Patient Classification and Hospital Payment: Methods for ... · comparisons across countries Dr....

Patient Classification and

Hospital Payment: Methods for Hospital Payment: Methods for

comparisons across countries

Dr. med. Wilm Quentin, MSc HPPF

Research Fellow

Department of Health Care Management

Berlin University of Technology

WHO Collaborating Centre for Health Systems Research and Management

European Observatory on Health Systems and Policies

18 July 2012 1ECHE 2012 Pre-Conference | Zürich, Switzerland

Rationale I

• Most important uses of DRGs are:

1. DRG-based hospital payment

2. Activity measurement/Performance assessment

� Require that DRGs are sufficiently homogenous

• Detailed cross-country comparison of• Detailed cross-country comparison ofclassification algorithms:

– Identification of alternative options for classification� optimization

– Comparison of size of hospital payment

– Preparatory phase for quantitative analyses

18 July 2012 ECHE 2012 Pre-Conference | Zürich, Switzerland 2

Patient Classification

Example:

The G-DRG

system


Definition of Episodes of Care

EoC Defined byICD 10

WHOICD 9-CM Diagnosis Exclude

Gastrointestinal diseases

Appendectomy primary

diagnosis +

procedure

K35-K38 47.0 main Age <1,

outpatients

Malignant growth

Breast cancer primary C50, D05 85.20-85.23, main Age <1,

Appendicit. Appendect.

Breast cancer primary

diagnosis +

procedure

C50, D05 85.20-85.23,

85.33-85.36,

85.4

main Age <1,

outpatients,

exclude

males

Cardiovascular diseases

AMI primary

diagnosis

I21, I22 excl.: 36.1 main Age <1,

bypass

surgery

outpatients


Breast

Cancer

Partial or Tot.

Mastect.

AMI Excl. bypass

Data sources: 11 countries

Country Data year Source of data

Austria 2008 Leistungsorientierte Krankenanstaltenfinanzierung (LKF)

database of the Bundesministerium für Gesundheit (BMG)

England 2007/08 Hospital Epsiode Statistic (HES)

Estonia 2008 Estonian Health Insurance Fund (EHIF) database

Finland 2008 Finnish Hospital Discharge Register

France 2008 Programme de Médicalisation des Systèmes d'Information en

Médecine, Chirurgie, Obstétrique (PMSI MCO)

Germany 2008 Fallpauschalenbezogene Krankenhausstatistik (DRG-statistic) of


Germany 2008 Fallpauschalenbezogene Krankenhausstatistik (DRG-statistic) of

the Federal Statistical Office (Destatis)

Ireland 2008 Hospital In-Patient Enquiry (HIPE)

Netherlands 2008 Diagnose Behandeling Combinaties (DBC) Onderhoud database

Poland 2009 Centralny rejestr świadczeń i refundacji (Register of episodes of

care and reimbursements) of the National Health Fund (NHF)

Sweden 2008 The National Patient register (NPR) of The Board of Health and

Welfare

Spain

(Catalonia)

2008 Hospital Minimum Basic Data Set (CMBD) database of the

Public Hospital Network of Catalonia (XHUP)

AMI DRGs in Germany

ICD-10:

I21 German

<1%

DRG7

DRG8

DRG1

DRG2

DRG9


I21

or I22

German

DatabaseDRG7

DRG3DRG4

DRG6DRG5

DRG1

AMI in Germany 2

<1%


DRG1

DRG2

AMI DRGs in Sweden 1

ICD-10:

I21 Swedish

<1%DRG5

DRG1

DRG2

DRG7


I21

or I22

Swedish

Database

DRG3

DRG4

DRG6

DRG1

AMI DRGs in Sweden 2


DRG1

DRG2

AMI DRGs overview

Major Category Partition (LOS before )

DeathProcedure Type of Admission Complications/

comorbiditiesAgeMain diagnosis LOS

Classification

variablesCountry

(DRG system)

