MTRC starts providing a service of reimbursement analysis in Canada

Canada is a complex country from a market access perspective. The healthcare system is decentralized, with provinces leading in the organization and financing of services.

While most provinces use a simple global budget model (based on historical costs) to finance hospital activities, in largest provinces (Ontario and  Quebec), casemix data reported via the DRG system also influences the budget determination. Physician activities are reimbursed separately according to provincial fee schedules. The market access landscape is complicated by the presence of national and provincial HTA frameworks and provincial funding frameworks.

MTRC uses the following sources for reimbursement analysis:

• Canadian Classification of Health Interventions (CCI), 2022
• International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA), 2022
• Case Mix Groups+ (CMG+) with the estimated average cost per CMG for inpatient care
• Comprehensive Ambulatory Classification System (CACS) with the estimated average cost per CACS for ambulatory care and day case
• Health Based Allocation Model (HBAM) Inpatient Group (HIG) with the estimated average cost per HIG (Ontario) for inpatient care
• Ontario Comprehensive Ambulatory Classification System (CACS) with the estimated average cost per CACS for ambulatory care and day case
• Schedule of Benefits – Physician Services (SOB) [Ontario]
• Physician Reimbursement Manual [Quebec]

MTRC uses the following sources for policy analysis:

• Canadian Agency for Drugs and Technology in Health (CADTH)
• Ontario Ministry of Health and Long Term Care (Quality Based Procedures, QBPs; Assistive Devices Program)
• Ontario Health
• Health Quality Ontario
• Ministry of Health and Social Services (MSSS) (Patient-Based Funding programs)
• Quebec Health Insurance Board (RAMQ) (Assistance programs)
• Quebec National Institute of Excellence in Health and Social Services (INESSS)

Contact us to discuss your analytical needs in Canada and potential solutions.