Diagnostic Related Groupings Saakat Add

8/3/2019 Diagnostic Related Groupings Saakat Add

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Diagnostic related groupings

Diagnosis related groupings (DRGS) are standard groupings of diseases that are

clinically similar, have comparable treatments or operations and use similar healthcare

resources. They are a measure of the case mix in a health facility.

Case Mix

A Case MIX (CM) is the related frequency of admissions of various types of patients,

reflecting needs for hospital resources or the distribution of in-patient cases treated by a

hospital as classified by patient illness characteristics and treatment processes.

Health facilities have patients with many different diagnoses and severity of illness

and who use different services. Thus, there is a case mix, which differs from health facility to

health facility.

Measurement of case mix

There are many ways of measuring case mix, some based on patients diagnoses or

the severity of their illnesses, some on the utilization of services and some on the

characteristics of the hospital or area in which it is located. CM measures or patient

classification systems (PCS) are standard groupings of clinically similar treatments that use

comparable levels of healthcare resource. There are ways of relating the types and

complexities of patients a hospital treats to the resources utilized by the hospital based on the

diagnosis, the treatment and the procedure carried out.

An examination of several case-mix measures for their validity and acceptability in a

per-case payment system reveals DRGSs to be the best available measure. They are mostly

groups of International Classification of Diseases (ICD-10) Diagnoses and procedures that


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have similar resource implications. The thousand and over ICD code is thereby reduced to a

manageable number.

The DRG is produced by grouping the 10,000+ ICD codes into a more manageable

number of meaningful patient categories. Patients within each category are similar clinically

and in terms of resource use. Each patient is assigned a DRG in a database.

DRG assignment is made by DRG grouper software which uses principal diagnosis,

secondary diagnoses surgical procedures, age, sex and discharge status of the patients

treated (DRG Definitions Manual, 1994) to assign in-patient records to a specific DRG. The

grouper requires that diagnoses and procedures be classified using ICD-10.

The tariff

a. Services covered by the Tariff

The National Health Insurance Scheme (NHIS) Tariff is payable to all healthcare

providers (HCPS) registered with the NHIS across the country. These include community-

based Health Planning and services (CHIPS), Health centres, District Hospital, Polyclinics or

Sub-metro Hospitals, Quasi-Government Hospitals, Private Hospitals, Clinics and Maternity

Homes, Regional hospitals and Teaching Hospitals.

The tariff covers outpatient services, in-patient services, ancillary services such as

physiotherapy and catering, and diagnostic services. It covers healthcare specialized areas

such as child Health (paediatrics), General Adult Surgery, paediatric surgery, Ear and Throat,

Orthopaedics, Accidents and Emergencies, General (Adult) Medicine, Maternal services,

Gynaecology, Maxillo-facial dental care and Eye care. It also includes surgical operations,

medical diagnostic and therapeutic procedures.

b. Services not covered by the tariff


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The tariff does not include all those conditions and services in the exclusive list. The

tariff does not include costs of drugs, direct, indirect and overhead costs of pharmacy and any

other costs related to drugs/medicines. It, however, includes costs of equipment and

consumables used to administer drugs such as syringes, syringe pump, infusion burettes,

needles cannula, etc. as these are consumables used directly in patient care.

Patient transport services are not included in the present tariff. Thus, ambulance

transport from one (HCPS) Healthcare Providers to another on referral is not presently

covered.

Accessing healthcare services under NHIS

c. Gate keeper principle

The tariff is determined based on the level of services provision known as the gate

keeper principle or system. The tariff that should be reimbursed to health facility reflects the

level and position as well as specialty and availability of services in each health facility.

Patient bill is supposed to be refunded to health facility based on the following processes.

The patient first point of attendance, except in the cases of emergency, shall be a

primary healthcare facility, which includes community-based Health Planning and Service

(CHPS), Health Centres, District Hospitals, Quasi-Government Hospitals, Private Hospitals,

clinics and Maternity Homes.

In localities where the only health facility is a Regional Hospital, the general out-

patient department shall be considered a primary healthcare facility. This means that, health

services provided by Regional Hospital at the out-patient Department will attract a primary

healthcare facility tariff which is lower than the tariff for the Regional Hospital. Regional

Hospitals are allowed to recover full regional tariff, when the patient is referred from the


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primary healthcare facility. In other words, a full refund of health service bill should be made

to health facility when the gate keeper system / process is completed.

All healthcare services provided in these facilities are paid for by the District Mutual

Health Insurance Schemes (DMHIS). All Services provided for by Tema General Hospital

are paid for by Tema Metropolitan Mutual Health Insurance Scheme.

Even though the National Health Insurance Scheme is decentralized on District,

Municipal and Metropolitan bases, Tema General Hospital provides services to all clients of

the various schemes all over the country and paid by Tema Metropolitan Mutual Health

Insurance Scheme.

These payments are offset when the National Health Insurance Authority is disbursing

funds from the Value Add Tax (VAT) and Social Security and National Insurance Trust

(SSNIT).

In case where the services are not available, all referred cases other than those in the

Exclusion list are paid for by DMHIS. Emergencies are attended to at any health facility

without regard to the gate keeper system. A gatekeeper principle is therefore followed which

means that the scheme is accessed only through the primary care level, that is health services

at the district level, and access to the higher levels is by referral from the primary and other

appropriate levels. The level of care therefore determines the type of services provided for

each specialty and the fees charged. Healthcare providers are reimbursed only for the services

they provide which are listed for their levels.

The National Health Authority (NHIA) believes that, strict adherence to this principle

is important and beneficial for all patients, Healthcare providers (HCPS) and the National

Health Insurance Scheme (NHIS).


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Regional and Teaching hospitals concentrate on the more complex diseases and

reduce the over crowding that occurs at their premises and therefore improve quality of care.

Goal of the g-rdgs tarrifs

THE National Health Insurance Authority believes that, this payment methodology

present a better understanding to both Ghana Health Service (GHS) and National Health

Insurance Authority (NHIA).

a. It provides reimbursement for full costs of services rendered.

b. It gives healthcare providers incentive to provide services efficiently. Full payment

means HCPS retain all the benefits of increased efficiency, although they bear the

burden if costs are above payment rates.

c. It makes payment more predictable, understandable and simpler for HCPS and

District Mutual Scheme Managers to the greatest extent possible.

d. It increases fairness among HCPS by paying them similar amounts for similar

services.

Tarrif structure

Table 1.

The tariff structure is shown below.

Unit/

Currency

Admission spell Illness Episode- Attendance


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Tariffs for:

All Admissions

All inclusive bundled for

all services provided to

inpatients.

Day case and in patientprocedures combined

Different tariff for children

and adult

Tariff for:

All OPD attendance

by specialty

One tariff for new and

follow-ups

All inclusive bundledtariff

Unbundled tariff for

health facilities that

do not provide all

services.

