EURO DRG PROJECT: CROSS-COUNTRY COMPARISON FOR BETTER INTEGRATION - PowerPoint PPT Presentation

EURO DRG PROJECT: CROSS-COUNTRY COMPARISON FOR BETTER INTEGRATION Thomas RENAUD, EuroDRG Project-IRDES Josselin THUILLIEZ, EuroDRG Project-CNRS European diagnostic reimbursement & Market access Brussels, 13-14 September 2012

Introduction

 Hospital financing: European countries moved (from global budget) towards activity-based payment  Incentivizing performance, transparency, benchmarking and efficiency  (Un)intended consequences on quality of care, innovation, coding … European diagnostic reimbursement & 3 Market access

 Understand, describe and assess the ability of DRGs to represent hospital activity and to base payment  12 countries accross Europe  Analysis of DRG- based hospital payment European diagnostic reimbursement & 4 Market access

 Hospital activity (inpatients in acute care here)  Similarities between countries: • Common principles to classify patients and casemix  use of DRGs ( Diagnosis-Related Groups ) • Activity-based payment systems  Differences :  Hospitals (size, organisation, public/private …)  Purchasers European diagnostic reimbursement & 5 Market access

 Why DRGs and DRG-based payment?  To get a common “currency” of hospital activity for : • Transparency (performance measurement) • Efficiency (and benchmarking across hospitals) • Budget allocation (or division among purchasers) • Planning of capacities • Payment European diagnostic reimbursement & 6 Market access

DRGs & Resource use in Europe

 DRGs first introduced in Portugal in 1984  Most countries introduced DRGs during the 90s European diagnostic reimbursement & 8 Market access

 From 1 to 10 years between introduction of DRGs and introduction of DRG-based budget allocation  Different systems of DRGs across countries (except Nord-DRGs for all Nordic countries)  Different levels of refinement and detail: • Number of groups: from 500 (Poland) to 2300 (France) • Revision and updates of classification: annual or biennal in most countries European diagnostic reimbursement & 9 Market access

 DRG algorithms: • Differ across countries • Commonly based on treatment, patient and providers characteristics • Sequentially organized classification • Particular attention to severity, complications and comorbidities (Require routine data collection) European diagnostic reimbursement & 10 Market access

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Country European diagnostic reimbursement & 17 Market access

1. Do some national DRGs systems systematically perform better than others? 2. Is there a need for refinement of classifications? If so, which additional patient/clinical characteristics should be taken into account? 3. Is “more DRGs” better? 4. Is there room for a common DRG classification and a commonly based payment system across Europe?  Require an empirical/quantitative analysis European diagnostic reimbursement & 18 Market access

Quantitative Analysis

1. To identify individual factors (patient and treatment characteristics…) that explain variation in resource use across patients 2. To assess the explanatory power of DRGs relative to these individual factors 3. To assess relative hospital performance in managing resources and the characteristics of hospitals that explain this performance European diagnostic reimbursement & 21 Market access

 Routinely collected at individual level (each stay)  On all hospitals or on a sample of them (5 countries)  Collection of characteristics on: • Treatment : diseases (ICD10) and procedures (variety of classifications) • Patient : age, gender, SES, geographic status … • Resource use : length of stay, cost, medical units …  Some discrepancies in data collection between countries European diagnostic reimbursement & 22 Market access

 Analysis of routine patient- Log of Cost: Appendectomy (France) 15 level data 10 • Costs or Length of stay for 5 patients having particular Episode of Care (EoC) 0 -5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10+ Log of Cost (€) • Diagnostic and treatment details Length of Stay: Appendectomy (France) 30 for all these patients 25 20  Analysis of the hospitals in 15 10 which patients are treated 5 0 0 5 10 15 20+ Length of Stay (Days) European diagnostic reimbursement & 23 Market access

 Year 2008 (for most countries)  Core characteristics for patients and treatment across countries: • No SES for example • Few common hospitals characteristics  10 Episodes of Care : • Appendectomy, Breast cancer, Hip replacement, knee replacement… • Identified through main diagnosis (ICD-10) and procedures (ICD9-CM or national classifications) European diagnostic reimbursement & 24 Market access

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 Why do some patients have different costs than others?  Are DRGs better than our patient-level variables? European diagnostic reimbursement & 26 Market access

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 Why the average cost in one hospital higher than another? European diagnostic reimbursement & 28 Market access

Description AGE N %  1-10 years 1816 18,25% Age and gender 11-15 years 2030 20,41% 16-20 years 1637 16,46%  Type of admission (emergency) 21-35 years 2250 22,62% 36 + years 2215 22,27%  Whether transferred to/from Description DRGs N % 06C091 - Appendectomy uncomplicated, level 1 6631 66,66% hospital 06C081 - Appendectomy complicated, level 1 2659 26,73% 06C092 - Appendectomy uncomplicated, level 2 209 2,10%  Counts of diagnoses & 06C082 - Appendectomy complicated, level 2 169 1,70% 06C083 - Appendectomy complicated, level 3 114 1,15% procedures All other DRGs 166 1,67% Diag and Proc N %  Asthma DV (DV 1 = yes 0 = no) 119 1,20% Charlson and other co- Hypertension DV (DV 1 = yes 0 = no) 269 2,70% morbidities Laparoscopy planned (done or failed) DV (DV 1 = yes 0 = no) 5913 59,44% Cdifficile DV (DV 1 = yes 0 = no) 1 0,01%  OECD patient safety indicators Obesity DV (DV 1 = yes 0 = no) 210 2,11%  Diag and Proc Mean SD Min Max N Urinary tract and wound Count of diagnoses 1,56 1,04 1 12 9 948 infections Count of procedures 2,55 1,77 1 14 9 948  Discharged dead or alive European diagnostic reimbursement & 29 Market access

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 Complementary not substitute way to evaluate DRG systems  No single national DRG dominates clearly  Generally DRGs have good explanatory power  Variation also driven by patient characteristics  Large variation in resource use among hospitals: scope for better utilisation of resources. European diagnostic reimbursement & 35 Market access

Conclusions & Discussion

 Capacity of DRGs to explain costs varies significantly across countries and EoCs  Using a high number of DRGs does not always improve resources description: scope for refinement but not necessarily for more groups  In some countries DRGs compensate generously for adverse events which are due to bad care quality European diagnostic reimbursement & 37 Market access

 Trade-off exists between encouraging certain technological innovations and the efficiency incentives of DRG-based hospital payment  Most countries have specific short-term payment instruments targeted at encouraging the adoption and use of technological innovations.  All countries update their DRG-based hospital payment systems but: • the frequency of updates and • the time lag to the data used for updates differ greatly European diagnostic reimbursement & 38 Market access

 Short-term payment instruments should be used very carefully, and granted only after careful assessments of the likely effects of the concerned technology on quality of care. • Increase European cooperation in HTA • Use Coverage with Evidence Development if uncertain about effects  Long-term updating mechanisms should assure that DRG systems are as up-to-date as possible: • Increase European cooperation in HTA • DRG systems can be updated more frequently than is currently the case in some countries • The time-lag to data used for updates could be shortened in several countries European diagnostic reimbursement & 39 Market access