Province-wide services
We recommend the Department of Health and Wellness, in collaboration with the Capital Health Authority and the Calgary Health Region, strengthen accountability for Province-wide services by:
• Ensuring information is reported that compares expected results with actual and explains significant variances
• Establishing relevant and reliable measurement of outcomes
Province-wide services are for all Albertans
Province-wide services (PWS) refers to a small range of highly specialized medical interventions which are generally complex, highly technical, and costly. They are concentrated in two regional health authorities for access by all Albertans. These are the Capital
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Health Authority (CHA) and the Calgary Health Region (CHR). PWS
includes organ and bone marrow transplants, major heart surgeries and angioplasties, neurosurgery, treatment of severe injury and burns, renal dialysis, high cost drug therapies as well certain cancer treatments and care of severely ill infants.
We reviewed the process used at the Department for ensuring accountability for PWS. We examined reports and procedures at the Department and interviewed staff. Excluded from the scope of review were the systems within CHA and CHR to manage PWS
services.
Funding in addition to population funding
Funding is given to the two health authorities in addition to, and apart from, regional population-based funding. The Department determines funding on a service-by-service basis by an established process that forecasts volume and price increases using information provided by a long-established hospital information system and additional information supplied by the RHAs.
The history of PWS budget and spending (in $ million) as reported by the Department is as follows:
Fiscal year Budget Actual Variance 2001-2002 350.5 Year in process N/A
2000-2001 303.9 320.5 16.6
1999-2000 257.2 257.2 0
1998-1999 206.7 231.0 24.3
The PWS system is designed to fund average actual costs as a means of encouraging efficiency in service delivery and for the RHAs to compare performance.
Our examination found weaknesses in the system of accountability for PWS.
Planned and actual results not compared
Funding should be reciprocated with accountability
While various reports are published showing trends in services, information is not produced that compares budgeted (targeted) activity and funds with actual services and costs.
Results not clear from extra funding
As with other areas, PWS is characterized by additional funding either increasing initial budgets or to cover amounts spent over budget. This amounted to $102 million for the four fiscal years from 1999 to 2002. However, except for a small fraction, additional amounts provided were not allocated to specific services and linked to increases in volumes and costs as is the case when budgets are established. Consequently, what was or will be achieved in particular with $102 million extra funding is unclear, except generally funding PWS.
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Relevant measures of costs and outcomes possible Reports sent to the Department by the two RHAs differ in structure, terms, and content. Therefore, the utility of information for
accountability purposes is uncertain. In terms of content, for example, analysis of renal dialysis (about $57 million) is limited because activity reporting is not consistent. One RHA reports
activity using therapy days and patient visits while the other reports the number of times dialysis is provided. Comparable cost per case figures cannot be derived.
Significant differences require validation
There is a need to ensure reliable data and comparable costing methods. One RHA reported total PWS cost increases for 1999-2000 of 11% while the other reported 27%. The Department could not reconcile widening cost differences with the information provided.
Numerous differences exist in individual case costs as well, notably for inpatient services. For example, during 1999-2000 angioplasties cost $8,893 each for 1,727 procedures in one RHA compared to
$10,535 each for 1,551 procedures in the other. Further, neonatology is indicated to cost 41% more per case in one RHA
compared to the other.
Bench marking would help The Department needs to understand why such differences happen in order to validate systems, improve the PWS budgeting process, and solidify commitment to a PWS budget. Benchmarking would be one means where costs, outputs and outcomes could be compared and stakeholders would benefit from understanding the causes of differences. Are differences the result of data, acuity levels, or the way services are delivered?
Opportunity to link costs and clinical outcomes
While symposiums on outcome accountability have recently been held, these focused on clinical issues and arguments for increased funding. Information on cost drivers and clinical outcomes is generally not available and difficulties are acknowledged relating to the coding of services. Collaboration and focussed work is required to bring data together, set clinical outcome targets, criteria, and reporting methods. This would serve PWS accountability and help quality control for improved care while potentially reducing costs.
Department has begun action
In conclusion, it is not clear that PWS is to be a contract for delivering services at an agreed standard at a given funding level.
The Department recognizes this and at the time of preparing this Report began drafting proposals for consideration by the PWS
Committee. We anticipate that by focussing on PWS, progressive steps can be taken showing how to achieve better financial and clinical accountability.
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