Monday 10 February 1992

Inquiry re Ministry of Health information

Robert MacMillan


Chair / Président(e): Offer, Steven (Mississauga North/-Nord L)

Vice-Chair / Vice-Président(e): Miclash, Frank (Kenora L)

Bisson, Gilles (Cochrane South/-Sud ND)

Christopherson, David (Hamilton Centre ND)

Conway, Sean G. (Renfrew North/-Nord L)

Eves, Ernie L. (Parry Sound PC)

Harnick, Charles (Willowdale PC)

Hope, Randy R. (Chatham-Kent ND)

Mills, Gordon (Durham East/-Est ND)

Murdock, Sharon (Sudbury ND)

Owens, Stephen (Scarborough Centre ND)

Scott, Ian G. (St George-St David L)

Substitution(s) / Membre(s) rempliçant(s):

Kormos, Peter (Welland-Thorold ND) for Ms S. Murdock

McGuinty, Dalton (Ottawa South/-Sud L) for Mr Conway

Wood, Len (Cochrane North/-Nord ND) for Mr Bisson

Also taking part / Autres participants et participantes:

LeDrew, Stephen, Cassels, Brock and Blackwell

MacMillan, Robert, Ministry of Health

Page, S. John, Cassels, Brock and Blackwell

Clerk / Greffier: Arnott,Douglas

Staff / Personnel:

Jackson, Patricia, Committee Counsel

McNaught, Andrew, Research Officer, Legislative Research Service

The committee met at 1406 in room 228.


The Chair: Seeing a quorum, I would like to call this meeting of the standing committee on the Legislative Assembly to order. All members are aware of the terms of reference of this committee as ordered by the House. We will commence with our inquiry in a few moments' time.

I would like members of the committee to recognize that the subcommittee has been meeting for over a week now to determine and develop certain rules of procedure in this matter, that some of the mechanics of this committee have been the subject matter of subcommittee meetings, and that as a result of the terms of reference we have retained counsel to the committee. Counsel is sitting to my left, that is Ms Patricia Jackson, and she has with her her assistant, Mr Bob Richardson.

Before inviting our first witness, I would just like to make two preliminary points, and this is to members of the committee and to all in this room. Under paragraph 10 of our terms of reference, it is stated that, "If there shall be any objection to the disclosure of information based upon the Freedom of Information and Protection of Privacy Act, the committee may continue the proceedings in camera." As we proceed, if there is that result, we will, as per the terms of reference as agreed to, be proceeding on an in camera basis.

The next matter which I would like to bring forward is that the opening questions as agreed to by the subcommittee will be taken by Ms Jackson. We have as a subcommittee decided upon that as one of her roles and responsibilities as counsel, and I alert members of the committee to that decision of the subcommittee. When Ms Jackson has completed her questioning, then we will, again as per an agreement by subcommittee, rotate questions to members of committee in the usual and normal course.

I wanted to make those preliminary points to inform committee members of some of the decisions of the subcommittee. I know that there has been a memorandum provided to members of the committee on other matters of a mechanical nature. Having said that, I would like to recognize Mr Christopherson.

Mr Christopherson: Thank you, Mr Chair. Just briefly, to focus on the matter of the in camera -- and I had hoped that Ms Jackson might just articulate a bit that that decision this morning was made on her recommendation, having reviewed the Freedom of Information and Protection of Privacy Act and other relevant pieces of legislation and other matters in terms of reference pertaining to this. However, that not having happened, I would just like to say that following our meeting, I met with the government members of our committee and advised them of our decision this morning so they were prepared for what would happen when we opened up. I just would like to say that while the committee members are supportive of the decision and believe that it is the right decision under the circumstances and that following the terms of reference this is what should happen, they did ask me to mention just a few concerns that they would like on the record -- not in any way meant to prohibit or prevent us from going in camera, but just there for the record.

The first is that they would like to be sure that we are very clear when we are advising the public about going in camera that the purpose is to receive very, very specific personal information, and that we not leave the perception that this open process is in any way being closed or turned inward. They were very concerned that that perception be very clear as to why this was happening and that it was not contrary to the terms of reference nor contrary to the wishes of the Legislature.

Second, they did want to acknowledge the possibility, once the information is given, for leaks, and just a concern that they had, given the personal nature of that, for the ramifications, the implications and that they were concerned about that.

Also, if there was any possibility that information could be given -- if there were any means that could provide that information be given other than going in camera -- for instance, if it was personal information and any individual might perhaps be willing to voluntarily have that information made public -- that would be a means of preventing the committee from going in camera. If those means or any other are at our disposal, we would very much like to see those pursued.

Two last points: One is that the committee go in camera as little as possible, that we spend as little time in camera as possible, and that that be something that we are constantly aware of. The last point is that we very clearly indicate the kind of information that we are going to be talking about, the subject matter, as much as possible in the public session so that the only thing left remaining to discuss internally is the actual information and facts at hand, and that the public understand why we are going in camera and what it is that we are going to discuss.

With all of those concerns out there, Mr Chair, I would just indicate that we are prepared to support the recommendation of counsel and the decision of the subcommittee.

The Chair: Thank you very much, Mr Christopherson.


The Chair: If there are no further matters, I would like to welcome Dr Robert MacMillan, who is the executive director of the health insurance division of the Ministry of Health. Dr MacMillan, you may, as a preliminary matter, wish to indicate those who are sitting with you at the table, and following that, we will allow Ms Jackson to open up questions.

Dr MacMillan: Thank you, Mr Chairman. I have my executive assistant, Mary Fleming, at my right, and two lawyers representing ministry personnel at these proceedings on my left, John Page, and on my far left, Stephen LeDrew. I thank you for the invitation to come and try to enlighten the committee. I think I do have a lot of information that they will be interested in, and I will try to speak honestly and openly about everything I know about this matter.

The Chair: Thank you very much, Dr MacMillan. Ms Jackson?

Ms Jackson: Dr MacMillan, I understand that you are, as the Chair has indicated, currently the executive director of the health insurance division of the Ministry of Health and that you have held that position since April of 1989?

Mr Page: We had discussed the witness going under oath.

The Chair: Excuse me.

Mr Page: Will the witnesses testify under oath?

Ms Jackson: I am sorry, I had understood that Dr MacMillan had been sworn.

The Chair: I have just been informed that Dr MacMillan has not yet been sworn, and I would remind all members that was a decision of the subcommittee. The clerk is now proceeding with that swearing of an oath.

Ms Jackson: While we are seeing to those arrangements, can I just ask if you can hear? There is some suggestion this mike is not working. Is it working now?

The Chair: The clerk is feverishly running down the halls of the Legislature.

Ms Jackson: Generating the only heat in the building.

The Chair: Ladies and gentlemen, we will just allow the clerk to get his seat. There will just be the administration of the oath. May we have order here, please.

Dr Robert MacMillan, sworn.

Ms Jackson: Dr MacMillan, now that you are under oath, sir, you are still the executive director of the health insurance division of the Ministry of Health and have held that position since April of 1989?

Dr MacMillan: Yes.

Ms Jackson: And, Dr MacMillan, you have provided the committee with a copy of your curriculum vitae, and if that is agreeable, Mr Chairman, I suggest we mark that as exhibit 1. The clerk has copies that he will be distributing around.

Dr MacMillan, without belabouring the many credentials that are set forth in this curriculum vitae, but just so the committee has a general sense of your background, sir, I understand that you graduated in medicine from Queen's University in 1964?

Dr MacMillan: Yes.

Ms Jackson: And received your certification in family medicine in 1973?

Dr MacMillan: Yes.

Ms Jackson: That you subsequently obtained a fellowship with the College of Family Physicians of Canada in 1981 and practised in the field of family medicine in Peterborough for 17 years?

Dr MacMillan: Yes.

Ms Jackson: After that, sir, and after serving as a provincial coroner for a number of years, in 1982 you became the chief coroner for eastern Ontario?

Dr MacMillan: Yes.

Ms Jackson: And in 1987 became the assistant deputy minister of Health, responsible for many things: community health, public health, health promotion, laboratories and community mental health?

Dr MacMillan: Yes.

Ms Jackson: And you have held, as we said, your present position since 1989?

Dr MacMillan: That is correct.

Ms Jackson: Now, Dr MacMillan, you have provided to me as well, and I will ask the clerk to distribute to the committee, a brief chart that shows the approximate organization of the health insurance division. Mr Chairman, could we mark that as exhibit 2?

The Chair: So marked.

Ms Jackson: As I understand it, Dr MacMillan, the health insurance division is one of three divisions in OHIP?

Dr MacMillan: Yes.

Ms Jackson: The other two are the claims payment division --

Dr MacMillan: Yes.

Ms Jackson: And what does that do, sir?

Dr MacMillan: The claims payment division is essentially the operational side, the cheque-writing factory for OHIP, whereas I administer the policy side and the liaison with the public and with providers, including physicians.


Ms Jackson: The other area of OHIP that is outside your direct purview is something called "information systems data"?

Dr MacMillan: Yes.

Ms Jackson: What happens in that division?

Dr MacMillan: That division is responsible not only for the systems network within OHIP but for the whole ministry as a whole. The systems division is of course a division of experts with regard to the whole support and management of data within the ministry as it relates to all the programs, including of course, for my purposes, those for the payment of claims to physicians.

Ms Jackson: Within the health services division there are I think three areas in essence?

Dr MacMillan: In the health insurance division I am responsible for three areas.

Ms Jackson: Those are set out on exhibit 2?

Dr MacMillan: Yes.

Ms Jackson: Could you point out what those are?

Dr MacMillan: One is the provider services branch. That branch is a group of about 37 people who are responsible for the daily dealings with physicians and other providers who are paid on a fee-for-service basis, and for the record those are physiotherapists, podiatrists, chiropractors and optometrists.

Ms Jackson: All those people are comprised in the term "provider" in this branch?

Dr MacMillan: That is right. The other branch is client services. That is dealing with the issue of your red and white health card and of course the eligibility, the administration and the planning for the policy of those who are eligible, those who are inappropriately in possession of a card and all the issues with regard to dealing with the public and their benefits.

Ms Jackson: Focusing for a moment on the provider services branch, Dr MacMillan, can you briefly describe the areas of activity that take place within that branch?

Dr MacMillan: The business of OHIP of course is only one purpose, that is, to pay claims from physicians and other providers. For the purposes of our discussion, it might be simpler if I keep calling them physician payments. The job of that branch is to develop all the policy respecting the payment, the dealings with the Ontario Medical Association with regard to the various fees ascribable for different procedures and examinations, the policy with respect to the use of the fee schedule by physicians and the monitoring and determination of the appropriate use of that fee schedule, and the detection in some cases of those who appear to us to be using it inappropriately.

In addition to that, we are also responsible for the out-of-country benefits with regard to OHIP and we monitor the payment policy regarding your benefits when you travel outside the country.

Ms Jackson: Can you describe, Dr MacMillan, for the committee the kinds of records -- and I am focusing here on the question of payments to physicians -- the provider services branch maintains in order to fulfil its job?

Dr MacMillan: We have to have of course every bit of input that has been given to us by the physician or his staff for the purposes of determining the legitimate claim and for ascribing the appropriate fee to that claim, and getting an amount determined and issued of course through computer to the claims payment division to issue the cheque to the physician.

Physicians commonly submit their claims either by paper, which is on a card like an IBM card that has various codes on it -- there is no personal information any longer as of last year, simply codes for a person's name, codes for the diagnosis, codes for the type of service rendered -- or, in about 60% of claims received, and that is of about 120 million claims a year to OHIP, we receive it on machinery that will input, usually in the form of a diskette.

That information is sent to OHIP, if I can use that general term. It is initially dealt with through the district offices which are scattered around Ontario and receive that information and then of course process it into the mainframe.

That information then can be retrievable either by the district office in the conduct of their business, which is often dealing with the physician or with his or her staff, and on numerous occasions, especially of recent time with thresholds, by our provider services branch. The provider services branch has, among its employees, approximately 12 physicians who have usually been community physicians who have had experience in general practice or one of the specialties who then, as I did, come into the employment of the ministry and with OHIP in order to provide that liaison between a very expert type of field and the ability to monitor and assist with payment.

Ms Jackson: You mentioned there were 120 million claims processed a year. It was not clear to me from what you were saying whether those were the ones that were electronically processed or whether that is the total for the year.

Dr MacMillan: Approximately 60% of the input presently comes on machine-readable input. We are moving towards eradicating paper claims as soon as possible because of the huge and expensive difficulty in dealing with hand-written claim cards.

Ms Jackson: As a result of the generation of the data you have just indicated, I take it that within the provider services branch you would have records, first of all, for every individual physician in the province.

Dr MacMillan: Yes, that is true, and when you say records, it is not as if their filing cabinet is full of records. The great amount of data is retrievable from the mainframe if and when those selected people who have authority to look for that information are given that authority and it is necessary for the purposes of the particular person's duties. We have every bit of information on every billing by a physician and we are able to, of course, look at profiles and comparisons and assess the physician's practice patterns.

Ms Jackson: All right. I am going to come to that in a minute, but just so we can have a sense of what is in the computer for these physicians, we have the physicians' names and in addition each of the services the physician has billed for.

Dr MacMillan: Generally when a physician issues a claim, as well as possible diagnostic or treatment information, we have the name of the physician, the identification number of the physician, which is unique to each physician in the province, the diagnosis of the patient, the procedure done and the payment code.

Ms Jackson: Is that done by code?

