CANADIAN PSYCHOANALYTIC SOCIETY, ONTARIO BRANCHES
INFERTILITY AWARENESS ASSOCIATION OF CANADA
ONTARIO COALITION FOR BETTER CHILD CARE
CITIZENS FOR QUALITY MENTAL HEALTH CARE
CONTENTS
Monday 1 November 1993
Expenditure Control Plan Statute Law Amendment Act, 1993, Bill 50, Mrs Grier / Loi de 1993 modifiant des lois en ce qui concerne le Plan de contrôle des dépenses, projet de loi 50, Mme Grier
Carole Rodrigue
Canadian Psychoanalytic Society, Ontario branches
Dr Paul Finnegan, president, Toronto branch
Dr Douglas Weir, chair, public affairs committee, Toronto branch
Infertility Awareness Association of Canada
Debra McNevin, advocacy chairperson, Toronto chapter
Diane Allen, coordinator, Toronto chapter
Alexander Franklin
Ontario Coalition for Better Child Care
Kerry McCuaig, executive director
Cheryl West, board member
Citizens for Quality Mental Health Care
Farida Karim, member
Jackie Ramsay, president
Phyllis Leonardi, president, Ottawa chapter
Marnie Judge
STANDING COMMITTEE ON SOCIAL DEVELOPMENT
*Chair / Président: Beer, Charles (York North/-Nord L)
*Vice-Chair / Vice-Président: Eddy, Ron (Brant-Haldimand L)
*Carter, Jenny (Peterborough ND)
Cunningham, Dianne (London North/-Nord PC)
*Hope, Randy R. (Chatham-Kent ND)
*Martin, Tony (Sault Ste Marie ND)
McGuinty, Dalton (Ottawa South/-Sud L)
O'Connor, Larry (Durham-York ND)
*O'Neill, Yvonne (Ottawa-Rideau L)
*Owens, Stephen (Scarborough Centre ND)
*Rizzo, Tony (Oakwood ND)
*Wilson, Jim (Simcoe West/-Ouest PC)
*In attendance / présents
Substitutions present / Membres remplaçants présents:
Sullivan, Barbara (Halton Centre L) for Mr McGuinty
Wessenger, Paul (Simcoe Centre ND) for Mr O'Connor
Also taking part / Autres participants et participantes:
Ministry of Health:
LeBlanc, Dr Eugene, executive director, negotiations secretariat, health strategies group
Wessenger, Paul, parliamentary assistant to the minister
Williams, Frank, deputy director, legal services
Clerk / Greffier: Arnott, Doug
Staff / Personnel: Gardner, Dr Bob, assistant director, Legislative Research Service
The committee met at 1535 in room 151.
EXPENDITURE CONTROL PLAN STATUTE LAW AMENDMENT ACT, 1993 / LOI DE 1993 MODIFIANT DES LOIS EN CE QUI CONCERNE LE PLAN DE CONTRÔLE DES DÉPENSES
Consideration of Bill 50, An Act to implement the Government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act / Projet de loi 50, Loi visant à mettre en oeuvre le Plan de contrôle des dépenses du gouvernement et modifiant la Loi sur l'assurance-santé et la Loi sur l'arbitrage des conflits de travail dans les hôpitaux.
The Chair (Mr Charles Beer): Good afternoon, members of the committee, ladies and gentlemen, for hearings continuing into Bill 50, An Act to implement the Government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act.
I'd just say to everyone, I don't know if this is worker health and safety, but it's awfully warm in here this afternoon. We have asked that the heat be turned down, but please remove jackets if you're feeling too warm.
CAROLE RODRIGUE
The Chair: We have a number of presenters this afternoon. The first one will be an audio presentation by Miss Carole Rodrigue, who is unable to be with us but who had asked to make the presentation via an audio cassette.
The committee listened to an audio presentation.
The Chair: If I might, on behalf of the committee members, thank Ms Rodrigue for that tape, that of course will form part of the record of our deliberations.
CANADIAN PSYCHOANALYTIC SOCIETY, ONTARIO BRANCHES
The Chair: I would then next call upon the representatives of the Toronto Psychoanalytic Society, if they would be good enough to come forward. You may wish to help yourselves to some ice water, given the southern climate here.
Members may have a schedule; I'm not sure if theirs has been changed as well. The group that was to come next called this afternoon to say they would not be coming, and that's why we've moved on to the psychoanalytic society.
Gentlemen, welcome to the committee. If you'd be good enough to introduce yourselves for Hansard, then please go ahead with your presentation.
Dr Paul Finnegan: I'm Dr Paul Finnegan, and to my left is Dr Douglas Weir. Good afternoon. I'm the president of the Toronto Psychoanalytic Society and represent, along with Dr Douglas Weir, our members and the members of the three other Ontario branches of the Canadian Psychoanalytic Society.
Currently, there are over 150 qualified psychoanalysts in practice in Ontario. About 90% of these people are psychiatrists who, after completing their medical degrees and subsequent psychiatric qualifications, have undertaken an additional five years of psychoanalytic training prior to qualifying to practice as psychoanalysts. Among these people are to be found many of the leading psychiatric educators within our province, men and women of outstanding qualification, expertise and commitment.
Our presentation today concerns the impact of recent proposals by the government of Ontario to place limits on the provision of psychoanalytic services under the Ontario health insurance plan. Thus we're here today to represent as well the interests of all of those citizens of this province for whom psychoanalytic treatment is or will become a matter of medical necessity. I'll call upon Dr Weir now to make our presentation.
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Dr Douglas Weir: Thank you. I was a little nervous about coming today, but if I'd known you were going to give me such a warm welcome, I wouldn't have worried about it.
As you may recall, the original text of Bill 50 included severe measures restricting access to psychotherapy services to a maximum of 100 hours per patient per year. The effects of such a move would be devastating to our patients and to our profession. Such restrictions would eliminate psychoanalysis as a proven, effective and medically necessary treatment.
Our patients are among the most vulnerable in society, and their neglect would end up costing our health care system more, both in direct and indirect costs. We strongly oppose such restrictions. We therefore support the amendments to Bill 50 which appear to retract these measures.
However, we are also aware that psychoanalysis could again become the target of arbitrary cuts and unilateral decisions by the government in the future. Our members, like other service providers in the health care field, understand the challenges we all face in the responsible management of health care costs in Ontario. However, we believe that arbitrary cuts and unilateral decisions about certain forms of treatment such as psychoanalysis and psychotherapy are a dangerous way to proceed. Our experience has shown that ill-conceived proposals combined with a lack of consultation can result in seriously flawed health care policy.
Our purpose in coming here today is to warn you against the dangers of delisting effective and medically necessary treatments, to point out the negative impact of arbitrary and unilateral decision-making on our ability to maintain clinical integrity, and to appeal to you to close the book on this unwarranted, unsupported and ill-conceived attack on psychotherapy and psychoanalysis.
For those of you who may not be aware of the details, the controversy surrounding the proposal to restrict access to intensive psychotherapy has been under way for more than a year and a half. In February 1992, psychiatrists in Ontario learned, without warning or consultation, that psychoanalysis was included on a list of so-called borderline cosmetic surgeries. This list was being considered for removal from the schedule of OHIP benefits. A vigorous defence of psychotherapy and psychoanalysis was launched. Despite the warnings, the government continued to give serious consideration to this proposal, and in March 1992 referred it to the joint management committee for its recommendation.
The OMA indicated at the time that it had not been consulted on the preparation of the list of services to be reviewed. The JMC reviewed the scientific evidence supporting the efficacy and medical necessity of psychoanalysis. On October 14, 1992, the JMC made a clear recommendation to the ministry to maintain psychoanalysis as an insured service and to develop a separate fee code for this treatment. The Minister of Health wrote to anxious patients reassuring them that the JMC subcommittee recommendation was for psychoanalysis to be maintained within the fee schedule and that no further action would be taken without consultation with the OMA and others. You can imagine their distress to find their ongoing treatments once again under attack with the introduction of Bill 50.
The reintroduction of the proposal clearly showed that the ministry was still operating in the Dark Ages with regard to an understanding of the medical necessity of psychoanalysis and the needs of hundreds of Ontario residents suffering from mental illness. The remarks of the Honourable Ruth Grier in the Legislature and elsewhere revealed that she was still using briefing notes based on inaccurate and misleading information.
On June 7, 1993, a backgrounder was released by the Ministry of Health with several alarming references. Without exception, all of the misleading statements in that document are false and unsupported by hard evidence. What is more alarming is that they have the effect of making clinical decisions on behalf of patients and of undermining the principles of medicare, affecting both comprehensiveness and universal access to needed treatment.
Hundreds of letters have been sent to the Premier, to the Minister of Health and to government officials detailing the facts that are supported by up-to-date scientific evidence. We have requested that the Ministry of Health backgrounder be retracted and corrected. We have received no confirmation that this has been done. We have held numerous meetings, tabled petitions in the Legislature and circulated information to NDP caucus members and opposition critics. The response has been varied, with vague assurances from the ministry that no final decision would be made until the expenditure control plan was complete.
We would like to acknowledge the support and assistance provided by the opposition critics, Barbara Sullivan and Jim Wilson. In particular, we are grateful to Mrs Sullivan for her order paper question concerning this issue. The documents provided to her, in addition to our own freedom of information request, have confirmed our worst fears.
The Ministry of Health does not have any real figures on the savings to be generated by this proposal, as it cannot, under the present system, report on the amount of psychotherapy being done for more than 100 hours per year nor on the amount of psychoanalysis being billed under OHIP.
Not only do the ministry documents reveal inadequate costing estimates but they also draw conclusions based on an incomplete search of pertinent scientific literature and professional opinion. It is interesting that the ministry's briefing note on this issue is an exact duplicate of that acquired from the government of Manitoba, right down to the incorrect spelling of the name of a researcher they cite.
It would appear that our own Ministry of Health accepted this highly questionable expert opinion to justify its proposal without even doing its own critical analysis. The ministry did not attempt to consult with psychiatrists or psychoanalysts in Ontario, and it would appear that it did no further investigation of the matter itself other than to reproduce the poorly written briefing note of another provincial government.
The ministry has failed to appreciate the adverse consequence the policies of the Manitoba government have had on patient care in that province. The weight of the evidence regarding the efficacy and cost-effectiveness of long-term psychotherapy and psychoanalysis for specific patient groups is considerable. In Manitoba, patients receive inadequate psychiatric care, which leads to continuing disability and dysfunction and often to increased medical, surgical and inpatient psychiatric costs.
Ontario psychiatric patients have been fortunate to have a complete range of psychiatric services, including intensive psychotherapy and psychoanalysis, paid for by OHIP since the inception of medicare in this province. Furthermore, psychoanalysts have made major contributions to the psychiatric profession in this province.
It should come as no surprise to the ministry that the proposal to limit psychotherapy was met with strong opposition. The psychiatric community in Ontario has the expertise to point out what a disaster this proposal is. In addition, there are thousands of patients in the province who know first hand the benefits of the therapies under risk.
The ministry neglected to consult widely on this issue. Bill 50, as it was introduced and before the amendments that came about because of the negotiations with the OMA, would not improve the situation. Instead of having to consult more, Bill 50 would have allowed the ministry a free hand to introduce proposals, such as the one to limit psychotherapy, with no requirement of having to consult with anyone.
In the standing committee on estimates, July 27, 1993, the Honourable Ruth Grier advocated the need to change health care management and delivery. Psychiatrists and psychoanalysts are aware of the need for changes. However, constructive change will not occur while the ministry is spreading misinformation and making proposals that threaten services which have been a valued part of medicare since its inception.
