent as a CEO in two hospitals within the Hamilton diocese.
With me are Mr Paul Wendling, chair of the board of trustees of St Joseph's Hospital, Hamilton, and member of the board of directors of St Joseph's Health Care System; Mr Allan Greve, president and CEO of St Joseph's Hospital, Hamilton; and Mr Brian Guest, executive director of St Joseph's Health Care System.
My comments, as well Mr Greve's, will deal mainly with the implication of this bill for community-based services provided by member facilities of St Joseph's Health Care System. Please understand that St Joseph's Health Care System recognizes the need for reform of health care in the province of Ontario and is committed to the communities it is privileged to serve.
St Joseph's Health Care System was incorporated in 1991 and represents a consolidation of the health care ministry of the Sisters of St Joseph of Hamilton, which has provided health and social service to the communities in the Hamilton diocese for over 130 years. Our health care ministry is governed through volunteer representation from our communities on local boards of trustees and encompasses programs and services offered by the following member facilities: St Joseph's Hospital, Brantford; St Joseph's Villa, Dundas; St Joseph's Hospital and Home, Guelph; St Joseph's Hospital, Hamilton; St Mary's General Hospital, Kitchener.
In 1993, we expanded the board of directors of St Joseph's Health Care System to include lay representation through the board chairs of our member facilities. As you can see, we are well represented in both the long-term and acute care sectors in delivering care. Our mission reflects our Catholic values and emphasizes our respect for the dignity of all persons, regardless of age, race, religion or infirmity.
Earlier today you heard from Bishop Tonnos and Mr Ron Marr from the Catholic Health Association of Ontario as well as representatives of the Salvation Army and Jewish hospitals in Ontario. I would like to state our unequivocal support for the content of their brief. I would also request that the panel reflect on the current and historical contribution to health care in this province made by denominational sponsors when considering this legislation.
I would like to reinforce our appreciation for the recognition given by all three political parties for the ongoing role and respect for the governance of denominational providers. St Joseph's Health Care System and the Sisters of St Joseph of Hamilton have always demonstrated leadership in this diocese during turbulent times in our history. We accept the challenges before all of us and we are most willing to be a part of innovative and creative solutions.
I will now ask Mr Allan Greve to highlight a number of key issues in this proposed legislation and the potential impact on our communities.
Mr Allan Greve: Thank you, Sister Joan. In our presentation we would like to deal with four major themes, namely: (1) the voluntary governance; (2) economics; (3) the relationship of the physicians and the hospitals; and (4) the Health Services Restructuring Commission.
First of all, voluntary governance is a cornerstone of what is right with health care in this province. Under the current system, boards of hospitals and homes for the aged are viewed as some of the most prestigious appointments for leaders in our areas where we live and as such we can attract men and women who have attained leadership roles in the places that they live and work on a day-to-day basis.
The changes as they submitted in Bill 26 range from: (1) the appointment of hospital supervisors; (2) the roles of the Lieutenant Governor in writing and dissolving existing hospital bylaws; (3) the unilateral determination of programs and services which are and will be offered by the facility; and (4) the forced merger of hospitals.
We are pleased with the amendments on the first two issues but would like to comment that the last two issues give us some concern in that these changes will no doubt have a major impact on the ability to recruit and to retain these same community leaders. The panel may wish to ask themselves if they would be willing to donate their time and services to community organizations and be compromised, perhaps, in how they would give that kind of time and energy.
You may also wish to consider how the membership and the demonstration by voluntary governors in the hospital and home boards stack up against their counterparts in the educational and municipal sectors who are elected and paid. I believe that's a very important point that this commission should consider. We feel that our voluntary board members are second to none, and any proposed legislation must surely consider the implications of this.
Economics: In this legislation there appears to be a predisposition to the utilization of forced mergers as a mechanism to achieve fiscal savings. Hospitals in Ontario have responded over the last several years to the economic realities we have faced by taking major measures to improve efficiencies and curb costs. We have, in essence, cut the cost but not the care. These include, but are not limited to, maintaining quality of care in light of reduced funded, improved inpatient utilization rates and increased efficiency through the use of ambulatory alternatives.
In St Joseph's Health Care System we have taken the leadership over the past 15 years through major things to take advantage of economies of scale in all of our facilities. These facilities, as you have seen, include a teaching hospital, a home for the aged, a health centre and a hospital that serves the broad community. Some examples of our initiatives include joint banking agreements, combined employee payrolls and benefits, consolidation of purchasing stores and matériels management, joint contracts and many, many more.
An independent audit of these services and system activities has indicated that overhead costs in the millions of dollars per year are saved and reassigned to direct patient and resident care.
Over the last years, we have expanded our horizons to include many hospitals from both the denominational and the non-denominational sector. In matériels management, for example, we currently coordinate the capital purchases for over 30 hospitals in Ontario, ranging from Windsor to Kingston and from Hamilton to Kapuskasing. This is an example of the kind of innovation which should continue to be encouraged.
The mindset of the day appears to be that of forced mergers and that forced mergers are the solution to all economic woes. This is clearly without foundation in health care. The research studies both in Canada and the US do not support this finding.
An alternative to these forced mergers is the meaningful cooperation and collaboration between partners on a voluntary basis after a careful development of the business plan and firm evaluation criteria. If we look at some studies, perhaps the latest one, which has been circulated to you, of Barbara Markham and Jonathan Lomas, published in Healthcare Management FORUM -- this recently published very important findings that mergers, when compared with other multihospital arrangements, are no more efficient in reducing costs or improving quality of care.
So I go back to this: We have many examples at St Joseph's Health Care System, ranging from contracting laboratory services in Brantford and Kitchener -- Waterloo to the major collaboration effort between St Joseph's Hospital here in Hamilton and the Hamilton Civic Hospitals, both in the clinical and the non-clinical sector. Our agreement with the Hamilton Civic Hospitals was developed following full disclosure and acceptance of the collaboration policy of St Joseph's Hospital and St Joseph's Health Care System. You have a copy of that, which is appendix A. Second of all, it is consistent with the Catholic Health Association of Ontario guidelines for collaboration. This represents a dynamic model for the province, while maintaining the integrity of the key governance issues.
Let me move to public versus private sector. We feel that the hospitals are willing and able to compete with the private sector in all areas of support and clinical services, providing there is a level playing field. For example, there are currently major inequities between the funding from the Ministry of Health for laboratory services in Ontario. The private sector laboratories receive approximately 20% more funds for the same tests that are done in a hospital-based laboratory. If the government is serious about rewarding innovation in hospitals, then it must develop mechanisms by which hospitals can compete in a meaningful fashion. We have concerns that any new arbitrary powers of the minister under, for example, the Independent Health Facilities Act, could leave a significant negative impact in this regard. A process must be in place that is open and encourages competition on an equal basis.
1600
Let me move to physician and hospital relationships. While this is not covered explicitly in the legislation, we are aware that the government is currently involved in intense negotiations with the Ontario Medical Association in a number of fronts.
We caution the government to be cognizant of the interrelationship between physicians and hospitals and the dependencies of our communities on this stable relationship. Medical staff voluntarily contribute time to ensure that the quality of care is not compromised, and any proposal which in effect would drive a wedge between the hospital and the physician must be carefully considered.
For example, there are current discussions between physicians and the ministry in respect of liability insurance. You heard this afternoon from the obstetricians and the chief of staff of Oakville, and while we do not wish to take sides on this issue of subsidization of this insurance, the minister needs to recognize the key role that family practitioners and obstetricians play in the provision of obstetrics in our communities and be cognizant of the potential negative impact on the ability of this care if insurance rates increase dramatically.
Health Services Restructuring Commission: One of the most significant aspects of this legislation is the formation of the Health Services Restructuring Commission. We note with approval the minister's announcement on January 17 of the proposed amendments limiting the terms of the commission, as well as certain powers of the minister, to a four-year period. Unfortunately, there are few details as to the membership or the terms of reference of this body. We do, however, have a number of suggestions for the minister if he proceeds with the commission. These include:
(1) The commission should be directly accountable to the minister for all of its terms of reference.
(2) There should be a well-defined appeal mechanism for the hospital board directly to the minister in the event that there is disagreement on any recommendations from the commission.
(3) Research and evaluation are essential components for health reform and need to be protected and utilized if we are to ensure the efficiency and the effectiveness of the system.
(4) The commission should receive a detailed orientation of governance issues, including those from the denominational providers and partners.
(5) The commission should be directed to consider briefs directly from impacted hospitals as well as from local DHCs or other bodies.
(6) Solutions to health care reform should not be limited to the traditional mandate of the local DHCs and should be opened to innovative solutions between communities and across sectors, similar to the kind of things that I was talking about between the St Joseph's partners in many sectors which have different district health councils. No community in this province can deal with all health care issues in isolation, and to this point there has been little attention given to the impact of local decisions on surrounding communities. As another example, the teaching hospitals in the Hamilton area, as many of you around the table know, have tertiary responsibilities and roles for the central-west region of our province.
(7) The commission should be mandated to study research in the United States, Canada, New Zealand and other countries on alternative models from both a quality of care and an economic standpoint. To suggest that the formation of cartels in health through forced mergers is a panacea defies well accepted business logic and research.
(8) The commission should be encouraged to challenge the health care industry to find new innovative solutions to traditional problems. For example, academic health care networks should be encouraged to participate in solving difficult problems in rural remote communities through collaborative endeavours.
