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Activity-Based Hospital Funding in Alberta: Insights from Quebec and Australia

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14 minute read

From the Montreal Economic Institute

By Krystle Wittevrongel

Quebec has experienced increased productivity and efficiency, as well as reduced costs, in those sectors to which ABF has been applied

Alberta’s healthcare system costs more than those of many of its peers across Canada and internationally, yet underperforms by many metrics—wait times perhaps being the most visible.(1) For instance, while Alberta consistently spends a fair deal more per capita on health care than Canada’s other large provinces do, the median wait time from referral by a GP to treatment by a specialist was 33.3 weeks in 2022, versus 29.4 weeks in Quebec, 25.8 weeks in British Columbia, and 20.3 weeks in Ontario. Albertans waited a median 232 days for a hip replacement that year, longer than those in Quebec, British Columbia, and Ontario.(2) In Australia, meanwhile, the median wait time for a total hip replacement in 2022 was 175 days in public hospitals.(3)

One of the things keeping Alberta’s healthcare system from better performance is that it relies on global budgets for its hospital financing. Such a system allocates a pre-set amount of funding to pay for an expected number of services, based largely on historical volume. The problem with global budgets is that they disregard the actual costs incurred to deliver care, while undermining incentives to improve outcomes. This ultimately leads to rationing of care, with patients viewed as a cost that must be managed.

Activity-based funding systems are associated with reduced hospital costs, increased efficiency, and shorter wait times, among other things.

An alternative is activity-based funding (ABF), which has largely replaced global budgeting in many OECD countries, and is starting to do so in some Canadian provinces.(4) With ABF, hospitals receive a fixed payment for each specific service delivered, adjusted for certain parameters.(5) If a hospital treats more patients and delivers more services, it receives more funding; if it does less, it receives less. In essence, the money follows the patient, which has a dramatic effect: patients are now viewed as a source of revenue, not merely as a cost. Studies have shown that ABF systems that include appropriate safeguards for quality and waste are associated with reduced hospital costs, increased efficiency, and shorter wait times, among other things.(6)

To increase its capacity and performance, Alberta should consider moving to such a system for hospital financing. As over 25% of total health spending in the province goes to hospitals,(7) driving down costs and finding efficiencies is of paramount importance.

ABF models vary by jurisdiction and context to account for distinct situations and the particular policy objectives being pursued.(8) Two jurisdictions provide interesting insights: Quebec, with ABF hospital funding being gradually implemented in recent years, and Australia, where after more than three decades, ABF is the rule, global budgets the exception.

ABF in Quebec: Increased Performance and Decreased Costs

Quebec’s hospital payment reforms over the past two decades have been aimed at better linking funding with health care delivery to improve care quality and access.(9) These patient-based funding reforms (a type of ABF) have resulted in increased volumes and efficiency, and reduced costs and wait times for a number of surgical and other procedures in Quebec.(10)

These reforms started in 2004, when Quebec applied ABF in the context of additional funding to select surgeries in order to reduce wait times through the Access to Surgery Program.(11) The surgeries initially targeted were hip replacement, knee replacement, and cataract surgeries, but other procedures were eventually integrated into the program as well. Its funding covered the volume of surgeries that exceeded those performed in 2002-2003, and it used the average cost for each specific surgery. Procedures were classified by cost category, which also took into account the intensity of resource use and unit cost based on direct and indirect costs.

The expansion of ABF in Quebec aims to relieve hospital congestion by driving down wait times and shrinking wait lists.

By 2012-2013, this targeted program had helped to significantly increase the volume of surgeries performed, as well as decrease wait times and length of stay.(12) However, as ABF was applied only to surplus volumes of additional surgeries, efficiency gains were limited. For this reason, among others, the Expert Panel for Patient-Based Funding recommended expanding the program,(13) and in 2012, the Government of Quebec began considering further pilot projects for gradual ABF implementation.(14)

  • In 2015, ABF was implemented in the radiation oncology sector, which resulted in better access to services at a lower cost, with productivity having increased more than 26% by 2023-2024, and average procedure costs having fallen 7%.(15)
  • In 2017-2018, ABF was implemented in imaging, which resulted in the number of magnetic resonance imaging tests increasing more than 22% while driving the unit cost of procedures down 4%.(16)
  • Following the above successes, in 2018-2019, the colonoscopy and digestive endoscopy sector also moved to ABF, which led to a productivity increase of 14% and a 31% decrease in the case backlog.(17)

Overall, then, Quebec has experienced increased productivity and efficiency, as well as reduced costs, in those sectors to which ABF has been applied (see Figure 1).

