Casemix Funding Research Articles

Prospective study of costs and outcome in a major adult Australian intensive care unit utilising the APACHE III severity scoring and prediction tool

Objective: To examine the unit and hospital outcome, appropriateness and costs of adult patients admitted to an intensive care unit (ICU). Design: Twelve-month prospective descriptive study using the APACHE III severity of illness and prognostic system. Setting: Twelve-bed general ICU in a 950-bed Australian teaching hospital. Subjects: A total of 1,137 consecutive adults admitted to the ICU during 1995. Main outcome measures: APACHE III prediction of death on day one, severity of illness, ICU standardised mortality ratio (SMR), hospital SMR, standardised ICU length of stay (SLOS), APACHE III activity level on day one, ICU cost per admission and case-mix funding versus costs. Results: Sixty-nine per cent of the patients were admitted as emergencies. ICU mortality was nine per cent (SMR 0.9), hospital mortality was 16.2% (SMR 1.2) and ICU LOS was 3.9 days (SLOS 0.8 p<0.01). Patients in the predicted day one mortality range of 61-80% had an ICU SMR of 0.7 with a SLOS of 0.64. The day one APACHE III activ...

Alcohol, casemix and hospitals: an opportunity?

The number of patients in hospitals who experience alcohol-related problems is high, and the provision of intervention for these patients is a significant public health measure. The current move towards casemix funding of acute hospital services provides an opportunity for the development of such programmes. Modifications to the Diagnosis Related Groups categorization of alcohol-related problems that would allow for appropriate funding are discussed.

Casemix funding of hospitals: objectives and objections.

Reform of the funding of hospitals and other health services has been one of the most important health policy initiatives undertaken by governments in recent years. A number of countries have adopted the casemix approach to payment, or are currently exploring the feasibility of its introduction. Under casemix arrangements hospitals are funded on the basis of the numbers and types of patients they treat. This paper analyses, and finds inadequate, various objections to casemix funding, including those which appeal to considerations of ethics and equity.

Casemix Funding of Hospitals: Ethical Objections

Casemix Funding of Hospitals: Ethical Objections

Casemix Funding of Hospitals: Objectives and Objections

Casemix Funding of Hospitals: Objectives and Objections

The Discharge Brokerage Program

In response to government policies on case mix funding and Diagnosis Related Groups (DRGs), Caulfield Community Care Centre, in consultation with the Inner South Community Health Service in Victoria, made a submission for government funding to run an early discharge program. It was called a Discharge Brokerage Program rather than an early discharge program, because of not wanting patients to be anxious about leaving hospital early.

Casemix funding in psychiatry: some problems and common pitfalls.

The aims of this study were to evaluate the accuracy of AN-DRG version 2.0 codings. Ninety-two separations, covering three of the most commonly occurring AN-DRG in psychiatry, were reviewed by a psychiatrist. The AN-DRG diagnosis was then compared to that given by morbidity coders. There was agreement for 69 (79 per cent) separations and disagreement for 18 (21 per cent) separations. Recoding of the 18 separations altered average length of stay data and the funding received. The high error rate of coding stimulated changes to the training of morbidity coders and registrars.

Hospital payment arrangements to encourage efficiency: the case of Victoria, Australia

The casemix funding arrangements introduced in Victoria on 1 July 1993 represent a significant departure from the previous approaches to public hospital funding in Australia. They are designed to change the economic incentives on hospitals by linking payment to the number and case complexity of patients treated. The new funding arrangements include a combination of fixed and variable payments to hospitals for inpatient services. Outpatient services remain funded on a historical basis. Special payments are made for teaching and research functions. Total payments to hospitals are capped through operation of an ‘Additional Throughput Pool’ which allows price to fluctuate inversely with volume to ensure an expenditure limit. Because of operations of specific conditions on the Additional Throughput Pool, hospitals were given an incentive to reduce waiting lists. Despite the success in reducing waiting lists and budgets, there are a number of problems with the casemix approach including both technical issues (how are payment rates to be updated?; the failure to address problems of capital) and ethical issues. These are discussed in the paper.

