Cost Effective Universal Access: Leveraging the strengths of Ontario’s Designated Physiotherapy Clinics to provide cost effective physiotherapy services.
Ontario’s health system is challenged by an aging population and a need to constrain costs. More health care dollars per person are spent on those over 65 than any other demographic—almost three times more than those 45-64.1 By 2021, the number of Ontarians over the age of 65 will increase by 800,000. The need to constrain costs is forcing healthcare providers to identify and implement efficiencies. The government has committed to transforming Ontario’s healthcare system, to provide better access to high quality care and achieve greater value for money, largely by delivering more care in the community. Efforts are being made to ensure that patients can access care as close to their home as possible.
With the rise in demand, Ontario’s 94 Designated Physiotherapy Clinics (DPCs) have been called upon to increase the number of low cost physiotherapy services provided to patients in clinics, patients’ homes, and Long Term Care (LTC) and retirement homes. DPC physiotherapists currently provide services throughout the province. The lowest cost provider of physiotherapy services, DPC physiotherapists provide the best value for Ontario health care dollars. The timely care they provide in the community and home keeps patients out of expensive emergency rooms and hospital beds.
As Ontario’s healthcare system is transformed into a more patient-centred system, the Designated Physiotherapy Clinics Association (DPCA) believes that access to the services they provide should be expanded. Greater utilization of DPC physiotherapy services and expertise will increase access, achieve cost efficiencies and increase patients’ quality of life by preventing visits to the ER, reducing lengths of stay in hospitals and enabling patients to live in their own homes longer. DPCA members have the infrastructure and capacity to provide universal access. Expanding the services provided by this effective, low cost provider at the community level will help the government achieve its objectives.
Our vision for Ontario is universal access to OHIP funded physiotherapy services for those who need it, where they need it, when they need it. To achieve this, we recommend:
1. Change the current regulations to permit existing DPC physiotherapists currently working in LTC and retirement homes to extend their services to patients in the community who meet OHIP eligibility criteria, thus leveraging the existing DPCA network to provide OHIP funded physiotherapy services in all communities across Ontario;
2. Instate DPC physiotherapists as members of Family Health Teams;
3. Expand OHIP funded community based rehabilitation to improve services for post surgical hips and knees;
4. Allow and encourage DPC physiotherapists to deliver Home Care;
5. Expand the scope of practice of physiotherapists to order x-rays, allowing Designated Physiotherapy Clinics to become primary assessment centers for patients with musculoskeletal and soft tissue injuries;
6. The DPCA and Health Quality Council should collaborate to develop Health Quality Indicators for OHIP funded physiotherapy services.
In addition to these six recommendations, as Ontario transitions to patient-centred funding models for hospitals, LTC and CCACs, the DPCA encourages the Ontario Government to continue to pay for OHIP-funded physiotherapy services through a model that is transparent, accountable and tied to outcomes. In addition to the current Fee For Service model, the DPCA will also propose alternate funding models that enable the delivery of patient-centred care, at the right time and in the right place. 2 Designated Physiotherapy Clinics Association1Ontario Ministry of Infrastructure, “Building Together: Jobs & Prosperity for Ontario”, Long Term Infrastructure Plan, June 2011
The Designated Physiotherapy Clinics Association (DPCA) is an association of licensed community-based physiotherapy service providers designated as able to bill OHIP on a fee for service basis. DPCA members serve patients in 94 registered Designated Physiotherapy Clinics (DPC) across Ontario and within the patient’s home, be it a private home, retirement home or Long Term Care (LTC) home.
In Ontario, physiotherapy services are provided in the hospital, in DPCs, private clinics and through the 14 Community Care Access Centres (CCAC). In 1963-64, to alleviate demand for physiotherapy services in the community that the hospital system was unable to meet, the Ministry of Health issued 94 licenses to privately owned physiotherapy clinics across Ontario, designating these clinics as able to bill OHIP for the physiotherapy services they provided to patients referred to them by a doctor. No new licenses have been granted since.
