LEGISLATIVE ASSEMBLY OF
Monday, May 4, 1992
The
House met at 8 p.m.
COMMITTEE OF SUPPLY
(Concurrent Sections)
HEALTH
The
Acting Deputy Chairperson (Mr. Jack Reimer): Will the Committee of Supply please come to
order.
This evening this section of the Committee of
Supply, meeting in Room 255, will resume consideration of the Estimates of Health. When the committee sat last, it had been
considering item 5.(a) Administration:
(1) Salaries, on page 87 of the Estimates book. Shall the item pass?
Mr.
Gulzar Cheema (The Maples):
Mr. Acting Deputy Chairperson, the other day I made it very clear to the
minister that‑‑[interjection] the deputy minister says, perfectly
clear, so I will try to make it an in‑between clear.
The many issues we have in this section
probably will be mostly addressed when the reform package will come, and it
will give us some idea which way the government is going, because the numbers
are all going to change very dramatically.
If they are not going to change, then we are not talking about health
care reform; we are talking about a patchwork.
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(2005)
I sincerely hope the government will move
forward, because I think they have an opportunity. People are willing to listen and they are
willing to accept, and as long as they can explain to us and to the public, I
think we will go a long way. I will just
go on, on a basic few other questions with which I have concern.
The other day we asked the minister to provide
us a copy of the deinsuring of services from the various other provinces. Can the minister tell us if they have done
work on that area?
Hon.
Donald Orchard (Minister of Health): Mr. Acting Deputy Chairperson, staff
attempted to contact the other provincial jurisdictions. I guess it is fair to say, they are all a
little sensitive about sharing information on what has been changed in terms of
their insured services planned.
Everybody is a little, I guess, gun‑shy on the use of the
deinsurance word. We apparently got a
lot of reports back which say nil, like nothing has been changed, and we know
that probably is an incorrect reflection.
In the meantime, for what it is worth‑‑and
I have just received this from staff right now, and maybe my honourable friend
has it‑‑Health and Welfare
They deal with public administration,
comprehensiveness, universality, portability with each province, and under
insured services they go through a list of what is insured. The difficulty that I can see from this‑‑and
I have a copy that I will give my honourable friend. The difficulty I see with this, just on first
blush, is that it does not get into the specifics like tattoo removal or
reversal of sterilization as we did last year.
We do not have an accurate tally that we can share with my honourable
friend which indicates what is happening in other provinces.
So, Mr. Acting Deputy Chairperson, I will
leave that for the member for The Maples.
Maybe he can offer suggestions or maybe we can discuss this further to
see what suggested next steps we might take.
I can think of a couple of steps which are not through the formal
administrative inquiry that we have made.
I guess we could attempt, through the various equivalents to the Manitoba
Health Organizations, to try and come to grips with it that way to get a sense
of what is happening, because they are generally in tune with changes.
The other thing I suppose we could do in part
or in whole, but we might have to collaborate, we could ask opposition caucuses
to give us a tally of what government is doing.
That would mean we would have to go to Liberal and Conservative and Social
Credit oppositions in the NDP provinces and Conservative oppositions in the
Liberal provinces and Liberal oppositions in the Conservative provinces, yes,
Liberal and New Democratic oppositions.
I do not know whether we would end up with as accurate an analysis of
what is really happening. Failing that, I
am open to suggestions.
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(2010)
I think what my honourable friend is asking is
a valuable piece of information, because it deals with where we have come at the
issue as Ministers of Health in terms of trying to assure some comparability of
services across
Mr.
Cheema: Mr.
Acting Deputy Chairperson, the minister is right, because all the provincial
governments are in a major confusion and in a panic to come up with all the
cost‑cutting measures and probably do not know which direction to
go. So they are watching the person next
door to see what the other provinces are going to do and then may go off to some
of what is their own services.
One thing is sure that we do not have, as I
said from the beginning, a universal system all across this nation. We have 12 or 13 medical systems put into
place, and that is why the Canada Health Act, as it stands today, basically
depends upon the provinces and their ability to pay, and that is what is going
to happen in the long run. Whether it
happens this year or next year, eventually those decisions have to be made.
