Casemix in 2012/13 and beyond Paula Monteith, the Casemix Service, NHS IC

Overview Deliverables in 2012 –Payment March 2012: Local Payment 2012/13 Summer 2012: SenseCheck 2013/14 Autumn 2012: RoadTest 2013/14 –Costing March 2012: Reference Costs 2011/12 Deliverables in 2013 –Payment March 2013: Local Payment 2013/14 Summer 2013: SenseCheck 2014/15 Autumn 2013: RoadTest 2014/15 –Costing March 2013: Reference Costs 2012/13 And Beyond… –Patient Pathway Groups (PPGs)

Local Payment 2012/13: HRG4 BaseReference Costs 2009/10 (but see LP 11/12 “out of synch” changes) Number1,527 HRGs (increase from 1,504 in LP 11/12) OPCS ICD-10 OPCS 4.6 (TOCE back to OPCS-4.5 RC 2009/10 design structure) ICD-10 4 th Edition (TOCE back to ICD-10 RC 2009/10 design structure) Key Design Changes Cross-chapter - enhanced length of stay logic for minor procedure HRGs to derive HRG from primary diagnosis if length of stay is longer than pre-set minimum (2 days*) Cancer Treatment Services (SB, SC) - Same Day admissions HRGs introduced for Chemotherapy / Radiotherapy to capture core HRG where only treatment is unbundled Dental Services (CZ) – 26 discrete HRGs for treatment of teeth Cardiac Procedures (EA) – redesign to accommodate cardiac devices and procedures Digestive (FZ) – net increase of 16 HRGs to better accommodate age, surgical approach New endoscopy HRGs to differentiate scope type, diagnostic only, diagnostic with biopsy, therapeutic and combined upper and lower GI tract Maternity Services (NZ) – effective redesign of delivery HRGs to introduce planned, emergency and with complications splits in C-sections, remove age splits, reflect differential resource use of Epidural / Induction / Intervention Key Technical Changes Flag Outputs Separate columns for each flag type (SSC, BPT and Flag) Will output flags for Non-Admitted Care (OP CDS) Will contain a prefix to denote the flag type to differentiate the sets (e.g. SS23 or BP88)

Reference Costs 2011/12: HRG4 Number1,657 HRGs (increase from 1,559 in RC 10/11) OPCS ICD-10 OPCS 4.6 ICD-10 (Not ICD-10 4 th Edition) Key Design Changes Cross-chapter – coding enhancements for “principal extended categories” (supports adherence to coding standards and (hopefully) improved data quality Cardiac Procedures (EA) – expansion of design to reflect (more) devices – e.g. EA57Z Transcatheter Aortic Valve Implantation (TAVI) Digestive (FZ) – increased granularity in HRGs for children (< 2 years, 2-18), improved recognition of High Cost Devices, separate identification of surgery for obesity – e.g. FZ85Z Restrictive Stomach Procedures for Obesity Hepatobiliary Surgery (GA) – clarification of HRG content by removal of “category” reference in labels Orthopaedic Surgery (HA / HB / HR) – introduction of site-specific “minimal” HRGs (more minor than “minor”) to narrow activity distribution of lower resource HRGs Breast Surgery (JA) – refinements to support BPT identification – Mastectomies split between “simple” and complex” reconstruction Urological Surgery plus (LB) – introduction of age splits, acknowledgement of highly specialised procedures – e.g. LB71Z Total Pelvic Exenteration Maternity Services (NZ) – effective redesign of non-delivery HRGs to support Maternity pathway aspirations (standard / specialised / complex) Diagnostic Imaging (RA) – age splits for specific HRGs (MRIs, CTs) to identify children’s activity, introduction of 3 new HRGs for Cardiac MRIs

HRG4 Recap ScopeUnderpinned by 4 national standard datasets for : Inpatient Care and Day Case Care (zero length of stay) Critical Care (Intensive Care for Adults, Children, Neonates) Outpatient Care (not admitted, hospital-based, includes interventions) Emergency Medicine (not admitted, hospital-based, investigations) ServicesIdentified by OPCS (intervention / procedure) and ICD-10 (diagnosis) for: All Surgical and Medical treatments, including Major Trauma Care Cancer Treatment Services Maternity Services Rehabilitation Services and Specialist Palliative Care MethodClinically owned (professional bodies), Policy Endorsed (Framework) Procedure-precedence in grouping, with discrete care events “unbundled” Recognition of additional resource use of: Patient Characteristics – e.g. age, complications, comorbidities Clinical Characteristics – e.g. multiple procedures BenefitsCosting, funding, benchmarking, service planning, performance measurement

