Case-mix Method Research Articles

A New Case-Mix Classification Method for Medical Insurance Payment

Rapidly rising medical expenses can be controlled by a well-designed medical insurance payment system with the ability to ensure the stability and development of medical insurance funds. At present, China is in the stage of exploring the reform of the medical insurance payment system. One of the significant tasks is to establish an appropriate reimbursement model for disease treatment expenses, so as to meet the needs of patients for medical services. In this paper, we propose a case-mixed decision tree method that considers the homogeneity within the same case subgroup as well as the heterogeneity between different case subgroups. The optimal case mix is determined by maximizing the inter-group difference and minimizing the intra-group difference. In order to handle the instability of the tree-based method with a small amount of data, we propose a multi-model ensemble decision tree method. This method first extracts and merges the inherent rules of the data by the stacking-based ensemble learning method, then generates a new sample set by aggregating the original data with the additional samples obtained by applying these rules, and finally trains the case-mix decision tree with the augmented dataset. The proposed method ensures the interpretability of the grouping rules and the stability of the grouping at the same time. The experimental results on real-world data demonstrate that our case-mix method can provide reasonable medical insurance payment standards and the appropriate medical insurance compensation payment for different patient groups.

PP265 Application Of A Case-Mix Method For Medical Consumables Management In Anhui Province, China Using Healthcare Big Data

IntroductionThe case-mix method involves combining cases with similar complexities and medical services. The process of treating one episode of the disease and receiving treatment is the research unit, thus achieving different medical units. The feasibility of the calculation method is verified by calculating the public hospital consumption ratio, medical income, health materials expenditure indicators, and the differences between the various types of surgical combinations. A decision-making basis can then be provided for the creation of government indicator standards.MethodsMedical records and data on the expenditure of medical consumables for the first and fourth quarters of 2017 were collected from seven third-class provincial hospitals. The medical consumption ratio for different diseases and surgical methods was calculated for the case-mix groups using a weighting method. Data were analyzed by descriptive statistics and the independent samples t-test.ResultsThere were significant differences in the proportions of combined use for different types of diseases. The same combination also had significant differences between different hospitals. In the fourth quarter of 2017, the operating group's consumption ratio was significantly lower than in the first quarter (p = 0.000).ConclusionsIt is reasonable to calculate the proportion of consumption by combined weighted analysis, which is also fairer for hospitals with better technical levels. This calculation method can be used by governments to manage the use and cost of medical consumables in hospitals.

Direct Health Care Costs Associated with Asthma in British Columbia

A better understanding of health care costs associated with asthma would enable the estimation of the economic burden of this increasingly common disease. To determine the direct medical costs of asthma-related health care in British Columbia (BC). Administrative health care data from the BC Linked Health Database and PharmaNet database from 1996 to 2000 were analyzed for BC residents five to 55 years of age, including the billing information for physician visits, drug dispensations and hospital discharge records. A unit cost was assigned to physician/emergency department visits, and government reimbursement fees for prescribed medications were applied. The case mix method was used to calculate hospitalization costs. All costs were reported in inflation-adjusted 2006 Canadian dollars. Asthma resulted in $41,858,610 in annual health care-related costs during the study period ($331 per patient-year). The major cost component was medications, which accounted for 63.9% of total costs, followed by physician visits (18.3%) and hospitalization (17.8%). When broader definitions of asthma-related hospitalizations and physician visits were used, total costs increased to $56,114,574 annually ($444 per patient-year). There was a statistically significant decrease in the annual per patient cost of hospitalizations (P<0.01) over the study period. Asthma was poorly controlled in 63.5% of patients, with this group being responsible for 94% of asthma-related resource use. The economic burden of asthma is significant in BC, with the majority of the cost attributed to poor asthma control. Policy makers should investigate the reason for lack of proper asthma control and adjust their policies accordingly to improve asthma management.

George Rupert Palmer--DRG carrier and champion.

Prompted by the retirement of the distinguished health economist, researcher and academic, Professor George Rupert Palmer, the purpose of this paper is to reflect upon and acknowledge one of his many contributions to health services research and development. By employing a conceptual framework devised by Kimberly and de Pouvourville (1993) for analysis of the diffusion of innovations, this paper argues that Palmer played a crucial role in the diffusion into and within Australia of a particular casemix method, diagnosis related groups (DRGs). Textual and interview evidence presented in the paper supports the identification of George Rupert Palmer as the principal carrier of DRGs into Australia, and as one of its key champions within Australia.

