SPER Committee Meeting

37th PARLIAMENT, 1st SESSION

Sub-Committee on the Status of Persons with Disabilities of the Standing Committee on Human Resources Development and the Status of Persons with Disabilities

COMMITTEE EVIDENCE

CONTENTS

Tuesday, January 29, 2002

¹

1530

The Chair (Ms. Carolyn Bennett (St. Paul's, Lib.))

Dr. Henry Haddad, (President, Canadian Medical Association)

¹

1535

¹

1540

¹

1545

The Chair

Dr. John C. Service

¹

1550

The Chair

Dr. Blake Woodside (President Elect, Canadian Psychiatric Association)

¹

1555

º

1600

The Chair

Ms. Adele Furrie (President, Adele Furrie Consulting)

º

1605

The Chair

Ms. Adele Furrie

º

1610

The Chair

Ms. Adele Furrie

The Chair

Ms. Adele Furrie

The Chair

Ms. Adele Furrie

º

1615

The Chair

Ms. Adele Furrie

The Chair

Ms. Adele Furrie

Dr. Claude Renaud (Associate Secretary General and Chief Medical Officer, Canadian Medical Association)

Ms. Adele Furrie

The Chair

Ms. Adele Furrie

The Chair

Ms. Adele Furrie

The Chair

Ms. Adele Furrie

º

1620

The Chair

Mr. Larry Spencer (Regina--Lumsden--Lake Centre, Canadian Alliance)

Dr. John Service

Dr. Claude Renaud

Mr. Larry Spencer

The Chair

Dr. Claude Renaud

º

1625

The Chair

Mr. Larry Spencer

Dr. Blake Woodside

The Chair

Mr. Spencer

The Chair

Mr. Spencer

Dr. Claude Renaud

Mr. Larry Spencer

Dr. Henry Haddad

º

1630

The Chair

Dr. John Service

The Chair

Dr. Blake Woodside

The Chair

Mr. Lanctôt

º

1635

Dr. Claude Renaud

The Chair

Ms. Adele Furrie

Mr. Lanctôt

º

1640

Ms. Adele Furrie

Mr. Lanctôt

The Chair

Ms. Adele Furrie

The Chair

Dr. Henry Haddad

M. Lanctôt

º

1645

Dr. Blake Woodside

Dr. John Service

Dr. Claude Renaud

Dr. Henry Haddad

The Chair

Mr. Tony Tirabassi (Niagara Centre, Lib.)

º

1650

Dr. Henry Haddad

Mr. Tony Tirabassi

The Chair

Dr. Henry Haddad

Dr. John Service

The Chair

Dr. Blake Woodside

Dr. Henry Haddad

The Chair

Dr. Claude Renaud

º

1655

The Chair

Dr. Claude Renaud

The Chair

Dr. Claude Renaud

The Chair

Dr. Claude Renaud

Dr. Henry Haddad

The Chair

Dr. Henry Haddad

Dr. Blake Woodside

The Chair

Ms. Wendy Lill (Dartmouth, NDP)

»

1700

Dr. John Service

The Chair

Ms. Nancy Karetak-Lindell (Nunavut, Lib.)

Dr. Claude Renaud

»

1705

The Chair

Dr. Henry Haddad

The Chair

Dr. Henry Haddad

The Chair

Dr. John Service

The Chair

Ms. Adele Furrie

The Chair

Ms. Nancy Karetak-Lindell

»

1710

Dr. Henry Haddad

The Chair

Ms. Adele Furrie

The Chair

Dr. Claude Renaud

The Chair

Dr. Claude Renaud

The Chair

Dr. Blake Woodside

The Chair

Ms. Adele Furrie

The Chair

Ms. Adele Furrie

The Chair

Mr. Robert Lanctôt

Dr. Claude Renaud

The Chair

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CANADA

Sub-Committee on the Status of Persons with Disabilities of the Standing Committee on Human Resources Development and the Status of Persons with Disabilities

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NUMBER 013

l

1st SESSION

l

37th PARLIAMENT

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COMMITTEE EVIDENCE

Tuesday, January 29, 2002

[Recorded by Electronic Apparatus]

¹  (1530)  

[English]

    The Chair (Ms. Carolyn Bennett (St. Paul's, Lib.)): I call to order meeting 13 of the Subcommittee on the Status of Persons with Disabilities of the Standing Committee of Human Resources Development and the Status of Persons with Disabilities.

    This is our happy little study on the disability tax credit. I think some of you know there was a moment, before we broke in the fall, when we thought we'd heard quite enough to be able to go and talk to the minister about it.

    We hope you're here with solutions for us. As you know, government deals better with solutions than problems. We hope you'll help us help the people of Canada, and particularly those who maybe haven't been served well by the program.

    We're going to start with Dr. Haddad, and will also hear from Claude Renaud, from the CMA.

    Dr. Henry Haddad, (President, Canadian Medical Association): It's a great pleasure to be here.

[Translation]

    My name is Henry Haddad. I am the president of the Canadian Medical Association, a practicing gastroenterologist and professor at the University of Quebec.

    As president of the Canadian Medical Association, I am here today representing more than 50,000 physicians from across Canada. The Canadian Medical Association's mission is to serve and unite the physicians of Canada and be the national advocate, in partnership with Canadians, for the highest standards of health and health care.

    I am accompanied by Dr. Claude Renaud, Associate Secretary General and Chief Medical Officer of the CMA.

[English]

    I want to thank the subcommittee for giving the CMA the opportunity to discuss issues related to the DTC program. I will focus my remarks on the DTC program in three areas: the relationship between the CCRA and the CMA on the DTC program; the integrity of the program; and the issues of fairness and equity within the program. I will also briefly explore how the DTC program fits in with the broader issue of a comprehensive review of the tax system, in support of health and social policy.

    Before I proceed, I would like to first officially acknowledge the CMA's support for the mental health issues and recommendations put forth today by Dr. John Service of the Canadian Psychological Association, and Dr. Blake Woodside of the Canadian Psychiatric Association.

    I will now turn to our first issue of the relationship between CCRA and the CMA. The subcommittee has heard from witnesses, including the CCRA, about the consultative process that has taken place on the DTC program and the T2201 form. The impression the subcommittee may have is that the CMA has been consulted extensively and on an ongoing basis. In fact, these meetings, although productive--and I stress the fact that these meetings have been productive--have only occurred on an ad hoc basis. At best, our working relationship could be described as hit and miss.

    Our first substantive contact on the DTC program was in 1993. Many of the observations made then still hold through today. You will find them in our brief.

    An example of the spotty relationship is a recent letter sent by the CCRA minister, asking current DTC recipients to requalify for the credit. The CMA was not advised or consulted about this letter. If we had been advised, we would have highlighted the financial and time implications of sending 75,000 to 100,000 individuals to their family physicians for recertification. We also would have worked with the CCRA on alternative options for updating DTC records.

    We would have reviewed what the objectives were, and how best to deal with them. Finally, realizing that a buy-in from an already overworked medical profession was essential, we would have reviewed the questions to make sure they were appropriate, and considered a phase-in cleanup over two to three years--or it could have been three or five years.

    Unfortunately, we cannot change what has happened, but we can learn from it. This clearly speaks to the need to establish open and ongoing dialogue between our two organizations. Physicians are our key point of contact for applicants of the DTC, and given the way the program is structured, they are vital participants in its administration. Therefore, it's imperative that the CCRA establish a high-level, ongoing, and meaningful consultative process with the CMA.

    It's our recommendation that the CCRA establish a senior-level advisory group to continually monitor and appraise the performance of the DTC program, to ensure it is meeting its stated purposes and objectives.

    Representation on this advisory group should include, at a minimum, senior program officials, preferably at the ADM level; those professional groups qualified to complete the T2201 certificate; various disability organizations; and patients, for the integrity of the process.

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[Translation]

    Turning to the DTC program itself, a primary concern and irritation for physicians working with this program is that it puts an undue strain on the patient-physician relationship. This strain may also have another possible side effect, a failure in the integrity of the DTC program process.

[English]

    With the current structure of the DTC program, physicians evaluate the patient, provide this evaluation back to the patient, and ask the patient for remuneration. This process is problematic for two reasons. First, since the patient will get the form back immediately following the evaluation, physicians might receive the blame for denying their patient the tax credit, not the DTC program adjudicators. Second, a physician does not feel comfortable asking for payment when he or she knows the applicant will not qualify for the tax credit. It's being paid to say no.

    For the integrity of the DTC program, physicians need to be free to reach an independent assessment of the patient's condition. However, because of the pressure placed by this program on the patient-physician relationship, the physician's moral and legal obligation to provide an objective assessment may conflict with the physician's ethical duty to consider the well-being of the patient first.

