Quality-Based Procedures
Initial 2015/16 Allocation
Central East LHIN Board of Directors
June 24, 2015
System Finance and Performance Management
Overview
•
•
•
•
•
•
•
Health System Funding Reform (HSFR): Year 4
(2015/16)
Provincial Approach to Hospital Quality-Based
Procedures in Year 4
Central East LHIN Year 4 Initial Hospital QBP
Allocations
Central East LHIN System Considerations
Engagement of the HSFR Local Partnership
Recommendation
Next Steps
2
Health System Funding Reform (HSFR): Year 4 (2015/16)
•
•
•
Ontario’s HSFR Strategy is now in its 4th year
Both components of HSFR Strategy – the Health Based
Allocation Model (HBAM) and Quality-Based
Procedures (QBP) – have and continue to undergo
expected refinements
Funding for QBPs will be revised to take account of:
• population changes
• demographic changes
• expert advice in additional clinical areas:
• knee arthroscopy
• prostate cancer surgery (Cancer Care Ontario)
• colorectal cancer surgery (Cancer Care Ontario)
3
Provincial Approach to Hospital QBPs in Year 4 (2015/16)
•
•
Ministry of Health and Long-Term Care (MOHLTC) shared
preliminary details with LHINs in late March 2015, and
sought advice on options
MOHLTC signaled its readiness to shift from health service
provider-level to system-level allocations beginning in
Year 4:
• Historically, MOHLTC calculated and communicated
QBP allocations (cases/volumes and associated funding)
at the health service provider (HSP) level, and informed
the LHINs
• Going forward, MOHLTC will provide LHINs with one
QBP envelope for entire local health system, enabling
them to calculate and communicate allocations and
reallocations at the HSP level
4
Provincial Approach to Hospital QBPs in Year 4 (2015/16)
•
•
MOHLTC also signaled its readiness to provide initial,
additional modest financial resources for “growth”
LHINs, including Central East LHIN, experiencing
population increases
MOHLTC and LHINs agreed to:
• confirm 2014/15 QBP case/volume numbers,
associated Case Mix Index (CMI) acuity weight, and
associated funding as starting point for 2015/16
• distribute additional financial resources to “growth”
LHINs over and above 2014/15 levels
• confirm formal opening allocations in late June 2015
• support LHINs to make in-year reallocations relative
to the confirmed opening allocations later in 2015/16
5
Provincial Approach to Hospital QBPs in Year 4 (2015/16)
•
•
Cases/volumes and associated funding for non-MOHLTC
hospital QBPs are excluded from the initial allocation
details
Non-MOHLTC, hospital QBPs are those led by Cancer
Care Ontario (CCO)/Ontario Renal Network (ORN):
• Chronic Kidney Disease
• Chemotherapy – Systemic Treatment
• Gastro-Intestinal Endoscopy
• Associated funding for CCO/ORN-led QBPs in
2014/15 was ~$122.1M
6
Central East LHIN Year 4 Initial Hospital QBP Allocations
Type of
QBP
NonElective
Elective
Total
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
QBP
Congestive Heart Failure (CHF)
Chronic Obstructive Pulmonary Disease (COPD)
Hip Fracture
Neonatal Jaundice
Non Cardiac Vascular Aortic Aneurysm (AA)
Non Cardiac Vascular Lower Extremity Occlusive
Disease (LEOD)
Pneumonia
Stroke Hemorrhage
Stroke Ischemic or Unspecified
Stroke Transient Ischemic Attack (TIA)
Tonsillectomy
Unilateral Cataract Surgery
Unilateral Hip Replacement
Unilateral Knee Replacement
Bilateral Joint Replacement
2,413
2,584
1,479
690
92
2014/15
Weighted
Cases
3,665.79
3,631.91
3,441.37
305.01
450.36
$18,732,489
$19,437,918
$18,191,228
$1,656,890
$2,405,879
139
263.58
$1,290,403
