Essential Casemix PREPARED BY: ANNA COOTE & HEATHER GRAIN Objective To provide a plain English explanation of Casemix what it is? why its used? how it is done? 1
Cost per... cost to deliver care Terms... DRG ABF COSTWEIGHT MDC CASEMIX GROUPER OUTLIER INLIER 2
What is casemix... cost to deliver care A patient classification that provides a clinically meaningful way of relating: the types of patient treated in a hospital to the resources used by the hospital in the of the similar patients Why to: provide a job costing system for healthcare group patients of similar cost, disorder DRGs are based cost to upon: deliver care Patient age Sex Diagnosis Procedures Length of stay Mental health status Urgency of admission Same day status Mode of separation (discharge, transfer, death) are calculated automatically via an algorithm which identifies the DRG to which an episode of care is assigned. 6 3
Major Diagnostic cost to deliver Category care 06 DRG SURGICAL HIERARCHY BY MDC AND DRG DRG MDC 06, DISEASES & DISORDERS OF THE DIGESTIVE SYSTEM STOMACH, OESOPHAGEAL & DUODENAL PROCEDURES 308 311 MAJOR SMALL & LARGE BOWEL PROCEDURES 302 303 RECTAL RESECTION 300 301 PERITONEAL ADHESIOLYSIS 304 305 APPENDICECTOMY 316 317 MINOR SMALL & LARGE BOWEL PROCEDURES 306 307 ANAL & STOMAL PROCEDURES 312 HERNIA PROCEDURES 313 315 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES 318 319 7 Major Diagnostic cost to deliver Category care 06 Hernia Age >9 Y N Inguinal or femoral only N Y 313 314 OR procedure 315 3 Other Dig system OR procedure Com &/or comorbi dity 318 319 8 4
DRG 314 cost to deliver care DRG 314 INGUINAL & FEMORAL HERNIA PROCEDURES AGE >9 OPERATING ROOM PROCEDURES Unilat ing hernia repair Repair direct inguinal hernia Repair indirect inguinal hernia Direct inguinal hernia repair graft Indirect inguinal hernia repair graft Inguinal hernia repair graft Bilat inguinal hernia repair Bilat direct inguinal hernia repair Bilat indirect inguinal hernia repair Bilat direct/indirect inguinal hernia repair Bilat Direct inguinal hernia repair graft Bilat indirect inguinal hernia repair graft Bilat direct/indirect inguinal hernia pro Bilat inguinal hernia repair graft Unilat femoral hernia repair graft Unilat femoral hernia repair Bilat femoral hernia repair graft Bilat femoral hernia repair 9 DRG Structure 4 DIGIT NUMERIC STRUCTURE Eg. A12B The last digit indicates the level of the DRG A the highest weight for a DRG B the second highest weight for a DRG C the third highest weight for a DRG D the fourth highest weight for a DRG Z no split (DRGs with a final digit of Z have no other possible last digit) 5
Average cost AVERAGE COST: average cost of all DRGs. = cost of providing inpatient services for all episodes of care in the period / total number of episodes in the period all episodes all care DRG Cost Weight DRG COST WEIGHT the average cost of a DRG compared to the AVERAGE COST It is a representation of the difference in cost of a DRG to the average cost. Hence: Each DRG has a Cost Weight, which can then be translated into a monetary unit (dollars, riyals, etc.). 6
Here s a fictitious example for DRG X12Z: Average Cost Weight for the year 2014 = $5000.00 DRG: X12Z weight = 0.500 $5,000 X 0.500 = $2.500.00 A case with DRG X12Z is considered to have a service delivery cost of $2500.00 This weight can then be used to pay the hospital for the service This means that there is only one calculation of the price to be paid for an admission. All procedures, products, services are covered within the cost weight for the calculated DRG NOTE: The average length of stay for a DRG is also calculated. 7
National & cost International to deliver care DRG variations Cost weights will vary between regions, however the DRG system does not take this into account. ANDRGs are based on the Australian Health Care system. Users of ANDRGs outside Australia will eventually need to develop their own DRG Cost Weights. A DRG Mix Components of hospital cases based on similarities of diagnoses, Diagnosis procedure ICD ACHI codes DRG Weight Colonoscopy for Family History of Ca Z12.1 Z80.0 32090 00 Z64B 0.16 Colonoscopy for constipation K59.0 32090 00 G44B 0.66 Colonoscopy polypectomy for tubular adenoma of the sigmoid colon D125 M8211/0 32093 00 G44C 0.19 Colonoscopy for PH polyps Z09.0 Z87.12 32090 00 Z40Z 0.19 Table 1. DRGs for Endoscopy 8
DRG Creep cost to deliver care Process where hospitals manipulate diagnostic information to achieve DRGs with higher weights in order to receive high payment. Inlier & Outlier cost to deliver care INLIER length of stay fits within the range of LOS resource use for that DRG the case costs can be expected to be covered (or exceeded by) the amount received. OUTLIER case which has an unusually long hospital stay, or whose requires an unusual amount of resources. the case costs more than can be expected to be covered by the amount received. 9
A Inlier Mix of & hospital Outlier cases based on similarities of diagnoses, 10
Implications Less complicated billing system Requires competent clinical coders Potential for one issue focus Potential for inappropriate discharge of patients Improvement of hospital efficiency (clinical billing) Loss of essential but low performing hospitals (Service Vs financial efficiency) Swings cost Roundabouts to deliver care 11
Swings cost Roundabouts to deliver care Managing Payments We paid you too much You paid us too little A Clinical Mix of hospital Coding cases based DRGs on similarities of diagnoses, 12
A Clinical Mix of hospital Coding cases based DRGs on similarities of diagnoses, Casemix ambulatory care???? Watch this space 13
A Any Mix of Questions? hospital cases based on similarities of diagnoses, Bettong 14