SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
ONTARIO HOSPITAL ASSOCIATION REGIONAL COUNCIL 4
UNITED STEELWORKERS OF
AMERICA, LOCAL 677
CANADIAN AUTO WORKERS, LOCAL 1451
KITCHENER-WATERLOO ASSOCIATION FOR COMMUNITY LIVING
CHAMBER OF COMMERCE OF KITCHENER AND WATERLOO
KITCHENER-WATERLOO ACADEMY OF MEDICINE
PERTH COUNTY COALITION FOR SOCIAL JUSTICE
CANADIAN AUTO WORKERS, LOCAL 1986
REGION OF WATERLOO PHARMACISTS' ASSOCIATION
ONTARIO HEALTH RECORD ASSOCIATION
CONTENTS
Wednesday 17 January 1996
Savings and Restructuring Act, 1995, Bill 26, Mr Eves / Loi de 1995 sur les économies et la restructuration, projet de loi 26, M. Eves
Rx Plus Inc
Robert Morel, president
Ontario Hospital Association, regional council 4
Al Collins, chair
United Steelworkers of America, Local 677; Canadian Auto Workers, Local 1451
John Cunningham, president, USWA Local 677
John Coleman, representative, CAW Local 1451
Kitchener-Waterloo Association for Community Living
Jack Scott, community worker
Deborah Moskal, president
Chamber of Commerce of Kitchener and Waterloo
Ron Carther, president-elect
Ed Lemont, chair, federal-provincial affairs committee
Glen Mathers, chair, health committee
Norfolk General Hospital
Ruth Pennington, chair, board of directors
Harold Shantz, executive director
Kitchener-Waterloo Academy of Medicine
Dr Pierre Kugler, president
Dr John Wright, representative
Waterloo Public Interest Research Group; Waterloo Regional Council of Retirees; Waterloo District Health Council
Daryl Novak, staff, Waterloo Public Interest Research Group
George Goebels, representative, Waterloo Regional Council of Retirees
Gavin Grimson, executive director, Waterloo District Health Council
Perth County Coalition for Social Justice
Karen Haslam, vice-chair
Linda Mackay, education and media committee
Canadian Auto Workers, Local 1986
Don McFarlane, vice-president
Region of Waterloo Pharmacists' Association
John Ibbotson, president
Sherry Peister, past president
Sheila Richardson
Ontario Health Record Association
Gloria Ringwood, president
Marci MacDonald, representative
Ontario Health Coalition
Julie Davis, co-chair
Dan Benedict, co-chair
STANDING COMMITTEE ON GENERAL GOVERNMENT
Chair / Président: Carroll, Jack (Chatham-Kent PC)
*Carroll, Jack (Chatham-Kent PC)
Danford, Harry (Hastings-Peterborough PC)
Kells, Morley (Etobicoke-Lakeshore PC)
Marchese, Rosario (Fort York ND)
Sergio, Mario (Yorkview L)
Stewart, R. Gary (Peterborough PC)
*In attendance / présents
Substitutions present / Membres remplaçants présents:
Caplan, Elinor (Oriole L) for Mr Sergio
Clement, Tony (Brampton South / -Sud PC) for Mr Kells
Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart
Johns, Helen (Huron PC) for Mr Danford
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Churley, Marilyn (Riverdale ND)
Crozier, Bruce (Essex South / -Sud L)
Kwinter, Monte (Wilson Heights L)
Leadston, Gary L. (Kitchener-Wilmot PC)
Martiniuk, Gerry (Cambridge PC)
McLeod, Lyn (Fort William L)
Wettlaufer, Wayne (Kitchener PC)
Witmer, Hon Elizabeth (Waterloo North / -Nord PC)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel: Fenson, Avrum, research officer, Legislative Research Service
The committee met at 0859 in the Valhalla Inn, Kitchener.
SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
Consideration of Bill 26, An Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring, Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda / Projet de loi 26, Loi visant à réaliser des économies budgétaires et à favoriser la prospérité économique par la restructuration, la rationalisation et l'efficience du secteur public et visant à mettre en oeuvre d'autres aspects du programme économique du gouvernement.
The Chair (Mr Jack Carroll): Good morning, everyone. Welcome to the hearings on Bill 26 conducted by the standing committee on general government. We are delighted to be in Kitchener this morning. We have a couple of motions by Ms Lankin to deal with very quickly, and then we'll get on with our first presentation.
Ms Frances Lankin (Beaches-Woodbine): You just need Ms Lankin to deal with them. Thank you, Mr Chair. My motion is as follows:
Whereas there has been overwhelming public interest in Bill 26 and that 36 groups and individuals have requested to appear before the standing committee on general government in Kitchener, which far exceeds the 15 spaces available today for hearings;
I move that this committee recommends to the government House leader that when the House returns on January 29, 1996, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged for the community of Kitchener;
Further, that this committee recommends that the three House leaders meet as soon as possible to discuss this issue.
The Chair: As with yesterday, in the interests of time, do we have all-party consent for one-minute statements?
Mrs Elinor Caplan (Oriole): Oh, sure.
Ms Lankin: I fully predict, prescient as I am, that the government members will defeat this motion, as they have in other communities. I should make it clear that I have moved this motion with respect to other communities, because in every community we've gone into there has been a long list of presenters who will not have the opportunity to be heard before this committee but who would like to have their voices heard.
It's true that as the hearings go on, we've had an opportunity to hear from a wide variety of people and we are seeing some very important themes emerge with respect to concerns the public has with the legislation. But I remain amazed that every day there is still something new, a different angle, a different understanding, a different implication the act has for a particular group of individuals or a circumstance within our society and our communities of which this committee was unaware before that presentation.
I also think we have not had the opportunity to look at some parts of the bill in depth because the presenter is only having half an hour. It is true that they are focusing on the most pressing and the most important issues to them. I believe certain of these areas are so important in terms of public policy that they deserve to have a greater in-depth study, so that's why I'll be supporting the motion I've tabled today.
Mr Tony Clement (Brampton South): I appreciate the direction in which Ms Lankin is going, but I have problems with her premise. The presentations we have heard thus far, in the close to three weeks of hearings, which have been public hearings, have been of a high quality and have grappled with the issues at hand very well, both for and against the government's position. From my perspective, the whole process is working well. By the end of this week, both sides of the committee will have heard from 750 presenters, from a wide range and multiplicity of views.
From my perspective, it is now time to grapple with some of the recommendations that have come from the presenters, which we'll be doing next week in clause-by-clause. Ultimately, we as legislators have to act and have to choose the path we are going to take so we can reform the health care system for the benefit of all Ontarians.
Mrs Caplan: We've dealt with similar motions. We had motions at the very beginning of these hearings to extend the time once the tremendous demand across the province became obvious. We know it was the government's original intention not to allow public hearings across the province at all. I find it personally very frustrating that once the government realized the extent of interest across the province, it has refused to extend the hearing hours to allow individuals and groups to attend. They have done that, obviously, because they consider the presenters who are coming to be vested interests. I think that's objectionable and an insult to the people who definitely have an interest and should have an interest in this legislation.
I know the government's going to defeat this. Some would say, "Why are you even debating it?" It is important that we put on the record how distressed we are that the government has chosen to stifle debate and to stop people having access.
I would also point out that a package of bills, the advocacy, consent to treatment and substitute decision legislation, while important, compared to this deals with one health issue, whereas this bill deals with a dozen health issues. On that bill the government allowed three full weeks of public hearings, that bill alone. We appeal to the government and ask them to look at the precedent they have established in allowing adequate time on important health issues. Hopefully, they will take that message to their House leader.
Our leaders at the very beginning agreed that if there were really essential things the government had to --
The Chair: Ms Lankin, we agreed on a minute apiece. We're into three minutes.
Ms Lankin: That's Mrs Caplan, Mr Chair.
The Chair: Mrs Caplan, rather. Sorry.
Mrs Caplan: They could be dealt with on the 29th, but this could still be split and we could come back on those issues that truthfully do not have to be passed on the 29th. I will be supporting the motion.
The Chair: Ms Lankin, you used up a minute and a half of your minute too.
Ms Lankin: I noticed that. The government's concern about vested interests and special interests is very upsetting to me, and the sorts of groups that aren't going to be heard today, these vested interests, are groups like the Halton Regional Coalition for Social Justice, the Kitchener-Waterloo hospital nurses, the Kitchener-Waterloo Pharmacists' Association, the Ontario Social Development Council, St Joseph's Health Centre -- lots of individual requests; it goes on and on. I think it's an inappropriate categorization. You know the numbers, Mr Chair: Over 1,000 groups and individuals applied to be heard these two weeks of hearings and there were less than 300 committee spaces.
We believe there are major ramifications in terms of public policy in the delivery of health care services that deserve to be understood in depth, to be debated and amended appropriately, not by the process the government has set out, which is not only less than satisfactory, I would argue it's less than democratic.
I hope the government members see the light today and support my motion, but I'm not holding my breath.
Recorded vote.
Ayes
Caplan, Lankin.
Nays
Clement, Ecker, Johns.
The Chair: Just for the information of the audience, the people who voted were the only people eligible to vote. The motion is defeated.
The second motion, and maybe we could stick to the one minute on this one out of respect for our presenters.
Ms Lankin: Whereas there are only three days remaining for public scrutiny on Bill 26; and
Whereas public interest in this bill has been overwhelming; and
Whereas the vast majority of presenters to the standing committee on general government have recommended major changes be made to the bill;
I move that this committee recommend to the government House leader that the 68 individuals and groups that requested to appear before the standing committee on general government in Kitchener be given the opportunity today to see the government amendments to Bill 26.
Mr Chair, I'll try to take less than the minute you've allocated me. In light of the fact that the government is absolutely committed to proceeding on a timetable which sees us beginning clause-by-clause debate on Monday and voting on the bill the following Monday, it is absolutely untenable that here we are, three days to go, and we've haven't yet been presented with the full package of amendments to this bill.
I requested this of the Minister of Health the first day of hearings, December 18, in Toronto. I was informed by him then that we would get them in a timely fashion. I specifically requested that that be before we start the two weeks of travel on the road so the public could know what the amendments were, could comment on the amendments, and so the opposition had an opportunity to develop their amendments in light of the government's full intention of what it intended to present and to pass in the Legislature.
I understand today that we may have the first few amendments, and I applaud the government for finally getting us those first few, but I understand it will only be the first few and there will be more to come tomorrow and Friday, and maybe Saturday and Sunday and Monday morning, and then Monday we start to debate without having had any time for analysis. It's a repetition of the process we've undergone with this bill from the beginning and it is, as I said, untenable.
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Mr Clement: I cannot support the motion as read. But I appreciate and the Minister of Health, Jim Wilson, understands, where Ms Lankin is coming from, where the opposition is coming from, because we were in the same boat six short months ago.
I can assure the committee that the government is working as hard as it can to try to intake some of the public input that we've had over this process and respond to that input while still keeping the core of why we need this legislation in the first place: to restructure our health care system so we have the resources available within health care that are so necessary in the new and emerging areas of health care reform.
With that in mind, I would like to table at this time amendments the government would like to propose for Monday morning regarding schedule F of Bill 26. I herewith deliver these to the clerk for distribution. As Ms Lankin has mentioned, this a portion of what we intend to move as amendments. But as per Jim Wilson's and our commitment on the government side, we'll make them available as soon as we can, once we're comfortable that we have mirrored what we have heard as part of this very worthwhile public process. But I have to vote against the motion, because we're not quite ready to table all the amendments yet.
Mrs Caplan: I'll try to keep it to a minute, but I must admit I did get tremendously frustrated when I hear the government say that. The minister had acknowledged that there would be amendments coming. That was done the day of his statement, the first day of these hearings, almost a month ago. The fact that they are just tabling a few of the amendments today tells me that their initial plan to have had this bill passed by Christmas was outrageous. The fact that the amendments are being tabled at the end of this process and the intention is that they will not be available in total in time for people to make representation to them is the best argument for extension of the public hearings.
Clearly, this bill is seriously flawed. We expect to see many amendments. I'm pleased that we are seeing some today so we will perhaps get an intention of where the government is heading. But it is inadequate to tell us that they're working on amendments; that we may not have them all before the end of the public hearings.
It also galls me to hear Mr Clement tell us how important this process is and that we know we're hearing new things every day and they're going to respond to that in amendments. If they'd extend the hearings, we know we would see additional amendments coming forward.
I will be supporting Ms Lankin's motion. It's important that we get those amendments in enough time for the public to be able to review them as well. I'm disappointed that the government has chosen to drag its feet, acknowledge how seriously flawed this bill is but not have the amendments.
The Chair: Thank you. We'll now have the vote.
Ms Lankin: Sorry, Mr Chair, just a quick wrapup. Holy mackerel -- section F only, dealing with the amendments to the supervisors' powers in the hospital mergers and closures. I'm glad there's a lot of them, but I'm going to need some time to understand what these are. I suspect you all will, too. They're not really referenced in any way to Bill 26 in terms of where we find the parts being amended in Bill 26, which are amending parts of other bills. And this is just the first group of them.
The Chair: Is this relevant to the motion, Ms Lankin?
Ms Lankin: I think so. I think it speaks to the fact that it is going to take us considerable time to understand all the government's amendments to all aspects of the bill. To be in a position to deal with them on Monday, I urge you -- I understand you're going to vote against this motion today -- please get the rest of these amendments prepared to be tabled tomorrow, because we will not be in a position to adequately debate with full understanding if we don't have these and have the time at night for the rest of this week to go through them and understand what it is you're intending to do.
The Chair: I'm going to call for the vote. Those in favour of Ms Lankin's motion? Those opposed?
The motion is defeated.
RX PLUS INC
The Chair: We now call on our first presenter, representing Rx Plus Inc, Robert Morel, the president, and Charles Truax, the vice-president of information systems. Good morning, gentlemen. Welcome to our committee. I apologize for the delay. You've got a half-hour of our time. Questions would begin with the Liberals, should you allow time for them. The floor is yours.
Mr Robert Morel: Thank you for the opportunity to appear before the committee this morning. We certainly feel somewhat privileged, given the number of people who would like to attend, and we do thank the three parties for giving us this opportunity this morning. My name is Bob Morel. I'm president of Rx Plus. With me is Charles Truax, vice-president of systems for Rx Plus. I'd indicate that the submission we are providing today is fully endorsed by the entire management team of Rx Plus. My comments today will focus specifically on the proposed amendments to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act.
To give you a little background about our organization, Rx Plus was founded in 1974 and is a prescription benefit administrator responsible for the management of over 1,200 corporate prescription programs from coast to coast. Rx Plus clients, among others, include Honda Canada, Purolator, Navistar, Suncor, Wood Gundy, CanWest Global, the University of Toronto, McGill University, all the employees of the Toronto-Dominion Bank, to name just a few. In addition, Rx Plus administers a number of drug programs for 12 insurance companies.
We believe Rx Plus manages and maintains the largest national pharmacy network, with over 6,800 pharmacies, representing 98% of all the pharmacies across Canada. In addition, Rx Plus manages a prescription drug base of approximately $750 million on an ongoing basis. Rx Plus systems are very sophisticated and have been designed to control ingredient price markups, professional fees charged by the pharmacist in each of the pharmacies, as well as any other markups that may be involved in the pricing of prescription drugs. The controls in place in the systems managed by Rx Plus allow Rx Plus clients to enjoy a net discounted saving of approximately 15% per prescription or, in other terms, approximately $6 per prescription.
What we do is very similar to the Ontario drug benefit organization. You will notice a number of similarities today, in that ODB is responsible for managing a single drug program for approximately 2.4 million Ontario residents, while we are responsible for administering several hundred different kinds of drug programs for approximately 400,000 individuals across Canada. Not only can we bring experience with regard to what we have been doing in Ontario, but we also have the experience of what we are doing in each of the other nine provinces. Hopefully, that will prove helpful to you today.
Specifically, we wish to focus on four areas today: first, the elimination of the best available price, also known as BAP, and the deregulation of the price of medication in the private market; second, the introduction of copayments and deductibles; third, linking prescribing guidelines to reimbursement; and finally, a comparison between the public sector and what we have been doing in the private sector to achieve similar types of goals to those the government today is trying to accomplish and how they are somewhat different.
If I may begin with the elimination of BAP, best available price, and the deregulation of price in the private sector, in 1986 when the Liberal government introduced Bills 54 and 55, the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act, Rx Plus supported the introduction of BAP for the government ODB plan in order to eliminate the practice of spread pricing.
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We also recommend at this time that the government not legislate the private sector. We remain consistent in our belief that the government should not intervene in the private sector since it is not the primary payer. Therefore, Rx Plus supports the change to the Prescription Drug Cost Regulation Act which will result in the deregulation of the price of pharmaceutical products in the private sector market. We would like to stress, however, contrary to reports by the press, that we believe, on behalf of our clients, that deregulation will not result in significant price increases on patented drugs for consumers. In fact, the competition in the free market should keep prices stable and may well result in decreases.
On behalf of our clients, Rx Plus has agreements with pharmacies that ensure that all three components of the prescription cost are controlled: the product ingredient costs, the allowed markups and the professional fee. This would not be affected by government deregulation.
In support of our position, we confirm that our clients' average prescription cost in the province of Ontario between January 1993 and December 1995 -- in other words, the last three years -- increased on average only 4.9%. This is substantially different from the numbers we have heard recently, in the area of 16.4%. If we go back to 1986, when amendments were brought in, the government was incurring cost increases at the rate of 23% per year. We understand that this increase is lower than that experienced not only by the ministry here in Ontario but other ministries in other provinces.
Included in the above are pharmacists' professional fees, which range from $1.99 to $12.50. The range in pharmacy fees is based upon open competition, location, size of prescription and the total cost of the prescription.
With regard to the introduction of copayments and deductibles to the residents of Ontario, Rx Plus recognizes the fiscal pressures facing the Ministry of Health and the opportunity for the introduction of a copayment or deductible for recipients of the ODB program. We believe that any copayment/deductible must be structured in a way that will protect those who need the provincial plan the most.
Our many years of experience with hundreds of plans with deductibles and copayments indicate that caution must be exercised when implementing these measures. We'll give you some examples of what we're talking about.
(1) While the implementation of a $2 deductible per prescription does not appear to have any impact on the drug utilization patterns, the implementation of annual deductibles even as small as $20 single and $40 family per year does impact on the utilization of prescription drug programs.
To prove our point, a May 1995 Compas study commissioned by Rx Plus relating to the 470,000-federal-employee benefit program indicated that 8% of the employees said they had instances over the last couple of years when they were not able to afford the purchase of their prescription drugs. These are individuals who are well paid, yet 8% of them were not in a position, because of deductibles, to obtain their prescriptions.
(2) In the case where very large deductibles were implemented, such as those of the Saskatchewan government, we acknowledge that government disbursements have significantly decreased. More important, the main reason is a transfer of liability and payment to the patient. Large deductibles, in our opinion, discourage the appropriate and necessary use of prescription drugs.
We strongly believe that non-compliance associated with large deductible programs increases the cost to the other health care sectors, such as physicians' visits and hospital stays, thereby negating any potential saving. In a recent review of the literature of the University of Toronto, the economic costs of non-compliance were estimated at $7 billion to $9 billion.
(3) Linking prescription criteria to reimbursement: While increased consumer responsibility and accountability is critical for a more rational use of health care resources, the introduction of copayment deductibles in our opinion will not address abuses in overmedication. A 1994 Ministry of Health study entitled Drug Programs: Framework for Reform reports rates of inappropriate prescribing, utilization and non-compliance of 25% to 40% in Ontario. Each year in Ontario, 17,000 people are treated for prescription drug interactions, and one of out of every five seniors is admitted to hospital for the same reason. A recent study conducted by McGill University reached similar conclusions.
RX Plus supports these studies and believes that inappropriate prescribing and utilization must be addressed. In light of these statistics, we understand the Ministry of Health's intentions behind the proposed changes to the Ontario Drug Benefit Act, which will permit the government to restrict payment for specific drugs to situations in which prescribed clinical criteria are met. However, we are concerned about how these guidelines will be developed and who will ultimately be responsible for their implementation and management. The development of guidelines or prescribing criteria must involve an open process which will permit the participation of all sector stakeholders who have expertise to contribute to the process. Specifically, therefore, these guidelines should be clinically based as opposed to being based on cost containment.
It is important to note that prescription drugs account for only 6% of Canada's $71 billion in health care expenditures as compared to 47% for hospitals. Canada's growing aging population will continue to rely on innovative medications to improve their health and quality of life. Appropriate use of medications means reduced physician visits and hospital stays, better health care outcomes and improved cost savings to the overall health care system.
Just as an aside, we have to keep in mind that in terms of the overall costs the government is incurring at this time, there are things that can be done and there are things that can't be done. I can remember that in 1974 when the program was initially introduced, there were 700,000 members in the program. When we met again in 1986 the 700,000 members had increased to 1.3 million members. Here we are again 10 years later, again addressing the same issues, and we now have 2.4 million. Every 10 years, the number of participants is doubling. Is it any wonder that the costs are going up by 6.4%, as has recently been reported? Unless we are prepared to change the membership, those numbers will continue to increase, and as the average age of our population rises and the baby boomers continue to move through, we know from our database that utilization increases at the rate of 10% for each year the population ages, and there is nothing you can do about it.
Rx Plus believes that greater emphasis must be placed on the physician if the issues of inappropriate prescribing and utilization are to be addressed. However, we are concerned that the proposed change to the Ontario Drug Benefit Act which allows prescribing criteria to be linked to reimbursement may result in financial penalties to physicians which may supersede their professional judgement used when prescribing.
In addition, to be able to implement the kind of programs we're talking about to manage utilization and compliance, you need some very sophisticated systems. Those systems do not exist today. They do not exist within the government and they certainly do not exist with the gatekeeper, which is the pharmacist who sits at the other end of the telecommunication line. We know that the software that sits on the pharmacy prescribing counter cannot handle the kind of things we are talking about, because we were talking with them today about implementing programs that are not dissimilar and we are doing it on the basis of cooperating with the pharmacists. Because without their cooperation at the other end of the communication line, we can have the very best computer systems and the very best regulations and the very best ideas in terms of how things should be done, but someone at the other end who is talking to the patient, the cardholder, at the time the prescription is being dispensed -- the pharmacist -- is the one who will have to communicate whether this is appropriate for this particular individual.
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On that point, Rx Plus believes that pharmacists must not be penalized, but rather encouraged and empowered to work with prescription benefit managers like Rx Plus and the ODB to act in the best interests of the patient. We therefore encourage the Minister of Health to consult with the stakeholders in this process before implementing prescribing criteria and linking them to reimbursement.
Rx Plus believes the ministry should seriously consider meaningful partnerships between ODB, the private sector, the prescription benefit managers such as Rx Plus, the pharmacists, the physician and, most of all, the patient.
We support improved patient education. As an organization, I can tell you that within the next few days we will be announcing the implementation of disease management centres that are being fully funded by the pharmaceutical company Eli Lilly Canada, and we will be involved with the management of some of these clinical centres. They will manage diseases such as diabetes, which affects 6% of our population.
For these kinds of centres and the costs associated with them, we have been able to identify that for every $1 invested in these education centres that are specific to diseases, there is a $7 return for each of those investments. I can also tell you that a number of major corporations have already signed up to participate in these new education centres, because it is new to Canada. They include, as an example, some of our large major financial institutions.
I'll just talk a little bit about the private sector and Rx Plus as an organization and how we perhaps differ from ODB. Through our technology, Rx Plus continues to monitor very closely over $750 million of prescription drug claims in an online real-time environment. Our online real-time network allows us to develop new software applications which substantially increase our communication with our pharmacists. We recognize the important role the pharmacists play in our approach and endeavour to maximize their professional skills in serving our customers. Today, approximately 94% of all prescriptions that are received in our data centre located in Sudbury from pharmacies across Canada are received in an online real-time environment. That's 94%. So we have very sophisticated systems in that area.
We have also implemented new drug intervention programs which will provide greater quality of health care as well as economic value to our customers. In addition, we can design drug formularies specifically targeted to the characteristics of each of our individual clients. You can imagine that a drug program for the employees of Falconbridge Nickel Mines may be different than the drug program we would design for the employees of the Toronto Dominion Bank, because the employee populations are very different. These intervention programs for some of our clients have resulted in savings in excess of $1 million per year without taking anything away from any of the employees.
Finally, Rx Plus is working with Eli Lilly Canada to launch disease management and education centres focused on the treatment and management of specific diseases such as diabetes. Our data clearly indicate that 20% of our employee population, of our cardholder population, which is 400,000, actually incurs 70% of all the prescription claims. Through improved disease management, patients will experience a better quality of life, which is our first goal, while effectively delivering lower cost to our plan sponsors, which is our second goal.
Rx Plus will welcome an opportunity to assist the Ministry of Health and this committee to use our private sector experience and expertise and provide further information on how these programs have adapted well to the private sector and how they may be adaptable to the public sector as well. We believe that our technology systems application and health care focus are best suited to deliver optimal health care outcomes to our cardholders, which is priority number one.
The Chair: Thank you very much, gentlemen. We've got a very short period of time for questions, two minutes per party, beginning with the Liberals.
Mrs Lyn McLeod (Leader of the Opposition): Let me begin by saying we certainly believe there are cost-savings to be made with good pharmacological management that involves professional pharmacists and physicians and patients. We have a number of concerns with Bill 26 and how the government's changes in drug benefits may interfere with that. You've noted a couple of them in terms of whether or not prescribing guidelines will be clinically based. We've also heard concerns about how quickly government can respond to new clinical evidence and make changes to its guidelines.
You've also noted a concern about actual cost of copayment plans, which is rather ironical, to think this could be more costly for government. You've noted non-compliance. We've also heard concerns about increased volume in dispensing in order to save the dispensing fee and also cost of administration.
Let me turn to the area of deregulation, which seems totally inconsistent with the whole issue of pharmacological management in any event, and seems rather philosophical rather than related to the reduction of costs for government. You've said you believe deregulation will not result in significant price increases. In the course of our hearings we have heard so many different opinions on what will happen that I think no one, and I suggest least of all the government, knows what's actually going to happen with drug prices under deregulation.
London Life Insurance yesterday said clearly drug prices would increase; no question about that. The Ministry of Health has said that in the short term they'll increase. The CDA generic representatives said they couldn't get enough information to know whether drug prices would increase or not. I guess one thing that is clear is that it's going to lead to different drug prices, and I'd like your comments on what you think might happen in terms of differential drug prices. What would happen particularly in smaller communities? What evidence can you present for your belief that drug prices will decrease overall?
The Chair: Unfortunately, Mrs McLeod, you didn't leave any time for an answer.
Ms Lankin: I'm actually very interested in that question as well and have found it confusing, if not frustrating, that one day we'll have the brand-name pharmaceutical industry tell us that it will be okay, and the generics come forward the next day and say no, it won't. London Life says that in the long run they think competition will bring prices down, but the tools aren't there for parts of the industry to deal with helping competition. So I would like your comments on that.
Then one other quick point on user fees. I would say that my understanding of the majority of the increases that we've seen in the drug benefit program really has come from new drugs being brought on, and they're highly effective but they're new, high-priced drugs. It's not an increase of utilization per senior. There may be more seniors and more people coming on to the plan, but it's not more drugs per individual, and therefore the user fee actually will give the government a shot of revenue and bring their costs down to a new level, but the plan will continue to grow. It's not a cost-containment strategy, and therefore I think prescribing guidelines is more the way to go. I'd like you to comment on that too.
Mr Morel: I'm going to try to cover both a little bit, if I may. If we compare what we have been doing in terms of the private sector in terms of being able to control price, we have been able to meet with the pharmacy associations, we have been able to meet with the pharmacy chains, we have been able to negotiate agreements in terms of negotiating prices that we believe are reasonable. There's no question that a single individual who goes into a pharmacy as a standalone consumer does not have any negotiating power, but certainly ODB has negotiating power and certainly an organization like ourself has negotiating power, and we have the systems and the database to be able to negotiate very effectively.
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I mention in our brief that of our entire client database, our costs have only increased at the rate of 4.89% for each of the last three years. So we have been able to control the cost of the drug programs for our employees. If you talk to the insurance sector, however, where each individual pays for their prescription, then sends in the receipts after the fact, you will find that their costs have been increasing in the area of 14% to 15%, not dissimilar to the government sector.
In terms of pricing, I think we will see strong competition in terms of buying groups, in terms of the pharmacy chains, in terms of the independent pharmacists. We know that pharmacists here in Ontario own drug trading and they use drug trading as their main buying facility, so they do buy as a group, and we will continue to see ongoing development in that particular area.
Mr Wayne Wettlaufer (Kitchener): Thank you for appearing today. You say that 17,000 people were treated for drug interactions and that one out of five seniors was treated for the same reasons. Do you have any figures on how many were treated because pharmacists couldn't read the doctor's writing?
Mr Morel: Oh, my goodness.
Mr Wettlaufer: Okay, let's get on to something a little more serious. But there is an element to that.
Quite often seniors coming in to a pharmacist for a prescription are under a considerable amount of stress. The writing on the bottles is quite often too small for the seniors to read, and they quite often get the instructions from the pharmacist on how often to take the medication. Usually they forget because they're under stress at the time of getting the prescription filled. How often do you think that would be causing the drug interaction?
Mr Morel: I wouldn't want to venture a guess.
Mr Wettlaufer: I'm just pointing out --
The Chair: Thank you, Mr Wettlaufer. Thank you, gentlemen. I appreciate your attendance here today and your interest in our process. Have a good day.
ONTARIO HOSPITAL ASSOCIATION REGIONAL COUNCIL 4
The Chair: The next presenter is Al Collins, the CEO of the Grand River Hospital Corp. I understand he's presenting on behalf of OHA region 4. Good morning, sir, and welcome to our committee.
Mr Al Collins: Thank you, Mr Chairman. On behalf of OHA Regional Council 4 and the Grand River Hospital Corp, I'd like to extend my appreciation to you and the members of the standing committee on general government for allowing me the opportunity to appear today to present the region's views on Bill 26.
On December 18 in Toronto, the Ontario Hospital Association presented to your committee a provincial hospital perspective on Bill 26. Regional council 4 was consulted during the preparation of the OHA submission and provided input. We are supportive of the OHA's submission to the standing committee on general government on Bill 26, most specifically that in its present form we cannot support those sections of the bill containing certain amendments to the Ministry of Health Act and the Public Hospitals Act.
In reviewing schedule F of Bill 26, OHA Regional Council 4 feels that as presently drafted the bill would certainly not support the principles or practices of voluntary trustee governance of the hospital system in our region of the province.
I would first like to provide a brief description of the hospitals represented within OHA region 4. To meet the diverse needs of its members and to strengthen the association's leadership and advocacy role, OHA member hospitals are organized into five regions representing north, east, southwestern, south-central and the greater Toronto area. Each area has a regional council which elects members to the OHA board of directors. The regional council structure provides the OHA with a network for regional consultation and advice.
Regional council 4 is composed of hospital members within the counties of Simcoe, Dufferin, Wellington, Waterloo, Halton, Hamilton-Wentworth, Brant, Haldimand-Norfolk and Niagara. Within OHA region 4, there are 14 small hospitals, 18 community hospitals, three chronic care facilities, two mental health facilities and three teaching hospitals, for a total of 40 hospitals.
