Thursday 6 June 1991

Annual report, Provincial Auditor, 1990

Ministry of Health



Chair: Callahan, Robert V. (Brampton South L)

Vice-Chair: Poole, Dianne (Eglinton L)

Bradley, James J. (St. Catharines L)

Conway, Sean G. (Renfrew North L)

Cooper, Mike (Kitchener-Wilmot NDP)

Cousens, W. Donald (Markham PC)

Haeck, Christel (St. Catharines-Brock NDP)

Hayes, Pat (Essex-Kent NDP)

Johnson, Paul R. (Prince Edward-Lennox-South Hastings NDP)

MacKinnon, Ellen (Lambton NDP)

O'Connor, Larry (Durham-York NDP)

Tilson, David (Dufferin-Peel PC)

Substitution: Ramsay, David (Timiskaming L) for Mr Conway

Clerk: Manikel, Tanis

Staff: McLellan, Ray, Research Officer, Legislative Research Service

The committee met at 1010 in room 228.

After other business:


The Chair: I have a resolution moved by Mr Tilson "that the standing committee on public accounts adopt the draft report as report number 1, 1991, and that the Chair present it to the House and move its adoption."

Motion agreed to.


The Chair: Now we have before us Dr Barkin, and perhaps you could introduce the gentleman to your right. Is that David McNaughton?

Dr Barkin: Dave McNaughton, and to his right, Dr Robert MacMillan, executive director of the health insurance division.

The Chair: I am not certain whether you understand why we have asked you to come. If you are certain, I will not bother to explain.

Dr Barkin: No. I would most appreciate hearing it again.

The Chair: The committee had expressed a concern about looking at the question of drug facilities and alcohol treatment centres in Ontario and then comparing those with what is available in the United States. The second half of that is still up in the air, for reasons the committee knows, so maybe you could just assist us in terms of what is available in both drug and alcohol treatment, and perhaps even include in that if anyone has knowledge of any delays there may be, backlogs and so on.

Dr Barkin: I was not as certain of your needs for information as I am now, so I thank you for that. That is one of the reasons I brought a variety of people, people from the drug treatment side as well as people from the OHIP side, in preparation for questions that would come either on payments of services or questions around the availability of services.

On the drug treatment side, I would introduce to the committee, and I will bring to the table if that is the line of questioning as is appropriate, Celia Denov, who is the executive director of community health programs, Steve Lurie, who is our mental health and addictions co-ordinator for the Ministry of Health, and I have asked to come along from the provincial anti-drug secretariat Dr Jon Kelly, who is director of the anti-drug secretariat, so that the committee would have available the expertise, at least, that is available in the government on the subject.

I thought with my opening comments I would explain the role of the bureaucracy in the Ministry of Health in managing the out-of-country payments first, so that the committee understands the legislation under which we operate. This is actually not the first time I have been before this committee on the subject of OHIP payments. I was before the committee in early 1988, a couple of months after assuming the position of Deputy Minister of Health in Ontario, and at that time I did make some comments about the comparisons of the facilities available in the United States and in Canada. We have had subsequent research and studies which confirm that those statements are an accurate reflection of the status quo, and I will refer to those later on.

I did, however, make two statements to the committee at that time which, as events have evolved, turned out to be not as I predicted they would be, and I think it is fair to start with that.

At the time I commented that there would be a doubling of programs in Ontario, both institutional and non-institutional programs, and that there would be a considerable registry developed in Ontario over the next couple of years. In fact, that did take place. Our detoxification centres went from 15 to 24; our assessment referral centres went from seven to 35; our non-residential centres went from 30 to 60; our short-term residential centres went from 22 to 43; and our long-term residential centres remained stable, in keeping with my comments to the committee in 1988 about the balance between residential and non-residential treatment and the cost-benefit of the two forms of treatment in our society.

The total number of patients treated went from 47,000 in 1985-86 to 61,000 in 1988-89, and those figures are from our report. Then in 1989-90 we produced a catalogue, of which an update will be coming, of all of the alcohol and drug treatment resources in Ontario, identifying where they were, what languages were available, their accessibility and their waiting lists. I will be pleased to leave you the 1989 copy, but the 1991 update is still in the process of preparation. It will be substantially thicker and more complete.

