Legislative Assembly of Ontario

HEALTH REGISTRATION SYSTEM MINISTRY OF HEALTH

CONTENTS

Thursday 25 August 1994

Health registration system

Ministry of Health

Margaret Mottershead, deputy minister

Donna Segal, director, registration and claims branch

Larry Stump, director, registration enhancement project

Mary Catherine Lindberg, assistant deputy minister, health insurance program and related services

STANDING COMMITTEE ON PUBLIC ACCOUNTS

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

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

Acting Chairs / Présidents suppléants:

*Crozier, Bruce (Essex South)

*Marchese, Rosario (Fort York ND)

*Murphy, Tim (St George-St David)

Bisson, Gilles (Cochrane South/-Sud ND)

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

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

*Marland, Margaret (Mississauga South/-Sud PC)

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

*Owens, Stephen (Scarborough Centre ND)

*Perruzza, Anthony (Downsview ND)

*Tilson, David (Dufferin-Peel PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Haeck, Christel (St Catharines-Brock ND) for Mr Bisson

Murphy, Tim (St George-St David L) for Ms Poole

Also taking part / Autres participants et participantes:

Peters, Erik, Provincial Auditor

Clerk / Greffier: Decker, Todd

Staff / Personnel: Anderson, Anne, research officer, Legislative Research Service

The committee met at 1009 in room 228.

HEALTH REGISTRATION SYSTEM MINISTRY OF HEALTH

The Chair (Mr Joseph Cordiano): Good morning, members of the public accounts committee. This morning on our agenda we have the Deputy Minister of Health, Margaret Mottershead. Welcome to the committee. I understand you have a number of your assistants with you, and the assistant deputy minister. The best way I think to approach this is to introduce whomever it is that is appearing at that particular time.

Now I understand you also have a presentation. Could I get a sense from you of the amount of time you would require, so that we may structure time for questions by members of the committee?

Mrs Margaret Mottershead: I have with me the assistant deputy minister for the health insurance program and related services, Mary Catherine Lindberg, who's sitting here beside me, and Donna Segal, who is the director of the registration programs branch, and directly behind her, Larry Stump, who is the director of the health registration project, ie, the new card.

We have in fact prepared a couple of detailed presentations, because your invitation was specific in terms of wanting to hear about the health card, our plans, our operational approach and the way this whole thing might be rolling out. We are prepared to speak to that in detail this afternoon if the committee wishes. My presentation this morning is just basically highlighting an overview of the plan that we do have, but it doesn't get into a lot of detail. It's probably 45 minutes at most.

The Chair: Okay, then perhaps we could start with that and allow the second hour for questions by members of the committee, if we can proceed that way.

Mrs Mottershead: Okay, good. Let me formally thank the committee for giving me the opportunity to appear. I believe, as I mentioned just a minute ago, that I was specifically invited to deal just with the question of registration and the new health card and the process that we are considering for registration of all eligible residents of the province.

The introduction of the new health card does represent the most significant effort in combating fraud and maintaining the integrity of our health system. But as you know, there are other operational, process, policy, control, system and delivery aspects that are integral to the effectiveness and efficiency of any program, including the health insurance program.

Last year the committee carefully and thoroughly reviewed the ministry's operation of the health registration system, the problems which had emerged following the registration in 1990 and the steps the ministry had taken to address the problems that had been identified.

From my reading of your report, the committee was generally supportive of some individual ministry initiatives. However, your report was clear on the point that the ministry didn't appear to have a formal strategic plan. I'm here with my colleagues from the ministry today to tell you that we do have a plan, a comprehensive management plan across the whole spectrum of the program.

The management plan itself is neither simple nor neat, because the issues that we have dealing with a population of 11 million people and with the individual and unique features of the individuals in that population are not neat. They're very complex and we are in fact in the process of trying to address many of the questions that are being posed as we go through the development phases.

I will admit to you that we don't have all of the answers. Our plan is carefully and closely monitored and the lessons we are learning in one area and the experience gained in managing change has been put to work in many of the other areas. We know our priorities, we know which of our programs need to change, we know what processes and procedures need to be reformed. Our approach is to move towards an integrated comprehensive response, and with your permission today we'll give you the details.

I do want to let you know that the plan basically focuses on five areas: (1) enhancements in the operation of the registered persons database; (2) the activities of the card validation project; (3) the operation of the investigative unit and the Medical Review Committee; (4) the health network for the drug benefit plan -- and later on this morning and this afternoon it will be clearer with respect to the benefit that platform will provide to many of the aspects of health program integrity; (5) the new health card development and delivery process.

I want to take us back for a moment to the beginning of this year, January 1995. In January I announced a new organization for the Ministry of Health --

Mr Robert V. Callahan (Brampton South): What year?

Mrs Mottershead: I'm sorry, 1994. Of course, I'm moving forward.

Mr Callahan: I thought maybe your clock was out of order.

Mrs Mottershead: No, I'm a little wound up. I think that explains that one.

In 1994 I announced a new organization for the Ministry of Health. Two main features of the reorganization involved:

(1) The consolidation of programs and services in mental health to facilitate planning and delivery of services in the continuum of care from institutional to community setting, thus improving client service and coordination; and

(2) Of most relevance to today's discussion, the consolidation of all Ontario health insurance plan functions, services and responsibilities under the leadership of one ADM.

Prior to January 1994 resident eligibility for health insurance was the responsibility of one ministry executive, while the process for actually registering and the related procedures -- training and verification of eligibility -- rested with another executive.

On the provider side, the officials who helped to develop provider policy or procedures for implementing outcome of negotiated agreements, medical rules and schedule of benefit changes, for example, did not report to the same ADM responsible for payment of claims and the various verification functions related to the claims processing function. Although there was much communication and interaction between ADM groups, it is not the same as having one responsible and accountable head for the whole operation.

In March 1994 we had finalized an organizational structure and management plan for the investigative unit after extensive review by both internal and external experts on the skills, qualifications, mandate, authority and structure for the unit. The unit was moved from reporting to the director of internal audit to a direct reporting to the ADM of corporate services.

I'm pleased to advise members that by October we will have hired an additional seven investigators for a total of nine. The unit itself will have 11 people in it. Our recruitment efforts have yielded hundreds of qualified candidates -- we had over 700 applications -- and the screening and selection process has been lengthy, but I'm sure it will be very, very fruitful.

Since April 1994 more stringent documentation requirements and protocols have been put in place to demonstrate residency in Ontario and therefore eligibility for a new health card or replacement card if the current card was lost or stolen.

Since April 1994 a three-month waiting period for out-of-province applicants provides time for verification of eligibility.

Since April 1994 we have moved to the use of full name only to ensure integrity of the registered persons database.

Since April 1994 we only accept original documents as proof of citizenship, for example.

Tighter business processes now require in-person rather than mail-in applications in all but a limited number of circumstances.

We are extending and strengthening point-of-service validation of the card owner's eligibility for benefits.

We are providing read-only, on-line access to registration and health card information to hospitals and some providers.

We are improving one resident-one card verification, that is, one registration record with unique and complete information existing for only one individual.

The current health card integrity and validity is being further safeguarded by ensuring that cards relating to eliminated records are retrieved and that health care providers are able to distinguish ineffective cards.

We have concluded negotiations with the College of Physicians and Surgeons of Ontario on the operational support requirements for an expanded Medical Review Committee. The minister is in the process of finalizing the recommendations for appointment of members to the MRC, which will see this committee expand from eight to 24 members in September 1994. This will allow the establishment of six panels that can sit concurrently to deal with the issue of potential abuse of the system.

We have finalized negotiations with the Ontario Medical Association with respect to version codes on the cards which help to differentiate between effective and ineffective cards.

We have a program under development to improve the sensitivity of the physician monitoring system software.

We are providing on-line eligibility checking in pharmacies as part of the Ontario drug benefit program network.

We are pursuing and negotiating information exchanges with other ministries and other jurisdictions to improve the information integrity of our registered persons database.

We have initiated a public education campaign to encourage individuals to report changes of address and other registration information and, as you know, Bill 50 provides the legislative basis for fraud reporting and card repossession. The regulations, we hope, will be passed in September 1994 that will bring this whole process into the operational stream.

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As a result of the announcement in May 1994 by the Minister of Health that a new health card with significant tamper-proof and security features will be introduced in the spring of 1995, the ministry staff have been working very hard with colleagues from the Ministry of Transportation and Management Board on a comprehensive operational plan. We will share the details on the card features under consideration, the development work and the approaches to registration later today.

Finally, I want to let you know that as of last week, August 19 to be exact, we have begun issuing our transitional health card. This enhanced card now includes on the face the card bearer's date of birth, gender, issue date and expiry date.

I hope that the Chair and the committee members will give us an opportunity to thoroughly review the plan. We're basically in your hands as far as the procedures for the rest of the morning and the day. Thank you.

The Chair: I understood that you would have a further detailed presentation. Perhaps we could complete this and then go to questions after your presentation.

Mr Callahan: There's a second part, isn't there?

The Chair: That's fine. We can probably ask questions at this point and then --

Mrs Mottershead: We can do the card presentation now, if you wish.

Mr Callahan: No, no.

The Chair: I would think so. I think it ties --

Mr Callahan: Let's deal with them one at a time.

The Chair: Let's just complete the presentation and then go to questions.

Mrs Mottershead: There are two major components in the card itself and it's hard to disentangle the question of eligibility and the registered persons database from what we're actually doing with the card rollout. So I'll ask Donna Segal, I think, to come up first to give you an overview of all of the system-related improvements that we've contemplated, and then Larry Stump on the health card itself, on the rollout and what we're contemplating. So if you'd like to come up.

Ms Donna Segal: Good morning.

The Chair: Good morning and welcome.

Ms Segal: Thank you. Perhaps it would be helpful if I outlined what my responsibilities are within the ministry at the outset.

My name is Donna Segal. I am the director of the registration and claims branch of the ministry. It's that part of the ministry that essentially manages all the OHIP offices across the province; therefore, we have responsibility for the claims payment operation that's contained within those offices for OHIP payments to providers.

We also register individuals, the customers, the residents of Ontario for OHIP eligibility. We also, on behalf of some other programs and agencies, process claims on their behalf, so it's an indirect function.

Lastly, we also facilitate on behalf of another branch within the ministry, but still under Mary Catherine's aegis. We facilitate the registration of physicians so that we have an integrated database identifying which physicians are functioning in Ontario.

There are three items of importance in the function of my particular branch and its activities that I think are of relevance this morning, and I'll speak to those after some brief background comments. The three areas that I wanted to address are the registration or the application for OHIP benefits process itself and the changes that have taken place to that process over the recent past, and also the anticipated changes in the future.

I also wanted to take a moment to speak to you about enhancements that we've put in place over the recent past to manage the registered persons database, which is the dataset of personal information as opposed to health-related information of all individuals who are registered with OHIP.

I wanted to speak to you if I could for a few minutes about the pilot that we've had in place for the last year on health card validation and our plans for the rollout of that pilot starting in September. By way of background, I think you may have seen this slide actually last year, so I thought I'd just raise it. There are a number of issues that have come up in the past which create the situation in which we find ourselves right now. Essentially it's no secret that we had a great number of individuals registered, of families registered under OHIP, a great many more individuals than were suspected were living in Ontario.

We also eliminated OHIP premiums, which caused further confusion in terms of direct input of individuals, where individuals were no longer relating specifically to the OHIP management people but only to providers, so it caused our information to go a little bit out of control at that point.

In 1990 what we did was we introduced the original and unique health number for each individual living in Ontario, and we began the process of registering people.

Then 1991 was the year where we required and began using the health number as the basis for access to health services, so that 1990-91 was the transitional period where we were also using OHIP database.

In 1992, as you know, the registration program branch was established, and that's the precursor of my particular branch. In fact my branch has absorbed many of the functions of the registration program branch as well as aspects around OHIP district office management.

But the major piece of information that became available to us in terms of identifying where we had weaknesses and where we had strengths was brought to our attention through the provincial audit that took place in 1992. In particular the auditor took time to peruse and explore our registration system very carefully, also with the view to identifying where our weaknesses were and where we might improve them.

I guess what I want to do is focus on what we've done since then. As you know, we appeared before you at public accounts last year, and also there had been references to a report that was prepared by individuals in the previous registration program branch, which essentially targeted specific population groups within the province to identify what the potential for fraud or what the weaknesses for fraud were among those population groups.

It gave us valuable information in identifying how liable and vulnerable the systems were in relation to those population groups, and gave us good information as to what kinds of things we should be doing in revising our registration system.

The OMA agreement in August of last year put forward a number of options, some of which had already been begun within the ministry and some of which were introduced through the physicians themselves. They asked in the OMA agreement that we pursue vigorously the health card validation exercise and they asked us to take a look at the issues around physician reporting of cards that were ineligible or ineffective. Essentially those are the two major issues that came up from my perspective in that agreement.

Since then we have conducted a number of meetings with various experts on anti-fraud. We've talked to various industry sectors that have common experiences in terms of maintaining effective card bases. We've also talked to technology experts who have indicated to us the things that we should be wary of, the things that are effective today and proven today, and also the things that are coming down the pipeline that are leading edge and where the system is, where the outside world is in readiness for those particular technology bases.

In 1994 we took to cabinet and received approval and ultimately announced that we would in fact carry out a major exercise, a major undertaking to reregister and therefore authenticate and verify the eligibility of each individual possessing a health card and OHIP coverage.

We announced that that would take place starting in February of next year. We also announced at that time different aspects to the health card itself, the actual structure and features of the card, and my colleague Larry Stump will make reference to those later.

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I just want to go back and indicate that we clearly understand, on the next slide, the Provincial Auditor has indicated to us that our individual-based registration system is the cornerstone, so we have a very important mission in ensuring that our registration process is an effective process. At the same time, we have a mission to review the information that has been provided to us in the past to ensure that it is both accurate and continues to be updated.

I thought I'd take a moment to review the Provincial Auditor's report findings and our responses to those. Essentially, the auditor indicated that we were using OHIP information to verify eligibility. Our response now will be that in the production, that is, the registration for a new photo card and in the introduction of a renewal cycle whereby on a repeated basis, on a regular basis, we will be reaffirming eligibility. We will access original information and reintroduce that into the system, so we will not be using old information but be using reaffirmed information as the process proceeds.

He indicated also that there was a lack of formal processes to update deaths, that is, to update or amend the registered persons database in order to incorporate deaths that had occurred. Since then we have put in place a regular monthly exchange with the registrar general where we in fact receive information which identified all those deaths reported to the registrar general and match it against their files, thereby updating and revising RPDB accordingly.

He also made comment that we lacked formal processes to update addresses, and more recently in February 1994 we have initiated a major address update campaign and I'll refer to that later. We also provide some exchanges of information with other programs within the ministry, and also potentially later with other databases with whom we are negotiating right now to identify where address databases differ. Then we'll have to go through a matching process to identify whose address on the dataset is accurate.

The auditor also commented that we had a slow start in investigating the accuracy of data. We have spent a great deal of energy, at least over the last year, investigating reported potential fraud, and I'll speak to that more specifically.

He also made comment that we had 300,000 more individuals on our dataset than Statscan estimated as the effective population of Ontario, and we've revised our estimates so that we're within 1% of Statscan's statistics right now.

I guess most importantly, his comment was that we had insufficient controls, and the reality is that we've put in place much stronger long-term controls. We envisage through the introduction of the photo card, and particularly the renewal cycle with individuals coming in on a repeated basis, a much stronger set of controls and updating protocols.

By way of background again, it might be helpful for you to understand the relationship of the registered persons database with the other elements or activities within the ministry. Essentially, the registered persons database is the depiction in the centre, and that database contains information, that is, the health number and version code and the name, the gender, the date of birth, addresses -- that's mailing and residency addresses; certain card status information -- when the card was issued, when it was made effective; and certain citizenship-type information -- what is the citizenship type or status according to criteria and categories given to us by Immigration Canada.

What I wanted to show in this diagram is the fact that RPDB is central to the management of ministry programs in the sense that it offers us identification of exactly who our client base is within Ontario. It's also altered and fed. Information is provided to us through Comsoc, through the registrar general, through other ministries, which allow us to alter and revise RPDB.

Moving clockwise from the top right corner, we are now in a pilot phase and will be introducing very shortly in a much wider and province-wide strategy point-of-service validation. That's point of service at the hospitals and at the physician and other providers' offices, most notably physicians and pharmacists as they provide or fill prescriptions, in order to assist us with validating that the card being presented by the individual acquiring health services is in fact a valid or effective card.

There's a relationship between the registered persons database and the drug benefit and claim system, again in the same way, looking at the assurance of eligibility and verification and the creation of consumer profiles.

The registered persons database gives us an opportunity to create demographic information which feeds into other programs in the ministry for planning purposes. It feeds into the health programs area within the ministry, which is used for resources planning, that is, for identification of where services are required and/or where physicians and other practitioners are required.

It links up also with other roster systems, on the far left at the top, and by that I mean systems which also register individuals for particular program purposes within the ministry. An example would be those individuals who are now registered under the assistive devices program or those individuals who are now registered within CHOs. So essentially there's a match and there's an opportunity to look at how the individual within the RPDB corresponds to information within the various roster systems.

From a control perspective, from a management perspective, the important elements for me to carry out are due regard to the application process, and I'll talk to that, a need to ensure that the card and its features are as secure as possible and an opportunity to review at point of service the card that is being presented and that will be the basis for billings provided to the ministry and whether those billings, therefore, will be accepted or rejected, and afterwards the monitoring function.

If I can speak to the first, the applications group, we have for some time now been requesting original documentation which would identify the entitlement of an individual to be in Canada and in fact in Ontario, and also some indication that the individual actually resides in Ontario.

We didn't actually require the original documentation until late last calendar year if the individual presented in person. We still were allowing for the mail-in of appropriate documentation and not original documentation until early this calendar year. In March or April of this year we stipulated a requirement which would have individuals presenting, whether in person or through the mails, only original documents. So we had a staggered implementation of this original documentation requirement.

The current status is that individuals who walk in or individuals who apply for new cards or apply for replacement cards must mail in or walk in, present personally the original documentation. We do not accept any of those changes over the phone. When this information is provided to us over the phone, we ask people to either mail in corresponding information or visit one of our OHIP offices.

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Clearly the issue of original documentation was in direct response to comments from many experts who indicated that copied documents could easily be defrauded, tampered with and counterfeited. So we are looking at original as a much more secure method of ensuring that the documents in fact belong to the individual.

We have set up a major campaign in each of the district offices and we've prepared flyers that we've sent out and information in various handouts -- in the chart here -- which outline specific documents that we accept in each category. We're essentially asking for a -- I don't have that in here. I can get copies of it. There's a smaller version done in a flyer, and I'll get you copies and circulate that over the noonhour.

Essentially we ask for three documents.

The first document is a certification of entitlement, and that could be anything from a birth certificate, to a Canadian passport, to an immigration document, to a Canadian affidavit of citizenship, to the certificate of Indian status: an indication clearly in a documented and understood document that has a registration number which we can follow back to the original data sources to determine that this individual has in fact the entitlement to be in Canada.

The second piece of information that we require is information which links the individual to a bona fide address in Ontario, a residency in Ontario. Here we're looking for, it could be a letter from Revenue Canada, which is obviously sent to the individual and sent to the residency address. A common source of information here is the driver's licence. It can be information from a school in the instance of children where they're affirming that they're residents. There are a number of them, and I will circulate you this list which identifies what those documents are.

The third piece of information that we're looking for again confirms residency, but really is in fact the confirmation of the identity of the individual. We're looking for a photograph or signature so that we can compare the documentation with the appropriate name to the individual who is claiming the name and the signature of that individual.

So it's three pieces of documentation we're requiring. In the event that one piece of documentation provides two functions, we're allowing for that as well. It's the three functions that we're looking for.

Mr Callahan: This says a document with picture on it. What if somebody doesn't have a driver's licence?

Ms Segal: There are other identifications that have pictures.

Mr Callahan: Like what?

Ms Segal: But it doesn't have to have a picture --

Mr Callahan: Like what?

Ms Segal: Like employee cards. There are things like --

Mr Callahan: What if they don't have an employee card? What I'm getting at is if they don't have a picture, do they get -- I mean, this sounds like a bank.

Ms Segal: I didn't say that.

Mr Callahan: You've got to have three pieces of information.

Interjections.

The Chair: Order, please. Could we wait --

Mr Callahan: I'm just trying to find out.

The Chair: Order. Could we allow the presentations to be completed and then we will get to questions.

Ms Segal: I'd like to clarify my comment. I said we were looking for a piece of identification which had a photograph or a signature, and there are many identifications that have photographs or signatures.

The second major activity we have undertaken that I referred to earlier was the address change campaign, which was put into full swing in February of this year. We have circulated in every physician's office and in many other public sites application forms inviting individuals to confirm with the Ministry of Health their --

The Chair: There are too many private conversations. It's difficult to hear the presenters. If you wish to have a private conversation, please take it outside.

Ms Segal: We've asked people to update the ministry regarding our address information base within RPDB. We've asked them to fill in this card and send it in. We've made reference to this in many publications and information pieces that the ministry has sent out. We've also published a large poster, which is again displayed in physicians' offices, asking people to please update their address with us.

In fact I'm pleased to report that there's an escalation in the number of address notifications or change notifications that come in to us. We've received in the month of July 1994 alone over 16,000 indications of address change, which is a great improvement over activities that have occurred in the past.

We're using those address change notifications to revise and update the registered persons database. We are allowing, again, address changes to be conveyed both through the mail-in campaign, that is, through the submission of the form, and also by individuals who choose to walk in and present themselves to an OHIP office.

The deputy has referred to card changes that have taken place over the recent past, which also have contributed to cleaning up the registered persons database and averting confusion and potential duplication. There was a time when we allowed individuals to indicate which name they would prefer to have on their health card. We've now changed that as a policy and require the full name to be on the card. That has enabled us to pull out some of the duplications within the database and to clarify that William Smith is in fact the Bill Smith and the Billy Smith referred to through other applications.

My colleague will speak to the introduction of the transitional health card referred to earlier, which has recently been introduced, that is, as recently as last week, and demonstrate to you the features of that card. Essentially it's a card that is intended to, between now and the active reregistration and the new photo card which will appear -- the registration process which will begin in February of next year, allow us to apply additional security features or identification features to the current card.

You can appreciate that these various changes in policy associated with the application and registration process have had an impact on customer service and have had an impact on transfer payments. We're asking people to give up original documents and it's no secret that many are afraid to trust their original documents to the mails. Whereas we used to receive most of our applications by mail, we're now receiving the greater proportion of our applications for new cards by walk-in.

This has had tremendous significance in terms of our customer service capacity in our district offices. The staff numbers in offices have not increased dramatically over the last while and yet their business function has. We are actively pursuing at this moment in time ways of extending business hours and providing greater service, all within our current financial capabilities.

