EXTERNAL REVIEW OF THE ONTARIO HEALTH INSURANCE PLAN S OUT-OF-COUNTRY PROGRAM ` Recommendation Ministry Response Implementation Status

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1 ` Increasing Awareness and Access to Information for Patients and Providers 1. Develop an icon for the Program on the Ministry website with a direct link to the Program to improve access to information for patients and providers. Information on the website should include a fact sheet, application forms and clear instructions on completing them, as well as guidelines relevant to administration and decision-making within the Program. 2. Increase awareness of the Program through outreach and mailings to physician to support their interactions with patients. These initiatives should use and build on existing distribution and outreach channels such as communication with the Ontario Medical Association, Cancer Care Ontario, etc. The Ministry has developed a website dedicated to the out-ofcountry (OOC) program including a description of the prior approval process with Fact Sheets, Application forms, and Administrative guidelines The Ministry will prepare an information bulletin on the OOC program and distribute to all physician, hospitals and associations in Ontario as well as place on the OOC website. January 2009 Page 1 of 8 STATUS: COMPLETE An OOC website was created for the public and physicians of Ontario to view documents and forms relating to the program: gram/ohip/outcountry_services.html Program icon on Ministry website links to OOC website: Links were created to related ministry programs and external organizations STATUS: COMPLETE A bulletin was mailed to all physicians, hospitals, and associations in Ontario. A follow-up bulletin providing an overview of the program and ministry contact information was also distributed and posted to the OOC website gram/ohip/outcountry_services.html A 3 rd bulletin has been prepared and is expected to be distributed to Ontario physicians in January Internal communication was distributed to ministry staff to remind them of the OOC process and contact information. The ministry is streamlining the requests for diagnostic testing OOC. Two letters have been sent out to all physicians requesting they indicate the specific test they are requesting and that they submit a copy of the

2 actual requisition form. This will enable ministry staff to process these applications more efficiently. In June, 2008, ministry staff provided a presentation regarding the OOC prior approval process to residents of the Windsor- Essex community. Staff explained the process for completing and submitting the application in detail. Residents/physicians were encouraged to contact the ooc unit with any questions (the website for the ooc unit was provided as well as the toll free number and account information). Similar presentations have also occurred in Toronto and Sault Ste. Marie. ogram/ohip/outcountry_services.html or send an to: OOCPriorApprovalInq.moh@ontario. Supporting Applications & Decisions 3. Develop clinical guidelines with disease specific experts to support the Program s decision-making process. Where feasible, guidelines should be specific to a medical condition or treatment and be published on the web-site for ready access physicians. 4. Develop a roster of disease specific experts to provide the Program with The ministry currently has an arrangement with Cancer specialists in Ontario to obtain medical advice and expertise the ministry will expand the arrangements to capture other medical expertise. The ministry has a roster of Ontario specialists that provide advice on The Ministry hired an external consultant to develop qualifiers (clinical guidelines) relating to specific medical services. Qualifiers relating to PET scans have been posted to the OOC website. The names of some U.S. facilities that perform gastric bypass surgery have also been posted to the OOC website. Formal arrangements have been made with Page 2 of 8

3 advice and recommendations on individual applications. 5. Applications that do not meet guidelines should be reviewed for exceptional or unique circumstances specialized treatment sought out-ofcountry. The ministry will continue to expand the roster. All applications are reviewed on their own merit; the ministry will set up a process for unique requests received for OOC funding. provincial experts to obtain expert advice regarding proposed services. A roster is being expanded of specialists and experts regarding specific diseases (e.g., transplants, cancer treatment) for ministry staff. STATUS: COMPLETE Applications are reviewed for exceptional or unique circumstances on an on-going basis. The ministry has dedicated staff working on these applications. In these cases, ministry medical consultants follow up with the Ontario physician directly by telephone and/or fax to request clarification and/or additional information. Contact is made to both physician and patient when there is an admission date noted on the application. Ministry staff explain the process in detail and review the application to explain what is missing from the application to support the request for ooc funding. Patient and physician are advised that there is no funding in place until a decision letter has been sent from the ministry. Assisting Physicians and Patients with the Process 6. Redraft the letter denying coverage ( denial letter ). The letter should be written in plain English, and focus on the medical basis of a decision. A copy of this letter should continue to be sent to the patient. The denial letter has been redrafted to focus on the medical basis of the decision. STATUS: COMPLETE The ministry has made improvements to correspondence regarding denials to the physicians and patients/families. A plain language editor has reviewed the letters. The use of plain language in the denial letter is consistent with the information posted on the Page 3 of 8

