Diagnosis-Related Groups in Europeeurodrg.projects.tu-berlin.de/publications/Korean_edition_DRG_book.pdf · Diagnosis-Related Groups in Europe Moving towards transparency, efficiency

,

DRG

Reinhard Busse, Alexander Geissler,Wilm Quentin, Miriam Wiley

Diagnosis-Related Groups in Europe

Open University Press

2012 12 17

2012 12 21

/

/

/ ()

/ ()

/ 2001 10 15

/ 6-0425

/ 4 336 15

/ (02) 921-0653

e - m a i l / [email protected]

/ www.medbook.co.kr

/ 32,000

I S B N / 978-89-94467-81-8 93510

Original English language edition copyright [2011]

Open International Publishing Limited. All rights reserved.

Korean language edition of

[Diagnosis-Related Groups in Europe] by

[Busse, Geissler, Quentin and Wiley]

Copyright [Daehan Medical Book Publishing] [2012] All rights reserved.

.

DRG - ,

Diagnosis-RelatedGroups in Europe

Moving towards transparency,efficiency and quality in hospitals

Edited by

Reinhard Busse, Alexander Geissler,Wilm Quentin, Miriam Wiley

Open University Press

viiContents

Contents

1

01 DRG 3

MiriamWiley

02 DRG : 9 AlexanderGeissler,WilmQuentin,DavidScheller-Kreinsenand ReinhardBusse

03 DRG DRG 23 WilmQuentin,AlexanderGeissler,DavidScheller-Kreinsenand ReinhardBusse

04 DRG DRG 37 ConradKobel,JosselinThuilliez,MartineBellangerand Karl-PeterPfeiffer

05 DRG : ? 61 SiokSwanTan,LisbethSerdn,AlexanderGeissler,MartinvanIneveld, KenRedekop,MonaHeurgrenandLeonaHakkaart-vanRoijen

xi

xvii

1 xix

2 xxiii

xxv

List of contributors xxvii

viii Diagnosis-Related Groups in Europe

06 DRG : 79 FrancescCots,PietroChiarello,XavierSalvador, XavierCastellsandWilmQuentin

07 DRG : , 99 AndrewStreet,JacquelineOReilly,PadraicWardandAnneMason

08 DRG : For better or worse? 125 ZeynepOrandUntoHkkinen

09 DRG 141 WilmQuentin,DavidScheller-KreinsenandReinhardBusse

10 , : 159 ReinhardBusseandWilmQuentin

2

11 : LKF 187 ConradKobelandKarl-PeterPfeiffer

12 : HRG (Healthcare Resource Group) 211 AnneMason,PadraicWardandAndrewStreet

13 : GHM (homogeneous groups of patients) 239 ZeynepOrandMartineBellanger

14 : G-DRG 261 AlexanderGeissler,DavidScheller-Kreisen, WilmQuentinandReinhardBusse

15 : 293 JacquelineOReilly,BrianMcCarthyandMiriamWiley

16 NordDRG: 315 MiikaLinnaandMarttiVirtanen

ixContents

17 : NordDRG 325 KristiinaKahur,TnisAllik,AinAaviksoo, HeliLaarmannandGerliPaat

18 : DRG 347 KirsiKautiainen,UntoHkkinenandJormaLauharanta

19 : DRG 367 LisbethSerdnandMonaHeurgren

20 : JGP (Jednorodne Grupy Pacjentw) - DRG 387 KatarzynaCzach,KatarzynaKlonowska,Mariawiderekand KatarzynaWiktorzak

21 : DRG 25 409 CuMateus

22 : DRG - 431 FrancescCots,XavierSalvador,PietroChiarello, MontseBustinsandXavierCastells

23 : DBC (The Diagnose Behandeling Combinaties) 457 SiokSwanTan,MartinvanIneveld,KenRedekopand LeonaHakkaart-vanRoijen

Index 480

xiAbbreviations

Abbreviations

A&E Accident & Emergency (department, services) (, )

AC Autonomous Community ()

ACCC Australian Casemix Clinical Committee

ACHI Australian Classification of Health Interventions

ACRA Advisory Committee on Resource Allocation

ACSS Central Administration of the Health System(Portugal)

()

ADRG Adjacent DRG ADRG

AFS Annual financial statement(s)

AFSSAPS Agency for Safety of Medical Products (France) ()

(A)LOS (Average) Length(s) of stay ()

AMI Acute myocardial infarction

AN-DRG Australian National DRG AN-DRG

AOTM Health Technology Assessment Agency (Poland) ()

AP-DRG All-Patient DRG AP-DRG

APG Ambulatory Patient Group(s)

AR-DRG Australian Refined DRG AR-DRG

ARH Regional Hospital Agencies (France) ()

ARS Regional Health Agencies (France) ()

ATIH Technical Agency for Hospital Information (France)

()

ATU Temporary access for treatment (France) ()

AWBZ Exceptional Medical Expenses Act (Netherlands) ()

BQS Federal Office for Quality Assurance (Germany) ()

CART Classification and Regression Trees

CAT Computerized axial tomography ()

CC Complication and co-morbidity

CCAM French classification of procedures (France) ()

CCSAE Clinical Costing Standards Association of England

xii Diagnosis-Related Groups in Europe

CED Coverage with Evidence Development ()

CHS Catalan Health Service

CM Major category (France) ()

CMA Severe/acute/complicated episode(s) (France)// ()

()

CMBD Joint standardized minimum basic dataset (Spain)

CMD Major diagnostic categories (France) ()

CMI Casemix index

CMS Centers for Medicare and Medicaid Services

CMU Casemix unit (Ireland) ()

COPD Chronic obstructive pulmonary disease

CQUIN Commissioning for Quality and Innovation (framework)

()

CT Computerized tomography

CVZ Healthcare Insurance Board (Netherlands) ()

DBC Diagnosistreatment combinations (Netherlands) -()

DBC-DIS DBC information system (Netherlands) DBC ()

DBC-O DBC onderhoud (Netherlands DBC administrative organisation)

DBC

( DBC )

DEA Data envelopment analysis

DG Day grouper

DIM Medical information units (France) ()

DIMDI German Institute of Medical Documentation and Information

DoHC Department of Health and Children (Ireland) ()

DPG Day-patient grouper

DRG Diagnosis-related group DRG

ED Emergency department

EHESP Ecole des hautes tudes en sant publique (School of Public Health)

EHIF Estonian Health Insurance Fund

ENC National Cost Study (France) ()

ENCC Hospital cost database (France) ()

ESRI Economic and Social Research Institute (Ireland) ()

EU European Union

EU15 European Union Member States prior to May 2004 2004 5 EU

xiiiAbbreviations

FPG Case Fees Act (Germany) ()

G-BA Federal Joint Committee (Germany)

GHCA General Health Care Act (Spain) ()

GHJ Homogeneous groups of days (French patient classification tool)

GHM Homogeneous groups of patients (French patient classification system)

GP General practitioner

HAS High Health Authority (France) ()

HCAT HIPE Coding Audit Toolkit (Ireland) HIPE ()

HCFA Health Care Financing Administration (United States) ()

HDG Main diagnosis group (Austria) ()

HES Hospital Episode Statistics

HIPE Hospital In-Patient Enquiry (Ireland) ()

HNDP Hospital Network Development Plan

HPID Health Policy and information Division (Ireland) ()

HRG Healthcare Resource Group(s) (Ireland) ()

HRID Health Reserch and Information Division (Ireland) ()

HSE Health Service Executive

HTA Health Technology Assessment

ICD International Classification of Diseases (WHO) (WHO)

ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification

9

ICD-10 International Classification of Diseases,Tenth Revision

10

ICD-10-AM International Classification of Diseases,Tenth Revision, Australia Modification

10

ICD-10-GM International Classification of Diseases,Tenth Revision, German Modification

10

ICHI International Classification of Health Interventions

ICPM International Classification of Procedures in Medicine

ICS Catalan Health Care Institute (Spain) ()

ICU Intensive care unit

IGZ Healthcare Inspectorate (Netherlands) ()

InEK Institute for the Hospital Remuneration System (Germany)

()

xiv Diagnosis-Related Groups in Europe

IRDES Institute for Research and Information in Health Economics (France)

()

IR-DRGs International Refined DRGs IR-DRGs

IRF-PPS American Inpatient Rehabilitation Facility Prospective Payment System

IT Information technology(ies)

JGP Homogeneous groups of patients (Polish patient classification system)

JGP( )

KAKuG Federal Hospitals Act (Austria) ()

KHEntgG Hospital Remuneration Act (Germany) ()

KM Swedish national classification system for non-surgical procedures

KRUS Agricultural Social Insurance Fund (Poland) ()

KV Swedish national classification system for surgery andnon-surgical procedures

LDF Procedure- and diagnosis-oriented case groups (Austria)

()

LKF Performance-oriented hospital financing framework (Austria)

()

LTR Swiss performance-oriented payment system for rehabilitation

MAS Major ambulatory surgery

MBDS Minimum basic dataset

MDC Major diagnostic category

MEL Single medical procedure (Austria) ()

MERRI Missions denseignement, de recherche, de reference et dinnovation (teaching, research, recourse and innovation, France)

, ,

()

MFF Market forces factor

MIGAC Missions of general interest and assistance with contracting, including payments for education, research and public health programmes

