Identification and assessment of a comprehensive set of structural factors associated with hospital costs in Switzerland.

Structural factors can influence hospital costs beyond case-mix differences. However, accepted measures on how to distinguish hospitals with regard to cost-related organizational and regional differences are lacking in Switzerland. Therefore, the objective of this study was to identify and assess a comprehensive set of hospital attributes in relation to average case-mix adjusted costs of hospitals. Using detailed hospital and patient-level data enriched with regional information, we derived a list of 23 cost predictors, examined how they are associated with costs, each other, and with different hospital types, and identified principal components within them. Our results showed that attributes describing size, complexity, and teaching-intensity of hospitals (number of beds, discharges, departments, and rate of residents) were positively related to costs and showed the largest values in university (i.e., academic teaching) and central general hospitals. Attributes related to rarity and financial risk of patient mix (ratio of rare DRGs, ratio of children, and expected loss potential based on DRG mix) were positively associated with costs and showed the largest values in children's and university hospitals. Attributes characterizing the provision of essential healthcare functions in the service area (ratio of emergency/ ambulance admissions, admissions during weekends/ nights, and admissions from nursing homes) were positively related to costs and showed the largest values in central and regional general hospitals. Regional attributes describing the location of hospitals in large agglomerations (in contrast to smaller agglomerations and rural areas) were positively associated with costs and showed the largest values in university hospitals. Furthermore, the four principal components identified within the hospital attributes fully explained the observed cost variations across different hospital types. These uncovered relationships may serve as a foundation for objectifying discussions about cost-related heterogeneity in Swiss hospitals and support policymakers to include structural characteristics into cost benchmarking and hospital reimbursement.

Effects of a DRG-based hospital reimbursement on the health care utilization and costs in Swiss primary care: A retrospective "quasi-experimental" analysis.

INTRODUCTION: In Switzerland, a nationwide Swiss Diagnosis related Groups (Swiss DRG) system for hospital reimbursement was introduced in 2012. However, the impact of DRG systems on primary care is still unclear with respect to number of consultations and costs. The aim of this study was to investigate the effect of the implementation of DRG on costs and volumes in the primary care sector, on a nationwide basis in Switzerland. METHODS: The study retrospectively analysed yearly data, from 2008 to 2014, of almost 60 Swiss health insurers that covered almost all Swiss general practitioners, with a total number of patients which represented approximately 76% of the Swiss population. GP consultations, total numbers and rates, and the relative costs reimbursed (TARMED tariff values) in the Swiss federal states, cantons, which already introduced a DRG-like system before 2012 (AP-DRG), were compared to the GP consultations and costs reimbursed in the other cantons (DRG-naive). Regression discontinuity design analysis and mixed regression models, at cantonal level, were performed to evaluate the effect of the nationwide implementation of the Swiss DRG on health care demand and costs in the primary care setting. Change in outcome level and yearly trend pattern difference between groups (AP-DRG vs. DRG-naive) were examined. RESULTS: Overall, the total number of GP consultations and the relative TARMED values increased from 2008 to 2014. In the DRG naive, 15 cantons: in 2008, the number of GP consultations were 13,114,126, with a TARMED value of 1,194,957,157 CHF, and in 2014, the GP consultation were 13,752,511, with a TARMED value of 1,513,861,260 CHF. In the AP-DRG group, 11 cantons, the total number of GP consultations increased from 8,787,646, in 2008, to 9,347,168 in 2014 and the TARMED value increased from 896,673,657 CHF in 2008, to 1,100,203,508 CHF in 2014. The yearly trend pattern of GP consultations and TARMED values, in the AP-DRG group, were not significantly different from the respective trends in the DRG- naive and, overall, no significant change was detected in consultations and costs trends before and after 2012. DISCUSSION/CONCLUSION: This study found no evidence of any effect of the introduction of the SwissDRG on the yearly trend of primary care consultations and costs. Nevertheless, potential negative impacts on vulnerable patients, as chronically ill patients, could not be excluded and further investigation is required.

Managerial workarounds in three European DRG systems.