(9) A separate opportunity for debate and input on the Health Services Restructuring Commission should be conducted when the draft membership and terms of reference are established.
I just want to close by drawing to your attention one last thing: the Hospital Labour Disputes Arbitration Act. We agree with the thrust and the proposed changes to this act. However, we are concerned that, as drafted, it may not have the desired effect. Hospitals cannot be left in the middle; we cannot be the ham in the sandwich in respect to this. The government must be clear. It must have definition to what it is saying. We request then a clarification of the ability-to-pay criteria and a modification of the external comparison criteria to enable comparisons to similar private sector jobs.
In addition, we request a criterion that would require arbitrators to consider the employer's need for staffing flexibility as hospitals restructure. I think we're all aware that, consistent with other jurisdictions, Ontario's experience with the public sector price and compensation review act of some time ago demonstrated that arbitrators cherish their independence and in many cases give lip-service to legislation around ability-to-pay criteria. If the objective is to ensure that arbitrators adhere to these criteria, then all awards should be consistent with it. From the hospital's point of view, we seek that clarification. Health care is difficult to deliver in its present mode and we do not need ambiguity.
The last thing is that there is $17.4 billion in this system. We have been promised that all those dollars would stay in the system. I guess I'm going a little further to say that I believe that around this table and in this community, the $1 billion that is assigned to the Hamilton-Wentworth area should also be left in the envelope for Hamilton-Wentworth to resolve issues of local priorities and our needs.
I'd like now to pass it back to Sister Joan.
Sister O'Sullivan: I would like to summarize the key points raised in our brief.
First, voluntary governance: It works. Don't destroy it by minimizing its mandate. The appointment of a supervisor should only be made in extraordinary situations.
Secondly, economics: Reward efficiencies but be open to alternatives. Monopolies are not the answer. Hospitals need a level playing field to compete with the private sector.
Physician-hospital relationships: Be wary. Consider the interrelationship between hospitals and physicians.
Health Services Restructuring Commission: This body should be accountable to the minister and open to creative solutions.
The Sisters of St Joseph of Hamilton and St Joseph's Health Care System welcome the opportunity to work with our elected representatives in government and our communities to find innovative, constructive ways to reform our health care system. We ask, as others have, to be considered part of the solution and not part of the problem.
Mr Agostino: I will just take the first part very briefly and then Mrs Caplan I think will do the rest. I just want to acknowledge on the record the tremendous work the Sisters of St Joseph's have done over the years in the health care industry in this community, a 130-year record, and particularly the work of Sister Joan in her years as the CEO for St Joseph's and as well the work of the board of directors, Mr Greve, and the whole community and the diocese that has been involved in I think developing a first-class facility. The presentation today is an example of that type of leadership they provide, and again in particular Sister Joan, on behalf of the community. Thank you very much for the dedication you have given to St Joseph's and to the health care system in this community for a long, long time.
Mrs Caplan: I'll be very brief. I too would like to just acknowledge the work that has been done in Hamilton to provide a system, and to suggest that what I've heard you say today is that, with some assistance from the ministry, you really could get on and do what else has to be done on your own, to do the reallocation in the community. Is that correct? What you're saying is: "We know change has to happen. We've been the leaders in the past. Leave us alone and we'll be the leaders in the future. Don't threaten us. Don't coerce our physicians. Create a climate that will be a positive one where there can be partnerships. Don't poison the environment."
Mr Greve: Yes, exactly.
Mrs Caplan: We know -- I know; not everybody knows -- Hamilton has always been an example of cooperation among the hospitals and rationalization of services and good relationships between the hospitals, not only lack of inappropriate competition but real cooperation in the system's development.
1610
Mr Greve: I would just add a few words to that. Perhaps we might just take as proof of that our latest interrelationship, our collaboration agreement with the Hamilton Civic Hospital. There's a perfect example where voluntary governance from St Joseph's and also with the Civic can work, is working, and it provides the efficiencies, the effectiveness; it provides the interrelationship of the physicians into the system. It produces quality care at a very reasonable price. It's efficient and effective.
Mr Christopherson: I have a brief comment and then my colleague Frances Lankin will have a question. I'm sorry I missed most of your presentation. I had an urgent call to make. But I did want to also join with my colleague Dominic Agostino and acknowledge the contribution St Joseph's Hospital makes. It's in the heart of my riding. I was born there; more importantly, my daughter Kayla was born there, so I will always think the world of the staff and the management of the people of that hospital. The contribution you've made overall to health care in Hamilton I'm sure will stand the test of time as we go through these very difficult times.
Ms Lankin: I wanted to talk to you a little bit about the issue of voluntary governance. Some of you will remember when I was Health minister I walked right into this issue, when there were musings about elections of hospital boards and I didn't understand what that meant in the area of denominational hospitals, and you very quickly educated me, if I remember.
In general on this issue of voluntary governance, not just for your own hospital but non-denominational hospitals, I can remember the current Minister of Health being very critical of me as I was trying to work in the long-term-care area and trying to end duplication at the local community level of a myriad of organizations delivering services to seniors, and we were trying to get them combined together in a multiservice agency, still with voluntary boards and everything.
I mean, this was horrid, the thought of forced mergers -- I'm going to use your words -- of these organizations. The minister in those days called me a person who saw no value in voluntary governance and volunteers, and undermining the role of volunteers. I want to know what changed, in your mind. I have the sense from your presentation that you're as worried about that from the perspective of this minister, forced mergers of hospitals and what it means around the voluntary governance of hospital boards, as that minister was when he was Health critic on multiservice agencies. Am I correct?
Mr Brian Guest: I wonder if I can respond to that. I think one of the significant issues that we face in all our communities, particularly in our smaller communities, is the tremendous time in defensive posture our volunteer members get put in. The reason they join the boards -- and again I'll echo what Allan says. I believe the quality of people is second to none in both the denominational and non-denominational sectors. What's unfortunate now in this era of perhaps intuitive thought without business reasoning is that they spend an inordinate amount of their time defending their organization versus what they joined the board for in the first place, and that's to represent their community to deliver quality of care.
So a sound look at why people join these boards and to bear in mind that they should not be put in a position of continual reorganization, restructuring -- they should be put in a position of representing their communities and determining what is best for their communities. That's why they joined in the first place.
Mrs Johns: I'd like to thank you for your presentation today. I just wanted to talk a little bit about the role of the district health council and how you view it from the perspective of the denominational sector. If a district health council had good community discussion and they came to a plan that they felt and that the community believed broadly outlined what the community wanted with respect to health care, for example, and let's say that in a particular case, obviously not in the Hamilton case, that it was suggested that a denominational facility shouldn't go on, is it your position that you would recognize what the district health council had said and abide by that and it's only the governance issue that you're concerned about, or is it the whole issue of the hospital and the consultation process?
Mr Guest: With respect, there's not much of a governance issue if the facility ceases to exist. I think the district health councils vary the same as perhaps hospitals in their ability to deal with some of these issues, and the community supports -- it depends on the process which is taken. What we're asking is that the individual facilities, whether denominational or non-denominational, be given the opportunity of direct access to present their case. The case has to be based on business logic, not somebody with a cookie cutter who says, "Well, I've got the way to do it; let's merge these places, and that must save money," and nobody has done a good analysis.
What we're saying is -- I mean, there are going to be perhaps facilities where the Catholic hospital is the provider, and I would expect the non-denominational will be as thrilled about that as we are in the alternative -- there needs to be direct access. I would suggest that with the district health councils, with the greatest respect -- we have the joy of four different district health councils in our system and it varies. We want the opportunity, and we would suggest that all hospitals and homes, if they're involved, have the opportunity, to present our case and their case on an equal footing.
The Chair: Thank you very much, folks. We appreciate your presence and your interest in our process.
Mrs Caplan: I'd like some questions on and at the same time reference a letter from Dr David McCutcheon, who is the present chief executive officer of the Hamilton Civic Hospitals. They have said in their letter, "We believe that in our community Bill 26 is unnecessary." The bottom line in their letter, the last paragraph: "We believe, as do our partners, all health care providers and supporters in Hamilton, that we have the ability, the will, the right and the demonstrated track record to effect a made-in-Hamilton solution to health care within our region. If we are wise, you may be able to show Ontario and the rest of Canada a model for effective health care."
I'm not going to read the whole letter. We have one of the partners here at the table. We had the district health council. My question to the Minister of Health is: Why will you not permit communities which are willing to show this kind of leadership and which are willing to work with the ministry without the coercions of Bill 26 to show you what they can do? Will you delay the passage of Bill 26 to allow communities like Hamilton to become a model for the province of Ontario?
1620
ONTARIO ASSOCIATION OF SPEECH-LANGUAGE PATHOLOGISTS AND AUDIOLOGISTS
The Chair: The next presenters are from the Ontario Association of Speech-language Pathologists and Audiologists: William Hogle, executive director; David Barr, president; and Fiona Ryner. Welcome to our committee.
Mr William Hogle: Thank you, sir. You had the names of the presenters today quite correct. Mr Chairman, members of the committee, my name is Bill Hogle and I'm executive director of the Ontario Association of Speech-language Pathologists and Audiologists, better known, fortunately, as OSLA. OSLA is the professional association which represents over 1,600 speech-language pathologists and audiologists across Ontario. With me is David Barr, OSLA's president. David is a practising audiologist and has been a member of our government affairs committee for a number of years. Also with me is Fiona Ryner. Fiona is a speech-language pathologist with over 26 years of clinical and management experience in Ontario. She is the immediate past president of OSLA and has been active in a great deal of health care work, including work with district health councils.
