Tuesday 2 November 1993

Expenditure Control Plan Statute Law Amendment Act, 1993, Bill 50, Mrs Grier / Loi de 1993 modifiant des lois en ce qui concerne le Plan de contrôle des dépenses, projet de loi 50, Mme Grier S-471

Ontario Public School Boards' Association

Donna Cansfield, executive vice-president

Ontario Dental Association

Linda Samek, director, professional affairs

Frank Bevilacqua, director, government relations

Patients' Rights Association

Anne Coy, president and co-founder

Harry Beatty, vice-president

Shalom Schachter


*Chair / Président: Beer, Charles (York North/-Nord L)

*Vice-Chair / Vice-Président: Eddy, Ron (Brant-Haldimand L)

*Carter, Jenny (Peterborough ND)

Cunningham, Dianne (London North/-Nord PC)

*Hope, Randy R. (Chatham-Kent ND)

*Martin, Tony (Sault Ste Marie ND)

McGuinty, Dalton (Ottawa South/-Sud L)

O'Connor, Larry (Durham-York ND)

*O'Neill, Yvonne (Ottawa-Rideau L)

*Owens, Stephen (Scarborough Centre ND)

*Rizzo, Tony (Oakwood ND)

Wilson, Jim (Simcoe West/-Ouest PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Harnick, Charles (Willowdale PC) for Mr Jim Wilson

Sullivan, Barbara (Halton Centre L) for Mr McGuinty

Wessenger, Paul (Simcoe Centre ND) for Mr O'Connor

Also taking part / Autres participants et participantes:

Ministry of Health:

Wessenger, Paul, parliamentary assistant to the minister

Williams, Frank, deputy director, legal services

Clerk / Greffier: Arnott, Doug

Staff / Personnel: Gardner, Dr Bob, assistant director, Legislative Research Service

The committee met at 1533 in committee room 1.


Consideration of Bill 50, An Act to implement the government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act / Projet de loi 50, Loi visant à mettre en oeuvre le Plan de contrôle des dépenses du gouvernement et modifiant la Loi sur l'assurance-santé et la Loi sur l'arbitrage des conflits de travail dans les hôpitaux.

The Chair (Mr Charles Beer): Good afternoon, ladies and gentlemen. This is a session of the standing committee on social development, Tuesday, 2 November. We're here to examine Bill 50, An Act to implement the government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act.


The Chair: Our first witnesses this afternoon are representatives from the Ontario Public School Boards' Association. If you would please come forward, we would be happy to hear you. If you feel like some good Queen's Park water, just go right ahead. If you wouldn't mind just introducing the members of the delegation to the committee and for Hansard.

Ms Donna Cansfield: I'm Donna Cansfield, executive vice-president of the Ontario Public School Boards' Association. Michael Benson is the executive director of the association and Brian Conway is policy adviser.

The Chair: We all have a copy of your presentation as well, so please go ahead.

Ms Cansfield: I'll just go through and highlight some of the issues we would like to identify. We're pleased to have this opportunity to comment upon one aspect of the standing committee on social development's deliberations on Bill 50 which is of concern to the Ontario public school boards, the definition of and the impact of new changes regarding third-party services. We are concerned that the provincial government's efforts to control expenditures in the area of health care must not have a detrimental impact upon youth and children in Ontario's publicly funded schools.

A 1992 agreement between the Ministry of Health and the Ontario Medical Association made significant changes in coverage of services provided through the Ontario Health Insurance Act. The Ontario Public School Boards' Association is concerned that this agreement was reached and implemented through changes in regulations without public consultation.

The current discussion by the standing committee on social development of Bill 50 provides an opportunity to raise some of the concerns regarding third-party services. The standing committee has before it a government motion to define third-party services. Third-party services are those services requested by parties other than the patient or physician that would no longer be covered by the Ontario health insurance plan.

As a result of the ministry's agreement with the OMA, Ontario regulation 785/92, made under the Health Insurance Act, amended regulation 552 by incorporating the substance of the agreement. Three specific impacts upon school boards arise from the regulation: admission to or continued attendance in a day care or preschool program or a school, community college, university or other educational institution or program; obtaining or continuing employment; an absence from or return to work.

School boards do require information or documentation provided by physicians or practitioners related to insured persons. This information is required in the school boards' capacities both as educational institutions and as public sector employers. We have examples for you.

Early and ongoing identification of children's learning needs: We're required under the Education Act to implement procedures for early and ongoing identification of the learning abilities and needs of pupils. The Ministry of Education and Training policy memorandum number 11 states that these procedures should continue throughout a child's school life. As a component of these procedures, many boards require that children attending for the first time should have a medical assessment before attending school. As well, medical information about pupils may be requested by school boards on such matters as allergies, medication and fitness for strenuous activities, and especially for pupils participating in athletics and field trips. This is not covered.

Subsection 2(3) of regulation 305 authorizes that where a special education identification, placement and review committee, an IPRC, "determines that a health assessment or psychological assessment, or both, of the pupil are required to enable the committee to make a correct identification or determination in respect of the pupil, and with the written permission of the parent, obtain and consider a health assessment of the pupil by a legally qualified medical practitioner." This too is not going to be covered.

Then, of course, there is home instruction. The home instruction section of regulation 298 permits a principal to arrange for home instruction "where evidence that the pupil cannot attend school is provided to the principal." This is not covered, and typically this is also a medical assessment.

Of concern of course is the tuberculin test, not only for employees of school boards but as you're well aware we've a very serious issue with immigrants and refugees where school boards now will be requiring that children under the age of 12 will have to have a TB test prior to entrance. We're discussing immigrants and refugees. They will not be covered.

Then we of course, as employers, have the back-to-work medical certificate. For years, the provincial government has passed on to the local governments increasing financial responsibility for a wide range of services, especially in the areas of health and social services. The Ministry of Education and Training estimates -- and I give you this as a conservative estimate -- school board expenditures in this area, psychosocial support, which is outside of the education mandate, to be $346.6 million for 1991 alone.

The Ontario Public School Boards' Association is opposed to further downloading of responsibilities and costs from the provincial government to school boards. I suggest that passing the buck is not restructuring.

We are concerned about the impact that changes regarding third-party services will have on children and their learning programs. We're more concerned about that than the bureaucratic production of documents. Medical assessments are required by school boards so that they can meet their responsibilities with respect to early and ongoing identification of children's needs, special education needs identification and appropriate supervision of home schooling. This issue is about fundamental rights of children to equal education opportunity.

Medical assessments constitute a vital source of information regarding the early and ongoing identification of children's learning needs and contribute to the health, safety and wellbeing of students. Information obtained through medical assessments can be used proactively to foster improvements in the school environment for the benefit of the learner.

For us, we clearly want services and documents that school boards require to be covered by OHIP, and we wish to be exempt from the legislation.


There are equity implications to changes regarding third-party services. The decision to discontinue insurance for these medical services for children and youth may well compound inequities already in the existing educational system. School boards across Ontario are in a financial crisis. Small, northern and rural school boards in particular are unable to absorb any additional financial pressures. Inability to pay for required medical assessments will have a negative impact on the learning environment and, without access to required medical assessment, educators will not have the appropriate information to ensure that special learning needs of children and youth are met.

We are also concerned about the impact that changes regarding third-party services will have in exacerbating the increasing pressures which school boards currently face in the broader public sector. Decisions made at Queen's Park have escalated the cost of providing education in Ontario. As well, school boards have been squeezed by the social contract, the expenditure control program and cutbacks in specific program areas, such as adult and continuing education, education technology and literacy, and this is just another example of how in fact the learner is going to be impacted once again.

We appreciate the opportunity to have the chance to make comments on Bill 50 to the standing committee on social development and we urge you to clearly consider that the changes be made so that the youth of this province are protected.

Are there any questions?

The Chair: Thank you. We have a little more time this afternoon because of some witnesses who were not able to come. If you wanted to read your recommendations into the record, I think that would be fine.

Ms Cansfield: Thank you. Yes, I would. I was trying to leave some time.

The Chair: I appreciate that.

Ms Cansfield: OPSBA recommends that in Bill 50 the definition of "third-party services" be defined and elaborated so as to minimize the negative impact on children, their learning programs, school boards and the local property taxpayers.

(1) That the definition of third-party services be amended to specifically include as an insurable service under the Ontario health insurance plan a service that is provided by a physician or practitioner in connection or partly in connection with a request or requirement made by a person or entity that information or documentation relating to an insured person be provided relating to admission to or continued attendance in a day care or preschool program or school.

(2) That the definition of third-party services be amended to specifically include as an insurable service under the Ontario health insurance plan the production or completion of a document or the transmission of information to a person other than the insured person if the document or the transmission of the information relates to admission to or continued attendance in a day care or preschool program or a school.

(3) That the definition of third-party services be amended to specifically include as an insurable service under the Ontario health insurance plan the production or completion of a document if the transmission of the document or the transmission of the information is related to obtaining or continuing employment with a day care or preschool program or a school.

(4) That the definition of third-party services be amended to specifically include as an insurable service under the Ontario health insurance plan the production or completion of a document, if the transmission of the document or the transmission of the information is related to an absence from or return to work or a day care or preschool program or a school.

I ask you to really give serious consideration to the original intent of the legislation and the fact that I do not believe that it was really intended to scoop into its understanding children. I don't really feel that anybody would be prepared to put children at risk and, in fact, that's what this will do; it will put children who are already suffering some of the inequities of the system, especially the children who are identified as special needs, at risk. It will put those children who are from immigrant or refugee families who are already in a dysfunctional way at a greater disadvantage when we will refuse them entrance because they do not have a TB test.

