value in health forum: standards, quality and economics...ices primary care and population health...

ICES Pr imary Care and Populat ion Heal th Research Program Ins t i tu te for C l in ica l Eva luat ive Sc iences ICES Pr imary Care and Populat ion Heal th Research Program

Value in Health Forum: Standards, Quality and Economics

January 19, 2017

Translation of Health System Quality into

Value: Funding, Accountability and Performance

Rick Glazier, MD, MPH, CCFP, FCFP

Senior Scientist, Institute for Clinical Evaluative Sciences

Scientist, Centre for Research on Inner City Health, St. Michael’s Hospital

Staff Family Physician, St. Michael’s Hospital

Professor, Family and Community Medicine, University of Toronto

ICES Pr imary Care and Populat ion Heal th Research Program

Faculty/Presenter Disclosure

Faculty: Rick Glazier

Relationships with commercial interests:

– Grants/Research Support: none

– Speakers Bureau/Honoraria: none

– Consulting Fees: none

– Other: none


Presentation

• Role of primary care

• Canada in an international context

• Ontario’s primary care transformation • patient enrolment

• new payment models

• inter-professional teams

• Successes and challenges with lessons for Alberta

• Discussion


Health System Role of Primary Care

•Health services accessed each day

- extensive contact with the public

•Primary care and health outcomes

- better health outcomes, satisfaction with care, lower costs

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Health Services Accessed Each Day (ICES Primary Care Atlas)


Primary Care and Outcomes

•Primary care associated with

• Lower • mortality, premature mortality, infant mortality

• disparities in overall mortality, infant mortality, low birth weight, stroke mortality, self-reported health, and avoidable hospitalizations

• Higher • satisfaction in relation to overall costs

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Macinko J et al. Health Services Research. 2003;38:831-65

Shi L et al. Health Services Research. 2002;37:529-50

Engstrom S et al. Scand J Prim Health Care 2001; 19:131-4


Physician Supply, OECD

(Canada rank = 7/30 primary care, 25/30 specialists)


Why Change: Health System Transformation

• Internationally - IHI Triple Aim

• improve the experience of care

• improve population health

• control per capita costs

• Canada • spends a lot per capita relative to OECD

• health status pretty good, slightly above OECD average

• health system performance consistently below comparators

http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx


Access to Primary Care: Provincial Comparisons


Systems are Transforming

•Health systems reforms

•rapid change – teams, EMRs, guidelines, payment reform • Australia – GP Divisions, Medicare Locals, Primary Health Networks

• Canada – different in every province/territory, Patient’s Medical Home

• U.S. – PCMH, ACOs, Affordable Care Act, MACRA

• U.K. – constant reform of funding, incentives

• New Zealand – independent practitioner associations

• Netherlands – regulated competition

• other countries – multiple reforms

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Primary Care Transformation – Canada

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Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada: systems in motion. Milbank Q. 2011;89(2):256-88. doi: 10.1111/j.1468-0009.2011.00628.x.


Implementation in Ontario

• Blended capitation

• age-sex specific capitation payments, basket of services

• 15% fee-for-service billings for in-basket services

• formal rostering

• incentives for severe mental illness, chronic disease management

• performance payments for thresholds of immunizations, cancer screening

• Free choice of models

• choice often based on income projections

• fee-for-service, blended fee-for-service, blended capitation

• Inter-professional teams

• nurses, nurse practitioners, social workers, pharmacists, dietitians

• only for those in blended capitation or salary

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Ontario’s Large-Scale Experiment

Hutchison B, Glazier RH. Health Affairs 2013:32:695-703

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Transformation in Physician Payment

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Hutchison B, Glazier R. Health Affairs 2013;32:1-9


Payments

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Successes of the Ontario Transformation

• Primary care workforce has grown and diversified • inter-professional teams available to a quarter of the population

• medical student preference for family medicine increased

• Physician satisfaction and incomes improved

• High proportion of the population (94%) has a primary care provider

• Most practices now have an EMR (80%)

• Team models have quality improvement plans

• Evidence of improved diabetes care, cancer screening

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Medical student choice for family medicine

Canadian Resident Matching Service



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Diabetes processes of care Colorectal cancer screening

Kiran T et al CMAJ 2015


Payment Reform Challenges Devil in the Details

• Increased costs

• choice of capitation largely based on increased income

• thousands of doctors joined rapidly

• entry into capitation now been limited by government

• Selection of healthier practices

• payment the same for healthy and sick patients

• sicker practices stuck in older models

• Misalignment with system needs

• ‘access bonus” for avoiding outside use (negation)

• created an incentive to send patients to ED (where bonus not affected)

• urban practices with lowest ED visits, best after hours access penalized

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Capitation Payments

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Sibley LM, Glazier RH. Health Policy. 2012;104(2):186-92.


System Challenges

• Inverse care law and inequity

• only capitation models could have a team

• sicker practices did not join capitation so could not have a team

• those needing a team the most could not get one

• fewer in large urban areas joined capitation – immigrants left out of teams

• Pay-for-performance did not perform

• cancer screening, diabetes care

• costly with little evidence of impact

• Timely access to care did not improve

• largest system challenge

• no provisions in new models

• No models changed in past decade: “paradigm freeze”

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Pay-for-Performance: Cancer Screening (up to $2200 per year for cervix and breast, $4000 for colorectal)

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• No change in cervix or

breast cancer screening

• Net increase of 1.7% per

year in colorectal

screening after incentives

• Combined annual costs

more than $35 million

Kiran T. et al. Ann Fam Med. 2014 Jul;12(4):317-23


Access – Time Trends

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Glazier RH, Kopp A, Schultz SE, Kiran T, Henry DA. Healthc Q. 2012;15(3):17-21


Transition to Capitation: Timely Access

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Health Analytics Branch MOHLTC: Ontario Health Care Experience Survey 2012/13

Capitation Fee for Service


Those Left Behind Kiran T, et al Ann Fam Med 2016;14:517-525.


Lessons that may be applicable to Alberta

• Be nimble and prepare for change

• pilots are a good idea, evaluate from the start

• build measurement capacity

– prepare to adjust models

• Direct resources to greatest needs and align incentives

– case-mix adjust capitation (e.g. new CIHI POP)

– mitigate or eliminate negation for urban centres

• Direct attention to system priorities

– require timely access, after-hours care

• consider risk and costs sharing, bundled payments

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value in health forum: standards, quality and economics...ices primary care and population health...

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