Certainly, I would like the minister to give
us some idea whether in our province where most people now realize that the health
care issue is not a political issue, and I personally believe it is a
nonpolitical issue. They want to look at
everything. They want to see what
services we are delivering. Can we deliver some of those services in a more
meaningful way? Can we have more efficiency in the delivery of some of the services? Can we probably go back and decide what is a
medical necessity and what is the first level, second level, third level or
fourth level of services?
I certainly want to ask the minister if they
are considering in having a good look at the whole system. Certainly, I do not want to pre‑empt
the whole health care reform, but I would like to have some direction, the minister's
own views and his government's views on whether they have had a good look at
the whole range of services which are presently covered. Has there been a reasonable doubt or other
reasons where some of the services which are presently covered are not
medically a necessity, as last year some of the services were taken out?
Initially, there was a lot of cry that we are
going to lose so much and everything is going to crumble. But now it has been more than a year, and
some of those things have not happened. Certainly, whenever change in the
services is being made by this administration it has so far simply been able to
define them under the regulation.
Whenever the services are required for medical reasons, they have to be
insured.
If not, then I think we should have a good
look at the system, and I just want to know in this reform package, will we see
any drastic or major changes?
Mr.
Orchard: Mr.
Acting Deputy Chairperson, let me take issue with my honourable friend in terms
of the 10 or 12 systems across
My honourable friend is right when he
indicates that the ministries of Health operate 10 or 12 somewhat differing
services across
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(2015)
For instance, hospital admissions and a number
of medical procedures that have a great deal of commonality are covered in every
health plan across the province. If I
could put an analogy out that as far as Canada Health Act services go, and you
could go on a scale of one to 100 in terms of procedures, I think you would
find commonality in procedures being included as an insured service in,
probably, 85 out of 100 cases.
It is only in the last 15 percent, if my
honourable friend follows what I am getting at, that you might find any kind of
variation between provinces. I think it
is within those procedures that there is the gray area that needs to be
discussed as to whether they are medically necessary services or whether, indeed,
they have simply been put there because of pressure from negotiations or
pressure from providers or varying pressures that have allowed these procedures
to be included.
Let me give you the example that comes most
quickly to mind, that being in vitro fertilization. The in vitro fertilization program was funded
independently at the Health Sciences Centre a couple or three years back. When they decided they could no longer carry
it on‑‑and they did not even, as I recall, ask government for
financial support, because they did not meet their projected budget in terms of
revenues, et cetera‑‑they dropped the provision of service.
Now that becomes a confused issue in that it
was an insured service by some allegations, and it was being dropped as an insured
service. The point was it was never an
insured service in
When my honourable friend makes the case that
there are 10 or 12 different differing health systems, he is right, because for
instance in
Some provinces are more generous in their
senior support in that
A number of other services‑‑some
services insure to one degree or another chiropractic services or optometric
services. There is that variation because the Canada Health Act does not mandate
that chiropractic, optometric, et cetera, is part of the
Similarly, there is a great degree of
variation in the way ambulance services are funded province by province,
because the ambulance service is not part of the Canada Health Act and a mandated
funded service, so that we have a system that provides per capita support and
some other funding formula enhancements and enrichments, but it is not
certainly consistent across
From the standpoint of services provided
beyond the mandate of the Canada Health Act, yes, we do have significant
variation. I think my honourable friend might agree that, on the Canada Health
Act insured services side, we may have as much as 80 percent uniformity in
service provision across
Mr.
Cheema: The
second aspect of the Canada Health Act, which each and every province deals
with in a different fashion, is the so‑called tray fee or facility
fee. The provinces have not been able to
restrict those tray fees, because the Canada Health will only punish if you
have extra billing or you are charging user fees, as long as those two criteria
are not met. That is why in some
provinces the tray fees are being asked by the professional to be paid by the
patients. I think that is unfair,
because if somebody goes to a doctor's office and they have to pay $15 to $18,
but if the same person were to go to a hospital where he still does not have to
pay from his pocket, it just creates a problem.
