Roadmap for DRG-Based Case Mix Systems Implementation

Presented by: Jean marie Rodrigues

and Dana Burduja, Mumbai meeting 20 October 2017

Session Overview

n  DRG implementation and development

n  Main uses of DRGs

n  Institutional responsibilities for key technical components n  Designing a Pilot Project

n  Lessons learned , questions and recommendations

Who is Using or Studying DRGs? n  Estonia n  Australia n  USA n  France n  Portugal n  Canada n  Ireland n  Italy n  Spain n  Germany n  Hungary n  Czech Republic n  Bulgaria n  Romania n  Slovenia n  Moldova

n  Indonesia n  Switzerland n  England n  Iceland n  Norway n  Sweden n  Denmark n  Finland n  Belgium n  The Netherlands n  Japan n  Singapore n  Malaysia n  Thailand n  Korea

n  Taiwan n  China n  New Zealand n  Turkey n  South Africa n  Latvia n  Lithuania n  Ghana n  Many Others

Western health care Systems clasification

Idéal type Tax funding (public) Centralised (NHS)

UK Ireland Portugal Greece FRA ½intégré

Idéal type health Insurance Bismarckian

Germany Belgiium Austria Japan The Netherlands Swittzerland (2000) Luxembourg France (before 1996) Turkey Post Communist Countries NCE ½ Bismarckien

Decentralised Sweden Spain Finland Italy Norway Canada Denmark Australia

Libéral

USA? Chine?

Penetration of DRG/Casemix-Type Applications

Coding Systems Used Around the World (ICD10)

COUNTRY DIAGNOSIS PROCEDURES

Austria ICD10 Local (MEL, Medizinische Einzelleistung) Croatia

ICD10 ACHI

Cyprus ICD10

Czech Rep. ICD10 ICPM (International Classification of Procedures in

Medicine - local adaptation)

Denmark ICD10 NCSP (Nomesco Classification of Surgical Procedures)

Estonia ICD10 NCSP

Finland ICD10 NCSP

France ICD10 CCAM (Classification Commune des Actes Médicaux)

Germany ICD10 (GM) Local (ICD10AM based)

Coding Systems Used Around the World (ICD10) cont

COUNTRY DIAGNOSIS PROCEDURES

Hungary ICD10 ICPM (local adaptation)

Iceland ICD10 NCSP

Lithuania ICD10 (ICD10AM) (ACHI)

Norway ICD10 NCSP

Slovakia ICD10

Sweden ICD10 NCSP

Switzerland ICD10 CHOP

Turkey ICD10 Local

Moldova ICD10 (ICD10AM) (ACHI)

Coding Systems Used Around the World (ICD-9-10-CM)

COUNTRY DIAGNOSIS PROCEDURES

Belgium ICD10 CM ICD10 CM

Bulgaria ICD9CM ICD9CM

Greece ICD9CM ICD9CM

Italy ICD ICD10CM

Netherlands ICD9CM CVV

Portugal ICD 10 CM ICD10CM

Spain ICD9CM to ICD 10 CM ICD9CM to ICD10

CM

Coding Systems Used Around the World (ICD-10-AM and ACHI)

COUNTRY DIAGNOSIS PROCEDURES

Romania ICD10AM ACHI

Ireland ICD10AM ACHI Croatia ICD10AM ACHI Hong Kong ICD10AM ACHI New Zealand ICD10AM ACHI Samoa ICD10AM ACHI Australia ICD10AM ACHI Fiji ICD10AM ACHI Saudi Arabia ICD10AM ACHI Slovenia ICD10AM ACHI

GROUPING Systems for Hospital Acute Care Inpatients (i)

COUNTRY SYSTEM

Austria LKF

Belgium APR DRG

Bulgaria IR DRG, AR DRG

Czech Rep. AP DRG, IR DRG

Denmark DkDRG (NordDRG)

Estonia NordDRG

Finland NordDRG

France GHM

Germany G DRG (AR DRG based)

Greece HCFA

Hungary LOCAL (HCFA based)

GROUPING Systems for Hospital Acute Care Inpatients (ii)

