Best Care is a Right, Not a Privilege Quality-Based Procedures

Activity-Based Funding Conference

January 29, 2014

Michael Stewart

Executive Lead, Decision Support and Knowledge Transfer

Ministry of Health and Long-Term Care

2

Background and Overview

• Ontario‟s Action Plan

• Activity-based Funding

• Transition from global budgets towards

a patient-focused funding system

3

4 Pillars of Transformation

Empowering

people to make

healthier choices

and improving

health outcomes

for children

Wellness & Prevention

Right Care, Right Place, Right Time

Maximizing

investments by

shifting services to

more appropriate and

cost effective settings

and optimizing

existing resources

Funding Reform

Paying for health care

services based on

the on needs

of the patient and

performance to drive

quality, efficiency

and effectiveness in

the system

Integration & Execution

Strengthening

coordinated care to

improve access to

health care

services and

maximizing quality

and value

Ontario‟s Action Plan creates a system that improves quality care for

patients as it delivers more value for taxpayers

Global Funding

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An evidence-based approach with incentives

to deliver high quality care based on:

• Best available evidence and best practices

• Needs of the population served

• Services delivered

• Number of patients

A historical approach where health service providers

received lump sum funding

• Hospitals, on average, received 75-90% of their funding

from global budgets

• Majority of the funding is in the form of:

o Base annualized funding

o New incremental funding

o Remaining funding acquired from other sources

(i.e. preferred accommodation, alternative revenue etc. )

We are moving from the global provider-focused

funding model to one that revolves around the person

Health System Funding Reform

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Activity Based Funding (ABF)

What is ABF?

• Method of funding health-care providers (i.e. acute-care hospitals, long-term care

facilities, rehabilitation facilities) for the care and services they provide1

• Under ABF, health providers receive funding based on the number and type of “activities”

they perform2

• Payment model based on the volume and type of services provided to each patient for

hospital care. Its main objectives are to increase efficiency and reduce wait times. 3

Where is it being used?

Numerous countries are already using some form of ABF. Examples include, but not limited to:

• Australia

• United Kingdom

• United States

• Europe

References:

1 [CIHI: https://secure.cihi.ca/free_products/ActivityBasedFundingManualEN-web_Nov2013.pdf

2 [http://www.policyalternatives.ca/sites/default/files/uploads/publications/BC%20Office/2012/01/CCPA-BC_ABF_2012.pdf]

3 [http://www.cadth.ca/products/environmental-scanning/health-technology-update/ht-update-12/activity-based-funding-models-in-canadian-hospitals]

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Ontario‟s Health System Funding Reform approach will draw from over 25 years of international Activity Based Funding experience

• Patient focused funding systems reimburse

providers at an established rate, based upon

quality care for standard patient groups

• Ontario is one of the last leading

jurisdictions to move down this path.

Patient Focused Funding Adoption Timeline

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Benefits of ABF include, but not limited to:

• Focus on improving clinical processes and patient outcomes

• Improving quality

• Decreasing wait times/improved access to care

• Reducing unit costs per admission

• Reducing variation in both costs and clinical practice

• Ensuring pricing and funding transparency, and the accurate

and visible allocation of funding to Health Services based on the

activities they perform

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Risks of ABF

• More potential fluctuation in budget dollars

• Less flexibility for facilities to manage all their programs and services

• Potential focus shift from the quality of patient care to volume of service

o Hospitals may be inclined to treat simple cases over complex cases

o Rural and small health care facilities could be negatively impacted

• May create perverse incentives such as:

o Over-servicing

o Discharging patients too early, without appropriate safeguards

against readmission

o Upcoding (coding patients in more resource-intensive groups for

increased compensation)

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Implementation of ABF needs to be closely

monitored for potential adverse effects rising

due to …

• Insufficient funded volumes

• Poor data quality

• Inability to measure key indicators

• Timeliness

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Canadian doctors for Medicare support

experiments with ABF, if it does not undermine

the public system …

“If not implemented and

monitored carefully, ABF can

provide a disincentive for

hospitals to provide low-volume but

needed care and lead to hospital

closures in rural communities”