% included cases

DRG

Estonia

(NordDRG V2003)

97% of cases

circulatory system

diseases

OR

procedure

medical

AMI or compl.

of AMI

PCI

non-AMI

AMI or compl.

of AMI

< 4 days

>3 days or

no death

123

121

122

112

w/o cc

with cc


Sweden

(NordDRG Swe)

98% of cases

disease of

circulatory

system

OR

procedure

PCI

invasive

cardiologic

diagnostic

evaluation

AMI or compl. of AMI

medical

non-AMI

AMI or compl.

of AMI

< 4 days

>3 days or

no deathw/o

cardiovasc cc

with

cardiovasc cc

123

121

122

w/o

cardiovasc cc

with

cardiovasc cc124

125

112F

112Ew/o cc

with cc

Comparison of DRG weights

DRG National DRG

weight

% of

cases

Classification

variablesCountry

(DRG system)

% included cases

Estonia

(NordDRG V2003)

97% of cases

Major Category

circulatory

system

diseases

123

121

122

112 45.8% 7 424

33.0%

10.8%

1 172

672

4.7% 542

Partition

Index Case

age 70, AMI (NSTEMI) without complications, no invasive diagnostic

evaluation, no PCI, discharged alive, treated as inpatient for 8 days


Sweden

(NordDRG.Swe V2008)

98% of cases125

121

8.8 %

20.8%

0.75

1.04

112E 20.4 %

124 1.9 %

1.84

1.13

112F 7.2% 2.11

122 36.1% 0.75

circulatory

system disease

123 3.0% 0.35

AMI DRGs overview

Major Category Partition (LOS before )

DeathProcedure Type of Admission Complications/

comorbiditiesAgeMain diagnosis LOS

Classification

variablesCountry

(DRG system)

% included cases

DRG

Estonia

(NordDRG V2003)

97% of cases

circulatory system

diseases

OR

procedure

medical

AMI or compl.

of AMI

PCI

non-AMI

AMI or compl.

of AMI

< 4 days

>3 days or

no death

123

121

122

112

w/o cc

with cc


Sweden

(NordDRG Swe)

98% of cases

disease of

circulatory

system

OR

procedure

PCI

invasive

cardiologic

diagnostic

evaluation

AMI or compl. of AMI

medical

non-AMI

AMI or compl.

of AMI

< 4 days

>3 days or

no deathw/o

cardiovasc cc

with

cardiovasc cc

123

121

122

w/o

cardiovasc cc

with

cardiovasc cc124

125

112F

112Ew/o cc

with cc

Index Case

age 70, AMI (NSTEMI) without complications, no invasive diagnostic

evaluation, no PCI, discharged alive, treated as inpatient for 8 days

Comparison of DRG weights

DRG National DRG

weight

% of

cases

Classification

variablesCountry

(DRG system)

% included cases

Estonia

(NordDRG V2003)

97% of cases

Major Category

circulatory

system

diseases

123

121

122

112 45.8% 7 424

33.0%

10.8%

1 172

672

4.7% 542

Partition

1.00

11.05

1.74

0.81

DRG weight

index

(index case = 1)


Sweden

(NordDRG.Swe V2008)

98% of cases125

121

8.8 %

20.8%

0.75

1.04

112E 20.4 %

124 1.9 %

1.84

1.13

112F 7.2% 2.11

122 36.1% 0.75

circulatory

system disease

123 3.0% 0.35

122 36.1% 0.75

1.00

1.39

2.45

1.51

2.81

0.47

1.00

Comparison of Hospital Payment

Principal diagnosis

(ICD-10-WHO)

Secondary diagnoses

(ICD-10-WHO)

Procedure

(ICD-9-CM)

Age

(years)

Setting Death

during

admission

LOS

(days)

Index case Unilateral hernia

(K40.9)

None Unilateral

(53.0)

