Diagnosis-related Groups System Research Articles

The Use of Diagnosis-Related Group-Based Reimbursement in the Czech Hospital Care System.

(1) Background: Diagnosis-Related Groups (DRG), one possibility of a hospital payment system, are currently used in most European countries. Introduced to the Czech system in the 1990s, the DRGs are currently used mainly for care reporting and partly for reimbursement. According to most experts, the use of DRG remain controversial. The goal of this paper was to study the effects of the current Czech DRG system on hospitals financing and, on this basis, to propose possible changes to the reimbursement mechanism in the Czech Republic. (2) Methods: Qualitative research methods were used for evaluating DRG mechanisms of application in three selected healthcare establishments in the CR in the period of 2012–2018. (3) Results: Our study shows that the current implementation of the DRG system is set up in a way that is very similar to traditional flat rates and is unlikely to yield major positive effects of the DRG mechanism, such as predictability of payments for hospitalisation cases, care quality and efficiency and transparent financing. (4) Conclusions: Based on our results, deep systemic change of the reimbursement mechanism in the Czech Republic is necessary. We propose five partial measures leading to the cultivation of the Czech DRG.

Depiction of cardiovascular surgery in the current modified German DRG system 2021

EinleitungDas Jahr 2020 wird immer im Schatten der durch die „coronavirus disease 2019“ (COVID-19) ausgelösten Pandemie stehen. Die ersten 3 Quartale 2020 waren geprägt von einem beispiellosen Herunterfahren der elektiven stationären Leistungserbringung und einem Freihalten von Intensivkapazitäten für die Behandlung von COVID-19-Patienten. Auch für die Herzchirurgie resultierten dadurch deutliche Auswirkungen auf die Leistungserbringung. Die Akteure in den Kliniken waren im Jahresverlauf zusätzlich mit einer Fülle von Änderungen der gesetzlichen Rahmenbedingungen konfrontiert. Dennoch wurde das aG-DRG-System 2021 durch das Institut für das Entgeltsystem im Krankenhaus (InEK) kalkuliert. Dieser Beitrag beschreibt und bewertet die wesentlichen Veränderungen des aG-DRG-Systems 2021 für die Herz-Thorax- und Gefäßchirurgie.MethodikAnalyse der relevanten Diagnosen, Prozeduren und G‑DRG-Strukturen in den Systemversionen 2020 und 2021 anhand der durch InEK und das Bundesinsitut für Arzneimittel und Medizinprodukte (BfArM) publizierten Informationen.ErgebnisseErweiterungen der relevanten Klassifikationssysteme für Diagnosen (ICD-10-GM 2021) und Prozeduren (OPS 2021) führen zu einer Zunahme spezifischerer Kodierungen von wesentlichen Interventionen und Operationen der Herz- und Gefäßchirurgie. Im Rahmen der Anpassung der G‑DRG-Strukturen sind besonders die Kondensation der bisherigen Fallpauschalen für die Herztransplantation zur aG-DRG A05Z und Abwertungen koronarer Bypassoperationen und rekonstruktiver Gefäßeingriffe zu nennen.SchlussfolgerungFür die Herz- und Gefäßchirurgie finden sich vielfältige Veränderungen mit z. T. erheblichen Auswirkungen auf die Fallerlöse. Hinzu kommt, dass die Auswirkungen der „Coronapandemie“ für viele deutsche Kliniken noch nicht abschließend absehbar sind. Ein weiterer, immer dringlicherer insbesondere die Gefäßmedizin betreffende Einflussfaktor ist der zunehmende Druck zur Ambulantisierung von Leistungen. Hier wird der im Jahre 2022 erwartete und voraussichtlich deutlich erweiterte Katalog für Ambulantes Operieren im Krankenhaus (AOP-Katalog) den Zwang zur ambulanten Erbringung bisher noch stationär erbrachter Leistungen sicher noch einmal deutlich erhöhen.

Diagnosis-Related Group (DRG)-Based Prospective Hospital Payment System can be well adopted for Acute Care Surgery: Taiwanese Experience with Acute Cholecystitis.

