Thursday 13 June 1991

Annual Report, Provincial Auditor, 1990

Bellwood Health Services

Addiction Research Foundation

Continued in camera


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)


Dadamo, George (Windsor-Sandwich NDP) for Mr Johnson

Wilson, Gary (Kingston and The Islands NDP) for Ms Haeck

Clerk: Manikel Tanis

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

The committee met at 1007 in room 228.


Resuming consideration of the 1990 annual report of the Provincial Auditor.

The Chair: Good morning, everyone. On our agenda this morning we are dealing with a briefing on section 3.13 of the Provincial Auditor's 1990 annual report, OHIP billings.


The Chair: We have before us this morning Dr Linda Bell. Dr Bell, would you come forward, please. You have to sit up here, otherwise we cannot preserve your words for posterity.

Ms Bell: Mr Chairman, for clarification, I am not Dr Linda Bell. I am Linda Bell, but I do not have the distinction of being a doctor.

The Chair: All right.

Mr Cousens: We will give you an honorary degree.

Ms Bell: Thank you. I would be pleased to accept.

The Chair: Do you have a presentation first to brief us, or are you just ready for questions right off the bat?

Ms Bell: I did prepare a few comments that I would like to share with the committee in order to provide a framework or context from which to understand the issue, as I understand the issue.

The Chair: That is fine, okay, if you would like to start then.

Mrs MacKinnon: I wonder if there are copies of this presentation.

The Chair: It will be in Hansard when it is given. Go ahead.

Ms Bell: I am Linda Bell from Bellwood Health Services and I am certainly grateful for the opportunity to speak with you today around the issue of the cost of alcohol and drug treatment in Ontario to the Ontario government. As a preamble, as I said, I have made a few comments. I do have copies of the comments, if you would like to have them. I could either hand them out now or at a later time.

The Chair: Perhaps if you give them to the clerk, she can hand them out to the members. They may wish to have them.

Ms Bell: Bellwood Health Services operates a private hospital and a recovery centre here in Toronto. We are located in Scarborough and I think it is interesting that at a time when we are purchasing services from private hospitals in the United States, we have empty beds. We would like to find a way of working in partnership with the government to have those beds funded so that we can treat Ontario residents here at home.

We would like to be able to find and be part of the solutions with the Ontario government to redirect some of the $40 million that is currently being used to purchase services from US hospitals to create the services here in Ontario. The intent of my presentation is to look at this from the perspective of cost saving to the government, job creation within the province and improved services and an improved infrastructure within Ontario.

I would like to give you a brief overview of Bellwood, and towards the end of the presentation, I have brought Frank Fuernkranz from our staff to review a brief financial comparative value with the US services that I think you will find very interesting, because we are looking at a possibility of saving the Ontario government $11 million on an annual basis. In this committee, I thought you might be interested in looking at those numbers.

Bellwood at the present time is unable to compete fairly with US hospitals that are providing services to the government of Ontario because there is preference given to purchasing services from private US hospitals compared to Ontario private hospitals. It is very frustrating for me, as an individual and as a taxpayer, when at the same time the Premier is attempting to reassure the business community that the province wants to work with the corporate community, we are purchasing these services from the United States. This week he is talking to the federal government and giving some direction about cross-border shopping, when in fact our government is one of the biggest cross-border shoppers in the province in the area of addiction services.

It is very frustrating when we run a cheaper service. Our cost on a daily basis would be cheaper and we could look at saving between $100 and $150 a day at a minimum, and often more, because the hospital rates in the United States range anywhere between $450 and $800 or $900 a day. There are a lot of mixed messages that are filtering through the government and I think we have an opportunity, because we are recognizing the extent of the problem, to provide some creative solutions. Bellwood would like to be part of that.

Our history is that Dr Gordon Bell started treating patients with an alcohol or drug problem in 1946 by bringing them into his home. He has set up a variety of hospitals since that time: a private centre for men in the 1940s, the first hospital for addiction for women in North America in 1951 and the Bell Clinic, which was a co-ed facility, in the mid-1950s. Then, when the time came to work towards socialized health care, we set up the first public hospital for the treatment of addiction in Canada and the first hospital to be accredited for addiction treatment.

We have a history in this province of the government working in co-operation with the private sector in many areas, and the government works with private accounting firms, architectural firms. We work with physicians, we work with organizations like Woods Gordon, Peat Marwick Thorne, Miller Thomson, a legal firm -- all private companies -- and we work in a collaborative way, because you set the policy and the guidelines for working in this relationship.

Because there is concern about dealing with privatization in the health care field, I thought it was important to address this issue of our history and the fact that we do work with the private sector in Ontario, but we do not work appropriately with the private sector in health care in Ontario. We work with the private sector in health care in the United States, and that is creating jobs in the United States and putting money into the US Treasury, not into the Ontario Treasury.

We established Bellwood because there were no public funds, either from the government or from the public through donations, to set up expanded services for addiction treatment. We went to the private sector, to a brokerage firm. Our investors are people like the Sisters of St Joseph, pension funds associated with major unions in this province and people who have themselves recovered from chemical dependency. They invested in Bellwood to set up the treatment services so that the capital cost would not be a burden to the provincial government and we could then work in co-operation.

They have made at this point a very poor investment. If we had set up in the United States, they would have made a very wise investment, because the Ontario government would purchase services from Bellwood if we were a private hospital in the US and we would be cheaper than any other American you are currently buying services from.

Within the current health care system, we know that general hospitals are having trouble balancing their budgets. We know there is restraint on capital funds. We know the private sector will work in co-operation with the government to provide the capital needed to expand services in this area, but we need an honourable relationship for the province of Ontario, the citizens of Ontario and the people working in that service.

We need expanded services in Ontario. The concept of developing more assessment and referral offices makes no sense at this point if you are not going to do something significant to expand addiction treatment services here. We need more beds, more treatment spaces. We have less treatment spaces in Ontario for our citizens than do British Columbia, Alberta, Manitoba and Saskatchewan. We can do better than that in this province.

The treatment in the United States is not better treatment than we provide here. In fact, we have trained many of the Americans in our treatment methods. One of the famous institutions in the United States is the Betty Ford Centre. Betty Ford was treated in the US naval hospital in Long Beach, California. The US navy trained here in Toronto. We have a long history of working with people from outside the country and a high recognition outside the country.

The problem with addiction services in the United States is that there is very poor continuing therapy and that people tend to drop through the cracks when they come back to Ontario.

Bellwood currently operates 40 beds, of which 12 are funded through the Ministry of Health. The other beds are fee-for-service beds. As a result, we had an occupancy rate of approximately 68% in 1990. We always have empty beds. The insured beds are 100% filled, but there are always empty beds. Today, 13 June, 27 of those 40 beds are occupied, 13 of those beds are vacant, and today the Ontario government is purchasing services from the United States for many more people than would fill those beds. I could admit them this afternoon if we had an arrangement comparable to the US or some other option that would be workable.

Bellwood treatment costs, as I said, are less than those being paid to the United States. They are around $300 a day Canadian. If the government were to insure those 40 beds by the end of June, in this fiscal year alone you would realize $2.5 million in savings, looking at some of the lower-cost centres in the United States. It could even be higher than that.

Bellwood also has space available in our centre to expand. We have beds that are ready to go. The rooms are furnished. We could expand to 70 beds and we could expand 70 outpatient spaces over the next few months if we could work out an arrangement to do that.

Just before I turn it over to Frank to talk to you about the cost saving involved in funding those 40 and 70 beds, because we are looking at a potential of $11 million, I would like to just conclude by saying that the resolution of this problem is in your hands. It is your decision to implement some type of policy whereby the civil service is able to work with the private sector in health care, which has a reputation and a history of working with this government, to provide this service at home rather than purchasing the services in the United States. We can do that. Every day we refuse to make a decision to take some action is costing us more and more money.

If I could just ask Frank to share with you the last schedule on the document that was handed out, we will very quickly show you what can happen on an annual basis.