Different tariff for

children and adults

Source: Originally from National Health Insurance Scheme Tariff and Benefits package

Operation Manual (2008)

The tariff is made up of the estimated direct and indirect costs of providing the

various services to each patient depending on the patients G-DRGS and the level of care.

The tariff and level of healtcare

The tariff structure recognizes the different levels of care in Ghana: Primary,

Secondary and Tertiary levels. The tariffs are graduated from the lowest to the highest level.

This graduation is mainly due to the increase in indirect and overhead costs of Health care at

higher levels.


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The components of costs reimbursed by the tariff are summarized below:

Figure 2.

The components of the tariff

Source: Originally from National Health Insurance Scheme Tariff and Benefits package

Operation Manual (2008)

Analysis of cost for treatment

The direct cost (DCs) are those costs incurred in providing direct service to the patient

depending on the diagnosis and/or procedure (i.e. the G-DRG).The DCs consist of:

Human resource costs. The man hours of medical, nursing, and other staff needed to

directly provide the services. It includes, for example, the costs of a laboratory

technician working on blood or other tissue sample, the nurses assisting in an

operation in the theatre, wards,, etc., and the doctors consultation, examination and

Total Direct care cost Indirect and Overhead cost

Direct care

Costs

Investigation

Cost

Anaesthesia

CostsTotal Indirect

and Overhead

Costs

Catering

Costs

Consumables:

Ward

Theatre

Recovery

ProcedureUnit

Consumables:

Reagents

Stains

General

consumablesX-rays

Specimen

containers

Consumables

Theatre

Drugs

Human

Resource

Human

Resource

Human

Resource

Vehicle running and

MaintenanceUtilities

Administration

House keeping

Capital and

equipment cost

Maintenance of

building and

equipment

Food

Materials

Human resource Human

Resource


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theatre operation. All the above mentioned man hours are factored into determining

the tariff for a patient/client who may be suffering from one or more of the medical

conditions. The tariff does not take into consideration the material for example the

cost of the reagents and their types that will be needed by the laboratory technician,

x-ray technician or any investigative staff. It came to light that, the complexitys of

the condition of a client/patient, the higher the cost of investigation of the condition.

The material/ reagents or x-ray frame needed to conduct the investigations was

determined without considering the changing cost of the investigative materials.

Prices of investigative materials have changed since 2004, when the NHIS started

operation.

Consumables and other disposable costs. These are the costs of items used in the

direct care of the patient. They include gloves, syringes, etc., laboratory reagents and

stains and diagnostic imaging consumables such as x-rays, barium meal, etc. For

anaesthesia, this also includes all anaesthetic drugs and infusions, including blood

transfusion, used during and after operation.

It was established by the researcher that, that anaesthestic drugs which is purchased as

a drug was combined with consumables. The determination of how much anaesthestic drug

would be needed for a particular condition or procedure was not considered. The fact that

drugs are separately billed makes the combination incorrect and does not follow the logic that

established the NHIS, which states that drugs must be separately billed.

Another inconsistency is the fact that, blood transfusion is consolidated with

consumables without factoring in the processing cost, which is made-up of important

reagents that are used in ensuring that, the blood is safe to be transfused or given to a patient

or client.


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The claim by the NHIA that direct costs (DCS) are incurred in the following areas

needed to be analyzed.

The assumption that Government of Ghana (GOG) take care of all indirect costs may

hold in the light of the fact that all public resources belong to Government, but it is also true

that Government is limited in providing the necessary needs of public health institutions to

enable them provide quality health service to patient/client. Therefore, there is the need to

decouple every cost in the health delivery system to enable the management of public health

facility

Provide the necessary health provision resource for health service provider to give

quality health service to patient/client.

The direct costs (DCs) are incurred at the following areas:

i. Outpatients department (OPD)

ii. Wards Various

iii. Diagnostic services- Pathology, Haematology, bacteriology, blood bank/

transfusion, imaging diagnostics etc. Note that mortuary and post-mortem

services are not included.

iv. Theatre and recovery wards, intensive care units, neonatal intensive care

units and high Dependency units

v. Other procedures or investigation units such as-endoscopy suites, treatment

and ressing rooms, procedure rooms, ECG, EEG, hearing tests etc.

The type and number of diagnostic test for each patient on admission are taken into

account for each G-DRG. These were determined based on the National Treatment


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Guidelines expert opinion of good medical practice. For example, a patient with Acute Renal

Failure without dialysis (G-DRG) on a medical ward (at levels D- Regional Hospital or E-

Tertiary Hospital or Teaching Hospital) is costed to have a basic medical investigation

package of full blood count, blood urea, electrolytes and creatinine (BUE&Cr), liver function

test, chest x-ray, routine urine examination, abdominal and pelvic ultrasound, plus 3 repeat

BUE&Cr to monitor progress.

Change in the cost of the reagents was not factored in the determination of inpatient

G-DRGs tariffs. The numbers of times that the test will be conducted were determined taking

into consideration the number of days that the patient or client will spend in the hospital. The

tariff requires Doctors to discharge patients/clients or transfer to the higher health facility if

they spend longer days in hospital. This does not enable health providers to give quality

health services to patients/ clients. When health providers look at the tariffs and the services

that a patient/client might have received, if even they can do more, due to limitation of

resources and for the fact that public health facility depends heavily on (IGF) internal

generated fund will rather transfer or discharge if the patient could be managed at home or

the higher facility.

Indirect costs are those which cannot be attributable to a particular patient but can be shared

by a number of patients. Examples are: house keeping costs of cleaning a ward, laundry,

materials such as thermometers etc used for all patients etc.

Overhead costs are the costs of running and maintaining the health facility or

unit/department thereof. They include human resource costs, vehicle running and

maintenance costs, utilities, planning, administration, finance and the general maintenance of

building, grounds and the cost of capital (rent, new building or building replacement costs)

and equipment.


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The total overhead and indirect cost is made up of the sum of the indirect and overhead costs

of service areas utilised in providing service for the particular G-DRG. Examples of service

areas for teaching hospitals are:

Service Areas

Accident & Emergency

Accident & Emergency Theatre

Blood Transfusion Service

Laboratory

Medical Wards

Obstetrics & Gynaecology Theatre

Obstetrics & Gynaecology Wards

OPD, Dental

OPD, ENT

OPD, Eye

OPD, Medicine

OPD, Obstetrics & Gynaecology

OPD, Paediatric

OPD, Surgery

Paediatric Wards

Physiotherapy

Radiology

Surgical Theatre

Surgical Wards

For example, the total indirect and overhead cost for G-DRG MEDI18, Ischaemic

Heart disease, admitted on the medical ward is made up of the indirect and overhead costs of:


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Service Areas

Medical Wards

Laboratory

Radiology

Those for G-DRG ASUR01, Operations of thyroid and parathyroid glands, are:

Service Areas

Surgical Wards

Laboratory

Blood Transfusion

Radiology

Surgical Theatre

The indirect and overhead costs for each service area are a product of the frequency of

use of that service area (average length of stay for wards, number of sessions of treatment for

physiotherapy and number of investigations for diagnostic services) and the unit cost for that

service area.