    There is a solution to this problem, and it's a model already in use by the Canada Pension Plan disability program. Under the CPP disability program the evaluation from the physician is not given to the patient, but is sent to the government, and the cost to have the eligibility form completed by a physician is subsumed under the program itself. Under this system the integrity of the patient-physician relationship is maintained, and the integrity of the program is not compromised.

    To highlight the frustration of physicians with the DTC program, I want to bring to the committee's attention a recent letter from a British Columbia physician. In the letter, which I have here today, the physician complains about a form he has recently been sent by the CCRA. It is over five pages long, and it asks about 40 detailed questions. The questions are complex, and it would take a lengthy examination to complete. Therefore, the cost would be much higher than completing the regular T2201 form. The patient whose form was being completed happened to be an elderly patient and not really able to afford to remunerate the physician for completing the form. However, once again, it states that the patient is responsible for fees related to the completion of this longer form. In this case, as with the majority of cases involving the DTC program, the patient seeking the tax credit may not have the money to cover the cost associated with the program, and therefore the physician is reluctant to charge fees, again, reluctant to be paid for saying no.

    Thus, in this and many other cases, a physician has performed two evaluations, the original DTC21 form and this form, completed two forms that, combined, could take well over an hour, with a complex case particularly, for which there is absolutely no payment. The situation leads to frustration for both the patient and the physician. It often ends up compromising the physician-patient relationship. It also leads to an increased mistrust of the system.

    With this in mind, our recommendations are that CCRA take steps to separate the evaluation from the determination process and address the remuneration issue. The model the CMA would suggest the CCRA adopt to achieve this result is the CPP disability program.

    Then there is the issue of fairness and equity.

¹  (1540)  

[Translation]

    Turning to our third area of concern, the CMA recommends a standard of fairness and equity be applied across all federal disability benefit programs.

    One of the problems with assessing disability is that it is difficult to define in several situations. Even in the most widely used definitions, such as the World Health Organization's, the word “disability” is defined in very general and subjective terms.

[English]

    The DTC and other disability programs do not use the same criteria for defining disability. To qualify for the DTC, a disability must be prolonged, which means over a period of at least 12 months, and severe, which means that it must markedly restrict any of the basic activities of daily life that are defined.

    Though CPP criteria uses the same words, “severe” and “prolonged”, they are defined differently. Severe means it prevents applicants from working regularly at any job and prolonged means long term or may result in death.

    Other programs,such as Veterans Affairs Canada, have entirely different criteria. This is confusing for physicians, patients, and others involved in the application process. If the terms, criteria, and information about the programs are not as clear as possible, it could result in faulty interpretation on the part of physicians when completing the forms. This could then inadvertently disadvantage those who in fact qualify for benefits.

    I would like to stress that the concept of disability is difficult to define, that disability is usually defined in very general and subjective terms, and that more than one definition is used by government. As other presenters will mention, the CMA would like to see some consistency in definitions across the various government programs. This does not mean that the eligibility criteria must be identical, however.

    The final issue I would like to address today is the broader issue of better integrating tax policy with health and social policy.

    In our 2001 pre-budget consultation document to the Standing Committee on Finance, the CMA recommended that the federal government establish a blue-ribbon national task force to study the development of innovative, tax-based mechanisms to synchronize tax policy with health and social policy. Such a review has not been undertaken in over 25 years, since the Royal Commission on Taxation in 1966, known as the Carter commission. A study of this nature would look at all aspects of the taxation system, including the personal income tax system of which the DTC is a component.

[Translation]

    To conclude, the CMA believes that the DTC is a worthwhile benefit for those Canadians living with a disability. The CMA's recommendations I presented today and the additional recommendations contained in our brief would certainly be helpful to all involved—the patient, health care providers and the programs' administrators—but only in the short term. What would be truly beneficial in the longer term would be an overall review of the taxation system from a health care and social policy perspective.

    This could provide tangible benefits not only for persons with disabilities but for all Canadians, as well as demonstrate the federal government's leadership in ensuring the health and well-being of our population.

    Thank you.

¹  (1545)  

[English]

    The Chair: Merci.

    Dr. Service, you're next.

    Dr. John C. Service(Executive Director, Canadian Psychological Association): Thank you, Dr. Bennett, and members of the committee.

    The Canadian Psychological Association is certainly pleased to have this opportunity to come to talk to you today.

    To begin, I'd like to say that psychology is the study of the biological, cognitive, social, affective, and cultural dimensions of behaviour. So it's a broad field, and within it there's health. Part of what we're going to talk about today is a subset of health, but I wanted to make sure that some of our comments come from that broader context of human behaviour.

    The committee has heard from a number of interested parties. We've had excellent input, and I've been at one of the sessions. I don't think it's necessary for me to go over a lot of that stuff, so we'll just move along to our position.

    The DTC was originally designed for those with physical impairment, such as blindness. It's evolved over the years, with important efforts made to include Canadians with disabilities, diseases, and conditions that fall outside of this physical or psychological domain. This evolution is to be commended; however, the result has been an attempt to use what is essentially a physical health template and culture to assess mental illness or psychological problems. This is part of the problem we face today.

    Some changes have occurred over time to improve the assessment process. After input from groups such as the Learning Disabilities Association of Canada and others, psychologists were included with physicians to assess impairments of perceiving, thinking, or remembering. This decision was a good one. It allows Canadians to access quality services and assessments and treatments and has provided more access to them.

    The issues before us today are I think more those of interpretation and definition than of basic principles. The nature of impairment is defined by a number of criteria. An impairment must be severe and prolonged, as my colleague said, using a benchmark of 12 months. This is reasonable.

    Basic activities of daily living are defined as perceiving, thinking, or remembering. This also is a reasonable benchmark. If we open the act, we may want to look at different criteria and definitions, but that is certainly okay for the present time.

    However, the interpretation of this benchmark, which requires the impairment exist all or almost all of the time--the 90% rule--is reasonable for some Canadians who have, for example, a neurological injury, but not for many Canadians with mental illness or psychological disorders. For Canadians who fall within this latter group, it is more appropriate to consider other criteria to determine eligibility.

    For example, the decision taken in Radage v. the Queen is instructive. The decision there was that the judge used as a benchmark disturbances of perceiving, thinking, or remembering that deviate significantly--and this is important--in a diagnostic, statistical, or functional sense, from normal human experience. It's a standard that's used widely in many forms of evaluation, and this would be reasonable.

    Severe and prolonged mental illnesses are very debilitating. Impairment is present by definition for a long period of time, exceeding, in this case, 12 months. Within this framework symptoms may increase and decrease in severity but the impairment remains constant. Sometimes the onset of increased symptom severity is not predictable. The eligibility criteria need to be sensitive to these factors, and the CCRA information and forms need to make this clear to practitioners.

    Mental illnesses can be devastating in their long-term effects that are secondary to the illness, but which seriously compromise the individual's ability to hold a job or take care of personal affairs. These Canadians are very disabled by the secondary effects of their illnesses.

    The impairment must be a marked restriction of the performance of basic activities of daily living. This is a reasonable benchmark for some Canadians--for example, those with a significant developmental delay or serious brain injury--but not for many suffering from a severe and prolonged mental illness or other psychological conditions. These Canadians are able to perform many basic activities needed for daily living, but they are not able to conduct their personal affairs without serious negative consequences or supervision. We have examples of that.

    The concept of the effective management of personal affairs appears in earlier versions of the eligibility criteria for the DTC. It would be a useful concept to bring back, as it more appropriately judges the level of disability of many who have a mental illness or a learning disability. For example, the solution might be to add the phrase “or basic personal affairs” to the text that follows the question, “Can your patient perceive, think, or remember?”on part B of the form CT-2201. The sentence could read: “For example, answer no if he or she cannot manage or initiate personal care or basic personal affairs without constant supervision.”

¹  (1550)  

    The form itself asked if the patient can “perceive, think and remember”. Now, case law has concluded that this criterion should read, “perceive, think or remember”. This also falls into line with current CCRA practice, and we think it is a positive development and should be clear on the form.

    If the answer to the question “Can the patient perceive, think and remember” is yes, then the tax credit is not allowed. If the answer is no, the person's application is then considered, once subsequent questions are answered satisfactorily. The asking of the question in this manner and the 90% threshold automatically eliminate many deserving Canadians, and it is confusing for many practitioners. As stated above, practitioners will answer yes, not knowing this virtually disqualifies deserving applicants.

    It would be more efficient to reword the question to give the practitioner a better opportunity to define the level of disability. This would be clearer to the practitioner and give CCRA officials a more realistic benchmark to work from. If the answer is no, then the question virtually means that the person is actively and acutely delusional or significantly brain-damaged throughout the 12-month period. It's our opinion that this obviously sets the bar too high in terms of the DTC and in terms of a fair comparison to physical illness.

