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Appropriateness Working Group Recommendations

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Appropriateness Working Group Recommendations

Ministry of Health

Established by the Kaplan Board of Arbitration, the physician-led Appropriateness Working Group (AWG) reviewed several OHIP-insured services. The AWG used evidence, best practices and expert opinion to identify and update the delivery of certain services to help ensure the most effective care for Ontario patients. 

Beginning October 1, 2019, the following OHIP-insured services will be updated as a result of the working group's review.

IMPROVE THE QUALITY OF PATIENT CARE

Use More Accurate Diagnostic Imaging for Sinus Problems

  • Current evidence indicates that imaging of the sinuses is not required when diagnosing most sinus problems.
  • When imaging is required, X-rays are not as effective as other approaches such as CT scans.
  • Avoiding unnecessary X-rays of the sinuses will prevent patients from being needlessly exposed to radiation.

Refer Patients to Specialized Clinics for Chronic Hip and Knee Pain to Improve Arthritic Care

  • Reduce unnecessary hip and knee CT/MRI scans and surgical consultations by referring patients to the new province-wide system of musculoskeletal rapid access clinics.
  • Patients who are referred to musculoskeletal rapid access clinics are seen promptly by a specially trained physiotherapist, nurse or physician in order to evaluate the next best steps for their condition.
  • This change will result in greater access to CT and MRI imaging for patients who need it most and reduce the exposure to needless radiation for others.

Update the use of Ambulatory Cardiac Monitoring Devices (Loop and Holter Monitors)

  • New minimum technical requirements for outpatient cardiac monitoring tests to help ensure high-quality cardiac diagnosis consistent with current clinical guidelines will be specified.
  • Loop recorders, an older and outdated form of technology used to evaluate cardiac electrical activity in out-patients, will no longer be funded.

Improve Access to Primary and Specialty Care by Simplifying Referrals to Specialists

  • Sometimes patients are asked to visit their primary care provider to obtain a referral letter to see a specialist they have recently seen for the same problem.
  • When a stable patient is seen by the same specialist for the same problem, the medically necessary care is categorized as an assessment not a consultation.
  • This would make it easier for a patient to see a specialist for the same problem within a two-year period as an additional visit to their primary care provider would not be needed.
  • Patients will continue to receive necessary access to speciality care.
  • Hospital-based specialist consults will not be affected by this change.
  • This change will have the added benefit of increasing access to primary care physicians.

Use More Effective Testing to Diagnose Infertility

  • OHIP will continue to fund more effective testing to diagnose infertility, including semen analysis to detect male factor infertility, test to rule out tubal blockage and assessing uterine cavity or ovarian function.
  • OHIP will no longer cover post-coital testing of cervical mucous, which is an outdated test and no longer considered best practice.
  • Alternative tests would be based on a physician's clinical judgement and unique patient circumstances.
  • The more effective tests for diagnosing infertility continue to be insured by OHIP.

REDUCE MEDICALLY UNNECESSARY SERVICES

Perform Procedure to Remove Ear Wax Only When Medically Necessary

  • For many patients, softening of ear wax with easy to use over the counter treatments resolves the problem over time without medical intervention.
  • Ear wax removal will be covered when it is causing hearing loss and simple over-the-counter treatment is unsuccessful, or if the immediate removal of wax is needed to diagnose or treat other ear conditions.
  • Patients who ask their doctor to remove ear wax when it's not medically necessary may be required to pay.
Conduct Larynx Examinations During Stomach Examinations Only When Medically Necessary

  • When there is no suspicion or evidence of a problem with the patient's larynx, completing an additional examination of the larynx as part of the examination of the stomach is not medically necessary or helpful to the patient.
  • This will prevent unnecessary laryngoscopy services (an examination of the vocal cords) being performed at the same time as an examination of the stomach.

Continue Access to Urine Pregnancy Tests When Medically Necessary

  • Blood pregnancy tests - which provide more information remain insured for all patients.
  • When urine pregnancy tests are done, blood tests are also frequently required, creating unnecessary duplication.
  • Dipstick urine pregnancy tests performed in a physician's office, which provide far less information, will be insured when there is an immediate need to determine pregnancy to prevent imminent harm to the patient.

Improve Primary Care Access by Streamlining Pre-Operative Assessments

  • Pre-operative "history and physical" assessments are often requested by surgeons and performed by family doctors or specialists as an administrative requirement by hospitals.
  • These assessments are not medically necessary.
  • All patients are assessed by their surgeon and anesthesiologist prior to surgery to ensure that the patient is suitable for the proposed surgery and to determine the appropriate anesthetic care.
  • This change means patients have improved access to specialist and family physician care as it will cut down on unnecessary visits, procedures and testing.

Improve Access to Knee Arthroscopies for Patients with Degenerative Knee Disease

  • The latest evidence shows that knee arthroscopies are not effective for many patients with arthritis.
  • Patients who benefit from knee arthroscopy will still have access to this treatment option. This includes patients with degenerative knee disease in specific situations such as a loose bone or cartilage causing significant functional problems that have persisted despite non-surgical treatments.
  • For those who do not meet the above conditions could receive non-operative therapy focussed on pain management and physical therapy to provide pain relief and improve mechanical function of the knee joint.
  • Reducing ineffective knee arthroscopies will prevent unnecessary surgery and improve access for those with knee injuries and other conditions which do benefit from surgery.

Fund Physician Premiums for House Calls Only for Frail Elderly and Housebound Patients

  • Premiums to support house calls will be paid only in circumstances where patients must be seen at home including frail elderly, housebound and palliative patients.
  • Patients that are not frail elderly or housebound can be seen in their doctor's office.

PREVIOUS APPROPRIATENESS WORK

There is a long history of implementing effective, evidence-based care. Past appropriateness changes include the following:

  • Sinus ultrasound
    This procedure has been replaced by CT or sinus endoscopy, as these have been deemed as a more effective standard of care.

  • Pre-operative echocardiography (ECG)
    Pre-operative ECGs for non-cardiac elective surgery are only eligible for payment when the service is medically necessary and is not payable solely for the pre-operative preparation of the patient. Pre-operative ECGs and chest x-rays prior to colonoscopy, cystoscopy, carpal tunnel release and arthroscopy should not be routinely requested as part of the preparation and are not eligible for payment when ordered solely in preparation for these procedures, unless deemed medically necessary.

  • Hyperbaric oxygen therapy (HBOT)
    Idiopathic sudden sensorineural hearing loss (ISSHL) was added to the list of insured indications for HBOT use. HBOT is eligible for payment for ISSHL when the patient is treated concurrently with corticosteroid (unless corticosteroids are inadvisable in the particular case), and treatment is initiated within 14 days of a diagnosis of ISSHL is made or confirmed by an otolaryngologist.

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