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DRGs and Clinical Pathways:
Chalk and Cheese
or Cheese and Cheese?
RIC MARSHALL
2008 CASEMIX CONFERENCE
CASEMIX EVOLUTION: EXTENDING THE BOUNDARIES
16-19 NOVEMBER 2008
ADELAIDE CONVENTION CENTRE
Casemix and clinical pathways
Some history and experience?
What makes them happen?
What do they have in common?
What are the differences?
How so they contribute to good healthcare?
Do they have any adverse effects?
How are they being used?
What is the potential?
Where did casemix come from?
NHIF HEALTH SYSTEM
MoH OPERATORS,
INSURERS REGIONS,
PATIENT HMOs
EMPLOYED PRACTITIONERS HOSPITALS,
Drug, MD SUPPLIERS HEALTH CLINCS,
SUPPORT SERVICES PRACTITIONERS
MANUFACTURERS
The halcyon days of DRG development
POLITICAL WILL
POLICY
OFFICIALS
GOVERNMENT
MINISTERS
INDUSTRY EXPERTS
EXECUTIVES
The Epidemic of the DRG Grouper
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1990
1989
1988
1987
Accountability 1
Look! You spent too much on
patient 15644
But patient 15644 was
different from normal
I've checked, and patient 15644
wasn't different at all!
Accountability 2
Sorry, I'll try not to do it
again
„Casemix - a case of mixed priorities‟–Vic 98
Has the drive for efficiency gains contributed to the hospital NO OR
having to, in some cases, shift costs in the following areas: YES OTHER
From hospital service providers to community-based providers (e.g. to
general practitioners, day clinics, community health centres) – 50% 50%
From casemix/variable funded hospital units to casemix/fixed grant hospital
units – 16% 84%
From lower category hospitals to tertiary referral centres – 12% 88%
From hospital-funded pharmaceuticals to Pharmaceutical Benefits Scheme-
funded medication – 33% 67%
From outpatient to Same Day inpatient (e.g. rehabilitation) – 16% 84%
Transfers of post-acute inpatients down to lower category hospitals (e.g. to
small and rural hospitals) – 36% 64%
From public hospitals to the Metropolitan Ambulance Service – 2% 98%
From public hospitals to discharged patients – 25% 75%
OVERALL SHIFTING ???????????????????????????????????? 19% 81%
The grand vision for clinical
pathways
FROM DRG FUNDING TO CLINICAL
PATHWAYS
NHIF HEALTH SYSTEM
MoH OPERATORS,
INSURERS REGIONS,
PATIENT HMOs
EMPLOYED PRACTITIONERS HOSPITALS,
Drug, MD SUPPLIERS HEALTH CLINCS,
SUPPORT SERVICES PRACTITIONERS
MANUFACTURERS
The grand vision for clinical pathways
Pieter and Don‟s work on clinical teams
Delegated work, process specification approach to quality/efficiency.
The Scottish website – and all the others -
The cult of the „evidence based‟ guidelines
The NICE program – making evidence based clinical guidelines
accessible
Clinical protocols
The privacy and INFORMED consent movement
The growth in clinical litigation
The quality and safety in healthcare movement
The electronic health record,
templates,
clinical decision support
and the „archetype‟
Why everyone wins:
pathways put clinicians in the centre
Controlling waste
Clinical
practice
standards
Ensuring
customer
focus
Setting
prices
Improving payment
classifications
Integrating care
Pathways and DRGs might connect
1:1 DRG 1 Pathway A
DRG 2
M:1 Pathway B
DRG 3
DRG 4 Pathway C
M:M
DRG 5 Pathway D
Cookbook medicine or cookbook medicine
DRGs as cookbook healthcare
„If you pay hospitals the same for every patient they will do the
same for every patient‟
Clinical pathways as cookbook healthcare
„If you give hospitals a clinical pathway for every patient they
will do the same for every patient‟
Does anyone want ‘non-cookbook’
healthcare?
Do we need more „tunnel vision‟ in healthcare?
Focus and attention to detail?
Are they really the same thing in a different form?
Alternatives to „cookbook healthcare‟
Creative healthcare?
Sloppy healthcare?
Inaccessible healthcare?