The obvious implication also is on our transfer payments. With the introduction of these new application processes, some individuals whose cards are seen to be ineligible and who have been investigated as to whether or not the cards were actual or fraudulent cards -- the cards have been invalidated as a result of their not being able to identify or to prove that they are residents of Ontario. In effect, we've had a reduction in the number of individuals who have made claims on the system. We've had cancellation of cards, and I'll go into the specifics of that.

The next slide speaks to the enhancement to the registered persons database from a management perspective. We carry out essentially two sets of activities: a sphere or constellation of activities, what I've termed maintenance functions, what are we doing on an ongoing basis to ensure the integrity of RPDB, and the second set is follow-up activity or activity to investigate specific eligibility of individuals of population groups because, for some reason, we suspect that there's a problem.

In the first constellation of activities around maintenance, one thing I'd like to point out is that we receive periodically notifications from Immigration Canada regarding the individuals whom they've deported. At this point we have received 2,042 cancellations of cards as a result of information from Immigration Canada.

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Mr Tim Murphy (St George-St David): Can you just repeat that? I didn't hear that, sorry.

Ms Segal: We have cancelled 2,042 cards as a result of those deportation indications. It's important for me to indicate to you that we are actively pursuing, and just about to conclude, a negotiation with the federal Immigration department which will allow for the regular reporting and the complete reporting of these instances. I suspect that that will increase these numbers tremendously. Right now it's only happening on an irregular basis.

We are also notified, through several means, of individuals who actually leave the province. Clearly some people actually just call us and let us know that they're leaving the province, or we learn from them via address changes that they've left the province and we update RPDB accordingly.

The Advisory Committee on Institutional and Medical Services, ACIMS, agreement also is an agreement interprovincially which provides for other provinces reporting to us those individuals who were once residents of Ontario but who have now registered in other provinces. In 1993-94 we processed over 51,000 out-of-province moves and therefore amended the RPDB base by 51,000 individuals.

We also receive death notification from a number of sources, identifying individuals who have died and therefore we should be updating our base in order to take that into account. The registrar general, as I said, gives us a regular monthly feed which we process. This year so far we have received over 30,000 cancellations of cards as a result of the registrar general's data feeds. We also receive information from providers, usually physicians, who, when they bill certain procedures, there's a flag on that billing identifying that they are reporting a death. There are almost 5,000 notifications from physicians as to individuals' deaths. We process each of those registrar general and provider notifications and update RPDB accordingly.

Duplicate card investigation: It's no secret that when we first carried out our registration effort in 1990-91, a number of individuals in frustration at not having received their first card may in fact have applied for a second, so we had several individuals on record with two cards. We have gone through a series of systems applications and direct contact with some individuals. We've produced almost 5,000 cancellations of duplicate cards.

Random sampling, I guess, is the last activity that I'd like to identify. On a random basis we review the eligibility of individuals who are canvassed. We determine the accuracy and whether or not the information is up to date, and based on information that's provided to us, we either suspend or cancel the card. We have researched so far almost 20,000 instances or individuals randomly, and of those random samples, we've only cancelled actually 15 cards.

We have suspended, on other hand, 331 cards. The suspended cards are cards of individuals who have not responded to a mailout by the Ministry of Health asking individuals to confirm their residency. When we do not hear from them or when the letter is returned to us with a return mail indicator, indicating that there's not that person living at that address, we suspend the card. So no billing activities occur opposite suspended and cancelled cards.

Mr Callahan: Excuse me, do they have to wait three months to get a new card if that happens?

Ms Christel Haeck (St Catharines-Brock): Can you hold your questions?

Mr Callahan: I'm sorry, these are things that I want clarification on. Maybe the --

Ms Haeck: We all --

Mr Callahan: It's a very simple question: Do they have to wait three months if the card is cancelled?

Interjections.

The Chair: Order.

Mr Anthony Perruzza (Downsview): Bob, we're all anxious. Were you like this when you were improving your card in 1988?

The Chair: Order. Could we please have some courtesy for the people who are presenting and for others on this committee. Thank you.

Ms Segal: We are still processing over 1,000 of those instances which bear researching need, so we have over 1,000 of these issues still in progress. That's on a random basis, and I would call that maintenance functioning.

By way of follow-up activity -- that's specific investigations in order to look at particular individuals or datasets where we suspect that there's a problem -- we carry out a number of things. We do some special projects, and by way of a special project, I've identified an example, a project around border residents where we took a sample of over 22,000 individuals within borders and asked for verification of residency and asked for verification of eligibility.

The result of that is that we again suspended 2,895 or almost 3,000 cards where we have received a return-mail indicator indicating that the individual no longer resides at that address, and we actually cancelled 123 cards of individuals who were clearly not eligible for OHIP benefits. So out of 22,000 people, there are no more than 3,300 individuals who have been affected, who may in fact be ineligible or who are definitely ineligible.

We also carry out a number of activities, the remainder in that list, which I will lump together as essentially eligibility investigations. We investigate information that comes to us from the ministry's infoline. We also investigate tips that are brought directly to our attention, individuals who are indicating that they suspect the eligibility of an individual. We also follow up on all Health 65 card instances, where the health card has been mailed out to an individual whose death notification we have not received.

We also follow up in instances, for example, where we know that there are multiple residents at one particular address and where we suspect that it could be a mail post-office box drop, or some instance where it doesn't actually depict a residency status, and we ask for residency confirmation. We also look at individuals who have reported frequent losses of cards, and I'm just not talking about one or two cards but many cards. Obviously that's an indication that tweaks our curiosity and we ask for confirmation around that.

I know that you're probably interested in the infoline, so I can give you some explicit information there. The infoline in the ministry has received a little over 800 fraud-related calls, and 518 of those calls have been referred to the verification unit. The remainder are calls which had insufficient information to be followed up or in fact are commentary as opposed to asking for investigation.

The 518 calls that were referred to the verification unit, which is a unit under my branch, have produced -- it's a mushrooming kind of thing; once you have a call related to a particular number, there may be other numbers related to that that you also want to investigate at the same time -- so the 518 potential instances of fraud have resulted in fact in almost 1,200 cases that were investigated by our unit, and of those 1,200 cases, we cancelled 241 cards. We still have about 600 cases that are being investigated. They're in progress.

In our investigation process it's probably helpful for me to outline what we do. Once we are told that there's a problem with a particular card or a particular number, we send out a letter inviting the individual affected to provide us with original documentation which affirms their eligibility to be registered with OHIP.

If that letter is returned to us, as I've indicated earlier, we suspend that file, which means that claims coming in opposite that are alerted, brought to our attention. We endeavour to follow up with the individual who has presented to that particular practitioner, to identify if we can get them to give us the information that we're looking for.

If the letter is sent out and not returned to us but not responded to, we send a second letter out asking for further follow-up information, and it's as a result of the follow-ups for the second and third time with certain people that we have a large number of cases in progress, 593 cases in progress around the infoline calls. That's infoline only.

Other eligibility investigations: We've conducted approximately 13,000 investigations in the unit, and of those 13,000 investigations, in over 12% of the cases the individuals are in fact eligible. In over 20% -- 20.7% -- the individuals are in fact ineligible and their cards have been cancelled. We have a large number that remain in progress to review the actual eligibility of the individuals remaining in those investigations.

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The last piece of information I wanted to provide to you on this is that we currently have over 20,000 suspended cards -- not cancelled, but suspended cards -- which alerts us when a claim comes in opposite those cards that they have approached the system and we should be approaching the provider who met with that particular client to try to elicit information which would help us to determine their actual address so we can pursue it.

Follow-up activity: That's what we're doing, and what are we doing now? You have been told this morning that Bill 50, which amends the Health Insurance Act, has allowed for the mandatory reporting by prescribed persons of health care fraud. Physicians and other practitioners will be such prescribed persons. So the reporting of potential fraud is mandatory. The voluntary reporting by other individuals is around such things as administration, the more administrative aspects of the card and its management.

The bill will also allow for the voluntary surrender of health cards, that is, the receipt by physicians of the cards and subsequent submission of those surrendered cards to the Ministry of Health. Bill 50 will also allow opt-in physicians to bill individuals whom they question as being eligible, who are unable to provide at time of presentation to the point of service, to the physician's office -- they are unable to prove that they are in fact the individual that is holding the card.

Enhancements to the registered persons database management system: The only other aspect that I wanted to draw to your attention is that we are pursuing vigorously relationships with the Ministry of Transportation, with Immigration Canada and with the province of Quebec in order to allow us to match elements of their databases opposite RPDB so that we can identify where there are discrepancies in information. That will allow us to investigate why those discrepancies occur and to pursue the correction of the information in RPDB.

That is a summary of what we're doing to counter fraud as an ongoing management function within my particular branch. I could pause here now, if you'd like. I do have information I'd like to talk to you about around the health card validation exercise, which is quite distinct.

The Chair: I think it would be good to go to questions at this point since we've had a fairly lengthy presentation, and then continue with other presentations later. Now let me try to divide some time up here between the three caucuses.

Mrs Margaret Marland (Mississauga South): Mr Chair, just before we do that, could we find out what the balance of the presentation is that we are not hearing at this point?

The Chair: Yes, sure. Could we get an indication from you about further presentations?

Mrs Marland: How much more and what is it that you wish to cover.

Ms Segal: The validation exercise I can summarize in probably 15 minutes.

Mr Murphy: Does that complete the total presentation? No, because Mr Stump has a presentation as well.

The Chair: To be fair, I think the members definitely indicate a preference to go to questions. At some point we will have to try to deal with the remaining presentations. Could you give me an indication? Are there one, two, three --

Mrs Mottershead: May I just add, in terms of the health card rollout itself, the presentation can in fact take about 10 minutes to let you know what we're preparing in terms of the health card. If you wanted to hear that, we can go back some time this afternoon to the validation, which is the rest of Donna Segal's presentation. It's up to you. We're in your hands.

The Chair: Why don't we deal with those in the afternoon and deal with questions at this point, since there is obviously this real interest in going to questions. I will divide up the remaining time in 15-minute intervals for each party and we'll start with the --

Mrs Marland: Why not just do a 20-minute interval and take an hour?

The Chair: Fine, we can do 20 minutes, starting with the opposition party. Mr Callahan and then Mr Murphy.

Mr Callahan: I'm going to have to ask these questions fast and you give the answers afterwards, because I've only got about seven minutes.

First of all, I'm pleased to see that there is an operation going on to try to determine this and I applaud you for that. I'm also pleased to see that you've accepted what Mr Decter came back and said he would accept on the last occasion. I raised it that previously you could put applications eight different ways; you could be listed eight different ways. I raised that and I said to him that's an opportunity for fraud, and I was pleased to see that he came back and agreed and that you're following up on that.

I guess the first question is, have you gone out to determine how many of those were in fact done that way? In other words, how many people took advantage of, for want of a better word, the eight-way opportunity that you could get eight health cards? I think a lot of people probably did. Have you followed up on that? That's my first question.

The second one I interjected. Suspended people, I take it from what you said afterwards, continue to get services from the doctor, but the doctor's supposed to get some more information for them. So I gather that they don't have to wait the three months, as they would if they left the province.

The other thing is, your letters that go out are a great idea, but you've got a problem in this province, I would think, and in this country, with the question of language. If they only go out in English, or even French, they're not going to mean much to a person who's Portuguese or whose language is Punjabi. I'd like to know whether or not there's something to match that up with the name of the person who is involved.

The other thing I'd to suggest, and I don't understand why it's not being used: For instance, we have a whole host of processes like Might Directories, which I think are updated every year now on computer disc. It gives you the name and address of people. I don't know much about computers but I would think you can plug that in with the process you've got and this would zap people in and out. I doubt very much that you're going to get people who are going to, in the main, send in something about a change of address unless you make it mandatory, like they do under the Highway Traffic Act, where you get fined unless you do it.

There are also things like Revenue Canada, and I don't understand; it's not just Ontario that's losing money on this. I'm sure they're losing it all over the country, since we seem to be the kindest country in the world in terms of providing health care services to all and sundry. I'm sure the social insurance number must be updated every time somebody files an income tax return, the address and all the rest of it. I'm wondering why there are not linkages with --

Interjection.

Mr Callahan: Could I ask my questions, perhaps, without other members interfering, Mr Chair? They interfered when I tried to --

Mr Larry O'Connor (Durham-York): -- exactly the same person.

The Chair: Order. Mr Callahan has the floor.

Mr Callahan: I think the purpose of all of us -- obviously you people are working at it -- is to try to ensure that the scarce money we have is being provided for people who are entitled to receive it.

Mr Murphy: Time's up.

Mr Callahan: It's not up. I guess finally, because I'm probably getting close to the period of time, I'm curious to know why you would not accept notarial copies of documents, as opposed to the originals. I'm not trying to make a pitch for the lawyers, but they could go before a lawyer or any official of a court or a person to get a notarial document done. That way you save the in-person attendances. They could be sent in. I would think a notarial copy should be satisfactory.

These are just some suggestions I'm making because I think it's incumbent upon all of us -- my friends across the way seem to think I'm being partisan on this issue. I'm not. I think it's an important issue that whatever government's in power, it get a handle on this thing because it is a mess, and it's a mess that has inured to the benefit of the Conservatives when they were in power, to the Liberals and to the NDP. I think the answer is that we all want to get it straightened out.

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Finally, in my last couple of seconds, if somebody comes into this country as a visitor and has procured private coverage and winds up in a hospital where that coverage is not sufficient to cover the stay, what is done by OHIP in terms of covering this person?

We seem to read in the newspaper every day that we're covering people who come here for all sorts of things and the bill is just absorbed. I think certainly Ms Lindberg would be aware of a case that I've sent to her from a constituent in my riding who had $25,000 worth of coverage. She came here perfectly well. She arrived here, had a stroke, and before we could get a minister's permit to get her an OHIP card, she died and now she's being potentially sued by a hospital in this city for $100,000. Yet, I read every day in the paper about people who come here and don't pay a nickel. I'd like to know, maybe, what that policy is.

The Chair: Mr Callahan, if you'd like a response, you have about a minute remaining in your time.

Mr Callahan: Maybe she could get me all those answers in that time.

Ms Segal: Would you like me to --

Interjection.

Ms Segal: In response to your questions directly --

Mr Callahan: The last one. I'd appreciate an answer to the last one, perhaps, on the record.

Ms Segal: First?

Mr Callahan: Yes.

Ms Segal: I'm familiar with the instance that you've raised and I've talked to your staff about this. It's truly unfortunate that the individual was advised to purchase only $25,000 worth of insurance. But you're asking what OHIP will do. In essence, OHIP does not have the responsibility for providing coverage to individuals who are not eligible for OHIP benefits. So, it is by law indicated that we cannot provide coverage to those who are not residents.

Mr Callahan: Can I interject? If somebody arrived here illegally they get a card. I don't understand if, the minute they set foot on Pearson International Airport's tarmac, they're eligible for an OHIP card and I just don't understand how someone who took the steps to get $25,000 worth of coverage -- whereas when I fly Air Canada, the national airline, it has brochures from Voyageur travel saying to get $15,000 worth of coverage if you're coming into Canada. So I don't understand.

Ms Segal: The only individuals who are actually getting OHIP coverage now, were they to come into the country, are individuals who are legally entitled to stay in Canada, who are either permanent residents or who are certain categories of temporary residents which we've explicitly specified. The individuals you're referring to: A landed immigrant would have coverage, an applicant for refugee status would have coverage, but not an individual who's a transient or a visitor.

The Chair: Mr Murphy.

Ms Segal: What about the other question?

Mr Murphy: He's done.

Mr Rosario Marchese (Fort York): Is she going to give answers to the questions?

Mr Murphy: Yes, later today.

Mr Marchese: Later on. Okay, that's really great.

The Chair: Mr Marchese, for your information, the Liberals have decided to divide their time evenly. Mr Callahan's time is up.

Mr Callahan: We're a very agreeable family.

Mr Marchese: Sure, I understand.

Mr Murphy: Thank you for your information. I wanted to follow up on some of the information you did on investigations, your maintenance and follow-up functions. What I'm wondering is -- you detailed a fair number of cancelled cards because of information from a variety of sources -- have you gone back and checked those cards against claims against those cards and totalled up the sum of claims against those cards that were cancelled?

Ms Segal: No, I have not.

Mr Murphy: Do you know if anybody's done that? The point I'm trying to get at is that, obviously, the public debate has been focused on fraud in the system. Much of this activity is derived from a mixture of concern about fraud and the Provincial Auditor's comments. It strikes me as a reasonable investigatory conclusion to find out whether or not these cancelled cards have had claims against them in a period of time when they were appropriately cancelled. Are you saying no one's done that, because there you've outlined over 100,000 worth of cards, I would think, that have been cancelled in some six-month period of time.

Ms Segal: A couple of points: First of all, when we eliminate duplicate cards for one individual who has several cards, in fact, all we would really be doing is collapsing the health care costs under one particular number as opposed to three numbers. So, in that instance there wouldn't necessarily be "a fraud element" to the --

Mr Murphy: No. Absolutely. I'm not saying "necessarily," but you've got 2,000 deportees, 51,000 in other provinces, 30,000 in the registrar general.

Ms Segal: We do send cases for further investigation and potential prosecution on to the investigative unit, run by Mr Sudds. It is true that when they actually do the investigation and prosecute, restitution is an issue that is considered in the course of those --

Mr Murphy: But how do you know? For example, let's take the 2,042 cards you said are identified as deportees'. Presumably, you'd know from Immigration when these people were supposed to be deported. You could calculate, therefore, take a date and say from the time that you found out, from the time the deportation was ordered, what claims were made against those cards, and that total, if the 2,000 had $40 million worth of claims -- I don't know; I'm pulling a number out of the air -- that would give you at least some evidence. It strikes me as a bit odd that you haven't done that at least to give you an inkling of whether there is some value in doing a follow-up. So you're telling me you haven't done that?

Ms Segal: That's a good point. I have not done that.

Mr Murphy: Can you tell me whether you plan on doing that?

Ms Segal: I think now that you raise it, it's important for us to follow up, at least do some trial runs against the cards of individuals who have been deported, just to check the system for possibilities of usage of the system when in fact they wouldn't have been eligible. I think it's really important to make the distinction that as long as an individual was, for example, a refugee claimant, in that process there is eligibility coverage. Once a determination is made that they're not eligible, at that point the deportation order might take effect and it's at that point that we would receive the notification. So it's unlikely that an individual would receive months of health services, but it's a good point you make and I think we will, just to satisfy our own curiosity on this, follow it up.

Mr Murphy: I want to make it clear I'm not saying because there is a claim it's necessarily a fraudulent claim, but it's at least something that gives you an indication of what to follow up. My concern is that we're going to spend $130 million, I think is the number, on a new system without any really good, solid evidence one way or the other of what the extent of fraud in the system is and whether that new system will pay for it.

Here is an opportunity to provide at least a sense, because you've identified, through good efforts, I must say, approximately 100,000 cards that are worth cancelling. The interprovincial agreement -- you said 51,000. I can think of an example in a place near Cornwall where there were 700-plus double- or triple-dipping circumstances. I'm sure there's a base of people where you can take the other provinces' claim record, match it up against a claim record here and it will give you a sense of whether somebody is claiming in two different jurisdictions, or whether two different people are claiming. I would suggest that you follow up not just in the "deportees" category but in all the other categories. Can you give me an indication that you'll do that?

Ms Segal: Yes. You have our commitment that we'll do that.

The Chair: One minute, Mr Murphy.

Mr Murphy: One minute, okay. I guess I'll deal with the new card process when we come to that. The border resident follow-up activity, you said you did 22,000. Was that a random mailing?

Ms Segal: Yes, it was.

Mr Murphy: And out of that you suspended almost 3,000 cards?

Ms Segal: Yes. I'd have to --

Mr Murphy: I guess when you compare that against your other random sample, you said you did a random sample generically, about 20,000, and ended up suspending only 331, and yet when you did a border resident check you had a suspension rate that was almost 10 times higher.

Ms Segal: That's right.

Mr Murphy: That would lead me to conclude that in border communities there's a problem, so what I'd like to know is -- that's a big red flag to me -- what are the plans to follow up? That's a greater than 10% problem rate in border communities. What are you going to do to follow up on that?

Ms Segal: The suspended cards for the sample of 22,000 in the border population are instances where we haven't confirmed, in fact we've received --

Mr Murphy: Absolutely.

Ms Segal: You're quite right in saying that the incidence among the border population group seems to be much higher than the incidence in the general population. I'm not sure that's actually a surprise to us.

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Mr Murphy: But wouldn't that lead you to conclude that that's in fact a focus of activity and that you should spend a lot of time checking out border community --

Ms Segal: That's right, and we are.

Mr Murphy: Okay, that's what I want to know: What does that lead you to conclude, and therefore what are you doing in respect of border communities?

Ms Segal: The random sampling that I told you about earlier is sampling sometimes province-wide and sometimes centred on a particular geographic area, and we've used the random sampling approach to investigate areas that are of potential concern. So, embedded within the random sampling also would be particular attention being provided to certain geographic areas.

Mr Murphy: Exactly, so this would suggest to me that you should send out 100,000 random samples focused on border communities. When you're getting a response rate of suspension that's higher than 10%, logic tells you that's where you concentrate. So are you telling me you're concentrating on border communities in the next set of mailings?

The Chair: You're exceeding your time. Mr Crozier.

Mr Bruce Crozier (Essex South): Thank you for the opportunity of meeting with you this morning. A more direct question: If someone has an emergency and they're admitted to hospital, would it be correct that regardless of residency coverage, whatever, they're injured in an accident and they're treated?

Ms Segal: Yes.

Mr Crozier: And if they're required to stay longer-term, if they have an injury that requires admission to the hospital and they stay and then they're found to be either an illegal immigrant or a non-resident, what happens then?

Ms Segal: At that point the hospital will talk about potential payment schemes with the individual affected.

Mr Crozier: But they won't withhold care.

Ms Segal: I would hope not.

Mr Crozier: Okay. I live in a border community and I'd like to talk about registration, but I can't do that without asking --

Mr Callahan: He's one you suspended, I think.

Ms Segal: So mail it in.

Mr Crozier: -- about eligibility. I run into a number of what I guess would be landed immigrants, but they're retirees, someone who has decided to retire to Ontario. Provided they can qualify federally, then, they can retire to Ontario, having never contributed to the system, having reached an age when their care is liable to be greater, perhaps, than when they were younger and yet be eligible for OHIP coverage or for --

Ms Segal: Are these people Canadian citizens who are coming back?

Mr Crozier: No, they're people who are United States citizens who decide to retire in Ontario.

Ms Segal: If they apply for landed citizenship within Ontario, upon their eligibility for landed status we would give them eligibility for OHIP, but not before they were recognized as being permanently entitled to remain in Ontario.