Catering

Catering is not provided by all (HCPs) Health Care Providers. Thus, catering costs is

only reimbursed to those HCPs that provide catering. For each level of health care there is

therefore one tariff inclusive and another exclusive of catering.

Availability and Use of Diagnostic Service

The tariff took into consideration the availability of diagnostic services at each level

of healthcare; higher levels of health care have in general more facilities for investigations

than lower levels. For example, a patient with cerebro-vascular accident (G-DRG MEDI14)


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will not have a CT scan from level C (District Hospital-Tema General Hospital ) while this

might be available at the Teaching Hospital (level E).

The tariff also took into consideration that not all patients with the same G-DRG will

have or be provided with certain investigations. For example, not all cerebro-vascular

accidents at the teaching hospital will undergo a CT scan. However, in line with good

medical practice, certain basic investigative procedures, depending on the specialty or (MDC)

Major Diagnosis Catergory, were costed for each hospital spell or illness episode. For

example, all surgical patients who undergo surgery under general anaesthesia (GA) are costed

for a basic investigation package required for GA. On top of this basic package are costs for

investigations needed to diagnose the particular disease and to monitor progress pre- and

post-operatively.

Tariffs for (HCPs) Healthcare providers without diagnostic facilities

Most of the tariffs are inclusive of all necessary services provided in one facility.

However, there are many HCPs that do not provide any or provide some diagnostic services.

This means that such HCPs refer patients to other HCPs for such services. The tariff has

considered this by unbundling the costs of such diagnostic services from the all-inclusive

tariff. For example, tissue histology is not done at any district hospital but are sent to regional

or teachings hospitals, therefore tissue histology is removed from the tariff for those G-DRGs

that need it at District and lower levels.

HCPs that do not provide all services are mostly those at the district and health centre

levels including (CHPS) community health providers compounds, maternity homes and

private practitioners. For these HCPs GDRGs for outpatient consultations unbundled from

investigations and other services have been determined.

G-DRGs for diagnostic services have been set up for those HCPs which provide these

services for other HCPs. Thus, while the total cost of providing the complete management for


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a particular G-DRG is the same, the reimbursement is split between two HCPs, the one

providing the care and the other providing the diagnostic services. Thus, for example, a

patient with stroke may be cared for at a District Hospital and be referred to a Teaching

Hospital for a CT scan. The Scheme will reimburse the District Hospital for the care of the

patient through the tariff which does not include a CT and will reimburse the Teaching

hospital by the CT Scan G-DRG.

Where a HCP, which was providing the all-inclusive bundled service, is temporarily

not able to do so and therefore refers insured patients to another HCP for that service, special

local arrangements for reimbursement have to be made between that HCP, the District

Scheme and the other HCP now providing the service. For example, HCP1 cannot provide x-

ray services it had been providing because its machine has broken down and it sends its

patients to HCP2.

The District Scheme and the two HCPs should agree on arrangements for

reimbursement. That arrangement, however, will depend on whether the second HCP was

also contracted to provide service by the Scheme. If HCP2 was contracted to provide service,

the Scheme could reimburse HCP1 with the OPD tariff less the unbundled investigation tariff

(in this example that for x-ray) and reimburse HCP2 with that unbundled investigation tariff.

If HCP2 is not contracted with the Scheme, then the Scheme is not legally able to deal

directly with that HCP.

HCP1 should therefore arrange with HCP2 (contract-out arrangements) to pay it for

the service while claiming the all-inclusive bundled tariff from the Scheme. It is important

that in all such situations:

The District Mutual Insurance Scheme be informed and agreement obtained as soon

as this situation occurs


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Insured patients are not put in the position of paying for services which HCP has been

contracted to provide.

To prevent double claims by HCPs, Scheme managers should, at the onset of the

contract, agree with HCPs, based on the report of the accreditation committee, which of the

two tariffs should apply for each HCP. No one HCP should claim for the all-inclusive bundle

tariff and the tariff for diagnostic service for the same patient. Furthermore, patients referred

for diagnostic service should not be treated as if they had in addition been provided other

services.

The HCP should claim only for the diagnostic G-DRG and not others, such as OPD.

This would then break the fundamental rule that each patient should have only one G-DRG.

Government support to healthcare providers and the tariff

The tariff recognizes the differential Government support to various HCPs. The tariff

reimburses the full cost of service provision for those HCPs that do not have any Government

of Ghana (GOG) support and for those that have GOG support, the full costs less of that

support.HCPs that have GOG support are:

All public health facilities under the MOH (Ghana Health Service and Teaching

Hospitals) of which Tema General Hospital is classified.

(CHAG) Christian Health Association of Ghana hospitals, health centres and clinics

Quasi-Government health institutions

For the HCPs supported by GOG, the tariff does not include the following:


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* There seems to be two sub-groups of institutions in this group: one that is owned by and

part financed by the GOG and another one that is publicly owned or partly owned by the state

but do not receive direct support for the GOG.

Outpatients Tariff

General

The Outpatients (OPD) tariff is an all-inclusive bundled payment per visitfor OPD

services provided to the patient including laboratory, imaging, and other diagnostics,

supplies, physiotherapy, equipment, human resource and any other input in the OPD. The

tariff does not differentiate new from follow up cases, nor specialist from general OPD at

regional and district hospitals . This is to ensure simplicity and ease of processing claims.

The OPD tariff was determined in the same way as the in-patient tariff using the G-

DRGs grouping for the common outpatient attendances in the country. The direct and indirect

costs for each G-DRG were determined and a weighted average for each specialty (MDC)

HCP Cost not included in tariff

GHS and Teaching Hospitals:

HR

All Human Resource (HR) on GOG pay roll.

on IGF is included in tariff

Capital and equipment costs

CHAG health facilities:

HR

All Human Resource (HR) on GOG pay roll.

on IGF is included in tariff.

Quasi-Government health

facilities*

HR on IGF is included in

tariff.

All Human Resource (HR) on GOG pay

roll.

Capital and Equipment costs


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was calculated to set the OPD tariff. Thus, there is one tariff for OPD attendances for each

specialty at teaching hospitals. For regional hospitals, district hospitals and health centres all

the cases,

except dental, eye and ENT, were put together and a weighted average determined to produce

one general tariff for each level. These were done because at the regional and lower levels the

same OPD facilities and the same mix of health personnel are used for both the specialist and

general OPDs. The costs were, not surprisingly, the same. On the other hand, all OPD

services at the teaching hospitals are specialized and held in separate departments. Similarly,

Eye, Dental and ENT services are mainly provided separately at all levels.

