EXPENDITURE CONTROL PLAN STATUTE LAW AMENDMENT ACT, 1993 / LOI DE 1993 MODIFIANT DES LOIS EN CE QUI CONCERNE LE PLAN DE CONTRÔLE DES DÉPENSES
Monday 15 November 1993
Expenditure Control Plan Statute Law Amendment Act, 1993, Bill 50, Mrs Grier / Loi de 1993 modifiant des lois en ce qui concerne le Plan de contrôle des dépenses, projet de loi 50, Mme Grier S-489
STANDING COMMITTEE ON SOCIAL DEVELOPMENT
*Chair / Président: Beer, Charles (York North/-Nord L)
Vice-Chair / Vice-Président: Eddy, Ron (Brant-Haldimand L)
Carter, Jenny (Peterborough ND)
*Cunningham, Dianne (London North/-Nord PC)
*Hope, Randy R. (Chatham-Kent ND)
*Martin, Tony (Sault Ste Marie ND)
McGuinty, Dalton (Ottawa South/-Sud L)
*O'Connor, Larry (Durham-York ND)
*O'Neill, Yvonne (Ottawa-Rideau L)
Owens, Stephen (Scarborough Centre ND)
*Rizzo, Tony (Oakwood ND)
Wilson, Jim (Simcoe West/-Ouest PC)
*In attendance / présents
Substitutions present / Membres remplaçants présents:
Ramsay, David (Timiskaming L) for Mr Eddy
Sullivan, Barbara (Halton Centre L) for Mr McGuinty
Sutherland, Kimble (Oxford ND) for Mr Owens
Wessenger, Paul (Simcoe Centre ND) for Ms Carter
Also taking part / Autres participants et participantes:
Ministry of Health:
Wessenger, Paul, parliamentary assistant to the minister
Williams, Frank, deputy director, legal services
LeBlanc, Dr Eugene, executive director, negotiations secretariat, health strategies group
Clerk / Greffier: Arnott, Doug
Staff / Personnel: Schuh, Cornelia, deputy chief, Legislative Counsel Services
The committee met at 1559 in room 151.
EXPENDITURE CONTROL PLAN STATUTE LAW AMENDMENT ACT, 1993 / LOI DE 1993 MODIFIANT DES LOIS EN CE QUI CONCERNE LE PLAN DE CONTRÔLE DES DÉPENSES
Consideration of Bill 50, An Act to implement the Government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act / Projet de loi 50, Loi visant à mettre en oeuvre le Plan de contrôle des dépenses du gouvernement et modifiant la Loi sur l'assurance-santé et la Loi sur l'arbitrage des conflits de travail dans les hôpitaux.
The Chair (Mr Charles Beer): Good afternoon, ladies and gentlemen, and welcome to the clause-by-clause hearings of the standing committee on social development. We are dealing with Bill 50, An Act to implement the Government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act. We've had several days of hearings and we're now at clause-by-clause review of the bill.
We will begin forthwith and I will call section 1. Shall section 1 of the bill carry?
Mr Paul Wessenger (Simcoe Centre): There's an amendment that we have.
I move that section 1 of the bill be amended by adding the following subsection:
"(2.1) Despite subsection (2), this section does not apply to obligations arising under,
"(a) a collective agreement as defined in the Labour Relations Act;
"(b) a sectoral framework designated under subsection 11(1) or 36(1) of the Social Contract Act, 1993, or a local agreement implementing the sectoral framework;
"(c) an agreement made on or after June 14, 1993;
"(d) an agreement made before June 14, 1993, if a sectoral framework, a local agreement implementing the sectoral framework or another agreement made on or after June 14, 1993, by the same parties as the earlier agreement provides that this section does not apply to obligations arising under the earlier agreement."
The purpose of this amendment is to meet the concerns that were expressed with respect to agreements entered into under the social contract legislation and also collective agreements. It was raised by the presenters, and this I believe meets those concerns, because it was certainly the intention that the act only apply to specific agreements with the sectors.
The Chair: Any discussion of this amendment?
Mrs Barbara Sullivan (Halton Centre): I would like some clarification to find out for sure if it's the government's intent that the word "designated" in clause (b) of the amendment means that in fact there may not have been an agreement but the government has said there is one. I refer specifically to the hospitals.
I would also like specifically to know where pharmacists fit in, even with this kind of an amendment. Basically, this section of the bill empowers the government not to pay existing obligations if the government so determines. This new amendment would eliminate from consideration those areas which are under the social contract. Where does that leave pharmacists?
Mr Wessenger: I will ask legal counsel to respond to that.
The Chair: Would you mind just identifying yourself for Hansard.
Mr Frank Williams: Frank Williams. I'm counsel with legal branch, Ministry of Health. The purpose of the section is to provide the government the right, if necessary, to designate obligations where there is no agreement with a particular party with respect to the expenditure control plan measures of the government vis-à-vis that particular party.
The purpose of the amendment is to make it clear that where there have been contracts entered into under the social contract or ECP, we can't override them. That's the purpose of the amendment. It also addresses the two issues, as the parliamentary assistant mentioned, that were raised during committee hearings.
Mrs Sullivan: I haven't had the answer that I'm looking for. I want to know specifically how this amendment affects hospitals and pharmacists. Hospitals did not sign the social contract, nor did pharmacists.
Mr Wessenger: I understand that the hospitals will be under the fail-safe provisions. The exemptions here would certainly not apply to hospitals, because, as I understand, they haven't had a designated sectoral framework. Is that correct? I believe so.
Mrs Sullivan: Are they designated?
Mr Wessenger: Perhaps I could ask what the status of the hospitals is. Are they a designated framework or not? I'm not certain of the answer on that one.
Mrs Sullivan: We seem to have a number of questions not answered.
Mr Wessenger: Dr LeBlanc, if you wish, just take the end of it here.
Dr Eugene LeBlanc: Eugene LeBlanc, executive director, Ministry of Health. As I heard, there were two questions. What about pharmacy? There are two answers to pharmacy.
Number one is that this is dealing with the Health Insurance Act and the pharmacists are covered under different legislation, so in that direct sense, they're not covered by these amendments.
Number two, with respect to hospitals, the sector to which they have been assigned has already been designated. The fact that they have not signed it is not the end of the story yet. They have, for the remainder of this year, the capacity to sign on. The sectoral agreement was inclusive of hospitals even though they didn't sign, and what applies to them is being covered directly by Bill 48, so their economic circumstances are covered directly by legislation.
Mrs Sullivan: I want to again query the pharmacist issue because subsection 1(1) suggests that this section of the act applies and, in fact, this is not the Health Insurance Act in this section of the bill.
This section of the act applies to employers in the health sector within the meaning of the Social Contract Act, 1993, associations representing such employers and other providers of health services. This is not limited to the Health Insurance Act. Furthermore, pharmacists were included in the Social Contract Act as part of the health care sector as were hospitals. Hospitals did not sign; pharmacists did not sign. We know that pharmacists are going to have a hit with Bill 81. Is this another way of getting at them, is what I'm saying.
Dr LeBlanc: Pharmacists are able, if they choose to, to participate in the independent practitioners' sectoral agreement, which was also a designated agreement, and they have indicated that they so wish to negotiate inclusion.
Mr Williams: In addition, the section provides that we cannot override statutory obligation, so if there was a statutory obligation imposed by pharmacists under Bill 81, we could not override it by a designation under this act.
Mrs Sullivan: I suppose the difficulty is that in the area of pharmacy, we have a situation where the government has refused a decision or recommendation and pharmacists have been left in a situation which is clearly called limbo until Bill 81 is dealt with. You can bet there will be a fight on Bill 81.
The question with respect to hospitals is, if they were included because they are designated under your new clause (a) -- or is there to be any other agreement?
Mr Wessenger: If I understand, it would appear that since there is a sectoral framework under which hospitals are covered, then the sectoral framework is one of the exemptions, and if they were to enter into an agreement on or after June 14, that would again be exempted under this clause.
Mrs Sullivan: We're certain about that, are we?
Mr Wessenger: Yes.
The Chair: Any further questions on the government amendment? If not, shall the government amendment carry? Carried.
Shall section 1, as amended, carry? Carried.
We then move on to section 2. I have two amendments to subsection 2(1), a government motion and a Liberal motion. We will begin with the government motion.
Mr Wessenger: I move that subsection 2(1) of the bill be amended by adding the following definition to section 1 of the Health Insurance Act:
"`health card' means a plan identification card issued by the general manager."
The Chair: Any comments?
Mr Wessenger: Yes. This change requires the inclusion of the definition of "health card" in accordance with the agreement between the Ontario Medical Association and the government. It also will assist the ministry with the whole question of health card fraud.
The Chair: Any questions or comments?
Mrs Sullivan: I wonder if I might comment both on the amendment which I propose to put forward as well as on the government amendment.
The Chair: I thought you might, somehow.
Mrs Sullivan: Thank you. I looked at the government amendment and I think it is useful to have a definition of "health card" in the bill and, additionally, latter sections which specifically address the ownership of the health card itself and so on.
In looking at what a health card is, it seems to me that we have been discussing for a long time the role that a health card can play in the management and analysis evaluation of the system. The government amendment would limit a health card to being a document or card which does one thing, and that is to identify the insured person, although even that isn't quite as clear in the government amendment.
We looked at various words before proposing our own amendment and started, frankly, from the position that a health card should be a document that is in a prescribed form which doesn't limit it to being just a plastic card with a strip on the back. It could become a smart card or it could become another card that takes advantage of new technology, but the form would be prescribed by regulation. We had also talked about an opportunity to include information on the card beyond the identification factors; ie, the identification of the insured person who is entitled to receive insured services.
