Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Wednesday 11 June 1997

Ministry of Health

Hon Mr Wilson

Ms Margaret Mottershead

STANDING COMMITTEE ON ESTIMATES

Chair / Président: Kennedy, Gerard (York South / -Sud L)

Vice-Chair / Vice-Président: Bartolucci, Rick (Sudbury L)

Mr RickBartolucci (Sudbury L)

Mr MarcelBeaubien (Lambton PC)

Mr GillesBisson (Cochrane South / -Sud ND)

Mr Michael A. Brown (Algoma-Manitoulin L)

Mr John C. Cleary (Cornwall L)

Mr EdDoyle (Wentworth East / -Est PC)

Mr BillGrimmett (Muskoka-Georgian Bay

/ Muskoka-Baie-Georgienne PC)

Mr MorleyKells (Etobicoke-Lakeshore PC)

Mr GerardKennedy (York South / -Sud L)

Ms FrancesLankin (Beaches-Woodbine ND)

Mr TrevorPettit (Hamilton Mountain PC)

Mr FrankSheehan (Lincoln PC)

Mr BillVankoughnet (Frontenac-Addington PC)

Mr WayneWettlaufer (Kitchener PC)

Substitutions present /Membres remplaçants présents:

Mr JimBrown (Scarborough West / -Ouest PC)

Mr PeterKormos (Welland-Thorold ND)

Mr TonyMartin (Sault Ste Marie ND)

Also taking part /Autre participant:

Mrs MarionBoyd (London Centre / - Centre ND)

Clerk / Greffière: Ms Rosemarie Singh

Staff / Personnel: Ms Alison Drummond, research officer, Legislative Research Service

The committee met at 1538 in committee room 2.

MINISTRY OF HEALTH

The Vice-Chair (Mr Rick Bartolucci): I call the meeting to order. Ladies and gentlemen, the NDP is to go next in our normal rotation; however, they're not here. If we can get consensus, we'll move to the government side for their 20 minutes; I'm sure the NDP will be here by the time they're finished, and then we'll move to them. Do we have concurrence? Great.

Mr Bill Grimmett (Muskoka-Georgian Bay): Minister, on previous days we've talked about the doctors' agreement. I'd like, if you wouldn't mind, to talk about nurses for a while. In my riding I've had the opportunity to sit down with a number of nurses, some representing their colleagues as a whole and some on an individual basis. They wanted to talk to me about the changes occurring in health care. I've even had some student nurses come in to speak to me about the opportunities or lack of opportunities in health care.

It's my understanding that with the changes taking place in hospitals and in the health care system generally, there may in fact be opportunities opening up for nurses. I wonder if you could perhaps advise the committee if this is so, and if that is the case, perhaps some details.

Hon Jim Wilson (Minister of Health): I'd say in a general sense that as we look at the restructuring that's gone on across Canada -- in Great Britain, for example, where restructuring to the degree we're entering into has already occurred, it did in the end produce more jobs for nurses.

I've recently met with the Ontario Nurses' Association and the Registered Nurses Association of Ontario. Also, we just celebrated Nurses Week a while back, and I had the opportunity to attend a number of nursing events and have round tables and dialogues with nurses. Health care is a growing business. As the population grows and ages, certainly there will be an increased need for nurses and other health care providers.

I also took the unusual step on behalf of nurses, when I spoke with region 3 of the Ontario Hospital Association, to remind them that we need to come to a consensus on what the appropriate staff mix is in hospitals. There really isn't.

Our nurse adviser on my staff is Kathleen MacMillan, who's highly respected in the nursing community. She's a nurse herself, has a master's in nursing and is working on her PhD in nursing. She's of the opinion, and the advice we hear is, that we have to work more carefully and closely, and we're doing that, with the Ministry of Education to make sure we do a better job of planning in the province these human resource matters and provider resource matters. We've seen in my lifetime shortages of nurses and surpluses of nurses. We have to do a better job as government, working with the associations, to plan better so we don't have these ebbs and flows and ups and downs with respect to the supply of nurses in the province.

There's a study from Laurentian University and a press release they put out a few months ago indicating that with our community reinvestments they expect there will be a shortage of baccalaureate-prepared nurses in the province by the turn of the century, by the year 2000. In that press release, which we will table for the committee -- I have a copy right here, in fact -- it indicates that people should not be discouraged from going to university and getting a baccalaureate degree in nursing, because there will be jobs. Our community investment of $170 million into community-based care, for example, creates a number of jobs for nurses and other health care providers.

When I appeared before the Ontario Hospital Association, I brought to their attention the fact that during Nurses Week this year the Registered Nurses Association gave an award to Mount Sinai Hospital. Mount Sinai has decided to increase its number of registered nurses on staff. They are one model out there that we're encouraging other hospitals to look at as they decide their staff mixes. They feel that by increasing the nurses they have and decreasing the number of generic workers or less skilled and less trained workers, they will indeed provide quality care and meet the fiscal objectives and targets that have been set for that hospital.

More work needs to be done in that area. We have a very good relationship with the Registered Nurses Association of Ontario. One on one, anyway, we have a good relationship with the Ontario Nurses' Association. We are working together.

We have done some things at the ministry. We came to office and we extended the nursing effectiveness, utilization and outcomes research unit at McMaster University and the University of Toronto, which will advise the government on how best to use nurses in a restructured system. We put $1.7 million into that research unit a few months back so we'd get good advice as we go through restructuring. We don't want to end up like Britain, where they have a chronic shortage of nurses right now as a result of the restructuring they went through. In fact, I think they're actively recruiting nurses from Canada now to go to Great Britain.

Hospitals are the employers of nurses, and we're trying to encourage them and indicate to them that there's more than one model out there and to please look at Mount Sinai, which received the first annual Employer of the Year Award from the Registered Nurses Association.

I'm sorry about the rather scrambled answer. But we are working very closely with nurses and we're concerned. Here's the Laurentian press release of March 22, 1997. It says, "Survey Points Towards Increased Employment Opportunities for University-educated Nurses." This was done by Professor Johanne Pomerleau, director of Laurentian University's school of nursing. It says:

"The results of the survey indicate that there will be an increased demand for baccalaureate-prepared nurses in all sectors of health care after the present health restructuring is completed. Other countries, such as Great Britain and Australia, have completed these changes and are now dealing with shortages of university-educated nurses. These nurses are able to function in the new health environment which requires more independent practice and autonomous decision-making."

To enable nurses to practise to their full potential of their education and training, we've also introduced, as you know, the nurse practitioners legislation, which is long overdue. The previous government made the announcement that nurse practitioners would be trained in the province and they did open up the university courses so that nurses could go back and participate in those programs and become qualified. However, they didn't move forward on the legislation; they sent that off to the Health Professions Regulatory Advisory Council, where it sat for about two years until we came to office. We brushed the dust off that one and brought it forward and now have that before us in the Legislature, and I think we have all-party agreement to move forward as quickly as possible on it.

I also mention that in addition to having joint policy committees with the hospital association, for example, the province also has the JPNC, which is the Joint Provincial Nursing Council. It's also working with us very quickly and very closely to advise the government, as I said earlier, on how the ministries of education and health can work more closely together to make sure we're projecting the needs of nursing in a proactive way, ahead of time, so that we're training enough nurses in the system to meet the needs.

Mr Ed Doyle (Wentworth East): I understand that Ontario was the last government in the country to introduce a copayment for drugs and that the copayment we have offered is actually one of the best bargains offered by any government in the country. I wonder if you could detail for us some of the benefits we have under the increased numbers of drugs and pharmaceuticals that are available to the patients of the province.

Hon Mr Wilson: When we came to office, we had just seen five years of delisting some 260 drugs from the drug formulary. What delisting meant was that the cost of drugs taken off the formulary became 100% the responsibility of seniors.

In the senior seminars I have held each year in my riding in June, Seniors' Month, at the last three seminars I've asked seniors in the room to put up their hands if they're now paying 100% for a drug that was previously covered by the formulary. We have reversed that in the last 18 months in that we've added 465 new drugs to the formulary. All the money that's coming in from copayments is being applied towards new drugs, and some of those drugs are extremely expensive. We have, for women's health, for example, Taxol, a cancer drug. We're covering a full range of AIDS and HIV drugs. I think it would be very interesting to provide to the committee a list of some of these new drugs.

Pharmaceutical companies went through a period of about five years where they couldn't introduce any breakthrough drugs. There's a rigorous process you go through. Mind you, we've shortened the process; we got rid of a lot of the red tape. But it is a benefit to health care in general and to the people of the province, seniors in particular, that we add new drugs. The approvals process is based on, if this drug is added, what are its benefits across the system? Will we see fewer hospital admissions etc? We do that.

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We've taken all the money we've seen in copayments and we're investing it in new drugs, and we've also lowered the deductible on the Trillium drug plan, which is the drug program the NDP introduced, a good program. That entitles the working poor, defined as those people who are working and are therefore not on social assistance -- their income levels are above what one would be at to qualify for welfare or social assistance, but at the same time they're by no means able to cover the catastrophic drug costs.

The deductible, when introduced, was $500, which meant people would have to pay the first $500 of their drugs in any given year and then they would qualify for the Ontario drug benefit plan, which is essentially the same plan; they weren't a senior and they're not on social assistance. We lowered that to $350, which again is unmatched in Canada. Nobody else has a program like it. Those people who have catastrophic drug costs now have to pay the first $350 but we pick up everything after that.

I encourage you to tell your constituents that. You'll note in the estimates, going back to what we're here for, that there's some underspending in that area. The money's sitting there available to people because we haven't had the enrolment in the Trillium drug program that we expected, frankly, although the applications are available at every pharmacy, every doctor's office in the province and MPPs' offices, and we mail out hundreds of applications to people who call in. We certainly wouldn't mind if MPPs as part of their seniors' seminars or as part of their constituency meetings mention the Trillium drug plan, because it's something we're extremely proud of.

The Vice-Chair: Anyone else from the government side? Then we'll move over to the third party.

Mr Tony Martin (Sault Ste Marie): I want to follow up on Mr Doyle's question, as it is quite relevant and timely. A significant number of the calls to my office and the letters I get are in reference to the difficulty seniors in particular are having in accessing the drugs they need to take care of themselves in a manner that's healthy and speaks to quality of life.

I know of a number of seniors who, because of the new copayment and other complications, for example, the fact that people are being released from hospital a lot sooner now than they ever were before and so must purchase the medication they would normally get if they were in the hospital -- it's becoming quite a burden to them. In spite of the gleam you put on what's happening in the area of seniors and drugs, there's still a big problem out there, indicated very clearly by the number of people who are having great difficulty, who are in distress now because of the added cost to people who are for all intents and purposes on fixed incomes.

How do you put that juxtaposition together? You obviously very confidently sit and tell us in your response to Mr Doyle of all the good things that are going on and how it's all working in the best interests of seniors out there, and yet when we go back out to our constituencies we hear a very, very different story. Who is telling the truth and who isn't? Which reality do we believe?

Hon Mr Wilson: My advice would be that you pass on those cases to the ministry. We've closed a number of gaps. Yes, it used to be the case under your government when people were discharged from hospital -- and by the way, people are not going out any earlier than they were during your period of time in office -- they couldn't get their drugs covered that were covered as part of the hospital, but the reason we've been adding 465 drugs to the program is to close those gaps. If a particular person, a senior, is discharged from hospital and they need the drug, then we want to hear about that.

Mr Martin: We do, though. We work really hard in our office. The constituency workers in my office are forever working with individual seniors and others in the community, trying to sort out some of those issues. I don't know where you get your statistics. Actually the closest I get to the reality of what's going on is when I go back and I talk to people who are coming out of our hospitals and I talk to the professionals in the hospitals and when I have family members of my own go in.