41 Inpatient No 2Uncomplicated unilateral hernia, open surgery

Inguinal Hernia Case Vignettes


Comparison of Hospital Payment

Principal diagnosis

(ICD-10-WHO)

Secondary diagnoses

(ICD-10-WHO)

Procedure

(ICD-9-CM)

Age

(years)

Setting Death

during

admission

LOS

(days)

Index case Unilateral hernia

(K40.9)

None Unilateral

(53.0)

41 Inpatient No 2

Patient 1 Bilateral hernia, with

obstruction (K40.0)

None Other, bilateral

(53.1)

60 Inpatient No 3

Patient 2 Bilateral inguinal

hernia, with

gangrene (K40.1)

None Laparoscopic,

bilateral (17.2)

45 Inpatient No 5

Patient 3 Bilateral inguinal

hernia,

uncomplicated

Disruption of operation

wound (T81.3)

Infection following a

Other, bilateral

(53.1)

30 Inpatient No 12

″A bit complicated“ bilateral hernia, open surgery

Complicated bilateral hernia (with gangrene), laparoscopic surgery

Uncomplicated unilateral hernia, open surgery

Uncomplicated bilateral hernia, wound infection, open surgery, long

LOS

Inguinal Hernia Case Vignettes

uncomplicated

(K40.2)

Infection following a

procedure (T81.4)

Patient 4 Unilateral or

unspecified inguinal

hernia, with

obstruction (K40.3)

Foreign body left in body

after procedure (T81.5)

Diabetes with compl. (E11.8)

Dilated cardiomyopathy

(I42.0)

Sequelae of stroke (I69.3)

Other,

unilateral

(53.0)

70 Inpatient Yes 6



hernia, with

gangrene (K40.4)

None Laparoscopic,

unilateral

(17.1)

12 Inpatient No 7



hernia,

uncomplicated

(K40.9)

None Laparoscopic,

unilateral

(17.1)

35 Day case No 0


LOS

Uncomplicated unilatera hernia, with multiple complications, open

surgery

Complicated unilatera hernia, laparoscopic surgery, age < 18

Uncomplicated unilatera hernia, laparoscopic surgery, day case

Grouping of Case Vignettes

Estonia

(NordDRG

2008)

99.2% of

cases

digestive

system

diseases

inguinal &

femoral hernia

procedures

with cc

without

cc

161

162

163

8.7%

80.3%

10.2%

1.00

1.21

0.94< 18

≥ 18

surgery

Major Category Partition Type of admissionProcedureComplications/

comorbiditiesDRG

Age

% of

cases

Classification

variablesCountry

(DRG system)

% included cases

DRG

weight

index

Patients 1, 2 , 6

Patients 3 and 4

Patients 5

Quasi

Price

(Euros)

523

633

493


Sweden

(NordDRG.Swe

V2008

98.9% of cases)

digestive

system

diseases

inguinal hernia

procedures

inpatientwith cc

without

cc

161

≥ 18

surgery

8.2% 1.19

inpatient 162 21.7% 1.00

day case 162O 67.9% 0.62

163inpatient 1.1% 1.28< 18

Patients 1, 2

Patients 3 and 4

Patients 6

Patients 5

3,307

2,780

1,737

3,562

Conversion Rate

Quasi Price

DRG weight

Relative weight

Raw TariffBase Rate

National Average TariffX = Quasi PriceRaw Tariff

ScoreNational Average Tariff

Point Value

X = Quasi Price

national

average,

incl. full cost

where possible


Patient classification and

hospital payments:

Results for three episodes of care

Jacqueline O’Reilly

Economic and Social Research Institute, Ireland

18 July 2012

Overview

1. How are patients categorised to diagnosis-related

groups (DRGs) within the EuroDRG countries?

� Based on DRG algorithm maps

� Example of acute myocardial infarction (AMI)

2. What is the relative resource intensity/complexity 2. What is the relative resource intensity/complexity

of DRGs within the EuroDRG countries?