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(2020)
Anyway, in the hospital it is more expensive
and the minister's staff will tell them it is quite expensive as compared to the
offices. That issue has been raised by
professionals as well as by the patients, and I think there has to be some
clear definition. I want to make one
thing very clear. That did not start in
1988 or '89, that has been there as of '85, '86, and '87. That is not a new phenomenon as far as this
province is concerned.
In B.C. I know for sure that the tray fee is
not allowed, because I think they have made it very clear that the tray fee is a
form of extra billing and it should not be charged to a patient. I would like to ask the minister, rather than
the patient paying a tray fee in the doctors' offices where they perform the
same services they would perform in a hospital‑‑so I would like to
have some clarification from the minister.
Mr.
Orchard: Apparently
in terms of the issue of tray fees, I cannot confirm whether the circumstance
in B.C. is as my honourable friend described, but pretty well every other
province has a system similar to ours which is really no system, if I can be
that direct.
Only
Mr.
Cheema: Mr.
Acting Deputy Chairperson, I think that is unfair, because somebody has to pay
in a doctor's office a fee, and the same person, if he would go to a hospital,
does not have to pay anything. In a way,
it is costing more to the government and no cost to the professionals or to the
patient. I think it should be looked at
from a point of view to make sure that the patients are treated fairly both in
the hospital as well as in doctors' offices, and that issue I think needs some clarification
on whether the government is going to make sure that this fault which has
existed for some time will be corrected.
Mr.
Orchard: Mr. Acting Deputy
Chairperson, I accept my honourable friend's concern and will undertake some
discussions within the ministry, but I cannot give my honourable friend tonight
or even in the near future a commitment of any action that we might undertake,
but I recognize what my honourable friend is saying in terms of the potential
of this issue.
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(2025)
Mr.
Cheema: Mr.
Acting Deputy Chairperson, can the minister tell us, have they received a large
number of complaints from the patients over this issue?
Mr.
Orchard: No, we
have not received a large number of complaints.
I have maybe received a couple, three letters in the last couple of
years.
Mr.
Cheema: Mr.
Acting Deputy Chairperson, can the minister tell us through his staff, have
they received any complaints in terms of extra billing in our province that any
patient or any physician has been charging, for example, a standby fee?
Mr.
Orchard: Mr.
Acting Deputy Chairperson, this issue came up a couple, three years ago, or
maybe two years ago, and I thought it was resolved, and I guess it is.
I am informed that the standby charge that
some psychiatrists have asked does not contravene the Canada Health Act because
there is no charge for standby as a schedule of reimbursed fees, and it does
not contravene the act because it is telephone advice that is being, in
essence, charged for a low‑‑I mean, it is a standby fee for
telephone advice, basically. So it was
left as a patient provider issue, because it did not contravene the Canada Health
Act, apparently.
Mr.
Cheema: Mr.
Acting Deputy Chairperson, I just want to clarify. I think there was an issue that was about two
and a half years ago. After that, if
there have not been any complaints, then it has not been a major issue and that
seems to be okay with me.
Can the minister tell us about the other issue
in terms of the facility fee now? We have
five clinics, and I must say five of them‑‑I think four started
back in 1985, '86 and '87 and now the fifth, the Western Surgery Centre, which
has also started some of the procedures.
For example, they are doing some outpatient orthoscopic or some knee
surgery, even though they are getting patients from the Workers Compensation
Board or a third‑party liability.
The question remains that those facilities are still charging a so‑called
facility fee, and that even does not legally contravene the Canada Health
Act. Those facilities are all approved
by the
I wanted to know what the minister is doing
and/or the department is doing setting up remote outpatient surgical procedures
where the patients can go and have those surgical procedures done, so that they
do not have to pay or wait or at least not feel that we have a two‑tier
system. I think it is unfair for someone
to wait for 18 months and the other person next door can go within six weeks or
three weeks and get his surgical procedure done.
Mr.