Dr MacMillan: Yes. Now that we have moved into a unique identifier, of course we no longer identify people by their names. Again, the measure was taken in part to protect confidentiality as much as possible. The patient's name is now a number that is matched to the patient's date of birth and that provides the identification necessary for a retrieval of data.

So in addition to information on the physician, the physician is providing, for purposes of a claim, as has occurred for decades in Ontario privately before and now publicly -- the fact is that we have all the information on why people attend physicians and the particular diagnosis and treatment they had undertaken on behalf of the physician.

Ms Jackson: I take it from what you have said, Dr MacMillan, that in addition to having the physicians identified, the patients identified and the services identified by code, you would have as well records of how much was billed in what time period for each of those services?

Dr MacMillan: That is correct.

Ms Jackson: You mentioned that you sometimes do profiles with respect to physicians. Can you explain what meaning or meanings are ascribed to the words "physicians' profiles" as you were using it?

Dr MacMillan: Yes. The profile of a physician becomes important when we are trying to assess the justification for a physician's billings. Having had experience on the private side of course for many years, I always like to give my opening comments respecting this to say the vast majority of the profession in the province are diligent and follow the rules impeccably. However, in the privileged world of physicians being able to now bill the public coffers, often at their own discretion, and making a lot of judgement calls about how to use that schedule of benefits that all physicians have in their offices, which includes about 5,000 different codes from which to choose, it is obviously very necessary and responsible for the government and OHIP in particular to exercise their best efforts in a fair environment to detect those people who like to go beyond the regular and allowable rules. Certainly the College of Physicians and Surgeons of Ontario endorses that rigorous review and so does the Ontario Medical Association, and any physicians out of the 20,000 physicians in the province who are deemed to be bad apples, of course they want us to detect them and bring them back on course. So I would say that this profile and the knowledge that we conduct these profile reviews is the best deterrent for physicians who may be enticed into aberrant behaviour.


Ms Jackson: Dr MacMillan, can I just interrupt you? In a minute I am going to ask you about the process of analysis that you go through to determine whether there is something that should be examined in a physician's practice, but before we get to that point, and that will be a little way down the road, you used the words "physician's profile," and I think it would be helpful to the committee if you could explain what that phrase means or if it has more than one meaning when it is used in your branch.

Dr MacMillan: When we talk about a profile, it is not simply the raw data on the doctor as an individual and the billings but includes other things such as the cost-per-patient ratio. These would all be compared with physicians in that particular physician's specialty. The ratio of higher-priced to lower-priced services, for example; in the schedule there is an intermediate assessment. When you go to a doctor and there is something a little more than a simple thing and there is a minor assessment and the doctor has the discretion of picking one of those services according to his or her determination of the nature of the service, we look at that ratio of the intermediate assessment to the minor assessment.

We look at the frequency of repeat visits, whether one particular doctor has patients who tend to come back more than others. There can be justifiable reasons for that, but that is examined. There is the frequency of diagnostic procedures: To what extent does one physician in a particular specialty order tests and do procedures in his office on his patients or her patients more than other colleagues? The frequency of assessments billed in addition to procedural fees is looked at, and the daily and monthly volumes of the particular physician. That type of examination, both intricately looking at the individual physician's billing, but as important, comparing to the profile of his or her colleagues, is what we call the profile.

Ms Jackson: Would I be correct to understand that when you say "profile" it may include some or all of those things, depending on the purpose for which the profile is generated?

Dr MacMillan: Yes, but there are some standard things. Indeed, where the profile is much more valuable is in general practice. It is found to be so valuable that indeed we mail it to every physician in the province once a year with a covering letter for the physician to pay particular attention to his or her profile and see that there are no significant aberrations, and if there are they might like to examine why they are so far off the mark as compared to their colleagues.

That is a very useful educational tool and is appreciated by the profession. They can order a more detailed profile if they wish, but we do not do that with specialties yet because the variance of types of work by specialties and subspecialties makes it much more difficult to look at a profile and analyse it. We have not found it of much value to just ship it out to individual physicians.

Ms Jackson: When you talk of obtaining a physician's profile, is it correct that in some cases you would get the full range of data you have described and in some cases you would get a much more summary description of some of the results of that full range of data?

Dr MacMillan: Yes, that is correct.

Ms Jackson: In any case, does a profile in any form exist without being specifically generated for each physician in the province?

Dr MacMillan: No. As I said, one is initiated for about half the physicians in the province, or general practitioners, but a profile is not generally brought forward from the computer, so to speak, unless we are looking at it for some particular reason.

Ms Jackson: I would like to talk to you for a moment about the procedures that are used to protect the confidentiality of the information you have just been describing and the other kinds of personal information that exist within OHIP. First, can you tell the committee what are the main statutory constraints on the disclosure of information within OHIP?

Dr MacMillan: The two main pieces of legislation are the Health Insurance Act and the Freedom of Information and Protection of Privacy Act. Section 38, RSO 1990, or section 44 if you have the old RSO 1980 book, stipulate certain requirements on the part of personnel involved in the administration of the Health Insurance Act, which is abundantly clear that confidentiality must be held in high regard and protected at all times. In addition to that, of course, the whole government including OHIP is covered under FIPPA legislation.

Ms Jackson: What do you mean by FIPPA?

Dr MacMillan: I am sorry. Freedom of Information and Protection of Privacy Act, which demands that certain rules are followed with regard to not only the disclosure of information but also with regard to the protection of personal and private information. In addition to that, although I am not versed in it, I believe there is a public service legislation which also imposes confidentiality requirements on civil servants in the province.

Ms Jackson: Thank you, Dr MacMillan. I am going to ask that some of the salient extracts from the legislation that you made reference to now be circulated to the committee members. Perhaps in the interest of keeping it organized we will circulate those when the clerk comes back.

I am going to provide to members of the committee a description of personal information that is contained in the freedom of information act section 42, which prevents the release of personal information; section 38 of the Health Insurance Act, and section 10 of the Public Service Act, which will be coming around shortly.

On this topic I understand there have been prepared some briefing notes that summarize some of the security measures in place in OHIP, and I am going to ask that we mark as an exhibit some of those briefing notes and the security manual that is in place. I see the security manual, so I suppose we can start passing that around.

Mr Chairman, could I suggest, so we could keep track of this, that we mark these three statutory sections that will be distributed when the clerk returns, as the next exhibit, which would be I think 3.

The Chair: They are being distributed right now.

Ms Jackson: The two briefing notes should be exhibit 4 and the security manual exhibit 5, if that is agreeable, Mr Chairman. Can you, Dr MacMillan, while these are being distributed, assist the committee generally? The security manual, as I understand it, is one that has been in place for some time.


Dr MacMillan: Yes, it has been in place some time, Ms Jackson, but I would like to point out that last fall it was updated, reviewed and reprinted, so it is a very fresh version of the security measures taken by OHIP and by the ministry with respect to the issue.

Ms Jackson: Of the two briefing notes -- I have called them briefing notes -- one is entitled Collection and Disclosure of Personal and Physician Records. Can you explain when that came into existence and for what purpose?

Dr MacMillan: I would like to say that our daily business is really exchange of information, so it is an area of considerable activity within the health insurance division. We act, to a great extent, as the interchange between the public and providers, even though claims payment --

Ms Jackson: Dr MacMillan, I am sorry. I think you may be anticipating what I am going to do next, but just so the committee understands where these two documents came from, the first one, which is entitled Collection and Disclosure of Personal and Physician Records, what is that document and how did it come into existence?

Dr MacMillan: We made it up as a summary for the benefit of the committee when we knew we were going to appear.

Ms Jackson: Thank you. Similarly, the briefing note that talks about the issue being, "The standing committee of the Legislative Assembly will be performing an investigation into the dissemination of information obtained from the Ministry of Health," when did that come into existence and for what purpose?

Dr MacMillan: At the same time, in order to benefit the committee -- within the past week.

Ms Jackson: I would like to focus, if I may, Dr MacMillan, on the briefing note that has the heading Briefing Note. As you move through that document you come to a page entitled "Access to Personal and Physician Records -- Provider Services Branch." Do you see that?

Dr MacMillan: Yes.

Ms Jackson: I want to review with you, Dr MacMillan, the circumstances that are listed there as to when personal information relating to patients or physicians may be communicated outside the branch. I take it that is what these notes are, that they relate to circumstances in which that information goes out of the provider services branch?

Dr MacMillan: Yes.

Ms Jackson: The first instance you list there is to providers. Can you explain what that is?

Dr MacMillan: Yes. Again, physicians would be included as providers, and the branch I referred to earlier works in communication on a daily basis with physicians and their staff. In addition to that, of course, the district offices work on a close one-to-one basis with physicians' offices. We take precautions to be certain when a physician makes an inquiry by telephone or in person that indeed that is the physician. You can understand that many of the local people begin to know and recognize the voice and so on of physicians and their office employees with respect to their billings. We often request the provider number, which is generally limited, and the physician would identify himself or herself not only by name but also by providing the unique provider number. We have not experienced any difficulty in that liaison. There is always the chance of someone misrepresenting himself, but staff are generally well trained and use prudence in giving any information, especially when it relates to a physician's income or any information about patients whose claims were sent in by that physician.

Ms Jackson: Dr MacMillan, the next indication is that you provide that information to clients. Can you explain to the committee when that happens and under what circumstances?

Dr MacMillan: Out of 10 million people, of course, there are always individuals who have trouble with their benefits, either here in the province, in other provinces or, of late, outside the country. Those patients have often paid a bill on their own. They may have had a problem with what they perceived to be a charge made by their physician. They call with all sorts of concerns about their health benefits. There is constant liaison with the public with respect to general information and policy, and also very sensitive and detailed information, often including diagnostic information.

Again, if it is of a general nature, staff try to give good customer service, both locally and at our client services branch, which I am responsible for, and it usually works very well. In addition, however, when requests are made about what a doctor has diagnosed them as having or what charges doctors or a group of doctors have made, claiming to be the patient, we always refer that type of information to our freedom of information coordinator. They are obligated to go through the proper process of this freedom of information legislation in order to retrieve their personal information.

Ms Jackson: Why is that?

Dr MacMillan: Well, it is obvious, because we have less ability to be certain of the identity of a person, because with 10 million people out there as compared to 20,000 who depend on their livelihood from OHIP, there are people who would sometimes use the information in a negative way. Often estranged spouses and so on are trying to gather information. Staff are very sensitive to that and just automatically provide no information by telephone or in writing about diagnostic information provided by providers, and send them to the freedom of information coordinator.

Ms Jackson: And the next thing that you list on this page is that you provide that information to the finance and accounting branch. First of all, what is the finance and accounting branch?

Dr MacMillan: The Ministry of Health, as you know, is a very big ministry. We operate very large programs. The finance and accounting branch is another branch of the Ministry of Health, under the corporate services division, which is responsible for the writing of the cheques, allocating the amounts of money to be paid for persons or clients who are to receive cheques; as a good example, all of the hundreds and thousands of bills we have from American hospitals. When the determination is made as to the amount of money, the finance and accounting branch must have written direction as to what that particular hospital is to be paid.

In addition, they come into play in many of the individual cheques that we have to write to physicians, many of the administrative problems that we are faced with, most recently the threshold and directing the finance and accounting branch when a particular physician has reached the threshold and therefore to have that physician's cheque reduced in the appropriate amount.

Ms Jackson: Do I take it from that, Dr MacMillan, that the only information that ever goes to this branch is the information with respect to what amount is going to go on the cheque?

Dr MacMillan: Yes.

Ms Jackson: The next one is the district offices. Are the district offices within your division, Dr MacMillan?

Dr MacMillan: Just a minute, please. Go ahead.

Ms Jackson: Are the district offices within the health insurance division?

Dr MacMillan: The district offices are under the claims payment division management. There are seven district offices in the province and 11 satellite offices, the district offices being in London, Hamilton, Mississauga, Toronto, Oshawa, Kingston and Ottawa.

Ms Jackson: What information do the district offices have of the sort that is described here, personal information?

Dr MacMillan: As I indicated earlier, they of course deal with the physicians on the initial basis, receiving all their claims and often dealing on a daily basis with the various problems that crop up with respect to billings. At the district offices we have, in each district office, a medical consultant who is under my direction, who is technically under the provider services branch I talked about earlier, so that in addition to the clerical staff and the administrative and management staff in the district office, there is a physician who has a very significant role in dealing with physician issues and issues of the professional sending in bills.

Ms Jackson: Do the district offices have the physician records, by which I mean the information concerning a physician's billings, for what services, in what amounts, over what period of time and for what patients, for all the physicians in their area?


Dr MacMillan: Certainly the physician has access to it. I am not certain to what degree they would have to have the assistance of senior people in the provider services branch to gain more detailed information, but part of the role and function of the district medical consultant, of course, is the initial scrutiny of claims made by physicians. It is sort of a twofold role that a medical consultant has. One is to be of assistance to providers and allow for the bureaucracy to work smoothly. At the same time, the physician is also there to educate the physician when he seems to be straying with regard to legitimate billing patterns and also to take a more punitive role, possibly in detecting untoward billings and notifying head office, where we would pursue it.

Ms Jackson: But Dr MacMillan, just in terms of the records that the district office has, do I understand that it has records with respect to all of the physicians in that district?

Dr MacMillan: Yes.

Ms Jackson: And it has records of the amounts that they billed during any particular period of time and for what services?

Dr MacMillan: I am not certain I know to what extent the period of time would extend. Certainly those yearly billings would be readily available to the medical consultant and the district officer.

Ms Jackson: I take it from that that they go through the district office, but after they are processed the records come pretty much directly to provider services?