As a consequence, having taken out several words that, after discussion with counsel, were seen to be irrelevant, we are then putting forward a proposal for an amendment which would leave us in the position of a health card being "a document in a prescribed form which is issued by the general manager." Then the prescribed form itself could refer both to the nature of the card, whether it's plastic or cardboard or a file folder or whatever -- in fact, didn't somebody talk to us at one point about there being an opportunity for putting some kind of ink dye in everybody's ear or something? Anyhow, the health card could be a document in whatever form and the information would also be prescribed and would be part of the form of the card.
Frankly, I think that ours is a better amendment and I urge the government to stand its amendment down.
Mr Wessenger: Could I just have some clarification here from legislative counsel with respect to the Liberal amendment as to whether --
The Chair: Just so everybody is clear, while Ms Sullivan cannot move her amendment, it might help the discussion if she just reads it so everyone, including those watching anxiously on television, will know what we're discussing. Ms Sullivan, without moving it, if you could just read the relevant parts.
Mrs Sullivan: Our definition of a health card would be that a "`health card' means a document in a prescribed form which is issued by the general manager."
The Chair: And just so we're clear, the government amendment says "`health card' means a plan identification card issued by the general manager."
Mr Wessenger: I would like to ask legislative counsel about the use of the word "document" as distinct from "card," whether legislative counsel has any recommendations with respect to that description.
The Chair: Legislative counsel? Sorry; if I could just ask you to identify yourself before --
Ms Cornelia Schuh: I`m Cornelia Schuh, deputy chief legislative counsel.
"Document," I suppose, could be something on paper or in any other visible printed form. It could perhaps also be some kind of electronic record. "Card" could also be an electronically readable card. I'm really not sure of what other differences there might be between the two.
Mr Wessenger: Basically, you'd be satisfied with either language, then?
Ms Schuh: It would really depend on what I was told you wanted the definition to accomplish.
Mr Wessenger: Do you think "document" would be a broader concept than "card," then? Is that fair to say?
Ms Schuh: Perhaps. It's a little strange to think of a wallet-size card as being a document, but there's no linguistic reason why it couldn't be described as a document. A document could also be a text that's captured on a disc.
Mr Wessenger: If I might just ask Ms Sullivan, obviously, if we were to accept the amendment, we would need a corresponding amendment to the regulation-making under the section of the act to provide authority to prescribe such a form. I assume that amendment would be accepted.
The other question I would ask legislative counsel is whether the words in the Liberal amendment, "which is issued" -- would it not be perhaps clearer just to say, "health card means a document in a prescribed form issued by the general manager"?
Ms Schuh: I'm a bit confused because the wording of the Liberal motion I have before me is slightly different.
Mrs Sullivan: We have been through about six draftings.
Ms Schuh: This is the motion as actually tabled?
Mrs Sullivan: I can literally take those words out.
Ms Schuh: I'm not sure that I see any substantial difference between Mrs Sullivan's motion and Mr Wessenger's motion.
Mrs Sullivan: Mr Wessenger's motion limits the card itself to identification features. I'm suggesting that the definition of a health card should be broader.
Mr Wessenger: Could I suggest we just take out the words "which is" and I will stand down my motion.
The Chair: So the government is going to stand down its motion. I just want to be clear: By standing it down, do you mean you are withdrawing it or do you want to come back to it?
Mr Wessenger: What I'm going to suggest is it be withdrawn after Ms Sullivan's -- we've asked it be withdrawn after her motion is dealt with.
The Chair: So you would stand yours down in order to deal with Ms Sullivan's and then you --
Mr Wessenger: Withdraw.
The Chair: Yes. Ms Sullivan, the government motion is stood down. If you would now move your motion. Depending on what happens to that, we'll known what will happen to the government motion.
Mrs Sullivan: I move that subsection 2(1) of the bill be amended by adding the following definition to section 1 of the Health Insurance Act:
"`health card' means a document in a prescribed form which is issued by the general manager."
The Chair: Any discussion?
Mrs Dianne Cunningham (London North): Only to say that I think we would be in favour of the more open approach, not quite so narrow a description of what a health card is. I think it gives the government more flexibility in dealing with the paperwork that's required to identify oneself.
Mr Wessenger: I'll be supporting the amendment, but I'd ask that legislative counsel draft a corresponding amendment to the regulation-making section, if that could be done.
Ms Schuh: I can certainly prepare that. I should also point out that this motion has been tabled in English only. We can try to produce a French version of this motion in time for committee tomorrow, if that's acceptable to the committee.
The Chair: Is that acceptable to the committee? Yes, fine.
Mr Randy R. Hope (Chatham-Kent): Just so I'm clear what everybody's doing here, first of all, the prescribed form: We'll leave it to counsel to decide what the prescribed form would be.
Mr Wessenger: Yes.
Mr Hope: So I'm clear on that part.
The other question that I have now, at least to the French version, is, when we vote on this, does that mean that the French version is automatically accepted, or are we going to do English version and French later?
The Chair: No, your first comment, that it would be automatically accepted if we accept this. All we're doing is just the translation. Any further comment? Legislative counsel.
Ms Schuh: There's one more thing that I wanted to point out, which is that this definition of "health card" will require a regulation. Under the original government motion, it would not have been necessary to make a regulation in order to issue a health card. Under this approach, a regulation is necessary and it is necessary to amend the regulation to make changes in the form of the card.
Mr Hope: Which now leads me to some questions. What if we were to change the planned identification to, instead of using the word "card," use "document" in that one? Would that still prescribe the changes now in the regulations? Because I'm understanding you to say that you would have to do some current changes in order to make the current system work.
Ms Schuh: No, I don't think it would be necessary to make changes to make the current system work, but once these changes were proclaimed it would be necessary to make a regulation to support the existing system and it would be necessary to make further regulatory changes if there were to be changes in the health card.
Mrs Yvonne O'Neill (Ottawa-Rideau): In support of the amendment, Mr Chairman, I think in the presentations we had, particularly from the professionals, there were definitely indications that there were further possibilities of the use of cards or some form of documentation that would plug into health care, whether it is keeping regular data on an individual's usage of the system or all of these other things.
I think what we're trying to get at here is a much broader usage, which could tie into the thing we all have been saying we are not in favour of, which is health care fraud. It also gives a prescribed form. Then everyone knows what they're dealing with, and it's in writing by regulation. Therefore, the people who are most involved and the people who will be using this will hopefully have another opportunity to have input into this regarding the best way in which it can be done. I think with that discussion focused, this amendment can't do anything but increase the effectiveness of this bill.
Mr Wessenger: I'd just like a point of clarification about the French translation. That's to be provided for information purposes only, is that correct?
The Chair: No, it --
Mr Wessenger: It doesn't slow -- we could still pass this motion today.
Ms Schuh: If the committee wants to proceed in that way, you can pass this motion now and in effect trust legislative counsel to produce a French version that is appropriate. We can have it tabled tomorrow. But you're not passing an English version only. You don't need to go over the French version separately, if that's the way you wish to proceed.
The Chair: We have before us then the Liberal motion, and again, "`health card' means a document in a prescribed form which is issued by the general manager."
Is there any further discussion on that amendment? If not, shall the Liberal amendment carry? All opposed? Carried.
I would then call upon the parliamentary assistant to withdraw the government amendment.
Mr Wessenger: Yes, I withdraw that motion.
The Chair: Just for the record, if you could indicate what it is you're withdrawing.
Mr Wessenger: I'm withdrawing the amendment to subsection 2(1) of the bill with respect to "health card."
The Chair: It is then withdrawn.
We move on to the government amendment to subsection 2(3.1).
Mr Wessenger: I move that section 2 of the bill be amended by adding the following subsection:
"(3.1) The act is amended by adding the following section:
"11.1(1) A health card remains the property of the minister at all times.
"Taking possession of card
"(2) A prescribed person may take possession of a health card that is surrendered to him or her voluntarily.
"Return to general manager
"(3) On taking possession of a health card under subsection (2), the person shall return it to the general manager as soon as possible.
"Protection from liability
"(4) No proceeding for taking possession of a health card shall be commenced against a person who does so in accordance with subsection (2)."
The purpose of this, of course, is to protect from liability the prescribed person who takes the card that is voluntarily surrendered.
Mrs Sullivan: Our party has expressed reservations with respect to the provisions for taking possession of a card, in committee and in discussions with some of the health care providers, in the context of whether these kinds of policing duties are those of the health care providers, whether it's under their scope of practice if they are under a college or whether it's under their legislation if it's an independent health facility and a person acting on behalf of that facility.
We assume that this motion will go ahead, but I think we want to express our reservations about what the proper role of the professional is and whether indeed this kind of amendment and this kind of action may not add to some of the dangers that person may face.
The Chair: Any further discussion on the government amendment? If not, shall the government amendment carry? All those in favour? Opposed? Carried.
I then have an amendment proposed by the Progressive Conservatives to (3.1), I believe.
Mr Wessenger: Are you sure?
The Chair: I'm not sure, so I'm just going to check.
Mr Wessenger: I think we still have the government's; 19.1 comes before 26.
The Chair: Right. We then move first to the government amendment. Go ahead, please.
Mr Wessenger: I move that section 2 of the bill be amended by adding the following subsection:
"(3.2) The act is amended by adding the following section:
"Refusal of payment
"19.1(1) Despite sections 12 and 13, the general manager shall not authorize or make a payment for insured services rendered in Ontario by a physician if,
"(a) the physician is not an eligible physician; and
"(b) the insured services are rendered on or after the day this section comes into force and before April 1, 1996.
"(2) Subsection (1) applies whether the claim for payment is submitted to the plan by the physician, by the insured person to whom the services were rendered or by any other person.