,

MRI Magnetic resonance imaging

MS-DRG Medicare Severity DRG DRG

NCECI NOMESCO Classification of External Causes of Injury

NOMESCO

NCSP NOMESCO Classification of Surgical Procedures NOMESCO

NFZ National Health Fund (Poland) ()

xvAbbreviations

NHS National Health Service

NOMESCO Nordic Medico-Statistical Committee

NordDRG Nordic patient classification system

NPR National Patient Register

NUB New Diagnostic and Treatment MethodsRegulation (Germany)

()

NZA Dutch Healthcare Authority

OECD Organisation for Economic Co-operation and Development

OPCS Office of Population Censuses and Surveys (British Classification of Surgical Operations and Procedures)

( )

OPS Procedure classification codes (Germany) ()

OR Operating room

P4P Pay for performance

PbR Payment by Results

PCCL Patient Clinical Complexity Level

PCS Patient classification system

PCSI Patient Classification Systems International

PCT Primary Care Trust

PERFECT PERFormance, Effectiveness and Cost of Treatment episodes

PERFECT

PLICS Patient-Level Information and Costing Systems

PMSI Hospital activity database (France)

PRIKRAF Private Hospitals Financing Fund (Austria) ()

QMS Quality management system(s) (Germany) ()

RBG Rehabilitation Treatment Groups (Germany) ()

R&D Research and development

RRI Relative resource intensity

RSS Patient discharge summary (France) ()

RUM Departmental discharge summary (France) ()

RV Relative value(s) (Ireland) ()

SALAR Swedish Association of Local Authorities and Regions

SAM State Agency of Medicines (Estonia) ()

SD Skewed distribution

SGB V German Social Law, Fifth book

xvi Diagnosis-Related Groups in Europe

SHF State Health Fund (Austria) ()

SHI Statutory health insurance

STAKES National Research and Development Centre for Health and Welfare

TB Tuberculosis

TUB Berlin University of Technology

UBA Basic Care Unit (Spain) ()

UMBDS Uniform minimum basic datasets (Portugal)

VAT Value-added tax

VHI Voluntary health insurance

VWS Ministry of Health, Welfare and Sport (Netherlands) ()

WHO World Health Organization

XHUP Public Hospital Network (Spain) ()

ZBC Independent Treatment Centre (Netherlands) ()

ZUS Social Insurance Institution (Poland) ()

ZVW Health Insurance Act (Netherlands) ()

xviiForeword

( )

(Robert Fetter) 1970 1980 DRG

. ,

DRG .

2012 5 , ,

. OECD

.

, , DRG

.

DRG , DRG

, DRG

.

. , DRG

.

DRG ,

.

. DRG

. 1983 DRG

, .

. DRG

. , DRG

,

.

xviii Diagnosis-Related Groups in Europe

DRG , ,

. , DRG

, DRG

. EuroDRG (www.eurodrg.

eu) DRG

. , ,

DRG ,

DRG .

.

.

DRG .

, DRG ,

. .

DRG DRG

.

DRG .

2012 7

Reinhard Busse, Alexander Geissler and Wilm Quentin

xixForeword

1Foreword 1

, ,

.

(OECD) 1980 DRG 30

, DRG

. DRG ,

? DRG

? ? DRG

DRG , DRG

.

,

. DRG

one size fits all .

DRG ,

, , , ,

. ,

, casemix system

. , DRG

.

DRG

. ,

. 1980 (William

Roper) DRG

capitation .

,

.

xx Diagnosis-Related Groups in Europe

OECD

. World Bank

, .

,

. ,

. 1970 1980

, ,

.

DRG , DRG

. 1990 , 10

, .

(: , ,

) .

OECD

. 50% ,

58%, 60% , 70%

. .

line-item budget

.

, DRG . OECD

, , software grouper

. 350

DRG .

. ,

, 5 10 .

. ,

, ,

.

xxiForeword

,

. .

. , OECD

.

, , , ,

.

. , ,

DRG . ,

, , DRG

, .

, ,

. ,

, , ,

.

, , ,

.

, , .

European Observatory on Health Systems and Policies ,

. European

Observatory on Health Systems and Policies

.

, .

Jack Langenbrunner

xxiiiForeword

.

1990

.

clinical pathway

. .

. 40

, ,

. ,

,

,

.

. ,

.

10 68% ,

.

. (

),

.

,

.

?

?

?

.

2Foreword 2

xxiv Diagnosis-Related Groups in Europe

, DRG

.

DRG , ,

DRG

.

, 1 DRG 2

12 DRG DRG

.

. , ,

.

Stefan Konstantinov

xxv Foreword

Acknowledgements

EuroDRG

.

. 1

,

Dana Forgione Frank Hartmann . ,

Nicole Russell Jonathan North .

EuroDRG .

(2009), (2009), (2010), (2010), (2011) (2011)

EuroDRG Alexandra Starke, Carola Haring, Esther

Martinez Amor, Reelika Ermel . EuroDRG

EuroDRG Pascal Garel,

Bernhard Gibis, Luca Lorenzoni, Predrag Djukic, Predrag Stojicic

.

, .

EHMA Hospital Financing: Diagnosis Related

Groups-Leading the Debate (2009). 4 Nordic Case-

mix Conference (2010). EMHA Annual Conference (2010).

8 European Conference on Health Economics (ECHE)

(2010). Polish DRG System Directions of Future Devel-

opments (2010). Funding Models to Support

Quality and Sustainability - A Pan-Canadian Dialog (2010).

Patient Classification Systems International (PCSI) Winter School

(2011). 3 German Association of Health Econom-

ics Conference (2011). Health Financing Reforms to

Improve Efficiency and Quality of Care (2011). 12

xxvi Diagnosis-Related Groups in Europe

European Federation of National Associations of Orthopaedics and Trau-

matology (EFFORT) (2011). European Observatory on

Health Systems and Policies Changing the Payment System

for Hospital Care in Bulgaria to Improve Equity and Efficiency (2011).

8 World Congress on Health Economics (2011).

.

.

European liaison office Annette Schade, Silke Hnert, Katrin Dudwig

.

, (Seventh Framework Programme, research

area HEALTH-2007-3.2-8, reference: 223300) Diagnosis-Related Groups in Eu-

rope: towards efficiency and quality research project

.

, Phillipp Seibert, Claudia Brendler, Claudia Reiche, Julia

Rttger .

Reinhard Busse

Alexander Geissler

Wilm Quentin

Miriam Wiley

xxviiList of contributors

List of contributors

Ain Aaviksoo, PRAXIS Center for Policy Studies, Estonia

Alexander Geissler, Berlin University of Technology, Germany

Andrew Street, University of York, United Kingdom

Anne Mason, University of York, United Kingdom

Brian McCarthy, Economic and Social Research Institute Dublin, Ireland

Cu Mateus, Universidade Nova de Lisboa, Portugal

Conrad Kobel, Innsbruck Medical University, Austria

David Scheller-Kreinsen, Berlin University of Technology , Germany

Francesc Cots, Hospital del Mar Research Institute, Spain

Gerli Paat, PRAXIS Center for Policy Studies, Estonia

Heli Laarmann, PRAXIS Center for Policy Studies, Estonia

Jacqueline OReilly, Economic and Social Research Institute Dublin, Ireland

Jorma Lauharanta, Hospital District of Helsinki and Uusimaa, Finland

Josselin Thuilliez, National School of Public Health, France

Karl-Peter Pfeiffer, Innsbruck Medical University, Austria

Katarzyna Czach, National Health Fund, Poland

Katarzyna Klonowska, National Health Fund, Poland

Katarzyna Wiktorzak, National Health Fund, Poland

Ken Redekop, Erasmus University Rotterdam, the Netherlands

Kirsi Kautiainen, National Institute for Health and Welfare, Finland

Kristiina Kahur, Estonian Health Insurance Fund, Estonia

Leona Hakkaart-van Roijen, Erasmus University Rotterdam, the Netherlands

Lisbeth Serdn, National Board of Health and Welfare, Sweden

Maria widerek, National Health Fund, Poland

Martine Bellanger, National School of Public Health, France

Martin van Ineveld, Erasmus University Rotterdam, the Netherlands

Martti Virtanen, Nordic Casemix Centre, Finland

Miika Linna, National Institute for Health and Welfare, Finland

Miriam Wiley, Economic and Social Research Institute Dublin, Ireland

Mona Heurgren, National Board of Health and Welfare, Sweden

xxviii Diagnosis-Related Groups in Europe

Montse Bustins, Catalan Health Service, Spain

Padraic Ward, University of York, United Kingdom

Pietro Chiarello, Hospital del Mar Research Institute, Spain

Reinhard Busse, Berlin University of Technology, Germany

Siok Swan Tan, Erasmus University Rotterdam, the Netherlands

Tnis Allik, North Estonian Medical Centre, Estonia

Unto Hkkinen, National Institute for Health and Welfare, Finland

Wilm Quentin, Berlin University of Technology, Germany

Xavier Castells, Hospital del Mar Research Institute, Spain

Xavier Salvador, Catalan Health Service, Spain

Zeynep Or, Institute of Research and Information on Health Economics, France

1

01 DRG

02 DRG :

03 DRG DRG

04 DRG DRG

05 DRG : ?

06 DRG :

07 DRG : ,

08 DRG : For better or worse?

09 DRG

10 , :

3DRG 01

DRG MiriamWiley

1.1

. ?

formulate .

