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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(2030)
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 know my honourable friend knows
this, but the analysis done on a number of processes and procedures and policies
in government, and their outcomes, as analyzed by the Centre for Health Policy
and Evaluation guides us in providing protocols, if you will. Protocols is not the right word to use for
some of their analysis outcome. It is in
some cases but not always. But it
provides us with better guidelines to formulate policy around because it is a
knowledgeable analysis of what we do and what the outcomes are.
The reform of the system is envisioned to be
very wide‑ranging, not narrowed to merely the issue of how many beds do
we have, but rather what we do to provide maintenance of health, and in the
case where health is unable to be maintained, what sort of appropriate
interventions can we focus the system to deliver to hopefully bring an outcome
of increased health or life or mobility or any number of quality of life issues
that can be identified in the analysis of providing medical services to cure illness
or treat disease.
We are not going to take and deal narrowly
with the system as a physician issue, as a nursing issue, as an institutional
issue, as a community issue. We are
going to bring the system under one umbrella for an understanding of how it
interrelates and how you can make shifts within the system without compromising
the patient care and, at the same time, develop several other tracts in terms
of analyzing where there can be crossover of professional disciplines, for
instance, where fee schedule reform fits, where distribution of physicians
fits. I mean, there is a whole
complexity of issues there that are all part of ongoing process and discussion
centred around the general theme of reform of the health care system.
Mr.
Cheema: The
minister has described his protocol and guidelines, I think, in the most
suitable fashion. I think that is the
message the professionals have to get is that the protocols and guidelines are
not only to protect taxpayers but to also protect them.
I think that will help the province and also
the Manitoba Medical Association to come to grips with the problem. The problem is the system is guided by a fear
of malpractice suits, and we are seeing within five to eight years time the
health insurance for the practitioner has gone up by more than 180 percent in
some cases, and that is just a tip of the iceberg as compared to the
When I have gone through so much education, I
know what to do. I think that issue has
to be taken. It is not a question of what
they know. It is the question of what
are the normal guidelines and what is possible based on the scientific analysis
on a major population base and on our geographical basis and our location and
everything else has to be considered.
*
(2100)
That is why if we have guidelines, and if
those guidelines can be changed accordingly, I think the process is going to evolve
that way, that something which is going to be put in place now, it will require
some changes on a year‑to‑year basis or just some of the changing
needs of the society. I think naming guidelines
and protocol is the same, so that it seems probably so intrusive, if I may say
that. I think it is their ability to practise
medicine or somebody who is, for example, the Associate Deputy Minister of
Health is being told, these are your protocols, we are going to make sure that
we are going to monitor every week. That
cannot function. I think there have to
be some guidelines which will be very, very helpful to safeguard the patients,
health care providers and, above all, the taxpayers who are paying the
bills. I think that is very positive.
The other statement the minister has made, I
have said for four years now that the system cannot function in a piecemeal approach. Each and every part of the system has to
function in a way so that other parts of the body know what the first half is doing,
the head knows what the toes are doing.
It has to function in a very, very co‑ordinated fashion.
That had been missing for a long, long time,
and the Ministers of Health have taken four years as a period of getting it
good publicity, raising their profiles, but not really meeting the needs of the
patients and the taxpayers. I think that
had been lacking in the past, and I think that was very unfortunate because if
the decision was made in 1985, '86, we would not be having problems now. The decision we are sure going to make it now
as a team probably‑‑not probably, I should say they will help, no
question‑‑in 1993 or '94, whoever comes to take care of the
ministry. I think that kind of approach
has been lacking for a long time.
(Mr. Marcel
Laurendeau, Deputy Chairperson, in the Chair)
I think those three issues from our point of
view are very essential to discuss in a very open fashion to see how it could be
done in a different fashion. The
government should put to the organization, how would you do it in a different
fashion if you had to make a decision?
How are you going to spend this $1.8 billion? If you are sitting around the same table in a
very active role and you still have the same patient and the same amount of
money, how would you divide it? I think
that kind of issue has to be discussed very openly, and we are going to challenge
each and every health care professional group to tell us how they will do it in
a different way and whether they will consider the ability of taxpayers to
pay. If they are not going to consider
that, then I think we are missing the point here.
I think it is so essential that those issues
are discussed, and we are going to judge the health care reform from that point
of view. The minister knows that
anything which is going to be done has to be based on five or six of those
major principles which we stated when I had my opening statement. Those were the basic principles: the ability of taxpayers to pay, what is a necessity,
what is not a necessity, the changing needs of technology and, above all,
making sure the patient is the focus of attention, not a specific interest
group as had been the case in the past.
One other issue I want to ask the minister was
the health fee schedule form, one issue the general practitioners have been raising
with me personally. They have been
asking why in the major part of their practice‑‑and the staff is
here, they are very knowledgeable in that area.
The general practitioners do provide more than 80 percent of the
care. They have been lagging behind all
of the specialties across this nation and in this province specifically.
If a patient goes to their office, whether
they can see the patient for a partial exam or they can see them for complete physicals,
in between the more than one area if they are examining, they cannot bill more
than $85.09; that is partial exam billing.
If they bill $85.40, which is a complete physical, then the Medical
Review Committee will come and ask them why they are overbilling. It is not overbilling, because they do not
know which way to go. Either they can
bill partial examination, which is original examination, or they can bill the
complete physical.
I think that has caused a lot of confusion and
they know, with the publicity which we have had recently with the medical group,
more and more physicians have called me and asked me to ask the minister. They feel that they have lacked the input in the
fee negotiation for the last few years, in some cases, and they have not been
able to present their case very well.
I would ask the minister through his staff to
make sure that when the system is being reformed, they should also look at some
of the major technical problems which do exist, and when the Medical Review
Committee looks at the whole billing practices of a given physician, that is
causing a major problem in terms of general practitioners. I am sure Mr. Harvey is well aware of that
issue.
Mr.
Orchard: I do not
understand that issue, but I take my honourable friend's suggestion seriously
and I will take that up with staff.
Let me deal with the issue of the system‑wide
reform, Mr. Deputy Chairperson, because, as I have said to my honourable friend,
I look forward to listening to the response, listening to the criticism, but I
have also offered some caution to some of the groups that I have met with that
if there is criticism and there is significant disagreement with the process
that they publicly state, my first question is going to be: You do not like this, how do you suggest we
improve the process?
I have been very, very blunt and very direct,
that I am not going to stand idly by and listen to complaints which are driven by
other than patient concerns. If this is
turf protection, if this is job protection, if this is prestige protection, or
any number of the dynamics that can be part of the system, and that is what is
driving criticism of the reform process; I put people on notice that they are
going to be asked to come up with an alternative that will work better and,
bearing in mind one of my honourable friend's considerations in terms of
reforming the system, that being the taxpayer's ability to pay. If the criticism comes up as to how we
approach reform and the alternate suggestion on how we proceed means pouring
more money at it, that is a nonstarter.
That is just a nonstarter, and I have said that very clearly.
I do not say it to intimidate or to quash
debate. That is impossible to do in a
major system‑wide change, but I do it to make sure that there is the open
opportunity for an honest second opinion and difference of opinion. We have done that before as my honourable
friend well knows when I have had proposals that I have put before the
Legislature and he has found fault with some of them. Where that fault is legitimate and
remediable, we have done it, and I intend to approach this reform of the system
in the same fashion.
We do not have all of the answers, but I do
not expect‑‑like, it is a delicate balance. If groups want to be genuinely involved in
the reform process, then they have to genuinely be committed to change which
may impact them negatively but benefits the patient, because we all have to a
common denominator in this and that is the individual needing care in the
*
(2110)
I want to close though by broaching a couple
of things. In terms of the medical
liability insurance, we are sort of at a nonstarter stage with the Pritchard
report, and I think Sherry Wiebe in your caucus was a member of the committee
that developed the Pritchard report. I
do not understand all of the stumbling blocks to that report, and we are
implementing some of its recommendations, but it seemed to me that it had a
pursuable goal‑‑I will put it to you that way‑‑that
maybe offers some of this check and balance against going the American way of litigation
and enormous malpractice suits.
Not tonight, because I do not want that to
take up the time tonight on that, but if my honourable friend had advice on
that and where we should go, I would be interested in hearing that at a later
date.
Two other points that I want to make. My honourable friend commented that any
changes we make to the situation around the reform process are going to be
beneficial two, four and five years from now.
My honourable friend is right, and I often harken back to discussions I
would have with Mr. Desjardins. When he was Minister of Health, he said, some
of the things we are doing or wanting to do will make your job easier in government. I have to say, in retrospect, I now fully
appreciate that, because when the no‑deficit policy, for instance, came
in and there were a number of bed closures in '86 or '87, Mr. Desjardins
pointed out to me that we would probably benefit from those‑‑and he
is right‑‑from both of those policies.
I simply say that my honourable friend's open
approach on the debate of health care and where the system is going has made my
job considerably easier, because I want to tell my honourable friend I would
not have been able to go to the Faculty of Medicine and be the guest lecturer
at noon on Friday on the ethics of health care expenditure and throw the kind
of challenges out if I would have been facing an opposition critic who was
going to take every one of those all or completely out of context and come to
the House and talk about, well, the government is going to do this, that and
the other thing.
I think from the feedback we have got in terms
of the presentation I made on Friday, I think there have been an interesting
challenge of thought process that has emanated from that. I think that is nothing but healthy for the
change in the system where I have the ability to stand and, without fear of extreme
political retribution, lay some honest questions on the line as to what has to
be considered by people in the health care system.
So the reform process we hope is
comprehensive; we hope it identifies a lot of the challenges and a lot of the
goals and a lot of the methods of achieving solutions; and that it enjoys a pretty
wide and complete opportunity for debate by Manitobans as well as care
providers.
Mr.
Cheema: We have
talked about professionals, their accountability. How about patient's accountability? Are we going to monitor patients, also see
whether patients should be seeing four doctors, five doctors, three doctors,
two doctors, one doctor? I think we have
to have some kind of policy, from the government's point of view, whether the
patient has to be notified in terms of how they are going to use some of the services.
Mr.
Orchard: My
honourable friend might recall a little bit of a kafluffle we got into with the
MMA back about a year and a half ago, because apparently going back maybe even
four years ago or five years ago, there were discussions to try and establish a
PURC committee, they called it, Patient Utilization Review Committee. I know during the last negotiation, there was
some correspondence that emanated from my predecessor, I think, on the patient
review committee, a suggestion back and forth to undertake establishment of
this committee.
I am informed that current discussions with
the MMA and with the ministry are leading to the formation of that committee
and a commencement of its review of multiple doctoring by individual patients. I think my honourable friend recognizes the
necessity and so does the MMA, and so we are moving towards the establishment
of that Patient Utilization Review Committee. Hopefully we will have maybe some
suggested methods of dealing with the issue after discussion with the MMA.
Mr.
Cheema: Mr.
Deputy Chairperson, one very sensitive question, to which certainly the
minister can say yes or no or maybe: Are
we considering in terms of capping some of the insured services, for example,
how much a health care provider in a given speciality can charge to the
taxpayers?
I mean, that is a question which has come up
in other provinces and which is under consideration in many areas, and I think
that issue needs some clarification and some discussion. I think the issue is a very important
one. I mean, the issue is, what is the
value of your profession and how much in a fee‑for system your value can
be paid by taxpayers? I think that is
the issue, and I would like some comments from the minister.
Mr.
Orchard: Mr.
Deputy Chairperson, let me deal with one other piece of information on the
Patient Utilization Review Committee. We
are also going to have representation on that committee from the Manitoba
Pharmaceutical Association.
I have to indicate to you that the
pharmacists, the professional association, in meeting with me for several years
now, have pointed out some pretty interesting cases of multiple doctoring in
terms of acquisition of prescriptions.
They are very concerned about trying to bring methods of check and
balance in place because they consider it to be a very abusive practice which
is completely outside of providing needed medical services.
In terms of capping,
Today, like right now, we are not giving that
consideration. I am going to be quick to say that who knows but what two and three
years down the road we may not have to consider it. We are not considering it right now because I
think there is far more value to working co‑operatively with the MMA in
trying to come to grips with some of these issues.
One of the ways that I think there may well be
an opportunity‑‑well, I definitely think there will be an opportunity‑‑is
in terms of free schedule reform, the example I gave earlier, where technology
had changed the procedure to such an extent that quite significant billings
were now possible.
The MMA is not, I do not think, happy about
that circumstance either. I mean, that
can be used in a very negative way, reflecting on their association and the way
that the fee schedule is developed over the years. I sense genuine concern to try and resolve
the issue with the MMA, and certainly we have our consultants set to do fee
schedule reform. I think that we will end
up with some reasoned approach other than simply an outright cap on total
income by a given specialist or general practitioner.
One of the things that you may incur, and
again, I only share this because it was part of the rumour mill around
If you have a fee schedule which allows a
pretty significant generation of income, is the method of dealing with the
growth of that income in capping it so that you cap the number of procedures,
or is it in fee schedule reform where maybe, if it is too generous a fee
schedule, you do not deny patients services by putting a cap on, but you
readjust the fee schedule to make a more reasonable income possible? I prefer the latter. I think it will work without the opportunity
to have government accused of denying practice capability which would deny
patients service.
*
(2120)
Mr.
John Plohman (Dauphin):
Mr. Deputy Chairperson, I wanted to ask the minister if he could tell me
exactly what month of the year in 1990, I believe it is according to the
report, that the CT Scanning Committee was established.
Mr.
Orchard: What is
the question again?
Mr.
Plohman: What
month in what year did the minister establish the CT Scanning Committee?
Mr.
Orchard: Mr.
Deputy Chairperson, I would only presume that there were some preliminary
discussions with Dr. MacEwan, our radiology consultant, but given the issue of
requests for installation of CT scanners had come in in a fairly regular basis,
we asked in February of '91, Dr. MacEwan to visit each facility to review
requirements, et cetera, and receive input regarding a policy approach
government should consider. So that looks‑‑February
'91.
Mr.
Plohman: Mr. Deputy
Chairperson, the
Can you tell us when the first approach was
made for a CT scanner, with funds raised by the
Mr.
Orchard: Mr.
Deputy Chairperson, we do not have Dauphin's circumstance here, but it could be
any time after, oh‑‑when did we approve
Let me take my honourable friend back prior to
May 1988. When I came into office in May of 1988,
I landed in the middle of that issue as the
new Minister of Health, and we took some seven or eight or nine months to come around
the issue with many, many meetings with
So we set up a number of criteria that we
believed might be appropriate back in '89, and they were criteria by which we
could guide the installation and operation of the scanner at
So do you go into the first part of '91, which
is about when we put Dr. MacEwan to survey all of the hospitals in terms of their
need? We indicated that the only
conditions under which we would approve facilities, I think that is a fair way
to put it, would be under similar criteria to
Subsequent to that we have eight organizations
fundraising for CT scanners. As recently
identified in the CT Scanning Report, we do not need eight additional CT
scanners in the
That has not met with universal approval or
like, but the simple question that has to be answered by each of the facilities
is: Where do they believe they will get
the additional operating costs from within their global budget to operate a CT
scanner? Because with few exceptions, and I say few exceptions because I know
of none that have been demonstrated today, can they operate that scanner on the
basis of access costs of patient transfer to other facilities where scanning is
to be done. If they believe they have
additional dollars within their global budget that they can reallocate to the
operation of a CT scanner, then obviously they cannot very well make an
argument that their deficits are simply because of short funding of
government. Do you see the argument I am
coming to?