In a moment you will be hearing from David and Fiona. Before you do, Mr Chairman, I would like to thank you and your colleagues for giving us the opportunity to present today. We appreciate the high level of public interest in your deliberations and we're grateful to be included in your tight schedule.
At the very least, Bill 26 is a huge meal requiring some time to digest, and we do commend the Legislature for its wisdom in making this forum available. It is also particularly gratifying to address such a senior panel in terms of leadership experience in Ontario's health care system, a panel that includes two former Health ministers, one of whom I had the honour of serving at one point during a 27-year career with the ministry. Indeed, Mrs Caplan, that was an honour.
Our presentation this afternoon will be non-partisan but it should not be construed as universal support for Bill 26. Rather, it's a recognition of the reality and of certain opportunities that do exist, we believe, within this legislative package to correct some long-standing system flaws, opportunities that will never be realized, however, in the absence of a political will to do so.
Communication disorders: One in every 10 of us suffers from a communication disorder. That probably surprises you. Unfortunately, it surprises most people. In part because of their invisibility, communication disorders and the treatment for them often have been poorly understood, we believe, by the makers of public policy in Ontario. Your committee can remedy that situation. I'll now turn the presentation over to Fiona Ryner.
Mrs Fiona Ryner: Let me start with some background. Speech-language pathologists are regulated health professionals with a master's-level education in their specific field. They address the speech, language, voice, fluency and swallowing needs of individuals across the entire age spectrum. Services are funded primarily by public moneys, with the ministries of Health and Education and Training as the predominant paymasters and a small component being funded by the Ministry of Community and Social Services. Clients can access service on a self-pay basis outside of institutions and have some limited opportunities for third-party reimbursement.
Speech-language services are both needed and valued by consumers. Communication is the basic medium for all cognitive functions, and therefore intact communication is a requisite for most of what individuals do. Unaddressed communication problems can therefore have substantial ramifications for both the individual and the system.
In recent years, we have experienced the first wave of what we anticipate is an ongoing trend of service reductions and eliminations. The lack of a mandate within any sector to provide speech-language services, coupled with substantial autonomy that has been afforded to hospitals and other health care institutions in managing their funds, has rendered our services highly vulnerable. While this has been occurring throughout Ontario, in the interest of time I will speak only about the greater Toronto area.
A few years ago, York Central Hospital closed its speech-language pathology service, leaving a large segment of York region without services. Two years ago, Joseph Brant Memorial Hospital closed its outpatient speech-language pathology service, leaving a service void in a portion of Halton. This translates into children entering school with unaddressed communication difficulties who are experiencing and continue to experience substantial social, behavioural and educational ramifications. It also translates into adults who do not redevelop their understanding and expression of speech and language after a stroke and whose social and vocational lives are therefore effectively ended, or adults who may lose their jobs due to severe stuttering or perhaps a hoarse voice.
The Joseph Brant closure was followed in the last year with two of their neighbouring hospitals in Halton and Peel considering major reductions in speech-language services. Consumer distress and opposition were evidenced in a public outcry in all four of these instances, but two of the four remained firm in their decision and the other two communities continue to face significant uncertainty about the future.
We have seen a growth in private services within the profession in direct response to service cuts and we therefore have a burgeoning two-tier system where out-of-pocket expenditures are no longer a personal choice but rather the only option available in some communities. Consumers call the OSLA office asking where they can access insured services. They've been frustrated in their attempts as they've pursued a desperate quest to access any degree of service possible. We have no answers, so many go without.
Without a mechanism to monitor and manage system restructuring, this erosion will escalate. Only an effective resource allocation process can prevent further and irreversible damage. Bill 26 appears to offer a damage control mechanism.
I would refer the committee to the 1995 final report of the Metropolitan Toronto District Health Council hospital restructuring committee. This report identifies 12 hospitals for closure, since amended to 11, and includes some broad references to relocation of services. This report has also identified a proposed expansion of inpatient and outpatient rehabilitation services to respond to existing shortages and future increases in need. It also projects a 0.8% increase in direct patient care providers by the year 2001.
As the committee knows, DHCs have been the minister's advisers on regional health care resource allocation and reallocation. The Metropolitan Toronto District Health Council report makes recommendations to the Minister of Health. This report has attracted considerable attention, and other DHCs will follow suit across Ontario.
As a result, OSLA has developed its position for your committee: This report underscores the need for any rational restructuring process to ensure that not a single speech-language pathology position is lost in the re-engineering of the system.
The commitment of this government to maintain health care spending at $17.4 billion should accommodate protection of needed services. But without the development of appropriate mechanisms to oversee redistribution of funds, this will not happen.
As hospitals downsize, speech-language pathology services must be relocated to other funded community settings. Relocation options could include community health centres, children's treatment centres, public health units, shifts to other hospitals or perhaps an independent health facility. We understand that with Bill 26, speech-language pathology could be designated as a service under an IHF. We also understand that this is unlikely, because speech-language pathology is currently not an insured service. It is our intent, therefore, to let you know that OSLA believes that an independent health facility could be an appropriate alternative model for the delivery of speech-language services.
I now return to the restructuring mechanism.
Bill 26 amendments to the Ministry of Health Act identify a Health Services Restructuring Commission. We note with some concern that there is little information about its structure and function, but we also note that it will be given extraordinary power and authority through regulation and is therefore seen as the "high court" of system restructuring. To reiterate our concern that no speech-language pathology position should be lost during restructuring, it is therefore critical that our profession be represented through a seat on whatever is to become the appropriate element of this commission.
In the absence of information, the restructuring commission casts a shadow on the role of district health councils. OSLA supports the DHC process as a proven resource allocation facilitator and would recommend that DHCs remain as a key participant within the restructuring commission.
To summarize, Mr Chair and members:
OSLA believes that every speech-language pathology position that is displaced must be immediately restored elsewhere in the community.
OSLA supports the potential of Bill 26 to provide a mechanism to make this happen. In order to realize this potential, OSLA wishes to be represented on whatever becomes the appropriate element under the Health Services Restructuring Commission.
OSLA urges this government to maximize the potential for district health councils to facilitate the work of the restructuring commission.
OSLA encourages developments of provisions under the Independent Health Facilities Act to provide access for currently non-insured services such as speech-language pathology.
Thank you for your time and attention. I'll now pass the floor to my colleague David Barr.
1630
Mr David Barr: Audiologists, who are also trained in graduate school, are involved with the hearing aspect of communication disorders. We assess the nature and degree of hearing loss and prescribe hearing aids for those whose loss is not amenable to medical or surgical intervention. In addition, audiologists act as gatekeepers, referring patients to physicians when medical intervention is indicated.
Audiologists provide their services in hospitals, children's treatment centres and through other such facilities. They also work in private practice.
Under the Regulated Health Professions Act and the Audiology and Speech-Language Pathology Act, they can provide their services independently, but as they are an insured service under OHIP, they must be delivered under the supervision of a physician. Under OHIP, audiological procedures are classed as delegated acts.
There are presently 243 audiologists practising in Ontario. At one point the number was 272. This is despite the fact that the government provided funding to increase the number of graduates from four to six to 15 as of 1991. It is not reasonable to expect highly trained independent health professionals to work in an archaic system where their expertise is reduced to a delegated act.
Under the OHIP system, a physician can delegate hearing testing to a fully trained audiologist or to an untrained or undertrained person such as a secretary. In either case, OHIP compensates at the same level. While not illegal, this does raise quality assurance and overutilization issues. With untrained or undertrained people testing, significant problems are missed. Young children with significant hearing loss can have their rehabilitation delayed because they confuse the tester into thinking they have normal hearing. It also allows for the following:
An ENT surgeon can have a test performed by an untrained person in his office and OHIP pays as if it were a proper test. The surgeon can then look at the results and think, "Perhaps we need a more in-depth assessment," and refer the patient across the street to a hospital-based audiologist, where a second test is performed, this time an accurate one. OHIP is again billed, and the ENT, actually having been paid for the first test, can receive part of the second OHIP payment if he is the "billing physician" for the hospital audiology department. So not only did we overutilize, not only did we pay for a test that wasn't accurate, but we rewarded the physician, because of the present system, for this situation.
Some months ago a Toronto Star article quoted the executive director of the Canadian Hearing Society as saying that it is "not uncommon to find that surgical decisions are made on the basis of invalid test results." Another official was quoted as saying, "Incorrect testing done by untrained workers leads to repeat testing and costs the health care system far more than it needs to."
But our complaint's not with the physicians; it's with a system that is corrupt and ripe for abuse. It's a long-term problem that I've personally been involved with on OSLA's government affairs committee for over 10 years.
Many years ago, in less sophisticated times, a physician would have a technician perform a simple hearing test. The physician would interpret the results and counsel the patient. However, for many years, audiologists trained at the graduate level have been the acknowledged experts in the area of hearing assessment and rehabilitation. The formal training of an ENT surgeon in hearing assessment is necessarily rudimentary, and what training exists is provided by audiologists. The physician under the OHIP system is then expected to supervise an audiologist? This is quite inappropriate.
Some time ago Health ministry officials suggested that the solution to these difficulties may lie in using the Independent Health Facilities Act for the provision of audiology services. OSLA believes that through a standalone IHF for audiology, standards could be established and monitored which would result in safer, more efficient and less costly service delivery. OSLA would of course be pleased to assist in the establishment of such standards.