1,576
136
1,205
252
1,524
14,181
930
2,257
1
2,224.07
376.34
2,635.54
175.40
425.06
2,002.90
1,513.71
3,336.38
2.53
$10,955,697
$2,051,818
$13,099,597
$967,005
$2,049,473
$7,076,652
$7,892,848
$17,307,947
$13,222
29,459
24,449.96
$123,129,064
2014/15
Cases
2014/15
Funding
7
Central East LHIN Year 4 Initial Hospital QBP Allocations
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•
In the first week of June, MOHLTC requested Central
East LHIN confirmation of initial allocation ($261,023)
for incremental “growth” funding
Based on a risk assessment, and input from affected
HSPs, COPD has been identified as the sole QBP to be
targeted:
• 34 additional cases
• 48.59 additional weighted cases, with average CMI
value of 1.37
• five of six HSPs to receive allocation
• $260,071 allocated
8
Central East LHIN System Considerations
•
•
Early sharing by MOHLTC of QBP allocation details
presents a range of opportunities to LHINs and HSPs
Helps LHINs to:
• engage HSPs
• manage resources at the system level
• use resources sustainably, as investments in the system
• recognize and advance high performance and high
quality
• develop and implement risk mitigation strategies and
tactics inside the LHIN and beyond
• assess, test, and adjust historical resource distribution
patterns
9
Central East LHIN System Considerations
•
Helps HSPs to:
• meet service need
• advance quality and appropriateness of care, including in
relation to QBP clinical handbook recommendations
• engage in regional planning, to ensure delivery of QBP
volumes are aligned with other program and service
needs
• manage undesirable cost and service variances, including
by addressing readmissions and lengths of stay, shifting
services to the community, and standardizing purchases
• engage clinical expertise, including for long-term
capacity planning work, resource planning, and
allocation decisions
10
Central East LHIN System Considerations
•
Helps HSPs to:
• develop locally appropriate models of care and promote
best practices
• manage risks, including in-year pressures
• drive the collection and analysis of quality metrics,
trending and other performance data
• engage in volume planning, including through efforts to
review the incidence of disease and factors influencing
disease in the communities they serve
• engage in regional innovation and implementation,
including through appropriate central intake and
assessment processes
11
Central East LHIN System Considerations
•
Early sharing by MOHLTC of QBP allocation details also
supports the development of a locally appropriate
allocation methodology, one that can take account of a
range of variances, including:
• Utilization rates (Slide #13)
• “Unfunded” QBP volumes (Slides #14-15)
• Financial capacity to provide services (Slide #15)
• Implementation of QBP clinical handbooks
(Slides #16-17)
• Readmission rates
• CMI
• Quality
12
Central East LHIN System Considerations
Age and Sex Standardized Utilization Rates per 100,000 Population by QBP
and LHIN of Service, 2013/14
QBP
CELHIN
Rate
Minimum
Among
14 LHINs
Maximum
Among
14 LHINs
Ontario
Average
Percentage by which
CELHIN Rate is Above
or Below Provincial
Average
NON-ELECTIVE QBPs
CHF
162.31
161.30
251.86
174.47
-6.97%
COPD
170.66
105.98
339.94
176.28
-3.19%
Hip Fracture
91.26
77.09
107.92
90.91
0.38%
Jaundice
50.92
22.88
61.45
49.34
3.20%
Non Cardiac Vascular AA
8.96
7.30
15.21
9.82
-8.76%
Non Cardiac Vascular LEOD
10.52
8.96
19.80
11.89
-11.52%
Pneumonia
106.17
96.47
235.49
116.29
-8.70%
Stroke Hemorrhage
