Wednesday 8 September 1993

Annual report, Provincial Auditor, 1992

Ministry of Health

Michael Decter, deputy minister

Peter Burgess, director, registration program branch

Gilbert Sharpe, director, legal services branch

Karim Amin, direct, audit branch

Robert Cavanagh, director, systems support branch

Patricia Malcolmson, assistant deputy minister


*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:

Rizzo, Tony (Oakwood ND) for Mr Duignan

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

Also taking part / Autres participants et participantes:

Peters, Erik, Provincial Auditor

Clerk / Greffier: Decker, Todd

Staff / Personnel:

McLellan, Ray, research officer, Legislative Research Service

Smith, Cynthia M., director, Legislative Research Service

The committee met at 1011 in the Humber Room, Macdonald Block, Toronto.


The Chair (Mr Joseph Cordiano): Good morning, everyone. I'd like to resume our sitting of the public accounts committee. We will continue with questions for the Deputy Minister of Health, Mr Michael Decter, and his officials who are once again gathered here this morning. Mr Wessenger, you have a point.

Mr Paul Wessenger (Simcoe Centre): I just want to be on the list for questions.

The Chair: I will note that you're very interested in being on the list. We will start this morning with rotation: 20 minutes I thought would be a nice time to allocate for each party, and we will commence with the official opposition and then move in rotation.

Mr Michael Decter: I wonder if I could correct something. Right near the end of yesterday, we were asked a question about how many cards we were issuing. The answer I gave was smaller than the right number; it was essentially how we're issuing to newborns. I have a piece of paper with how many we are issuing in total which runs on a monthly and an annual basis.

I also have attached, if we went to a three-, four- or five-year renewal cycle, how many that would be. So I wanted to correct that. The correct number is more like 80,000 a month and just under a million a year when you include immigration, newborns, the Health 65 cards and changes. I thought it was important to have the right numbers for the committee, and we gave an incomplete answer yesterday.

Ms Dianne Poole (Eglinton): On a point of clarification, Mr Chair: Are you saying there would be a million net more per year? Or is that a million more, then there would be some taken off because of deaths or moving out of the province?

Mr Decter: No, the numbers are essentially how many we're putting out a year. That's the gross figure. The net figure would be much smaller because it would take off deaths and outmigration.

But in terms of the question of essentially how much additional work would it be to move to a cycle, I guess part of our answer is, we're already handling almost a million issuances a year now. If we went, for example, to a five-year renewal cycle, that would come up to three million. If we tried to do it in a three-year cycle, that would come up to four and a half million.

It's partly my statement that we don't want to try and do 10 million again in a compressed time period, so we're looking at which cycle would be best. About half of that is new registration; about half of that is card replacements on the current basis.

Mrs Barbara Sullivan (Halton Centre): I wanted to start my questioning by walking through the history, as Mr Decter started his presentation yesterday. In 1985, when the Liberals came into power, there were 26 million people in Ontario who were considered to be eligible for health services. My understanding is that there were 26 million people who were covered under the old family registration system.

If you take the ministry's own figures, we're looking at more than double the population that in fact had some kind of access to health services, and with a potential of 1%, which the ministry has identified as being the potential for fraud or misuse, whether it's consumer fraud or professional fraud, the problem at that point was identified, I believe, as somewhere in the range of a $225-million problem, and that's why we went into the individual health card system in the first place. That was one of the main reasons, although there were others as well, including alternative payment requirements and so on for health care professionals.

With the individual cards that have been put into place to reflect eligibility, the strategic plan that was put into place at the time included several components. One of them was registration of people on an individual basis who were eligible for health services. The second was an enforcement process which was phase 2 of the initial step, which would have ensured that the access to health services was provided only to people who were in fact eligible for health services, and there was to have been a continuing enforcement and investigative unit. Then the third phase of course would have been to add additional smart card features, if you like, health record features, to the card for use by health care professionals and by the consumer.

We note that until the Provincial Auditor identified a very clear problem in enforcement, in eligibility for services and so on, in the auditor's report -- and he was very clear in that report with respect to initiatives that had not been put in place -- there had no been action taken, it appears, by the ministry to ensure that phase 2 of the project was in fact implemented; in other words, that the investigation-enforcement provisions that were included in the first strategic plan were in fact put in place. It appears that there was a delay, a gap, between phase 1 and phase 2 that created much of the problem that the auditor identified.

Can you talk to us just for a brief period, because I want to move on in terms of the strategic plan, about why phase 2, which was an integral part of the introduction of the individual health card plan, was not put into place when the government changed?

Mr Decter: There may be others here who can help me. That predates my time in this position.

Mr David Tilson (Dufferin-Peel): Revisionist history.

The Chair: It's important to look back.

Mr Decter: My impression, gained from my transition with Dr Barkin, was that phase 1 took longer than had been anticipated. That is, the registration itself turned out to be a bigger problem. Part of that may be accounted for by the reality that there turned out to be a good deal more people out there than had been forecast so that the target was a little bigger.

But there may be someone who predates me in these matters who can speak more specifically to that. I came into this position somewhat later. I can also take the question as notice, and we can try to get you a more detailed accounting.

When I arrived, we were in the difficult stages of trying to complete the reregistration. My earliest memory was, I guess the first week on the job, going up to our office on Yonge Street. There were 700 or 800 people who weren't very happy, standing in line waiting to register for cards, and this was attracting some considerable attention.

I think the general answer I can give you is that phase 1 took longer and that delayed us moving to do the enforcement issues. I guess the second answer I'd give you is there was a Peat Marwick study, and those recommendations were taken very seriously. That was about that time.


The other answer I can give you is that we did change our approach on the information technology side. There was a rather ambitious overall plan to move to an Encounter system, which would have seen the single number in every transaction. For two reasons -- one, the fiscal reason that we simply didn't have access to the magnitude of resources required and, two, because on examination I think our overall view was to take a building blocks approach to get the various pieces, first the registration database and second the drug program, before trying to bring it all together -- there was not good acceptance of the Encounter card approach from the provider groups and we were not significantly automated on the billing side.

After discussion, our decision was to try and get more of the building blocks in place. I still think the decision to go to a unique health number and the decision to use that for all health-related purposes is fundamentally the right decision in every sense, but getting there turned out to be more complicated than I think the original strategic plan contemplated. But as I say, there may be others here who can speak more to the history of it.

Mrs Sullivan: I would like if the deputy, through his officials, can prepare something more of a report with respect to the time lines on the introduction of the program in written form or to present later to the committee. I think it's important to look at the issue.

In your testimony to the committee last February, you indicated that you thought the problem with a $20-million problem -- that some of the figures which had been floating through the press and through others were inaccurate in terms of the difficulty in the entire health card system.

Yesterday you told us that indeed now ministry officials and those who are working with the registration system are looking at 100,000 cards which are suspect, with a potential of abuse of 1%. If we take the $1,400 per person per year figure, I want you to confirm to us that what you're saying to us today or at this appearance is that you're seeing the problem as being more of a $1.4-million problem than a $20-million problem, which you identified earlier. What is the problem? I think we want that clarification.

Mr Decter: Two things: I had undertaken yesterday to give you the updates of the registration analysis report and I have that. That was where I was quoting numbers from yesterday.

I would go back to what I did say when I was here in February. We were dealing with two ways of coming up with an estimate. I want to separate the two, because they're quite different. One is what is the difference between the number of people we believe to be eligible and the number of cards out there, and at that time we were debating 1.4 million and we were showing you that the actions we had taken had reduced that.

What I indicated to you yesterday is that the change in population comes very close to eliminating that, depending on what view you take, so there isn't any more a good basis on that side, in my view, for estimating that we may actually have fewer cards out there than there are eligible persons based on the numbers.

The other basis for looking at the fraud issue is to take all of the 51 individual studies we've done and in some way try and aggregate them up. When I was here in February, I didn't have the full report. What I had was a listing of the individual studies. I was asked the question and I chatted with staff over the noonhour and asked them the question, "What percentage are we finding in the individual studies?" and the answer I got was something in the 1% range.

I then, probably foolishly, tried to do a calculation on the back of an envelope as to how that would blow up.

I think what I specifically said was that we were finding stuff down around the 1% level, and depending on what base you put that across, that might be something on the order of $20 million. I went on to say that if it turned out to be 5%, which we were finding in some other studies, it could be much as $100 million and I gave I guess at that point a personal view that I thought it would turn out to be in the lower end of the range. It's always hazardous, I guess, for a Deputy Minister of Health to give a personal view on anything.

The report which you have that arrived in March gave much bigger figures based on the work, and the updated report, which I think is the best we've done so far, gives a range which runs from some low numbers to some high numbers.

I can't give you a precise number, and I'm not sure that anyone will ever be able to, because as we tackle the problem we're hopefully going to reduce the number, whatever it is. But I think our best view at this point is that you can arrive at a range that runs from the level of about 0.14% all the way up to 1.5%, and that's the $24 million to approximately $250 million. So it is a wide range, and I think some of that's evident if you've read the report. We looked at the areas with the most probability, in our view, of fraud, whether it's border towns or people who've just received cards, so we tended to look at the most probable place, as you would, I think, in the normal course expect to find more potential for fraud in Kingston, adjacent to the border, than, for example, Hornepayne, which is a good distance from the United States.

That's I think the best we've been able to do. There are staff here who could elaborate on it. But I think, in fairness, I wasn't here in February trying to convince you of any particular number. I was trying to give you our best knowledge at the time, and I will continue to do that. I make no apology for it. That was the best information we had in February when we were here and we're now providing you with the best information we now have.

Mrs Sullivan: One of the things that I think we want to have clarified in some detail for us is indeed the strategic plan which will be put into place for continuing development of the health card system that will ensure that there is controlled access to only those people who are eligible for health care services and that the card can be used in another development phase for other purposes, including personal health care records, and that would be accessible to the health care professional and to the individual. I am very uncertain, from the testimony that you provided yesterday, that indeed there is a full strategic plan that has been costed, where the cost-benefit analyses have been done and, given the range that you're speaking about today of $24 million to $250 million of potential problem, if the measures which are now being taken are indeed appropriate. I think one of the poignant comments you made to the committee last February was that one shouldn't be spending 2% to solve a 1% problem. In fact the range of $24 million to $250 million of potential problem is an enormous range -- it's 1 to 10 -- and developing a strategic plan that is fully costed, that has a time line and that's implementable and clear doesn't seem to be evident to us. I just wonder if you could comment on what kind of strategic plan is in place, how much costing is being done. You indicated yesterday that ministry officials had not calculated, by example, the cost of adding photo identification to the card system. What cost-benefit analyses have been done as a strategic plan is being developed, or has a strategic plan been developed? Are you just running by the seat of your pants?


Mr Decter: No, I think I was very clear yesterday in saying that we had not developed our recommendations to cabinet, that that work is ongoing. It's also clear that we'd retained Lindquist Avey to give us some assistance in looking at various areas where we might need red flags in our system to detect fraud.

So the answer is no, we don't have a strategic plan fully developed and we don't have our costing fully done. There are some very major policy issues that will have an effect on the cost. That's not to say there hasn't been a great deal of work done, but it has been work done in preparation for having a full plan to go forward to the cabinet on this fall. So we're not there yet, and we do intend to get it right before we go forward with it and to consult widely with experts in the field.

I would just remind you that we're here at your invitation to give you a progress report; we're not here proposing a strategic plan. We will go forward to the cabinet when our minister is convinced that we have all the questions answered. We don't at this point.

We have looked at other jurisdictions, and we have gained enough confidence to believe the photo is well worth adding as a feature of a new card. But I would say to you again what I said yesterday: The photo in and of itself is not a panacea; it's a useful additional feature. So are the enhancements that we intend on an interim basis.

So you're quite right. I think it's fair to say there was a strategic plan in place when this was launched and there were some very big benefits identified and I think the auditor has been critical of the inability to fully identify those savings in what's taken place to date, which has made us very much more cautious about estimating benefits.

I think it's also fair to say that we've backed up to a building-block approach because we want the whole thing to come together and the grand architecture that had been contemplated at one point ran smack into the reality of implementation. It did not roll out as smoothly as anticipated and that has left us with some residual problems. To be frank, it would have been better to solve the address updating problem before we started into the whole project, but it remains one that we now have to solve if we want the integrity of that database to be what it could be.

The Chair: I interrupt to use the Chairman's prerogative to ask one question, which I hope will elicit information for the whole committee. If you're going to bring forward a plan, would it be possible for the entire committee to see what shape that plan would take in its framework? I know this will go to cabinet. We're not interested in the actual details of the plan but what kind of process you're putting in place, or processes, within a framework or a general structure. I think that would go a long way informationally to assist the committee in knowing that you're tackling this problem in an efficient and cost-effective manner. Maybe we can't get to the questions of cost, but we can understand what you're doing in terms of the framework.

Mr Decter: I think I tried yesterday to sketch the elements of our overall approach. I think you're right, it's awkward -- I guess more than awkward; inappropriate -- for us to be here in advance of going to cabinet with the details of a plan, because our accountability in that sense runs very clearly to the cabinet. I think it might be a very good idea for us, once that plan has approval, to make it public and to share it with this committee in terms of laying out in a very open way all the elements of the strategy, with the exception that we want to be a little vague about particular security features of the new card since we're not eager to make that easy.

I think I want to reject the idea that we're somehow not pursuing these issues in a fairly organized way. The study that you have from March is the most thorough examination of fraud in the system that, to my understanding, has ever been carried out, and it has given us a great deal to deal with. The card issue is a much narrower issue that sits inside that, and that issue still has some decisions and some costing to be taken before we go forward.

I will say to you that I am somewhat sceptical about the merit of a detailed cost-benefit analysis in this field. You tend to get very large benefit forecasts that are largely cost-avoidance and you tend afterwards to have a great deal of trouble documenting that, I guess something our political scientists call a priori overdetermination, which is simply that at the end of the day it's hard to tell whether the new card, the new agreement with the OMA, the work of Dr Naylor, what one of a dozen factors could influence how much we get billed was really the causality. So we have a great deal of difficulty determining.

Obviously we have a base of these 51 studies which can be replicated a year from now or two years from now. We can look at whether those incident rates have come down.

But I have to tell you that it's easy to hire a firm to do a cost-benefit study. Most of the reality of those studies is what assumptions you make, and it's easy to assume that you're going to achieve something and then claim you've achieved it.

I think we are there. I'm certainly willing to give an undertaking that we would come back once we have a plan approved by cabinet on the card. If you want something more formal from us than the presentation yesterday on the broader plan, I think we could undertake to produce such a document for you.

But, again, it isn't as though we've got one area of the ministry dealing with this. The range of things on this issue involves virtually all of the areas of the ministry and different issues are being handled in different places. We have negotiations with the federal government around the eligibility and payment issue. We have work going on on utilization. I spent the early part of the morning with the OMA on the joint management committee on how we're going to deal with utilization issues.

I don't know if you're asking me, can we come back with a detailed plan on the card enhancements and the new card, which is the narrow issue, or you're asking, can we come back with a more comprehensive piece on the whole financial control and fraud detection and elimination, which is a much bigger piece.

The Chair: I don't want to take any further time because there are many people who are interested, but I think it would be possible to come back with just exactly how you're going to tackle this problem and set a process in place. For example, new cards, tendering that: Do you have a process in place that will determine what the best technology will be? This committee undertook some work back several months ago to examine that. We don't have the expertise to come up with a final recommendation that would satisfy, I'm sure, the in-house experts that you have, but we want to be reassured that you have a process in place that's capable of doing that.

I'm going to turn back to the Liberals and add three minutes to their time because I took it away from them, and then we'll move in rotation from there.

Mrs Sullivan: I can understand, Mr Decter, your scepticism about cost-benefit analysis, because of course that's only one aspect of the analysis of the entire process, but I feel that cost-benefit analysis is an essential part of a strategic plan, and what we see happening is steps being taken in the absence of a strategic plan. We heard promises yesterday, by example, that the photo card would be in place by December, we have an agreement with the OMA that eliminates the version codes and so on. So in the absence of a strategic plan, steps are being taken now on card enhancement and on some aspects of the financial and other controls, without a full plan that appears to be in place. I think that's where the concern is. In the next round of questions, we want to ask more specifically about particular steps, but the concern is that there is no plan and that action is being taken that may well not prove to be viable in the absence of a full plan.


Mr Decter: No, first of all, there was no statement here yesterday that a photo card would be introduced by December. The statement was that a decision would be taken by December. I think we were very clear that the introduction of a photo card would be sometime beyond December of this year, a date not yet established.

Second, I would frankly reject the suggestion that you can't take action absent a plan. All of the actions we're taking have to be actions that justify themselves on the action itself, and we are proceeding to do a number of things. I don't think you need a grand plan to understand that if the federal government were paying nine other provinces for something and not Ontario, it's sensible to pursue the federal government for that cost-sharing or for that payment.

I also don't think that, given repeated comments by the Provincial Auditor to the extent that the backlog at the MRC is too long and has extended and that's a problem, going before the Legislature with legislation to expand that committee is somehow invalid because of the absence of a plan.

I agree with you completely that we have to have a full, costed and logical and justified plan for any changes to the card, and I think that, frankly, is what we're working on. But there are a number of things that I think get us a return on the investment to date that are worth doing on an ongoing basis, and we have to undertake some amount of piloting. The technology that was demonstrated yesterday, you don't get the bugs out by studying it; you, frankly, get the bugs out by field-testing it and finding out what works and what the acceptability is to the provider groups. We're in that process, both with the swipe reader and the interactive voice response technology. It's got to be user-friendly and it's got to be cost-effective, and we are working on that. But this is a very big, complex problem and I make no apology for tackling the parts of it that can be tackled as rapidly as possible.

I agree that on the card front, yes, before we go to cabinet we need to have all of our costing done. We will do cost-benefit analysis. I'm just saying I, for one, am sceptical of the kind of large benefits that historically tend to get rolled up in those analyses; not that you shouldn't do them, but you have to balance that analysis against your experience in the field.

Mr Tilson: Mr Chairman, I'd like to continue on with the question that you asked Mr Decter, and that is, we had an OHIP system that didn't work, we had a red-and-white card system that obviously hasn't worked and now we're about to embark on a new system through stages, as you showed us in your presentation yesterday, to an interim card and finally to a photo card. I think the question the Chair asked is quite relevant, that we as a committee are looking at this topic, just as you are looking at it in your last few comments, having pilot projects, reviewing it with groups. This committee I don't think would be doing its job unless we understood, whether at the same time or before you make a presentation to cabinet -- obviously, cabinet is going to make a decision, but I think it's fair game for this committee to receive information from you. Obviously, I understand you can't tell us matters of security, but I'm quite concerned that this committee is not going to have an opportunity to hear full details until after you have made a presentation to cabinet.

Mr Decter: Let me try, if I can: One, I'm delighted that this committee takes it seriously and is going to hear from a range of people, and we will follow what you hear pretty closely, and would be very interested in your recommendations around this issue before we proceed.

Mr Tilson: But we can't make recommendations until we hear details as to what you're going to do, and you say you're not prepared to tell us what you're going to do until you've had an opportunity to review this matter with cabinet.

Mr Decter: Let me see if I can walk down the road here a little more constructively. I can't share with you a plan that hasn't been approved by cabinet. We're working on that plan. We're consulting widely on the technology options and on the system options.

I think, frankly, it's wrong to say that the move from the OHIP system to the red-and-white plastic card didn't work and now we're abandoning it. I think the registration database worked fine. We're now looking at whether we could enhance the card itself by putting a photo and some other features on it. But the movement to a single health number, I think, has worked very well. It's not completed. We still have lots to do on it, but I'm not trying to avoid this committee. Again, I just say the choice of timing was yours, not ours. I'm happy to come back here in a couple of months and be more specific about the various technology choices as we get closer on them.

We have at this point only taken two decisions: that we believe a photo makes sense on the card, and that is largely based on the providers saying to us: "Without a photo on the card, at the point of service, we have a lot of trouble matching up people and cards. A photo on it is going to enormously enhance our capacity to do that," and on the Quebec experience, which is a year old.

But I'm not resistant to being back here in a couple of months when you've heard from experts outside and when we've heard from experts and before we go to cabinet. I'm not resistant to that. I'm just saying there are some parts of cabinet government that I can't come here and put some of those tradeoffs on the table for you. I can certainly come back on the technology issues and on the system issues. I think those are very much, frankly, non-partisan issues in terms of everyone wants to get this right in terms of these enhancements.

Mr Tilson: I quite agree everyone wants to get this right and that's why, to be quite frank, this committee is concerned with the processes that have been followed. You came here in February to review the red-and-white card system and we were all very concerned.

In fact, we're even more concerned now. At that time, just as an example, you told this committee that there was a $20-million loss with respect to fraud and other matters, although you now tell us that was done on the back of an envelope, although you continue to stick to that information notwithstanding the fact that this registration analysis report has come out with a loss of $284 million. That was the following month.

To be quite frank, I'm concerned because I understand that members of your staff had a summary of the registration analysis project available when you were to this committee, and I guess we have good cause to be concerned, whether you're looking at $20 million or whether you're looking at a billion dollars, and quite frankly, the figures that are flying around this province, I don't know what the loss is. You have given figures, but there are all kinds of others report this. The registration analysis report by itself has talked about $284 million. Mr Chairman, I think your question is valid. Hopefully we will be pursuing that at a later date.