As indicated earlier, we support the recommendations and concerns advanced by OHA in its December 18 presentation to the standing committee. However, in our presentation today we wish to provide a regional perspective on some of the concerns with the bill.
The proposed section 6 of the Public Hospitals Act provides the minister with new and sweeping powers. OHA region 4 agrees that government needs effective mechanisms to implement the restructuring reports being received by the minister from district health councils. We also welcome the announcement that the minister will be recommending sunsetting the proposed Health Services Restructuring Commission. However, we feel that the following overriding powers vested in the minister under section 6 must also be sunsetted: specifically, those allowing the minister and his staff to direct that a hospital cease to operate as a public hospital; to direct the board of a hospital to provide or cease to provide specified services, or to increase or decrease the extent or volume of specified services; to direct the boards of two or more hospitals to take all necessary steps to amalgamate; to make any other direction related to a hospital; and to amend or revoke a direction.
Region 4 believes these powers are far too broad and sweeping and do not respect the principles of voluntary trustee governance and local community decision-making. However, we recognize that it will not be easy for institutions individually to cope with the major reduction in funding announced by the government in November. Ostensibly, Bill 26, according to the government, is about giving transfer payment partners the tools they need to assist them in downsizing while still maintaining accessible, quality public services.
There are elements of this in Bill 26 and the economic statement; for example, guidelines for arbitrators, multi-year funding commitments, revisions to operating and capital plan processes, facilitation of access to other sources of revenue such as hospital crown foundations and copayments. These tools are welcome. But the section 6 amendments to the minister's powers are not tools for stakeholders but rather for the ministry. There should be no misunderstanding about that. They are in fact powerful controls, not simply tools.
Nevertheless, we are prepared to recognize that collectively, hospitals and government need to move expeditiously to ensure there is a rational and rapid restructuring of the hospital system in our region and elsewhere. Given the funding reduction of $1.3 billion, we are prepared therefore to endorse the OHA's recommendation "that the time-limited provision for all of these powers in section 6 be four years, ending March 31, 1999. In this way, the statute will assist hospitals and the government in the restructuring of the hospital system, yet at the same time preserve the fundamental principle of voluntary governance for the future."
The government should endorse this reasonable amendment and approach. Mr Chairman, hospitals want to work with government, not for government. We believe this is hopefully the government's intent as well in the purposes of the Savings and Restructuring Act, as was set out in the explanatory notes to the bill. It says "to achieve fiscal savings and promote economic prosperity through public sector restructuring, streamlining and efficiency."
The appropriate relationships between hospitals and the provincial government should be restored after the restructuring commission finishes its work in the year 2000. This can only come about if the minister's absolute powers to control and manage the system are sunsetted at the same time as the commission completes its work. We note that in his opening statement to this committee on December 18, the minister said, "The Minister of Health will not be exercising these powers unilaterally," and that he expects the powers of the commission to "cease with the task."
If the minister does not intend to use the powers himself and the commission's mandate will expire in four years, why would the minister wish to continue to retain powers he says he doesn't intend to use? Logically, if the commission is terminated, the minister's powers should also be terminated. Otherwise, one has to assume that the acquisition of these powers is ultimately about something not tied to restructuring at all, but is related to something bigger and not yet disclosed to the public and this committee. If the new powers are merely something required to complete the restructuring of the system over the next four very tough years of restraint and downsizing, government should have no difficulty in embracing the OHA's suggested amendments for sunsetting the minister's extensive interventionist powers.
Local community-based solutions are preferable. There are many examples of such in our region. For instance, mergers have taken place recently, such as with Orangeville District Hospital and Shelburne District Hospital, which have amalgamated and are referred to as the Dufferin-Caledon Health Care Corp. Here in Kitchener, the Freeport Hospital and the Kitchener-Waterloo Hospital have merged and are now known as the Grand River Hospital Corp. A very recent announcement was that the boards of Chedoke-McMaster Hospital and Hamilton Civic Hospitals have agreed to work towards a merger. Also, in the spring of last year, the St Catharines General Hospital and Niagara-on-the-Lake General Hospital underwent an operational merger, resulting in a more appropriate alignment of operational programs overseen by one senior management structure. The region believes that plans for mergers and amalgamation developed voluntarily by hospitals and approved by district health councils should not require intrusion from the commission.
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Mergers within the region have taken place and others will take place because hospital boards and managers recognize that this is required and they are in fact prepared to act on it. The volunteer trustees of my hospitals and, I dare say, all hospitals within the region play a vital role in decision-making, and this should be respected.
The bill proposes that the powers of closure and amalgamation and any other matters related to a hospital may be delegated by the minister to any person or body. This approach removes the accountability for such major public interest decisions from elected representatives.
Region 4 members believe that elected officials must not be able to delegate these sweeping powers. The minister must make decisions on closures and amalgamations based on information provided by the most appropriate body and refer approved plans to the commission for implementation.
OHA region 4 supports the recommendation that the powers under subsections 6(1), that is, affecting hospital closures, 6(3), affecting hospital amalgamation, and 6(5), making any other direction related to a hospital, not be delegated.
The region has also outlined other concerns related to specific areas of the bill which I'll summarize briefly.
In the area of due process, region 4 hospitals feel that it's essential that part of the restructuring process, whether conducted by district health councils or other planning bodies, must include an opportunity for hospitals and the communities they serve to submit their views and to be heard.
With respect to the role of the supervisor, the region feels that given the powers of a supervisor are sweeping and could have great impact on the hospital, its board and potentially the hospital corporation, the appointment of a supervisor should not be undertaken without reasonable notice and an opportunity for the hospital to respond.
As there are limited details on the Health Services Restructuring Commission, hospitals in our area believe that, as a minimum, the membership on the commission should include appropriate representation of hospitals from the region who have successfully initiated and completed restructuring initiatives.
Relating to hospital bylaws, the provision for the regulation-making power of the government must be removed from the bill. The minister must not have the power to write hospital bylaws.
In relation to hospital funding, region 4 hospitals believe that the proposed amendments in Bill 26 would give the minister unrestricted powers in terms of imposing terms and conditions on hospital funding and that the unrestricted nature of these proposals would lead to micromanagement of hospitals, thereby imposing a degree of inflexibility in day-to-day operations.
In conclusion, region 4 would like to reiterate support for the Ontario Hospital Association recommendations presented in the December 18, 1995, submission to this committee. We concur with the OHA that, in its present form, we cannot support these sections of Bill 26 containing specific amendments to the Ministry of Health Act and the Public Hospitals Act, which I've emphasized today. There must be changes relating to the minister's powers, delegation of authority, due process, role of the supervisor, the Health Services Restructuring Commission, hospital bylaws and hospital funding.
As presently drafted, the bill would most certainly not support the principles or practices of voluntary trustee governance of the hospital system in Ontario, including the south-central region of the province. Thank you, Mr Chairman.
Ms Lankin: Well, thank you very much and I appreciate your presentation. While you were presenting I was flipping through pages here, looking at the old Public Hospitals Act, looking at schedule F of Bill 26 and the amendment to the old Public Hospitals Act and looking at the first of what I assume will be a raft of amendments that the government will be filing over the next number of days with respect to schedule F, which amends the old Public Hospitals Act. I'm trying to understand whether your concerns have been addressed or not. You might be pleased to know that some of the recommendations of the OHA in fact have been addressed and we can quickly identify those. If the minister is going to use his extraordinary powers to unilaterally close the hospitals, he's at least going to give you 30 days' notice so you have a chance to talk to him about it, I guess.
The powers to do that, which are the powers in section 6, which the hospitals have been concerned about, will also be sunsetted at four years along with the commission. So that's a positive thing, and we should say it's good the government was listening on that.
The powers in section 8, however, remain in terms of being able to appoint a supervisor at any time they want. However, again, if he's going to use that unilateral power he'll give you 14 days' notice of that so that the hospital at least does get notice that a supervisor is going to be appointed under these extraordinary powers. I would argue that the government's got to go back and take a serious look at that. It seems that if a supervisor's going to be appointed for purposes of closure or merger or whatever, that might be an appropriate way to go. But in any other circumstances all the due process protection that existed in terms of investigators, investigator reports, a response from the hospital, all that should be there. And the extraordinary powers under section 8 should be sunsetted at the end of four years as well. That's not there.
They've taken out the bylaws provision, which you like, but it's pretty clear they still want you to file with the ministry. That's still there, so we've got to figure out what that means about your being able to implement your own bylaw changes. I obviously don't know the answer to that one.
There are some changes around the powers of revocations of doctors' privileges. It tightens it up a little bit, so that's some concern there.
However, let me tell you what they haven't listened to you on. The powers under subsections 6(1) and (5), closing, merging hospitals etc, it's very clear from the hospital sector that they want that power. If the minister's going to make unilateral decisions they want the minister accountable for it and not delegating it, and the delegation provision's still there.
Also, I think all of us have been talking about both the hospital restructuring commission's work should be tied to local DHC processes and your request that the minister's decision to close or amalgamate be tied to that. No reference to any of that. So there's still unilateral action on the part of the ministry not linked into any kind of local planning processes. Essentially, the government's still saying, "Trust us on that one."
With respect to all of the issues around micromanagement like the imposition of physician human resource plans and all of those sorts of things, they're all still there; none of that's gone.
That's a lot, I'm sure, for you to absorb because I just rattled through it, but it means that you've been heard partly. It means that you've made a whole presentation on a number of issues today that we appreciate getting but you perhaps didn't have to touch on. You could have spent more time on some of the other areas to convince the government of your argument, and it means you've got two days to get the rest of your colleagues who are coming before us to concentrate on the areas that are yet to be changed.
I provide you with that information because I think it's important that the public that's presenting knows that.
The areas that are left, the DHC-related areas, the sunsetting of powers around supervisors, some of the due process protections, are those areas you would like to see us continue to push the government for amendments on?
Mr Collins: That's correct.
Mr Clement: Thank you very much for your presentation. As you know, about half an hour before you started your presentation the government did table its proposed amendments to schedule F to deal, I think substantively, with a number of the concerns that were raised by the Ontario Hospital Association by its member hospitals that presented to us and by individuals and other groups who made their views known. I feel quite confident that we have maintained the core tools necessary to change the hospital system for the better and reallocate those savings to other areas within the health care system, and have met some of the concerns that have been presented to us. For instance, section 6, which you spent a lot of time on, the so-called extraordinary powers to merge, close or amalgamate hospitals, has been sunsetted after four years. We have accepted that recommendation.
I would note that Ms Lankin made reference to the district health councils, and I would remind her yet again that section 8.1 of the Ministry of Health Act, which deals with district health councils and their ability to plan, to analyse and to advise, is still in effect and has not been touched by our legislation. I would note that under due process we have given the hospitals 30 days to respond if there is a merge, amalgamate or close decision that's been made, and I would note, with respect to the role of supervisor, as you have indicated, that that's an extraordinary power and we have given the hospital 14 days to respond before a supervisor is put in. I would note that a supervisor and his or her powers were present in the old legislation, so this is not a new power. We have changed the 30-day period under the old legislation to a 14-day period, and I acknowledge that that is a different day but I think it's reasonable under the circumstances. And we have heard with respect to hospital bylaws that the government and its bureaucracy should not be in the business of writing bylaws, that is, for the voluntary boards of the hospitals.
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I know that's a lot to put on you in a short period of time. I'm merely glad we were able to table them, as per both our intentions and opposition demands, as soon as we could. Do you feel we've at least gone part of the way to satisfy your individual concerns?
Mr Collins: I believe that the government, with the amendments you're talking about this morning, has gone part of the way. We still have concerns in the other areas I mentioned but I am pleased that we have been heard in those areas and I would hope that we would have somehow more opportunity to have dialogue with the government before the bill is actually implemented.
Mr Clement: I can assure you the dialogue will be continuing both before and after the bill is passed. It's our intention as a government to work with the hospital sector to achieve the savings and the sector that we need to have the hospital care that our citizens need, but also to reinvest the savings in other areas. So I want to assure you, if I can take my last 15 seconds, that will be an ongoing process and this is the start of the process, not the end of the process.
Mrs McLeod: I can't help but remark that it might not have taken the government quite so long to come up with such minimal amendments if it had consulted with the OHA before it brought in the bill.
Mr Clement: You're never satisfied, are you?
Mrs McLeod: Certainly not, and I would say to the government members that I can't take a lot of comfort from the sunset provisions, because my primary concern is with what's going to happen in the next four years. I say that because the government has made it very clear in bringing forward this bill -- and it is a Minister of Finance bill -- that this isn't about really giving powers to communities to make decisions for communities; this is about giving government the powers it needs to cut $1.3 billion out of hospital budgets.
I worry about the unilateral powers of the minister to close hospitals, or to delegate those powers to another individual or commission to close hospitals, when it comes in the context of needing to make that $1.3 billion in cuts. I guess my concern is that over the course of the next four years, in fact over the course of the next six months, expediting the process is going to be a lot more about making those cuts than it is about what is in the best interests of the community.
In the context of that concern, I believe community processes can work. Sometimes they take longer than we'd like, but I think they can work, and this is an area, as you've noted, that demonstrates that in spades. Can you comment on what you think is needed as an incentive for community planning processes to work? I'm thinking in terms of some commitment of dollars back to the community so that the savings that are realized by restructuring are actually used to serve the health needs of people in your community.
Mr Collins: I think you've hit on a very important point, Mrs McLeod. I believe that most communities in the province that are going through restructuring processes agree that they need to be done, but where the restructuring results in some savings, perhaps, in the institutional sector, those savings should be retained by the community to be reallocated for provision of health services that are identified as needs by the citizens of the community. I think one of the greatest incentives that government could provide would be to allow at least some of the funds saved in restructuring to remain within communities for redistribution.
Mrs Caplan: I think an interesting point was raised this morning. I could understand the minister needing to have the power, where a hospital board en masse resigns, to be able to send someone in, but I'm trying to understand why he would need, or any minister would need, the power to eliminate a hospital board, given all of the other powers he has under this legislation, no access to court challenges on his decision. Why do you think they're putting that provision in, to be able to bring in a supervisor with 14 days' notice to a board?
Mr Collins: I think that's the point we are making in the presentation. We are concerned about that, Mrs Caplan, that the powers are far too sweeping. I think there are powers that are available to the minister under existing legislation --
Mrs Caplan: Absolutely.
Mr Collins: -- that would permit this sort of thing, and we do have some real genuine concerns that these powers are far too broad, far too intrusive.
Mrs Caplan: Do you think individuals in communities will be reluctant to serve on hospital boards as volunteers, knowing that the ministry and the minister have these enormous powers to look over their shoulder and in fact come in and wipe out a board, without reason, I guess? You know, the public interest test is so broad and general. I would be very concerned about the reaction of the voluntary governance -- the nature of our province -- just given the attitude.
Mr Collins: That could be a concern. The voluntary governance has always been the backbone of the hospital system in Ontario, and I think that if people feel, as I mentioned, they are working for government rather than with government, there will be less incentive to volunteer in the system. There's no question.
The Chair: Thank you, sir. We appreciate your presentation this morning.
UNITED STEELWORKERS OF AMERICA, LOCAL 677
CANADIAN AUTO WORKERS, LOCAL 1451
The Chair: The next presenters are John Cunningham, president of United Steelworkers of America, and John Coleman, from the Canadian Auto Workers, Local 1451. Welcome, gentleman. The floor is yours.
Mr John Cunningham: Good morning. I'm John Cunningham. Mr Chairperson and committee members, thank you for the opportunity to present today. It's nice to see Minister Witmer out today. She doesn't make many public appearances in her own riding and her own constituents to face her own constituency. We are happy to share our time with John Coleman of Local 1451, CAW. My name is John Cunningham, as I said, Local 677, USWA.
Interjection.
Mr Cunningham: We'll give you the floor later, Elizabeth.
The Chair: Excuse me for a second, sir. I would like to hear what the gentleman has to say. I would appreciate it if we keep our conversations at the table to a minimum.
Mr Cunningham: We represent 900 workers in Kitchener manufacturing tires. Our local, in its 35-year history, has maintained a viable, flexible workforce with one strike of seven days' duration. This local's historical ability to negotiate has kept a thriving business in a community when most of the rubber industry has turned its back on Canada.
Schedule F, sections 5 and 6: Section 5 overrules the regulation on how provincial aid was granted. Now it has imposed terms and conditions and requirements of security for repayment. This is to be determined by the minister by what is called "deemed public interest." Section 6 gives power to the minister to close, amalgamate or specify services to be delivered. We have seen in the WCB system how the vague term "deeming" can be stretched beyond the believable.
Public interest in the past was determined by caucus, committee, standing committees, polls and consultation with professionals and experts in the field. The Legislature had to be hijacked -- an act of piracy, some said -- to get woefully inadequate hearings where hundreds all over the province still want to be heard. The government is jamming closure on many other bills, with ministers, let alone backbenchers, spewing little information but much rhetoric. Few are reassured of the nebulous phraseology of "in the public interest" in the hands of a government that refuses to listen to its own people.
Subsection 8(1): We see "or any other matter relating to the hospitals where the Lieutenant Governor in Council considers it in the public interest" as a catch-all that allows a grab at the unknown.
Section 9 gives powers to an appointed supervisor to completely take over a board of directors or corporation where previously the board only had the obligation to follow the supervisor's advice. It was presumed in the past that if a board ignored the super's advice, the press coverage and public opinion as well as the minister would move a board to act upon the recommendations of the supervisor. Now we see a continuing spread of the oligarchy as the supervisor reports to and follows only the directions of the minister.
Clause 9.1(1)(d) gives room for contract raiding tools in finally stating what public interest overrides are, "the availability of financial resources for the management of the health care system and for the delivery of health care services." If cutting taxes, the availability will surely be strained beyond belief.
This and others, in section 13, deliver the final stroke contained also in all other places in Bill 26, that the minister and the cabinet are protected from any legal liability and without accountability from decisions as a result of their direction. Most people or institutions that act without regard to any legal liability are considered criminals or kings. This government would act above the people and set itself above the laws by not making itself liable for its own actions. Instead of the word "protected," the term should have been "irreproachably absolved," as we see protection built into section after section, act after act.
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Independent Health Facilities Act: It would appear again that an all-powerful minister can take the redefined "facility fee" and allow independent health facilities to charge over and above the prescribed regulation. The definition of an independent facility is expanded at the minister's pleasure, and the direction points to the end of the tendering process, moving away from the Canadian-owned, non-profit facilities towards the two-tiered US system.
Schedule G: The danger is that deregulated drug prices, which was not in the Common Sense Revolution, with patent protection provided in C-91 installed by the federal government, will escalate through the roof. Ontario is the only province without drug price controls. This bill gives the cabinet unfettered power to enact regulations setting user fees which are a marked difference from those announced by the minister.
The cause of escalating costs for the Ontario drug program is the high cost of drugs covered by patent protection, overmedication and overprescribing, not abuse by users of the system. We are told that deregulated drugs will go down in price. Boy, is that believable. I can see myself haggling with some pharmacist over some penicillin for my children like a can of tuna. The last group, or the group before, also reported that prices rose 4.5% last year.
Cabinet will also assume the powers to determine which drugs will be listed as well as their cost. This was done in the past by a drug formulary committee. As a local, we have had no increase in benefits since 1992, fighting off lifetime caps, yearly caps and reduction of benefits, only to have the government pull the rug out.
In the termination of the Ontario Pharmacists' Association bargaining rights and the government's power to overrule physicians on appropriate medication, the reading of these two additional gatherings of power is as draconian as it sounds, replacing sound professional advice and knowledge from the bodies that did deliver those services and placing them in the swollen hands of the cabinet and minister.
The release of confidential medical information is what this government found abhorrent when on the other side of the House and hooted and hollered and hounded the government of the day for months. In society today, we all must sign away the ability to check the validity of claims we make for illness or accident insurance. We must sign and allow full disclosure to justify our claims. We expect that the minimum of professionals will view the claim, if the information is needed only. To know that government officials could view anyone's file is a gross misuse of power.
Reversals of court decisions is a recurring theme, that this government must wipe out anything that is not in its image, that court officials must all be card-carrying NDP. In one of its decisions, the court ruled that the government failed to comply with the orders, that the government must faithfully discharge its obligations under the law. The government is being a sore loser and now seeks to nullify those decisions by legislation. Acting as a banana republic and showing contempt for the law is opening the province for business conglomerates, not for business.
Schedule H: Bill 26 removes all references to medically necessary services and gives broad powers to cabinet to decide those services to be insured and under what conditions or limitations by the future regs.
With the slant at the WCB that repetitive strain and lower-back injuries are not real or compensable in the future -- at least that is the contemplation -- what a saving to lend the same definition to non-workplace illness in determining if those services are medically or therapeutically necessary.
Throughout Bill 26, fees payable pops up, tools to raid or open up contracts appear and new powers are accumulated, the right to be untouchable and above the law for newly created laws and to repeal old laws and court decisions. While spending tens of thousand more on fees payable, and while being the new Ontario poor -- and growing poorer -- class, to have fewer and fewer benefits and pay more and more for services while telling us that you will save a few thousand over several years on tax rebates does not balance. Most Ontarians share the value of great caring for each other. The majority of Ontarians know you must pay for a just society. Most Ontarians want to be assured that the moneys they are taxed are paying for the services they want.
The common non-sense election document promised a fully funded health care system and, "Under this plan, there will no new user fees." The document said you looked at delisting, user fees and copayments, "but decided the most effective and fair method was to give the public and health professionals alike a true and full accounting of the costs of health care, and ask individuals to pay a fair share of those costs, based on income."
These hearings became a reality only after the rightful sit-in of the Legislature. You have hijacked due process. You would have jammed the bill through without one day of hearings. The amount of people who want to respond to your revolution would indicate that poor Alvin Curling should have held out for a month so that the people of Ontario could have been heard.
Don't drag out that tired rhetoric that this is what you promised in your campaign, as you did not promise this at all. Every day people who supported you are phoning us in fear and panic asking what to do, where to protest and where to go to be counted as opposed. In the spring, the sleeping giant of the uninformed electorate shall arise. Even doctors are practising the form of protest that only money can buy, this very day, in radio, TV and newspaper spots against Bill 26. Whether you call me a socialist or we call you fascist has little bearing. It will be you who have lost the respect and support of the people of Ontario, just as you have federally.
Mr John Coleman: John Coleman, president of CAW Local 1451, representing some 1,500 members at Budd Canada. Obviously, my presentation was written -- I'm not aware of the amendments that have gone through. However, in general, our so-called difference in philosophies, as I'm told by the government in power today -- ours obviously is we have some concerns. I want to reiterate basically what John said. I'm not covering as large an area as John, but I would like to certainly key in on some critical areas that we have a major concern with.
Bill 26 is systematically moving our health services towards a two-tier system. The thrust is towards user fees and extra-billing as means of reducing costs. There is nothing in this bill that would indicate that the government's intent is to improve services to its clients, the people of Ontario. Like everything else that this government has undertaken, the only priority is to cut spending, no matter what the consequences are to those who are less fortunate than some of us.
It becomes obvious as we familiarize ourselves with the contents of Bill 26 that one of the government's major objectives is to gradually move more of our medical services over to the private sector. The for-profit, private sector's natural goal is to maximize it's bottom line. Therefore, it is very likely that services will be sacrificed for profit.
I wish to share the experience of one of my parents, who live in England, which has adopted a two-tier health care system. Both of my parents pay for additional private health care. My mother fell and injured her knee. This was in the late afternoon. She was taken to the private hospital, expecting to receive the attention she had paid for through her additional premiums. When she arrived she was told that they had no doctors on duty, only nurses at that time. There were no doctors to make the necessary examination, diagnosis and administer the appropriate medical procedures. She would have to attend a public hospital that provided 24-hour doctor services. When she inquired as to why the private, for-profit facility did not have the appropriate medical staff available, she was told that if they were to maintain 24-hour medical staff, costs would increase significantly and they would have to substantially increase client fees. They added that from their experience, there was not a great enough need during the evening and early morning hours for doctors' services.
The lesson I believe is clear: When it comes to health care, private, for-profit facilities do not deliver the services that a public sector hospital would and should provide. As in the case with my mother, private sector health care facilities will cash in on the use of public sector hospitals to provide the services when they cannot because of their concern with the bottom line.
One only has to observe our neighbours across the border in the US and their health care system. Because they depend on private sector hospitals and they have to provide all of their services 24 hours a day, seven days a week, the cost of medical care is phenomenal. As more and more medical services are contracted out to the private sector, it will only be a matter of time before we end up with a two-tier health care system in Ontario, and eventually in Canada. That's sad.
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Schedule F of the omnibus bill: Health service restructuring amendments give enormous powers to the minister and cabinet. It removes the previous powers of the district health councils whereby the communities had at least some influence. The new hospitals restructuring commission could diminish this opportunity considerably. I do understand some of that's been changed. I still don't think it's far enough, but some of it has been changed.
Bill 26 takes away the independence of hospitals and the communities they are located in. The possibility that a hospital can be closed at the stroke of a pen -- and I believe this now has been changed -- by one individual is unbelievable.
Ms Lankin: They can still do it.
Mr Coleman: They can still? Oh, okay. They just give 30 days' notice. Is that right?
Ms Lankin: Yes.
Mr Coleman: Okay. It is all very well to scoff and say that this will not happen; the fact is that it could happen. And there are no safeguards to make sure that this does not happen. There are also no procedures to allow people within the communities affected to have an opportunity to prevent the closure. References are made to the minister's authority to decide funding based on a hospital's quality of management, quality care and treatment of patients and proper management of the health care system. It sounds reasonable until you come across this statement: that funding is also decided on "the availability of financial resources for the management" -- and the delivery -- "of the health care system." Once again the priority is costs, not the delivery and quality of services. The omnibus bill gives the minister the power to virtually dictate any aspect of the operation of a public hospital. When the only objective is to reduce costs, this kind of power is frightening.
I wish to close by emphasizing, as I did last time when we spoke in general on Bill 26, that the most shocking theme throughout Bill 26 is the extraordinary decision-making power put in the hands of a few, with no virtually no avenue to appeal or protest those decisions. In fact, in the majority of situations, those decision-makers are protected from any accountability through various amendments to those acts that have been addressed.
I thank you for this opportunity to give our opinion.
Mrs Janet Ecker (Durham West): Thank you for coming forward with your views. While there may be differences in philosophy between some of the organizations that have come before us and some of the members who are sitting at these tables, that's the purpose of the hearings, and I'd like to thank you for bringing forward your views.
You make the point that only the private sector would be paying attention to the bottom line. I would submit that the public sector hospitals have had to pay attention to the bottom line for many years now, and that's one of the reasons we've closed 9,000 beds in Ontario -- because of problems with affordability.
One of the things about the Independent Health Facilities Act is that it's about quality, and Mrs Caplan likes to talk about that. Her government brought it in and it's an excellent piece of legislation which promotes quality assurance in facilities. One of the difficulties is, if as part of a role change that a hospital goes through as part of the local planning process, which is something that this government supports, that a hospital were to wish to change its role into an ambulatory clinic of some kind and become an independent health facility, regulated and licensed under that, do you believe that we should force that hospital to go through a complete RFP?
Mr Cunningham: To tell you the truth, other than the comments that we made -- I mean, you've had a greater opportunity to examine and make those observations or draw your conclusions. I finished my presentation a scant 10 minutes before driving down here. So do I believe health care needs revision and/or observation as to its operation? Any institution needs that in a continuum in today's society. But the manner in which you do it can be destructive, and I believe that the manner you have set out can and will be destructive.
Mrs Ecker: Okay, but do you not appreciate the point that we need to have further quality provisions within the health care system, which is what the Independent Health Facilities Act and extending that to other facilities is all about? So that regardless of ownership, profit or non-profit -- and there are for-profit clinics now in the system -- those quality mechanisms remain the same. To me personally, anyway, that strikes me as being a positive thing for the system.
Mr Coleman: A positive thing for the system, but I still want to emphasize the fact that your government still only looks at the costs. I'm saying there is a line drawn where quality can be affected because of the costs.
Mrs Ecker: How do we continue to provide health care when we're using borrowed money to do it?
Mr Coleman: We can discuss that, but that's a different issue. We have other ways --
Ms Lankin: How do you give a tax cut?
Mrs Caplan: Yes, use your tax cut.
Mr Coleman: That's right, and we said that last time. I don't think you were here, Janet, but that was what we said. You want to use that tax cut. Use that tax cut and look at tax reform too, because there are other areas that you can be looking at where corporations have a far greater advantage than the average taxpayer.
Mr Bruce Crozier (Essex South): Thank you, gentlemen, for two comprehensive submissions. You represent labour, of course, as many labour groups have come before us, and we're still to hear from others. I must warn you, though, that according to some information that was circulated in Windsor on Monday and that we are told continues to be sent to interested Ontarians, you are a vested interest and this government looks upon you as a vested interest, notwithstanding the fact that you have the democratic right to represent your workers.
In the line of representing workers, I wanted to ask a question, again, that appears on the information that the government is circulating. These aren't my words, by the way; I don't know whose words they are. But it says, under the "Reality Check," that a myth is that "Bill 26 caps pay equity payouts to 100,000 of the lowest-paid women in this province." As they say, the reality is, "There is no cap," and that may be the case, but "Bill 26 only changes how pay equity is achieved." As you're well aware, one way that "how" is arrived at is that there's no longer the proxy system.
So I wonder, in your representation of labour -- and I certainly don't consider you a vested interest; you have a legitimate interest -- how that part of this bill affects the 100,000 lowest-paid women in this province and what you think of that.
Mr Cunningham: That was last week's topic, but we'll be happy to answer it.
Mr Crozier: Well, there are many low-paid women in the health care field.
Mr Cunningham: We also hope that vested interests stay within our pension and some of those pension vehicles that seem to be questioned within the public service remain for any schedule of payment. It's obvious that those things were set out to relieve the lowest members of the health care industry. That they are female is coincidental and that we should strive to raise those people above their sufferings is apparent. It goes with contract rating and the ever overused "tools." How do I possibly answer your question unless we've got about seven days or more?
Mr Crozier: It's interesting, and I agree with you that we should have more than seven days. You referred to that earlier, that there have been various descriptions of how our methods used to obtain what hearings we have were arrived at. In fact, as you probably well know, I was one of them who felt my rights were being restricted when I was locked up in a room when this bill was introduced.
Ms Lankin: There were a number of opposition members in that situation. I think that the concerns of how the bill is being handled continue as we see ourselves closing in on the end of public hearings. While I appreciate receiving the first few amendments today, every day we'll be seeing more amendments. I assume this weekend we'll be going through rafts of paper like this, trying to make sense of it, without an opportunity for informed debate.
I want to ask you a question that's very different than your presentation. I understand the points you make about the bill. Particularly, John, you were talking about a two-tier system and what comes out of that. But both of you represent workers that work in major industries, and I'm going to pick one. I'm going to talk about the auto industry, because you would have auto parts and be contributing to auto parts in both of your memberships.
My experience in dealing with auto manufacturers, the Big Three in Canada in particular, and all of the component parts companies that go into it, is that their major competitiveness right now is in the cost of their car and its comparativeness to the United States, and the biggest reason for that is the cost of health care. The cost per employee for health care benefits in the United States in a two-tier system where the employer starts to pick up, through negotiations with your colleague unions in the US, is $4,000 per annum, the average cost in large industry. The average cost in large industry here, in the Big Three let's say, for those Canadian employers is $700. That is a huge difference in the cost per car.