PURPOSE: Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy. DESIGN/METHODOLOGY/APPROACH: We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N = 154), analysis of policy documents (N = 111) and an action learning set, began in 2010-12, with additional data collection from key informants and administrative documents continuing in 2018-19 to supplement and update our findings. FINDINGS: Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load 'ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed 'floor' volume. RESEARCH LIMITATIONS/IMPLICATIONS: Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the 'managerial workaround' still further. PRACTICAL IMPLICATIONS: In the case of DRGs, the managerial workarounds were instances of 'constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the 'managerial workaround'. SOCIAL IMPLICATIONS: Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection. ORIGINALITY/VALUE: So far as we are aware, no other study presents and tests the concept of a 'managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

[Determinants of time required by medical information technicians for quality control of hospital activity coding, in French medico-administrative system]. / Déterminants du temps nécessaire au contrôle qualité dans le cadre du programme de médicalisation des systèmes d'information (PMSI), dans le champ médecine, chirurgie et obstétrique (MCO) d'un centre hospitalier régional, par les techniciens d'information médicale.

BACKGROUND: Since 2008, in France, hospital funding is determined by the nature of activities provided (activity-based funding). Quality control of hospital activity coding is essential to optimize hospital remuneration. There is a need for reliable tools to allocate human resources wisely in order to improve these controls. METHODS: The main objective of this study was to identify the determinants of time needed by medical information technicians to control hospital activity coding in a Regional Hospital Center. From March 2016 to the beginning of January 2017, medical information technicians reported the time they spent on each quality control, and the time they needed when they had to code the entire stay. Multiple linear regressions were performed to identify the determinants of quality control or coding duration. A split sample validation was used: model was created on one half of the sample and validated on the remaining half. RESULTS: Among the controls, 5431 were included in the analysis of determinants of control duration (2715 kept aside for model validation). Seven determinants have been identified (stay duration, level of complexity, month of control, type of control, medical information technician, rank of classing information, and major diagnostic category). The correlation coefficient between predicted and real control duration was 0.71 (P<10-4); 808 stays were included in the analysis of determinants of coding duration (404 kept aside for model validation). Two determinants have been identified. The correlation coefficient, between predicted and real coding duration, was 0.47 (P<10-3). We performed the same multiple regression, on 2017 activity data, to estimate the weight of each hospital activity pole, regarding quality control of hospital activity coding. CONCLUSION: We succeeded in modeling time needed for quality control of hospital stays. These results helped to estimate human resources required for quality control of each hospital pole. Nevertheless, the second analysis did not give satisfactory results: we failed in modeling time needed to code hospital stays.

Technocratic recentralization in the French health care system: A critical evaluation.

The French health care system implemented several corporate management recipes such as diagnostic-related groups (DRGs), benchmarking, and activity-based management in a bid to restore fiscal discipline and to "reassert the center." The government also regrouped health policy decisions with the Regional Health Agencies and opted for a top-down line of command to ensure policy implementation. Though reforms emphasized evidenced-based policy and outputs measurement, outcomes were below expectations in many areas and led to a shift in values. Professional autonomy and patient engagement receded. This leads us to a critical evaluation of the French audit society.

Competencias profesionales, gestión clínica y grupos relacionados de diagnósticos: el caso de hospitales públicos chilenos / Professional competences, clinical management and diagnostic related groups in Chilean public hospitals

RESUMEN Objetivo Definir un modelo competencias profesionales para el desarrollo de un sistema de información de apoyo a la Gestión Clínica basado en Grupos Relacionados de Diagnósticos-GRD en hospitales públicos chilenos. Método Mixta. Investigación cualitativa, descriptiva, basada en entrevistas focalizadas con un muestreo teórico o intencionado a cuatro líderes expertos en GRD en Chile, con análisis de contenido; Investigación cuantitativa, con uso de Método Delphi a 18 gestores encargados de la implementación de las unidades de GRD en Chile, con 3 rondas. El análisis de los datos cuantitativos se realizó por conglomerados. Resultados Luego de cinco iteraciones, se evaluaron 78 competencias de un total de 179 en nivel "alto", del tipo: Conocimientos del líder de los equipos, formación profesional preferentemente enfermeras, 15 actitudes y valores, 17 habilidades o destrezas y 12 competencias específicas relacionadas al sistema de codificación. Conclusión Existe tendencia en los profesionales, a requerir el máximo de competencias, se observó una conducta masificadora, con baja discriminación y priorización. Se propone analizar las causas que dificultan la toma de decisiones y priorizar las competencias requeridas; Determinar para cada competencia el nivel requerido, las brechas entre la oferta de competencias y su demanda, y finalmente diseñar un sistema de evaluación del impacto del modelo en el desarrollo de competencias de los equipos.(AU)

