Wednesday 24 February 1993

Annual report, Provincial Auditor, 1992

Ministry of Health

Michael B. Decter, deputy minister

Peter Burgess, director, registration program branch

Gilbert Sharpe, director, legal services

Fred Hazell, executive director, information systems division

Eileen Mahood, director, claims payment operations


*Chair / Président: Mancini, Remo (Essex South/-Sud L)

*Acting Chairs / Présidents suppléants: Duignan, Noel (Halton North/-Nord ND); Callahan, Robert V.

(Brampton South/-Sud L)

*Vice-Chair / Vice-Président: Cordiano, Joseph (Lawrence L)

Cousens, W. Donald (Markham PC)

*Frankford, Robert (Scarborough East/-Est ND)

Haeck, Christel (St Catharines-Brock ND)

*Hayes, Pat (Essex-Kent ND)

Johnson, Paul R. (Prince Edward-Lennox-South Hastings/Prince Edward-Lennox-Hastings-Sud ND)

*O'Connor, Larry (Durham-York ND)

Sorbara, Gregory S. (York Centre L)

*Tilson, David (Dufferin-Peel PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Fletcher, Derek (Guelph ND) for Mr Johnson

Perruzza, Anthony (Downsview ND) for Ms Haeck

Wilson, Jim (Simcoe West/-Ouest PC) for Mr Cousens

Also taking part / Autres participants et participantes:

O'Connor, Larry, parliamentary assistant to the Minister of Health

Peters, Erik, Provincial Auditor

Clerk / Greffière par intérim: Deller, Deborah

Staff / Personnel: McLellan, Ray, research officer, Legislative Research Service

The committee met at 1503 in room 151.


The Chair (Mr Remo Mancini): The standing committee on public public accounts is called to order. I appreciate the attendance of members and staff from the Provincial Auditor's office, along with the Provincial Auditor and officials from the Ministry of Health. If I could have everybody's attention, we only have a couple of hours today. I wasn't in the Chair when we adjourned yesterday afternoon, so I don't know who had the last round of questions.

Mr Robert V. Callahan (Brampton South): Actually, Mr Chair, we went around, and then we did a five-minute wrapup. So the government would have been the last people to have spoken on this issue.

The Chair: Okay. I appreciate that information. Is there any information from the ministry?

Mr Michael Decter: Yes, we have information on five issues that I could go through -- I think four of them very quickly in terms of tabling information, and then on the fifth issue, freedom of information, I have Gilbert Sharpe, our director of legal services, who can answer the specific question that was asked and then if there are any follow-on questions on the FOI front. Would you like me to proceed?

The Chair: Yes, I would appreciate that.

Mr Decter: Okay. Well, first, let me say that I think a small inaccuracy crept into our comments in the discussion of the issue of whether we put on the card the full name as it's shown on the birth certificate or passport or some variant of that. I believe at one point in the testimony we indicated that we checked three data points. That's accurate. I understand the three that we check are surname, gender and birth date, and we might have said "address" at some point yesterday, so just to clarify.

We also had a meeting of the group involved after adjournment yesterday, and we agreed that the suggestion, I believe from Mr Callahan, that we put the full name as it appears on the supporting documentation on future health cards is a recommendation that we think is a very good one, and so we are going to change our policy. We're going to use the full name to the extent it fits. If it's too long to fit, we'll have to use some subset.

So I think it was a very constructive suggestion. We're happy to take it on board.

Mr Callahan: It's made my eight years here worthwhile just to accomplish that.

Mr Decter: The second thing I thought I should table, and I believe someone has copies, is that we made reference to a number of studies we've done, and I thought we should give you a list which is essentially the table of contents of our book with all the studies, just so you get a sense of --

Mr Peter Burgess: Section 11 is the actual list.

Mr Decter: Yes, section 11 is --

The Acting Chair (Mr Noel Duignan): Are there copies for committee members?

Mr Decter: Okay. We will get copies made, so you know all of the things that we have looked at.

The third was the question, which I believe was Mr Runciman's question, in terms of reviews of physicians, and I indicated I would get some clarity in the annual screening. What we do is, we do a once-a-year computer screen of all of the physicians, the some 20,000 who are in the OHIP system. We rank them, through that computer process, according to the unusualness of their billing practice -- that is, its variance from averages. Out of that process, 450 profiles are then referred for review by the professional staff and then, further from that, some 150 or so go on into a further review. So I think we were accurate in saying that they are all reviewed, but it's a machine review, against standards. Only the 450 that are at variance significantly from the averages are specifically reviewed. So that's, I think, the answer on the physician review.

I made reference yesterday to interprovincial comparative data, and we have a table that shows how we compare to other provinces on hospital and medical costs per capita. That can also be made available to the members.

That takes me, on my list of follow-up, to the question of whether the phone-in validation that we're implementing meets the test under the freedom of information act. For that, I'd like to turn to Gilbert Sharpe, our director of legal services, to address the question.

Mr Gilbert Sharpe: I'm going to go through the material in the sequence I understand the questions were raised. The first issue that was put to me was whether it would be lawful for the ministry, in response to a physician's request, to inform that physician that the health card number is or isn't valid and, if the answer to that is yes, would it be lawful to indicate in what respect the number is invalid -- for example, an invalid version code or an incorrect birth date.

Our view is that with proper security in place -- I think you've heard evidence about how the physicians would have to put their own number into the system in order to get a response -- the ministry may inform a physician that a particular number is or isn't valid and can indicate why the number is invalid. This is authorized by existing legislation and is consistent with FOI.

To get into our rationale a little bit for this opinion: Assuming that disclosing this information, saying that it is or isn't valid, is the disclosure of personal information -- and one might argue it isn't, but for the purpose of our discussion today we'll say that it is -- there are three sections in the freedom of information act that could be applied to justify this. One is clause 42(a), which provides that personal information can be released in accordance with part II of the freedom of information act. Well, clause 21(1)(d) -- and I can provide you with copies of this so that --

Mr Callahan: We have it.

Mr Sharpe: Do you have it? Or if you wanted a copy of --

Mr Callahan: I think we have copies of the act.

Mr Sharpe: Okay.

Mr Callahan: But we'll take copies of your opinion as well.


Mr Sharpe: Sure. We can get you copies of that too. But 21(1)(d) permits disclosure "under an act of Ontario...that expressly authorizes the disclosure." Well, there's a Health Cards and Numbers Control Act that was passed in 1991, and subsection 2(2) of that states that "a person may collect or use another person's health number for purposes related to the provision of provincially funded health resources to that other person." So, in our view, the validation scheme would fall within this section. I have a copy of that legislation here as well if the committee members would like to see it.

There's also clause 38(2)(c) of the Health Insurance Act. I also have that with me. That states that the general manager of OHIP can furnish to the service providers -- that would be the requesting physician here -- information concerning "for whom" the service was provided. In our view, the validation scheme would fall within this provision where the doctor requests validation after the service has been provided.

There's also an argument under 42(c) of the freedom of information act that permits the disclosure of personal information where the disclosure is "for the purpose for which it was obtained or compiled or for a consistent purpose." I brought with me some rulings of the freedom of information commissioner that give a fairly broad interpretation of "consistent purpose," which we also feel would apply here.

Finally, there's clause 42(e) of the freedom of information act, where the disclosure is "for the purpose of complying with an act of the Legislature," and we feel that because of the reference I've made to the provisions of both 38(2)(c) of the Health Insurance Act and 2(2) of the health card legislation, one could also argue under 42(e).

So, in a very brief overview, that's the basis of our opinion that the scheme that was described to you does not offend the freedom of information act.

Mr Decter: To be fair, we didn't fully describe the scheme yesterday and, just to be very precise about it, the physician who calls in will have to code in a provider number. That is, they will have to code in their physician provider number or lab provider number, a password, and then the health card number in question. So there is not, in our view, a possibility of someone simply calling into the number and testing out a series of health card numbers without being properly identified as a provider.

I don't know if there are specific questions for our legal --

The Chair: You're finished. Is that it?

Mr Decter: Yes.

The Chair: Mr Callahan, let's try 10 minutes.

Mr Callahan: All right. I'm going to make one more suggestion to you that might be very inexpensive and might be a way of safeguarding the integrity of the system. As you're probably aware, if you go into a bank or a trust company and you have a deposit book, you sign your name in the front of the deposit book and they run it under an ultraviolet light and they can determine whether or not the signature you're giving on the deposit or withdrawal slip is that that appears on the deposit book.

If you were to have a system in place on the back of the card where the signature, perhaps taken from the application form itself, would be put on to the magnetic strip or some other type of material that would allow a doctor to simply run it under one of these small ultraviolet lights -- I'm sure they're very inexpensive -- and have the person sign their signature and match it to the two of them, there'd be no way that there would be any service that could be provided to a person other than a legitimate holder of the card. So I offer that to you as a way of safeguarding the system.

Having said that, it's my understanding that you still maintain an eight-digit number for some people -- am I correct? -- as well as 10 digits.

Mr Decter: I'm not aware of --

Mr Burgess: Fred is perhaps a better person to answer this question, but an eight-digit number is utilized within the processing of a claim to enable the history that applies to the individual from, if I can put this in quotes, "the old OHIP days" so that we can look at activities which have occurred over an individual's lifetime for a check.

Mr Callahan: So it's retained internally.

Mr Fred Hazell: Yes, but it's not used externally.

Mr Callahan: Every time you duplicate a system, it costs more money to maintain it. What is the purpose of maintaining the eight-digit number at this point if you've already got the cards out in place?

Mr Decter: My understanding is we're in the process, through claims rewrite, of moving that data across to the 10-digit number inside our system. It's simply that we didn't want to lose the data stored against the old numbers, so it's unfinished business in terms of the project. I think Fred could speak to the timing of the claims rewrite, but it is the last piece of eliminating the eight-digit number internally to our data storage system.

Mr Hazell: We're presently doing the analysis required to rewrite the claims system, so this is an interim measure until we get there.