For the same reasons as above, no significant differences in the costs of OPD services

for children and adults were found at regional and lower levels. The OPD tariff is therefore

the same for children and adults at regional and lower levels.

Health Episodes

The basic currency or unit of the OPD tariff is the ill health episode. This is the period

of time in which the patient is regarded as ill until he is declared healed. Ill health episode is

easy to understand in the case of acute illnesses, such as malaria, in which health services are

sought in episodes of ill health, that is, whenever the patient is sick, for the illness episode

ends within a certain time. Access to the health services takes place within that time. The

period of ill health

when health services are rendered is the ill health episode.

During the ill health episode the patient makes an initial consultation at which he/she

is assessed, certain investigations are requested and treatment may be initiated. The patient is

asked to report for review consultation(s), for assessment of the treatment and/or to report

back with results of investigations. An ill health episode therefore consists of an initial

consultation and review consultation(s).


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To ensure good quality of care, the committee of experts suggested that the ill health

episode should consist of an initial visit and two review visits within two weeks. At the first

visit, clinical assessment is made, a working diagnosis is made and investigations requested.

The second visit is for review of the investigations and review of the diagnosis. The third

visit is for evaluation of treatment.

The total costs of providing this ill health episode was computed for each G-DRG and

the weighted average found for the MDC groupings at the teaching hospitals and for all cases

except antenatal, dental, ENT and ophthalmology (EYE), at the regional, district and health

centre levels. These ill health episodes costs are reimbursed by a tariff which should be

claimed as one lump sum at the end of the illness episode. To ensure that this lump sum is

paid out for the actual patient visits, the total ill health episode tariff is divided equally into 3

parts according to the expected maximum number of OPD attendances. If a patient only

attends 2 OPD sessions during the two weeks, only two-thirds of the total tariff is

reimbursed; if the patient attends 3 OPD clinics, then, the full tariff is provided.

Acute Illness OPD attendance

According to the present tariff structure, only a maximum of two (2) reviews within

two (2) weeks of the first consultation are allowed and will be reimbursed. Thus, for acute

illnesses a maximum of three (3) visits will be reimbursed over the two weeks.

If after the two-week period the same patient presents with the same or other illness,

he/she has restarted another ill health episode. If, however, it is the HCP that schedules an

OPD attendance beyond two weeks of the first attendance for the same illness then this is

outside the ill health episode and that OPD attendance/visit should therefore not be

reimbursed.


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Claim for acute illness OPD attendance should be made after the illness episode, that

is after 2 weeks of the first attendance. HCPs should make internal arrangements to ensure

that they have all records to fill in the claim form at the end of that period.

Chronic Illness OPD Attendance

For patients with chronic illnesses/conditions such as diabetes, hypertension, epilepsy,

chronic asthma, etc., the follow up period does not end. For such patients who usually attend

specialist clinics and are given follow up appointments, the tariff expert committee has

recommended that a maximum of six (6) OPD visits (inclusive of the first visit) within 12

months of the first visit should be reimbursed.

For patients with acute illnesses the tariff allows for a maximum of three visits within

two weeks. For patients with chronic illnesses the tariff allows for a maximum of Six (6)

visits within each year.

Claim for reimbursement for chronic OPD attendance can be made after each OPD

attendance. If a patient with a chronic illness presents with another ill health problem, he/she

has a different illness episode and reimbursement should be claimed as such. Thus, for

example, a patient who has a chronic condition such as diabetes and visits for the first time

makes an initial consultation, subsequent consultations arranged by the health facility for

follow up of his/her diabetic condition are follow-up or review consultations up to a

maximum total of six visits in twelve months. If, however, the diabetic patient has a

complication of his/her original disease or has other disease such as malaria, and makes a self

initiated consultation, this new consultation begins a new illness episode of the acute illness

type a maximum of 3 visits in two weeks in addition to the chronic illness follow up visits

remaining. If the follow-up visit falls within the two week acute illness episode that chronic


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follow-up visit is counted as part of the 3 visits for the illness episode and is therefore not to

be reimbursed as extra.

Antenatal OPD attendance

Antenatal attendance provides a special situation; it occurs over a longer period but

less than a year. Reimbursement is for a maximum of four (4) visits per each pregnancy.

Claim for reimbursement can be made after each antenatal visit.

As in the case of chronic illness OPD attendance, if a pregnant woman attends

antenatal visit because of an acute problem, related or not related to her pregnancy, outside of

her scheduled antenatal appointment, she has made an acute illness episode visit and has

initiated an acute illness episode. Reimbursement for that episode should be managed as for

an acute illness episode in a patient who has chronic illness as above.

Surgical patients OPD attendance

Patients with elective surgical conditions are usually seen at the OPD and, after the

initial consultation, are given follow up visits for assessment of the investigations and then

are placed on waiting list until surgery. In order to reduce the waiting list time and also not to

pay for unnecessary OPD attendances, the expert committee recommended a maximum of

four (4) OPD visits (inclusive of the first visit) within twelve months from the date of the first

visit.

In-patients discharged to OPD

The concept of ill health episode also applies to patients who were originally on

admission and were discharged and reviewed at the OPD. If the condition for admission was

an acute one, such as caesarean section, acute appendicitis, pneumonia, etc., then a maximum

of three (3) review consultations over a maximum of six (6) weeks will be reimbursed. If the


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condition for admission was a chronic one, such as chronic osteomyelitis, thyroidectomy,

renal failure etc., post discharge consultations related to the disease should be billed for a

maximum of six (6) visits per each twelve months.

Detention for observation

A tariff for short stay (detention for observation and treatment) is set for health

facilities, such as health centres, clinics and maternity homes, where admission facilities are

not available and for other health facilities where patients are detained for observation for not

more than 24 hours or overnight.

Accident and emergency and casualty consultations

Accident and Emergency and casualties have three groups of patients. Claims for

these are to be made according to the table below:

Emergency Patient Groups Tariff

1. Managed similar to OPD Use OPD tariff (G-DRG appropriate for level)

2. Detained for less than 24 hours Use Detention for Observation tariff (G-DRG

Appropriate for level)

3. Admitted. Use In-patient G-DRG (G-DRG appropriate

for level)

Multiple specialty OPD attendances

Some patients may be seen on one day during the same illness episode by more than

one Specialist. This may occur because the initial referral may be wrong, the initial specialist

may refer the patient for an opinion or the patient may have more than one illness. For


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simplicity and to avoid internal referral to higher costing specialties for double

reimbursement, such multiple specialty OPD attendances on one day during each illness

episode should be recorded as one outpatient visit and paid at the tariff for the highest cost

specialty.