The Chair: Fine. Thank you very much. We'll begin the questioning with Ms Sullivan.

Mrs Barbara Sullivan (Halton Centre): I'm particularly appreciative of your participation in the committee today. We have had one other presentation on the third-party billing issue from representatives from child care centres and day nurseries who were concerned about the question of who pays, which I think is very much a part of your report. But as well I think you've raised other issues with respect to equity in terms of service requirements and with respect to the determinants of health, which we know are fundamental to a proper health care system.

One of the surprising announcements which came yesterday was that the Ministry of Health would cover the costs of such tests in certain circumstances where the Ministry of Health required those tests. In this case it's the regulations under the Education Act that would require that tests or medical examinations be undertaken with respect to children or staff, and the expectation presumably would be that the Ministry of Education would cover those costs.

I'm wondering if you'd comment on the kind of bureaucratic snafu that would occur in comparison, say, to OHIP simply covering the matter in a routine, normal way with the physicians submitting their accounts in a normal, routine way as compared to the physician submitting the account to the patient, who submits the account to the board, who submits the account to the Ministry of Education. I think there's also a process issue here that is useful to have comment on.

Ms Cansfield: Actually, you raise a number of issues. Obviously, trying to access the Ministry of Education as an individual is virtually impossible. I think the analogy was that if you need an ambulance, do you call the Minister of Health? No, you call your local ambulance service. It's the same sort of thing.

If in fact the school board requires that a child entering needs a TB test, the last thing that parent or child needs to try and do is access the Ministry of Education in order to secure the test in order to get to the school. It obviously makes sense to do it at the local level.

The other thing is that recently it was the Ministry of Education that amended the legislation that permitted school boards in fact to demand that test because we have active TB cases in our schools. So now we have the same ministry, or the same government, that is going to prohibit what they just in fact allowed, which somehow doesn't seem to make any sense.

As I say, I truly believe that there wasn't intent to catch the children in the net, but the fact is the children are caught and there will be the inequities and they have to be resolved. To consider that the people would start phoning the Ministry of Education -- and I know there's a lot of room at the Mowat Block -- you'd have to set a whole floor aside just to deal with the bureaucratic nightmare that would occur if you had the Ministry of Education accessing third-party billing.

Mrs Sullivan: I'm interested that not only have you discussed in your brief the issues associated with identifying the students' individual needs, whether it's for special-education programs or assessing whether a student would have an ability to participate in a travel program or an athletic program or whatever, with the public health needs, but also the figure you obtained from the Ministry of Education and Training, which estimates that the cost of these tests or examinations which are required now for public health or education assessment is $346.6 million. Were those costs to be transferred to the boards, which could also be where the responsibility lay, what kind of inequities would you see across the province, rich board versus poor board?

Ms Cansfield: Why we identified: The $346.6 million are current funds already expended by school boards across the province. So this would be adding to that amount, and there are no more dollars. I don't know how many times that can be stated. If it's stated from the government's side, with its expenditure control program, there are no more dollars on the school board side as well. So of course when you look at the isolate boards and the northern boards, where they are in such extraordinary circumstances, they wouldn't even begin to be able to provide the services for a specially identified child.

In a lot of cases, children are just currently being identified with -- let's take autism. It's almost like an umbrella, and they use the word just to try and get the assessment to find out what the real need for the student is. If they can't access that assessment, they don't know whether they're dealing with a behaviour problem or a learning problem.

Of course the board in the urban area has far more access by virtue of Sick Children's Hospital down the street or maybe a support service that is already existing in the school and a child goes on a waiting list, but you couldn't even begin to put that into any kind of context with a northern board, and in particular with an isolate board.


Mrs Sullivan: I want to just in conclusion do two things. One is to congratulate OPSBA on preparing a very thorough and concise brief given extremely limited time, because we've just seen these amendments within the past week or so. Secondly, I'd like to ask the parliamentary assistant if he could clarify what the government's intention is with respect to who pays.

Mr Paul Wessenger (Simcoe Centre): Yes, if I might just indicate what the status presently is concerning third-party payment, the Ministry of Health is conducting a review of all the legislative requirements, that is both under statute and under regulations, with respect to the provision of medical certificates. That review, originally, was to be completed some time next year. Hopefully, it can be completed at an earlier stage.

I might also indicate at the moment that it has been requested by the opposition that we provide a list of the statutes and regulations which are under review, and I'd like to indicate to the opposition critic for the Liberals that hopefully next week we're going to have a list provided to the committee. It will not be a complete list. It should be a complete list as far as the Ministry of Health is concerned, but there are many other ministries involved, so it may not be complete because of the number of ministries that have this requirement.

But we're going to provide that information, and the review will determine appropriate recommendations with respect to how to deal with the concerns, for instance, such as you've raised today.

Mr Charles Harnick (Willowdale): I'd just like to thank you very much for being here, because what you've essentially pointed out is an area of insured services that will not be available to children. It really is an impediment that is being placed in front of a family in terms of the educational opportunities a child may or may not have. Essentially, that's what I read from the brief that you've presented today.

What I wonder is if you can tell us what your experience has been in terms of other similar situations where OHIP has not been available for non-medical situations but that are parallel situations where you need to obtain, at some cost, information in order to advance a child's educational opportunities.

For instance, it comes to my mind, psychological testing, where you may have to send someone to a psychologist, where there has to be a payment made by the board to the psychologist, where there's a report prepared, where there might be a dental problem where you might have to use an outside dentist or a speech pathologist or auditory testing that might be outside of medical areas but where an expense is incurred. How difficult have those situations been in terms of dealing with those extra costs? What impediments do they create?

Ms Cansfield: It's an excellent question and actually it's a good question that will bring out an opportunity to illustrate maybe some of the inequities in the system.

Recently, as you've heard, there was a lady in the north who was going to quit her job because of the issue around suicide with children, and that there was supposed to be some movement put into the situation by government, and it has not happened.

We have similar situations, obviously, in southern Ontario, and in the large Metropolitan area, we have children from dysfunctional families or even from functional families who go into severe depression, and we have an issue of suicide. We can't deny it. It's something that's part of the society that we have to deal with.

Certainly, as a large urban board, we have the opportunity to pull in a psychiatrist who can maybe then access, through his own personal pool, some sort of bed in a hospital wing to help that child, that dysfunctional youth. That isn't there in the north, because they don't have the psychologist or the psychiatrist to begin with. So you can already see some of the inequities. The cost of that psychologist is part of this $346.6 million.

The other is, you get into the issues around social workers. The number of children who take early excused leaving from school -- SALC, that is, supervised alternative learning centre, or SALEP, that is, supervised alternative learning for excused pupils -- the attendance and counselling that's required for that and the social work is to deal with dysfunctional families.

There is a recent statistic that will tell you that a single-parent family typically has a higher risk of a dysfunctional family and/or children with disabilities, because it tends to separate families. So here you are, you've got a parent who is single with a child with special needs and you're placing another burden on that individual by virtue of the fact that you're now going to say, "You have to pay for those assessments that we might demand in order to try to provide the necessary schooling for the child." It is another impediment.

The fact is, the boards are having to prioritize themselves and say, "We can only do so much with what we've got." How do you deny a child? How do you in good conscience deny a child whom you say is your future? "Education is the future, the children are the future, except, excuse me, we'll throw these bricks in your path and you may never get to your future." My position is, put your money where your mouth is. If you believe in children, you believe in children.

Mr Harnick: Do I have another moment?

The Chair: You have a supplementary, yes.

Mr Harnick: Am I wrong in categorizing this as really user fees on children? Is that what we're talking about here, user fees being imposed on children so that they can continue their education?

Ms Cansfield: Certainly it could be categorized that way. I would like to think, in all fairness, that it was never the intent of the legislation to capture the children. I think they fell through the crack. Maybe I'm wrong. I certainly read that regulation and it hurt a little, because it identified school boards, but in fairness, the actual legislation did not. Of course it's a user fee. You could find another name for it, but it is. It's putting in the path --

Mr Harnick: Parental contribution.

Ms Cansfield: All right, parental contribution would do. I really don't believe that it was intended to come out that way. I can't in my heart believe that.

Mr Stephen Owens (Scarborough Centre): Just a very, very quick question. I think you're absolutely right that it's certainly not intended to disadvantage children or anybody else for that matter. In terms of employers requesting medical notes for disciplinary purposes etc, this certainly falls under that bailiwick.

I'm sorry I missed the oral part of your presentation but I did read through your recommendations and I'm a little bit concerned that it's your view that children will be denied psychological services, that they will be denied testing as a result of this bill going through.

I'm sorry, but I don't see it that way. Maybe I missed your reasoning as to why your association feels that children are going to be denied. Maybe you weren't here yesterday, I don't think you were, but the ministry and the parliamentary assistant indicated that the ministry will be the payor of these costs.

Mrs Sullivan: We need a clarification.

Mr Owens: It's a matter of clarification. Maybe you can explain to me why in your view you feel that children will be disadvantaged.

The Chair: Mr Owens, could I ask the parliamentary assistant? He just wants to make a clarification about what he said yesterday.

Mr Wessenger: I think we should clarify that the review of the third-party situation is going to result in recommendations. It's going to first of all look at the requirements to see if they are necessary or not. There may have been many requirements under regulations that are no longer necessary today, in which case recommendations would be made that they would be eliminated as requirements.


The second issue would then be to look at the question of who is the appropriate payor with respect to such a requirement. That could result in some situations -- for instance, if you're getting a pilot's licence now, the situation is that the person who wants a pilot's licence pays their own costs. That would undoubtedly be the same in the future. That's an example of where the individual pays. In other instances it may be appropriate that the government pays; in other instances it may be appropriate the party requesting pays. That review will determine what the appropriate recommendation is in each instance. I hope that clarifies the situation.

