Tuesday 7 September 1993

Annual report, Provincial Auditor, 1992

Ministry of Health

Michael Decter, deputy minister

Peter Burgess, director, registration program branch

Robert Cavanagh, director, systems support branch

Kevan Malden, senior technical specialist

Dawn Ritchie, technical support analyst

Larry Stump, manager, Ontario drug benefit project

Patricia Malcolmson, assistant deputy minister

Subcommittee report


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

*Vice-Chair / Vice-Présidente: Poole, Dianne (Eglinton L)

*Callahan, Robert V. (Brampton South/-Sud L)

Duignan, Noel (Halton North/-Nord ND)

Farnan, Mike (Cambridge ND)

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

Hayes, Pat (Essex-Kent ND)

Marland, Margaret (Mississauga South/-Sud PC)

Murphy, Tim (St George-St David L)

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

*Perruzza, Anthony (Downsview ND)

*Tilson, David (Dufferin-Peel PC)

*In attendance / présents

Substitutions present/ Membres remplaçants présents:

Sullivan, Barbara (Halton Centre L) for Mr Murphy

Wessenger, Paul (Simcoe Centre ND) for Mr Hayes

Wilson, Jim (Simcoe West/-Ouest PC) for Mrs Marland

Wiseman, Jim (Durham West/-Ouest ND) for Mr Farnan

Clerk / Greffier: Decker, Todd

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

The committee met at 1407 in the Humber Room, Macdonald Block, Toronto.

The Chair (Mr Joseph Cordiano): Members of the standing committee on public accounts, we will come to order to deliberate on the matters before us. I trust that everyone has a copy of today's agenda before them. Before we move to the scheduled items for today, a copy of the report of the subcommittee will be coming to each of you. That lists a number of items we agreed to deal with in the two weeks before us. We will have that shortly and we can review that, and any questions about the subcommittee report can be entertained following our deliberations today.


The Chair: Let's move right into the agenda item we have before us. Today we have the Ministry of Health, Deputy Minister Michael Decter, before us. Welcome to the committee.

Mr Michael Decter: Thank you very much. It's a pleasure to be back.

The Chair: I understand that you have a number of people with you. Are they going to be introduced at this time?

Mr Decter: I think perhaps I could introduce them at this time. Maybe they could just stand up so you know who they are: Patricia Malcolmson, assistant deputy minister of corporate management and support; Peter Burgess, director of our registration program branch; Bryan Brown, the manager of the analysis unit in the registration program branch; Larry Stump, the project leader for our Ontario drug benefit project team; Fred Hazell, the executive director of our information systems division; Bob Cavanagh, director of systems support branch in ISD, and Doug Grasse, director of user support in ISD; I'll let Bob Cavanagh introduce two other individuals on his staff when he gets to the demonstration. We also have Karim Amin, director of our audit branch, and Ahsan Sadiq, director of central region claims payment operations. The people not on my list are Gilbert Sharpe, someone who probably needs no introduction to a group of legislators, and David O'Toole is over at the slide projector.

The Chair: Thank you very much. Today's subject falls under section 3.10 of the Provincial Auditor's report, the health registration system. Obviously, you're going to elaborate and bring us up to date about what the ministry has decided to move forward with in that regard. I will leave it in your capable hands to use the time as you deem necessary, and if you think it necessary to have questions asked at the end, I know all members would like to ask questions and if permitted would ask some questions at the end.

Mr Decter: I'm very pleased to have the opportunity to be here. When I was last here in February the then Chairman suggested making me a permanent member of the committee. I'm not sure that I'm yet ready for that.

The Chair: How about a regular guest appearance?

Mr Decter: A regular guest appearance might be something.

This is obviously an issue of great concern. I guess the first thing I should say is that in the scheme of things there's no group as eager to eliminate fraud in the health system as those of us who work in the Ministry of Health. We have rather more demands on our resources than we have resources to meet those demands, and therefore anything that's helpful on that front is very appealing to us.

There has been a lot of activity since February, and I thought what I'd do is walk through that. I did mention Mr Cavanagh earlier; we have brought along a couple of the pieces of technology that we're introducing into the system so that you can actually see what they look like and how they work rather than taking our word for it.

I think we take a broad view. I know it has been the case that there's been a tendency to label this issue, at least publicly, as health card fraud. I think that's an oversimplification. Our view in the ministry is that we're concerned primarily with financial management, that fraud is not just something related to the health card: that we have fraud that is related to the health card and we also have behaviour by providers that is fraudulent, we have a whole category of what we would term inappropriate use or inappropriate utilization of the system, and then we have some issues around the bills going to the right place, both the third-party bills and also the federal-provincial bills or the federal bills. There's a tendency to pull it all in together, and I want to be careful today to try and separate those issues because they have different remedies, in our view.

I think you have the package, but let me walk you through the background and give you a little overview of the presentation: first, the events leading up to public accounts; second, a summary of recommendations from the Provincial Auditor's report; third, an overview of financial management in the ministry; fourth, financial control measures; fifth, fraud control actions; and sixth, our agreement with the OMA which was recently arrived at.

First, on events leading up to public accounts, I probably don't need to remind this committee, but I will anyway, that we have followed, as a ministry, a number of reports from the Provincial Auditor.

The 1987 report was the one that underscored the concern with the family-based OHIP number and the reality that at that point there were 25 million numbers, if you like, outstanding, about two and a half times that of the population; I guess a little bigger than that.

In 1989 was the elimination of OHIP premiums.

In 1990, individual registration begins.

In 1991, health numbers were required for health services. I think this is a very important point to underscore. We had worked for almost two decades significantly on the honour system, without much concern for directly linking the possession of a card or a number with one's eligibility for service. It's been since the new registration that we've been able to draw a much tighter link between eligibility, your card, your card number and services.

In 1992, the registration program branch was established. The Provincial Auditor identified concerns with the registration system. We were here in February setting out some of the directions we were going. We received -- I have to look at the date -- I believe in March, the registration analysis project, the project completion report. I believe that's been provided to you.

I can take you back to the auditor's report of August 1992. Just to reiterate the Provincial Auditor's finding: "The new individual-based registration system is the cornerstone of the ministry's plan to reshape Ontario's health care system. Without effective controls over the accuracy and completeness of registration information, the province's investment is at risk." I agreed with that statement at the time and I still do. Our efforts have gone to ensuring that the investment is not at risk and enhancing the accuracy of the system.

Let me say that there are two opportunities here, if you think about it. One is at the point of service, where an individual, eligible person or ineligible person, is seeking to have some health service. The other is at the point of registration. Again, I think we need different approaches and are proposing different approaches there.

Just to look at the auditor's comments specifically, the first comment was that we had based, as a ministry, the re-registration or the registration on, to a significant degree, previous OHIP information to verify eligibility. Our response at this point -- when I was here last we were not as far along in thinking about a photo card; I believe my minister in the House in July also said we hadn't taken a final decision.

We have taken a decision to add a photo to the card and to move to a renewal cycle. We're not yet there on all of the security features of the new card -- and I'll come back to that -- and the cabinet has not yet been presented by our ministry and minister with a full set of recommendations. I will say on that that we're going to take a little time and make sure we've got it right and that we've consulted the leading people in this field, both in Canada and internationally, before we move ahead on the photo card.

Other criticisms raised:

A lack of formal processes to update deaths: We have instigated an exchange with the registrar general.

"Update addresses" I think is, at the moment, our biggest weakness in the registration program. We have the possibility of exchanges and we have an address communication campaign, but it's fair to say of the information we have on each individual that the address is much more likely to change than the gender or the name, and therefore keeping the address linkage, developing it, is quite important.

There was criticism that we had made a slow start in investigating the accuracy of data. We've done a good deal of work there to accelerate that. The reports you have I think underscore that.

The next point was a very live point when I was here last, and that was the gap between the number of registered persons and the population of the province. On that side, Statistics Canada revised its estimate of the population of the province. I'll come back to that issue, but essentially we were reducing the number of eligible numbers by our work on removing people who were deceased and so on, but the major impact since February was that Statistics Canada decided there were significantly more people in this province living and eligible than it had previously felt.

Finally, insufficient controls: We're working on this both on the short term, in terms of tightening controls, and also with the photo card and a renewal cycle.

Let me step back to the overall issue which I spoke to at the beginning, because I think it's important for the committee to understand that reducing fraud, while important, is only one aspect of dealing with financial management of the health care system. It's an important element, I think it's fair to say it's one that has caught the public's imagination, and clearly a number of the provider groups have become quite vocal on this subject. I will say, although it's not been the happiest issue, in some sense, for us as a ministry, that we welcome greater attention to this, that we're hoping that that greater attention will lead the 300,000 people who work in the health care system to become our allies. I believe the OMA agreement is indication that one of the major groups is now willing to roll up its sleeves and help us solve this issue.


The utilization issue needs to be tackled in a different way. This is not an issue of ineligible people accessing the system; this is an issue of eligible people for a variety of reasons -- some consumer behaviour, some provider behaviour -- excessively utilizing the system. We're tackling this with a public education campaign. We've chosen some test sites for the campaign. We have the cooperation of the medical profession, other providers. This is really a matter of dealing with the reality, for example, that the number one reason people visit a doctor in this province is the common cold, even though it's not something that doctors can, by and large, do very much for. So we're looking at how to convince people not to go to an emergency room when that's inappropriate, not to rush to the doctor when they have a self-limiting illness.

On the provider side, the institute that David Naylor heads, the Institute for Clinical Evaluative Sciences, which I spoke to when I was last here, has started to produce some very good research work which we're hoping to see translated into a change in provider behaviour.

Finally, the whole area of supply, and I know this has been an issue with some turbulence publicly, but if you don't have the system scaled to the right size, and the nature of the system we have put too many physical resources out there, there's a tendency for them to be used, and in that sense if we don't get the number of providers right, don't get the system built to the right scale, we are also not managing the resources.

So there has been some blurring of the edges between fraud and overutilization and we think both are important issues to tackle, but they have significantly different approaches. I guess it's overall worth noting that after a period of quite rapid growth from really the inception of medicare but certainly through the 1980s, the ministry budget pretty much tripled, we've had a plateauing of growth in recent years and a greater concern with allocation of resources.

Again, just a note on the financial controls: We have a very active internal audit group which Karim Amin heads and which does a good job of recovering funds. These are not funds that have been fraudulently obtained; these are funds that are the result of overpayments. They recovered from labs, nursing homes, hospitals, just under $8 million in the last fiscal year. There was another $20 million of unspent money. In some cases we advance funds and audit to find out whether they've been needed for the purpose. We have also had some recoveries through the medical review committee from physicians, and you will know that we have a bill before the House to expand the medical review committee. The auditor noted in 1990 in his report that because the size of that committee was set in statute and hadn't changed for almost two decades we had a bottleneck in our system and a three-year backlog. The amendments to the Health Insurance Act in Bill 50 would allow an increase in the size of that committee, allow us to clear up the backlog and, frankly, to increase our recoveries in that area.

We also have three areas where we have a great deal of money that is not paid out based on thresholds and rules we have in place -- thresholds in the case of physicians, lab discounts in the case of labs, and medical rules in the case of OHIP -- so there is in excess of $200 million of pre-payment controls.