The two areas that I highlighted, where my predictions were overtaken by some interesting events, were that this doubling of capacity would in fact deter or stop patients seeking treatment in the United States, and that our 75% payment policy would be an added and sufficient deterrent for that purpose. Neither of those comments took into account what would become one of the most aggressively marketed services in North America, the public substance abuse services from clinics and centres in the United States, many of which were free-standing and affiliated themselves with hospitals, if in fact it was not the hospitals themselves that went into the business of drug abuse treatment.

In this heavily marketed environment the American payors went to immediate restrictions and prior assessment and prior approvals to deal with that. We were a little remote from the problem in Canada, and it took some time for us to become aware of just how heavily and aggressively that would be marketed. So although we were treating 60,000 to 70,000 patients in Canada, and when our own assessments demonstrated that specific need for services in the United States that were not available would account for about 1% or 1.5% of need, patients without assessment, who could go directly to the United States in response to that marketing process, accounted for about 5% of our patient volume but a lot higher than 5% of our costs, because of the costs of American residential drug treatment. The 75% payment policy, which we thought would be a deterrent, turned out to be subverted by the Americans' charging practices, in which they tended to forgive the 25% for reasons that became apparent later on in the course of the subsequent 18 to 24 months as we began to follow how quickly and rapidly this phenomenon unfolded.

I said I would give some background as to how the health insurance program is administered by the ministry, and I just have a few points to explain. Our administration of the health insurance program is governed by the Health Insurance Act, and within the act there is the appointment of a general manager, who is appointed by the Lieutenant Governor in Council under subsection 4(1) of the act. The general manager is the chief executive officer and has independent authority under the Health Insurance Act.

Mr McNaughton in addition to being the assistant deputy minister, is general manager under the act.

The general manager, under clause 4(2)(c) of the act, has the power to make payments by the plan for insured services, including the determination of eligibility and amounts, and under section 24 of the act the general manager shall "approve and assess claims for insured services, determine the amounts to be paid therefor, and authorize the payment thereof, in accordance with this act and the regulations."

Where a person receives treatment in a hospital outside Canada as an inpatient or outpatient, the cost of the insured service paid by the plan shall be the amount determined by the general manager.

Finally, disputes over medical necessity and over payment are handled by an elaborate appeals process as defined by the act, and sometimes by an appeals process outside of the act, which involves appeals to the Ombudsman.

The policy of 75% payment for elective and 100% payment for emergency was implemented in Ontario in 1962, at which time it represented a reflection of the costs of these services as they were delivered in Ontario. Of course, from 1962 to 1990 there has been some divergence between the costs of services in Ontario and elsewhere, but by that time, as time passed, the 75% and 100% went from the general manager's discretion to being a matter of government policy just by virtue of the fact that that is the way it had been for several decades.


Finally, the recent changes in the process announced by the minister in the House dealt with that, changed those processes, and with the balance of changing the payment policies of the government with respect to out-of-country services, both for emergency services -- that is, services required while travelling for some other purpose -- as well as for services that are not available. The minister specifically identified substance abuse programs, the process of prior approval and payment policies for the United States, and in her statement referred to a commitment for, and I will simply quote her statement, "expansions of existing addiction services: residential programs, youth services, case management, detoxification services and day treatment, as well as an enhancement of assessment and referral services. And new treatment registry is planned."

So all the way through, in dealing with the payment for services available or not available in Ontario, in the United States the concern was that when services could not be provided in Ontario that were either appropriate or timely, we not cut off access to places where those services were available.

Those are my opening comments with respect to the payment side. For the comparison side, I refer for greater detail to Steve Lurie, who is our expert in this area. There have been a number of reviews carried out comparing substance abuse treatment facilities in Canada and the United States for alcohol and illicit drugs. One of the reviews was carried out by the Addiction Research Foundation in 1985. On balance and in general there is little difference between residential treatment programs available in the United States and those available here. Ours seem to have more professionals working in them than those in the United States, and Steve can speak to the details of that comparison.