Ontario’s DPCs provide high quality, medically necessary, prevention-focused care. They see patients within 24-48 hours upon receiving a physician referral. DPCs are the lowest cost provider of physiotherapy services in Ontario, billing OHIP at a rate of $12.20 per treatment, for a maximum of 100 treatments per year per patient (patients identified by their doctor as having “exceptional need” may receive an additional 50 treatments). OHIP only covers services provided to patients under 19 and over 65 years of age, patients on social assistance and acute, overnight hospital patients. OHIP is only billed for the treatment of patients without extended health insurance who cannot afford to pay themselves.
In LTC homes, DPC physiotherapists provide critical services to residents to prevent falls, establish appropriate transfer and mobility status. They also provide timely rehabilitation for post-surgical hip and knee patients so they can be discharged quickly from the hospitals back to the LTC homes. Infrastructure and leadership provided by DPC physiotherapists within LTC homes adds value and support above and beyond the actual physiotherapy provided (reduce falls, limit restraint use). It is estimated that over 90% of LTC residents have been referred to receive at least 100 physiotherapy treatments.22 Data is collected by DPCA members and provided to LTC providers.
Value for money: the costs of physiotherapy services
CCACs receive $50 – $60 million per year to deliver physiotherapy services in the home and community. Treatments provided through these programs cost $120 per visit, for a maximum of five visits. As wait lists grow, and less intensive consultative models of treatment are deployed, patients are waiting longer for fewer treatments with less emphasis on the direct 1:1 treatment utilized by the DPCs.
Private clinics charge an average of $80 per assessment and $60 per treatment- five times more than DPCs. Availability and accessibility are not synonymous; many patients do not have the means to access private practitioners, regardless of their proximity to a private clinic. The erosion of publicly funded physiotherapy services creates barriers to good health.
The OHIP funded fee for physiotherapy provided by DPC physiotherapists in clinics and LTC homes is $12.20 per treatment. This rate has been in effect since 1992 and has not received any inflationary increase. The existing billing codes eliminate the need for additional layers of costly bureaucracy. This Fee For Service (FFS) model of payment is accountable, flexible and transparent – OHIP is only billed for services rendered and this funding follows the patients. 3 Designated Physiotherapy Clinics Association
Since 2004 there have been numerous modifications to physiotherapy funding. In the 2004 Budget, the Ontario Government announced its intention to delist physiotherapy, optometry and chiropractics from the OHIP Schedule of Benefits. The outcry from seniors and families of LTC residents was so significant that physiotherapy was partially relisted. This would have eliminated an entire stream of physiotherapy services and created a significant gap in access to community-based physiotherapy.
On its own initiative, to expand access to seniors living in LTC, in 2005-2006 the Ontario Government extended government funded physiotherapy to the approximately 250 LTC homes that had previously been without access to OHIP funded physiotherapy services. Expanding access to care into these 250 facilities significantly increased the total spend on OHIP funded physiotherapy. The Government also developed an alternative funding mechanism with an allocation set at $600 per bed per year. This funding level was based on, roughly, 100 treatments per year, at the $12.20 level, assuming that only 50% of LTC residents require physiotherapy. No metrics or data have ever been produced to support this funding formula.
Today, DPC facilities provide OHIP funded physiotherapy services to almost 600 of Ontario’s 680 LTC homes; few use the alternative funding model. The alternative funding mechanism added approximately $15 million to the Government’s overall LTC physiotherapy expenditure. Approximately 75% of the LTC homes that signed up for the alternative funding mechanism have not renewed their contracts and now use DPC services, as the $600 per bed per year model was found to be unsustainable.
All Ontarians should have timely access to the physiotherapy services that they need. These services should be available to all patients within their own community, in the quantity that they need, without excessive wait times that negatively affect their outcomes. In this paper, we demonstrate how DPC facilities and services create value and savings across the Ontario health care system and argue that the system will benefit from an expansion of the scope of practice of physiotherapists and an expansion of the mandate of the DPCA members. We encourage the Government of Ontario to leverage the existing network of the DPCA physiotherapists to provide the right care, at the right time, in the right place- ensuring that Ontarians have access to the best physiotherapy in the best possible location for them.