The Department of Health and Social Services continued to expand ABF to more surgeries in 2023, following which it was expected that about 25% of the care and services offered in physical health in Quebec hospitals would be funded in this manner, with the goal of reaching 100% by 2027-2028.(18) Further, the 2024-2025 budget expanded ABF again to include the medicine, emergency, neonatal, and dialysis sectors.

This expansion of ABF aims to relieve hospital congestion by driving down wait times and shrinking wait lists.(19) It will also align Quebec’s health care funding with what has become standard in most OECD countries. In Australia, for instance, ABF is the rule, not the exception, covering a large proportion of hospital services.

Australia’s Extensive Use of ABF

Australia also implemented ABF in stages, as Quebec is now doing. It was first introduced in the 1990s in one state and adopted nationally in 2012 for all admitted programs to increase efficiency, while also integrating quality and safety considerations.(20) These considerations act as safeguards to ensure efficiency incentives don’t negatively impact services. For instance, there are adjustments to the ABF payment framework in the presence of hospital acquired complications and avoidable hospital readmissions, two measures of hospital safety and service quality.(21) If service quality were to decrease, funding would be adjusted, and payments would be withheld. Not only has ABF been successful in increasing hospital efficiency in Australia, but it has also enabled proactive service improvement, which has in turn had a positive impact on safety and quality.(22)

ABF now makes up 87.0% of total hospital spending in Australia, ranging from 83.6% in Tasmania to 93.0% in the Australian Capital Territory.

Currently, ER services, acute services, admitted mental health services, sub-acute and non-acute services, and non-admitted services are funded with ABF in Australia. This includes rehabilitation, palliative, geriatric and/or maintenance care.(23) Global budgets are still used for some block funding, but this is the exception, restricted to certain hospitals, programs, or specific episodes of care.(24) Small rural hospitals, non-admitted mental health programs, and a few other highly specialized therapies or clinics or some community health services tend to be block funded due to higher than average costs stemming from a lack of economies of scale and inadequate volumes, among other things.

When first introduced, ABF made up about 25% of hospital revenue (approximately where Quebec currently stands).(25) ABF now makes up 87.0% of total hospital spending in Australia, ranging from 83.6% in Tasmania to 93.0% in the Australian Capital Territory (see Figure 2).

There is more variability, however, at the local hospital network level within territories or states. For instance, between 2019 and 2024, an average of 92.3% of total funding for the hospitals in the South Eastern Sydney Local Health District was ABF, and just 7.7% was block funding.(26) For the hospitals in the Far West Local Health District, in comparison, ABF represented an average of 72.0% of total funding, and block payments 28.0%, over the same period.(27)

The proportion of ABF funding per hospital is dictated, for the most part, by the types and volumes of patient services provided, but also by hospital characteristics and regional patient demographics.(28) For example, there could be a need to compensate for differences in hospital size and location, or to reimburse for some alternative element of the fixed cost of providing services. In the Far West Local Health District, on average 65.1% of block funding between 2019-2020 and 2023-2024 was provided for small rural hospitals, while only 1.4% of the block funding in the South Eastern Sydney Local Health District was for these types of hospitals.(29) Ultimately, these two districts serve very different populations, with the Far West Local Health District being the most thinly populated district in Australia.(30)

Overall, ABF implementation in Australia has significantly improved hospital performance. Early after ABF implementation, the volume of care in Australia increased, and waiting lists decreased by 16% in the first year.(31) Between 2005 and 2017 the hospitals that were funded by ABF in Queensland became more efficient than those receiving block funding.(32) In addition, ABF can contribute to reductions in extended lengths of stay and hospital readmission,(33) both of which are expensive propositions for health care systems and also tie up hospital beds and resources.

Conclusion

ABF has been associated with reduced hospital costs, increased efficiency, and shorter wait times, areas where Alberta is lacking and reform is needed. To increase its health system performance, Alberta should consider emulating Quebec and moving to an activity-based funding system. Indeed, based on the experience of countries like Australia, widespread application should be the goal, as it is in Quebec. Alberta patients have already waited far too long for timely access to the quality care they deserve. The time to act is now.

The MEI study is available here.

* * *

This Economic Note was prepared by Krystle Wittevrongel, Senior Policy Analyst and Alberta Project Lead at the MEI. The MEI’s Health Policy Series aims to examine the extent to which freedom of choice and entrepreneurship lead to improvements in the quality and efficiency of health care services for all patients.

The MEI is an independent public policy think tank with offices in Montreal and Calgary. Through its publications, media appearances, and advisory services to policy-makers, the MEI stimulates public policy debate and reforms based on sound economics and entrepreneurship. 

