Tuesday 23 February 1993

Annual report, Provincial Auditor, 1992

Ministry of Health

Michael B. Decter, deputy minister

Peter Burgess, director, registration program branch

Fred Hazell, executive director, information systems division

Eileen Mahood, director, claims payment operations


*Chair / Président: Mancini, Remo (Essex South/-Sud L)

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

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

Cousens, W. Donald (Markham PC)

*Duignan, Noel (Halton North/-Nord ND)

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

Haeck, Christel (St Catharines-Brock ND)

*Hayes, Pat (Essex-Kent ND)

Johnson, Paul R. (Prince Edward-Lennox-South Hastings/Prince Edward-Lennox-Hastings-Sud ND)

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

Sorbara, Gregory S. (York Centre L)

*Tilson, David (Dufferin-Peel PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Fletcher, Derek (Guelph ND) for Mr Johnson

Perruzza, Anthony (Downsview ND) for Ms Haeck

Wilson, Jim (Simcoe West/-Ouest PC) for Mr Cousens

Also taking part / Autres participants et participantes:

McCarter, James R., executive director, ministry and agency audits, Office of the Provincial Auditor

Peters, Erik, Provincial Auditor

Clerk / Greffière par intérim: Deller, Deborah

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

The committee met at 1013 in room 151.


The Chair (Mr Remo Mancini): The standing committee on public accounts is called to order. The standing committee on public accounts is continuing its review of items chosen from the 1992 annual report of the Provincial Auditor.

This morning we have asked senior officials from the Ministry of Health to join us to discuss the health registration system. Mr Decter, we welcome you back to the committee. We may even offer you a permanent seat if you continue to show up at our meetings. I'm sure you wouldn't mind.

Mr Michael B. Decter: It's always a pleasure to be at the public accounts committee, particularly at the beginning.

The Chair: It's always a pleasure? That's what we thought. Mr Decter, we'll just ask you for the record to introduce the officials that you have with you and their areas of responsibility. I understand that you have a presentation that you wish to make to the committee. Once the introductions are over for the general public that is watching and for Hansard, I would just ask you to move right into your presentation, please.

Mr Decter: Thank you very much, Mr Chairman. It is a pleasure to be here and to continue our relationship with the committee as we jointly struggle with some of these issues.

I'd like to introduce Julie Legatt, the executive director of our administrative management division, Fred Hazell, the executive director of our information systems division, and Peter Burgess, the director of our registration program branch. They are the three officials in the ministry most directly involved with the health registration system.

I will make a brief apology at the beginning. I'm fighting a bit of a cold. I think my voice will hold up.

It was our intention to take you through a brief presentation. As we evolved the presentation it became clear that some of the complexity of the issues would require some time. It's my understanding you've allocated us some 40 minutes to do the presentation. We will try to get through it more rapidly if we can. I don't know whether you have a view on whether you want to save questions till we're through or take them as we go. We're open.

The Chair: I would prefer that we save questions, unless members find it impossible to restrain themselves.

Mr Joseph Cordiano (Lawrence): Forty minutes without speaking?

The Chair: Forty minutes without questions is a long time; it's almost an eternity.

Mr Decter: Yes. I understand that.

The Chair: Let's try our best.

Mr Decter: Okay. Health registration system: I would like to cover, essentially, some historical events briefly, how we got where we are. We would like to cover some of the details of the Provincial Auditor in his most recent report, and I think what we mostly want to do is talk to you about work we've undertaken since the auditor's report to address a number of the issues and, essentially, what progress we're making in moving forward.

In terms of the background, we have, I guess, categorized it in five groupings: the OHIP family-based system; the 1987 audit highlights; our own information technology plan; the individual health number; and the registration project.

Let me try to deal with 18 years of history rather quickly, the 1972 to 1990 period, in which we were reliant on a family-based number known variously as OMSIP, which goes back to 1966, and later on as OHSIP, which was the system that brought together 35 private insurers and a small number of insurance brokers.

In 1972 Ontario formally met the federal provisions for cost-sharing by implementing OHIP. We combined our hospital and medical coverage and we used the eight-digit numbering system for premium collection that was already in place, because it covered virtually 100% of the population at that time. The difficulty with the family-based registration system was in fact that it didn't have unique identifiers and it made it extremely difficult to therefore catch duplicates. There were no limits on the number of family members that were allowed.

Enrolment and application was largely through employers; about 80% came that way while an additional 20% came through individuals or groups of less than five employees. Eligibility to receive benefits was tied to premiums, although there were premium assistance mechanisms for those in need.

It was a relatively administratively complex system to administer. It was costly and it raised a number of universality issues. The processing of claims under that system was batch method, which had few automated controls. The entitlement card in those days was a paper card, and multiple versions could be issued with no indicator that they were multiple versions. In addition, every time an individual in Ontario changed jobs, he was issued, generally, with a new OHIP number, and other changes, marriage, divorce, reaching 21, also triggered issuance of a new card.

If we go to the 1987 audit findings, which were really, I think, the propellant for us to change how we tackled this, the audit findings were in summary: Our computer system was outmoded and unresponsive to present-day needs; we were not using advances in computer system design. I think most important, as we get into numbers, there were 25 million numbers on file under the OHIP system as of 1987 against a population of somewhat less than 10 million; that was an enrolment of nearly three times the provincial population. We also had a good-faith policy in place, and under that policy we were paying some $50 million a year.


If you look across you can see that significant efforts were made, have been made, to tackle those issues. We moved to an on-line system with implementation in August 1990. We undertook the registration project to get a unique identifier, and we have -- and I'll come to much more detail on this -- but we have roughly 10.8 million as opposed to the previous 25 million, which we believe to be within 4% of the provincial population. I'll also come to the issue of some uncertainty between ourselves and Statistics Canada about what the actual population of Ontario is at the moment.

The premiums were abolished in January 1990 which removed that base and we have seen a reduction in good-faith payments to roughly $1.5 million annually. We are under way on a claims rewrite project which will clean up the last part of the movement to the new world.

In 1989 the ministry put together an information technology strategic plan which looked at how we would cluster health data and how we would essentially link together the various information we were collecting. This had been recommended to the ministry as early as 1970 by the Ontario Council of Health; later in 1983 by a report called Health Care in the 80s and Beyond; and again in 1987 when Dr Robert Spasoff's report, Health Goals for Ontario, was published. Essentially everyone had been calling for movement to a unique health care number to allow us to have databases that allowed both management of the system and planning of the system.

There was a very large effort undertaken: Three years of consultation, involvement by over 400 staff in the ministry to develop a plan --

The Vice-Chair (Mr Joseph Cordiano): Excuse me, Mr Decter. It's a little difficult to see the on-screen from this distance. I would ask if you had a handout that could be made available to all members. I don't believe we have that.

Mr Decter: We can, I think, get a handout. I don't know how rapidly we can do that. As rapidly as possible.

The Vice-Chair: Okay. I would appreciate that. Perhaps we could carry on.

Mr Decter: As we get through the historical piece into the more current issues I'll slow down and walk people through what's on the screen, so it will be a little easier to follow and we will have copies.

The registration project inside the IT plan really had as its objective linking a unique health number to all of the health services provided to individuals. We had a very program based ministry, very, if you want to think about it, vertical where programs were not linked together and where services to individuals were not linked together in planning terms.

The other thing that was initiated at that time was the encounter card pilot project in Fort Frances which is our attempt to look at smart card technology and how we might use that. That took us essentially to the issue of why a unique individual number, and I think there are five good reasons for it.

The first is public understanding, and I think that's self-evident. The second is confidentiality. We wanted one database that we could have proper security on rather than small databases everywhere in the ministry using different identifiers. Third is customer service. Obviously it's easier to provide customer service if you know who you're providing those services to.

Planning is a very central issue for us. As you can imagine, planning a health care system for 10 million people requires a lot of insight into what services are being delivered and in the days before the unique number, we didn't have a good idea of to whom services were being delivered.

Finally, eligibility control. As we've moved to have a universal system we still, of course, have eligibility rules, and to manage and police those rules there is much to commend a unique number.

The basic features of the new registration system are:

(1) an individual permanent health number for every resident of Ontario;

(2) a durable plastic card issued to each individual;

(3) a registration system that didn't rely on the premium system for identification or registration;

(4) an enriched registration database including, at a minimum, date of birth, sex and address;

(5) a common registration database which would be used by all ministry programs, which would allow linkage of ministry service on a historical basis and, finally, a one-time universal reregistration program to implement the new system.

Those were the basic underlying reasons for doing it and we undertook, as you're aware, to move forward on that. I think the next diagram sets out how we went about the process of having people apply and it kind of walks through the mail application, the use in some circumstances, of citizenship documentation, the processing and the mailing of cards.

This was a fairly massive effort, commencing in May 1990. I think, if you go to the next slide, you can see the sort of time period over which -- you can see the major part of the registration project, commencing in May 1990, and ramping up quite rapidly to February 1991, and then a bit of a plateauing. The two lines, the black line is the standard health card and the dotted line, the lower one, is the Health 65, the card people get when they turn 65 years of age.

The universal reregistration project was a major investment and, as you can imagine, it didn't go totally smoothly. There were backlogs in processing and you can see from the black line there that those backlogs peaked in about August 1991 and have come down substantially since, to a level that we believe is a manageable level.

It was a huge task for the ministry, I think, carried out in the end well, but with probably some underestimation of the degree of difficulty on the front end. We now have the vast majority of people in Ontario equipped with the current health card, which you would know looks something like that, and I believe this is not an actual card. This is one made up for the occasion. Everyone has their own card, we hope, and we hope that you're all carrying it.

Let me come now to the health number registration system, because this was the subject of the auditor's most recent report and the major activity I want to talk about. Yes?

Mr David Tilson (Dufferin-Peel): Excuse me, could you just flip back to that card?

Mr Decter: Certainly.

Mr Tilson: I guess we're just looking -- I just happened to pull out my card, which is -- excuse me, Mr Chairman, may I jump in at this point? We're all getting our cards out.

The Vice-Chair: I'm going to allow a point of clarification.

Mr Tilson: Thank you.

The Vice-Chair: Rather than a question.

Mr Tilson: It's just that I'll probably forget, if I don't ask the question.

The Vice-Chair: Point of clarification, go ahead.

Mr Tilson: I look at the card that you have and it has the word "expiry" on there. That's not on my card. Is there a reason for that?

Mr Decter: Yes, I'll let Peter speak to that. We have a few variations on the cards.

Mr Tilson: Are there different cards? My card seems to be different from that card.

Mr Peter Burgess: Perhaps I can clarify. Some temporary cards have been issued for a limited period of time. They will have, in the bottom left-hand corner, an expiry date. They are for migrant workers and other individuals who are covered for health care for a very limited period while they are here in the province.

The two initials, VC, down in the bottom right-hand corner, are a version code. Hopefully, not too many of you will have a version code on your card. It signifies that you have had more than one card.


Mr Tilson: Oops, I've got a number down there. Do I have more than one card and don't know it?

The Vice-Chair: Order, please.

Mr Burgess: Let me just add one other significant number that appeared on the cards that were first produced in the initial registration. They have an eight-digit number and that is your old OHIP number. That was supplied at that time, I understand, because the providers were given a period of time during which they could bill services rendered either on your OHIP number or on your new unique individual health number.

Mr Tilson: Okay, we'll spend more time on that later, but I guess my observation was on the word "expiry." I thought that a temporary card was simply a piece of paper, that if you didn't have any identification as to who you were or you didn't have a fixed address or something, you could somehow get a piece of paper; you didn't get a card.

Mr Burgess: The picture that is showing on the screen is in fact a picture of either the paper card or the health card. They look identical other than the fact that one is plastic and one is paper, and the paper card for those who have limited eligibility has an expiry date on the bottom left-hand corner.

Mr Tilson: Mr Chairman, one more question.

The Vice-Chair: One final question.

Mr Tilson: Thank you. The permanent card does not have an expiry date on it.

Mr Decter: No, and if it hasn't been reissued --

Mr Burgess: It would not have a version code either.

Mr Decter: -- then it wouldn't have a version code. We wanted to show everything that could be there and I believe -- are those accurate percentages currently that about 1.2% of cards would have an expiry date and about 8% would have a version code?

Mr Burgess: That's right.

Mr Decter: So 90%-plus would have neither, although the early ones would have the old OHIP number on them to assist providers in making the transition. We'll come back to these issues a little bit later.

The Vice-Chair: Perhaps we can carry on and not have too many questions as we agreed not to ask questions till the presentation was finished.

Mr Decter: In terms of the registration system, one of the things we wanted to do, because there have been a lot of questions about us versus others, was to give you -- and it's a bit of a confusing slide -- the comparison with other provinces. This one will be a little easier when you've got it in front of you.

To walk down it a little bit, I guess the thing most easy to see is that there are a good number of variations. We are one of five provinces with a plastic card. We are one of three provinces with a mag stripe. We are one of two provinces with a version code. All of the provinces have the name on the card and six of them have the sex on the card; we have it on the mag stripe on the back. Where it says UR, that is "under review," so we're considering, and I'll come back to it later, whether we would add both the sex and date of birth to the front of the card.

Anyway, I won't go through each and every one of these. The major point we're making here is that each of the 10 provinces has done things a little differently in this respect and that I think Ontario sits sort of in the middle of the pack in terms of doing this.

The province that's moved the furthest in terms of the elaboration of the card is Quebec. They now have a photo on their health card and that's something that we're looking at. As indicated in the response to the auditor's report at the time of the initial reregistration, it was seen as beyond our resources and means to move to 10 million photographs on 10 million cards. But the issue is one that's currently under review and we're very interested in learning from Quebec more about its approach.

I guess another issue is that four of the provinces have a card renewal cycle which we're also looking at and five of them have a telephone validation capacity which we're more than looking at; we're looking at implementing an ability for providers to validate health cards by way of a telephone line.

Again, the point of this is really to say that we are looking at innovations in other jurisdictions, and I guess I'd just underscore that fully five of the provinces are still using paper cards at this point, although I believe most of those are looking at the issue.

Let me take a special look at the New Brunswick experience, because New Brunswick, of the other provinces, has probably tackled this issue. They felt they had a great deal of cross-border shopping, if I can put it that way, from their shared border with Maine. They are a slightly smaller population than our own of some 724,000. Their ministry, which is a combined Health and Community Services ministry, has a budget of about $1 billion a year.

They reissued a new card in the summer of 1992 which, although I think it remained a paper card without a photo, did have an expiry date on it, a staggered period of time. They issued about 7.1% more than their expected population and have started into a reconciliation. To date, I believe they've reconciled 33,000 individuals which means they've still got 18,000 or about 2.5% of their total population unaccounted for.

The efforts have gone to, I guess, one extreme in New Brunswick. They have actually published posters entitled "Medicare Fraud -- You Can Help Stop It," and they've involved Crime Stoppers, so they are in fact taking a very aggressive approach to the issue in that province.

We are watching what they are doing. They've had, according to the most recent information, 25 medicare-related tips since their program began in mid-January and their tips are both fraudulent provider as well as fraudulent consumer tips. I think, to come back to it later, the New Brunswick measures are seen by some of the other provinces as perhaps somewhat strident but nevertheless worthy of monitoring and seeing how it works out.

If I come to our own situation -- to get into the numbers -- I think fundamentally the issue for us is how many cards have we issued and how are we moving back from the issuance to having a good congruence between the number of cards out there and the number of eligible people, so let me try and walk you through this at a macro level and then I'll come back to the specific measures.

We have, as of January 1993, produced 12.2 million health cards. Of those, 1.4 million are ineligible. Those are cards that have been struck off eligibility for one reason or another. That leaves us with 10.8 million people on the database with eligibility.

I'll give you the other view on population in a minute, but the Treasury and Economics view of our population is 10,080,000 so if you subtract that from who we've got on the database, we then have 740,000 entries on the database that need reconciliation. Of that, if you want to break it out, we have, we believe, 273,000 who are eligible but not in the population estimate. Let's divert and go back and we'll tell you who those are.

Mr Tilson: I didn't hear that last number you said.

Mr Decter: It was 273,000 who are not counted in the population estimate but we believe have eligibility.

Mr Jim Wilson (Simcoe West): What's your total population estimate?

Mr Decter: It's 10,080,000, is the one we're using in this go-through. So if you take the --

Mr Tilson: I'm sorry to interrupt, but these facts are very critical for us to understand and that's probably the main reason you're here. Is all this on a sheet somewhere, these facts that you listing off, that we could get?

Mr Decter: Sure.

Mr Tilson: That's probably the most critical of what you've been saying.

Mr Decter: If someone wants to simply go and make a copy of this package very quickly, then you'll have them in front of us. Let's hang on and do one more. Okay, I think you should make copies of that rapidly then.

This is very critical, and we'll probably spend significant time on it today and tomorrow. But let me take the first piece of the reconciliation, which are those people who are eligible but would not be counted in the population number. There are five groupings here. I'll work around from the bottom: 72,000 temporary residents. These would be foreign workers and students. That's the biggest group -- 38% of it. These would not be counted by Statscan in the census.

The Chair: Mr Decter, if I can have your attention for just a moment, it has been suggested to me that we take a short five-minute recess until all the material comes in and that way can be easier for us to follow your presentation and may in fact save us quite a bit of time later on. The committee stands adjourned until approximately 10:45. Thank you.

The committee recessed at 1042 and resumed at 1045.

The Chair: If I could just have everyone's attention, the information that we requested is now being distributed, and I'd like to call the committee back to order so that we don't lose any further time. I know members are also anxious to ask questions.

Mr Decter, do you think it might be possible to wrap it up by 11 so that the members could get on with the questions? I don't know how much longer I can withstand their interest.

Mr Decter: We'll try and go quickly. I just think that we might actually spare people some questions if we're precise in the presentation, but I recognize there's a balance here between preventive presentation and --

The Chair: Anyway, the members are anxious to --

Mr Larry O'Connor (Durham-York): As a suggestion, maybe we can ask the deputy minister to provide us a copy of the full package of slides that's being presented. Maybe we can have that. If we alert them now, maybe we can have that for this afternoon's session even.

Mr Decter: Yes, I believe they're working on it and we should have you the full package. I apologize for not having it this morning.

The Chair: No, that's okay. That's fine.

Mr Decter: We're back on case 1. You'll have in your package case 1, which is the lower population estimate, and then case 2, which I'll speak to in a minute. But on case 1, if you're working down, then the first cluster, which is the 273, these are people who are not in the population estimate but are eligible and are therefore on our database. I'll go quickly.

The groups include the temporary residents, the largest group, then transients and our aboriginal people, who are underenumerated. Others include refugee claimants and approved absences. We have a process for approving longer-than-the-regular absences. That would reduce the kind of gap, if you like, between what's on the database and what the population is to a little under half a million, 466,000.

The Chair: You're looking at case 1?

Mr Decter: Yes, I'm looking at case 1 and I'm down to chart 3. I don't want to overplay this, but these are the relatively easy-to-remove registrants, and we are working on removing all of these. So of the problem, better than half of it is really four groups: as-yet-unreconciled deaths, some 42,000; duplicates, 153,000; outstanding deportations, that is, there are a little over 30,000 people who have outstanding deportation orders who are not yet off the database; and immigrants of some 46,000.

These are, if I can put it this way, people who are still on the database at this point but whom we are working very specifically to remove. That will, if we continue down case 1, reduce the gap to 194,000, and we presume these people to be ineligible but we haven't so far in our efforts been able to fully list them. I would just note there that that amounts to about 1.8% of our population, somewhat lower than the New Brunswick 2.5%; certainly higher than we would like, but it is a process of elimination and working through.

We are, if you like, taking the easy cases first and working towards the hard ones. Let me make just a brief comment on case 2, because the issue of how many people there are in the province is a live issue between Treasury and Economics and Statistics Canada. The federal government recently admitted that it missed 430,000 residents of Ontario in the census -- rather a significant omission -- and if one adds that number back, one would have a population of 10.5 million.

I'm not here to tell you that we believe the population of Ontario to be 10.5 million. I am here to tell you that I think Statistics Canada is feeling that it may have understated it, and work is going on between Statistics Canada and Treasury and Economics -- I guess now renamed the Ministry of Finance -- to reconcile this.

I will also tell you that other provincial jurisdictions -- the one I'm most familiar with is Manitoba -- have historically been able to win a case. Manitoba has always had a unique identifier. In the 1970s the Manitoba government was able to convince the government of Canada that the Manitoba Health Services Commission records provided a better estimate of the Manitoba population than did the census, and significant changes in cost-sharing between Manitoba and Canada resulted, that is, more money for the province because the government of Canada accepted that the health records were a more comprehensive measurement.

So we put case 2 here not to say that the problems will all go away on the basis that the people are really there and really eligible, but just to say that until we have agreement on the population, the gap issue becomes quite different. If you take the larger population estimate, then the assumed ineligible drops off to a very small number.

I'm not here to tell you that that's a more accurate number. I am here to tell you there is some genuine belief on our part that some of what we've captured are real people in Ontario who may well have been missed by other measurements. It doesn't change our approach. We still will be moving -- and I'll describe some of the measures here very quickly -- to reconcile.