Reference:

[http://www.canadiandoctorsformedicare.ca/Activity-Based-Funding/abf-bulletins.html]

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Health System Funding Reform

• Health-Based Allocation Model

• Quality-Based Procedures

(focus area of today‟s presentation)

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Health System Funding Reform (HSFR)

has two funding components

• HBAM is a „made in Ontario' funding model that determines optimal amount of funding based

on patient demographics, clinical data and financial data

• QBPs are clusters of patients with clinically related diagnoses/ treatments and functional needs

identified by an evidence-based framework as providing opportunity for:

1. Aligning incentives to facilitate adoption of best clinical evidence-informed practices

2. Appropriately reducing variation in costs and practice across the province while

improving outcomes

3. Ensuring we are advancing right care, at the right place, at the right time

Note: At the culmination of HSFR, HSPs will account for approximately 70% of funding

HSFR

Health-Based

Allocation Model

(HBAM)

Global

Funding

(Non-HSFR) Quality-Based

Procedures

(QBPs)

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QBPs have been selected using an

evidence-based framework…

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The “Quality” in Quality-Based Procedures

• Best practices informed by clinical consensus and best available evidence

• Engage in clinical process improvement/ re-design and adopt best practices

• Best practice pricing to strengthen the linkage between quality and funding

• Develop indicators to evaluate and monitor actual practice

• Broaden scope of QBPs to strengthen the continuity of care

• Ensure every patient gets the right care, at the right place, at the right place

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Developing best practices through the

QBP Clinical handbooks

Ministry had asked the agencies (such as

Health Quality Ontario) to convene Clinical Expert

Advisory Groups for each assigned QBP

Expert Panel Members included multi-disciplinary

(i.e. specialists, family physicians, nurses, health disciplines,

patients, decision support managers),

multi-sectoral and cross-provincial representation

Expert Panels deliverables included:

• Defining patient inclusion/ exclusion criteria

• Developing best practices

• Recommending performance indicators and

implementation strategies for the defined episode of care.

These deliverables have been compiled in a

‘QBP Clinical Handbook’

Agencies

Clinical Expert

Advisory Groups

Deliverables

Evidence Best Practice “Interim”

QBP Price

Local Adaptation to Practice and

Price

Best Practice Price

Regional Capacity

Plan

Performance Evaluation/ Feedback

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A staged approach has been adopted to

develop and implement the QBPs

Agencies

Clinical Engagement/ Knowledge Transfer

Alignment with quality levers such as Quality Improvement Plans etc.

PHASE 1 – Clinical Foundation PHASE 2 – Development of Best Practice Price PHASE 3 – Implementation

Key Advisors

Clinical Experts Clinical Experts and Technical Advisory Clinical Experts & Stakeholders

(i.e. LHINs, HSPs etc.)

Measure and monitor key indicators

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7

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Developing and implementing QBPs

Acute Inpatient

• Entering Year 3 (FY 2014/15) of QBP implementation

• To date (FY 2012/13 and FY 2013/14), QBPs represent 11% of the total

provincial budget

Transition from Acute Inpatient Admissions

• Existing QBPs expanded to address transition from inpatient

admission/episode

Community

• Concurrent work underway to define community-focused QBPs

Integrated Indicator Scorecard

• Provide a starting point for monitoring and evaluating the impact of the

introduction of each QBP

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Lessons learned to date from

QBP implementation (1)

1. National and international experiences

2. Improving quality is ongoing

3. Need for strong structural supports

• Establishment of HQO

• Agencies such as CCO, CCN, PCMCH as a partner

• Expert panels

4. Risk and consequence of imperfect data and poor understanding of cost

structures and historical condition-specific utilization patterns

5. Need for focused change management

• Change is difficult

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Lessons learned to date from

QBP implementation (2)

6. Continue to communicate, communicate, communicate

• Need for robust, multi-faceted communications strategy at varied levels

• Identify system champions early on

7. Lay out a multi-year plan to better understand the financial consequences

8. Communicate clear guiding operational principles

• Establish an integrated project management approach that clearly

delineates roles and responsibilities of various project partners

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Coding and data quality: raising the bar

