Assemblée législative de l'Ontario

1996 ANNUAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH

CONTENTS

Thursday 6 February 1997

1996 annual report, Provincial Auditor: drug benefits program

Ministry of Health

Ms Margaret Mottershead, Deputy Minister

Ms Mary Catherine Lindberg, assistant deputy minister, health insurance and related programs

Ms Linda Tennant, director, drug programs branch

STANDING COMMITTEE ON PUBLIC ACCOUNTS

Chair / Président: Mr Bernard Grandmaître (Ottawa East /-Est L)

Vice-Chair / Vice-Président: Mr Richard Patten (Ottawa Centre /-Centre L)

*Mr Marcel Beaubien (Lambton PC)

*Mr Dave Boushy (Sarnia PC)

Mr Gary Carr (Oakville South / -Sud PC)

Mrs Brenda Elliott (Guelph PC)

*Mr Gary Fox (Prince Edward-Lennox-South Hastings / Prince Edward-Lennox-Hastings-Sud PC)

*Mr Bernard Grandmaître (Ottawa East /-Est L)

Mr John Hastings (Etobicoke-Rexdale PC)

Mr Jean-Marc Lalonde (Prescott and Russell / Prescott et Russell L)

*Ms Shelley Martel (Sudbury East / -Est ND)

*Mr Richard Patten (Ottawa Centre /-Centre L)

Mr Gilles Pouliot (Lake Nipigon / Lac-Nipigon ND)

*Mrs Sandra Pupatello (Windsor-Sandwich L)

*Mr Derwyn Shea (High Park-Swansea PC)

*Mr Toni Skarica (Wentworth North / -Nord PC)

*In attendance /présents

Substitutions present /Membres remplaçants présents:

Mr Gerard Kennedy (York South / Sud L) for Mr Lalonde

Mr Wayne Wettlaufer (Kitchener PC) for Mrs Elliott

Also taking part /Autres participants et participantes:

Mr Erik Peters, Provincial Auditor

Clerk / Greffière: Ms Donna Bryce

Staff / Personnel: Ms Elaine Campbell, research officer, Legislative Research Service

The committee met at 1003 in Room 228.

1996 ANNUAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH

The Chair (Mr Bernard Grandmaître): This morning we are still considering section 3.13 of the 1996 annual report and we still have the same three witnesses from the Ministry of Health: Margaret Mottershead, deputy minister; Mary Catherine Lindberg, assistant deputy minister, health insurance and related programs; and Linda Tennant, director of drug programs branch.

Witnesses, welcome this morning. Will the deputy minister take the stand.

Ms Margaret Mottershead: I'll take the stand and we're available to answer questions. We don't have any further presentations but we're interested in knowing whether the committee members have any need for information, if there are any specific areas you'd want us to look at in terms of making a formal presentation for purposes of this discussion and others that we're going to have over the next couple of weeks.

The Chair: Very good. This morning we'll start with the PC caucus.

Mr Derwyn Shea (High Park-Swansea): Thank you very much, Chairman. How much time do we have?

The Chair: Ten minutes each.

Mr Shea: And then we keep going around in rotation?

The Chair: Yes, as long as necessary.

Mr Shea: All right. That's just grand.

I appreciated the presentation by the deputy minister and the staff. I found it a very helpful and optimistic one. There were clearly a number of responses by the ministry to the auditor's report which give me some hope, but there are some questions I would like to ask.

Can I focus on the issue of the formulary? I have a different profession, so you have your formulary and I have mine. Can I talk about that for a moment? As I understand it, it is currently a printed vehicle.

Ms Mottershead: Yes.

Mr Shea: And it is printed with what frequency?

Ms Mottershead: Depending on how many additions we have, or changes to the formulary, we normally have changes two or three times a year. Mary Catherine has with her a copy of what the formulary actually looks like.

Mr Shea: For purposes of the record, that's about two inches thick and so forth, and that would be reprinted about twice a year?

Ms Mary Catherine Lindberg: Just pages.

Mr Shea: The pages are printed and changed. Can I ask if there's a reason why you continue with the print, with this vehicle, as opposed to focusing more and more on online?

Ms Lindberg: We actually do this because this is a regulation, and we do it loose-leaf so we only have to print pages, but we are also thinking about putting it on a CD-ROM or online. It is online, actually, in the dispensaries. The pharmacists have all this information through the health network because they enter the DIN number, which is the number here, and then they know whether that drug is covered or not. So it is actually online in pharmacies; it's just not online for physicians who need to use it to prescribe from, or for other professionals who would need to use it.

Mr Shea: But you have an intention of addressing that part as well?

Ms Lindberg: Yes.

Mr Shea: In what time frame?

Ms Lindberg: Once we get the technology into the doctors' offices, putting this network into doctors' offices, which will take us a few years. There are 20,000 of them and there are only 2,000 pharmacists.

Mr Shea: Who will be paying for that? The physicians?

Ms Lindberg: It will probably be shared. We will do part of the network and they will pay for the work in their offices.

Mr Shea: Has there been any work done on a proposal in that regard?

Ms Lindberg: Yes. We're looking at primary care models and some of the primary care pilots. One of the first things we'll do is put this health network into the doctors' offices in those pilot projects.

Mr Shea: But the pilot project has been written up, which includes the expansion of the system across the province into every physician's office?

Ms Lindberg: Eventually, yes.

Mr Shea: So you have done that and that has received government approval.

Ms Mottershead: We're going forward with that proposal to cabinet shortly. That is a plan that we have, starting with primary care reform: to link physicians to each other in a particular catchment area. It's to put on to the network that we have the drug formulary and perhaps prescribing clinical guidelines to physicians, as well as linking to laboratories as the next step, because we want to see how many tests are done for individuals where there might be duplication or sensitivity around that. It is a proposal. I want to be clear that it has not yet had government approval.

Mr Shea: Fair enough. I appreciate that clarification. That's clearer for me to understand. I'm appreciative also that you're pushing the horizon and trying to find new ways of involving people. Can I assume from your response as well that it is the intention, Deputy Minister, to involve the pharmacists of this province in whatever that final proposal might well be?

Ms Mottershead: Yes.

Mr Shea: And the physicians?

Ms Mottershead: Yes, it is. We have already had many discussions with a number of the stakeholders around the technology component. There's a group coming together quite frequently to have a look at where we're going and the incremental approach we're recommending so that we can say to government when it comes to have the decision made what the issues are from those stakeholders, including pharmacists, and also what their recommended approach would be to doing this project.

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Mr Shea: I know the minister has spoken about the possibility of introducing a 1-800 line where people could call for health information. I presume this means the general community, not just those involved in the caring professions. Do you see that not only emerging, but emerging in the immediate future?

Ms Mottershead: We think consumer education is an important component of individual responsibility with health care and the health care system. At the moment the 1-800 number proposal -- and it's just a proposal at the moment; it doesn't have government approval at this point -- is to include it as part of the primary care model so that there would be services available to everyone on a 24-hour basis. It is also our recommendation to government that the 1-800 line be used for information around drugs, that if people are concerned about the colour of this tablet versus that and, "Which one I should take?" that also be made available.

Mr Shea: So it would be less, "I have an ache and pain. What should I do?" That's not what you're talking about. It's a matter of, "What is this particular drug?" or "What is this I have in my hand?" As you put it, it's an education vehicle as opposed to a prescriptive vehicle.

Ms Mottershead: That's correct.

Mr Shea: That's fair enough. Can I just go back to the formulary for a moment? The DQTC -- I'm still trying to get familiar with all of these terms, but as I understand it, the federal government does the initial review of drugs for Canada. It determines what drugs will be licensed for use in Canada. It's up to each province to determine which ones on the list it will choose and how it will choose them, so it has a mechanism for making that selection.

There is some suggestion that this process, from the provincial side, may be a little slow in some instances. Let me just suggest, for example, that people I deal with in other settings who are wrestling with AIDS and so forth may have a concern about the speed with which certain drugs get into our formulary. If that is the case, have you got any suggestions as to how we can fast-track some of the selection, or are you satisfied with the selection process at this point?

Ms Mottershead: There are a number of initiatives that are going on concurrently between provinces and the federal government, for example, and within our own province in our ministry. I'd like Linda Tennant to answer the question, given that this morning she was before a group of drug manufacturers telling them how we've streamlined the process.

Mr Shea: That was timely.

Ms Linda Tennant: Just coincidental.

Maybe the most striking figure I can give you to illustrate how far we've gone with our streamlining with the federal government -- we're just introducing phase 2 of the streamlining. In fact, the regulations became effective on February 1, 1997.

If I look at 1994 -- I have the data with me -- the total number of submissions received by the branch was 128, and in that year we actually listed 98 products on the formulary. Since April 1, 1996, we have received 393 submissions, and as of this date we've listed 269 products on the formulary. The branch has done that with slightly less staff time than in 1994, so I think that demonstrates quite clearly that we've made considerable progress in streamlining with the federal government and eliminating duplication and overlap with what they do.

Mr Shea: The figures you gave are indeed year-to-year comparisons; the 128 and 98 are within the one year of 1994, and the next figures of 393 and 269 are within one year.

Ms Tennant: Within one year.

Mr Shea: There has been a dramatic closing of the gap, so the time frame is moving.

Ms Tennant: Yes. The other point I would like to make is that manufacturers have historically made comments around the fact that there was a queue in the branch and there was a delay in processing. Again, as of this week, and in fact for the last five or six months, the branch has had no queue; there is no lineup. We are processing submissions as they are received and DQTC is looking at them within a three-month cycle.

Mr Shea: That's a remarkably fine accomplishment. Do I still have time, Chair?

The Chair: You have two minutes

Mr Shea: I'll go to another committee member.

