Health care on the cutting block: Ministry hopes for efficiency with search and destroy tactics

By David South

Today’s Seniors (Canada), August 1993

It’s search and destroy time at Ontario’s ministry of health: search out savings and destroy inefficiency and waste. But many remain apprehensive that not all the cuts are going to be logical and fear the province’s health and well-being will be affected. 

As part of the social contract deal, the Ontario Medical Association must find $20 million in cuts from the list of services covered by OHIP. The OMA and the provincial government are currently haggling over which procedures and examinations will be cut. 

“We look at services that aren’t medically necessary,” says health ministry spokesperson Layne Verbeek. “Because we were wealthier in the past, we were able to cover some services. We aren’t in that position now. But I don’t see how eliminating medically unnecessary treatments will affect the population.”

The fallout of the Rae government’s attempts to reign in costs and recover lost revenues may take years to unfold, but it is already apparent that Ontarians will be paying more. 

“Access to necessary treatment should not depend on a person’s ability to pay,” says health policy critic Carol Kushner. “What disturbs me about any delisting program is that virtually every medical service could be termed medially necessary. There are very few services that are an out-and-out waste of time.

“We often point to the fact that Ontario spends $200 million a year treating the common cold. Well, most of that is a waste of time. But delisting even that kind of service would be a detriment to the public’s health, because a small group of patients really do need to see a doctor when they have a cold.”

OMA spokesperson Jean Chow says it’s too early to pin down the exact cuts that will be made. “It’s a little premature to try and speculate what the final list will be.”

The newly-created Non-Tax Revenue Group is hard at work finding fees, fines and penalities the government can add or hike to boost revenue from this source from $5 billion to $10 billion a year. 

The spring budget saw the first hit, with the addition of $240 million in non-tax revenue. 

A radical reshaping of medicare is taking place. Private sector services - for which consumers pay directly or through insurance companies - now make up 34 per cent of Ontario’s health care funding, compared to 42 per cent in the United States, according to a recent study by the Canadian Medical Association. 

Health minister Ruth Grier has also floated the idea of widespread hospital closures. Both the Toronto and Windsor district health councils (DHCs) are carrying out feasibility studies on “reconfiguration.” The ministry is remaining tight-lipped about which hospitals will get the chop. 

“One suspects there’s room for efficiency - there are a lot of empty beds in a number of different places,” says ministry spokesperson Verbeek. 

“All hospitals are being reviewed, with a view to closing one or two hospitals,” says health planner Lisa Paolatto, who is working on a feasibility study on “reconfiguration” for the Essex County District Health Council, along with Toronto’s DHC. 

Closing hospitals could present a serious political hot potato for the government. In Britain, the Conservative government is still recovering from the bad feelings surrounding proposals to close world-renowned hospitals in the London area. The public feels great loyalty to local hospitals, a feeling that has been further fostered by hospital charities that raise millions a year from the communities’ good will. 

“This is going to open up new discussions of money between doctors and patients,” says Kushner. “Seniors are a unique group in Canada because they remember what it was like before medicare - what it was like not to be able to pay for the doctor, to forgo treatment that they thought was necessary. They understand the financial hardship that could occur if they were unlucky enough to have a family member who needs expensive medical treatment.” 

Critics blast government long-term care reforms

“They cut hospital beds and lay off staff without having community health care services ready…”

“When the elderly… decide that facility-based care is the best option, they can’t get it…”

By David South

Today’s Seniors (Canada), October 1992

Seniors should keep a close eye on the Ontario government’s proposed long-term care reforms. According to critics, the plan has more than a few bugs. 

The term long-term care encompasses an often confusing web of services, from home-provided community services like meals on wheels to institutional care including homes for the aged, seniors’ apartments and chronic care hospitals. 