To say that people are being discharged now at the same rate as they were discharged back two or three or four years ago is just not telling it like it is. There's a juxtaposition here. There's you on one hand saying there is no problem, that seniors can access drugs, that it isn't creating stress, that people aren't being shipped out of hospital sooner than they were before and so the cost of medication to them has not changed, and yet the people we deal with on a regular basis in our communities are saying otherwise.

Just a new question to this, because it's the same question over again basically: You mentioned the Trillium drug plan and the fact that people aren't taking it up. It could be that you've set the criteria so tightly that they just don't qualify, because we have people come into our office who want to access Trillium. We work with them and with their doctors to see if we can get them to fit, and the difficulty is the criteria, not unlike -- and it's important to tie these things together because it's a bit of a pattern -- the fact that my community returned to your ministry last year about $400,000 in long-term-care money because they say they couldn't spend it. When we dug into it a little bit we found out that the reason they couldn't spend it was the criteria were so tight and narrow that people who really needed the long-term care -- and it's seniors again for the most part -- aren't getting it because they don't fit the criteria.

On one hand you're saying, "Everything's fine; we've got enough money to look after people," yet on the other hand our experience of it is in fact that you're not and that where there is something that people could access, the criteria are so narrow and so strict that they can't access it and they're having difficulty. Are you looking at maybe loosening up some of that or backing away from some of the very difficult pressure you're putting on seniors where it comes to accessing some of the drugs they need?

Hon Mr Wilson: We didn't change the criteria of the Trillium drug plan. What we did was expand the program so that 140,000 more working poor people could access the programs. So the criteria are the same.

I think things are improving and they can always continue to improve. There was a day when you were discharged from hospital and there wasn't a program except a very limited ODB program for which you had to be on welfare or a senior citizen to qualify.

Your government moved forward to bring Trillium and now some of those drugs, unless they are under a special drugs category or some other circumstances, people do have to pay for depending on their family income bracket, up to the first $350 of their drug costs in that year. The best I can say is that it's by far the best program in the world. There's no better place to live than Ontario if you're a senior or if you're the working poor.

Certainly we will strive to continually improve it within the reality of the fiscal situation of the province. We're spending 20% more per capita on health care in this province than anyone else in Canada and we rank up there with the best in the world. The nurses' association, many of the associations out there indicate that we are spending enough money on health care; it's just targeting that money. That's the idea of the Trillium drug plan and others, to target the money to people who need it.

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The $2 deductible or the $6.11 copayment or the $6.11/$100-a-year premium is by far the lowest in Canada. In Saskatchewan, as you know, it's $600 every six months. Nobody comes close to Ontario, so I don't think this government or your government or any previous government in Ontario should make any apology for not having the best programs and the most generous programs. All I can say to you is we're doing the best we can.

With respect to discharge from hospital, remember, people cannot by law be discharged from hospital unless there is a plan in place to look after them in the community. We do not have waiting lists anywhere in the province today for in-home nursing, and the criteria haven't changed one iota. It is driven by need; it is driven by medical experts. I don't decide whether you need 10 hours of nursing a week or 40 hours of nursing a week. That is decided as a part of the discharge planning process by the team at the hospital or the institution you're coming from, and that is to be in place prior to discharge.

Also, anyone who is not going through the institutional route into home care phones our community care access centres and a nurse is sent out right away to do an assessment of the client's needs. I think it's a very reasonable system. We can't do everything for everyone, but those who have medical needs are looked after in the province, and we've been pumping increasingly more and more money into that system.

Mr Martin: Minister, I appreciate your optimism, I really do, and I hope in the best interests of my constituents that you're right. But the reality that's rolling out there right now is not proving to be that way. We have story after story that we've documented out of our community alone where the level of service that is being offered in hospitals now is diminishing, some of them quite dramatic, some of them written up in a very troubling way in local newspapers as people get to a point where their frustration level is so high they feel they have no other choice but to speak about it publicly and let people know what's going on.

After just such a series of stories in our community we went to the hospital board and administrators and asked them what was going on. The response they gave to us was, among other things, that we no longer can afford in Ontario first-class -- they call it "hotel service" delivery of health care. We asked them what they meant by that. Is it that we can no longer give back rubs, we can no longer feed people, we can no longer bring a glass of water to the bed? Is that considered a frill?

Trying to set up an analogy of some sort, I'm thinking, you know, I bring my car in to the garage and they change the water pump. They take the water pump out and then they give me the car back. They don't wash it or shampoo it. But to compare that to the care of people who go into a hospital, who are sick -- and anybody who knows anything about health care know that a holistic approach, where you look after the needs of the whole person when they go into the hospital, is very, very important where it concerns the getting better, the well-being, the improvement in health of that person.

If you're moving our hospitals to a situation where it's similar to going in and getting your water pump changed, in and out, bang, bang, the meter goes on when you go in, the meter goes off when you go out and that's what gets billed and we keep track of it in that way, as opposed to looking at the whole person when we bring them in -- because that's what everybody thinks they pay into when they pay their taxes, that they should get everything they need to make them comfortable and make them better so that when they leave they are in better shape than when they arrived.

That's the scenario. That's what the people who are running hospitals out there are saying to some of us: "We can no longer afford a first-class, hotel type of operation where we give back rubs or bring water to the bed or even feed people." Some of the stories are quite alarming.

I put that together with the agreement you've made now with the doctors. Actually, the day after the agreement was announced, I met with a health care coalition in Sault Ste Marie to discuss just that. The doctor in that group, who is president of the local academy, was, with us, first of all happy that you had an agreement with the doctors. All of us are happy that you have buried the hatchet with that group and found a way to work together with them, but the extra cost to the system that it's going to take for you to meet that agreement -- the question from all of us was, "Where's that money coming from?"

Is that now going to be fewer hotel services to people? Whereas now we don't get hotel services but we still get the first-class water pump, are we going to get discount parts and pieces? What's the situation going to be? How are you going to account for the extra money that it's going to cost you?

To add to that a further concern, when you bring on the nurse practitioners, which is good news again, where's the money going to come from to cover the cost of that? Is the pocket already there or is there going to be new money? How is all that going to be looked at? It just runs up a million red flags for us out there who have any kind of genuine concern about how we deliver health care to our constituents.

Hon Mr Wilson: We made very clear when we signed the agreement with the OMA that new money will be required in the health care budget. Some of that is reflected this year; you'll see it more as we proceed through the year. We're dealing with other providers also. We've taken the clawback off other provider groups that your government had in place and are trying to be very fair across the board to all the providers in the system. We've taken it off for optometrists, for example, and chiropractors. We're in negotiations with them right now.

Remember, you brought in the social contract, which was three years. Rather than permanently lowering anybody's expectations, all you did was create pent-up demand for three years. We came to office and now everybody says to us, "It's been three years since our problems were addressed; we want X, Y and Z." We are in negotiations trying to deal with all the demands.

We're concentrating on the patient, though, and less on the provider arguments. The deal with the doctors is for patients, not for doctors. Doctors did not get a fee increase. The pool is being adjusted to reflect the growing and aging population so that the people who go to the doctor will be seen by the doctor.

We are doing the very best we can. The deputy was reminding me recently we had a number of delegations from other countries, including the United States, who can't believe the level of services we are able to provide in our hospitals and the amount of money we spend. I just finished last year being chair of Canada's health ministers, and in fact three weeks ago had a meeting in Montreal with provincial health ministers on the blood issue. The ribbing we take is, "Wilson, how can you spend so much money on health care?"

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We're trying to focus the system on outcomes, less on these dollar arguments. Wouldn't it be nice if politicians could get off dollar arguments and actually focus on what the professionals, like the nurses, are saying? That is, let's measure outcomes. Is our population healthier for all the money we spent on health care? Is there evidence that pumping in hundreds of millions of dollars more going to do anything to make your population healthier? We have to move rapidly, I think more so than we have in the past, towards what nurses have been telling us, particularly the Ontario Nurses' Association, and that is doing more on the prevention side. That's why for the first time in Ontario we have province-wide immunization programs for seniors and for school-aged children with hepatitis B.

We are, as best we can, trying to bring a balance to the system and put additional dollars also into public health: our healthy babies program, a first of its kind certainly in this part of Canada -- BC is doing something similar -- to try and give infants a healthy start in life; the Premier's breakfast program, which is not costing the taxpayers money but was done in cooperation with the private sector. Literally dozens of those programs across the province are an effort to try and --

Mr Martin: You take 22% away from the families that feed most of the hungry people in this province and then you introduce a breakfast program and suggest for a second that that somehow replaces it?

Hon Mr Wilson: Our welfare rates are much higher than anyone else in Canada, including other NDP governments. The fact of the matter is, even with the rate reductions in all categories, we're still above the national average. I think we still have a very generous program and we've expanded the drug programs and other benefits that people on social assistance receive. We won't get into a social assistance debate today; there are others more qualified to do that.

Mr Martin: Maybe since you suggested it, let's talk for a second about the impact on families, on people in this province, of reducing the income to some of the most vulnerable, our children particularly, by 22%. That in itself has contributed in a very significant way to the impoverishment and to the poor health of many of our children and of our families. We're seeing it in our communities and we're seeing it on the streets of Toronto.

How can you say you are at all interested in health promotion and prevention, particularly for those who are most vulnerable, and at the same time support your colleagues' making a decision two months into your mandate which in fact probably shocked me more than anything you've done to date so far, although I've been shocked on a number of occasions? How do you square that, Jim?

Hon Mr Wilson: I think with common sense. Bob Nixon, I think, was the most honest ex-politician to describe the STEP program, where he said perhaps our benefits were becoming a disincentive to go to work.

Mr Martin: But there is no work.

Hon Mr Wilson: We are, unlike other governments, targeting those benefits, as you say, to the most vulnerable, to the people who actually need it. Having people on welfare who could work siphons benefits away from those families who absolutely need the help. That's the focus of this government, and you'll note that every other government in Canada is now following Ontario's lead.

The Vice-Chair: We'll return to our normal rotation now and we'll start with the official opposition.

Mr Gerard Kennedy (York South): Minister, I want to bring you to a summary of what we hope to discuss with you in the next little while. I think it's important that people get a true picture of what's happening in terms of the estimates, in terms of your overall programs, one of which is that you actually reduced health care spending last year. We established that yesterday. The accounting trick of --

Hon Mr Wilson: No, you established that on your own --

The Vice-Chair: Hold it, hold it.

Hon Mr Wilson: Excuse me, Mr Chairman. The honourable member established that in his own mind yesterday.

Mr Kennedy: Minister, I'll be happy to provide you with the figures.

Hon Mr Wilson: No, no. There's no evidence --

The Vice-Chair: Gentlemen.

Hon Mr Wilson: No, I'm not putting up with this. We've no evidence at all in the estimates --

The Vice-Chair: One second. Nor am I, Mr Wilson.

Hon Mr Wilson: Throw me out, Chair.

The Vice-Chair: Yes, right. You'd like that.

Mr Kennedy: I have a copy for you of the figures that establish that. We established yesterday that what you announced in the budget, $1.3 billion to offset hospital restructuring, we learned from you and your deputy that only $218 million, or 17% of that, will be spent and that none of it was spent last year. So there's a phantom quality about the dollars you put into health care.

I want to refer you specifically -- you have talked about investment in community and you have talked about home care, and particularly that there are opportunities for nurses. How much money did you increase home care by last year?

Hon Mr Wilson: Of the $170 million we've announced, we've been flowing over $130 million of that and by the end of this calendar year the rest will go. The system, by the way, when you talk to the experts, can't take an injection of $170 million all at once. We don't have the capacity.

Mr Kennedy: I wonder if they could take what actually happened.

Hon Mr Wilson: You want to talk to some home care experts.

