DRG Workshop Belgrade, 18-22.November 2013. Gaming. Sub-acute patients. RIC AND LINDY.

DRG Workshop Belgrade, 18-22.November 2013. Gaming. Sub-acute patients. RIC AND LINDY

DRG Workshop Belgrade, 18-22.November 2013. Paper cases administrative discharges and readmission in Hungary Change of care type in NSW. Empty cases in Slovenia Admitting cases in Emergency Departments and Outpatients ?can these be legitimate? Generating additional data counts for more funding

DRG Workshop Belgrade, 18-22.November 2013. DRG INPATIENTS SAME DAY INPATIENTS ED PATIENTS DEFINITIONS AND RULES BUNDLED OUTPATIENTS FFS AMB PATIENTS CHRONIC CARE PROGRAMS TRAUMA AND ACUTE ILLNESS AGED CARE AND MENTAL HEALTH PROGRAMS PRIVATE AND DISCRETIONARY ELECTIVE??

DRG Workshop Belgrade, 18-22.November 2013. Rapid growth in Victoria of same day episodes Clear evidence of admitting cases that can be treated in ambulatory setting Cases that can be treated either way becoming all inpatient eg dialysis and chemotherapy REMOVE PAYMENT INCENTIVE - CAPS Admitting outpatients as short stay inpatients

DRG Workshop Belgrade, 18-22.November 2013. UPCODING CA$EMAX 1000 500 100 0 70% ACCURACY 30% CREATIVITY SUBECT TO EDITS

DRG Workshop Belgrade, 18-22.November 2013. 6 Source: Nagy, J., 1999. DRG creep in Hungary

DRG Workshop Belgrade, 18-22.November 2013. How many times per stay? How many times per day? Can we pay for them both together? What is the right time? Change of care type or discharge and readmission for rehabilitation

DRG Workshop Belgrade, 18-22.November 2013. All casemix systems adjust the system every year New cost weights and recalibrated price Potential to cap or reweight overprovision. How to detect and control gaming The only way to pay doctors is to change the system every three years, because by then they will have found ways to get round it to their own advantage Bob Evans

DRG Workshop Belgrade, 18-22.November 2013. 9 Fine tuning of the system: addressing negative effects Upcoding (creep), paper (readmitted) cases Monitor and control provider reporting of cases Continuous cost weight revision Efficiency and quality Addressing undertreatment (quality/effectiveness): creating new groups *DRGs for sophisticated care, but only selected providers Quicker-sicker problem: readmission before maximum day limit does not pay extra

DRG Workshop Belgrade, 18-22.November 2013. Fraud is repeated offences with intention Fraud is knowing violation of reporting rules Fraud is materially profiting from systematic mistakes Fraud is attempting to hide payments claimed that do not relate to a real service The difference between gaming and fraud

DRG Workshop Belgrade, 18-22.November 2013. How can these issues be addressed in Serbia? What is done now about professional review? How is fraud detected and controlled? QUESTIONS

DRG Workshop Belgrade, 18-22.November 2013. SUB ACUTE CASEMIX PART 2

DRG Workshop Belgrade, 18-22.November 2013. SUB ACUTE CARE REHABILITATION PALLIATIVE CARE GERIATRIC EVALUATION AND MANAGEMENT PSYCHOGERIATRIC ??MAINTENANCE (OR NURSING HOME TYPE)?

DRG Workshop Belgrade, 18-22.November 2013. SNAP SUB ACUTE INPATIENT

DRG Workshop Belgrade, 18-22.November 2013. SNAP SUB ACUTE AMBULATORY

DRG Workshop Belgrade, 18-22.November 2013. CHANGE OF CARE TYPE DAY OF EPISODE OF CARE OR SPELL CARE TYPE REHABILITATION SERVICES ACUTE SERVICES

DRG Workshop Belgrade, 18-22.November 2013. CARE PATHS AND CLASSIFICATIONS For a clinical pathway you must have: FOR DRGs you must have: an episode of care. diagnoses. a care planning process. know what was done to the patient - at least in general terms. a team approach to patient management. discretion in choice of the most cost effective care. decisions made before the treatment is undertaken. decisions made after the treatment is completed.