I would like to pursue some of the issues. You've explained to us yesterday with your slide presentation as to the different stages, that the ministry intends to go through an interim process and finally to a photo system, and that is going to be done gradually, over a period of time.

My concern is some of the issues that have been raised in the House, particularly by Mr Wilson, our Health critic, and most of which are reviewed in the Registration Analysis Report, of examples of fraud, everything from non-residents using it, to the example that Mr Wilson gave, I think, earlier on in the spring on the woman in Kingston giving birth in Kingston one day and Richmond Hill the next, to people on welfare visiting multiple doctors to get drugs for resale on the street. All of these examples are given in this report.

It would appear, whether you're talking an interim system, an interim card or a card that's going to be changed over a period of time, there doesn't seem to be any plan that you have informed us of that's going to stop or slow down this fraud. Can you tell us what plans you have?

Mr Decter: Number one, and let's back up to it because I really will not be misrepresented on this point. I will read you what I said here in February on the issue of the number. I really frankly resent, in my attempt to be direct and forthright with this committee, that this would be taken as an attempt to mislead the committee, as has been suggested, not in this room, but in the assembly.

I came back after a lunch break. I spoke to the staff, the very staff that did this report, and I will quote you from the transcript: "Mr Burgess provided me with some figures over the noonhour. I asked the question, in the 50 studies we've done to date, what percentage of fraud are we finding? I'm overstating it. Fraud isn't there until you've proved it in a court of law, but what percentage of what we're finding seems to be suspicious? Despite our expectations, it seems to be down around the 1% level."

I then went through the calculation. "If you take $1.4 million times the 1,400 times 1%, we have a $20-million problem that we're pursuing. If you take it times 5%, then it's a $100-million problem. If you had to ask me on what I now know about how big is the issue of either fraudulent consumer activity or fraudulent provider activity, I think a good ballpark is probably in the 1% to 5% range and I would believe it to be, on the basis of the work we've done, closer to the low end of the range, that it's more likely to be in the $20-million range." That's what I said. That was based on the work we'd done to date, and I'm back with here with the numbers that are the most current numbers we have.

So I'm pleased to be here, but if the intention of this committee is try and make an issue of us providing you with the best information we have when we're before the committee, I can be very careful. We'll take everything as notice and we'll have every piece of paper that comes before this committee qualified. That's maybe more traditional in government. I haven't taken that approach here at any point. We try to be as direct and honest and yes, a month after I was here, we got a rollup of that report that came up with much bigger numbers. That report was not concealed by the ministry. It was received; we took action on it.

You ask me what our plan is. You cite the example of people using our health system to obtain drugs which they then sell. Larry Stump provided you yesterday with an overview of the automation of the drug program, which we hope to have in place within the next couple of months which will bring a halt to that practice. It will stop, at the point of service, someone from having the same prescription filled multiple times, which is a point the auditor has made.

So on the drug program side, I think we have a very clear plan. We've got a very good partner in Green Shield and moving forward on it. I think I've tried yesterday to describe the actions we're taking in terms of the health card, but I do believe we have a plan. We are taking a number of very concrete actions; we have set up an investigative unit. So I understand the job you have to do, but I think we ought to be careful with these numbers. As we learn more, the numbers may move. They may move up or down.

Mr Jim Wilson (Simcoe West): With respect to the numbers, though, I guess the concern being expressed by my colleague is that, if not yourself, certainly Pat Malcolmson, the ADM, up until very recently, with full knowledge, one would assume, of the analysis project, was still using with the media the $20-million figure. Your ministry was still using that figure, sticking to it, at least as it was reported in the press. Now you've made it clear both yesterday and today that this perhaps is a misrepresentation to some degree of what the ministry's position was, but as you know, a lot of our information comes through the media when you're in opposition.

I do want to pursue what Mr Tilson's been talking about, though, and that's with respect to your plan. I don't think you're going to be deputy minister in two years. I don't think the NDP are going to be the government in two years. I perceive the ministry, while trying to clean up the database and do a bit around the fringes in terms of adding security, is dragging its feet on this, and I think you're dragging your feet on this.

I think that to find out yesterday that you're going to phase in photo ID -- starting God knows when, because this morning you tell us it's not December, it's whenever -- is foot-dragging. I can see at the rate that I think you're suggesting that it may take 10 years to phase in photo ID. I can also see in the case of my own health card, for example -- I don't think you'll ever get my health card unless it's a sort of standard Ontario resident, unless you're going to do a recall of some sort. You tell us you're not going to do that. You've got, by the ministry's own admission, thousands of possibly fraudulent cards there. I don't think you're doing enough in terms of upfront verification still. Frankly, I think --

Mr Anthony Perruzza (Downsview): You're telling me in two years you're going to be minister and you'll clean it all up?

Mr Jim Wilson: Frankly, I think that's exactly what I'm worried about. Either a Conservative or a Liberal Health minister is going to be stuck where Mr Decter is in a couple of years trying to give the same answers that Mr Decter's giving this committee.


Mr Jim Wilson: I guess our frustration is we're running out of patience with this. I really would like a better answer in terms of what exactly you are going to do to bring in what I think is needed, which is a new system. Or can you at least give us a time frame on your phase-in? I'm not happy with it.

Mr Decter: Let me say -- because obviously I wasn't clear enough yesterday. I said yesterday we hadn't taken a decision on the renewal cycle. We had taken a decision that we will go to a renewal cycle. That means everyone's card, whether it's three, four or five years, gets replaced in that cycle and then replaced on an ongoing basis like a driver's licence or a passport. So in saying that we haven't decided whether your card will be a three-year, a four-year or a five-year card, we have decided that there will be a renewal cycle. I think that's quite important. That's a fundamental change. We're not going to simply wait for everyone to move in and out of the province or for everyone who has a card to die so we can issue them to newborns. That process, at about a million cards a year, goes on. So we have, if you like, an implicit renewal of about 10%, something on that order, of the card base. We are going to move to a renewal cycle, and the decision will be, I believe, whether three, four or five years is the appropriate cycle. So, yes, as part of that we will obviously have to recall people's old cards or render them inactive, which achieves the same result once the system is put together.

But again, I'd come back to it and, I mean, I take your point. If I were here in two years, I'd be the longest-serving deputy minister of Health not only in Canada but in the history of the ministry for quite some time. This is not a job with -- how should we put it? -- a long life expectancy.

But I would also say I have a lot of respect for what my immediate predecessor undertook on this issue. The database is the right answer and is an essential part of this. We're now talking not about throwing away a huge investment in getting the database there; we're talking about some continuing investment to converge.


I'll say that when I was here in February, we had quite a significant gap between the number of people in the province and the number of people in the database, and that was a legitimate, big concern of this committee. That issue has been significantly dealt with, both by our actions of getting ineligible cards off, numbers off, and by the population adjustment. So I'd say to you that I think a great deal has been done since I was here in February on this issue and I think you're going to see a great deal more done over the next six months to a year on this issue. The drug program automation will give us an enormous leg up on a big part of our active users of health care in the province.

So, do I share your frustration? Yes, I would like all of this to move faster than it's possible to move it, but we are not going to move faster than our ability to deliver. I think a lot of this turns on our ability to get proper assistance, proper information exchanges. Candidly, it's boring. It's not really exciting. It's much more exciting to convict a couple of people of fraud, and we're going to do that as well, than it is to arrange a data exchange with Employment and Immigration Canada. But our real answers tend to lie in areas like data exchanges, getting people who are illegally in Ontario off our list of eligible people so that they're not using health services.

Mr Tilson: The data exchanges that you just referred to, of course, are itemized on pages 14 and 15 of the analysis project, which I think you have before you. At what stage are discussions related to those exchanges? What stage are we at?

Mr Decter: I think I've got it in the update that you were handed this morning. I think I've got an update of the data exchanges and I can walk you through them. It's on page 6 of the update.

In terms of Employment and Immigration Canada, in early November 1992, a memorandum of understanding was produced to enable the exchange of information regarding refugees and those who had been deported. The final legal wording is now being finalized to enable the exchange to take place on a regular basis.

With the Ministry of Transportation, discussions are currently under way as part of the discussions regarding cooperation between the two ministries in the reissuance of health cards.

In terms of the interprovincial, it is ongoing with all provinces for reciprocal billing purposes. An exchange of registration information with Quebec was initiated in June 1993.

With Health and Welfare Canada an exchange was initiated in June 1992; however, the federal legislation would not support the exchange for purposes of registration verification. The federal legislation has been amended and negotiations have reopened effective July 1993.

We have discussions under way with the office of the registrar general regarding changes to the newborn registration process. In addition, the information exchanges with the registrar general to ensure timely removal of deceased persons from our files were placed into production on a monthly basis in August 1992.

With the Ministry of Community and Social Services, ongoing exchanges with MCSS regarding drug program eligibility and reference numbers have brought to light a number of situations that are under investigation by its staff.

That's the status of information on the data exchange.

Mr Jim Wilson: With respect to smart card technology and your Encounter card pilot project, I very much am coming to the conclusion that photo ID is not the way to go and I'm worried that several million more dollars will be committed perhaps this year and spent over the next few years, as you say, phasing in that technology.

I hear Mr Pouliot, the Minister of Transportation, announce earlier this year that he'd like to go to a magnetic strip on the back of drivers' licences. We have social assistance cards, we've got the new ODB system to be up and running soon, seniors' cards, all kinds of plastic government cards out there. Your own analysis of the smart card pilot project suggests there is the possibility out there of one card for government services. We have Outdoors cards, and I'm told by a number of the people in the smart card business that really your imagination can fly with respect to what's possible. Can you tell us what you're doing and what coordination you have with respect to a card technology with other ministries?

Mr Decter: We have very direct discussions with MTO because of the photo issue. Management Board secretariat have been doing work on a government card, if I can use that word, to look at what range of programs they might be able to include. My impression of that, and you may want to talk directly to Management Board staff, is that that's on a fairly long-time horizon, but we continue to talk to them about it.

I think we've shared the evaluation of the smart card pilot with you. In addition to getting the evaluation, I did go and spend a day in Fort Frances with the people involved. Intriguingly, the biggest impact seemed to be not so much the smart card and what was on it but that it compelled all of the providers -- the physician, clinic, the hospital and the pharmacy -- to automate their own records, which they found to be a big change. Their comment informally to me was, "The smart card wasn't really the thing that caused the change; it was us putting our own house in order in terms of records."

I guess we're torn a little bit here between the obvious benefits of a card that would combine a number of government programs into a single card and the other reality, which is that you people are going to be mad as hell at us if we don't get the fraud issue in health dealt with -- not just you individually but the OMA and the coalition of public sector unions, both of which have been quite active on this issue. So we are being pushed to move rather quickly.

There are a number of privacy issues once you get into a multiple-program card and a multiple-ministry card, and a lot of concern about cross-connecting databases that are connected for different purposes with personal identifiers. So in the same way that there's a balancing act, as I indicated yesterday, between the management issues and the privacy issues even within the drug program automation, those issues are there as well. As I said, there may be someone in the group who is more familiar with where the Management Board secretariat are on this issue at the moment.

Mr Jim Wilson: It's crucial that we hear from --

The Chair: I'm sorry, Mr Wilson; I allowed you three extra minutes. Mr Wessenger.

Mr Jim Wilson: On a point of order, Mr Chairman: I would request that at some point we ask representatives from Management Board to tell us where they are with respect to government cards, because that's going to be the essence of our final report, I would say.

The Chair: Might I suggest, Mr Wilson, that you do have an additional period of time in rotation, and you could bring that point up at that point. Thank you.

Mr Wessenger: I was interested in your comments, Mr Decter. I just am somewhat in a cynical mood today, maybe because I'm not feeling very well, but what I'm concerned about is this fraud issue: Are we really fighting a perception rather than a reality? That's my major concern. I'd like you to comment on that because I know that individual cases often distort overall reality, and I'm very concerned that we may be putting too much of an effort into, for instance, the establishment of a new card. It seems to me like we're making very good progress with respect to information exchange, with respect to tightening up registration. If we're fighting a perception, perhaps it would be interesting to know -- I'll just ask the factual matter of what the additional costs are of tightening up the auditing and enforcement procedure with respect to fraud, to know what costs are involved in that. I'd just like a comment on some of those issues.


Mr Decter: Again, a general comment: We are not abandoning anything. We are looking at both pulling the levers we have available to us at the present by tightening the registration, by tightening eligibility, by enhancing the integrity of the registration database, and by automating as much of our interactions with the providers as we can, the physician billing system, the pharmacy system.

I think all of those things are worthwhile, all of those things will help on the fraud front. All of those things will make it harder, in several ways, for fraud to be committed. They will make it tougher at the point of service, they will make it tougher at the point of registration and they will give us an ability to analyse data and focus in on where the patterns are. Lindquist's main strength is that these are the best forensic accountants in Canada, people who've led white-collar crime fighting at the OPP, at the RCMP. They're very good at telling us where we're at risk in all of our systems and where we need to put our resources.

This is being carried out to date with internal resources. This very big report and the studies were carried out by ministry staff redeployed from elsewhere, and the ministry staffing has been steadily shrinking over the last couple of years. We have a hiring freeze, we have redeployment so, frankly, by automating physician billings, we free up some people who can then be helpful on these other issues.

You ask a very, I think, important question up front: Are we reacting only to public perceptions or are we reacting to the reality of a situation? I think both are important. The public, in any of the opinion surveys, are very concerned about the future of the health care system and their attitudes have hardened a good deal around abuse of the system, and I think that's fair to understand. A system that was growing 10% a year in spending was not a system that forced a lot of tough choices at the margin. As we've reduced the growth in spending, in fact flat-lined it, we have a lot more stresses among both consumers and providers around choices at the margin. We will be, for example, delisting some number of services. We're working with the profession and there will be a public process.

I think for all of those groups, whether they're consumer or provider, the idea that someone is beating the system is an extraordinarily offensive idea at this point in time, more offensive than it was back in the old OHIP premium days, where there was not this attention. When I talk to people who worked in the ministry 10 and 15 years ago, they said it really wasn't an issue then. It was not an issue with the public; it was not an issue, significantly, with the ministry.

I don't think we're only reacting to public perceptions. I think that, and the studies underscore it, we have found in a number of areas both things that we could tighten and we have also found evidence that looks very much like fraud and we are pursuing those cases. Our new investigative unit will pursue those cases. It's also just evident that, as you expand both the number of providers and consumers, unless you assume that as you have more providers they suddenly become more honest, you're going to have a small minority of providers who attempt to abuse their privileges as providers.

History would say our recoveries have increased over the years from MRC referrals. They're still not large on a system basis. We're talking a couple of million dollars a year, I think $2 million last year against almost $4 billion of billings. That is not high enough, from my point of view, to cover the kind of percentage you would expect to find.

So I think we have a real issue. As would be evident, we're not absolutely certain of how big it is, but it is significant enough to warrant some efforts, frankly, aimed at both dissuading the behaviour as well as catching it; I think, frankly, having some media attention around the reality that borrowing someone's health card and using it to obtain services is fraud, a Criminal Code offence.

We have tended to treat health fraud, I think, more gently. We've tended treat it as a case of overbilling on the providers' side and attempt to recover the money through a long process. Similarly, we have not been very tough-minded. Our hospitals haven't been very tough-minded. They have the major, along with physicians, point of contact.

Would we be going as hard at this issue if the economy were booming and the issues in health were more around managing growth than managing a flat-lined resource? I think probably not. But when you begin to say to people, there are very real limits to what we can afford to provide as a system, then I think every efficiency we can find and every management improvement we can find becomes very important to the ministry, to the government, to the assembly and to the people of Ontario.

In saying that we're going at this rather harder now than we have in the past, I don't believe we're simply reacting to a changed public environment. I think we're reacting to a very changed real environment for the ministry. We're expected to find several per cent of productivity improvement a year so that we can continue to invest in new hospitals, new technology, to fund midwifery, which is coming in. No one's giving me more money to do that. I have to find it from within, as does the whole ministry, and that takes us very squarely to the fraud issue, the overutilization issues.

Mr Wessenger: To follow up on the photo aspect, you indicate to some extent the photo card is to not only protect against consumer fraud but also provider fraud by clearly having evidence that if a provider has treated someone wrongly, you have the card as a backup for a prosecution. I can certainly understand that.

It seems that photos would be very inappropriate for infants and young children. Obviously, there's going to have to be an age cutoff with respect to photos and some sort of requirement that parents or custodial persons provide identification with respect to providing health care services to those persons.

Mr Decter: Yes. It will come as a shock to parents of any newborn, but they do all look a little alike. I remember going around with pictures of mine and thinking they were the most beautiful babies ever born. Looking back on those photos, they kind of look like everyone else's babies. But we are not planning to go at the newborn end. I think we're looking at an age start. I don't know if someone here can talk about whether we're looking at 16 or how that integrates with the driver's licence.

Mr Wessenger: On the question of new cards, I know you don't have any estimates of costs.

Mr Decter: Except generally.

Mr Wessenger: Perhaps you could indicate, are the major costs involved in the reissuing of cards on a cycle basis more so rather than adding a photo? Would that be fair to say?

Mr Decter: Let me turn to staff for some help there on what we do know about costing in terms of Quebec. Don't be bashful. It's a little lonely up here.

Ms Poole: Don't all rush up at the same time.

Mr Decter: That's it. Welcome aboard, Peter.

Ms Poole: There's loyalty, then there's loyalty.

Mr Peter Burgess: We've done some very preliminary costing of a variety of options, but they're very difficult to split out because, as has already been discussed, we want to change some of the basic information on the front of the card anyway, in an embossing sense, to put things like an expiry date and date of birth and so on.

Adding the photograph itself, over and above a straight, regular plastic card, would appear to be in the very high number of cents-per-card region, like 70 to 80, based on the sorts of volumes that we're looking at. Frankly, by the time you get into the law of large numbers, if you're doing some eight million of these as an approximation over some three or four or five years, that's a very large number of dollars. Frankly, however, the cost of the card itself is relatively insignificant in terms of the total cost of implementation and getting that card correctly into the hands of the correct consumer.


We are grappling today with issues surrounding utilization of other ministries; namely, the Ministry of Transportation's facilities to perhaps take the picture, but still have not yet determined the appropriate solution for actually physically producing the cards. Does one take the picture in a variety of government sites across the province and only issue the card from a central site or does one take the picture at those remote locations and right there and then physically produce the card with the photograph on it? There are clearly some benefits and some drawbacks to each one of those two very easily understandable alternatives.

Frankly, we haven't come to the end of that discussion. I'm having a lot of discussion, as are my staff, with other jurisdictions -- Quebec being one -- including those who have used drivers' licences in the States. Our own MTO, of course, we're spending an awful lot of time with and, frankly, I don't have enough comfort level yet to say that we will definitely or we should, even, definitely do it one way versus an alternative way.

Mr Wessenger: Fine, thank you.

Mr Decter: I could give you the Quebec numbers just briefly on what we know. The unit cost for a renewal card is estimated by Quebec to be $4.10; the unit cost of a replacement card, $9.10.

Quebec, just on the previous point, exempts children under 14 and persons with disabilities from requiring the photo, and they don't charge for the initial card. They do charge a $10 card replacement fee but they exclude senior citizens for that. They are considering a penalty fee for registrants who don't renew prior to expiry date on their card. Based on that, we are probably talking in a $4 to $10 kind of ballpark, but it will change depending on volume, depending on the method we choose to do it.

If you think about it, there are quite different methodologies in place. With your passport, you go and get a photo anywhere and get it certified. With your driver's licence, you go in and have your picture taken in a very specific place, so we're trying to canvass all the available options.

We're also faced with technology that is rapidly changing. Information technology is the most rapidly changing part of the technology world, which gives us, I guess, both opportunities and perils that will do something and it will be passed by with some integrated system.

Mr Robert Frankford (Scarborough East): Let me suggest that there are very different alternatives that could be looked at, and if this committee is going to be suggesting ways of going, for a start, let me observe that a lot of this is predicated on a fee-for-service system and not everyone is enthusiastic about that. I think a significant number of thoughtful physicians are asking to go off it and I think you would find that a lot of the need for this would disappear in non-fee-for-service approaches.

Although I totally agree with the need for registration, I don't think the advantages of registration in terms of epidemiology and rational approaches to health care, and some very cost-effective ways of dealing with medical problems have been mentioned here.

If we look at the identification of diabetes, let alone the more innovative things which are happening in Britain where seniors actually get an annual letter reminding them that they should have a physical -- there's no cost to the system; in fact, that's ensuring that the system is getting value for money. These are things which I think we should be looking at. I think we got very much sidetracked into a fiscal transfer approach.

I could go on for a long time about this, but let me just mention one thing that occurs to me, this question of registration but not necessarily cards. The ministry is developing I think five comprehensive health organizations. It would seem to me that you could perhaps make a good case that the people belonging to a CHO should not have a card, if the advantage of a card is that you can go around generating as many costs in as many places as you want. That's really contrary to the intent of a CHO, as I understand it. Would you maybe consider that enrolment in a CHO, you actually give up your card or you have a new card or a new number or something?