Mr Marcel Beaubien (Lambton): My question is with regard to the reform of the Trillium drug plan, the mailout that we had. On page two, under the title "Trillium Drug Plan -- Problems and Solutions," it says, "While the principles behind the creation of the Trillium Drug Plan are sound, there are several operational aspects of the plan which severely reduce accessibility, particularly for low-income earners."

If we look at the information that we had the previous week, we have 2.3 million Ontario drug benefit recipients, 42 million Ontario drug benefit claims per year, a total budget of $1.4 billion. First of all, how many employees do we have administering the plan? Secondly, reading the mailout that we had, the briefing notes that we had, it seems, especially when we look at the recommendations, that after a year and a half this particular plan seems to be a boondoggle. It doesn't seem to be working or addressing the problem for whom it was intended. I'm wondering, when you say, "Urgent reform of the Trillium drug plan is needed," do you think that by implementing those four recommendations we will fix the problem that we are facing right now?

Ms Mottershead: Are you referring to the recommendations of the Provincial Auditor?

Mr Beaubien: No, I'm talking about the "urgent reform" in the briefing notes we had, namely, "Eliminate the `deductible' for low-income earners...; Allow for the `deductible'...."

Mr Richard Patten (Ottawa Centre): Chair, maybe I can clarify. That was a document that I received in the community. I asked that the clerk circulate that to members and that the staff present it to the ministry and to the auditor. This was a representation that I had received from the community, from people who are affected by that program.

Mr Shea: May I have the two minutes back?

The Chair: You can have your two minutes back.

Ms Mottershead: I see now what you're referring to, and that is the recommendations from the AIDS Action Now group, I guess:

"Eliminate the `deductible' for low-income earners -- and spread the payments for others;

"Allow for the `deductible' to be assessed on current-year income;

"Grant interim approval of Trillium applications as soon as they are received;

"Eliminate the reapplication process for people with long-term illness."

I think it is fair to say that these kinds of recommendations and advice would be something the government would consider. I don't think it would be appropriate for me to respond in terms of government policy to these kinds of recommendations at the moment. Certainly, it's something that we would consider in any changes that might be contemplated to the Trillium drug plan.

Mr Patten: Good morning. Welcome to the committee. I was going to follow up a little bit. I appreciate the position that you're in, that that would have to be vetted by the minister and probably go through a political review, but along that vein, I'm curious as to whether the ministry has a mechanism that freely enables the ministry staff, those who are appropriate, to contact groups that have indicated that they have some difficulties in the interests of gathering information to ameliorate a program or to make suggestions.

By the way, I must say, in terms of that paper, that the group that spoke with me was extremely diverse. They were a very thoughtful group. They acknowledged the importance of the intent of the program. They felt it was needed. They applauded that the program was there but they did have some extreme difficulties, for some people, in the application of part of it. I'm curious to see -- because these things take so damned long with government, and I often wonder why; of course, I don't see it as a bureaucrat, I see it as a politician -- to try to gain some empathy and to give you a forum to comment and say where you are limited in your ability to go out and listen to some of these groups which are the recipients or, as you might use the term, consumers -- I don't; I call them people -- to hear some of their comments.

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Ms Mottershead: I'll let Mary Catherine answer that one, but one of the things you may be familiar with is that the federal government recently released the report of the National Forum on Health. One of the recommendations in that report was to actually recommend the establishment of a universal drug program, as an insured program under the Canada Health Act, I assume. There was an indication by the federal Minister of Health that perhaps we should be working in that direction. What that report and the recommendations suggest is that the universal aspect of it means there would be no cost to the taxpayers; that's what an insurance plan is about.

I think we'd be very interested in having discussions with the federal government on how one might work towards something like that and also whether the federal government would be interested in funding of this particular proposal, so that would see that we would be engaging in some conversations soon.

With respect to your specific question, Mary Catherine.

Ms Lindberg: We actually routinely meet with groups such as the individuals involved with AIDS and the physicians involved with AIDS. We have met with groups such as transplants, who have some difficulties with some of the drugs they receive. We meet with a number of the groups routinely and talk to them about any kinds of difficulties they're having, whether it's senior citizens with the drug benefits or whether it's the AIDS people who have difficulty with the Trillium side or whatever, but we do meet with them and take their considerations.

One of the improvements we're making on Trillium this year is that for those people who are currently on Trillium we'll use the same income and allow them to just resubmit their income information, not have to go through the whole reapplication process, so that we can then identify them early and get them on the system so that then they can start building their deductible. That is a change. That actually was recommended by the AIDS group.

Mr Patten: Presumably you have fewer inspectors now than you had a year ago or two years ago. I know you've got inspectors in different fields. I gather from your comments last week that your hopes are high for the network in terms of the computerization. I would expect the government of course would say that this is going to be the be-all and end-all that will do away with the need for inspectors to perform some regular audits and inspections. That's not only affecting health, it's throughout the government, as I'm sure you well know. How many inspectors do you have across the board now?

Ms Lindberg: We have four.

Mr Patten: This is just in terms of the drug program?

Ms Lindberg: Just in the drug program. We actually call them pharmacy liaison officers, because they go into the pharmacies to talk to the pharmacists about the program as well as look at their records and ensure that appropriate billing is happening and the right people are getting the right drugs.

Mr Patten: Is that enough?

Ms Lindberg: It probably is enough on the ground with the network, because what we do is take off computerized printouts from each pharmacy, relating them to the people who are eligible, making sure the people are eligible. But you need to be able to take those then and go into the pharmacy and actually verify that. Four can do that as long as you have the network. When you don't have the network, it's not as easy a task.

Mr Patten: For sure. I would grant hypothetically -- well, not hypothetically -- that a good computerized program would be very helpful. However, the computer doesn't think. You need judgement and you need people who can follow up a secondary possibility of a loophole in the system or whatever it may be.

The auditor suggested of the program -- and I gather the ministry will be following up on it -- that while there were only about 170 inspections out of 2,600, I think it was, there was no indication of where an audit had been. Will that show up in the computer program; in other words, who has been audited last year? What other flashpoints do you have? In other words, where you suspect things are happening, what indicators might there be, or is that a trade secret?

Ms Lindberg: Some of it is, because you don't want them to understand where you're going and who you're following up. But quite often, if you've got a large payout and not very many people eligible, that is the kind of thing you look at. It could be legitimate, because you might have only patients who have a really rare disease who use a very expensive drug, and you could have four patients receiving a lot or you could have a lot of patients not receiving -- it's checking two things: the payout, the total volume payout; and the number of recipients you're seeing, if you're seeing the same card number too many times. Those are the things you look for.

Mr Patten: As police inspectors might experience, knowing a community that well, there are certain characters who tend to reappear and reoffend. Presumably in your program, although some of it is new, after a while you'd see a certain --

Ms Lindberg: You see patterns, yes. You definitely see patterns and you definitely follow up on the patterns.

Mr Gerard Kennedy (York South): As a whole, from my understanding, there's going to be a $162-million drop in funding for the drug program. How is that going to be achieved?

Ms Mottershead: That is the budgetary number for this year. That was as a direct result of the copayment, the deductible and the dispensing.

Mr Kennedy: So the $170 million in revenue you'll receive from that is being offset directly? That's the whole basis for the cut?

Ms Mottershead: I'm not sure I understand what your question is.

Mr Kennedy: I see it in the estimates as the outlay being reduced by $162 million. Often the ministries show the revenue on another side. But you're saying that's just the effect of the revenue you'll bring in from the copayment.

Ms Mottershead: That's right. The revenues are consolidated in the consolidated revenue fund and are not part of the Ministry of Health estimates.

Mr Kennedy: That's what I'm asking about. You're saying the expenditures of the Ministry of Health on the drug program will be down by $162 million, but you're saying that's due to the offset.

Ms Lindberg: That's due to the offset of the copayment. We're not now paying pharmacists the dispensing fee; the patient pays the pharmacist the dispensing fee. We pay the drug cost and markup and a dispensing fee. On the copayment, the pharmacist's dispensing fee is what the consumer or the people pay.

Mr Kennedy: I see, it's paid directly to the pharmacist. I'd like to ask a little bit more -- and please, if I'm being repetitive, let me know -- about the program for the Trillium Foundation; $6.5 million of it was taken up last year out of a budget of $75 million and yet the special drugs program was over budget by $30 million. Is there a relationship between those two fiscal outcomes and your plans for this year?

Ms Lindberg: The special drugs program is first-dollar coverage and it's specific disease entities, it's only certain disease entities, so those people who are eligible for special drugs programs get the full coverage. The Trillium program is based on a deductible based on 4% of your net family income. The difference is that for the special drugs program they happen to be very high-cost drugs and they are very rare disease entities: AIDS, cystic fibrosis, transplantation, human growth hormone. Ceredase is used for nine people in the province.

Mr Kennedy: What is the basis then for the reduction of $30 million in the special drugs program?

Ms Lindberg: The basis for the increase?

Mr Kennedy: The reduction. I believe it's being reduced from $75 million to $45 million.

Ms Mottershead: No, it isn't.

Ms Lindberg: No, that's the Trillium. Trillium has just been slow in the uptake. It's not as well known out there that there is a program that is available, so we haven't had as many people taking advantage of it. But each year there are more and more people as they become aware of the program. The majority of people who are taking it up are people between 55 and 65 who have no employer drug program.

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Ms Shelley Martel (Sudbury East): Let me go back to the revenue coming in from copayment. How much money is actually coming as a source of revenue into the consolidated revenue fund? Is the ministry able to access that from finance?

