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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
4
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
5
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]
6
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
7
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
8
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)
9
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
10
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]
11
Health System Funding Reform
• Health-Based Allocation Model
• Quality-Based Procedures
(focus area of today‟s presentation)
12
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)
13
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
19
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
20
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.
21
One example of data challenge:
22
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
23
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
24
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
26
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:
or call 416-327-8379
29
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.
30
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
31
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?
32
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
34
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)
35
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.
36
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
37
Activity Based Funding is about Patients
Ambulatory
Nursing
Clinical Laboratories
Peri Operative Services
Health Disciplines
Pharmacy
Medical Imaging
Infrastructure