DRG-Oriented Mathematical Calculation Model and Method of Integrated Medical Service Cost.

In the context of the new round of medical and health reform, in order to alleviate the problem of "difficult to see a doctor and expensive to see a doctor," the state focuses on reducing the cost of medical services, so it puts forward the calculation and method research of medical costs. The purpose of this study is to calculate and predict the cost of medical services in a DRG-oriented integrated environment. In this study, activity-based costing and weighted moving average methods are used. First, basic data of medical services are collected, then all medical activities are confirmed and all service costs are collected, then a cost database is established, and a calculation model of medical costs is designed. Finally, calculation suggestions and optimization methods are put forward by analyzing the calculated data. The experimental results show that the actual demand of drugs predicted by the general moving average method is relatively insufficient, with the maximum error of 41%, the minimum of 5%, and the average error of 19.8%; the maximum error of drug demand predicted by the weighted moving average method is 24%, the minimum is 2%, and the average is 15.4%. It can be concluded that the prediction effect of the weighted moving average method is better than that of the ordinary moving average method, which plays a good and effective role in the prediction of medical cost. The activity-based costing method is more detailed and organized for the cost calculation and classification of medical services. It provides a certain value for the effective management and control of medical service cost.

Multiyear Rehospitalization Rates and Hospital Outcomes in an Integrated Health Care System.

Importance: Since the introduction of the rehospitalization rate as a quality measure, multiple changes have taken place in the US health care delivery system. Interpreting rehospitalization rates without taking a global view of these changes and new data elements from comprehensive electronic medical records yields a limited assessment of the quality of care. Objective: To examine hospitalization outcomes from a broad perspective, including the implications of numerator and denominator definitions, all adult patients with all diagnoses, and detailed clinical data. Design, Setting, and Participants: This cohort study obtained data from 21 hospitals in Kaiser Permanente Northern California (KPNC), an integrated health care delivery system that serves patients with Medicare Advantage plans, Medicaid, and/or Kaiser Foundation Health Plan. The KPNC electronic medical record system was used to capture hospitalization data for adult patients who were 18 years of age or older; discharged from June 1, 2010, through December 31, 2017; and hospitalized for reasons other than childbirth. Hospital stays for transferred patients were linked using public and internal sources. Exposures: Hospitalization type (inpatient, for observation only), comorbidity burden, acute physiology score, and care directives. Main Outcomes and Measures: Mortality (inpatient, 30-day, and 30-day postdischarge), nonelective rehospitalization, and discharge disposition (home, home with home health assistance, regular skilled nursing facility, or custodial skilled nursing facility). Results: In total, 1 384 025 hospitalizations were identified, of which 1 155 034 (83.5%) were inpatient and 228 991 (16.5%) were for observation only. These hospitalizations involved 679 831 patients (mean [SD] age, 61.4 [18.1] years; 362 582 female [53.3%]). The number of for-observation-only hospitalizations increased from 16 497 (9.4%) in the first year of the study to 120 215 (20.5%) in the last period of the study, whereas inpatient hospitalizations with length of stay less than 24 hours decreased by 33% (from 12 008 [6.9%] to 27 108 [4.6%]). Illness burden measured using administrative data or acute physiology score increased significantly. The proportion of patients with a Comorbidity Point Score of 65 or higher increased from 20.5% (range across hospitals, 18.4%-26.4%) to 28.8% (range, 22.3%-33.0%), as did the proportion with a Charlson Comorbidity Index score of 4 or higher, which increased from 28.8% (range, 24.6%-35.0%) to 38.4% (range, 31.9%-43.4%). The proportion of patients at or near critical illness (Laboratory-based Acute Physiology Score [LAPS2] ≥110) increased by 21.4% (10.3% [range across hospitals, 7.4%-14.7%] to 12.5% [range across hospitals, 8.3%-16.6%]; P < .001), reflecting a steady increase of 0.07 (95% CI, 0.04-0.10) LAPS2 points per month. Unadjusted inpatient mortality in the first year of the study was 2.78% and in the last year was 2.71%; the corresponding numbers for 30-day mortality were 5.88% and 6.15%, for 30-day postdischarge mortality were 3.94% and 4.22%, and for nonelective rehospitalization were 12.00% and 12.81%, respectively. All outcomes improved after risk adjustment. Compared with the first month, the final observed to expected ratio was 0.79 (95% CI, 0.73-0.84) for inpatient mortality, 0.86 (95% CI, 0.82-0.89) for 30-day mortality, 0.90 (95% CI, 0.85-0.95) for 30-day nonelective rehospitalization, and 0.87 (95% CI, 0.83-0.92) for 30-day postdischarge mortality. The proportion of nonelective rehospitalizations meeting public reporting criteria decreased substantially over the study period (from 58.0% in 2010-2011 to 45.2% in 2017); most of this decrease was associated with the exclusion of observation stays. Conclusions and Relevance: This study found that in this integrated system, the hospitalization rate decreased and risk-adjusted hospital outcomes improved steadily over the 7.5-year study period despite worsening case mix. The comprehensive results suggest that future assessments of care quality should consider the implications of numerator and denominator definitions, display multiple metrics concurrently, and include all hospitalization types and detailed data.