Mr Decter: A couple of comments there: I did say when I was last here, and I'll say it again, that there are enormous values in having a longitudinal, over time, database with a unique health identifier. Manitoba took that decision when it brought medicare in, and as a result the epidemiological studies that can be done in Manitoba on diseases like multiple sclerosis, you can go back now a couple of decades with unique identifiers and you can trace diseases in family groupings. Manitoba is getting chosen as a site for some amount of research, so it's a very valuable thing to have. We're beginning to build that.

Clearly, the Institute for Clinical Evaluative Sciences will benefit as we have that database, so there is enormous value, not just in management terms but in health and health care policy terms and epidemiological terms, to having an ability to look at not just services but the course of diseases going back historically.

It's hard to quantify that and put a value on it, but some of the major breakthroughs in terms of new therapies, new drug therapies, even the discerning of whether a particular disease is passed along genetically or has some other causality is helped by that.

When it comes to the movement away from fee for service, you're right; we are moving in the comprehensive health organization direction and we have a number, as you would be more aware than anyone else, of health service organizations. We still need the registration there because essentially, instead of paying people for service, we're paying them for looking after the health needs --

Mr Frankford: I don't disagree at all. As I say, it's a vital record epidemiologically.

Mr Decter: Yes. We're looking at the issue and we negotiated some changes in the latest round around the so-called negation issue. If you're being paid so much a month to look after someone as a CHO and one of your group goes off and absorbs a lot of services somewhere else, how does that affect your budget? On the one hand we're looking at giving the CHO or the HSO scope to provide a different package of services; on the other hand, the kind of check on providing no services is that the person needs to remain eligible to go somewhere else. There's a balance there. It's tough to introduce a capitation model in, if you like, an oversupplied fee-for-service system, but I think we'll learn more as we move along. But I think in the first round it's not so much that you need to produce your card when you go to the CHO; it'll be important that you produce your card if you go somewhere other than the CHO so that --

Mr Frankford: Why is that, because presumably you would be only referred within that CHO process? Wouldn't it be better that it's a number transfer rather than carrying -- I mean, it has a potential for eliminating fraud, it would seem to me.


Mr Decter: I think our dilemma here is, and let me walk you a little down the road -- say we are making good progress on the CHO in Wawa, Ontario, and we get there and everyone in Wawa enrols and so on, then someone from that CHO without a referral turns up, presents at a doctor's office in the Sault or in Sudbury or somewhere in Toronto. Our concern is that we could be paying twice, in a sense, if we don't have some way of capturing that data; not to say there wouldn't be very legitimate cases where someone is --

Mr Frankford: If you understand what I'm saying, I think that if that person did not have a card, but if he or she were only electronically registered, then it would work better. The other provider would have to get back to the CHO to find a number, and I think this is strengthening my case that we should really not presume that cards are intrinsically good. I think one can argue that cards encourage an item of service, a go-wherever-you-want approach. Maybe we've tapped into people's perceptions that a credit card is perceived as something where you get things for free.

Mr Decter: I think you make a good point. We're really after getting people the most appropriate care as close to home as we can and having them looked after by a team of providers over a long period of time. We're not trying to encourage, in fact we're actively trying to discourage the kind of one-time use of walk-in clinics and hospital emergency wards.

Having said that, I think we do have the reality, in certainly the metropolitan parts of the province, of a very mobile population which gives us problems on the address side and some real issues there. But you raise a good point and we are working through how that relationship between the CHO and its enrolled population and the rest of the health system will work.

We're also trying to link needs and resources in the north so that we're flying fewer people out of the north for services and having more northerners get the services they need from northern providers. So that's a very good point.

I don't think we're trying to encourage a credit card mentality about this in the sense of, "It's free and you're going to get as many services as you can." I don't think most people want more medical services than they actually need, but I do think we have the reality now that it is a credit card and we're trying to tighten the management of it. At the same time, we're looking at models that would be less transaction-, less fee-for-service-based, more continuum-of-care-based. It's certainly not our intention to try and drive the use of the card into areas of the system like public health, for example, where we're providing an approach that looks at healthy communities. On the other hand, the information is very valuable in giving us a map as to how resources really do flow in the system. So there's a bit of a balancing act.

Ms Poole: I'd like to take a look at the registration system. We've already heard yesterday and this morning that in 1985 we had a situation that there were 25 million OHIP registrants in less than 10 million population. I was looking through your registration analysis report this morning to see how the new red-and-white card system compared to that, and there's a paragraph that says: "This leaves about 10.8 million people registered in Ontario with medicare coverage. This is within 6,000 of the Ministry of Finance's current estimate of the provincial population." That's on page 1 of the executive summary.

Earlier this morning, a member of the third party said that the OHIP registration system was a failure and the red-and-white card system was a failure, but I would estimate that if it's within 6,000 of the current estimate of the population, that's actually a fairly small percentage. Could you give us some more details of that? Is that a fairly small percentage?

Mr Decter: I think again we will give you the most up-to-date numbers we have. I think if you look at two charts that were provided yesterday -- I'll hold them up to remind you of them. One looks like this and one looks like this --

Ms Poole: Mine wasn't coloured.

Ms Sullivan: Yours looks better than ours.

Ms Poole: Can we trade?

Mr Decter: I could you the coloured ones. We probably didn't make them in colour because we didn't want you to think that we're extravagant in any way. I'll let maybe Peter speak to the issue of the difference between the two estimates.

Mr Burgess: Quite simply, the numbers changed in a major way in May 1993, effective in June, and that was as a result of Statistics Canada changing its basis from the 1986 census to the 1991 census. In fact, what happened as a direct result was that a difference 599,700, I believe, to be specific, was added to the base of believed Ontario residents in June 1993. We have in fact, since about last December, been talking to the Ministry of Finance, formerly Treasury and Economics, staff to make sure that our numbers were or were not correct.

We still, frankly, at the detailed level, have some concern, but at the overall level we're satisfied that while it's a bit like grappling with Jell-O or trying to hit the proverbial moving target, we are relatively satisfied that at the grossed-up level our numbers are reasonably close, in fact very close, and are reasonably consistent. So while we have some specific concerns within that population of 10.6 million or 10.8 million, where it looks like a subset of that 10.8 million, as we see that subset on our database versus Treasury and Economics or Ministry of Finance's projections appear to be a little bit off, at the grossed-up level it appears that we are okay.

That's all I'd like to say right now, other than the fact that clearly it's not something we're prepared to drop. We need to work on that to make sure that even at those individual levels, we do accurately cross-check.

Ms Poole: Just one other question, because I know our critic has a question she'd like to ask right now: It was originally anticipated that registration would take about a year and, Mr Decter, you mentioned this morning that it did take longer because of other factors, including a larger population base than anticipated. I'd like to know that once it was considered completed, given the fact that it never is completed, but primarily completed except for new births and new people moving into the province, what steps were taken at the time of the completion to verify eligibility and to eliminate fraud? How many people, for instance, worked in that particular unit that looked at that aspect? What kind of funding was granted to that unit in the 1991-92 fiscal? The last figure I could understand you wouldn't have readily available at your fingertips, if you want to provide that later.

Mr Decter: We could certainly provide that. I'll let Peter give you what we have, but I think on the specific budget numbers, we could try and get that for you.

Mr Burgess: I'm not sure, actually, whether this made it into your executive summary, because I haven't seen the final copy. However, in terms of historical background, the initial registration started in fact in April 1990 and was, as I said before, "completed" by January 1, 1991. In April 1991, that same year, a very small unit, approximately 12 people in the then existing client services branch of the health insurance division, was given responsibility for verification.

I should also state that in the fall of 1990 and the spring of 1991, the two audits that our deputy referred to, the Kates Peat Marwick audits of both the initial registration activities and the ongoing registration process were completed and presented in April 1991. Between April 1991 and May 1, 1992, when the branch I currently head, the registration program branch, came into effect, the total funding was sufficient for 12 full-time individuals within the Ministry of Health.


Mrs Sullivan: I want to move to the security enhancements at the point of service and to move back to the recent OMA agreement which, among other things, included the elimination of the version code. The version code was added at one point to enhance the personal identifiers and draw to attention the problem with duplicate cards, by example. I wonder what analysis went into the agreement to eliminate the version code at this point in time when other steps to improve the security of the card will not be put into place until significantly, or perhaps somewhat, later points in time.

Mr Decter: I think you may have a bit of a misunderstanding of timing on this. The agreement reads that there is a series of undertakings. Undertaking 10 by the government is ensure use of the version code is discontinued for health cards with photographs. The version code will not go until the photo arrives. Essentially, we're looking at the cycle and other measures to replace the version code as a security feature. So we're not getting rid of the version code now. The version code will remain until we move to the photo, which essentially replaces it.

Mr Jim Wilson: Mr Decter, I saw on the news this morning that New Brunswick is now producing photo health cards. I was wondering if you've had contact with the Department of Health and Community Services in New Brunswick. You've mentioned that you're communicating with Quebec. I'm wondering if it's the same type of communication with New Brunswick, since they're going through similar debates in their province right now. In fact, as I understand from just the news piece I saw, they are producing these cards.

Secondly, with respect to the OMA agreement, I think you began your remarks yesterday by talking about convincing people not to go to emergency wards if they just have a cold. You were talking about utilization, and perhaps overutilization by some people. As part of the news piece on New Brunswick this morning, they also mentioned that they would be sending people a copy of their bill. Health care consumers would, on a periodic basis, receive an invoice letting them know what they cost the health care system. Is Ontario considering a similar process here?

Mr Decter: The simple answer is yes, on the statement. We're looking at the experience Sunnybrook has had as a hospital doing that. We're not all the way there on the ability to do that. It's currently done as part of the MRC process on small samples; that is, when they're looking into a particular practice, they will send statements to patients for verification. I think we do want to explore that. I know my minister is very keen to know when and on what basis we'll be able to do that for health services.

With regard to New Brunswick, I am seeing my colleague deputies next week and will pursue it then. I understood they were planning an announcement on the photo card. I didn't know they'd actually made that announcement yet. I think it's fair to say we're not the only province in which this has become quite a live issue. Peter may want to add to that.

Mr Burgess: I was just going to add that back in the latter part of last year we had some extensive exchanges by phone with New Brunswick about their problems, and they surely were facing the same sorts of issues that we were facing, but since then we haven't. I also must have seen the same news broadcast this morning, but I took the news clip to say their announcement would be made next week as to whether they did in fact have a photo on their card or not.

Mr Jim Wilson: Except that the images that went with the story showed the actual machines producing the card.

Mr Burgess: They showed the machines producing the cards in Quebec. They were Quebec cards.

Mr Jim Wilson: Oh, those were Quebec cards. I was misinformed then.

Mr Tilson: I'd like to return to an area Mr Wessenger had started, and that is with respect to fraud. Mr Decter, you indicated that you agreed the ministry has to start getting tough on fraud. I'd like you to provide details specifically as to how the ministry intends to do that. I believe there's only been one charge, a Kingston charge, in the last number of years dealing with fraud, and that came from a criminal investigation.

Mr Decter: Let me walk you through what steps were taken. We have established an investigative unit, and we have an individual to head that unit. He's come over from Environment and has a background in law enforcement. We'll be relying on his advice and the advice of Lindquist in terms of how big that investigative unit should be. We want to have some sense of how to properly size it. The role of the unit will be the link between our program areas and the relevant law enforcement authorities.

There have actually been more charges and convictions. I think the distinction here is between charges that are laid in response to a hospital or someone out there. In the case of the recent case in Kingston, although we were drawn into it and played a role in it, the alleged fraud was, in the first instance, against a hospital. There's an awkwardness there that in many of these situations we are one step removed. The fraud against us isn't really committed until someone tries to bill us for the service; the fraud is immediately committed against the hospital.

There has been some reluctance on the part of various policing authorities to jump in on these cases. I think one of the aspects of having someone with that background in the ministry heading a unit is to develop the kind of linkages that will get our cases (a) on our side, get the evidence gathered in a way that it can be used in a proceeding, and (b) on the external side, have the linkages and relationships there. Candidly, there is a bit of competition for which cases will get pursued.

Mr Tilson: But you believe that some cases will be, because it appears to date there haven't been any.

Mr Decter: There have been a handful of cases: four.

Mr Tilson: I didn't realize that. I thought there was just the one and that was the result of criminal investigation, the Kingston one. However, I don't want to debate that. Whether it's one or four, and you're talking of fraud of $284 million or $700 million, whatever you're talking about, I guess the question is the issue of deterrence, what procedures, what plans we have. Are people going to be required to pay moneys back that they have defrauded the taxpayer out of?

Mr Decter: There are two different regimes one falls into here. If one commits fraud, that can be pursued under the Criminal Code, and the penalties there are quite severe. They're obviously discretionary at the hands of a judge following a conviction, but they run up to 10 to 14 years' imprisonment or the relevant penalties, as well as fines and restitution. Under the Health Insurance Act there are much more modest penalties. On the consumer side, frankly, our intention with the investigative unit is to put these cases as they develop much more directly into the criminal side, both for deterrence value and also because they are fraud. Historically, that hasn't been -- maybe I should get Gilbert up here to give us a history lesson on this.

On the provider's side, under the Health Insurance Act, we've tended to refer physicians to the medical review committee, which has been a bottleneck.


Mr Tilson: Why has it been a bottleneck?

Mr Decter: Because the size of the committee was set in statute some 20 years ago at eight and there's no capacity to expand the size of the committee. Bill 50, which we have in, would let us expand the committee. It's just simply that eight people can only deal with so many cases. That backlog, as I indicated yesterday, when the auditor wrote about it in 1990, was 20 months. It's now 37 months. That's not something the profession is very happy about either. It leaves anyone who is referred with this three years of uncertainty. The amendments that are in Bill 50 would allow us to expand the committee.

We also have the capacity, as yet not frequently used, maybe not ever used, to directly refer something that appears to be fraud to relevant policing authorities. Maybe Gilbert could expand on that.

Mr Tilson: Have we got time for some elaboration, Madam Chair?

The Vice-Chair (Ms Dianne Poole): You have approximately one minute, maybe two.

Mr Gilbert Sharpe: The only thing I would add is that you raised the question of how do we get this money back from members of the public who've defrauded the system. Apart from the criminal penalties the deputy has referred to, there is of course scope for civil action. I would assume that if we had a basis to establish some kind of order for restitution under criminal, but also civil liability for defrauding the system, an action in tort of some kind would be pursued and we would one way or the other be able to regain the money that had been defrauded.

Mr Tilson: In short, though, you are preparing a plan, because obviously, whether it's one or four, there doesn't appear to be any -- or very few -- charges against individuals who have defrauded the province of Ontario of substantial amounts of money.

Mr Decter: Yes. As I said, it has historically not been the case that there's been a desire to pursue these.

Mr Tilson: Can you provide the committee with some sort of details on that at a later date?

Mr Decter: In fairness to the head of our investigative unit, Mr Sudds, we only got him over from Environment, which has had a very aggressive track record in recent times in pursuing cases, as of September 1. His history is not solely in environment. He has a history in law enforcement prior to that. He's joined us. Karim Amin, our head of internal audit, is leading our effort to develop that plan. We have retained Lindquist Avey, as I mentioned, to help also. So we now have at least a leader for the team in place. Again, we don't have a full plan for the investigative unit, but we are already, frankly, thanks to the publicity, getting a steady stream of cases coming at us from the public, I think some 150 to date, so we've got a good basis to build on.

I should just underscore that my minister is very determined on this issue and wants to see a great deal of action rapidly, so I can assure you this will have a lot of attention. It has already got a lot of attention, but I expect you will see a lot more charges laid. We want to be sure that we aren't just laying a lot of charges or causing charges to be laid, but that we actually have the evidence in place so that we get convictions. Otherwise, the credibility of this initiative will be short-lived.

Mr Tilson: That's why we're all here.

Mrs Sullivan: Could I have a short supplementary just before we're finished this section? Could you tell us about the process of actually laying the charges? Do you have to go through the Attorney General to lay the charges?

Mr Decter: I'll let Gilbert answer, but I think it depends on who is laying the charge.

Mr Sharpe: If, for example, in the Kingston case, the hospital discovers the fraudulent card, then the hospital would contact the local police. The police in the normal course would investigate, presumably come in with a search warrant to look at records and obtain possession of the card and so on, as in any other normal kind of investigation. If, as the deputy indicated earlier, someone fraudulently attempts to gain payment, then we could directly involve the police and provide them with the necessary evidence, pursuant to law enforcement provisions and FOI which permit us to do that sort of thing.

Mrs Sullivan: So in fact the Ministry of Health does not launch that prosecution.

Mr Sharpe: No, my understanding is that initially the hospital would contact the police and bring them into it.

The Vice-Chair: Since the Conservatives went two minutes over and since Mrs Sullivan has had a Liberal interjection for a couple of minutes, I'm going to add two minutes to the government caucus's time.

Mr Larry O'Connor (Durham-York): It certainly is interesting to go through this public process of trying to take a look at the health care system that we have and some of the problems that we face. I know that my colleagues feel some amount of frustration. I know that they'd like to see the documentation before it gets to cabinet. We're hearing that today. I know Mr Callahan probably is relieved that he's actually had some impact through this committee in the use of a full proper name on the card.

Mr Robert V. Callahan (Brampton South): It's the first thing I've accomplished since I've been around here.

Mr O'Connor: So we're actually having some impact here at this level of discussion.


Mr O'Connor: Excuse me, Mr Wilson. I have the floor. As has been suggested to me on occasion, the Outdoors card that many Ontario residents do have has an identifier on it that identifies --


Mr O'Connor: It has your height, your weight, your hair colour, your date of birth on it. I just wondered if that, as opposed to going straight through to a photo ID, would not offer the same unique identifier that would be necessary to do the same, I think, very credible work that can be done as you'd suggested in your discussion with Mr Frankford about the research.

Mr Decter: I think Peter may want to comment. One issue is that the health card is a card for everyone, looking at the total population. Yes, there are other cards and you named one that has a good deal of information. I couldn't give you off the top the total number of those cards, but I would expect it to be a much smaller percentage of the population, and that's an issue.

Mr Burgess: Clearly there are a number of issues that the card attempts to address. One is obviously an identification issue, and the other, in our particular case in the Ministry of Health, is a payment issue, a payment for services rendered. That's why the card has a number and that's currently why the card has a version code.

I guess, when you break down the identification side of the equation, the Outdoors card has chosen to put identifying features on the face of the card in an embossed fashion which attempts to identify the cardholder. Because, after all, you have to have a permit to go and shoot something or catch something in Ontario for which you pay a certain fee.

At the time that we implemented the card in 1990, we clearly did not think at that time that identification would be an issue; an identification in terms of dates of birth, hair colouring, eye colouring or whatever. It's quite clear that identification has become an issue over the last little while, and we have considered, from an identification perspective, the option of including height, weight, hair colour, eye colour, embossed on the front of the card.


We believe that if you're going to go to that trouble, that expense, to have a form of identification which still doesn't really get you much further down the line, you might just as well take the next step and add the incremental cost. As I said, the incremental cost is relatively small to get a photograph, which is a much better identifier if that's what you're interested in.

Mr O'Connor: The question, though, that I have, would that type of an identifier then allow the epidemiological work that Dr Frankford suggested to take place using that type of an identifier? I don't know whether a photo ID will add to that aspect of the card.

Mr Decter: No. Let me separate between the vehicle, if you like, of the card and the number. The thing that gets you the big gain in terms of management of health information and epidemiology is having a number to which you can link all of the services that have been provided, a number that corresponds with a unique individual. That's the piece of it that was the big advance in the last few years, and that's the piece of it that isn't under any question other than the steps we can take to enhance the functionality and integrity of that database.

The question of what the individual has in addition to his number is the question of the vehicle, and that's the question of, is it better to put a lot of written information on the card, to put it on a mag stripe, to put a photo? That's quite separate from what information you have and what you're able to link in the database, and is more concerned with the issue of someone inappropriately or fraudulently obtaining services, someone who's not an eligible person. That issue isn't going to affect the general use of the database for epidemiology.

I should, if I can, piggyback one additional answer on the previous question. In the Kingston case, the hospital called our 1-800 number to seek advice, and frankly I think that just underscores how new this whole thing is for the system, that a hospital would essentially call us for advice on what to do about a fraud case. Our advice was to get the local police and provide them with the evidence and let them lay charges.

Our line isn't turning out to just be a line that an individual can call to say, "Hey, I think the person across the street is doing something illegal." It's also turning out to be a resource for our partners out there.

Mr Frankford: I'd like to continue with at least raising the possibilities of non-fee-for-service and non-card approaches. I think this will be more just a discussion with the ministry, but will be part of the broader discussion that this committee is going to have.

Perhaps I could draw to people's attention an article in the most recent Ontario Medicine, a proposal by Dr Rosser and Dr Forster, who are the chiefs of family practice at U of T and the University of Ottawa respectively, which is proposing essentially a universal primary care registration approach. I'd be happy to provide the article and perhaps it could be circulated. Are you aware of this?

Mr Decter: Yes. We have a good deal of advocacy from a number of directions on changing essentially the basis of payment for primary care. I think there is a sense that fee-for-service for surgical and other specialty procedures has considerable merit, but there's a lot of questioning, not just in Canada but internationally, and there has been some significant movement away from fee-for-service in a number of other jurisdictions.

