Bill 8 - Commitment to the Future of Medicare Act 2003 | Ontario Federation of Community Mental Health and Addiction Programs

Bill 8 - Commitment to the Future of Medicare Act 2003

Submission to the Standing Committee on Justice and Social Policy

The Federation of Community Mental Health and Addiction Programs and St. Jude Community Homes

May 2004

The Ontario Federation of Community Mental Health and Addiction Programs and St. Jude Community Homes welcome the opportunity to make a submission in support of Bill 8, the Medicare Commitment Act.

This legislation speaks to issues that are very important for people with mental illness, for the volunteers who lead the organizations that provide services and for the public.

The Ontario Federation of Community Mental Health and Addiction Programs (The Federation) envisions a community mental health and addiction system which is accessible, flexible, comprehensive and responsive to the needs of individuals, families, and communities, shaped by many partnerships, respectful of human dignity and rights, and accountable to those it serves. The Federation brings together over 200 community mental health and addiction services in the province of Ontario to help members provide effective, and accountable high quality services.

St. Jude Community Homes is a private not for profit supportive housing program in Toronto. The organization is governed by a Voluntary Board. Its mandate is to provide high quality housing and housing supports for individuals with serious mental health problems and to support these individuals on their unique journey of “Recovery”.

Much has been written about Recovery and the concept has been highlighted in the Mental Health Implementation Task Force Reports. Simply put…recovery is learning to live with the effects of having a mental health problem…the stigma, isolation, low self-esteem and poverty, successfully managing symptoms and getting on with life to the best of one’s ability.

St. Jude Community Homes opened in 1991, serves 36 citizens and hopes to serve 30 more by 2005 with a grant under Phase two of the Ministry of Health Homelessness Initiative.

Together, we are here today to speak specifically to Part 3 of Bill “Accountability” and briefly comment on other aspects of the Bill. The response to Bill 8 is divided into three sections. The first section deals Accountability and the establishment of the Ontario Health Quality Council; the second with the preamble and commitment to Medicare and the Canada Health Act; and the third to insured health services.

Part 1: Accountability Framework

Bill 8, 2003, which has received second reading and has been referred to committee, would require “health resource providers” (including hospitals) to enter into an accountability agreement with the Minister of Health and Long-Term Care. That agreement would permit the Minister to issue compliance directives and impose sanctions in the event of non-compliance. Until that Bill is passed, health care institutions are under no specific legislated obligation to account for the billions of dollars of public money they spend.

For community mental health and addiction programs, those accountability mechanisms are already in place. In addition, these current agreements seem to hold community mental health and addiction programs to a higher standard than are proposed in Bill 8.

In 1998, the Government directed that Ministries establish written agreements with all agencies receiving transfer payment funding. As well, service agreements for mental health programs were identified as one of the characteristics of a reformed mental health system in “Making It Happen” and are consistent with the work of the Mental Health Accountability Reference Group as well the document “The Road Ahead” identified similar issues for the Addiction sector. The Ministry of Health and Long-Term Care reviewed the application of the existing operating plan process of Mental Health and Addiction Programs. Subsequently, the Mental Health and Addictions Branch decided that it was appropriate to develop and implement a common transfer payment agreement for community mental health and addiction programs in addition to the operating plan process. The Ministry of Health and Long-Term Care Transfer Payment Accountability Project was initiated with the intention of improving compliance with the 1998 Directive on Transfer Payment Accountability, raising awareness of accountability issues, and encouraging continuing improvement of transfer payment management with reference to best practices (Memo from John King, Assistant Deputy Minister, Health Care Programs May 9, 2002).

At that time, the Government of the day stated: “The experience of government overall is that clear expectations, terms and conditions of funding, performance monitoring and reporting requirements documented in an agreement between the Ministry of Health and Long-Term Care and funded agencies is the most appropriate way to provide certainty and protection for both sides. The agreements are designed to deliver on these elements. The agreements represent a significant benefit for both the agencies and the Government in terms of clarifying expectations and the conditions of the funding” (Letter to Board Chairpersons from Marnie Weber, Regional Director, Toronto, Region undated).

