Agency Governance

Medical Eligibility Committee
Business Plan 2016-2019


Medical Eligibility Committee
151 Bloor Street West, 9th floor
Toronto, Ontario M5S 1S4
Telephone: 416-327-8512
Toll free: 1-866-282-2179
TTY: 416-326-7TTY (889)
TTY Toll free: 1-877-301-0TTY (889)
Facsimile: 416-327-8524

       Comité D'admissibilité Médicale
       151, rue Bloor ouest, 9e étage
       Toronto, Ontario M5S 1S4
       Téléphone : 416 327-8512
       Sans frais : 1 866 282-2179
       ATS : 416 326-7889
       ATS sans frais : 1 877 301-0889
       Télécopieur : 416 327-8524


The Honourable Dr. Eric Hoskins
Minister of Health and Long-Term Care
Minister's Office
Hepburn Block, 10th Floor
80 Grosvenor Street
Toronto, ON
M7A 2C4

December 31, 2015

Dear Minister:

RE: Medical Eligibility Committee

On behalf of the Medical Eligibility Committee (MEC), it is my pleasure to submit the Business Plan for the 2016-2019 period.

The MEC is committed to the strategies outlined in the plan and to its role in ensuring high quality health services for the Ontario public.

Yours sincerely,

Orginally signed by:

James Brooks, M.D.
Chair
Medical Eligibility Committee

c.: Sara van der Vliet, Manager, Health Boards Secretariat
Registrar, Medical Eligibility Committee


Introduction

This Business Plan was developed to guide the work of the Medical Eligibility Committee for the period of April 1, 2016 to March 31, 2019. It confirms the mission and vision of the organization and establishes strategic priorities for the next three years.


Table of Contents


Mandate of the Medical Eligibility Committee

The Medical Eligibility Committee ("MEC" or "committee") is created under the authority of the Health Insurance Act, R.S.O. 1990, C.H.6, and is given independence in the determination of all questions of law and fact with respect to matters within its jurisdiction. When there is a dispute regarding a decision by the General Manager that an insured person is not entitled to an insured service in a hospital or health facility because such services are not medically necessary, the matter may be referred to the MEC.

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Mission Statement

The Medical Eligibility Committee will act with integrity to provide fair, ethical and professional review of the cases before it while complying with all applicable laws and being accountable for its decisions and actions.

MEC Overview of Service

The MEC considers the facts relevant to disputed decisions between the General Manager and an insured person. After giving consideration to the matter, the MEC shall make recommendations to the General Manager that the sum or sums claimed by the insured person should be paid, or that the General Manager may refuse as such services have been found not medically necessary.

The MEC caseload of 2014-15 fiscal year and anticipated future projections are outlined below.

MEC Caseload
Workload Requirements 2014-15  [1]
Actual
2015-16 [2]
Estimated Work Volume
2016-17 [3]
Estimated Work Volume
2017-18 [4 ]
Estimated Work Volume
2018-19 5]
Estimated Work Volume
New Requests Received 5 4 4 4 4
Matters Considered 4 4 4 4 4
Decisions Issued 4 4 4 4 4
[1] Years are based on fiscal, not calendar time periods
[2]Years are based on fiscal, not calendar time periods
[3]Years are based on fiscal, not calendar time periods
[4]Years are based on fiscal, not calendar time periods
[5]Years are based on fiscal, not calendar time periods

The outcomes (disposition) in those matters previously appealed to the MEC which proceeded through to review are below.

MEC Decision Disposition
Disposition April 1, 2012 – March 31, 2013 April 1, 2013 – March 31, 2014 April 1, 2014 – March 31, 2015
Denied 3 7 4
Approved 0 0 0
Defence 1 1 0
Total Number of Matters Reviewed 4 8 4

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Strategic Directions

  1. To continue to deliver its mandate under the Health Insurance Act (HIA).
  2. To deliver quality services efficiently.
  3. To attract and retain skilled and experienced members.
  4. The MEC will strive to complete reviews in a timely manner, upon receiving a request. As has occurred in the recent past, the Committee anticipates that it will meet two to three times yearly to consider approximately eight to twelve cases in a fiscal year.
Initiative Outcomes/Results Performance Measures
To continue to deliver its mandate under the Health Insurance Act (HIA). Parties coming before the MEC will feel heard and confident that the provision of publically funded health services is being applied correctly.
  • Completing an efficient and transparent review process with less than a five-month turn-around for reviews, from intake of cases to issuance of decision.