Mr Crozier: Exactly. So the point I'm making, as opposed to a question, perhaps, is that this is in fact happening: People who find that hospital care is either better or less expensive in Canada, in my border area, which is southwestern Ontario, are retiring to Essex county and enjoying the same weather, almost the same -- they can go back and forth to Detroit, in fact, if they like. I guess it's just to point out that they've never contributed to the system and yet they can take up legal residency and be eligible. To me there's something wrong with that, but that's for another day. I merely wanted to comment on it.

The other thing, perhaps again as a comment, but you may want to say something: There's also a fairly large Mennonite community in my area. Subsequently, there are a number of missionaries. They do missionary work. They're very dedicated to missionary work and, as you well know, they may be out of the country for a year or more, they return to the country, having been lifelong residents up till that time, and yet they have to go through the three-month waiting period. They in fact may only be here for a relatively short time before they go back again, but each time they have to come through this three-month waiting period. I think that's unfortunate.

Ms Segal: There is one instance where that would not be the case. If, before they left Ontario to go on their mission, they applied for an extended absence from Ontario's health insurance coverage, we would provide them an exemption and when they came back they would be reinstituted. But it's in the event where they actually don't apply but simply leave without indicating to us and getting confirmation from the ministry that their coverage has been extended while they're out of country --

Mr Crozier: How long is the exemption?

Ms Segal: It depends on the circumstance, but it can be two years.

Mr Crozier: I understand it's one year and they can apply to have it extended to two.

Ms Segal: It's two years, but it's one year and then reapplication for the second year.

Mr Crozier: And then again, and this is not a comment towards you folks, because I appreciate you being here, things happen that bother me and it's my first chance to speak to them. Except in the case where the individuals go to the newspaper and kick up a stink and then the ministry changes its mind, and I think I've written someone in the ministry recently -- I'm concerned that on too many occasions our policy is driven by publicity rather than logic.

Ms Segal: I can indicate to you, in having to consider a number of instances that have come to my attention, that we are adamant within the area to remain within the eligibility policies. The exemption issue is one that troubles us greatly. On the other hand, there is a policy in effect -- it has been in effect for some time -- around the exemptions for people who leave the country and notify us that they're leaving the country. But we are quite consistent in our application of policy in relation to others who haven't applied for those extensions.

The Chair: Mrs Marland and then Mr Tilson.

Mrs Marland: You're going to advise us of 10 minutes, are you?

The Chair: Yes.

Mrs Marland: Thank you. Mr Tilson.

Mr David Tilson (Dufferin-Peel): You're going to be spending some time on the new system later?

Ms Segal: Yes.

Mr Tilson: It's estimated that there is fraud, billing errors and other losses to the taxpayer of almost $700 million a year. The minister, as you have, Ms Mottershead, has indicated that the first card will come in the early part of next year and then they'll be spread out over a period of three years, and that it will cost approximately $30 million a year and then $19 million a year after that. I think those are the figures that have been given.

You're going to talk about the new system, but it's going to take a while, and I'm sure you'll assure us that the new system will have very little fraud and very little opportunity for billing errors, and I'll be looking forward to hearing that. But my concern is that over that period of time, the existing systems, whether these interim cards that you've spoken of -- all the other cards are still going to be in the system. I need to have some assurance, as do members of the committee and members of the public, that this $700 million a year in fraud and billing errors is going to stop.

You've talked about, well, you're going to hire --

Mr Perruzza: It's $700 million?

Mr Tilson: It's $700 million a year.

Mr O'Connor: That's the Tory estimate, though.

Interjections.

Mr O'Connor: Michael Decter never gave a number like that. Come on.

The Acting Chair (Mr Bruce Crozier): Gentlemen --

Mrs Marland: Let's agree not to interject.

The Acting Chair: Margaret, you're cutting into your time.

Mr Perruzza: There's a little thing called responsibility.

The Acting Chair: Gentlemen, please, do you listen to the Chair at all?

Mr Perruzza: Some days.

The Acting Chair: Today isn't one of them, right?

Mr Perruzza: Depends who's there.

The Acting Chair: Well, if it's me, I'll move and you can have someone else. David?

Mr Tilson: I hope that you'll take their time and give it to me for that loss of time.

I guess what my concern is, and you can dispute the figures, but it's a substantial amount of fraud. That's the information that's been given to us.

You've talked about, you're going to hire some more investigators next month, notwithstanding that Mr Decter came here last year and he assured us there were going to be all kinds of investigations done. I haven't heard of any, or at least I haven't read of any.

Mr O'Connor: We haven't got to that part of the presentation.

Mr Tilson: I haven't read of any in the newspapers. Mr Murphy has asked a question as to what you do when you find out a card's been cancelled, and I gather very little, if anything.

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My question is, what assurance can you give us, not with the new system but the existing system, that this fraud's going to stop?

Mrs Mottershead: Let me respond, Mr Tilson, by saying that the bureaucracy as well as the political arm of government that we work for are very much committed to a zero tolerance policy and any amount of fraud is just too much. So I will not debate the numbers but agree that we have to do our best to eradicate it in whatever way we can.

I was hopeful that this morning's presentation, particularly the presentation by Donna Segal here, would have given you a much higher level of confidence that in fact we are doing everything that is possible to deal with the issue of elimination of the duplication. Doing our random sampling, tightening up eligibility in terms of both policy and procedures in how you get your card and how you update your information in the registered persons database are real indications of commitment that we're trying to do our best.

In addition to that, and we'll get into a little bit more of a discussion this afternoon with a subsequent presentation, you will hear more about the efforts that we have under way, which will grow over the next year, around validation of the card and the integrity of the information at the point of service. I think that's another important feature that we have in this.

Mr Tilson: Let me ask this specific question then: How does the ministry intend to have individuals, where you feel that there has been fraud committed, reimburse the system?

Mrs Mottershead: Through the investigative process. We do have and we've gone through a court case or two already where restitution has been a feature of the judgement that's been brought into place. So that is one part of it, and the courts are dealing with that aspect --

Mr Tilson: We heard that last year.

Mrs Mottershead: -- once we go through that. We do have examples; we do have some cases that have gone through. Our investigative unit is actually looking at over 500 cases and we do have, in terms of actual investigative, hard work, over 177 cases that are being pursued. We have cases that are with a number of police forces right now and I can't comment on those, but we hope that as part of the judicial process, one, we will get the issue of restitution addressed.

The second part of that relates to the provider fraud or abuse issues, and through our medical review committee, with the extension of that, and the six concurrent panels that will be available starting in September, we will deal with that issue.

One of the things that we are pursuing as well -- and I'm not confident in terms of the government's time with the legislative agenda. We certainly indicated in our response to the Provincial Auditor that we are looking at the possibility of changing the authority of the general manager under the health insurance program to actually conduct some investigations and introduce the notion of penalties for providers and others who may be found to be abusing the system. So we are pursuing some legislative things.

Mr Tilson: Mr Decter said much the same last year. Personally, I'm not confident as to what you're doing, and it may be because maybe there haven't been enough public relations going forth. But I haven't heard of a single charge against anyone since Mr Decter was last here a year ago.

Let me ask another question. There was an issue raised last year about the forensic accounting firm of Lindquist Avey and some other names making a report to you. Is that report available for the committee?

Mrs Mottershead: When we commissioned the report, we commissioned it on the understanding of basically two elements; one, internal security issues that were related to that. The Lindquist people were specifically hired to have a look at every single aspect of our processes and procedures to determine areas of weaknesses, and for that purpose we protected it under freedom of information and so on because it deals with issues of real security.

The second aspect is that it was very much intended to be used as part of the advice in development of a cabinet submission that dealt with the issue of the new health card, the security aspects of the new health card, as well as the registration process, so from my perspective it is protected information.

Mr Tilson: Can you tell us how it differs from the --

Mr Perruzza: Point of order, Mr Chairman: Can I ask Mr Tilson a question through you?

The Chair: No. We ask questions of our witnesses.

Mr Perruzza: I just wanted to ask him if he knew of anyone who's defrauding the system.

Mrs Marland: He's taking up our time.

The Chair: Mr Perruzza, that's not a point of order. Mr Tilson has the floor.

Mr Tilson: Can you tell us how this report differs from the task force performed by -- I think it was the registration analysis report. Can you tell us how it differs from that?

Mrs Mottershead: Well, for one thing, the firm itself has very highly skilled individuals. One, they have forensic accountants and, two, they have law enforcement officers, and their particular bent in terms of looking at it was from the perspective of what could potentially attract opportunities for abuse in the way we have set up the processes and procedures. In that way I do believe it substantially differed from previous studies, including the ones that we have done.

We certainly didn't have that kind of expertise on staff, and these people have all of the qualifications. So from my perspective it's much more rigorous in terms of the system elements and all of the components of the system, rather than looking at card population and trying to figure out through extrapolation methodology where the problems might be. Quite significant changes.

The Chair: Mrs Marland, I believe.

Mrs Marland: I wonder if I could ask you, Mrs Mottershead, about how much money the ministry has budgeted for health card verification measures this year.

Mrs Mottershead: In terms of actually segregating it down, the verification and analysis portion, including the validation, I would say is about $1 million, in that neighbourhood. We can get more accurate information for you this afternoon if you wish that number confirmed.

Mrs Marland: All right, that would be excellent. I'd appreciate it.

Some of the questions I'm asking, I am asking on behalf of the member for Simcoe West, Mr Wilson, who is our Health critic. Mr Wilson is sitting on another committee and not able to ask these questions. How many Ontario hospitals now have swipe readers to determine the validity of health cards?

Mrs Mottershead: We've got pilot projects going on right now. The whole analysis and evaluation of the pilot project has been concluded actually, and we'll be rolling out a broader pilot over the next couple of months. There are currently four hospitals that have the swipe technology, and another eight have the interactive voice response system.

Mrs Marland: And how many hospitals do we have in Ontario?

Mrs Mottershead: Two hundred and twenty-three.

Mrs Marland: Are these four major hospitals in terms of size, and do you know which ones they are?

Mrs Mottershead: Yes, Donna can give you that.

Ms Segal: We have four. One is a major downtown hospital in Toronto. Two are the acute centres in Kingston. The entire city of Kingston -- the acute facilities are covered through swipe. The fourth is --

Mrs Mottershead: Ottawa Riverside?

Ms Segal: No, Riverside is an idea. Memory escapes me, but I can certainly give you that information this afternoon.

Mrs Marland: Okay. That's fine.

Ms Segal: That's only the pilot stage. The pilot stage has been completed and now we're poised to roll out the implementation stage in September.

Mrs Marland: Do you have the money to ensure that every hospital has swipe readers?

Mrs Mottershead: We, as part of our activities and initiatives on the health card, have put forward a requirement to expand our pilot projects and have in fact considered a request to government for additional funds.

Mrs Marland: So right now you don't have the money.

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Mrs Mottershead: We've got the money that supports the pilots, but in terms of expansion, we are negotiating, I would say, with the Treasurer.

Mrs Marland: So right now you have money for the pilot project, which is four hospitals, but right now you do not have money to have swipe readers in all of the hospitals, or even the largest-number-of-beds hospitals in the province. That money hasn't been given to you.

Mrs Mottershead: I don't know how familiar people are with the whole budgeting process in government. We do have an amount of money that actually has been put into our allocation but is on holdback, pending the government's receipt from us of the complete plan and how many we want to do and that kind of thing. So there is an amount of money that has been designated but not made available, subject to a full plan development.

Mrs Marland: Okay. Is the amount of money designated enough money to cover all the hospitals, or a major number of the beds in this province, to be covered with swipe readers? You said the money hasn't been approved, and yet now you're saying the money is there in a special fund.

What I'm asking is, if you're introducing a new system and telling us that your verification system will work, how can it work if you haven't got the money to have the swipe readers in the hospital?

Mrs Mottershead: I'm confident that the government will. Like I say, the money is on holdback in Treasury and they're just waiting for a plan. Our commitment has been to try to introduce the reader technology to about 50 hospitals in 1994-95 -- at least that's the plan if we can move that quickly -- and another 50 in 1995-96. That would in fact cover the majority of beds in the province.

The difficulty here -- and we've had some experience in terms of our introduction of the Ontario drug benefit network -- is that it's a lot of work in terms of hooking up to individual hospitals. You have, first of all, some of the difficulties inherent in hospital systems. They've got their own information systems and we have to try, first of all, to find a way to be compatible with that particular system without causing a lot of financial hardship on the hospitals to redo their systems. That's point number one.

Second, the information highway that connects the individual hospitals to the Ministry of Health database has to be put out. We're not just talking, pull a switch and it all happens. There is a lot of work that's involved here that involves the cooperation of the hospitals, recognizing their financial requirements and their ability to work with us on that.

That's the plan. The government has indicated an intention, as I said, recognizing that money is required for this, and it's just waiting for us to finalize the detail of our plan to access that money.

Mrs Marland: So you've told us there are 223 hospitals --

Mrs Mottershead: Yes.

Mrs Marland: -- in Ontario and you've said that hopefully you will have swipe readers in 50 of them by 1995-96. What we're saying is that we've got 173 hospitals that won't have the verification measures complete in terms of the actual use of these new cards, because there will be that gap for another two years. So for another two years we really don't have this new system working because we won't have the swipe readers in the hospitals. I'm quite sure that the hospitals, because of the cutbacks, will be saying to you, "We can't have them unless we get the money from you."

On the one hand the ministry is saying, "This is the solution, because we're going to have new cards and we're going to have swipe readers," but in fact what you're telling me is we're having swipe readers for less than 25% of the hospitals in this province.

Mrs Mottershead: Let me just clarify or flag for the members the fact that I can name you 50 hospitals which, all lumped together, wouldn't have anywhere near the number of beds that one hospital we talked about that has been part of the pilot project, Toronto General, would have. So you have to think about exactly what it is that we're talking about. That's one.

The other hospital that is involved is Chedoke-McMaster, another very large teaching hospital where we feel that the information is really quite important to try it in that setting as well.

You just can't say we're only covering a quarter or a half of the hospital population. Technically you may be correct, but in terms of actually covering beds and population we'll probably have it triple that amount, as I mentioned.

Mrs Marland: But if I want to use a fraudulent card, if I want to use a card fraudulently, then I now know where I have to go to use it.

Mrs Mottershead: Well, you wouldn't be able to go for a triple heart bypass into a small, rural hospital. That's the other reality. It's the kind of service that you're going for if you intended --

Mrs Marland: Those procedures are being done in centres outside of Hamilton and Toronto, so I'm a little bit nervous about the fact that --

Mrs Mottershead: Donna may have other information that she wanted to add to your question.

Ms Segal: The only point that I wanted to add is the 50 by the end of calendar year 1994, we're pretty comfortable and confident that we'll be in a position to make sure this occurs. That's something that the government --

Mrs Marland: Gives you the money.

Ms Segal: No, approves our plans and allows us to move forward.

Mrs Marland: I know. But in fairness to you --

Interjections.

Ms Segal: Can I finish? I haven't finished.

The Chair: Mrs Marland, your time has expired.

Mrs Marland: In fairness to you, you are saying that you've got these plans, but in fairness to you, you're also saying that as of today you do not have the money.

Mr Stephen Owens (Scarborough Centre): That's faulty logic, Margaret.

The Chair: Thank you.

Mrs Marland: When it's up to the Treasurer, he's got lots of priorities for money.

The Chair: I have Mr Frankford, Mr O'Connor, Ms Haeck and Mr Marchese. Would you like to divide the time evenly among you or --

Interjection: Yes.

The Chair: Proceed on a one-by-one basis?

Mr Robert Frankford (Scarborough East): Can you clarify for me: We're talking about new cards. Are we also talking about new numbers? Or do we keep the same lifetime number that was the intention --

Ms Segal: I'm sure Mr Stump will speak to that this afternoon, but the intent is that you would keep your same health number.

Mr Frankford: So it is a lifetime number?

Ms Segal: It is still intended to be a lifetime number. That's right.

Mr Frankford: I'd like to ask about the question of expiry dates. My possible interest in this in the future will be apparent.

Ms Segal: Yes.

Mr Frankford: What does an expired card mean? Does that mean that I as the provider am going to be penalized because someone has not taken the trouble or, whatever the reason, has not gone through the procedures of renewing their card? I really have trouble with this, because the analogy with a driver's licence I think breaks down, the connection. I understand perfectly well that I've got to renew my licence and that I could be stopped by the police and all sorts of adverse comments could happen, but I don't see the analogy with the access to what is a citizen's right to care.

Ms Segal: I think, as Mr Stump will say this afternoon undoubtedly, there will be a procedure put in place to encourage people to come in before the expiry date actually comes, in approaching the expiry date. As a physician, were you to see the card, it would say to you that this particular card is no longer valid or eligible, and it would prompt you to ask, for example, the individual who's appearing before you whether in fact this is the most recent card or whether the individual has gone in to reapply and to renew their registration.

We need some kind of mechanism to ensure that cards and access to the system are maintained only by individuals who are in fact eligible. The expiry date is the most effective means of encouraging people to come in and renew their card periodically to ensure that continuation of proof of eligibility. I don't know how else to answer your question.

Mr Frankford: But, you know, and I'll just make it my final comment, as the provider I'm going to make a good-faith visit. You don't even have to respond, but I would just say, is there or should there be a good-faith payment policy that I will get paid whether or not the person has gone through the procedures required?

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Ms Segal: All we're talking about is whether or not the claim that is made to OHIP as a result of the services is in fact covered by OHIP, so whether or not the individual is eligible to bill OHIP. It would be very possible for the physician to say to the individual, "This indicates that your eligibility has expired. If you still want me to treat you today, I have the authority to charge you for that," because this individual is clearly and could be evidenced through the validation scheme as not necessarily being eligible for services.

Mr Frankford: Well, I don't know if that addresses my question, but I'll pass on to the next person.

Mr O'Connor: On the red-and-white card that we have today, the bottom of it, I see the number that was issued to me because I had a job. I got this number many years ago because I got a job; didn't say whether I was eligible or ineligible or whatever. That's how we ended up with the 25 million cards under the Tory system.

Now the Liberals come into office, and the Provincial Auditor said in 1987: "Hey, we got a problem here 'cause we got 25 million numbers out there. We got a problem. We gotta clean this system up." So the Liberals said: "What we're going to do to fix this up is we're going to mail everyone in the province a card. Now everyone in the province is going to get a nice red-and-white card." Right?

Mr Perruzza: Liberal red and white, isn't it?

Mr O'Connor: Oh, it's a nice card, a nice red-and-white card. The problem is that there was no verification of this. And then all of sudden, of course, we realized that we've got a problem here. Now all of a sudden we realize that we've got a big problem with the Liberal red-and-white card and there has to be something done. The Provincial Auditor states that there are a number of cards out there.

How do we ensure that we don't follow the mistakes of the Tories and the Liberals when we go through to the next stage?

Interjection.

Mr O'Connor: How do we know that the plan is going to be there? Because I know we're going to be in government for a long time, so I want to make sure that we do it right.

Mr Crozier: You'll get your job card back.

The Chair: Order, please.

Interjections.

Mr O'Connor: I don't know if that's an answer to the question. Obviously they've got a cautious plan under way, and I want to hear some more of the plans.

Mr Owens: Those great business people over on that side built a power plant they still haven't paid for.

Ms Segal: The registration process this time --

Mr Owens: Where's Margaret Marland when you need the responses?

Ms Segal: -- will take pains to ensure that everybody who personally presents, who steps up to the counter and says, "I want to register for a card," will present documentation which verifies that they are indeed entitled to remain in Canada and are a resident of the province. It will be original documentation and it will be verified, carefully authenticated, to ensure that it hasn't been tampered with. And during the period, the interregnum between when the individual steps up to the counter and when the actual card is produced and sent out, there will be a short period of time which will allow us, as the system, to doublecheck in the instance where the same document is being referred to by more than one individual as their personal birth certificate number, so we will be able to verify any suspected cases of fraudulent use of the original documentation.

Mr O'Connor: Okay. So the Liberal plan was, if it went out in the mail, then it had to be right. What we're going to do is there's got to be personal presentation of the information, so it's going to be direct information; the person is going to have to be there in person and present it.

The question then I would have as an MPP: With the 100,000 constituents that we all have, give or take a few thousand, within our ridings that we represent, how can we possibly avoid the huge lineups that could be there presenting the information to make sure that we get it right, as opposed to the mail-out system that the Liberals did, and the Tories who had no system for the 25 million cards they had?

Mr Callahan: Is this a partisan statement, by any chance?

Interjection: Don't be cruel.

Mr O'Connor: Oh, not at all. Not at all.

The Chair: Order, please.

Ms Segal: In order to increase the number --

Mr Perruzza: If he said 700 million, it's not partisan.

Interjections.

The Chair: Order. Perhaps we should send some members to finishing school.

Ms Segal: In order to increase our service delivery network, we've enlisted the support and the assistance of the Ministry of Transportation. The Ministry of Health itself, through my offices, only has about 20 offices or 22 offices at this moment in time, and we're going to be enlisting the support of another approximately 360 offices or service agency outlets that are now controlled by the Ministry of Transportation. As Mr Stump will talk about, in ruling out the strategy and ruling out the actual registration process, we're looking carefully at what the demand will be on each of those offices so that we can make sure resources are available to minimize inconvenience and to properly serve the public.

Mr O'Connor: A follow-up question to Ms Marland's question about the hospitals and the fraud that takes place there: How many people go to the hospital directly to access the service and how many are referred in from another primary care giver who would refer them to the hospital? Obviously, then, the initial check of this card has already taken place before they even go to the hospital. And how many just show up on the doorstep and that's their initial access point? Do you have any numbers on that?

Ms Segal: I don't have those numbers, no. I can't tell you that right now.

Mrs Marland: What are you saying? It's been cleared up at the primary care provider?

Mr Perruzza: Whoa, whoa. I wasn't permitted to do that. The rules are the rules.

Interjections.

The Chair: Order. No interjections. Order, please.

Interjections.

The Chair: Could we please carry on? We're cutting into Mr O'Connor's time. Mr Perruzza, you are -- order.

Mr O'Connor: Thank you, Mr Chair. I'll pass the floor on to my colleague.

The Chair: I have Ms Haeck.

Ms Haeck: I actually want to follow up a comment that Mr Crozier made. I too live on the border and am aware, at least from some reports -- the CBC actually had something done back several months ago relating to a Windsor physician who was aware that one of his patients was living out of country but had maintained either an address or a post office box or some sort of appearance of legitimacy for eligibility.

I'm just wondering how you're going to be able to capture someone who is originally Canadian but has been a long-time out-of-country resident, but maintains this kind of façade of legitimacy. Are you going to be asking questions around post office boxes, that those people who maintain that for postal delivery provide additional addresses to confirm where in fact they may reside?

Ms Segal: Yes. We'll be spending a great deal of time verifying the actual residence, where they live as opposed to where their mailing address is, as well. I guess the other point is that we're very much hoping the implementation of Bill 50 and its associated regulations will encourage physicians to report where they believe that an individual may not be a resident of Ontario.

In those reported circumstances I believe the physicians may or may not have known that the individual was not in fact a resident, but for reasons of patient confidentiality and the medical responsibility to provide service did not actually report this as a potential incidence of fraud. Bill 50 will make it mandatory that they do bring this to our attention. So their failure to do so would be seen as an illegal action, and we believe that will provide some impetus to helping us to identify those particular instances.

Ms Haeck: Very good. I also want to pursue another point Mr Crozier raised, because we have similar communities, as my mother-in-law who lives in Detroit asks about the weather and I say: "We have the same as you do in Detroit. It starts there and comes our way." It's sort of interesting that we have a fairly large Mennonite population and we do have a number of people who have inquired with my office, quite recently again, from the point of view of being missionaries, but we also have a fairly large out-of-country population that goes for at least three to six months to Florida or Arizona.

In your response to Mr Crozier you made a comment which, I must admit, in looking at some of your documents before has never quite twigged. You said that you can apply for an extension --

Ms Segal: Under certain circumstances.

Ms Haeck: So that someone who was leaving the country to be a missionary in Africa for a year in fact could in advance of leaving apply to you for an extension so they don't have to go through a waiting period?

Ms Segal: The short answer to that is yes, in that particular instance. That same circumstance does not necessarily apply to individuals who are leaving the province for pleasure or for non-employment purposes. But in the instance that was referred to earlier, yes, it's possible that they could apply for an extended absence for one year and then a second year extension.

Ms Haeck: Very good. That will in turn answer a number of queries I've had in my office and I think relieve a certain anxiety that is out there.

Ms Segal: Can I just also add that the other most frequent example of that is for Ontario students who leave to study elsewhere. Were they to apply, we also grant them extensions for up to four years for them to continue and pursue their studies outside the province. That's the other major category.

Ms Haeck: Very good. How much time do we still have?

The Chair: Your caucus has five minutes left.

Ms Haeck: I will ask one more question, then turn it over to my colleague. You raise an interesting point in your discussion, Ms Mottershead, with regard to the information technology and the fact that to date there doesn't seem to be a standardization of the technologies used by the various hospitals. I know that in talking to the nursing staff in the different hospitals within my riding, that's always been a point of controversy, because they realize that it's difficult for one hospital to talk to the other one, moving information about patients back and forth.

There was the recent discussion about the hospital economic development strategy, and I know that related to much more a procurement of supplies, but is there something envisaged to assist hospitals in moving to a more standardized form of information technology so that these kinds of information transfers will be expedited?

Mrs Mottershead: The answer to your question is yes. There is a major effort under way to standardize all hospital information. It's called the management information system initiative. The government put about $10 million towards it two years ago. It's a five-year project basically to bring everybody up to line, to the same standard in terms of information classification, data fields and so on, right down to a common chart of account numbers, so that in fact we can now start comparing between hospitals. We have consistent financial reporting data as well as HMRI data, which is essential for us to do a lot of our research and evaluative work. So that's a major activity that's going on. It's going to take, as I say, another couple of years before all of the hospitals across the province are fully automated on the same system.

The Chair: Mr Marchese.

Mr Marchese: Mr Chair, I have five questions, so I'll resume those questions when we come back.

The Chair: Mr Perruzza is on the list as well.

Mr Perruzza: I'm passing.

The Chair: All right. Mr Owens?

Mr Owens: I'd like to go back at the swipe card issue that the member for Mississauga South raised. I'd like to get some information with respect to the pilot: the duration of the pilot; I guess some technical details on how the system will work; whether or not it's the ministry's view that you go hell-bent for leather to buy a whole bunch of technology that you don't know is going to work; what kind of check-ins you have with respect to the technology; and what will be the decision point as to whether or not the technology works with its primary function and whether or not it could be used for more advanced purposes.

Ms Segal: The actual swipe card project part of the pilot was initiated in approximately June of last year, 1993, and its evaluation was carried out and published early in 1994.

Frankly, it was quite successful in the sense that it provided, at a very basic level, "Yes, this card is a valid card," or "No, this card is not a valid card" information to the hospitals indicating whether or not -- as to the effectiveness and the validity of the card.

One of the good features about this particular pilot and what we presume it will allow in terms of a larger strategy is that it gives us real-time access to RPDB, as the hospitals will actually be making inquiries of the then-current RPDB system as opposed to --

Mrs Marland: What does that stand for?

Ms Segal: Registered persons database. I'm sorry.

Mr Owens: Is it RPDP or RPDB?

Ms Segal: Registered persons database, so RPDB. It's "B"; there's a typo. I shudder. I'm sorry. Mea culpa.

The real-time access is an advantage in the sense that we're not checking the person's validity opposite some older information that's been batched and pulled together, but in fact at that moment when the inquiry is made. So it's a very important feature.

The results of the pilot were very supportive. We undertook the pilot in cooperation with the OHA and representative hospitals from the OHA, as well as the OMA. All the groups -- the ministry staff and those staff -- were quite comfortable with the results.

As a result of that, we've pulled together what are termed technical specifications, appreciating that different hospitals will want different aspects of the system to be available in their own hospital's circumstance. So we've given a basic technical description of what is required in order to hook up to the system. That is now what's being explored hospital by hospital in an explicit survey to identify and help us to determine what they're looking for and how they want to attach themselves to the system.

Mr Owens: Once my constituents are satisfied that we're dealing with the issue called fraud -- and nobody to my satisfaction has quite figured out what the fraud is or how much or who's benefited from it -- the question they ask me is: "What's this going to do for my health care? How is this going to help me become a healthier person" --

Mrs Marland: You won't have to cut off the seniors if you don't have the fraud.

Mr Owens: -- "or maintain the current state of good health that I enjoy?"

Ms Segal: What we're talking about is the integrity of the system. What we're talking about is preserving whatever resources we are spending in order to provide health services to the people of this province. So the more that we can perfect our system to ensure we are providing services to those individuals who are eligible, and not necessarily providing services at our cost, at public cost, to those who are not eligible, it allows us to manage the system in a more effective manner and therefore ensure that we're being as --

Mr Owens: Will there be kind of live-time, real-time interactive health studies ongoing with respect to the efficacy of treatments, the efficacy of medications etc, through the use of databases?

The Chair: If I may just interrupt, that is a pretty involved question. The time has expired.

Mr Owens: The member for Mississauga South was yapping during my time, and I would appreciate an answer.

The Chair: I did grant you an additional two minutes, Mr Owens, so I would like to adjourn at this point for lunch and come back at 2 o'clock. We'll resume our proceedings then. Thank you, members of the committee.

The committee recessed from 1208 to 1410.

The Chair: Members of the public accounts committee, we'll continue where we left off this morning. Welcome back this afternoon, Deputy Minister Mottershead, and some of her colleagues whom she will introduce shortly, I would imagine. We'll continue with further presentations, I believe. We'll start with that and then move in to a questioning session after that.

Mrs Mottershead: Let me introduce Larry Stump, who is the project director for the health card registration and the new health card. Larry has a presentation. I believe the projector has been set up so, if the committee is comfortable, we'll go right to the presentation.

Mr Larry Stump: Thank you for the opportunity to talk to you about the health card. I'm looking forward to it. As the deputy indicated earlier this morning it is one piece, and just one piece, of a comprehensive and complex management plan for health care fraud. I think, from some of the discussion I heard during questions around the table, there's also a recognition that it's a continuum. The 25-million number, the 11-million number and what we're about to embark on now, is not the final answer. The management plan gets set, it gets updated on a regular basis and we keep moving forward on it. I think some of the things Donna has told you about give credence that it's an ongoing process as well.

I'm going to very quickly touch on a bunch of subjects. The transitional health card -- give you a little bit more detail on that and show you a mock-up. We'll talk a little bit about the health card; the three-year reregistration cycle; the five-year renewal cycle that will allow us to continue to make improvements in the system through that continuum; the in-person registration; and a little bit about our partnership with the Ministry of Transportation in order to do some good customer service things.

The background, I think we're all aware, is that in 1990 we introduced the current card. We very quickly registered everybody in the province to deal with the problems of that day. We had some difficulties and we continue to have some difficulties in verification of eligibility of people who registered at that time. Our subsequent assessments, in part due to the Provincial Auditor and consultants and internal studies we've done, is that we have to do a little bit of work on that card.

To cover off some of the points that are the highlights of Donna's discussion this morning, we've taken a bunch of actions on strengthening the card issuance and the controls around it. We're strengthening the card application procedures. We've conducted other verification activities in terms of data exchanges and our mailings etc. We've done our pilots on the point-of-service validation and, as part of our full package going forward to the government, we have the point-of-service validation, the health card and a number of other items in that comprehensive management plan.

The transitional health cards, as you heard this morning -- the first ones -- were sent over for production on the 19th and the new enhanced card is another item in that area.

We've strengthened the application procedures with original documentation. We've set standards for documentation. Donna discussed that and provided some handouts around our requirements on that area. We've trained our people. We are continuing to learn about documentation, worrying about some of the issues that were brought up this morning, and what types of documentation, in conjunction with other pieces, would provide a full package to ensure that only eligible people are being registered in the province. We've started bringing people in, when they lose their card or they need a replacement card or their card has expired, for an in-person type registration, so we've done an awful lot in the application process.

You've probably heard in the past, and again today, about our linkage with the registrar general in terms of death information so that we stop some of the practices of sending cards to people who are no longer living. We have formal agreements either very close to completion or in completion with other levels of governments in other provinces: ACIMS, the federal government Immigration. We have provided some opportunities for the public and providers to inform us of any abuse in the system, and we've enhanced our verification and created the investigation unit.

We've started one of the key initiatives in terms of the point-of-services confirmation of the validity of the health card so that no matter how many cards are out there, only valid ones will be eligible for services. We're not being as fast as I'm sure many of us would like, but I think there is a plan in place to roll it out, not only for hospitals but through the interactive voice technology, to all of the providers in the province and to hospitals that would choose to use that rather than modify their existing system. So I think the bases are covered in that area.

We're introducing a photo card and that will allow our providers to make a visual check on people. They'll be able to see that when somebody comes in with a female's card, a male will obviously be caught on the spot. It is not going to be a perfect system but it's going to be a lot better than what we have today.

On the transitional health card -- as I mentioned, we instituted the first of them last week; the 19th I think was last week -- we've included the gender on the card, the date of birth, the issue date and the expiry date, so every card that's being introduced today now has a life and that life will be tied into the renewal cycle.

With the tighter registration features we've talked about in terms of applications, documents and now some visual indication on the card, I think we've made considerable progress in coming to terms with the issue even today.

Now we get to the meat of, I guess, my area of expertise: the new health card. The minister announced the new health card in May of this year. We're planning on starting the reregistration process in February of next year and we're in partnership with the Ministry of Transportation.

That slide doesn't fit very well. We'll hand out copies of the package afterwards. We have the population of Ontario, about 11 million people, to reregister over that three-year period. The question this morning came up of customer service and lineups and the rest of it. We'll talk about our strategy for spreading the population out over the three-year period and some of the things we'll be doing to minimize the lineups and making sure that people are treated very well.

Each person in Ontario will be receiving an invitation to renew and it will indicate to them, within 60 days. when they should wander into a Ministry of Health or Ministry of Transportation office. They'll appear in person at one of those offices with their invitation to renew. They'll have marked any indications of changes of address or corrections to information that we've previously collected on them. They'll be asked to provide their proof of citizenship, their right to remain in Canada, their residency and, as well, who they are. Their picture will be taken at the office and they will be asked to sign a declaration, understanding that the health card is the property of the government and that they have a responsibility to take care of the health care system as well as we do.

That information will be taken from the office and shipped overnight to a central computer. We will then conduct some additional verification activities and that will be part of a continuum. We're hoping in the short term to be able to augment our checking with birth certificates against the registrar general's file of legitimate births in Ontario. So if somebody has given us a birth certificate that's been manufactured and we weren't able to tell, we'll be able to verify that this birth certificate has only been used once, it belonged to the person and that it actually exists in the records of the registrar general. There will be other items as well. We're looking at verifying with Immigration Canada the certificates of immigration we receive. So we're doing an additional, after-the-fact verification with other databases.

That information will then be sent to a card production facility and the card will be packaged up, put on a carrier and mailed to the individual. Essentially, that's the registration process you'll be seeing next year.

I guess we've looked at the health card project in three different facets. One is, how are we going to manage it -- and by "we" I mean the Ministry of Health, our partners in the Ministry of Transportation and Management Board secretariat. We've set up a number of steering committees, interministry steering committees, and hopefully we're doing a good job of making sure that we do the right things for the right price and at the right time.

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On the left-hand side, we've taken a lot of care to include a consultation process and I'm sure that all three of the groups we're very concerned with get involved, and we'll talk a little bit more about that on the next foil, as well as the customer service delivery people in the 400 offices that are going to be involved.

We're very concerned that people get the service they're entitled to and that it's in keeping with modern customer service practices.

We've set up the expert advisory forum to represent three subgroups, and that's a group of providers, the people who are going to be on the receiving end of the health card presentation, the recipient that's going to carry it around and meet with the health care provider for services, and then finally a group of technical experts that can keep giving us the best advice available.

That process is broken out into three planned activities as well. We have a planning and design session coming up in September where we'll be asking people for input on not only the card design, the card contents, but the processes as we envision them. We'll be looking at having taken that input, going back to the group in January and saying, "We've taken your input, we've used our best judgement, we've taken our own input as well," and we'll be telling them exactly how the process is going to work before we actually implement it.

Then we're looking at a final, hopefully positive, feedback in the summer or fall of next year to find out how well we've done in that planning exercise. We'll be able at that point, with a limited number of invitations having been mailed out, to amend our processes and correct them as we see fit.

That's from the public side of the consultation. On the internal side, we have representatives from each of the regions and districts. We have members of OPSEU, the union that generally is involved in the service delivery, working on making sure the people who are going to be on the front line can tell us of their experiences today, and we can build on their knowledge to do it as well as possible. So we're not planning this in a vacuum from the people who are going to be delivering the service on the front line.

Essentially, the same three types of phases: We want to get their input before we start developing all the procedures and doing all the forms and issuing the invitations. We want to make sure they understand it and we have a lot of work to do on our training program for both our internal staff and the Ministry of Transportation employees, as well as issuer agents. Then finally, we want to get their feedback as to what's happening on the line, what's happening on the counter as we go through the registrations.

The small mock-up of the transitional health card will show you what it looks like, if you haven't gone in to replace your card, and if you do then this is what you will get from now until some time next year or perhaps the year after, depending on where you fit on the renewal cycles.

It's pretty hard to read on the foil, but essentially at the bottom you have the period the card is valid for, when the person was born and what was their sex. The version code -- I think we've had some feedback from the provider community -- has been moved up near the number so that it's very prominent, that the version code does exist and what it is.

In the new card, what we will be enhancing will be, in terms of content, a colour photograph that's taken at the site, your signature recognizing the terms and conditions attributable to the card --

Mr Callahan: Excuse me, if I can just jump in there, the one before is just a transitional card?

Mr Stump: Transitional. That's the one that's good for the next little while, and the next foil we have is a mock-up that doesn't look anything like what the new card will look like, but at least it shows the elements to you.

Mrs Marland: Is the number on the transitional the same as the number we have now?

Mr Stump: Yes, it is.

Mr Callahan: They've got that till they pass on.

The Chair: Will the colour stay the same?

Interjections.

Mr Stump: Are we open for questions at this point?

Mr Tilson: Musings by the Chair.

Mr Stump: We'll be adding the address, gender identification, issue and expiry date. We're looking at security features to make it a little more difficult for people to counterfeit the card, such as rainbow printing, microprinting, which is just very, very fine printing which makes it impossible to -- impossible, there's nothing impossible any more -- just makes it very difficult to reproduce and requires you to spend a little bit more money on your counterfeiting operation, and a hologram. We'll carry on with the mag stripe and we're planning on introducing a bar code as well for those hospitals that are very heavily into bar coding.

Mr Callahan: Is there any suggestion that cards have been counterfeited? You're putting a lot of effort into keeping them from being counterfeited. Do we have any evidence that there have been counterfeited cards?

Mr Stump: Like most of the fraud, we have a lot of anecdotal evidence that people are doing things, whether they're tampering with them or whether they're making them up. There's been some suggestion, and I don't think it's a fraudulent intent, at one point you could get souvenirs made of your health card. They don't look anything like it. Nobody should take it, but what we're saying is we're trying to button down the system, so we're making it tamperproof. You're not going to be able to change your picture and substitute someone else's. You're not going to be able to modify the birth date, the gender. We don't want to open up a new door after we've spent an awful lot of money going through the process to close it.

Mrs Marland: But a lot of those decisions you haven't made yet.

The Chair: Can we save the questions till later? I'm sorry. Mr Callahan has asked a question. I know it's unfair.

Mr Stump: In terms of data content, we're fairly sure what's going to be on the card. We do want to make sure that the consultations we go through in September are very meaningful. If you want the bureaucrats and have taken input from a number of groups that made presentations to us last year, we've had an awful lot of input from the OMA over the years, the OPA, the OHA, and it's been an ongoing dialogue. What we're doing now are mock-ups based on what we believe is necessary, but I don't think we want to close the door until we've had a chance to talk to everybody.

Mr Murphy: Is purple the colour you get when you mix red, blue, green and white.

The Chair: Don't answer that.

Mr Stump: That would be the perfect bureaucratic answer, wouldn't it? There's a story behind that when we came out with the colours for these foils, and it goes back to a seminar held in June, but I don't think you're too interested.

Card features: Once again, we've got a whole pile of models under development. Some of this information moves from the front to the back and vice versa.

On the front in this particular example you have the digitized photo. We're exploring some exemptions, including children, people who don't want to have or can't have their picture taken for a variety of reasons, and we'll talk a bit more about that later.

We're looking at ways we can maybe make it a little more convenient for a family to register as a group, because, as you'll see a little later, the algorithm we're using for distributing the population would tend to break up the family into distinct units to register.

The bar code on the front we've talked a little bit about, and I think it'll be quite an effective card as well as hopefully somewhat attractive.

On the reverse side, what you see is a signature. That most likely will be captured at the time you have your photograph taken rather than added on after the fact so that, right from the time we've seen you, your signature is part of the record.

There's an enhanced ownership statement. I gather from our legal information we're told the ownership is not quite as strong as it should be, that it's the property of the province of Ontario, and it is a right but it's also a privilege that can be revoked for misuse.

We've had discussions with the organ retrieval people as well as with the Ministry of Transportation; the organ donation indicator will also appear on the card.

We are planning at this point to include an address on the card in the hopes of making sure we keep the information current and that in terms of improving health care, maybe at some point in the not-too-distant future we can be able to do better mailings in terms of the breast screening exam programs and things like that.

Moving on to how are we going to get this out into the province, the message that I've been given quite loud and quite clear and I think all the people who are working with me have adopted with great enthusiasm is that we have to have a quality process. We were taking it very seriously that going into the process, and throughout the process, we're going to be constantly looking at it. We'll be bringing in experts as well to make sure we maintain the security throughout it. We want to do it as well as we possibly can do.

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Customer service: Clearly, the population is going to have to be a participant in this. We want to be seen as good deliverers of customer service and not the simple bureaucrats that get bashed in cartoons all over the place.

We'll be looking for efficiencies in terms of our target groups, and we'll be moving towards full operational capacity within the parameters set earlier, can we do it right and can we do it fast?

In terms of customer service, we're looking at convenient access. I think that's one of the primary reasons we've entered into a partnership with the Ministry of Transportation. Establishing 380 service points will certainly make it a little more convenient for the population of Ontario than the Ministry of Health's existing 20 offices. We are also doing quite a bit of analysis right now to find out where the population lives and where they've previously gotten their driver's licence in case there's a shift between residence and work to make it convenient for people to register. On the basis of that information, we'll be going back and looking at, as Donna expressed earlier, the hours of service, the days of the week that we're open in both ministries and where we may need new offices, and if that's necessary, then I think we'll be getting the support necessary to open those offices.

We're looking at a very aggressive and very informative campaign in terms of educating the public. It's going to be much more complex for the public this time, because last time everybody got a mailing and a bunch of ads that said please send in that form, and the message went through fairly well. If I recall correctly, you were always able to go to the post office or somewhere, your doctor's office, to get more forms. In order to manage the customer service component, as I said, you're going to get an invitation to renew. So you'll hear that people are getting new health cards. It may take as long as three years before you get invited to appear at one of the offices and renew your health card. That's going to be a very challenging piece of the campaign.

The renewal cycle: We've talked a little bit about it. Nominally it's a five-year cycle. Actually it would be four to seven to average out and smooth the workload for the future.

As I've said before, key to this whole exercise is proving the process, making sure that we've got our documentation correct, that our verification activities work, that the processing is correct, efficient and swift, that our service delivery is good, and I think everybody's going to be fairly well motivated to do a good job of it.

We're taking special care to consider family groupings. I think in a family with two or three children, each of whom has a different birthdate, then nobody wants to walk into the office in January, February, March, April and May reflective of their birthdate. So we will be trying to package families together so you can go in as a family unit or one of the parents can take all of the children in.

We're giving consideration to seniors, perhaps who also travel, to make sure we're not inconveniencing them in terms of coming in to get their new photo card but at the same time making sure they get registered in --

Mr Owens: Sign-ups in Florida?

Mr Stump: I don't think they will be quite that convenient.

We've already started discussions with some of the agencies around the homeless people and some of the disadvantaged groups, and everybody I think who has worked with them previously in the last registration effort is going through our current changes, and so far it looks pretty well.

I'm going to skip over this one. This goes into explaining the MTO renewal algorithm.

The next foil will basically allow you to determine when you're going to get your own personal new health card invitation to renew. On the left-hand side you'll see date of birth, the first to the sixth, for example. If you are born on the first to the sixth of a month, you will receive your invitation to renew approximately two months beforehand. In other words, if your birthday is September 6, in July you'll receive an invitation to renew. If your birthday is September 6, you'll receive that invitation in 1996. If it's August 10, two months prior to August 10 in 1995 you'll receive your invitation. If you are drivers, if you look at your driver's licence right now for your expiry date, then you'll be able to figure this calculation out much easier. It'll tell you on there. That's what we'll be trying to coincide with. The purpose of that is, not only will you be able to get your health card, we'll try and tie into your driver's --

The Chair: Point of order?

Mrs Marland: No.

Mr Marchese: Go on. Please continue.

Mr Stump: Okay. If you're going in to renew your driver's licence, it would be very convenient for you in the same transaction or at the same visit to an office to be able to acquire your health card -- a customer service issue. Just to give you an idea of the requirements, if you look down the left-hand side, we've used the largest metropolitan area as an indicator, but these are catchment areas. For example, Kingston has a population of about 90,000 to 100,000 people. Its catchment area runs all the way down to Cornwall, so it's a very large area, and areas you're more familiar with cover a large geographical area.

On the right-hand side, and you'll be able to see that a little bit better on the paper copies, is the number of Ministry of Health offices to service those populations, the number of Ministry of Transportation offices and private issuers. So that'll give you an idea of the size of the exercise.