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2025 Federal Election

The High Cost Of Continued Western Canadian Alienation

Published on

From EnergyNow.Ca

By Jim Warren

Energy Issues Carney Must Commit to if He Truly Cares About National Cohesion and be Different From Trudeau

If the stars fail to align in the majority of Western Canada’s favour and voters from Central Canada and the Maritimes re-elect a Liberal government on April 28, it will stand as a tragic rejection of the aspirations of the oil producing provinces and a threat to national cohesion.

As of today Mark Carney has not clearly and unequivocally promised to tear down the Liberal policy wall blocking growth in oil and gas exports. Yes, he recently claimed to favour energy corridors, but just two weeks earlier he backtracked on a similar commitment.

There are some promises Carney hopefully won’t honour. He has pledged to impose punitive emissions taxes on Canadian industry. But that’s supposedly alright because Carney has liberally sprinkled that promise with pixie dust. This will magically ensure any associated increases in the cost of living will disappear. Liberal wizardry will similarly vaporize any harm Carbon Tax 2.0 might do to the competitive capacity of Canadian exporters.

Carney has as also promised to impose border taxes on imports from countries that lack the Liberals’ zeal for saving the planet. These are not supposed to raise Canadians’ cost of living by much, but if they do we can take pride in doing our part to save the planet. We can feel good about ourselves while shopping for groceries we can’t afford to buy.

There is ample bad news in what Carney has promised to do. No less disturbing is what he has not agreed to do. Oil and gas sector leaders have been telling Carney what needs to be done, but that doesn’t mean he’s been listening.

The Build Canada Now action plan announced last week by western energy industry leaders lays out a concise five-point plan for growing the oil and gas sector. If Mark Carney wants to convince his more skeptical detractors that he is truly concerned about Canadian prosperity, he should consider getting a tattoo that celebrates the five points.

Yet, if he got onside with the five points and could be trusted, would it not be a step in the right direction? Sure, but it would also be great if unicorns were real.

The purpose of the Build Canada Now action plan couldn’t be much more clearly and concisely stated. “For the oil and natural gas sector to expand and energy infrastructure to be built, Canada’s federal political leaders can create an environment that will:

1. Simplify regulation. The federal government’s Impact Assessment Act and West Coast tanker ban are impeding development and need to be overhauled and simplified. Regulatory processes need to be streamlined, and decisions need to withstand judicial challenges.

2. Commit to firm deadlines for project approvals. The federal government needs to reduce regulatory timelines so that major projects are approved within 6 months of application.

3. Grow production. The federal government’s unlegislated cap on emissions must be eliminated to allow the sector to reach its full potential.

4. Attract investment. The federal carbon levy on large emitters is not globally cost competitive and should be repealed to allow provincial governments to set more suitable carbon regulations.

5. Incent Indigenous co-investment opportunities. The federal government needs to provide Indigenous loan guarantees at scale so industry may create infrastructure ownership opportunities to increase prosperity for communities and to ensure that Indigenous communities benefit from development.”

As they say the devil is often in the details. But it would be an error to complicate the message with too much detail in the context of an election campaign. We want to avoid sacrificing the good on behalf of the perfect. The plan needs to be readily understandable to voters and the media. We live in the age of the ten second sound bite so the plan has to be something that can be communicated succinctly.

Nevertheless, there is much more to be done. If Carney hopes to feel welcome in large sections of the west he needs to back away from many of promises he’s already made. And there are many Liberal policies besides Bill C-69 and C-48 that need to be rescinded or significantly modified.

Liberal imposed limitations on free speech have to go. In a free society publicizing the improvements oil and gas companies are making on behalf of environmental protection should not be a crime.

There is a morass of emissions reduction regulations, mandates, targets and deadlines that need to be rethought and/or rescinded. These include measures like the emissions cap, the clean electricity standard, EV mandates and carbon taxes. Similarly, plans for imposing restrictions on industries besides oil and gas, such as agriculture, need to be dropped. These include mandatory reductions in the use of nitrogen fertilizer and attacks (thus far only rhetorical) on cattle ranching.

A good starting point for addressing these issues would be meaningful federal-provincial negotiations. But that won’t work if the Liberals allow Quebec to veto energy projects that are in the national interest. If Quebec insists on being obstructive, the producing provinces in the west will insist that its equalization welfare be reduced or cancelled.

Virtually all of the Liberal policy measures noted above are inflationary and reduce the profitability and competitive capacity of our exporters. Adding to Canada’s already high cost of living on behalf of overly zealous, unachievable emissions reduction goals is unnecessary as well as socially unacceptable.

