Revisiting the inpatient rehabilitation case-mix and funding model in Ontario, Canada: lessons learned Kristen Pitzul, Emitis Moshirzadeh, Jan Walker, Kevin Yu, Sandro Serino, Imtiaz Daniel
Quick Facts 2017: Ontario (Population: 13,982,984) Actual expenses for inpatient rehab beds: 585 million CAD; 13 free standing rehabilitation facilities with total expenses of 130 million Canadian. 2
Ontario Context: Health System Funding Reform (HSFR) Introduced in 2012 3
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 4
QBP Roadmap 2012-13: 1. Primary hip replacement 2. Primary knee replacement 3. Cataract 4. Chronic Kidney Disease 2012-13: 5. Chronic obstructive pulmonary disease 6. Stroke 7. Congestive heart failure 8. Non-cardiac vascular 9. Chemotherapy 10.Gastrointestinal endoscopy 2014-15: 11.Hip fracture 12.Pneumonia 13.Tonsillectomy 14.Neonatal jaundice 2015-16: 15.Cancer Surgery - Prostate 16.Cancer Surgery - Colorectal 17.Knee Arthroscopy 2016-17: 18.Cancer Surgery - Breast 19.Cancer Surgery - Thyroid Source: MOHLTC 5
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)
Background MOHLTC mandate and fund the implementation and ongoing collection of rehabilitation care data using the FIM-based data set for patients in MOHLTC designated inpatient adult rehabilitation beds in Ontario hospitals in April 1, 2002. In 2004, a Rehabilitation Technical Working Group (RTWG) with the mandate to evaluate and recommend FIM-based groupers and associated weights Design of existing RPG groups was based patient s lengths of stays in 2005-06 Classification and regression tree methods used to describe groups of patients Roughly replicated the methodology followed by Medicare in Inpatient Rehabilitation Facility (IRF) case mix methodology
RPG Rehabilitation Group RPG 1100 Stroke 1100. M=12-38, Age<=68 1110 Stroke 1110. M=12-38, Age>=69 1120 Stroke 1120. M=39-50 1130 Stroke 1130. M=51-84, C=5-25 1140 Stroke 1140. M=51-84, C=26-29 1150 Stroke 1150. M=51-68, C=30-35 1160 Stroke 1160. M=69-84, C=30-35 1200 Traumatic Brain Injury 1200. M=12-13, C=5-21 1210 Traumatic Brain Injury 1210. M=14-47, C=5-21 1220 Traumatic Brain Injury 1220. M=48-84, C=5-21 1230 Traumatic Brain Injury 1230. M=12-44, C=22-28 1240 Traumatic Brain Injury 1240. M=45-84, C=22-28 1250 Traumatic Brain Injury 1250. M=12-84, C=29-35
Background Presented in July 2014 a beta inpatient rehabilitation grouper and weighting system. Objective: Re-design the RPG case mix classification system using available patient cost data Original weights Rehabilitation Cost Weights (RCW) - for RPG based on MIS data and length of stay data Expansion of Ontario Case Cost Initiative (OCCI) afforded opportunity to revise RCW and use patient cost data from OCCI RCW are now based on complete NRS episodes, RPG case mix groups, and OCCI data 9
RPG Design - Data Over the period 2010-11 to 2012-13 there has been more patient level costing data. NRS and OCCI data for fiscal year: 2010-11, 2011-12, 2012-13 Year NRS OCCI 2010-11 29,425 11,562 2011-12 29,857 15,673 2012-13 29,911 16,078 10
RPG Design - Data Not all NRS episodes link to OCCI data Hanging, or incomplete episodes at end of fiscal years Year Linked Records 2010-11 10,798 2011-12 15,410 2012-13 15,824 11
Purpose As part of the first step in the task force s review: The purpose of this study was to conduct a jurisdictional scan of inpatient rehabilitation classification systems and activity-based funding models in jurisdictions outside of Ontario 12
Methods Two-pronged approach: Literature review and semi-structure interviews of content experts from each jurisdiction; Conducted simultaneously from January 2017- June 2017 Searches for both grey and peer-reviewed literature were conducted on January 18 th 2017 and limited to English-language articles and reports published from the year 2000- onwards Titles and abstracts/executive summaries were screened for relevance (Level 1 screening) Jurisdictions were then contacted based on the following: Were found in the literature review Known as content experts to the study team Relevant context to Ontario s health care system
Methods The full-text of articles/reports were then screened for inclusion (Level 2 screening) prior to abstraction Content experts from the following jurisdictions were then contacted: Countries involved in the development and implementation of NordDRG case mix system: Sweden, Denmark, Iceland, Estonia, Latvia, Norway, Finland The Netherlands, United Kingdom, Australia, United States European countries involved in EuroDRG development (current contacts are in Germany& Estonia) A set of interview questions was used to guide the content expert interviews 14
WHAT DID WE LEARN? 15
Norway Contact: Fredrik A.S.R. Hanssen, Director of Financing and Case Mix, Norwegian Directorate of Health Health System Context: Publically-funded global coverage. Rehabilitation services are spread between the two types of care: specialists (e.g., hospitals) and primary Inpatient and Outpatient Rehabilitation funding (in place since the year 2000): NordDRG: Only 2 DRGs for rehabilitation, complex and simple Cost weights: Associated with LOS and the 2 NordDRGs. Facilities receive the most amount of funds for the first 4 days stayed, less for the next 10 days stayed, and even less for remaining days stayed Blended funding model: 50% block grants, 50% from NordDRG model Data Availability: National Patient Registry Rehabilitation datasets (both inpatient and outpatient) not mandatory, poor data quality (including quality of cost data). Outpatient rehabilitation dataset does have functional items derived from ICF and similar to FIM. 16
