DRG Workshop Belgrade, November Gaming. Sub-acute patients. RIC AND LINDY

DRG Workshop Belgrade, November “Paper cases” administrative discharges and readmission in Hungary Change of care type in NSW. “Empty cases” in Slovenia Admitting cases in Emergency Departments and Outpatients – ?can these be legitimate? Generating additional data counts for more funding

DRG Workshop Belgrade, November DRG INPATIENTS SAME DAY INPATIENTS ED PATIENTS DEFINITIONS AND RULES BUNDLED OUTPATIENTS FFS AMB PATIENTS CHRONIC CARE PROGRAMS TRAUMA AND ACUTE ILLNESS AGED CARE AND MENTAL HEALTH PROGRAMS PRIVATE AND DISCRETIONARY ELECTIVE??

DRG Workshop Belgrade, November Rapid growth in Victoria of same day episodes Clear evidence of admitting cases that can be treated in ambulatory setting Cases that can be treated either way becoming all inpatient – eg – dialysis and chemotherapy REMOVE PAYMENT INCENTIVE - CAPS Admitting outpatients as short stay inpatients

DRG Workshop Belgrade, November UPCODING CA$EMAX % ACCURACY 30% CREATIVITY – SUBECT TO EDITS

DRG Workshop Belgrade, November Source: Nagy, J., DRG creep in Hungary

DRG Workshop Belgrade, November How many times per stay? How many times per day? Can we pay for them both together? What is the right time? Change of care type or discharge and readmission for rehabilitation

DRG Workshop Belgrade, November All casemix systems adjust the system every year New cost weights and recalibrated price Potential to cap or reweight overprovision. How to detect and control gaming „The only way to pay doctors is to change the system every three years, because by then they will have found ways to get round it to their own advantage” Bob Evans

DRG Workshop Belgrade, November Fine tuning of the system: addressing negative effects Upcoding (creep), “paper” (readmitted) cases – Monitor and control provider reporting of cases – Continuous cost weight revision Efficiency and quality – Addressing undertreatment (quality/effectiveness): creating new groups *DRGs for sophisticated care, but only selected providers – Quicker-sicker problem: readmission before maximum day limit does not pay extra

DRG Workshop Belgrade, November Fraud is repeated offences with intention Fraud is knowing violation of reporting rules Fraud is materially profiting from systematic ‘mistakes’ Fraud is attempting to hide payments claimed that do not relate to a real service The difference between gaming and fraud

DRG Workshop Belgrade, November How can these issues be addressed in Serbia? What is done now about professional review? How is fraud detected and controlled? QUESTIONS

DRG Workshop Belgrade, November SUB ACUTE CASEMIX PART 2

DRG Workshop Belgrade, November “SUB ACUTE CARE” REHABILITATION PALLIATIVE CARE GERIATRIC EVALUATION AND MANAGEMENT PSYCHOGERIATRIC ??MAINTENANCE (OR NURSING HOME TYPE)?

DRG Workshop Belgrade, November SNAP – SUB ACUTE INPATIENT

DRG Workshop Belgrade, November SNAP – SUB ACUTE AMBULATORY

DRG Workshop Belgrade, November CHANGE OF CARE TYPE DAY OF EPISODE OF CARE OR SPELL CARE TYPE ‘REHABILITATION SERVICES’ ‘ACUTE SERVICES’

DRG Workshop Belgrade, November CARE PATHS AND CLASSIFICATIONS For a clinical pathway you must have: FOR DRG’s you must have: an episode of care. diagnoses. a care planning process. know what was done to the patient - at least in general terms. a team approach to patient management. discretion in choice of the most cost effective care. decisions made before the treatment is undertaken. decisions made after the treatment is completed.

DRG Workshop Belgrade, November REHABILITATION CASEMIX

DRG Workshop Belgrade, November REHAB CAN BE ACCESSED As part of an acute episode (DRG) (usually?) As a separate “ACUTE” DRG episode As a separate admission type (where substantial) – Different care type – ‘SUBACUTE’ As a series of one off referrals from a community provider for eg PHYSIO, OT, PSYCHOLOGY, SPEECH THERAPY, POD ETC As a planned package/program of care on an ambulatory basis or combination.

