Introduction of Innovation into an Activity-Based Funding System in Ontario Stroke Endovascular Treatment (EVT)

Transcription

1 Introduction of Innovation into an Activity-Based Funding System in Ontario Stroke Endovascular Treatment (EVT) Imtiaz Daniel, PhD, MHSc, CPA, CMA Director, Financial Analytics and System Performance, Ontario Hospital Association Adjunct Lecturer, University of Toronto Board of Directors, Ontario Shores Mental Health and Addictions Centre Marnie Weber, MHSc, MSc, CHE, Executive Director, Strategic Developments, University Health Network, Toronto Dr. Leanne K. Casaubon, MD MSc FRCPC Associate Professor, University of Toronto Division of Neurology - Stroke Program Director, TIA and Minor Stroke (TAMS) Unit Toronto West Regional Stroke Centre

2 Quick Facts 2017: Ontario (Population: 13,982,984) 2

3 Laying the Foundation for Quality: The Excellent Care for All Act (ECFAA) Source: MOHLTC 3

4 Ontario s Hospital Funding in the Past Health Service Providers received 75-90% of their funding in lump sums (global budgets) Few opportunities to change funding to meet the demands of the populations being served Little incentive to improve performance or quality Source: MOHLTC 4

5 Health System Funding Reform (HSFR) Introduced in

6 Ontario Context: Health System Funding Reform (HSFR) Introduced in

7 Quality-Based Procedures (QBPs) The original idea: a new activity-based funding model for hospital-based services (funding = price x volume, adjusted for case mix) Each year, QBPs implemented for an expanding range of patient populations For each QBP, historical global budget funding carved out for estimated costs of current activity in QBP patient population Hospitals are then re-paid for activity using standard provincial prices The vision: In future, prices will be based on the cost of best practice QBP Expert Panels established through provincial agencies to define patient populations to be funded and define best practice care pathways to be costed 7

8 QBP Roadmap : 1. Primary hip replacement 2. Primary knee replacement 3. Cataract 4. Chronic Kidney Disease : 5. Chronic obstructive pulmonary disease 6. Stroke 7. Congestive heart failure 8. Non-cardiac vascular 9. Chemotherapy 10.Gastrointestinal endoscopy : 11.Hip fracture 12.Pneumonia 13.Tonsillectomy 14.Neonatal jaundice : 15.Cancer Surgery - Prostate 16.Cancer Surgery - Colorectal 17.Knee Arthroscopy : 18.Cancer Surgery - Breast 19.Cancer Surgery - Thyroid Source: MOHLTC 8

9 Episode of Care lifecycle QBP topic selection and scoping Monitoring, evaluation and feedback Expert panel formation Population utilization analysis Develop implementation tools and supports Ministry QBP policy design & implementation Health sector adoption & implementation Define cohort, episode of care and case mix adjustors Recommend performance indicators Develop recommended practices Evidence and guideline synthesis

10 Clinical Handbooks Development For Stroke patients specified clinical population, an expert advisory group was convened to deliver the following as compiled in a Clinical Handbook : a) Define the population / patient cohorts for analysis b) Define the appropriate episode of care for analysis in each cohort c) Seek consensus on a set of evidence-based clinical pathways and standards of care for each episode of care d) Provide recommendations on performance indicators and implementation considerations for the episode of care X Detailed costing and unit cost analysis Out of scope: Pricing and payment methodology design In 2012, focus on the hospital stay for the initial QBPs; subsequently expanded to include post-acute care

11 QBP Clinical Handbooks Health Quality Ontario website: Source: MOHLTC 11

12 Health Based Allocation Model (HBAM) Clinical data Financial data Actual Service Volume Actual Expense Data Service Component Adjustments Clinical and Demographic Characteristics SES/Rurality/Age Adjustments Population Growth Service Component HBAM Unit Cost Component Expected Expenses Unit Cost Adjustments Teaching and Hospital Type Rural Geography Economies of Scale Specialized Services (Level Of Care) HBAM adjusted results are used to calculate each hospital's expected share of the HBAM funding envelope ($5.15B) 12

13 Funding Formula

14 Mathematic Funding Formula

15 Initial Analysis Confirms HSFR is Associated with Evidence of System Changes in the Acute Care Sector 15

16 Stroke Cohort - QBPs

17 Clinical Trials - Endovascular Stroke Trials Halted for Benefit The first-generation devices showed no benefit over medical therapy alone in a first round of trials in this field. IMS-III (Interventional Management of Stroke III), MR RESCUE; SYNTHESIS EXPANSION studies Second-generation endovascular devices were more effective at opening the artery with less arterial injury and fewer hemorrhagic adverse effects than the first-generation devices. SWIFT (Solitare With the Intention for Thrombectomy) TREVO (Thrombectomy REvascularization of large Vessel Occlusions in acute ischemic stroke) MR CLEAN (Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands) Two other trials evaluating endovascular interventions were stopped after early interim analyses showed benefit in the intervention group ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) EXTEND IA (Extending the Time for Thrombolysis in Emergency Neurological Deficits - Intra-Arterial) 17