INFORMATION SYSTEMS
DRG LEVEL
BUSINESS OBJECTS COGNOS,BRIO, EXCELL
SAS ,SPSS, STATA, ACCESS
STATISTICAL REPORT REPORTING
CUBES
ANALYSIS REPOSITORY
PIVOT LAYER (MIS)
DATA
AED WAREHOUSE
EMD MH
Aggregate
ESIS DW MH
MDSs ODS
PATHWAY LEVEL
CLINICAL
Oracle, SAP, etc
MH
MPI CMI
SUPPLY HR FMIS PAS EHR
BUSINESS LAYER
If they are not the same where do they
intersect?
For a clinical pathway FOR DRG’s you must
you must have: have:
• an episode of care. • an episode of care.
• diagnoses. • diagnoses.
• a care planning process. • know what was done to the
patient
- at least in general terms.
• a team approach to patient • discretion in choice of the
management. most cost effective care.
• decisions made before the • decisions made after the
treatment is undertaken. treatment is completed.
What is a clinically meaningful DRG?
What do you get for a plane ticket from Ankara to Adelaide?
Flight Ankara to Additional services for
Istanbul lost luggage
Flight Istanbul to Hong Flight crew 1 extra hour
Kong Flight delay crew
Flight HK to Melb standby 4 hours
Flight Melb to Adelaide Engineering
unsheduled repair
Diversion to avoid
storm, delayed landing
“They think they need DRGs but what they
actually need is clinical pathways”
The Suisse recommendation in China
The UK approach to mental health casemix
classification
Why has Turkey not gone ahead with DRG payment
implementation yet?
The Suisse recommendation in
China
WHY GO TO DRG DEVELOPMENT
WHEN YOU CAN FOCUS ON
CLINICAL PATHWAYS FIRST?
The Suisse recommendation in China
Regionalised system of healthcare delivery.
Strengthening lower end health institutions.
Balance between:-
Quality of care and spreading resources more equitably.
Modern and traditional healthcare services???
Universality and strengthened role for private health insurance
to reduce out of pocket problems.
Development of management tools – especially
clinical pathways – performance measures.
Do not proceed with DRG development until clinical
pathways have been implemented.
ISSUES
Uniform data collection and reporting.
Settign performance improvement goals
Measuring achievements.
Records standards.
System availability and standardisation.
DRG‟s in POC stage in Beijing region.
Trial funding simulations proceding this year.
Private sector interest in the DRG tool for service
planning and performance benchmarking.
Greater public investment at the lower end.
Reducing out of pocket.
The Beijing DRG Forum
ENGLAND
THE CURRENT ENGLISH
APPROACH TO MENTAL HEALTH
CASEMIX CLASSIFICATION
The UK approach to mental health casemix
classification
A CLASSICAL DRG MDC APPROACH
A MH-CASC LIKE PAYMENT CLASSIFICATION
DEVELOPMENT
A CLINICAL PATHWAYS BASED
CLASSIFICATION FOR PAYMENT
A SPECIFIC PURPOSE CLASSIFICATION FOR
FUNDING FORENSIC MENTAL HEALTH
SERVICES
RESOURCE HOMOGENEITY VS CLINICAL
MEANINGFULNESS REVISITED
http://www.southwestyorkshire.nhs.uk/documents/440.pdf http://www.ic.nhs.uk/webfiles/Services/casemix/Updates/Mental%20
Health%20End%20of%20Stage%20Report,%20FINAL.pdf
T01 Senile Dementia
T03 Schizophreniform HRG v3.5 MH
Psychoses without Section
T07 Depression without CATEGORIES
Section
T08 Presenile Dementia DX BASED DSM4?
T09 Anxiety Syndromes BROAD SCOPE
T10 Alcohol or Drugs Non- Eg A&D INCLUDED
Dependent Use >18
T11 Alcohol or Drugs Non- IP / OP ?
