Labservices
Labservices
Expert Panel
Final
November 12, 2015
The Panel would like to offer our thanks to the many individuals in the community, hospital and public
health laboratory sector and to the many helpful officials within the Ontario government who were
responsive to our requests for rapid turn-around on material. Thanks also to the numerous
professionals who offered their time, expertise and ideas from across Canada to help bring this report
to fruition. Special thanks are due to the staff of the Program Development and Delivery Branch within
the Negotiations and Accountability Division at the Ministry of Health and Long-Term Care who
facilitated our multiple interactions with the field and within the Ministry. Finally, special recognition and
thanks go to Melissa Tamblyn, who was our most able project leader for this effort.
On behalf of our Panel, we are pleased to submit this report on recommendations for
modernizing the community laboratory services funding model in Ontario.
We appreciate your confidence in asking the Panel to undertake this review. We hope that our
report and recommendations will help to bring value to the patients of Ontario, the physicians
who order tests, and the Ministry of Health and Long-Term care who retain stewardship for
laboratory services.
We would be happy to follow up in any way regarding the recommendations in this report.
Yours sincerely,
Today in Ontario, a mix of public and private sector organizations deliver laboratory services,
with the slight majority delivered through public hospitals. The sector as a whole has moved
towards varying degrees of consolidation and integration over the past decade. A significant
consolidation of ownership has occurred in the community laboratory services sector, where two
major commercial laboratory providers now account for approximately 95 per cent of all activity.
The distribution of all activity is depicted in table 1 below.
Table 1: Distribution of testing and funding across Ontario’s laboratory sector
In developing its recommendations, the Expert Panel reviewed previous reports and analysis,
conducted a literature and evidence review, and undertook a jurisdictional scan. A full summary
of the literature and evidence review can be found in Appendix C. A full summary of the
jurisdictional scan can be found in Appendix D.
Insight gathered from this review informed an in-person consultation phase with key
stakeholders and policymakers, which included meetings with over 25 organizations and
involved representatives of government and the community, the public health and hospital
laboratory sectors, external experts, and specialists from other jurisdictions. The primary focus
of the Panel’s review was an examination of the funding model for community laboratories
services, at the core of which is a fee-for-service payment structure with caps. The Panel
reviewed the limited existing community laboratory arrangements and related documentation,
and had extensive briefings on the current process for engaging and compensating community
laboratories, the details of which are included in section 3.0 of this report. See Appendix E for a
list of consultations.
Following its consultations, the Panel deliberated and developed a set of working directions for
discussion with core sector stakeholders. Meetings with community laboratory CEOs and the
Laboratory Advisory Forum concluded the review process, after which the Panel finalized its
recommendations in this report. All of this activity supported the conclusion that a move to
performance-based contracting is an essential modernization step for funding community
laboratories.
4. Appropriate Utilization
6. Innovation in Genetics
In addition, a number of key findings relating to the broader laboratory sector emerged,
including issues pertaining to testing performed in hospitals, public health laboratories and
physician offices that may impact the overall funding and modernization of laboratory services in
Ontario.
The Panel’s greatest concern lies in the complete absence of formal performance contracts and
service level agreements with individual laboratories to clearly identify roles and responsibilities
and deliver better value.
For example, there are currently no contracts directly with the individual laboratories for cap
funding, which amounts to approximately $650 million annually. Similarly, limited contracts exist
for the $23 million in out of cap funding that is distributed to the laboratories annually. In both
cases, framework agreements with the Ontario Association of Medical Laboratories (OAML) are
in place; however, not all laboratories are members of the OAML, nor do these agreements
serve to bind any individual laboratory to specific performance standards. It is also of note that
the Ministry funds the OAML to perform this intermediary role on behalf of the laboratories at a
cost of approximately $900,000 annually. In the view of the Panel, this process of direct
payment by the ministry should be discontinued to allow the laboratories to make their own
arrangement with respect to an association.
The existence of multiple, parallel funding envelopes for capped and non-capped services (e.g.