Understanding case mix across three paediatric services: could integration of primary and secondary general paediatrics alter walk-in emergency attendances?

OBJECTIVE: To understand the case mix of three different paediatric services, reasons for using an acute paediatric service in a region of developing integrated care and where acute attendances could alternatively have been managed. METHODS: Mixed methods service evaluation, including retrospective review of referrals to general paediatric outpatients (n=534) and a virtual integrated service (email advice line) (n=474), as well as a prospective survey of paediatric ambulatory unit (PAU) attendees (n=95) and review by a paediatric consultant/registrar to decide where these cases could alternatively have been managed. RESULTS: The case mix of outpatient referrals and the email advice line was similar, but the case mix for PAU was more acute. The most common parental reasons for attending PAU were referral by a community health professional (27.2%), not being able to get a general practitioner (GP) appointment when desired (21.7%), wanting to avoid accident and emergency (17.4%) and wanting specialist paediatric input (14.1%). More than half of PAU presentations were deemed most appropriate for community management by a GP or midwife. The proportion of cases suitable for community management varied by the reason for attendance, with it highestl for parents reporting not being able to get a GP appointment (85%), and lowest for those referred by community health professionals (29%). CONCLUSIONS: One in two attendances to acute paediatric services could have been managed in the community. Integration of paediatric services could help address parental reasons for attending acute services, as well as facilitating the community management of chronic conditions.

The Effect of Diagnosis-Related Group Payment System on Quality of Care in the Field of Obstetrics and Gynecology among Korean Tertiary Hospitals.

PURPOSE: To examine changes in clinical practice patterns following the introduction of diagnosis-related groups (DRGs) under the fee-for-service payment system in July 2013 among Korean tertiary hospitals and to evaluate its effect on the quality of hospital care. MATERIALS AND METHODS: Using the 2012-2014 administrative database from National Health Insurance Service claim data, we reviewed medical information for 160400 patients who underwent cesarean sections (C-secs), hysterectomies, or adnexectomies at 43 tertiary hospitals. We compared changes in several variables, including length of stay, spillover, readmission rate, and the number of simultaneous and emergency operations, from before to after introduction of the DRGs. RESULTS: DRGs significantly reduced the length of stay of patients undergoing C-secs, hysterectomies, and adnexectomies (8.0±6.9 vs. 6.0±2.3 days, 7.4±3.5 vs. 6.4±2.7 days, 6.3±3.6 vs. 6.2±4.0 days, respectively, all p<0.001). Readmission rates decreased after introduction of DRGs (2.13% vs. 1.19% for C-secs, 4.51% vs. 3.05% for hysterectomies, 4.77% vs. 2.65% for adnexectomies, all p<0.001). Spillover rates did not change. Simultaneous surgeries, such as colpopexy and transobturator-tape procedures, during hysterectomies decreased, while colporrhaphy during hysterectomies and adnexectomies or myomectomies during C-secs did not change. The number of emergency operations for hysterectomies and adnexectomies decreased. CONCLUSION: Implementation of DRGs in the field of obstetrics and gynecology among Korean tertiary hospitals led to reductions in the length of stay without increasing outpatient visits and readmission rates. The number of simultaneous surgeries requiring expensive operative instruments and emergency operations decreased after introduction of the DRGs.

