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3 insights from Ontario's big health policy shake-up

March 21, 2019

    Earlier this month, Ontario's government introduced Bill 74, or The People's Health Care Act. The widely anticipated proposal lays the groundwork for the creation of two new-in-kind population health entities:

    April 2 webconference: What Ontarians need to know about ACOs

    • Integrated delivery networks: These systems, called Ontario Health Teams (OHTs), will be voluntary networks of multiple providers that deliver coordinated care for a specific geography or patient population; and
    • An Ontario 'super agency': This entity, called Ontario Health, will consolidate all 14 of Ontario's current planning and commissioning bodies with six other agencies, including Cancer Care Ontario, Health Quality Ontario, and eHealth Ontario.

    Most news coverage thus far has understandably focused on the super agency, as the phrase 'super agency' is bound to generate headlines. However, consolidating and redirecting reporting lines are not new concepts to health care.

    What is truly new-in-kind, though, are the Ontario Health Teams. These will have serious implications for providers who are now being asked to form care networks and voluntarily manage populations in ways never before seen in Ontario.

    We analysed the proposed legislation to understand the key implications for providers and offer guidance on how to navigate the transition to OHT-status. Here are the three biggest insights to keep top-of-mind, with key guidance on each:

    1. OHT aspirants require more clarity on how patients will be attributed to their networks.

    The proposed Health Teams share clear similarities to accountable care pushes elsewhere. Similar to the ACOs in the US, OHTs are voluntary endeavours. And similar to Integrated Care Systems in the UK, OHTs are slated to be larger in size, and provision of primary care isn't required to participate (see insight number three below). Further, all three models prioritise digital health and share the overall goal of reducing total cost.

    However, there are some components that remain unique to Ontario. One is that OHTs will have the choice of caring for a specific population or a specific geography. This could create challenges around who 'owns' the patient. For example, a cancer patient could theoretically be attributed to one OHT that covers their catchment area as well as another one that cares only for oncology patients. If not thought through, this will lead to duplication and complicate financial reporting due to care 'leakage' outside of each network.

    Advisory Board guidance: The US and the UK have approached this problem from different angles. The US attributes patients to ACOs based on which GP the patient is enrolled with. Conversely, the UK attributes patients to ICSs based on where they live. And each has rules for how to financially account for a patient that seeks care outside the network. At this stage, providers should look to both countries to learn about their implications and push Ontario's Government to clarify how this specific component will work. Register here for our upcoming Ontario-only webconference on US and UK accountable care models.

    2. Ontario has yet to dictate how it will incentivise doctors to participate in the model's development and success.

    The bill does not explain how specialists will be attributed or paid, but assuming they remain independent practitioners who have little financial incentive to shift toward value, assembling an 'accountable physician enterprise' will be no simple task.

    Accountable care organisations thrive when their physicians can accomplish two things: adhering to cost-appropriate care standards set by the system, and keeping their referrals in-network. This second one is particularly important: OHTs will need to consistently care for patients over time in order to coordinate their care and manage their conditions longitudinally to keep costs down. If a patient is referred outside of the network, each visit could result in unforeseen care plan changes or costs.

    Advisory Board guidance: It's easy to assume that alignment efforts are for naught unless you can employ doctors, but our research shows that even employed doctors refer in-network only around two-thirds of the time. Conversely, there are a range of doctor alignment tactics that urge them to be more loyal to the system: nicer technology, transparent reporting on quality, a culture that prioritises the patient experience, etc. Systems should begin using these levers as soon as possible. Read more about bolstering doctor loyalty here.

    3. Primary care's 'optional' status should be read with pause.

    Bill 74 allows an OHT to assemble if it has the ability to "deliver in an integrated and coordinated manner" at least three of the following types of services:

    • hospital services;
    • primary care services;
    • mental health or addictions services;
    • home care or community services;
    • long-term care home services;
    • palliative care services; and
    • any other prescribed health care or non-health service that supports the provision of health care services.

    While primary care is optional here, lessons from around the world show that it is mission-critical for managing populations. If GP services are not financially and operationally connected to the broader population health network, it will be very difficult to improve population health outcomes.

    In both the US and the UK, systems have been successful at reducing downstream demand and controlling total cost when GPs are able to adequately treat patients at a cheaper site of care and catch risk factors before they escalate into acute episodes.

    Advisory Board guidance: Primary care should be seen as a mandatory partner rather than an optional one. It's no secret that partnering with GPs has historically been challenging, but there are mechanisms to help. Consider extending system 'sweeteners' to GPs to engage them in OHT goals, and give them a seat at the table when deciding on standards that promote preventive care. Read more on partnering with GPs here.

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