Until now, however, no government has shown the political will to move forward. It is our understanding that Bill 26 was intended to correct this problem, and accordingly we applaud this initiative, but there are some issues that may require further attention.
Bill 26 amends section 4 of the Independent Health Facilities Act to enable the minister to "designate health facilities or classes of health facilities as independent health facilities." An amendment to subsection 5(1) permits the minister to authorize the director to request one or more proposals. These amendments do appear to provide for the creation of new audiology-based IHFs, and if so, we are heartened.
Subsection 7(1) of the act is also amended under Bill 26. This would permit "a person who is operating a health facility on or before the day the facility is designated as an independent health facility under clause 4(2)(b) to apply to the director for a licence to operate the health facility as an independent health facility." This sounds like Monty Python to me.
It is our understanding, however, that "the person" applying to run an existing IHF in subsection 7(1) as amended would be the physician instead of the audiologist. If this is the case, an existing audiology clinic would not qualify as a standalone non-physician IHF. In other words, I have a clinic now that I own and operate, but under the rules of OHIP the bills go through a physician I'm associated with, and under these amendments it's he who would have to make the application for the independent health facility and I'd still be paid through a third party. I urge the committee, in the strongest possible terms, to correct this oversight.
In summary:
OSLA believes that overutilization, an inappropriate reimbursement mechanism and lack of adequate quality assurance have resulted in a badly flawed audiology system.
OSLA believes that the non-physician IHF model offers an opportunity to solve these problems.
OSLA urges the committee to ensure that the IHF Act contains the provisions necessary to ensure that both new and existing audiology clinics are eligible to become IHFs.
Mr Chairman, perhaps you or your colleagues have questions resulting from what you have heard from us.
Mr Christopherson: Thank you for that presentation. It was quite informative. In listening, one gets the impression that you're really just floating out there in the system somewhere and not really anchored in the way you'd like to be, both in terms of lack of standards and the fact that you're not on the insurance schedule. If I'm reading it correctly, you've probably got every reason to be even more concerned than some of the other stakeholders in the health community, given that they at least are rooted in existing legislation and now are concerned about changes. You're looking at changes that are happening and at the same time trying to get rooted, if I'm understanding correctly; if you get a sense I'm not, please help me out.
I don't know an awful lot about this. What is the worst-case scenario for you as you see Bill 26 in its current form? What's the worst that could happen to you, your colleagues and your respective professions?
Ms Ryner: The worst-case scenario right now that the speech-language pathology profession is facing is that with the potential for cutbacks and restructuring and the authority Bill 26 carries in terms of making some of these things happen, our services could just get lost in the process and there could be no services to communities, unless there's also the mechanism to ensure that they are relocated elsewhere.
Mr Barr: The worst-case scenario from the audiology perspective is that the government would do nothing. Even though as audiologists we do have a college and have quality assurance built into our practice, as it happens under OHIP, that isn't necessarily so. Next to the worst-case scenario is that they designate audiology under IHF but only allow the physician to apply to run the IHF.
1640
Mr Clement: Thank you very much for your presentation. Your comments are close to home, because one of the facilities affected on the speech pathology side is in Brampton's Peel Memorial Hospital, so I've been very aware of that issue.
Dealing first with the speech pathology side, I think what we're hearing is that the restructuring has to allow for new types of services to occur, which is another reason this restructuring has to take place: that we're spending money in an ill-fitting manner; that some services are not really necessary but we're spending money on them, yet there are other services for which there's a crying need but we don't have the resources. It's possible that if we do our jobs properly, as a government and as a health care sector, we can find the money to reallocate into such worthwhile things as speech pathology. Is that one of your hopes as well?
Ms Ryner: I would agree with you. Many people agree that there's enough money in the system; it's how it's being allocated at this point. The difficulty for us is that currently, for example, preschool services are in acute-care hospitals. They are trying to balance the bottom line, and they have to save lives and do cardiac surgery and all these wonderful things, so they see an opportunity to balance their bottom line by eliminating services such as ours. That money is then swallowed up within that hospital environment and there's none to reallocate elsewhere.
Mr Clement: Could I maybe provide a clarification and make sure this makes sense to you? You made a very poignant point that there is still a role for the district health councils to play. Under our proposed legislation, the district health councils' position to analyse, to plan, to make recommendations is still intact under section 8.1 of the Ministry of Health Act. If that is the case -- I encourage everyone to read the original Ministry of Health Act -- that the district health councils are still in place and would have that interaction with the Health Services Restructuring Commission, would that go some ways to alleviating your concerns?
Ms Ryner: It would, but with all due respect, they currently don't have enough clout, if I could use that word. They can still very easily be overly dominated by the large institutions in their communities.
Mrs Pupatello: You were sounding fairly positive when you began. Have you been given assurances from the ministry that you'll be included? Have you had consultation with the minister?
Mr Barr: We've had no consultation with the minister. We've had consultation with people within the ministry, but nothing from the minister proper.
Mrs Pupatello: I'm hoping you're going to make representation to the Ministry of Education and Training as well and to the Comsoc ministry, in terms of your position. In light of the $400 million being cut from education, have you heard of a definition of "classroom" yet? The role you play with students, and I'm talking specifically of children's services -- yours is one of those services children need; it is critical to get them at that early age because so much of it is treatable when you're allowed to intervene. The cuts that are coming in education I'm fearing will specifically affect your area because you won't be considered "classroom." I wonder if you've heard about that definition, because I would think that would be of grave concern to your field.
Mr Hogle: I'm not familiar with the definition to which you refer. However, we are very familiar with the problem you're addressing, that is, the problem of services within the educational system for speech and services within the health system for speech.
One has to recognize that speech pathology means something different and is treated in a different fashion in education than it is in health. Health is a medical model; education is a language model. Our association will be providing what we're calling the OSLA report, and that report we expect will provide government, education and health with a tremendous opportunity to rationalize these services. But your point is a strong one. Indeed, Fiona addressed it when she talked about the lack of mandate. That lack of mandate is across the system, not just within health.
Mrs Caplan: Mr Chair, I have a question for the record, and it follows on the very excellent presentation. It is a question to the ministry. Since the Ontario Association of Speech-Language Pathologists and Audiologists would like to know whether it is the intention of the minister and the ministry to include audiology and language services in independent health facilities under Bill 26, could the ministry give us and them the information about whether it is their intention to provide those services? Particularly -- and this is also for the record and part of the question -- what we heard today is that hospital-based services are being cut because of the $1.3-billion in funding cuts. Is it the government's intention to fully fund audiology and speech-language pathology services in independent health facilities as an insured service? It's important that they give us a time line as well, because what we've heard today is that vital and important services are being cut and decisions are being made that may be irreparable unless the government moves quickly to do that.
The Chair: Are you finished with the question or statement?
Mrs Caplan: It's not a statement; it is a question. You see, we haven't had any policy statement from the ministry that this is the intention. It's my own view that they could do that without this bill. Just by declaring your services insured services, you could then be funded in numerous settings, so you don't need Bill 26. But is that the rationale, is my question, for the delivery of services to the hearing-impaired and to people with speech problems?
The Chair: The question has been put. Thank you very much, folks.
Mr Agostino: Mr Chairman, just for the record so the committee's aware of three other groups that made presentations at the shadow hearings today: Tona Mason, an individual, made a presentation; Doreen Brown, on behalf of the Hamilton Senior Citizens Centre, and I'd like to table that brief; and one from the Ontario Nurses' Association. These briefs were presented to the shadow hearings held in the convention centre today, and I would like to give this to the clerk of the committee for reference and for conclusions of committee deliberation.
Ms Lankin: Mr Chair, I've got a question and I need your help. I'm not sure; it may be directed half to Mr Clement and half to the clerk. It may be that they have to come back to me with an answer.
I was just on the phone to staff in our research, talking about the amendments you've tabled. I've been trying to get some information and some research work done on them. In fact, there was a commitment made to folks in Queen's Park that the clerk's office would file the amendments with the appropriate research staff while we're on the road. They have not received the amendments yet. The reason they've been given from the clerk's office is that the clerk's office is still busy sorting the amendments to ensure that the package they deliver to opposition party staff has the amendments that have been tabled so far, and they indicated that more will be tabled on Monday. I had understood that in fact you had tabled the entire package.
I recognize that that may not be the case with the other committee; I don't know. You may know that information, but I just wanted a clarification from you. If you think all the amendments have been tabled in both committees, could you, Mr Chair, through the clerk, see if we could sort this out? I'm at a grave disadvantage.
Mr Clement: I do have some information.
The Chair: Out of respect for the doctor who's here, can we sort this out after we hear our presentation?
Ms Lankin: I'm just wondering whether some work could be done on that while the presentation's going on. I don't want to take up any more time, but I indicate to you that that research work needs to be going on or I won't be able to provide you with my amendments in light of what you've just tabled.
The Chair: But the answer to that can come after we've heard from our last two presenters.
Ms Lankin: Oh, yes.
The Chair: We're already late. Mr Clement, I presume, will work on that.
1650
DR RANDY ZETTLE
The Chair: Our next presenter is Dr Randy Zettle.
Dr Randy Zettle: Good afternoon, Mr Chairman, ladies and gentlemen of the committee. Thank you very much for the opportunity of addressing you this afternoon. I present to you as a physician who has practised in the province for the past nine and half years. I practised five years as a family physician and four and half years as an emergency room physician.