Surveillance of imported hospital requiring malaria in Portugal: can it be improved?

Although eradicated in Portugal, malaria keeps taking its toll on travellers and migrants from endemic countries. Completeness of hospital requiring malaria notification in Portugal 2000-11 was estimated, using two-source capture-recapture method. Data sources were: national surveillance database of notifiable diseases and the national database of the Diagnosis-Related Groups resulting from National Health Service (NHS) hospital episodes. The completeness of notification was 21,2% for all malaria cases and 26,5% for malaria deaths, indicating significant underreporting and urging for complementary data source in surveillance, for disease burden estimates and retrospective monitoring, namely hospital episodes statistics.

Do diagnosis-related group-based payments incentivise hospitals to adjust output mix?

This study investigates whether the diagnosis-related group (DRG)-based payment method motivates hospitals to adjust output mix in order to maximise profits. The hypothesis is that when there is an increase in profitability of a DRG, hospitals will increase the proportion of that DRG (own-price effects) and decrease those of other DRGs (cross-price effects), except in cases where there are scope economies in producing two different DRGs. This conjecture is tested in the context of the case payment scheme (CPS) under Taiwan's National Health Insurance programme over the period of July 1999 to December 2004. To tackle endogeneity of DRG profitability and treatment policy, a fixed-effects three-stage least squares method is applied. The results support the hypothesised own-price and cross-price effects, showing that DRGs which share similar resources appear to be complements rather substitutes. For-profit hospitals do not appear to be more responsive to DRG profitability, possibly because of their institutional characteristics and bonds with local communities. The key conclusion is that DRG-based payments will encourage a type of 'product-range' specialisation, which may improve hospital efficiency in the long run. However, further research is needed on how changes in output mix impact patient access and pay-outs of health insurance.

The effects of reimbursement mechanisms on medical technology diffusion in the hospital sector in the Italian NHS.

OBJECTIVES: The aim of this study was to investigate how the differences across the regional reimbursement mechanisms and in particular the use of the DRGs impact on the level in the high technology equipment diffusion. METHODS: Based on hospital sector data at a regional level we build up indicators to measure the regional diffusion of high technological medical equipment in the period 1997-2007. These indicators are regressed on regional healthcare characteristics to investigate the relationship between the different reimbursement systems offered by Italian regions and the level of high technological medical equipment. RESULTS: Our results suggest that the per-case payment system is generally associated with a lower level of regional technology endowment per million of inhabitants, especially for the complex and expensive medical equipment. CONCLUSIONS: Our findings cast some doubts that an effective regulation of reimbursement mechanisms cannot limit the excessive diffusion of medical equipment that is a relevant driver of the increase in expenditure.

Hospital innovativeness and organizational performance: evidence from English public acute care.

BACKGROUND: Hospitals around the world dedicate increasing attention and resources to innovation. However, surprisingly little is known about the nature of hospital innovativeness and its relationship with organizational performance. Given both the specific characteristics of the hospital sector and the rather mixed evidence from other industries, a positive innovation-performance link should not be taken for granted but requires empirical examination. PURPOSES: The purposes of this study were to introduce a perspective of hospitals as vital generators of innovation, to unpack the concept of innovativeness, to propose a measurement model for hospital innovativeness, and to empirically investigate the innovativeness-performance relationship. METHODOLOGY: We conducted a large-scale empirical study among the entire population of public hospital organizations that are part of the English National Health Service (n = 173) and analyzed the data using exploratory factor and regression analyses. FINDINGS: Our analyses suggest a significant positive relationship between science- and practice-based innovativeness and clinical performance but provide less unambiguous support for the existence of such a relationship between innovativeness and administrative performance. In particular, we find that higher levels of innovativeness are rather associated with superior quality of care than with measurable bottom-line financial benefits. PRACTICE IMPLICATIONS: Hospitals investing in innovation-generating activities might find their efforts well rewarded in terms of tangible clinical performance improvements. However, to achieve measurable financial benefits, numerous hospitals have yet to discover and capture the commercial value of some of their innovations-a challenging task that requires a holistic innovation management and an effective network of complementary partners.