The Chair: Before you do that, you have told us that Bellwood was founded by the person who founded Donwood.

Ms Bell: Yes.

The Chair: Donwood is a separate entity, is it not?

Ms Bell: Yes.

The Chair: Is it still operated by Bellwood?

Ms Bell: No. Donwood is a special public hospital. In order to avoid any conflict of interest, we removed ourselves from Donwood to set up the new expanded service.

The Chair: So the Donwood is a public hospital?

Ms Bell: Yes.

The Chair: But the same principles that are used in Bellwood obviously are used in the Donwood.

Ms Bell: That is correct.

The Chair: What is the occupancy of Donwood?

Ms Bell: Donwood has 47 inpatient beds. They treat about 24 patients a month on a day-treatment basis. They also have an evening clinic. The Donwood has been using temporary quarters for over 20 years, trying to get money to expand.

The Chair: But they are a public hospital.

Ms Bell: Yes.

The Chair: So there is no question of licensing beds; the beds are already --

Ms Bell: Yes.

The Chair: Is it paid for through OHIP?

Ms Bell: Yes, it is paid for through the health facilities branch of the Ministry of Health.

The Chair: So if a person can get in, it is paid for by OHIP.

Ms Bell: That is right.

The Chair: Just to clarify, in the Bellwood scenario, your being a private facility, only 12 of your beds are accessible by people who have nothing other than OHIP.

Ms Bell: Twelve of the beds are insured by OHIP, yes, through the same branch, the health facilities branch.

The Chair: So that people who are poor and have no visible means of support but do, thank God, have OHIP could have access to only 12 of those beds.

Ms Bell: They have access to 12 of those beds. The problem too is that not all of our services are paid for by the Ministry of Health, so there is a fee for the long-term follow-up support program as well as for the family services program. Those programs are funded at the Donwood, but they are not funded at Bellwood at the current time. If all of our beds were insured, we would not have to charge for those services. There are economies of scale that would result.

The Chair: I just wanted to clarify that because I was not sure I was clear, nor members of the committee.

Ms Bell: I would like to turn it over to Frank Fuernkranz. Frank is our vice-president of finance and administration. He put together the table that you have on the last page of the document.

Mr Fuernkranz: Good morning. I will just run you very quickly through the document referred to as appendix A, "Comparative Costing."

Twelve of our beds, as Ms Bell has stated, are globally funded through the institutional health division of the ministry. That works out to a per diem of about $300. We have 40 beds under our wing, as Ms Bell pointed out. We are operating generally at around 25 to 28 beds. On this schedule, we have assumed that under current capacity the 40 beds were fully occupied. Each bed, at 365 days, works out to 15,042 patient days. At our global per diem, that works out to $4,513,000. The comparable figure for some of the lower-priced US hospitals works out to $450 a day. Using the exchange rate of 1.18, that works out to $7,986,000.

The Chair: You could probably double that, I would think, because $450 seems to be awfully cheap.

Mr Fuernkranz: Yes, some of the psychiatric hospitals are as high as $1,100 and $1,200 a day, it is quite true, but we have used a modest figure.

The next line is "Potential Expansion." There are 70 beds available within the facility we are in. We are tenants in a large, licensed, accredited nursing home. It has a retirement home in it as well. There are a lot of empty beds. Another 70 beds would be immediately available. They are furnished. Using the same logic, they would yield another 25,550 patient days which, at $300 a day, would cost $7,665,000. I have used just a straight extrapolation there. There are no economies of scale built in there. I think 100 beds are significantly less per patient to operate than 25. The comparable cost to a US facility would be $13,568,000. The annual saving, therefore, on that expansion would be $5.9 million.

If you would just drop to the third line, at Bellwood it would have cost $12,178,000, and that is including the aftercare and the family program. At a US hospital it would cost at least $21,554,000. Now that $12 million is with accountant's arithmetic, but it is really business sense. Based on that 110 beds, it would create 210 to 300 jobs. In the addiction field, $25,000 to $35,000 is average, depending on their qualifications. The payroll, therefore, would be about $7.6 million. Federal and provincial income taxes would generate $2 million in personal income taxes, which would go back into the coffer, only about a third of it into yours, ladies and gentlemen, but nevertheless it would be $2 million back into the Canadian economy.

So that cost would be $10,178,000. That assumes they are all inpatients, as they were treated in the United States. Although they were treated on an inpatient basis, clinically all of them would not have required inpatient treatment. Day patient treatment is significantly less costly than inpatient treatment.

The Chair: But it also, I gather, includes follow-up, which is not the case in the United States.

Mr Fuernkranz: Yes, that is right. Some of the US hospitals are providing follow-up through local agencies. Some of them are referral agents and some of them are legitimate counselling services. In our case, we provide up to a five-year follow-up.

I guess that is the extent of my comments.

Ms Poole: First of all, thank you for coming today. Your presentation has been very helpful to us in focusing on the depth of the problem.

In your brief, you mention that out of the 40 beds you have only 12 receive any funding whatsoever through the Ministry of Health. You also mentioned, earlier in the brief, that the basic problem is that you cannot compete with the American system because the Ontario health care system favours the American institutions. I just wanted to follow up on that. Is that because you are being capped, you are being told only a proportion of your beds are being funded by OHIP, while patients going to the United States simply need a doctor's referral and then they can go to any of these institutions and be automatically reimbursed for 75% of the cost? Is that the major factor in the lack of competition?

Ms Bell: It is the major factor, because they write off the other 25%.

Ms Poole: That is what we have heard.


Ms Bell: Yes, they write off the other 25%. If they did not write off the other 25% our non-insured fees would compete, but because they write it off the treatment in the United States is essentially free and ours has a fee, so we are less attractive. In addition, they can not only write it off but pay a brokerage fee and fly the people down, because of their significantly higher per diem rate.

The third component is that the Americans bill on a daily basis and they are paid for on a daily basis, whereas hospitals in Ontario receive a global budget. So there is a capping, in a sense.

Ms Poole: Is the Donwood the only public institution that deals with drug and alcohol rehabilitation? Are there others in that situation?

The Chair: You are talking about private as opposed to public?

Ms Poole: Yes, private as opposed to public.

Ms Bell: The Donwood is not private; it is a public hospital.

Ms Poole: I am sorry. That is what I thought I was asking. Are there others like the Donwood?

Ms Bell: There are other treatment centres in the province -- some are hospital-based and some are non-hospital-based -- that provide services as well. Most of those services are backed up. That is the problem. That is why we tried to set up Bellwood, because we had such an extensive waiting list and we had people dying on the waiting list.

Ms Poole: Could you tell us something about your long-term follow-up? From what you have said and from other information we have, that is one of the problems with the American institutions. Many of them do not have a follow-up system and they certainly do not provide services for people once they are back in Ontario. I think it was mentioned earlier that you have up to a five-year follow-up.

Ms Bell: Yes.

Ms Poole: Is this additional, over and above the OHIP fee for the 12 beds, for instance? This follow-up would not be included in that fee?

Ms Bell: No. We have a situation where we are funded for only 12 beds. None of our outpatient services receives any funding, and the follow-up is an ongoing outpatient therapy program.

We know there is an importance in having long-term support. Basically, primary treatment only sets the stage for people in the area of treatment. They have to make the major lifestyle changes, with support. Otherwise, you will not be looking at a very good outcome. So we provide an ongoing follow-up program that involves them coming back, a minimum of weekly for the first year and twice a month for the second year. Additionally, we are on call up to three years. So it is a total of five years. We send them weekly letters. We have an 800 line so they can call us from anywhere they are travelling across the country.

We run mini-programs every two months so that if people are from out of town, and we do get people from a distance coming to us, they can come back to refresher programs. If an individual is experiencing some difficulty and needs to come back in for two or three days, we will bring him back in for two or three days as a little bit of a refresher. If they live in Toronto, they can live at home and come in during the daytime. If they live out of town, maybe they will have to stay in. We provide that service in order to basically put an insurance plan around your primary treatment, and it has been very effective.