,

.

.

(Dr Eugene Codman, Address to the

Philadelphia County Medical Society, 1913)1

20 Massachusetts General Hospital (Codman)

100

(Fetter, 1991). 1960

(Robert Fetter) .

utilization review quality assurance

.

20 (Fetter, 1991,

p.4). 1965 Medicare

, DRG

1 Codman, 1913~1917

01

4 Diagnosis-Related Groups in Europe

1983 .

. 1970 information technology

(Fetter, 1993). 1973 DRG

54 Major Diagnostic Categories 333 DRG

. Federal Social Security Administration , 83

383 DRG (Fetter et al., 1980).

1978 . DRG

Health Systems Management Group Health

Care Financing Administration (HCFA) ,

(Rodrigues, 1993). 23

470 DRG HCFA-DRG

Prospective Payment System 1983

.

(Mayes)

2 (Mayes, 2007, p. 21),

,

(ibid, p. 21).

.

DRG 30

,

.

1.2

1983 DRG

.

.

1980 ,

.

5DRG 01

. 1984

, , , 5

DRG (Robert Fetter)

. 2 11 .

1987 15

,

Patient Classification Systems International (PCSI) .2

1984 DRG .

DRG DRG

DRG

.

DRG 1986 , 1987 , 1988

. DRG

, DRG

.

DRG ,

.

PCSI DRG , DRG

.

DRG

. 1985 DRG

, OECD Organisation for Economic Co-operation and Development DRG

(Rodrigues, 1989). 1980

European Union (EU) DRG

DRG .

(Casas & Wiley, 1993; Leidl et al., 1990).

WHO DRG

.

, DRG ,

, DRG

.

1988 DRG

2 PCSI PCSI (www.pcsinternational.org, 2011. 7. 26 )


(21 ).

30% . 1991 1993

DRG (Magnussen & Solstad, 1994). 1993

DRG (15 ). DRG

1988 . 8

1988~1993 DRG , 1992

AN-DRG .

1993 DRG (McNair

& Duckett, 2002).

1.3 : DRG

DRG casemix ( )

(Kimberley et al., 2008). ,

.

. DRG

DRG

. DRG

. DRG

.

EU 7 Framework Programme(FP7)

EuroDRG 3 ( ) . 12

EuroDRG (, , , , , ,

, , , , , ) ( vs. ,

vs. ), (National Health Service vs.

Statutory Health Insurance), EU ( vs. )

. . ,

, , , DRG

.

.

3 EuroDRG (www.eurodrg.eu, 2011. 7. 26 ).

7DRG 01

. 1 DRG , 2

12 DRG ,

.

, DRG

. 1 DRG

, (Fetter, 1993,

p. v) DRG .


1.4

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Codman, E.A. (19131917). The product of a hospital (Philadephia address) (Box 4, Folder 77), in E.A. Codman. Ernest Amory Codman papers, 18491981: Finding Aid. Boston, MA: Boston Medical Library and Francis A. Countway Library of Medicine (B MS c60).

Fetter, R.B., ed. (1991). DRGs : Their Design and Development. Ann Arbor, MI: Health Adminis-tration Press.

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Fetter, R.B., Shin, Y., Freeman, J.L., Averill, R.F., Thompson, J.D. (1980). Casemix definition by diagnosis-related groups. Medical Care, 18(2):153.

Kimberly, J.R., de Pouvourville, G., DAunno, T., eds. (2008). The Globalization of Managerial Innovation in Health Care. Cambridge: Cambridge University Press.

Leidl, R, Potthoff, P., Schwefel, D., eds. (1990). European Approaches to Patient Classification Systems. Berlin: Springer-Verlag.

Magnussen, J., Solstad, K. (1994). Case-based hospital financing: the case of Norway. Health Policy, 28:2336.

Mayes, R. (2007). The origins, development and passage of Medicares revolutionary prospective payment system. Journal of the History of Medicine and Allied Sciences, 62(1):2155.

McNair, P., Duckett, S. (2002). Funding Victorias public hospitals: the casemix policy of 20002001. Australian Health Review, 25(1):7299.

Rodrigues, J.M. (1989). LEurope des DRG. Sozial- und Prventivmedizin, 34:152155. Rodrigues, J.M. (1993). DRGs: origin and dissemination throughout Europe, in M. Casas, M. Wi-

ley, eds. Diagnosis-Related Groups in Europe, Uses and Perspectives. Berlin: Springer-Verlag. Wiley, M. (1990). Patient classification systems: overview of experiments and applications in Eu-

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9 DRG : 02

2.1

1983 DRG , DRG

(Paris et al., 2010). DRG

. DRG

casemix .

DRG payment rate . DRG

. DRG

(Busse et al., 2006;

Schreyogg et al., 2006).

2.2 DRG

, DRG

. , DRG

(6 ). DRG

. 2,

3 fee-for-service

global budgets . 2.4 DRG

,

.

DRG :

AlexanderGeissler,WilmQuentin,DavidScheller-KreinsenandReinhardBusse

02


DRG .

.

2.2 DRG

(2.4 ) DRG

.

, ,

.

.

( ) .

2.1 DRG 2010

. DRG

, DRG

.

2.1 DRG

DRG 2010

1997 ,

1992

2003

1995 ,

, ,

1991

2003

1992

2005

2008

1984

() 1996 ,

1995 ,

: 2

: DRG ,

DRG ( 2.1 ).

11 DRG : 02

2.1 1980 DRG .

DRG ,

. DRG

, DRG DRG

. 10

. DRG .

1992 DRG 1993 .

DRG DRG

. DRG

.

2010

2005

2000

1995

1990

1985

1980

LKF

HRG

NordD

RG

NordD

RG

GHM

G-DRG

AR-DRG

DBC

JGP

AP-DRG

()

AP-DRG

(CMS-DRG)

NordD

RG

DRG

DRG DRG

2.1 DRG DRG

: 2

: 1993 HCFA-DRG 2003 AR-DRG


DRG , ,

. DRG

. DRG

.

. 1990 2000

DRG .

,

.

, DRG

(Shle-

ifer, 1985) (7 ).

1980 DRG

. , , ,

, , , ,

, DRG ,

. DRG

.

2.1 , DRG

. , AR-DRG AP-DRG CMS-

DRG . DRG

, .

, , NordDRG

(16 ).

DRG , DRG .

(2.3 )

(2.4 ) DRG .

13 DRG : 02

2.3

DRG (Lan- DRG (Lan- DRG (Lan-

genbrunner & Wiley, 2002). DRG fee-for-service

global budgets . DRG

. DRG

. ,

.

. , , ,

, .

.

. 2.2

.

2.3.1

DRG

fee-for-service payment .

.

.

.

2.2

/

+ + - 0 0 - 0

DRG + - 0 + 0 - +

- - + 0 0 + -

: Barnum et al. (1995) WHO(2000)

: + /-: /; 0: ; 7


.

,

.

.

. ,

.

.

2.3.2

global budgets DRG

.

.

.

.

need

.

target budgets .

.

( 2.2).

.

DRG .

2.3.3 DRG

DRG .

DRG .

DRG DRG-based payment

. DRG

,

. DRG

15 DRG : 02

. DRG

DRG .

DRG DRG

, ,

.

. DRG

DRG .

( 2.2).

. DRG

DRG . DRG

.

,

( 10.2).

. 2.4 .

2.4

,

.

(Miller, 1977).

, ,

. 1980

.

(McKee & Healy, 2002).

. .

2.3 DRG 1995 2008 2

12 .

DRG

.

12 1990 2008


2.3 1995 200

8

-

2008

1995

2008

1995

2008

1995

2008

1995

2008

1995

2008

1995

2008

10

1.8

1.6

-12.8

5.1

2.8

-45

.7n.a.

n.a.

n.a.

3.8d

3.2

-16.8

2.6

2.2

-14.9

1.7

1.2

-29.3

5.0

1,000

6.5

5.6

-13.2

6.6

3.9

-41.9

3.0

1.9-36

.24.9a

3.6

-27.1

6.9

5.7

-18.2

3.1

2.7j

-13.1

3.0

100

21.9

26.7

22.0

17.2

16.8

-2.6

19.9

19.0

-4.7

20.3

16.7

-18.1

19.2

20.7

8.0

14.6

13.6

-7.2

2.4

,

9.7

6.8

-29.9

10.5

5.8

-45

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3.9

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5.9

5.8

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6.6

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-5.8

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%

,

77.0

80.4

4.4

74.9

69.7

-7.0

74.0

n.a.

n.a.

75.3

76.4

1.5

81.8

76.2

-6.8

82.5

88.9

7.8

1.6

%

40.4

40.0

-1.0

35.7

c33.0

-7.6

42.1

35.0

-16.9

40.9

37.3

-8.8

36.4

34.1

-6.3

n.a.

n.a.

n.a.

1.9

1,000

3.5

4.6

32.4

3.2

3.3

4.9

2.2

2.7

24.1

3.3

3.4

4.5

3.1

3.6

16.1

2.1

3.1

48.2

2.1

%

56.2

55.1

-1.9

n.a.

67.1

n.a.