Starting Insulin Therapy in Patients With Type 2 Diabetes

Although experimental studies show that insulin therapy can be safe and efficacious in improving glycemic control in type 2 diabetes under optimal conditions (ie, using patient volunteers with close monitoring under strict study protocols), little is known about its effectiveness, complication rates, and associated resource utilization in actual clinical practice. Cohort study. Large staff-model health maintenance organization. A total of 8668 patients with type 2 diabetes cared for by generalist physicians from 1990 through 1993. Resource use (hospitalizations, outpatient visits, laboratory testing, and home glucose monitoring) and glycemic control were evaluated using combined clinical, survey, and administrative information systems data. Detailed clinical case-mix data, including a newly validated case-mix method, the Total Illness Burden Index, were collected on a subsample of 1738 patients. Among patients starting insulin therapy, hemoglobin A1c (HbA1c) decreased by 0.9 percentage point (95% confidence interval, 0.7-1.0) at 1 year compared with those receiving stable medication regimens; however, 2 years after starting insulin therapy, 60% still had HbA1c levels of 8% or greater. There was no evidence that some primary care physicians achieved better results than other primary care physicians when starting insulin therapy in their patients. Patients with the poorest baseline glycemic control achieved substantially greater HbA1c reductions; those with a baseline HbA1c level of 13% had a 3-fold greater decline in HbA1c than those whose baseline HbA1c level was 9%. For a subset of all patients for whom detailed clinical case-mix data were obtained, those taking insulin had higher resource use than those taking sulfonylureas, independent of illness severity. After adjusting for age, sex, race, socioeconomic status, disease duration, and severity of diabetes and comorbidities, insulin users had slightly more laboratory tests performed, 2.4 more outpatient visits per year, and almost 300 more fingersticks for home glucose testing per year compared with sulfonylurea users (all P<.01). Although 15% of patients receiving insulin therapy reported weekly symptoms of hypoglycemia, insulin therapy was not associated with an increase in emergency department visits (after case-mix adjustment) and resulted in only 0.5 hypoglycemia-related hospitalizations per 100 patient-years. For patients with type 2 diabetes who were cared for by generalist physicians, starting insulin therapy was generally safe and effective in achieving moderate glycemic control in patients who initially had poor glycemic control. However, insulin therapy was associated with increases in resource use and was rarely effective in achieving tight glycemic control, even for those with moderate control.

Adjusting planning guidelines for cardiac-care units

The principal concern of this paper is the development of procedures for adjusting the criteria currently being used for federally-legislated health planning activities. These procedures would enable the planner to account for the demographic, geographic and health-system conditions which cause variations in the need for health-care services in local communities. A case-mix method, hospital chart-abstract data and demographic, geographic and health-system data from New Jersey were used to: create a list of diagnoses eligible for treatment in a Cardiac-Care Unit (CCU); select a sample of hospitals for study, and conduct a step-wise regression analysis of CCU utilization in these hospitals. It was concluded that CCU utilization was affected by factors such as the in-hospital availability of CCU beds, the type of hospital, CCU-patients' clinical severity, and the availability of ambulances and mobile intensive care units. Procedures for adjusting planning criteria to account for local conditions have yet to be developed. However, a method for using the types of results presented in this paper to develop such adjustment procedures was presented and illustrated. It is recommended that this method be used to create such adjustment procedures for the planning criteria for all hospital services and hence to assist Health Systems Agencies in rationalizing the distribution of our hospital care.

A case-mix method for developing health planning criteria for hospital services.

The principal concern of this article is the inadequacy of the planning criteria currently being used by existing federally funded health planning agencies. A case-mix method was created for developing appropriate criteria. Chart-abstract data from New Jersey were used to create a list of those diagnoses eligible for treatment in the cardiac care unit (CCU), select a sample of hospitals for study and analyze the relationship between CCU bed need and CCU clinical practice. It was shown that existing bed-need criteria for CCU planning represent current CCU clinical practice patterns, which are probably not cost effective. The method was also used to develop empirical values of these criteria, which do represent cost-effective practice. It is recommended that the method be used to strengthen and update continuously all hospital-service need criteria used in current planning activities, including Plan Development and Certificate of Need Review.