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Health and Long Term Care Proposed Evidence Based Changes for OHIP
Monday, March 14, 2011 at 5:05:25 PM

HEALTH AND LONG TERM CARE
PROPOSED EVIDENCE BASED CHANGES FOR OHIP

Ontario is proposing evidence based changes to OHIP coverage for certain health care services as well as proposed changes for OHIP-funded out-of-country procedures. The public is invited to comment on the proposed changes which are posted on Ontario’s Regulatory Registry until March 13, 2011.

Ontario consulted with experts, including the Ontario Medical Association, in developing these proposed changes.

PROPOSED CHANGES TO OHIP PAYMENTS FOR HEALTH SERVICES INCLUDE:

• New fee codes for CT (virtual) colonoscopy and CT cardiac angiography that will clarify when the procedure is covered by OHIP.

• Removal of payments for sinus ultrasound as this procedure has proven to be ineffective.

• Restriction of payments for pre-operative testing prior to certain procedures, such as colonoscopy, cystoscopy, carpal tunnel release, and arthroscopy, as evidence indicates it is not effective.

PROPOSED CHANGES TO THE FUNDING OF THE OHIP OUT-OF-COUNTRY PROGRAM INCLUDE:

• Aligning out-of-country drug funding with the Ontario Public Drugs Program.

• Restricting approval of out-of-country coverage if an identical or equivalent service is performed in Ontario by an available Ontario doctor who can perform that service within their scope of practice;

• Requiring the support of a specialist when applying for funding of an out-of-country health service.

• Ensuring other provinces are considered before sending a patient for an out-of-country service.

• Clarifying the funding rules for out-of-country laboratory services, including genetic testing.

THE PROPOSED CHANGES TO OUT-OF-COUNTRY SERVICE FUNDING WOULD NOT IMPACT EMERGENCY PROCEDURES:

This proposal is part of Ontario’s Excellent Care for All strategy which ensures that funding for health care is supported by evidence based practices. It also makes sure that funding is directed where the evidence shows the greatest value, without compromising access to health care services that are deemed medically necessary by experts.

QUICK FACTS

• The proposed changes to OHIP payments for health services would save $5.1 million annually.

• Funding of the out-of-country services has grown at an average rate of 21.2 per cent over the past six years. The proposed changes to the Out-of-Country Prior Approval Program would save $28.5 million annually.


NEW EVIDENCE AND QUALITY-BASED CHANGES PROPOSED FOR OHIP

Ontario is focusing on medical evidence to ensure funding is provided for services that improve patient care. After consulting with experts, Ontario is proposing a number of changes to OHIP coverage. As well, Ontario is bringing more services to Ontarians closer to home by making improvements to the Out-of-Country program.
These changes will be posted on the Regulatory Registry until March 9, 2011 and are expected to save $33.6 million annually if implemented.
CT (VIRTUAL) COLONOSCOPY ($0.1 MILLION IN SAVINGS)
A CT (virtual) colonoscopy is a test for viewing the colon by computed tomography (CT) when a standard colonoscopy cannot be performed. Some patients have difficulty undergoing a colonoscopy due to previous surgery or scarring. The virtual colonoscopy provides access to patients for testing who would otherwise have difficulty undergoing a colonoscopy.
Ontario is proposing a new fee code that describes when virtual colonoscopy is insured. The service will not be insured when used as a general screening tool.
SINUS ULTRASOUND ($0.1 MILLION IN SAVINGS)
Sinus ultrasound is an older technology to view facial sinus cavities of patients with chronic sinusitis.
Ontario is proposing to remove payment for this service because it is an effective technology for sinuses and has been replaced by CT or sinus endoscopy.