This government, while they may be ideologically interested in a two-tier system, should understand the competitiveness factor. Could you comment on that from the perspective of your employees and what you know about the huge increase in investment in the auto sector in Ontario and what that means to our economy?
Mr Coleman: I can tell you that probably some of those plants and those factories would not be in Ontario, despite the competitiveness, the rhetoric that you keep putting across, they wouldn't be here if it wasn't probably for the lower costs of medicare in Ontario and in Canada in general. Obviously Ontario is a good location for their assembly plants in the US. But everything we produce in Canada goes into the US.
Of course the Canadian dollar has got something to do with it too. There's no question of that. That's part of it. But also, as Frances was pointing out, the lower costs in medical care are definitely a factor.
I don't know where you would want to go or where we would be if you ended up with a similar system to the US, and if we start going with a two-tier system, eventually that's where we will end up. I just don't understand the ideology behind that, I really don't. I'd like someone to explain that to me. You may not have time today, but some day, somewhere maybe you, Elizabeth, can spend some time with us and explain to us that philosophy or that ideology.
The Chair: Thank you very much, gentlemen. We appreciate your appearance here today, your interest in our process. Have a good day.
Out of necessity, we're going to have to have a quick two-minute recess.
The committee recessed from 1033 to 1036.
KITCHENER-WATERLOO ASSOCIATION FOR COMMUNITY LIVING
The Chair: Okay, folks, we'll get back to business. Our next presenter is Jack Scott from the Kitchener-Waterloo Association for Community Living. I see that Jack is joined by Deborah Moskal. Welcome to our committee.
Mr Jack Scott: Ladies and gentlemen, I am Jack Scott. I am the community worker with the Kitchener-Waterloo Association for Community Living. I will be introducing our presentation and I'll be followed by Deborah Moskal.
This is a response to Bill 26 by the K-W Association for Community Living. The association is a voluntary, non-profit organization run by families and individuals who work on behalf of those with developmental challenges, for example, mental retardation. We do support, advocacy, education and community development work with individuals, families and the community at large.
Our vision of the association is that of a community that is aware, accepting, compassionate and tolerant so that people who are developmentally challenged and their families have access to opportunities, supports, rights and services which enable them to participate as fully integrated members of the community. Our mission statement says that people with developmental challenges are included equally in all aspects of community living according to their choice.
Behind our vision and our mission we have some very significant values. Our focus is on person-centred supports in the community. Because we believe citizenship is the right of every person, we strongly value the whole person. We recognize the need to support different options for different people. We also have an openness to diversity. Because we value listening to different points of view, we respect that people and their ideas are limitless.
Our stand in this presentation: We feel that the government's approach in this consultation process is contrary to our basic belief in community inclusion for people with developmental challenges.
We are having difficulty speaking to many of the specifics of different sections of Bill 26. First, we are going to address the broad impact of your approach to implementing these changes in the health field.
The government's consultation process is non-consultation. Its attempts to rush Bill 26 through so quickly destroys consultation. The government has given only three weeks for consultation with the whole province, and very little preparation time has been given. This is inadequate, and for our community of people with developmental challenges it is particularly significant.
Generally speaking, we find that the community at large is not very knowledgeable about the potentials and needs of people with developmental challenges. It is our community of individuals with developmental challenges and their families who are the most expert and knowledgeable. To make sure that the best policies and decisions are made, we must be consulted effectively. Effective consultation would allow more reasonable time to prepare and to respond. History has shown that where the wrong decisions have been made with our group, excessive waste and cost have been incurred.
The Association for Community Living supports the closing of the large institutions that have proliferated around our province and country over past decades to house people who were developmentally challenged, but the current program of deinstitutionalization is a significant example of this wrong decision-making process. Along with this closing of institutions has been the movement towards living in the community that has accelerated in the past decade.
Our association supports the direction of closing institutions, which have been an inadequate and costly way of life for any citizen, but we do not support the government's policy of eroding community supports at this time when they are most needed. Living in an inclusive community is a more appropriate way of life, more cost-effective, if it is done correctly and with the right supports.
Because of their significant handicaps, people with developmental challenges must have appropriate supports in order to be able to realize their potential. Otherwise they could be a drain on our economy and society instead of being able to be contributing members. But it is we in the community who best know how these supports must be built in and we must be consulted effectively, not in the government's rushed way.
Our families are overburdened. They have many extra stresses related to the severity of the handicaps of their family members. These stresses will not go away because the handicaps usually cannot be cured. They must be understood and included in the social and economic fabric of our society. But also our families are an average cross-section of our society. They are the same as you and I.
In our association of families and individuals there is the potential for the highest levels of leadership. Through our adversities we have developed significant strengths. We can help save our society in its present crisis, if the government will only listen to us more. Instead it is cutting services blindly, taking away our community voice, dividing us by forcing us to take action in so many different directions to save our services and making us powerless over the directions of our lives.
The government has told us that people with developmental challenges are one of their priorities, that no more cuts will be made in this sector. But we understand that significant cuts will be made to drug benefits through user fees. People with developmental challenges often rely on medications for their various medical conditions, such as seizures. The spinoff impact of this decision has not been looked into well enough.
Our Association for Community Living works most effectively in support of people who have developmental challenges when we follow a path of empowerment, people having control over the direction of their own lives. In the government's Bill 26, this power is now effectively taken away from all of us when our an ability to appeal any of your decisions, any of the government's decisions, is taken away through the government's "immunity from liability." This is written all through the bill. No one can question, sue, charge, appeal etc. We must trust that the government is "acting in the best interests," "in good faith." We ask you to trust us too, that we are acting in the best interests and in good faith.
The government has the power to make choices, to decide on what process to follow in its consultations. We ask the government to please make the right choices for our sakes and for theirs. The government can weaken our valid input, reduce our power over our lives, prevent this group of people who have developmental challenges from having equal citizenship; or the government can seek our input effectively, empower us so that we can gain strength through feeling more in control of our destiny and support our mission of equality in all aspects of community living. The choice belongs to the government.
We are asking the government to moderate its stand over privatization, centralization and broad, deep cuts in the social services. They are destroying our social fabric, which we do not want to lose. Share your concerns about our economic plight more with us. We have the same concerns. Keep us as equal partners in a positive process of community consultation. Do not isolate and polarize us be restricting communication. The social costs will backfire on the government as well as on all of us because its efforts to solve our plight will have less chance to succeed. Even as we are speaking now, there are frightening signs that we're slipping back into a recession. We must learn to work together more effectively to save this.
Go slower; listen more; be more compassionate; work together with us.
Ms Deborah Moskal: What I'm going to say is not written down. That's because I simply have not had the time to process what I was going to say as well as write it down at the same time.
We also had hoped that a self-advocate would be able to come and speak to you as well, but because of the time that we were given to organize this, we were unable to get one who was willing to give up their time at work or able to give up their time at work to come and speak with you.
I grew up as a middle-class person in Kitchener-Waterloo and I remained that way until 1983, when my son, at three weeks of age, had a massive stroke. At that time we went into the hospital here and then into the hospital in Toronto and we received excellent care. Within a month my son was diagnosed and received treatment. We came home and we continued to get treatment and we continued to get services so that he could develop to the point where he was well past what had been expected due to the damage from the stroke. The complete damage ended up being one entire hemisphere and the frontal lobe of the other hemisphere.
At that time he was expected to be profoundly retarded, blind, deaf, just to lie there and do absolutely nothing, but because of the care that we received at that time he was able to progress. Right now he's in grade 7. He's behind significantly, but he is counting and speaking and seeing and doing and he is living a full life.
He has many medical difficulties, and we do use the health care system a fair bit. We would probably be considered by the Mike Harris government as a drain on society. I always worked until 1990. I was employed by a private company which decided to do some restructuring and I was one of the people who was restructured out.
At that time I totally lost my mind. I didn't know what to do and, being a single mom, I needed to go on social assistance and that was probably the worst thing that happened to me in my entire life. But my son needed me and I had no job, so I went back to school and I have been upgrading my education in this time.
Unfortunately, the care of my son has taken a toll on myself and I have actually been, as I'm sitting here today for the last two days, in extreme pain due to a back condition that I have that's exacerbated by the fact that my son does not walk and that I need to carry him and transfer him. But I'm not complaining; what I am is afraid. I'm afraid that my son will not have choices or that we will not have choices for medical care for my son, that he will not be able to get the exemplary medical care that he has received in the past.
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I'm afraid that I will not be able to care for my son because of my medical problems, because I will not be able to get the medical care I will require as my condition progresses. Presently I'm seeing a chiropractor every two weeks. OHIP pays a certain amount of that, not the whole amount, and that is certainly a help to me and enables me to continue. If I were unable to do this, then I probably would be in a wheelchair myself and be unable to care for my son at home.
I don't see anything about that in the act, but I do see a power in the act that allows the government to do what it wants to almost anything that is in relation to the health care system. That is our fear: losing the ability to have choices, being dictated to, what we can do, what we can't do, having no power. Right now we are a population of people who have very little power. We are very reliant on services, we're very reliant on professionals, and many of those professionals are very intimidating to our families.
We feel that we have no choices, but if this act goes through as it is written we will have no choices. That will impress us more and that will put us into deeper poverty than we're already in. I would not have the opportunity to go back to school and work. As of April I will be finished my courses. I will be working and I will be able to support my son. But many people will not have that opportunity if their choices are taken away and if they're being oppressed more and they become depressed and they feel bad about themselves.
I have a fear about the medical records being opened up. I don't know what's going to happen to me if my medical records and my son's medical records are opened up. Raising a child with a disability that's as extensive as my son's is a very difficult thing. Sometimes we have feelings of anger; sometimes we have feelings of frustration. These things we're able to speak to our doctors or our social workers about without fear of other people judging us based on our feelings, and we're allowed to feel that way. I have no idea -- either I won't be able to speak to people and get any sort of support that I need or I will live in fear of my child being taken away from me because I'm having feelings that someone else might not feel are normal or acceptable because they're not living in my shoes and they're not doing the things that I'm doing and they're not understanding what we do as a population.
We have people, as Jack had mentioned, who are living on a shoestring. Adults with developmental disabilities who are either living in residence or are living in the community in supported independent living situations have very little money. Those people who are regulated under the Homes for Retarded Persons Act -- which is very archaic -- are living on a $118-a-month comfort allowance. That comfort allowance is used to buy sundries, clothes, vacations. Some of the people who have greater needs, such as using Depen, need to spend some of that money to purchase Depen, and now they're going to have to use $2 per prescription to buy their prescription. What will probably happen in some cases is that they will not do without prescriptions; the money will come out of agencies which are already strapped and that money will be taken out of somewhere else.
People who are living in supported independent living situations are living in rent geared to income but they are paying for transportation, they are paying for food, telephones, cable, all the necessities of life, and they have very little money based on the pension that they make. Many of them, as Jack indicated, are able to live in the community only because they take prescription drugs that allow them not to have to be in a health care facility. They may not choose to buy those drugs and they may not then be able to remain in the community, or they will have to not eat or do other such things that may not be acceptable to them. Their socialization, their recreation right now are limited.
If user fees are charged, then these people will not be able to access recreational -- and I'm speaking of the user fees that will probably be imposed by the municipalities when they're given the power to do so. That may not seem like a health issue, but it is, because people then become isolated and they then become depressed and they then are unable to live their lives to the fullest. If you look at health in its truest form, which would be whole-life experiences and what impacts on your health, then there are so many things that can impact that we can't even touch upon them.
I guess one of the biggest things is the fact that we just don't know the impact of this. We're afraid of losing any sort of power, any sort of say. Again, there has been no consultation. When my son was having some difficulty with his eye, when he developed an inflammatory condition in his eye, we went to a doctor at Sick Kids in Toronto and I started asking him questions. He told me that he had no answers and that I just needed to go to the library and look up the readings of a doctor from Cambridge, England, to learn about my son's condition. I was able at that time to switch doctors. Can you say that will be able to happen in the future? I don't think so.
I'm afraid that we won't have the health care, that we won't have the ability to live as truly equal and functioning citizens in this community. We will become more impoverished and, again, lose hope and be a drain on society. We will be undesirable. In the older days, not too long ago, people with developmental disabilities were put into institutions. Will those decisions be made by the government again, that our children will need to go into institutions?
We have a fear that this particular bill opens up the possibilities for anything and we want people to know that our children are fully functioning individuals. They have personalities, they are people and they do have needs, they do have wishes, they do have goals and they do have dreams. We want them to be able to live in a community, in a province, in a country that respects that, respects them as citizens and believes they can contribute and that they can be asked for their input and live a full life.
Mrs McLeod: Thank you very much for your joint presentation. Yesterday in London we heard a very passionate presentation from two self-advocacy groups for the disabled. They put a real face of fear and helplessness to this bill because nobody does know what it's going to do, and you've added to that in a very meaningful way.
There are a lot of aspects of your presentation that I'd like to ask you about a little bit more. Maybe I'll pick up on the issue of the changes to the drug benefit plan, the introduction of copayment. You've spoken to the $2 and the effect that can have on those who are on a disability allowance and they have $118-a-month comfort allowance with that. Could I ask whether or not all of the families or individuals that KWACL is working with are on a drug benefit plan or whether there would be families and individuals who pay their own cost of drugs?
Ms Moskal: I believe there would be families paying their own costs, but I believe that would be minimal.
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Ms Marilyn Churley (Riverdale): Thank you for your presentation. It helps all of us, I guess in particular the government members, who have the power to bring these new laws forward, to hear individuals like yourself who have struggled so hard and successfully to raise your own child and I think seeing real people struggling and making their lives better despite all the obstacles you face is very, very important.
This government has already, before this bill, made changes that have hurt the disabled in terms of redefinition of disabled. Some people in my area, Toronto for instance, their kids have lost their transportation; therefore people have had to quit their jobs or will have to quit their jobs because their kids no longer get the transportation and it would spiral downwards. Welfare cuts have in fact hurt some disabled. There are already problems there, so I understand the fear that there's more to come.
It's interesting that you brought up the drug problem because in fact that's what I was going to ask you about. In Toronto right now, we have people freezing to death already this winter. There are more families in motels who are homeless. It's shocking what's happening and we haven't heard from this government yet. We have to ask, where is Mike Harris and where is this government? We haven't heard a statement or comment or anything about what they're going to do. People are freezing in the streets. We're afraid there are going to be more deaths.
So my question is, coming back again, you stated your fears very, very well and the disabled community has those fears. The issue you mentioned about drugs is one of importance because I know already --
The Chair: Unfortunately, Mrs Churley, your two minutes are up.
Ms Churley: Thank you for raising that and I hope that the government will consider trying to support people with those problems.
Hon Elizabeth Witmer (Minister of Labour): I'd like to express my sincere appreciation to both of you. I know the hardship that you have tried to overcome to raise your son and I respect you for it. I guess I'm personally very concerned to hear you say that you face continued uncertainty. I know that this has been ongoing now for several years as governments have made changes. There's been the discharge of people from the institutions and we seem to have not been able to do a very good job of providing the support at the community level. I guess I'd like to ask you, how can we somehow give you some comfort and degree of certainty? What do we need to do that's going to help you?
Mrs Caplan: Scrap the bill.
Ms Moskal: I don't know if I can answer that just in a nutshell. First of all, Jack has said very clearly that you need to talk to us and find out what we want, and we recognize that you have spoken to us, not in terms of this bill but in terms of other situations. You have to change the bill so that it does not give the government altruistic power to make unilateral decisions without consulting the community and without considering -- well, without consulting the community and the people it impacts on.
You need to give some more support to people in the community. At this point in time it appears like decisions can be made with no recourse for appeal action and again that makes us feel very powerless. We need to feel that we know what's going on, first of all, and that it's something that's compatible with us.
The Chair: Thank you for your presentation, folks. We appreciate your interest in our process.
CHAMBER OF COMMERCE OF KITCHENER AND WATERLOO
The Chair: Our next presenter is the Kitchener-Waterloo chamber of commerce, represented by Ed Lemont, the chair, Ron Carther, the president-elect, and Glen Mathers, the chairman of the health committee.
Mr Ron Carther: Our third person may yet join us. We will proceed. Good morning. My name is Ron Carther. I am president-elect of the Chamber of Commerce of Kitchener and Waterloo. Ed Lemont, chairman of the federal-provincial affairs committee, will assist me in making this presentation.
Firstly, thank you for the opportunity to present the position of the Chamber of Commerce of Kitchener and Waterloo to this group. This presentation will deal only with the health aspects of this bill and is based on a high-level, preliminary review of the proposed amendments contained in the bill. It is the intent of the chamber's standing committee to continue its analysis of the various proposed amendments, critically evaluate proposed regulations and encourage an ongoing dialogue with the government of Ontario, this really in conjunction with the Ontario Chamber of Commerce.
As background, the Chamber of Commerce of Kitchener and Waterloo is the product of a merger of the Kitchener chamber and the Waterloo chamber in 1992, a move which recognized the need to cost-effectively service the business community for the two cities. Our mission is to serve business in Kitchener-Waterloo and be its voice in the betterment of the community.
Today, this chamber has a membership of approximately 1,200 businesses representing all sectors of the business community. Our membership includes small, medium, to the largest employers within our market who provide thousands of jobs in one of Ontario's most progressive and economically productive regions.
The chamber supports in principle the stated purpose of Bill 26, which is to reduce government spending, to promote economic prosperity through public sector restructuring and to create a climate which will attract investment, create jobs and encourage businesses to grow.
Deficits averaging nearly $10 billion annually over the last four years and an accumulated debt of approximately $90 billion are just not acceptable to our members, and therefore we urge the government to get its financial house in order.
In our opinion, the general initiatives proposed in Bill 26 are strategically correct. However, I would like to make several general observations before dealing with the specifics of the bill.
Tough economic decisions must pass the test of time, and from our perspective, there are two: democratic scrutiny, which you heard about, and debate, and in the government's own words, common sense.
Orders in council and centralization of regulatory powers must not become indiscriminate tools used to exploit special interests and to deny society at large the creativity inherent in public disclosure and the democratic process.
We strongly wish to reiterate that we do not feel we have a revenue problem in this province; ladies and gentlemen, we believe we have a spending problem. Spending must be limited at all levels of government.
Ontario businesses clearly require a health care system that meets the health care needs of our employees. Business also requires an effective and efficient health care system that will make Ontario an attractive place to invest and expand business activity. That creates jobs. Business is pleased that the Ontario and federal governments are both determined to effect major changes in the delivery and funding of health care, and the business community, as one of the many interested stakeholders, has much to contribute to this discussion.
Increasing demand for services and a limited supply of resources is a problem that is best addressed by cooperative, problem-solving initiatives by governments, health care providers themselves, businesses and the public. This must involve the critical evaluation of the type of public services that can be delivered and how best to reform and restructure the existing health care system to achieve effective and efficient health care delivery.
Public policymakers have a number of options, we think, any combination of which can help to achieve our stated goals. They are: increasing taxes, cutting back services, extending user fees or copayments, expanding the private sector in financing and delivery of health care, eliminating waste and duplication and introducing changes to current health provider reimbursement systems. To this point in time, Ontario governments have focused on the first two items; that is, increasing taxes and cutting services.
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The total cost for health care in Ontario is enormous, by anyone's calculation, representing about one third of the provincial budget. Since 1982, federal government changes to established programs financing have resulted in an anticipated revenue shortfall of $18 billion for Ontario.
It is the opinion of business that fraud exists in the system and we urge the government to take firm action to eliminate it. However, and this is something that's very important to us, the confidential relationship between a doctor and a patient is a trust which the courts recognize, and initiatives to detect fraudulent use of health care must not, in our opinion, violate that sacred trust.
The concept of user fees or copayments should be implemented judicially. A recent COMPAS survey of the public indicates that Canadians prefer some form of copayment/user fee over an increase in taxes or service cuts as a means to control or reduce utilization of services. However, the income thresholds that trigger copayments or user fees are, we think, too low and should be moved higher. From our perspective, $16,000 should perhaps be moved as high as $18,000 for a single person and from $24,000 to $26,000 for a family. While user fees do not exist for core health services in Canada they do exist for non-core services such as ambulance services, chronic care accommodations, assistive devices programs etc.
We would also recommend that the Ontario drug benefit program adopt a sample drug plan which is currently operating, and we understand operating satisfactorily, in the province of Quebec. The objective of this plan is to reduce waste. When an individual receives a new prescription, they receive only a few days' supply and the balance of the prescription is only supplied and paid for when the patient finds that the drug has no side-effects. This eliminates the buildup of unused prescription drugs in medicine cabinets.
Surveys continue to show that many users do not appreciate the cost of services provided to them. Therefore, we urge the government to implement a system whereby an annual service confirmation would be sent back to users, for their acknowledgement, as a means of informing them of the real cost of services consumed. Feedback will assist the public to make informed choices and provide user scrutiny of bills to OHIP.
I'd like to now turn the presentation over to Ed Lemont, who will carry on from here.
Mr Ed Lemont: Schedule F of Bill 26 deals with health services restructuring. The business community is in favour of these actions which permit market forces to operate and policies which encourage institutions to capture operating efficiencies.
Part I of schedule F is amendments to the Ministry of Health Act. To the extent that the proposed Health Services Restructuring Commission applies prudent economic principles in carrying out its mandate, we support these amendments.
Part II of schedule F is amendments to the Public Hospitals Act. Ontario hospitals have demonstrated a willingness to work with community agencies to consolidate and rationalize services within and among hospitals without government intervention. The benefits are reported to far outweigh any negative outcomes. For example, in this community we have the combination of the Kitchener-Waterloo Hospital and the Freeport Hospital into the Grand River Hospital Corporation.
I would just read some of the advantages from a document that was published by that organization, some of the benefits that they expect from the combination of the two facilities: 90% outpatient care delivery; more beds for acutely ill inpatients; more efficient in- and outpatient surgery; a more accessible emergency area; the delivery of more healthy babies; an adolescent outpatient unit; reducing operating costs; enhanced health promotion and disease prevention; and new standards in health care delivery.
Amendments which encourage this process to continue are supported by the chamber. However, due consideration must be given for community participation by taxpayers as partners. Decisions of the minister must be defensible on economic grounds and not based on political motivations.
Part III of schedule F, amendments to the Private Hospitals Act: The chamber of commerce agrees with these amendments, provided that the concept "in the public interest" has a strong economic connotation and that decisions are open to court review.
Part IV is amendments to the Independent Health Facilities Act. The chamber of commerce favours these amendments, with the exception of -- and I emphasize with the exception of -- those regarding the collection and disclosure of personal information. We are opposed to powers which break the confidential trust in the patient-doctor relationship. Also, we are not sure what extending immunity to the crown and the minister is intended to accomplish. It should not be intended to reduce or eliminate public accountability.
Schedule G, amendments to the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991: The chamber of commerce is in general agreement with the strategic intent of these amendments. In our general comments, we made several references to our support of the concept of copayments or user fees.
In conclusion, we support the broad strategic initiatives of Bill 26. However, we urge the government to continue to enhance the quality of democratic debate in the pursuit of achieving economic savings, improving operating efficiencies and restructuring of government.
Our members desire a health care system which meets the needs of our employees and through its effectiveness and efficiency attracts investments and business expansion in Ontario as well as improves the quality of life of residents of the province.
Governments, health care providers, business and the public are partners in our health care system and all must play a role in restructuring and reforming our system.
We previously identified six tools which can be used to achieve our health care goals, namely: increasing taxes, cutting back services, extending user fees or copayments, expanding the private sector in financing and delivery of health care, eliminating waste and duplication and, finally, introducing changes to current health provider reimbursement systems. The government should concentrate on all six of these tools, rather than the first two.
We urge the government to pursue policies to reduce fraudulent use of the health care system without destroying the confidential trust relationship between patients and doctors. Confidentiality of patient information must be protected at all costs. We support the concept of copayments and user fees. We recommend the adoption of a sample drug plan along the lines currently operating in the province of Quebec. We encourage the implementation of policies which encourage consolidation and rationalization of services outlined in schedule F.
The Ontario Chamber of Commerce, of which we are an active member, has developed a complete discussion paper on the subject of health care reform, and a copy will be forwarded for your reference. That's this study here.
We appreciate the opportunity for input regarding health care legislative amendments, and we look forward to the continuing participation of the chamber of commerce in the process of restructuring and reform.
Mr Carther: Glen Mathers has joined us. Glen is a member of our federal and provincial affairs committee and has also been our liaison person with the Ontario chamber's working committee on health issues.
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Ms Lankin: I truly appreciate your presentation and your suggestions of certain areas where we should be cautious. I want to make a comment, and I hope you will accept this in the spirit in which it's intended. You say, "public policymakers have a number of options, any combination of which can...achieve our stated goals" and you list the six areas. You say government has only concentrated on taxes and cutting services, those two, with respect to health care. I take exception to that and point out to you -- you say we haven't done anything in introducing changes to current health care provider reimbursement system. I have to talk about billing thresholds and caps on overall OHIP fees for doctors, alternative payment plans we've negotiated with Queen's and the whole academic staff in teaching hospitals. Those areas are being pursued, and I think it's worthwhile to mention that they should continue to be pursued.
Eliminating waste and duplication: I would think that in the health care sector, many hospitals would be duly insulted by your comments. We have been working a lot over the last number of years to rationalize services. You've pointed out in your own area some of what's gone on to eliminate waste and duplication, and government has been part of working with and facilitating that. There's much more to be done, and I acknowledge that, but I think you should acknowledge that that has been identified and is being worked on.
Expanding the private sector in financing and delivery of health care: This one is interesting. Certainly I would say not in the delivery of health care and I would have some questions about that, but in terms of involvement in financing and the private business of health care products and applications, tremendous work has been done with a health economic development unit that's been established. I look at projects like LARG*net in London where many private sector companies are being brought together with hospitals to develop ATM technology for digital compression of imaging, for long-distance consulting. That's going to improve delivery of health care services and it's going to produce a product which is eminently marketable around the world and consortia of the private and public sectors working together, which will bring revenue back into the public sector as well as they use their consulting expertise on these projects.
I point that out to you, and I think it's important that those things be acknowledged by the chambers as well.
I would like to ask a question about user fees in the drug section. You have said that you think there should be some limits, the $16,000 or the $18,000, and that perhaps we shouldn't have the $2 user fee below that. I'm inferring that and I'd like a comment on that. You also say it could help to control or reduce utilization. All the studies have suggested that with respect to seniors and drugs, the user fee doesn't do that. Do you just see it as a useful means for revenue, or if it doesn't control utilization, should we not pursue that and look at other measures?
Mr Glen Mathers: First, I think one thing was overlooked. To go back to your first comments, we acknowledge all those things; we're just trying to stress in this paper that there needs to be more looking at all the areas where there are duplications of services. Strides have been made, but a lot more needs to be done.
Ms Lankin: I tried not to be too personally defensive on it.
Mr Mathers: We mentioned the issue in Quebec, for example, where they have the sample drug program. Put that in perspective. I'm sure everyone of us in this room at some time has got a prescription, you take it home and it doesn't work for you, or it disagrees with you. You have 100 tablets in the bottle and you've taken four. What they've done in Quebec is that you get a sample, you get 10 tablets. The pharmacist charges his fee, does all the work he should do for that fee in talking to the patient to make sure the drug is being used properly. And then, only if it is good for the patient, do they go back and pay for the balance -- but not a second dispensing fee, just for the balance of the medication. There is a tremendous cost saving in that.
Did the pharmacists talk to you about this? I know they've been working on this issue for a while.
Ms Lankin: Yes, trial --
The Chair: Thank you, Ms Lankin.
Mr Wettlaufer: Thank you very much for your presentation, and for coming and spending your time with us today. I especially appreciate that you made some recommendations rather than just complaining about the bill, because it's the recommendations which are so very important to us.
Interjection.
Mr Wettlaufer: You've had your time already.
In terms of the drugs themselves, do you believe that someone who is paying a portion of the prescription cost would be more willing to go out and shop around from pharmacy to pharmacy, given what we've already heard this morning, that the cost of a prescription can vary anywhere from $1.99 to $12.50, depending on which store they get their prescription at? Would you support the view that the patient might be willing to shop around more?
Mr Mathers: I think the patient may be willing to shop around a little more, and sometimes when it comes to getting a prescription they're maybe not completely out of yet, because a lot of people stock up before they go away on a holiday.
Mr Carther: I think we've all seen examples of that.
Mr Wettlaufer: So you agree with the view that the limitation should be three months as opposed to six months.
Mr Mathers: Yes.
Mr Gerry Martiniuk (Cambridge): You started off your presentation by saying that we have a spending problem, not a revenue problem, yet one of the six tools you've enumerated is higher taxes. I don't understand that consistency.
Mr Carther: What we've tried to focus on is that the first two items are typically, from our perspective, those that governments have spent the majority of their time on, and again we acknowledge the comment that perhaps efforts are starting to be made in the other four. But clearly, past governments have focused the majority of their time and energy on either increasing taxes -- the flip side is to cut services. That's merely to reinforce that.
Mr Monte Kwinter (Wilson Heights): Thank you very much for your presentation. In your third item you talked about the principles of the bill, which is to reduce government spending, to promote economic prosperity through public sector restructuring, and to create a climate which will attract investment, create jobs and encourage businesses to grow. I don't think you'll find a single person in Ontario who would object to that. I think the problem we have is that the principles outlined in what the bill is supposed to do and what the bill does are two different things. That is the problem.
I'd also like to ask a rhetorical question you can answer later. Do you consider yourself a vested interest? There seems to be a mood by the government to put out publications talking about vested interests, but only selective ones, ones it feels have a bone to pick with the government. They say, "Ten great things about Bill 26 that you won't hear from the vested interests." I would be curious to know whether you consider yourself a vested interest.
Mr Carther: Let me say that I think every citizen in this province has a vested interest in the health care system.
Mr Kwinter: You say, "Deficits averaging nearly $10 billion annually over the last four years and an accumulated debt of more than $90 billion are not acceptable to our members." I'm sure you understand that if you take a look at the government's own projections -- not opponents', not critics', but its own projections -- when it finishes its mandate it will have taken the debt of the province to about $120 billion and it will not have balanced the budget.
Through this whole exercise, they will not have left the province in any greater shape fiscally but will have imposed a draconian rule on the quality of life. You are businessmen, and I'm a businessman as well. That quality of life has been the most attractive environmental -- I'm talking about the broad environmental -- climate that attracts business, attracts activity to Ontario. When we go out and compete for Ford, which looks at putting it either in St Louis, Missouri, or in Oakville, they take a look at that broad quality of life to get their executives to come up here and to get their investment here.
There has to be that balance. To pick up on my colleague's comment that we don't have a revenue problem but a spending problem, you can't divorce them; you can't have one in isolation from the other. You've got to work on both of them. You've got to increase your revenues because your revenues will allow you to provide the kind of infrastructure and services that make us attractive as a place to live and as a place to invest. If all you're working on is the spending, as I think we're doing now -- we've gotten rid of the fat, and that's been done by successive governments. We're now cutting into the muscle. When you start doing that, you provide an environment that does not make us competitive, does not do the kind of things you want to do. Do you have any comments on that?