    Now for recommendations. It is important that CCRA officials and interested parties such as those who have appeared before you, ourselves and other interested parties, have the opportunity to discuss these important issues. Recommendation one is that CCRA officials and interested parties, providers, and patient groups commit to continuing the consultation process to address the issues specific to mental illness and psychological disorders.

    Two, include the performance of personal affairs with personal care as a benchmark for determining eligibility.

    Three, ensure eligibility criteria are sensitive to the issues of impairment coupled with symptom variability over time in this severe and prolonged framework.

    Four, define disturbances of perceiving, thinking, or remembering as those that fall significantly outside the scope of normal human behaviour.

    Five, let “perceive, think and remember” be changed to “perceive, think or remember”, and let information be sent to practitioners so they clearly understand the template being used by CCRA officials.

    We strongly support the positions taken by our colleagues as well in terms of the more macro issues of disability and text policy.

    Thank you very much.

    The Chair: Thank you very much.

    Dr. Woodside.

[Translation]

    Dr. Blake Woodside (President Elect, Canadian Psychiatric Association): Thank you, Madam Chair. I am pleased to have this opportunity to make a presentation here today.

[English]

    Madam Chair, respected members of the committee, my name is Blake Woodside. I am presenting today as president-elect of the Canadian Psychiatric Association. I am a psychiatrist, a medical doctor. In my day-to-day work I head an in-patient program in Toronto that treats severe anorexia nervosa.

    Thank you for inviting psychiatrists to discuss with you what can be done to improve the fairness and administration of the disability tax credit program, specifically as it affects those suffering from a mental illness.

    May I firstly commend this committee for taking the time to hear from the many different individuals who, to date, have presented concerns around the special issues affecting Canadians disabled by mental illness.

    Social and health policy discussions have too often neglected the particular issues surrounding mental illness and we hope that this is beginning to change. As some of you know, the Canadian Psychiatric Association has been working with four other major national organizations, the Schizophrenia Society of Canada, the Mood Disorders Association of Canada, the National Network for Mental Health, and the Canadian Mental Health Association to draw Canadian policy-makers' attention to the needs of Canadians with mental illness.

    Through what is still a small coalition called the Canadian Alliance for Mental Illness and Mental Health, we have developed some proposals for national action in this regard. These are outlined in a paper called A Call to Action: Building Consensus on a National Action Plan on Mental Illness and Mental Health in Canada, copies of which we have available today.

    In this discussion paper, we included a recommendation that one of the steps the federal government can take is to ensure that the needs of the mentally ill are considered in all of its policies. They should apply it to its tax policies as an important component of Canada's social policies, and the distinct needs of psychiatric disabilities should be adequately considered in Canada's other social policies related to disabilities.

    The Canadian Medical Association has outlined how physicians have been affected by the current design of the program. We generally concur with their global recommendations for program integrity and standardization. Some of our mental health colleagues, such as the Canadian Mental Health Association and the Canadian Psychological Association, as well as individual consumers, have presented evidence about how the program affects caregivers and those living with a severe mental illness.

    I am here to present some considerations and recommendations based on the experience of psychiatrists with this program. I will try not to repeat the expert evidence you have already heard. I will address the following two main points. The first is the lack of perceived fairness due to restrictiveness of definitions and/or the lack of clarity about applicability to mental illness, and the second is administrative issues in relation to mental illness, namely the lack of appropriateness of the form and the need for guidelines and better information.

    So first, restrictiveness of definitions and lack of clarity about applicability to mental illness. Mental illnesses are amongst the most prevalent causes of disability. They account for five of the ten leading causes of disability worldwide and the number four is depression. So we should expect this to be the most common type of claim if fairly and equitably administered. Yet there is a perception that this tax credit unfairly discriminates against those living with a severe mental illness. While we do not have the data to determine the relative proportion of claimants for each category, many psychiatrists report anecdotally that the criteria, as presented in the instructions to the form T2201, mean that their patients do not qualify, regardless of the severity of their illness.

    In part, this is due to the restrictiveness of the conditions under which individuals are eligible for the credit. The Canadian Psychological Association and individual earlier presenters have already commented that the criteria used in the definition of basic activities of living, specifically that of the inability to think, perceive or remember, and “markedly restricted”, meaning almost all of the time, the 90% rule, means that only those with severe neurological disorders will qualify.

    Others have noted how the definition for “prolonged” disqualifies many with mental illness because of the episodic manifestation of the symptoms of most mental illnesses. The problem here is the word “inability”, a term clearly borrowed from physical disability. A person is judged to be unable to see, for example, when they meet the agreed-upon criteria to qualify as legally blind, which criteria do not require a 100% absence of vision. No such criteria are in place to evaluate the severity of mental illness.

    The use of primitive efforts, phrases such as “almost all of the time”, “greater than 90%”, or “prolonged”, simply does not address the complex issue of characterizing psychiatric disability. This lack of clear definition is the primary reason the current system discriminates against those with mental illness. Fortunately, as I will come to later, there is a straightforward approach to finding a solution to this problem and we need to find a solution.

    Approximately 3% of the population is affected by a severe mental illness that produces profound and persistent disablement, that is a diagnosed mental illness using DSM IV criteria, such that it severely impairs daily functioning.

¹  (1555)  

    These individuals, who suffer from severe and persistent illness, while alive and mobile, have no ability to see, hear, or perceive their existence in any fashion that you would recognize as consistent with your everyday experience. It is easy to see why persons living with severe mental illness feel the current disability tax credit program is unfair or even discriminatory.

    A fair system will not be one in which individuals with any mental illness have unfettered access to the disability tax credit, but rather one in which the same care, consideration, and consultation taken to define “mental disability” are the same as the care, consideration, and consultation taken in the past to find the various types of physical disabilities that qualify under the tax credit. The system as it is lacks this fairness.

    The restrictiveness and the lack of clarity about eligibility also affect the many family members who care for those living with a severe mental illness. They take on not only the emotional burden of caring for their family members with a mental illness, but also the very significant financial burden this tax credit appears to have been intended to recognize. With the ongoing reorganization and constriction in the health care system, families of all disabled persons must take on an increasing burden of care for their loved ones.

    Secondly, I'll address administrative issues. As reported by others, psychiatrists generally find form T2201 inappropriate. In an attempt to make the form easy to complete, it is now too simplistic. Clearer definitions of psychiatric and mental health disabilities must be developed to allow practitioners to accurately describe their patients' conditions. The development of more detailed guidelines must be accompanied by an education strategy for practitioners.

    Finally, the requirement for this most severely mentally ill group—often homeless or on welfare—to pay for the form to be completed is a blatant example of discrimination, and it unduly restricts the group most in need from having access to this program.

    In conclusion, as a first step, the federal government should clarify whether or not the intent of the social policy that stands behind this program is to recognize the special needs and burden of care for those with a severe diagnosed mental illness as being at par with physical restrictions. We believe it should recognize the unique burdens suffered by those living with severe mental illnesses, as well as the family members who care for them.

    Specifically, we suggest, first, that the CCRA work with patient and professional groups involved in the diagnosis and treatment of individuals with mental illnesses, in order to come up with a mutually acceptable and understandable set of criteria that recognize the burden of mental illness in a manner that is comparable to the way the credit currently recognizes the burden of physical disability. This will allow the achievement of the principle of parity between physical and mental disabilities. This is an easily achievable goal, and the Canadian Psychiatric Association will be pleased to partner with other stakeholders in this effort.

    Second, a more appropriate set of questions should be provided to practitioners to allow for a more accurate characterization of the patient's disability as a consequence of his or her mental illness. Again, this should be taken in consultation with appropriate stakeholder groups.

    Third, more detailed interpretation guidelines for professionals required to complete the forms should be developed, accompanied by an education program for professionals.

    Fourth, clear guidelines should be available to potential claimants, and an education program should be created to ensure that persons with mental illnesses are aware of their rights to claim.

    The CPA would be pleased to work with others to bring parity, fairness, and clarity to the disability tax credit program. We have members who have special expertise in this area, and they would be most willing to work on behalf on the Canadian Psychiatric Association, with officials and other professional groups, as well as with patient groups, to help to develop clearer definitions, criteria, forms, and educational materials.

    Thank you very much, Madam Chair.

º  (1600)  

    The Chair: Thank you very much.

    Our next witness is Ms. Adele Furrie, who helped design and implement the definition of “functional limitation” for the Health and Activity Limitation Survey in both 1986 and 1991.

    Ms. Adele Furrie (President, Adele Furrie Consulting): Thanks very much.

    I am pleased to have the opportunity today to speak with you about the questionnaire and also about the process that is used by CCRA to establish eligibility for the DTC.

    To add a little to my work experience, firstly, I retired from Statistics Canada in January 1996 after 40 years of service with the agency. My last position there was as the director responsible for the post-censal program that included those two disability surveys.

