On December 17th, 2013, the Ontario Minister of Health and Long-Term Care, Deb Matthews (the “Minister”) released the Policy Guide for Creating Community-Based Speciality Clinics (the “Policy Guide”). The Policy Guide supports the Minister’s plan to move certain procedures out of hospital and into Community-Based Speciality Clinics as announced in Ontario’s Action Plan for Healthcare, 2012.

The Policy Guide provides an overview of the key principles and expectations for Community-Based Specialty Clinics and is directed at potential applicants who seek to operate a Community-Based Specialty Clinic to perform certain procedures which are currently being performed in public hospitals. It provides high-level information about the application process which is expected to begin in early 2014, including, broad eligibility criteria, quality assurance requirements and labour relations expectations. It is anticipated that the first call for applications will be for the provision of cataract surgery.[1] Specific application guidelines will be provided when a call for applications is released.

The Policy Guide states there will be two types of Community-based Specialty Clinics:

  • Public hospital-based ambulatory care centres that operate under the Public Hospitals Act; and
  • Independent Health Facilities (“IHFs”) licensed under the Independent Health Facilities Act (the “IHFA”)[2].

Eligibility Criteria

We understand that there will be separate application processes for IHFs[3] and hospital-based ambulatory centres. The final details on the requirements for applicants will not be clear until the call for applications is issued by the Ministry, however, the Policy Guide does provide some guidance.

Not-for-Profit

The Policy Guide is clear that Community-Based Specialty Clinics must be operated by not-for profit entities. The Policy Guide states that existing for-profit IHFs may apply but must be willingand able to convert to not-for-profit entities. New applicants for an IHF Community-Based Specialty Clinic must provide proof of their not-for-profit status.

LHIN and Hospital Support

Endorsement by the Local Health Integration Network (“LHIN”) is required in order for an applicant to be successful. Further, all Community-Based Specialty Clinics must have the support of and be aligned with a public hospital (evidence of this alignment and support must be provided with the application). Such alignments will require that agreements be entered into in order to formally set out how patient records will be shared, how emergency room coverage will be maintained and address physician privileging.

Staffing

Applicants will need to provide evidence that the physicians and other health professionals who will be practicing in the clinic are competent, in good standing with their regulatory body (if applicable) and possess the requisite training and certification in order to perform the procedures.

Additionally, applicants will need to provide a detailed staffing plan that sets out the potential impact that shifting procedures out of hospital and into a Community-Based Speciality Clinic may have on physicians and hospital staff. If there is any impact on hospital staff, the Clinic, LHIN and hospital will have an obligation to comply with all applicable labour and employment legislation, including the Public Sector Labour Relations Transactions Act, 1997.

Funding

The Ministry has enacted changes to regulations that facilitate the funding of Community-Based Speciality Clinics by the LHINS and allow the LHINS to incorporate Community-Based Speciality Clinics into their local service plans.[4]

Funding for these Community-Based Specialty Clinics will be based on the Ministry of Health and Long-Term Care’s (the “Ministry”) Quality-Based Procedure price (“QBP”) for each procedure. The Policy Guide defines QBPs as:

Groups of services or procedures for patients who require similar care. QBPs will be reimbursed on a “price X volume” basis using evidence-informed rates based on best practices and adjusted for patient complexity.[5]

QPB pricing is intended to cover the direct costs such as nursing care, medical supplies, pharmaceuticals and indirect costs such as housekeeping and utilities associated with the procedure. The physician fee for the provision of insured services will continue to be covered on a fee-for-service basis by OHIP as it currently is in the hospital setting.

The Policy Guide also states that:

If health care providers determine that they are unable to deliver the volumes or quality of care required within the Ministry-set QBP price, they may discuss alternative approaches with their LHIN… to ensure that patients receive the necessary care and that access to care is maintained.  In some instances, this may mean considering whether the service should be provided within an acute care hospital setting or whether high quality patient outcomes can be achieved outside of an acute care hospital, in speciality clinics.[6]

The Ministry will not be providing any funding for capital equipment and applicants will need to provide a capital plan setting out how capital equipment will be obtained and maintained.

The services provided by the Community-Based Specialty Clinics will be insured services to the extent that those services were insured while performed in hospitals. The Community-Based Specialty Clinics will be permitted to charge for any uninsured services. However, the Policy Guide states that the Community-Based Specialty Clinics will be required to make patients aware that uninsured services are optional and patients must be provided with a “Ministry Hotline” for inquiries about uninsured services.

Quality Assurance

The Community-Based Specialty Clinics will be required to operate under quality assurance regimes currently in place. Specifically, hospital-based ambulatory centres will be required to participate in the hospital’s mandatory quality committee which is overseen by the hospital’s board as required under the Excellent Care for All Act. IHF’s will be required to participate in the existing quality assurance program for IHFs that is administered by the College of Physicians of Surgeons of Ontario. This process includes ongoing assessments of the facility.