Mrs Yvonne O'Neill (Ottawa-Rideau): We had a lot of discussion on this both when we began the introductory remarks by the parliamentary assistant and again yesterday.

I'd like to go back to page 3 of your brief. There are many sections of the Education Act that are "shall" and there are some that are "may," and you've highlighted both of those. I want to get some comment on that from legal counsel, through the parliamentary assistant, because what was stated yesterday was that there's a chargeback possibility from one ministry to the other, and I wonder if the operative words in these parts of the Education Act being "shall" and in other parts being "may" will have anything to do with the chargeback proposal. I also wanted to reiterate, and I think I'm correct, that the things that are at the top of page 3 could definitely change from board to board, that not every board in the province would have the same regulation, nor would every municipality.

I find that there is an incongruity in what is happening and who is going to make the determination of what is medically necessary. The medically necessary to return to a child care centre in my mind is directly related to what's medically necessary to return to school and, in some cases, for employees to return to work, depending on their setting.

What I'm suggesting is that the air seems to get murkier and murkier around this. I can understand why your boards are concerned, and we certainly understood why the coalition was disturbed yesterday. I've spent quite a bit of time thinking about this in the last 24 hours. Can I get some clarification?

Mr Wessenger: I probably can answer the last question about in whose opinion something is medically necessary. It's set right out in the regulation as being in the opinion of the physician or practitioner, so that's who determines what is medically necessary.

Mrs O'Neill: But in some parts of the act medically necessary is "shall" and in some parts of the act medically necessary is "may."

Mr Wessenger: I will ask legal counsel to comment on that.

Mr Frank Williams: Which statute are you talking about? The Education Act?

Mrs O'Neill: Right. I'm talking about when we have home instruction, for instance, it's a "may" require. When we have the IPRC system, it's a "shall." All through the Education Act there are shalls and mays, and medically necessary requirements are in all of those. I don't know who's going to eventually say a shall will become a may or a may become a shall in the Education Act.

Mr Williams: I can't comment. I haven't read the Education Act in any great depth, but it would be premature for me to comment before the review has been made as to what the determination is going to be, but certainly it's not going to hinge on whether it's a shall or a may. If there's a third-party service in any way, shape or form, we'll look at it and we'll be examining it.

I think it's also fair to say there are certain situations now where there are chargebacks to government. WCB is probably a good example where we pay for it and we charge them back and they reimburse us. There are certain situations now where the government in fact does pay as a third-party requester.

Ms Cansfield: If I may, I'd like to add into your deliberations that as you are deinstitutionalizing the children and putting children back into the community in an integrated service, or you hope to, children who have been historically considered very high-risk for a variety of emotional behaviour and educational needs, there are no shalls or maybes there. It's not grey. These children must have that kind of assessment.

Then to add to your complications in your deliberations, typically governments use these things with regard to grants. What about those school boards who do not receive grants and who in fact have been paying for those chargebacks wholeheartedly because they believe in the needs of children or youth? Possibly next year, because of the social contract, I also suggest there will be more boards in that kind of situation where they also will have to be prioritizing as to what they cannot do. There is a need to maybe fully investigate the act under special education and the needs of the children, where there is no question that they must have these in order to be able to provide the service. If you have a multiple-handicapped child, developmentally, physically, behaviourally, there are no grey areas; the children have to have assessments and they have to have them on an ongoing basis. Who pays?

The Chair: Mr Martin. I don't mean Mr Martin pays, but he has the next question. I would remind you, Mr Martin, if you wish to make that suggestion to pay, I'm sure it would be accepted.

Mr Tony Martin (Sault Ste Marie): Can I talk to my wife first?

I think it's really valuable that you come forward and raise the red flags you do re this whole question. It's a very difficult exercise we go through as we try to manage the fiscal reality in front of us today. We need to do it together in partnership because, as I've seen through the discussion that I've watched over the last few days, this is a complicated issue, and the more we get into it the more complicated it gets. We'll only get to a bottom line that is manageable if we work cooperatively.

You made some comments, though, that brought me to a question. I come from the north, and you mentioned the issue of children and suicide. I hope you weren't suggesting that some policy or some initiative or direction of this government is what's getting in the way of some of the folks who live in northern Ontario getting the kind of psychiatric care they need, particularly children and where it concerns the possibility of suicide. We're trying every which way but loose to get psychiatrists to go up into the north, and they just aren't going. We've offered all kinds of incentives. There are underserviced area programs, there are things we're trying to do, and I am personally involved the Sault in those attempts. Do you have any other suggestions about what we might do to --

Ms Cansfield: The use was an analogy; there was no intent. I recognize, as we all do, the very serious issues in the north trying to access medical care, but in fairness, if you're trying to look at issues in a fair and equitable way, there is no question that something like this puts the north at a greater disadvantage by virtue of location geographically, if nothing else, and then also because economically the whole province is depressed. From the north, you know how serious that is, as it is here in my jurisdiction, which is Etobicoke.

I agree with you. There's the need to look at these issues realistically and to find ways and means so that, of all the people you do not prejudice, it's the children, because they are the future and you wouldn't want anything, I would think, that would stand in the way of a child receiving whatever it is they need to succeed. If it's a medical assessment, then I think we should find every way to take that bar and place it in a flat position, not in a vertical one, because that's the child who needs to succeed even more. That's where I was coming from using that analogy. We all understand most fully the issues in the north and how difficult it is to access a number of psychosocial support services.

Mr Martin: If we could get them up there, we'd gladly pay them.

The Chair: Ms Sullivan, you had a point of information, just before we end?

Mrs Sullivan: Yes. I am quite concerned with the response from the Ministry of Health, the parliamentary assistant, with respect to this particular issue. We've heard about how third-party billing can incrementally add to the inequities that exist and so on, but I am most disturbed at the evidence that the analysis, first of all, of who this section of the act would apply to has not been done; how it would apply has not been done; that there has not been the policy thinking surrounding the questions, by example, of who pays and whether there's going to be another tax load at the local ratepayer level; whether the Ministry of Education is going to be required to pick up additional costs or if parents are going to be required to pick up additional costs.

I think we are all concerned as we're looking at this bill with the integrity of OHIP, that the requirements for payment fit not only the specifics of the Canada Health Act but as well the traditions that have grown up in our province with respect to what is medically necessary or medically efficacious. I would be very interested in seeing if the government would be willing to stand down these amendments and re-present them when the homework's done.


Mr Wessenger: Perhaps Dr LeBlanc might be able to assist with something with respect to the whole question of the review.

But I might point out that the normal legislative process is that you do. If you look under all our legislation, you have the act passed and the regulations involve an extensive consultation process. If you look at, for instance, the Regulated Health Professions Act, there's an extensive consultation process and review before you come up with the regulations. I'd suggest under this bill it's the same situation. We have the legislation, and the normal process is to have your reviews and consultations done before the regulations are drafted and after the legislation is passed.

The Chair: The issue is clearly on the table. I want to thank the representatives from the public school boards association for coming in and presenting their views. As you can see, that has elicited a lot of interest and will be continued. Thank you for coming.

Ms Cansfield: Thank you very much for the opportunity. I would just like to say in closing that although the wheels of legislation will continue to roll, the children continue to grow and their needs do not change. I ask you keep the consideration of the needs of the children in mind.

Mrs O'Neill: We've just been told that the regulations are going to come after the legislation. Could we then know whether the regulation that keeps being quoted by both the parliamentary assistant and legal counsel, regulation 785/92, is not going to hold? This is referred to as the parts that are going to be exempt in this bill. Is this not going to hold? The impression I get is that there's a possibility that's going to change.

The Chair: We just have two more presentations. Could we do those and then come back to your question before we break, because we'll have time.

Mrs O'Neill: I'm patient.


The Chair: I call the representatives from the Ontario Dental Association. Welcome to the committee. Would you be good enough to introduce yourselves for the committee members and Hansard and then please go ahead with your presentation.

Ms Linda Samek: The Ontario Dental Association is pleased to have this opportunity to speak with the committee on Bill 50. I am Linda Samek, the director of professional affairs for the Ontario Dental Association. With me is Frank Bevilacqua, our director of government relations.

Our association, the ODA, is a voluntary professional organization which represents the dentists of Ontario. Our mission is to support members in the provision of exemplary oral health services and to promote the attainment of optimal health for the people of Ontario.

One of the goals of the ODA is to improve access to dental care. We are here today because we have some concerns about the items listed in Bill 50 which will have an impact on access, patient-practitioner relationships and the ability of practitioners to maintain an efficient working environment. In our view, many of the administrative responsibilities of the Ministry of Health will be, for want of better words, downloaded to the practitioner. Such requirements clearly add to the burden of conducting a health care practice.

Ontario dentists have specific concerns about the policing requirements outlined in the revised amendment package. As we have reported previously, the ODA does not believe that health care practitioners should be responsible for ensuring that patients register for health care coverage. Similarly, we do not see the dentist as a prescribed person who would take possession of a patient's health card. Most particularly, dentists do not want to be responsible for determining whether a patient is a resident.

We are disturbed that this bill not only expects practitioners to be investigators, but also expects practitioners to report privileged and confidential information. Dentists are qualified health care providers who work with their patients in a relationship based on trust. Legislation designed to withhold funding need not invade a patient's right to privacy. We do not understand why this bill proposes to violate patient confidentiality and practitionerpatient trust.