That's all the presentation material I have, Mr Chair.

The Chair: Are there any other presentations, or shall we deal with this section and then move on?

Mrs Mottershead: If you wish to deal with this section, we can do that. We just had a wrapup presentation on the validation project to get into more detail from Mrs Segal, and also some information on the drug network to show you the platform and the rollout on that, if the committee wishes to --

The Chair: I think we should ask questions at this point, unless members indicate otherwise.

Mrs Mottershead: We're in your hands.

Mrs Marland: I wonder, Mr Chairman, on a point of procedure, if --

Interjections.

The Chair: Order, please.

Mrs Marland: This week we've been sitting from 2 until 4 reviewing past reports and confirming them. I'm just wondering, because we have the deputy minister and her staff here, if we could agree today, because of the amount of time that's been taken for the presentations, which are important, to sit until 5.

The Chair: We certainly could, if there is agreement.

Mr Perruzza: Can we come back tomorrow?

The Chair: Unless the ministry officials --

Mrs Marland: Can we agree to sit till 5?

Interjections.

The Chair: Order. Let me ask the deputy minister if that is okay, because we did not indicate that would be case.

Mrs Mottershead: I think, if I can get an assurance that promptly at 5 -- actually, I'm hosting deputy ministers from provinces and territories and the federal government here in Toronto this afternoon, this evening and all day tomorrow, so --

The Chair: Good. Then we will --

Mrs Marland: Yes, but 5 would be okay?

Mrs Mottershead: Yes, 5 would be just fine.

The Chair: Order.

Mr Callahan: Is there going to be a ball game?

The Chair: God. Really. Like, talk about --

Mrs Marland: Okay, it'll be prompt at 5. We can agree to that.

Interjections.

The Chair: Order. Could I please have some order so we can --

Mr Perruzza: Perhaps we could go around the table.

The Chair: Would you like to take over on this seat so perhaps we could have a very orderly committee?

Mr Perruzza: If you're soliciting contributions, that's what I want to do.

Mrs Marland: Okay. It's 2:45, Mr Chair. Let's go.

The Chair: If you'd like to make a point of order, please raise your hand and I will recognize you.

Mr Perruzza: I'm responding to the suggestions.

Mrs Marland: Well, we've got unanimous agreement to sit till 5. Let's get on to it.

Interjections.

The Chair: Order.

Mrs Marland: We do; it's all-party.

The Chair: We will sit till 5, there's been unanimous agreement, or at least I gather there is, so could you please continue? We will then --

Mr Perruzza: I'm just telling you there isn't unanimous agreement.

The Chair: Mr Perruzza, would you like to make a point of order?

Mr Perruzza: Yes. You don't have unanimous agreement.

The Chair: Okay, fine, we don't have unanimous agreement. So we'll have a vote.

Mrs Marland: No, it's unanimous by party, not individuals.

Mr Perruzza: No, we should put it to a vote, Margaret.

Mr Callahan: All right, let's put it to a vote.

The Chair: There's no unanimous agreement, so therefore I am not able to do that.

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Mrs Marland: All right, I'll place a motion, if we're going to be like kindergarten. I'll move, because of the importance of this subject and the fact that there's a tremendous concern by the general public in this province on this subject, that we sit until 5. We have, graciously, the agreement of the deputy that she can stay till 5. I'm moving that we sit until 5.

Mr Perruzza: Does that mean we automatically adjourn at 5 o'clock?

Mr Marchese: Call the question.

The Chair: Order. Mrs Marland has placed a motion on the floor. All those in favour of Mrs Marland's motion?

Mr Perruzza: Do we automatically adjourn --

The Chair: All in favour of Mrs Margaret Marland's motion? All opposed? The motion carries.

Mrs Marland: Thank you.

The Chair: If we could then proceed, we will entertain questions at this point and then have a subsequent --

Mr Marchese: Mr Chair, I'd like to raise a question of order. I would like to listen to the entire presentation and then ask all our questions at that point instead of doing it piecemeal.

The Chair: I asked that question earlier, and there seemed to be agreement around asking questions now.

Mr Marchese: Let's see if there is agreement. Is there agreement to proceed in this way and ask questions now and then continue? Is that what you want to do?

Mr Murphy: That's what I'm going to do.

Mrs Marland: I want to ask questions.

Mr Marchese: All right.

The Chair: Can we proceed to ask questions?

Mr Marchese: Yes, let's go now. They said yes.

The Chair: That's what I thought we had earlier. Would you like to entertain questions? We will have a rotation of perhaps 20 minutes for each caucus, and then we'll go back to the further presentation following that question period. So I'll turn to the opposition party first, Mr Murphy, 20 minutes from each party.

Mr Callahan: I thought we were going alphabetically.

Mr Murphy: Beat you this time.

The Chair: Your name begins with a Z. How's that?

Mr Murphy: I want to get an understanding of the process of issuing the photo card, if I can. Is the best guess at this point still that the photo card process will be about $130 million? I read that. It may be wrong, but do you have a sense of what it's going to cost, the whole photo card process?

Mr Callahan: That's the transition, isn't it?

Mr Murphy: Let them answer; they're the experts.

Mrs Mottershead: The three-year registration process will cost $30 million a year, $90 million at the end of three years. The $19 million has been a number that's been used, but that is the ongoing cost for renewal. Don't forget that after we do the registration of the full population, we will be contemplating a renewal cycle on an ongoing basis for the life of the project.

Mr Murphy: At some point or other, I think in 1993, there was a ministry report which calculated $691 million as the amount of -- I think everything was thrown into that: billing error, a few other things, fraud. Is there still a sense that that is an accurate calculation of the total slippage in the system for whatever reason?

Mrs Mottershead: Mr Murphy, I did mention this morning that I didn't come here prepared to debate numbers. I feel there has been a commitment made to eradicate any amount of fraud out there. Even $100 is $100 too much of the taxpayers' money, and therefore the assessment that we have, and the minister has made this statement publicly as part of her announcement, is that if you were to look at a number of cards that may be invalid for one reason or another and you applied an average hospital or physician cost to it, we estimate it, according to methodology that has been tested by the financial community, to have a potential risk of about $65 million. Therefore, the expenditure of $30 million a year to get into a reregistration and to produce a card that has all of the tamper-proof and security features to it, as well as the improvements we are making, have made and will continue to make in the whole registration process, will in fact save the taxpayers in excess of $30 million a year.

Mr Murphy: Now, that $65 million is obviously based on a statistical average as opposed to an actual analysis of experience, because it strikes me from the questions I asked this morning about the 100,000 cancelled cards that were identified that you don't have a sense of what claims have been made on those cards. Am I right that for the bulk of those 100,000 cancelled cards you identified this morning, in fact those cards are not returned to the ministry's possession? You cancelled the number but the card's still out there.

Mrs Mottershead: Well, once the number is cancelled, it automatically becomes invalid, and that's the point to be made.

I just want to also add another comment, and that is --

Mr Murphy: I'm sorry. I just have a limited amount of time and I really want to focus on the answer to the question.

Mrs Mottershead: Okay.

Mr Murphy: When you say it's automatically invalidated, my understanding is you, from your ministry perspective, cancelled the number, but if I still have one of those cards with a cancelled number, from your perspective, and go to a doctor for services, unless the doctor is suspicious and checks, the person gets service on that number and it's only when the physician files a claim on that number that, at this point in time, in any event, it's discovered that claim is made on a cancelled number. Is that right, at this point in time?

Mrs Mottershead: There is that possibility at this point in time. I should let members know that half of the physician population, 11,000 physicians, have already expressed an interest in participating in the project, either IVR or swipe technology, and we are in the process of moving with that as quickly as we can.

Mr Murphy: Have you got a sense, for example in the last six months, the number of claims made against cancelled numbers in the last six months? Do you know that figure?

Mrs Mottershead: I know that in terms of the claims processing function, and this committee had a discussion about that last fall, the numbers related to version codes have been falling dramatically, and I think that's as a result of the large effort on the part of staff to deal with the validation and to weed out all of that.

Mr Murphy: But I was just asking a very specific question, which was, January to June of this year -- to be fair, you've made efforts to try and get at a problem that's been identified. What I'm wondering is if you'd have an analysis from January to June of this year of claims made against cancelled card numbers. How much in total in that six month period?

Mrs Mottershead: We don't have the information right at the moment, but we can get it for you.

Mr Murphy: Okay, that'd be great. Thank you. I appreciate that.

Have you tendered for the photo card yet?

Mrs Mottershead: We are actually using the Ministry of Transportation system. What has happened is that they issued a tender several months ago on the driver's licence with the capacity for increased volume. That was a public tender and we're piggybacking on that particular business activity to produce, actually produce, the card.

Mr Murphy: One final question: I saw the information you were planning at least at this point to put on a card, and I know there was a discussion in our committee, without really a conclusion, to be fair, about whether or not additional health-related information could be included on a card, like a pharmaceutical record, you know, one of the issues being oversubscribing for seniors being a problem, and whether pharmacists then could use a card like that to have access to find out whether there's an oversubscription problem. Could you just explain for me and the committee the logic behind rejecting such additional kind of health-related information in terms of what you'd put on the card?

Mrs Mottershead: One of the major additions that we are contemplating, for example, the bar code, is intended to do exactly that. Hospitals have indicated that they wished it, and perhaps see the photograph when people present and have a signature as a specimen in their health record. They've been contemplating things like perhaps having blood type included in the record at the hospital that we can capture by the fact that we do have the spaces in the code to capture that additional information. Larry may have more information to add to that.

Mr Stump: I think in the example you were using in terms of the drug prescriptions, right now I guess 1,600 of the pharmacies are linked up to the health network, and I think there was an offer of a presentation a little later. All of your drug history, if you're eligible for Ontario drug benefit, is stored centrally. So whenever a prescription is filled under the Ontario drug benefit plan, then that date is analyzed and the information is fed back to the pharmacist and then either to the prescriber or patient, if necessary.

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Mr Murphy: I'm just wondering why this card technology wouldn't incorporate that.

Mrs Mottershead: The platform that is being built on the card technology is going to make sure that we can in fact integrate our systems to integrate health information. Also, because of the renewal cycle that we're contemplating, you can build an increased platform for more and more health information to be added.

The Chair: Mr Callahan.

Mr Callahan: You mean there's time left? Oh, sorry. I'll give it to Bruce; Bruce wanted it.

Mr Crozier: Oh, thank you. I don't want to appear glib on this, but I saw on the card that it says "sex" and I've heard the word "gender" used. Generally, when I see "sex" on an application, I answer yes or no. I wonder, seriously, if you might consider "gender" as opposed to the word "sex," if there's really no big difference.

Mr Callahan: I want three copies of that for his wife.

Mr Crozier: There were some questions that were asked last September that the committee would appreciate hearing answers to, and one of those was, "What are the projected ministry costs for paying first payment under the J-8 rules (example, good faith payment)...?" I think it was brought up this morning. "Comment on the cost implication of these policies." Could you answer that?

Mrs Mottershead: I can't answer that. I don't have that information, but I will undertake to get it.

Mr Crozier: Oh, okay.

Mrs Mottershead: We have continued the J-8 policy, as you know.

Mr Crozier: Okay, and if you could give me a comment, sir, the chosen vehicle has been a photo card, but it has been suggested by others that a smart card with a fingerprint identification may be a better way. Was that looked at? If it was, why didn't we choose it? If we didn't look at it, why didn't we look at it?

Mr Stump: Definitely, a smart card was looked at. The ministry undertook a pilot in Fort Frances on smart card technology about three or four years ago. I guess as a result of that we learned several things. One is that the technology isn't generally available now in the provider community to use it. The technology is really not mature, either, in terms of reliability, standards and compatible devices out there. A lot of training has to go into both the provider community and the population.

I guess two other things are cost, the cost right now is still enormous, and, the final, that the information you're going to collect on your smart card has to be kept backed up as well, so that if you lose your wallet or you lose your card, you have to have a capacity to re-create that information in order for it to be useful. The information has to have integrity, and when a provider looks at it they have to be able to trust that it is complete, because an incomplete record is probably worse than none.

You need a central capacity in order to re-create that card at any point. If you have the central capacity and you have a network in order to maintain that central capacity and to re-create the card when necessary, then the utility of the smart card becomes somewhat a little less attractive. It becomes more of just an additional security device, because you definitely can make encryption algorithms and PINs and all of that sort of thing. But in terms of health care benefits, you're not gaining a heck of a lot, at least in this planning horizon.

With the introduction of the renewal cycle, then we felt that we can look at it again in two years, three years, five years as the technology develops and other people start infiltrating the marketplace with smart card reader devices and writer devices.

In terms of fingerprint, I think that is a viable option, as well as hand geometry and a number of other things. But once again, our providers are not trained fingerprint interpreters to make sure the swirls match. You'd be talking about high technology to do the matching. Most people can look at a photograph and be reasonably assured. It's a question of technology and practicality right now.

Mr Callahan: When we had these hearings, I had suggested that a transitional process, as opposed to the one that you're suggesting here, would be something just as simple as this: I go to Canada Trust. I've got a savings deposit book. My name is signed on the strip. You can't see it unless you hold it under something as simple as an ultraviolet light, which costs peanuts. It would allow as a transitional purpose to have someone sign their name and the person, the provider, would put this under an ultraviolet light and if it matched as best he or she thought it did the signature that had been affixed, they'd be paid.

It seems to me that if you've only got -- and I'm trying to be helpful, not critical -- 10 of these slash machines in the hospitals right now and you expect 50 next year and 50 the year after, we're still going to be a lot of hospitals short. Was any consideration given to something as simple as that? It doesn't seem to me that it's going to be any less effective than what you're proposing here, which we're going to spend an awful lot of money on just as a transitional type of thing, to then go to the photo card. Was any consideration given to that?

Mr Stump: Any system has got problems. We have an issue with the signatures with young children and injured people. We're back again into somebody making an interpretation on signature. On the security of the ultraviolet light, I think many of the bars have ultraviolet lights and I guess restaurants even make the tablecloths look whiter than white, so the security is limited.

Mr Callahan: Yes, but you're not getting medical services inside of a bar. What I was suggesting was that this was going to save a doctor having to spend money on maybe a slash machine now and find out in about two years' time, when you've got the permanent process in place, that there's something more advanced than the slash technology.

I'm sorry; it's a commendable effort to try and stop the fraud, but I'm concerned that the process we're using as the transitional process is something where we're just feeding money into the great black hole. We should have something simpler to go into the permanent process. The permanent process is the answer, obviously, and it's either the picture or it's a fingerprint, but I just find -- it's my own belief, so you don't have to respond to it, because obviously they didn't consider it, I guess.

Mrs Mottershead: Mr Callahan, I think I'd like to respond to that by saying that a lot of providers, whether in hospitals or physicians in their offices, as regular individuals themselves are becoming a lot more comfortable with the swipe technology. I mean, you use it all the time in terms of credit cards, all kinds of things, and the physician population has indicated that's certainly something they feel comfortable with and there seems to be a preference for that, because it's proven. That's where we are.

Mr Callahan: So they all have them? They're expensive, I gather.

Mrs Mottershead: They're not that expensive. I don't have the actual per-unit cost.

Mr Callahan: I'm limited in time, so maybe you could just check that. I gather there will be a cost. First of all, how often will you renew the permanent card?

Mr Stump: Every five years.

Mr Callahan: Will there be a cost involved in renewing for the individual consumer?

Mr Stump: There are no plans to charge for replacement cards or the renewal cycle at this time.

Mr Callahan: So it will be free. I see. Okay.

Finally, because I think my time is running out, I know when the committee looked at this, we all considered why we were reinventing the wheel, as it were. Visa, MasterCard, American Express, all these cards have been around for a long time and have managed to put in place backup and protection to ensure that the use of them improperly, as opposed to non-payment, was not that great. Were there any discussions with these companies to use their technology, to piggyback on them, rather than set up our own whole system?

Mr Stump: There were a lot of discussions, I believe, with the banking community over the last year in terms of not only how they do things but what their experiences are with fraud. A number that pops to mind is that 53% of the fraud in the credit card business is as a result of lost or stolen cards. We were speaking to them. I think the minister, and the deputy has confirmed this morning -- how big a problem are Ontarians willing to live with? 10% may be perfectly acceptable in the credit card business, or 5%, or some number that's manageable and you can deal with in terms of interest rates. I don't think the government is willing to live with 10% of a $17-billion business, or 5%, or 1%.

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The Acting Chair (Mr Tim Murphy): This is your last question, Mr Callahan.

Mr Callahan: But if you factor in the cost, the annual cost, you're talking about a three-year cost which is fairly significant and then you're talking about a $19-million cost thereafter. I think if we're honest with one another we'll realize that if it's $19 million now, it's probably going to be twice that or three times that. You're projecting in today's dollars for the future. Was that factored in there to determine that maybe going with a piggyback or some system that's already in place, that if you factored in the money that it's going to cost the taxpayers of this province in the future for the renewals and all the rest of it, you might be prepared to accept that slight bit of leakage.

Mr Stump: One per cent of the health care budget is enormous, just absolutely enormous, and towards the cost of the card. I'm not aware of any discussions to try to have a health card-MasterCard combination.

Mrs Mottershead: I believe that not a lot of serious consideration was given to that, given that we have a card that gives you access to health services. We wanted to make sure that it is a distinct card and that people understand the value of having the card and the privilege that goes with the ownership of that card. It isn't just a banking transaction and it isn't one that you can use to get your groceries at the same time. We're dealing with the health care system here and there was an effort to concentrate it that way rather than open that up.

Again, I just want to stress and emphasize that the whole plan here, in terms of the renewal cycle, the five-year, doesn't preclude other partnerships happening or maybe a card that has many more functions other than just health. There have been discussions in terms of one access card for government services. We're not there yet simply because the card itself is not the answer. It's all of the technology and all of the systems integration and all of those other things that go behind the card that have to be available and ready to make that kind of a possibility a reality. That's where we are today.

The Acting Chair: It's the Conservatives' turn. Who's going to lead the inquisition? Mr Tilson? Twenty minutes.

Mrs Marland: I was going to go first.

Mr Tilson: Oh, I'm told that Mrs Marland's going first.

The Acting Chair: Madam Marland.

Mrs Marland: We take turns.

The Acting Chair: We all bow before your authority.

Mrs Marland: It's very democratic.

After we get over the three years of the introduction of the new card at $30 million a year, you said it's going to cost $19 million a year annually from then on. Correct?

Mrs Mottershead: Yes.

Mrs Marland: We only have 11 million people. Are we saying that one card costs $500,000? How does it cost $19 million a year to issue cards to 11 million people?

Mrs Mottershead: You're breaking up the population, don't forget, according to the algorithm. What we have right now is a cost of approximately $6 and change per card production. That's basically the cost of the card and you've got to take that into account. You have the related service function that goes with it, and that is the mailing --

Mr Perruzza: I get $8.60 a card.

The Acting Chair: Mr Perruzza, order please.

Mrs Mottershead: I've just added the fact that we have, together with the card, a cost related to the mailing, the invitation, the customer service aspect of people behind counters actually serving people, the systems upgrade and continuing to serve that whole thing. It's an integrated process. You can't just separate that this is the cost of the card when you're delivering a full spectrum of service in order to get the card.

Mrs Marland: You said this morning when I was asking you about the swipe card, the swipe readers in the hospital -- I notice in the minister's press release of May 3, of which I have a copy here, that she says, "Doctors' offices and hospitals will check the validity of cards with swipe readers and touch-tone keypads similar to those stores use to check credit cards." This morning you told us that you actually have $1 million for health card verification measures for this year and you said that there is money, you understand, on hold in the treasury, but as of today there is no money that's actually been budgeted and allocated into your ministry for the hospitals and the doctors' offices.

What I'd like to know is, if we spend $30 million a year, which we will starting next spring, on these new cards and you have a large number of hospitals which, from your own confirmation this morning, won't have the swipe readers, are you going to ask the hospitals to buy their own swipe readers and are you going to ask the doctors to buy their own, or else who's going to provide them?

Mrs Mottershead: What we have been doing over the last several months is have the discussions with the physician groups and with the hospitals. For your information, a card reader only costs $150, so I can hardly imagine a hospital that has a budget of X hundreds of millions of dollars -- in some cases it's only $40 million or $50 million; in other cases it's lower than that -- that would want the government or the taxpayers to add that kind of minimal cost to their budget for that service. I don't think we're going to get a lot of hospitals being bankrupted as a result of having to purchase. What the government is doing --

Mrs Marland: You didn't say that this morning. That's the point I'm making. I mean, a hospital obviously is going to need a number of them. If the hospitals are going to pay for them, and that's simply what I'm saying, is it your expectation that they will pay for them?

Mrs Mottershead: There are a number of elements to the whole swipe technology and I want to be clear about who is doing what in that field. The Ministry of Health is actually responsible and is going to be paying for -- and part of the cost that we have in our budget now and that we want treasury to release from holdback is the cost of wiring our system from Kingston to all of those places across the province. There's a real cost there and we don't feel that it's appropriate to ask providers or the hospitals to participate in doing the information-paving to their doorstep.

Mrs Marland: What is the cost to provide the installation?

Mrs Mottershead: I really don't have that information. I don't know if Donna does in terms of --

Mrs Marland: So you've no idea what it's going to cost.

Mrs Mottershead: I don't have the information here right now, but we do know what it is going to cost.

Mrs Marland: Is the $30 million a year the cost for the in-the-ground cable system hookup to the central information?

Mrs Mottershead: The $30 million a year is not related to the card validation project, which is what we refer to in terms of the card swipe technology or the interactive voice response.

Mrs Marland: So the $30 million a year is only for the --

Mrs Mottershead: It's related to the production.

Mrs Marland: The production of the card itself?

Mrs Mottershead: Of the card and the delivery of the card.

Mrs Marland: So how much on top of the cost of the delivery of the card is the cost of the delivery of the system, the actual hardware and whether it's telephone lines or fibre optic systems? Surely you must know what the cost is going to be to have the system work once you have the cards. What is the price of the system installation in Ontario?

Mr Perruzza: How can they know that?

The Acting Chair: Please, Mrs Marland has the floor.

Mrs Mottershead: I just want to re-emphasize that the cost of the card production and registration is as has been announced. We have the other elements of the system that we've been talking about this morning, which includes the validation project with the kind of rollout, the 50 in 1994, another 50 in 1995 and, with the physician offices coming on stream, the 11,000 I mentioned, which are going to cost in addition to the amount of money that has been announced by the ministry.

Mrs Marland: I understand that, but how much?

Mrs Mottershead: That would be a few million dollars. I mean, it all depends on how quickly the rollout happens. It will be in the neighbourhood of perhaps around $5 million.

Mrs Marland: For all of the installations from wherever you establish the information base to all the hospitals?

Mrs Mottershead: The installations that we mentioned this morning. I'm saying a ballpark of $5 million. It could be $5 million to $7 million, depending on how many we do and the time frame and the rollout and how quickly we get it there. If you could do it all in two years, it might cost you $10 million. If you wanted to do it over a longer period of time, obviously on an annual basis it would be a lot less. But that's the ballpark we're working with.