The registration program branch was established on May 1, 1992. It has a mandate, which I will read: "To manage the ministry's health-number-registered persons database by undertaking activities to secure registration data and maximize efficiencies inherent in the ministry's one-number approach to insured services."

My own rendition of that is a little shorter. The creation of the branch was to secure our investment in the registration database. We invested some $40 million in reregistering everyone, issuing the unique health numbers. Without the follow-through investment, we risk no return or a limited return on the initial investment.

I know one issue flagged by the auditor is, "What is your return and how optimistic were those early Management Board submission estimates around how much this would yield?" In my own view, without the sustained effort which the registration program branch is giving, our yield will be greatly diminished and we run the risk of drifting back towards the old OHIP experience, which is if you keep issuing and you don't take numbers out, obviously it loses its value.

Let me describe a couple of the specific projects that are under way under the branch, and I'll go lightly through. We did have two reviews by the KPMG firm looking at how well the registration had gone and making recommendations on how we might tighten the system. We have implemented those measures or started to implement them.

Let me come to the program branch. It has three units: an analysis unit, a verification unit and a planning and policy design unit. This really is a significant dedication of staff on our part, staff, I should say, freed up by some amount of automation on the claims processing side within health insurance. The effort here is really to identify a long list of ways that we can resolve the list.

The verification unit, as the name would imply, has both process and substantive concerns: reviews, for example, of border towns; reviews of easy-to-find duplicates, errors and omissions.

The planning and design unit is more focused on policies, areas like registration of special groups, newborns, the homeless, natives, data access and security and the card itself, should we change the format.

The analysis unit has the focus of identifying high-yield ventures that we could undertake to reconcile. Let me describe the first of these, and it will sound very straightforward but it's been seven months of work with our respective legal branches simply to obtain automatic notification of deaths from the registrar general.

You would presume that the group that we would most rapidly like to take off the database is in fact those eligible persons who are no longer eligible by virtue of being deceased. It turned out to be a fairly major undertaking to get that done. We have received some 200,000 death notifications and we have eliminated two thirds of them. Some had already been eliminated. We're still working through the rest and we have an issuant in terms of finding matches within the database. That will be a continuing, ongoing relationship to make sure that, as happened with the old OHIP database, we do not keep people who are no longer eligible by virtue of death on the list.

The second issue I should talk to is newborn registration. Oddly enough, we haven't found a way for newborns to enter the world clutching their health cards, and there was a significant issue there. We have got, I think, a good system by providing to hospitals and birthing centres pre-allocated health numbers. Since we implemented the new system, 91% of newborns have been registered within 15 days of birth and plastic health cards have been issued to 85% of newborns within 15 days of birth. We're getting there on the newborns, and you can see the cycle here. We're also looking at how we might work with the registrar general to integrate the birth data. So we're doing better on newborns but we're not all the way there.

The third major initiative is a point-of-service survey we decided we would look at. In a voluntary survey in Kingston and Windsor, using a questionnaire which had freedom of information approval, what was actually happening at, if you like, the coal face where people were coming in to receive service, these are some interesting responses. This was admittedly a small sample but we wanted to find out what was going on right out there at the point of service: 89% of people had their health cards; there were seven incorrect cards presented, which was only 1%; there were inaccurate registration data in 4.5% of cases.

Here's a real problem for us: People don't notify us when they change address. We are working on that but we had a high rate of wrong addresses based on people moving, and that has led us to a poster which we hope will be getting wide circulation, and to work with the post office to get people to notify us when they're moving so we can keep the address side up to date. I would say our highest inaccuracy in the database at the moment is probably on addresses and will need the most work.

Some of the errors were simply, as you might understand, people registering under Tony rather than Anthony and some of those kinds of rather understandable issues. The comparative statistic -- I guess 65% of people who move notify the Ministry of Transportation but only about 20% of people who move notify us. So we need to address that.


I'll move along, knowing the time pressures. We have also done eligibility investigations, and the results here have led to cancellations. We've looked into 3,254 cases. These are currently under review. We've completed on 2,400. In terms of cancellations, most of them have been duplicate health numbers, deportations, former residents. So we see some significant yield from the eligibility investigations and we will continue along.

We've also been working with the Employment and Immigration department of the government of Canada. We're working with them to allow a direct exchange of data to confirm residency status between the two organizations. We have done a mail survey. This was of people who were registering for health numbers using Canadian immigration document numbers, and we have some significant duplication in here, so that's another one we're working on.

An additional effort is being made in the border communities, because we feel these are the communities most susceptible perhaps to some transborder shopping. These are early days; we have sent letters and we are following up, particularly on the undeliverable letters that have come back.

An additional change we've made recently. We referred to the version codes earlier. Version codes come on two ways: one, if you apply for a second card on the basis of having lost a card, or, I believe when you turn 65 you get a Health 65 card, which would have a version card.

For the past three years we have been paying physicians against wrong version codes and sending them a list every month of those numbers that have wrong version codes, in the expectation they would clean up their records. That hasn't happened, so as of February 1 we have indicated that we will not pay on incorrect version codes. In our view, this amounts to about 3% of claims we're receiving. We get about 10 million claims a month; about 300,000 of them are against wrong version codes.

Now, this does not -- and I'll be direct in saying this -- mean the people are ineligible; it may simply mean that someone -- Mrs Jones, who's turned 65, has brought in her old number, or the physician has her old version code on file and has not updated it with the new one.

As you would imagine, the Ontario Medical Association is not delighted with what it sees as an increased burden on physicians. Our view from the ministry is that they've had three years to clean this up. We think it'll clean up very quickly, that they have, after all, all of the previous information we've sent them to look at, and it does not amount to a large number of claims per physician.

I would refer to a document from the US government, in which they looked at the burden on physicians. This is the General Accounting Office evaluation of Canadian health insurance. "According to the Ontario Medical Association, billing and other claims-related activities place little demand on a Canadian physician...." This is as compared to American physicians who spend as much as "4.4% of their time functions."

We've asked the physicians of Ontario to help us out in cleaning up the version code issue and we've given them the added impetus of non-payment of wrong version code bills. That started as of February 1 of this year, so we will see over the next couple of months how rapidly that deals with the issue. We are trying to help them out by looking at an interactive voice where they could code in a number and version code and get an automated response that would say "This is correct" or "This is incorrect," and we're looking at card swipe readers in high-volume areas.

An additional measure we've taken is to increase the automation. We have much more accuracy in claims submitted in machine-readable form than in claims submitted on paper. We are now at just under 80% of claims coming in machine-readable, and we hope to be at 98% a year from September. To accelerate that, as of January we've said that new providers coming in have to come in automated and we've indicated that as of next July there'll be a 50 cents-per-claim processing charge for claims that are still coming in on paper.

We're seeing a steady ramping-up, so I don't think we're going to get rich on the 50 cents per claim. I think by the time next summer arrives we'll be getting the vast majority of claims in the machine-readable form, to improve our accuracy and allow us to deploy more staff to looking at what the claims are for rather than simply processing them.

I'll go quickly here because I sense the restlessness of the committee. We are working on information exchanges with Employment and Immigration, and we hope to have this implemented by the third quarter of this year. There are significant legal and privacy concerns on both sides, but we have a shared interest here in terms of getting accurate information exchanges.

The analysis project encompasses some 47 individual studies. We have looked at, for example, whether people are using our health cards to access social assistance in a way that's fraudulent and we have detected some amount of that, so we're working jointly with the Ministry of Community and Social Services to clean that up. We're looking at extreme service in the first 30 days of eligibility, that is, people who gain eligibility and immediately go for major procedures and whether that's an indication of something amiss, and we're looking at eligibility checking in the hospitals.

We're really focused in the registration analysis project on high-risk areas -- high risk of fraud or abuse -- and I could give much more detail on each of these efforts that's under way. You'll have a list in your package. In the interests of time I would just say that we welcome any suggestions and we're pursuing, as you can imagine, with 47 different initiatives, all of the promising leads that have been forwarded to us.

In terms of an overview of the future, we have significant efforts under way. We want to realize on the future potential of the database, and in terms of balancing, on one hand, some of the FOI concerns that were embodied in the specific piece of legislation put forward, we do believe that allows us to integrate more with the registrar general around birth reporting, to go to perhaps a common form for getting those data for both purposes. I think realistically we're looking at early 1994 for implementation there.

In terms of initiatives other than birth reporting, getting the duplicates off the database is very high on our list. We are looking at point-of-service validation, particularly in the hospitals. We're looking at what changes we might make to the health card itself, whether we should add a photo. We are looking at eliminating the paper health cards and we are examining everything the other provinces are doing.

We are also looking at a consumer monitoring system: how to bring the consumer into the loop and how best to do that. One way of doing that is, of course, to feed back to individuals an annual statement of services to see if in fact they remember receiving those services or can validate that they have.

Finally, and I should touch on it, there is enormous potential for this database. We're less far along than I would like to be in realizing on the investment in the ministry.


We're also engaged now in automating the Ontario drug benefit program, the target of next summer. We've been out on a request for proposals. The advantage of that is that we will have a second linked database covering about something over two million of our eligible people, essentially everyone over the age of 65, and that will allow us a second source of information to cross-reference both services for planning purposes and eligibility.

I think I'd say, and probably a speculative thing for me to say, it doesn't strike us that a lot of people with a second health card are going to use twice as many health services. It just doesn't stand to reason. It is, however, the case that in the drug program and in obtaining social assistance the use of a health card may allow someone either to obtain drugs for resale or to obtain a direct financial benefit fraudulently. So we're very sensitive to working with both the drug program and with MCSS to jointly review those issues.

The final point I'd make is that we are experiencing declining utilization, a slowing of the growth in utilization in OHIP. I think we can just go to a couple of the slides, and maybe that one is the most powerful. Those are annual percentage increases in utilization of physician services, our major source of services. As you can see, history has been anywhere from around 4% in some years to as high as nearly 7% or 8%. The year we're in, and this is an estimate, but we think with a little over a month to go, a pretty good one, we're going to be somewhere between 1% and 2%.

Some of the credit here goes to the change in out-of-country policy, and some of the credit here should certainly go to the new agreement between the OMA and the government. But I'll put it this way: I think, although impossible to measure at this point, moving to the unique health number is starting to help us clean up some of the problems in the system. We're not all the way there yet, but I can tell you, I'd be a lot more worried about the use of the card if this number were at the high end of the range rather than the lowest number we've seen in many, many years. To give you a little more specificity on that, these are the quarterly numbers, so you can see the trend line is continuing down through the past three years. This is the period during which the card has been implemented.

The note I would conclude on is that we think there's huge potential to this database. We're clearly not all the way there; we have a lot of work to do to realize on the investment made. We think with 20-20 hindsight that it was the right investment to make. I think that probably as a ministry we underestimated the amount of work involved beyond the simple issuance of the number to making sure that the number was put to good use. It has been a colossal task and we are, I think, getting progress. We have some frustration around some issues; there are some very real balancing acts here, and I should just flag them.

One is, we don't want on one hand, fraud, so we want accountability. On the other hand, the last thing we want to do is deter access. So we've got to be very careful that we take steps to make sure services are there for the homeless and other groups who may have fallen through the cracks of our society but are eligible persons for services. We need to balance also our desire to really use the number for better management of the system against the very real privacy and individual protection concerns that were embodied in the statute. So there are a couple of important balancing acts, and we will get better at this over time.

With that, let me thank the committee for its tolerance in letting us get this presentation on the record. Copies will be available, and we're in your hands as to questions from here.

The Chair: Mr Decter, I want to thank you and your staff for the presentation this morning. We in fact have a long list of members of the committee who wish to ask questions. I think what I'm going to do is limit each caucus to 10 minutes, and that way it guarantees us at least one rotation this morning. We're going to start with the official opposition, then the third party, then the government members.

Mr Cordiano, you have 10 minutes for questions.

Mr Cordiano: I appreciate the extensiveness of the presentation and your patience with respect to some questions that were asked. But let me make this one statement as an opening remark.

I think that our interest as a committee obviously is to ensure that you are applying the most effective and efficient methods available, given the system that's in place now. I think it's important to note that a number of changes and alterations can be made to the system that's been presently put in place without additional huge costs being exacted or spent with respect to a complete revamping of the system, which some people have suggested. I don't, for one, believe that it's necessary to do that at this time, if in fact you follow the course of action you have indicated today that you'll be following.

I think there are a number of recommendations that we possibly can make as a committee to you regarding changes which will be, I think, effective. We'll also have an opportunity as a committee to examine these alternative systems, which I think we will endeavour to do as the week goes on and we call in other witnesses, and I imagine that we'll be doing that further on in the week.

But let me just say that I think this is one of the most important issues that this committee is dealing with, given the magnitude of the dollars that are involved, and I think one of the questions that comes to my mind with respect to dollar figures is that we can't put a dollar figure on what some people have termed the bleeding of the health care system.

I don't think anybody has really made an accurate assessment of that, unless you can give some indication as to what it's actually costing this province in terms of access to health care by ineligible people. I think we have a rough idea and it concerns me that you have pointed out that there are some 300,000 version codes or claims that have come in in version codes and cannot be verified as to whether those are duplicates or, as you indicated, people who have become senior citizens and are now eligible on a different card.

That concerns me a great deal because that's still a huge number of the number of claims that are coming in each month. I think you indicated there were 10 million a month, and 300,000 are these version code claims. We still have some question as to the eligibility of those people. I think you indicated there is a certain amount of duplication and you don't have precise figures with respect to that duplication.

Mr Decter: If I can try and address that, we know that we've issued 8% of registrants with a replacement health card, in essence, one with a version code, so we know the total size of that group, and we know on the other side that we're getting, as I mentioned, some 3% of monthly claims with wrong version codes. I don't think we'll know until we've had a few months experience with physicians resubmitting how many of those 3% clean up easily; that is, they get the right card with the right version code, how many of those are truly ineligible people, and therefore, the claim isn't resubmitted successfully. We will need a couple of months to be able to evaluate that.

But I want to caution that I think, because it's been very recent that we've been getting the deceased persons off the file because of the automatic issuance of version code cards to people 65 and over, there is considerable potential for surviving spouses, for example, to be still in the physician's file under a wrong number.


I don't want to make light of this. When you're responsible for $17 billion a year of spending on health, all of these issues weigh pretty heavily on all of us in the ministry. There really are some juggling acts between investments to tighten down the system and investments to make sure that people are getting the health care that they're eligible for. I'd say we're getting good cooperation from both the Ontario Hospital Association and the Ontario Medical Association leadership, although they're not thrilled with the version code.

Mr Cordiano: What is it exactly that they're assisting you with? Can you be a little more specific? What is it that you're planning with physicians?

Mr Decter: In the case of physicians, we want them to automate their billings, and we're getting just under 80% of them. Our sense is by July, with the impetus of the fee, we will get much higher than that. The second really is the version codes.

Mr Cordiano: Is there a cost factor with respect to automation?

Mr Decter: There is a cost factor for the physician with automation, but the majority of them have already automated with no assistance. The tax side of it is fairly generous. They can write off the equipment, I believe, at a very rapid pace, so the net after-tax cost isn't that great.

They're not compelled to automate. They can remain with paper cards and pay us a processing fee, or there are companies that operate to process claims and actually charge a fee somewhat lower than our 50 cents, so that a physician -- one of the continuing concerns has been for an elderly physician who might be planning to retire, why should he or she have to automate?

The approach we've taken isn't to force anyone. It's to give them a pretty strong incentive to automate. That will pull down the error rate. I'm going from memory, but I believe our error rates on paper claims are between 4% and 5% and on automated claims they're under 2%, down around 1.6% or something. So simply getting them automated is going to start to make this a more efficient and effective system.

Mr Cordiano: Very briefly -- I think I'm running out of time -- but it concerns me that you indicated that you're working with MCSS to limit the amount of fraud, and somehow you're working with them simultaneously to what? To detect, to have more people in the field who are going to go out and inspect for eligibility, because we heard from the Ministry of Community and Social Services with regard to its efforts to reduce the amount of fraud.

There seemed to be a real concern with the number of people who would be employed to do this. Staffing requirements were less than satisfactory, at least from what I heard, that there was a great pressure on the ministry in fact to keep up with the demands on it at the present time for additional applications for social assistance, let alone have enough inspectors on hand to determine eligibility.

If you're relying on the Ministry of Community and Social Services to detect instances of fraud or some sort of cross-ministry cooperation, how will you do that without the additional efforts of some people whom you're going to employ to do that?

Mr Decter: I think perhaps Peter could speak to that. We're working jointly, but in terms of the specifics of the initiative, I'd ask Peter to say some things.

Mr Burgess: Certainly. It's actually a very exciting analysis that's been undertaken just recently by members of the analysis unit.

We, on a monthly basis at the Ministry of Health, have a data feed from MCSS for those receiving welfare benefits who, as part of that benefit, will receive the right to free drugs. We have over the last few months taken that feed of information from MCSS and attempted to match it against our database.

MCSS, in a lot of cases, has in fact got the health number of the individual who is receiving the benefit. In some cases, they do not. Where they do not have a health number, they issue a thing called an MCSS reference number. Those we are still having trouble reconciling. If I can put that still potential problem, which we have not yet finished analysing, to one side, the activities that we have under way right now with MCSS, following this exchange of information, in which we've spent many hours in meeting with the MCSS operational folks and our folks, we have narrowed down a set of occurrences where it appears to us, receiving the combined data from MCSS, that an individual is receiving overlapping benefits, benefits from two or more offices over the same period for family or general welfare.

As it turned out, our information was correct. It did look as if there were overlapping benefits. However, once we had some input from the MCSS staff, it appeared that that in fact was a correct occurrence. Of the 16,000 events that were exchanged, we have over the course of the last three months narrowed it down to, I believe, six cases where MCSS says yes, that looks like pure fraud. That looks like an individual getting two coverages either to ODB eligibility cards and using them, or two welfare cheques. There are a further 49 as of the end of January. Now, our staff in Kingston are still working alongside MCSS, but there were at that time a further 49 which were jointly being looked at.

The Chair: Thank you. Mr Carr, 10 minutes.

Interjection: Mr Wilson.

The Chair: Mr Carr had his hand up first.

Interjection: There's no Mr Carr.

The Chair: Mr Tilson.

Mr Tilson: Mr Wilson.

The Chair: Oh, I'm sorry.

Mr Jim Wilson: Thank you, Chair, and thank you, Mr Decter and your officials, for appearing before the committee this morning.

Mr Decter, using your best case numbers as presented this morning, what your charts tell me is that there are 1.4 million health cards in circulation that can be used by any resident of this province or anyone that's in this province or anyone that may come to this province who gets hold of a health care card. What I want to know, because you have them in your chart as either lost, stolen, replaced or deceased, and you made it clear when I raised this in the Legislature in October -- the minister made it clear and seemed to be satisfied that the ministry has cancelled those numbers in the ministry computers.

But the fact of the matter is, if you have a card, you can get physician services in this province. There's no upfront verification. I want to know and I haven't been able to find out, and the auditor told us yesterday that he hasn't been able to find out how much money has been charged against those 1.4 million cards that either belong to deceased people, are fraudulent, are lost or stolen.

Mr Decter: I don't have a number for that. I don't know if someone here would have a number for that.

We can certainly take that question and try to get you an answer. But I think it's important to recognize that the 1.4 million inactive cards are not stolen or ineligible cards. The vast majority of those would be someone who's lost a card, had it replaced, he's an eligible person, and his eligibility isn't affected by having a second card nor, in our view, is an eligible person going to consume more health care simply because he's ended up with two health cards.

I think you have to be very careful in any kind of a multiplication of the number of cards that have been taken out of the system against any kind of average use. But we will undertake to give you the best answer we can to that question at tomorrow's sitting.


Mr Jim Wilson: I appreciate that, because I understand that it is possible to obtain that information from your computers. I think it's important for the committee to understand the extent of any fraudulent use, or the extent of the amount of money that's being charged to those cards that are in circulation. Without an accurate figure from your ministry, if we use the auditor's own formula, which is that on average Ontarians charge about $1,400 each to their health card each year, if you take 1.4 million extra cards in circulation and you multiply that by $1,400 per card, you have a potential fraud of just under $2 billion. I would say the potential for leakage to the health care system is astronomical. That is an astronomical figure.

Before you comment on that, I also want to just go back to review history a bit. I think, to be perfectly frank, and I want to ask you the question, how you can come before this committee today, when the government, in its justification for this new health card system and for perpetuating the system that was brought in by the Liberals, says, "Well, it's better than the 25 million numbers we had out in the old OHIP number system." Now, I agree with that. But inherent in the new system is the fact that the eight-digit old OHIP number and the old OHIP database are used to verify the new cards that are issued. So how can you defend a system that in fact perpetuates the problems of the past, and you're still using it?

I see with the newest form that one must fill out to receive a new health card, you still ask for previous health numbers if any, and you're still using the old database which, by your own admission today, is flawed, as a verification tool. I'd like you to comment on that.

Mr Decter: Let me comment on both of them, but I'm going to ask Peter Burgess to speak to the first one. I think and I say that I think any attempt to multiply the inactive cards by some average figure will get you a huge number which is wholly inaccurate and unrealistic. Let me ask Peter. We did do a special survey to try to get at an estimation and I'll ask him to speak to it, because I think it provides a base for a much more realistic calculation of what we may be up against. Then I'll come back to your second question on the eight-digit number. Peter?

