Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА Ric Marshall Tuesday, 6th December 2011 Gaming and Sub-acute patients

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА “Paper cases” administrative discharges and readmission in Hungary Change of care type in NSW. “Empty cases” in Slovenia Admitting cases in Emergency Departments – ?can these be legitimate? Generating additional data counts for more funding

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА 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??

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА 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

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА UPCODING CA$EMAX % ACCURACY 30% CREATIVITY – SUBECT TO EDITS

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА 6 Source: Nagy, J., DRG creep in Hungary

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА 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

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА 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

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА 9 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

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА 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

Serbia Health Project – Additional Financing Training for Trainers on AR-DRG, Република Србија МИНИСТАРСТВО ЗДРАВЉА How can these issues be addressed in Serbia? What is done now about professional review? How is fraud detected and controlled? QUESTIONS