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Mr Lemont: I would suggest that when you reach a level of taxation that makes you uncompetitive -- and if we're not at that level now, we're very, very close to it -- that's not an alternative, to increase taxes. You have to look at your expenditures. And to go back to your comment, if the current government finishes its term increasing the debt up to $120 billion and not getting the annual deficit any closer to being balanced --
Mr Kwinter: They're going to get closer, but they're not going to --
The Chair: Thank you, gentlemen. We appreciate your presentation with us this morning.
NORFOLK GENERAL HOSPITAL
The Chair: The next presenter is Ruth Pennington, the chair of the board of the Norfolk General Hospital. She's joined by Harold Shantz, the executive director. Good morning and welcome to our committee.
Mrs Ruth Pennington: Thank you for the opportunity to speak to this committee today. We too appreciate the actions taken by all parties which have resulted in these hearings where the public and stakeholders may be heard. I realize there have been announcements made this morning about which we knew nothing, so of course there may be parts of this presentation that are redundant. However, I think it is important that you do realize that there are many of us who do not live in urban areas or even in the north, where they have special problems, and that we do have concerns of our own.
My name is Ruth Pennington and I'm the chair of the board of directors of Norfolk General Hospital. As has been mentioned, I have my executive director here, Mr Harold Shantz. We are here as representatives of a rural community hospital located in the town of Simcoe to comment on some of the issues that will affect the operation of hospitals such as ours if Bill 26 is implemented in its present form. I should add at this point that our hospital is a member of region 4 and we fully endorse the comprehensive presentation made by Mr Collins this morning.
Bill 26 sets up the Health Services Restructuring Commission to deal with restructuring of all hospitals across the province as a direct result of decreased funding to these institutions. While we agree that the provincial financial situation dictates a change in the manner in which hospitals operate, we feel that reference to the way in which these cuts are made is essential. Situations vary across the province, and we do not believe across-the-board cuts are the answer. We would also emphasize that the government's commitment to reinvest savings taken from hospital budgets into the larger health care sector is an important part of this discussion.
We are a rural community hospital serving a population of 50,000 drawn from a large geographical area in the western portion of Haldimand-Norfolk on the north shore of Lake Erie.
Rural hospitals are no different from their urban counterparts in that we have been making the necessary changes to operate more efficiently during the past several years. In our own case, we have lowered hospital patient days by 30% and reduced our number of acute care beds from 136 to 94. We presently operate below 600 hospital days per 1,000 population and do not feel that hospital services can adequately be provided to the residents of Haldimand-Norfolk at much less than this. Like most others, we have eliminated 4% from our hospital budget due to the social contract and at the same time have faced increased costs for government-mandated programs such as pay equity and employee benefits.
Rural hospitals do not usually have another hospital in close proximity, making shared services more difficult than in urban areas. In our own area, we share laboratory and speech pathology services with others. Norfolk General also provides detoxification and rehabilitation and placement coordination services to the entire region of Haldimand-Norfolk. The 80-bed Norfolk Hospital Nursing Home is also administered by our hospital.
In moving to other methods of funding, governments must take into account the utilization patterns of hospitals to ensure that adequate hospital services are provided in rural areas served by single hospitals. Across-the-board reductions to our budget would be devastating and cut deeply into our services to patients.
The sheer magnitude of the announced reductions will result in some rural hospital closings. There is a need to restructure the hospital system even in rural Ontario, and Norfolk General Hospital does support restructuring and has so indicated to the Haldimand-Norfolk District Health Council. What we do feel very strongly about is that hospitals and their communities have a right to be heard in the process. We also believe that any dollars saved in rural areas should be reinvested in health services in those areas. Rural areas tend to be underserviced to begin with, so we do not want all resources to be transferred to urban areas. In fact, we believe each community's restructuring exercise should fund itself.
For our presentation, we have chosen to comment from the perspective of a rural hospital. However, we are a member of the Ontario Hospital Association. As such, we had the opportunity to provide input into the presentation they made to this committee. We agree with their recommendations and support their proposed amendments, particularly that the powers in section 6 of the Public Hospitals Act be time-limited to four years in order to preserve the voluntary governance of our hospitals.
We also have a brief comment on the government's proposed amendment to the Hospital Labour Disputes Arbitration Act. We wonder whether the ability-to-pay criteria will be effective. Common sense would dictate that allowing arbitrators to award increases while we are downsizing and reducing our staff is not appropriate. We support the Ontario Hospital Association's proposed amendments to the Hospital Labour Disputes Arbitration Act.
In conclusion, we support the restructuring of our hospitals, provided that the communities and hospitals involved have input into decisions, whether to our district health council or other planning body. We support the establishment of a Health Services Restructuring Commission, subject to recommendations 7 and 8. We are against across-the-board cuts to each hospital's budget and we feel very strongly that money taken from hospital budgets should be reinvested in health services in their communities.
We take our responsibility to oversee the provision of health service through the governance of Norfolk General Hospital very seriously. Our concerns are real, and we appreciate your consideration of the matters presented in our brief. We did include sections of the Ontario Hospital Association's brief just for reference, and we have added our three main recommendations at the end of theirs.
This concludes my presentation.
Mrs Ecker: Thank you very much for coming to share and bring forward some concerns and comments and amendments to Bill 26. I think the hospital community has been very well represented through these hearings, and what we're starting to see in many different kinds of groups are very common themes, common concerns, and in some cases even common suggestions, which I think, as indicated by the amendments today and the further amendments, have been very, very helpful.
I have some resonance, if you will, since I was born in Simcoe, but I quite appreciate your comment about across-the-board cuts to hospitals and the impact that has. I know that the ministry and the Ontario Hospital Association, under the joint policy and planning committee, are working very hard to develop and finish the funding formula which will hopefully be able to provide appropriate guidance for allocating the moneys according to appropriate needs.
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I come from a growth region. We've heard at the hearings that every area has unique needs, and in our area they make the argument about needing more money and reinvesting because of the growth needs.
I guess the question I have is that in order to restructure within the health care envelope, which is what we've talked about doing, this means that somehow some areas are going to have to give up, while other areas are going to get more. That may come in funding of hospitals; that may come in funding to specific programs in different regions and areas.
One of the concerns the minister has had is that while we've had the local restructuring plans under way that the previous government got under way, and they've been working very well in some areas and had problems in other areas, in order to have a provincial picture we somehow need to try and stitch together all those local plans, and we have to somehow have a mechanism to take the local input, but at the same time somebody has to make a decision about how the allocations are going to be made. Because you're right: We can't do it across the board. So some are going to have give and some are going to get.
Is it possible to do that kind of restructuring, that kind of allocation process, without some kind of body or commission? That was the intent of having the restructuring commission. With the appropriate amendments and suggestions that have been put forward, any comments on how it is possible to do that stitching together, if you will, to put together the quilt in Ontario for health care?
Mrs Pennington: I'm not really sure how the commission is intended to work, but I think the point we're really trying to make is that before anyone comes in to make changes in an area, the community, the hospital boards, have a chance to provide input through a local planning body. I presume that what the local planning body comes up with would be looked at by the commission -- I don't know this -- and that perhaps they would have a larger view of the province and would see how this fits in. If it doesn't meet with what they feel it should be, then we would hope they would come back and say, "This is how it doesn't fit in," and maybe we would still have input into how it would be done.
Mrs Ecker: One of the things that I think is important to keep clear is that the district health councils, as we've stated before, which I think are very much part of the process, remain very much a part of the process. In the dealings and what has happened here with your district health council, have you been comfortable with the way the DHC here has been proceeding with the work they're doing?
Mrs Pennington: I believe we're changing; tactics are being changed. There was a restructuring committee, which did not do a lot as far as the hospitals. The hospitals themselves were doing their own restructuring, but things have changed. They have assured us that they're very interested in taking a lead role. We've indicated that we're very interested in being a big part of it, and there is a meeting called already. So hopefully at least that part of it will be working.
Mrs Ecker: Yes, because I know in some areas that's been a bit of a tension between hospitals and district health councils in terms of who should lead the reform. So you think that's been resolved.
Mrs Pennington: We're hoping that they would make a good planning body for us.
Mrs Ecker: One of the suggestions that's been made is that we take the restructuring commission's terms of reference and broaden it from just hospital restructuring to very clearly articulate that there is a community side to this process as well. We've certainly heard from many community groups about the need to continue to try and shift money from the hospital sector into the community care sector. Any comments on that?
Mrs Pennington: Yes, I think that would be really important, because I think one of the points we tried to make is that we realize that savings have to be made, but we are also underfunded in some areas of the health sector; in our own area, for example, mental health and probably home care.
We feel that the purpose of removing the money from hospitals is to go into the broader sector, but we don't really want to be losing all that money because we have needs ourselves in our own community. If the commission was able to look at a larger picture, I don't see why that wouldn't work.
Mrs Caplan: Thank you very much for an excellent presentation. I want to point out to you that of your 13 recommendations, three have been addressed in the amendments that were tabled today, and I want to go over some of the ones that have not been addressed. You made some excellent and very thoughtful recommendations, and I hope the government will listen to what you've made.
Even though the Ontario Hospital Association and many hospitals that have presented before the committee have recommended that the minister not be able to delegate his powers, those provisions remain. I think there's a general consensus, and I agree, that if you're going to have a hospital restructuring commission, it has to have the ability to implement plans. But what this bill does is give them the power to make the decisions, and I think -- would you agree? -- that's what people fear. Also, the view is that given the accountability, the minister should be accountable for making those decisions.
Mrs Pennington: Absolutely. We feel that he should not delegate his powers.
Mrs Caplan: I want to go on record as saying I will not support a commission if it has those kinds of powers. I would support it if it was advisory to the minister and given the authority to implement plans that the minister had approved. I will go on record today and say that, because I was disturbed that it was not included in the package of amendments tabled this morning.
Secondly, they have addressed the suggestion of notice of 14 days and one month. You can tell us if you think that is reasonable or not, but they have addressed it today. You have time to think about that.
The question I have is your concern about the process. This bill does not guarantee any process. There's no role identified for the district health council, and while we've had some assurance from the government that the DHC's role will not change -- because it's in other pieces of legislation -- as an advisory planning body to the minister, I have heard Jim Wilson say they intend to change the DHC's role back to what it was originally intended 20 years ago when a Conservative government brought it in.
Would you feel more comfortable if there was a section in this legislation that guaranteed a role -- I'm not talking about power, I'm talking about a role -- for the district health councils and a requirement that, before a minister can approve any restructuring plan, there had to have been a community process and public hearings and so forth?
Mrs Pennington: I don't think we'd have any problem with that. As we have stated, we're very concerned that we do have a local planning body that has input, and the district health council should be able to perform that role. We certainly wish them to have a role.
Mrs Caplan: You recommended that the power to appoint hospital supervisors be time-limited, and that was not included in the amendments. Again, I think that while there is general agreement that if a hospital board should resign en masse, the minister must have the authority to appoint a supervisor, that's a very exceptional circumstance.
Can you think of any other circumstance where a minister would want to wipe out a voluntary board of governance by appointing a supervisor, given the fact that he already has the power if he's concerned about the fiscal behaviour of that board or jeopardizing patient care because of the decisions of that board? I'd ask you to comment on the effect on voluntary governance of that provision if it remains as it is.
Mrs Pennington: I think it could have an effect. There could be people who would feel that perhaps their contribution would be of no use in that case. I don't know enough about the supervisor's position to know exactly how that would fall out but, to me, that would be a very unusual circumstance.
Mrs Caplan: There are a couple of recommendations that you have here about issues that are not actually included in the bill. There are no guarantees or commitments from the government that they will not reduce space budgets arbitrarily or across the board, and I understand your concern.
This is not a partisan comment, but I was very disappointed that the previous government did not proceed with the reallocation funding formula. I think it is the way to go. That was worked out with the Ontario Hospital Association joint committee, and I think it will make it more difficult now to implement that kind of formula without having had the opportunity to have had it done last year as well.
I understand your concern and I have always supported reallocation funding formulas. As you know, the equity funding formula was the first step in that direction, but that's not included in this bill and there's no guarantee that that will be done. Neither is there a guarantee, and in fact they've done the contrary -- dollars that are saved will not in total, or in any specific portion, be guaranteed to be invested in a local community. Jim Wilson has made that absolutely clear so I doubt that they'll accept that recommendation on reinvestment in your local community.
Thank you for an excellent presentation.
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Mrs Pennington: I might just comment that we realize several issues we addressed were not particularly in the bill, but we wanted people to know that it's the way in which this is done and that we have some concerns in that area.
Mrs Caplan: It would have helped if you had health legislation as opposed to a fiscal policy before you, I agree.
The Chair: Thank you, Mrs Caplan. Did you want any time, Ms Lankin?
Ms Lankin: Maybe just a minute or two. Actually, I don't think I will take all my time. I think Mrs Caplan covered a number of the areas that I was interested in.
I do want to explore one issue just a bit further, though, and that's about the appointment of supervisors. I recognize that you indicated that you're not too familiar with how that section of the act works or when it has been used, and that's because it has rarely, rarely been used. The existing section gives the minister the ability to appoint a supervisor to go into a hospital --
Mrs Caplan: After inspection.
Ms Lankin: -- I know that, Mrs Caplan. I'll get there -- when there are concerns about primarily quality and level of patient care, something of that nature that's wrong. There's a process that's set out and there's an investigator who's appointed first.
Mrs Pennington: Yes, I understand that.
Ms Lankin: There's a report that's prepared, and the hospital gets a chance to respond to the report and then a decision is taken about appointing a supervisor. The supervisor's role is clear in terms of working with the board, and any major decisions of the board have to be checked with the supervisor. That's true -- there are a lot of checks and balances, I guess is the best way to say it -- but even that has only been used a couple of times in the history of the province. When I asked the Minister of Health, because he said this would be extraordinary and there was a rarely used existing section, "Why do you need more powers if you don't use the existing section often?" he didn't really answer and couldn't really answer that question.
Here's my concern about what's in the new bill, which is that the minister can appoint a supervisor any time he wants. The amendments we saw today simply say he has to give you 14 days' notice now, so at least you know it's coming. But there's no process for you to be able to respond or to get a response back from the minister. I would think the government would say that's assumed, but usually that ability to respond in writing and to get a response or a hearing with the minister, whether it would be set out, that's not set out in the amendment.
The supervisor can still take over the day-to-day operation of the hospital, and those words are right in the legislation. The hospital board has no ability to make independent decisions at all. It used to be they could make decisions they'd have to check with. Now that's stripped, so the voluntary board is stripped. The reasons that you can send someone in are expanded to include the fiscal situation and resources available. I'm assuming that the time the government thinks they might need this is if they're trying to close a hospital and for some reason the board is just absolutely digging in and refusing to cooperate and be closed. It's the only thing I can come up with in my mind.
It seems to me if that's the reason, it would be useful to set out the criteria in the legislation of when the minister is able to use this extraordinary power and that for any other reason you have to go through the normal process where there is an investigator's report and an opportunity for the hospital to respond. It's a quality issue. There's a process that's served as well in this province. That's one suggestion I would make, and I'm interested if you would agree with that.
Secondly, I really believe that if they are taking this extraordinary power with respect to supervisors and taking away the voluntary governance of a hospital in extraordinary circumstances related to closures, that also should be time-limited to the four years, the same as other aspects of the bill which they've agreed to with respect to closures and mergers. Could you comment on those two recommendations for amendments?
Mr Harold Shantz: I believe that the necessary power is there already in the act and what has been added is just to extend that power. I would agree that the only time you'd use that is in a closure situation by the way it's set up, because the additional items that have been added there have to do with the proper management of the system and financial resources.
Ms Lankin: So would you be supportive of those kinds of amendments? We didn't see that today from the government, but I will continue to push the government in that direction.
Mr Shantz: Yes.
Ms Lankin: Okay. Mr Chair, I'm going to give up the rest of my time. I appreciate the presentation, it was very thorough, and I understand the issues. The two out of the 13 that they've agreed to is great; the other 11 we'll continue to push for.
The Chair: Thank you for your presentation this morning. We appreciate it.
KITCHENER-WATERLOO ACADEMY OF MEDICINE
The Chair: We're entertaining an extra group at lunch today and it is the Kitchener-Waterloo Academy of Medicine, represented by Dr Pierre Kugler, the president. Good afternoon, doctor. Welcome to our committee.
Dr Pierre Kugler: I'd first like to thank the members of this committee, and especially Mr Carroll, for accommodating the academy of medicine today over their lunch period. I'm sure after the morning people are very hungry and the minds are very numbed, but thank you for giving me the opportunity to speak.
My name is Dr Pierre Kugler. I am the president of the Kitchener-Waterloo Academy of Medicine, representing the physicians in this community. I shall be joined in a moment by Dr John Wright, a family physician from Owen Sound, who is a member of the board of the OMA.
The Chair: Just for your information, doctor, to give credit to all the parties, they all agreed to your presence here at lunchtime, so I can't take credit for it.
Dr Kugler: Then I'll thank all the parties present.
I could walk in and start to deal with specifics on Bill 26 right off the bat; however, I thought it might be best if we could start very quickly with something of a history lesson. I'd like to go back, if I may, to the spring of 1986. The Liberals had just been elected to power in a minority government and, largely at the urging of the NDP, then-Premier David Peterson decided that the health care system was not working.
Mr Peterson told the public that the way to make the health care system work better would be to strip physicians of their professional autonomy, deny them the right enjoyed by every other profession in the province of Ontario, that is, the right to decide what the value of their services they provide are worth, and ban what they called extra billing or what the profession called balanced billing.
Again at the urging of the NDP they painted a picture for the public of a society in which only the wealthy could afford health care and no one else could. This in fact was not the case but they did do a very good job of creating a climate of fear and mistrust among the public and Bill 94 subsequently became law.
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Five years later, in 1991, the Liberals were no longer in power. Bob Rae had been swept to a majority government in 1990. The problems facing the health care system, such as shortages of primary care in remote regions of the province, were worse than they were before. Many of our best specialists were now working for Uncle Sam instead of Big Brother Bob, and Mr Rae then told the people of Ontario that the way to solve these problems and improve the delivery of health care in the province of Ontario was to set individual caps on what any physician in any given year could earn. The public, still dealing with the fear and mistrust generated in 1986, embraced this concept, as did the media, and income caps became law.
By 1993, the problems of waiting lists and physician shortages in remote areas, were worse than they were two years earlier, and the province was dealing with ballooning debt and deficit as well, for which Mr Rae again said the doctors were to blame. He told the people of Ontario that the way to improve the health care system was now to set a global cap on how many services would be paid for by the province of Ontario in any given year, with any excesses being recovered from the profession in subsequent years. The people of Ontario seemed quite willing to forgive any failings of earlier legislation and again embraced this concept wholeheartedly and the social contract became law.
Now in 1995, this region, the Kitchener-Waterloo region, for the first time in its history is dealing with a shortage of primary care physicians; that is to say, family physicians. The question is, how did this happen? There are several reasons for this.
In the past year, four family physicians have relocated to the United States. That's four more than have relocated in any given year prior to that for the past decade. There has been normal loss of physicians through attrition; that is, retirement and death.
The thing that distinguishes 1995 from previous years, ladies and gentlemen, is that young graduate physicians no longer seem to be coming to this region to establish a practice, and many other regions are having that same difficulty. The primary reason for this, it is believed, is that a graduating physician, who already has incurred from $25,000 to 50,000 of student loan debt, does not wish to supplement that debt by another $50,000, the approximate cost of establishing a practice in this province, only to face a very uncertain future, which is what physicians have faced since 1993 under the social contract. So we continue to deal with a primary care shortage.
Now, in 1996, we have before us Bill 26. I am forced to ask the Conservative members of this committee and of caucus, members who campaigned on the platform of less government and less regulation, if they have learned much of anything from the failings of their predecessors.
The problems, if there are problems facing the health care system, of shortages of service, waiting lists, shortages in underserviced areas, have failed to be legislated out of existence by previous governments. I wonder about the rationale the government has in thinking that this legislation can succeed where others have failed. I feel the solution to the problem, again as was stated during the campaign by the Conservatives, is not more regulation but less intrusion.
Dr Walter Rosser is the chair of the Department of Family Practice at the University of Toronto. His polls of family medicine residents show that up to 80% of the graduating class is seriously contemplating relocation to the United States, again because of the uncertainty we as physicians face in this region. I am uncertain how this legislation will be able to reverse that trend.
Surveys by the Canadian Medical Association show that Canadian doctors practising in both Canada and the United States have left largely because of the uncertainty they face in this country and this province at this time. Between 1988 and 1993, the number of physicians leaving for the United States increased by a total of 245 per cent, roughly 30% per year. Health Canada data for 1994 indicate that the number of Ontario physicians leaving the country compared to those returning from abroad is a ratio of about 4 to 1. In the high malpractice premium specialties such as obstetrics, orthopaedics and anaesthesia, this ratio could be as high as 8 to 1. This could be exacerbated by the recent decision to discontinue CMPA rebates to some of these professions.
Basically, we have a climate now in Ontario that is not attracting physicians to regions like Kitchener but is in fact driving them away. The costs of establishing practices are prohibitive, the assurances of reasonable income that would allow an individual to meet the expenses of day-to-day practice are not there and physicians increasingly feel that they are being told they're a part of the problem instead of being treated as part of the solution.
The ministers of Health in both this administration and previous administrations have stated that doctors are part of the reason why the province is facing a financial crisis. I am forced to ask, is this true? Many facts are in dispute. According to our statistics, since 1990-91, utilization of the health care system per capita has risen at an annual rate of 1.1%. This is not the uncontrolled growth that the ministers have referred to.
We also know that we have an aging population. Those residents of Ontario over the age of 65 have increased by upwards to 60% between 1981 and 1996. The cost of providing medical services to a senior are significantly higher than for younger patients. In 1993-94, the number of medical services provided per patient to individuals in the 70-79 age group was 31.1, while it was only 17 services per patient in the 30-39 age group. The cost per patient in the 70-79 age group was close to $762; the cost per patient of the 30-39 age group is about $390. Yet the prevailing sentiment we get from all three parties, from the media and from the public is that we are the ones responsible for this increase in cost.
The 160 million services provided by all physicians translate to less than 15 services per Ontario resident per year, or approximately 1.25 services per person per month. The Ministry of Health has talked about a 10% rise in services per patient since 1987. This translates to approximately a 1.4% increase per year. This does not seem to me to be putting the financial strain on the province of Ontario that we are told.
In summary, I just think that there are very few in this province who would say that the delivery of health care in Ontario is better now than it was in 1986 when this story began. What we have seen in the last decade are exercises in trying to improve the government's bottom line, but I am not sure if they have been able to translate into improved delivery of care.
Bill 26 is a truly remarkable piece of legislation, amending 44 acts, creating three new ones and repealing two others, and allowing for sweeping and unprecedented powers to a handful of cabinet ministers. We can debate, and have debated over the last few weeks, the merits and the pros and cons of this legislation ad nauseam. As a physician, however, and as a representative of the physicians in this community, I can only address those issues relevant to health care and specifically to physicians. I fear that the powers being given under this bill to the ministers to, in theory anyway, tell physicians where and how to practise medicine, regulate how they would work up, investigate and treat patients, and review confidential records will do more damage to the system than good. I fear that this, like every other piece of legislation we've seen since 1986, will only exacerbate the problems that we're trying to correct.
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Mr Wilson, when campaigning prior to the election, said that to make the system work we need to first re-establish the trust and the cooperation of the physicians of Ontario and undo the damage that had been done in relations between government and the OMA in the past decade. I don't think Bill 26 will do that.
In conclusion, I'd like to leave you with one more thought. Groucho Marx once said that politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies. The exercises we have seen in the past decade would tell me that the spirit of Groucho is probably alive and well in Ontario. I would ask the Conservative members of caucus, again who campaigned on less regulation and less government intrusion, to reconsider some of their positions on the issues of health care as it applies to the delivery of health care directly by physicians in the province of Ontario before January 29. We're open to questions.
Mrs Caplan: I would like to explore the issues of manpower planning and distribution. They have been a problem in the province for a long time. I thought I'd start out by telling you that I do not support billing numbers and never have. I think they're the wrong solution and that there are other solutions. I would like to ask if you support the recommendations of the College of Family Physicians of Canada. I understand the OMA also supports the notion of patient selection and rostering.
Dr Kugler: From my perspective, again, I am not well-read in that particular issue. Perhaps Dr Wright would like to address that.
Dr John Wright: If I might, the work on primary care reform within the OMA is an ongoing project under the care of Dr Wendy Graham. We are indeed looking at what the benefits of rostering would be in order to try to eliminate waste and so on. We are quite willing to explore those concepts and have shared some of those ideas in their preliminary state with the minister. We are willing to continue to explore those, in addition to a number of methods of alternative remuneration.
So far, as we have gone to some of the alternative plans, problems have occurred in the interface between the fee-for-service system and taking money out of the globe to pay for the new system and what counts for what. We're told that services that should be paid for under some of those plans now are being cost-shifted out into the community and some of the centres that are receiving capitation or salaries are no longer doing the work that they were doing before. So it's a complex problem.
We have proposed an economic incentive program for northern and rural underserviced areas. It needs some time to work. Okay? You cannot try it out for two or three months and say, "Well, it didn't work, and therefore we're going to impose some other drastic system." I can say that when, under the former administration, there was a suggestion that young physicians would not be allowed to work anywhere they chose and that they might have to go to underserviced areas, and there was a lot of publicity then, that was when the Lake of the Woods district and Red Lake and Hanover and all of those areas began having the problems for the first time that we couldn't get locums to come to rural areas.
I was seriously ill about a year and a half ago and needed a locum and could not get one under any circumstances because our young people are so frightened of the prospect of being locked into an area when they haven't decided that's where they want to stay. So we have to be very careful how we apply some of those.
Ms Lankin: There are two issues I want to touch on. First of all, in the amendments that were tabled this morning to the Public Hospitals Act, there are some changes with respect to the issue that we have been discussing with doctors about revocation of hospital privileges. Under Bill 26, in the situation where a hospital closed, privileges could be revoked and there was no appeal. There were other sections in Bill 26 that said that if under any other circumstance the minister deemed, that could also happen, essentially.
The amendment we saw today actually clarifies what the intent of that was and takes the broader nature of the power away, but adds to hospital closures the circumstance where a hospital ceases to provide a service. So in hospital rationalization of services, where services perhaps are amalgamated and moved to another site, the question will remain whether doctors have any ability to follow their patients and their work there. I'd like you just to comment on that and whether that's a satisfactory amendment or whether there are still problems or there's more that needs to be done.
You referred to a few of the specialties and the problems around the CMPA rebate. The minister has indicated that he understands the issue with respect to obstetrics. We don't know what he's going to do about it -- we haven't seen any amendment on that -- but there are other specialties you mention. Could you tell us, if he fixes obstetrics, is that good enough, or are there other areas where we're going to be short on specialists?
Dr Wright: Who would you like to hear from first, and on what?
Ms Lankin: Perhaps on the privileges first.
Dr Wright: On the first one, we have not had a chance to study or see those amendments in detail. We'll be looking at them.
I think the overriding thing throughout all of the medical parts of the act is the fact that due process is abrogated, the right of appeal is abrogated; the right to have an understanding that things are not going to happen in a totally arbitrary fashion is really the crucial fear that is gripping the public and gripping the medical profession and gripping the entire health community. That absolutely must be addressed in all parts of the act.
I'd like to make one quick point about confidentiality. That is, I have had patients in the last few weeks starting to ask for the first time in numbers that I not record what they're telling me in the record. That puts me in a really difficult position, because the College of Physicians and Surgeons says I have to, the medical review committee says I have to, but the patients do not want it recorded that I've ordered an AIDS test or that they've discussed something and is this a risk factor, or the family problems they're having. There are real problems with this legislation.
Ms Lankin: And CMPA, a quick comment on that?
Dr Kugler: I think it is a good thing that the minister has recognized the issue of the high premiums faced by obstetricians and gynaecologists in this province. There are, however, other specialties such as orthopaedics and anaesthesia that have exceptionally high premiums as well, again, orthopaedics being an area where we have a shortage in this region as well, with no evidence or no signs that any young graduates from orthopaedic residency are planning to relocate to this area.
I don't see the present legislation and the withdrawal of CMPA rebates helping that situation at all. So we have something of a shortage of orthopods right now, but that will be exacerbated in the next few years as older orthopods retire, and if younger ones are driven out of the country it will only be worse.
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Mr Clement: I wish to defer to Mr Wettlaufer after asking a question. I'm glad we were discussing the situation respecting underserviced areas, because it's been a concern of previous health ministers and governments for two decades that, because of government's fault and that's a portion of the blame, we haven't tried hard enough to solve it, I suppose is the way to put it.
My view, though, is that the situation right now -- and I think this is what you're saying -- creates a two-tier health care system, because in some areas you have no access to a doctor and that is a different tier from those who have access to a doctor. So we're talking about a very critical problem that we face in Ontario and we are looking for different solutions, rather than the ultimate weapon, if you will, being restricting billing numbers, and the minister has made that clear.
Some doctors have come before this committee over the past couple of weeks and said: "Look, we're keen on differential fees. We're willing to apportion among ourselves differentially to reward those serving in the underserviced areas." Do you have a reaction to that?
Dr Wright: In general, if you look at the incomes of doctors who are in the underserviced areas, and if I take the extreme example of the north, they're the highest-paid doctors in all of Ontario. What they tell you is that they don't want more money; they want more time. They need relief. They need people to come to share the workload.
However, you have to have people who are appropriately trained, and we have been working on providing special training for people who wish to go to rural areas. You really have to have somebody who has the training, who has the interest and who wants to stay there.
I don't think solutions that are going to force people there when that's not where they want to go or only for economic reasons -- this is a big, multidimensional problem and simplistic solutions are being suggested. That's why our program looks at leave, looks at continuing medical education, and I would suggest that the government revisit that incentive plan and look at it carefully and look at every element that's there and why it's there, because those are the things that the doctors in the underserviced areas tell us they're looking for.
Mr Wettlaufer: Thank you, doctors, for your presentation. I'm somewhat sympathetic to the plight of physicians in this province. I am a little bit concerned, however -- I have a background in insurance -- about the size of your surplus in the CMPA. I'm not going to speculate on how big it is or how much too much it might be, but I was wondering if the OMA might consider petitioning the CMPA for independent actuarial advice to determine whether or not it is in fact too large or too small, and if it would be too large, that it could result in a lowering of insurance premiums.
Dr Wright: The size of the so-called surplus is really just the amount of money that the actuaries have told us is required to be set aside for future settlements, and unlike many government programs which are sort of a pay-as-you-go -- "If there's a claim this year, we'll get it out of taxes this year" -- I paid my premium for work that I did in, let's say, 1975 and moneys were set aside for any lawsuit that arises in the future from that year. That is what that surplus is. It is not money for doctors, it is not money for the CMPA; it is money to pay out claims to patients when the courts decide that there has been negligence.
There are a number of things that could affect that. You could look at tort reform. That's not always very popular with the people who would say they're being victimized and not being allowed to have the type of settlement they need so that they can go on with a decent standard of living if they happen to suffer a medical catastrophe. But I think there's a great misunderstanding about what that surplus is.
You have an unfunded liability in the Workers' Compensation Board that you are concerned about.