Health care in the 1990s: Practice Implications For Social Work

Abstract The Australian health care system is experiencing major changes as it struggles to adapt to demographic shifts, technological advances and changing treatment philosophies against a background of fiscal restraints. Current health policies and the planned introduction of casemix funding are supporting the development of a market-driven health care system which is challenging social work in health care to redefine its services. This paper reviews the changes affecting health care and the need for social work to respond in a more creative and competitive way to ensure that the psychological impact of illness on patients and families continues to be recognised and treated.

Designing a funding system for rehabilitation services Part 2 achieving efficiency and quality of care

This paper examines the objectives of a funding policy for rehabilitation services. A casemix funding system comprises two sets of instruments: a classification system and a payment system. Attention is given to identifying which policy objectives are best pursued through each of these instruments. The paper then analyses the effect of various instruments on creating incentives for efficiency and quality, and assesses policy options with regard to their capacity for dealing with the heterogeneity of rehabilitation patients and controlling various forms of gaming. In conclusion, the paper canvasses four major areas warranting consideration in advancing policy: the use of a blended payment system; dealing with functional gain; the development of an information base; and the focus on designated rehabilitation units.

Quality of care under casemix.

The introduction of casemix funding in some States has led to concerns that hospitals, faced with budgetary problems, may be tempted to discharge patients prematurely after inadequate treatment--the "quicker and sicker syndrome". There are no significant Australian data on quality of care before and after casemix funding, but a large study in the United States found that, in general, there was no evidence of a deterioration in care. Contrary to expectation, readmission rates were unaltered. There was, however, some evidence of an increase in discharge of patients in an unstable state and more were transferred to nursing homes. There are significant reasons why these conclusions can not be readily transported to the Australian environment, and there is a need to monitor the discharge status of patients, particularly the frail elderly, with casemix funding in Australia.

The NSW health outcomes initiative and economic analysis

The New South Wales Health Department's initiative on health outcomes promises some important advances in the planning and priority setting of health services. However, the potential to promote better health care will not be realised unless resources are redeployed to the programs where health outcomes (and other benefits) can be purchased most cheaply. The initiative reflects firmly the economic concept of efficiency but leaves less certainty about how concerns for equity are to be handled. This paper proposes that program budgeting and marginal analysis be used to create a framework for redeploying resources to follow the good buys--in terms of health and other outcomes. Additionally, the paper argues for creating the right incentives to promote efficiency, and expressly argues against the use of diagnostic related groups or casemix funding, as such funding is concerned, by definition, with cases and not with health per se. The goal of the initiative of trying to maximise health outcomes implies that there are no other valued gains to be had from health care. This is challenged. In reaching decisions about how best to deploy resources, more account should be taken, in a structured way, of community values.

Case-mix funding and legislated psychiatric care

The importance of adequately providing acute care hospital services for psychiatric patients can be argued on both humanitarian and cost-effective grounds. In the recent past, however, the humanitarian argument has proved insufficient to insure that the mentally ill receive adequate care. For example, although the humanitarian intentions of those who originally heralded deinstitutionalization are not contested, more recent evidence describing the grim plight of the mentally ill in communities seems to have had little impact on service improvements and, in most communities, services for the mentally ill remain underfunded. According to Gralnick, “deinstitutionalization results in relative neglect of the acutely ill and the consequent amassing of the chronically ill” (Gralnick, 1985). Considering a cost-effective argument, the burden of mental illness on the population is known to be large, making mental illness a major public health problem. In established market economies, for example, 19% of all disabilityadjusted life years are lost to neuropsychiatric disease and intentional injuries. Mental disorders are tied with cancers as the leading causes of disabilityadjusted years of life lost. Worldwide, 10.5% of all disability-adjusted years of life lost are attributable to serious mental disorders and intentional injuries, more than any other health problem (The World Bank, 1993). Community epidemiological surveys conducted in the United States and Canada reveal that approximately 22% of the adult population are affected by a mental disorder during any given year (National Advisory Mental Health Council, 1993; Bland, Newman, and Orn, 1988), and that between 2% and 3% of the adult popula-

Casemix payment in the real world of running a hospital.