Orchard: I agree
with my honourable friend in terms of the apparent fairness issue because that
is a serious issue. That is why this
whole waiting list and numbers on the waiting list issue is being investigated
very diligently right now with Dr. David Naylor out of
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Here is the issue. If I can be so blunt, the issue of waiting
lists and waiting times is often a lever used in the system to garner more
money to do more things, and it gets all into this whole issue of: Are we doing the right things? Just because we have established a demand
that we should be doing more procedures as judged by the professionals doing
the procedures, the question is, do we need to do more procedures? The variation in surgical rates as you go
region by region of the province and/or the country are demonstrating that the
waiting list or the demand for the procedure may not always be outcome‑driven
for the patient's improvement of health.
I will tell you how we have been handling the
system to a degree within our office.
When we have received phone calls‑‑because from time to time
some physicians who put a patient on a waiting list which may have a slated
time for elective surgery six months, 12 months, or even 18 months down the
road, in some cases such as hip replacements, the physician, the provider says,
to the patient when they ask why so long, phone the Minister of Health, the
government is not giving us enough money.
When we have had those phone calls, we have made the very direct
suggestion: Have you considered referral
to another specialist? There is a great
diversity in the number of procedures performed by given specialists throughout
the system. Some of the busiest ones will have the longest waiting lists, and maybe
other practitioners can provide a little quicker service.
That does not take away the overall
constraints on the system of surgical time in other hospitals and other areas
of the same hospital, but if we fall victim to the pressure of the waiting list
and the length of the waiting list as the only indicator that our service is
deteriorating, that has not analyzed a number of things, including the
appropriateness of choice of individuals for a procedure which we have left up
to the discretion, we have never asked for a second opinion of practitioners.
Secondly, the waiting list itself when it is
developed by 10, 15 or 20 different specialists for a similar procedure or the same
procedure, we have found that we are at a real quandary and that we have not
had an ability to analyze the waiting list globally to assure that the right
patient is being prioritized for the first service. Example, someone who has a waiting list of 30
people versus someone who has a waiting list of 60 people, the person with the
shorter waiting list might have someone with less urgent requirements advance
simply because he has fewer patients to put through his allocation of surgical
time. That is one of the areas that Dr.
Naylor and the vice‑presidents of medicine are attempting to develop
criteria around.
I do not understand the necessity or the
timing of, for instance, cataract surgery because that one often comes up. I have had some discussions with
professionals which indicate that there is a less than optimum time to perform
the surgery and a more optimum time.
Sometimes, patients will not accept a waiting period of time for the
disease maturity. I do not know whether that
is right or wrong, but I have to trust the information that I have received
unless I misunderstood what was being said. Again, sometimes the pressure for
the cataract surgery is pushed by the patient without necessarily having all of
the information on when and how the procedure ought to be undertaken. So there is a whole dynamic in this argument.
In the majority, though, the private surgical clinics‑‑Western,
for instance, I think it had its start up in terms of a free‑standing
surgical clinic for plastic surgery, because back seven or eight years ago a
number of plastic surgery procedures were removed from the insured services
list. They were deinsured, and that led
to that clinic, for instance, being established to provide the noninsured
service where it was entirely paid for either by the individual or private
insurance.
The same is not exactly true for the cataract
surgical centre that was, for instance, in
Mr.
Cheema: Mr.
Acting Deputy Chairperson, the minister has touched on many issues within his
answer. The first issue that he has
raised deals with the waiting list and with various procedures. One report was the Fraser Institute report
from
There are so many aspects of a waiting list,
but something has to be done, because the government is paying those bills. There
should be some co‑ordination, probably a central registry place where the
waiting list can be rechanneled to make sure that people do not have to wait
extra when the others are available or the other hospitals can do those
procedures, especially when the patients are coming out of the
The other issue, the minister has said, well,
the waiting list is not the true indicator for health care services, and that may
or may not be true, but the issue here comes, as I have asked the minister many
times, when you do not have protocols, when the patient has to be referred, at
least there should be some guidelines.
There are special circumstances when the rules can be changed, but most
of all there have to be protocols. That patient
has to be seen; the patient has to be referred; the patient has to undergo
surgical procedures. I think that would eliminate
a lot of problems, because, as I said the other day, it does not matter how
many medical review committees you have, there are always answers to those
questions, as long as the health care providers can justify, and most of the time
they can. So I think there has to be a
mechanism where the protocols are being followed because the taxpayers are
paying the bills. Each and every government is talking about the issue.