The Chair: Thank you, doctors. We appreciate your attendance with us this afternoon and your interest in our process. Thank you. Have a good day.
Just a couple of housekeeping notes: We have to check out by 1 o'clock. You can leave your luggage at the front desk, those travelling on the bus, and we are recessed until 1 o'clock.
The committee recessed from 1226 to 1301.
WATERLOO PUBLIC INTEREST RESEARCH GROUP
WATERLOO REGIONAL COUNCIL OF RETIREES
WATERLOO REGION DISTRICT HEALTH COUNCIL
The Chair: Good afternoon, ladies and gentlemen. It is 1 o'clock, and that's the advertised time to start. We do believe in respecting our guests' time frame, so we're going to start on time.
Our first presenter this afternoon is the Waterloo Public Interest Research Group. I don't have your names, so I'd ask you to introduce yourselves.
Mr Daryl Novak: Good afternoon. My name's Daryl Novak, and I'm a staff person with the Waterloo Public Interest Research Group, WPIRG. We have chosen to share our timeslot, so I will be making a very brief presentation in order to give time to George Goebels, representing the Waterloo Regional Council of Retirees, and Gavin Grimson, representing the Waterloo Region District Health Council.
WPIRG is an incorporated, non-profit, non-partisan, volunteer-directed organization based at the University of Waterloo, with a membership of over 13,000 students and community members. Our mandate is to research, inform and take action on issues affecting our community's wellbeing, and we support any measures taken by the current government to foster constructive social change, providing the measures respect the diversity, equality, dignity and civic participation of all members of our community.
Unfortunately, in our view Bill 26 falls far short of these criteria and appears to meet others; namely, expediency, privatization and profit.
Health is so much more than being able to see a doctor. To create conditions for good health people need access to employment at decent wages, adequate housing, education, food, a clean environment, peace, a strong social safety net, and safety in the workplace. If public policy does not enhance these conditions for everyone equally, it simply is not good public policy.
Certainly the citizens of Ontario are concerned with the provincial debt and inefficiencies in the delivery of government services. However, WPIRG fundamentally believes in the right of people who are affected by decisions to be an equal participant in the planning process. For the government to unilaterally suspend the rights of citizens and wield extensive new powers to introduce irrevocable changes is nothing short of totalitarianism.
This might seem like strong language, but let's look at the facts:
(1) We are all quite familiar with how this government attempted to put this legislation through without debate and how the current timetable does not allow for meaningful stakeholder participation. Many democratically run organizations, including our own, could not orchestrate an adequate review of a bill of this nature in such a short time frame.
(2) This bill gives powers to the cabinet that will be beyond the reach of parliamentary debate or public discussion.
(3) This bill contains no provisions for public input or appeals.
(4) This bill excludes health care providers from the decision-making process and leaves them without a meaningful arbitration process. For example, there is no mention of district health councils, and considering other elements of Bill 26, it is apparent that decision-making on the local level has been deemed expendable.
(5) This bill will give cabinet the power to completely override local hospital decisions.
(6) This bill limits access to government documents, particularly for individuals, and increases fees to be paid under the freedom of information act.
(7) Finally, this bill protects the government-empowered decision-makers from any liability or court challenges.
It seems that everything this government is doing is a disincentive to people to be civically minded. You want the public to stand back and absorb the changes that you will tell them are in the public interest. You cannot create a culture of participation and community cooperation by proclamation while eliminating mechanisms for meaningful involvement.
We do not support the status quo. If this government would consider one recommendation from us, we would ask that it extend the period of review of Bill 26. Functional democracy demands the use of checks and balances. Democratic principles should not be sacrificed for expediency. This government should be engaging everyone in the process of reforming the health care system and building consensus and reaching compromise that the entire citizenry will stand behind, not just those who stand to profit.
Although the government might not agree with us, we would like more time to make our case for a health care system based on universal coverage, equal access, public non-profit administration, comprehensive care from large institutions to the home, affordable drugs, expanded methods of health care and fair treatment of health care providers.
I recently spoke with a senior citizen on social assistance who just won $5,000. When I asked her what she was going to do with her money, every item she mentioned centred around her health needs that had been neglected for some time -- her teeth, a new pair of glasses. I hope this doesn't become the legacy of the current government.
Mr George Goebels: George Goebels, with the Waterloo Regional Council of Retirees. For some time now the people of Ontario have been inundated with leaks of what the provincial government is proposing in the Legislature and has finally tabled. Some of these cuts have already been instituted, such as a cut of 21.6% to welfare assistance.
Kitchener MPP Wayne Wettlaufer is quoted in an article in the K-W Record as having said that the Tories picked easy targets first. These easy targets were the people on welfare, senior citizens and the disabled. They seem to have chosen this route instead of closing tax loopholes and many and various other ways such as tax deferrals -- you name it. They don't seem to want to hurt their wealthy friends. Cutting day care subsidies will hurt the lower-income people first and most.
A real radical proposal now tabled is what Premier Harris has referred to as copayments or deductibles but is nothing less than user fees. All those single individuals with an income of under $16,000 a year and families with an income under $24,000 will pay $2 on every prescription. The ante goes up as your income does.
If there are seniors who will be able to afford these user fees, I haven't had the pleasure of meeting them. People on welfare, even before the 21.6% cut, were on a mere existence level, and I have no idea how these people can be expected to pay $2 on every prescription they may need to sustain some measure of health and dignity. If there are people on welfare with an income that they should be or are paying income tax on, should they really be receiving welfare?
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It seems that the poorest of the poor -- the disabled, the seniors and people on welfare -- are being blamed for the high cost of drugs. Why, for a change, isn't the blame put where it belongs? Some years ago, the federal government passed Bill C-22, which gave international drug manufacturers a 10-year guarantee that no generic drug manufacturer could copy or produce a similar drug. Then came Bill C-91, which changed the 10 years to 20 years. If this bill were scrapped, it would likely reduce the cost of drugs, but I question whether a provincial Conservative government would try to get a former federal Conservative government's bill scrapped.
Isn't the real reason the cost of drugs is skyrocketing, as Premier Harris claims, due to the 20-year guarantee? Premier Harris, in an article in the same paper, seems to be covering his behind by insisting his government is not breaking an election promise. If drugs are not part of health care, I am sure I don't know what they are. He claims, further:
"`What we've indicated so far and we're committed to is we will respect the Canada Health Act, which calls for no user fees for those services which are deemed to be medically necessary.' And he adds: `There is debate which services are necessary. We respect the Canada Health Act and we will live with that.'
"But the Premier argued that the drug plan is not, in the government's opinion, a medically necessary service. He also claims: `There is no obligation on the government to provide anything. The drug plan is one of them.'
"The proposed legislation will require recipients to pay a minimum of $2 per prescription in user fees. The annual charges a person could face might add up to thousands of dollars, he said."
Throughout that whole article, and since the minibudget on November 29, 1995, the Premier is really playing with words. It is also clear since then that the government is giving itself dictatorial powers never before seen in this country by any government. This could only be the start of what he probably promised his friends is to come, namely, the elimination of the Health Care Act.
The new bill the government tabled that day, called the government Savings and Restructuring Act, 1995, which was to be passed by the Legislature by December 14, 1995, gives it power to do practically anything it likes by order in council or, in some cases, by the minister involved. We thought Hitler was bad. It looks like we are in for worse than that.
Here in Ontario, because of our deficit, our new Conservative government plans to put its fiscal house in order. That's good. However, it has unjustly targeted the poorest of the poor and the marginalized people to carry this out, to give more tax breaks to their wealthy friends.
Some of the most disturbing of their recent decisions have been: the 21.6% cut in social assistance rates; the introduction of increased qualifications and requirements for the disabled; user fees for the above and seniors on drugs; the moratorium on non-profit housing; the closing of women's shelters; the reduction of day care. Why do the poorest have to pay the deficit reduction alone?
We therefore ask you to work on the real problems. We realize that the Ontario drug plan may be in trouble. To get out of this problem is not only to take from the have-nots. We must all work to eliminate Bill C-91 and force the multinational drug manufacturers to compete with the generic drug manufacturers in an open market. This, without a doubt, should reduce prices.
It seems most of this foolishness started at the federal level when that government reduced transfer payments to the provinces. Now the provincial government, just as foolishly, cuts the grants to regional and municipal governments, as well as most service agencies. These are now expected to raise more or most of their needs locally. The money will again have to come from the have-nots instead of those who control our destiny.
It is the responsibility of the provincial government to subsidize local governments and charitable organizations. Many charitable organizations save senior levels of government a lot of trouble and money by providing services the government is unable to. Charitable organizations need these subsidies if they are to continue to do the jobs they were set up to do. Raising money locally just to survive was not and is not part of that job.
On the second last page of the other section, escalating drug prices are mentioned as the cause of user fees for drugs. So what happens? Price controls on prescription drugs will be removed. This alone will guarantee that the cost of drugs will rise. Caring Ontarians and Canadians decided a long time ago what kind of health care system they want and have and do not want to see it destroyed. The public's access to information about the government's activities will be more strengthened by raising the fees charged for same. Organizations will also have a new right to completely refuse to deliver the information requested.
This bill probably covers nearly everything, over 40 different laws. Even lawyers and legislators seem to have a real problem interpreting it, partly because of its vagueness. Yes, this government is giving itself dictatorial powers. It looks to us as if fascism is just around the corner in this province. God forbid.
Mr Gavin Grimson: Good afternoon. My name is Gavin Grimson, executive director, Waterloo Region District Health Council. To my right is Joyce Cruikshank, formerly chair, Waterloo Region District Health Council.
First of all, I would like to thank Daryl for allowing us to share his spot on this presentation to committee. Waterloo Region District Health Council is one of 33 district health councils in Ontario, covering 100% of the province's population. Over 8,000 volunteers contribute more than one million hours province-wide every year to community health planning through DHCs.
With some reservations, Waterloo district health council generally supports the government's method for implementing hospital restructuring. Waterloo district health council is willing and able to provide input and support to maximize the value of the Health Services Restructuring Commission. The critical link between local planning and implementation has to be maintained. Needless to say, the district health council believes that local planning makes a significant contribution to achieving cost savings across Ontario and local planning has an ongoing, essential role in developing integrated health service delivery systems.
Most of the comments that I will make now refer to schedule F of Bill 26. The roles and responsibilities of the commission and district health councils must be clarified to ensure that planning and implementation of integrated health service delivery systems are carried our smoothly and effectively to the benefit of patients.
Decisions of the commission should be based primarily on planning and analysis conducted by councils to ensure that community health needs are addressed through an approach to developing an integrated health service delivery system.
Implementation of hospital restructuring must ensure that community health needs are met through alternatives to hospital services which have either been downsized or eliminated. There is a close relationship between the commission and district health council and this is critical to advancing the implementation of hospital restructuring.
Implementation, wherever possible, should be done by consensus to serve the health needs of the community, and the community should, wherever possible, be included in this exercise. Only as a last resort should the commission be brought in to bring the various parties together to ensure that the needs of the community are met in the most efficient, effective and economic way possible.
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To some extent the commission is seen as a roadblock buster to bring to the attention of the minister changes to regulation, policy, bureaucratic red tape that are necessary to advance reform; to analyse common trends that impede implementation of restructuring activities, recognizing the need for local communities to, wherever possible, chart their own course within provincial parameters that reflect the health care needs of their community.
Schedule F, the structure and composition of the commission: The commission structure should be based on clearly defined roles, expectations and responsibilities. District health councils and providers and the community should also have clearly defined expectations and responsibilities.
Cost savings and any reinvestments achieved through hospital restructuring: It is believed that there should be a formula for reinvestment in the community of cost savings achieved through any restructuring to ensure that resources required to provide health care are those that are required within the region.
New models for health care facilities and physicians should provide incentives to improve utilization management to encourage the development of alternatives, satisfactory levels of care and the enhancement of community resources wherever necessary. Incentives should also be provided to facilities and organizations to encourage new and innovative directions in care to the benefit of patients and public.
Benchmarks: There's a critical need for aggressive planning benchmarks for health services which are public and agreed to to ensure that the health care system is responsible to the needs of individuals.
A relationship between local planning and implementation is critical to the success of hospital restructuring implementation. Without clear directions, roles and responsibilities, confusion and public dissatisfaction will arise.
Recommendations re the Public Hospitals Act: The caution is that the appointed hospital supervisor may play a necessary role in the implementation of health service restructuring. However, voluntary governance provides a mechanism for critical community input in decisions affecting local health care and this should be respected in the decision-making process.
Again on schedule F, part III: Decisions on the operations of private hospitals should be based primarily on analysis of local health needs that are provided through district health councils currently.
Universal access to the best possible primary care, treatment and medical technology is highly valued by Ontario residents and should continue within the government's fiscal framework. This is only possible if provincial standards on the numbers and types of health services and facilities are established within the context of ensuring universal access to high-quality health care.
Schedule F, the Independent Health Facilities Act: Licensing, funding and quality assurance of non-hospital health facilities that provide selected varieties of diagnostic and treatment services should be assessed within the context for developing integrated health delivery systems based on the community's health needs.
Brokerage, wherever possible, should be completed at the local level. This may be required to ensure the forging of effective links between hospitals and community agencies by adding to the variety of services provided by independent health facilities.
Provincial standards on the numbers and types of health services and facilities should be established within the context of ensuring universal access to high-quality medical care. Health is so important that market forces should not determine the numbers and types of service available. Quality of care is too important and must be preserved above all else.
Schedule G re the Ontario Drug Benefit Act etc: The government should work with consumers, physicians and suppliers to control drug costs in ways that do not cause a deterioration in patient care and at the same time are more effective and economic.
Schedule H, the Health Care Accessibility Act and Health Insurance Act: The government may wish to ensure that in making the health system more responsive to all, equal accessibility is available to everyone in the province and that user fees do not create a two-tier system.
Schedule I, the Physicians Services Delivery Management Act: It's recommended that it is essential to ensure communities have access to primary physician care. The ministry should continue to reimburse physician insurance in underserviced areas where the lower and fluctuating volume of cases makes for an extremely sensitive break-even point between payments received for practising obstetrics and the involved insurance costs and for all other medical services.
The government should work with all involved in health care to ensure that all health services are available throughout the province. Thank you.
Ms Lankin: I appreciate the presentations of the groups. I want to indicate to you I have a point of personal privilege, but I'll wait until the three parties have responded.
May I say to the seniors' organization, I'm sure you were around in the days when the universality principles of medicare were created. I share your worries about what this bill will mean for that and I wondered if from your position as an elder in our community you could give us some words of wisdom about the reasons for the drive to medicare as it has been created and the dangers if we move away from that universal system.
Mr Goebels: Yes, I was around quite a few years before there was any kind of health care and I hope I don't have to see it again. Most of us seniors have extended families of three or four generations and naturally we've got to think about their health care as well. We can't just give up once we're retired and let them look after themselves.
Mrs Helen Johns (Huron): I just wanted to ask a question of the district health council. Mr Grimson, I can see that you're basically working on your report and you're looking at the implementation of the restructuring. Do you envision problems? Is that why part of your support of schedule F is coming about? Can you tell us the problems that you think may happen within the community or how the restructuring will unfold?
Mr Grimson: There are always problems in any restructuring or in any change, and I think the province has seen so many councils throughout the province putting forward suggested reforms for health services within their area that have subsequently been blocked, for whatever reason, that this is seen to be a way of unblocking the blockages.
Mrs Caplan: You've been very diplomatic, thoughtful, and I share your concern which I think is implicit in everything that is in here about local planning. As you know, there is nothing that guarantees local planning in this document, and I see you nodding. You can comment on this if you wish, and I understand you need to be diplomatic because the minister has been so uncertainly clear. He has not been clear about his intention for the role of the district health councils. I have heard him say that he intends to see the role revert to what it was 20 years ago, which was simply as an advocacy group and not doing the kind of leadership and planning that we see today. I know that your role has been evolving. I was actually very pleased to hear from the Norfolk hospital, which was here, that its district health council is assuming a more significant role in local planning. So I'd like you to talk about local planning, if you could.
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The Chair: Thank you, Mrs Caplan. Time is up. Thank you very much, folks. We appreciate your being here this afternoon. Unfortunately, we're on a very tight time frame, so we have to run it this way. Thanks very much for your interest.
Ms Lankin: On a point of privilege, Mr Chair: I believe that my rights and privileges as a member of this legislative committee have been violated. You know that I have for days been bringing forward a motion asking for all amendments that the government was aware of and had approved and that were ready to be tabled. You know that I raised that in the first week of committee hearings and got an assurance from the minister. You know that I raised it again this morning, and what we saw were seven or eight amendments tabled and a statement at that time of tabling that there were not other amendments that were ready and that the government was sympathetic and would get them to us as soon as possible etc.
I have been made aware that there are other amendments which are ready and were ready and that members of the media have copies of those. I as a member of this committee do not have copies of those and I believe my rights and privileges have been violated.
Now, I understand that the government will be taking actions to correct and remedy this situation by tabling these further amendment, but I'm sorry, I'm very angry that we are in this situation when I have asked repeatedly for these amendments all to be tabled. If we're now going to have to get them in dribs and drabs, by whatever means we can when the media get them, I feel that will be an ongoing and continuing violation of my rights, Mr Chair. I would hope that you will look into that and you will rule with respect to whether or not my rights have been violated. Even in the event that the government now tables those few amendments, I think this issue may well repeat itself over the course of the next couple of days.
Mrs Caplan: Point of privilege.
The Chair: Excuse me a second. You folks don't have to sit there for the rest of this. It doesn't particularly involve you, so you can --
Ms Lankin: It sure does. They don't get a chance to see it either.
Mrs Caplan: Point of privilege, Mr Chairman: In fact I am outraged, because I did not even know that the media had been given amendments. I am very concerned as a member that my privileges have been seriously impinged upon. The fact that this government is giving amendments to the media before it is giving them to members of this committee is an outrage.
I have been asking for those amendments from the very first day that this committee began, and if they are attempting to manage the news and not give the members of this committee the right to review those amendments in a timely way, that we are not receiving those amendments first is unacceptable to me and I would ask that you review the procedure, sanction the government and tell them that they must present and table those amendments here at this committee before they leak them to the media or hand them to the media or give them to the media. We, as members of this committee and as members of the Legislature, deserve that kind of consideration and appropriate treatment. It is outrageous that they would do that.
The Chair: Mr Clement.
Mr Clement: Thank you for the floor, Mr Chair. Through inadvertence, the procedure that we wished to employ to ensure that this committee saw amendments first that the government felt comfortable in tabling was breached, again through inadvertence, this morning. I apologize to my colleagues for that minor breach. I would say, however, it was a minor breach.
I am willing to table the three amendments that Ms Lankin referred to. They are all housekeeping amendments; they are not substantive amendments. Again, I apologize that it's back to front, that the media got it first. That hopefully will not happen again. Sometimes individuals in organizations make mistakes, and a mistake was made. There was no wider conspiracy involved. We have no other amendments that are ready to be tabled. This is the extent of the amendments to date that we feel comfortable in tabling with the committee. As soon as there are other amendments to table, we will table them as soon as we can.
Ms Lankin: I'd like to ask for a clarification. You said sometimes people and organizations make mistakes, and I'd like to know whom you're referring to. Are there members of public organizations who have been requesting amendments with whom you have shared your version of amendments and did this inadvertent action come from one of those outside groups, or was it from someone in government?
I am aware as well that there are people in this room who are part of organizations that have been presenting before this committee who are aware of the detail of government amendments that you intend to file before this committee, when I have been asking, for days, to have these amendments tabled so that the broad public would be aware of them and would be able to respond to them in their briefs and so that the opposition, who are madly scrambling to prepare our own amendments, know what the damned bill is that we're trying to amend. What's the final version going to look like?
So I would like some clarification as to how this happened and if in fact there are other organizations that are aware of the amendments that you intend to table.
Mr Clement: If I can respond to that, I believe it was the opposition parties who were urging us to discuss possible amendments to this bill with representative organizations, representative of their particular members, such as the OMA, OHA -- I'm not limiting it exclusively to that group. So has the government and has the minister had discussions with them? Yes, we have, and we are proud to acknowledge that.
Ms Lankin: That's not what I asked.
Mr Clement: If I can just respond, Ms Lankin, the process that this government chooses to employ is, as the government -- we're not the whole committee and we acknowledge that -- we on the government side who have sat through these hearings have listened very closely to the presenters and are interacting with the Minister of Health and with his ministry to come up with amendments that we feel accurately keep us to the core of what we have to achieve for Ontario, but do it in ways we are comfortable with and the presenters are comfortable with.
I can assure the member that there are no other amendments, that I have reached that stage where we are comfortable with them and the ministry is comfortable with them and the presenters are comfortable with them. As soon as we have that nexus of points of view, we will present them to this committee. We are committed to that and the Minister of Health is committed to that.
The Chair: I believe that's enough discussion on the point of order. Thank you very much, folks.
Our next presenter is Karen Haslam, representing the coalition for social justice.
Interruption.
The Chair: I'm sorry, sir --
Interruption.
The Chair: The committee is recessed.
The committee recessed from 1337 to 1339.
The Chair: The meeting is reconvened.
Mrs Caplan: Mr Chairman.
The Chair: Yes, Mrs Caplan.
Mrs Caplan: I will be brief.
The Chair: Is this on the same point of order?
Mrs Caplan: Yes.
The Chair: I've ruled that point of order is over.
Mrs Caplan: It's on my point of privilege. It's not on the same point of order. I would like to respond to what Mr Clement said.
The Chair: No, that's the same point of privilege and I have ruled on that, Mrs Caplan.
Mrs Caplan: Well, I'd like to speak to a point of privilege. I will be very brief.
The Chair: We are going to hear from these presenters.
Mrs Caplan: Yes, we certainly will, and I will be very brief, but I'd like to be heard.
The Chair: Mrs Caplan, we are going to hear from these presenters.
Mrs Caplan: Mr Chairman, I'm asking for a minute to be heard.
The Chair: No, you're not going to be heard. I'm sorry.
Mr Crozier: What a dictator. I've never heard anything like it. Jack, you were a better guy than that when you started.
The Chair: Mr Crozier, you're out of order.
Mr Crozier: What are you going to do about it? Are you going to kick me out?
The Chair: Karen Haslam, the coalition for social justice, the floor is yours. You have a half-hour of our time to use as you see fit. Questions will begin with the New Democrats.
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Mrs Caplan: Your true colours are showing. People are going to see the kind of dictatorial authority you want. The way that you're conducting hearings is an outrage.
Interjection.
Mrs Caplan: Well, then, let me have one minute. Unanimous consent that I can have one minute --
The Chair: There's going to be another five-minute recess.
The committee recessed from 1340 to 1344.
The Chair: Okay, welcome --
Mrs Caplan: Mr Chairman.
The Chair: Yes, Mrs Caplan.
Mrs Caplan: I request unanimous consent to have one minute to address the committee.
The Chair: Is it on the same point of order?
Mrs Caplan: Mr Chairman, I'm making a motion for unanimous consent that I be given one minute to address the committee.
The Chair: Is it on the same point of order?
Mrs Caplan: Mr Chairman, I have the right as a member of this committee to move a motion. My motion is that I ask for unanimous consent to have one minute to address the committee, on whatever matter. I've been told by Mr Clement that they have no objection to that motion.
Mr Clement: But it's the Chair's call.
The Chair: I would ask you to state if it's on the same point of order.
Mrs Caplan: Mr Chairman, I have moved a motion. I'm asking for unanimous consent for one minute to address this committee.
The Chair: Well, Mrs Caplan, I guess you and I are going to differ on this one.
Mrs Caplan: Call for unanimous -- say, "Do I hear unanimous consent, yea or nay?"
The Chair: We'll do this whatever way you want. We'll delay the proceedings until you decide to answer my question.
Mrs Caplan: Mr Chairman, as a member of this committee, I have moved a motion, and my motion is that I be given one minute to address the committee. I ask that you, as the Chair of this committee, put the question and say, "Do I have unanimous consent, yea or nay?"
The Chair: Is it on the same point of order?
Mrs Caplan: That motion is in order.
The Chair: Is it on the same point of order?
Mrs Caplan: It is not on a point of order.
The Chair: It's not on the same point of order?
Mrs Caplan: It is not on a point of order.
The Chair: It's not on the same point of order. Okay, Ms Haslam, you have the floor.
Mrs Caplan: Mr Chairman, I have moved a motion and I ask that you call the question. It is appropriate for the Chairman to say, "Do I have unanimous consent to Mrs Caplan's motion to have one minute?"
The Chair: You're going to win this one, aren't you? This is all about the press. Do I have unanimous consent for Ms Caplan's motion?
Mr Clement: Agreed.
Mrs Caplan: Thank you, Mr Chairman. I appreciate that.
What I would like to say is that I accept the apology of the government in the way the amendments were tabled, but I would like them to clarify, for the presenters and those who have had motions shared with them, that in fact it was not any organization, other than someone within government, that was responsible for the media receiving the package.
Mr Clement: Yes, it was the government's mistake.
Mrs Caplan: Thank you very much.
PERTH COUNTY COALITION FOR SOCIAL JUSTICE
The Chair: Coalition for social justice. You have a half-hour to use as you see fit. Questions will begin with the government.
Ms Karen Haslam: Thank you very much. I must admit it's much more active this afternoon than it was this morning. It's nice to see some life after lunch. My name is Karen Haslam, and I am the vice-chair of the Perth County Coalition for Social Justice. With me is Linda Mackay, who serves on our education and media committee. We'd like to thank you for the opportunity to come here today to express the concerns of the individuals in our organization about this omnibus bill, a bill that will have serious consequences for the quality of life of the citizens of this province.
The Perth County Coalition for Social Justice is a grass-roots organization made up of various individuals and representatives from community associations, such as co-op housing, counselling services, labour and activists in the women's movement. We banded together after we saw what was happening in our community as a result of the election of the Harris government.
Our community's second-stage housing development, the Emily Murphy Centre, which provides abused women and their children with affordable, safe housing and services, was going to have to close its doors due to a cut of $100,000 to its program budget. Funding to the Stratford-Perth Counselling Centre covering its program for men who abuse was cut.
The mobility bus and taxi funding was cut, resulting in shorter hours of operation and less access for disabled clients. Welfare cuts were resulting in people being evicted from their homes. Demands for subsidized housing increased, yet a co-op housing development for seniors had its funding withdrawn. The library lost funding for computer access to the information highway, the great leveller for anyone, poor or rich, for access to knowledge.
The Stratford Jail was scheduled to close, and family court proceedings may be moved. Jobs will be lost, as well as access to the legal system and protection.
The food bank reported that clients increased by 33% since September, including several new clients as well as old clients who have been forced back into needing help.
This was all before November 28, 1995. Then came the financial statement and more cuts were announced, more attacks on women, children and the disadvantaged. And Bill 26? Just look how it was introduced.
As the Perth County Coalition for Social Justice worked together to formalize our mission statement and outline our concerns, we became increasingly aware that under the Harris government, the general population had little or no input to government decisions. This was not social justice.
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What is social justice? The Perth county coalition believes, "Social justice can only exist in a free society in which all people have equal opportunity and full access to the resources needed for their physical, emotional, intellectual and spiritual wellbeing." Our statement of purpose is attached to this brief, but I would like to note number 6, "To take our statement of purpose seriously and insist that others in positions of influence and power fulfil their responsibilities in maintaining Canada's tradition of social justice and protection of the vulnerable in our society." That brings us here.
The Perth County Coalition for Social Justice is calling for the scrapping of this omnibus bill. Primarily we believe Bill 26 attacks our democratic process. It will devastate our public services and impose hardship on our communities, a hardship that will be especially felt by those who are most economically disadvantaged: children, seniors, unemployed workers, the disabled, and persons on assistance, the majority of whom are women-led, single-parent families. The quality of life of essentially everyone in this province will be eroded and the disparity between the haves and have-nots will increase.
As we endeavoured to look into this complex and far-reaching bill, we found out that the compendium provided with Bill 26 ran about 2,200 pages, even though it does not include the full text of all the acts being amended. We also found out that it amends 44 acts. As a fledgling group with little or no money, we couldn't begin to address the myriad of changes or begin to understand the intricate legislative text, but we did understand the unprecedented power it gave to government ministers and the Ontario cabinet and the lack of input, parliamentary debate or public discussion it imposed on the people of our communities.
While we obviously were concerned with the rollback of pay equity for women, the new powers allowing municipalities to impose user fees and poll taxes, losing some of our fundamental rights under the freedom of information act amendments, and environmental short cuts, it is schedules F, G, H and I in the health section of the omnibus bill that we wish to address today.
Firstly, as we understand it, in the health section of Bill 26, the cabinet, Minister of Health, hospital supervisors and boards of directors are protected by the legislation against any liability or court challenges. Yet health care providers and citizens have not been provided with any vehicle to appeal decisions or to provide input to the decision-making process. This is unacceptable.
Some of the most remarkable powers the minister would have revolve around our hospitals. As we understand it, apparently he could close our hospital. He could order amalgamation. He could specify the services to be delivered by our hospital. And all this if he deems it to be in the "public interest."
But what ties in with this is the fact that under a new section, 9.1, the issues to be considered in determining the public interest are defined, yet the minister and cabinet are not limited by these and can consider "any matter they regard as relevant." Included in the list is the availability of financial resources for the management and delivery of the health care system. Bottom line: He could make decisions about our community's access to a hospital without looking at the health issues at all, just the financial issues. This is unacceptable.
All of this without input from the medical community or the people affected, the public, and as mentioned previously, the minister and cabinet under section 13 are protected from any legal liability from any decisions as a result of their direction or level of funding. This is unacceptable.
As we understand it, Bill 26 repeals the existing preference to Canadian-owned, non-profit health care providers and public tendering. We are not in favour of encouraging American for-profit companies to take over an increasing part of our health care system, eventually leading to the privatization of many of our public institutions.
I would like to read into the record a letter published in the Financial Post on March 11, 1995. It's entitled "Don't Buy Into US Health Care."
"Canadian friends sent me a column by Neville Nankivell (Jan 14-16) that implied some Canadians want a US-style health system.
"As an American and a survivor of this system, let me enlighten those Canadians so inclined.
"I paid Blue Cross and Blue Shield premiums for many years. In 1984, I was diagnosed with cancer and as a result had a kidney removed. This procedure cost me, personally, $42,000 over and above the amount paid by Blue Cross totalling $160,000. I then was refused further health insurance due to what was described as a risk factor.
"As a result, I now have no insurance, no job and no money. My only hope is to survive 10 years when, at age 65, I shall be eligible for medicare, which in itself only allows partial coverage.
"Please let the word go out to those Canadians who hearken to the propaganda of the medical lobby, be it in the US or in Canada."
This was signed by Henry Korz, South Padre Island, Texas.
Privatization, coupled with changes to the definition of "facility fee" and the ability of hospitals to charge extra fees, will produce a two-tiered, Americanized health care system. This is unacceptable.
As we understand it, Bill 26 deregulates drug prices. We find it interesting that the government is willing to set aside the BAP, best available price, system now used for pricing drugs in favour of negotiating with the manufacturer but will set the maximum ODB dispensing fee by regulation so it doesn't need to negotiate with pharmacists. The pharmacists have had little or no increase in their fees for a number of years. However, under the federal Bill C-91, the patent on drugs was extended so drug companies could charge the highest price for their medication for a longer period of time. This government actually believes that negotiating with large drug company consortiums is preferred over negotiating with the pharmacists' association. Ontario will become the only province that does not regulate drug prices to keep the costs under control. This is unacceptable.