Health care providers and patient groups have been ignored by the ministry as it follows its own misguided course. We hope you will take the initiative to see that the record within the ministry is corrected and that health care policy is not given over to this flawed process in the future.
These comments are an abbreviated version of the Toronto Psychoanalytic Society's written presentation on Bill 50. I would urge you to read the details, which put meat on the bones of the arguments I am presenting. We will be pleased to answer any questions of the committee or to provide clarification on any of the points we have raised.
The Chair: Thank you very much, and thank you very much for a very detailed written brief, which we all have, as well as the questions and answers at the back, which I just note for the record, dealing with the Canadian Psychoanalytic Society and its work.
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Mr Jim Wilson (Simcoe West): Thank you, Dr Weir and Dr Finnegan, for your excellent presentation. I am glad you took the time out of your busy schedules to appear before the committee because, as you may know from following the committee hearings, I'm certainly not convinced that we're out of the woods yet with respect to the delisting issue. On our last day of hearings last week, I tried to get a very firm statement from the parliamentary assistant, in fact to get it in writing, that psychoanalysis or psychoanalytic therapies would not be delisted. We were unable to do that. I think, it being my opinion that Bill 50 underwent some cosmetic changes from its original draft, that the intent of the government is still there, although it did pull out of the new version of the bill some of the more offensive wording and paragraphs. All those powers are still contained, for the most part, through regulation now under this bill.
I thank you for coming forward and encourage you to have people who are currently in therapy or have had it in the past to continue pressuring the government. You did an excellent job on the lobbying side, I have to say. It leads me to, how do we stop this attack on psychotherapy from happening again? One thing I've learned as critic, in speaking with you and others over the past few years, is that this just keeps cropping up. What is the long-term solution? You mention part of it is to get the briefing notes up-to-date and make sure they're made in Ontario. That would be helpful. I'm astonished to hear that the ministry would be reading from a briefing note in the Legislature that was prepared in Manitoba.
But in terms of the OMA and the government now still having a closed-door process of matching lists of what's to be deinsured between now and Christmas, how do we open up that process, or how do we make sure that some time down the road when next year's lists are prepared psychoanalysis doesn't again appear?
Dr Weir: I share your concern about that because, like you, I'm concerned about next year's list. I've accepted the vague assurances that we're not on this year's list but, like you, I'm concerned about next year. It needs to be an open process. The public needs to be involved, there needs to be much more involvement of the profession. It is very much a small group within the OMA and the ministry that is negotiating this. My hope would be that under the new mandate they've set up with the OMA, they would involve patient groups, they'd have open public hearings.
I only saw the final results of the JMC when I read it in the notes that were sent to Barbara Sullivan; I'd never seen the minutes of the JMC before that. I'm the one who provided the information that the JMC reviewed, yet I never had a chance to look at the minutes of those meetings. In that sense, I think it has to be a much more open process and professionals and patients need to be involved in the process and given a chance to speak.
On the other hand, I think also what we've learned out of this is that we need to take the time to better educate the people who are in that position. Obviously, last year what happened was that we breathed a sigh of relief in October and we shouldn't have done that. We should have stuck around and continued to educate and so forth.
The other thing that I think has to happen is that clearly we're aware of the need to control costs. There's a joint task force of the OMA section of psychiatry and the Ontario Psychiatric Association that's looking at the whole issue of guidelines for psychotherapy, which would include psychoanalysis, so that people have the appropriate training to do these kinds of therapies and so there is some sort of guideline so that the appropriate patients are being seen in the appropriate kind of therapy, and that if there are abuses there is a mechanism to monitor them.
Mr Jim Wilson: With limited health care dollars, if government pursued, as you said, a more open process, would you be in favour of some sort of prioritizing of what's to be covered by medicare in this province and what isn't? Would psychotherapy, do you think, if the public were asked, be a very high priority for them?
Dr Weir: The public perception of psychoanalysis is that it's a luxury treatment for people, so I don't think that's necessarily the answer. In some ways, the model of a priority list is the Oregon model of reviewing services. The problem with that is that the Oregon model does not include any mental health services, not to mention psychoanalysis. It doesn't mention any psychotherapy, drug rehabilitation programs or inpatient psychiatric programs.
The problem with that kind of model is that psychiatric services of all sorts tend to be low priority in the public's mind, and they tend to be neglected over more sexy items like heart transplant surgery, so I have a sense that that wouldn't necessarily be the way to go, especially for psychiatric services, which tend to be in the public's mind not necessarily essential until you need them.
Mrs Barbara Sullivan (Halton Centre): I think it goes without saying that we appreciate your being here in front of the committee because this has been a recurring issue and one that has caused many people a lot of concern as the government's position appears to have changed from time to time with respect to the issue.
We were interested in noting last week in hearings that while I had asked for the list of measures which are proposed for delisting from OHIP in the House, and Mr Wilson asked in committee for assurances that psychotherapy was not on the list, the parliamentary assistant to the Minister of Health indicated to us that he was advising his constituents that psychotherapy was off the list, but in fact we have had no formal indication that psychotherapy is neither on the OMA list nor on the Ministry of Health list. I think that is something we were all eager to pursue.
I was interested in your responses with respect to the process of ensuring that professional expertise is involved in making decisions about what should be covered, what are the most efficacious methods of approaching illness or disease, and the evaluative mechanisms that have to be put into place.
There are a couple of other aspects I wanted to pursue, not particularly in those areas -- I happen to believe they're very important in managing the system -- but with respect to the kinds of impacts that you've seen on your patients with respect to the on-again, off-again issues associated with the listing-delisting of psychotherapy controversy.
The second area that I wanted to move to, if you want to do this all in one, was specific aspects that were included in the amendments the government has brought forward, and with respect to mandatory reporting and the kinds of relationships that Ms Rodrigue spoke about, the relationship of trust, intimacy, the personal relationship with the therapist. She referred to psychotherapy as a life support system for her and for other people.
I'm interested in your views of the kind of reporting that would be required of the professional, given grounds to believe that a person is not a resident, and for thereafter capturing an OHIP card.
I've given you lots of width, but with two specific directions.
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Dr Finnegan: If it pleases the committee, I'll address the first part of that question about impact on patients, and ask Dr Weir to say something about the question of mandatory reporting of health card fraud.
I was very moved by the tape we heard in this committee just before Dr Weir and I came to the table. This lady put before you, I think, a view and a feeling that is commonplace in my office as a practising psychoanalyst.
The patients we see in psychoanalysis are really a very carefully selected population of patients for whom psychoanalysis is a specific treatment. They are often people who have been very damaged by early experiences in life, either by loss of an important object in their life, the death of a parent, divorce, neglect or abuse of some sort.
In my practice in particular, I have a number of patients who have been in various ways abused, exploited, neglected and abandoned in their early childhood, and I can tell you that with regard to the on-again, off-again threat to the continuation of a treatment which is designed to help them to recover from the impact of all of that on their character and personality, the impact is to have them revisit the feelings of having been abused, exploited, neglected and abandoned. In other words, they experience this movement on the part of government to cut off their treatment as the same kind of abuse, neglect and abandonment that they experienced in childhood.
For many patients, questions of trust and intimacy and the durability of relationships are absolutely central to their lives and need to be worked through in therapy and psychoanalysis in order that they can go on to have successful relationships with other people.
A speaker beforehand on the tape, Ms Rodrigue, spoke of her treatment as a life support system, and I expect that's quite true in her case and in many other cases as well, but it is not a life support system that goes on unendingly. Psychoanalysis becomes a treatment in which dependency is fostered not so that it will last for ever, but rather so that it can be resolved, so that people can go on, without their treatment, to live happy and fulfilling lives.
The impact on patients of this on-again, off-again measure to restrict their treatment has been singularly devastating to many patients, and it also has had the unfortunate effect in this province over the past year and a half of unnecessarily prolonging treatments because of the disruption that these government initiatives have had on the treatment process. There's no good that's come from this.
Dr Weir: If I could just answer the second part of the question, which had to do with the mandatory reporting of health card fraud, as a society we don't have a position on this but I'll give you my personal views, which are that I think psychoanalysts, more than anyone else, are aware of the importance of the relationship between the patient and the physician and the importance that plays not only in therapy but in any kind of clinical contact.
I think the wording of this needs to be very well thought out, and I guess one of my concerns, which I think has been echoed by both the Ontario Medical Association and the College of Physicians and Surgeons, is that the wording should be more specific than things like "a suspicion of." I think people have to know what they're reporting and what they're not reporting.
This is a very delicate area, and we don't want to go into it without some specific guidelines. At the same time, I think we all want to do something about health card fraud, so it's sort of a delicate balance between respecting the patient-doctor relationship and also, if there's fraud going on, I think something has to be done.
When it comes to "suspicion of residency" and other kinds of phrases like that, I tend to not know what they mean. I'm very suspicious. I mean, I'm very suspicious that next year psychoanalysis will be on the delisting list again, so I may end up reporting a lot of people. Some colleagues who are not so suspicious may not report as many. That's all I have to say about that.
Mrs Sullivan: I just have one other question.
The Chair: Just one.
Mrs Sullivan: I know that you did a lot of work in analysing documentation that you received from the ministry. Do you have any sense of where the three different estimates of cost savings came from? The first was $1 million, the second was $26.5 million and the third was $42.4 million that the ministry projected could be saved by limiting services in psychotherapy and psychoanalysis. Do you have any sense where those figures came from?
Dr Weir: The short answer is no. It's on page 8, if you want to see the details of this in the long version. When this first came out in February 1992, the estimate at that time was that they could save as much as $1 million. A year later, in April 1993, that figure ballooned to $26.5 million, and then in June 1993 it totalled $42.4 million. There has never been an explanation, and going through all of these documents I've never found an explanation of where they got the figure of $42.4 million. Similarly, they don't explain where they got the estimate of $1 million, so it's hard to know.
I think it's unlikely that there would be $42 million worth of savings. First of all, the point we make over and over again is you may save the money in terms of psychotherapy, although I'm sceptical of that, but you'll find in other jurisdictions what has happened is that these patients end up going up for other medical costs or the money gets spent on hospitalization. So it's a false saving, if it is a saving at all.
Similarly, you have to remember that half of our patients earn less than $40,000 a year, so presumably they would not be able to continue their treatment. Psychotherapy is in high demand. Most psychoanalysts would fill up their time with people for less than 100 hours a week, and so there would be zero savings as far as I can see and patients would not be getting the care they need.
It would probably prolong care because patients -- I think, as Dr Finnegan pointed out, the goal and the reason for the intensity of treatment is not to keep people in treatment for ever but to help them resolve their dependency and to get on with leading productive, independent lives.
The Chair: Thank you. The parliamentary assistant.
Mr Paul Wessenger (Simcoe Centre): Thank you very much for your presentation. You expressed some concern about having a process that was open to the public and also a process where I gather you wanted a level of expertise in determining this whole question of what medical services should be given priority. I'm going to ask Dr Eugene LeBlanc to perhaps give some indication of the public process part of the matter of dealing with the question of delisting and also perhaps some assurance that this is a continuing process rather than --
Dr Weir: Can I just make a comment? I wasn't opposed to a public process, I was opposed to a priority process in terms of -- rather than determining whether things are medically necessary but making a list, like they do in Oregon, where mental health services tend to be neglected.
Mr Wessenger: No, I understand that you're not in favour of the Oregon system, nor is the government, but I'll ask Dr LeBlanc to indicate to the committee.