Incidence of neonatal herpes simplex virus infections in a managed-care population.

OBJECTIVE: To determine the incidence of possible neonatal herpes simplex virus (HSV) infections, HSV infection status of women with infected infants, and use of measures to reduce risk of HSV transmission to the neonate in a large US managed-care population. STUDY DESIGN: Retrospective analysis of administrative claims from the Integrated Health Care Information Services National Managed Care Benchmark database. RESULTS: Of 233,487 infants born to 252,474 mothers from January 1997 to June 2002, the numbers assigned an ICD-9 code reflecting possible neonatal HSV infection

[Elevated costs of treatment in medical inpatients with psychiatric comorbidity are not reflected in the German DRG-system]. / Höhere Kosten bei internistischen Krankenhauspatienten mit psychischer Komorbidität: Fehlende Abbildung im DRG-System.

OBJECTIVE: So far, it remains unclear whether treatment of psychiatric comorbidity in medical inpatients is appropriately reflected in the German Diagnosis-Related Groups (DRG) system. Therefore, we investigated the relationship of psychiatric disorders and costs, returns, net gain, and duration of hospitalization in internal medicine inpatients. METHODS: For a period of 1 year, we analyzed costs, net gain and other outcome variables according to the DRG system for all inpatients of a university department of internal and psychosomatic medicine (n = 697). Psychiatric disorders were diagnosed by the treating physicians based on clinical criteria and results from the Patient Health Questionnaire (PHQ). With respect to the outcome variables, we compared three groups of patients with none, one, and more than one psychiatric disorder controlling for sociodemographic characteristics. RESULTS: The average total costs of the hospitalization (M +/- SD) for internal medicine patients without psychiatric comorbidity (4357 +/- 5312 euro), for patients with one psychiatric disorder, (4733 +/- 5389 euro), and for patients with more than one psychiatric disorder (7163 +/- 8277 euro) differed significantly (p = 0.0003). However, the increased costs for patients with psychiatric comorbidity were not related to elevated returns: the net gain for patients without psychiatric comorbidity was 457 +/- 2884 euro; in contrast, the treatment of internal medicine patients with one and more than one psychiatric disorder resulted in a net loss of - 260 +/- 2389 euro and - 348 +/- 3370 euro, respectively (overall group difference, p = 0.03). CONCLUSIONS: Additional work and expenses caused by patients with psychiatric comorbidity should be documented and reflected in the revenue systems. Practical self-report screening questionnaires may help to detect and treat psychiatric disorders in internal medicine inpatients as early as possible.

Patterns of ambulatory care utilization in Taiwan.

BACKGROUND: We used the insurance claims of a representative cohort to quantify the patterns of ambulatory care visits, especially the doctor-shopping phenomenon, in Taiwan. METHODS: The ambulatory visit files of the 200,000-person cohort datasets from the National Health Insurance Research Database in 2002 were analyzed. Only a visit with physician consultation would be considered. We computed the visit patterns both by visit count and by patient count. RESULTS: In 2002, there were 182,474 eligible people with 2,443,003 physician consultations. During the year, 87.4% of the cohort had visited physician clinics and 57.5% had visited hospital-based outpatient or emergency departments. On average, a person had 13.4 physician consultations and consulted 3.4 specialties, 5.2 physicians, and 3.9 healthcare facilities in a year. In 2002, 17.3% of the cohort had ever visited different healthcare facilities on the same day; 23.5% had ever visited physicians of the same specialty at different healthcare facilities within 7 days and the percentage of second visits was 3.8% of all visits. Besides, 7.6% of the cohort had visited two or more specialties at the same facility on the same day, and such visits make up 2.5% of all visits. CONCLUSION: The people in Taiwan did visit the physicians and outpatient departments frequently. Many patients not only consulted several physicians of different specialties and at different healthcare facilities during the year, but also switched the physicians and facilities quickly. An effective referral system with efficient data exchange between facilities might be the solution.