As we understand it, Bill 26 introduces user fees for seniors and social assistance recipients on the Ontario drug benefit plan and will no longer pay the difference between the generic and brand-name cost for patients whose doctors recommend no substitution in their prescriptions. Furthermore, given the power the minister will have over doctors, what is a necessary health service will no longer be decided by a doctor but by the Minister of Health, who is defining all of this based on financial resources rather than on any medical criteria. This is unacceptable.
One of the most damning sections is the new section 29. As we understand it, this section gives the minister and the general manager of OHIP the power to collect and disclose patient information. Patients are deemed to have given their consent for the collection of information, and as previously mentioned, the minister and general manager have immunity from any prosecution as a result of any disclosure. This is unacceptable.
There are many other substantial changes in this omnibus bill, but no sector is as significantly affected by Bill 26 as the health sector. Medicare as we know it is under attack. Privatization and corporate profits have now taken precedence over the health of our communities. This is unacceptable.
Attacks on the elderly, the poor, women and children and the disadvantaged in our society through extra-billing and a two-tier medical system is unacceptable.
The Perth County Coalition for Social Justice does not feel that adequate time has been given to the public, indeed to the members of Parliament themselves, to review this monumental piece of legislation. In watching the beginning of this committee's meetings on the parliamentary channel, I was intrigued that not even the Minister of Health himself was able to answer questions regarding certain aspects of this bill put to him by Ms Lankin.
The public interest is ostensibly the reason legislators pass laws and are elected to govern our province. It is our contention that the public interest would not be well served by the proposals in this omnibus bill. Accordingly, we add our voices to those who are calling for the withdrawal of Bill 26.
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Mrs Ecker: Thank you very much for taking the time to come and present, and a particular welcome to Ms Haslam. The committee has had close to eight or 10 presentations from previous MPPs now engaged in other careers. Welcome to the committee, and I very much appreciate your comments.
The quote you've used from the newspaper in the States is an excellent example of the kind of health care system that -- if there is one thing Canadians and those in Ontario agree on, it's that we don't want the American health care system. But we've also heard from these committee hearings that the system in Ontario, as it currently stands, needs to be reformed, needs to be changed. We've heard some very eloquent presentations from communities who argue that there is indeed a two-tier health system there now: those who have physicians and those who are not able to have physicians. We've heard about overprescribing. We've heard about the need for guidelines. There have been lots of examples of why the system needs to be reformed, and that is something that the government, as you know, is trying to respond to and trying to make those changes.
You raised a couple of questions in your presentation. I can certainly appreciate, as a community group, your point about not having resources to do legal analysis of legislation. I would like to suggest that in terms of the minister's power to prescribe information, to collect information, to make agreements and arrangements about information collected in the health care system, there are different but similar powers in the current Health Insurance Act. One of the fundamental principles of the system is doctor-patient confidentiality, and we certainly appreciate that. That's one of the reasons we've been willing to sit down with the privacy commissioner and work out ways to ensure that that principle -- we believe it is still there, but we want to ensure that those who have expressed concern about it see it as being still in the system.
The other point you made was the concern about who was deciding what was medically necessary. Again, in the current Health Insurance Act, in order to go after potential misuse in the system, the general manager of OHIP does have grounds to make what are considered "medically necessary" decisions which are made with reference to the Medical Review Committee. Most physicians who've come forward have said that process is something they would like to continue to see, that they'd like to see that use of information stay under the Medical Review Committee. We've certainly been prepared to entertain suggestions and amendments to make that system work better, because the organization that runs it currently, the college, has expressed some concerns about the way it is being run and we've been willing to make some changes there.
The other reason it's been important to try and have access to information, while at the same time making sure we're protecting patient confidentiality, is the use by some consumers of the system. For example, in one month over 7,000 individuals used five or more family physicians, which most people agree is an overuse of the system. The way we were able to track that is to use something like smart cards or other technology. Again, that is a need for patient information.
I know it's something your government wrestled with, misuse within the system, and there's always a debate about how much is there and whatever. How would you suggest we continue to go after misuse in the system by whomever, while at the same time protecting the confidentiality of patients, which we all agree is --
The Chair: Unfortunately, Mrs Ecker, your question's just a little too long.
Mr Crozier: Thank you for your presentation. It's nice to see you again. You said in the first part of your brief that, "The Emily Murphy Centre, which provides for abused women and their children with affordable, safe housing and services, was going to have to close its doors due to a cut of $100,000 in their program budget." The minister responsible for women's issues -- I would be paraphrasing -- has essentially said in the Legislature when it's been brought to her attention that this has happened, that these halfway houses are under a threat of closing, "No, they're still there; we haven't closed any of those houses." But you would be able to explain to us what may ultimately happen, that they may be right that they're not be physically closed, or that the government may not physically close them, but it will amount to that.
Ms Haslam: I must point out that this situation was probably the most lightning-rod thing in our community that brought us together. This was the beginning of the women in the community having an open, public forum and talking about some of the changes coming and some of the effects of those changes.
Ms Mackay works at Optimism Place, another battered women's shelter. This Emily Murphy Centre is the second phase. That means longer periods of time when mothers escaping abusive situations go into a building and are secure in that building. What was happening was that they were losing the additional counselling services and programs for their children, for themselves, for their self-esteem. It was becoming a shell of a building where they were being ghettoized, having this second-phase housing to go to that was supposed to be very secure and it didn't offer anything for them.
As a matter of fact, in this situation, because they share funding with the Ontario Ministry of Housing and the Ontario Ministry of Health, the Ministry of Health was withdrawing its support and it affected some of the joint things they were able to put into the building for security. For instance, they were being requested to sell off their computer system, to sell off the monitors for the cameras in the building, so what they had was a secure system without any way of making it secure. They had the cameras, but no monitors. They lost a staff person to help monitor what wasn't there anymore. They lost the services for the children to have a self-esteem program. They lost the services of a staff member to go with these women to court, to be with those women, to support those women when they were going through difficult times in the court system. What they lost were the services in that building, and it become an empty shell building with no services.
Ms Linda Mackay: I'd just like to add that there's been no commitment whatsoever. The building exists. Women can live there. They have absolutely no security. They have no guarantee of how long they can live there. They're there in a risky situation without staff, security implemented, let alone the programming.
Ms Lankin: Thank you very much, Karen and Ms Mackay. It's a pleasure to see you here. We appreciate the presentation from the coalition. You might have gathered, having watched, that I'm a little perturbed about the situation and not being able to get amendments and to know exactly what's going to be changed. Ms Ecker just told you that essentially the powers to gather and review and disclose information by the minister or the general manager were already there in the old bill. "They're different but they were already there," I think were her words. In fact, they were very different. There was no such thing as the clause in there now in 21(1)(d), which says the minister can prescribe any other purposes for which he can gather, review and disclose that information. It's extraordinary.
I've been hearing for a week and a half that they've been meeting with and talking to the privacy commissioner and are going to make amendments. The privacy commissioner presented before this committee in the week of December 18, the first week of hearings. They've had over a month to get this done. Where are they? Why can't we see them? Why couldn't you focus on other issues today in your presentation and not have to worry about that?
On the issue of medical necessity, again Ms Ecker glosses over the nature of the change, which takes it from the general manager having reasonable grounds to think there might be a question around medical necessity and sending it to peer review, to doctors in the medical review committee to look at and decide, to the decision being made by a bureaucrat. They say they're going to do something that might fix it and put it back to the old way. I'd like to see those amendments.
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I wanted to ask you about your concern around medicare, universality, the two-tiered system. We heard from a bioethicist who said this act fundamentally allows the system to be changed, to move in the directions you talk about -- whether the government does it or not, we don't know; it's a blank cheque and they haven't filled the number in yet -- and that there hasn't been the debate, and the values of medicare are among the core values of Canadian society. Can you comment on how you feel about that?
Ms Haslam: The underlying issue here for us as a grass-roots organization is process and our chance for public input and public interest, which -- you're absolutely right -- is medicare at the core. Our concern is the unprecedented powers that are given without any opportunity for redress and without any input from those of us in small rural communities. Stratford is in the middle of a very rural area, a small community. We have little access to have our input into the decisions. There are too many powers in that.
When you mention a two-tiered system already being there, I'm talking about a two-tiered system where there is a doctor present and we still can't access the health care. There are people in our group who can't afford the user fees, who can't afford the possibility of a user fee in the hospital for the food and accommodation and the other issues. That's a two-tiered system.
To me, a two-tiered system is not in the north where there is only one doctor instead of three. A two-tiered system to those we represent is that even given we have a doctor, even given we have the prescribed number of doctors in our county, the two-tiered system this becomes open to is that we still can't access it. It has taken away the universality of the health care.
I'm not fully cognizant of many of the reports out there, but it has always been my understanding that there are surveys and studies that have shown that user fees do not effectively solve the problem about access to the medical system and only hurt those at the lower tier. If I'm wrong, you can correct me.
Ms Lankin: No, you're absolutely right.
Ms Haslam: For me, public input and public interest is where we are very concerned in this bill.
The Chair: Thank you very much for your presentation this afternoon. We appreciate your interest.
CANADIAN AUTO WORKERS, LOCAL 1986
The Chair: The next presenter is the Canadian Auto Workers, Local 1986. Good afternoon, and welcome.
Mr Don McFarlane: Good afternoon. My name's Don McFarlane, vice-president of Local 1986. I'd like to thank the committee for allowing me the opportunity to be here today. Currently, I'm a benefits representative for the A.G. Simpson chain, which has 2,200 members, as well as vice-president of CAW Local 1986 in Cambridge, which covers another 2,000 members.
I must say in opening that the contents and undemocratic process by which this Bill 26 has been forced upon us is, in the lightest terms, disgusting. When before in the history of Ontario politics has the public been denied a fair and democratic right to appear before a travelling committee such as this? I'm making reference to the number of individuals or groups who have been denied standing at these hearings.
I am here today not as an expert on the health care system but as a concerned citizen and a representative. My concerns are based on what I perceive to be the Americanization of our health care system, a system designed for the rich, and on the other tier will provide little or no affordable services for the working poor, unemployed, underemployed, welfare recipients, students, elderly and single parents. How heartless of a government to decide that life isn't hard enough. Now these abovementioned individuals will be asked to pay user fees and asked further to line the pockets of the multinational drug companies, asked to shop for a hospital or a for-profit clinic that will service them. All this, but don't ask any questions, because even the right to appeal by a health care provider or a citizen will be destroyed by Bill 26.
Let's look at the changes to schedule F. Schedule F amends the Ministry of Health Act, the Public Hospitals Act, the Private Hospitals Act and the Independent Health Facilities Act.
Ministry of Health Act: Bill 26 creates a hospital services restructuring commission that will implement the government's agenda on hospital restructuring. This commission is totally protected from any liabilities surrounding said restructuring. Gone is any reference to district health councils in section 8 of the Ministry of Health Act.
Public Hospitals Act: Bill 26 gives the minister total unlimited power to dictate how hospitals are funded, operated, closed or amalgamated.
Private Hospitals Act: The minister has the power to close or terminate any grant of any private hospital without notice. Repealed is the right to appeal. Also, the minister is protected against liability.
Independent Health Facilities Act: Bill 26 repeals current language in this act under subsection 6(3). In this section, it directs the minister to give preference to non-profit Canadian operators. Under the repealed language, the minister can direct that proposals be limited to one or more specific persons. Does this open the door to for-profit American health care providers?
Schedule G amends the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991.
Bill 26 introduces copayments and deductibles for seniors and social assistance recipients. It also deregulates prescription drug prices, and this certainly puts Ontario on the map as the only province that does not regulate prices. The Ontario drug benefit user fee or copayment will come into effect June 1, 1996. Dispensing fees will now be regulated unilaterally by the cabinet. The past process allowed for these fees to be negotiated between the government and the Ontario Pharmacists' Association. Bill 26 also gives the minister the unilateral right to determine which drugs will be listed and delisted. No longer will the markup on drugs be restricted to the 10% to 20% mark, as it is now. The markup will be set by regulation.
The minister has the power to override the decision of the doctor or pharmacist as to what is suitable medication, leaving the individual to bear the cost between approved drugs and prescription drugs. All these changes are magnified by other sources; for example, federal changes to the patent protection of Bill C-91. If you expect us to believe that deregulating drug prices is going to make the price go down, forget it. As we stated in our fight-back campaign against C-91, there were alternatives -- such measures as control of overprescribing by doctors, and to control the high costs and profits of multinational drug companies. Gone is the healthy competition of generic drugs and open is the market for wider profits. But whom does this affect? By far seniors and welfare recipients are going to feel the biggest effects. But what about those fortunate enough to have a job with insurance plans? The changes to Bill 26 will have a definite effect on premium increases, which in turn mean higher costs to the employers as well as the employees.
Schedule H, Amendments to the Health Insurance Act and the Health Care Accessibility Act: Bill 26 removes reference to medically necessary services and installs the power to the cabinet to decide what services will be insured. The cabinet has the power to determine the type of services provided to persons in prescribed age groups. It gives cabinet power to unilaterally establish basic fees payable for insured services. One amendment to the Health Care Accessibility Act gives cabinet the power to make regulations that would permit hospitals to charge patients user fees for any hospital services.
Schedule I: The Physician Services Delivery Management Act strips the Ontario Medical Association of any negotiating rights and says judges' ruling decisions, awards or orders shall be of no force or effect.
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Schedule J, Amendments to the Pay Equity Act: Effective January 1, 1997, Bill 26 repeals the proxy provision for an estimated 100,000 low-paid women in such areas as nursing homes and day care who work for employers with no dominant male job classes. They will have their right to fair pay abolished. It is obvious that this government feels their support was derived from the male population of this province only. Congratulations.
Schedule K, Amendments to the Freedom of Information and Protection of Privacy Act: It will be harder to gain access to documents. Institutions will be able to deny access on the grounds that the request is frivolous or vexatious. It will be easier to dismiss appeals when access is denied. New user fees will be introduced, starting with an application fee and an appeal fee, both to be set by regulation. The first two hours of search time will no longer be free. This amount of the fee will be set by regulation, as well.
Tom Wright, the Information and Privacy Commissioner, says the measures would threaten the fundamental right of people to know what is happening in their government. He says the new fees may deter people from seeking out information.
Mike Harris talked about democracy. If Bill 26 represents the vision of democracy maybe we should replace the trillium with a sickle or even build a wall around this once-proud province. The bill only represents power, power for the government and for corporations of Ontario. Perhaps congratulations are in order for giving the people of Ontario a reason to fight, as this bill will affect every household in Ontario.
As a representative I would like to again file my disgust. What this bill will do to our members in relation to their work is take pay increases out of their pockets and we'll have to use them to cover the increased premiums of insurance plans this bill is sure to bring. Thank you.
Mrs Caplan: Yes, thank you very much. You've raised, at the very beginning of your discussion paper, which was very thoughtful and very passionate, the issue of Americanization and you raised that issue in the context of the move to two-tier, the potential of which of course is there with the aspect of hospital user fees. Although the drug plan formally isn't under the Canada Health Act, we now will have two-tier for those who are covered under the Ontario drug benefit plan. There's a very definite two-tier, one paying a copayment, one paying a deductible, no question about it. That's a slippery slope and I think that's what you were alluding to.
While this government has said that it is going to adhere to the Canada Health Act, we do see some very significant Americanization. I'm going to read you a quote from a New York Times article on January 15: "`They are basically moving to a US managed-care model,' said Peter Coyte, professor of health administration at the University of Toronto. `The rigid protocols of American managed care intended to check the rising costs, clash with the underlying principle of the Canadian system that the doctor alone should decide what is appropriate for an individual.'" That statement was made by a University of Toronto professor.
What we see is indeed that this government, with Bill 26, if you take certain parts of it and put it together, will have the power to bring in US managed-care organization and they will be able to do that with the power of cabinet setting what is a medically necessary service. Just as you have preauthorization in the United States, that will give the power to the minister to do that, with the added ability to share information and disclose for any other purpose, which is new in this legislation, those in combination will allow the Ontario Ministry of Health to start behaving like a US insurance company with their managed-care organization catch to it.
I wondered whether you had realized, when you talked about the Americanization of the system, that that was possible as a result of this legislation.
Mr McFarlane: As I said, I'm certainly no expert, but I have my visions and I would certainly share some of those visions that this is possible.
Mrs Caplan: The concern I have is that this isn't being presented as health legislation; this is treasury policy, fiscal legislation, carried by the Finance minister. We have nobody here carrying the legislation from the Ministry of Health, and we are seeing potentially fundamental change and Americanization of Ontario health care. That's one of the reasons that I am so tremendously frustrated, particularly when I hear people such as yourself coming here and talking about their fears. Thank you very much.
Ms Lankin: Mr Chair, just on that point, I tabled a series of questions last week -- you may remember them, because you were a little perturbed that I had so many of them -- with respect to health management organizations, and actually there were some other questions over the course of the week that I tabled and that Mrs McLeod tabled. We've not received answers to any of them. I'd point out there are only two days of public hearings left.
I wanted to talk to you about the concern you raised on process, of how this is all being done and the powers being taken into government and no public input and things done by regulation. I want to give you an example. It's not like there aren't other pieces of legislation that allow regulations to be made, but it's a question of how the government will use it. We've heard a lot from this government that it would never abuse this new power it's taking on to itself.
This morning in Toronto the Environmental Commissioner urged the government not to weaken the environmental bill of rights and alleges that it has done that very significantly by a regulation that it passed behind closed doors in cabinet, regulation 482/95; no public debate. She points out that this is a blow to the province's most significant and far-reaching legislation in that area. The timing of this regulation was concurrent with the tabling of the fiscal and economic statement announced by Finance minister Ernie Eves as well as the first reading of Bill 26, the Savings and Restructuring Act. They all occurred on the same day. This regulation exempts the Ministry of Finance from the environmental bill of rights, temporarily suspends specific public notice requirements for environmentally significant proposals for the next 10 months and violates the spirit and the intent of the environmental bill of rights.
There's a lot more material here, but it shows you what can happen behind closed doors, that none of us knew about. Thank God someone has brought it to our attention. Can you talk about how you feel, as a member of the public, about the process of how laws are made and what government should be doing in public with consultation versus behind closed doors in the cabinet room?
Mr McFarlane: Well, specifically to this bill, it's so massive, I really understand how many people still in Ontario, even as we skim the surface here, understand what's behind all this and what motives there are in giving the power. You're correct. I think, in preparing this and looking at how massive it is, it would have been better served to carve pieces of this out and take committees on certain aspects of this around so the public could have a true input on it rather than try to, even myself, grasp enough information that I could prepare anything to be here today.
Ms Lankin: Okay, I appreciate that. Thank you.
Mr Clement: Thank you for your presentation. I mean no disrespect when I say it's important for us to hear those views. I'm not sure we share entirely all the points you've made, but it's important that the government continue to be exposed to differing points of view, and I thank you for doing that this afternoon.
I have one general question and one specific question. The general question is that -- you've been very eloquent about how you wish us to steer away from the development of a two-tier medical system. I made a point earlier -- you may not have been in the room at this point -- that in a sense we've got some elements, which I think are negative elements but some elements none the less, of two-tier health care delivery in Ontario already. For instance, some communities have doctors and others don't have any access to doctors. Some people don't have the discomfort associated with waiting in line for medical services; other hospitals and other health care providers in our system have long, long queues of days, weeks, months of waiting in line for health care delivery. So that's the problem with the status quo I guess is what I'm saying. Do you buy into that, or am I going off on the wrong track?
Mr McFarlane: For me personally, I would agree with the previous speaker on what "two-tier" means and what it means to the average public citizen who may at some point not be able to afford, whether it's a prescription, whether it's services because of fees. Those are the sorts of tiers I'm talking about that fees are going to install.
Mr Clement: We've got a difference of definition, but I appreciate your point. Can I ask you a specific question? You may not have an answer, but I guess I wanted to relay something to you when you talked about the need for healthy competition of generic drugs.
We do have a provision in the bill relating to Ontario drug benefit recipients. It's called "no substitutions." Where the doctor usually wrote on it "no substitutions" you had to deliver the brand-name drug to this patient, and even if there were comparable and chemically identical generic drugs available, we the taxpayers, we the community, paid for the brand-name drug being provided.
We've severely restricted the ability of that activity to take place. Is that something in line that you would agree with?
Mr McFarlane: I would support generic drugs. As I said, I talk about healthy competition. Without the competition, now that the market's wide open, where are the controls? It's unregulated. There's no control to say: "Okay, we can only have 10% to 20% now that it's wide open. There you go, multinationals. Walk into Ontario. It's a great market; lots of profits. Come and get our poor."
Mr Clement: I just want to make sure I understand. Do you agree with our position on no substitutions?
Mr McFarlane: No, I don't. My point is that I agree with generic drugs, end of question. I agree that is needed for healthy competition and it's also accessible to people who can't afford the brand-name drugs.
Mr Clement: I agree. Thank you.
The Chair: Thank you. We appreciate your presentation here today.
The next group is the Canadian Bar Association, Health Law Section, represented by Tracey Tremayne-Lloyd, the former chair. Not here?
The Region of Waterloo Pharmacists' Association?
Mrs Caplan: Perhaps you could see if any of the other presenters are here at this time.
The Chair: Guelph Wellington Coalition for Social Justice? Sheila Richardson? Ontario Health Coalition? Ontario Health Record Association?
Maybe we'll just recess until somebody shows up.
The committee recessed from 1432 to 1451.
REGION OF WATERLOO PHARMACISTS' ASSOCIATION
The Chair: The Region of Waterloo Pharmacists' Association has arrived a bit early, so we can get back to work. Welcome to our committee.
Mr John Ibbotson: Mr Chairman and members of the committee, good afternoon. I am a community pharmacist at Hoeglers, an independent pharmacy in Kitchener, and currently president of the Region of Waterloo Pharmacists' Association. With me is Sherry Peister, my right-hand person. Sherry is a pharmacist with Shoppers Drug Mart in Waterloo and current past president of the Ontario Pharmacists' Association, as well as past president of this association. We are pleased to be here today to express our thoughts on Bill 26.
Our local association is made up of 75 community pharmacies and represents approximately 200 community and hospital pharmacists in the region. The association currently organizes continuing education events for local pharmacists and keeps our membership current on events happening in the region.
We have successfully worked in partnership with the Waterloo regional community health department and have jointly launched a pharmacist-manned telephone information line for seniors. This line provides information concerning over-the-counter medication and clears up any confusion and questions regarding appropriate medication use to seniors.
We have also worked in partnership with local employers and benefit consultants over the last few years to help them in addressing their concerns over rising health care costs. We always try to address the issues and provide some guidance.
We also worked successfully with the University of Waterloo to develop therapeutic guidelines for rational prescribing, a customized formulary with an exception process, all prior to the Ministry of Health's interest in developing therapeutic guidelines.
The association has also promoted wellness programs and spoken at many of the local workplaces on various topics. We correspond frequently with the physicians in our area over cost issues of drugs as well as other topics we feel need to be discussed. Our association has successfully used the approach that by working together with other health professionals and listening to each others' concerns, this has enabled us to find solutions that benefit everyone.
We were quite dismayed to find this government trying to push forth such an all-encompassing bill without thorough consultation with all parties involved. We are also concerned that this legislation will put the power of change into the regulations, thereby circumventing the current system and allowing cabinet to unilaterally make and implement change. We do, however, applaud this government in its commitment to cut costs and in holding these public hearings.
Our association would like to address three major issues contained within Bill 26 which directly affect our profession and our membership. They are: (1) deregulation of drug pricing; (2) the loss of our negotiating voice; and (3) the issue of copayments.
First, deregulation: In 1986 the government of the day legislated acts 54 and 55, and thus was born the concept of best available price, commonly referred to as BAP. I will briefly describe the concept of BAP.
Prior to the introduction of acts 54 and 55, there was a spread on drug acquisition cost dependent on your volume-buying power. In most business environments this is a healthy and accepted business practice. Not so in the health care sector, since the commodity being purchased is medication, which affects the wellbeing of all residents in the province. Large corporations could purchase drugs at a lower acquisition than smaller independent pharmacies. BAP was put into place so that the price to the customer would remain the same whether you purchased the drug from a chain drug store in downtown Toronto or from a corner independent in Thunder Bay. This act was put in place to protect the public when purchasing prescription medication.
BAP is based upon the lowest cost of that drug in the largest quantity available directly from the manufacturer at the time that the Ministry of Health releases the ODB formulary. The ODB formulary contains approximately 2,100 prescription medications, including some specialized over-the-counter, non-prescription products. The cost of a formulary drug is defined as BAP plus 10%. The 10% margin is to cover such costs as medication which cannot be purchased directly from the manufacturer and therefore goes through a wholesaler, some drugs whose price per unit is not the same for small and large sizes, and some drugs which are purchased in smaller quantities for safety reasons, such as narcotics.
As you can see, the regulation of drug pricing is quite complicated. The government intends to keep the regulation of pricing within the ODB market and deregulate the rest of the market. It is apparent that the government does not believe free market competition among the manufacturers will ensure competitive pricing of products.
Manufacturers have always wanted acquisition cost rather than best available price. This would allow them to produce smaller quantities and charge higher prices per unit due to packaging. This practice is already in place. For an example, we can quote Zovirax. The Zovirax ointment in a four-gram tube costs $13.75, for a unit cost of $3.44 per gram. Buying it in a 15-gram tube is $36.70, which is $2.45 per gram. If you buy Zovirax in the 30-gram tube, it's $68.65, for $2.29 per gram.
Conversely, best available price encourages pharmacies to purchase larger quantities and have them on hand to fill your prescriptions. If acquisition cost was in place, pharmacists could purchase supplies as they needed them, not keep them in stock and not have them immediately available for use by the consumer. As well, this cost would be more expensive to the consumer since the smaller, more expensive packaging would be purchased.
We also wish to give another example of how the market fluctuates. This is an example from 1990. At that time a drug called methotrexate was available for cancer patients. A side-effect of the drug was that it proved to be a breakthrough for treatment of rheumatoid arthritis. The manufacturer applied for a new indication of the drug. They repackaged, renamed and repriced the drug from $55 to $100.53, which is almost a 100% price increase. A public outcry from pharmacists, physicians and patients using the drug successfully brought pressure upon the manufacturer to reduce their price. Ironically, this drug continued to be available to hospitals at the reduced cost and to retail pharmacies at the higher cost during the first few months of entry in the marketplace.
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The proposed legislation leads us to ponder if similar comparisons will be drawn between the ODB program and the private sector. Drug prices could vary between chains and independent pharmacies, consumers living in various parts of the province, and between those who participate in the ODB program and those who pay cash.
A letter recently went out to manufacturers from the Ministry of Health for a price freeze this year on their products. Mestinon 60 mg was available for purchase in December 1995 for $14.91, and in January 1996 the price went to $42.95, direct from the manufacturer. When we see these types of drug increases in a regulated market, we are concerned about the impact on our patients if pricing is not kept regulated. Since our association's commitment to patient care is forefront, our position to the government is to maintain the current standard of regulation of drug costs and the BAP plus 10% concept.
Second, negotiations: As stated previously, we believe that by listening to each other and working cooperatively together, we can be quite successful in our achievements. To this end, we were quite disappointed and disillusioned with the Ministry of Health, in finding that Bill 26 effectively eliminates the negotiation process now legislated between the Ministry of Health and the Ontario Pharmacists' Association.
In a letter to every pharmacist in the province of Ontario dated July 5, 1993, Minister Wilson, then the Health critic for the Conservative Party, stated strongly that they would not support a bill, Bill 29 at that time, that enabled the government to end-run the current fee negotiating process. We have an appendix at the end if you would like to refer to that later.
We have never negotiated with the Conservative government and find it hard to believe that they would eliminate a process which they have never participated in, albeit a poor one that is without binding arbitration. The elimination of the legislation will leave pharmacy at a complete loss to discuss remuneration for services, since pharmacy would find themselves in violation of the Competition Act.
Such services that pharmacy is currently looking at are trial prescription programs, such as the one that is now operating in British Columbia; payment for not dispensing prescriptions -- there's a program in Quebec at this time; payment for cognitive services -- this is also a Quebec program; therapeutic interchange, which would be a private sector initiative; and therapeutic guidelines.
The trial prescription program in British Columbia currently under way suggests from data collected and collated that significant cost savings are achievable. Results currently show that 57% of prescriptions filled were not renewed after the first trial portion was dispensed. This cooperative effort between the Ministry of Health in British Columbia and the British Columbia Pharmacists' Association has shown how an innovative program can successfully save the government money. Anyone wishing to have further information on this program should contact the Ontario Pharmacists' Association for a copy of the project.
British Columbia has also recently implemented a program similar to Quebec's where pharmacists are paid a professional fee not to dispense a prescription. Pharmaceutical opinion in Quebec reimburses pharmacists not to dispense and for a schedule of other interventions, including irrational choice of a product. The Ontario Pharmacists' Association would also be happy to provide this document upon request.
Implementation of any or all of the above can result in savings within the ODB program. We have seen these effective models already in place in other jurisdictions. We believe that pharmacy should be remunerated for the services provided at a level that is fair and reflects the level of service received by our patients. The issue of payment for services and other changes occurring in the managed care environment must be addressed by the government. The Region of Waterloo Pharmacists' Association would like the government to keep the Ontario Pharmacists' Association as the negotiating voice for pharmacy and to work on a process that is fair and equitable to both parties.
Third, copayment: Copayments or user fees have always been a contentious issue. Does implementing such create an awareness of or a responsibility for drug usage, or does it cause undue hardship to those who can least afford to pay? We do not question the need to control the spiralling ODB program expenditures to help maintain the program's viability. We support this initiative.
The recommendation as set out in Bill 26 to collect a $2 or a $6.11 copayment based on income levels seems complicated and appears to be in violation of the patient's right to confidentiality at the pharmacy counter. In the Common Sense Revolution Premier Mike Harris states that no user fees will be implemented and that a new fair share health care levy may be introduced. As our association has heard nothing concerning this fair share health care levy, we would like to see this concept explored further before the government implements a copayment schedule as set out in the legislation.
We would also like to explore the possibility of a consumption tax rather than the proposed copayment for participants of the ODB program. A 2% tax could be collected at the point of sale in a pharmacy and collected on behalf of the government in the same manner as the GST and PST.
We feel that there is still much investigation and thought to go into other means of potential cost-saving measures before the implementation of a user fee. For this reason, the Region of Waterloo Pharmacists' Association cannot support copayment as set out in Bill 26.
We thank you for the opportunity of presenting this brief to you today. We truly believe that by working together and by government listening to the voice of the people workable solutions can be found, palatable to all those involved. Rational medication use, reduction in medication waste by reducing quantities dispensed, pharmacists' interventions with appropriate remuneration and implementation of pharmaceutical care are approaches that will save the government money without hindering patient care. Thank you, gentlemen and ladies.
Ms Lankin: Thank you. I want to ask you about the deregulation of drug prices and the best available price plus 10% concept, that whole area you addressed.
