Abstract Background In the early 2000s, Ontario and Quebec, two provinces of Canada, began to introduce hospital payment reforms to improve quality and access to care. This paper (1) critically reviews patient-based funding (PBF) implementation approaches used by Quebec and Ontario over 15 years, and (2) identifies factors that support or limit PBF implementation to inform future decisions regarding the use of PBF models in both provinces. Methods We adopted a narrative review approach to document and critically analyse Quebec and Ontario experiences with the implementation of patient-based funding. We searched for documents in the scientific and grey literature and contacted key stakeholders to identify relevant policy documents. Results Both provinces targeted similar hospital services—aligned with nationwide policy goals—fulfilling in part patient-based funding programmes’ objectives. We identified four factors that played a role in ensuring the successful—or not—implementation of these strategies: (1) adoption supports, (2) alignment with programme objectives, (3) funding incentives and (4) stakeholder engagement. Conclusions This review provides lessons in the complexity of implementing hospital payment reforms. Implementation is enabled by adoption supports and funding incentives that align with policy objectives and by engaging stakeholders in the design of incentives.