How do hospitals respond to payment unbundling for diagnostic imaging of suspected cancer patients?

Payments for some diagnostic scans undertaken in outpatient settings were unbundled from Diagnosis Related Group based payments in England in April 2013 to address under-provision. Unbundled scans attracted additional payments of between £45 and £748 directly following the reform. We examined the effect on utilization of these scans for patients with suspected cancer. We also explored whether any detected effects represented real increases in use of scans or better coding of activity. We applied difference-in-differences regression to patient-level data from Hospital Episodes Statistics for 180 NHS hospital Trusts in England, between April 2010 and March 2018. We also explored heterogeneity in recorded use of scans before and after the unbundling at hospital Trust-level. Use of scans increased by 0.137 scans per patient following unbundling, a 134% relative increase. This increased annual national provider payments by £79.2 million. Over 15% of scans recorded after the unbundling were at providers that previously recorded no scans, suggesting some of the observed increase in activity reflected previous under-coding. Hospitals recorded substantial increases in diagnostic imaging for suspected cancer in response to payment unbundling. Results suggest that the reform also encouraged improvements in recording, so the real increase in testing is likely lower than detected.

Insights on DRGs, guideline compliance and economic sustainability. The case of mastectomy with immediate breast reconstruction.

Background: Immediate breast reconstruction is recommended for eligible patients undergoing mastectomy, raising the issue of economic sustainability of both mastectomy and breast reconstruction performed within the same hospitalization, as opposed to two surgical procedures in two different hospitalizations. Study design: A retrospective analysis was conducted to compare economic sustainability of mastectomies with or without immediate breast reconstruction. Methods: Economic data on hospitalizations for mastectomy in a Teaching Hospital between 1 January 2019 and 31 March 2021 were analyzed to assess their sustainability. Results: 338 admissions were selected (63.9% with immediate breast reconstruction (CI 99%: 57.2% to 70.6%). Compared to mastectomy alone, mastectomy with immediate breast reconstruction had higher cost of € 2,245 (p < 0.001), with operating rooms and devices as main cost drivers. Current reimbursements rates (which are the same for mastectomy alone and for mastectomy with immediate breast reconstruction) led to an average loss of € 1,719 for each mastectomy with immediate breast reconstruction. Conclusion: Current DRGs reimbursement rates for hospital admissions for breast cancer surgery do not guarantee immediate breast reconstruction's economic sustainability. DRGs system should be revised, or other solutions as bundled payment should be implemented in the light of the costs of innovation in healthcare, considering mastectomy and breast reconstruction steps in a path of linked actions aimed at improving patients' health.

The DEMATEL method explores the interdependent relationship structure and weights for diagnosis-related groups system.

Purpose: This study constructs a structure of interaction between dimensions and criteria within the diagnosis-related groups (DRGs) system from a quantitative system and identifies key factors affecting the overall performance of medical services. Method: From September to December 2020, the influence relation structure diagram (IRSD) of the dimensions and corresponding criteria was developed from the practical experience of a group of domain experts, based on the DEMATEL method. Subsequently, all dimensions and criteria construct influential weights from a systems perspective. Finally, the main influential factors were identified based on the analysis results. Results: The IRSD results showed that, in the overall performance of medical services, "Medical service capacity (C 1)" was the main influential dimension, influencing both "Medical service efficiency (C 2)" and "Medical service safety (C 3)." At the criteria level, "Case-mix index (CMI) (C 12)," "Time efficiency index (C21)," and "Inpatient mortality of medium-to-low group (C32)" were the main influential criteria in the corresponding dimensions. The influential weight results showed that "Medical service capacity (C 1)" was also a key dimension. "Case-mix index (CMI) (C 12)," "Cost efficiency index (C 22)," and "Inpatient mortality of medium-to-low group (C 32)" were the key criteria in their respective dimensions. Conclusion: Patients and managers should first focus on the capacity of medical service providers when making a choice or deciding using the results of the DRGs system. Furthermore, they should pay more attention to medical safety even if it is not as weighted as medical efficiency.

Improving the clinical ability and quality of endocrinology department with diagnosis-related groups tool.