Mr Kennedy: If I could refer you to the page in the estimates that deals with long-term care, home care. I'll have that for you in a moment. That would be facing page 175. Do you have the page? In column (e), the amount of money you spent last year, $1.032 billion, is $4 million less than was spent the year before. In fact what you budgeted -- and this is very important for the people of Ontario, Minister --

Mr Trevor Pettit (Hamilton Mountain): Page 174.

Mr Kennedy: It's facing 175. There isn't a page number there, but yes, thank you, Mr Pettit.

Where the figures are in column (e) and column (g), comparing the interim actuals in column (e), we see that actually $4 million less was spent on home care by you, Minister, last year. You underspent your budget by some $120 million. I think there's just no credibility that you can ascribe to that. When you talk about increases in home care, you've actually decreased it by $4 million. That's what the figures say.

Hon Mr Wilson: You can check. Under our accounting system now the day the announcement is made is the day the money's available.

Mr Kennedy: We have figures in front of us here. Wouldn't you agree there's $4 million less spent?

Hon Mr Wilson: I agree that the money was available last year and that the home care agencies frankly didn't have the customers, is what they told us. What am I supposed to do? This is the same argument. Am I supposed to set up a trust fund now in a community and say, "There it is." The trust fund is us. It's the Provincial Auditor. The money's there.

Your first question was: "What have you spent over the last two years?" We've injected $130 million of the $170 million so far and the rest will flow. We had a capacity problem last year. You can't just flow dollars out. By the way, we flow these dollars on an invoice basis, so we don't flow it out ahead of time. Simply, we pay the invoices every 30 days from the Red Cross, the VON and the 1,200 agencies. When they have the customers, they provide the service and we pay for it. Last year, if there's slight underspending, and there is, you're right --

Mr Kennedy: Slight?

Hon Mr Wilson: -- it isn't that the money wasn't available. It's why today we do not have waiting lists for in-home nursing. We do have some waiting lists, as I said, for some of the therapies, occupational therapy and speech-language pathology, in-home therapies. That is more a result of not having the trained professionals to provide the services. We have actual money sitting in long-term-care offices, but we don't have a professional to send out to the home, so we need to train more young people.

But in terms of home care services it's an invoice system. The money's available and this year the agencies are better geared up. We were told by many of the home care agencies when we made the announcement of $170 million at the press conference that there would be lag time of eight to 12 months to hire the people, train them, deliver the services and see the clients, as they're referred to, come on line.

Mr Kennedy: You made that announcement more than 12 months before and the facts are, you spent $4 million less on home care than you did the year before.

Similarly, when it comes to mental health, you talked a lot and you made a lot of noise about improving spending on community-based mental health services, but I refer you to page 103, page 102 to be correct, the figure page.

Hon Mr Wilson: I just point out that on home care the money was put in the estimates, and yes, it didn't get spent because we didn't receive the invoices. This year we hope we'll receive more invoices.

Mr Kennedy: That frankly is an incredible answer.

Hon Mr Wilson: That is the answer. You don't like any of my answers, but that is the answer. You make up your own, but that is the answer.

Mr Kennedy: That's the best of your answers and we'll let other people judge how credible it is.

Do you have a similar explanation for page 102, because you promised a $21-million community investment fund. You promised a lot of things for community mental health and in fact you didn't spend it. You spent only $3 million more and you had $202 million budgeted. How are people to believe that you're actually going to spend the money when in these crucial areas you've filled the airwaves over and over again saying that you're spending money and you didn't spend the money you said you would. How do you explain that? There must be an explanation for this.

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Hon Mr Wilson: How do you explain your proposition to set up a system and just throw the money out on the street as a free-for-all? It's not how any system works anywhere in the world that I'm aware of. For example, the money has been budgeted. It's available to the groups in mental health also, and it's more than $21 million, it's $23.5 million, the community investment fund. All of that's been announced, all of it's available to the groups.

To set up a crisis response team in Hamilton didn't take a month; it took a year. So they're not sending us an invoice till they get the team set up. To set up the crisis response in Metro, they're not set up yet even though we've announced them.

The fact of the matter is, these are human beings at the other end of these announcements. There are professionals to be recruited, to be trained, teams to put together. When we get the proposals, we go through them, we approve the proposals, we approve the dollar amount to those proposals, and under our accounting system now, which is the pre-1985 accounting system, the day the announcement is made is the day the money's available. The groups have to provide the service though. We just don't give them a bunch of money to run around and keep in bank accounts.

Mr Kennedy: More than understandable. However, I attended a number of those announcements with you and was startled to learn that many of the mental health groups had their programs in place eight months before and that the reason they did is because you announced the same funding programs eight months before.

Hon Mr Wilson: No. In fact, you'll find the announcement was made about two years before by the NDP.

Mr Kennedy: But you personally made the announcement eight months earlier --

Hon Mr Wilson: Under the old accounting system and it was a false announcement --

Mr Kennedy: -- to the exact same programs and the money did not flow. Everybody in long-term care and home care was wringing their hands wondering when this money was going to come. You know it's a joke in those circles. They hear the $170 million and they laugh because it's been talked about and talked about and the money hasn't flowed, and it certainly didn't flow last year.

Hon Mr Wilson: Exactly. In every one of those announcements, if you pay attention to the speech, I always say, "How many times have you heard this figure?" Because we've changed the accounting system, the money's available today, and that's why I say that in my remarks. I was one of the critics for four and a half years who said, "Jeez, I've heard this figure," but I can tell you, the money wasn't flowing. It's flowing now and the announcements have been made and the money's available.

Mr Kennedy: It didn't flow last year and you stand accountable for that.

I want to turn your direction to the drug program. You have made cuts now over two years that add up to some $165 million to the Ontario drug benefit program. I'll pass you a copy of those figures, but they're also available to you on page 92.

You made these cuts of $165 million. You talk about --

Interjection.

Mr Kennedy: I'll direct your attention to the amount of money that you're planning to spend in 1997-98 compared to the actuals you spent in 1996-97, and it is a cut, from $903 million to $836 million. That is a cut.

Hon Mr Wilson: Offset from the copayment. The budget is up --

Mr Kennedy: The fact is --

Hon Mr Wilson: Can I explain what you're looking at?

The Vice-Chair: Mr Kennedy, would you allow him to explain the figures and you can ask another question.

Mr Kennedy: Yes, certainly.

Hon Mr Wilson: The copayment brings in about $225 million a year, so you're seeing a substraction of that when you get into the estimates. The money will be spent. Some of it is being offset by the copayment coming in.

Also, I've explained on this that with respect to Trillium drugs we fully admit -- we're still planning to spend $75 million in column (a) -- we only spent $18 million because of the takeup. Now we're not taking away the $75 million. It's still there. We're encouraging people to sign up for the program. The $75 million is the same $75 million that we planned to spend last year, but we could only spend $18.9 million because we just simply didn't have the invoices.

Mr Kennedy: You are spending less on drugs this year than you did last. Because of the copayment program, the government investment is lower. Is that correct?

Hon Mr Wilson: No.

Mr Kennedy: How do you explain the figures? If you go to column (g), $1 billion was spent. If you go to column (e), $903 million was spent, and your plan for next year is $836 million. How do you explain that?

Hon Mr Wilson: Let's look at last year. We planned to spend $938 million and we spent $1.03 billion. So you're looking at an estimate and we will spend, I can assure you, well over the billion-dollar mark on drug program this year even with the offset of $225 million in copayment.

Mr Kennedy: But even at that figure it's still $100 million less than it was the year before.

Hon Mr Wilson: No, it isn't.

Mr Kennedy: You have two figures here, you've $1.1 billion and then you have another one for $1.03 billion. It is less no matter how you slice it.

Hon Mr Wilson: I've already explained that you've got to offset the revenue that's coming in on a program that didn't come in before.

Mr Kennedy: I want to move on to that revenue you're talking about.

Hon Mr Wilson: The deputy points out that from estimates projection to estimates projection it's actually up $45 million. We're projecting to spend more money this year, if you look at columns (f) versus (b).

Mr Kennedy: We'll come back to that because we'll look at why, for example, the special drugs program is in the position it is and we'll talk about the Trillium drug program, with your indulgence.

You talked about revenue coming in. The $100 user fee being collected from seniors earning $16,000 a year: Would you say that, as you referred to it, is revenue, in other words, you want to raise money, or was that in place to act as a deterrent for seniors and others, that income, using the drug system? Which would you say is its objective to you?

Hon Mr Wilson: It is an offsetting cost because we're reinvesting all of that money and more into expansion of the drug program, both the availability of drugs on ODB and also the Trillium program. Secondly, we did see some utilization chill back in July and August of last year, but that may have been because just prior to the announcement of the copayment we saw a huge increase in utilization as people stocked up. We won't know for a little while, but I don't think it had -- at least we don't have any evidence at this point, and Dr David Naylor just looked at this. It wasn't a deterrent to seniors getting their drugs and seniors are getting their drugs. These drugs are getting more and more expensive all the time and we have, by far, the best program available.

The Vice-Chair: A quick question to end your round, Mr Kennedy.

Mr Kennedy: We will certainly come back to that because there's ample evidence you do not have the best program in Canada.

But let me just ask you, do you know, do you have proof, do you have indications of how much additional cost there's been in hospital care or in visits to physicians as a result of seniors becoming ill because they couldn't afford to take their medication? Do you have indications of that? Do you have studies it prove it one way or the other?

Hon Mr Wilson: Yes. We have Dr David Naylor at the Institute for Clinical Evaluative Sciences who looked at that particular question. He is charged with continuing to monitor that question. We had the experience of every other province before us that brought in a copayment, many of them years ago. All nine provinces had the copayment prior to us and we do not see that they're a barrier where the copayments are reasonable. I don't know what the experience is in those provinces where the copayment is hundreds of dollars every six months.

Mr Kennedy: We'll come back to that study and we'll talk about it.

Hon Mr Wilson: Certainly ours we have from the Institute of Clinical Evaluative Sciences.

Mr Kennedy: Absolutely. I have it right here and we'll talk about it.

Mr Martin: I want to follow up on a line of questioning that I started, among others, in my last opportunity, around the agreement with the doctors. You certainly speak very positively about your interest in an integrated health care system where everybody who practises a particular level or type of health care, and I'm talking of nurses, nurse practitioners, physiotherapists, chiropractors, all that kind of thing -- bringing them into the mix and making sure that each one plays the role they're trained to play and in that way improve the way we deliver health care in the province. You talk about your support of the nurses' approach to this.

In the agreement you made with the doctors, you struck a committee to look at the further development and implementation of, for example, alternative payment schemes. You said a few minutes ago that you wished we would get away from the money end of things and focus more on the health and the people end, but at the end of the day, if we're not able to pay for the service that different professionals are wanting and we need to provide, it doesn't matter what kind of an integrated model you have, it isn't going to work. How does the establishing of a committee made up mostly of doctors to look at the development and implementation of alternative payment schemes and integrated delivery systems fit with your view of an integrated system and the nurses' view of an integrated system?

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The Vice-Chair: Mr Martin, could you please repeat the last part of your question?

Mr Martin: Sure.

The Vice-Chair: I'm sorry. I distracted the minister.

Mr Martin: No problem. How does your view of an integrated health care system, which includes a whole lot of professionals, including nurse practitioners, fit with the agreement that you cut with the doctors that sees them playing the major role in the development and implementation of alternative payment schemes and integrated delivery systems?

Hon Mr Wilson: It's a good point. The interpretation unfortunately that was put on the agreement -- the Ontario Nurses' Association was the one that put this interpretation on, and I met with them and indicated to them that their interpretation was not correct. They saw because of the way this was portrayed in the media that this was some exclusive committee looking at integrated health care systems.