10.73
9.45
15.75
11.45
-6.29%
Stroke Ischemic or Unspecified
83.16
70.05
105.25
84.64
-1.75%
Stroke TIA
17.38
13.15
49.74
21.30
-18.40%
ELECTIVE QBPs
Tonsillectomy
89.88
60.76
129.56
86.84
3.50%
Unilateral Cataract
889.69
527.43
1150.77
878.72
1.25%
Unilateral Hip
87.27
64.59
119.97
95.07
-8.20%
Unilateral Knee
167.67
134.94
208.59
169.98
-1.36%
Bilateral Hip/Knee Replacement (1)
3.01
0.31
9.23
3.72
-19.09%
Unilateral Hip Replacement (1)
89.01
63.01
123.15
95.07
-6.37%
Unilateral Knee Replacement (1)
170.29
135.97
217.37
169.98
0.18%
Note: (1) Age, sex and arthritis standardized utilization rates for Hip and Knee Joint Replacements per 100,000 population by
patient LHIN, 2013/14
13
Central East LHIN System Considerations
“Unfunded” QBPs (As of February 2014/15)
Type of
QBP
#
1
2
3
4
5
Non6
Elective
7
8
9
10
11
12
13
Elective
14
15
QBP
CHF
COPD
Hip Fracture
Neonatal Jaundice
Non Cardiac Vascular AA
Non Cardiac Vascular LEOD
Pneumonia
Stroke Hemorrhage
Stroke Ischemic or Unspecified
Stroke TIA
Sub-total
Tonsillectomy
Unilateral Cataract Surgery
Unilateral Hip Replacement
Unilateral Knee Replacement
Bilateral Joint Replacement
Sub-total
Total
2014/15 2014/15
2014/15
Funded
Cases
Variance in
Cases Projected
Cases
2,413
2,530
+117
2,584
2,855
+271
1,479
1,335
-144
690
639
-51
92
87
-5
139
171
+32
1,576
1,864
+288
136
141
+5
1,205
1,259
+54
252
267
+15
1,524
14,181
930
2,257
1
1,517
15,821
1,046
2,594
TBC
-7
+1,640
+116
+337
TBC
29,459
32,126
+2,667
Funding Impact
(Over/Under)
$895,022
$2,040,262
($1,534,432)
($113,291)
($125,136)
$311,125
$1,956,403
$73,779
$554,752
$57,560
$4,116,043
($8,789)
$818,259
$983,711
$2,586,185
TBC
$4,379,366
$8,495,410
14
Central East LHIN System Considerations
“Unfunded” QBPs by HSP
HSP
Incremental Expenditures compared to
LHIN- Approved QBP Funding (Over/Under)
as of February 2015
2014/15
Year-end Total
Margin
(Consolidated)
(Source: Q4 SRI)
Non-Elective
QBPs
Elective
QBPs*
Total
$1,555,818
$1,006,541
$2,562,359
$31,167,733
Northumberland Hills Hospital
$674,897
$44,193
$719,090
$1,357,653
Peterborough Regional Health
Centre
$134,508
$1,344,919
$1,479,427
$40,856,910
Ross Memorial Hospital
$531,271
$109,383
$640,654
$1,839,217
$2,304,953
$204,960
$2,509,913
$17,385,613
$794,310
$1,686,378
$892,068
$3,788,489
$4,407,137
$4,396,374
$8,803,511
$96,395,615
Lakeridge Health
Rouge Valley Health System
The Scarborough Hospital
TOTAL
* Excludes QBPs for Inpatient Rehab for Hips and Knees
15
Central East LHIN System Considerations
Self-Reported Clinical Pathway Implementation (MOHLTC QBPs)
Knee Arthroscopy
Colposcopy
Retinal Disease
1
3
5
5
5
1
1
1
1
1
6
6
6
6
6
6
4
1
0
0
0
1
6
1
6
6
6
6
6
6
2
2
2
2
1
6
6
1
2
1
6
6
6
1
1
3
4
4
4
4
4
3
3
3
3
3
4
4
4
4
4
4
4
2
2
2
5
4
1
5
4
4
6
6
1
2
2
2
2
4
1
4
2
1
6
5
5
4
4
4
4
4
3
4
4
2
2
4
3
2
3
2
7
4
Coronary Artery
Disease
Aortic Valve
Replacement
Neonatal Jaundice
1
Aortic Aneurysm
1
Congestive Heart
Failure
Lower Extremity
Occlusive Disease
Tonsillectomy
Outpatient Rehab Hip
Replacement
Outpatient Rehab
Knee Replacement
Chronic Obstructive
Pulmonary Disease
Stroke Ischemic/Unspecified
Pneumonia
2
Hip Fracture
1
Year 4
(2015/16)
Stroke - TIA
1
Year 3
(2014/15)
Stroke - Hemorrhage
1
Year 2
(2013/14)
Cataract
HSP
Primary Unilateral Hip
Replacement
Primary Unilateral
Knee Replacement
Inpatient Rehab Hip
Replacement
Inpatient Rehab Knee
Replacement
Year 1
(2012/13)
1
6
4
0
Not started yet
4
Complete
1
Started - Gap analysis complete
5
Re-evaluation of implementation and outcomes
2
