Ontario home-care agencies spending almost $1 billion a year on administration costs: auditor

Ontario’s network of agencies that co-ordinate home and community-based care spend over $930 million dollars per year on administration — 39 per cent of their total budget — the provincial auditor has found.

THE CANADIAN PRESS/Frank GunnOntario Health Minister Eric Hoskins “full accepts” the auditor general’s report and plans to work to implement her recommendations. 

The review of the province’s Community Care Access Centres (CCACs) is the first full audit since they were created in 1995. The agencies fund and deliver home care to over 600,000 Ontarians each year, and they are often the first point of medical contact after someone leaves hospitals. They are the source of frustration for many patients already coping with serious illness and many have long questioned their worth.

CCACs gobble up $2.4 billion a year, less than five per cent of the $50-billion health care budget. Some critics suggest they need much more to meet demand as the provincial Liberals seek to push more patients from costly institutions and into the community.

Now, Auditor General Bonnie Lysyk is urging the government to take a “hard look” at how well the system is serving patients, how much money is spent on administration and paperwork and the uneven distribution of quality care across the province.

“It’s time to look at different models out there,” Lysyk said upon her report’s release Wednesday. She said patient experiences vary not just between the 14 CCAC regions, but even within them. She also found the government program set up to help the most critically ill patients, or those with compounding factors like developmental disabilities or mental health issues, was failing to meet its goals.

Fotolia Many patients would prefer to be cared for at home, but it’s also a much cheaper way for the province to cope with an aging population. Personal support workers provide most of the home care that makes it possible. 

Rapid-response nurses are supposed to see such high-needs patients within 24 hours of discharge from hospital, but Lysyk said that’s only happening about half the time. Over a quarter — 28 per cent – wait longer than 48 hours.

Why?

At least in part because CCACs don’t staff on weekends, Lysyk say.

There are no standard treatment guidelines across the province’s home and community care, Lysyk said, which contributes to the uneven experiences. She said some sick Ontarians might wait just hours or days, while others much longer. Some CCACs have internal guidelines, others leave best practices up to the private companies that deliver care.

The province’s 14 Community Care Access Centres (CCACs) use third-party companies to provide most of their hands-on care. Of the $2.4 billion the CCACs received in the 2013/14 fiscal year, about $1.5 billion went to outside contractors.

Health Minister Eric Hoskins said the government “fully accepts” Lysyk’s report and recommendations. He highlighted an ongoing review of home care already underway — though that could take years to complete. He said he’s already called on CCAC boards to be more transparent and his ministry is “reviewing the system from top to bottom.”

We can do better

“We can do better,” Hoskins said, though he cautioned it was “premature” to say CCACs should be scrapped or rolled into other health-care agencies to save administration costs. He said the province’s new “bundled care” that starts in hospital and ends at home is one way they are improving the system.

But taking pilots and trying to apply them across the province is one of the problems Lysyk highlights. The report finds several new programs to help the sickest patients. Those with mental health issues or in palliative care were added to the system without a cost benefit analysis.

The solution is not simply to add new programs and make adjustments to existing services

“The solution is not simply to add new programs and make adjustments to existing services,” Lysyk said. “This will only leave core problems and inconsistencies entrenched.”

The system is not only complicated for patients, but the audit shows how costly the byzantine bureaucracy has become. CCACs spend about $930 million a year on administrative activities or “care coordination” as opposed to direct patient contact.

The auditor notes that the agencies claim to spend 92 per cent of their budget on patient care, but “that percentage falls to 72 per cent when a stricter definition of direct interaction with patients is applied. And it drops even further, to 61 per cent, for actual face-to-face treatment of patients.”

That means a full 39 per cent of the overall budget is dedicated to running the system.

That figure includes some activities the auditor said are necessary and laudable, such as “coordinated care” programs that link together family doctors, specialists, nurses and the personal support workers who deliver the bulk of home care. That coordination includes, for example, an employee setting up appointments for a patient’s care and ensuring all health care providers get test results.

Of the approximately $1.5 billion the CCACs pay third parties to provide home care, about 5 per cent — or $75 million — becomes profit, the auditor found. She highlighted that many CCAC executives got bonuses and raises in recent years despite an ongoing provincial wage freeze. She said many raises were for “unclear” reasons and the average CEO earned $249,000 in the fiscal year ending March 31, 2014.

“You cannot continue to invest in a structure that doesn’t work,” NDP health critic France Gélinas said, adding the increase of for-profit companies competing with each other for home care contracts exacerbates the uneven patchwork of care. She said Premier Kathleen Wynne’s early morning press conference about beer was meant as a distraction for reporters, but the political machinations simply highlight “how damning the report is for the Liberals.”

She said they have had 12 years to fix a broken system and have only made things worse.

It’s “alarming” the highest-needs patients are often waiting days, even weeks, for care, she said.

“Health care is not a nine-to-five job,” progressive conservative health critic Jeff Yurek said, adding he was surprised to hear long wait times were attributed to a lack of weekend staffing.

The opposition parties, the Progressive Conservatives in particular, have long criticized the CCACs as a wasteful layer of bureaucracy in need of drastic reform. Yurek wouldn’t say if they party still wants to scrap them all together, pointing to an upcoming policy convention next spring, but that “the province should be treating home care as its first resort, not its last.”

He said a greater investment than five per cent of the health care budget would save money in the long run.

CCAC costs also vary widely across the province, Lysyk said. The auditor found per-client costs range from $2,892 to $3,775 depending on where the CCAC is located.

The auditor also found great disparities in how much the third-party agencies charged CCACs. In one example, a company charged $49 dollars per hour in one region, but just $29.50 elsewhere in the province.

Personal support workers who are employed by these third parties make an average of about $14.50 per hour.

Lysyk will release two related audits, one specifically on CCAC home-care and personal-support services and the other on Ontario Local Health Integration Networks that fund CCACs as well as local hospital and other local health-care services.