4 website. The toll free number ( ) is provided for the patient and physician on the denial letter for easier direct access to the ministry all calls are returned within 24 hours (working days). 7. Develop a process under which Program consultants would work with physicians to ensure applications are accurate and complete and assist them where appropriate in accessing services in Ontario or Canada. The ministry is currently contacting physicians by fax and phone when there is missing information, giving every opportunity for the physician to provide additional/required information. The ministry continues to improve communications with Ontario physicians to obtain all required information, and as required, provide information regarding where services are available in Ontario. Ministry medical and senior consultants follow up with the Ontario physicians in these cases to request and/or provide clarification as required. A toll free number ( ) was introduced in 2007 (all calls are returned within 24 hours working days; as well as an account (OOCPriorApprovalInq.moh@ontario) for patient and physicians to send in questions, responses are sent out within 3-7 working days). A new toll-free fax number ( ) was introduced in June 2008 to receive prior approval applications and supporting medical documentation for requested ooc services. Ministry medical consultants are making regular contact with Ontario physicians to assist in finding medical specialists in Ontario. Page 4 of 8

5 Clarifying the Terms of Regulation Develop administrative guidelines to clarify terms and support the interpretation of regulations that support the Program. Where appropriate, amend regulations to ensure equitable and consistent decision-making. The Ministry will clarify Regulation 552: clearly define the meanings of: experimental; generally accepted and identical or equivalent procedure; and clearly define the types of out-of-country hospitals or health facilities whose diagnoses/treatments are covered under the Program. Provide the criteria used in making decisions (ensure physicians and patients applying for out-of-country medical services are aware of the criteria). Draft regulation amendments as required The Ministry has developed administrative guidelines to clarify terms and support interpretation of regulations. A review of the regulatory framework is underway. Ensuring Equitable Access to Drugs 9. The Ontario Drug System Secretariat should be responsible for the availability and payment for necessary drug therapies subject to the implementation of a robust and effective Exceptional Access mechanism for patients under the Ontario Drug Benefit Act. Provider Services Branch will initiate discussions with the Ontario Public Drug Programs (OPDP) This is being considered as part of the regulatory framework review. OOC is involving OPDP in the review of any new drug therapy applications for ooc funding. Most recently, this included the new cancer drug, Vectibix which is used for the treatment of metastatic colorectal cancer. Page 5 of 8

6 Helping People to an Excellent Job 10. Encourage and support the Program in developing process improvements for reviewing and reconsidering applications, and managing appeals to the Health Services Appeal and Review Board (HSARB). The Ministry has developed written processes for staff. Processes are being written for staff to follow in order to streamline the processing of applications and manage appeals to the HSARB. A procedural manual has also been developed and distributed to all OOC staff. A registry of inpatient substance abuse treatment facilities available in Ontario and OOC is being developed as a reference tool for ministry staff. The ministry has established an Internal Review Process, which will allow all supporting medical documentation being introduced for an appeal to be reviewed prior to the actual hearing. If the supporting documentation supports the request for funding ooc, the ministry can reverse the decision prior to the hearing. 11. Build linkages to other ministry areas and to relevant external organizations. Staff has developed linkages with Cancer Care Ontario; program needs to expand linkages to include other relevant external organizations. STATUS: ONGOING The ministry continues to develop linkages to other ministry and external organizations including Registration & Claims Branch (RCB), Ontario Drug Benefit (OPDB), Ontario Public Drug Programs, Cancer Care Ontario, Health Services Appeal and Review Board (HSARB), Page 6 of 8

7 CritiCall and ConnexOntario. Staff are working together to ensure that ministry publications are written in plain language and contain consistent messaging. Investing in Provincial Capability 12. Undertake annual reviews of the Program to identify trends and encourage the development of treatments in Ontario for services or procedures that reach a specific financial or volume threshold. The ministry will provide Local Health Integration Networks and other ministry agencies information regarding services and procedures that reach a threshold (to be determined); in order to develop the treatments in Ontario The Ministry has developed an annual report that identifies trends and supports development of treatments in Ontario for services or procedures that have reached a specified threshold. The OOC unit is working with other ministry branches to support increased capacity for inpatient treatment for adolescents between the ages of who require psychiatric care (including treatment for substance abuse); and increased capacity for gastric bypass surgeries in Ontario. Preferred provider agreements will be established for select services being requested ooc. The names of the preferred providers will be posted on the ooc website for easy access by the referring Ontario physician. Review of Success 13. Undertake a review of the program in the summer of 2008 to evaluate effectiveness of program improvement. Staff will conduct a mid-year review of the program to evaluate effectiveness of changes made to date. STATUS: TO BE ASSIGNED Results of this review will be reported in the near future. Page 7 of 8

8 14. Public evaluation of the improvements implemented to date by the OOC unit. Communications Branch is planning to conduct a survey of a select group of patients who have applied to the OOC program since November 1, 2007 to measure customer satisfaction. Approved and denied applicants will be contacted for this purpose. Criteria is currently being established, (i.e. time frame, volume and service type) to facilitate this initiative. Page 8 of 8