DRG Workshop Belgrade, November The Oz classification smorgasbord

DRG Workshop Belgrade, November TWO EXAMPLE REHAB CLASSIFICATIONS

DRG Workshop Belgrade, November MEASURES OF FUNCTION AVAILABLE FOR CLASSIFICATIONS ICF – International classification of function – WHO FIM Barthels RUGs

DRG Workshop Belgrade, November Rehabilitation Patient Groups – Ontario RPG in the new classification system Relies on the following data elements where applicable: – 1. Rehabilitation Client Code – 2. Admit Motor Functional Independence Measure (FIM) score – 3. Admit Cognitive FIM score – 4. Patient Age

DRG Workshop Belgrade, November Rehabilitation Patient Groups – Ontario 2008 –1 of 2 (M = motor FIM score; C=cognitive FIM scores) 1. Stroke M=12-38 and Age<=68 5. Traumatic Spinal Cord Injury M M=12-38 and Age>= M=17-41 and Age <= M= M=17-41 and Age >= M=51-84 and C= M= M=51-84 and C= Non-Traumatic Spinal Cord Injury M M=51-69 and C= M=29-54 and Age >= M=69-84 and C= M=29-54 and Age<=50 2. Traumatic Brain Injury M and C M= M=14-47 and C= M= M=48-84 and C= Amputation, Non- Lower Extremity M M=12-44 and C= M= M=45-84 and C= Amputation, Lower Extremity M M=12-84 and C= M= Non-Traumatic Brain Injury C M=65-84 and C= C=22-32 and Age <= M=65-84 and C= C=22-32 and Age>=62 9. Osteoarthritis M C= M= Neurological M Rheumatoid Arthritis and Other Arthritis M M= M= M= M=75-84

DRG Workshop Belgrade, November Rehabilitation Patient Groups – Ontario 2008 –2 of Pain M Pulmonary M and Age > M= M=37-84 and Age >= Fracture of Lower Extremity M and Age > C=5-33 and Age <= M=12-30 and Age <= C=34-35 and Age <= M=31-47 and Age <= Burns M and C M= Major Multiple Trauma, Other Multiple Trauma and Major Multiple Fracture M M=52-84 and Age >= M=25-55 and Age <= M=52-84 and Age <= M=25-48 and Age >= Replacement of Lower Extremity M and C M=49-55 and Age >= M=12-53 and C= M= M=54-68 and C= Major Multiple Trauma, with Brain or Spinal Cord Injury M M=54-60 and C= M= M=61-68 and C= M= M= Ventilator Dependent Respiratory Disorders M and C Other Orthopedic M=12-51 and C Other Disabilities M M=12-51 and C= M= M=52-64 and C= M=59-84 and Age <= M=52-64 and C= M=59-84 and C=5-33 and Age >= M= M=59-84 and C=34-35 and Age >= Cardiac M and C M=12-49 and C= M=50-67 and Age <= M=68-84 and Age <= M=50-84 and Age >= 83

DRG Workshop Belgrade, November Victorian Rehabilitation Designated Rehabilitation Units – –Agencies are designated for Rehabilitation Units –10 beds or more and must meet designation criteria –Paid by per diem grants (or for CRAFT agencies a mix of episode & per diem since 1999) Non-Designated – –Payment through Casemix AN-DRG system by WIES

DRG Workshop Belgrade, November CRAFT Development Objective to develop a casemix classification system for Rehabilitation patients which could be effectively adopted as a casemix funding method Important therefore that the model meet the following criteria: – –Clinical similarity – –Resource homogeneity – –Administrative ease – –Suitable for funding agencies

DRG Workshop Belgrade, November Functional Status Issues Functional status is not used in other DRGs, but Functional status is basic to rehabilitation practice, assessment and theory – – so important to consider in a classification Main issues with regard to functional status: – Choice of standard measure instrument Barthel FIM Barthel was chosen originally by Clinical Panel of advisers for collection in Victoria. It can also be mapped to FIM

DRG Workshop Belgrade, November Craft Categories.Short Stay (overnight stay 1-3 days) 1Stroke/NeurologicalAdmission Barthel score <60 2Stroke/NeurologicalAdmission Barthel score ≥ 60 3Orthopaedic Fracture Admission Barthel score < 60 4Orthopaedic Fracture Admission Barthel score ≥ 60 5Orthopaedic Replace Hip/Knee Admission Barthel score < 60 6Orthopaedic Replace Hip/Knee Admission Barthel score 60 – 79 7Orthopaedic Replace Hip/Knee Admission Barthel score ≥ 80 8Other Orthopaedic Admission Barthel score < 60 9Other Orthopaedic Admission Barthel score ≥ 60 10Cardio/Pulmonary 11Amputation 12Head Injury/Major Multiple Trauma 13Spinal 14Burns 15Other Rehabilitation Admission Barthel score < 60 16Other Rehabilitation Admission Barthel score ≥ 60

DRG Workshop Belgrade, November Casemix Rehabilitation and Funding Tree (CRAFT)