Dr Eugene LeBlanc: It's Eugene LeBlanc, Ministry of Health. The parliamentary assistant, I think, has said most of what I could say. The first is that the contractual proposal is in fact a public process drawing upon both expertise and lay input, unlike the Oregon process which, whether you liked it or not, was dominated by health professionals. Virtually no rank-and-file people participated in that process. It's intended to permit both. It is not, however, at least contemplated at the moment as a permanent process, but a time-limited process to deal with outstanding issues that have been left over from the past.
I think one should make clear that it's not quite, as the previous speaker put it, a list derived from cosmetic surgery. It was in fact based on an interprovincial study lasting some years in which detailed studies were done of provincial fee schedules, identifying those codes that were not common across the country. It turns out that the dominant number of such codes were cosmetic but it was not a cosmetic study. It was a study of codes that didn't appear across the country.
Having said that, I think the government and the OMA agreed that a process that did not have public input was not the way to go and so it has set up such a process, which I'm hoping starts very soon, and that both the proposed items for discussion, the timing and places and times by which people can make their input, will all be made available broadly to the public at the same time.
The Chair: Thank you. I'll just allow for a brief question.
Mrs Sullivan: I'm interested in Dr LeBlanc's characterization of the OMA-MOH process as being a public process. It's conducted behind closed doors with two people who represent the public sitting as part of a committee. No one knows what's on anybody's list; there's no public discussion. If psychotherapy is on the list there is no guarantee, by example, that members of the medical profession who are engaged in that particular aspect of treatment will in fact be consulted. This is not a public process.
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Dr LeBlanc: Maybe I didn't explain myself thoroughly. The process that is contemplated and is in fact spelled out within the contract would be a public process, not a JMC process but a public process with an independent chair. What it was looking at would be made public comprehensively and a means by which either professional input or, somewhat atypically, direct patient input could be provided. So the process that is being contemplated under the current OMA would be a public process. What has not been provided for is that it would be a permanent process. But for the one cycle, which is this year, the process would be public and it would be publicly known who the committee members are, where it's meeting and what its agenda is, so that those who have interests to express would be able to do so.
The Chair: I'll allow a last comment.
Dr Finnegan: I wish the Ministry of Health had been as able to accept our offers of consultation in this matter as the gentleman to my far left has been willing to come in and encroach upon our time. We have come here to present the society's point of view and the point of our view of our patients, to speak to them and to discuss the impact of what we thought was a very improper process in the past. We hope this message has gotten through to the committee.
The Chair: Thank you very much for coming before the committee today.
INFERTILITY AWARENESS ASSOCIATION OF CANADA
The Chair: I next call upon the representatives from the Infertility Awareness Association, if you would be good enough to come forward and introduce the members of your delegation.
Ms Debra McNevin: My name is Debra McNevin. I'm the advocacy chairperson of IAAC Toronto. With me is Deborah Tennant, who is the public relations chairperson of IAAC Toronto. We are also expecting our coordinator, Diane Allen, but she has not yet arrived.
IAAC is the Infertility Awareness Association of Canada, which is a national charitable organization offering assistance, support and education to people experiencing infertility. IAAC is committed to increasing awareness and understanding of the causes, treatments and emotional impacts of infertility.
Currently, all funding for our organization comes from membership and donations from interested individuals, organizations and professions. IAAC Toronto offers information, telephone support, educational seminars, support groups, training for support group facilitators and advocacy on issues of importance to the infertile community.
Infertility is a medical condition affecting one in six couples of childbearing age in Canada, including me and my colleague with me today. Thirty per cent of infertility is caused by abnormalities in the female reproductive or endocrine systems, 30% in the male reproductive or endocrine systems and 30% is caused by both male and female factors. For the remaining 10%, no cause is ever discovered. Infertility has many different treatments, including in vitro fertilization, which has been considered non-experimental since 1985.
So why are we here? We are here because notwithstanding that Bill 50, which I'll call "the bill," makes no mention of it, the Ontario government is proposing to control health care costs by removing currently funded medical services from OHIP coverage, and we believe that IVF is on the chopping block.
When the bill was first introduced, it contained two subsections which allowed the government to limit services covered by OHIP: subsection 2(5), which basically repeated clause 45(1)(i) of the Health Insurance Act, which I will call "the act," and allowed the government, by regulation, to determine which services would be covered and to prescribe circumstances in which they would be covered; and subsection 2(6), which allowed the government to limit the number of times that a service would be covered within a particular time period.
You probably recall that the OMA had an extensive advertising campaign against these sections. I brought a sample just so you'll remember how much time and effort was spent by the OMA on those issues. In response to that campaign and negotiations with the OMA, the bill has been amended and these sections deleted. The OMA seems to be satisfied that its significant concerns have been addressed in the amended bill. However, we are still concerned because the apparent waiver of the powers in these sections means very little, as the government retains the same power by clause 45(1)(i) to reduce services by delisting or by limiting circumstances under which services will be covered. I suggest that the addition to Bill 50 which caused such controversy was not required as long as clause 45(1)(i) remains in the act.
This regulation-making authority gives unlimited power to the Ministry of Health. There are few guidelines or criteria to govern the decision-making process. I could find only two guidelines in the legislation: that medically necessary services must be funded and that experimental procedures must not. These requirements can only be inferred from the definitions sections in the act and in the Canada Health Act.
The act defines "insured services" as "all services rendered by physicians that are medically necessary" and the Canada Health Act defines "insured health services" as "physician services provided to insured persons." "Physician services" means "any medically required services rendered by medical practitioners." To receive the full cash contribution available from Ottawa, Ontario's program must insure all medically required services. Neither the Canada Health Act, the Health Insurance Act nor Bill 50 define "medically necessary" or "medically required."
We suggest that the first step in deinsuring services should be to define "medically necessary." We understand that a joint management committee of the government and the OMA has been working for months to do so, and we suggest that its work be completed before any decisions are made.
The second step should be to elaborate the criteria for coverage of services, because many criteria, in our submission, are applied without being clearly stated. We have agreed as a society that all medically necessary services must be covered and this is clear in the legislation, but we actually fund medically appropriate services, for example, eye examinations, joint replacements and yearly physical exams. Until these unstated criteria are clarified, an appropriate service could be eliminated because it does not fall within the stated criteria.
The third step should be to establish procedures to finalize definitions and criteria. Initially, the process should be a joint one with the OMA and MOH. Input should then be sought from expert groups, for example, IAAC, as the representative of the infertile population. Then the public should be allowed to participate in this very important discussion. If objective and specific criteria and definitions can be established, further public input would often not be required when a decision about a specific service was necessary.
The fourth step should be to establish procedures for public input when decisions about funding specific services are pending. Procedures for public input must be made accessible by including them in the legislation. There is no provision in the bill or in the act setting out procedures to be followed to determine which services are to be eliminated after criteria are established. Despite numerous calls to the ministry, the OMA and the Liberal and Conservative Health critics, we haven't been able to confirm that public input will be allowed -- until I heard from Dr LeBlanc today -- nor have we been able to confirm the form of the input.
We understand that there's a procedure in the agreement between the doctors and the government which presumably satisfies the doctors for now, but it's not included in the bill. This suggests that the structure will only exist for the life of the agreement and that there is no commitment on the part of the government to the procedure. We would like to know when the proposed list will be released, how we can get copies of it and when hearings will be held. Public input, to be meaningful, requires public information.
The legal profession has a saying that justice must be done and must be seen to be done. This principle is no less important in government. We suggest that a procedure be determined for establishing the proposed list of services to be discontinued, that time frames be established, that the form of public disclosure and input be described and that all these things be enshrined in the legislation.
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The OMA conducted an expensive, extensive campaign against the provisions of the original bill and was successful in being heard and having its issues addressed. Few groups have the funds or the expertise to do the same. We do not know why delisting is not mentioned in the bill, why there is no definition of "medically necessary," why the procedures to determine which services to be delisted were not included and why there is no provision for public input into these issues. Another public campaign should not be required to have these issues heard, but they should be dealt with now and the bill amended.
The Chair: Thanks very much for your submission. Before we go to questions, I welcome -- I'm assuming it's Diane Allen who's joined you.
Ms Diane Allen: It's Diane Allen, yes.
The Chair: I apologize, Ms Allen. We got a little ahead of schedule, so we got started. Welcome to the committee. We'll begin questions with Ms Sullivan.
Mrs Sullivan: Thank you very much. This is a useful brief, particularly following as it does the brief from the psychoanalytic society, which has faced many of the same issues that you have faced over a period of time, and knowing that the services of the people for whom you advocate are being threatened with delisting and knowing as well of the extraordinary confusion about what's occurring.
I've been very interested in the reproductive technologies over a period of years, particularly with the decision which was made by our government to include in vitro fertilization as an insured service under OHIP. In doing some work in this area, I've discovered that the World Health Organization, by example, classifies infertility as a disease, and it's a recognized international approach that treatment which follows infertility is therefore medically necessary. I believe the Canadian Medical Association itself has classified infertility and the treatment of infertility as a medically necessary treatment.
The process you put forward as proposals for dealing with the determination of what is medically necessary and therefore what should be included as part of our medicare program I think is useful input, and you've put a lot of thought into that. The one aspect that I think has been left out is evaluation; that's something that on an ongoing basis and from a personal basis you're faced with on a day-to-day basis.
My understanding -- this is rumour, I suppose you could say -- is that the lists that are being prepared which will be discussed with respect to what will come off medicare, one prepared by the Ministry of Health and one prepared by the Ontario Medical Association, have a difference with respect to in vitro fertilization. My understanding, once again rumour-based, is that the Ministry of Health list includes in vitro fertilization and the doctors' list does not. Have you heard any of that kind of information? How would you respond if you saw the people who are professionals suggesting that in vitro is medically necessary and should remain a part of OHIP in comparison to those who come from a more bureaucratic background and who are suggesting that this is an easy target for removal?
Ms McNevin: We understand that IVF is not on the OMA's list. We haven't been given a copy of their list, but we've been told it's not on their list. We have no idea of whether or not it's on the ministry's list, but IVF has been on the ministry's hit list for a long time, so we have no reason to assume your information is incorrect. We have a lot of concern that IVF is being targeted for reasons that are not medical reasons. Obviously, in our minds, if IVF is not on the OMA's list, the OMA, the doctors who are the professionals, think it's necessary. We wonder how a faceless bureaucrat can contradict the professionals' opinion on that issue.
I suggest too that that's a reason why the lack of definitions in the act is a problem. It allows the ministry to say IVF is not medically necessary because there's no definition at all of what is medically necessary in the act or the bill.
Mr Jim Wilson: I want to thank the presenters for an excellent brief. You've pointed out very succinctly to the committee the crux of the problem; first of all, with your comments and observations about the Canada Health Act, with no clear definitions there. There is no list in Canada enshrined in legislation of medically necessary services that are to be covered by the provincial medicare plans. You've pointed that out. It's something we've tried to make clear over the past few years, because the public has a perception that there's an enshrined list and that the provinces can't touch them.
What we've seen is provinces pick on what they perceive to be easy pickings in terms of delistings. Had you not done what you did in terms of public lobbying and increasing the public understanding of the need for infertility treatments, and indeed defining them and making sure there was an understanding that they are indeed medically necessary treatments -- you've done a great public service, but it's unfortunate, as with psychoanalytic services, that you have to do that time and time again.
I want to commend you also for the process. You've not only come to tell us of the medical necessity, but you've outlined in a very thoughtful way a process that I think would be helpful if the government would adopt some of your suggestions with respect to public input on a permanent basis.