"(3) A physician is an eligible physician for the purpose of this section if,
"(a) the physician received a degree in medicine from an Ontario university;
"(b) the physician successfully completed at least one year of post-graduate medical training in Ontario,
"(i) in an internship program accredited by the committee on accreditation of preregistration physician training programs, or
"(ii) in a residency program accredited by the College of Family Physicians of Canada or by the Royal College of Physicians and Surgeons of Canada;
"(c) the physician engaged in the practice of medicine in Ontario at any time before August 1, 1993;
"(d) before August 1, 1993, the physician was assigned or applied for a provider number or its equivalent, for use in connection with insured services rendered in Ontario;
"(e) before August 1, 1993, the physician was granted an appointment to the medical staff of a hospital in Ontario or an appointment to the teaching staff of a faculty of medicine in Ontario, and the appointment took effect on or after August 1, 1993 and before January 1, 1994;
"(f) before August 1, 1993, the physician incurred significant financial obligations in connection with the commencement of the practice of medicine in Ontario on or after August 1, 1993, and the physician engaged in the practice of medicine in Ontario before January 1, 1994; or
"(g) the physician is a member of a class of physicians that is prescribed as being eligible for the purpose of this section.
"(4) Despite subsection (3), a physician is not an eligible physician for the purpose of this section if he or she is a member of a class of physicians that is prescribed as not being eligible under this section.
"Physician resource agreement
"(5) In subsection (6), `physician resource agreement' means an agreement that,
"(a) is made between Ontario and one or more of,
"(ii) a province of Canada, and
"(iii) a territory of Canada; and
"(b) meets the criteria for a physician resource agreement set out in paragraph 1.4 of schedule 3B of the `1993 Interim Agreement on Economic Arrangements' entered into by the government of Ontario and the Ontario Medical Association on August 1, 1993.
"Effect of physician resource agreement
"(6) To the extent that a physician resource agreement provides, subsection (1) does not apply to the physicians or classes of physicians specified in the agreement, on and after the date specified in the agreement (which must be later than the date the agreement is entered into) or, if no date is specified, on and after the date the agreement is entered into.
"Minister may exempt
"(7) The minister may exempt a physician or a class of physicians from the application of subsection (1), subject to such terms and conditions as the minister specifies, if in the opinion of the minister the services of the physician or the class of physicians are required,
"(a) to meet a need,
"(i) in an academic area, or
"(ii) in a medical specialty, domain of medical practice or geographic area that the minister considers to be underserviced; or
"(b) to fulfil a prescribed purpose."
Mr Wessenger: The purpose of this is to try to determine the eligibility of physicians, for those who are within the province of Ontario or educated in Ontario and made arrangements to practise in Ontario, and to provide for exceptions by a prescription with the underserviced areas of practice and geographically.
Mrs Sullivan: I think this is an area that we're going to want to talk about for a few minutes in terms of the clause-by-clause issues here. To a certain extent, a positive approach is being taken with respect to physician resources planning. Whether this is the appropriate way in the context of an expenditure control bill is another matter, in that it seems to me one should plan resources not only for the short but for the long term, with funding and financial arrangements being a part of that plan, rather than seeing the plan done in the context solely of restraint.
We have areas in the province, and they are not limited to northern communities, which are underserviced. We have areas of the province where hospitals are now being asked by their doctors to provide additional funding, or the community is being asked to provide additional funding for emergency and on-call coverage in those situations.
It is understandable why those demands are being brought forward. In many communities, the doctor who is providing the emergency services is the only doctor on call and is having to face not only the full-day work with patients, but as well the 24-hour coverage through emergency services and other provisions. This particular amendment addresses only the physician resources issues and only addresses them in a limited way, and I do have some technical questions that I would like some responses to.
Some of the alternative payment mechanisms are hinted at, although not specifically spelled out in this amendment. I think this amendment frankly owes a lot to Dr John Evans and his committee, which did a fair amount of work in this whole area when the government came forward and the Minister of Health came forward with her ludicrous proposal to unilaterally cut newly graduating physicians to 25% of the fee schedule unless they practised where, when and how the minister prescribed.
In terms of this particular section and the questions, the agreement with respect to the supply and distribution measures is subject to -- I'll just refer you to the OMA-Ministry of Health contract agreement, section 3A, "Distribution Measures: 1, Direct Contracts"; paragraph 1.4 of the agreement.
Basically, the background of this is that the government may make contractual agreements with general and family practitioners and so on to provide services in identified communities. Paragraph 1.4 says, "Conditions of the contract will be governed by a master contract agreed to before October 31, 1993." I'd like to know if that agreement has been completed and what's in it.
Mr Wessenger: I will ask legal counsel to indicate what the status of the master agreement is.
Mr Williams: To the best of my knowledge, it's being worked on now in conjunction with the OMA and is near completion, but it hasn't been finalized yet.
Mrs Sullivan: What does that mean, therefore? The agreement was signed between the OMA and the MOH. This bill and the provisions of this bill are in front of us precisely -- although they have a far larger public policy effect and public effect, this bill is largely here to deal with the OMA-MOH agreement. We are now told that on a particularly important area with respect to physician resources planning and the implementation of planning measures, one of the contractual agreements with respect to timing of master contract drafting has not been undertaken.
Mr Wessenger: If I might just generally respond with respect to some of the comments made by Ms Sullivan, first of all, the long-term plan with respect to the question of physician resource matters is to be dealt with under the physician resource agreement, hopefully, that will be entered into between all the provinces and Canada. The overall physician resource areas are to be dealt with under that plan.
With respect to the specific problems of underserviced areas, first of all, you're quite right, the direct contract is the longer-term measure for dealing with underserviced areas, though I might point out that this amendment provides that there can also be an exemption for a physician on fee-for-service billing, also in an underserviced area as well. Either approach, either the direct contract approach or an exemption on the fee-for-service billing -- although I understand the general consensus is that the direct contract is a more likely approach because the financial arrangements would be more satisfactory to a physician in an underserviced area to be under direct contract than it would be to be on a fee-for-service basis.
Mrs Sullivan: When Bill 50 came forward, while the public impression of that bill was quite different than perhaps insiders in the Ministry of Health understood it to be -- and people were deeply, deeply worried about Bill 50 in its original form -- there's no question in my mind now and in the minds of many other people that Bill 50 was put on the table so that the government would have a hard stance as its first position to take to the bargaining table with the Ontario Medical Association.
When, perhaps as a result of the threats of Bill 50 and perhaps for other reasons, some steps were taken and some conclusions drawn between the Ministry of Health and the Ontario Medical Association, we now have an agreement on which these amendments are based. In other words, the OMA is participating with the Ministry of Health in writing legislation for the province. It behooves us, therefore, to look at, and very carefully, what is included in the OMA-Ministry of Health agreement. There are substantial sections of that agreement with respect to distribution measures that provide various options. They lay out timetables and they lay out responsibilities on both of the parties with respect to those options. One of the options is direct contracts.
The agreement says that those contracts will be governed by a master contract agreed to two weeks ago. We have not seen those, but they will specify, by example, compensation and benefits, vacation and other paid and unpaid leaves, access to programs and services provided by the community etc. It will also provide for accountability and reporting. Designated communities and how they are to be determined are included in that agreement; health care institutions involved in the recruiting are included in that agreement; locum tenens' programs are included in that agreement; locum registries are included in the agreement; regional health clinics are included in that agreement.
What I'm saying to you is that if the agreement, as we were told by the Ontario Medical Association, is writ in stone, then what has precedence, the agreement, which specifies dates which have not been adhered to, or the legislation, which doesn't have dates and under which, we're told by the parliamentary assistant, anything is subject to a meeting of federal and provincial ministers of Health? We need to plan our own resources both within Ontario, and perhaps using some of the principles, but we must have remote and underserviced communities covered in a way in which they are now, and that planning has to be put into place.
Are you saying we have to wait for a meeting of the federal and provincial Health ministers? We know how effective those meetings are.
The Chair: Parliamentary assistant, Mr Hope had a related question. I don't know whether, Mr Hope, you want to put that now.
Mr Hope: The thing is, I'm hearing about underserviced area communities, and mine happens to be one that is felt by the major part of our communities. And I'm looking at this amendment that's been forwarded and listening to some of the comments saying about an agreement had to be in place before the end of the month. It also stipulates in the agreement that the doctors would work to make sure that we could utilize and move doctors into underserviced area communities.
So when we are speaking about the context of the agreement that was signed between the OMA and the Ministry of Health, I think it's important to underline the other areas that were committed to in the agreement that say if an agreement takes a little longer than that which is required, then there are provisions for the minister to try to get doctors, and even the doctors agreed to try to get doctors, to these communities that were faced with underserviced areas.
When I look at this amendment, I find the amendment to be worthwhile and to allow us in rural communities who have a problem with doctors a way of getting to a solution for our communities. While the minds of the to-be's of the Ministry of Health and the OMA figure out what they're going to do, it allows the minister the opportunity to extend help to us in those communities in underserviced areas.
Looking at the amendment, I fully support the amendment, but I also understand that we have to do it in a global context which is looking at Canada.
Mr Wessenger: I'd just like to reiterate what Mr Hope has indicated. The whole purpose of this is to get physicians in the most needy areas of the province, those underserviced areas, and I certainly think this amendment very much assists in that regard.
We have to look at the past. Attempts to provide physicians in underserviced areas have not been successful, and in this instance we now have the OMA working in cooperation to meet these needs, as distinct from the isolated government moves on its own. So I think this is the first time we have a sort of coordinated approach and the first time we have a good chance of being successful.
The Chair: Are there any other comments? Mrs Sullivan, and then I think we'll have to move on.