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Mrs Marland: In the same press release that I just read from, the minister announces that the amount in fraud is the figure that you just referred to, $65 million annually. What I would like to know is, how many new investigators has Mr Sudds -- I don't know whether it's directly under him or it's under your authorization, Ms Mottershead. How many new investigators have been hired to deal with the subject of fraud and abuse?

Mrs Mottershead: There are currently two investigators on staff, and I mentioned this morning that we had undertaken a public recruitment process. We've received 700 applications. We're in the process of short-listing those and going through the qualifications, and I mentioned this morning that we will have hired by September or October nine investigators. That's seven in addition to the two that we have.

Mrs Marland: Okay, so that's the eight that the minister announced in May. So we're going to get them about five months or six months later. Is that right?

Mrs Mottershead: The reality of what I've just said and the recruitment process and so on has brought us to this point.

Mrs Marland: I'd like to ask you about the situation involving the Akwesasne reserve. I have a memo in front of me that's dated February 15 of this year. It actually was sent to Donna Segal and it describes the potential for fraud at the Akwesasne reserve as "cryptic."

The memo states that 52 individuals are registered for benefits under three health plans: Ontario, Quebec and New York; 123 individuals are registered under Ontario and Quebec health plans; and 588 individuals are registered under Ontario and New York health plans. This memo is six months old and I'd like to ask you what the status is of this investigation. Was there fraud involved and, if so, how much, and were the police called to investigate this matter?

Mrs Mottershead: I know that Ms Segal has been the person who has been looking after this particular issue. She's had discussions with the investigative team and probably can give you a better sense because I've delegated that to her, and the investigation.

The Acting Chair: Ms Segal, please come forward.

Ms Segal: In the numbers that you just gave out, the 52 individuals who are registered and the 123 individuals who are registered are actual names, so we know the identity of those individuals.

Mrs Marland: Sorry?

Ms Segal: We know the actual names of those individuals. The 588 figure that you referred to is a statistical average. It's an assessment of how many of a larger sample might be teased out, identifying with those particular characteristics. So in fact I only have within my possession, or the possession of the branch, 52 names and 123 names relating to individuals who have multiple cards.

We've chosen to treat the analysis of this as constituents of a broader population, and we've done random samples of the various groups in order to address the issue of duplicate cards and appropriate eligibility for those individuals. In other words, of that group, we've asked individuals to please confirm their residency status, and those are under investigation right now.

Mrs Marland: Now this memo is six months old, so when you say they're under investigation now, was there fraud involved?

Ms Segal: The issue came forward to our attention as a result of one individual or a number of individuals having double cards, having two cards. The question you're asking is whether the individuals had a right in fact to avail themselves of OHIP benefits. The question from our perspective is, first, are they in fact eligible, before I determine whether or not there's fraud involved.

Now, in the case where I determine that any --

Interjections.

Mrs Marland: Tony, excuse me; I can't hear.

Mr Perruzza: I can.

Mrs Marland: Sorry, Donna.

Ms Segal: That's all right. Consequently, I'm not in a position to say whether there was fraud. I am in a position to say that is a regular course of our investigations. If we determine an individual is ineligible, we make reference of those cases to Mr Sudds's investigative team.

Mrs Marland: Are the police involved at this time?

Ms Segal: I have not brought the police into this. They normally would not be brought into this kind of analysis. Our investigative officers within the branch are quite adept at providing the preliminary analysis. The next normal course of action is to refer them to Mr Sudds, who does work with the legal authorities.

The Acting Chair: You have about seven minutes left for your caucus, Mrs Marland.

Mr Tilson: There have been statistics obtained by the ministry indicating the number of doctors who have received overpayments going back a number of years. Most of those doctors you have investigated have paid those moneys back, for whatever reason. Do you have any specific information on that?

Ms Segal: I do not.

Mr Tilson: Not you, but does your ministry?

Mrs Mottershead: Yes, we do have information on the number of cases before the MRC. Is that what you're referring to?

Mr Tilson: I guess the concern is that the allegations that have been made that substantial amounts of moneys -- and I understand in one specific case there was one doctor where an overpayment was made for $462,543. That amount of money was paid back. No interest was charged. No investigation was made. No charges have ever been laid against any doctors. I don't know whether those are legitimate allegations or not, but perhaps that should be clarified for the committee.

Mrs Mottershead: In 1993-94, there were 27 physicians who were investigated. There were 21, as a result of that investigation, who were requested to repay a total of $1.4 million. Those are the latest figures that we have.

What we have done in terms of the MRC is that in terms of prior processing, the ministry would wait for the results of the MRC and then deal with the issue of recovery of that money.

Mrs Marland: What's the MRC?

Mrs Mottershead: The medical review committee, which is a committee under the auspices of the College of Physicians and Surgeons, which actually does the investigation and the hearing once we've made a determination of some irregularities in the billings. So the Medical Review Committee in the past has had its finding, turns the information over to the general manager of health insurance and a process is started for collection.

Quite often that process has taken anywhere from six months to two years, plus. What we have instituted now is, the general manager will in fact start reduction of claims made by the physicians to the amount that is under question, so it's expediting the process. Rather than waiting for two years until that decision is made and then doing the recovery, we're saying we have sufficient --

Mr Tilson: If I could stop you, I understand all that. I do have the figures of 1993-94, $1.4 million; 1992-93, $2.2 million; 1991-92, $2.1 million; 1990-91, $3 million. So I'm aware of that. I'm aware of those repayment processes. I'm aware of the fact that there was a doctor who had to repay -- I don't know whether he's repaid it or whether he's in the process of repaying it -- $462,000-plus. It is this that I'm looking for a specific answer to: It is my understanding that those doctors did not have to pay interest on those moneys.

Mrs Mottershead: That's right.

Mr Tilson: You're indicating the answer to that is yes. I also understand that no investigations or, indeed, charges were ever laid against those doctors.

Mrs Mottershead: I know that there were a couple of cases that had been referred to the OPP and that is the one that you may be referring to.

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Mr Tilson: Well, I'm even going back to 1990, which was the commencement of this government. There have been no investigations and no charges since that time.

Mrs Mottershead: With all due respect, Mr Tilson, I did mention this morning that we are looking at a number of other options that we want to present to government. One deals with the legislative authority. Right now, under the Health Insurance Act, we have no authority to actually issue fines, penalties or charge interest on accounts that are repayable. We are definitely looking at that to give the general manager that kind of power.

I believe I also mentioned this morning that the courts have in fact looked at the issue of restitution as part of that whole process of sentencing, and that --

Mr Tilson: I'm aware of the issue of restitution; however, you've answered the question and it doesn't appear that -- I would hope in the future, and even in the past -- there's nothing wrong with your investigating going back into the past -- you would consider that. If it was done through inadvertence, that's fine, although hopefully interest would be paid. It's a lot for the doctors to get interest-free loans for that amount of money. But if there has been some impropriety, there's nothing wrong -- and you do have the authority -- in going to the police.

Mrs Mottershead: I absolutely agree with you, and one of the things that our investigative unit is doing, working with the ministry people in claims payment operations, as well as the MRC outcome, is looking at the repeaters. And if we in fact have the two or three, then it can no longer be a coincidence or an accident and we are going to be turning that material over to our investigative unit to follow up on. That's a decision that has been made.

Mr Tilson: How much time do I have? One minute. I hope you'll go further than that.

The final question I have -- I have one minute left -- is that if I lose a driver's licence, if I lose a credit card, if I lose any other form of licence, I'm in big trouble. Number one, I can't drive a car. Number two, if I lose my credit card and I don't report it, I'm in big trouble. Is there anything in your plans for this new system that will encourage members of the public to attach value and worth to the cards in the same fashion that they would to a credit card?

Mrs Mottershead: There will be a statement on the back of the card, and as part of affixing a signature, when you go and get your new card or your replacement card, that actually says that this is the property of the province of Ontario or the government of Ontario, and that this card is your key to the health care system. You should be proud of it, you should protect it, and you have an obligation to report on incidents of loss or stolen -- it's that kind of statement that we're developing. I can't give you the language right now, but that will definitely appear. A statement of that sort will appear on the back.

Mr Tilson: Unfortunately, we're not all girl guides or boy scouts. If you do not take some action with respect to a lost credit card or take some action with respect to a lost driver's licence, you're in deep trouble. No one in your system has that obligation to do that, and Dr Frankford this morning -- I'll tell you who's going to get burnt: It's going to be the doctor.

The Acting Chair: Mr Tilson, I'll have to cut you off. I'll let you respond.

Mrs Mottershead: There is an obligation to report. I might just add that there is an obligation to report, and in reporting, I must reinforce the fact that it invalidates that particular card, so that it can't be used if it falls in other people's hands.

The Acting Chair: I have four members of the government caucus on the list. Am I to assume you're each to get five minutes?

Mr Marchese: It would be fair.

The Acting Chair: Okay, I have Dr. Frankford first on the list.

Mr Frankford: I don't think we should be getting into discussions of alternatives like smart cards, but I would at least like to remind the committee that we did look at other alternatives in the past such as a card-free system using universal primary care registration, but that's not what I would like to discuss at this time, because I don't think that's what we came here for. But I would like to ask some questions in relation to the mechanics of implementation and how it's going to affect my constituents, perhaps in relation to drivers' licence offices.

I have one in my riding that I know of. There is another one that I have mostly used over the years in a different riding, and I hear from Mr Owens that he has one in his riding. Now, these are serving, I would say, quite a substantial population. Particularly in relation to one, I just wonder about the sheer capacity of that office in terms of the space to add a substantial number of people coming in.

In addition, perhaps you could enlighten me about the arrangements of licence offices now. I think the ones I'm talking about are sort of private concessions, and perhaps you could tell us how you're proposing to pay. Is the payment on a per case basis, or is there a retainer? I'd be interested in knowing how that works and what the incentive is for the concessionaires to provide an efficient and effective service.

Mr Stump: The issuers are actually paid on a per transaction basis. If they're not a government employee, they're paid per unit of work, if you will, whether it's a driver's licence renewal or a vehicle renewal licence, or in the case of a health card, we'll have negotiated in advance of that a fee that's payable for reregistration activity.

Mr Frankford: Can you or will you set criteria about the space available? One fears, you know, that there isn't room and people will be lining up in the middle of winter.

Mr Stump: For the last, I guess, almost two months now, we've been analysing the population of Ontario, the distribution, the demographics in each office's domain. We're trying to match with the driver's licence and where you got your driver's licence. We know the algorithms so we know when we're going to invite you in. We're being very careful to anticipate what the increased workload will be in the office.

At the same time, the Ministry of Transportation is moving from a three-year renewal cycle on their driver's licence to a five-year renewal, so they're seeing a bit of a drop in demand on the issuers. We're going to great lengths to predict what the demand is going to be and then we're going to map it back to the physical sites and tell people how many people to expect on any given day. So we're going to do a lot of work on that.

Mr Frankford: I'm just a bit concerned that it sounds unpredictable. On the one hand, this could be a nightmare for those operators who don't have the capacity and suddenly they're asked to provide more space and staff, whatever. On the other hand, for all we know this is an enormous windfall for people who happen to have got into that line of work.

Mr Stump: It won't be a surprise. Before people are rolled out, we'll have considered the accommodations, we'll have looked at the current customer service level, the transaction volumes and we'll predict how many people are going to show up.

At the same time -- we've talked earlier about the quality process and customer service -- we're not looking at, on day one of the invitation cycle, renewing everybody who's eligible. What we want to do is, we'll take it slow. We'll invite a percentage of the population and we'll alter our rollout schedule and we'll actually see what's happening. We're going to take our time to do it. If there are customer service problems, if there are waiting room problems, then we'll have time to deal with them in a real world.

The Acting Chair: You have about 30 seconds.

Mr Frankford: Okay. I'd like to ask another question, completely different, but on the question of Akwesasne and the native reserves. I understood -- and I've raised this in the previous sessions with the previous deputy -- that in fact the obligation to pay for them is a federal one. Even if we are issuing an Ontario health card for ease of access, should we not have some sort of code number which would enable us to identify them, so that we could bill the appropriate level of government, which I believe is not us?

Mrs Mottershead: The Canada Health Act is very explicit that the provision of health care services is the responsibility of the provinces within the framework of the Canada Health Act and therefore we're obliged to provide health services. There are some services that the federal government provides to on-reserve native Indians, and what we have been doing over the last little while as part of our aboriginal health strategy is to determine that that separation, in terms of some real infrastructure contributions that the federal government makes versus the ongoing health service provision, is a responsibility of the provinces.

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The Acting Chair: Mr Perruzza, five minutes.

Mr Perruzza: I just wanted to go back to the whole issue and really pick up on something that Mrs Marland was talking about, and sort of the costs. When we look at this stuff we say, "Well, $30 million a year," so it's $30 million a year, and when I divide that into the population I get $8.57 per card; you said it was $6 and change. I guess my first question is, what does the $30 million per year pay for and how does that get broken down? How much is the card and what do you attribute the other costs to?

Mrs Mottershead: The current estimate on the card is $6.17.

Mr Perruzza: How come I get $8.57 in $30 million?

Mrs Mottershead: Because what you're looking at is the production. To produce the card, a plastic card with all of the features --

Mr Perruzza: What does the $30 million include?

Mrs Mottershead: The $30 million includes the fact that somebody has got to process your documents, has got to input your documents. You've got staff who are providing that service, you've got overhead, you've got mailing costs in terms of giving you that invitation, there is postage that's involved here and there's printing. There's the support network that actually produces that piece of plastic that you're going to walk away with. It isn't just the card production.

Mr Perruzza: Which gets to my next question, precisely. There's all this work, so how do you break it down? How do you develop this guesstimate that it's $30 million? How much, for example, is the Ministry of Transportation paying? How much is it costing the Ministry of Transportation to renew a driver's licence per unit? I believe it happens every five years.

Mrs Marland: You should ask Mr Pouliot, not Mrs Mottershead.

Mr Perruzza: I presume that would be something that would be looked at by you in terms of developing your own guesstimates around this, because I don't see how you can say, "Well, it's $30 million"; you know, in Italian we say, "Punto e virgola," and that's it and we're going to walk away. If you give us that, we aren't going to come back for more or we're not going to give you a refund, because there won't be any money left over.

Mrs Mottershead: Let me just be very clear. The reason why we went into a partnership with the Ministry of Transportation, in addition to the issue of access and customer service, convenience and all that, is because it does have some experience in dealing with production and also in dealing with a large volume of registrations. The estimate on the $30 million includes all of the other factors around the card. Whether the people are in Ministry of Health offices or in an expansion of a driver-issuing office is really immaterial because that's part of the infrastructure to support that.

Mr Perruzza: Let me tackle this from another perspective, okay? If you were to say to me, "Anthony, go away and figure out how much this is going to cost per card," I would say to you in very simple language, "What are the things that I need to factor in?" So, could you give me a list of the things that you're factoring into what this card would cost?

Mr Stump: May I? We start with the computers in the offices. We have to figure out how many there are out there for drivers' licences, for example. We know how many we have to add in the Ministry of Health offices; the number of cameras on the sites.

We have to buy the signature equipment. We have to perhaps make accommodations changes, changes to the counter to put the equipment in. We might have to do other modifications for electricity. We have to put telecommunications facilities in to handle it. We have to set up a call centre for people to phone in. We have to be able to move those calls around among the various offices so that people can handle the peak loads, so we can move a call from Sudbury to Kingston, for example, if there are available operators.

We have to provide technical help to the MTO agents if there's a problem with their computer or there's a question of policy interpretation until people are put in place: Is a photocopy of a passport legitimate? There are the training costs. There are the accommodations for the card production equipment, a big fixed cost shared --

Interjection.

The Acting Chair: Mr Perruzza, you've used up your time. If Mr Marchese is prepared to let you have some --

Mr Marchese: One minute of my time.

The Acting Chair: Please go ahead, Mr Perruzza.

Mr Perruzza: How do you sit down and say moving a phone around is worth X number of dollars and that's the cost we attach to that? I guess in my history, when you cost out things you say, "Well Jeez, you know, in some things there's 10% waste and in some things there's 20% waste and in some things there's 50% waste," so you factor that into the price. What's your factor in all of this, and couldn't you be off 50%, 60%, 70% either way, come in way under or way over what you're suggesting we should take away as Holy Grail in terms of what the costs of this new system will be?

Mr Stump: I would love to come back here in a year and say we were 60% under budget. Normally --

Interjections.

The Acting Chair: Order, please.

Mr Stump: Normally, rarely do you underestimate the size of something. I guess my most recent example is on the health network project. We came forward once and we asked for this much money over four years, this much over five, and so far we're within budget. We're getting better at estimating these things, but sometimes we will make mistakes.

Mr Perruzza: Ontarians are looking to you for some breaks.

The Acting Chair: Mr Marchese, you have four minutes.

Mr Marchese: Thank you, Mr Chair. I have about three or four questions. What I'd like to do is to pose them, and if there's time remaining, for you to answer some of them.

One of the questions Mr Callahan raised is of interest to me as well, and that is how you are dealing with the different linguistic groups in Ontario. Clearly, you're going to have more problems with some communities than others in terms of how communication is received by them, if at all, including the literacy problem that's connected to the linguistic problem in some parts of the community. So, I'd like to know how you're dealing with that particular issue.

The second one connects to the same issue. If someone leaves the country for six months or beyond and doesn't tell you, there's a penalty for that individual. How do you deal with the fact that some of those people obviously won't know that this an issue, won't know that this is a problem? Yes, the campaign's been on; they should know and all that but they don't. How do you reach a lot of the people who, for one reason or another, will have a problem, either a linguistic or a literacy problem? How are you dealing with that?

The third question has to do with the issues of the photo on the card. I think you identified some of the people you need to work with in terms of where you may have difficulties putting the photo on the card. I'd be interested to know, are you developing a plan around how that's going to work with the different specific groups around which it's going to be a problem, seniors or children, people with disabilities? What is the plan? I'm not sure what they've done in other provinces, but I think Eric was saying 15% of the people could not be photographed in Quebec. That is a figure that I heard. That may or may not be correct. That could be transposed into our own communities. That's a large figure. What is the plan for that?

The fourth question has to do with the fact that you're obviously dealing with, through this health card, ensuring that health services are provided only to eligible people, and there's a whole system you're putting into place to deal with that. Part of the question that I think the auditor raised as well is, how are you dealing with the fact that this Ontario health card could provide an information base to support the formulation of health policies for ensuring that the appropriate level of health service is provided to eligible people?

That's a good point that is raised. This card can be used as an information base for a whole list of things that could provide an interesting knowledge base for us in terms of what kind of health should be provided. I'm interested in that. Are you looking at that? Have you thought about it? What is the plan?

And the fifth question, if there are a few seconds, is --

The Acting Chair: You have a minute to pose your last question and get all your responses.

Mr Marchese: -- on restitution. You were dealing with the issue of restitution, you said, and you're looking at what the legislative framework is as to why you can or cannot do that. Does that require a legal change, either provincial or federal, or do you have, within the regulations, power to do so? Obviously, there's a quick answer to that.

The Acting Chair: You have a minute. Go.

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Mr Stump: Yes, yes, yes, yes, and I'll have to turn the fifth one over.

Languages: Clearly, our information line currently handles 10 languages. Our media plan does involve other than English- and French-language communications. We are working with Welcome House and a bunch of other groups in terms of dealing with ethnic populations.

If people going out of the country and notify us, then certainly we're not going to issue the invitation to renew until they've come back. People who fail to notify us who are out for more than six or seven months are going to walk back into the whole eligibility question of being out of the country for a protracted period of time. So they're going to have to come in and talk to us in any case.

Photo exemptions: We've been talking around religion, age, medical impairment. We're aware of it. We are working on plans. Do we have them all in place today? No, but we've got them down on the project plan to deal with.

Health policy of the database: Clearly, right from the original ministry information technology strategic plan the health number is one of the underpinnings. Right now all of our information, as Donna explained earlier this morning, is key to it. We have a lot of restrictions in accessing information, bringing it together because of technological reasons, but all of the ministry's systems are geared towards being able to collate your information and in the future do a lot better job in terms of health policy planning.

Restitution, I'm going to have to turn --

Mrs Mottershead: If we had the powers of regulation, I can assure members that it would have already been done. We've had legal opinion on it that we do need legislative authority for the general manager to impose penalties and interest and other measures.

The Acting Chair: Mr Owens, you have two minutes.

Mr Owens: Just in terms of the tracking that you mentioned, I would like you to clarify this for me. It's my understanding that billing practices are determined by practice models and that when a physician falls outside of that model, that's when his or her card is spat out of the computer. Can you tell me what your plans are to change those models, if any, the kind of cooperation that you're receiving from the physicians themselves on this process?

Mrs Mottershead: We've actually engaged the services of a couple of people from Queen's University to have a look at our current physician monitoring system, to have a look at the algorithms that have developed so far to tease out the irregularities. Those irregularities vary from a physician seeing just too many patients in one day, in terms of numbers of visits and interfaces with a particular population, to too many procedures of the same sort done at a time when it's almost impossible, in terms of population profile, to do that many procedures on the population that lives there. There are other models that actually tease out those irregularities. The people who have been working with us from Queen's have looked at the possibility of refining some of the models to get to an even more finite slice of the data that will give us some variable statistics and information on the physicians. To my knowledge, I have not been aware of any physicians complaining about the fact that we are working on this. I think, by and large, the physician population really has very little stomach or tolerance for those very, very few individuals who have some different or aberrant practice pattern deviations.

I haven't heard of anything and we know that the Ontario Medical Association knows we are looking at that project. We gave it visibility when we tendered it, for example, that we're doing it, and certainly our own ministry staff who are physicians are actually working on the project.

The Acting Chair: Sorry, that's all the time we have. I understand there is an additional presentation. Do you know how long whatever you have left is going to take?

Mrs Mottershead: We can complete in about five minutes. We can do this quickly on the validation, because there have been a lot of questions, particularly from Mrs Marland, around card swipes.

The Acting Chair: Perhaps what I could propose, subject to what the committee thinks, is that we have until 5 for you. We could basically let you complete what you have and then divide up the rest of the time into 20 minutes each and that should get us to 5 o'clock.

Mr Tilson: Mr Chairman, point of order.

The Acting Chair: Mr Tilson.

Mr Tilson: I am quite agreeable to sit until 5. I'm concerned with the conditions in this room. I seem to recall we sat over in one of the buildings for I don't know how many weeks in the past while this area was being refurbished for air-conditioning and other such things and I don't think there's too much air-conditioning going on in this room. In fact, quite frankly, I'm dying.

Mr Marchese: We're worse.

Mr Tilson: I say that for future meetings, Mr Chairman, if this is the most comfortable they can make us, I would hope they would find us another room.