I want to give you a chance, though, to explain a little bit about infertility treatment services now, because it's my understanding -- and I have really learned a lot in the last two and a half years with respect to IVF and other infertilities -- that we have somewhat of a two-tiered medical system in this area now. I have friends who can afford to go outside medicare and receive treatments, counselling and the whole gamut, and others are on waiting lists. It seems to me that in fact there's a need to beef up the area, rather than what the government perceives is an easy target to simply stop funding.
Can you describe what it's like now for a young couple, for example, and what they would go through to either be covered or not be covered currently?
Ms Diane Allen: I think you have to separate IVF from the rest of infertility. Specifically with IVF, there are publicly funded clinics at five hospitals in Ontario. There are also several private clinics.
In order to be treated at a public hospital, you have to meet certain criteria, usually age criteria: under 37 for the woman. You're only allowed three trials at that hospital. If you don't meet that criterion, then your only choice is to use a private clinic. The clinic fees are about $3,000 a treatment cycle, plus some additional costs, plus your drugs, which will run between $2,000 and $6,000 a treatment cycle and for which many people have no drug coverage.
The private clinics and the hospitals are all billing OHIP about $1,500 to $1,800 a treatment cycle on top of that. So if the OHIP funding for IVF is pulled, the fees at the private clinics will go from $3,000 a cycle to $4,500 or $4,800 a cycle, because they don't have the operating grants the hospitals have to cover their overhead, their staff, their equipment. Not a lot of people will be able to afford that kind of cost.
If you look separate from IVF, it's very interesting, because for somebody, for example, doing a procedure called intra-uterine insemination, which is commonly done and for which the doctors are billing about $1,000 a cycle to OHIP -- IUI, we call it -- there are some doctors in the province who are not billing over OHIP, who are only charging the patients for procedures or items that OHIP doesn't cover: things like a cervical cap, a sperm wash.
There are other doctors who, for the same procedure, are charging $1,000 or more in "administrative fees." If you want to look at donor insemination, OHIP doesn't pay for the sperm. I don't know how they think you do donor insemination without sperm. So you've got the cost of the sperm, plus the cervical cap, plus the sperm wash, which will bring you up in the $500 or $600 per treatment cycle range with a doctor who's not billing over OHIP. There are doctors in this city who are charging as much as $2,300 in administrative costs per treatment cycle. They call it a program-matching fee.
I make this point because there are already significant barriers to service under what is supposedly a universal health care plan.
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Mr Jim Wilson: Obviously if the government delists this, clearly only the rich will have access to IVF.
Ms Diane Allen: I think the other risk of delisting is that there is a real lack of standardization in terms of procedures, recordkeeping, the way drugs are used, and it really leaves the patients wide open to a lot of risks. There is also no certification program in infertility medicine. If you go to a cardiologist, you know that's someone who's done a lot of specialized training and written exams. That doesn't exist in infertility.
You have everything from somebody who's done post-graduate work in reproductive biology and endocrinology and worked for years specifically in infertility, and on the other end of the continuum you've got obstetrician-gynaecologists with an interest in infertility but who lack the specialized training and experience. You also have, in some cases, family doctors handing out fertility drugs.
From my perspective, delisting and moving stuff more into the private sector leads to a much worse situation in the way of lack of standardization, recordkeeping, control and monitoring. There is very little at the moment going on and the guidelines that exist are generally voluntary. They are violated all the time and the person who's at risk in all this is the patient. If you had the time to listen to me, we've spoken to over 1,000 people on our telephone support line and had about the same number come to seminars. We have lots of anecdotal stories on what's going on and patients are really at risk by some of the practices that are going on.
Mr Stephen Owens (Scarborough Centre): Let me begin by thanking you for your presentation this afternoon. I did, on behalf of constituents of mine, write to the Minister of Health requesting that this service not be delisted as it's my view that there are good reasons to have it on the list. In terms of your presentation this afternoon, you talk about public consultation with respect to delisting, whether it's this particular code or any other services that are provided.
I'd like to have an idea of how you would go about, first of all, conducting a consultation of that nature and how would you determine what a consensus decision is at the end of the day.
Ms McNevin: On the public consultation question, there are a number of models we could choose from, and probably the one most familiar to everyone here would be the process we're going through right now. Amendments to a bill are proposed, the bill is published, you could pick it up at the Ontario Government Bookstore and then there is an opportunity to make submissions. You call the Clerk's office or you read the ad in the newspaper, as we did, asking for submissions. I think that kind of process is one that's required.
We were just, in a way, lucky that we had been in the midst of a letter-writing campaign because we knew IVF was potentially going to be delisted. There are a lot of other groups that have no idea that whatever service that may be important to them is on the block. We just happened to know.
So I think you have to have public information before you can have public input. I think that if the process were included in the legislation, then everyone would be aware that a process existed and would know how they could participate in it.
There are a couple of other models that you could look at: the Oregon model, on which we, I guess, agree with the psychoanalysts. We don't particularly advocate that one. IVF is not a popular procedure either and it's a little understood one. I think this kind of process is what's required.
Possibly the committee the OMA will set up at this point, with the two lay people, the two doctors and the two government people, could hear submissions from the public after they establish definitions and criteria, because I think the public input is important. Obviously, you had the doctors and you heard how important psychoanalysis is to a lot of people.
In our area, the patients have a perspective that we can offer that the doctors can't. For example, our opinion may not be the same as the doctors' on some of these issues. Some of our doctors aren't particularly concerned about whether IVF is delisted or not, because they can probably make more money if it is delisted than if it remains listed.
We also have an opportunity to see the whole process from start to finish and could make some recommendations to a committee about how money could be saved. We have, like the psychoanalysts, some concern that if IVF is delisted, people will just participate for a longer and longer period in the lesser treatments, to no effect.
Does that answer your question on public consultation?
Mr Owens: Yes. In terms of the kinds of anecdotal evidence that you folks were talking about towards the end of the presentation, I'm alarmed by the lack of continuity across the field, that while reproductive technology is perhaps one of the newer kids on the block with respect to medical procedures, it's certainly not the newest procedure to hit the street. So in terms of the lack of continuity, the issue with respect to the differentials in services and fees for that service, I find that quite of concern.
My question to you is, given that kind of anecdotal evidence based on the numbers of members and people who have called you, have you spoken with the College of Physicians and Surgeons? Are you prepared to take up the call against this kind of activity?
If what you're telling us is what is happening out there, then I am gravely concerned, not only for the economic wellbeing of people but also for their health. We don't want people going for backstreet abortions, nor do I want people out there having backstreet artificial inseminations.
Ms Diane Allen: We don't want it either. Even though the royal commission's short report that was released several months ago talked about in 1991 there were two practitioners who were identified as using fresh sperm for donor insemination and thereby exposing patients to the risk of AIDS, that's still going on in this city. In fact the fresh sperm is being offered for less money than the frozen sperm.
Last week, I talked to someone who was treated at a private clinic for IVF. This was a woman who was ovulating, who'd had her tubes tied from a previous marriage. She was, in my view, really overly medicated. She hyperstimulated. She ended up in the hospital. She haemorrhaged. She lost both ovaries and her appendix and she had a collapsed lung. She was an hour or two away from death.
Upon looking into this, I find that it's the patient who must complain to the College of Physicians and Surgeons. Somebody who's been through an experience like that is wrecked. To start that sort of complaint process can be really intimidating.
We have a lot of information that really concerns us. The fees certainly concern us because many patients don't know that maybe there's another doctor who's just as good who isn't going to charge them this kind of money. You can bet that the doctor they're seeing who's asking for it isn't going to tell them. Many people don't access treatment which would be appropriate for them, and the financial burden adds incredibly to the emotional strain that they're already under.
I am certainly willing to do whatever is necessary to try to correct the situation. When I first heard this stuff about fees, I thought it was extra billing, but no, I'm told that they can do it, that they're administrative fees.
The Chair: I regret that we don't have more time this afternoon, but I know I speak on behalf of all members of the committee. Thank you very much for your brief and for your answers to our questions. We appreciate your coming here today.
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ALEXANDER FRANKLIN
The Chair: I'd like to call our next witness, Dr Alexander Franklin. Would Dr Franklin be good enough to come forward. Welcome to the committee, Dr Franklin. We have a copy of your statement. Please go ahead.
Dr Alexander Franklin: This is regarding Bill 50, paragraph 6(8)3, as it applies to physicians.
The summary is: To encourage the appropriate distribution of physicians throughout Ontario, physicians in rural areas should be officially part of the academic world of medicine. To do this, there are some suggestions:
(a) The five medical schools in Ontario should each take on the post-graduate responsibility of one fifth of the province, in north-south bands.
(b) Area tutors should be available for advice and teaching.
(c) A new medical school should be established in the north. McMaster could be relocated in Sudbury, Sault Ste Marie or Thunder Bay.
(d) Residents should spend at least a year in a northern community hospital.
(e) Study and travel grants should be given to physicians in designated northern areas.
(f) Paid sabbatical study leave should be a benefit for northern physicians.
(g) The Order of Ontario should be awarded to northern physicians after 20 years of service.
There are advantages of a northern medical practice: less professional competition; lower practice costs; cheaper housing; field, winter and water sports at hand.
There are, however, some disadvantages of northern medical practice, and those can be broadly grouped into medical and social.
With regard to the medical: no chance of academic advancement; professional isolation; with fewer specialists available, more diagnostic and therapeutic uncertainty, and thus higher risk of complaints to the College of Physicians and Surgeons and the Health Disciplines Board; a lower standard of medical care available to the physician and family; and the difficulty of finding locum tenens for time away from practice.
As to the social disadvantages: more severe climate; expense of travel; fewer educational opportunities for children such as schools, museum programs, art, music, libraries and major public events; the continual social contact with patients, and this can be referred to the dangers in Bill 100; and the difficulty of a single physician in an isolated area in finding a life partner.
When it comes to the recruitment of physicians for northern Ontario and underserviced areas, I suggest a profile of the physician most likely to succeed and stay. The physician would be about 32 years old and should have above-average medical knowledge. This person should be married, with the number of children planned already born; this avoids the problem of delivery. A certificate in emergency medicine and a diploma in public health would be useful, as would bilingual skills in French and English and a strong interest in northern sports.
That completes my presentation.
The Chair: Thank you very much. I don't believe, Dr Franklin, you mentioned at the outset where you are practising, but I take it you're from the north?
Dr Franklin: Actually, I practise in Toronto, but I have practised for many years going to the north several days every month. By "north," I mean Elliot Lake, Sault Ste Marie, North Bay, Sudbury.
The Chair: We'll move to questions, then.
Mrs Sullivan: Thank you very much. This is an interesting presentation because it's the first one that we've had during consideration of Bill 50 with respect to the human resources in the medical sphere. We have, as you know, been faced as a province for a number of years with problems with respect to coverage of remote or rural areas.
I think that Dean Sinclair of Queen's University, among others -- but I think he's been more vocal than many others -- has put forward ideas which are comparable to your own with respect to the attachment of medical schools to remote areas to provide support and a continuing relationship between those who are actually in the field and the academic environment that many of them seek as they want to continue practice. As well, his suggestion would go further to suggest that those schools should have a particular working relationship in developing practitioners for areas and supplying people, by example, for locum tenens or where there is a particular lack of a specialty.
I think that as we've looked at many of the questions with respect to remote regions, we've discovered that there is more than one reason that there is an undersupply of physicians in certain areas. One of the areas, of course, where there is a lot of attention now is with respect to specialty treatment care areas -- I think of cancer, I think of kidney, other illnesses -- where there is a particular population ratio deficiency.
I'm sure that you're familiar with Dr Sinclair's approach. How does that fit into some of the recommendations you've made?