85.1

81.2

j-4.6

47.1

54.1

14.9

48.2

51.1

6.0

53.2

47.1

-11.4

2.1

17 DRG : 02

2.3

- 2008

1995

2008

1995

2008

1995

2008

1995

2008

1995

2008

1995

2008

10

0.8

0.6

-23.2

2.2g

2.0

-6.9

1.4

1.3

-7.1

1.5

1.2

-17.6

1.1

0.9f

-21.6

n.a.

n.a.

n.a.

5.0

1,000

3.5

2.9

-19.2

5.8

4.4

-23.4

3.2

2.8

-13.6

3.0

2.5

-18.0

3.0

2.2h

-28.2

2.3

2.7

19.2

3.0

100

9.6

11.1

15.4

n.a.

n.a.

n.a.

11.1

11.2

j0.9

10.7

11.4

6.7

16.3

15.2

j-6.6

21.2

12.2

-42.5

2.4

,

9.9

5.9

-40

.4n.a.

n.a.

n.a.

7.9

6.8j

-13.9

8.2

6.5

-20

.75.2

6.0

j15.4

8.5d

7.4

-12.8

1.9

%

,

73.3

55.7

-24.0

n.a.

n.a.

n.a.

72.6

72.6

j0.0

76.4

77.7

1.7

75.9

n.a.

n.a.

82.3

d84

.83.1

1.6

%

49.1

39.6

e-19.3

n.a.

32.0

n.a.

33.9

20.8

i-38

.631.0

28.2

-9.0

54.7

29.6

j-45

.9n.a.

n.a.

n.a.

1.9

1,000

2.9b

3.7j

26.1

2.3

2.2

-6.7

2.9

3.7

25.2

2.7

3.5

30.1

2.9

3.6i

24.0

1.8

2.6

46.4

2.1

%

n.a.

38.1

jn.a.

n.a.

52.1

n.a.

60.2

54.1

-10.1

53.1

61.1

15.1

n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

2.1

Key

: a 1993

; b 199

7; c

199

9; d

2000; e 20

01; f

2003; g

2004; h

2005; i

2006; j

2007 1995

2008

.

: WHO

, 20

11

: n/a:


. 1 2008 12

3~5 . 1995 3~6 .

. 1995 2008 18.1%,

42.5% . (2.6%),

(4.7%), (6.6%) (7.2%) .

22% 15% .

(

45% , 2% ). 1995, 2008

2 ( ). , ,

, , 1995 2008

. 2008 (89%) (56%)

1995 1.6 .

. 2008

.

.

,

.

. , ,

.

( 2.4).

DRG . DRG

. DRG

. DRG

.

2.5

DRG .

DRG , ,

19 DRG : 02

.

.

. 1(1~10) DRG

, DRG

. 1 DRG

DRG .

DRG DRG

. 3 DRG DRG

. 4 DRG (PCS) . 5

. 6

DRG ,

. 7 8 DRG

. 9 12 DRG

. 10

DRG .

2(11~23) EuroDRG 12 DRG

. 12 , , ,

, , , , , , , .

. DRG

2.4 ( %), 2008

(%) (%) (%)

73 19 9

89 0 11

66 9 25

49 36 15

88 0 12

0 100 0

95 0 5

86 7 8

74 17 9

98 0 2

96 4 0

: Paris et al., 2010

: (17 ).


.

DRG . 2

DRG

. DRG

DRG 1 . 2 DRG

. 3

DRG DRG . 4 DRG

. 5

DRG , 6 DRG

. 7 DRG

8 DRG .

21 DRG : 02

2.6

Barnum, H., Kutzin, J., Saxenian, H. (1995). Incentives and provider payment methods. Interna-tional Journal of Health Planning and Management, 10(1):23-45.

Busse, R., Schreygg, J., Smith, P.C. (2006). Hospital case payment systems in Europe. Health Care Management Science, 9(3):211213.

Fetter, J., Shin, Y., Freeman, J.L., Averill, R.F., Thompson, J.D. (1980). Casemix definition by diagnosis-related groups. Medical Care, 18(Suppl. 2):153.

Langenbrunner, J.C., Wiley, M. (2002). Hospital payment mechanisms: theory and practice in tran-sition countries, in M. McKee, J.H. Healy, eds. Hospitals in a Changing Europe. Buckingham: Open University Press.

McKee, M., Healy, J.H. (2002). Hospitals in a Changing Europe. Buckingham: Open University Press.

Miller, T.S. (1997). The Birth of the Hospital in the Byzantine Empire. Baltimore, MD: Johns Hop-kins University Press.

Paris, V., Devaux, M., Wei, L. (2010). Health Systems Institutional Characteristics: A Survey of 29 OECD Countries. Paris: Organisation for Economic Co-operation and Development (OECD Health Working Papers No. 50).

Schreygg, J., Stargardt, T., Tiemann, O., Busse, R. (2006). Methods to determine reimbursement rates for diagnosis related groups (DRG): a comparison of nine European countries. Health Care Management Science, 9(3):215223.

Shleifer, A. (1985). A theory of yard-stick competition. RAND Journal of Economics, 16(3):319327.

Street, A., Vitikainen, K., Bjorvatn, A., Hvenegaard, A. (2007). Introducing Activity-Based Financ-ing: A Review of Experience in Australia, Denmark, Norway and Sweden. York: University of York Centre for Health Economics (CHE Research Paper 30).

WHO (2000). The World Health Report 2000 Health Systems: Improving Performance. Geneva: World Health Organization.

WHO Regional Office for Europe (2011). European Health for All Database (HFA-DB) [online database]. Copenhagen: WHO Regional Office for Europe (http://data.euro.who.int/hfadb/, ac-cessed 20 July 2011) (July 2011 update).

23 DRG DRG 03

DRG DRG WilmQuentin,AlexanderGeissler,

DavidScheller-KreinsenandReinhardBusse

3.1

DRG

(Kimberly et al., 2008) .

DRG DRG

(France, 2003).

DRG

DRG . DRG

, , ,

(Brgger, 2010), DRG

.

DRG

DRG .

EU Directive on the Application of PatientsRights in

Cross-Border Healthcare (European Parliament and Council, 2011)

EU DRG

. DRG EU EU

.

03


(Chapko et al., 2009; Busse et al., 2008 ).

(1) 12 DRG

(2)DRG

DRG ,

. DRG

DRG . DRG

DRG ,

. DRG

DRG . 4

9 . DRG

. 10

1 1 9 .

3.2 DRG DRG

DRG DRG

.

,

. 3.1 .

DRG (4),

(5), DRG

(6). 3.2.1 .

(7) (8), (9)

DRG , 3.2.2

. DRG

. DRG

.

25 DRG DRG 03

3.2.1

DRG (4)

DRG (PCS) . (1)

(2) , DRG . (3)

, (4) . DRG

.

. , DRG . DRG

.

4

DRG ( DRG )

DRG

5

()

DRG

DRG

DRG

DRG

7

9

DRG

: ,

,

,

8

DRG

6

DRG

,

DRG

3.1


DRG . DRG

.

DRG (4).

8(, , , , , , ,

) 1980 HCFA-DRG Health Care Financing Administration-

DRG DRG .

AR-DRGAustralian Refined-DRG .

, , DRG . ,

. DRG

DRG ,

DRG .

DRG

. . DRG

.

ICD-10International Classification of Diseases 10th

, OPCS the Eng-

lish Office of Population Censuses and Surveys .

DRG DRG .

DRG (4 ) DRG

(Quentin et al., in press).

DRG . ,

DRG . DRG

DRG DRG

. DRG

. DRG

(6 ),

.

DRG

DRG

(9 ). DRG

3.1 (5 ).

27 DRG DRG 03

DRG .

DRG DRG .

DRG DRG (18, ).

DRG DRG ,

(23, ).

DRG .

. DRG .

(Lave, 2003; McCrone & Phelan, 1994).

DRG

(4, 10 ).

(5)

3.1 (1)DRG (2)()

. DRG DRG

.

, DRG data-driven approach

. DRG

, DRG

. DRG

DRG

.

. , ,

DRG DRG .

DRG aggregated cost-accounting

figures (: ) .

DRG .

DRG . , DRG

( DRG

), ,

. .


DRG . DRG

DRG DRG ,

.

.

.

bottom-up micro-costing approach (5

)

(Schreygg et al., 2006).

, . ,

.

, DRG

(Berki, 1985).

DRG

. DRG

. DRG DRG

DRG .

. 3.1

DRG . DRG

.

DRG (6)

DRG .

DRG . DRG

. DRG

DRG , ( ) DRG

. DRG ,

DRG

29 DRG DRG 03

DRG .

( DRG ) (CMI,

) .

, DRG

. DRG DRG

, DRG

.

DRG : (1)

, (2) , (3) . ,

. ,

DRG ( ), DRG

, DRG

.

DRG DRG

. 3.1 DRG

(1) relative weights, (2)raw tariffs, (3)scores

. .

DRG

DRG

(6 ). 3.1

DRG DRG .

: DRG DRG

. DRG

, ,

.

3.1 DRG

DRG DRG () /() ()

(Relative weight) 1.95 2,000 = 3,900

(Raw tariff) 3,000 1.3 = 3,900

(Score) 130 30 = 3,900


DRG (:

) .

, .

DRG (18 ).

DRG DRG

. ,

DRG ,

/

.

