Managing and Regulating Contracted Medicare Services in Non-Hospital Facilities

Allin S., Sherar M., Church Carson M, Jamieson M., McKay R., Quesnel-Vallée, A., Sproule J., & Marchildon G.


Conference:
CHSPR 2020
Date: March 4, 2020


Abstract


T
he number of for-profit, free-standing, non-hospital facilities (NHFs)providing advanced diagnostic and surgical services has grown in recent decadesWe compared the mechanisms used by provincial governments to holdNHFsaccountable for the quality and cost of publicly funded advanced diagnostic (e.g. MRI, CT Scans) and surgical services under Canada Health Act (or Medicare) rules, considering three levers of accountability: regulation, financial incentives, and information.

Using astructured data collection templatewe drew on literature and consultations with local experts (and ministry of health/ health authorities in some cases), to collect relevant information in the two sectors (diagnostic and surgical) in five provinces: British Columbia (BC), Alberta, Saskatchewan, Ontario, and Québec. We found considerable variation in the approaches taken by these provincial governments to regulate and contract with NHFsHowever, all rely primarily on regulatory approaches, with limited use of financial incentives and performance information. 

In diagnostics, Québec has delisted all advanced diagnostics provided in NHFs from the provincial insurance program,thus all services provided at NHFs are to those with the willingness and ability to pay out-of-pocketIt is the same in Alberta, save a single NHF contract. BChas two NHFs owned by a health authority, but opted-out physicians may still operate NHFs. Ontario is the only province which bans direct patient billing, so private NHFs can only operate on Medicare patients at the direction of the ministry. Saskatchewan has a “buy two, get one” approach where each privately funded scan requires the provider to perform one for the public system at no cost.

The majority of surgeries performed in publicly funded NHFs are ophthalmologic and gynecological in all five provinces.The western provinceshealth authoritiescontract NHFs directly for Medicare services (each with their own unique payment mechanism). Ontario’s ministry of health sets standards and contracts providers using global budgets, whilepublicly funded surgeries in NHFs in Québecare limited to a pilot project with three NHFs launched in 2016.Although in all provinces NHFs provide surgical services to Medicare patients, only in Ontario is there a ban on private payments for surgeries in NHFs. 

Poster designed by Monika Roerig and Michael Sherar.

View the poster here [PDF]