    I should point out here that both of those surveys used activities of daily living questions that were developed by a working group of the Organization of Economic Cooperation and Development, the OECD. These questions are widely accepted throughout the world as a means of identifying individuals with physical and sensory impairments, but not for people with mental impairments.

    We struggled in both 1986 and 1991 to try to include those individuals in those surveys. One of the activities of daily living questions, the ability to walk 50 metres, is included in the T2201 as a means of determining ability to walk.

    Back to my experience at Statistics Canada, I had four international assignments during those last eleven years, all dealing with disability statistics. I have continued to work in that field, both with New Zealand and the United States. In fact, one of my ongoing contracts now is with the Bureau of Labour Statistics in Washington to help them design a set of questions to measure the employment characteristics of persons who meet the Americans with Disabilities Act definition of “disability“.

    So all of that is to give you a context for my comments on the transformation of the definition of the disability tax credit that appears in subsection 118.3(1) of the Income Tax Act into the specific conditions that are set out in section 118.4 of the Income Tax Act, and then into the questions that are used by the qualified person to establish eligibility.

    In my professional opinion, the form T2201 fails, both in terms of validity and reliability, the two basic requirements of any questionnaire.

    Let me elaborate by taking you quickly through the information that is in the Income Tax Act. I know you know this much better than I, but I need to be able to use it to structure my detailed comments on the questionnaire.

    I had hoped to be able to use some overheads for my presentation, but unfortunately I had them only in English, so bear with me as I walk you through them verbally.

    Let us start with how the DTC is defined in subsection 118.3(1) of the Income Tax Act. It is defined using three key phrases: the first one, “severe and prolonged mental or physical impairment”; the second one, “markedly restricted”; and the third one, “ability to perform a basic activity of daily living”.

    Section 118.4 of the act provides definitions for some of these words in these three phrases. “Prolonged” is defined in the context of lasting, or can reasonably be expected to last, for a continuous period of 12 months or longer. The words “severe”, “physical”, and “mental” are not defined. “Markedly restricted” is defined in terms of frequency and being blind, or frequency and ability, or time. “Frequency” is defined as substantially all, as all, or substantially all of the time. “Ability” is defined as unable to do the activity, and “time” is defined as requiring an inordinate amount of time.

    So, unable to do, or takes a long time, for all, or substantially all, of the time, defines “markedly restricted”. No definition in section 118.4 is given for “blind”, “substantially”, or “inordinate”.

º  (1605)  

    The basic activities of daily living are set out--six of them--including what can't be included, such as working, housekeeping, social, recreational activity.

    Speaking and hearing activities include a definition that includes a reference to a person familiar with the individual and a quiet setting. Both elimination body functions are stated, but the other three categories include no explanations.

    What do we have in the act that goes forward into the administration of the DTC that has not already been defined? We have severe mental, physical, blind, substantially inordinate, perceiving, thinking, and remembering, feeding and dressing, and walking.

    Let's turn to the questionnaire, the T2201, and see how CCRA transforms the definitions and explanations into the eligibility questionnaire. I would ask the clerk if all the committee members have a copy of the questionnaire, because I want to walk you through it.

    The Chair: It's in the briefing document on the last page, I think, for the committee, from the library. Does the committee have it?

    Ms. Adele Furrie: Can I proceed?

º  (1610)  

    The Chair: Does everybody have one?

    Yes.

    Ms. Adele Furrie: Skipping over what is the disability amount and supplement, let's look at who can claim the disability amount. There are three bullets. The first one, “You are blind all or almost all of the time”--part of the definition of “markedly restricted”--“and the impairment is prolonged.” But now there is a new wrinkle--“even with the use of corrective lenses or medication”. No mention is made of the use of devices or medication in the act, but it appears here on the questionnaire.

    The second bullet makes no mention of the use of devices, but now in the definition of “markedly restricted” that appears in this second column on the cover page, we now have added to the definition “even with therapy (other than life-sustaining therapy) and the use of appropriate devices and medication.”

    You'll also note that the words “inordinate amount of time” that appear in the act have now been replaced by “an extremely long time”, with no definition of what that means.

    I'm nit-picky, but I'm a statistician and....

    The Chair: We're lost.

    Ms. Adele Furrie: You're lost. We're on the cover page. We're looking at the bullets, and we're looking at the definition of “markedly restricted”. Okay?

    Before we leave the cover page, I'd like to make a few....

    The Chair: I'm sorry. Are you saying that's the difference between this form and the last form, or is it the difference between this form and the act?

    Ms. Adele Furrie: I never looked at the other forms, Madam Chairperson.

º  (1615)  

    The Chair: Okay.

    Ms. Adele Furrie: I'm just looking at this new form--

    The Chair: And the act.

    Ms. Adele Furrie: --and comparing it to the act.

    Before we leave the cover page, I'd like to make a few comments about the definition of qualified person--and there are four of them sitting here at the table.

    Dr. Claude Renaud (Associate Secretary General and Chief Medical Officer, Canadian Medical Association): We'll let you know.

    Ms. Adele Furrie: All right.

    From my experience, it seems the assignment of disabilities to qualified persons is made thinking only of persons with physical disabilities. An individual with a disability because of a cognitive impairment might need to be assessed by many of the qualified persons, and yet perhaps one qualified person could do it all.

    For example--and now I have an example, so bear with me--an individual who is developmentally delayed may have serious problems in feeding and dressing himself or herself, perceiving, thinking and remembering, and also difficulty with speaking. Does this mean three assessments have to be done if it isn't a medical doctor who is doing the assessment? What's wrong with having the psychologist or the occupational therapist complete the assessment for those people? Right now they can't, the way it's defined on the questionnaire. Maybe there's something I'm not seeing, but at first blush, it seems a complexity that isn't really necessary.

    So let's skip to part B of the questionnaire. This part combines three methods for determining yes and no answers, two very objective measures, one for seeing and one for life-sustaining therapy, one quasi-measure for determining a yes or no answer for walking, and five very subjective measures for the remainder--but I'm jumping ahead again.

    Take a look at the lead-in that appears just above the patient's name. The qualifier of use of therapy, “appropriate devices or takes medication”, is articulated again, but now there's no mention made of time. It's just devices, or support, if you like.

    Now we have the individual questions, starting with, “Can your patient see?” The explanation that follows this question and the two sub-questions that deal with visual acuity and visual field are very objective. In respect of reliability, if ten doctors or optometrists filled in a form for an individual, the probability is high that they would all complete it in the same way.

    It is similar with the last question pertaining to life-sustaining therapy--an objective definition that includes specifics about the number of times per week and the number of hours, and how those hours are calculated.

    Now we get to what I call the quasi-objective measure to assist the qualified person in determining a yes or no answer: “Can your patient walk?” How did CCRA decide that an appropriate measure to determine ability to walk was 50 metres? The activities of daily living questions had a number of elements one could use.

    The Chair: I misinterpreted you. I thought you meant that was an OECD standard.

    Ms. Adele Furrie: It is one of four OECD questions that are used to measure ability to walk.

    The Chair: Thank you.

    Ms. Adele Furrie: But why did they choose the 50 metres?

    The Chair: Yes, I've always wondered.

    Ms. Adele Furrie: And more importantly, why does the “yes” response on the questionnaire require additional information about the number of hours confined to the bed or wheelchair? Why is this additional information needed? It's not in the act.

    Again, if this question and this process was developed in consultation with a wide variety of people, and this was in fact the best measure that could be used, fine. But in none of the material that I reviewed did I see it documented.

    Also I started my discussion about this question using the word “quasi-objective”. CCRA attempts to objectively quantify ability to walk, but unless you actually have the individual try to walk the 50 meters, you move into a subjective assessment again that is not reliable.

    Which brings me to the question, “Can your patient hear?” Why doesn't CCRA use an approach here similar to what they did for seeing? I think there are some objective ways of measuring an individuals ability to hear. Why not include that objective measurement on the questionnaire?

    Another comment about the hearing question as it appears on the questionnaire is that the phrase “another person familiar with the individual” has been dropped from the explanation following the question. It's in the act, not on the questionnaire.

    Another interesting anomaly on the form is the structure for the subjective responses for these two questions: “Can your patient feed or dress himself or herself?” and “Can your patient perceive, think, and remember?” For some reason or other, the feeding and dressing responses are separated. You have two possibilities; you can answer yes to feeding and no to dressing, or vice versa. But this is not the case for perceiving, thinking, and remembering. I don't know why there is a difference. And take a look at the example for perceiving, thinking, and remembering. Now we have constant supervision thrown in as yet another way of reducing “markedly restricted”.