3.2.2 DRG

(7)

DRG

. DRG

.

.

technical efficiency,

allocative efficiency,

cost efficiency.

DRG yard-stick competiton (Schleifer, 1985).

( DRG) ( DRG)

. DRG

DRG .

. ,

.

.

, ,

.

,

, , DRG

(6 ). .

31 DRG DRG 03

. .

DRG .

DRG ,

data envelopment analyses (DEA) stochastic frontier

analyses(SFA)

(Jacobs et al., 2006).

, ,

. DRG

DRG

longitudinal perspective . 7

.

DRG

. , longitudinal perspective DRG

. DRG DRG

(Berki, 1985). DRG

DRG

.

(8)

DRG (Davis

& Rhodes, 1988; Farrar et al., 2009). DRG

.

DRG

. ,

. DRG

(Rogers et al., 1990).

DRG

.


DRG

(Legido-Quigley et al., 2008).

(Chalkley & Malcomson, 1998). Donabedian(1966)

, , .

.

.

(Smith et al., 2010).

.

.

.

. risk adjustment .

DRG DRG

. 8

DRG

.

, DRG .

DRG

. , ,

DRG

(8 ).

(9)

DRG , DRG

(OTA, 1983; MedPAC, 2003; Shih & Berliner,

2008). DRG

( ) .

. DRG

, . DRG

33 DRG DRG 03

. ,

DRG (

).

DRG .

. , DRG

.

DRG DRG .

DRG (1)DRG DRG

(2) .

DRG

. DRG

. 9 ,

.

3.3 : ?

DRG DRG

. DRG ,

. DRG

DRG .

3.2 1 .

1 10 4 9

. (1) DRG

, (2) DRG DRG

.


3.2

4:

DRG

DRG

1. DRG ?

2. ?

3. ?

4. ?

5. ?

5:

DRG :

?

1. ?

2. ?

3. ?

4. ?

5. ?

6:

DRG :

1. DRG ?

2. DRG ?

3. ?

4. ?

5. DRG ?

7:

DRG

:

,

1. DRG ?

2. DRG ?

3. DRG ?

4. ?

8:

DRG :

For better or worse?

1. DRG DRG

?

2. DRG ?

3. DRG ?

4. DRG ?

9:

DRG

1. DRG ?

2. ?

3. DRG ?

4. DRG ?

35 DRG DRG 03

3.4

Berki, S.E. (1985). DRGs, incentives, hospitals, and physicians. Health Affairs (Millwood), 4(4):7076.

Brgger, U. (2010). Impact of DRGs: Introducing a DRG Reimbursement System. A Literature Re-view. Zrich: SGGP (Schriftenreihe der SGGP, Vol. 98).

Busse, R., Schreyogg, J., Smith, P.C. (2008). Variability in health care treatment costs amongst nine EU countries results from the HealthBASKET project. Health Economics, 17(Suppl. 1):18.

Chalkley, M., Malcomson, J.M. (1998). Contracting for health services when patient demand does not reflect quality. Journal of Health Economics, 17(1):119.

Chapko, M.K., Liu, C., Perkins, M. et al. (2009). Equivalence of two health care costing methods: bottom-up and top-down. Health Economics, 18(10):11881201.

Davis, C., Rhodes, D.J. (1988). The impact of DRGs on the cost and quality of health care in the United States. Health Policy, 9(2):117131.

Donabedian, A (1966). Evaluating the quality of medical care. The Milbank Memorial Fund Quar-terly, 44(3)2:166203.

European Parliament and Council (2011). Directive 2011/24/EU on the Application of Patients Rights in Cross-Border Healthcare. Brussels: Official Journal of the European Union (L88/45-L88/65).

Farrar, S., Yi, D., Sutton, M. et al. (2009). Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis. British Medical Journal, 339:b3047.

France, F.H.R. (2003). Casemix use in 25 countries: a migration success but international compari-sons failure. International Journal of Medical Informatics, 70(23):215219.

Jacobs, R., Smith, P., Street, A. (2006). Measuring Efficiency in Health Care. Cambridge: Cam-bridge University Press.

Kimberly, J.R., de Pouvourville, G., DAunno, T., eds (2008). The Globalization of Managerial In-novation in Health Care. Cambridge: Cambridge University Press.

Lave, J.R. (2003). Developing a Medicare prospective payment system for inpatient psychiatric care. Health Affairs (Millwood), 22(5):97109.

Legido-Quigley, H., McKee, M., Nolte, E., Glinos, I.A. (2008). Assuring the Quality of Health Care in the European Union: A Case for Action. Copenhagen: WHO Regional Office for Eu-rope on behalf of the European Observatory on Health Systems and Policies.

McCrone, P., Phelan, M. (1994). Diagnosis and length of psychiatric inpatient stay. Psychological Medicine, 24(4):10251030.

MedPAC (2003). Payment for new technologies in Medicares prospective payment system, in MedPAC. Report to the Congress: Medicare Payment Policy. Washington, DC: Medicare Pay-ment Advisory Commission.

OTA (1983). Diagnosis-Related Groups (DRGs) and the Medicare Program: Implications for Med-ical Technology A Technical Memorandum. Washington, DC: Office of Technology Assessment.

Quentin, W., Scheller-Kreinsen, D., Geissler, A., Busse, R. (in press). Appendectomy and diagno-sis-related groups (DRGs): patient classification and hospital reimbursement in 11 European countries. Langenbecks Archives of Surgery (in press).


Rogers, W.H., Draper, D., Kahn, K.L. et al. (1990). Quality of care before and after implementation of the DRG-based prospective payment system. A summary of effects. Journal of the American Medical Association, 264(15):19891994.

Schreygg, J., Stargardt, T., Tiemann, O., Busse, R. (2006). Methods to determine reimbursement rates for diagnosis related groups (DRG): a comparison of nine European countries. Health Care Management Science, 9(3):215223.

Shih, C., Berliner, E. (2008). Diffusion of new technology and payment policies: coronary stents. Health Affairs (Millwood), 27(6):15661576.

Schleifer, A (1985). A theory of yard stick sompetition. The RAND Journal of Economics, 16(3): 319327.

Smith, P.C., Mossialos, E., Papanicolas, I., Leatherman, S. (2010). Conclusions, in P.C. Smith, ed. Performance Measurement for Health System Improvement. Cambridge: Cambridge University Press.

37 DRG DRG 04

DRG DRG ConradKobel,JosselinThuilliez,

MartineBellangerandKarl-PeterPfeiffer

4.1

Patient Classification System (PCS)

. DRG

. (1)

(2) , DRG (3)

, (4) . DRG

1970 (Robert Fetter)

DRG (Fetter et al., 1980; Fetter, 1999) .

DRG (PCS).

12 8(, , , , , , ,

) (HCFA) DRG ,

, , (PCS) DRG

. 4

(PCS) DRG DRG

. (PCS) DRG

(23 ). (PCS) DRG

DRG-like PCS .

DRG (PCS)

,

04


. DRG

DRG .

(European Parliament and Council, 2011).

DRG (PCS)

.

4.2 12 DRG

(PCS) . 4.3 DRG (PCS)

, Major Diagnostic Categories

(MDC) . 4.4 (PCS)

. 4.5 (PCS) , 4.6

(PCS)

. 4.7 DRG (PCS) , 4.8

DRG (PCS)

.

4.2 DRG (PCS)

4.1 DRG (PCS)

. DRG (HCFA) (

CMSCenters for Medicare and Medicaid Services) DRG , HCFA-DRG

. 4.1 DRG

(PCS) HCFA-DRG (Fischer, 2008).

1970 DRG DRG

. (HCFA)

DRG medicare

.

1986 HCFA-DRG DRG GHMGroups

Homognes des Maladies() (ATIH, 2010). 1988 3MTM

Health Information System pathologies

HCFA-DRG (3M, 2005). AP-DRGAll Patients

DRG , AP-DRG

39 DRG DRG 04

G-DRG

APR-D

RG

NordD

RG

Swe

HRG 1

HRG 3.5

JGP

LKF

NordD

RG E

st

NordD

RG E

st

DBC

NordD

RG

NordD

RG

NordD

RG

Yale D

RG

HCFA

-DRG 12.0

HCFA

-DRG 8.0

HCFA

-DRG 4.0

HCFA

-DRG 2.0

HCFA

-DRG

MS-D

RG 25.0

CMS-D

RG 18.0

GHM

GHM

AP-D

RG

AP-D

RG 12.0

AP-D

RG 18.0

AP-D

RG 21.0

AP-D

RG 23.0

AP-D

RG 25.0

AN-D

RG 1.0

AR-D

RG 5.1

AR-D

RG 4.0

AR-D

RG 4.1

AR-D

RG 5.0

AR-D

RG 6.0

4.1

: Fische

r(20

08), Sch

rey gg

(200

6), AT

IH(2010), 3M

(200

5), Australian Governm

ent(200

4), InEK(200

9), NHS Information Cen

tre for H

ealth and

Soc

ial Care(20

10)

2

*

;

H

CFA

-DRG

,

(flat-rate)/

(add

ition

al paymen

t) (Fallpau

scha

le/Son

derentge

lt)

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

NordD

RG Fin


DRG

. AP-DRG severity resource intensity

APR-DRGAll Patient Refined DRG

. AP-DRG APR-DRG DRG AN-DRGAustralian

National DRG . AN-DRG AR-DRGAustra-

lian Refined DRG (Australian Government, 2004). 2003

AR-DRG (15 ), AR-DRG DRG

G-DRGGerman-DRG .

