Island - Costanalysis and audit

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					    Case-costing and audit in
      Swedish Health Care
     Meeting In Island 16/9 - 2002

  Mona Heurgren, Senior economist
Federation of Swedish County Councils,
                Sweden
            Agenda

 The Case-costing system
 The use of Case-costing
  from different perspectives in
  health care
      Case-costing in Sweden
   A National Case-costing project is finished
    this summer (1999-2002).
   50% of the County Councils have local
    projects (70-80% of all cases)
   National guidelines for Case-costing
   For the year of 2000 we have 25% of
    Swedish inpatient care in the national Case-
    costing database
   Case-costing development in out-patient care,
    psychiatry and primary care
              The Case-costing process
Factor inputs     Intermediate Products

Labour            Nursing care


Supplies          Laboratory tests
                                          Patient-Specific   PATIENT
Capital           Drugs                   Services Mix


Other resourses   Surgery                 Characteristics


Overhead          etc
    An example of a patient in a case
     costing database - Fractures of
                 femur
Intermediate
Products           Costs        Characteristics
Nursing Care       11 950       Length of stay        5 days
                                                               (Hip & femur procedures
                                                               exept major joint, age >17,
Physician (ward)   3 540        DRG                    211     without CC)
Hotel costs        5 700        Clinic                 311
Surgery            6 522        Age                     72
Intensive care     2 911        Sex                   Female
Anestisia          10 957       Acute                  Yes
Laboratory tests   1 846        Principal Diagnosis   S7240    Fracture on lower parts of femur
Imaging exams      2 629        Procedures            NFJ59    Fracture surgery, femur
Other products     4 333                              NFJ09                 "
                                                      NFJ99                 "
Total cost         50 388 SEK
                               A case-costing model

                         1. Identify the accurate total cost
                         2. Allocate indirect costs to the
in achieving quality in dataabsorbing costs centres
                         3. Identify intermediate products
                            and calculate their costs
                         4. Distribute costs to patients
Personal identification number
   All citizens of Sweden have a unique
    personal identification number, given to
    the person at birth
   The personal identification number has
    a general use, and is also used in every
    contact with Health care
   Gives us the opportunity to easily
    connect activities and costs to the right
    patient in our IT-systems
IT-structure of a case-costing system

                          RAD      LAB       IVAIVA
     PAS




DB     DB          DB      DB      DB        DBDB

  Collect      Collect   Collect   Collect     Collect




     Process
            D Data warehouse
      IT-structure cont…
process
   D Data warehouse

                      Data in the Case
                      Costing system:
                      -Patient
 The case             characteristics
 costing
                      -Cost data
 system
                      -Medical data
     Important issues for Case-
              costing
   IT-systems
   The need of national guidelines for
    Case-costing
-   Identify the accurate total cost
-   Allocate indirect costs to the
       absorbing costs centres
-   Identify intermediate products
       and calculate their costs
         Why case-costing?
   Management support for clinics and
    hospitals
   Support to buyers of health care
   Benchmarking studies of costs and
    medical praxis
    Development of the DRG-system and
    calculating of weights and prices
        Management support
   Process oriented analyses of health
    care – what do a certain diagnosis or
    treatment cost? Medical praxis –
    outpatient/inpatient, activities e t c
   Management of a clinic, ex key
    indicators, costs for different patient
    groups
   Process budgeting, internal buy-sell
    agreements, product calculation
          The Kungalv study
   Aim of the project: To improve results
    and quality with equal or decreased
    costs for patients with prostate disorders
    (DRG 336-337)
   Method: Case-costing in combination
    with process analysis and Balanced
    Score Card.
                               Treatment of Prostate Disorders
                       Cost of individual hospital stays ranked by cost
      140000

      120000

      100000

       80000
SEK




       60000

       40000

       20000

           0
               1   5   9   13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73
                                       Hospital stays
                                 Treatment of prostata disorders
                  Cost of nursing ward and operation at individual hospital stays
                               Ranked by total cost of hospital stay
      90000
      80000
      70000
      60000
      50000
SEK




      40000
      30000
      20000
      10000
         0
              1   5   9   13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73
                                           Hospital stays
                                     Nursing ward     Operation
    Results of the Kungalv study
   Cost reduction and improved quality
    by:
-   Better planning of surgery
-   Better routines in different parts of the
    process
-   Better information to the patients
  The Haematological project
1.To describe and calculate episodes of
   care.
2.To analyse possible means to reimburse
   Haematological care
3.To compare two Haematological clinics
   from a cost perspective
4. To do follow up of medical guidelines
   for multiple myeloma. The costs for the
   treatment will also be calculated
Acute leukaemia 2000
Costs for inpatient care               Average per
Intermediate products:                 Case (SEK)

Per day cost                                  54 803
Drugs                                         10 478
Laboratory tests                              16 360
Imaging exams                                  2 502
Surgery, anaesthesiology                       1 310
Medical supplies                                 310
Intensive care                                 2 985
Miscellaneous                                  1 941