Dr MacMillan: Again, I have told you before, and I will just repeat it, that records per se are in the mainframe of the computer, which rests on the top floor of the Macdonald-Cartier building in Kingston. So they have access, yes, to data which would provide them with physician billing totals, but I do not believe that most of us keep records on individual physicians in our offices any more. We do not need to.

Ms Jackson: So they have probably not much in the offices; it is the access to the mainframe in Kingston that the district offices have.

Dr MacMillan: I believe that is the best answer I can give you.

Ms Jackson: Do you know, sir, what security arrangements are in place in the district offices to protect the confidentiality of access to that information?

Dr MacMillan: I believe the security arrangements are the same in the district offices as they are in head office, so when I describe them I think I can be rather uniform in saying that we undergo similar precautions. We are subject to the security manual whether we are in Kingston or a district office and we are also of course subject to the same three pieces of legislation.

Ms Jackson: The general statutory framework is the same and the security manual is the same. Do you actually know how that works in practice in the district offices?

Dr MacMillan: I think I am not the best witness to question on that further. I have given you the best indication I can. I spoke as recently as this morning with our official security officer, who is solely responsible for these procedures across the ministry, inspecting them and being certain that managers are following them. He gave me assurances this morning that he was quite proud of the maintenance of these policies by ministry staff in the district offices as well as head office.

Ms Jackson: But so the committee understands, Dr MacMillan, if members of the committee want to find out in detail what happens in the district offices, they should not be asking you. Is that fair?

Dr MacMillan: That is right.

Ms Jackson: The next item on this list is the medical eligibility committee. What is that, Dr MacMillan?

Dr MacMillan: The medical eligibility committee is, in essence, an appeal board. It is set up by statute, in the Health Insurance Act. It is a group of physicians or other providers -- a group of physicians, I am sorry -- who are appointed by the minister who sit in adjudication of bureaucratic decisions. My staff, in assessing whether or not a claim is to be paid to a physician, or indeed for a benefit to be given to a patient -- the best example and one of the most common ones is something that we believe is cosmetic surgery, which is not covered as a benefit, and the patient believes it should be covered as a benefit because there are some medical symptoms associated with the cosmetic defect.

That committee then adjudicates cases in which, rather than simply flatly turning down the patient, we take it upon our initiative to refer cases, indicate to the patient or the physician that we are asking for a second opinion, as you would, and go by the decision as final, what the medical eligibility committee decides.

Ms Jackson: Do I take it that the only information, then, that the medical eligibility committee gets would be information with respect to a particular service in a particular case that is under review?

Dr MacMillan: Yes, and they are subject by the act to exactly the same degree of confidentiality that we are.

Ms Jackson: The next one listed here, sir, is the medical practitioner review committee, and I would like to defer that for a minute and come back to it. Then you list the Health Services Appeal Board. What is that, Dr MacMillan?

Dr MacMillan: The Health Services Appeal Board is, again, a court or tribunal that looks into appeals of patients in particular, but also physicians, with regard to payment policies or eligibility. So on the client's side, if we deny someone, for instance, OHIP coverage -- maybe they are out of the country too long or we have found they are not legally entitled to remain in Ontario -- that appeal mechanism is through the Health Services Appeal Board. Again, appointments are made by the Minister of Health: a chairman, I believe the board has two positions appointed, and the rest are lay people. They would hear in a quasi-judicial way our side of the story and the patient's side of the story.

On the physician's side, they become involved in decisions, again, where we rule against a physician, and the physician, in particular in interpretation of the schedule of benefits, would have a different view. The appeal mechanism is well known by physicians, and they will take their concern there with respect to our ruling.

Out-of-country payments would be another example where patients feel they should, of late, be covered for 100% of benefits for a service that was not available in Ontario and in the United States, and they are beginning to make appeals to the Health Services Appeal Board about our decision that it was not medically necessary for an urgent trip to the United States.

Ms Jackson: I take it the only information that would go to the Health Services Appeal Board is the information relating to the particular case brought by the appellant, be that a physician or a patient.

Dr MacMillan: Yes.

Ms Jackson: That is a public hearing?

Dr MacMillan: Yes.

Ms Jackson: Then the next thing that you list, Dr MacMillan, or that is listed here is the negotiations secretariat. What is that, Dr MacMillan?

Dr MacMillan: The negotiations secretariat is the recent terminology for a small unit in the Ministry of Health that is at Queen's Park. It is on the ninth floor of the Hepburn Block, and it is directed by Dr Eugene LeBlanc, who is an executive director. This unit was set up shortly after the recent agreement between the government and the Ontario Medical Association, which was signed on June 4, 1991, and took effect back on April 1, 1991.

This agreement is rather a landmark agreement for Ontario which is very, very different from the 15 or 20 agreements that have taken place since medicare began, and it provides for a number of things that never before were contemplated and never before had to be administered. As a result, the deputy minister has set up this small unit to work in close cooperation with the health insurance division in order to assist the transition of physician payments in this new world and provide the policy and direction to the health insurance division as to its impact on physicians, and I will describe that later for you.

Ms Jackson: In what circumstances would personal information with respect to an individual physician's billings go to the negotiations secretariat?

Dr MacMillan: The information that has come in to both sides has been --

Ms Jackson: Both sides of what?

Dr MacMillan: By both sides I mean in Toronto the negotiations secretariat, their small unit of three or four people, and my larger operation in Kingston. Information has come in from many different sources but in general, the profession out there -- the medical profession, especially those affected by the threshold -- have been constantly communicating with Dr LeBlanc and his staff with regard to the same issues that they also tend to communicate with us. There has not been a very distinct division between the operations and the tasks that we perform in Kingston with regard to the implementation of the thresholds, and Dr LeBlanc's office, so there has been a fairly free and cooperative transmission of information back and forth, although most of the information on physicians' billing and so on is coming from the physicians themselves who are writing us, pleading exemption to the recent threshold agreement. Most of those letters have been channelled through Dr LeBlanc.


Ms Jackson: They come through Dr LeBlanc to you?

Dr MacMillan: Yes.

Ms Jackson: But in terms of going the other way, for what purpose is personal information about a particular physician's billings sent from you to Dr LeBlanc's secretary? I say you; I mean your division.

Dr MacMillan: Yes. I do not think I have ever seen anything spelled out, as when something is up and running and clearly defined. We see job descriptions, we see organizational charts, we have been working diligently to invoke the terms of this agreement, and it has been an absolutely necessary thing that information travel both ways. As a result, "personal" information, if you want to use the word -- I would say it is not so much personal but billings by a physician and how he or she might be affected by the threshold -- is passed both ways from our office to Dr LeBlanc on a number of occasions, and the other way around.

Ms Jackson: Billings information by an individual physician is personal information as that term is understood under the freedom of information act, is it not?

Dr MacMillan: Yes.

Ms Jackson: And that does go from your division to Dr LeBlanc's secretariat?

Dr MacMillan: Yes.

Ms Jackson: For what purpose?

Dr MacMillan: For implementing the threshold with regard to the physician who is affected, and indeed to a great extent to assist the physicians who are very harshly hit by this threshold, to assist in finding ways to lessen the blow to their particular cash flow. It has always been done in a very congenial and collegial way with physicians who see us, for the most part, as their allies in trying to implement this in the fairest possible way.

Ms Jackson: So are you speaking of situations where particular physicians contact Dr LeBlanc?

Dr MacMillan: Yes.

Ms Jackson: And in those circumstances he sometimes asks for their personal billing information?

Dr MacMillan: Yes. To the extent that has happened, I cannot answer right now. I will try to determine more closely the degree to which there has been transmission of information. As I said earlier, in the vast majority of cases, the information is coming to us more than not, but Dr LeBlanc has attended alone and with me on many occasions sitting down with doctors, looking at their particular financial problem and looking to see to what degree the ministry can offer any assistance in the transition into this new agreement.

Ms Jackson: Do you know if the personal physician information that is transmitted sometimes from your division to Dr LeBlanc's secretariat is used for any purpose other than dealing with that individual doctor?

Dr MacMillan: I am aware of one case where a briefing note was required and personal information on the physician was sent.

Ms Jackson: Other than that instance -- and it is one we are going to come to in more detail very shortly -- are you aware of whether there are not other instances where personal physician information has been transmitted to Dr LeBlanc for a purpose other than speaking directly to the physician in question, or dealing with the physician in question?

Dr MacMillan: No.

Ms Jackson: Do you know if there are? Sorry, that was not a very well-worded question. You do not know if there are?

Dr MacMillan: No, I do not know that there are. I doubt that there have been, but I am not certain and I would be glad to find out.

Ms Jackson: Would you be able to find that out?

Dr MacMillan: Sure.

Ms Jackson: Would you? Thanks. What is the time frame within which you might be able to find that out, Dr MacMillan? It has to do with how we get this --

Dr MacMillan: By tomorrow, I think, to continue tomorrow. I will do my best.

Ms Jackson: I have the sense you may still be here tomorrow, so we will deal with that.

Are you absolutely content with the practice of transmitting this information outside the provider services branch into the negotiations secretariat in Toronto?

Dr MacMillan: I have thought a lot about that question. I would have to answer that if one were to do it again, it might be better to define a bit more appropriately for civil servants who are way down in Kingston who are sometimes intimidated somewhat by Queen's Park and senior officials in the Ministry of Health. There is a natural tendency for demands that come for our action -- and they come daily -- to jump, and there are time commitments and so on.

I believe that where information was being transmitted outside the health insurance division and the very careful and scrutinizing rules that we try to apply, we become more vulnerable to information being misused. I believe it is prudent to suggest, and indeed I have, that we define more appropriately and direct staff as to the exact protocol. In retrospect, I feel that had that been done, we might have conducted ourselves a little differently.

Having said that, again, the pressure is on in a very intense administrative area that has created tremendous uproar, upheaval and antagonism. We have been limited by fiscal constraints. We have not been able to add staff that we feel are necessary. People are working under a great deal of pressure and long hours and indeed judgements may not always be the best in those circumstances.

Ms Jackson: You say you have given some thought to whether there should be a protocol for the release of information from the provider services branch to outside the health insurance division. Are you able to give the committee any indication of what you think such a protocol would specify?

Dr MacMillan: Indeed, I think we do have a protocol for information. Indeed the Freedom of Information and Protection of Privacy Act does stipulate that we do not transmit information unless there is a "need to know." Certainly, it was the perception of our staff that people dealing with negotiation and transfer into the threshold world did have that need to know and therefore we were readily transmitting necessary information. That would not necessarily be the case with a totally different branch or division.

This particular unit, as I said, was set up by the deputy minister. It was urgently needed to be the transition here in Toronto with our head office in Kingston and provided a very useful and valuable aid in our trying to administer this very difficult new world of monitoring certain physicians' payments and paying them at a different level.

Ms Jackson: It would be fair to say that in the fall of 1991, at least until the end of December, from what you say, there was a presumption within your branch that if the negotiations secretariat asked for this kind of information, there was a need to know.

Dr MacMillan: Yes.

Ms Jackson: Let me then move on to the next item on this list. There is a reference here to briefing notes. You have provided me, Dr MacMillan, and let me ask to be passed out to members of the committee, something called a Priority Briefings Guideline Booklet. That will be exhibit 6, Mr Chairman, if you are agreeable?

The Chair: That will be exhibit 6.

Ms Jackson: Briefing notes, as that term is used in the briefing note we have been looking at, and priority briefings in this guideline booklet, Dr MacMillan, are those the same things?

Dr MacMillan: I do not understand the question. Say it again.

Ms Jackson: On the list we are going through, you make reference to something called briefing notes.

Dr MacMillan: No, not necessarily. Briefing notes, as most MPPs would know, of course, are created for a number of different circumstances. They are created when a new government takes over. They are created for issues that various people in the ministry determine to be newsworthy and of prominence. They occur in an official way that we in the Ministry of Health, at least, refer to as priority briefings, which usually signifies a current issue of the day that is of newsworthy function on which the minister would require information and possibly the Premier for questions in the House, for response to the press, for response to the problem. So it is a gathering of information, as we understand it, for priority briefings, essentially for the use of a minister in that particular ministry.


Ms Jackson: Whereas briefing notes may be gathered for other purposes as well.

Dr MacMillan: Yes.

Ms Jackson: The procedure that was in place for the gathering of information for priority briefings in the fall of 1991 is the one set forth in exhibit 6?

Dr MacMillan: Yes.

Ms Jackson: I wanted to ask you, Dr MacMillan, to turn to page 18 of that guideline. The number may be actually a bit hard to see. It is about six pages from the back, under the heading "Confidentiality."

Dr MacMillan: Yes.

Ms Jackson: There is a description of personal information in the middle of the page. That clearly would include, I take it, physician billing information.

Dr MacMillan: Yes.

Ms Jackson: Then there is a three-part test that is set forth there,

"The person to whom the information" -- that is, personal information -- "is going must: (1) need the information in the performance of his or her duties, (2) be performing duties that are a proper function of the ministry, and (3) be using the information for a purpose consistent with the reason for which the information was first collected."

Just stopping there, that is the need-to-know test that you were referring to before?

Dr MacMillan: Yes.

Ms Jackson: And that test applies to the dissemination of personal information, whether in the priority briefings process or any other process.

Dr MacMillan: Yes.

Ms Jackson: It should only be circulated within the ministry to the extent that there is a need to know.

Dr MacMillan: Right.

Ms Jackson: And it should never be circulated outside the ministry.