Ms Mottershead: Let me just say that I want to correct the consolidated revenue fund comment. The $2 copayment on the drug is paid by the individual, so it becomes an individual responsibility. As a result of the individual's paying for that, it means there is less government expenditure, as Mary Catherine indicated, therefore the reduction in our estimates for this year is a direct result of having people participate now more directly to that expenditure.

Ms Martel: Where did the reinvestment of the revenue that would have been paid by the ministry then end up? The funding that would have gone that is otherwise now being covered by the copayment, where was the money, the difference, reinvested?

Ms Mottershead: I want to just clarify that revenue question. Previously, before copayment and deductibles and so on, the ministry's budget included payment directly to pharmacists for their dispensing, which was at $6.11. Right now, with the changes that are made, pharmacists get part payment of their dispensing fee paid directly by consumers so that the government doesn't pay, and there is no revenue to the government. It's just an expenditure decrease.

Ms Martel: Is it fair to say that you're picking up $4.11, then, and the person at the counter is paying $2?

Ms Mottershead: That's right.

Ms Martel: Having said that, the $4.11 translated across so many patients would accumulate to be how much revenue the ministry is no longer paying? Is that the $170 million? Okay. Where was that $170 million reinvested into the health care system then?

Ms Mottershead: I'm not sure what you mean by reinvestment in this context. What we had was a program that was about $1 billion in terms of previous expenditures and with the policy change is now $107 million less this year as a result of the government not having to pay for the copayment portion of that. I should point out, and Linda Tennant mentioned, the speed with which we are making changes to the formulary to add new drugs. There have been over 360 new products listed over the past short period of time and we are paying for more drugs than ever in the history of the province. There are more products and more drugs available now to people than ever before, so we are paying for that, and you might say that's where the reinvestment is going.

Ms Martel: Let me ask about the network. Originally, when we looked at implementing it, one of the big motivating reasons for going ahead with it and making the expenditure was because we wanted to get a clear handle on prescribing patterns and how we could change those. There was a whole body of evidence showing that many seniors were in hospital and shouldn't be, were it not for the drugs they were being prescribed or the mix of drugs they were taking. You may have answered this last week, and I apologize for asking it again if you did, but can you give us a clear sense of what evidence has been gathered to date? Has there been enough over the life of the network so far to identify prescribing patterns and make some recommendations around how negative prescribing patterns can be altered?

Ms Lindberg: We've had fairly good success with the Health Network in actually identifying doubledoctoring, as we call it, where senior citizens go to two different doctors -- they go to their GP and then the cardiologist -- and get two different kinds of heart medication and they take both of them. We have been able to prevent a senior citizen from getting the same class of drug from two different doctors. We've had fairly large success on that particular point.

The other one is drug interactions, where you're taking one drug, you get another drug and you're not aware that there's an interaction. On the computer system itself interactions actually come up, are flagged up on the computer screen that says, "This is really an important drug-to-drug interaction." Pharmacists will look at that and will probably phone the physician -- it could be via the same physician but he's just not aware that these two drugs interact -- and get the drug changed. We've had a great deal of success in preventing those kinds of interactions.

The other thing we've been doing fairly successfully is looking at the practice patterns of doctors and how they are prescribing. Probably the best example of that is using the anti-infective guidelines that we've currently developed. We have anti-infective guidelines -- they're back here -- that physicians actually carry with them and look at what's the best drug to use for the disease entity they're diagnosing. It's been very successful in helping to get a better prescribing profile from physicians.

Ms Martel: Have you seen any evidence that there's just straight overprescribing?

Ms Lindberg: Yes. We see some evidence that there are drugs inappropriately used for conditions they shouldn't be used for. We don't see physicians actually prescribing what we call limited-use drugs very well. We see them using them for conditions other than the conditions we have actually prescribed them for in the formulary, those kinds of things. We can identify those and have been working with physicians and a group of U of T officials to do some work on how you educate physicians in better prescribing. They've actually gone out using the anti-infective guidelines.

They've done two things: They've done what they call academic detailing, which is sending in a pharmacist to detail what they should be prescribing, using a profile; or small groups. The small groups don't work as well, unless they're physicians who like each other, for some unknown reason. They're having a lot better success with the one-on-one detailing. Obviously the success is because that's what pharmaceutical manufacturers had success in doing for years. If we do the same thing using our guidelines, we get the same sort of success rates.

Ms Martel: Is it possible to quantify at this point what the saving might be then because of implementation of the network on the health care side either in the prescribing of less costly drugs, fewer drugs, and alternatively, fewer seniors in hospital because they are sick because they are overmedicated, or has the program just not been in place long enough to do that? Does the ministry have the capacity to do that?

Ms Lindberg: We have some of those numbers. I just don't have them with me but I could probably get you some of those numbers.

Ms Martel: I would be interested in seeing that, actually, because it was certainly part of the reason why we thought the investment was worthwhile in the first place. It was the longer-term cut to health care costs.

Ms Mottershead: On that, we have information. You know it's an avoidance of a cost that is being dealt with rather than a specific saving. To give you an example, if you have been able to intervene in terms of a bad interaction and stop somebody from having heart failure, a heart seizure or something, you've stopped hospitalization. It doesn't necessarily mean that you actually saved money in the system. I just wanted to be clear. We'll provide the information but it doesn't necessarily mean an actual saving today. You can't say Toronto Hospital saved $50,000 as a result, because that's not the way it works. It's cost and stresses on the system that are being avoided.

Ms Martel: I wanted to return to some of the recommendations Mr Patten gave to committee members that came from the Access AIDS Committee. I appreciate that you're not in a position to tell the committee which you could move forward on -- that would have to be a political decision -- but I wonder if it is possible to have some costing done with respect to what those recommendations, if implemented, would cost either the plan or the health care system. I think all of us have had constituents who are in a particularly difficult situation who have to pay for what you could call catastrophic drugs who usually end up, because they can't work because they're too sick, on social assistance and even have trouble making the deductible. I think it's worth our while, as a committee, to know whether we could ask you to do that work, whether you have the mechanism to find out what it would really cost the system to implement some of the changes that have come forward from that particular community.

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Ms Mottershead: What you have, though, is a recommendation coming from a particular community that has implications for the total population of the province.

Ms Martel: That's true.

Ms Mottershead: I mean, of who is eligible for the program. I think if one wants to look at anything that's available at the moment, it is the kind of analysis that was done by the National Forum on Health in making the recommendation to go to a universal plan. My understanding is that the cost is in excess of $3 billion across the country. Given that Ontario represents more than 36%, 37% of the population and so on for the country, that would be a significant cost to actually deal with one recommendation, which is to eliminate all deductibles. If you paid 100% of everything for 11 million people, I think you're looking at huge costs.

Mr Shea: Would it be reasonable to assume that when Mr Dingwall made his comments that said the Ontario health care system seems to be in good shape, you would at least be heartened?

Ms Mottershead: I firmly believe that the Ontario health care system is in very good shape as it respects the question we have before us today on the issue of drugs. We have the most universal coverage of any province in Canada and the most generous subsidy for prescription drug plans, and I think one can be heartened by those comments.

Mr Shea: I want to pick up on a point you and the other deputants had raised earlier, particularly I think as Linda talked about the decline of the backlog to a point where you're now almost in real time processing applications, which is good news from where we were. Would you characterize that as saying that you have moved away from being paper processors into being more information managers, that you're now much more effective in the way you're managing the system?

Ms Mottershead: If you look at the ministry's business plan that was tabled this year and future plans, you will see that our focus is really to move away from processing and being very transaction-oriented. We want to use our information systems to deal with questions around, are there patterns here that are disturbing, should we be taking a different policy position, and be more manager of the system rather than individual transactions?

Mr Shea: Will you confirm figures that I made a note of in your last deputation that astonished me? I think we need to look at them. Obviously I'm coming back to a point raised by Ms Martel in terms of where costs are being reinvested and so forth, and I'll go back to that in a moment. Do I have it clear in my figures that some of the new AIDS drugs, four new AIDS drugs, for example, have been introduced or listed and they run something in the order of $5,000 per patient, per year?

While you're finding that figure, the other figure I had was for some of the new MS drugs that are there, something in the order of $12,000 per year. Are the costs in these special drug areas now running something in the order of $24 million?

Ms Mottershead: The expenditures in the special drugs program that has been noted by Mr Kennedy I guess are rising, and we are spending at a level that is about 40% more than has been budgeted for.

Mr Shea: I see.

Ms Mottershead: So we are actually adding more drugs and covering --

Mr Shea: So the envelope is maintained, but obviously there are reallocations within the envelope.

Ms Mottershead: There have been reallocations at play of the underspending in the Trillium drug plan, but overall within those two programs, the special drugs program and the Trillium plan, the total of the two budgeted numbers is still within allocation.

Mr Shea: I presume you might still continue to expect some pressure in that area, and I focused on AIDS just as a case in point. As the whole cocktail theory and so forth of drug therapy is applied, I presume you might suppose the cost would continue to move in that direction.

Ms Lindberg: We have not added any new drugs to the special drugs program in the last three years. Every time we have a new drug, such as one of the new AIDS drugs that costs about $5,000, we put it on the Trillium plan and then they have to pay their deductible.

Mr Shea: That's the 4%?

Ms Lindberg: Yes, 4% of the net income.

Mr Shea: Okay. Let me go back to a question also raised in terms of fraud. The auditor --

Ms Mottershead: Can I just --

Mr Shea: Yes, of course.

Ms Mottershead: I want to add a point to that. Even though the drugs have been frozen on the special drugs program -- the AIDS drugs, we mentioned, have been put on the Trillium -- there are still a number of significant drugs for AIDS patients, for example, that are on the special drugs program. The number of people is growing, people are living longer as a result of being on the drugs, so that's why the pressure continues to rise. You say, "Well, the drugs haven't changed," but there are more people and people live longer.