    And we shouldn't forget the question on speaking. Again, is there not an objective standard test a speech language pathologist can administer that could be used here? I don't know, but one would think that there would be. If we're going to get these qualified professionals to complete the questionnaire, we might as well get them to use a standardized approach. Another thing about this question, the reference “by another person familiar with the individual” is also missing from the explanation following the question.

    Finally, the bowel and bladder function question also includes a reference to personal help in terms of caring for his or her ostomy, but doesn't mention needing help to get to the toilet or help in transferring to the toilet. Would this be sufficient to answer no? Maybe for some qualified persons it might; for others it wouldn't. And that's the problem with subjective questions.

    Finally before I sum up part B, take a look at the explanation for feeding, speaking, bowel and bladder functions. The word “inordinate” is back after having been replaced on the cover page by “extremely long time”. So it's inconsistent. The questionnaire gives you an explanation on the front page and then reverts back in this instance to the actual terminology that appeared in the act.

    Now I'm going back to some of the words or categories that are not defined on the questionnaire. “Blind” is defined on the questionnaire--no question about it. “Inordinate” is replaced on the cover page with “extremely long”, but reappears in the questions' explanations. An attempt is made to define walking, but it remains a subjective response. And still no definitions are given for dressing, feeding, thinking, remembering, and perceiving.

    The most critical thing in terms of my assessment of the form was that CCRA has introduced the use of personal help, therapy, medication, and appropriate devices as a way of reducing “markedly restricted”. Is this a valid interpretation of the act, or does this use effect the validity of the outcomes as they pertain to the income tax DTC definition?

º  (1620)  

    Finally, I have two comments before I close. If you turn back to part A of the form and you look at the paragraph that starts “We will review your form”, in the top right-hand corner, part A goes on to say, “We may ask our medical advisors to review your claim to determine if you meet the eligibility criteria”, and they “may contact you or the qualified person for more information”. If this is part of the process, why can't the questionnaire be amended to include as many of the additional information requirements as possible? What we're doing is, we're leaving the need to get additional information in the hands of yet another person, who makes a subjective assessment at CCRA as to whether additional information is required. The individual himself or herself doesn't know what that information is going to pertain to. It's then sent back out to the qualified person for additional work.

    My final comment is that I would strongly recommend that the questions and comments I have put forward be shared with CCRA officials. My concern is that we have an instrument, a process, that is neither valid, if the addition of devices and personal help are not to be considered, nor reliable, since the questionnaire is mostly subjective and is subject to the need for additional information requested only after review by a CCRA employee.

    Thanks.

    The Chair: Thank you very much.

    I think all the witnesses have been extraordinarily helpful in underlining our instincts about what we've been hearing until now, and you've been able to fill in the facts. Also, I think Adele Furrie has certainly made me better understand why it was crazy-making filling out the form for me as a lowly family physician. You could have ticked off “can't think, perceive or remember” on me after I tried to do one of these forms, so thank you very much

    Mr. Larry Spencer.

    Mr. Larry Spencer (Regina--Lumsden--Lake Centre, Canadian Alliance): I don't think we ought to have any questions except, how do we get this thing changed?

    Maybe I've heard this before, but how did CCRA develop these questions and especially these little additions you've put in there? Are you aware of that at all?

    Dr. John Service: We had our first meeting with CCRA officials--and a very good meeting, I should say--in September, so we're not familiar with the history. CMA has had a much longer relationship.

    Dr. Claude Renaud: We've had an ad hoc-ish relationship with CCRA over the years, and although very productive...some of these meetings have allowed us to provide input. The linkage between the act and the CCRA forms is something that obviously needs to be re-examined. The assumption that was being made all along was that we were being asked to provide input on a form as opposed to legitimizing the content of that form with respect to the legislation it supported. Obviously, the intent was appropriate in the sense that they wanted our input and that input was provided. But a lot of the input we did provide was not taken into account.

    We would certainly like to suggest that CCRA develop a more consistent, standardized, and longitudinal relationship with the provider groups so together we can come up with the kind of process and content that are required to help Canadians with disabilities.

    Mr. Larry Spencer: Thank you.

    The Chair: Do you have a comment as to the information or a suggestion you'd made that wasn't included?

    Dr. Claude Renaud: We can provide that information to you.

º  (1625)  

    The Chair: Thank you.

    Mr. Larry Spencer: Could you cite for us clearly what you understand to be the real purpose of the DTC?

    Dr. Blake Woodside: I can take a crack at that one.

    Very quickly, no. It's totally obscure at this point whether it's meant to accommodate people who are unfortunately blind or disabled. Nobody knows really what it's for any more. It's so confusing. But that's a flip answer to a very serious question.

    The Chair: I think we felt after some of the hearings, particularly with the hard of hearing society, that it was for unreceiptable expenses, the out-of-pocket expenses, certainly that the Council of Canadians.... If you're in a wheelchair, for example, you're going to have to pay higher parking to go to work; you're going to need a closer parking lot. There are some easy things.

    But when we heard from the hard of hearing, these people can pay all kinds of out of pocket expenses on their hearing apparatus, their telephone. And there are blind people or the visually impaired, who need to pay a whole bunch of junk in order to disqualify for this credit. I mean, they will pay all of this, and then if they fill out the form properly, they can do these things, but they spend a whole bunch of their own money to do it. And we thought that was the purpose of the credit.

    So that's why we're a bit confused in terms of the intent.

    Mr. Larry Spencer: Exactly.

    The Chair: We're glad the psychiatrist is also confused on this.

    Some hon. members: Oh, oh!

    Mr. Larry Spencer: It confirms what we always knew.

    Dr. Claude Renaud: There is a medical expense deduction program that's available. I guess we thought at the CMA that the purpose of the DTC program was to provide additional support to severely disabled patients. The problem is in arriving at an understanding of who is severely disabled, and that's been the struggle, I think, for all family physicians, for all practitioners--physicians and other practitioners across Canada.

    It's a difficult issue, because obviously we want to maintain, support, and nurture a strong, trusting patient-provider relationship, and with those kinds of stumbling blocks, it does put a lot of strain on the relationship we desperately need to maintain if we're to protect the therapeutic process.

    So obviously, all of what's been said here today I think sums up what needs to be done in terms of rejigging this program so that it is delivering the right support to those who need it.

    Mr. Larry Spencer: Good.

    You may have answered my next question, which was can you think, perceive, or remember why it's so restrictive and narrow in scope? You've just stated that it was really designed for the severely disabled, but I think you're agreeing with me. It would seem to me that anyone who's much less disabled than what this form would require should deserve some kind of special consideration through a tax credit.

    You made the statement that the whole Income Tax Act needed to be reworked and better synchronized, in harmony, or integrated with health. How would you see some of this happening, especially related to other issues, not just this particular one?

    Dr. Henry Haddad: What we're in fact recommending--and we don't have the answers of course--is that a blue ribbon task force be formed to see how better we can harmonize tax policy with health and social policy. This hasn't been looked at for 25 years. We know the problems our health care system is having. We know there is a need for additional funding. People have been talking about pharmacare, about long-term care. It's clear with the actual situation of funding, we're not going to be able to offer pharmacare and long-term care to Canadians unless we look at innovative ways to finance the health care system within our tax policy.

    We're not talking about raising taxes; we're looking at how best we can harmonize our tax policy with social and health policy. If we just look at some of the issues, for example the 3% tax deduction from taxable income, you take it off; it's not a refund. Yet some people who don't pay taxes pay it out of pocket.

    There are a number of issues we could be looking at. More and more there are home cares, and it's mainly women who are doing it, who are leaving their work to take care of their sick mother or father. And they're having problems making ends meet. We have trouble recognizing the work these family members are doing. So there are a whole host of issues we have to look at.

    I think what we have to do is realize that our health care system should go beyond paying for doctors and paying for hospitals. There are other issues we have to go look at. And if we want to look at those issues, if we're serious about looking at those issues, as they have in a number of other countries in the world, then we have to look at innovative ways to support these policies.

º  (1630)  

    The Chair: Dr. Service.

    Dr. John Service: I would just like to underline that very strongly. For example, we expect that in ten years, if the trend continues, probably 70% of psychological services will be provided in the private sector for pay-as-you-go, or through private insurance, because of the way the public system is structured. We sit back and say, “What about access for Canadians? How are we going to solve the access for Canadians issue, particularly for those with less income, less money?”

    One of the ways to do that is through creative tax policy. We think that should be really seriously looked at, in terms of the access of Canadians to a broader scope of comprehensive medical health services. We strongly support that.

    The Chair: Mr. Woodside.

    Dr. Blake Woodside: One of the top ten causes of disability in this country is mental illness, and we have no national strategy to approach that problem.

    One element of the national strategy would be to take a careful look at tax policy and how it interacts with social policy. The expectation is that the cost of mental illness is only going to increase in the next 20 or 30 years. It's an area where the federal government can act, irrespective of concerns about federal-provincial jurisdiction problems.