You cannot have it both ways, that you have
surplus money within your budget to operate a scanner above what you currently have
for patients going out, and then say but this deficit is because you did not
give us enough money. It cannot be both
ways.
Our discussions with the facilities are going
to be very, very direct and very, very firm.
We will see how they react in terms of their proposals to government,
should they make any. We have a very
definitive plan of action that we intend to undertake to assure the integrity
of our imaging capability in
My honourable friend is familiar with the
figure that I have often used that over a period of 15 years, from '73 to '88 I
believe are the numbers, we went from $16 million or, pardon me, $13 million?‑‑$16
million to‑‑well, it does not matter, it is a 450 percent increase
any which way.
Experts like Dr. MacEwan and the Centre for
Health Policy and Evaluation are concerned that this is an inappropriate use of
a very scarce resource, and it has not contributed to health status improvement. It is a status symbol, yes, but whether it contributes
with additional capacity to health status improvement is definitely not
provable.
*
(2130)
Mr.
Plohman: The
minister is saying really if there can be system savings overall that there
could perhaps be additional scanners approved, but only if it saved dollars as
opposed to cost additional dollars. Does
he feel that reconfiguring the existing scanners is one possibility as well in
terms of servicing adequately and efficiently existing patient loads?
Mr.
Orchard: I am not
sure I understand my honourable friend's suggestion about reconfiguring current
scanners, but I will give him an opportunity to explain that later on. I am saying to my honourable friend that the
case made by hospitals is that their patient load and their cost of scanning,
all they have to do is bring those home and they can operate a scanner. That is not accurate. The cost of operating that scanner are
significantly higher than the costs of replacement services outside the facility.
The next proposal that appears to be going to
be made is that we can find the additional operating dollars from within our budget,
and then the next breath is, but we have a deficit because you did not give us
enough money.
What we are saying is that anyone who comes to
us with a proposal that they can operate a scanner is going to receive quite
rigorous examination of their proposal to assure the integrity of their
budget. If they cannot prove that
integrity of the budget, we will not be approving the installation of a CAT scanner.
Mr.
Plohman: The
chairman of the hospital board in Dauphin is saying that when the
Mr.
Orchard: I would
think neither, because I would find it pretty strange that the previous
government, even though the member for Dauphin (Mr. Plohman) was around the
cabinet table, would have said to Dauphin, you buy a scanner, we will operate it,
when
Mr.
Plohman: That is
what they are saying. The Liberal critic
is talking about pretty strong statements.
It is his own supporter in Dauphin, as the chairman of the board, Mr.
Sarin, who has said this in fact, has made the statement that the government
did say that they would operate it. I
just wanted to ask the minister whether in fact that is an accurate statement. The
current chairman of the board was not the chairman of the board at the time the
minister would have been discussing this, obviously. It may have been Bob Forbes who is no longer
with the board, as the minister knows, I think a couple of years now, but was a
long‑time member of the board and chairman of the board.
So the funding was undertaken, nevertheless,
with the idea that a scanner could be purchased and operated. I am wanting to determine from the minister
what kind of a commitment he or his staff had given to the Dauphin board prior
to their undertaking a major fundraising effort. We know that any funding that came from the
foundation was committed after this government was in power because the
foundation was established since 1988.
It was a private members' bill by myself, so I realize, of course, that there
was no funding undertaken through the foundation for a scanner prior to April
1988. So I wanted to see whether the minister
had made any commitment with regard to operating that, given them any
encouragement, anything at all in that regard.
Mr.
Orchard: No, Mr.
Deputy Chairperson, the only thing that my honourable friend might be able to
refer back to his chairman is the
I do not know who would have said that to the
new chairman. You might want to check and find out who indicated that to him because
I would be interested in finding out. It
was not myself, and I do not believe it would have been any member of the
staff. If my honourable friend made that commitment to the
Mr.
Plohman: Well,
certainly the minister knows that commitment was not made prior to '88 because,
at that time, the board was not in a position of actually pursuing this
issue. They had pursued a number of
other issues with the government on a number of building projects and changes
to the existing building that were in the plans at that time, and the minister
knows full well about those.
I do not think they would have also been
encouraged by what happened at the
I want to ask the minister, if he did not give
any such undertaking, we will have to find out where this came from, but the
chairman of the board is attributed to saying that in the latest edition of the
Dauphin Herald, just last week's.
The minister could perhaps shed some light on
the waiting period for residents now in facilities for CT scans. It has referenced Dr. Keith McIver of the
Dauphin General, the chief of staff, as saying that there is a large waiting
list in all facilities in excess of six weeks.
I ask the minister if that is an accurate statement attributed to the
Dauphin chief of staff, Dr. Keith McIver.
Mr.
Orchard: I
presume that‑‑now I do not have specific information as I thought
on Brandon, but Brandon has been very, very‑‑in relative terms, has
a much shorter waiting time than, say, HSC or St. Boniface. I think Dauphin uses the
Emergency and urgent are immediate scheduling;
there is no waiting for those. It is
elective that do have some period of time for waiting. Now, with the McEwan report, currently there is
a waiting list analysis and it is in progress.
*
(2140)
I will give you what was found just as to,
say, a couple of months prior to my announcement. Initially it was believed that there were
6,000 patients on the waiting list and many of them with serious
illnesses. That was the allegation, and
maybe this has something to do with the quote that my honourable friend is using. So, initially, they believed there were 6,000
patients on the waiting list.
On analysis, there were only 2,500 patients
awaiting examinations so that the list immediately dropped from 6,000 to 2,500,
and the delays were from three to eight weeks.
On analysis, two‑thirds of the patients had appointments requested
by their physicians or at the patient's convenience. In other words, they set the date in which
they would get their scan. Only one‑third of the patients were
experiencing delay, and almost all of them on study would not benefit medically
by an earlier examination. That is the
finding of Dr. McEwan, the provincial radiology consultant on the issue. One‑third of the 2,500, so roughly 800
of the patients were experiencing delay, and almost all of them on study would
not benefit medically by an earlier examination.
Subsequent to this report and analysis, we
have struck‑‑the chairman is Dr. McClarty‑‑a committee
to go through and analyze on what basis the last statement was made. Bear in mind two‑thirds, or 1,600 of
the 2,500 roughly, were within that three‑ to eight‑week waiting
period because they had booked that time, so I think my honourable friend would
understand the delay. The one‑third
who were experiencing delay‑‑none of these would be urgent or
emergent because those are access scanning very quickly, immediately for that
matter‑‑almost all of them on the study would not benefit medically
by an earlier examination.
That issue is one of the issues that will be
undertaken for a review by the new committee because it says almost all of
them, not all of them, but almost all of them.
What we want to try and establish through Dr.
McClarty's committee is how we determine who those excluded by the "almost
all" can be identified and how their case can be advanced as opposed to
others who would not be compromised by a three‑, four‑ or five‑week
wait.
Mr.
Plohman: The
committee that the minister refers to has, I take it, not yet been established,
the ongoing committee. If it has, that
is another request or concern. Of
course, they are asking to meet with the minister‑‑that the
Is the minister going to have rural
representation that has not yet been established? If it has, who are his rural representatives? Will he be inviting the Dauphin community to put
forward a name, or will he be choosing someone from the community on this
committee, especially in light of the fact that this goes back to some time
around the Victoria Hospital situation that the minister outlined and that
fundraising has all but been completed for the purposes of purchasing a
scanner.
Mr.
Orchard: Mr.
Deputy Chairperson, is my honourable friend saying that simply because a
community raises funds for a purpose, government should fund that purpose in
health care, because that seems to be the implication?
Mr.
Plohman: It is a
factor. I asked you another question as well.
Mr.
Orchard: No, but I
mean let us get‑‑it is a factor.
So in other words, that should influence how government spends and establishes
new programs.
Mr.
Plohman: I wish
the minister‑‑in the interest of dealing with these issues, if he
wants to talk around circles, we can all do that. I asked him a very direct question of whether
he has established the committee, whether he has rural representation and
whether he is going to be inviting representative from the Dauphin community. That was the direct question.
I also gave some rationale in light of the
fact that the community had begun this process when there were obviously very unclear
guidelines established by this minister for expanding the use of CT scanners in
the province. They had some
understanding, whether the minister wants to admit it or not, that he may be considering
funding the operation if they were able to raise the funding for purchase of
the scanner. They may put forward a very
good case that there could be net savings, as the minister outlined earlier, in
terms of the transfer of these patients to other facilities to access the same
services.
In terms of what the minister is saying, no,
that is not a criteria for spending government money. What I asked the minister was whether it was
his consideration that they would have a representative on the committee as
they are requesting.
Mr.
Orchard: Mr.
Deputy Chairperson, I cannot answer whether Dauphin will, because we are asking
MHO to provide for us a rural community hospital official to be on that
committee. It may well be Dauphin; it
may well be Morden‑Winkler; it may well be Steinbach; it may well be
Thompson. I cannot presuppose whom MHO might
suggest.
The reason why I am quite interested in my
honourable friend's position on whether simple fundraising in a community and
the existence of funds raised in a community should be the reason why
government then provides the operating costs, what his position is on that now
that he is in opposition and representing a hospital which has allegedly raised
the money, is that I simply point out to my honourable friend that, when in
government, my honourable friend did not believe that was an appropriate process. As a matter of fact, he was a member of a
government that in a circumstance very similar to that‑‑mind you it
was not in his own home constituency, but in a constituency of another MLA or
another part of the province‑‑when they raised the funds, the
government he was part of said: we will
not provide, under any circumstances, the operating costs.
My honourable friend now seems to be saying,
well, maybe it should be considered. I
find this quite interesting because this is yet another change in New
Democratic approach and policy from government where they say one thing, and
then when they get in opposition, they say another thing, particularly if it
happens to be in their backyard.
Mr.
Plohman: The
minister knows better than that. He
should realize that there was a rather‑‑well, could be that he
wants to take the position that the opposition can have it both ways, but in
reality there was a major expansion in the number of CT scanners over the
latter part of the '80s. So because of
that, it was time to take a look at what criteria was being used, and where
this should all stop because it is expensive.
That is perhaps one of the criteria that the minister at that time was looking
at, to establish some guidelines before moving forward with
I want to ask the minister if he has
information as to the precise annual operating costs of a CT scanner, which is
really what we are talking about here?
Mr.
Orchard: The
investigation by Dr. MacEwan would indicate annualized operating costs of
$800,000 to $1 million a year.
Mr.
Plohman: Yes, the
report, executive summary, seems to indicate an operating cost of $1 million
each. I wonder why they use that term if
the minister says there is a range there.
It is a significant difference.
The cost that was referred to in the Dauphin
area was $300,000. Is that by no means
accurate or even close to accurate? Can
it be significantly less that $800,000?
*
(2150)
Mr.
Orchard: Mr.
Deputy Chairperson, my honourable friend just chastised me because I gave a
range of $800,000 to $1 million when the report says $1 million. I do not believe that $300,000 is an
achievable operating cost for a CAT scan.
I believe that because that is what those expert in analyzing the costs
of CT scanning operation have indicated is an impossible operating cost on the
annualized basis to achieve.
Mr.
Plohman: Yes, Mr.
Deputy Chairperson, the minister's report from the CT Scanning Committee also
talks about six scanners per million population as the Canadian average. Does he feel that there is anything unique
about
Mr.
Orchard: Mr.
Deputy Chairperson, as my honourable friend knows from the chart that is in the
consultant's report, six puts us roughly at a Canadian average, seven would put
us slightly above, and certainly, acceding to all the other requests would put
us at approximately double the Canadian capacity.
That would be inappropriate by anyone's
analysis, even in their wildest dreams of demand would not think it reasonable
to dedicate the resource that 14 CT scanners would put upon the system serving
a population of one million.
The distribution of those scanners: you must recall that from opposition we urged
and the government of the day acceded to the placement of one of those scanners
in
You have to appreciate that requests out of
northern
When my honourable friend made reference
earlier on to the distribution of the scanners, I was wondering what he meant
by that. I would be interested in
getting his thoughts and his suggestions on that because we are always guided
by good advice from opposition members.
The current distribution is two in each of the
teaching hospitals and one at Victoria and one at
When we discussed this issue with another one
of my honourable friend's colleagues about three weeks ago, he made the argument
that it was quite traumatic that patients be transferred from
So it is always a decision as to where it is
appropriate to have them, but there are minimum requirements of service and protocols
for access to that service which guide both the numbers and the location. Right now, the group who studied the MacEwan report
presented a report to us with the recommendation, and if my honourable friend
has it in front of him, that the available funds contemplated for an additional
CT scanner and space should be used for patient needs at the present sites and
that no money be allocated for acquisition or operation of additional scanners at
this time, and that an ongoing committee be established to deal with the issue
of CT scanning and MRI.
Mr.
Plohman: I
recognize that those are the recommendations, and of course, the minister is
not‑‑and I am not even asking him to outline where that committee
might say would be the best location and distribution of these services in the
future.
I would take it from that establishment of
that committee, though, the minister is not ruling out going slightly above the
Canadian average insofar as the number of CT scanners available to Manitobans.
Mr.
Orchard: Mr.
Deputy Chairperson, the original deliberation of the CT Scanning Committee was
to give a recommendation as to whether we ought to consider the installation of
one additional scanner. They gave us the
best possible guidance that they could as to where that scanner could be
located. Their recommendations were as I
just read.
Mr.
Plohman: So that
is precisely what Dauphin was waiting for in terms of the scanner. They were hoping that the recommendation
would be, obviously, that would be located in Dauphin and they could
proceed. They were told not to proceed, and
there would be no funds to operate with in the meantime. They waited a good
year or more for that report and, of course, now it says continue to wait.
I am asking the minister whether the
establishment of that additional committee, that ongoing committee, will serve
as a decision‑making body, a recommendation body, for the minister for additional
scanners in the future?
Mr.
Orchard: That
committee may well, in terms of establishing a protocol, reinforce the decision
that our current scanning capacity is sufficient for a population of one
million.
Mr.
Plohman: The
minister has mentioned that there was a scanner established in
Insofar as ruling out Dauphin or talking about
criteria, does the minister feel that the Residency Program in Dauphin has any impact
on this kind of a decision? Also keeping
in mind that the
Certainly, we need to have greater economic
development in our rural areas if we are going to maintain our communities and indeed
they are going to grow.
At the present time, not only serving the
community of Dauphin, the hospital serves a much broader area, and it is from that
respect a regional hospital and with a residency program, I would ask the
minister whether in fact‑‑he talked about the teaching hospitals‑‑he
feels that this is a significant factor in that kind of a decision?
*
(2200)
Mr.
Deputy Chairperson:
The hour now being ten o'clock, what is the will of the committee?
An
Honourable Member: Proceed.
Mr.
Deputy Chairperson: Proceed.
Mr.
Orchard: Mr.
Deputy Chairperson, that is not a deciding factor as to whether
Mr.
Plohman: It is
quite evident that many hospitals will never have a CT scanner; it is just not
possible to afford to have a CT scanner in every hospital.