DRG Workshop Belgrade, November Options for Funding Episode Costs -Payment for an episode of care – Advantages: Promotes and rewards efficiencies and standard practice across agencies Provides a clearer benchmark for units for planning, funding and the evaluation of services– – Disadvantages: Variability in LOS (“Quicker And Sicker” risk) Per Diem Costs -Payment based on a day rate– – Advantages:– More closely approximates existing care May better reflect service differences– – Disadvantages:– Does not encourage efficiencies or standard practice across agencies Consultations with field –episode preference

DRG Workshop Belgrade, November NON-ADMITTED DIFFERENCES Lower? cost structures (usually, not necessarily): – Can be a substitute program for admitted or – A separate different care model (eg voc placement). – Community can be an essential part of the rehab. Goals can be staged – series of sub programs. Function dependent goals and decision points. Combinations of services can change depending on progress. – Dx can change – certainly needs can.

DRG Workshop Belgrade, November PAYING FOR NON-ADMITTED REHAB Minimum requirements Oz Criterion 1 Rehabilitation care provided by a specialist rehabilitation team on an admitted or non-admitted basis in a specialist rehabilitation unit (a separate physical space.) – and Criterion 2 Rehabilitation care provided by a multi-disciplinary team which is under the Clinical management of a consultant in rehabilitation medicine or equivalent. – and Criterion 3 Rehabilitation care provided for a person with an impairment and a disability and for whom there is reasonable expectation of functional gain. – and Criterion 4 Rehabilitation care for whom the primary treatment goal is improvement in functional status. – and Criterion 5 Rehabilitation care which is evidenced in the medical record by: – an individualised and documented initial and periodic assessment of functional ability by use of a recognised functional assessment measure. – an individualised multidisciplinary rehabilitation plan which includes negotiated rehabilitation goals and indicative time frames. MORE DETAIL

DRG Workshop Belgrade, November MENTAL HEALTH CARE AND CASEMIX

DRG Workshop Belgrade, November Mental Health Services as a Part of Health Care? (1/2) We spend between 7 and 13% of recurrent health expenditure on mental health as the primary condition. Compared with cardiovascular diseases (10.9%), nervous system disorders (9.9%), musculoskeletal diseases (9.2%), injuries (8.0%), respiratory diseases (7.5%) and oral health (6.9%). AIHW (Mental health services in Australia 2004–05). The big growth factor in the last decade has been increased expenditure on drugs for depression. DEPRESSION has highest burden of disease disease where Quality of Life is factored in (rather than mortality).

DRG Workshop Belgrade, November Mental Health Services as a Part of Health Care? (2/2) Acute hospitals – MH alone 3% of separations, 9.7% of bed-days – MH+D&A 3.7% of separations, 10.7% of bed-days. Special inpatient facilites – Mental health is one of the few clinical specialties where a proportion is done in specialised inpatient and outpatient treatment services. – These are operated both on a voluntary and compulsory basis – and they may involve legal incarceration. – $534AUD million pa in Australia Private sector hospitals / clinics – Mental health is one of their biggest products – Both as direct care and as a comorbidity with other conditions – liaison psychiatry – major issue.

DRG Workshop Belgrade, November What is the scope of mental health services? (1/2) Drug and alcohol services are grouped together as the same service statistics? Community support services – even such things as housing assistance can be included in mental health care. Rehabilitation and social independence programs Cognitive diseases often associated with aging – Alzheimers, Senile dementias etc – may be here or in Aged care. – “Psychogeriatric” can be siloed as a completely different care stream.

DRG Workshop Belgrade, November What is the scope of mental health services? (2/2) “Developmental” disorders – Autistic disorders – Severe learning disorders – Hyperactivity What about mental health as a CC of other conditions? – Mental health diagnoses and their related treatments are one of the most common comorbidity factors in the treatment of physical conditions. – Generally these costs are not taken into account in the estimates on mental health expenditure. – Some patients can be treated for mental health problems when actually not eligible from their health insurance status – by being admitted for a less urgent physical condition.

