Special Series: Quality Care Symposium
Perspective
International Efforts in Health Care Reform: Systemic Treatment Funding Model Reform in Ontario
Cancer Care Ontario, Toronto; and Credit Valley Hospital, Mississauga, Ontario, Canada
Cancer Care Ontario (CCO) is the government agency responsible for planning cancer services in Ontario, using a collaborative administrative-clinical approach to improving system performance. Annual reports on the quality of Ontario’s cancer care, the Cancer System Quality Index (CSQI) have been publically published since 2005.1 Systemic treatment (chemotherapy and biotherapy) in Ontario is delivered in a regionally organized network of 77 facilities that provide four graduated levels of service.2 In fiscal 2012-2013, there were 45,000 new patients seen for systemic treatment in Ontario. Health care is universally funded by a single public payer, the Ministry of Health and Long Term Care, and currently flows from multiple, un-aligned budgets that support clinical and systemic treatment suite operations, drug procurement, and physician remuneration. In addition, the support for operations is through a fixed amount of per-case funding, triggered at initial consultation to support the lifetime of care for the patient, regardless of case complexity. Finally, there is a long history of guideline development and disease pathway mapping by provincial disease site expert groups, although funding is not currently aligned with concordance to evidence-informed practice, patient outcomes, or quality of care. In this context came opportunity. Ontario is undergoing health system funding reform, which will transform the funding of selected clinical services to a patient-based approach anchored in evidence-based practice and quality of care. In support of this approach, a new systemic treatment funding model (STFM) was developed and implemented on April 1, 2014.
Model Development The scope of the new STFM includes direct patient care activities associated with ambulatory systemic treatment in the 77 designated provincial facilities in Ontario. Inpatient activities, laboratory and imaging services, and physician remuneration are currently not in the scope of model implementation; however, they may be considered for future phases. The model has been developed using a collaborative multistakeholder approach. The governing Working Group is composed of multidisciplinary clinical, administrative, and financial experts, representing all 14 health care regions of the province. The Working Group is supported by subgroups, constituted to develop detailed recommendations for a number of specific 190
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OF
ONCOLOGY PRACTICE
•
complex issues. Inputs into model development have included CCO clinical data holdings, provincial claims data, provincial guideline documents, and disease pathway maps. A comprehensive strategy for Knowledge Translation and Exchange is being used to engage internal and external stakeholders on a regular basis.
Model Description The new model will transition funding for systemic treatment from the current combination of lifetime per-case and hospital base remuneration to an episode-based approach where funding will flow for clinically relevant bundles of care that mirror patient care pathways (Figure 1). The episodes that make up the bundles of care are defined from a patient, not provider, perspective to allow for innovations in the model of care that could improve efficiency, while maintaining quality of care. The core funded care bundles include patient consultation, treatment with adjuvant and/or curative intent, and treatment with palliative intent. The consultation bundle contains all patient-related activities that should occur from the time of patient referral to the start of treatment or the decision not to treat. Evidence-informed practice was determined by a survey of all treatment facilities, clinical data, and claims data, then subsequently validated by a nursing and pharmacy expert group and priced according to a detailed microcosting process, using average provincial rates. The adjuvant-curative treatment episode is usually clinically well defined and time limited. It will be funded as a bundle that includes the full course of treatment for regimens used with this intent, for both solid tumors and hematological malignancies. The list of evidence-informed treatment options has been determined by provincial disease site group experts, supported by an analysis of all chemotherapy delivered in Ontario by disease site and intent in the 2-year period from 2011 to 2013. Experts also defined the components of each regimen and advised on the post-treatment well patient follow-up strategy for each clinical scenario (Figure 2). Funding for these bundles will be aligned with the current procurement process for expensive chemotherapy drugs through the Provincial Drug Reimbursement Program (PDRP). The full course of treatment for each regimen has been priced, and those regimens of a similar price have been “banded” to reduce complexity of implementa-
V O L . 10, I S S U E 3
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at MICHIGAN STATE UNIVERSITY on March 9, 2015 from 35.8.191.249 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
By Leonard Kaizer, MD, Vicky Simanovski, Irene Blais, CGA, MBA, Carlin Lalonde, MBA, and William K. Evans, MD
Systemic Treatment Funding Model Reform in Ontario
Current State
Future State
Consultation
Carve-out
Unmodeled
Hospital base funding
Palliative therapy
Active patients not on treatment
Figure 1. Transition from the current funding structure to an episode-based funding model. Lifetime per-case funding refers to funding provided by CCO to support the full lifetime of activities related to systemic treatment. Hospital base funding refers to the hospital’s base funding envelope related to systemic treatment. Carve-out refers to the recovery of all funding related to systemic treatment in the current state, for redistribution according to the future state.
tion. A final four-band model results in the same reimbursement profile compared to the reimbursement of each regimen according to its individual price both for the whole province and for individual facilities.