Laparoscopic cholecystectomy (LC) is a common procedure for cholelithiasis paid by diagnostic-related groups (DRGs) systems. However, acute cholecystitis (AC) patients usually have heterogeneous conditions that compromise the successful implementation of DRGs. We evaluated the quality/efficiency of treating AC patients under the DRG system in Taiwan. All AC patients who underwent LC between October 2015 and December 2016 were included. Patient demographics, treatment outcomes, and financial results were analyzed. Patients were reimbursed by one of the two DRG schemes based on their comorbidities/complications (CC): DRG-1, LC without CC; and DRG-2, LC with CC. Hospitals were reimbursed the costs incurred if they were below the lower threshold (balanced sector); with the outlier threshold if costs were between the lower and outlier thresholds (profitable sector); and with the outlier threshold plus 80% of the exceeding cost if costs were higher than the outlier threshold (profit-losing sector). Among 246 patients, 114 were paid by DRG-1, and 132 were by DRG-2. In total, 195 of 246 patients underwent LC within 1 day after admission, and patients with mild AC had shorter hospital stays than those with moderate or severe AC. The complication rate was 7.3% with only one mortality. In total, 92.1% of patients in DRG-1 and 90.9% of patients in DRG-2 were profitable. The average margin per patient was 11,032 TWD for DRG-1 and 24,993 TWD for DRG-2. DRGs can be well adopted for acute care surgery, and hospitals can still provide satisfactory services without losing profit.

How do hospitals respond to cross price incentives inherent in diagnosis-related groups systems? The importance of substitution in the market for sepsis conditions.

This study addresses the question of how hospitals respond to the cross price incentives inherent in reimbursements based on diagnosis-related groups (DRG). Unique market-wide administrative data allow to exploit a natural experiment in Germany in which the relative attractiveness of greatly divergent reimbursements for clinically similar patients changes in the market for sepsis conditions on January 1, 2010. This natural experiment provides-unintentionally-extra reimbursements in cases in which hospitals reorganize transfers for deceasing patients to other facilities, alter the time of death, the choice of the condition being chiefly responsible for the hospital admission (primary diagnosis), or the intensity of mechanical ventilation. The differences-in-differences results demonstrate that hospitals primarily alter the primary diagnosis. As the choice of the primary diagnosis is the backbone of the design of modern DRG systems, the findings suggest that payment contracts between hospitals and payers based on modern DRG algorithms may not necessarily improve patient welfare.

Estimated length of stay calculated by “diagnosis-related groups” in patients with prostate cancer: a retrospective analysis

INTRODUCTION: To evaluate whether the presence of bone metastasis in hospitalized patients with prostate cancer (PCa) is associated with a longer length of stay (LOS) when compared to LOS estimated by diagnosis-related groups (DRG). METHODS: We performed a retrospective analysis of 86 admissions of patients with PCa at our facility in 2018-2019. Admissions were divided into two groups based on actual LOS and LOS estimated by DRG: group 1 (actual LOS≥DRG-LOS) and group 2 (actual LOS<DRG-LOS). The association of bone metastasis and other variables with increased LOS was evaluated by logistic regression with univariable and multivariable analysis, controlling baseline patient characteristics. RESULTS: Longer LOS was not associated with baseline characteristics (age, body mass index, and presence of comorbidities), but was significantly associated with type of admission and ICU (intensive care unit) admission during hospitalization (p<0.05). Bone metastasis was observed in 28 (68.3%) of group 2 admissions and was independently associated with increased LOS (group 2) on univariable and multivariable analysis (OR=4.76, 95% CI=1.91-11.8, p=0.001; OR=3.48, 95% CI=1.08-11.2, p=0.03, respectively). CONCLUSION: Among clinical or surgical admissions of patients with PCa over a 1-year period, presence of bone metastasis was independently associated with increased LOS when compared to LOS estimated by DRG. The presence of bone metastasis may be used to identify possible outliers not recognized by the DRG system.

Performance Pay in Hospitals: An Experiment on Bonus-Malus Incentives.

