Ontario Health System Funding Reform: Overview Presentation by: Irene Blais, Director, Funding Unit

Date: Wednesday September 11 th , 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

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Health System Funding Reform and CCO’s Role

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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

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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

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HSFR: The model

Hospitals, Community Care Access Centres and Long Term Care are the first sectors incorporated into the funding strategy Patient-Based Funding is based on clinical activities that reflect an individual’s disease, diagnosis, treatment and acuity Patient-Based Funding (70%) Patient-Based Funding will include HBAM and Quality Based Procedures Health Based Allocation Model (40%) Health System Funding Reform Quality-Based Procedures (30%) Global (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? • 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 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? • •

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

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

Products

Clinical

Product Details • 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

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Current QBPs – Systemic Treatment

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•

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 Funding Provided

$3400

RCC RCC RCC RCC RCC RCC RCC RCC Community Hospital

$3400 $3400 + $3300

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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 13

The Bundled Payment Model- Phased Approach

Consultation Diagnosis/ Staging Bundle Consultation for Systemic Treatment

For future phase development & implementation Developed and to be implemented 2014/15

Treatment/ Follow-up 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

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 Evidence Informed Practice

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

All Practitioner Review

-All Disease site regimens sent to all practitioners for 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 evidence informed 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)

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Current QBPs – GI Endoscopy

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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

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Scope of GI Endoscopy QBP

Evidence gathered during QBP development suggests that the colonoscopy QBP should be expanded to include all endoscopy services: 1.

2.

Better patient care when multiple interventions are required Many services performed in the endoscopy suite, and the associated resources, cannot be decoupled 3.

4.

5.

The quality agenda for colonoscopy and endoscopy are tightly aligned Economies of scale exist when multiple endoscopy services are preformed together Overlap of funding across the breadth of services provided in an endoscopy suite is substantial

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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 $ 139,422,824 Day Surgery

21,661 10,972 4,515 2,804 4,015 3,637 11,390 545 707 1,046 6,564

67,856 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

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New QBPs – Cancer Surgery

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•

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

2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

2012/13

27,569 37,441 44,696 43,610 46,384 41,904 47,265 41,802

43,691

1,145 3,300 4,329 5,237 7,008 7,828 6,438 8,166

8,497

1,145 3,300 4,329 5,041 5,379 6,414 6,438 8,166

7,968

Unfunded Volume

0 0 0 (196) (1,629) (1,414) 0 0

(529)

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Cancer Surgery Wait times

Cancer Surgery Percent Completed Within Each Target

95% 90% 85% 80% 75% 70%

66% 64% 70% 68% 71% 68% 73% 72% 73% 71% 74% 72% 76% 72% 78% 72% 80% 77% 80% 78% 82% 80% 85% 83%

65% 60% % Completed within Each Target 2012/13 Target

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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 - Colposcopy

Colposcopy Summary FY 2011/12 (Source: OHIP) #S744 Count of procedures by Location and Ohip Fee Code Z729 Z730 Z731 #Z766 Z787 Total Hospital

3,613 1,971 32,047 28,219 3,874

Non-Hospital*

Total 772 1,050 27,129

25,593

1,699

4,385

3%

3,021

2%

59,176

42%

53,812

38%

5,573

9,507 79,231 5,036 61,279 4%

14,543

10%

140,510

100%

Total

56% 44% 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 #S744 Z729 Z730 Z731 #Z766 Z787 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 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) 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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