ABSTRACT Objective To define a professional skills model for the creation of an information system to support clinical management based on diagnosis related groups (DRG) in Chilean public hospitals. Methods Mixed methodology. Qualitative, descriptive research based on focused interviews, with a theoretical or intentional sample of four leading DRG experts from Chile, with content analysis. Quantitative research using the Delphi method on 18 managers in charge of the implementation of DRG units in Chile, with three rounds. The analysis of quantitative data was carried out by clusters. Results After five iterations, 78 skills were evaluated out of a total of 179 as "high", including knowledge of the team leader, professional training (preferably nurses), 15 attitudes and values, 17 skills and 12 specific skills related to the coding system. Conclusion There is a tendency among professionals to require the maximum skills; a massive behavior was observed, with low discrimination and prioritization. To analyze the causes that make decision-making difficult and to prioritize the required skills is proposed to determine the necessary level for each skill, the gaps between skill offer and demand, and to design a system for evaluating the impact of the model on the development of the skills among the teams.(AU)

Application of case mix index in the allocation of nursing human resources.

AIM: To investigate the feasibility of the case mix index and compare the allocation of nursing human resources between two departments of a hospital with different case mix indexes in China. BACKGROUND: The case mix index is used to assess the resource allocation of all cases in two departments of a hospital. Its values can determine the resource allocation required to diagnose and treat the patients. METHODS: Clinical data were obtained from 23 different departments in 2015 and analysed retrospectively from October to November, 2016. Factors influencing the allocation of registered nurses were identified, and balanced quantities of patients with different case mix indexes were chosen from two departments. Spearman correlation analysis was performed. RESULTS: The per capita nursing workload was significant (r = .669, p = .000). The length of hospital stay, quantity of nurses, and department case mix index were correlated with the nursing workload (t = 4.211, p = .000; t = 2.962, p = .008; t = 2.266, p = .035). Education levels (Z = -1.391, p = .164) and the professional titles (Z = -1.832, p = .067) of the nurses were not statistically significant, whereas the registered nurse level differed between two departments (Z = -2.125, p = .034). CONCLUSION: The case management index provides references for the efficient allocation of registered nurses in clinical practice.

Developing and utilising a new funding model for home-care services in New Zealand.

Worldwide increases in the numbers of older people alongside an accompanying international policy incentive to support ageing-in-place have focussed the importance of home-care services as an alternative to institutionalisation. Despite this, funding models that facilitate a responsive, flexible approach are lacking. Casemix provides one solution, but the transition from the well-established hospital system to community has been problematic. This research seeks to develop a Casemix funding solution for home-care services through meaningful client profile groups and supporting pathways. Unique assessments from 3,135 older people were collected from two health board regions in 2012. Of these, 1,009 arose from older people with non-complex needs using the interRAI-Contact Assessment (CA) and 2,126 from the interRAI-Home-Care (HC) from older people with complex needs. Home-care service hours were collected for 3 months following each assessment and the mean weekly hours were calculated. Data were analysed using a decision tree analysis, whereby mean hours of weekly home-care was the dependent variable with responses from the assessment tools, the independent variables. A total of three main groups were developed from the interRAI-CA, each one further classified into "stable" or "flexible." The classification explained 16% of formal home-care service hour variability. Analysis of the interRAI-HC generated 33 clusters, organised through eight disability "sub" groups and five "lead" groups. The groupings explained 24% of formal home-care services hour variance. Adopting a Casemix system within home-care services can facilitate a more appropriate response to the changing needs of older people.

Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays.

There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines.

A New Strategy to Evaluate Technical Efficiency in Hospitals Using Homogeneous Groups of Casemix : How to Evaluate When There is Not DRGs?

The public health system has restricted economic resources. Because of that, it is necessary to know how the resources are being used and if they are properly distributed. Several works have applied classical approaches based in Data Envelopment Analysis (DEA) and Stochastic Frontier Analysis (SFA) for this purpose. However, if we have hospitals with different casemix, this is not the best approach. In order to avoid biases in the comparisons, other works have recommended the use of hospital production data corrected by the weights from Diagnosis Related Groups (DRGs), to adjust the casemix of hospitals. However, not all countries have this tool fully implemented, which limits the efficiency evaluation. This paper proposes a new approach for evaluating the efficiency of hospitals. It uses a graph-based clustering algorithm to find groups of hospitals that have similar production profiles. Then, DEA is used to evaluate the technical efficiency of each group. The proposed approach is tested using the production data from 2014 of 193 Chilean public hospitals. The results allowed to identify different performance profiles of each group, that differs from other studies that employs data from partially implemented DRGs. Our results are able to deliver a better description of the resource management of the different groups of hospitals. We have created a website with the results ( bioinformatic.diinf.usach.cl/publichealth ). Data can be requested to the authors.

How do Hospitals Respond to Price Changes? Evidence from Norway.