Dr MacMillan: No, not unless you have the consent of the person to whom the information refers.

Ms Jackson: The note goes on to say that if that information is to be put in a priority briefing, it must be on the basis of the test noted above, and then over on the next page there is an indication:

"Where to Place the Information: If personal or third-party information must be included in a priority briefing, it should be placed in the separate `advice to the minister' section that follows the list of contacts. It should also be marked: sensitive and not to be disclosed."

When was that added?

Dr MacMillan: That had been the policy for a number of years. It was changed and it became the policy again following the incident with the last minister.

Ms Jackson: Ms Gigantes.

Dr MacMillan: Yes.

Ms Jackson: When you are talking about the more general kinds of briefing notes other than priority briefings, does the same rule apply that if there is to be confidential information, it should be separately noted and identified?

Dr MacMillan: Not necessarily. I would have to question, as I hope most of my employees would, the need for more detailed information if we knew that it was not going to the minister. The briefings of course could be for the deputy minister; they could be for someone in another area. I think that there is a great weight put on the knowledge that the minister is in need of the receipt of this information, and for purposes of interpretation of this request, when it comes from Queen's Park, we interpret that the minister needs to know, not that somebody on staff needs to know somewhere. So I would say that when we issue briefing notes that we do not believe are for purposes of the minister's information, we should certainly not be providing any confidential or personal information.

Ms Jackson: So for briefing notes other than priority briefings, it would be your view that it is not appropriate to pass on confidential information, or personal information, as I have used that term.

Dr MacMillan: Yes.

Ms Jackson: When a priority briefing request comes in to the provider services branch, who decides whether or not personal information will be included in the response?

Dr MacMillan: Each area, including mine, has a priority briefing coordinator, who in my case is my executive assistant, Mary Fleming, and we have a further very experienced employee who is the assistant briefing coordinator, who would act in the absence of my executive assistant.

Ms Jackson: Who is that?

Dr MacMillan: Jacqui Heath.

Ms Jackson: That is when the request for the priority briefing comes in.

Dr MacMillan: The request comes in usually from the executive assistant of our ADM, our particular area, and that is then delegated by the coordinator to someone in the branch who is appropriately capable of putting together the notes for the briefing. After it has been edited, possibly, by my executive assistant, I would then give final approval before it went out of my division, and going out of my division, it would go on to the executive assistant to the ADM, in this case normally Dr Dave McNaughton, and it would then be possibly edited or signed off again before going on to the minister.

Ms Jackson: So before personal information was included in a briefing to the minister, it would be vetted first of all by Ms Fleming, second by you and third by Dr McNaughton?

Dr MacMillan: Yes.

Ms Jackson: In the case of a non-priority briefing note, when that request comes in and is responded to, who is responsible for ensuring that it does not contain personal information?

Dr MacMillan: Whoever is asked for the briefing, to construct the briefing and get information for the briefing and be responsible for the writing of the briefing, sometimes has to get information from other branches within the ministry. It could be an issue in dialysis but you would have to involve the hospitals, maybe, as well as a freestanding clinic. It could be other issues that would require information out of one or two or maybe even three branches. In those cases, we would not have prime responsibility for the briefing to be forwarded. Although under normal circumstances our area is all on one floor, it would be often that I would be involved, or Mary Fleming, in finalizing or approving of anything going forward.

Ms Jackson: But that is not necessarily the case?

Dr MacMillan: No.

Ms Jackson: In which case the question of whether what goes forward has personal information or not is the decision of the person preparing the note?

Dr MacMillan: I would think it is more commonly at least the level of a branch director.

Ms Jackson: Does it have to be?

Dr MacMillan: No, because you must understand that there are many, many briefings or pieces of material, sometimes sentences, that are required for update. Briefing notes are updated routinely, and the request for information to be updated is made frequently to people who are involved in the program, which, with their good judgement, does not require the whole formal process to be engaged in all over again.

Ms Jackson: So is it just left to the personal judgement of the person who is responding what vetting the answer should have before it goes back to the person who requested the information?

Dr MacMillan: That has been, up until recently, the way it has worked.

Ms Jackson: Has that changed?

Dr MacMillan: We have implemented more formal processes to be able to further assess the degree and nature of the information being sent for accuracy and confidentiality before providing information to another part of the ministry.

Ms Jackson: When did that change?

Dr MacMillan: It changed after the incident on --

Ms Jackson: November 13?

Dr MacMillan: November 13, when I became aware of a document that judgement could have been better.

Ms Jackson: Can you assist us as to when it changed? Some time after that, but --

Dr MacMillan: We are working now on developing formal policy, but, again, it has been word of mouth directed that all briefing notes will come through my office.

Ms Jackson: Which means either you or Ms Fleming, does it?

Dr MacMillan: Yes, or if I am not there, someone who is acting in my position.

Ms Jackson: Let me return to this list we were marching through, and we are near the end. Freedom of information requests: Can you just briefly explain? That is a request for information under the freedom of information act?

Dr MacMillan: Yes, and we have one person solely designated in the division who works full-time, almost, on these numerous requests and the proper processing and work with the coordinator in Toronto for the act.


Ms Jackson: And last you list research studies, and I take from what you say there that in circumstances where people consent to have their personal data included in a research study, you will release it for a research study?

Dr MacMillan: Yes, and that happens rarely and it is always in writing.

Ms Jackson: It is always --

Dr MacMillan: In writing.

Ms Jackson: I had said we would defer the question of the medical practitioner review committee and I would like to return to that now, Dr MacMillan, and ask you to explain for the committee the various processes by which physicians' billings are reviewed within your division. That, I take it, sir, looking at the organizational chart that we looked at earlier, would take place -- if I can find the chart. What is the name of the branch within which that takes place?

Dr MacMillan: Provider services branch?

Ms Jackson: Sorry, it takes place under the manager of monitoring and control?

Dr MacMillan: Yes.

Ms Jackson: Who is that?

Dr MacMillan: Mr Peter Quinn.

Ms Jackson: What circumstances lead to a review of a particular physician's billings, first of all within the branch, within the provider services branch?

Dr MacMillan: There are a number of reasons why a physician may come to our attention, and I will try for the most part to give you an idea of what might spark a second look: Obviously, physicians who have very high-billing practices, and those high-billing practices can be a significant variant from their own colleagues in that same speciality. It may be, as I told you, variances in the cost-per-patient ratio. A physician could see as many patients as another physician, but the cost to the public purse could be double what it is for the average colleague in the same specialty. It could be an indication by the medical consultant in the district that he may have had difficulty rationalizing the way in which a physician was billing, and he could spark a further look by that unit in Kingston in order to assess the physician's proper billing. We could have complaints from patients. Indeed sometimes patients for some reason get the impression a physician may be billing on their behalf for services never rendered to them or rendered inappropriately. We would look at the physician's billings in that case to determine as best we could whether or not the services indeed were rendered.

In many cases, where in these various ways physicians rise to the top in this unit, we often will flood the practice with verification letters. I do not know whether you have ever received a verification letter, but we send out routinely to a random sample of patients in the province sort of a receipt for services that you should have received over a period of time in which not only the physician is indicated but the date, the type of service and the charge made on your behalf to OHIP. When we flood a practice, and if we indeed find the physician has been charging for services which patients come forward and tell us were never rendered -- even, in rare cases, the patients never have heard of the physicians -- those cases become obviously clear cases of fraud, and that source of detection of fraud, along with other reports and police interventions, amount to about two a year.

Ms Jackson: So the prospect of fraud or criminal charges is not a usual outcome of any kind of billing review within your ministry?

Dr MacMillan: That is correct.

Ms Jackson: If you get one of these sort of prompts for a second review, either from reviewing the profile of the physician's billing and its amount or from your regional office or from a complaint or an audit letter, what is the next stage of examination of a physician's billing?

Dr MacMillan: The analysis of all these data is done by a very experienced physician, who may well be testifying here, who has had years of experience in trying to make a fair determination of whether or not the physician has a particular reason for the abnormal services or abnormal costs. It may be, for instance, a demographic consideration. If he has got a very high geriatric patient load, that may result in more services. Or there may be other unique circumstances, such as a doctor in an area where there are insufficient such specialists and they may have to work harder than they may even want to. So there are many legitimate reasons for aberrations from the usual and customary charges, but where those do not seem to be explained to us we then make the next move and that is through the legislation, refer this issue, this particular physician on to the medical review committee of the College of Physicians and Surgeons of Ontario, which is named in the Health Insurance Act as being responsible for the more detailed audit and assessment of physician accounts in the province that are of disturbance to us.

Ms Jackson: Dr MacMillan, you have provided to me, and I ask that it be passed out to the committee, a brief bulletin that describes this process dated December 19, 1989. Do I take it the description in there continues in general terms to apply to the process as it exists today?

Dr MacMillan: Yes, that is correct.

Ms Jackson: Could we mark that, Mr Chairman, as exhibit 7? The examination that you have just indicated takes place within the division. You mentioned that is done by an experienced physician. What is that doctor's name?

Dr MacMillan: Dr Simon Kovacs.

Ms Jackson: The result is that some accounts, as you say, are sent on to the MRC and it is listed in this bulletin. That happens when there is reason to believe that all or part of the insured services were not rendered, all or part of the services were not medically necessary, all or part of the services were not provided in accordance with accepted professional standards of practice or the nature of the services is misrepresented. But do I understand from what you have said, Dr MacMillan, that that analysis is just on the basis of the paper record of the billings; there is no attempt to go out and actually look at what happened or talk to patients or anything of that sort?

Dr MacMillan: No, we do not have the power of audit of a physician's office. I should say that there are sometimes conversations, of course, about the billing pattern, in which we try to provide an educative role, and where we believe that the physician has not become educated we then may resort to referring it on to the MRC. I think the point you are making I would agree with is that we do not have all the information in order to make a decision, and some subsequent decisions provide information which we know exonerates the physician. Nevertheless, at the level we have made that determination we believe there is a strong suspicion the doctor may be inappropriately billing OHIP.

Ms Jackson: And therefore it should be looked at further by inspection in the medical review committee?

Dr MacMillan: Yes.

Ms Jackson: So the fact that a physician is referred on to the MRC does not necessarily mean there is anything wrong?

Dr MacMillan: No.

Ms Jackson: It is actually described in the second page of this memorandum, but can you give the committee just a capsule summary of what happens when a physician's billing is referred to the medical review committee?

Dr MacMillan: For one thing, there is one big, long delay. The people who wrote the legislation in the Health Insurance Act unfortunately put the size of the medical review committee of eight people in the statutes rather than in the regulations at the time when there were probably half as many physicians in the province. There are eight people listed to be appointed to the medical review committee, as I said: six physicians nominated by the College of Physicians and Surgeons and appointed by the minister and two laypeople appointed by the minister. That makes up, in essence, two teams.

It has limited our ability to administer OHIP as effectively as we would like, because we are faced with a huge backlog of cases to the extent that we do not even refer as many physicians that we believe should be referred. Over the past period of time, for instance, it has taken an average of 23 to 26 months from the time I sent a referral to the college before it gets back with its decision, so it is over two years in which if there has indeed been a bad pattern of billing, where the public purse is vulnerable to continued bad habits during that period of time.

When the MRC does make a decision, all its adjudication, all its investigations and all its decision-making is done in private; it is not open to public knowledge. Indeed the response from the medical review committee is also confidential. The penalty is to simply pay back what the committee adjudicates as being inappropriately billed during that window or that period of time two years earlier that we identified, what we thought to be bad behaviour. We have taken some steps recently to make other measures to educate and assist physicians in proper billing habits which we are ready to initiate, but sooner or later the MRC will have to be expanded in order to properly do the job it has been given.


Ms Jackson: Dr MacMillan, can you briefly tell the committee what the stages of this process are once it gets to the medical review committee?

Dr MacMillan: I will give it as best I know it, but I have never been there so I am not certain of it. The fact is that we, confidentially, under the signature of the general manager of OHIP, who during the past several years has been Dave McNaughton -- that individual signs the final document that we and our staff prepare, which goes to the medical review committee secretary, who is an associate registrar, Dr Roy Beckett. That information is then assimilated by staff, as I understand it, within the medical review committee, which is somewhat separated from the College of Physicians and Surgeons.

They likewise maintain a close confidential ethic with regard to their work. Indeed they are also subject to exactly the same confidentiality requirements under these pieces of legislation. They then decide on the basis of what we had sent them whether or not the physician should be inspected. If they determine that that next step should take place -- and in the vast majority of cases they do -- they will appoint a physician or physicians of the same specialty to contact the physician so reported to make a mutually convenient time to review records and will enter the office of the physician for a period of time, which could be a short period or several days, in order to scrutinize charts, in order to look at books and in order to make the determination of whether the charges were legitimate or not legitimate.

They report, as I understand it, to the MRC, and the next threshold is whether or not the physician will be invited to an initial hearing before the committee. If the physician is not invited, then the inspection proves concerns to be invalid. The physician, as I understand it, is so notified and the ministry is notified that no recovery is recommended.

If, however, the physician, on the basis of the inspection and the material we had sent, is still under question, he may be invited to this first meeting and even a subsequent interview to further elucidate the details with regard to the billing. It is upon that second hearing that the MRC then adjudicates and decides whether or not billings have been appropriate.

We have been making an average of 60 referrals per year, but because of this backlog of about 130 cases we have this turnaround time which is unacceptable. It is very stressful indeed on the physician as well, who is living, obviously, in great concern over this lengthy period of time wondering whether or not he has done something wrong. But the average rate with which the MRC concurs with the Ministry of Health upon this more detailed evaluation is that anywhere between 60% and 70% of cases are found to have billed OHIP improperly. The MRC makes a decision to the extent of that excess billing and recommends to the ministry a recovery, and then we take over again with regard to the collection of that income.

