Orthopedics coding and funding.

The French tarification à l'activité (T2A) prospective payment system is a financial system in which a health-care institution's resources are based on performed activity. Activity is described via the PMSI medical information system (programme de médicalisation du système d'information). The PMSI classifies hospital cases by clinical and economic categories known as diagnosis-related groups (DRG), each with an associated price tag. Coding a hospital case involves giving as realistic a description as possible so as to categorize it in the right DRG and thus ensure appropriate payment. For this, it is essential to understand what determines the pricing of inpatient stay: namely, the code for the surgical procedure, the patient's principal diagnosis (reason for admission), codes for comorbidities (everything that adds to management burden), and the management of the length of inpatient stay. The PMSI is used to analyze the institution's activity and dynamism: change on previous year, relation to target, and comparison with competing institutions based on indicators such as the mean length of stay performance indicator (MLS PI). The T2A system improves overall care efficiency. Quality of care, however, is not presently taken account of in the payment made to the institution, as there are no indicators for this; work needs to be done on this topic.

Improving the accuracy of payment classifications through use of a case management protocol.

OBJECTIVES: The purpose of this study is to determine if a Case Management Protocol (CMP) improves the accuracy of assignment of Medicare patients to the appropriate payment classification. METHODS: MetaStar, Wisconsin's Quality Improvement Organization (QIO), invited Wisconsin hospitals to participate in this project; 19 hospitals did so. A CMP enables physicians to enter an order in the medical record to "admit the patient under the case management protocol" when it is not obvious to the physician whether the patient should be admitted as an inpatient or placed in an outpatient status. A trained case management professional accesses the documentation in the medical record and makes a recommendation to the physician as to the appropriate status. The decision is ratified by the physician in the form of a signed order. RESULTS: In comparing 1-day inpatient stays as a percentage of all hospital stays in a group of hospitals that considered the use of the CMP, to that same percentage in the hospitals that did not consider the use of a CMP, there was a reduction of 1-day stays for the former group that was significantly (P<.01) greater than for the latter group; the decrease in target payments for the former group also was significantly greater than that for the latter group (P<.01). CONCLUSION: The use of a CMP to assign Medicare patients to appropriate payment classifications is an effective method of increasing the accuracy of such assignment.

[Chemotherapy and DPC, prospective payment].

In 2003, the Japanese government introduced a prospective payment methodology into acute inpatient care services by developing a new, national patient grouping, called Diagnosis Procedure Combination(DPC). It raised issues relating to; 1) settling charges for combinations of treatment modalities in a single admission, 2) large practice variations in chemotherapeutic regimens and its pharmaceutical costs, 3) effects of shorter length of stays and outpatient chemotherapy, 4) payment adjustment for hospitals providing care to terminally ill, relapse and metastatic cases. In order to overcome these issues; a) oncologists need to develop treatment guidelines and standardize chemotherapeutic regimens, b) refine DPC to incorporate chemotherapy protocols, c) develop adjustment measures for different densities of care and casemix.

[Evaluating the first German diagnosis-related groups (G-DRG) in cardiological patients: problems in the correct medical and economic grouping]. / Probleme bei der Abbildung kardiologischer Erkrankungen im deutschen Fallpauschalen-System (G-DRG).

About three years ago, the German Government initiated a complete change in the reimbursement system for costs of the in-hospital treatment of patients. A commission of representatives from every component of the German health system decided to adapt the Australian refined Diagnosis Related Groups (AR-DRG system). The AR-DRG system was selected as it would fit best to the German system and because of its high flexibility and preciseness reflecting severity of diseases and treatments. In October 2002, the first German Diagnosis Related Groups (G-DRGs) were calculated from the data of about 116 hospitals. These data now allow first analyses in how far a correct and precise grouping of patients in specific hospital settings is indeed performed and corresponds to the actual costs. Thus, we thoroughly calculated all costs for material and personnel during the in-hospital stay for each patient discharged during the first 4 months of 2002 from our cardiological department. After performing the grouping procedure for each patient, we analyzed in how far inhomogeneous patient distribution in the DRGs occurred and which impact this had on costs and potential reimbursements. Several different problems were identified which should be outlined in this work regarding three G-DRGs: costs of patients who received an implantable cardioverter defibrillator (F01Z) were markedly influenced by multimorbidity and additional expensive interventions which were not reflected by this G-DRG. Use of numerous catheters and expensive drugs represented a major factor for costs in patients with coronary angioplasty in acute myocardial infarction (F10Z) but seemed to be not sufficiently included in the cost weight. A specific area of patient management in our department is high frequency ablation of tachyarrhythmias which is included in other percutaneous interventions (F19Z). Complex procedures such as ablation of ventricular tachycardia or new innovative procedures as ablation of atrial fibrillation were associated with high costs leading to inadequate reimbursement. Furthermore, problems in the associated codes for diseases and procedures became apparent. Opportunities for future optimization such as specific new DRGs, splitting of DRGs, or the impact of changes in reimbursement for high-outliers were discussed.

Charge-process strategies for outpatient prospective payment.

One of the most important strategies for operating successfully under the outpatient prospective payment system is to establish an effective charging process. Achieving control of the process begins with a thorough assessment of chargemaster coding, how charges are structured in the chargemaster, and how hospital departments use the charges. Once problems are identified and corrected, the next step is to develop a system to maintain and monitor both the chargemaster and the charging process. Perhaps the most important component of the monitoring system is to include a mechanism to provide the necessary feedback to departments regarding errors related to the charge process.

The prospective risk adjustment system.

The Episode Classification System is intended to perform two tasks. First, it will be a prospective capitation risk adjuster and predict future health care costs. It will do this by assigning each individual a single capitation risk adjustment category based on an analysis of the medical history and of health care services rendered during a specific period of time. Second, the Episode Classification System will create retrospective severity adjusted Episodes of illness or Episodes of Care. These latter Episodes will provide a framework for relating patient characteristics to the amount, type, and duration of services provided during the treatment of a specific disease. These Episodes will give users the ability to understand past costs and the risk of mortality. As such they will form the basis for provider profiling by allowing users to analyze a complete clinical episode.