Community Mental Health and Addiction Programs understood why the Ministry of Health and Long-Term Care thought it appropriate to implement a standard form of Funding Agreement uniformly across the sector. We understood that a uniform funding agreement gave the impression that all parties were being dealt with in a consistent manner and we appreciated the ease of administration in such an approach could be beneficial in certain circumstances and it was because we recognized and respected the need for the provincial government to ensure that its programs were administered in an effective manner that transfer payment agencies signed these agreement, which were standard contracts and could not be tailored to the needs of individual agencies and in many cases the current agreements do not completely satisfy all legitimate concerns raised by agencies. However, failure to sign the TPA would result in funding being withdrawn.

The TPA that each agency signed requires that agency to:

Ensure that funds are only used for the purposes set out in the annual Operating Plan.
Not make any changes to the Operating Plan without prior written consent of the Ministry

The TPA also grants the Ministry these powers among other:

To impose additional terms and conditions on the use of funds, as it considers appropriate.
To inspect and copy financial and non-financial records on 24 hours notice and conduct a full or partial audit of any kind.
To terminate the agreement immediately under specified circumstances

These mechanisms, the active involvement of service recipients in organizational decision-making, and our members’ strong connections with their communities, ensure community mental health and addiction programs are accountable to government, for the public money they spend; to the people they serve, for the quality of their services; and to their community for enhancing quality of life. System tools such as DATIS, Catalyst and the Psychosocial Rehabilitation Toolkit all form the building blocks needed by government to ensure effective outcomes, quality services and accountability to the people of Ontario (The Benefits of Funding Addiction and Mental Health Services 02/04).

Taking care of the public interest involves:

Stating clearly collective roles and responsibilities including the role of the Ministry of Health and Long-Term Care as the funder of these services.
Transparency.
Continuous quality improvement.
Value received for money spent.
A process for public reporting.
Consistency and trust.
A focus on Outcomes.

Why should accountability of “health resource providers” in jurisdictions articulated in Bill 8 be different? In fact we believe that to transform the health care system, all parts of it must have similar accountability structures so that we can compare outcomes on a level playing field.

Accountability related to Bill 8

We agree that all transfer payment agencies must be accountable not only to the government, but also to their clients and the public and we support the government’s initiative to identify opportunities for greater and more consistent accountability across the health care sector continuum.

Community mental health and addiction providers are already accountable through transfer payment agreements and take seriously their obligations to use the resources they are approved with in an appropriate manner to serve citizens living with mental illness. However, there is always room for improvement. There are strengths and weaknesses to current arrangements between the Ministry, hospitals and health care agencies and principles of collaboration and consultation must prevail if we are to work together effectively and successfully.

Recommendation #1: In developing new accountability arrangements and reviewing current ones signed by community mental health and addiction programs, the government should be guided by the principles of consultation, collaboration, transparency and acting in the public interest.

An effective accountability mechanism must:

§ Provide information that can be used to improve the quality of services

§ Minimize the time that staff providing direct service must spend entering data instead of working with clients

§ Have sufficient funding available to enable effective implementation

Recently, the Ministry of Health and Long-Term Care has started requiring mental health service providers to provide data to the Management Information System (MIS), a system that was initially intended to collect hospital data. Although it is still in the early stages of implementation, there are some significant barriers that need to be considered in developing any accountability system. The major impediment is the cost of implementation. Community mental health and addiction providers have not had an increase in base budget funding for more than 12 years. During this same period, demand for services has grown significantly.

In order to meet these needs, priority has been given to using available funds for direct service, rather than for administrative costs, including purchasing software and up-to-date computer systems. The result is that many providers are finding it expensive and, in some cases, impossible to use the MIS system without diverting funds from their direct service budget. To date, the Ministry has identified that it cannot provide any additional funding to support the implementation, including the purchase of computers and the additional staff time that is required to enter the data into the system.

Recommendation #2: That any accountability mechanism takes into account the principles stated above, and include adequate funding for implementation, so as not to divert resources from clients.

As a volunteer-led charity, we acknowledge that in extraordinary circumstances, the Ministry of Health and Long-Term Care must have the authority to intervene, in order to ensure that the services provided by a health service organization are safe and effective; and are not interrupted were it is clear that the organization no longer has the capacity to meet its obligations. This may occur, for example, where a board resigns or is reduced below the required quorum. As in any organization, health system organizations are not immune from the rare situation in which a senior executive has acted outside of their authority.