I sincerely hope the government will come up
with some kind of policy in the reform package to deal with this very, very serious
problem, and not only for the patients but also for the health care
providers. They also have to feel
comfortable that they are protected, because when they have a protocol, then
they do not have to do something that a patient will demand, or the treatment
is guided by the very high technology, or some of the results that may or may
not have a high outcome value.
I think one example is the CT scanner
issue. The second is the mammography
issue. I think those are the two very
prime examples then of how things can be changed. So certainly we hope that the minister will
come up with some policy or some statement in terms of dealing with this very
major issue.
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(2040)
If you look at the books, how much‑‑$297,941,000‑‑is
paid for the medical insured services, that is a lot of money‑‑no
question about it, 2,000 practising physicians.
Certainly they are also a major employer. They employ a lot of people, and that issue
has to be taken into account.
The way that things are happening now, either
we will have a system or we will not have a system within a few years, unless you
have some kinds of checks and balances put in place. The fee system, which was set up in 1966 and later
on affirmed in 1984, was never meant to be the way it is right now. It was meant to serve in a way, with the
ability of taxpayers to pay the system.
But, at that time, they did not take into
account the various other factors, such as the technology, the population, the
high patient demands, and this view or this phenomenon that the medicare system
is free, and that is certainly not the case.
I think so many things have contributed over a 26‑year period to much
of the proliferation of the health care services. In a system which was supposed to serve the
patient, I think it has lost touch to some extent; from the patient, it has
gone in the other direction. That is why
we are having such a serious difficulty.
So I would like the minister to tell us if we
are going to see some major changes in his health care reform as regards the fee
for services and also the setting of protocols and having some say from the
taxpayers' point of view.
Mr.
Orchard: Mr.
Acting Deputy Chairperson, the issue of fee schedule reform has been on the
agenda for some time. That very much
starts to get at some of the challenges in the way we dispense a very
significant portion of that $297 million in the medical line.
I had the opportunity to be‑‑I do
not know; what did they call it?‑‑the guest lecturer on Friday at
the‑‑it was good, it was a good session.
Basically, the issue is around bioethics and
the ethics of health care expenditure because there is a lot of discussion across
I used a fair bit of information and some
overheads at the discussion, and I have to say to my honourable friend I was
maybe a little more provocative in some of the information that I laid out than
what has been possible in the past.
Generally, Ministers of Health have had to
soft‑pedal around these kinds of issues and probably would have carefully
been busy elsewhere rather than going to present a one‑hour lecture on
the ethics of health care expenditures, but I think the opportunity is there to
have the kind of discussion my honourable friend has been urging on me and on
government in terms of how the system has to change and serve a blueprint for
that change and a goal and vision for that change.
An interesting thing came out of it. I made the point in fee‑for‑service
billings of physicians. Let me
background the issue. The issue came to
me as one that because the availability of finances is constraining our ability
to carry on many things in the health care system, allegedly, if we cannot find
more money, then we have got to consider rationing. Therefore, how do we get around the issue of
rationing? How do we curtail certain services
to certain people, if that is a bottom‑line definition of rationing?
I presented some other challenging thoughts in
terms of how we currently spend. One of
the things that I pointed out was that right now we have physician billings on
fee‑for‑service, and we do not keep track of anyone who bills less
than $40,000 a year. The range in that
billing goes from the $40,000 at the bottom end of the range‑‑there
are some that bill less, but we do not keep as close a tab on that‑‑and
it ranged up in the last full year to $998,000 of fee‑for‑service
billing by one physician. The billings
for the one physician leads to two analyses which I shared with the group on
Friday.
First of all, that ability to generate $998,000
annually of billings has been enabled through a vastly changed technology in the
procedure offered by that specialist.
The fee schedule was set at a time when there was very, very difficult‑to‑use
technology, the skill requirement was considerable, and the time commitment was
quite considerable. The fee schedule
reflected that commitment of knowledge and time and expertise.