Background: To evaluate the use of the diagnosis-related groups (DRGs) tool to promote the diagnosis/treatment ability and quality of the endocrinology department under the new policy of grouping payment-related to disease diagnosis. Methods: We compared the income structure of the endocrinology department in a 3a general hospital between the first half of 2019 and the same period in 2021. We also observed the changes in cost efficiency indexes (CEIs), time efficiency indexes (TEIs), case-mix index (CMI), number of DRGs, risk weight (RW) proportion, and surgery number in the inpatient department. Furthermore, the distribution of inpatients with diabetes of the whole hospital and the improvement of treatment efficiency indexes of the sub-specialty department were analyzed. Results: In the first half of 2021, compared with the same period of 2019, the total revenue of the endocrinology department decreased by 20.05%, the average hospitalization cost decreased by 11.72%, the CEI decreased from 1.31 to 1.06, and the TEI decreased from 0.74 to 0.64. Additionally, the number of DRGs increased from 162 to 176, the average CMI value increased from 0.80 to 0.84, and the proportion of RW 1-5 cases increased. Moreover, the number of surgical cases increased by 60.50%, minimally invasive surgery increased by 53.54%, grade 4 surgery increased by 66.67%, and the proportion of entering the clinical pathway increased from 77.76% to 86.64%. From May to August, 2021, the admission rate of endocrinology sub-specialty increased significantly, the number of DRGs showed an increasing trend, and the CEI and TEI decreased significantly. In the first half of 2021, inpatients with diabetes in the departments of rehabilitation, neurology, nephropathy, ophthalmology, and general administration accounted for 21.99-38.54%. Conclusions: The DRGs tool can be used to improve the clinical diagnosis and treatment ability of the endocrinology department, as well as optimize the CEI, TEI, CMI, and RW values. It is an effective way to promote the development of the endocrinology department under the new DRGs payment policy, carry out blood glucose management in the hospital, build endocrinology sub-specialties, and improve surgical and operation capacity.

DRG grouping by machine learning: from expert-oriented to data-based method.

BACKGROUND: Diagnosis-related groups (DRGs) are a payment system that could effectively solve the problem of excessive increases in healthcare costs which are applied as a principal measure in the healthcare reform in China. However, expert-oriented DRG grouping is a black box with the drawbacks of upcoding and high cost. METHODS: This study proposes a method of data-based grouping, designed and updated by machine learning algorithms, which could be trained by real cases, or even simulated cases. It inherits the decision-making rules from the expert-oriented grouping and improves performance by incorporating continuous updates at low cost. Five typical classification algorithms were assessed and some suggestions were made for algorithm choice. The kappa coefficients were reported to evaluate the performance of grouping. RESULTS: Based on tenfold cross-validation, experiments showed that data-based grouping had a similar classification performance to the expert-oriented grouping when choosing suitable algorithms. The groupings trained by simulated cases had less accuracy when they were tested by the real cases rather than simulated cases, but the kappa coefficients of the best model were still higher than 0.6. When the grouping was tested in a new DRGs system, the average kappa coefficients were significantly improved from 0.1534 to 0.6435 by the update; and with enough computation resources, the update process could be completed in a very short time. CONCLUSIONS: As a new potential option, the data-based grouping meets the requirements of the DRGs system and has the advantages of high transparency and low cost in the design and update process.

Performance evaluation of medical service for breast cancer patients based on diagnosis related groups.

BACKGROUND: To evaluate the performance of medical service for patients with breast cancer in Henan Province, China, using diagnosis related groups (DRGs) indicators and to provide data to inform practices and policies for the prevention and control of breast cancer. METHODS: The data were collected from the front pages of medical records (FPMR) of all hospitals above class II that admitted breast cancer patients in Henan Province between 2016 and 2019. Breast cancer patients were the subjects in our study. China DRGs (CN-DRGs) was used as a risk adjustment tool. Three indicators, including the case mix index (CMI), number of DRGs, and total weight, were used to evaluate the range of available services for patients with breast cancer, while indicators including the charge efficiency index (CEI), time efficiency index (TEI) and inpatient mortality of low-risk group cases (IMLRG) were used to evaluate medical service efficiency and medical safety. RESULTS: Between 2016 and 2019, there were 103,760 patients with breast cancer. The total weight increased over the study period at an average annual rate of 21.71%. The TEI decreased over the study period by 15.60%. The CEI exhibited an increasing trend, but the average annual rate of increase was small (2.94%). The IMLRP was 0.02, 0, 0 and 0.01% in 2016, 2017, 2018 and 2019, respectively. CONCLUSION: The performance of medical service improved between 2016 and 2019 for breast cancer patients discharged from study hospitals in Henan Province. The main area of improvement was in the range of available services, but medical institutions must still make efforts to improve the efficiency of medical services and ensure medical safety. DRGs is an effective evaluation tool.