Of course, the minister has established this
committee. I understood from his earlier
comments that various hospitals will be making presentations or proposals, and
they will be scrutinized with very tough guidelines as the minister said. Are they going to be making this to the
committee, proposals for a CT scanner in their facility, or are they going to
be making these to the minister?
Mr.
Orchard: The
committee is designed to provide guidance to government as to where the needs
can be met, to analyze the current waiting list and methods of management on
that waiting list which will reduce some of the accusations my honourable friend
has shared with us tonight about length of waiting time, et cetera. It will also hopefully establish some
protocol which will guide the utilization and the patient access to CT
scanning, and any application for any technology, whether it be CT scanning or
any other technology that is made to the ministry for installation and any of
the many hospitals we have goes through a process of analysis to identify
need. Should the analysis identify that
the need is legitimate, and if funds are available, decisions are made to
proceed to allow the facility to proceed with the acquisition of that
technology.
So there is a general committee process to
deal with the global issue of installation of CT scanning technology, and there
is the specific facility‑by‑facility request as stimulated by the availability
of purchase funds through fundraising which is a separate approval process and
which will have very stringent scrutiny.
Mr.
Plohman: One last
question on this issue, Mr. Deputy Chairperson.
I just want to ask the minister if he determines as a result of these
recommendations that there should be no more scanners purchased this fiscal
year, and does he go further than that, or does this mean for this fiscal year
when they say, at this time? What is the
interpretation of that recommendation?
(Mr. Gerry
McAlpine, Acting Deputy Chairperson, in the Chair)
Mr.
Orchard: At this
time, means until there is a justifiable case for an additional scanner and
where it should be located. Then, at this time, becomes a decision at some time
in the future potentially to install and fund another one, but at this time can
last until that justification is identified to the ministry.
Mr.
Plohman: Yes, Mr.
Acting Deputy Chairperson, and the minister then expects that this new
committee will be up and operating to deal with these issues when?
Mr.
Orchard: Very
shortly, Mr. Acting Deputy Chairperson.
Mr.
Plohman: Has the
committee been established and named?
Mr.
Orchard: The
committee has been named. It is called
the Manitoba Imaging Advisory Committee and the chair has been determined to be
Dr. McClarty. We are seeking
representation from a number of other disciplines and organizations including MHO.
Mr.
Plohman: Mr.
Acting Deputy Chairperson, we will watch with interest on that issue.
I wanted to ask the minister a couple of brief
questions regarding the current operating budget and status of the
Mr.
Orchard: Mr.
Acting Deputy Chairperson, the deficit at the hospital is approaching $400,000
and in quite recent meetings with the board a deficit retirement plan has been
created and approved, which will take a commitment by the
Mr.
Plohman: Mr.
Acting Deputy Chairperson, has it been determined that deficit was the fault of
the administration of the
I refer to possibly the fact that the hospital
is basically a new facility operating without an established budget for a
number of years, and therefore, because of the uncertainty in establishing that
for a new facility, a period of years was required to establish what would be a
relatively appropriate level of funding to ensure that all beds were operating
and fully staffed.
Could the minister indicate whether, within
this commitment or deficit reduction exercise, the province is sharing in that reduction
directly? Is it only by way of perhaps
closing some beds or understaffing that is being accomplished, or how is it being
accomplished?
Mr.
Orchard: Mr.
Acting Deputy Chairperson, the $400,000 was an accumulated deficit. I am informed that this past year they have operated
in fact with a surplus budget, and it is my understanding that they accumulated
the deficit because they were operating above the staffing guidelines that were
provided to them within their budget.
They had done that for at least two to three years which led to an
accumulated deficit. They are now operating
within their staffing guidelines as provided for in the budget, and hence
believe they are able to achieve retirement of the deficit in that two and a
half year period of time
Mr.
Plohman: Are they
operating now autonomously as most major facilities, of course having to
justify their budget when they go in, but in terms of not operating line by
line through MHSC?
Mr.
Orchard: Mr.
Acting Deputy Chairperson, they are operating on a global budget, and it is
within the global budget that they are retiring the $400,000 deficit over the
next two and a half years.
Mr.
Plohman: Has it
been determined that the operation that was above and beyond the guidelines at
the time they were established has changed?
In other words, are they allowed additional dollars for operating based
on a review that might have been made or a case that might have been made, or
is it still on the basis of the same guidelines that were in place during that
period of time?
Mr.
Orchard: Some
minor adjustments on nonglobal items, but basically operating within the global
budget.
Mr.
Plohman: Could the
minister just indicate perhaps some reasons why there might be 25 beds closed
at any one time at the hospital there at the present time?
*
(2210)
Mr.
Orchard: Tied in
with the shift of patients over to the personal care home the new 25 beds that
we built, and I am informed there is no waiting list for PCH placement now and no‑‑[interjection]
Oh, for surgeries? Oh, sorry. No waiting lists for the surgeries right now
and they are utilizing their bed capacity for appropriate medical needs. They are not admitting people who do not need
to be at a hospital, in other words.
Mr.
Plohman: So the
minister is saying that all of the panelled patients are now in the personal
care home and there is no waiting list that has to use acute care beds for the
purposes of personal care patients?
Mr.
Orchard:
Essentially, that is correct.
There is not "no" panelled patients in the hospital, but a
significantly lowered number of panelled patients in the hospital with the
opening of the 25 beds.
Mr.
Plohman: Just on
that, Mr. Acting Deputy Chairperson, is the Dauphin addition to the personal
care home now operating fully normal and fully staffed and with all beds being
utilized?
Mr.
Orchard: Without
having exact numbers, it is pretty close to being fully operational now, if not
fully operational.
Mr.
Plohman: Can the
minister indicate why there were no LPNs hired in that operation?
Mr.
Orchard: I do not
even know whether that is accurate, so I cannot indicate why.
Mr.
Plohman: The
minister has no information or any speculation he could make as to why the
administration, in consultation with MHSC, would not have approved the staffing
with LPNs in any way? Is this the normal procedure for all personal care homes
in the province now, or is this procedure for all new personal care homes?
Mr.
Orchard: Mr.
Acting Deputy Chairperson, first of all, as I indicated to my honourable
friend, we do not have knowledge as to whether my honourable friend's statement
is correct. If it is correct, I have no
explanation because I have received none.
If my honourable friend's statement is correct and he wishes an explanation,
we will ask that of the administration.
Mr.
Plohman: My
understanding is that the staffing complement is arrived at as a result of MHSC
working closely with the administration to determine the needs and the type of
staff that would be included in that kind of operation. If I am wrong, I would be pleased to be
corrected.
Mr.
Orchard: We will
see what we can do in that regard.
Mr.
Plohman: I thank
the minister for that undertaking. I
think it is something that the nurses in the facility are extremely concerned
about. I would have assumed that would
have found its way back to the minister at some point. If it has not, then I am pleased that he has
taken note of it today.
There are a couple of other questions I wanted
to ask the minister. He may recall that
I did send a letter to him suggesting that he might want to look at publicly
elected boards as opposed to the situation in Dauphin where the shareholders or
members could vote for the board members.
There was quite a controversy there last year over the abortion issues,
the minister may recall, and there was a lot of polarization of the community. This issue came up in terms of how the board represents
the public at large, and there was some discussion about whether there should
be a change in the way they were elected or appointed.
Can the minister indicate whether he has
looked into that any further, into the issue of having publicly elected
hospital board members?
Mr.
Orchard: Mr.
Acting Deputy Chairperson, this issue has come up. It came up most recently at the debate of the
MNU. The nursing as a profession
suggested a way that they might achieve greater representation on the board as
to public elections.
We have given some thought to that but at the
present are not convinced that necessarily will resolve the kind of problem
that my honourable friend identifies in terms of polarization of the community.
I will give my honourable friend two points to
ponder, and he might give me some guidance as to whether he wishes me to pursue
that with the
I would be interested in making sure that my
honourable friend in advancing that is not advancing it on behalf of the property
owners of Dauphin.
Mr.
Plohman: Mr.
Acting Deputy Chairperson, it is a nice argument on the part of the minister
that there really is no relationship to the question asked. In this particular case, my reference to the
polarization was a characterization of the problem that resulted, not
necessarily that this was the solution, but it was a problem that caused a
searching of souls really to look at the way the operation did take place, and
maybe some changes that could be made, and whether it might help in the future
with accountability‑‑let us put it that way‑‑at least a
perceived and perhaps real accountability in the eyes of the public.
So that was why that idea was put forward and
one that certainly would deal with at least the perception of accountability, I
think, in terms of the vote if all people could vote for those elected
officials in real accountability. But it
did draw attention to the operation of the hospital which had not been
something that was foremost in the minds of the majority of the public for
perhaps many years. There was just a
board there that went about their business and did their job. It was not something that was forefront in
the minds of the majority of people.
I think in terms of the deficit, that is
something that the minister is responsible for and MHSC as well as the administration
of the hospital. Together they have to
work that out. It may be that the
guidelines were not sufficient to allow for proper operation. The minister has admitted that there have been
some adjustments that have taken place.
I hope that it is realistic and that we cannot lay the blame for closure
of beds on the feet of this minister because he is underfunding. I hope that is not the case, and I have
prevented myself from making that kind of direct allegation until I know that
that is a fact. I think it is something that he should consider when something like
this happens, when you are dealing with a new facility as well as how it was
administered at that time. All of these things
have to be considered.
So I just ask the minister whether he has, in
fact, looked at some changes to how boards were appointed, and even
incorporated as was brought forward. It
was not a fact of knowledge for the majority of the public that that was a
privately incorporated facility using public funds. There was some concern about that as well,
that there should be a change under The Health Act.
Maybe the minister could indicate how many
facilities are incorporated in a similar way to the
Mr.
Orchard: We can
get specifics, but most of our major facilities are incorporated under private
act.
But, you know, I am intrigued with my
honourable friend's statement that he says, deficits in hospitals are now
government responsibility. My honourable
friend now wants to be a little more narrow in his statement by saying, that
deficit meaning the
Mr.
Plohman:
Possibly. You heard it all, put
it in context.
*
(2220)
Mr.
Orchard: Now he is
saying possibly. I mean, my honourable friend
is a typical New Democrat.
When in government my honourable friend sat
around a cabinet table with Howard Pawley and the Minister of Health, I believe
it was Wilson Parasiuk at the time, and when they ordered the mandate of the
closure of 130‑some hospital beds in
Now my honourable friend, from the comfort of
opposition, is saying, deficits are the government responsibility. He has flip‑flopped on a policy put in
place while he sat around a cabinet table and agreed to a policy of the Howard
Pawley government. I mean, that is the
kind of moral bankruptcy we run into with New Democrats consistently across
this country.
That is why the government of
Mr.
Plohman: Mr.
Acting Deputy Chairperson, I have a number of other questions. I do not know that that response deserves to
be dignified. It is clear that the
minister has found a way to misrepresent the position I have made. I will, for the record, indicate clearly that
in the case of the
As I indicated, it was quite possible that
there was an obligation on behalf of the minister, and he has admitted to that to
a certain extent earlier on. I think we
can leave it at that, and I will not dignify his comments with regard to flip‑flopping. He obviously chooses to hear certain things
and not hear other things.
(Mr. Deputy
Chairperson in the Chair)
Two questions that I have wanted to ask: Has the minister looked at the issue of
psychiatric services and beds for the
Mr.
Orchard: Mr.
Deputy Chairperson, as discussed earlier when we were dealing with the Mental
Health review line, in the interest of brevity and not wanting to repeat
answers, my honourable friend might want to consider some of the discussion around
the Parkland, Westman, West Central Mental Health Council co‑operation
around developing an action plan for service provision in those respective
regions which has input from Dauphin, et cetera. They will be presenting to government what they
view as a reasonable plan of action to implement over the next little
while. Elements such as my honourable
friend has suggested may well be part of the recommendations for action that the
Regional Mental Health Councils of Parkland, Westman and West Central come up
with.
Mr.
Plohman:
Certainly it is a serious issue of concern to the community in terms of
the general psychiatric services in rural areas, and particularly in
I point out to the minister, as he knows, that
you cannot necessarily accomplish everything at once, but you certainly can work
towards it, and I think the minister should be doing that. I make that plea on
behalf of the community of Dauphin because it is a serious issue.
I want to raise one other question before I
turn this back‑‑and the patience of my colleague the critic is
certainly acknowledged here‑‑the issue of naturopaths being covered
under medicare. I was looking through
the information that the minister just tabled‑‑and I will turn this
over to my colleague as well‑‑for the outline of the various
programs in the various provinces.
Naturopathy has been something that several constituents have brought to
my attention that the
I was looking through the information the
minister presented here. It is not
mentioned in most provinces as to whether it is excluded or not, but P.E.I.
does not allow naturopathy and neither does
Has the minister had representation from
people in the
Mr.
Orchard: Mr.
Deputy Chairperson, I just want to indicate to my honourable friend in terms of
Mental Health Services provision, yes, I fully agree with my honourable friend
that you do not make changes overnight.
It has taken us four years to get to where we think we are going to make
some changes. I know that my honourable
friend will be dismayed to know that a lot of plans have been before previous
administrations starting in about 1971 and not acted upon.
The advantage that I have today in terms of
being Minister of Health is I have at least one of my critics urging reform of
the mental health system and I intend to harness that good will amongst the
opposition party. Unfortunately, my
honourable friend was a member of government when they had the luxury as myself
as opposition critic, even using Dauphin as a specific example, to develop more
community‑based mental health systems. My honourable friend, as a
minister of that government, could not even persuade the minister of the day to
make some modest changes to Dauphin when the critic in the opposition
Conservatives was suggesting Dauphin be chosen.
So I appreciate my honourable friend
understanding how difficult it is to move things in government because he
certainly must have been totally frustrated at his lack of achievement in Dauphin. I understand my honourable friend's
frustration, not getting anything done.
Naturopaths are not covered in any province
except
Mr.
Plohman: Well, the
minister obviously was not very familiar with this service, and perhaps, he
would want to look into it to see whether in fact it might be a cost‑effective
way and certainly fit into the preventative health model that would certainly
avoid the high costs of hospital care and drugs and so on that cost a way more,
much more. So it can be a cost‑avoidance
by ensuring that this treatment is something that is broadened in
*
(2230)
Mr.
Orchard: I
appreciate that piece of policy advice from the official opposition as to where
they think government should be moving in health care.
Ms.
Judy Wasylycia-Leis (St. Johns): Mr. Deputy Chairperson, let me first of all
apologize if I repeat any questions that have been asked in my absence for the
last couple of hours, and if I do ask a repeat question, please indicate and I
will withdraw the question and check Hansard.
I would like to begin by asking for the
information that the minister said he would make an effort to bring forward
this evening, the first being the unachieved target for this past fiscal year
for urban hospitals, the second is the target‑‑and I am going to
use the word "restructuring" target because that is how it has been
put to me‑‑for the present fiscal year for urban hospitals, and how
both the unachieved of last year and the target for this year are being
allocated in terms of on a hospital‑by‑hospital basis. Those are two questions.
The third is the operating grant for the psych
services building, Health Sciences Centre.
