Ontario Health System Funding Reform:Overview

Presentation by: Irene Blais, Director, Funding UnitDate: Wednesday September 11th, 2013CAPCA – 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

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Health System Funding Reform and CCO’s Role

Health Service Providers(e.g. Community Care

Access Centres, Hospitals)

Global Funding HSFR

What is Health System Funding Reform Vision?

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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

Funding Reform: Two Key Components

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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

Patient-Based Funding will include HBAM and Quality-

Based Procedures

Patient-Based Funding is based on clinical activities that reflect an individual’s

disease, diagnosis, treatment and acuity

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(70%)

Health Based Allocation Model

(40%)

Quality-Based Procedures

(30%)

Global(30%)

HSFR: The model

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Recap: An evidence and quality-based framework has identified Quality-Based Procedures that have the potential to both improve quality outcomes and reduce costs

• Is this aligned with Transformation priorities?• Will this contribute directly to Transformation system re-design?

• 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?

• 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 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?

• 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?

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2013/14 Funding Allocation Update

Slide provided by MOHLTC

CCO/ORN leading full implementation of Quality-Based Procedures including…

• Quality-Based Procedures’ Definitions• Best Practices • Better Practice Hospitals• Clinical Handbooks• Clinical Engagement

Clinical

• Quality-Based Procedure Best Practice Price• Quality Overlay FrameworkPricing/ Funding

Capacity Planning

• Integrated Quality-Based Procedure ScorecardMonitoring and Evaluation

• Regional/System Volume Management/Capacity Planning Strategy• Capacity Utilization and Forecasting Program

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Products Product Details

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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

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Current QBPs – Systemic Treatment

Why Reform Systemic Therapy? Limitations of the Current Model

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Consult Treatment start

Further treatment

RCC Patient does NOT require treatment $3400

Funding Provided

RCC RCC RCC

$3400RCC RCC RCC

$3400 + $3300RCC RCC Community Hospital

• 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

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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

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Move from a lifetime payment approach to funding for specific bundles of activity to funding that follows the patient

The Bundled Payment Model- Phased Approach

Parenteral Treatment- Adjuvant, Curative, Neo-Adjuvant

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

Consultation Treatment/ Follow-up

Follow-up (may be multiple bundles)

To be developed for 2014-15 implementation

Consultation for Systemic Treatment

Developed and to be implemented 2014/15

Diagnosis/ Staging Bundle

For future phase development & implementation

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DSG Chair Review -Identify standard regimens and evidence-informed practice for each regimen -Feedback incorporated (follow-up call if req’d) & sent back to DSG Chairs for validation

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’

All Practitioner Review -All Disease site regimens sent to all practitioners for feedback re: evidence-informed regimens

Validating Evidence- Informed Practice

Next Steps:1. Incorporate feedback from all DSG Member

Review(where appropriate)2. All Practitioner Review (fall 2013)

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Current QBPs – GI Endoscopy

Scope of GI Endoscopy QBP

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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

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Scope of GI Endoscopy QBPEvidence 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 required2. Many services performed in the endoscopy suite, and the

associated resources, cannot be decoupled3. The quality agenda for colonoscopy and endoscopy are tightly

aligned4. Economies of scale exist when multiple endoscopy services are

preformed together5. Overlap of funding across the breadth of services provided in an

endoscopy suite is substantial

Scope of GI Endoscopy QBP

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Endoscopy Activity

Procedure Combination Endoscopy

Suite Day

SurgeryInpatient ER Total

1a. Inspections 104,010 21,661 2,276 64 128,011 1b. Excisions and/or Biopsies 72,510 10,972 2,588 12 86,082 2a. Inspection and Gastroscopy 23,684 4,515 3,487 6 31,692 2b. Excision and/or Biopsy and Gastroscopy 20,134 2,804 2,464 1 25,403 3a. Inspections and Other 16,744 4,015 518 4 21,281 3b. Excisions and/or Biospies and Other 21,386 3,637 830 1 25,854 4a. Gastroscopies alone 83,199 11,390 16,980 577 112,146 4b. Gastroscopies and Other 4,153 545 3,528 144 8,370 5a. Inspection and Gastroscopy and Other 3,054 707 461 1 4,223 5b.Excision and/or Biospy and Gastroscopy and Other 5,607 1,046 701 - 7,354 6. Other 43,128 6,564 4,331 13,349 67,372 Total 397,609 67,856 38,164 14,159 517,788

139,422,824$

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

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New QBPs – Cancer Surgery

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)

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Fiscal Year Total Volume All Incremental

Funded Incremental

UnfundedVolume

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)

Cancer Surgery Wait times

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Q1 07

/08

Q2 07

/08

Q3 07

/08

Q4 07

/08

Q1 08

/09

Q2 08

/09

Q3 08

/09

Q4 08

/09

Q1 09

/10

Q2 09

/10

Q3 09

/10

Q4 09

/10

Q1 10

/11

Q2 10

/11

Q3 10

/11

Q4 10

/11

Q1 11

/12

Q2 11

/12

Q3 11

/12

Q4 11

/12

Q1 12

/13

Q2 12

/13

Q3 12

/13

Q4 12

/13

60%

65%

70%

75%

80%

85%

90%

95%

66%64%

70%68%

71%

68%

73%72% 73%

71%

74%

72%

76%

72%

78%

72%

80%

77%

80%78%

82%

80%

85%

83%

Cancer Surgery Percent Completed Within Each Target

% Completed within Each Target 2012/13 Target

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nt

Co

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d W

ith

in T

arg

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New QBPs – Colposcopy

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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.

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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.

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Current State - ColposcopyColposcopy 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 non-hospital setting

OHIP Code Description

#S744Cervix- cone biopsy - any technique with or without D&C

Z729Cryoconization, eletroconization or CO2 laser theraphy with or without curettage for premalignant lesion (dysplasia or carcinoma insitu), outpatient procedure

Z730 Follow-up colposcopy without biopsy with or without endocervical curetting

Z731Initial investigation of abnormal cytology of vulva and/or vagina or cervix under colposcopic technique with or without biopsy(ies) and/or endocervical curetting

#Z766Loop Electrosurgival Excision Procedure (LEEP)

Z787 Follow-up colposcopy with biopsy(ies) with or without endocervical curetting

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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

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