DRG Workshop Belgrade, 18-22.November 2013. REHABILITATION CASEMIX

DRG Workshop Belgrade, 18-22.November 2013. REHAB CAN BE ACCESSED As part of an acute episode (DRG) (usually?) As a separate ACUTE DRG episode As a separate admission type (where substantial) Different care type SUBACUTE As a series of one off referrals from a community provider for eg PHYSIO, OT, PSYCHOLOGY, SPEECH THERAPY, POD ETC As a planned package/program of care on an ambulatory basis or combination.

DRG Workshop Belgrade, 18-22.November 2013. The Oz classification smorgasbord

DRG Workshop Belgrade, 18-22.November 2013. TWO EXAMPLE REHAB CLASSIFICATIONS

DRG Workshop Belgrade, 18-22.November 2013. MEASURES OF FUNCTION AVAILABLE FOR CLASSIFICATIONS ICF International classification of function WHO FIM Barthels RUGs

DRG Workshop Belgrade, 18-22.November 2013. Rehabilitation Patient Groups Ontario 2008 83 RPG in the new classification system Relies on the following data elements where applicable: 1. Rehabilitation Client Code 2. Admit Motor Functional Independence Measure (FIM) score 3. Admit Cognitive FIM score 4. Patient Age

DRG Workshop Belgrade, 18-22.November 2013. Rehabilitation Patient Groups Ontario 2008 1 of 2 (M = motor FIM score; C=cognitive FIM scores) 1. Stroke 1100. M=12-38 and Age=691510. M=17-41 and Age = 31 1130. M=51-84 and C=5-251530. M=42-84 1140. M=51-84 and C=26-29 6. Non-Traumatic Spinal Cord Injury 1600. M-12-28 1150. M=51-69 and C=30-351610. M=29-54 and Age >=51 1160. M=69-84 and C=30-351620. M=29-54 and Age

DRG Workshop Belgrade, 18-22.November 2013. Rehabilitation Patient Groups Ontario 2008 2 of 2 11. Pain 2100. M-12-68 16. Pulmonary 2600. M-12-36 and Age >- 80 2110. M=69-84 2610. M=37-84 and Age >= 80 12. Fracture of Lower Extremity 2200. M-12-47 and Age >- 84 2620. C=5-33 and Age

DRG Workshop Belgrade, 18-22.November 2013. HRG v3.5 MH CATEGORIES T01- Senile Dementia T03- Schizophreniform Psychoses without Section T07- Depression without Section T08 - Presenile Dementia T09 - Anxiety Syndromes T10 - Alcohol or Drugs Non- Dependent Use >18 T11 - Alcohol or Drugs Non- Dependent Use

DRG Workshop Belgrade, 18-22.November 2013. UK PbR STUDY SETTING DEPENDENT CATEGORIES Cty No or std CPA Low prob daily act HONOS10 Cty No or std CPA High prob daily act HONOS10 Cty Std CPA Low prob daily act HONOS10 Cty Std CPA High prob daily act HONOS10 Cty Enh CPA Low prob daily act HONOS10 Cty Enh CPA High prob occ act HONOS12 Cty Enh CPA Low prob occ act HONOS12 IP/OP no or std CPA working age IP/OP no or std CPA above working age IP/OP enh CPA Low cog prob HONOS4 no section ord IP/OP enh CPA Low cog prob HONOS4 section ord IP/OP enh CPA High cog prob HONOS4 0-2 phys prob IP/OP enh CPA High cog prob HONOS4 >2 phys prob IP Low social prob HoNOS social IP Med social prob HoNOS social IP High social prob HoNOS social 17 CATEGORIES 17 CATEGORIES SETTING/ PROBLEM / FN BASED SETTING/ PROBLEM / FN BASED CARE APPROACH CARE APPROACH SMALL DATASET SMALL DATASET COSTING? COSTING? RELIES ON HONOS RELIES ON HONOS CPA=Care Programme Approachhttp://www.gpsa.org.au/media/docs/mentalhealth/honos_information.pdf