Mr Shea: I understand, and some of the therapies are changing as well, but the Trillium responds to that in part.

Ms Mottershead: Yes.

Mr Shea: I want to go to the fraud issue for a moment because there was some question being raised about the four inspectors. Would you confirm for me that there have been four inspectors for some time, that this is not just a new figure?

Ms Mottershead: It hasn't changed in the last -- not since I've been here.

Mr Shea: Will you confirm that? It has not changed; it has been four for some time. Would you also confirm that in addition to that there's an investigation branch which has other investigators involved and that number has not changed either?

Ms Mottershead: There are 10 investigators that we have in that particular --

Mr Shea: And that has not changed either? It has continued the same?

Ms Mottershead: That's correct.

Mr Shea: I appreciate that information. Now I want to go to that very good question raised by Ms Martel. I wanted to get at that point -- well, I'll come back to that in a moment. There are a couple of other things I just want to pick up very quickly about the prices of drugs in Ontario. Have you been monitoring the cost of drugs, item by item, very closely? How do we compare with other provinces?

Ms Tennant: We have a record of what happens in other provinces and we do monitor drugs. Ontario is probably the fastest at putting drugs on to the formulary by virtue of our process and the fact that manufacturers will target the larger provinces first.

We did a spot check recently of 10 drugs, let's say fairly well used drugs in terms of total cost to the program, and we found that in five of those drugs Ontario had a lower price than the other provinces, in four we had the same price and in one we were about one hundredth of a cent above three other provinces. So it's something we do on a regular basis.

When we talk to manufacturers before we list drugs, we go through a series of discussions or price negotiations and that's one of the issues that's obviously covered. By virtue of the fact that we're one of their biggest customers -- in fact, we are the biggest customer in Canada -- we should be competitive.

Mr Shea: So this has given you good buying power as well on behalf of the taxpayers and the patients of this province.

Ms Tennant: We try to combine price and volume so that we get --

Mr Shea: Sure. You used a word there that was intriguing, the word "listing." I want to go to delisting because it brings me back to a point that Ms Martel was segueing into in terms of the health care budget envelope. In your answer you demonstrated how the copayment has aided in the listing of more drugs, and of course we have added 140,000 new people, I think, to the Trillium drug program as a result of that and so forth.

The previous government, I know from my figures, delisted something in the order of about 260 different drugs to try to keep costs in line. To your knowledge, has this government delisted any drugs to save money?

Ms Tennant: There haven't been any drugs removed from the formulary, no, not by the government. There have been some drugs removed at the request of manufacturers. Usually when they bring out a new dosage form or a different --

Mr Shea: All right. But the government has not been using delisting as a vehicle for cost saving?

Ms Tennant: No.

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Mr Shea: I'd like to go back to the Trillium to make sure we're very clear. Is there still a backlog in Trillium in terms of applications? Is that still the case, and has it been closing as well as the other backlogs?

Ms Tennant: The backlog at this moment is about eight weeks. With every processing day that passes, we now cover about five days of the backlog.

Mr Shea: What would the backlog have been, say -- let me pick an arbitrary figure -- three years ago?

Ms Tennant: Actually, Trillium only came in April 1, 1995.

Mr Shea: Good answer. That was a trick question.

Ms Tennant: You were testing if I was awake. I think part of the difficulty with Trillium has been startup. With any new program there is a developmental process.

Mr Shea: Great. I appreciate that answer. I'll come back. We'll be coming around again. Thank you.

Mr Kennedy: I guess I'll follow that line of questioning. You say you have an eight-week backlog. Is that what you mentioned?

Ms Tennant: In Trillium, yes.

Mr Kennedy: And you're able to eliminate five days of that as each week goes by?

Ms Tennant: At this point in time --

Mr Kennedy: So you're looking at 40 weeks before you're caught up. Is that correct?

Ms Tennant: By the end of February, I would hope, we would be completely clear.

Mr Kennedy: By the end of February, so the cumulative effect would be that by the end of February -- what would you consider to be caught up? Because one of the problems, and you've already had a paper circulated so you know that a six- to eight-week delay in the Trillium program is proving to be an onerous hardship for people. That's part of the backlog I guess that you're referring to and I assume that's why there is that kind of delay. It's because you have a backlog of applications and so forth?

Ms Tennant: That's right. The delay is due to the volume of applications and the type of applications, the difficulties we've had with the program being new and some lack of understanding, quite frankly, of what is required.

Mr Kennedy: That's curious to me, as a layperson. Catastrophic drugs must be a fairly definitive condition for people. What is the nuance in terms of the processing that you have to do that requires six to eight weeks? How does that take that kind of time?

Ms Tennant: I would separate out of the fact that people who apply to Trillium cover a broader group than those with catastrophic drugs. Trillium covers people whose drug costs are high relative to their income, so we have a whole range of people who apply for the program. Probably about one quarter of the people who are on the program right now haven't met their deductible, so their drug costs haven't reached the point where they would qualify for free benefits under the program. Then we have a situation where some people have particularly high drug costs, and I think some of the AIDS folks would be good examples of that. Others would be some cancer patients who are receiving drugs in the community.

What we try to do there is, once those individuals are identified, we fast-track the applications. We can put them on the system within a two-hour period and then process their receipts.

Mr Kennedy: That experience is not what many people in the community are relating as being their experience, so there's a gap there. I'll leave it at that. That's obviously the kind of responsiveness one would expect if there was a clear-cut case, that it wouldn't take that kind of time to make happen.

Ms Tennant: We've spoken about the fast-track process with various groups such as the AIDS groups. We've given them the program manager's name and telephone number and set up a process with them as to how individuals in particular need can access the fast-track process. Part of the difficulty is that perhaps through discussions with groups you don't necessarily reach everyone who is involved. But we've spoken with, for example, physicians in the AIDS clinics, we've spoken with the transplantation centres so that they can advise their patients, and we've tried to encourage them to let people know that they can apply for Trillium at any point in time. They don't have to wait until they have receipts for drugs in order to do so. You can apply for Trillium before you incur any drug costs whatsoever.

Mr Kennedy: You know also from the paper that there's a hardship by using last year's income, in terms of people who become ill and also people who have to pay that deductible right away. Private plans allow them to put their deductible against the cost of drugs and it makes it more affordable for them. I understand that flexibility isn't yet part of this program.

Ms Tennant: As a matter of fact, it is. We do assess on current year's income. We're requested to do so by the individual, so that facility is available now. It's available for seniors and also for Trillium applicants.

Mr Kennedy: Coming to the question I had before: a $75-million expenditure last year in the special drugs program; a budgeted line item this year of $45 million. I didn't quite understand the explanation of how that will be achieved. How will you reduce the cost? You had $75 million in actual last year, correct?

Ms Mottershead: Let me just say that the total of the two programs is not being exceeded so that --

Mr Kennedy: But I would like dwell on that a little bit. Somehow the special drugs program, which is a different program -- you're going to see some of that need transferred to the Trillium program, is that correct?

Ms Mottershead: Can I just highlight an example for you using sort of personal experience? You've got $5 in your savings account and $5 in your chequing account; the sum is $10. Basically you're paying all your bills using either your chequing account or your savings account. What we have here is a program in the special drugs that is overprescribed and a program called the Trillium drug program, because of some of the delays and other things, is underprescribed. But both programs are being fully funded and all the obligations met on behalf of the individuals applying for them. That's my simple explanation: One is over and one is under, but we're well within the budget and what the Legislature has approved for drugs in general.

Mr Kennedy: Relative to your plan for this year, though, and your plan for next year, would you see that -- as more people come on to the Trillium fund, the complementarity of the over- and undersubscribing will change. What are the plans the ministry has to accommodate that?

Ms Mottershead: We're going through the estimates process right now. We will be indicating, as part of that process, to government what the requirements are in both of those plans and that decision will be made by the government in the budget. I suggest we need to wait until the estimates are tabled to see what the new appropriations are going to be.

Mr Kennedy: Is there any end-year understanding of what the takeup is now in the Trillium portion of the two programs? Any idea what you're headed for in terms of end-year?

Ms Tennant: It will still be less than $40 million this year.

Mr Kennedy: Less than $40 million.

Ms Tennant: Perhaps considerably less; we're not sure.

Mr Kennedy: I just want to refer a little bit to some of recent announcements. Are you aware whether the change in welfare responsibilities will affect the funding for the drug program available to welfare recipients and, if so, how?

Ms Mottershead: The changes proposed that you're referring to are, I believe, in the Ministry of Community and Social Services?

Mr Kennedy: Yes. So only to that portion?

Ms Mottershead: Our estimates only include the Ministry of Health component.

Mr Kennedy: Are you not involved in the operation of that part of the drug program as well that relates to welfare recipients?

Ms Mottershead: There is some involvement: however, it's two completely different estimates lines and budgetary lines. One is in the Ministry of Community and Social Services and the other is in Health.

Mr Kennedy: So you're not aware --

Ms Mottershead: Yes, I'm aware of the proposal that has been made.

Mr Kennedy: Because the other question I have has to do with your overall goal in terms of making the drugs work for the protection and promotion of the health of Ontarians. You have the new copayment plans taking place, $2 and $7 charges on people and a deductible of $100. The auditor's recommendations found some practices, as he probably will in every ministry and every program, that need to be improved.

With this new program, what practices do you have in place to tell how well the health of the Ontarians who have to pay copayments will be protected? What kind of monitoring are you doing? What kind of impact studies are under way by the ministry? What kind of things will occur to ensure that their health and wellbeing is not harmed by that new program?

Ms Mottershead: Mr Kennedy, before we answer your question I'd like to know, what is the new program you're referring to?

