Table 1 Key elements of each programme in Quebec and Ontario
From: Hospital funding reforms in Canada: a narrative review of Ontario and Quebec strategies
Quebec | Access to Surgery programme (ASP) | Colorectal cancer (CRC) screening programme | Radio-oncology programme | Computed tomography (CT) scans and magnetic resonance imaging (MRI) programmes |
|---|---|---|---|---|
Year | 2004 | 2011 | 2015 | 2016 |
Context | Response to the 2003 Accord on Health Care Renewal—Addressing wait times issues | 2011, in response to the National Public Health Institute of Quebec (INSPQ) report on practice variations in colonoscopies |  |  |
ABF, P4P, or hybrid | ABF | P4P | ABF | ABF |
Policy goals | Reduce wait lists and wait times | Improve performance, quality and access for CRC treatment and detect and treat the cancer before symptoms appeared | Improve efficiency | Improve access and reduce wait times |
Implementation timeline | Modified in 2011 | First introduced in eight pilot sites before being extended to all healthcare organizations in 2016 | In 2016, the Ministry brought some modifications to the programme after hearing hospitals’ concerns. Modifications:  Pricing was adjusted to reflect the first quartile of the average provincial costs (aiming at efficiency), adjusted by 2%. The 2% was a subjective measure. It also now includes salaries, benefits and social charges as well as maintenance and furniture costs  Changes to the way volumes were calculated. The number of treatments to measure the volume of care was substituted by the number of hours of treatment | Modifications in 2018:  Theoretical capacity was used for MRIs to set the minimal and optimal number of exams to be conducted in each work shift  Actual operational hours and production objectives used to determine how many exams should be conducted during the day, evening and night shifts. Opening hours take into account weekends, holidays and maintenance |
Implementation strategies | The additional funding associated with the ASP was given to regional health authorities, who then had to redistribute it to hospitals across their territories No funding limit given on the amount the hospitals could receive from the ASP No quality indicators were included | The CRC screening programme was implemented through the adoption of clinical guidelines and associated financial incentives The clinical guideline was developed in collaboration with the Ministry of Health and Social Services and their cancer branch. It stipulated that a faecal occult blood test (FOBT) should first be administered and that a colonoscopy should only be prescribed in the case of a positive FOBT Funding was allocated upon the achievement of volume and other performance targets There is no funding limit associated with this programme | Funding given to the hospital according to the volume of activity accomplished in a year | Each treatment price corresponds to the average provincial cost for the year 2014–2015, indexed each year. If a hospital has a negative volume compared to the baseline for one type of exam (CT or MRI), it will only receive funding if the global result is positive. If the additional total volume achieved for one exam (CT or MRI) does not compensate for the negative volume of the other (global result negative), no funding is allocated |
Funding model characteristics | Additional funding was allocated to the providers upon achieving additional surgeries using the volume of 2002–2003 as the baseline | Performance criteria include:  Targeted volume accomplished based on the number of colonoscopies achieved in 2010–2011 (and updated in 2014 to be the number achieved in 2014–2015)  The production of at least 12 colonoscopies per room per day Funding was also conditional on the provider following the established guidelines and the quality standards, including as it relates to complications Additional funding is allocated for every unit of colonoscopy performed if all conditions are met. Pricing for each unit represents 100% of the average cost of a colonoscopy. The pricing of the treatment is based on the average total cost of human resources, supplies, sterilization, laboratory services and maintenance | It is a prospective payment with a holdback and a reconciliation process. An expected volume is calculated at the beginning of the year, and 90% of the funding is given in advance based on the unit price | An ABF model was put in place to allow healthcare providers access to more funding based on exceeding volumes of care compared to the ones achieved the previous year. The model was for direct operating costs only and did not include depreciation costs |
Unintended consequences | Since only surgeries performed in the operating room (OR) were part of the programme, hospitals began using the OR for surgeries that did not require it. Tied to this issue, the categories were not specific enough to adequately reflect the costs of all the treatments that comprised them In 2011, the programme was modified to increase the number of categories from five to 16 and to include surgeries conducted outside of the OR as well. Although increasing the number of categories of surgeries improved the precision of the funding in relation to the operational costs, experts still considered the categories to be insufficiently precise. Additional measures were later implemented, including an information system, a definition of responsibilities regarding access to surgeries and a review process for the programme | Â | Â | Â |
Results | Results of the ASP show both an increase in volume and a reduction in wait times in most categories. From 2002–2003 to 2012–2013, there was a 20% increase in volumes for all surgeries. With the introduction of new categories of surgeries, we can see changes for the period 2008–2009 for the different types of surgeries. There were no changes in mortality. Results show a wide variation in the percentage change in wait times in days, although this may be due to reporting in percentages rather than actual numbers The evolution of volumes was more volatile for hospitals outside of urban centres. An increase in volumes in those hospitals occurred until 2006, but they then dropped to lower levels than before the introduction of ASP. No information could be found to explain those results | The clinical standardization included in the programme contributed to decreasing the length of stay for patients in the hospital to an average of 2.2 days, as well as increasing the use of less invasive techniques. No effect was noted on the readmission or mortality rates. The financial incentive in itself was only found to decrease the hospitalization rate. Overall, from 2009–2010 to 2011–2012, the volume of colonoscopies increased by 4600 units each year, though this could be in part due to a temporary catch-up process of volumes. From 2010–2011 to 2012–2013, average wait times were reduced by 24 days | Results of the programme show an increase in efficiency. Spending increased due to a growth in volume, but efficiency gains reduced the cost per treatment. An increase in the hours of treatment declared after the modifications introduced in 2016 was also noted, which could be linked to an increase in quality since more time per patient allows for more precise diagnostics and more patient-centred treatments | No evaluation results were found on the effect of this programme |