Let me turn now to the fraud control actions. Just to note them, we have had 193,000 cancellations of eligible numbers; 182,000 are deceased persons, so our major progress has been getting that aspect of the system cleaned up. There have been also investigations of eligibility and duplicates. A major step forward for us was to establish a new unit. It just came into existence recently to look at fraud. I think there it's important to underscore in a sense how important it is for us to do our investigative work with some professional guidance. The point of the unit isn't that people in the program areas can't identify suspicious billings or potentially fraudulent billings, but for us to get convictions we need that evidence to be gathered in a manner that is sufficient to the test of the courts.

We have retained Lindquist, a major forensic auditing firm, to give us some advice on both where the loopholes may still be and also how we should link our investigative unit to various police authorities. That's going to be very important for us to have those linkages so that we get prosecutions. I make no criticism of police forces, who are stressed in terms of their resources, but there has been less emphasis on, I think, what would be seen as white collar or victimless crime than on some other forms of crime. In our view, it's not at all victimless. Someone who steals from the health care system is in fact stealing from ill people and elderly people in need and that, to us, is an extraordinarily savage assault on the quality of life here.

We have reporting. We have a toll-free line. We have had some amount of business on that toll-free line. I think we've captured some amount of media interest on the issue, and that's led to a greater amount of reporting than we'd had previously.

The investigative unit will give us the ability to do something with that suspected abuse in a way that we hadn't in the past. We have had some charges laid, frankly, just recently, in a Kingston case.

I won't go through the nearly 100 pages of the agreement with the OMA. I will say that it does represent a new partnership between the ministry and the OMA. Embedded in the agreement are a number of things we'd intended on the card front.

The major achievement is to get the physicians, who after all are at the front line, to retrieve and return invalid cards to the ministry, and we're going to also have a pilot process on fraud. In our discussions with the OMA, their concern was protection for their members, protection so that they wouldn't be violating confidentiality in making a report, and also insurance that we would be able to provide them with timely information.

In terms of current status, a number of items here. I won't read the list; I'll just plunge in.

On the registration reconciliation: I spoke to one aspect of it. If you think about it, there are really two aspects to this. The first is, how close does our eligible persons list conform to the population of the province? As I say, we spent a great deal of time in February on that issue and our mission there is to have the same numbers of cards as there are eligible people in the province.

With the revision of the population by nearly 600,000, as of June 1, 1993, we are now within 100,000 of the population estimate, and I think you can see on a chart that we've closed that gap significantly. This was, I think, at one point, if one remembers numbers, the 1.4 million gap that is now down to something on the order of, if you look at those numbers, 100,000.


The second part of this whole reconciliation process was to look at a large number of specific areas where we might be vulnerable to fraud, and that's what's reflected in the registration analysis project report. So there are sort of two sides to it.

I will say also that the upward adjustment of the population is not simply an academic point for us or a point related to this. There were significant federal moneys that flowed to the province as a result of the recognition of the larger population, including some winning of debates by the province on temporary residents and some other long-standing issues that Ontario has sought proper compensation for.

I don't know if at this point I should ask Peter Burgess to come up and maybe we could look at briefly the verification activities, because I value his expertise on it and, if we do a careful walk through, it may help on some of your questions.

Maybe, Peter, you could walk people through the detail of the verification activities just so they're clearer. That's the chart that's up there on verification.

Mr Peter Burgess: Surely; let's try. We've done, within the verification unit, a total of fractionally over 4,000 relatively detailed investigations. We actually timed, over the space of a week, a number of different investigations that we were looking into. The average -- and like all averages, it's somewhat misleading perhaps to talk about averages, but the average is in excess of three hours to do each one of these. If you get really lucky, you can do one in about 20 minutes; if you get really unlucky with some very difficult names, spellings and so on, it can end up taking weeks.

We've done a whole series of investigations with the 17 people in the verification unit that are primarily handling these investigations. We have to date cancelled some 2,300, and that's about, as you can see, a 52% ineligible rate.

I hasten to add that these are started upon based on a number of factors. Either we will have sent out some sort of verification letter and have had back either no answer or answers that lead us to want to find out more information. They may be based on tips, phone tips from next-door neighbours, phone tips from friends of the family and so on.

We also looked through our activities with Immigration Canada at some number of individuals that had been deported. We were not getting notice of deportation at the time that the deportation was taking place through Immigration Canada. We set up a pilot, and through the auspices of Immigration Canada here at the airport in Toronto we are now getting notification of certain individuals over a pilot period that they are deporting. We are then able, of course, because clearly the individual is no longer resident in the province, to cancel coverage at that point.

In terms of border residents, we've again, by mail, done a survey of some 21,000 border residents, primarily in the Windsor area, although there are others, but primarily Windsor. We have had a variety of interesting returns, to say the very least, and we've cancelled, as a result of the information provided to us, 43 coverages of the individuals who self-confessed to be residents of the US.

In addition, we've decided that if mail is returned to us we will cancel coverage, so the number you see there of 23% is as a result of getting no response from the individuals who were being asked to complete the survey.

Duplicates elsewhere: The deputy has given a number of duplicates that have been removed from the system. We have processed what we term "easy to find" duplicates. It's actually a misnomer; it only means they're somewhat easier to find than others that are very, very hard to find. We scan our database, all 12 million entries on the database, and we look for a match based on name, sex and date of birth, with two different health numbers. We then look at those health numbers to see in fact if they are being utilized. We then process again through the verification unit either a cancellation to one of that pair of numbers or we do further investigation. We have some 22,000 in the pipeline.

In terms of the death notifications, as the number says, we've processed in excess of 182,000 which we've cancelled. These are exact matches with the data that are sent from the registrar general. Unfortunately, the data the registrar general sends is, in many cases, not suitable to match against out database: Our database operates based on name, sex and date of birth; in many cases, the information on the registrar general's file only has date of death and does not have date of birth of the individual. That means we have a certain number, some 25% of those we receive on a regular basis, that we have to further investigate. On a regular basis, again speaking in averages, we get about 10,000 death notifications from the registrar general on a monthly basis; about 2,000 of those are required to undergo further investigation by the analysis unit, again a relatively time-consuming operation.

Mr Decter: There's just some further detail in a number of pie charts on that giving you an idea; for example, on the registrar general death notification, just under 70% are a system match and you have some that are a manual match and a few go on.

Mr Burgess: If I may, Deputy, the interesting number there is not only the 13,000 that are manual and matched; it's the 30,000 that have been manually looked at, reviewed and, unfortunately, not able to be matched against our database. That means, in most cases, that the individual who has since deceased was not registered with us at the time we registered the population between 1990 and 1991. They are in the hopper as 29,900, a backlog of 30,000 any way you look at it.

Mr Decter: If I could move to, in terms of current status, changes to the health card --

Mr David Tilson (Dufferin-Peel): Mr Chairman, we appear to be going through this presentation in sections. I'm wondering if it would be more useful to ask questions after each section is finished, as opposed to waiting for the end.

The Chair: I leave it up to the entire committee to deem what is its desire in how to proceed. I think that could be useful. We have the deputy back tomorrow, and we could proceed in that fashion. We don't necessarily have to deal with the entire report today; we could deal with it in stages. That's one suggestion. I want to get opinions on that.

Mrs Barbara Sullivan (Halton Centre): Frankly, I would prefer to have the deputy walk through the system with his officials, because I find that already several questions have popped up from Mr Decter's comments which have led to either further questions or eliminated other questions in the second presentation. From my point of view, I think we could narrow our questioning or expand our questioning more readily if we have the full presentation today and, if Mr Decter is generous enough with his time, tomorrow, to ensure that we have adequate opportunity to go at him.


Mr Jim Wiseman (Durham West): Sounds good to me.

The Chair: I am tempted to proceed in that fashion, more or less, but if there is consensus to do something else, I would entertain it. Otherwise, we'll proceed in the way we're proceeding: You would go through the entire presentation and whatever time is left over, we could use for questioning, and if not, we'll move into tomorrow's session as well on the same basis.

Mr Decter: Just to speak to that briefly, I think we can get through the presentation with still a good deal of time today for questioning. I understand that I'm with you tomorrow morning. Tomorrow afternoon I'm up against an airplane flight towards the end of the afternoon but we've sort of organized it so that staff will be here if there are further detailed questions. In the member's words, you will have plenty of time to have at me, but I think we may be able to answer some questions by doing the presentation and that may give you more focus to where you want to go at us.

The Chair: Perhaps we can proceed.

Mr Decter: Changes to the health card: We don't see the photo card moving directly from the current situation. We are going to try and squeeze as much additional benefit out of our existing investment as possible. Just to remind members of the committee, one very constructive suggestion when we were here last was that we move to a full legal name, and we have done that. We have also looked at putting expiry date and the version code, actually indicating that it is a version code, to eliminate confusion; as the slide indicates, we're ready for that as of later this month.

On the subject of the version code, as you'll recall when I was here in February, we had just indicated to the profession that they would have to resubmit in cases where the claim was against an ineligible number. We have since February rejected 5.7 million claims with a value of $105 million. Before people think that's a saving, the vast majority of those claims were successfully resubmitted, often within the same billing cycle, with valid numbers or with correct version codes. It has had the, we believe, positive impact of getting the health number and the health card into the interaction at the point of service, and we believe we have effective control through this of the 1.7 million inactive cards.

We've also eliminated the payment for claims against inactive cards. The graph shows -- our view was that there would be, as you'd expect, a big blip at the beginning and then a fall-off; I think I'd use the percentage 3%, and it has in fact come off to about that level. This is not something the profession was very happy with because it has meant some additional work on their side, but we have tried to help them.

Perhaps I could ask Bob Cavanagh to fire up our little demonstration over here and let me speak to automated verification systems -- or it might be safer to let Bob speak to automated verification systems. Just a general comment: Frankly, we do want providers, whether hospitals or pharmacists or physicians, to make sure that what they've got is a valid health number and an eligible person at the point of service. We also don't want to make that solely their problem, so we've been looking at automated verification systems on a pilot basis as a prelude to moving forward on a system basis. We are committed to having technology in 50 hospitals -- that would be about a quarter of the hospitals -- next year and 50 more the year after. If it works well, we certainly may go faster than that. With that, let me ask Bob Cavanagh to take you through the technology.

Mr Robert Cavanagh: Basically, we're going to show you two different pilot systems that we're running today. We've been running these for the past couple of months. We're in the process of evaluating them right now and we will hopefully find the things that we want to change on them and finally get them rolled out into production use.

Mr Robert V. Callahan (Brampton South): I presume we're going to be looking at that. I wonder if my colleagues opposite could maybe move down a bit or move out so we can see it.

Mr Cavanagh: The first demonstration is totally audio, and then perhaps we can shift around and get it available.

The Chair: As the visual becomes apparent, we'll make arrangements for that.

Mr Cavanagh: There are two approaches taken by these pilots. One is using what's called interactive voice response technology. It's very simple for the health care provider to use, as all that's required in the remote location is a touch-tone telephone. We're going to be demonstrating that for you. It's aimed at the provider who has a relatively stable practice, does not have the need to check every health card that passes through the practice, but every once in a while has some new patient they wish to verify.

The second pilot uses card swipe technology similar to what's used in credit card verification, and it's aimed at the higher-volume use, definitely hospital emergency rooms being the most obvious example, but many of the larger clinics that have perhaps a more volatile patient base will opt for this approach. Both have their place in the final solution, so we're not evaluating one against the other; we do believe that both have their place.