Dependent Use <19 DATASET FOR
T12 Alcohol or Drugs GROUPER NORM
Dependency
T13 Eating Disorders or
Obsessive Compulsive
Disorders
T14 Acute Reactions or
Personality Disorders
UK PbR
Cty No or std CPA Low prob daily act HONOS10
Cty No or std CPA High prob daily act HONOS10
STUDY
Cty Std CPA Low prob daily act HONOS10 SETTING
Cty Std CPA High prob daily act HONOS10 DEPENDENT
Cty Enh CPA Low prob daily act HONOS10 CATEGORIES
Cty Enh CPA High prob occ act HONOS12 17
Cty Enh CPA High prob occ act HONOS12 CATEGORIES
Cty Enh CPA Low prob occ act HONOS12 SETTING/
IP/OP no or std CPA working age PROBLEM / FN
IP/OP no or std CPA above working age BASED
IP/OP enh CPA Low cog prob HONOS4 no section ord
CARE
IP/OP enh CPA Low cog prob HONOS4 section ord
APPROACH
IP/OP enh CPA High cog prob HONOS4 0-2 phys
prob SMALL
IP/OP enh CPA High cog prob HONOS4 >2 phys prob DATASET
IP Low social prob HoNOS social COSTING?
IP Med social prob HoNOS social
RELIES ON
IP High social prob HoNOS social
HONOS
;W/o Section;No or std CPA;Dx= F0, F2, F5, F6, F7;;;
;W/o Section;No or std CPA;Dx=F1, F3, F4 ,F9;No or low prob daily
activities (HoNOS 10);; UK PbR STUDY
;W/o Section;No or std CPA;Dx=F1, F3, F4 ,F9;High prob daily activities SETTING INDEPENDENT
(HoNOS 10);Wkg age;
CATEGORIES
;W/o Section;No or std CPA;Dx=F1, F3, F4 ,F9;High prob daily activities
(HoNOS 10);Above wkg age;>3 HoNOS psych ONLY WORKING
;W/o Section;No or std CPA;Dx=F1, F3, F4 ,F9;High prob daily activities AGE +
(HoNOS 10);Above wkg age;1-3 HoNOS psych
;W/o Section;Enh CPA;Dx=None, F1, F7, F8;No or low prob daily
activities (HoNOS 10);;
LEGAL, DX AND
;W/o Section;Enh CPA;Dx=None, F1, F7, F8;High prob daily activities
(HoNOS 10);;
HoNOS
;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Med or hi CRU
complexity;Low or no cognitive prob HoNOS4;
78% RECORDS
;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Med or hi CRU
complexity;High cognitive prob HoNOS4;
EDIT REJECTED
;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Low CRU
complexity;;
;W Section;>2 HoNOSpsych;Enh CPA;Dx= None, F1, F3, F4;;
N=11,364 pat
;W Section;>2 HoNOSpsych;Enh CPA;Dx=F0, F2, F5, F6, F9;;
;W Section;>2 HoNOSpsych;No or std CPA;;;
;W Section;0-2 HoNOSpsych;;;;
Acute non-psychotic low
Acute non-psychotic med
Categories
Acute non-psychotic high Suggested by the
Non-psychot overval idea
Non-psychot chaotic &
Care Path Study
challenging
Drug & alcohol CARE PATH
DEFINITIONS
First episode psychosis
Chronic severe low sympt CLINICIAN
Chronic severe high sympt GROUPING VS
Severe psychot episode ALGORITHM
Severe depression GROUPING
Dual diag
COST VARIANCE
Assertive outreach ANALYSIS
N=2,287 PATIENTS
Ideas on classification dimensions
from the forensic MH study.
DEMOGRAPHIC STUDY
Socio demographic DISTRIBUTION OF
Offence ACCESS AND SERVICE
Clinical
PROVISION
SECLUSION AS
IP/cty
MANAGEMENT TOOL
Medico-legal
COSTS
Seclusion
TURKEY
WHY HAS TURKEY NOT GONE
AHEAD WITH DRG PAYMENT
IMPLEMENTATION YET?
The Health Transformation Programme
Special
Funds
GERF
Universal
Current Health Financing Health
Schemes
SSK
Green Insurance
Card
01/01/2009
Private BAĞ-KUR
Insurance
Financing Side 70M people
Why is Turkey yet to go ahead with DRG
payment implementation?
Large scale access to detailed utilisation data.
General view by the payer (3000 doctors as claims
inspectors) that they can control efficiency and
quality by examining detailed claims and rejecting a
percentage of them.
