After a decade of focusing on access to health care services, the Ontario government appears to be turning its attention to improving the quality and costs of these services.

At the moment, there is considerable variation in how health care is delivered in Ontario’s hospitals, so patients with the same diseases are receiving different qualtiy of care depending on where they are treated.

To address this, the Ministry of Health and Long Term Care has embarked on a massive restructuring of how hospital are paid, with the next stage set to roll out on April 1st.

The goal of Ontario’s new approach is to improve standardization of care across the province, to ensure all hospitals are following evidence-informed best practices. In an attempt to accomplish this, the Ministry of Health is in the process of replacing a large share of hospitals’ global budgets with standardized bundled payments for what it is calling Quality Based Procedures (QBPs).

Quality Based Procedures

The idea behind QBPs is to identify certain conditions where there is currently wide variation in clinical practice, contributing to both uneven quality and costs, and to carve these out from hospitals’ base budgets. Hospitals will then receive funding to treat these conditions through a separate mechanism that ties funding to the implementation of best practices and improved quality.

Four QBPs were rolled out last year (hip replacement, knee replacement, cataract surgery and dialysis); with another six set to roll out on April 1^st (congestive heart failure, stroke, chronic obstructive pulmonary disease, elective vascular surgery, chemotherapy and colonoscopy).

QBPs are not a new idea in health care. They are a variation of what some jurisdictions call activity based funding, payment by results, or bundled payments.

Here in Ontario, the Ministry has struck an expert panel for each of the QBP conditions, which are tasked with developing best-practices for treating these conditions. “The focus of these panels is exclusively on quality,” says Chaim Bell, co-chair of the Chronic Obstructive Pulmonary Disease (COPD) panel, “we were not asked to look at costs.”

These panels are made up of health care professionals from both academic and community hospitals. They have been asked to review the best available international evidence, along with data from Ontario’s Institute for Clinical Evaluative Sciences, in order to develop standardized care pathways based on best clinical practice.

Care pathways are tools used in health care to improve standardization. They are a sort of map, which plot out a patient’s journey through the health care system. A care pathway for COPD, for example, would determine whether a patient’s condition should be considered mild, moderate or severe, based on the patients’ specific symptoms. Then, based on this initial classification, the pathway would further define which treatments should be used, as well as criteria to evaluate whether a treatment was successful, and if treatment was unsuccessful, which treatment should be offered next.

Creating care pathways does not mean that all patients must be treated the same. Doctors can deviate from a pathway if a patient’s specific condition requires it, but existence of a pathway and accompanying checklists requires that this variation be documented, which helps ensure that the variation is for a good reason.

Bob Howard, CEO of St. Michael’s Hospital believes this approach to standardization is an important step in the right direction, saying “when you improve standardization, you instantly improve quality. Everyone on the care team, including the patient, knows what’s supposed to happen.” When everyone on the team knows what the best practice is, it’s easy to spot and correct deviations from the pathway.

“The devil is in the details”

Improving quality through the development of care pathways based on best-evidence has broad support within the health care system. Where the road begins to get rocky is the effort to connect hospital funding to quality outcomes. “Everyone supports the goals of QBP,” says Ken Tremblay, CEO of Peterborough Regional Health Centre, “but the devil is in the details.”

These details include a deficit of measurable quality indicators and limited evidence on best practices for some procedures.

For payments to be effectively tied to quality, both processes and outcomes must be continuously measured in Ontario’s hospitals. But in many cases hospitals are not measuring relevant quality indicators. According to the clinical QBP guidebook from the COPD expert panel, the indicators of patient outcomes currently measured by hospitals, which include COPD admission rates and length of stay, “do not measure the quality of care provided.”

Further, according to the expert panel, process indicators that could potentially be developed using existing data, such as use of noninvasive ventilation for COPD patients, have not been validated. Validated process measures from other jurisdictions, such as spirometry testing and access to pulmonary rehabilitation, have not been developed in Ontario and would require entirely new data collection systems.

Also challenging is that not all of the conditions identified as QBPs have the same quality of evidence available upon which to base best practice care pathways. According to David Alter, co-chair of the Congestive Heart Failure expert panel, there is significantly less definitive evidence for standardized treatment of congestive heart failure than for cataract surgery or hip replacement.

However, as significant as these challenges are, Alter emphasizes that these are not deal-breakers. “Getting to this stage, where we have evidence-based recommendations, wasn’t easy – there were a lot of challenges, but nothing valuable is easy. We can meet these challenges if we keep working at them,” he says.

Could cost control trump quality improvement?

Using QBPs to standardize quality across the province is challenging enough, but they are also meant to standardize costs.

Originally, the plan for QBPs was to determine the price of providing the best practice care pathway, and to pay hospitals for each patient they treat through this pathway. Thus all relevant costs required to provide the best practice care pathway (nursing costs, imaging, food, laboratory work, etc.) would be calculated and bundled so that hospitals would receive an appropriate payment for providing standardized, high-quality care.

However, despite the scheduled April 1^st roll-out for the six new QBPs, the quality based pricing is not in place for all of them, admits Susan Fitzpatrick, the Assistant Deputy Minister at the Ministry of Health responsible for QBPs. “Currently the six expert panels are all at slightly different stages of execution,” she says, “we thought we’d get their best practice guidelines in time to do micro-costing on the care pathways. That has not been able to be done in every case.”

Nevertheless, the carve-out of hospitals’ global budgets is set to go ahead. While hospitals will receive bundled payments for QBP services, the prices for these bundled payments will be based on the average cost of providing a QBP service in Ontario at the present time, rather than on the price of following best practice.

Fitzpatrick believes that the combination of being paid the average price along with monitoring of quality indicators identified by the expert panels will prompt hospitals to start looking at how they can implement best practices.

However, others worry that until payments are tied to actually providing best practices and improving quality, it is unclear whether these new bundled payments will successfully promote quality, or whether they will simply promote cost control as some hospitals struggle to get their costs down to the average.

QBPs the first of many steps – process will be “hard, but necessary”

Changing the ways hospitals are financed is only one step on the path of improving quality in a health care system. “This is a first step,” says Fitzpatrick, “the expert panels are still constituted and one of the next steps for them is to look beyond hospitals to how care is provided in the community.”

“In order to truly transform the system, we have to be bold” says Garth Matheson, a Vice President at Cancer Care Ontario which is responsible for three QBPs. “Look, this is going to be a bumpy road, and things aren’t going to change overnight… but this is how we actually improve the whole system.”

Bob Howard agrees. “The bottom line,” he says, “is that hospitals know this process is going to be hard, but also know that it is necessary.”