I work in Brampton, in Peel Memorial Hospital. In 1995, our emergency department saw approximately 64,000 patients. Of those, approximately 9,400 required hospital admission. The admissions through the emergency room accounted for approximately 38.8% of all hospital admissions in 1995.
In my presentation I'm going to use examples relating to family practice and emergency medicine, because those are the areas about which I have personal knowledge. There are three issues I'd like to address with you this afternoon relating to Bill 26. The first pertains to schedule H, section 12, proposed sections 18 to 18.2, that deal with the payment of accounts and repayment for unnecessary services. The second is schedule H, section 11, proposed section 17.1, that contains the provisions that would allow the minister to set and adjust fees and impose thresholds by regulation. Finally, I'd like to address the issue of the use of the Rand formula by the Ontario Medical Association.
With regard initially to section 12, sections 18 to 18.2, it appears that the drafters of these sections intended to protect OHIP and therefore the taxpayers of Ontario from bearing the costs of unnecessary medical services. In the furtherance of that objective, I think this is a very laudatory and necessary section and I have no problem with it the way it's drafted.
However, I believe section 18.2 may produce unfair results. If you recall, section 18.2 is the section under which a physician who orders a service that may be considered not medically necessary may later be required to pay back the costs of that service he ordered if it was provided. I believe that unilaterally penalizing the ordering physician for requesting a service that is not medically necessary would be unfair.
The decision to order either an investigative or a therapeutic service is made jointly between patients and physicians. In addition, the physician, the practitioner or the health facility that provides that unnecessary service cannot be said to be entirely free from blame either if it's provided. Under these circumstances, to require the ordering physician to bear the cost of that service I believe would be most unfair. As a result, I urge you to delete section 18.2 in its entirety, as written.
The second issue I'd like to address with you is section 17.1, the section that allows the minister to set fees, adjust fees and impose thresholds by regulation. I believe section 17.1 is necessary, based on three considerations. The first is the elimination of the medical malpractice insurance premium reimbursement. The second is the number of inequities that exist in the current schedule of benefits that I believe are contributing to the maldistribution of physicians and patterns of practice of physicians in this province. The third is the issue of utilization of our health care system.
First, let us consider the elimination of the medical malpractice reimbursement. I believe it is an important step to eliminate the medical malpractice insurance reimbursement program. The arrangement as it's structured I believe operates contrary to public policy. By reimbursing physicians in a blanket fashion for any increase in their malpractice insurance premiums relative to a base rate, you in effect insulate them from the financial consequences of their actions in professional practice. When you do this, any deterrent effect of the tort system is thereby greatly reduced. Under the reimbursement program, physicians are not forced to bear the risk of malpractice insurance premium increases, irrespective of how they practise.
However, as a corollary to that, physicians who provide high-risk services who are now faced with higher malpractice insurance premiums have to be adequately compensated so they can now pay those higher premiums and still make a reasonable profit if they're going to continue providing those high-risk services.
In Ontario we compensate physicians on a fee-for-service basis. Therefore, it would be necessary to increase the fee for those high-risk services. Services that would be considered high risk would be the delivery of babies, either by obstetricians and gynaecologists or by family physicians; certainly orthopaedic surgery and fracture management; heart and vascular surgery; brain surgery; or assessing and treating patients in emergency departments.
I believe that the enactment of this section in Bill 26 will ensure that the government has the power to adjust the individual fee codes. A good example is the POO6 code, the management of labour and delivery code, which compensates family physicians and obstetricians for delivering babies, in order to adequately compensate the practitioners who provide these high-risk services to ensure that they will continue providing these services for the residents of Ontario.
A second issue I'd like to address under this heading is the number of inequities that exist in the current fee schedule that I believe play a significant role in adjusting physicians' patterns of practice.
Firstly, let's consider two examples: If a 50-year-old man presents to his family physician with a cold, that physician will be paid $24.80. If at 10:30 on a Friday night that same man now presents to the local emergency room with chest pain that might well be a heart attack, the emergency room physician gets paid $1.75 more. He gets $26.55 for treating that individual. This difference, $1.75, certainly does not compensate the emergency physician for treating a much more serious, difficult and time-consuming problem associated with a far greater medical malpractice liability, at albeit a most inconvenient hour. An emergency room physician's annual medical malpractice insurance premium, the 1996 rate, is $4,332. A family physician's is $1,932. The emergency room physician's premium is 124.2% higher.
Let's consider a second example: Assume we have a very complicated medical patient. If they present to their family doctor in the office, that doctor would perform what's termed under the fee schedule a general assessment, an A003 code, for which he would be paid $48.20. If the following day the patient was still not feeling better or was dissatisfied with the previous treatment, they could then telephone one of the many house call services which are available in the urban centres and a physician would attend at their house to deal with their problems and assessment. The house call physician would be paid $54.95. If that evening the patient then went to the emergency department for assessment, the emerg physician would only get $26.55. So the family physician gets 81.5% more and the house call physician gets 107% more for seeing this same patient.
There are a couple of other examples which I have listed in my brief for your reference at pages 8 and 9.
In light of these inequities in the fee schedule, is it any wonder that few people are willing to practise in a low-volume emergency room in rural Ontario? Clearly, it's far more lucrative to practise in a high-volume urban area. Essentially, you can see patients who are basically well in your office and those who are potentially seriously ill you can send to the local emergency department.
In addition, under the fee schedule, as an office-based practitioner, you can bill for additional services. If we take our 50-year-old man, if he presented to his family doctor with chest pain, if the family physician performed and interpreted an electrocardiogram, the family doctor would be additionally compensated for reading the electrocardiogram. There's a code for that, G313, and the fee is $8.90. However, in the emergency department, interpreting the electrocardiogram is considered part of the base fee, $26.55.
I believe the Ontario Medical Association, in conjunction with previous governments, has not rectified these inequities in the fee schedule, and these that I present are just a sampling. There are many, many more. I believe that it is only by enacting provisions such as section 17.1 that provide the minister with the power to set and adjust individual fees and impose thresholds where appropriate that these types of inequities may be corrected and any resultant adverse effect on physician practice patterns removed.
The third issue I'd like to deal with under this heading is the issue of utilization. Clearly, both physicians and patients are important in determining the utilization of the health care system. However, the problem I'd like to address with you is that there are a small but significant number of family physicians who are seeing large numbers of patients per day. In British Columbia it's been estimated that about 5% of family physicians see 50 or more patients per day, and I can see no reason why the numbers in Ontario would be any different.
The question I ask is, is the public being well-served by being churned through a physician's office in this high-volume fashion and would all of these services withstand close external scrutiny? In a recent article in the Medical Post, the president of the British Columbia Medical Association was quoted as saying that doctors seeing many patients a day were "pushing the envelope on quality."
1700
I believe that section 17.1 is very important in that it will let the minister impose reasonable limits on the number of services that are provided by practitioners. As well, the other provisions in schedule H will allow and provide the government with the ability to more closely monitor the provision of services and the billing practices of physicians.
The final issue I'd like to address is the Ontario Medical Association's use of the Rand formula. I believe that with the enactment of Bill 26, the Ontario Medical Association's ability to use the Rand formula to collect membership dues in the absence of voluntary membership should be discontinued. The OMA should be a voluntary association which members of the profession can join and support with dues if they wish. The OMA is not a professional regulatory body, it is not a licensing body, it is not a medical malpractice insurer and it is not a trade union. I believe that the OMA should recruit members and collect dues like other voluntary professional associations. It should not be given preferred status through the use of the Rand formula.
Once Bill 26 is enacted, I believe that it would be punitive to continue to allow the OMA to demand annual fees of $900 for an ordinary member at 1996 rates from the physicians in this province. I also believe that if the Rand formula persists, this will engender a significant amount of ill will and ill feeling between the physicians of this province and the current government.
It's my impression that the OMA performed much better in an advocacy role on behalf of physicians prior to the introduction of the Rand formula. I suggest to you that the Rand formula should be discontinued. If the OMA then performs well in its advocacy role, physicians who want to join and support the association and be a part of it will. However, this should be voluntary on the part of the association. Physicians should not be forced to fund an association to the extent that the OMA is currently being funded. To that end, I ask that you give serious consideration to including a provision in Bill 26 that would revoke the OMA's continued use of the Rand formula.
These are my submissions.
Mr Clement: Thank you, doctor, and for my colleagues opposite, Dr Zettle practises in Brampton, and now you know how I was created, with such very good, commonsensical suggestions from the good doctor.
Interjections.
Mr Clement: I just thought I'd give it a try.
Just to flesh out the record a bit on one particular issue, because I think we have addressed that, Dr Zettle, today in our proposed amendments, in your dealing with section 18.2 and the previous legislation's preference to have a general manager make the first decision as to whether a service is medically necessary, we have now altered and improved that section so that the general manager is required to consult with the Medical Review Committee, with at least one physician representing that committee, and to abide by the arrangements that have been worked out with the OMA and the CPSO. If that amendment does come to pass and is voted to be included in this bill, would that go some way to alleviating your concerns in that area?
Dr Zettle: I just want to make sure we're talking about 18.2 and not 18(2). Subsection 18(2) is the one that says that the general manager, if he has reasonable grounds, may refuse to pay all or part of the service that's not medically or therapeutically necessary.
Mr Clement: That's what we're talking about.
Mr Zettle: It was my impression that not medically or therapeutically necessary, the guidelines in respect of that would have been put together through some combination of physicians and government officials.