Mr Burgess: Surely. We have again in the analysis unit, as of yesterday morning, completed some 50 studies. These are clearly against a cross-section of the population and, as a result, the numbers, while accurate of and by themselves, should be treated with that proviso.

One and only one of those 50 studies was a point-of-service survey which Mr Decter alluded to in his presentation. That was a survey in the Windsor hospitals and Kingston hospital of people who had not yet received services. It was a voluntary survey. Some 750 people -- who were clearly in need of services, because they were in a hospital to receive them -- were asked prior to receiving that service for information surrounding their health card. In only five cases out of the 750 that were interviewed were there grounds for suspicious use. Now I reiterate grounds for suspicious use.

In all of our studies, I have to say that we can clearly detect fraud. There is not a shadow of a doubt about that. There is some fraud. However, in all of our studies the percentage is significantly lower than that which is covered by the popular press. We have the report here; it is shortly to be released.

Mr Tilson: If I could just stop you at that point. You talked about, you're replacing the good-faith policy that used to be; in other words, all these numbers of OHIP numbers that were illegal, registered their canaries, everything under the sun, the allegations that were being made, terrible things. That's why you put this new policy forward, and yet you implement this new policy and just my own personal card has got my old OHIP number. I mean, I could be a canary. These guys'll probably say I am a canary.

But I guess my point is, and what Mr Wilson's trying to get out of you, when you look at the forms that you had people complete, the only real confirmation method that you have for almost every one of these cards that's out there is the previous OHIP number. So, you know, have you not replaced a good-faith policy with another good-faith policy, in fact the same good-faith policy?

Mr Jim Wilson: At a cost of $39 million.

Mr Burgess: Without wishing to pre-empt my deputy, to address the issue of why the old OHIP numbers, it's purely to be able to go back against the history that we have collected for an individual over the past number of years to prohibit things like multiple hysterectomies or multiple services being charged against an individual that clearly are --

Mr Jim Wilson: But that's not the only use of the old OHIP number. If people filled out the original forms and gave you an OHIP number, you issued them a new card. That was the only verification system in place. Yet you admit you did that on a faulty and badly flawed database. So, you know, the new system doesn't make any sense. It got off on the wrong foot.

Mr Decter: Let me try on that. I think there were good reasons for linking the information we had stored against the old numbers to the new numbers and I think Peter has touched on that. We certainly didn't want to throw out all of the data we had, but if you think about this logically, we have only got -- and I stress only -- 10.8 million on the database, so the vast majority of non-functional old numbers are gone. They're no longer there, so we have a job of getting through 10.8 down.

Mr Tilson: Stop right there. How are they gone?

Mr Decter: There is simply no eligibility attached to them.

Mr Tilson: But, sir, when you fill out these forms to get the card in the first place, you use the old number. How have you got rid of all these improper numbers that you listed or explained in your opening remarks that were in existence in the first place?

Mr Decter: Well, simply, there was no one there to apply for them, but the OHIP number is not the only identification that we're using with people when they register.

Mr Tilson: Do you know their name, their sex, their birth date?

Mr Decter: Their address.

Mr Tilson: Their address?

Mr Decter: Yes. And you know, as I've indicated, a lot of the work the branch is doing is now to tie into other databases, so that we can cross-reference that. Just on the same point, and Peter will clarify where we got this, but Julie has a note for me that 4 out of 72,000 deceased persons was the sort of ratio. Was that from Windsor?

Mr Burgess: If I remember the numbers correctly, we did a survey. There had been accusations of cards being utilized after individuals had died. There was an accusation that cards were being sold. We did a survey of some 77,000 cards that had been identified to us as deceased in our first exchange of information with the registrar general back in June or July of last year. Only some 4 cases out of those 77,000 looked like the services were being charged after the date of death, and in fact, on further review in those cases, there were clear, valid reasons for those claims. In one case, it was an organ donation made after death. Clearly, services had been billed by an individual after the registrant's death to take account of organ donations; and in the other, phone calls to appropriate providers cleared up a billing problem.


Mr Jim Wilson: The point is, just to make it clear to everyone, if someone has one of those 1.4 million cards that are circulating out there, the extra cards, they can go to any physician or any hospital and receive services in this province, health care services, and that with your after-the-fact verification system the doctor won't know until his billing is denied, some 30 or 60 days later, that indeed that was a fraudulent card. Meanwhile, services have already been rendered and taxpayers have paid for that.

I want to ask you, because it was raised back in October, we had a Dr Keith MacLeod, an obstetrician, from Windsor who says that he has about 12 regular patients he believes live across the border in Detroit and receive health care services at his clinic. What have you done about that transborder health care shopping?

Mr Decter: I'll let Peter speak to the specific measures, but I'll say, and I've said this to the OMA president and their leadership, if physicians are aware of fraudulent use of cards, they have an obligation to make that known at the point of service. This is not a system that the government, with 22,000 physicians, is ever going to be able to police totally at the point of service.

The Chair: Thank you. Time has expired for the Conservative caucus. We have Mr Pat Hayes and Mr Noel Duignan.

Mr Pat Hayes (Essex-Kent): I'd like just extend that question that Mr Wilson raised here. There are a lot of people who have mentioned to I know myself and I'm sure many other members that are elected that there are people who do come into this country and sometimes they come in here long enough to get medical treatment. Then you have the other people who come from the US, for example, that have cottages in some of our areas. We hear claims that these people are over here and using this system illegally and being able to get away with it.

I would like to know specifically what we are doing about this. Do you have an estimate on how many people there may be that are in both of these situations, people that come across the border from the US, for example, and those people that stay for the summer and take advantage of the system?

The Chair: We should force them to buy gas while they're here and maybe they won't come back.

Mr Hayes: You'll get your turn, Mr Chairman.

Mr Decter: We have put some particular emphasis on the border towns as a first search for people who, leave aside your summer visitors' issue, although I am aware that in some of the resort areas the hospitals receive significant revenue from billing out-of-country residents -- the Lake of the Woods District Hospital in Kenora is a good example of that. There are clearly people who come for the summer that are paying for services as they go, but let me ask Peter to take you through our efforts to look at that.

Let me underscore here that we're early days on this and I don't want to oversell what we've been able to do to date. What we've been doing to date are a lot of investigations to see where our highest yield or our highest risk, if you like, might be, and also to clean up the easiest parts of the database to clean up, the deceased persons being a good example. Let me ask Peter to take you through those of the 50 investigations that have focused on the category you're looking for.

Mr Burgess: I'll try to summarize it. It's out of 50 analyses that our staff have done, all of which have consumed inordinate hours of analytical resources and countless hours of computer resources. We have touched on a variety of issues that have been raised here. We have done a survey following on the doctor's complaint, and I would reiterate the deputy's comment that if anybody has a suspicion, please call me in Kingston and we'll look into it.

We did do a look at births in Windsor hospitals and in fact we found less than 1% cases that were questionable following up on our analysis of the Essex county births. We took a control group elsewhere in the province and compared the control group, which was Perth, north of Kingston, and compared the questionable births following the same sample period of some three months, and while we had some questionable registrations in the Essex county area, they were twice the questionable registrations in our control group. Putting it the other way, the control group was half the problem.

These are early days. We have done a variety of studies of the population based on census in the various cottage and border areas and we suspect that the registrations with eligibility that we have on our database are within 2% of the -- and in most cases lower than the census data.

So we have a number of studies, all of which point out areas for further analysis and for potential policy changes. I haven't been specific about any one of the 50 other than the births in the Windsor area, but I've got enough data to keep going if you want me to.

Mr Hayes: Really what you're saying is that if there are physicians who suspect, it's their responsibility to contact the system about these people?

Mr Burgess: If they contact me, we will look at it. We have had a number of tips to date which are in fact most of what our verification unit has been working on. We have a number in excess of 1,600 -- 1,700 today, I believe -- of cases that have been notified to us for a variety of reasons, either by physicians themselves or by neighbours or friends or concerned citizens, and we've looked into each one of those cases. In every one of the 1,700 that I mentioned we have terminated eligibility, notified the individual, where it has been possible to find the individual, and received the card back, and in other cases we have handed over the details to our provider services branch for further follow-up.

Mr Noel Duignan (Halton North): Welcome to the committee and thank you for the information provided to us today. I think I'd like to take up a point by Mr Wilson. Mr Wilson indicated that there are some million-odd cards floating around out there with the potential of error and misuse but, for heaven's sake, we had 25 million OHIP numbers prior to the implementation of this new system. We have come a long way and fair credit to the previous government who began to tackle this mess left by their previous government, the Tory party, which let the system go on unabated for 15 years.

Mr Jim Wilson: You're perpetuating it. You don't correct one problem in the old system.

Mr Duignan: We are correcting the problem.

Mr Jim Wilson: Name one problem --

Mr Duignan: You had your turn.

The Chair: Order, please.

Mr Duignan: The facts obviously hit home here, Mr Chairman. It is a good system and I think we can find a way to improve the system. I want to get at that: How can we improve the system? I want to --


The Chair: We can't hear Mr Duignan. Can we have some order, please.

Mr Duignan: I want to ask about, right now in a community somewhere in, I think, northern Ontario you're experimenting with a smart card, and also you're looking at a system with the health benefits card and this will be used by seniors and people who are on the drug benefit system. When they go to a pharmacy, as I understand it, you'll be able to swipe the system through and within five seconds coming back to the screen will be the answer whether this card is eligible, or the people are eligible for this particular benefit or not. Can this system be used anyway, even by the large users, with the health card?

Mr Decter: You're right on the two initiatives. Fort Frances is the community where we've got the pilot under way using a smart card. It's a relatively expensive technology -- and I say relatively; the cost of the current cards was about 40 cents a unit; the smart card is several dollars a unit, maybe as much as $10. So it's a road that would have significant cost if we went down it, not cost relative to $17 billion, but it's somewhere between a $50-million and $100-million item. We want to make sure we know everything about it before we embark down that road.


We haven't fully evaluated the Fort Frances experience. I was up there for a day last summer. The comments I had from providers were that it had forced them to organize their records in a way they hadn't before, so the major impact wasn't so much on the individual but it was on the providers, because now that all that information was on the card they had to have a backup of it in their own system. So it had caused the hospital, the clinic and the pharmacy to automate. We're looking at that and, you know, it would be a major decision to go that direction. We want to look at it very carefully.

The second issue you raised: Yes, the automation of the Ontario drug benefit program will mean that when someone goes into a pharmacy to get a prescription filled, the pharmacist will swipe their card or punch in their card number and they will have on a screen all of the prescriptions that have been filled against that number in the last 30 days or 60 days; my memory fails on how long a period that is.

That will have two impacts: First, it's going to save us a lot of overmedication on seniors at the moment, and this is a complaint from seniors' organizations. We pay for and overmedicate seniors to an extraordinary degree in this province by any measure. This will put the pharmacist in the position of saying, "I'm sorry, Mrs. Jones, I won't fill that prescription because you've had that same prescription or a similar one filled last week or yesterday."

It will also help us on the fraud issue. The auditor has identified individuals who go to multiple doctors, get multiple prescriptions and then get them filled presumably so they can resell the drugs. That will come to a grinding halt in terms of the use of a single card once we've got that automation done, and our target is next summer. So I think in terms of the billion-dollar drug program, we expect to see some significant impacts from that.

Eventually we'd like to link that to hospital emergency rooms, so when seniors come in or people come in who are under our drug program and they're not fully able to describe their condition, the physician can get a reading on what drugs they're taking in a similar fashion by linking to the drug database. That, we think, will improve care and save money.

Those are both important initiatives. I will tell you, I'm a little leery of the smart card based on what I've seen to date. There's a tendency to think of it as a panacea. It has many of the same difficulties as any card does and it has the additional FOI privacy consideration in that it will have someone's complete medical record on it, which makes it a much more difficult card in terms of third parties trying to get at it. So we have some real concerns there.

The Chair: Sorry. There's no further time. I'm going to allow Dr Frankford one question and then we're going to go back to Mr Callahan for a round.

Mr Robert Frankford (Scarborough East): I'm surprised at the suggestion that there are many Americans who've come over here expressly to get free medical services.

Mr Robert V. Callahan (Brampton South): You can't get it in the US; you may as well come here.

The Chair: Order, please. Dr Frankford, just continue.

Mr Frankford: Well, of course, the reality is that the Americans are very used to paying large amounts there. They're used to spending the first half-hour of going to a hospital having their insurance checked out and possibly being turned away. So to think that their way of thinking would be that they want to see how much they can get away with here seems rather unlikely.

The mention of births again: How can one be sure when the birth is going to take place, or do you become a resident here? It seems to me that anyone can get medical services here. If they're not eligible then they have to pay. The implication seems to keep on being made that unless you are both eligible for Ontario health services and getting a service, you're committing a fraud, which is obviously not the case.

On the question of paying gas or taxes, why don't we make it clear that people may need to bring their own insurance or conceivably we should be selling insurance? If the figure of $1,400 a year is mentioned, why not charge that as an upfront premium, which I think for an American is really quite cheap, and for seniors it might actually be equivalent to what they have to pay in addition to their medicare for seniors, which does not cover the whole shot.

Mr Decter: You hit a couple of important points. It is certainly the case that we provide care to people who are not eligible under our program and they either pay through their other insurance or pay cash on the barrelhead.

Certainly if you look to some of our leading hospitals, the Hospital for Sick Children has a lot of referrals internationally and from the US and is extremely well regarded. A number of our hospitals in border towns have significant revenue from non-Ontario residents, so that goes on.

But we have had a study done which we've now shared with the hospital association of whether we need to look further at that road. It poses some real dilemmas in terms of if we're stretched, and we are in some cases, to find the resource to provide all of the care that the people of this province need and want.

How do we deal with the queueing issue if we were to have others paying, and that's an issue that has some real significant potential for difficulty. So we've been cautious on it. We have had some discussions with the hospital association. As I say, we had a study done of whether a preferred-provider arrangement might work to utilize some capacity here. So I'm a little cautious on that issue.

But we do a disservice in suggesting that there are only people who are eligible and people who are taking advantage of the system. There's a third substantial category of people who understand they're not eligible and in fact use other coverage or pay directly.

We've also in the most recent round with the OMA clarified the third-party situation, and this was, if I can be direct, an abuse that had grown up in the system. Health insurance never paid for things, it was never designed to pay for things like medicals for summer camp or other services that were not for reasons of medical necessity.

Nevertheless, we had been paying for a number of them over the years, and I think we've got some clarity and I know it's been a source of some concern, but it really is not a movement away from the principles of medicare. It really is a clarification that if I want to send my children to summer camp and the camp wants them to have a medical, that's something I should pay for and not something that the taxpayers of Ontario should pay for. We've had that clarity now, and I think it's an important clarity.

Mr Callahan: I'll probably carry on into the afternoon, but I'd just like to get into another issue, and the one that concerned me was the computer system that you use. We've received from the auditor's report information that over 12,000 Toronto data centre users could read an unprotected password for a powerful user code on the Kingston data centre and access registration information.

I know that in your response to it you say you've corrected this, but what I want to know is, and you may or may not be able to help me in this regard, you have a system in place -- other ministries in the government have a system in place and I think most specifically I was saying yesterday of MTO, the Ministry of Transportation. If somebody had access to their computer system, if it's run in the same way this one was, they could change the suspension of a person's licence. In other words, if a person had his licence suspended for impaired driving for a year, they could just blip that right off the screen by hacking. What this tells me is that there are 12,000 people out there, 54 users who could circumvent existing access controls, which is astounding, 15 former employees who had worked on registration.

Mr Derek Fletcher (Guelph): That's better than the US State Department.

Mr Callahan: I find that to be extremely negligent. People yesterday on the committee said, "What could you change on the health card information?" I suggested, if you were creating cards -- I'm sure it wouldn't be terribly difficult to create the card I've got in my wallet -- you could change the information to correspond with the card. It's kind of like looking up tombstones for voters or for passports, as was done in the James Earl Ray situation.

Mr Frankford: Tell us about it.

Mr Callahan: In any event, I'd like to know what you've got in the mill, because I understand, from reading the newspapers, that the Treasurer's talking about letting IBM turn this thing into a --

The Chair: Your question, Mr Callahan, is?

Mr Callahan: What have you got on line in terms of making certain that this system remains sacrosanct? Have you got any type of chain of command where one person might know a little bit and the other person would know something else, or are all these people going to have the same information?

Mr Decter: I'll ask Fred Hazell to comment on the security measures. I would indicate that my memory from briefing is that the access of the 12,000 was an extraordinarily time-limited event and it was corrected as soon as it was brought to our attention. Not just as a result of this auditor's report, but also as a result of the report by the privacy commissioner, we've tightened information access in our Kingston operation significantly. I'll let Mr Hazell speak to some of the measures.

Mr Fred Hazell: Just in terms of background, in terms of understanding the issue, our Kingston regional computing centre is run and managed by your CTS, computer and telecommunication services. It's not run by the Ministry of Health itself, that particular operation. What is being referred to in the auditor's report was that everyone within the CTS who had access to that facility had a generalized password which would allow him or her access into that system. That was changed once it was pointed out by the Provincial Auditor. So there was a one-time affair which was corrected.

Mr Callahan: I'd hate to think of a bank having a one-time shot like that.

The Chair: One question from Mr Tilson.

Mr Tilson: These cards are worth, I suspect, if there is a black market, a lot of money, if there are a lot of illegal cards out there. I guess I'm going to ask you to comment on a page in the auditor's report, specifically page 112, where it states:

"The ministry does not publish a listing of invalid or suspect health cards for service providers. Additionally, they do not provide a telephone call-in service for card verification."

So if you have a black market card or an illegal card, from your presentation this morning and certainly from the auditor's report, there doesn't appear to be any system to stop this from continuing.

Mr Decter: We are setting up a telephone validation number. That's a commitment we gave the physicians when we informed them that we wouldn't pay on wrong version codes. I don't know if someone else at the table can tell me how rapidly we'll be there.

Mr Hazell: The equipment has arrived. It's being installed and we'll have a voice response system in place by the middle of March in the Toronto area. We'll be expanding that across the province.

Mr Tilson: What did that cost?

Mr Hazell: What did that cost? I don't have the numbers.

Mr Tilson: Perhaps you could get that, plus the information that Mr Wilson asked you, Mr Decter, this afternoon.

The Chair: One last question.

Mr Duignan: Just getting back to the questions I was on, you didn't particularly answer the question I asked. However, will the pharmacist have the ability to pull the card if the information on the screen indicates that the card is fraudulent?

Mr Decter: No. The pharmacist's obligation, I believe, will be not to dispense drugs against the card. I don't think we've yet addressed the question of whether we would ask them to retain the card. You raised a very good question and we will look into that. We certainly have asked other providers to retain ineligible cards and return them to us, and we've certainly asked consumers if they have an ineligible card either to destroy it or return it to us. But I don't know that we've addressed that.

Mr Hazell: It's a reporting system right now, rather than a retention of the card.

The Chair: Thank you. Time for this morning's session has expired. The committee will reconvene at 2 pm this afternoon.

The committee recessed at 1204.


The committee resumed at 1400.

The Chair: The standing committee on public accounts is called to order. This morning when we adjourned, we had completed a 10-minute round and a very short round of questions. I think what we'll do for this afternoon is -- do you think 20 minutes is too long? Is 15 minutes better for questions and answers?

Mr Frankford: Fifteen is fine.

The Chair: Fifteen is a little better. Okay. Mr Callahan, we'll start with you. You have 15 minutes. You can go until 2:20, and that includes all the answers. Then we'll go to the Conservative caucus and then to the government members, Mr O'Connor, then Dr Frankford and then Mr Duignan.

Mr Callahan: There was a policy introduced by the minister whereby a person who didn't reside for a full six-month period within the province of Ontario would lose his or her benefits. That is a policy of the government, is it not?

Mr Decter: Yes. We moved from a policy, that someone will clarify for me, to the six months --

Mr Burgess: Six months plus a day.

Mr Decter: -- six months plus a day, which I believe is the same basis on which one pays Canadian income tax.

Mr Callahan: In light of what we've heard and what we've learned from the auditor's report and some of the answers that have been given, how would you ever possibly expect to implement that policy? How could you do it?

Mr Decter: I'm not sure of the nature of your question. We've implemented the policy by indicating it to all the consumers and providers. In terms of how we police the policy --

Mr Callahan: That's right, yes.

Mr Decter: Well -- and I would ask others to jump in and help -- we certainly police it by monitoring claims, and claims made by people who we would have some basis to believe have been out of the country. We run into this mostly because -- and let me deal with this one -- if someone is out of the country, they are still eligible for our piece of the services. Most of our people who would be in Florida for part of the winter would simultaneously have OHIP coverage up to our limits and then would buy supplementary insurance, so this usually becomes an issue when claims are made. It would be at that point that we would have some ability to look at what period of time they had been out of the country. But if you are asking me whether we can perfectly police this, I think the answer is probably no. We rely to a considerable degree on people's good faith in this matter.

I don't know if anyone wants to add on the six-month residency issue.