From downcoding to upcoding: DRG based payment in hospitals.

A prospective disease group-based payment is a reimbursement rule used in a wide array of countries. It turns to be the hospital's payment rule to imply. The secret of this payment is a fee payment as well as a hospital's activity based payment. There is a consensus to consider this rule of payment as the least likely to be manipulated by the actors. However, the defined fee per group depends on recorded information that is then processed using complex algorithms. What if the data itself can be manipulated? The result would be a fee per group based on manipulated factors that would lead to an inefficient budget allocation between hospitals. Using a unique French longitudinal database with 145 million stays, I unambiguously demonstrate that the implementation of a finer classification led to an upcoding-learning effect. The end result has been a budget transfer from public non-research hospitals to for-profit hospitals. The 2009 policy lead to upcoding disconnected from any changes in the trend of production of care.

Impacts of Hospital Payment Based on Diagnosis Related Groups (DRGs) with Global Budget on Resource Use and Quality of Care: A Case Study in China.

BACKGROUND: China has implemented numerous pilots to shift its hospital payment mechanism from the traditional retrospective cost-based system to prospective diagnosis-related-group (DRG) -based system. This study investigated the impact of the DRG payment reform with global budget in Zhongshan, China. METHODS: A total of 2895 patients diagnosed with acute myocardial infarction (AMI) were selected from local two largest tertiary hospitals, among which 727 were discharged prior to the payment reform and 2168 afterwards. Difference-in-difference (DID) regression models were used to evaluate the policy effects on patients' percutaneous coronary intervention (PCI) use, hospital expenditures, in-hospital mortality, and readmission rates within 30 days after discharge. RESULTS: Patients' PCI use and hospital expenditures increased quickly after the payment reform. With patients with no local insurance scheme as reference, PCI use for local insured patients decreased significantly by 4.55 percent (95 percent confidence interval [CI]: 0.23, 0.72), meanwhile the total hospital expenses decreased significantly by US$986.10 (b=-0.15, P=0.0037) after reform. No changes were observed with patients' hospital mortality and readmission rates in our study. CONCLUSION: The innovative DRG-based payment reform in Zhongshan suggested a positive effect on AMI patient's cost containment but negative effect on encouraging resource use. It had no impacts on patients' care quality. Cost shifting consequence from the insured to the uninsured was observed. More evidence of the impacts of the DRG-based payment in China's health scenario is needed before it is generalized nationwide.

Which Reimbursement System Fits Inpatient Palliative Care? A Qualitative Interview Study on Clinicians' and Financing Experts' Experiences and Views.

Context: Internationally, a variety of reimbursement systems exists for palliative care (PC). In Germany, PC units (PCUs) may choose between per-diem rates and diagnosis-related groups (DRGs). Both systems are controversially discussed. Objectives: To explore the experiences and views of German PCU clinicians and experts for PCU financing regarding per-diem rates and DRGs as reimbursement systems with a focus on (1) cost coverage, (2) strengths and weaknesses of both financing systems, and (3) options for further development of funding PCUs. Design: Qualitative semistructured interviews with PCU clinicians and experts for PCU financing, analyzed by thematic analysis using the Framework approach. Setting/Subjects/Measurements: Ten clinicians and 13 experts for financing were interviewed June-October 2015 on both reimbursement systems for PCU. Results: Interviewees had divergent experiences with both reimbursement systems regarding cost coverage. A described strength of per-diem rates was the perceived possibility of individual care without direct financial pressure. The nationwide variation of per-diem rates and the lack of quality standards were named as weaknesses. DRGs were criticized for incentives perceived as perverse and inadequate representation of PC-specific procedures. However, the quality standards for PCUs required within the German DRG system were described as important strength. Suggestions for improvement of the funding system pointed toward a combination of per-diem rates with a grading according to disease severity/complexity of care. Conclusions: Expert opinions suggest that neither current DRGs nor per-diem rates are ideal for funding of PCUs. Suggested improvements regarding adequate funding of PCUs resemble and supplement international developments.