Mr Clement: Well, yes. What's happening now is that it's a judgement essentially of your peers. There's no definition. It's hard to define, as you can well imagine, but it would be a decision of your peers, rather than a decision exclusively of the general manager. If that is in fact how this legislation is amended, if that amendment passes, does that go some way to alleviating your concerns in this area?
Dr Zettle: Just to clarify the record, I didn't have any concerns about subsection 18(2), because I think that under subsection 18(2) having a group of my peers establish guidelines when we're talking about refusing claims that are submitted at first instance would be an ideal situation. But under 18.2, as I read the provision, this is where the doctor orders a service, it's then provided, it's then termed to be not medically necessary and then the doctor is required to pick up the cost of his service that was provided. Under those circumstances, there are really three parties involved in the decision to pursue the unnecessary service and it would be unfair to penalize the person who ordered the test.
Mr Clement: I think we've met your concern, but I thank you for raising it again.
In terms of the malpractice insurance premiums and your suggestions in that area, we heard an earlier presentation today where we had a bit of a discussion about whether differential fees for service could be used to alleviate, as you have made mention here, the premium cost in certain areas: neurosurgery, obstetrics, what have you. There was one claim by a doctor -- he did not issue it as a threat, and he made that very clear, but he did make the claim -- that that could provoke job action by your brethren because the differential fees would create some internal dynamics which he did not predict would end amicably. Do you share the same fears, or is that overblown?
Dr Zettle: That's a very difficult question, because when you're dealing with a capped global funding model, when you increase the fees to compensate those people who provide high-risk services, it has to come at the expense of somebody else. It should come at the expense of either people whose fees are currently overvalued, where the experience, time, skill and the malpractice risk to provide a service is excessive vis-à-vis the fee in the fee schedule, or people who provide high-volume, low-risk services. If we're going to serve the population of Ontario, there has to be some adjustment within that.
In terms of other people's considerations of job action, I haven't heard anything to that effect.
Mrs Caplan: Thank you very much for a very interesting brief. It's very different from any of the ones that we've heard from other doctors.
Mrs Pupatello: Different from all the ones.
Mrs Caplan: My colleague says, "Different from all the ones."
Mr Agostino: Tony liked it, though.
Mrs Pupatello: Dr Clement enjoyed that, yes.
Mrs Caplan: While there were some in support of significant reform and change, yours is the first one that actually says you believe the minister should have the power unilaterally to be able to make these changes. I'm wondering why you reject the option of partnership.
Dr Zettle: I guess my experience in nine and a half years is that we've had a partnership, and here's where we are today. I don't see how you can effect the types of changes that need to be effected in a true partnership arrangement, given that in the nine and a half years I've been practising, these fee schedule inequities have been present and still persist to the current day. I think it would be prudent to accept input from the physicians and from their representative bodies, but ultimately I think somebody has to make the hard decision to adjust the fees. And I think, as Mr Clement mentioned, it's going to be unpleasant for some people. You may have threats of job action. Who knows what other threats people might make. But in terms of making the hard decisions, somebody has to make them, and I don't think in a partnership arrangement they'll get made.
Mrs Caplan: CMPA: I was a part of the government that agreed to the OMA's suggestion that part of the payment of the insurance premium would be in lieu of an increase to the fee schedule. I think the decision to unilaterally change that without negotiation and discussion is offensive, but it also raises the issues that you have raised of obstetrics and anaesthesia and orthopaedics, which have very high premium increases and where, particularly on obstetrics, although the minister has said he's going to do that, by not solving it first or saying exactly how it's going to be done, my concern is that if that's the style of how things get done, doctors will not feel appreciated and secure and that insecurity will have an impact on patient care. Do you have any comment on that?
1710
Dr Zettle: I guess my feeling would be that if something was done, if in the near future the obstetrical fee code was suddenly raised to say, "We acknowledge that you're now facing this burden of higher malpractice insurance premiums," if as a result of this bill the clawback was eliminated, I would find it difficult to see how people could complain about that situation. If you're saying, "I can't provide the service because you don't pay me enough because my malpractice is so high," and somebody says, "Well, that's okay. I will now compensate you so that you can have a reasonable return to cover the increased costs because we value that medically necessary service. It may be high risk, but we as a society want to have babies, want to have doctors attend on the delivery of babies," I would find it difficult as an individual to argue against that adjustment.
Mrs Caplan: The last question I have is regarding Rand. My own position was that if the Ontario Medical Association wanted to become a union, that was their right, and that they should have gone through a certification process. Rather than having the government arbitrarily take Rand away, would you favour the possibility of allowing the membership to apply for decertification, or do you think it should just be taken away and start the certification process all over again if that's what the membership wants?
Dr Zettle: I think it should be just taken away, and if the membership wants to apply to be certified, then by all means let them go ahead. Right now the fees strike me as being quite high. Certainly it's a significant amount of money that's involved annually. I think that if the membership wanted the OMA to represent them, if the physicians in this province wanted that, then they could then apply for certification. Then if the certification went through, so be it; then the Rand formula would be in place as opposed to having it imposed as part of an agreement.
Ms Lankin: I've commented on a number of occasions that every day something new is brought up, and here we are in the second-last public presentation and, I have to admit, I've been waiting for the Rand formula to be brought up. I was chuckling to myself as you did it, not in terms of the issue but just that at some point someone was going to have to realize that the government was stripping the OMA of its rights and role in terms of bargaining, which is one of the many things the association did, that someplace in the membership someone was going to say, "So why are we paying dues in a compulsory fashion?" So this doesn't surprise me.
I'm sort of interested -- the OMA representatives that were here have gone, so they haven't heard your plea. Someone better give them a call and tell them in case the government's busy writing amendments over the weekend. They might want to comment on it.
I really appreciate your presentation. I'm kind of a detail person and you've raised a lot of issues that are important in terms of the inequities, and I think you're quite right that it has been very difficult to get at that. I'm not sure myself that the minister having the unilateral right to do these things is going to fix the things that you're raising, but who knows? We'll see what happens with that.
What I would like to ask you about is your comment about the BC process of dealing with high-volume doctors, and I preface it by saying that a lot of doctors who have come forward have said: "Yes, there are some in the system, but don't penalize all doctors for the some. Deal with the some." They've also pointed out high utilizers of the system in terms of patient abuse as well.
One presentation told us about a project in Manitoba where 100 people who used the system, an extraordinary -- in fact, the numbers they gave me I couldn't quite believe; you'd have to go to three doctors or two doctors a day every day of the year to get these numbers. But they dealt with those people and essentially rostered the individuals to a doctor for their care and brought the utilization way down.
I was thinking, between that and if you could explain to us a little bit more about BC, maybe this is a reasonable thing to look at to try to deal with the extremes in the system that we know of instead of fixing the rules that affect everybody when most patients and most doctors are not the extreme.
Dr Zettle: First of all, in dealing with it, I agree with you that it probably is only a very small percentage, but the problem is that when you're dealing with a small percentage in terms of the large amount of moneys that are involved in health care, you start to deal with quite significant amounts of money. So to not address it because it's only a small percentage I think does it a disservice.
As I understand the BC issue, what they did was there was a province-wide referendum by the BCMA and the majority of their members approved limiting full fee-for-service payments for office visits for the first 44 patients seen per day, and then for the 45th to the 62nd basic office visit, fees would be paid at half the basic rate. For any visits beyond the 62nd per day, nothing would be paid.
Ms Lankin: It's interesting in terms of that approach -- and I agree with you about the amounts of money. This Manitoba study suggested that those 100 people were actually utilizing 1% of the Manitoba health care budget, which is again extraordinary numbers.
One of the questions I have in that, and this is something people would have to work out, is I had an experience myself attending a specialty practice. I'd been referred there and had to go for a number of visits. This particular physician was a high-volume physician -- I recognized that quite quickly -- who scheduled four people every 15 minutes into different rooms and went in. I don't think that's the majority of practice, but that's the case. If you cut it off at 44, say, or you did the threshold, someone like that who actually chooses to practise that kind of medicine might well still just do their four patients every 15 minutes and, yes, they lose money and they stop seeing people for that period of time but they don't necessarily expand the amount of time they spend with each patient. I don't know if there's a way for us to get at that issue or not, but this is a very innovative suggestion. I know there's never a perfect answer. Do you have any thoughts on that?
Dr Zettle: In the review I read on the BC issue, their referendum was based on family physicians, not specialists, and they raised that issue. They didn't know how to deal with that. I don't know the answer to that, how you can force people to spend more time per patient. If somebody's in the habit of spending only six minutes per patient and you're going to try to force them to spend 15, I don't know what they're going to do for the other nine minutes. So I don't know the solution to that problem.
The Chair: Thank you, doctor. We appreciate your presentation and your interest in our process.
Mr Clement: Mr Chairman, I would like to table for the benefit of the committee some answers to various questions that have been raised by members of the committee, from the ministry.
Mr Agostino: Mr Chairman, as well, I want to table further information on the community shadow hearings. First of all, a list of the panel members: Rev Peter Hoyle, the chairman; Tom Atterton; Marsha Baker; Denise Brooks; Marvin Caplan; Brian Charlton; Mike Davison; Andrea Horwath; Norma Laforme, and Marlene Thomas-Osbourne served on that panel today. A letter from Rev Hoyle to the committee -- the chairman of the shadow hearing committee -- after deliberations today, and a petition signed by over 400 people urging the government to withdraw Bill 26. I'd like to table these with the committee today on behalf of the shadow hearings that were held in the convention centre.