The Victorian casemix funding initiative has achieved initial success in implementing massive budget cuts while increasing hospital throughput and reducing waiting lists. For hospitals to survive, the relationship between casemix and resource use must be managed and this can only be achieved by the involvement of clinicians. With effective information systems and accommodating clinicians, games to maximise casemix, and hence revenue, will undoubtedly emerge. Side effects may include reduced access to "unprofitable" services, increasing pressure on "unprofitable" clinicians and the wooing of "profitable" ones, increasing difficulty in delivering continuity of care and the politicisation of the diagnosis-related groups pricing system. In the end, State governments will be left with a complex control system without resolving the fundamental dilemma inherent in being both the provider of hospital care and the payer.

Small Rural Hospitals and Casemix Funding: Victoria, 1993‐94

Small Rural Hospitals and Casemix Funding: Victoria, 1993‐94

Ambulatory Case Mix Funding Systems in Canada

The implementation of inpatient case mix funding in Alberta and Ontario does not allow for adequate incentives to shift resources to an outpatient basis, where appropriate, or to provide outpatient care efficiently. This paper explores the prospects and problems of further extending case mix tools into this area. The availability of tools to characterize output for day surgery, special clinics and emergency care is surveyed. We conclude that case mix funding is desirable and feasible for ambulatory surgery; however, it is questionable for emergency care and special clinics. However, developments in this area in the United States will continue, and this will likely maintain an interest in Canada.

Patient Classification Systems and Casemix Funding: Implications for Rural Nursing Practice

ABSTRACT: The focus of this article is the demand for nurses to demonstrate that they have specific skills which produce tangible outcomes and which can be shown to provide ‘good’ value for money services. This article provides an overview of a recent study commissioned by the Department of Health and Community Services in the introduction of the ‘Omaha’ system devised by Martin and Scheet for community nursing in the USA, to the District Nursing Services of south western Victoria.

Victorian public hospitals: taking a sledgehammer … ?

Until relatively recently, there have been few attempts to introduce strong forms of competition into publicly funded hospital systems, whether in Australia or elsewhere. The Victorian government has done so by implementing a casemix funding formula from July 1993 and in the process has foreshadowed that the least efficient hospitals will close. While it is of vital importance to improve the efficiency of Australian hospitals, and a key factor is to use casemix funding to achieve microeconomic reform, it is not appropriate to use competition to close hospitals. Arguments against using marketplace forces to determine the fate of hospitals include: the difficulties that could ensue with an inappropriate distribution of hospitals in Victoria; the necessity to provide hospital services for the public good; whether reducing the public sector is actually economically beneficial; and the conclusion reached by many in the United States, that health care should not be treated as a commodity. I argue for the development of a more sophisticated policy than one which uses the principles of laissezfaire and relative efficiency to close public hospitals.

Pick a method, any method--quality activities and casemix funding.

Pick a method, any method--quality activities and casemix funding.

Computerisation of emergency department clinical attendance records

ABSTRACTA relatively simple computerised emergency department (ED) attendance record was installed at the Western Hospital with no increase in staffing. The system allows for the entry of patient information and file creation, triage classification, diagnosis and disposition details. A McDonnell Douglas ED module (1988 version), upgraded at Western Hospital, was installed one year prior to the study period. Such systems have the potential to allow data from the 4,000,000 ED annual attendances in Australia to be analysed productively. The recent interest in workload indices and casemix funding formulae has added impetus to the need to computerise ED attendance records.Data entry was performed by clerical staff at the time of registration and following discharge. Diagnostic coding was performed by hospital medical officers. The introduction of the computerised attendance records was associated with no increase in staffing and was accepted by the staff with minimum difficulty.