In progress - Gap analysis complete and implementation plan
defined
6
Not a priority
3
Evaluation of outcomes underway
Not applicable
16
Central East LHIN System Considerations
Self-Reported Clinical Pathway Implementation (CCO QBPs)
3
4
1
6
6
5
Re-evaluation of implementation and outcomes
2
4
4
0
6
6
6
Not a priority
3
5
4
3
1
1
4
4
4
4
1
1
5
6
4
4
1
1
6
4
4
4
2
2
Colorectal Surgery
1
HSP
Prostate Surgery
GI ─ Endoscopy
Year 4
(2015/16)
Chemotherapy –
Systemic Treatment
Year 2
(2013/14)
Chronic Kidney Disease
Year 1
(2012/
13)
0
Not started yet
1
Started – Gap analysis complete
2
In progress – Gap analysis complete and implementation plan defined
3
Evaluation of outcomes underway
4
Complete
Not applicable
17
Engagement of the HSFR Local Partnership
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•
•
•
The development of a locally appropriate QBP allocation
methodology is being undertaken under the auspices of the HSFR
Local Partnership (LP)
LP’s purpose is twofold:
• inform, coordinate, and advance HSFR implementation and
change management at the local level
• give appropriate voice to Central East LHIN issues, concerns,
and perspectives at the provincial level
LP is an advisory body to the Central East LHIN
LP has senior representation from community and hospital HSPs
and the Central East LHIN, and comprises clinical and program
leaders, financial leaders, and experts in quality and performance
improvement
18
Engagement of the HSFR Local Partnership
•
•
•
•
•
LP is working in direct alignment with the Vice President and
Chief Nursing Executive (VP/CNE) Steering Committee and the
Hospital CCAC Financial Leadership Group (HCFLG) to secure
their expert advice
At its May meeting, the LP accepted the HCFLG’s April motion
regarding in-year QBP re-allocations and its commitment “to
[develop] within the next 2 to 3 months a methodology or
framework for in-year reallocations at the end of Q2”
HCFLG has moved vigorously in May and June to act on its
motion
It is focused on meeting the expectation that it advise the LP by
September
LP’s QBP re-allocation recommendations will be made to the
Central East LHIN Senior Team later in September, and the Board
thereafter
19
Engagement of the HSFR Local Partnership
•
•
HCFLG has arrived at a consensus framework, determined the scope of its
work, defined its data requirements, and agreed key guiding principles
Key factors for consideration and discussion include:
• shifting cases among HSPs (“netting effect”)
• HSP overachievement of cases
• allocation of case weight (and not just cases/volumes)
• reallocation at HSP-specific price vs. provincial price
• impact on smaller hospitals
• one-time adjustments vs. permanent adjustments
• allocating cases in a way that:
• consciously favours lower cost without compromising quality
• takes explicit account of the extent to which each eligible hospital
has implemented QBP-specific clinical best practices
• recognizes and rewards improved performance
• recognizes the extent of integration between specific hospitals and
their wider community
• attempts to lessen relatively excessive service provision at the per
capita level
20
Motions/Questions/Discussion
21
Next Steps
•
•
•
Review confirmed MOHLTC- and CCO/ORN-led QBP
allocations, and HBAM allocations, expected in late June
Collaborate with HSPs to assess and mitigate risks arising
from confirmed 2015/16 allocations
Continue collaboration through the LP with the VP/CNE
Steering Committee and HCFLG to secure advice on a
QBP reallocation methodology
22