Hospital Funding Policy and Activity-Based Funding
The Provinces of British Columbia, Alberta and Ontario have each recently announced plans regarding changes in the way hospitals their provincial hospitals will be funded. The hospital funding changes represent a departure from the status quo and have the potential to significantly alter the landscape of hospital funding in Canada.
At $45 billion annually, hospital spending comprises the largest proportion of health care spending dollars, and is consequently a key target for provinces trying to reduce their health care costs. At the same time, provinces face pressures to reduce surgical wait times, and maintain high quality, safe care for the public. Thus, policymakers are left with the seemingly paradoxical objective of trying to reduce hospital costs to meet budget targets while increasing surgical volume to reduce wait times.(1)
In Canada, hospitals have traditionally been funded with a ‘lump sum’ to provide treatment and care of all patients within a given period. As a hospital funding policy, this approach is known as ‘global budgeting,’ and while not the sole technique for funding hospitals, this is the norm in Canadian provinces.(2) While global budgets provide flexibility to hospital managers to allocate funds to respond to changes in demand or patient characteristics, this policy largely bases hospital payments on historical payments, politicking, and perceived need of the local population; because of this, global budgets are criticized for their lack of transparency, perpetuating cultural spending norms and their impediments to innovation.
To address these limitations, the provinces are interested in exploring different mechanisms to fund hospitals. One policy that has garnered significant interest is activity-based funding (ABF). ABF remunerates hospitals based on two factors: 1) the type of services they provide to their patients; and 2) the volume of services.
The principle of ABF provides that each patient’s hospitalization is funded by a pre-determined amount whose level is set according to the characteristics of the patients and the type of services provided by the hospital. For example, a hospital receives more funding for a kidney transplant than it does for a normal delivery of a baby. This policy leverages hospitals economic interests by allowing hospitals to retain the difference between the funding level and actual cost. In theory, cost efficiencies are sought by shortening the length of stay and changing the mix of labor and non-labor inputs to hospital care. The biggest criticism of ABF is that by minimizing cost, hospital quality may suffer by ‘skimping’ on costs or quality.
Whether increasing the amount of hospital care is desirable, or can even be realized in Canada, remains to be determined. However, there is breadth of international experience with ABF upon which we can draw insights. Originating from the United States (US), ABF was found to be associated with shorter length of stays and greater use of post-acute care.(3-5) More closely mirroring Canadian health care, many European countries and Australia have also adopted ABF and have also reported shorter lengths of stay and shifting of activity to post acute care.(6-14) However, some literature notes ABF is correlated to increases in the number of patients treated and increasing spending. (6, 11, 14-20)
We turn to these international experiences to anticipate potential outcomes of ABF in Canada. Three important aspects of hospital care that are relevant to Canadians include volume of hospital care, access to care, and quality.
With regard to volume of hospital care, Australia, Norway, and Sweden have all reported an increase in patients treated after implementing ABF policies, (8, 11, 14). Greater patient throughput results in the generally desireable effect of reducing wait times for surgical procedures. Increase in volume, however, is not without its drawbacks; research from some countries suggests that ABF may lead to an over-provision of hospital care, particularly for care that tends to be the most profitable. (11, 21-24) Under the US Medicare program, for example, the treatment of heart bypass is more profitable than the treatment of pneumonia; consequently, MedPAC (the agency responsible for paying Medicare) has observed an increase in treatment capacity of the former relative to the latter. (25)
While access may be improved by shortening waiting times, the US has observed reduced access for more costly patients when hospitals are paid for the ‘average’ patient (25), and those with chronic illness or disability, because they are more expensive to treat, may find reduced access to care. (26) Moreover, efforts to ‘centralize’ some hospital services to capture economies of scale may lead to reductions in geographic access.(27)
The effect of changing funding policy on quality of hospital care has also been studied. Mortality was been unchanged in the US (28, 29), England (9) and Italy (30) after ABF implementation; while an evaluation of 28 other countries detected a weak association between ABF policies and lower mortality.(6) Based on patient surveys, Norway has found an increase in patient satisfaction as a result of lower wait times attributed to ABF.(31)
ABF in Canada
While ABF has not been widely implemented in Canada, some Canadian provinces (notably BC, Alberta and Ontario) are experimenting with ABF policies aimed at increasing volumes for certain surgical procedures. For example, hip and knee replacement, cataract surgery, selected cardiac and diagnostic imaging procedures have all been the targeted with ABF policies (i.e., “incremental funding”), as provinces try to utilize perceived excess capacity in hospitals.