, 1996 DRG

NordDRG (HCFA-DRG [PCS])

. NordDRG ,

NordDRG (16 ).

NordDRG . NordDRG

2003 2010 1 NordDRG (17 ).

, NordDRG

Full NordDRG .

, (PCS) .

1992 HRG Healthcare Resource Group()

, . HRG GHM

JGPJednorodne Grupy Pacjentow .

(PCS) LKFperformance-oriented hospital financing system(

) 1997 (17 ).

( ) - DBCDiagnose Behandeling Combinaties

2005 (23 ).

4.3 DRG (PCS):

DRG (PCS) , (PCS)

DRG .

4.1 9 DRG (PCS) .

(PCS) .

(PCS) 650~2,300 . JGP

41 DRG DRG 04

(PCS) 518 , DBC

2010 3 DBC .

HCFA-DRG DRG (MDC)

. HRG JGP DRG (PCS)

chapter . LKF DBC

.

body parts disease entity ,

DRG (PCS) . DRG

(PCS) , (PCS)

25 . JGP DRG

. DRG

, (PCS)

.

DBC DRG (PCS) parti-

tion () .

( (OR)) . DRG

. GHM

(ATIH, 2010).

4.2 DRG .

HCFA-DRG DRG(MS-DRG)

, DRG (PCS)

4.1 DRG (2008 )

AP-

DRG

AR-

DRG

G-DRG

()

GHM

()

NordDRG

( )

HRG

()

JGP

()

LKF

()

DBC

()

(group) 679 665 1,200 2,297 794 1,389 518 979 30,000

(MDC)

/(chapter)25 24 26 28 28 23 16 - -

(partition)

2 3 3 4 2 2* 2* 2* -

: (Nordic Casemix Centre [2011]) 2

* HRG, JGP, LKF (partition) ,

(treatment driven) (diagnosis driven) .


. LKF LKF

DRG . DBC

. cell

(PCS) . (PCS)

. ,

. HRG

. (PCS)

, (JGP) (NordDRG), HIV (AP-DRG, G-DRG,

GHM) 4.2 .

4.2 DRG (PCS)

DRG (PCS) ,

(PCS)

. , GHM

JGP . ,

DRG (PCS)

.

. .

(PCS) 10%

, HRG 4.5% . , Pre-MDC

, GHM

. /

,

.

4.4 :

, DRG

(PCS) .

. ICD-10International Classifica-

tion of Diseases 10th Revision ( 10 ) .

AP-DRG ICD-9 ICD-9 .

43 DRG DRG 04

4.2 8

D

RG

DRG

: 20

09

BMG

; NHS Information

Cen

tre for H

ealth and

Soc

ial Care, 2010; AT

H, 20

10; InEK, 20

09; A

ustra

lian

Governm

ent, 20

04; 3M,

2005;

(Nordic C

asem

ix C

entre

)

(2011);

20(

)

AP-DRG

(678)

AR-DRG

(665

)G-DRG

(120

0)

NordDRG

(794

)GHM

(229

7)HRG

(138

9)JG

P(518)

LKF

(978)

Error D

RG

Pre-MDC

(Nervo

us S

ystem)

(Eye

)

, , , (Ear, Nos

e, M

outh &

Throa

t)

(Res

piratory S

ystem)

(Circ

ulatory System)

(Vas

cular Disea

ses on

ly JGP)

(Diges

tive System)

(Hep

atob

iliary System &

Pan

crea

s)

(M

uscu

loskeletal S

ystem &

Con

nective Tissue

)

,

(Skin, S

ubcu

tane

ous Tissue

& B

reas

t)

(Breas

t Problem

only NordD

RG), (Burns

),

(End

ocrin

e, N

utritiona

l & M

etab

olic S

ystem)

(Kidne

y & U

rinary Trac

t)

(M

ale Rep

rodu

ctive System)

(Fem

ale Rep

rodu

ctive System)

,

(Pregn

ancy, Childbirth

& P

uerperium)

(New

born &

Other N

eona

tes [Perinatal P

eriod])

,

(Blood

, Blood

Forming

Organ

s & Immun

olog

ical D

isorde

rs

(M

yeloproliferative DDs [Poo

rly D

ifferen

tiated

Neo

plas

ms])

(In

fectious

& P

aras

itic DDs)

(Hum

an Immun

odeficienc

y Viru

s Infection)

(M

ental Disea

ses & D

isorde

rs)

/

(Alcoh

ol/D

rug

Use

or Indu

ced

Men

tal Disorde

rs)

,

(In

jurie

s, P

oiso

n & Tox

ic E

ffect of Drugs

)

(M

ultip

le S

ignifican

t Trau

ma)

(Fators Influen

cing

Hea

lth S

tatus)

(Other)


, ICD-10 ,

ICD-10 ( 4.2).

ICD-10

. ICD-10

. ICD-10 ICD-10-GM

O84 ,

Z37 . , .

.

.

Australian Classification of Health Intervention (ACHI)

, CCAMclas-

sification commune des actes mdicaux, Leistungskatalog

multi-axial procedure classifications . .

4.2

ICD-10-BMSG-2001 Leistungskatalog

ICD-10 OPCS

ICD-10 NCSP

ICD-10-FI NCSP-FI

CIM-10 CCAM

Classification Commune des Actes Mdicaux

ICD-10-GM OPS

Operationen- und Prozedurenschlssel

ICD-10-AM ACHI

Australian Classification of Health Interventions

ICD-10 Elektronische DBC Typeringslijst

ICD-10 ICD-9-CM

ICD-9-CM ICD-9-CM

ICD-9-CM ICD-9-CM

ICD-10-SE KVKlassifikation av vrdtgrder( NCSP)

NordDRG ICD-10 NCSP

Nomesco Classification of Surgical Procedures

: (Nordic Casemix Centre[2011]) 2

45 DRG DRG 04

LKF 1,500 ,

Operationen-und Prozedurenschlssel (OPS)

20 30,000 .

4.5 DRG (PCS) classification algorithm

DRG (PCS) . DRG

(PCS) ,

(PCS) DRG .

. , , DRG

(PCS)

(NHS Information Centre for Health and Social Care,

2010; BMG, 2009).

(23 ).

HCFA-DRG (PCS) DRG

(PCS)

.

4.5.1 HCFA-DRG (PCS)

4.3 HCFA-DRG (PCS)

DRG . NordDRG

.

.

(1)

. (2) (: ) Pre-MDC

, (3)

( neonatal

). (4) OR procedure ,

. AR-DRG, G-DRG

GHM non-OR procedure (,


1 2 3 4 5 6

Pre-MDC

Base-DRG/

DRG

4.3 HCFA

-DRG

(

)

:

. AT

IH(2010), InEK(2009), Aus

tralian Governm

ent(2

004), 3M

(2005), 13(

), 14(

), 15(

)

Base

DRG

DRG

DRG

DRG

DRG

Error

DRG

DRG

DRG

DRG

AR-DRG,

G-DRG &

GHM

DRG

AP-DRG

AP-DRG,

AR-DRG, G-DRG

GHM

Error

DRG

PreMDC

DRG

DRG

MDC

MDC

Base

DRG

Base

DRG

DRG

DRG

MDC

/

47 DRG DRG 04

) / other/non-OR

. NordDRG

/ (

). GHM

(13 ).

(5) DRG 2 ,

, , ,

. AP-DRG

DRGbase-DRG .

DRG ( 4.3 DRG

).

AP-DRG major-CC class

(3M, 2005).

DRG

( G-DRG ). AP-DRG DRG

. AP-DRG

AR-DRG

G-DRG . hip fracture

/ DRG AR-DRG G-DRG

Error DRG .

, (6) DRG .

class/base-DRG DRG

( 4.3 DRG 2 DRG

). / DRG DRG

. DRG DRG . DRG

DRG .

2 , , , ( ) DRG .

4.5.2 , , DRG (PCS)

4.4 DRG HRG, JGP LKF

. JGP HRG DRG


Pre-MDC

/

D

RG

HRG and JGP

all

HRG LKF

Pre-MDC

errorDRG

/

/

4.4 HCFA-DRG (PCS) ( )

: ; ATIH(2010), InEK(2009), Australian Government(2004),

3M(2005), 13(), 14(), 15()

(20 ). 4.4

, 5~7 .

. HCFA-DRG

.

,

(CT),

49 DRG DRG 04

. (HRG JGP ) (: LKF

) , (PCS)

add-on groups .

( )

(PCS)

. HCFA-DRG (PCS)

(4.8 6 ).

.

HRG , Pre-MDC .

multiple trauma Pre-MDC

HRG . ,

procedure-driven partition,

diagnosis-driven partition .

, HRG JGP ,

(HRG ) (JGP ) .

, HCFA-DRG .

LKF HRG JGP

. HRG JGP

base-group/root .

.

. LKF

. , .

HCFA-DRG

(PCS) , .

. HRG JGP

. LKF

.


4.5.3 DBC

DBC . DBC

. (1)

27 . (2)

(: ). (3)

(4) ( )

( ) .