COUNTRY SYSTEM Iceland NordDRG Ireland AR DRG Italy HCFA, APR DRG Lithuania AR DRG, Netherlands DBCs Norway NordDRG New Zealand AN DRG Portugal AP DRG (previously HCFA) Romania RO DRG (AR DRG based) Slovenia AR DRG Spain AP DRG Sweden NordDRG Switzerland G DRG (previously AP DRG) Turkey AR DRG

GROUPING Systems for Hospital Acute Care Inpatients (iii)

COUNTRY SYSTEM

Australia ARDRG

New Zealand AN DRG

Singapore AR DRG

Samoa AR DRG

Fiji AR DRG

Japan DPC

Hong Kong IR DRG

Malaysia IR DRG and now UNU-CG

Indonesia IR and now UNU-CG

Philippines UNU-CG

Thailand Local (based on ARDRG)

Mongolia Local, basic (20 to 100 groups)

Vietnam UNU-CG

COUNTRY COSTING REIMBURSEMENT

(YES=100% DRG based)

Denmark local CWs Mixed (10% local+5% national)

Estonia local CWs YES

Finland local CWs Mixed, 50%

France local CWs 80% -100%

Germany local CWs YES

Hungary local CWs YES

Ireland local CWs YES, retrospective

Netherlands local CWs YES

Norway local CWs 50%

Portugal mixed YES

Romania mixed YES

Slovenia local CWs YES

Spain local CWs Mixed

Sweden local CWs Mixed

Switzerland local CWs Mixed

Countries Examples

of Cost Weight/ Relative Weight

Development And DRG

Financing System Implementation

Session Overview

n  DRG implementation and development

n  Main uses of DRGs

n  Institutional responsibilities for key technical components n  Designing a Pilot Project

n  Lessons learned , questions and recommendations

Main Uses of Various DRG Case mix Systems

n  Activity and performance management

n  Contracting and/or payment

n  Costing of health services

n  Research (epidemiology, economics etc.)

n  Monitoring and measurement for the quality of care

n  Standardization of medical practice??

Session Overview

n  DRG implementation and development

n  Main uses of DRGs

n  Institutional responsibilities for key technical components n  Designing a Pilot Project

n  Lessons learned , questions and recommendations

Roles and Responsibilities for Key Technical Activities

n  Establishing “who is responsible for what” by institution framework is critical for the following:

n  Coding, collecting the minimum basic data set of clinical data n  Collecting the clinical data n  Validating and grouping the clinical data n  Collecting cost data and modelling it for relative weight development n  Designing the financing system/preparing the formulas or contracts

based on DRGs n  The designation of who is responsible may vary based on

whether you are in a pilot testing phase or have moved to national implementation

n  There is no one or “correct” answer to who should be responsible for what; this varies by country

responsibilities for key technical roles n  Coding

n  Institutions taking care of patients; national or regional

n  Clinical Data Collection n  MoH or health insurance, or independent agency or Health Informatics

Center n  Grouping/Assigning DRGs

n  Central and local level n  All countries using DRGs for financing group data at the central level

n  Costing n  Varies based on national, regional or local arrangements, but typically the

oversight is by the reimbursing institution

n  Designing the financing system/preparing the formulas/contracts n  As a general rule, the reimbursing institution or payment authority is in charge

J.M Rodrigues USE/PCSE 19

Collection organisation

Specification of

requirements

Participant training

Data collection

Receipt and

checking

National quality

assurance

Analysis and report production

NHCDC Cost

Report

Peer Grouping Package

Other products

National Database(s)

Hospitals Coordinators Hospital

Reference Manual

Stage 4 : analysis and reporting

Stage 3 : national receipt and processing

Stage 2 : collection Stage 1 : preparation

Costing process overview Collection

organisation

Session Overview

n  DRG implementation and development

n  Main uses of DRGs

n  Institutional responsibilities for key technical components n  Designing a Pilot Project

n  Lessons learned , questions and recommendations

n  Select pilot hospitals

n  Select a coding and grouping system

n  Provide coding training

n  Select your costing method

n  Provide costing training

n  Begin capturing and analyzing information n  clinical data from hospitals n  expenditure/cost data from hospitals n  group clinical data into DRGs n  create relative weights or identify a weight set to borrow/adapt

n  Identify financing mechanism options and begin modeling

Designing a Pilot Project (the basics)

