Comparative analysis of the current payment system for hospital services in Serbia and projected payments under diagnostic related groups system in urology
Abstract
Background/Aim. Global budget per calendar year is a traditional method of funding hospitals in Serbia. Diagnose related groups (DGR) is a method of hospital payment based on classification of patients into groups with clinically similar problems and similar utilization of hospital resources. The aim of this study was to compare current methods of hospital services payment with the projected costs by DRG payment method in urology. Methods. The data were obtained from the information system used in the Clinical Hospital Center “Dr. Dragiša Mišović” – Dedinje in Belgrade, Serbia. The implemented hospital information system was the main criterion for selection of healthcare institutions. The study included 994 randomly selected patients treated surgically and conservatively in 2012. Results. Average costs under the current payment method were slightly higher than those projected by DRG, however, the variability was twice as high (54,111 ± 69,789 compared to 53,434 ± 32,509, p < 0,001) respectively. The univariate analysis showed that the highest correlation with the current payment method as well as with the projected one by DRG was observed in relation to the number of days of hospitalization (ρ = 0.842, p < 0.001, and ρ = 0.637, p < 0.001, respectively). Multivariate regression models confirmed the influence of the number of hospitalization days to costs under the current payment system (β = 0.843, p < 0.001) as well as under the projected DRG payment system (β = 0.737, p < 0.001). The same predictor was crucial for the difference in the current payment method and the projected DRG payment methods (β = 0.501, p <0.001). Conclusion. Payment under the DRG system is administratively more complex because it requires detailed and standardized coding of diagnoses and procedures, as well as the information on the average consumption of resources (costs) per DRG. Given that aggregate costs of treatment under two hospital payment methods compared in the study are not significantly different, the focus on minor surgeries both under the current hospital payment method and under the introduced DRG system would be far more cost-effective for a hospital as great variations in treatment performance (reduction of days of hospitalization and complications), and consequently invoiced amounts would be reduced.
References
Street A, Vitikainen K, Bjorvatn A, Hvenegaard A.. Introducing Activity-Based Financing: A Review of Experience in Australia, Denmark, Norway and Sweden. York, UK: Centre for Health Economics, University of York; 2007.
Jovanovic M, Lazic Z, Jakovljevic V, Djukic A, Velickovic R, Antu-novic M. Current efforts and proposals to reduce healthcare costs in Serbia. Ser J Exp Clin Res 2011; 12(4): 161−3.
Roger France FH. Casemix use in 25 countries: a migration suc-cess but international comparisons failure. Int J Med Inform 2003; 70(2−3): 215−9.
Jacobs R, Smith P, Street A. Measuring efficiency in health care: analytic techniques and health policy. Cambridge: Cambridge University Press; 2006.
Fetter R, Shin Y, Freeman JL, Averill RF, Thompson JD. Case Mix Definition by Diagnosis-Related Groups. Medical Care 1980; 18(2 Suppl 3): 1−53.
Busse R, Geissler A, Quentin W, Wiley M. Diagnosis related groups in Europe: moving towards transparency, efficiency and quality in hospitals. Berkshire, England: Open University Press, Mcgraw-Hill; 2011.
Legido-Quigley H, McKee M, Nolte E, Glinos IA. Assuring the Quality of Health Care in the European Union: A Case for Action. Copenhagen, Denmark: WHO Regional Office for Europe; 2008.
Paris V, Devaux M, Wei L. Health Systems Institutional C ha-racteristics: a Survey of 29 OECD Countries. Paris: OECD Health Working Paper; 2010.
Fischer W. Die DRG-Familie. Stand 2007. Wolfertswil: Zen-trum für Informatik und Wirtschaftliche Medizin (ZIM); 2008.
Kimberly J. The Globalization of Managerial Innovation in Health Care. Cambridge: Cambridge University Press; 2008.
Farrar S, Yi D, Sutton M, Chalkley M, Sussex J, Scott A. Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis. Br Med J 2009; 339: b3047.
Freitas A, Silva-Costa T, Lopes F, Garcia-Lema I, Teixeira-Pinto A, Brazdil P, et al. Factors influencing hospital high length of stay outliers. BMC Health Serv Res 2012; 20(12): 265.
