Needsbased Funding for Home Care and Community Support Services in Ontario

1
Needs-based Funding for Home Care and Community
Support Services in Ontario

• Jeremiah Hurley, PhD
• Brian Hutchison, MD, MSc
• Gioia Buckley, MA
• Christel Woodward, PhD
• Centre for Health Economics and Policy Analysis,
• McMaster University
• Presented by Gioia Buckley, June 27th 2002

2
Acknowledgements

• This work was conducted in collaboration with the
  Ontario Ministry of Health and Long-Term Cares
  Community Funding Review Committee
• Funding to the Centre for Health Economics and
  Policy Analysis is provided by the Ontario
  Ministry of Health and Long-Term Care (MOHLTC)
• None of the above bear any responsibility for the
  contents of this presentation or the contents of
  the final report

3
Background (1)

• MOHLTC allocates funds for home care and
  community support services using a historical
  budget method
• Since 1994-95, MOHLTC has been using a capitation
  formula (Equity Funding Formula) based on age and
  sex to allocate incremental funds across
  Community Care Access Centre (CCAC) regions for
  home care and community support services

4
Background (2)

• Objective of the Equity Funding Formula is to
  more adequately allocate resources in line with
  the needs of the population across CCAC regions
• In 1998 MOHLTC began a review of the formula to
  improve it
• In 2000 CFRC engaged CHEPA research team as
  consultant for the technical component of this
  analysis

5
Study Objectives

• Develop a population needs-based funding formula
  that represents, as accurately as possible, the
  relative need for home care and community care
  resources among 43 Ontario CCAC regions

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June27flowchart.ppt
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Data

• Number of observations 22,855
• 1996-97 Ontario Health Survey linked to
• Home care utilization data (OHCAS)
• Physician utilization data (OHIP and HSO)
• CIHI In-patient and Day Procedure files
• Additional data as required (e.g., Community
  Support Services Budgeting System data for home
  care service costs)

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Constraints of Linked Utilization Data

• Survey respondents of age 12 or over only
• Only data on direct home care service utilization
  are available, no community support service data
  (e.g., meals-on-wheels delivered by CSS agencies,
  friendly visiting, etc.)

9

• Analysis for the Population Aged
• 12 or over

10
Distribution of Home Care Expenditures
21,579
11
Analytic Strategy (1)

• Two part utilization model to estimate an
  individuals expected home care expenditure
  (EHCE)
• EHCEij Prob(useij) E(amount of useij some
  useij)
• PART 1 PART 2
• Part 1 Weighted logistic regression model
• Part 2 Weighted gamma General Linear Model (GLM)

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Variable Specification Dependent Variables

• Part 1 Dichotomous variable indicating whether
  respondent used publicly funded home care
  services in 32 months surrounding interview date
• Part 2 Dollar value of total home care
  expenditures incurred in the 32 months for each
  respondent

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Variable Specification Independent Variables

• Adjusters
• Need variables
• Enabling and predisposing variables
• System-level variables
• Interaction variables
• Adjusters classified as need vs. control
  variables for development of funding formula
• Model built using decision rules pertaining to
• Statistical significance
• Conceptual plausibility

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Independent Variables Included in our Model for
Part 1 Regression
15
Independent Variables Included in our Model for
Part 2 Regression
16
Measures of Explanatory Power and Goodness of Fit
for Logistic Regression Model
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regrresults.ppt
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Graph 1 Probability of Using Home Care by Age
and Sex
Males
Females
1
.75
Predicted probability of using home care
.5
.25
0
12
35
57
80
102
Age
23
Graph 2 Home Care Expenditures and Age, by
Number of ADLs, Females
No ADLs needing help
1 ADL needing help
2 ADLs needing help
3 ADLs needing help
4 ADLs needing help
5 ADLs needing help
9535.18
Predicted home care expenditure if user, dollars
315.34
12
35
57
80
102
Age
24
Graph 3 EHCE and Age by Number ofHospital
Admissions, Males
1 admission
No admissions
2 or more admissions
1813.42
Expected home care expenditure (EHCE), dollars
1.79
12
35
57
80
102
Age
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Analytic Strategy (2)