In terms of the efficacy of treatment programs, however, the comments I made before this committee in 1988 were as relevant then as they are today. That had to do with the limited necessity for residential treatment and the overwhelming applicability and superiority of non-residential alcohol and drug treatment, in terms of the broader base of population that can be served in this way, in terms of the cost-effectiveness of providing such treatment and in terms of the long-term success rates. Those were my comments in February of 1988, and I think subsequent research and evaluation and the most recent paper on the subject will confirm that still remains the general belief today.

With those opening comments, I and my staff are pleased to answer the committee's specific questions.

The Chair: Has there been or is there any more recent examination of the US facilities since the 1985 review?

Dr Barkin: If I may, I refer that question to Mr Lurie, who is an expert.

The Chair: I think he is shaking his head, no.

Dr Barkin: Steve, come up. You will have to be picked up by a microphone.

The Chair: We try to preserve words of wisdom for posterity by having you speak into the microphone.

Mr Bradley: Even words that are not wisdom.

The Chair: That is right. We just picked up yours, Mr Bradley.

Mr Lurie: Since 1985 there have not been formal reviews, although in the last few months the ministry has received some comments from people who have been approached by some of the US facilities. They are suggesting that while some of them are quite good, there are certainly others where they would not recommend we make any referrals or pay for services. They are suggesting that some of them use techniques of behaviour management that would be illegal under the current Ontario Mental Health Act.

The Chair: Would you be able to provide that information to the committee?

Mr Lurie: Yes. I have two --

The Chair: Perhaps not on the record, since those comments may or may not be ones people would want on the public record. If you can provide those to us, it would be most helpful.

Ms Haeck: Fairly recently I had a constituent in a position of needing some treatment and whose counsellor or doctor got a recommendation to a facility in New Orleans. In negotiating with some staff within the OHIP offices, he received a letter saying he was required to pay 25% and that he had to provide proof that he paid 25% of those costs.

The newspaper reports have made it known very widely that that obligation is not universal, that in fact patients on a fairly regular basis, and maybe through some of these brokers who are used here, seem to be able to work out some other deal, that the facility in question will accept the 75% OHIP payment and the patient is not required to pay the 25%. To what degree can you comment on the veracity of the newspaper accounts, and what is the position on the obligation of an individual to pay 25%?

Dr Barkin: In my opening remarks I commented on the fact that one of the factors that tended to negate the 75% I referred to, or thought would be a reasonable deterrent in 1988, was the practice that you have described of facilities finding ways to "forgive" the 25%. It is not a consistent pattern, but certainly one we became aware of through the latter part of 1990. As far as the ministry's change in procedures to try to deal with that, I will let the general manager of OHIP comment on that, if I may.

Mr McNaughton: The attention has increased on this particular aspect about a country and payment. Dr Bob MacMillan and his staff in Kingston have reacted in an appropriate way, in the sense of more scrutiny of everything passing our desks. The law is quite clear, and I think what you are commenting on is that every effort is being taken to apply the law at this time, particularly because of the magnitude of the problem, the attention on the problem and so on. We are in a period of time now, until new policy takes over, that will be much simpler. The reason for new policy obviously is to avoid the kind of situation you just described. It is not an ideal situation and hopefully a new policy will avoid such situations. What you are describing is application of the current regulations with full rigour by our staff in Kingston.

Ms Haeck: So those individuals who go down to the US on an elected basis will be required to pay and provide proof of payment of 25% of those charges?

Mr McNaughton: That is correct, and we are just standing watch stronger in that regard. I would like to stress that, as the minister announced, in the fall a new policy will take over.


Ms Poole: On a slightly different topic, we have received reports of headhunters who are primarily hired by US facilities to come up to Ontario and lure people down to those facilities. Could you tell me what investigative work the ministry has done in this regard and whether there have been any reports on it? How serious do you think the problem is, and has the minister taken any steps to remedy it?

Dr Barkin: We think the problem for those patients who are going to the United States without prior assessment is a serious problem. We have been carrying out two kinds of audits, actually, since last fall. One deals with the financial side of the invoices, to be sure we are paying only for the medical treatment and not for ancillary things like transportation and commissions payable. The other is a medical audit, which requires a lot more expertise. We bring that expertise in from outside to ensure that all of the services billed to us are medically necessary and indicated.

As far as the numbers of those and the exact technique, if I may, Ms Poole, I will refer to Dr MacMillan, whose division is actually overseeing those two surveillances.