[Translation]

    The Chair: Mr. Lanctôt.

    Mr. Robert Lanctôt (Châteauguay, BQ): First of all, we are back. Hello, everyone. Bill C-36, the Anti-terrorism Act, is letting me get back to other things. The justice committee's work certainly did take a lot of my time.

    As you know, I inherited this file also. I am glad to be back, except that we realize there are problems—you know this even better than I do—for people with disabilities. I am back here and I want to laugh and cry at the same time. I was not here when the other witnesses spoke about these tax credits. However, I did come so that this would be dealt with, and I would like to thank the subcommittee for addressing this issue so quickly.

    I want to thank the other witnesses who are here. I find this disconcerting, and there are two reasons for that: the huge amount of work that needs to be done to bring things up to date, and also, to some extent, the fact that I am hearing that the definition should be more restrictive, whereas I do not see definitions... I apologize for reacting as a lawyer, but definitions are usually put in place to make things more restrictive, and when you want more definitions to limit something or to make it more consistent or more specific, I am sorry, but I think that that will do harm. I have the impression that that approach may be detrimental to people with disabilities. Perhaps the form needs to be clarified, but it needs to be broader and not more restrictive. In any case, that is the impression that I have. So that would be the kind of comment I would make, perhaps later, to the subcommittee. In any case, I am a bit surprised by your remark, Ms. Furrie. Perhaps you could try to explain it to me better, but I think that we need to broaden the scope.

    I understand that this form that I see and that I read at the last minute, since I was asked to come here again today... In reading it through very quickly, I too was shocked, because you are talking about people with mental impairments or disabilities of that kind. I think that if we make the questions even more restrictive than they are already or if we ask for even more information in the form, there will be so many problems. We see this at the end of the form. If it takes physicians more time... As it is, these are people who do not have much money and who have to pay physicians to fill out this form that must take considerable time, since there are assessments involved and so on, so if we ask for other information as well... Perhaps we should ask that the cost be paid by the government rather than by the individual. I think that that would solve a big problem right there.

    I do not simply want to make comments; you are the expert and not me. What do you think of the comments that I have just made? I would like to hear what you have to say on this.

º  (1635)  

    Dr. Claude Renaud: Madam Chair, Mr. Lanctôt is quite right. Indeed, our position and responsibility as health professionals is to implement a process which enables patients to obtain specific rights legislated either by the provincial or federal government.

    In this case, it is the federal government which passed an act enabling severely disabled people to obtain some type of compensation or remuneration through income tax.

    Now, let's come back to Mr. Spencer's question. He wanted to know what the goals of the program were. The objective of the program is clear, and if you want to take this a step further, it becomes a sociopolitical decision. I am a mere health professional, and as such, I intend to implement this decision to the best of my ability. However, in order to do this in an objective way which does not undermine the relationship that I have with my patients, I need specific tools. This is crucial.

    Consequently, I believe that there remains a lot to be done, and here I am referring to the legislative approach. Legislation needs to be redefined along the lines that you have set out. I find your approach completely acceptable.

    Secondly, we need forms which reflect legislation and which are easy to interpret and which can be easily implemented by health care professionals and providers in private practice.

[English]

    The Chair: Ms. Furrie.

    Ms. Adele Furrie: I hope my remarks didn't suggest that we should make it more and more complex. What I hoped I was putting forward was that we should attempt to the extent possible to make objective measures that take the subjectivity out of it so that all persons with disabilities who are attempting to apply for a disability tax credit are treated in exactly the same way and that it's not up to the doctor or the other qualified person to have their subjectivity associated with the assessment.

[Translation]

    Mr. Robert Lanctôt: Indeed, all these issues, in my opinion, should not in fact be specified, but rather withdrawn. A health professional is a health professional. He is well able to identify shortcomings. We do not need formularies to identify shortcomings for health professionals, be they psychiatrists or medical doctors. As for the disables... I know this issue well. I have a three-year old child who is disabled and who was supposed to have died but who in fact is still among us. I am aware of what disability means and I don't need a questionnaire to tell me whether my child is disabled or not. That's what health care professionals are for.

    Why would we attempt to describe in writing what walking means? You gave the example of 50 metres. That's ridiculous. If my child is not able to walk for any reason, I can see that fine well for myself. Health care professionals will tell me why my child is not able to function normally or is unable to walk. I do not need a public servant or even less so the Minister of Revenue to tell me whether these individuals are able to walk or not.

    Why should we try to complicate a very simple issue? In Quebec and in the rest of Canada, we have health care professionals who are very skilled in what they do. I believe that we should stop trying to complicate matters and that we should try to adopt a more objective or subjective approach. I'm sorry, perhaps in some cases subjectivity would be very important because the medical background of a particular child would enable doctors to diagnose why a child has a particular temporary or permanent illness much better than a potential formulary.

    I do not want to labour this point, but I hope that health care professionals will agree to the development of a very simple formulary. We should ask health care professionals whether a particular individual is disabled or not and if we did so there would be less difference between, for example, an individual being blind, visually impaired, and the extent of visual impairment.

º  (1640)  

[English]

    Ms. Adele Furrie: I totally agree, but given that the process established was to use a questionnaire--the questionnaire was put forward as a way to evaluate--one has to first look at whether there is a problem with the process. I've identified some particular problems with the way in which the act is being interpreted.

    If we go your route, and say that we should leave it up to qualified persons to determine whether or not this person meets the criteria, and that's the end of it, fine. But I've been a bureaucrat for long enough to know that it still gets into the hands of a bureaucrat who will then take this assessment, interpret it, and go back to the physician or the qualified person and say “But, but...give me a further explanation behind these comments”. So one has to look at the process.

[Translation]

     Mr. Robert Lanctôt: I understand what you mean. However, those involved in charges involving, let's say, 20 different files, will see that doctors do not tend to provide justification for the wording on formulary. Doctors would be much more likely to certify a patient as disabled. I believe that this type of approach would open the door to future challenges, and I think that lawyers are going to love me for what I am saying today, but these challenges would perhaps be limited in nature because there would be room for manoeuvre. Health professionals would not be restricted to a predetermined definition.

[English]

    The Chair: Just as a follow-up from Monsieur Lanctôt, as a professional I sometimes think they have a little of all of the above. It's enough that they aren't very good at personal care or their personal affairs, but technically they don't meet the maximum criteria that will tilt them over. If you add it up this way, however, they wouldn't.... They clearly are disabled, because they don't see very well, they don't hear very well, and they don't think very well, but they don't max out on any one thing.

    Can you help us with that?

    Ms. Adele Furrie: That in fact is the approach we used on both the 1986 and 1991 disability surveys, to try to establish mild, moderate, and severe. If you had some difficulty over a number of the activities of daily living, you were then identified as having a severe disability, because it affected all different aspects of your life.

    So you're right; the way in which they've designed the form here means that if you don't max out on one, you have these little stovepipes. If you don't max out on one of those, you're out the door. But you could be, for instance, 50% on all of them, which sure as heck affects your quality of life, and in other definitions being applied, would surely allow you to be defined as having a severe disability.

    The Chair: Dr. Haddad.

    Dr. Henry Haddad: In 1993 we had in fact made a number of recommendations. Nine years later, they're back with us again. We had felt at that time that the program did not meet the needs of the disabled. It's too hit-and-miss. We had in fact recommended that a suitable evaluation of claimants and medical components of the process should be undertaken, and that's what I'm hearing today.

    I think there's an important issue here. As you know, we're now into all kinds of health reform. We're hearing all kinds of... We have Mazankowski, Romanow, and so on. But I think the issue, the primordial issue for us, is the one of Canadian values, those of fairness and equity. What we're saying is that this program does not deal with the Canadian values of fairness and equity, and I think that's what it should do above all. It's there to meet the needs of people who need it. Let's be more generous than less generous.

[Translation]

    Mr. Robert Lanctôt: If you don't mind, I would like to make a brief comment, Madam Chair. I found your presentation interesting, but I have been a member of Parliament since November 2000 and despite the fact that we often produce unanimous committee reports—our last one was unanimous—we expect answers and funding and especially policies to fulfill the promises contained in the Speech from the Throne. But everyone knows what happened. So, even if we produce another unanimous report, even if we work hard to ensure it works, it is ultimately the government which must translate the words into action.

º  (1645)  

[English]

    Dr. Blake Woodside: All I wanted to say is that help is available from among people like those at this table to help make this a much better process while respecting the government's need to decide what it wants to provide a tax credit for. We can help; we would love to help.

    Dr. John Service: I don't know if you're aware, but another 13 or 15 supplementary questions can then be asked once the form is filled out, and there are problems with those questions as well. Some of them are not appropriate; some of them give information that doesn't allow for a good assessment. As well as the T2201 form, these questions are also somewhat problematic.