The Acting Chair: Let me say if this is air-conditioning I'd hate to see it when it's warm. I think the concern is noted. The clerk has noted it and will pass it on to whatever powers that be.

Mr Tilson: Thank you, Mr Chairman.

The Acting Chair: If that's all right, if the ministry can complete its presentation by 4, then we can divide up the balance of the time.

Mrs Mottershead: Mr Chair, may I just let the members know that we also had another presentation on the Ontario drug benefit program, the network, how it's working and where we are with picking up all the pharmacies and why that's an important piece of experience related to what we're doing with the health card. If you would like, I'm in your hands in terms of hearing that piece of --

The Acting Chair: Would the committee be interested in that presentation?

Interjections.

The Acting Chair: Is that a yes?

Mr Marchese: Yes, it would be useful to have it.

Mr O'Connor: Margaret would be interested in the network.

The Acting Chair: Can I get a sense from the deputy: Every presentation you have, how much time will that take, including the ODB and the validation?

Mrs Mottershead: We can shorten the presentations to have both of them done in 15 minutes, five and 10.

The Acting Chair: Fine, why don't we have both and then we'll have questions afterwards.

Mrs Marland: Could I ask that we have copies of the overheads that you used earlier today?

Mrs Mottershead: We'll get the clerk to make the copies tomorrow.

Mrs Marland: Or some time this afternoon. Yes, that's great.

The Acting Chair (Mr Rosario Marchese): Whenever you're ready, please go ahead.

Ms Segal: I'll make this very quick, because in fact I've answered many of your questions and have spoken to the information on some of these sheets already.

Essentially, under health card validation the important thing to convey to you is that we initiated the pilot projects relating to both interactive voice response, which is IVR, and also the swipe card technology health card reader, HCR. We initiated the pilots in the spring, in the June time frame of last year, 1993, and had evaluations on those pilots in the early part of 1994, as late as March.

I believe that you had a presentation last year on what constitutes IVR and on the swipe card reader, so I won't go into a lot of technicalities associated with the technology except to say that both provide real-time access to RPDB -- the typo, note it again -- and therefore immediate accurate information.

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The IVR uses existing touch-tone phone technology, so essentially a physician in his or her office would use his or her touch-tone phone to call either a local Toronto number or a 1-800 number, register a registration number and a PIN number and then key in the health number and associated version code to determine whether or not that card is eligible.

On the HCR, which is the health card reader, it involves a simple magnetic swipe technology used to validate your credit cards, the same technology.

The essential benefits that I wanted to point out to you are clearly that it will enable us to identify lost or stolen cards; that it will enable us, in IVR, to eliminate billing rejects which are due to the version code.

In the agreement with the physicians in August 1993, a major point of contention was the disruption involved with physicians as they bill and their bills are rejected as a result of version code error. This validation technology will enable them, at point of service, before in fact the service is provided, to validate that the version code on the card is accurate.

Importantly from our perspective, both IVR and HCR technology will prompt the physician and/or the provider who is in-taking the information, to request address changes when a return mail indicator is identified on the message that's provided back through the IVR and, in particular, through the HCR technology.

As I indicated this morning, we do have four sites that are current hospital pilots; just to review: Chedoke-McMaster, Toronto General, the Hotel Dieu and the Kingston General Hospital, both in Kingston. We have additional hospitals which are currently being hooked up as we speak: Mount Sinai in Toronto, St Michael's in Toronto, the Royal Victoria in Barrie, the Sunnybrook hospital in Toronto and St Thomas-Elgin in St Thomas.

Further to that, we have 10 hospitals -- I mentioned eight earlier, but it's 10 hospitals -- using the IVR technology. Those are the Hotel Dieu in Windsor; now St Mike's in Toronto -- obviously they'll convert over to the HCR as soon as possible; Riverside Hospital in Ottawa -- some of you may have seen the media piece a week or two ago regarding their use of the IVR technology; Collingwood General in Collingwood; Hotel Dieu Hospital in Cornwall; Lake of the Woods hospital in Kenora; Laurentian Hospital in Sudbury; St Joe's in Thunder Bay; and North York General in Willowdale.

We are hoping to roll out our strategy. In fact, the deputy mentioned over 11,000 -- the most recent count, as of yesterday, was over 12,500 -- indications of interest from physicians and other practitioners that they wish to avail themselves of IVR technology. So we are poised to go province-wide when we appreciate that we have the confirmation from government as to the expenditure of those funds.

Around the HCR technology, we have always indicated, per our agreement with the OMA, our indication to make HCR technology accessible to 50 hospitals in 1994.

We would like to be more ambitious and we certainly wish to move as quickly as possible over the remaining hospitals, but obviously that will have to be tempered with available funds.

The Chair: Questions.

Mr O'Connor: We're going to hold our questions until after the next presenter.

The Chair: Oh, there is still a further presentation.

Mrs Mottershead: Mary Catherine Lindberg is going to be doing the presentation on the drug network.

Ms Mary Catherine Lindberg: Thank you. I have with me David O'Toole, who is the project manager also of the Ontario drug programs project. This is called the health network. So that you all remember what Ontario drug benefit is, it is the drug program that provides people over 65 their drugs, and those on social assistance, people who receive home care, residents in long-term care facilities and homes for special care.

The reason this project became important for us is that we currently are spending $1.2 billion on 20% of the population. We pay 42 million claims. We have 2,300 drugs covered. We have 2.2 million recipients. The average claim per person is 27. That means 27 prescriptions, not different drugs but prescriptions, per year. The average claim per person including social assistance is 10, and the average price is $27. That became an issue when we decided that we should have the network.

What we'd like to do today is tell you about the network. Last year we told you that we were going to do it. This year we're coming back to tell you we have done it.

The primary objectives of the network have been that we should improve health care and not just look at how we can make this more efficient. Two of the benefits that have come forward have been on improving the health care of senior citizens. It also has given us many efficiencies.

We've will have in the near future telenetworked all of the pharmacies. We've reduced the amount of paper and looked at the paper guidelines so the formulary now can be accessed on the computer. We give real-time, on-line adjudication of when a person is eligible and whether the drug is eligible, and we also can give potential warnings on drug interactions.

The status of this is that we put the first pharmacy on line in November 1993. The majority of the pharmacies are now on in 1994, and by December we'll have completed the first phase, which is really the phase that identifies the recipients, gives the claims processes, looks at the first idea of prospective drug interactions.

There are two other phases that we will be looking at with this over the next year and those are to look at the benefits management systems and the full function of a prospective DUR, or drug utilization review. These two systems are actually very essential to us because one of the other programs that we currently operate is called the special drugs program, which is drugs we pay for for people with specific diseases. If we can put this on the same network, we'll be able to look at how we're utilizing those kinds of drugs also.

There are a number I'll skip over, but what I'd like to talk to you about is how well we are doing. There are potentially 2,244 drugstores that should come on. We currently have 1,705 on, with 539 left. What that really tells us is that we currently have about 64% of the pharmacies, but those pharmacies have 75% of the number of claims we're currently processing. So we really are starting to get a lot of reactions from this and to be able to do some real live looking at drugs and rejecting drugs.

I have no idea what slide it is, but if you can get on to "Project Status" I think that is the one we're most proud of. We were able to build into this system, making sure that we protected confidentiality, three different kinds of notices that come back to pharmacies when they fill a drug.

One is called a drug-to-drug interaction. We've had 385,000 drug-to-drug interactions reported back out of these pharmacies that are currently connected. That means that you've had one drug dispensed and another drug is being dispensed and there could be a potential interaction. That interaction could be as minor as just a potential of a stomach upset or as dangerous as it could be causing you anaphylactic shock. If it is very dangerous, the name of the drug will come back to you. If it's just another interaction, there are levels of interactions that show up.

We can't claim here that there are 385,000 prescriptions not filled, but we do know that there are 385,000 contacts made by a pharmacist to that patient to prevent him or her from getting an interaction that could have been potentially fatal.

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The other one is that we have been able to prevent people from getting what we call double doctoring. That's about 16,000 claims so far, and this is just from May to August, so it's not a lot of time. But as we look at it, double doctoring means that you could've got the same drug dispensed by a different doctor. You went to your family doctor and you got a drug. You go to your specialist and he maybe will give you the same class of drugs. That would come back as a notice to the pharmacist that this drug should not be filled because you've already previously received that same drug in the last few days. There were 16,000 of those, and that means that we probably did prevent a number of those kinds of interactions.

Again, we can't say, but we do know that we had pharmacists practising the profession of pharmacy in a much more professional manner because they had knowledge of drugs that were filled. They didn't necessarily have to be filled in their own drugstore -- they could've been filled in another area, another place -- but they had their drugs and there was monitoring going on.

The duplicate prescriptions: We know we've saved at least 1,892 of those because that means that somebody from the same doctor on the same day was trying to get the same drug. So we did prevent those kinds of interactions. Again, understand that this is only a fairly limited sample, so the potential of this for health outcomes as well as prevention of a number of fraudulent kinds of things is proving to be very much of a benefit.

The managed care system that we're about to build will help us define and maintain the coverage of groups of recipients or agents and prescribers and manufacturers that we would like to use that are either on or not on ODB but are receiving drugs. We could put a chemotherapy system on this; we could put on our special drug program. So it has a number of potentials to look at the other things.

The next phase also of this is that we'd like to move it into hospitals and doctors' offices eventually, so that emergency rooms, especially, would have access to this information so that they could access a file, know what drugs were -- especially if it's an elderly person who is comatose or not able to speak. You could actually enter the card number on this line and you could get back the information of the drugs that person has taken, probably a history file of the last year, maybe at least six months; and then to also try to put this into the physicians' offices as we move into that area.

If there are any other questions, I can cover it, but I think that'll probably cover the project for now.

The Chair: Questions. Perhaps we'll go in rotation again, if that's the desire of the committee.

Mr Crozier: Perhaps you can start with them. I have no questions.

The Chair: Okay. Then we'll start with the Conservatives. Mr Tilson had his hand up first and Mrs Marland. We're going till 5 o'clock, so we have approximately one hour left, so we'll go in 20-minute rotation again.

Mr Tilson: What you've just explained, the drug programs project -- I think I understand most of what you're saying. That's on the presumption that druggists, doctors, hospitals have all this equipment that Mrs Marland has been spending some time on. Unless you have the equipment, then it won't work.

Ms Lindberg: The pharmacists were all computerized. They all have computers, and they were all giving their claims in to us on a disc.

Mr Tilson: So all pharmacists today are computerized.

Ms Lindberg: They are computerized, and they were before we started this, so our costs were to do the network costs to get every pharmacy telecommunicated. The pharmacists themselves spent the money to buy the software so that they could have the software to interact with our network.

The reason they did that is because each pharmacy, again, has a different software package from another pharmacy. Shoppers Drug Mart pharmacies all have the same network, a network of theirs. So they spent the money to put in their own software package; we wired them to the drugstore. They put a software package -- they all have computers -- into their computer configuration, so they now have instant adjudication of their claims.

The advantage for them was that they know that every claim they now put forward is valid. They don't have an invalid claim, because if it is invalid, it has already been rejected.

Mr Tilson: So they're connected to a central system to your ministry.

Ms Lindberg: Yes.

Mr Tilson: In other words, if I go and get some drugs at drugstore A, and then I go an hour later to drugstore B, they'll know I've done that. Drugstore B will know I've been to drugstore A.

Ms Lindberg: Only if you're an ODB customer at this point. Only if you're a recipient of our Ontario drug benefits.

Mr Tilson: Yes.

Ms Lindberg: The potential is it could be expanded, but right now it's only for the people we supply drugs to.

Mr Tilson: I guess that leads to a general question of information for the database which we, the ministry, all of you have been talking about this morning, and this afternoon to some extent. That sounds very admirable, because this is really part of it. It would all be part of it. You could essentially have your record, whether you're at Dr A's office -- doctors don't have this equipment, of course. Dr A prescribes it and I suppose you're saying it would be picked up in drugstore A or drugstore B. That would be the safeguard.

Ms Lindberg: Currently, that's they way it is.

Mr Tilson: However, it gets back, I guess, to the questioning that Mrs Marland was asking, and that is that if you don't have all this equipment -- the hospitals, the doctors -- and I must confess I wasn't aware that all pharmacists had this type of equipment. If you don't have all this, then that won't work. This system or the expansion of it simply won't work.

Ms Lindberg: Some 97% of physicians send their claims in by computer disc now. We know that all hospitals have computer systems, and every lab also, by the way, is computerized. So must providers are already computerized. So the technology and the investment on the side of the provider is to get their software vendor for their computer to set up a compatible system for our network. It's not that difficult, now that the vendors have a fair amount of experience with it. It's even easier for drugstores to do it. So the expense is the software package only for the provider.

Mr Tilson: This is on another card, of course.

Ms Lindberg: No, it's on the same card.

Mr Tilson: It's on the same card? Because I understood that the card that -- I can't remember his name; he's gone -- described --

Mrs Marland: Larry.

Mr Tilson: Larry. The information is limited; you can only get so much. Is that the downside of the photo card, as opposed to the smart card?

Ms Lindberg: What the pharmacists currently do is they key in -- they don't swipe -- the number on their computer. It's an interactive system like your bank card. You key in the number. It says, "Yes, this person is eligible." The next thing he keys in is the drug identification number, which is the prescription that they're going to receive. That goes in and it says "Yes" -- and this is a 15-second turnaround -- "that's a valid drug, that drug is covered by our formulary." Then the calculations are done for the price, and if there's no interaction, it's a simple dispensing function. What happens is --

Mr Tilson: Could I just stop you? That sounds admirable. It's almost as if you're describing the smart card.

Ms Lindberg: It's an interactive technology.

Mr Tilson: But I have it in my head that the photo card that you've developed, the strip is like a strip on the back of a credit card, I assume --

Ms Lindberg: Yes, it is.

Mr Tilson: -- and there's only so much room for that information on that card.

Ms Lindberg: The information on the drug side is in the computer in -- it's not in Kingston, is it? It's in Windsor.

Mr Tilson: I'm sorry, I didn't catch it.

Ms Lindberg: The information is on a computer in Windsor, and it goes in and out, in and out, in and out. So it's like a smart card, except it's interactive technology. It's what we call interactive. You put the mag stripe in. The mag stripe reads the name, the address, and verifies that person is an eligible person.

The next thing it verifies, because our formulary is on this piece of computer also, is that the drug is eligible, and what price that drug is and the quantity. So it does a calculation of 30 times 50 ampicillin to give you the price. If, by the way, it says you've already had codeine and there's going to be an allergic reaction, it'll flash up, "Allergic reaction, allergic reaction."

Mr Tilson: How is this card different from the smart card?

Ms Lindberg: It's different because you don't carry it around in your --

Mr Tilson: It's not on the card.

Ms Lindberg: It's not computed on the card.

Mr Tilson: It's on the machine.

Ms Lindberg: You swipe it; it's on the machine. So it comes back and forth. It's on a mainframe or a large computer.

Mr Tilson: I guess I'd like to ask some questions with not only this topic but the whole system, and that has to do with how it's going to be paid for. I understand it's difficult to estimate, depending on how fast you're moving and where you're going and all that sort of business that you've told us. I look at $30 million a year, unless that's changed, and then there will be other costs.

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I don't want to get into the argument whether it's $6 or $8. My question is that we have fees for drivers' licences, for fishing licences, hunting licences, every sort of licence you can think of, which are a lot more than $6 or $8. Has that been canvassed by the ministry? In other words, if I've got to pay -- I don't know what I pay for a fishing licence. Does anybody know? Forty bucks? I don't know, but it's certainly a lot more than $6 or $8. Why wouldn't that be the case for these cards? If I want to get health services, why shouldn't that service -- in the same way with respect to fishing licences?

Mrs Mottershead: The government has outright rejected --

Mr Tilson: So it's a government position.

Mrs Mottershead: It's a government position.

Mr Tilson: Okay.

Mrs Mottershead: It's a government policy decision that has been taken not to charge for health cards.

Mr O'Connor: You've got to earn a new driver's licence. You're entitled to health care in the province, so you don't have to pay for it. A driver's licence is something you have to earn, it's not something that you just get. It's a privilege you get after you're qualified to receive it. It's a little different approach.

Mrs Marland: Is it my turn?

Mr Tilson: Mrs Marland, I just wanted -- you're saying that in your capacity as parliamentary assistant.

Mr O'Connor: I'm saying that as a member of this government.

Mr Tilson: Okay, that's fine. Thank you. Mrs Marland has some questions.

Mr O'Connor: We know you're advocating for user fees.

Mrs Marland: I need to get back to what's going on between Quebec and Ontario, on behalf of Mr Wilson, the member for Simcoe West. Apparently last year Ontario and Quebec governments exchanged information to determine how many individuals were registered under health plans in both provinces. In fact, I have a copy here of a memo from Mr Julian Young. In this memo he says that "OHIP provided RAMQ with a file containing those persons whose surname begins with the letter A. RAMQ then provided OHIP with a similar file of the letter B. The initial findings of this analysis identified approximately 1% of persons are registered in both provinces with health care eligibility." That's a direct quote from Mr Julian Young's memo of December 21, 1993. Another exchange apparently was done with the letter C and contained similar results.

Some of the numbers are pretty amazing, because I notice that on the file between RAMQ and OHIP, on the B file, there were 8,043 names. That means 8,043 people are registered and they can access health care in Ontario and health care in Quebec.

I guess the interesting thing about this, of course, is that it does relate in some cases to the Akwesasne reserve because in fact in the summary of discussions it says RAMQ has received authorization to terminate eligibility of all 932 native persons residing in the USA who have RAMQ health cards. It's a pretty scary thought that poor old Quebec has 932 people that it's been able to identify as native persons living in New York state that it's been covering. "Letters of notification will be sent to each person informing them of this action and the opportunity to appeal."

What I'd like to know, on behalf of Jim Wilson, is why haven't more exchanges been done? We're talking about two letters of the alphabet. We're talking about a report that's eight months old -- or nine months old, I guess, at this point, it was December 9. How many of these individuals registered in both plans are collecting welfare benefits in both provinces? I realize that's not your ministry, but I think that was part of the comparison that was done. And how many of these individuals registered in both plans are billing OHIP for services not covered under the Quebec health insurance plan? Is that your responsibility, Donna, or is it --

Ms Segal: It is in part. The memo from Julian Young -- could I ask you the date of that memo?

Mrs Marland: December 9, I said, 1993.

Ms Segal: Okay.

Mrs Marland: Pardon me, there's two. One is --

Ms Segal: December?

Mrs Marland: The memo is October 28, 1993, and then there are meeting notes with RAMQ from December 9, 1993, and these have been obtained through the freedom of information. They're quite interesting, because when you get down to something that's quite interesting then there's a blank and there's something -- I'll give you an example.

This page looks very interesting, and then all you get is the identification of the stuff you can't get. But based on the information we do have, we're very concerned. We think this is a very serious matter that we have people registered in both provinces and, in some cases, both provinces and one state.

Ms Segal: It is an issue that is disconcerting and does require ongoing vigilance, there's no question about it. I wonder if I could indicate to you, though, the subsequent actions of RAMQ in terms of the 800 individuals you made reference to -- the fact that their coverage in Quebec is being terminated.

As a result of accusations by certain groups in Quebec as to the termination without having given the opportunity to the individuals affected to challenge or to question that --

Mrs Marland: I don't want to interrupt you, but these 932 were all native persons, so I'm assuming these 932 persons were all on the Akwesasne reserve.

Ms Segal: And I'm indicating to you that in fact RAMQ did not terminate their coverage at that particular time. Instead, they adopted the same kind of strategy as is employed consistently with Ontario, that they in fact reinstated the coverage of all of those individuals and effected a reregistration of the entire population that was claiming Quebec residency status.

Their tactic initially was very interventionist. They were reprimanded legally for doing so and taken to court and, rather than pursue the legal court, what they did was reinstate coverage and then pursue a very deliberate action to reinstate or to review the eligibility of the affected individuals.

Similarly, in the course of several approaches to looking at residency status, not only of the native population but of all border populations and also to extend across the total population of Ontario, we have sought to confirm the eligibility and residency of individuals who claim to live in Ontario. I don't have the statistics in front of me that relate specifically to the native population. In fact, we don't gather them in that fashion. What I can say is that as a normal course of action, as did Quebec, we review the eligibility and we review the actual residency.

Perhaps I can reinforce that as time continues we will continue to review, both by random sampling and also by specific reviews of susceptible populations, namely border populations, we too will be able to refine the information base to assure ourselves that all the individuals, whether they're of native or any other extraction, are in fact residents of Ontario.

Also, we will be carrying out, as part of the registration exercise over the next three years, starting next spring -- we will be working with the native council and working directly with the individuals involved who will come forward and reregister, just as you and I will reregister in order to acquire our health cards. They will have to prove their Ontario residency.

Mrs Marland: You know what's interesting about this particular page -- and I see that Julian Young is senior business analyst for the registration analysis unit -- is that in the summary of discussions under Akwesasne there were four summaries, and the only ones that have been left are the ones about Quebec. So out of this, the white-outs are the Ontario ones, and it's in here that they're saying -- well, a number of things but all about RAMQ, including that it was noted that the native declaration of residency prepared by RAMQ will not be utilized.

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Ms Segal: The white-outs are part of the administration process of carrying out a request for information under freedom of information. I have no control, nor do ministry staff, other than individuals who have the direct responsibility for determining what information goes forward. I can't speak to why those particular pieces or what was in those pieces --

Mrs Mottershead: But I think you can be assured that they have to deal with the issue of protection of personal information and for that reason they had to be delivered to the requester in that way.

Mrs Marland: What about the Lindquist Avey study? Why can't we have that?

Mrs Mottershead: I believe I answered that question this morning. In engaging the firm to do its review, we had two issues we were concerned about. One is the security aspect and the other one was the advice to government in the context of a proposal, a cabinet submission that would be developed around the new health card, both the card itself with all the features and the processing and the registration process. Our agreement with Lindquist and the way the documents have been prepared for us have been already protected right from day one in our engagement with them.

Mrs Marland: So are you saying it's their decision, not the government decision?

Mrs Mottershead: No, that was the government decision to engage --

Mrs Marland: Did the government pay them to do the study?

Mrs Mottershead: Yes, the government paid them to do the study.

Mrs Marland: And you're saying that the facts in it can't be made public without --

Mrs Mottershead: That's correct.

Mrs Marland: Even if they remove anything that's identifying, you can't make public a report that tells us what the situation is about abuse and fraud in the health care system.

Mrs Mottershead: They, I mentioned this morning, looked at every single aspect of our operations and our procedures, processes, manuals, right down to the front line in terms of their interaction, the way they input data into the computers, the whole operation. Because of that and because we explicitly asked them to do that and flag areas of vulnerability, we made sure that the information would be protected for purposes of security. So it wouldn't serve the public interest to actually put a document out there that indicated where the vulnerabilities are and to in fact increase the possibility or probability of further abuses in the health care system.