You mention one piece, but essentially the College of Family Physicians of Canada have come forward with a mixed payment model that would combine some capitation and some fee-for-service features. We have a major project under way in the ministry with a lot of external involvement looking at what we're calling community health framework and, as part of that, we are looking actively at primary care. We've also agreed, under the OMA agreement, to have a task force to look at the financing of medical services, which will look at other jurisdictions internationally and nationally over a fairly compressed time period and make some recommendations.

I think it's becoming more and more accepted by people who are in family medicine that fee-for-service may not be the best basis for payment, that it doesn't allow substitution, doesn't allow, to the extent necessary, teamwork among different providers. The health service organization and the comprehensive health organization are both different models that look at a different approach, more of an envelope of funding.

I think there is continuing advocacy. I think it's also our observation that the new graduates in family medicine are much more interested in a different basis of payment. We will be going to a salaried approach rather than -- our approach in underserviced areas historically has been to top up fee-for-service with some additional money to try and get people there. Under the agreement with the OMA, we will be going to a salaried approach with a negotiation to essentially say to physicians who would go to north or other underserviced locations, "We will take away your risk of establishing a practice by paying you on a salaried basis."

That, for the new graduates, has a great deal of appeal. We are dealing with, I think, a bit of a generational problem. My guess is if you surveyed physicians over 50 years of age in the province in general practice, they would heavily favour fee-for- service. If you surveyed physicians under 35 or under 40, they would be much more in favour of a different basis of payments. I think you will see that change happen. This was an issue of enormous contention five years ago, 10 years ago, with the profession. They were really not very keen. There's now a great deal more openness and some advocacy on at least part of the profession's behalf to move to different payment methods.

Mr Frankford: I think we can agree that a salaried system is really not defraudable.

Mr Jim Wilson: You can go golfing.

Mr Frankford: Mr Wilson says --

Mr Jim Wilson: You might go golfing.

Mr Frankford: That's very true. It requires some different approach to professional accountability, which I think my colleagues in the profession would very much welcome. Leaving the cynicism aside, I think that this has the potential for doing a whole lot of good things and taking away the fraud, unless Mr Wilson wants to prosecute doctors for goofing off.

Mr Decter: Let me say that there is certainly some appeal to moving to a system where you will be paying people for looking after a group of patients. I will say that I had a visit a few months back from the head of one of the large health plans in Israel. They're on a totally salaried-unionized physician basis, and much to my astonishment he was saying that they were thinking of moving to fee-for-service to try and get some reform in the system, that they felt they weren't getting the appropriate care they needed.


The Vice-Chair: Actually, Dr Frankford, I think we're a couple of minutes over. We've kind of rambled a little near the end.

Mr Decter, I believe you have to leave around 4 o'clock today. Is that correct?

Mr Decter: A little earlier than that. I have to catch a plane. I should probably be out of here somewhere between 3:15 and 3:30. Patricia Malcolmson, who is standing in for me at the joint management committee this morning so I could be here, will be back for 3 o'clock and can certainly deal with all of these questions for that balance of time.

The Vice-Chair: I think we should reconvene sharply at 2 to make the most of our questions. Mr Callahan had suggested we meet earlier.

Mr Callahan: One o'clock. It's essential that we have as much time with the deputy minister as possible.

The Vice-Chair: Is that agreeable to members?

Mr Callahan: Sorry. Did you preserve that for posterity or would you like me to repeat it again?

The Vice-Chair: First of all, as a courtesy to our witness, the deputy minister, we should ask him if he would be available to come back --

Mr Jim Wilson: For me, 1:30 would be better. I have a meeting.

Mr Decter: That's fine. I will eat my salad faster.

The Vice-Chair: Okay. We will adjourn quickly so you can eat your salad and we'll reconvene at 1:30.

The committee recessed from 1210 to 1336.

The Vice-Chair: I'd like to convene this session of the standing committee on public accounts. We have as our witness Michael Decter, deputy minister of the Ministry of Health.

Mrs Sullivan: I had begun in the last round of questioning to look at some of the initiatives that the government had agreed to, in association with the OMA, in the last agreement. We spoke about the elimination of version codes once the photograph was introduced. I'm interested, just by way of comment, in the fact that that agreement was made before cabinet has approved the introduction of the photograph, in the first place, and would extend, if I understand the testimony that's been provided to the committee, beyond the life of the OMA agreement, in that I think we've had a guesstimate that the photo cards would not be completely implemented for perhaps as long as five years, which is longer than the time line of the committee.

I'm going to ask the deputy this: How much money, or can it be quantified this way, has been saved through the introduction of the version code, which was one of the first steps taken to tighten up the verification; in other words, what savings in claims have been made at this point in time? As well, to move into another section of the OMA agreement with respect to the good-faith payments, the OMA agreement would allow payments to be made under the former J-8 rules for claims which were submitted for services to uninsured people. I cannot find in the documentation any estimate of what the cost would be for continuing to make those payments, other than those which have previously been estimated for good-faith payments to hospitals, which are about $1.9 million a year. I wonder if we could have some clarification of those two issues. What are the costs associated with those areas of the OMA agreement?

There are other costs we would like to know about. The government has committed to a one-time cost for extending swipe reader technology into the hospitals. We'd like to know what the costs of that would be. What would be the cost, which I understand would be borne by the government, although the deputy may want to correct me on that, for making the interactive voice response technology available to all physicians be? If the government is not going to cover that cost, what arrangement has been agreed to with physicians in terms of the introduction of that technology, and who pays for it, and who pays for ongoing maintenance etc? What dollar costs would be attached to a public education program dealing with the use of the cards and registration for cards?

Those are mainly dollar questions, but we have not heard any testimony before the committee about the initiatives that were agreed to in the OMA agreement, and if the deputy would like to further add comments with respect to that agreement I think the committee would be very interested in hearing them.

The Vice-Chair: Mr Decter, do you happen to have that information with you at this time, or would some of it have to be provided in writing?

Mr Decter: I can make some general comments on the agreement between the government and the Ontario Medical Association, but I think specific costing of specific items we would want to provide on a written basis; in some cases, it depends on agreements yet to be reached on implementation. The joint management committee is having its first meeting today since the signing of this agreement in early August and there's a good deal of work to do to develop the specifics, but we would have costing in response to the questions asked and we could provide that in writing.

A general comment I'd make on something in the preamble: While it's true we have not gone to cabinet and won't go till later in the fall on the health card enhancements and the photo card as a total proposal, all the items in the OMA agreement were before the cabinet frequently during the negotiations so that, as often happens in our relationship with groups external to government, some amount of policy was made in the process of reaching the agreement. There's certainly nothing in here that wasn't under way, but I think it's fair to say that the cabinet, in approving the negotiating mandate and in ratifying the agreement, did make a number of policy decisions. That's one of the dualities we have in the ministry: As we do more business by way of partnerships and agreements, we tend to make some decisions in terms of cabinet approvals that way. So the basic decision to introduce the photo card was taken and is embedded in the agreement.

Some of the other issues yet to be determined: Obviously, we have to sit down and work through, with the Ontario Medical Association and the Ontario Hospital Association, what we've learned from the swipe card pilot project that you saw illustrated yesterday, and then how we can work on which hospitals we should put that technology into and how rapidly.

One issue you've asked about that we may have an immediate answer on. I did provide you yesterday with the overall value of the claims rejected for having incorrect version codes, the $105 million and the 5.7 million claims, and I did indicate that the majority of those claims are resubmitted with correct version codes. Someone in the audience may be able to give me a percentage on those that are not resubmitted; failing that, we will get it for you in writing.

I'm being advised that it's about a 90/10 split, that is, about 90% of the claims that are rejected for having an incorrect version code are subsequently resubmitted and 10% are not; that would tend to suggest a value of about 10% of $105 million.

I guess what I'd say, though, is that this is not a pure cost. In agreeing to this package of measures with the OMA, we believe we will have the system significantly cleaned up, and I think that's evident in the graph that I provided yesterday. In essence, when we started in February rejecting incorrect version codes, we were rejecting in excess of 5%. That's fallen off to 3% as physicians and hospitals have kind of cleaned up their records in terms of patients. We expect, with the additional things we're doing, that that will get further cleaned up.

So our saving in the front end is larger than our loss but that saving will diminish as time goes by, and we believe that with the additional measures contemplated we are not, in agreeing to make the first payment under the J-8 rules, incurring an enormous additional future cost. But we will get those numbers for you.

Mrs Sullivan: Could you give us some rationale for the portion of the agreement that would once again have the government paying for hospital-based claims under the J-8 policy? Why was that a part of the agreement?

Mr Decter: I think the most general comment I can make is that the agreement involved both sides moving a good distance from original positions and that you have to see the agreement as a package. Having said that, I think the policy logic which was there under J-8 and would be there again is that in providing the first payment we are not putting the provider in the position of being out of pocket for a less than perfect situation.

I would note that under clause 11 of this part of the agreement it isn't purely that we're going to -- well, I'll read you the clause; I think it sets out a balancing act. "Pay under the former J-8 rules claims submitted within the same billing cycle for services rendered to currently insured persons who subsequently, by virtue of law, become uninsured persons. In return for this one-time payment, physicians will provide to the ministry the address, date of birth etc of the person who is no longer eligible."

We're contemplating here that some people may lose eligibility, for one reason or another, and in essence our quid pro quo with the physicians is that they will let us know that, they will let us know that a patient has moved to Florida, and in return for that we will make the payment under the former J-8 rules. A slightly different regime in terms of services in-hospital: Again we contemplate an information exchange, that what we will get from the hospitals and physicians is information, address, date of birth, name etc, which will allow us to improve the accuracy of our records.

I think our overall view here is that we would like to be paying claims only against eligible health numbers. As part of an effort to get the system cleaned up, we took first the unilateral action of stopping payment; that followed a couple of years of paying all the claims on a good-faith basis. We're now going some distance back to the middle, where, in return for information that will allow us to enhance the database, we will make the payments.

Mrs Sullivan: It appears that you're contemplating that providers and health care facilities would have the authority to demand the card and destroy the card as well as to report evidence of fraud or of misinformation to OHIP. What legal authorization do providers and facilities have to do that? What would their liability be for being an agent of the government in terms of its enforcement mechanisms? Is there a legislative change required to ensure that the health care provider becomes a part of the enforcement system?

Mr Decter: The direct answer I'll give you is that have not fully come to a conclusion on that. As you'd be aware, there is a private member's bill currently introduced in the House that addresses this issue. We are currently examining, under the current statutes, what authority we have, and there are some grey areas around ownership. We are looking at all of the options, both legislative and non-legislative, to both protect providers and to ensure that there's clarity of their right, their ability, to seize and destroy a card or seize a card and return it to us.

We have given the undertaking in the agreement to the physicians that we will provide a detailed mechanism by which a physician can report detected or suspected fraud without incurring liability. I think we've reached the conclusion that you could do this through legislation. We are currently studying to what degree we could implement this without additional legislative authority.


Mrs Sullivan: Are you contemplating regulation in this area?

Mr Decter: I think we're looking at all of the aspects. Gilbert is here and could speak to it, but I guess there are, as a non-lawyer, aspects of contract law. Clearly, when you sign for your Visa or your MasterCard, we don't pass legislation to protect that transaction; it's protected, I take it, under contract law that you essentially acknowledge who owns the card and so on at the time of receiving it and their ability to retrieve it and so on. So we are looking at both our existing statutes in terms of authority and also whether there's some contractual basis on which this could turn.

Mrs Sullivan: There are two areas that were not specifically included in the OMA agreement that the OMA has formally and informally registered some concern about in the past. One of them is the issuing of bulk cards and ensuring the appropriate control and validity over those cards. Perhaps we can just move into that area first.

Bulk cards, I understand, are issued to such places as the children's aid societies, nursing homes and so on. What effective controls are you now contemplating on the distribution of cards in bulk and what steps will you be taking to increase the security over the distribution of those cards?

Mr Decter: I will need some assistance there. I know that to deal with the newborn issue we have been doing some block issuance of numbers to hospitals, but I think we're relatively confident on that end of the system.

Mr Burgess: That's correct. We issue a block of numbers to a hospital for newborns and we account for that number in an inventory control fashion.

In terms of bulk issuing of numbers, we don't issue bulk numbers, to the best of my knowledge, to any other institutions. We issue cards to individuals upon receipt of an application from a children's aid society or whatever, but it's on an individual-by-individual basis. We don't send 400 cards out and, "Let us know when you've run out of them."

Mrs Sullivan: Could you check that information for us and come back? Because my understanding is that -- in fact I recall that the minister responded in the House to a question of that nature indicating that cards were distributed in bulk to children's aid societies and to nursing homes.

Mr Callahan: We were told that in public accounts too.

Mrs Sullivan: I think that we really do need some clarification of that issue.

Mr Callahan: The auditor is nodding. Excuse me, if I could just confirm that, we were told that at public accounts as well and the auditor has just confirmed -- I believe that was the case, was it not, that we were told they were issued in bulk, in our February meeting, I think?

Mr Erik Peters: No. I stand corrected. I nodded to something else.

Mr Callahan: My recollection is that if we look at the Hansards from February, we'll find that they did in fact indicate that.

Mr Burgess: I recall there was a question in the House about a specific address having received 400 cards, but from our records, from looking at the entire database, no individual residence had in fact received 400 cards. There are residences that received a large number of cards, but not on a block basis. Each one of the applications for the person resident in the nursing home -- at the time of producing the new red and white card, each individual application was processed as an individual application and was processed on that basis. It might have been mailed back to Mrs Smith, care of the Rosedale Nursing Home, and Mrs Jones, care of the Rosedale Nursing Home, but they were as a result of individual applications.

Mr Decter: To the best of my knowledge, other than the newborn issue -- for the obvious reason it was hard to get the unborn to fill out application forms, we moved to a block issue for the hospitals, under a tight control. I'm not aware of any other instances of other than an individual application, but we will certainly look into it, and if we find anything different, we will let you know.

Mrs Sullivan: The other question that the OMA has raised on other occasions is with respect to tracking multiple doctoring, whether it's the senior citizen who's lonely and moves from physician to physician or whether it's someone who in fact has an intent to defraud the system, perhaps through obtaining prescription for drugs for resale or for whatever reason. The OMA agreement provides no mechanism whereby a physician can participate in an analysis or a determination of whether a patient has in fact been seeking multiple doctoring. Is that on the table with physicians? How will doctors themselves be participating in analysing the multiple doctoring problem?

Mr Decter: Well, I think, although we covered a great number of issues in the agreement with the profession, we've left a number of issues of that sort to be discussed at the joint management committee table and to see what progress we can make on the issue. Our own analysis report did indicate that there are, certainly statistically, people who visit significant numbers of physicians, suggesting the multiple doctoring issue is not just anecdotal, that it's real and statistical.

The issue poses some very tough policy questions in terms of dealing with it. The right of choice on the part of a patient of a physician or other provider is very central to the system. The only places we've abridged it somewhat have been in the health service organizations, and even there we haven't really abridged it; we've just gone to a system where the HSO physician or group would give up some financial resource if their patients sought a lot of help elsewhere. We think that it is an issue to be tackled, but we don't have a specific resolution of it at the moment, and there are, as I understand it, medical conditions where people seek medical assistance for imagined problems. That's Münchausen's syndrome. So it is a real issue.

I think on the multiple doctoring in search of prescriptions that the ODB system we're putting in will give us a control on that. So the extent of that subset of people who are going either because they want a lot of drugs just for the sake of having them or they want a lot of drugs for the sake of reselling them will, we think, come to an abrupt end once we have the system on line.

Mr Tilson: I'd like to turn to the registration analysis project report, specifically pages 4 and 5. The report indicates that the analysis unit had developed 41 major recommendations, and then they outlined what they've called eight key ones, many of which you, if not most of you, have already referred to in your previous presentations. The final paragraph on page 4 under item 1.4 says:

"To realize the full benefits of the health number, the philosophy of zero tolerance of health care abuse is required. This involves concepts such as litigation, increasing penalties for fraud and the recovery of money from consumers, not just providers, for fraudulently obtained services. It means that ancillary controls are also required, for example, a tougher policy on good-faith payments and more restrictive registration procedures."

Some of those areas were answered in questions that I asked this morning. Looking at these generally, I don't think you've covered all of these eight items, but I'd like to know the status. I'd like to know specifically the status of activities that have been undertaken to implement these eight recommendations and more specifically what is being done presently, immediately, what's being shelved and who's involved in the decision-making.


Mr Decter: We have an action report. Let me walk you through them, and if elaboration is required, then Peter can assist me in elaborating. In some cases, as with any report in the ministry that comes up to the senior level, it's not the only report we're contending with, and some of them pull in different directions.

Mr Tilson: Before we get into that, that's an issue that perhaps we should clear up. Obviously there was much ado in the media that this is a shelved report, that it was secret, that not necessarily you personally but the minister didn't like it and it was trying to be kept quiet and then one of the reporters gets hold of it and they have all kinds of fun for the next two weeks taking shots at you and everybody else. I'd like you to comment on all that.

Mr Decter: I guess a general comment. Maybe the best way to get a lot of attention from reporters is to stamp "confidential" on it, because it did draw a lot of attention. It went very early. I don't know if the Kingston radio station actually received it before I did, but it did gain considerable external attention early on, before it had been considered at senior levels in the ministry, and then it rebounded some months later.

The status of the report is that it has been taken very seriously by the ministry since it was put together. I think frankly if you look at a document the ministry made public just after the budget, the document entitled Managing Health Care Resources, you will see reflected in it a number of initiatives that are based pretty directly on what's in this report.

I guess the unusual quality of any report is that generally in the ministry we feed in what advice we get into our decision-making. So, for example, "negotiate with the federal government to recover payments for classes of persons under their jurisdiction" went forward by us as an expenditure control measure. It's something we've been looking at. This report just further underscored that we had some work to do there.

There has been, as far as I'm concerned, no attempt to shelve, hide or anything else of a negative sort with this report. I was happy that we'd commissioned it. I was happy to receive it. We did have, and I think the minister was pretty direct, some issues around whether the rollup of the numbers from the individual studies to the large numbers -- I spoke to that yesterday -- was completely sound, but the report itself contains numerous qualifications which were not featured prominently. The media didn't say, "The numbers might be as high as," they headlined, "$700 Million of Health Fraud."

Mr Tilson: Mr Decter, I understand what you're saying, but the Chair, Mr Cordiano, I think wrote a letter on behalf of this committee in May and said, "We want a copy of everything," and the next thing we see of this report is that some media person's waving it around. In fact that's where I got my copy. I called her up and said, "Will you mail it to me or send it to me?" and she did. I think by that time finally members of the committee had got it.

I guess I'm talking about communication with the ministry, that hopefully when a committee such as public accounts asks a ministry for all reports, we get all reports. That's the gist of my question.

Mr Decter: I may have to do a mea culpa there. As you'd be aware, from March 30 through some time in June I was asked by the Premier and cabinet to lead the social contract negotiations, and that put some considerable stress on me. In addition, the ministry's focus over that period of time was on the expenditure control side. I do think that we have been forthcoming with the committee in providing information generally, and if we didn't get you this report on as timely a basis as we should have, I regret that. But there has been, and I'd underscore it, no attempt on our part to do anything other than get on with implementing those recommendations that we can see a way to implement. In some cases, we bump up against existing legislation and other constraints. I can tell you, I've a number of reports on my desk where I'd like to devote more resources, but we have a limited resource. You have to make those judgements.

Mr Tilson: Having interrupted my own question, maybe you could continue on with your thoughts on page 4 and 5 as to the questions that I put on those eight points.

Mr Decter: In terms of creating a permanent, dedicated unit, we are under way on that. I will say here that I think we need to bring eligibility and registration together under one roof. We are looking at how to do that in a realignment of function in the ministry, because it's clear that when you look at registration, you begin to surface questions of eligibility, and we do not have consistent eligibility across all ministry programs. So we are looking at how to bring together, if you like, under one roof the registration analysis and also some policy work on eligibility.

Mr Tilson: What sort of staffing for this unit, Mr Decter?

Mr Decter: I'd have to turn to Peter.

Mr Burgess: Bryan Brown, who is the manager, is here today.

Mr Tilson: He's it. That's the staff.

Mr Burgess: Today, that's it.

Mr Tilson: Do you have any anticipation of increasing that staff?

Mr Burgess: Yes, we have three positions being advertised and hopefully competed for in either the balance of this week for interviews -- by that I mean tomorrow and Friday or early next week.

Mr Tilson: Thank you.

Mr Decter: In terms of the second, establishing a unique government-wide identifier for all provincial benefits and programs, we are certainly participating in discussions -- and I mentioned them earlier -- of a future Ontario service card. But I think we feel we need to move forward more rapidly on the health front. But again, cabinet, when we get there, may choose to accelerate other development. But we do account for a third of provincial spending, and I think it's, from our point of view, important that we have that piece of it well in hand.

My list here is slightly in a different order. In terms of amending --

Mr Tilson: Before you leave that, the identifier issue, which of course most of our discussions are dealing with at this committee currently, obviously it's going to take some time before this whole process is completed. It certainly won't be in 1993, 1994 and possibly 1995 or 1996 before the whole evolution takes place.

It's been suggested that in the interim that there be some sort of secondary piece of information, that when you go to a provider, you're obliged not only to have the number, but you must have some other identification. Has the ministry looked at that?

