Basics of HCI reporting in DRG system

DRG Workshop Belgrade, 18-22.November 2013.

Basics of HCI reporting in DRG system

– RIC AND LINDY


Implementing a DRG funding system

• Activity data – coding accuracy and completeness – don’t wait for perfection.

• Costing data – from a sample group of hospitals – can import initially.

• Modeled budgets and phased implementation plan with adjustment period.


The reasons why hospitals want to measure what they do?

• Manage to a budget.

• Perform to peer benchmark with best value services.– Technical efficiency– Allocative efficiency– Quality

• Give the best service possible to their community.


Measuring efficiency and quality of health services

• Cost per weighted unit of output

• Performance indicators on outcomes– Negative – hospital acquired complications– Positive – eg milestone indicators – health

status outcomes – satisfaction …

• Process compliance with best practice protocols


Typical experience with DRGs


What Do You Do Without Casemix?

BEDDAYS … Discharges … Shroud waving Global budgets and top-ups

SERVICE AVAILABILITY Quality?? Value????


http://www.aihw.gov.au/publications/health/ihhac/ihhac-c06c.pdfBeds LOS and DRGs


“But our hospital gets all the difficult cases”

Measuring efficiency and effectiveness ‘Doing the thing right’

‘Doing the right thing’

How many hospitals do you need - where?

How many MRI scanners do you need - where?


Item Japan Germany France Korea, U.K. U.S.A

Rep.

Hospital beds (per 1,000pop) 12.8 8.9 7.7 7.1 4.2 3.3

Physicians (per 1,000 population) 2.1 3.4 3.4 1.6 2.2 5.5

Medical care expenditure/GDP (%) 7.9 11.1 10.1 5.6 8 15.2

http://209.85.135.104/search?q=cache:Uscfbb-xVvgJ:www.stat.go.jp/english/data/figures/zuhyou/1696.xls+beds+per+1000+international&hl=en&ct=clnk&cd=5&gl=au

OTHER INDICATORS

ARE THESE MEASURES REALLY LIKE WITH LIKE??????????


Where should the budget (growth) money go?

To the regions that have the most people?

To the towns that have the most hospitals?

To the hospitals that do the most work?


TYPICAL PROBLEMS

• Perverse incentives/inefficient resource allocation

• Lack of transparency• Poor clinical data (diagnoses and

procedures)• Poor measures of expected cost per case

type• Mistrust between funders and care

providers• Unclear vision about mid-term goals


o HOWEVER - it's hard to agree, because data are never good enough

o It's hard to compare locally or internationally

o ‘MY CASES ARE HARDER THAN YOURS!’

o We are arguing about things that could and should be measured

Need to agree on fair measurements


The casemix development program

• A ten year program from 1989

• Included DRG redesign program

• Data standards and reporting– National health information agreement

• Linkages to – Budgets

– Funding

– Payment

• “1 2 3 – DRG” ?????


INDUSTRY

EXECUTIVES

ACADEMICS

POLICY

OFFICIALS

GOVERNMENT MINISTERS

EXPERTS

IMPLEMENTATION SUPPORT


From .. Medicare .. to ..Australian Healthcare Agreements

• Common data standards – casemix and data quality

• “ONE SIZE FITS ALL” DRGs? – The case for localisation

• Minimum datasets – where did my data item go?

• Performance feedback in useful timeframes? Examples later


EARLY IMPLEMENTATION THROUGHPUT

700,000

750,000

800,000

850,000

900,000

950,000

1,000,000

1993/94 1994/95 1995/96 1996/97 1997/98 1998/99 1999/00

Total WIES Total Separations

MORE CASES WITHOUT EXTRA BUDGET – LOWER LOS


SOME EXPERIENCE

Hospital costs per separation1991/92 to 1997/98

1900

2000

2100

2200

2300

2400

2500

2600

2700

1991-92 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98

Cos

t per

sep

arat

ion

(198

9-90

val

ues)

Cost per patient

reduced by 26%

($713) in the first

years of Casemix

Pay increases to

doctors and nurses


DRGs Applications Impact

# of Beds: 500# of Beds: 500# of Inpatients: 26,000 # of Inpatients: 26,000 Avg. Length of Stay: 6,0 d.Avg. Length of Stay: 6,0 d.Bed Turnover rate: 52 pat.Bed Turnover rate: 52 pat.