On this point, we simply do not understand how any practitioner is expected to know if a patient is a resident. Practitioners like dentists are professionally educated and clinically trained to provide diagnostic, therapeutic, rehabilitative and preventive health services. They are not detectives, police or enforcement agents.

With respect to the reporting requirements, we would ask for clarification on the matters of voluntary reporting. In subsection 43.1(1), the prescribed person or practitioner "shall promptly report" to the general manager. The bill continues to outline the defence for delaying or failing to make a report, yet the next clause, section 43.2, refers to voluntary reporting. In this context, we don't understand if all reports are to be voluntary or if there are additional reports that are to be completed on a voluntary basis. For the record, we simply don't support mandatory reporting.

We also want to know if dentists are to be captured under the revisions to clause 45(1)(c.1). It is our understanding that the Ministry of Health and the Ontario Medical Association have entered into an agreement that is to limit the number of physicians who can bill OHIP. However, the ODA has not entered into such an agreement with the ministry.

Bill 50 continues to outline the implementation procedures regarding the agreement between the government, or the Minister of Health, and the Ontario Medical Association related to the making of regulations on numerous matters related to third-party services. We would like assurance that such regulations would not relate to the services provided by dentists.

Where any related regulations will impact upon OHIP-insured services and/or payments to dentists, the ODA must be included in the regulation-making process. In any event, the reference point for fee-for-service charges related to dentistry should be the ODA-suggested fee guide for general practitioners.

For purposes of clarification, we would like to explore this point further. For example, it is our understanding that this committee has been informed that the social contract proposals relating to the delisting of OHIP-insured services from the schedule of benefits for physicians do not affect other professions, yet general anaesthesia that supports a non-OHIP-insured dental procedure is on the list of services to be removed from the OHIP schedule of benefits.

First, you should know that the majority of dental services are not covered by OHIP. A very limited number of in-hospital surgical procedures are included in the OHIP schedule of benefits for dentists. Even then, there are additional preconditions regarding the patient's health status for some of the listed procedures. So even when patients require hospital dental care, there's no automatic OHIP coverage.

Should the ministry and the OMA agree to delist these needed general anaesthetic services, many medically compromised dental patients will be placed at a great disadvantage. Just harkening back to the presentation before us, here we're talking about children as well, and I think this is an important point for us to remember.

To ensure that patients are protected, we need to have a comprehensive consultation process. With this in mind, we recommend that where regulatory changes might impact upon the delivery of care provided by nonphysician practitioner groups, these professions be specifically included in the regulation-making process.

Even if the current proposals regarding third-party services are not intended to extend to dentistry, we question the merit of establishing yet another layer of bureaucracy to determine disputes regarding third-party services. Further, we do not agree that decisions made by such a body should be binding, with no right to appeal.

Our final comment is about the first clause of the bill, designation of obligations. Are such obligations limited to the Social Contract Act or is it any obligation of the crown? In our view, the current wording is too broad and should be more focused.


As we have stated throughout our presentation, it is not clear to us exactly which section of the bill will affect dentistry. The language is not clear with respect to which practitioner groups might be affected by Bill 50. We trust that you will be able to address our concerns through this committee process. If there is any way in which the ODA can assist during your deliberations on Bill 50, please don't hesitate to call us.

The Chair: Thank you very much for your submission. We'll begin questioning with Mr Hope.

Mr Randy R. Hope (Chatham-Kent): First of all, as I was going through your presentation, in the first part you have a problem with the OHIP cards, questioning the whole ethics behind 43.1 and 43.2. Then on page 3 in the last paragraph, you indicate that the majority of your services are not covered by OHIP, a very limited number in hospital surgery.

I'm asking, why do you have such a problem getting at some of the fraud issues that we hear about and the allegations that are being made about abuse in the system? The first question would be, why would you have such a problem reporting? I don't see where the patient confidentiality or a patient trust relationship -- if somebody is inappropriately using a card that is not theirs, where the problem would be in that trust aspect.

Number two is, why are you speaking out so fully against it when you tell me that the majority of your dental services are not covered by OHIP, and if they are, they're in hospital? The hospital came to this committee in the first place and has no problem with grabbing the cards if they're inappropriately used. I guess I have to seriously ask that question.

Ms Samek: You've raised two issues. One is that my understanding of the language says that even if there are questions of confidentiality or other legislation in place, the practitioner would be required to violate that. So we're not clear exactly what you're talking about. You don't limit it to that; you have some overriding exclusions. We don't know what those exclusions are, so that's what we're referring to.

The other one is quite frankly that it's not a matter of how many people are able to provide these services. Our people are not there to do that. They are there to provide services. They are there to work with their patients in a relationship of trust. It doesn't matter who pays the bill; they're supposed to provide quality care in an ongoing way, and we don't want the payment mechanism to become the issue for the patient-practitioner relationship. We don't want everyone running around continuously, trying to understand, "Are you in fact a bona fide OHIP card carrier?" I think that's a real issue.

Mr Hope: A lot of this information you're going to search out prior to that. Let me tell you, a lot of people in the province of Ontario do not have dental coverage and do pay for it out of their pocket, either through private insurance with their employer, or they pay directly out of their own pocket for dental services, or they're covered by a government program. There are a lot of working families who don't have it.

When you're talking about scheduled surgery, there is a process before it gets to a scheduled surgery process. When you go in to see your dentist, there's information that's required, like most surgeries. You have all these forms to fill out before even going into surgery. When you're starting with a new dentist, all this information -- it's not somebody new just being dropped in your lap whom you have to provide dental service for.

Ms Samek: There is no way that the practitioner can determine whether or not this is a resident who is a qualified, bona fide health card holder.

Mr Hope: Steve wants to go ahead.

Mr Owens: Thank you, Ms Samek and Mr Bevilacqua. We run into each other again in another health-related issue. I think your question of clarification is an interesting one, and perhaps the parliamentary assistant, at either the end of the proceedings or at this time, can clarify for the ODA where exactly the ministry views dental practitioners falling into this particular piece of legislation.

The Chair: Perhaps it would be appropriate to do that now.

Mr Wessenger: Yes. First of all, I think it should be made clear that there will be consultation before any prescribed persons are named under the legislation. So I would like to assure the dental association that there will be consultations before any regulations are passed in this regard. That's the first thing.

The second thing is, with respect to the card, it should be noted that there's not a mandatory requirement that a prescribed person or practitioner take a card. It's purely permissive. It allows the prescribed person to accept the surrender of a card. I don't know whether I've covered all the items. I think those were the two items that were raised.

With respect to the whole question of general anaesthetic for dental procedures, as I understand, a letter was written by the Ministry of Health back on May 27, 1993, that indicated that if it was necessary that patients be hospitalized in order to conduct a dental procedure, they would still be covered by OHIP. It's only if it was an elective hospitalization, as distinct from required for medical reasons.

Mr Owens: Just on a supplementary and a point of clarification: If in fact a patient is admitted to hospital for this procedure, where does the duty fall with respect to the health card? Would it fall on the practitioner in his or her office, or does it fall on the hospital admissions person at the time of admission for that procedure?

Mr Wessenger: It would apply to the hospital.

The Chair: Would you like to ask a question with respect to that clarification?

Ms Samek: I guess we're pleased to hear that, because we had heard that in the letter. But subsequent to that, we continue to see the delisting of general anaesthetic related to non-OHIP-insured dental services on both the government's list, we understand, and the OMA's list for delisted services, so we don't feel confident that this hasn't fallen between the cracks.

Mr Wessenger: I can only comment that I'm not aware of any change in that circumstance, as set out in the letter of May 27, 1993.

Mrs Sullivan: We have been asking for the list of procedures that are being recommended by both the OMA and government to be made public. That has not been done so far and we feel very strongly that this process is an offensive one.

I would like you to talk, because we don't know what is on those lists, about the difference between oral surgery that would be considered elective in comparison to those procedures which are already included under the OHIP schedule. It seems to me that the parliamentary assistant is describing elective measures as a matter of consumer choice rather than perhaps a matter of oral health. I think the question of anaesthesia with respect to oral health care is a fundamental part of what is overall health, and that's been shown through studies over many years.

Ms Samek: I think, just to start, that we're talking in this particular instance about, perhaps, restorative services being provided to, for instance, a Down syndrome patient who may require hospitalization because of the other medically compromising situation that patient is in, so as an adjunct to that, there would be a requirement for anaesthetic services. The elective services, if you will, as has been proposed, the restorative services that would be provided, are not OHIP insured in those instances, even though the patient may be medically compromised and requires some hospital care.

There would be a number of different situations we could talk about, but that's really the one that comes to my mind first, because we're talking about special needs of a special patient population. That patient is going to require the anaesthetic, is going to require perhaps in-hospital service, but would no longer be able to have that part of it covered by OHIP because OHIP would not see that as being medically necessary because it was supporting what is deemed to be an elective service.


Mrs Sullivan: I appreciate that, and I think that's useful for the record. One of the other areas you speak about is the difficulty of the professional determining whether a person is a resident or not a resident or acting on a suspicion or belief. We will be proposing amendments to that particular drafting, and I suspect the government has heard enough on that issue that it too would be doing that.

Once again, your profession, like virtually everyone else, did not know or had no notice about the third-party billing issues. Our feeling is that the sections of the act with respect to those areas are premature. The work hasn't been done and the consultation hasn't taken place.

You have a very extensive information network with respect to dental services. Do you think the services you have available could be used as any kind of model on a third-party billing process that could be put into place?

Ms Samek: We'd certainly be able to explore that with anyone who was interested. Clearly, what we heard a little earlier is that often the patient is paying. In fact, we think it's important for patients to be involved in the process of understanding what they are getting as treatment -- and, by the way, there are some costs involved in that.

