Ontario Health System Funding Reform:
Overview
Presentation by: Irene Blais, Director, Funding Unit
Date: Wednesday September 11th, 2013
CAPCA – Chief Operating Officer Roundtable
Agenda
• Health System Funding Reform and CCO’s Role
• Current QBPs
• Systemic Treatment
• GI Endoscopy
• New QBPs
• Cancer Surgery
• Colposcopy
• Q&A
2
Health System Funding Reform
and CCO’s Role
3
What is Health System Funding Reform Vision?
Global Funding
HSFR
Health Service Providers
(e.g. Community Care
Access Centres, Hospitals)
Evidence-based funding driven based on the highest quality, most efficient
care
How many patients they look after
The services they deliver
The evidence-based quality of these services
The specific needs of the population they serve
Slide provided by MOHLTC
4
Funding Reform: Two Key Components
1. Health Based Allocation Model (HBAM)
• HBAM is a made-in-Ontario model that informs funding
allocation to health services providers based on population
needs
2. Quality-Based Procedures (QBP)
• Price x volume, evidence based clinical pathways ensure quality
standards
• Opportunity for process improvements, clinical re-design,
improved patient outcomes, enhanced patient experience
5
HSFR: The model
Hospitals, Community Care
Access Centres and Long
Term Care are the first
sectors incorporated into
the funding strategy
Health System
Funding Reform
Patient-Based Funding is
based on clinical activities
that reflect an individual’s
disease, diagnosis,
treatment and acuity
Patient-Based Funding will
include HBAM and QualityBased Procedures
Patient-Based
Funding
Global
(30%)
(70%)
Health Based
Allocation Model
Quality-Based
Procedures
(40%)
(30%)
6
Recap: An evidence and quality-based framework has identified Quality-Based
Procedures that have the potential to both improve quality outcomes and reduce costs
• Does the clinical group contribute to a significant proportion of total costs?
• Is there significant variation across providers in unit costs/ volumes/ efficiency?
• Is there potential for cost savings or efficiency improvement through more
consistent practice?
• How do we pursue quality and improve efficiency?
• Is there potential areas for integration across the care continuum?
• Is this aligned with Transformation priorities?
• Will this contribute directly to Transformation system re-design?
• Is there a clinical evidence base for an established standard of care and/or
care pathway? How strong is the evidence?
• Is costing and utilization information available to inform development of
reference costs and pricing?
• What activities have the potential for bundled payments and integrated care?
• Are there clinical leaders able to champion change in this
area?
• Is there data and reporting infrastructure in place?
• Can we leverage other initiatives or reforms related to
practice change (e.g. Wait Time, Provincial Programs)?
• Is there variation in clinical outcomes across providers,
regions and populations?
• Is there a high degree of observed practice variation across
providers or regions in clinical areas where a best practice or
standard exists, suggesting such variation is inappropriate?
7
2013/14 Funding Allocation Update
Slide provided by MOHLTC
8
CCO/ORN leading full implementation of Quality-Based Procedures including…
Products
Product Details
Clinical
•
•
•
•
•
Quality-Based Procedures’ Definitions
Best Practices
Better Practice Hospitals
Clinical Handbooks
Clinical Engagement
Pricing/ Funding
•
•
Quality-Based Procedure Best Practice Price
Quality Overlay Framework
Capacity Planning
•
•
Regional/System Volume Management/Capacity Planning Strategy
Capacity Utilization and Forecasting Program
Monitoring and Evaluation
•
Integrated Quality-Based Procedure Scorecard
9
Why is CCO part of HSFR?
• Government’s Advisor for Cancer & Renal Services.
• Principles of equity, evidence-based recommendations,
performance-oriented goals, and value for money (help build the
best health system in the world)
• Motivate change through the cause, evidence and data, and
funding levers
• Oversee more than $800 million in patient-based funding
• Robust clinical leadership model based on regional networks
• Well-developed evidence review and guideline development
processes
• Well-developed performance management model
10
Current QBPs – Systemic Treatment
11
Why Reform Systemic Therapy?
Limitations of the Current Model
• Systemic Treatment if funded in a variety of ways:
•
•
•
RCCs: Lifetime payment triggered by a consultation (C1S)
Non-RCCs: Per case (unique patient) or funding per visit in some cases
Some facilities receive PCOP funding (per visit)
• This results in:
•
•
Inequities: Not all hospitals receive funding for systemic treatment
Duplication: In some cases, double-payment exists
Consult
RCC
Treatment
start
Further
treatment
Patient does NOT require treatment
RCC
RCC
RCC
RCC
RCC
RCC
RCC
RCC
Community Hospital
Funding Provided
$3400
$3400
$3400 + $3300
12
How will the new funding model address these
limitations?
• Move from a lifetime payment approach to an activity-based bundled payment
approach
• A Bundled payment approach allows funding to follow the patient, thereby:
•
Recognizing incident and prevalent cases
• Particularly important as survivorship improves
•
•
•
Reducing & eventually eliminating inequities in funding
Supporting the shared care model (resulting from a consistent/fair funding model)
Recognizing the work associated with the delivery of oral chemotherapy regimens
• Incent for high-quality care:
•
•
•
Identifying and funding for appropriate care according to evidence-informed practice
Ensuring patients get access to care they need
Optimizing use of resources
Developing a new funding model for systemic treatment is a priority for
CCO under the RSTP Provincial Plan released in 2009
13
The Bundled Payment Model- Phased Approach
Consultation
Treatment/ Follow-up
Parenteral TreatmentAdjuvant, Curative, Neo-Adjuvant
Diagnosis/
Staging Bundle
Consultation
for Systemic
Treatment
For future phase
development &
implementation
Developed
and to be
implemented
2014/15
Developed & undergoing validation, 2014-15
implementation
Other treatment bundles:
- Parenteral Treatment-Palliative
- Oral Treatment (may be multiple bundles)
To be developed for 2014-15 implementation
Follow-up (may be multiple bundles)
To be developed for 2014-15 implementation
Move from a lifetime payment approach to funding for specific bundles of activity to
funding that follows the patient
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Validating EvidenceInformed Practice
All Practitioner Review
-All Disease site regimens sent to all
practitioners for feedback
re: evidence-informed regimens
All DSG Member Review
-All DSG members review list of
standard regimens for their Disease Site
-DSG members to provide feedback
re: evidence-informed regimens
DSG Chair Follow-up Calls
-Follow-up calls with DSG
Chairs (if required) to
incorporate feedback from ‘All
DSG Member Review’
DSG Chair Review
-Identify standard regimens and evidenceinformed practice for each regimen
-Feedback incorporated (follow-up call if req’d)
& sent back to DSG Chairs for validation
Next Steps:
1. Incorporate feedback from all DSG
Member Review(where appropriate)
2. All Practitioner Review (fall 2013)
15
Current QBPs – GI Endoscopy
16
Scope of GI Endoscopy QBP
GI Endoscopy Activity in Hospitals (517,788 cases in 2011/12)