Mr Decter: I don't think we've explored that in great detail. We have gone to original documentation for new registrations, and I made reference to that earlier. So we've done something on the actual obtaining of a card. But we have not looked -- we may have looked at; we have not come to any conclusion on requiring additional identification at the point of service.

Mr Tilson: That may not solve all of the alleged frauds, but it certainly, it would seem to me, reduce it, at nil cost. You simply require the provider, if you want to get health services, in addition to having the red-and-white card, or whatever colour it's going to be -- probably it will be a different colour this time -- but you have further information. I don't know what that information would be -- a driver's licence; it could be anything, I suppose.

Mr Decter: We did, in some of these studies, in essence do that, ask people for an additional piece of identification in, I guess, the Kingston and Windsor studies.

Mr Burgess: That's right, and it is an issue that we have been apprised of and we have looked at in addition to others that have been suggested, like signing for receipt of services. There's been a significant amount of discussion around those issues.

Mr Tilson: Thank you. Continue.


Mr Decter: In terms of walking down the list, in terms of amending registration legislation, regulations, policy to promote a stronger enforcement philosophy, I think the creation of the investigative unit and the tightening of eligibility criteria will go a long distance that way as well as some of the changes we've got under way in the registration process, but I think we have probably more to do there.

In terms of negotiations with the federal government, I've mentioned that we have initiated those negotiations and the concern there -- I'll be direct about it -- is that we don't want to eliminate coverage for people until we're certain the federal government will in fact pick them up, and that's the direction we've had. As soon as we have that assurance, then we will step back from that coverage.

In terms of improving communication strategies to educate health care consumers and providers regarding Ontario health coverage issues, we do have some work under way, and I think I listed some of the posters and directives yesterday. Today -- I guess right now -- the joint management committee is hearing a presentation on public education efforts that we would hope to go forward on jointly with the profession.

Mr Tilson: Would it be useful for this committee to hear someone from Management Board?

Mr Decter: From Management Board of Cabinet? I think that would be your judgement.

Mr Tilson: No, I'm asking you -- to help us better understand the issues.

Mr Decter: I think on the Ontario service card, it certainly would, because they're the ones that have the leadership on that issue. My reference is the joint management committee between the profession and the government and you have the co-chair of that committee here as deputy minister, and I understand you've got the Ontario Medical Association coming in next week, so he'll cover that base. But specifically on the Ontario service card, the Management Board staff would have more to tell you than we do.

On the integration of the registered persons database with other internal and external program areas, I think that you saw yesterday the start of that in terms of the swipe reader. That's very much a one-way communication. Peter may want to elaborate on some of the other things we see doing there. We are talking about wiring this system together in a way where information moves both ways, and if you think back to my comments on the J-8 where we're saying we'll make the payment but you will in return give us accurate information, that starts a flow back. Up till now, candidly, providers haven't had much of a reason to send us information unless, frankly, it pertains to them getting paid. Their appetite for it is limited.

Mr Burgess: I don't think I can add anything.

Mr Decter: In terms of the third-party data exchanges, I went through the list this morning and we are active on that.

On the development of analytical tools and systems, I think we're hoping to get some good advice from Lindquist there.

In terms of our own audit group, I think we need to strengthen our systems capacity. I think this is a general issue with auditing in a computer environment, that you need more people looking at more ways of analysing the data. We are getting data that's in a form that allows us to analyse it better, but if I can put it pretty bluntly, one of the upsides of getting our people out of keypunching physician billings from paper claims is that we then can have some people available to move into looking at more complex issues of verification.

I think it's fair to say we've got activity under way on all of these areas. We're more advanced on some than on others. The report has been a real source of confidence to us that we've poked the flashlight into all the dark nooks and crannies of the system and we've discovered where we think we can make a difference.

Mr Tilson: So the allegations in the media about disillusionment and poor morale among ministry staff are not founded?

Mr Decter: I don't think there's a good basis for it. I will say that these are times when morale -- and not just in the ministry but in the public service generally, there are some real stresses. We're asking people to do more. We don't have salary increases; in fact, we have the opposite for them. I would be, I think, quite naïve if I didn't tell you that we have overall a morale issue to deal with in public service.

I will tell you that I feel quite the opposite about the registration group, who are almost missionary in their zeal to get on with this and do it, so I'm not surprised if there's some frustration. People here are too professional as public servants to give any hint of it, but the group sitting behind me, I'm sure, think we're moving more slowly on these things than we ought to be, just as my group that are involved with cancer control think we're not doing enough there and the groups that are piloting the tobacco legislation don't think we're moving fast enough on that.

I have a ministry filled with very determined people who are looking at the health system out there and the challenges we have and want to see very rapid action, as I do. I think you'll also see, if you have followed the recent history of our relationship with a number of the provider groups, that they feel in some senses we're going too fast and that we're putting more stress on them than they're capable of absorbing.

So I think there's no basis for feeling that the ministry has done anything other with this report than what we would do with any important piece of work, which is to study it to decide where we can move and to move forward on it.

Mr Tilson: I guess the issue is that we have a report that's dated March and it surfaces in August. It's a long time to be studying a report confidentially. In fact, it wasn't confidential. It was issued in March and it took until August to be made public, and it was made public, presumably, by some brown envelope.

Mr Decter: With respect, I've just signed off on a report from 1991 that's been sitting waiting to go out. I don't want to tell you how many reports we do in the ministry and what the time lines on them are, but candidly six months from the time we receive a report to be able to report out publicly significant progress and implementing recommendations is fast for the Ministry of Health.

We have significant reports where it takes literally years to get action. We've had areas where we had advice from the Scott task force on various issues of testing that we have not been able to find a way to implement, so this one has moved, in my view, at a pretty determined speed. Probably not fast enough for some, but we aren't just dealing with one issue in our ministry; we've had a whole --

Mr Tilson: I understand. Are there other reports that would help the committee or the Provincial Auditor in our dealing with this issue that you have available now?

Mr Decter: I'm not aware of any that we haven't shared. We shared the update; we shared the smart card evaluation. I think the auditor's staff has had pretty open access to our place in terms of work. We have not received anything of a report from Lindquist. They are still in their first phase.

Mr Tilson: When will they be reporting to the minister?

Mr Decter: I would have to turn to Karim, who has been dealing with them, to get a sense of the timing.

Mr Karim Amin: Lindquist has just joined the ministry's project. I don't think I can answer the question as to when the report could be available to us. There are, of course, significant aspects that they'll be reporting upon. Next week we're due to have a preliminary meeting with them. I'd like to tell you that we could give you a progress report on the activities that Lindquist will be undertaking with us.

Mr Tilson: You can do that when? When will you be able to provide us with that?

Mr Amin: Like I said, we'll be meeting next week.

Mr Tilson: So some time in the next two weeks?

Mr Amin: We could give you an idea, yes.


Mr Frankford: I'm going to return to the possibility of more significant structural change and non-card solutions. I'll pass on, if the committee would like, the article I referred to this morning from Ontario Medicine relating to Dr Rosser and Dr Forster.

When I spoke this morning, I hadn't seen the Globe and Mail today, which I don't know how many people have seen. It has a letter "Solving Improper OHIP Billings" from Dr Haresh Kirpalani and Dr Gordon Guyatt, who are both well-respected clinicians and researchers. I believe they are both based at McMaster. They, I think, are adding to the growing number of physicians who are saying that there is a structural alternative. I'll read some of this letter. It was started by a letter from Professor Ernie Lightman, which members might also wish to read, published on October 26. Kirpalani and Guyatt say:

"The real culprit is our fee-for-service billing system in which doctors are reimbursed for every patient they see, every test they interpret and every procedure they carry out. The system rewards doctors for delivering unnecessary care and penalizes them for taking time with patients. Conscientious physicians who take time to provide careful explanations earn less than those who practise revolving-door medicine.

"The solution to the problem is to reform the mechanism of physicians' reimbursement. Primary-care physicians should receive a set amount for each patient under their care no matter how many times they see the patient. The possible abuses of such a capitation-based system" -- I think this sentence is very important for everyone to note -- "are minimal and the system rewards physicians for practising efficiently and for keeping their patients healthy. A capitation-based system could also include community health centres staffed by salaried physicians.

"Once again, the salaried physician has no incentive to provide unnecessary services.

"Capitation-based systems have worked in other countries, and they can work in Ontario."

Mr Decter: There are a number of articulate advocates within the profession and within the academic community, and Gord Guyatt is one, for movement away from fee-for-service. The ministry has taken some steps in that direction with the health service organizations and with negotiations around alternative payment plans. So you won't get a disagreement from this deputy minister about the merits of other than fee-for-service-based methods.

You will get a very practical observation that the Ontario Medical Association, which represents all of the physicians of the province, those practising in fee-for-service and those practising in other payment modalities, is very interested in being part of that movement. We have negotiations ongoing with a couple of the academic health science centres, McMaster and Queen's, about moving their entire population of physicians out of fee-for-service into an envelope or globe. We have some plans in effect.

It has not, frankly, moved as rapidly as I think might have been contemplated in my predecessor's time. We've run into a couple of significant issues. One is getting the other model right. We did run into some real obstacles with the health service organizations where we hadn't protected the funding that was to go to the HSOs in terms of having it flow to patient services. In some cases, it was pretty clearly getting capitalized into much higher incomes. Physicians were taking the additional money and, rather than using it to add to their team, they were, if you like, adding it to their income, and their patients were seeking care elsewhere.

We've had two rounds of negotiations in the last two years and I think we've dramatically improved the HSO model. We're now contemplating whether we could reopen it, because it's been closed to new entrants. We are, in terms of negotiations with a number of the community-sponsored HSOs, looking at a conversion towards a community health centre or comprehensive health organization model. I guess Sault Ste Marie, given the group health centre's long and significant history there, probably is the one that is furthest along.

In the spectrum of, "How do you deliver health care versus how do you pay physicians? -- because those get lumped together but they're not the same issue -- I wouldn't call it a setback, but the community health centres are not at all sure that they want to be physician-based. That is, we're getting some advocacy from community health centres saying: "We don't really want a physician in our CHC. We want to have a different care model." They're moving more along the active kind of public and community health stance. So one can move in these directions, but they do require a lot of negotiation.

I would agree with your central point that moving to another modality than fee for service for primary care would allow us to have a more multidisciplinary approach and would allow this issue to have less of a significance, because you'd be looking after a range of needs.

Mr Frankford: I feel that we're primarily here around the issue of fraud. I repeat the point which is made here that these are structurally fraudproof, virtually. Now, this is another reason, a good reason, for putting a lot of emphasis into looking at these methods. I think there's a real decision to be made in the ministry or politically around the great effort that is being devoted to card systems and technical solutions to fraud when it seems to me quite possible that sooner or later we would address these other alternatives where all those things become redundant and where I would even suggest the cards become redundant.

The other thing I would like to mention which we're led to believe around the question of fraud, although that's still not really been proved satisfactorily to me, is that this is a function of lack of insurance in the United States. I'm a guarded optimist, but I would believe that problem is going to be solved in this presidency or certainly before the end of the century.

So some of these efforts, if we're talking about card renewals for ever and ever, again may become totally redundant, or not totally but to a significant part redundant; we would just be dealing with people from outside of North America.

Mr Decter: I would be delighted if the Americans got their act together and covered their 35 million people who are uninsured at the moment and the other tens of millions who have inadequate coverage. Clearly, if someone in Detroit is now adequately covered in the US, that's going to dramatically decrease their likelihood of borrowing someone's health card and making a trip across the border to Windsor. But I think we also have to live in the reality that reform of the American health care system, which seems to be getting under way, is going to take some time.

I don't think there's anything that would prevent a future government from receiving the advice that we'd outlived the health card and that some other solution had been found. My own sense is, in terms of changing primary care, that it won't move in a kind of Big Bang way; it will require some movement. There are members of the profession, and you would know them as well as I would, who are quite adamant about their attachment to the existing fee-for-service system. I think that is changing. We have committed ourselves to a reform of primary care, to looking at alternative, flexible funding and compensation methods. I think you will see more rapid change than you have in the past, but we're not going to move away from fee for service in the next short period.


I think the fraud concerns are real. Just because we're before this committee at this point on the fraud issue, though, is not a suggestion that that's the major task the ministry has before it. It's one we're taking very seriously, but we are significantly engaged in a reform of how we deliver health care. We are engaged in a significant shift of resources into the community and into long-term care and, where we can find opportunities, tobacco being a good one, into the preventative end rather than into the treatment end. So the main event for us is managing health care resources, as we set out in the spring. Part of it is the fraud issue, and we're taking it very seriously, but, you know, there are other places I get to appear other than public accounts on the broader health policy issues. They're not being abandoned or sidetracked in any sense in favour of a sole focus on fraud, but we've had, you know, a continuing series of efforts to make sure that people getting service are eligible, and continuing efforts to make sure that those are appropriate and necessary services. We are engaged in a very big debate at a national level over what "medically necessary" means.

Mr Frankford: Again, I think it probably can be addressed by a change of system, and when you get away from fee for service, then that will dissipate.

Mr O'Connor: I guess one thing that this committee is concerned about, the primary concern, stems back to the Provincial Auditor pointing to possible fraudulent use of the health care system through the health care card. I know that my colleagues of the opposition, of course, are very diligent in bringing matters of potential fraud to the Legislature. In fact, I'm looking at a clipping here, and I recall the day when my colleague Mr Wilson stood in the House and, in a question to the minister, asked about a 65-year-old woman who had been deceased for a couple of years receiving a health care card. Of course, I imagine for the family itself it was probably a moment that was very disheartening because, you know, the woman had been gone for a couple of years.

I just wondered, in going through this process -- and I know there's a lot of work that's been happening, stemming right back to your brainstorming session that I read about a year ago, August 1992, that the ministry held. A lot of work has gone into it. I recall back in February when you were before us that you did present us with a table of contents for the project report, though we didn't get the report at that time.

I guess what I'd like to have -- it may be some assurance for some of the committee members -- is, working with the registrar general's office regarding people who do pass away, what is the lag time that would be acceptable for registration of someone's death certificate through the registrar general's office? What would be a reasonable length of time for OHIP then to know that we shouldn't be sending out a card? Maybe there is a time frame that's acceptable, that an incident like Mr Wilson had raised is acceptable but three years obviously isn't. I realize that you did point out to us in the committee that you never even had that capability a year ago.

Mr Decter: We did indicate that it was about a year ago, August 1992, that we started getting the regular exchanges. I think Peter indicated yesterday that we're still having trouble getting that information to match up easily with our own database because ours is driven by birthdate and the registrar general's is driven by date of death. But maybe Peter could expand a little bit on what our objective or what our goal is on this front, where we'd like to get it to.

Mr Burgess: Let me give you a couple of things. First, as the deputy has mentioned, we are now automatically, every month, receiving an update on deaths from the registrar general. The registrar general can be up to six months in obtaining information that it then shares with us about the death of an individual. So there may well be a time lag in the process before we get that notification.

As a result, what we have done is, through the ongoing negotiations with the OMA, instituted a new fee schedule code which the physician, in terms of pronouncing death, uses. I believe it's an A777 billing code. That then will go directly against our database. That in turn will, of course, have the health number of the individual, because that's how the physician gets paid, and that will automatically update the database.

It's a bit of belt-and-braces approach, but I think if you look at our report, we actually take great pains, I believe, to say there is no one way of getting 100% of all these events captured. In all cases, we've suggested one, two or even three exchanges of information to make sure we've got it all.

In the particular case you're referring to, which was raised in the Legislature by Mr Wilson, we had in fact, about two weeks prior to the issue being raised, marked the individual as deceased on our database. We had received it from the registrar general and it had not matched on the first processing of receipt of notification of death against our database and this was because of a name-spelling problem. On our particular database, we'd had a Scottish name, in fact, spelled with an Mac versus an Mc and our computer system was unfortunately not smart enough to, at that time, try the phonetic spelling of McTavish as well as the actual spelling of MacTavish. I know I'm using the incorrect name, but I'm using the right example; it was a Mc and a Mac.

Mr Callahan: It certainly went amok.

Mr Burgess: Yes. That particular transaction got rejected, as I said yesterday, as one of those which went to our verification unit for manual review and I think I mentioned yesterday that there is a backlog of these sorts of activities. It was one that was in the backlog. It was processed out of the backlog. I particularly researched that one particular matching capability, and the clerk had to go through 35 different gyrations of the name before the clerk got the right match and was able to correct the database.

Mr O'Connor: I appreciate the answer. Our time's limited, so if you don't mind, I'll cut you off there.

The question I've got that then comes to mind: Is there a lot of -- because it's not fraud until somebody uses that dead person's card, the deceased person. Have there been a lot of cases, up to this point -- and I know you've just hired the investigators to look into it -- but reasonably are there a lot of dead people's cards out there being charged to the OHIP system now? Kind of abrupt, but our time's limited.

Mr Burgess: I believe I'm right in saying that the only further studies we've done on the issue other than the relatively panic study we did as a result of Mr Wilson's question -- I believe the only study we have done at all on dead people is relating to people notified to us as dead, yet still appearing on the MCSS interface.

It's a study that was just under way a couple of months ago. We have no valid data to share out of that. In fact, the study has been suspended due to lack of staffing and due to other activities. So I don't believe we have any data with which to answer your question accurately. I'm sorry, Mr O'Connor.

Mr Decter: Two quick points: One, the issuance of cards at age 65 was driven by the requirement of the Ontario drug benefit program. With the new network, we won't have to do that because eligibility will be able to be decided on the network. That issuance will go so, given that most of the deaths in the province take place, fortunately, at older ages, that should eliminate a good deal of that possibility.


The auditor did look at the drug benefit program and did highlight, I think about 18 months ago, out of about $1 billion of spending at that time, that $100,000 of claims had been paid on behalf of people who were deceased. When we looked into that, we found that most of those, about 90% of those, were cases where the surviving spouse had used the wrong number. So it was, if you like, an innocent error, where the surviving spouse had used the deceased spouse's health number in getting a prescription.

In the other cases, we did go after pharmacies for recoveries and did get some recoveries. I think that's our only major experience with looking at that. It's certainly an area we need to look further at.

Mr O'Connor: I'm sure any frauds that are uncovered will be quickly sent to your investigative unit and looked at, so I appreciate you taking the time to explain that to us today.

Mr Decter: We do have an update on the locked numbers question.

Mr Callahan: Having scored on convincing you guys to have one name on the application form -- I consider that a coup -- I want to try the other one. I had suggested to you at the last public accounts meeting in February that rather than going to this space-age stuff you were passing around here, the slash card and all this other -- I feel like I'm working with Visa --

Mrs Sullivan: Smart.

Mr Callahan: The smart card -- I had suggested something as simple as requiring an individual coming in with the card to sign their name, and that name would also be signed on the back of the card at the time they applied for it, and you'd just pass it under one of these ultraviolet bulbs like they do at the local trust company. If they match, then the doctor provides the service and the doctor gets paid. If it turns out that somebody's smart enough to fraudulently forge the signature while writing it out for the doctor or signing something for the doctor, then too bad; the doctor has done as much as he can possibly do.

Mr Frankford: What if they're unconscious?

Mr Callahan: What?

Mr O'Connor: What if they're unconscious, knocked out?

Mrs Sullivan: Unconscious, in an emergency situation.

Mr Frankford: They might be having a diabetic coma.

Mr Callahan: We're dealing at the moment with conscious people, I think, anyway. In any event, what's wrong with that? I find this thing about taking 100 hospitals and giving them this smart card and paying for it --

Mr O'Connor: Swipe card.

Mr Callahan: Swipe card, sorry -- is not solving the problem that you're here before us for, this fraud. The most pressing issue -- it seems to me that everybody's running around, and I say this with the greatest of respect, trying to figure out some way to devise a card that is foolproof.

I suggested to you at the last public accounts meeting a very simple way that could be done, even if just on a transitional basis, to ensure two things: first of all, that doctors get paid for the services they provide and that they're not the patsies when the card happens to be improper, because we should be the patsies. It's the government that's got the problem. The second thing is to provide something as a hiatus between now and coming up with the proper program.

I understand in here that after you introduced these smart cards and all the rest of it, you're going to have a panel that's going to then review whether it was a good idea. I'm sorry; that to me seems to be a totally unacceptable process in that it's kind of like, "We'll invest some money now on the chance that we might be able to stop the flood."

The other thing was, it seems to me that on the magnetic strip that's presently on the back of these cards, I think it shows your sex; I think the date of birth is on there. What's wrong with someone being required to, if you don't want to go with the signature bit -- and I've had doctors who have said they don't want to have to have somebody sign -- what's wrong with the maiden name of the person or the pre-marriage name being on the magnetic strip and when the person comes in, they have to tell you what that is? Again, you just put it underneath one of these ultraviolet bulbs.

I believe in simple and quick remedies, and then you can get into the more exotic ones after you've had a little more time to think about it. I think what you're doing is rushing headlong on to a solution for this because it's become politically embarrassing that a report was in the mill that the amounts that were alleged being lost were understated. The press got a hold of it and the government is embarrassed. I for one don't believe that's the way we should operate. I think we should operate in the calm of trying to solve the problem.

I guess I've asked a lot of rhetorical questions. Have you considered the simplistic -- and I'm leaving myself wide open, having said it that way -- suggestion that was made at the public accounts meeting in February 1993?