Total inpatient care                         90 690
Costs for outpatient care              Average per
Per medical procedures                  visit (SEK)

Bonemarrow exam                                5 760
Visit nurse                                    1 500
Visit Physician                                3 004
Laboratorytest package                             0
I.v treatment                                  3 725
Chemotherapy i.v                               3 344
Stamcell collection                           23 273
Transfusion – erythrocytes                     5 811
Transfusion – platelets                        7 414
Venesectio                                     1 309

Total outpatient care                          4 673
Number   of   cases                              203
Number   of   visits                             911
Number   of   patients                            87
Number   of   inpatient days                   2 077
Average       length of stay (days)            10,2
Average       cost per case (SEK)            90 690
Average       cost per visit (SEK)            4 673
Average       cost per patient (SEK)        260 540
                         Costs and reimbursement –
                               outpatient care
                                             Cost per visit and reimbursement per visit 2000

                   800
                                            Reimbursement, Visit to nurse,
                   700                      1970 kr


                   600                             Reimbursement, Visit to
                                                   physician, 2655 kr
Number of visits




                   500

                   400                                                                                               Serie1

                   300

                   200

                   100

                    0
                         0   1000   2000   3000        4000         5000     6000   7000       8000   9000   10000
                                                                  Cost, kr
Haematological procedures
Haematological procedures Number      Average
                                     cost (SEK)
Chemoteraphy i.v               503     3 042
I v treatment                  155     3 812
Transfusion - erythrocytes     239     5 289
Transfusion - platelets         78     6 443
Venesectio                       6     3 443
Tissue punctation                6     3 106
Bone marrow exam                96     3 740
Visit physician                909     1 848
Laboratory test package         14     1 973
Visit nurse                    174     1 970
Total                        2 179     2 907


The R2 value is 0,87
Results from the Haematological
            project
   Figures and facts about 12
    haematological episodes of care
   Suggestion to a new reimbursement
    system for outpatient care. Suggestion
    to a new coding for patients in inpatient
    care.
   Analysis and cost calculation of the
    medical guideline program for multiple
    myeloma.
Support to buyers of health care
   Costs for the treatment of different
    groups of patients
   Cost per geographical area
   Information about activities, medical
    praxis
   Price negotiations
   Neurosurgery – a comparison in
            Stockholm
                                                       Differ from
                                                       Stockholm
Neurosurgery 1999                                      average
                                          Average                    West and
                                          for       North            Central South
Key indicators                            Stockholm parts            parts    parts
Number of DRG-points per case                 2,9715        -4,0%        -0,4%     4,2%
Cost per day                                  16 144        -2,0%         0,6%     0,8%
Average length of stay                           7,2         8,1%        -1,8%    -4,0%
Cost per case                                116 905         5,9%        -1,1%    -3,2%
Cost per DRG-point                            39 342        10,3%        -0,8%    -7,1%

Number of cases per million inhabitants         943         -20,4%       14,2%     0,7%
Cost per inhabitant                             110         -15,7%       12,9%    -2,6%
Benchmarking studies of costs
     and medical praxis
   Internal benchmarking – between
    clinics, wards and physicians
   Extern benchmarking – between
    hospitals or different functions
   Comparisons over time
Benchmarking – key indicators –
      Acute leukaemia
Key indicators               Sahlgrenska       Skövde        Total            Diff %
Number of cases                        144           59                203             144%
Number of visits                       625          287                912             118%
Number of patients                      69           22                 87             214%
Number of inpatient days             1 469          608              2 077             142%

Outpatient care (costs)                16,3%         32,3%            18,8%        16,0%
Average lenght of stay               10,2          10,3             10,2             -1%
Median length of stay                 5,0           6,0              5,0            -17%
Inpatient days per patient           21,3          27,6             23,9            -23%
Average cost per case             111 417 kr     40 102 kr        90 690 kr         178%
Average cost per visit              5 006 kr      3 930 kr         4 668 kr          27%
Median cost per case               45 133 kr     28 336 kr        37 858 kr          59%
Max cost per case               1 095 339 kr    172 327 kr     1 095 339 kr         536%
Average cost per patient          277 870 kr    158 818 kr       260 540 kr          75%
Benchmarking hospitals –
    Case-mix index
                                  Cost index Average= 100

                                            Real
                                            cost    Case-
                                   Real     exkl     mix   Outlier
Hospital                           cost    outliers index costs %
Karolinska Sjukhuset                 118        113    104   30%
Huddinge Universitetssjukhus          95        100    100   21%
Norrlands Universitetssjukhus        100         97    102   28%
Sahlgrenska Universitetssjukhus       97         94     97   27%
Skaraborgs Hospital                   73         81     98   15%
Universitetssjukhuset i Lund         116        117    102   25%
    The use of case-costing data
      from a DRG-perspective
    Two main areas:
   To test the DRG-systems cost-
    performance, how reliable are
    DRG’s in predicting the patients’
    resource utilisation?
   To calculate DRG-weights and cost-
    outlier limits
           Examples
 Method   for calculating outlier
  limits and weights
 DRG-profiles