(e.g. FOBT and PSA testing) are not well aligned with a comprehensive management approach
The rigidity of the current licensing regime may also create barriers to point-of-care testing and
new testing technologies. This has had a negative impact on the development and use of
innovative solutions to provide better access and quality care.
The accreditation of laboratories takes place through the Institute for Quality Management in
Healthcare (IQMH), which is under the corporate control of the Ontario Medical Association
(OMA). The Ministry remains responsible for inspecting specimen collection centres. There is
currently a movement towards the IQMH accrediting specimen collection centres wherein a pilot
was completed in 2015 which is slated to “IQMH does good work, but they need to
expand in the coming years. support utilization management and
appropriateness….it feels a little like the ‘fox is
Currently, there is no public visibility into the in the henhouse’ on this one…”
results of laboratory accreditations or ~ Key Informant Interview
inspections. The Panel is concerned that this
OMA structure is lacking the degree of independence and transparency typically required from
accrediting institutions, and may create challenges with respect to appropriate utilization
management by physicians.
Additionally, the Ministry covers all accreditation costs and most of the proficiency test costs on
behalf of the community laboratories (approximately $4.6 million annually), which is not
consistent with other accreditation programs, such as Accreditation Canada.
Appropriate Utilization
The literature suggests that the number of inappropriate laboratory tests has increased over the
last decades. This challenge is not unique to the Ontario health system and is also prevalent in
other jurisdictions.21,22 Sources suggest that between 20 and 50 per cent of laboratory tests
ordered may be inappropriate.23,24 According to a recent US based meta-analysis using the 50
most frequently order tests at Beth Israel Deaconess Medical Center, mean rates of
LABORATORY SERVICES EXPERT PANEL REVIEW 19
overutilization are 20.6 per cent while underutilization stands at 44.8 per cent.25 According to the
broader literature, overutilization poses
significant financial and psychological “The fact that we do not monitor the requests
burdens on the health system and on from physicians is a lost opportunity….we need
meaningful evidence based demand side as well
patients, resulting in increased costs, longer as supply side management”
hospital stays, false positive diagnoses, and ~ Key Informant Interview
patient anxiety. 25,26,27 The potential for cost
saving lies not only with the reduction of inappropriate laboratory tests, but also with the
subsequent elimination of medical activities following the testing.28
While there seems to be an existing consensus around the goal to improve the appropriate
utilization of laboratory tests, as demonstrated by the increasing number of intervention
research activities in Canada and internationally, there is mixed evidence as to how to get
there.24,29
The most commonly used interventions to reduce inappropriate testing include the education of
physicians, feedback on individual test ordering patterns, modification of laboratory requisitions
forms, electronic-based prompts and system interventions, and incentives or penalties.30,31,32
Despite the variable success of these interventions, there have been some exciting results in
this area.30,33 Physicians who ordered referred-out tests in Calgary exceeding a threshold of $20
were requested to justify their order. This initiative led to a remarkable reduction of around 50
per cent of ordered tests.33 Other interventions including electronic prompts showing real time
pricing of laboratory tests on electronic health records, elimination of reflex testing, the review of
test requests by experts, feedback and peer performance comparisons, and laboratory profile
changes demonstrated improvements in the reduction of physicians’ orders 28,34,35,30,36. The
evidence suggests that multiple interventions and those focusing on fewer tests are the most
successful.30,32 A method to reduce inappropriate testing by assigning interventions to particular
tests is the laboratory test utilization management tool box.37 This is further described in
Appendix F.
In Ontario, we have witnessed the launch of Choosing Wisely Canada, a campaign to help
physicians and patients engage in conversations about unnecessary tests, treatments and
procedures. There are examples of the impact of utilization management on the use of tests in a
number Ontario hospitals upon which to build.
