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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
13
14
15
16
18
20
22
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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