Mr Burgess: Let me try to add something. Certainly we do not come from the perspective that you must prove at all times that you are a resident. However, in cases where we have grounds to believe that you are not a permanent resident, have not spent six months plus a day here in Ontario, we'll ask you. One of the ways of looking at that is if, for instance, you have landed permanent status in the US. If you have landed permanent status in the US, the US government says you are there and must be there for six months plus a day. Clearly we have to ask, if you have landed permanent status in the States, are you truly a resident of Canada? We ask the question and then we take your answer.

Mr Callahan: What I'm getting at is that with all that we've seen with these cards and the limited control you seem to have over them in the fact that there are 1.4 million more that were issued that aren't, apparently, to Ontario residents, or at least recordable ones, how in the world are you ever going to possibly lift somebody's card or have any information on that person's card? As long as their card reads, "10 Main Street, Brampton," or whatever, how are you ever in the world going to know that they haven't disappeared to the US or some other country of the world with that card and come back for major health services? How are you going to do that?

Mr Decter: I don't think we can contemplate going to a situation in which we would be ever-present with people, but it's not as though there's a lack of documentation when someone sets up residence somewhere else for an extended period of time. Again, we are undertaking a series of initiatives. I guess the answer in part might be that we will have some continuing difficulty with individual instances of this sort.

Mr Callahan: I don't want to be pejorative, but I think you haven't got a prayer. You haven't got a hope in hell. In light of the fact that these things have nothing more on them than residency, or it doesn't have anything to pinpoint people being there, I don't see how you can police that policy at all.

In any event, I had heard rumours, and I'm sure others had as well, that cards were being rented. Did the ministry ever hear anything about that, that cards were being rented to people outside of Ontario for use by US residents, for rather large dollars?


Mr Burgess: I suppose we've heard exactly the same rumours as everyone else. All I can say is that our efforts to track down that rumour and turn that rumour into fact so far have been a failure.

I referred this morning to an incident where a physician in Windsor had claimed in the press that he had some US patients. I failed to mention this morning that we in fact did phone that physician. He stated that he had been misquoted, that the situation that he was referring to had come from some number of years before and he in fact was not able to give us the names of any individuals who he thought were US citizens and incorrectly utilizing health care services in Ontario.

The Chair: That shouldn't be surprising at this stage.

Mr Callahan: I wouldn't be surprised at him saying that, either.

Mr Burgess: All I'm saying is that we are attempting to track down and turn rumours into fact, but at this point in time we have not been successful.

Mr Callahan: Okay. The second thing: Were there indications to the ministry as well that cards were being sold, ie by people who perhaps were granted one on coming to Canada and claiming status in Canada and not obtaining it and being removed from the country? Was there been any effort to get back those cards from them?

Mr Burgess: Again, if I can jump in there, in terms of individuals leaving the country, yes, we have an arrangement where if people locally leave the country, or at least leave the country in the care of an official -- ie, being deported -- we get those cards back.

The only case that I am personally aware of is a case that has come to court in the last two weeks where individuals from outside the country were charged with production and sale of health cards. They were paper health cards. They had clearly identifiably incorrect numbers on them. They would not pass the first stage of checking. The case is ongoing and I have not yet heard the results of that, but we have given that evidence at that case and that is the only case that I am aware of.

Mr Callahan: So these are the paper documents from which the plastic card initiative generated.

As was being said by my colleague this morning, the way you got a plastic card was you used the paper card, and you relied on that information. Were there any cards issued as a result of that, or did you detect it right off the bat?

Mr Burgess: There has been no card issued as a result of that specific case.

Mr Callahan: Have the police ever been called in on this matter?

Mr Burgess: The police were called in on this matter. In fact, the police asked us to testify at the trial two weeks ago, which we did.

Mr Callahan: No, I'm not talking about the paper one. I'm talking about the allegations that the ministry has heard, about the rental of cards and the sale of cards. Have the police ever investigated that matter?

Mr Burgess: Not to the best of my knowledge, because, as I say, I can't narrow it down.

Mr Callahan: So any investigation you're talking about has been conducted by the ministry itself.

Mr Burgess: In that particular case, yes.

Mr Callahan: Well, into the whole matter of -- I mean, it seems to me that if we've got 1.4 million extra cards out there in circulation --

Mr Decter: Let me come back with that, because let's be very clear what the 1.4 million is. The 1.4 million are cards that were issued that are ineligible. We will not pay claims against those cards. So anybody's prospect of obtaining much service on those cards is, at this point, as of the first of February, foreclosed. So, one, most of them were issued to eligible people and they have been replaced by subsequent cards; and, second, these are not valid health cards.

So I want to be very careful when people keep referring to 1.4 million. Five years from now, that number will be three million, because people will continue to be born and we will issue them new cards, and people will continue to move out of the province or die and their cards will go ineligible. So it isn't as though there are 1.4 million cards out there. That 1.4 million is the difference between the total issuance of numbers and the current valid listing of health numbers.

Mr Callahan: Are you telling me definitively that every one of those 1.4-whatever-plus million cards has been deactivated?

Mr Decter: I'm telling you that those are no longer eligible numbers against which this ministry will pay claims.

Mr Callahan: What about people who die outside of the province of Ontario and their death is listed with the Registrar General in that province? You wouldn't have any information about those people, would you?

Mr Decter: They wouldn't be part of the 1.4 million; they'd be part of the 194,000 that we indicated this morning we're still working on that are presumed ineligible, but we haven't tracked them down. What I'm trying to say is that the 1.4 million are, in essence, dealt with. It's the 200,000 that are the ones we presume to be ineligible that we haven't yet been able to track down and get off the list.

I don't know if I could bootleg an answer here to the question about our estimate of what fraud potential there is or if you want to have me hold. There were two questions at the end of this morning. I don't want to intrude on any individual member's time, but I do have answers to them.

Mr Callahan: If they weren't the ones I asked, I don't want an answer to them.

Mr Decter: Okay. I'll try and wait till we get back to whose questions they were.

Mr Callahan: But the 1.4 million: Are you saying that includes cards that were issued to such eminent people as dogs, cats and so on? I don't understand that. Someone came forward with a piece of paper, I gather. That was what triggered the issuance of the plastic card; isn't that right? That's the way I understand it. So somebody out there in this total number had a paper OHIP card that he or she used to trigger a plastic card, right?

Mr Tilson: Somebody named Fido.

Mr Callahan: The 1.4 million weren't all dogs and cats. They must have been human beings, weren't they?

Mr Decter: Let me back up and see if I can walk through this carefully. We have produced and issued 12.2 million cards to date; 1.4 million of those are inactive. Now, that doesn't mean that any of those 1.4 million were ineligible at the time they were issued the card; all that means is that as time has marched along, 1.4 million people have died, have been issued a new card by virtue of turning 65 or needing a replacement card or have moved away, and this will grow because of the continuing process of birth, death and movement. Over time, the 12.2 million will continue to grow, the 1.4 million will continue to grow and our task and the task we've tackled is to get the 10.8 million -- these are names on the database with eligibility, names for which we will pay claims -- converged down to the level of the population.

We believe our problem is the 194,000 people whom we assume to be ineligible who still have eligibility, not the 1.4 million which, as far as we're concerned, is a dead issue, because even if they have a card, we won't pay a claim against it.

So we may have some providers who, in the first round, are not very happy about that. The reason we're setting up the call line is so they can verify those numbers. If they call in on the line when we have it set up next month and it says it's ineligible, then our advice is for them not to provide the service until they obtain an eligible card number.

Mr Callahan: Okay. Have the 25,000 paper OHIP things that were out there as reported by the auditor been either collected back or was it a condition that you hand in your paper card to get your plastic card or are the 25,000 paper OHIP cards still out there?

Mr Burgess: Is it 25,000 or are you talking about the 25 million health cards?

Mr Callahan: It's 25 million. I'm sorry I dropped a few zeros there.

Mr Burgess: No. The paper OHIP card with its eight-digit number on it was never handed in. The eight-digit OHIP number was used at the time of initial registration to receive the 10-digit health number and your red and white plastic card. That's the only use for that eight-digit number at that time.

Mr Callahan: So the long and short of it is that they're still out there in circulation.

Mr Burgess: But they won't do you any good. You can't take the eight-digit OHIP number card to a provider of services and get services.


Mr Decter: It's not as valuable as last year's driver's licence.

Mr Callahan: No. I have to say that I think anyway that when your computer system was in the shape it was in where people could tap into it, they could very easily have tapped in and changed a number on the record of the computer, then simply changed the name or made an appropriate change and then taken the paper in and gotten another plastic card, could they not?

Mr Decter: Let's remember that 99%-plus of the people who reside in this province are eligible people, and that's a different issue than whether they have a valid health card. Is it possible that someone had somehow hacked into our system to alter their personal information to obtain a health card? I turn to Fred Hazell to talk about how easy that would be to do. I don't imagine it would be a very easy task.

Mr Hazell: Just as a point of clarification for this morning, the information I got in response to the question asked about security was that there was one individual in the group managing our computing centre in Kingston who had coded a password into one of the programs. If we knew that individual had in fact coded the password and knew which program it was, we could go in and look at that program, pick up the password and then be able to access all the programs. That was the extent of the 1,200 in the security issue raised this morning. It was not a situation --

The Chair: Thank you. I'm sorry. Your 15 minutes have expired. Mr Tilson and Mr Wilson.

Mr Tilson: You commented this morning that you or Mr Hazell were now devising a telephone call-in service and you were going to tell me the cost of that.

Mr Hazell: I haven't been able to get that number yet.

Mr Decter: Actually, I was able to obtain it over the noon hour and I'll give it to you in a couple of components, reminding you that the initial thing will be in Toronto only. So this doesn't include line charges if we go province-wide with a 1-800 number. The initial cost will be in the $50,000 to $60,000 range. That will enable 30 concurrent calls to come in, and there's an access cost of about $3.50 per port per month, so it's not a major dollar item, given the magnitude of what we're looking at.

I don't have a total cost, but to give you an idea, if we extend it province-wide, which I think would be our intention if it gets used in Metro Toronto, we'd have about a $25-per-hour connection time to do a 1-800 number on it provincially. Having said as of February 1 to providers that we won't pay against ineligible numbers, we want to be able to say to them by mid-March, "You can validate numbers," and this is in addition to them having three years of data that they can go back through to determine appropriate health numbers for their patients.

Mr Jim Wilson: Mr Decter, perhaps I can ask what's changed in terms of the law from the time I asked the minister a question in the Legislature last October. I brought up the example of the Toronto doctor who had phoned your ministry suspecting a fraudulent card and was given a response by one of your officials that there was no way, given the privacy laws of this province, that he or she could be told over the telephone whether that was a valid card or not. So what has changed in terms of the privacy laws over the past few months, and what will change between now and March to ensure that you'll be able to do on-line telephone verification?

Mr Decter: I would have to go back and look at the answer my previous minister might have given in the House, so I'll be very careful without going back to look at that to give this answer. We believe that the service we will offer in mid-March does comply with the FOI and privacy legislation. If you'd like, I'd be happy to bring one of our people along tomorrow to specifically speak to that. There are some complexities in the FOI and privacy legislation.

Mr Tilson: I think we'll need that information, Mr Chairman. I know Mr Callahan was going along in a train of thought in that area as well, perhaps a different angle, but I think the freedom of information materials would be useful. If Mr Decter can produce such a person, we're not meeting until 3.

The Chair: That's 3 pm. The morning session has been cancelled due to the funeral services for Mrs Farnan.

Mr Tilson: That's fine. Let's assume you are able to answer Mr Wilson's question, which is an important question, because if you can't answer it, then you're not going to have a call-in system and the whole thing is unworkable. But let's assume for the moment that you are able to get around that --

Mr Jim Wilson: Can I just interject on that? Research has provided us with a copy of the Freedom of Information and Protection of Privacy Act. If you look at clause 21(3)(c), it says,

"A disclosure of personal information is presumed to constitute an unjustified invasion of personal privacy where the personal information relates to eligibility for social service or welfare benefits or to the termination of benefits levels."

I'd be interested in your legal opinion on that, because research has provided us with an unofficial opinion that you can't do on-line telephone verification.

Mr Decter: We will certainly provide you with the advice we are relying on to move forward on this. It is our view that we can do it, and it may have to do with the reality that we would be supplying the information to providers, but I don't know. There are obviously protections not only in the FOI and privacy legislation but also in the health card information privacy act itself, if I have that statutes name right. Being a non-lawyer, I would prefer to have our experts on this subject let us know.

Mr Tilson: I think we've indicated that we'd like to spend some time on that, and I trust you'll have people there. Let's assume for the moment that you can do this, that the information that is coming to us appears to be incorrect. So if you find out that a particular card is not valid, or for whatever reason, you've cancelled a card or a card is invalid or inactive or any of those reasons, what do you do?

You've indicated that you're not going to pay. The difficulty is, and I'd like you to clarify this, because the Provincial Auditor, on page 111 of his report indicated, "If an individual used an invalid card, the ministry would reimburse the service provider for the medical care and notify the provider that the card was invalid." Could you clarify that?

Mr Decter: As of February 1, we've changed our policy, and that is that we will no longer reimburse the provider on the first round. We will ask them to go back and obtain a valid number from the patient. Again, I don't want to overplay this, because we have issued new card numbers with new version codes. Our belief is that the vast majority of it is not fraud; it's simply physician or provider records that haven't been kept up to date. We think most of this will clear up with a simple phone call.

Mr Tilson: If a doctor or the X-ray people or the lab people goof, they're out of luck?

Mr Decter: Yes. They are out of luck, and in the first round they can certainly resubmit, and with automated billings they can resubmit within the billing cycle in the same month. So we think in many of these cases what will happen is the that provider's office, not the providers themselves, will contact the patient and say: "We have such and such a number. Do you have a newer health card that has a different number on it or have you turned 65 or has some change taken place?" We think that of the 3%, most of it will clean up relatively quickly. But as I said this morning, this is a new policy as of February 1.

Mr Jim Wilson: Why did this policy take so long, when you've had over a million cards in circulation out there?

Mr Decter: I can't really answer why February 1 as opposed to January 1 or last October. I will say that the extent of these issues is something that we've come to know a lot more about since we've set up the branch that Peter Burgess had in May, so we've been undertaking a series of actions. We felt that we wanted to move the automation project for billings along some distance before we added the issue of the version code. For those who feel we're going too slow, you might want to invite the OMA in here and it will tell you, chapter and verse, why it thinks we're going too fast on this issue.


Mr Jim Wilson: I just wanted to ask you that. How are things going with the OMA in terms of asking doctors to help police the system?

Mr Decter: I think that at the level of principle, they're generally supportive. They don't like the timing -- they think it's too fast -- and they would have liked the on-line verification in place before we moved to the non-payment.

Again, it's a balancing act on all of these things. We're of the view that most of the problem will clear up with a little bit of clerical and secretarial work at the physician's office. If we're right, then by the time we have the verification in place, we'll be down to the much smaller subset of ones that have real problems. If we're wrong, we may have a large number of unhappy physicians on our hands.

Mr Jim Wilson: Is that fair to physicians, though, in terms that the government created the system and they're stuck with it? It's not their fault you issued 1.4 million more cards than there were people. Now you're asking them to --


Mr Jim Wilson: A fairly heavy-handed approach to policing the system.

Mr Decter: I don't think so. We're asking physicians, after all, to look at about 3% of their claims. I tried to make the point this morning that medicare in Canada and in Ontario is a tremendous administrative bargain for our physicians. The enormous overhead they have in the US, by comparison, is something we carry here. They have a single payer. They have really no bad debts historically. I don't think it's too much to ask. It is an additional burden and I think it will depend a lot on how easy it is for their offices to deal with this issue.

I've had a few letters, a handful so far, on the issue, and we've agreed with the OMA that we will discuss it at each of our joint management committees monthly and see how it goes. But I don't think we have an alternative. As I say, I think overall our system imposes far less administrative burden on the physician than virtually -- well, certainly than the American system, with multiple payers. I don't think this is too much to ask in a time of great fiscal and other difficulty for the province, for physicians to help us clean up this aspect of the situation.

Mr Tilson: Mr Chairman, if we could continue, I guess that's what it gets down to, is that there's a certain urgency to all of this. The Treasurer keeps telling us how broke we're getting, and the health budget is a third of our budget and is more than the total budget of many provinces across this country, so it's a serious crisis that we're in.

Clearly, the auditor's report has revealed a very open-ended system to start up for getting health cards. You've responded by saying that you're closing some of those up, and I appreciate that, as late as February 1. But we need to know more. There are no expiry dates. Do you have any plans to improve on the qualifications or correcting what has happened? My understanding is that if you want to get a health card, all you need is a birth certificate; that's all you need. I got my health card over the mail and I suspect that most people in this room got that. The person who gave me the health card had no idea who I am.

Mr Callahan: We know, though.

Mr Tilson: They have no idea who I am, and I suspect that that's been fairly consistent. It's very easy to get a birth certificate. It's very easy -- that's been established -- to get birth certificates.

There doesn't seem to be a process for two pieces of ID. There doesn't seem to be an expiry date in the works. I mean, the bank cards all have expiry dates. My card, it appears to me, is good for life, notwithstanding the fact I may become a non-resident for a period of time. I may become a non-resident, I may go work in another country, but I can come back and I can use this card and there's nothing to preclude me from doing that. I could die and my next of kin could continue using this card in different ways. There doesn't seem to be any process of stopping all the very serious allegations that have been made by the Provincial Auditor, by the press, by members of this committee.

As a member of this committee, what I'm asking you is, what are your plans? Because the card you have isn't going to work. The comments about the freedom of information -- even if that issue is put aside, it's still not going to work. So my question is -- and this issue has been on the table since the Provincial Auditor presented his report -- what do you have in the works so that we can have some reassurance that this unbelievable cost to our health service isn't going to get out of control? Because if we don't move fast, we're not going to have a health service.

Mr Decter: Let me be a little balanced about an answer here, because I think it's a mistake to think that the problem isn't being dealt with or that we haven't taken very seriously the advice of the Provincial Auditor. What I've spent most of the day so far describing are a series of actions that really constitute our response to the auditor's report, and I've indicated that we are not done.

I would parenthetically note that we are, having printed our health estimates for the current year, just under 2% above last year. We are spending then under 1% above last year. It will be the first time, I believe, in the recent history of the province, certainly the first time since medicare, that health costs have gone up less than inflation. I would say that we in the ministry think that we're taking very seriously the challenge of managing the system.

But let me come to the issue before us: What are we doing to tighten down the system? First of all, I think that the move to a unique identifier was the right move, and although there are still some tougher measures that need to be put in place, I think that we're going in the right direction: that the reregistration was right, that the issuance of the cards was right.

What else are we prepared to do? We are, on application, requiring original documentation, although we're still accepting photocopies on mail-ins, and we're reviewing that policy. So we are getting tougher about what we want to see before we'll issue a new card.

We are working with the registrar general to integrate birth registration. We are working with Immigration Canada because immigration is a major source of new people coming into the system and we need to tighten that. In terms of card controls, we are looking at an expiry date and we are looking at photos. We haven't come to a conclusion on those yet.

As you can imagine, we've been trying to go at what we see as the highest-yield areas first. Those have, in our view, been tightening down the existing system and, frankly, taking a tough decision not to pay claims against invalid numbers. That's a very big decision. I don't want to underestimate the amount of controversy that may yet cause us with the provider community. That's a very major step, to say we're very serious about making progress on this, and we expect that will cause a large number of invalid cards to come out of the system and will get us some significant progress. We won't know till some time goes by.

We're looking also at what are called "swipe card readers." The current card does have sex and birthdate on the mag stripe. We're looking at putting swipe readers into the high-volume areas -- hospitals and clinics -- so that a hospital can swipe your card when you come in and it can see if you look to be a 16-year-old female or if the gender is wrong or the birthdate seems at variance. We in essence have more information on the card than we're currently using at the point of service. So while putting swipe readers in 22,000 offices would be an expensive proposition, we are looking at hospitals and major clinics.

The Chair: Okay, we have Mr O'Connor, Mr Frankford and Mr Duignan.


Mr O'Connor: We certainly have had a really interesting discussion here. I guess we could take a look back at the 1987 audit and the information you've given us. Looking at the client identification, you said that there are 25 million participants on the claims file. The interesting thing, I find -- I have to commend you for trying to integrate the post offices, integrate with Immigration and the registrar general, because that should help us bring the numbers down to a more realistic point.

I guess my pet peeve and something that constituents always bring up to me as an MPP is the fact that they've got these little cards from every hospital they have ever gone to. Of course, encoded in that little card that they have got has been the OHIP number. So if we take a look at past practice and look at 25 million possible, well, I think that that number could possibly be 150 million, because when you multiply that times every one of those little plastic hospital cards, there have been OHIP numbers floating around this province by the millions and millions, hundreds of millions. So I think that moving to this new process is going to eliminate some of that.

Has there been an attempt to integrate with the hospitals -- perhaps the avenue to do it is through the swipe cards -- to get them to eliminate this practice of having that little plastic card that uses up somebody's staff time? Somebody sits in each hospital and punches up one of those little plastic cards, and if you didn't happen to bring it with you, then the next time you go they're going to sit there and they're going to punch up another one of those little plastic cards. So not only do we have maybe some concern here, but we've got an awful lot of waste in the system there: millions of those little plastic cards floating around.