,

(: 11 2 ).

, (Warners, 2008; 23 ).

4.6 DRG (PCS)

, DRG

DRG split . base-group

/ .

4.6.1

DRG (PCS)

. 4.3 DRG (PCS) , /

, .

. , DBC

(PCS) ,

.

. (: AR-DRG, G-DRG LKF)

.

(: GHM HRG) ,

diagnosis hierarchy .

, (

) . G-DRG

AR-DRG ,

(InEK, 2009). HRG, JGP

51 DRG DRG 04 4.3 D

RG

(PCS)

AP-DRG

AR-DRG

G-DRG

GHM

NordDRG

HRG

JGP

LKF

DBC

/

--

--

--

-

--

--

--

-

/

-

--

-

-

-

-

(

)

--

--

--

--

--

-

--

-

-

--

--

--

/

-

--

-

-

--

--

--

--

-

--

--

--

--

--

-

-

--

--

--

--

--

--

--

--

/

3*

4

52

33

-

-

PCC

PCC

-

--

--

: AT

IH(2010), InEK(2009), Australian Gov

ernment(20

04), 3M

(2005), BMG(2009), NHS Inform

atio

n Centre for Health

and Social Care(2010),

Warners(2008)

(Nordic C

asem

ix C

entre

[2011])

2

*

(

C

Cs

DRG

2

4

1


LKF , (4.5.2 ).

, (: )

DBC .

NordDRG ,

(:

).

DRG (PCS)

. . mechanical ventilation

,

.

G-DRG

, tracheostomy

.

4.6.2

4.3 DRG (PCS) .

. NordDRG

, HRG .

(AR-DRG HRG) .

GHM ,

short stay day cases .

G-DRG LKF ,

. DBC

.

4.6.3

DBC LKF , 2

.

DRG (PCS) 2

, HRG

, .

53 DRG DRG 04

.

2 .

(PCS) ,

.

2 AR-DRG G-DRG

Patient Clinical Complexity (PCCL) 2

, DRG 2

. GHM 2 ,

, . DBC

2

DBC .

4.7

DRG (PCS) . ,

DRG (PCS)

. ,

. , DRG

.

4.7.1

1990 , DRG

. 4.4 DRG day care

. DRG

, (PCS) (

, , ) DRG .

(PCS)

. GHM DRG

, 0 (ATH, 2010).

NordDRG ,

(19 ). , , ,

, 0 .


HRG (NHS

Information Centre for Health and Social Care, 2010).

, DRG (PCS)

( 4.4). (PCS)

dominant

procedure .

, ( )

. Rehavilitation Treatment Groups (RBG) (Neubauer

& Pfister, 2008) Inpatient Rehavilitation Facility

Prospective Payment System (IRF-PPS) (Med-PAC, 2009)

. , ,

. GHJ Groupe Homogne de journes (Homogeneous groups of days) ( )

(Metral et al., 2008) LTR Leistungsorientiertes Tarifmodell Rehabilitation (

) (Fischer et al., 2010) .

4.7.2

4.5 DRG (PCS)

. , (GHM)

(HRG)

. G-DRG 2010

(PCS) 2010 .

DRG (PCS)

. ,

. G-DRG

DRG DRG .

DRG ,

.

, DRG (PCS)

. ,

. , , ,

55 DRG DRG 04

4.4 DRG-

a - -

e - -

b b

a 2013 -

-

a

a -c -c

-d - -

: 2

: a (day care)

; b DRG ,

DRG (18 18.5.1 ); c

DRG , ; d

(surgical day cases) AP-DRG ; DRG

(International Refined [IR-] DRG) ; e DRG

.

2,500

2,000

1,500

1,000

500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

AP-DRG()

AR-DRG()

G-DRG()

GHM()

HRG()

JGP()

LKF()

Common Full NordDRG

4.5 DRG (PCS)

: (Nordic Casemix Centre[2011]), 2


(9 ).

. ,

.

, cost accounting

(PCS) (5 ).

DBC DBC (PCS)

4.5 . DBC

. 2005 10 DBC 2010

DBC 3 . DBC 3,000

DRG (Warner, 2008).

4.7.3 (unbundling / sances )

DRG

DRG

. HRG `unbundling . `unbundling

( , , , , )

HRG (NHS Information Centre for Health and Social Care,

2009). HRG ,

supplementary payments (6 ).

GHM sances , ,

unbundling .

(14 ),

, unbundling sances

.

DRG (PCS)

. MS-DRG

,

. ,

.

(Or & Hakkinen) 8 .

57 DRG DRG 04

4.8 : EuroDRG

DRG (PCS)

. DRG (PCS)

( DRG )

. DRG (PCS)

: (1) (2)

, DRG . (3) ,

(4) . EuroDRG

(PCS) .

4.6

,

. 4.4

. DRG

(PCS)

map-

ping system . (EU) Health Monitoring

Programme Hospital Data Project

(Magee, 2003). WHO ICD-10

ICD-11 ,

.

. DRG

(PCS) 1,000~1,500

.

, DRG

. DRG

,

DRG .

, DRG (PCS)

.

, DRG (PCS)


. EU EuroDRG

11

, DRG

. ,

(5 ).

DRG .

4.2 DRG HCFA-DRG

. DRG (PCS) DRG

. EuroDRG

.

DRG .

DRG ,

.

, ,

. DRG (PCS) 10

DRG (PCS) , DRG

(PCS) EuroDRG

.

. DRG (PCS)

, (PCS)

.

59 DRG DRG 04

4.9

3M (2005). All Patient DRG Definitions Manual (Version 23.0). St. Paul, MN: 3M Health Informa-tion Systems.

3M (2003). All Patient Refined DRGs (Version 20.0) Methodology Overview. St. Paul, MN: 3M Health Information Systems.

ATIH (2010). Manuel des GHM, Version 11b. Lyon: Agence Technique de lInformation sur lHospitalisation (http://www.atih.sante.fr/index.php?id=000250002DFF, accessed 10 August 2010).

Australian Government (2004). Australian Refined Diagnosis Related Groups Version 5.1. Defini-tions Manual Volume One (DRGs A01Z-I78B). Canberra: Commonwealth of Australia Depart-ment of Health and Ageing.

BMG (2009). Leistungsorientierte Krankenanstaltenfinanzierung LKF Modell 2010. Vienna: Bundesministerium fr Gesundheit.

Chilingerian, J (2008). Origins of DRGs in the United States: A technical, political and cultural story, in J. Kimberly, G. de Pouvourville, T. DAunno, eds. The Globalization of Managerial Innovation in Health Care. Cambridge: Cambridge Universtiy Press.

European Parliament and Council (2011). Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the Application of Patients Rights in Cross-Border Health Care. Brussels: Official Journal of the European Union.

Fetter, R.B. (1999). Casemix classification systems. Australian Health Review, 22(2):1634.Fetter, R.B., Shin, Y., Freeman, J., Averill, R.F., Thompson, J.D. (1980). Casemix definition by

diagnosis-related groups. Medical Care, 18(2):i53.Fischer, W. (1997). Patientenklassifikationssysteme zur Bildung von Behandlungsfallgruppen

im stationren Bereich Prinzipien und Beispiele. Wolfertswil: Zentrum fr Informatik und wirtschaftliche Medizin (ZIM).

Fischer, W. (2008). Die DRG-Familie. Wolfertswil: Zentrum fr Informatik und wirtschaftliche Medizin (ZIM) (http://www.fischer-zim.ch/textk-pcs/index.htm, accessed 10 July 2011).

Fischer, W., Blanco, J., Butt, M., Hund, M., Boldt, C. (2010). Leistungsorientiertes Tarifmodell Re-habilitation (LTR). Neurologie & Rehabilitation, (16)3:118.

Goldfield, N (2010). The evolution of diagnosis-related groups (DRGs): from its beginnings in casemix and resource-use theory, to its implementation for payment and now for its current utilization for quality within and outside the hospital. Quality Management in Healthcare, 19(1):116.

InEK (2009). German Diagnosis-Related Groups Version 2010. Definitionshandbuch Kompakt-version Band 1 (DRGs A01A-I98Z). Siegburg: Institut fr das Entgeltsystem im Krankenhaus gGmbH.

Magee, H.F. (2003). The hospital data project: comparing hospital activity within Europe. Euro-pean Journal of Public Health, 13(Suppl. 1):7379.

MedPAC (2009). Rehabilitation Facilities (Inpatient) Payment System: Payment Basics. Washing-ton, DC: Medicare Payment Advisory Commission (http://www.medpac.gov/documents/Med-PAC_Payment_Basics_09_IRF.pdf, accessed 20 July 2010).


Metral, P., Ducret, N., Patris, A., Steunou, P. (2008). Improving casemix for description and fund-ing in rehabilitation in France: additive model is better than tree-classification. BMC Health Services Research, 8(Suppl. 1): A2.

Neubauer, G., Pfister, F. (2008). Entwicklung einer leistungsorientierten, fallgruppenspezifischen Vergtung in der Rehabilitation: Abschlussbericht. Munich: Institut fr Gesundheitskonomik (http://www.bdpk.de/media/file/358.Abschlussbericht_Prof._Neubauer_Februar%202008.pdf, accessed 20 July 2010).