Mrs Sullivan: In subsection (7) of the amendment, the specific exemptions which are provided to physicians who are not Ontario-trained physicians are with respect to meeting certain needs. Those certain needs have become very clear to us in recent days. I'm thinking, by example, of radiation oncologists, who have been identified as being in extremely short supply not only in the short term but in the long term.
We had been assured in the Legislature by the Minister of Health that she had undertaken steps and had contacted the immigration department with respect to letting them know that Ontario would welcome radiation oncologists from other jurisdictions to meet our needs in what would be a medical speciality and domain of medical practice as it's included in this particular bill.
I suppose what I am asking is, if there is no contractual agreement with respect to the design of the contract, how is this recruiting going on that the Minister of Health has suggested to us is occurring lickety-split? There is no contractual agreement with respect to a master contractual model between the OMA and the government. It's late now. Three weeks ago in the House, the minister assured us that that recruitment was going on. On what basis? There is an urgency here that is pressing.
Mr Wessenger: I think it's fair to say the present underserviced area program will continue.
Mrs Sullivan: I'm not talking about an underserviced area program. The underserviced area program needs to be completely revamped. I'm speaking about specific needs for specialists in an academic area, medical speciality or domain of medical practice, which is where the radiation oncologists fit in and where foreign medical graduates would be exempted under the terms of this bill.
I agree that they're going to have to be exempted. But what I'm saying is, the government hasn't pulled up its socks and put the mechanisms in place so that the appropriate recruitment can be done. You haven't even reached an agreement with the OMA on the nature of the contract by which the oncologists would be brought into the country and into Ontario.
Mr Wessenger: I'm going to probably have to ask ministry staff to indicate the situation in this regard, but I would assume that there's nothing under the existing situation that prevents the recruitment of radiation oncologists into Ontario. That's continuing. The failure to have the master agreement does not prevent the recruitment of radiation oncologists.
Mr Williams: If I can add to that, I would support what the parliamentary assistant has said, plus I would go on to say that all the exceptions that are set out here dealing with the various supply issues, certainly there have been doctors -- in fact 40 or 50 of them -- who have applied to us to come into the province under the various exemptions, and we are working with them now to ensure that they can in fact fulfil the need where the need requires. So even though we're discussing the bill at this time, there are provisions being made for those particular doctors.
Mrs Sullivan: According to the OMA agreement, that is not quite correct. The OMA agreement provides that contractual agreements will be available, and it talks about GPs and so on, and "other specialist physicians to provide services in identified communities," laterally in specified domains.
The bases of those contracts are the bases of the recruiting. The conditions of the contracts will be governed by a master contract, which was supposed to have been agreed to before October 31, 1993. That contract has not been agreed to. How is the recruiting going on? On what basis are, by example, the radiation oncologists -- and there are other shortages, surgery being one -- going ahead?
You have an agreement here that says there will be contractual arrangements made, contractual agreements, for any exemptions that are given under the bill.
Mr Wessenger: I'm going to ask Dr LeBlanc to respond specifically to that.
Dr LeBlanc: Radiation oncologists are salaried positions within the cancer foundation clinics, and therefore they already have a salary structure within which to be recruited. Radiation oncology is a monopoly of the cancer foundation in Ontario. The master contract that is being dealt with is for community-based physicians at the moment and is only being negotiated for general practitioners and psychiatry. There is no negotiation of a master contract for radiation oncologists. Those would be handled by exemption into the cancer clinics.
Mrs Cunningham: I, as you know, Mr Chairman, haven't been attending these meetings on a regular basis but trying to follow them through Hansard, so I'm particularly interested in some of the comments that are being made. I'd just like to take a step backward as to why this amendment is being, I think, received with some degree of relief throughout the province, and I think it's probably in some ways something that should never have been necessary. I just want to put on the record for those members of our medical communities a couple of their concerns that I think I should remind the government about.
In the last week I've been visiting some medical centres in southwestern Ontario and the group of people who speak to me more frequently than anyone else is medical students who are working in the hospitals, residents, and many who are -- even this morning, as I came from London to Toronto -- going north for some of their placements for their training. It's, I think, a very depressed and angry group of young people.
I'd just like to remind the government that I hope never again will it ever negotiate in public some unrealistic proposals such as reducing or discounting fees by 75% for new general practitioners, paediatricians and psychiatrists for a period of five years. By doing that, we have sent the wrong message to many of our young people, and possibly it's going to take a long time to recover, not only for the young people but for the physicians who are supervising them, not only in those fields but others.
At a time when the public are looking for physicians who for the most part have been trained in Ontario and Canada, for a lot of reasons -- first of all, we think our education is superior and, secondly, we know it's extremely expensive -- I hope we never send that kind of message to the medical community again.
I'm looking at this as an amendment that we will support, and a drastic improvement over what we were looking at in the spring of the year.
With regard to the utilization of our physicians, I certainly agree with my colleague Mrs Sullivan in her exemplary way of putting forward the concerns of the medical community and of the public in looking at a plan for utilization of physicians across this province.
I didn't hear the parliamentary assistant respond in any explicit way as to when that plan would be in place, and I'd like him to do that. If he did, I'd like him to say it again.
Mr Wessenger: I'll have to ask Dr LeBlanc to respond to --
Mrs Cunningham: I'd like it in writing, Randy, because you and I have both answered questions. It's nice to have a Hansard.
Mrs Cunningham: Perhaps Mr Hope could respond on behalf of the government, then.
The Chair: Order, please. The parliamentary assistant asked if Dr LeBlanc could --
Mrs Cunningham: Whoever. If Mr Hope has more information than the parliamentary assistant, I'd be happy to quote him if that's what has to happen. It doesn't matter as long as I'm quoting the government.
Mr Hope: It's not a problem.
The Chair: Mr Hope, you were next on the list if you were going to speak to that issue. You had a different issue?
Mr Hope: I'm not finished.
The Chair: I realize that, but I didn't know whether you wanted to answer that. The parliamentary assistant had asked Dr LeBlanc to comment.
Mrs Cunningham: It's a question I get asked and I just want an answer.
Mr Wessenger: You wanted some explanation of what the progress is?
Mrs Cunningham: Just the status. That's right.
Mr Wessenger: The status of the physician resource agreement, how it's being negotiated?
Mrs Cunningham: Yes.
Mr Wessenger: I think Dr LeBlanc would probably be in the best position to tell you how far it's progressed.
The Chair: Dr LeBlanc -- or Mr Hope?
Mr Hope: Sorry, I'm not in the ministry.
The Chair: The parliamentary assistant has asked if Dr LeBlanc could --
Mr Wessenger: Yes. Ms Cunningham would like to know the progress with respect to the resource physician agreement with the other provinces.
Dr LeBlanc: I heard the issue in writing. The current federal-provincial plan is to consummate that as early as this March. The work plan would have it in March, and then the ministers normally meet in June every year. Then they would presumably give their final okay.
Mrs Cunningham: Could I just ask a subsequent one? Perhaps I could refer to a document at the same time: the Operation Equity document, the Report of the Committee on the Impact on Medical and Health Facilities and Services, the Regional Municipality of Sudbury, August 1993. There are a number of recommendations. I think this was presented to this committee at some time.
Mr Wessenger: Before I ask Dr LeBlanc just perhaps for clarification, I assume your question relates to how we are assessing the areas that should qualify for underserviced designation?
Mrs Cunningham: My understanding is you have a list of underserviced areas. It was certainly quoted to me this week in two different physical locations in southwest Ontario that there was a list of underserviced areas that you're dealing with. I just think it's underserviced in general, but I'm not sure.
Mr Wessenger: I believe there's some process that the district health councils may become involved in, assessing --
Mrs Cunningham: As a matter of fact, I was at a district health council when this list was being reported on.
Mr Wessenger: Dr LeBlanc?
Dr LeBlanc: I'm at a disadvantage in commenting because much of this material is before the minister, and it's her prerogative to answer and decide on how this stuff is --
Mr Wessenger: I should indicate that the list of underserviced areas and criteria and designations is presently available from the ministry, those areas that are presently designated as underserviced areas. Certainly that information is available. But I don't know whether that was your question.
Mrs Cunningham: Perhaps you could make that available to the committee tomorrow. That would be helpful to me.
Mr Hope: The thing is that we're dealing with an old system, which is underserviced areas. A lot of rural communities had a hard time. I believe it was even described in the London Free Press about what was underserviced.
The new system we all wait for is the agreement on what a new underserviced area community will look like, which we wait for between the health officials and the OMA, when we start talking about what the doctor needs are in our communities. But when we're starting to talk about this amendment, I'm wondering how all these long statements are getting into the direct question in clause-by-clause. I'm still having a hard time understanding that. But what this does is allow us to take, under this legislation, appropriate action until such agreements are in place that will allow us a province-wide system which can be agreed to by whomever.
In situations right now, like in my own communities, under the current underserviced area program, we're not designated underserviced because of the current criteria. We know the need is there, and we need doctors in our community. We wait for that new definition of "underserviced" to come forward.
The list that Ms Cunningham refers to is available today. If they were actually able to apply under the old system and be designated, they were lucky, because it was mostly focused in northern communities, not in southwestern Ontario and rural communities.
Mrs Cunningham: Could I be a little more specific? The question has two parts. First of all, there are a number of recommendations in here that speak specifically to Sudbury and the region but do impact on my next question, and that is, how is the government dealing specifically in Ontario with the list of underserviced areas? What are our immediate plans for that? We're certainly not going to wait for some federal-provincial agreement before we deal with underserviced areas where the needs are very specific now. I say that in context of this one report, and there are others.
My staff has just advised me that there was an agreement in August -- and correct us if we're not correct -- that there would be a list made at the end of September where they were taking in some of the concerns that Mr Hope has stated.