Like other provincial governments, the Rae government is trying to rein in escalating health care costs - and long-term care services aren’t immune. They hope that emphasizing prevention and healthy lifestyles, plus providing more services in the home and community, will reduce reliance and expensive health care services like high-cost drugs, surgery and high-tech equipment. According to health minister Frances Lankin, this will preserve medicare in the age of fiscal restraint. 

The government has outlined seven goals for its long-term care reforms: prepare for the coming surge in the over-65 population; cater services to better reflect the cultural, racial and linguistic make-up of Ontario; eliminate confusion over what services are available; involve the community in planning so that services reflect community needs; lessen reliance on institutions; provide support to family caregivers; tighten regulations governing government-run and private facilities; and improve working conditions for the largely female caregiving workforce. 

But many people are wary of the proposed reforms and worry that if they aren’t managed properly, some seniors will fall through the cracks. 

A report released in July by the Senior Citizens’ Consumer Alliance for Long-Term Care Reform blasts the government for being simplistic in its plans. The report compares the present reforms to the failed attempt in the 1970s to move psychiatric care out of the institutions and into communities by closing 1,000 beds. The tragic result in that case was homelessness for many psychiatric patients who found community services unable to help, or, more often than not, non-existent. The Alliance fears seniors - the biggest users of health services - could fall victim to reforms in a similar way. 

Emily Phillips, president of the Registered Nurses’ Association of Ontario, is blunt: “The NDP’s plans sound good on paper, but they can’t give a budget or direct plan on how they hope to carry out reforms. They are going about things backwards. They cut hospital beds and lay off staff without having community health care services ready.”

The Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS) - which operates charitable and municipal homes for the aged, non-profit seniors’ apartments. chronic care hospitals and community services serving over 100,000 seniors - says 4,300 seniors are on waiting lists for their member facilities right now, and things won’t improve if the government continues to reduce the number of long-term care beds. 

But Lankin insists that beds are available in homes and hospitals and it is funding formulas that prevent them from being filled. 

To help carry out its reforms, the NDP will reallocate $647 million by 1996-97. In bureaucratese, this funding is said to be “back-end loaded”, or mostly spent close to 1996-97. 

The problem with this, according to the Alliance, is that the government has already embarked on a radical “downsizing” of hospitals, closing beds and laying off health care workers. Lankin claims the worst case scenario for layoffs this year won’t exceed 2,000, but the Ontario Hospital Association claims 14,000 jobs are in jeopardy. Because of this, the Alliance wants money to be spent earlier to avoid gaps in services. 

Phillips believes it will be hard to pin down the extent of job losses. “For every full-time job cut many part-time and relief positions go with it,” she says. 

Dr. Rosanna Pellizzari, a member of the Medical Reform Group and chair of the Ontario Association of Health Centres, wants better community accountability for hospitals before they lay off staff and cut services. “Sometimes it makes sense to bring people to hospitals,” she says. “Planning must be at the community level, open and democractic. Health care workers, who are mostly women, should not be scapegoated for financial problems. Doctors and management should go first. Physicians experience very little unemployment.” 

Many nursing and charitable homes for the aged are facing financial crisis. According to OANHSS, six charitable homes for the aged have closed since 1987 due to deficits. In 30 homes, the total annual deficit has increased 125 per cent since 1987. The Ministry of Health recently allocated special funds of $8.1 million to ensure these facilities survive until January, when a new, needs-based funding formula will be introduced. It is intended to better match the actual care requirements of the 59,000 consumers living in long-term care facilities. 

Michael Klejman, executive director of OANHSS, agrees with helping seniors to stay in their homes. “But when the elderly and their care-givers in Ontario decide that facility-based care is the best option, they simply can’t get it,” he notes. “We know from experience that many of them remain in acute care hospital beds with a cost to the province of about four times what it would cost them to fund a long-term care bed. And many, unfortunately, remain in their own flats or apartments at considerable risk to themselves, isolated and dependent on a patchwork of services.” 