A significant change in hospital funding policy in Canada is not without risks; ABF relies very heavily on standardized, timely and accurate hospital data.(32) Moreover, the provinces and hospitals have to agree on hospital output definitions and set realistic, achievable funding levels. (33, 34) While the story of ABF’s implementation in Canada has yet to be written, it will only be through careful study that we can begin to understand the consequences of these policies on hospitals and patients.
Jason Sutherland, Assistant Professor
Trafford Crump, post doctoral fellow
Centre for Health Services and Policy Research
University of British Columbia
(1) Canadian Institute for Health Information. National Health Expenditure Trends, 1975 to 2009. Ottawa, Ont : CIHI, 2009.
(2) McKillop, I., Pink, G.H. and Johnson, L.M. Acute care in Canada. A review of funding, performance monitoring and reporting practices. Ottawa, Ontario : CIHI, 2001.
(3) Kahn, K.L., Rubenstein, L.V., Draper, D., Kosecoff, J., Rogers, W.H., Keeler, E.B. and Brook, R.H. The effects of DRG-based prospective payment on quality of care for hospitalized Medicare patients. Journal of the American Medical Association. 1990, 264(15): 1953-1955.
(4) DesHarnais, S., Chesney, J. and Fleming, S. Trends and regional variations in hospital utilization and quality during the first two years of the payment system. Inquiry. 1988, 25: 374-382.
(5) Guterman, S., Eggers, P.W., Riley, G., Greene, T.F. The first 3 years of Medicare prospective payment: An overview . Health Care Financing Review. 1988, 9(3): 67-77.
(6) Moreno-Serra, R. and Wagstaff, A. System-wide impacts of hospital payment reforms, evidence from central and eastern Europe and central Asia, Policy research paper 4987. Washington, USA : Development Research Group, Human Development and Public Services Team, The World Bank, 2009.
(7) Jackson, T. Using computerised patient-level costing data for setting DRG weights: the Victorian (Australia) cost weight studies. Health Policy. 2001, 56(2),149-163.
(8) Duckett, S.J. Hospital payment arrangements to encourage efficiency: the of Victoria, Australia. Health Policy. 1995, 34: 113-134.
(9) Farrar, S., Yi, D., Sutton, M., Chalkley, M., Sussex, J. and Scott, A. Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis. British Medical Journal. 2009, 339:b3047.
(10) Kroneman, M. and Nagy, J. Introducing DRG-based financing in Hungary: a study into the relationship between supply of hospital beds and use of these beds uder changing circumstances. Health Policy. 2001, 55: 19-36.
(11) Ettelt, S., Thomson, S., Nolte, E. and Mays, N. Reimbursing highly specialised hospital services: the experience of activity-based funding in eight countries. London: London School of Hygiene and Tropical Medicine, 2006.
(12) Forgione, D.A., Vermeer, T.E., Surysekar, K., Wrieden, J.A., and Plante, C.C. DRGs, costs and quality of care: An agency theory perspective. Financial Accountability and Management. 2005, 21(3): 291-308.
(13) Stromberg, L., Ohlen, G. and Svensson, O. Prospecive payment systems and hip fracture treatment costs. Acta Orthop Scand. 1997, 68(1): 6-12.
(14) Street, A., Vitikainen, K., Bjorvatn, A. and Hvenengaard, A. Introducing activity-based financing: a review of experience in Australia, Denmark, Norway and Sweden. University of York, UK : Centre for Health Economics, 2007.
(15) Kjerstad, E. Prospective funding of general hospitals in Norway – Incentives for higher production? International Journal of Health Care Finance and Economics. 2003, 3: 231-251.