Disease Site Groups
Data
Adjuvant/Curative Treatment Bundle Based on a course of treatment Includes: No. of cycles No of chemotherapy suite visits No. of ambulatory clinic visits Nursing time Pharmacy time Non-PDRP funded drugs Supportive drugs Supplies Follow-up visits during and after treatment
Multiple Price Points
Model Implementation and Next Steps
Figure 2. Inputs and components of a bundle of care: patients receiving chemotherapy with adjuvant or curative intent. Disease Site Groups refers to experts who author guideline documents under the direction of the CCO Program in Evidence Based Care. Data refers to information extracted from the CCO database describing treatments delivered to patients in 20112012 and 2012-13. Nursing time and Pharmacy time were defined by nursing and pharmacy working groups who identified the workload associated with each treatment regimen and each phase of care. Non-PDRP funded drugs refers to drugs that are not funded by the CCO Provincial Drug Reimbursement Program.
Copyright © 2014 by American Society of Clinical Oncology
The care path for patients treated with palliative intent is much more variable, as it depends on response to treatment and toxicity. It can include multiple lines of parenteral or oral therapy and periods of time when patients receive complex supportive care during breaks from active treatment or at the end of life. For this reason, the approach taken for this bundle will be to fund the care provided in monthly time-based units. The same general approach to defining evidence-informed practice and quality of care has been taken, and once again four bands of varying complexity and monthly price have been established, with the base band price defined by a month of supportive care off active treatment. In addition, funding will also flow (Figure 1) to support the care of untreated patients, for a limited number of unbundled services funded in a price-times-volume approach, and for facility infrastructure to support direct patient care (clinical directors, managers, staff educators, etc). A number of special projects have strengthened the development of the STFM. The CCO Psychosocial Oncology program has developed a framework to define patient supports by disease site for each of the bundles of care. Among others, a data collection subgroup has defined data quality standards, and a clinical trials subgroup has been integral to considering the potential impact of the new model on clinical research.
M A Y 2014
On implementation, an impact analysis and a mitigation strategy will support system stability during a multiyear transition from the old funding methodology, so that individual facilities can absorb clinical and financial changes in a graduated fashion. Facilities have been provided with regular Knowledge Translation and Exchange packages over the past year, which summarize clinical activity analyzed by bundles of care. These analyses include comparisons to overall provincial performance benchmarks and have enabled both improvements in data quality and given administrators and providers a head start on aligning clinical practice to the new model. •
jop.ascopubs.org
191
Information downloaded from jop.ascopubs.org and provided by at MICHIGAN STATE UNIVERSITY on March 9, 2015 from 35.8.191.249 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Lifetime per-case funding +
Adjuvant/ neo-adjuvant, or curative therapy
Kaizer et al
Discussion Although many funding approaches for cancer care exist, each with strengths and weaknesses,3 the transition from a largely capitation payment system in Ontario to an episode of care– based funding model represents an opportunity to explicitly align remuneration with evidence-informed practice, a key component of a high-quality cancer system.4 Funding for episodes of care should also promote innovation in the model of care and potential efficiencies,5and accountability through an ongoing evaluation of performance and outcome will be critical to ensure that the quality of each bundle of care is maintained. Although theoretically appealing,6 the real-world experience with episode-based funding for cancer care and other chronic diseases has been limited, and evaluation of pilot programs has revealed many challenges in implementation.7 The approach taken here in Ontario is step-wise, given the jurisdiction-level scale of 13.5 million citizens in a publically funded health care system. The initial framework involves the core episodes of systemic treatment in the ambulatory setting. Once implemented and evaluated, the model will be extended to include an
increasing number of the components of care for patients who require systemic treatment in Ontario. Physician remuneration is not within the scope of the initial implementation. The majority of physician funding currently flows through a blended model of base salary and fee for service. Oncologists are jointly accountable with administrators for access and quality of care, with a strong culture of public reporting and a commitment to collaborative performance improvement. However, the long-term goal of better aligning physician funding to the defined episodes of care will only strengthen this partnership. Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. Author Contributions Conception and design: All authors Collection and assembly of data: All authors Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Leonard Kaizer, MD, Cancer Care Ontario, 620 University Ave, Toronto, Ontario, Canada M5G 2L7; e-mail: [email protected]. Acknowledgment Presented in part at the ASCO Quality Care Symposium, San Diego, CA, November 1-2, 2013.