Progress and implications of the DRG-based prospective payment system ( DRG-PPS ) reform in China / 中国卫生政策研究

DRG-based prospective payment system ( DRG-PPS ) is one type of mature inpatient care payment mechanisms in most countries and pilot projects would be introduced to China in 2017. This article provides an overview of the previous typical DRG-PPS reform initiatives on provincial, municipal and county level respectively. It also summa-rizes the characteristics of the reform programs, describes the diversities of policy implementation, and discusses the suc-cessful experience and implications of the initiatives. The paper puts forward some suggestions on the upcoming DRG-PPS pilot projects based on the progress and problems of the initiatives, to promote the DRG-PPS reform in China.

Adjusted cost consumption index of major diagnosis-related group data in hospital medical performance evaluation / 中华医院管理杂志

Objective To study the calculation of the cost consumption index adjusted with major diagnostic classification (MDC), for optimal use of DRGs index in hospital performance evaluation. Methods The adjustment method of CMI value in DRGs index system was used as reference, and we compared the different cost consumption indexes(both MDC adjusted and non-adjusted) of two hospitals(S and Y) in Guangdong province. Then we compared the different rankings of 82 tertiary general hospitals in the province before and after the adjustment. Results The cost consumption index of S hospital was higher than that of Y hospital by the non-adjusted method (1.30 >1.28). But as calculated by the adjusted method,the index of S hospital was significantly lower than Y hospital (1.31 <1.38). The rankings of these 82 hospitals also showed major changes,which prove that the cost consumption index, the same as CMI,will be affected by MDC cases makeup.Conclusions The MDC adjusted cost consumption index, when applied to hospital performance evaluation, renders more stable and reasonable results. This is an evidence that the adjusted cost consumption index is of great practical value in hospital performance evaluation.

Acquisition standard of medical record homepage and impact on BJ-DRGs grouping / 中华医院管理杂志

BJ-DRGs grouping process was cited as an example, to describe the factors affecting the grouping process, grouping results and assessment results, and the solutions in transferring homepages into WJT form 4-1 for inpatient medical record homepages (WJT form 4-1 for short).Authors analyzed how to better information acquisition quality of such homepages by unifying the data interface standard of WJT form 4-1, for the purposes of enhancing BJ-DRGs grouping efficiency, and expanding its functions as a tool for medical quality management and that for medical insurance payment management.

Introducing diagnosis-related groups: is the information system ready?

Diagnosis-related group (DRG) system is a classification system widely used in health managements, the foundation of which lies in the medical information system. A large effort had been made to improve the quality of discharge data before the introduction of DRGs in Beijing. We extract discharge data from 108 local hospitals spanning 4 years before and after standardization to evaluate the impact of standardization on DRG grouping performance. The data was grouped on an annual basis in accordance with Beijing's local DRG system. Proportion of ungrouped data, coefficient of variation (CV) and reduction in variance (RIV) were used to measure the performance of the DRG system. Both the descriptive and regression analysis indicate a significant reduction in terms of ungrouped data and CV for expenditure, increase of RIV for expenditure and length of stay. However, when there was no intervention, that is, between 2005 and 2006 and between 2008 and 2009, changes in these indicators were all insignificant. Therefore, the standardization of discharge data did improve data quality and consequently enhanced the performance of DRGs. Developing countries with a relatively weak information infrastructure should strengthen their medical information system before the introduction of the DRG system.

Healthcare Reimbursement and Quality Improvement: Integration Using the Electronic Medical Record Comment on "Fee-for-Service Payment--an Evil Practice That Must Be Stamped Out?".

Reimbursement for healthcare has utilized a variety of payment mechanisms with varying degrees of effectiveness. Whether these mechanisms are used singly or in combination, it is imperative that the resulting systems remunerate on the basis of the quantity, complexity, and quality of care provided. Expanding the role of the electronic medical record (EMR) to monitor provider practice, patient responsiveness, and functioning of the healthcare organization has the potential to not only enhance the accuracy and efficiency of reimbursement mechanisms but also to improve the quality of medical care.