Mr Callahan: I have a few more questions here. Is it correct that the registration system has recently been reporting persons as dead who in fact are alive?

Mr Burgess: Yes. That did occur.

Mr Callahan: How often?

Mr Burgess: I'm not sure of the numbers and I'm not sure that I have them with me. It was a relatively small number where true duplicates in fact were removed from the file erroneously, true duplicates being when matched against the registrar general's death notification that we received in July or August, where a Fred Smith, where there was more than one Fred Smith on the file and we had no accurate date of birth coming over from the registrar general, the system erroneously removed or indicated the wrong person as dead. To the best of our knowledge, there were a relatively small number, tens rather than hundreds, and they've all been corrected.

Mr Callahan: Was this because you only took a sampling from the registrar general once a year?

Mr Burgess: This was because we had never taken a sampling from the registrar general prior to that time.

Mr Callahan: Is it intended that eventually we'll have on-line computers with the registrar general and a whole host of others, MTO, Ministry of Transportation, or whatever it's called now?

Mr Burgess: I'm not sure about the use of the word "on-line," but certainly we are now, on a monthly basis, exchanging a tape of information from the registrar general, matching it against our files, and since we have been doing that exchange on a monthly basis, there has been no occurrence of an incorrect assumption of death. We've changed our matching algorithm, the way that we match against our file. As our deputy mentioned yesterday, we have ongoing plans to exchange data to improve the accuracy of our file, particularly in the area of addresses, with other organizations like MTO, yes.

Mr Callahan: This committee learned through the auditor's report -- I think it was the auditor's report -- that in fact birth certificate blanks, I guess they were called, had been taken from the registrar general and used in an inappropriate fashion. Is there any evidence that any of these birth certificates were used to obtain health cards?

Mr Burgess: We have no evidence that would suggest that, no.

Mr Callahan: When you do catch somebody, if you have, other than the one you told us about where I think you said you were giving evidence on a prosecution, do you prosecute people when you find that they fraudulently used the document? Do you try to retrieve the health card? In addition to that, do you try to recover the claims for the ineligible claims? The reason I say that is that I understand that a doctor who accepts the card and it turns out to be a card that's not active, that doctor has to, to use the vernacular, eat the cost of the services. I guess what's fair is fair. First of all, have you caught people with illegal cards; have you prosecuted them; have you retrieved the card; and finally, have you attempted to collect the cost of the services that they have fraudulently obtained?

Mr Burgess: Let's see if I can get them in the same order, but I won't guarantee that I will.


I checked with my staff in Kingston this morning. We have currently five cases under review by the police. None of those cases have come to trial yet. What will happen, I couldn't judge. Prior to that, where we have prima facie evidence of an individual having a card without an entitlement, we indicate to the individual that we are cancelling eligibility. The individual then has the right to appeal to the Health Services Appeal Board. If my memory serves me correctly, up until August of this year we had gone to the Health Services Appeal Board with some 64 or 65 cases. I think our decision had been upheld in all but one or possibly two cases. The Health Services Appeal Board may then make the decision as to whether restitution is made or not.

Mr Callahan: Or if they're convicted you could also ask for restitution.

Mr Burgess: That's right, but as I say, we haven't come to the conclusion with those five cases yet.

Mr Callahan: On the question of physicians, over the period from 1989 to 1992, can you tell me how many physicians have been investigated and how many have been requested to repay overpayments they received?

Mr Burgess: I really can't tell you.

Mr Callahan: How about if I help you out? In 1989 to 1990, there were 59 physicians investigated; 47 physicians were requested to repay an amount of $1,511,119. Does that sound accurate? In the year of 1990 to 1991, there were 53 physicians investigated; 40 physicians were requested to repay a total of $3,062,799. In 1991-92, 37 physicians were investigated; 32 physicians were requested to repay $2,114,913.

Mr Decter: These are numbers that our communications branch supplied to the public in response to a question some months ago.

Mr Callahan: Is that right?

Mr Decter: Yes.

Mr Callahan: So they are accurate.

Mr Decter: I believe those to be accurate, yes.

The Chair: Mr Tilson, you have 10 minutes.

Mr David Tilson (Dufferin-Peel): Mr Decter, you made a comment yesterday that if it was discovered that certain cards were not valid or illegal or for whatever purpose not valid, payments would not be made. That policy came into effect as of, I believe, February 1.

Mr Decter: Yes.

Mr Tilson: In doing some research, one of the concerns that I have is that my understanding is that if a patient comes to a doctor, the doctor must provide that service whether he has a card or not. In other words, if someone comes and asks for medical assistance and his card turns out to be invalid as a result of a check, the doctor can do one of two things. He can not provide the service or he can bill the patient. My concern is that by your statement yesterday, essentially are you not telling the doctor to break the law, because the Health Insurance Act says, "Thou shalt provide medical service, no matter what," no matter whether there's a card or what. It's putting the medical association into a great deal of concern. Would you comment on that?

Mr Decter: Yes, and I'll ask Gilbert to help me out on the legal aspects. My understanding is that a practitioner is not able to refuse urgent care to someone, but the decision and determination of who the proper payer is, in a non-urgent case, is a contractual matter between the patient and the provider. That is, if someone presents at a physician's office and he has no health card or an invalid health card, the physician may well wish to provide the service on the basis of another contractual arrangement. That is, if we take the case of a tourist visiting from the US, the physician is well within his or her right to insist on seeing how the bill will be paid before he or she renders the service.

So the compulsion, as I understand it, on the part of providers, is in the case of emergency or urgent cases where there is a legal compulsion, but if I present at a physician's office and am unwilling to provide evidence that I'm an insured person, then I don't believe the physician is under any obligation to render me a service. But I'll ask Mr Sharpe, who has a much longer history in these matters than I, to see if that's an accurate condition.

Mr Tilson: I appreciate that Mr Sharpe may have some thoughts on this, but I guess there's the issue of implication that simply, "If you don't have a valid card you're not going to get health service; we're not going to pay for it." That appears to be the philosophy of the Ministry of Health, which puts the doctor in a very difficult position.

Mr Decter: I think I walked through this yesterday carefully and I'll do it again now.

Three years ago when the new health card/new health number came in, the government changed its policy to allow payment where the card number or the version code was invalid. We are now reverting to a policy that says the physician has to, along with a claim, submit a valid health number. Every physician in this province, every laboratory, every clinic and every hospital that bills OHIP has three years of remittance advice from OHIP indicating which numbers that they've been billing against are valid and which numbers are not valid.

We have spent three years and considerable effort to feed back to everyone involved the information they need to update their records. Now, for whatever reasons, we have not seen that updating take place, so as of February 1st we have indicated that the updating will need to take place prior to the physician or the hospital or the lab or the clinic being paid for the bill.

What's important to note here is that these are 3% of total claims that we receive on a monthly basis. It is our expectation that the vast majority of these can be cleared up with data already in the hands of providers.

Mr Tilson: I guess all I'm asking you to do is that before you pursue that policy you check the provisions of the Health Insurance Act. Mr Sharpe may or may not have some comments, but it's just that the impression that has been left is, "Doctor, we're not going to pay," and then the doctor's in a terrible position because he has to comply with the Health Insurance Act, and if there's something very serious he's got a big problem.

Which leads to another question, Mr Decter, and that is --

Mr Decter: I don't agree with your summation. The Health Insurance Act is here and we have someone capable of giving, I think, a very good interpretation of it. I don't accept that we have placed physicians in a position where they're going to provide care and not be reimbursed.

Mr Tilson: Well, that's not quite true. You have said that "If you don't have a valid card, we're not going to pay for it." That's what you've said.

Mr Decter: And we have also said that, "We have been telling you for three years which card numbers are valid and which are invalid, and that we will pay the claim immediately upon resubmission with a valid health number."

Mr Tilson: Notwithstanding the duplicate problem that this system has created?

Mr Decter: Well, I would take the view that this system has reduced by 14 million the duplicate problem rather than increasing it; it's not solved yet. We are not saying that we are unwilling to pay these claims; we are saying that to be paid they have to be accompanied by a valid health number and that, as every provider in this province has three years of data that they can look at to determine which patients -- and understand here, most patients do not present once. We are dealing with 10 million claims a month; that's one claim for every person in this province on a monthly basis, 120 million claims a year. In virtually every case we are dealing with multiple claims from the same provider for the same patient.

Yes, we are asking physicians to help us by making the records accurate, but I think it is frankly unfair to suggest that we are catching the physician between some significant volume of service and unwillingness to pay. We will pay all of these claims once it's established that they have been rendered to an eligible person.


Mr Tilson: I guess the concern that one has is that there may or may not be an issue that a card is a valid card. The systems haven't been perfected yet. One of the questions that I understand that has come from ministry officials that I've spoken to is the issue of retroactivity. In other words, a card may be valid today and could be retroactively deleted in the future. I don't know what the system is going to do with situations like that.

Mr Decter: Well, my view would be unless there's some organized case of fraud involved, we certainly don't intend to go back retroactively. This is a new policy as of February 1. If the card number was valid at the time the service was rendered, then we will of course pay for it.

I should stress --

Mr Tilson: You have that guarantee to the doctors, do you, that --

Mr Decter: Yes.

Mr Tilson: -- notwithstanding any retroactive position of invalidity, in other words a card may be valid today but tomorrow it may not be valid, the fact that the doctor has something -- how are you going to ensure that the doctor will know that the particular card is valid?

Mr Decter: I guess two ways. One, we will provide remittance advice to the physician on a monthly basis indicating which, if any, of the numbers submitted are invalid. If the physician has a valid number against which he's been billing and it goes invalid -- someone dies, for example -- and then we get a billing, we're not going to pay that billing. But if we've made an error, if for some reason that person is still alive, still is a valid eligible person, then when that's corrected we will pay the claim.

Mr Tilson: I'm trying to anticipate the section, because there are all kinds of holes in the system that have been pointed out to you, and you're working to solve those and I appreciate that.