[Translation]

    Dr. Claude Renaud: Madam Chair, I will make the following comment in my capacity as a family physician. In fact, it addresses the issue raised by Mr. Lanctôt regarding the importance of, or the sense of responsibility felt by, family physicians and health care professionals in terms of wanting to treat everyone of their patients in a just, equitable and fair manner.

    I'm concerned about the degree of restrictiveness contained in the form. This concerns me. I would like us to be a little more generous. But we know that we live in a world where there are limits. You are aware of this. We don't have unlimited funding for the Canadian public. Therefore, in that regard, I think that it would be better to spend more money on people who need it the most. But if we decide to take that approach, we will have to design a form which will help us distinguish between those in need of compensation and those who don't. It's a difficult decision to make and it raises ethical issues, but I for one would appreciate that level of detail. Of course, this does not mean we need a fifty-page form.

    The federal government has straightforward forms. The Canada Pension Plan form is well designed. Other types of forms allow us to determine fairly quickly an individual's level of disability, but that is clearly not the case with this one; it is very complex. Furthermore, we have just learned that it is not referenced with the legislative document.

    Dr. Henry Haddad: A physician must assess the overall situation of an individual. This is done in sections. The individual is assessed section by section.

    Another approach is to view the individual as a human being. This person's mental, psychic, family and work situations are assessed. That is the type of evaluation we make, as well it should be, and taken together... This person may be able to walk 75 meters, but who cares? If he has many other kinds of problems, such as not being able to earn a living...

    Therefore, I feel we should assess an individual as someone who has a family and children, and who is employed.

[English]

    The Chair: Merci.

    Tony.

    Mr. Tony Tirabassi (Niagara Centre, Lib.): I too would like to thank the witnesses for appearing here.

    As Mr. Spencer mentioned, it's not so much the questions, but rather I'm anxious to see where we go from here with this. There seems to be unanimous agreement from witnesses who have appeared before, that is, the organizations representing many of the disabled, that there are problems. It's been brought up again here today. I can tell you that it's been brought to my attention in my constituency office, by constituents coming in waving the form and waving the letter, and by numerous phone calls as well.

    I was very curious; I had an opportunity to quickly glance through this submission that you've tabled here. When the officials were in from the CCRA we asked questions about the cost of completing the form, and to their best recollection, the $30 to $50 range was what they heard. I had a constituent who told me she was charged $150, and this has reflected that exact figure, $150, on page 5 of your report.

    I guess my question is, should we get beyond this and see some sort of a revision to this?

    I need to know a little more about your organization. I'm from Niagara Centre, in southern Ontario. How does your organization work? If you're going to go, hopefully, through this consultation with the CCRA, have some revisions, how do you then communicate your message or agreement to physicians in the local offices? Do you go through, as in our case, the OMA ? How does that structure work so as to ensure some consistency in Quebec, Ontario, out west?

º  (1650)  

    Dr. Henry Haddad: The Canadian Medical Association, as I mentioned, regroups about 50,000 to 52,000 physicians. We have our divisions. We have a division in each province and each territory. We're in contact every day with the divisions.

    So whatever policy we come up with, we consult our divisions to make sure we have a consensus and we're talking as the voice of Canadian medicine. So that would answer your question. Whatever we do, we do in conjunction, in consensus, with one voice, with our provincial and territorial divisions.

    Mr. Tony Tirabassi: Very good.

    My final comment is that we're not talking about a lot of money here. I've heard that back in the office and from people who've appeared here. Every little bit helps.

    I'm really hoping we can get beyond this and to the next step. That's what I'm really anxious about.

    I don't have any more questions at this time.

    The Chair: Just to follow on Tony's question, Tony had some constituents who were actually charged $100 or so to have the form filled out. When we met with the officials--and I don't know whether it was at the hearing or when I met with them informally--we thought they believed doctors weren't going to charge to complete this form. Where did that come from? It's pretty clear-- it's not in the fee schedule.

    Again, this is in terms of the communications between the CMA and the divisions. How could that sort of idea get to CCRA?

    Dr. Henry Haddad: I really don't have an answer, Madam Chair.

    Dr. John Service: I can tell you that's never been the case with the Canadian Psychological Association. As I said before, for our members who are in the private sector--who aren't in hospitals or in the public sector--it has always been the case that they will either do it pro bono, which some do, or at a reduced rate because of the financial circumstances of the patient or client.

    It's unfair then to say it costs $50, because that was a donation, in fact, by the psychologists who did it, or they would charge the full rate. If it takes an hour and a half, it's far more than $50 in private practice.

    The Chair: Blake.

    Dr. Blake Woodside: It might simply be wishful thinking, Madam Chair.

    Dr. Henry Haddad: From what I understand, the $150 fee comes from the two evaluations and the two forms. Physicians will charge up to $150 for the two evaluations and the two forms. On the other hand, I think we have numerous examples where physicians do it pro bono. They don't charge.

    I don't think I've ever charged for filling out an insurance claim in my life. I usually tell the patient, if they offer me money, to put it in the little box for donations at the hospital. I say, “The hospital needs the money more than I do.”

    The Chair: We can look at the testimony and figure out whether it was something I heard at the meeting, but I think there was some evidence around a survey of physicians, or something. That has certainly been my experience, with the physicians I know.

    Dr. Renaud.

    Dr. Claude Renaud: I think this whole area is quite problematic, because when you think of it, there is no consistent way of charging patients. It's a real dilemma, I can tell you. We have secretaries to pay, nurses to pay, and office equipment to pay for. It's an issue, so it's a professional dilemma. It's a problem, especially when you know that the likelihood of the patient qualifying is close to nil.

    It's a tough issue for us to deal with, so why not do what CPP is doing? Let's just clear the air on this one. Just that piece, in my view, would help increase the appropriateness of this program.

º  (1655)  

    The Chair: Do you think there are some physicians who just say forget it, don't bother me with the stupid form, because you're not going to qualify; I'm not charging you anything, so why don't we just forget the form?

    Dr. Claude Renaud: It's an interesting question. Because you know--

    The Chair: Why would we fill out the form if we know they're not going to qualify?

    Dr. Claude Renaud: When physicians see forms coming into the office--

    The Chair: We're a bit obsessive.

    Dr. Claude Renaud: --there's this funny feeling you get. That shouldn't happen if things were consistent, standardized and appropriately fairly set, so both providers and consumers benefited in this process.

    Dr. Henry Haddad: The issue we're being told, as physicians, is not the level of remuneration. The issue is that the remuneration is like a wedge between the patient and his or her physician. That's what's bugging Canadian physicians. It's not the $50 or $75. They'll take less. But they don't want this interfering with the relationship between the physician and the patient.

    The Chair: The vision test and everything for drivers' licences got put off-site, so it isn't the doctor who has to yank somebody's driver's licence. Isn`t that right?

    Dr. Henry Haddad: Imagine how uncomfortable you'd feel going through the whole thing and then the patient looks at it and says, “Doctor, you answered no nearly everywhere”. The doctor says, “I'm sorry, but I don't think you're going to get it”, and then turns around and charges the patient $50. I don't know many doctors who would feel comfortable doing that.

    Dr. Blake Woodside: Another special issue for health professionals is that some of the people who want this form filled out require a long period of time to have it explained to them. For someone with chronic schizophrenia, for example, who's having less than 90% difficulty in thinking, perceiving or remembering but is still very impaired, it may take an hour or so to actually explain to that person what the form is about and how you're answering the questions. That's all non-remunerated time.

    When you get a paranoid patient who says you didn't answer the question right, you know, “You're against me, too, like the rest of them”, it becomes a very, very difficult situation.

    The Chair: Wendy.

    Ms. Wendy Lill (Dartmouth, NDP): Thank you very much for coming here. It's very interesting.

    As the chair said at the beginning of the meeting, we all feel so strongly about this issue we've actually had a press conference already on this and sent a letter to the minister asking that these letters, the100,000 letters, be withdrawn and an apology go out. We have asked that the status quo be maintained until a decent process is agreed upon by health care professionals, advocacy groups and persons with disabilities, all of whom should take part in how to evaluate this program on an ongoing basis.

    We were feeling pretty good about everything we knew already. But I must say that what you have contributed has been really important. I think the idea that in the short term, the short term being let's get back to the status quo....the short term being using the CPP disability model where there is a separation between the physician's report and the eligibility, that idea. Let's straighten out the definitions. We hear constantly from people that there are too many definitions for disability and they're confusing people. So we could move to that model on the short term. but as you say, the important issue is to actually look at the broader issue of integrating a better tax policy with the health and social policy. That's really an exciting concept. If anything good comes out of this whole mess, it will be that we draw even further attention to that issue and maybe put more pressure on it.