Dr MacMillan: Unfortunately there is nothing illegal in Ontario with regard to attempting to market patients towards a particular hospital, whether it be in Ontario or in the United States. The climate in the United States is such that hospitals are often running at 50% to 60% occupancy because the private plans in the United States have been so tough with the in-hospital treatment of drug addiction. They are looking for new markets through various ways: hiring Canadians, setting up branch offices of their hospital networks here in Toronto or elsewhere in Ontario. We are well aware of at least 12 so-called headhunting agencies that are operational in this very city that are using very unethical techniques, to say the least, in attracting people and enticing them to go across the border, often with their transportation paid or even with financial incentives to do so, we are told lately.

We are getting very tough with the hospitals in the United States. We have communicated universally with them several times, indicating our policies and attempting to bring them into line with the appropriate conduct governing our regulations and policies. We are not winning the battle, but in the move to a new policy of prior approval and so on we believe we will have it totally in hand.

Ms Poole: Thank you, Dr MacMillan. Every time I see you, I think of things like the Independent Health Facilities Act and Health Professions Legislation Review and all sorts of things. I am trying to get my mind back on to drug abuse. It is difficult.

Dr Barkin mentioned that the ministry has been active in trying to ascertain whether commissions are being added to the fees and whether transportation has been added. Has it been the finding of the ministry, when you have been doing these types of investigations, that the American facilities are taking this kind of as a loss, building it into the fees? Is it in addition, or are they actually eating it in order to attract more patients down there?

Dr MacMillan: We have talked about this many times. It certainly is not out of the goodness of their hearts. They have obviously attempted to use the funds obtained through OHIP in order to fund this entire marketing process, I am certain, including the transportation. As a result, as the deputy said, we have been far more careful in sending these accounts, especially from noted offenders, to expert medical auditing firms and have already been successful in clawing back a significant amount of money, although it is at the early stages in some accounts.

In addition, I think the very knowledge on the part of the hospitals in the United States I wrote to last December warning that we were going to do this has been a deterrent to some degree. We have seen hospitals that used to deal primarily in these, in many cases frivolous, referrals to the United States now going through the process we have recommended where consultation is made with our staff at OHIP and a medical consultant, where a referral is made not just from the headhunting agency but through a physician, to try to make it legitimate and prove the medical necessity before the person gets down there. So within this old policy, I think we have taken almost every step we can to deter people from inappropriate activity, to detect inappropriate billing, which would be a padded account representing the travel and the marketing costs. The message is certainly to family physicians and referral agencies to make the proper referral process work.

The Chair: Apart from the climate in places such as Texas, Florida and New Orleans, most of these facilities are located in not terribly exotic places, with all due respect to the United States -- Cleveland, Minneapolis, Something-or-other Falls. What is the attraction? That is what we would like to know. I mean, if these people are going, clearly there must be something they are doing right that we are not doing enough of, well enough or whatever, to make them go there. They are not going there for the weather, other than the ones I have just explained. Can you help us with that?

Dr Barkin: Perhaps I will quote a comment I made before a recent committee of the US Congress that was visiting Toronto. This is of course a very peculiarly American phenomenon, and that is what I said then, that almost every jurisdiction has difficulty getting all the health care that people need for the people who need it. No jurisdiction can afford to get all the health care the people want, or are marketed to want, to them. In our view, the difference between what is needed health care and what is marketed health care is what is reflected in the attraction to these particular places.

When we have patients who are put through assessment and referrals by assessment referral centres in Ontario, the number of times we have to seek help from facilities for very special circumstances in the United States accounts for about 1% to 1.5% of patients who are being assessed. I think Steve can give you the exact numbers of the last group that was appropriately assessed.

When patients are marketed to directly and leave Ontario by their choice in response to those things, the rate at which that occurs is extremely high. What we are dealing with is not that there is something there that gives an outcome of treated substance abusers with the lowest possible incidence of recidivism or return to the addiction state but that there has been an aggressively marketed holding out of promise to that particular individual at one of the most vulnerable times in any individual's life.

Whether one is an addict or is suffering from a severe illness, at the point at which one has decided this is the time he wants to change his life, this is the time he wants to get out of the hole of addiction -- and for addicts and their families this is one of the horrible diseases of the 20th century -- the marketing to those individuals of treatment facilities is almost exploiting that vulnerable state.