The fourth is the details on the capital construction of the psych
services building, specifically the information on a stage basis for the construction
of that building with information pertaining to tendering and the lowest
bidder.
There are some other things I will come to
that the minister made a commitment to get, but it will come back to that.
Mr.
Orchard: Deficits
are $4 million from across the Urban Hospital Council group, and unachieved
targets from last year, $12 million.
They are going to be prorated amongst the facilities on the basis of, we
anticipate, their allocation of the global budget.
Pardon me, that allocation is only on the $12
million. The $4 million, of course, is
facility by facility as incurred.
Ms.
Wasylycia-Leis:
Just to get clarification, the minister is saying the total deficits for
urban hospitals for this past fiscal year or this present one is $4
million. I am not sure what‑‑
Mr.
Orchard: As close
an estimate as we can achieve without consolidation of the books at fiscal year‑end,
March 31, 1992.
Ms.
Wasylycia-Leis:
The minister has indicated that the unachieved restructuring target for
this past fiscal year is $12 million, and that is being prorated across the
board?
Mr.
Orchard: Prorated
to the eight urban hospitals on the basis of their percentage of budget.
Ms.
Wasylycia-Leis: I
am still having some difficulty with this, and I will try to be as succinct as
possible. Could the minister ndicate,
first of all, why it is that if certain hospitals did not meet this
restructuring target last year, that the unachieved target is being prorated
across the urban hospitals?
Mr.
Orchard: The $12
million was a target issue put before the Urban Hospital Council, and when
unachieved, is distributed according to their budget.
Ms.
Wasylycia-Leis: Could the minister indicate who directed the restructuring
target to begin with?
Mr.
Orchard: Mr.
Deputy Chairperson, last year when the hospitals struck their budget, they
asked for X number of dollars, and government said, no, we can give you this
number of dollars. Within that, a target
reduction of $18 million was between the total request and what we could accede
to. That had to be found and was not
found.
That has caused deficits to be brought forward
into this year which are the first call on the increase of $53 million in the hospitals. This year we are asking the hospitals to meet
their commitments with new budget money.
We have provided dollars for certain salary categories that have already
been agreed to. We have given a funding
mandate for contracts which are to be negotiated, and we have given some
increase on the supply side. We are asking the hospitals to manage within the
budget of $949 million or $948 million, an increase of $53 million to our hospital
system this year over last year.
Some of the budget goals that were set last
year, in terms of the negotiations of demands placed by the hospitals on the
system and our ability to provide the money, were not met and must be met from
this year's budget.
Ms.
Wasylycia-Leis: Mr. Deputy Chairperson, this is very confusing,
and I do not think it is because it is late or that I am not able to analyze
the numbers given to us.
I think there is a great deal of confusion
created by the minister and this whole process of budgeting. I do not know if it is deliberately designed
to confuse us or not, but it certainly is having that effect.
How can the minister say that whenever we have
raised the question of these budget reduction exercises that urban hospitals tell
us they are going through, whenever we have asked about these restructuring
targets, the minister has consistently said that the numbers we are talking
about are the difference between what the hospitals have requested and what the
government has allocated? He has
consistently turned it back to us and said, do we believe in a deficit policy
or not for hospitals?
Yet now as we piece our way through this it
becomes clear that there really are two separate issues. There is an issue of deficits, and unless I
have mixed this up, the minister has said that the first call on the $53 million
this year will be $4 million in deficits held over from last year.
So if there are $4 million worth of deficits
from our urban hospitals, how can there be $12 million unachieved, so‑called
restructuring target, when in fact that number is supposed to be all a result
of deficits which are a result of the facts that hospitals asked for more than
this government was prepared to give.
* (2240)
Mr.
Orchard: No
matter how confusing the issue is, there was $898 million, I believe, available
for the hospitals last year. Their demands were maybe $950 million? I do not know what the total number was. The budget number was $898 million. From that the Urban Hospital Council was
mandated with a $12‑million agenda across the board to reach their
portion of the $898 million of hospital spending. That was not achieved.
That has to be achieved out of this year's
global increase of $53 million, and that is going to be the first call before
the hospitals can consider new program or whatever because there is no
deficit. They did not meet their
budgetary goals and targets last year.
Now, the easy answer, of course, is to simply
go to the taxpayers or the money markets, borrow more money and put it into the
system. But that is not what we are
doing. That is not what has been done
ever since the no‑deficit policy was put in place.
Now, this year there is $53 million more for
the hospital system than we budgeted last year.
That is to meet all the requirements of the hospital system, salary
increases, a negotiating mandate, a supply increase and retirement of unmet budget
goals from last year.
I cannot make it any plainer than that, and
the only thing, I suppose, that makes it plainer is if we said, okay, we will
give you the money in addition to the $53 million that you ran in deficit last
year and in the targets you did not meet.
But we are not doing that because we are asking the system to come around
and manage better, bluntly put, and that is going to mean making management
decisions.
I will give you an example.
We are making the similar proposal to all of
the hospitals. I make no bones about it, they all want more money. But we are not in a position to provide more
money. We have budgeted $53 million more
expenditure this year than last. I will
put that, and the only exception I will make because I simply do not know whether
I know that we are significantly higher than
I know
In the process of providing an opportunity to
make management decisions in our hospitals, we are providing $53 million more this
year than what we budgeted for last year to cover hospital activities. It is not enough, but it is significantly
more generous than other provinces are making available to their hospitals. We are asking our managers of the system to
undertake management initiatives to operate within budget and to not compromise
patient care. We hope they are able to
accede to that.
As we talk, shall I say, they are developing
management and action plans to present to government as to how they will be
able to carry out their operations with the budgets that are being contained in
a $950‑million approximate hospital budget, $53 million higher than last
year.
Ms.
Wasylycia-Leis: I
am not trying to make any case any which way.
I am not trying to argue more money for hospitals or less money for
hospitals; I am simply trying to get information so that we can then make
judgments. I still have not got all that
information, so I will have to ask a few more questions.
At the start of that last long answer, the
minister said, both the $4‑million deficit money and the $12‑million
unachieved target would be the first draw on the $53 million this year. Now is it both, is it one or the other, or is
it $12 million plus $4 million?
Mr.
Orchard: Both.
Ms.
Wasylycia-Leis:
We now have for the $53 million:
$14.5 million for anticipated salary negotiations; $17.5 million for pay
equity‑‑although I know there is some adjustment based on personal
care homes that we have to subtract from those numbers, settlements pertaining
to personal care homes, so there is some reduction there‑‑$12
million for the unachieved target hospital budget reductions of last year; $4
million in hospital deficits‑‑and I fail to still see the
difference between the unachieved budget reduction target of last year and the $4‑million
deficit, which the minister had said before was the same thing‑‑and
we have a new restructuring target or hospital reduction target for this year
of, I understand, $10 million.
I understand that there is $15‑million
divided over the next two years, $10 million for this year and $5 million for
next year. That is where this number
that has been in the press of $27 million appears to come from, the $12 million
unachieved of last year and the $15 million for this year and next year. So we are now looking at more than $53
million.
Could the minister give us some clarification
on that, and is that $10‑million restructuring target also part of this
$53 million?
Mr.
Orchard: The $53
million is an increase in money year over year out of which the operations of
the hospitals can be achieved. Included
in that, they have to retire their deficits, meet unmet targets, provide monies
for the increased negotiated salary agreements.
There is a figure in there of‑‑what was it?‑‑$14.7
million for all of the contracts that are coming up, but that is personal care
home and hospital.
Ms.
Wasylycia-Leis: The minister can describe this in any way he wants,
but as far as I understand it, and I may be wrong, in fact there has been quite
a shift in terms of hospital financing in the last couple of years and I am
just trying to get a clarification of that.
I am not saying one way or the other if it is bad, good or indifferent,
I am simply trying to get an understanding of that shift.
Now the minister is pointing to other
provinces where there has been that dramatic shift and change in the way
hospitals are funded and considerably less money on the table to deal with hospital
needs. That may be something we have to
look at, but I am trying to figure out what happened last year and this year that
is quite a change.
By all accounts, these are people in the
system saying this, that last year was really the first time since‑‑I
think the year given is 1970, that hospitals have actually seen a cutback and that
in fact funding to hospitals has been far less than inflation. While there may be an increase on the supply
side there has been a serious decrease or even zero percent on the salary side
so that hospitals end up in effect with budgets insufficient to meet even the most
basic of services as happens with the cost of living and inflation. They end up with less money and that in
effect is a cutback.
*
(2250)
Now, maybe that is the only way we can deal
with hospital budgets right now. I do
not know, but I am trying to get a sense of that and what it means, and when we
get all the details at some point from the minister about the present fiscal
year and the budgeting for hospitals what it is going to mean in terms of services. Can the minister indicate that there was a
shift in policy starting last year with financing of hospitals and that there
were in fact directives to hospitals to cut‑‑I know the minister
does not like the word "base," but that is what it amounted to, cuts
to the base, because the increases did not at all keep up with cost of living
and wage settlements and therefore there were reductions to the base and that
is a cut to the base.
Mr.
Orchard: If we
went back to last year now, I think the hospital line increased by‑‑we
can get that kind of number, but it was probably in the neighbourhood of $48
million or whatever. I realize that gets to be kind of confusing when my
honourable friend is hearing tales of woe from somewhere in the system.
How in the world can you possibly come around
an issue where your analogy is you have cut back when you have provided $50 million
more funding in last year's budget over what was in there for what would be '89‑90? I guess the answer simply put is just: Give them everything they ask for and then
they will not bother you.
That is not the real world. Each year we have provided more money not
less to hospitals; not as much as they have wanted, not as much as they would
like to have spent, but certainly the biggest single increase in program line
expenditure in my department has gone to the hospital side.
Yes, it is not as much as they have asked for
and in restructuring their operations we are asking them to use less dollars
than what they are asking for, yes. They
are developing the management plans to tell us how they can structure their service
delivery with the least impact upon the patient to deliver care within an
increasing budget, but not increasing as fast as they want it to be.
Now, my honourable friend makes the case about
"less than the inflation rate."
Well, I do not know whether I buy into that or not, because what is the
inflation rate? The inflation rate is something
like 4 percent last year. But yet
nurses' salaries, which are a significant component of the hospital, went up by‑‑how
much last year?‑‑by the time you have had added the two increases,
about 10 percent.
So, you know, if my honourable friend says we
should be providing funding at the rate of inflation, I would be glad to, because
this year the rate of inflation is projected to be something under 2 percent,
and we are providing 6.1 percent more money.
But you know what drives the hospital budget
is the salaried negotiations of employees, and pay equity, and other
legislative initiatives that put money in caregivers, not to provide more care,
but more money to provide the same hour of care they did last year, the year
before, the year before, the year before.
As long as we have wage settlements approaching double digit per year,
and you provide even 6 percent increase in funding, you are going to run into
squeezes somewhere in the institution.
That is why this year all the demands are there for the support workers to
demand more.
They have gone through a salary freeze, and we
dealt with this issue before supper.
Love to give them a hefty raise, but you know what? The real world out there in the rest of the economy
of Manitoba were without government support, probably has had wage freezes,
wage rollbacks, layoffs, closures, all the things my honourable friend's
colleagues daily get up and with glee point out to the people of Manitoba that
the private sector is rolling back, is doing this and making tough decisions.
At the same time, we seem to be of the thought
pattern emerging here that, by golly, we can operate hospitals in isolation to
that reality in the rest of the economy.
Well, not so.
Certainly they want more money than what we
are giving them, but more money is not available. So they are going to have to manage, and they
are going to have to manage in a way that does make a best effort at protecting
patient services and remaining within budgets, without deficits. They are developing action plans, hopefully,
to be able to do that.
I am not saying it is easy decisions for the
hospitals. I do not have easy decisions
in the ministry of Health. The Minister of
Finance (Mr. Manness) does not have easy decisions in allocating $101 million
more to the ministry of Health. It is not
going to be enough, but it is a heck of a lot more than other areas of
government have received, certainly a lot better than other provinces are
doing.
Now, to fill out my argument with my
honourable friend: For the fiscal year
'91‑92 that we have just nicely ended, we had a $47‑million increase
in hospital funding that year, not a decrease, but a $47‑million
increase. That was 5.6 percent compared
to 6.1 percent this year. Not enough,
but it is a total of 11.7 percent over two years when inflation would total 6 percent
over those two years.
You know, how much more do we pour into the
hospital system before we ask the hospital system to operate within budget and
to do more with less money? In almost
every place you go in the
Ms.
Wasylycia-Leis: Again, I am just trying to get all of these different
statistics straight, and the overall policy of this government clear, because
it is still not clear. Until it is clear,
we cannot really be that helpful in terms of the minister's overall strategy,
and we cannot make a decision one way or the other if what the government is
doing is good, bad or indifferent.
Again, the minister refers to a $47‑million
increase to hospitals last fiscal year, the one we have just ended, but it appears
that this government is very good at giving with one hand and taking with the
other, because in fact he gave $47 million to hospitals. We do not know exactly how that broke
down. Then it also took away $18 million
as part of this hospital budget reduction.
If the minister would like to clarify that,
that would be fine. I will pose that as
a question then. Let me ask a related question
to that since I can get it all out and we can get the definitive answer.
I think I was quite wrong when I suggested
that of the $53 million this year that included the roughly $14 million or so
for contract settlements, the $17 million or so for pay equity adjustments and
the $4 million for deficits. Then I also
suggested the minister was rolling in near the $12 million unachieved from last
year and the $10‑million restructuring target for this year, but in fact
that cannot be the case. The unachieved
target and the new target for this year is what the minister is taking off of
the $53 million.
So as far as I can tell, and I would be glad
for the minister to clarify this, we are looking at roughly the $14.5 million
for contracts, $17.5 million for pay equity‑‑although we have got
to take off the personal care homes out of that‑‑$4 million for deficits,
and that leaves about $18 million which must be for supplies. Therefore, that is about a 2 percent increase
on supplies which is less than the cost of living. Then on top of that the minister is saying,
take off $27 million, or, for this year I guess it is $12 million and $10
million, so that is $22 million. Is that
not the case?
*
(2300)
Mr.
Orchard: While my
honourable friend is saying that government gives with one hand and takes away
with another hand, I want my honourable friend to give a slight amount of consideration
to how and for all intents and purposes these budget numbers, which have been
approved, have been at least expended, maybe a million or two more, okay? For fiscal year '90‑91, the budget was
$845 million for
For '91‑92, that figure grew to $892
million, and for '92‑93, that figure I am asking concurrence around, is
$947 million, and we expect them to spend it all.
Now, how can my honourable friend make the
statement without some questioning as to what is happening when you go from 845
to 892 to 947. You say we are giving
with one hand and taking away with the other when 60 percent of that is being
expended each year by the hospitals that she says, we give on one hand and take
away with another.
They spent the money, increased money. They did not spend as much as they asked for
because we would not give it to them. That is where we get into $12 million,
$18 million, $4 million, all of the numbers that bounce and float.
But my honourable friend has to acknowledge
that we go up every single year in funding, and if we threw the floodgates wide
open, this year's budget would have been a billion dollars, not $947 million,
and that would have meant $53 million that we‑‑well, I suppose an
easy solution would be to have flattened the home care budget and pulled $7
million of increase out of home care and put it into the hospitals, because
they would have spent it. But I do not
think my honourable friend would have been happy with that somehow.