Colonoscopy Inspection procedures

Gastroscopy Inspection procedures

Excision/Biopsy/Destruction procedures

Other GI Endoscopy: ex. EUS, ERCP and Laser procedures
Hospital Care Setting

Endoscopy suite

Day Surgery Room

Inpatient

Emergency Room
Expenses

$139M in hospital direct costs (2011/12)

Pathology laboratory is out-of-scope

Physician fees are out-of-scope
17
Scope of GI Endoscopy QBP
Evidence gathered during QBP development suggests that the
colonoscopy QBP should be expanded to include all endoscopy
services:
1. Better patient care when multiple interventions are required
2. Many services performed in the endoscopy suite, and the
associated resources, cannot be decoupled
3. The quality agenda for colonoscopy and endoscopy are tightly
aligned
4. Economies of scale exist when multiple endoscopy services are
preformed together
5. Overlap of funding across the breadth of services provided in an
endoscopy suite is substantial
18
Scope of GI Endoscopy QBP
Endoscopy Activity
Procedure Combination
1a. Inspections
1b. Excisions and/or Biopsies
2a. Inspection and Gastroscopy
2b. Excision and/or Biopsy and Gastroscopy
3a. Inspections and Other
3b. Excisions and/or Biospies and Other
4a. Gastroscopies alone
4b. Gastroscopies and Other
5a. Inspection and Gastroscopy and Other
5b.Excision and/or Biospy and Gastroscopy and Other
6. Other
Total
$
Endoscopy
Suite
104,010
72,510
23,684
20,134
16,744
21,386
83,199
4,153
3,054
5,607
43,128
397,609
Day
Surgery
21,661
10,972
4,515
2,804
4,015
3,637
11,390
545
707
1,046
6,564
67,856
139,422,824
Inpatient
2,276
2,588
3,487
2,464
518
830
16,980
3,528
461
701
4,331
38,164
ER
64
12
6
1
4
1
577
144
1
13,349
14,159
Total
128,011
86,082
31,692
25,403
21,281
25,854
112,146
8,370
4,223
7,354
67,372
517,788

The table above summarizes the number of G.I Endoscopy procedures by procedure
combination in each of the 4 identified settings in 2011/12.