Dr Franklin: Ms Sullivan, I'm not actually familiar with Dr Sinclair's approach, but from what you've mentioned, it seems extremely good.
Mrs Sullivan: When you are practising in the north, I assume it's on a locum tenens or a specialty area replacement or call-in, is it, to replace physicians?
Dr Franklin: Actually, it was regular visits to clinics over the years.
Mrs Sullivan: I see. In those circumstances, were those clinics always pre-approved in the Ministry of Health?
Dr Franklin: These were regular doctors' offices.
Mrs Sullivan: I see. So you have been basically practising both in the north and the south, travelling to get there.
Dr Franklin: Exactly. Precisely.
Mrs Sullivan: I see.
The Chair: Last question, please.
Mrs Sullivan: Oh, sorry. One of the difficulties many northern practitioners face as they want to move out into more remote areas of the north is that they aren't able to get the Ministry of Health approval for travelling to conduct those clinics, particularly in specialty areas; I think of bones as being one. So that question, then, does not apply to you?
Dr Franklin: No.
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Mr Randy R. Hope (Chatham-Kent): I'm interested in some of the synopsis here. I come from rural Ontario and I notice you don't mention that very much, other than the north. But I want to touch on a couple of areas here. One is about dealing with the professional isolation in rural Ontario.
You say the "lower standard of medical care available" to physicians and their families, and I take it when you're making these comments that you're only specifically focusing on the north, because you start off at the beginning talking about rural areas.
One of the problems, listening to some of the concerns that are raised in our communities, is the "old boy" network, the don't-step-on-my-turf approach. When the new doctor comes in, he or she is trying to fit into the network of physicians who are already there. You talk about working in the hospitals. One of your paragraphs said you ought to spend some time in a community hospital. What about shared responsibility beyond that year, helping out all the physicians in your area with emergency room work and other work that is there?
When I read this, I know what you're trying to get across, but I guess a lot of us, when we do take jobs on, do not necessarily have all the social activities that we would like to have, but what we are trying to do is a fulfilment of a community and a fulfilment of our own lives, to help other people. I guess I just wanted to express that, because not everything is a perfect world. We don't live in Utopia. But at the same time, we have people around this province who need assistance and doctors.
I looked at one model, which would be instead of having the billing numbers designated to a doctor or physician, having the billing numbers designated to a community, and those communities hold the billing numbers. Then when the doctor requirements are there, you don't have to worry, and if you want to transfer, you transfer if there's an available opening of a billing number in a community, versus the billing number being established to the doctor.
Dr Franklin: I'd like to respond to Mr Hope. The point about the resident spending a year in a northern community hospital is not an original idea. This has been the practice in the UK for, let us say, at least 30 years. Residents rotated from the main teaching hospital for at least a year or so -- that's what I did when I trained -- and so you would have community experience as well as the more academic experience. This is the point I was making.
Also, residents spending at least a year in a northern community hospital might like the area very much and might continue practising after they get their qualifications, so that was the point to that.
As to the general medical care, this applies to everyone, of course, in rural and northern areas. One will not be able to get the selection of specialists and tertiary care available in main centres.
Mr Hope: Even for some of us who live in rural communities, an hour's drive one way or the other is not necessarily inconvenient, but you still have a problem. I see what you're trying to put across as points, but I don't think it's the end-all and be-all. I think there has to be a more definite distinction about billing numbers. I'm one who believes that a billing number ought to be designated to a community, and that way you're able to control and make sure that there are physicians there. Then, if physicians wish to expand their horizon in Toronto, for instance, and there's a billing number available, they have the right to move, but if there's not a billing number available, it does allow us to make sure that we're meeting the needs of people in rural Ontario.
Dr Franklin: I'll respond to that. I was really thinking of someone in Elliot Lake, for example, who would have to drive two and a half hours either to Sudbury or to Sault Ste Marie, more in terms of that period. One hour, I would almost call a Toronto time.
The Chair: A final question to the member for Sault Ste Marie.
Mr Tony Martin (Sault Ste Marie): I found your comments about perhaps the lifestyle of northerners and the attractiveness or unattractiveness of living up there -- sometimes we who do live up there resent the inference that somehow there's something less to be offered. I just wanted to, for anybody who might be watching, assure them that to live in a place like Sault Ste Marie or Elliot Lake or Sudbury is indeed a wonderful experience and can be quite fulfilling even to the professional ranks of physicians.
Mr Owens: Even Sudbury.
Mr Martin: Yes, even Sudbury.
There's been the idea put forth by our own government caucus on various occasions and by folks in the north that perhaps a medical school in the north might be a good idea. I know in my own community there's the group health centre that provides a support service to physicians that allows for a lot of freedom to go away for personal or professional reasons and still have their practice maintained, those kinds of things. I see some potential there for the development of a package of services that could be delivered to not only the larger centres like the Sault but outlying regions. Would you comment on that as a possible resolution?
Dr Franklin: I entirely agree with Mr Martin. I think when one looks at the map of Ontario, one sees the urgent requirements of a medical school in the north. If ministries are moved, why not medical schools?
The Chair: I'm afraid we're running over time. Dr Franklin, I want to thank you for coming before the committee. We appreciate it.
Dr Franklin: Thank you very much indeed.
ONTARIO COALITION FOR BETTER CHILD CARE
The Chair: I call upon the representatives from the Ontario Coalition for Better Child Care, if they would be good enough to come forward. Please just introduce yourselves for Hansard and then go ahead. We have a copy of your presentation.
Ms Kerry McCuaig: I'm Kerry McCuaig. I'm the executive director of the coalition.
Ms Cheryl West: I'm Cheryl West. I'm the executive director of Pat Schulz Child Care Centre here in Toronto and have been executive member of the board of the coalition.
The Ontario Coalition for Better Child Care was founded in 1981 to advocate for a universally accessible, high-quality, publicly funded, non-profit, comprehensive system of child care. Our members include child care advocates, educators, researchers, early childhood educators and programs, as well as unions, teachers and professional organizations.
We welcome this opportunity to express our opinions on Bill 50, An Act to implement the Government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act.
There are approximately 2,900 child care programs in Ontario, offering care for some 130,000 children. Child care in Ontario is legislated and regulated through the Day Nurseries Act.
In conjunction with the act, there are some 217 regulations governing the operations of child care, from staff qualifications and ratios to physical space, to health and safety requirements. Area offices of the Ministry of Community and Social Services are responsible for licensing and enforcing the DNA. This work is complemented by local health authorities which are named in the act as responsible for the interpretation and enforcement of health regulations.
Research has shown that high-quality child care has a positive long-term effect on children in areas of school readiness, protection for children at risk and the development of positive social integration. High-quality child care includes health safeguards. Without these safeguards, infectious illness such as gastroenteritis, rubella, parvovirus B19, meningitis, conjunctivitis, pinworm, scabies, scarlet fever, even head lice, can become rampant in a group child care setting, sometimes with tragic results. Among the methods child care programs use to contain the spread of infectious illness is requiring a doctor's note certifying that a child or staff member who has been infected is well enough to return to the program.
The coalition is concerned that if Bill 50 passes as is, staff and/or parents will be required to pay for essential doctors' visits. For example, under the amendments concerning third-party billing, Ontario's health plan would no longer cover doctors' visits to ensure that staff or children are able to return to the program following an infectious illness. If a staff member is required to produce a doctor's note after absence due to illness, she will be forced to pay for the doctor's visit.
It is worth noting here that child care is the lowest-paid job category in the country. Medical examinations required by staff or children before working or enrolling in a program will no longer be covered by health insurance. Medical examinations required by volunteers who work with children will no longer be covered.
Subsidy regulations often require parents to provide a doctor's note if their child is absent from day care for a certain period. Failure to produce this documentation can result in a parent losing her subsidy. These parents, the ones with the least resources, will now be required to pay for these notes.
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This is not merely a matter of money. Bill 50 is endangering the health of children and staff in child care programs. Parents and staff will be less likely to report infectious illness to their program, thereby raising the risk of exposure to others. As a result, programs will be less able to warn staff and parents that cases of infectious illness have been reported and to be on the lookout for the symptoms. This legislation is opening the door to epidemics of infectious illnesses sweeping through child care programs.
There are economic consequences for child care programs as well which will be passed on to parents and other ministries funding child care. Staff will, quite rightly, put pressure on parent boards to pay the cost of work-related doctors' visits. Health care benefit premiums will rise to cover the costs of medical visits not covered by the province's health plan. There is a certain irony here since programs and parents, in attempting to comply with the rules and regulations of one ministry, will be charged for their compliance by another government ministry.
The Ontario Coalition for Better Child Care urges this committee to review the amendments requiring third-party billing with the view to maintaining health care coverage (a) to preserve health standards, particularly in community programs serving children, and (b) when the requirements are dictated by federal, provincial or local legislation.
The Chair: Thank you very much for your presentation. We'll move to questions.
Mrs Sullivan: Once again, this is a very useful presentation because it's the first we have had from groups which are concerned about the impact that a revised Bill 50 will have, not only on service delivery but on the cost of that delivery. We had asked last week, in the first week of hearings on this bill, if the ministry could provide us with a list of all those third-party-request situations which might be impacted by changes that are proposed in this bill. That list has so far not become available. Is it available today?
Mr Wessenger: Perhaps I should give some further clarification with respect to the presentation made. As I understand it, the items listed in the presentation are presently not covered by the health insurance system and it would be, in effect, the parents' responsibility to cover that cost under our existing system. There has been no decision made to this stage to transfer that liability from the parents to the child care programs.
Ms McCuaig: That's not the point that is being made here. The point that is being made here is that programs, the local health care authorities and the child care programs operating in compliance with the local health care authorities, require parents and/or staff to provide doctors' notes before they re-enter a program. So if the child has been out because of an illness, the program, operating in compliance with the local health authority, which in turn operates under the Day Nurseries Act, would have the right to require a doctor's note. Right now, those doctors' notes are paid for under the province's health care plan; parents are not being charged for taking their children to the doctors for these purposes. Our fear is that, under Bill 50, that becomes a danger.
Mr Wessenger: Perhaps I'll ask someone from the ministry to respond to that, because if I've given incorrect information here --
The Chair: As Chair, I just want to be clear. There was also a request about a list.
Mr Wessenger: I think I've indicated that no decisions have been made yet with respect to the matter of the list.
Mrs Sullivan: The importance of the list was made quite clear. There are many areas: The Education Act has specific regulations which require certain health care procedures to be undertaken; the Day Nurseries Act; there are regulations with respect to people who deal in food safety handling. There are regulations in many other areas as well with respect to health care, such as the Nursing Homes Act.
What we want to know and what we have requested quite specifically is all of those regulations now existing that require some form of health inspection. In the past, until December 1992, those inspections, those physical examinations were covered under OHIP. They were not included necessarily as part of the Canada Health Act or under the OHIP list, but by tradition they had been covered. That cutoff has been made. What this bill will do is introduce a new mechanism for the collecting of those fees.
What I hear the coalition for child care saying is: "Who's going to pay? Is it going to be the staff, the centre, the parents or the ministry, if those regulations aren't changed?" We want to see what specific regulations and what specific facilities are being contemplated by the government with respect to this section of the act. If it's not the Day Nurseries Act that you're thinking of changing, then that answers many of the questions the presenters have raised today.
The Chair: The parliamentary assistant.
Mr Wessenger: I will ask counsel to indicate what the situation is at present.
The Chair: Would you mind just introducing yourself for Hansard?