So my question is, has there been any discussion with them to try to integrate them, or can we try to improve that system?

Mr Decter: There hasn't been a lot of discussion. They were obviously involved in the pilots in Windsor and in Kingston, but we have wanted to have something concrete to discuss with them, and I think the swipe reader option is the one that we're going to talk to them about.

I agree with you that there is a great deal of extra work in the hospital patient identification. A lot of hospitals are only now getting to one number, you know, so that when you're in the hospital they don't have a separate record for you in X-ray or radiology, a separate record on the ward, and a separate record somewhere else. So some of the hospitals are well ahead of others, and I've been before the committee before on at least some of the issues around computerization in the hospitals. The OHA are very keen on us putting more investment there. We've agreed to allocate our $10-million hospital initiatives fund for the current year entirely towards improving information systems in the hospital sector, but there's a huge distance to go here. Hospitals have operated independently. They have issued you, when you come in, with a new number unique to that visit to the hospital, and we've got a lot of work to do on that. It does strike the ministry as well as individual patients as a redundancy in the system.

Mr Frankford: Yes. I have this initial registration form in front of me here, and I notice that in the fourth line, citizenship status, there's a check-off box for North American Indian. Now, my understanding is that North American Indian health care is actually the responsibility of the federal government.

Mr Decter: In constitutional terms, that's true. I think in historical terms, Ontario has tended, along with the federal government, to provide service to our aboriginal people in the province. We have -- how shall we put it? -- a mixed history with the federal government. There are parts of the province in which they pay the majority of costs for nursing stations and for hospitals in aboriginal communities. There are other cases where the province has gone ahead and provided service. So I don't believe at the moment we have an overall effort to rebill the federal government. Our success in claiming things from the federal government that we think are their responsibility has not been enormously successful in recent years, so we have not denied anyone coverage on the basis of that issue.

Mr Frankford: But it would seem to me that with this information you have on your database, you could pass on the claim.

Mr Decter: Yes, there's no question. I had a meeting as recently as last week with my federal counterpart, who's relatively new to his job. We talked about two aspects of this: our concern with appropriate cost-sharing, but also our very deep concern that in some of the aboriginal communities proper immunization is not being done, and that poses a health risk, both in those communities and generally.

Mr Frankford: I noticed on this chart on eligible registrants who apparently don't have cards yet, you've got 39,000 natives --

Interjection: Underenumerated.

Mr Frankford: -- underenumerated. If I use the $1,400 figure, which I believe in fact is an underestimate, because I thought that the per capita cost was more like $1,600 --

Mr Decter: Not all of it is on insured services. We actually spend, in total, about $1,700 per capita, but some of that is in programs, like public health that aren't on a population basis.

Mr Frankford: Okay. Using the $1,400, I calculate that's $54 million which one might state is the responsibility of the feds.

Mr Decter: It's possible to construct a rather large number, in terms of what costs the province bears, that are costs pertaining to health care for aboriginal people. Again, I'd simply reiterate it's not a new decision. I had occasion to ask Dennis Timbrell why certain provincial expenditures were in place. He said he became tired of waiting for the federal government to do the right thing and went ahead and made those investments.

I think that is part of the history of this province, people not being willing to catch the aboriginal population in a jurisdictional tussle. But will the new registration help us to make a good claim? Yes, we will be able to make a more forceful case as to what services we're providing.

Mr Frankford: Just one final question. As a practitioner, if there was some easy way, if there was, say, an initial number or a combination of numbers which identified a native person, this could be helpful. My understanding is that the feds are responsible for the costs of prescription drugs, so this might be quite helpful in deciding appropriate treatment.

Mr Decter: Yes. I just note, on that, that Quebec has taken a much more organized and aggressive stand towards the government of Canada on certain aspects of the costs of new immigrants, refugees, and has had some success in claiming. We currently have some work under way with Citizenship to look at whether we can make a parallel case.

It's aided in Quebec because it's also taken over administration of a good chunk of the front end of the immigration system, so it has a much better ability to know what its costs are. It's not an issue that has been before the cabinet, so all I can tell you is that we're working on it. I don't know where the government will eventually go but we do face a rather steep bill for new arrivals to the country.

Quebec has taken the view that if it agrees to accept the new arrival, then after a certain period the costs should be borne by the province. But where it's overruled by the federal government, for example, on a medical inadmissibility, where the federal minister issues a permit to allow someone to stay, Quebec takes the view that if the federal authority has decided, then the federal authority should bear the cost. They're having some success in pressing those claims.

The Vice-Chair: Mr Duignan, you have five or maybe six minutes.

Mr Duignan: I want to talk a little bit about the security aspect of the computer system in Kingston. The auditor identified:

"Over 12,000 computer users could potentially access and change registration information without authorization. This included over 12,000 Toronto data centre users...; 54 users who could circumvent existing access controls; and 15 former employees who had worked on registration.

"We also determined that a weakness in the implementation of the security software would allow any of the almost 1,800 mainframe users to disable access controls entirely."

I know you have tightened up on some of those aspects. I'm just wondering, could you maybe update us on where you are now? Have all those problems identified by the auditor been addressed and the problems now controlled?

Mr Decter: I'll ask Fred Hazell to speak to that. Again I would stress, though, that the access by the 12,000 was corrected, I believe, within days of it being brought to our attention by the auditor during the course of the audit, so it was something that was addressed very rapidly. I'll let Fred speak to the rest of the package.


Mr Hazell: As the deputy mentioned, the problem was corrected and we now have about 30 or 34 individuals who have access to the system. That's the number we keep looking at to make sure that those individuals do need access to the registration system. We only want to give individuals access who must have access because they're actually working on the system, or in the program area they need access to do their jobs, to do the analysis required on that system.

Mr Duignan: That leads to the question of the password. Originally, the resource access security facility had a default file. That would mean that the password didn't come up on the screen, but that has been changed and the password now comes up on the screen. Anyone working on a system can lean over somebody and see that password on the system. How's that being addressed, and why was the default value changed to allow the password to come up on the screen?

Mr Hazell: I think that was human error. I think I mentioned before that a big part of that problem was that someone had coded a password in a particular program which could be seen by anyone who knew it was there and hence have access to the system. That was corrected.

Mr Duignan: Has it gone back to the default system?

Mr Hazell: No. Now you have to actually put something in but you can't see.

Mr Duignan: So that has been corrected.

Mr Hazell: That's been corrected.

Mr Duignan: Okay. That's good to know.

Mr O'Connor: Mr Chair, can I put on the supplementary --

The Vice-Chair: Mr O'Connor, same supplementary.

Mr O'Connor: I guess one concern I've got is viruses, and I think that kind of blends with what you talked about. Is it possible that a virus could get into the system and then, "There we go; we've just lost this entire database"?

Mr Hazell: It's always possible. We sweep our systems for viruses on a regular basis. I think we check for about 21 different viruses that we are aware of. It's something which is ongoing, and our security people do take those precautions on a regular basis.

Mr Decter: Mr Burgess has just passed me a note saying that he can't get access to the system, which gives you some idea of how restricted it is, since it's his branch that has responsibility for working through this. I presume some of your people would have access if they have a need to have access.

Mr Burgess: I think it's fair to say that occasionally we complain bitterly about not being given access to what we perceive is our data. However, I think it's an illustration of the fact that security is not just a word that's bandied around and that the actions since the Provincial Auditor's report have been taken very seriously.

Mr Duignan: The question of the 15 former employees who had worked on the registration system: All but two of those 15 people have been identified, and the two that have not been cancelled out are for persons who are basically working for the minister at this point of time. That leaves the 13 other people -- did they at any time breach the security of the OHIP number? Did they use that access wrongly? Was there any follow-up?

Mr Hazell: We have no evidence that there was a breach of security. We had a situation where, again, if you had specific knowledge and knew what you were about, you could get into the system; no question about that. But we have no evidence that security was breached.

Mr Duignan: Okay.

The Vice-Chair: Mr Perruzza, you had a quick question.

Mr Anthony Perruzza (Downsview): Yes, a very short question, and mine has to do more with access to confidential files. If someone does access a file, whether he has legitimate access or not, does he have to sign off before he closes the file so that there's a documented fact that someone has actually looked at a personal, private medical file?

Mr Hazell: This is a computer record.

Mr Callahan: How would you know if they hadn't?

Mr Perruzza: Well, a computer record or a hard file. When you access someone's file and you're looking at their medical history in terms of billings and what have you, when you have to exit, is there a mechanism by which you have to sign off and say, "Yes, I looked at it," and there's a log-in for the amount of time that you were actually in the file and that kind of thing? Is there a mechanism for it?

Mr Hazell: On the computer side, our database administrators can trace what someone did on the system. You have to sign on and identify yourself. We can tell what you've done on the system.

Mr Perruzza: And there's a record of that.

Mr Hazell: There's a record of that.

Mr Perruzza: Then how about actually a paper file? Does the same principle apply to personnel who have access, legitimately, to those files as well?

Mr Decter: I'm not sure what files those would be. We don't have paper files.

Mr Perruzza: If you looked at it for a medical history or something in a doctor's office.

Mr Decter: These are all kept, and I guess this was a significant issue with the committee inquiry into what I guess I could only call the Martel inquiry. There was in fact -- and that situation hasn't changed -- no paper file to be accessed. These records are kept in electronic form and there is a record of who logs on and from where and what they access. There are not paper files on individual patients or individual physicians anywhere in the ministry.

Mr Tilson: Someone took a lie detector test --

The Vice-Chair: Order, please. I have to move on. You'll have another rotation. I'm going to use the Chair's prerogative to ask one question, if I may, Mr Callahan, in rotation.

I just want to pursue the matter with respect to photo IDs, the Quebec model that's being implemented. Did you say earlier that you were actively pursuing this as a system that might be considered for our province, or is this something you're interested in but you're not really pursuing?

Mr Decter: I think it's in the category of something we want to understand more about, what it's cost Quebec and what benefits it sees from it. At one point a group of our people were going to visit Quebec. I don't know if that's happened or is going to happen. Maybe Peter can help me out there.

Mr Burgess: We have not yet visited Quebec. In fact, we have asked that a meeting be held, preferably in Kingston because some of us are resident in Kingston, of representatives from all of the provinces with --

Mr Callahan: It's the city you're talking about.

Mr Burgess: City, sorry -- with all of the provinces that have an interest in registration and registration concerns, and we all have them. We have a number of alternatives that we have already studied in terms of expiry dates, photographs and other forms of identification and an options paper has in fact already been submitted, out of my group, to our assistant deputy minister as a first draft. But to reiterate again, no, we have not yet been to Quebec, deputy. We're hoping to get Quebec and every other province together.

The Vice-Chair: So you're not averse to having a system whereby photographs would be required.

Mr Decter: No, we're quite open to anything that would be an improvement, understanding that we need to balance the cost against what we think it'll gain us. There is some advantage in having someone else go first so that we can evaluate their experience. But no, let it be very clear that I'm not here to tell you we think the current health card is the end of the evolution. We're very interested in anything that can improve our ability to manage the system. If that's a birth date or an expiry date in a cycle or if that's a photo, we're wide open to that. We're just not there yet in terms of coming to a conclusion on the issue. It's going to be a few more months.

The Vice-Chair: There's just one final point I want to make. I thought we as a committee perhaps, coming on the heels of this, would be making recommendations, looking at ways in which you could improve your system. That's something that I would consider looking at as a committee. Obviously that's one of the many ways in which we could be inclined to improve the system. So I'm glad to hear that you're not averse to that and we'll pursue it. Mr Callahan.

Mr Callahan: Yes. I want to go back just to clarify something. You'd indicated that the good faith policy had been terminated as of February 1, 1992. Am I correct in that regard?

Mr Decter: In 1993.

Mr Callahan: In 1993, yes. But prior to that -- I just want to be clear -- was the policy that you would pay it and then you would tell the doctor, "We won't pay any future claims"? Is that the way it worked?


Mr Decter: We were paying them on the wrong version codes and sending back with their remittance advice an indication that the version code was not correct. We sent out a bulletin as of January 15 indicating that: "The ministry will only pay claims submitted with a correct version code. Claims without valid version codes will be returned to the provider for correction and resubmission." We added the note, "Automated providers may often be able to correct and resubmit claims within the same billing cycle," so there's an incentive for them to get it cleaned up.

Mr Callahan: I want to pursue the computer aspect. I recognize that as soon as the auditor identified it, you corrected it. I think the thing that scares the heck out of me is twofold. First of all, we hear the Treasurer talking about selling all the computers in government and leasing them back from some computer company. That scares me in terms of how you maintain confidentiality, but it does have one good prospect to it: that you might all be on the same computer system.

It's a little different, maybe a little far afield from what we're talking about here today, but I think really what we're talking about is proper management of money, the services for residents or the taxpayers in this province and also the terms of collecting taxes from them. When I look at the scandalous activity that's been going on with the tickets -- you know, I always figured that for the last five years, when you paid for your licence plates, you couldn't get your licence plates unless you paid all your tickets, and here we see this outrageous statement being made that unless you can prove that you paid them, you'll have to pay again. If you did that out in the private sector, that would be called theft. When you do it in government, I guess it's called promulgation of policy.

But the concern I've got, and maybe you're trying to follow where I'm going to, is the fact that I'm told the reason that happened was because MTO --

Mr Perruzza: We're having a little trouble following you, Bob.

Mr Callahan: That's all right. Just listen; you might learn something.

MTO and the Attorney General's department couldn't get their acts together in terms of the computer systems. I can't believe that any successful company would ever carry on if everybody had their own computer system and their own program and their own way of doing things.

I suggested this morning that what the auditor has identified in your computer system -- which you've corrected, and I applaud you for that; I'm half tempted to send him out to look at MTO's computer system. MTO's computer system would be far more serious than your system if it was tapped, since it could eliminate some guy's suspension for impaired driving or it could eliminate his demerit points or what have you. It's got a very significant feature, and I gather that your system is entirely different than MTO's.

Mr Decter: I don't know if it's entirely different. You have to be careful about describing it as our system. Our data system is operated for us by the Ministry of Government Services. So while it's our data and it's essentially our software, it's their hardware, if that's the split.

Mr Callahan: You obviously know a lot about computers. Is that the same thing with all of the --

Mr Hazell: Each ministry has its own arrangement. Ours is leased and managed by the MTO.

Mr Callahan: So MTO may not necessarily be with Government Services. That concerns me, and that may be my next endeavour, to have the auditor go in and take a look at particularly the Ministry of Transportation. That's a very lucrative field if that ever happened. You could get your demerit points erased or your suspension erased.

The other aspect I'd like to ask you about is the question of the Americans. Your key indicator seems to be residency, and I think one of my colleagues over there may have either asked you about this or alluded to it. If a person has a residence in Ontario, if he owns a piece of land or has a cottage or is maybe giving as his address a business address, does that mean he can get a card? Would that be sufficient residency for him to obtain a health card?

Mr Decter: I believe we're looking for evidence of citizenship or ability to maintain permanent residency, not simply that someone had been here for a period of time.

Mr Callahan: Is that on the form you gave us this morning? Is that the new form that's now being filled out? I guess it is, down on citizenship status.

Mr Decter: Yes.

Mr Callahan: That definitely has to be filled in, does it?

Mr Decter: I'll ask Peter to go through the three criteria for eligibility which would be assessed here.

Mr Burgess: The three criteria for eligibility for health care in Ontario are you must be (1) legally entitled to be here; (2) you must make your home here; and (3) you must ordinarily be present in the province. It's that "ordinarily present" that has been interpreted through policy as being present in the province of Ontario for six months plus one day. Those are the three sets of criteria.

Mr Callahan: What happens if you get sick before the six-month period?

Mr Burgess: As I said earlier, we're not down to the edges there, but if it appears that you live for 12 months or 10 months of the year outside of Ontario, we're going to ask you to prove that you are a permanent resident of Ontario.

Mr Callahan: That's assuming you've lost your ticket, as it were, and you're getting a new one. If you're just coming in for a new one completely, that doesn't matter, I gather.

Mr Decter: You would not be able to succeed on this application by leaving that field, this part of the document, blank. You would have to answer it one way or the other and provide documentation. As I indicated earlier, if that documentation were being mailed in, we're still accepting photocopies. If it's being walked into one of our offices we want to see original documents, and we're reviewing the mail-in policy to see if we should move that to original documents as well.

Mr Callahan: So you haven't gone the step that the passport office has, where it requires people to come in, walk in off the street and show the original documents?

Mr Decter: No, we haven't gone that step yet.

Mr Callahan: But what about a person who comes to this country by whatever means and is retained in custody pending a hearing? They obviously have health care coverage right from the minute they arrive here, do they not?

Mr Decter: We have provided some money, significant money, to the community health centres in the province which provide care without a health card -- they're not on a fee-for-service basis -- to address some of those populations, but I would have to defer to my colleagues on the exact status of -- there are a variety of statuses people could have on arrival. As is made clear in this document, "tourists, transients and visitors to Ontario are not eligible" for coverage.

I don't know the status of someone who is in the process of being deported for being here illegally, whether we would provide care or not. The one underlying principle of the system is that no one has the right to refuse urgent or emergency care. I think that's pretty fundamental. There is no ability on the part of a hospital or a provider to turn someone away who's in urgent need of medical attention on the basis of an ineligibility. But given that the vast majority of interactions with the health care system are not of an emergency nature, we can apply the eligibility issue.

Mr Callahan: You've certainly helped me, because it was my understanding that a person, upon entry to Canada by whatever, got a health card and was eligible for health services. That was my understanding.

Mr Decter: Do you want to try that one, Peter?

Mr Callahan: Is that not the case?

Mr Burgess: I'll give it a try, but remember that this is not my field and I'll gladly get --

Mr Callahan: If you feel uncomfortable about it, maybe you can get me that information, but that's my understanding.

Mr Burgess: We will clearly get you the information, but as far as I understand it, the issue is being legally entitled to be here. If, for instance, you are legally entitled to be here and you have not yet gone through the refugee process with the federal government, we will still cover you for health care under the Ministry of Health, and as such will issue you with a health card, and there are a variety of specific issues that --


Mr Callahan: Just one final question. What about the situation of person who have been ordered deported but have appealed their deportation and are out on bail pending the hearing of the appeal? Are they covered?

Mr Burgess: In that particular case, as I understand it -- and again I'll double-check -- that individual is still legally entitled to remain in Canada while awaiting his final deportation hearing, so as such he is covered.

Mr Callahan: He's within the 10 million cards that are acceptable. He's part of the population.

Mr Burgess: That's absolutely correct.

Mr Callahan: He must have been counted by Stats Canada then, because you're matching Stats Canada's figures.

Mr Burgess: He may or may not have been. If you look in detail at our reconciliation, you will see there are some areas that Stats Canada counts and we don't, and vice versa.

Mr Callahan: Thank you.

Mr Decter: The chart that had been tabled earlier, the refugee claimants -- some 23,000 were people we added to the population who aren't in the population estimate but are eligible. So there are people who are in the province and eligible for coverage on our policy who are not part of the population of Ontario for Statistics Canada purposes.

The Vice-Chair: Mr Wilson. I have to move on.

Mr Gary Wilson: Thank you, Chair. I note that the Provincial Auditor has been sitting patiently all morning and this afternoon, so I thought perhaps I'd take this opportunity to ask Mr Peters a question.

Mr Peters, you wrote in your annual report, under the section entitled "Justification," that, "The ministry had not proven that the registration system and process were the most workable and cost-effective solution, nor could it support $137 million of the $150 million in estimated project benefits."

Since writing those words, have you heard anything today or in the last little while where the ministry has shown that it is able to show an effective cost-benefit analysis of this new card system?

Mr Erik Peters: I have not, but I'll ask James if he has anything.

Mr James R. McCarter: No. I think our concern was that it wasn't specifically itemized as to where the $150 million was coming from. We haven't really gotten into that today, but nothing that I've heard yet has been to serve the specifics.

The Chair: Sir, can you speak up?

Mr McCarter: I haven't heard anything that's gone into the specifics of $150 million, and that's what we were looking for.

Mr Jim Wilson: Perhaps Mr Decter would like to take a crack at that for the record, in terms of explaining to the public the cost-benefit of this new system.

Mr Decter: The cost is, I think, fairly easy to quantify to date; it's on the order of $40 million. We are continuing, obviously, an investment with the branch that Mr Burgess heads.

In terms of the benefit stream, I think it's only going to be with the passage of some additional time and implementation of these measures that we can accurately document what the benefit stream has been, and even there, some of it's going to be a little elusive to get at. We suffer from what I guess the political scientists call a priori over determination, which is that we have a declining utilization and we have multiple causes that one could point to, and so delineating what contribution the new health cards have made as distinct from other things is difficult.

I would express to you a concern, and it's not limited to the ministry that I now head; I've had experience in hospital settings and other settings. People tend to overstate the benefits of automation and they tend to be very loose about their documentation. We've changed that policy in the ministry and I think you'll see, in future projects, a much tighter justification on the front end. The first one, where we've set out I think more modest expectations, is in the automation of the drug benefit program.