We do have several concerns with the legislation and are making recommendations that we believe will allow the government to meet its objectives of protecting the public in extraordinary circumstances, while not undermining the role and authority of volunteer boards, clients, and their employee, the Chief Executive Officer.

The accountability section represents a significant change in the relationship between government and transfer payment agencies. Up until now, most transfer payment agreements permit the government to cancel the agreement, often with little notice or compensation; however, this legislation goes farther and allows the Minister to act as employer, changing the terms and conditions of employment for executives.

Recommendation #3: The Minister of Health and Long-Term Care may require a CEO or board to enter into an accountability agreement only where there is an extraordinary breach of their legal responsibilities or of the funding agreement, to the extent that it places the clients in jeopardy or is unable to meet its obligations.

As currently drafted, the circumstances under which the Minister can require these agreements or issue a compliance order are so broad that they could be used with almost any organization funded by the Ministry. As a result, the volunteers who dedicate their time and energy to serve on boards will be reluctant to serve, knowing as they would that the Ministry has such a broad mandate to intervene.

Where the Minister of Health and Long-Term Care exercises its authority under these provisions, the chief executive officer and/or board may apply to the Health Services Review Board (or court) for a determination as to whether the Minister’s discretion was appropriately exercised.

For there to be true accountability, not only of the service organizations, but of the actions of the government, there needs to be a mechanism that allows the use of this authority to be challenged. Without any review process, the only other alternative would be litigation to determine whether the Minister properly interpreted the language. This would be a much more expensive and cumbersome process.

The protection is particularly important where the terms and conditions of employment of a CEO are changed, since this is in effect, constructive dismissal, without providing any compensation.

The government has a responsibility to provide Chief Executive Officers and/or boards the support it needs to carry out their obligations.

There are an increasing number of legal and regulatory obligations that boards are required to deal with, including the Income Tax Act and the Charities Accounting Act for charities, as well as the Employment Standards Act, the Pay Equity Act, the Workers Safety and Insurance Board Act, privacy legislation and legislation specific to certain sectors.

Volunteers take their responsibilities seriously to ensure that they are aware of, and act in accordance with these obligations. At the present time, there is very little support for the training of volunteer boards and/or CEO’s who may not be familiar with these regulatory schemes, as well as Ministry requirements.

Recommendation #4: That the government be required to provide appropriate resources or education to enable volunteer boards and/or CEO’s to understand and meet their obligations.

This type of preventative measure should reduce the need for intervention and support the ongoing quality improvement of the services, one of the goals of the legislation.

The legislation creates a situation with respect to the compliance agreements, where the Ministry, for all intents and purposes, becomes the employer of the CEO. That relationship is however, limited only to those parts of the directive and do not deal with other statutory or contractual obligations of the CEO. This may result in a situation where the Ministry makes it impossible for the volunteer board or the CEO to meet their obligations, for example, under the Income Tax Act or to other funders, such as United Way.

It may also create a situation where the government is deemed to be the employer and is required to comply with all of the statutory requirements of an employer, including pay equity. At the same time, the volunteer board may also remain as employer for other employees, creating a very complex situation.

Recommendation #5 The legislation must be clear as to:

§ The purpose for the intervention – What is the intended goal?

§ Ensuring that the intervention will achieve that goal with minimal interference with the organization’s activities and the role of the volunteer board

§ Whether the Minister or Ministry is assuming responsibility as employer

§ Where the intervention prevents the volunteer board or CEO from meeting their obligations to other organizations, funders or under other legislation, that the Minister or Ministry is required to meet those obligations.

In addition to the recommendations suggested above, additional changes will be needed throughout this section to create a framework that addresses the most serious issues without creating a situation in which volunteer boards and CEO’s are reluctant to work in this sector.

Ontario Health Quality Council

We strongly support the creation of an Ontario Health Quality Council, as one mechanism for improving accountability and transparency, and to monitor and report to Ontarians on the issues of access to publicly-funded addiction and mental health services, utilization of health human resources, consumer and population health status and health system outcomes. We endorse the recommendations put forward by the Centre for Addiction and Mental Health and the Canadian Mental Health Association and more specifically that members of the Health Quality Council include experts in “family issues” and “physical and mental health service provision” as well as patient and consumer issues.