North York General Hospital (NYGH) is one of the early adopters of the Choosing Wisely
Canada campaign, launching in June 2014. Their campaign focuses on areas where evidence
overwhelmingly shows that a test, treatment or procedure provides little to no benefit to a
patient. Building on the success of its computerized physician order entry, order sets, pharmacy
and bed utilization initiatives, the NYGH program focused on improving lab and medical Imaging
utilization. Evidence to date shows gains in Emergency Department, Pre-Op Clinic and
inpatient laboratory testing. Unnecessary emergency Department laboratory testing has
decreased 40 per cent per month since September 2014. Pre-Op Clinic laboratory testing has
decreased 40 per cent per month since February 2015. Inpatient laboratory testing has
decreased five per cent per month since January 2015.38 Similar success has been achieved in
LABORATORY SERVICES EXPERT PANEL REVIEW 20
Hamilton where the Hamilton, Niagara, Haldimand Brant Local Health Integration Network
(LHIN) Laboratory Medicine Network (now known as CoLabs) has established a collaboration
across 17 licensed hospital laboratories to streamline and standardize processes and
continually improve the quality of service for their patients. In addition to saving over $1 million
annually through test consolidation and other collaborative efficiencies, CoLabs has also been a
leader in the implementation of Choosing Wisely and has been able to discontinue some testing
and improve utilization across the board.39
Despite these successes, much opportunity remains to enhance cost savings and improve
patient care through the demand side of the laboratory services equation, particularly in the
community sector. The Panel believes that as the health system increasingly relies on electronic
health records, a special focus should be put on electronic order entry prompts to manage
utilization.
Currently, there is variation in laboratory services utilization across Ontario, some of which may
relate to access and geography. As the table below indicates, laboratory services utilization
rates range from a low of 37.5 per cent in the North West LHIN to a high of 52.3 per cent in the
Central LHIN. Further work is needed to define appropriate ranges of laboratory services
utilization, adjusted for age and other relevant population factors.
Further work is also needed to find balance between underutilization of services, overuse of
services, and supply-induced demand. There is no evidence to suggest that increasing billing or
points of service reveal consumer preference. Opening new capacity or adding more doctors in
areas with low utilization may help foster appropriate utilization. Opening new capacity in areas
with high utilization requires caution, however, as it may be an invitation for supply-induced
demand.
Table 2: Community laboratory services rates in Ontario for fiscal year 2013-14, including
number of visits, number of claims, and billing value per patients by LHIN.
Population /o of Population
0 #of visits #of Tests B illing Value
Patient LHIN
Total with a lab test per patient per patient per patient
Data Source: Claims History Database (CHOB). MOHlTC • extracted July 2015: Registered Person Database (RPOB), MOHLTC · extracted July 2015: 201 t
Census·based Ministry of Finance Population Estimates (201 I ·2013) and Projections (20141·204 t) f« Loe.al Health Integration Networks • updated Jat'Klaf)' 20tS:
Postal Codes to LHINs COO\tersion Fie, MOHlTC · updated 2013
The majority of testing is for fertility and methadone (Point of Care drug testing), with a
concentration of services in larger urban centres of the Province. There is also anecdotal
evidence that a number of these tests may be sent to community laboratories for confirmatory
testing, resulting in double billing which may not be required.
Quality oversight for physician in-office testing was flagged as an issue in the 2005 Auditor
General’s report.42 The other significant issue with physician in-office testing is its exemption
from the Licensing Act, which means that no accreditation or inspection of this testing is
required. In addition, physician in-office test result data is not captured in OLIS today. As the
figure above indicates, the escalation in volumes of physician in-office testing speaks to the
need for an appropriateness or utilization review of this activity, a process which does not exist
today.
PATIENT CENTRED
Accessible & convenient
VALUE ADDED Safe, elfectiv·e &
Financially sustainable appropriate
Timely services to physicians Stable and reliable service
Maximizes public value Consistent patient cost and
Delivery of medically necessary services in a coverage regardless ol
consistent and appropriate manner where service is accessed/
Provides opportun~ies lor innovation delivered
CATEGORY DESCRIPTION
Figure 7: Process for evaluating and procuring new test technologies in Ontario, from
test technology discovery to maturation.