We probably all have our own policy change preferences. One of my personal favourites would require the federal government to cease funding environmental organizations that disrupt energy projects with unlawful protests and file frivolous slap suits to block pipelines.

Admittedly, it is a rare thing to have all of one’s policy preferences satisfied in a democracy. And it is wise to stick to a short wish list during a federal election campaign. Putting some of the foregoing issues on the back burner is okay provided we don’t forget them there.

But what if few or any of the oil and gas producing provinces’ demands are accepted by Carney and he still manages to become prime minister?

We are currently confronted by a dangerous level of geopolitical uncertainty. The prospects of a global trade war and its effects on an export-reliant country like Canada are daunting to say the least.

Dividing the country further by once again stifling the legitimate aspirations of the majority of people in Alberta and Saskatchewan will not be helpful. (I could add voters from the northeast and interior of B.C., and southwestern Manitoba to the club of the seriously disgruntled.)

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2025 Federal Election

Next federal government should recognize Alberta’s important role in the federation

Published on

From the Fraser Institute

By Tegan Hill

With the tariff war continuing and the federal election underway, Canadians should understand what the last federal government seemingly did not—a strong Alberta makes for a stronger Canada.

And yet, current federal policies disproportionately and negatively impact the province. The list includes Bill C-69 (which imposes complex, uncertain and onerous review requirements on major energy projects), Bill C-48 (which bans large oil tankers off British Columbia’s northern coast and limits access to Asian markets), an arbitrary cap on oil and gas emissions, numerous other “net-zero” targets, and so on.

Meanwhile, Albertans contribute significantly more to federal revenues and national programs than they receive back in spending on transfers and programs including the Canada Pension Plan (CPP) because Alberta has relatively high rates of employment, higher average incomes and a younger population.

For instance, since 1976 Alberta’s employment rate (the number of employed people as a share of the population 15 years of age and over) has averaged 67.4 per cent compared to 59.7 per cent in the rest of Canada, and annual market income (including employment and investment income) has exceeded that in the other provinces by $10,918 (on average).

As a result, Alberta’s total net contribution to federal finances (total federal taxes and payments paid by Albertans minus federal money spent or transferred to Albertans) was $244.6 billion from 2007 to 2022—more than five times as much as the net contribution from British Columbians or Ontarians. That’s a massive outsized contribution given Alberta’s population, which is smaller than B.C. and much smaller than Ontario.

Albertans’ net contribution to the CPP is particularly significant. From 1981 to 2022, Alberta workers contributed 14.4 per cent (on average) of total CPP payments paid to retirees in Canada while retirees in the province received only 10.0 per cent of the payments. Albertans made a cumulative net contribution to the CPP (the difference between total CPP contributions made by Albertans and CPP benefits paid to retirees in Alberta) of $53.6 billion over the period—approximately six times greater than the net contribution of B.C., the only other net contributing province to the CPP. Indeed, only two of the nine provinces that participate in the CPP contribute more in payroll taxes to the program than their residents receive back in benefits.

So what would happen if Alberta withdrew from the CPP?

For starters, the basic CPP contribution rate of 9.9 per cent (typically deducted from our paycheques) for Canadians outside Alberta (excluding Quebec) would have to increase for the program to remain sustainable. For a new standalone plan in Alberta, the rate would likely be lower, with estimates ranging from 5.85 per cent to 8.2 per cent. In other words, based on these estimates, if Alberta withdrew from the CPP, Alberta workers could receive the same retirement benefits but at a lower cost (i.e. lower payroll tax) than other Canadians while the payroll tax would have to increase for the rest of the country while the benefits remained the same.

Finally, despite any claims to the contrary, according to Statistics Canada, Alberta’s demographic advantage, which fuels its outsized contribution to the CPP, will only widen in the years ahead. Alberta will likely maintain relatively high employment rates and continue to welcome workers from across Canada and around the world. And considering Alberta recorded the highest average inflation-adjusted economic growth in Canada since 1981, with Albertans’ inflation-adjusted market income exceeding the average of the other provinces every year since 1971, Albertans will likely continue to pay an outsized portion for the CPP. Of course, the idea for Alberta to withdraw from the CPP and create its own provincial plan isn’t new. In 2001, several notable public figures, including Stephen Harper, wrote the famous Alberta “firewall” letter suggesting the province should take control of its future after being marginalized by the federal government.

The next federal government—whoever that may be—should understand Alberta’s crucial role in the federation. For a stronger Canada, especially during uncertain times, Ottawa should support a strong Alberta including its energy industry.

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