The idea of the clinical pathway as a post episode
audit mechanism?
Recent change of payment structure.
Extremely cautious approach to coding quality.
Component E, the objective and expected
outputs...
Analysis of cost differences in inpatient
healthcare services by hospital types and regions
DRG-based clinical coding and costing studies will be
conducted in 40 hospitals that are able represent
geographical distribution, distinct hospital types and various
cost structures (evaluation)
A management information system will be established to
ensure central compiling and analysis of DRG clinical coding
and costing data so that necessary information will be
obtained for management of healthcare services (evaluation)
Data Flow
Hospital Information Systems
Hospital Financial Data
Minimum Basic Data Set-DRG Cost Sheet
Data Entry Tool -Allocation Statistics
- Clinical Data, DRG
- Resource Consumption Data
(preparecostsheet)
(analysistool)
(volumefile) (costfile)
(separationstbl)
Diagnosis and Procedures
Combo Software
Analysis Reports PICQ Software
Coding Analysis Reports Data Analysis Reports Cost Reports
National Registries...
• Health Services Providers Registry
(1200 Hospitals, 4500 Clinics - Total 23.000 Service Providers)
• Physican Registry
(78.553 Physican)
• Medical Devices and Consumables Registry
(2500 Firms, 1.052.347 Devices)
• Drug DataBase 6.800 Drugs
(237 Drug company, 6849 Drugs)
• Medical Data Dictionary
(SNOMED-CT, ICD-10TRM, ACHI, ATC, GMDN,
UNSPS....National Codes )
MEDULA
• Turkish National Health Insurance Fund MEDULA
system
• Web User Interface Online
17800 Pharmacies, 5600 GP, 4500 Med. Centres
• Web Services Offline
1200 Govmt. Hospitals, 338 Private Hospitals
• An e-invoicing legislation has been passed by
Parliament so no paper will be needed in 2009
Online Running System NHIF MEDULA
HEALTH INFORMATION SYSTEM
ELECTRONIC CLAIM PROCESSING STRATEGIC RESOURCE PLANNING &
E-HEALTH HEALTH ECONOMICS
SOLUTIONS
Health
Patient Transactions
Database Database
Healthcare Healthcare PROCUREMENT
Information Providers HUMAN
&
Systems Application RESOURCES
INVENTORY
Healthcare Physican
Providers DataBase
Database
Pharmacy
WEB Pharmacy
Automation
Application
ELIGIBILITY & ACCURAL
Systems SERVICES
CONTRACT &
MANAGEMENT REIMBURSEMENT
Medical
Provision &
Data
Rule Engines
Diagnosis/ Diagnosis Dictionery
Laboratory Laboratory
SystemS Application NATIONAL INSURANCE
HEALTH PREMIUM
PROGRAMS COLLECTION
Family Family
WEB Drug/Device Contract
Practioners Practioners Database
INTERFACE Managemet
SystemS Application
DECISION SUPPORT &
NATIONAL HEALTH STATISTICS
Accural &
Ambulatory Administrative Medical
Reimbursement
Services Rule Base Knowledge
Application
DOCUMENT & WORKFLOW
MEDULA Pharma Major Outcomes
Reduction in the number of prescriptions (5 %)
Reduction in the drug consumption (20-35 %)
Merger of Claim Processing Units (58722)
Reduction in the health expenses (5-25 %)
Reduction in the outsourced lab and rad. tests happening due to LMHOM Syndrome
Reduction of unnecessary health services use
Detection of uncontrolled expensive drug usage
SOME METRICS...
IN CONCLUSION
DRGS AND CLINICAL
PATHWAYS:
CHALK AND CHEESE
OR CHEESE AND CHEESE?
IN SUMMARY CLINICAL PATHWAYS AND
DRGs ………….
Both could be used for payment
but SHOULD they be?
Both can describe generalised groups of patients
DRGs by focus on need as described primarily by Diagnoses.
CPs by focus on the detail of what is going to be done for the
patient.
DRGs are a post episode summary of the type of case
it was in general terms.
CPs are a working tool to help the team work
together most efficiently DURING the episode.
Both can be costed – DRGs after – CPs before.
So – chalk and cheese?
Well actually bread and cheese
They go very well together
.
THANK YOU
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