Mr Kennedy: The copayment the ministry is charging on the drugs.

Ms Mottershead: I didn't know whether you were back to the municipal --

Mr Kennedy: No, but having to do with welfare recipients and seniors both, that copayment plan. I have another part to that question that relates to the welfare program expressly, but I'm wondering what kind of plans you have in place to tell what impacts they're having.

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Ms Mottershead: The network is a good example of what tools we have at our disposal to actually monitor. We have found that there has been no decrease, for example. There was a concern, I guess, that people couldn't afford a $2 copayment at some point. However, we have found that there has been no decrease at all between what happened pre-copayment and what happened after in terms of the number of people who are actually receiving drugs or having drugs prescribed to them. That's the reality we have, and we can certainly track that information because we know who they are, we know if they were on before and they're not on now, and we know those ones who have chronic conditions that would require continual taking of certain drugs.

At least from the information we have on the network, there has been no change. People have not stopped taking medication as a result of having to pay a $2 copayment. That is our intelligence network in terms of monitoring --

Mr Kennedy: It's a gross measure you're using, about the number of people who are accessing the system. Are there any specific studies under way by the ministry to know what the impact will be of the copayment on people's health?

Ms Mottershead: Not specifically acquired or tendered research projects per se. I just want to reiterate the fact that we have the network, we have people who are looking at it all the time, and that is certainly our major tool. You are also aware that there are a number of organizations out there that come to us with concerns or if they think there's a perception about certain concerns, and in working with them we follow up on their issues and we know that there isn't a quality question at all.

Mr Kennedy: Are you aware of some of the concerns raised by Ontario food banks about having to provide food to people who in the first instance have to pay for drugs that used to be on the formulary list? Some 20% of people who utilize food banks in the Toronto area have to use some of their food money to pay for drugs that used to be covered by the plan. Those are statistics that have emanated for the last three years and have increased in the last year. Are you aware of those associations' concerns?

Ms Mottershead: I can't suggest that I have validated or verified the kind of numbers that you have put forward. I'm not sure whether you can tell me, using your statistics, whether those were recipients of the Ontario drug benefit plan or whether they're over-the-counter drugs or what.

Mr Kennedy: Prescription drugs covered by the Ontario drug benefit plan previously and not covered now and that continue to be paid for by the recipients.

Ms Mottershead: We have knowledge of a number of pharmacists and pharmacies who have actually attempted to eliminate the $2 copayment in cases where they have identified hardship, so I'm not going to suggest that that is a universal kind of problem because there have been many other participants to ease some of that burden.

Ms Martel: I'd like to go back to the drop in expenditures of $170 million so that I have this clear in my head. You mentioned that it was true that there are $170 million ministry dollars being spent this year because the government is not picking up some of this cost, the consumers are picking up some of the cost, and that in fact what the ministry was doing was paying for more drugs on the ODB.

I guess my question is, if that were the case, why wouldn't the ministry expenditures have stayed at the same level? Because if you are paying for more, then you are obviously paying the same amount of money and what we would see is no decline in expenditures but a large growth in the number of people coming on to the plan and drugs being paid for. As it is, we still see a cut in the budget line of $170 million.

Ms Mottershead: The budget number that you have is a forecast of what we estimated would be fewer requirements this year as a result of some of those changes. You cannot make the direct correlation that $170 million would be the value of the drugs that have been added to the formulary. It's not a one-for-one situation. But we are forecasting that our requirements before the end of the year will probably be a little bit higher than what we have in the forecast and in the budget as a result of adding some more drugs and having more people eligible every month who turn 65, for example.

Ms Martel: So it might be $150 million or $120 million. Is that what you're saying?

Ms Mottershead: It might be. We don't have the final forecast for the year-end yet.

Ms Martel: Okay. You still have some figure that appears as a decrease in expenditures. It might be $170 million, it might be $150 million, it might be $120 million at the end of the fiscal year when you balance that all out. Is that still not a cut from this program? How else do I view that?

Ms Mottershead: It's not a cut from the program because there has been absolutely no delisting. I've mentioned that the government has added more than 360 new products on the formulary. I've indicated there's more growth in terms of the number of eligible recipients to the program. The reduction has occurred as a result of not having taxpayers in general paying directly for the individual copayments.

Ms Martel: On the other hand, the argument could be made that it comes at the expense of people who used to not pay for drugs now paying for that, and that in fact the expansion of the number of products on the formulary also comes as a direct result of those people paying for drugs where they did not before.

Ms Mottershead: I just want to come back to the point that the drug plan that is available in Ontario and all the other provinces is not a medically insured service under the Canada Health Act. Provinces have been paying, through the taxpayers, some costs for drugs in all provinces, and I just want to come back to the fact that this province is the one that is most generous of any province in terms of its taxpayer contribution to individual drug requirements and plans.

Ms Martel: Don't take me wrong; I'm not blaming you. You didn't make the promise about no copayments, so I don't expect you to have to defend that government action. What I'm trying to get at is that somewhere in this program there is $150 million less government money being spent. I don't know how else to describe it. It might be $170 million, it might be $150 million, it might be $130 million, but at the end of the fiscal year when everyone does their numbers and we know it's not estimates any more but the actual money that was spent, we are going to see on a budget line in this program $150 million less Ministry of Health money spent.

Ms Mottershead: I don't disagree with that point. There will be, whatever the number is -- $170 million, $150 million -- less spent in this particular area than in previous years. I just want to let you know in terms of my position as the chief administrative officer for this corporation called Ministry of Health that the money that is being reduced from one side is also being reinvested in other sides because I'm the one who's responsible for implementing the areas where the government has decided to reinvest. There has been a tremendous amount of money that is going to reinvestments in other areas of health care that I can attest to because of my position as chief administrative officer.

Ms Martel: And you would feel confident that whatever savings we find here -- $170 million, $150 million etc -- we will also see have been reinvested in the same fiscal year that that money was actually cut from this budget line: reinvested somewhere else in the health care system?

Ms Mottershead: As I mentioned in my example around the chequing and savings account, I think it's fair to say that overall there are reinvestments. We cannot -- and you know from going through an estimates process -- make a line-for-line tradeoff: This investment goes against this saving; this saving goes against this investment. That's not the way we work.

Ms Martel: Let me go back to my original question. Can we do a costing around, for example, eliminating the deductible? You talked about what's happening at the federal level. My view is I've got to deal with what's happening today. That might be an election promise that the Liberals are making; we might never see that. Let me try and phrase it in this way: Does the ministry, within the Trillium program, for example, have a listing of catastrophic drugs? The reason I ask that is I'm wondering if it would be possible to give this committee a figure of what it would cost, for people who participate in Trillium now who use catastrophic drugs, to have the deductible removed for those people. Is that a figure that could realistically be provided to this committee?

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Ms Lindberg: I guess we'd have to have the definition of what is catastrophic.

Ms Martel: That's what I'm asking, if you have a listing of that at all.

Ms Lindberg: AIDS drugs are expensive, and they use the protease inhibitors or those kinds of things that are expensive. But the person who is 55 years old and has $10,000 or $12,000 in annual income and has had a heart attack, his drugs are very catastrophic also. So it's the definition of what you would want us to look at as catastrophic, because I think it's unfair to say that because they're AIDS patients and they have these high drug costs -- the person who has a very low income and has had a heart attack, his drugs are very expensive too, or for the woman with MS who has some drugs that are not that expensive but takes a lot.

I think we could pull those out if we had definitions of what you were talking about or what categories you were talking about.

Ms Martel: My original question: Does the ministry have a category of that at all for the purposes of --

Ms Lindberg: We don't have a category called "catastrophic."

Ms Mottershead: In terms of that term, it had been used originally to indicate that there are a number of drugs that one must take, in order to function and to live, over a lifelong term. Whether that's a hormone drug or something else, it's something that you're critically dependent on for every day that you live in a normal life cycle. That was the original definition of a catastrophic drug.

I think it's fair to say it has migrated over time, because obviously any drug that can make you better or stop something from happening is lifesaving, or could be lifesaving, and therefore the definition has migrated. So there isn't a current definition, although I understand the previous Liberal government did have one that was very narrow: You need it every day for the rest of your life kind of thing.

Ms Martel: Given the participants in the program now, what would be the cost to remove the deductible for all of the participants in the Trillium program at this point? Is that a fair question to ask? Well, you would know because you have to --

Ms Lindberg: Each individual person has a different deductible --

Ms Martel: Right, but that's geared from their application, right?

Ms Lindberg: -- because we're doing it in a step by step -- I mean, we base it on 4% of your net family income. Because it's net family, one person might have all of the drug costs but the whole family becomes eligible, so then we pick up a full family cost, where we only, on ODB or something, pick up an individual cost, or on special drugs we only pick up an individual cost. So it's very difficult to look at that. An AIDS patient with a spouse, although maybe taking hardly any drugs, once the deductible is paid for, that spouse's drugs are also covered.

Ms Martel: Okay. Take the people, whoever's applying, the straight numbers of people who are applying on any single form --

Ms Lindberg: Yes, we could go through 40,000 forms or something.

Ms Martel: But you wouldn't have a good sense of what that is?

Ms Lindberg: No, we don't know.

Ms Martel: My concern is, I think it's unlikely we're going to see a universal drug program in the very near future across this country. I just don't think that's on. There might be some negotiations, but we're in an election year and it's hard to say what will happen after that. Any number of other provinces are in very different stages of having some kind of coverage for people in need of drugs, and I suspect if money was going to go anywhere from the federal government, would end up going to those provinces that have -- I don't want to say the worst programs, but the least well-defined programs in place. So if Ontario is going to take this initiative around meeting some of the recommendations that have been put forward, it will be Ontario's decision to do that. I don't think it's going to depend on what the feds do, because I think it's unlikely that something's going to happen at that end in short order.