With changing technology, fibre optics being,
I guess, the main driving factor, that procedure is turned into a very, in relative
terms, quick one, but the fee schedules remains the same so that the individual
can do significantly more of these procedures on an annual basis at the same
rate as reflected by old technology.
I put the challenge out. I said, before we even talk about rationing,
should we not be coming around that? Let
us even say that the income was reduced to a half‑million dollars per
year, I mean, the Canadian industrial wage for the same year was $26,000 across
I do not want to get into an alarmists' debate
on this, but before we are driven by the system to consider curtailment of service
or rationing of service or whatever, I suggest that is an issue that Manitobans
would insist we come around.
The other corollary of the system is that in
one procedure that is a fairly common procedure now in medicine, the Manitoba fee
schedule pays something over $2,300 for that procedure, whereas in
The normal reaction in the past has been, let
us solve it by putting more money in.
Well, we cannot solve it by putting more money in today. We want to solve it by using the existing
budget in a more appropriate fashion through a reformed fee schedule. After
bringing that issue up, I am pleased to say that the new president of the MMA
indicated to the meeting that he wished to pursue a fast‑tracking of our
fee schedule reform now that we have a consultant on board. I simply say that we intend to pursue that
and see how quickly we can come around fee schedule reform, because it has a
significant impact on what we do.
Waiting lists, yes, the process in place that
is structured and has not begun to operate in terms of trying to come to grips with
the waiting lists in a number of key areas of service delivery.
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(2050)
The report from the Fraser forum in February
told an interesting story. If you read
that thing, or if you read the media coverage of it you would think
Then, on some very key services like coronary
artery bypass, when you analyze the waiting list time,
What did get reflected was primarily, if I can
find it, the waiting list on hip surgery‑‑because arthroplasty is
hip surgery, is it not?‑‑and there we were behind all of the other
provinces in that we had a 41.9 week waiting time whereas B.C. identified 27.3,
In terms of trying to come to grips with
changing the way the system spends $1.8 billion, yes, we are going to look at
fee schedule reform; yes, we are going to try to establish provincially, where
we can, protocols for access of service. Where we can deal with the protocols
for access of service, we are going to try to engage national standards so
there is some consistency across
I presented this protocol argument on Friday,
and protocols, I think, I have to tell you that my sense right off the top
right now is that a number‑‑or quite often physicians will consider
the protocol initiative as being an infringement on their right to practise. I think that is a fairly general analysis of
why protocols have not necessarily been generally developed.
I presented the counterargument on Friday and
the counterargument is this: the American
system has incredible fee schedules and those incredible fee schedules, they
far outstrip our fee schedules for surgical procedures. They will be double, triple, quadruple,
sometimes five and six times what we pay in anywhere in
What is not told is the fact that the
malpractice insurance is so incredibly high down there, their fee schedule has
to be a multiple of ours. Some
obstetricians delivering babies in the States have minimum $100,000 annual
malpractice. Ours is in the neighbourhood
of $10,000, which is amongst the highest in
I have said that I do not want to get into the
U.S.‑driven system whereby practitioners practise defensive
medicine. They go through every known
and available test that they can, so that they cannot then be, if something is
not found or the patient unfortunately dies, that someone cannot sue that
practitioner for not having done every last possible, conceivable, identifiable
test to cover not necessarily disease identification or patient concerns but to
cover themselves from malpractice.
I can see the protocols if we can get our
minds around them provincially and then nationally as being‑‑how do
I put it so that it is understandable?‑‑a method of preventing
litigation. Like, if you have followed the protocol that is set provincially or
nationally, saying that these are the appropriate investigations one ought to
undertake and you have done that, then you do not have to practise defensive
medicine which means the CAT scan, the MRI and blood tests and I mean on and
on, and you will not have some underemployed and overzealous lawyer suing you.
You know, the development of protocol, as my
honourable friend has mentioned this time and on a number of occasions‑‑and
I agree with him and we are trying to move in that direction‑‑I think
if we can get beyond sort of the preconception that protocols are meant to
curtail one's opportunity to practise, but rather to put some sense around what
is an appropriate level of care to avoid litigation, I think that puts a
different light on protocols.
We are moving in that direction in terms of the reform, and I cannot overestimate and I