I think my answer's really twofold: It's too early to fully document the benefits, and there will be an aspect of those benefits being difficult to document. I can tell you that I genuinely believe they will far exceed the $40 million that it cost us. But can I give you a detail on $150 million of benefit? Not at this point. I think a year from now we'd be in a better position to give you a good estimate of it.

Mr Jim Wilson: It disturbs me that if we look at some of the political record on this, we had my leader, Mike Harris, suggesting in June 1990 that the system be scrapped and that the government cut its losses. We waited for, and we're still waiting for, the cost-benefit analysis of the system to justify it to the taxpayers. You must have had some basis when Frances Lankin went to cabinet as Health minister in mid-1991 and got another $6 million to pump into this registration system. You must have had some documentation before cabinet, some numbers presented there that would justify pumping in another $6 million and not cutting your losses at that time and starting over with a more effective system. Do you want to comment on that?

Mr Decter: The extension of the budget in March 1991 to, in essence, finish the job I think was really justified on the basis of what had been encountered along the way. It didn't represent a revisiting of the original decision.

I still think and I've said that the original decision was the right one, and I've been through all of the historical documentation. As you'll be aware, much of this happened before my time, which is only to say that you have to read between the lines a little bit in some of the documentation to fully understand it. But I don't think we had a choice whether this is the best system. By the time my previous minister went to cabinet, it was a matter of finishing a job that was well down the road.

I think we are seeing benefits. I would differentiate between being able to quantify those benefits in a detailed way and those benefits being absent. Without the investment in unique health identifiers, we would be unable to take the steps we're taking to tighten the system, and those steps will yield significant benefits to the province.

Mr Jim Wilson: Can you just give us an example of one step that would tighten the system or of an individual identifier?

Mr Decter: One of the areas in which we've had some impacts to date is that we pay health service organizations on a capitation model. These are physicians' practices where, instead of paying fee-for-service, we pay them a certain amount per enrolled person. With what we call the cleaning up of the roster, we've seen some significant cost reductions in that program because now we've had a better reading of who's enrolled rather than more people enrolled. I think in some cases that's been as much as 20%.

That's not our largest program; that's a program with a cost in the order of $80 million or $100 million a year, so it's an illustration. But again, we have not yet used the health number as thoroughly as we need to throughout the ministry, so I pick that as a rather clear illustration of where you can actually measure and say, "We paid X this year and we paid" --

Mr Jim Wilson: But you'd know that information under the old OHIP system. I mean, everyone under that system had a number, and if they attended a health service organization you were still able to track what services and billings were provided for those individuals. It may have cleaned up the numbers, but you were still able to track that information, were you not?

Mr Decter: No. The problem under the old system was that people had multiple numbers and they didn't have unique identifiers, so in some cases we were paying for people who weren't really there. The way the HSOs work, they enrol the population, which means they need a number. But what's happened with the new health number coming to bear is that some of those rosters have dropped in size because they had duplication or they had ineligible people on them.

I don't want to place a huge emphasis, as this is only one program. It's a little different than the others in that it runs on a capitation basis. But it's a clear area where we've seen some impact from the numbers. Others may want to contribute --

Mr Jim Wilson: I'm just sort of wondering. Your example hinges on the fact that there was duplication, but there's still duplication, according to the Auditor and according to yourself, under this system. We have several thousand people in the province who perhaps have two numbers assigned to one person. What I'm getting at is, how does the new system improve on the old system other than that the overall number of duplications is down?


Mr Decter: In the order of magnitude, we are down from 250%, if you take the 10 million versus the 25 million, to what we think is something in the order of about 2%, so it's a change. There's still duplication, but there's a whole lot less of it and that's where we're seeing the benefits. We're working to reduce what exists. But if you're asking me the if the new system is perfect; no, it's not perfect. We still have a distance to go to get the full value out of it but we are seeing some considerable value so far.

Mr Jim Wilson: I'd just want to ask a quick question for my colleague. If you're to move to expiry dates and perhaps photographs and adding addresses to the information so that it's contained in the magnetic strip, wouldn't you have to recall the 12 million cards you've already issued? How do you deal with the population that has a card now?

Mr Decter: One option would be to start with the issuance of new cards to seniors as they turn 65, which we are doing. The over-65s are our highest-use group, so that would be one strategy. Again, I think everywhere we're trying to do something. We're trying to look at where we will get the largest payoff for the least effort. I tell you we had approaches from the banks and some others around smart card technology.

Faced with a choice between investing some money to get some benefit out of the $40 million already invested for some additional benefit or going to a whole new issuance, my bias was to tighten down what we already had. If we went to expiry dates, I think we'd have to either start with a birth year, that is, issue newborns with one that a cycle, or potentially with the over-65s. I don't know if there are other thoughts Peter might have on that.

Mr Burgess: I guess the only thing I want to add is that prior to the implementation of any renewal cycle, which we would obviously attempt to do as much by mail as opposed to unnecessarily getting everybody to walk in, certainly in terms of sending stuff out, we need to spend some time cleaning up our existing address data. That is the largest single part of our current file which is inaccurate. Clearly, people are much more mobile than they used to be and addresses are not being updated, so that would have to be done.

The Vice-Chair: Mr Tilson.

Mr Tilson: How much more time do we have?

The Vice-Chair: You have approximately five minutes.

Mr Tilson: Thank you. Turning to page 107 of the Auditor's Report, there's item 3.10, which is the background section. There is a chart which talks about the actual cost compared to the budget. Obviously, when Mr Wilson first raised this in the House back in October, and the Provincial Auditor has now been raising all the issues that he has, I guess the question I have is that just looking at the amount that was spent on registration planning compared to processing applications, producing the health cards and all the other items, the least amount of funds that was spent was in registration planning. In other words, we're putting forward a very expensive program. Presumably you have put some thought behind it, but the strange part is that this is the area you've put the least amount of effort into. Can you explain why?

Mr Decter: I'm not sure that I can give a good explanation for that. You will note that we overspent the planning piece by the largest margin, so clearly what we actually spent on planning was more than double what we planned to spend.

Mr Tilson: I can see that. I guess I find it strange that when you are trying to introduce a new system to correct a system that's clearly defective. With all the OHIP numbers -- and you've gone through all that -- I would have thought you would have spent a considerable amount of time on all the different systems -- I think we're the last province to change our system, if not, then one of the last provinces -- and that you would've looked at all of those; there would have been time spent on looking at the American jurisdictions. I'm just not sure you did do that. It's just that I find it strange that, whether it's the amount spent or whether it's the amount budgeted for, that's the least emphasis, whereas the greatest emphasis was on the matter of processing applications.

Mr Decter: I can't, obviously, say very much from personal experience on that; 20-20 hindsight would tell me that probably spending more on the planning end would've been a good idea. You're right that some other provinces put in unique health identifiers at the advent of medicare and have had some sizeable benefits from having done that. You have to sort of live with the history in your own jurisdiction. I think that with the ending of the premium-based system here, there was real pressure to move on this.

But again, I've read an enormous amount of background and tried to read between the lines on some of it. I'm quite willing to accept the criticism that we should've put more effort into planning. I know when I arrived, my early description of the problem was that there were 700 people standing outside an office at 2195 Yonge, and there was a lot of pressure to get them dealt with on a timely basis. I went up there to sort of see how we were doing and found some tremendous efforts by some overworked front-line staff to deal with the actual processing. I think we probably underestimated the magnitude of the tasks involved.

I think we certainly underestimated the number of new people arriving to Ontario, particularly in Toronto. I guess I'd just underscore there that our immigration levels are running, I think, higher than at any time in recent memory. So we were pursuing a somewhat growing issue, and I don't think we've got the full solution on that one yet.

Mr Tilson: Having said that, and we're obviously in midstream now, we're finding a system that you admit has got some defects, and it's quite obvious that it's got some major defects. You mentioned immigration, you mentioned the fact that we should be looking at ID cards and you say you are doing that, photo cards, smart cards. Probably there are all kinds of cards under the sun that you could be looking at. Have you budgeted? Have you put an amount forward for the government to look at as to how much all this is going to cost, to look at new potential systems that perhaps you should have looked at in the first place?

Mr Decter: No, we have not. At this point we are doing the work. We have budgeted the smart card pilot project in Fort Frances, including an evaluation phase. So on that particular piece, until we have the results of that pilot, I think it would be premature to look at costing on a smart card.

Many of the other measures are part of the ongoing management of the ministry. There isn't a separate budget for that; it's a matter of the ongoing work that Peter and his people do. As they finish one project, they move to another, so it doesn't have a big price tag. I can tell you that we are not going forward on any grand design on the technology side unless the program area can cost-justify it. Unless we have a business case of a very tough sort, I won't go forward to Management Board on automation projects.

Mr Tilson: Well, I guess --

The Vice-Chair: I'm sorry. We're out of time.

Mr Tilson: I'm finished?

The Vice-Chair: We have to move on to the next round. I have Mr Fletcher.

Mr Fletcher: Just a couple of things. When OHIP was first introduced and the little cards were handed out, there were problems in the system. Is it correct to say that there were problems in the system, that some people were getting them who shouldn't have gotten them, that it was hard to keep track of where they were going?

Mr Decter: We relied on employers, really, in the initial days, back in the early 1970s, to submit and that had its own dilemmas.

Mr Fletcher: With people changing jobs frequently and things.

Mr Decter: Yes.


Mr Fletcher: Certain outside things that were uncontrollable always had an impact on what was going on in the ministry, such as what's going on now. You know, we talk about the number of cards that are out there, and I know that when the Liberals started introducing this, the program was introduced to try to cut down on the amount of fraud and cut down on the number of cards that were being sent out erroneously, and yet it was still occurring. The system changed because it had to change with the times, with the way things were changing. Now we've come another step further.

Would you say that the goals of the ministry are consistent with the steps that have been taken from the beginning, when OHIP was first introduced, that we're trying to get to a certain stage and that each step is a learning process, that we learn from one step and move on to another step?

Mr Decter: I'd certainly agree with that. There are some shifts in our whole philosophy in approaching health more recently, in the last five or six years. I think we saw health care as insured services. That is, the government stepped in to be the insurer and to pay primarily for hospital and physician services and, for part of the population, drug services or drug benefits. We're moving to much more of a view that the determinants of health are a good deal broader than that.

On one hand we have the challenge of managing the services we're delivering, and the health number at its current stage represents progress on that front but not perfection. But we also have the challenge of making some different investments in the things that determine how healthy people are as opposed to the treatment of illness. So we have more of a balancing act.

One of the things we need better data for, which the health card provides, is really to look at epidemiology, both clinical epidemiology and population epidemiology. Clinical epidemiology is, do the procedures we're paying for actually work? Do they improve people's health? And population epidemiology is, do the investments we're making create a healthier population? Without knowing who's getting service and what service they're getting and being able to track them, you really can't get at those two fundamental pillars of where we need to go in this decade.

So yes, I believe that the steps that have been taken again don't represent perfection but they do represent substantial progress.

Mr Fletcher: I've also read some previous auditors' reports from previous governments. A lot of the things that were being said then -- not to say that things haven't changed -- have been said again but not on this same scale.

The other thing is that you talk to people about credit card companies such as MasterCard, Visa, and they spend a lot of money, in fact probably too much money on trying to detect fraud, whether it be lost or stolen cards, cards that were issued to family pets, which is common in the private sector also, things that are going on. That's one area. I'm just interested in combating the fraud issue or where the cards are being sent, when even in the private sector one of the biggest problems is having correct information. You can only have the information people send in.

Mr Decter: It's very tempting, I think, to get heavily focused on the fraud issue. It's an issue, we are accountable to the taxpayers and the auditor is very good at helping us.

Mr Fletcher: The credit companies are using my money.

Mr Decter: Yes. But let me come to the Visa comparison. I was asked earlier, what was the reaction of the OMA to the version code decision? Their initial reaction was to say that when they go into a hardware store to buy something with their Visa cards, they give their Visa cards to the merchant, to the store owner or the clerk and that clerk verifies that it's a real card before the purchase is processed. They said, "Why don't you do that for us?" I said we've looked at it. What you have to understand is that that merchant, the owner of the hardware store, pays Visa or MasterCard 1% or 2% or 3% or pays American Express 4% or 5%. If you're willing to do that, if you want that system, I'm prepared to recommend it to ministers. But understand that it's going to cost you some money.

The OMA hasn't given us an answer on that. I think it's a big expense to deal with a problem that we're not sure of the scope of. The investigations we've done to date have detected where there's a suspicious activity it's down around the 1% level, and whether you'd want to spend 2% to solve a 1% problem becomes an issue.

We certainly want to deal with fraud, but I think the upside of the health number is that we're going to be able to plan a much better health care delivery system with the information we get, not the individual information but the aggregation of it, and that's going to help us make a lot better and more precise decisions about what investments we ought to make in health care delivery.

Mr Fletcher: That's more important.

Mr Decter: They're both important. People in the province want the system to remain affordable, and that means making the right investments. It also means making sure that we're not being taken advantage of, so there's a balancing act. The unique health number helps on both those fronts.

Mr Hayes: There's one issue here that I would like to really get a clarification on. There are numbers that are being bandied around. Mr Wilson has raised several times the 1.4 million invalid cards that are in circulation and then of course he multiplies that by $1,400 per resident. They've come up with some pretty astronomical numbers and you have actually indicated that the 1.4 million is not really a credible number to be using.

I guess what I want to know is what is being done now and what can be done to make sure that these cards or the invalid numbers can't be used. I'd like you to be specific, for the record, on really addressing these 1.4 million cards that have been mentioned to the media, in the House and all over the place. If that's not an accurate number, I'd like you to clear up that particular issue.

Mr Decter: Let me try again. I've tried a couple of times. I will, in the course of trying to answer it, also answer or try to answer Mr Wilson's question about what our estimate is of how much the cost of fraudulent billings might be. It's a wide range, but I'll speak to it.

First, on the 1.4 million, this is simply the difference between the total issuance of numbers and those currently valid. I'm making the comparison I tried to make before. We've issued 20 million drivers' licences in the province of which, at this moment, 6 million are valid. You could say there are 14 million invalid drivers' licences, and you would quickly have to say that 10 of them are your old ones that you're not using any more. So the difference is that we haven't put a particular expiry date on our health cards so, conceptually, if they lost one and were issued a new one and lost it, someone could have multiple numbers. But the main protection we have is that we're only going to pay on the valid ones.

As indicated, I think the 1.4 million is not the issue. The real issue is coming down from the 10.8 million towards the population and how much of that we have got off the books or we are in the process of getting off the books.

Mr Burgess provided me with some figures over the noonhour. I asked the question, in the 50 studies we've done to date, what percentage of fraud are we finding? I'm overstating it; fraud isn't there until you've proved it in a court of law. What percentage of what we're finding seems to be suspicious? Despite our expectations, it seems to be down around the 1% level. If you take the 1.4 million times the $1,400 times 1%, we have a $20-million problem that we're pursuing. If you take it times 5%, then it's a $100-million problem.

If you had to ask me, from what I now know, how big the issue is of either fraudulent consumer activity or fraudulent provider activity, I think a good ballpark is probably in the 1% to 5% range, and I would believe it to be, on the basis of the work we've done, closer to the low end of that range. That is more likely to be in the $20-million range.

Mr Jim Wilson: On a point of order, Mr Chairman: If you're going to answer my question, you should be sure that my question was how much was charged, not the estimate, to the 1.4 million cards prior to February 1.


Mr Jim Wilson: No, that was my question.

Mr Perruzza: Mr Chairman, that's not a point of order.


The Vice-Chair: Order. That was not a point of order. We'll rotate.


The Vice-Chair: Order. I ask members of the committee to come to order. That was not a point of order; it may have been a point of clarification. We have to carry on.

Mr Hayes: Really, what you're saying, in fact -- and correct me if I'm wrong -- is that if someone has two or three cards, only one of those cards is going to be valid where the person is going to be able to use it. Is that correct?

Mr Decter: Yes.

Mr Hayes: Just one more real quick question so I can be clear: What happens when services are billed by a provider to an invalid number?

Mr Decter: As I indicated earlier -- I have the bulletin here -- we send back to the provider essentially the claim with the information. I'll read it to you precisely. This is the bulletin that went to all physicians, hospitals, clinics and laboratories as of January 15, "Claims without valid version codes will be returned to the provider for correction and resubmission."

It's a longer bulletin. "To assist in identifying the correct version code, it is recommended that:

" -- Health cards be seen when service is provided and compared with patient records;

" -- Remittance advices" -- that's the information we send with payment -- "be reviewed and patients contacted to provide updated information where necessary to reduce the likelihood of future returned claims;

" -- Patients be contacted when incorrect version code claims are returned. It is important to confirm that the patient holds and is using the correct card;

" -- If patients require assistance, they are to be advised to contact their Ministry of Health office; and

" -- Once the version code is updated, the claim is resubmitted to the ministry for payment."

We believe that in terms of multiple cards, we have issued two cards to 821,000 people, we have issued three cards to 91,000, four cards to 14,000, five cards to 1,635 and six cards or more to 163 people. The vast majority of the multiple cards, some 80%-plus, are somebody getting a second card, most of them on turning 65.

The Vice-Chair: Could I just ask a question with respect to clarification?

Mr Hayes: As long as you take it from Bob's time.

The Vice-Chair: It won't be off anyone's time. We'll add time to it. The auditor has sort of indicated to me that what you were referring to was total inactive cards, 1.4 million.

Mr Decter: Yes.

The Vice-Chair: How many of those are invalid?

Mr Decter: I believe they're all invalid.

The Vice-Chair: So they're all invalid cards?

Mr Decter: Yes.

The Vice-Chair: The auditor may want to follow up.

Mr Peters: I just raise it as a point of clarification to help out in the answer because everybody's going after this particular point. When you say they are inactive and they're all invalid, if those cards were presented, how would they show up as invalid in your system? In other words, one of these shows up at a doctor's office and they come to you and ask for billing. How would you identify it as invalid? That may help the members to just explain how this would work.

Mr Burgess: I'm not sure that I can clarify any better than the deputy's done so far, but let me try.

In the case that a second card gets issued or in the case of death or in the case of a card running out of eligibility, for those cards that have eligibility, that 10-digit number on the card is immediately invalidated. That means it cannot be used. If that card, following February 1, 1993, is presented to a physician or other provider for services, those services will not be paid for.

Mr Tilson: There's no difference between "valid" and "active"; is that what you're saying?

Mr Peters: As of February 1. This is really the point of clarification that people seem to have missed that was missing in the explanation; as of February 1. The only other point is, are the health providers provided with some sort of evidence that identifies for them that the card they're facing is invalid?

Mr Decter: I'm going to introduce Eileen Mahood, who's our director of claims payment, because she's got the payment end of the business. But let me say -- and I'll ask her to speak to it -- I believe we've been providing, with remittance, advice to providers over the last three years of wrong billings. We haven't been not paying them, but we've been telling them, "We're paying you, but this is a wrong number." But the point here is very right. When the auditor identified this problem, it was a real problem, and we have only addressed the problem as of February 1 in the very direct way of saying, "Not only is that an invalid number, but we're not paying a claim against it."

Mr Callahan: No ticky, no washy.

Mr Decter: Exactly, and maybe Eileen could speak to that and just make it very directly clear how the process works.

Mrs Eileen Mahood: For this provider who is submitting to us on a machine readable input format, that claim is rejected out of the system and goes immediately back on an error report to the physician, to the provider, as the claims come in. So that doesn't even appear in our system for any adjudication. They will have to now, as of February 1, get that number validated and then resubmit the claim. So they're out of the system. For paper claims, of which there are still a significant number, that's done by a clerking process. Again, the system will show on a screen that this is an invalid number. That claim card will have to be pulled and sent back to the physician.

The Vice-Chair: If I may just follow up on that, is there a pre-screening verification that this number is invalid? Is there anything to forewarn a physician that this number is not accessible, or is that after the fact?

Mr Burgess: Perhaps I can jump in there, since this is particularly relevant to the case that I mentioned this morning. All our cards with their 10-digit numbers on them pass a modulus 10 check digit routine. That check digit routine is a little mathematical computation that we can all go through in our heads mentally, should we choose to do it, but it was shared with the provider community some three years ago when the numbering scheme was developed for the individual, unique number. Each one of the physicians' in-practice systems has that modulus 10 check digit; we have shared it with the provider community. So if you type in the number that is shown on the overheads that you've been given, that will immediately flash on the screen as a totally invalid number. It's invalid. It's got nothing to do with, "Did it have eligibility? Does it have eligibility? Will it have eligibility?" It is invalid, just a random collection of 10 digits, and it is not and never will be a health number.

Mr Callahan: That's if it's a phoney card.

Mr Jim Wilson: The 1.4 million were real cards.

The Vice-Chair: Order, please.


The Vice-Chair: Well, let's hear from the --

Mr Decter: Three things here. Let me do them quickly.

When we have the phone line in place, a provider will be able to call in, subject to us being clear with you on the FOI considerations, punch in the number, and an electronic voice will say: "This is a valid number," or, "This is an invalid number." We're discussing whether it will give any further -- any reason for it being invalid.