How is it that hospitals should be treated any
differently than any other part of government?
They are given a budget and they are asked to operate within it, and
they are going to have all sorts of opportunities to create pressure on
government to make them recant and give them more money, aided and abetted by anybody
who wants to argue for them. We have
given more money each and every year including this year.
It is not as much as they want because they
have incurred deficits and have not met targets, but does that mean we recant on
the process of trying to bring some management discipline to the
hospitals? I say no. But you cannot make the argument that, as you
just did five minutes ago, we give with one hand and take with another, because
otherwise that means somebody is living pretty fat and sassy with a Swiss bank
account with $47 million more spent last year and are going to sit in a bigger
bank account in Switzerland with $53 million more this year, if we have given
and then taken away. That is
balderdash] We have given, given, given.
Ms.
Wasylycia-Leis: Mr. Deputy Chairperson, the question is, if this
minister and this government have given, given, given, and hospitals have
received dollars to the tune each year at least equal to the cost of living,
then they would not now be in deficit situations or having unachieved targets
or cutting back services. So that does
beg the question since the hospitals are not getting that money in terms of the
operating budgets, where does the money then go? [interjection] The minister
says they are. The fact of the matter
is, if all these hospitals were getting these kinds of increases, we certainly
would not be looking at the kind of cutback scenarios we are today.
Now, there is another whole element here at
play which I am not necessarily objecting to, I am just trying to sort
out. We are dealing with two different
processes, two different elements to this minister's strategy with
hospitals. One is the annual budgeting
process and how they figure out the cost of living and what they are going to
give for supplies and what they expect salary negotiations and how much money
is on the table for all of that. There
is a separate process for so‑called reform purposes where this government
and this minister is asking, urban hospitals at least, to come up with
reductions to their hospital budgets for the goals of downsizing hospitals
presumably.
That is being translated in terms of these
dollar figures that are bandied about all over the system so they are not fantasy
on my part. The numbers of $18 million
and $12 million and $27 million and $15 million are widespread in the system. The
hospitals have been trying to come to grips with these targets for the last
number of months. As well they have been
handed bed‑target‑reduction figures.
So there are two separate processes going on
here. I do not necessarily object. I am trying to understand what hospitals have
been asked to do because, in fact if it was a simple, straightforward matter of
hospitals getting the money that the minister is talking about, we would not be
sitting here today talking about why are some hospitals looking at major bed downsizing,
why are some hospitals talking about closing operating rooms, why are some
hospitals saying they cannot meet the waiting list for surgery, and so on and
so forth.
There is clearly some other dynamic here from
the department and the minister, and I am just trying to get that clarified.
Mr.
Orchard: Let me
help my honourable friend. In the last
two years the combined increase on the Hospital line has been 11.7 percent,
significantly greater, almost double the inflation rate. My honourable friend asked the very
legitimate question, what in the world is going on? They are getting more than double the
inflation, or they are getting approximately double inflation rate. Why is it they are talking about all of these
dire consequences because of underfunding at double the inflation rate?
Exactly the question because we asked them for
fiscal year '90‑91 to spend $845 million.
We asked them in '91‑92 to spend $892 million. We are asking them this year to spend $947 million. The difficulty is that last year they spent
more than $892 million, if you want to be blunt, without authority to do so,
and under the no‑deficit policy that is in place they have to make that
up first call on this year's budget. But
that begs the question, why was it not achieved last year? Good question. It is not because the funding increase was
not there because the money is gone, it has been spent by the hospital and
more.
Now, if my honourable friend believes that
there should be some other method by which we attempt to get hospitals to
develop operating plans to stay within budget, I am listening. I am listening, because we have given
increased financial commitments every single year that we have been in
government. It has not been enough in
some years, and that is leading hospitals to tell my honourable friend, oh,
this dire agenda, or whatever they may or may not be telling my honourable
friend. The problem is I do not have any
more money to give them, because the taxpayers do not have any more money to
give them, and furthermore other departments in government do not have any more
money to give hospitals.
That leaves the challenge to operate with the
budget that is increased by 5.7 percent last year, 6.1 percent this year on the
Hospital line and attempt to maintain services through better management and
more effective use of the resource.
There are management decisions that can be
made within hospitals to allow that. You
know what will not happen?‑‑is if they believe they do not have to
undertake those management decisions, because somebody is going to make a
political issue out of their lack of funds because they are over deficit. That is the first and foremost thing that has
happened and allowed the hospital system to command over 50 percent of the
operating budget of the ministry of Health.
It can go on forever, but we cannot afford that.
Now, if we had provided less money in the last
three years, I would be standing here defenseless, but when we have provided more
money and my honourable friend is making the case that the more was not enough
more, well, that is fine, I accept that.
I mean, that is a different argument.
To try to make the argument that we did not provide
them more money is not legitimate. We
asked them to spend $845 million in '90‑91; $892 million in '91‑92,
and we are asking them to spend $947 million this year. Last year, we know they spent more than that. That is the problem.
*
(2310)
Ms.
Wasylycia-Leis: Maybe if we break this down again, and if I pose
a few more specific questions, maybe we will be a little further ahead.
Perhaps, the minister then could explain, if
the reason for the deficits and unachieved targets, which is the first draw on the
$53 million of this year, is a result of hospitals spending more than the $892
for 1991‑92 fiscal year, then what is the right number? Is it $4 million? Did hospitals overspend that amount by $4
million or by $12 million?
Mr.
Orchard: Overspent by $4 million and did not achieve a $12‑million
target.
Ms.
Wasylycia-Leis: See,
we are right back where we started, because the minister is not clearly setting
out what he is up to. I mean, I am going
to have to come back to this. Maybe he should
get a flip chart out or a blackboard.
He keeps coming back to the fact that this
whole situation that we are in is because hospitals spent‑‑let us
just use the 80, comparing the last two years‑‑more than this
government was prepared to fund, and that being $892 million. That is what he keeps coming back to.
If that is the case, and that is the case,
which the minister says amounts to $4 million, then would the minister please explain
once more where the $18‑million budget‑reduction target came from,
what it applies to? If it is not to do
with the difference between expectations or desires or wishes versus what the
government is prepared to accommodate, then what is it a target against, where
did it come from, why do we have a $12‑million unachieved target for this
coming year?
Mr.
Orchard: Because
it was not achieved in the fiscal year in which it was proposed to be
achieved. You know, I do not know how to
help my honourable friend here, but we have ourselves a situation where every year
the budget has increased. I can run through
the numbers again in terms of overall increase to the hospital system.
It is not enough. I agree it is not enough, but I also do not
agree that the simple solution is putting the money in as my honourable friend
would seem to suggest, and I am even putting words in her mouth there. Basically I get that sense, that that would
solve all the problems if we simply give them more money. That is what the
member for Dauphin (Mr. Plohman) said earlier on this evening and certainly the
member for Brandon East (Mr. Leonard Evans) has said that, but there are other
issues that need to be addressed in terms of the management of our hospital system. Well, I am going to suggest that after a
couple of minutes here we just take a couple of minutes break and then come back.
You know, within the hospital systems
hospitals are major organizations and they are spending significant amounts of
money, and the easy answer every time there is a challenge on the budget is,
well, we are going to have to reduce service.
My honourable friend mentioned closing an operating theatre, closing
beds, laying off nursing, et cetera.
Well, you know what? We have some
other suggestions to make as the operating plans come in, i.e., management and
compensation levels in management.
Every organization in the private sector is
operating with a flattened management structure now. Every private sector company with few
exceptions that are surviving today have a flattened management structure. Is that not a reasonable request for hospitals
to take a look at the management structure?
It means tough decisions. You
might have to actually eliminate a layer of management possibly. But is that a more appropriate management adjustment
to budget to contain budget growth than the immediate consideration, which is
very highly politically charged and will gain public support against
government, of closing an operating room or laying off nurses or closing beds
or reducing service level?
Is there not an opportunity to take a look at
areas of comparable service delivery within our hospitals like personnel, like
purchasing, like training programs and a number of other issues that we have
before the Urban Hospital Council where not every hospital develops everything
they want within their four walls and their jurisdiction, but they develop a
shared service concept?
I mean, that is what has happened two years
ago or a year ago I guess in
I have broached a little topic recently, and I
would love to have this analysis. I am
going to describe it to you briefly because I think it would help us all
understand. I would like to see a scale
developed of one to 100 of our hospitals, regardless of size, and you analyze
for the budget and you develop an effectiveness rating based on how many
patient days of given medical and surgical services you do on the basis of the
beds and the hospital count. A real DRG,
if you will, across all hospitals, because I want to tell you that I think we
would find some pretty dramatic and successful smaller hospitals that do one heck
of a job on a very modest budget.
Some of our larger hospitals have got involved
in any number of ancillary activities with layer upon layer of activity, and when
you find how many dollars actually come out the end of a tube in terms of
patient care you might find it to be significantly less than some of our
smaller and more effective hospitals.
That is not a precise science, and we do not know whether we can achieve
that kind of analysis, but I would like to have it because otherwise government
keeps getting buffeted around by institutions that are major and significant
saying that unless we have more money we are going to have to close operating theatres,
as my honourable friend has already mentioned, obviously from some prediction
from someone in the system, or that we are going to have to close beds or
reduce patient services.
Well, I want to tell you, before we accept
those kinds of plans we are going to ask the other very pertinent questions: Have
you considered, for instance, your personnel departments, your purchasing
departments and other departments which are nonpatient care and have an
opportunity for shared services beyond the confines of individual hospital
institutions? Until we get an answer, we
are going to have some very tough negotiations, and that is what this whole
exercise is about. Each year as we have given more money it has not been
enough. It has not been as much as
requested. It never will be. We are into some tough decision making at all
levels of government, and health care is no exception. This budget round is no exception, where we
are asking hospitals to develop management plans to present to government as to
how they are going to deal with the expenditure of $947 million this fiscal
year.
*
(2320)
Mr.
Deputy Chairperson:
Would it be the will of the committee to take a two‑minute break?
[Agreed]
* *
*
The committee took recess at 11:20 p.m.
After Recess
The committee resumed at 11:28 p.m.
Mr.
Cheema: Mr.
Deputy Chairperson, can the minister tell us, have they done any study in terms
of the patients who live, for example, six months in Manitoba and six months
somewhere in Los Angeles or Florida and enjoy the sunshine and the weather, and
how much money we are paying on their behalf to the private insurance companies
out of the province?
Mr.
Orchard: Mr.
Deputy Chairperson, let me get my honourable friend's question correct. Do you want to know how much we are paying
for Manitobans who are out of province up to six months in terms of medical
services they access, how much we pay to the providers out of province? Let me ask for further clarification. People may be down only a month, but they
access medical services. If we can give
you a number that would show what we have paid for out‑of‑province
services regardless of whether the person is gone one month or up to the six
months, that would be sufficient?
Now bear in mind that there is another side to
that coin that we do not have, and that is the amount‑‑okay, we pay
equivalent Manitoba physician rates, equivalent Manitoba hospital costs based
on a hospital of the same size that a person is in, on an average per diem
basis, and anything in addition to that is picked up by the individual's
private insurance coverage. It is that
latter thing that we do not have. We
will have that figure tomorrow.
*
(2330)
Mr.
Cheema: Mr.
Deputy Chairperson, we are only concerned about the money we are paying at par
with what we are paying in
I will try to explain it again. For example, if somebody is going to the Mayo
Clinic, which is referred by the physician for services we do not have in
Manitoba, how much have we paid for the last years on a year‑to‑year
basis, '88, '89, '90, '91, '92?
Mr.
Orchard: There
are two separate issues. The first one
is those who leave the province, maybe spend some time in
Mr.
Cheema: Just to
the
Mr.
Orchard: We can
pull that.
Mr.
Cheema: Mr.
Deputy Chairperson, can the minister also find the amount of money we have paid
to other provinces for some of the services which are not available? Not the amount if somebody is visiting and
gets sick, I am not talking about that, but just for referral for special
cases?
Mr.
Orchard: Yes, we
will attempt to provide that for out‑of‑province Canadian
referrals. [interjection] We may not be able to get the out‑of‑province
Canadian referrals for tomorrow, but the other two we have. So we will, for sure, have the first two and
we will make our best effort at the third one.
Mr.
Cheema: Mr.
Deputy Chairperson, as long as we can get them within a week or two weeks, that
is fine. Just for our own information,
we want to know how much the province is paying for these services.
Can the minister tell us what the policy is in
terms of what the minimum residency level is for somebody who would like to go to
a personal care home, because there have been some incidents that people have
asked us, if they were here for two years or three years and if they leave the
province for more than six months, whether they can get into the personal care
home and still qualify for the benefits?
Mr.
Orchard: Two
years immediate prior residency, minimum requirement, or‑‑how does
the 30‑year rule work? [interjection] Okay‑‑a combination of
previous residency in the province of 30 years or more. Either scenario will qualify you, but for
people newly moving to
Mr.
Cheema: Mr.
Deputy Chairperson, the reason I am asking that question is because some
individuals who are, for example, newcomers and are coming into Manitoba, if
their parents are also coming with them and within six months or one year they
get into a situation where they have to be panelled for a personal care home,
in those circumstances, it has become very difficult in terms of some of the
individuals as far as their financial status is concerned. Also, I think, if they are continuing to
occupy a hospital bed, they cannot go home.
So somebody else is paying their bills.
I would like the minister to review that
policy in view of the changing demographics and changing needs of Manitobans.
Mr.
Orchard: I am
informed that we have a residency program‑‑no, let me explain this
better. After three months, an
individual can become eligible for hospitalization, if you will. [interjection]
Only from other provinces, that is right.
It seemed they were as‑‑after our two‑year residency
rule would trigger here, yes.
Mr.
Cheema: Mr.
Deputy Chairperson, if somebody is coming to
Because that would have been okay, probably,
10 or 20 years ago, but with the changing needs of Manitobans, the newcomers
and their families are coming, there have been situations where patients and
their families are in a very difficult situation. I think that needs to be reviewed from a
practical point of view.
Mr.
Orchard: Yes, just
in talking with senior staff here now, apparently when these rules were all
developed, some provinces did not provide any assistance on the Personal Care
Home Program.
So this was put in place to prevent‑‑well,
like with the medical program, I mean, the national, because it is an insured service
and every province has it. There was an
instant eligibility or, well, not instant, there is a three‑month waiting
time, but your former province‑of‑residence's program would cover you
for that first three months in Manitoba, so you are always covered, but on the
long‑term care side, yes. But now
that most provinces have, that is an interesting issue maybe to advance to see
whether we can narrow the reciprocal arrangement and maybe work in concert with
other ministers.
Mr.
Cheema: Mr.
Deputy Chairperson, the second part of the question is that somebody is coming,
for example, new to
That situation is going to become more and
more of a problem in the future because of the make‑up of
I am not talking about from province to
province; that can be taken care of with consultation with other
provinces. Where somebody is coming for
the first time to this country and ended up in
Mr.
Orchard: Not that
I want to get into the success or nonsuccess of a challenge, but bear in mind
that the Personal Care Home line is not an insured service under The Canada
Health Act, and it is at each provincial government's program implementation
that it is available.