In actual fact, what we're demonstrating is really one and the same. It's the same transaction back into the registered persons database. We are simply putting different front ends to access it, which is appropriate for various types of medical practices and locations.

The system you're about to see is using components that are already in use in government. We tried to piggyback as best we could on what was available, minimizing overall costs.

The interactive voice response system: I'm going to have it demonstrated first by Kevan Malden, who's one of the developers of the system. The voice you're going to hear from the automated system is actually the other developer of the system, who isn't here today. Kevan, would you like to give us a demonstration of the system?

Audio presentation.


Mr Kevan Malden: It does seem sort of complex with all the keys. I'll go through another one that I'll do fast as you get used to it.

Now it's actually doing the query. It'll go to the database and look.

This obviously hadn't planned on getting this far, but -- this is sort of always going to happen. Because it's live, because we didn't go with the test side of this, this is going to happen to me. We're going to try this again. What I'll do is I'll do a number that actually exists this time.

Does anybody need to see another one? I can do another one if you'd like.

I'll just hang up on it.

Mr Callahan: Will anybody be getting busy signals while he's doing that one? How many accesses to these are you going to have?

Mr Cavanagh: Right now there are four simultaneous ports and they're being expanded. Part of the work on the pilot is to determine just how much usage the average provider makes of this so that we can do the kind of provisioning studies that need to be done to determine how many ports will have to be available.

Mr Callahan: Because any of the 1-800 numbers that have been instituted, constituents tell me they can never get through to the thing; they're constantly busy.

Mr Decter: There is a call abandonment rate problem with many government 1-800 lines, the health one as well; they're hard to get through to. I just note the reason for doing the pilot was to get the scale right.

This is not the only source that providers have of updating their records. We've been sending back with the monthly remittances for two and a half years now a listing of all of the eligible and ineligible numbers so that an alternative route for physicians -- for example, someone who's turned 65 and they've got it showing as ineligible -- is to have their nurse phone Mrs Jones and say, "Please bring in your new health card or give us the new number over the phone." So there's also a feedback loop in terms of the billings.

Maybe we should show you the swipe reader. It's a little quicker as a technology.

Mr Cavanagh: Just to complete the IVR portion there, needless to say we'll be making some revisions to it. I think you could all see areas where you could trim down such a transaction, but in actual fact, the quick survey we've done of the providers who are using the system has had quite positive feedback on it and virtually no comments about the verboseness of it. I think the system is designed to prompt you to the nth degree and then allow you to bypass that prompting as you become more familiar with it.

We'll move on to the swipe reader that will be demonstrated by Dawn Ritchie. Dawn, are we connected to the --

Miss Dawn Ritchie: We're just going to be dialling up here.

Mr Cavanagh: The system right now is using the government network, where we dial into it from the public network. It's not a production-ruggedized approach. It's certainly not something we would roll out to a large number of sites. The three hospitals that are currently participating in this pilot are dialling into it first thing in the morning and then they leave it connected and they can operate through the day with it.

We're just in this process of getting this connection in place now. Dawn will identify herself to the system, go through our security controls and then we'll be ready to run the demonstration.

While we're waiting here for the service to be initiated, what we're actually demonstrating here, visually, will be something that would be duplicated in the final production version. What we're working on actually is a better network connection which will be much simpler and much more cost-effective to roll out to the hospitals and to other providers.

Are we ready, Dawn?

Miss Ritchie: Yes, we're ready. We've got our screen up here. Basically, I'm just going to take your average health card and swipe it through the card reader. It's going to pick up the health card version code combination from the card and process a query. In this particular case it was yes, the health card version code combination is valid or is okay. We're back now to our main screen, ready to swipe the next card. It happens very quickly, and yes, the health number version code combination is okay.

Mr Cavanagh: We have about a half-second delay time in the processing of the transaction. The rest is the time it takes to move the data through the wires.

Miss Ritchie: In case your card is invalid or the health card number version code is invalid, then of course we get the message back that no, the combination is not okay. Then we're ready to do our next query.

Mr Cavanagh: The answers to these questions are very simplistic and are a result of some perhaps reticence, initially, and concern about freedom of information. I think a lot of that has been resolved now and our production version will probably give a little more useful information, perhaps indicating to the provider the reason why the health number and version code are not valid, which may be of some further help to the provider in resolving the difficulties.

Thank you, Dawn.

Mr Decter: The other technology we brought along is our point-of-service terminals, which are more likely to be what would eventually roll out. I don't know, Bob, if you just want to hold them up.

Mr Cavanagh: Yes. Perhaps David could do it over there. In the eventual system that we're designing, it's designed to be used from both this type of terminal -- you can just pass two of them around. I have three units that we've just borrowed from several vendors who are very eager to get our business. The two that are coming around are examples of Visa-like terminals that could be programmed to operate with our system. The third one, which you can actually go around and play with a little bit, is a smart phone that has a touch display on it. It would be capable of much wider use in terms of health Encounter information collection. They range in price from a few hundred dollars to about $1,000, so they're not terribly expensive in terms of today's technology.

Mr Callahan: How much?

Mr Cavanagh: The smart phone, I understand, in quantity, would be under $1,000 each.

Mr Callahan: I notice that's an American company. Is it made here in Canada?


Mr Cavanagh: I don't believe that any of this is made in Canada at the moment, to my knowledge. These are just examples that we could bring along just to show you. We're not particularly recommending any one approach here. As a matter of fact, probably the approach we advise for most providers would be to put the card reader on their own internal office systems and have those systems connect in to make the query, and that way their records get updated at the same time they're doing the query through to us. Everything we're doing on the production system is designed to work that way, so you'll have a range of options from connecting computer-based systems that are there already back in to making a query or using one of these standalone devices, at the choice of the health care provider.

Mr Decter: The other end of this is automating the billing system itself. On the fee-for-service medical provider's side, we have achieved a bit of a milestone. After I guess a decade of this being an issue, the government took the policy decision about a year ago that there would be a 50-cent-per-claim charge for submitting paper claims as opposed to machine-readable input. At that point, if my memory's correct, we were down around 70-something percent of the claims coming in machine-readable. That's jumped, not surprisingly, with the charge, and as of the end of last month we were around 95%.

There are several advantages to that: (1) We have an enhanced accuracy. There were far more errors on the paper claims than on the machine-readable. (2) We had a good number of people in Kingston doing keypunch and we were able to not have that allocation of staff.

The next step here is to move to a direct file transfer which would speed up feedback. Essentially, this is a process of allowing the billings to come in machine-readable and feedback to go back to the provider.

The other big piece of this, and I'm going to ask Larry Stump to speak to it briefly, is that we're into the implementation phase of an automation of the Ontario drug benefit program that is wiring all of the pharmacies into real time, which will have some significant benefits not just for the drug program, but for our ability to cross-link to the rest of the database. So maybe, Larry, if you'd like to --

Mr Larry Stump: I have overheads. Can I talk to them?

Mr Cavanagh: Sure, why don't you do that.

The Chair: Perhaps you could be seated and someone could assist you in changing over from one seat to another. That way you could be heard right into the record.

Mr Decter: Just to give you kind of global numbers here, the drug program this year will be about $1.2 billion in spending as against physician claims, which will be down to about, depending on how we do, somewhere between $3.7 billion and $3.8 billion. For the ministry, after hospitals and doctors, the drug program is our third-largest area. The second-largest area is fee-for-service billings.

Mr Stump: I guess I have to say I am as nervous as a cat. I figured that I'd have probably another year or so before I got invited by the Provincial Auditor to appear before this committee to tell you what a good job we did in 1993. But I welcome the opportunity to bring you up to date on what we're trying to achieve and some key areas that we think we've done some innovative work in.

The Chair: We'll make that a date now and set a time for it.

Mr Stump: I'm not sure whether, by the end of the presentation, you'll ever invite me back, because you might not be able to get rid of me. I get very excited about the project and I will tend to ramble. I'm based in Kingston, and I'm planning to go home after this meeting, so if I'm not breaking protocol too much, then I would invite you to interrupt and ask questions as I go through the foils, and I would be glad to expand as much as you'd like.

The Chair: On points of clarification only, I might add.

Mr Stump: You mean I can't sell all day long? I guess many people are calling it the network system, and as much as we'd like to call it the Ontario drug programs project, to set a focus on it, the first phase is largely to deal with community pharmacy. As time passes, we expect to get involved with the hospital association and with the OMA in terms of prescriber information. So our focus over the past 18 months has been on community pharmacy, and what we're trying to do -- and our first partner was brought in early in the project, and that's the computer and telecommunication services division of Management Board secretariat. So we're working very closely with them on the telecommunications aspect.

We've gone out to tender and had a very exciting exercise in doing that and acquired some private sector participation to put in the adjudication system and help us with implementation of the system and the network. Some of the things that we're trying to do to get up to the 20th century. Our existing system is as old at the medical system, about 20 years old, and it's not doing much in terms of improving our efficiency or the quality of care. That's something that we believe very strongly, that automation can do that, and I think that we've been encouraged over the years by both the OMA and the OPA and many people in health care to work on the drug situation because it's a fast-growing expense and it's also a very dangerous product that we're dealing with. Many seniors are not only helped by drugs; they're also hurt by overuse of certain products because of a mix of services provided by different physicians that nobody is completely aware of.

So what we're implementing is an on-line adjudication system where, if you're serviced by the Ontario drug benefit program, for example, and you go into the pharmacy, you'll present your health card, they'll swipe it or key it as they see fit, they'll enter the information regarding your prescription, the prescription number, the quantity, the drug that's being dispensed at the time, and it will travel over the telecommunication system to the ministry's house computers, where it will look up, verify the eligibility of the person for the particular drug, the program that they're eligible under, will check against prescription history and make sure that there's no potential drug interactions based on other products that are currently being taken by that individual. So we're doing the adjudication, the drug interactions.

At the same time as dealing with the point-of-service system, we're also building a much more flexible management structure to identify where our $1.1 billion is being spent, whom it's being spent on, whether it's being spent appropriately, whether the right people are getting the right medication at the time. There's a lot of work going on in my boss's office in the drug reform secretariat, to look at drug use review and determine with all of our partners in health care in hospitals and medical associations and pharmacy, what the right regimens are for drug therapy. The new system will give us an unheard-of ability to do some of the analysis that Peter Burgess has talked to you about in terms of registration on a very massive database. We process 42 million claims annually for the Ontario drug benefit program for drug use review activities. I guess five years is considered a normal amount of data to retain, so we're talking about 240 million to 250 million records that we'd have to examine to do proper analysis.

For some of the studies that they would like to do longitudinally, they're talking about 25 years' worth of data to really look at it properly. So we're looking at enormous databases that make our registered persons database pale in comparison, but we're also looking at new technology in order to be able to deal with those data.

We're registering new network users and have a strong emphasis on access and security and our audit branch is working very closely with us to make sure that we don't make any mistakes in that area. I think one of the questions I heard a little earlier was about government 1-800 numbers, and we as well are implementing a dedicated help desk. We're expecting that we're staffing at the correct level to make sure that we have an abandonment rate that is tolerable by pharmacy because we will have a customer standing on the other side of the pharmacy counter, waiting to get their drugs, and presumably, they're sick at the time.