Really, one of the things we're here for today is clarification. If that comes today, we would certainly look forward to working with the ministry or whoever is involved in helping us understand where we fit into this process, if there is going to be an impact for dentistry and its patients.

Mr Harnick: I just want to touch on the OHIP card aspect of this. I gather there are some services for which OHIP covers dental work that has to be done, and your concern is that if someone comes in and presents an OHIP card to a dentist, you don't want to be in the position of being the policeman or the investigator. You want to take that card at face value, correct?

Ms Samek: Yes.

Mr Harnick: The same way, if we go into a store and use our American Express or MasterCard, the store person looks at the card and runs the strip through the little machine; it's a valid card and it's in use and nobody's said anything about it, so you can assume it's a valid card. What you're saying, as I understand it, is that it's your job to look after people's dental needs and dental health, and it's the government's job to look after the validity of the cards that are out in circulation. Am I missing something here?

Ms Samek: That's pretty much what we thought we said. I like your thought of a swipe card process. If it were something that was easy for practitioners to handle in their practice, you may find there was more acceptance of this. But what I hear is that the version cards have been a mess, that there have been long delays in payments for patient services because the version has been incorrect, even though the patient assures that the version has been correct, so there are some real problems there already. If we had something that was, as you said, a swipe authorization, we may be able to look at it in a different way, but right now we see just a horrendous process in front of everyone.

Mr Harnick: What I fear is the idea that you now have to become something more in the dentist-patient relationship. You have to be the person who's going to look after the patient and you also have to be the person who investigates the patient. Quite frankly, if you want my opinion, for what it's worth, that's wrong. It's wrong for somebody to have to be in a position of on the one hand giving care to a person and on the other hand investigating them. It's the government's job to do that and it shouldn't be trying to circumvent its own obligations. I think we're on the same wave length.

The other aspect of your brief that I find very interesting is on page 4, where you say, "Many medically compromised dental patients will be placed at a great disadvantage." I suspect, knowing a little bit about health care, that there are many people who, for whatever reason, cannot undergo the basic treatment that the mainstream will undergo and need an anaesthetic to be able to have the work completed, maybe because they're too nervous, maybe because they have a blood pressure problem, maybe because they have other health problems.

Just for my own clarification, I would like to know what percentage of people would be at risk in terms of having to pay for the cost of dentally necessary treatment if anaesthetic services were taken away from what would be elective but necessary dental services.

Mr Frank Bevilacqua: I don't think we know the percentage exactly, but what causes us most concern is the issue involving the delisting of GA from insured services, simply because a large number of patients who obtain treatment are on social assistance. Many are children and they are part of CINOT, the children in need of treatment program. The problem with delisting is that if that happens, then these individuals may not necessarily be captured by the medically indicated conditions listed in the OHIP bulletin and there isn't an ability to pay by these individuals. I think that's what causes us most concern. We want to make sure that people of that nature do not fall through the cracks.

Clearly, as you indicated, it's not possible to do the work on these individuals within a dental office. It has to be done within the hospital environment.

Mr Harnick: It may help in terms of the way we have to look at these issues if we had some idea of the number of people or the percentage of patients who would be affected. I appreciate you don't have that now, but if that information could be conveyed, it may be helpful.

The Chair: Could I ask the parliamentary assistant to comment.

Mr Wessenger: I'd like to perhaps get to the crux of the situation. I understand your major concern is about the children in need of treatment program, is that correct, with respect to the general anaesthetic?

Mr Bevilacqua: It's one of the concerns.

Mr Wessenger: For instance, in the letter that was sent to the president of the association, it was indicated that those patients who currently have their uninsured dental services paid for under the children in need of treatment program administered by the ministry's public health branch will also have associated uninsured anaesthetist services paid for through the same program, so it is guaranteed that this will continue under that program.

Mr Bevilacqua: There were updates that were sent after that letter indicating that the whole thing had been on hold just because of the amount of confusion that was created. To our knowledge, there hasn't been further consultation, and all of the details have not been worked out.

There are simple, logistical issues related to that. For instance, in the CINOT schedule, I believe it only calls for six or eight units of GA. The question that immediately comes to mind is, what if a child has to be under longer than that? There are various problems with that and there were issues that needed to be resolved in that regard.

Ms Samek: Just as a follow-up, one of the other things we've had to deal with over the last little while is that the CINOT program has really been hitting its limits in different regions of the province, so there have been some severe limitations placed on how much they can do and now we're adding another burden to that. If there is going to be a way to take care of these children, we welcome that, but we caution you that we've already seen some funding problems with CINOT over the last year.

Mr Wessenger: Just for the purpose of information, I'm wondering if you could indicate how often you would be billing OHIP; how often a dentist would be billing OHIP. Would it be very often?

Ms Samek: No. There are 6,000 dentists in Ontario; 417 of them billed OHIP in 1992. We're not talking about great numbers of dentists, we're not talking about great numbers of services. In fact, we're looking at approximately $8 million in OHIP billings for dentistry. This is, if you will, a related service. It's not a dental service and it won't affect the dentist. It will affect the patient's ability to be able to get into that hospital. That's what we're really concerned about.

The Chair: Thank you very much for coming before the committee today. We appreciate it.



The Chair: I call on the Patients' Rights Association, if they would be good enough to come forward.

For those whose legs have frozen, we are trying to get a little more heat in here. Yesterday we died of heat prostration; today it's the reverse.

Welcome to the committee. We're pleased you could join us this afternoon. Would you be good enough to introduce yourselves for Hansard and for the members of the committee and then please go ahead.

Mrs Anne Coy: Very well. I have a bad throat and I need a doctor. He's gone.

The Chair: Do I dare pose the question: Is there a doctor in the house?

Mrs Coy: My name is Anne Coy. I'm the president and co-founder of the Patients' Rights Association, not to be confused with parents' rights, because parents tell me they don't have any.

The Chair: That's a whole other issue. We'd better be careful.

Mrs Coy: Harry Beatty is the vice-president, and he has prepared the brief and will discuss it with you.

Our position is outlined in detail in the brief that is before you. What we have been trying to do for about 18 years, and we're not discouraged yet, is to establish the fact that the patient is a stakeholder in the health care system. I was on the public hospitals review committee and was seen to be quite radical when I said that, because the stakeholders were described as the providers of care. It's an issue of career on behalf of one part of the partnership, and life and wellbeing on the part of the other.

We are concerned, mainly in the health care system, with the avoidable medical accident not being repeated. We thought it was a noble cause. We didn't think it would take us so many years to get the idea across.

Because of the time element, I'll pass it over now to Harry Beatty.

Mr Harry Beatty: I'm going to summarize the brief rather than read it verbatim, in the interest of time.

Essentially, we have a systemic concern about the way Bill 50 and the agreement between the government and the OMA have developed. We recognize that the social contract concept is a good one, not to say a necessary one. We recognize that this year the provincial government found itself in a very difficult fiscal position with regard to health care funding. None the less, we have major concerns about what we identify as exclusion of the public from the health care policymaking process.

Bill 50 is intended, in large part, to implement the agreement between the government and the Ontario Medical Association, although other health professional services are also affected. Under the terms of the agreement, broad health policy areas such as payment for third-party services, measures to control health care fraud, availability of physicians, delisting of OHIP services, implementation of the Consent to Treatment Act and Substitute Decisions Act, drug reform, issues relating to physician legal liability and public education initiatives are all subject to bilateral negotiations between the OMA and the government.

In our view, these go beyond economic arrangements. Essentially, what happens is that the government and the OMA are now developing the framework within which these issues will be addressed on a confidential basis, and members of the public, both individually and through their organizations, are essentially left to react to these proposals, and where there are cutbacks, to fight a rearguard action.

While again we can see the necessity for the government to arrive at some arrangement with the OMA, we wonder where in this process there will be a timely opportunity for northern and rural communities -- this issue has already been addressed today -- individuals who require special health services and drugs because of their illnesses or disability, groups concerned about the implications of third-party payment rules.

Are they going to be left presenting their concerns after the fact? There have been several steps taken over the last decade to give the consumer a bigger role in the health care system, but we believe this may well be a change in direction. We also do not see a commitment on the part of the government to make disclosure about the impact of Bill 50 and the agreement on the system.

We also want to address, however briefly, some of the major issues that have been raised around Bill 50 by other organizations.

Health care fraud is addressed largely in Bill 50 as a consumer-based problem, and we're not denying that that is real, but we also believe that providers are responsible for abuse in the system as well. Certainly there should be a focus on ineligible individuals not receiving services, but there should also be measures to control the unnecessary provision of services, looking at the quality of service to ensure that a lot of money isn't going into inadequate or unnecessary services, and also there should be rules around conflict of interest, for example, in referring practices of health professionals.

With regard to the health card system, it is important that the confidentiality of health care information be protected. We would be in a somewhat better position if we had comprehensive health record confidentiality legislation, as Mr Justice Krever recommended some 15 years ago. But we believe in any event that the health card system has to be looked at carefully to ensure that confidential information about a person's health status is not released inappropriately in this process.

We have not worked out a detailed position on mandatory reporting, but we would generally support the idea of very specific legislated rules. We are concerned that the major provider groups seem to have a great deal of difficulty with interpreting these rules and believe that their members will not be able to interpret them consistently. We believe the reporting of what are identified as abuses should not be left to individual interpretation of practitioners. We also would support the concept that verification of eligibility should be the responsibility of the Ministry of Health, so far as that is feasible.