All the doctors said in the two years of negotiations at the table was that they wanted to be at the table on integrated health care systems. They were worried that because the commission has put out vision statements and talked a great deal about integrated health care systems, the Health Services Restructuring Commission would become the exclusive body.

Just off the top of my head, while you were speaking, I wanted to tell you all the different groups who are working on integrated health care systems. As I've said many, many times publicly and in the Legislature and elsewhere, my job as minister, as I see it in the next while, is to integrate the integrators.

We have the JPNC, which is the Joint Provincial Nursing Council, working on integrated health care systems. We have the JPPC, which is the joint policy and planning committee between the OHA and the ministry working on integrated health care systems. We have the primary care reform committee under the leadership of Dr Wendy Graham from the OMA, which is made up of a range of experts including George Pink from the University of Toronto. The deputy named a whole pile of other names working on that committee.

We have the Health Services Restructuring Commission. We have PCCCAR, which is the academic health sciences centre committee that's been long established. Then we have the OMA agreement which simply says that doctors will be part of the discussions on integrated health care systems in the province. It's not an exclusivity clause that they would be the only group we would talk to, but they were expressing at the table over the last two years a similar frustration that the Ontario Nurses' Association was expressing in feeling that somehow they were being left out of discussions on integrated health care systems.

Plus we have about seven district health councils that have submitted integrated health care system reports to the ministry and at least two hospitals I can think of, I think North York being one. East York general under Gail Paech is another one. She's been working at it for years in fact. There is Queensway. We have a pile of hospitals that are working on integrated health care systems -- the Willett in Paris. That's just off the top of our heads.

Our job at the ministry right now is we're working with all of these groups to get a framework together for integrated health care systems. I've often said, what does it mean? There are a lot of people who, depending on who you talk to, have a different idea of what the term "integrated health care system" means, so we need to all pull on the oars in the same direction and come up with a definition, not a cookie-cutter approach but a definition, and a policy framework in which to evaluate all the good ideas and proposals we're getting from hospitals and district health councils, the OMA and all kinds of groups.

Mr Martin: But the fear out there, however, is that in fact the reins, the control of the biggest, probably, line item in your ministry's budget is still in the hands of the doctors. If you've agreed in your new agreement with them --

Hon Mr Wilson: No, that was your government.

Mr Martin: Pardon?

Hon Mr Wilson: It's not in the hands of the doctors. You gave the pool exclusively under the 1992 agreement with the doctors. We cancelled that and that's what got them angry when I came to office. They do not have any exclusivity. The deal specifically has a line in it that says the government reserves the right to set the OHIP budget, and that is a right we had to take back because you gave it to the OMA in 1992. Plus you gave them the fee schedule.

Mr Martin: Again, that's your view of the evolution of this.

Hon Mr Wilson: No, it's not my view; that's reality. That's the agreement you signed with them.

Mr Martin: It's your view. From the discussion we've had here so far in the short time I've been here, we seem to be having a very serious difference of opinion, ourselves and you --

Hon Mr Wilson: There's no opinion here.

Mr Martin: -- and the Liberals.

Hon Mr Wilson: Ask your learned lawyer friend to read both agreements and you'll see there's no opinion here. There's no room for opinion here. There's fact.

Mr Martin: Then the reality, the fact. You and your cohorts are obviously very good at twisting the truth to suit a view of life that you hope will play politically out there in a way that at the end of the day, in my mind, will continue to have a certain number of élites running this province in a way that will see fewer and fewer services. We're talking here today about health services available to the ordinary working family out there and our concern is even in this agreement that you've made, that you've cut now with the doctors.

You can cast as many aspersions on us as you will. We tried in our short time in government to balance some of the table that was out there, but in this instance, by agreeing to the kind of increase -- and you suggested in comments earlier that there was no increase. If there was no increase, why is it going to cost an additional $500 million over the cap; $362 million in year one, $424 million in year two, $486 million in year three, $1.2 billion in year four to actually meet the requirements of the agreement that you struck with the doctors?

How are we going to square all that with an integrated health care system that includes all of the professionals out there and in a way that deals right now with a budget that obviously isn't delivering the kind of quality care we've all come to expect that a province as rich as Ontario should be able to deliver?

Hon Mr Wilson: It obviously is delivering quality care. Our cases in most categories are up. Quality's been maintained. We have no evidence, in spite of all the bodies that are monitoring this on a daily basis, of the suffering of quality in the system.

Secondly, I don't know where you get your figures on the doctors' deal. I'd ask you to read it. It's 1.5% for growth. I went through this yesterday and I'd be happy to go through it again. The doctors don't receive one penny more per procedure under this deal than they did the day before the deal was signed. It's still the same rate in the fee schedule for you to walk into that doctor's office and have your examination as it was the day before the deal was signed.

We recognized after a few years of the pool not being adjusted -- and it took us two years to negotiate this in fairly hard negotiations. We agreed to expand the pool for new doctors, new Canadians, new patients coming on line and the growing and aging population, at 1.5% in each of the next three years. My calculation of 1.5% on a $4.1-billion pool is $60 million per year.

I don't know where people get $1 billion. The only other additional cost in the agreement is $45 million to retain and recruit physicians and increase our incentive programs to get physicians out to underserviced areas, rural and northern Ontario. We also have in the deal the discount that you cannot go into an overserviced area. You'll receive a 25% penalty if you graduate this year. By the way, our first class is graduating now, almost 500 doctors a year. We're starting to see a very positive effect as doctors don't want to take the 25% discount to go to an overserviced area like Toronto, so they're starting to look outside the overserviced areas and go where in fact they are needed.

The other expense in the agreement is for the malpractice insurance as per the 1986 agreement that was set by the Liberal government. So there's no way this deal cost $1 billion.

I remind you that you set caps in 1993 at $400,000 per doctor. Our new caps are $380,000 for specialists and $300,000 for general practitioners.

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Mr Martin: I hear what you're saying, but if anybody for a second thought that the doctors, after the fight they've put up for the last year and a half, were going to walk away from the table agreeing to a deal that gave them nothing -- I mean, has that ever happened in your experience of negotiations?

Hon Mr Wilson: The thing is we got rid of the clawback.

Mr Martin: That a negotiating team would walk away from the table and recommend unilaterally to their membership that they agree to this when in fact there's nothing in it for them?

Hon Mr Wilson: You'll recall that as part of negotiations we threatened not to pay the CMPA, so yes, they were happy to get it back. We went through two years of very public negotiations with the doctors, but I think they were very happy to get back some of the things they had gained in previous agreements, which is what they got back and not a penny more in some of these areas. Their big demand was to get rid of the clawback, because it doesn't make any sense. It doesn't make any sense to this government; it makes no sense to any other government in Canada except BC, which now is doing a bit of a clawback. They don't like it, but they're doing it. To claw people's gross billings back after they've rendered services to patients is a crazy way to run a system. They don't want to have the clawback, but in exchange for that we lowered their caps.

Mr Martin: Your arithmetic and my arithmetic and the people who put together the numbers -- they're not just the research people in our caucus; I'm sure the Liberals are finding the very same thing -- there are folks out there who are distant from any political persuasion who are saying quite differently, that in fact, as I said before, the increase to the cost of health care in the province -- I said before as well that if you have to reach an agreement with doctors that recognizes the contribution they make and gets them back into the hospitals and into their businesses in the way we think they need to be to deliver first-class, quality health care, it's costing you $362 million extra in the first year, $424 million extra in the second year and anywhere from $460 million to $1.2 billion in the third year of the agreement.

You said earlier you were going to put some more money in. The question still is, are you going to put that much money in --

Hon Mr Wilson: No, because that's not the cost of the deal.

Mr Martin: -- or is it going to come from someplace else in the system?

Hon Mr Wilson: Mr Martin, you can make up any figures in the world you want. If you believe them, fine, but I'd invite you to read the agreement. Do the math yourself. Don't rely on your researchers who are trying to put some spin on it up to $1 billion.

Mr Martin: This is the math --

Hon Mr Wilson: No, it isn't the math.

Mr Martin: -- and the sad part of it is that as this works its way down into the system, we begin to see the outcomes. The stories are legend now across the province, of people dying in corridors, people dying in hospitals in a state that has never been seen before, people in hospitals -- I've seen it myself first hand -- calling for nurses who are worked off their feet, who can't get to them because they have two or three other things they need to do before they get there, a deterioration in the quality of health care in this province, unprecedented, under your tutelage and your direction.

I don't know where you've living, Jim; I really don't. When you were on this side of the table, you could tell the stories. You were out there, you were talking to people, you were in your constituency office and hearing from folks in a way that certainly was critical of what we were doing. We accepted that and tried to correct some of the shortcomings, but we can't even get you to accept that a lot of these things are actually happening. I'm under the impression that sometimes you think we're making these things up.

Hon Mr Wilson: Mr Martin, you don't have a corner on talking to people. I've toured far more hospitals probably than you'll ever tour unless you're Minister of Health. That's my job. I talk to people every day. That's all I do.

Mr Martin: Maybe you're talking to the wrong people.

Hon Mr Wilson: I don't have a life beyond being health minister, unfortunately, and I do riding appointments every Friday and Saturday in my office in Alliston and Collingwood. So you have neither a corner on compassion nor a corner on talking to people.

Yes, we're going through a period of change in the system. Given that restructuring has not occurred, it is on the drawing boards right now, given that we've not gone into it, when I hear complaints now, it tells me more than anything that the status quo is not acceptable and that we have to change the system, as the experts and the nurses and others have been telling us to do for years.

You talk about politics. The easy politics would have been to do what everybody else did in this office, and that's nothing about restructuring. Unfortunately, you sent out, at a cost of $26 million, at least 30 district health councils that produced about 60 different studies that began to come on to my desk as health minister in August-September 1995. They were just coming in. There was no plan left behind, either with the bureaucracy or there didn't seem to be any political plans left in the books on what you were supposed to do. Well, that was great. You spent your five years doing what the Liberals did. The Liberals sent them all out, beginning in 1986, to do these studies. The studies all came in. You said, "I don't want to make any decisions about hospitals or anything, so let's send them all out," at a cost of $26 million, which, by the way, buys you one heck of a pile of dialysis services and heart surgeries and everything else.

Given that we were the last province to go through restructuring, given that we felt we could do it with the good advice of the experts and we absolutely -- you're making the case yourself that it's necessary. We've got lovely buildings with beautiful atriums, but there are fewer and fewer services. We need to concentrate on community-based services. They were going to continue to be the poor cousin if we didn't dramatically restructure the system. Survey after survey has shown that seniors would prefer to stay in their homes, where it's appropriate, for as long as possible, so you had to change the system.

The easy politics would have been to do nothing and to somehow bluff our way through the next three or four years, but it wouldn't have been morally or ethically right, and you would have seen an increase, I think, in the number of complaints in the system.

We are going through a transition now. I can guarantee you at the end, though, we're going to have a better health care system and more dollars focused on front-line services and those providers and the patients and away from administration and the duplication and waste that's in the system now.

Mr Peter Kormos (Welland-Thorold): Minister, I'm compelled to raise a matter that was addressed by me in members' statements today and then by Mr Kennedy and Mr Duncan in question period, and that's about the illegal billing on the part of some doctors. I have before me an article by Sharon Kirkey, Southam Newspapers out of Ottawa; it happened to be in the St Catharines Standard. I also have a letter from a doctor's office in Niagara and the letter reads:

"Dear Patient:

"As you know, most of your medical needs are covered by the Ontario hospital insurance plan. However, more and more services are provided that are not covered. Accordingly, the Ontario Orthopaedic Association has recommended that all Ontario orthopaedic surgeons implement a surgical administrative fee to be paid by the patient."

Going on, "If it is decided that surgery is required...you will be required to pay a surgical administration fee of $50 per procedure.