Ms Poole: It certainly sounds like it is very comprehensive. The figures in appendix A, I presume, would not include the follow-up program. Do you have any figures for the total?

Mr Fuernkranz: No, when you are getting over 40 beds, you could include the follow-up at $300 a day.

Ms Poole: So $300 a day would include everything then?

Mr Fuernkranz: Yes, because there are economies of scale when you get up to those numbers for your facilities and your staffing.

Ms Poole: So not only would you be providing the care in a much more cost-effective way, but you are also going to provide more because that follow-up would be included.

Mr Fuernkranz: That is correct.

The Chair: Is that if you get to the 70 beds or the 110 beds?

Mr Fuernkranz: Oh, no. I think you could probably do it at upwards of 50 beds.

Ms Poole: So for your expansion you are talking 70 additional beds on top of the 40.

Ms Bell: We have the potential to do that. We have the space to do it within our own structure. We would not have to build. We are in a position that we can negotiate that space and it could be implemented very quickly. It would just be a matter of hiring the staff. Right now we are staffed for those 40 beds.

Ms Poole: I just have one last question, if that is all right, Mr Chair.

The Chair: Mr Cousens is being very relaxed there.

Ms Poole: It is regarding the outpatient care. I was under the impression that the Bellwood provides only residential care. Is that correct, or do you have outpatients?

Ms Bell: We provide outpatient care. We are not receiving any government support for providing outpatient care, so we absorb that in some areas and in some areas we charge for it.

Ms Poole: So for some outpatient care you would actually be absorbing the cost yourself and there would be people who simply cannot afford it who you would try to fit into the program.

Ms Bell: If we only treated people on an inpatient basis, from a clinical perspective I think we would be doing a disservice to some of our clients and to the government, because certain of our people do not need to be in a hospital bed for all of their primary treatment time. As soon as they are ready to go home and look at taking the skills they learned during the day and dealing with family problems and business problems, etc, in the evenings in their home, we want them to do that because it enhances the treatment. There are some people who do not require a hospital bed at all, so we will bring them in and give them an outpatient program, but we receive nothing for that.

Mr Cousens: I see you are on the advisory committee on drug treatment that has been established. Your name is among the signatories to the recent report, so that in itself shows something extra that you are giving back to the community. I think it was quite a comprehensive report.

Ms Bell: I felt it was a privilege to be on the committee and I really enjoyed it. I worked with Garth Martin on that committee and I am very proud of the documents. There has been a very favourable response around the province from people in the addiction field. They have needed to have someone speak to them for a long time and it has now happened.

Mr Cousens: I think we can all take a certain amount of credit for the research and just the preparation of it. I ranked it as one of the better ones that I have seen when I looked at it. My background, though not as close to yours in that work, but I was a therapist for the criminally insane at Oak Ridge. I appreciate the approach that was taken and commend you for it.

I want to ask a couple of questions; one has to do with accreditation. I want to be satisfied that the standards of Bellwood, as an independently, privately funded health service, has equivalent accreditation in the delivery of its services of those who are there, the professionals and the people involved. I do not know what system they use in drug treatment, whether there is a way you can draw a comparison between the level of staff capability that you have versus that in the United States or public institutions in Canada. I am really saying you versus the Canadian public and the United States. Is there any kind of statement you could make on that?

Ms Bell: I would be glad to answer that for you. We have a multidisciplinary team at Bellwood. It encompasses physicians, nurses, psychologists, addiction counsellors, family counsellors, physiotherapists, fitness instructors and nutritionists. It is a total health approach and a multidisciplinary professional team. We pay the Canadian Council on Health Facilities Accreditation to come in and inspect us. They grant accreditation on a one-, two- or three-year basis. Bellwood has received, each time it has been inspected, two-year accreditations. We were accredited six months after we received our hospital licence from the government. We have to meet the standards of both the mental health facilities and the psychiatric departments of hospitals, as well as general hospitals, so we meet two standards.

In addition to that, we are inspected every year by the Ministry of Health. I had a very interesting phone call recently where a private hospital in Woodbridge was recommended by the Ministry of Health to contact Bellwood because it needed to develop policies and procedures and we had the most comprehensive set of policies and procedures this particular member of the Ministry of Health had ever seen. They came down and I gave them our documentation. They spent half a day with us and took many materials back with them, and we were delighted to be able to help them improve their quality of service, and they were not in the addiction field.


Mr Fuernkranz: If I might add, the ministry too is usually a three-man team. There is the leader of the east team, Doug Piercey, and there is a physician, Dr Seaver, and then there is a nurse who comes along as well. Last year they were in twice actually.

Ms Bell: Yes, and they come in within 24 hours' notice.

Mr Cousens: I appreciate your completeness in your answer. How do Canadian institutions compare with US standards?

Ms Bell: There is reciprocity between the Joint Commission on Hospital Accreditation in the United States and the Canadian Council on Health Facilities Accreditation, so they are recognized as equal bodies in both countries.

Mr Cousens: It is a very important answer as far as I am concerned, because I think you want to make sure you are on a level playing field when you are comparing US services versus ours. Your answer is an important one.

The second area has to do with the breakdown of people served by your institution. You may not have it handy with you, but native peoples, types of people who are going through, if possible, and then whether you are dealing with alcohol addiction only or you are dealing with cannabis, cocaine and other forms of addiction. Could you give us some sense of your statistics of services?

Ms Bell: Yes. We treat alcohol dependence, prescription drug dependence. We treat street drugs, we treat crack cocaine and heroin. We have developed the first specialized treatment program for crack cocaine in the country. We do treat some native people. When the Oka problem was in force last summer we certainly had a number of native people from the Cree reservation in Quebec. I think the largest native group that we treat within Bellwood are Inuit. They send them to us from the Northwest Territories. They are very pleased with the service we have at Bellwood because of the holistic approach. In fact I am going to Yellowknife at the request of the territorial government a week Friday to spend a week evaluating the addiction services up in the territories.

We treat a number of aboriginal people, we treat a number of women, we deal with men's issues, we deal with women's issues. In addiction today you are dealing with a lot of sexual abuse issues, so you really have to have a very broad range of services that you are addressing. We also deal with a number of people with dual diagnosis of psychiatric problems and addiction problems.

The Chair: Which is not done anyplace else, I might add.

Ms Bell: The Donwood Institute deals with some dual diagnosis as well. However, there are some special needs for certain people with axis 1 psychiatric problems that really do require specialized care and I would not say that we deal with those people at this particular point. We would be prepared to develop a program to do that if we could get some funding to do so.

Mr O'Connor: Do you treat adolescents and youth? You never mentioned them. That is the only reason I ask.

Ms Bell: We have treated adolescents in our adult program and we have not been very successful. As a consequence, a number of years ago I approached a treatment centre in the United States that specialized in adolescent care, because we had a number of requests. I will refer people to that American centre and provide follow-up for them. The problem with that service is that there has not been any funding. We have subsidized it for three years and we are targeting to close that service.

The Chair: Can you tell us the name of that centre?

Ms Bell: I use mainly St Luke's Hospital in Cleveland. They run an excellent program.

The Chair: That is for adolescents.

Ms Bell: Primarily for adolescents. It is a general hospital in Cleveland that has an adolescent substance abuse program. I chose it because of its per diem rate, the quality of care and close proximity to Toronto. You can drive there.

The Chair: Is there any facility in Ontario that you are aware of that has an adolescent program for drug treatment?

Ms Bell: I have referred people to Alwood in Ottawa, which is a small program outside Ottawa in Carleton Place. There are services now funded up in Thunder Bay. It has been mainly outpatient, and I understand just recently they received some funding for residential for adolescents.

The Chair: Could you furnish to the committee at some later date a list of treatment services that are available in Ontario and those that you are aware of in the United States that appear to be good?

Ms Bell: Yes, I certainly could do that.

