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2.
Med Care ; 29(5): 452-72, 1991 May.
Artículo en Inglés | MEDLINE | ID: mdl-1902278

RESUMEN

This article describes a new case-mix methodology applicable primarily to the ambulatory care sector. The Ambulatory Care Group (ACG) system provides a conceptually simple, statistically valid, and clinically relevant measure useful in predicting the utilization of ambulatory health services within a particular population group. ACGs are based on a person's demographic characteristics and their pattern of disease over an extended period of time, such as a year. Specifically, the ACG system is driven by a person's age, sex, and ICD-9-CM diagnoses assigned during patient-provider encounters; it does not require any special data beyond those collected routinely by insurance claims systems or encounter forms. The categorization scheme does not depend on the presence of specific diagnoses that may change over time; rather it is based on broad clusters of diagnoses and conditions. The presence or absence of each disease cluster, along with age and sex, are used to classify a person into one of 51 ACG categories. The ACG system has been developed and tested using computerized encounter and claims data from more than 160,000 continuous enrollees at four large HMOs and a state's Medicaid program. The ACG system can explain more than 50% of the variance in ambulatory resource use if used retrospectively and more than 20% if applied prospectively. This compares with 6% when age and sex alone are used. In addition to describing ACG development and validation, this article also explores some potential applications of the system for provider payment, quality assurance, utilization review, and health services research, particularly as it relates to capitated settings.


Asunto(s)
Atención Ambulatoria/clasificación , Grupos Diagnósticos Relacionados/métodos , Adolescente , Adulto , Anciano , Niño , Preescolar , Análisis por Conglomerados , Árboles de Decisión , Demografía , Femenino , Humanos , Lactante , Masculino , Maryland/epidemiología , Persona de Mediana Edad , Modelos Estadísticos , Morbilidad , Análisis Multivariante , Método de Control de Pagos , Revisión de Utilización de Recursos
6.
Med Care ; 27(7): 750-7, 1989 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-2501596

RESUMEN

Medicare's diagnosis related groups (DRGs) payment system has been criticized for not making adequate allowances for severity of illness differences within DRGs. The respiratory diseases major diagnostic category (MDC) has been a particular target; therefore, ability of several procedure codes that identify patients with assisted respiration (temporary tracheostomy, endotracheal intubation, and mechanical respiratory assistance) to identify high-cost patients in that MDC was examined. Total charges were used as the dependent variable in a 10% sample of Medicare hospital discharges from 1985. A consistent and strong association was found between the procedures and total charges for both Medicare "outliers" and "nonoutliers." Patients requiring either intubation or mechanical respiratory assistance had average charges two to three times higher, and patients with tracheostomy four to five times higher than charges for patients without assisted respiration. Patients with assisted respiration tended to resemble each other more than they resembled the other patients in their respective DRGs without assisted respiration. These findings provide the basis for recent revisions in Medicare's classification scheme for the respiratory diseases MDC.


Asunto(s)
Grupos Diagnósticos Relacionados/métodos , Respiración Artificial/economía , Índice de Severidad de la Enfermedad , Connecticut , Honorarios y Precios , Humanos , Tiempo de Internación/economía , Traqueostomía/economía
7.
Pa Med ; 92(7): 34-5, 1989 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-2502768
8.
Mil Med ; 154(5): 255-9, 1989 May.
Artículo en Inglés | MEDLINE | ID: mdl-2499841

RESUMEN

The evolution of Diagnosis Related Groups (DRGs) is discussed briefly. Use of DRGs for resource allocation in the Veterans Administration is examined. Implications of the use of DRGs for resource allocation and other management functions in the Department of Defense are discussed.


Asunto(s)
Grupos Diagnósticos Relacionados , Agencias Gubernamentales , Grupos Diagnósticos Relacionados/historia , Grupos Diagnósticos Relacionados/métodos , Grupos Diagnósticos Relacionados/estadística & datos numéricos , Historia del Siglo XX , Humanos , Estados Unidos , United States Department of Veterans Affairs
10.
Am J Public Health ; 79(4): 441-4, 1989 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-2494894

RESUMEN

For 48 of the most common diagnosis-related groups (DRGs) at our hospital, we examined the ability of clinical laboratory tests, demographic data, and ICD-9-CM codes, which provide a measure of severity of illness, to predict patients' length of stay (LOS) more accurately than DRGs alone. For 10 of 20 medical DRGs and 13 of 23 surgical DRGs examined, we were able to increase the ability to predict LOS by at least 10 per cent. The laboratory tests that proved most predictive of LOS over all DRGs were the mean serum sodium, potassium, bicarbonate, and albumin. The system is data driven, objective, and flexible, thus ensuring its utility for the purpose of equitable reimbursement.


Asunto(s)
Grupos Diagnósticos Relacionados/métodos , Tiempo de Internación , California , Dióxido de Carbono/sangre , Demografía , Humanos , Potasio/sangre , Análisis de Regresión , Albúmina Sérica/análisis , Índice de Severidad de la Enfermedad , Sodio/sangre
11.
Chest ; 95(3): 705-6, 1989 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-2493359
12.
Arch Intern Med ; 149(2): 417-20, 1989 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-2492795

RESUMEN

There are many health policy issues related to diagnosis-related group (DRG) hospital payment. Previous work by our group had suggested that some DRGs did not adequately comorbidities. Despite recommendations by federal advisory committees, the secretary of Health and Human Services has proposed no major changes to DRGs along these lines. We analyze resource consumption in any of the 88 non-complicating condition (CC)-stratified medical DRGs using the DRG prospective "all payor system" in effect at our hospital. Analysis of 12,340 medical patients by payor (Medicare, Medicaid, Blue Cross, and commercial insurance) in these non-CC-stratified medical DRGs for a three-year period demonstrated that patients with more CCs per DRG for each payor generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, higher financial risk under DRG payment, and a higher mortality, compared with patients in these same DRGs with fewer CCs. These findings suggest that new prospective DRG all payor systems may be inequitable to certain groups of patients or types of hospitals vis-à-vis the non-CC-stratified medical DRGs. Health policy leaders should be encouraged to stratify many medical DRGs by the numbers and types of CCs to more equitably reimburse hospitals under DRG all payor systems.