But there is the pragmatic problem of, if you
have got the person hospitalized, which they qualify for immediately‑‑and
I hear what my honourable friend is saying and will try and see whether there
is any‑‑I want to get a handle on what the potential costs are,
too. I hate to be that crass, but I just
was under pressure earlier on tonight to help our hospitals along. We are under those kinds of demands
constantly.
Given the anomaly and immediate versus two
years, yes, that deserves a revisit to see whether there is an opportunity for
a refinement of the policy.
*
(2340)
Mr.
Cheema: Mr.
Deputy Chairperson, I will try again.
For example, a patient ended up in hospital, and they landed only a few
months ago, and they have a condition which requires hospitalization and after
that two months, if you revise their status, and they are supposed to be
panelled for a personal care home.
The family cannot afford the normal rate if
they are not qualified. In that
circumstance it becomes very, very tough for them to continue to afford the
medical necessity. They are asking, why
are we not being covered? So if you tell
them that is the policy, and they are raising a lot of questions, is the minister
right or will that uphold in a court of law.
It is just a matter of time till a certain
group gets together and lobbies the government; probably they will have no choice
than to change the regulation.
Mr.
Orchard: My
honourable friend is making a legitimate case or a reasonable argument, and we
will have a discussion on this a little later on if that would suit my
honourable friend.
Ms.
Wasylycia-Leis:
Just before I go back to hospital budgets, one question on this whole
area of insurance, and this has to do with Order‑in‑Council No.
334. I am wondering if the minister could
explain what the reason‑‑unless this has already been asked [interjection]
I am wondering what the reason for this change
was, and what the implications of the‑‑I am referencing the change
as listed in Order‑in‑Council No. 334 which changes‑‑I
do not know what it means, but it has to do with wording around medical
services in respect to benefits payable rendered to persons outside of Manitoba;
specifically, I see the biggest change pertaining to sections with respect to
more elaborate wording, whenever the following phrase is referenced in the
opinion of the commission could not be adequately provided in Manitoba. I am wondering if the minister could give us
an explanation for that Order‑in‑Council change and why it was
necessary.
Mr.
Orchard: I think
all that regulation does is clarify the procedure of when Manitobans can access
and have paid for referral services out of province. It did not provide any change in
approach. It only clarified or committed
to regulation the rules under which referrals for out‑of‑province
services unavailable in
Ms.
Wasylycia-Leis:
So is the minister saying that the change by this Order‑in‑Council
does not have any impact in terms of who can access services outside of
Mr.
Orchard: Mr.
Deputy Chairperson, it does not change the eligibility under the Manitoba plan
for individuals who are referred out of province, particularly to the U.S.
because in the Canadian system we just have reciprocal billing arrangements but
for accessing services, for instance, at Mayo Clinic as an example.
It clarifies the rules of eligibility and the
circumstances under which we would cover those costs for a
Ms.
Wasylycia-Leis: With respect to hospital budgets, perhaps I will
start asking some more specific questions.
I will try to be more specific.
First of all, could the minister tell us for
this past budget year and the one we are in what is the total budget for just
the urban hospitals?
Mr.
Orchard: For my
honourable friend the member for The Maples under regulation under the Health
Services Insurance, entitlement to personal care, there is a clause in here
which does allow for flexibility in decision making. I will read the Clause 37(2), The commission‑‑this
will all be changed to the minister I guess, basically‑‑may waive
the waiting period requirement for a person who meets the criteria set out in
Clause 36(b), if it is satisfied that a waiver is desirable to avoid an
inappropriate use of health care resources, i.e., hospital placement for a panelled
person.
Mr.
Cheema: That does
not solve the problem for the family members.
I think the decision then is left up to only the Department of Health
and the hospital. Then the family still
has to apply and go through all the procedures.
I think it should be uniform, acceptable like somebody else. I mean, if someone's family is here and
established their roots already, and they ended up coming within three months
or six months, they should be allowed to have access to the services the way
the others would have.
Mr.
Orchard: Getting
back to the question‑‑I have forgotten the question, I am sorry.
Ms.
Wasylycia-Leis:
Let us start all over again trying to figure out this question of
targets and budget reductions and so on by asking the minister for what the
total is for this past fiscal year and the one we are in for just urban
hospitals or members of the Urban Hospital Council.
Mr.
Orchard: I will
tell you what we will do. We will try to
give the figures for the Urban Hospital Council members basis preliminary
reconciliation on '91‑92. That was
the question, was it not?
Ms.
Wasylycia-Leis:
My request was for, based on the figures the minister has given for
overall expenditure for hospitals, $892 million for the past fiscal year, $947
million for the one we are in; of that, how much is for urban hospitals?
Mr.
Orchard: In '91‑92,
of the $892 million we have been talking, $680 million was for our urban
hospitals and that would include
Ms.
Wasylycia-Leis:
And for this fiscal year, the one we are in?
Mr.
Orchard: Now we
are asking tricky questions. An increase
of $43 million, 6.4 percent actually.
Ms.
Wasylycia-Leis: Does
that make it $723 million?
Mr.
Orchard: Uh‑huh.
Ms.
Wasylycia-Leis: One
other clarification before I figure out this issue of targets, the $4 million
figure that the minister gave us for deficits I presume was for all hospitals
in the
Mr.
Orchard: No.
*
(2350)
Ms.
Wasylycia-Leis: Was
it for Urban Hospital Council members?
Mr.
Orchard: I have
already indicated that about 14 times, yes. It is included in the number that
my honourable friend arrived at.
Ms.
Wasylycia-Leis:
Mr. Deputy Chairperson, if the minister would give us full information and
not in such a disjointed way, then maybe I would not be asking the same
questions over and over again, but it is still hard to figure this all out and
put it all together.
Of the $680 million, was the $18‑million
target off of that number or off of something else?
Mr.
Orchard: That was
an included number.
Ms.
Wasylycia-Leis:
So is the minister saying that‑‑could the minister explain
for us the difference between the $4 million incurred in terms of deficits, and
the $12‑million unachieved target?
Mr.
Orchard: Both
were included in the $680 million for last year and the $723 million this year.
Ms.
Wasylycia-Leis: Is
the minister saying there was a $4‑million deficit for urban hospitals
going into the '91‑92 fiscal year?
Mr.
Orchard: No. Look, let me try to help my honourable friend. Six hundred and eighty million dollars was
what we had projected the Urban Hospital Council members would expend last year. They spent more than that, and out of the
$723 million that we expect they may well spend this year, they have to retire deficits
and unachieved targets from last year which were included in arriving at the
$680‑million global budget. That seems
rather straightforward‑‑$680 million was the achieved spending
targets for the eight urban hospitals by the Urban Hospital Council
members. When they did not achieve that,
they carried forward those unachieved goals, whether it be achieving the budget
goals through no deficits or achieving targets for expenditures, they did not
achieve them. They carry forward any unachievements
in their budget. In other words any overexpenditure
from last year, above the 680, they carry forward the 723 this year. That is the first call. That is the way it has always been.
Ms.
Wasylycia-Leis: If
they did not achieve it, is that not a deficit?
Why is the minister using two different figures, 4 million and 12
million?
Mr.
Orchard: Because
the Urban Hospital Council agreed to work towards $12 million and did not
achieve it.
Ms.
Wasylycia‑Leis: Where does the $4 million come from then?
Mr.
Orchard:
Overexpenditures. Deficits.
Ms.
Wasylycia-Leis:
The minister has been very good at using a lot of bafflegab this
evening, and maybe he is taking advantage of the lateness of the hour. He has clearly not answered the questions I
have posed to try to get an understanding of where these numbers come from.
Mr.
Deputy Chairperson:
Order, please. Could I ask the honourable
members to go through the Chair so that Hansard does not run into a problem.
Mr.
Orchard: Six
hundred and eighty million dollars was the budgeted expenditure of the
hospitals. The Urban Hospital Council to
live with the $680‑million budget had to achieve $12 million of
identified program savings or operational savings in the hospital. It did not achieve that. So that is first call on the $723
million. In addition to that, they
overexpended by some $4 million, roughly.
That is not finalized because the year‑end reconciliation is
simply not calculated out to the last dollar, and that is a deficit position
that comes out of, with the no‑deficit policy, this year's budget. I mean, they more than spent the $680 million
last year, and now with those kinds of overexpenditures and targets not being
met that is first call on the 723 we are putting up this year.
Ms.
Wasylycia-Leis: Did they overspend the $680 million by $4 million
or $12 million or is it a combination of both?
Mr.
Orchard: Probably
two hours ago, eight hours ago, a combination of the both.
Ms.
Wasylycia-Leis: Is
the minister then saying that urban hospitals are running deficits for this
fiscal year that we are now in to the tune of $16 million? Is that now what the minister is calling this
unachieved target?
Mr.
Orchard: In the
Urban Hospital Council they agreed they would attempt to find $12 million of
program and other reduction expenditures‑‑just straight global
expenditure reduction. They did not
achieve that last year to stay within a $680‑million budget. So they have to achieve that this year out of
the $723‑million budget. In
addition to that, they overexpended by some $4 million by last calculation in
terms of deficits, and depending on which hospital incurred the deficit, it is
first call for whatever dollars it is of the $4 million. I do not know the distribution rate now, but
roughly 50 percent of our urban hospitals will probably have that $4‑million
deficit. Some will not have deficits.
Ms.
Wasylycia-Leis:
So is the $18 million which was the target for '91‑92 not then a
target against the base of urban hospitals?
Mr.
Orchard: It is
the first call on the $723 million this year.
Ms.
Wasylycia-Leis:
Let me try another angle. Could
the minister indicate what this so‑called target set by his department or
the Urban Hospital Council is for, to be deducted from the base of the '92‑93
budget?
Mr.
Orchard: Let us
take my honourable friend back to April 1, 1991. Demands were made in terms of how much money
the hospitals wanted to expend. We said
no, here is what we want you to spend.
That figure happened to be $680 million.
That was the baseline budget that was established for the Urban Hospital
Council membership last year. This year
it is $723 million, and the first call is unachieved targets on budget last
year. In other words, any dollars they
expended above the $680 million is first call on the $723 million this year,
because that is what "no deficit" means. That is what it means by meeting your budgetary
targets.
Ms.
Wasylycia-Leis: Unless the minister is prepared now to say finally
that the $12‑million unachieved target is actually a deficit, then I
think we are dealing with something quite separate and apart from this whole
issue of hospitals running deficits or not, because in fact the minister has
not ever said the $12‑million unachieved target is a deficit in clear
terms or, as he put it, an overexpenditure.
Therefore the requirement of meeting that unachieved target is not tied
to a no‑deficit policy. It is a
separate issue.
*
(0000)
Mr.
Deputy Chairperson:
The hour now being 12 midnight, what is the will of the committee? Carry on?
Mr.
Orchard: Yes. I do not know how many times we can dance on the
head of a pin, but $680 million was the budget for the Urban Hospital Council
members last year. I just asked whether
we had '90‑91's numbers so that my honourable friend could see that in the
progression that I shared with her earlier on, where we went from $845 million
to $892 million, the members of the Urban Hospital Council shared in a
significant portion of the $47‑million increase. It was not as much as they asked for, and when
they did not achieve their budgets within $680 million and the global
adjustments and the targeted adjustments, out of the $53 million this year,
they have to find the deficits as first call.
That has not changed since‑‑my
honourable friend sat around the table and should have asked these questions of
the Minister of Health in her administration.
What we are in the process of receiving from the members of the Urban
Hospital Council now are plans of action, one and two years in duration
depending on the facilities, telling us how they are going to meet the budget target
of $947 million globally for the hospitals, $723 million of that to be
dedicated to the Urban Hospital Council members. Those action plans will detail
the operational initiatives of the hospitals to expend $723 million this year.
If my honourable friend wants to know, did
they ask for more? Yes. If my honourable friend wants to ask, did
they want their deficits covered?
Yes. If my honourable friend
asks, did they want targets to be eliminated?
Yes, but what we have done is set a global hospital budget $53 million
more this year than last year, of which the Urban Hospital Council members are
being asked to expend $723 million. In
acceding to that request, they are developing action plans to show how they
will structure their operations to achieve that targeted expenditure rate of
$723 million for the Urban Hospital Council.
Ms.
Wasylycia-Leis: Could the minister give us that figure for 1990‑91
for Urban Hospital Council members?
Mr.
Orchard: $645
million.
Ms.
Wasylycia-Leis:
Could the minister tell us, what is the total value on the request made
to government for each of those three years from the Urban Hospital Council?
Mr.
Orchard: We do
not have that, but it was significantly above $645 million in '90‑91,
significantly above $680 million in '91‑92, and significantly above $723
million in '92‑93. I do not know
whether it was $50 million more or $75 million more in each particular
year. I do not know, but it was more.
Ms.
Wasylycia-Leis: I
would ask the minister to provide us with that information, since it is the
minister who has, whenever we have asked the questions about these budget
target reductions and restructuring targets and so on, said, the numbers we are
dealing with are the difference between what urban hospitals have demanded and
what government was prepared to fund.
So I would like to know in the case of going
from '90‑91 to '91‑92, what the figure is, because the minister
says one day it is $18 million and now he is saying it is a significantly high number,
it might even be $50 million. So there
is clearly a difference here, and I am wondering if he could provide us with those
figures, so I can understand then what these targets mean.
Mr.
Orchard: I would
suspect that the budget goes through a first blush, a second blush, a third
blush and then you get down to negotiating.
That is why I cannot tell you what the original request was from the
hospitals.
I think if my honourable friend remembers her
brief tenure as a minister, probably the first time you looked at your
Estimates from your department there was a request‑‑and I will just
pick a figure. Let us say your department
had a budget in the previous year of $30 million, I would venture to say the
first time you looked at Estimates the request was probably for $40 million. Then
you came back because you had Treasury Board targets that said, no, you cannot
spend $40 million, you can only spend XYZ. They would come back at somewhere,
maybe $35 million, and then finally you would end up at a figure of maybe $31
million or $32 million.
There is a whole process of discussion and
negotiation, where you go from the optimal request of all program expansions,
new expansions, et cetera, could come down to where the real budget discussions
are going to be, around the maintenance of service within the hospitals. That has always been the $18‑million difference,
but what the hospital started out requesting before we got down to the $18
million, I cannot answer that. It could have
been $50 million more, $60 million, $100 million more. I do not know.
That is rather irrelevant and pointless,
because institutions and people in health care make incredible demands. One might recall in October of 1989, the
Manitoba Nurses'
The real difference is in the $18 million that
they said was bare‑bones operation, and we said, no, here is bare‑bones
operation from government's standpoint.
That is the difference between what they indicated would be, if I can
use such nondescript language, bottom line on each case. We asked, is the funder to manage within $645
million in '90‑91, $680 million within '91‑92, and $723 million
within '92‑93?
What those original requests were, I suggest
they were a fair bit less this year than two years ago and three years ago, because
there is some sense of reality coming even within the health care system that
they cannot make unlimited demands on the public treasury. What the original total, all up request was
is a meaningless figure because it has never been acceded to. The $18 million was a bottom‑line
absolute difference that hospitals said they needed. We said, we could not provide, manage your
way across the system to make it happen, and that is where the $18 million came
in.
