Casemix classification payment for sub-acute and non-acute inpatient care, Thailand.

BACKGROUND: There is a need to develop other casemix classifications, apart from DRG for sub-acute and non-acute inpatient care payment mechanism in Thailand. OBJECTIVE: To develop a casemix classification for sub-acute and non-acute inpatient service. MATERIAL AND METHOD: The study began with developing a classification system, analyzing cost, assigning payment weights, and ended with testing the validity of this new casemix system. Coefficient of variation, reduction in variance, linear regression, and split-half cross-validation were employed. RESULTS: The casemix for sub-acute and non-acute inpatient services contained 98 groups. Two percent of them had a coefficient of variation of the cost of higher than 1.5. The reduction in variance of cost after the classification was 32%. Two classification variables (physical function and the rehabilitation impairment categories) were key determinants of the cost (adjusted R2 = 0.749, p = .001). Validity results of split-half cross-validation of sub-acute and non-acute inpatient service were high. CONCLUSION: The present study indicated that the casemix for sub-acute and non-acute inpatient services closely predicted the hospital resource use and should be further developed for payment of the inpatients sub-acute and non-acute phase.

The development of Version 2 of the AN-SNAP casemix classification system.

This paper presents the results of a recent review of the Australian National Sub-acute and Non-acute Patient (AN-SNAP) classification system. The AN-SNAP system was developed by the Centre for Health Service Development, University of Wollongong in 1997. The review was conducted between August 2005 and September 2006. Four clinical sub-committees comprising more than 50 clinicians from sub-acute services across New South Wales as well as representatives from Queensland and the Australian Capital Territory were established to develop a set of proposals to be considered for incorporation into Version 2 of the classification. It is proposed that the final AN-SNAP Version 2 classification will be available for implementation from 1 July 2007.

Evaluating the planned substitution of the minimum data set-post acute care for use in the rehabilitation hospital prospective payment system.

OBJECTIVE: The objective of this study was to evaluate the payment implications of substituting the Minimum Data Set-Post Acute Care (MDS-PAC) for the FIM trade mark instrument for use in the planned prospective payment system (PPS) for inpatient rehabilitation hospitals. FIM trade mark is a trademark of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activites, Inc. RESEARCH DESIGN: We used a prospective cross-sectional design using consecutive sampling. SUBJECTS: We studied all Medicare admissions with stays of 3 days or more over a 2-month period to 50 inpatient rehabilitation hospitals in 22 states. MEASUREMENTS AND METHODS: Each participating institution completed both the FIM and the MDS-PAC assessments on all participants. Items from the MDS-PAC were combined and translated to create "FIM-like" items. We assessed agreement of classification into prospective payment cells using FIM assessment data and also using MDS-PAC data. Statistical adjustments were applied to improve the level of agreement. RESULTS: The mean differences between the FIM motor and cognitive scales and their MDS-PAC translations were 2.4 (mean = 45) and 0.0 (mean = 28), respectively, with scale correlations of.85 and.84. Weighted kappas on individual items ranged from.32 to.64. There were substantial hospital-specific differences in scoring. Payment cell classification using FIM data agreed with that using MDS-PAC data only 56% of the time. Twenty percent of the facilities experienced revenue shifts larger than 10%. CONCLUSION: Despite better item-level agreement than previously observed, poor payment cell agreement and substantial revenue shifts indicated that the MDS-PAC should not be substituted for the FIM trade mark instrument in the rehabilitation hospital PPS.

Hospital-based and freestanding skilled nursing facilities: any cause for differential Medicare payments?

Differential Medicare payments for hospital-based and freestanding skilled nursing facilities (SNFs) were eliminated by the SNF prospective payment system initiated in 1998. Closures and high negative margins of hospital-based facilities have prompted consideration of the need to revisit payment adjustments for this group of SNFs. We examine case mix-related and other factors behind the cost differences between hospital-based and freestanding SNFs. Some payment adjustment, notably for nontherapy ancillary services, may be reasonable for the short term.

Rehabilitation therapy in skilled nursing facilities: effects of Medicare's new prospective payment system.

In 1998 the Centers for Medicare and Medicaid Services (CMS) began phasing in a new prospective payment system (PPS) for Medicare payments to skilled nursing facilities (SNFs). I examine the effects of the new PPS on the level of rehabilitation therapy provided in SNFs. The percentage of residents of freestanding SNFs receiving extremely high levels of rehabilitation therapy dropped significantly, and the percentage receiving moderate levels increased. Freestanding SNFs, particularly for-profits, dramatically altered the services they provided in response to new financial incentives. This responsiveness underscores the importance of efforts now under way to refine the SNF PPS.

[Can emergency admissions to departments of internal medicine be replaced by planned admissions?]. / Kan akutte indlaeggelser konverteres til planlagte indlaeggelser på medicinske afdelinger?