This August agreement is public information. We were listening to this at one of the health council meetings on Friday of last week. Could you please tell me, and I said I would ask for it, what has happened with that list that was to be prepared by the end of September? There's got to be somebody here from the joint management committee who understands what I'm asking for.
Mr Wessenger: I fail to see how this is particularly relevant to this amendment. I can understand the concerns that are being raised, but the provisions of the section provide that there are exemptions to meet a need in a special domain of medical practice or a geographic area that the minister considers to be underserviced. This act permits the designation by the minister of areas that are underserviced so that the needs can be met.
The Chair: Just before Ms Cunningham and then Mr Hope, I am allowing a fairly broad discussion of this amendment.
Mr Hope: Really broad.
The Chair: Well, Mr Hope, there are I think some reasons around some of the amendments where perhaps by having a broader discussion it may avoid some other problems, and that's why I'm allowing that. However, I do think we are getting close to where we've probably plumbed the issue, at least in terms of identifying, from whosever perspective, what the pluses and minuses are. I just want to say that. Miss Cunningham, if you would like another comment, and then Mr Hope.
Mrs Cunningham: I think we're all finding ourselves in a bit of a -- we have to explain the legislation and talk about how it works, and it's not my intent to raise issues here that don't relate. If they don't relate, part of my problem may be, and I think others' as well, that this is a new amendment -- it's my understanding it is -- so I didn't have a chance to get totally briefed on it. But I do get questions with regard to how it's implemented, and my colleagues probably do as well. So I think I've asked a specific question, I would like an answer, and I would be happy to have it tomorrow if that's appropriate.
There was an agreement in August as to coming up with a new list of underserviced areas. It was supposed to be ready by the end of September, and I'd like to know the status of the agreement and the list. If it isn't a new list and it hasn't been prepared, just tell me. But I'm getting the question -- I'm out again tomorrow -- and I would like to be able to answer it. If in fact it can be brought to my attention before 6 o'clock, it would be even better because I am in three communities tomorrow and I'd like to be able to answer the questions. That's all.
Mr Wessenger: I hope I'll be corrected if I give an answer that's not correct, but I understand that there will not be a new list available for a certain time. I don't know what the time frame will be, but I understand the policies are being developed and I think that's going to be a fairly long process.
Mr Hope: First of all, the list I think is a public document. I don't know what the secrecy is. There is currently a list of those communities that are designated under the current underserviced area program.
Mrs Cunningham: I've seen that list. I'm looking for a new one.
Mr Hope: And the new list, which we all anticipate and wait for, is the one that will come up between the OMA and the Ministry of Health and will identify underserviced areas in a broader context so that people from rural communities -- instead of being northern-focused, it can be rural-focused also and allow us to participate in having a voice or an opportunity to have doctors. But I guess we all wait for that new agreement between the two organizations, the OMA and the Ministry of Health, to come up. The one you're looking for right now is a public document that's already available which identifies --
Mrs Cunningham: No, it's not.
Mr Hope: It is available because I've been able to access one.
Mrs Cunningham: That's available; we agree. That's not the one I'm looking for.
Mr Hope: The one we're all waiting for is the new list, but first of all, the biggest problem we have is that we don't have a new definition; the Ministry of Health and OMA have not come up with a new definition yet.
Mrs Sullivan: I'm interested in Mr Hope's comments with respect to what the new definition of "underserviced area" will be. It seems to me that those areas are in fact included fairly precisely in subsection (7) of the government amendment. They would indicate that an underserviced area will be expanded beyond a geographic area to include a medical specialty, a particular domain of practice, a specific academic area or any other thing that the minister may determine to be underserviced.
One of the things I'm interested in is that the minister has power under this legislation to exempt a physician and the agreement says that any national agreement can't leave an Ontario medical graduate at the whim of the minister in terms of differential fees and so on, which previously had been included in Bill 50. What is the intention with respect to the process that the minister takes in order to exempt a physician in those particular specialties or domains?
Mr Wessenger: From reviewing the legislation, it's clear that once the minister determines an area where an academic speciality is underserviced --
Mrs Sullivan: Yes. I guess my question is, how does the minister determine that?
Mr Wessenger: I think the answer to that is that the full criteria have not yet been developed for making those determinations, although in some areas it would be very easy to make a determination, for instance, in the area of medicine for HIV and AIDS treatment. That probably is an area where there has been a determination of underservice.
Again, there are certain areas that are obviously geographical. The question of oncologists is obviously an area that's considered to be underserviced. I don't think I can go any further than to say there are obviously areas that are presently considered in that domain. There are further areas that have to be looked at, and obviously any Minister of Health is going to have to be continually revising the process, once the criteria are established, to determine who qualifies and who doesn't. It has to be an ongoing, continual process. It's not something that's a one-or-all situation.
The Chair: I think we have explored this. There are obviously some issues there, but I think they have been put out and we should now put the question. So I would ask, shall the government amendment carry? All in favour? Opposed? Carried.
The next motion is, I believe, the Conservative motion, Mrs Cunningham, which has been distributed, the changes to sections 26.1 and 26.2. Would you be good enough to move that motion.
Mrs Cunningham: Just to correct, I think one of the notions, before I get into this --
The Chair: I'm sorry, this is a point of notion?
Mrs Cunningham: You called the vote and I just wanted to correct something that I think is worth correcting with regard to that process around the list. It's the government's responsibility. The OMA has advised me that it is not putting it in concert.
Mr Hope: It's in the agreement.
Mrs Cunningham: I'm not going to argue the point. I've just been told.
The Chair: Perhaps we could move on.
Mr Hope: It's in the agreement to establish an underserviced area. It's right in the agremeent.
Mrs Cunningham: I'm just telling you that I think it's handy for the government members to blame the OMA. I'm just telling you, Mr Chairman, that it is in fact a reality that it's up to the government to come up with a list, and that's what I'll be saying.
With regard to this motion, I'm looking for some direction here. I'd like to read it into the record so that people can consider it, but I have to say that because of the limited time available, it isn't complete. We haven't analysed the whole motion, by adding sections 26.1 and 26.2, in any detail. It's because we've been trying to work with legislative services today.
The Chair: That's fine. Would you like to move it and stand it down then?
Mrs Cunningham: I would like to do that so that it's on the record and the parliamentary assistant can consider it, because there isn't enough time, given the process.
I will move subsection 2(3.1) of the bill, which is sections 26.1 and 26.2 of the Health Insurance Act.
I move that section 2 of the bill be amended by adding the following subsection:
"(3.1) The act is amended by adding the following sections:
"26.1(1) Despite this act, for the purpose of giving effect to an agreement between Her Majesty in the right of Ontario or the minister and the Ontario Medical Association, the general manager shall,
"(a) decrease the amount of any payment that would otherwise be made by the plan to a physician or any other person for insured services rendered in Ontario by a physician, by an amount determined in accordance with the regulations; and
"(b) make a payment to a physician, or increase the amount of any payment to a physician, in or by an amount determined in accordance with the regulations, whether or not the physician submits his or her accounts directly to the plan under section 15.
"(2) If the payment referred to in clause (1)(a) is wholly or partly for an insured service rendered by a physician who did not submit his or her accounts directly to the plan under section 15, for the purpose of the Health Care Accessibility Act the amount payable under the plan for the service shall be deemed to be reduced by an amount determined in accordance with the regulations.
"Application of provisions
"26.2 If an agreement between Her Majesty in right of Ontario or the minister and a prescribed association or other entity respecting payments for insured services rendered in Ontario by the practitioners or health facilities referred to in the agreement so provides, section 26.1, clauses 45(1.1)(k) and (1) and subsection 45(6) apply, with necessary modifications, for the purpose of implementing the agreement."
Mr Chairman, I think that under the OMA-government agreement -- do you want me to read my comments in so people can consider it, or shall I just stand it down? Would you prefer the comments?
The Chair: If you wish to put your comments, the only thing I'd say is that may incur other comments.
Mrs Cunningham: Well, that's fair. The thing is, because we haven't finished it, I was hoping we could deal with it tomorrow, but at least the parliamentary assistant can consider the comments and give us some feedback.
The Chair: Fine.
Mrs Cunningham: As well as the Liberals, because I'm working with my colleague here too.
The Chair: I've never known Ms Sullivan to refuse an offer like that.
Mrs Cunningham: And with Mr Hope.
The Chair: Nor Mr Hope.
Mrs Cunningham: It's my understanding that everybody's working towards an agreement on the wording on this, so I'll read this in.
Mr Hope: That's questionable.
Mrs Cunningham: Well, it may be, but that was what I was given, so that's why I'm doing it.
The Chair: Please go ahead.
Mrs Cunningham: Recuperation of funds -- this is referred to as a clawback amendment. Under the OMA-government agreement, the joint management committee is charged with the responsibility of ensuring that payments to physicians do not exceed the negotiated limits.
I'm reading this into the record because it's something that we've all agreed to in our group, especially Mr Wilson, who I'm speaking on behalf of to a great extent today -- those of us who are interested in health care in the PC caucus. It isn't all of us today, but it's a lot of us.
There will clearly have to be some form of a clawback or reduction in amounts payable to physicians this year, and of course we heard the debate in the House today. The joint management committee has already agreed to an interim 4.8% reduction on amounts payable. Everybody knows this. It's not new.
The OMA is presently considering various options as to the fairest and most equitable way to ensure that payments to physicians do not exceed the negotiated limit, ranging from an across-the-board reduction to individualized limits based on previous year's billings, and all of us read the media on the weekend.