Mr Decter: If I could just underscore that, the big advantage of this system is, it's going to be in real time. You will go into a pharmacy with your prescription. They will test your eligibility in real time while you're standing there. So it's going to allow us to have information there at the point of service in a way that we really haven't had in this program in the past. It also gives us significant benefits in terms of -- if you think about it, the group covered by ODB, particularly seniors, are the group that use the largest amount of health services in the province, so it gives us a second database, if you like, on those individuals. Sorry to jump in.

Mr Stump: That's okay. Please jump in when you think it's helpful.

One of the other things that I don't have on the slides is, we are going to try to help out with collection of address updates for the registered persons database for the population that's served by the Ontario drug benefit program. The Ontario Pharmacists' Association has agreed on a voluntary basis to provide that data. They do collect it at the store level right now as part of the prescription drug act. It requires them to keep a current address, and they've offered to share that with us, which is most helpful.

To put the program into context, we've got, I think, a $1.1-billion program right now. Over the past 10 years, the costs have been rising at 20%, and I don't think that's sustainable in the current economic situation, nor is it desirable. The $1.1 billion is the government's share of pharmacy in Ontario. I think the entire retail pharmacy or community pharmacy business is about $4 billion to $5 billion a year. That includes their over-the-counter products and other miscellaneous merchandise they sell.

There are 2,500 independent businesses that the government deals with, scattered in every corner in the province, from large centres to very, very small ones. There are probably close to 50,000 people working in the community pharmacies, so we're going to have an effect on 20% to 25% of their business at least, and it will be very dramatic on not only the business but also on their staff, training. We'll talk a bit more about that later.

There are about 2.5 million people covered under Ontario drug benefit programs, and that's including the senior citizens as well as social assistance recipients. But 6.7 million have third-party or private insurance, and I'll tell you why we've introduced that topic when we get to the next foil.

This is one that I'm going to have a hard time talking to from here. At the top -- I still like to dance around -- of it, you'll see that we've identified either third-party adjudicators or major third-party insurers who are covering that population of 6.7 million. We've partnered with this group, which represents essentially all insurers who offer coverage in Ontario or Canada for drug packages, to share network facilities so that the pharmacy, one of those 2,500 businesses, doesn't have to deal with a multiplicity of people to update their computer systems in order to deal with the Ministry of Health and then to deal with Green Shield or Shared Health or any one of the people up at the top.

So one of our objectives early on, when we sat down with the OPA, was to reduce the complexity at the pharmacy and to reduce the complexity in establishing an electronic link-up, not only with the Ministry of Health but with other insurers. So we're pretty excited about getting everybody on board.

We will represent 40% of the claims submitted electronically. The private sector marketplace has about 15% of its claims coming in electronically now. They expect, as a result of the penetration, to increase that, either at least double and perhaps as high as four times in the next two to three years. They also expect to move most of their business to an electronic format. So they'll be joining us in terms of re-engineering their businesses so that at point of sale not only is the public coverage checked but the private coverage will also be available. They're helping us out with the cost of implementation on this, so we're very excited in terms of making some of our cost savings targets.

Down below the cloud, which I guess is a commonly accepted diagram for a network, and to the right you'll see a box labelled a Propharm processor. There are actually four groups that have decided to set up their own private network to service parts of the pharmacy community, parts of the 2,500. There are Propharm, Krollnet, the PIN network and Big V Pharmacies. So for strategic business reasons, they said: "Well, we don't necessarily want to use a government network. We would like to set up a network to service our customers. We believe that we can add services to that network that are exciting to pharmacy and also create new business opportunities for the software developers and network companies." A Propharm example is wholesale drug ordering: In their network they'll be able to order their drugs electronically through an EDI-type facility from a drug trading company.

Equally, they've said any person who's on the ministry network or any other network will also be able to use that service. There's an opportunity for them to build new services and deliver them to pharmacy because of the magnitude of the project. Anybody who cares to can also join a ministry or a government network, which is the left-hand side.

I see some puzzled faces, so I'm more than welcome to answer questions. I sometimes go too fast.

I guess the message I was trying to pass out there is that the ministry in this endeavour is working not only with the OPA, with the 2,500 businesses; we have a number of pharmacy chains that we've been working very closely with; we have software developers. There are approximately 40 software developers that have to change their systems to work with the ministries and with the private insurers, and there are about 10,000 people out there who are going to have to be trained to interact with this system.

One of the most exciting things that we found is that all of these people working together can find a solution that provides a big win for government -- we're achieving the objectives we set out to do; a big win for pharmacy -- they're solving some of their business problems in terms of dealing with insurers, some of the technical complexity; and the insurers themselves are also being able to re-engineer their businesses, and we hope to be able to deliver that at less cost than we had originally anticipated.

The Chair: Mr Wilson had a point.

Mr Jim Wilson (Simcoe West): I guess a point of clarification is, the government has committed $72.5 million to this system, and the deputy mentioned in his remarks just a few minutes ago that, really, you are establishing a second database. I assume you're here today to tell us how your database fits in with the health card database.

Mr Stump: It's not a second database. I guess where we exchange data between the two databases, for example, because of our link with the pharmacies, we'll be collecting the address updates, passing them on to the registered persons database and we'll populate our database from the registered persons database.

One thing that we want to be careful to avoid is a duplication of data maintenance procedures, because as soon as you have two they're going to get out of sync and then we'll be back here in another year's time saying, "Why does this database say this and that says that?" So we're being very careful to make sure that we have a single flow of data.

Mr Decter: I should have said "second system" or "point of service" rather than "database." I'm not as good on the technical end of this as I ought to be, but it does give us that second source of information, but as Larry's pointed out, not to develop a second, standalone database. We will have one eligible persons database.


Mr Jim Wilson: Okay, thank you. Secondly, what exactly does the pharmacist key in? The health card number or the senior --

Mr Stump: It depends. If you're a senior citizen, you key in your Health 65 card number, the version code, if it exists, as well as the data related to the prescription. If you're a social assistance recipient and there's a health number available, you key in the health number. If there isn't a health number available, then you key in your MCSS drug benefit eligibility number.

The Chair: Ms Sullivan, a point of clarification?

Mrs Sullivan: I don't know if you're going to call me out of order, Mr Chairman, but frankly I see a bit of a convoluted process here, an overlap. With not having first eliminated the senior citizen number and the Comsoc number and simply adding a new file to the health card number, in fact you're going to create more problems ultimately than you will solve, it seems to me. Why was the decision not to use the health care card number as the single number for eligibility for all other programs, whether it's the ODB or whether it's --

Mr Stump: The goal is to use the health card number, and I guess in circumstances where the Ministry of Health can control it, that's exactly what we do. With the Ministry of Community and Social Services, then at times somebody I guess who's in dire need of social assistance, doesn't have a health card for whatever reason, it's 5 o'clock on a Friday afternoon, they've just come from a physician, perhaps, with a sick child and they say, "We need to get drugs; we have no money," the Ministry of Community and Social Services issues a card on the spot. I guess the Ministry of Community and Social Services generally wants to make sure that the worst-case scenario is avoided.

We've been working on a project basis with MCSS to try and get them to convert. It's not a simple undertaking, because you not only have the provincial social assistance plans; you also have municipal social assistance plans. Getting them to change all of their computer systems when funding has been cut back is not easy. It's going to take time. We've identified it as a goal. I think Peter Burgess's branch, registration programs branch, has taken the lead to work with the Ministry of Community and Social Services to come up with a better way of doing it. And no, I don't think we're satisfied with it either. It's what happens today, and all we can do is try to work to improve it.

Mrs Sullivan: Have you, by example, started to add a new file on the senior citizen cards with the health card numbers?

Mr Stump: We have the seniors registered on the registered persons database today, and that's the source of data for this system as well.

Mrs Sullivan: Then why do they continue to receive a different number and a different card?

Mr Stump: Oh, when they turn 65?

Mrs Sullivan: Yes.

Mr Stump: That will stop. There won't be a reason for it when this system is put in place. Right now the card itself is a way to identify to pharmacists that you're eligible for drug benefits. With the introduction of the system, there'll be no need to issue a new card when you turn 65.

Mrs Sullivan: That's right. You'll just have a new file number on the health card.

Mr Stump: It'll be the same card, the same information on it, but as soon as it enters the system, because of the on-line real-time adjudication, we'll look up and say, "Yes, this person turned 65 a month ago and therefore is eligible."

The Chair: It will be automatic then.

Mr Stump: Yes, it'll be automatic. We'll be eliminating some of the work, and no, there won't be a second card issued any more.

Mrs Sullivan: So the problem then will continue to be the Comsoc duplicate cards.

Mr Stump: Comsoc is an area that I think we all recognize we have to work on.

Mr Decter: I should just say that the government has released a discussion paper on reform of social assistance and in there there's active internal discussion of separating health benefits from social assistance. Exactly how that'll be accomplished is not yet decided, but the government's general policy direction is to try and not have -- one of the barriers now to getting off social assistance is that you lose your eligibility for drugs and that creates a barrier, particularly for single mothers with children, who face a big risk to their coverage for their children. So we're in active discussion.

From our point of view, we'd like to run the whole health benefit system with integrity based on a single number, but getting there isn't as easy as waving a wand because we have to contend with the other values that are at play in different program areas. But I expect that as part of the sorting out of health benefits and probably moving the health benefits to some other basis, perhaps income testing rather than having an abrupt you're either eligible or you're not, we will hopefully get that resolved.

We didn't feel we could wait on automating the drug program. We've had the senior citizens' consumer alliance telling us that overmedication is frankly killing seniors. This system will very rapidly deal with that in real time because the pharmacist will be able to know what other prescriptions that particular senior has received.

The auditor has been very direct in pointing out cases where individuals have had multiple prescriptions filled on a fraudulent basis. At the moment we don't have the ability to stop that at the point of service; we have to do it after the fact, and that's a lot harder. So we felt we needed to move ahead on this and bring the two together down the road.

Mrs Sullivan: I want to go further into policy issues associated with this later on, but the only other question that's of a technical nature is, are the mail-order drug suppliers also included in this network?

Mr Stump: They're simply another pharmacy.

Mrs Sullivan: They're considered as community pharmacies.

Mr Robert Frankford (Scarborough East): I probably should know the answer to this, but there must be a significant number of people who are permanently disabled who are receiving free drugs who are under 65. What do they get at the moment?

Mr Stump: I'm afraid I'm not going to be able to answer a lot of the details on that. There are specific programs for long-term care agencies, for home care; there are a variety of subprograms, if you will. In some cases they get the full formulary; in other cases it's restricted to I believe the drugs that are needed to get them out of hospital and keep them at home.

Mr Frankford: But say someone who's retarded who's on tranquillizing drugs or insulin or whatever. There must be people who are permanently on medication.

Mr Stump: I'm afraid I'm over my head here.

Mr Decter: If there's one place where our health system unfortunately replicates the American, it is on drug coverage for people currently in the province who are not over 65 or on social assistance. Here there are real, if I can call it this, massive different eligibilities in programs. We pay for certain drugs under the special drugs program. Under the Health Insurance Act and the Canada Health Act we of course pay for all drugs while you're in hospital. When you get into the outpatient setting, it genuinely is not really run on the same basis as the rest of the health care system. That's why we're out on a major reform looking at how to deal with it. People have private coverage, they have employment-based coverage. So in kind of miniature, it replicates President Clinton's dilemma of, how do you get coverage? We have people in the province who have catastrophic illness and are not covered for drugs. That's not something that I'm very proud of. That's something we're working to address. But at the moment the answer is not a very clear one and it would depend on your specific connection to the system and your age and whether we pay for that particular drug or not.

