Development of a Paying for Quality (P4Q) Approach for Schizophrenia Care in Ontario, Canada

Imtiaz Daniel ^a, Fiona Fu ^b, Philip Klassen ^c

Background
In Ontario, inpatient schizophrenia care accounts for 41% of the inpatient mental health activity in 54 acute and 4 specialized mental health hospitals with total expenses of approximately $700M annually. In the absence of a patient classification system for inpatient mental health, policy makers would like to explore payment mechanisms which will incentivize the adoption of best practices leading to better patient outcomes.

This initiative investigates a new paying-for-quality approach to incentive quality improvement using schizophrenia quality standards developed by provincial expert advisors. Ontario has 11 quality statements for care for adults aged 18 years and older with a primary diagnosis of schizophrenia who are seen in an emergency department or admitted to an inpatient setting. In addition, there are 15 quality statements that address care provided in the community for adults aged 18 years and older with a primary diagnosis of schizophrenia. The proposed funding model allocates funding based on measured performance according to best practices established in the quality statements. The initial phase includes all Ontario hospitals with inpatient mental health services. The second phase expands into the community setting using four integrated care networks prototypes of hospitals and community mental health providers.

Approach
Schizophrenia quality statements and performance indicators to be used for the funding approach were selected using a modified-Delphi technique with a provincial panel of expert clinicians, healthcare administrators and academics advisors. The specifications and data collection for measuring concordance to the quality statements were developed and implanted using Ontario's established data system (the Ontario Mental Health Reporting System - OMHRS) used to collect inpatient mental health patient activity in all Ontario hospitals. Initially the Ontario Hospital Association developed and administered a survey to collect baseline data for 2019/20 and the data elements were refined and translated into the OMHRS tool and hospitals were mandated to send data elements to the Canadian Institute for Health Information beginning April 1st, 2021/22.

Using payment for results and behavioural economics principles to incentive quality processes, the approach allocates a proposed quality funding envelope to a hospital based on a hospital's relative performance to benchmarks and annual improvement. The benchmarks and thresholds were established by the expert panel with a strong emphasis on the targets were realistic and achievable.

For the second phase in the community, a similar approach was undertaken. However, two expert panels were used: partners with lived experience and clinical/administrative advisors. The technical specifications and data systems were developed for all metrics. Only four integrated networks are collecting this information as a prototype for large scale implementation in the future.

Results
Four quality statements were selected from the Ontario Quality Standard for Adults with Schizophrenia Care in Hospital and four indicators were measured. In FY2021/22, there were 9,087 schizophrenia patients in 58 hospitals. In Q1 and Q2 of 2022-2023, the performance for following indicators were measured: Care Plan made available within 7 days (78.6%, 85.3%); Treatment received with long-acting injectable antipsychotic medication (52.2%, 58.3%); and Treatment received with Clozapine (40.0%, 50.5%).Follow-up by a physician within 7 days after hospitalization will be calculated after availability of Q3 data (currently reported to be 28.3% in FY2021/22). Most hospitals improved performance from Q1 to Q2 reporting. These improvements may be due to improvement in care as well as data reporting. The inter-quartile ranges for each indicator were large with many outliers at Q1 but were reduced in Q2.

Conclusion
The implementation of P4Q schemes began internationally in the late 1990s. Researchers identified primary care schemes incentivized mostly process and structural quality with emphasis on prevention and chronic care while P4Q schemes in hospital care incentivized improvement in health outcomes and patient safety. Studies have shown the size of the financial incentives could vary from 0.5% to 10% of the total provider income in hospital care. This Ontario investigation of P4Q proposed 0.5% as an initial funding amount.

The early results of this made in Ontario approach for mental health demonstrate effectiveness of adoption and measuring concordance to the quality statements. Organizations began gaining insights from these measures for quality improvement and began collaboration with their peers across the province. This innovation will accelerate standardized mental health and addictions services and will provide accountability to investments in these sectors. When fully implemented, this proposed Ontario P4Q scheme can be used with provincial quality improvement initiatives of public reporting and audit and feedback to be a cost effectiveness strategy for schizophrenia care.

^a Ontario Hospital Association, University of Toronto, Canada
^b Ontario Hospital Association, Canada
^c Ontario Shore Center for Mental Health Sciences, Canada

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