The fact of the matter is that it would appear from statements that have been made that a card could be valid today but for some unearthly reason it could be made invalid tomorrow. The doctor phones you up -- not you but whoever, these machines or whatever you're implementing -- and it's determined that at that time the card is valid. He or she performs the service; then they find out later that the card is invalid. What happens then?

Mr Decter: It will be as of the date of service. Let's look at a couple of ways --

Mr Tilson: What evidence will the doctor have that the system, that the card -- all he's got is a telephone call.

Mr Decter: Well, he's got a call saying the card was valid at a date. We may have some adjudication, but let's look at how a card might become invalid.

Mr Tilson: You are going to have a lot of adjudication if this happens.

Mr Decter: Well, time will tell. I want to be clear on two things. One, we don't think the new policy as of February 1 solves all our problems. It is one of a whole large range of measures that we feel we have to take to improve the effectiveness of the system and the database and to make sure that we're not paying claims we shouldn't.

Let's look at how someone's number might go invalid. If the patient turns 65 they get issued a new card with a version code. Their old number goes invalid. That one's relatively easy for providers because they would have in their records a birth date and they would know when a patient was 65. So that one is simply a matter of saying to the patient, "Mrs Jones, you've turned 65; you have been issued a new health number; please bring it along so we can update our records."

The second case might be someone comes off the list because they're deceased. In that case we're not very eager to be paying claims for a deceased person.

Mr Tilson: Mr Decter, if I could --

The Chair: Thank you. Mr Perruzza.

Mr Anthony Perruzza (Downsview): Thank you very much, Mr Chairman. I understand that I have 10 minutes, and I don't think that my questions will extend to 10 minutes.

The Chair: I know Mr O'Connor has questions, and Mr Hayes has questions left over from yesterday. We'll use the 10 minutes.

Mr Perruzza: Okay. All right, fine. My questions basically have to do with card access, and I'd like to pick up a little bit on where I left yesterday with my own questions, and it relates to access. I wanted to know, very briefly: What kind of access does the individual person have with the cards as they relate to ministry files? Would I be able to contact you or write you and say I'd like to be able to access my file, I guess it would be my billings file with my doctor, and know what's on my file? What information would you give to me if I did that?

Mr Decter: I'll ask others at the table. I don't believe we would have a file organized on a patient basis. We would store data on the basis of claims from providers. The only file that I believe would exist would be your patient record and that would be held by your provider/physician/hospital. But let me ask others to comment briefly.

Mr Hazell: We would very likely refer you to your physician, because we would not be keeping a file on you per se. It would be a provider or physician file that we'd be carrying on the system.

Mr Perruzza: So in keeping with that, how does one go about catching fraud? For example, let's say I go to a doctor and I get visited by Dr X and I give them my health card number etc and I go away and Dr X doesn't see me for a long time but decides that they're going to submit a bill on my behalf to the ministry.

Mr Callahan: You're suggesting doctors do that?

Mr Perruzza: I'm suggesting that there's a potential for it. I'm just picking up on, actually, your thinking and how one can be creative in circumventing the rules of the game for monetary gain. So how would I be able to do that and how would one check that?

Mr Decter: Someone more knowledgeable than I has whispered in my ear: Under FOI we will provide you with all of the services that we have paid on your behalf as an insured person. So if you wanted to know what services we have paid for on you, we would, under FOI, make that information available. Now, that would constitute a record under FOI; it wouldn't constitute a very elaborate -- you know, it would be the code under which the billing had been taking place. So, for example, if your doctor saw you for a general examination, it would have a code and probably say "general examination." It wouldn't say what the diagnosis was or what the treatment was.

We have looked at whether we might send out to a certain percentage of people a profile. I believe that's done by the medical review committee when it investigates. When they're investigating a particular physician they would contact a number of patients to make sure that the services have been rendered. I don't know if we'd do that, other than on request, at the moment. Would we do a sample?

Mr Burgess: I'm not sure. Again, Fred is probably the better person to answer this.

The Chair: Let's hear from Fred, then.

Mr Burgess: I know that we used to randomly select and send out for confirmation. Fred?

Mr Decter: I can get you the per cent, but we do send some percentage of the people of Ontario their profile each year and ask them whether those services were in fact rendered.

Mr Perruzza: So you automatically send it to them, even though they may have an invalid card. Do you do that on the basis of the number? Do you do a random sort with your computer and say, "We're going to pick up these 5,000 people and send them a questionnaire on their medical services"? Is that the way it's done?

Mr Hazell: My understanding is it's done on a random basis or it can be done on a selective basis. It's automatically done each year on a random basis.

Mr Perruzza: Okay.

Mr Decter: Maybe I'll bump the lawyer to the back row and ask Eileen Mahood from claims payment to give you a more precise answer. Sorry, Gilbert. I always feel more secure with my lawyer.

Mrs Eileen Mahood: Yes, I know. I don't offer as much protection as the lawyer.

We do a random audit by claims service, not by health number. Therefore, we send you a letter and ask you, "Did you receive this service from this provider on this date?" and we ask you to validate that. Then, those that are returned, if they are "No," we investigate; if they are "Yes" --

Mr Perruzza: So it's just simply a yes or no answer, or is it a complicated form? What if the form's not returned?

Mrs Mahood: If it's not returned, we can't do anything about it. We don't follow up on that. We do it as a random audit check, but most people are serious about this, so we believe we have a good rate of return, but I can't tell you the exact number that is sent out. It's done monthly. It's a random sampling from the claims file.

Mr Perruzza: When someone under -- you said FOI; I guess that's freedom of information. That's a freedom of information form that they have to fill out, and not necessarily a Ministry of Health access-to-information form. Is that correct?


Mr Decter: It could come in any form. We receive freedom of information requests in letter form, fax --

Mr Perruzza: And you would send it on the basis of a request for a letter? "This is what my health card number is; signed," and then you would get that. But you don't necessarily get confidential medical information. You'd just get, "Yes, you went to Dr X on such and such a date for this service."

Mr Decter: Yes, medical information by and large rests in the patient record which is held by the physician. So if you were writing to us to say, "I want to know what my diagnosis was or my treatment," we would refer you to your physician or other provider. If you wanted to know what services we had paid for on your behalf then we would provide that list of services, so there's a distinction between the services and the medical record, which we don't hold.

Mr Perruzza: My last question is, there isn't a proactive policy to provide people with what it actually costs in terms of medical services for a year. You don't randomly do that so that kind of information is provided to people so that people are a little more conscious of what a doctor's visit actually costs or a visit to a specialist or a visit to an emergency section of an hospital. It has been my experience that when people are actually confronted with and are provided with that information they're just astounded at what medical services actually cost. You know, they sit and scratch their heads and then they try to figure out the kinds of services that they could do without. It's very easy to just simply pick up and go to a doctor or, if you wake up and you have a stomach-ache in the middle of the night, to drive over or have yourself driven over to the local emergency ward, but when people actually know that visit is going to cost you $400, $500 or $600 or cost somebody that amount of money, people tend to be a little more cost-conscious. So there isn't a proactive policy, is the question.

Mr Decter: There isn't yet, but if you look in the package of slides that we presented yesterday, and I think this one was very near the and that I went by it pretty quickly because the committee was eager to get on to questions, we made reference to a consumer monitoring system and at the very bottom "annual statement of services." We are moving towards having the ability to do this and we would like to do it in the future to provide people with an annual statement of their services. Whether we would provide everyone or we would provide a certain percentage every year I don't think is a question we've addressed. One of our hospitals, Sunnybrook Hospital, did start to do this.

We have a little bit of concern and want to do some testing. Our concern, if I can be direct about it, is we don't want to cause fear in some of our senior citizens, in that no matter what you put on it they might see it as a bill. Although we would like people to be aware of how expensive health care is, we're very worried about creating fear among any of our seniors that would cause them not to seek services they need. As you can imagine, getting something in the mail that might look like a bill and might add up to tens of thousands of dollars might have an effect of actually causing fear and illness. Sunnybrook had some reaction of that sort. I think we'd have to do some good focus testing. We'd probably need to have a good communication strategy. I think it's an excellent idea. There is a small downside in that some of these bills would come as a real shock to some people, and our desire is to inform, not to scare people.

The Chair: Thank you. Mr Perruzza, you've used up 13 minutes instead of 10, but that's fine. They were important questions. Let's try a 15-minute round. Mr Cordiano, then Mr Callahan.

Mr Joseph Cordiano (Lawrence): I just have a quick question with regard to future projections in terms of the number of cards. Do you have a handle on how many new issuances there will be, which includes of course new births and net new immigrants, coming into the country over a year-to-year basis and what the projection is for that? Do you have these projections that you're making?

Mr Decter: I believe we're currently experiencing 150,000, ballpark, new births a year in the province and I believe our immigration is running -- it varies a little bit -- at 40% to 50% of the national. I believe the national is 250,000. On that basis, we're looking at another 100,000 to 125,000, not quite as many coming in through that route as through the birth route, but if you put the two together, it's somewhere in the order of 250,000 to 300,000 new eligible persons a year.

Mr Cordiano: You also have this reconciliation process for people who are taken off as invalid -- deaths etc?

Mr Decter: Yes.

Mr Cordiano: And people leaving the country, which I imagine also occurs.

Mr Decter: We would have deaths and immigration, either out of the country or to other provincial jurisdictions, coming off, so the net would be smaller than the gross. Peter, deaths are?

Mr Burgess: It's a little in excess of 100,000 per annum. It's somewhat less than the birth rate.

Mr Cordiano: I have just one final question, Mr Callahan. I asked this question yesterday. With respect to the equipment which will automate doctors' offices, screening equipment, you gave me a figure yesterday, I believe, of approximately $5,000 per unit in cost, which would have to be added. Is that correct?

Mr Decter: I don't recall giving a figure, but --

Mr Cordiano: I may have read it in some briefing material.

Mr Decter: Okay. Eileen, again, can help out here. Apparently the number's right even if I don't remember giving it.

Mr Cordiano: The number's correct?