Recommendation #6: The factors to be considered in selecting members of the Council should be amended to read:

2(3) In appointing the members of the Council, regard shall be given to the desirability of appointing,

(a) experts in the health system in the areas of patient, consumer and family issues and health service provision, including mental illness and mental health services;

(b) experts in the areas of governance, accountability and public finance;

(c) persons from the community with a demonstrated interest or experience in health service. (Proposed amendments are underlined.)

We do not agree with the provision that allows the business plan to remain confidential. Given that the purpose of the Council is transparency and accountability, it is essential that the operation of the Council reflect that principle as well.

Recommendation #7 That section 5(5) be amended to remove the exception to tabling the business plan and require the plan to be made public once it is approved by the Minister.

One of the major difficulties pointed to in the area of mental health and addiction service delivery is the lack of good data to monitor health outcomes and accountability. We will make specific provisions below; however, we are concerned that the apparent lack of data may make it difficult or impossible for the Council to carry out its mandate fully. It also results in mental health and addictions not being considered in policy development because the data to support the policy is not there. For example, there has been a lot of attention paid to emergency room utilization and ways to reduce the crowding. In the proposed solutions, there is little or no attention paid to the fact that people with mental illness and or addictions are among the most frequent users of emergency rooms. This is due, in part, to the fact that the data collection of emergency room utilization is based on health cards. The reports specifically note that people with mental illness, many of whom may be homeless or do not have a health card. are not included in the statistics.

Recommendation #8: That the Council be authorized to recommend to the Minister of Health and Long-Term Care or to any other appropriate governmental body, the collection of statistical or other information necessary to carry out its mandate.

Part 2: Commitment to Medicare and the Canada Health Act

The Canada Health Act states in the preamble that Parliament recognizes:

“--that Canadians can achieve further improvements in their well-being through combining individual lifestyles that emphasize fitness, prevention of disease and health promotion with collective action against the social, environmental and occupational causes of disease, and that they desire a system of health services that will promote physical and mental health and protection against disease.”

The Ontario Federation of Community Mental Health and Addiction Programs strongly supports the principles set out in the preamble to the legislation and the strong, clear commitment to Medicare and the Canada Health Act and affirms the system of publicly-funded health services as fundamental to Canadian values.

The preamble to the Bill sets out the fundamental principles underlying the delivery of health care in Ontario. The principles are applicable not only to this legislation. They provide a framework for the system as a whole. Briefly, the key principles are:

Commitment to a publicly-funded health care system based on the five principles set out in the Canada Health Act: universality, accessibility, portability, comprehensiveness and public administration, including the prohibition of two-tier medicine and extra billing.
Access to services based on need rather than ability to pay. Pharma Care and Home Care services are critical components as health care continues to shifts to the community.
Access to Primary Care.
Collaboration between consumers, government and providers.
Public accountability to ensure high quality services are being delivered in the most efficient way possible.

Increasingly, there is recognition that the scope of the Canada Health Act, which covers physicians, hospital costs and in certain circumstances, other health services, is too narrow. This is true for people with a mental illness and or addiction. Essential services such as psychological counseling are available only through privately-paid systems or, in limited circumstances, through publicly-funded mental health services. The result is that many people do not have access to these services that would improve their health and, ultimately, reduce other health-care costs including physician visits and hospitalization. Even the limited services that have been available in hospitals and other agencies are being lost because of funding cuts. Even private insurance benefits that do cover services such as psychological counseling, often limit the number of visits, regardless of the benefit.

There are many other services, such as case management, supportive housing and crisis response, that have also proven to be highly effective, not only in improving the health and quality of life for people with a mental health problem and or addiction, but also in reducing the use of more expensive services such as hospitals. These services are also essential in the many areas of the province. Because of limited funding, including a 12-year freeze on operational funding for community mental health services and similar constraints for addiction providers, there are currently, extensive waiting lists around the province, some as long as two years.

Recommendation #9: That the preamble acknowledge that the Canada Health Act does not encompass the full range of services that improve the health of Ontarians. It should also state that these other services are essential and that as the health care system evolves, they must be considered to be an integral part of the health care system.

Including this in the preamble is consistent with the accountability section of the legislation, which does cover publicly-funded health services, even those outside of the health insurance scheme. Many Addiction and Mental Health services need to be recognized for their extensive role in the health of Ontarians.