  • Reduction in inquiries received from the Ombudsman of Ontario.
To deliver quality services efficiently. Parties and the public will be assured of the value for dollar services provided by the MEC and have a sound understanding of the role of the Committee.
  • Health Boards Secretariat staff engage in diversity, accessibility and French language services training annually.
  • Parties will receive services and communications provided by the MEC in English and/or in French.
  • Creation of a public MEC website in 2016 that will provide information about the Committee's mandate and jurisdiction.
  • The MEC website will be in alignment with Accessibility for Ontarian's with Disabilities Act, 2005 and the French Language Services Act.
To attract and retain skilled and experienced members. Consistent and legally sound decisions will be issued by the MEC following a review.
  • The retaining of membership which is diverse in background and medical knowledge.
  • The receiving of positive feedback from the membership regarding the value add of their work for the Ontario public and the support received from the HBS staff.

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Overview of Current and Future Programs

The MEC considers the facts relevant to the disputed decisions, including any medical records and reports about the insured person. When considered necessary by the MEC, the Committee may interview the insured person and discuss the matter with him/her and/or their physician. Decisions of the MEC are binding upon the General Manager of OHIP.

Administrative support is supplied by the Health Boards Secretariat ("HBS" or "Secretariat"). The Ministry funds applicable per-diems and approved expenses, such as those for travel, incurred by the members in fulfilling the Committee's mandate.

Future programs of the MEC will continue to evolve in the areas outlined below.

Member Recruitment and Development

Governance

  • The Adjudicative Tribunals Accountability, Governance and Appointments Act, 2009 aims to increase efficiencies and transparency in the Committee's operations while maintaining independence in decision-making. Since transitioning from the Health Services Branch to the Health Boards Secretariat in 2015, the Committee is reviewing their accountability documentation to ensure the requirements of ATAGAA are being met.

Access to Justice

  • The MEC will create and make available to the public a website that includes information regarding the mandate and composition of the Committee, provides links to relevant legislation and governance and accountability documents required under the ATAGAA legislation.

Stakeholder Outreach

  • Systemic or procedural issues will be addressed to ensure a transparent and efficient experience for parties and annual meetings will be held with the General Manager of OHIP or their delegate to work collaboratively to address any systemic concerns.

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Risk Analysis

There is inherent risk associated with every decision and action that is undertaken by an adjudicative agency. Within the legislated framework which directs the MEC activity, as well as sound governance and controllership structures in place, these risks are well mitigated. Current

MEC risks are outlined in five distinct categories:

  • Strategic
  • Accountability/Compliance
  • Operational
  • Workforce
  • Infrastructure and Information Technology (I&IT)

Strategic Risk

The jurisdiction of the MEC is limited and each review is adjudicated by a panel that sits independently and is responsible for interpreting and applying the relevant legislation. An inability to demonstrate accuracy and consistency in interpreting and applying the legislation may result in a lack of confidence from Ontarians when attempting to access health care services from the Ontario Health Insurance Plan (OHIP). Committee access to independent legal counsel in future and the physical relocation of the MEC from the Health Services Branch of OHIP to a health adjudicative agency cluster will aid in reducing the errors in application of legislation and highlight the Committee's independence in decision making.

Accountability / Compliance

The adjudicative health boards, including the MEC, receive administrative and case management support from the Secretariat. Human and financial resources are not dedicated to any one Board within the Secretariat; instead a financial allocation and 21 permanent Ontario Public Servants are assigned to the Secretariat. These resources are distributed in line with the mandate of the Secretariat, which includes supporting the adjudicative agencies in meeting their legislative requirements.

With increasing public interest in government expenditure, particularly in the sector of agencies, boards and commissions, it is challenging to demonstrate transparency in expenditure related to any one Board, in particular given the shared resourcing structure. There are risks associated with the public's perception that some costs incurred by any one Board in particular may be reported in line with general Secretariat expense, such as staff salaries. This risk is balanced by the financial and operational efficiencies gained through the operating of a shared resourcing structure, with the benefit of the ability to shift resources as needed in line with what can be variable appeal volumes amongst the adjudicative tribunals. This shared resourcing model is in line with recent clustering trends in the administrative tribunal sector in Ontario.

Operational

The legislated structure of the MEC outlines that the Minister may appoint such number of physicians as he/she consider appropriate from time to time, not to exceed fifteen. The Health Insurance Act, R.S.O. 1990, requires a minimum of three members in order to constitute a quorum and that a quorum is sufficient for the exercise of all functions of the Medical Eligibility Committee.

Given the historic and anticipated minimal intake volumes, the MEC will face challenges in maintaining a membership base that is well trained and engaged in the operations of the MEC. To mitigate against this risk, the MEC will work collaboratively with the Public Appointments Secretariat to ensure that a knowledgeable and diverse membership is maintained. Additional training will also be provided to ensure that new and reappointed MEC members maintain a sound understanding of the applicable legislation and insurer benefits.