Mr Decter: Let me make a couple of comments on that. I think we are giving this careful attention. I don't think we've rushed headlong into anything here, despite lots of advocacy to have an instant answer on a lot of these questions. I'd reiterate our intention is not to make all the decisions and then seek the advice of an expert panel. The thought of an expert panel is a group we would consult external to government before going forward to cabinet, much in the same way that this committee, I understand, intends to seek advice from other than the ministry on card and technology issues.

The issue -- and I think it goes to the signature idea, a number of other ideas -- for the profession is that it wants us to verify in real time the eligibility of a card number --

Mr Callahan: So they can get paid.

Mr Decter: So they can get paid.

Mr Callahan: They're concerned that they won't get paid, that's why.

Mr Decter: Yes, but their concern is they want something that interacts with us, not simply the individual proving that they're John Smith, because they could well prove by signature that they are John Smith and have a card and still be ineligible. So the physicians, I think when you look at it, and the hospitals are not interested in more complexity, but they are interested in being able to find out at the point of service whether they're dealing with an eligible or an ineligible person. I guess that's a combination of features on the card and the link.

But the swipe technology is not a lot more complex than an ultraviolet light. It reads what's on the back of the card and puts it up on a visual display. It also, in the model you saw yesterday, ties into our database and allows that hospital to verify whether the person is eligible. I guess the flaw in the signature piece is it proves that it's John Smith, but it doesn't give you any hint as to whether John Smith is an eligible person or not. Peter may want to comment further on that.

We have, sort of, two linked issues. One is the person presenting who they say they are, and a signature would probably work not quite as well as a photo. But all of the features on the card are part of that establishment of the identity of the person. It's the link to eligibility, and the link to eligibility, in the view of, I think, the providers and ourselves, needs to be a link to that database.

Mr Callahan: What I'm concerned about is the cost. The link to eligibility is the real trick: You've got to make certain that the cards that are issued are issued properly. If they had been issued on the basis of someone having one piece of identification, be it a birth certificate, a naturalization certificate or whatever, you could then get to the point where you have the cards properly issued. If you put an expiration date on them so they had to be updated very five years or every two years, or every three years as the drivers' licences are, then in fact the signature would be adequate.


I think the signature's better than the picture because the picture is going to change, and you can certainly doctor them. As I think if anybody here from MTO could attest to, there are people driving around this province with licences that belong to someone else that have got their photo on them. The cops stop them and there's no way that they can check it out, and these people actually are getting away with it. I think you're going to get the same thing with a health care card when you put a picture on it.

Mr Decter: We certainly are committed to tightening the registration end in a variety of ways, but I think we still want an ability to remove someone's eligibility during the period of the card's life and we can only do that if we've got a link between our database and the providers. Your status may change -- someone may move out of the country, someone may lose eligibility one way or another -- and we want an ability to cut off that eligibility, independent, frankly, of retrieving the card; we'd also like to retrieve the card.

I guess what I'm saying is that I think we would agree that we need to tighten the registration end, the issuance end, but we also need to tighten the link between payment and eligibility.

Mr Callahan: Can you give us the details of a contract set up by the previous Liberal government in order to rebuild, modernize the old OHIP system into the new health card system and to establish the registered persons database that you referred to yesterday? How much money was originally set aside for these projects and how much of it was actually utilized and on which projects? You can do this in written reply, if you'd like. Can you provide us with detailed information about what happened to these projects within the ministry since they were completed? You can get these off Hansard and you can do it in writing; the best way probably.

Was this project or any that were part of it involved in the cancellation of government contracts mandated by the NDP government in 1991? If so, what other measure was the ministry involved in to ensure that the new system was properly outfitted to detect and prevent fraud? Had it not been for this moratorium on outside contracts, would additional projects have been completed for the health card system or any aspect of enforcement for it? Why didn't the ministry release the registration analysis project in March, when it was completed? I got the impression you said it was leaked, deliberately leaked; that was to put some emphasis on how important it was.

Last February -- Mr Tilson asked you this -- when you appeared before this committee, you indicated you believed the problem of fraud to be approximately $20 million per year. Have you changed your predictions on that number and what do you believe the figure to be now?

Mr Decter: You've asked a series of questions, a number of which are historical, and we will provide written answers. The tail-end ones are not historical and I will provide you with a very direct answer. I think I already have both clarified what was said in February, which was that, to the best of our information at that time, we thought we were dealing with a 1% to 5% problem, and I won't re-read into the record here the answer that I gave this morning on that.

Mr Perruzza: Bob wasn't here this morning, were you, Bob?

Mr Decter: I have tabled with you the update to the registration analysis project, which does provide a range of figures, which I gave yesterday afternoon, provided in written form. I think that represents our most up-todate thinking on the magnitude of this problem, which is still in the same percentage ballpark.

We will give you written answers on those historical questions.

The Vice-Chair: There's approximately one minute left if you have a very quick question, Mrs Sullivan.

Mrs Sullivan: No. The questions I want to pursue relate to the integrity of the registration with respect to addresses and actions that are being taken in that area, where we are told there's a 26% margin of error. If we can prepare for the next round, I'd appreciate that.

Mr Burgess: Could I perhaps address the question you asked in the last round about multiple registrations? I've checked with staff in Kingston, and I was right: There are not and have not ever been any block registrations since registration of the new unique number started, with the one exception we said about newborns. I am told -- this is hearsay to me -- that there were some discussions through the planning phase of perhaps thinking about continuing the block numbering that was used under the old OHIP system for things like provincial correctional institutions. But I reiterate that there is no block issuance of numbers; every registration, at initial registration, was an individual registration.

Mrs Sullivan: Thank you. I appreciate that information.

Mr Jim Wilson: I just want to say for the record that the reason I raised the issue of the dead person being issued a new health card upon turning age 65, when the person had been dead for several months, was that I got the very distinct impression, Mr Decter, when you appeared before this committee last February, that this was not to happen again, and I'm somewhat getting the same feeling, that all is fairly well and we need not worry about these things. I admit I can't quote you verbatim, but I can only tell you the feeling I had at that time was that the relationship between the Ministry of Health and the registrar general with respect to getting these people off the active database in the health card system was pretty much resolved, so I left it for three or four months until a case was brought to my attention.

I want to ask you today, given that I'm having a bit of déjà vu all over again, the warm and cosy committee here where it seems everything's being solved, is it possible today that someone could have a dead person's card, receive health care services in this province and your ministry wouldn't know anything about it for some time after the services had already been rendered?

Mr Decter: You're asking two questions. The first is, did we give you an assurance that we had this problem fixed when we were here in February? I apologize if I instil more confidence than I ought to. I think what I said then and what I've said again today is that we're working on these issues. We did start getting monthly exchange from the registrar general a year ago, that is, in August, but as Peter Burgess indicated yesterday, we only get a 70% match on the system and then an additional manual match, so then we have a number of notifications which are not matched.

I guess the answer I would have to give is that yes, it's conceivable that because we're not getting all the deceased people off the database instantly -- we're now getting, from the look of it, and maybe Peter can confirm it, 70% of them off relatively rapidly and we're working on the additional amount -- that yes, there would still be people who are deceased who would show up as eligible on a database.

Mr Burgess: I don't have the exact percentage with me, but it's closer to 80% than 70%. In averages, about 10,000 individuals die per month and about 8,000 get automatically removed from the database; unfortunately, that leaves 2,000 to be added to the backlog.

Mr Jim Wilson: But my point there, Mr Burgess, is that you can remove them from your database, you can put them down as ineligible, you can do whatever you have to do to the database, but they still have the card, which is a currency that can be used to obtain health care services. As you know, my theme has been, all the way along, that we don't have enough upfront verification measures.

I gather that since you were last here the interactive phone system you're now showing this committee is the phone line that you promised to set up last February, that was going to be up and running in March, so that physicians, if they were suspicious that somebody was using an invalid card, could phone that line. How available is this phone line now, that was supposed to be set up in March?


Mr Decter: Let me distinguish between two types of phone lines --

Mr Jim Wilson: I'm not interested in the 1-800 squeal line. That thing is very interesting in itself, but it was not the subject of the debate back in February.

Mr Decter: If Bob's still here, he can give you the extent to which we've got that interactive system up, but I will reiterate that there is no obstacle. Physicians call all of our claims offices on a regular basis, and there's never been any barrier to them letting us know about something that --

Mr Jim Wilson: That wasn't the point. The point was verifying whether it was a valid card. Anyone can phone any MPP and do that, sir.

Mr Decter: Yes. But Bob can tell you the extent of the interactive system and its implementation.

Mr Robert Cavanagh: I hope I made it clear yesterday that what you saw was a pilot, so the numbers are relatively small. I think there's somewhere around 20 to 30 users of the interactive voice response system at the moment, and we will probably expand that further for the pilot before we actually roll out the production system, but we've got a number of weeks yet to run on the pilot before we evaluate it and can determine the usage of the lines, and there are a number of factors that we have to get resolved.

Mr Jim Wilson: If I were a physician today and I was suspicious of a health card, what do I do?

Mr Cavanagh: You call the district or regional office that you normally deal with, and it would check the number for you, in a manual sense, today.

Mr Jim Wilson: So that's readily available and physicians are aware of that process.

Mr Cavanagh: Yes. One other thing I might add is that in terms of those who are on the pilot now using the IVR system, the actual usage for the typical, say, primary care practitioner is very low. We checked with some of them to find out: "Do you like the system? Is it working for you, or have you given up on it?" The answer we were getting back consistently was: "Yes, it does exactly what I want, and I'm happy with it. I only have a few cards I need to check."

Mr Jim Wilson: One assumes that's the case everywhere, and I'm sure they are happy. They have to eat the billing if they don't get it right the first time.

In terms of the case in Kingston where you've laid a charge with respect to a person who was caught by the hospital in Kingston using a card that wasn't her own, how did the hospital discover it wasn't her card?

Mr Decter: I want to be careful here, because I think there are problems now that this is a case that's in process; I don't think I enjoy the same immunity that others in the room do. My understanding of the case is that the allegation -- I think at this point the police have laid charges -- is based on a difference between the signature on the consent form and the card presented.

Mr Jim Wilson: In fact, the allegation is that she signed an entirely different name; she forgot what name was on the card. I just wanted to put that on the record, because I think you left the impression earlier -- again I might be wrong -- that the system was working and the system caught this fraud. It was simply that she screwed up and signed the wrong name.

Mr Decter: I think what I was trying to say was that I don't think in the past the hospital would necessarily have done anything about it; the hospital might well just have written it off as a bad debt, or conceivably we would have been billed for it on the physician side and paid it. What I was trying to saying was that I thought there was a heightened awareness out there, so the hospital, when it detected this, in fact called our 1-800 line and sought some advice, and our advice was to go to the police.

What I was trying to do was underscore how unusual that is, that a major hospital in a border community that obviously is dealing with tens of thousands of cases a year wouldn't have the in-house knowledge of what to do about a case of fraud. I think I was trying not to say we've got it fixed, but this is so new.

Mr Jim Wilson: I doubt there are many hospitals writing off these things to bad debts, with the cuts these days. Mr Tilson has a question.

Mr Tilson: The acting Minister of Health, David Cooke, in the middle of August gave a press conference over this report that surfaced, and he suggested at that time that providers of health services could be prosecuted for their involvement. Could you give specifics as to what the government is proposing in that regard?

Mr Decter: Yes, I can. What we're proposing, and I've spoken a couple of times to Bill 50 on expanding the Medical Review Committee, what we're looking at and what we've determined we have the legal ability to do is that in cases at the moment, the general manger of OHIP would have the responsibility under the act for referring cases to the Medical Review Committee. So our group in Kingston reviews physician billings, it finds things that are out of line dramatically, it gets referred to the Medical Review Committee and investigated and subsequently the Medical Review Committee would recommend either recoveries or prosecution.

Mr Tilson: Isn't that done now?

Mr Decter: That's what is done now. What we will be doing in addition to that, and we want to speed that side of it up, is where, in the view of our investigation unit, there is sufficient evidence on the provider side that it's not a case for the Medical Review Committee, it's a case with sufficient evidence of fraud, the general manager of OHIP will be referring those cases to the relevant police authorities for charges to be pursued.

Up till now, we've had one route. The other route has always been there.

Mr Tilson: Just never used it.

Mr Decter: It just hasn't been used, and I think what acting Minister Cooke was signalling was that --

Mr Tilson: So that's what he meant?

Mr Decter: Yes, that we are going to do that.

Mr Tilson: I'd like to return to the Lindquist forensic accounting firm --

The Chair: One final quick question, Mr Tilson.

Mr Tilson: That was a quick three minutes.

Can you specifically tell me what their task is and how it differs from the task of the authors of the registration analysis project?

Mr Decter: I'll give you a general answer and then Karim Amin could give you a more specific answer. Their basic task is to help us understand where our vulnerabilities are and to help us develop the linkages between the investigation unit and our various inspection services. In the sense of understanding our vulnerabilities, it builds on the work of the registration program branch, and I want to be, I guess, careful here.

Lindquist has some really unusually specialized expertise in the forensic area that we don't possess in-house in the ministry. Essentially, having gotten a very good piece of work as to where we are generally vulnerable, we are going to the best in the business to give us a more specific set of advice on how to build into our system some of what they call red flags. But Karim has been, on our behalf, dealing directly with them and he'll give you a little more detail.

We're not redoing any work; we're looking. This is part of how to implement essentially the recommendations we've received.

Mr Tilson: I would like more details because certainly the way it's been described to date, it is a carbon copy of the project completion report of March.

Mr Amin: I think one of the fundamental principles we're operating under is that if the ministry can do the job, Lindquist will not do that job. Lindquist, as the deputy said, is going to do for us what it called a red flagging system. They have done that for major corporations, major insurance industries, the federal government etc and we are not --

Mr Tilson: Why can't the government do that?

Mr Amin: Sir, I tell you, if we could have done it, we would have done it. The issue of forensic accounting and the issue of identifying the high-risk areas for fraud etc is one that is quite specialized. We have to confess that we do not think we can do that ourselves and it's for that reason that we've gone outside the government for that kind of assistance. As you very well know, forensic accounting and forensic procedures are extremely difficult to develop and to have in-house.


Mr Decter: Just let me make it very clear, because it's a fundamental principle for us: We're not asking them to do anything we can do ourselves. We're asking them to give us some advice, which may include how we upgrade training and skill levels for our staff.

The test I guess is made more difficult on two fronts: One, because we're now going to pursue investigations and prosecutions, we have the higher test that the courts require in terms of the evidence. In our current activities, if we determine that someone isn't there any more and we cut off their eligibility, there's an appeal process. But we're not going before a court to make our case. We're simply removing the eligibility and if we've got it wrong, the person appeals under the Health Insurance Act. Once we head into the courts on these cases, we've got to be sure that we have the documentation in a form that can sustain a court test.

The second is that a great deal of this goes into the technology area and goes into how to get the best return on our technology investment. As a former partner in I guess what's now the largest consulting and accounting firm in the country, I can tell you that even within our partnership, which was like 400 when I left, with some 3,000 staff, you could put all of our forensic people in a small room. There are only a handful of people in this country who have real expertise on this, and we've gone to them to get the best advice we can. We're not planning on having them take over ministry functions. It's to give us some advice on how best to do this and how to link our audit and investigation functions properly together.

Mr Tilson: One final question: You spent some time on the issue of eligibility and how it will be determined in the new system. How does the ministry propose to verify eligibility periodically? In other words, an Ontario resident moves to New York state or some other country or area and doesn't notify anyone of the change of address and keeps the card. How will the ministry track cardholders to weed out those who are no longer eligible for OHIP coverage?

Mr Decter: I would turn again to our people who are already doing that. I think we've indicated that the address area is our area of major concern in terms of the database, but we do have some flags that go up on movement of people at the moment.

Mr Tilson: Tell me about these flags. This thing has been popping up all afternoon. What is that?

The Chair: It was noted, if I may just interrupt for a moment, that the deputy had to leave. Can I get a further five minutes from the deputy? There are additional questions and we'll do that, and it will be fair for everyone if we have that additional five minutes.

Mr Tilson: And come back and talk about flags?

Mr Decter: Let me be careful here. I've used that phrase "red flags" and Karim has. That's a phrase that Lindquist used in terms of its approach to this: Whether it's the ODB system or the OHIP system, how do you get red flags, indicators that pop up and let you know that there's something you should be looking at. Let me turn to Peter on the question of how at the moment we would know if someone had moved out of the country and neither surrendered the card nor let us know.

Mr Burgess: We, on an infrequent and irregular basis, have the ability, or used to have the ability and hopefully will have the ability again, to scan our claims files by individual. If the individual has submitted nothing but out-of-country claims for a nine-month period and no in-province claims, it would be reasonable to imagine that the person might well have moved out of the province. At that point in time, we would start to do some investigation. We might phone the US immigration service to see if the individual has a green card. If so, they are not eligible to receive Ontario health coverage, that sort of thing.

Mr Tilson: They'll come back over the bridge.

The Chair: I'm going to move to the government members.


The Chair: Order, please. I've allocated an additional seven minutes to your party. I'm going to try to be fair and allocate an equal amount of time for each of the other parties. There are a number of interested members who want to ask questions, and this is the only fair way we can move forward. I know the deputy has to leave. I'm going to ask for his indulgence to have an additional 10 minutes, if I may -- five minutes to the government party and five to the opposition party. Is that acceptable with you?

Mr Decter: I'll just have to drive faster on the way to the airport.

The Chair: Okay, five additional minutes if there are any questions on this side. Mr Perruzza has a question and then Mr Wiseman.

Mr Jim Wiseman (Durham West): No, I was next. You're doing a lousy job.

The Chair: Thank you very much. Would you like to take over?

Mr Perruzza: Who in the province of Ontario is entitled to a health care card?

Mr Decter: Someone who is "ordinarily resident in Ontario" is, I believe, the terminology in the current act. We have made a definition of "ordinarily resident" that conforms with the income tax definition, that is, to be resident in the province for six months of the year.

Mr Burgess: And must legally be entitled to be here.

Mr Decter: I'm sorry, "legally entitled to be here and ordinarily resident." So someone who is illegally here, someone, for example, with a deportation order outstanding is not eligible. But if you're legally entitled to be here and you're ordinarily resident here, then you are eligible for coverage.

Mr Perruzza: I just want to get at this whole thing of fraud, because I keep hearing it over and over again and quite frankly I'm quite sick of it. I think the whole term "fraud" has taken on sort of a much nastier and much more sinister meaning to it.

I was late in getting my health care card; I was about a year late in applying and getting my health care card not for any other reason than the fact that it's just something I always neglected to do. I always felt I never needed it and didn't apply for it. So at the end of the deadline, when the OHIP card expired, I was without a health care card. If perchance I had fallen unconscious one day and someone in my family had taken me to the hospital and had used his or her card -- I'm eligible and I meet the requirement -- would that show up on your system as a fraudulent use or a fraudulent way for me to receive health care?

Mr Decter: In terms of our system, if you're an eligible person, if you have eligibility, then you're entitled to receive the services and there's no ability to refuse you urgent care. In that case you'd receive the care, and presumably, after you'd received the care, you would, in the normal course, be issued with a health number and all of the providers would be paid in that circumstance.

You're asking me the more difficult question of whether it would be fraud for you to use someone else's card. I believe yes, using someone else's card would be fraud. It wouldn't be a fraud of any particular benefit since you'd have eligibility, but it would be fraud. It would be the same as using someone else's driver's licence if you had one of your own. You would be -- where's Gilbert when I need him? -- impersonating somebody else by using his or her driver's licence or passport or whatever other document. That's separate from the eligibility issue.

Mr Perruzza: So while that technically shows up on your system as a fraudulent way to get health care, at the end of the day it wouldn't be a fraud because I would have been entitled to receive the health care anyway. When we use the word "fraud," and I know the minister-in-waiting Wilson uses it quite frequently, it's a fairly broad term and --

Mr Jim Wilson: Fraud is fraud. There is no good fraud.

Mr Perruzza: I know what you would have done. If I had been unconscious, you would have let me die.

The Chair: Order. Mr Perruzza, I'm sure you have a valid question, but time is running on. Mr Wiseman, I have one rule as Chairman on this committee: I do not recognize members if they're going to behave in an uncivil and discourteous fashion.

Mr Wiseman: I was supposed to be on the list from the last round, and your not being in the chair --

The Chair: If you have difficulty with that, then you have difficulty with the way I run meetings.

Mr Wiseman: My question to Mr Decter is --

The Chair: Order. I haven't recognized you.

Mr Wiseman: How would you be able to --

The Chair: We will adjourn for five minutes because I do not recognize Mr Wiseman.

Mr Tilson: A point of order on your adjournment: Mr Decter, out of courtesy, has indicated he has to leave. I think we better let him go.

The Chair: I'm not going to move forward in that regard, in that way, on this committee, and that's the rule. If you want to challenge the Chair, then I'm going to leave it open to challenge.

Mr Tilson: No, sir, I wouldn't challenge the Chair. I'm concerned because --

The Chair: I understand Mr Decter has to leave, but --

Ms Poole: Mr Chair, might I make a suggestion?

The Chair: Yes, you may make a suggestion.

Ms Poole: Our caucus --

Mr Perruzza: Adjournment is not debatable. We've adjourned the debate for five minutes.

Ms Poole: We are willing to waive our five minutes of Mr Decter so he can leave.

Mr Perruzza: We're adjourned right now.