Use of risk-adjusted change in health status to assess the performance of integrated service networks in the Veterans Health Administration.

OBJECTIVE: Health outcome assessments have become an expectation of regulatory and accreditation agencies. We examined whether a clinically credible risk adjustment methodology for the outcome of change in health status can be developed for performance assessment of integrated service networks. STUDY DESIGN: Longitudinal study. SETTING: Outpatient. STUDY PARTICIPANTS: Thirty-one thousand eight hundred and twenty-three patients from 22 Veterans Health Administration (VHA) integrated service networks were followed for 18 months. MAIN MEASURE: The physical (PCS) and mental (MCS) component scales from the Veterans Rand 36-items Health Survey (VR-36) and mortality. The outcomes were decline in PCS (decline in PCS scores greater than -6.5 points or death) and MCS (decline in MCS scores greater than -7.9 points). RESULTS: Four thousand three hundred and twenty-eight (13.6%) patients showed a decline in PCS scores greater than -6.5 points, 4322 (13.5%) had a decline in MCS scores by more than -7.9 points, and 1737 died (5.5%). Multivariate logistic regression models were used to adjust for case-mix. The models performed reasonably well in cross-validated tests of discrimination (c-statistics = 0.72 and 0.68 for decline in PCS and MCS, respectively) and calibration. The resulting risk-adjusted rates of decline in PCS and MCS and ranks of the networks differed considerably from unadjusted ratings. CONCLUSION: It is feasible to develop clinically credible risk adjustment models for the outcomes of decline in PCS and MCS. Without adequate controls for case-mix, we could not determine whether poor patient outcomes reflect poor performance, sicker patients, or other factors. This methodology can help to measure and report the performance of health care systems.

An analysis of high-cost users at an Australian public health service organization.

High-cost users generate extremely high costs when compared with average users in the same diagnostic-related group (DRG). They represent a major financial loss for a health service organization. The research was conducted using an area health service patient database for online analytical processing to produce descriptive statistics and graphs of 'high-cost' and 'non-high-cost users'. Trends and patterns were identified across key variables derived from clinical, financial and operational categories. The main results are: 20% of costs are spent by 3% of the population; elective admission is higher in the high-cost group; tracheostomy has the most number of cases and is the most expensive DRG; LOS is mostly longer for complex cases however, high costs can be attributed to other factors. In conclusion, these findings are potentially useful to patients, medical staff, management and health service decision-makers. The limitation of this study is the exclusion of profitability.

[The amount of nursing care for patients with myocardial infarction--a descriptive study]. / Die Erfassung des Pflegeaufwands bei Patienten mit der medizinischen Diagnose Myokardinfarkt. Eine deskriptive Studie.

In Germany nurses have no evidence-based data about the amount of nursing care for patients with specific medical diagnosis. These data are necessary for the demanded appropriate consideration of criteria of nursing care in a German-DRG. The pilot study "The amount of nursing care for patients with myocardial infarction", which was part of a students research project at the University of Witten/Herdecke, can provide a basis for this consideration. The amount of nursing care for a convenience sample of 26 patients during their stay at a university hospital in Munich is the focus of a cross-sectional descriptive study. A standardized instrument measuring the amount of care was developed by the project group. The nursing intervention system LEP was used to determine the nursing care hours. The patients' average length of stay is 9.5 days. 73 percent spent 2.4 days in the intensive care unit. The average amount of nursing care is 32.2 hours per patient or 3.4 hours per patient and day, respectively. Typical nursing activities as well as an amount of nursing care pattern in the course of the stay can be seen. Variations of nursing care and length of stay show the inhomogeneity of the investigated group. Older patients and patients with associated diagnoses show an increase of the amount of nursing care and length of stay. The amount of nursing care of old patients in the category "motion and transfer" increases drastically compared to younger ones. The results of this pilot study confirm the assumption that just the diagnosis myocardial infarction is not sufficient to predict and describe the amount of nursing care. Based on this study, further research with larger samples and a longer investigation time is necessary.