Recent policy reforms in Germany require the introduction of a performance pay component with bonus–malus incentives in the inpatient care sector. We conduct a controlled online experiment with real hospital physicians from public hospitals and medical students in Germany, in which we investigate the effects of introducing a performance pay component with bonus–malus incentives to a simplified version of the German Diagnosis Related Groups (DRG) system using a sequential design with stylized routine cases. In both parts, participants choose between the patient optimal and profit maximizing treatment option for the same eight stylized routine cases. We find that the introduction of bonus–malus incentives only statistically significantly increases hospital physicians’ proportion of patient optimal choices for cases with high monetary baseline DRG incentives to choose the profit maximizing option. Medical students behave qualitatively similar. However, they are statistically significantly less patient oriented than real hospital physicians, and statistically significantly increase their patient optimal decisions with the introduction of bonus–malus incentives in all stylized routine cases. Overall, our results indicate that whether the introduction of a performance pay component with bonus–malus incentives to the (German) DRG system has a positive effect on the quality of care or not particularly depends on the monetary incentives implemented in the DRG system as well as the type of participants and their initial level of patient orientation.

Effects of a DRG-based hospital reimbursement on the health care utilization and costs in Swiss primary care: A retrospective "quasi-experimental" analysis.

IntroductionIn Switzerland, a nationwide Swiss Diagnosis related Groups (Swiss DRG) system for hospital reimbursement was introduced in 2012. However, the impact of DRG systems on primary care is still unclear with respect to number of consultations and costs. The aim of this study was to investigate the effect of the implementation of DRG on costs and volumes in the primary care sector, on a nationwide basis in Switzerland.MethodsThe study retrospectively analysed yearly data, from 2008 to 2014, of almost 60 Swiss health insurers that covered almost all Swiss general practitioners, with a total number of patients which represented approximately 76% of the Swiss population. GP consultations, total numbers and rates, and the relative costs reimbursed (TARMED tariff values) in the Swiss federal states, cantons, which already introduced a DRG-like system before 2012 (AP-DRG), were compared to the GP consultations and costs reimbursed in the other cantons (DRG-naive). Regression discontinuity design analysis and mixed regression models, at cantonal level, were performed to evaluate the effect of the nationwide implementation of the Swiss DRG on health care demand and costs in the primary care setting. Change in outcome level and yearly trend pattern difference between groups (AP-DRG vs. DRG-naive) were examined.ResultsOverall, the total number of GP consultations and the relative TARMED values increased from 2008 to 2014. In the DRG naive, 15 cantons: in 2008, the number of GP consultations were 13,114,126, with a TARMED value of 1,194,957,157 CHF, and in 2014, the GP consultation were 13,752,511, with a TARMED value of 1,513,861,260 CHF. In the AP-DRG group, 11 cantons, the total number of GP consultations increased from 8,787,646, in 2008, to 9,347,168 in 2014 and the TARMED value increased from 896,673,657 CHF in 2008, to 1,100,203,508 CHF in 2014. The yearly trend pattern of GP consultations and TARMED values, in the AP-DRG group, were not significantly different from the respective trends in the DRG- naive and, overall, no significant change was detected in consultations and costs trends before and after 2012.Discussion/ConclusionThis study found no evidence of any effect of the introduction of the SwissDRG on the yearly trend of primary care consultations and costs. Nevertheless, potential negative impacts on vulnerable patients, as chronically ill patients, could not be excluded and further investigation is required.

Stapled intestinal anastomoses are more cost effective than hand-sewn anastomoses in a diagnosis related group system

PurposeCreation of an optimal bowel anastomosis with low postoperative leakage rate is an immanent part of colorectal surgery contributing to recovery, length of hospital stay and overall hospital costs. We aimed to investigate costs of small and large bowel resection, length of hospital stay, anastomotic leakage rate and its risk factors depending on the anastomotic technique. MethodsRetrospective analysis of 198 patients (67 stapled and 131 hand-sewn anastomoses) undergoing elective bowel resection with a single anastomosis without protective ileostomy either stapled or in double-rowed running suture technique between 1st October 2012 and 30th September 2018 at Charité University Hospital Berlin, Campus Benjamin Franklin. We analyzed costs of treatment, total length of hospital stay, rate of anastomotic leakage and possible risk factors for anastomotic leak. ResultsNo significant difference between both anastomotic techniques could be detected for hospital stay (p = 0.754), 30-day-readmission rate (p = 0.827), or anastomotic leakage (p = 606). Neither comorbidities (p = 0.449), underlying disease (p = 0.132), experience of the surgical team (p = 0.828) nor scheduling of the operation (p = 0.531) were associated with anastomotic leakage. Stapled anastomoses took 22 min less operation time than sutured anastomoses (130 vs. 152 min. Median) (p = 0.001). Operations with stapled anastomoses saved 183 € in operation costs and 496 € in overall hospital costs. ConclusionStapled and hand-sewn bowel anastomoses can be performed equally safe without differences in postoperative outcome. No patient, procedure or surgeon related risk factors for anastomotic leakage could be detected. Bowel resections with stapled anastomoses take less time and save operation and overall hospital costs.