Outpatient transfers

Transfers or referrals from OPD will be reimbursed for maximum of two (2) OPD

attendances. It is the experts view that by the second visit enough evidence would have been

obtained to arrive at the decision to refer.

Outpatients Procedures

Outpatient procedures are included in the G-DRG tariff for their respective MDCs.

Note that if an OPD procedure is performed as an inpatient procedure reimbursement will

still be as an outpatient. On the other hand, if an inpatient procedure is performed as an

outpatient one, the inpatient tariff will still be reimbursed, resulting in cost saving for the

HCP. Providers should note the readmission rule.

In-Patients Tariff

Unit/Currency

The tariff for admitted patients is based on the spell of admission to discharge,

transfer out or death for each patient. This is the basic currency or unit for the inpatient tariff.

Claim for reimbursement can only be made after discharge, transfer out or death of the

patient.

For inpatients, the tariff is made up of an all-inclusive bundle of direct and indirect

costs of providing the full range of services to each patient during their spell for each G-DRG

on the wards.


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Each patient is given one G-DRG based on the procedure or the principal diagnosis

and this is used to reimburse the HCP

Emergency readmission

In principle, emergency readmission of patients with the same or related diagnosis

should not attract reimbursement if it was due to the HCP not providing sufficient quality of

service or preparing the patient adequately for discharge.

No reimbursement for emergency readmission should be provided if:

The readmission is to the same HCP, and

The readmission is within 14 days of discharge

The duration of the previous admission was less than one and half (1.5) times the

average LOS for the G-DRG.

Reimbursement at the G-DRG rate is provided for all other cases of readmission.

Inpatient transfer out

To encourage good medical practice of early referral and to prevent dumping of cases

to other HCPs while claiming full G-DRG tariff, a tariff for referred cases has been

determined. This tariff is based on minimal investigations and procedures needed to make a

diagnosis and adequate time for first aid treatment and assessment to arrive at the decision to

refer. The tariff is based on a time that is less than the average LOS for the G-DRG and is

therefore less than the full tariff for that G-DRG.

Admission through accident and emergency and outpatient wards


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Attendance at Accident and Emergency or OPD and subsequent admission on another

day should be reimbursed at the usual OPD rate. If however, admission occurs on the same

day of A&E or OPD attendance, then the in-patient G-DRG tariff should be applied.

Multiple procedures in one admission spell

When more than one procedures are recorded for a patient, the procedure with the

highest tariff is used to assign the G-DRG. This is in keeping with the cardinal rule that only

one G-DRG is assigned to each spell.

Example: 19 year old young man admitted and operated for typhoid perforation. He was then

dialysed for acute renal failure. His possible G-DRGs are:

Diagnosis G-DRG TARIFF*

Typhoid perforation Laparotomy for peritonitis GH 350

Acute renal failure complicating any condition

Acute Renal failure with dialysis 12 yrs GH 850

* These figures are illustrative only and may not be the true values.

The acute renal failure with dialysis G-DRG is the dominant one and should therefore

be recorded and used to claim for payment.

Multiple diagnoses, complications and comorbidity

The tariff emphasises simplicity. It is therefore not flexible enough to be split into

varying severity and complexity levels within each G-DRG. As above, where there are more

than one diagnoses and therefore more than one possible G-DRG, the dominant (highest cost)

diagnosis should be used to assign the single G-DRG. If a complication necessitates an

operative procedure then according to the G-DRG algorithm the operative procedure should

be used to assign the G-DRG.


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Code structure for G-DRG

The G-DRG uses seven alpha-numeric code structure in the format: AAAANNA. The

first 4 characters are alphabets (A) and represent the Major Diagnostic categories( MDC) or

specialty (e.g. OBGY = Obstetrics and Gynaecology). The next two characters are numbers

(N) and represent the number of the G-DRG within the MDC. The last character, which is an

alphabet (A), is for any split for the GDRG, e.g. age groups.

The code structure is represented below:

MDC G-DRG No. Split

AAAA NN A

MDC

The G-DRG consists of the following MDCs:

MDC Description

ASUR- Adult Surgery

DENT- Dental and Maxillofacial Surgery

ENTH- Ear Nose and Throat Surgery

INVE- Investigations

MEDI- Medicine

OBGY- Obstetrics and Gynaecology

OPDC -OPD Consultation

OPHT- Ophthalmology

ORTH- Orthopaedics

PAED- Paediatrics

PSUR- Paediatric Surgery


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RSUR -Reconstructive surgery

ZOOM- Cross-MDC

G-DRG- No.

Two numeric codes which identifies the G-DRG in the MDC.Split

Each G-DRG is split by a code for age. Patients aged 12 years have an ending code of A and

those


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diagnoses. For example, for a patient who had asthma as a child and has an inguinal hernia

operation, the asthma, which no longer exists, should not be recorded as other diagnosis.

However, there are certain chronic illnesses such as diabetes that must always be coded even

if they are not being treated during the present episode of care.

How to determine the G-DRG and tariff

This section will enable you to determine the G-DRG from a given set of

diagnosis/procedure information in the patient notes/folder. The determination of the G-DRG

starts right from the first encounter with the patient/client at the records department and

continues after the end of the spell or illness episode.

It is important that all health personnel realise and play their roles properly. Indeed,

all health personnel are involved directly or indirectly in the coding and determination of the

G-DRG.

The biodata: name, age, sex, address should be properly entered into the notes. The

date of admission and discharge or end of illness episode should be clearly recorded.

Determine the G-DRG

For each patient spell or illness episode one G-DRG has to be determined to arrive at

the tariff.

Record diagnosis(es) and procedure(s)

a. Clinicians should clearly record the diagnosis(es) and procedure(s), if any was/were

performed, during the spell or illness episode.

b. At the end of patients spell in hospital (that is, after patients discharge) or illness

episode (that is, at the end of two weeks for acute illness episode or at the end of each


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chronic follow-up OPD attendance), the biostatistician or other health personnel

should review the patients notes and extract the diagnosis(es) and procedure(s)

performed.

Determine the (ICD-10) International classification of disease code

The next step is to determine the ICD-10 code. This can be done by the records

department from the ICD-10 code book or computer programme available in the health

facility. You can also use the Code to Group tables provided. The Code to Group Table

( ANNEX C) shows the relationship between the underlying patient diagnosis, ICD- 10 code,

procedures and the appropriate core G-DRG. It is to enable you to quickly locate individual

ICD-10 codes and to identify the core G-DRG to which they are assigned. Even though a

grouper software will eventually be used to perform this function in the future, you still need

to know and understand this procedure and logic, for a better use of the system.

a. Which specialty looked after the patient? Use the specialty which looked after the

patient to help you look at the appropriate table. For example, if the patient was seen

at the ENT clinic then use the ENT Code to Group Table.

b. Look at the column with the list of diagnoses and find the nearest diagnosis in that list

to what is written in the notes. Find the appropriate ICD-10 code for that diagnosis

from the same row in the ICD-10 code column. Repeat this for all the diagnoses in the

records.