Ms Jackson: So at the end of this process, which as you have said takes 23 to 26 months, you get a report back that says either a clean bill of health or some money is owed, is that right?

Dr MacMillan: And their decision as to why it was billed improperly and what they are basing their recovery on.

Ms Jackson: Now for the committee, because the committee has to consider as you know, Dr MacMillan, the question of confidentiality within the ministry, I think it might be helpful to understand how many people would know of this process by the time it has run to fruition, to the extent that you can help them with that. You say it starts with a review by Dr Kovacs and presumably his staff. About how many people would know about that?

Dr MacMillan: Within Dr Kovacs's area there are three or four people who assist him in the preparation of profiles and the accumulation of the package necessary for sending up the line and on to the MRC. Then it would go to presumably the secretary of the director of the branch. The secretary would provide it to the director for review and signature if she agreed with it. The director of the branch then would send it on to my secretary and I would review it to co-sign the document before it went on to the assistant deputy minister, Dave McNaughton, in his capacity as general manager of OHIP. He would then send it directly to Dr Roy Beckett, associate registrar of the college.

At the college -- I am not free to speak precisely, but I am aware that a number of people review the documents there in order to assimilate and prepare the material for the review committee to decide whether or not an inspection is made. There would be a number of secretaries, registrars and personnel, along with I suppose the elected or appointed people on the committee who would have knowledge by that time that a particular physician had been referred.

Following that, an inspector or inspectors, one or two at the most, I understand, would be asked to go and visit the doctor and would make telephone calls and communicate with the doctor or the doctor's staff with respect to their attendance at the physician's office, which, I might add, I believe often includes some discussion with a physician's employees with respect to billing practices, inasmuch as many physicians are a little away from some of the billing habits and patterns and that is left to management staff.

To add to that, although this is very unofficial, but the committee may be interested in this from other witnesses, there is a general feeling among the profession that it has never been a very critical thing, in a doctor's career or in his life, to have the knowledge of his referral made before the committee among his colleagues. Indeed, I have had experience with doctors coming into the coffee lounge saying: "Guess what? I got a letter from the MRC. They're going to come and check me out." The degree to which that is even held to be confidential by physicians who are affected is quite variable. But I have no knowledge of any particular case; I am just speaking in generalities.

Indeed the OMA, of which I am a past president, often was requested to represent physicians in their dilemma in the investigation, and in particular in their review, when they had to go before the medical review committee. So the OMA has acted as the agent for its members whenever they have requested representation. More recently, in the last month or two, I have noted that the Canadian Medical Protective Association is now offering to do that role as part of its services to physicians when they are in legal trouble.

Ms Jackson: So at the end of the day -- I am just counting up what you said -- it sounds like about 10 people in your division might know, including the secretaries of the people who are involved; an indeterminate number, but clearly several people within the medical review committee; inspectors if inspectors are sent out; office personnel to the extent that they may become aware of it, plus whoever may happen to learn of it if, as you understand, doctors sometimes share the information somewhat casually.

Dr MacMillan: Yes.

Ms Jackson: I take it, from the comment that doctors sometimes sort of chat about this in the coffee lounge, that the review process per se is not always considered to be one of particular stigma from the point of view of the doctors whom you have had experience with.

Dr MacMillan: In many cases that is the case.

Ms Jackson: It is sort of like a tax audit, is it?

Dr MacMillan: I would say it is much more like that than some type of charge before the courts.

Ms Jackson: Within the ministry, though, the existence of this kind of investigation would be a piece of confidential information that would be protected under the Health Insurance Act and the freedom of information act.

Dr MacMillan: Yes.

Ms Jackson: Within the medical review committee, do you know in general whether there are any statutory constraints on the confidentiality of that process?

Dr MacMillan: I think they are under the same act, since the medical review committee is specifically defined within the Health Insurance Act and the duties of section 38 apply to that committee as equally as they apply to us.


Ms Jackson: Dr MacMillan, let me turn then to the question of the threshold or framework agreement that you have made reference to earlier in your testimony. I am going to ask you, sir, to review some elements of that agreement for the committee so that they can understand what its implications are in terms of the issues before us.

I think it might be helpful, Mr Chairman, if the committee members could have in front of them a document that is entitled Sudbury Package, December 5, 1991. That will be --

The Chair: Exhibit 7.

Ms Jackson: Exhibit 7, Mr Chairman? Thank you.

The Chair: I am sorry, it is exhibit 8.

Ms Jackson: Dr MacMillan, I understand this was a package of material put together in connection with a visit by certain ministry officials to Sudbury on December 5, 1991.

Dr MacMillan: Yes.

Ms Jackson: And all of the information that is contained in it is public, not confidential.

Dr MacMillan: Yes.

Ms Jackson: This package includes, as an appendix to a speech by the deputy minister, copies of the agreements reached between the government of Ontario and the Ontario Medical Association. Do those include the threshold or framework agreements you spoke of earlier?

Dr MacMillan: Yes.

Ms Jackson: When was that agreement made?

Dr MacMillan: The negotiations took place in early spring of this past year, culminating in a final signature on the agreement on June 4. After a bit of a stormy session through the medical professions branches, the agreement was retroactive to April 1, 1991.

Ms Jackson: Dr MacMillan, can you describe in general terms for the committee how the threshold agreement works? What is the threshold and how does it operate?

Dr MacMillan: There are in fact two thresholds that we are talking about with this agreement. I am going to be very brief on it because I think if you want more detail it is in writing, and also Dr LeBlanc, who has been even involved in the negotiations of the agreement, will be here to give evidence.

But essentially and simply, there are two thresholds. One is a global threshold which for the first time when the utilization, or the demand for services results in the utilization, goes over a certain predetermined level, the profession will participate equally with the government. That means that for the first time the government is getting closer to being able to budget the OHIP vote instead of looking at what happened at the end of the year after the fact. But as well as that, individual physicians can now face a threshold. The agreement calls for the reduction of a physician's fees by one third after the physician has reached $400,000 of income paid by OHIP and faces a further reduction of two thirds of the fees originally allocated if the physician bills over $450,000.

Ms Jackson: Are all of a physician's billings included in income for the purposes of deciding whether the physician is above or below the threshold?

Dr MacMillan: No, there are a number of sources of income that a physician would have both within OHIP and outside of OHIP that would be exempt. Obviously WCB payments, third-party insurance payments, non-insured benefits, cosmetic surgery and so on would all be exempt from the threshold because they are not part of the OHIP pool or vote of money.

Within the OHIP vote of money there was the determination that those services that we would determine as being technical fees would be exempt from the threshold. Technical fees are traditionally listed in the schedule of benefits that I have referred to and it would be easy for a physician to look at that book and determine whether or not a fee would be exempt from calculation of the threshold.

An example of that might be an electrocardiogram, where there is a technical fee for doing the electrocardiogram and supplying the paper and so on and the technician to do it; but the professional fee, which is the doctor reading, interpreting and treating the patient on the basis of the electrocardiogram, is the professional fee. Generally, if you think of technical fees as being listed in the schedule for services that have a significantly higher overhead than the customary examination of looking at your throat with a tongue depressor, it is X-rays, where there is a large technical fee, other types of diagnostic tests and so on. Because it is according to the schedule, there are many physicians, of course, who were upset that there were not more things included as technical fees. But that is the best way to describe it for you.

Ms Jackson: What are epilation services?

Dr MacMillan: Epilation was a code in the schedule of benefits, the electrolysis of hair, hair removal, that for certain women was a benefit up to November 15 of this past year. Epilation had been debated for many months and many years as a service that was supposed to be a benefit to a certain group of women and denied to another group of women based on rather non-specific diagnostic criteria such as testosterone levels. Women sometimes were lucky enough to get it as a benefit; the majority probably were not.

We had been one of the few provinces to allow this as a benefit, and I believe the figures went roughly from about $16,000 as billable to OHIP by physicians who were engaged in this type of practice, up to about $8 million last year as a result of the use and increasing use of this benefit. Because of a lot of controversy, advisory committees were held, including patients and physicians and electrologists and those who had a direct interest, and it was determined by the minister towards the early fall, I believe, that the delisting of electrolysis was the only way to be fairly dealing with this problem and turning the job back to electrologists in the community, who for a long time had advocated such a change.

Ms Jackson: So it ceased to be listed as an OHIP service when?

Dr MacMillan: It ceased to be listed as a service on November 15, 1991.

Ms Jackson: And was it at any point included in threshold income?

Dr MacMillan: Can I preface the answer to that question by saying, a number of services that physicians and in fact those who represented them, the Ontario Medical Association, felt should be technical fees, indeed in the schedule were not technical fees. We had a major meeting with the Ontario Medical Association in order to come to some consensus on what should be defined more fairly for purposes of the threshold, and it was decided that although epilation, the electrolysis code, was not in the schedule as a technical fee, we would consider it such, and retroactive to April 1, 1991, any income earned by a physician who is engaged in electrolysis, those fees would not be taken into consideration in the calculation of his or her threshold.

Ms Jackson: Under the framework agreement, what physicians are exempt from the threshold, or what income is exempt from the threshold?

Dr MacMillan: The agreement called for two sections of the agreement. One -- and I am not quoting from it -- implied that physicians who are engaged in the underserviced area program would be exempt from calculation of the threshold. So, never mind whatever their professional technical fees; they were exempt. The minister defined that in the strict sense those physicians who were enrolled and signed up in the underserviced area program, which I can describe if you wish, were exempt.

Ms Jackson: Just briefly, what is the underserviced area program?


Dr MacMillan: They were exempt, but physicians who were no longer signed up, even though the specialty might be determined to be underserviced, would not be exempt.

A number of years ago, a long time ago, in order to attract physicians to the north, in addition to the physician being able to bill the fees -- which of course are the same fees that a physician would bill in southern Ontario -- the government offered incentive grants which, although there are variations, in general is a $40,000 tax-free grant paid over a four-year period, as long as the physician remains in that particular service and specialty in that location in the north. It has been reasonably successful in augmenting the ratio of physicians to population in the north, and indeed in many areas we have no longer had to provide the incentive because the physicians have remained and do provide those services in the north.

There are physicians in that four-year period who, by virtue of this agreement, it was deemed were exempt; and there are physicians, of course, who may have come up there on the underserviced area program who are no longer in it; or there may be older physicians who were there before the incentive grants were even available. I mention that because obviously those who were lucky enough to be deemed to be in the program who could escape the threshold, they were quite happy. There was extreme discontent on the part of many physicians who interpreted possibly, and in our view inappropriately, the fact that they may be exempt because they were in an underserviced designated specialty, and yet they were not under this program where the tax-free grant was being made.

In addition, there was another component to the agreement that you will see in the agreement within the package, and that allowed for the minister and certain specialty or geographic areas to have the prerogative to extend the exemptions. On October 2, Frances Lankin announced the decision to --

Ms Jackson: Are you referring now, Dr MacMillan, to the decision to end the exemption?

Dr MacMillan: No, I am referring to the decision by the minister and her communication to the profession that there would be no further exemptions allowed under section 2 of the agreement. I believe it was about November 13.

Ms Jackson: Those communications are found at the back of this package on November 13. Is that right?

Dr MacMillan: Yes.

Ms Jackson: Just to tie off the exemptions -- and I ask the committee members to bear with me on this because it will be clearer later why this is worth threshing through -- under the underserviced area exemptions, in addition to people who were on the four-year $40,000 grant, are there any other people who have a portion of their income exempt from the threshold?

Dr MacMillan: Yes, there are physicians in southern Ontario and indeed in northern Ontario who travel -- usually for a day or several days -- to an underserviced area in the north, and are paid a grant on a daily basis. That income generated through that service to underserviced areas was also deemed to be exempt, so we have in summary only two groups of physicians who would be exempt from the threshold, other than what they could exempt from their technical fees: Group 1 was the group on the $40,000 grant program and still receiving that grant money, and group 2, indefinitely those who were serving in designated underserviced areas, physicians either from the north or from the south who travel to the north.

Ms Jackson: In this package, Dr MacMillan, there is a list two thirds of the way through that is headed Specialists on Program. Could you turn that up for a moment please?

Dr MacMillan: Yes.

Ms Jackson: Have you got that section?

Dr MacMillan: Yes.

Ms Jackson: And that shows, as I understand it, Dr MacMillan, a list of the specialists who are in the underserviced area program in the sense that at least up until the 1991 year they were on this four-year $40,000 grant.

Dr MacMillan: Yes.

Ms Jackson: By way of example, if you flip over to the pages with the Ks on them, we have on page 6 a Dr Kosar who is shown as being an ophthalmologist in Sudbury. It shows, under the column "Date Support," 01.07.90. I take it that means that Dr Kosar started to get a grant on that day.

Dr MacMillan: Yes.

Ms Jackson: Since his grant runs for four years, as is noted in the last column, he is still on the grant.

Dr MacMillan: Yes.

Ms Jackson: I take it from what you have said that you could tell from this that Dr Kosar would not be subject to the threshold.

Dr MacMillan: Yes.

Ms Jackson: Can you tell from this what Dr Kosar's income is?

Dr MacMillan: No.

Ms Jackson: If you look over earlier on page 5 there is a Dr Hollingsworth in Sudbury, an internist whose grants started on 07.06.88. I take it, then, Dr Hollingsworth would not be subject to the threshold.

