2015 SCFEA Pre-Budget Consultations
James Swan, MD, F.R.C.P.(C) F.A.C.C.
Ontario Association of Cardiologists
January 30, 2015
The Ontario Association of Cardiologists (OAC) welcomes the opportunity to provide input to the development of the 2015 Ontario Budget through the Standing Committee on Finance and Economic Affairs’ consultations. We expect our recommendations will be useful to this committee and the Ontario government as it develops its health care fiscal agenda for 2015-16 and beyond.
Through this document, we intend to provide recommendations for what the provincial government can do, in co-operation with Ontario’s cardiologists, to not only maintain but improve and protect the current access patients have to cardiac care services in all communities throughout Ontario, while helping to control costs and reduce the current Ontario deficit.
We would like the privilege to have continued dialogue with this committee, the government and the opposition parties of the Ontario Legislature in the coming weeks and months.
The OAC is a voluntary professional organization representing Ontario cardiologists. Our board and members work each day with the provincial government, the Ontario Medical Association (OMA) and the Ministry of Health and Long-Term Care (MOH) to maintain and improve the quality of cardiac care in Ontario.
The OAC exists independently of OMA to ensure the voice of cardiology is heard loud and clear regarding issues that affect the care of cardiac patients in Ontario. While all cardiologists in Ontario are required to be members of the OMA, the OMA does not provide its Section on Cardiology with the financial resources or the infrastructure to allow it to act as an effective advocate for cardiac patients. The OAC fills this gap, and without its ongoing advocacy program the continued high standard of cardiac care in Ontario is at risk.
Our membership is diverse, comprising community cardiologists and entire Divisions of Health Sciences Centers. The OAC has a long history of serving the profession and working to improve cardiac care in Ontario. In 1995, ours was the first professional organization in the province to create and publish standards for the performance of echocardiography. Ontario Cardiologists are the major authors of the Cardiac Care Network of Ontario’s 2012 Standards for the Provision of Echocardiography in Ontario.
Cardiology in Ontario
According to a 2011 Statistics Canada report, cardiac disease is responsible for 29% of the deaths in Canada. The Conference Board of Canada estimates that it costs the Canadian economy nearly $21 billion and is rising steadily as the burden of cardiac disease increases each year in our country. The Cardiology services our members provide 24/7 save lives, prevent, diagnose, treat, manage, and rehabilitate patients with cardiovascular disease, the #1 killer in men and women and the major public health threat to the Canadian economy.
Cardiologist care for cardiac patients directly saves lives. An April 2013 ICES study concluded among patients with higher baseline cardiovascular risk who were discharged from the hospital emergency department after evaluation for chest pain in Ontario, follow-up with a cardiologist was associated with a decreased risk of all-cause mortality or hospitalization for heart attack at 1-year compared with follow-up with a primary care doctor or no physician follow-up. Similar data is available for the congestive heart failure patient.
Ontario cardiologists want to work with government to make decisions together so that we can protect and improve the current level of care for cardiac patients and expand cardiac care services in a time of fiscal constraint.
OAC’s 2015 Ontario Budget Priorities
The following are the OAC’s priorities for the 2015 Budget:
- Address the Negative Impacts Associated with the January 2015 Unilateral Government Cuts to Cardiology
On January 13, 2015, the MoH implemented massive cuts to the OHIP budget after failing, once again, to come to terms on a physician services agreement with the OMA. Since then, this committee and the government have heard directly from many representatives and organizations within Ontario’s medical community about the significant negative repercussions this arbitrary action is poised to have on patient access to care in Ontario in the coming years. The OAC echoes these comments. If the government does not reverse its plan and agree to meet with groups like ours in the coming days to discuss alternate approaches to meeting its health care obligations and fiscal objectives, patient care in Ontario will be jeopardized.
In cardiology, the government’s cuts are manifested in the following way:
- Across the Board Fee Cut (3.15%)
An across-the-board fee cut of 3.15% will be applied to all physicians, including cardiologists, effective February 1, 2015 for fee-for-service physicians and May 1, 2015 for alternate payment plan physicians. At the same time, government is underfunding the expected growth in costs associated with the provision of medical care in Ontario. This includes increased overhead, an aging and more needy chronic care group as well as the projected growth of the overall population by 140,000.
- E078 – Chronic Disease Assessment Code
The chronic disease assessment code that cardiologists use when treating their most complex patients for congestive heart failure will be eliminated effective April 1, 2015. The care of this particular group is complex, extremely difficult and requires a significant investment of time and effort. Lives will be jeopardized unless there is a change in the regulatory amendments currently proposed by Cabinet. This billing code is also being eliminated for three other specialty groups: Nephrology, Internal Medicine and Gastroenterology, while other medical specialties are not restricted from using it.
An Issue of Fairness
The government’s unilateral cuts, if enacted, will place the sole burden of underwriting the increasing costs of patient care on physicians. Every year there are approximately 140,000 new patients entering the system and the government’s own statistics indicate that this represents a 2.75% increase in costs to doctors. The government plan however is to cover less than half of this in the coming years. There is also no recognition of increased overhead costs that are occurring in the physicians’ office.
Moreover, it is unfair to require physicians to pay for “savings” that have not been realized under the 2012 physician services agreement. The OAC has made recommendations that would have helped significantly in saving dollars and reducing the deficit. If the government had not delayed over the last two years in implementing the Cardiac Care Network of Ontario’s Standards for the Provision of Echocardiography Services in Ontario, $44 million in annual savings would have been realized (estimated by ICES). The OAC has advocated for their implementation for more than three years and has and continues to volunteer its services to make it a reality (see Recommendation #3 below).