Dr Shahram Ghaffari’s/ Pr Terri Jackson Implementation Schema

-Coding system -Coding rules

-Coding training/ workforce

-ICU -High cost DRG

-External /’Bor

rowed’ cost weights

-Local study

EVALUATE AVAILABLE DATA

Clinical data

Broader episode

Financial & cost data

SELECT EPISODE DEFINITION Management/Planning

Epidemiology/Research

DECIDE POTENTIAL USES

Clinical relevance Resource homogeneity

DESIGN CONTROL/ FEEDBACK/ AUDIT SYSTEM

Trimming method

Inpatient sameday & multiday

Activity based costing (bottom up) Cost modeling (top

down)

Outlier treatment Volume control Exclusions

Inpatient multiday

EVALUATE CASEMIX CLASSIFICATION/ DRG VERSIONS

ESTIMATE LOCAL COST WEIGHTS

DESIGN PAYMENT/REIMBURSEMENT/BUDGETING SYSTEM

Funding

-Local study

CLINICAL REVIEW

CLINICAL REVIEW

CLINICAL REVIEW

Minimum Set of Data and Decisions Required for Pilot Simulations n  Total number of cases for at least six months to one year

from selected hospitals

n  Aggregate expenditure data from selected hospitals, for the same time period as the clinical data/cases

n  All hospital cases from the selected hospitals grouped into DRGs

n  Relative weights, either adjusted using pilot hospital cost data or borrowed weights

Session Overview

n  DRG implementation and development

n  Main uses of DRGs

n  Institutional responsibilities for key technical components n  Designing a Pilot Project

n  Lessons learned , questions and recommendations

Lessons Learned From Other Countries n  Be clear about what case-mix can and cannot do

n  Be clear about what your objective is with using case-mix

n  Have the “right mix” of people and institutions working together…both strategically and technically

n  Involve stakeholders from the state, specifically with respect to policy/decision-making that will be required of them

n  Select pilot hospitals carefully

n  Coordinate, communicate, and educate

n  Balance technical readiness with the political pressure to “start”

n  Implement an auditing and monitoring system right away!

n  Starting with a neutral budget/neutral impact gives everyone time to learn

Lessons learned from other countries cont ...

n  Assess what level of knowledge and interest there is and why

n  Decide the who, what, where, why, and when

n  Assess what capacity exists within your country

n  Decide what can be “borrowed or adapted” at least during the initial years rather than trying to create everything from scratch!

n  Be practical and realistic about timing!

Implementation Questions to face

n  What is expected from implementing DRGs? What’s the goal? n  What’s the timing and who will be involved? n  What capacity, knowledge, data, infrastructure exists? n  Can data be collected in a standardized manner? Who will collect it? n  What coding, costing, classification, grouping systems will we select? n  Can existing laws be charged or new ones created? n  Do hospital managers have autonomy to manage under DRGs? n  Will fines or penalties be enforced for fraudulent behavior? n  Will debts be forgiven or additional funding allocated if hospitals

exceed their case-mix budgeted amount? n  Others, what have you seen or faced?

Every Country is Unique it It’s Approach to Case-Mix Due to Different Goals, Needs, Infrastructure, Culture, and Politics...BUT there are Many Cross-Cutting Technical and

Political Issues That are Part of Every Implementation That Must Be Addressed!

List of recommandations to begin n  One size does NOT fit all - country experiences vary greatly!

n  Countries that follow the 80/20 rule often do better

n  Investment decisions – now or later – often depends on level of decision-maker commitment n  Remember, DRGs do NOT have to be used for financing, but if they are, then the system

must be developed carefully with an eye on the following:

l  Accurate coding, data collection, and grouping cases into DRGs

l  Accurate costing for creating relative weights or careful adaptation of borrowed weights

l  Development of incentives that promote efficiently and quality of care

l  Implementing a monitoring/audit mechanism

l  Technical capacity & political will are drivers of implementation & sustainability

n  DRGs will not automatically solve broader healthcare system issues such as managing demand, defining a benefits package, or increasing the money available, etc. but it can shed light on the volume, types, and costs of hospital services

Thank you and Discussion

Annex :Glossary

PCSI Summer School June 2011

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