We are very concerned that patients may be refused or delayed in receiving needed health care if providers are required to have a detailed eligibility determination process in place. Think of yourself arriving at a hospital emergency department with an ill youngster and some of the anxiety it might cause if there were a lot of demands on you to produce documents and that kind of thing. In effect, we think that eligibility should be determined before the actual services are required. However, practically, I think the provider would have to play some role in ensuring that the person coming for treatment actually is who he says he is and so on.


In the area of third-party payment we have, like other groups, concern about the Bill 50 solution. Consider the individual who requires a medical report in order to qualify for sick leave benefits or maybe to combat disciplinary proceedings. The employer is the third-party payor. If we understand Bill 50 correctly, the physician may bill the employer directly, but unless there is some guarantee, some arrangement between the employer and the physician, we would expect the choice would usually be to bill the individual patient and get paid at the time.

Now, under the act the employee in this scenario may be entitled to reimbursement from the employer. But if you put yourself in the position of the employee, would you really want to be pursuing a civil remedy against your own employer? Basically the same thing applies if the third party is an insurer providing benefits to you, or a camp that your youngster wants to go to, or a school, and you heard the presentation from the school board on this issue.

There may be other things that can be done. There are an awful lot of organizations that require medical certificates from people, and perhaps the right to request them should be addressed directly in legislation. Another idea would be to have a sort of standard form medical report so that even if organizations were requesting them, they would have to accept a standard form one rather than presenting the individual and the physician with a confusing variety of forms.

Also, in our experience, it causes a lot of pressures on the doctor-patient relationship or on the patient relationship to other health professionals, where the professionals are the de facto gatekeepers, the people who are really deciding the person's eligibility for something else.

We believe that health reports should just be that, health assessments, and that we should not have systems where physicians in particular are deciding whether people should receive benefits from government or from insurers, where the doctor is the effective decision-maker. Essentially, we believe the Ontario Medical Association agrees with that position.

Delisting of services and drugs and the limitations on availability of physicians, which are implicit in the agreement, are clearly matters of great public concern. Again, since we don't know what is coming forward, it's hard for us to respond specifically. Clearly, there are many health care consumers who are going to be deeply concerned about losing OHIP funding or losing their drug coverage or not having sufficient numbers of appropriately qualified physicians available in their community. But we believe there may be an announcement that the limitations are made and then, to come to back to our basic concern, people will be essentially trying to rectify decisions that have already been made and where implementation is under way.

Finally, on physician liability issues, Bill 50 and the agreement that it authorizes have brought incorporation of physicians' practices to Ontario and also have continued a large subsidization of Canadian Medical Protective Association fees. The issues in this area are admittedly difficult, but basically what we are asking is that there be a review of the law in this area.

There was a major review conducted by Robert Prichard, now the president of the University of Toronto, at that time I believe the dean of the law school, which dealt with many of these issues in a comprehensive way, but it seems to have been entirely forgotten by the governments that paid for it. Certainly, there are many things in that report that will require being examined in more detail, but it would nevertheless be a good starting point.

The Chair: Thank you very much for your presentation, and we'll begin the questioning with Ms Carter.

Ms Jenny Carter (Peterborough): First of all, I'd just like to congratulate you. I think the Patients' Rights Association is a very necessary organization and I have a very great deal of sympathy with you. I think the patient has to be the centre, period. That's what it's all about.

I'd just like to hark back to the three acts, the substitute decisions, consent to treatment and advocacy, which this government has brought in, although we haven't seen it all in action yet. I believe that the motive behind those acts was to empower consumers. That's what it's all about.

The advocate is somebody who's going to listen to a person and do what that person wants. Living wills are going to be honoured. People are going to be able to make decisions in advance about the kind of treatment they will want and so on. So I think we are making progress in considering the consumer as being the centre, and we did listen to a lot of people when those bills were having hearings who were consumers and certainly gave a lot of importance to their opinions.

I am just wondering about this question of how we make sure that there's no fraud. It was mentioned by Mr Harnick a moment ago that cards can be used in such a way that you just pop them into a machine and a bell rings or something if that card is blacklisted and is not valid. But I wondered whether you might feel it would be better to get away from that system all together.

My colleague Dr Frankford I see has left -- he was here -- but I know he believes very strongly, and I sympathize with him, that a system of registration would be more efficient, where each consumer was signed up, as it were, with a particular doctor who would then be responsible for whatever care they received and for the payments connected with that, or do you feel that the card is the best way to go?

Mr Beatty: Actually, Mrs Coy and I spoke briefly with Dr Frankford before coming in and he raised this possibility with us. It might be ideal, I suppose, that everybody be a member of a health service organization or something of that nature, and then they would sort of take responsibility for registration. But in fact, in our experience, many people now do not have a family doctor or any health organization they see on a regular basis, so it would require I think a very major restructuring of things to associate every individual with some particular practice or health service organization. I think that's what Dr Frankford was suggesting but, as I said, a lot of people right now don't have any health organization they're affiliated with to register at.

Mrs Sullivan: I think this is an extraordinarily good brief. I think that it provides a reality check that too frequently we're missing as we're approaching this legislation because we're offered erudite things about the philosophical impact of mandatory reporting and so on.

What you've done is bring this right down to the practical level of access to care and the mechanisms that are available to the patient with respect to receiving care and the kinds of conflicts that are set up or an unease that may be built if a patient knows, by example, that a physician is responsible for determination of their eligibility as well as for providing treatment.

I also think that some of the suggestions you have made -- by example, going back to the Krever report is one that's really worthwhile looking at. We have not had anyone else before the committee to this point speak about the issue of incorporation and the issue of the CMPA fees. I think that was a very useful intervention. I wondered if you just wanted to take a minute or two to expand on some of the issues you see as problematic in a corporation or where you see that other government policy choices should be made.


Mr Beatty: Frankly, we have not had a chance to look at the rules that have developed around the incorporation in other jurisdictions. The general concern, though, is that right now an individual physician is responsible for the treatment provided. As incorporation is now coming in, will that individual responsibility of the physician or other health professional for the treatment provided still be there? One reason you often have incorporation is to limit the liability of the individuals involved. It's hard to be specific, but say that several physicians have joined together in an incorporated practice and that the individual patient is actually treated by a number of them in rotation or something of that nature. If something goes wrong, who is actually responsible? That's really the question we're raising.

Mrs Sullivan: As the issue goes along, if your organization wants to put its mind to that particular issue, we'd be very interested in hearing what you have to say. I too share your deep concern. In fact, I've indicated that I'm offended with the lack of information with respect to the delisting proposals. We have asked for the lists. We are concerned about the mechanisms that are being put into place. We feel that people have a right to know what the components of their medicare system are going to be and to participate in those decisions. We do not like this kind of bilateral arrangement. I just wanted to underline that, but we'd certainly like to hear from you again on the other issue.

Mr Harnick: You have made the statement, and I'm very impressed with it, under health card fraud that the PRA also recommends that verification of eligibility should be the responsibility of the Ministry of Health. That's a very unequivocal statement. Could you please expand on that in terms of how you see the doctor-patient relationship being changed by reporting and investigatory obligations which I, personally, don't think should be on the back of the doctor. I wonder if you can talk about that, because it may be very helpful for the committee.

Mr Beatty: I think a starting point is that when the person arrives at the doctor's office or health care facility, it's often, to some extent, an emergency or a crisis or something of that nature. The person may not be prepared to advance documentation if that is required. Also, when the consumer comes to the office, I would assume that usually this would not be the individual health professional doing it, a doctor, but it will be delegated to a secretary or receptionist or someone in that role. We have problems seeing how that can be implemented. We also have concerns that there may be mistakes made by the support staff person who is doing this. We just feel it would be better to have an automatic system so far as that can be done. Whether you can take all responsibility away from the provider, I don't know, but to the extent that could be done, it would seem to us to be better.

Really, the most fundamental reason for our concern is that the provider groups are expressing it. They're saying: "We don't know how to do it. We're concerned about what will happen. It's going to be very confusing for our members." If that's their perception, if the rules are not clear, then they're not going to be able to implement it. At the very least there should be clear rules, and I think a minimum of the verification should be at the practitioner's office.

Mr Harnick: You brought up the issue of incorporation. It may well be that the parliamentary assistant can help us out, but it was my impression that although doctors would be permitted to incorporate, in so far as their liability for negligence was concerned the incorporation would not permit them to limit their liability by incorporation. As I understand the incorporation aspect of this, nothing will change if a doctor is negligent and is sued. If it's the group proposal that you talked about earlier, with a number of doctors working together in a group and that all may have had a hand in the negligence, my understanding is that the rules would remain the same. You'd still sue all of the doctors who might have been negligent and they can't avoid personal liability by incorporation. Am I correct about that?

The Chair: The parliamentary assistant has indicated he wants to speak to that point.

Mr Wessenger: I'd like to confirm that Mr Harnick is absolutely correct. The ability to incorporate would not in any way limit the personal liability of the physician. This is probably a standard that I assume applies to all professionals who are allowed incorporation. As well as physicians, I know it applies to proposals to incorporate with respect to lawyers, and I would assume it's a standard provision that all professionals cannot escape personal liability through the incorporation route. I'd like to assure the presenters that this will be the case here as well.

The Chair: Mr Beatty, did you wish to make any comment on that?

Mr Beatty: Simply that I didn't see any reference to it in the legislation itself.

Mr Wessenger: I don't think the legislation refers to incorporation at all. It's to be dealt with as a separate matter.

The Chair: Thank you both very much for coming before the committee this afternoon. We appreciate your presentation.



The Chair: I call our final presenter this afternoon, Mr Shalom Schachter. Mr Schachter, we have a proposed amendment that I believe you have prepared which is being circulated to members of the committee. Welcome, and please go ahead.