Beatrix Robinow, who worked on the Alliance’s report, was not impressed with the government’s initial plans, especially the proposed creation of 40 service coordination agencies whose mandate would be to control the delivery of home care services to seniors. Robinow thinks this would add to the confusion and just be another layer of bureaucracy. Many people who appeared at the Alliance’s public hearings expressed confusion over how the long-term care system worked. 

Robinow says that the government could save money by trimming the bureaucracy and using present organizations like the little-known District Health Councils. 

“District Health Councils have nothing to do with social services,” says Robinow. “But we want them to be expanded to include long-term care and general supervision of community services. We are waiting to hear if they are interested. I would urge the government to make sure that services are in place before pushing people out of institutions.” 

The health minister is cautious about the government’s next steps. “The Alliance’s report has been very helpful,” she says. “We are in the process of developing options. Two other ministers are involved and we also need to take this through Cabinet.

“Ontario is much larger and more complex (than other provinces). The range of services is more developed. We also have a mess in jurisdictions between municipalities and the province. And in Ontario there isn’t a concensus that this is the way to go. 

“We have been doing a lot of rationalization and streamlining for longer than other provinces. Most thinking people looking at the situation agree that doing nothing would hurt the system. It is not sustainable at present. You hear a lot of things about user fees. That would be the slippery slope for medicare. That would make people think they could buy better services.”

Ironically, user fees were recently endorsed by the Canadian Medical Association, suggesting the minister will have a fight on her hands with angry doctors. 

Amidst all the confusion, Dr. Perry Kendall was appointed on Aug. 24 as the provincial government’s special advisor on long-term care and population health. This veteran of both the City of Toronto as Medical Officer of Health - and the groundbreaking Victoria Health Project in British Columbia (often seen as the model for community services to seniors) seems well qualified. “One problem in the past has been the creation of smaller and smaller organizations every time somebody felt the system was not responsive to their needs,” he says. “This created organizational chaos. The challenge  now is to get all the organizations back together to share their expertise.”

Lankin says she hopes to have a conference on the reforms in the fall. 

Cut services to elderly, says doctors’ survey… but leave our salaries alone!

“With a guaranteed income and job security, I don’t know one doctor who has suffered in the recession…”

By David South

Today’s Seniors (Canada), January 1993

If the results of a nation-wide survey of doctors are right, Canadian physicians love medicare but abhor government attempts to make them accountable for its costs. It also suggests that doctors are more willing to talk about cutting services to seniors and people with “unhealthy lifestyles” than to discuss cutting their own wages to save money. 

However, according to some doctors, physicians’s anger with the provincial government is founded on ignorance and poor analysis of the larger forces affecting health care. 

The survey, Breaking the Wall of Silence: Doctors’ Voices Heard at Last, was commissioned by The Medical Post, a national newspaper for doctors. It sent questionnaires to 12,000 doctors, receiving 3,087 responses. The Post also conducted in-person interviews to better gauge the mood of doctors. 

The survey’s title is somewhat misleading, considering that doctors have been making noise over a number of issues this year; targets included proposed right-to-treatment legislation, cuts to the Drug Benefit Plan, capping of yearly billings at $450,000, and inquiries into charges of sexual abuse by doctors. And most significantly, the last conference of the Canadian Medical Association passed a resolution calling for a two-tier health system in which those with money can hop the queue. 

Post editor Diana Swift says the poll shows fairly strong support for limiting services to the elderly, although the survey question is short on details: “I feel it is reasonable that access to high-cost services such as transplants should be rationed according to such parameters as the patient’s age and/or unhealthy habits.”

Yet just under 70 per cent of doctors opposed any capping of their salaries, despite 56 per cent of the public supporting this measure according to a 1991 Globe and Mail-CBC poll. 

When questioned, Health Minister Francis Lankin expressed surprise that doctors felt so strongly, and denied the government is considering rationing services to seniors. Lankin feels the volatile mood of doctors is a reaction to the rapid changes taking place in health care. 

