Access to Information Orders
Decision Information
• Record 1 - a statement of the amounts paid to laboratories for OHIP services from 1972 to the date of the request; and Record 2 - portions of a Coopers and Lybrand study on laboratory services dated in 1997.
• Scope of the Request - Ministry ordered to conduct a further search for responsive records
• 17(1)(third party information) - not upheld
• Section 18(1)(d) and (f)(economic interests) - not upheld in relation to Record 1 and upheld in relation to a portion of Record 2.
• Section 23 (public interest override) - not upheld.
• Record 1 to be disclosed in its entirety.
• Record 2 to be disclosed in part.
Decision Content
BACKGROUND
This appeal relates to payments made by the Ministry of Health (the Ministry) to community laboratories for services that are insured under the Ontario Health Insurance Plan (OHIP). The maximum amounts to be paid in a fiscal year by the Ministry for insured laboratory services are prescribed in the Health Insurance Act (HIA).
The Ministry provided the following background information in their representations:
Community laboratory providers are facilities that at the request of a health professional, carry out tests on a specimen that are helpful to the health professional in diagnosing or treating a patient. These tests are billable to the Ontario Health Insurance Plan (“OHIP”). In 1993 the Ministry, recognizing that it needed to allocate a finite amount of health care dollars effectively, introduced a ceiling (“industry cap”) on the total amount payable by OHIP for community lab services carried out in a particular fiscal year.
Laboratories were necessarily engaged in battles for market share because each laboratory’s share of the total payments is detrimentally affected by increases in billings submitted by other laboratories. Private medical laboratories cannot compete for market share by reducing prices because the fees payable for insured services are fixed by regulation.
In 1996 the Ministry and the OAML [Ontario Association of Medical Laboratories] engaged in consultations to address the problem of over-utilization of laboratory services and to create fairness in funding distribution on a geographic basis. The corporate cap payment model arose out of these consultations. Under the corporate cap model, the Ministry only pays each individual laboratory up to its threshold amount (“corporate cap”). A corporate cap is the maximum total amount that a particular lab could be paid by OHIP in a fiscal year. This means that the amount a lab bills over its corporate cap is not funded by OHIP and is therefore absorbed by the laboratory.
The Ministry submits that the corporate cap has had the desired effect. The growth of medical laboratory testing is under control, funding of laboratories has stabilized and the incentive for excessive utilization of laboratory services is removed. The positive effects are evidenced by a slowed growth in laboratory testing since the inception of the corporate cap system.
The corporate cap model is set out in Regulation 2/98 (reproduced in Appendix A to this order) which amended Regulation 552. Sections 22.1 through to 22.11 are relevant. These sections prescribe the industry-wide cap and set out the formula for the calculation of the corporate cap. The formula initially requires the calculation of the base year amount which generally represents the laboratories’ share of the total amount payable by OHIP in the 1995/1996 fiscal year. Once the base year amount is calculated, the corporate cap amount can be calculated having regard to a number of variables set out in the regulation.
As a practical matter, and as a general rule, if laboratories work above the corporate cap, they are offering a discount for their laboratory services because they will be subject to a claw back by the Ministry of the amounts billed in excess of the corporate cap. Laboratories that work below the corporate cap will face a reduction in the base year amount which will then result in a reduction of their corporate cap amount.
NATURE OF THE APPEAL:
The Ministry of Health and Long-Term Care (the Ministry) received a request under the Freedom of Information and Protection of Privacy Act (the Act) for access to information relating to the funding of medical laboratories.
Subsequently, the requester and the Ministry had discussions regarding the scope of the request which resulted in the narrowing of the request by the requester. In response, the Ministry issued a decision letter in which it described the narrowed request as follows: