1 eurodrg fc busse berlin171111

8/9/2019 1 EuroDRG FC Busse Berlin171111

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Diagnosis Related Groups in Europe:Moving towards transparency, efficiencyand quality in hospitals

17 November 2011 DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s 1

Reinhard Busse, Prof. Dr. med. MPH FFPHDepartment o $ea"t# %are Management, &er"in 'niversity o (ec#no"ogy

) European *bservatory on $ea"t# +ystems and o"icieson be#a" o t#e EuroDRG team

Understanding DRGs in Europe the EuroDRG project


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po!ic" #uestion in the $th EU Frame%or& Programme'-#y do costs o #ea"t# services di er among E' countries att#e micro "eve".

Ho% ( got interested in DRGs )*++*

6,0007,0008,0009,000

NHS

2

01,0002,0003,0004,000

,

Cataract Hip Knee

UK privateFrance

The first nine patients sent toFrance by the English NHS

(not shown: the 40 journalistswho accompanied them)

Are these data realistic?Are they representative?

How can the differences be explained?DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s17 November 2011


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5916,455599,30

7450,22

5369,53

8282,36

6225,55

7616,89

9374,21

6000,00

7000,00

8000,00

9000,00

10000,00

in

Using -+ standardised /ignettes0 acrosscountries

E.g. Acute myocardial infarction

395,97

1025,76

1861,02

2465,322866,36

5013,64

308,88592,15

2236,40

2868,16

483,05

1415,79

2541,845 2733,38

1181,531282,55

3720,88

4384,724161,15

0,00

1000,00

2000,00

3000,00

4000,00

5000,00

Hungary

(N=2)

Poland

(N=5)

Spain

(N=5)

Denmark

(N=3)

Germany

(N=13)

England

(N=3)

France

(N=3)

Netherlands

(N=6)

Italy

(N=5)

//DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s17 November 2011


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5916,455599,30

7450,22

5369,53

8282,36

6225,55

7616,89

9374,21

6000,00

7000,00

8000,00

9000,00

10000,00in Acute myocardial infarctionpatient /aria1!es

medica! and managementdecision /aria1!es

gender, age,main diagnosis, ot#er

diagnoses, severity

Open question 1: How much do

395,97

1025,76

1861,02

2465,322866,36

5013,64

308,88592,15

2236,40

2868,16

483,05

1415,79

2541,845 2733,38

1181,531282,55

3720,88

4384,724161,15

0,00

1000,00

2000,00

3000,00

4000,00

5000,00

Hungary

(N=2)

Poland

(N=5)

Spain

(N=5)

Denmark

(N=3)

Germany

(N=13)

England

(N=3)

France

(N=3)

Netherlands

(N=6)

Italy

(N=5)

mi and intensity o procedures,tec#no"ogies and #uman

resource use

e g si3e, teac#ing status4urbanity4 wage "eve"

structura! /aria1!es onhospita!2 regiona!2

nationa! !e/e!

variation (and do DRG systemstake them into account)?

DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s17 November 2011


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5916,455599,30

7450,22

5369,53

8282,36

6225,55

7616,89

9374,21

6000,00

7000,00

8000,00

9000,00

10000,00in

none mixed all

Acute myocardial infarction:Hospitals performing PCI (PTCA/ Stenting)

395,97

1025,76

1861,02

2465,322866,36

5013,64

308,88592,15

2236,40

2868,16

483,05

1415,79

2541,845 2733,38

1181,531282,55

3720,88

4384,724161,15

0,00

1000,00

2000,00

3000,00

4000,00

5000,00

Hungary

(N=2)

Poland

(N=5)

Spain

(N=5)

Denmark

(N=3)

Germany

(N=13)

England

(N=3)

France

(N=3)

Netherlands

(N=6)

Italy

(N=5)

> factor 4:value for money?

5DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s17 November 2011


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5916,455599,30

7450,22

5369,53

8282,36

6225,55

7616,89

9374,21

6000,00

7000,00

8000,00

9000,00

10000,00in Acute myocardial infarction

none mixed

Open question 2: If costs differ so

all

Acute myocardial infarction:Hospitals performing PCI (PTCA/ Stenting)

395,97

1025,76

1861,02

2465,322866,36

5013,64

308,88592,15

2236,40

2868,16

483,05

1415,79

2541,845 2733,38

1181,531282,55

3720,88

4384,724161,15

0,00

1000,00

2000,00

3000,00

4000,00

5000,00

Hungary

(N=2)

Poland

(N=5)

Spain

(N=5)

Denmark

(N=3)

Germany

(N=13)

England

(N=3)

France

(N=3)

Netherlands

(N=6)

Italy

(N=5)

muc w t treatment, w at a outthe quality of care?



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8000

10000

12000

t ( E u r o s

)

Hip implant

Hospitals in NL

0

2000

4000

6000

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Total cost (Euros)

R e

i m b u r s e m

e

DenmarkEnglandFranceGermanyHungary

ItalyNetherlandsPolandSpain

77DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s17 November 2011 7


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8000

10000

12000

t ( E u r o s

)

Profit-making plausible through comparatively low case complexity

Open question 3: If costs differ so muchwithin countries, why do countriesdevelo their own DRG s stems

Hip implant

0

2000

4000

6000

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Total cost (Euros)

R e

i m b u r s e m

e

DenmarkEnglandFranceGermanyHungary

ItalyNetherlandsPolandSpain

(rather than a European one)?

What data would be necessary for this?



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For the new project, we then chose to look atDRGs specifically. These are introduced to get acommon currency of hospital activity for

transparency efficiency benchmarking &performance measurement (protect/ improve quality),

budget allocation (or division among purchasers), planning of capacities, payment ( efficiency)

Exact reasons, expectations and DRG usage differamong countries due to (de)centralisation, onevs. multiple payers, public vs. mixed ownership.



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SuomiFinland

Countries covered by EuroDRG project17 November 2011 10DRGs in Europe: Moving towards transparency, e iciency andua"it in #os ita"s


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3hat did %e do4

Phase ( )5 session ( toda"$ow do DRG system in Europe wor9. -#y and w#enimp"emented. $ow does patient c"assi ication wor9.

-#ere do data come rom. 'ni orm or regiona""y adapted.$ow o ten updated. mpact on e iciency and !ua"ity. ;

Phase (( )5 session (( toda"

$ow do DRG systems per orm. (o empirica""y ana"yse t#at,we c#ose 10 countrycomparisons o actua" c"assi ication, reimbursement, actorse p"aining cost variation, cost>!ua"ity re"ations#ip ;

Phase ((( )5 this afternoon%onc"usions or po"icy>ma9ers wit#in and beyond Europeancountries ;

17 November 2011 11DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s


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E c"uded costs?e g or in rastructure4in 0.'. also #-ysician ser!ices @

ayments or non>patient care activities?e g teac#ing, researc#, emergency avai"abi"ity@

ayments or patients not c"assi ied into DRG systeme out atients, da cases, s c#iatr , re#abi"itation

For %hat t"pes of acti/ities4 :cope of DRGs )(

DRG61ased case pa"ments,DRG61ased 1udget a!!ocation

?possib"y adKusted or out"iers, !ua"ity etc @

*t#er types o payments or DRG>c"assi ied patients?e g g"oba" budgets, ee> or>service@

Additiona" payments or speci ic activities or DRG>c"assi ied patients ?e g e pensive drugs, innovations@,

possib"y "isted in DRG cata"ogues

DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s 1/17 November 2011


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=rigina!DRG system

DRG system

DRG system DRG system

For %hat t"pes of acti/ities4 :cope of DRGs )((

Ps"chiatr" Da" casescute

inpatient care=utpatient care Reha1i!itation

s"stems

separate romorigina" DRGs@

separate romorigina"DRGs@di erent toorigina" DRGs@

separate romorigina" DRGs@

DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s 117 November 2011


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Data co!!ection

Price settingctua!

reim1ursement

L Demograp#ic data

L %"inica" dataL %ost dataL 'am#le si ere$ularity

Essentia! 1ui!ding 1!oc&s of DRG s"stems

2

/

Patientc!assifications"stem

L DiagnosesL roceduresL +everityL re+uency of re!isions

L%ost weig#tsL &ase rate?s@L rices tari sL Average vs


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cti/it"E>penditure

9ontro!7echnica!Efficienc"

?ua!it"dmini6

strati/esimp!icit"

7rans6parenc"

;um1er ofser/ices per

case

;um1erof cases

Hospita! pa"ment s"stemsDRGs for pa"ment' d/antages and disad/antagesof different forms of hospita! pa"ment

16

Fee6for6ser/ice @ @ 6 + + 6 +

G!o1a!1udget 6 6 @ + + @ 6



17/31

cti/it"E>penditure

9ontro!7echnica!Efficienc"

?ua!it"dmini6

strati/esimp!icit"

7rans6parenc"

;um1er ofser/ices per

case

;um1erof cases

Hospita! pa"ment s"stems

DRGs for pa"ment' d/antages and disad/antagesof different forms of hospita! pa"ment

dumping (avoidance), creaming(selection) and skimping (undertreatment)

up/wrong-coding, gaming

17

Fee6for6ser/ice @ @ 6 + + 6 +

DRG61ased

pa"ment

6 @ + @ + 6 @

G!o1a!1udget 6 6 @ + + @ 6European

countries 1990s/2000s

USA 1980s



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Main #uestions re!ating to data co!!ection

Clinical dataclassification system for diagnoses and classification system for procedures

Cost dataimported (not good but easy) or collected within countr better but needs

Data co!!ection

L Demograp#ic data

standardised cost accounting)

Sample sizeentire patient population ora smaller sample

Many countries: clinical data = all patients;cost data = hospital samplewith standardised cost accounting system

L %"inica" data

L %ost dataL 'am#le si ere$ularity



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;um1er )share of costdata co!!ecting hospita!s

Direct costa!!ocation to patients

Data used for ca!cu!ation ofDRG %eights

ustria20 re erence #ospita"s?O P o a"" #ospita"s@ grosscosting

Eng!and a"" #ospita"s top down microcostingEstonia

A"" #ospita"s contracted byt#e N$ B top down microcosting

Fin!and5 re erence #ospita"s

?O/0P o specia"ised care@ bottom up microcosting

Data co!!ection

L Demograp#ic dataL %"inica" dataL9ost dataL 'am#le si e

re$ularity

9o!!ection of cost data

France88 #ospita"s ?O 1/P oinpatient admissions@

main"y top downmicrocosting

German"125 #ospita"s

?O 6P o a"" #ospita"s@main"y bottom up

microcosting(re!and > > >Po!and > > >Portuga! > > >

7he ;ether!andsunit costs: 15>25 #ospita"s

?O 2 P o a"" #ospita"s@ bottom up microcosting

:pain > > >

:%eden?O 62P o inpatient

admissions@bottom up microcosting



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cost %eight 1ase rate or

Price setting

L %ost weig#tsL &ase rate?s@L rices tari sL Average vs


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Country DRG weight(unit)

Applicability of DRG weight

Austria Score Nationwide

England Raw tariff Nationwide

Estonia Relative weight Nationwide

Finland Relative weight Nationwide (8 districts), District-specific (5 districts)

France Raw tariff Nationwide (separate tariffs for public and private hospitals)

Germany Relative weight Nationwide

Price setting

L %ost weig#tsL &ase rate?s@L rices tari sL Average vs


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Ho% European DRG s"stems reduce unintended1eha/iour' -. !ong6 and short6sta" adjustments

Revenues

+#ort>stayout"iers

ong>stayout"iers

n"iersctua!

reim1ursement

*+Deductions?per day@

+urc#arges?per day@

ower *+t#res#o"d

'pper *+t#res#o"d

L o"ume "imitsL=ut!iersL $ig# cost casesL ua"ityL nnovationsL Negotiations

2/DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s17 November 2011


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Ho% European DRG s"stems reduce unintended1eha/iour' *. Fee6for6ser/ice6t"pe additiona! pa"ments

ctua!reim1ursement

Eng!and France German" ;ether6!ands

Pa"ments perhospita! sta"

*ne *ne *ne +evera"possib"e

Pa"ments forspecific high6

'nbund"ed$RGs or e g :

+Tances G$M ore g :

+upp"ementarypayments or e g :

No

L o"ume "imitsL *ut"iersLHigh cost casesL ua"ityL nnovationsL Negotiations

cost ser/ices %#emot#erapy

Radiot#erapyRena" dia"ysisDiagnosticimaging$ig#>cost drugs

%#emot#erapy

Radiot#erapyRena" dia"ysis

Additiona"payments: %'

Emergency care $ig#>cost drugs

%#emot#erapy

Radiot#erapyRena" dia"ysisDiagnostic imaging$ig#>cost drugs

(nno/ation6re!ated addA!pa"ments

Ces Ces Ces Ces ? ordrugs@



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Ho% European DRG s"stems reduce unintended1eha/iour' . adjustments for #ua!it"

ctua!reim1ursement

England & Germany: no extra payment ifpatient readmitted within 30 days

rm n i n r n mi in liL o"ume "imitsL *ut"iersL $ig# cost casesL?ua!it"L nnovationsL Negotiations

data England: up 1.5% reduction if quality

standards are not met

France: extra payments for qualityimprovement (e.g. regarding MRSA)



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C. Fre#uent re/isions of P9: and pa"ment ratesCountry PCS Payment rate

Frequency of updates Time-lag to data Frequency of updates Time-lag to data

Austria Annual 24 years 45 years 24 years

England Annual Minor revisions annually; irregular

overhauls about every 56 years

Annual 3 years (but adjusted for

inflation)

Estonia Irregular (first update

after 7 years)

12 years Annual 12 years

Finland Annual 1 year Annual 01 year

France Annual 1 year Annual 2 years

Germany Annual 2 years Annual 2 years

Ireland Every 4 years Not applicable (imported

AR-DRGs)

Annual 12 years

Netherlands Irregular Not standardized Annual or when

considered necessary

2 years, or based on

negotiations

Poland Irregular planned

twice per year

1 year Annual update only of

base rate

1 year

Portugal Irregular Not applicable (imported

AP-DRGs)

Irregular 23 years

Spain (Catalonia) Biennial Not applicable (imported

3-year-old CMS-DRGs)

Annual 23 years

Sweden Annual 12 years Annual 2 years



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Ho% do DRG s"stems dea! %ith inno/ations4

ctua!reim1ursement


L o"ume "imitsL *ut"iersL $ig# cost casesL ua"ityL (nno/ationsL Negotiations


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9onc!usions so far

DRG>based #ospita" payment is t#e main met#od o providerpayment in Europe, but systems vary across countries Di erent patient c"assi ication systems DRG>based budget a""ocation vs case>payment Regiona" "oca" adKustment o cost weig#ts conversion rates

(o address potentia" unintended conse!uences, countries >

operate DRG>based payment toget#er wit# ot#er payment mec#anisms re ine patient c"assi ication systems continous"y ?increase number o groups@ p"ace a comparative"y #ig# weig#t on procedures base payment rates on actua" average ?or best>practice@ costs

reimburse out"iers and and #ig# cost services separate"y update bot# patient c"assi ication and payment rates regu"ar"y

done rig#t ?w#ic# is comp"e @, DRGs can contribute to increasedtransparency and e iciency J and possib"y !ua"ity



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EuroDRG consortium members

icture: 22nd [anuary 2010, aris

/0DRGs in Europe: Moving towards transparency, e iciency and !ua"ity in #ospita"s17 November 2011


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