But to date, what every provider has, whether it's a hospital, a clinic, a lab or a physician, is all of the advice we've given them over the past three years about which numbers are valid or invalid. We've been sending those to them monthly. So on the basis that most people see the same physician or go to the same hospital or get tested in the same lab, what all of the providers have is three years of data that they can go through, and they can discover for themselves that Mrs Jones's claim was valid with this number and was invalid with that number. So all of the providers have on hand, at the moment, an ability even before we bounce back any claims to determine where their problem is. This is a problem at the level of approximately 3% of claims, as I recall. So it is not a huge problem. It's a big problem for us, but for an individual provider, on average we're talking maybe one claim a day or less. So they have one additional phone call to make to track down a right number if they want to get paid, and we don't think that's a huge burden.

The Vice-Chair: I have Mr Hayes who had the floor. Have you concluded your questions? You have a couple of minutes left, and Mr Frankford asked --


Mr Hayes: Mr O'Connor actually wanted my time, or --

Mr O'Connor: Thank you, Pat.

Mr Hayes: Go ahead. We like to share here.

The Vice-Chair: You have two minutes left.

Mr O'Connor: Thank you. I guess one point that was brought up the other day in closed session was the fact -- I don't know if it's a fact or what, but perhaps you can give me some clarification on hospitals having rolls of cards to use for newborns, that they can give out a number automatically. Of course, that then points to perhaps a potential for abuse. Perhaps you can clarify that information. Do the hospitals have rolls of cards that they can possibly issue for newborns? What's the correct procedure that would be followed for registering newborns?

Mr Decter: The answer is yes; we've given hospitals blocks for newborns. As you can understand, we faced some considerable criticism that newborns weren't able to rush out and get a health card in time for their -- they're provided a bill, but I'll let Peter speak to the detail of how we're doing it.

Mr Burgess: We pre-publish, pre-allocate against database, a certain number of valid health numbers. Based on the historical number of births in a particular hospital birthing centre, we send that number every three months. Then, on a regular basis, on a monthly basis, we track actual births against anticipated births and run an inventory control system of the number of pre-allocated numbers and forms that have been sent to an institution and how many we've had back. We just keep doing that on a regular monthly basis. It's a classic inventory control.

The Vice-Chair: Okay, I'm going to move to the next round. I'm at the mercy of the committee. Do you want to have a last round, or shall we carry on with 15-minute rounds?

Mr Callahan: Do one more 15-minute round.

The Vice-Chair: Okay, we'll go one more time around for 15 minutes. Is that acceptable to everyone? Okay? Mr Callahan.

Mr Callahan: I notice that on the new form that you've got, it's got down at the bottom "Name Style Preference." Mr Robinson can have his name as Daniel Martin. He can have his name as Daniel M. He can have his name as Daniel Robinson. He can have his name as D. Martin Robinson. He can have his name as Martin Robinson -- I'm sorry, no first name, but simply a middle name, Martin Robinson. He can be D.M. Robinson; he can be D. Robinson; he can be M. Robinson. He can be any one of those eight variations.

Interjection: "Robbie."

Mr Callahan: Now, I'd like to ask the person who is familiar with computers: If I come in and fill out the form and I choose to use on my first application "Daniel Martin Robinson" and I fill out all the information and provide some proof of who I am -- it doesn't necessarily have to be citizenship; it says, "Canadian birth, citizenship, or baptismal certificate or a Canadian passport," or then it says any other document. If I come in and do that and they punch in my name as Daniel Martin Robinson and I give them an address, I get a card with that on my card because that's my preference. All right. Then I come in the next day to another -- I'm just trying to think this out. I come into another application centre and ask for one for Daniel M. Robinson, and I produce the same thing and give a different address. Am I not correct that each of those would receive a valid health card number, and the computer is not capable of determining that you have now got eight cards out in different names for Mr Robinson?

Mr Hazell: It really does depend on the number of identifiers that you choose to use. If you simply gave me your last name with a different address, I'd assume it's two different individuals. One of the things we do, of course, is to use the birthdate as well, so the date of birth would in fact trigger the last name, the same address. The date of birth would very likely trigger someone saying this is very likely the same individual that we're dealing with.

Mr Callahan: Let's say I didn't give you my birth certificate as proof, but I gave you something else.

Mr Hazell: With a different --

Mr Decter: You would still have to give a date of birth.

Mr Callahan: The reason I'm suggesting this is that it has come to my attention, and this has been in talking to police officers, that there are people who actually, when their licence is suspended, get a new licence by simply changing the way their name appears. If they're called Daniel Martin Robinson on the one, they just open up a new file in the computer for Daniel M. and they get a new licence and they drive around with it. If the police stop them, they check CPIC and all they do is find that Daniel M. Robinson is an upstanding citizen, whereas Daniel Martin Robinson is probably a scoundrel who has lost his licence for 20 years.

Mr Perruzza: If he's dishonest --

The Vice-Chair: Mr Callahan has the floor.

Mr Callahan: Maybe if you listen, you will understand.

Mr Perruzza: Well, I am listening to you.

Mr Callahan: Well, listen, then.

Mr Perruzza: Surely fingerprinting --

Mr Callahan: Listen. Listen.

The Vice-Chair: Order. Mr Callahan has the floor.

Mr Callahan: You'll agree with me that in computers you can do that. You have many ways you can pull up a file and many ways that you can identify a file as being similar, but does anybody actually go through the computer and pull out the item on the basis of one of those matched components? Let's say we use your example that the birthdates are the same.

Mr Hazell: We need at least three items to match: the last name, the date of birth and the address.

Mr Callahan: Okay. But let's say that I don't give you my birth certificate as being a piece of evidence of my residency in Canada. I simply give you my citizenship card or my baptismal certificate. You see what I'm getting at? This system you've got in place right now, with all due respect, even with all of its updates after the auditor has brought to your attention certain glitches, and in this computer world -- it's got flaws. It's open to significant fraud. Would you agree with me that there's at least the possibility of that in light of what I've just said?

Mr Hazell: If you stated it differently, I could possibly agree. But, no, seriously, it really does come down to the number of things you want to match. You could of course go ad infinitum in terms of the number of matches. We've chosen to match three things. You can make the case, obviously, that if you want to match a fourth, you're more accurate than simply relying on three.

You're correct in the sense that if you're using only the name as an identifier and someone spelled the name differently or changed the name, then certainly you've just created a brand-new file. If you're matching three or more items, I think you stand a very good chance of being able to identify that you're dealing with the same individual. That's the tack that we've taken.

Mr Callahan: Are there three items? It's birth --

Mr Hazell: The date of birth.

Mr Callahan: I hate to be giving information to somebody out there who might be watching, but there are three items that are checked?

Mr Decter: Birthdate, surname and the address.

Mr Callahan: Because I go back to my major concern in this whole issue. Obviously the major concern is the money that has been lost as a result perhaps of these extra cards, but more importantly, if we're going to use a computer technology, which certainly we have to, then we have to come up with some way to plug all the gaps. Even if you take three checks, as I say, people could come in and get those cards, and those cards are worth a lot of money, not for health services necessarily. That card may give them access to opening a bank account that will establish some degree of legitimacy in being in this country. It might give them access to any type of official document: a driver's licence or what have you.

It becomes most specifically significant if, as I understand it, you're going to use this same card for the drug benefits, because drug benefits already cost us a lot of money, and that will be a loss there as well.

I would ask you to look at that, that that be blocked, that you not be given an option as to how you want to be shown on your card, but that you're shown on your card exactly the way you are on the document that is presented as identification. That's one way of avoiding even the possibility of that happening. That's my first suggestion. Would you agree that would make it a much tighter scenario?

Mr Hazell: It would. The only thing I would add in terms of clarification is that we actually see the document. What you're doing is to choose how you want that name to show on the actual card, but if we see the document --


Mr Callahan: I'm suggesting that we not give them a choice, that if you're asking them to present a document, that document is what you're relying on in terms of the veracity of that person before you're collecting the card. I would suggest that you look at the question of not giving people the choice of how they want to appear on the card. If you're asking for proof of who they are, then there should only be one choice and that's exactly the way it appears. I mean, you don't get that choice in passports. They don't say, do you want to appear as Daniel Martin Robinson or Daniel M. Robinson? You're identified specifically. I think that's the first step that tightens it up and eliminates any possibility of someone trafficking in these things.

The second question I would ask: There was a report in the Hamilton Spectator which seemed to allude to these things about the good people in Detroit using our medical services and so on gratis Canadians. But more importantly they referred to Martyn Cooper, who is, I guess, the manager of the Royal Bank's Toronto-based technology integration division. Have you people talked to this gentleman at all?

Mr Burgess: I have not personally spoken to Martyn Cooper, although my staff and I and Julie Leggatt have made arrangements on the week of March 22 to visit the Royal Bank.

Mr Callahan: I wonder if we could use your good services, since you now have this link with this gentleman, to perhaps arrange to have him come before this committee. We'd like to talk to him, but we're not interested in spending taxpayers' dollars to get an expert here to tell us how it should be done. This guy seems to have it in place. By the way, this was October 1992, so it's some time ago. He said:

"The bank is interested in providing the information management expertise it has amassed over the years computers have been in the financial world, developing technology that could one day be exported and make Ontario a leading force in health care information storage and delivery, says Martyn Cooper, manager of the bank's Toronto-based technology integration division.

"Perhaps, he says, the bank could one day provide the government of Ontario with use of a highly confidential, encrypted information network capable of handling the health information of 10 million-plus Ontario residents."

What that says to me, if this report is accurate, is that this man has all of the credentials to eliminate the problems we've discussed about confidentiality of people's records, to eliminate perhaps the use of cards improperly and to put a cap on not just our health care system but on our drug program as well. I would certainly like to hear from him and I think other members of the committee would. If you can help us out in that regard we would be much appreciative.

I want to know why it is taking until March -- this is where the jab comes in -- of this year to meet with this gentleman, when apparently Mr John Burman of the Spectator knew about this fellow's offer to give this kind of information to the Ontario government? Why did we not use it sooner than that?

Mr Decter: Let me address that issue, because it's not at all accurate to suggest there's been any delay. My minister and I met with a consortium of the banks a year and a half ago to discuss their proposal in this regard. Their proposal was for a public utility to own the computer system managed by the banks. They were looking for a public utility rate of return in the order of 15% on their investment, which they estimated to be $200 million to $300 million. I didn't feel at that point that we were ready to contemplate an additional cost in the order of $40 million, $50 million or $60 million a year, ballpark.

We didn't say no to those discussions. I had subsequent follow-up meetings with the group. They were pushing very hard a particular smart card technology, to which our answer was that we want to evaluate our pilot before we jump into 10 million smart cards and a whole system. So we have had ongoing discussions.

I had lunch in the fall, at the Premier's request, with Helen Sinclair from the Canadian Bankers Association to explore its interest as an association in this matter, and we take very seriously their offer to help. So far, I think it's fair to say -- and I'd welcome the committee meeting with them -- their proposal is a little rich for our blood. The smart card is an expensive piece of technology. I think the banks would acknowledge that the reason they haven't moved to smart cards for Visa and MasterCard is that you have to have a lot of functionality out of a card to justify the expense.

We may well all be carrying smart cards in 5 years or 10 years. We want to keep the dialogue open. We've had great help from the bankers on electronic data interchange, on actually moving funds payments. We now deposit our physician payments directly into their bank accounts rather than mailing them a cheque, which saves us money.

So we're not at all averse to this, but our first look at it -- really it was a big-ticket item and we wanted to secure our existing investment before moving forward.

Mr Callahan: Understood, but when you say that they -- I wasn't quite sure what you were saying. Were you saying that they wanted to have the handle on the computer bank? Is this what the Treasurer is talking about now, the sale and leaseback of computers?

Mr Decter: I think their proposal could have been seen as a much earlier variant of that. What they were saying was: "We, the banks, have the expertise over here. We understand that for all sorts of confidentiality reasons, you probably don't want health records in the bank, nor do the people in Ontario want health records in the bank." But their proposal was to look at a computer utility that would be like a crown agency, but with a management agreement to them.

Mr Callahan: So I can assume that what the Treasurer is doing right now may be part of this whole move towards that?

Mr Decter: I think the bank's proposal to us really represented a marketing efforts around its expertise. I think I'd leave it to the Treasurer to speak to what he has under way in terms of --

Mr Callahan: Maybe we'll have the pleasure of his company here one day.

I just want to get something very clear. You had addressed the question, if the 10-digit number was one that was made up, in other words if it was a counterfeit card totally, this message would flash, "Not a valid number." But you weren't saying for one minute that if it was a card that had a legitimate 10-digit number on it, the doctor who performed the services, unless he had an electronic scanner, could in fact have performed his services gratis because he wouldn't be paid by anybody.

Mr Decter: That's correct.

Mr Callahan: I just wanted to clarify that issue. But I strongly urge you to look at the question of a single option for a name, not eight. It's nice for people to want to be called something other than their own name, but if that's the case, let them change it legally and not have options like that. I know banks won't allow you to do that either. They'll tell you to sign a cheque exactly the way it's made out, even if it's made out incorrectly. You've got to sign it exactly that way and then you sign your normal signature. The very reason for that is to keep people from opening bank accounts under 20 different names and using that as a tool of fraud.

How much time have I got?

The Vice-Chair: You have one minute left.

Mr Callahan: In the one minute, I would certainly ask for the committee to be kept up to date on an ongoing basis of just where this process is going, because when we prepare our report it's going to be for recommendation to the ministry in terms of that. We would like to do that in conjunction with you, obviously.

We also want to know that this is not going to be something where if we send the auditor back in a year from now, we're going to find there are other glitches open. As I've said often, Canadians are very sensitive to other Canadians. They're prepared to allow these safety nets for people, for all of us, but if the system is abused, I think people will slowly come to the position that they don't want these any more. That's what I'm concerned about: losing those things that make our country worth living in.

The Vice-Chair: We've run out of time, so I'm going to have to move on to Mr Tilson.


Mr Tilson: Mr Runciman and I both have some questions. If you could divide the time between Mr Runciman and myself and stop me after half the time, I'd appreciate it.

Mr Decter, when my colleague the member for Simcoe West raised this issue in the Legislature last October, I believe, the Minister of Health indicated that cards, at least at that time, were issued on the honour system to anyone who applied for them. At that time, she admitted there were between 300,000 and 400,000 unaccounted-for cards. I guess the minister's saying that the cards were being on the honour system gave all of us grave concern, particularly with the possibility of fraud and other incidents. Can you tell me whether that system has changed since the minister made that statement in October of last year and, if so, how has it changed?

Mr Decter: I think I'd already indicated that we are looking to see original documentation when people come in to apply and that we are still relying on photocopies when people submit by mail, so that is some alteration. The honour system is, I guess, a term that's a little hard to define. We have a number of voluntary programs in the country including the income tax system. We do rely on people to inform us of changes, but that's not the only thing we're doing. So in a sense, by integrating with the registrar general and seeking to get accurate information from others to update our records, we are moving to supplement the honour system. I think that would be the best way of describing it.

Mr Tilson: I guess the concern I have is the issue of fraud. Those allegations have been made from all over the place: the suggestions of fraud, people using cards for fraudulent purposes and taking advantage of a very expensive system. The feeling most people have is that there should be zero tolerance towards fraud, and if you have a system where fraud is allowed you should move as quickly as possible.

It's fine for me to sit here and tell you to move as quickly as possible, but the fact is that we're in this mess. I guess I was asking that line of questioning when our time ran out the last round, and I get back to it. How fast can we make the system? How fast can we change the system that isn't working?

Mr Decter: Again I'd have to come back to it. You make a very rapid leap from allegations of fraud to a suggestion that the system isn't working. We're very diligent about investigating any allegations we have. It's obviously impossible to investigate something as vague as a rumour that people feel in Windsor that somebody is coming over and taking advantage of our situation. We do investigate anything we've got that's specific. We have undertaken a number of reviews to look at classes of problems to see if they're there, such as tackling the Windsor and Kingston hospitals.

I think we are making progress. We take it very seriously, as witness the 50 or so initiatives and studies that we've already undertaken. We welcome the advice of the auditor and we welcome the advice of this committee on what more we might do. But I think I have to say there's a big leap in conclusion from allegations to substantive evidence, and where we have evidence of fraud we will take action.

Fraud is an offence under the Health Insurance Act and there are penalties. Historically, there hasn't been much pursuit of that. It has run largely on the honour system. As we move to tighten it, we have to make sure we bring people, both providers and consumers, along with us in this process, so we have some amount of public education to do as well.

Mr Tilson: I guess I'm going to leave this and get into another area.

Mr Wilson raised this and there has been some concern, certainly in our caucus, about the slowness and how long it took the Provincial Auditor to make the ministry move. In fact, as late as February 1, you indicated that you no longer are going to pay providers if there's evidence of service being provided when they know that cards are invalid. I again emphasize the statement that certainly the Progressive Conservative caucus believes, as I believe and many people in this province believe, that there should be a zero tolerance towards fraud. I know you're having difficult times trying to determine -- you've probably got a financial restraint, but I just emphasize that concern when we talk about one third of the provincial budget being health and getting more and more out of control.

How much time have I got?

The Vice-Chair: You have two minutes.

Mr Tilson: The minister at that time -- and it may well be that we have to wait for another round -- talked about a system of verification. She talked about a 20-point program of implementation which involved verification. My concern is that that appears to contradict what you and the minister are saying. On the one hand we're going on the honour system, and yet you do appear to have some sort of system of verification. I don't understand that. I don't understand those two statements of the honour system versus some sort of system of verification.

Mr Decter: Let me try to be clear. We're moving from a system that historically was largely the honour system to supplementary measures. The 26 measures that the minister made reference to in her October comments are now up to 50, if you take the initiatives which we could table a list of. We've provided some of them in the overview, but a number of them are very specific measures. So I don't disagree with you that we should have a zero tolerance attitude towards fraud, but I would also say that it's easier to make an allegation than it is to detail what exactly that allegation is.

I would frankly look to that same October discussion in the House, where Mr Wilson indicated that he was recently contacted by a woman who works in a neurology clinic in Toronto who told him that four Iranian citizens routinely visit Ontario for health care treatment. Without something more to go on, it's impossible for us to know which of the thousands of potential providers that involves. If there is further information, we would like to have it and we will investigate it.

Mr Tilson: What facts does the ministry have of fraud, Mr Decter? What facts can you give this committee of incidents of fraud in the system?

Mr Decter: I would turn to Peter Burgess to indicate what we have. I would say we want to be careful if any of these things are before the courts.

Mr Tilson: I'm not asking for names. I'm just asking for incidents.

Mr Burgess: One instance, as an example --

Mr Tilson: No, I'm asking how many incidents since this system has been implemented have come to your attention where there's been fraud.

Mr Burgess: Let me clarify the question: that have come to my attention by phone calls or as a result of the analyses?

Mr Tilson: Anything.

Mr Burgess: We have, from May of this year, cancelled some 1,600 or 1,700 cards as a result of activities that we have undertaken as a result of individuals having a card for which they were not eligible.

The Vice-Chair: Mr Tilson, I want to remind you you're running into Mr Runciman's time that is now pending.

Mr Tilson: Thank you, Mr Chairman. Mr Runciman has two questions.

Mr Runciman: I just wanted to direct a couple of quick questions to Mr Decter about physician overbilling. I know you in the ministry developed a billing profile and look at doctors' billings. Do you review each and every doctor in the province based on that profile?

Mr Decter: I don't think we have anyone here from that particular section. I believe that we review, based on profile, the 22,000. We have been working on a project where we are going to share with physicians -- it's called the interactive physician monitoring project -- and working with the OMA to find a way of sharing profiles with doctors in a way that would cause them to examine their practice pattern. We do refer those that seem to be extraordinarily out of line to the Medical Review Committee.

Mr Runciman: I understand that.

Mr Decter: That's on the order of 200 a year.


Mr Runciman: I don't think I got a clear answer there. I asked specifically, do you review the billing practices of each doctor in the province against the billing profile that you've developed, or is it just sort of a hit-or-miss process?

Mr Decter: Perhaps I can get some information on that. We will get you an answer, I think, momentarily. The only piece of this I'm unsure of is whether we look at each and every doctor each year, or whether our system just kicks out the ones that are two steps deviated from the main.

Mr Runciman: How often is that profile reviewed?

Mr Decter: Again, I believe it's once a year. We have a group to do that on an ongoing basis.

Mr Runciman: Are you and the ministry happy with the whole question of overbilling by physicians, with the way the process is working? Do you think there are a lot of people slipping through the cracks, or are you relatively satisfied?

Mr Decter: I think I can speak to it. Personally, as you would know, I have not one but two new ministers. This isn't an issue I've had a chance to talk to either of them about in the couple of weeks they've been with us. They have a rather large briefing to get through.

My own view would be the combination of the discounting in the new agreement and what we've seen on the utilization front -- it gives me a sense that we're beginning to come to grips with some of it, but I think we still have a distance to go. Much of it is not overbilling in the sense of a physician doing something in a deliberately wrong fashion. Much of it is physicians who have a certain approach that they take to a particular case, and the reason we've put $4 million a year into the Institute for Clinical Evaluative Sciences at Sunnybrook is to get at those utilization questions.