RISING DEMAND: THE NEEDS OF AN AGING DEMOGRAPHIC
Ontario’s population is aging. In five years the number of people over 65, seniors, is projected to grow from 1.8 million to 2.3 million and will reach 4.2 million by 2036. As people age they require access to higher levels of services. Seniors use more health services than any other age group; in 2008 an average of $10,802 was spent on the health care per person over 65- three times that spent on those ages 45-64.3 Seniors are the greatest beneficiaries of the OHIP funded physiotherapy services provided by DPCA members; demand for DPC services grows in tandem with the aging of the population. The number of individuals who accessed OHIP funded physiotherapy in 2005 was 59,500. By 2010 that number swelled to 152,355. The majority of services are provided by DPCA members, who currently serve 4.9% of Ontario seniors.43 Ontario Ministry of Infrastructure “Building Together: Jobs & Prosperity for Ontario”, Long Term Infrastructure Plan, 2011 4 In a report provided to the Physiotherapy Services Committee, MOHLTC provided summary utilization and related fee data “Utilization and Trend Analysis of Physiotherapy Services in Ontario for the period FY 2005 – FY 2009” 4 Designated Physiotherapy Clinics Association
Despite this rising demand, the quantity of services provided by hospitals and CCACs has eroded. The provincial government funds physiotherapy services provided in hospitals but payment for these services comes out of the institution’s budget. Under continuous budgetary pressure, and looking for savings, hospitals are cutting and off-loading services. 27 Ontario hospitals have closed their out-patient physiotherapy departments and clinics, discharging patients to the community without guaranteeing them access to rehabilitative or chronic care services. CCACs, under financial constraint, have cut the quantity of services they supply, providing home care physiotherapy to 18,368 fewer patients in 2008 than they did in 2007.55 The DPCA requested and received MOHLTC utilization data on CCAC Physiotherapy services from 2005/2006 – 2008/2009 6 MOHLTC, “Utilization and Trend Analysis of Physiotherapy Services in Ontario for the period FY 2005 – FY 2009”
Demand for physiotherapy services has also grown substantially within retirement homes, LTC and the community. The supply of LTC beds has not kept pace with the growth in demand. The number of LTC beds has only increased by 581 since 2006 and now 25,000 patients are waitlisted for the province’s 76,000 beds. Waitlisted patients place great demands on existing community providers. Many seek care in retirement homes, which provide varying levels of care. Most retirement homes are unable to manage their patient’s needs on their own as one fifth of their residents have complex medical needs that meet or exceed the requirements to be admitted into a LTC home.
Increasing patient acuity is also driving the rising demand for physiotherapy. Data from 64 Ontario retirement homes show that patient acuity increased by 12 percent in 2008 and 10 percent in 2009. The rising number of patients identified by their doctor as “exceptional need” is further straining the system, as these patients require access to an additional 50 treatments. Between 2006 and 2009, the number of LTC located services for “exceptional need” patients increased by 52 percent.6 This reality is significantly contributing to the rise in the quantity of services billed to OHIP by DPCA members.
To meet the rising demand for physiotherapy services, the DPCA has put forward recommendations that will increase access to care. The consequences of long wait times are: decreased patient quality of life, inequality in health outcomes and higher overall long term costs to the health care system.
Decreased quality of life
Without timely access to physiotherapy care, the patient’s health outcomes deteriorate, they lose their mobility and eventually their capacity to live independently. Their quality of life decreases.
Inequality in health outcomes
A patient’s health outcome is directly impacted by timely access to services; the longer the wait, the worse the outcome. Health outcomes are unequal when wealthy individuals realize better health outcomes because they can purchase expensive, timely care from a private provider while those who cannot afford to pay are forced to wait, helpless as their prognosis deteriorates.