18 Clinical Evidence Supports this Innovation 8 RCTs were included in a meta-analysis EVT significantly improved functional outcomes in a selected group of patients with acute large-vessel ischaemic strokes. Proper patient selection to identify largevessel occlusions with limited completed stroke volumes using CTA with or without perfusion imaging is critical to treatment success. Use of modern stent-retriever devices during procedures achieving high rates of complete or near-complete revascularization may provide additional safety and efficacy.

19 ESCAPE Clinical Trials Five Ontario Hospitals participated in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke clinical trials University Health Network St. Michael s Hospital London Health Sciences Centre The Ottawa Hospital Sunnybrook Health Sciences Centre ESCAPE was stopped early due to findings of 25% increase in excellent outcomes (functional independent living) and a 50% reduction in death rate for severe and moderate stroke patients with EVT. 19

20 Provincial Stroke EVT/Embolectomy Case Costing Report Participants 5 Hospitals - London Health Sciences, St. Michael s Hospital, Sunnybrook Health Sciences Centre, The Ottawa Hospital, University Health Network The goals of the Provincial Case Costing Committee for Stroke Embolectomy were to complete and review case costing for stroke embolectomy compare stroke embolectomy costs to the existing stroke ischemic QBP ( which excludes interventions such as embolectomy cases) recommend how stroke embolectomy can be incorporated into a provincial QBP strategy advise MOHLTC on a funding strategy that successfully ensures access to Stroke EVT/ Embolectomy in select Ontario hospitals for acute ischemic stroke patients who would benefit.

21 Methodology Each hospital case costing staff met with the lead clinicians (Interventional neuroradiologist, interventional neurologist, endovascular neurosurgeon and stroke neurologist. Patient Cohort: Acute ischemic stroke patients who arrived through ED, underwent an endovascular thrombectomy (embolectomy) procedure and were admitted. The cases were verified by the clinical team and then costed using hospital case costing data base for 14/15. Costing Analyses were done Stroke Embolectomy/ EVT cases Stroke- Ischemic QBP cases ( which do not include stroke embolectomy/ EVT cases) All case costing and HIG results were discussed to ensure methodological consistency between hospitals. Results were reviewed both by the technical subcommittee as well as the provincial case costing committee. 21

22 Results the average total cost for Stroke EVT cases is $34,832 (2014/15 case costing data) 2.4 X higher than the average total costs of Stroke ischemic cases in the QBP ($14.850) A combined rate is only be $15,957 per case which is $18,875 less than Stroke EVT (54% underfunding) QBP Stroke ischemic cases (non- surgically with TPA only) could be over funded by $1,038 or 7.0% per case. 22

23 Results Hospital B has a lower length of stay than others - transfer of stroke EVT cases to other adjacent hospitals post procedure. Part of a Regional Stroke Program to repatriate cases to surrounding community hospitals. Hospital C had lower case complexity and used step down beds. Hospital E were treating more complex ischemic stroke patients with embolectomy. This hospital had advanced clinical expertise in EVT combined with other intracranial neuro interventional procedures (ie. intracranial stents, multiple passes, radial access, etc) 23

24 Provincial Stroke EVT/Embolectomy Case Costing Report Recommendations For these reasons, there is a strong recommendation that Stroke EVT become a new clinical stream with its own pathway and appropriate QBP funding rate to reflect the much higher costs needed to do these invasive neuro interventional intracranial EVT procedures. Recommend that the MOHLTC provide $34,832 per Stroke Embolectomy/EVT case as an interim for 17/18 funding year.

25 Stroke EVT QBP Task Group - Mandate Review the cohort definition of the Stroke EVT QBP. Review the costing methodology of the Stroke EVT QBP. Advise on an appropriate pricing methodology. Advise on a method for funding this QBP under HSFR.

26 Methodology Hospitals were asked to submit their case costing data for 2015/16 to the Ontario Hospital Association The final data source for the calculation of the Stroke EVT QBP price were the provincial data sources. 26

27 Cost Differences Missing Interventional Costs 27

28 Cost Adjustment 28

29 Price Adjustments The average Ischemic-level HBAM adjustment amount is $1,625 29

30 Summary The price for was based on the patient cohort definition in the QBP Clinical Handbook for Stroke One-time data quality adjustment to include interventional radiology (IR) costs in the emergency room (ER); Limit the Health-Based Allocation Model (HBAM) adjustment to the adjustment for the ischemic QBP; and Fund EVT using price per case, not a weighted price per case. 30