Mr Shalom Schachter: I'm a labour relations practitioner for a union in the health sector and therefore am affected by and deeply concerned with the provisions of Bill 50. I have some submissions with respect to both section 1 of the original bill and section 3. My primary concerns deal with section 1.

You may recall that there was some worker concern with the provisions of Bill 48, the Social Contract Act. Well, if you think that affected worker rights in any way, Bill 50 in section 1 affects worker rights in the health sector in a far more prejudicial way, because it allows the Lieutenant Governor in Council to make unenforceable any provision of a collective agreement in the health sector. There is no criterion to say, "In these circumstances, the government has an absolute ability to make unenforceable until March 31, 1996, any provision of a collective agreement in the health sector."

I suggest this is completely unnecessary if the government merely wants to make sure it can uphold its policies from Bill 48, the Social Contract Act. I suggest the provisions in the Social Contract Act itself are sufficient. But even if the government felt that Bill 50 was necessary to help it implement Bill 48, there's nothing at present in section 1 that limits the power of the government to make unenforceable provisions of collective agreements only if they are inconsistent with the Social Contract Act.

I suggest that if this committee wants to try to deal with my concerns by making an amendment that would say that the power to designate obligations will not apply to obligations under the Social Contract Act or framework agreements or local agreements, that in itself will be insufficient to respond to my concerns.

The reason is twofold. First, most of the bargaining units in the health sector did not succeed in achieving local agreements with employers. The reason was not the unwillingness of the workers through their unions to enter into such agreements; the reason was the opposition of the employers, primarily the hospitals through the Ontario Hospital Association, and its direction not to enter into such agreements. So there are no local agreements or framework documents that will affect those employers, because they haven't signed on.

Second, the obligations I'm concerned about are obligations that are created by collective agreements. They are not obligations that are created by the Social Contract Act or by the sectoral framework document or local agreement. So it's insufficient to protect obligations arising under the social contract documentation; it is necessary to protect obligations arising under the collective agreement itself.

My first preference is to simply exempt provisions in or practices under a collective agreement. But to the extent that you may feel it's necessary to have Bill 50 in section 1 give some greater enforcement to Bill 48, then at least in the alternative you should protect obligations that provide employees' benefits if that union supported the health sector framework plan that was designated by the minister under the Social Contract Act.

That's my main concern. It's insufficient to respond to my concern to say that this wasn't the intention of the framers of Bill 50 and that I can rest assured that the government under Bill 50 will not make unenforceable provisions of collective agreements, because we all know that government intentions can change and governments can change. There's still a long time before March 31, 1996, and we can't leave it open to the good intentions of the present government.

There is also a section 3 in the original bill that will require the parties to interest arbitrations under the Hospital Labour Disputes Arbitration Act to pick up the costs of arbitration and to no longer have those costs assumed by the province. I have no problem with that in general, other than to express the view that there should be some consistency. If the government is going to make the parties to this type of litigation assume the entire costs of the litigation, then that should be so for all litigation. The costs of any kind of court litigation should have to be fully assumed by the parties to that litigation, the costs of both judges and clerks, and it should not just be in the field of labour relations but it should be in all forms of litigation.

But if the government is intending to pursue that, to pursue the obligation on the parties to interest arbitration to assume the full costs, then it should not only cease this subsidy to labour relations but should also cease its other, much larger, subsidy it pays to the hospital employee relations service of the OHA. There is a sizeable grant that it gives to the OHA every year to subsidize the costs of labour relations, and it should end that grant as well.

Finally, if the parties to interest arbitration under the HLDAA are going to have to pick up the full shot, then the arbitrators who are going to be appointed to issue those decisions and to deal with those disputes should have to be approved by the parties. Right now there is a process of approval of arbitrators under the Labour Relations Act rights arbitration, and I suggest there should also be a process of approval of arbitrators under the Hospital Labour Disputes Arbitration Act, and there should be a separate advisory panel for the approval of those arbitrators.

Right now, there is a panel composed of labour and management representatives that approves persons who are on the rights arbitration panel. Because interest arbitration is a specialized field and only involves certain unions and certain employers, there should be a separate panel composed of those parties, who will then review the names of arbitrators who are put on the interest arbitration panel. Those are my submissions.

The Chair: Thank you very much for bringing those specific points forward. I think perhaps it might help in our questions and answers if we begin this time with the parliamentary assistant in responding to your proposals.

Mr Wessenger: I'd like to thank you for your presentation. I should indicate that in response to a previous delegation with respect to this concern about Bill 50 overriding collective agreements and agreements entered into under the social contract, we will be bringing forth an amendment to hopefully clarify that position. We'll certainly take your drafts into consideration in doing that amendment and assure you that we hope to put down on paper what the intention was. So you'll have that assurance.

With respect to the second point, I just might indicate that in other areas of arbitration the costs are, I understand, borne by the parties, so this really is just bringing this situation in parallel to that of other arbitration situations.

Mr Harnick: I'm somewhat new to this committee, but what you're asking for is that an obligation may not be designated if it is the subject of a collective agreement. Isn't that what the whole social contract was about, suspending collective agreements?

Mr Schachter: The Social Contract Act suspended certain portions of collective agreements. They prevented workers from enjoying increases that were supposed to take place on or after June 14, 1993, but there was nothing in the Social Contract Act that said a provision that you had before June 14, 1993, is now going to be unenforceable for any period of time. So along comes Bill 50 and it says, "If we didn't sock it to you enough under Bill 48, we're going to sock it to you 100 times harder under Bill 50."

Mr Harnick: As I understand it, and I'm not a labour lawyer so you can correct me if I'm wrong, Bill 48 went ahead and looked after the monetary provisions. It stopped any raises, essentially, even though the raises were contracted before the date of the effective operation of the social contract. Bill 50, which was the companion action, as I understand it, really looked after all of those, what I guess laymen call, fringe benefits. All of those health care fringe benefits that may have been available and that may have kicked in in subsequent years are all frozen as well. Am I right about that?

Mr Schachter: No. It goes far worse than that.

Mr Harnick: You mean it's even worse than that?

Mr Schachter: Yes. In fact, the fringe benefit freezing even takes place under Bill 48. But suppose I had a dental plan and the plan said that I will be able to go to the dentist and have the plan pick up the cost of fixing my teeth. Bill 48 says you can't have any improvement in that, but Bill 50 comes along and says if the government chooses to designate the obligation of the provision of a dental plan, you can no longer force your employer to pay the premiums under that dental plan. Bill 50 allows the government to say: "You had three weeks' vacation in your collective agreement. We designate that obligation, and you can no longer force your employer to give you three weeks' vacation." It even allows the government to designate a wage obligation. The collective agreements could say the employer has to pay you $15 an hour. The Social Contract Act says you can't get any increases over the $15 an hour. If a government would designate that obligation, the employer wouldn't even have to pay you the $15 an hour, and all you'd be left with is the minimum-wage provision in the Employment Standards Act.


Mr Harnick: Based on what you've seen transpire in terms of Bill 48 and Bill 50, do you seriously think that the government is going to pay any attention to this amendment? I don't mean to be disrespectful; I'm trying to play devil's advocate here. When I look at this amendment, I say to myself, "My God, this is absolutely, totally contrary to all of the things that I heard Bob Rae and Floyd Laughren talking about." It's a neat amendment, because it sort of tries to sneak it in the back door and get back a little bit of what you lost. Are you with me?

Mr Schachter: We were told by Mr Peter Warrian, who is the chief administrator under the Social Contract Act, that there was no intention by the government to designate normal obligations under collective agreements. I believe what he had to say; I believe it may well be the intention of this government not to designate these types of obligations. However, we've seen governments change their position on things in the past; we've seen this government change its position on things in the past. It may well be that next week this government may feel: "We haven't saved enough money. We haven't cut back compensation costs in the public sector enough. We have to change our intention and designate these things."

Even if this government keeps its intention and doesn't change it, its mandate will last only until September 1995. The people of Ontario may choose not to give this government a renewed mandate, and a new government led by the leader of your party, who has not been known to favour worker rights, or led by Ms McLeod, who also hasn't come out in favour of worker rights, may say: "We're going to take advantage of Bill 50 that was passed by the previous government. They had no intention of going beyond Bill 48 and they were prepared to allow to stand a dental plan or a vacation provision, but we're going to take advantage of that and we're going to take that away from the workers." That's my concern and I feel it needs to be dealt with in an amendment to Bill 50.

Mr Harnick: Have you been given any indication as to whether Bob Rae is in favour of this amendment?

Mr Schachter: I have not spoken to Bob Rae about this or about many other things.

Mr Harnick: Has anybody involved with the social contract told you that this is okay?

Mr Schachter: I'm prepared to accept the assurances that were given by Mr Peter Warrian only if they are incorporated through an amendment to this bill.

Mr Hope: SEIU was before us earlier. I didn't know there was a fund out there for this labour relations process, and I find it very interesting. One of my questions to SEIU was, "How many times do you negotiate collective agreements and how many times do you arbitrate?" I wonder what the success ratio would be: 95% successful or only 10% successful in negotiating versus arbitrating.

Mr Schachter: Under the Labour Relations Act, most bargaining disputes are resolved amicably and very few result in strikes or lockouts. Unfortunately, under the provisions of the Hospital Labour Disputes Arbitration Act, the right to strike is removed and that makes it a lot more difficult for a group of workers to get the employer to take bargaining proposals seriously, so there are a fair number of arbitrations under the Hospital Labour Disputes Arbitration Act. I'm pleased to say that in the hospital sector, recently there have been a large number of settlements without having to resort to interest arbitration, but there have been a very large number of resorts to interest arbitration.