PRE-OPERATIVE TESTING ($3.0 MILLION IN SAVINGS)
Pre-operative testing is routine testing (ECG and chest x-ray) prior to surgery. Hospitals have historically required tests for all surgeries, but evidence from medical studies does not support the practice.
Ontario is proposing to restrict pre-operative testing for colonoscopy, cystoscopy, carpal tunnel release, and arthroscopic surgery. In medically necessary cases (e.g., if patient has a constant cough or an abnormally high hear rate), doctors would still receive payment for these tests if the ordering doctor can demonstrate the need for the test and obtain approval from the Ministry.
Changes to Funding for Insured Services Received Out of Country
DRUG ALIGNMENT ($22.0 MILLION IN SAVINGS)
The Ontario Public Drugs Program, which has a rigorous drug review process, is responsible for determining which drugs receive public funding in Ontario through programs including the Ontario Drug Benefit Program, the New Drug Funding Program and the Exceptional Access Program.
Historically, out of country (OOC) drug therapy may be funded where the drug is not available in Ontario. However, the decision process for OHIP funding of OOC drug therapy currently is not aligned with the decision process under the Ontario Public Drugs Program. Ontario is proposing an amendment that would align OOC drug therapy with the Ontario Public Drugs Program.
UTILIZING ONTARIO EXPERTISE ($3.0 MILLION IN SAVINGS)
Prior approval from the Ministry of Health and Long Term Care is required in order for patients to receive OHIP funding for out-of-country hospital and medical services. Approval is not granted for out-of-country services when an Ontario doctor can perform an identical or equivalent procedure without critical delay.
Ontario is proposing an amendment that would ensure that an identical or equivalent service is performed in Ontario, rather than out-of-country, if there is an available Ontario doctor who can perform the service. This amendment would enhance patient safety and eliminate the need for Ontarians to unnecessarily travel-out-of-country for health services. It would also support development of expertise within Ontario which benefits all Ontario patients.
REQUIRING SPECIALIST ENDORSEMENT FOR APPLICATIONS ($1.0 MILLION IN SAVINGS)
Current regulations require that an application for prior approval of funding of an out-of-country health service be submitted by a practicing Ontario doctor.
Ontario is proposing a regulation requiring that an application for funding be endorsed in writing by a specialist. This measure will ensure that applications are assessed by specialists who can ensure that the requested services are medically necessary, appropriate and not experimental. The specialist would also be able to confirm that the services are either not performed in Ontario or cannot be obtained without medically significant delay.
All other provinces (except Alberta) have this requirement for out-of-country services.
CANADA FIRST ($0.5 MILLION IN SAVINGS)
There is currently no mechanism for the province to redirect patients who have applied for funding for out-of-country services to other provinces when those services are not available in Ontario.
Ontario is proposing to promote providers in other provinces over out-of-country providers for select services when other provinces may have the capacity that Ontario lacks.
Health services obtained in other provinces generally cost one-third to half to as much as the same services obtained out-of-country, and usually can be billed in whole or part at rates established by inter-provincial agreements. All other provinces in Canada have this requirement for out-of-country services.

LABORATORY SERVICES INCLUDING GENETIC TESTING ($2.0 MILLION IN SAVINGS)
The out-of-country funding for laboratory testing currently does not align with in-province funding or the prior approval process for all other out0of-country services. The proposed amendments would align the funding with the services, including:
• Require that an application for payment of an out-of-country laboratory test be endorsed by an Ontario doctor with a designation as a Fellow of the Canadian College of Medical Geneticists.
• Require that an out-of-country laboratory test including a genetic test must be for the purpose of diagnosis, prevention or treatment.
• Clarify that the funding of out-of-country lab testing is to be determined under the lab provisions of the regulation and not under the more general out0of-country hospitals and health facilities provisions.
This proposal would help to ensure that genetic tests funded out-of-country provide necessary information to make meaningful decisions on the management of the specific patient.

TRANSITIONAL PROVISIONS
Transitional provisions would ensure that patients whose out-of-country treatment was approved prior to the effective date of these amendments would not be adversely affected. This measure ensures that existing approvals for these services will not be affected by these proposed changes.