" A significant amount of professional time is required on your behalf in connection with the surgery which is not compensated by OHIP. Examples are arranging hospital beds and operation room time, arranging surgical assistance, consultations, blood work and EKGs."

It requests the patient to sign that, indicating that he or she understands that.

To be fair, in this particular case the constituency office resolved this with the doctor. My constituency office has also filed a report with the College of Physicians and Surgeons with respect to another and we trust that they're dealing with it appropriately, and all that's fair and good.

Having said all of that, my constituency office and I are very concerned that merely putting the onus on the patient to report this isn't good enough. Patients are sick, patients are elderly. They're afraid to complain in case their surgery is going to be cancelled or delayed even further. Orthopaedic patients, who as you know, already have lengthy waiting periods, are concerned about even further delays if they don't effectively grease the doctor, because that's what, at the end of the day, this amounts to. It's reminiscent of the horror stories we heard out of the old Soviet Union, for instance, which may be even worse now. They may well be worse now, I suspect in fact they are, but some of the horror stories we heard out of those parts of the world.

The letter that was sent that the patient was required to sign strikes me as one that had its origins somewhere, not quite a chain letter but it seems that doctors have probably been passing along form letters as prototypes of what they might have patients sign. That's just a suspicion. I have no evidence to substantiate that, but the way it reads -- it's very well written. Doctors are good at many things but one thing they're not good at is drafting correspondence, by and large. You know that. They aren't and you know that.

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Hon Mr Wilson: I didn't say that.

The Vice-Chair: Your question?

Mr Kormos: Have you been able to track down the source, not only of this practice, but for instance the form material that goes along with it? I guess the first question is, have you been trying to track it down, and second, have you been able to track it down? Does it have a source somewhere?

Hon Mr Wilson: I can't answer the specifics of that letter, but we'd be happy to have the investigators at OHIP look at it.

I don't know a better system. If members have suggestions, I'd appreciate knowing about them and we'll come up with something better. I can't predict what every doctor is going to type out on his word processor and send to his patients. Right now the rules are very clear -- they weren't clear in the last five years -- of what's permissible and isn't.

Quite a few months ago the College of Physicians and Surgeons drew a line in the sand of what is acceptable and what isn't. That's been communicated to every doctor in the province. It is the subject of their recent Dialogue magazine once again, and it's been in there, as you know, many times. I think the member from Windsor was reading that out in the House today. So that's the college itself.

The Ontario Medical Association has taken a very responsible and stern approach to this and they've made it very, very clear to doctors. For instance, a surgical administrative fee just wouldn't be acceptable. The fee code is not just for the actual cutting or whatever. It contains money there for the consultations that occur before and after surgery, for the paperwork that has to be done. That's all built into the fee code, and doctors know that.

I think what we can do, and it's part of the recent OMA-government agreement, is work closer with the doctors to try and get at, as I was saying yesterday, some of the perceived or real unfairness and make adjustments to the fee code. Remember, the doctors had that since 1993. You gave them the entire schedule of benefits unilaterally and they could change fee codes within the global budget whatever way they wanted. They didn't make any changes at all. We've made the only change in the past umpteen years to the fee schedule, and that was we gave a 30% raise to obstetricians last year because we felt they were not paid enough for the services they had to render compared to other doctors.

We are doing a thing called relative value scheduling right now to try and bring some fairness so that doctors who feel they're not getting paid for their administrative work versus other colleagues who are getting paid, maybe we can bring some fairness to that in cooperation with the doctors.

Again, it's a complaint-based system. We want to know about it. Please, any cases you have, phone them in to OHIP. We have 1-800 lines across the province and every case, I'm assured, is looked at. If it's not resolved at the Ministry of Health level -- the doctor is contacted, for example, told it's inappropriate, that in the opinion of the general manager of OHIP it's inappropriate. Most of it is solved there. Most of the doctors say, "I didn't know," or something. We deduct it from their payments, their monthly cheque, remittance statement. If they rip someone off 50 bucks, we take it off there. There are no questions asked here, it's just done, and then we reimburse the patient when we have all of that information.

If it's something more serious than that where we don't get the cooperation of the doctor or whatever, it is referred, as a disciplinary case, to the College of Physicians and Surgeons. They take it from there in their quasi-judicial process.

Mr Pettit: In my riding of Hamilton Mountain -- beautiful, panoramic Hamilton Mountain, I might add -- roughly one in four or four and a half of my constituents are seniors. They have, and I believe rightfully so, valid concerns about the restructuring and reinvestment, exactly what's happening, where the dollars are going type of thing. I would hope, and I know they hope, and I'm hoping you're going to tell me, that one of the key forces driving your reinvestment strategy is to flow dollars to compensate for the changing demographics and a growing and aging population. Can you cite for us any examples of what the ministry is doing in terms of funding services or organizations to compensate for these changing demographics?

Hon Mr Wilson: I'll mention a couple that come to mind. One is the doctors' deal. After many years, finally government has recognized the case they've been making, but second, we changed the funding formula for hospitals -- yesterday I asked that the formula and its contents be tabled for the committee -- to recognize growth and aging in demographics in the catchment areas they serve. That's why we've put several million dollars -- I forget. What are we up to in terms of growth funding? We did $25 million the first year.

Ms Margaret Mottershead: Twenty-five again, repeated, plus another $31 million.

Hon Mr Wilson: We've put about $84 million back, targeted into high-growth hospitals around the province, which is a first. If we hadn't looked at the formula they would have continued to be funded on their historic funding base, which many of them complained for years didn't have any rhyme or reason to the new population and all the subdivisions that had popped up and that sort of thing.

It's not just growth. I've often used the example of Barrie where it's also the needs of the population. We don't fund on a per capita basis, as you know, because that wouldn't make any sense in health care, although the argument is often used, per capita. We use it to compare ourselves with other provinces because it's a simple comparison, but a population of seniors -- for instance, let's use Barrie versus Wasaga Beach, where I live.

The permanent population of Wasaga Beach is over 70% seniors. They require three, four, five or six times more money per person for health care than a population like Barrie which is essentially a young population where the greatest demand is obstetrics. They're in the baby stage of their life; young couples having babies. So we do fund now, and are doing a better job all the time refining the funding tool with the joint policy and planning committee. I don't set the funding formula. I just set the general direction, which is, "Hey, folks, we can't just keep funding hospitals based on what they got last year," and you give them plus or minus a bit more. We actually have to look at what is the population they're serving.

There are two examples off the top of my head where you can assure seniors we're targeting the money to those populations that we know will need the health care, because anatomically they're at that stage in their life where they're going to need more care than someone my age, for example, who is quite healthy. Maybe the deputy has other comments on that. She knows our funding formulas.

Ms Mottershead: The other areas are in cardiac care and dialysis, areas like drugs, where we don't actually fund directly to a transfer payment and its individuals, for example. We do forecast what the demographic change is likely to be. We know that 7,000 people a month turn 65, for example, so that is built into our estimate of what the drug plan would be. Those are examples.

Also in hospitals, in the growth, it wasn't, if you notice, GTA-targeted. It was growth anywhere in the province where it exceeded a provincial average and therefore that was taken into account. Also, in the basic hospital methodology we look at the issue of the aging population and changes in demographics because we do a review of each case in a hospital and apply a methodology to it so that we know what the expected costs should be, given those changes in population needs.

Hon Mr Wilson: The last example, Mr Pettit, is we've moved to levels of care funding in our long-term-care facilities too. Now, rather than just a flat rate per client, which is the way it was prior to the introduction of Bill 101 -- the NDP brought the legislation in but they never applied it because they ran into union difficulties and all kinds of problems -- a team of nurses from a home down the street or from another town goes in at least once annually and actually assess the care needs of everybody in every bed.

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There's a funding formula now that's adjusted to the actual levels of care required. What was happening very clearly was some of our homes were not accepting the heavy care patients. If it's a flat rate, then why would you be bothered taking Mrs Jones who needs a lot of care when you can find perhaps another Mrs Jones who needs less care and the government's going to pay you and you can make a profit even though you're called a "not for profit," which is a misnomer by the way, in the province.

Now there's actually an incentive. I met with one of my nursing homes -- and I don't think they'd mind me using their name, the Collingwood Nursing Home -- two Fridays ago in my riding appointments, indicating that they were wondering how they'd get more -- it was kind of a strange appointment -- higher-level-care patients because it's worth more money to them now.

I said: "Don't talk to me. Talk to the new community care access centre in Barrie and let them know. That's where everybody goes now. You phone the one number in your area, because the placement coordination is there and long-term care is there. You phone that number and as a provider you should phone them and say, `Look, we want your next heavy cases that live in Collingwood.'"

That's an entirely different attitude than the system created. You're not bad people in the system, but with the system before, when you paid strictly on a flat rate, there was no incentive to look after people with high levels of care. Now there is because the dollars match the level of care required by the actual client.

Mr Wayne Wettlaufer (Kitchener): Minister, I want to talk about mental health, but before I do there's something else I want to ask and that relates to employee benefits in the ministry. To help you, that's on page 22. I was just wondering -- because the media are going to get hold of this and I'm going to be asked this question back home -- about the reasons for the dramatic increase in employee benefits. I think I know the answer. I think it's related to termination because I see a dramatic decrease in the salaries and wages. Am I correct in that?

Hon Mr Wilson: The deputy will have to explain employee benefits because it's an area where as minister you don't have any discretion. There are collective agreements and Management Board does that and those negotiations, but I will know that our savings would have been higher in the Ministry of Health in terms of administrative savings, because we are restructuring ourselves just like we're asking our partners out there to do, but we did absorb and decide to fund, like it hasn't been funded before, the seniors secretariat. So when Mr Jackson came over, they went from a relatively low funding in a shell ministry to -- Cam now has substantial responsibilities, and all of that is included in the Ministry of Health --

Mr Wettlaufer: So there are additional employees and employee benefits in there.

Hon Mr Wilson: We're down in employees, net, but we would be -- if you're comparing last year's estimates to this year's, I'd just ask you to keep in mind that there were some additional costs with the seniors secretariat. We got a little bit from that old ministry, in fact we've got a little bit from every old ministry because there are about 10 ministries that don't exist today, and all of that money and more has gone into the health care budget. But employee benefits is a very good question. I'll ask the deputy to comment on that.

Ms Mottershead: It's an adjustment that was made due to the actual requirements of the ministry both to cover off things like severances, to cover off a pension adjustment because of a holiday that was taken during the social contract and now the requirement to put that back in. So it's a number of factors.

Mr Wettlaufer: Okay, great. Going to mental health, which is an area that concerns my riding as we are having some mental health patriated, there are actually two pages; we'll use 102.

Is it safe to say, first off, that you do not have interim actuals before you when you're preparing the budget figures? Am I correct?

Ms Mottershead: We don't have the actuals. That's why we call that column the interim actuals because the books haven't been totally finalized.

Hon Mr Wilson: We know up to a point in the fiscal year, and then we have to sort of project the last months.

Mr Wettlaufer: Okay. So you are doing the estimates in January, perhaps, or December.

Ms Mottershead: January, February, March.

Hon Mr Wilson: You don't get much of a holiday and you start almost after the budget. The one year's tabled; you're almost into the estimates process for the next year.

Mr Wettlaufer: I had a reason for asking that particular question because it was pretty obvious to me that the Liberal critic for health didn't understand what was going on in that respect.

In mental health, there is an increase in the estimates to the tune of $34 million. How much of this would be going to research, to organizations like the Alzheimer Society or to manic-depressive, paranoia organizations, something along that line? Do we know that?

Hon Mr Wilson: We would know it right down to the dollar. I just don't know if we have it with us today.

Ms Mottershead: We will be providing in this year, 1997-98, $444,000, almost $445,000 to the Ontario Mental Health Foundation that does all of the coordination of --

Hon Mr Wilson: That's on page 112.