# of Beds# of Beds: 380: 380# of Inpatients# of Inpatients: 42,800 : 42,800 Avg. Length of Stay:Avg. Length of Stay: 3,23 d.3,23 d.Bed Turnover rateBed Turnover rate: 113 pat.: 113 pat.

% 24% 24% 64% 64% 46% 46% 117% 117


Clinical Quality Indicators

• Perforation of the colon following a colonoscopy procedure

• Anastomotic breakdown – following large bowel resection and

anastomosis for cancer of the • - colon - rectum

• Bile duct injury following cholecystectomy requiring operative intervention

• Mortality following repair of abdominal aortic aneurysm


Australian Implementation Experience

• The importance of – Risk management – modelled effects– Transparency of the rules

• Learning from mistakes• Australia still refining models• New challenges – solve some, others

appear• Some basic building blocks


http://www.health.gov.au/internet/wcms/publishing.nsf/Content/15033D7F2949990CCA256F1D00294D9F/$File/tbl8b_17.pdf


National Admitted Patient Care Collection (NAPCC)

http://health.gov.au/internet/wcms/publishing.nsf/Content/health-casemix-data-collections-statistics


National Hospital Cost Data Collection (NHCDC)http://health.gov.au/internet/wcms/publishing.nsf/Content/health-casemix-data-collections-statistics

PUBLIC

PRIVATE


COST WEIGHTS FOR AR-DRG VERSION 5.0, Round 10 (2005-06)

DRG Description Cost Standard Number Number ALOS Average Cost per DRG ($) Average Component

Cost per DRG ($)

Weight Error of Seps of Days (Days) Total Direct Ohead Ward Medical Ward Nursing Non Clinical Salaries

Pathology

DRG

Direct Ohead Direct Ohead Direct Ohead

A01Z Liver Transplant 30.69 0.21 137 4,331 31.59 108,709 92,924 15,785 16,753 1,759 11,187 1,626 5,379 5,435 1,592

A03Z Lung Or Heart/Lung Transplant 23.26 0.19 83 2,047 24.72 82,402 71,684 10,719 7,516 1,407 8,443 1,257 1,590 5,881 1,186

A05Z Heart Transplant 34.11 0.77 66 2,489 37.72 120,834 104,122 16,712 14,812 3,488 10,904 1,498 1,857 7,358 1,242

A06Z Tracheostomy Or Ventilation>95 23.69 0.04 8,281 253,574 30.62 83,925 68,096 15,828 4,124 719 5,328 1,085 1,733 3,343 568

A07Z Allog Bone Marrow Transplant 21.98 0.16 337 12,011 35.65 77,849 64,183 13,667 4,799 1,212 15,915 2,153 4,355 9,801 1,656

A08A Auto Bone Marrow Transplnt+Ccc 11.68 0.16 447 11,014 24.67 41,367 32,621 8,746 2,713 741 9,542 2,217 1,498 3,786 881

A08B Auto Bone Marrow Transplnt-Ccc 4.74 0.14 377 4,282 11.36 16,778 13,267 3,511 958 245 3,812 565 931 1,485 320

A09A Renal Transplant+Pancreas/+Ccc 14.48 0.14 191 2,949 15.4 51,303 43,958 7,345 2,959 518 6,575 861 1,540 3,296 389

A09B Renal Transplant -Pancreas-Ccc 8.38 0.08 389 3,342 8.58 29,681 25,608 4,073 2,624 355 4,019 549 1,087 1,303 171

A40Z Ecmo - Cardiac Surgery 38.40 0.24 89 2,877 32.23 135,998 111,112 24,886 8,653 1,787 6,276 1,114 1,496 10,202 2,124

A41A Intubation Age<16+Cc 6.22 0.05 752 6,934 9.22 22,038 17,220 4,818 1,785 201 3,300 450 944 948 187