Mr Frank Williams: I'm Frank Williams. I'm a counsel with the Ministry of Health, legal branch. Some of the comments that were made are fair comments to the extent that one of the things we did identify early on when we were drafting these motions was exactly the sort of thing you're talking about now. In fact, there is a whole host of other regulations and statutes that would require third-party services to be provided in various situations.
One of the things that we committed to do with the OMA was to examine all those regulations and statutes, and we're still trying to identify all of them, before March 1994 and exactly identify how we're going to address some of these third-party services. Some might well be services that, after close examination, would no longer be required to be provided.
In fact, one of the clauses in the draft motion, clause (c), where we refer to something that's prescribed as a third-party service was intentionally put in the motion to address this exact issue, so that we give ourselves the ability to both consult with other ministries and other service providers as to whether or not whether these should be added as third-party services, in addition to the list of third-party services that we've already identified as being uninsured services in the present regulations.
Ms McCuaig: I'd like the committee to keep in mind the way this plays down on the floor of a child care program. Right now, when a parent has been told a child is sick, he takes the child to the doctor. The doctor says, "You have chickenpox," or whatever the infectious illness is. The parent comes back to the program and says: "Johnny's going to be out for a couple of days. He has chickenpox."
If the requirement then is that before Johnny comes back into the program he has to have a doctor's note and that parent can't afford the fee that is associated with that doctor's note, what you're going to have is parents not disclosing to programs that their kids are sick. They're going to either put their kids back into the program -- there's already pressure on parents to do that because they can't be away from their jobs. They get pressure from their employers and they try very hard to get sick kids back into programs. What you're doing is putting an extra cost on top of what they're losing in terms of lost wages and what you're opening the door to is to having parents not be honest with their child's program about their child's health if there is a cost associated with it.
Mrs Yvonne O'Neill (Ottawa-Rideau): I just wanted to say, Cheryl and Kerry, that we really did discuss this at great length. You may want to look at the Hansard of the first couple of days. What I took from the discussion, and of course today it's a little different, is that we immediately go to your final steps: that the individual isn't going to, that we're really out to get employers. I am no doubt paraphrasing what I heard, but I thought that we would directly go to parent boards and health care benefit programs. But of course we know how that affects you as well because of the lack of subsidies. So the air is very unclear around this one, and after today's notice I think it's even more unclear because we really don't know what the intent of this is or what acts are going to be affected. That's why we wanted the list. But as you can see, it's not happening at the moment. Your concerns are before us.
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The Chair: The parliamentary assistant had some further clarifications.
Mr Wessenger: Yes, I think we have some further clarification which may put this matter hopefully to rest. Mr Williams.
Mr Williams: The comments I was making were very general comments. It wasn't necessarily directed at your particular situation. But I point out that paragraph 1.2 of regulation 785/92, which was the regulation that the government passed last year identifying which were insured and which were non-insured services for the purposes of the particular exercise that we're going through, identified that a return to a day care or preschool program after a temporary absence would not be considered a non-insured service. So that would still be something that would be covered.
It was our intention to, for the most part, adopt that regulation as being a third-party service type of situation. In any event, in the type of situation that you're talking about, or some other situation, were it to be identified, the third party would be the ministry; it wouldn't be the parent or the day care. The person who's requesting a requirement requiring the note is, in essence, the ministry, so the ministry would be liable, not the parent or the day care. I should make that clear right up front. Even if this section was not here, that would be the situation.
Ms McCuaig: What about the case of staff who are also required after an infectious illness to produce proof?
Mr Williams: Again, that would be a regulated requirement. The third party in this case would be the ministry.
The Chair: This will have to be the last question.
Mrs Sullivan: We have just had a policy statement that has not been provided to us in the past indicating that, by example, if the Ministry of Community and Social Services requires under the Day Nurseries Act physicals for children returning to a child care situation, Comsoc would be responsible for paying for that.
That is the first time we've heard that. That has never, ever been on the table before. It is also, in my view, not on the table in terms of this bill. The bill does not contemplate the ministry being responsible for the payment.
I still want to see the list of the regulations that require health examinations before a certain event occurs as a consequence. I want a further explanation in written form of what in fact the government policy is and what went through cabinet with respect to who pays. I think that's very important. We cannot go into clause-by-clause without that information.
The Chair: I think the issue is clearly on the table. The request has been made. I want to thank the representatives.
Ms McCuaig: Could I just note one thing in relation to what Ms Sullivan was saying?
The Chair: I apologize. Just briefly, because we are tight.
Ms McCuaig: I'll make this quick. Under the Day Nurseries Act it's the local health authority that has responsibility for enforcing the health regulations and for interpreting the health regulations. It's not going to be quite so cut and dried. It's not that you're going to get a list from Comsoc saying what these requirements are, because they may be one thing in Sarnia, another thing in Timmins and another thing in Metro.
However, the local child care program still has to comply with whatever the local health authority says, because they're invested under the act to enforce it. So just for you to keep in mind when you're getting that list, it's not going to be a very clean list. We still have to live with it out here.
The Chair: Thank you. I'm sorry, can I just --
Mrs O'Neill: I just wanted to ask legal counsel if they will please give in writing to us that regulation regarding the day care exemption and the statement that the ministry would be responsible. These are very important revelations that we've just had now, especially the one about the ministry picking up the bill. We discussed this for an hour last week, and we didn't get anything like that.
The Chair: I believe that one document was in the binder that was distributed, but the other information has gone to the ministry. I'm sure they will try to provide any further documentation that's required.
CITIZENS FOR QUALITY MENTAL HEALTH CARE
The Chair: I would then like to call on the Citizens for Quality Mental Health Care, if they would be good enough to come forward.
Welcome to the committee. If you'd be good enough to introduce yourself and the members of your delegation, then please go ahead.
Ms Farida Karim: My name is Farida Karim. On my right is Phyllis Leonardi and on my left is Jackie Ramsay. I know you've been sitting in meetings for days and days, but I really want you to listen to what we're saying. Try to put aside your prejudices or preconceived ideas about things and just listen to our words.
We represent the Toronto and Ottawa chapters of Citizens for Quality Mental Health Care. We're a patient-led and -driven organization that was formed in response to the Ministry of Health's proposed cuts to psychotherapy and psychoanalysis, not only through the introduction of Bill 50 but through earlier moves as well.
This is not the first time we have come before some of you to express our concerns. Please keep in mind also that we are the ones who are capable of speaking to you. There are many members of our group who cannot come today and are incapable of speaking in front of you, and many who fear their loss of confidentiality as patients.
We're here to address Bill 50 and its amendments. We feel that it's a very dangerous bill. We would like to see it withdrawn. Bill 50 gives arbitrary power that allows the Ministry of Health and its bureaucrats to play doctor and make medical decisions of which they are incapable and it leaves patients like us vulnerable to the whims of politicians.
By proposing these cuts, politicians and bureaucrats are telling doctors how to treat patients, and this sets a very dangerous precedent, because if bureaucrats are allowed to make decisions regarding our treatment, then they will target other patients. The decision about treatments should be made between the doctor and the patient and not by bureaucrats.
Now, we realize that health care expenditures are of great concern to all of us. However, we have shown you in several of our documents -- and I believe you have two in front of you today -- that cutting mental health care only increases costs in other areas of the medical budget, such as hospitalization and increased visits to other doctors.
How can we be expected to believe that Bill 50 and its amendments won't be used against us? No one is listening to us. How can politicians determine, without any knowledge of the treatment and the success rate of psychoanalysis and psychotherapy, the maximum number of treatments that are medically necessary?
Ruth Grier, the Minister of Health, has informed our group that she would actually never implement the restriction of services outlined in Bill 50. But we have to ask you: Why then does the NDP government need this gun-to-the-head type of approach that frightens both doctors and patients?
I'm just going to put my script aside for a minute. I'm in psychoanalysis. I chose to pursue it. The options for me aren't viable. I don't want to be medicated, I don't want to be hospitalized, and for me this treatment works. I'm so frustrated and angry that I have to miss work to come here today. You are probing into something that is so highly personal and confidential, and I wonder why somebody started this rampage against mental health care patients. We wonder if some of you people just wanted to see who would come out of the woodwork.
Well, I've come out of the woodwork, and I am a brown-skinned woman who has experienced prejudice living in this province, and I must say that the NDP government is giving me a fine dose of a bit more. I just want to caution the government that discrimination towards mental health care patients and the process can only be based on fear and lack of understanding.
Now I want to pass you over to my colleague Jackie Ramsay.
Ms Jackie Ramsay: In early 1992 patients were aware of a government list of cosmetic items to be deinsured. Psychoanalysis was on that list and later psychotherapy was added.
Our group has met on numerous occasions with MPPs, bureaucrats and Ministry of Health officials and we have appeared in newspapers, as you can see here -- lots of them -- on television and radio and have been forced to expose our painful personal histories and risk our dignity and self-respect.
Our members have mailed thousands of letters, postcards, signed petitions in protest to the proposed threat of deinsuring. In the meantime, we have also answered approximately 25 telephone calls per day from frightened, distressed, traumatized patients, some of whom can't even finish their conversations with me. They just go to pieces on the phone.
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Does a patient with breast cancer have to come here and undo her blouse to show the scar where her breast once was? In essence, that's what I am being forced to do here, and so is Farida and so is Phyllis. It disgusts me, frankly.
Most of the patients in psychotherapy and psychoanalysis are low-income earners, and 60% of patients are women. We have been victimized and discriminated against by an unfeeling, uninformed, prejudiced NDP government. This political process is harming individuals who are seeking treatment for trauma, severe childhood abuse and incest, among a whole other load of things. With our treatments, we are able to function and lead productive lives that include working, supporting ourselves, our families, and paying taxes.
Ruth Grier and others in the NDP have said they do not have the studies that show the efficacy and high rate of success of these treatments. You know these studies are available, so we wonder in horror how the government can terminate these treatments, because limiting them means terminating them basically.
Again, no one is listening. How many more petitions, letters, postcards, committees do you need? How many more politicians do we need to meet with and how many more insults do we have to endure? How many more times do we have to personally expose ourselves to get the message across?
I'd also like to add that prior to the delisting list, prior to Bill 50, my therapy was a safe, predictable place where I was dealing with my crippling depression and my wish to die. My rheumatoid arthritis, my asthma, my eczema were under control at that time. Now that I am in constant fear of losing my treatment, I am unable to focus on the issues of my past that are basically ruining my life. I am constantly sick and run down. I require frequent cortisone shots for my rheumatoid arthritis that keeps flaring up, and I am now on steroid inhalers to keep my asthma under control.
These are all specialists I have to see as well, which costs OHIP a lot of money as well. I mean, it's basic.
Who's going to pay the mortgage when I am unable to work any more, be it my psychological issues or my physical issues? The delistings in Bill 50 are already endangering my health and my life, and they haven't even been implemented yet.
Ms Phyllis Leonardi: This has been a tough battle. Since March 1992 when analysis and psychotherapy were put on the delisting list, we have been insulted by members of the NDP government who have told us to go on medication; by NDP bureaucrats who have suggested that we see our priest, try hypnotherapy once a month, that we are the "worried well." One bureaucrat hesitated to meet with us because he "did not want a bunch of psychos" in his office. We have been called "rich, bored housewives."
Over the past two years we have been told many conflicting reasons as to why the government proposes to deinsure and/or limit psychoanalysis and psychotherapy. Why these treatments have been targeted as cost-saving mechanisms is beyond us. We can only assume that it comes down to prejudice and discrimination against a vulnerable group of patients never expected to fight back.
No money will be saved. In May 1993 a government document stated that $26 million would be saved by limiting psychotherapy and psychoanalysis. One month later the government reported it would save $42 million. No one in this government will tell us where these arbitrary numbers originated, nor can anyone tell us how the government will save any money on this issue.
As well, the NDP government leaders have misled us on numerous occasions. After written confirmation from Frances Lankin that the joint management committee had recommended that psychoanalysis and psychotherapy not be delisted, less than one year later the government went against its own recommendations when the new Minister of Health once again started the process to delist. Then Bill 50 arrived on our doorstep.
We want to know that nothing is going to happen to our treatments. Our members want this government to stop its prejudicial behaviour towards patients in psychotherapy and psychanalysis.
The NDP government has falsely implied that all patients of psychotherapy and psychoanalysis are seen several times a day, several days a week, indefinitely. This simply is not true. The success of psychotherapy and analysis is based on the frequency and duration of treatment, but these are medical decisions between doctor and patient.
The NDP government should consider that many other democratic countries fully cover these treatments and experience the associated cost benefits in overall health care budgets. Why does the NDP government persist in trying to emulate the American health care system? If we continue on this path, we will end up with a two-tiered American system: one for the rich and one for the poor.
I'd like to say that nobody embarks on this treatment as anything other than a method of getting well when you are debilitated, usually by deep, repetitive depressions and periods of despair that might be suicidal. It is not something you can even stick with unless you need it. That's all.
The Chair: Thank you very much for coming before us. We'll move to questions, but first, on behalf of the committee members, we do appreciate the comments you've made in terms of your own personal stories and appreciate you all the more for coming because of that. We'll begin with Ms Sullivan.
Mrs Sullivan: Thank you very much. I think your organization first came to my attention around the time Frances Lankin was Minister of Health and the first list emerged. Since that time, I should tell you, Mr Chairman, that Jackie Ramsay's become a particular favourite person to drop by my office from time to time.
One of the things that has impressed me in terms of dealing with and working with your association is that the patients I see -- and many of them are, as you say, not in a position where they could come before the committee in any kind of public way. We heard today an audiotape from Miss Rodrigue that I thought was useful to start this session. But one of the things that's impressed me is that as I see patients who are fighting to maintain their psychotherapy or psychoanalysis, they're people who are informed consumers. They have looked at the alternatives, they have discussed the issues with their own practitioners, frequently with their family or other close friends or with a support group or whatever. I think that's something that's commendable and I wanted to mention that.
Secondly, I think it's clear to all of us that the unease over the approach the government has taken to the potential of delisting has caused increased trauma and stress and added to the problems. I think either Dr Finnegan or Dr Weir earlier today confirmed that that was their professional feeling as well.
Our view now -- and I don't know that I have any questions -- is that, based on rumour, psychotherapy is no longer on either the OMA list nor the Ministry of Health list. We are committed to ensuring that it stays that way. However, once again, we want to see that list.
Mr Jim Wilson: I want to thank each of you for your presentation. I know it isn't easy to appear before a committee like this and to expose your personal lives. You mentioned that it's been a tough battle to date, and I want to commend you also. From the early days I had with your group, before you were a group, actually, you've done just a tremendous job. You presented today one of the most articulate arguments in the short period of time you're given and your background material is tremendous, and I think you've partly won the battle. At least things are a little better -- the government members are going to tell you this, anyway, when it's their turn -- since we were up there doing the second reading debate. I know many of you and your group were in the galleries at the time.
But having said that, because the government will say you're probably out of the woods for a little while, we've tried to extract from the government a written commitment to that effect, because its word in the past hasn't been worth anything, on just about any issue I can think of in my three years around here. I'm going to give you a chance today to ask the parliamentary assistant directly what you would like to see, because I gather that you really don't trust, and rightly so, the government and its mutterings with respect to the fact that psychoanalysis and psychotherapy won't be delisted.
Ms Jackie Ramsay: We have it in writing and we've had it in words too from this government that our treatments wouldn't be delisted. I have two letters here from Frances Lankin stating that to different patients. That was last year, I guess. It changes every year. It seems to be the on-again, off-again government. I don't understand it.
Mr Jim Wilson: What is the date of that?
Ms Jackie Ramsay: February 1, 1993, and January 29, 1993.
Mr Jim Wilson: And yet the issue flared up again.
Ms Leonardi: Oh, certainly. I'd like to see the government pay attention to the studies that are worldwide and also here. His name is Doidge and he was even called in by Mrs Clinton to talk to them because the Americans were trying to get this complete coverage for mental health care. I know the evidence is clear through my life, my friends, my family. It saves money in the overall health care budget, believe me. I think you know that in your own lives; I don't see how you can't know that. We all know about stress, we all know about the cancer personality, we all know about the type A behaviour, which has long been accepted. I just would like the government to be sensible and go along with the studies.
Ms Karim: I just want to say that when it gets quiet, that's when it gets dangerous, because if we don't yell and shout and write letters, then we can't be assured that the government won't turn around and do it. I don't want this to be my second job. I will fight for it because I just believe so much in it, but when the Minister of Health changes, do we have to come back to you again and say hello? The facts stay the same. Ministers of Health change, but this treatment isn't changing; it is still valid and useful for us. So give us that assurance, please.
Mr Owens: I'll leave some time for the parliamentary assistant or legal counsel. I'm sure they have some comments they would like to make.
In terms of the attitude you talk about in your brief, I find that quite disturbing. I certainly would never advocate medication for anybody. I certainly would never call anybody a rich, bored housewife, and I certainly would never call anybody a psycho and disinvite them from my office.
What I will certainly give you is a commitment on two things: Again, that I have written to the minister with respect to your issue and, secondly, that I will take this matter with respect to -- you call them NDP bureaucrats; I would hesitate to call them NDP; bureaucrats perhaps, but I'm not sure about their political affiliation -- that I will take this up with the minister. I don't think it's appropriate, whether it's your group or any other group, to have your issue undermined and belittled by any staff person, be they employees of the ministry or political staff, in any way, shape or form. I thank you for bringing this to the committee's attention.
The Chair: Thank you very much for coming before the committee this afternoon.
The committee, after a brief recess, will move into closed session. We will begin again tomorrow afternoon in public session at 3:30.
The committee recessed from 1743 to 1746.
MARNIE JUDGE
The Chair: Would you please come forward, Miss Judge. At your request, we are meeting in closed session. I'll just go over the understanding so you and all the members of the committee know what is going on. Your testimony is being taped and will form part of the Hansard of the record of our deliberations, but as there is no television picture, the only thing that can be heard is your voice. Does that meet with your understanding of what we are doing?
Ms Marnie Judge: Yes, that's fine.
The Chair: With that, then, I'll ask you to go ahead with your presentation. We have received from you two documents.
Ms Judge: Thank you for allowing me to appear before you in a closed session today. I'm here to discuss my concerns regarding Bill 50, in particular subsection 2(6).
I realize that this section has been deleted from the bill, according to the revised amendments. However, its initial inclusion was the cause of significant fear and anxiety to psychoanalytic patients, and the fact that it has been deleted still leaves me far from reassured.
I'm here today because I shouldn't need to be. I am here to explain why I think the government's earlier proposal to delist psychoanalysis and intensive psychotherapy was not only shortsighted but potentially destructive and devastating on a major financial and human scale. This simply should not have happened.
Over the past several months I met with many members of the government and Ministry of Health staff. In the process of these meetings it became apparent to me that the government's proposal was ill-informed and made with little understanding about who requires psychoanalytic treatment and what the treatment entails.
According to a recent study by Dr Norman Doidge of the Clarke Institute of Psychiatry and the University of Toronto, patients requiring psychoanalysis have frequently suffered childhood traumas: 21.3% the death of a parent or sibling, 23% traumatic separations, 22.2% physical abuse and 23% sexual abuse. Another group that Dr Doidge studied are patients with severe personality disorders who require sessions three or four times a week.
The difference between supportive psychotherapy and psychoanalysis is not merely one of frequency. For some patients, an understanding of the underlying problem is the only way to alleviate their symptoms. For others, a less intensive therapy may provide all the support they need. The goal of psychoanalysis is to help the patient create a strong, healthy personality system, one with insight and one that can function independently to their full potential.
Patients in analysis have been described as the relatively healthy or the walking wounded. Perhaps it is the efficacy of analysis which allows the wounded to be walking, to be employed, to be consumers and taxpayers and to be productive members of society.
Those requiring psychoanalysis make up a small percentage of mental health expenditures. It is certainly not a treatment recommended for all. Individuals suffering from a biochemical disorder should be treated with medications, and those who would best be served by supportive psychotherapy should be so treated. But these must remain decisions based on sound clinical judgement, not based on a government protocol. You must realize that each and every patient is an individual with specific needs. Beyond the numbers and the statistics, there are real people who have been seriously affected by the proposals raised in the debates on Bill 50.
Over the past year and a half, the government has threatened to delist psychoanalysis several times. The announcement as to which services would be delisted has not been made, well beyond the stated date for its release. Patients in psychoanalysis feel great anxiety over this threat to their medically necessary treatment. Yes, there are real people who have been seriously affected by these proposals, and I would like to share with you how this proposal has affected me.
I would ask you to turn to the next page of your brief. This is my story. This appeared in the Toronto Star on Friday, May 14, 1993, as an op-ed piece:
"The government of Ontario [is] seriously considering removing psychoanalysis from its list of insurable services. I have been in psychoanalysis for one year and can honestly say that it has saved my life.
"I am...married with young children, and attend university in an honours program. Two of my children have special needs that require additional attention and support. I am an active member of my children's parent-teacher association, a leader of a church committee, and a volunteer facilitator in a parenting support group.
"People see me as active, capable and confident, a supportive friend and a loving wife and mother. What most people don't see or know is the person behind the mask, the one with a history of mental illness.
"In my early years I suffered sexual abuse at the hands of my father during my mother's prolonged absences due to her mental illness. As a result, I have had a history of depression for as long as I can remember. I was in treatment for several years with two general psychiatrists, who prescribed various tranquilizers and anti-depressants.
"My mental health necessitated three hospitalizations, including one after a serious suicide attempt. I attribute my feelings of despair, which arose at this point, to the merely supportive nature of the therapy. For someone with my history, this was clearly inadequate. There was no significant improvement in my condition and life became unbearable.
"After the suicide attempt, my psychiatrist terminated my treatment because he felt he had insufficient skills to continue working with me. A physician referred me to a psychoanalyst, with whom I have been in treatment.
"Analysis is very hard work, an ongoing process that takes place day by day. I realize that analysis is a long-term commitment of time, energy and health care resources. I believe these resources are being well spent.
"Without psychoanalysis, I might have spent the rest of my life in supportive therapy or, perhaps, I would have been medicated repeatedly.
"This would have negatively affected my ability to function productively within my family and society. Frequent hospitalizations would severely disrupt family life, tragically depriving my children of their mother just as mental illness deprived me of my mother's care.
"Perhaps the worse scenario would be a successful suicide. In this event, the health care system, although saving the cost of my care, would undoubtedly incur the cost of treatment for my husband and children. They would also have the need for additional social and educational services to help them deal with their loss.
"Through the process of psychoanalysis, I have begun to understand the dynamics of my earliest years and how they affected my life. My prior therapy, which focused on problems in daily living without addressing underlying causes, could have continued indefinitely.
"Working with a skilled psychoanalyst, I have become aware of the unconscious motivations for my emotions and behaviours. This work is painful and intense. The frequency of the sessions is vital in providing a consistent and safe environment for the difficult exploration of past traumatic experience. The goal of treatment is its eventual conclusion: The patient achieves the ability to function independently.