Mrs Mahood: It's a range and it depends on how sophisticated you want to be. We estimate that to be between $5,000 and $8,000 unless you want, without being product-specific, to go to the very high end. You can spend much more than that, but you certainly don't need to. For that you will get more than just a simple billing package. You will get other things in the software package that will let you do other practice management. It's in that range -- hardware and software.

Mr Cordiano: All right. I won't get to this next question, but I'll do that tomorrow. One of the local doctors in my community asked me to ask this question, but I'll do it tomorrow.

Mr Callahan: I wanted to re-emphasize, just so you're clear on what I'm talking about with the signature, that this is a passbook. It's my passbook.

Mr Decter: This isn't rehearsed, I assure you. I should have one too.

Mr Callahan: I'm not trying to do an ad for Canada Trust. What they do, and I'm sure it's the same as in yours --

Mr Decter: Right in here there's a signature. They put it under the ultraviolet.

Mr Callahan: In the front of it there's a signature which cannot be seen except if it's run under an ultraviolet light. I don't know what an ultraviolet costs, but I'm sure it's a lot less expensive than these machines we were talking about. If in fact you had a process whereby the application was made by the person, he had to sign his signature in the presence of someone and that signature's on file, either on microfilm or on regular copy at the Kingston office, when the person goes in to get the service from the doctor, in order for that doctor to collect that person would have to sign at the bottom of some form. Then he could just simply ask for the card.

The signature wouldn't even have to appear on the card itself. That would be dangerous as well because people could in fact forge it. If somehow it's on the magnetic tape, just as its been done on this book here, they just run it under an ultraviolet light, take a quick look-see at whether it matches the other one. I think that way you could be fairer to doctors too, because if a doctor did that, similar to the merchant who calls down to the Visa or Mastercard outlet when a purchase is over $100 and gets a number from that person, then he is entitled to be reimbursed. Even if that card has been stolen or is being fraudulently used, they get paid.

I would suggest that if you set in process this type of procedure, then I think it would be fair that a doctor or a health care provider would be paid so long as he had checked the signatures rather than the numbers. You could tell that very easily because it would be their obligation to do that. I suggest that's an avenue to pursue. It's a lot less expensive than bringing in all these machines we were talking about yesterday, the swipe machines. I don't know what they cost, but I'm sure they're more expensive than ultraviolet light. I offer that to you as a suggestion of an inexpensive way to accommodate not just the doctors but also the public and to avoid fraud.

Having said that, I have a few questions. Perhaps legal counsel can help me with this one. We understand that the availability of a health card and health services is if you can prove you're a resident of Ontario. If a person obtains a US green card to go work in the US, is he deemed to have ceased to be an eligible resident of Ontario for the purposes of the Health Insurance Act?


Mr Sharpe: That's a good question. I'd have to take a look at the interpretations of residency. Could I bring that answer back?

Mr Callahan: Okay, sure.

Mr Sharpe: My assumption would be that if he's factually still a resident of Ontario and receiving services here, the fact that he may have obtained a privilege to work in the States at some point doesn't necessarily render him ineligible. But I'll do a bit of research on it and get you the answer.

Mr Callahan: Okay. The reason I asked is that I asked questions yesterday about the policy that was introduced by the minister some time in the last sitting of the House. I can't remember when it was, the sitting was so long ago.

The Chair: Some time last year.

Mr Callahan: I think it was in 1992. I want to avoid the partisanship, Mr Chairman.

The policy is similar to the income tax arrangements, people who resided outside of Ontario for 183 days. I understand it's not just outside of Canada. If you went to glorious Prince Edward Island for 184 days, you should, under that policy, be denied access to coverage in Ontario. The question was, how were we going to police that? I was given an answer and I guess it was the best answer you people could give. I appreciate it's a very difficult one, but I think the problem is that you're going to have people who are going to observe that to the letter and then you're going to have a whole host of people who are going to just ignore it. I would urge you to suggest to the minister that it's probably a policy she should wipe right off the books. It's not enforceable.

It's kind of like when I was at city council. We used to pass bylaws and I always got upset when we passed the bylaws because I said, "You haven't got enough bylaw enforcement officers to check the bylaws." What happens is, you pass all these things, they're only enforceable on complaint and suddenly the law because an ass -- that's a donkey, a mule -- and there's not much point in doing it if you can't enforce it. I would urge you to take that back to the minister and suggest that this policy is unenforceable and all it does is scare senior citizens who are going to be constantly checking their calendar to make certain they haven't stayed out, trying to keep the days together. I think all it does it cause them anxiety.

In line with that, I always thought that the policy of health coverage was universal, and yet it seems to me that in every province of this country there are different rules and regulations. I would ask you, in a province other than Ontario, if a person becomes ill in Florida or someplace outside of Canada, does he receive just the rate that OHIP or whatever the equivalency is in that province pays or does he get full compensation paid?

Mr Decter: Let me tackle a couple of these because, without giving full answers, I can give you partial answers. On the green card issue, we have a Health Services Appeal Board case where they ruled that someone who held a green card was ineligible by virtue of that. This is an appeal board. It's not a final, final authority, so that may or may not hold up, but we have at least that case.

There are quite different circumstances if you're not in Ontario but in another province of Canada. After 90 days you're covered by the other province's plan.

Mr Callahan: Automatically?

Mr Decter: Automatically. Well, you have to apply, but there is no circumstance in which you're without coverage. If you're a Canadian and you move between provinces, you're either covered by the province you've left for 90 days or you're eligible for coverage in the province you've moved to. Although you're right that there are differing rules, slightly different coverages among the provinces, significantly different coverages on things like drugs that are not covered in the Canada Health Act, the package of insured services is quite similar across the 10 provinces and two territories. A Canadian citizen or a Canadian resident is not in any peril moving. They are covered on one end or the other.

If one goes out of country, Ontario had actually been the province out of line with the others in that until the change of policy in October 1991 we had been paying full rates out of country. Most of the other provinces never paid more than their own rates and some of the other provinces never paid anything at all out of country. It's completely discretionary under the Canada Health Act. Ontario was, in essence, the generous province in that regard. When we pulled back to paying Ontario rates, we became very concerned that our Ontario people, when they go out of country, buy the supplementary insurance.

Our concern is as much that from day one out of country, if you don't have supplementary coverage, you've got a risk as at the end of six months out of country. We don't want the taxpayers of Ontario to be paying the portion of six months plus a day. Our concern is very much that people understand that our coverage, although it's sufficient in Ontario, is no longer sufficient once you go out of the country, but people who travel among the provinces have portability of benefits among the provinces.

Mr Callahan: What is the penalty if a person who would normally be eligible for health insurance fraudulently uses the card. Is the card taken away and they lose access to the health care for ever?

Mr Decter: The penalty under the Health Insurance Act makes it an offence to obtain benefits fraudulently or to provide false information in an application. Section 44 provides for a general penalty upon conviction of a fine of not more than $5,000.

Mr Callahan: That's about $25 in realistic terms, if they were convicted in a court.

Mr Decter: We had one conviction last year. This was a person using another person's health card. They were to receive hospital services and the retribution or payment was $600 in that case.

Mr Callahan: What was the cost of the service that was defrauded?

Mr Decter: I don't have that information. I think we have not had a lot of court experience in these things. Generally, I believe if someone were even, post an offence, an eligible person, he would have a health card. If they were not an eligible person, obviously they would not have a health card. There's no penalty in terms of being deprived of benefits that are lawfully yours. There is, however, a fine under the act for either fraudulently obtaining services or providing false information in an application.

Mr Callahan: The summary conviction range of penalties was increased to what? Generally, I think it's $10,000 or higher. I would certainly recommend that the outside limit of that penalty be much higher. I'd even recommend that instead of prosecutions under that act, in the appropriate cases they should be done under the Criminal Code. We're trying to nip in the bud the potentiality and the actuality, because you've told us that there are cases where cards have been improperly obtained, where services have been improperly obtained. We're talking about the health -- not to use a pun -- of this system in terms of ensuring that people recognize that it's a privilege to live in this country and to have access to that type of health care.


We watch what's going on down in the United States: That's probably one of the most singular things that got Clinton elected, the promise of a universal health care system that's the envy of the world, and yet unless we have a penalty system that makes it significant enough that people aren't going to cheat or participate with others in cheating, then I think all we're doing is putting a licence fee on cheating.

Mr Decter: We have some proposals under way to consider increasing the level of fines in the statute, and I believe that we also have access to -- or the Attorney General would, under the Criminal Code -- pursuing prosecution there.

The Chair: Thank you. Mr Wilson; you have 15 minutes.

Mr Jim Wilson (Simcoe West): Mr Decter, I just want to go back to the discussion we were having yesterday concerning the 1.4 million cards out there in circulation that, you tell us in your reconciliation summary provided to the committee, are deemed inactive -- and I take your word that you believe they are inactive -- on the system. I just want to ask you: How did you determine which of the 12.2 million cards that have been issued were deemed part of the 1.4 million that were subsequently deactivated?

Mr Decter: I think I'll ask Peter Burgess to deal with that question.

Mr Burgess: Surely. I don't have the reconciliation in front of me, but there are a number that automatically get deemed ineligible when the new card gets issued for those who turned 65. In the case of a card being reported stolen, it is immediately deactivated and a new number issued.

Mr Decter: So, looking back to yesterday's presentation, about one million Health 65 cards have been issued as of November, so one million of the 1.4 would have become invalid, because we would have issued to people turning 65 a new card with the new version code. As to the other 400,000, I think we would have to look at the reconciliation numbers to be able to give you that.

Mr Burgess: There were -- this was as of January 20 -- 1,056,046 cancelled or voided cards that had been signified to the database. There were 15,493 that had been reported as damaged; they were identified in the database as being no longer eligible. There were 267,288 cards notified to us as being lost -- we again struck those from the database -- and 63,675 had been stolen. That comes to a total of 1,402,502.

Mr Jim Wilson: So let's just explore this for a minute. You issued, as of January 1993, 12,201,149 cards. Break down how many you've deactivated. A million because they'd turned 65 --

Mr Decter: Well, I was trying to read off this chart. We've deactivated --

Mr Burgess: That would be in here.