Many publicly funded health systems use activity-based financing to increase hospital production and efficiency. The aim of this study is to investigate whether price changes for different treatments affect the number of patients treated and the mix of activity provided by hospitals. We exploit the variations in prices created by the changes in the national average treatment cost per diagnosis-related group (DRG) offered to Norwegian hospitals over a period of 5 years (2003-2007). We use the data from Norwegian Patient Register, containing individual-level information on age, gender, type of treatment, diagnosis, number of co-morbidities and the national average treatment costs per DRG. We employ fixed-effect models to examine the changes in the number of patients treated within the DRGs over time. The results suggest that a 10% increase in price leads to about 0.8-1.3% increase in the number of patients treated for DRGs, which are medical (for both emergency and elective patients). In contrast, we find no price effect for DRGs that are surgical (for both emergency and elective patients). Moreover, we find evidence of upcoding. A 10% increase in the ratio of prices between patients with and without complications increases the proportion of patients coded with complications by 0.3-0.4 percentage points.

Development of Case Mix Based Evaluation System in Japan.

DPC (Diagnosis Procedure Combination) is the Japanese original Case Mix system. The principal purpose of DPC introduction is not only for payment arrangement but also for modernization of the health system. To improve the quality of hospital management, to strengthen the responsibility of hospital for accountability, and to rationalize the health system are the three main objectives of the project. Based on the current DPC database, patients can know the clinical performance of each acute care hospital, such as volume stratified by diseases and disorders and related quality indicators. Furthermore, DPC data is used for regional health care planning. In this article, the author provides an overview of the DPC system with some examples.

Hospitals and Big Data: Use of Case Mix and E-claim Data in Japan.

The ageing society issue has necessitated the Japanese government conducting health reform. In order to reorganize the health service delivery system, the Ministry of Health, Labour and Welfare (MHLW) has prepared two massive health related data bases; DPC (Diagnosis Procedure Combination) data and NDB (National Receipt Database). The former gathers about 11 million discharged cases from 1,900 acute care hospitals annually. The latter gathers more than 1.7 billion claim data from all medical facilities every year. Using these data bases, we can evaluate the current system and estimate the future health needs of each region. As the backbone of the Japanese health system is a publicly funded private dominant supply system, the existence of useful information concerning health needs is crucial for sound management, especially for the private sector. In this article, the author reveals some examples of the application of these two massive databases for regional health planning and hospital management.

[Quality management in emergency departments: Lack of uniform standards for fact-based controlling]. / Qualitätsmanagement in der Notaufnahme: Fehlende einheitliche Standards zur kennzahlenbasierten Steuerung.

BACKGROUND: The general high occupancy of emergency departments during the winter months of 2014/2015 outlined deficits in health politics. Whether on the regional, province, or federal level, verifiable and accepted figures to enable in depth analysis and fact-based controlling of emergency care systems are lacking. OBJECTS: As the first step, reasons for the current situation are outlined in order to developed concrete recommendations for individual hospitals. METHODS: This work is based on a selective literature search with focus on quality management, ratio driven management, and process management within emergency departments as well as personal experience with implementation of a key ratio system in a German maximum care hospital. RESULTS AND CONCLUSION: The insufficient integration of emergencies into the DRG systematic, the role as gatekeeper between inpatient and outpatient care sector, the decentralized organization of emergency departments in many hospitals, and the inconsistent representation within the medical societies can be mentioned as reasons for the lack of key ratio systems. In addition to the important role within treatment procedures, emergency departments also have an immense economic importance. Consequently, the management of individual hospitals should promote implementation of key ratio systems to enable controlling of emergency care processes. Thereby the perspectives finance, employees, processes as well as partners and patients should be equally considered. Within the process perspective, milestones could be used to enable detailed controlling of treatment procedures. An implementation of key ratio systems without IT support is not feasible; thus, existing digital data should be used and future data analysis should already be considered during implementation of new IT systems.

Internal Controlling of a Radiology Department.

Caused by legal reform initiatives there is a continuous need to increase effectiveness and efficiency in hospitals and surgeries, and thus to improve processes.Consequently the successful management of radiological departments and surgeries requires suitable structures and optimization processes to make optimization in the fields of medical quality, service quality and efficiency possible.In future in the DRG System it is necessary that the organisation of processes must focus on the whole clinical treatment of the patients (Clinical Pathways). Therefore the functions of controlling must be more established and adjusted. On the basis of select Controlling instruments like budgeting, performance indicators, process optimization, staff controlling and benchmarking the target-based and efficient control of radiological surgeries and departments is shown.