DRG Workshop Belgrade, November Casemix classifications of mental health? (1/2) DRG type Classifications – AR-DRGs – CMS DRGs – HRGs – etc Ambulatory and community classifications – APCs?? – DBGs Care path based classifications – Care packages – Care programs – DSM 4 Procedure axis

DRG Workshop Belgrade, November Casemix classifications of mental health? (2/2) Mental health status classifications - eg – HoNOS - – - – CIDI – DIS – BDI – HAS – etc. etc. ml ml – General assessment tools – mental status components. Sf36, SF FIM - ICF - Mixed classifications – Combination of inputs relating to patient characteristics and Px’s – DSM

DRG Workshop Belgrade, November The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) The CIDI is a comprehensive, fully-structured interview designed to be used by trained lay interviewers for the assessment of mental disorders according to the definitions and criteria of ICD-10 and DSM- IV. The CIDI allows the investigator to: - Measure the prevalence of mental disorders - Measure the severity of these disorders - Determine the burden of these disorders - Assess service use - Assess the use of medications in treating these disorders - Assess who is treated,

DRG Workshop Belgrade, November Is Mental Health so different from other health services? COST RISK FACTORS MENTAL HEALTH OTHER SPECIALTIES Legal status ++- Social support differentiation ++++ High level of “talking therapies” High level of discretionary treatments High variability in proven efficacy for most treatments +++?-?+?

DRG Workshop Belgrade, November SOME PRACTICAL PROBLEMS Discrete funding silos – Continuity gaps – Availability versus suitability Information barriers – Privacy – Professional territoriality – Patient disempowerment – stigma - chronicity Accessible/current best practice protocols

DRG Workshop Belgrade, November Why do some insurers want to limit access to MH care? Differential eligibility restrictions – eg – Longer wait for coverage for mental health as a pre-existing condition. – Exclusion of mental health coverage. USA’s parity legislation – THE OBAMA REFORMS Expenditure caps – lifetime hospital admission cap.

DRG Workshop Belgrade, November USA CMS – INPATIENTS Episode and per-diem mixture

DRG Workshop Belgrade, November AUSTRALIAN CASE STUDY “YOU CAN KEEP SOME OF THE PEOPLE HAPPY SOME OF THE TIME….”

DRG Workshop Belgrade, November 2013.

DRG Workshop Belgrade, November

DRG Workshop Belgrade, November AR-DRG CATEGORIES U40Z Mental Health Treatment, Sameday, W ECT U60Z Mental Health Treatment, Sameday, W/O ECT U61ASchizophrenia Disorders W Mental Health Legal Status U61B Schizophrenia Disorders W/O Mental Health Legal Status U62A Paranoia & Acute Psych Disorder W Cat/Sev CC or W Mental Health Legal Status U62B Paranoia & Acute Psych Disorder W/O Cat/Sev CC W/O Mental Health Legal Status U63A Major Affective Disorders Age >69 or W (Catastrophic or Severe CC) U63B Major Affective Disorders Age <70 W/O Catastrophic or Severe CC U64Z Other Affective and Somatoform Disorders U65Z Anxiety Disorders U66Z Eating and Obsessive-Compulsive Disorders U67Z Personality Disorders and Acute Reactions U68Z Childhood Mental Disorders 12 CATEGORIES DX BASED ICD LEGAL NO D & A LARGE DATABASE FOR GROUPER CALIBRATION INPATIENT ONLY

DRG Workshop Belgrade, November DRGs/HRGs and Mental Health Politically rejected for payment because “poor predictor of individual service cost” – Are other specialities so sensitive?? Not usually considered for use with other variables – Facility – level – availability support. – Extended care programs – capitation – add on

DRG Workshop Belgrade, November MH-CASC.. CONTINUING STORY OR GRAND FAILURE?? Scoped to fund MH by outcomes – or even outputs – across all settings How can you get a setting independent input independent grouping of ‘products’ – Diagnosis – Severity measures – Comorbidities – Chronicity – Acuity – Social constraints – eg supports, legal risk

DRG Workshop Belgrade, November UK CASE STUDY RESOURCE HOMOGENEITY VS CLINICAL MEANINGFULNESS REVISITED

DRG Workshop Belgrade, November HRG v3.5 MH CATEGORIES T01- Senile Dementia T03- Schizophreniform Psychoses without Section T07- Depression without Section T08 - Presenile Dementia T09 - Anxiety Syndromes T10 - Alcohol or Drugs Non- Dependent Use >18 T11 - Alcohol or Drugs Non- Dependent Use <19 T12 - Alcohol or Drugs Dependency T13 - Eating Disorders or Obsessive Compulsive Disorders T14 - Acute Reactions or Personality Disorders DX BASED DSM4? BROAD SCOPE – Eg A&D INCLUDED IP / OP ? SMALL DATASET FOR GROUPER NORM INCLUDES A & D