DOI: 10.1200/JOP.2014.001389
References 1. Cancer Quality Council of Ontario: Cancer System Quality Index (CSQI) 2013. http://www.csqi.on.ca 2. Vandenberg T, Coakley, Nayler J, et al: A framework for the organization and delivery of systemic treatment. Curr Oncol 16:4-15, 2009 3. Deloitte: Episode Based Payments: Perspectives for Consideration. http:// www.deloitte.com/assets/dcom-unitedstates/local%20assets/documents/ us_chs_episodebasedpayment_perspectivesforconsideration_091609.pdf
192
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OF
ONCOLOGY PRACTICE
•
4. Ganz PA, Levit LA: Charting a new course for the delivery of high-quality cancer care. J Clin Oncol 31:4485-4487, 2013 5. Cutler DM, Ghosh K: The potential for cost savings through bundled episode payments. N Engl J Med 366:1075-1077, 2012 6. Bach PB, Mirkin JN, Luke JJ: Episode-based payment for cancer care: A proposed pilot for Medicare. Health Affairs 30:500-509, 2011 7. Hussey PS, Ridgely MS, Rosenthal MB: The PROMETHEUS bundled payment experiment: Slow start shows problems in implementing new payment models. Health Aff 30:2116-2124, 2011
V O L . 10, I S S U E 3
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at MICHIGAN STATE UNIVERSITY on March 9, 2015 from 35.8.191.249 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
An evaluation framework specific to the STFM and incremental to the annual CSQI report has also been developed, with a series of indicators to measure the effect of funding model change on a scorecard of quality dimensions. An STFM management committee will be in place to address implementation issues as they are identified, and the Working Group will continue to refine the model, expand its scope (laboratory/imaging services, inpatient episodes, etc), and better align it with physician remuneration.
Perspective
International Efforts in Health Care Reform: Systemic Treatment Funding Model Reform in Ontario
Cancer Care Ontario, Toronto; and Credit Valley Hospital, Mississauga, Ontario, Canada
Cancer Care Ontario (CCO) is the government agency responsible for planning cancer services in Ontario, using a collaborative administrative-clinical approach to improving system performance. Annual reports on the quality of Ontario’s cancer care, the Cancer System Quality Index (CSQI) have been publically published since 2005.1 Systemic treatment (chemotherapy and biotherapy) in Ontario is delivered in a regionally organized network of 77 facilities that provide four graduated levels of service.2 In fiscal 2012-2013, there were 45,000 new patients seen for systemic treatment in Ontario. Health care is universally funded by a single public payer, the Ministry of Health and Long Term Care, and currently flows from multiple, un-aligned budgets that support clinical and systemic treatment suite operations, drug procurement, and physician remuneration. In addition, the support for operations is through a fixed amount of per-case funding, triggered at initial consultation to support the lifetime of care for the patient, regardless of case complexity. Finally, there is a long history of guideline development and disease pathway mapping by provincial disease site expert groups, although funding is not currently aligned with concordance to evidence-informed practice, patient outcomes, or quality of care. In this context came opportunity. Ontario is undergoing health system funding reform, which will transform the funding of selected clinical services to a patient-based approach anchored in evidence-based practice and quality of care. In support of this approach, a new systemic treatment funding model (STFM) was developed and implemented on April 1, 2014.
Model Development The scope of the new STFM includes direct patient care activities associated with ambulatory systemic treatment in the 77 designated provincial facilities in Ontario. Inpatient activities, laboratory and imaging services, and physician remuneration are currently not in the scope of model implementation; however, they may be considered for future phases. The model has been developed using a collaborative multistakeholder approach. The governing Working Group is composed of multidisciplinary clinical, administrative, and financial experts, representing all 14 health care regions of the province. The Working Group is supported by subgroups, constituted to develop detailed recommendations for a number of specific 190
JOURNAL
OF
ONCOLOGY PRACTICE
•
complex issues. Inputs into model development have included CCO clinical data holdings, provincial claims data, provincial guideline documents, and disease pathway maps. A comprehensive strategy for Knowledge Translation and Exchange is being used to engage internal and external stakeholders on a regular basis.