Mr Decter: Yes. That's 1,056,046 cards that have been cancelled or voided, the vast majority of those because people have turned 65, and the balance of the 400,000 lost, stolen or damaged. So the 1,402,000 cards have come off the database on the basis of those four reasons, leaving the 10,820,573.

Mr Jim Wilson: Okay. What I'm wondering is, of the 12.2 million cards issued, how many would be duplicates, and where do they show up on your reconciliation summary?

Mr Burgess: The duplicates show up under the column -- I believe it's entitled "Registrants that should be removed." We have 153,025 duplicates on the file.

Mr Jim Wilson: My number there says 272,000.

Mr Burgess: Yes, that's part of that 272,000. Sorry.

Mr Jim Wilson: So of the 272,531 --

Mr Burgess: Yes. Of that number, 153,025 are duplicates.

Mr Jim Wilson: And of the 153,025 duplicates -- first of all, when did you start adding version codes to the information contained in the magnetic strip?

Mr Burgess: From day one.

Mr Jim Wilson: Not in July of 1991 or thereabouts?

Mr Burgess: From day one. I mean, the first time -- if a card had been issued in July 1991 -- July 1 -- and reported lost on July 2, a new one would have been issued on July 3 with a version code.

Mr Jim Wilson: When did you start issuing cards?

Mr Burgess: In July, 1991.

Mr Jim Wilson: That's the first issuance of cards?

Mr Tilson: In 1990.

Mr Burgess: Sorry -- 1990.

Mr Jim Wilson: So what happened between July of 1990 and July of 1991 with respect to version codes?

Mr Burgess: Sorry. Let me go back. The first day that we issued the first card, 1990, the time that we put version codes on, was the first time that one had been reported lost or stolen.

Mr Jim Wilson: So -- just to clear this up -- so there were never multiple cards issued to a single person with the exact same information on them. You're saying, any subsequent card after the first issuance always contained a version code.

Mr Burgess: Yes. That's, to the best of my knowledge, absolutely correct.

Mr Jim Wilson: And how does a physician know -- say he runs it through the magnetic strip reader that some have attached to their computers now; they're not interactive with the ministry, but they're interactive with their own computers -- and he has version three of the card, whatever the coding is for that: the auditor told us it was an ABC system, but some of the cards I have that are duplicates have a P in the bottom corner and things like that.

Mr Burgess: Yes. Perhaps I could take 20 seconds to explain about the version code. The version code is not a numeric or ascending sequence assigned; it's a purely random sequence. It's a two-digit, so the first one you get could be Q; it could be Z; it could be XX.

Mr Jim Wilson: Okay. Now, how does a physician, then, under that system -- if I have a couple of cards -- well, I might have 15 cards --

Mr Tilson: How many do you have?

Mr Jim Wilson: And I bring in card number 7 under this hypothetical case and the admitting nurse or whatever doesn't say, "Mr Wilson, is this card number 7, 6, or 13 or 14 or -- how many of these do you actually have?" Here's the question. Every new card issued gets a new version code, and you deactivate the previous number, the previous card -- you invalidate it, I assume, in the computer system, automatically. So obviously the question I'm driving at is, how does the physician know that I'm presenting the latest version, and that you won't, 30 days later when the billing goes in, reject that?

Mr Decter: Let me try this. The first card you get doesn't have a version code.

Mr Jim Wilson: No. It has the eight-digit OHIP number at the bottom.

Mr Decter: Yes. Well --

Mr Burgess: Only those cards issued in the initial registration of the population had the OHIP number. If you --

Mr Jim Wilson: That's the period I'm looking at, in particular.

Mr Decter: Yes, but in terms of the physician, if you have two cards and one doesn't have a version code and one does, the one with the version code is the newer card.

Mr Jim Wilson: But I might have one initial card and 13 version code cards.

Mr Decter: You would be one of 163 people. In terms of the overall numbers, we have issued a second card to 821,000 people, so a physician in those cases --

Mr Jim Wilson: That's a lot of second cards.

Mr Decter: No, but in those cases with the two numbers a physician would know instantly that the version code card was the newer one. We have issued three cards --

Mr Jim Wilson: But does he know it's the newest one?

Mr Decter: I'm trying to work at that. In the sense that only 91,000 people have been issued three cards, 14,000 four cards, 1,600 five cards and 163 six or more cards, we don't have an easy way, until we have the phone-in validation in place, to help physicians sort among people with more than two cards, but that's a relatively small portion: under 1% of total card holders. So in 99% of cases, a physician can readily tell. In the other cases, they would have the three years of remittance advice, I believe.

Okay, I'll let Eileen say that.


Mrs Mahood: We also have, during business hours, the physician can call any of the 20 offices that are in the province and with proper identification, and either a callback from us or his physician number or something that validates that he is the provider of that service to that person, we will now tell him whether that's the valid card or not.

Mr Jim Wilson: When did that policy come into effect?

Mrs Mahood: We've always done that.

Mr Jim Wilson: You didn't back in October when the Toronto physician called me and said that MOH couldn't tell her whether that was a valid card or not. I raised that in the Legislature and I got an FOI response from the minister.

Mrs Mahood: If we can validate who the provider is and we're comfortable that that is the provider of that service to that patient, we will validate then whether that's a valid card or not. What we will not do is change any information. If it's an invalid card we will simply say that's an invalid number, and it's up to the person with that number to get to us and correct the information.

Mr Jim Wilson: Thank you. Mr Tilson.

Mr Tilson: Time left, Mr Chairman?

The Acting Chair (Mr Robert V. Callahan): Yes, you have about three minutes.

Mr Tilson: Three minutes. I'd like to go back to the new policy that you're implementing with respect to newborn infants and the prearranged-number issue. My understanding is that for an infant to receive a prearranged number, you look at the number of the parent. Is that correct?

Mr Decter: Either parent, I believe.

Mr Tilson: Either parent. The concern that I have with that is: How do you prove who the father is? I can think of potential scams with that policy. I can think of, for example, a man bringing his girlfriend or friend from another country who is expecting. He gives the number to that friend. He has no connection with her. Nobody else knows. All they know is, they fill out the form and they put down the man's number. That health card is given to that child and that lasts for ever. Worse yet, a potential scam could be where a man devises a scheme of bringing over American women who are pregnant. There is no possible check to confirm who that man is, whether he is the father of that child. I guess I express a concern as to using the number of either parent as opposed to the woman.

Mr Decter: I'm going to try and see if I can answer that without getting myself in some degree of difficulty --

Mr Tilson: I've never seen you do that, Mr Decter.

Mr Decter: -- around the role of natural or other fathers in this whole process. My understanding is that we pre-allocate the numbers to the hospital. Parents, and this could be either parent, complete the registration form before discharge, but then they have to subsequently fill out the rest of the form. So that what we've done is not to change the overall process -- we would still need a birth certificate for the child -- but I think if you are asking, are we going to look behind both parents in a birthing situation, if the baby is validly registered as an Ontario birth, then I believe we will take that as evidence that they're eligible for health insurance.

Mr Tilson: My information is --

The Acting Chair: I'm sorry, Mr Tilson, your time is up. We have to move on.

Mr Tilson: Thank you, Mr Chairman.

The Acting Chair: Mr O'Connor. You have 15 minutes, by the way. Do you want to split it up five, five and five?

Mr Larry O'Connor (Durham-York): I may share some of this time, yes.

The Acting Chair: Oh, I see. You're in control, are you?

Mr O'Connor: I've got the floor.

Through this hearing process we're certainly going to hear a lot of interesting proposals. I was intrigued by Mr Callahan's proposal about the signature on the card, which seems to have some merit. I question how much the signature of my son Patrick, who's six years old, will change over the life of this card that we've got out there now. I imagine it would change quite a bit, so we could run into problems, but it's interesting to have these discussions anyway. It certainly does bring forward a number of ideas.

Looking at your presentation yesterday, the flimsies, on page 26 I noticed the paper card. Only Ontario seems to have this paper card. I just wondered if you can talk about this paper card. I believe you had mentioned that the paper card is going to be eliminated. With the elimination of this card my question is, what purpose did the card serve? Are we going to be cutting health care benefits to somebody who may have used that paper card in the past, who may need that paper card or something that's going to provide him with medical services? Because health care is something that all Ontarians, and in fact all Canadians, believe sacrosanct. It's an entitlement. It's a right. My concern is, are we going to eliminate service to people?

Mr Decter: I don't believe we are. First, just to be clear, half of the provinces have permanent paper cards; the other half have plastic cards. We're the only province that has had both as a transitional measure. That is, we've maintained a temporary paper card as part of the system. The reason for doing that was there were individuals who required immediate health services and the plastic card wasn't available, or when we had a very limited period of eligibility, someone who was only going to be in the province and eligible for three months or less, we didn't want to produce a plastic card. My understanding is that we're looking to eliminate the paper card over the next six months. I believe we will only do that when we're certain we won't be eliminating anyone's ability to obtain coverage. I will ask Eileen to say exactly how that's going to work.

Mrs Mahood: We have run a pilot in Toronto on this very issue, because that is the place where most people, in terms of total walk-ins or show-ups at the door, are. This pilot proved that, in most cases, people don't have an immediate need for a paper card. The situation, though, is that should someone be going to a physician immediately, we'll verify that he is eligible for coverage but has not yet received his plastic card. That will allow them to obtain the service whether they have their card or not, so we won't have to actually issue a paper card that could be used at another time.

The other thing is that the paper cards that were issued had an expiry date on them so that they became ineligible. We were trying to match that to the amount of time it took to get the plastic card produced. In the very initial issues, when the plastic card was going to multiple volumes of people, the time frame from submission to obtaining was long. Now that there aren't as many cards being produced, that has significantly been reduced, so that people are receiving their plastic card within two to three weeks of submission. Therefore, the need for paper has shortened significantly and we believe we will be able to eliminate that as long as we have a verification for anyone who is getting immediate medical attention.