If there's a way to advise this committee of what that particular cost would be, that is something I would be interested in having because I think there's a very serious problem for a group of folks out there who are not capable of working because they are so sick and who are having terrible times trying to pay for drugs that they really need to maintain their life. I really think we need to take a look at what is the cost to deal with that group of people.

Ms Mottershead: I just want to say that in looking at the Trillium program -- and it was the previous government that introduced the program, recognizing that the high cost of drugs had an impact on a number of individuals and families -- what existed before that was a worse situation. There was no plan at all for covering individuals, and somehow people managed. What this program has done, in effect, is to help those individuals who have applied manage even better.

The removal of a deductible altogether, regardless of income, a state of family or a state of illness or whatever -- and I don't speak for the government on this issue -- I personally don't think is a practical idea at this point in time, given that there may be other issues in health care that would require some immediate attention.

Mr Shea: Could we go back? A couple of questions raised by Mr Kennedy I think create some confusion, and for the purpose of the record we might just restate them in another way, perhaps with more clarity.

Would you confirm that individuals in this province who are earning under $16,000, for example, or a couple with incomes of $24,000 or less, in terms of drugs the maximum they would pay is the $2 fee, the copayment?

Ms Tennant: The numbers you quote are for seniors.

Mr Shea: Yes, for seniors. I'm sorry, yes.

Ms Tennant: Yes, that's the maximum.

Mr Shea: Would you confirm also that in your experience at this point a number of pharmacies are waiving the copayments?

Ms Tennant: A number of pharmacists have gone public with that. Other pharmacists we know are making individual or individual-specific decisions according to the customer with whom they are dealing.

Mr Shea: In terms of his questioning, I was perplexed by his question as it led into the issue of apparently a time period where some drugs were covered and gave the impression that now there are drugs that are no longer covered in the plan. I suppose we could ask Hansard to read back his last question. The deputy minister tried to deal with that, and I think she was going down one track while Mr Kennedy may have been going down another track, and I don't want to read his mind because that would be presumptuous and scary.

Mrs Sandra Pupatello (Windsor-Sandwich): Not as scary as that tie.

Mr Shea: Oh, I think there's cause to ask the Chair to rule on that.

Having said that, I don't know if Hansard could read back the question. But if I misphrase this I know Mr Kennedy will try to correct me, and I would welcome that because I'm quite sincere in trying to flesh this out a bit.

To your knowledge, are there drugs now that are not covered? Are there drugs that people are not covered for now in this province that were until just recently covered?

Ms Mottershead: This government has not delisted any products. The notion that maybe was alluded to that there have been delistings and as a result people are now having to pay out of pocket for drugs that have been delisted is not true. This government has not delisted any products at all. The Hansard will show that the director of the drug programs branch mentioned that some have come off the formulary as a result of --

Mr Shea: To be replaced by something else?

Ms Mottershead: -- the manufacturer having indicated that they should come off.

Mr Shea: You are confirming that the copayment has permitted an expansion of the Trillium list and so forth, the numbers involved in the Trillium plan?

Ms Mottershead: And the new drugs that have also been added.

Mr Shea: New drugs have been added, significant numbers of new drugs have been added to the formulary.

Ms Mottershead: That's correct.

Mr Shea: In response to a question -- and this may be one of the reasons why the federal Minister of Health has been so pleased with the current state of the Ontario health program -- you were very clear to maintain that as far as you are aware, the integrity of the $17.4-billion health budget of this province is being maintained, that there are movements within the lines and movements within programs and so forth, but at this point to your knowledge that envelope is still maintaining its integrity. Is that correct?

Ms Mottershead: Absolutely correct.

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Mr Shea: Thank you. You also said something that really caught my attention. It's my understanding that Ontario was the very last province to introduce copayments. Is that true?

Ms Mottershead: That's right.

Mr Shea: Do you have a sense of how far beyond this other provinces clicked in? Has it been just in the last year or have some been in the program even much longer?

Ms Mottershead: Mary Catharine probably has more knowledge of this, but a lot of provinces have been into this sharing of costs for a significant period of time, years.

Mr Shea: Years?

Ms Mottershead: Years. In terms of just giving you a little bit of a stark contrast with respect to this plan, you have here for seniors and others at a certain income level a contribution of $2 whereas in some other provinces -- the one we'd like to refer to is Saskatchewan, which has a copayment requirement or deductible of $1,600 a year, $800 every six months, just to juxtapose the two plans.

Mr Shea: I do not want to make this a partisan committee and respond accordingly, but is my information correct? For example, Prince Edward Island seniors pay $7 per prescription plus the dispensing fee? Would that seem about right? I'm getting some comparative figures of where we are now.

Ms Mottershead: Seven dollars is correct.

Mr Shea: All the other provinces have much larger caps than we do and so forth. That comes back to your comment that this is the most generous of any province in terms of its health care.

Ms Mottershead: In terms of its taxpayer contribution to other taxpayer requirements, yes.

Mr Shea: Do you want to add any more to that? I think that is something we really need to get on the record. We are always trying to improve the programs and systems in this province, but I think it's equally important that we balance the naysayers and others with at least some of the good news by comparison to where we are in other areas across this country.

Ms Mottershead: We have comparisons in terms of what is happening in other provinces. I want to emphasize also the fact that there was absolutely no requirement to have drugs under the Canada Health Act paid for 100%. In fact, this province was paying 100% for seniors and social assistance recipients until just recently. The $2 copayment, $100 deductible is one of the most generous plans in the country.

There has been indication by some of the other provinces at this point in time that they're looking at those plans again to perhaps increase, because we're facing across the country an aging population and the stresses that causes in the health system. Thanks to medical interventions and new technologies and better drug therapy we have people living longer. That means the system itself is under a lot of pressure.

We have a number of provinces, as I indicated, looking at increasing the contribution that citizens make towards this type of program. To my knowledge, there are no plans by this government to do anything like that.

Mr Shea: We can only hope that our NDP brothers and sisters in Saskatchewan come to their senses and join Ontario in this grand march to improved health care.

The Chair: On that sweet note --

Mr Shea: Wasn't that marvellously timed?

The Chair: -- we'll go on with Mr Kennedy.

Mr Kennedy: I will be careful not to reveal too much of the inner workings of my mind to Mr Shea, given his apprehension about how that might affect him. I want to come back to the question I raised earlier.

The replacement of drugs off the formulary list, which is the substitution you mentioned, has indeed caused some people to retain those same drugs which you say have been substituted for and pay for them out of their own pockets on a fairly significant basis. The data for that have been available from groups and associations in this province for some years. I'm wondering, pursuant to your last answer, and you say you can't verify those figures, it seems you perhaps aren't aware of those figures. Is that correct?

Ms Mottershead: I just want to be absolutely clear for Hansard. I don't know what your statistics are, what year they're for and from and so on, but this government has not delisted any product, therefore I don't quite understand the substitution comment you've made.

Mr Kennedy: Previous governments have?

Ms Mottershead: Yes.

Mr Kennedy: What we're talking about -- and I'll just bring you back to the line of questioning -- is the auditor's insight that certain practices should be followed. We're asking about the new cuts, in the sense that there are copayments, which represent a cut in net benefit. You've reflected already on your opinion of the generosity of that. But certainly we're wondering whether there are studies to track that. I'm talking about, under your jurisdiction, previous changes that have been made, wondering whether the ministry has been aware of them, and the potentially harmful effects of those changes of delisting drugs, of putting substitutions on, and whether people, particularly people for whom the main benefit of these programs is intended -- lower-income people and seniors -- have been deleteriously affected. I'm asking that as a question. I'd appreciate what response you can give.

Ms Mottershead: I'm going to pass it on to Mary Catherine. My understanding of the previous government's delisting of some products is that they were not products that would or should have created hardship on anyone. I'll let Mary Catherine, who has a better recollection of that, comment.

Ms Lindberg: There were two categories of drugs, I think, that you're talking about. We took out a number of over-the-counter drugs, as they're called, and we took out what we call sustained-release drugs. The exact, same medication is still available in the formulary, except that it's not in a sustained-release form. We were finding that the manufacturers, where you would have a generic form of the regular-release form, which would be the lower cost, were promoting the sustained-release formulation over the generic because then they would get the market. There was no real advantage to sustained-release drugs other than that you don't have to take them as often during the day.

Ms Mottershead: It's long-lasting medication.

Ms Lindberg: Yes, it's called sustained-release or long-acting. We felt that the most suitable way for people to take those drugs was in the generic applications, the regular form of the drug which worked just as well, did just exactly what we required, was the right drug at the right price at the time we were looking at it. The sustained-release medications, which really had a better health outcome because they were sustained-release, are still in the formulary.

Mr Kennedy: I'm not going to get into a pharmacological discussion, because I don't have that background, but it sounds like a relatively benign explanation. However, again my point is, referencing the deputy's point: How does your ministry monitor the effects of changes in government policy with respect to the drug benefit program? The answer given was associations' complaints monitoring the community. I'm referencing monitoring that's been done in the community to say that it has not been a benign effect. There have been people who pay out of their pocket for these drugs.

I've been personally involved in advocacy with some of your committees that review drugs, and I know this is not quite as benign -- I'm not saying it's widespread or inordinately different -- but the impact on people's health is documented, is significant. The impact on their income, which is what this program is supposed to replace, is significant. I wonder if your ministry is aware of the studies that food banks here and in Kingston and in Ottawa and so on have had on the impact of the program. Is there any response to that? Does that relate to perhaps a need for studies to be done on the current copayment plan?