Dr. Michael Rachlis, health care critic and author of the book Second Opinion, says the survey’s low response rate means that the answers reflect “redneck physicians, who are more likely to respond.” Swift admits to a high response rate from young male physicians, who since the 1986 doctors’s strike in Ontario, have been considered the profession’s most militant. 

One response which some may find alarming was towards the “Oregon model.” In that American state, medical procedures are rationed to seniors and individuals covered by medicare. Anybody needing uncovered emegency treatment has to pay for it themselves. A disturbing 65 per cent of survey respondents supported such a move. 

Dr. Gerry Gold, associate registrar at the College of Physicians and Surgeons of Ontario, feels that some doctors lack perspective. “The complaints are a reflection of frustration with increasing involvement of government. But if physicians understood the role of the government in the U.S., they would realize they, along with insurance companies, intervene far more.”

Gold says doctors have had the same complaints ever since the beginnings of medicare. “Many front-line doctors lack the information to make informed comment,” he says. “They aren’t being consulted or informed by the government.”

Rachlis says many doctors fail to realize how privileged they are. “Canadian physicians don’t realize medicare has protected their autonomy more than in the U.S.,” he says. “Doctors are always angry because they have large chips on their shoulders from being brutalized in their training. They don’t realize the government has given them a privileged monopoly over health services. With a guaranteed income with job security, I don’t know one doctor who has suffered in this recession.”

Gold doesn’t foresee strikes or job actions by doctors, but predicts further government cuts, and more services being de-insured by OHIP. A recent example involved removing coverage for third-party medical exams such as those requested by employers or insurance companies. As medical procedures end up outside of OHIP, Gold foresees physicians charging whatever they like. 

A perennial idea is the user fee. This is one of the few ideas that gathers support from a majority of doctors and the general population alike. But Rachlis feels these measures are meanspirited and avoid the real problems plaguing health care. “When Saskatchewan introduced user fees for physician and hospital care in 1968,” he says, “health costs remained the same and it discouraged the elderly, the poor and people with large families from seeking service. 

“When providers are allowed to charge users for care, as in the United States, where more than 20 per cent of health care costs are paid our of pocket, overall costs go up.” 

Feds call for AIDS, blood system inquiry: Some seniors infected

By David South

Today’s Seniors (Canada), July 1993

HIV-tainted blood transfusions given in the early 1980s have left some seniors with AIDS, but it is feared many are unaware of their HIV-positive status. 

Between 1979 and 1985 - before testing of blood products for HIV became mandatory - 266 transfusion recipients and over 677 hemophiliacs are known to have been infected in Canada, according to the Centre for AIDS Statistics. 

But the final numbers are unkown - estimates range from 400 to 1,000 cases of HIV transmission among the 1.5 million Canadians given blood products during this time. 

This uncertainty is fueling public concern. With such a serious public health danger, many are shocked by the confusing messages being sent by governments, the Canadian Red Cross Society and hospitals. 

But it took the report of an all-party Parliamentary subcommittee on health, released at the end of May, to shock the federal government into calling for a public inquiry into the blood system. The report is highly critical of the decision-making process involved in blood collection and distribution. 

“We have members of our group who are seniors,” says Jerry Freise, spokesperson for advocacy organization HIV-BT (Blood Transfusion) Group, whose wife was infected with HIV due to a blood transfusion. “And many of them went for years being misdiagnosed and treated for something other than HIV. Others have gotten sick, and one died without knowing it because nobody told him. 

“A classic case is Kenneth Pittman who was infected in 1984. The Red Cross found out in 1985 and they allegedly took two years to tell The Toronto Hospital. The hospital took two years to tell his doctor, and his doctor decided not to tell anybody. 

Infected

“Another couple, a lady of 59 and a man of 64, called us April 1. She found she was infected, and the reason she took a test is because her husband turned out to be HIV-positive three weeks before a transfusion in 1983. He had gone for years without a diagnosis from doctors.” 

This runs counter to the Red Cross’s story. 