This was considered at the OMA council meeting on Saturday, and so we've had some access to what's happened. It's our understanding that the council is leaning towards an option other than the 4.8% across-the-board holdback on the gross. So some concern has been raised about whether the existing provisions of the Health Insurance Act are flexible enough to allow the OMA and government to implement the various clawback options which are being considered, other than an across-the-board clawback, and they're looking at those kinds of alternatives. It's even been suggested that there may be some limitations on the ability to implement an across-the-board clawback.
We've worked with the OMA on this amendment, and I understand that others have as well. I think it's a matter of simply ensuring that there is legislative authority for OHIP to implement the clawback mechanism agreed to by the OMA and the government. A clawback decision must be made and implemented as soon as possible, particularly since the 1993-94 fiscal year is over half over.
It's our understanding that the only way to ensure this can be done is to include the amendment in Bill 50. Quite frankly, it's a practical thing and that's why we're putting it forward. I've already explained why we haven't completed our amendment with regard to sections 26.1 and 26.2.
I think I'll just leave it at that, and appreciate any comments the government may put forward.
The Chair: So we will stand this down and return to it tomorrow.
Mrs Cunningham: Yes, with the intention that we all work together to solve a problem here.
The Chair: Okay, fine. Then the Conservative amendment is stood down and we will come back to it tomorrow.
The next amendment before us, then, is a government amendment.
Mr Wessenger: I move that section 2 of the bill be amended by adding the following subsection:
"(3.3) The act is amended by adding the following sections:
"36.1(1) For the purposes of this section and sections 36.2 to 36.4, a third-party service is a service that,
"(a) is provided by a service provider in connection or partly in connection with,
"(i) a request or requirement, made by a person or entity, that information or documentation relating to an insured person be provided, or
"(ii) a request or requirement, made by a person or entity, that an insured person obtain a service from a service provider;
"(b) is not an insured service or is deemed, by a regulation made under clause 45(1)(i), not to be an insured service; and
"(c) is prescribed as a third-party service or is prescribed as a third-party service in circumstances specified in the regulation.
"(2) For the purposes of this section and sections 36.2 to 36.4, a third party is a person or entity who makes a request or requirement referred to in clause (1)(a).
"(3) For the purposes of this section and sections 36.2 to 36.4, a service provider is a physician, practitioner, hospital or health facility, or an independent health facility as defined in the Independent Health Facilities Act.
"Regulations re third parties
"(4) Despite subsection (2), a regulation may be made in relation to a specified third-party service or in relation to a third-party service provided in special circumstances,
"(a) prescribing another person or entity as a third party instead of or in addition to the person or entity who makes the request or requirement referred to in clause (1)(a);
"(b) if more than one person or entity make the request or requirement referred to in clause (1)(a), prescribing one or more of them as third parties and providing that the others are not third parties; or
"(c) providing that there is no third party.
"Deemed requirement or request
"(5) For the purpose of subsection (1), a person or entity shall be deemed to have required or requested that information or a document relating to the insured person be provided, or that the insured person obtain a service from a service provider, if providing the information or document or obtaining the service is related to the person or entity doing or not doing anything in relation to the insured person or related to the insured person receiving or not receiving anything from the third party.
"Third party liable
"36.2(1) If a service provider who provides a third-party service to an insured person renders an account for payment to the third party, the third party is liable for payment of the account, subject to subsection 36.3(3).
"(2) If an insured person pays all or part of an account rendered to him or her by a service provider for a third-party service provided to the insured person, the third party is liable to reimburse the insured person for the amount paid, subject to subsection 36.3(4).
"Insured person's liability to pay
"(3) Nothing in this section affects any liability of an insured person to pay a service provider's account for a third-party service.
"Right to render account at time of service
"(4) Nothing in sections 36.1 to 36.4 affects any right of a service provider to render an account for a third-party service at the time the service is rendered.
"No double recovery
"(5) The total amount that the service provider recovers in respect of a third-party service shall not exceed the amount of the account rendered.
"Application of section
"36.3(1) This section applies to,
"(a) an amount owing by a third party to a service provider under subsection 36.2(1);
"(b) an amount owing by a third party to an insured person under subsection 36.2(2); and
"(c) an amount owing by an insured person to a service provider for a third-party service provided to the insured person by the service provider.
"Proceeding to recover payment
"(2) An amount referred to in subsection (1) may be recovered in a court proceeding or, if a body is designated or established under clause 45(1.1)(f), in a proceeding before the body.
"Court, body may reduce amount payable
"(3) In a proceeding to recover an amount referred to in clause (1)(a) or (c), the court or body, in addition to any other order it may make, may order the third party or the insured person, as the case may be, to pay the service provider an amount that is less than the amount charged by the service provider for the third-party service if the court or body finds that the amount charged by the service provider for the third-party service is excessive.
"(4) In a proceeding to recover an amount referred to in clause (1)(b), the court or body, in addition to any other order it may make, may order the third party to pay the insured person an amount that is less than the amount paid by the insured person to the service provider for the third-party service if the court or body finds that the amount charged by the service provider for the third-party service is excessive.
"Determining whether excessive
"(5) In determining whether an amount charged by a service provider other than a physician for a third-party service is excessive, the court or body shall consider any applicable guidelines respecting third-party services and any applicable schedule of fees, and may consider any other relevant factors.
"(6) In determining whether an amount charged by a physician for a third-party service is excessive, the court or body shall consider the Ontario Medical Association's guidelines respecting third-party services and its schedule of fees, and may consider any other relevant factors.
"(7) The Lieutenant Governor in Council may, in a regulation, provide that the court or body shall consider other matters in addition to or instead of the guidelines and schedules of fees referred to in subsections (5) and (6).
"Adding service provider as party
"(8) No order shall be made under subsection (4) unless the service provider has been added as a party to the proceeding.
"(9) The service provider may be added as a party to the proceeding referred to in subsection (4) on such terms as the court or body considers just.
"Service provider to reimburse insured person
"36.4 If, under subsection 36.3(4), the court or body orders the third party to pay the insured person an amount that is less than the amount paid by the insured person to the service provider for the third-party service, the service provider is liable to repay the difference to the insured person."
This provision really relates to placing an obligation on third parties who request services, the legal liability to pay for those services. These of course were all determined by regulation, what prescribed services are subject to this third-party liability. It's consistent with the provisions of the OMA agreement.
Mrs Sullivan: For many years under OHIP there were many tests and procedures which were in fact covered by OHIP, as part of the tradition of medicare, that in fact had never been questioned or designated as medically necessary.
For the first time, on December 17 -- I continue to remind you, a week before Christmas Eve -- our new regulations were brought in to specifically delineate those specific procedures that would not be covered under OHIP but which had in the past traditionally been paid for by OHIP. In many cases it was reasonable; these don't fit into the usual contextual thinking of medically necessary.
I'm thinking, by example, of requirements by employers for health certificates, although some of those requirements may not be medically necessary for the individual involved but in fact may be an appropriate intervention at the time. One doesn't want, for instance, an active tuberculosis patient dealing with food. There are other examples. None the less, the third-party requests -- and certainly I've had them in the past from my children's camps, my children's schools and so on -- have become a drain on the system.
As I make my comments and my criticisms here with respect to the government's preparation, I want it to be very clear that I think there had to be an accommodation made with respect to what should be included and what shouldn't be included as an OHIP-paid-for procedure or treatment or diagnostic approach. But I don't think the government has done its homework, and that's where my difficulties with this particular section and the way it is written lie.
First of all, we are told that there are a number of areas that are under review with respect to what should be covered and what shouldn't be covered by OHIP. We know, by example, from testimony that was provided to the committee from school boards, from day nurseries, child care centres, that in fact there is something more than the medical necessity of tests to the individual. There is a broader concern that those organizations have with respect to the health safety of others in the group whom they have to take account of.
Similarly, the issues that were brought to our table by those two organizations were dollar issues. Who pays? If the third party is responsible, and that is extremely clear, then that's fine. What that means is the school boards are going to have to pay if and when a requirement is made for tests or diagnoses, diagnostic actions, that the school boards and perhaps the Ministry of Education and Training itself believe are appropriate.
However, the school boards may say, "No, we are not going to pay," and, fundamentally, under this there is an override that says the individual must pay. We are apparently moving the burden to the third party. The third parties, as in the case of school boards, have no assurance that the Ministry of Education would cover the costs associated with any of these procedures, so what we are seeing is simply another passing on of costs to the school board level.
That has not been determined. We had no assurance that those costs would simply not be passed on. We had an assurance from the parliamentary assistant that those costs from the Ministry of Health for areas covered by the Ministry of Health when third-party requests were made would be covered. For other ministries, we do not have that same guarantee that there would be a rollback.
Once again, I just want to point out that while the government may say, under section 36.2, that a service provider who provides a third-party service is liable, that provision is overridden in subsection (3) of the same section, when it says that nothing in fact in this section affects the liability of the insured person, himself or herself, to pay for the provider's account.
I put those concerns on the table. I'm also distressed that there were many groups and organizations that did not know, because this was not part of the original bill -- this entire area was not part of the original bill -- that this was coming forward. They did not know what their liability was or is likely to be, and in fact we have not heard from a single employer's group, a single insurer, a single pension plan or any of the other multitudes of parties who have a very strong interest in this particular section of the bill.
Mr Hope: Just to respond to some stuff, currently under some of the school boards' initiatives, they already require that. First of all, they pass the costs off to the parents, and as one who deals with two children in the current school system, I know about the costs that are associated.
I only use this example because it has been brought up and I want it to be brought up in the proper context, that they're also asking for doctors' notes to apply medicine or whatever, but that's standard policy in the class. There's always been a board. It has been put on the parents. We've always had to pay for notes or whatever for my children, either through puffers or whatever. We've always had to cover it. So I'm having a hard time understanding where the problem is around third-party billing.