    I guess we should come up with forms that actually reflect what is in the law. The nuttiness of different language appearing in different places leads one to ask if anyone has ever proofread these things. Is it a matter of that, or am I giving them the benefit of the doubt?

    Finally, this whole thing does not meet Canadian values of equity and fairness. That's my final belief as well. Let's be more generous, as opposed to less generous, and in that spirit review this process for the benefit of all people with disabilities in this country.

    I guess that was a little speech. I don't have anything else to say.

    Some hon. members: Hear, hear!

»  (1700)  

    Dr. John Service: Thank you.

    The Chair: Thanks, Wendy.

    Nancy, we'll give you time to wrap up.

    Ms. Nancy Karetak-Lindell (Nunavut, Lib.): Thank you.

    I'm a little confused, and I guess frustrated with what I'm hearing. These are people who are already having so much difficulty with life, and they find that it depends which doctor they go to, which definition is interpreted by whom. I'm getting the picture that two people in different parts of the country with the very same situation, the same disabilities, can get different answers, one being approved and one not being approved. I find that very difficult when we're trying very hard, as legislators, to say that one law applies the same way to everyone in this country.

    I come from an area where the definition of access to health care is very different. I look at the list of the qualified persons, and I can't find one of those people living in my community. So that also determines who is even going to try to apply for the credit. I can tell you that there are probably very few people who are going to delay filing their income tax returns because they're waiting to get one of these forms completed by any of these six occupations that they don't have access to in their community.

    Just having access to services in my part of the country is so different that I can honestly say that very few people will even try to fill out that form. Again, that makes it different for the Canadians in my part of the country. When you talk about fairness and equity, I interpret that very strongly. How do we get this credit to people when other Canadians who do have access to a qualified person are going through, as you say, subjective criteria?

    I find it very difficult to look at the definitions of “prolonged” and “severe” being different in different departments of our own government. That's something I feel we have to deal with, because I find it very difficult that if you apply through Veterans Affairs versus Human Resources, you're going to get different definitions for the same two words. So I say we have a lot of work to do in that field.

    Going back to the current situation of trying to recertify, in your opinion, what would be an easier, more cost-effective way of getting recertified than what we're doing right now, sending out all those letters to those unfortunate people who have to recertify themselves?

    Dr. Claude Renaud: I think the mail-out is symptomatic of a program that's in disarray. The fact that you would have to send out a letter to make the program more equitable, to correct some wrongs, is symptomatic of the fact that the forms are inadequate. The forms aren't consistent with the legislation. The updating process was bureaucratized, as opposed to being supported by the political wing of government or the government itself or society itself.

    I think a better way would be to go back to the board, in terms of looking at the legislation. If Canadians want this tax credit to become more generous, then a decision is made to make it more generous. As you've said, let's look at the definitions and let's look at the operational issues, the logistical issues, and make sure that the admin process we've developed is a good one, one that can be validated effectively at all levels.

    The eligibility criteria can be different between disability programs, but the definitions should be the same. There shouldn't be any confusion about that.

»  (1705)  

    The Chair: Nancy's question, though, was that you referred to a process you thought would take two or three years. Clearly, this is a post-HRDC situation. They look in the file folders and they don't have what they need, so they decide they'd better go get what they need. So they send out a letter to 106,000 people. How would you suggest that they could have done that better, in a way that might have been more long term?

    As we know, and as Nancy heard, there were a whole bunch of people with CNIB cards who got these letters. What do you suggest would be a better process by which the department gets the information they think they're missing?

    Dr. Henry Haddad: There were two things we were recommending, one being that we had to sit and look at clear objectives: What were we trying to achieve? We recommended that the profession, patients, and the public be involved in an ongoing process so this is not just bureaucratically driven.

    We also recommended that we take into consideration a manpower issue, physician manpower or whatever, those who are responsible for filling out the form, who are already overworked. We felt that if we did want to do a process like this--that is, to really put the forms and clean them up, or whatever term we want to use--this should not have been a one-shot deal but could have been done over two, three, or four years. We would have liked to inform our divisions across Canada to see where they felt the problems were and sit with the government officials before that was done. That's why we mentioned in our brief that we would have liked to be consulted before having an undertaking of this nature, which is an enormous undertaking.

    I hope that responds to your questions.

    The Chair: And the response in the health care system of this...? Do you think most people got a free visit from their provincial health system and then got charged for the form, or do you think...? We've now sent all these people in for a visit with their doctor, at which time they probably discussed something else, and therefore something was billed to their provincial system at the same time, right?

    Dr. Henry Haddad: It could well be.

    The Chair: So this costs some money to the country.

    Dr. John Service: Sure, or to the individual. If it's to a psychologist who's in the private sector, it's out of pocket.

    The Chair: Nancy, did you have another question?

    Oh, Adele had an answer, and then we'll go back to Nancy.

    Ms. Adele Furrie: In response to your process question, I think initially what has to happen is all the stakeholders have to get together--persons with disabilities, the advocacy groups, the CCRA officials, the qualified persons--and come together to understand what they're trying to do and come up with a form and a process that everybody agrees to. Then, however many people are on the current rolls for DTC, look at how long they've been on, stratify it by the amount of time that they've been receiving the DTC, and send out so many per year for requalification. So it's not a process that's going to happen to all 100,000 people all at once, but could be a process that might take every five years and might have to be repeated ten years down the road for another iteration.

    The Chair: Again, around the people available in her community, if the form was clearer, it wouldn't even have to be a nurse practitioner who filled it out; any RN should be able to fill this out if there were very strict criteria in terms of hearing or seeing.

    Is that your question, Nancy?

    Ms. Nancy Karetak-Lindell: As it is, most of our health centres in Nunavut are serviced only by RNs. We don't have medical doctors, and if they do come in, it's every couple of months. So you're talking about waiting time of a patient even to have access to any of these six people.

»  (1710)  

    Dr. Henry Haddad: To the point we were talking about, fairness and equity across Canada, across every section of this country, and I think this has to be primordial in whatever we do.

    The Chair: Ms. Furrie.

    Ms. Adele Furrie: I don't think there's anything magical about the list of qualified persons, and if the form is objective enough so that anybody can complete it--I don't mean just anybody, but the RN, for example, who is in the community, who knows the people, who lives with the people, interacts with the people--why could they not also be designated as a qualified person?

    The Chair: Claude.

    Dr. Claude Renaud: As well, there are probably other ways of accessing the kind of services you need. Clearly in the more difficult cases, complex cases, you could use telemedicine; you could use on-line support. You could connect the various providers of care in your community to the zone hospitals for that kind of linkage. So there would be ways of accessing it.

    But going back to your initial question of sending out 75,000 letters, I guess, as you've suggested, this process hopefully will not be repeated until we've done what has been said or suggested, which is making sure that what's going out is good, because if you just get more information that's bad, the program won't benefit.

    The Chair: Is that okay, Nancy? All right.

    I just had one other question. When I was first elected, the cystic fibrosis people were pretty upset with this form. They didn't qualify, because breathing was not viewed as an activity of daily living. It's very clear from this change to the form, in terms of life-sustaining therapy, that the form has been adjusted to make sure breathing is still not a criteria of daily living, because they don't want all those chronic bronchitics with oxygen tanks qualifying, right?

    Dr. Claude Renaud: Right. They're just breathing some of the time.

    The Chair: Yes.

    What they did was create this special box at the bottom of part B that has “life-sustaining therapy”, in order to find a way in which only cystic fibrosis qualifies, not just breathing. Do you think this question is fair, or is there something else that people would suggest?

    Dr. Blake Woodside: It's hard to understand why somebody who needs renal dialysis, who is there three times a week, is covered, whereas a chronic schizophrenic who must go to a day program five days a week, and who must be treated with medication to make him or her functional enough just to get to the day program, is not covered. That makes no sense.

    The Chair: Adele, did you have a comment about this box?

    Ms. Adele Furrie: It's a bizarre box.

    Voices: Oh, oh!

    Ms. Adele Furrie: It's very objective. It clearly defines certain people who qualify, but it's again done outside of the context of everything else.

    The Chair: So it's a bizarre box on a stupid form.

    Ms. Adele Furrie: That's it.

    The Chair: Okay.

    I can't thank you all enough. This has been really helpful. I do think all the practitioners trying to fill out these forms have given us huge insights, and we've also had the expertise of Adele Furrie.

    We're very grateful that all of you came. We do hope that as we put forward the recommendations of the committee—and as we come to that point, we will have Bill and Kevin helping us—we will start to get to a process by which these things can be avoided in the future.

[Translation]

    Mr. Robert Lanctôt: I agree with you. Thank you, you have been of great help to us. Let's hope that we will now be able to return the favour.

    Dr. Claude Renaud: If there is anything else we can do, please don't hesitate to call.

    The Chair: Good bye.