• Obtain CCAC region needs-based shares by
• inflating individual-level estimates using sample
  weights
• summing by CCAC region
• dividing by total provincial home care
  expenditures

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B) Calculation of CCAC Shares for the Population
Aged0 to 11
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Methodology

• Used the provincial per capita home care cost by
  age-sex category (0-4, 5-9, 10-11)
• Multiplied the total number of people in each
  category by the cost, then summed by CCAC to
  obtain the total expenditure for each CCAC (Xi)
• Summed across CCACs to obtain the total
  provincial expenditure (Y)
• Divided CCAC expenditure by provincial
  expenditure (Xi/Y) to obtain CCACs share of
  the budget for the population aged 0 to 11

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• C) Assessing the Relationship Between the Average
  Cost of Providing a Home Care Service and CCAC
  Region Characteristics

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Scatter plot of Relationship Between Average Cost
of Providing a Unit of Home Care Service and CCAC
Region Total Population (b)

• (b) Plot Average Cost of Nursing Services
• vs. CCAC Region Population
• 83.6472
• A
• v
• e
• r
• a
• g
• e
• C
• o
• s
• t
• 
  

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Scatter plot of Relationship Between Average Cost
of Providing a Unit of Home Care Service and CCAC
Region Total Population (a)

• (a) Plot Average Cost of Homemaking/Personal
  Support Services vs. CCAC Region Population
• 25.9046
• A
• v
• e
• r
• a
• g
• e
• C
  
• o
  
• s
  
• t

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Scatter plot of Relationship Between Average Cost
of Providing a Unit of Home Care Service and CCAC
Region Total Population (b)

• (b) Plot Average Cost of Nursing Services
• vs. CCAC Region Population
• 83.6472
• A
• v
• e
• r
• a
• g
• e
• C
• o
• s
• t
• 
  

32
Scatter plot of Relationship Between Average Cost
of Providing a Unit of Home Care Service and CCAC
Region Population Density (a)

• Plot Average Cost of Homemaking/Personal Support
  Services
• vs. CCAC Region Population Density
• 25.9046
• A
• v
• e
• r
• a
• g
• e
  
• 
  
• C
  
• o
• s
• t

33
Scatter plot of Relationship Between Average Cost
of Providing a Unit of Home Care Service and CCAC
Region Population Density (b)

• (b) Plot Average Cost of Nursing Services
• vs. CCAC Region Population Density
• 83.6472
• A
• v
• e
• r
• a
• g
• e
• C
• o
• s
• t
• 
  

34
Scatter plot of Relationship Between Average Cost
of Providing a Unit of Home Care Service and CCAC
Region Historical Funding (a)

• (a) Plot Average Cost of Homemaking/Personal
  Support Services vs. Ratio of CCAC Region Actual
  to Equity Funding
• 25.9046
• A
• v
• e
  
• r
• a
  
• g
• e
  
• C
• o
  
• s
  
• t
• 
  
• 
  

35
Scatter plot of Relationship Between Average Cost
of Providing a Unit of Home Care Service and CCAC
Region Historical Funding (b)

• (b) Plot Average Cost of Nursing Services
• vs. Ratio of CCAC Region Actual to Equity Funding
• 83.6472
• A
• v
• e
• r
• a
• g
• e
• C
• o
• s
  
• t
  
• 
  

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costresults.ppt
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Conclusions of Cost Analysis

• Analyses reveal that there is no systematic
  relationship between a CCAC regions average
  costs and these CCAC regional characteristics
• There is no evidence at this time that CCAC
  funding shares require adjustment to reflect
  differences in average costs across CCAC regions
  that differ with respect to population size,
  population density or across CCAC regions whose
  historical funding levels have differed