Asunto(s)
Grupos Diagnósticos Relacionados/métodos , Reembolso de Seguro de Salud , Seguro de Hospitalización/economía , Costos y Análisis de Costo , Tiempo de Internación , New York
13.
Health Care Financ Rev ; Spec No: 39-52, 1988 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-10312971

RESUMEN

A study of 3,427 nursing home residents in New York State, measuring both resources used and resident characteristics, was used to develop a resident classification system for payment purposes. The system balances clinical, statistical, and administrative criteria, making it useful both for the New York State Medicaid payment system and for quality of care and facility management.


Asunto(s)
Grupos Diagnósticos Relacionados/métodos , Tabla de Aranceles , Cuidados a Largo Plazo/clasificación , Medicaid/economía , Casas de Salud/economía , Actividades Cotidianas , Modelos Teóricos , New York , Método de Control de Pagos
14.
Arch Gen Psychiatry ; 45(11): 1037-40, 1988 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-3140757

RESUMEN

Characteristics of a psychiatric setting, such as staffing intensity and scope of services, are examined to see if they contribute to explaining variation in length of stay over that explained by commonly available patient descriptors. For short-stay admissions (less than 31 days), only a small improvement in predictive ability was found. Implications for prospective payment systems are discussed.


Asunto(s)
Grupos Diagnósticos Relacionados/métodos , Hospitales Psiquiátricos/organización & administración , Tiempo de Internación/economía , Servicio de Psiquiatría en Hospital/organización & administración , Adulto , Femenino , Capacidad de Camas en Hospitales , Hospitales con Fines de Lucro/organización & administración , Hospitales Provinciales/organización & administración , Humanos , Masculino , Medicare Assignment/economía , Personal de Hospital , Sistema de Pago Prospectivo/economía , Estados Unidos
15.
Med Care ; 26(9): 833-6, 1988 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-3138506
18.
Med Care ; 26(4): 423-9, 1988 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-3127642

RESUMEN

The Diagnosis-Related Group (DRG)-based Medicare Prospective Payment System has raised a number of concerns. One major concern has centered on both the definition of outlier patients and how hospitals are to be paid for their care. The epidemiology of outlier patients, however, has received relatively little attention. Using a retrospective database, we constructed a case control study in which the cases were DRG outliers and the control patients were DRG-matched inlier patients. We then examined both the prior hospitalization experience of outlier patients and inlier controls, and the prior outlier experience of the attending physicians of outlier patients and inlier control patients. We demonstrated that DRG-based outlier patients were more likely to have had prior admissions to the hospital as compared with DRG-matched inlier control patients. Moreover, DRG-matched outlier cases were more likely to have had prior outlier admissions as compared to controls--an effect that was more pronounced when only the subset of patients who actually had a prior admission was evaluated. Finally, physicians of the DRG outlier patients were more likely to have had previous outlier patients than physicians of the DRG-matched inlier control patients. In summary, we were able to demonstrate that DRG-based outlier patients have a different prior admission and outlier experience than DRG-matched inlier control patients. However, because we showed the same relationship when we evaluated the outlier experience of physicians of outlier patients as compared to physicians of DRG-matched inlier controls, we were unable to determine if the effect was patient- or physician-based.(ABSTRACT TRUNCATED AT 250 WORDS)


Asunto(s)
Grupos Diagnósticos Relacionados/métodos , Hospitalización , Pacientes Internos/clasificación , Tiempo de Internación , Pacientes/clasificación , Humanos , Readmisión del Paciente , Pautas de la Práctica en Medicina , Estudios Retrospectivos , Estados Unidos
19.
Med Care ; 26(2): 124-31, 1988 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-3123815

RESUMEN

The present Medicare Diagnosis Related Group (DRG) classification system contains 95 DRG pairs, where one DRG of the pair contains patients within a distinct diagnostic category who are under 70 years of age with no comorbidities or complications (CCs). The other DRG of the pair contains patients in the same diagnostic category who are over 69 or who have CCs. This study examines whether it is appropriate for reimbursement purposes to group those patients who are 70 years of age or older but have no CCs with patients who have CCs. Our findings show that age alone, in the absence of CCs, increases length of stay and cost of care only slightly. In fact, using only CCs as a classification variable reduces the within-group variance more than the present classification based on both age and CCs. Therefore, it is inappropriate to group Medicare patients who are older than 70 years of age without CCs with Medicare patients who have CCs.


Asunto(s)
Anciano , Grupos Diagnósticos Relacionados/métodos , Economía Hospitalaria , Factores de Edad , Anciano de 80 o más Años , Recolección de Datos , Honorarios y Precios , Registros de Hospitales , Humanos , Tiempo de Internación , Medicare , Persona de Mediana Edad , Estados Unidos
20.
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