(16) Biorn, E., Hagen, T., Iversen, T. and Magnussen, J. The effect of activity-based financing on hospital efficiency: A panel data analysis of DEA efficiency. Health Care Management Science. 2003, 6: 271-283.
(17) Rogers, R., Williams, S., Jarman, B. and Aylin, P. “HRG drift” and payment by results. British Medical Journal. 2005, 330: 563.
(18) Arnaboldi, M. and Lapsley, I. Activity based costing in healthcare: A UK case study. Research in Healthcare Financial Management. 2005, 10(1): 61-75.
(19) Mikkola, H., Keskimaki, I. and Kakkinen, U. DRG-related prices applied in a public health care system- can Finland learn from Norway and Sweden? Health Policy. 2001, 59: 37-51.
(20) Magnussen, J., Hagen, T.P. and Kaarboe, O.M. Centralized or decentralized? A case study of Norwegian hospital reform. Social Science and Medicine. 2007, 64: 2129-2137.
(21) Ginsburg, P.B. Recalibrating Medicare payments for inpatient care. New England Journal of Medicine. 2006, 355(20):2061-2064.
(22) Berenson, R.A., Bodenheimer, T. and Pham, H.H. Specialty-service lines: Salvos in the new medical arms race. Health Affairs. 2006, DOI 10.1377/hlthaff.25.w337.
(23) Medicare Payment Advisory Committee. Report to Congress: Physician-Owned Specialty Hospitals. Washington, D.C. : Medicare Payment Advisory Committee, 2005.
(24) Hayes, K.J. Pettengill, J. and Stensland, J. Getting the price right: medicare payment rates for cardiovascular services. Health Affairs. 2007, 26(1), 124–136.
(25) Ginsburg, P.B. and Grossman, J.M. When the price isn’t right: How inadvertent payment incentives drive medical care. Health Affairs. 2005, DOI 10.1377/hlthaff.W5.376.
(26) Batavia, A.L. and Dejong, G. Disability, chronic illness, and risk selection. Archives of Physical Medicine and Rehabilitation. 2001, 82(4), 546-552.
(27) O’Reilly, J. and Wiley, M. Working paper no. 237: How local is hospital treatment? An exploratory analysis of public/private variation in location of treatment in Irish acute public hospitals. Dublin, Ireland : Economic and Social Research Institute, 2008.
(28) Mayer-Oakes, S.A., Oye, R.K., Leake, B. and Brook, R.H. The early effect of Medicare’s prospective payment system on the use of medical intensive care services in three community hospitals. Journal of the American Medical Association. 1988, 260(21): 3146-3149.
(29) Dismuke, C.E. and Guimaraes, P. Has the caveat of case-mix based payment influenced the quality of inpatient hospital care in Portugal. Applied Economics. 2002, 34(10): 1301-1307.
(30) Louis, D., Yuen, E.J., Braga, M., Cicchetti, A., Rabinowtiz, C., Laine, C. and Gonnella, J.S. Impact of a DRG-based hospital financing system on quality and outcomes of care in Italy. Health Services Research. 1999, 34(1): 405-415.
(31) Hagen, T.J., Veenstra, M. and Stavem, K. Efficiency and patient satisfaction in Norwegian hospitals. Oslo, Norway : Health Organization Research Norway, 2006. ISSN 0808-7857.
(32) Preyra, C. Coding response to a case mix measurement system based on multiple diagnoses. Health Services Research. Vol. 39(4), 1027-1046.
(33) Clement, F.M., Ghali, W.A., Donaldson, C. and Manns, B.J. The impact of using different costing methods on the results of an economic evaluation of cardiac care: microcosting vs gross-costing approaches. Health Economics. 2009, 18: 377-388.
(34) Botz, C.K., Sutherland, J.M. and Lawreson, J. Cost weight compression: impact of cost data precision and completeness. Botz, C.K., Sutherland, J.M. and Lawreson, J. (2006). Cost weight Health Care Financing Review. 2006, 27(3), 1-12.