DRG Workshop Belgrade, 18-22.November 2013. UK PbR STUDY SETTING INDEPENDENT CATEGORIES ;W/o Section;No or std CPA;Dx= F0, F2, F5, F6, F7;;; ;W/o Section;No or std CPA;Dx=F1, F3, F4,F9;No or low prob daily activities (HoNOS 10);; ;W/o Section;No or std CPA;Dx=F1, F3, F4,F9;High prob daily activities (HoNOS 10); Wkg age; ;W/o Section;No or std CPA;Dx=F1, F3, F4,F9;High prob daily activities (HoNOS 10); Above wkg age;>3 HoNOS psych ;W/o Section;No or std CPA;Dx=F1, F3, F4,F9;High prob daily activities (HoNOS 10); Above wkg age;1-3 HoNOS psych ;W/o Section;Enh CPA;Dx=None, F1, F7, F8;No or low prob daily activities (HoNOS 10);; ;W/o Section;Enh CPA;Dx=None, F1, F7, F8;High prob daily activities (HoNOS 10);; ;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Med or hi CRU complexity;Low or no cognitive prob HoNOS4; ;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Med or hi CRU complexity;High cognitive prob HoNOS4; ;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Low CRU complexity;; ;W Section;>2 HoNOSpsych;Enh CPA;Dx= None, F1, F3, F4;; ;W Section;>2 HoNOSpsych;Enh CPA;Dx=F0, F2, F5, F6, F9;; ;W Section;>2 HoNOSpsych;No or std CPA;;; ;W Section;0-2 HoNOSpsych;;;; ONLY WORKING AGE + ONLY WORKING AGE + LEGAL, DX AND HoNOS LEGAL, DX AND HoNOS 78% RECORDS EDIT REJECTED 78% RECORDS EDIT REJECTED N= N= 11,364 pat

DRG Workshop Belgrade, 18-22.November 2013. Categories Suggested by the Care Path Study Acute non-psychotic low Acute non-psychotic med Acute non-psychotic high Non-psychot overval idea Non-psychot chaotic & challenging Drug & alcohol First episode psychosis Chronic severe low sympt Chronic severe high sympt Severe psychot episode Severe depression Dual diag Assertive outreach CARE PATH DEFINITIONS CLINICIAN GROUPING VS ALGORITHM GROUPING COST VARIANCE ANALYSIS N=2,287 PATIENTS

DRG Workshop Belgrade, 18-22.November 2013. Ideas on classification dimensions from the forensic MH study. Socio demo Offence Clinical IP/cty Medico-legal Seclusion DEMOGRAPHIC STUDY DISTRIBUTION OF ACCESS AND SERVICE PROVISION SECLUSION AS MANAGEMENT TOOL COSTS

DRG Workshop Belgrade, 18-22.November 2013. INPATIENTS SAME DAY INPATIENTS ED PATIENTS DEFINITIONS AND RULES BUNDLED OUTPATIENTS FFS OUTPATIENTS CHRONIC CARE PROGRAMS TRAUMA AND ACUTE ILLNESS AGED CARE AND MENTAL HEALTH PROGRAMS PRIVATE AND DISCRETIONARY ELECTIVE??

DRG Workshop Belgrade, 18-22.November 2013. So??

DRG Workshop Belgrade, 18-22.November 2013. Patient Classification Systems There is no such thing as a bad classification only people who are more or less happy with the category to which their case is assigned Ric Marshall, PCSI Summer School, 17 June, 2010

DRG Workshop Belgrade, 18-22.November 2013. Patient Classification Systems There is also the validity of the classification categories for particular uses. And then there is the reliability of the data Anon

DRG Workshop Belgrade, 18-22.November 2013. Gaming. Sub-acute patients. RIC AND LINDY.

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