Ms Poole: If the government member --

The Chair: Order. I said I'm going to adjourn the committee. I did not say we are adjourned.

Mr Perruzza: No, you said we are -- well, look, you don't have Instant Hansard here, but I can read it back to you.

The Chair: The committee is adjourned: a five-minute recess.

The committee recessed from 1521 to 1530.

The Chair: I call the committee back to order. I'm going to try to allocate time evenly, as fairly as I can. I foresee us going to about 4:30 today since we started at 1:30, if that's agreeable to everyone. If that's agreed, then we will divide the time up in 20-minute slots for each party.

Mr Wiseman: Point of order, Mr Chair: I believe I still had a question. I was in the rotation when you adjourned, and there were three minutes left.

The Chair: Unfortunately, the time had elapsed. I had intentions of allocating five minutes to the government party and five minutes to the official opposition when the deputy was here, but that time had elapsed, unfortunately.

Mr Wiseman: You had recognized me and then you called an adjournment, so I would assume that I had at least some time left.

The Chair: No, I had recognized you to tell you that I had certain rules that I abided by and that I had hoped you would recognize those as being of a civil nature and that we would proceed in that fashion. If that's not conducive to the kind of operations that you see with the committee, then you're open to challenge the Chair at any time. But that's the rule that I make around here, that people conduct themselves in as civil a fashion as possible and that there are no personal attacks, either on myself or anyone in the committee. That, for me, signals that the committee is not in order or that we've lost order on the committee, and then I call for a recess. It's very simple. If there's a problem, you can challenge the Chair, but I'm going to proceed on that basis.

Mr Wiseman: Mr Chair, I understand we still have time on the clock and I do challenge you on that basis.

The Chair: Okay, that's fine. We have to have a vote on that matter.

Shall the ruling of the Chair be sustained? All those in favour? All those opposed?

Shall the ruling of the Chair be appealed to the Speaker?

Mr Wiseman: I'd be satisfied if you'd just give me three minutes so I can ask my question.

Ms Poole: Mr Chair, might I suggest that's a reasonable compromise, rather than --

The Chair: Let me just clarify this. I'm going to take two minutes and recess to clarify the position with the clerk so that we can move in a formal procedural fashion that abides with the rules on the committee. We will then call the committee back to order. We're recessed for three minutes.

The committee recessed from 1533 to 1536.

The Chair: I call the committee back to order. Having conferred with the clerk, he informs me that this matter can be appealed to the Speaker. If that is the intention of the committee, then I would ask that the committee signal that. Is that the intention of the committee? Do we have a consensus around that? No?

Ms Poole: Mr Chair, rather than just worry about all these procedural issues, why don't we all agree as a committee that Mr Wiseman can ask his question and then we will not have to go to the Speaker for a ruling on this.

Mr Callahan: You couldn't find him.

Ms Poole: That's true. The Speaker may not even be here at this time. Then that will just deal with the issue and then we can divide the remaining time.

The Chair: Okay. Shall I then award Mr Wiseman several minutes of time for his question and that's agreeable to everyone? Agreed. Mr Wiseman, you have two minutes.

Mr Wiseman: Thank you. My question has to do with how we would find out if someone was ineligible for a card in the United States. Do you have some kind of liaison with the United States that, for example, applications for homestead or something would be turned over to you or you would be notified by some bureau in the United States?

Ms Patricia Malcolmson: Peter Burgess may wish to assist me with this, but when we have some reasons for suspicion with respect to individual registrants, we have in our verification unit a capacity to deal with the US immigration service and others there. I guess the intent of your question was, do we have a regular data feed from the US immigration service or something comparable that might be like the kind of feed we have from the registrar general, and Peter can correct me, but as far as I know, the answer is no.

Mr Burgess: That's absolutely correct. We dig for any and all information available on a case-by-case basis.

Mr Wiseman: How would you find out if somebody has applied for a homestead permit and then suspend their card? How would you do that?

Mr Jim Wilson: What's a homestead?

Mr Wiseman: They've bought a property in the United States and they've applied to live there.

Mr Burgess: A homestead grant or title, as I understand it, is only applicable to certain states. It's not US-wide. But on a state-by-state basis, we will phone the state authorities if we have reason to believe that someone is in a fact a permanent resident of the state of Florida or the state of Arizona. They cannot be a permanent resident of the United States of America and Canada at the same time, obviously; that's impossible.

When we get on a case-by-case basis confirmatory information from the appropriate jurisdiction, we approach the individual, if we can track them down, which we typically can by phoning the tax authorities and so on in the States, and we just notify them that their coverage has been cancelled due to ineligibility and we offer them the right to appeal to the Health Services Appeal Board.

Ms Poole: I'd like to ask some questions about the smart card technology and what could be and will be included on the card. I know the focus of this particular public accounts has been on fraud and trying to ensure that the proper verification is in place, but earlier this year we had several people who were very active in the area of smart card technology make presentations to our committee, and one of the things they said the smart card was capable of was having a microchip which would list all the drugs that person had and the prescriptions and the particular medical care. I think that was a very important concept, not only for the cost savings but also for the fact that it's very unhealthy for people to be overprescribed. If one doctor doesn't know what another one's prescribing, then it could be a problem.

My understanding is -- and I may be wrong on this -- as far as drug interaction, there is only going to be a record of those who are on the Ontario drug benefits.

Ms Malcolmson: That's correct.

Ms Poole: In other words, those are the ones where the taxpayer's footing the bill. Did the ministry investigate the cost of having this information put on all cards, this ability for the pharmacist or the physician or the hospital to have access to this kind of information on a microchip on the card, and why was the decision made that it would only be for the Ontario drug benefit recipients that this information would be kept, as opposed to on a broader scale?

Ms Malcolmson: I believe, as Mr Decter indicated yesterday, and Mr Stump, who is the manager of that project, when we was here, the idea here was to move one step at a time. I believe Ms Sullivan addressed some other similar questions around, where could you potentially expand the drug network? Yes, there's considerable potential for expansion, but this is already a reasonably costly system. We want to see what we can achieve with a network. We think there are considerable benefits to be gained, as described yesterday, from having that network without carrying it farther.

We do have people in the room who are able to talk to smart card technology per se. You would have to issue people with those cards, which are much more costly than the existing card. The drug network is able to use the mag stripe that's on the back of the current card in order to achieve its objectives. You also would have to have a whole additional network system which would allow each provider to be connected to the network and then to be able to read what was on that person's card.

I think, as we mentioned yesterday, there are also considerable concerns around data exchange, freedom of information, when you carry things that far. I also would not think that the government readily has the legislated authority to collect data on transactions over which it has no control and for which it does not pay.

Ms Poole: We've heard several times about phase-ins and taking one step at a time, but I have two questions in that regard. How much more is it going to cost by having to wait to implement further technology? Secondly, what is the time frame, in your opinion, for a fully operational interlink system so that all the phases are completed and we have a card which gives us access to information, which has security features and which provides health coverage to every legitimate resident of this province? What is the time frame and what is the fully mature cost that's anticipated for doing this?

Ms Malcolmson: I think, as the deputy indicated yesterday, we are in the course of preparing a submission to cabinet on the development of the enhanced card, and we don't have final costings on that. I'm not sure whether your question has moved from the drug network to the enhanced health card itself. I'll address my comments at this point to the card itself.

As the deputy described yesterday, we are looking at a renewal cycle for the card, and we're expecting to recommend to cabinet a mode of implementation which will be gradual and will take some time to implement. Once fully implemented, depending on the renewal cycle -- every three years, every four or five years -- a card would be renewed. Five years is what the Ministry of Transportation has moved to, a five-year cycle.

With a renewable card, you can add a different feature if you wish. If your evaluation of what you have in place suggests that you need to add another visual characteristic on the front of the card or you need to add another data element to the mag stripe on the back, you can incrementally do that as part of your renewal cycle without starting from square one and beginning with a full reregistration of the entire province. So that's one aspect of the question.

The other is, yesterday the deputy was speaking about an interim card that could be used on the way to a photograph card. The interim card would be able to add characteristics in terms of labelling on the front side of the existing card that would make it more secure for any cards that are issued between the date of cabinet approving us going forward to a new card and actually getting cards with photographs and other security measures into the hands of all residents. So that's one aspect of it.

We are improving the application controls at the front end of the system. That's something that we can do administratively in terms of asking for only original identification requiring reconfirmation of residents with documentation. If an individual wants a card replaced because they've lost it or they want a card replaced because they've married and wish another card issued with a new name on it, in those cases we're doing things like trying to recover those cards.

There are a lot of measures along the way that we will be undertaking -- and I think most of them have already been in one way or another described -- that will increase the confidence we have in the system as we move towards a card with a photograph.

There are some key decisions that have to be made and cabinet will have to make them. You might look at the example of the province of Quebec, where it's basically ambulatory adults to whom cards with photographs are being issued. In that particular population, children, I believe under the age of 14, are issued with a card that does not have a photograph on it. If we recommended the same thing, the card that would be issued to children would have the additional labelling characteristics on the front of expiry date and sex and date of birth, those kinds of characteristics, and when a child reached a certain age, they would then as part of the renewal cycle be issued with a photograph card.

Mrs Sullivan: Thank you. I don't know if the ministry can provide this information or legislative research, but I think it would be interesting to review the Quebec experience with photo cards and any analysis that has been made in that province of the costs of implementation, of savings and security benefits that have entered the system as a result of their introduction of the photo cards.

I wanted to move further into the integrity of the addresses on the cards. Your project analysis report estimates that 26% of the addresses now on the database are incorrect. The testimony before the committee has provided an indication that there will be a considerable reliance on the service provider to update and provide correct information with respect to addresses as well as other things. The technology which we have been shown, however, appears to be one-way technology, so it appears that from a technological point of view there is not the opportunity for an update through the technology we have seen, whether it's the voice-activated mechanism or others. I'm wondering what specific mechanisms you intend to put into place so that the service provider can provide an update.


I'd also like to hear from the Ministry of Health what its views are of its legal authority to collect information or share information with the Ministry of Revenue or the Ministry of Transportation or other provincial ministries to ensure a linked update, and whether it's the ministry's opinion, because we are certainly going to be hearing from the Information and Privacy Commissioner etc, that additional legislative authority would have to be required before there is a mechanism that can be operable with respect to information exchange.

Ms Malcolmson: To take your second question first, I don't think the ministry has at this point fully determined whether legislative change would be required in order to share data. We have, however, been liaising with other ministries. We will be meeting with officials from the freedom of information office. Our legal staff is of course examining exactly what authority exists for making those kinds of exchanges of information. We already have, with respect to things like the death notifications, an exchange of data with another ministry which is supported by a legal agreement, and we have draft memoranda of understanding in other areas that are waiting final legal approval.

Certainly, as we go forward, we have to ensure that it is legally possible for us to proceed and that we can meet any concerns that the Freedom of Information Commissioner may have, and we intend to do that.

With respect to the addresses themselves, your second question would really be part of my answer to your first question, that yes, we would hope to be able to do a fair bit of address updating via exchange with other parts of government that have reason to obtain updated addresses from individuals.

As I believe Mr Stump explained yesterday, with the implementation of the drug network, which covers I believe 2.5 million residents in this province, we will have the capability of receiving updated addresses from pharmacies with respect to those individuals who have drug coverage along with their health coverage.

Mrs Sullivan: What is the mechanism for inputting that into the system? I think there's a problem.

Ms Malcolmson: Bob can talk to that. I am assuming that it will, if not initially, ultimately be via an electronic feed. The drug network is the first network to be put in place which follows the government's broad telecommunications plan, and we would hope it would ultimately be extended to providers' offices. Once you technically have a network in place, you can exchange information on a two-way basis, but Bob is the expert on this.

Mrs Sullivan: If I can just go back a couple of steps, Mr Decter earlier indicated to the committee that as a result of the OMA agreement there was two-way communication required: On the one hand, doctors would be paid for services provided to people who were becoming ineligible; on the other hand, the tit for tat, doctors would be expected, as would hospitals, to provide to the ministry updated information they come across with respect to the database.

We have seen examples of the technology that is now being tested in pilot projects. We see no mechanism that is secure for that information to be put into the system and be readily implementable within a short period of time. If you're saying to me that pharmacists, by example, will be able to update the record, the individual patient record, then I'm wondering whether you have examined the security of that. It seems to me that the provider ought not to be able to change the OHIP record.

What I'm asking is, what mechanisms are there in place so that the information will flow in an appropriate way and be confirmed, with the patient's involvement, to OHIP?

Ms Malcolmson: With respect to the exchange of addresses in the drug network, the mechanism is not fully in place; well, the network itself is not in place at this time. It is the subject of discussion in terms of security and appropriateness with technical systems security people, with freedom of information people. There may be someone else who has more expertise on that.

With respect to the OMA agreement, there was no mechanism for the exchange of that information specified in the agreement. How that information is exchanged initially will be the subject of discussion with the OMA as part of the joint implementation team to put in place various aspects of the agreement under the social contract.

Mrs Sullivan: Did the ministry have any proposals to put before the doctors before the agreement was signed?

Ms Malcolmson: With respect to the technological mechanisms for exchanging that information, I don't believe so.

Mrs Sullivan: This is very loosey-goosey.

The Chair: If I may, the auditor has asked to ask a couple of questions, and we will just add on some time.

Mr Peters: The questions I have are just to help to clarify some issues that have come around, so they're strictly questions of clarification.

The first one is just to deal with the swipe cards for a moment. Yesterday in the presentation, the presentation was made only to the effect that the cards that were swiped were either valid or invalid. Yet this morning, based on a question, there was a statement made that the recipient of the view of the screen could also ascertain from the screen basic information of the health card content; I think the deputy said this morning that it would verify the gender, the age etc. That was not demonstrated -- am I mistaken on that? -- because the demonstration was only as to validity.

Mr Cavanagh: There was a lot more to be seen on the screen than what we were giving you verbally; unfortunately, due to time, we didn't have a chance to gather around and look at it. All of the information that's on the magnetic stripe, that particular computer program does pick up that information, displays it on the screen and then does the query and comes back with the result of whether it is currently eligible or not eligible. That information is available to any provider or anybody who has a swipe reader on their own local system.

Mr Peters: That's helpful, because it gave the impression that we were only checking validity and not eligibility. I just wanted to reconfirm that.


Mr Cavanagh: There is an issue that technically we are checking eligibility. Technically, that's what the check is: eligibility for basic OHIP services, not a guarantee of payment or anything like that; it's just that basic eligibility. What's in this pilot is very limited information. It was based upon what our freedom of information people said we could obviously release to a bona fide health care provider, and no more.

Since we've developed the pilot, there's been further work, and undoubtedly, when we roll it out, we will provide more information. There's obviously a lot more that could be provided. It's going to be a decision as to what is appropriate and proper to provide.

Mr Peters: Thank you very much; I think that clarifies the point. You're quite right, and the demonstration was difficult to see from here in terms of what exactly was provided.

The second question deals with the two-hysterectomies case. According to the report you have left with the committee, these turned out not to be fraud cases but rather, in the vast majority of cases, billing errors.

While there has been a lot of questioning along the line of fraud, there's of course also concern, as we expressed in our report, and continued concern, about how much we're spending on the basis of paying for the wrong procedures or paying the wrong person; in other words, committing any other billing error. There also could be diseconomies or inefficiencies in that regard. It was kind of astonishing that those all turned out to be billing errors.

There was also a secondary question raised about the new OMA agreement, whether the doctors, who up till now -- at least a number of them have gone public in saying that administration of the health services is a ministry responsibility and that the doctors' responsibility is to provide service. Under the new OMA agreement, are there any steps taken that in fact would reduce the billing errors? As supplementary information, I think you yourself are using right now in excess of 5,000 billing codes for medical services, so the potential is certainly there that the wrong procedure is billed and that billing errors occur. Does the OMA contract help you, and in what way?

Ms Malcolmson: In terms of intention, it definitely does. I believe the preamble to that section of the agreement indicates the OMA's concern with the problem of fraud and with the efficient and effective management of the health care system and indicates their desire as part of that agreement to work in partnership with the ministry to try to address the problems which exist. As we proceed along the way of implementing the social contract and continue to work together through the joint management committee, we will in fact be addressing together measures that can be taken to reduce fraud.

I believe the deputy had mentioned yesterday that in addition, we are now looking at some of the things we can do to improve controls on the provider side of the system; those analyses are still in progress. We know there are more medical rules that could potentially be put in place. Again, as with the registration analysis project, we hope on the provider side to find those places where we can best target our actions. That's part of the answer to your question.

One of the things that the registration analysis project did in this particular study was to point out that sometimes things that start off, in terms of analysis, appearing to be something that the people doing the work expect is going to show up as potentially some kind of problem on the client side does indeed turn out to be a problem on the provider side. Where the specific cases have been carried out, we have taken follow-up action in order to recover moneys where there have been inappropriate billings, and we're going to act more aggressively on that front just as we are acting more aggressively on the client side of things.

Mr Jim Wilson: Ms Malcolmson, yesterday in the deputy's presentation, one of his overheads dealt with social assistance reform. The line below that title said "Delinking Health Benefits from Eligibility for Social Assistance." It was contained in the policy legislative changes section of his presentation. Can you tell me what that means and what's planned with respect to delinking health benefits from eligibility for social assistance?

Ms Malcolmson: As the deputy minister indicated yesterday, the whole area of social assistance reform is in its investigative stages, but the general idea here is that there has been in the past some difficulty with respect to the welfare program when people who maybe should no longer be eligible for welfare have become disadvantaged because, in going off welfare, they also lose access to health-related benefits. I believe the deputy used the example yesterday of a single parent with a number of children who, while she's on welfare, are in receipt of additional medical benefits.

While I can't provide specifics about how it's going to be done, because those have not been decided yet, the idea is to move health benefits into the Ministry of Health and separate them in some fashion, which will be determined by the Ministry of Community and Social Services and not by the Ministry of Health, from income-related financial benefits.

Mr Jim Wilson: That's an interesting answer but --

Ms Malcolmson: The work has not been completed and it's not being done by the Ministry of Health, so I can't --

Mr Jim Wilson: It was part of the deputy's presentation, though, and part of his sales job with respect to initiatives that are being taken by the government. I read that to mean you'll no longer be automatically eligible for certain health care benefits just because you're eligible for welfare. Delinking, to me -- can you further explain what's intended there?

Ms Malcolmson: As I say, the work is in the early stages. I think there may be a couple of people in the room who have worked with the people in MCSS, but they haven't come forward with a formal proposal.

Mr Jim Wilson: Perhaps we should call a few. It's important because, and I don't say this with arrogance, it's one of the few things I've learned in the last couple of days. This hit me yesterday. I meant to ask the deputy, and other things about health cards, since it was part of his presentation.

Ms Malcolmson: Staff have indicated to me that drug coverage, for instance, under the Ontario drug benefit plan for social welfare recipients, does expand coverage to the working poor and unemployed. This has been proposed under drug reform, which is part of the work going on under the auspices of the drug programs reform secretariat, as part of the work being done there. I don't know if there's anyone else who can speak to this, because it's not at base a health initiative. It has not got to the point of formal, detailed proposals.

Staff are telling me here that there is a proposal, which has not been made public, that has gone to cabinet with respect to general welfare recipients who do not otherwise qualify as permanent residents of the province, who receive in certain circumstances welfare benefits but who would not, if separate from the welfare system, be eligible for a health number in the province.


Mr Tilson: One further question. On the issue of the photo cards, you appear to have made the decision that you're going to use the photo cards. At the same time I get the impression you're still working on a whole slew of things, and you may even be open to other things, I don't know. I guess the fact that Visa, the oil companies and Mastercard and all these other people don't use photo cards -- Mr Burgess and, I think, Mr Decter indicated that they're having discussions, albeit maybe informal discussions, with the people in Quebec as to the success of photo cards.

There are charts indicating all kinds of plans all over the province. There's no real specific control program that I have heard from anyone -- Mr Decter, Mr Burgess, anyone -- with respect to the control of fraud with respect to photographs being put on cards. The whole issue is: Can you produce a fraudproof card? I haven't heard anything to that effect. I assume you're looking at all kinds of things. You may not even have finalized your report for cabinet. So my question is: Are you looking at alternatives other than the photo card?

Ms Malcolmson: We're looking at a variety of measures that would alter the way the card looks. I think it's worthwhile noting that some other areas are in fact moving towards photo cards. Citibank is using a photo card in the US. We're talking to those people and we intend to continue our consultations and consult broadly before we finalize our cabinet submission.

The photo is only one aspect of the enhancement of the card itself. An enhancement comes with the addition of information on the front face of the card; it comes with the renewal cycle; it comes with the method that can be employed with respect to photographs. I think someone had mentioned what the Ministry of Transportation has now with respect to a photograph card, but what we are looking at is a process whereby the person's photograph is taken on the spot and digitally produced on to the plastic card rather than just being laminated. The signature can be digitized in the same way. There are additional features that can be added to the card such as a security film over the top.

Mr Tilson: I understand. Mr Chairman, I guess what I'm really doing is returning to your question some time today as to why this committee can't really look at the final product before it goes to cabinet. I don't know what's secret about it. I understand there may be some security matters and I again express the same concerns that you've raised. We listened to Mr Decter back in the spring or February talk about cards, we have now discovered that there may have been problems with the red-and-white cards -- not may have; there are problems with the red-and-white cards. I think it's fair that this committee be permitted to hear the final presentation, taking out perhaps the issue of security, because we've spent a certain amount of time ourselves. That's the gist of that question.