This solution would require fielding to an appropriately qualified expert organization, such as
Health Quality Ontario, or an expert panel with broad clinical input. These experts would be
responsible for convening laboratory leaders and outcome-focused researchers to build
guidance on the appropriateness of common tests as well as the most expensive tests ordered.
A. Strategically position genetic testing services to meet current and future needs
Given the rapid growth in molecular diagnostics and genetic testing, the Panel recommends that
a detailed program plan be developed as a high priority to address these challenges. This
would include optimization of the number and location of genetic testing sites, a rationalization
of testing, and a growth in capacity for the analysis of complex data.
Historically, hospitals have played an important role in developing new testing technologies for
use in Ontario. An example of this is non-invasive prenatal testing (NIPT), which was
extensively studied and evaluated at Mount Sinai Hospital as a new alternative to
amniocentesis.
While hospitals are often not the best candidates to perform very high volume routine testing,
the Panel recommends that the role of hospitals in the innovation and discovery cycle be
explored in greater detail as part of a new process to evaluate and approve new testing
technologies for use in Ontario. This will ease the transition of research-based tests from a
clinical or academic setting into a production-oriented laboratory setting, for consideration on the
Schedule of Benefits.
As previously identified in analysis and reports, some hospital outpatient testing may be more
conveniently and more economically performed in the community. In fact, this is a practice
already in place today in some hospitals. This practice may not be advantageous in small, rural
D. Conduct a reference full cost accounting study across the broader laboratory
sector (community, hospital and public health) to inform rationalization of test
menu across sector
A rationalization of the test menu would ensure the right test is assigned to the best supplier or
suppliers based on a number of criteria, including patient convenience, cost and quality.
Currently, a considerable degree of overlap in testing occurs across the broader laboratory
sector, where the same test could be performed in different settings. While there are
circumstances in which this is appropriate and redundancy is useful, there are examples where
a more rationalized approach is warranted. Testing should be performed where the best value is
realized in terms of clinical use, patient-centredness and price. A full study of test costs across
the sector would inform a rationalization of the test menu, and would also support ongoing
updates to the Schedule of Benefits.
E. Provide quality oversight and develop comparable payment for physician in-
office testing in relation to community laboratory testing
Physicians conducting in-office testing should be accountable for quality to an oversight body,
such as the College of Physicians and Surgeons of Ontario. The current physician exemption
20
from the Licensing Act should be rescinded.
OLIS has significant potential for a variety of purposes. The ability to access previous tests and
see patient history across multiple institutions and providers is a key benefit to clinicians. At a
system level, OLIS data also has the potential to support improved sector management. The
utility of OLIS is maximized when all test data is available. All remaining hospitals, community
laboratories and physicians conducting in-office testing should be brought onto the OLIS
platform, and efforts should be made to ensure interoperability between OLIS and existing
clinical information systems at the point-of-care to maximize adoption and use.
• Strengthen Ministry
FUNDING MODEL
Negotiation
• Implement independent
• Develop plan for IQMH • Implement accreditation
independence of IQMH • Plan accreditation cost cost recovery
recovery
From 1993 to 2001, Dr. Sullivan was the founding President of the Institute for Work & Health
(IWH). From 1986 to 1992, he held senior roles in the Ontario Ministries of Health, Cabinet
Office and Intergovernmental Affairs. He was Assistant Deputy Minister, Constitutional Affairs
and Federal-Provincial Relations during the Charlottetown negotiations. He served two
successive First Ministers of Ontario as Executive Director of the Premier's Council on Health
Strategy, including a period as Deputy Minister (1991).
A behavioural scientist, Dr. Sullivan is Professor at the Institute of Health Policy, Management &
Evaluation, Dalla Lana School of Public Health at the University of Toronto and Adjunct
Professor of Oncology at McGill University. He has provided a range of improvement advisory
services to client health care organizations in Canada and internationally.
Prior to joining the Office of the Auditor General, Mr. Minto was employed in the private sector.