 Reduction in variance
            Exempel på ytterfallsberäkning för DRG 183
              Example of outlier calculation for DRG 183
Frequency
                                                       Outlierlimit
                             Medelvärde ca 9
                              Medium cost 9
                                                       around 25 000
                             Median 6
                              Median 6                 SEK
                              Stand dev ca 14
                                                         Q3+k(Q3-Q
                                                       Q3+k(Q3-Q 1) 1)

                                                           Ersättning
   Q1 Q                                         Q3Q3
       1                                                   ca 8 500 Kr




                                                           Cost
       Calculation of Weights -
              NordDRG
   Cost outliers are calculated and
    excluded (around 5% of all cases)
   An average cost is calculated for every
    DRG-group
   The average cost for each DRG is
    related to the average cost for all inliers.
   Complementary rules for DRG:s with
    low frequency
DRG 122 Other circulatory disorders w ami W/O
cc
                                            Drg 122 Cirk.sjd m.infar kt u tan större ko mpl levande
                  Q1        Med        Q3                                      Yg
   300




   250


                                                                                                n = 4 57 5 Vtf
   200                                                                                          min = 1 75 7 k r
                                                                                                Q1 = 13 21 0 k r
                                                                                                median = 18 58 2 k r
   150
                                                                                                Q3 = 26 97 5 k r
                                                                                                Ytterfallsgräns = 5 8 0 00
                                                                                                max = 218 90 3 k r
                                                                                                otrimmat medelv = 22 88 2 k r
   100
                                                                                                trimmat medelv = 20 45 0 k r


    50




     0
                 13

                       17

                            21

                                  25

                                       29

                                            33

                                                 37

                                                      41

                                                           45

                                                                49

                                                                     53

                                                                          57

                                                                                61

                                                                                     65

                                                                                          69

                                                                                               73

                                                                                                    78

                                                                                                         82

                                                                                                              86

                                                                                                                   90

                                                                                                                        94

                                                                                                                                2

                                                                                                                                       6

                                                                                                                                              7

                                                                                                                                                     3

                                                                                                                                                            3

                                                                                                                                                                   6

                                                                                                                                                                          5
     1

         5

             9




                                                                                                                             10

                                                                                                                                    10

                                                                                                                                           11

                                                                                                                                                  12

                                                                                                                                                         13

                                                                                                                                                                14

                                                                                                                                                                       16
DRG 403 Lymphoma and non-acute leukemia
w cc                                               Drg 403 Lym fom & icke-akut leukemi m kom pl
      Q1        Med                      Q3                                                                             Yg
 70




 60
                                                                                                         n = 1 4 93 Vtf
                                                                                                         min = 2 0 28 k r
                                                                                                         Q1 = 9 1 88 k r
 50
                                                                                                         median = 20 8 72 k r
                                                                                                         Q3 = 45 7 45 k r
 40                                                                                                      Ytterfallsgräns = 1 28 0 00 k r
                                                                                                         max = 8 21 9 63 k r
                                                                                                         otrimmat mede lv = 39 6 89 k r
 30                                                                                                      trimmat mede lv = 28 8 18 k r


 20




 10




  0
      11
           16
                21
                     26
                          31
                               36
                                    41
                                         46
                                              51
                                                   56
                                                        61
                                                             66
                                                                  72
                                                                       77
                                                                            82
                                                                                 87
                                                                                      92
                                                                                            97

                                                                                              4
                                                                                                     0
                                                                                                            7
                                                                                                                   3
                                                                                                                          8
                                                                                                                                 8
                                                                                                                                        8
                                                                                                                                               6
                                                                                                                                                      4
                                                                                                                                                             9
                                                                                                                                                                    7
                                                                                                                                                                           7
                                                                                                                                                                                  6
                                                                                                                                                                                         6
                                                                                                                                                                                                5
                                                                                                                                                                                                       4
                                                                                                                                                                                                              2
  1
       6




                                                                                           10
                                                                                                  11
                                                                                                         11
                                                                                                                12
                                                                                                                       12
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                                                                                                                                                                               24
                                                                                                                                                                                      25
                                                                                                                                                                                             30
                                                                                                                                                                                                    36
                                                                                                                                                                                                           71
      Reduction in variance

Year DRG-      Reduction in Reduktion in
                           2
     System    variance - R Absolute
                             Residuales – RAR
96   HCFA           59,6             37,0
97   NordDRG        56,3             34,7
98   NordDRG        63,0             39,0
99   NordDRG        57,1             35,0
00   NordDRG        59,0             36,0
Management of health care- What
   sort of data do we need ?
   Individual data
   Case-Costing data
   Secondary Classifications
   Outcome data
    With this sort of data we can
    calculate productivity and efficiency
    of health care.
   Address on the web


The National Case-costing
project:
www.lf.se/sek/kpp.htm

				
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