Model Description The new model will transition funding for systemic treatment from the current combination of lifetime per-case and hospital base remuneration to an episode-based approach where funding will flow for clinically relevant bundles of care that mirror patient care pathways (Figure 1). The episodes that make up the bundles of care are defined from a patient, not provider, perspective to allow for innovations in the model of care that could improve efficiency, while maintaining quality of care. The core funded care bundles include patient consultation, treatment with adjuvant and/or curative intent, and treatment with palliative intent. The consultation bundle contains all patient-related activities that should occur from the time of patient referral to the start of treatment or the decision not to treat. Evidence-informed practice was determined by a survey of all treatment facilities, clinical data, and claims data, then subsequently validated by a nursing and pharmacy expert group and priced according to a detailed microcosting process, using average provincial rates. The adjuvant-curative treatment episode is usually clinically well defined and time limited. It will be funded as a bundle that includes the full course of treatment for regimens used with this intent, for both solid tumors and hematological malignancies. The list of evidence-informed treatment options has been determined by provincial disease site group experts, supported by an analysis of all chemotherapy delivered in Ontario by disease site and intent in the 2-year period from 2011 to 2013. Experts also defined the components of each regimen and advised on the post-treatment well patient follow-up strategy for each clinical scenario (Figure 2). Funding for these bundles will be aligned with the current procurement process for expensive chemotherapy drugs through the Provincial Drug Reimbursement Program (PDRP). The full course of treatment for each regimen has been priced, and those regimens of a similar price have been “banded” to reduce complexity of implementa-
V O L . 10, I S S U E 3
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at MICHIGAN STATE UNIVERSITY on March 9, 2015 from 35.8.191.249 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
By Leonard Kaizer, MD, Vicky Simanovski, Irene Blais, CGA, MBA, Carlin Lalonde, MBA, and William K. Evans, MD
Systemic Treatment Funding Model Reform in Ontario
Current State
Future State
Consultation
Carve-out
Unmodeled
Hospital base funding
Palliative therapy
Active patients not on treatment
Figure 1. Transition from the current funding structure to an episode-based funding model. Lifetime per-case funding refers to funding provided by CCO to support the full lifetime of activities related to systemic treatment. Hospital base funding refers to the hospital’s base funding envelope related to systemic treatment. Carve-out refers to the recovery of all funding related to systemic treatment in the current state, for redistribution according to the future state.
tion. A final four-band model results in the same reimbursement profile compared to the reimbursement of each regimen according to its individual price both for the whole province and for individual facilities.
Disease Site Groups
Data
Adjuvant/Curative Treatment Bundle Based on a course of treatment Includes: No. of cycles No of chemotherapy suite visits No. of ambulatory clinic visits Nursing time Pharmacy time Non-PDRP funded drugs Supportive drugs Supplies Follow-up visits during and after treatment
Multiple Price Points
Model Implementation and Next Steps
Figure 2. Inputs and components of a bundle of care: patients receiving chemotherapy with adjuvant or curative intent. Disease Site Groups refers to experts who author guideline documents under the direction of the CCO Program in Evidence Based Care. Data refers to information extracted from the CCO database describing treatments delivered to patients in 20112012 and 2012-13. Nursing time and Pharmacy time were defined by nursing and pharmacy working groups who identified the workload associated with each treatment regimen and each phase of care. Non-PDRP funded drugs refers to drugs that are not funded by the CCO Provincial Drug Reimbursement Program.
Copyright © 2014 by American Society of Clinical Oncology
The care path for patients treated with palliative intent is much more variable, as it depends on response to treatment and toxicity. It can include multiple lines of parenteral or oral therapy and periods of time when patients receive complex supportive care during breaks from active treatment or at the end of life. For this reason, the approach taken for this bundle will be to fund the care provided in monthly time-based units. The same general approach to defining evidence-informed practice and quality of care has been taken, and once again four bands of varying complexity and monthly price have been established, with the base band price defined by a month of supportive care off active treatment. In addition, funding will also flow (Figure 1) to support the care of untreated patients, for a limited number of unbundled services funded in a price-times-volume approach, and for facility infrastructure to support direct patient care (clinical directors, managers, staff educators, etc). A number of special projects have strengthened the development of the STFM. The CCO Psychosocial Oncology program has developed a framework to define patient supports by disease site for each of the bundles of care. Among others, a data collection subgroup has defined data quality standards, and a clinical trials subgroup has been integral to considering the potential impact of the new model on clinical research.