Mr Frankford: Just one comment. You could envisage a time when the health card would link in through the pharmacy to either the whole formulary or a specific range of drugs.

Mr Decter: Yes.

Mr Frankford: But we're not there yet.

Mr Decter: No, we're not there yet, but our intention is to use the single health number for all programs and it is certainly to get a better linkage of need and benefit in terms of drug programs. We see the automation and the network as an essential piece. You can't do anything without it, really.


Mr Stump: I guess to add on that, the system has been designed so that you can tailor the program down to an individual drug or an individual person or an individual situation. So the government will have I guess an awful lot of flexibility to establish the programs that are most appropriate and affordable.

The Chair: For purposes of planning the rest of the time that's available to us, could I get an indication of the length of the rest of the presentation so that we may at this time make ourselves aware of how much time will be available for any questioning today? Otherwise we will probably have to do that tomorrow. It was my intention to go till about 4 o'clock today, and we're scheduled for tomorrow at 10 o'clock. We can go a little beyond 4, 4:30, shall we say?

Mr Larry O'Connor (Durham-York): To 5 o'clock?

The Chair: Okay, 5 o'clock it is.

Mrs Sullivan: How about 6? What time does he catch his plane?

Mr Decter: That's not till tomorrow.

The Chair: There's still tomorrow. You have all day tomorrow, let's not forget.

Mr Wiseman: So we'll go to 2 tomorrow afternoon -- just keep going.

Mr Decter: As you may be aware, I've been in some long meetings in the last few months.

I think I can get through the rest of the presentation in perhaps 15 to 20 minutes, if I make the assumption that there's going to be a lot of questions on the registration analysis report and that perhaps I don't have to go through it in exhaustive detail. We do have an update to that report that we could probably get in your hands today. That might again address some of your questions.

The Chair: We have the rest of the day tomorrow for questions.

Mr Tilson: On that chart, as well as some of the areas that were being pursued, is access to information. From the way you've described this, there will be companies, pharmacists, staff who work for pharmacists, all kinds of people who will have access to what in the past has been termed confidential information as to what people are taking for prescription and other relevant information. Isn't that a problem?

Mr Stump: I'm glad you asked that question.

Mr Tilson: I'm glad I asked it too. I hope you'll be able to enlighten us.

Mr Stump: We've asked ourselves that question an awful lot in the past year and dealt with it in many ways. We've been speaking with the freedom of information commissioner and are very sensitive to that one.

With the private insurers, the data that flow between the private insurer and the pharmacist the ministry will never see.

Mr Tilson: No, I'm talking about the clerk who works in the drugstore.

Mr Stump: Okay, I'm going to carve pieces out till we get down to what the ministry's relationship with the pharmacist would be, if that's all right.

We're not involved with the private insurers. They're just using the wires that we put in place. What happens between the private insurers and the pharmacist is something that we're not in control of. That's a relationship between those two business entities. I believe they're all going to follow the same standard format from the Canadian Pharmaceutical Association. Version 3 of the format I think is where everyone is heading.

In terms of the ministry's relationship and the public data that we hold and keep very confidential, very, very, very, very limited information is being provided to the pharmacists. In the CPA standard format in terms of drug use review, we will accept the data they provide us which they currently provide on a claim. So we're not collecting new data. We will feed back to them an acknowledgement of that claim data as well as a payment of that.

In terms of the drug use review and when we get into drug therapy, what we will feed back is that the drug that is currently being dispensed may have an adverse reaction with another drug, and we'll name that drug, that is currently being consumed. So we will be providing to the pharmacist the fact that the patient they're currently servicing may react badly to the drug and end up in hospital or perhaps dead.

So what we're asking pharmacy at that point, and we've got the support of the OPA on this position, is to have the pharmacist discuss the situation with the patient to make sure that those drugs are still being taken, talk to the prescriber or to other prescribers if that patient has been visiting multiple doctors for different diseases.

We're not providing any personal data other than the fact that this particular drug may be taken, and it's a situation where your health is at risk and it's being provided to somebody who's covered under the health professions discipline act. Disclosure of that information can cost them their licence. It's information that is necessary for them to give good, quality health care.

Mr Tilson: A pharmacist will have available all other drugs.

Mr Stump: No. The only thing that will be provided back to the pharmacist is the drug that might interact with the current medication. We're not providing a "give us your health number," as on the telephone, "and we'll give you a list of drugs." We're saying, "Tell us what you're dispensing." We'll do an automatic analysis of that drug based on currently accepted medical references, Hansten, and publicly available information against our database and come back and say nothing, because there is no serious adverse reaction, or we'll just come back and say: "Yes, this is a serious problem. Talk it over with the prescriber and with the patient because you're prescribing" -- one of the examples I think I can understand is some sort of an Aspirin-type drug, Warfarin, which I think can be used, a heart drug, that could cause haemorrhaging and I guess eventual death.

Mr Jim Wilson: What about multiple prescriptions of the same drug? You're worried about double-doctoring, you're worried about --

Mr Stump: We'll come back and say that this drug is being refilled too soon. If you're taking a drug that there should have been a 30-day supply on, then we'll come back and say, "This drug is being refilled too soon," at which point the dialogue can start up between the patient and the pharmacist: "How many pills are you taking a day? You should only be taking three, based on my records." It could be a simple explanation. It could be that the three-year-old in the household flushed the drugs down the toilet for a prank. What we're doing is providing limited information, only in situations where we feel that quality care is at risk.

The Chair: There's one final point of clarification from Mrs Sullivan, but I would like to get some indication from the committee. If we'd like to ask questions at this point, then I will distribute the time evenly; if not, we should proceed with the rest of the presentation. Is that fair? Okay.

Mrs Sullivan: Frankly, the information that you have just provided to us, I think, is new to everybody on the committee. I don't think we understood when we were discussing the drug network, either in estimates committee or on other occasions, that indeed the network would provide pharmacological information. I'm interested, then, in what will be recorded and how records will be maintained of interactions with over-the-counters which have been removed from the ODB list.

Mr Stump: We will not be recording any products that are not provided under the Ontario Drug Benefit Formulary as it currently exists, so if the drug is not on the formulary, we won't know about it. If you're claiming under, perhaps, a Blue Cross program that you have outside of the seniors' program, for whatever reason, we will not have that data available to us. It is going to be of limited use because we will not have all of the data, whether it's over-the-counter or even nutritional products.

Mrs Sullivan: Is it going to be of any use at all if only drug products that are included on the ODB list -- and there are many, many that aren't -- are included on the network, on the information system?

Mr Stump: We believe so.

Mr Decter: Despite some of the deletions from the formulary, we still have a formulary with in excess of 2,000 products on it and we do comprise the major program for drug benefits for the seniors population. As well, most, although not universally true, over-the-counter drugs are of less concern in terms of interreactions. I believe that we are going to capture, although not a comprehensive drug profile, the major drugs that seniors are taking. I guess I'd contrast that -- the average hospital formulary would be much smaller, maybe down around 300 to 400, so we are covering a broad spectrum of drugs. Although I know it's contentious -- the various moves we've made to reduce the scale or the size of the formulary have been contentious -- it's still a fairly comprehensive set of medications.


We do think this will be well worthwhile, but there is a balancing act here between the privacy concerns and the management concerns. If we were purely concerned with management, we would go a lot further in terms of personal information and linking patient records but, because we have a balancing concern, as set out in the Freedom of Information and Protection of Privacy Act, we have to take account of that as well, so there is for us a balancing act in this.

The Chair: I see this question has provided more interest, so I'm going to proceed with questions in the interests of being fair to all.

Mr Frankford: It seems that your example of anticoagulants and Aspirin is not a very good one because I'm not sure Aspirin is listed right now. Perhaps this is an example where the system could operate and not work, and perhaps the responsibility should be more on the prescriber than --

Mr Stump: I think that where we have to get to with the system, as I said earlier, is we can start with community pharmacies. I think a logical place is to work with the hospitals in emergency rooms where we will have to deal again with what information is provided to an emergency room physician when somebody's wheeled in on a stretcher, because at that point it might be because of a drug reaction and you're going to want to make available to the emergency room physician the drug history. I think, ultimately, the prescriber is going to have to get much more involved with the pharmacy working out a drug therapy program.

Mrs Sullivan: I think the reason this network is interesting is that through it we see the movement of the health card system from an eligibility and registration system to a utilization control and then ultimately leading into a record of medical and other health care treatments that can be reviewed by the professional to assist in subsequent decisions about health care that's ultimately delivered. As we're moving through this, what we're all wondering is how smart is smart, if we're moving into that kind of smart card system.

What kind of analysis was done within the ministry with respect to a comparison and discussion of the question of confidentiality of information versus security of information? I think they're two quite different things and have two different places in the system.

Mr Stump: I guess, if I'm understanding correctly, confidentiality is information that you're expecting we might exchange with a pharmacist; security in the system is making sure that nobody can get unauthorized access to the system for whatever reason.

I guess on the first part, we've worked closely with the Ontario Pharmacists' Association to find out what actually is needed. We've looked around North America in terms of what information is currently being used, what plans people have in place to do this, and they do vary. British Columbia, for example, is in the process of going to tender on a similar system, where they would provide all of the information to the pharmacist to work up a drug profile on the individual. We've taken a much more cautious approach.

From a community pharmacy's perspective, they're going through an evolution in pharmaceutical care. Their model of community pharmacy is changing to one where they get much more involved in a counselling role as opposed to what the average citizen perceives, as somebody just taking the pills out of the big bottle and putting them into the little bottle. I think there's timing on their part to change the layout in pharmacies so that they can dialogue with their patients privately in a professional setting, as well as the practical reality of running a $5-billion business that they have to be able to flow customers through the store in order to make a living at it. I think right now it's a balance in terms of what's the absolute minimum information that you can provide in order to improve quality of care, coupled with the pharmacy's ability to conduct its business practically and professionally.

Mrs Sullivan: When will the doctors be introduced to this system?

Mr Stump: I'd turn to my steering committee, but I don't think I'm going to ask them that until we've implemented this one and we prove it works. Clearly in the directions I've been getting: Emergency rooms are next on your list and then let's start to work with the prescribers.

Mr Decter: We are looking for a prescriber number.

Mr Stump: We are going to start collecting.

Mr Decter: Yes, so we will be collecting from day one the physician number, which will allow us to look at perhaps non-identified physician prescribing profiles.

I just want to say, one of the real issues for us is that a great deal of good analysis with policy consequences can be done without personal identifiers. It doesn't turn out to be in every case as important to know exactly who is taking a drug but, for example, David Naylor and Geoff Anderson did an analysis recently published under the title A Day in the Life of the Ontario Drug Benefit Program. They looked at classes of drugs and identified some real systematic misprescribing, prescribing of one drug where there's a far less expensive, equally effective alternative.

Unfortunately, we have that one solved, if one's a brand name and one's a generic, because of the requirement of the Ontario Drug Benefit Act, that people prescribe or dispense the generic. Where you've got either two generics or two brand names, we're not into that level of utilization management. I guess I'd answer your question by saying in part: We want to do a lot of analysis that doesn't violate -- violate isn't the right word -- doesn't test any limit on confidentiality because we're not using personal identifiers and we can aggregate the data and do that work.