Higher long term costs to the health care system
A failure to invest in preventative care today will result in higher costs of delivering more services in future. Without access to timely, rehabilitative care, a patient is more likely to experience a significant and complicated injury in the future. They are more likely to end up in the ER, to occupy a hospital bed and to stay in hospital until they can be moved to the community where they will require access to publicly funded physiotherapy. 5 Designated Physiotherapy Clinics Association
THE SOLUTION: DPC PHYSIOTHERPAISTS PROVIDING THE RIGHT CARE AT THE RIGHT TIME IN THE RIGHT PLACE
Ontario’s doctors, patients and communities have been turning to DPCA members to provide an increasing number of OHIP funded physiotherapy services. Since 2006, the DPCA fee for service claims has grown by 54 percent, a dollar increase of $36 million. This is because DPCs are seeing more patients; between 2006 and 2009, the total number of individuals serviced by DPCA members increased by 26 percent (37,000 individuals). In that time, the number of unique individuals served in LTC homes grew by 18 percent and by 93 percent in private homes.77MOHLTC, “Utilization and Trend Analysis of Physiotherapy Services in Ontario for the period FY 2005 – FY 2009” 8 MOHLTC, “Utilization and Trend Analysis of Physiotherapy Services in Ontario for the period FY 2005 – FY 2009” 9 Carly Weeks, “Falling Seniors: A preventable problem, a huge health burden”, Globe and Mail, May 29, 2011 10 Ontario Health Quality Council, Quality Monitor: 2010 Report on Ontario’s Health System, (section 4.5, 4.6, 12), 2010 11 REVERA Living, the largest provider of LTC and retirement homes in Canada – presented the results of an analysis they performed on their internal data collected on the incidence of falls in their homes, which span the country.
Ontario doctors are referring more patients to DPCA members
Doctors are referring more patients to DPCs and are identifying more patients as requiring additional services. Of the $36 million increase, $9 million is attributed to DPCs treating more patients in LTC and $14 million is due to the increase in the number of treatments per person in LTC. Because the wait lists for LTC beds and CCAC services are so long, doctors are referring wait listed patients to DPCA members to provide them with immediate care in their home. This is why the number of patients seen in private homes by DPCA members has increased by 93 percent since 2006.8
Ontario’s DPCAs offer the best value for money
DPCA members are the most cost effective service providers, providing the greatest value per health care dollar spent. Billing OHIP at a rate of $12.20 per treatment, DPC services are provided at a lower cost per unit than all other publicly and privately funded physiotherapist services. While total spending on DPCA providers has increased, since DPCs provide more services per dollar spent than other providers, the total number of services available to patients is significantly greater than if these services are provided by others.
DPC Fall Prevention programs decrease the incidence of falls, emergency department visits and hip fracture injury, thus decreasing the overall health care expenditure
In 2008-09, nearly 75,000 Canadian seniors were hospitalized after falling. Falls injure/kill thousands of seniors every year, costing the health system $2.8 billion and society $6 billion. 90 percent of hip fractures are caused by falls.9 Hip fractures are of particular concern because they are extremely debilitating, requiring extensive surgery, time in hospital and often result in the individual having to move into a more intensive care facility.
Physiotherapy interventions have been proven to decrease the incidence of falls among seniors. According to findings in the Ontario Health Council 2010 annual report, despite the increase in patient acuity in LTC homes, since the initiation of fall prevention programs there has been no change in the rate of serious falls in LTC homes.10A study conducted in the GTA observed that in LTC homes where patients participated in a DPC physiotherapist led “fall prevention” program, the incidence of hip fractures was 33 percent lower than in homes run by the same operator that did not implement such a program.11 The average annual per patient cost of physiotherapy for LTC residents of 16 visits at $12.20 is much less than the cost of resolving a hip fracture, or a one night stay in an alternate level care bed. 6 Designated Physiotherapy Clinics Association
COST EFFECTIVE UNIVERSAL COVERAGE: FUNDING THAT FOLLOWS THE PATIENT
In the 2012 Ontario Budget, the government committed to reform health funding by accelerating the move to patient-based funding (PBF) for hospitals, LTC and community providers. As the Ontario government develops and implements these changes, OHIP funded physiotherapy should be incorporated in a way that ensures that funding follows the patient and that the physiotherapist continues to treat the patient, until the patient no longer requires treatment. Since DPCA members provide physiotherapy to patients in every region of Ontario, the Ministry could expand access to services by creating PBF models that utilize the existing DPCA network to provide physiotherapy in hospitals, community based clinics, in LTC homes and personal residences across Ontario.
