1. Ontario Health System Funding Reform: Overview
Presentation by: Irene Blais, Director, Funding Unit
Date: Wednesday September 11th, 2013
CAPCA – Chief Operating Officer Roundtable

2. Agenda Health System Funding Reform and CCO’s Role Current QBPs
Systemic Treatment
GI Endoscopy
New QBPs
Cancer Surgery
Colposcopy
Q & A

3. Health System Funding Reform and CCO’s Role

4. What is Health System Funding Reform Vision?
HSFR
Global Funding
Health Service Providers
(e.g. Community Care
Access Centres, Hospitals)
The vision of Health System Funding Reform is to shift Ontario’s health care spending from global funding to HSFR.
What is global funding? Historically, Ontario has used a global funding approach that focuses on budget adjustments over time for growth, inflation and other changes for facilities. Factors such as a provider performance and patient and community demographics are not accounted for in a global budget.
We are now transitioning away from full global funding to HSFR. HSFR is a more flexible system where funding follows the patient as they access the services that they need, both in a hospital and community setting.
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

5. Funding Reform: Two Key Components
Health Based Allocation Model (HBAM)
HBAM is a made-in-Ontario model that informs funding allocation to health services providers based on population needs
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
There are 2 components for HSFR in Ontario.
The Health Based Allocation Model, or HBAM as it is more commonly known, is a made in Ontario funding model. HBAM distributes an amount of health care funding to organizations in accordance with population projections and their ability to provide cost-effective care.
2) Quality Based Procedures (QBPs) are clusters of patients with clinically related diagnoses or treatments that have been identified by an evidence-based framework as providing opportunity for process improvements, clinical re-design, improved patient outcomes, enhanced patient experience and potential cost savings 5

6. HSFR: The model Health System Funding Reform Patient-Based Funding
10/04/2017
HSFR: The model
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
(N.B. 40% and 30% noted is hospital specific; will be different for other sectors)
Health Quality Branch 6 6

7. 10/04/2017
Recap: An evidence and quality-based framework has identified Quality-Based Procedures that have the potential to both improve quality outcomes and reduce costs
Health Quality Branch 7

8. 2013/14 Funding Allocation Update
Slide provided by MOHLTC

9. Monitoring and Evaluation
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

10. 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

11. Current QBPs – Systemic Treatment

12. 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
Treatment start
Further treatment
Funding Provided
$3400
RCC
Patient does NOT require treatment
$3400
RCC
RCC
RCC
RCC
RCC
RCC
$ $3300
RCC
RCC
Community Hospital

13. 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

14. The Bundled Payment Model- Phased Approach
Consultation
Treatment/ Follow-up
Parenteral Treatment-
Adjuvant, Curative, Neo-Adjuvant
Developed & undergoing validation, implementation
Diagnosis/ Staging Bundle
For future phase development & implementation
Consultation for Systemic Treatment
Developed and to be implemented 2014/15
Other treatment bundles:
- Parenteral Treatment-Palliative
Oral Treatment (may be multiple bundles)
To be developed for implementation
Follow-up (may be multiple bundles)
To be developed for implementation
Move from a lifetime payment approach to funding for specific bundles of activity to funding that follows the patient

15. Validating Evidence- Informed Practice
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
Validating Evidence Informed Practice
Next Steps:
Incorporate feedback from all DSG Member Review(where appropriate)
All Practitioner Review (fall 2013)

16. Current QBPs – GI Endoscopy

17. 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

18. Scope of GI Endoscopy QBP
Evidence gathered during QBP development suggests that the colonoscopy QBP should be expanded to include all endoscopy services:
Better patient care when multiple interventions are required
Many services performed in the endoscopy suite, and the associated resources, cannot be decoupled
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

19. Scope of GI Endoscopy QBP
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

20. New QBPs – Cancer Surgery

21. 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

22. 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
2005/06
37,441
3,300
2006/07
44,696
4,329
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
2011/12
41,802
8,166
2012/13
43,691
8,497
7,968
(529)

23. Cancer Surgery Wait times

24. New QBPs – Colposcopy

25. 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.

26. 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.

27. 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
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%
4,385
3,021
59,176
53,812
5,573
14,543
140,510
100% 3% 2%
42%
38% 4%
10%
* 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
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

28. 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