Ms Lindberg: The decision is whether we're prepared to pay for the right drug for the right condition at the right cost, versus patient preference. One of the things when you're dealing with a program in this order of magnitude of costs is that if that's a patient preference, we have said the patient has to pay for it.

Lots of times people don't want the generic. We have compulsory interchangeability in the formulary. We only pay for the lowest-cost drugs in the formulary within a generic group. You can get the brand name if you want but you have to pay the difference. We are not denying anybody adequate and probably, in some cases, from the kinds of studies we've seen, the best therapeutic applications versus patient preference. You've done studies of the impact on food banks, and I understand that, but we've done studies on the impact on health outcomes of the difference in using these two different kinds of drugs. You can use the one that's the lower cost and get the same therapeutic outcome and the same outcome for patients, so it's patients' preference.

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Mr Kennedy: I guess I see some resistance to the idea. Referencing the associations, I'm just wondering, have those specific impacts -- I'm not talking about the veracity back and forth of them, but certainly people and their physicians, very often their physicians, believe that their health outcomes would be worsened and therefore they are keeping with drugs that are of significant cost to them to sustain. Out of very scarce moneys they are paying for these drugs which used to be covered by the program. You're saying back that there isn't any problem with that. I'm wondering if, because the drug copayment certainly is going to be an economic problem, it's an economic program in many ways as much as a health program.

Ms Lindberg: If the physician wrote us and told us that it was very important that this patient have that drug and they have it under the drug benefit program or whatever, we have a process where we pay for that drug. It's called a section 8 process. We'd pay for some of those drugs that we took out under that if the physician says there would be dangers to the health outcome of the patient. However, we don't pay when the physician says, "My patient wants," versus, "My patient needs."

Mr Kennedy: I want to bring it away from the specific thing. I've had experience with physicians who have had great trouble getting section 8 or anything done. I'm aware of a case that is 18 months in progress. I'm not looking at that specifically. I'd like to bring it back to the question of, will the ministry undertake specific studies to know the outcomes on the protection and promotion of health for people in your drug program of the copayment cuts? Is that something that the ministry may do? Is it a change in practice?

The auditor seems to be saying to us as legislators that there should be certain protections in place, certainly with respect to cost savings, certainly with respect to your price costs -- 25% he has cited were higher than out of province -- how those things are responded to. But also we're interested to know, where you are saving money, that the health outcomes are being protected. We have a massive new program affecting all of the people who are beneficiaries of your program. I'm wondering, just because I'm trying to get at how you are monitoring the health outcomes, what will you do in respect specifically to copayments?

Ms Mottershead: I'll respond to that by saying that our chief medical officer of health, who's responsible for looking at how well we're doing with respect to the health of Ontario's population, what specific interventions are necessary from time to time, does a lot of the research and looks at particular areas of need. His report comes out every year, in the fall.

Mr Kennedy: Might that include the copayments?

Ms Mottershead: I can certainly put the question to him. It is a determinant of health. Income and economic prosperity and so on are determinants of health, and that could be a question that I could put to him.

In terms of health outcomes, there are a number of studies that take place on a fairly frequent basis. One is called the Ontario Health Survey, and there is the Canadian Health Survey. That is done. That is not just using technical, medical or clinical kinds of information; it actually asks people on the street how well they think they're doing, when was the last time they had to have something and maybe couldn't get it. It's that kind of very personal indication and telling us what people feel and think about their health care, their health outcomes.

I just want to say that last year the provinces, all together, finished a survey of Canada's population with respect to health outcomes, and that's a published report that was made available by ministers of health last fall, September 1996.

Mr Kennedy: I guess I was hoping, and I still would encourage you, to look more specifically at the outcomes of specific measures this government, the past government, that your ministry specifically takes. You mentioned the reinvestment funds. In your capacity as the overall administrative officer for health, would it be possible for you to provide this committee with an idea of where the reinvestment fund commitments have been made in this year for the $170 million taken from the drug program, for the $365 million taken from hospitals and so on? Could we see that as a reference to understand the picture you've given us of this money and some of the outcomes which may or may not happen and which I'm recommending studies for? How can we see how that is taking place? Is there a guide that you can give us to the reinvestments that have been made by the ministry so far?

Ms Mottershead: Certainly one of the guides is what has been put into the budgets of the various programs, and the estimates process that we go through is an opportunity to see that and have the discussion. The other I think you'd be very familiar with, and that is that the Minister of Health has been announcing over the last several weeks and months the level of expenditure and commitments -- very, very public commitments. There are announcements that are made, there are news releases that get sent out. As late as yesterday afternoon, I believe, the Minister of Health did indicate that there was over $680 million worth of reinvestments that were made, and we haven't even finished the 1996-97 fiscal year, which hasn't actually taken out the whole $365 million worth of reductions in hospitals.

Mr Kennedy: It would be greatly appreciated if we could get a copy of the $680 million of announcements which have been referenced, and I would much appreciate that. I hope I can have that undertaking.

We were given to understand the Ministry of Health was part of a consortium of ministries that were doing advertising across the province and that the ministry's ads were prepared but it was decided not to utilize them. I wonder if you could tell us a little bit about that program and why those ads didn't see the air and so on.

Ms Mottershead: I guess I have one comment and a question. The comment is that I don't know what you're talking about and the question is, what does that question have to do with public accounts today?

The Chair: We'll have to wait for the answer.

Mr Kennedy: What did they have to do with the drug plan?

Ms Mottershead: Or the public accounts discussion.

Mr Kennedy: -- the ads that were pulled had to deal with the drug plan in any way?

Ms Mottershead: We did indicate that we were looking at a 1-800 line as a possibility for doing some customer information and education. That is one area that we are looking at.

The Chair: We must move on.

Ms Mottershead: I don't know what you're referring to in terms of ads.

Ms Martel: In your capacity as the chief executive officer, whatever you want to call it, for the Ministry of Health, can you tell this committee how much the Conservatives cut from hospitals last year?

Ms Mottershead: Last year being 1995-96 or the current year we're in?

Ms Martel: You have a $1.3-billion amount that's going to come out of hospitals over the next three years. Can you give me what that is in the fiscal year we just ended? I understand that cut was just announced to hospitals across the province yesterday or so, because it was raised in the Legislature, and what is the estimated cut to Ontario hospitals next fiscal year?

Ms Mottershead: There was no cut in 1995-96. There is a reduction in transfer payments this year, 1996-97, and that reduction is $365 million. The announcements in terms of the three-year reduction plan were made by the Minister of Finance in November 1995. That number for three years has been public in that document and it's $1.3 billion over three years.

Ms Martel: But you must know what the figure is for next year, because it was just released --

Ms Mottershead: It's $435 million.

Ms Martel: But hospitals this week were told of a cut that's upcoming. What is the nature of that cut? Is it about $463 million, $465 million?

Ms Mottershead: It's $435 million.

Ms Martel: What's the anticipated cut for next year?

Ms Mottershead: About $500 million.

Ms Martel: I'm wondering if in May 1995, on a televised leaders' debate, you heard Mike Harris say that he had no plan to cut or close hospitals?

Ms Mottershead: Can I ask the Chair if it's an appropriate question to be asked, given that this is public accounts and that this is a discussion around drug programs?

The Chair: I would say that you would try and accommodate the questioner, and if you don't want to answer the question, simply say so.

Ms Mottershead: I have no comment.

Ms Martel: With respect to the drug program, would you argue or would you agree that a copayment for seniors is a user fee?

Ms Mottershead: I would say that it is a contribution towards the cost of your drug.

Ms Martel: Okay. Did you read what Mike Harris said in the Common Sense Revolution, that there would be no new user fees? He promised that to Ontarians before the last election.

Ms Mottershead: I don't make a habit of following political debates.

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Ms Martel: I don't want to be partisan today, but let's be clear, Derwyn --

Mr Shea: I'm making notes.

Ms Martel: -- about the commitments that were made, because in relation to the copayment issue in particular, a very specific commitment was made by this Premier that there would be no new user fees in --

Mr Shea: On a point of order, Chairman: I'm quite pleased to engage Ms Martel in partisan or non-partisan debate, because I have a consummate respect for her ability and her concern for this province. I share that concern with her. I am equally concerned that we do not engage our bureaucrats in that political arena and I'm sure Ms Martel would agree with me in that regard. As she edges to the precipice, I just put that on the record, Chairman. I'd like you to make sure we support that.

The Chair: Very good. I suppose we'll have to strike out your own note about the NDP government in Saskatchewan.

Mr Shea: I'm sorry, on a point of order: Do not strike that out. I did not raise that asking them to --

The Chair: I think we have to move along.

Ms Martel: I'm sure if the deputy wants to offer observations about other governments, she would like to offer the same about what's happening in this province.

Let me ask, though, if we could get for this committee the listing of members of the DQTC at this point and their résumés. Can you also tell me, are there any vacancies right now on that committee?

Ms Tennant: There are no vacancies. It has 12 members and we keep it completely filled.

Ms Martel: Can you provide to this committee then the backgrounds of those who are on it?

Ms Tennant: Yes, we can do that.

Ms Martel: Can you also give for each of the 12 members when they were appointed and when the expiry date is due for each of those?

Also, you said earlier with respect to people who are on the Trillium drug program right now that you will be, if I understood it correctly, mailing them a request which would ask them just to send in a list of their income this year and they would automatically qualify for the program again, they don't have to fill out a new application form.

Ms Tennant: Yes. For people already on file with Trillium, we will be printing a form for them. What we're asking them to do is simply confirm that the information we have available is still in effect. So for a large number of people whose income will remain the same, we're using 1995-96 income, the same as we used for this year. All they have to do is sign the form and send it back.