Ranković A, Rančić N, Jovanović M, Ivanović M, Gajović O, Lazić Z, et al. Impact of imaging diagnostics on the budget – are we spending too much. Vojnosanit Pregl 2013; 70(7): 709−11.
Simić S. Social medicine. Beograd: Medicinski fakultet; 2012. (Serbian)
Jakovljevic MB. Resource allocation strategies in Southeastern European health policy. Eur J Health Econ 2013; 14(2): 153−9.
Owens WD, Felts JA, Spitznagel EL. ASA physical status classifi-cations: a study of consistency of ratings. Anesthesiology 1978; 49(4): 239−43.
Dindo D, Demartines N, Clavien P. Classification of surgical com-plications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240(2): 205−13.
Croatian Institute for Health Insurance. Available from: http://www.hzzo-net.hr/ (Croatian)
Wiley M. From the origins of DRGs to their implementation in Europe. In: Busse R, Geissler A, Quentin W, Wiley M, editors. Di-agnosis-Related. Groups in Europe. Moving towards transpa-rency, efficiency and quality in hospitals. Berkshire (UK): World Health Organization on behalf of European Observatory on Health Systems and Policies, Open University Press, McGraw-Hill; 2011.
Lave JR. The effect of the Medicare prospective payment sys-tem. Annu Rev Public Health 1989; 10: 141–61.
Berki SE. DRGs, incentives, hospitals, and physicians. Health Affairs 1985; 4(4): 70−6.
Volkmer BG, Stredele R, Petervari M, Petschl S, Pühse G. Amend-ments to the German diagnosis-related groups (G-DRG) sys-tem for urology in 2012. Urologe A 2012; 51(8): 1109−16. (German)
Kahn KL, Keeler EB, Sherwood MJ, Rogers WH, Draper D, Bentow SS, et al. Comparing outcomes of care before and after im-plementation of the DRG-based prospective payment system. JAMA 1990; 264(15): 1984−8.
Ellis RP. Creaming, skimping and dumping: provider competi-tion on the intensive and extensive margins. J Health Econ 1998; 17(5): 537−55.
Martinussen PE, Hagen TP. Reimbursement systems, organi-sational forms and patient selection: evidence from day surgery in Norway. Health Econ Policy Law 2009; 4(2): 139−58.
Newhouse JP, Byrne DJ. Did Medicare's prospective payment system cause length of stay to fall. J Health Econ 1988; 7(4): 413−6.
Wenke A, Gaber A, Hertle L, Roeder N, Pühse G. Complexity level simulation in the German diagnosis-related groups system: the financial effect of coding of comorbidity diagnostics in urology. Urologe A 2012; 51(7): 975−81. (German)
Schreyögg J, Stargardt T, Tiemann O, Busse R. Methods to deter-mine reimbursement rates for diagnosis related groups (DRG): a comparison of nine European countries. Health Care Manag Sci 2006; 9(3): 215−23.
Shleifer A. A theory of yard stick competition. Rand J Econ 1985; 16(3): 319−27.
Gertman PM, Restuccia JD. The appropriateness evaluation pro-tocol: a technique for assessing unnecessary days of hospital care. Med Care 1981; 19(8): 855−71.
Payne SM, Ash A, Restuccia JD. The Role of Feedback in Re-ducing Medically Unnecessary Days of Hospital Care. Med Care 1991; 29(8 Suppl): AS91–105.
Bentes M, Gonsalves ML, Santos M, Pina E. Design and devel-opment of a utilization review program in Portugal. Int J Qual Health Care 1995; 7(3): 201−12.
Burgers JS, Grol R, Klazinga NS, Mäkelä M, Zaat J. Towards evi-dence-based clinical practice: an international survey of 18 clinical guideline program. Int J Qual Health Care 2003; 15(18): 31−45.
Cheah J. Development and implementation of a clinical path-way programme in an acute care general hospital in Singapore. Int J Qual Health Care 2000; 12(5): 403−12.
Apolone G, Alfieri V, Braga A, Caimi V, Cestari C, Crespi V, et al. A survey of the necessity of the hospitalization day in an Ital-ian teaching hospital. Qual Assur Health Care 1991; 3(1): 1−9.
Aruldas V. Appropriateness Evaluation Protocol: An Applica-tion in a Multi-speciality Hospital. Vikalpa 1999; 24(3): 19−28.