Citizens with mental health and addiction problems face significant challenges in having access to the full benefit of the health care system. Roy Romanow described mental health as the “orphan child” of health care. It is important that this legislation, which constitutes a confirmation and renewal of the fundamental principles of the Canada Health Act, reflect an evolving focus on community care, promotion of wellness, prevention of illness and the changed attitudes and understanding of mental illness. If this is to be the overall promise to Ontarians concerning health care, it is essential that it explicitly recognize that mental health and or addiction services are an integral part of the health care system, particularly given that mental illness and or addictions affects almost everyone during their lifetime, either because of their own illness or that of a family member.

People with mental illness and addiction problems are entitled to receive the equal benefit of publicly-funded health care services.

We also recommend that the preamble be amended to acknowledge the needs of Ontario citizens who suffer from mental illness or addictions and to recognize the importance of mental health and addiction services to the health care system. In light of the historic discrimination and stigmatization faced by persons with mental illness and addiction problems, and the barriers that continue to make it difficult for them to receive the equal benefit of the services, we are recommending that the preamble be amended to include the following statement:

Recommendation #10: That the people and Government of Ontario recognize that the promotion of health and the prevention and treatment of disease includes mental and physical illness and that all Ontarians, regardless of whether they have a physical or mental health / addiction problem are entitled to the equal benefit of the publicly-funded health care system

The impact of mental illness on Canadians is staggering. Over 1.5 million Canadians are currently experiencing clinical depression, a disorder that affects 15% of Canadians at some point in their lives. Twenty percent of Canadians in any given year suffer from a broad range of mental illness or addiction, and 3% suffer profound and persistent disablement. Despite these facts, mental health and addiction services are largely absent from mainstream health care reform initiatives and are often not explicitly recognized as an integral part of the system. Similarly, studies show that Addictions accounted for over 114,481 hospitalizations and conservatively cost the economy of Ontario $7.02 billion in 1992. We recommend:

Recommendation #11: That the people and Government of Ontario recognize:

…that the promotion of health, and the prevention and treatment of disease includes mental illness and addictions.

In addition, we urge the Premier and Minister of Health and Long-Term Care to ask their federal and provincial counterparts to ensure that people with addictions and or mental illness receive the same benefit from the health care system as all Canadians and that these benefits be enshrined in any future legislation or policy.

We agree that primary care, including health promotion, prevention and treatment of disease, is the cornerstone of the health care system.

We are recommending a minor amendment to the paragraph dealing with primary care to make it clear that primary health care is more than the services provided by primary care physicians or nurse practitioners; and that it encompasses health promotion, prevention and treatment of disease. There is a danger that without an amendment, the term could be narrowly defined because it is used in legislation dealing primarily with publicly-funded health insurance, which is limited to physicians.

Recommendation #12 That the preamble be amended to read: “Recognize that access to primary health care, including the promotion of health and the prevention and treatment of disease, is a cornerstone of an effective health system. Primary care should meet the needs of the consumers and be delivered by health professionals or services with the most appropriate skills to meet that need. (new text is underlined)

We support the references in the preamble to catastrophic drug coverage and home care as essential components of the health care system. We endorse the recommendations made by the Canadian Mental Health Association, Ontario and the Centre for Addiction and Mental Health that amendments be made to the preamble of Bill 8 to ensure that people with mental illness and addiction problems are entitled to equal benefit of these publicly –funded programs

Last November, the Romanow Commission recommended that priority be given to funding home-care services for people with mental illness. We support that

recommendation and are anxiously awaiting further action on the part of the provincial government to implement it; however, that will deal with only a portion of the need. We know that people with serious addictions and or mental illness can be maintained in the community if services are available.

This not only benefits the individual and their families, but will have a significant impact on overall health spending by reducing hospitalization. In 1999, 3.8% of all admissions to general hospitals, representing 1.5 million hospital days, were for seven different mental illnesses. Many people would be surprised at the extent to which mental illness contributes to hospitals costs.

Overall, in 1999/2000 individuals with mental illness had more than 9,000,000 days in the provincial psychiatric and general hospitals. Yet research

demonstrates that where housing and appropriate support services are provided hospitalization can be significantly reduced. The same justification

for giving priority to funding for home-care services to seniors and to people currently hospitalized, applies to people with addictions and or mental illness.