Mr O'Connor: Just following along with the cards and some of the discussions we have had, I have noted that after eight years Mr Callahan feels he's made a real impact. Perhaps the rest of this committee may feel we may make an impact in suggesting possible changes to the health care card system. In fact, technology changes all the time and I'm sure that what we see in the card today won't be what we see on the card in the future. Are there any plans for changing the present card system that we have, say, within the next 10 years? Do you have some sort of plan? Maybe you could just comment on that, some sort of renewal cycle for the present card system we have.


Mr Decter: Again, I think in the time I had yesterday I went through it probably pretty quickly. We're looking at a number of issues to do with changing the card. One of those would be to add an expiry date. Another of those would be to put the birthdate and sex on the surface of the card. The additional one, which we want to evaluate, is Quebec's experience, which would be to go to a photo on the card. These things are all under review.

I think the most certain thing I can say is that I'd be very surprised if 10 years from now the card looked as it does now, but exactly which of the changes and when I think is an issue we have not yet made recommendations to our minister on. Our previous minister was quite keen to have advice on this. I expect our new minister or ministers will as well, but we're not quite there in the briefing yet. It is early days, but we are looking at all of these issues and I think of them, obviously if we go to an expiry date, that ups our cycle of how many we'd be producing, depending on the length of the cycle. Either Peter or Eileen should feel free to jump in and say more if there are things I've missed, but these are live issues with us and it's just hard to say when exactly we will come to a conclusion.

Mr O'Connor: That's fine, Mr Decter. Perhaps I can yield the floor to my colleague Derek Fletcher, who has a question.

Mr Derek Fletcher (Guelph): Just a couple of things: Over the years governments -- and it doesn't matter who has been in government -- have wrestled with duplication of cards, fraud and everything else that's going on. In fact, I've been looking at this thing in front of me, this paper article from the Star of 1990, and it says something like 27 million OHIP numbers being in service over the years of OHIP. This is not a new problem that's just being identified today. When it comes to the broad issue, exactly what is the percentage of the cost involved with fraud? Is it 1%?

Mr Decter: Let me try and then I'll ask Peter to jump in. I obviously don't have the skills that those of you who have to face the electorate have, but if one reads the three major newspaper one gets a different set of views. What I tried to say to the press yesterday and to this committee in response was that in the investigations we've done -- and you now, I believe, have a list of all those individual investigations -- the amount of suspicious card cases has been down around the 1% level. Those investigations have tended to focus on areas where there was already some cause to look, so that isn't 1% of the total $4 billion of physician payments or $5 billion of OHIP payments, but where we did look it seemed to be down around the 1% level. I'd ask Peter to comment on that. I think we were comfortable that if you have to give a figure, that's the figure you could give.

Mr Burgess: Certainly many of our studies are down around the 1%. Picking up on your first comment about duplicates and referring back to Mr Wilson's questions about duplicates, we actually did a survey of the duplicates we spotted on our file. Of those duplicates, we looked very quickly to see which of the duplicates had actually been used. Of the number, in excess of 100,000, 6,772 have been used. We then did a quick survey of that 6,772, and to cut to the bottom line, some 79 appear to be used by different people. That study has taken us from very early in our analysis project life cycle, around about November, through until towards the end of February. We are now down to some 79 potentials which we're looking at and still working towards. That is, I believe, somewhere around just less than 1% of that number.

Mr Fletcher: The other part is that the auditor's report is not a report that is here to say that the ministry is running its shop all wrong and that everything that's going on is all blown out; it's to identify some of the problems with the administration of the system and then what you are doing to correct them. You are taking steps to correct what the auditor's report has shown. Is that not right?

Mr Decter: Yes, I think we've tried in our whole appearance here to be very clear that --


Mr Decter: I thought it was an excellent question. I was happy to answer.

Mr Fletcher: I heard what your answer was. It was a good answer.

As far as ultraviolet lights, fingerprinting and voice prints are concerned, we could have so many things to try to identify some of the problems. Someone would find a way around some of the best security systems in the world. Correct? We can look at the US defence department as far as the hackers who are getting into the system are concerned.

Mr Decter: I think I've indicated throughout that, first, we welcome the auditor's report. We've taken a great deal of action based on it in the time since we received it and we will continue down the road of implementing programs.

I guess the second is that of course no system is perfect. We think we've made some major improvements, but we have many more to make to the system. But at some point you have to balance our faith that the vast majority of people in this province are honest. That's the premise on which we operate. We do want to get at the small minority who are taking advantage.

Mr Fletcher: I have one more question. As far as the health card system is supposed to make a more efficient business out of this, analyse health trends across the province, did you start off with a perfect system?

Mr Decter: No. I think we've had steady improvement in the system --

Mr Fletcher: I agree.

Mr Decter: -- over the period of medicare, but we have a great deal of distance still to go.

Mr Fletcher: And it's through all governments that we've had improvements?

Mr Decter: Yes.

The Chair: Thank you. Bob Frankford, very briefly.

Mr Robert Frankford (Scarborough East): I'm wondering about the word "fraud." I think it is used in a very loose and certainly not a legal sense. To me, fraud means getting away with money that one's not entitled to.

Mr Callahan: You don't have to get away with it; you can just try it.

Mr Frankford: Can I have the floor, please? To get medical services to which one might be entitled, but on the wrong card, is that fraud?

Mr Decter: No. If someone's an eligible person but has an ineligible card, has brought a card that is the wrong card, there's no fraud involved at all in that. It's no different than the kind of issue that would be there if you presented your Visa card after it expired. That isn't fraud; you simply need to have the new card.

Mr Frankford: It's like my borrowing Mr O'Connor's library card and taking a book out.

Mr Tilson: No, that's fraud.

Mr Callahan: It's fraud.

Mr Frankford: Is that fraud? I'm talking about entitlements.


The Chair: Let Dr Frankford place his own question, please.

Mr Frankford: With every eligible person, everyone in the province, because health care is a universal entitlement in this province, how can one start saying it's fraud to get it on the wrong card?

Mr Jim Wilson: What if you give your card to an American?

The Chair: Order.

Mr Decter: If I could be careful, the universality of entitlement is for those people who are residents of Ontario under the Health Insurance Act, legally entitled to be resident in Ontario. There are, and I think we described them yesterday, some groupings of people who would not be legally entitled to be here; for example, those with outstanding deportation orders who would be committing a fraud if they sought to obtain services or someone who's a foreign national who has no legal rights. Your basic point is right, that there are 10-million-plus people in this province with eligibility and that the vast majority of them also have a valid health card.


Mr Frankford: And despite the discounting by the members opposite who think that hurdles to entitlement are a good thing and one way of saving costs, we have a significant body of people who are fully entitled who are at increased risk who have not taken the steps to get it. We have street people, we have the Mennonite population, we have people with dementia, we have people with serious health problems, and if we go along with the bureaucratic scenario which is actively encouraged both by the people on the other side of here, we are asking for increased morbidity and mortality.

Mr Decter: Again, it's a balancing act. We are equally concerned with making sure that homeless people obtain health coverage, and we've taken major steps to ensure that they have access. We've taken two kinds of steps --

Mr Frankford: I'm more interested that they obtain health care than they obtain health coverage, and it seems to me that they should. I would say that in fact you are subject to legal challenge, because you talk all about these mechanisms which can hinder by not having the right version. I would suggest that this may not be in accordance with the Canada Health Act.

Mr Decter: No, I would say that we certainly believe -- and I don't know if our legal people are here -- that we are operating well within the Canada Health Act, and I'd go further.

We've invested considerable funding in alternative systems. We've spoken here about the health insurance system, which is a very important component, but it is, after all, less than a third of our total spending as a ministry. We have put significant dollars into things like community health centres that are targeted very much at the difficult-to-reach populations.

Mr Frankford: You must admit that they are very spotty in their distribution. It's very hard to find them.

Mr Decter: There are fewer than we would like, and we're increasing the number of them, but I think it's --

The Chair: We'll give you some time at the next round. We'll have you start the next round. The Provincial Auditor had a couple of questions before we start the final round of questions for today.

Mr Erik Peters: I didn't expect it this soon. I'm just about ready.

Just a quick one to put me almost personally out of my misery: One of the points you just made was that OHIP covered outside-the-country expenditures fully up to 1991. Maybe I misunderstood your comment, but I've been paying Blue Cross premiums ever since I went out of the country as long as I've been a resident of Ontario. Maybe, along with others, you might want to put me out of my misery that I haven't wasted my money.

Mr Decter: I believe that your Blue Cross coverage would have provided some things supplementary to our OHIP coverage even prior to October 1991. For example, we were paying, I believe, 75% of the cost of repatriation, flights, and I think Blue Cross would have picked up the other 25%, and you would see it reflected in your new premium. As of October 1991, the difference between your costs out-of-country and what we would pay changed dramatically. But I think it's fair to say that there have always been extras that you could insure out-of-country that would not have been covered by OHIP. Eileen might be able to give a couple of examples. We want to make sure you got your money's worth.

Mrs Mahood: I'll just give you one clarification on this. First of all, in an emergency situation prior to the new one, we were covering 100% if it was an emergency when you were out-of-country, on invoice, but for non-emergency, we were only paying 75%. So if you presented yourself with something that was considered non-emergent, you needed to have some extra insurance. The other thing was, the rates were related to ward practices, so if you were charged semi-private rates and things like that, that was not covered.

So there always was a valid reason for having some additional insurance, but what it was, how much it actually kicked in, has changed since we changed the rates now.

Mr Peters: I don't want to waste the committee's time, but I broke three fingers playing tennis in Florida in 1984. The medical bill from the hospital was about $1,100, of which OHIP covered only $400 and Blue Cross was asked to pay $640 at that particular point, so OHIP did not cover the 100%, and this was an emergency. I'm a little bit at sea here.

Mr Decter: We're very careful not to discuss individual cases.

Mr Peters: No, I think that's fair enough, but I just wanted a clarification of this statement that you paid 100%.