Mr Wettlaufer: Okay.

Hon Mr Wilson: It's part of the detail breakdown.

Mr Wettlaufer: That's for research?

Ms Mottershead: That's for research. That's what the foundation does primarily and only in the area of mental health. We have a research budget with about $34 million that is in the ministry administration end of things and we fund a number of organizations, research institutes, the universities, to do specific kinds of research. I couldn't tell you off the top of my head in terms of that $34 million precisely how much goes into Alzheimer research, for example, but we can get you that information.

Mr Wettlaufer: It's okay. I was wondering how much of the $34-million increase in mental health spending was going to research, and in actual fact none of that $34 million increase is going to research because there is another area under administration that covers that. Am I correct or are you talking program administration?

Hon Mr Wilson: It's a little tricky because some of our programs involve services to clients too, of which there is a research component. Many of our community investment fund announcements -- the Clarke Institute is a good one -- but even when you hear a crisis response team, sometimes in the proposal they'll have an evaluation unit built in and we'll pay for that too. We're very interested in what the outcomes are. So it's not that cut and dried. There is a research line item in the administration budget but I don't want to mislead you there; that's for a number of ongoing research projects.

Ms Mottershead: Can I just clarify in terms of, on page 112, that $205 million does include the Ontario Mental Health Foundation budget, so that $445,000 is part of the overall budget, so there is in fact research activity going on in addition to patient care.

I just want to pick up on something the minster said, and that is that a number of our psychiatric hospitals, for example, are teaching hospitals affiliated to universities and in that context when they have a professor, a psychiatrist-in-chief, they use some of their clinical work and apply some research to that, so that while you're looking after a patient and prescribing certain treatments, those kinds of things can get documented and used as part of research activity to better help people with schizophrenia and other things like that.

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Mr Wettlaufer: So this $34 million is an actual layout of extra moneys for treatment; that's over and above any increase in moneys for research?

Ms Mottershead: Yes, it is.

Hon Mr Wilson: That $34 million went to proposals that are primarily treatment. What we're saying is, on examination you may find that they built in a bit of research but usually it's an evaluation portion, which makes sense, because we now demand and want to know what we're getting in terms of outcomes for the money.

Research is a good one, because I think for the first time in many years we had some outside people like Vandna Bhatia from MDS and a team of people come in --

Ms Mottershead: Duncan Sinclair.

Hon Mr Wilson: -- and Duncan Sinclair prior to being appointed to the commission -- actually in my first few months in office and find out what we were doing for the $40 million worth of research. They made a number of recommendations and we've been implementing those.

God love them, but previous governments were doing healthy gardens as part of research in community health. While healthy gardens are, I'm sure, important, I don't think they should be coming out of the health budget when we have had and continue to have -- and we're working on it -- huge waiting lists for other services that I think should receive a higher priority.

We've done a lot of work to get some outside advice and to better target our research dollars. Today I can tell you we're very confident that the money's going to very good and reputable researchers and institutions that will help us create a better health care system and better health outcomes for the province. We've tried to get away from grants just because you applied, which is somewhat the way business was done in this province for many years.

Mr Wettlaufer: That's great, thanks. Just one last thing as far as the deputy is concerned: If you could get me a breakdown as to the amounts of money that we're flowing to these organizations for research, I'd appreciate that.

Mr Kennedy: We were discussing hearing from the minister -- and I know it certainly has been a concern to a lot of seniors when they were confronted with a $100 copayment and then charged for it a second time within eight months. Both situations raised a lot of concern among seniors' organizations, the people they talk to. Anecdotally they heard about a lot of problems. They wondered whether or not your ministry had done any studies in advance to know what the consequences would be of imposing this. We had a drug program that didn't make those charges, and after 20 years of that, you imposed it.

You referred to the ICES report. I wonder if you could tell us a little bit about the scope of that report. Which seniors were actually interviewed and asked if they had difficulties with the copayment? How many people did they talk to in that regard? Did they talk to seniors resident in long-term-care facilities? Did they deal with people who were paying the $2 copayment, low-income seniors? Was that all part of the study that ICES did?

Hon Mr Wilson: I don't want to pretend that I can explain to you the methodology used by Dr David Naylor, other than to say he's absolutely world-class and he did a very legitimate study and the committee should have him in. His conclusion was that copayments in this province are not a barrier, although in the study he indicates that he'll continue to monitor this, and that's what he's paid to do, at arm's length. The institute is not a day-to-day agency of the ministry. It's scientists, it's got a bit of everything over there, and it's there to provide advice to the government, and to providers and hospitals. He gets calls every day from hospitals asking how they can do things better and he helps develop clinical guidelines and that sort of thing.

Perhaps you should ask those questions to him. I think there probably is, when I read the study -- it's been a while now -- a methodology section there and you'd know what the sample size was, because I know that's in the document.

Mr Kennedy: I apologize for the wording of it, because in point of fact no seniors were spoken to in the report. I should have made it perhaps clearer that what I was looking for was if there was anything that you knew beyond what was in the report. The report makes clear no seniors were spoken to at all. Seniors resident in long-term-care facilities, which have been a very strong source of concern, weren't even part of the study and low-income seniors weren't part of the study. The only people who were part of the study were the people for the $100 copayment and that income group.

The ICES study said that prescriptions dropped by 14.2% and the distribution of drugs, the actual quantities of pills, went down by 6%. Minister, I want you to comment on that. I appreciate this is not intended to be a technical thing, but when we learn in that report that arthritis drugs were down by 20% in quantity, 20% fewer in the aftermath of your copayment -- and it should be stressed that this study came a year after the fact, so we went into this apparently with no studies about what could happen -- did those figures bother you? What do you draw from them and, more importantly, what might you do about them?

Hon Mr Wilson: Let's just see what Dr Jan Hux, who's the ICES scientist who headed the study, said:

"Although there's been a marked decrease, slightly more than 14% of the number of prescriptions filled by seniors since the introduction of the copayment, it has been offset by a smaller decline in the amount of drugs dispensed, 6%. This suggests physicians have tried to limit the impact of the copayment by increasing the quantity of drugs per prescription. Some pharmacies may also have helped maintain access by waiving the copayment for low-income seniors."

There is nothing in there to conclude that it was a barrier.

Were there were studies done ahead of time? We had the experience of nine other provinces. We did a cross-country survey before cabinet even looked at the first proposal on copayments and we didn't find any evidence. In fact, because we want to be held to a measure -- we couldn't find a measure in Canada -- we asked David Naylor. We said: "We're going to do this copayment. Would you please, at arm's length from us, using your credibility and your institution, monitor the introduction of this copayment." That's the first study. He's going to produce one I think frequently because we welcome the scrutiny. You will not find this scrutiny in any other jurisdiction, including those headed by Liberal governments in this country.

You'll also note that he does a bit of bragging in releasing that, saying, "We're the first ones to comprehensively look at the introduction of copayments." We welcome that because we're trying to do this in a very responsible and fair way. He has a next-step section in here that says, "Future studies will further examine access to medications by vulnerable patient groups, particularly those on multiple medications and those receiving anti-psychotic agents."

Mr Kennedy: I think you know, Minister, and I'm sure your deputy knows, that in point of fact there was a study in New Hampshire that showed conclusively a number of things. In 1994, the study was done in the New England Journal of Medicine. It talked about seniors and about the reduction, which is also noted in this report, of anti-psychotic drugs being so severe -- and there is a severe reduction in our province that is unexplained in this report. The New Hampshire report talks about it being so severe that they are actually able to pick up the cost impact on the health care system. This study that is done by Mr Naylor and by ICES doesn't do anything of the kind. But the New Hampshire study said that there's severe cost to the health system resulting from the limitations that were put on the Medicaid program there, and it's not incorporating the pain and suffering that must have been there, for example, for those people who didn't get arthritis medication because they couldn't afford it. There was 20% less arthritis medication purchased in this aftermath.

Hon Mr Wilson: Twenty per cent less frequency but more drugs dispensed per --

Mr Kennedy: No, Minister. I'll just tell you, because you're being very loose with the figures in a number of cases today.

Hon Mr Wilson: It's not my study. What don't you have David Naylor here and ask him?

Mr Kennedy: I want you to know that in the report it says very clearly on page 7 that when it comes to arthritis pills there was a 24% reduction in prescriptions and a 20% reduction in quantity. So you've been not as tight as we might wish in terms of some of the figures thrown around today. This is in the report. I gave you an opportunity to comment; I'm sorry you did not.

What I would like to know is, what will you do? You had the New Hampshire study ahead of time. You knew there was a prospect that people would be harmed by this. Your people knew this. The New Hampshire study, from the people I've talked to in the field, was well understood. It's the most comprehensive study that's taken place. It was done in 1994. Seniors have paid some kind of price, a 6% reduction in drugs. I want to know what further you're going to do. Do you have any concerns at all from the information that ICES uncovered? He refers, by the way, to the New Hampshire study and he talks about not being able to give you assurances based on what he's been able to do so far. Are you concerned, Minister?

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Hon Mr Wilson: He's monitoring it. It's the appropriate thing to do. I am not a physician, but if you have David Naylor in, he can explain that there are alternatives with respect to arthritis pills that don't necessarily require a prescription. Some of that happened apparently, where people are taking aspirin, for goodness' sake. The fact of the matter is he doesn't find any evidence -- this is an open process. They are reputable scientists, and I invite the committee, or some other committee, to have him in and ask him these specific medical questions.

I want to read a letter, though, if I may, real quick, about a new anti-psychotic drug that we've put on. This is a letter to me. It says:

"I'm compelled to write to you and thank you for making the funds available that I may take Zyprexa, the newest anti-psychotic....

"I am so much better now and still improving. I'm able to enjoy going out, where before I was virtually housebound. My motivation is at a level I've not seen since I became ill 18 years ago. I'm doing volunteer work and have even made a few friends. I rediscovered reading, writing, music and drawing. I can't believe the changes taking places, which is why I'm compelled to write.

"Once again, thank you."

That's a true letter to us. That's the typed version, but it was in handwriting originally.

You mentioned anti-psychotic drugs. I'll take the opportunity to tell you that we've been adding expensive anti-psychotic drugs to the program because people need them. The seniors need them.

Mr Kennedy: I want to talk to you about those expensive drugs, but the fact is your spending on drugs is down this year. Your spending is down $165 million over the last two years, and all of that has come out of the pockets of seniors and poor people.

You told us a minute ago you didn't have additional concerns, that if we wanted we could get technical information. You didn't have concerns after the first year of operation. I think that's an atrocious position for you to be taking as Minister of Health, after 20 years abruptly changing this program. It's not what we're hearing from seniors.

Minister, I wonder if you'd like to take the opportunity to apologize to seniors for having double-charged them for the eight and a half months. First of all, before you do that, because I think it's important, I'd like to congratulate you for your part in Mr Jackson's announcement yesterday. I think it's due and appropriate to seniors that they not be double-charged, that after eight and a half months they not be made to pay the copayment again and, further, they not be made to pay for part-years as they were, because that was palpably and demonstrably the source of hardship. So I want to congratulate you, but I wonder if in addition you would take the opportunity to apologize to seniors for that, because it was 71 days in coming since they told you that this was hurting a lot of people out there.

Hon Mr Wilson: I certainly don't mind apologizing at all. In fact, I'll be having my seniors' seminar in Collingwood on Friday and I'm sure the question will come up. I'll apologize and assure people that if there's money owing, it was never the intention of the program to have what happened. When we realized the experts had set the computer program up slightly wrong, it took us 72 days to correct it, but we've now corrected it. As soon as we knew about it, we corrected it. We're actually giving a break to seniors now. When we err, we now err on their side and there's a whole period when they're not being charged the copayment. It's being credited. We're bang on to what we announced, which is that certainly no one should pay any more than $100 a year and the dispensing fee each time, if they are in that high-income category. So I don't mind doing that.