Principal-agent theory-based cost and reimbursement structures of isavuconazole treatment in German hospitals.

Isavuconazole (ISA) is a frequently used antifungal agent for the treatment of invasive fungal diseases (IFDs). However, hospital reimbursement data for ISA is limited. The primary objective of this study was to analyse the different perspectives of relevant stakeholders and the (dis)incentives for the administration of ISA in Germany. To that aim, the health economic effects of using ISA from a hospital management perspective were analysed. Based on principal-agent theory (PAT), the perspectives of (a) the patient (principal) as well as (b) physicians, (c) pharmacists and iv. hospital managers (all agents) were analysed. For the evaluation of the cost-containment and reimbursement strategies of ISA, the German diagnosis-related group (G-DRG) system was used. Hospitals individually negotiating additional payments for innovative treatment procedures (zusatzentgelte [ZE]) within the G-DRG system is a key element of hospital management for the reduction of total healthcare expenditure. Our analysis demonstrated the beneficial role of ISA in healthcare resource utilisation, primarily due to a shortened overall length of hospital stay. Depending on underlying disease, coded G-DRG and ISA formulation, large differences in total reimbursement and the amount of ZE was shown. The PAT demonstrated disincentives for hospital managers to use innovative drugs. Based on the PAT, beneficial, detrimental and indifferent perspectives of different stakeholders regarding the usage of ISA were shown. A reduction of bureaucratic hurdles is needed in Germany for the extension of effective and innovative antifungal treatment strategies with ISA.

Fast-track extubation after cardiac surgery in infants: Tug-of-war between performance and reimbursement?

ObjectivesTo compare the safety and resource-efficacy of the fast-track (FT) concept (extubation ≤8 hours after surgery) versus the conventional approach (non-FT, >8 hours postoperatively) in infants undergoing open-heart surgery. MethodsInfants <7 kg operated on cardiopulmonary bypass between 2014 and 2018 were analyzed. Propensity score matching (1:1) was performed for group comparison (FT vs non-FT). Intensive care unit (ICU) personnel use and unit performance were evaluated. Postoperative outcome and reimbursement based on German diagnosis-related groups were compared. ResultsOf 717 infants (median age: 4 months, Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery mortality score: 0.1-4), FT extubation was achieved in 182 infants (25%). After matching, 123 pairs (FT vs non-FT) were formed without significant differences in baseline characteristics. FT versus non-FT showed a significantly shorter ICU stay (in days): 1.8 (0.9-2.8) versus 4.2 (1.9-6.4), P < .01, and postoperative length of stay (in days): 7 (6-10) versus 10 (7-15.5), P < .01; significantly lower postoperative transfusion rates: 61.3% versus 77%, P < .01; and tendency toward lower early mortality: 0% versus 2.8%, P = .08. Reintubation rate did not differ between the groups (P = .7). Despite a decrease in personnel capacity (2014 vs 2018), the unit performance was maintained. The mean case-mix-index of FT versus non-FT was 8.56 ± 6.08 versus 11.77 ± 12.10 (P < .01), resulting in 27% less reimbursement in the FT group. ConclusionsFT concept can be performed safely and resource-effectively in infants undergoing open-heart surgery. Since German diagnosis-related group systems reimburse costs, not performance, there is little incentive to avoid prolonged mechanical ventilation. Greater ICU turnover rates and excellent postoperative outcomes are not rewarded adequately.

