Casemix and DRG

บุญชัย กิจสนาโยธิน MD., PhD. (Health Informatics) ศูนย์พัฒนามาตรฐานระบบข้อมูลสุขภาพไทย ศมสท. THIS

สถาบันวิจัยระบบสาธารณสุข

Thai Health Informatics Academy Seminar ครั้งที่ 8/2555

13 ธันวาคม 2555

Casemix system development in a resource limited country

Supasit Pannarunothai

Centre for Health Equity Monitoring

Faculty of Medicine, Naresuan University

Definition of DRG and Casemix

Diagnosis related group (DRG) Fetter et al 1980

Patient classification system for acute inpatients

Iso-resource group (lengths of stay, cost)

Used in the US prospective payment system (PPS)

Casemix

More generic term of patient classification systems

Covers all modes of care

Principle of iso-resource group

Diagnosis Related Group is a patient

classification system for acute inpatients to

measure hospital output. Patients in the same

DRGs will have the same lengths of stay and

the same level of hospital resource uses

What is DRG?

ระบบข้อมูลของกองทุนประกันสุขภาพต่างๆ

ระบบข้อมูลของ สปสช.

eClaim

Disease Management IS : NAP, DM, PPIS

OP individual etc.

ระบบข้อมูลของกรมบัญชีกลาง

ระบบข้อมูลของประกันสังคม

ระบบข้อมูลของพรบ.อุบัตเิหต ุ

DRG and alternative payment mechanisms

The Movement to Inclusive Payment

FinancialRisk

Cost Item Per

Diem

Per

CaseEpisode Capitation

Provider

Payor

Unit of Payment

% of

Premium

DRGs CRGs

Time 3MHIS 2001

Payment methods and risk distribution

Retrospective

Full cost

Discount

per diem Hospital

IP DRGs

IP and

OP

DRGs

Bundled

Hospital -

MD DRGs

Full

Capitation

Minimum Maximum Provider Risk

Per

Discharged Per

member

เคร่ืองมือการเงินประกนัสุขภาพ

สมดลุของการจา่ยชดเชย = ประสทิธภิาพ

ประสทิธผิลการรักษา

คา่ใชจ้า่ยสขุภาพ

CaseMix

Fee schedule

History of Thai DRG developments

1993 started research on Accident & Emergency DRG (N = 100 DRGs)

1995 researched on all patient DRG (500 DRGs)

1999 additional payment to hospitals for high cost low income inpatients (DRG RW>3)

2003 DRG version 3 (1,200 DRGs) payment to all hospitals (including teaching hospitals) by NHSO

2010 DRG version 5 is to be released (covers acute, subacute and psychiatric cases)

Allocation of DRG General principle Major

Diagnostic

Category

OR Procedure

DRG

Principal

Diagnosis ICD10

ICD9CM

Secondary Diagnoses

Age Discharge type

Version Refined Diagnosis

code

Procedure

code Groups Implement

1 No ICD-10 (WHO)

1992 ICD-9-CM

2000 511 Nov 1998

2 No ICD-10 (WHO)

1992 ICD-9-CM

2000 511 Feb 2001

3

3.0 5 levels

ICD-10 (WHO) 1992

ICD-9-CM

2000 1,283 Oct 2003

3.1 5 levels ICD-10 (WHO)

1992 ICD-9-CM

2000 1,283 Apr 2005

3.3 5 levels ICD-10 (WHO)

2005 ICD-9-CM

2005 1,283 Feb 2006

3.5 5 levels ICD-10 (WHO)

2005 ICD-9-CM 2005 1,467 -

4 5 levels

ICD-10 (WHO)

2007 + ICD-10-TM*

ICD-9-CM

2007

with extension

1,920 Oct 2007

Thai DRGs

* Thai Modification for data entry only (not for new classification)

Important features of Thai DRG

Adapt to Thai health care environments

Change from the US-DRG to AN-DRG for

more details on severity of illness

High practicality

Reclassification

Recalibration

How DRGs are calculated?

DRG Grouper

Diagnosis

ICD 10

Procedures

ICD 9 CM

Age

Sex

Discharge

status

Length of Stay (LOS)

DRGs

Co-morbidities

RW Adj RW

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Data needed for DRG system

Classification Diagnosis : Principle and Secondary Diagnosis Age Gender Procedure performed: Type of Discharge

Calibration Cost/Charge

How DRGs code look like?

DRG DRG Descriptions RW n %

15540 Newb adm wt >2499 gm wo CC 0.1699 84 6.53

06580 Gastroenteritis age < 10, no CC 0.2196 72 5.59

14500 Vaginal delivery wo complicating Dx 0.3652 45 3.5

14010 Caesarean delivery wo complicating Dx 1.3938 36 2.8

15541 Newb adm wt >2499 gm w other CC 0.4172 34 2.64

16500 Red Blood Cell Disorders, no CC 0.3368 30 2.33

02070 Other lens procedures, no CC 1.2643 29 2.25

04520 Respiratory infection/inflammation, no CC 0.6156 22 1.71

06070 Appendectomy, no CC 1.3054 22 1.71

04550 Chronic obstructive pulmonary disease,

no CC

0.6958 21 1.63

16 Srisangworn hospital data (Dec 2007)

Spectrum of Healthcare services

Preventive care

Ambulatory Care

Urgent& Emergency

Care

Acute care

Subacute care

Chronic care Home care Hospice

care

Success factors of Thai DRG

Continuous research grants (mostly domestic funds)

International inputs (study visits, experts)

Champions (financing, coding, programming, audit)

Opportunity on cost containment, efficiency

Information technology (cheaper, integrated network and faster)

Involving teaching hospitals in the public hearing processes

Cautions and limitations

Accuracy of coding data

Accuracy of cost data

Logics for calibration

Data library for each Major Diagnostic Category

Human resource: competency and number

Financing policy: global cap

Casemix Groupers

TDRG 5.0 Grouper

TSNAP 1.0 Grouper

TMHC 2.0 Grouper

All Patients

Grouper Manager

From: Zungsonthiporn 2008

Thai-Mental Health Casemix – TMHC

Thai-Subacute Nonacute Patient – TSNAP

Thai-Diagnosis Related Group - TDRG

Casemix Grouper

- PDx as defined - Basic data as for TDRG - Additional data + HoNOS

TMHC 2.0 Classification

Health of the Nation Outcome Scale - HoNOS

Principal Diagnosis - PDx

Thai-Mental Health Casemix – TMHC

Thai-Diagnosis Related Group - TDRG From: Zungsonthiporn 2008

Casemix Grouper

- PDx as defined - Basic data as for TDRG - Additional data + Modified Barthel Index + MMSE + Transfer Date

TSNAP 1.0 Classification

Mini-Mental State Examination - MMSE

Thai-Subacute Nonacute Patient – TSNAP

Thai-Diagnosis Related Group - TDRG Zungsonthiporn 2008

Lesson learnt

Short cut start by the classification and calibration using data from x hospitals

Focus on hospitals that have already keyed in clinical data of all patients with billing data

Critical success factors include:

Human resource factors

Data pooling power

Involvement of key players at the beginning

Case mix complexity

Severity of Illness

Risk of Mortality

Prognosis

Treatment Difficulty.

Need for Intervention

Resource Intensity

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