The Chair: Steve, could you give us the numbers on the assessments for the last little while?

Mr Lurie: Yes. The assessment referral centres saw 16,000 people in the province last year and, of those, they found that only 18% needed residential care. Of that total, only 1.4% were referred to US services.

They did a survey of their programs for the period between April and October 1990 and found that out of 5,000 people who would have been assessed during that period across the province, only 69 people were referred to the United States.

They have identified that one of the problems people face is the assumption that you need residential treatment if you have an addiction problem. The literature suggests you do not, and they have suggested one of the things the ministry should be doing in the years ahead is trying to map a public education program to deflate the myth that residential treatment is the only cure for an addiction problem.

The study the Addiction Research Foundation did for us in 1985 identified that another reason people go the United States is that there are fairly liberal admission criteria to the existing programs. You do not have to be detoxified to go into a program, so there are some people who go and in fact they are detoxified as part of the program, whereas here we try to encourage people to get detoxified before they engage in a program.


The Chair: So it does not have anything to do with the waiting lists. The reason I ask is that some of the research material we got from our research officer in anticipation of looking into this matter seems to show very impressive success rates in the United States.

Mr Lurie: Certainly for some services there are waiting lists, and we have identified in the anti-drug strategy report that for certain people with specific problems there are some services that are unavailable or where there is a wait that would be found to be a problem. But when you look at the number of people the assessment referral centres have said required it, 69 out of 5,000 is a relatively small number. For example, for people with dual disorders, who have a psychiatric and an addiction problem, there is a need to get them into a comprehensive treatment program, and the resources are a bit strained here.

Similarly for some of the youth, the provincial anti-drug secretariat identified in its report that there really was a need to expand youth programs. But for the bulk of people, I think the general comments that both the deputy and I made apply here: Most people do not require residential treatment. The research evidence is overwhelming that outpatient treatment can be as cost-effective.

The other point the experts in the field could provide you with is that the issue of immediacy is not critical. You do not necessarily need treatment tomorrow. What you may need is detoxification tomorrow and support, and that is certainly the direction in which we are trying to move the system.

Mr O'Connor: You touched on the waiting list. If I could just try to narrow that down a little bit, is there any relationship there to certain addictions? One area that has been brought to my attention through constituents is the youth being attracted to some of these and the marketing that is used to attract our youth down to the United States. I do not know whether they are more susceptible to being coerced into treatment across the border, but if that is true, is there any difference in the quality of treatment they are receiving down there as opposed to what they could receive here? Are the facilities available here for that treatment?

Mr Lurie: With regard to youth treatment, there certainly has been an identified need to expand programs here. At the same time, the recruitment of people to the United States does not necessarily mean that the treatment they get is appropriate. At the anti-drug strategy hearings, we heard testimony from a lot of youth service agencies that said they had real difficulties with some of their clients who in fact went to the States, were treated and then came back without appropriate case management support. They found they had to pick them up and they were no better than when they went before; they were back using the drugs.

I think the other dimension of this is that among street kids there really is a very high incidence of alcohol and drug abuse. Those youth are multiproblem youth, and a 28-day program in the United States is not likely to yield the kind of benefits they need. What we are looking at here, and certainly what the anti-drug strategy report recommended is the development of a more comprehensive program that provides both stable housing and life skills and offers young people an opportunity to change their approach. That is also the need that the youth service agencies identified in the hearings on the Vision 90s report.

Mr O'Connor: Is there any relationship to the length of stay -- I guess there is no actual cure for it -- for a person returning to that addiction or whatever?

Dr Barkin: Perhaps I could help out a bit. Actually, I commented on that in 1988 when I was before the committee and I think my comments then are relevant today. At that time I said the treatment and rehabilitation of the patient who suffers from substance abuse is not a one-shot item that goes on for three weeks, six weeks or eight weeks in order to achieve a cure. One must have in the community where one lives, from the time one went into the process of treatment until one has gone through the various stages of recovery, a support system, a support network to achieve this.

