Changing Patient Classification System for Hospital Reimbursement in Romania

Autor: Ciprian-Paul Radu, Cristian Vladescu, Delia Nona Chiriac
Jazyk: angličtina
Rok vydání: 2010
Předmět:
Zdroj: Croatian Medical Journal
Volume 51
Issue 3
ISSN: 1332-8166
0353-9504
Popis: Under a prospective payment system (PPS), a provider receives a fixed payment, established in advance, to cover an episode of care provided during a specific period of time. The idea is to establish the payment in advance based on what it costs an efficient provider to serve the patient. Consequently, the efficient providers make money; the inefficient lose money. PPSs are increasingly used around the world to reimburse health care providers, especially hospitals (1). One option for a hospital PPS is to have a patient classification system to group hospital cases and apply predefined fees for each type of these cases. The most common patient classification system used for PPS is the system of diagnosis-related groups (DRG). The DRG relates types of patients to the amount and type of resources they consume during hospital treatment. The DRG system classifies patients with similar characteristics into the same category, and it is assumed that the patients within one category will require similar resources (2). The DRG hospital payment is seen as a way to increase hospital efficiency while keeping the same quality of services (3). The United States Health Care Financing Administration (HCFA) first introduced the DRG system for PPS in 1983, making their own classification system named HCFA-DRG (4). Several European countries, including Portugal, Austria, and Italy, followed in the 1980s and 1990s, and they usually used locally adapted HCFA-DRG systems (5). In central and eastern Europe, Hungary was the first country to implement a DRG system in July 1993 (6). Romania started to evaluate the use of DRG system in 1999, and in 2003 it used this mechanism to reimburse 23 pilot hospitals. Subsequently the DRG hospital payment system was implemented in 185 hospitals in 2004, including all public universities, district and municipal hospitals; 276 hospitals in 2005, after inclusion of city hospitals; and 291 hospitals in 2009, after inclusion of the Ministry of Transportation hospital network. Currently, in Romania, almost all public hospitals providing acute care are reimbursed using the DRG system; exemptions are rural hospitals and the Ministry of Defense hospital network. Private hospitals are contracted by the National Health Insurance House (NHIH); they are not paid on DRGs, but on a negotiated fee-per-case basis. Selecting a DRG classification system depends on the predefined goal: patient classification may be desirable in order to compare hospitals, departments, or even physicians, or to compare hospital reimbursement levels. It also depends on the resources available. Some DRG systems are free, being in the public domain, while others require a license (7). Most countries that have implemented DRG started with one classification scheme and updated it in subsequent years, as is the case with Hungary, Australia, and the US, but the literature on the effects of changing a DRG system within one country is scarce. Romania is one of the countries that experienced the transition from one DRG system to another. Romanian hospitals operating under the DRG scheme used the US HCFA-DRG (version 18) since the start of the scheme in 2003 until July 1, 2007. After a few years, Romania moved toward a new one in order to increase the accuracy of patient classification and to increase objectivity in financing by ensuring that hospital reimbursement is based on the number and type of patients actually treated and not on other criteria (8). Thus, the Australian Refined DRG (version 5) was implemented from the second half of 2007, together with a new classification of diagnoses – the International Classification of Diseases version 10 with Australian Modifications (ICD10AM). The main reasons for changing the DRG system were problems with HCFA-DRG regarding the clinical aspects of the classification and the utilization of several mapping systems for diagnoses and procedures (HCFA-DRG system requires International Classification of Diseases version 9 with US Clinical Modifications – ICD9CM, and Romania uses ICD10AM). The DRG hospital payment in Romania is a mixture of prospective and retrospective reimbursement systems. At the beginning of the year, hospitals contract with the Health Insurance House for an annual budget based on the previous year's activity and reflected in the number of cases and case mix index (CMI). This is the prospective dimension of the reimbursement system. The CMI is an indicator that relates the resources needed by hospitals with the patients treated. A particular DRG is assigned a cost weight (CW), also known as relative weight, based on resource consumption in terms of diagnostics, therapeutics, bed services, and length of stay. A higher CW is assigned to more severely ill patients. A patient in a DRG with a CW of 2 is reimbursed twice as much as a patient in a DRG with a CW of 1. The array of patients across DRGs in a hospital is the hospital’s case mix, and the average DRG weight for these patients is the hospital’s case mix index (9). The CMI is calculated as the sum of all relative weights divided by the number of cases per year. This prospectively established annual hospital budget is divided into quarters. Then, every month, the hospitals receive sums from the Health Insurance House according to the number of actually discharged patients and the contracted (predicted) CMI. Every quarter, there is a reconciliation of the sums, based on the number of actually discharged patients and the CMI of these cases. This is the retrospective dimension of the reimbursement system. In this approach, hospitals entitled to more money based on the real quarterly reports will get that money only if the payer (the Health Insurance House) saved some money from hospitals that did not discharge as many cases as they predicted. If a hospital has fewer cases and is therefore entitled to less money than the contracted budget, it will receive funding only for the discharged cases. This type of hospital reimbursement scheme with a retrospective dimension has led to several problems in Romania. It has created an incentive to discharge more patients or to increase the CMI in order to gain more funds at the quarterly reconciliations. We wished to examine to what extent these practices occur, and to determine how the change in the DRG system in 2007 affected these practices. We analyzed data regularly sent by hospitals to the National School of Public Health and Health Services Management and the Hospital DRG Reimbursement Database, and we conducted interviews with key health care managers. We carried out this assessment in 2009, two years after the system change, since we wanted to give hospitals at least one year to adapt to the new system.
Databáze: OpenAIRE
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