M A Y 2014
On implementation, an impact analysis and a mitigation strategy will support system stability during a multiyear transition from the old funding methodology, so that individual facilities can absorb clinical and financial changes in a graduated fashion. Facilities have been provided with regular Knowledge Translation and Exchange packages over the past year, which summarize clinical activity analyzed by bundles of care. These analyses include comparisons to overall provincial performance benchmarks and have enabled both improvements in data quality and given administrators and providers a head start on aligning clinical practice to the new model. •
jop.ascopubs.org
191
Information downloaded from jop.ascopubs.org and provided by at MICHIGAN STATE UNIVERSITY on March 9, 2015 from 35.8.191.249 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Lifetime per-case funding +
Adjuvant/ neo-adjuvant, or curative therapy
Kaizer et al
Discussion Although many funding approaches for cancer care exist, each with strengths and weaknesses,3 the transition from a largely capitation payment system in Ontario to an episode of care– based funding model represents an opportunity to explicitly align remuneration with evidence-informed practice, a key component of a high-quality cancer system.4 Funding for episodes of care should also promote innovation in the model of care and potential efficiencies,5and accountability through an ongoing evaluation of performance and outcome will be critical to ensure that the quality of each bundle of care is maintained. Although theoretically appealing,6 the real-world experience with episode-based funding for cancer care and other chronic diseases has been limited, and evaluation of pilot programs has revealed many challenges in implementation.7 The approach taken here in Ontario is step-wise, given the jurisdiction-level scale of 13.5 million citizens in a publically funded health care system. The initial framework involves the core episodes of systemic treatment in the ambulatory setting. Once implemented and evaluated, the model will be extended to include an
increasing number of the components of care for patients who require systemic treatment in Ontario. Physician remuneration is not within the scope of the initial implementation. The majority of physician funding currently flows through a blended model of base salary and fee for service. Oncologists are jointly accountable with administrators for access and quality of care, with a strong culture of public reporting and a commitment to collaborative performance improvement. However, the long-term goal of better aligning physician funding to the defined episodes of care will only strengthen this partnership. Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. Author Contributions Conception and design: All authors Collection and assembly of data: All authors Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Leonard Kaizer, MD, Cancer Care Ontario, 620 University Ave, Toronto, Ontario, Canada M5G 2L7; e-mail: [email protected]. Acknowledgment Presented in part at the ASCO Quality Care Symposium, San Diego, CA, November 1-2, 2013.
DOI: 10.1200/JOP.2014.001389
References 1. Cancer Quality Council of Ontario: Cancer System Quality Index (CSQI) 2013. http://www.csqi.on.ca 2. Vandenberg T, Coakley, Nayler J, et al: A framework for the organization and delivery of systemic treatment. Curr Oncol 16:4-15, 2009 3. Deloitte: Episode Based Payments: Perspectives for Consideration. http:// www.deloitte.com/assets/dcom-unitedstates/local%20assets/documents/ us_chs_episodebasedpayment_perspectivesforconsideration_091609.pdf
192
JOURNAL
OF
ONCOLOGY PRACTICE
•
4. Ganz PA, Levit LA: Charting a new course for the delivery of high-quality cancer care. J Clin Oncol 31:4485-4487, 2013 5. Cutler DM, Ghosh K: The potential for cost savings through bundled episode payments. N Engl J Med 366:1075-1077, 2012 6. Bach PB, Mirkin JN, Luke JJ: Episode-based payment for cancer care: A proposed pilot for Medicare. Health Affairs 30:500-509, 2011 7. Hussey PS, Ridgely MS, Rosenthal MB: The PROMETHEUS bundled payment experiment: Slow start shows problems in implementing new payment models. Health Aff 30:2116-2124, 2011
V O L . 10, I S S U E 3
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at MICHIGAN STATE UNIVERSITY on March 9, 2015 from 35.8.191.249 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
An evaluation framework specific to the STFM and incremental to the annual CSQI report has also been developed, with a series of indicators to measure the effect of funding model change on a scorecard of quality dimensions. An STFM management committee will be in place to address implementation issues as they are identified, and the Working Group will continue to refine the model, expand its scope (laboratory/imaging services, inpatient episodes, etc), and better align it with physician remuneration.
