Diagnosis Related Groups (DRGs) were the first health management tool to group patients in clinical meaningful categories with homogeneous resources consumption. DRGs have been selected in 1983 as the prospective payment system for MEDICARE patients in the USA. This innovation migrated to several Western countries first, in Eastern Europe and in Asia soon thereafter. What is the present situation? This book describes the actual state of case mix uses in twenty countries all over the world. Experts from Australia, Austria, Belgium, Denmark, Finland, France, Germany, Great Britain, Ireland, Japan, South Korea, Mexico, the Netherlands, Romania, Russia, South Africa, Spain, Sweden, Switzerland, the USA accepted to describe the development and adaptations of case mix in their country. In addition, they provide a concise analysis of health care organization, financing methods, and information checking in these countries. Such information cannot be found easily in the literature. It gives physicians, hospital managers, researchers and policy makers a basis for making decisions on new paths to develop in health care delivery systems.
The case mix concept has been introduced in the U S A more than twenty years ago in order to measure hospital productivity and to promote quality of care.
The DRGs (Diagnosis Related Groups), developed by a team of researchers led by Robert Fetter and John Thompson at Yale University, were selected by HCFA (Health Care Financing Administration) in 1983 as the case mix classification system for the MEDICARE prospective payment system (PPS).
The DRG was the first “health management tool” to group patients in clinically meaningful categories with homogeneous resources consumption. All diagnostic categories and procedures based on medical record summaries could be coupled with financial data about resource uses, for individual patients, in order to differentiate high and low cost care.
Even if shortcomings were underlined since their beginning, DRGs are still used in the USA as the main tool for a case based, clinical encounter focused, payment.
What happened elsewhere? Many other countries have adopted the case mix concept after long periods of testing and accepting, but with large variations in data collection, information standards, grouping tools, financing methods and quality of care developments all over the world. Each country has developed a local clinical and political culture about case mix tools. The present book is intended to update the case mix situation, country by country. The available literature does not allow following the evolution in this specific area that modifies healthcare professionals' behaviour.
Some countries have gained experience in case mix for hospital financing, while others are only beginning to implement such system.
What are the objectives of their initiators? What results have they obtained? What difficulties have they encountered? What works and does not work? Can “DRG creep” be avoided? Would it be possible or not to obtain international comparisons, given the differences observed?
When preparing the joint Patient Classification system/Europe 2001 - EFMI (European Federation for Medical Informatics) working group 1 Conference to be held in Bruges on 10-14 October 2001, the editors felt that in the case mix area, there are “global views and local actions”. They decided to publish a book, in addition to the proceedings of the Conference on the present status of case mix in various countries in 2001.
Globalisation is not synonymous of universality. Globalisation implies that a single product could be sold to everyone. Universality, by contrast, is something more specific, with local empowerment taking in account cultural differences, where “global views” are shared all over the world but where local actions take into account local identity.
In the case mix area, like in many others, similar concepts have been endorsed in most countries, and global technologies are more and more used by everyone. However, health care delivery is influenced by each culture. This has a great impact on health care management, which has a strong local dimension.
Cultural clinical differences will lead to differentiation both in health care delivery, management and funding.
So health care delivery systems differ, but we need to learn from each other experiences. The book is an instrument to keep informed on the different local actions focused on implementing health management tools like case mix. We need to find a way to compare information about the health care delivered to patients by global case mix tools. A lot still has to be done to reach this universal objective. The PCS/E conferences and the EFMI Working Group 1 will maintain a global action to offer a platform for the local actors.
The increased rate of use of information systems by health care professionals will lead to improved basic patient data, which is the starting point for the development of good health management tools. Patient empowerment using information systems, requiring equity in health care, might be the driving force in future to modify present socio-cultural behaviours in using these tools.
Detailed nomenclatures, clinical classifications, and diagnostic related groups lay along a common continuum of patient description, albeit at different levels of abstractions. The intellectual origins of classification, and present challenges of practical terminologies, and a unified potential future are outlined. Today’s classifications should be created and published as rule-driven databases, defined from well-formed patient descriptions at a detailed, nomenclature level. Then, analogous to the DRG grouper process, we can realize administrative and resource efficiencies from the detailed encoding of patients, which will enable an era of evidence-based medicine and best-practice as the norm.
Since 1997 there is a new case based hospital financing system for inpatients in Austria. Before these hospital have been paid for the length of stay independent of the diagnoses and procedures. The fees for the length of stay have not been sufficient and therefore the deficit. was paid by the owners of the hospitals. The new system is called “Leistungsorientierte Krankenanstaltenfinanzierung (LKF)”, which means that diagnoses as well as procedures are used for the classification of a patient. The system is similar to the DRG-system in its basic concept. A learning set of approximately 500.000 data set was used for the identification of cost-homogenous groups of patients. The system is very flexible and it was possible in the last years to improve, modify and adapt it continuously.
This system has shown different effects on the behaviour of hospitals, like reduction of the length of stay, an improvement in data quality or higher awareness of costs. Furthermore the data can be used for an improved controlling and further development of the hospital system.
This presentation will describe the new Austrian hospital financing system, the systematic revision of the model, the evidence of some changes based on empirical data as well as the discussion of some necessary extensions of the model for special departments and outpatient care.
Uncontrolled increases in Medicare expenditures spurred U.S. policymakers to turn from a cost-reimbursement system to episode-based hospital financing in the 1980’s. The Diagnosis Related Groups (DRGs ) were used to define patient types, and fixed national prices for patients covered by Medicare were defined to create economic incentives for hospitals to become more efficient. Today, U.S. hospitals are treating only the most seriously ill patients. Simpler procedures are being performed outside the hospital. Nursing care is increasingly moved to intermediate-care facilities or is given during home visits and recuperation is occurring outside the hospital, where patients and families have more responsibility in the recovery process. This paper describes the DR G experience, how hospitals and physicians changed the use o f hospitals, the successes and failures of that experience, and lessons that may be learned as other countries adopt similar hospital financing schemes.
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