In any event, I'll get to far more mundane matters. One other question, and maybe in part of the response to our report, you related to the strategic plan. When I, as you appreciate, as a new reader looked at the chart that was presented on page 3 of our report, I noted that the two areas where you did not spend the budget, or spent less than the budget, was in communications to Ontario residents and on the registration kits. In all other areas, the actual costs were supplemented by supplemental budget, and I'm just wondering if, in the strategic plan that you have now, whether there is increased communication with Ontario residents in order to ensure that this point, which has been raised very often, that we have a right to health care, is protected by informing residents of Ontario further as to how they can protect this right by proper use of the health card.

Mr Decter: We have stepped up our communication efforts, and we have, I think, recently sent each physician office a poster that sets out some basic information around this. I think we've also done that in the case of the third-party services agreement reached with the Ontario Medical Association.

We haven't done enough to communicate, and I think it's fair to say that one of the dilemmas we have as managers of the Health ministry is that Canadians have come to expect not only a high quality of care but they've also come to believe that the system is completely comprehensive. In some cases it comes as a surprise to them to find that no, the Canada Health Act does not mean that all services are provided by the health system, that there are clearly medically necessary services, that there are other services that we pay for, but it's not a universally publicly financed system. It never has been, but I think the public has gained some very high expectations, and at times we need to communicate more clearly to have them understand where our coverage begins or ends. We have some difficult cases in the drug program area of that sort.

It is the case that the Canada Health Act came in at a time when hospital and medical services were the vast bulk of the health care system. As we move to more community care, we have some difficult challenges in explaining to people exactly what is covered and what is not covered. But we are stepping up our communication efforts and making available fact sheets to providers and consumers.

Mr Peters: May I have a third, quick question? In part of our report we referred to the benefit of the system, to this projection that was made originally of $1.5 billion over 10 years, and one of the reasons for the benefit that was stated was that it would allow to analyse better the use of health care services. You may just want to clarify a little bit further: There was a question raised, I believe, as to what information you could provide in terms of somebody phoning in and finding out what services were charged against a particular card in this regard, and you said that yes, you could provide the information as to the visits made and what services were rendered, but you could not provide the actual nature of the health services provided because that would be in the physician's records.

Mr Decter: Yes.

Mr Peters: Are there any plans to capitalize on that particular benefit you envisaged?

Mr Decter: Yes. Our major effort was the creation of the Institute for Clinical Evaluative Sciences, a joint creation between the Ontario Medical Association and the government under the joint management committee. We've invested some $4 million a year.

The institute's a year old. It's located at Sunnybrook Hospital, on their campus. It's headed by Dr David Naylor, who, I think I would not be contradicted in saying, is one of Canada's leading clinical epidemiologists. It has a scientific advisory panel drawn from nine of the leading people on the planet in this field. We have a data agreement with them, and the unique health identifier will allow Dr Naylor and his staff to dig in on the utilization issues.

Our main issue here is not that very many of the procedures -- there are some 5,000 fees for different procedures that we pay for -- in our view aren't medically necessary; maybe none. Our problem is that often they're done inappropriately or too frequently. The most celebrated case, I guess, is the Caesarean section one, where our rates of Caesarean sections are higher than the experts think they need to be. What we haven't had an ability to do until we got to this data system and until we had some experts in place is really two things: Is it a problem that a few physicians are doing far too many or is it a problem that all physicians or all physicians involved in that procedure are doing a few too many, and then how do you change the behaviour?


What we've learned is, physicians don't react very well to ministry advice or directives. They want to hear from other physicians about the nature of evolving knowledge in the field. Our effort with ICES, which is the name of the institute, is to have the leading physicians in a particular area convince their colleagues that there's newer and better knowledge available.

I think we'll succeed. The stakes are rather large. The health research community -- and I would include people like the Rand corporation, Dr Robert Brooke and others -- estimates -- and this is not a Canadian estimate; it's a North American estimate -- that as much as 30% of what's done and paid for is inappropriate or unnecessary. Now, whenever my minister says that or I say that, we immediately incur the wrath of the physicians. This is not an assault on physicians; this is simply our best knowledge of what percentage of things, viewed after the fact, might not have been effective.

Physicians quite rightly say: "It's very fine for you to tell me I shouldn't have done that procedure. You weren't there at the time. You weren't facing the issue with the patient." That's true as well, but what we're hoping to do over a comparatively short period of time is bring to bear better guidelines.

I'll give you a very small example. A group of very determined emergency room doctors in Ottawa looked at ankle X-rays. It seems like a small issue. Almost every patient that presents at a hospital with a sore ankle gets X-rayed. These doctors worked up a protocol to say, "You can ask a few questions, you can do a few examinations and you can decide whether an ankle X-ray is really indicated or not." Dr Naylor is now trying that protocol in a dozen hospitals and we think we will reduce substantially the number of ankle X-rays and improve the quality of care.

So it isn't one big initiative, but what the unique identifier and the information attached to it will let us do is, over a period of time with the help of Dr Naylor and the physicians, improve the quality of care by reducing the number of inappropriate services that are rendered. These are not services that are rendered by anyone in a fraudulent way or in anything but the best standards of practice. What's happening is we're facing a revolution in knowledge in medicine. We need to find ways of translating the new knowledge to 20,000 physicians in practice in a way that's acceptable to them, in a way that isn't the Ministry of Health making the suggestions but leaders in the medical community.

I would pay tribute here to Dr Adam Linton, who was a tremendous loss to this province, who pushed for this institute as president of the OMA. So the gains over 10 years and whether they're going to be in the order of magnitude that was suggested earlier I can't tell you at this point, but we believe they will be substantial, that we will get better-quality care and we will get it at a better cost to the total system. But that's where the data are going to come in. Without unique identifiers, that work is made, if not much more difficult, nearly impossible.

The Chair: Mr Callahan, five minutes.

Mr Callahan: Just as an opener, I asked one of you yesterday whether the patch -- you all know what the patch is -- was covered by OHIP, and I was told it was not. I say that for the benefit of one of my colleagues here in the room who thought it was. The question I leave hanging out there -- and it's not for you to answer; it's for the minister to answer -- is that if we have all the data we have on the factor that smoking is injurious, not just to the health of the person who smokes, but also to people around him, why in the world are we denying access to the cost of the patch to those people of Ontario who probably need it most, the people who perhaps are too poor to pay for it themselves, and even those people who can afford to pay for it? I think if we're going to encourage the cessation of smoking, we should be looking into that. In any event, you can't answer that, so I won't pursue it.

Mr Decter: I think it's an Ontario drug benefit plan issue rather than an OHIP issue. I think if there were coverage, we would view it, because it contains a drug, more as a drug than a procedure. I can't honestly answer whether we cover the patch under ODB for eligible people. I can get you that answer.

Mr Callahan: If it is covered, I guess you have to wait till you're 65 before you get it free.

I had a constituent call me up, I guess as a result of watching the television the other day. He's from North York. He indicated that on occasions when he has been asked for identification, the person specifically asked to see his health card, which I thought was rather bizarre. This happened on about four or five occasions. The same individuals were asking to see his health card and not his driver's licence or whatever else he had. That makes me interested in the question that was asked by one of the members of the government. I gather he could ask to receive from the ministry, on his own behalf, a list of the procedures that had taken place over perhaps the last year to determine whether these people had in fact wanted to see his OHIP card simply to use his number in a fraudulent way.

Mr Decter: If these persons were not health care providers, they don't have a right under the act.

Mr Callahan: They weren't. One of them was the post office, he tells me.

Mr Decter: To control the private use of cards issued and numbers assigned to insured persons under the Health Insurance Act, I believe it's illegal in this province to ask someone to produce his health card for any other purpose than the receipt of health benefits. That act, which was given royal assent in April 1991, was very much to prevent what happened with social insurance numbers; that is, their movement from a specific purpose to a general purpose. I believe that person is in fact being asked an illegal question.

Mr Callahan: I hope he's watching. It'll save me answering by mail, but I'll do it anyway.

Finally, we hear every day about partnerships, being linked with business to accomplish things the government wants to accomplish. Here's a perfect opportunity, in my view. Some of the credit card companies out there are suffering; you can now leave home without American Express because it's having troubles. If the Ministry of Health were to enter into a joint arrangement with them, or some credit card company, I'm sure that you could develop significant technology to assist them in putting a picture on their cards, because I think it would help them. At the same time, through cooperative measures, you could share the cost, you could share whatever technique you come up with and save the taxpayers of this province the cost of our having to come up with our own system at a very high cost, I think you told us. The Royal Bank people, when I asked if you'd talked to them, the cost was 15% --


The Chair: I'm having a hard time hearing Mr Callahan. I'll add a couple of minutes to your time, Mr Callahan.

Mr Callahan: Thank you very much. Each time they speak, would you add a few minutes to my time?

The Chair: It's the only way to keep order, I'm sure.

Mr Callahan: I think there's an avenue there for consideration. We are talking about the same type of card, in a sense. The commercial card provides goods, services and money. The health card provides services. If it's not adequately done or not properly done, then we're losing services, we're losing money, we have people who are doctors who are losing fees. Perhaps, if we continue with the question of de-activated health card numbers, I would certainly encourage -- and I'm going to ask my colleagues in their report to suggest that -- that here's a great opportunity to join in partnership with the business community to come up with a card that may be something where the expertise might even be exportable. But if we go it alone and they go it alone, nobody's going to come up with a card that can't be used in a fraudulent way. If we go it alone, the taxpayers of this province are going to pay for the whole shot. We don't need that.


Mr Decter: We have had discussions and are quite interested in continuing discussions with other people in the card business. There are some tough issues, which I guess goes back to your first question in terms of the extent to which the Legislature would contemplate multiple benefits or multiple use of the same card or number for different programs. Again, there's a balancing act between the efficiency goal which would say, "Put a lot of things against the same number," and the privacy goal which says, "We don't want anything to do with people's health information getting commingled with financial information". But we are continuing to have an open discussion with the private sector. We're both wrestling with the tradeoff between cost and service.

