PHASE 6.1:

GOVERNMENT REIMBURSEMENT

description

gov·ern·ment / re·im·burse·ment

 To be publicly funded by the Ontario Government, a product associated with a service must undergo a Health Technology Assessment (HTA) (see Phase 5.1: Government HTA) by Health Quality Ontario. The outcome of the HTA will determine the recommendation made by the Ministry of Health and Long-Term Care (MOHLTC) to either fund or not fund a new health product. It is important to be aware that a positive recommendation made by the MOHLTC does not mean a product will be reimbursed and/or adopted by the Ontario health care system. Decisions to purchase products are largely influenced by Government funding priorities, strategic political objectives announced by provincial Ministers of Health or local administrators, and by Physician/Laboratory Fee Schedules.

Navigating the government payment pathway for disruptive innovations might require changes to the current Physician/Laboratory Fee Schedules to accommodate the adoption of new health product. Fee Schedules can be lobbied separately from the government reimbursement process.  Changes to fee codes can take up to several years. The government must also remain agnostic to specific product vendors while supporting a solution for a particular need. A product that does not receive a positive recommendation for public reimbursement may need additional testing or product redevelopment to produce the type of evidence required for funding decisions made by the Ontario government.

The MOHLTC does little direct purchasing of products. Instead, the ministry funds hospitals through the Ontario local health integration networks (LHINs) and reimburses physicians for services outlined in the Physician/Laboratory Fee Schedules. It is up to the physicians and hospitals to purchase the products needed to perform those services reimbursed by the government. The government may agree to carve out a new funding program for a service associated with a product, however it is individual hospitals and health organizations, care providers and consumers that pay for the technology.

Certain exceptions to purchase products have been made by the Ontario government. For example, some people with long-term physical disabilities require customized equipment and supplies. In these cases, the province’s Assistive Devices Program (ADP) helps to cover 75% of the costs associated with specialized equipment and supplies. However, 25% of that cost is paid for by the person requiring the specialized equipment and/or supplies, and it is their responsibility to select the vendor and purchase the product upfront.  

While the Ontario government holds the decision-making power for publicly funded health care, this is not the only payment pathway. For alternative payment pathways, refer to Phase 6.2: Hospital Procurement and Phase 6.3: Alternative Payer.


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innovator's checklist

  • Determine whether the product falls under an existing billing code(s).

  • Verify that the product has the evidence required for funding decisions made by the Ontario government.

  • Consider alternative pathways for reimbursement in addition to government funding of the product. 

 

Last update: 2018-Nov-26

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