LEGISLATIVE ASSEMBLY OF MANITOBA

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.

* (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 Canada puts out a Canada Health Act annual report, 1990‑91, and their relevant sections in here indicate‑‑I will just give you an example, starting with Newfoundland and going across Canada.

       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.

* (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 Canada.  All of us are dealing with providing medically necessary services.  Where we find that we are not under the fee schedules, we make adjustments.  We have done it in Manitoba, and we know other provinces have done the same thing, but we have a difficulty in coming up with a reconciliation of that across Canada.

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 Canada.  In essence, I want to make a separation with my honourable friend.

       My honourable friend is right when he indicates that the ministries of Health operate 10 or 12 somewhat differing services across Canada.  But basically, as far as compliance with the Canada Health Act goes, on the mandated, if you will, services that are being provided there is probably a great deal of consistency across Canada.

* (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 Manitoba and probably will not be under current circumstances.  But, for instance, Ontario does provide it as an insured service, and that is a difference that is in that top 15 percent of the plan.  So that is sort of the analogy that I use for my honourable friend.

       When my honourable friend makes the case that there are 10 or 12 different differing health systems, he is right, because for instance in Manitoba under Pharmacare we provide coverage for everybody.  Everyone under 65 has a codeductible of approximately $190, and then 80 percent copayment thereafter.  We are unique, with the exception of Saskatchewan so far, I believe, in having that complete a coverage.  Most other provinces provide extreme financial hardship support and provide seniors support in varying ways.

       Some provinces are more generous in their senior support in that Ontario, I believe, has, until very recently at least, provided a 100 percent coverage.  We do not.  I mean, we still insist on seniors paying an upfront deductible on a copayment.

       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 Canada Health Act.

       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 Canada.

       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 Canada with the balance of 20 percent showing some degree of variation province to province.  That is where I think, as time moves along and as budget constraints force changes, we will even get more consistency in that last 20 percent.

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.

* (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 Alberta has included in their schedule of medical benefits with the AMA a tray fee.  I think major tray service is $15 and a minor tray service is $5.  They are the only province that has allowed that or has included that in their manual or schedule of benefits.  We have not, and my honourable friend is quite correct.  This is something that is not a new phenomena and it has been a practice that has carried on since our passage of the parallel act in Manitoba to the Canada Health Act federally. Ever since the '84 passage of that act, tray fees have from time to time been charged to the individual; and, to put it bluntly, because it has not been objected to in a strenuous way, we have not moved to intervene on that process between the physician and the patient.

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.

* (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 College of Physicians and Surgeons for the purpose of serving a specific kind of procedures.  I have no difficulty with that point of view, but we still have a problem in terms of some of the patients who can pay a facility fee, for example, $800 or $900 for cataract surgery, and somebody who has to wait for 18 months because they do not have $800 to $900.

       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 Toronto chairing a committee composed of the vice‑presidents of medicine at St. B., Health Sciences Centre and Victoria Hospital, Dennis Roch and Ken Clarke out of the ministry staff.

* (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 Brandon where we pay the physician fee, the surgeon fee, but we do not pay for lens or facility fee which leads to that approximate cost of $1,000 per eye.

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 Vancouver, and that report was not very scientific, but those things come from time to time.  The professionals do have a waiting list, and it depends upon where they are practising, or whether they have enough OR room available, or whether they are more in demand than the others.

       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 Winnipeg area.  Certainly that can be improved.

       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.

* (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 Canada right now as to how we develop our funding and our policies to preserve medicare, and the issue of rationing comes up and deciding who receives treatment.

       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 Canada, Manitoba slightly below that.  To say that we are going to bring in a mechanism which may restrict this physician's opportunity to bill to a half‑million dollars annually makes a lot of people out there, slugging very hard to make a living, shake their heads and say, what the hell is going on basically?

       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 Ontario, the same procedure, the specialist bills for slightly over $1,200.  That does not make sense in relative terms, and at the same time I am told that a similar skill‑required procedure as one surgical specialist can bill $2,300 in Manitoba for, a similar skill time requirement procedure of another internal specialist in surgery would only bill something in the neighborhood of $800.  There are disparities in the fee schedule, and we have been trying to get fee schedule reform, which is a difficult process to come around, because the MMA over the last number of years has been solely responsible for the allocation of their portion of that $297 million, and in doing so, without question, have created disparities within the fee schedule.

       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.

* (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 Manitoba was a basket case. That is not so.  First of all, only five provinces reported, and this report was developed by surveying physicians.  Physicians in five provinces and two territories obviously did not respond. Within the provinces that there was some response it was by no means all of the physicians.  In Manitoba a total number of 69 physicians responded in 10 areas.  We probably have 700 physicians in there so there might have been a 10 percent response rate at best.

       Then, on some very key services like coronary artery bypass, when you analyze the waiting list time, British Columbia reported 12.3 weeks, Manitoba 11 weeks, New Brunswick 10 weeks, Newfoundland 52 weeks, and Nova Scotia 26 weeks.  We are within one week of the lowest in Canada but yet that was not the impression we got in terms of the presentation of that.  In terms of other open‑heart surgery, B.C. was 16.5 weeks on average, we were 8, New Brunswick was 10, Newfoundland 33, and Nova Scotia 26 again.  We were the lowest, but that did not get reflected.

       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, New Brunswick 16.5, Newfoundland 19.3 and Nova Scotia 20. Yes, we are significantly different from the other ones, but that is a worst case scenario.  Others certainly do not indicate that kind of difficulty.

       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 Canada.

       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 Canada.  That has left the United States being quite a magnet for some of our very best practitioners and I do not suspect we will ever be able to stand up to prevent that from happening.

       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 Canada.

       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