Surgical Site Infections and their economic significance in hepatopancreatobiliary surgery: A retrospective incidence, cost, and reimbursement analysis in a German centre of the highest level of care.

Surgical site infections (SSI) in open Hepatopancreatobiliary (HPB) surgery are common complications. They worsen patients’ outcomes and prolong hospital stays. Their economic significance in the German diagnosis related groups (DRG) system is mostly unknown. To investigate their economic importance, we evaluated all cases for SSIs as well as clinical and financial parameters undergoing surgery in our centre from 2015 and 2016. Subsequently, we carried out a cost‐revenue calculation by assessing our billing data and the cost matrix of the InEK (German Institute for the Payment System in Hospitals). A total of 13.5% of the patients developed a superficial, 9% a deep incisional, and 2.4% of the patients an organ space SSI. Compared with Patients without SSI, Patients with SSI had more comorbidities, were older, and their average length of stay was extended by 19 days (P < .001). The financial loss per SSI‐case was €‐7035.65 despite increased reimbursement, which resulted in a calculated total loss for the hospital of €‐802 064.62 in 2015 and 2016. Surgical site infections are common complications of open HPB surgery, which lead to a significant increase in the cost per case. Further prevention strategies need to be developed. Besides, an adjustment of revenues must be demanded.

Patient Risk Profile for Unplanned 90-Day Emergency Department Visits Differs Between Total Hip and Total Knee Arthroplasty.

Numerous studies have explored 90-day readmissions following total joint arthroplasty; however, there is a paucity of literature concerning 90-day emergency department (ED) visits. The authors aimed to characterize the risk factors for ED presentations and to determine the primary reasons for return, hypothesizing that certain medical comorbidities would account for resource utilization. The institutional database was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were stratified based on return visits to the ED within 90 days postoperatively. Univariable and multivariable analyses were performed to determine the factors most predictive of ED return for each THA and TKA. A total of 10,479 procedures resulted in 1234 90-day ED visits made by 937 patients. Significant predictors of 90-day ED return after THA included black race, age older than 80 years, congestive heart failure, valvular heart disease, metastatic disease, peripheral vascular disease, alcoholism, drug use, depression, and discharge to a skilled nursing facility. In contrast, only black race, liver insufficiency, cancer, and pulmonary hypertension were predictive of ED return following TKA. The primary risk factors for ED return differ for THA and TKA, and this is not currently reflected in the medical severity diagnosis-related group system. Specifically, black patients with multiple comorbidities are at high risk for unplanned ED visits following THA. This should be considered in patient counseling and outreach programs when attempting to mitigate the postoperative risks and to decrease 90-day resource utilization in this patient population. [Orthopedics. 2020;43(5):295-302.].

Influence of a spontaneous bacterial peritonitis, nosocomial infections and acute-on-chronic liver failure on treatment revenues in patients with decompensated cirrhosis in Germany

The economic effects of spontaneous bacterial peritonitis (SBP), nosocomial infections (nosInf) and acute-on-chronic liver failure (ACLF) have so far been poorly studied. We analyzed the impact of these complications on treatment revenues in hospitalized patients with decompensated cirrhosis. 371 consecutive patients with decompensated liver cirrhosis, who received a paracentesis between 2012 and 2016, were included retrospectively. DRG (diagnosis-related group), "ZE/NUB" (additional charges/new examination/treatment methods), medication costs, length of hospital stay as well as different kinds of specific treatments (e. g., dialysis) were considered. Exclusion criteria included any kind of malignancy, a history of organ transplantation and/or missing accounting data. Total treatment costs (DRG + ZE/NUB) were higher in those with nosInf (€ 10,653 vs. € 5,611, p < 0.0001) driven by a longer hospital stay (23 d vs. 12 d, p < 0.0001). Of note, revenues per day were not different (€ 473 vs. € 488, p = 0.98) despite a far more complicated treatment with a more frequent need for dialysis (p < 0.0001) and high-complex care (p = 0.0002). Similarly, SBP was associated with higher total revenues (€ 10,307 vs. € 6,659, p < 0.0001). However, the far higher effort for the care of SBP patients resulted in lower daily revenues compared to patients without SBP (€ 443 vs. € 499, p = 0.18). ACLF increased treatment revenues to € 10,593 vs. €6,369 without ACLF (p < 0.0001). While treatment of ACLF was more complicated, revenue per day was not different to no-ACLF patients (€ 483 vs. € 480, p = 0.29). SBP, nosInf and/or ACLF lead to a significant increase in the effort, revenue and duration in the treatment of patients with cirrhosis. The lower daily revenue, despite a much more complex therapy, might indicate that these complications are not yet sufficiently considered in the German DRG system.