It was not that the hospitals started out
saying, we need $698 million last year.
That was not their first request.
I do not know what their first request was, but it was higher than that. Negotiation took it down, where they said
this was their absolute bottom line; our analysis said, you can manage on $680 million
and that is what we made available. That
is what we asked them to manage around.
They did not achieve that. That
is why it is carried forward this year.
That is why we are developing one‑ and two‑year management
plans to deal with it.
You might recall some discussion‑‑well,
you were not here, but the member for Dauphin (Mr. Plohman) was talking about
the deficit at the
We accept that management plan from the
But all of them are developing one and two
management plans to indicate to us how they will deal with it in this fiscal
year, with an increased budget of $723 million to deal with, over the $680‑million
budget they dealt with last year.
I know my honourable friend is wanting to use
the language of cutbacks and it‑is‑not‑enough. That accedes to the argument that you give
them what they ask for; we are not there.
I hope that has been a reasonable explanation which takes one from step
A to step B.
*
(0010)
Ms.
Wasylycia-Leis: Hardly a reasonable explanation, because, in fact,
it is the minister who has confused this dialogue by referring, one minute to
$4 million in deficit that is the first call on the $53 million; then he says
there is the $12 million, which is the unmet target. One minute it is okay to lump it all together
and say that is deficit, and that is all on the first call against $53
million. The next minute it is they are
two different things. Why would he have
come out with these two different figures if they did not mean two different
things?
Is he saying that if the $12 million
unachieved this year and the $10 million, or whatever, for the fiscal year we
are in, target is not met, that is going to be considered not in compliance
with the no‑deficit policy?
Mr.
Orchard: Any time
a hospital operates beyond the budget, that is deficit, and it naturally comes
to the first call on their next year's budget.
They presented government with management plans, as Dauphin did, to
operate or to reduce their deficit within a management plan over a two‑and‑a‑half‑year
period of time. One‑ to two‑year
operational plans are being developed now around the budget target of $723
million for urban hospitals.
They must take into account deficits if they
incurred them, or unmet targets from last year's $680‑million
budget. Yes, they have to consider
those. Those are not magically paid
dollars. We are asking them, within $723 million, to manage care delivery, et
cetera, and to give us management plans to show us how they are going to do it.
Ms.
Wasylycia-Leis: At
the risk of sounding like a broken record, I will ask this again. The $4 million in accumulated deficits for
the Urban Hospital Council members, are, the minister says, a result of
overexpenditure. The $12 million from the
Urban Hospital Council members is unmet target.
I do not know the difference between
overexpenditure and unmet target. It seems
to me the outcome is still the same. There is a difference between what was
required in the minds of the hospitals and what the government was willing to
pay, and that money has to be found from somewhere, dealt with in some way,
either by way of government changing its targets or forgiving deficits or for
hospitals to reduce parts of their operation.
So there has been no explanation to date, the
whole evening that we have gone around and around this issue, for the difference
between this $4‑million deficit and the $12‑million target. I think, in fact, what is the case is that we
are dealing with, as I said before, two separate processes, two separate parts
of a government agenda, and rather than the minister just simply being
straightforward and saying what it is so we can get on with it, he continues to
provide us with a lot of bafflegab to bamboozle us with different figures and
keep changing the line around them and moving the target and playing a shell
game so that we really cannot get at the heart of the matter.
I simply wanted to understand where these
targets came from, why they exist and on what basis they were established, and
yet I cannot get that answer. The
minister has not clarified.
He has even made me more suspect of the
government's agenda by throwing out different figures tonight, by saying on the
one hand there is a $4‑million deficit.
That is the first draw on this $53 million, and then changing it and
saying there is another $12 million which is the first‑‑whatever
word he uses‑‑draw on this $53 million.
He has indicated that there is more this year
in terms of a target and may be spread over two years, but that is a lot of money
that adds up to be drawn against the $53 million, to the point where there is
not a lot left for salaries, for supplies, for basic inflation in hospital
budgets, never mind everything else he said was part of the $53 million which
was any new projects, any new programs in hospital, any new capital projects in
the operations of those renovations or additions or new facilities.
I am still left with the conclusion, after all
of this, that we may be dealing with what we suspected all along, which was a zero
percent budget to hospitals, because if you subtract everything the minister says
must come against the $53 million, what is the funding policy? What does it amount to for hospitals? What percentage are we actually talking about
when all is said and done?
Mr.
Orchard: I guess
I do not know how I can argue against my honourable friend's logic or lack
thereof, and I do not want to be offensive, but how in the world can one get
into this circumstance where there are cutbacks, where there are reductions in
funding, where there are allegations of dire consequences, when for the Urban
Hospital Council membership you go from $645 million in fiscal year '90‑91
to $680 million in fiscal year '91‑92, to a projection of spending of
$723 million in fiscal year '92‑93?
Each year, an increase. Each
year, a pretty significant increase.
Each year, not as much as requested.
Each year, operating under a no‑deficit policy. Each year, more money. And my honourable friend is saying, I do not
understand what is happening here.
What is happening here is hospitals are
spending $645 million, $680 million and projecting to spend $723 million. In addition to that, they have run incurred
deficits which they must take as first call against their current budgets.
I do not know what else to tell my honourable
friend except to indicate to her that if she reckons this is a fairly tough policy
in Manitoba for hospitals to deal with, it might be kind of interesting to pick
up Hansard on the debates in Ontario and Saskatchewan, for example, or Nova
Scotia or New Brunswick or Prince Edward Island or Newfoundland where hospitals
are significantly constrained. My
honourable friend from the luxury opposition as a New Democrat is saying, give
them the money.
Point of Order
Ms.
Wasylycia‑Leis: On
a point of order, I have never once suggested give money, give more money, give
less money. I have simply tried to get a
handle on this government's funding policy vis‑a‑vis hospitals, and
if asking questions suggests to this minister that I am on one side of the
issue or the other then I do not see why we have Estimates, what we are doing
here, why he keeps questioning the integrity of opposition members and suggesting
that there has always got to be some hidden agenda behind everything. All I am trying to do is understand what the minister's
policy is. Now, let me ask it this way‑‑
Mr.
Deputy Chairperson:
Order, please. Let us start with
the fact that the honourable member did not have a point of order. It was a
dispute over the text.
* *
*
*
(0020)
Ms.
Wasylycia-Leis: If
the budget for urban hospitals for '92‑93 is $723 million, but, if as the
minister says, we must subtract from that amount $12‑million unmet target‑‑and
I am just repeating what the minister has said to me. When you subtract against that $12‑million
unmet target $4‑million deficit level, $10 million as I understand it to
be the new target for '92‑93, we get a total of $26 million which must
come against 723 which brings it down to 697, which means an increase of $17
million from '91‑92.
If that is what the minister is saying,
fine. I just want to hear what is
left? What is left to handle normal
negotiations and inflation in terms of supplies. Never mind new programs and everything else,
let us just deal with some of the basics and what hospitals are up against.
I am not for one minute suggesting we do not
have to look at finding ways to trim hospital budgets. I have said before, I have talked about the
top‑heavy administration, I have talked about unnecessary procedures and
places to find savings in hospitals. I would
be happy to have that kind of more in‑depth dialogue, but I cannot even
get to square one in terms of understanding what level the minister is prepared
to fund hospitals to, once we have taken into account all of these different
scenarios which clearly must be put against the so‑called new, increased
levels for hospitals.
Mr.
Orchard: Mr.
Deputy Chairperson, you do not deduct from $723 million the numbers that my
honourable friend has just talked about and end up with a net figure of $696
million to spend. They will spend $723 million.
They will spend $723 million, not $696 million. If I could get away with that, I would.
I would love to have that imposed on them that
you only spend $696 million. That is the
first suggestion I have got from my honourable friend that I have some sense of
agreeing with, but do you know what? Can
you imagine the screams and hollers that you would hear when your alleged
people you are talking to hear that you only want to give them $696 million
now, that you are deducting all of these things?
I am saying to you that last year's budget was
$680 million. This year's budget is $723 million. If they have over‑expended last year
and they spent a million dollars more on their budget last year, that million
dollars is part of the increase that they will get this year. It means they will still spend $723 million this
year, not less‑‑$723 million more than last year by $53 million in
the whole Hospital line.
My honourable friend surely must understand
that when she was around the cabinet table, passed the no‑deficit policy,
and hospitals incurred deficits, their increase the next year had to pay for
the deficit of the previous year first.
That is nothing new. I mean, what
is baffling about that?
They are going to spend the $723 million this
year. I hope they do not. That would be delightful to have some lapsed funding
in hospitals, but I suspect they will spend it all. They are not having it reduced down to $696
million, as my honourable friend has done her mathematics to arrive at. No.
They are going to spend $723 million this year.
They want more. Not unusual.
I do not know how I can get my honourable friend into the thinking that
nothing has changed in terms of the way hospitals cannot incur deficits; where
they exceed their budget allocation, they must retire it in ensuing years'
budgets.
Dauphin, $400‑million deficit
accumulated over three years of operation prior to last fiscal year. Action plan, operational plan to retire that
within the global budget over the next two and a half years. An action plan to reduce the deficit, not to have
government give them more money, not to have government give them less money,
but to give them their global increases and within that they will manage the
elimination of a $400,000 deficit.
They are going to have a bigger budget in
Dauphin this year than last year. All of
the Urban Hospital Councils are going to have a bigger budget than last year,
but where they have incurred deficits from last year, they must retire those
from the budget increase this year, from the global budget this year.
That is what has happened every single
year. My honourable friend finds that
baffling, difficult to understand, confusing, and on and on and on. Tt is a very simple concept: if you have over‑expended from the
previous year, your increase in the current year will have to recoup that
deficit either in one year or a two‑year period of time, action plans for
the expediting of that being developed right now.
Nothing terribly baffling about that, except
that they are not getting less money, they are getting more money. I can go through the numbers again if it
gives my friend any comfort, but they will be the same numbers I give her for
the hospital budget globally, or for the Urban Hospital Council membership for
three fiscal years.
More money every year, not less. Not as much more money as they would like,
but more money as to manage within the no‑deficit policy passed by Howard
Pawley and the NDP in 1986‑87.
Continued in May, 1988 on by the Progressive Conservative administration
of Gary Filmon. Can I help my honourable
friend with any more information?
Ms.
Wasylycia-Leis:
Just a couple of short, brief questions here. Is the minister saying that there is a $4‑million
deficit for urban hospitals for 1992‑93 that must be retired first and its
first call against any increase which happens to be $53 million for
hospitals? That is the first question.
Mr.
Orchard: The $4‑million
deficit they have to achieve where they incurred in this year's budget. Not every facility has incurred a deficit, in
other words.
Ms.
Wasylycia-Leis: Is
the minister saying that as far as his Estimates reveal, he believes there will
be‑‑there is for 1992‑93 a $4‑million deficit from
among urban hospitals, from members of the Urban Hospital Council, that it must
be retired by the definition of the no‑deficit policy, and therefore that
is the first call on the $53 million.
Mr.
Orchard: That is
the first call on the Urban Hospital Council portion of the $53 million.
Ms.
Wasylycia-Leis: I
would like clarification on the other part of this equation, and that is the
$12‑million unmet or unachieved target set by the Urban Hospital Council
last year for the 1991‑92 fiscal year.
That unmet target, unachieved target of $12 million, must also be part
of the first call or next in line in terms of the portion of the $53 million
set aside for the Urban Hospital Council.
Mr.
Orchard: The $680‑million
budget for last year '91‑92 was predicated on achievements of no deficit
and had the built‑in $12‑million target adjustment achievement to
be at 680. This year, 723 is the global
budget for the Urban Hospital Council membership with that budget unachieved
having to be achieved. Yes, exactly as I have said ever since about 3:00, no,
about 4:00 this afternoon. I cannot make
it any clearer to my honourable friend.
I do not know what is so confusing. I mean, I have said that‑‑this
must be about the 25th time I have said that.
What is so confusing about that?
What is it that you cannot quite understand when I say, yes, it has to
be achieved, it has to be achieved. It
has to be achieved within the budget that went from $680 million last year to
$723 million this year, not a decrease as my honourable friend is wont to
believe, but an increase.
*
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Because I know my honourable friend has a
great fondness in her heart for two other provinces,
If we funded a la
I do not know how much more plainly I can make
it. They are in raw terms $30 million
better off in the
I fully recognize and acknowledge, as I have
acknowledged now for the last five hours today, for approximately 30 hours
before that when we talked hospital funding, they asked for more, yes. They did
not get more; they did not get as much more as they requested, I should say,
but they got more. If they were in two other
jurisdictions they would have got significantly less more than what they are
getting in
That does not make for very good English, but
it is a very accurate fact. The
difference is $30 million between an Ontario funding formula and a Manitoba
funding formula, $30 million less if we followed the Ontario model and‑‑I
just have to make sure I have it right because this seems‑‑61 not
51‑‑$61 million less in dear old Saskatchewan, under a Saskatchewan
funding formula.
I wonder where they would rather be, Ontario,
Saskatchewan, or Manitoba, because if you think for one minute the hospitals in
Ontario and Saskatchewan are not going in with deficits, because there are no‑deficit
policies in place in those provinces, too, and they are being asked to deal
with pay equity for which they have had no funding over the years, salary
increases which there has been no funding provided in the baseline funding, and
an increase in funding even giving my honourable friend the generosity of 2
percent in Ontario and 2.8 percent less in Saskatchewan. Let us put it into perspective. Where would you rather be?
I know my honourable friend says, just give
them the money. Let them spend it. That
is not what New Democratic Parties in two neighbouring province, east and west,
are saying when they are in government.
You know, I bet you the frustrating part of it is, I bet you the
Minister of Health, my honourable colleague Frances Lankin, in Ontario is
having to deal with this issue with probably a Conservative critic who is
saying, give them more money. I do not
know what is going to go on in
Does my honourable friend see any sort of
anomaly in here that is building up? We
are talking about less money and being unable to operate and all these dire
consequences when there is a 6.1 percent increase in the budgetary allocation
year over year. It is not as much as they asked for, but it is a significant increase
in monies which we are asking them to manage, and I will go through it again.
They develop one or two management plans to
deal with their budget allocations, as Dauphin has done, not with a $400‑million
deficit, but only a $400,000 deficit. I
had a little slip there in case the good folks in Dauphin are reading
Hansard. We can go on and talk about
this for another 20 hours, I do not care.
The answer I am going to give my honourable friend is going to be the same
one I have given now for approximately 25 hours of discussion. It is not an answer that satisfies my
honourable friend. I do not know what
would satisfy my honourable friend, because on the one hand she is saying that
she does not want them to have more money, but then when they are getting more
money, she seems to be saying to me, well, it is not enough, it is not real. Well, it is real.
There is going to be $723 million spent by
those hospitals this year. That is real
money, real tax dollars, real deficit, because if you want to get blunt about
it, every dollar we are spending here is a borrowed dollar. I do not know what else I can provide to my
honourable friend in terms of information, but I will try. I will try to answer my honourable friend's questions.
Ms.