� Using DRG relative weight index

� Example of inguinal hernia repair

3. How do reimbursement rates for standardised

patients compare across the EuroDRG countries?

� Drawing on analysis of patient vignettes

� Example of appendectomy

1. How are patients categorised into DRGs?

Classification system

Source: Adapted from Schreyögg et al., 2006; Fischer, 2011


Classification system (contd)

� Number of groups

� 518 in Poland vs 2,297 in France vs approx 30,000 in

Netherlands

� Trend towards higher number of groups

Source: Kobel et al., 2011


Number of DRGs – Acute myocardial infarction

Derived from

common DRG

system


Classification system (contd)

� Number of groups

� 518 in Poland vs 2,297 in France vs approx 30,000 in

Netherlands

� Trend towards higher number of groups

� Number of severity levels

� Relative importance of diagnoses and procedures

� Common classification variables

� Age, diagnoses, procedures, discharge status, length

of stay

Source: Kobel et al., 2011

Acute Myocardial Infaction

4

31 May 2012 2012 Nordic Casemix

Conference | Oslo, Norway

24

16


4Complications/comorbidities:

Two severity levels in Estoniavs

Four severity levels in France



25

16


4Age

No age split in Estonia vs

Two age groups in France



26

16

Overview


groups (DRGs)?




of DRGs within EuroDRG countries?




patients compare across countries?



1.5

2

2.5

2. What is the relative resource intensity/

complexity of DRGs within EuroDRG countries?

Inguinal hernia repair

.5

1

0

Austri

aEng

land

Eston

iaFin

land

Franc

eG

erm

any

Irela

ndN

ethe

rland

sPol

and

Spain

Swed

en

1.5

2

2.5




Equivalent to inpatient

.5

1

0

Austri

aEng

land

Eston

iaFin

land

Franc

eG

erm

any

Irela

ndN

ethe

rland

sPol

and

Spain

Swed

en

Equivalent to inpatient

with diagnosis of unilateral

inguinal hernia,

undergoing open repair

1.5

2

2.5



Inguinal hernia repairAged > 17 years,

level 3 comorbidities/

complications,

length of stay ≥ 4 days

.5

1

0

Austri

aEng

land

Eston

iaFin

land

Franc

eG

erm

any

Irela

ndN

ethe

rland

sPol

and

Spain

Swed

en

Day case,

aged ≤ 17 years

1.5

2

2.5




Aged ≥ 18 years,

with comorbidities/

complications

.5

1

0

Austri

aEng

land

Eston

iaFin

land

Franc

eG

erm

any

Irela

ndN

ethe

rland

sPol

and

Spain

Swed

en

Aged < 18

years

Overview


groups (DRGs)?




of DRGs within EuroDRG countries?




patients compare across countries?




patients compare across countries? Appendectomy

€8,000

€10,000

€12,000

€14,000

Uncomplicated appendicitis + open

appendectomy

Complicated appendicitis + open

appendectomy

€0

€2,000

€4,000

€6,000

Complicated appendicitis w/

comorbidities + old age + open

appendectomy


comorbidities + long LOS + open

appendectomy

Unspecified appendicitis + laparoscopic

appendectomy

Source: Quentin et al., 2012

€8,000

€10,000

€12,000

€14,000


appendectomy


appendectomy



€0

€2,000

€4,000

€6,000



appendectomy



appendectomy


appendectomy


€8,000

€10,000

€12,000

€14,000


appendectomy


appendectomy



€0

€2,000

€4,000

€6,000



appendectomy



appendectomy


appendectomy

Note: LOS, length of stay.


Conclusion

� More differences than similarities across the

EuroDRG countries with regard to

1. Categorisation of patients to DRGs

� Common classification variables, but differences in their � Common classification variables, but differences in their

specification

2. Relative resource intensity/complexity of DRGs

� Cross-country divergence in range between least and most

resource intensive DRGs

3. Reimbursement rates for standardised patients

� Variation in marginal effects of patient characteristics on

rates

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