Mr O'Connor: Further to the referrals that you have made, are there any other referrals that because of the economies of scale you have not treated, beyond the adolescents?

Ms Bell: Yes. We refer many people within the system here in Ontario, and I have referred adults as well to American facilities if they needed primary treatment immediately. They are all assessed by a physician, they are all pre-cleared through the Ministry of Health in the OHIP office and they are all pre-cleared by immigration prior to going down to the United States.

The Chair: Could you give us a list of those names too?

Ms Bell: Yes.

The Chair: We may be assuming we can get the imprimatur of the mandarins around here. Strike that from the record. I would not want them to see that. We may be visiting some US facilities. We may have to go by bicycle or car, but we are going to get there. So if you could provide that list to our research people, we would be very happy.

Ms Bell: I would be delighted to do that, because I will not work with American centres unless I have had an opportunity to evaluate their program and I have an agreement with them that they will send them back to us to do ongoing, continuing therapy.

Mr Hayes: I want to make some comments, more than a question. I want to thank you very much for coming here today. You have made a very good presentation. I just have a couple of concerns here. I know sometimes we get a little personal when we sit in some committees or make presentations.

I notice you made the comments about the Premier attempting to assure the corporate community and these things about working with business and industry, and I can say, as a member of the government, we are attempting to do that. We want to do that and we also want to deal with spending in the United States. I think it is very important for you people to know that we are pleased that you are here. We want you here and we invited you here to discuss these things with us.

I just want to make it clear that there are not really the mixed messages from this government. These things that have happened did not just happen on 6 September, and I think people should realize that. That is why we are sitting on this committee and we want to deal with this problem. There are a lot of other sectors in this province that have not had an even playing field and we certainly want to address those situations.

The Chair: In fairness, Mr Hayes, I do not think Ms Bell was trying to be pejorative. I think she could have included the words of other leaders if they were in the appropriate position at this time.

Mr Hayes: Excuse me, Mr Chair, I am not attacking these people. All I am saying is that you are saying "Mr Rae" here, and I am here to say that the Premier is concerned and that is why we have this committee and we want to work with you. I hope we can certainly settle this problem that we have with cross-border shopping or any other kind of services that we go over there in the United States to receive, when we know that there are services here.

Ms Bell: I can support what you are saying as well, because in 1984 we presented a document to the government and at that point we had traced $3.5 million going to the United States to purchase services for alcohol and drug addiction. We looked at the extent of the problem at that particular time. It has moved from $3.5 million to over $40 million.

The other thing that is very interesting is that if you look at the correspondence from the government of Ontario in 1984-86, you have the government logo in one corner and you have the Shop Canadian logo in the other corner. You no longer see the Shop Canadian logo on the letterhead since 1987. We were buying a lot of services in the United States at that point. It is an interesting point of what has happened.

The Chair: I think the nuts and bolts of what she is saying is that she is not indicting the present government for that. This is something that has existed throughout all three parties, I would think, and it is our job to get at the root of it and try to solve it.


Mr Hayes: All I am saying is that I think maybe government should start talking more the way I have been talking here today. I do not mind any criticism at all, being part of the government, because we are there to represent people and we are supposed to be able to handle criticism. But I think we may have to educate the public a little bit that all of these things did not happen on 6 September 1990. That is all, and we certainly will work with you. Thank you very much.

Ms Bell: I think there is an opportunity at this particular point. We have to understand too that within this country, not just this province, the awareness and the acceptance of alcohol and drug problems as a major health issue has really not been addressed adequately. We are starting to do that now, and I am very hopeful. That is why I said I was proud to be on the committee and I am proud to be here today.

Mr Dadamo: I have a simplistic kind of question and it may have been answered. I am not so sure, so I apologize if it is very simple. Has your organization, any other organization in the greater Toronto area or other parts of this province, or any government official ever gone down to study what a Canadian might receive at one of these foundations or hospitals?

Ms Bell: I have personally gone down and sent staff to some of the hospitals we work with.

The Chair: Can we have a list of those, please?

Ms Bell: Yes, I will provide you with a list of those. I know Mr Martin has gone down on behalf of the Addiction Research Foundation as well, to inspect those facilities. He would have some comments on that.

Mr Dadamo: Okay, good. Thank you very much.

Mr O'Connor: One thing we have not talked about and this is new to me, though, the need for treatment. It is something I have recognized and I am glad there are services available for the people in need. As to the funding for it, we have talked about the proportion you are receiving from OHIP. Could you explain for me other ways patients are receiving funding for the treatment you provide?

Ms Bell: Frank, would you like to talk about that?

Mr Fuernkranz: I am sorry. I did not --

Ms Bell: Who pays the non-insured fee? Where does it come from?

Mr Fuernkranz: An increasing number of employers, through extended health plans, pay the non-insured fee now. In some instances families, and in some instances the patients themselves. We try to accommodate them as far as even extending payment terms. But there is an increasing awareness in the workplace actually. Corporations, through employee assistance programs, bill these components into their extended health benefits.

Mr O'Connor: Could you relate those figures to us perhaps, so we can see just which areas. Maybe there are some areas that are in greater need. Could you tell us the percentage that are funded through government OHIP and the other portions you have mentioned?

Ms Bell: I am not sure if I understand your question, but let me try to answer it in this way. If you have an individual who comes to Bellwood for treatment with an alcohol problem, the non-insured fee is $1,800, and that person is usually in the primary treatment program for approximately four weeks.

If they are in for treatment of a drug or alcohol and drug, poly-drug, problem, the primary treatment would be seven weeks and the non-insured fee would be $4,000. If their primary problem is cocaine or crack, the primary treatment is 12 weeks graded down from intensive inpatient to half-days. The non-insured fee is $8,900. Does that answer your question?

Mr O'Connor: It does, but I worry about that individual and the financial assistance. There are some you have mentioned that have, of course, through the government assistance, OHIP premiums paid, negotiated employer benefits, and there are also the other ones. Could you break that down?

Ms Bell: Many come to us that might not have the resources to pay, and in that case we would refer them to other facilities here. If it was an emergency situation, we might go through the procedure I outlined to you earlier about seeing if we could get approval to send them to the United States.

It is difficult to say what the numbers are. We get 250 to 300 phone calls a month. We do about 25 assessments a week and we can admit anywhere between zero and 10 people in a week. All of that will not necessarily be based on money. Some of it is based on medical complications referred somewhere else, that type of thing.

If, though, we were able to work out an arrangement with the Ministry of Health that would take the current daily rates it is paying us and expand it on a wider basis, we would no longer have that problem.

The Chair: Really what you are talking about, Mr O'Connor, is shuffling money around. If you do not pay it now for this service, you will pay for it in the correctional system, in crime on the streets, in family violence and the whole shemozzle. So it is good planning really.

Mr Cousens: Is there any part of the cost you are charging the patient recoverable from the Ministry of Health where doctors or other professionals' fees are claimable through their own professional services under OHIP?

Ms Bell: I guess the only cost, other than what is paid for through our global budget from the Ministry of Health, would be the doctor's billing for the medical work in the program.

Mr Cousens: So only the doctor?

Ms Bell: Only the doctor.

Mr Fuernkranz: That is not part of the $1,800. Was your question, "Is any part of that recoverable?" No.

Mrs MacKinnon: I started out okay there, I got confused somewhere along the way. Are you telling us that only a percentage of the cost is paid by OHIP? I thought, when I go to an accredited hospital, I do not take anything out of my pocket.

Ms Bell: OHIP does not pay for the continuing therapy program or any of the outpatient services at the present time at Bellwood.

The Chair: Even if it is a licensed bed?

Ms Bell: No, it pays for the licensed bed only.

The Chair: Okay, but that is what I am saying. Even if it is a licensed bed, the aftercare has to be paid for by the patient. Does that answer your question?

Mrs MacKinnon: I am still confused. I have had to take physiotherapy. I did not pay anything for it, it came under my OHIP.