"I spent six years in the health care system in supportive psychotherapy without an accurate diagnosis of my condition. Through psychoanalysis, I have been correctly diagnosed with multiple personality disorder. Prevalent among victims of abuse, this disorder arises as a means to cope with the unbearable pain of their experience. Psychoanalysis is widely considered the treatment of choice for these individuals.
"I, like so many others, did not choose the traumas of my past. Psychoanalysis is helping me overcome them. This is not a cosmetic or frivolous procedure. By removing psychoanalysis from the list of insured services, the message that the Ontario government...is conveying is that mental illness is not a legitimate concern.
"In the past, we closed our eyes and ears to the knowledge that children were being physically, emotionally and sexually abused. We must acknowledge that those children are now adults who may desperately need the appropriate, intensive and effective treatment of psychoanalysis."
I chose to deal with my inner conflicts or problems in a highly effective and healthy way, by seeking appropriate psychoanalytic treatment. But imagine, if you will, that I had chosen another method of dealing with my problems.
If I acted out my problems by being sexually promiscuous without being responsible for birth control, OHIP would pay for any necessary abortions. If I acquired a sexually transmitted disease or AIDS, OHIP would pay for my treatment. If I abused alcohol or drugs, OHIP would pay for any health-related costs and rehabilitation expenses. If I engaged in reckless or dangerous driving, OHIP would pay for treatment of my injuries and the injuries inflicted on others. If I was a sexual offender myself, government-sponsored help would be available.
Studies have shown that a majority of health problems are lifestyle related, whether from smoking, alcohol consumption, overeating, lack of exercise or drug abuse. Those of us with emotional or mental illnesses did not choose our illness. Those of us in analysis are working hard to get well. Psychoanalysis is very hard and painful work. It is essential work, keeping many patients not only alive but functioning and productive.
As a woman who once felt powerless and violated in my earliest experiences with relationships of trust, I now have through psychoanalysis the opportunity to acknowledge and to understand my past, as painful as it may be.
I'm here today because I shouldn't need to be. This government-initiated threat to treatment should never have occurred.
I'm here to ensure that the effective and skilled treatment I am receiving is not denied to me. But I'm also here speaking for others. I'm here for my husband and children, my friends, colleagues and my community, who all benefit because of my improved health. I'm here for all the other patients who by the nature of their illnesses do not have a voice and cannot come forward. I'm also here for you because no one is immune from mental illness, for it touches one in three and one in eight will require treatment. Life has no guarantees.
I'm here today with the hope that you will take back to the government recommendations ensuring that in the future, health care decisions of this magnitude will be made after careful consideration by the government and the medical profession in the context of the joint management committee.
The threat of delisting psychoanalysis has hung over the heads of this patient population. I hope you have been convinced by my arguments of the medical, economic and social efficacy of keeping psychoanalysis as an insured treatment.
The Chair: Thank you very much for your submission. I know it wasn't an easy decision, but thank you for coming before the committee.
Mr Jim Wilson: Thank you very much for your presentation and for all of the work you've done on this issue over the past many months.
A frustrating time: I don't know what the solution's going to be. The government is now telling us that psychoanalysis is not on the delisting lists of either the OMA or the government, but I don't know what the long-term solution is.
I'm a little confused by the second-last paragraph in your presentation because that's sort of the status quo, ie, the government and the OMA through the joint management committee or other committees behind closed doors are making these decisions. Do you want to expand on that?
Ms Judge: I haven't been privy to what is actually happening. I don't really know. The reason I included the second-last paragraph was that I felt this was a decision that simply cannot be made by the government alone. It has to be made with input from the medical profession, whether it's within the context of the framework of the joint management committee, which is how these decisions, I believe, were handled in the past, or within some other framework.
I feel quite strongly that there needs to be more input from the people who actually perform this sort of treatment. There needs to be more input from psychiatrists and psychoanalysts. Their knowledge and their background and their skill are essential to informing these kind of decisions. It cannot be made based on gut feelings by various different government members.
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Mr Jim Wilson: You raise a very good point there because the government will tell us it's through the OMA agreement, ie, Bill 50, that these decisions will be made. I guess you raise part of the problem, which is that even within the OMA the psychiatrists, until more recently, didn't have a very strong voice and weren't necessarily at the table, is my understanding, until more recently, and until really you and others like you made it a public issue. I was of the very strong feeling, as of course you were and perhaps still are, that we're not out of the woods yet on this.
Ms Judge: No.
Mr Jim Wilson: What about public input? Some presenters have suggested that perhaps yes, they can make up their lists, but at some point that should go to a full public airing before the government decides.
Ms Judge: I believe there should be public input, and I'm a member of the public, but there is a problem in that too, because people perceive the patients who are in psychoanalysis as sort of Woody Allens, I suppose. People don't really know what takes place in psychoanalysis. Many general physicians do not know what takes place in psychoanalysis.
When I spoke with members of the Ministry of Health and various members of the government over the past several months, people would say to me, "Who performs your psychoanalysis, your family doctor?" It's not something that people really have a thorough understanding about, so it's quite difficult to think that members of the public will have a say or have a final say or have a significant input into these kinds of decisions, just like I certainly couldn't inform decisions regarding cardiac surgery or cancer treatments. These are decisions that have to be made by people who are skilful and knowledgeable in that particular area.
Mr Jim Wilson: If I'm correct then, it wouldn't serve any useful purpose to necessarily put these treatments out to popularity contests, but --
Ms Judge: Well, it's hard, because patients aren't going to come forward. I'm here, and this is very, very difficult for me, and at great cost, and I'm sure the other people who came forward who are patients were also here with great difficulty, but most patients are not going to come forward. They're not.
Mr Jim Wilson: But essentially you're saying that if the government, or whoever takes the decision -- as long as it's based on good academic research and we're provided with that, you could understand that.
Ms Judge: Absolutely, yes.
The Chair: I have Mr Hope and Ms Sullivan and we'll continue until we finish with their two questions.
Ms Judge: Okay.
Mr Hope: First of all, I apologize for being late for the presentation. I thought he said a few minutes and it would allow me enough time for a cigarette.
I want to ask you specific questions, being as we're in closed session. Once you discovered what had happened in your life and you discovered the problem, has there been a care plan established talking of an outcome, like once you've done the discovery aspect and found out where the actual problems are and what had happened in your life? Because I have a constituent in the same position you are in and she said it took a long time to find the discovery of what actually went on. It was being blocked out of her mind for so long, and eventually it did come out. But my question would be, has there then been a care plan drafted to say what projected outcomes you're hoping to achieve between yourself and your doctor?
Ms Judge: Psychoanalysis doesn't work that way, because it's a relationship. The treatment takes place within the context of a relationship, and the relationship is the tool that the psychoanalyst and the patient use. Well, the relationship is a tool that the psychoanalyst uses. So you can't really draft a care plan at the beginning, because things change. You never know what's going to be around the next curve of the road and you never know what repressed memory may come up next week or tomorrow or a month from now. Obviously you're going to have to just go with it.
As far as a proposed outcome is concerned, hopefully it's some kind of integration and recovery of painful memories, and understanding them and putting them in their place and going on from there.
Mr Hope: But when I'm talking about a plan -- and I know what you're saying. As you start to talk about it, the mind starts to open up and allow you to start talking about it. Yes, there will be curves in every road. It's not a clear-cut plan. My understanding through this individual is that there is a simulated plan of how to try to achieve the overall outcome, I guess, which is to try to understand what actually happened and then to try to then become -- you're using the words "productive in society." It's not that, because she is very productive in our society, but it's just trying to get the outcome of getting over this and getting on with it. I know that what you're talking about is that there is every curve that will be established in the road on the way to that.
Ms Judge: I think that's a question that would be best answered if you asked one of the psychoanalysts.
Mr Hope: Okay.
Ms Judge: I'm the patient.
Mrs Sullivan: I wanted to again express the appreciation of people on the committee for your coming forward and also for the very articulate writing that you've been doing in the Toronto Star and other publications with respect to the threat of removal of psychoanalysis. I think we've all learned from some of the public work you've done, and that should be acknowledged.
One of the things I was interested in was your referral to Woody Allen. It seems to me that perhaps some of the prejudice associated with psychoanalysis and one of the reasons it's an easy target is the imagery that comes with the Hollywood star who's in analysis or whatever. "I saw my analyst yesterday," they said on the late-night show.
The social status issues are the ones that tend to reach the public in terms of their information, rather than the care issues. That's a quite simplistic analysis, but I find it's interesting that on two occasions this kind of therapy has come back to the table for removal from the health care system when it's been found to be medically efficacious. That's the only reason I can think of, that the glamour of Hollywood has tainted the public perception of the treatment.
I don't know if you as a patient find that when people are talking to you about it, when you are saying, "Gosh, I have to write another article or fight another fight," when you're dealing with other patients in a patient group or whatever.
Ms Judge: I'll tell you, there's still a stigma attached to being mentally ill and being in psychoanalysis. Quite frankly, as you're aware, Marnie Judge is not my name; it's a pseudonym I'm appearing under. Most people don't know that I'm in psychoanalysis. I wonder sometimes if one of the reasons psychoanalysis has been slotted for delisting is because patients are primarily female. I don't know. This is just a thought I have and it's not a well-educated opinion, but it is a thought that I've had: If the majority of patients in psychoanalysis were male, would it be on the table for delisting?
Mrs Sullivan: I always say that if men had the second baby and every alternate baby, there would only be the first child, or at least the third child, I guess it would be, wouldn't it? But I don't know. Who knows if that's the rationale?
Mrs O'Neill: I just wanted to say I was surprised. I don't know whether you were here for the previous presentation --
Ms Judge: No, I wasn't.
Mrs O'Neill: -- that it was only 60% of the patients who are women, because I've had 11 of my constituents write to me or come in; three of them have come in after their letters. They're all women. I do think that it's not appreciated how long it takes to get to the stage of even finding the right psychoanalyst.
Ms Judge: I spent six years in the system before I came to psychoanalysis, six years seeing general psychiatrists, being prescribed medications, being hospitalized, being told, "You have a depressive disorder that's going to continue for the rest of your life." I was not productive until I got to psychoanalysis. I'm an honour student at the university. I'm a mother of three. I'm a professional. I'm productive now, and I wasn't able to function in those capacities prior to my psychoanalysis.
Mrs O'Neill: That's the story I've been hearing, and I'm not sure too many appreciate it. I hope that what your suspicion is -- that it has nothing to do with gender. This would be more destructive than ever. Let's just hope. But I'm glad you surfaced that, because certainly the patients that I've had anything to do with have all been women.
The Chair: Ms Judge, again, everyone has expressed their thanks for your coming before the committee.
Mr Hope: Just on a point, if I may ask for a little clarification, you said you spent six years in the system before you found the right one. I think that might be some of our problem, to try to filter out some of the maybe myths that are out there about it.
Ms Judge: Not the right psychoanalyst; I was in supportive psychotherapy, twice-a-week therapy, once-a-week therapy, twice-a-week therapy with antidepressants and tranquilizing medications, prior to going to psychoanalysis. Those treatments could have continued for the rest of my life. They weren't helping me. They were supporting me for the moment, but they weren't helping me understand the underlying causes of my problem. By understanding the underlying causes, I can finish with it.
One day I hope that I will be finished with my treatment and get on with my life. That's the purpose of psychoanalysis, the eventual conclusion. It's not something that continues for ever.
The Chair: Thank you very much.
Ms Judge: You're welcome; thank you.
The Chair: The committee stands adjourned until 3:30 tomorrow.
The committee adjourned at 1811.