Wasylycia-Leis: That was an awfully long, defensive answer for
a straightforward question about what constitutes basically the $53‑million
increase, since my question had to do with the fact that the minister has
indicated already that the $12 million unmet target and the $4‑million
deficit resulting from overexpenditure, and the new target for this fiscal year
of roughly $10 million are put against the $53 million. So I am simply trying to get an understanding
of what is the real increase, because, in fact, I am not any more satisfied
after several hours of going around and around this issue that we are dealing
with a real increase and not anything more than creative accounting and some
pretty interesting budgeting processes put in place by a minister who is no
stranger to creative bamboozlement and bafflegab.
So let me ask once more. Let me try it a different way. Of the $53‑million increase for
hospitals, what is the share for urban hospitals of that?
Mr.
Orchard: For about
the 20th time, $43 million.
Ms.
Wasylycia-Leis: Could the minister give us now the breakdown for
urban hospitals of the $43 million?
Mr.
Orchard: By
hospital? No, I cannot give it to you by
hospital.
Ms.
Wasylycia-Leis:
Not by hospital, but by category as we discussed earlier with respect to
the overall $53 million.
Mr.
Orchard: The
major components are: just about $11
million out of the MNU agreement, and then we have annualization of pay equity
on top of that, which is just under $3 million.
So that would be, I suppose, salary adjustments. Then we have economic increases, including a
provision for the contract settlements that are to be negotiated that we have
given them the funding mandate for, which would total about $14.5 million for
those economic increases, supplies and other parts of the budget, included in
that being the allocation for salary bargaining under the unions that are
coming to the bargaining table this fiscal year. Then we have a little over $3 million in
other funding.
So that should come up pretty close to the $43
million when you add in new construction.
*
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Ms.
Wasylycia-Leis:
Just a clarification there, $3 million, what was that for again?
Mr.
Orchard: Just
about $3.5 million on dialysis and other programs.
Ms.
Wasylycia-Leis: So
does that mean about $10 million for capital?
Mr.
Orchard: A couple
of million more.
Ms.
Wasylycia-Leis:
Mr. Deputy Chairperson, of that, how much, and this relates to an
earlier request, has been set aside for operations of the new psych services
building, Health Sciences Centre?
Mr.
Orchard: A fair
bit of the new construction costs are there, and we do not have that broken
out.
Ms.
Wasylycia-Leis: My
question had to do with operating dollars for the psych services building. Why would that be under new construction?
Mr.
Orchard: Because
there are interest costs associated with the investment in new construction and
they are pretty significant, and in terms of the operating cost, I cannot
provide what the final figure is going to be in this budget, because we still
have not completed our negotiations with the Health Sciences Centre.
I will be very direct. How do I put this genteelly? The requests to operate the new facility are
significant, and we are being very pointed in our negotiations to achieve a
lowered operating budget than what is being asked for, i.e., my honourable
friend has probably heard some of the speculation around increased operating
costs, et cetera. Not that I want to reinvent
the issue around budget again, but again there is a difference between what is
asked for and what is finally negotiated and achieved, and we are still working
on that budget finalization.
We do not have a finalization nor is it an
urgent issue, because we are looking at roughly a September gearing up. But the one thing that we do know is that we
have an investment, and we have the capital construction costs, new
construction additional costs that, with interest, are adding a fair significant
chunk of that approximate $11 million that is part of this budget increase.
Ms.
Wasylycia-Leis: Is
the minister now prepared to give us the information we had requested with
respect to details pertaining to the construction of the psych services
building, the tendering process on a stage basis and the actual expenditure and
the lowest bid for each stage?
Mr.
Orchard: The
psych health building was undertaken by project management. A request for proposal was sent out and five respondents
were interviewed. The successful
proponent was UMA Spantec and offered one of the lowest, total cost proposals
and was prepared to work within a fixed‑fee amount. In other words, for their project management
fees they were willing to, on their proposal, operate with a fixed‑fee
amount.
Construction tendering was by sequential
tendering of multiple bid packages, the staging. There were approximately 32 bid packages to
subtrades as the work progressed. UMA
Spantec acted as the general contractor for their fixed fees.
All tenders were by prequalified bidders selected
by Spantec and the Health Sciences Centre from those subcontractors who answered
the public call for consideration of their qualifications. In the course of the construction there was
only one subcontractor that disputed the qualification criteria, and I believe
that was resolved, but I do not think that particular subcontractor received
any of the work.
We had allocated $51,700,000 for the project
all up, and we believe that upon completion that it will be achieved for $50,705,000. So as it stands right now, it looks as if it
will come in slightly under what we had projected in the '92‑93 capital
budget.
Ms.
Wasylycia-Leis: Could the minister give us the details with respect
to the 32‑bed packages? Could he
break it down in terms of the tendering process and the lowest bid?
Mr.
Orchard: Well,
not tonight. I would have to provide
that information. It might take us a day
or two to get it.
Ms.
Wasylycia-Leis: That had been the intent of my earlier question
to have that level of detail pertaining to the staged construction and
tendering process of the psych services building, so if the minister could
provide that as soon as possible I would appreciate that.
Mr.
Orchard: I will
make every effort. Yes, indeed.
*
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Ms.
Wasylycia-Leis:
Let me just try one more question or a couple more before we call it an
evening. Back on the‑‑I
would not want to not end on the question of hospital budgets. I just want to ask the minister, now that he
has given us sort of a breakdown of the $43‑million increase for urban
hospitals, and it is covered in terms of MNU, pay equity, economic increases,
new programs, capital and bargaining.
He has also said that the $4‑million
deficit must come against the $43 million and the unmet target of $12 million,
and presumably the new target for this year, does that mean hospitals for that
have those deficits and those targets to meet that they will have that much
less in terms of dealing with contract settlements, increase on supplies, pay
equity, MNU, new capital and so on?
Mr.
Orchard: They will
have their budget increased from last year to qualify for their portion of the
$723 million. It is a roughly similar
increase with the exception of where new construction may have a greater impact
on facility A versus facility B. Some
facilities probably do not have any‑‑oh yes, there would be a
number of our Urban Hospital Council members who have no commitment from the
capital construction costs, so they would not access any of that. The Urban Hospital Council members must
develop their budgets around the reconciliation of their share of the $723
million which is being provided, and that is $43 million additional. If they have incurred a deficit, they must
retire or offer to government an action plan by which they will retire unmet
commitments from the previous year's budget, just as we recently concluded with
Ms.
Wasylycia-Leis: To
just follow that up with a hypothetical example, if a facility has, say, a $2‑million
deficit, in other words, overexpended the previous year and has been assigned,
say, $8‑million target, that is a combination of unachieved target of the
past year and new target for this year, then that $10 million must first be met
and addressed before. Then whatever is
left, if there is anything left, goes toward meeting the requirements in terms
of salary negotiations, increase in supplies, pay equity, capital‑‑no,
never mind capital‑‑everything else but.
Mr.
Orchard: Mr.
Deputy Chairperson, I cannot deal with a hypothetical facility which may have
XYZ. Every facility is going to have an
increase in their budgetary commitment this year over last year. It will vary, and the reason it will vary is whether
there is new capital construction that is coming on. Otherwise, there is
roughly‑‑and I think I am accurate in saying roughly‑‑the
same commitment to their budget in terms of past agreements such as the
Manitoba Nurses'
The bargaining mandate and supplies and the
other general economic increases, they are consistently applied across the global
budgets that the respective facilities have.
The variation which will come in is dependent on how well the respective
facilities were able to achieve management of last year's budget, which in
total was $680 million and this year is $723 million. So they are going to have to manage and meet
new and past obligations out of the $43 million, and that will vary facility by
facility. Some facilities did not have
deficits and in fact had a modest surplus.
Their problems in managing their share of the $723‑million budget
will be less than those who have incurred deficits.
The $723 million will be expended by those
facilities, and in order to indicate to government how they will expend those dollars,
they are developing action plans, action plans which will outline how they
maintain their program with the level of funding commitment, the renewed and
increased level of funding commitment, that we have made this year over last.
Within these respective management plans that
varying facilities will offer to us from the Urban Hospital Council will no
doubt be a variation of plans according to whether they have deficits from last
year, et cetera, and that will vary each plan.
Some will be relatively less difficult to
achieve than some of the ones where deficits have been incurred, but they are
to develop their plans around an increased budget of $43 million at their
disposal, not a decreased budget, but an increased budget. It is not a big
enough increase, as I have said before, but it is an increase over what they
had budgeted last year. Each one of them
will be developing their plans and presenting them to government for approval.
Ms.
Wasylycia-Leis:
Could I just get a‑‑I was going to say get a quick answer,
but I should not be so presumptuous‑‑raise the issue briefly of
these bed reduction target numbers that we have discussed before that, I
believe the minister has indicated are part and parcel of the Urban Hospital
Council decision‑making process and related to the budget reduction
targets. Are these bed reduction targets
part of these budget reduction targets or in addition to the budget reduction
targets?
Mr.
Orchard: Mr.
Deputy Chairperson, I do not want at one o'clock in the evening to get into my
honourable friend's desire to speculate around bed closures, the advent of any
and all, that the system is going to reduce the size of the acute care hospitals,
and in doing so will mean a reduction in size of the teaching hospitals
according to their bed complements.
In the process of doing that it is not a
narrowed isolated exercise of dealing with the hospitals only. It is putting the patient at the centre and
using much of the information that my honourable friend had the privilege of
seeing Wednesday last, and managing around appropriate admissions, length of
stay and other issues of management wherein we believe that the patient's opportunity
to access needed care in a reformed health care system will be uncompromised.
That means shifting resources to community and
to lesser cost institutions where appropriate for the patient and where achievable
within the context of system‑wide reform.
That process is a process for discussion and action over the next ensuing
months. I am not getting into my
honourable friend's speculation around that issue right now.
But I do indicate to my honourable friend that
with all of this speculation that she may be hearing that the reform of the health
care system on the acute side is accompanied by a $53‑million increase in
our hospital funding, not a decrease, but a $53‑million increase in our
hospital funding, and a $7‑million increase in terms of our Continuing
Care Program.
In addition to that, funds specifically
targeted in the health services line, the $3 million for reform projects. In addition to that Health services
development funding increased by $4 million to provide bridge funding where
appropriate in terms of the reform of the acute as well as the mental health
system. In addition to that, the Support Services for Seniors programs will be
undertaking the funding of some additional projects this year.
All in a deliberate effort to shift our
resources with the patient to the most appropriate cost‑effective level
of care. That is a reform of the system that is said by many to be long overdue
and will be a subject of significant discussion in the near future.
*
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Ms.
Wasylycia-Leis:
Again, Mr. Deputy Chairperson, I raised a question that was not passing
judgment or making comment, I was simply questioning where these targets are
being set, what they mean, what they are based on. I will not pursue it at this late hour, but I
will come back to it again, since it is a question that needs to be asked if we
are going to be able to understand what the minister's plans are with respect
to change in our health care system.
I would like to ask just a couple of brief
questions before the evening is over.
Could the minister just tell us, what is the overall increase being set
aside for community health clinics?
Mr.
Orchard: Just
about three‑quarters‑of‑a‑million dollars.
Ms.
Wasylycia-Leis:
Could the minister give us some idea of how he is breaking that down as
he is doing with hospitals?
Mr.
Orchard: It is in
terms of their program delivery, and it is to meet their salary obligations,
their supply obligation, same as what they have to do in the hospitals.
Ms.
Wasylycia-Leis: Perhaps it is too late to ask for this now, but
I will ask the minister now for‑‑perhaps, he could provide it tomorrow‑‑how
he breaks down the three‑quarters of a million in terms of, as we have
gone over this evening, with respect to hospitals, in terms of salary
negotiations, supply increases, programs and so on?
Let me just conclude this evening by asking
one other small area of this whole section and that has to do with the‑‑and
it ties into the hospital issue and the Urban Hospital Council, and that is the
hospitals innovations fun. This new fund
of $3 million as described in the Estimates book, this fund is to be administered
by the Urban Hospital Council, yet is to apply to all facilities or all
hospitals in the
Is that the case, and if so, what is the
rationale for that?
Mr.
Orchard: It is an
administrative procedure to launch a new hospital innovations fund.
Ms.
Wasylycia-Leis:
We are referring now to the Manitoba Health Status Improvement
Fund. I am assuming we are all talking
about the same thing. Could the minister
indicate why this fund is to be administered by the Urban Hospital Council,
when it is the Urban Hospital Council that is in fact trying to come to grips with
the size on the institutional side and working among themselves for reducing
budgets and achieving bed reduction targets?
Mr.
Orchard: I guess
we could have created a new committee and established another committee, and
then my honourable friend could have said all we do is establish new
committees.
The concept is in terms of hospitals
innovation fund. Our CEOs are members of
the Urban Hospital Council and probably have as much collective and combined
experience in management of hospitals to recognize a good innovation plan as
any group that I am aware of in the province, and their assistance is, we
think, probably valuable as we launch this fund in helping hospitals to achieve
program changes and operational changes which will make them more effective
care deliverers in the new realities of constrained budgets of the 1990s.
If my honourable friend is unsatisfied with
the answer as to why the Urban Hospital Council, then, I give up. Tell me who should be doing it, if not them.
Ms.
Wasylycia-Leis: Could the minister indicate if he has consulted
with rural hospitals and how they feel about their chances of accessing this
fund that will be administered by the Urban Hospital Council?
Mr.
Orchard: Well, my
honourable friend might be aware that we are meeting with our Rural Hospital
Council which is newly established. At
the time of production of Estimates, we did not have a Rural Hospital
Council. There will be an opportunity,
as the council in rural
If my honourable friend is concerned that
there may be some inability for rural facilities to access it, because the old boys'
club in the Urban Hospital Council might trample them, I accept that concern,
and that is why we are open to the consideration of our rural health council
having the ability to make decisions around a portion of that fund.
Ms.
Wasylycia-Leis: As
a last question, what mechanism will be in place, if any, to involve the Centre
for Health Policy and Evaluation, which by all of their reports in the seminar
of last week, is dealing very much with quality improvement issues? Will there be a role for, or some connection
there between Urban Hospital Council and this centre that is dealing with
quality assurance?
Mr.
Orchard: I would
expect that should there be an analytical role that would be most appropriately
accomplished by the Centre for Health Policy and Evaluation around applications
to this health services improvement fund, we would certainly not hesitate in
seeking their input and analysis.
Ms.
Wasylycia-Leis: I
certainly look forward to continuing this dialogue tomorrow.
Mr.
Deputy Chairperson: The hour being approximately 1:10 a.m., what
is the will of the committee?
Committee rise.
EDUCATION
AND TRAINING
Madam
Chairperson (Louise Dacquay): Order, please. Will the Committee of Supply please come to
order. This section of the Committee of
Supply will continue to consider the Estimates for the Department of Education
and Training. We are on page 39, Item 2,
Financial Support ‑ Schools (a) School Grants and Other Assistance.
Would the minister's staff please enter the
Chamber.
Mrs.
Sharon Carstairs (Leader of the Second Opposition): Madam Chairperson, just before we adjourned
at five o'clock I had asked some questions which the minister had answered by
saying that she had not in fact entered into any negotiations because they had some
concerns that the independent schools might want to open other concerns.
I just want to make the comment that if you have never raised the issue with the association, then you have no way of knowing whether they would be inamenable to seeing some financial changes made, provided that the spirit of the agreement was not in