Ontario | Wait Time Strategy (WTS) | Emergency Department (ED) WTS | Quality-based procedures (QBPs) | Bundled care |
|---|---|---|---|---|
Year | 2004 | 2008 | 2012 | 2015 |
Context | 2003 First Ministers' healthcare agreements | 2006 Ministry commissioned a report to review the problem of overcrowding | After the 2010 Excellent Care for All Act, Ontario introduced PBF programmes under the system-wide Ontario Health System Funding Reform (HSFR) | Under the system-wide HSFR |
ABF, P4P, or hybrid | ABF | P4P | Hybrid | ABF |
Policy goals | Increase volume of services to reduce wait times in five key areas: cancer surgeries, cardiac revascularization procedures, cataract surgeries, hip and knee total joint replacement surgeries, and medical imaging [53, 55] | Reduce wait times, length of stay and crowding in the ED | Promote best practices | Strengthen home and community care |
Implementation timeline | 2004 | The programme broadened through three waves: the first wave included 23 hospitals, the second 46 and the third 71 | In 2012–2013, the QBP tariff corresponded to the 40th percentile of the 3-year average cost of treatment, excluding physician fees, in participating institutions. From 2013 onwards, it was changed to provincial average using the facility case mix index (CMI) as the price times the weighted cases for the volumes. A reconciliation process was also introduced | 2015 |
Implementation strategies | CEOs and clinical leaders had to sign a purchase service agreement to receive funding. This agreement specified the responsibility of the hospitals in the maintenance of the baseline cases and the additional cases, the management of all wait times and the provision of wait times and quality information Accountability to the population increased with the use of a single wait time information system as well as a public forum on wait times Critical care improvement coaching available to help providers improve efficiency in service delivery Additional funding allocated for innovations and employee training Single rating scale introduced to help providers across Ontario determine the urgency of a patient’s condition Systemic savings made by purchasing CT and MRI equipment in bulk |  | Combination of pathways, analytical decisions and evidence to determine best practice and best cost P4P system that appeals to the hospitals’ aversion to loss, to encourage achievement of targets | It resembles the QBP funding programme, but it covers wider pathways that start when the decision for treatment is made and end after rehabilitation The pathway includes acute and post-acute care; partnerships needed to be created between providers |
Funding model characteristics | ABF model to encourage a higher volume of care. It allocates additional funding to providers when they achieve more services than the baseline. Hospitals asked to volunteer the number of additional cases they could treat and to estimate their production cost. The final price per case set by a committee constituted of members from hospitals and the Ministry of Health and Long-Term Care (MOHLTC). It reflected full operational costs of the unit to ensure minimal impact of the increased volumes on other activities |  | Payment given up front to the providers but taken away if targets were not achieved. Performance targets changed depending on the wave, but they were always related to volume of care or patients’ length of stay in the ED. If the target was reached, providers were offered a fixed amount, except in the third wave, where a variable funding incentive was introduced [54, 56]. There was no competitive component between providers to access the funding Volume-based payments for QBPs represent 30% of funding | QBP prices were used to fund the part of the pathway that was the same as the QBP A price for the non-acute care included in the pathway was added to the QBP price. This non-acute care price is based on probabilities of different costs depending on the site where the care occurs |
Unintended consequences | Even though overall results show a decrease in wait times for cancer surgeries, that was only the case for eight cancer groups. The other 11 groups showed an increased wait time average | Â | Â | Â |
Results | Results of the programme show an increase in volumes. From August 2005 to April 2007, wait times also decreased in all areas, but targeted medically acceptable levels were only met in cancer and cardiac surgeries | Overall results of the programme indicate modest improvements. In the first year of implementation, three out of 23 hospitals participating in the programme met all targets. All waves considered, the program was associated with a reduction in overall wait times for admitted and non-admitted patients and in the percentage of patients leaving before being seen by a physician | Results of QBP implementation are varied depending on the QBP analysed. For example, the effects of the hip and knee arthroplasties were analysed at the London Health Sciences Centre, where patients were involved in the care process. Preadmission was intensified to better identify patients who needed medicine or anaesthesia consultations and plan their care accordingly. Strategies for patient education and early mobilization were also implemented to reduce hospital-acquired complications and readmissions. Results show a reduction in the length of stay of 1.7Â days for hip and 1.8Â days for knee arthroplasties, as well as an increase in overall patient satisfaction | Each programme was composed of a specific partnership between acute and post-acute care organizations, who were free to determine their clinical focus and set of services for the pathway. This made for considerable heterogeneity between the different programmes |