Even though the existing regulations only allow clinic based visits to be located at one site and only within the municipal boundaries in which it is licensed, believing that the absence of a physical clinic should not be a barrier to accessing physiotherapy care, DPCA members have created a network of physiotherapists across Ontario. DPCs can send physiotherapists into any setting- home, LTC, clinic or hospital- in every region of Ontario, without having to create new administrative offices or incur added management and human resources costs. DPCs could provide physiotherapy to ambulatory seniors in every community in Ontario, enabling them to remain living at home and staying out of more costly hospital or LTC homes.
DPCs are flexible, able to deploy staff where they are needed. Patient’s care needs are not static- whether in the community or LTC, they fluctuate. In LTC homes, as DPCs have contracts with multiple operators and homes; instead of contracts that require a fixed number of hours per week, DPC physiotherapists can be deployed to provide only the services required in a given LTC home at a given time. This eliminates waste and reduces the risk that would have otherwise been incurred if the LTC had had to purchase a fixed number of hours. The services provided by DPCs also compliment the proposed Care Coordinator role which the Liberal government has signalled it will create to enhance patients’ navigation of the health system. This role will enhance the system’s ability to ensure that patients receive the proper care, including physiotherapy, in the right setting, and prevent patients from falling through the cracks as they move through the system.
DPCA members provide the most cost effective, best value for money physiotherapy services and recommend that these be seen as a benchmark for incorporation into the new PBF model. In this model, the funding will follow the patient and the physiotherapist will follow the patient. Thus the fee calculation will vary depending on the location of the care and the intensity of the care provided.
Allocating more resources to services provided by Ontario’s DPCs will decrease the total number of health dollars spent per patient. We look forward to working with the Ministry of Health and Long Term Care to develop protocols and methods to provide universal access to physiotherapy services for all those who need it, especially seniors. Funding physiotherapy services in the community will improve seniors’ health, prevent costly falls, decrease ER visits and keep patients out of expensive hospital and LTC beds. A strategy that broadens the scope of practice for physiotherapists, and the mandate of DPCA members, is in congruence with the continuum of care model of health service delivery that Ontario is currently implementing. 7 Designated Physiotherapy Clinics Association
To achieve universal access to OHIP funded physiotherapy services for vulnerable populations, especially seniors, the Designated Physiotherapy Clinics Association recommends that the Ontario government:
1. Change the current regulations to permit existing DPC physiotherapists currently working in LTC and retirement homes to extend their services to patients in the community who meet OHIP eligibility criteria, thus leveraging the existing DPCA network to provide OHIP funded physiotherapy services in all communities across Ontario
Many communities lack access to licensed DPC clinics. The DPCA believes that inequality in access to DPC facilities is unfair and leads to unequal health outcomes. The DPCA believes that universal accessibility can be achieved without issuing new licenses. Since DPC physiotherapists work in LTC and retirement homes across the province, access to services could be expanded by changing the regulations to enable DPC physiotherapists to provide their services to OHIP eligible patients within the community. The absence of a physical clinic should not be a barrier to access to physiotherapy care; leveraging the existing DPCA network of physiotherapists would make OHIP funded physiotherapy treatments accessible to patients living in almost every community across Ontario.
2. Instate DPC physiotherapists as members of Family Health Teams
The geographic expansion of services could also quickly be achieved by incorporating designated physiotherapists into the province’s Family Health Teams. Physiotherapy is listed as one of the inter-professional primary health care initiative called Family Health Teams. The government should approve the inclusion of physiotherapy in these teams and should use DPCA members to deliver OHIP funded services as members of these teams.