DRG Workshop Belgrade, November UK PbR STUDY SETTING DEPENDENT CATEGORIES Cty No or std CPA Low prob daily act HONOS10 Cty No or std CPA High prob daily act HONOS10 Cty Std CPA Low prob daily act HONOS10 Cty Std CPA High prob daily act HONOS10 Cty Enh CPA Low prob daily act HONOS10 Cty Enh CPA High prob occ act HONOS12 Cty Enh CPA Low prob occ act HONOS12 IP/OP no or std CPA working age IP/OP no or std CPA above working age IP/OP enh CPA Low cog prob HONOS4 no section ord IP/OP enh CPA Low cog prob HONOS4 section ord IP/OP enh CPA High cog prob HONOS4 0-2 phys prob IP/OP enh CPA High cog prob HONOS4 >2 phys prob IP Low social prob HoNOS social IP Med social prob HoNOS social IP High social prob HoNOS social 17 CATEGORIES 17 CATEGORIES SETTING/ PROBLEM / FN BASED SETTING/ PROBLEM / FN BASED CARE APPROACH CARE APPROACH SMALL DATASET SMALL DATASET COSTING? COSTING? RELIES ON HONOS RELIES ON HONOS CPA=Care Programme Approachhttp://

DRG Workshop Belgrade, November UK PbR STUDY SETTING INDEPENDENT CATEGORIES ;W/o Section;No or std CPA;Dx= F0, F2, F5, F6, F7;;; ;W/o Section;No or std CPA;Dx=F1, F3, F4,F9;No or low prob daily activities (HoNOS 10);; ;W/o Section;No or std CPA;Dx=F1, F3, F4,F9;High prob daily activities (HoNOS 10); Wkg age; ;W/o Section;No or std CPA;Dx=F1, F3, F4,F9;High prob daily activities (HoNOS 10); Above wkg age;>3 HoNOS psych ;W/o Section;No or std CPA;Dx=F1, F3, F4,F9;High prob daily activities (HoNOS 10); Above wkg age;1-3 HoNOS psych ;W/o Section;Enh CPA;Dx=None, F1, F7, F8;No or low prob daily activities (HoNOS 10);; ;W/o Section;Enh CPA;Dx=None, F1, F7, F8;High prob daily activities (HoNOS 10);; ;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Med or hi CRU complexity;Low or no cognitive prob HoNOS4; ;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Med or hi CRU complexity;High cognitive prob HoNOS4; ;W/o Section;Enh CPA;Dx=F0, F2, F3, F4, F5, F6, F9;Low CRU complexity;; ;W Section;>2 HoNOSpsych;Enh CPA;Dx= None, F1, F3, F4;; ;W Section;>2 HoNOSpsych;Enh CPA;Dx=F0, F2, F5, F6, F9;; ;W Section;>2 HoNOSpsych;No or std CPA;;; ;W Section;0-2 HoNOSpsych;;;; ONLY WORKING AGE + ONLY WORKING AGE + LEGAL, DX AND HoNOS LEGAL, DX AND HoNOS 78% RECORDS EDIT REJECTED 78% RECORDS EDIT REJECTED N= N= 11,364 pat

DRG Workshop Belgrade, November Categories Suggested by the Care Path Study Acute non-psychotic low Acute non-psychotic med Acute non-psychotic high Non-psychot overval idea Non-psychot chaotic & challenging Drug & alcohol First episode psychosis Chronic severe low sympt Chronic severe high sympt Severe psychot episode Severe depression Dual diag Assertive outreach CARE PATH DEFINITIONS CLINICIAN GROUPING VS ALGORITHM GROUPING COST VARIANCE ANALYSIS N=2,287 PATIENTS

DRG Workshop Belgrade, November Ideas on classification dimensions from the forensic MH study. Socio demo Offence Clinical IP/cty Medico-legal Seclusion DEMOGRAPHIC STUDY DISTRIBUTION OF ACCESS AND SERVICE PROVISION SECLUSION AS MANAGEMENT TOOL COSTS

DRG Workshop Belgrade, November INPATIENTS SAME DAY INPATIENTS ED PATIENTS DEFINITIONS AND RULES BUNDLED OUTPATIENTS FFS OUTPATIENTS CHRONIC CARE PROGRAMS TRAUMA AND ACUTE ILLNESS AGED CARE AND MENTAL HEALTH PROGRAMS PRIVATE AND DISCRETIONARY ELECTIVE??

DRG Workshop Belgrade, November So??

DRG Workshop Belgrade, November Patient Classification Systems “There is no such thing as a bad classification – only people who are more or less happy with the category to which their case is assigned” Ric Marshall, PCSI Summer School, 17 June, 2010

DRG Workshop Belgrade, November Patient Classification Systems “There is also the validity of the classification categories for particular uses. And then there is the reliability of the data” Anon