We have heard very differing views of what this will mean. The brand-name pharmaceutical industry says that it will bring drug prices down. The generic say they're not sure: they don't think it'll bring it down, but they can't say for sure if it'll make them go up. A lot of consumers believe they will go up. The pharmacists' association thinks prices will go up. London Life said that in the short term, three to five years for sure, they'll go up and maybe after large benefit companies like them have tools, they'll be able to monitor it. Rx Plus this morning said it'll bring it down. I've admitted this on a number of occasions, but I am quite confused.
The pharmaceutical industry says that transparent pricing policies, which show not just the dispensing fee but the markup of pharmacists and the base cost of the drug, would allow consumers to drive competition which would bring the price down. Could you comment on that? Does that solve the problem from your point of view?
Mr Ibbotson: Sherry might like to comment on that.
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Ms Sherry Peister: I think it's an issue that's confusing to everyone. I know that the London Life article about the prices going up in the short term was in the paper this morning. It's hard for anyone to actually say what's going to happen to the pricing market at this time. We can only just -- I hate to use the word "speculate," but that's really what you have to do.
But we can see that when the deregulation happens, what happens to that, as we've stated in the brief, is that larger-volume-buying groups such as the large chains will be able to purchase the drugs for a lower cost. We feel that independent pharmacies, some of them up north in Thunder Bay or Sudbury, may not be able to purchase that drug at that same price.
We also think that the manufacturers could charge an extra distribution charge and as well -- it's both counts: pharmacies as well as manufacturers. Pharmacies that are in locations where there's only one pharmacy may also charge the extra burden on to the customer, so that the customer in the north of the province or in a town where there's only one pharmacy may be hindered by that deregulation of the price.
Ms Lankin: In terms of the ability of small or independent pharmacists to purchase the drug at the same discount volume that a large chain could, it was pointed out, I think, by one of the presenters or in one of the briefs that small independents had the opportunity to buy through the Drug Trading Co of the OPA. I don't know what that is, but it's like a cooperative buying, I guess. Will that solve the problem and is that accessible to all independent pharmacies and can we be assured that it will put them on an equal footing with the Shoppers etc?
Ms Peister: I don't think so, because currently Drug Trading purchases drugs for that group of independents. They go under the Guardian and the IDA banners, that part of the Drug Trading Co group, which are shareholders in the company. It actually works as a wholesaler, so the Drug Trading Co purchases drugs from manufacturers and then passes them on, so there's an upcharge in there as well. Whether they can buy it cheaply, I don't know. There are products on the market right now in the formulary where big chains like Big V, which has the largest buying power in the province, cannot purchase a drug for the best available price currently.
Ms Lankin: A last quick question: In some of the historical newspaper articles we read about people driving all the way from Hamilton to Toronto, to Honest Ed's, to be able to get good drug prices. Is there any reason to think that competition wouldn't recreate that situation of big-volume stores and people having to travel long distances to be able to afford cheap prices on drugs?
Ms Peister: It may happen. We have seniors who go on outings, on a bus trip, to go and get something, so they may go ahead and look for a lower price. But I think it's going to be an awful burden on the patient that they are going to have to phone five, 10, 15 different drugstores to find out what the price is at different drugstores, what the fee is at different drugstores. "Are you going to charge me the copayment? Are you not going to charge me the copayment?" I think it just becomes such a complicated issue, and obviously we wonder, how can the ministry regulate within the ODB program for the same drugs that are going to be deregulated out in the marketplace? I think it's just creating a lot of confusion, and we really wonder how it's going to be handled.
Mrs Johns: Thank you very much for your presentation. We've heard from a number of pharmacists and we appreciate the input we're getting, a little different view every time. I just wanted to ask you a couple of questions. My dispensing fees: I notice them when I get drugs for my kids, for example, very much across where I buy my drugs. Can you comment on why that happens, that the dispensing fees are in such a different range?
Ms Peister: We like to refer to our dispensing fees as professional fees, because they're for the professional service that we render. I think a lot has to be taken into account -- location of a pharmacy, what overhead costs that they have, whether they're renting or if they own, the type of labour they have involved in the store. It's all a business attitude of what you can afford to get a markup on your drugs, because we are in the health care business but we're also in business to make a profit. That's why dispensing fees are different. There are some people who can operate on a lower margin. Smaller independents need a larger margin to be able to provide that level of service.
Mr Ibbotson: And does the pharmacy deliver?
Mrs Johns: No. But that's okay. I understand.
Mr Ibbotson: There are all kinds of services offered in that fee.
Mrs Johns: I understand that they can vary -- we've heard quotes and articles in the ministry -- from $1.99 to $16 or $18. Is that not the force of the market that pushes the price down? Would that not be the same force that would be pushing the price of the drugs down also? What's the difference between the deregulation in the dispensing fee versus the deregulation in the drug cost?
Mr Ibbotson: No, because the manufacturer doesn't compete with the public to sell his products. All he has to do is get a doctor to write his prescription. It's a different marketing force.
Mrs Johns: If there was only one product that could serve that need, correct?
Mr Ibbotson: A lot of drugs are only single-source products.
Mrs Johns: There are lots of generics that fulfil the need of --
Mr Ibbotson: Not for 20 years for the new ones.
Mr Gary L. Leadston (Kitchener-Wilmot): I value your professional opinion in terms of the initiative with the government in Quebec with regard to the sampling. I'm not sure whether it's called a program or sampling prescription.
Ms Peister: The trial prescription program.
Mr Leadston: Yes. I'm interested in your opinion with respect to a plan of a similar nature being introduced in Ontario. Do you see that as a benefit to the citizens?
Ms Peister: I think it would be a major benefit. We've been dealing with the ECHO group in the private sector, and ECHO is interested in running in some of their companies a trial prescription program. It's been very successful in British Columbia. Up in Timmins they call it the Timmins project, and I'm sure you've already heard about that earlier this week or last week. They have been successful in giving a seven-to-10-day supply on a new medication to a patient, and if it's needed again, if they have no side-effects, if their liver enzyme tests come back properly, they fill the rest of the prescription.
In British Columbia they've already had studies coming in that 57% of the prescriptions that were filled as a trial prescription have not come back for repeats because they've had drug interactions with something else, a food allergy, drug allergy or they just couldn't tolerate the medication. We think it would show significant savings in the marketplace.
Mr Crozier: Thank you for taking the time to make your presentation. There has been a lot said. We've had various independent drug firms appear before us. You raised a good question: Why should it be regulated within the Ontario drug plan and not outside? My concern goes further in that there are people -- the working poor and those not covered by a drug benefit plan -- whom we have to take into consideration in these instances. In fact, there are those who are covered by drug benefit plans but we have to be concerned about what costs do to their premiums. There's a wide scope we have to be concerned about when it comes to regulation.
If it were to be deregulated and we were to assume that prices would increase, it's been suggested by various people, "Then you can shop around for the best price." I mention that because I want to get to this point. My wife, for example, insists that we go to the same drugstore all the time because the pharmacist knows us, knows those prescriptions we have been using. If we were encouraged to shop around and if our druggists don't have the appropriate system to interconnect with each other and know what prescriptions I may have been receiving at another drugstore, how can we rely, as we do now, on that professional advice? It's great advice we get. We get printed forms now that tell us about the drugs and what effects there are. What would happen to that professional advice if we were encouraged to go out and shop around?
Ms Peister: That's an excellent point, and it's a point we've been trying to make, the Ontario Pharmacists' Association and local associations across the province. We feel that by going to different pharmacies you get a fragmented patient profile, so if you were a diabetic or on heart medication, we may not know about that if you got that prescription filled at a different store. If you came in when you were out shopping and wanted a decongestant for a cold, if you took that drug and we didn't know you were on a heart medication, you could have an interaction between the two drugs that could put you in the hospital. We have always advocated that you deal with the same pharmacy so your patient profile is there, we know exactly what drugs you're allergic to.
My store is open on Saturdays and Sundays late in the evening. We have people coming in who went to an urgent-care clinic to get a prescription because their doctor wasn't available to see them. The doctor writes for a penicillin type of medication, and you have an allergy to penicillin. If you went to a different doctor and to a different pharmacy that wasn't familiar with you, there could be disastrous results.
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Mr Crozier: So the idea of shopping around --
Ms Peister: Is not a good one.
Mr Crozier: It's okay when it comes to tires but not so much when it comes to drugs. I'm serious. There could be serious consequences.
Mr Ibbotson: Would you shop around for a doctor?
Mr Crozier: Well, if Bill 26 goes through, we may have to.
Ms Peister: I think shopping around for your health is terrible.
Mr Crozier: Thank you. That's the point I wanted to make, that it's risky business.
The Chair: Thank you very much, folks. We appreciate your interest in our process and your presentation here today.
Mrs Caplan: I'd like to place a question on the record. There was inadequate time for me to question the excellent presentation from the region of Waterloo -- and no, it's not your fault. They've made some very serious suggestions of integrity on the part of the minister. In their presentation there's a letter dated July 5, 1993. The only thing that think happened between July 5, 1993, and July 5, 1995, was that the minister went from being the Health critic to the Health minister. The question I would put on the record and ask that the minster answer is why, given the letter he wrote on July 5, 1993, did he bring in the policies in Bill 26 that he vehemently argued against in his letter to the pharmacists on July 5, 1993?
My question to the minister is, doesn't he believe that the pharmacists' association, when he said, "Section 7 of the Ontario Drug Benefit Act provides the government and pharmacists with existing mechanisms that allow for fair and reasonable dispensing fees," had a reasonable expectation that this would be his policy in government? Doesn't he feel he owed them at least the courtesy of consulting with them before he brought in Bill 26, which dramatically changed what he led them to believe in July 1993?
I'd ask that he answer that as quickly as possible. I'm shocked by the presentation from the pharmacists' association and the evidence of duplicity that has been presented today. It's a question of integrity, and I'd like the minister to answer that very quickly. Obviously, something happened other than just the election. I'd like to know what information he had to suggest that he should not negotiate with the Ontario Pharmacists' Association and that section 7 was no longer valid. The PC Party told them nothing between 1993 and the 1995 election -- told them nothing had changed. I would like to know what happened to change Jim Wilson's mind on how to deal with pharmacy issues.
SHEILA RICHARDSON
The Chair: Are the people from the Guelph-Wellington Coalition for Social Justice here? I understand that Sheila Richardson is here. Would you mind coming forward and doing your presentation at this time? You can get home for dinner earlier that way. Welcome to our committee.
Mrs Sheila Richardson: Good afternoon, fellow taxpayers. I am a registered nurse. Currently, I work full-time as a front-line staff nurse providing direct patient care in a small community hospital.
Recently, I had the privilege of representing thousands of staff nurses, having just completed a four-year term on the Ontario Nurses' Association board of directors. As the previous region 5 director, my representation included the regions of Halton, Peel, Dufferin and York. Therefore, I can speak with some authority and experience regarding health care reform and the proposed changes under Bill 26.
I am extremely pleased to be one of the fortunate few to have the opportunity to address this committee. I have come today as an advocate for patients, parents, nurses and the senior citizens of Ontario because I care very deeply about the health care system as a whole. Health care reform is an absolute necessity if we want to maintain a publicly funded system that upholds the historic, humanistic, Canadian principles of public administration, portability, universality, affordability and comprehensiveness.
I will be focusing my submission on the following schedules set out in Bill 26: schedules F, G, J and Q.
Schedule F amends the Ministry of Health Act, the Public Hospitals Act and the Independent Health Facilities Act.
The establishment of the Health Services Restructuring Commission is a move in the right direction. I suggest that the jurisdiction of the Health Services Restructuring Commission be expanded to include community health and long-term-care facilities, not simply hospitals. For far too long governments have piecemealed the health care system and not provided mechanisms for proper coordination between institutional and community care. This has resulted in a great deal of frustration for consumers and providers, creating fragmented care that only helps to drive up the costs to the system. During this time of fiscal restraint, as hospitals deal with ever-shrinking budgets, patients are being discharged to the community more quickly, requiring a much higher level of care than previously. This process only shifts the cost from one sector to another. The long-term-care and community sectors are then left to absorb an increased patient load, yet, also dealing with decreased funds, they are cutting services too. In the end the patient suffers, with increased risk to the stability of their health as they slide through the many cracks and crevices with no resources available to stop their impending descent.
We need to fundamentally change the system and look towards a primary health care network model. This model would coordinate all sectors of health care, servicing a defined population or area. It will focus on health promotion and prevention, and consolidate health and social services. This challenge should be met by a salaried multidisciplinary team, which will provide the right service at the right time by the right provider for the right price to the right client. Salaried rather than fee-for-service providers will ensure that quality health care remains a priority. Current fee-for-service payments do nothing to address quality of care. It only encourages the provider to increase the number of clients seen per day. I'm sure we've all had to wait a spell in a doctor's office and then felt rushed through our appointment, often forgetting crucial information and questions we had.
Nurses can save the health care system money by providing some of the services currently being provided by physicians. Nurse practitioners need to be utilized to a greater extent. I encourage the government to address the necessary pieces of legislation to make this a reality.
The taxpayers of Ontario deserve to have their tax dollars spent wisely. Ensuring coordination of the system towards a seamless continuum of care will help to achieve this. It will decrease the readmission rates to hospitals due to a lack of care provision. An emergency room nurse recently told me, "I'm tired of becoming an expert at starting scalp vein intravenous on dehydrated, severely jaundiced infants." Mothers and infants are being discharged on average 24 to 48 hours after birth. The result is a rising readmission rate, especially of newborns. We need to ensure that there is enough time and staff to do the teaching required to help prevent these occurrences, with follow-through to the community. This is what preventive medicine is all about. It will save money in the long run. The commonsense saying "A stitch in time saves nine" certainly applies.
The role of district health councils in relation to the Health Services Restructuring Commission is unclear. The commission should work in conjunction with the district health councils, providing a link to local communities and permitting a vehicle for community input into decisions affecting local health care. District health councils have been studying and planning towards future health care for years, thus developing a priceless jewel of information and expertise that should not be ignored.
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To the best of my knowledge, the nursing community has yet to be officially consulted by this government in relation to the restructuring that is and will be occurring. I wonder why. Nurses form the largest group of health care providers in the system. The nursing perspective needs to be given the consideration it is due. After all, we're out there providing the direct care at all hours of the day and night.
We want to help create an efficient, cost-effective health care system. That is why I believe it is critical that the membership of the Health Services Restructuring Commission include representation from a prominent, front-line nurse. The proposed changes to the Public Hospitals Act require that physician-human resource plans be developed. I would go further to say that there are a lot more people providing care in hospitals than just doctors. If we are truly going to shift resources to the community, then we need to consider not only the money but the human factor as well. A comprehensive health-human resource plan needs to be developed that allows for redeployment to the community. We need to build on the human resources currently in our system so the knowledge, skill and experience will not be lost.
Throughout schedule F there are many recommendations that will help in restructuring efforts but many require expansion and a need to be more fully developed with appropriate regulation. There is, however, one aspect in the schedule that I find extremely disturbing. The extraordinary, unprecedented powers given to the Minister of Health with no appeal process whatsoever seem rather communistic to me. As far as I know, I'm still in Ontario, a supposedly democratic society. Not only does the Minister of Health obtain these broad, sweeping powers, but he does so without having to accept any of the responsibility for his actions. Time and again it is referred to that no actions against the government for acts under this bill will be permitted, creating instant immunity from liability. By doing this, the government has set itself above the law to which all persons are normally held accountable. I urge you to more clearly define the overriding powers of the Minister of Health and set guidelines that will ensure the input of advisory bodies in the decision-making process with an allowance for an appeal mechanism. One person should not hold such an enormous balance of power in the palm of their hand.
Schedule G, Amendments to the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991: The proposals under schedule G concern me greatly. Clearly this is nothing more than a new form of tax on the poor, sick and elderly. I predict the copayments will quickly become known as Harris fees and shall return to haunt this government by actually increasing costs to the health care system. By instituting a $2 fee for each prescription filled under the Ontario drug benefit plan, you will be encouraging seniors to request the maximum 100-days dispension of a drug. With medications taken routinely, this won't be a problem, but with new, untried prescriptions, this practice could result in substantially increased cost. The $6.11 dispensing fee per prescription and the $100 deductible per year per person may not be able to be absorbed by some seniors, even with an income over $16,000.
I guess the more medications you require, the sicker you potentially are and the more you're going to have to pay. End result: seniors trying to defray their own costs, becoming their own pharmacist and physician, filling only certain prescriptions. The direct consequence will be a dramatic increase in hospital emergency room visits and admissions and a resultant escalating placement of the elderly in long-term care facilities. The potential number of heart attacks and stroke victims should horrify us all.
These amendments are not going to stop doctors from reaching for the every-ready prescription pad, nor will it change the mindset that a pill is the answer to everything. The government needs to address the real issue here, which is a very clear need for a proper drug utilization program. Education is the key.
These proposals will most certainly have a negative impact on the health of the poor and elderly, driving up the costs of our system in totality. I urge the government to very seriously rethink these proposals for the betterment of all Ontarians.
Schedule G: amendments to the Pay Equity Act. The Ontario Nurses' Association has a long-standing history as an advocate for pay equity. We represent 50,000 nurses in a 98% female-dominated profession. The government is proposing the elimination of the proxy method for achieving pay equity effective January 1, 1997. The proxy method was developed to assist women working in employment settings that had no comparable male job classification. An adjustment of 3% of an employer's 1993 payroll will be all that the women trapped in the proxy methodology will receive as pay equity compensation.
As a fellow nurse, I feel compelled to speak against these amendments. I know of nurses personally working in the nursing home sector and for the VON who will be affected by these changes. Under these proposals, they will never have an opportunity to achieve full pay equity. This is unjust and, simply put, unfair.
What the government will be doing is rewarding employers who have procrastinated in their pay equity obligations. These employers utilized stalling tactics to the very outer limits of reasonable, wasting an exorbitant amount of time, energy and money that could have been put to better use. For our members directly involved, it adds injury to insult that this type of irresponsibility can reach such a deplorable conclusion.
This government should uphold the principles of pay equity that you are on record as supporting when the original bill was tabled in 1987.
Furthermore, I support ONA's suggestion of allowing proxy payments to be phased in at 1% of an employer's payroll for a period of eight years. This is the current method afforded under the proportional and job-to-job value scenarios. To not extend the same opportunity to the nurses caught in the proxy method is to heap discrimination on top of discrimination.
I respectfully encourage the government to reconsider their proposal and seriously consider ONA's fiscally responsible alternative suggestion.
Schedule Q, Amendments to Various Statutes with Regard to Interest Arbitration: The amendments regarding interest arbitrations will require arbitrators to consider an employer's ability to pay in settling wage awards. This sounds fairly reasonable when it's viewed narrowly. However, my experience tells me that it will only increase the delays and costs of our already overburdened arbitration system. The employer will argue ability to pay and the union will counterargue, and so on and so on and so on. The number of appeals, along with costs, will skyrocket, and the only ones laughing will be the lawyers, all the way to the bank with our tax dollars. It also gives an economic incentive to employers to mismanage funds, something for which employees should not have to suffer.
Schedule Q needs to be removed from Bill 26. We need to improve the collective bargaining and arbitration process. Central bargaining is a cost-effective method and should be strengthened. The government needs to sit down with employers and unions to find workable solutions to the arbitration process.
In conclusion, I would like to encourage the government to provide for increased consultation and evaluation of submissions regarding Bill 26. This is a massive piece of legislation that needs to be broken up into sizeable chunks so it can be dealt with appropriately.
Change to our health care system needs to occur. We do have too many hospitals and inefficiencies that currently exist. Coordination between hospitals, community and long-term care must be facilitated to create a seamless system that truly meets the needs of everyone. The time to start this process is now. Working together, we can do it. We possess much of the information needed to forge ahead and create a shared vision of health care as it ought to be.
Our health care system is too precious to lose. Having worked in Texas in the early part of my career, I know this to be true. I really value our system. The overcare for those who had money and the undercare for those who didn't left a great impression on me. I remember one specific 49-year-old patient who had a cardiac arrest, and the subsequent argument that took place outside her room between a resident and intern after she had been resuscitated. You see, she didn't have any health insurance. Consequently, money won the argument and she was placed on a step-down cardiac unit rather than the intensive care where she would have gone had she been insured. She died two days later, and I'll never know if her placement made that defining difference between life and death. I'll never know, but I rather think it did.
The decisions we make today regarding health care will determine whether we preserve a publicly funded system for tomorrow. The business community should take heed. Our health care system provides us with a rare competitive advantage. We spend 10% of our gross national product on it compared with the 14% that the States spend on theirs. Four per cent of billions of dollars is a lot of money.
There exists a terrible danger that the very speed of health care reform and the lack of appropriate consultation and professional input may not give us time for common sense. Slashing and burning without a comprehensive plan for our future could cost us all dearly in money, decreased health status and our very lives.
Nurses are the glue that holds the health care system together. Twenty-four hours a day we are on the front lines assessing, planning, providing and evaluating patient care. I cannot emphasize enough the importance of a nursing perspective in decisions about health care reform. Nurses, since the time of Florence Nightingale, have put patients and their best interests first. We will continue to do so. For all the knowledge, skill, expertise and dedication that nurses possess, we have frequently and repeatedly been ignored by government. This is one of the major reasons health care is in the state it is.
ONA and the nurses of Ontario are ready to assist you. Involve us now so Ontario will not lose the opportunity to make substantive, constructive changes that will enhance and preserve our health care system for future generations.
Thank you for allowing me this time and your attention regarding these very critical issues.
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Mrs Ecker: Thank you very much for coming, and please don't feel you need to apologize for feeling very strongly about this issue. If there's one issue that unites all of us from all three parties, it is a concern for the system. While we may differ in some ways about how we maintain the system, most of us in this country very much care about it.
One of the interesting comments in the document you handed out to us today is:
"Health care myth: Ontario's health care system is underfunded.
"Not at all. Ontario has the most expensive publicly funded system in the world.... Of each dollar in Ontario's health care budget, 44 cents goes to hospitals...27 cents goes to OHIP.... But people here do not live as long as those in Japan or Australia, both of which have less expensive systems. The problem is not money -- it is the fact that money is poorly allocated and inefficiently used. We can't buy our way to better health, but we can think and spend smarter."
That probably sums up very quickly what governments have wrestled with to try and reallocate resources within the system.
One of the suggestions you make, which has come up throughout the hearings and which I find quite interesting, is that the hospital restructuring commission, you quite rightly point out, should be linked to the district health council local planning. That should be very clearly there, and the district health councils do remain in the legislation, and their role as written in the legislation does not change.
One of the interesting points you make is that the role should be broadened, that the commission's terms of reference should include something to do with community services. Do you want to elaborate on that? I find that a very interesting concept.
Mrs Richardson: If we're going to shift the resources to the community, we can't just deal with the hospitals. That's what we've done historically. Everyone stayed in their own little silos, the hospitals over here, community health there, and meanwhile you've got administrative functions being duplicated everywhere and costing us a fortune. We need to reallocate the dollars, and you need to have the commission broadened so it can deal with all aspects of health care and not just the hospitals. Staying in one silo is not going to break down the walls and allow us to create the health care system we need to create, which should be comprehensive and should allow for patients moving from the hospital quickly into the community.
Mrs Ecker: One of the other points you made is doctors reaching for prescription pads. We have heard some concern from seniors about what they've seen as overprescribing of seniors. With your experience in the system, dealing with physicians on a daily basis, do you have any advice for what would be the best way to encourage physicians to use drug utilization guidelines or prescribing guidelines or whatever the term might be?
Mrs Richardson: What we're probably looking at is the fee-for-service system. That needs to be scrapped. Fee-for-service does nothing for quality of health care. As I said in my presentation, the doctors, through no fault of their own -- they want to make a good salary so they book and overbook and overbook. They're seeing patients and turning them in and cranking them out just as fast as they can see them.
It's the same thing in the hospitals with the patient- weighted case costs. All that tells the hospitals to do is move the meat faster. That's what they've been doing, and you end up with people out on the street with no community resources set up to look after them, and then they're readmitted back into the hospital.
As for how you get through to the doctors, you need to put them on salary and then they will have the time and devote the time. You also need to utilize nurse practitioners. Nurse practitioners have been in the system for a long time. They've been working up north where no doctors are willing to work and they've been coping with a lot of the skills that the doctors utilize down here.
Nurses are trained not just to treat the sick mode. We're trained to look at preventive medicine, and preventive medicine is what we need to develop more. Nurses are probably very well trained to do that.
Mrs Caplan: Thank you for an excellent brief. I'm going to start by agreeing with you that the commission in Bill 26 is in fact for hospital restructuring and has to do with hospitals only. It is not a health systems approach, nor is it an approach that will see to the proper shift and see that those aspects are in place, necessarily, because we don't know how it's going to work, what the mandate is. It's unclear. We have not had any of that policy discussion before us, because this isn't a health bill; it's a money bill.
One of the things we're trying to put in place -- because notwithstanding what Mrs Ecker was just saying, there's no guarantee of any process. While the district health councils, it is true, remain advisory to the minister, there's nothing in this legislation that requires a report from the district health council and, frankly, nothing in this legislation that requires a transitional plan or a labour adjustment plan or any of those policies to be put in place. I'm very concerned, because nurses should have been consulted, as should the doctors and other important stakeholders that this government sees as vested interests. It's an insult to have left you out of any consultation.
Do you think that before the commission is able to implement the restructuring, there should be a human resources plan in place, with transitional policies that will give some comfort to the staff, nurses and other hospital workers, doctors who may lose their privileges? Don't you think the minister should have to approve that kind of plan before the commission is permitted or has any authority to implement a restructuring?
Mrs Richardson: You make a very good point. How do you know where you're going to go if you don't have the plan behind you?
Mrs Caplan: This doesn't require a plan.
Mrs Richardson: Our real concern is that, as you say, district health councils are completely left out of section 8, where they were before; they are not mentioned. In fact, I met with an MPP in the riding where I work and he more or less implied that district health councils could potentially be a thing of the past. I'm extremely concerned. You're going to lose all this expertise that has taken years to develop. And I would go further to say that district health councils need to be mandated to have front line providers on them. We see some that do, but some district health councils tend to be very administrative- and provider-heavy.
Ms Lankin: To follow up, there is a requirement on the composition, but some of the problem is in the definition of "front-line," the way nurses see it and the way some other health professionals might be viewed to be front-line. I understand the problem that gives rise to in DHC makeup in some communities.
Sheila, I'm really pleased you got a chance to present. I realize that you're here on your own and not officially representing ONA, but I'm glad you're here. ONA hasn't been able to get on. They had one spot very early in the first week and had to give it up because they didn't have time to finish their analysis of the bill, and they haven't been able to get on anywhere else. We've only had one other nursing presentation from Vickie Kaminski from RNAO. We've been through almost three weeks of hearings now and you're the second nursing presentation. The whole profession really has not been heard from, and there are other health professions and health practitioners very much affected by this bill who also haven't had a chance. So I'm glad you're here.
I've got two questions. One's quite technical and quick. You referred to nurse practitioners and the change in legislation required to allow them to come into practice. I maybe have forgotten, but I thought that under the Regulated Health Professions Act, when we fiddled around at the very end with the scope of practice for nursing, we left room for that to grow under the college with college input, so it wouldn't require a legislative change to bring back nurse practitioning. Am I wrong?
Mrs Richardson: Actually, having just finished on the board in December, we had a discussion regarding this and certainly the college is looking towards developing and implementing that. However, pieces of legislation do need to be opened. One is the pharmacies act because of the dispensing situation. The other is the laboratory act in regards to withdrawing blood.
Ms Lankin: As long as you're not telling me that we have to open the Regulated Health Professions Act again.
Mrs Richardson: Unfortunately, different acts that do have to be opened --
Ms Lankin: The ministry staff over there are all laughing, and you know why. They went through three governments and eight ministers of Health trying to get that piece of legislation done.
My other question is about your experience in the United States. I'm also looking at this publication -- which I remember getting when I was Minister of Health but haven't seen for a while -- about the Oregon model. We've heard people make reference to a list of core services and the Premier talk about things we do now that aren't medically necessary. I read into the record a letter to the Minister of Economic Development, Trade and Tourism about a conversation he had with a doctor where he talked about a core list of services.
In Oregon where they did this priority listing -- it involved a public process, so that part of it was good, but they excluded about 15% of the services because they couldn't pay for it. It was bottom-line fiscal. These exclusions included things like the common cold, treatment for obesity, aggressive treatments for terminal cancer, AIDS and premature infants. Can you comment on what that move to core services, particularly under this bill where there's no public process left, might mean here in Ontario?
Mrs Richardson: That will mean increased health costs because when people don't get the services they need or are afraid they're going to end up having to pay for, they will not go to see a physician and will end up in emergency rooms in a much sicker condition than they would have been originally.
The Chair: Thank you, Mrs Richardson. We appreciate your interest in our process. Is the Guelph-Wellington Coalition for Justice here yet? We're going to recess for five minutes till we see if our next presenter arrives.
The committee recessed from 1552 to 1556.
ONTARIO HEALTH RECORD ASSOCIATION
The Chair: The Ontario Health Records Association, represented by Marci MacDonald and Gloria Ringwood, are here nice and early and have agreed to go ahead. Please come forward, and you also will get home for dinner earlier.
Ms Gloria Ringwood: Thank you very much. I'll briefly give a background on the Ontario Health Records Association. We were established in 1935 to represent and advocate for health record professionals in the province. We represent some 800 members employed in a variety of health care settings: hospitals, community health care and so forth. The association's focus is on health information management, which includes the management of patient records. That will be our focus today.
In response to Bill 26, our association has looked at four of the schedules outlined, schedules F, G, H and K. We've listed points that are themes through these four schedules that we would like to express our concern about.
(1) The schedules refer to:
-- The collection of patient information. The concern is with who will be collecting the information.
-- The disclosure of patient information. Again the concern is with who will be disclosing the information collected and to whom it will be disclosed.
-- Destruction and/or storage of patient information. The concern is with who will provide the storage and the collection of this information, under what conditions, and how or when the collected information will be destroyed.
(2) The specificity of requested information contained within the patient's record is not identified. Will the requested information be identified with the patient's name, date of birth, address, medical history etc, or will the information be aggregated in such a way as to maintain the anonymity of the patient?
(3) How will individuals designated to inspect and/or obtain patient information on behalf of the minister or general manager be selected? What specific professional and/or other qualifications will be employed? How will privacy and confidentiality of the information be maintained with these individuals?
(4) The Minister of Health and general manager may disclose patient information. Again, what information, to whom, and under what circumstances? Will the patient be notified? Will patient consent be obtained? Is the patient's right to privacy and confidentiality being respected?
(5) Bill 26 addresses the need to access patient information, to review the information and to disclose the information regardless of the patient's right to privacy where their personal information is involved. How will this concern be addressed?
Due to this issue, there is the potential for health care providers to avoid the comprehensive documentation that currently occurs with patient medical history. Conversely, the patient may be reluctant to disclose the full nature of their health condition for fear of disclosure of this information to a third party.
(6) Currently, OHIP completes random audits of physician billing by sending to a patient a form. This form indicates the procedure and/or treatment provided, asks the patient to complete the form, provide their consent to disclose the information, and this completed form is then forwarded to OHIP.
The key points are: Is the patient aware that their personal health care information is being accessed? They are providing their consent in that case. Under the provision of Bill 26, how will the patient be apprised that their personal information is to be accessed and how will the patient's consent be obtained?
