On December 6, 2017 the Auditor General of Ontario, Bonnie Lysyk, released her 2017 Annual Report. The report dedicates five of the 14 value-for-money audits to health care issues including cancer treatment services, community health centres, laboratory services, public drug programs and chronic disease prevention. The audit also focused on emergency management and its impact on public health and safety.
The Minister of Health and Long-Term Care released the following statement in response to the audit.
The following summary highlights the Auditor General’s key observations in each topic.
Section 3.02 – Cancer treatment services
The audit found that the Ministry of Health and Long-Term Care (MOHLTC), Cancer Care Ontario (CCO) and hospitals generally provide cancer treatment in a timely, equitable and cost-effective manner for most patients, but not all. Some cancer services are not provided in manner that meets the needs of Ontarians. For example:
- There are significant regional variations in wait times for some urgent cancer surgeries.
- Some radiation treatment plans are not reviewed according to clinical guidelines.
- Radiation treatment is under-utilized.
- Inequities exist in access to take-home cancer drugs.
- Supports are inadequate for patients on proper and safe usage of take-home cancer drugs.
- No oversight of cancer drug therapy is provided at private specialty clinics.
- Stem cell transplant wait times are long.
- There is insufficient capacity for stem cell transplants.
- Symptom-management support is inadequate.
- Psychosocial cancer services are insufficient and inconsistent.
- Ontario is slow to adopt advances in positron emission tomography (PET) scans.
- Significant regional variations exist in CT scan and MRI wait times for cancer patients.
- Wait times for biopsies are long.
- There is no provincial peer review program for diagnostic-imaging results.
- Cancer funding is inequitable.
Read the cancer treatment services audit in depth
Section 3.03 – Community health centres
The Auditor General found that Ontario’s 75 Community Health Centre’s (CHC) provide health care and community programs to vulnerable populations and can contribute to reducing the strain on the health care system and other provincial government programs. However, the audit concluded that the MOHLTC and the Local Health Integration Networks (LHINs) do not have sufficient information to ensure that CHCs deliver programs and services in a timely and cost-effective manner that meet the needs of their target population groups. Other observations include:
- Split responsibility between Ministry and LHINs on primary care in the last decade is not conducive to effective primary-care planning.
- Utilization of CHC services varies across the province.
- Inter-professional primary care is not available in all LHIN sub-regions in Ontario.
- CHC staffing model and types of services have not been defined.
- Funding to CHCs is not tied to number of clients served.
- LHINs do not sufficiently monitor CHCs.
- Meaningful data is not collected to evaluate effectiveness of CHCs.
Read the community health centres audit in depth
Section 3.07 – Laboratory services in the health sector
The audit found that laboratory services are generally provided safely and accurate laboratory test results and generally provided to health care professionals in a timely manner. Despite this, the audit found that several areas relating to cost-effectiveness, accessibility, and performance measurement and reporting of laboratory services need improvement. Observations include:
Cost to the Ministry and to patients:
- Outdated laboratory test price list resulted in overpayments to community laboratory service providers.
- Price list not updated using all relevant cost data.
- Medically necessary tests remain uninsured.
- More action needed to reduce unnecessary testing.
- Inadequate strategy for genetic testing results in costly out-of-country testing.
- More effort needed to identify and improve underserved areas of laboratory services.
Regional inequities:
- Inadequate strategy for genetic testing results in costly out-of-country testing.
- More effort needed to identify and improve underserved areas of laboratory services.
Ontario’s laboratories’ performance:
- Limited investigation of large in-office laboratory test volumes and billings by physicians.
- No licensing and quality management of physicians’ in-office laboratory testing.
- Lack of regional co-ordination and integration of hospital laboratories.
- No oversight of billing practices by hospital laboratories.
- No consistent performance measurement and reporting of laboratory services.
- No provincial target, data collection and monitoring of wait times for laboratory services.
- No assessment of the effectiveness and efficiency of laboratory service providers by Ministry.
