IN THIS ISSUE

The Assistive Devices Program will introduce a new pricing framework that includes new pricing principles and changing to a fixed price model. Prices will be based on fair market analysis and a pricing review will be conducted every two years. In addition, a set target vendor margin will establish the final price for each device category. The program will continue providing direct funding to clients through grants.

Implementation of the new pricing framework will be done in two phases, with phase one expected to occur on August 1, 2004. The planning process for phase two will begin as soon as the implementation of phase one is complete. Phase one will begin with the device categories that were part of the pricing review conducted by an external-consulting firm as follows :

• Burnscar Pressure Devices
• Lymphedema Compression Garments and Pumps
• Communication Aids
• Visual Aids
• Externally Powered Upper Limb Prostheses
• Conventional Limb Prostheses
• Conventional Orthoses
• Enteral Feeding Supplies
• Respiratory Equipment
• Wheelchairs, Positioning, and Ambulation Aids

Since 1982, the ADP has grown and expanded both in size of its budget and type of devices funded. Except for new devices, the ministry's prices have not been adjusted since 1993. This has resulted in some devices being under-funded and others being over-funded by today's market prices. The new pricing framework will include a review of device pricing every two years to ensure that the ministry is financing the ADP program at appropriate cost levels.

Assistive devices play a critical role in comprehensive health care. By undertaking this initiative, the government is ensuring they are available to those who need them. The new pricing framework will make certain that Ontarians have fair and affordable access to assistive devices and provide vendors with a fair and predictable return on their investment. This initiative is part of an inclusive and continuing dialogue with stakeholders and is based on an objective, third party analysis.

The Assistive Devices Program plays an important role in community health care. This initiative :

• Focuses on keeping people with disabilities active and well in the community;
• Improves the government's ability to deliver in a timely manner the services people with disabilities need ;
• Enables people with disabilities to stay in their homes as long as possible and remain healthy;
• Ensures that needed medical devices and supplies are affordable and available therefore providing the health care we need.

The ADP's stale dating policy for the submission of applications and invoices is being reduced from twelve months to six months. The ADP tracking systems have identified that this more closely reflects current client and vendor behaviour, and will assist in the more timely processing of payments and financial forecasting.

Registration for new vendors will be closed between June 1, 2004 and September 1, 2004, while the new pricing framework is being implemented. This will not affect existing vendors who are currently going through a change in ownership.

• The pricing model will ensure a long and stable supply of the ADP devices on a province-wide basis;
• The pricing model will ensure that the ADP and its clients are paying fair market prices for devices;
• The pricing model will allow the ADP to better predict its expenditures: and,
• The pricing model will encourage the desired behaviour of various stakeholders.

• Stakeholder information sessions have been held with:
• ADP standing committees,
• Consumer associations who represent the ADP client groups; and,
• ADP registered vendors.
• The ADP policy, administration and information technology changes are being made to support the new pricing framework.
• The ADP policy manuals including new pricing will be distributed to registered vendors and authorizers by July 1, 2004.
• Phase one implementation of the new pricing is expected to occur on August 1, 2004.

Clients will appreciate that the new pricing framework is clear and transparent so they can anticipate their costs in advance. Consumer associations and other non-profit organizations will see some relief from the pressure to support the client's co-payment.

The ministry has made a commitment to complete a review of pricing every two years. Some of the ADP devices currently have pricing that is well below market value and these will be brought up to date. Other devices currently have pricing that is well above market value and these will be brought into line with the ADP's vendor target margin of 25 per cent.

The Respiratory Services Standing Committee has recommended changes to the Respiratory Products Category, which have been approved for implementation by the ADP, August 1, 2004.

A) Medical Eligibility Criteria :

In accordance with the accepted standards of care, as defined by the College of Physicians and Surgeons of Ontario, the medical eligibility criteria for Positive Airway Pressure Systems has changed from, "only people with a diagnosis of Obstructive Sleep Apnea (OSA)," to" only people with a diagnosis of Obstructive Sleep Apnea Syndrome (OSAS)".

The ADP has also approved the recommendations of the Pediatric and Adult Enteral Feeding Device Category working groups.

A) Medical Eligibility Criteria  :

1. The medical eligibility criteria for funding through the Enteral Feeding Program will change from, "clients must have a diagnosis directly associated with the need for enteral feeding," to :

a. Applicants must have a disability requiring the use of enteral feeding equipment and supplies for six months or longer,

b. Applicants must have a functional or mechanical impairment requiring enteral feeding to maintain nutritional status,

c. Applicants with the following medical problems will not be accepted for funding assistance through the Enteral Feeding Program : food allergies; anorexia or bulimia, and short-term disabilities such as post-operative conditions.

2. The eligibility criteria to receive funding assistance for feeding pumps will also change. Funding is currently only available for clients on continuous feeds for six hours or more. The new eligibility criteria will state :

a. Enteral feeding pumps are available through the ADP, only for clients requiring feeding to be delivered by a pump for six hours or more during a 24-hour period.

B) Service delivery model

1. Renewal of funding assistance

To renew funding for enteral feeding supplies, clients will need to complete a new ADP ESA form every three years instead of every two years.

2. Funding for feeding pumps

The ADP currently funds 75 per cent of the approved cost of enteral feeding pumps and supplies, (or 100 per cent if the client is receiving social assistance), up to a maximum amount over the claim period. The new funding model :

a. will continue to fund 75 per cent (or 100 per cent for clients receiving social assistance) up to a maximum amount over the claim period, but for enteral feeding supplies only, and

b. the feeding pump will be funded separately from the supplies. The funding assistance for feeding pumps will be based on the ADP approved price. The ADP will pay 75 per cent of the ADP approved price (or 100 per cent if the client is receiving social assistance).

The Prosthetics and Orthotics Standing Committee has accepted service delivery changes recommended by the Orthotics Task Force, that have been approved for implementation by the ADP August 1, 2004. The changes include :

1. The ADP will recognize prescriptions for initiating a device claim from a general practitioner or a specialist. The only exceptions to this will be Reciprocating Gait Orthoses (RGO's) and Shoulder-Elbow-Wrist-Hand-Finger Orthoses (Brachial Plexus Orthoses) that will continue to require a medical specialist's assessment and signature.
2. The requirement for the clinic model, in which simultaneous assessment of the client by the physician, certified orthotist and rehabilitation assessor is needed, will be removed.
3. The requirement for the rehabilitation assessor's assessment and signature will be removed for current three (3) tier devices (example, knee-ankle-foot orthoses). The rehabilitation assessor's assessment and signature will be required only for RGO's and Brachial Plexus Orthoses.

Public Information :

• Previous issues of the "ADP Today" newsletter
• List of assistive devices covered and not covered
• Contacting ADP
• Device fact sheets
• Forms (ADP Applications)
• Program information
• Questions and answers

Health Care Providers :

• Contacting ADP
• Standing committee members
• ADP Policies and Procedures Manual
• Forms (ADP Applications)
• Previous issues of the "ADP Today" newsletter

The Health Services Division of the Ministry of Health and Long-Term Care has the responsibility for administering the Assistive Devices Program (ADP). Through the ADP, the ministry provides funding to Ontario residents with physical disabilities to purchase personalized assistive devices and supplies, to support them in independent living.

Assistive Devices Program
Operational Support Branch
Ministry of Health and Long-Term Care
5700 Yonge Street, 7 ^th Floor
Toronto, Ontario
M2M 4K5
Canada

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