This bulletin continues our series on Bill 74: The People's Health Care Act, 2019. Bill 74 received Royal Assent in the Legislative Assembly of Ontario on April 18, 2019.
As we reported in our last bulletin, the Ministry of Health and Long-Term Care (the "Ministry") has begun the application process for Ontario Health Teams. Ontario Health Teams are referred to as "integrated care delivery systems" in the Connecting Care Act, 2019, which was enacted into law by Bill 74 and will come into force once proclaimed by Ontario's Lieutenant Governor.
In this bulletin, we look specifically at the governance models expected for Ontario Health Teams and at how Ontario Health Teams will be funded. We first describe what the model is expected to look like at maturity (defined below), and then how governance and funding considerations form part of the application and implementation process.
The Ministry has provided a guidance document for applicants, Ontario Health Teams: Guidance for Health Care Providers and Organizations (the "Guidance Document"), which provides an overview of the intended structure of Ontario Health Teams. The Guidance Document recognizes that the framework will be further developed as the new health care model becomes operational. The Guidance Document includes an initial self-assessment to be completed by health service providers seeking to be part of an Ontario Health Team. It also sets out expectations to be met in the first year of operations after a successful application ("Year 1"). Following the application and an in-person visit but prior to receiving an integrated funding envelope, providers/organizations are referred to in the Guidance Document as "Ontario Health Team Candidates" and are expected to implement the Ontario Health Team model using their existing funding. After full implementation (referred to as "maturity"), the Ontario Health Team Candidate will be designated as an Ontario Health Team and will operate within a single accountability framework under an integrated funding envelope.
Governance of Ontario Health Teams
Ontario Health Teams are expected to provide a full and coordinated continuum of care for a defined population within a geographic region. While each Ontario Health Team will be permitted to self-organize and design its own governance model, the Guidance Document sets out certain key requirements.
A central expectation is that each Ontario Health Team will operate through a single clinical and fiscal accountability framework. Each Ontario Health Team will be free to determine the governance model that suits its needs and the needs of its patients and community, but it must do so with an emphasis on unity. Where an Ontario Health Team consists of multiple providers or organizations, they will be required to formalize their relationships through governance arrangements or other agreements specifying their roles and responsibilities, and addressing matters such as decision making, conflict resolution, performance management, information sharing and resource allocation. This is likely to be the case for most, if not all, Ontario Health Teams. Technically, based on Section 29 of the Connecting Care Act, 2019, a single organization could be designated as an Ontario Health Team if the organization provides at least three of the enumerated services (listed in one of our earlier bulletins) — for example a large hospital with an emergency room that provides, among its many other services, mental health and addictions care and long-term care. However based on the government's intention that Ontario Health Teams provide a full continuum of care for a roster of patients, we think it is unlikely that an application will succeed without providing most of the enumerated services. According to the Guidance Document, submissions that include a minimum of hospital, home care, community care, and primary care services will be prioritized at the application stage. The Guidance Document acknowledges that governance structures may evolve as the separate providers/organizations adapt to working together.
Ontario Health Teams are also expected to have patient representation and leadership in their governance. This could include, for example, a patient advisor. The Guidance Document also underscores the importance of physician leadership and that Ontario Health Teams should consider involving families and/or caregivers in their governance.
The Guidance Document describes the creation of Ontario Health Teams as a fundamental shift in the way that health care will be delivered and funded in Ontario; a means of overcoming the systemic barriers to coordinated and seamless care arising from the current funding model. Currently, there are 4,500 transfer payment recipients across the province. This, according to the Guidance Document, creates fragmented funding and accountability, and duplication of services. Integration is intended to address administrative and bureaucratic hurdles to coordinated care. Existing funding and accountability agreements will remain in place during the application and implementation stages.
At maturity, Ontario Health Teams will receive funding through an integrated funding envelope based on the care needs of their recipient patient population. The integrated funding envelope will be paid to a single fund holder, which we understand to mean that where an Ontario Health Team is comprised of multiple providers or organizations, one organization will be the recipient of the funding on behalf of the group. Ontario Health Teams will be clinically and fiscally accountable for meeting all of the health care needs of their patient population. The funding envelope will include population-based funding, as well as activity-based funding for specific episodic care. Physician services will, the Guidance Document suggests, continue to be funded through existing remuneration models (e.g. fee for service).