Reimbursement After Congenital Heart Surgery in Germany: Impact of Early Postoperative Extubation.

Duration of mechanical ventilation is an important variable used by German Diagnosis-Related Groups (G-DRG) system to establish cost weight values for reimbursement after congenital heart surgery. Infants are commonly ventilated after open heart surgery. As of year 2015, we strived to achieve early postoperative extubation. This work studies how this approach impacted reimbursement after infant open heart surgery. Data of infants who underwent surgery on cardiopulmonary bypass (CPB) from 2014 to 2018 were reviewed. Successful early extubation was defined as end of mechanical ventilation within 24 hours postoperatively, without reintubation at a later point. Mean cost weight values (case mix index [CMI]) of achieved DRGs were used for estimation of reimbursement. Evolutions over years of early extubation and of reimbursement were compared. A total of 521 infants underwent operations on CPB. Of these, 161 (31%) procedures were of higher risk Society of Thoracic Surgery and the European Association for Cardio-Thoracic Surgery (STAT) categories 3 and 4. Early extubation was achieved in 205 (39%) patients. The rate increased from 14% (year 2014) to 57% (year 2018). Case mix index amounted to 8.87 ± 7.00 after early extubation, and 12.37 ± 7.85 after late extubation: P value <.0001. It was 8.77 ± 6.09 after early extubation in patients undergoing lower risk STAT categories 1 and 2 operations, and 8.09 ± 2.95 when categories 3 and 4 procedures were performed (P = .18). An overall 14.4% decrease in hospital reimbursement per patient was observed. Early extubation could be progressively obtained in the majority of infants. This resulted in lower reimbursement. Surgical complexity was disregarded. The current G-DRG system appears to favor longer mechanical ventilation durations after infant open heart surgery.

The effectiveness of the neonatal diagnosis-related group scheme

The goal of this study is to investigate the effectiveness of the neonatal diagnosis-related group scheme in patients affected by respiratory distress syndrome. The variable costs of individual patients in the same group are examined. This study uses the data of infants (N = 243) hospitalized in the Neonatal Intensive Care Unit of the Gaslini Children’s Hospital in Italy in 2016. The care unit’s operating and management costs are employed to estimate the average cost per patient. Operating costs include those related to personnel, drugs, medical supplies, treatment tools, examinations, radiology, and laboratory services. Management costs relate to administration, maintenance, and depreciation cost of medical equipment. Cluster analysis and Tobit regression are employed, allowing for the assessment of the total cost per patient per day taking into account the main cost determinants: birth weight, gestational age, and discharge status. The findings highlight great variability in the costs for patients in the same diagnosis-related group, ranging from a minimum of €267 to a maximum of €265,669. This suggests the inefficiency of the diagnosis-related group system. Patients with very low birth weight incurred costs approximately twice the reimbursement set by the policy; a loss of €36,420 is estimated for every surviving baby with a birth weight lower than 1,170 grams. On the contrary, at term, newborns cost about €20,000 less than the diagnosis-related group reimbursement. The actual system benefits hospitals that mainly treat term infants with respiratory distress syndrome and penalizes hospitals taking care of very low birth weight patients. As a result, strategic behavior and “up-coding” might occur. We conduct a cluster analysis that suggests a birth weight adjustment to determine new fees that would be fairer than the current costs.

