Alberta
Activity-Based Hospital Funding in Alberta: Insights from Quebec and Australia
From the Montreal Economic Institute
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.
Alberta
Early Success: 33 Nurse Practitioners already working independently across Alberta
Nurse practitioners expand primary care access |
The Alberta government’s Nurse Practitioner Primary Care program is showing early signs of success, with 33 nurse practitioners already practising independently in communities across the province.
Alberta’s government is committed to strengthening Alberta’s primary health care system, recognizing that innovative approaches are essential to improving access. To further this commitment, the Nurse Practitioner Primary Care Program was launched in April, allowing nurse practitioners to practise comprehensive patient care autonomously, either by operating their own practices or working independently within existing primary care settings.
Since being announced, the program has garnered a promising response. A total of 67 applications have been submitted, with 56 approved. Of those, 33 nurse practitioners are now practising autonomously in communities throughout Alberta, including in rural locations such as Beaverlodge, Coaldale, Cold Lake, Consort, Morley, Picture Butte, Three Hills, Two Hills, Vegreville and Vermilion.
“I am thrilled about the interest in this program, as nurse practitioners are a key part of the solution to provide Albertans with greater access to the primary health care services they need.”
To participate in the program, nurse practitioners are required to commit to providing a set number of hours of medically necessary primary care services, maintain a panel size of at least 900 patients, offer after-hours access on weekends, evenings or holidays, and accept walk-in appointments until a panel size reaches 900 patients.
With 33 nurse practitioners practising independently, about 30,000 more Albertans will have access to the primary health care they need. Once the remaining 23 approved applicants begin practising, primary health care access will expand to almost 21,000 more Albertans.
“Enabling nurse practitioners to practise independently is great news for rural Alberta. This is one more way our government is ensuring communities will have access to the care they need, closer to home.”
“Nurse practitioners are highly skilled health care professionals and an invaluable part of our health care system. The Nurse Practitioner Primary Care Program is the right step to ensuring all Albertans can receive care where and when they need it.”
“The NPAA wishes to thank the Alberta government for recognizing the vital role NPs play in the health care system. Nurse practitioners have long advocated to operate their own practices and are ready to meet the growing health care needs of Albertans. This initiative will ensure that more people receive the timely and comprehensive care they deserve.”
The Nurse Practitioner Primary Care program not only expands access to primary care services across the province but also enables nurse practitioners to practise to their full scope, providing another vital access point for Albertans to receive timely, high-quality care when and where they need it most.
Quick facts
- Through the Nurse Practitioner Primary Care Program, nurse practitioners receive about 80 per cent of the compensation that fee-for-service family physicians earn for providing comprehensive primary care.
- Compensation for nurse practitioners is determined based on panel size (the number of patients under their care) and the number of patient care hours provided.
- Nurse practitioners have completed graduate studies and are regulated by the College of Registered Nurses of Alberta.
- For the second consecutive year, a record number of registrants renewed their permits with the College of Registered Nurses of Alberta (CRNA) to continue practising nursing in Alberta.
- There were more than 44,798 registrants and a 15 per cent increase in nurse practitioners.
- Data from the Nurse Practitioner Primary Care Program show:
- Nine applicants plan to work on First Nations reserves or Metis Settlements.
- Parts of the province where nurse practitioners are practising: Calgary (12), Edmonton (five), central (six), north (three) and south (seven).
- Participating nurse practitioners who practise in eligible communities for the Rural, Remote and Northern Program will be provided funding as an incentive to practise in rural or remote areas.
- Participating nurse practitioners are also eligible for the Panel Management Support Program, which helps offset costs for physicians and nurse practitioners to provide comprehensive care as their patient panels grow.
Related information
Alberta
Province considering new Red Deer River reservoir east of Red Deer
Central Alberta reservoir study underway
Alberta’s government is moving forward a study to assess the feasibility of building a new reservoir on the Red Deer River to help support growing communities.
Demand for water from communities and businesses is increasing as more families, businesses and industries choose to live and work in central Alberta. The Red Deer River supplies water to hundreds of thousands of Albertans across the region and expanding water storage capacity could help reduce the risk of future droughts and meet the growing water demands.
Alberta’s government has now begun assessing the feasibility of building a potential new reservoir east of Red Deer near Ardley. A two-phase, multi-year study will explore the costs and value of constructing and operating the reservoir, and its impact on downstream communities, farmers and ranchers, and businesses.
“Central Alberta is a growing and thriving, and we are ensuring that it has the water it needs. This study will help us determine if an Ardley reservoir is effective and how it can be built and operated successfully to help us manage and maximize water storage for years to come.”
Reservoirs play a vital role in irrigation, drought management, water security and flood protection. Budget 2024 allocated $4.5 million to explore creating a new reservoir on the Red Deer River, at a damsite about 40 kilometres east of the City of Red Deer.
Work will begin on the scoping phase of the study as soon as possible. This will include reviewing available geotechnical and hydrotechnical information and exploring conceptual dam options. The scoping phase also includes meetings with municipalities and water users in the area to hear their views. This work is expected to be completed by December 2025.
“Reliable water infrastructure is essential for Alberta’s growing communities and industries. The Ardley reservoir feasibility study is a vital step toward ensuring long-term water security for central Alberta. As we assess this project’s potential, we’re supporting the sustainability of our economic corridors, agricultural operations and rural economy.”
“Water is essential to the agriculture industry and if the past few years are any indication, we need to prepare for dry conditions. A potential dam near Ardley could enhance water security and help farmers and ranchers continue to thrive in Alberta’s unpredictable conditions.”
Once that is complete, the feasibility study will then shift into a second phase, looking more closely at whether an effective new dam near Ardley can be safely designed and constructed, and the impact it may have on communities and the environment. Geotechnical and hydrotechnical investigations, cost-benefit analyses and an assessment of environmental and regulatory requirements will occur. The feasibility phase will also include gathering feedback directly from Albertans through public engagement. This work is expected to be completed by March 31, 2026.
Quick facts
- The Ardley dam scoping and feasibility study will be undertaken by Hatch Ltd., a Canadian multi-disciplinary professional services firm.
- Once the feasibility study is complete, government will assess the results and determine whether to pursue this project and proceed with detailed engineering and design work and regulatory approvals.
- Alberta’s government owns and operates several large reservoirs in the South Saskatchewan River Basin that help ensure sufficient water supply to meet demand from communities, irrigators and businesses, while also maintaining a healthy aquatic environment.
- Water stored at Gleniffer Lake, the reservoir created by Dickson Dam, helps supplement low winter flows along the Red Deer River and helps ensure an adequate water supply for Red Deer and Drumheller.
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