BARBARA SULLIVAN
The Chair: Our last presenter is Barbara Sullivan. The floor is yours. Questions, should you leave time for them, will begin with the Liberals.
Mrs Barbara Sullivan: Thank you very much. I'm pleased to be able to be with you today, as a former legislator and now as a citizen, to raise some of the issues that I find troubling about Bill 26 and that I hope this committee will take back to Queen's Park as matters where there is some urgency for change.
There's no question that medicare as we see it today is very different than it was when it was first introduced, and those changes have brought significant benefit to people right across the country. The major area, however, in Ontario where we lack skills and talent and support is in the health information technology field. That is what I'm here to address with you today, and to caution members of the committee about proceeding with any areas of this bill, including those which have been amended, governing health information without the context of a fully developed policy, implementation strategy and full and frank input and understanding from the public.
There's no question that Ontarians want first-rate health services that bring them the finest, the most effective and the least intrusive care, alongside a commitment from providers that such care will be delivered in a cost-effective way. People believe their taxes and their employer contributions should be spent wisely. They know that duplicated X-rays or unnecessary return visits to professionals add to costs but not to their own health.
But despite the sophistication of health services which are being provided, we're not using modern technology to plan health care for the future, nor to evaluate that which is being provided today. As patients, we know that hospitals, doctors and others in the system have bits and pieces of our health records, but there's no one place where a full and secure record exists and we don't know the cost of the service that we've used.
Repetitive studies have shown that our senior citizens are overmedicated, frequently because health care providers don't know what other drugs have been prescribed or what non-prescribed drugs are being taken. Hospital admissions based on negative drug interactions are astonishingly high in our seniors population.
1720
In emergency situations, professionals frequently lack basic information: names of substitute decision-makers, allergies, pre-existing conditions and other essential information about the patient for whom they are providing care.
We are also told that many people are using our health care system when they are not eligible to do so. I was amused at the minister's use of a figure of $65 million in fraud in his opening remarks to this committee, because less than two years ago the same minister, albeit in a different role, claimed that there was $700 million in annual spending lost to fraud by patients and practitioners. Around the same time, I point out to you, the then deputy minister suggested that perhaps $16 million was more likely to be the extent of annual fraud costs in the system.
I believe that members of the committee ought not to be fooled by any such claims. They are guesstimates or risk projections at best, and fearmongering at worst. There has been no appropriate study ever conducted on the extent of fraud in the system, and one only has to look at the results of enforcement efforts to conclude that such claims are faulty.
None the less, I do believe people must be assured that the tax dollars they pay for health care are expended appropriately for eligible residents, and that charges to the system which whether by accident or design are not legitimate are eliminated. In fact, the technology is not in place in OHIP or in other parts of our health ministry which enables that appropriate tracking, and so our system is relying on anecdotal reports to uncover deliberate misuse of the system.
I believe that in the health information area there are many other issues. Practitioners often aren't able to track clinical changes that have taken place because they work in a multidisciplinary and multilocation environment. Physicians are often unaware of diagnostic tests which have been conducted and may well order duplicated tests.
The tracing of physician practice patterns and treatment modalities which can lead the profession to optimum clinical practice guidelines is inadequate. Research, whether it is epidemiological, utilization or outcomes research, is hampered by the lack of accurate data, and future health planning is therefore hindered.
From an administrative and management point of view, comparative costing of services is cumbersome at best and non-existent in most instances. At the management level, too many opportunities are missed in inventory control and in billing and payment systems. For the patient, there is no information on the value of benefits received under our medicare plan.
I think it is important to understand that this has been a bit of a hobby-horse of mine. Some of you have heard me speak in the past about the need for an information system that can bring and maintain a secure patient record, that can help us with the administration and management of health care, that can help us evaluate services that are provided and ensure that the most effective are used, and that can help us plan so we have the right facilities and people in place to deal with our health care needs.
The technology elements are relatively straightforward. I am going to skip those because there are other elements that I believe are more important for us to consider.
The private sector has moved well past the public sector in information technologies, and it is clear that there is significant private sector interest in assisting government to strengthen health information systems or to provide and manage a new system. Small steps which have been taken today, while laudable as introductions, are unconnected and not systematized. We can look at the Largenet project in London, the pharmacy network, the laboratory network, and what is perhaps the most sophisticated use of information technology to date, that which is applied in the cancer treatment centres.
But the technological questions, the ability to do the job, aren't the only ones that should be pursued. The ethical issues of access to and uses of material from a health information system must be addressed in an open way to ensure that there is accountability in the system and that patients' and providers' rights and obligations are protected and defined.
By including amendments in Bill 26 which would allow broad powers of access by the minister and the authority to distribute information as he sees fit, I believe the minister has seriously jumped the gun and I believe has really created an impediment to a properly conceived and developed health information system. Furthermore, the amendments affecting medical and therapeutic records in the bill are inconsistent with various standards applicable from one act to another act. I should tell you that while I have only seen the news release with respect to the amendments the minister put forward today, my view continues to be that action should not be taken on these particular amendments at this time.
I want to put to you some of the questions -- I happen to have 20 in number -- which I believe should be answered and the public has the right to ask, and the public has the right to participate in the formulation of the answers to these questions.
The first question is, who owns the record? The Public Hospitals Act says that the hospital owns the record of procedures which took place in the hospital. Under the common law, different conclusions have been reached, but only a portion of the broader question has ever been answered.
The second question, who has the right and the responsibility to add or delete data in a record? What information does a patient have a right to refuse access to by health professionals, providers or facilities? Why does some of our legislation require patient consent for disclosure, other legislation provide a possibility for patient consent, other legislation deem consent and still other legislation ignore the question in total?
What health care professionals, providers and facilities should have access to a patient's full medical record?
What health care professionals, providers and facilities should have access to a portion of a patient's full medical record? What are the defining features in providing that access? The professional scope of practice, the therapeutic service delivery, or are there other factors?
What information should OHIP be able to access about a patient? The basic information to determine and verify the eligibility, or a full medical and health services record?
What research agencies and institutions should have access to particular fields of information without patient identifiers?
What is the right of the public to the results of such research?
What information should be transmitted to patients about services provided and the costs of those services? What steps are necessary so that information remains confidential to the specific patient? I suggest to you that the right of a parent to information concerning health services provided to a minor child is but one area that will be a matter of important discussion if the government ever decides to send a patient an accounting of the value of services which have been offered to that person.
What information should be transmitted to OHIP for billing purposes by the practitioner, the provider or the facility? If electronic funds transfer for payment is contemplated, what information should be attached to verify the account?
What steps should be taken to develop a protocol for recording consent of patients to treatment, or to specific searches for organ and rare blood matching, or for organ donation, or for identifying substitute decision-makers in case of incapacity?
What protocols should be put into place for the use of specific data recorded about a health care provider such as might be used in identifying physician practice patterns or for professional disciplinary measures?
What should be the pace of implementation, and how are priorities for implementation to be addressed?
What verification data should be used for security purposes? Fingerprints, DNA screens, numbers?
What would be the nature of contracts entered into with the private sector for providing health information technologies, and what would be the provisions for ensuring the confidentiality of information included in whatever system is developed?
What use can or should be made by medical schools in accessing specific cases and specific records for teaching, continuing education, research or for distance education?
What scope should be included in a system for remote diagnosis or remote surgery -- which is technically possible -- and how are liability issues to be determined?
What responsibility should be attached to a representative of one body of health providers to report to another professional evidence of patient abuse of a course of treatment? I'll give you an example of what in fact can be done today. It is very simple for a laboratory to ascertain whether a diabetic is indeed following an appropriate course of treatment simply by whether the patient shows up for the next step in that course of treatment, for the next lab test. The lab is quite able to predict that the patient is not following the course of treatment that has been prescribed and could well ultimately become a candidate for dialysis as the disease progresses and other things occur.
1730
Right now there is no responsibility or obligation, and indeed there's a constraint, respecting the laboratory reporting to the physician that the patient is not indeed following and participating in the course of treatment that has been prescribed. There could be a benefit in doing that that could ultimately lead to greater health outcomes in the end. We should be talking about what obligations there are and what responsibilities are attached to that kind of information-sharing.
What part of a comprehensive system developed for Ontario should be available for purchase by interested parties within the province, the country or other jurisdictions?
Finally, what right does a patient have to his or her full medical record, and who should have the responsibility of making that record available or parts of it available?
I believe that those questions merely scratch the surface of those which should be addressed by the public generally, by health care professionals, practitioners and providers and by legislators in a carefully thought-out process of dialogue. They are ethical and legal questions that should not be given short shrift through hastily crafted legislation which provides all-encompassing powers to the minister to enter into agreements, to collect, use and disclose personal information concerning insured services provided by physicians, practitioners and health facilities, whether that information is collected directly or indirectly. The privacy commissioner has, I know, made a compelling argument about the issues which I am addressing today.
My recommendation to you, and I hope you will take it back to the minister and he will take it to cabinet, is that the government should withdraw all amendments respecting health information which are included in Bill 26 and engage in a proper consultation, which in this, as in many parts of the legislation, I believe it has not done.
I am certain that the opposition parties will support this recommendation, and I urge members of the government party to exercise their common sense and demand of the minister that a full discussion of these ethical and legal questions occur in advance of legislation and not subsequent to it, if at all.
