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 Brussels, 13-14 September 2012

European diagnostic reimbursement & Market access

Introduction

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• 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…

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• 12 countries

accross Europe

• Analysis of DRG-

based hospital payment

• Understand, describe and assess the ability of DRGs to

represent hospital activity and to base payment

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• 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

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• 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

DRGs & Resource use in Europe

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• DRGs first introduced in Portugal in 1984
• Most countries introduced DRGs during the 90s

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• 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

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• 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)

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Country

• 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

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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

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• 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

• Analysis of routine patient-

level data

• Costs or Length of stay for

patients having particular Episode of Care (EoC)

• Diagnostic and treatment details

for all these patients

• Analysis of the hospitals in

which patients are treated

5 10 15

• 5

5.5 6 6.5 7 7.5 8 8.5 9 9.5 10+ Log of Cost (€)

Log of Cost: Appendectomy (France)

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5 10 15 20 25 30 5 10 15 20+ Length of Stay (Days)

Length of Stay: Appendectomy (France)

• 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)

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• Why do some patients have different costs than
• thers?
• Are DRGs better than our patient-level variables?

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• Why the average cost in one hospital higher

than another?

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• Age and gender
• Type of admission (emergency)
• Whether transferred to/from

hospital

• Counts of diagnoses &

procedures

• Charlson and other co-

morbidities

• OECD patient safety indicators
• Urinary tract and wound

infections

• Discharged dead or alive

Description AGE N % 1-10 years 1816 18,25% 11-15 years 2030 20,41% 16-20 years 1637 16,46% 21-35 years 2250 22,62% 36 + years 2215 22,27% Description DRGs N % 06C091 - Appendectomy uncomplicated, level 1 6631 66,66% 06C081 - Appendectomy complicated, level 1 2659 26,73% 06C092 - Appendectomy uncomplicated, level 2 209 2,10% 06C082 - Appendectomy complicated, level 2 169 1,70% 06C083 - Appendectomy complicated, level 3 114 1,15% All other DRGs 166 1,67% Diag and Proc N % Asthma DV (DV 1 = yes 0 = no) 119 1,20% Hypertension DV (DV 1 = yes 0 = no) 269 2,70% Laparoscopy planned (done or failed) DV (DV 1 = yes 0 = no) 5913 59,44% Cdifficile DV (DV 1 = yes 0 = no) 1 0,01% Obesity DV (DV 1 = yes 0 = no) 210 2,11%

Diag and Proc Mean SD Min Max N Count of diagnoses 1,56 1,04 1 12 9 948 Count of procedures 2,55 1,77 1 14 9 948

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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.

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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

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• 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

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• 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

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• Important differences in national coding and

accounting practices

• e.g. recording of secondary diagnoses
• No-one knows the true costs of treatment!
• Should there be a EuroDRG system?
• What is the variation in medical practice?
• Great similarities in underlying architecture and data!
• Local ownership
• Availability of a strong information system for monitoring

quality & efficiency (wide gaps between countries)

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