The Catalyst for Change Change in Government (May 2010) has seen transformation of healthcare policy and national and local structures to commission / deliver it: Proposed Health and Social Care Bill 2011, will create new organisational landscape with: Clearer demarcation of specialist service provision (limited number of centres of excellence) and clearer responsibility for commissioning (regional / national levels) Increased need to identify “specialist” patient journeys at local / national levels Increasing number of groups responsible for commissioning of non- specialist NHS services Clinical Commissioning Groups (GPs plus) National organisations other than the Department of Heath taking responsibility for establishing the scope, structure, and levels of national tariff payment NHS Commissioning Board Monitor

HRG4+ (expected RC 12/13) Numberc. 1,800+ groups (2012/13) ScopeGoverned by national standard datasets as per HRG4, (APC, OP, CCMDSs, EM) but extending to Community Care – see Community Information Data Set (April 2012) ServicesIdentified by OPCS (intervention / procedure) and ICD-10 (diagnosis) for: All hospital-based Surgical and Medical treatments – see previous, plus Community Care (including nursing services, health visiting, outreach) MethodClinically owned (professional bodies), Policy Endorsed* (Framework) Procedure-precedence in grouping, with discrete care events “unbundled”, but Improved recognition of diagnosis in APC, including recognising the multiply comorbid (often with increasingly multiple interventions); extending the use of proxies for severity of diagnosis (previously trialled), acknowledging the interactive nature of (some) CCs - extended acknowledgement of truly “specialised” services, especially for infants (New): Use of diagnosis in Outpatients, Emergency Medicine, Community Improved Quality Criteria – extended procedure hierarchies, re-instigation of within chapter HRG relationship (renumbering, re-chaptering), and more BenefitsCosting, funding, benchmarking, service redesign - especially for “specialist services”: a response to the changing provider landscape

And Beyond: PPGs Number24 groupings initially (a working concept – 2013/2014?) ScopeUses national standard datasets across care continuum from : EM or Outpatient Care, through Admitted Patient Care to Community Care Assumes diagnosis can be used as a “common language” across care settings to identify patients with similar expected resource needs ServicesIdentified by updated ICD-10 (diagnosis) (4 th Revision) for 4 key service areas: Stroke (8) Diabetes (5) Chronic Obstructive Pulmonary Disease (COPD) (8) End of Life Care (3) Grouping logic requires ‘event’ qualification following diagnostic entry to pathway MethodInitial premise: for a subset of patients, healthcare interventions during a standard “year of care” can be indicated by diagnosis Based on National Institute for Health and Clinical Excellence (NICE) clinical standards for care pathways for specific long-term conditions Not a replacement for the HRG classification - uses HRGs to construct (therefore cost, and price) the care pathway to establish “expected” care, and begin to measure deviation from NICE “best practice” and / or the national norm, at a local level Aims to cover multi-provider, multi-setting care that continues beyond a single care event (e.g. disease management) Designed to respond to the changing commissioner landscape...

And Beyond: PPGs (ii) BenefitsFor NHS commissioners, possibilities include : Whether local healthcare delivery deviates from an approved clinical benchmark (NICE), and from national / regional norms, and to use this evidence to improve commissioning in future years; A reduced administrative burden by commissioning care pathways that reflect the needs of the local population without paying for individual events or paying for the same event twice Better visibility of the care provided across pathways and between settings, with standardised identification of patients on a pathway, and those that could or should be, but are not Improved understanding of the link between commissioning of care and clinical appropriateness and effectiveness at the patient level ValueNHS Costing (2009/10 approximations for admitted patient care medical admissions, excluding unbundled events) : Stroke £493m (≈1.3%) Diabetes £77m (≈0.2%) Chronic Obstructive Pulmonary Disease (COPD) £232m (≈0.6%) End of Life Care £69m (≈0.2%)

Summary HRG4 for 2012/13 LP (1,527) has substantially changed from 2011/12 LP (1,504) –More age splits (infants) and length of stay splits as proxy for severity –Greater precedence of diagnosis where appropriate HRG4 for 2011/12 RC (1,657) has substantially changed from 2010/11 RC (1,559) –More CC splits and (infant) age splits –More multiple procedures where feasible (and codeable) –More HRGs to capture specific devices (nb – costs!) –Accommodation of funding policy requirements from 2012/13 LP Improved documentation is available:- service/reference/downloads service/reference/downloads But, improved specificity and sophistication requires better coding and better costing HRG4 for 2012/13 RC will be HRG4+ (payment use subject to policy decision)

The Casemix Vision To enrich the current HRG4 classification and respond to the changing needs of the healthcare infrastructure Especially for providers of increasingly specialist care To prove the concept that PPGs are capable of recognising appropriate and effective commissioning, in a standard and formalised manner For local and national health populations To continue to maintain yet develop a Casemix Product Suite that supports innovative clinical practice and policy development And enhances understanding of care at the patient level Mystified, aghast, intrigued?