(7) Another issue we looked at was the terminology of "frivolous and vexatious" request for information. We wondered how this was going to be qualified.
(8) In the event of hospital closure within the hospital services restructuring, who will retain ownership of the health record? How will the patient information maintained electronically or on paper be retained for subsequent access? How will the privacy, confidentiality and security be addressed?
(9) There is also reference in the bill to the establishment of agreements for the collection, use and/or disclosure of personal information, that is, indirect collection of information for the minister. What individuals, businesses and/or agencies will be solicited? What qualifications will be required? How will patient privacy and confidentiality be maintained?
In summation, the Ontario Health Records Association has concerns, after reviewing Bill 26, in regard to the patient's right to privacy and confidentiality of their personal information, how access to personal information will occur and by whom, how and to whom personal information will be disclosed and how this personal information will be retained/stored or destroyed.
Furthermore, our concern is heightened not only with the issues pertaining to how information will be collected, disclosed, destroyed and/or stored, as outlined in the bill, but with the methods of electronic information transmittal, which are not addressed. Thank you.
Mr Crozier: Thank you for your presentation. You've raised some interesting questions. These folks here have attended many more of these sessions than I have, but you've raised some questions I haven't heard before except in the general area of privacy. I'd like your comments on a couple of things.
I asked a physician, if this bill were passed in its present form and those areas relating to privacy were left the way they are, might it lead to less information being on a patient's file because there may be a reluctance of physicians to record that information? I assume that's something you may have been concerned about.
You've raised these questions and you deserve answers, because you're professionals in your field. I suggest that what's going to happen is that the part that remains unseen yet, which we haven't discussed or been able to discuss, which is not in these 211 pages, are regulations. Regulations are written by the ministry and are put into effect without any debate in the Legislature. It may be that a number of the questions that you raised will be answered through regulation, but will they be answered satisfactorily and will you have an opportunity to have input on them? I think those are two additional questions.
I might say too, and you might be able to comment on this because of your involvement in the records profession, that part of what we seem to be after in this bill is to go after fraud. The only thing is, it appears to me, that it's fraud on behalf of health care givers where, I suggest, it's relatively limited.
What hasn't been addressed, or at least what I haven't come across yet and someone may want to comment on, is if we really want to get after fraud, I guess we want to get after abuse of the system where citizens of other countries may be coming to Ontario and accessing our health care system when they shouldn't be. That leads to what kind of cards we're going to use to access the system.
I hope you've been able to keep track of those three or four things that I mentioned and maybe give some comment on them.
Ms Ringwood: In regard to physician reluctance to document fully in the chart, I would think that would be a real concern. In contact with members of medical staff in various scenarios, that issue with them has been expressed and they will pursue, I think, a path of not fully documenting. They may keep their own private notes, but it's not going to appear on the chart. That causes concern when you're trying to deal with treatment of a patient across many different types of health care and you want to ensure that you have as much comprehensive medical history of a patient as possible. That is one reason why I raise that in the document. We do have concern with that.
Ms Marci MacDonald: Patients themselves may not feel comfortable disclosing it even to the physician.
Mr Crozier: Exactly. Under these circumstances.
Ms MacDonald: Yes. Very reluctant.
Mr Crozier: I raised more questions, I guess, in addition to yours really, and the only remaining one I have is, very quickly: Since you're an association, do you regularly have consultation by your association with the government?
Ms Ringwood: Not with the government. Indirectly. We have association with the Ontario Hospital Association directly. We do work with the joint policy and planning committee on certain issues, and minute times with the ministry themselves in terms of issues. But this issue is very near and dear to our hearts in terms of what our profession is all about, and very much so that we are concerned with the privacy, confidentiality and security aspects related to the bill.
Ms Lankin: In light of that, and I think I know the answer to this, given that you're the only professional association whose sole purpose is dealing with professionals who deal with health information, were you consulted with respect to the drafting of Bill 26?
Ms Ringwood: No.
Ms MacDonald: Absolutely not.
Ms Lankin: I thought I knew the answer to that.
Ms MacDonald: We're hoping that now you know we exist, you might do so in the future.
Ms Lankin: I actually was aware that you existed through the JPPC and the work that was being done on HMRI and everything. I knew that you were a party to that.
Ms Ringwood: It's just that when we get to the consultation processes around issues like this, it tends to be that associations such as ours are lost in the group of other professions that are out there, and we would very much like to be involved in any other consultative processes that do occur.
Ms Lankin: The government has said that it's certainly not their intent to disclose private health information willy-nilly, and I think we can believe them on that front. But the concerns are in the way in which the bill's been drafted and the open-ended powers, and even inadvertently what that means when there aren't really tight rules around who gets to see it. When you expand it to all the people who can have access it creates problems.
For the first period of time during the hearings, the government said that really this was about being able to go after fraud, and you would have to say primarily physician fraud, although Mrs Ecker refers to 7,000 patients who sought assistance from five family physicians or more in a given period of time. The way in which patient records and billings and those sorts of things are done, you can't cross-reference what one person does with their health card, where they go, but you can cross-reference what one doctor has sent in in terms of billing. So it would only get at physician fraud and, quite frankly, it's the billing information and financial accounting you need, not the personal health information. So that sort of gets dismissed.
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Just recently they brought up this issue of the Institute for Clinical Evaluative Sciences needing this information to do epidemiological. Again, you don't need individual, you need HMRI data, which is being provided to David Naylor and ICES --
Ms Ringwood: That's right. As long as it's aggregated data. The patient identifier is not an issue.
Ms Lankin: Let me tell you what I believe that provision is for, to be able to do anything else you want with and disclose at any given time. It is to contract out OHIP and the health card.
The minister, when he was the critic, was very concerned about health care fraud, Americans using our health care etc, and a new health card is being introduced. In the previous government's time they did a pilot project of smart card technology. They determined that the issue of the electronic transmittal of data was very, very complicated with respect to privacy considerations and that if we move in that direction, which has a lot of value, should be phased in and there's a five-year renewal on that new health card and smart card technology can be phased in as we get the privacy problems all worked out.
The new minister, to make his splash, wanting to go to smart cards, has put the other health card on hold and has said he's going to go to smart cards. He can't do it inside, he's going to contract that out, and all that information needs a provision to be able to disclose it to the company that's going to provide it. There are lots of issues around electronic transmittal which have not been worked through. Can you comment on that, because I believe that's the real purpose behind these provisions.
Ms Ringwood: The Ontario Health Record Association recently, because we recognize that there is definitely a weakness in that area within the province, has a variety of community information networks that are being established and were through the Ministry of Economic Development, Trade and Tourism. Their intent is to build central repositories where patient information is stored and therefore accessed within the community by several individuals.
What we see as an issue is what patient information is going to be housed in these repositories and who is going to access it. There have been indications where pharmaceutical companies at times have made indication that this would be information that they would like to have access to for their own purposes, research and so forth. In light of that, our association has formed a steering committee and what we've tried to do is bring together as many stakeholders as we can.
We do have some representation from the Ministry of Health in the sense of their information systems branch. We have OHA, we have OHMISA, which is the Ontario Hospital Management Information Systems Association in the province, ourselves. We have had contact with the Ontario Medical Association, which is willing to participate, also the privacy commissioner's office.
The intent of that group was to establish one committee that would be able to start to address the issues in terms of standards as they arise, recognizing that we're all independent associations, some volunteer, some not. The ability to do this on a more global perspective may be limited, but it is something our association would like to see brought to the forefront, possibly with some backing from the ministry, because I definitely see that we need to address the transmittal of electronic patient information.
Ms Lankin: I wish you well in that work. What the privacy commissioner would argue, and I suspect he would argue this because he argued it with me when I was minister, is that we've got to get on top of these issues before we move to smart card technology. In fact we should probably have health information privacy legislation, specific legislation unto itself. I think what the minister's trying to accomplish is too open-ended here and we need the rules written in legislation.
Ms Ringwood: That's exactly what we're trying to point out, that it's too loose and we need to have a specific regulation.
Mr Wettlaufer: Thank you for your presentation. Could you tell us how many people today and who they are who would have access to a patient's records?
Ms Ringwood: If you're in a health/hospital institution it would be anyone providing health care to that patient, depending on their need-to-know basis. It could be a patient's insurance company. It could be their family physician. It could be from a legal perspective, that there is either a claim against the Facility or they're pursuing their own claim when they've been in a motor vehicle accident, and therefore you're working with their legal counsel. Myriad individuals would be able to have access.
There are safeguards in place, and that's what our profession works towards. We are employed in the facilities to provide a secure environment for the information and to maintain privacy and confidentiality of those records by ensuring that work is done with the corporations and that the necessary policies are in place to support that.
Ms MacDonald: One thing I'd like to add is that in all the scenarios Gloria pointed out, there are all kinds of cases where they've given written authorized consent for that disclosure.
Mr Wettlaufer: Nevertheless, a fair number of people would have access to those records.
Ms Ringwood: But with patient consent.
Mrs Ecker: What about access under some of the regulatory colleges' investigations, the Medical Review Committee, some of the quality assurance provisions in a hospital? Are there specific patient consents for that information?
Ms Ringwood: We're looking at quality assurance information. The intent behind that information is to assess the quality, the care within the institution, to provide the most appropriate care. They are looking at aggregate data. They're not specifically looking, I would say in 90% of the cases, at the patient; they're looking at the procedure, the treatment, the care provided, the outcome.
Mrs Ecker: That's right, but they do need access to the patient record to do that, as you point out, very useful, worthwhile --
Ms MacDonald: Or more often it's compiled by folks like ourselves, and then the aggregate totals and the final stats are presented to the committee. Very rarely will they sit down and look through 100 patient records.
Mr Wettlaufer: This is the medical review committee that does this.
Ms Ringwood: It also could be the corporate quality assurance program.
Mrs Ecker: The medical review committee, as I understand it, basically, if there is a question of billing or something, would take literally hundreds of records from that physician to look into them, and I didn't know if there was an actual request to those patients to say, "We are going to take your file." They sometimes go to patients and ask them but the actual review overall didn't necessarily ask for permission from a patient to include that file in the medical review process.
Ms Ringwood: In certain circumstances, there will be consent; not in all. Recognizing that these individuals looking at the charts are health professionals providing care, and they do practise --
Mrs Ecker: Public members are on the medical review committee. I'm not trying to --
Ms Ringwood: I'm just looking corporately. I'm trying to think of a public member in the corporation where I work, and we don't have one.
Mrs Ecker: There are public members on the medical review committee who are there to balance it out.
Ms Ringwood: But they're looking at aggregate data; they are not looking at the charts.
Mrs Ecker: In some cases, the charts are part of that process, as I understood it.
Ms MacDonald: I understood patient information, such as name and address and date of birth, would've been removed.
Mrs Ecker: They are trying to do that now. They didn't originally.
Your points about confidentiality are quite valid, and confidentiality of records is a principle we all respect and all want to maintain. The interesting point is that very few people have any idea what the current access is to health records and that, as Ms Lankin has pointed out, the commissioner has been lobbying many governments to have actual health confidentiality legislation, which might indeed in the long run be quite helpful.
Ms Ringwood: It would very much be helpful.
The Chair: Thank you very much. We appreciate your presentation today and your interest.
Has the Guelph-Wellington Coalition for Social Justice arrived? I guess they're not going to show up. The only other group to hear from is the Ontario Health Coalition. They will not be ready until 4:30, so we will recess for 10 minutes.
The committee recessed from 1618 to 1630.
ONTARIO HEALTH COALITION
The Chair: Our last presenter for the day has arrived. The Ontario Health Coalition, represented by Dan Benedict, co-chair, Julie Davis, co-chair, and Adrianna Tetley.
Ms Julie Davis: We're here today to make a presentation on behalf of the Ontario Health Coalition. Our coalition is a coalition of seniors, anti-poverty groups, women's groups, nurses, doctors, Indian friendship centres, coalitions for social justice, and labour. We have members throughout Ontario, from the far north to the south, from cities to towns and throughout rural Ontario.
The Ontario Health Coalition is committed to maintaining and enhancing our publicly funded, publicly administered health care system, and we believe that the principles of the Canada Health Act must be honoured and strengthened. The Ontario Health Coalition endorses the 10 goals for improving health care put forward by the Canadian Health Coalition, and we believe that all members of the community should have the right to food, security, adequate housing, quality child care, employment, education, health care and a safe environment in our homes and our communities. We will promote social and economic justice to build a society where every participant contributes fairly.
We believe Bill 26 totally violates our vision statement, and we call on the government of Ontario to immediately withdraw Bill 26 in its entirety. Any consideration of the elements of Bill 26, in our view, should be retabled and discussed in manageable pieces, and the public should have the opportunity for democratic discussion, debate and full consultation.
For any changes which affect our health care system, we would argue that the government must establish a consultation process that involves users and providers of the health care system, advocates for health care, for health care workers, labour and members of the medical profession. The 10 goals for improving health care for Canadians, which is part of the appendix, must provide the basis for any review of the health system in Ontario.
We welcome the opportunity to make our concerns clear to you today, although we are appalled that it took such drastic action inside and outside the Legislature before this government succumbed to even this limited consultation process. We protest against the obstacles to a far broader consultation and we hold the government responsible for driving the citizens of Ontario to hold unofficial parallel hearings in order to voice their concerns, as took place in Sudbury earlier this week.
Our concerns with the omnibus bill are overwhelming. We want to start by addressing some of our concerns with what we believe are the ideological underpinnings of this bill.
First of all, we do not believe that Bill 26 is about the debt and deficit, or about getting spending under control. According to Stats Canada, Ontario's social program spending per capita is about 9% below the national average for all provinces and the overall provincial taxes per person in Ontario in 1993 were 4.4% lower than the national average. We also know that health care spending in this province is not out of control. It has not increased in the last four years, and this reason definitely does not justify taking over the most minute aspects of our health care system, shutting hospitals or introducing user fees.
Bill 26 is also not about reforming the health system for the benefit of Ontario and it is not about ensuring that we have a health care system in the 21st century. To our minds, Bill 26 is about three things: finding dollars to pay for the income tax cut for the rich, privatizing our health care system and putting unprecedented arbitrary power in the hands of the ministers of this government.
It is about taking our publicly managed health care system and turning it over to the private corporations without regulations or controls. It is about handing our health care system to the private sector to make profits on the backs of the poor, the middle class and the vulnerable. It is about two big corporate winners: private health care firms and multinational drug firms.
It is about government turning its back and its responsibility for being the guardian of our social programs. It's about entrenching an environment of survival of the fittest, where anyone in need is seen as a blight on society.
It permits, and we would argue that it even encourages, extra billing and entrenches two-tier medicine: one tier for the rich and one tier for the poor. We believe that it clearly violates the Canada Health Act.
We also believe that it's an assault on democracy, in that it takes all power away from local hospitals, local communities and the medical profession and places it all in the hands of the ministers and cabinet.
The ministers and cabinet or anyone they appoint are not held liable for any decisions or actions they may cause, and the bill states they have power over the courts and no one -- not citizens, not the workers, not the doctors, not the hospitals -- has any right of appeal. We believe this to be an arrogant show of power and self-righteousness when the cabinet and the ministers feel that they and they alone have the right and the knowledge to make decisions affecting the health of citizens in Ontario.
Throughout Harris's mandate, he constantly tells the public and the poor to break their dependence on our social security programs, yet in Bill 26 he shelters his ministers and his appointees from any responsibility for themselves or the situations they might create.
No sector is as significantly affected by Bill 26 as the health sector, and we have serious concerns with several aspects of the schedules that affect health.
Schedule F is a direct attack on the principles of the Canada Health Act. It gives the ministers and their delegates the arbitrary power to close public hospitals and the equally arbitrary power to invite private American or other profit-making corporations to open licensed fee-charging facilities in Ontario. It permits a wide use of user fees and extra billing practices and firmly establishes two-tier medicine.
The Ontario Health Coalition cannot support any move in these directions, and we call on the government of Ontario to withdraw schedule F, the schedule that amends the Ministry of Health Act, the Public Hospitals Act, the Private Hospitals Act and the Independent Health Facilities Act.
Specifically, we oppose the following amendments to the Ministry of Health Act: the establishment of a Hospital Services Restructuring Commission with a mandate to implement the government's agenda on hospital restructuring, without any accountability to the community and with total protection from any liability for the negative consequences of its implementation of hospital restructuring; and the deletion from the Ministry of Health Act, section 8, of any references to district health councils.
In the bill there are no restrictions on the duties of this hospital restructuring commission. The minister can delegate any authority he wishes to this commission, which will be empowered to carry out restructuring in whichever way they deem appropriate. There is no requirement to consult with the community.
The government can order it to run roughshod through communities, close or merge hospitals, all in the next four years. The government can then blame the commission for any community outcries because, as stated in a recent press release, "The powers will be given to the commission, not the Minister of Health, to restructure hospitals." On top of this, both the government and the commission are protected from any liability or damages.
In the proposed amendments to the Public Hospitals Act and the Private Hospitals Act our coalition opposes:
-- The virtually unlimited power given to the Minister of Health to dictate every detail of the hospitals, including the funding, operation, closure and amalgamation of public hospitals.
-- The fundamental changes to the democratic community governance structure of community boards of directors of hospitals and the overriding power of the Minister of Health over all decisions of the community board of directors without their input.
-- The power of the minister to close or amalgamate hospitals on fiscal and budgetary reasons alone, without regard to the quality of care.
-- The definition of "public interest." The minister can determine that the only public interest issue is the availability of resources. The availability of resources is a matter of priority. The Minister of Health may well find less resources available for health care because more is needed to cut the income taxes of the well-to-do.
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We also oppose the power to direct hospital supervisors to implement the minister's decision and to take over the powers of the local board of directors; the protection of the minister, investigator, hospital supervisors and board of directors from any liability as a result of hospital restructuring; the power of the minister to close or terminate any grant of any private hospitals without notice; and the fact that all hearings or rights of appeal have been repealed.
Why is Ontario in such a hurry to close and merge hospitals? For those of you who may think we have too many hospitals with too many empty beds, maybe we should stop and ask the question why the beds are empty in the first place. At times it was because the funding had been cut over the years and the hospitals had no choice but to leave those beds empty; at times it was because people had been sent home before they were physically ready to go and before arrangements could be made for the necessary community services, if they existed at all; and at times it was because people had been refused admission.
Ontario already has the lowest length of stay for patients in hospitals and the fewest number of hospital beds for every 1,000 people in Canada. The pressure is continually to get these numbers down, to reduce the length of stay in hospitals and to reduce the number of beds, yet no one is asking the very important question: What about the quality of care? What should be the standard to provide good quality of care for the residents of Ontario as we enter the 21st century? Bill 26 does not respond to this vital and pertinent question. Instead, it is cost, not quality of care, that is determining our standards. Bill 26 gives the arbitrary power to the minister and to the hospital restructuring commission to close and merge hospitals based on cost alone.
In 1994, the Provincial Auditor stated that the Minister of Health does not have a system in place to monitor bed closures to ensure that service levels are maintained as beds are reduced and that service reductions are not offset by increased waiting periods for treatment. He went on to state that the Ministry of Health does not collect waiting list data, with the exception of cardiovascular surgery and cancer radiation. Also, no one is monitoring the readmission rates of people who have been discharged too quickly and then readmitted sicker than before.
Finally, there is also no statement in the bill that states that any potential savings from the hospital restructuring would be reinvested in the community to cover gaps in service. There is no attempt to move or retrain workers. There is no commitment to ensure that capital dollars are in place to modernize the remaining facilities to today's standards.
Under the proposed amendments to the Independent Health Facilities Act, we oppose:
-- The power of the minister to unilaterally create independent health facilities by regulation alone.
The power of the independent facilities to charge a facility fee over and above what they receive from the government for insured services. This is called extra billing.
-- The deletion of all preference for non-profit or Canadian, thus opening the doors to private American or profit-making corporations to open licensed, fee-charging facilities in Ontario.
-- The removal of the requirement for public tenders, that allows the minister to handpick the corporations or organizations to deliver the service, thus creating an open invitation to favouritism and/or corruption.
-- The deletion of the definitions of "health care" and "health record" and the changing of "insured service" to just "service." This allows for deinsuring services and implementing user fees in other parts of Bill 26.
-- The powers of the minister to deduct from physician payments any amount that in the minister's opinion should not have been paid, with no right of appeal for the physician. This means that if a doctor provides a service that later the government decides was unnecessary, the doctor will not get paid for providing that service. This process could lead to doctors hesitating to send people for assessments.
Schedule F proposes changes to the Independent Health Facilities Act that will challenge our ability to maintain a universal, accessible, not-for-profit publicly administered health care system in Ontario. It provides the framework for the further entrenchment of the two-tiered health care system, one for the rich and one for the poor. It specifically accelerates the privatization and incorporation of our health care system, and the deletion of the tendering process allows the Minister of Health to handpick corporations or individuals who will be able to open up businesses and franchises of health care clinics that charge people money.
In tandem with the massive cuts to hospital services, the new legislation allows the health care gaps to be filled by more private clinics or organizations intent on making profit from the sick or the elderly. It's a potential gold mine for the American corporations who are extremely interested in our health care system. That corporate world calls Ontario, and I quote, "the world's largest unopened oyster," and they refer to care for the elderly as "mining grey gold." There are alternatives to privatization, and government must work with users, the providers and the unions to review and implement alternatives without privatization and without user fees.
Mr Dan Benedict: I'm Dan Benedict. I'm co-chair, along with Julie, of the Ontario Health Coalition. I'm also the co-chair of the Ontario Coalition of Senior Citizens' Organizations.
We call for the withdrawal of schedule H, which amends the Health Insurance Act and the Health Care Accessibility Act. We oppose the removal of all references to "medically necessary" services. This opens the door to serious delisting of services. We also oppose the power of government to unilaterally determine whether medically necessary services are insured services or not.
We oppose the power of cabinet to determine the types of services provided to persons in prescribed age groups and the power of the general manager of OHIP to determine whether services were medically or therapeutically necessary. Some of you may have visited lands in different parts of the world where ancient people are sent up on mountain tops to disappear from circulation, and you might find that as useful in solving the problem of older people who get sick as the government's intentions here.
We're also opposed to the power of cabinet to unilaterally establish the "basic fee" payable for insured services; and the power of the minister and general manager of OHIP to collect and disclose patient information for any "purpose as may be prescribed." We want you to keep government's hands off our medical records. People have a right to some kind of confidentiality with their doctors, especially because we're afraid that this will open the door to further privatization of the OHIP administration and the giving of our personal medical information to private corporations. After all, they might pay you something for it.
We're opposed to the amendment to the Health Care Accessibility Act that gives cabinet the power to make regulations that would permit hospitals to charge patient user fees for any hospital-based insured services, including those presently covered by OHIP. Examples of user fees would include accommodation and meals, necessary nursing services, laboratory and other tests, drugs and emergency room visits. Speaking of laboratories, we are also concerned about this tendency to move things into private laboratories, very often part of foreign-owned multinational companies that take away from our own hospitals the possibility of carrying out this work.
With the removal of the term "medically necessary," many services can be delisted. Differences could exist in the care provided by hospitals, independent health facilities and private hospitals. The government could easily differentiate on the basis of age, severity of illness and other criteria as the government determines in order to delist services.
Of course, you may feel that because I'm a senior I'm particularly sensitive to some of these things. Thus far, I've been fairly lucky. I'm 78 years old and I intend to continue fighting for a decent health system in this country. I hope you, if you live to be that age, continue to fight for something decent too.
The prescribed age groups clause is especially ominous. This could be interpreted to mean that the minister could decide that anyone over a certain age could no longer be treated for a heart bypass, or that a person with Alzheimer's could not be treated for pneumonia. The sad possibilities are unlimited, and what they suggest is the slippery slope to handling the problem referred to as the burden of an aging population. There is nothing in Bill 26 to prohibit such decisions. Under ever-increasing pressure to cut costs, and to get patients out of hospital, government officials and health care providers could make value judgements and even lethal "devalue" judgements based on age alone.
It's outrageous that the general manager of OHIP can refuse to pay an account submitted by a physician, practitioner or health facility if he has reasonable grounds to believe that all or part of the services were not medically or therapeutically necessary. This may mean that a family physician may refer a patient to a specialist because he or she believes the patient may have a serious condition. Then, if the specialist finds out that the patient is fortunate enough not to have that condition, the family physician could be liable for the specialist fee. Medical intervention for the comfort of those who are dying could also be deemed therapeutically unnecessary.
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Allowing hospitals to charge user fees for any hospital-based insured services, including those presently covered by OHIP, is a violation of the Canada Health Act. Most hospitals now have a financial situation with the capacity to identify specific costs and to charge user fees for accommodations, meals, necessary nursing services, laboratory and other tests, drugs, use of obstetrical delivery rooms, emergency room visits and so on.
The bill also authorizes an administrative fee of up to $150 which hospitals may charge to patients.
These user fees are completely unacceptable and should be prohibited. People in this province who are poor, who can barely pay the rent and feed themselves certainly do not have $150 to pay if they're hospitalized, especially since people with a marginal income also have a higher risk of illness and also have more frequent emergency situations.
Schedule H attempts to modify the concept of medically necessary services without any real public debate. It attempts to whittle down the services that are insured under the Canada Health Act. It's another route to two-tier medicine. Those who can afford it will buy insurance to cover whatever the Canada Health Act no longer covers, and multinational insurance companies such as Liberty Health -- you've heard of them -- are just waiting to move in.
The bill states that cabinet will not make regulations permitting charges for hospital services that contravene the existing act. Alberta is already demanding changes to the act that will give the provinces the flexibility to add new user fees. Is this the Ontario government's plan as well?
The Ontario Health Coalition also calls for the withdrawal of schedule G, which amends the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act of 1991.
Specifically, we oppose:
-- Giving the power to cabinet to introduce user fees for drugs through copayments and deductibles for seniors and social assistance recipients. Everybody seems to forget that the copayment isn't just the two bucks they talk about, but it's also the $6.11 dispensing fee and then of course the deductibles which start at $100. History shows that what starts, ends up a lot bigger.
-- Deregulating prescription drug prices that make Ontario the only province that does not regulate drug prices.
-- Giving power to the minister to unilaterally determine which drugs will be listed and delisted on the formulary.
-- Giving power to the minister to overrule the decision of a doctor or pharmacist as to what is appropriate medication by refusing to pay and by requiring the patient to bear the full difference in the cost between the approved drug and the prescribed drug.
-- Authorizing the government to put itself above the law. In court decisions concerning generic drug companies, the bill states that the court decisions will have no force and effect. What the government couldn't win in the courts, the government is now seeking to override by legislation. Their contempt for the law is clearly obvious.
User fees are not cost-cutting measures; they are new revenue sources which hit the poorest of our society the hardest. User fees, deductibles and copayments for prescription drugs do not reduce the need for prescription medicine but they will reduce the number of prescriptions filled by seniors and families with limited incomes. It will increase the need for crisis intervention, hospitalizations, long-term treatment and other social services.
Supporters of user fees claim that the problems of drug costs are caused by the abuse of users in the program. This is factually wrong. The escalating costs for the Ontario drug program come from overmedication, overprescribing and the high cost of drugs. User fees shift the blame for the high cost of the drug programs on to the victims -- the seniors and those on social assistance -- and does not put the responsibility on the perpetrators: the federal government and Bill C-91.
We don't want anybody to feel that we're only worried about what the provincial Tories do. We're also worried about some of the things the federal Liberals do. The fact is that what they have done, especially with Bill C-91, and the fact that some doctors have prescribing patterns that need revision, and above all the already high costs and profits of the drug companies, all add up.
In addition, the creation of a costly administration system to collect user fees will effectively distract energy and attention from real drug reform. The Ontario Health Coalition supports drug reform, not user fees. The way to improve health and save money is to control the way doctors prescribe and to implement a public education campaign. According to the Ministry of Health consultation paper on drug reform, 25% to 40% of all prescriptions are inappropriate. Each year, 17,000 people are treated for prescription drug problems in Ontario. That's why we think it's so important for seniors to have programs, so that they learn to handle the use and misuse of drugs.
Up to 20% of all hospitalizations for seniors are related to medication misuse or adverse drug reactions. Seniors in Ontario are prescribed far more drugs than seniors in every other province except Quebec. There is ample evidence that the high number of prescriptions is not from the Ontario drug benefit participants using the system but rather is a direct result of the prescribing patterns of doctors. According to the Senior Citizens' Consumer Alliance for Long-Term Care Reform, the Ontario branch of the Canadian Society of Hospital Pharmacists estimates that Ontario could save $300 million from that program each year by documenting annual reviews of seniors' medication. As well, there'd be substantial savings if the high rate of hospitalization for seniors due to adverse drug reactions were reduced.
The Ontario Health Coalition acknowledges that some users' lack of knowledge on the use and overuse of certain types of medication also contributes to the cost of the program. However, a more viable approach to dealing with this issue is through education. An excellent example of this type of program is the Canadian Auto Workers retirees' medication awareness program in the Sudbury and Niagara areas, where seniors work with each other to learn the elements of responsible drug use.
The Ontario Health Coalition strongly supports the expansion of the current program to low-income persons not now eligible for benefits. No one should be denied medically necessary prescription drugs because of an inability to pay. However, this should be financed from reform in the drug program and not from the imposition of user fees.
I will now jump over schedule I, which you can read at your leisure, and move on to the final summary.
Bill 26 will irreparably harm the lives of every woman, man and child in Ontario. This bill is unparalleled in its contempt for democratic processes, both in the way it was introduced in the Legislature and in the sweeping powers it gives to government. If this bill becomes a reality, it will have a negative impact on our neighbourhoods, devastate public services and destroy local democratic institutions.
During the election campaign, Mr Harris pledged that there would be no cuts to health care. Yet, on November 29 Harris announced that $1.3 billion would be pulled from hospitals over the next three years. That's an 18% cut. If that doesn't give the lie to his election campaign, what does? He also promised he would not introduce any new user fees for health services. That's a clear lie too.
The omnibus bill gives the government permission to implement big cuts and user fees and impose many more, on top of the expenses that I talked about a few minutes ago of the whole idea of a new fee structure and so forth. The privatization and profitization of health care and the deregulation of drug prices point to more expenses, not less, a blind moving towards a US-style health setup, the meanest and most costly in the industrialized world, 40% more costly than any other country's; that's what it is.
The cumulative impact of the provincial actions, along with the federal destruction of our social safety net and the municipal implementation of the cuts, will have catastrophic and far-reaching consequences for the people of this province. We know it will make life extremely difficult for the poor and the vulnerable, but it will also hit the middle class hard. For the past 50 years we've fought to equalize our society, and our achievements are at risk.
You have the responsibility of trying to suggest some way of improving this situation. Please don't come in with face-saving amendments that mean nothing. Saying you've put in an amendment so that something is only applicable for the next four years is a joke, but a sad joke.
All in all, this bill is an ideologically driven attempt to drive us back into the 19th century just when we see the 20th century ending. That's a heck of a note. It's an ideologically driven attack on 100 years of striving for a decent society of human and humane achievement.
We call once more on the government of Ontario to withdraw this bill.
The Chair: Thank you very much. We appreciate your presentation this afternoon. You've effectively used up all your time, so there's no time for questions. We stand adjourned until tomorrow in Niagara Falls.
The committee adjourned at 1702.