Determine the core G-DRG.

The core G-DRG is primarily determined by the dominant procedure or the principal

diagnosis. Each patient can have only one G-DRG. If a procedure was performed then

this will determine the G-DRG. Therefore in this step answer the question: Was a

procedure performed?


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a. Yes procedure was performed

If a procedure was performed use the dominant procedure to determine the G-DRG.

Look at the column containing the list of procedures in the tables for the surgical

specialties for the procedure(s) performed. Look at the G-DRG column for the core

G-DRG that corresponds to the row you found the name of procedure.

If more than one procedure was performed then repeat the step until you have found

all the core G-DRGs.

b. Procedure not performed.

If a procedure was not performed then use the principal or main diagnosis to

determine the G-DRG. Look at the column containing the list of diagnoses and find the row

that contains the principal diagnosis. Find the corresponding G-DRG in the column of G-

DRGs for the principal diagnosis.

If there is more than one diagnosis then repeat the step until you have found all the

core G-DRGs.

Determine the final G-DRG

All G-DRGs are split by age into two child and adult. Having determined the core

G-DRG use the Ghana DRGs Table (see ANNEX D) to find the final G-DRG.

a. Find the name of the G-DRG in the appropriate column. You may find that in some

tables there are 2 rows with the same G-DRG name. Which row you chose is

determined by the age of the patient. Is the patient less than 12 years old?

b. If the age of the patient is less than 12 years then look at the G-DRG column for the

core G-DRG that you have previously determined and find the one that ends with

C. this is the final G-DRG.

c. If the patient is 12 years or more then look for the G-DRG with the same core GDRG

but ends with A. This is the final G-DRG for the patient.


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Determine the tariff

Having determined the G-DRG it is easy to arrive at the tariff. Look at the G-DRG to

Tariff table for your health facilitys level of health care, find the G-DRG and one the same

row find the tariff that corresponds to it for your level of health institution.

Instructions for completion of claim forms

There is one claim form to be used by all HCPs even if they provide all or part of

health services to a client or patient. If the health care provider only provided drugs,

diagnostic services or the all-inclusive service at OPD or on the wards, the HCP should fill

the various relevant aspects of the one claim form.

The Claim Form is shown in page 114. The number of the points below corresponds

to the numbers on the form.

Claim for reimbursement shall include:

1. The Health Institution (HI) name and HI Code this should be pre-printed for each

HCP and no entry is required.

2. Claim number This should be a pre-printed information and no entry is required.

3. Clients Surname and other names Complete in full. Ensure that the names match

those on clients NHIS ID card

4. Clients sex Enter as M or F.

5. Clients date of birth. If available. Ensure that this matches those on patients NHIS

ID card.

6. Clients age - This is important especially when client does not remember birth date.

7. Clients NHIS Registration number ensure that this is accurately recorded.


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8. Hospital Record number This is important to track the folder or hospital record. The

hospital or folder or OPD card number should be accurately copied here.

9. Type of Service this is to be filled in by all HCPs.

a. Tick the type of service provided to client: Outpatient, Inpatient, Diagnostic or

Pharmacy. Note that In-patient, Outpatient and Investigation services are

mutually exclusive for any one HCP. That is, you cannot claim for those services

together for the same client. Therefore tick only one out of the three in that box.

b. Tick if an all-inclusive or unbundled service has been provided to client. If you

provided only OPD or in-patient service and the diagnostic services were done outside

of your facility then tick unbundled service. If you provided care and investigations in

the health facility for this patient then tick All-inclusive service.

10. Dates of service provision Enter date(s) when service(s) was/were provided. The

first visit date is the first date of attendance at the OPD or date of admission of the

patient.

The second date is the date of the second OPD visit or the date of discharge or

outcome event recorded in number 12. Record the third and fourth visit dates if

patient made those OPD visits. Note that for acute ill health episode a maximum of 3

OPD visits will be reimbursed.

11. Duration of Spell. Enter the number of days of the spell of admission, illness episode.

For those admitted this is the duration of admission and is the difference between the

recorded 1st Visit/Admission and the 2nd Visit/Discharge dates. For In-patient

clients, this should be the difference between the first and up to the 3rd visit and

cannot be more than 2 weeks.

12. Outcome this is to indicate whether the client died, was discharged, transferred to

another health institution or absconded/discharged against medical advice.


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13. Type of Attendance this is to indicate whether the patient initiated the hospital

attendance or the health facility made an appointment. If the patient self referred or

was referred by another health facility and came as an emergency or an acute ill

health episode then tick Emergency/Acute episode. If your health facility made the

appointment in a chronic follow-up such as in a diabetic clinic or antenatal clinic etc.,

then tick chronic follow-up.

14. Specialty this helps you in determining the G-DRG. Indicate which specialty looked

after the client. The choice is General, Adult surgery, Dental, ENT, Medical,

Ophthalmology, Orthopaedics, Obstetrics and Gynaecology, Paediatrics, Paediatric

surgery, Reconstructive surgery.

15. Procedure If any procedure was/were performed enter the procedure(s). Enter the

description of the procedure(s) performed as written in the code to group list (see

ANNEX C), the date and the G-DRG. The description should verify the G-DRG. The

date(s) should be within the dates of service provision filled above (see point 9

above).

16. Diagnosis list the diagnosis(es) for which the patient sought the health service. List

the Principal diagnosis or main problem first. Sequence the other diagnosis based on

their impact on resources provided. For each diagnosis, look up and enter the ICD-10

code and the G-DRG. Every patient seen at an outpatient or inpatient should have at

least one diagnosis filled otherwise the claim cannot be processed.

17. Diagnostics fill in this section of the claim form only when your facility has

provided

diagnostic (laboratory and imaging) services unbundled from inpatient and outpatient

services. Enter the description/name of the investigation, the date done and its G-

DRG.


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18. Medicines Enter the name of drug(s), the quantity prescribed and the date

dispensed.

Enter also the code of each medicine.

19. Client Claim Summary this summarises the information in the form in this section.

This section will ensure quick assessment of claims. The rule of thumb here is the

rule of one. There can be only one entry in each column. There can be only one G-

DRG code for each patient and this code can be either an Inpatient, Outpatient code or

Diagnostics. The G-DRG is that of the primary procedure or principal diagnosis Only

one of cells A, B, or C can be filled. There can be only one pharmacy amount and

only one total claim.