First of all, though, I want to say, I don't have the letter here but I can remember CARP, which is the Canadian Association of Retired Persons, the day we introduced that they were here -- sorry, they weren't here. I met with them about a week later, and the other seniors' groups. At the time we didn't have a seniors' minister, so I was the seniors' minister. We have letters on file, which I have read into Hansard before, congratulating the government on bringing in a long-overdue copayment. CARP said that and, I know, one or two other associations. So I didn't have any letters at that time from any seniors' groups that you've mentioned saying they were against it. I don't have any. Most seniors that I know, certainly that these associations represent, felt it was fair that they pay something towards it as long as the money wasn't going to treasury, as long as it was going back into health care, and we've more than lived up to that.

Second, when the seniors brought this to our attention, we acted immediately to make the program changes. It certainly wasn't our intent to have the foulup that we had. These things happen, and as Bob Rae said, the measure is, do you take corrective action when it's brought to your attention? We did that immediately when it was brought to our attention.

Mr Kennedy: I want to congratulate you for that and I won't mitigate against it. It wasn't immediate, but still I congratulate you for having done so. But seniors are not sanguine about what's happening. All the groups you've mentioned have formed a coalition and they're going to want to talk to you. They want to talk to you about the harmful impacts they're seeing.

They're not comforted by the study you referenced and the very narrow basis it was on: only computer-generated figures, no people spoken to, not looking at the range of impacts on seniors. They want to know a few things. They want to know why you keep talking about this as being the best program in the country and elsewhere. You and the minister for seniors' issues keep doing that; you said North America.

In fact, New Hampshire has a $1 copayment program. But drug programs in the Yukon and the Northwest Territories don't charge seniors for drugs. In British Columbia seniors pay 100% of the dispensing fee but a maximum of $200 a year. There is no fee for residents of long-term-care facilities. We charge them the same as everyone else.

In Ontario, $200 means 16 prescriptions a year, but your own ministry average says we do 27 in terms of the cost to seniors. Clearly our program is more expensive to seniors, and at $6.11, that's $264 a year. It can be substantially more. In New Brunswick seniors pay $9.05 per prescription, no deductible and no charge for seniors in nursing homes. So again, if we use the average number of prescriptions, they'll pay less than the ones in Ontario. There are also no charges in Manitoba for residents in long-term-care facilities. So we'd like to reconcile some of your statements.

This is based on a Ministry of Health and industry study. You should not be putting that forward, because seniors know better. They know you've put in the $2 charges where there's $1 elsewhere, where some on welfare aren't charged at all, and they know there are other people paying less per year.

Hon Mr Wilson: There isn't anybody else paying less.

Mr Kennedy: Before you answer, too often we leave the people out. Iris Johnston came down here to the media conference to help remind you -- I think it was at about day 57 or day 62 or something -- to really tell you that this was hurting people. On the $100 extra that you charged her, it was the principle. She says, "The government is robbing someone who can't afford it."

She has $16,028 for her income, so just above the level, and she has to get seven prescriptions a month. She had to pay $500 last year out of her pocket, far more than a lot of people have to pay, maximum, in British Columbia, for example. She also, and it's something I hope we'll have some time to touch on, has to pay for medications that aren't covered by the Ontario drug benefit plan. Her total prescription drug bill is $1,000.

This is Iris Johnston, 71 years old, and she said, "It's a case of do we eat food today or do we take our medicine." That's the kind of life change you've brought about with your introduction. She's aware intuitively of what the New Hampshire study could have told you. She says, "If I don't take my medications -- I've got to do that with other tradeoffs because I've got to keep my health or I'm going to get sicker and I'm going to end up using hospitals." She's upset.

When you talk about having the best program, you don't have the best program in the country. Other programs are less expensive to seniors and you shouldn't put it forward. More importantly, you should recognize the impact this is having on seniors. Will you agree at least that you do not have the best program for drugs in the country? Then we can start talking about a baseline of how it could be improved.

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Hon Mr Wilson: It is the best program by far in the country. I invite you to come to a meeting of seniors' ministers or health ministers, where a lot of them are quite angry because now their public is demanding Ontario's program.

I'll give you the comparison sheet, the provincial comparison based on 25 prescriptions and $753 worth of medication a year, which is the Ontario average for seniors. In Ontario, for those 25 prescriptions and $753 worth of drugs, you would pay about $270. That includes your $100, plus $6.11 each time above that.

The Saskatchewan comparable figure is $753. The deductible for seniors is not $100, it's $1,700 a year. In Manitoba that same pile of prescriptions that cost $270 in Ontario would cost $355. It's a $130 deductible in Manitoba, plus 30% of the cost of each prescription, regardless of the cost of prescription. So if it's a $300 prescription, they'd also have to pay 30% of that on top of their first $130 worth of drugs every year.

In Quebec, that same $270 basket of drugs would cost $463; that's a $200 deductible plus 25% of the cost of each prescription. In Alberta, that same basket of $270 worth of drugs in Ontario and 25 prescriptions would cost $625, or 30% of the cost of the prescription, up to $25 per prescription. So rather than $611, or $2 per prescription, they are paying up to $25 per prescription, or the first 30% of the cost.

In PEI, that same $270 cost -- and this is oranges to oranges -- would cost $370 because their copayment is $14.75 per prescription. In Nova Scotia, the same $270 basket of drugs in Ontario would cost $350 because their premium is $215 a year, plus 20% of the cost of drugs.

So we have the best program, plus you have to take into account, after you pay --

Mr Kennedy: New Brunswick and British Columbia, Minister?

Hon Mr Wilson: I don't have those before me.

Mr Kennedy: I do.

Hon Mr Wilson: But what I will tell you, though -- I will compare it to any one, and I have.

Mr Kennedy: Minister, I have them right here and I already read them out. They cost less there.

Hon Mr Wilson: But you asked what you get for there. Once you pay your $100 in Ontario -- and by the way, this is only for upper-income seniors; low-income seniors pay $2.

Mr Kennedy: We'll touch on that issue.

Hon Mr Wilson: The fact of the matter is you then have access to more drugs listed and paid for out of that plan than any other drug plan in Canada. If you add the two together, once you get your premium out of the way, you have an extremely generous plan, to which we've added over 460 new drugs, that is unmatched anywhere in this country, and that is a fact.

We're always the first to add things -- not always, but I'd say most of the time. We were the first to add Taxol, we were the first to add Zyprexa, we were the first to add all of the AIDS drugs. In fact, Dr Anne Phillips told me two weeks ago, when I was meeting with our AIDS advisory committee, that we have -- she has just finished a study of all North American drug plans. I thought they were going to come in and have a list of things they need. She said, "I just wanted to have the meeting with you to tell you that you have the best drug plan in North America." That is Dr Anne Phillips who has been critical of this government and she wanted to have a meeting to tell me we have the best drug plan.

Mr Kennedy: Minister, that may be your characterization. It is not the best for seniors. There are a number of provinces that have better. You haven't addressed what happens in long-term-care facilities.

Hon Mr Wilson: Do you ever accept any facts?

Mr Kennedy: Only facts, Minister, not your mischaracterizations of facts.

Hon Mr Wilson: Why don't you believe the deputy, who's worked for 30 years with governments of all three stripes?

Mr Kennedy: Minister, if you're prepared to table a comparative study here, then do so, but you keep declining to do that. Even estimates figures you won't accept on their face.

The Vice-Chair: Mr Kennedy, our time is up and we have to move to the New Democratic Party. Mr Kormos.

Mr Kormos: With some trepidation.

The Vice-Chair: Yes, right. I'm sure you'll tread lightly.

Hon Mr Wilson: It's the new politics, Peter. Are you going to sit here and take it?

Mr Kormos: I want to get back to what we were discussing about the illegal billing. I heard what you had to say in response and again, as I indicated earlier in the House, our office has, on behalf of one of the recipients of this type of request from their doctor, filed a complaint. As of yet we haven't received a response from the college and that we understand.

Please, you've got to understand that -- I'll speak here more so perhaps for Niagara than other parts of the province -- there are many doctors who are not taking on new patients. In fact, some people have difficulty literally finding a doctor. People have a rapport with their doctors that may be developed over -- obviously, over any length of time, generationally it's developed. And the doctors who are using or engaging in this type of illegal billing practices may, notwithstanding the illegality of that, in their own right be very competent doctors with good doctor-patient skills.

Surely you understand how reluctant a patient is -- I want to get to the point of how you educate patients not to take this -- to file a complaint with the College of Physicians and Surgeons. You know full well what a doctor's response to that is. Doctors don't appreciate being referred to the College of Physicians and Surgeons.

How do you respond to the proposition that it isn't good enough -- we'll get into alternatives perhaps later -- to simply say, "The patient should make a complaint"? It's a very difficult thing to do. Many patients are quite frankly simply going to pay the $50 to avoid generating a conflict with their doctor. That's the long and short of it. How do you respond to that?

Hon Mr Wilson: It's a good question. I know my mother pays $100 and she asked me the same question. I said, "First of all, you don't have to pay it." So maybe we need to educate patients that in spite of the doctor's demands, there's no requirement under the law to pay anything to your doctor. My mother said, "But I want to pay it because I like my doctor and he does do things for us that I know he's not paid for."

My father just went into hospital three weeks ago with pneumonia and the doctor, who is a wonderful fellow -- my dad wouldn't go. He gets paid nothing for the 35 minutes on the phone with my father to convince him, "Jack, it's either the grave or go over to the hospital and get on oxygen."

He had tears in his eyes when I visited him that night, because we got the call here and I went up to Allison. He said: "You know, if it wasn't for Dr Affoo, I wouldn't be here. He spent 35 minutes on the phone with me, because Theresa" -- his wife, my mother -- "has no influence on me any more in these matters," even though of course she knows better and she puts up with him. But Dr Affoo spent 35 minutes on the phone -- this is his story -- and he didn't get paid for that.

When the $100 was discussed, my mother said, "Look, we'll pay him the $100, the block fee." Dr Affoo in Alliston is not sending out these other letters of nickel and diming people to death. His block fees are in line, he had them approved ahead of time, and they're for things, extra services that aren't covered under OHIP and never were covered under OHIP.

Mr Kormos: And there's no problem with that being illegal? That's acceptable?

Hon Mr Wilson: But if you have other suggestions --

Mr Kormos: But what I'm getting to obviously is the impoverishment, I suppose, of the response of the ministry, which is: Patients are entitled to effectively lodge a complaint, to initiate an investigation and prosecution of their doctor. You appear to understand the concern I raise, which I think is pretty universal. Why won't the ministry investigate means of detecting this practice, certainly means of educating the public? My impression is that the public isn't well-educated about this, especially when you've got certain practices like letters for insurers, that sort of thing, which a doctor can legitimately bill for, so there's a great deal of confusion there. Granted the constituency office -- I'll bet you dollars to doughnuts everybody else gets calls where we've told constituents that the doctor is properly billing you for an insurance company letter, or for a back-to-work letter.

First, shouldn't there be a program? I appreciate this involves money, but if you're going to want to involve the patient in the detection process, in the reporting process, you need some sort of public education program. Then I would suggest some way where the investigation can be initiated without the patient involvement, and appreciating that is difficult as well. I am inquiring why the ministry can't -- I'll leave it at that because there's another question I want to put to you.

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Hon Mr Wilson: We do send out 3,700 letters a month, spot checks, to people to ask them if the billing -- we give them a copy of the billing and a postage-paid envelope and form to send back to say, "Please verify that you had these tests at this time and that these were the proper" -- there aren't dollar figures attached to it -- "procedures that the doctor billed on your behalf."