[Suggestions for implementation of DRG in the fields of Orthopaedics and Trauma Surgery for 2004]. / DRG-Anpassungsvorschläge der Fachgebiete Orthopädie und Unfallchirurgie für 2004.

OBJECTIVE: The Implementation of a DRG-Variant in Germany - voluntarily since January 1 st, 2003 and obligatory from January 1 st, 2004 - has been leading to uncertainty, particularly in the hospitals, due to fears that currently practised German diagnostic and therapeutic measures will not be financed properly by a DRG-Variant. The G-DRG-Version 1.0 that was drawn up in connection with an executive order law is to a large degree identical to the Australian AR-DRG-Version 4.1. Adjustments to German requirements were made only marginally. Therefore it is necessary for every medical field to investigate by stock-taking to what extent currently practised German diagnostic and therapeutic measures are considered in the G-DRG-Version 1.0 and whether and where modifications and adaptations need to be made. In order to make qualified statements scientific evaluations of possible problems have to be made based German data. Therefore an evaluation was made of the mapping of the medical fields of orthopaedics and trauma surgery. The German Society of Trauma Surgery (DGU), the German Society of Orthopaedy and Orthopaedic Surgery (DGOOC) in cooperation with the DRG-Research-Group of the University Hospital Muenster, the German Hospital Federation (DKG) and the German Medical Association carried out a DRG evaluation project in order to investigate the medical and economical homogeneity of the case groups. METHOD: 12,645 orthopaedic and trauma surgery cases from 23 hospitals - 11 university hospitals and 12 non-university hospitals - were collected within an period of three months and were scientifically evaluated with regard to their performance homogeneity and length of stay homogeneity. RESULTS: The data formed the basis for the proof of suspected deficiencies of mapping of orthopaedic and trauma surgery cases within the G-DRG-Variant. Based on the data and additionally on conclusions of medical experts when the number of cases were small, 14 suggestions for adaptation were proposed and submitted by the deadline of March 31 st, 2003 to the InEK. CONCLUSION: The results of the DRG-Evaluation Project demonstrate the problems of mapping the very heterogenous and complex medical performances of orthopaedy and trauma surgery to a flat rate financing system that is not adapted properly to German conditions. The G-DRG-Variant Version 1.0 does not offer the sufficient possibilities of differentiation that are needed to map the various orthopaedical and trauma surgical measures in Germany.

Phantoms in the snow: Canadians' use of health care services in the United States.

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians' use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994-1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

The funding of private hospitals in Australia.

Private hospitals are an essential component of Australia's complex mix of public and private health funding and provision. Private hospitals account for 34.3 per cent of all hospital separations, and over half (56.2%) of all same-day separations. The revenue (funding) of the sector approached $4 billion by 1998/99, and as a result of its recent rapid growth capital expenditure in the sector was nearly $550 million in the same year. Private casemix of private hospitals is distinctive, and characterised by a high proportion of surgical procedures in general (48.1 per cent), and more than a majority of all services in such areas as rehabilitation, orthopaedics (shoulder, knee, spinal fusion, and hand surgery), alcohol disorders, same day colonoscopy and sleep disorders. This chapter synthesizes data from a multitude of sources to produce a comprehensive picture of Australia's private hospital sector and its funding. It examines the funding (revenue) sources of private hospitals, and considers how and why private hospitals approach the issue of funding from a different perspective than their public sector colleagues. To illustrate how Australian private hospitals approach revenue (funding) strategically, a series of indicative types of hospitals is explored.

Public versus private hospital maternity length of stay: a gamma mixture modelling approach.

Application of a gamma mixture model to obstetrical diagnosis-related groups (DRGs) revealed heterogeneity of maternity length of stay (LOS). The proportion of long-stay subgroups identified, which can account for 30% of admissions, varied between DRGs. The burden of long-stay patients borne was estimated to be much higher in private hospitals than public hospitals for normal delivery, but vice versa for Caesarean section. Such differences highlights the impact of DRG-based casemix funding on inpatient LOS and have significant implications for health insurance companies to integrate casemix funding across the public and private sectors. The analysis also benefits hospital administrators and managers to budget expenditures accordingly.