The Chair: You will find historically that some people were funded and in fact you will find some physiotherapists who cannot get into that program. I think that is the case anyway. But these were people who were funded before the gate shut and they are funded. With these people here, I guess the services outside of that are not contained in any fee schedule in OHIP. Would that be about what it is?

Ms Bell: I must reiterate that it is very confusing. The whole thing gets very confusing.

The Chair: There are a few envelopes around, you see, different envelopes. That is what it is all about and if anybody ever puts them all together, they might get someplace.

Mr Hayes: I had a friend a number of years ago who went over to Brighton, Michigan, for alcohol treatment and one of the reasons he had gone, I am sure -- he just left and as far as others were concerned, he was on vacation -- was just a case of not being embarrassed with his fellow workers; he was in a pretty high-level job. I believe that was his choice to go over there.

Do we have any statistics on people saying, "I'm going to go to Michigan or Minneapolis or wherever"? Are the doctors actually recommending they go to these places? What I am trying to get at, is there encouragement from other fields or other areas to say, "You go here, and you there," rather than going in Ontario? Brentwood Recovery Home for Alcoholics was a few blocks away from his house and he could very well have gone there, but instead went to Brighton, Michigan. I do not believe it was considered a better facility or better treatment than Brentwood, for example.

Ms Bell: At this particular point, from my understanding, there are starting to be some checks and balances put into place, but I do not believe there has had to be a requirement in the past that it was a doctor's referral. Basically, people could go on their own. Mr Martin might be able to answer that in a little bit more detail as well.


Mr Hayes: A concern I have had is that several of these people are probably going over, but not necessarily from the doctor referring them to these places. They may be saying, "I want to go there." The point I am trying to make is they did not really have to go there.

Ms Bell: I do not think they have to go there, but one of the problems is if you have somebody recognized in the business community as having an alcohol or a drug problem, they are an occupational hazard if you are working in a plant, and we have cases and laws around health and safety that we have to respect. If an employer is going to refer somebody for primary treatment, a bed is required and there is not a bed available and you have to wait for six weeks or whatever for a bed, the employer has to put that individual on sick disability for six weeks and hold him, then give him so many weeks off for treatment and then bring him back to work. From a business point of view, why would you not send them to immediate treatment for four weeks, or whatever it is, and get them back to work as quickly as possible?

Mr Hayes: That makes good sense.

Ms Bell: That is a real dilemma, and there is a lot more awareness and a lot more responsibility in the corporate community about this problem. They want access to fast treatment.

The other problem that has happened, though, is, because we are only learning about this problem, many people insist it has to be residential care, and if it is not residential treatment then it is not good care, and that is not the case. Many people could do well on outpatient treatment or day treatment, and that is the importance of doing a proper assessment. But I think we make a mistake if we say everybody should be treated in exactly the same way. That is like saying everybody who has chest pain has indigestion, and we know some of them might need a triple bypass. So you need a proper assessment.

The Chair: We would like to thank you. There was one question I asked of Dr Barkin when he was before us. I asked 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 when these people who are in there perhaps because of alcohol or drug addiction problems come out through the revolving door they are going to be any less addicted? You do not perform any contract services in the correctional institutions, I gather?

Ms Bell: Not at the present time. We did in the 1950s and 1960s.

The Chair: I suppose you or facilities such as your organization would be available to do that?

Ms Bell: Certainly.

The Chair: Have you ever been approached by the former government, the government previous to that or the present government in terms of providing that type of contract service?

Ms Bell: As I said, in the past there was a program run by Dr Bell out of Mimico Correctional Centre. There are a few programs that still exist within the correctional centres, but I believe there is a tremendous need there, when you look at 70% people there are with alcohol or drug-related crime. But we have not been approached recently to do anything in this area.

The Chair: Looking at how this whole thing got started in 1946, I want to make it very clear for the record, because there will be discussions about profit or not-for-profit services, it looks as though Dr Gordon Bell got into this not to make $1 million, but because he had a very sincere interest in alcoholics. I have to gather that from having started in 1946 taking them into his own home.

Ms Bell: If you knew the history of the financial status of the Bell family, you are absolutely right, Mr Chairman. The number of times we edge on the area of bankruptcy is amazing. We seem to be bailed out at the last minute one way or another. We have not made a lot of money. Dr Bell would have made an awful lot more money if he had worked in any other field.

The Chair: I know your program is excellent. I practised for 30 years in the criminal courts. We could eliminate 80% of those people from the courts if we could find effective treatment. The times we have scurried around to try to find a bed for somebody is absolutely immoral. But Donwood and Bellwood provide an excellent service, and I think it is more a service of the heart as opposed to a service of economic empire building. At least that is my experience.

Ms Bell: Absolutely. If you look at our investors, as I said, the Sisters of St Joseph and pension funds and that type of thing, they are not looking for huge returns. But they would like maybe to get at least what you would get at the bank. It only makes sense.

Basically the reason we set up Bellwood was to try to do something to expand the services, because there had been such waiting lists, and we could not raise the capital to expand at the Donwood Institute. If we can work out a way to work with this government to continue moving ahead and working with other agencies -- because there are many other agencies that are doing very good work as well. I do not think we have all the answers, but we have some and we would like to be part of the solution.

The Chair: Okay. Finally, I thought it was mentioned that you operate on a lease basis out of a nursing home?

Ms Bell: Yes. We share the building with a nursing home, a retirement home, general physicians' offices and a couple of laboratories, and we rent space.

The Chair: My reason for asking that was I chaired the select committee on health, and we were discussing for-profit and not-for-profit, and the allegation was made -- I think quite unjustified in all cases, maybe in some cases -- that the reason not-for-profit was preferable to for-profit was that the for-profit people were simply in it to speculate in real estate. Whether you like it or not, those were the comments that were made. I think it is very important that we be clear that the services provided by Bellwood and Donwood have to be looked at on their merits and not on the basis of whether they are for-profit or not-for-profit. We have a real problem in Ontario, and if we do not deal with it, it will be like the streets of New York.

I want to thank you very much for coming, and we hope you will come back after we have either motored to Buffalo -- bicycled or whatever -- but we are going. We are going if we have to get there on our own. We would appreciate receiving from you those areas you say we should visit. We want to come back knowing what they have to offer, with a hope that we can have some direct input in terms of making the situation better in Ontario. So maybe you will come back at some later stage for us.

Ms Bell: I will come back any time you ask me to come back. I want to thank the committee for inviting me to be here today and for the support and the interest in this area. I think it is key for the citizens of this province.

The Chair: Could I just ask one final thing? This may help us at the Board of Internal Economy. Is there any benefit to us, as parliamentarians, in visiting some of the exotic places like Columbus, Ohio, Buffalo and Cleveland?

Ms Bell: You do not want to go to Laguna Beach?

The Chair: If we did that, they would accuse us of trying to get to the sunshine. I have to ask you, and I am going to ask Mr Martin the same thing, is there any benefit to us in actually seeing some of the selected areas, to bring them back to the balance of our colleagues?

Ms Bell: From the perspective of increasing your knowledge and your awareness, I think it is very important. I think the fact that this group is meeting here and you are discussing this is very important, because as I said, the decisions here have to be made at a policy level so that civil servants know how to implement properly and do something that is going to be creative for this province. I think that, if you are going to go to the US, you should certainly come and take a look at some of the services you have here as well.

The Chair: We are going to do that first.

Ms Bell: You are more than welcome to come to Bellwood, and I am sure you would be more than welcome to come to many other treatment centres in the city.

The Chair: That was our intention, I suppose, today. Thank you very much, and we invite you back again at some later stage.



The Chair: Garth Martin, could we have you come forward now, please.