“Whenever a blood donor tests positive for HIV antibodies, we go back and trace the prior donations,” says spokesperson Angela Prokoptak at the Society’s national office. “The Red Cross supplies blood to hospitals, so we know which units went to which hospital. But the hospital must go through their records to find who they transfused. 

“After identifying the recipient, the hospital contacts the recipient’s physician, and then they have them tested. There are of course limitations.

“Since 1987, the Red Cross has been advising people who may be concerned to consult their physician for counselling and advice.”

But subcommitte member Chris Axworthy, an NDP MP, found that hospitals and the Red Cross hesitated to notify former patients for fear of lawsuits. He says the federal government should show some leadership and stop passing the buck to other agencies and departments. 

Only two hospitals in Ontario - Toronto’s Hospital for Sick Children and Princess Margaret Hospital - have tried systematically to contact former patients. 

Ontario health ministry spokesperson Layne Verbeek says it is a laborious and costly task for hospitals to notify former patients. “We’ve always informed people if they are thought to be at risk, but many hospitals aren’t in the position to trace. If people are at risk or have doubts, they should be tested.”

Verbeek says recent media coverage has caused an increase in the number of people seeking HIV blood tests - requests for the test doubled after the Sick Kids hospital went public. The provincial government’s lab went from 700 tests per day to 1,300, but Verbeek says that has started to taper off. 

The ministry of health is happy with the number of people coming forward to be tested, says Verbeek. 

But Friese says the different players are more concerned about lawsuits than informing the public. He is especially upset at the Red Cross for not taking a leadership role in disseminating information. 

“The Red Cross and the medical system have failed miserably to contact people. Even today they are reticent to tell people they were part of a risk group and should get treated.” Friese feels the various governments and the Red Cross are leaving the job of informing the public to his group and the Canadian Hemophiliacs Society. 

Beat the drums

“It’s my job to beat the drums for the media while I’m dealing with my wife being infected? That’s my job, when these are the ministers of health?”, Friese says with anger.

The effect of AIDS on seniors isn’t new to US-based National Institute on Aging researcher Marcia Ory. She and colleagues helped sound the alarm back in 1989 with the book “AIDS In An Aging Society: What We Need To Know.” In the US, over 10 per cent of AIDS cases have occurred in people over 50. 

“Surprisingly, people have ignored older people and the AIDS issue,” says Ory. “You had older people in hospitals who might have complained about fatigue which was thought to be age-related. Older people aren’t as likely to be diagnosed as early because of the assumption that they are not at risk from AIDS.

“We don’t want older people in general to be overly fearful, but we want them to acknowledge the possibility, and to engage in good preventative practices if they are at risk.” 

Ron deBurger, director of AIDS prevention for the Canadian Public Health Association, would like assurances that the security of the blood supply has improved. 

“The subcommittee came to the right conclusion asking for a public inquiry,” says deBurger. “I would hope the terms of reference are broad enough to take a look at the whole issue of the safety of the blood supply, not only in terms of what happened in the past, but, more importantly, what’s happening today.”

Other than hemophiliacs, who require large quantities of blood, deBurger believes anybody who received one transfusion has a small risk. “If you had blood once, I think the odds are pretty long that you are going to end up with tainted blood. But AIDS does take eight to 10 years to manifest itself, and we might still be picking up pieces for the next four to five years that we don’t know about yet.” 

Friese recommends that anybody who received blood or blood products between 1979 and 1985 get an HIV test. If their doctor says it isn’t necessary, they should call the AIDS Hotline about anonymous testing. 

Anybody who has tested positive for HIV and would like support and counselling can call Robert St-Pierre of the Canadian Hemophilia Society at 1-800-668-2686.

For information on anonymous testing call the Ontario government’s AIDS Hotline in Toronto at 416-392-2437. For support write HIV-BT Group, 257 Eglinton Avenue W., Suite 206, Toronto, Ont., M4R 1B1.