20. Signature Claim forms must bear the name and personal signature of the approved

HCP officer. The officer must be delegated in the institution to coordinate the form

filling. The form, can be filled by multiple personnel (such as records officers,

biostatisticians, pharmacists, nurses, account clerks etc.) especially in large facilities.

The responsible officer checks each form and ensures completeness. He/she then

summaries all the claims, writes a cover letter to be reviewed and signed by the chief

executive of the hospital/facility before onward transmission to the scheme office.

Itemized billing

As indicated above, itemized billing is the collection of various costs of resources that

has been used on a client in a health facility to establish the bill of a client/ patient.

It details out item by item used on patient without any assumption as to weather the

patient actual received or use any item or medical resources. Currently Tema General

Hospital is using itemized billing for uninsured client and the G-DRG for insured

client/patients.


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The itemized billing tariff is determined by the hospital management who considers

the cost of medical resource in the market and fixed tariff that will recover cost incurred by

the hospital or the resources used on the patient.

The above procedures and diagnosis are selected from various specialists who

consume more of medical resources. It is important to note that, all in-patient client

consumable are higher than the G-DRGS charge by the national health insurance.

Drugs/ medicine in both cases are not added to services. Every drug / medicine that is

taken by a client/ patient is paid separately, except anesthesia drugs which were added to

every procedure performed in the theatre.

Determination of the itemized billing for out-patient/ clients

a. Consultation

1. Patient folder 1.15

2. Patient identification card (I/D) .05

3. Claim form . 05

4. Patient confirmation sheet .05

5. Investigations

-X-ray Chest 17.00

-ECG 10.00

-FBC (Full blood count) 8.00

-Scan (abdomen) 10.00

Total cost 46.30


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Determination of the itemized billing for in-patient

a. Thyroidectomy

GH

1. Gauze 12.00

2. pack 6.00

3. Sutures vicry 1 24.00

Plain 0.60

Nylon 2.40

4. Corrugated drain 3.00

5. Surgical gloves 4.45

6. Examination gloves 2.00

7. Nelaton catheters, spirit, blade, cotton 2.00

8. Betadire / Lotion 4.50

9. Plaster 0.50

10. Miscellaneous 10.00


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11. Anesthesia (Drug) 100.00

12. Procedure fee (Condition) 200.00

13. Maintenance of monitor 2.00

14. Electricity 1.5

15. Water 1.00

Total 375.95

b. Surgical hernia

1. Gauze (30) 6.00

2. Sutures vicry (3) 12.90

Sutures Nylon (3) 1.80

Sutures plain (1) 0.60

3. Scapel blade, Cotton, spirit 2.00

Lotion/ Betadire 4.50


5. Examination gloves 2.00




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14. Electricity 1.5

15. Water 1.00

Total 143.00

C.Hernia with anaesthesia

Maintenance of monitor 2.00

Anaesthesia 40.00

Total 185.00

d. Total abdominal hysterectomy (tah)

1. Gauze 9.00

2. Pack 9.00

3. Sutures Vicry 1 43.00

Plain 0.60

Nylon 1.80


5. Disposal gloves 3.45

6. Betadine/Lotion 4.50

7. Nelaton Catheter, spirit 10.00

8. Blade, Cotton 2.00


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9. Miscellanous 10.00


11.TAHand Spiral Anaesthesia 40.00

12.Maintenance of monitor 2.00

13. Electricity 1.5

14.Water 1.00

Total 342.30

e. Tah with general anaesthesia

Total cost of d. 342.30

General anaesthesia 100.00

Total 442.30

Obstetrics and gyaecology

f. Caesarian section

1. Gauze 6.00

2. Pack 6.00


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3. Suture-vicry1 21.50

-plain 0.60

-Nylon 0.60


5. Disposable gloves 2.00


7. Nelatoncatheter, spirit, blade, cotton 10.00


9. Spiral Anaesthesia 40.00

10. Extra Anaesthesia 20.00


12. Electricity 1.50

13. Water 1.00

Total 220.15

g. Caesarian section under general anaesthesia

Total cost off 220.15

Generala naesthesia 100.00

Maintenance of monitor 2.00


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Total cost 322.15

h. Bilateral tubal ligation

1 Gauze 3.00

2. Suture-vicry 1 4.30

-plain 0.60

-Nylon 0.60

3. Surgical gloves 4pair 1.48

4. Disposable gloves 1/2 1.00


6. Nelatonca theter, spirit, blade, cotton 3.00



Total cost 60.98

The above disease and treatment procedures illustrates the itemized billing system in

Tema General Hospital.


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Data analysis

On the question of the system of billing in Tem General Hospital, 75% of the selected

sample staff was aware that, the Hospital uses the G-DRGS system.

According to them, the Hospital was asked not to use any system of billing apart from

G-DRG system for both Insured and Uninsured. It was to serve as an incentive for the

uninsured clients/patients to enroll into the National Health Insurance Scheme.

Fifteen (15%) of the staff knew that, the hospital uses both the Itemized and the G-

DRGS system of billing, because in the second quarter of the year 2010, the management

decided to introduce the itemized billing system to cater for the uninsured client/patient. The

major reason for the introduction of the itemized billing was that, G-DRGS tariffs was

inadequate considering the kind of service the Hospital offers. Others was due to the location

of the Hospital, there are always foreigners who are not insured seeking health services in the

hospital, and therefore, the Hospital should take the opportunity to recover the right cost to

enable it procure consumable to give quality health service to patients. Ten (10%) of the staff

was not sure of the system in use, and therefore referred researcher to accounts/finance

department.

The question of which institution developed the itemized billing/tariffs? Only 30% of

the staff knew it was developed by the management of the Hospital. 70% thought it was done

by Ghana Health Service (GHS) in Consultation with Ministry of Health (MOH) which is

then distributed through GHS to all hospital for implementation.

The third question of how the itemized billing was determined? Again only 30%

which was mostly paramedical staff or supporting staff said, it was determined on the bases

of item by item to enable the hospital recover the cost of item/ consumables use for a


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patient/client. Majority of the 30% staff was finance staff. 70% could not tell, but with mix

feeling that, some of the item cost was not realistic, special oxygen and anaesthetic drugs

which are usually part of the procedure or operation in the theatre. Most of the service

providers think that, there should be margin of profit, but the management staff is thinking

that as public institution where all salaries and wages as well as capital expenditure are

undertaken by Government it should only recover cost and not to make profit.

On question four, 70% thought the G-DRGS was determined by the Metropolitan

Mutual Health Insurance Scheme, simply because the schemes are near to Tema General

Hospital. They did not even know that, the schemes were been regulated from the National

Health Insurance Authority. They did not also know that GHS was involved in the

determination of the G-DRGS tariffs. According to the NHIS manual of 2008 page one (1), it

was done in consultation with all stakeholders including GHS.