3. Expand OHIP funded community based rehabilitation to improve services for post surgical hips and knees
Patients who have undergone hip and knee surgery should have access to the OHIP covered post-acute rehabilitation provided in DPCs. DPCs are able to see patients within 24-48 hours of the discharge from hospital. The DPCA proposes a rehabilitation program that provides Quality Based Procedures in a DPC. We recommend three treatments a week for a maximum of four weeks. Since these services will be more complex than a basic DPC clinic visit, we propose a fee that is bundled into a onetime fee of $360 for the four week program.
4. Allow and encourage DPC physiotherapists to deliver Home Care services
The DPCA should be a principal provider of community based services. DPCA members will provide home care visits at $60 per visit, half the rate currently charged by the CCACs. The DPC fee is lower due to operational efficiencies and reduced administration costs. Services will be provided 24-48 hours after discharge from hospital. Providing immediate primary treatment, education and consultation in the home will save the province money by: decreasing the amount of time spent in hospital, decreasing CCAC wait lists, keeping patients in the community and increasing their self sufficiency. We propose that DPCs provide a bundled package of Home visits, not to exceed 10 visits, for a bundled fee of $600 (instead of the five visits for $600 currently provided by CCACs). At a cost that is twice as efficient as that of the CCAC, this will save the province a significant amount of money. 8 Designated Physiotherapy Clinics Association
5. Expand the scope of practice of physiotherapists to allow them to order x-rays, making Designated Physiotherapy Clinics primary assessment centers for patients with musculoskeletal and soft tissue injuries
Ontario’s Bill 179, the Regulated Health Professions Statute Law Amendment Act, 2009 expanded the scope of practice of regulated health professions, including physiotherapists. Bill 179 allows physiotherapists to order x-rays. With the expanded scope of practice of physiotherapists, the DPCA proposes that the Ministry could utilize the existing infrastructure and billing relationship with the 94 DPC facilities across Ontario, by expanding their mandate to allow them to become primary assessment centers for patients with musculoskeletal and soft tissue injuries. There is no need to invest in new facilities or issue new licenses. Congestion in the ER and physician’s offices will be reduced and more services will be provided at a fraction of the cost of an ER visit.
6. The DPCA and Health Quality Ontario should collaborate to develop Health Quality Indicators for OHIP funded physiotherapy services
The DPCA proposes to collaborate with Health Quality Ontario to develop and report outcome data that demonstrates both improved health outcomes and lower overall health costs. The DPCA has invested significantly in fall prevention programs, collects outcome data and has developed data that demonstrates improved health outcomes, better health function and decreased emergency room stays. We would be happy to share this information with Health Quality Ontario.
The DPCA is proud of the OHIP funded physiotherapy services we have provided to Ontarians for the past 45 years. We have the capacity and infrastructure to provide universal access to government funded physiotherapy services at a significant cost savings to the Ministry. We believe Ontario’s DPCs should play an expanded, central role in providing OHIP funded physiotherapy services to Ontarians.
We trust that this document will initiate a meaningful and thorough discussion about how Ontario’s health care needs can be greater served by expanding the services delivered by Ontario’s DPCs. Expanding the services delivered by the DPCs will achieve cost efficiencies and increase patients’ quality of life by reducing the number of visits to emergency rooms, reducing lengths of stay in hospitals and enabling patients to live in their own home longer. The expansion of services by an effective, low cost provider at the community level fits with the government’s implementation of the continuum of care model which is increasing access to care within the community. The DPCA has the infrastructure and capacity to provide universal access and offers the best value for cost services. As the government continues to move forward to design and apply patient based funding models for all aspects of health care delivery, the DPCA members encourage the government to give consideration to how physiotherapy provided by DPC physiotherapists can be delivered in the hospital, in home, in the community and in LTC.
Tony Melles, Executive Director
Designated Physiotherapy Clinics Association