Having a 28-day or a 56-day residential treatment go that gets you off drugs in that artificial setting is not a cure for substance abuse. In order to get some greater understanding of how our community programs actually work, I went to visit some of them. What I found is that in these community-based programs, first, as they had their meetings there was tremendous mutual support within the community for the successful addicts -- the one I am referring to that stands out in my mind is a cocaine addict group -- and second, they celebrated their successes with pins and emblems that celebrated a success of six months, 12 months, 18 months, 24 months and so on.

The notion that one can be cured in 28 days was quickly dispelled in my mind when I saw the kind of continuing, ongoing support that some of the more severely addicted people -- and this was a youth program as well -- need to have on a long-term and ongoing basis in the communities in which they live in order for them to live productive lives in those communities. The notion that someone, as I said in 1988, can go down to the United States for 28 days, get off drugs, come back here and say "Hey, I'm okay" simply has nothing to do with the reality of addiction.

Ms Poole: If I might digress for just a moment to another area, could I ask for somebody from the OHIP billing side to give the committee information as to the total amount of out-of-province OHIP billings over the last three- or four-year period to show whether there has actually been a serious increase, and second, specifically how much of this was devoted to the drug and alcohol abuse facilities? I do not know whether you would have that information with you.

Dr Barkin: I do not have it all with me, as you have asked, but we can certainly obtain that for you. I think we can give you some approximate numbers, subject to further verification from Mr McNaughton.


Ms Poole: That would be helpful.

Mr McNaughton: Ray has copies of my data there that might help me answer this question. In approximate terms, total out-of-country costs to OHIP have gone from $100 million three years ago to $200 million or $220 million now. Bob, if you would just help by nodding, I believe the addiction component is around $40 million.

Dr MacMillan: That has gone up 600% in the last three years and is now at least $40 million.

The Chair: So it is not an insignificant problem.

Dr Barkin: No, it certainly is not.

Ms Poole: So today approximately $40 million would be spent on the drug and alcohol abuse, about 25% of what is being spent out of country. Thank you.

Mrs Mackinnon: I am departing just a little bit from drug and alcohol abuse but it is still involved a little bit. In my riding, it was really astonishing; after I was elected, four professionals came to me individually, not knowing the others had come, and had documentation and even an ad out of a newspaper enticing people who had been recently bereaved to go to some exotic place -- don't even ask me where, because I was not interested; it was in the States -- to help them deal with bereavement. All they had to do was have a paper, like you get signed by a doctor, saying "You can be off" or you can do this or you can do that. Lo and behold, they had a planeful in 24 hours. One doctor refused to sign any of them; he is to be commended because he would not go for it, but needless to say they found somebody. I am wondering if you have any answer for this. Do you know if this happens on a regular basis? How much of a problem is it? Have you heard of it?

Dr Barkin: We have certainly heard of the marketing of a variety of treatments in the United States. Our policy up until now is that they had to be delivered through an accredited hospital. As Mr McNaughton and Dr MacMillan indicated, with the financial status of American hospitals, they have gone into a lot of activities that are not traditionally hospital activities in the last two years, and certain specialized, or I would say targetted, mental health services, rehabilitation services and addiction services belong to that category.

When that became apparent to us, it also became apparent that the overall policy for payment for services in the United States in that market environment would have to change. So we are aware, not of the particular story you have raised -- although they may be familiar with them, I am not -- but stories like that is what has prompted the change in the government's policies with respect to out-of-country payment which will become effective in the fall of this year.

Mr O'Connor: Is the anti-drug secretariat looking at this issue, and is there a way that some of what it has been looking at can be shared with us? Is there perhaps a way that we can enhance what they are looking at?

Dr Barkin: Jon Kelly of the anti-drug secretariat joins me at the table to answer Mr O'Connor's question.

Dr Kelly: Mr Chairman, the answer is yes. We are looking with our colleagues in the Ministry of Health at this very complex set of issues. The parliamentary assistant to the minister responsible for the provincial anti-drug strategy co-chaired a set of hearings around this drug treatment issue with the parliamentary assistant to the Minister of Health. So there has been a lot of analysis done by the secretariat and the Ministry of Health in looking not only at how to curtail the out-of-province treatment but at what needs to be done in this province, a considerable amount in the last year -- in the last six months particularly -- but in the last year.