Section 3: Health Insurance Issues

We support the provisions in the section on health insurance, including the prohibition of extra billing, and including the fact that where a person is charged contrary to the legislation, they are reimbursed by the Ontario Health Insurance Plan. It is very important that patients not be forced to recover those payments on their own. We also support the prohibition against asking for or receiving a benefit of any kind in order to receive preferential treatment.

Annual or block fees will be allowed only as prescribed in regulation. However, no practitioner or physician can refuse to provide insured services or stop providing those services because someone will not pay the fee. Block fees are defined as a set fee for non-insured services, paid regardless of how many services are provided.

The legislation does not address the fees that can be charged by physicians to complete reports for government, employers or to access other benefits. People with mental health problems rely on benefits for income and other supports. While government programs may pay for some reports, this is not the case across the board. At the same time, we recognize that preparing the reports can be time consuming for the practitioner.

Recommendation #13 We recommend that the Ontario Health Insurance Plan cover the fees for the preparation of reports, where it is not paid for by any other third party and it is necessary for a person in order to obtain income or other benefits essential to their health and well-being.

We concur with the recommendation made by the Centre for Addictions and Mental Health that there be a 60-day period devoted to consultations related to the regulations under this legislation and that those consultations not be limited to stakeholder groups that represent the traditional interests of the health care system.

We appreciate the opportunity to respond to this proposed legislation and would be pleased to work with the government on changes to the legislation, as well as the policy and implementation framework, to ensure that it meets the goal of enhancing the health of Ontarians by improving the accountability of the service system.

Bill 8: Summary of Recommendations

Recommendation #1: In developing new accountability arrangements and reviewing current ones signed by community mental health and addiction programs, the government should be guided by the principles of consultation, collaboration, transparency and acting in the public interest.

Recommendation #2: That any accountability mechanism take into account the principles stated above, and include adequate funding for implementation, so as not to divert resources from clients.

Recommendation #4: That the government be required to provide appropriate resources or education to enable volunteer boards and/or CEO’s to understand and meet their obligations.

Recommendation #5: The legislation must be clear as to:

§ The purpose for the intervention – What is the intended goal?

§ Ensuring that the intervention will achieve that goal with minimal interference with the organization’s activities and the role of the volunteer board

§ Whether the Minister or Ministry is assuming responsibility as employer

Recommendation #6 The factors to be considered in selecting members of the Council should be amended to read:

2(3) In appointing the members of the Council, regard shall be given to the desirability of appointing,

(a) experts in the health system in the areas of patient and consumer issues and health service provision, including mental illness and mental health services;

(b) experts in the areas of governance, accountability and public finance;

(c) persons from the community with a demonstrated interest or experience in health service. (Proposed amendments are underlined.)

Recommendation #7: That section 5(5) be amended (insert from above) be deleted and that a section be added requiring the business plan to be made public, once it is approved by the Minister.

Recommendation #8: That the Council be authorized to recommend to the Minister of Health and Long-Term Care or to any other appropriate governmental body, the collection of statistical or other information necessary to carry out its mandate.

Recommendation #9: That the preamble acknowledge that the Canada Health Act does not encompass the full range of services that improve the health of Ontarians. It should also state that these other services are essential and that as the health care system evolves, they must be considered to be an integral part of the health care system.

Recommendation #10 That the people and Government of Ontario recognize: that the promotion of health, and the prevention and treatment of disease includes mental and physical illness and that all Ontarians, regardless of whether they have a physical or mental health problem are entitled to the equal benefit of the publicly-funded health care system

Recommendation #11: That the people and the government of Ontario recognize that the promotion of health, and the prevention and treatment of disease includes mental and physical illness.

Recommendation #12: That the preamble be amended to read:

“Recognize that access to primary health care, including the promotion of health and the prevention and treatment of disease, is a cornerstone of an effective health system. Primary care should meet the needs of the consumers and be delivered by health professionals or services with the most appropriate skills to meet that need.

Recommendation #13: We recommend that the Ontario Health Insurance Plan cover fees for the preparation of reports, where it is not paid for by any third party and it is necessary for a person in order to obtain income or other benefits essential to their health and well being.

S.C. 1984, c. 6

Health Canada, A Report on Mental Illnesses in Canada, 2002

Reference CMHEI

s,. 16

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Bill 8 - Commitment to the Future of Medicare Act 2003