Recommendation #1: The OAC is asking the government to re-consider and allow the E078 code to be billed by all medical specialties for the congestive heart failure patient using new criteria that has been developed by the Ontario Congestive Heart Failure Working Group, working with the OAC.
- Approve and provide funding support to the OAC’s Congestive Heart Failure (CHF) Regional Hubs Pilot Project
The OAC’s CHF Regional Hubs pilot project is an initiative aimed at providing timely and expert transitional care for high-risk CHF patients that currently does not exist in most Ontario communities. These patients, when they are admitted to hospital and are “uncomplicated” cost $12,000, and if “complicated” cost a minimum of $42,000. The proposed program, which was submitted to the MoH earlier this month, will pilot a practical and scalable infrastructure for providing rapid access to CHF expertise that can be integrated into the existing infrastructure without displacing current CHF programs. By assuring timely access to the best available CHF treatment options, CHF Regional Hubs will improve the current level of care available to high-risk CHF patients and reduce the need for costly hospital-based care.
CHF Regional Hubs will facilitate the implementation of the evidence-based care paths for CHF treatment put forward by the CCN, CCS and other professional organizations. It will do this by making specialist-based expertise available to Primary Care Physicians and other providers at an early stage in the CHF patient’s transition from acute to chronic care. Each hub will also serve as a resource to Primary Care Physicians and other health care providers to facilitate and improve community-based models of care. CHF Regional Hubs will facilitate an integrated approach that provides patients with the best available treatment options, improves their outcomes and care experience, and avoids unnecessary hospitalizations.
Specialist expertise to assist the transitional care of acutely ill CHF patients is not currently available in most Ontario communities. The OAC model with CHF Regional Hubs will complement existing programs. It will also enhance emerging integrated care models including Health Links and Quality Based Procedures by providing specialist expertise and input. The program will leverage emerging EMR technology to improve both the sharing of health care information among providers and the ability to measure clinical effectiveness and cost effectiveness.
CHF Regional Hubs will be piloted in a medium-sized Ontario City (Ottawa) and a smaller Ontario community (Peterborough).
Recommendation #2: The OAC is asking the Ontario government to approve and fund its CHF Regional Hubs pilot project at a cost of $3 million. The Executive Summary is available to the committee if it wishes to see it.
- Speed up the implementation of appropriateness guidelines for non-invasive cardiac diagnostic tests in accredited facilities
The OAC is committed to eliminating “inappropriate” non-invasive cardiac testing in Ontario i.e. testing that does not benefit the patient and contributes unnecessary costs to the current system. Accredited labs will ensure that the right patient receives the right test, at the right time, by the right physician for the right reason.
In 2012, the Cardiac Care Network of Ontario released its Standards for the Provision of Echocardiography in Ontario, 2012, which addresses the issue of “appropriate” testing in echocardiography. ICES estimated that the Ontario government could save as much as $44 million (Institute for Clinical and Evaluative Sciences report, 2012) by implementing these standards. The OAC supports this report and, along with the Section on Cardiology of the Ontario Medical Association, we have been working very hard with the Cardiac Care Network of Ontario, the OMA and the MoH to actively implement the report’s recommendations. As of December 2014 only a small fraction of the total number of echocardiography labs in the province have been accredited.
Recommendation #3: For 2015 Budget, we call on the MoH to (1) fully implement the 2012 Echocardiography Standards, and (2) develop and implement appropriateness standards for the provision of other non-invasive cardiac diagnostic tests such as electrocardiograms (ECGs), stress tests, holter monitoring, MRI, PET scanning, nuclear cardiology testing, and CT Angiography (CTA). This has the potential to save millions of dollars annually while improving patient care.
- Support the continuation of e-health integration initiatives for specialists to provide efficient, seamless, and cost-effective care to patients
Much of the MoH’s work in electronic medical records over the past several years has focused on servicing Ontario’s primary care providers. The needs of specialist physicians, unfortunately, have been ignored.
One year ago, the OAC set out to change this by bringing together Ontario’s imaging physicians, which includes cardiologists, radiologists and nuclear medicine specialists, to work closely with two agencies supported by the Ontario government – OntarioMD and eHealth Ontario – in an effort to build a constructive working relationship. The objective of this working relationship is to facilitate access for Ontario cardiologists to emerging e-health tools that will aid in the provision of more efficient and cost-effective medical care. The benefits of this project extend to all medical specialties. Webinars on the technology integration are available to any Ontario physician.
These tools include:
- Hospital Report Manager
- Diagnostic Image Repositories
- Electronic Medical Record Integration Initiatives
- Connecting GTA
- Cardiology Customized EMR Development
Recommendation #4: The OAC is calling on the Ontario government to ensure that funding aimed at advancing and integrating e-health initiatives to support this goal is provided in the 2015 Budget.
The OAC appreciates the work this committee is doing to receive input from various stakeholders and the general public on the 2015 Budget. Through this submission, we urge the government to work with the OAC now to make sure the current regulation relating to the E078 code is modified so that the care of the CHF patient will not be jeopardized. The CHF patient is the most vulnerable and weakest patient in the health care system. Funding for the OAC’s CHF Regional Hubs pilot project, implementation of the Standards for the Provision of Echocardiography Services in Ontario, and the willingness of government to work with Ontario cardiologists to look for other ways to achieve savings rather than the unilateral 3.15% cut across the board, would ensure that cardiac care and access for patients is not jeopardized in a time of financial constraint.
On behalf of our members and their patients, thank you for giving us the opportunity to contribute our ideas. We are pleased to provide the committee with additional information at any time. For more information, please contact:
James Swan, MD, F.R.C.P.(C) F.A.C.C.
Ontario Association of Cardiologists
34 Eglinton Avenue West
Toronto, Ontario M4R 2H6