- Inadequate oversight of quality management program.
Read the laboratory services audit in depth
Section 3.09 – Ontario public drug programs
The audit made the following observations on Ontario public drug programs:
Brand name drugs:
- Negotiations for brand-name drugs have led to significant rebates from drug manufacturers, but it is difficult to know whether the Ministry is obtaining the best possible value compared to other jurisdictions.
- The processing of rebates for brand-name drugs is too slow and prone to error.
Generic drugs:
- Generic drug prices in Ontario have dropped significantly in the last 10 years, but the Province still pays more than foreign countries.
- The Ministry paid significantly higher amounts for a number of commonly used generic drugs than some Ontario hospitals.
Exceptional Access Program:
- Many patients requesting exceptional drug coverage waited excessively.
- The Ministry has acknowledged weaknesses in processing exceptional access requests since 2010.
Oversight of payments to pharmacies:
- The Ministry did not inspect and/ or recover many payments for invalid claims, leading to about $3.9 million of inappropriate payments.
- The Ministry did not refer several potentially fraudulent billings to the Ontario Provincial Police (OPP) in a timely manner.
MedCheck program
- The Ministry does not know if the MedsCheck program ($550 million between 2008/09 and 2016/17) is effective.
Opioid crisis
- Despite numerous initiatives taken by the Ministry in dealing with the recent opioid crisis in the province, it does not have the critical information needed to inform its decisions in addressing the issues.
Read the public drugs programs audit in depth
Section 3.10 – Public health: Chronic disease prevention
The audit found that public health units’ performance in chronic disease prevention is not measured fully by the MOHLTC. Other observations include:
- Ontario has no overarching chronic disease prevention strategy.
- Some public health units faced challenges in accessing schools to provide health promotion programs.
- No consistent provincial leadership to co-ordinate public health units’ updating of evidence, sharing of best practices, and development of monitoring systems on health promotion programs.
- Not all public health units have access to necessary epidemiological data.
- Public health units individually indicated that they have limited capacity to perform epidemiological analysis to help guide and monitor their programs.
- At some public health units, program evaluations were not conducted to determine whether their programs had a positive impact.
- Current provincial performance indicators do not fully measure public health units’ performance in preventing chronic diseases and promoting health.
- Ministry has started to address funding equity but full implementation of the needs-based funding model may take up to 10 years.
Read the chronic disease prevention audit in depth
Section 3.04 – Emergency management in Ontario
The audit found The Provincial Emergency Management Office (EMO) and the selected ministries need to improve their policies and procedures to ensure that fully effective emergency management programs would be able to respond quickly if needed to protect the public and sustain provincial and municipal operations.
Additionally, EMO needs to better co-ordinate the provincial emergency management program by providing tools and resources to ministries and municipalities. EMO and the ministries also did not have effective processes to measure, evaluate and publicly report on the emergency management program’s objectives. In addition, we found that emergency management operations at EMO and the ministries, including the disaster financial assistance programs, are not always carried out with due regard for economy and efficiency. The audit found:
- The current governance structure for emergency management in Ontario is not effective for overseeing a province-wide program.
- Lower than expected priority given to emergency management.
- Risk identification and assessment processes are not sufficient to ensure that the provincial emergency management program includes all areas of concern.
- The Province does not have a co-ordinated information technology (IT) system in place for emergency management.
- The provincial emergency management program does not focus on all five components of emergency management: prevention, mitigation, preparedness, response and recovery.
- Emergency response plans have not been updated to reflect current events or operations.
- The approach to practicing for emergencies does not ensure that the Province is prepared to respond to emergencies.
- The Province’s overall state of readiness to respond to emergencies needs significant improvement.
The audit noted the following concerns with regard to Ontario’s state of readiness:
- Numbers of trained staff are not sufficient for a lengthy emergency.
- A standardized approach for emergency response has not been mandated after eight years in development.
- Agreements are not in place for resources that may be needed in an emergency response.