I know there was a pilot project in Thunder Bay with respect to the smart card.

Mr Wiseman: Fort Frances.

Mr Tilson: Was it Fort Frances? I'm sorry. Why did the government, looking at that pilot project, reject the smart card?

Ms Malcolmson: I could ask someone to come up and talk about the specifics of the actual report there, but essentially that project showed that technically a smart card can work and provide security with a high degree of confidence. However, it is a fairly costly technology both in terms of the card itself and the need to have databases to back up the card, the need to replace and replenish data, a large amount of data, if a card is lost.

I guess in the health care setting there are a few practical problems, that you and your card may well be there when you give blood; you may not be there when the results of the tests performed on that sample are actually made available. So there's a necessity to always make sure the card continues to be updated. If there are problems around that, are there issues of confidence with respect to the data on that card, from a medical perspective not a security perspective? But really, is this the most up-to-date information, if that's what you're going to rely on with respect to --

Mr Tilson: So you've ruled it out, in short.

Ms Malcolmson: -- your particular patient?

Mr Tilson: You've ruled the smart card out, is what you're saying.

Ms Malcolmson: For any large-scale application. I think the results of the project suggested that there might be some small-scale situations in which it was --

Mr Tilson: I have a question Mr Wilson has raised in the past that has to do with hospital cards and the issue that with a health card, a red-and-white card, you can go into any number of hospitals, which have their own machinery, their own computers and, it appears, with the consent of the ministry, have a whole slew of hospital cards which, to use Mr Wilson's words, are technically available on the street, can be disposed of.

What does the government propose to do about the potential fraud of the health card system as triggered by the hospital health cards? Do you intend to allow that process to continue immediately, even now and during the interim period and, finally, during the final photo card?

Ms Malcolmson: As Mr Decter indicated yesterday, we have initiated discussions with the Ontario Hospital Association with respect to the blue cards that are used in hospitals. I believe he also indicated that there's considerable variation in opinion on to what extent there is exposure to fraud in that particular situation. Certainly, as we move towards a combination of extending swipe card technology and having an enhanced health number identification card, we're hoping to be able to work with the OHA to see if in fact there is a way in which a single card can provide what is needed across the province. So those discussions are under way at this time.

Mr Tilson: Do you know of any immediate -- do you have any knowledge of fraud that's going on now, or any irregularities that are going on now, with hospital cards?

Ms Malcolmson: I suppose there has been some mention of suspected cases in the press. It may be that members of the registration program branch can speak a bit more to that, but since our core concern in the ministry and in this branch is with the health card, we've not done extensive investigations on that front.

Mr Tilson: That's not true. With my health card I can go in and get any number of hospital cards, even from the same hospital. I can just say I've lost it; I need that blue card. So it's all tied in and then I don't need the health card. I can keep going back to the hospital or I can pass one around the room. There are all kinds of copies. To me, it's potentially a serious problem.

Ms Malcolmson: It's because there is some concern in that area that we've undertaken discussions with the OHA.

Mr Tilson: Okay, and what are your conclusions now?

Ms Malcolmson: We have not reached conclusions because we're still in the process of discussing with them these cards and the potential for alternatives to them. I gather there are other pieces of information typically on those cards that are made use of within a specific hospital environment which are not currently on the present card. I believe it was mentioned yesterday that the possibility exists for adding a stick-on label to the current or future health card to add the additional identification that might be needed in a hospital environment and we're looking, with the OHA, at what kinds of options exist that will serve their purposes and ours and reduce exposure.


Mr Tilson: I understand. Hopefully you'll come forward with a report to the public or the committee indicating the results of those discussions, because I look at it as a serious problem, as Mr Wilson has indicated.

The registration analysis project recommends the philosophy of zero tolerance on health card abuse so as to realize the full benefits to the system that was introduced by the Liberals in 1990. Given the extent of the abuse that has been unfolded in the media and before this committee, is this feasible?

Ms Malcolmson: I would say that zero tolerance, from the perspective of those who monitor databases and do sampling and controlling investigations, is a goal. One hopes to get as close as is reasonable to a goal of zero tolerance. I think if we didn't proceed with the objective of having as fine a system as possible, we wouldn't be doing our jobs properly. I don't think there's any --

Mr Tilson: As a goal, but is it feasible?

Ms Malcolmson: I don't think there's any system that can be probably 100%, but what we are attempting to do in responding to the findings of this report and other concerns is to move closer to zero tolerance than we have been before in terms of the way the system works, in terms of the attitudes and procedures inside the ministry. The deputy has also alluded to partnerships with the medical profession, with hospitals, to heighten awareness among members of the public, so I think we're moving closer to that goal. I don't think anyone can possibly say you could ever be 100%.

Mr Tilson: Can I just ask one more question to Mr Burgess that remained unanswered?

The Chair: There are exactly three minutes left and I'm going to --

Mr Tilson: I won't even ask it again, Mr Burgess. It has to do with the person who goes to the United States and does not stay there but comes back or gives the card to someone else to come back.

Mr Burgess: In terms of the question that Mr Wiseman asked, if we have an opportunity --

Mr Tilson: No, it wasn't in terms of the question Mr Wiseman asked. I'm talking about the Ontario resident or citizen who goes down to the United States, has an Ontario card, doesn't have a service down there, comes back and has the service recorded here, still has his old address in Ontario or gives it to someone else.

Mr Burgess: If we do not get a leak on that particular individual, there is absolutely no way, given the current state of our systems, that we can track that individual. However, we are getting leaks from neighbours, others, and we are taking action on those that we find out about.

Mr Jim Wilson: A quick follow-up on that, though, with respect to physician responsibility in helping us police the system: I recall a Toronto Star article where a Windsor doctor admitted late last year, "Oh, I know 12 of my patients are residents of Detroit." What's going to happen now when a physician -- in conversation, physicians often find out where people really live.

Mr Burgess: As I reported at the last public accounts, we actually did phone that physician and he claimed to have been misquoted and did not give us any information about those patients. That's that specific case. However, we have had other physicians in border areas who have phoned us and have given us information either to our 1-800 hotline number or directly to my office and we have acted on each one of those pieces of information. If anyone calls me, we dig into it; we find out what we can; we take appropriate action.

Ms Malcolmson: I might add to Mr Burgess's comment by saying that as part of the agreement with the OMA, we're moving to remove the primary concern that providers have in this kind of situation, which is any legal liability they may have or any concerns about being culpable because of release of potentially confidential information. We have legal staff working on that, so we hope that the level of disclosure to us of suspect cases will in fact rise as a result of the resolution of those ancillary problems.

Mr Jim Wilson: Yesterday, we heard mention by Mr Decter of some comment about a government smart card which would encompass all the ministries and all the plastic cards out there that governments issue. Before you do a final report, I don't know how we could do one at least asking Management Board what the status is of its progress on that, because the Ministry of Health hasn't been able to provide a lot of information about that. The worry, I think, of the committee is, are you going to spend a few more million dollars on putting photos on the current cards when, five years from now, we may end up with a government smart card?

Mr Perruzza: Where are you? On the deck of the starship Enterprise?

Mr Callahan: It's not Star Trek.

Mr Jim Wilson: I'm looking for direction on this.

The Chair: Perhaps, Mr Wilson, we will be in closed session tomorrow and will have an opportunity to discuss where the next set of directions might be for the committee to go on this matter. That's the opportunity we have in camera tomorrow. I think that can be pursued further at that time.

Mr O'Connor: I guess what I'd like to start off with is to point out the fact that we have come a long way in the last decade. In the last decade, we've seen the OHIP numbers go up to 26 million, and now we're down to bringing something in line. I guess we should thank the Liberals for starting something. Maybe what they started wasn't perfect, but we're improving on it. We've got a long way to go.

Mr Jim Wilson: That's how we got in this mess.

Mr O'Connor: I know that the minister has been extremely persistent on the fact that there be developed an investigative unit to --

Mrs Sullivan: That's how we got out of your mess.

Mr O'Connor: Excuse me. The minister is persistent that there be an investigation unit set up to take a look at any misuse of the OHIP card. She's very concerned about that. The Medical Review Committee, in taking a look at medical physicians who have billed and then have had to repay to the government, within the last decade we've seen it go from around $700,000 to over $2 million for last year. So we've seen an incredible change in that.

Obviously, going through that, then, there has been a recovery system that's happening. I guess what I'd like to ask, and maybe we could get someone here from the auditing team of the Ministry of Health to take a look at, because we are in the public accounts committee, and go through some of the practices that they follow, because obviously some of the practices that they follow are improving the system. We've seen the numbers in the last decade go from $700,000 to over $2 million, an incredible amount, so there's a lot of change happening. Do you have somebody here, behind you, who might be able to help me from the auditing team?

Ms Malcolmson: Yes, Karim Amin, the director of our audit branch, is here and certainly, as the deputy's presentation yesterday clearly indicated, the work that is done by our audit branch is extremely valuable to the ministry and to the government in managing the costs of the health care system. The mandate of the audit branch extends well beyond the health card issues that we've been discussing primarily in this meeting.

Mr Amin: Mr O'Connor, I think the $2 million you refer to extends from work done by the MRC; is that correct?

Mr O'Connor: That's right.

Mr Amin: Our branch does not get involved in the profile management or what are considered to be deviations from our practice that are done by the provider services branch within OHIP. So I guess I couldn't discuss specifically that part of your question.


Mr O'Connor: You are involved in the project development of the special investigations unit, though?

Mr Amin: Yes. We are doing that, and as you know, that is just a few weeks old. As the deputy said, we have engaged the firm of Lindquist Avey to help us in that area.

Mr O'Connor: Will that team then work with the audit branch if there are areas that it feels need to be investigated?

Mr Amin: Conceivably, yes. The protocols for exchange of information and for referral of cases to the investigation branch are yet to be worked out, but I'd like to think that eventually whatever comes to the investigation branch will come on referral from other areas of the ministry. It could be from the physician area, it could be from the drug benefits area, the nursing home area, because you do have a number of areas in the ministry where we have inspection or quasi-investigative functions.

Mr O'Connor: How large is your team of auditors?

Mr Amin: The branch has 31 employees.

Mr O'Connor: They audit every aspect, then, of health care that is billed through the ministry?

Mr Amin: They audit, on a priority basis, operations of the ministry and of transfer payment agencies. I say on a priority basis simply because, with the size and the sheer numbers of our operations, it is virtually impossible for 26 auditors plus a few supervisors and support staff to do all operations on a cyclical basis. It's just impossible. What we do is we chase down those situations that are really hot fires or where management requires information or opinions.

Mr O'Connor: Has your department then found areas that concern you, that could be fraudulent, that will or could be sent to the special investigation unit?

Mr Amin: I think in the past we have done work with forensic accountants based upon some of the findings from the audit branch and we have engaged forensic accountants to assist in the past. I think now that we are developing enough expertise, the linkage between the audit branch and the forensic area or the investigative area will be something quite formal, and we'll be expected to have a very close relationship with that unit. Suffice it to say that I happen to be the director of both areas, so we shall ensure that their linkage is quite appropriate.

The Chair: Mr O'Connor, just on a supplementary, I'll add one minute of time, but I think this is important in this context for our committee because your branch does auditing of financial statements and not the kind of auditing that would involve value-for-money that the auditor would undertake to do. Is that correct? Is that a fair assessment?

Mr Amin: I have to disappoint you. We do value-for-money. We do management reviews and we do financial reviews also.

The Chair: You're not disappointing me then. You're making us happier.

Mr Amin: Then you make me happy also.

Mr Tilson: I think I want to hug somebody. Are we all happy?

The Chair: Now we're all happy.

Mr Amin: I think it's wonderful when the political and the bureaucratic ends can say those things to each other.

We do a broad range of work and there are occasions on which we second physicians and nurses or health care workers to our branch so that we can have that expertise to deliver our service to senior management. So we do a broad range of work.

Mr O'Connor: I want to thank the Chair for that interjection because it certainly did seem to help the morale within the ministry. I appreciate his momentary interjection and would yield the floor to my colleague.

Mr Frankford: I wonder if we could explore some of the things that have happened in Quebec. Are you aware that having picture cards has made any impact on the overall costs?

Ms Malcolmson: I think perhaps there are staff here who have talked to the people in Quebec. They are, I believe, still in the process of evaluating their experiment because they are renewing to a photo card on a cycle, so I don't think they in fact have done all of the province as yet. But in even having people contacted to reapply for a card that would require both a photograph on it and additional documentation confirming residence, a significant number of people did not reapply, obviously suggesting that they were not eligible and were now being put in a situation where their ineligibility would be exposed.

Mr Frankford: How does one become ineligible?

Ms Malcolmson: Well, either they weren't eligible in the first place or they no longer are eligible, as in the difficult situations that Mr Burgess was speaking of before when someone may have been perfectly, legitimately eligible when they applied and then they leave the province permanently to live elsewhere and have not given up their card so that eligibility ceases.

You might be interested to know, though, with respect to other provinces, that when you leave one province, you go and you apply for coverage in another province, and we have an exchange on a monthly basis of registration information with other provinces and territories in this country which allows us to delete no-longer-eligible persons from our database on the basis of information supplied by other provinces, and of course they can do the same. That information is increasingly in fully automated form, which will make it progressively more useful in a timely fashion.

Mr Frankford: But there you're talking about bona fide Canadian residents, so they would always be covered somewhere. They can in fact get Ontario health care on a BC card if they happen to be here, and there is a reciprocal arrangement, is there not?

Ms Malcolmson: If someone is simply visiting, there is a reciprocal billing arrangement. But obviously any provincial jurisdiction, and I guess particularly in these times, is anxious to ensure that it is providing health benefits only for those persons who are indeed legitimate residents of the province.

Mr Frankford: But in a sense Ontario pays for Ontario services because of a reciprocal arrangement, although I think Quebec is an exception, isn't it?

Ms Malcolmson: Yes, the reciprocal billing arrangements are meant to serve individuals who are residents of a given province when they are travelling in other provinces in the country. What I was referring to in terms of the exchange of information is when an individual moves permanently out of one jurisdiction into another one. Yes, there is a reciprocal process and, yes, Quebec is the primary exception to that.

Mr Frankford: On the photo issue, we had some clippings provided earlier in the year, and it seemed to me that there were some difficulties in implementation. I believe individuals had to pay and had to go to a passport photographer; they couldn't just use a machine. I'll just remind the committee that it was politically quite contentious, certainly from those clippings early on, and I don't know if that situation continues.

Ms Malcolmson: I don't think I'm the person who could speak with expertise on the Quebec system, but with respect to learning from their experience, ministry staff have consulted with the province of Quebec and will as we develop our final cabinet proposals, so we can benefit from their advice as we are benefiting from the advice of this committee.

Certainly, in terms of the technical aspects of the photograph, we are looking in Ontario at options that involve the photograph being taken at the place where you submit your application rather than bringing a photograph with you which is, I believe, the procedure currently in Quebec. I don't know whether, Peter, you can add to this. I think that they themselves in evaluating it have, as we hope to do, a renewal cycle. They may wish to make changes to improve any deficits, and we would hope to learn from them.

Mr Frankford: Again, I don't know if you can help me, but the question of exploring non-card alternatives, do you know if, with the community health centres, CLSCs, centres locaux de services communautaires, do you register? Do you have to have a card? Do you know the procedure?


Ms Malcolmson: I believe everyone in the province of Quebec has a health card.

Mr Frankford: But the community health centres, CLSCs, which are, I think, more extensively provided than in Ontario, do you know if --

Ms Malcolmson: I am not aware of whether or not it is mandatory to present your Quebec card in that particular situation as it is in a physician's office.

Mr Frankford: Ms Campbell's suggestion that there should be a $5 user fee for, as I understand it, CLSC users or registrants or whatever if they go to emergency departments, that implies to me that there is some way of identifying the individual as a health centre, CLSC user. I guess we may have to investigate this more, but it does suggest that there is some sort of registered population and, as I have pointed out, with a registered population with some attachment to a health centre, you can get into a non-card approach which, listening to all the complexities of the card system, I think we should be looking at it very seriously.

Ms Malcolmson: You would have to ask people in the province of Quebec exactly when the presentation of a card is required, but certainly in this province, in Ontario, the existence of a health card for members of the eligible population coexists with a roster-based system in HSOs because the system does not, as we know, apply to all of the population or to all of their health needs so that even if you are receiving health services in a rostered situation, you may have other circumstances in which you need to definitely use your health card.

Mr Frankford: Then we also have budgeted CHCs which don't in fact require any card at all, so far as I know. That was one of the reasons for their being brought into existence. If you go to a CHC, it is set up to provide care for refugees and people with no coverage.

Could I request that the researcher provide some information on the CLSC registration system?

The Chair: From our research?

Mr Frankford: Yes, as to whether you do have to register or whether you require a card and to provide some more information to us about possible non-card approaches.

The Chair: We can our research people to come up with some of the information on that, if that's possible, perhaps for tomorrow.

Ms Cynthia Smith: I'll try.

The Chair: If not, we'll have to get back with that information. Mr Wiseman.

Mr Wiseman: I'd like to go down another route. I understand that, I think it was Sunnybrook hospital that was giving out bills, "Do not pay this," but it itemized down the list all of the services that had been provided to the patient and then the patients was required to sign the bottom, if I understand it correctly.

Whatever happened to that study? What did we learn from that in terms of (1) the accuracy of billing and (2) the ability of that type of activity to make the system more accountable in terms of who used it and what they received?

Ms Malcolmson: I don't know that the Sunnybrook study was particularly aimed at accuracy, if filling in the information there was meant to provide individuals with what the total cost of their care for a particular episode of illness had been, most of which was hospital-based care so a lot of the costs being indicated are not ones that are billed on a fee-for-service basis, although there might be a physician component somewhere along the line.

I believe that the people at Sunnybrook consider it a valuable method of patient education, and certainly I believe various Health ministers of all parties have at various points in time expressed considerable interest in having a capacity to report the cost of people's health care on a periodic basis to at least some portions of the population.

If you'll recall from Mr Decter's presentation yesterday, the possibility of providing a financial statement to holders of health cards was in the list of future possible initiatives. It would take a fair bit of work and in hospital situations some kind of extrapolation of what portion of a global budget was attributed to an individual's care as well as the care that is paid for via the fee-for-service system. So it's always an area in which there has been, I think, a considerable amount of interest.

In the Sunnybrook situation, I believe it was quite closely linked to their own fairly detailed case mix management process, whereby they were trying, for their own internal management purposes, to be very accurate about the costs of different procedures and different lengths of stay in that hospital, and in effect a spinoff or partial spinoff of that was the provision of information to some patients. If the committee wished more information on that, I would recommend that it actually go to the people at Sunnybrook and request their evaluation of what they've been doing.

The Chair: Any further questions, although we've run out of time?

Mr Wiseman: Tomorrow's fine.

The Chair: We won't have the ministry people back tomorrow. We're in in camera session.

Mr Wiseman: Then one really quick question. I raised this issue yesterday with Mr Decter and I had another conversation with my disabled friend last night. There are a whole host of requirements that the disabled have to get a letter from their doctor for, and some of them are really absurd. I don't think the system should be required to pay for them. But they have to go and get a letter from their doctor if they are applying to have their sidewalk shovelled under some municipal program. How much does it cost for a visit like that, just to check up for some person who is permanently disabled to be told that he's still permanently disabled?

Ms Malcolmson: I'm not sure whether that would fit in under the third-party arrangements which have been recently exempted from payment by the government, whether having a form signed, a checkup not for a reason of medical necessity, but as with the case of camp medicals, those are things for which the ministry no longer pays and those things can be billed directly to patients.

I'm sure there are ambiguities in the situation of people who are disabled, because there may be some variations. A person may be permanently disabled but perhaps their physical condition is deteriorating over time and they may be eligible for higher levels of one support or another that may actually require medical intervention.

However, as the deputy mentioned yesterday, I think there's a growing acknowledgement that in many cases it is inappropriate to use the very high level skills of physicians for sophisticated bookkeeping purposes. I'm sure this is exactly the kind of thing that we will wish to put on as part of our agenda for discussion in the joint management committee which we have with the medical association. The deputy did indicate yesterday that we will take under advisement your suggestion that perhaps there may be some way to provide perhaps, whether it's on the mag stripe or something else, some indication of status with respect to disability that might be helpful.

I'm sure there are lots of issues around those kinds of things. Certainly when we looked at the initial reregistration on the previous occasion, we had representation of the sort that you're talking about and also from individuals who thought it would be a good idea to have blood type indicated on the card, others who thought that some indication on your card could replace an organ donor card. Those are some good ideas that need to be evaluated along with the others that we've received from this committee as we move forward with the fine points of our submission to cabinet.

The Chair: Thank you very much. We've run out of time. I want to thank all of you ministry officials for being patient with us today as we waded through this exercise and I'd like to thank you for appearing before us today. I'm not sure that we won't be coming back to this subject again some time in the fall, but I think we've made some progress today. Thank you very much for your cooperation.

Ms Malcolmson: Thank you for the input that you've given us to the process that we consider to be as important as you do in making the system better and more secure.

The committee adjourned at 1651.