Workforce

In receiving administrative and case management support from the Secretariat, which is staffed by 19 of 21 positions belonging to bargaining agents, the MEC may be impacted by labour related actions. The MEC activities are not deemed to be an essential service; however, the mandate is vital to the parties engaged in the appeals process. Prolonged disruption to service may result in a lack of confidence in the ability and authority of both the MEC and the Ministry.

Experienced and efficient staff at the Secretariat is vital to the MEC's operational efficiency and to the delivery of its legislated mandate. To ensure this efficiency, a comprehensive education and training program must be in place for all staff, particularly those members of the Case Management Team who process the requests from intake to decision issuance. A further reduction of OPS staff, or any prolonged vacancy rates impact the appeal processing times, and may impede upon the quality of services provided to the MEC and, in turn, the Ontario public.

Infrastructure and Information Technology

The MEC is required to handle highly confidential personal information. Breaches in privacy may result in significant risk not only to the Ministry, but also to the applicant whose personal health information is no longer secure. As such, the Secretariat has implemented a number of measures to mitigate against these risks and members and staff are trained in best practices of I&IT security and the responsible handling and disposing of parties' personal health information.

With an administrative appeals process in which the exchange of documents between parties and the Committee is vital, the MEC relies upon the Secretariat's I&IT resources. Without adequate resources to maintain and develop the case management system(s) and the computer infrastructure, the MEC is at risk of not meeting its legislated mandate. A comprehensive Continuity of Business Operations Plan is in place, as is a daily backup of all systems information, which is stored at an offsite location.

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Environmental Scan

Internal Assessment

Strengths

Health Boards Secretariat staff have significant experience assessing matter for appropriate board mandate and processing matters efficiently. Secretariat staff have been engaged in diversity, accessibility and French language services in order to best assist the Ontario public. MEC members currently possess a significant number of years of experience on the Committee and are well versed in the mandate and legislative boundaries of the Committee.

Challenges

Adding new members to the MEC remains a challenge. This may be attributable to the difficulty in attracting physicians willing to participate because scheduled meetings may be cancelled if no requests are received. This could result in a loss of compensation for physicians, as they do not book appointments for patients when scheduled to attend a MEC meeting. The Health Boards Secretariat and the Chair will continue to work with staff of the Public Appointments Secretariat to identify and confirm new members.

As current members reach their ten year maximum appointment term, in accordance with the Adjudicative Tribunals Accountability, Governance and Appointments Act, 2009, the MEC may not be constituted for a period of months while awaiting new member appointments. New members will also require training and ongoing Committee activity in order to become familiar with the mandate and jurisdiction of the Committee, which may result in delays in the issuance of appeal decisions due to a minimal volume of appeals, resulting in limited training and appeal assessment opportunities.

External Assessment

Strengths

The jurisdiction of the MEC is quite narrow and allows for only a limited number of decisions to be within the Committee's mandate for consideration. This increases the transparency of the Committee as there is limited room for misinterpretation or broadening of the Committee's jurisdiction.

Challenges

Given, the jurisdiction of the MEC is quite narrow, any change to the applicable legislation may curtail the jurisdiction of the MEC completely, or require additional staffing, membership and resources should the jurisdiction of the Committee be enhanced to include issues beyond those relating to services in hospitals or health facilities which are considered uninsured due to the service being deemed not medically necessary.

While the MEC continues to transition from the Health Services Branch to the Health Boards Secretariat, it will be difficult to communicate a complete set of operational procedures and estimated processing timeframes to stakeholders given the infrequency of the testing the complete lifecycle process.

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Communications Plan

A key strategy for maintaining communications with parties to MEC cases is through the use of a case management model in delivering services. Any party to a review will primarily receive service from one case manager who will maintain their file from the time the request is received, until the time that the Committee has rendered its final decision. This structure will maintain consistency in communications to the parties and improves customer service through regular information sharing between the parties and case manager who can ensure any special needs (i.e. accessibility or language) are being met.

An additional communications strategy includes the creation of a public website. The Secretariat is devoting resources to creation of a MEC specific website and it will include general information about the Committee, as well as links to relevant pieces of legislation, MEC decisions, policy and contact information, Ministry and public accountability documents. The MEC website will meet all requirements set out under the Accessibility for Ontarians with Disabilities Act and be written in plain language that can be understood by both the general public as well as those accessing the MEC's services.