He obtained his C.A. Designation while employed at Touche Ross & Co. Mr. Minto joined the
CARE Canada Board in 2010 and serves as the Chair of the Finance, Audit and Risk
Management Committee. In 2014 he was became a member of the Government of Canada’s
Audit Committee,
Melissa Tamblyn provided support to the Panel in its research, consultation and report
development activity. With a Masters of Public Administration in Health Policy, she has worked
in health care for over 15 years and has a range of management and advisory experiences in
the public and private health care sector within Canada.
In 2012, Ontario’s Action Plan for Health Care laid the groundwork for health system
transformation-redesigning the system to allow for more flexible models of health care delivery
which promote access and quality but also allow for services to be provided in a fiscally
sustainable manner. Most recently, the 2014 Mandate letter for the Minister of Health and Long-
Term Care notes that as part of the commitment to move forward on accountability and
transparency, the Minister will “…explore opportunities to optimize quality and value in
community laboratories and the broader laboratory sector”.
Ontario’s laboratory sector consists of community laboratories (providing about 47% of
provincial volumes), hospitals and public health laboratories (combined provide 53% of
provincial volumes) and physician office laboratories. The Ministry spends $1.7B annually for
medical laboratory services, in which community laboratories account for the largest funding
envelope among the subsectors, with an annual budget, or industry cap, of approximately $687
million.
Starting in the 1990s, the Ministry introduced a cap to the community labs line (known as the
industry cap) followed by a corporate cap (an amount based on each lab’s market share) to
manage utilization and growth.
In the following decade, program funding outside the industry cap was introduced to support
specific Ministry of Health initiatives, and in 2011, performance-based funding was introduced to
incentivize labs to focus on delivering care in underserviced regions, reducing wait times at
specimen collection centres and fostering innovation in the sector.
Considering the highly constrained fiscal environment, the Ministry is seeking opportunities to
optimize the community laboratory sector, starting with an evaluation of whether the current
Funding Model(s)
o Analysis of the current funding model and its value for money to government in the
areas of industry cap, corporate cap and volume utilization.
o Recommendations for a procurement model for lab services that is fair, sustainable,
and predictable. Funding models to be explored will include, but not be limited to the
existing market share model, long-term contracts, tendering and managed
competition.
o Role of Schedule of the Benefits for Laboratory Services (SOB-LS) in proposed
funding models
Broader Impacts
o Role of public health and hospital lab services under each of the proposed models.
o Opportunities for community lab coordination with hospital and public health
laboratories
o A framework for how performance targets, currently captured through performance
funding agreements, such as reduced wait times, enhanced remote/rural service
delivery and innovation in patient experience can best be incorporated into a funding
model and through which community laboratories can be evaluated at regular
intervals.
o Impact of funding model reform on patient experience
Advisory Forum
As part of the community modernization initiatives that support the government’s goals of better value,
access and quality in health care; the Ministry has established an Ontario Laboratory Services Advisory
Forum (Forum). The Forum has members from all three laboratory subsectors (community, hospital and
public health), as well as professional (i.e., Ontario Hospital Association and the Ontario Association of
Medical Laboratories) and Ministry agency representation (Health Quality Ontario). The diverse
membership of the Forum will serve as a resource for the external expert undertaking the Review.
For access to the Summary MOHLTC Literature Review, select this link
ORGANIZATION NAMES
ORGANIZATION NAMES
Government
ORGANIZATION NAMES
Other Jurisdictions/External
ORGANIZATION NAMES
All tests,
especially those A uniform policy across a
with utilization system can be supported by Requires authority
that is a formulary, in the same and buy-in from
Laboratory test recognized, way as a pharmacy multiple factions in a University of Michigan
Strong
formulary after analytics, formulary. Exceptions to medical system, and (43).
to be above formulary can be vetted by likely participation by
what is a committee or individual multiple specialties.
expected or tasked with these decisions.
justifiable.
Depends on the
payment system
present in the
medical system.