Mr Runciman: Let me ask you a specific question. Of the eight doctors in 1991-92 who overbilled in excess of $100,000, when you take a look at that, how accidental is it for eight physicians -- and they're the ones you caught, so to speak. How accidental is it for someone to bill in excess of $100,000 annually?

Mr Decter: Virtually all of our physicians bill in excess of $100,000 annually, but if you're asking in excess of what they should bill --

Mr Runciman: Yes.

Mr Decter: I frankly don't think we look at enough physicians. We have a constraint there, and it's an historic one. When the Medical Review Committee was put in place in the act, we had a lot fewer physicians. There is a constraint, given the size of the committee and how it operates, on how many cases they can look at a year.

Having said that, I would defer to Dr MacMillan, who I think can join us tomorrow. This is more his area than mine. The comments I've had from people in the ministry are that we probably don't look as hard as we should, but understand that our process refers physicians to the Medical Review Committee, which is independent of the ministry and is cast in legislation. So we live with the architecture of that legislation.

Mr Runciman: There is a tie-in to this, if I've got time, Mr Chairman, with respect to the changes you have made in respect to placements into medical schools in Ontario and trying to drastically reduce the number of graduates from medical school for a period of time, I gather.

If you take a look at the situation now, you obviously feel you have a surplus -- or do you feel you have a surplus? -- of doctors in the system now by the order of, what, 2,000 to 3,000 doctors, who are all billing the system somehow? What their average billings across the province would be, I don't know. But I'm just wondering: If you take a look at those 2,000 to 3,000 surplus doctors, all billing the system for $500,000 -- I'm tying this into unnecessary billing. I called it overbilling, but it could be deemed unnecessary billing as well.

Mr Decter: It's a very real issue. If you look at our per capita spending as a province on hospitals, we're in the middle of the pack. We spend $1,735 -- I'm sorry; I have the number wrong, but we will table the data. We spend about the average in the country per capita on hospitals. Our neighbouring provinces spend more per capita. On the physician side, we are the national leaders. We spend close to $500 per capita. The average in Canada is under $300, and our neighbouring provinces spend less than $250 each. So that's a combination of a somewhat more generous fee schedule and a significantly higher number of doctors to population.

We'd be happy to table what happens if you apply the Royal College standard to Ontario. It does show a significant surplus of physicians, largely in our urban areas, largely in general practice. That's the reason that last week, along with the other provinces, we reduced medical school enrolments 10% and we narrowed the door on visa trainees, largely to keep them, not from entering Canada for training, but from staying in Canada when they shouldn't.

The Vice-Chair: Sorry, we've run out of time. We have to move on. I have Mr Frankford next on the list and then Mr O'Connor.

Mr Frankford: Have you done these studies about the consequences of underregistration? We've already dealt with the issue around the natives, you know. It would seem that this produces insufficient transfer payments. I'm thinking of other groups like street people. I think there may be consequences of people getting underserviced, and then one is talking about a high-risk group. Should there perhaps be some sort of active registration process instead of a passive registration process?

Mr Decter: We had some very good recommendations. There's an organization in Toronto called Street Health, of which the ministry is a funder. It came forward with some very critical comments about the ministry and registration. We met with them and I think we've taken some strong steps, which I'll ask Peter to outline, to deal with this: How do we make sure we attach people who don't have an address to our health care system? It's not as easy as getting them a card. We fund a lot of organizations to try to deal with them where they are and reattach them to society, but in terms of a health card, I'll let Peter discuss how we're tackling that.

Mr Burgess: In terms of Street Health, we were particularly keen that someone be available in terms of having -- it's the old problem that in order to get a health card, you need a name, you need to know your date of birth and you need to have an address. Well, right there, you've got a problem. So we were able to relax some of our processes and procedures, with the help of Eileen's people. We had an actual targeting campaign on the street, most particularly in downtown Toronto, although downtown Hamilton as well was visited. I personally visited St Joe's in Hamilton. We spent a lot of time with the support groups that are there in place for those of our community who are less fortunate than us. Suffice it to say that we found ways of making sure there was a health number available and that the community centre, the local hospital, had access to that. In fact, we set up in Toronto, through the auspices of the Oshawa office, a phone line specifically where calls could be made and we could find out whether a health number had previously been issued for a particular individual.

Let me reassure everybody here that to the best of our knowledge, no one went without health care for the lack of a health card. I'd just also add that we also had an outreach program in terms of registration in the native communities in the north, where people from our Thunder Bay office physically went out into the community and assisted the population with registering and getting health cards.

Mr Frankford: Here we are dealing with, I would assume, a high-risk, high-need population with significant health problems. It seems to me that perhaps there's a difficulty if you're talking about using the registration process for planning. Perhaps this would be worth studying, because I don't know if anyone can assess how much --


Mr Burgess: I think one of the concerns we have always had is making sure that whatever data we capture we can tie back to that individual. I mean, that surely is the essence of an individual health number, being able to link the activities that have happened in the health field to that individual and then, by factoring up, make some sorts of rules or some sort of judgement about what services are required for certain segments of the population or certain target areas in the province. Unless we can in fact ensure that we have accessibility to the same health number, we then start to lose that linkage of services provided to the individual for whom they were provided.

Mr Frankford: What about another group which may or may not be registered, the users of community health centres where it's certainly not on a fee-for-service basis.

Mr Burgess: No, that's correct.

Mr Frankford: Another unusual group which I believe exists is not registered are people who choose not to do it on principle, and I'm thinking of Mennonites.

Mr Burgess: That's absolutely correct. For religious purposes, there are a number of people who choose not to register for health care. I believe -- it's somewhat of a guess but I believe it's reasonably close -- there are about 12,000 whom we know of in the province.

Mr Frankford: Again, I think perhaps a somewhat increased risk group because of the genetic inbreeding.

Mr Burgess: Possibly.

The Vice-Chair: Mr O'Connor.

Mr O'Connor: I guess the question that I've got -- legislative research always does a very admirable job of getting us information and providing us really good documentation. Of course, in reviewing some of this, it goes back several ministers and we've got the two present government ministers, past ministers' statements and one from the Liberal minister who was originally involved in setting up a lot of this.

My question has to do with the information requested for the health care card on the original application form. It seemed to really be based on an honour system, a system where there wasn't perhaps as much checking into it as could have been. We talked a little bit during our discussion about how we've used the old OHIP number system. In fact, a lot of committee members here looked at their card and saw their old OHIP number right on there. I guess that means we haven't been married or changed our names or anything like that.

But my question would be who developed that system, under what government or what was the process, to give us a little bit of history? Who made those decisions?

The Vice-Chair: We know it wasn't your party.

Mr O'Connor: Anyway, if you could give us a bit of history about some of those decisions that lead us up to the current situation.

Mr Decter: I can tell you when decisions were taken. I can't --

Mr Callahan: On a point of order, Mr Chairman --

The Vice-Chair: Order, please. Although it is getting on late in the day, I will allow some humour, but we do have to complete this round. Mr Decter.

Mr Callahan: That is really asking an unelected person, a person who is a civil servant --

Mr Perruzza: That's an opinion. That's not a point of order.

Mr Callahan: -- to comment on the policies of a government, which is really something that elected representatives have --

Mr Perruzza: I suggested that's not a point of order.

Mr Callahan: How would you know? You wouldn't know a point of order if you fell over it. In any event, I --

The Vice-Chair: On the point of order.


The Vice-Chair: Order, please.

Mr Callahan: That's not a fair question to ask people who are not elected representatives, Mr Chair, and I submit that it is a valid point of order. Certainly when I was Chair I would never allow a question that dealt with policy to be asked of a civil servant.

Mr Perruzza: He's not in the chair.

The Vice-Chair: Order. I have listened to the point of order and I will say this. I believe that if the deputant does not wish to answer that question, he does not have to answer that question with respect to the partisanship involved. So if you feel uncomfortable answering that question, please ignore it.

Mr Decter: I do have the view that it's a very awkward question to put to a public servant. Along with my immediate predecessor, Dr Barkin, I think between us we've worked now for five, maybe six ministers during the period of implementation of this. I also think my previous minister addressed the issue in the House in October in terms of her sense of it. As I started to say, I can tell you when decisions were made but I think the principles of cabinet confidentiality really prevail. We do not have any insight into the judgements that were made at the time in the weighing of options. We do have documentation which the auditor has seen on the very specific technical proposals about how the thing was to be carried out, but I don't really feel qualified to comment on a fundamental policy issue like, should there have been upfront verification, in the context of changing ministers and governments and so on.

The Vice-Chair: That is perfectly understandable.

Mr Callahan: That's the first legitimate point of order that's ever been made.

The Vice-Chair: Order, Mr Callahan. It's perfectly acceptable.

Mr Perruzza: Point of order.

The Vice-Chair: Mr Perruzza, a point of order.

Mr Perruzza: In reference to the point of order that was raised earlier, there's nothing worse than a politician trying to keep information from the public.

The Vice-Chair: That's not a point of order, Mr Perruzza.

Mr Callahan: Do you really belong in this place --

The Vice-Chair: Mr Callahan, Mr O'Connor has the floor. Would you please continue. You have approximately five minutes left.

Mr O'Connor: Thank you, Mr Chair. The intention behind that question wasn't to point a finger or point any blame at anybody. I think the auditor pointed out in 1987 that there was a problem with the situation. There was certainly some sort of plan to try to evolve the system and bring it up to present-day standards. Far be it, Joe -- a little bit of partisanship entering the committee once in a while.

Something that intrigues me then about this system -- because we're then looking at a new system that's going to provide better information than we'd had in the past, hopefully, and allow us to perhaps analyse the information better. In the system before, with the 25,000,000 cards out there, I think it would have been rather hard to try to do any long-term planning or any planning of any sort or try to analyse any of the information that was provided. Does this system then allow us to analyse information, and what kind of information? Obviously, there have been some improvements made. Perhaps you can share some of that with the committee.

Mr Decter: It certainly does dramatically enhance our ability to understand the link between the services that are being provided and the impacts on people's health. I think we were struck the other day by a presentation by Dr Fraser Mustard, who heads the Canadian Centre for Advanced Research. He related the story of how two very talented epidemiologists, Dr Noralou Roos and Dr Leslie Roos, had chosen to go and locate in Winnipeg, Manitoba, several years ago despite offers from Yale and Harvard. They had a unique identifier from day one, and therefore in that system you can now look back 20-plus years and do a lot of studies with that database.

With this investment, we're going to be able to do more of that work over time. That's the work Dr Naylor is undertaking, jointly for us and the Ontario Medical Association, at Sunnybrook. So yes, it does enable us, and this is the real payoff for health as opposed to the payoff for the financial side. They're both important, but the payoff for health is when you can start to track people over a period of time, you can start to understand the course of diseases, you can start to understand what works and what doesn't work in terms of interventions and compare interventions at a level of really valid scientific studies.

I know most of our focus today has been on the financial issues, and they're important, as is accountability, but I don't want to underplay for a moment the health benefits. This will let us know much more precisely which things we should be expanding in the way of health services, which things may be not very effective, and that's a lot of trying to manage the system, which is the challenge we have.


The Vice-Chair: Time has expired, Mr O'Connor. It's been requested that we have a five-minute windup, so I'm going to allow each of the caucuses five final minutes for today and then we'll adjourn until tomorrow. I remind everyone that tomorrow we are starting our session at 3 pm and we'll go until approximately 5. Mr Callahan, you have the floor.

Mr Callahan: One of the interesting things in this committee, unlike many of the committees in this place, is that it's supposed to be non-partisan. The purpose of all the members of this committee is to ensure that the taxpayers' dollars are spent wisely and are secured and that our programs are secured as best we can. It's not to comment on the policy of the government of the past; it's to concentrate on what exists today. We appreciate having you people before us, and I certainly am very happy that the auditor went in and made these observations and that they are being approached, but still there are things to be done.

I once again urge you that the choice of how you appear in your nomenclature on the card should not be an option. That should be exactly the way persons identify themselves to demonstrate that they're legally entitled to a card. That way, I would suggest, you close one gap.

I am very concerned about the overall approach, not just your ministry but I'm guessing many ministries of governments, in terms of securing access to very vital and important information in the computer world. That gives me very serious concern. The computer being able to be broken into by a hacker or just by an employee who decides to retire and has an access code is extremely critical. It's one I think should be monitored with a great deal of care. I understand you're doing that now, but I think there's a lot more that can be done in all ministries to ensure that not just the confidentiality of the public's records is maintained but also the integrity of the system.

There's an awful lot that could be sold to the world out there for big bucks if you have access to computers. I guess that's one of the difficulties of computers if you don't have a sophisticated system set up, to ensure that not everybody has access to a code, that it's a very secured arrangement, and I think you can have real problems.

I think about it and I don't say this to discredit other ministries, but if we were to send the auditor into, say, Comsoc, and found that you could tap in there and have a cheque sent out to you, I mean, think of the matter. It's not only in terms of lost revenue to the government but also in terms of the integrity of the system.

I'm a firm believer that, as I said before, Canadians are prepared to allow safety nets for those people who have difficulty looking after themselves, but they get mad as H when those systems are abused. We were looking at family benefits: $170 million lost in one year through various reasons, sent to a collection agency, which is within the government, which interestingly enough -- and this is not a partisan shot at all, because that collection agency has a rather shaky track record -- collected 10% of $140 million that was sent to it.

I find it really interesting that we're sending those traffic tickets and all these people are lining up at my provincial courts and all over this province because they've already paid their tickets and are screaming like crazy. If those are going to be sent to the collection agency, I would tell the people in Ontario you don't have to worry about it too much because as it presently stands, they won't collect it anyway.

I think the important thing is that we come out of this whole process with a modern, updated informational scheme that will allow people who are legitimately entitled to health cards to be able to use them without concern of anybody that the public is being ripped off. I think it's also important that the doctors who are providing the service to these people are not going to have to do a detective look-see to determine whether or not the card they're accepting, in all fairness, is one that's not going to be honoured. I don't think that's fair to the doctors in this province if they provide services.

So in the final analysis I see all of those things. If that's the result of this committee, then I think we've done our job and hopefully we've been of help to the ministry.

Mr Jim Wilson: Mr Decter, you selectively quoted me from the October 22 Hansard of last year regarding the four Iranian women who were reportedly using -- excuse me, the woman who had reported to me that four Iranians were reportedly using our health care system. I think, to be fair, you should have mentioned that in my question to the minister -- it happens to be my constituent, the women who reported this to me, and what I indicated to the minister was that this woman had phoned Patricia Malcolmson, the minister's assistant deputy minister for corporate management and support, on September 11, 1992. I asked the question in the House a month after the woman had phoned Ms Malcolmson because Ms Malcolmson had never called back my constituent, nor was any investigation ever carried out to that point. So it was fair and proper and, in fact, my duty as an MPP to bring that forward in the Legislature, which is the proper forum for that.

I do want to ask you a question, in that you have never answered my question throughout the day of exactly how much money was charged to the 1.4 million extra health cards that had been put into circulation.

Mr Decter: Let me say that we will try to get at this number, but as you would understand, you're asking a question that requires a time definition. Are you asking the question of how much has been charged in total to the 1.4 million numbers, both when they were eligible and after they ceased to be eligible, or are you asking for us to look at when each of the 1.4 million ceased to be eligible and track from there?

Mr Jim Wilson: Actually, you bring up an interesting point. A comparison before and after February 1 would be quite useful.

Mr Decter: Well, we will look at what would be involved in doing that and I will try and give you an answer tomorrow.

Let me say that I quoted quite selectively not because of any grand intent, but just to underscore the difficulty we have. I was not aware of the history, and I will --

Mr Jim Wilson: It's in the question you quoted from.

Mr Decter: Well, let me just see.

Mr Jim Wilson: It's right here if you'd like it.

Mr Decter: No, I have it.

Mr Jim Wilson: Because the point you made in response was that you take these matters seriously, and if it's reported, you do something about it. The point I was making in the House was that somebody attempts to report this last year and nothing's done about it.

Mr Decter: Well, I will tell you what was done about it. Repeated attempts were made to contact the woman in question. She did not return calls. When she was finally contacted, she refused to give more detailed information. We can share with you a detailed briefing on the issue.

Having said that, let me retract any suggestion to do with the individual case. It was a very bad example on my part to choose. In this case, you did everything to bring it to our attention, including asking a question in the House. But I will say that we encounter allegations that aren't specific enough for us to pursue, and in this case, the individual was unwilling to give us enough information to pursue it when we finally did contact her.

So I apologize for any suggestion and any selectivity. We really are very serious about this. That doesn't mean that we're always able to get to the bottom of the cases that surface.

Mr Jim Wilson: Thank you.

The Vice-Chair: Mr Tilson, one quick question.

Mr Tilson: I'm going to ask the question and hopefully you'll be able to answer it tomorrow, because I don't think you'll have the time to do it. It's a question -- comment -- with respect to page 108 of the auditor's report where the auditor made a statement, and I'd like you to comment on this tomorrow:

"We found that the ministry had not adequately analysed the costs and benefits of some project options. For example, the ministry decided to assign a new health number to every registrant with an existing OHIP number. However, a powerful incentive for the registration project was the elimination of invalid records existing on OHIP. We concluded the ministry had not adequately evaluated the costs and benefits of its decision to rely on the former OHIP data as proof of eligibility for free Ontario health coverage."

I suspect that there is insufficient time to comment today, but if you could keep that in mind tomorrow.

Mr Decter: Certainly. Thank you.


The Vice-Chair: Mr Duignan is next on our list.

Mr Duignan: Very briefly, because I want to yield to the parliamentary assistant to the Minister of Health, I appreciate your coming along here today and giving us the information that you have. I'm sure we all have a concern about the misuse or the errors occurring around the health card issue, and hopefully after the interplaying or interacting between the committee and yourselves today, we will maybe come up with some helpful suggestions that will be able to help you as well.

The Vice-Chair: Mr O'Connor is next.

Mr O'Connor: I know that quite often when we get into the process of the committee hearings, there are times when we do get a little bit raucous. But it has been good for the committee to hear some of the initiatives that you have been undertaking to try to get this situation cleared up, to try to make improvements. It's interesting to see some of the dynamics that perhaps we never even thought of initially: that integration with the post offices around changes of address, with the registrar general in the instances of births and deaths, and with Immigration Canada too, of course, for new Canadians coming over. So it certainly has pointed to a lot of improvements to be made.

One quick question. In your slide presentation, on the page that referred to the birth reporting with the registrar general, target 2Q94 implementation, what is that target?

Mr Decter: The target is to have a single registration form so that when someone registers a birth in Ontario, he would fill out one form that would serve our purposes and the registrar general's, and to have that in place by the second quarter of 1994. That's our hope. It does go to trying to make government more understandable and sensible to the people out there, who after all don't live in little compartments called "registrar general" or "health insurance," but wonder why there's so much paperwork. So it's our attempt to get to a unified, single point of entry for births.

Mr O'Connor: As MPPs, I'm sure we'll all hope that does take place, because I know we do get a lot of calls with birth certificate problems.

The Vice-Chair: Mr Perruzza, you can have the final word for your caucus. There isn't too much time left.

Mr Perruzza: Mr Chairman, recognizing the time constraints, I just want to say that sitting in here in committee and listening to this has been very informative. I recognize that there are some administrative problems with our health care system, but we continue to work towards a better health care system. It's important to recognize that one of the underlying cornerstones of our health care system is that every Ontarian who gets sick and requires medical intention gets it. I think we're all going to work together to ensure that continues to happen. Thank you very much, Mr Chairman.

The Vice-Chair: Thank you, members of the committee. To our deputants, I'm sorry; we've run out of time.


Mr Perruzza: Mr Fletcher wants to --

The Vice-Chair: We'll get to it tomorrow, Mr Fletcher. You'll have plenty of time tomorrow.

Mr Fletcher: Thank you very much.

The Vice-Chair: I would like to once again remind members and our deputants that we will be starting our session tomorrow at 3 pm and we will probably end at 5 pm, so just to --

Mr Tilson: A point of order, Mr Chairman, just to Mr Decter as to who he is bringing tomorrow. You're bringing someone to talk about freedom of information?

Mr Decter: Yes, we will cover the freedom of information issue. I will bring someone on that. On the issue of Mr Runciman's question, I think I may be able to get a detailed answer for that. I don't want to bring someone down from Kingston if I can avoid it. It seemed to be quite a specific question, but --

Mr Tilson: Mr Chairman, if I could just ask: The freedom of information is certainly crucial, and I trust that you'll have some legal person who has advised you and your ministry?

Mr Decter: Yes.

The Vice-Chair: One final thing, Mr Decter. This is a request from our researcher on a question that I asked with respect to one of the discussion papers that you were preparing called the card options; you referred to that earlier. Would it be possible to make that available at some point for the committee's use?

Mr Decter: It's still at the level of a draft paper within the ministry. It hasn't come up to either my level or the minister's level, and I feel a little awkward, not sharing the thinking behind it, but sharing a document in advance of it reaching me or the minister.

The Vice-Chair: That's fine.

Mr Decter: We are, I think, certainly willing to talk about the ideas in it, but --

The Vice-Chair: Fair enough. If it's not for public consumption, then obviously that is not something I would demand of you to make available to this committee, so I appreciate that.

We're adjourned until tomorrow.

The committee adjourned at 1656.