The Committee is committed to meeting the requirements for public posting of Board governance information as set out in the Adjudicative Tribunals Accountability, Governance and Appointments Act, 2009 (ATAGAA). In line with these requirements, the MEC publishes an annual report which is submitted to the Minister of Health and Long-Term Care. The annual report contains important information regarding the MEC's operational and financial activity for the fiscal year. In addition, the Committee makes publically available the Board's Memorandum of Understanding which details the relationship and obligations of the Board and the Ministry. The Committee also makes available its annual Business Plan, which plans the operations of the MEC for a minimum of three years to come.

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Resources Required to Achieve Goals and Objectives

Funding for the MEC has been directed through the Health Services Branch to the Secretariat from the Consolidated Revenue Fund. Funding will formally be assumed by the Secretariat during fiscal year 2016-2017. Administrative support to the MEC is supplied by the Health Boards Secretariat. The Ministry funds applicable per-diems and approved expenses, such as those for travel, incurred by the members in fulfilling the Committee's mandate.

The resource requirements for the MEC overlay with those of the Secretariat. In order to succeed with the initiatives set out in this plan, the Secretariat must maintain the staffing levels assigned in its allocation of human resources and it must continue to be innovative with its financial and I & IT resources.

There are limitations in detailing some specific resource requirements as they relate to the individual agencies both for past expenditure as well as for those forecasted. Expenses such as salaries for staff, as well as costs associated with facilities are not specified in the resource requirements as it would be arbitrary to determine which portion of cost should be attributed to each individual agency. These costs are incorporated in the fiscal planning cycle of the Secretariat and are both reported and forecast to the Ministry.

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Forecasted Operating Expenditure

MEC Financials [1]
Description 2014-15
Actual
2015-16
Estimated Financial Requirement
2016-17
Estimated Financial Requirement
2017-18
Estimated Financial Requirement
2018-19
Estimated Financial Requirement
Per Diem Costs $1,328 $1,500 $1,500 $1,500 $1,500
Travel Costs $111 [2] $500 $500 $500 $500
Total $1,439 $2,000 $2,000 $2,000 $2,000
[1] All figures in Canadian dollars.
[2] Travel costs have been updated to reflect actual expenditure.

The MEC's members submit expense/travel forms to the Health Boards Secretariat for approval and payment. If the Health Boards Secretariat is satisfied that the submitted expense meets the criteria/requirements of the directives, the expense form is approved for payment from the allocated budget.

Expenditures are limited to the reimbursement of approved travel and honoraria costs on a per meeting basis as set out in the budget table inserted above. Currently the honorarium is set at $664.00 per diem for all members (including the Chair).

The number of meetings held is directly related to the number of appeals received by the MEC. On an annual basis, four quarterly meetings are tentatively scheduled. However, as the Committee only meets if it receives requests for hearing, the number of meetings held may vary according to the volume of requests sent to it for consideration.

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Medical Eligibility Committee Membership

The Minister of Health and Long-Term Care can appoint up to fifteen physician members to the Committee, however, there are currently only three members, including the Chair. As per the Health Insurance Act, R.S.O. 1990, CHAPTER H.6, any three members constitute a quorum and are sufficient for the exercise of all functions of the Medical Eligibility Committee. In order to meet legislative requirements and ensure operational efficiency, the MEC is currently recruiting for new member appointments in early 2016 in line with the competitive and merit based processes outlined in the Adjudicative Tribunals Accountability, Governance and Appointments Act, 2009. All MEC members are part-time appointees.

MEC Appointees as of December 31, 2015

Physician Members as of December 31, 2015
Last Name, First Name City Occupation Start Date Expiry Date
Brooks, James Stewart Niagara-on-the-Lake Family Physician 01-Jan-1987 19-Mar-2016
Huryn, Mark J. Colborne Family Physician 25-Jun-2001 29-Oct-2016
Au, Susan Toronto Family Physician 06-Feb-2008 05-Feb-2018

Health Boards Secretariat Staff as of December 31, 2015

Staff Member Position
Sara van der Vliet Registrar
Sandra Evora Deputy Registrar
Anna Dunscombe Executive Assistant / Researcher
Kamyla Chutkaë Scheduler / Administrative Assistant
Natalya Demyanenko Case Management Coordinator
Alpha Aberra Bilingual Case Officer
Maureen Baker Case Officer
Margaret Bolinas Case Officer
Miso Choi Case Officer
Andrew Clifford Case Officer
Randi Cull Case Officer
Natalie Moskowitz Case Officer
Glenn Sequeira Case Officer
Shanti Persaud Administrative Coordinator
Ann Ing Administrative Assistant
Desiree Ashton Administrative Assistant
Tiffany Sarfo Administrative Assistant
Joy Steele Administrative Assistant
Suketu Bhavsar Senior Technology / Business Systems Administrator
Ketan Patel Systems Analyst / Programmer
Aldeen Watin Senior Systems Analyst / Lead Programmer

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