Ms Martel: When will that be going out?

Ms Tennant: We are starting the process the week after next. We'll be issuing them in batches for ease of processing and they'll all be going out within about a one-week period.

Ms Martel: Will it be possible for you to provide notices to MPPs' offices that those are going out and a copy of the information that's going out to participants in the program right now, so that if we have people who have questions or indeed people who maybe lose it, we will also have duplicates in our office that we can provide to constituents?

Ms Tennant: Yes, we can do that.

Ms Martel: What are pharmacists being advised with respect to that? Are they being told that this is what the ministry's plans are so they can also tell consumers who come in who have questions?

Ms Tennant: We notify pharmacists instantaneously through the Health Network, through regular messages. They will be notified. We have notices going out to the Trillium applicants, to specific groups of individuals who may be interested, to the pharmacists. I think that's about it for the moment. But pharmacists will be notified. Pharmacists will also receive copies of the new 1997-98 form for individuals who don't receive the preprinted application.

Ms Martel: That would be helpful. If you can get that to MPPs' offices too, that would be helpful, because we receive a number of inquiries in our offices with respect to the program.

Can I go back to the DQTC? This is a follow-up to questions that were raised last week about the program. If I remember correctly, there was some conversation that the nature or the responsibilities or the mandate of the committee was going to be changed. Am I correct in my recollection of the conversation last week between yourself and one of the Conservative members? Is there a change or am I thinking about the wrong issue?

Ms Tennant: The DQTC is subject to sunset reviews every three years and the terms require us to look at the role and mandate. So a sunset review is under way at this moment looking at the role and mandate. We have no doubt that some of the functions will change due to the changes in the streamlining of the drug submission process. For example, the federal government has introduced new requirements for declaring bioequivalence between drugs, which makes it easier for the province to declare interchangeability. That in turn changes the DQTC's functions.

Ms Martel: Who is involved in the sunset review?

Ms Tennant: We have a panel of four members led by Dean Perrier, who is dean of pharmacy at the University of Toronto.

Ms Martel: Have they just started that review or is it well under way and you're expecting a result in the very near future?

Ms Tennant: The first draft of the report is due next week.

Ms Martel: But in all likelihood it would not be that the committee itself is going to be disbanded but its mandate and its role and responsibility will be changed in response to some changes at the federal level. Are you in a position to comment on that at all?

Ms Tennant: I don't see the role changing that much, no.

Ms Martel: Can you tell me, and maybe this is not a fair question to ask, is there a community pharmacist now on that committee?

Ms Tennant: Yes, there is, a community pharmacist from Thunder Bay as a matter of fact.

Ms Martel: Do you have one or do you have more than one?

Ms Tennant: The committee has 12 members and we have medico-pharmaco-economic, health-economic and pharmacy membership. We only have one community pharmacist, but we also have pharmacy background. It's a more scientific or technical application, so we have a range and mix of members. The committee also uses fairly extensive reviewers or a cross-section of reviewers or other experts to enable it to complete its work.

Ms Martel: What tie-in do they have to the federal panel that deals with drugs that's headed by Bob Elgie? Is there any link whatsoever?

Ms Tennant: We have no direct link, no. We have informal links with the various federal departments with which we work.

The Chair: We have 11 minutes to go and the auditor has asked to address the committee for about three minutes, so whatever time is left will be split among the three caucuses.

Mr Erik Peters: Thank you, Chair. If there are other members' questions, of course, I don't want to infringe on your time. I just want to follow up very briefly on an answer to a line of questioning that was pursued by Mr Patten when he talked about the inspection, one of the answers he received to his question as to whether four inspectors were enough. Part of the answer was that there was also an investigations branch in being and they worked together.

I was wondering if we could possibly have some elaboration on how they actually relate and how they work, particularly in light of the fact that we expressed concern in our report that, 70% of the prescriptions being verbal, there may be a number of false billings go undetected. I was just wondering, if the inspectors run into false billings, would they involve the special investigations branch and how does that work and when do you get to the police and how does that process work?

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Ms Lindberg: The pharmacy liaison officers, as we call them, who are inspectors, are pharmacists and we ask them to be pharmacists so they can go in and look at the records and review the records from a perspective of what would happen in a pharmacy from that kind of professional viewpoint. The inspectors in the inspection unit are special warrant type officers who actually do more of a real in-depth investigation like a police unit would.

When the pharmacy liaison officer goes in and detects a problem or sees a problem on the computer from a practice pattern, goes in and sees there could be fraudulent handwritten prescriptions by the pharmacist, which means that they've made a record that is not actually valid, what happens after some verification work is that they send it over to the inspection unit. The inspection unit then takes it on to do the work so we can get enough evidence and take enough evidence to go to the police and a warrant can be sworn out, and then we can get the police involved. There are two steps: first, our people in the drug program, then they go over and work with the inspection unit. We have a number of ongoing investigations in that kind of category right now.

Mr Peters: Thank you.

The Chair: That's it? I'll accept one question from the government caucus, and then the Liberals and Ms Martel.

Mr Shea: In three parts, one question: Issues were raised about section 8 and, behind that, the issue of concerns about health studies and impacts of health studies. The issue that might arise from that is whether the ministry has ever done health studies, impact studies, as a result of the cutting of thousands of beds in Ontario over the last 10 years or the delisting of drugs in Ontario over the last several years or whether the federal health ministry has ever made such studies raising that question.

In more precise terms, to go to section 8, and I want to come back into that, I'd like your comments on what the process is to get a section 8, how long it takes and whether that can be used towards a Trillium deductible.

Ms Mottershead: I'll pass that to Linda to give you the detail on that.

Ms Tennant: Section 8 is used in a number of situations, but basically it's a process by which the branch is able to seek expert advice to assess claims for drugs that aren't on the formulary. Sometimes these are brand-new drugs that a manufacturer has just brought on to the market that aren't on the formulary as yet. A physician has to send us a letter saying why, the clinical reasons the individual requires the drug. For certain drugs, we use a fax process, which takes about 24 to 48 hours. Those are situations where the individual needs the drug immediately. In other cases it can take about two to three weeks, because we do use external advice through the Drug Quality and Therapeutics Committee to assess the clinical criteria and give us a recommendation for payment. It varies. We have no backlog at this point in time for processing on a daily basis.

Mr Kennedy: Just to clarify, we'd like to ask that your ministry provide the data referred to in terms of the health outcomes from the substitutions of the previous government, you mentioned as where it has taken place, or the delistings, where it has been expressed that those outcomes have been benign; the detail of the $680-million reinvestment that shows where the drug funds have gone in the past year; and the overall outlook in terms of what data, which the deputy referred to, exist around utilization in this year when the copayment program is being put in place. Is there any problem with this committee receiving that data so it can evaluate where the drug program is headed, all of which was referred to, I believe, in the testimony.

Ms Mottershead: We can undertake to provide you with whatever data exist.

Mr Kennedy: Okay. Can I take that as a yes? Those were all referred to by you or by the different directors.

Ms Mottershead: I've referred to a number of studies that have been conducted, I've referred to the health survey, I've referred to the network where we get information. There is some information that does not exist in a form that you could see or benefit from, for example, the drug network. We go into it, we look at it, we've got inspectors who look at what's going on, but there isn't a report or data collection that's done on that per se.

Mr Kennedy: With your indulgence, Mr Chair.

The Chair: I'm sorry, I want to be fair on this, Mr Kennedy. Ms Martel, please.

Ms Martel: I wonder if you can provide to the committee how many pharmacies of the total number operating in the province are actually waiving the copayment, if you have that information, because I heard you, Ms Tennant, say that the ministry did know there were some that were waiving a fee and I don't know if you have a listing of that. I'd be interested to know what the breakdown is between the pharmacy in Wal-Mart, for example, and community pharmacies doing that.

Ms Tennant: I'm afraid we don't have a list, because it's not something we require. We know from the publicity that was given that Wal-Mart, Loblaws and various other places advertised directly to the public that they were waiving the copayment. The other information that we received, quite frankly, is anecdotal or experiential and we have no numbers.

Mr Shea: On a point of order, Mr Chairman: Will I have an opportunity to ask for further information to be tabled along with Mr Kennedy? It's a good question.

The Chair: Mr Shea, I would like to tell you about next week's meeting. Then if there's time, by all means.

Mr Shea: Can I just be clear about your response to my question?

The Chair: I did say if there is time after my announcement, then you can ask Mr Kennedy or whomever your question.

Mr Shea: I just want to add on, asking for more information for the committee.

The Chair: Let me read what our agenda will be next week. February 13 we'll be looking at section 3.12. Today will conclude 3.13, and next week we'll be looking at assistive device services activity with the same ministry again. We'll start with a 30-minute closed session, and then we'll carry on with the review of the section. Mr Shea.

Mr Shea: Chairman, I appreciate that. I wanted to pick up on the point and ask the deputy minister, having been asked for any information or studies of health impacts, whether or not they would have any such studies on health outcomes provided by the federal government. I assume the federal government would be even more interested in doing such studies, and if they have them, perhaps they would provide them. If the deputy minister also has received any of those health outcome statements from various food banks and if they've been subjected to any empirical evaluation, can we have them presented for analysis as well? Any of that which has been brought forward, but particularly federal government.

After all, it's the one where the federal Minister of Health has said that Ontario's health system is in good shape, so I'd like to see what they have said in response to the issues such as health outcome of the cutting of beds, the delisting of drugs and so forth in the past, as well as what may be alluded to today. If that could be tabled, I'd be most indebted.

The Chair: It being close to 12 o'clock, and we'll be called to vote on private members' issues in a very short while, this committee stands adjourned until next Thursday, February 13. I thank you very much.

The committee adjourned at 1158.