I think we're going to walk, frankly, more cautiously down the road of making sure we remain in conformity with the FOI and Privacy Act in terms of collecting and using information only for the purpose for which it's collected. That whole issue is quite vital to us. Are we collecting information, for example, to manage the drug program or are we collecting information to manage the health care system? It's my belief we're collecting it for the second reason: to manage the health care system.

You then have a set of important concerns, concerns about how to protect people's individual privacy through this process, and candidly, when you automate something, it does make access a much bigger issue -- not that a physician assistant in a pharmacy couldn't look at someone's prescription now in a paper form -- but what checks have we got in place as we automate that system to contain it? It's a very real question. We've been working very closely with our own legal people, our own FOI people and the commissioner on these issues and we will continue to.

Mrs Sullivan: When the physicians are hooked up to the system, will they have the complete drug profile of the patient?

Mr Decter: You're asking a very theoretical question because we're not that far down the road yet, but I believe a physician would now have, as part of their patient record, what they've prescribed for that patient and --

Mrs Sullivan: Knowing what the physician himself or herself has prescribed -- they would not have a record of what is in fact a problem with overutilization, that is, doctor shopping.

Mr Decter: I don't have an answer. I don't think we've crossed that bridge yet.

Mr Stump: I think we're taking it step one, two, three, and I think it would be working with the OMA the same as we did with the OPA to find out what is necessary and what is appropriate.

Mrs Sullivan: So there's work to be done?

Mr Stump: Yes.

Mr Tilson: I guess that comes back to my initial question. If you're going to implement a system like this or even consider implementing a system like this, isn't that the real issue: Who is going to have access to this information? How much information? How are you going to have a check on who is having access to the information and how frequently, particularly when you're going to be talking about transfers of information between different governments, whether provincial, federal or municipal? You get into all kinds of things in the availability of all of this medical information which in the past has been very confidential.


Mr Stump: First of all, I guess we've looked at the community pharmacy issue, I think, in the terms that you've just outlined. We haven't looked at hospitals or physicians' offices simply because we haven't got that far along the road. If we never implemented anything for hospitals or physicians' offices, I think we'd all be disappointed, but I think that the system would serve a very practical need today in community pharmacy. We will get to those questions for hospitals and we will get to those questions for physicians' offices.

For the community pharmacy, we're collecting essentially the same data as we've collected for the past 20 years. We've added the prescriber ID. They've offered us some address updates. In terms of communications back to the pharmacies, basically, we're only going to communicate back anything that might cause a serious health care incident.

Mr Decter: Perhaps I could move on to policy and legislative changes to give you a current status. Because of the three issues I identified at the beginning, the fraud, the overutilization, the supply, embedded in this is the question of eligibility. The government has been taking a look, and we did, in our Managing Health Care Resources paper in the spring, indicate that there would be some changes made. We are currently in negotiations with the federal government and we have some policy approval not yet fully at implementation in terms of tightening of eligibility.

Frankly, the introduction of the unique health number and the work done by the registration program branch highlighted a number of areas where our eligibility policies were less than clear. There's eligibility per statute, but interpretation of exactly how eligibility is established has been an issue for returning residents, for newly eligible persons. So you will see some movement to both tighten and clarify eligibility.

I'll give you one small example. Although all foreign students coming to Canada are told by Employment and Immigration that they should buy private coverage, we have also been providing OHIP coverage for foreign students, and that's a policy issue being addressed by the government. Many of them also receive, through bursaries or scholarships, money for health insurance.

The second policy change I mentioned earlier, Bill 50, will allow us to extend the Medical Review Committee, and I just refer back; frankly this is one that has been an issue for some time. In 1990, the Provincial Auditor criticized the time between a referral from the general manager of OHIP and the recommendation of the committee, noting that the average time was 20.5 months, up from 7.5 months in 1984. As of last year, the average time was 34 months and that has widened into 37 months. So it's now 3 years on average between a referral by the general manager of OHIP to the Medical Review Committee under recommendation from that committee.

That's not the fault of the committee. Their size is set in legislation, and until we get that bill through, we're stuck with that situation. It's simply that time has passed by that provision, and we badly need to clean that issue up. It's less of a pressing issue with other provider groups, but we have made provision in the bill to allow us, by order in council, to establish larger committees where they're needed.

I've mentioned the social assistance reform. It will delink eligibility for some health benefits, particularly drugs, from social assistance.

In terms of operational enhancements, we are not -- I said this earlier -- waiting for a new card as a single solution for a couple of reasons. There are many things we can do now; there's a bit of a list there. As of November, we will be requiring original documents for replacement cards. I believe we're doing that now on the walk-in side but not until November on the mail-in side. We are working on additional supporting documents. We have eliminated the interim paper cards. We are intending to move forward on procedures in terms of return of cards. We have a draft of a revised notice for new cards. We have a "dos and don'ts" poster. Maybe I could ask that they be distributed as a kit which gives you our current forms and information that are going out to people as they receive cards so that we have started to try to communicate. As I noted earlier, we've reduced the name preference options to one.

In terms of communications, we are moving forward with a number of posters and other communications vehicles to try to get the public more on board with us in terms of sending us address changes and in terms of carrying and using their cards appropriately.

In terms of the registration analysis project report -- you have the report -- let me just remind you of the mandate, which was to look at real and potential problems in the use of the database and to design and test methods to facilitate correction and to maximize opportunities for use of the data by other program areas. There were 51 separate studies. I think that list was provided in February. We were not, in February, in possession of the full report. It was still under way, although many of the individual studies had been completed.

The report's conclusions -- first, I should say the report had, I think, the appropriate caveats in its executive summary in terms of use of the report, and I would just underscore it. The report did a worst-case and indicated that, and I'll just quote the small bit, "These numbers are likely overstated because there exists some potential for a registrant to be counted in multiple analyses." This is from page 3 of the report.

I think staff were careful. I can't say that all of the media repetition of numbers from this report has been quite as careful in putting the appropriate qualifiers there.

The report identified quite large numbers in three areas. On the fraud side, there was an indication that registration fraud could be a potential liability or exposure of $284 million. In the case of abuse -- this is excessive utilization -- a $47-million number was cited. I will indicate there that the major studies done by Harvard, the Rand Corp and others on inappropriate use of medical procedures are much higher. They run anywhere from a quarter to as much as 50% of all medical procedures being unproven as to their beneficial outcome.

That's a little different than abuse, but when you get into utilization, we're into issues like the high rate of Caesarean sections. I'm pleased to report that for the first time we've seen that rate come down from over 20% to about 18%, but that's more the mission of a Dr Naylor and the institute to really get at moving towards best medical practice. I'd also say, because it's a point of extraordinary sensitivity with the profession, that it's easy to do an after-the-fact study and conclude that something might have been less than fully indicated. At the point of providing that service, many physicians are faced with a choice of erring on the side of preventing something that might be catastrophic, so one doesn't want to push that argument all the way on the epidemiological side.

The other indication was that there was potential for what were termed recoveries in two areas. The federal government is paying for groups of persons for medical benefits in other provinces that they're not paying for in Ontario. We are pursuing the federal government very hard on those issues at the moment. The other one was the sense of potential vis-à-vis the Ministry of Community and Social Services, and we're working with them. The report did indicate, through all of its studies, that we had some real risks here. I would say on the record that I think the staff did a superb job of working on the individual studies.


I would echo my minister in saying that some of the rollup to the big numbers, and particularly the way some of those potential exposures were seized on out there, contributed to probably a view that the fraud issue -- I think I've seen numbers bandied around publicly in the $700-million to $980-million range, which I think dramatically overstate the fraud issue. My own view is that it doesn't matter whether it's one in 1,000 or it's one in 100. The mission we have as a ministry is to fix the problems and to eliminate the exposure, and that's frankly what we've been doing since receiving the report.

There were 41 major recommendations. Many of them have already seen movement in terms of implementation. You've got the material; I don't think I need to go through each and every one of them. I would say that a number of these are very high priorities in various areas of the ministry. The negotiations with the federal government are being carried out by Margaret Mottershead, who's my most senior assistant deputy minister, and we have divided up the workload across the ministry to see movement on these issues.

We may see greater movement on some of them more rapidly than others. Negotiating with the federal government is not the easiest task or the most rapid. I'd also say that this is the first time an analysis of this sort has been attempted, and I think we're pleased to be seeing that the individual health number allows us to really dig in for the first time and get at some of these issues in a very practical way.

Again I'd just underscore that I don't think the issue is to arrive at a total-exposure number. The issue is to identify those areas with the highest probability of fraud or abuse and to find ways of solving them.

I'd say in that area we don't think that we've got all of the answers in the ministry itself, hence our retaining of Lindquist, a very strong forensic accounting and audit firm, to give us some advice not to do the work for us, but what they've done for the federal government and others is everything from diagnosis to running training programs for staff.

We have quite a large inspection staff, in the ministry, spread out among the program areas, and we think if we add some training to those individuals, we can get a pretty good value-added out of it.

I would say in terms of next steps, we're working between the program branch and other program areas of the ministry. We are getting some expert outside help. I would say very ultimately to this committee that any advice you have for us will be taken very seriously, as the advice of the Provincial Auditor has, both on the card issue itself and also on the broader issue of fraud and abuse.

We are continuing to look at the extrapolation issue because it's a tough one in terms of, what conclusions do you draw from small-size studies? And we will continue. We need better mechanisms, what Lindquist termed red flags within our systems, things that should indicate potential risk and cause us to take action early on.

The other thing we will be doing is a parallel exercise on the provider side, and here I'd like to be direct with you. Almost all of the focus in recent times, not only our focus but also the public focus, has been on potential fraud or abuse by consumers of services. We're very concerned that we're having an equally hard look at providers of services. It stands to reason, in our view, that a small minority of people on both sides of the consumer and provider spectrum have potential to be committing fraud, and we think we need to do the same kind of brainstorming and series of studies and analyses on the provider side to make certain that we're on top of that. Certainly, the pharmacy system will help, as will the expanded MRC, as will the inspection unit.

In terms of three basic areas, the registration and payment control framework, I think we have a chart, and I'll apologize for one spelling error on this chart. Under post-payment, it says "toil-free line to report fraud." That's intended to be "toll-free line." It's certainly not without toil. But you can see that we're looking across the spectrum, starting at the application end, moving to the card end, point of service and post-payment. We are looking at strengthening in each of the areas.

In terms of -- I'll walk you across the proposed line: On application we're looking at tightening eligibility. We are looking at verifying with Immigration Canada. We're looking at intensified exchanges with the registrar general.

In terms of the card itself, we believe the photo is our single biggest asset in terms of the point of service and the card. We also think a renewal cycle is essential, and we are looking at enhanced security features and doing some consulting there. I will be frankly a little vague about enhanced security features since we're not interested in tipping our hand too far in terms of those who might be actively looking at how to beat any card we produce.

In terms of the point of service, we've demonstrated both the audio and the swipe readers. Those are at the pilot stage, but we intend to roll out those systems so there can be point-of-service verification and on-line adjudication of drug claims.

In term of post-payment, we have, under the OMA agreement, achieved a fraud-reporting regime or agreement from physicians. We are looking at other measures in the post-payment area. Certainly, our investigation unit will be of considerable help here, as will the help of the public.