It‟s not the Ministry‟s data: it‟s the organization‟s

• Overt and transparent link between coded patient data and funding

• Improved data quality benefits everyone

• Documentation (physician and departmental) challenges need to be resolved,

need for issues to be escalated

• Likely need new data elements; keeping abreast of standards even more

important

Patient Assignment to all QBPs based on coded data

• Funds to be paid for different QBPs will vary

• Not all patients fit a QBP criteria

• Capacity planning…it‟s not just about volume reconciliation

Planning and budgeting; conducting internal impact analysis, combining clinical

(coded), utilization (volumes), and financial data

A five year review of case volumes was commissioned.

The results showed that the hospital had seen a significant

decrease in case weights over the five years. All programs and

physicians refuted the charge, saying they were working harder

than previously and the data was wrong. However, the numbers

told a different story.

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One example of data challenge:

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Observations and result:

Upon review:

• The analysis had not ensured that all patients be regrouped to the

same CMG year

• A comparison based on five differing weighting values was useless

Result:

The programs felt the system and information was useless and unusable and

vowed amongst themselves to only trust their own data

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The Trouble with Data

Data not understood is bad data

No matter how much data we have, we always want more No matter how good and validated the data is,

we always want it to be better

No matter how quick it is, it could always be available quicker Everyone else has better information systems than we do

The darn data never answers the questions it should

The data doesn‟t always prove what we know is right

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Capacity Planning

Health Service Providers must build expertise in impact analysis.

They must understand:

• Their case mix

• Trend in patient populations and illnesses

• Discharge disposition patterns

• Utilization by patient population

Coding review to ensure standards are followed and all patients are

assigned to their most appropriate CMG

Review and understand utilization by patient groups.

Outreach Sessions Face-to-face outreach sessions with HSPs with representation from front-

line staff as well as senior management to obtain feedback and identify

improvement opportunities for QBP implementation

Education Comprehensive education resources available to assist HSPs in

understanding and learning about HSFR

e.g. Online Self-Study Modules

Support Resources Support resources continually added to ensure HSFR field knowledge is

up-to-date

e.g. Methodology Guidelines, FAQs, Memorandums, HBAM Manual,

Summary of Changes to HSFR Funding Model

Technical Tools Specific tools developed to assist HSPs to examine HBAM’s impact on

their facility e.g. Variance, Service, Unit Cost

Websites Public and private websites contain extensive repository

e.g. HBAM results, recorded webcasts and presentations

Helpline Telephone and email helpline available to provide opportunity to HSPs to

submit HSFR-related questions 25

Supporting the sector…

Education and other transitional communication supports are available to assist

HSPs with change management

LHIN Best Practice Initiatives

St. Joseph’s

Integrated

Comprehensive

Care Project

Innovative pilot project that ensures seamless transitions for patients from the hospital to

the community.

Success Factors include, but not limited to:

• Integrated Care Coordinators (ICC) follow patients through the various care

settings and work collaboratively with existing providers including primary care

• Single contact number to access the team on a 24/7 basis.

Waterloo

Wellington LHIN

Developed a regional, cross-continuum stroke system of care focused on building

downstream capacity

Toronto East

General Hospital

Changes to processes related to Hip and Knee replacement improved the patient

experience and Length of Stay

Mount Sinai

Hospital

Incorporated QBP’s into strategic planning and budgeting process

Health Sciences

North

Developed strong Data Quality culture and put emphasis on data capture and reporting

done by front line staff

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Success Stories - Examples

Additional success stories are available on the public and private websites: http://www.health.gov.on.ca/en/pro/programs/transformation/care_stories.aspx http://www.hsimi.on.ca

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In summary…. Best Care is a Right,

not a Privilege

• Aim for improved patient outcomes

• Define best care

• Implement best care

• Encourage routine/ scheduled updating of best care standards

• Allow for creativity and innovation

• Use funding to incent adoption

• Goal is a sustainable financial system

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Contact Our Helpline with Your Questions!