On the question on discussion, 30% management or supporting staff was sure that the

tariffs were developed in conjunction with other stakeholders.

Question (5) five which sort to established how the G-DRGS tariffs were determine

also came out with almost the same result as the previous question, about 75% could not tell

how it was determined, even though the use it. They claimed there was no training on the G-

DRGS tariffs, hence their answer of no knowledge on the determination of tariffs. The 25%

who have knowledge about the tariffs expressed mix feelings. The conceptual framework of

which the tariff was developed seems not achieving the standards they sort to set. Standards

such as:

1. The tariff should encourage efficiency and not pay for inefficiency

2. The Tariff should be simple and easy to administer.

3. The tariff should encourage providers to provide good quality care


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4. The tariff should ensure uniformity in claims.

5. The tariff should ensure equity and fairness.

6. The Tariff should be based on the principal diagnosis for each patient

7. The tariff should reflect the total costs, both direct and indirect, except capital and

equipment costs, incurred in patient care to form the basis for reimbursement.

8. The total costs of services are to be arrived at irrespective of who was to pay and

irrespective of ownership of the health facility

The 25% group believes that efficiency can only be achieved if the right health

infrastructure is provided. According to them, the grouping of hospitals without regards to the

level of specialist does not create room for efficiency. In others words no matter the high

level of medical infrastructure and the quality of medical and paramedical personnel, once the

institution is classified under District Hospital, she must recover her cost using District

Hospital tariffs. They believe that due to the group tariff, Tema General Hospital should have

been raised to Regional Hospital B. to enable it at least recover a reasonable proportion of the

losses.

On question (6) six, 99% of the selected staff knew that, out-patient treatment was an

all inclusive one, that is consultation and all investigation (Laboratory, X-ray, Scan, ECG) are

all added to consultation. 1% could not tell simply because they were new trainees (staff).

It came to light from the accounts department that, due to the combinations or all

inclusive nature of the G-DRGS tariffs, there is much difficulty to assess the efficiency of

Cost and Revenue centre such as the OPD, LAB, X-RAY, SCAN, and ECG which have a

different needs of medical resource.

According to them, Itemized billing was easy to assess the efficiency of the above

mentioned Centres, the G-DRGS system of billing have shifted the standard parameters of


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assessing performance in the health sector, making it difficulty to determine the performance

of each department.

Question (7) seven 65% think that consultation should be Doctor Service and

Documentation, while 45% believes, it should be Doctors service and investigation.

Question (8) eight, contrary to the responses on seven above, 95% think that there is

clear difference in cost between consultations and investigations, according to them, the cost

of reagents are very important factor in the treatment of a patient and therefore should not be

mix-up or added to consultations. They claim, cost for reagents increase daily and the

frequency of request for investigation by medical practitioners have increase as well as the

level of specialty. That is the levels of medical judgment without investigation for treatment

of patients have reduced. Every Doctor want to be sure of what she/he is treating and

therefore will request more investigation than ever. For them, the assumption that, not every

patient require investigation should be discarded, because it will create cost problems for the

Hospital if all inclusive treatment continue.

Question (9) nine based on the itemized billing, 90% knows that it will cost between

GH5-GH10 to conduct an investigation for a simple disease, and 10% do not know because

they have no access to itemized tariff.

Question (10) ten the same percentage as in question (9) knows that, it will cost

between GH60-GH100 to investigate complex disease and those who do not know remain the

same as in the previous question.

Responses to question (11) eleven also brought to light of 90% with certainty that, it

will cost between GH6-GH10 to come out with a clean x-ray in a simple investigation and

10% do not know due to non access of the itemized tariffs.

For a complex x-ray for question (12) twelve, the percentages in question eleven

remain the same regarding their knowledge which they confirm to be between GH60-GH100.


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On question (13) thirteen, according to the response it cost far more than just the

production. They claim all the papers use for ECG investigation are all imported at cost of

GH10.00 in addition to the special gel used in conducting the investigation. 85% of the staff

said, the cost of ECG will be above GH12. 15% of staff could not come out with any figure

because they have no knowledge on the determination of the tariffs.

Question (14) fourteen 75% of they Medical officers and others involves in

performing this investigation is between GH10-GH12. Question (15) 90% of the staff said, it

was possible to conducted all investigation in Tema General Hospital. 10% also agreed with

the 90% but indicated that, Tema General Hospital can not conduct CTC scan. According to

them, this is only done in korlebu Teaching Hospital.

Question (16) 100% of the staff think that it is not feasible to combined investigation

with consultation. According to them, it will be difficult to access the performance of the

Revenue and Expenditure centers.

Question (17) seventeen 100% of the respondents stated that it was not possible to

differentiate between feeding, investigation, Medical consumables and documentation in an

patient billing or charge since under the G-DRGS system, they are included in the tariffs

determined by the system.

Question (18) eighteen, 100% responded in the negative. Question (19) nineteen, 95%

said, it was the combination of medical services, consumables and drugs, whiles 5% could

not determine the combination.

Question (20) 100%, knew that patients are fed three times a day. Question (21) 25%

could estimate the cost of meals, 75% could not tell but refer researcher to the catering

department in the hospital. They estimated the cost between GH2-GH5.

Question (22), 99% think that the introduction of G-DRGS did not improvement the

Revenue base of the Hospital, according to them, it rather introduce loss due to the fact that


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several cost and revenue centre are combined making it impossible to assess the performance

of those centre. 1% could not respond to the question, because they have little knowledge

about the G-DRGS system of tariff.

Question (23) 20% said the Hospital was losing between 5%-10% monthly due to

either the patients taking filled claim form home or the insurance schemes rejecting the claim

for inconsistency in diagnosis and drugs prescribed for patients and many others factors. 80%

could not tell the losses, but are very sure that the Hospital lose so much In the G-DRGS

system of billing.

Question (24) 95% said it take the NHIS from three months and above after

submission to get reimbursement. 5% could not put time period but said the NHIS delays in

the payment.

Question (25) 92% of the staff state the recovery rate between 90%-95% while 12%

could not tell but state knowledge of some percentage loss in the reimbursement.

Question (26) 99% said, service and drugs were separately bill and therefore separate

accounts are been maintained for each.1% thinks the are put together.

Question (27) 30% know of the exclusion of capital from the determination of the G-

DRGS System. 70% thought all was factor in the determination of G-DRGS system.

Question (28) 97% said, salaries was paid by (GOG) Government of Ghana, 13% said

their salaries are paid from the (IGF) Internal Generated Fund.

Question (29) 100% said, it was difficult to assess performance since cost and revenue

centers are put together in the G-DRGS system.

Diagnostic Related Groupings Saakat Add

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