Mrs Marland: Okay, I can understand your answer now. What you're saying is it would tell people how to. Does the Provincial Auditor have access to the Lindquist Avey study?

Mr Erik Peters: Yes, we do.

Mrs Marland: That makes me feel better. What about the fact that you've only done two letters out of a 26-letter alphabet between the exchange of information between Quebec and Ontario?

Ms Segal: We've been working for some time in formalizing a relationship with the province of Quebec where we can regularly interchange data. The interchanges you're referring to that were made available to you through freedom of information represented isolated pieces of information obtained through -- they were not part of a regular data exchange process. They were simply to identify whether or not there may be a fraud vulnerability or problem or, in this case, in fact, a duplicate card, as in registration in dual. I'd like to be clear, that may or may not be fraud, but it does indicate that the individual does have possession of two cards.

Mrs Marland: How could a person be entitled to a card in each province?

The Chair: I'm sorry. Mrs Marland, your time is --

Ms Segal: No, that's not what I said. What I said was that because an individual may have two cards does not necessarily imply that they are fraudulently using both of those cards at the same time. In any event, your original question to me was why have we only done the two letters. My response is, we are very much looking forward to the formalization and finalization of an agreement that's appropriate through freedom of information and through appropriate legislative channel, which will allow us to interchange that data on a regular basis --

The Chair: Thank you, Mrs Marland.

Mrs Marland: Will you let her finish? She was just in the middle of a sentence.

The Chair: Yes, I will let her finish. I just wanted to go on to the next question, but you can finish the answer to this one.

Ms Segal: And in fact I know there is another meeting between the Ontario and Quebec staff that's planned for the month of September to further our deliberations. It's been a protracted process, sometimes frustrating for all staff concerned, but it's been very complex legally and we have to be sure we're not compromising the security and the privacy of information illegally.

Mrs Marland: Thank you for your --

Interjection: You want to be careful of that.

The Chair: Thank you. Mr Frankford.

Mr Frankford: I think probably for Mr Stump: To return to the question of licensing officers as registration points, I think you said they would be paid per case.

Mr Stump: Per unit, yes.

Mr Frankford: Has the payment been agreed on?

Mr Stump: No, we're negotiating that. We still have all of the elements of the transaction to define. We have to come to agreements on how many different types of documents people are going to get, because the length of a transaction will vary. We talked about whether we can get families in, there'd be some efficiencies there. There are a lot of factors that go into negotiating that arrangement.

Mr Frankford: And who do you negotiate -- is there some sort of association or -- ?

Mr Stump: There isn't an association of issuers. We'll be doing the negotiation with the Ministry of Transportation.

Mr Frankford: Has that started?

Mr Stump: No.

Mr Frankford: Okay. So there's a lot of assumption that we --

Mr Stump: We have to make some of the fundamental decisions and we talked earlier that a lot of things are still in the planning process. We've talked about other outreach programs, how many transactions are people going to get, so there's still a way to go.

Mr Frankford: And they would have to come to you and sort of talk about how many staff they anticipate needing, or whatever.

Mr Stump: We should be able to anticipate that once we've figured out how long these things should take.

Mr Frankford: They will have computers now connected with the MOT and all that.

Mr Stump: That's right.

Mr Frankford: But you would not be using the same computer, would you?

Mr Stump: We'll be using the same computers in the offices and we'll be using some common computers at the central site.

Mr Frankford: Sorry, the same computer will link to both ministries?

Mr Stump: Yes, there'll actually be three different computers involved. The Ministry of Transportation's driver system -- we have a linkage in that if you're coming in to do both transactions. There is a computer to store the photo image. We'll both use the same computer for that. And then there's the ministry's computer that it uses for registered persons database, so all of these have to work together.

Mr Frankford: With photo storage, then, each individual would -- an individual with a driver's licence would have two images stored, in fact, would they?

Mr Stump: We're discussing that right now, whether you need to store two or one.

Mr Frankford: Okay. So in principle, you could say --

Mr Stump: You definitely could. Now the question is whether you will want to and whether that's appropriate under freedom of information etc.

Mr Frankford: And then, for children, one photo lasts five years. At least --

Mr Stump: We're discussing what an appropriate age is for somebody to have to have their picture taken and how long it's good for. Children may be one of the exemptions.

Mr Frankford: Okay. Changing over to the drug network and perhaps more to make comments than to ask questions -- except perhaps my comment is, as far as doctors go, why wait? Because I've done that. In essence, I did it myself. I practised with a computer on my desk out of which, with a printer, I gave a hard copy to the patient. If I was doing that today, I would have a modem and fax or e-mail it to the pharmacy, which I think would be dead easy.

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I used the OHIP number as a unique identifier, which has many advantages. Now we have one unique identifier, which makes it very easy. I personally feel -- this is more of a comment -- that the whole is very straightforward, that there are plenty of motivated individuals who like doing it, who realize the advantages to patient care for themselves, and maybe one should sort of take that group before saying this is something that has to be negotiated with the OMA, which I think just makes things complicated. I'm sure in the fullness of time, you probably do need some agreement like that, but I think for now one could be doing pilot projects on a totally voluntary basis.

Mr Tilson isn't here, but I was going to comment --

Mrs Marland: I'll pass it on.

Mr Frankford: -- in relation to smart cards, as I hope a constructive comment, that when you put things on a card, they also have to be read. The question is, who's going to read it? It seems to me the best person to produce and probably to read it later is that let's call it primary care or that physician at the front line.

It's not clear to me what you get by putting it on a card. As I've said in these hearings before, it's easy to get carried away by cards, but it seems to me that they are a solution in search of a problem. I think we have to be very cautious about saying it's the way of the future and we have to jump on it, because I don't believe the usefulness of cards in this sort of context has been demonstrated. They may be useful for some simple bank transactions and keeping your accounts up to date, although it's interesting to note that the banks themselves have not embraced something which should be really quite straightforward and perhaps to the benefit of consumers.

I would be happy to try to put smart cards to rest, because I think it's easy to get fascinated by them, but it's very questionable how useful they are.

Mr O'Connor: I appreciate your coming before us and spending as much time as you have. I know that we've cut into your day a little bit.

I guess a real concern that this committee has had and the reason we've spent as much time as we have of course goes back to the auditor's report, and the concern is that when we moved into the red-and-white card, it was done quite quickly. There were many reports of the vast number of cards out there, and action had to be taken. I guess you could call it a quick fix in going to the red-and-white card, but obviously it was an action that had to be taken, given that there was a problem.

I wondered if you might be able to comment on two things: some timetable or review dates or trigger points that are going to allow you as ministry officials to make sure that everything we're doing is on track and that we're not going on a fix-quick stream and that we're going to make sure everything is covered. I think that having the individuals come before us certainly shows it's going to be more awkward for anyone to try to create something that's going to be fraudulent.

My concern would be in that, though, perhaps you can spend a minute or two going over seniors. How about seniors in long-term care facilities? Are we going to have to bundle them all up and take them down to the local MTO office, and rent mini-vans or whatever? And how do we deal with the homeless in Toronto? There are a number of people who live on the streets. I know that my colleague Dr Bob Frankford mentioned this earlier on, but now as we proceed further into the process, I wonder if you might be able to give us some idea how we're going to ensure that these people, who are entitled to health care, are going to receive the health care they're entitled to.

Mrs Mottershead: I'll start off by just indicating that in terms of the registration in 1990-91, many lessons were learned and it was a tremendous experience to draw on in terms of the planning now. One of the key areas, and I'll let Larry speak to it further, is the treatment of the homeless and those that are shut in for one reason or another, and other populations, and I'll leave that for a moment.

I'd like to indicate that we have in our discussions this morning suggested that we are going to be continuing the process of validation, not in the sense that Donna talked about in card swiping, but validating all of the assumptions that we are making so far in the process by using experts, and Larry indicated that there are three sessions. One is starting next month in terms of bringing in the providers, as an example, a stakeholder group, as well as technical experts in the business of credit/financial instrument cards and so on, to look at everything we're doing so far.

The other thing that I think is important to flag for Dr Frankford is the fact that in terms of the MTO offices and in terms of the costing that Mrs Marland has also raised, we have to continue to work on things like time-and-motion studies to actually look at how long it would take to process someone with certain documentation so that we have a sense of confidence that the forecast and the estimates we have put together so far are really going to hold out in the long run as we go ahead and proceed with the process. So there's lots of work to be done between now and the early part of the spring next year when all of this activity takes place. I don't want to underestimate the fact that there's this work that has to be done. It's of a significant magnitude and we'll do it as diligently as we can.

I'll turn it over to Larry, who has some information to share with you on previous approaches to the population you've talked about, as well as some of the current thinking.

Mr Stump: I think you mentioned the homeless as well. We've had a couple of meetings now with a coalition of groups that service the homeless in Toronto, not only to deal with what we are going to do for the new reregistration, but also to set up some communications vehicles to help them deal with problems they're facing today. We've worked with those people I guess in the first round of registration back in 1990, and they're being very cooperative, very helpful in terms of giving us some ideas. They'll be participants as well at the advisory forum in September, along with the other groups that they have to work with as well in terms of the providers, so we're not going to try and just parcel people into a little package and deal with them. We think this is a group effort.

In terms of the people who are locked in long-term care institutions or facilities, or perhaps correctional institutions, no, we don't expect them to bundle up and walk out of the prison in the middle of the winter either. We are looking at an outreach program that would see people leaving the Ministry of Health in a van with portable equipment and going to a destination and, as conveniently as possible, arranging for their reregistration.

Mr O'Connor: A concern was pointed out to us about a children's aid society being given bulk cards, as a result of our previous deliberations. Would there be anything like that happen again? By having the person in front of you who's being issued the card, I guess we could clear that up, but are there any situations like that which could be a problem?

Mr Stump: I have not come across any exceptions now that would see us handing out block numbers. I think that and temporary cards are things that were done in reaction to specific problems, and hopefully by now we have a better process developed to deal with that.

The Chair: Any further questions from the government side? If not, Mr Callahan.

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Mr Callahan: I'm just looking at this flyer that you were good enough to give us. I guess maybe it's 30 years of practising in the criminal courts that have made me think like a criminal. I was just thinking of a situation. Let's say that someone's a Canadian and they --

Mr Perruzza: So you were representing --

Mr Callahan: I've never represented you, I don't believe. Have I? No. But I'm looking at this and I'm thinking to myself, a Canadian citizen who moves to the United States and becomes an American citizen decides they want to have heart bypass surgery. They attend at the office and they give you their Canadian birth certificate, because they still have it. They give you, let's say, an unconditional offer to purchase on a piece of property because they're going to invest in Canada. They give you their social insurance number, and the operation is booked for three months hence, because they've got a three-month waiting period. How do you stop that?

It's nice to have universal health coverage, but I find it really exceptional that people who move out of this country, change their citizenship and don't pay one nickel into this country come up here and have a heart bypass. How would you deal with that? You couldn't. They'd be perfectly entitled to a health card.

Ms Segal: You're making reference to an immigration issue also, the issue that an individual who is now in the States and has taken up American citizenship can in fact retain their right to Canadian citizenship. I'm sorry, I think that issue is beyond our control. While I may or may not agree with you personally, the issue is that that individual has the legal entitlement to remain in Canada once they can identify that they are in fact a Canadian citizen.

Mr Callahan: I don't think they lose their right as Canadian citizens. I think there's now an ability to have dual citizenship. I just throw that at you. Those are some of the real problems. Let's face it: If you're going to have a heart bypass operation in the United States, it's going to cost you megabucks. You can get it here for free, virtually.

Ms Segal: We are hopeful that the three-month waiting period will discourage people from coming across the border for one reason or another, applying immediately, whether it's through a landed status or through reassuming their Canadian residency, and acquiring services immediately.

Mr Callahan: I want to go back, and you'll understand why, to my constituent's situation that I raised this morning. That's the constituent who purchased $25,000 worth of coverage and tried in every way, shape or form to comply and wound up with the hospital -- I'm told, and I checked during the afternoon, the hospital actually told their children that they had to sign this, and these people got no advice. They assumed that if they didn't sign it, the treatment would not continue, although I think you or perhaps the deputy minister said this morning that the hospitals would have to continue the treatment even if it was --

Ms Segal: What did they sign?

Mr Callahan: They had signed a guarantee. Once they got to the $25,000, the hospital required them to sign a guarantee. I guess if they had had some advice, they probably wouldn't have signed it and the hospital would have had to keep them there, because this woman was dying of a stroke.

I guess I'm advocating on behalf of my constituent, which is my job. I find it absolutely incomprehensible that a person can arrive in this country illegally -- and I'm certain this is a fact -- and get a coverage under OHIP. They'd have a card that if they suffered, if they required health treatment while they were here appealing their deportation order or, after it's been found out that they've overstayed their visit, applying under the refugee process, they would in fact be covered by health care.

Ms Segal: Could you describe to me what you mean by them being here illegally and still having coverage?

Mr Callahan: We've had instances of it: They come in on a boat on to the shores of Canada. As I understand it, those people had health coverage from the minute they landed on the shores of Canada.

Mrs Mottershead: As refugee claimants, yes.

Ms Segal: They perhaps would have refugee --

Mr Callahan: No, no, they were here illegally.

Interjection.

Mr Callahan: I'm sorry; I'm talking about two constituents of mine who live in an apartment, have a child, and the husband's on WCB and the wife is --

Mr Perruzza: What's their name and where do they live?

Mr Callahan: That's not important.

Interjection.

The Chair: Can we have some order, please.

Mr Callahan: In any event, I find it absolutely incomprehensible that people in good faith purchase $25,000 worth of insurance and this hospital is going to come after them to try and collect a debt of $75,000. I find that absolutely incomprehensible and I think any well-meaning and well-thinking Canadian would find it absolutely unbelievable that we cover all these other instances but we don't cover that situation or deal with it. I find that really tough to take. I'll tell you, these people could go bankrupt for $1,100 and that hospital wouldn't get one nickel. They're taking pretty poor legal advice if they decide to sue them for the $75,000.

In any event, I simply want to raise that again because it really grits me that we do that, that our system provides for that.

I want to go back to another thing. I've got a card here from St Michael's Hospital. These things are produced by every hospital in Ontario, so you never pull out your health card. They are probably in the millions, I would think. What are you going to do to eliminate that? I mean, these things are probably peddled around the city, I would think. There's nothing on it to say, have them identify it. They just walk into the hospital, hand them this card and get the service. What is being done to protect that or to retrieve it or to stop it? This is not my health card. This is a card that's reproduced in every hospital in Ontario, for some reason, and they never ask you again for your health card; they ask you for this. How are you going to deal with that?

Ms Segal: I would suggest that once the health card reader capacity is in that hospital they are likely to ask you for your health card and swipe it rather than making use of the card that you have in your hand. There's no security attached to the card that you have in your hand and they will know that there's security attached to your new health card, your new photo card. The reality is that we are in combination with the OHA. We've investigated, adding the additional feature of the bar code on the new photo card so that we can in fact meet some of the needs that they have assumed by printing this kind of card, at the same time as availing themselves of a card that has much more security attached to it.

Mr Callahan: I'm not trying to make life difficult for you, believe me, but I have to ask these questions. This is the public accounts committee. If only four hospitals -- am I right? -- have this capacity at the moment, and 50 in 1995 and 50 in 1996, what are we doing to put the finger in the dike to stop somebody from getting one of these at St Michael's Hospital and handing it to somebody on the street or selling it to them and they go in and get the services?

Ms Segal: But that card is only useful in St Michael's Hospital.

Mr Callahan: Oh yes, but I'll bet you I could go around to every hospital in Metro --

Ms Segal: And it'll be a different card.

Mr Callahan: -- and get one and I would then have different colours, but I could go down Yonge Street and say, "Here, pick one. That'll be $100" or whatever.

Mr Perruzza: What kind of services do they give with this card?

Mr Callahan: Everything. I could go in and have a heart transplant with this card.

Mrs Mottershead: May I suggest that there is another major element here. You can't walk into the hospital, just walk into an emergency department. You'd have to have some kind of emergency event happen to you to have that kind of thing through an emergency.

We're forgetting one very critical element in this whole business, and that's the physician. When you talked earlier about the case of the American cousin who's got dual citizenship, that individual can't walk into the hospital and say: "Gee, I need a triple heart bypass. Give it to me now or otherwise I'm going to lose my three-month waiting period." There's that whole physician interface.

Through Bill 50 I think the government and the OMA have in fact decided to take some ownership for the fact that they have to be a lot more diligent in screening and weeding out those situations where they know. They'll know that if they don't have a frequent contact with that particular individual, there's something suspicious about that.

1650

Mr Callahan: You're quite right with the doctor. I think when you go into a doctor's office, they normally do ask you for the health card, but if you go into a hospital you don't even see the doctor. This is given to somebody sitting behind a desk who takes a look at it and notes it somehow and then you go into the clinic and see the doctor. He doesn't care where -- you know, it's paid for earlier.

Ms Segal: But if you were to go into the Toronto General, where they have the swipe reader now, they wouldn't accept their old card.

Mr Callahan: Oh, I appreciate that.

Ms Segal: They would accept only the card that has --

Mr Callahan: But that's my point. My point is that if we only have four now and only 50 in 1995 and only 50 in 1996, that's 104, and we've got 273 hospitals in the province of Ontario. What I'm saying is, who's got their finger in the dike, who's got their finger in the dike to stop this? It's happening, I'll bet you, if you go out and check. Who's going to stop that money flowing out between now and 1999 or 1998 when we'll have, hopefully, machines in all the hospitals?

Ms Segal: It is our plan to put in place at least 50 hospitals in this fiscal year and at least 50 as a result of the OMA agreement. That is certainly a minimalist approach and that's not our intent. Our intent is to make it available to as many hospitals as is possible. That's been our objective. Clearly, that has to be tempered with the moneys that are made available to us in order to implement the plan.

Mr Callahan: Can I make a suggestion? I suggest that the Minister of Health tomorrow morning write to every hospital in Ontario and tell them to get rid of their plastic machines, they can no longer do this, that if they wish to be paid for the services in the hospital they have to ensure that someone has seen the present health card, because if you don't do that -- I mean, it's like night follows upon day that this money is still draining out through the great black hole. You haven't got just 20 million health cards out there, the legit ones; you've got probably 40 million of these.

Mr Perruzza: Bob, can you say irrevocably that they have no policing system for those cards?

Mr Callahan: Yes, I can, because I have gone into the hospital, in answer to my colleague's question, and handed that to a person behind a counter. They ran it through some sort of a scanner or something or took a picture of it, and then I went into the clinic and got the services. They never even asked who I was.

Mr Perruzza: Were you being recommended by your doctor or did you just walk in off the street?

The Chair: Order.

Mr Callahan: I just walked in with that card. They give you that card once --

Mr Perruzza: What did you ask for? You said, "Look, I'm bleeding, please take care of me"?

Mr Callahan: No. The hospitals in Toronto -- I can't speak for all of them --

The Chair: If I may, Mr Callahan, Mr Peters would like to comment on what you're saying.

Mr Peters: If I may, when you got this card you were asked to produce a health card.

Mr Callahan: Yes, it's got all my details on it.

Mr Peters: Exactly, and that is the point. There is a safeguard here, and I'm speaking from the background at the moment of being a volunteer member of a board of directors. Firstly, this card is issued by the individual hospital on the basis that they have a patient information system in the hospital, and they're all different. I think this was the point made by the ministry this morning, that of all the patient information systems there are very few that are the same from hospital to hospital. The order to disuse or discontinue the card would not be a practical one at this point because that card ties into their local information system.

The other point is that the hospitals themselves are not on a fee-for-service basis. They are on a funding basis from the ministry for the hospital funding. Whether 15 people show up with this card or 150 show up with this card, it really doesn't make much difference to the hospital. They're not getting any more money or any less money because more or fewer people show up. So the use of this particular card as an alternative to the health card would not be a practical way to do it. They rely on getting the health card.

The other problem that a hospital has, the real problem, is, most of the time, the emergency. That's where the problem can occur. In other words, if you get a car accident victim there, the last question you want to ask is, "Are you having health coverage?" or whatever. You look after the person, fix them up and do whatever. For the quadruple bypass, you need a reference from a GP to a specialist, a specialist has to come in, you have to schedule --

Mr Callahan: That's maybe a bad example, but what I'm saying is that a procedure that -- all I'm concerned about is somebody's losing money. It may be, as you say, Erik, that it's the hospitals that are losing some of their global money, which means they can't provide all the services and they have to collect $75,000 from indigent people in my community because of that. But all I'm saying is that the card is out there and it is in fact being used, I'd be willing to bet, by a lot of people who shouldn't be using it. That's all I'm saying.

Interjections.

The Chair: Let him have the floor.

Interjections.

The Chair: No, the point is, you do not have the floor and you do not have a point.

Mr Perruzza: Look, why don't we all just come in here and just say what we want, okay, so that it can be repeated, and if it's repeated enough times --

The Chair: You're out of order, Mr Perruzza.

Mr Perruzza: -- then it becomes fact. Right?

The Chair: You had your opportunity when your party had its time.

Interjection.

The Chair: I understand that, but you cannot interfere with another member's time in a reasonable fashion.

Mrs Marland: I have to show my health card with my hospital card.

Mr Perruzza: There you go. Show it, Margaret.

Mr Peters: If I may make one other additional comment --

Mr Callahan: Well, it's not the case in Toronto.

Mrs Marland: I'm talking about Toronto.

The Chair: Mr Peters, if you would like to make a comment, I will allow some additional time.

Mr Peters: May I come back on one other point, Mr Callahan, that maybe helps out in this? The decision whether or not to pursue a patient for payment actually rests with hospital management, which is independent. It's not with the minister.

Mr Callahan: I appreciate that, but there are instances, and it's happened in all governments that have been in power, that an order in council can be made. I've seen it happen, and I've seen it happen more times than I can think of, where in fact the Ministry of Health, by order in council, says, "You're covered." Cabinet can do anything.

All I'm saying is that in this case I find that if this money is all going out the tube on the global budgets of hospitals, if I'm right that these cards are doing that, then why is my constituent being penalized for having taken the steps to provide $25,000 worth of coverage for her, where all this other stuff's going on and there doesn't seem to be any control over it?

The Chair: Thank you, Mr Callahan. It is now 5 o'clock. I've had a round for each of the parties and we will conclude with this segment. I'd like to thank the ministry for appearing before us. I believe there will be an opportunity for us to deliberate on this matter as a committee further. We will be in touch with you on that basis. Thank you once again for your patience.

Mrs Marland: Mr Chairman, I just want to say on the record that I've enjoyed asking the deputy and the staff questions today and getting direct answers. It's a pleasant change from asking the minister questions.

The Chair: I would concur with you that it was certainly a pleasant experience for everyone and we did get straightforward answers.

Mr Perruzza: They're already moving into the office. I love it.

Mrs Mottershead: We do have a number of answers still to provide and we will do that through the clerk of the committee.

The Chair: Thank you. We're adjourned.

The committee adjourned at 1658.