Please email or direct your enquiries related to HSFR to the

ministry‟s health system funding Helpline:

HSF@ontario.ca

or call 416-327-8379

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Appendix

In 2008, four Vancouver hospitals enrolled in the Emergency Department

Improvement Initiative, through which hospitals receive additional payments for

treating patients within a specified time frame. The Vancouver Coastal Health

Authority affirms that the overall health care delivery has since improved.

Other provinces have the support from their health ministry to move ahead with

activity-based funding. For example, Alberta started to implement the new

model in their province in April 2010. New Brunswick also may be headed in this

direction, and Quebec has received recommendations from its former health

minister, Claude Castonguay, to adopt this approach as a way to sustain its health

care budget.

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Activity Based Funding Across Canada

Reference:

http://www.cadth.ca/products/environmental-scanning/health-technology-update/ht-update-12/activity-based-funding-models-in-canadian-hospitals11

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QBPs have been selected using an

evidence-based framework…

• 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 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?

• 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?

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QBP Clinical Handbooks

• Serve as a compendium of the evidence-based

rationale and clinical consensus guiding QBP

implementation

• Intended for a broad clinical and administrative

audience

o Do not mandate health care providers to

provide services in accordance with the

recommendations

o The recommendations included are not

intended to take the place of the professional

skill and judgment of health care providers

Key Principles

• Recommended practices should reflect the

best care possible, regardless of cost or barriers

to access

• Costing or pricing are out-of-scope

• Recommended practices, supporting evidence,

and policy applications will be reviewed and

updated at least every two years

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QBP Multi-Year Roll-out Plan

Year QBPs

FY2012/13 1. Primary hip replacement*

2. Primary knee replacement*

3. Cataract

4. Chronic kidney disease

FY2013/14

1. Chronic obstructive pulmonary disease*

2. Stroke*

3. Congestive heart failure*

4. Non-cardiac vascular

5. Chemotherapy

6. Gastrointestinal endoscopy

FY2014/15 Wave 1

1. Hip fracture*

2. Pneumonia

3. Tonsillectomy

4. Neonatal jaundice

Wave 2

5. Coronary artery disease

6. Aortic valve replacement

7. Cancer Surgery

8. Colposcopy

9. Knee Arthroscopy

10. Retinal Disease

*These QBPs have or are being further developed and expanded to address transition to post-acute phase in Year 3 (FY 2014/15).

QBP Specific indicator QBP Best

Practice Key provincial

indicators

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The approach to developing an Integrated QBP

Integrated Scorecard and indicators for acute care

QBPs will be adapted for the CCAC QBPs

Key evaluation

questions

Objectives of

QBP

Introduction of

QBP based

funding

Ministry - based on internal & external expert consultations and review literature QBP Clinical Expert Advisory Group

GUIDING PRINCIPLES:

Relevance

The integrated scorecard should measure the response of the system to introducing QBPs

Importance

To facilitate improvement, the indicators in the scorecard should be meaningful for the various

stakeholders (clinicians, administrators, LHINs, MOHLTC and patients)

Alignment

The integrated scorecard should align with other indicator-related initiatives where appropriate

Evidence

The indicators of the integrated scorecard need to be scientifically sound or at least measure what is

intended and accepted by the community (clinicians, administrators and/or policy-decision makers)

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Example: Integrated Scorecard approach

with associated key provincial indicators and

resulting (acute) stroke QBP indicators

CONTENT (QBP SPECIFIC INDICATORS AND RESULTS) DIRECTION (AREAS OF NEEDED INFORMATION IF RELEVANT FOR RESPECTIVE QBP)

Domain

(QBP Goal) What is being measured? Key provincial indicators QBP-specific indicators (Stroke)

Effectiveness

What are the outcomes of care received by patients? Do results vary across providers? Can any variance be explained by population characteristics? Is care provided without causing harm?

1. Proportion of QBPs that improved outcomes

2. Proportion of QBPs that reduced variation in outcome (risk-adjusted differences in outcome across hospitals)

3. Proportion of (relevant) QBPs that reduced rates of adverse events and infections

• Risk-adjusted 30-day mortality rate

Appropriateness

Is patient care being provided according to scientific knowledge and in a way that avoids overuse, underuse or misuse?