The 11 procedure combinations are mutually exclusive meaning that a patient encounter can
only be mapped to one combination.

The total expenses for these procedures are estimated at $139MM based on 2011/12 data
19
New QBPs – Cancer Surgery
20
Cancer Surgery Agreements (CSA) to…
Quality Based Funding (QBP)
• CCO has been advising the Ministry of Health and Long-Term Care
on the allocation of incremental funding for cancer surgery
procedures since 2004
• Good progress – decrease in wait times
• Strong linkage to quality via Schedule B
• Cancer Surgery is well positioned for transition to QBP
• Strong quality program & guidelines & pathways
• Benefit from knowledge gained from CSA process & methodology
• Disease site approach
• Prostate will be the initial disease site
• Unknown – possible that CSA will exist for some disease sites
Annual Cancer Surgery Volumes
2004/05 – 2012/13
(incremental funding $70MM 2012/13)
Fiscal Year
Total Volume
All
Incremental
Funded
Incremental
Unfunded
Volume
2004/05
27,569
1,145
1,145
0
2005/06
37,441
3,300
3,300
0
2006/07
44,696
4,329
4,329
0
2007/08
43,610
5,237
5,041
(196)
2008/09
46,384
7,008
5,379
(1,629)
2009/10
41,904
7,828
6,414
(1,414)
2010/11
47,265
6,438
6,438
0
2011/12
41,802
8,166
8,166
0
2012/13
43,691
8,497
7,968
(529)
22
Cancer Surgery Wait times
Cancer Surgery Percent Completed Within Each Target
Percent Completed Within Target
95%
90%
85%
85%
83%
82%
80%
80%
80%
78%
77%
76%
80%
78%
74%
73%
75%
71%
70%
68%
70%
66%
72%
73%
71%
72%
72%
72%
68%
64%
65%
60%
% Completed within Each Target
2012/13 Target
23
New QBPs – Colposcopy
24
Current State - Colposcopy
• In Ontario, colposcopies are conducted both in hospitals and also
within the community, primarily private practitioner offices and
clinics.
• Based on clinical expert feedback at CCO, variations in practice exist
in all settings across the province of Ontario.
• In addition, a consistent, system-wide approach for accountability
over the quality and efficacy of colposcopy services provided does
not exist.
• The 2008 Program In Evidence-Based Care (PEBC) Colposcopy
standards (which describe the optimum organization for the
delivery of colposcopy services in Ontario) are currently in the
process of being revised.
25
Current State - Colposcopy
• CCO foresees the need to include both hospitals and community
settings in order to appropriately apply these standards across the
province of Ontario.
• Practice variations, as well as the lack of consistent mechanisms for
measuring quality, each present an opportunity to increase quality
and efficiency across the system by including both hospitals and
community settings in the definition of the Colposcopy QBP.
• The Colposcopy QBP aims to improve quality, decrease wait times
and reduce lost-to-follow-up rates.
26
Current State - Colposcopy
Colposcopy Summary FY 2011/12 (Source: OHIP)
Count of procedures by Location and Ohip Fee Code
#S744
Z729
Z730
Z731
#Z766
Z787
Total
Total
Hospital
3,613
1,971
32,047
28,219
3,874
9,507
79,231
56%
Non-Hospital*
772
1,050
27,129
25,593
1,699
5,036
61,279
44%
Total
4,385
3,021
59,176
53,812
5,573
14,543
140,510
100%
3%
2%
42%
38%
4%
10%
100%
OHIP records where the hospital master number was blank and it was assumed that the procedure happened in a nonhospital setting
*
OHIP Code
#S744
Z729
Z730
Description
Cervix- cone biopsy - any technique with or without
D&C
Cryoconization, eletroconization or CO2 laser theraphy with or without curettage for premalignant lesion (dysplasia or carcinoma insitu),
outpatient procedure
#Z766
Follow-up colposcopy without biopsy with or without endocervical curetting
Initial investigation of abnormal cytology of vulva and/or vagina or cervix under colposcopic technique with or without biopsy(ies) and/or
endocervical curetting
Loop Electrosurgival Excision Procedure
(LEEP)
Z787
Follow-up colposcopy with biopsy(ies) with or without endocervical curetting
Z731
27
Next Steps – Policy and Strategy
• Continued Policy and Strategy development including but not
limited to:
• Cancer funding ‘Think Tank’
• Funding across multiple sectors including homecare
• Models of Care
• Environmental scan
• Evaluation framework
28
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