There are policies out there. There are things that are initiated by the Ministry of Education that have to happen, but there are things that are initiated by school boards that are not part of the joint requirements between the two. There are some things around some of the current policies versus actual legislation that I think have to be cleared up as we talk through this part. I believe that the amendment does address the current situation, in my opinion, as one who is a parent and has children in the school system today.
Mrs Cunningham: Perhaps I'll be a bit repetitive but I think it might be helpful with regard to some of the concerns. I would like to ask, and perhaps the parliamentary assistant could be prepared for this, with regard to the document that was sent to us today along with the amendments. It's called Review of Legislative Requirements for Third-Party Services. I have some questions with regard to that document, especially with regard to the process and status.
I'll just continue here with regard to third-party services. I'm in agreement with both of my colleagues who've spoken to this in that there seems to be some confusion over who is responsible for paying for the various third-party services. It's already been mentioned. The Ontario Coalition for Better Child Care and the Ontario Public School Boards' Association made some presentations before the committee regarding inequities and problems associated with third-party services which I feel should be addressed.
Specifically, the Ontario Coalition for Better Child Care expressed concern that the government amendments concerning third-party billing would result in a number of issues that they presented to the committee, and I think in fairness I'd like to do that again.
"Ontario's health plan would no longer cover doctors' visits to ensure that staff or children are able to return to the program following an infectious illness."
It was raised by Mr Hope that he was concerned about some of the examples. These are the examples that were given where they themselves don't understand how this amendment will affect them, so I think I'll just raise them. Perhaps the parliamentary assistant could be specific if he has to be.
The second concern they had was that "Medical examinations required by staff or children before working or enrolling in a program will no longer be covered by health insurance." If they're not correct in their assumptions, then take them one by one and answer so that we can again respond. These are the questions we get.
The third point they made was that "Medical examinations required by volunteers who work with children will no longer be covered." It's a fairly big one in many of our family and child care agencies across the province, that right now volunteers are asked to be in good health.
"Subsidy regulations often require parents to provide a doctor's note if their child is absent from day care for a certain period. Failure to produce this documentation can result in a parent losing her subsidy."
Those are the specifics that perhaps the parliamentary assistant could address with regard to child care.
The public school trustee and executive vice-president of OPSBA, Donna Cansfield, listed some examples of third-party services necessary to meet the learning needs of children. I'd just like to list them again. Maybe it would be easier if we got an answer to these in writing or maybe we could be responded to today, but I do expect to have these before this bill is passed. I'm sure my colleagues would feel the same way. They were raised and we need an answer:
-- A medical opinion on the learning abilities and needs of children attending school for the first time, which is a requirement.
-- A physician's advice as necessary on matters such as students' allergies, medication and fitness for strenuous activities, which is now paid for by OHIP.
-- A health and/or psychological assessment when this information is needed to determine the needs of special students, often in association with recommendations for drug administration, which teachers have to deal with.
-- A medical opinion to verify a child's need to be taught at home, because then home care comes in, but without the medical opinion you can't deal with it.
These are examples that, where boards are concerned, either they or low-income parents will get stuck with the tab for paying for just these examples. These are medically necessary services to meet the learning needs of children.
Ministry responses to questions raised as a result of the presentations were inconsistent. I certainly ask that they be documented, because it's not appropriate that we make that statement without giving examples. So I'd like to do that. Maybe what we had were not correct responses or maybe there's another reason for these statements.
The parliamentary assistant claimed that third-party services raised by the Ontario Coalition for Better Child Care "are presently not covered by the health insurance system and it would be, in effect, the parents' responsibility to cover that cost under our existing system." There are many who would argue that the services I've described are not at present paid for. I can say, having run a very large agency in London, that all of these would have been covered. We would not have expected families to pay for these.
He also stated, "There has been no decision made at this stage to transfer that liability from the parent to...child care programs." Now, those are two inconsistent statements. One says that the system doesn't pay for them -- and we say they do -- and the other one says that the system does pay for them and there's been no agreement that this payment should be transferred to the programs. So they're different answers to the same question.
The legal counsel to the Ministry of Health went on to say -- I think his name was Mr Williams, if I'm correct -- with regard to regulation 785/92 of the Health Insurance Act, that "a return to a day care" for medical reasons "after a temporary absence would not be considered a non-insured service." He then claimed that many child care situations would involve liability on the part of the Ministry of Community and Social Services.
Mrs Sullivan: That's right.
Mrs Cunningham: So these are inconsistencies that have to be addressed. I don't see how we can support this third-party part if we don't get answers, because it wouldn't be fair for us, with these inconsistencies, to support it. They're going to have to be responded to later on this afternoon, or immediately or whatever.
The same ambiguous, contradictory responses were provided by the government in response to the Ontario Public School Boards' Association. The committee requests for a written explanation of what current government policy is and what has been approved by cabinet with respect to third-party services have been ignored. The committee made that request and we haven't had a response. I can remember reading the Hansards when the committee did that. In asking my staff today, understanding that I was going to be here in place of my colleague, I was advised that we still don't have an answer to that.
I don't think it's fair for the government to ask us to respond to this amendment today, although in principle we agree with it, without knowing how it's going to work, and with the inconsistent responses on the record. It makes us all look just a little bit silly, for want of a better word. I think we shouldn't be proceeding in this clause-by-clause without the information.
I have to add that grievances have also been filed with the Grievance Settlement Board on this matter. It's my understanding that the government has agreed, as part of the August 1993 agreement with the OMA, another part of that agreement, to complete an examination of all legislative or regulatory requirements for third-party services, in consultation with the OMA, by March 1994 -- which isn't September 1993, luckily, but we can't ask for that, can we? -- and that the OMA has agreed to develop a revised guide to billing for uninsured services, including third-party services, within the next six months.
Those are my remarks for the parliamentary assistant to deal with. At this point in time, I'd just like to ask what the purpose of this statement was. Why did we receive it? What does it really mean?
The Chair: Excuse me. This is the review of legislative requirements for third-party services which the Ministry of Health --
Mrs Cunningham: Yes. I've got a number of questions about it; I'm sure my colleague does as well. I guess the specific question after he answers that is, what's the difference --
The Chair: I wonder, just because there are a number of questions, do you want him to answer the questions first?
Mrs Cunningham: If he can answer the other ones first, by all means, let's deal with them. Oh, yes.
The Chair: Then we could go on to this, or at least see if he can answer these.
Mrs Cunningham: That would be great.
Mr Wessenger: I think the first thing that should be made clear is that the amendment to Bill 50 does not change what is now an insured service or what is not an insured service. That in no way changes what is insured under the health insurance program or what is uninsured.
What the bill basically does is to have a provision that the government can prescribe certain services which are not now covered by OHIP to be the obligation of third parties. So it gives the power to put a legal liability on the party requesting; where it's prescribed, where the government makes a decision it's appropriate that that service be provided when it's asked for by a third party, the third party be liable for it. That's the issue with respect to the bill.
However, there's been a great deal of discussion on the issue of the review of what is covered and what is not covered under the health insurance program. I don't know whether the memo gives the list of all the items which are insured, but these are some of the items that are insured:
"Where the document is part of usual physician or practitioner's recordkeeping requirements;
"Providing advice to other health care professionals about the patient;
"Where the document is required by a law or program as a condition to being admitted to or receiving health services...in a hospital, nursing home, home for the aged...charitable institution...or home for retarded persons;
"Required under any program administered by the Minister of Health;
"Required to receive welfare, social assistance or vocational rehabilitation...benefits or services;
"Required by an independent health facility.
"In connection with a child's health where the child is under the supervision or care of a children's aid society, is in a place of detention under the Young Offender's Act or the child resides in a children's residence (as defined in Child and Family Services Act);
"Where required as evidence of immunization status relating to admission to an educational institution or program;
"Where required to prove disability in order to obtain a benefit for the purposes of a transportation program or law;
"Examinations under the Mental Health Act or for the purposes of investigation of an alleged sexual assault (in accordance with provincial government guidelines)."
This is what is included.
Mrs Cunningham: Can I ask you what you're reading from?
Mr Wessenger: That's information provided to me about what the list is. Is that not in the memo?
Mrs Cunningham: Do I have it somewhere?
Mrs O'Neill: That's not included in the memo.
Mr Wessenger: It's not in the memo?
Mrs Cunningham: No. That would have made sense.
The Chair: Is this something which could be provided to members of the committee?
Mr Wessenger: Yes, we could table that. There's no problem. I can certainly undertake to table that. I didn't have the memo in front of me.
The Chair: Would it be possible, given that it's almost 6 o'clock, to have that run off so people could have it for this evening?
Mr Wessenger: Yes, we'll give you both lists. I thought that was supposed to be provided.
The Chair: Both lists by 6 o'clock? Is that feasible? I don't know how many pages we're talking about, but we've got tomorrow, and it may be that members would want to look at it.
Mr Wessenger: Yes.
The Chair: Just before you go on, Ms Cunningham, did you have a question?
Mrs Cunningham: I'm just going to let the parliamentary assistant know the frustration of this process. As we try to do these things, it's given to us in the House at 3:15 in the afternoon; we've got two days to do this work. Obviously, you're as surprised as I am that we weren't given the information. I'm trying to read between the lines and see what's new, and now I'm probably going to be provided with something that's already regulation.
The question I would have asked is, what's the difference between the amendment and the current regulations? I'm going to find out. I've already been told that now we have legal liability on the third party. Is that the only difference? I don't know, Mr Chairman. You're nodding your head, but maybe that's all we've got. If that's the case, it's very important that we know exactly. I'd like the parliamentary assistant to deal with the examples one by one in writing, yes or no, with regard to legal liability that I put on the record as well, so we don't have to take up the time of the committee.
Mr Wessenger: I might ask that if there's going to be a request to respond in writing, it would be useful to have the request in writing.
Mrs Cunningham: I can give you what I read. I would not have asked for it in writing if I had known that the only difference between the existing regulations and this amendment is not any change in the list at all but is just a legal liability on the third party.
Mr Wessenger: That's right.
Mrs Cunningham: I wouldn't have asked. I'm not being smart here. I'm asking you now because I realize that all of those issues could be a legal liability. That's the only reason. If you haven't got it in the Hansard, I'd be happy to leave you my notes.
Mr Wessenger: Yes. I will try to get them. I just want to --
Mrs Cunningham: Well, why don't I just leave the notes?
Mr Wessenger: I want to make sure that you get your questions answered.
Mrs Cunningham: I will leave the notes.
Mr Wessenger: That's the only reason for the request.
I might add to this another point of clarification with respect to the review that's being undertaken with respect to the question of items that might be under third party in future.
On the question of what should be covered in OHIP and what shouldn't be, first of all, there's a review of whether an item is necessary or not. We're reviewing all government regulations that require the production of medical certificates to determine whether they're necessary and to see whether some of them can be eliminated. That's one of the aspects of the review.
Mrs Cunningham: That's good.
Mr Wessenger: A second aspect will be to determine, where there is something that is required, should there be an alternative payment mechanism to the fee-for-service aspect? In other words, there could be another way of dealing with the payment provision other than through a fee-for-service provision. Then they will look at those that should be the obligation of a third party and those that would remain the obligation of the individuals themselves. All those categories will be looked at in the review.
Mrs Cunningham: Could I ask you a question just for my own interest? When was this list put together and in effect? Because some of these charges are being administered now. Was this list, were these regulations, put together within the last year or two years? Could you tell me when?
Mr Wessenger: About a year ago the regulation was passed.
Mrs Cunningham: So the date will be on whatever document we're getting, I'm assuming.
Mr Wessenger: That was the December 17 date that Mrs Sullivan referred to.
Mrs Sullivan: In the dead of the night a week before Christmas Day, right?
Mr Wessenger: A copy of that regulation is actually --
Mrs Cunningham: 'Twas the night before Christmas stuff, right?
Mr Wessenger: No, no. It was available in the briefing notes, but --
Mrs Sullivan: Nobody could see.
Mr Wessenger: Nobody could see. It was available in the briefing notes.
Mr Williams: If I could, for Mrs Cunningham's information, there's a copy of the regulation, I believe, in the front of the binder. I'm not sure if your binder is the same as mine, but I think --
Mrs Cunningham: Oh, that's fine, if it's there.
Mr Williams: The regulation is there.
Mrs Cunningham: It's just another one of my --
The Chair: Mrs O'Neill has been waiting patiently for a question.
Mrs O'Neill: I want to go back to the actual amendment itself. I have quite a bit of concern about the quantity of time -- actually, the thrust of this amendment, in that court and the process of court is so much part of it all. I would like to ask the parliamentary assistant what the anticipation is regarding 36.2(3). What occasions or what areas do they feel, with this emphasis on courts -- I have another question about that, but where do you foresee the real difficulties? There must be some kind of a premonition or we wouldn't have such an emphasis on court proceedings.
Mr Wessenger: I think probably the most common situation where this would come into effect, an example I might give for third-party situations, is where an employer requests a note from a physician with respect to the employee being away from work. That would be a situation where the third-party provisions would likely be brought into effect. I should say that they're still working on -- we don't have it finally determined what's going to be under those third-party situations, but I think it's fair to say that would be a situation that would undoubtedly be under the third-party situation, where an employer requests the person to justify their absence with a note. That would be an example of the type of thing that would be appropriate for a third-party liability.
On the other hand, for instance, in the situation where somebody's getting a flying licence, then of course that's obviously appropriate for the individual, as it is now. But I don't know whether I can go any --
Mrs O'Neill: I have difficulties, as I say, because --
Mr Wessenger: The aspect is that certainly from the OMA's position its opinion is that it would undoubtedly see this as a better means of collecting from a third party than it is of collecting from an individual.
Mrs O'Neill: Will there be any limits or entry point at which a court proceeding would begin? Some of these things cost $50 and some of them cost --
Mr Wessenger: I'm going to ask counsel to explain, because I think it's envisaged there will be an alternative mechanism to a court process.
Mrs O'Neill: It's not mentioned here.
Mr Williams: Before I get into the specific question the member asked, I think the intention, both on the part of the government and the OMA, is to try to institute as quickly as possible some alternative mechanism other than the court. The idea is to use a tribunal such that we can have an exchange of documents so that we don't get into an adversarial type of situation where people feel there is an onus to appear and be cross-examined. We want to keep it as low-key as possible.
Mrs O'Neill: There's no mention of that in this legislation.
Mr Williams: It talks about a tribunal.
Mrs O'Neill: Okay. Sorry; I must have missed that. If I can go to the page --
Mr Williams: If I can go back and partially try to answer the question you asked, we envision that somebody would go to the court or go to the tribunal in a case where they felt that -- I'll give you an example where, let's say, an employer requests that an employee get a note --
Mrs O'Neill: To come back to work.
Mr Williams: -- and the doctor charges $70 to have that service and the note produced and bills the third party. The third party might well say, "I'm sorry but I only pay $50 for those kinds of notes." That would be the kind of situation where the third party would take the doctor to court and say, "Look, you charge an excessive fee," or it could be that the bill is given to the patient, the patient pays the doctor, goes to the third party and asks for reimbursement. In this situation the patient would then go to the third party and the doctor and say: "Look, you've charged me too much. I want to get reimbursed for the full amount." The section provides that where there's an excess fee and the court finds there's been an excess fee charged, the doctor is liable to pay back the patient for the excess amount charged and the third party pays for the balance. So it's clear that the --
Mrs O'Neill: That's what's frightening to me, that the court system is going to be somehow burdened with things that are around $100.
Mr Williams: My suspicion is that because they are such low amounts, this will be worked out long before you ever get to court. That's my hope.
Mrs O'Neill: Good. My next one is on the framework or whatever you provided to us. I think it is helpful in that it basically indicates there is no definitive answer at this present time. Everything is being decided. I'm quite concerned about this cost benefit of maintaining the requirement that the ministries are going about. Are we going to be having comprehensive audits? Who's going to be making decisions about cost benefit? Are they going to be uniform across ministries?
We're talking about health matters. We're talking about requirements that could have something to do with communicable disease or certainly an ability to perform tasks. How's that being done? It's just thrown in here, "cost benefit." There has to be, I hope, some real professional manner in which this is being accomplished with real professionals making the decisions.
I really think this committee needs to have some answer to that. That is a very important matter that's under discussion. I think the general public, if we're talking about quality of care and quality of provision of services, has to know that's being done properly. Okay, it's great not to have to do something, but if it was a very important decision and requirement, particularly in reference to children and care of children, I think we have to be sure that the decisions are being made on some basis.
Mr Wessenger: Yes, there definitely will be criteria established for determining. It will be determining whether it serves any useful purpose from a medical point of view. The requirement will be reviewed, first of all, as to the current medical necessity under current medical practice and whether it's the necessity of the services to achieve the purpose of the statute or regulation, consideration of alternatives to achieve the same purpose without making it a legal requirement and the cost benefit of maintaining the requirement. Those are the basic criteria.
Mrs O'Neill: I hope there'll be some auditors involved in that as well as the doctors. Could we have what you have just read?
Mr Wessenger: This will be an internal ministry review, not a review, I think, by the medical profession as I understand it.
Mrs O'Neill: You'll likely have some questions about that from some people. I think that's all for now.
The Chair: It is, in the immortal words, almost 6 of the clock. I know there are more questions on this particular amendment and I'm just wondering whether this is perhaps an appropriate time to recess. I suspect not, because I see a hand up. Mrs Sullivan.
Mrs Sullivan: I think it would be helpful, rather than just the little document that summarizes the regs, it would be far more useful for people on the committee if they actually received full, integrated regulations as they now exist. Section 24 of regulation 552 delineates thoroughly and without editorial comment what's covered, what's not covered and what was added in the dead of the night on December 17 last year and came into effect on January 1, 1993. If the ministry doesn't have that list, I do.
The Chair: In that instance then, parliamentary assistant, are you --
Mr Wessenger: I'm not quite clear exactly what is requested.
The Chair: Mrs Sullivan, the parliamentary assistant is not quite clear on what it is you've requested.
Mrs Sullivan: I would like to see the entire printed regulation, section 24 of regulation 552, Revised Regulations of Ontario, 1990. Okay?
Mr Wessenger: I think it's in your binder. That's what I'm advised.
Mrs Sullivan: I think that some members did not receive it, and frankly it makes it a lot easier to follow the entire issue if everyone has it.
The Chair: Which tab was it just so members can check their own books? Do you know which tab it was?
Mr Williams: It's tab 3 in my binder. I'm not sure it's all the same. It's tab 3.
Mrs Sullivan: Tab C. No, that's not the full, integrated regs, tab C. That just includes the regulations, I think.
Mr Williams: Not section 24. It's got the amendment to section 24, which is 785/92.
Mrs Sullivan: Does it include all of the updates?
Mr Williams: Yes. What you see is the form that we have it in the ministry. There's no difference. There is no consolidated regulation after 1990.
Mrs Sullivan: Yes, there is; I've got it right here.
The Chair: Mrs Sullivan, perhaps what we could do when we break, if you could show what you have which is different, we could sort that out prior to tomorrow's sitting.
Mrs Sullivan: Far easier to follow.
The Chair: If we could do that, then the committee will stand adjourned until 3:30 tomorrow.
The committee adjourned at 1804.