Effects of the new diagnosis-related group-based payment system and the increased incentive policy rates on the utilization rate of diagnostic laboratory test in Korea

A new diagnosis-related group (DRG) based payment system has been implemented in most public hospitals in Korea. We investigated the effects of the new DRG system and its incentive policy on the utilization rate of diagnostic laboratory tests. Three groups were categorized; 36 hospitals under the new DRG system (participant group), 72 hospitals (control-1) matching with 36 participants according to the number of beds, and 42 tertiary hospitals (control-2). The patients of acute myocardial infarction, cerebral infarction, type 2 diabetes mellitus, and gonarthrosis receiving total arthroplasty were included. We analyzed the mean length of stay and the number of diagnostic laboratory tests conducted during hospitalization of the three groups according to the new DRG system and the incentive policy rates under the new DRG system. Before participating in the new DRG system, the number of diagnostic laboratory tests in the participant group was less than that in the two control groups for all four diseases. However, although the participant group’s length of stay decreased under the new DRG system, the number of diagnostic laboratory tests increased as the maximum incentive policy rate increased. The increment of the number of diagnostic laboratory tests was prominent in the period of a maximum of 35% incentive policy rates. Finally, the number of diagnostic laboratory tests of the participant group was similar to or exceeded that of the control-2 group. The new DRG system’s incentive policy rates played a driving force on the increased utilization rate of the diagnostic laboratory test. For preparing in advance for the change in incentive policy rates, monitoring and guidelines for the utilization of diagnostic laboratory tests are necessary.

Inpatient treatment costs, cost-driving factors and potential reimbursement problems due to epileptic seizure-related injuries and fractures

HintergrundDie Analyse krankheitsspezifischer Kosten gewinnt in einem zunehmend ökonomisch ausgerichteten Gesundheitssystem an Relevanz, wobei vor allem chronische Erkrankungen aufgrund der langen Krankheitsdauer sowie häufiger Hospitalisierung und Arztbesuche von besonderem Interesse sind. Epilepsien stellen eine häufige neurologische Erkrankung dar, welche mit paroxysmal auftretenden epileptischen Anfällen und häufig hiermit assoziierten Verletzungen einhergeht und alle Altersgruppen betrifft.ZielZiel der Arbeit ist die Aufarbeitung der stationären Behandlungskosten anfallsbedingter Verletzungen sowie die Analyse hinsichtlich relevanter kostenverursachender Faktoren. Mittels alternativer Kalkulation der Versorgungskosten soll zusätzlich der Frage nach potenziellen Vergütungsproblemen im aktuellen DRG-System („diagnosis related groups“) nachgegangen werden.MethodenGrundlage dieser monozentrischen, retrospektiven Analyse ist der tatsächliche Erlös der stationären Behandlung von 62 Patienten, die zwischen 01/2010 und 01/2018 im Universitätsklinikum Frankfurt aufgrund von Verletzungen im Rahmen epileptischer Anfälle erfolgte. Die Analyse potenzieller kostenverursachender Faktoren bezog sich auf relevante soziodemographische und klinische Aspekte, die alternative Kalkulation der Versorgungskosten wurde mit gängigen gesundheitsökonomischen Methoden durchgeführt.ErgebnisseDer mittlere DRG-Erlös betrug 7408 € (±8993 €, Median 5086 €, Spanne 563–44.519 €), die mittleren kalkulierten Kosten 9423 € (±11.113 €, 5626 €, Spanne 587–49.830 €). Als signifikant kostenverursachender Faktor konnte eine Liegedauer ≥7 Tage (p = 0,014) identifiziert werden. Aufgrund des signifikanten Unterschieds (p < 0,001) zwischen Erlös und kalkulierten Kosten erfolgte eine Analyse nach Faktoren für potenzielle Vergütungsprobleme, welche für eine Aufenthaltsdauer von ≥7 Tagen (p = 0,014) sowie für eine Behandlung auf Intensivstation (p = 0,019) signifikant verblieb.SchlussfolgerungDie stationären Versorgungskosten von Patienten mit Frakturen aufgrund epileptischer Anfälle sind hoch und daher gesundheitsökonomisch relevant. Generell scheint die auf Fallpauschalen basierende Vergütung nach G‑DRG die tatsächlichen Kosten zu decken, bei Patienten mit einer langen Liegedauer oder einen Aufenthalt auf Intensivstation können jedoch Vergütungsprobleme bestehen.