In media reports the minister has justified the extensive amendments which he has put forward regarding health information on the basis of controlling fraud, but the scope of these amendments is much broader, including those which have themselves been amended.
The amendments to the Public Hospitals Act, the Independent Health Facilities Act, the Health Insurance Act and the ODBA which are included in Bill 26 provide the minister with unique and broad powers to collect and disseminate personal medical and health records or to enter into agreements to do so. Only the amendments in the original proposals which were put forward included any reference to confidentiality requirements binding the party with whom the minister makes an agreement.
I want to refer you to the news release which the minister provided today, in which the minister indicates that he will ensure that patient information is made anonymous when disclosed or released under agreement for the purposes of managing or evaluating health care services. There is no change, however, to the section of the bill which allows individual records, including those of the Ontario Drug Benefit Act, which may be collected "for any purpose," and those records which are collected "for any purpose" appear under the new amendments which the minister has put forward to be excluded from the confidentiality provisions which the minister insists he has added.
So I ask, what are those other purposes? If they are to open the way to a broader health information system that will provide us with the data that are useful for care management, for administration, for planning and research, those goals are valuable. But as legislators you have an obligation to ensure that they are implemented in an accountable way.
Let's be very sure that no one's rights are trampled and that there is open and valuable discussion that leads to a precise and thorough health information policy, and I urge that there is separate legislation dealing with health information that is transparent and into which accountability mechanisms are built. The health information sections of Bill 26 are too much, too soon, and I urge the government to withdraw them. Thank you very much.
Mrs Caplan: Thanks, Barbara. What an excellent presentation and thoughtful analysis of the bill. I know you're not here as a partisan and I also know your background and history in fighting for the development of medicare.
One of the things that upset me today was that the minister released his amendments, stating that the bill had always protected confidentiality, even in light of the fact that the commissioner had come before us.
I know that information technology has advanced very rapidly and that there is a real need for significant changes when it comes to how that's done. I've also called for a new piece of legislation and a halt on everything until it comes, but frankly, I don't think they're going to do it. You've put it in such a very good way, and all those questions that have to be answered should be dealt with in a forum.
Is there any one particular concern that you have? Is there anything you can see in this bill that couldn't wait when it comes to confidential information? Is there anything that is so urgent that you think it has to be done immediately and couldn't wait for that legislative package? Because we have made the offer that says, "If there is something that's urgent, identify it and we'll deal with that and then move to a comprehensive package." I haven't been able to find anything in here that is so urgent that it couldn't wait for a spring session debate on health confidentiality and health protection privacy legislation.
Mrs Sullivan: That was one of the questions I asked myself when I considered even making a presentation to the committee. Certainly, from the early 1980s, the entire question of how one moves into a broader information system in health care has moved along haltingly, and in some cases with advancements in the industry itself. There are bodies which have given considerable thought to these issues, not the least of which were professional bodies themselves, but also medical and legal-ethical bodies and institutes such as the institute for health informatics.
My sense is that until the public heard about some of the provisions of this bill, there was very little public discussion of the meaning and nature of having personal health and medical records available to other people for whatever purposes, whether they be legitimate or not, and it seems to me that not only does the expertise, which has already been put into place among health care providers and those people involved in the ethical issues, but the public ought to be brought together so that there is a policy from which the technology flows.
Mrs Caplan: Exactly.
Mrs Sullivan: That's where we should start.
Ms Lankin: Barbara, it's really great to see you, and just for the government members' benefit, in the days when the current Health minister was Health critic and used to rail about $700 million, Mrs Caplan was the official opposition's Health critic and didn't indulge in such excesses at all with respect to her criticism, as I recall as minister at the time.
Mrs Caplan: No. It was actually Mrs Sullivan.
Ms Lankin: Mrs Sullivan. Sorry.
Mrs Ecker: You're doing it now.
Mrs Caplan: It's all right. It's late in the day.
Ms Lankin: I'd like to take this moment actually to share some stuff in a rare moment of non-partisanship. Many governments have had an opportunity to introduce health information privacy legislation. The privacy commissioner has been urging that for a long time, and in the way in which governments set their priority legislative agendas, these considerations go on in cabinet, and as time goes on, you narrow it down and you start to focus more.
I can tell you through the course of time in our government the commissioner urged me a lot, and while it was on the list of maybes, it never made it in terms of priority because it was too late by that point in time. It never made it under the Liberal government and, quite frankly, although Jim has now committed to it, unless you come away from this process -- and I think there's a compelling reason now -- and go back and place it on your agenda, the Common Sense Revolution agenda will take over and you won't get to it either.
1740
The other thing I want to say is that the current government has committed itself to smart card technology and has stopped the other health card. We did a pilot project on smart card technology, and we know, I think all of us, the value of the health information base and from health care, both epidemiological and individual patient care.
The questions that Barbara spells out here are absolutely what we ran into, square into the face. The working group that's been put together is trying to work through some of these questions, and you heard from the health information management folks who were here. They're trying to deal with some of this, and electronic transmission of data.
The new health card that was being implemented was being done on a phased basis to allow, at a certain point in time, those that were being issued to people to become smart cards or on the five-year renewal so that could happen. You can't hold up the card waiting for smart card technology, because you won't be able to do smart card technology until you deal with the health information stuff.
The suggestion that's being made here, and I know it's the last presentation of the very end of the processes before we go into clause-by-clause, but given that there are still a couple of problems in terms of the Ontario Drug Benefit Act and the disclosure there and whatever, while it would be very hard to do, it would be a very wise thing to do, to try and pull those sections out, put them under the umbrella of health information privacy legislation, with the goal to implement your smart card, which gives you the political capital to go back to cabinet and get it.
I urge you really genuinely, in a non-partisan way, to consider it, because I think the issues that Barbara has identified are ones that are really important for the system that we all have to grapple with irrespective of -- they're not partisan. Let me just put it that way. They're just real issues that have to be dealt with before you can move with the new technology.
Mrs Johns: I'd like to thank you for being here. I know that it's the end of a long day and we all look a little tired, but there were lots of interesting things that you had to say in your presentation. From my standpoint, I could tell that it brings back amounts of knowledge with the health care system and ties it into understanding about the needs analysis of an information system.
To me, that was a really good process, because as every one of us comes into politics we always say, "Why are they dealing with these antiquated cards? Why can't we get more information?" and as each of us has gone through the Ministry of Health, I think we all wonder about that and wonder how we could make that better.
I want to tell you that we had probably only one other presenter on the health information system, and it was a group that talked about verification. They were from Mytec, and they had some very interesting ideas about the starts of information systems, but you've given us some good questions to be asking.
My question was a lot like Frances's, and maybe she answered it for us. But I want to know if you could tell me -- this is obviously an important issue to everybody -- what are the difficulties that every government seems to have had to be able to move towards this process of having a better information system?
Mrs Sullivan: That would require another 20-minute presentation, and I know it's the end of a long public hearings process for you. There are a number of issues.
To sum up, first is the question of money, which is a large question, and the shifting of resources, or the will to enter into public-private sector arrangements where some of the capital and introductory costs can be carried by other bodies. That itself raises other ethical questions, but money is certainly one of the issues.
Another very key issue over the recent past is that Ontario has only very recently become an international centre of technology and has only recently developed the expertise that is now being sold to other jurisdictions in other fields. Now we have it all right at our doorstep, and frankly, in my view, the introduction of this kind of technology can also be an export opportunity for the province and for those who participate with the province in developing the system. Frances has talked about the will and other priorities. That is very clearly one of the reasons that it hasn't moved forward. But we're at a time, I believe, when our systems now are costing us money and costing us a health benefit, and we bloody well better have a look at it pretty quick.
The Chair: Thank you very much. We appreciate your presentation today and your interest in our process.
Mrs Caplan: A question for the record? And also, if you'd like, I'd be happy very briefly to answer some of those questions.
The Chair: Let's just put your question, Elinor. It's been a long day.
Mrs Caplan: Okay. I'll tell her privately.
There are two questions that I want to put. The first: I want to clarify the earlier question that I asked, is it the policy of the ministry to provide audiology services in IHFs, independent health facilities, as an insured service? Clear and simple.
Mr Clement: That's a lot better.
Mrs Caplan: The second: I would ask the ministry to answer -- obviously they have to have thought about -- the 20 questions in Barbara's brief. Hopefully through --
Mr Agostino: For Monday.
Mrs Caplan: Let me put it this way. Before this bill has completed clause-by-clause. Let's have some of the ministry's thinking on this, because these are the issues that have to be addressed, and we've got the privacy commissioner coming on Monday. I don't think it would hurt if we could have them by then, but I won't hold you to that time line. I would appreciate it before the end of clause-by-clause debate.
Ms Lankin: This is with respect to an answer that was tabled to an earlier question that I asked. I'd like to thank Mr Clement for tabling an answer to my question of Friday, December 22, one month later, about subsection 18(1) of the Health Insurance Act, to which you tabled amendments today making my question and the answer totally redundant. Thank you.
The Chair: Just a couple of housekeeping things: Copies of all the submissions that have been sent directly to the clerk's office, some have been distributed to your offices back in Toronto today and the balance will be there first thing Monday morning.
Our meeting with the privacy commissioner is set for 9 o'clock Monday morning in committee room 1.
We stand adjourned until 10 o'clock in Toronto on Monday in the Amethyst Room.
Ms Lankin: Thank you, Mr Chairman, for a great job.
The committee adjourned at 1748.