INTRODUCTION: The aim of the study was to describe the pattern of admissions to a medical department and to analyse how far acute admissions can be replaced by planned subacute admissions to an outpatient department. MATERIALS AND METHODS: All acute admissions to the medical department during two six-day periods were registered. The department's registrars filled in a structured questionnaire and the senior registrars evaluated the admissions. In addition, a local general practitioner evaluated one-third of the admissions. RESULTS: Altogether, 214 consecutive patients were entered in the study. One-third of the patients had consulted their GP in the week before the admission. Admissions from the casualty department and from GPs were assessed as appropriate in 92% and 71% of the cases, respectively. The senior registrars assessed that 17-20% of the acute admissions could have been replaced by a subacute, planned admission. Only 5% of the patients shared this conclusion. The ability to predict the total length of stay was limited, and greatest accuracy was achieved in prediction of short-term stays. DISCUSSION: In a medical department with many acute admissions, it is possible to replace acute admissions with planned subacute admissions for a large group of patients.

Prospective per diem rates for skilled nursing care.

On July 1, 1998, Medicare's cost-related reimbursement method for skilled nursing facility care was replaced with a prospective payment system that includes a case-mix adjustment based on the Resource Utilization Groups to which Medicare residents are assigned. Shortly thereafter, Congress modified the new system in response to the industry's complaints about low payment rates. The new system aims to align Medicare payments more closely with the costs facility's incur in serving Medicare residents and slow Medicare spending growth. Recent rate increases have reduced the new system's ability to trim Medicare outlays.

Low-care residents in nursing homes: the impact of market characteristics.

Approximately 30% of nursing home residents were recently identified as low-care cases; that is, residents with low levels of acuity. Other institutional venues, board and care homes and assisted living facilities, for example, are often recommended as alternative domiciliaries providing more appropriate and less expensive care for these residents. In this investigation the effect of nine market factors on the prevalence of low-care residents in 14,646 nursing homes are studied. Government regulations, competition from other providers, and the overall munificence of the market are found to influence their prevalence. These results are discussed along with several issues inherent to channeling low-care residents to other care setting.

Assessing the RUG-III resident classification system for skilled nursing facilities.

Resource utilization groups, version III (RUG-III) is used by CMS to classify skilled nursing facility (SNF) residents into Medicare payment groups. Using a sample of 1,304 SNF residents with Medicare-covered stays, we find that RUG-III only explains 10.4 percent of the variance in total per diem costs. RUG-III explains variance in staff-time costs fairly well, but does not explain variance in non-therapy ancillary costs. Receipt of special treatments such as intravenous medications and respiratory therapy is strongly associated with high residual costs (p < 0.01). Modifications to the RUG-III system can increase its variance explanation.

Expansion of Medicare's definition of post-acute care transfers.

In October 1998, the definition of a transfer in Medicare's hospital prospective payment system was expanded to include several post-acute care (PAC) providers in 10 high-volume PAC diagnosis-related groups (DRGs). In this methodological article, the authors respond to a congressional mandate to consider more DRGs in the definition. Empirical results support expansion to many more DRGs that are split in ways that understate total PAC volumes, including 25 DRG pairs (with/without complications) and DRG bundles (e.g., infections) that together exhibit high PAC volumes. By contrast, some DRGs (e.g., craniotomy) are questionable PAC candidates because of their heterogenous procedure mix.

Getting clinicians involved: the Australian experience.

This paper explores the clinical changes that occurred following the introduction of casemix in Australia and more importantly how casemix classification systems and methodologies were influenced by clinicians. It highlights some of the important milestones, major events and key processes that were associated with the diffusion of Diagnosis Related Groups. Clinical leadership was critical. This was achieved through the combined activities of clinicians working through various national committees and organisations including the Australian Casemix Clinical Committee, the National Centre for Classification in Health, the various Commonwealth and State health departments and the respective specialist colleges and associations. These combined activities delivered a clinically meaningful, state-of-the-art casemix classification underpinned by a coding and data collection system that is both sophisticated in terms of its ability to meet the needs of practicing clinicians as well as being technologically advanced.

Final inpatient rehabilitation PPS rule improves on proposed rule.

On August 7, 2001, the Centers for Medicare and Medicaid Services (CMS--formerly HCFA) released the final rule for a new prospective payment system (PPS) for inpatient rehabilitation services describing the process that must be used to receive payment for such services provided to Medicare beneficiaries. The process consists of five steps: First, a clinician performs assessments of the patient upon admission and at discharge. Second, the patient is classified into a case-mix group (CMG) with an assigned relative-value weight within that CMG. Third, the Federal prospective payment rate is determined by multiplying the relative-value weight by an annually updated, budget-neutral conversion factor. Fourth, the Federal prospective payment rate is adjusted to account for facility-specific factors. Finally, the facility-adjusted payment rate may be adjusted for case-specific factors. The final rule eliminates three deficiencies in the proposed rule by providing increased payment for treating any comorbidities documented prior to the second day before discharge, providing more appropriate payment for transfer cases, and minimizing the paperwork associated with patient assessment.