Mr Martin: Mr Chairman, ladies and gentlemen, thank you very much for inviting me here. I appreciate the opportunity to make a few comments. My background is having spent about the last 18 years or so with the Addiction Research Foundation. I have been in clinical practice involving research and treatment administration and most recently chaired the provincial advisory committee on drug treatment and also shuffled off to Buffalo in 1985 at the request of the Ministry of Health with a couple of colleagues from the foundation to look into the quality of programs at that time, when this issue was also of some concern. It is not a new problem, but certainly it has become a much more substantial problem in terms of the amount of money involved in the last couple of years.

In the interest of time, let me say first that I have brought along a couple of documents: one, Drugs in Ontario, which would give you sort of an overall perspective of the issues of alcohol, drugs and tobacco in the province, and two, a position of the Addiction Research Foundation based on its submission to the task force of parliamentary assistants that went around the province and conducted public hearings on the advisory committee's report. I would be happy to make those available in whatever would be the most appropriate way.

I will make my comments very brief and try to highlight what I consider the critical points. First of all, I think the problem of United States treatment referrals has two major components: One is that there is a lack of services in Ontario, which creates a need to look elsewhere for services; two, we have very aggressive marketing of treatment services in this province, based on the opportunities available within the current context of OHIP regulations.

Just by way of background, one should understand the circumstances of the private hospitals in the United States, which over the last several years have been coming under increasing pressure because of the growing recognition that residential treatment is not necessarily the most cost-effective approach to dealing with alcohol and drug problems in general, although it clearly has a place. So third-party insurers, which cover most of the costs of people entering these private hospitals in the US, have become increasingly reluctant to fund these programs.

They have begun to limit the number of days they will cover and they have also begun to restrict the number of times they will cover a person's admission to such programs. In some instances, that may be zero; in other cases, it may be one, and so forth. So the occupancy of these programs is anywhere from about 50% to 60%. They are quite desperate, in terms of the need to keep their businesses operating, and a number of these programs have in fact been closing over the years because they simply cannot get clients to use their services.

We should know too that the vast majority of Americans with alcohol and drug problems cannot get access to these programs because there is no one to pay for it. It is only when they have access to the kind of health insurance regulations that have previously been in place, or their own third-party insurers, who have become more restrictive, that the Americans can make use of these programs.

A second point I would like to make is that the distribution of clients who go to these programs seems roughly similar to the people who use programs in Canada. So it is not clear that there is any one particular type of client who is most likely to be going to US treatment programs. Distribution by age, at least, is very similar. There are no complete data available to us in order to be able to look in more detail at the types of clients who are going there.

I would also reiterate, as my third point, what Ms Bell has already said: there is clearly no evidence that American treatment programs are more effective than Canadian programs. The principal reason for people going there is generally one of accessibility, that they can get into a bed, often within 24 hours. There are other considerations as well in some instances, such as a particular preference for the type of program. But also, to a large extent, there is a substantial marketing factor and a very active recruitment of individuals is taking place.

These programs are a good deal more expensive, which has already been pointed out, and I think that one of the things we have to be very conscious of is that the overflow of the Ontario system is into the most expensive treatment option available. So to the extent that we cannot manage these individuals in Ontario programs, they spill over into the most costly type of treatment.

For example, if one takes into account that there are approximately 217 programs in Ontario that treat individuals with alcohol and drug problems, which are funded to the tune of roughly $77 million, the cost of $40 million to treat 3,400 people amounts to something less than 5% of the cases absorbing more than 30% of the total cost of treatment. The $77 million spent in Ontario is the amount involved in the treatment of the 60,000-plus Ontario residents who are making use of Ontario services versus $40 million for the 3,400 individuals who are making use of US treatment services. So we have to be very conscious that the way this problem is spilling over, in terms of the absence of adequate capacity for treatment here, is at considerable expense.

Finally, I would say we also need to be conscious that in the context of addressing the problem, the solution is not simply to replicate the same kinds of programs that are there. We do know that a large number of the people who are going there probably do not need residential treatment. There is certainly a growing consensus in the treatment outcome literature that, for the majority of individuals, outpatient treatments are equally cost-effective.

So one would want to see, in expanding the service system in Ontario, some emphasis be given to expanding in the area of making more outpatient services available, primarily because, with limited dollars available for such expansion, we can be helping a lot more people on an outpatient basis.

In the short term, in terms of things that need to be done, we do need an expansion of services in the province. Changes are needed to the OHIP regulations because they are clearly being exploited. But we need to introduce the changes in a manner that will ensure that people do not get hurt in the process, because we have to bear in mind that there are clearly people who are going to the United States for treatment because it is the only option available to them.

While on the one hand there are serious exploitations of the system, there is also a great need. We have to balance the response in a manner that makes sure it is sensitive to meeting that need in the short term until the ultimate solutions are in place. Perhaps I will stop there and leave it open to questions.

Mr O'Connor: In regard to outpatients and the funding problem, I know when we talked to our previous guests here, they referred to some of the follow-up needed. Is there is a problem in the follow-up? Is it adequate? Are the patients receiving the correct amount of treatment? Is there a problem there because of the funding?

Mr Martin: I think I will give two separate answers to that one. One would be that in terms of people going to the United States, there are potentially problems because a good number of them do not necessarily get good follow-up at all. So the costs that are billed to the OHIP system, while ostensibly in some instances covering a follow-up, do not in not all instances do that. It covers the full range from people who come back to nothing to people who come back to a well-established follow-up plan.

Within the Ontario system, generally speaking, residential treatment programs that are funded publicly through the Ministry of Health or the Ministry of Community and Social Services would have the follow-up components of those programs funded.

Mr O'Connor: Trying to access the treatment needed as quickly as possible, for example, for employers who recognize there is a problem in treating it, the end result is more cost-effective if a good employee is retained. In trying to access fast treatment, if the treatment is not available in Canada, then they are referred to the US. Are there any ways of following the numbers for cost-effectiveness for the sake of the employer and the patient as well, to make sure this is the correct treatment and the follow-up takes place?


Mr Martin: I think the critical point is making sure some comprehensive assessment has taken place that ensures the needs of the person are clearly matched to residential treatment. In a number of parts of the province, for example, that occurs very effectively. We have a system of assessment and referral standards across the province and there are all sorts of other public centres that provide that kind of comprehensive assessment.

To the extent that this would occur, then a very carefully considered clinical decision would be made as to whether or not residential treatment was the treatment of choice.

Mr O'Connor: In trying to access the treatment as quickly as possible, do you feel there is a problem of a person receiving incorrect treatment when perhaps outpatient treatment and a more comprehensive follow-up system would be more effective than trying to have the person put in a residential program as quickly as possible?

Mr Martin: That becomes a bit of a dicey issue. I think there can be a tendency to put a person into a residential program because it is immediately available and no outpatient program is available, which of course makes it a much more costly solution. It may be just as effective for the individual. The reason outpatient treatment is more cost-effective is not because it works better; it is because it is cheaper. What may be happening in those kinds of circumstances is that in the interest of immediacy a person is being dealt with in a more expensive way than would otherwise be necessary.

Mr Cousens: It would be helpful for me to understand what I saw as a lack of emphasis on research priorities in your overall report. One of the worries I have is that we still do not have it together. I do not personally; maybe you do with your background. There is the lack of spending on research to develop the model to have a realistic assessment and whether or not you have achieved certain realistic objectives along the way. You have addressed some of these concerns on it. There is no reference in the report that came out on existing dollars for research in this area and where it should be, where it has been. Do you have any supplementary information on that aspect of the report?

Mr Martin: I do not have supplementary information with respect to the expenditures. I certainly share your concern. I think it was not the intention of the advisory committee to underestimate the importance of research. Certainly, wearing my Addiction Research Foundation hat, that is hardly the view of the foundation.

Mr Cousens: I know that.