Measuring data credibility and medical coding: a case study using a nationwide Portuguese inpatient database

Some countries have adopted the diagnosis-related groups (DRG) system to pay hospitals according to the number and complexity of patients they treat. Translating diseases and procedures into medical codes based on international standards such as ICD-9-CM or ICD-10-CM/PCS is at the core of the DRG systems. However, certain types of coding errors undermine this system, namely, upcoding, in which data is manipulated by deliberately using medical codes that increase patient’s complexity, resulting in higher reimbursements. In this sense, ensuring data credibility in the context of upcoding is critical for an effectively functioning DRG system. We developed a method to measure data credibility in the context of upcoding through a case study using data on pneumonia-related hospitalizations from six public hospitals in Portugal. Frequencies of codes representing pneumonia-related diagnosis and comorbidities were compared between hospitals and support vector machine models to predict DRGs were employed to verify whether codes with discrepant frequencies were related to upcoding. Data were considered not credible if codes with discrepant frequencies were responsible for increasing DRG complexity. Six pneumonia-related diagnoses and fifteen comorbidities presented a higher-than-expected frequency in at least one hospital and a link between increased DRG complexity, and these targeted codes was found. However, overall credibility was very high for nearly all conditions, except for renal disease, which presented the highest percentage of potential upcoding. The main contribution of this paper is a generic and reproducible method that can be employed to monitor data credibility in the context of upcoding in DRG databases.

Do hospitals respond to changing incentive structures? Evidence from Medicare’s 2007 DRG restructuring

In 2007, the Centers for Medicare and Medicaid restructured the diagnosis related group (DRG) system by expanding the number of categories within a DRG to account for complications present within certain conditions. This change allows for differential reimbursement depending on the severity of the case. We examine whether this change incentivized hospitals to upcode patients as sicker to increase their reimbursements. Using the National Inpatient Survey data from HCUP from 2005 to 2010 and three methods to detect the presence of upcoding, our most conservative estimate is an additional three percent of reimbursement is attributable to upcoding. We find evidence of upcoding in government, non-profit, and for-profit hospitals. We find spillover effects of upcoding impacting not only Medicare payers, but also private insurance companies as well.

Prevalence and burden of orthopaedic implantable-device infections in Italy: a hospital-based national study

BackgroundHealthcare-associated infections (HAIs) represent a serious burden to individual safety and healthcare sustainability. Identifying which patients, procedures and settings are most at risk would offer a significant contribution to HAI management and prevention. The purpose of this study is to estimate 1) orthopaedic implantable device-related infection (OIDRI) prevalence in Italian hospitals and 2) the gap between the remuneration paid by the Italian healthcare system and the real costs sustained by Italian hospitals to treat these episodes.MethodsThis is a cross-sectional study based on hospital discharge forms registered in 2012 and 2014. To address the first goal of this study, the national database was investigated to identify 1) surgical procedures associated with orthopaedic device implantation and 2) among them, which patient characteristics (age, sex), type of admission, and type of discharge were associated with a primary diagnosis of infection. To address the second goal, 1) each episode of infection was multiplied by the remuneration paid by the Italian healthcare system to the hospitals, based on the diagnosis-related group (DRG) system, and 2) the total days of hospitalization required to treat the same episodes were multiplied by the average daily cost of hospitalization, according to estimates from the Ministry of the Economy and Finance (MEF).ResultsIn 2014, 1.55% of the total hospitalizations for orthopaedic device implantation procedures were associated with a main diagnosis of infection, with a negligible increase of 0.04% compared with 2012. Hip and knee replacement revisions, male patients and patients older than 65 years were more exposed to infection. A total of 51.63% of patients were planned admissions to the hospital, 68.75% had an ordinary discharge to home, and 0.9% died.The remuneration paid by the healthcare system to the hospitals was € 37,519,084 in 2014, with 3 DRGs covering 70.6% of the total. The cost of the actual days of hospitalization to treat these episodes was 17.5 million more than the remuneration received.ConclusionsThe OIDRI prevalence was lower than that described in recent surveys in acute care settings, although the numbers were likely underestimated. The cost of treatment varied significantly depending on the remuneration system adopted.