Patients will be rostered with an Ontario Health Team. However, it will also be the case that patients will have a choice to receive care from providers outside of their Ontario Health Team. In order to avoid double payment (an issue that arises when a rostered patient also accesses care elsewhere), the Guidance Document indicates that the Ontario Health Team (or the entity within the Ontario Health Team that holds the funds) will be responsible for ensuring external services to their patients are appropriately funded. The Guidance Document does not explain the basis on which the Ontario Health Team will fund these services. It is not immediately apparent how rostering would work under all possible Ontario Health Team models.
The funding model will also include efficiency incentives. A portion of funding for Ontario Health Teams will be linked to a standard performance measurement framework. If an Ontario Health Team meets expectations at a lower cost than a pre-established benchmark, it will be able to keep a portion of the savings to invest in improving direct patient care.
Governance and Funding Considerations in the Application and Implementation Stages
In addition to describing the expectations of Ontario Health Teams at maturity, the Guidance Document sets forth the Ministry's detailed expectations of (i) applicants who wish to begin implementation of the Ontario Health Team model (becoming what is referred to as "Ontario Health Team Candidates"); and (ii) Ontario Health Team Candidates at Year 1.
All interested health care providers and organizations are invited to complete and submit a self-assessment form. The form requires applicants to identify the providers or organizations that would come together to form the proposed Ontario Health Team and an explanation of why they are coming together. Applicants are also asked to confirm their willingness to collaborate with others (i.e. other providers/organizations that are not part of the currently proposed Ontario Health Team) to become an Ontario Health Team if recommended by the Ministry.
The self-assessment form requires each applicant to evaluate the governance potential of the proposed Ontario Health Team, including the ability of its team or partners to demonstrate:
- a history of formally working with other providers or organizations to advance integrated care;
- a plan for physician and clinical engagement, including physician and clinical leadership as part of the team's leadership and governance structure;
- a commitment to the vision and goals of the Ontario Health Team model;
- a commitment to a central brand; and
- a commitment to working together towards a single clinical and fiscal accountability framework.
Teams of multiple providers or organizations must indicate their commitment to formalize their relationships through governance arrangements or other agreements.
Additionally, the self-assessment form requires financial assessment by each applicant, including of the ability of:
- each partner in its team to demonstrate a strong track record of responsible financial management (which may include successful involvement in bundled care and managing cross-provider funding);
- its team to demonstrate a basic understanding of its costs following Year 1 and at maturity; and
- its team to demonstrate a commitment to identify a single fund holder, work towards an integrated funding envelope, and invest shared savings to improve patient care.
Year 1 Expectations
At the end of Year 1, it is expected that each Ontario Health Team Candidate, will, among other things:
- enter into an agreement with the Ministry outlining service delivery and performance obligations;
- meet the reporting and other obligations set out in each provider's or organization's existing funding or service accountability agreement or service contract
- have a strategic plan in place for the Ontario Health Team, consistent with the target outcomes of the Ontario Health Team model;
- have a physician and clinical engagement plan in place; and
- identify the single fund holder.
A general overview of the path to designation as an Ontario Health Team, including a definition of "Ontario Health Team" and the steps to becoming an "Ontario Health Team Candidate", is included in our last bulletin.
Note, however, it is recognized that the most specialized conditions and procedures, such as transplants or neurosurgery, will continue to be delivered by a few specialized providers as they require an exceptional degree of clinical skill and oversight.
Double payment is an issue being considered by the Primary Care Working Group, which was established as part of arbitration between the Ministry and the Ontario Medical Association in respect of physician fees. Refer to our bulletin on the arbitration here.
At Year 1, the Ministry will examine obligations under an Ontario Health Team's current funding or service accountability agreements to determine what obligations should be revisited based on new obligations of the Ontario Health Team, and will seek to reduce reporting burdens where possible.