Perceived as unfair,
Similar to banning tests, this especially if the payer Trends in
Stop paying for intervention is effective at decides to stop reimbursement shown
Strong unnecessary Any test nearly ceasing testing, paying for something here (47), example of
testing depending on who decides without adequate medical policy here
to stop paying. justification. A (40).
physician may not
and the cost could be
transferred to know
that a test will not be
paid for, the patient.
repetitive test is
disallowed (i.e.
coagulation tests in
patients on
anticoagulants).
Limiting testing to
Complex single physicians who know how Multiple physicians Neurogenetic testing
tests, high unit to use a test increases the may want privileges, diagnostic yield ∼30%
Privilege ordering
Strong cost and/or prior probability in the tested even in the absence for very rare diseases
providers
difficult to patients, increasing cost of evidence that they when expert providers
interpret. effectiveness and diagnostic deserve them. order tests (51).
yield.
In the absence of a
Any test in a Computerized order cultural change Reducing testing in
Change supporting
system with changes can be made far coronary care unit (53).
Strong computerized order
computerized more difficult to subvert than modification of Change to routine
entry options
ordering. paper order form changes. ordering practices, a testing menu (54).
complete stop to a
specific order may
increase provider
abrasion. Unintended
consequences can
result if one is not
careful in designing
the intervention.
Requires an analyte
for which a cheaper
screening test exists.
Can work for computerized
If using paper forms,
or paper ordering. Is a form
one must realize that
Any test where of decision support that
paper forms have a
a cheaper allows physician to follow
significant half-life in Reflexive ionized
Offer reflexive screening test correct testing algorithm
Strong medical systems, and calcium (32),
testing. can be used with one order or click.
forms usually allow coagulation panels (55).
before a more Increases pre-test
providers to “write in”
costly test. probability for more costly
tests that they cannot
tests, making them more
find on the form, thus
interpretable.
allowing clinicians to
subvert the intent of
the reflexive panel.
informed decisions.
reimbursement/financial
Can be paired with
penalties, or associated with
peer feedback for added
strength.
“Pop-up fatigue”
occurs if too many
Selected tests Magnesium intervention
reminders are
with moderate (41), 1,25 dihydroxy
Computerized Can provide support in real implemented, leading
volume and Vitamin D email
Moderate reminders/decision time to physicians to to provider abrasion.
high likelihood reminder (59) [cited
support increase prior probabilities. Providers will also
of being example also uses
cease to continue to
misordered. privileging].
read pop-ups after
some time.
Selected tests
with moderate
volume and As opposed to pop-
high likelihood ups on computerized Redesigning test
Can provide support in real
Post guidelines on of being forms, written requisitions and
Weak time to physicians to
paper order forms misordered, but guidelines on a paper promulgation of
increase prior probabilities.
no are likely easier to factsheets (46,60).
computerized ignore.
ordering
available.
Required as a component of
Almost never works
nearly all successful
alone, or when it
utilization management
does, the effect Example showing effect
efforts. Interventions lacking
Education wears off over time or wearing off after time
an educational component
Weak alone/call for Any test completely (38), mixed effects of
risk failure due to lack of
enhanced vigilance disappears if new reminding physicians of
buy-in from interested
staff takes over (i.e. test costs (36–38).
parties who do not
in a teaching
understand the purpose of
hospital).
the change.
Source: Baird G. The laboratory test utilization management toolbox. Biochem Med [Internet]. 2014 Jun [cited 2015 Aug];24(2):223-234. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083574/
●Central East (14.1%), North West (36.8%), Waterloo Wellington (12.2%), 2,595,819 63.1 1,238,40 3,362,58 21,495,06 $161.1 $128.9
5.0 2.0 2.0
●Hamilton Niagara Haldimand Brant (12.0%), North Simcoe Muskoka (33.0%), 2,865,830 73.7 1,304,88 3,621,28 21,665,71 $161.8 $129.4
South West (28.7%) 3.0 7.0 3.0
●Central West (6.8%), Mississauga Halton (2.1%), North East (30.4%) 2,681,954 39.3 1,261,57 3,271,00 21,952,23 $165.7 $132.6
8.0 6.0 4.0
●Champlain (20.8%), South East (45.9%), Toronto Central (0%) 3,046,661 66.7 1,413,10 3,709,66 22,682,70 $175.2 $140.2
0.0 9.0 3.0
The market share of the smaller labs (i.e., 5-6% excluding LifeLabs and Dynacare – see Appendix) has not been removed from the scenario.