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D) CCAC Region Shares of Total Budget
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Results of CCAC Region Needs-based Shares
Compared to Actual and Age-sex Per Capita
Allocations
G
H
I
B
F
C
A
D
E
40
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Results of 9 CCAC Regions Needs-based Shares
Compared to Actual and Age-sex Per Capita
Allocations
151.73-404.87
203.65-374.28
41.05-432.98
54.95-125.52
95 CI 40.22-58.87
51.31-92.28
86.39-115.36
102.79-173.89
59.69-76.93
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Precision of Estimates

• For approximately one half of CCAC regions, the
  percentage difference between the upper
  confidence interval (CI) and the point estimate
  is greater than 20, for about one third of the
  regions the difference is greater than 25
• Even with this imprecision, both the current and
  equity funding shares fall outside the 95 CI for
  19 CCAC regions. We can be very confident that
  the needs-based share differs from the current or
  equity share in these cases

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Comparison of Population Characteristics in CCAC
Regions with Large Shifts in Funding Under
Needs-based Model Compared to Actual Funding,
ages 70 or over
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Conclusions Thus Far (1)

• An age-sex formula fails to capture substantial
  variation in need across CCAC regions
• This residual variation is highly correlated with
  demographic, health status and socio-economic
  characteristics measured in Canadian health
  surveys
• The point estimates for CCAC region needs-based
  funding indicate substantial reallocation from
  current and equity funding. Because home care is
  a relatively rare event among the general
  population, the sample size provided estimates of
  needs-based resource shares for some of the
  smaller CCAC regions that are less precise than
  desired

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Conclusions Thus Far (2)

• Adjustment of CCAC region resource shares to
  reflect differences across CCACs in the average
  cost of providing home care services is not
  necessary
• Adjustment of CCAC region shares for regions that
  experience seasonal fluctuations in the number of
  residents is not necessary

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Options for Revising the Method for Allocating
Home Care and Community Support Service Resources

• Long-run options increase the size of health
  survey samples
• Intermediate options

• Pool Ontario health survey data across cycles of
  the NPHS and CCHS
• Estimate CCAC allocations on Diagnosis-related
  information from administrative databases

• Short-run options the adjusted equity share
  method

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The Adjusted Equity Share Method

• Adjust the current Equity Funding Formula for
  needs beyond those accounted for by age and sex

• Use the NPHS data to estimate a model that
  includes age and sex adjusters, using the same
  age-sex categories upon which the current equity
  formula is based
• Estimate the full needs-based model developed in
  this analysis
• Calculate the percentage difference in the shares
  between the NPHS-based age-sex model and the
  NPHS-based full model
• Apply this percentage difference between the
  NPHS-based age-sex model and the NPHS-based model
  to the current equity shares

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Adjusted Equity Dollar Per Capita Allocations
(Table 12.2 of report)
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Conclusions (1)

• The current age-sex adjusted equity formula fails
  to capture variation in need for home care across
  CCAC region populations
• This residual variation is highly correlated with
  demographic, health status and socio-economic
  characteristics measured in Canadian health
  surveys
• The statistical model constructed in this
  analysis can provide a basis for a needs-based
  allocation formula that incorporates adjustment
  for a wide variety of needs-related
  characteristics of the population

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Conclusions (2)

• The point estimates for CCAC region needs-based
  funding shares indicate substantial reallocation
  from current and equity funding
• Because home care is a relatively rare event
  among the general population, the sample size
  available in the 1996-97 Ontario component of the
  NPHS provided estimates of needs-based resource
  shares for some CCAC regions that may not have
  the desired degree of precision

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Conclusions (3)

• In the long-term, this can be addressed through
  larger sample buy-in by Ontario of on-going
  regular national health surveys conducted in
  Canada
• In the intermediate and short term, it is
  possible to develop funding approaches based
  wholly on the population-based health survey data
  or an integration of such data with the
  traditional equity approach that will better
  allocate home care and community support service
  resources in Ontario in line with relative needs
  across CCAC regions

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• Thank you!
• Gioia Buckley
• buckle_at_McMaster.CA