4. Proportion of QBPs that reduced variation in utilization (age-gender adjusted)

5. Proportion of (relevant) QBPs that saw a substitution from inpatient to outpatient/day surgery

6. Proportion of (relevant) QBPs that saw a substitution to less invasive procedures

7. Proportion of (relevant) QBPs that saw an increase in discharge dispositions into the community

8. Proportion of QBPs that showed a reduction in LOS

• Volume of QBP stroke cases

• Discharge destination following acute admission

• Percentage of patients receiving CT/MRI within 24 hrs.

• Distribution of severity among inpatient rehabilitation patients

• Percentage ALC relative to Total LOS

• Time from referral to home-care visit

Integration Are all parts of the health system organized, connected and work with another to provide high quality care?

9. 30-day readmissions rate

10. Improved access to appropriate care providers for diagnosis/ treatment/ follow-up care

• 30-day readmission rate

• Risk-adjusted 90-day readmissions

• 90-day readmission (revisits) rate of ED

• Time between discharge from an acute facility and admission to a rehab facility (7 days)

• Proportion of eligible ischemic patients arriving in ED within 3.5 hours receiving thrombolysis

• Post-discharge follow-up visit primary care

Efficiency

Does the system make best use of available resources to yield maximum benefit ensuring that the system is sustainable for the long term?

11. Proportion of QBPs with actual costs ≤ QBP price • QBPs with actual costs ≤ QBP price

Access Are those in need of care able to access services when needed?

12. Wait times for QBPs / for specific populations for QBP

13. Wait times for other procedures

14. Distance patients have to travel to receive the appropriate care related to the QBP

15. Proportion of providers with a significant change in resource intensity weights (RIW)

No recommendations from Stroke Clinical Expert Advisory Group

Patient Experience

- under development -

Is the patient/user at the center of the care delivery and is there respect for and involvement of patients’ values, preferences and expressed needs in the care they receive?

16. Patient involvement in treatment decisions (TBD)

17. Coordination of care (TBD)

18. Involvement of family (TBD)

Under Development

* Indicators in italics will be calculated for all QBPs (where relevant) even if they are not recommended by the Clinical Expert Advisory Groups as they relate to other ministry priorities and/or have been deemed

important to evaluate the impact of QBP implementation. QBP-specific Indicators in grey text are currently being calculated / developed in collaboration with ministry partners.

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Integrated QBP Scorecard: Future thinking:

Provincial level (public) dashboard (example)*

Effectiveness

Appropriateness

Integration

Value

Access

Very Good: 25 QBPs improved

their outcomes and variation in

outcomes and adverse events

across providers have been

reduced.

Fair: Half (15) of the QBPs

reduced their variation in

utilization while numerous

QBPs saw in increase towards

less invasive procedures.

Poor: Only 10% (3) of the

QBPs improved their

readmission rate.

Good: In almost half (10) of the

QBPs relevant hospitals the

actual costs were ≤ QBP price.

Almost all QBS showed a

decrease in LOS.

Fair: No increase in wait times

for QBPs

Hip replacement

Very good:

> Provincial/LHIN rate of revisions

within 365 days after primary

joint replacement

> Provincial/LHIN variation in Deep

Vein Thrombosis rate (hospital

level)

> Provincial/LHIN level Pulmonary

Wound Infection rate

Fair:

> Provincial/LHIN variation in

revisions (hospital level)

Provincial/LHIN level Deep Vein

Thrombosis rate

High level Provincial summary of impact QBPs Details by QBP

Goals QBP Summary Actual performance on indicators

(Provincial / LHIN level)

QBP of

Interest

Knee

Cataract

CKD

Hip

…

Patient

Experience

Fair: Patients increasingly experience

that care is provided seamlessly across

continuum of care but still wants to be

more involved in treatment decisions

*Format adopted from CCO’s Cancer System Quality Index

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Activity Based Funding is about Patients

Ambulatory

Nursing

Clinical Laboratories

Peri Operative Services

Health Disciplines

Pharmacy

Medical Imaging

Infrastructure