Heterogeneity of European DRG systems and potentials for a common EuroDRG system Comment on "Cholecystectomy and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries".

Diagnosis-Related Group (DRG) systems across Europe are very heterogeneous, in particular because of different classification variables and algorithms as well as costing methodologies. But, given the challenge of increasing patient mobility within Europe, health systems are forced to incorporate a common patient classification language in order to compare and identify similar patients e.g. for reimbursement purposes. Beside the national adoption of DRGs for a wide range of purposes (measuring hospital activity vs. paying hospitals), a common DRG system can serve as an international communication basis among health administrators and can reduce the national development efforts as it is demonstrated by the NordDRG consortium.

DRGs in China: development, application and promotion / 中华医院管理杂志

Introducing the progress of DRGs work in Beijing, its application in medical insurance payment, as well as in hospital management and appraisal.Recommendations were made for DRGs development in the country, including unification of DRGs standards nationwide, orchestrated efforts of government departments, and acceleration of DRGs use in payment mode reforms.

The challenge and solution for the front page of inpatient medical record based on DRGs / 中华医院管理杂志

This article discussed the development, challenge and solution for the front page of inpatient medical record based on DRGs (diagnosis related groups).It will facilitate the stakeholders' understanding, unifying the standard of data, building quality control system, improving the quality of the front page of medical record.Thus, the information in the front page will contribute to the scientific evaluation of health service ability and quality for hospital.

Application of Diagnosis Related Groups evaluation index in performance management system of hospitals / 中华医院管理杂志

Objective To explore the use of Diagnosis Related Groups(DRGs)evaluation index in performance management system of hospitals.Methods The performance evaluation system was built based on medical business volume index,efficiency indicators,cost control indexes,drug control indexes, medical quality and medical safety indexes,by means of extracting the home page of hospital discharge records from 2009 to 2013 and grouping automatically with the“BJ-DRGs”group-maker.Results The operation evaluation indexes of the hospital have seen great progress since advent of the DRGs evaluation indexes.Conclusion Introduction of DRGs has scored great success in the performance appraisal system of the hospital.

Cholecystectomy and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries.

BACKGROUND: As part of the EuroDRG project, researchers from eleven countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Sweden, and Spain) compared how their Diagnosis-Related Groups (DRG) systems deal with cholecystectomy patients. The study aims to assist surgeons and national authorities to optimize their DRG systems. METHODS: National or regional databases were used to identify hospital cases with a procedure of cholecystectomy. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardised case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained and compared to an index case. RESULTS: European DRG systems vary widely: they classify cholecystectomy patients according to different sets of variables into diverging numbers of DRGs (between two DRGs in Austria and Poland to nine DRGs in England). The most complex DRG is valued at four times more resource intensive than the index case in Ireland but only 1.3 times more resource intensive than the index case in Austria. CONCLUSION: Large variations in the classification of cholecystectomy patients raise concerns whether all systems rely on the most appropriate classification variables. Surgeons, hospital managers and national DRG authorities should consider how other countries' DRG systems classify cholecystectomy patients in order to optimize their DRG systems and to ensure fair and appropriate reimbursement.

Systematically evaluating the impact of diagnosis-related groups (DRGs) on health care delivery: a matrix of ethical implications.

Swiss hospitals were required to implement a prospective payment system for reimbursement using a diagnosis-related groups (DRGs) classification system by the beginning of 2012. Reforms to a health care system should be assessed for their impact, including their impact on ethically relevant factors. Over a number of years and in a number of countries, questions have been raised in the literature about the ethical implications of the implementation of DRGs. However, despite this, researchers have not attempted to identify the major ethical issues associated with DRGs systematically. To address this gap in the literature, we have developed a matrix for identifying the ethical implications of the implementation of DRGs. It was developed using a literature review, and empirical studies on DRGs, as well as a review and analysis of existing ethics frameworks. The matrix consists of the ethically relevant parameters of health care systems on which DRGs are likely to have an impact; the ethical values underlying these parameters; and examples of specific research questions associated with DRGs to illustrate how the matrix can be applied. While the matrix has been developed in light of the Swiss health care reform, it could be used as a basis for identifying the ethical implications of DRG-based systems worldwide and for highlighting the ethical implications of other kinds of provider payment systems (PPS).