United Kingdom Contact: Lynne Turner-Stokes, Professor of Rehabilitation Medicine and Director Regional Hyper-acute Rehabilitation unit, Northwick Park Hospital Rehabilitation context: Level 1: Complex needs, discrete tertiary specialized rehabilitation services. Level 2: Specialist rehabilitation services, led/supported by a consultant specialist in rehabilitation medicine. Operating within a more local catchment area than level 1 Level 3: General rehabilitation services, very large volume (e.g, geriatric). Led by specialists other than physiatrists. Case Mix for Level 3: Rehabilitation complexity scale. Cases placed into 5 bands of complexity based on total RCS score. Total staff hours/week is calculated within each complexity band (via Northwick Park Nursing and Therapy Dependency Scale). 17
United Kingdom, continued Costs: Derived top down. Retrospective analyses of hospital budgets Found that staffing costs make up 66% of total costs, so facilities report annually for their staffing costs, and UKROC multiplies by 1.5 to get total cost of service Data Availability: United Kingdom Rehabilitation Outcome Center is closely modeled from the Australian equivalent (AROC) Inpatient rehabilitation: Detailed dataset published on UKROC It is required for facilities to report in this dataset Started first 7 years as NIHR project and is now commissioned by NHS Outpatient rehabilitation: Not reliable data (want to develop the model for community rehabilitation). 18
United Kingdom, continued Funding Model: 2013/2014: Multi-level weighted bed day (WBD) was introduced for level 1 and 2 services, along with a set of tariffs 2014/2015, the WBD was mandated, but the tariff was not. The WBD was implemented to support the admission of highly complex patients to rehabilitation by offering a higher reimbursement rate for these patients, but only while they had complex needs Figure 1. WBD example from patient with LOS=133 days 19
Australia Case Mix: AN-SNAP: 10 impairment categories are characterized by 45 classes that further breakdown into admitfim motor, or admitfim motor, admitfimcognitive, and admitage AN-SNAP, v4: Weighted admitfim motor Each FIM item is weighted according to its predictive ability of resource utilization (defined as cost) according to regression analyses FIM item weights are then transformed to sum to a total of 13 20
Australia, continued Adapted from: https://ahsri.uow.edu.au/content/groups/public/@web/@chsd/@aroc/documents/doc/uow207708.pdf 21
United States Context: Inpatient Rehabilitation Facility Prospective Payment System (IRF-PPS) Case Mix: 85 impairment codes, 21 rehab impairment categories that ultimately are composed of CMGs, which breakdown to admitfim motor and comorbidity, or admitfim motor, admitfim cognitive, age, and comorbidity Majority of patients fall into the no-comorbidity tier Original CMGs based on 1998 cost data (from time and motion studies) and that data has been updated over time for inflation Medicare: Adopted the weighted motor FIM after the implementation of the IRF-PPS due to data quality concerns Other adjustments: Rurality, share of low-income patients, wage index, and a small adjustment for teaching status 22
DISCUSSION & CONCLUSION 23
Discussion Results of the jurisdictional scan suggest that many jurisdictions are grappling with similar issues as Ontario Up to date and relevant peer-reviewed literature was scant for jurisdictions except for the United States Nevertheless, the content expert interviews provided a wealth of information along with access to relevant grey literature and lessons can be gleaned from a number of jurisdictions, including but not limited to: the use of a weighted motor FIM, the implementation of different cost weights for typical patients length of stay, and the inclusion of co-morbid conditions 24
Discussion The search was not peer-reviewed and screening was not completed in duplicate Biased towards English-speaking countries Limited to articles and reports published from the year 2000-onwards, with the exception of seminal articles or reports, due to relevance to the current health care context 25
Conclusion This jurisdictional scan suggests that there are a number of take-away lessons from other jurisdictions for Ontario However overall, it appears Ontario is relatively advanced with respect to patientlevel costing data, and currently has developed a relatively more complex patientbased inpatient-rehabilitation funding model compared to other jurisdictions worldwide Future work should focus fostering collaborations between jurisdictions to maximize information exchange, including solutions to challenges for inpatient rehabilitation case mix and activity-based funding models 26
Next Steps Inclusion of weighted motor FIM items in IPR case mix grouper (as in Australia and the United States) Trade off between resources spent and increase in predictive ability of the model Importance of inclusion of co-morbidities (as in the United States) Importance of diagnostic-related groupers (not used by the United Kingdom) Importance of inclusion of age in IPR case mix grouper (a rarity in most jurisdictions) Importance of other adjustments (e.g., facility type) Improving the percent of variance explained in the cost model (separate and distinct from the variance explained in the case mix grouping model). Modify short stay adjustment 27?
APPENDIX 28
Ontario Inpatient Rehabilitation Cost Weight (RCW) At discharge, each patient episode is assigned an Rehabilitation Cost Weight (RCW). The RCW depends on the assigned Rehabilitation Patient Group (RPG) and the length of stay (LOS) of the episode of care. Short-stay cases: Episodes with LOS equal to, or less than 3 days are assigned the same short stay RCW of 0.0667. Long-stay cases: Unique to each RPG. Long stay outliers are assigned a RCW which is the sum of the RCW and a per diem weight of days beyond the trim point. 29
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