Estimat
ed
Spend
Billing by
SUMME Value LHIN
TOTAL D% (in (in
POPULATI RURALI # Millio Million
COMBINED LHINS ON TY Patients # Visits # Tests ns) s)
●Central (47.0%), Waterloo Wellington (12.2%) 2,615,841 59.2 1,301,74 3,438,90 22,878,47 $173.9 $139.1
4.0 0.0 2.0
●Central East (14.1%), South East (45.9%) 2,084,008 60.0 1,049,89 2,892,94 18,253,65 $137.1 $109.7
0.0 3.0 5.0
●Central West (6.8%), Erie St. Clair (20.3%), North West (36.8%), Toronto 3,024,997 63.9 1,413,72 3,701,49 24,263,27 $186.1 $148.9
Central (0%) 3.0 1.0 9.0
●Champlain (20.8%), Hamilton Niagara Haldimand Brant (12.0%), North 3,205,655 65.8 1,501,57 4,130,50 24,944,32 $187.3 $149.8
Simcoe Muskoka (33.0%) 6.0 4.0 4.0
●Mississauga Halton (2.1%), North East (30.4%), South West (28.7%) 2,742,217 61.2 1,220,51 3,211,00 20,188,14 $151.1 $120.9
8.0 3.0 5.0
The market share of the smaller labs (i.e., 5-6% excluding LifeLabs and Dynacare – see Appendix) has not been removed from the
scenario.
Estimat
ed
Billing Spend
SUMME Value by LHIN
TOTAL D% # (in (in
POPULATI RURALI Patient Million Millions
COMBINED LHINS (% RURALITY) ON TY s # Visits # Tests s) )
●Erie St. Clair (20.3%), Hamilton Niagara Haldimand Brant (12.0%), South 3,031,801 61.0 1,401,4 3,923,7 23,581,9 $174.9 $139.9
West (28.7%) 81 84 12
●Mississauga Halton (2.1%), North Simcoe Muskoka (33.0%), Waterloo 2,451,787 47.3 1,140,0 3,007,2 19,392,1 $146.0 $116.8
Wellington (12.2%) 12 72 29
●Central (47%), Central West (6.8%) 2,751,531 53.8 1,417,6 3,677,5 25,244,4 $192.9 $154.3
15 74 43
●Central East (14.1%), South East (45.9%), Toronto Central (0%) 3,329,722 60.0 1,618,4 4,332,1 27,876,2 $214.3 $171.4
76 22 31
●Champlain (20.8%), North East (30.4%), North West (36.8%) 2,107,877 88.0 909,867 2,434,0 14,433,1 $107.4 $85.9
89 60
The market share of the smaller labs (i.e., 5-6% excluding LifeLabs and Dynacare – see Appendix) has not been removed from the
scenario.
●Mississauga Halton (2.1%), North Simcoe Muskoka (33.0%), 2,451,787 47.3 1,140,0 3,007,2 19,392, $146. $116.8
Waterloo Wellington (12.2%) 12 72 129 0
●Central (47%), Central West (6.8%) 2,751,531 53.8 1,417,6 3,677,5 25,244, $192. $154.3
15 74 443 9
●Central East (14.1%), South East (45.9%) 2,084,007 60.0 1,049,8 2,892,9 18,253, $137. $109.7
90 43 655 1
●Champlain (20.8%), North East (30.4%), North West (36.8%), 3,353,592 88.0 1,478,4 3,873,2 24,055, $184. $147.7
Toronto Central (0%) 53 68 736 6
The market share of the smaller labs (i.e., 5-6% excluding LifeLabs and Dynacare – see Appendix) has not been removed from the
scenario.