Dr MacMillan: That is correct.

Ms Jackson: But you could not tell from this what Dr Hollingsworth's income is?

Dr MacMillan: No.

Ms Jackson: If you flip back, there is a Dr Donahue on page 4 who is a dermatologist whose grant began on 31.08.87. It is shown, in the grant column, nil in 1991. Do I take it from that that Dr Donahue's grant ran out or came to a conclusion four years after it commenced, during 1991?

Dr MacMillan: Yes.

Ms Jackson: Can you tell from this when this grant ran out or came to a conclusion?

Dr MacMillan: It is, you know, a four-year period and it started on August 31. It would appear to run out by September 1, 1991.

Ms Jackson: So for the period up to the end of August of 1987 Dr Donahue's income would not be subject to the threshold and afterwards it would.

Dr MacMillan: That is correct.

Ms Jackson: Can you tell from this what Dr Donahue's billing income is?

Dr MacMillan: No.

Ms Jackson: Now, if you flip over further in this package, Dr MacMillan, there is a set of culled cases and it appears under the heading "Impact of Thresold Reductions." I take it these are intended to be illustrative of the impact of thresholds on different kinds of practices.

Dr MacMillan: Just wait until we get the document. Is that the bulletin you are talking about?

Ms Jackson: We are still in exhibit 8 and it is entitled "Impact of Threshold Reductions." It seems to be found sort of 15 pages from the back of the package -- case 1, case 2, case 3, etc.

Dr MacMillan: We may be deficient in our package.

Mr Page: We are not getting directly your exhibits which I asked to be sent around. So we are working from our own. If we got the exhibits that were given to the members --

Ms Jackson: We ought to be able to remedy that quickly. It might be a problem.

Mr Page: Our exhibits are usually consistent with your exhibits.

Ms Jackson: Just do not tell me we have to go back and do this whole afternoon over again.

Mr Page: No.

Ms Jackson: Do you have that yet, Dr MacMillan?

The Chair: Seventh page from the back.

Dr MacMillan: Is this case 4?

Ms Jackson: Mine is 12 pages from the back -- case 1, case 2, case 3, case 4.

Dr MacMillan: Yes, okay.

Ms Jackson: Got it?

Dr MacMillan: I have it.

Ms Jackson: That illustrates the impact of the threshold on different kinds of practices?

Dr MacMillan: Yes. Can I allow a word of explanation? This material was prepared for us to go to Sudbury to assist everybody understanding this very complex area. Because of the nature of information in here and figures and so on, we specifically took it to the coordinator for freedom of information to be absolutely certain everything that we were given was public information, which it was. We made that extra check.

The figures that you see before you here were drawn by my staff on the basis of examples in the south of Ontario, not in the north, and actually on the basis of only seven months' billings. So although they are used to reflect what might happen for one particular doctor's income, as an example, over a period of a year, indeed there are some actual figures in here from physicians' practices in the south over a seven-year period. It is simply to illustrate the ratio on average types of practices, between that which is vulnerable to the threshold and that which is exempt and the type of gross billings that would result in the type of net billings that would be received.

Ms Jackson: Why did you go to the south for your actual examples?

Dr MacMillan: So that nobody would make the accusation that we picked off someone in the north when were going to Sudbury.

Ms Jackson: Now, you have said that as of November 13 this business of the possibility of exemptions by specialty and by region was cut off. Can I take you, then, back to the fall of 1991, in particular the October-November period? Can you describe for the committee reaction of the medical community in Sudbury, first of all, to the threshold agreement?

Dr MacMillan: Well, I guess it was militant, to say the least. I, as many others, first became aware of it in the press, although we had had a large number of letters from physicians who either were affected or thought they were going to be affected from this threshold agreement.

Ms Jackson: Sorry, I am still listening.

Dr MacMillan: Okay.

Ms Jackson: After the end of the exemptions was dictated at the middle of November, did that add to the feeling in the north?

Dr MacMillan: I think there was a certain degree of expectation that a more liberal approach would have been given to the definition of "underserviced area;" and physicians who were exempted, who happened to be on the $40,000 grant, would be sitting beside physicians who might be working just as hard who would not be exempt because they did not have the fortune of having another $40,000 tax-free dollars. So there was a good deal of unfairness believed by the physicians in the decision as to who gets and who does not, and yet, as I said earlier, the government was following what most people, including the Ontario Medical Association, I believe, believed to be the interpretation of that section.

The north has always been in the medical community much more open and unified and aggressive and, in many cases, often feeling a bit hard done by by their medical colleagues in the south. Indeed, I am told that the OMA agreement itself -- of about 65 district societies in the province, the medical association from Sudbury was the only one that opposed the agreement. So they were already primed to take exception to the administration of the agreement, and it was in that environment that I made some steps to try to deal with them in October, by phoning the president of the Sudbury and District Medical Society to see if I could meet with them to discuss the implications of the agreement.

Ms Jackson: Dr MacMillan, in the course of being aware of this militancy in the north and the discontent among doctors in Sudbury, did you become aware of a Dr Donahue who figured in this opposition?

Dr MacMillan: Yes. I wonder, before we get into that, if we could have a break, Mr Chairman, for maybe 10 minutes.

The Chair: Yes, if that is your desire, I will have a recess for 10 minutes. We will come back at a quarter after 4.

The committee recessed at 1604.


The Chair: We will now resume questioning by Ms Jackson.

Ms Jackson: Dr MacMillan, I have put before you a collection of articles that appeared in respect of the opposition to this agreement and certain stances taken by Dr Donahue in the period, largely in the fall of 1991. Were you generally familiar with the positions being taken by Dr Donahue as set out in these newspaper articles?

Dr MacMillan: Yes, I just got these newspaper articles now, so I have just browsed through them. I have seen a great deal of press on this issue. I think my file is thicker than this. I was certainly very much aware of the issue as it was heating up about the threshold issue all over Ontario, but in particular in the north.

Ms Jackson: And in particular you were familiar with the general nature of the positions being taken and the information provided by Dr Donahue, as is set out in these articles.

Dr MacMillan: Yes.

Ms Jackson: Mr Chairman, could we mark those articles as exhibit 9?

I want you to please be careful, Dr MacMillan, not to tell me anything that would constitute what you well know to be personal information about Dr Donahue, but can you tell the committee whether prior to this fall period you had had any dealings with Dr Donahue?

Dr MacMillan: I had no personal, direct dealings with Dr Donahue. However, I did receive a letter from him in the past year as it related to epilation and his thoughts on the epilation issue.

Ms Jackson: That is the issue you just described for us a short while ago.

Dr MacMillan: Yes. It was received on May 11, 1990. It goes away back.

Ms Jackson: So to that extent you had had dealings with Dr Donahue in the past.

Dr MacMillan: Yes, but I had never talked to him or, I believe, ever written to him.

Ms Jackson: I am next going to ask you to look at a broadcast on MCTV, channel 4, Sudbury, dated November 8, 1991, which is an interview of Dr Donahue, and ask you if you became aware of that broadcast around the time that it was made.

Dr MacMillan: Is this an exhibit?

Ms Jackson: It is on its way down to you as an exhibit, yes.

Dr MacMillan: This was on November 8?

Ms Jackson: Yes, are you familiar with the broadcast by Dr Donahue on that date?

Dr MacMillan: Yes, I am.

Ms Jackson: And just generally, what was the issue that Dr Donahue was addressing on that day?

Dr MacMillan: The issue was the fallout from the removal of epilation, which would have occurred the following week, and the services to his patients in the north.

Ms Jackson: Could we mark the transcript of that interview, Mr Chairman, as exhibit 10? On the particular copy that you are getting, Dr MacMillan, you will see there are notes on the left-hand side. Are those notes yours?


Ms Jackson: That is all right. In fact, if the notes are not there that is even better because I was just going to get you to describe that they were not your notes and you did not know anything about them, but if they are not there we can skip that question.

I am next going to ask you to look at a transcript of a broadcast, again by Dr Donahue, on CBC in Sudbury on November 13, 1991, and ask you if you became aware of that broadcast on or around the time it was made.

Dr MacMillan: Yes, I am.

Ms Jackson: Do you recall when you first became aware of that broadcast?

Dr MacMillan: I cannot recall precisely, but I believe it was the same day, November 13th.

Ms Jackson: Okay. In general terms, do you recall what was the subject matter of this interview?

Dr MacMillan: Yes, I recall it and I also read it again this morning.

Ms Jackson: Can you briefly tell the committee what the nature of the broadcast was?

Dr MacMillan: Yes. That particular broadcast was an interview with Dr Donahue about a totally different issue, and that was the impact of the thresholds on health care in the north, in particular in Sudbury and in particular as it related to the practice of dermatology.

Ms Jackson: On November 13th do you recall whether you were in your office in Kingston?

Dr MacMillan: No, I was not. I was at the Sunnybrook Medical Centre for the second meeting of the joint management committee between the Ontario Medical Association and the government. The agreement also calls -- for the first time a joint team between the government and the OMA would sit down and look at utilization and other issues, including of course the impact of the threshold and the way it should be administered.

Ms Jackson: I understand that subsequently you have become aware and have seen copies of some e-mails that originated in your office in Kingston in relation to this broadcast while you were away.

Dr MacMillan: Yes, electronic mail is passed daily of course between Kingston and other offices of the Ministry of Health on the government electronic network.

Ms Jackson: And can be printed up into hard copies.

Dr MacMillan: Yes.

Ms Jackson: You have seen both electronic and hard copies of the e-mails that originated in your Kingston office on November 13th.

Dr MacMillan: Yes.

Ms Jackson: Can you confirm that they contain the following: first, an e-mail that is two pages long sent at 11:41 am from William Teatero?

Dr MacMillan: Yes.

Ms Jackson: It was sent to Diane McArthur in Toronto?

Dr MacMillan: Yes.

Ms Jackson: Who is Diane McArthur?

Dr MacMillan: Diane McArthur is the executive assistant to Dr Eugene LeBlanc.

Ms Jackson: That was a two-page e-mail?

Dr MacMillan: Yes.

Ms Jackson: It mentions Dr Donahue's name.

Dr MacMillan: Yes.

Ms Jackson: It makes reference to the details and amounts of his billings.

Dr MacMillan: Yes.

Ms Jackson: There is nothing in that e-mail that says Dr Donahue's billing is being reviewed in terms of the practice you have described earlier for the committee.

Dr MacMillan: By the medical review committee?

Ms Jackson: Yes.

Dr MacMillan: Yes, there is no reference to the medical review committee in the document.

Ms Jackson: Or to the existence of an ongoing review of his billings within your ministry.

Dr MacMillan: No.

Ms Jackson: All of the information in that two-page e-mail would be personal information, as that term is known in the freedom of information act and as we have been using it today.

Dr MacMillan: Yes.

Ms Jackson: In addition to that, you can confirm that at 2:20 in the afternoon of that day a second e-mail was sent from William Teatero to Diane McArthur.

Dr MacMillan: Yes.

Ms Jackson: Which provided some short additional information with respect to Dr Donahue's billings.

Dr MacMillan: Yes.


Ms Jackson: Lastly, that at 3:55 pm that afternoon, a further e-mail was sent from William Teatero to Denise Allen and to Maurice Jones, copied to Bob McBride and attaching the e-mail that we referred to earlier, of 11:41.

Dr MacMillan: Yes.

Ms Jackson: That last e-mail was essentially just forwarding the earlier e-mail?

Dr MacMillan: Yes.

Ms Jackson: It did not contain any additional information.

Dr MacMillan: That is correct.

Ms Jackson: In addition, that at least one of the hard copies of that e-mail that has been found within your division contains a note from one Peter Quinn to Dr Kovacs.

Dr MacMillan: Yes, a handwritten note over top of the memo.

Ms Jackson: Tending to suggest that it was seen by both Peter Quinn and Dr Kovacs.

Dr MacMillan: Yes.

Ms Jackson: Who is Denise Allen?

Dr MacMillan: Denise Allen was a communications officer in the Ministry of Health who, among other duties, was involved often in the preparation of briefing notes and priority briefing notes.

Ms Jackson: Where is she located, or was she at this time?

Dr MacMillan: She reported to the director of communications, Rhea Cohen, in the communications branch.

Ms Jackson: In Toronto?

Dr MacMillan: Yes.

Ms Jackson: And Maurice Jones?

Dr MacMillan: Maurice Jones serves a similar function and is in the same division.

Ms Jackson: Who is Bob McBride?

Dr MacMillan: Bob McBride works as my employee. He was in the position of acting director of the provider services branch, a position he had held for only five days because of the sudden illness of the director of the branch.

Ms Jackson: I apologize, Dr MacMillan, if I have asked you this question. I am just not sure if we have established if Diane McArthur, at the material time, was the executive assistant to Dr LeBlanc.

Dr MacMillan: Yes.

Ms Jackson: You have had occasion, as I understand it, more recently than November 13 to prepare a note of some of the events that took place on that day and the next.

Dr MacMillan: Yes.

Ms Jackson: Could I ask the clerk to distribute a copy of it to the members of the committee? This is a note that is headed, "Chronological events prior to November 13," and then it carries on. Mr Chairman, could I ask that this be the next exhibit, number 12? Who prepared this note, Dr MacMillan?

Dr MacMillan: I did.

Ms Jackson: When?

Dr MacMillan: On December 11, 1991.

Ms Jackson: Why?