Mr O'Connor: As we take a look at this issue, is there any way you think we can enhance what they have been looking at so we are not both following the same trail, maybe crossing paths on occasion?

Dr Kelly: We have copies of the report of the experts' committee on drug treatment that was done for the minister responsible for the provincial anti-drug strategy in December. It might be helpful to see that, to give you a sense of the analysis that has been done not only by Ministry of Health, the secretariat, but also the Addiction Research Foundation.

The Chair: Make that available to our research officer and he certainly will make it available to the committee.

Dr Barkin: We will get you one.

Mr O'Connor: Have they looked at US facilities?

Dr Kelly: They did not look specifically at US facilities in that review, although some of the experts on that committee were the ones who did the 1985 review of American treatment programs, so that it is the same people.

The Chair: We are going to have you back, I understand, but I would like to ask you a question just before we leave. Maybe somebody can address it who is here. What treatment is available on an in-custody basis for people within the provincial reformatory system? Other than AA meetings, which I know are conducted, what other facilities are available to ensure that these people, who are in there perhaps because of an alcohol or drug addiction problem, are going to be any less addicted when they come out through the revolving door?

Dr Kelly: We do not have the specific details. We could get those from Correctional Services.

The Chair: When you come back, I would be very interested, I am sure -- I think the committee would be too -- in having that information. Perhaps in addition to that, we would like to know when was the last review of how up-to-date those services are and what, if any, advances have been made in other jurisdictions in terms of providing the services more effectively?

Dr Barkin: Mr Chairman, I was informed prior to coming to this meeting that the author of the 1985 review, who has periodically updated his own knowledge in the area, could be made available if the committee likes, although he is not a public servant. I do not know if there are any rules of the committee that prohibit an outside expert from coming in along with me to help answer that question. Do you have his name?

Mr Lurie: Garth Martin.

Dr Barkin: Garth Martin from the Addiction Research Foundation? We can arrange for Mr Martin from ARF to be here.

The Chair: Actually, next week we are going to be hearing from Garth Martin as well as Dr Linda Bell of Bellwood.

Dr Barkin: I think Garth can answer those questions.

The Chair: All right, and we will be seeing people from the Ministry of Health on 20 June. We would like to see all of you, and I guess it makes it that much easier if questions come from committee members that we perhaps would have to wait for. So whoever can be here, we would appreciate it.

Dr Barkin: We will be sure, now that we understand the direction the committee would like to take, the people are available.

The Chair: Maybe even to put it into complete perspective, the committee is very interested in ascertaining quality, value for money. But at the same time we also are putting in a human component. We want to ensure that the very best treatment for these two particular difficulties is being made available in this province. It is like the mechanic says, "You can pay me now or pay me later." If we are not treating those problems, we are going to treat them down the line in terms of violence in our streets, breakdown in families and so on. Although we are charged with looking after fiscal responsibility, I think equally we have a concern about the other side of it.

Dr Barkin: So do we, and that is one of the reasons we continue to emphasize very strongly the importance of community-based programs, non-institutional-based programs, which are the most effective for the vast majority of substance abusers and the ones most likely to last the longest time; that is, keep people off drugs the longest time.

We recognize that for a small number -- and our assessments by outside experts confirm that it is indeed for a very small number -- there is a need for a period of institutional treatment. For a very small percentage of those, the institutional capacity and capability -- Steve gave you an example of some of those numbers -- is not what it ought to be in Ontario. Under those circumstances, but only under those circumstances, are we in a position to say that the United States has something that we do not as yet have a capacity for in Ontario.

Comparing facility for facility, when a facility is indicated, and I emphasize that point, our best advice at the moment, and subject to any further findings from the committee, is that our facilities are as good as anywhere when they are necessary. I repeat, only because it bears repeating, that institutional treatment is not always necessary and is certainly not the most cost-effective treatment when it is not necessary.

The Chair: I thank each of you for attending. I should clarify for the committee, and perhaps for those in attendance, that I had indicated we had responses from the US telling us its success rate was X. That actually was ascertained by them sending us that information to our research staff, as were the Ontario results. I guess you have to look at them in terms of the veracity of the sender. I just thought I would clarify that.

We stand adjourned until next Thursday at 10 o'clock in the morning.

The committee adjourned at 1203.