NHS Information Centre for Health and Social Care (2009). The Casemix Service HRG4, Guide to Unbundling. Leeds: NHS Information Centre for Health and Social Care.

NHS Information Centre for Health and Social Care (2010). The Casemix Service HRG4 Design Concepts. Leeds: NHS Information Centre for Health and Social Care.

Nordic Casemix Centre (2011). Nordic Common Version (based on NCSP+) (NordDRG manuals). Helsinki: Nordic Casemix Centre (http://www.nordcase.org/eng/norddrg_manuals/versions/common/, accessed 26 July 2011).

Schreygg, J., Stargardt, T., Tiemann, O., Busse, R (2006). Methods to determine reimbursement rates for diagnosis-related groups (DRG): a comparison of nine European countries. Health Care Management Science, 9(3):215223.

Warners, J. (2008). Redesigning the Dutch DBC-system; towards increased transparency. From ideas and directions for improvement to implementation. Patient Classification Systems Inter-national: 2008 Case Mix Conference, Lisbon, 811 October.

61DRG : ?05

DRG : ?

SiokSwanTan,LisbethSerdn,AlexanderGeissler,MartinvanIneveld,KenRedekop,MonaHeurgrenand

LeonaHakkaart-vanRoijen

5.1

cost-accounting systems reimbursement

, ,

(Finkler et al., 2007; Horngren et al., 2006). DRG

,

DRG (Nathanson, 1984).

. ,

(Cohen et al., 1993; Ott, 1996).

(Feyrer et al., 2005).

.

,

,

(6 ).

(Feyrer et al.,

2005).

1983 DRG

(2 ). DRG

05


(Berki, 1985).

5.1 DRG .

payment rate-setting mecha-

nisms DRG (Feyrer et al., 2005).

DRG (6

). , ,

DRG

.

. DRG DRG

.

DRG ,

. .

, sys-

tematic benchmarking managed competition

(Schuster et al., 2006; van de Ven & Schut, 2009).

.

(5.2)

(5.3), DRG

(5.4) . 5.5 DRG

.

, , , , , , , , , ,

, 12 .

( , )

DRG

DRG

5.1 DRG

63DRG : ?05

5.2

(St-Hilaire & Crepeau, 2000; Tan et al., 2009c).

1. overhead cost allocation : (5.2.1)

2. indirect cost allocation : (5.2.2)

3. direct cost allocation: (5.2.3)

5.2.1 overhead cost allocation

(Drummond et al., 2005; Williams et al., 1982).

cost-centre allocation(Finkler et al., 2007; St-Hilaire & Crepeau,

2000). .

, , , ,

. , ,

, .

allocation bases

(Finkler et al., 2007; Horngren et al., 2006).

activity-based costing cost-centre allocation

.

.

(Cooper & Kaplan, 1988).

, (m2),

(Drummond

et al., 2005).

, cost-centre allocation activity-based

costing ,

. direct allocation ,

( 5.2).


5.2 (direct allocation)

: OD: ; MD:

step-down allocation ,

.

. unilateral deliveries.

( 5.3).

.

5.3 (step-down allocation)

: OD: ; MD:

recip-

rocal . .

( 5.4).

5.4 (reciprocal allocation)

: OD: ; MD:

OD2

OD1 OD...

MD2MD1 MD...

OD2

OD1 OD...

MD2MD1 MD...

OD2

OD1 OD...

MD2MD1 MD...

65DRG : ?05

5.2.2 indirect cost allocation

, . cost-centre allocation

activity-based costing

.

(Finkler et al., 2007; Tan et al., 2009c):

marginal mark-up percentages:

.

weighting statistics: ()

.

relative value units:

.

5.2.3 direct cost allocation

(

), , / .

(Drummond et al., 2005; Jackson, 2000).

( 5.5).

( ) (

) (Tan et al., 2009b; Tan, 2009).

.

(Jackson, 2000; Tan et al., 2009b).

top-down gross-costing average patient ,

bottom-up gross-costing individual patient

.

top-down micro-costing

, (Tan et al.,

2009b; Wordsworth et al., 2005). , ,

, , .


(Clement Nee Shrive et al., 2009).

bottom-up micro-costing

.

(Tan et al., 2009b; Wordsworth et

al., 2005).

5.3

5.3.1

DRG

.

. ,

.

.

. analytical

accounting .

5.5 :

: Tan, 2009; Tan et al., 2009b

- +

-

+

67DRG : ?05

manual . case

.

DRG

DRG

(, , , , , , , ).

, ,

. Victorian Cost

Weights casemix modelling .

. DRG ,

United Kingdom Healthcare Resource Groups

(HRG) system (Version 3.5) .

DRG .

. 5.1 12

.

5.3.2

()

DRG .

(, , , ) (Schreygg et al., 2006). DRG

( [EHIF]) ()

.

.

15~25

, 3 - diagnosis-treatment

combinations .

.


payment for general interest missions (MiGAC)1

. 2003 2004

, 2005

. Institute for the Hospital Remuneration System (InEK)

.

. InEK 2008 9

(InEK, 2009).

.

(

). ,

, ,

(Schreygg et

al., 2006).

5.1

DRG

- -

- -

- -

-

-

- -

- - -

-

- - -

-

1

69DRG : ?05

(, ,

, , ) , () .

.

.

. ,

.

,

.

. , , ,

, , , ,

.

.

State Health Funds (264 113

) .

.

( ) (, , , ).

()

(, , ).

National Health Service (NHS) (PLICS)

. PLICS ,

. DRG

.


.

(, , , ) (

, ) .

, .

National Board of Health and Welfare National Patient

Register (NPR) ,

.

/

.

.

. , ,

unit cost .

. hip replacement

. (,

, ) (, , , ).

5.2 DRG 8

.

5.3.3 DRG

DRG DRG

(6.3 2 ). DRG

. DRG

75~85% .

(Schreygg et al., 2006):

1) DRG

.

2) DRG

.

3) .

71DRG : ?05

5.2 8

( )

20

( 8%)

()

()

EHIF

()

5

( 30%)

,

ENCC

99

( 13%)

()

()

InEK

125

( 6%)

()

: 15~25

( 24%)

()

( 62%)

,

()

(, , , ), (, ,

, , ), (, , )

DRG . DRG 1

, (), (), ()

. , ,

(6 ).

(, , , , ) (,

, ) DRG .


DRG

. (, , ,

) (, ). DRG

, , (), (), ()

.

5.4 DRG

5.4.1

DRG (Nathanson, 1984).

, DRG

. DRG

DRG (). DRG

,

. DRG

. ( )

. DRG

.

.

, ,

(Clement Nee Shrive et al., 2009).

DRG

(Busse et al., 2008; Heerey et al., 2002; Skeie et al., 2002; Tan et al.,

2009a). .

, DRG ,

.

,

, DRG

73DRG : ?05

DRG ( [CC]),

(PCS) (, , , ).

medical DRG surgical DRG

, DRG

. DRG

, DRG

(Jackson, 2000).

DRG

.

( ),

(5.4.2 )

5.4.2

DRG

.

.

.

( )

.

(St-Hilaire & Crepeau, 2000; Zuurbier & Krabbe-Alkemade,

2007).

,

.

,

(Tan et al., 2009c).

DRG .

DRG

.


DRG

(Jackson, 2000; Tan et al., 2009b).

.

(: ),

( ) .

,

, (Tan et al.,

2009b).

.

(Jackson, 2000; Swindle et al., 1999).

5.5

.

.

systematic benchmarking

managed competition .

, ,

.

. DRG

casemix

(, , ). ,

,

(Busse et al., 2006). DRG

(,

, , ). DRG

, .

, DRG

, , (6

).

75DRG : ?05

5.6

DRG . DRG

(Feyrer et

al., 2005).

. DRG .

DRG .

DRG

. DRG

.

: (1)DRG

. (2)DRG

. DRG

.

.

DRG DRG

. . ,

DRG

. ,

.

, DRG

. DRG

. DRG

,

.

DRG (: ,

) (2 ).

.

DRG

.

.


5.7

Berki, S.E. (1985). DRGs, incentives, hospitals, and physicians. Health Affairs (Millwood), 4:7076.Busse, R., Schreygg, J., Smith, P.C. (2006). Hospital case payment systems in Europe. Health

Care Management Science, 9:211213.Busse, R., Schreygg, J., Smith, P.C. (2008). Variability in healthcare treatment costs amongst nine

EU countries Results from the HealthBASKET project. Health Economics, 17:18.Clement Nee Shrive, F.M., Ghali, W.A., Donaldson, C., Manns, B.J. (2009). The impact of us-

ing different costing methods on the results of an economic evaluation of cardiac care: micro-costing vs gross-costing approaches. Health Economics, 18:377388.

Cohen, D.J., Breall, J.A., Ho, K.K. et al. (1993). Economics of elective coronary revascularization. Comparison of costs and charges for conventional angioplasty, directional atherectomy, stenting and bypass surgery. Journal of the American College of Cardiology, 22:10521059.

Cooper, R., Kaplan, R.S. (1988). Measure costs right. Make the right decisions. Harvard Business Review, Sep/Oct:96103.

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Diagnosis-Related Groups in Europeeurodrg.projects.tu-berlin.de/publications/Korean_edition_DRG_book.pdf · Diagnosis-Related Groups in Europe Moving towards transparency, efficiency