Dr MacMillan: Because at that time this issue was heating up, so to speak, and in my years as a coroner and working with police I found it always to the advantage of everybody to always document their notes as to their memory at the time, rather than waiting for three or four months down the road. So I not only did it myself, I told other people who were involved with this that I thought it would be a good idea.

Ms Jackson: The note contains, under the date Wednesday, November 13, a description of certain things that took place in the Kingston office. I take it that is not based on any personal knowledge that you have.

Dr MacMillan: Direct personal knowledge?

Ms Jackson: Yes, you were not there.

Dr MacMillan: No, that is correct.

Ms Jackson: You were not in communication with your office on that day about any of the matters that are described here?

Dr MacMillan: Not that I recall.

Ms Jackson: We know that on that day you were in Toronto, and you have mentioned that the director of the provider services branch had recently departed on an illness. Was there anybody else who would ordinarily be in the office and would deal with information requests who was not there that day?

Dr MacMillan: Not necessarily. The type of requests we will hear about would very likely normally have been channelled, as I said earlier, between the person who was charged with writing up or retrieving the material and the director of the branch to approve the content and forward it. In a priority briefing, if it were in the usual manner and following policy, it would have come through my office or whoever was standing in for me on that day or indeed phoning me at the number where they knew they could reach me and over the telephone getting my approval of such a briefing.

Ms Jackson: Had it been a priority briefing, do I take it Ms Fleming would also have been involved?

Dr MacMillan: She would have been involved in the priority briefing almost certainly, and if not, the other person I mentioned, Jacqui Heath, who is always there to fill in if Mary Fleming were not available.

Ms Jackson: Was Ms Fleming in the Kingston office on this day?

Dr MacMillan: She was not there in the morning; she was there in the afternoon.

Ms Jackson: You mentioned that in some circumstances, I think whenever there was a priority briefing, it also would be signed off by Dr McNaughton?

Dr MacMillan: Yes.

Ms Jackson: Was he in the Kingston office that day?

Dr MacMillan: No. I should explain that the joint management committee has the very senior level of people from the OMA and also the very senior people from the Ministry of Health, as we embark on this new trip. The deputy minister, the general manager of OHIP, Dave McNaughton, Dr Eugene LeBlanc and I, along with other members of the ministry and other nominees from the ministry, were all at Sunnybrook Medical Centre, McLean House, for this second, day-long meeting with the Ontario Medical Association.

Ms Jackson: Do we have, in this note of exhibit 12, all that you have subsequently been told about what took place in the Kingston office on November 13?

Dr MacMillan: I believe that is it in brief, yes.

Ms Jackson: All right. When did you first learn of these e-mails?

Dr MacMillan: I now recall that, slightly different than my note would imply, the first notification of such an issue was when Maurice Jones, the communication officer whom I later found out was involved in the preparation of a briefing note, came to me in Dave McNaughton's office where I had arrived the next morning, I believe about 8:30, and handed me a memo, an electronic memo headed by Denise Allen, which was signed by Maurice and Denise. This was a memo that gave a certain outline as to the request for information and the preparation of a briefing note on this particular issue. Attached to that sheet, which I presume had been produced on the machine of Denise Allen and then simply printed, were the, I believe, two interviews with Dr Donahue with the press: one, the television; one, the radio of November 8 and November 13. The last document attached was the two-page memo you referred to earlier, the e-mail sent by William Teatero to Toronto.

Ms Jackson: Mr Chairman, could I ask that the one-page covering memorandum be distributed to the members of the committee?

The Chair: That will be marked as exhibit 13.

Ms Jackson: Do you have a copy of that, Dr MacMillan?

Dr MacMillan: Yes.

Ms Jackson: What happened when you were given that by Maurice Jones?

Dr MacMillan: I looked at it and immediately became upset that the contents of the last two sheets of the package contained information that I felt was not wise to be passing to other personnel in the ministry in order that a briefing note be prepared. I told Mr Jones, "Thank you very much." I noticed that the document had been sent to a number of other people and I was concerned that I should retrieve it. I went to Dr LeBlanc's office shortly thereafter and further events transpired there.

Ms Jackson: Can you tell the committee what happened there?


Dr MacMillan: I was to see Dr LeBlanc anyway again about the threshold issues, and I immediately referred to the package that had been handed to me and the issue was discussed. I remember being a little upset, surprised, and immediately ordered -- strongly suggested -- that people get that document, that e-mail, and give it back to me to destroy it; who had it. Then I immediately picked up the phone to ask my acting director who gave authority to provide that kind of detail about a physician to staff in the Hepburn Block, and my acting director took responsibility for it, but --

Ms Jackson: Who was the acting director?

Dr MacMillan: Robert McBride.

Ms Jackson: This is the man who had been acting director for five days when this happened?

Dr MacMillan: Yes.

Ms Jackson: In that conversation, did he tell you anything more about what had happened other than what we saw on the front page of exhibit 12?

Dr MacMillan: He simply said that in his capacity, the office was requested for briefing material about a particular physician because of public concerns expressed about the threshold and how it impacted on this physician and, "Would you please forward as soon as possible any information in order that we can become more informed about the issue." That is how I understood the request was made to him and Mr Teatero.

Mr Teatero then, being a more experienced employee -- I believe over 10 years with the ministry -- retrieved and went to retrieve information of any nature he could find concerning the issue and the physician, and that was approved, unfortunately, to be sent by the acting director and went to the person you have identified, Diane McArthur, executive assistant at Dr LeBlanc's office.

Ms Jackson: In addition to the people who received the original e-mail or e-mails, whom you have identified, we see on exhibit 13 that copies were sent to Paul Howard. Who is Paul Howard?

Dr MacMillan: Paul Howard is with the minister's staff, the Minister of Health.

Ms Jackson: What position does Paul Howard fulfil in the ministry staff?

Dr MacMillan: I am not sure of the exact title, but it is in communications.

Ms Jackson: Within the ministry, or as a political --

Dr MacMillan: The minister's staff. Frances Lankin's staff person involved with communications.

Ms Jackson: Then the next addressee of this e-mail is Tiina Jarvalt. Who is Tiina Jarvalt?

Dr MacMillan: Tiina Jarvalt is the executive assistant to the deputy minister, Michael Decter.

Ms Jackson: And Eugene LeBlanc is the Dr LeBlanc you described and Dr MacMillan is yourself. Who is Mary Doyle?

Dr MacMillan: Mary Doyle works in the deputy minister's office.

Ms Jackson: Mr Decter.

Dr MacMillan: Yes.

Ms Jackson: What position does she have there?

Dr MacMillan: Administrative assistant.

Ms Jackson: Did you have any conversation with anyone on the 14th as to why this e-mail was sent to the people who are shown on exhibit 13?

Dr MacMillan: Yes. I tried to recall precisely the people who were in Dr LeBlanc's office when I expressed my views. It was definitely Dr LeBlanc. I believe Diane McArthur was there. Denise Allen may have been there. I believe Maurice Jones was there, and a little later I believe Helen Ambrose, also with the communications branch, came. I do not recall seeing anyone from the minister's staff there, but I do recall requesting the answer to whether or not anybody on the minister's staff had been in receipt of the memo.

Ms Jackson: You would have known, would you not, it having gone to Paul Howard, that it had gone to someone on the minister's staff?

Dr MacMillan: I am not sure when I recalled this, but I learned indeed that it did not go to Paul Howard. As I indicated, it was my understanding that this memo was not forwarded on the electronic mail but rather created on the computer and printed in the communications branch and hand-delivered to persons who could receive it. It is my understanding -- you can corroborate -- Paul Howard was away for a couple of days and did not receive it. It is also my understanding, but you will have to have it more direct, that Larry Corea, also of Frances Lankin's staff, did receive it.

Ms Jackson: When did you learn Paul Howard had not?

Dr MacMillan: I cannot recall. I heard he did not, I believe, that morning -- I heard he was away -- but I cannot remember.

Ms Jackson: When did you learn Larry Corea did?

Dr MacMillan: I do not recall precisely. I do not think I was ever certain that anybody did on the minister's staff. I must admit that in foreign territory up on the ninth floor of the Hepburn Block I simply expressed a very strong position of a senior executive director and I relied on Dr LeBlanc, who was responsible for the preparation of the briefing note and who I understood agreed entirely with me and would take every effort to retrieve the document. I did not do a personal follow-up of every secretary, every person named on the memo or everyone who was in the process of trying to prepare notes to be of value to the minister.

Ms Jackson: Do you know or have you ever been advised that anyone other than the people you earlier identified as being addressees or copies of the original e-mail, or the people who are shown as the addressees or as getting copies of exhibit 13, received a copy of the e-mail? When I say the "e-mail" I am always referring to the one that originated in your office on the 13th.

Dr MacMillan: No, I am not certain whether anybody else received or had involvement. I only know of the names I have mentioned and the names you have mentioned. Recognizing electronic mail and then the subsequent printing of it, obviously the Ministry of Health is very large and if someone were careless or chose to show someone else, there may have been somebody else involved in this preparation. I just do not know, with my office being in Kingston.

Ms Jackson: You said you are not certain. Has anybody ever said to you or given you reason to think that anybody other than the people listed as addressees received a copy of the e-mail?

Dr MacMillan: Not until December 10.

Ms Jackson: We will come to that in due course.

In the conversation in Dr LeBlanc's office, did you gain any further information as to why the e-mail had been sent to this group of people in the first place?

Dr MacMillan: I clearly understood it was for the preparation of a briefing note. By then I was fully aware of the most recent press involvement of Dr Donahue, and indeed I agreed about that time to be the ministry spokesperson for a Sudbury Morning North program to be aired the following morning, and in which I participated with respect to the issues raised by Dr Donahue.

Ms Jackson: The briefing note was to go to whom and for what purpose?

Dr MacMillan: I am not certain that I understood it was anything other than a briefing for the minister at that time. I some time later realized it had not sprung out of the morning briefing session that is described in the priority briefing booklet you have seen. So I only knew that a briefing was necessary. The issue was being raised in the public eye. It was quite likely that the minister or others would be asked as to the proper ministry response, and it seemed to me quite natural and obvious that information would be needed in order that a note be prepared, and indeed one was finally prepared which was very satisfactory.

Ms Jackson: Apart from giving the instruction or the view that you did in the meeting with Dr LeBlanc and the others you have identified, did you take any other steps to see that copies of the e-mail were erased or destroyed or collected up in Toronto, let's start with?


Dr MacMillan: No, not in Toronto. People came to me over the next short period and said, "Yes, we've got the copy back; we've destroyed it," and I just believed that everybody sincerely supported my decision. In fact, I cannot recall who had one, but someone brought in their copy that had so many black lines through it that there was more struck out than was still present and readable. So it was obvious that other people were trying to put this together without the confidential information that was sent from Kingston.

Ms Jackson: Do you have any information for the committee as to who kept copies of the e-mail in Toronto?

Dr MacMillan: No, I do not, but let me tell you something technical. You can press a delete on your computer, and you can then press Y, if any of you have that system, and that means, "Yes, I really do want to delete it," so you press the second button Y and it goes into "waste-basket." One would think that that is gone from the computer, but it is still on the mainframe and it is still retrievable. So we exit it from our own computer system, but it is still available.

Having said that -- which is quite far out -- to my knowledge everybody, I believed, felt and agreed with me that it should be destroyed, and I had faith that they would. There would be no way I could walk around and go into every office and try to prove it to myself; I just went away that day believing people understood, agreed with me, and my task was done. In addition, of course, I made the message very clear to my staff in Kingston about the memo and, again, was confident that my message got through. But I did not follow up personally to check their desks.

Ms Jackson: Do you know, once an e-mail is deleted and goes into the waste-basket -- let's just find out if you can tell us anything about that. Who can get it and for how long?

Dr MacMillan: Well, we have, again, in the security manual and other manuals, very strict procedures which we hopefully adhere to with regard to the destruction of paper mail. We of course recycle most of our paper that can be recycled, but any kind of files --

Ms Jackson: Sorry. When you described the waste-basket process, I thought you were talking about an electronic waste-paper basket.

Dr MacMillan: Well, I was, originally. Now I --

Ms Jackson: Okay. When it is deleted from the machine and it goes into the electronic waste-basket, for how long is it in the waste-basket, or do you know?

Dr MacMillan: I cannot answer that question.

Ms Jackson: Do you know whether anyone could pull it out of the waste-basket, and how?

Dr MacMillan: Those are good questions. I will get the answers for you for tomorrow morning. I just do not know that.

Ms Jackson: Okay. Now, you said you gave the message quite firmly to your staff in Kingston. Is that in the telephone conversation that you described with Mr McBride?

Dr MacMillan: Yes, and subsequent meetings, when I returned there the next morning.

Ms Jackson: When you returned, or at any time, did you learn whether anybody had a copy of the e-mail in Kingston, other than Mr Teatero, Mr McBride and the two people whom you have indicated wrote a note on the e-mail, Mr Quinn and Dr Kovacs?

Dr MacMillan: No, I do not believe that there was anyone else. I did not satisfy myself that there was anybody, but given the huge degree of information that is available there anyway, I was far less concerned about my own staff, even though this had happened, than I would be with unknown destinations in Toronto.

Ms Jackson: Because they have a lot of other confidential information that they have access to?

Dr MacMillan: A tremendous amount.

Ms Jackson: Did you ever learn whether hard copies of the e-mail remained in existence in Kingston?

Dr MacMillan: I was not very concerned about whether or not they were available in Kingston. I cannot say that that obsessed me. Again, people knew what was in the document who had read it, and I do not think that --

Ms Jackson: Dr MacMillan, I understand why it was not of concern to you, but could you none the less indicate whether you know whether hard copies remained in existence in Kingston?