We are very interested in the export sector. I should say that under our health and economic development initiative we have been working with a number of Ontario companies to get them to export our expertise. Dr MacMillan, who heads our health insurance division, will be shortly visiting Poland, where an Ontario company has a very large World Bank contract to help them set up a health system. Although this committee has got some very hard questions for us about how we're doing, we have a steady stream of visitors from all over the world who come to see how we do it in Ontario, because they believe we do it as well or better than anyone else on the planet.

I can tell you that one of my most popular outings is to be on US radio or television talking about the Canadian health system, because all you get are very positive callers calling in saying how much they would like a system like ours. Ours isn't perfect, but we've got a lot of countries coming to see us to learn how we do it, and there's some significant benefit to us in keeping an eye on export markets.

Mr Tilson: I have two questions and Mr Wilson has one. As a question to you, Mr Burgess, I understand that your analysis unit ends the end of March.

Mr Burgess: It was a temporary unit which was set up by secondment from other parts of the organization. I have been led to believe that it's been successful enough that arrangements will be made to keep, if not the same individuals, a group of similar individuals together for the foreseeable future.

Mr Tilson: But you don't have a budget. How are you going to do that? There's no money.

Mr Decter: If I might answer that question. We are before treasury board in the coming weeks with our estimates. Until they're approved, we don't have any money for any program in the ministry. Until treasury board renders its decisions, I don't have an ability to tell you what will or won't continue. I will partly support Mr Burgess's comment. This unit, this investment we've made has, in our view, been one that we feel has yielded significant results, but it is the case that until treasury board makes its decision and our estimates are presented to the House I can't tell you that we have any money for anything.

Mr Tilson: Mr Decter, you know perfectly well that there's a great deal of work that needs to be done, and the fact of the matter is that the analyst units are coming to the end of March and Mr Burgess is going to be left alone. I have a feeling he'll have a great deal of difficulty.

I have a question for Mr Hazell -- and then Mr Wilson has a comment -- and that has to do with the computer systems. How many computer systems have you gone through since 1990?

Mr Hazell: How many computer systems have we gone through?

Mr Tilson: Yes, I gather there's been a series of computer systems in developing the health card. Have there been different computer systems?

Mr Hazell: No, as far as I know there's been only one computer system.

Mr Tilson: Has there?

Mr Hazell: Yes.

Mr Callahan: You people got it for us, I think.

Mr Tilson: Has that been reviewed, Mr Hazell?

Mr Hazell: Has the system been reviewed?

Mr Tilson: Has the computer system been reviewed?

Mr Decter: We've recently had an internal audit. In addition to the good offices of the Provincial Auditor, we have an internal audit group. They have recently done a full review of the information systems division and given a report to Mr Hazell setting out their recommendations. In addition to this process, we have a continuing internal process of reviewing with auditors our internal operations. That review was completed when?

Mr Hazell: About six months ago.

Mr Tilson: How much time, Mr Chairman?

The Chair: Sure, I think you have time for another question.

Mr Tilson: Then Mr Wilson will ask the final question.

Mr Jim Wilson: Just going back to Dr Frankford's concerns about accessibility to our health care system, I thought it would be interesting if I read to the committee a very short excerpt from the Globe and Mail of February 17. It's a story by Richard Mackie, "Ontarians Warned to Brace for Further Cuts in Services."

It says: "Ontario residents can expect further cuts in some government services as the province tries to prevent a debt crisis that could eliminate even more programs, Finance minister Floyd Laughren says."

Here's a quote from Floyd: "`I think, in the end, we are going to have to do even more dramatic things than we have done. I don't doubt that,' Mr Laughren said in an interview yesterday.

"`I sure hope we can do it in a way that Ontario will still have a medicare system...."

That's fairly astounding stuff from an NDP Finance minister. I just read that to emphasize how important these hearings are and that any leakage or fraud in our health care system should be avoided, should be rooted out, and that there should be zero tolerance for fraud anywhere in our system and that our duty as members is to protect the taxpayers and the residents of this province.


The Chair: Do I have to add some time to Mr Wilson's allotted time? Is that what I have to do?

Mr Jim Wilson: If anyone's out there from another jurisdiction using an Ontario resident's health card, I hope the message he gets from these hearings is that as members we're very serious. I think our presenters have done a good job of trying to explain the efforts they're making to crack down on this sort of thing. With that I leave those comments with you, members.

Mr Decter: I wonder if I might have a moment, first, to thank the committee. I think that you've asked us some very hard but very important questions. Second, I would like to thank the Provincial Auditor for continuing assistance to us. Third, and I don't get a chance to do this often, so I'm going to take the advantage very briefly, the people who work in the Health ministry suffer many slings and arrows from the public, providers and others. They are -- and I've had the privilege of being their deputy minister now for a little over a year and a half -- a very hard working group of people. I think the public often doesn't see their hard work, but we have in the ministry not only very capable people, but people who are very determined that medicare will not only continue to exist but will be well managed. We will make progress. I want to say that and also to say that we are delighted to be invited by the committee to attend and will look forward to meeting with you at your convenience on this or any other issue.

Mr Callahan: That's a good way to close, Mr Chairman. Let's not ruin it now.

The Chair: I promised Dr Frankford.


Mr Frankford: I'll make a brief comment, and Mr O'Connor also has a comment. I would like to emphasize the importance of a unique identifier. I fully agree that it is essential for a system in the information age. I actually had some experience in this before because I used to write prescriptions on my computer, and in the family number system I made people unique by adding a decimal. It's essential, I think, that there are other approaches which could have been taken, but that's water under the bridge.

I think there is the problem of the non-registered population, which I think should not be minimized at all. I would like to keep on having discussions about that. I think the card issue is somewhat misleading, because I think to some extent it can be argued that we've been sidetracked by technology. It's rather attractive and everyone is used to having cards in their wallet, but I think we are talking unique identifiers.

I think we're being carried along by the assumption that we have a fee-for-service model. At the very least, we have a mixed model now. If you're looking for reporting, the non-fee-for-service system, which is now in many forms -- salaries, capitation, alternative funding, whatever -- makes it quite complex. I think your aim for a reporting system for planning is probably not as straightforward as it comes across. I'll leave that and pass it to Mr O'Connor.

Mr O'Connor: As parliamentary assistant to the Minister of Health, I've only been there since the fall. Any occasion I've had to work with the fine staff from the Ministry of Health, I haven't had any problems. I hope that that will continue. This committee hearing process has certainly pointed to some areas that members are concerned about. You've certainly highlighted some of the ways you're trying to alleviate some of those concerns, with the telephone system, the swipe readers.

I found the discussion that you had between you and the Provincial Auditor very enlightening because it pointed to the important need of collecting data. I think something I'd like to emphasize to the committee for you to take under consideration is the aspect of the moving. I think the ad that you've shown us in your handout is definitely very good. I think getting information out there is important.

I'd suggest that a lot of people in the province of Ontario, when they've got a problem with things, go to their MPP's office. I'd suggest that you send something out to all the MPPs, to members of this Legislature, so they can have that in their office. As members, we're very concerned about the health care system, and I'm sure we'd get unanimous support that we'd like to see that happen. That's perhaps an easy way that we can help out too.

on behalf of this committee, I want to thank you for coming and bringing forward all the information you have available and making yourselves as available as you have. Thank you very much.

Mr Pat Hayes (Essex-Kent): We're very honoured to have you on our committee, Larry.

Mr Noel Duignan (Halton North): Briefly, on behalf of the government side we thank you for coming along here today and say thank you to the staff of the Ministry of Health, who I believe operate one of the most efficient and best health care systems in the world.

The Chair: Mr Decter, thank you and all of your seniors.

Mr Tilson: I have a point of order: Before the delegation leaves, the government side of the committee asked for an adjournment of this committee so that members could attend the funeral of Mrs Farnan.

The Chair: That's correct.

Mr Tilson: That was by unanimous consent. As a result of that, however, we lost three very important hours; I think it would be three.

The Chair: Yes, that's correct.

Mr Tilson: We lost three very important hours on this topic. I have a number of areas that I'd like to cover from the Provincial Auditor's report. I'm looking to you as to how you intend to make up those three hours.

The Chair: Can you give me 24 hours to think about it?

Mr Tilson: I'll give you 24 hours, Mr Chairman. If I could just finish, the reason why I raise that now in the presence of the delegation is because obviously we would have to have the delegation return.

Mr O'Connor: On that point, if I could, Mr Chair.

The Chair: On the same point of order?

Mr O'Connor: On the very same point: I thank Mr Tilson for raising this because I'm sure any questions or information that any committee members might have on this very important issue should be answered. I think maybe the best way we can do it is we'll put a lot of thought into it and perhaps we can submit any questions we have through the clerk to the ministry and ask it to respond in writing, because we sure wouldn't want to miss any important information.

The Chair: Give me 24 hours. On the same point of order, Mr Duignan.

Mr Duignan: Maybe between the Chair and the other members of the subcommittee we can just have a brief discussion of this.

The Chair: Let's see if there are any options.

Mr Perruzza: On the same point: Just to expand on this a little bit, while I'd like to be able to sit and follow up on the three hours that were essentially missed, I would remind everybody that every time we sit here as a committee and every time we drag senior civil servants to appear before the committee, they lose valuable time within the ministry themselves. It costs an awful lot of money to do that. While I know that's an important thing to happen, and while I also know we can submit questions in written form through the Chair to the ministry and get any information we want --


The Chair: Will you let Mr Perruzza finish?

Mr Perruzza: I agree with the point. I think we should be able to sit and deal with these things, but it's also important to note, and I think it should be noted for the record, that every time this happens it costs an awful lot of money to have it happen, to drag civil servants away from their work and for the preparatory time that it takes for them to get ready for these committees. That should be noted as well.

Mr Fletcher: I'd say we wait 24 hours.

The Chair: I appreciate that. Mr Decter, thanks to you and all your senior staff for joining us. The committee stands adjourned until tomorrow morning at 10 am.

The committee adjourned at 1708.