Down the road, we list some things. I don't want to get too far ahead of ourselves. My own view is, every step in this process has to both cost-justify itself and it has to be secured and working before you go on to the next step. For that reason, we want to walk before we run.

The health card enhancement project has, as its key deliverables, implementing the photo card, tightening the process for new and replacement cards, moving to a renewal cycle for all cards and additional card security features. We believe this will give us improved client identification, improved card integrity, reconfirmation of eligibility within the cycle, time-limited value of cards, and it also allows us to add changes on the run, if you like. With a renewal cycle, because we are in an area of rapidly emerging technology here, a year ago I was told by the private sector that there was very little interest in moving to a photo card because it was simply too expensive. I was in Washington, DC, on the weekend, and Citibank was advertising a photo Visa card, a Visa card with your photo on it. I don't expect we've seen the last of technological evolution here. With the renewal cycle, we can then introduce new features to the card as we move along and as we have the capacity to use them, rather than being caught in a static situation.

We also see, as a spinoff benefit, more interaction with consumers about what they're using, and we are looking at the periodic benefit statement to consumers, although we're not yet in a position to do that on a broad basis.

Finally, on the health card enhancements, we've just got a quick illustration there that shows you the current card and what we're calling the interim card, because we think we'll make this in two steps. We want to get the renewal cycle, birthdate and sex. The birthdate and sex are on the stripe on the back of the card now, so this isn't additional information, but until we get to the photo card, it does allow a certain amount of verification of the user on an inspection basis as well as moving to an expiry date. Those features would remain; the photo would replace the version when it went on the card.


I think that takes me to the interprovincial comparison. I would say at the moment --

Mr Tilson: Can we get the dates when this will be implemented?

Mr Decter: I want to be careful here. We've committed to being at cabinet this fall on the photo card and we're committed in the OMA agreement to taking a decision by December and I think that's realistic. I can't, at this point, tell you when we will have the photo card in people's hands because that depends on a number of choices.

Again, I guess here I would say again we want to get it right; we want to do it properly. We are working with MTO. They already have a photo capacity in terms of the driver's licence. We don't, if it doesn't make sense, want to subject citizens of the province to going for two photos if there's a way of avoiding that. We want to make sure that the driver's licence photo process is secure enough for our purposes. So I think all I can commit to you on the photo card is a decision by December, which would also include time lines for implementing it.

On the interim card, I'd have to turn to others here as to how rapidly we can add some of these features. Patricia.

Ms Patricia Malcolmson: I'm Patricia Malcolmson. I think that in terms of adding features to the current card, that we could put them in place and have them tested and ready for implementation before the end of this fiscal year, subject to the broader decision to go forward with a photo card in a cycle.

The Vice-Chair (Ms Dianne Poole): I think we'll continue since, I think, for this portion we'd said there wouldn't be questions until the end, and I believe he's almost finished anyway. Mr Decter.

Mr Decter: I'm at the last slide in the presentation. In terms of just listing other activities, largely of a data exchange, we are looking to improving the accuracy of our database. In terms of the registrar general, we're looking at integrating birth registrations, we're looking at name-change updating, adoption integration, and, as Peter Burgess mentioned earlier, grappling with the death matching enhancement; that is, getting a better automatic match of deaths.

In terms of information exchanges, we're working with three federal government departments: Employment and Immigration, Health and Welfare and Revenue Canada, and within the government we're working actively with Finance, MCSS and MTO. We are also doing work with Quebec, who have been very helpful in terms of sharing their experience with us. Their experience with the photo card is, I believe, only about a year old. So it's a little early to draw dramatic conclusions there, and we are looking at working with other provinces on interprovincial moves.

I did mention earlier, and it may be a useful note to conclude on, that we have an update to the March report, a much shorter update, but trying to bring to bear on the March report both events like Statistics Canada's revision and also some activities since then. I don't know that I want to take you fully through this report. I think that I could do a couple of brief highlights from it and I think we could make it available. I don't know whether we have sufficient copies at this point.

Interjection: We could have it first thing in the morning.

Mr Decter: We could have it for first thing this morning. Staff have been pushed very hard, frankly, by me to do an update because we wanted to give up as up-to-the-moment information as we could on these matters. The report, if I can highlight it, and let me start with the negative part of it: We still haven't got the address issue solved and, in terms of the database itself, I think of the information, that is the area that we're least satisfied with. We have made more progress on a variety of other control measures.

We also, I think, have come to the conclusion that we still have significant risk in various parts of the system. I think some of that risk is resolvable with data exchanges. Some of it is only resolvable by getting to the point of service.

In terms of focusing on the numbers issue, because that has been a focus publicly, the update contains a rather wider range of numbers than previously. I think that's helpful. I would just reiterate -- well, to give you the wide range, the bottom-line number that staff have calculated shows a reasonable estimate of exposure in the range of 0.14% to 1.5%, which would give you a range in dollars -- I don't think my copy has the dollars in it -- of somewhere between $24 million and $250 million. Here, I have it; I do have one with numbers in it -- between $24 million and $257 million.

I think that range gives you some idea of the dilemmas in trying to put a number to this. We've gone at the areas with the highest probability and in some cases we have found, particularly in the Windsor and Kingston hospital situations, that there are some number of people presenting American documentation to back up an Ontario health card. We have some charges laid in connection with a Kingston case. So we have succeeded, I think, in beginning to get some attention at the hospital level on this issue. In any event, you'll have the updated report. My own view on this is that we have made good progress, given the situation, but we have a long distance to go and we're only to get there with a really determined effort with the people at the point of service. The ministry is not there in the physician office or there in the hospital and we need, both technologically and in terms of attitude, those providers on side with us. We also need their confidence that we've done enough tightening on the card and eligibility side that we're not offloading the task on them. So I think it has to be a genuine partnership and I think the degree of undertakings on both sides in the agreement between the government and the Ontario Medical Association is a good start to that.

We do have discussions under way, if I can anticipate one question, with the Ontario Hospital Association around the other card, the generally blue card that people get in hospitals and cards that are issued by hospitals. We think there are some answers to tightening that part of the system as well, although the hospital association, I think, in the initial realm, doesn't feel the risks are as large as the risks on our card, simply because of the process by which someone acquires that card. In any event, we've started a discussion on that side.

So in terms of our three major service points -- the hospital, the physician and the pharmacist -- we are at varying stages of working through the use of the health number, working through the use of card and communication technology, and within the ministry we are working at various levels to deal with the recommendations from the registration analysis project and really to reap the benefits of having a unique health identifier. I expect we have several years of hard work ahead of us to fully implement, fully achieve all of the benefits that are available.


We also have a much more aggressive approach on the fraud issue. I would say on this that it has perhaps been for many years taken too much on faith that because of the high regard in which Canadians hold their health care system, fraud or abuse of the system was an unlikely consequence. I think public attitudes have hardened. Frankly, the publicity about our health care system south of the border and the rather desperate straits of the American system have probably fed, although we have no basis for measuring, some greater interest in people tapping into our system.

I would say the hardening of attitudes is not just there in the public; it's there in the ministry, and you will see much more determined action on things that we might have treated in the past as an issue of recovering overpayments. We will be asking our investigation unit to look at whether they are genuinely cases for recovery of overpayments or they are cases of fraud which should be dealt with through the criminal process.

I have not tried to go into great detail on parts of this. We have lots more detail we can provide. The overall message I'd like to leave with you is that we take this issue, as we did in February, as we have over the last number of years, very seriously. The ministry is doing a great deal on this and we are very open to advice from this committee and from others. We do intend to consult all of the available experts in these fields before we go to cabinet on the photo card or the card enhancements. We really want to hear from people who are leaders in their fields as to what they think the future holds and what the best approach is.

The Vice-Chair: Thank you for your presentation, Mr Decter. The Chair had indicated that we would sit till approximately 4:30, at which time we'd discuss the report of the subcommittee. Since that would only allow about two and a half minutes per caucus, which really isn't enough time to even start questioning, would it be agreeable to extend that to five minutes per caucus, just to give you a chance at least to go at Mr Decter, I think was the phrase that was used, and to ask the questions over which you can't sleep tonight unless you get out in the open? I have three people who have indicated an interest so far, Mrs Sullivan, Mr Wilson and Mr Wiseman, and if there's time for your caucuses, Mr Tilson and Mr Callahan. I think you'll have about 30 seconds each for your questions. We'll start with the official opposition.

Mrs Sullivan: Thank you. It's not that fabulous, but we will get back to it again tomorrow for sure.

I was interested, when the news of the registration analysis project became public, in the responses that occurred from officials in the ministry, from the Premier, from the Minister of Health, with respect to the data that was included in the report. Indeed, I think many of those responses cast some doubt as to the validity and the expertise of those who had been involved in the project.

Having read the report, I guess my concern changed from what appeared to be a coverup to having some concern with what I saw were firm projections and estimates that were made from what appeared to be fairly small samples of study that had been done in various areas.

One of the things that has occurred to me now, having heard the presentation, is that it seems now that action is being taken on a relatively small sampling. I believe that in January you reported to the committee that there appeared to be in the Kingston survey about 4.5% inaccurate registrations. The eligibility investigations which have recently been done have cancelled the eligibility of 52% of the cards, it was reported to us this morning. I expect that those were the return mail cards, but that could be confirmed.

What happens if a person has simply changed an address and then is refused health care coverage based on cancellation of a card from a very small projection of risk?

Mr Decter: Let me give you two answers. The first and most important is that no one can be refused urgent care in the province on any basis, so there's no ability in the system to refuse urgent care to an individual on the basis of the invalidity of their health card number. There is then a mechanism for disputing or appealing eligibility and dealing with payment for those services, but the first message, and it's one that I think we have to be very direct with, is that there's nothing in this process of our trying to reconcile the database and make sure that service is going to eligible people that allows a hospital emergency ward or a physician to turn down someone in need of medical care on the basis that their card number didn't go through.

Just to be very direct there, concerned as we are about the financial integrity of the system, that is not in any sense a change in the legal requirement that care be provided. I don't think we've had any major cases. There have been a couple of cases that have come to our attention, but we don't sense a big ramp up in that.

On the report itself and the issue you comment on, there is a balancing act here. This was the first time that we've really dug in and looked at this, and I think there really is lots of appetite for getting to a very big number. Frankly, the people that I spent a couple of months with on the social contract would far prefer that it turned out there was $700 million of health card fraud, and then we could sort of eliminate all of the other burden that's falling on their members as a result of the social contract.

Similarly, I think the medical profession would far rather believe that there are masses amounts of fraud. The reality is that we're only going to learn how much there is by undertaking actions to eliminate it, and as we eliminate it, you cancel registrations because people don't respond. We won't know for some time, I presume, how many of those people subsequently turn up and say, "Well I actually was eligible but I moved and I was somewhere else."

Mrs Sullivan: Do you have a tracking system for that?

Mr Decter: I should get Peter up here to answer the more detailed questions.

But, no, the address side is the place that I think we've got the most work still to do and we have not got that solved. People don't tell us when they move, frankly. People move a lot. We've had cases where we've invested many, many multiple numbers at the same address. Some of the them have turned out to be hospitals, nursing homes, what you'd expect, and some of them have turned out, I guess, to be cases where you get a lot of turnover in the same apartment unit. So I don't think we've got an answer for that because we're not far enough along on it. There's a bit of a balancing act here between what we can know from a small study and how we can generalize that across the system.