By law, anyone at any time can -- we don't encourage it, because every time I say this we get a flood of requests, but you can write for your OHIP records to see what doctors have put in on your behalf. So at any time under freedom of information -- it's a service we provide. You don't have to fill out freedom of information forms. We just need your signature on a letter to give us consent to go ahead. We send out several thousand of those a year because a lot of people do know and they do phone in.

Doctors have been told where the line is. Their own college and the OMA has done it. There is a suggestion the deputy has: Every month when we send their remittance statement, which gives them the detailed breakdown -- you should ask for a copy of the remittance statement, of course with the doctor's name and number and everything and the patient name all blanked out. They get a very detailed whack of paper with their cheque every month that has the patient number and every procedure, every little lab test that was billed for broken down by code. So we do try and verify that.

In addition to that, which they get every month, we could in the next couple of months -- there's a comment section always available on the computer printout and we do that to notify them of various things -- sternly remind them again that these fees aren't allowed and put a summary of the guidelines in there again. Perhaps that would help. Then we know they saw it, because the cheque's stapled to it. That's the best I can do.

Mr Kormos: You may or may not know that my office spoke with your staff and identified a doctor who had been reported to us as engaging in what I'm told is called bundling, and that is both charging the patient as well as charging OHIP. I have every confidence that once it was reported, and I spoke with your staff, the appropriate investigations took place. The characterization of the doctor in that case was that he had a high new Canadian clientele and that these were people for whom English was not their first language. It was a doctor who -- I suppose you could call it an ethnic practice, and I'm not disparaging that at all; that's not at all uncommon for any number of professionals, be they lawyers, doctors, what have you. But here's a group of patients who in my view are particularly vulnerable. I'm not saying I have strong data to support that; I'm just using my instincts to reach that conclusion.

You've read about the criticisms of the government for its disinclination to attack OHIP fraud. You've read the newspaper reports and the critiques and the comments that OHIP fraud may be far bigger, from a variety of sources, including doctors, than anybody ever would imagine or perceive. Don't you regard this as a special problem? I appreciate what you're saying, adding to the computer printout. I suspect there's a highly vulnerable community of new Canadians for whom English is not their first language and for whom English will, perhaps with older people, never be fully mastered. Doesn't this create yet another aspect to this that should be addressed by the ministry?

Hon Mr Wilson: Again, I'm looking to your advice; you're a lawyer. Most other aspects of the law work on a complaints-type-base system. You know you're not supposed to speed, but when you do the complaint is you're caught. Then the process takes. Fraud is almost 100% a complaints system. Why would the Ministry of Health be different from the rest of the legal system, I guess is what I'm saying. We have to rely on consumers being our ears and eyes. I think most people understand there aren't user fees in health care. So when they get presented with a bill we get a lot of calls. People are generally asking the question, but a few, you're right, are being intimidated or caught. To be perfectly honest, I don't know any better system than the one we have, which is give the confidence to the public that we do follow up every complaint.

The other thing is we are renewing previous governments' efforts and adding our own special impetus to get doctors off fee for service and on to alternative payment plans where they're given a salary which includes all the counselling and allows them to spend more time with the patients. You know all the arguments for alternative payment plans. We've had a very good record in a short period of time. The previous government started with the Sick Kids and some of the big institutions to get them converted. If the current round of several dozen negotiations going on across the province is fruitful, then we're going to have a record number of doctors converted to alternative payment plans where they're not sending any bills out at all.

Mr Kormos: I'm not going to belabour the issue, but the practice you speak of, of OHIP sending out payment invoices to patients and asking them to comment, is more designed to identify doctors who are billing without performing the services, that element of fraud, than it is doctors who are bundling. Because the recipient of that thing can say, "No way was I at my doctor's office five times last year," but if there's bundling, the patient will look and say, "Yes, I received a shot," or, "I had a medical examination," quite right, dead on. But if they were given the line of goods -- I read to you what the one letter from the doctor indicated, that the $50 fee was above and beyond the surgical fee the doctor received. So the person receiving the doctor's report or the payout statement is not going to be inclined to identify bundling; they're going to be inclined to identify the traditional fraud, I suppose, of simply scamming OHIP.

As I say, I'm not going to belabour it. You get the drift. I just suggest to you that you're going to be plagued with this issue and I would encourage you quite frankly to perhaps consider a more proactive approach on the part of the ministry. My one suggestion -- you made reference to who is or isn't a lawyer, but --

Hon Mr Wilson: By the way, Mr Kormos, we're not alone in this. The actual enforcer of the Canada Health Act is the federal government, and they've been silent on this. What are they doing about this? It's their act, it's their enforcement. Frankly, as another way of maybe getting some help on it, we could take it up with the new federal minister and see if they can help us.

Mr Kormos: Well put, but it's not their essence, you understand. You know that.

Hon Mr Wilson: But they're the great defenders of it and yet this is happening. We're doing our best, but what will they do?

Mr Kormos: I'm suggesting that some specific attention to it might result in doing better. Again, at the end of the day, when a doctor defrauds OHIP he's picking the pockets of every Ontarian and Canadian. When he or she is bundling, though, they're not only picking the pockets of every Canadian or Ontarian; they're also picking the pockets of the patient. In some respects defrauding the public purse is more repugnant; in other respects whacking an individual and exploiting them is inevitably equally repugnant.

The suggestion that it be the prospect of making it a provincial offence as compared to merely a disciplinary offence is one that I wonder if the government has considered.

Hon Mr Wilson: It's not a provincial offence now, but the maximum penalty in discipline is loss of licence. It's not uncommon for the College of Physicians and Surgeons in severe cases then to refer to the criminal courts. The Medical Review Committee, for any type of fraud, when they feel even loss of licence isn't severe enough, if they have the evidence of intentional defrauding of the patient or system, will take that forward. Perhaps the deputy is more familiar with the process.

Ms Mottershead: There's the MRC process, but I was interested in a comment you made about not involving the patient when in fact even with a provincial offence you have to have a mechanism for detection or reporting. Someone's got to do it. You have to have a burden of proof. You have to prove that something was wrong and then you can take the remedial action, whether that's a charge, a conviction or a fine, whatever that is. I was interested in terms of your suggestion. How could you do it without the first party making a kind of declaration?

Mr Kormos: I appreciate that, and obviously that leads to the prospect --

Hon Mr Wilson: Our lines now are anonymous too, as you know, the health information lines. And so are our riding offices; we don't go around blurting out constituents' names without their permission. Maybe we could do a better job of making sure people know it's anonymous. We just need to know the name of the doctor to follow it up. If they want to press a charge or something, obviously we would need their name, but right now we don't need the patient's name, if that helps.

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Mr Kormos: But the practice isn't clandestine. I refer to a photocopy of a document that was being signed. It was well prepared; it wasn't the hand under the table, "Slip me 20 bucks." That's why earlier, when I spoke to you about this, it seemed to be an effort to develop schemes in the most creative possible way. My suspicion -- and only a suspicion -- is that doctors don't sit in their offices and think these up all by themselves, that these travel the circuit or travel through the culture in almost a samizdat type of way. It seems to me that in view of that tendency for it to travel throughout the culture, for instance, physicians should be encouraged to identify this sort of misconduct among their peers.

Hon Mr Wilson: You know the general law on fraud, though: Every citizen is obligated to report it. They're obligated today just as sure as heck as you and I are obligated as citizens to report it.

Ms Mottershead: Were you addressing the issue of whistleblowing, having the profession do that?

Mr Kormos: Yes, and reinforcing the professional duty to whistleblow, as some other professions have. It's an unpleasant prospect, I acknowledge that, but too bad, so sad, because we're talking about some particularly repugnant activity. It's not being done in a clandestine way; it's being done very openly. Doctors are trying to be clever about it to try to circumvent what they perceive as hardship under the current billing practice.

In any event, because we haven't got a whole lot of time, we can talk about another area of concern, especially for those of us in border communities. All of us are well aware, and many of us have made applications to the ministry and conducted appeals, of constituents who have incurred out-of-province health expenses. We understand the terribly strict interpretation that's given to the rare concession for out-of-province coverage -- I'm talking about post facto; I'm not talking about advance permission -- the almost impossibility, because the panel interprets the law very literally. I have no quarrel with that.

Those of us in border areas like Niagara region, like Windsor, have large communities that understand, are well aware, if they go to Florida as retirees, let's say, for a month, of the need to get out-of-province health coverage. However, because of the nature of the border, obviously Ontarians near borders cross the border for an hour, an hour and a half, two hours. I don't advocate cross-border shopping, but the reality is that it's something of a pastime for a lot of people, or just for the social activity.

All of our constituency offices in border communities have encountered them, more frequently among seniors, who are prone to, let's say, heart attacks, those types of medical crises. I'm concerned about them, and quite frankly the concern isn't just with you or this government. Previous governments, in my view, have failed to adequately advocate and advertise and remind people of the need for out-of-province health coverage not just for the protracted trip, which most Ontarians now know about, but for even the 15-minute or half-hour or two-hour visit. I'm asking you as Minister of Health, why wouldn't the ministry consider addressing that very specifically and educating the community with respect to the need for one-hour or two-hour coverage?

The Vice-Chair: Minister, you have about two minutes.

Hon Mr Wilson: To give credit where credit is due, your government probably did more on that, and all that is still in place. I know if you formally travel through a travel agent or anything like that, you get notices coming out your ears to remind you to get coverage.

Mr Kormos: Exactly.

Hon Mr Wilson: I think that's a result of the kerfuffle over the cut you made in out-of-country coverage, which we restored, by the way.

I'll ask the deputy to comment further. The last time I was at your border crossing there was a poster there. But it's only if you get pulled aside to be inspected that you actually get into the office to see the poster. There may be other things we can do in terms of getting the word out.

You're right, it's a lot of people, including business people who think they have it covered under their corporate policy or something. In fact, the other day I was asking; I don't know whether MPPs are covered on our business trips. We used to be. I've got a call in to the benefits section to find out. We used to be covered for up to two days on business.

Mr Kormos: You don't have a problem; you've got a ministerial credit card.

Hon Mr Wilson: I'm sure you'd say something if I put a heart operation or something on it.

The Vice-Chair: On that note, our time has gone by so quickly and so friendly.

Mr Grimmett: Mr Chair, may I just alert all the members of the committee that the health minister is not going to be able to be here next Wednesday, as I understand it, June 18. He has another meeting that is going to preclude his attendance. He'll be sending his parliamentary assistant that day.

The Vice-Chair: The minister will be here next Tuesday. All right, we will convene next Tuesday.

Mr Kennedy: Mr Chair, is it possible for us to inquire to see if the Premier's office will be ready to perhaps substitute for that day, as that is next? They were expected to be ready for the 18th from the beginning. Perhaps we could swap them if the minister is available the following Tuesday.

Mr Grimmett: The plan is to have the parliamentary assistant for the health minister here next Wednesday.

The Vice-Chair: Mr Kennedy, Ms Singh will just clarify what we have to do under the standing orders.

Clerk of the Committee (Ms Rosemarie Singh): You're required to look at the estimates in the order they were selected. If you chose to look at them out of sequence, you'd have to get a special order of the House.

Mr Kennedy: Also, would the committee be interested in having the minister available and forgoing next Wednesday's session?

Hon Mr Wilson: No. You'll live another day without me.

Mr Grimmett: We would like to proceed on the 18th.

Mr Kennedy: No, I'm having fun. I don't know what I'll do without the minister.

Hon Mr Wilson: I won't be here.

Mr Grimmett: We would like to proceed on the 18th with the parliamentary assistant, who will be able to deal with questions.

The Vice-Chair: We will see you next Tuesday. Thank you.

The committee adjourned at 1757.