Dr MacMillan: I cannot answer --

Ms Jackson: I have had you describe to some extent --

Dr MacMillan: I have a copy now. I have a copy and I gave you a copy. I think it is from a hard copy I had photostatted, but it might be off the machine itself.

Ms Jackson: You do not know where that came from?

Dr MacMillan: No. I can try to find out, if it is of importance.

Ms Jackson: All right. Could you, if you are able to, advise the committee tomorrow morning what copies you are aware of continued to exist after the 13th in hard or electronic copies in Kingston? Thank you.

Now, you indicated that once you had given the instructions that you had with respect to this original e-mail, another e-mail or briefing note was prepared. I would ask you to identify the briefing note that was subsequently prepared, dated November 14, 1991, 12:17: "Briefing Note: Delivery of Dermatology Services in Sudbury."

The Chair: That will be marked as exhibit 14.

Dr MacMillan: You are not passing that around?

Ms Jackson: I thought we were. I think we are.

Dr MacMillan: Yes, I just want to speak to what I understand to be the document.

Ms Jackson: Can you identify that as the briefing note you were earlier describing, Dr MacMillan?

Dr MacMillan: Yes, this is the final briefing note that was forwarded everywhere, I guess, within the ministry.

Ms Jackson: Do you know to whom it was forwarded?

Dr MacMillan: Well, it would go through a standard and routine dissemination to those who would have a bearing on this issue. It would go to the communications branch in case they had to, in their particular role, address the issue, to inquiries or to the press, and I believe it would have gone to the minister for purposes of informing her.

Ms Jackson: That briefing note, you can confirm, contains no identification of Dr Donahue or details of his billings?

Dr MacMillan: That is correct.

Ms Jackson: Now, you said, sir, that you then became a spokesperson for the ministry with respect to this issue and that you gave an interview. I am going to ask you to identify a transcript of that interview on December 15 -- pardon me, November 15 -- an interview, again CBC Radio in Sudbury, which was the program that had interviewed Dr Donahue two days before.

Dr MacMillan: Yes.

The Chair: That will be marked as exhibit 16.

Ms Jackson: Did you subsequently speak to Dr Donahue?

Dr MacMillan: Yes, I did.

Ms Jackson: And have you made a note of that conversation in general terms?

Dr MacMillan: Yes, I have.

Ms Jackson: And could you identify that note as one that is headed --

Dr MacMillan: "Confidential Notes Respecting Sudbury Visits."

Ms Jackson: When did you prepare that note, Dr MacMillan?


Dr MacMillan: I prepared that note on December 21.

Ms Jackson: For the same reason as the earlier one?

Dr MacMillan: Yes.

Ms Jackson: And is the note entirely prepared by you?

Dr MacMillan: Yes.

Ms Jackson: You recount in the first paragraph a conversation, or did you say possibly two conversations, with Dr Donahue regarding his personal situation. Now, without telling us anything about his personal situation, can you just describe generally to the committee how that came about and what kind of conversation or conversations you had?

Dr MacMillan: Give me leave to be just a bit longer on this question, because I have to tell the committee that with my 12 physicians who constantly talk about issues with physicians, we became aware, of course, of a mounting and heated-up objection to the agreement, especially as it related to the threshold area. In particular, the press, as you have seen, had a few common spokespersons who often related their own particular information in the press.

I became concerned, I guess, as a physician. In order to try to make certain that they had factual information about their particular impact, I became concerned that Dr Donahue's comments to the press, or alleged to have been given to the press, seemed to imply a misinformation on his part, a misinformation that went so far that I was shocked at the level of impact that he was alleging the threshold agreement would have. So I asked my staff to get for me something like: "Say, this Dr Donahue really seems to be hit by this thing. He's got to close his business, he says, in November."

So they got me information about his billings, about his epilation which, you know, he was involved with and about the allegations of how the threshold would impact, and I said to myself: "This is all wrong, from the newspaper. How come nobody is telling this guy?"

So I picked up the phone on November 28. Let me tell you I had already been in touch with the president of the Sudbury and District Medical Society saying: "You've got a real problem up there. Everybody's very upset. Why don't I come up to" -- I have to tell you this because I want to tell you that I had already arranged to come up with Dr DeBlacam, the president of the Sudbury and District Medical Society. So when I talked to Donahue, I knew that I was going to come up. I gave him information that I had about his particular situation. He said: "Well, thank you very much. I didn't know that. I didn't think that I was affected that way. This is new information to me. I really appreciate the call." I said, "Would you like to meet with me when I come?" He indicated that he would and that was the end of the conversation.

Ms Jackson: Now, I do not want you to speak about any of the other impacts on him of the threshold, but can I just ask you about the one that we did canvass that was publicly available? I take it that because he was on the underserviced area program until the end of August his income up until the end of that period would not have been subject to the threshold.

Dr MacMillan: He was not aware of that.

Ms Jackson: And you told him that.

Dr MacMillan: Yes.

Ms Jackson: Did you subsequently meet Dr Donahue?

Dr MacMillan: I went to Sudbury on December 5, at which time we anticipated we were going to meet with the Sudbury and District Medical Society, but it did not turn out quite that way. We had very little opportunity for interaction; it was much more of a demonstration than a meeting. Although I spoke for a moment with Dr Donahue, he did not indicate any desire to speak to me even though I was prepared to talk about his individual situation.

Ms Jackson: All right. Did Dr Donahue subsequently close his practice?

Dr MacMillan: To my knowledge he did, although I simply read that in the newspaper as well.

Ms Jackson: And then your note records, and you said you had indicated, that as a result of a conversation with Dr DeBlacam you would visit Sudbury. When did that visit take place?

Dr MacMillan: Just to be precise, can I tell you that I called him on Monday, November 18, and spoke to him for about 12 minutes? Again, he appreciated my call, was very courteous on the telephone, wanted to respond positively to my suggestion. I spoke to him again on Tuesday, November 19, at which time we were again trying to arrange a suitable meeting, a meeting which originally had been planned and was postponed, he indicated, because they were going to widen the audience of the meeting. Of course, the widened audience included many other persons, an open town hall meeting with the press and cameras, and so on.

Ms Jackson: All right, but dealing first of all with the first visit, you record in these notes a visit to Sudbury on November 30.

Dr MacMillan: Yes.

Ms Jackson: And when did you go up to Sudbury?

Dr MacMillan: I went on 29 November.

Ms Jackson: And who was with you from the ministry, anyone?

Dr MacMillan: Dr LeBlanc and Mr David Belyea, who was the coordinator for hospitals in the north.

Ms Jackson: Now, you indicate that on the Friday evening there was a supper-hour meeting among the three ministry officials and someone from the Sudbury Memorial Hospital and his wife. During that conversation, was there any discussion of the financial circumstances of any individual physician in Sudbury?

Dr MacMillan: No personal information was disclosed.

Ms Jackson: Was there any discussion --

Dr MacMillan: We were talking about physicians in general and how they would be impacted by the threshold; and, of course, the reason why the CEO of the hospital wanted to meet with us was because some of his very staff were going to be affected by the threshold and he was giving us their side of their particular situation as he knew it and, of course, expressing the threatened withdrawal of services for cardiovascular care in Sudbury at his hospital. I did not give to them any information respecting the billings of any of the physicians on their staff.

Ms Jackson: The next morning you note at the bottom of page 2 that the three people from the ministry met over breakfast with Floyd Laughren, Shelley Martel and Sharon Murdock, and a member of Mr Laughren's staff. Do you remember who that was?

Dr MacMillan: No, I do not.

Ms Jackson: Was there any discussion during that breakfast meeting of the financial circumstances of any individual physician?

Dr MacMillan: No.

Ms Jackson: And then there was a meeting with the cardiologists?

Dr MacMillan: And the hospital personnel.

Ms Jackson: And the three politicians just mentioned?

Dr MacMillan: Yes, and a few other people including representatives from the Sudbury and District Medical Society. I believe there were about 17 people or so.

Ms Jackson: Was there any discussion in that meeting of the financial circumstances of any individual physician?

Dr MacMillan: Yes, there was, but it was all in generic terms. There was no revelation of to what degree OHIP was making payments to any individual physicians. Collectively, we are always able to give out information. We usually use a cell of four, or more commonly five, but it is always given in such a way that no individual physician's income could be extracted from that aggregate data.

I would like to make a correction. When I wrote my notes, I was trying to remember everything I could, but I missed out another member of the breakfast meeting and that was John Rodrigues, MP from Sudbury, who was very interested in the issues at hand. He had been a patient of the hospital, he was pictured in their annual report, and he was very concerned and worried about the threat to services, especially in the cardiovascular area in Sudbury.

Ms Jackson: Now, you then say in this note that documents of a sensitive nature were present in the briefcases of ministry officials, no such documents were taken out of the briefcases over the breakfast, and no one recollects any confidential information being requested. What sensitive documents were you referring to there?

Dr MacMillan: I may have gone beyond my memory at that time. I certainly had sensitive documents in my briefcase. I assumed because Dr LeBlanc was involved in many of the same issues with the same doctors -- in fact, he often had more frequent interaction with individuals than I did -- he may have had some information in his briefcase as well. I doubt whether Mr Belyea, who was solely involved on the hospital side, had anything of a sensitive nature.


I had told you earlier that I had been attempting to meet Dr Donahue and he had expressed a desire to do that. But there were several other physicians, too, who talked with me and I looked at my telephone records and I remember why they are not there -- because they phoned me. They phoned me to see what they were going to do, how their cash flow was going to be adjusted by OHIP, when they would be affected by the threshold, was the minister going to expand the exemptions. So there was this constant communication, not only with me but with Mr Teatero, whose main job is to deal with the threshold, and Dr LeBlanc.

So I took with me some financial data on individual physicians' practices, including Dr Donahue's, in order that I would be prepared to talk intelligently with them if I had the opportunity to meet with them. Unfortunately, on that weekend was the annual Ontario Medical Association bonspiel and I know that a number of physicians were out of town. Possibly there were other reasons why a meeting at that visit never came to fruition, other than with the cardiologists, of whom I also had personal billing information and who had also approached me by telephone to debate the issues.

Ms Jackson: So you did not meet with Dr Donahue.

Dr MacMillan: No, I did not.

Ms Jackson: Did you have occasion to refer to your confidential information with respect to Dr Donahue in conversation with anyone during that November 30 visit?

Dr MacMillan: No, I did not.

Ms Jackson: Last, on this visit you record at the middle of page 3 a lunch meeting with the three ministry officials and Shelley Martel to further explore solutions to this dilemma. You point out later on in that paragraph, "Discussions took place of a general nature, and inasmuch as Dr Donahue had made numerous comments and statements about his particular position, his plight was discussed in general terms as it related to the availability of dermatological services in Sudbury." What was said?

Dr MacMillan: I want to preface my remarks by saying that the very serious concern of the minister, Shelley Martel, was of course the threat of cessation of cardiology services. That is why we were asked to go up there. That is why we were asked to meet just prior to the hospital meeting, why we were asked to attend the meeting. In fact much of the meeting was to bring the minister up to speed, I guess, on a very complex area that involved physicians, and indeed patients, in her riding.

As a result of the meeting in the morning that lasted about three hours, and because of the detailed data and arguments made by the physicians, which again was very much a one-way presentation, we began talking in the hall, and it went on a few minutes about the general issues of the Sudbury Memorial Hospital and the cardiology threshold issue. We were almost on our way to get an airplane and we somehow decided to further the discussion over a sandwich, so we stopped at a restaurant. I would think we were not there more than half an hour because we were in a rush. We discussed primarily the cardiology services in general.

Dermatology, as you can see, had reached a very peak in Sudbury, with a very vocal dermatologist and the threat of closure of his office, the cessation of services certainly by a very busy dermatologist, what effect that would have on the community, how dermatology specialty services would be served in the Sudbury area, how the fly-in program worked, how the incentive program worked. It was definitely a discussion about dermatology.

Dr Donahue's name was definitely mentioned; I can recall it. I do not recall, and I have thought a lot about it immediately after this, about the extent of that conversation, and I do not feel in any way that we divulged any private or confidential information that would be seen as being in breach of the legislation we live under. I am so sensitive to that, having gone through personally the Evelyn Gigantes release of information. I am above that. I just do not believe that I could have, inadvertently even, slipped out something about an amount of income or any other matter relating to Dr Donahue.

Ms Jackson: Was there any discussion at all about the amount of Dr Donahue's billings that you can recall?

Dr MacMillan: No, I do not recall discussing, again, the degree to which he was billing. Remember, please, that he has indicated that he must close because he is going to go bankrupt in November. Now, that is only eight months into the 12-month year. Recognizing with many physicians that maybe half of their billings are technical fee and exempt, and another portion may be exempt from epilation or other services that are not part of the threshold, it did not take an awful lot of brains to realize that this doctor was far beyond a $400,000 man. I mean, that was given in his assertations to the press. So I think the prevailing mood was that he did quite well, but I certainly did not release any kind of figures to indicate the degree to which that took place.

Ms Jackson: Was there any discussion in that lunch meeting at all of the possibility of any proceedings or investigation of Dr Donahue?

Dr MacMillan: No, I do not recall any mention of any kind of investigation or proceedings or charges or anything.

Ms Jackson: Thank you. Mr Chairman, I am proposing to go to a different day and a different subject.

The Chair: Thank you. At this point we will adjourn for the day. We will reconvene again at 10 o'clock tomorrow. Thank you.

The committee adjourned at 1717.