Mr Hope: With this labour-management fund -- and I guess I'm going to look into finding out how much money it is -- what is the goal and the objective of this labour-management fund, in your opinion?

Mr Schachter: I'm not sure which fund you're talking about.

Mr Hope: The one that you indicated earlier.

Mr Schachter: Right now, arbitrators or the boards of arbitration have their fees assumed by the government, and I'm not sure under which vote of the Legislature that happens, but that's what happens, and along comes section 3 and says the government and the people of Ontario will no longer pay for the costs of interest arbitration; the parties themselves will have to. I don't know how much the total bills have been in any particular year, and I'm not bothered by the obligation of the parties to assume that in the future. I was just pointing out, why should arbitration be different from other points of litigation? Why should the people of Ontario only pay for the cost of judges and not pay for the cost of arbitrators? If the parties to an arbitration are going to assume the cost of the arbitration, then should not the parties to other litigation assume the cost of judges and clerks etc?

Mr Hope: I guess this has always been in the public sector. I come from the private sector where you had the choice to strike or lockout or else the plant closes. Those are your choices. I guess in the public sector you have binding arbitration. I can imagine some of us in the private sector would've loved that opportunity because we wouldn't have faced wage roll-backs and stuff by that time.

I guess where I'm trying to get a balance is it takes, in my opinion, any idiot to go to an arbitrator, but it takes a negotiator, an intelligent individual, to collectively negotiate collective agreements. I'm just wondering, how do you make both sides -- because even in my own area, hospital workers are affected because the hospital association refused to accept the terms of the social contract, and now those workers will be victims. Now some of the hospitals are saying, "Please, Floyd Laughren, do something to protect these workers," when it was their own association that rebutted the process.

I'm trying to find a way to create a better labour-management relationship. You talk about the cost of arbitration. The one way to eliminate that cost of arbitration is not to go to arbitration and start to negotiate the process.

Mr Schachter: That's nice and fine, but what happens if the other side is unwilling to negotiate properly? Under HLDAA, you cannot resort to economic sanctions. But one of the things this government and previous governments have done that can be changed: Right now, the people of Ontario subsidize the cost of litigation in labour relations for public sector employers through the OHA. There are in the area of millions of dollars -- I don't know if it's $4 million or $7 million or some figure in the millions of dollars -- that the people of Ontario pay to the Ontario Hospital Association to subsidize its labour relations costs. I don't see why the government should continue to do that.

The Chair: A final question.

Mrs Sullivan: Just as an observation, I would suspect that any union that's going into collective bargaining over the next period of time that has been affected by the social contract would have as its first item on the agenda an attempt to reach an agreement that pre-June 14, 1993, obligations are honoured. One of the issues that has become a matter before this committee is with respect to what constitutes an agreement. A non-unionized worker, by example, would not have an agreement as it appears in this act. An agreement in this bill is not defined. If the parties or one of the parties to the social contract did not sign, is there an agreement if fail-safe is kicked in?

The parliamentary assistant indicated to us that there would be amendments, I presume with respect to subsection 1(2.1) of the bill. I wonder if he could tell us the direction those amendments will be taking.

Mr Wessenger: I think I'll probably have to ask counsel to clarify this since I haven't seen the draft.

Mr Williams: Certainly, as I indicated last time when SEIU appeared, we'd be addressing their concerns, and Mr Schachter's as well. We're certainly taking both of those matters that were raised into consideration when we present further amendments to section 1.


Mrs Sullivan: Will you be further defining what constitutes an agreement?

Mr Williams: We'll be looking at that when we draft the amendments. I'm not saying we'll be defining it, but we'll be looking at that. If it's necessary, we will; if it's not necessary, we won't. We'll be discussing that with legislative counsel.

Mr Schachter: I might suggest that if you have unorganized workers who are concerned about this, then one answer is for them to unionize. If you would provide me with their names I will do my best to assist --

Mrs Sullivan: Many people in the health care sector have chosen to come together and belong to a union. Many other people have chosen deliberately not to. If we respect the process of voluntary association for collective bargaining and other purposes, then clearly it should be a voluntary process and their rights should be respected just as much as people who are unionized.

The Chair: I want to thank you very much, Mr Schachter, for coming before the committee and for bringing your specific proposals.

Before we adjourn, I'd like to go back to Ms O'Neill's question earlier. Given that there have been a few words exchanged since then, perhaps you'd be good enough to refresh our memory on the points you raised.

Mrs O'Neill: When we get into the third-party concerns of this bill, at least twice that I remember and perhaps on other occasions, regulation 785 and its exceptions and the medically necessary four are quoted back as concerns that are attended to. But today the parliamentary assistant said that there will be regulations developed after this bill, so now I'm beginning to wonder about the status of even these few exceptions. Even with that, there's an awful lot of interpretation possible around the regulation as it exists.

Mr Wessenger: I will respond initially and then ask counsel to pick up anything I may have missed in the explanation. I think first of all we have to look back to the principle of an insurance plan; that is, it's the plan that determines what its obligations are and not the third party. We don't delegate to third parties to add on obligations to an insurance plan or otherwise you'd have a completely unworkable program.

Second, from the beginning of the health insurance system, third-party services have not been insured. What we've done in regulations is make exemptions to the situation where third-party services were not insured, so we've specified those areas where the plan would pick up a third-party coverage. That's been the way the whole system has been structured.

The regulation we looked at last was the most recent amendment to the third-party regulations, and what it did was clarify and specify more completely and comprehensively the exceptions to the third-party exclusions. I don't have the previous one in front of me, but there's some suggestion that it was an improvement in making it more comprehensive than the previous situation.

The current legislation does not deal with the question of the exclusions. The current legislation is only designed to clarify the question of the liability for third parties. At present, normally the liability rests either with if it's picked up by OHIP as one of the exclusions or it would be covered by the patient in normal circumstances, or there might be an arrangement made. I'll just see if Frank wants to add anything to what I've said.

Mr Williams: The process we've been referring to that's going to take place now is really an entirely separate process. I guess it's resulted both through the social contract and our agreement with the OMA, which is basically identifying all existing requirements in legislation and regulation that generate third-party situations; reviewing and determining if they can be eliminated -- that's really the key point -- and then identifying who the payor is in consultation with each particular ministry in question.

The Chair: Mrs Sullivan, do you have a question on that?

Mrs Sullivan: Yes, I do. One of the fundamental problems is identifying those which will be included for coverage by OHIP and those which will not be included for coverage by OHIP. In many cases, and we heard one particularly good example today from the dentists, what we will see happening is that people in the Ministry of Health, perhaps without reference to those people who have expertise about the medical necessity or the efficaciousness of a particular procedure, will determine whether or not a procedure will be covered.

The example that was put before us was with respect to limiting, by example, the number of units of general anaesthetic that could be provided to a patient who is receiving oral surgery in a hospital setting. That kind of limitation is itself a delisting of a service, and the clinical judgement may be quite different from what the regulations will ultimately allow.

I think this is highly problematic, and as we go through the legislation, we need to know far more about the process: how delisted items will be identified, what clinical data are available in terms of making decisions, and who's going to be making the decisions.

Mr Wessenger: I'll probably ask counsel again to respond, but I think we should be clear that they're two separate issues. The third-party issue is separate from the delisting issue, and in this legislation we're dealing basically only with the third-party issue, not with the delisting issue. I don't know what else I can add to that. The process we're talking about, a review process, is dealing with the third-party issue which has been described today and doesn't deal with the question of delisting, which is a separate process.

Mr Williams: That's correct.

Mrs Sullivan: The third-party payor issue, though, is linked specifically to the issue of OHIP coverage with respect to children's medical service needs for the purposes of public health or for assessment with respect to their abilities to function or to require additional assistance.

By example, you can say that OHIP and medicare aren't a part of that, but I sure as heck want to know who is going to make the decisions with respect to how children are treated and who will pay for services, because in lots of communities children will not get those assessments. They will simply not be done because the board can't afford to pay or because the public health unit says, "We don't have enough money." We know, as has been described in this and other places, that there is inequity across the province already.

These two issues are fundamentally linked, whether you like it or not.

The Chair: Parliamentary assistant, do you have anything further to add?

Mr Wessenger: I'll ask counsel.

Mr Williams: I only have one comment to make, in that Bill 50 doesn't change what are now insured services and what are not insured services. The regulation we passed last year sets out what are the uninsured services. All this bill does is address the issue of liability. It doesn't address and it certainly doesn't intend to add to the list of what are uninsured services.

The Chair: We will next be moving to clause-by-clause when we come back and we'll have a further opportunity to get into that issue.

Mrs O'Neill: I'd like to know if this regulation is under review. I did not get that answer. I got a whole lot of other -- I won't use any other adjectives, but I did not get whether this regulation is under review, necessarily. Are these exemptions going to be -- and if they're not, are they going to be clarified? That's a straight question.

Mr Wessenger: I think it's fair to say that the whole question of third party is under review, and I suppose the decisions that are made with respect to the recommendations after looking at the whole question of third party -- that could result in a new regulation being prepared. I think that's the best way to deal with it, to say yes, it could result in a new regulation after that review process is completed.

Mrs O'Neill: Okay, thanks. At least we know that.

The Chair: Just a couple of points before we adjourn. Mr Gardner informs me that we will have, before we rise on Thursday, the summary of recommendations and that will be provided to all members.

As everyone knows, we will not be sitting next week, so our next meeting will be Monday, November 15, when we will begin clause-by-clause. The committee stands adjourned until 3:30 Monday, November 15.

The committee adjourned at 1740.