A41B Intubation Age<16-Cc 2.49 0.10 457 1,668 3.65 8,808 6,955 1,853 601 53 1,037 122 298 292 48

B01Z Ventricular Shunt Revision 2.90 0.03 359 2,124 5.92 10,261 8,237 2,024 1,101 112 1,796 340 441 191 29

B02A Craniotomy + Ccc 9.01 0.02 1,775 32,523 18.33 31,909 25,830 6,079 2,927 417 5,577 1,107 1,020 1,167 194

B02B Craniotomy + Smcc 5.34 0.02 2,095 21,688 10.35 18,926 15,403 3,523 1,811 203 2,970 591 694 607 90

B02C Craniotomy - Cc 4.19 0.02 2,828 19,949 7.05 14,824 12,142 2,682 1,372 144 1,949 414 476 392 60

B03A Spinal Procedures + Cscc 6.99 0.05 183 2,844 15.52 24,760 20,474 4,286 2,476 313 4,975 904 1,353 608 125

B03B Spinal Procedures - Cscc 3.31 0.01 675 3,341 4.95 11,737 9,578 2,160 1,017 105 1,538 248 519 165 29

B04A Extracranial Vascular Pr +Cscc 3.72 0.01 548 3,832 6.99 13,181 10,566 2,615 1,546 189 1,877 341 438 347 53

B04B Extracranial Vascular Pr -Cscc 2.20 0.01 1,118 3,618 3.24 7,786 6,317 1,470 772 114 777 156 211 135 19

B05Z Carpal Tunnel Release 0.49 0.00 11,664 12,424 1.07 1,746 1,298 448 232 27 110 35 42 6 1

B06A Cbl Psy,Mus Dysy,Npthy Pr+Cscc 6.01 0.15 253 4,076 16.1 21,297 16,431 4,866 2,473 340 4,906 818 1,422 675 109

B06B Cbl Psy,Mus Dysy,Npthy Pr-Cscc 1.20 0.01 2,102 3,802 1.81 4,249 3,266 983 440 51 514 94 155 94 16

B07A Prphl & Cranl Nerv & Oth Pr+Cc 2.88 0.03 448 3,298 7.36 10,202 7,913 2,289 1,028 164 1,931 392 436 225 41

Public Sector Estm R10 06.xls


Mean cost/case

NursingMedicalAllied healthORPathologyImagingPharmacyConsumablesOverheadOther

Total

Our hospital

750500170420

9065

12075

450200

$2850

Other hospitals

550420180340

8050

11090

380200

$2400

Benchmarking by cost only …


But patient 15644 was different from normal

Look! You spent too much on patient 15644


Sorry, I'll try not to do it again

I've checked, and patient 15644 wasn't different at all!


Elements of cPaths

Admitted how long before procedure?

Post-op hours in CCU

Review of discharge plan at admission?

Discharge OK delegated?

Our hospital

9 hours

6 hours

No

No

Other hospitals

6 hours

Nil

Yes

Yes

… and benchmarking by clinicians


Giving feedback to hospitals on the efficiency and quality of their outputs


Feedback mechanisms

• Payment signals – price vs cost

• Bonuses for output target achievements

• Bonuses for performance indicator attainment:-– Waiting lists – ED – Elective surgery – – Capacity improvement

• Coding statistics

• Expenditure levels reporting


The 3 key components of a DRG funding system

1. Activity data

2. Expenditure data

3. Modeled budgets


1. Hospital (IP) activity by DRG

• tabulated to produce a table of hospital by DRG.

• activity data checked for completeness and accurate DRG assignment.


• hospital budget data – one years estimate and/or actual expenditure by hosptial

• inpatient fractions (IFRACS)

• throughput payment proportion or components (eg if salaries not included need to be taken out of – costweights and– payment model).

2. Budget/expenditure data


3. Modeled budgets

• Complete allocation of funding

• Service level agreements

• Targets for specific services– By period– By service type

• Caps on discretionary services

• Conditions of funding/payment - consequences


THE THREE MUSTS OF CSMX

• Start from where you are

• Decide where you want to go

• Take achievable steps

Documents

Basics of HCI reporting in DRG system