Mr Martin: You are absolutely right. There are important areas that we need to be researching because we do not have the answers. We tried, from the perspective of the treatment system, to capture what seemed to be some of the more critical areas with respect to operating the service delivery system now, such as trying to identify the characteristics that would help us know when to use residential treatment versus outpatient treatment and trying to get more sophisticated with this whole notion of dual disorders which, on the one hand, can be exploited and is being exploited within this context of people saying: "Oh, here's a special kind of problem. They have a special kind of need and they must go to this special program in the States." It becomes part of their marketing ploy. At the same time, it is a legitimate clinical issue and it needs to be addressed because it has become increasingly clear that the combination of substance abuse problems and other mental health disorders is part of the difficulty of achieving better outcomes.

Mr Cousens: I do not know how this will fit in. It is one of my pet peeves, a concern that I have. I think your answer is a good answer, it is a fair answer. When we are dealing with such a huge problem and so many areas of difficulty just in the delivery of it and so on -- I do not want to take away from the other emphasis of the report, but we in our society have to understand that there has to be more upfront investment. We are seeing it in so many other areas. If you have made the money and if you have invested the money into proper research, then you are going to be farther ahead later on. Again, it is the chicken-and-egg syndrome, how you do it.

Mr Martin: I am certainly happy to hear you say that. Coming from an organization whose principal mandate is research, it is good news. I think sometimes we are concerned that people tend to underestimate the importance of research, so placing that sort of emphasis is certainly nice to hear.

The Chair: Just to follow up on that, Mr Cousens, I think part of the problem is that we find that in the less popular disorders, such as schizophrenia, there is very little spent on investigating a cure for schizophrenia because most people think it will never affect them. Alcoholism is the same way. It used to be in the closet; now it is out on the street. Maybe drugs are enhancing the whole situation. If we do not get our act together, if we do not put the money there, not just for what treatments are the best but even investigating whether there is some medical cure to this, we are going to be in deep trouble on our streets in this province and in this country. If we do not do it now, we have got real problems. If for no other reason than survival as opposed to the humanitarian side of it, we had better get our act together.

Having said that, I have to go and speak in the House, so Ms Poole is up next. Maybe she could have the benefit of speaking from the chair while I go in and flap my gums.

Mr Cousens: Can I just have a supplementary? Is this all over now? Is your committee disbanded? You have no other charter now. You have completed your work and you are all doing your own things elsewhere, but you have no further involvement with the ministry on the advisory committee.

Mr Martin: That is correct. The committee's work essentially was done with the completion of the report. At the same time, it is not all over now because there was a set of hearings that went on across the province and there will be a report forthcoming from that. The advisory committee did play a role in that process. Essentially, the committee's work was done with the completion of the report.

Mr Cousens: That could be helpful then. If there is information that comes out of that advisory committee through the hearings across the province, there may be some value for us to have access to that rather soon by virtue of the emphasis we are placing on this out of the auditor's report.

The Vice-Chair: I guess one way to get on the speakers' list is take over the chair.

Mr Martin, you mentioned in your opening comment that 5% of the patients were actually receiving treatment in the US and at the same time they were incurring 30% of the Ontario budget related to alcohol and drug addiction. Looking at it in the short term, obviously a certain percentage of this 5% of patients could be dealt with in facilities that are available right now and are simply not receiving OHIP funding.

Do you have any sense of what percentage of the patients -- and I am again talking about the short term, I should clarify -- if OHIP and the Ministry of Health changed the rules to restrict going to the US, could be dealt with in the short term in Ontario right now with existing facilities, by just increasing the amount of money being sent to them by OHIP?

Mr Martin: Do you mean how many of the 3,400 currently going to the US.

The Vice-Chair: That is right. Your best guesstimate.


Mr Martin: I really do not know enough about the characteristics of the people who are going to give a very good guess. It would be wildly speculative to say very much. I think that a fair proportion of them do not require residential treatment to begin with, but then we have to recognize that we do not have adequate outpatient services in the province either. We have services that are probably a half to a third of what the per capita capacity is in some of the other jurisdictions, despite the fact that I think Ontario took the lead in terms of recognizing the cost-effectivenss of outpatient options. It is difficult to say, because part of the problem is the issue of putting people in a type of service that they do not need and part of the problem is that the one they do need is not available either.

I think it speaks to the need to try to expand services in a way that makes sure we place emphasis on the more cost-effective options. We need to have a registry that will ensure we can monitor the use of services effectively. Depending on how one works it through, you can either come up with an answer that says, "We need this many more beds in Ontario," or you can say, "If we only had a shift of something like 15% of the people currently in residential treatment to outpatient options in Ontario, it would free up enough space to make available beds for all of the people going to the United States who currently do need residential beds."

We really do not know where the answer lies in terms of those kinds of things, because there are not enough data available, details of the situation to really fine-tune it so it can come down to a question of where to start. One way of looking at that is to start by expanding the residential services and monitor the needs or start by expanding the outpatient services and monitor what happens with respect to the residential needs.

The Vice-Chair: Do we have the resources here in Ontario to cope with this extra 5%? I am not talking so much about the financial resources; I am talking about personnel and trained assistants. Do we have that kind of expertise at hand? I know what we have is very good, but do we have enough of it to cope if the ministry were to change the rules and regulations so that people would have a much greater incentive to stay in Ontario to get their care?

Mr Martin: I think we do in the short term. I think an issue that has to be addressed as part of a long-term plan is whether or not we are ensuring that we do have the appropriate kinds of human resources available, but I would not see that as the major impediment to proceeding with expansion. Also, what would be important would be recognition of the need to ensure that funds are available for training in that process. Certainly the Addiction Research Foundation provides many training programs.

Mr O'Connor: Sitting on a committee and being new to the Legislature, it seems we get an awfully large pile of information daily. Research provides us with it and, unfortunately, we do not always have a chance to read it all prior to somebody coming before us. I was going through this survey done by the Addiction Research Foundation doctors and I found it interesting that they felt physicians did not always feel strongly motivated to recognize problems. Perhaps if there were a better awareness raised of the issues within not only the doctors but many different areas, we could get treatment before the fact, before it becomes a problem, just by education. Could you comment on the doctors and the lack of recognition?

Mr Martin: I think you have touched on a very important area and one that certainly we have been giving considerable attention to at the Addiction Research Foundation. Doctors have not generally had extensive training in dealing with alcohol and drug problems as part of the medical curriculum, so one level of intervention in terms of dealing with this has been to try to ensure that there are more alcohol- and drug-related kinds of content incorporated into the curriculum of the medical training program. That has happened to some extent at some medical schools, but that is an ongoing issue we have been involved in.

Perhaps more pertinent are the sorts of statistics one has in general. I think it is something in the order of 75% of individuals have contact with their family doctor once within the course of a year. If we think in terms of opportunities for early intervention, there are few opportunities as good as that one. That is coupled with growing recognition that if you get at the problems early you get better outcomes.

We also know there are simple strategies, because we have developed some of those in the research program, that can be used by physicians with their clients. This is clearly an area one should be trying to pursue: the increasing involvement of physicians in terms of their ability to identify problems and to provide brief interventions that often are simply only a matter of advice about what to do.

This makes a difference, and physicians are in an excellent position to do these kinds of things. In studies of this type of intervention, the results have been very impressive and, of course, it is not a costly intervention, because these people are seeing their doctors anyway. It is an area we think is one that really should be pursued and we are doing so, and I think your point is very well taken.

Mr O'Connor: What about recognizing the need for treatment or approaching the problem before it ever becomes a problem with our adolescents in the school system? Is there a way that we can build an awareness among our teachers, who do spend an awful lot of time with our youth, to make sure they can recognize problems as well?

Mr Martin: Absolutely. Addressing alcohol and drug problems has to be a balance between the different perspectives: the prevention, health promotion perspective on one hand; the treatment perspective on another hand; and if there were a third hand, it would be the supply and enforcement regulations dimension. All three play a role, and it is important that they are in some proper balance in trying to deal with the problem. Clearly we need to be doing things in the area of prevention.

In some respects one can look fairly optimistically and positively at things that have happened. If you look at some of the school surveys and adult surveys of use of substances, over the last 10 years there have been declines in the prevalence of alcohol and drug use among the youth in schools and among the adult population in general. That is not to say there are not still enormous problems, but that speaks to the kind of thing you are saying. There have been a lot of prevention efforts over the years and it looks like some of them are having an effect.