The study was designed to give us maximum exposure -- what is our maximum exposure on this? -- and I think it's done that. Somewhere between the big and the small numbers is what the actual situation is. Peter may want to add to that issue.

Mr Burgess: I'll try to make it brief.

In terms of the two points, I believe you asked a specific question, was I aware of any tracking system? No, I'm afraid I'm not, but I am aware, certainly in the border community which I mentioned, of where people have had their eligibility terminated, have been to a physician in their new address, subsequently have been phoned by the physician and told, "Your card is ineligible, the one you gave me."

They have immediately gone into the local Ministry of Health office, they have immediately faxed their new address to us and been reinstated, as long as they can prove that they truly were eligible at the time of receiving the service. The physician gets paid for the services that were provided at the time of provision of service, and the individual is immediately reinstated.


In terms of your small sample, yes, you can look at it as if we did some small samples. But in specific cases, for instance, the case that was quoted quite widely in the newspaper regarding hysterectomies being performed on ladies who had previously had hysterectomies, we surveyed the 200 million or 300 million transactions that had occurred since the time of registering for the new health card and determined a certain number of possible occurrences and checked out each one of those and found in fact zero occurrences in that one sample. So while we were trying to sort of cut our suit according to the cloth available, we did, wherever possible, attempt to scan as much as much information as we possibly could to make ourselves feel reasonably comfortable with the results. We were inventing these techniques on the fly, I hasten to add.

Mr Jim Wilson: Mr Decter, I'm just curious to know how you're going to re-issue 10.2 million interim cards by March 31 next year and what the cost of that would be.

Mr Decter: We're not planning a re-issuance of cards. We have a steady process of issuing cards to people: to new registrants, to those who turn 65. What we're talking about are enhancements to the cards we're already issuing. We're not looking, and I should be very careful here, at a re-registration of the whole population, either on the interim card or the photo card in one go. We're looking at moving to a cycle where your card would have an expiry date and, as with your driver's licence, you would have to renew it every -- we're still looking -- three years, four years or five years, but we will phase it in.

Mr Jim Wilson: I don't understand that in terms of, for instance, I myself. If I never have any contact with the health care system, I will, I assume then, for many years yet to come continue to have the card that's in my pocket now with no expiry date or none of these verifications.

Mr Decter: No, no. I'm trying to distinguish between going out and --

Mr Jim Wilson: When will I get a new health card?

Mr Decter: Depending on what cycle the cabinet decides on, some time in the next three, four or five years you would get a new health card.

Mr Jim Wilson: So eventually, in the next three to five years, you're going to re-issue 10.2 million cards, plus the ongoing new admissions.

Mr Decter: Yes.

Mr Jim Wilson: What's the cost of that?

Mr Decter: We don't know the cost, because we haven't decided the features on the card yet. We haven't worked through how we're going to implement it. Obviously, if we work with MTO and they've already got a capacity to do photos, that's one thing. If we decide that's not secure enough, that would be another. I can't give you that. I will tell you, though, that also under active consideration is having that be a full-cost recovery operation.

Mr Jim Wilson: To the consumer?

Mr Decter: Yes.

Mr Jim Wilson: I notice in the chart that one of the provinces charges $10 for a replacement card. Is that what you're considering?

Mr Decter: We're looking at what our costs would be. I think I've seen numbers in the range of $5 to $10, based again on what technology gets chosen. I don't want to pre-empt the cabinet on that. We will make, certainly, our best efforts to look at all of the documents that people are currently charged for, birth certificates, passports and so on. There is also a very live issue of not imposing user fees between the consumer and the health system. When you ask me about cost, there is an issue about where the costs would be borne, as well as how much it would be. I think we're looking probably, ballpark, something in the order of $5 to $10 per card.

We will not, certainly as long as I'm deputy minister, go out and try and do 10 point-however-many million people in one registration process. I really think our quality control would be a lot stronger if we're doing it over an extended period of time and we get it with lots of documentation on the way through.

Mr Tilson: The last system, as of January 1992, cost about $40 million. That's what the Provincial Auditor says, at least.

Mr Jim Wilson: The current system.

The Chair: You mean the health cards?

Mr Tilson: Health cards. The current health card system costs --

Mr Decter: I thought it was higher than that.

Mr Tilson: I don't know: $39 million, $40 million.

I appreciate your talking about that individuals are going to be charged or may be charged, depending what the cabinet says, a fee per card, but there must be some estimate. You're obviously sophisticating the system substantially. Is it going to be much in excess of that $40-million figure? It may be $40 million as of January 1992, but --

Mr Decter: No, I don't think so, because we are currently issuing -- someone would have to give me a number. What number of new cards do we issue per year on the current -- 13,000 a month, so about 150,000 a year. Okay. It's not huge, but we're already issuing something like 150,000 per year now. I think we'd be upping that, depending -- so it's hard to put a number on it, but this is going to cost some tens of millions of dollars. There's no question of that.

Mr Tilson: I guess the problem we have is, whether it's the registration analysis project or other reports, your own admission is there's substantial fraud in the system. The next question is that if you're only going to do this by degrees over a period of years, that's going to take a long time, that process. How is the existing fraud going to stop?

Mr Callahan: Do you think it will go past 1995?

The Chair: If I may just interrupt for a minute, I would like to give you the opportunity to answer that question; however, we are running out of time. Could I suggest that we come back to that matter tomorrow and we move on in rotation to the government party and have the last five minutes --

Mr Tilson: Maybe he can just give me a quick answer.

Mr Decter: The quick answer is that we're doing a whole range of things to reduce and eliminate fraud. The new card is not seen by us as even the major -- I mean, it's a major part of a medium-term effort, but I think the investigations unit and tightening down the data that we already have in the system, that we already have in place, will get us significant gains on the fraud front.

Mr Wiseman: My question is very quick, actually, and it was raised by somebody at my constituency. It seems whenever a disabled person who is permanently disabled has to apply for some government support, they have to go back to the doctor to ask that the doctor give them a letter indicating that they're still permanently disabled. It seems to me, and it was their suggestion, that something be put on the card, like PD, permanently disabled, so that they wouldn't have to continue going back to the doctor to get a letter saying they're permanently disabled to get the driver's sticker or some of the other benefits that are available to them. This would probably save the system a lot of money.

Mr Decter: I can't give you a specific answer, and we'll take that suggestion under advisement. I can tell you that one of our structural issues in the system is that we've used physicians as gatekeepers for a lot of programs where you don't really need a medical gatekeeper and it's not appropriate. We are moving away from that in the long-term care system. I mean, physicians are our most expensive and also most skilled resource in the system. We want to use them appropriately.

One of our actions with the OMA was to get the third-party billings out of our system; that is, where someone's kid is going to camp and the camps say you need to have a medical, the only reason that child is going to see a doctor for a medical is the camp rule. Under the third-party billing agreement, the parents would pay for that rather than OHIP. Now what's happened in practical terms, and I can speak as a consumer, is a lot of camps have decided they don't need a medical review of the child. Schools don't.

So what we're finding is that over the years, people, in looking for gatekeepers, put physicians in, partly because we were paying the bill. We're now doing a very comprehensive policy review of that with the OMA. Obviously, they have an interest in not being blamed for excessive utilization when it's not being caused by their members; it's being caused by various other programs or by third parties like insurers. So we're working with them on that and I think we've made some good strides. But I don't know about the permanently disabled category. We will look at that.


Mr Wiseman: I have another question. I was cleaning out one of my drawers this morning looking for a document, and what I found in there was a hospital card that has been issued to me that I no longer need to show my health care card for. I've got one for Ajax, I've got one for Whitby, I've got one for Oshawa, I've got one for Scarborough General and I've got one for Scarborough Centenary. Those cards, if I ever lost them --

Mr Callahan: All different names.

Mr Wiseman: That's right. You've got it.

The Chair: Did this start to happen when you became a member?

Mr Wiseman: This has been happening over the last 35, 40 years. So my question is, if we're doing card changes, I don't know if you've looked at this, but eliminating hospitals duplicating that -- first, that's an expensive procedure that the hospital is running and, second, if I don't have to show my card, how do they know that it's me?

Mr Decter: This is a real issue. We are working with the Ontario Hospital Association on it. I don't have an immediate answer. They code a lot more data about you and your medical record driven by that card than I think we would want to have on our health card, but if we can get some integration of the two-in-one card that gets used, I think that would be a more ideal situation. Again, we have not had people value their health card in the way they value other cards in their wallet, and I think we are going through a bit of a change in attitude towards the card.

There are also other technologies like the ability of a hospital potentially to put a kind of adhesive stripe on your health card that would have their additional information. Those are becoming quite popular in some applications. So when I say we want to look at all of the available technologies, we really do. We want to get into something that's going to work for a significant period of time in that we may be able to combine their requirements and ours in some fashion.

Mr Frankford: We were talking of the media before. I wonder if you could clarify -- and perhaps this could wait till tomorrow for a reply. The article by Kevin Donovan in the Toronto Star of August 14 says:

"OHIP computer analyses show numerous examples of people obtaining a card one day, then racking up hundreds of thousands of dollars of medical services over the next 30 days. OHIP officials are aware of cases in which people have defrauded the Ontario system of as much as $250,000, for both kidney and heart operations.

"As well, US immigration sources say they believe several thousand American women give birth in Ontario and Quebec each year using Canadian women's health cards."

Have these been independently investigated?

Mr Decter: I'll again, I think, turn to staff to maybe comment on the specifics. We have found in one of the analyses significant use of the health care system by people in the first 30 days, I think it was, that they have their card. Peter, do you want to join me here?

Mr Frankford: I don't believe that's the same thing.

Mr Decter: No, no, but I --

Mr Frankford: That presumably is legitimate use, and I don't think that's addressing my question.

Mr Decter: Well, Peter, let me ask you --

The Chair: It sounds to me that we're going to have a lengthy answer on that. Perhaps you could just kind of sum up and then we'll deal with the details perhaps tomorrow, because that seems to me a very lengthy issue that we'll get into.

Mr Burgess: Sure. Let me just summarize. The numbers that are mentioned in the newspaper article are clearly out of the newspaper article. Our report, which unfortunately got leaked to the press, and some work that we have done subsequently, do look at new services received within the first 30 days after registering. There was a concern expressed that the individuals were not eligible to receive services. Suffice it to say that if you want more detail, I'd much prefer to go into it at a time when we can really get into it.

The Chair: We'll have all day tomorrow, so I think that's a very likely subject.

Thank you. We'll end the session here today.


The Chair: With regard to the report of the subcommittee, I need a motion to adopt. Mr Tilson. All in favour?

Mr Jim Wilson: I have a question.

The Chair: On the subcommittee report?

Mr Jim Wilson: I think it refers to your subcommittee. On Thursday's agenda, it's a little unclear to me whether it continues on this topic or whether you're going to GO Transit.

The Chair: This is to deal with this matter.

Mr Jim Wilson: This whole week is health card except Friday?

The Chair: Yes. Thursday was to deal with Health in the morning so that we could conclude and write a report on this matter, or at least give direction to our researcher in that regard, and the afternoon was scheduled as well for issues around the non-profit housing report. So that's how we're going to proceed. I think that was made pretty clear in our subcommittee.

Can we move to adopt the report? Agreed.

We're adjourned until tomorrow at 10 o'clock.

The committee adjourned at 1646.