Mr O'Connor: This is probably a difficult question, but once we get from school into the workforce, we have the employers there. A number of employers recognize it as a problem. An employee is valuable to them and they recognize the training that has gone into an employee and treats that employee. But is there any way that, as legislators, we should take a look at a way of getting the message to employers to make sure that a person with an abuse problem is not being treated inappropriately in that they are not recognizing that what they have there is a person with a problem and not necessarily a bad employee?

Mr Martin: Certainly anything that supports the concept of employee assistance programming is valuable. I would take it one step further and emphasize the early intervention dimension of that. It is important, in these employee assistance programs, to ensure the employees have opportunities to make choices before they get into a situation of "Either you do this or you lose your job," because we know, as I said, that early intervention works better than most treatments. They have higher rates of treatment success. So it makes sense to get at these problems soonest, and the employment context is one of the really marvellous opportunities to try to do that.


Mr Cooper: Just to carry on this line of questioning, we realize there is an immediate need for expanded facilities here in Ontario. I guess in the past they have looked at it as being more cost-effective to use facilities out of province.

Mr Martin: Hard to imagine that would be true.

Mr Cooper: The cost of setting up our facilities would have been enormous back then, but now we have developed the problem and it would be more cost-effective to develop them here. But with the prevention things that are coming up, are we going to be spending an enormous amount of money on expanding facilities now and then maybe finding we do not need them in the near future, or is this something that is becoming institutionalized in society now and it is just going to keep growing?

Mr Martin: This would be an interesting problem we would all be very grateful to have to deal with, if we ran out of the need for treatment services.

I do not envision it happening too soon, despite the indications of the effects of prevention. I think the thing to keep in mind is, it is usually estimated that at any given time only about 10% of the people with an alcohol or drug problem are seeking service, so it is a bit like if all of the depositors hit the bank on the same day and wanted to withdraw their money it would be in serious trouble. The treatment system would be in pretty serious trouble if all of the individuals with alcohol and drug problems showed up and said they needed help. I do not think we need to be concerned about that at this point in time.

Mr Cooper: Okay. I just wanted to make sure we were not just doing a quick knee-jerk reaction to what is happening right now at the time. Let us know that this is an ongoing problem that has to be addressed.

Mr Martin: I think we have something like a 2,000-year history of having alcohol problems or other drug problems. There are no signs of --

Mr Cooper: I think one thing to point out, though, is the value of what we are looking at.

The Chair: I think our knee-jerk is well overdue.

Mr Hayes: A question was asked of Ms Bell, I think, earlier about correctional services having treatment facilities there and assessments and what have you. I am not sure if I heard correctly. I think she said we did have it in the 1950s.

The Chair: That is what Ms Bell said.

Mr Hayes: Is there a reason this was stopped?

The Chair: I do not think that is a fair question to ask of either Mr Martin or Ms Bell, because it obviously would have been a policy decision. You would have to resurrect the minister who was in charge then, I would think. I do not know, maybe he can answer it.

Mr Martin: I cannot speak to the specifics about that particular program.

Mr Hayes: No, the only reason I am asking, Mr Chair -- I am not trying to stir up anything of that nature -- what I am trying to find out is, there was treatment available at one particular time. Is it a case of it just not being feasible or somewhere along the line just not working out?

The Chair: Maybe Ms Bell could tell us, but she will have to come up here so we can preserve her words on the record.

Mr Martin: I will just comment in general and I will let Linda Bell speak to that specific program. There are some programs in the correctional system and there are certainly individuals who are part of the correctional system who are making use of the public treatment system. Certainly from the perspective of the advisory committee we felt this was an area that needed a good deal of attention. We know, for example, estimates are that as high as 75% to 80% of individuals in correctional settings are there for reasons related to alcohol and drug problems. I think a lot more needs to be done in that area because there is clearly a strong association between the two problems.

The Chair: Maybe we could find out. Do you know why, Mrs Bell?

Ms Bell: I was just going to mention what Mr Martin said, that really there still are some services. There were some small services then and there still are some small services currently being provided to the correctional area. I do not think they have stopped. They just probably have not grown.

The Chair: They have not kept up to date with what has happened, I would assume is the situation.

Ms Bell: That is right.

Mr Hayes: So nothing has really changed. Like the Chair says, they have not expanded and grown with the times. I see your recommendations here that they have alcohol and drug treatment programs, and then of course you are asking for funding and things of that nature. I guess what you are saying is that you would like the same type of services in the correctional institutions that you may have in the industry on the outside.

Ms Bell: Yes. It makes a lot of sense, if you have somebody in a correctional centre, to do something while he is there, any time you can intervene with someone where he presents, whether it is in the correctional centre, whether it is in the courts with impaired driving charges, whether it is in a general hospital, whether it is in schools, as you were talking about, Mr O'Connor. Those are the recommendations we have within the committee report of how we can approach this problem within the province in a responsible and progressive way that could become the model again. The thing that is so sad is that we were the leaders for many years and we have fallen behind.

The Chair: Like the Argos football team or the Toronto Maple Leafs, we have fallen behind.

Ms Bell: We can all come back.

Mr Hayes: I think it certainly does make sense, because if you have a person with a drug or alcohol problem who is in a correctional institution for two or three years or five years, whatever, and then comes out and start saying, "Well, I had better treat my problem," it would make more sense to treat it there, having the facilities there to do it and the expertise to do it.

The Chair: We have become so unprogressive that 10 years ago there used to be a ploy used to get people directly into the Ontario Correctional Institute -- Bill 90 under the Liquor Licence Act, I guess it was. If a fellow was charged with his fifth impaired driving and you wanted to get him in there for some treatment, if he would plead guilty to being drunk in a public place they would send him off to OCI and get him in there immediately. Then he would come back and plead to the charge 90 days or 80 days later.

Somebody took that out. I do not know who it was, but it was certainly a step backwards, because it was a vehicle that got you direct access to treatment. If you do not treat these people, it is great political cosmetics to put them in jail, but when they get out they are going to be as bad if not worse. You may have a ticking time bomb there that is going to kill somebody. So I think it is important.

Dr Barkin also told us there was a report in 1985 and we have not been able to find it. It was a review of how to update these services -- let's see what I said: "When was the last review of how up to date those services are" -- that is the correctional services -- "and what, if any, advances have been made in other jurisdictions in terms of providing that service more effectively?" Dr Barkin told us he was told prior to coming into our meeting that the author of the 1985 review, who has periodically updated his own knowledge in that area, could be made available if the committee likes. We cannot find him. We cannot even find the report. Do you have any knowledge?

Mr Martin: Who is the author?

The Chair: They said you were.

Mr Martin: That is interesting. There may be some confusion here that explains the difficulty in chasing this down. I was one of three authors of a report in 1985 that was related to the review of three treatment programs in the United States and also covered issues related to why people were being referred there. It had nothing to do with --

The Chair: Nothing to do with correctional things. That solves --

Mr Martin: It has never been an area that I have made any major contributions to.

The Chair: That solves our problem. We will stop looking. I want to thank you very much for coming. We have one other item that we have to deal with before we adjourn and we will also hope that we can have you back at some later stage after we have roller-skated, bicycled or made our hitchhike to Buffalo, Cleveland and Columbus. We appreciate your coming on this very important issue, one that has to be dealt with.

Mr Martin: Thank you for having me.

Mr O'Connor: He spoke of a report that he did do in 1985, though. Is that one of the reports that we have requested?

The Chair: I think it was. I think we asked Dr Barkin for that report.

Mr Martin: If it is any help, I can leave you a copy of that. I have one here with me.

The Chair: Yes, that would be appreciated. Maybe we could follow up if we need extra copies. That will be filed.

We are now going in camera to discuss certain aspects of our report.

The committee continued in camera at 1149.